Can “Avatar Therapy” Help People Confront Hallucinations?

In a recent study, schizophrenics engaged the distressing voices they hear through digital audio-visual representations

A participant in the trial created this avatar. King's College London

About 75 percent of people with schizophrenia have auditory hallucinations, often in the form of “hearing voices.” These voices are frequently frightening or bullying, sometimes telling hearers the world is ending or urging them to kill themselves.

But what if hearers could confront their voices as if they were real people? Would that help make them less troublesome?

This is the question asked by a team of researchers in the UK. They’ve developed “avatar therapy,” where participants create a computerized audio-visual representation of the voice they find most problematic. They can then talk back to the voices during guided therapy sessions, challenging their statements or simply asking them to please go away.

The results are encouraging, according to a recent study published in the Lancet Psychiatry. After 12 weeks of treatment, patients receiving avatar therapy were less likely to be bothered by voices than patients getting standard counseling. And more patients in the avatar therapy group stopped hearing voices entirely than did patients in the counseling group.

Researchers believe the therapy may work in two ways. First, it functions as desensitization therapy, allowing participants to become less frightened of their voices simply by “seeing” them regularly. Second, it may boost self-esteem by helping participants confront real trauma.  

“Voices often echoed earlier lived experience of humiliation and abuse,” says Tom Craig, a professor at King’s College London and the principal investigator on the avatar project. “The conversation with the avatar, that was chosen to represent these former bullies or abusers, allowed the person to say things to the avatar that they were never able to say to the person at the time, to correct misconceptions and to demonstrate positive aspects of themselves.”

In the trial reported in the Lancet Psychiatry, 150 people with diagnoses of schizophrenia spectrum disorders or mood disorders with psychotic symptoms were randomly assigned to either an avatar group or a standard therapy group. All participants had experienced distressing auditory hallucinations for as long as 20 years, despite medication.

The participants in the avatar group helped create virtual representations of a persecutory voice, creating an image that looked like and sounded like what they saw and heard in their heads, down to the pitch of the voice. They then participated in weekly therapy sessions that involved 10 to 15 minutes of direct contact with the avatar. The therapist, in a different room, would voice the avatar, the software adjusting his or her own voice to sound like the participant’s imagining.

Both groups were evaluated after 12 weeks of therapy and again after six months to see how frequently they heard voices and how distressing they found them.

The idea of confronting voices is not new, Craig says. Some therapists use an approach involving an empty chair to represent a voice, which can then be part of a three-way conversation.

“The aim is to get the patient to have a greater sense of ownership and control over the voices,” Craig says.

But the avatar allows patients to confront voices with a higher degree of realism. Some participants found the treatment challenging, even scary.

“I found the avatar sessions intimidating at times,” says “Joe,” a 49-year-old participant, in an interview with researchers. “It was like bringing my voices out into the open. Sitting in front of a computer, which seemed to know my every thought. In some ways it allows me to share my experience, which can only be helpful.”

Craig believes the therapy could work for the majority of people with schizophrenia. But there are some people who don’t want to stop hearing their voices, either because they enjoy them or because they find the idea of treatment too terrifying. Other people may be hampered by thought and concentration difficulties that make the therapy very difficult.

Craig and his team hope to better understand how to optimize avatar therapy. Should it be used as part of long-term therapy? Could it be integrated with other virtual reality interventions? Larger trials will likely be needed before the approach could become widely available, Craig says.

Some experts question whether avatar therapy represents a dramatic departure from traditional approaches, noting that both the avatar group and the control group showed no significant differences after six months (the researchers also noted this). And while Craig and colleagues hypothesize that avatar therapy may work by raising self-esteem, participants showed no changes in self-esteem ratings over the course of the therapy.

“Important questions therefore remain regarding the role of AVATAR therapy in the resolution of ostensibly persistent auditory verbal hallucinations,” say psychologists Ben Alderson-Day and Nev Jones, writing in the Lancet Psychiatry.

Can the therapy work as an early intervention? What might make the effect more lasting? And how does culture influence the outcomes?

There is a larger movement in the mental illness community to reconsider what hearing voices means. Some say voice-hearing is simply a variation of human experience, and does not necessarily need to be pathologized. Research suggests the way people experience hearing voices is influenced by the culture they live in—in one study, Americans were more likely to find their voices violent or frightening, while Indians and Ghanaians were more likely to “report rich relationships with their voices.”

For years, mainstream psychiatry discouraged direct engagement with voices, with the belief that they were useless manifestations of sickness that could only distract from treatment. But now many experts and patients alike believe treating the voices as “real” is a helpful way to make them less disturbing.

“We should applaud the efforts of the AVATAR team and the considerable benefits they have enabled for voice-hearers in their trial,” write Alderson-Day and Jones. “[B]ut put simply, the question now is this—how does the conversation continue?”