People who have schizophrenia or other conditions involving psychosis (a disconnect from reality) frequently report auditory hallucinations or hearing voices. These voices often bully the person or urge them to harm themself. Even with antipsychotic medications and psychotherapy, some individuals still hear the voices. Over the past decade or so, researchers in the United Kingdom have been studying a novel digital treatment to help people confront their hallucinations: avatar therapy.
The treatment involves interacting with a digital avatar of the voice, under therapist supervision. It’s an interesting trend to keep an eye on for journalists who follow mental health and/or novel technologies and their use in health conditions. The largest trial of this therapy — published recently in Nature Medicine — demonstrated that people’s distress about the voices as well as the severity and frequency of the voices decreased after 16 weeks of treatment.
How it works
Through this process, a person hearing voices works with their therapist to create a computerized representation of the character that they hear in their head, called an “avatar,” according to a recent story in STAT. Patients can adjust the face shape, hair, tone of voice and other features to make an approximate match. Then, acting as themself and the avatar, the therapist guides the patient in a three-way conversation to confront and deflect the voice’s criticisms.
A YouTube video from King’s College London demonstrates how this works. When the voice tells a patient, “You’re rubbish. You’re a waste of space,” the patient is instructed to tell the avatar they’re not going to listen to the criticisms and to go away.
These interactions involve about 10-15 minutes of an overall hour-long therapy session. The aim is to reduce voice-related distress and build empowerment, so over a series of sessions, the avatar’s negative voice retreats in response to the patient’s comments. The overall experience for the person, therefore, changes from one that is frightening to one much more in the person’s control.
The evidence
The trial reported in Nature Medicine included 345 participants from three sites in England and one in Scotland, Medscape reported. It tested two versions of avatar therapy: a brief version in which participants confronted their avatars over six sessions, and an extended version more tailored to each person’s life history that lasted 12 sessions, the STAT story reported.
All participants heard voices for at least six months and at least once a week before the trial. Patients also were prescribed antipsychotic medications.
After 16 weeks, participants in both groups experienced improvements in areas such as voice-related distress, severity, empowerment, mood and well-being compared to a control group that received usual psychotherapy without the addition of avatars. Some of the effects lasted three months later, although those in the extended group had stronger, more lasting effects than those in the brief group, according to STAT.
Based on previous research leading up to this study, the UK’s National Institute for Health and Care Excellence (NICE) recommends avatar therapy as one of three digital health technologies that can be used in the National Health Service to help manage symptoms of psychosis while more evidence is generated.
The others are SlowMo, a digitally-supported reasoning intervention using a mobile app plus psychotherapy; and CareLoop, an app people can use to record and monitor their psychosis symptoms. CareLoop then identifies and shares worsening symptoms with mental health professionals to help prevent relapse.
Meanwhile, investigators are seeking to provide avatar therapy in routine health settings to gather real-world evidence of its effectiveness over the next three years, according to Medscape. The research team is also looking into cultural adaptations so it can be used in additional locales such as Ethiopia and India, STAT reported, and developing avatars that employ artificial intelligence as a possible way to facilitate conversations.
But it’s not perfect
It’s unclear when avatar therapy could be available in the U.S., although Canadian investigators are looking at similar research, according to Medscape. But reporting on it still must be tempered with reality.
Just because it’s a digital tool doesn’t mean it will enable “quasi-miraculous” outcomes, Nev Jones, Ph.D., a University of Pittsburgh social work professor, told STAT. Case in point: There was a 20% dropout rate in the brief arm of this study and a 40% dropout rate in the extended arm.
It’s also possible that there could be a “digital placebo effect” from telling people they’re getting advanced digital care, John Torous, M.D., director of digital psychiatry at Beth Israel Deaconess Medical Center in Boston, told Medscape. Still, despite its limitations, it’s exciting to give people new options for psychological therapy, he said.
Resources
- Digital ‘avatars’ emerging as effective treatment for psychosis — STAT.
- More Evidence Avatar Therapy Quiets Auditory Hallucinations in Psychosis — Medscape.
- Digital AVATAR therapy for distressing voices in psychosis: the phase 2/3 AVATAR2 trial — Nature Medicine.
- Understanding AVATAR therapy: who, or what, is changing? — The Lancet Psychiatry.
- Avatar therapy for schizophrenia — YouTube video.
