Relating behaviours and therapeutic actions during AVATAR therapy dialogue: an observational study

OBJECTIVES: AVATAR therapy is a novel relational approach to working with distressing voices by engaging individuals in direct dialogue with a digital representation of their persecutory voice (the avatar). Critical to this approach is the avatar transition from abusive to conciliatory during the course of therapy. To date, no observational study has examined the moment-to-moment dialogical exchanges of this innovative therapy. We aim to (1) map relating behaviours between participants and their created avatars and (2) examine therapeutic actions delivered within AVATAR dialogue. METHOD: Twenty-five of the fifty-three AVATAR therapy completers were randomly selected from a randomized controlled trial (Craig et al. The Lancet Psychiatry, 5, 2018 and 31). Seventy-five audio recordings of active dialogue from sessions 1 and 4 and the last session were transcribed and analysed using a newly developed coding frame. Inter-rater reliability was good to excellent. RESULTS: Fine-grained analysis of 4,642 observations revealed nuanced communication around relational power and therapeutic activity. Early assertiveness work, reinforced by the therapist, focussed on increasing power and distancing. Participants’ submissive behaviours reduced during therapy, but the shift was gradual. Once the transition to a more conciliatory tone took place, the dialogue primarily involved direct communication between participant and avatar, focussing on sense of self and developmental and relational understanding of voices. CONCLUSIONS: AVATAR therapy supports voice-hearers in becoming more assertive towards a digital representation of their abusive voice. Direct dialogue with carefully characterized avatars aims to build the voice-hearers’ positive sense of self, supporting the person to make sense of their experiences. PRACTITIONER POINTS: AVATAR therapy enables voice-hearers to engage in face-to-face dialogue with a digital representation (‘avatar’) of their persecutory voice. Fine-grained analyses showed how relating behaviours and therapeutic actions evolve during active AVATAR therapy dialogue. Carefully characterized avatars and direct therapist input help voice-hearers become more assertive over the avatar, enhance positive sense of self, and support individuals to make sense of their experiences

Avatar Therapy for people with schizophrenia or related disorders

BackgroundMany people with schizophrenia do not achieve satisfactory improvements in their mental state, particularly the symptom of hearing voices (hallucinations), with medical treatment.ObjectivesTo examine the effects of Avatar Therapy for people with schizophrenia or related disorders.Search methodsIn December 2016, November 2018 and April 2019, the Cochrane Schizophrenia Group's Study‐Based Register of Trials (including registries of clinical trials) was searched, review authors checked references of all identified relevant reports to identify more studies and contacted authors of trials for additional information.Selection criteriaAll randomised clinical trials focusing on Avatar Therapy for people with schizophrenia or related disorders.Data collection and analysisWe extracted data independently. For binary outcomes, we calculated risk ratio (RR) and 95% confidence intervals (CI), on an intention‐to‐treat basis. For continuous data, we estimated the mean difference (MD) between groups and 95% CIs. We employed a fixed‐effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. Our main outcomes of interest were clinically important change in; mental state, insight, global state, quality of life and functioning as well as adverse effects and leaving the study early.Main resultsWe found 14 potentially relevant references for three studies (participants = 195) comparing Avatar Therapy with two other interventions; treatment as usual or supportive counselling. Both Avatar Therapy and supportive counselling were given in addition (add‐on) to the participants' normal care. All of the studies had high risk of bias across one or more domains for methodology and, for other risks of bias, authors from one of the studies were involved in the development of the avatar systems on trial and in another trial, authors had patents on the avatar system pending.1. Avatar Therapy compared with treatment as usualWhen Avatar Therapy was compared with treatment as usual average endpoint Positive and Negative Syndrome Scale – Positive (PANSS‐P) scores were not different between treatment groups (MD –1.93, 95% CI –5.10 to 1.24; studies = 1, participants = 19; very low‐certainty evidence). A measure of insight (Revised Beliefs about Voices Questionnaire; BAVQ‐R) showed an effect in favour of Avatar Therapy (MD –5.97, 95% CI –10.98 to –0.96; studies = 1, participants = 19; very low‐certainty evidence). No one was rehospitalised in either group in the short term (risk difference (RD) 0.00, 95% CI –0.20 to 0.20; studies = 1, participants = 19; low‐certainty evidence). Numbers leaving the study early from each group were not clearly different – although more did leave from the Avatar Therapy group (6/14 versus 0/12; RR 11.27, 95% CI 0.70 to 181.41; studies = 1, participants = 26; low‐certainty evidence). There was no clear difference in anxiety between treatment groups (RR 5.54, 95% CI 0.34 to 89.80; studies = 1, participants = 19; low‐certainty evidence). For quality of life, average Quality of Life Enjoyment and Satisfaction Questionnaire‐Short Form (QLESQ‐SF) scores favoured Avatar Therapy (MD 9.99, 95% CI 3.89 to 16.09; studies = 1, participants = 19; very low‐certainty evidence). No study reported data for functioning.2. Avatar Therapy compared with supportive counsellingWhen Avatar Therapy was compared with supportive counselling (all short‐term), general mental state (Psychotic Symptom Rating Scale (PSYRATS)) scores favoured the Avatar Therapy group (MD –4.74, 95% CI –8.01 to –1.47; studies = 1, participants = 124; low‐certainty evidence). For insight (BAVQ‐R), there was a small effect in favour of Avatar Therapy (MD –8.39, 95% CI –14.31 to –2.47; studies = 1, participants = 124; low‐certainty evidence). Around 20% of each group left the study early (risk ratio (RR) 1.06, 95% CI 0.59 to 1.89; studies = 1, participants = 150; moderate‐certainty evidence). Analysis of quality of life scores (Manchester Short Assessment of Quality of Life (MANSA)) showed no clear difference between groups (MD 2.69, 95% CI –1.48 to 6.86; studies = 1, participants = 120; low‐certainty evidence). No data were available for rehospitalisation rates, adverse events or functioning.Authors' conclusionsOur analyses of available data shows few, if any, consistent effects of Avatar Therapy for people living with schizophrenia who experience auditory hallucinations. Where there are effects, or suggestions of effects, we are uncertain because of their risk of bias and their unclear clinical meaning. The theory behind Avatar Therapy is compelling but the practice needs testing in large, long, well‐designed, well‐reported randomised trials undertaken with help from – but not under the direction of – Avatar Therapy pioneers

