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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.”

 

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.