A recent study published in Nature Medicine has demonstrated the efficacy of AVATAR therapy in reducing voice-related distress in individuals with psychosis. The multi-center, randomized controlled trial, known as AVATAR2, compared two forms of AVATAR therapy—AV-BRF (brief) and AV-EXT (extended)—plus treatment as usual (TAU) against TAU alone. The findings suggest that AVATAR therapy can provide significant relief for those who experience distressing auditory hallucinations.
The AVATAR2 trial involved 345 participants recruited from mental health services across the United Kingdom. Participants were randomized into three groups: AV-BRF plus TAU (n=116), AV-EXT plus TAU (n=114), and TAU alone (n=115). The primary outcome measured was the reduction in distress associated with voices, assessed using the Psychotic Symptoms Rating Scales – Auditory Hallucinations (PSYRATS-AH) scale at 16 and 28 weeks.
AVATAR Therapy: A Digital Approach
AVATAR therapy is a digital treatment where individuals engage in face-to-face dialogues with a personalized digital embodiment of the voice they hear. The avatar is presented on a computer screen, allowing the person to directly address their resistance. In the AVATAR2 trial, two versions were used:
- AV-BRF: Consisting of six sessions focused on exposure, assertiveness, and self-esteem.
- AV-EXT: Comprising 12 sessions, with an initial phase mirroring AV-BRF followed by a personalized, developmentally focused second phase.
Both versions commence with an initial clinical assessment session, which includes creation of the avatar. Approximately 20 minutes are dedicated to making the avatar of the person’s main distressing voice. The created avatar tends to achieve a surprisingly good match. Each session consists of three parts: (1) pre-dialogue discussion; (2) active avatar dialogue; and (3) post-dialogue debrief. The whole takes 45–60 minutes.
Significant Reduction in Voice-Related Distress
The study found that both AV-BRF and AV-EXT, when combined with TAU, led to a statistically significant reduction in voice-related distress compared to TAU alone at both 16 and 28 weeks. This suggests that the benefits of AVATAR therapy are sustained over time.
Key secondary outcomes, including reductions in voice frequency and total severity scores on the PSYRATS-AH Scale, were also assessed. The results indicated improvements in these areas for the AVATAR therapy groups compared to the TAU group.
Methodology and Safety
The trial adhered to strict methodological standards, including assessor blinding and independent oversight. Participants were recruited from various mental health service providers, and inclusion criteria included being over 18 years old, under the care of a specialist mental health team, and experiencing frequent and distressing voices for at least 6 months. Exclusion criteria included primary diagnoses of substance disorder, personality disorder, or learning disability.
Therapists involved in the trial underwent comprehensive training, and treatment adherence and fidelity were closely monitored. The Avatar Therapy System, used to deliver the treatment, has been registered as a class 1 medical device.
Implications for Psychosis Treatment
These findings provide strong evidence for the potential of AVATAR therapy as an effective intervention for individuals experiencing distressing auditory hallucinations associated with psychosis. The digital nature of the therapy allows for personalized and targeted treatment, addressing the specific characteristics and impact of the voices heard by each individual.
Further research is warranted to explore the mechanisms of action underlying AVATAR therapy and to identify which individuals are most likely to benefit from this approach. However, the AVATAR2 trial represents a significant step forward in the development of innovative treatments for psychosis.
