The effects of an Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations (AVATAR therapy): study protocol for a randomised controlled trial

Relating behaviours and therapeutic actions during AVATAR therapy dialogue: An observational study

OBJECTIVES

AVATAR therapy is a novel relational approach to working with distressing voices by engaging individuals in direct dialogue with a digital representation of their persecutory voice (the avatar). Critical to this approach is the avatar transition from abusive to conciliatory during the course of therapy. To date, no observational study has examined the moment-to-moment dialogical exchanges of this innovative therapy. We aim to (1) map relating behaviours between participants and their created avatars and (2) examine therapeutic actions delivered within AVATAR dialogue.

METHOD

Twenty-five of the fifty-three AVATAR therapy completers were randomly selected from a randomized controlled trial (Craig et al. The Lancet Psychiatry, 5, 2018 and 31). Seventy-five audio recordings of active dialogue from sessions 1 and 4 and the last session were transcribed and analysed using a newly developed coding frame. Inter-rater reliability was good to excellent.

RESULTS

Fine-grained analysis of 4,642 observations revealed nuanced communication around relational power and therapeutic activity. Early assertiveness work, reinforced by the therapist, focussed on increasing power and distancing. Participants' submissive behaviours reduced during therapy, but the shift was gradual. Once the transition to a more conciliatory tone took place, the dialogue primarily involved direct communication between participant and avatar, focussing on sense of self and developmental and relational understanding of voices.

CONCLUSIONS

AVATAR therapy supports voice-hearers in becoming more assertive towards a digital representation of their abusive voice. Direct dialogue with carefully characterized avatars aims to build the voice-hearers' positive sense of self, supporting the person to make sense of their experiences.

PRACTITIONER POINTS

AVATAR therapy enables voice-hearers to engage in face-to-face dialogue with a digital representation ('avatar') of their persecutory voice. Fine-grained analyses showed how relating behaviours and therapeutic actions evolve during active AVATAR therapy dialogue. Carefully characterized avatars and direct therapist input help voice-hearers become more assertive over the avatar, enhance positive sense of self, and support individuals to make sense of their experiences.

Avatar Therapy for people with schizophrenia or related disorders

BACKGROUND

Many people with schizophrenia do not achieve satisfactory improvements in their mental state, particularly the symptom of hearing voices (hallucinations), with medical treatment.

OBJECTIVES

To examine the effects of Avatar Therapy for people with schizophrenia or related disorders.

SEARCH METHODS

In December 2016, November 2018 and April 2019, the Cochrane Schizophrenia Group's Study-Based Register of Trials (including registries of clinical trials) was searched, review authors checked references of all identified relevant reports to identify more studies and contacted authors of trials for additional information.

SELECTION CRITERIA

All randomised clinical trials focusing on Avatar Therapy for people with schizophrenia or related disorders.

DATA COLLECTION AND ANALYSIS

We extracted data independently. For binary outcomes, we calculated risk ratio (RR) and 95% confidence intervals (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and 95% CIs. We employed a fixed-effect model for analyses. We assessed risk of bias for included studies and created 'Summary of findings' tables using GRADE. Our main outcomes of interest were clinically important change in; mental state, insight, global state, quality of life and functioning as well as adverse effects and leaving the study early.

