Digital-Based 'AVATAR Therapy' Curbs Distressing Voices

By Will Boggs MD

May 26, 2020

NEW YORK (Reuters Health) - AVATAR therapy, a new type of digital-based relational treatment, can help control distressing voices and their negative effects on mental health, according to a review.

"The important thing about AVATAR therapy is that it offers an effective new approach to working with distressing voices (aka auditory hallucinations)," Dr. Thomas Ward of King's College London told Reuters Health by email. "It involves innovative use of digital technology to allow 'face-to-face' dialogue between the voice-hearer and a computerized representation of their voice (the avatar), with a therapeutic focus on increasing power and control over the voice."

A recent trial found that AVATAR therapy provided rapid and substantial reductions in voice frequency and distress, compared with an active control.

Dr. Ward and colleagues present the full range of therapeutic targets, as well as information on therapy acceptability and potential side effects, in their review of AVATAR therapy in Schizophrenia Bulletin.

AVATAR therapy has mostly been investigated in people with a diagnosis of schizophrenia and related psychoses who are experiencing distressing voices despite receiving otherwise adequate pharmacological treatment. The therapy seems to be less indicated for individuals reporting diffuse non-personified voice phenomenology where the experiences cannot be represented clearly by a single avatar.

While different therapy structures are possible, typical sessions involve exposure to the avatar voicing verbatim content while the patient is supported to respond assertively, the authors explain. This fosters desensitization and involves expectancy violation and dropping safety behaviors, components that are critical for attenuating the conditioned fear response.

AVATAR therapy can address at least 10 therapeutic targets, among them power and control, self-esteem/self-concept, identity/social inclusion, compassion to voice, experiential disengagement, and working with grief and trauma.

Acceptability of AVATAR therapy seems to be high. In one recent trial, 22 of 75 people randomized to receive therapy withdrew at some stage from therapy, but only eight of 17 who withdrew after having created their avatar gave reasons explicitly related to AVATAR therapy.

"The digital technology allows us to bring the person's experience of hearing the voice into therapy in a completely new way compared to anything that has come before," Dr. Ward said. "Voice-hearers have told us how important it has been for them to be able to share their experiences with someone as before therapy they have had to face these experiences alone."

"It was striking how naturally people engaged in dialogue with the avatar, speaking to it as if it was the actual voice they hear," he said. "This provided an opportunity for the person to take back power and control from voices which for many have criticized and threatened them for decades. Many people reported a sense of liberation from their voice through the AVATAR therapy after decades of feeling silenced and disempowered by the voice."

"Research is ongoing," Dr. Ward said. "We are looking at how we can further optimize and personalize AVATAR therapy with a view to wider implementation."

There remain challenges to effective AVATAR therapy, according to the authors. "AVATAR therapy is multifaceted and requires experienced therapists. It involves exposure to raw and painful experiences that the voice-hearer may have never shared," they note.

They add, "AVATAR therapy presents delivery challenges (e.g., switching between speaking as therapist and avatar in real-time) and ethical considerations for therapists who voice abuse (through the voice-transformed avatar) and reenact critical and abusive relationships. Clinicians should be mindful of the power of this approach and sensitive to emotionally loaded content (especially involving abuse and discrimination)."

SOURCE: Schizophrenia Bulletin, online May 6, 2020.