Avatar Therapy Model and Ethical Principles in the Treatment of Auditory Hallucinations in Patients with Schizophrenia

Schizophrenia is one of the most debilitating mental disorders. Auditory hallucinations, which are known to be closely related to interpersonal relationships, are the most common type of hallucinations observed in the course of schizophrenia. Virtual reality has been developing in various fields with the development of computerized technologies and has started to appear in the field of clinical psychology in the form of virtual reality therapies. Avatar therapy is among the interpersonal-based virtual reality therapy models that focus on auditory hallucinations among the symptoms of schizophrenia. The aim of avatar therapy is to enable the person to have control over auditory hallucinations. Within the scope of this review study; the past, present and future of schizophrenia treatment, effective intervention methods in the treatment of schizophrenia, virtual reality therapy, the main outlines of the avatar therapy model, the effectiveness studies of avatar therapy and ethical issues were discussed. The results of the research on the effectiveness of avatar therapy reveal the need for further research in this field

Avatar Therapy for auditory verbal hallucinations

O obxectivo deste documento é avaliar a Terapia AVATAR (AVATAR therapy, Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations)El objetivo de este documento es evaluar la Terapia AVATAR (AVATAR therapy, Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations

The role of characterisation in everyday voice engagement and AVATAR therapy dialogue

Background: Voices are commonly experienced as communication with a personified ‘other’ with ascribed attitudes, intentionality and personality (their own ‘character’). Phenomenological work exploring voice characterisation informs a new wave of relational therapies. To date, no study has investigated the role of characterisation in behavioural engagement with voices or within psychological therapy for distressing voices. Methods: Baseline characterisation (the degree to which the voice is an identifiable and characterful entity) of the dominant voice was rated (high, medium or low) using a newly developed coding framework, for n = 60 people prior to starting AVATAR therapy. Associations between degree of characterisation and (i) everyday behavioural engagement with voices (The Beliefs about Voices Questionnaire-Revised; n = 60); and (ii) interaction within avatar dialogue [Session 4 Time in Conversation (participant–avatar); n = 45 therapy completers] were explored. Results: Thirty-three per cent reported high voice characterisation, 42% medium and 25% low. There was a significant association between characterisation and behavioural engagement [H(2) = 7.65, p = 0.022, ɛ2 = 0.130] and duration of participant–avatar conversation [F(2,42) = 6.483, p = 0.004, η2 = 0.236]. High characterisation was associated with increased behavioural engagement compared with medium (p = 0.004, r = 0.34; moderate effect) and low (p = 0.027, r = 0.25; small−moderate effect) with a similar pattern observed for the avatar dialogue [high v. medium: p = 0.008, Hedges’ g = 1.02 (large effect); high v. low: p = 0.023, Hedges' g = 1.03 (large effect)]. No differences were observed between medium and low characterisation. Discussion: Complex voice characterisation is associated with how individuals interact with their voice(s) in and out of therapy. Clinical implications and future directions for AVATAR therapy and other relational therapies are discussed

