AVATAR therapy for auditory verbal hallucinations in people with psychosis

When those pestering voices say, “You’re worthless,” Who’s talking?  Who’s talking back? And who says this is a “relationship,” anyway?

Sources: The Lancet: Psychiatry


AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial

Prof Tom KJ Craig, PhD; Mar Rus-Calafell, PhD; Thomas Ward, DClinPsy; Prof Julian P Leff, FRCPsych; Mark Huckvale, PhD; Elizabeth Howarth, PhD; Prof Richard Emsley, PhD; Philippa A Garety, PhD.

Published: 23 November 2017


“A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy 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.”

[. . . .]

“The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations[.]”


But let’s not get too excited too soon . . .

Understanding AVATAR therapy: who, or what, is changing?
Ben Alderson-Day, Nev Jones
Published: 23 November 2017

“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.”

[. . . .]

“Thinking of voices as entities or agents that can be engaged with—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. 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 proposed1—but this study shows no specific changes in participants’ self-esteem ratings after therapy.

“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.10Moreover, 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.”

[. . . .]

“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?”

Take a Deep Breath. (It’s not just a cliché.)

How Exactly a Deep Breath Changes your Mind
⎯ Via Quartzy

By Moran Cerf

November 19, 2017
Kellogg School of Management, Northwestern University

https://quartzy.qz.com/1132986/

“[N]ew and unique research, involving recordings made directly from within the brains of humans undergoing neurosurgery, shows that breathing can also change your brain.

Simply put, changes in breathing—for example, breathing at different paces or paying careful attention to the breaths—were shown to engage different parts of the brain.”

 

How Sex and Philosophy Try to Cheat Death

In the English translation of Anne Dufourmantelle’s Blind Date, Sex and Philosophy, is this food for thought:

“Our finite nature is a prop for both sex and philosophy. Sex responds to death by cancelling out time; so does philosophy. The one uses desire, and so does the other.
[S]ex suspends time for as long as [ … ] we remain caught up in the moment and the act [, …] a  moment provisionally outside of time and without duration.

“Philosophy for its part proceeds by stages. It posits an argument, reasons, sidesteps the issue, delivers a judgment, calls it into question, takes one more step in the direction of the logic of being, and in the process [ … ] it sweeps time under the rug, believes it is escaping death by conceptualizing death. [ … ] Concepts do not die or age.”

Missing from this improbable twining is the subjective utility and objective cost of adding drugs to the recipe (uppers for sex and hallucinogens for thought), in both cases as if to stall the movement of time.  No time, no limits, no losses, no regrets.

On Personal Experience (and not taking it personally . . . . )

interabang

 

 

You wake up, stand up, and there you are again.

Standing at the center of the universe.

(Just like everybody else.)

 

It’s a trick of the senses. Hard not to be at the center of your experience of the world.
Your thoughts, feelings, talk and other actions, if there’s any movement at all, ripple outwards.

But it’s mostly familiar and therefore OK. Been here, done this before, right?

Or maybe not.  Maybe look again.
Imagine unfamiliar points of view, for example being responsible for the other end of a conversation. 

Of course it takes effort.
A lot of attention to details.
And persistently, repeatedly disregarding the obvious.

Having an opinion is easy.
Having a correct opinion is more difficult.  
But the hardest: paying close attention while not having to have an opinion. 

 

The King is Dead. Long Live the King.

cremation-urn

Back when I was (only) 40, my good doctor said, “That Pepsi and M&Ms diet is not working out for you. You’re diabetic. You need to make some changes.”  She wasn’t talking small or temporary. We’re talking life changes on a scale that maybe happens if you’ve ever been brave enough to do the fire walk. (Not this tenderfoot.)

Suddenly everything normal was toxic and life-threatening — like nearly everything that tastes good except cucumbers and oregano. Not only that, she said, “You want to cut out stress. Stress will kill you.”  This was a harsh sentence for a devout foodie who made his own pasta, had a survival kit stocked with chocolate, and was a young lawyer taking on other people’s stress for fun and profit.

But the sentence was imposed. And after a decent interval for denial, bargaining, mourning and the rest of it, I came to acceptance: The old me had to die (dammit) if I was going live.   

But how does that work? Die? Really?  Well, yeah, sort of . . . .

In my head there is an imaginary house, with an imaginary room, with an imaginary fireplace. Over that is an imaginary mantel and on that is an imaginary urn. And in that urn are the ashes of Old Greg.  Luv that guy! Don’t want to see him go. Those were some good times. So I visit that guy in that room from time to time. And the conversation is short but heartfelt and goes something like this:

     Hey, man.

