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)