A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy — invented by Julian Leff in 2008 — an acronym for Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations, is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. Researchers aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.

The study began as a pilot test published in PubMed and continued as follow-up research published in The Lancet.

Researchers did this single-blind, randomized controlled trial at a single clinical location in South London and Maudsley NHS Trust. Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum or affective disorder, and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned to receive AVATAR therapy or supportive counselling with randomized permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS–AH). Analysis was by intention-to-treat with linear mixed models.

Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy or supportive counselling. 124 (83%) met the primary outcome. The reduction in PSYRATS–AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling. There was no evidence of any adverse events attributable to either therapy.

To our knowledge, this is the first powered, randomized controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-center studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, researchers think it should become an option in the psychological treatment of auditory verbal hallucinations.


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