MAIN RESULTS

We found 14 potentially relevant references for three studies (participants = 195) comparing Avatar Therapy with two other interventions; treatment as usual or supportive counselling. Both Avatar Therapy and supportive counselling were given in addition (add-on) to the participants' normal care. All of the studies had high risk of bias across one or more domains for methodology and, for other risks of bias, authors from one of the studies were involved in the development of the avatar systems on trial and in another trial, authors had patents on the avatar system pending. 1. Avatar Therapy compared with treatment as usual When Avatar Therapy was compared with treatment as usual average endpoint Positive and Negative Syndrome Scale - Positive (PANSS-P) scores were not different between treatment groups (MD -1.93, 95% CI -5.10 to 1.24; studies = 1, participants = 19; very low-certainty evidence). A measure of insight (Revised Beliefs about Voices Questionnaire; BAVQ-R) showed an effect in favour of Avatar Therapy (MD -5.97, 95% CI -10.98 to -0.96; studies = 1, participants = 19; very low-certainty evidence). No one was rehospitalised in either group in the short term (risk difference (RD) 0.00, 95% CI -0.20 to 0.20; studies = 1, participants = 19; low-certainty evidence). Numbers leaving the study early from each group were not clearly different - although more did leave from the Avatar Therapy group (6/14 versus 0/12; RR 11.27, 95% CI 0.70 to 181.41; studies = 1, participants = 26; low-certainty evidence). There was no clear difference in anxiety between treatment groups (RR 5.54, 95% CI 0.34 to 89.80; studies = 1, participants = 19; low-certainty evidence). For quality of life, average Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (QLESQ-SF) scores favoured Avatar Therapy (MD 9.99, 95% CI 3.89 to 16.09; studies = 1, participants = 19; very low-certainty evidence). No study reported data for functioning. 2. Avatar Therapy compared with supportive counselling When Avatar Therapy was compared with supportive counselling (all short-term), general mental state (Psychotic Symptom Rating Scale (PSYRATS)) scores favoured the Avatar Therapy group (MD -4.74, 95% CI -8.01 to -1.47; studies = 1, participants = 124; low-certainty evidence). For insight (BAVQ-R), there was a small effect in favour of Avatar Therapy (MD -8.39, 95% CI -14.31 to -2.47; studies = 1, participants = 124; low-certainty evidence). Around 20% of each group left the study early (risk ratio (RR) 1.06, 95% CI 0.59 to 1.89; studies = 1, participants = 150; moderate-certainty evidence). Analysis of quality of life scores (Manchester Short Assessment of Quality of Life (MANSA)) showed no clear difference between groups (MD 2.69, 95% CI -1.48 to 6.86; studies = 1, participants = 120; low-certainty evidence). No data were available for rehospitalisation rates, adverse events or functioning.

AUTHORS' CONCLUSIONS

Our analyses of available data shows few, if any, consistent effects of Avatar Therapy for people living with schizophrenia who experience auditory hallucinations. Where there are effects, or suggestions of effects, we are uncertain because of their risk of bias and their unclear clinical meaning. The theory behind Avatar Therapy is compelling but the practice needs testing in large, long, well-designed, well-reported randomised trials undertaken with help from - but not under the direction of - Avatar Therapy pioneers.

Potential Applications of Digital Technology in Assessment, Treatment, and Self-help for Hallucinations

The field of digital mental health is rapidly expanding with digital tools being used in assessment, intervention, and supporting self-help. The application of digital mental health to hallucinations is, however, at a very early stage. This report from a working group of the International Consortium on Hallucinations Research considers particular synergies between the phenomenon of hallucinations and digital tools that are being developed. Highlighted uses include monitoring and managing intermittently occurring hallucinations in daily life; therapeutic applications of audio and video media including virtual and augmented reality; targeting verbal aspects of hallucinations; and using avatars to represent hallucinatory voices. Although there is a well-established Internet-based peer support network, digital resources for hallucinations have yet to be implemented in routine practice. Implementation may benefit from identifying how to market resources to the broad range of populations who experience hallucinations and identifying sustainable funding models. It is envisaged that digital tools will contribute to improved self-management and service provision for people experiencing hallucinations.

Fast and slow thinking in distressing delusions: A review of the literature and implications for targeted therapy

The recent literature on reasoning biases in psychosis and delusions is reviewed. The state-of-the-art knowledge from systematic reviews and meta-analyses on the evidence for jumping to conclusions is briefly summarised, before a fuller discussion of the more recent empirical literature on belief flexibility as applied to delusions. The methodology and evidence in relation to studies of belief flexibility and the Bias Against Disconfirmatory Evidence (BADE) across the delusional continuum will be critically appraised, and implications drawn for improving cognitive therapy. It will be proposed that dual process models of reasoning, which Kahneman (Kahneman, 2011) popularised as 'fast and slow thinking', provide a useful theoretical framework for integrating further research and informing clinical practice. The emergence of therapies which specifically target fast and slow thinking in people with distressing delusions will be described.

