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Voice of resistance

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  • Some people with psychotic conditions experience auditory hallucinations
  • AVATAR therapy allows patients to have a dialog with the voices they hear
  • Technology could lower barriers to mental health care

We all have a silent inner voice that “speaks” to us throughout the day. That voice is often helpful, but at times it can be negative or insulting. In the end, most of us understand that the voice represents our own thoughts, and we are ultimately in control. But for some who suffer from psychotic disorders, these thoughts are experienced as external voices. These verbal auditory hallucinations are often hostile, derogatory, and threatening.

Facing fears. Computer-assisted therapy helps people who experience auditory hallucinations. Courtesy King's College London.

Pharmacological therapy and cognitive behavioral approaches have a limited effect on this condition, and many mental health professionals are interested in novel therapies.

Professor Tom Craig and his team at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN) of King’s College London are investigating the effect of Audio-Visual Assisted Therapy Aid for Refractory auditory hallucinations (AVATAR) therapy on verbal auditory hallucinations.  

AVATAR therapy, originally created by psychiatrist Julian Leff in 2012, uses technology to promote dialogue between persons suffering from auditory verbal hallucinations and their most distressing voice. Professor Leff initially conducted a small pilot study which resulted in significant reductions in patient hallucinations and associated distress.

Following up on this result, Craig’s team decided to investigate AVATAR therapy in a larger, methodologically rigorous clinical trial that would compare AVATAR therapy with supportive counselling which does not specifically target the voices.

AVATAR is part of a new wave of therapies that focuses on the relationship between the person hearing voices and the voices themselves. The goal is to improve the way the person relates to the voices which often present themselves as dominant or even omniscient.

<strong>Dr. Mar Rus-Calafell</strong>, coordinator of the AVATAR clinical trial, emphasizes that the therapy must be delivered by skilled therapists trained in the treatment of psychosis. Courtesy Mar Rus-Calafell.AVATAR therapy begins with the client using specialized software to create a visual representation of the entity that they believe is talking to them. Additional software transforms the voice of the therapist to match the pitch and tone of the hallucinated voice. The result is a computer simulation (a virtual agent or ‘avatar’) that the therapist uses to communicate with the client.

In a typical AVATAR session, the client and therapist first discuss how the client has been doing for the last week. They may also reflect on the previous week’s therapy session. In the second phase, the client engages in an active dialog with the avatar. During the first 2 to 3 weeks of therapy, the avatar voices make scripted statements to the client. Over the next few weeks, the interactions gradually become dialogic in nature. As therapy progresses, the avatar behaves more considerately, and begins to speak in a less threatening manner.

The final phase of the therapy session is a post-avatar debrief. The therapist asks the client about how they felt when conversing with the avatar, and then provides support for resisting the avatar. An mp3 recording of the session is made, and the client is encouraged to listen to it any time they want. Listening to the recording may be especially useful at times when the voices are difficult to bear.

<strong>Fighting back.</strong> The AVATAR is closely matched to the voice and appearance of an individual's internal tormentor, so they can practice successful resistance to the hallucination. Courtesy King's College London.AVATAR therapy is not yet in widespread clinical use. Dr. Mar Rus-Calafell, coordinator of the AVATAR clinical trial, explains that the therapy must be delivered by skilled therapists with substantial training in the psychological treatment of psychosis. She says that future delivery of this therapy will require “specific training and continuous clinical supervision.”

Rus-Calafell calls AVATAR therapy “a clear example of how innovative digital tools can help the treatment of psychotic experiences.” She adds that this method should not be seen as a self-help treatment, but rather as a clinical aid.

“I am a great supporter of the inclusion of technology to enhance positive outcomes in psychological therapies, but never to replace the clinician.”

AVATAR therapy has shown clinically significant benefits for people who suffer from auditory hallucinations. By the end of Craig’s 12-week study, participants demonstrated a rapid and sustained reduction in the severity of their symptoms. Rus-Calafell notes that people with psychosis may be more motivated to receive treatment delivered with this and other virtual reality-based technologies. This could help bring down some of the barriers faced by people in need of mental health treatment.


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