         Hey.

     You good?

         I’m in a jar that’s in your head.

     Um, yeah.  Sorry about that.
     But you know you gotta stay there, right?.

          . . . .

     Those were some good times.

          True that.

     Well, I’m doing good.  Walking the walk and all.

          Miss me?

     Like you were me. All the time. But still . . .

          Yeah, I know, like they say in England  — 
          The King is dead . . . .

     Long live the King.

 

 

False Hope is Still Hope (sadly)

Road Sign with Hope and Sky


A recurring theme in mental life (and so in psychotherapy) is the wish for something that is missing, unavailable, or out of reach. Often it takes the form, “If only ______, then ______.” As in, if only I [had enough money/was loved/was better], then [everything would be OK/I would be happy/I would be vindicated/I would be at peace /. . . .”  Sometimes it boils down to wishful meaninglessness: “If only I were loved, then I would feel loved.”

When we are looking forward, hope is a motivator, even a lifesaver.  As Margaret Atwood said recently, “What hope means today […], is what it’s always meant: Where there is hope, there’s more hope. And, in view of the dire predictions we face, hope is the very least we need to keep going.”

Yet, when we are focused on the past instead of the present, hope can be a seductive dead-end. “If only something in the past had not happened/or had happened differently, then my life now would be so much better.” If only the past were not the past.

The seduction is in the approach: “If only” is a statement of hope. It feels hopeful and positive. If only [name any good thing] were true, then bliss/absolution/whatever. But the past has, of course, already happened. False hope always starts out feeling right, but crashes as it must on the rocky shore of reality. If we just believed hard enough in magic, then maybe the incantation of the if/then spell could finally work. We keep returning to hopeless hope, at least for the promise and the feeling of feeling hopeful.

But as they say in AA, the definition of insanity is doing the same thing over and over again, expecting a different result. The cost of moving forward is this: we have to give up all hope of having a different past. Give up all hope of being luckier, of having a partner who didn’t cheat, of having a parent who was emotionally supportive . . . . We have to forgive all that, mourn the loss, and start over. Start over without that fantasy. Star over with nothing. Give up the shoes that don’t fit for no shoes. The prospect seems, well, hopeless.

“Hope is the very least we need to keep going.” But let’s be hopeful about what comes next. Hoping for a different past is still hope, but if it changes nothing going forward, it’s just an old shoe, a drug of choice, a lie.

Forgiveness faces forward.

 

Another Pop-psych Myth Bites the Dust (statistically speaking)

Men and Women May Not Be So Different After All

According to a new article at PsychCentral —

“Despite considerable popular literature suggesting a vast psychological difference between men and women, a new study suggests that gender differences are relatively insignificant.

“Researchers studied a comprehensive list of characteristics ranging from empathy and sexuality to science inclination and extroversion. Overall, they performed a statistical analysis of 122 different traits involving 13,301 individuals.

“Their findings rebuke prior studies that suggested character traits often vary by gender.

“In the new study, the scientists were able to show that statistically, men and women do not fall into different groups. In other words, no matter how strange and mysterious your partner may seem, their gender is probably only a small part of the problem.”

See the full article . . . (really, you should).

and, here’s the original feed from the University of Rochester.

_______

Op.Ed.: Old Wine in New Bottles Dept.

Hey, Dr. Mars, maybe that game of yours on how to manipulate each other was
actually written 48 years ago, and we we are all just Earthlings out for a spin. Shocking.

Pot Causes Psychosis? Yeah, I knew that.

Cannabinoid Receptor Sites

From My Health News 2012-11-19:

No, it’s not a flashback to Reefer Madness. New research at King’s College London’s Institute of Psychiatry (Biological Psychiatry, Nov.15, 2012), indicates a genetic marker may increase the risk of psychosis from smoking cannabis.

“People who smoke pot may be at increased risk for psychosis if they have a certain genetic marker, a new study finds.

“The results show people with this genetic marker who use cannabis are twice as likely to experience psychosis compared with those who use the drug but do not have the genetic marker.” [ . . . . ]

“The genetic marker in question is one variation of a gene call AKT1. The new finding confirms earlier research, which also linked this marker with the risk of psychosis after smoking pot.” [ . . . . ]  The genetic marker likely acts along with other genes to contribute to the risk of psychosis[.]”