AVATAR Therapy Shows Some Positive Outcomes, Now What?

IIn a commentary piece, Ben Alderson-Day and Nev Jones discuss the AVATAR therapy research for psychosis and propose further questions


In a commentary published in the November issue of The Lancet Psychiatry, Ben Alderson-Day and Nev Jones comment on the state of AVATAR therapy. AVATAR therapy is a therapeutic approach in which individuals who hear voices design audio-visual representations of the voices and, along with their therapist, enter into a therapeutic dialogue with them.

Alderson-Day and Jones respond to an article published in The Lancet, in which Tom Craig of King’s College London and other researchers report results of a single-blind RCT that compared AVATAR therapy to supportive counseling. They report that after 12 weeks the reduction of auditory verbal hallucinations was significantly greater for those who received AVATAR therapy than for those who received supportive counseling.

The intervention also showed results at altering participants’ appraisals of voice characteristics, such as their perceived omnipotence. Alderson-Day and Jones point out that the significant difference detected at 12 weeks was no longer present at 24 weeks and that at the end of the trial the percentage of individuals who no longer reported hearing voices was about equal.

A few potential outcomes in the relationship between the voice hearer and the verbal auditory hallucination are presented. In AVATAR therapy, “the patient is encouraged to talk back to the voice and become more assertive and less dominated by the experience.” The authors write that this could result in an increase in self-esteem of the voice hearer as they develop ways to respond, challenge, and develop answers to their voices.

Secondly, it may be that the voice changes in content, valence, or power over the voice-hearer, as the therapist gradually adapts what the avatar says (this does not reflect changes in the voice itself). Lastly, it could be that neither the voice nor the voice-hearer change, but instead it is the perceived relationship between them that changes.

The authors go on to point out that “. . . 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.”

Alderson-Day and Jones urge researchers to consider who may be able to benefit from this therapy. For instance, it remains unclear whether AVATAR will only be used for those who have been hearing this voice for years and more work is needed to assess if individuals accessing early intervention services might benefit as well. Moreover, they question how the power relations between the voice and the voice-hearer are believed to change, and whether this effect is maintained after the completion of the therapy.

The authors call for longitudinal qualitative research to explore factors of change relevant to the voice-hearer. They end by writing:

“We should applaud the efforts of the AVATAR team . . . but put simply, the question now is this- how does the conversation continue?”



Alderson-Day, B., & Jones, N. (2017). Understanding AVATAR therapy: who, or what, is changing?. The Lancet Psychiatry. (Link)


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


Mad in America has made some changes to the commenting process. You no longer need to login or create an account on our site to comment. The only information needed is your name, email and comment text. Comments made with an account prior to this change will remain visible on the site.

Previous articleA Call for Obligatory Diagnostic Reporting and Appeals Mechanisms
Next articleFacebook Rolls Out AI to Detect Suicidal Posts
Bernalyn Ruiz
MIA Research News Team: Bernalyn Ruiz-Yu is a Postdoctoral Fellow in the Department of Psychiatry and Biobehavioral Sciences at the University of California, Los Angeles. She completed her Ph.D. in Counseling Psychology from the University of Massachusetts Boston. Dr. Ruiz-Yu has diverse clinical expertise working with individuals, families, children, and groups with a special focus on youth at risk for psychosis. Her research focuses on adolescent serious mental illness, psychosis, stigma, and the use of sport and physical activity in our mental health treatments.


  1. How not to think of Winnicott’s transitional object: dolls, teddies? Producers of video games have understood the players sometimes spent long time to customize their avatars, that is to say, to play the doll. Even without customizing the avatar, the players address the character they play by ordering it to jump, to accuse it of having failed, etc. The transitional object allows one to exteriorize one’s emotions on an external object, and to learn how to control them. It is therefore not surprising avatar therapy has favorable results.

    Thus avatar therapy is not totaly new, but its form is adapted to the modern culture and the age of the participants.

    Report comment

  2. When I watched the video of AVATAR, the technology struck me as innovative and exciting, but the therapist and his strategies felt old and worn out. He’s using a basic, rational, cognitive technique of fighting the negative voice with the evidence that the client is worthwhile (and it seems to me that helping mom with the groceries and coming to therapy are pretty limited grounds for sustaining his sense of self worth against a persistent and formidable foe). There’s no sign of gestalt, or play therapy, or “community of selves” in his work. Where’s the creativity a talented guided imagery therapist or an animal spirit guide facilitator or a trauma therapist working on integrating fragmented parts of self might bring to this scene?
    My question is “Who is going to be included in the conversation as tantalizing technologies like AVATAR emerge?” Technology alone can’t create imagination, especially if the people involved are boxed into limited formulations and treatment strategies.

    Report comment