Understanding AVATAR therapy: who, or what, is changing?

Abstract

The experience of persistent, distressing auditory verbal hallucinations (known as hearing voices) can be highly debilitating, and provision of better support for those affected is a priority for mental health services. A prominent and innovative approach is AVATAR therapy, in which staff help voice-hearers to design an audio-visual representation of the heard voice to facilitate a therapeutic dialogue, with the AVATAR voice being controlled by the therapist. After an initially promising pilot trial,1Leff J Williams G Huckvale MA Arbuthnot M Leff AP Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study.Br J Psychiatry. 2013; 202: 428-433Crossref PubMed Scopus (123) Google Scholar Tom Craig and colleagues2Craig T Rus-Calafell M Ward T et al.AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial.Lancet Psychiatry. 2017; (published online Nov 23.)http://dx.doi.org/10.1016/S2215-0366(17)30427-3Summary Full Text Full Text PDF Scopus (167) Google Scholar report encouraging evidence of AVATAR therapy's effectiveness in The Lancet Psychiatry. The authors noted reductions in the severity of auditory verbal hallucinations, as measured by PSYRATS–AH total score at 12 weeks after treatment, compared with an active control (supportive counselling; mean difference −3·82 [SE 1·47], 95% CI −6·70 to −0·94; p<0·0093). They also noted changes in appraisals of voice characteristics, such as its perceived omnipotence. Given that many of the participants in the study had been hearing voices for 20 years or more, such improvements should not be underestimated. Although these results are encouraging, significant differences between the treatment and control groups were no longer evident at 24 weeks, and the authors note a roughly equivalent number of participants in both groups reporting no voices at the end of the trial. Important questions therefore remain regarding the role of AVATAR therapy in the resolution of ostensibly persistent auditory verbal hallucinations, and mechanisms of action that potentially contributed to remission for some participants versus quantitative reductions in distress for others. Understanding the patient experience of the therapy—and the subjective effect of the virtual interaction—is crucial. AVATAR therapy shares a therapeutic focus with a range of methods that emphasise interaction with voices, such as Relating Therapy3Hayward M Jones A-M Bogen-Johnston L Thomas N Strauss C Relating Therapy for distressing auditory hallucinations: a pilot randomized controlled trial.Schizophr Res. 2017; 183: 137-142Summary Full Text Full Text PDF PubMed Scopus (76) Google Scholar and voice dialoguing.4Corstens D Longden E May R Talking with voices: Exploring what is expressed by the voices people hear.Psychosis. 2011; 4: 95-104Crossref Scopus (85) Google Scholar Technology can both obscure and enhance our view of reality, but in the case of AVATAR it seems to provide a powerful method of personifying and externalising an otherwise internal and often intrusive phenomenon. The method also foregrounds the agentic and characterful properties of auditory verbal hallucinations noted in phenomenological surveys.5Nayani T David A The auditory hallucination: a phenomenological survey.Psychol Med. 1996; 26: 177-189Crossref PubMed Google Scholar, 6Woods A Jones N Alderson-Day B Callard F Fernyhough C Experiences of hearing voices: analysis of a novel phenomenological survey.Lancet Psychiatry. 2015; 2: 323-331Summary Full Text Full Text PDF PubMed Scopus (135) Google Scholar Such qualities have received attention in recent theories of auditory verbal hallucinations7Bell V A community of one: social cognition and auditory verbal hallucinations.PLoS Biol. 2013; 11: e1001723Crossref PubMed Scopus (43) Google Scholar that go beyond accepted notions of command and dominance.8Trower P Birchwood M Meaden A Byrne S Nelson A Ross K Cognitive therapy for command hallucinations: Randomised controlled trial.Br J Psychiatry. 2004; 184: 312-320Crossref PubMed Scopus (232) Google Scholar Thinking of voices as entities or agents that can be engaged with9Jones N Shattell M Engaging with voices: rethinking the clinical treatment of psychosis.Issues Ment Health Nurs. 2013; 34: 562-563Crossref PubMed Scopus (9) Google Scholar—a notion largely ignored or discouraged for many years within mainstream psychiatric thinking—raises a key question: who, or what, is changing in AVATAR therapy? On the one hand, the patient is encouraged to talk back to the voice, becoming more assertive and less dominated by the experience. This differs from voice dialoguing, which typically encourages acceptance and recognition of voices as functional reactions to emotional distress.4Corstens D Longden E May R Talking with voices: Exploring what is expressed by the voices people hear.Psychosis. 