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?”