Assessing the subjective experience of participating in a clinical trial (AVATAR)

This study assessed the subjective experience of participating in a clinical trial, specifically positive and negative experiences and the experience of audio recording assessment sessions. The study was cross-sectional from a single blinded randomised controlled trial. Forty participants with a primary diagnosis of non-organic psychosis completed baseline and 12-week follow-up questionnaires assessing their experiences. Participants rated research interviews as moderately helpful in facilitating their therapy and talking to the interviewer as moderately helpful at baseline and 12-week follow-up. Self-report ratings of the degree of self-realisation promoted by the research questionnaires were significantly higher at 12-week follow-up compared to baseline. Participants adjusted quickly to being audio recorded and rated interviews as not at all disruptive and not at all to slightly intrusive. On average there were neutral emotional reactions, positive gains and minimal inconveniences as a result of participation. The main reasons for taking part were: 'To help myself', 'I was curious' and 'To help others'. The findings offer support to previous research reporting that individuals with mental health problems find participating in clinical trials a beneficial experience. This may alleviate concerns that participation in similar studies may be personally intrusive or harmful.

Virtual reality in the assessment and treatment of psychosis: a systematic review of its utility, acceptability and effectiveness

Over the last two decades, there has been a rapid increase of studies testing the efficacy and acceptability of virtual reality in the assessment and treatment of mental health problems. This systematic review was carried out to investigate the use of virtual reality in the assessment and the treatment of psychosis. Web of Science, PsychInfo, EMBASE, Scopus, ProQuest and PubMed databases were searched, resulting in the identification of 638 articles potentially eligible for inclusion; of these, 50 studies were included in the review. The main fields of research in virtual reality and psychosis are: safety and acceptability of the technology; neurocognitive evaluation; functional capacity and performance evaluation; assessment of paranoid ideation and auditory hallucinations; and interventions. The studies reviewed indicate that virtual reality offers a valuable method of assessing the presence of symptoms in ecologically valid environments, with the potential to facilitate learning new emotional and behavioural responses. Virtual reality is a promising method to be used in the assessment of neurocognitive deficits and the study of relevant clinical symptoms. Furthermore, preliminary findings suggest that it can be applied to the delivery of cognitive rehabilitation, social skills training interventions and virtual reality-assisted therapies for psychosis. The potential benefits for enhancing treatment are highlighted. Recommendations for future research include demonstrating generalisability to real-life settings, examining potential negative effects, larger sample sizes and long-term follow-up studies. The present review has been registered in the PROSPERO register: CDR 4201507776.

Anxiety Partially Mediates Cybersickness Symptoms in Immersive Virtual Reality Environments

The use of virtual reality (VR) in psychological treatment is expected to increase. Cybersickness (CS) is a negative side effect of VR exposure and is associated with treatment dropout. This study aimed to investigate the following: (a) if gender differences in CS can be replicated, (b) if differences in anxiety and CS symptoms between patients and controls can be replicated, and (c) whether the relationship between exposure to VR and CS symptoms is mediated by anxiety. A sample (N = 170) of participants with different levels of psychosis liability was exposed to VR environments. CS and anxiety were assessed with self-report measures before and after the VR experiment. This study replicated gender differences in CS symptoms, most of which were present before exposure to VR. It also replicated findings that a significant correlation between anxiety and CS can be found in healthy individuals, but not in patients. In a VR environment, anxiety partially mediated CS symptoms, specifically nausea and disorientation. A partial explanation for the differences found between patients and controls may lie in a ceiling effect for the symptoms of CS. A second explanation may be the partial overlap between CS symptoms and physiological anxiety responses. CS symptoms reported at baseline cannot be explained by exposure to VR, but are related to anxiety. Caution is required when interpreting studies on both CS and anxiety, until the specificity in measurements has been improved. Since anxiety mediated the CS symptoms, CS is expected to decline during treatment together with the reduction of anxiety.

