Abstract
SummaryBackgroundA quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.MethodsWe did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20–29) or affective disorder (F30–39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS–AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790.FindingsBetween Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS–AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference −3·82 [SE 1·47], 95% CI −6·70 to −0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy.InterpretationTo our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations.FundingWellcome Trust.
Highlights
Auditory verbal hallucinations, which are typically of a derogatory and threatening nature, are reported by approximately 60–70% of people with schizophrenia.[3]
Results from our study suggest a benefit for briefer therapies that employ digital representations of voices in dialogue and are focused on specific target processes, which could be incorporated within a broader therapy or offered as a standalone approach
This paper addresses the primary objective—to test clinical efficacy—with the following hypotheses: AVATAR therapy will be more effective in reducing the frequency and severity of auditory verbal hallucinations, by com parison with supportive counselling, at 12 weeks; AVATAR therapy will be more effective in reducing the reported omnipotence and malevolence of auditory verbal hallucinations, by comparison with supportive counselling, at 12 weeks; and the improvements attributable to AVATAR therapy will be maintained at 24 weeks follow-up
Summary
Auditory verbal hallucinations, which are typically of a derogatory and threatening nature, are reported by approximately 60–70% of people with schizophrenia.[3]. Several novel therapies build on the perspective that auditory verbal hallucinations are experienced as coming from entities that have personal identities, speak with purpose, and with whom the hearer establishes a personal relationship. The operation of power within this relationship is viewed as crucial.[6,7] The voice is typically experienced as dominant (even omnipotent), with the voice-hearer assuming a submissive role characterised by feelings of inferiority and powerlessness that can reflect social relationships more generally.[8] In light of this finding, explicitly relational and interpersonal approaches have been developed that locate voices (and voice relationships) within the person’s biographical context[9] and target key interpersonal dimensions such as power and proximity.[1,7]
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