2011; 4: 95-104Crossref Scopus (85) Google Scholar Visualisation of the avatar might render the voice an easier object of control. An emphasis on equipping the voice-hearer with responses, challenges, and answers of their own implies that the voice hearer is changing, but their voices might not be. This could have implications for self-esteem—as Leff and colleagues proposed1Leff J Williams G Huckvale MA Arbuthnot M Leff AP Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study.Br J Psychiatry. 2013; 202: 428-433Crossref PubMed Scopus (123) Google Scholar—but this study shows no specific changes in participants' self-esteem ratings after therapy.2Craig T Rus-Calafell M Ward T et al.AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial.Lancet Psychiatry. 2017; (published online Nov 23.)http://dx.doi.org/10.1016/S2215-0366(17)30427-3Summary Full Text Full Text PDF Scopus (167) Google Scholar On the other hand, the voices might change in terms of their content, valence, or power over the voice-hearer. More information is needed on the developing phenomenology of auditory verbal hallucinations during the course of therapy; part of the method in later sessions is for the therapist to gradually adapt what the avatar says during dialogues, but this does not necessarily reflect changes to the voice per se. Finally, neither voice nor voice-hearer might change as a result of therapy, but the perceived relationship between them could be shifting, therefore it might be important to explore the various social schema at play when people experience auditory verbal hallucinations.10Paulik G The role of social schema in the experience of auditory hallucinations: a systematic review and a proposal for the inclusion of social schema in a cognitive behavioural model of voice hearing.Clin Psychol Psychother. 2012; 19: 459-472Crossref PubMed Scopus (63) Google Scholar Moreover, individuals might differ: for some, the key change might be a reduction in distress or increased feeling of control, whereas for others it might be the resolution or disappearance of a distressing voice. To understand the complex dynamics of this kind of treatment, we need to look both back and forward. If auditory verbal hallucinations can be dialogued with in this way, is this a possibility only for those with many years of developing voices, or might it be relevant for the young person using early intervention services for the first time? In other words, how does a voice come to be agentic, personified and characterful?11Alderson-Day B Fernyhough C Auditory verbal hallucinations: social, but how?.J Conscious Stud. 2016; 23: 163-194PubMed Google Scholar If we think that the voices or their power relations have changed, does this actually persist beyond therapy, and why are gains apparently not maintained when compared with control interventions? It might be that we need to look beyond the individual and their voices to understand how social relationships and contexts, more broadly, might invoke relapse and distress once someone finishes therapy. Longitudinal qualitative research, possibly combined with ecological momentary assessment, could elucidate the potentially diverse and multifaceted factors contributing to changes relevant to the voice-hearer. We should applaud the efforts of the AVATAR team and the considerable benefits they have enabled for voice-hearers in their trial, but put simply, the question now is this—how does the conversation continue? We declare no competing interests. AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trialTo 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. Full-Text PDF Open AccessContinuing the conversation about AVATAR therapyI would like to accept the invitation from Alderson-Day and Jones1 to continue the conversation about what might be changing in AVATAR and similar relational therapies for distressing voices. If dialoguing with a voice is an act of communication,2 we need to identify the components of therapy that are both necessary and sufficient for such communication to become less distressing, at the conclusion of therapy and thereafter. Full-Text PDF