Avatar Therapy for Auditory Hallucinations
Auditory verbal hallucinations are reported by around 60–70% of people diagnosed with schizophrenia and are often experienced as aggressive, critical, or belittling (Paulik, 2012). These voices commonly place the individual in a position of inferiority, accompanied by feelings of powerlessness and diminished self-esteem, patterns that often reflect difficulties in wider interpersonal relationships. Although antipsychotic medication can reduce hallucinations, approximately one in four people with psychotic disorders continue to hear distressing voices despite ongoing treatment (Aleman & Larøi, 2011).
AVATAR therapy was developed to address the relational aspects of voice-hearing. The intervention involves guided conversations with a digital avatar that closely resembles the sound and tone of the person’s persecutory voice. During sessions, the therapist alternates between providing therapeutic support and speaking through the avatar, enabling the individual to practise standing up to the voice. Over time, this process aims to weaken the voice’s authority and foster a greater sense of agency and confidence in the voice-hearer (Craig et al., 2018).
Craig et al. (2018) evaluated the effectiveness of AVATAR therapy in a randomised controlled trial conducted within NHS services in South London. Adults who had been experiencing distressing voices for at least one year and had a diagnosis within the psychosis spectrum were randomly assigned to either AVATAR therapy or supportive counselling. Both interventions consisted of six weekly 50-minute sessions, delivered alongside usual psychiatric care. Outcome assessments were carried out by blinded researchers at baseline, 12 weeks, and 24 weeks.
At the 12-week assessment, participants who received AVATAR therapy showed greater improvements than those in supportive counselling, including reduced voice intensity, frequency, distress, and perceived threat. They also reported feeling less dominated by their voices and demonstrated increased acceptance and more proactive coping strategies. Although participants in the counselling group continued to improve over time, gains in the AVATAR group were largely maintained at the 24-week follow-up. No harmful effects linked to the therapy were identified.
More recently, Garety et al. (2024) conducted a large-scale trial comparing two formats of AVATAR therapy with treatment as usual. Out of more than 600 people assessed, 345 individuals with long-standing experiences of hearing voices were enrolled and randomly allocated to AVATAR-Brief (AV-BRF), AVATAR-Extended (AV-EXT), or standard care. Most participants had a diagnosis of schizophrenia and had been engaged with mental health services for over a decade. Follow-up assessments were completed at 16 and 28 weeks.
AV-BRF was designed as a shorter intervention focused on directly challenging the voice and strengthening assertive responses. AV-EXT included this initial phase but added a longer, personalised component that explored the links between the voice, past experiences, and emotional development. Findings showed that both versions led to reductions in voice severity shortly after treatment, particularly at 16 weeks. However, these improvements were not consistently sustained at 28 weeks. The extended version produced the most reliable effects, especially in reducing how frequently voices were heard.
Across additional outcomes, both AVATAR approaches were associated with increased acceptance of voices and greater use of active coping strategies. AV-EXT also led to wider benefits, including reduced perceptions of voice power, improvements in well-being, fewer delusional experiences, and gains in personal recovery, some of which persisted at longer follow-up. Changes in anxiety, depression, and stress were generally modest and tended to fade over time. No serious adverse events related to the interventions were reported. Nevertheless, participation was lower in the extended programme, and the absence of an active psychological control group limits direct comparisons with other therapies.
In summary, current evidence suggests that AVATAR therapy can reduce distress associated with hearing voices by reshaping the relationship between the individual and their voices. While short-term benefits are clear, particularly for more intensive versions of the intervention, further work is needed to improve engagement and to strengthen long-term outcomes.
References:
Aleman, A., & Larøi, F. (2011). Insights into hallucinations in schizophrenia: novel treatment approaches. Expert Review of Neurotherapeutics, 11(7), 1007-1015.
Craig, T. K., Rus-Calafell, M., Ward, T., Leff, J. P., Huckvale, M., Howarth, E., ... & Garety, P. A. (2018). AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial. The Lancet Psychiatry, 5(1), 31-40.
Garety, P.A., Edwards, C.J., Jafari, H. et al. Digital AVATAR therapy for distressing voices in psychosis: the phase 2/3 AVATAR2 trial. Nat Med 30, 3658–3668 (2024). https://doi.org/10.1038/s41591-024-03252-8
Paulik, G. (2012). The role of social schema in the experience of auditory hallucinations: a systematic review and a proposal for the inclusion of social schema in a cognitive behavioural model of voice hearing. Clinical Psychology & Psychotherapy, 19(6), 459-472.