Chapter 4 AVATAR Therapy for Refractory Auditory Hallucinations

AVATAR therapy is part of a new and exciting wave of therapies which adopt an explicitly relational and dialogic approach to working with the distressing voices. To understand the AVATAR approach, it is important to consider its position in the evolution of psychological interventions for distressing voices

The Voice Characterisation Checklist:Psychometric Properties of a Brief Clinical Assessment of Voices as Social Agents

Aim: There is growing interest in tailoring psychological interventions for distressing voices and a need for reliable tools to assess phenomenological features which might influence treatment response. This study examines the reliability and internal consistency of the Voice Characterisation Checklist (VoCC), a novel 10-item tool which assesses degree of voice characterisation, identified as relevant to a new wave of relational approaches. Methods: The sample comprised participants experiencing distressing voices, recruited at baseline on the AVATAR2 trial between January 2021 and July 2022 (n = 170). Inter-rater reliability (IRR) and internal consistency analyses (Cronbach’s alpha) were conducted. Results: The majority of participants reported some degree of voice personification (94%) with high endorsement of voices as distinct auditory experiences (87%) with basic attributes of gender and age (82%). While most identified a voice intention (75%) and personality (76%), attribution of mental states (35%) to the voice (‘What are they thinking?’) and a known historical relationship (36%) were less common. The internal consistency of the VoCC was acceptable (10 items, α = 0.71). IRR analysis indicated acceptable to excellent reliability at the item-level for 9/10 items and moderate agreement between raters’ global (binary) classification of more vs. less highly characterised voices, κ = 0.549 (95% CI, 0.240–0.859), p < 0.05. Conclusion: The VoCC is a reliable and internally consistent tool for assessing voice characterisation and will be used to test whether voice characterisation moderates treatment outcome to AVATAR therapy. There is potential wider utility within clinical trials of other relational therapies as well as routine clinical practise

Dialogical approaches to helping people who hear distressing voices: what are they and how do they work?

Section A is a scoping review of relational, dialogical approaches to helping people who hear distressing voices which are a new wave of therapeutic approaches which encourage and actively support dialogue between people and their voices. The review examines six extant dialogical approaches according to their similarities and differences in theory and implementation, together with empirical evidence of effectiveness. Section B is a qualitative study which presents findings on a novel, dialogical approach stemming from the Hearing Voices Movement, The ‘Talking with Voices’ (TwV) approach. The study explored experiences of the TwV approach from the perspectives of 10 voice hearers and also 10 of their voices using Interpretative Phenomenological Analysis. Results are presented according to participants’ experiences of change as a result of the approach, along with consideration of barriers of and facilitators to change. The findings provide support for the acceptability of dialogical approaches for helping people who hear distressing voices. The study itself also demonstrates how perspectives of voice hearers and voices can be centred in future evaluation in this are

The voice characterisation checklist: psychometric properties of a brief clinical assessment of voices as social agents

Aim: There is growing interest in tailoring psychological interventions for distressing voices and a need for reliable tools to assess phenomenological features which might influence treatment response. This study examines the reliability and internal consistency of the Voice Characterisation Checklist (VoCC), a novel 10-item tool which assesses degree of voice characterisation, identified as relevant to a new wave of relational approaches. Methods: The sample comprised participants experiencing distressing voices, recruited at baseline on the AVATAR2 trial between January 2021 and July 2022 (n = 170). Inter-rater reliability (IRR) and internal consistency analyses (Cronbach’s alpha) were conducted. Results: The majority of participants reported some degree of voice personification (94%) with high endorsement of voices as distinct auditory experiences (87%) with basic attributes of gender and age (82%). While most identified a voice intention (75%) and personality (76%), attribution of mental states (35%) to the voice (‘What are they thinking?’) and a known historical relationship (36%) were less common. The internal consistency of the VoCC was acceptable (10 items, α = 0.71). IRR analysis indicated acceptable to excellent reliability at the item-level for 9/10 items and moderate agreement between raters’ global (binary) classification of more vs. less highly characterised voices, κ = 0.549 (95% CI, 0.240–0.859), p < 0.05. Conclusion: The VoCC is a reliable and internally consistent tool for assessing voice characterisation and will be used to test whether voice characterisation moderates treatment outcome to AVATAR therapy. There is potential wider utility within clinical trials of other relational therapies as well as routine clinical practice

Digital health technologies in the psychosocial treatment of core symptoms of psychotic disorders - literature review and practical aspects

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