Tomorrow's world: current developments in the therapeutic use of technology for psychosis

There is now an established evidence base for the use of information and communication technology (ICT) to support mental healthcare (‘e-mental health’) for common mental health problems. Recently, there have been significant developments in the therapeutic use of computers, mobile phones, gaming and virtual reality technologies for the assessment and treatment of psychosis. We provide an overview of the therapeutic use of ICT for psychosis, drawing on searches of the scientific literature and the internet and using interviews with experts in the field. We outline interventions that are already relevant to clinical practice, some that may become available in the foreseeable future and emerging challenges for their implementation.

AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial

BACKGROUND

A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) 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. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition.

METHODS

We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20-29) or affective disorder (F30-39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised 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. The trial was prospectively registered with the ISRCTN registry, number 65314790.

FINDINGS

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 (n=75) or supportive counselling (n=75). 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 (mean difference -3·82 [SE 1·47], 95% CI -6·70 to -0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy.

INTERPRETATION

To our knowledge, this is the first powered, randomised 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-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations.

FUNDING

Wellcome Trust.

Human-Avatar Symbiosis for the Treatment of Auditory Verbal Hallucinations in Schizophrenia through Virtual/Augmented Reality and Brain-Computer Interfaces

This perspective paper faces the future of alternative treatments that take advantage of a social and cognitive approach with regards to pharmacological therapy of auditory verbal hallucinations (AVH) in patients with schizophrenia. AVH are the perception of voices in the absence of auditory stimulation and represents a severe mental health symptom. Virtual/augmented reality (VR/AR) and brain computer interfaces (BCI) are technologies that are growing more and more in different medical and psychological applications. Our position is that their combined use in computer-based therapies offers still unforeseen possibilities for the treatment of physical and mental disabilities. This is why, the paper expects that researchers and clinicians undergo a pathway toward human-avatar symbiosis for AVH by taking full advantage of new technologies. This outlook supposes to address challenging issues in the understanding of non-pharmacological treatment of schizophrenia-related disorders and the exploitation of VR/AR and BCI to achieve a real human-avatar symbiosis.

The most important things I have learnt in my career as a psychiatrist

This paper is something of a patchwork, incorporating many issues that have intrigued me during 34 years of research. I have included the importance of maintaining a solid base in clinical work, alongside research activities, and being alert to the possibility of a somatic condition contributing to psychiatric symptoms. I stress the value of careful observation of patients, their response to treatments and reasons for dropping out. In addition, I have included 14 more lessons, learned from my experience of research, which I hope will be of use to those readers who aspire to become researchers.

Psychiatry 50 years ago

The 1960s was a period of reform and innovation in the provision of care for people with mental health problems. The most important development was the move away from residential institutions and the development of community services based on district general hospitals.

Mind the gap

Research into the use of digital technology to deliver treatment for psychosis is turning up some fascinating applications, but enthusiasm for these products must be tempered with a realistic appraisal of the steps from initial proof of concept to a marketable device.

What Role Can Avatars Play in e-Mental Health Interventions? Exploring New Models of Client-Therapist Interaction

In the burgeoning field of e-mental health interventions, avatars are increasingly being utilized to facilitate online communication between clients and therapists, and among peers. Avatars are digital self-representations, which enable individuals to interact with each other in computer-based virtual environments. In this narrative review, we examine the psychotherapeutic applications of avatars that have been investigated and trialed to date. Five key applications were identified (1) in the formation of online peer support communities; (2) replicating traditional modes of psychotherapy by using avatars as a vehicle to communicate within a wholly virtual environment; (3) using avatar technology to facilitate or augment face-to-face treatment; (4) as part of serious games; and (5) communication with an autonomous virtual therapist. Across these applications, avatars appeared to serve several functions conducive to treatment engagement by (1) facilitating the development of a virtual therapeutic alliance; (2) reducing communication barriers; (3) promoting treatment-seeking through anonymity; (4) promoting expression and exploration of client identity; and (5) enabling therapists to control and manipulate treatment stimuli. Further research into the feasibility and ethical implementation of avatar-based psychotherapies is required.