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Augustin E, Beaudoin M, Giguère S, Ziady H, Phraxayavong K, Dumais A. The Relationship between Sense of Presence, Emotional Response, and Clinical Outcomes in Virtual Reality-Based Therapy for Treatment-Resistant Schizophrenia: An Exploratory Correlational Study. J Pers Med 2024; 14:614. [PMID: 38929835 PMCID: PMC11204393 DOI: 10.3390/jpm14060614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Avatar therapy (AT) is a novel virtual reality-based psychotherapy that has been developed to treat auditory verbal hallucinations (AVH) in treatment-resistant schizophrenia. Various psychotherapeutic components, such as emotions and sense of presence, could contribute to clinical outcomes. However, the interplay between sense of presence, emotions, and clinical response has seldom been investigated. This study aimed to explore the relations between sense of presence, emotions, and clinical outcomes in AT. To conduct this investigation, data from previous and ongoing AT trials were used. Sense of presence and emotions were assessed using standardized questionnaires. AVH were evaluated using the Psychotic Symptom Rating Scales. While sense of presence was positively associated with positive emotions such as control and serenity, no significant associations were found for negative emotions. Moreover, a higher level of sense of presence was associated with a bigger decrease in AVH. Overall, positive emotions seem to be associated with sense of presence in AT. Sense of presence also seems to be involved in the therapeutic outcome, thereby suggesting that this could be an important component related to clinical response. More studies are needed to confirm these trends, which could be generalized to other virtual reality-based psychotherapies.
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Affiliation(s)
- Elischa Augustin
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Mélissa Beaudoin
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Sabrina Giguère
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
- School of Social Work, Faculty of Arts and Sciences, University of Montreal, Montreal, QC H3T 1J4, Canada
| | - Hind Ziady
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
| | | | - Alexandre Dumais
- Research Center of the University Institute in Mental Health of Montreal, Montreal, QC H1N 3V2, Canada; (E.A.); (M.B.); (S.G.); (H.Z.)
- Department of Psychiatry and Addictology, Faculty of Medicine, University of Montreal, Montreal, QC H3T 1J4, Canada
- Services et Recherches Psychiatriques AD, Montreal, QC H1N 3V2, Canada;
- Institut National de Psychiatrie Légale Philippe-Pinel, Montreal, QC H1C 1H1, Canada
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Gutiérrez-Maldonado J. The Use of Virtual Reality Technology in the Treatment of Psychopathological Disorders. J Clin Med 2022; 11:jcm11185358. [PMID: 36143005 PMCID: PMC9501337 DOI: 10.3390/jcm11185358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 09/06/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- José Gutiérrez-Maldonado
- Department of Clinical Psychology and Psychobiology, University of Barcelona, Paseo Valle de Hebrón, 171, 08035 Barcelona, Spain
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Kapadia SV. Adapting AVATAR Therapy: Using Available Digital Technology for People Living with Auditory Verbal Hallucinations in Low- and Middle-Income Countries. Indian J Psychol Med 2022; 44:405-408. [PMID: 35949640 PMCID: PMC9301740 DOI: 10.1177/02537176221090106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Rus-Calafell M, Ehrbar N, Ward T, Edwards C, Huckvale M, Walke J, Garety P, Craig T. Participants' experiences of AVATAR therapy for distressing voices: a thematic qualitative evaluation. BMC Psychiatry 2022; 22:356. [PMID: 35610590 PMCID: PMC9129894 DOI: 10.1186/s12888-022-04010-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 05/11/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AVATAR therapy is an innovative therapy designed to support people with distressing voices. Voice hearers co-create a digital representation of their voice and engage in dialogue with it. Although it has been successfully tested in a powered randomised controlled trial (ISRCTN65314790), the participants' experience of this therapy has not been yet evaluated. We aimed to explore enablers and barriers to engagement with the therapy and potential for real-world impact on distressing voices. METHODS Thirty per cent of those who completed AVATAR therapy (15 people in total) and 5 who dropped out from therapy within the main AVATAR RCT were invited to participate in a semi-structured interview, which was audio-recorded and subsequently transcribed. RESULTS Fourteen therapy completers (28% of the full sample) and one person who dropped out of therapy after 1 active session, were interviewed. Thematic analysis was used to explore the interviews. A total of 1276 references were coded, and five overarching themes identified: AVATAR therapy set-up; voice embodiment and associated emotions; working in a safe space (supported by the therapist); learning new ways of relating to the voices; impact of therapy on everyday life. Overall, the therapy set-up, with its digital components and its distinctive features as compared with common face-to-face talking therapies, was satisfactory. The inclusion of technology was well accepted as both a means to deliver the therapy and a tool to create a digital representation of the person's distressing voice. The co-creation of the avatar and the enactment of the relationship between the person and the voice were perceived as a very helpful process to promote the therapeutical dialogue. Participants reported engaging well with the therapist and feeling supported and identified specific learnt strategies to deal with the voices and how they have had an impact on everyday life. CONCLUSIONS AVATAR therapy is acceptable and provides benefit for participants with psychosis. Our results highlighted the enablers and challenges of working dialogically with distressing voices using a digital representation and dealing with highly demanding emotional, cognitive, and relational processes linked to the experience. Our analysis also identified the core strategies learnt by participants and how these were generalised to their daily life resulting into a positive change in different domains, and in particular broader social relationships.
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Affiliation(s)
- Mar Rus-Calafell
- Mental Health Research and Treatment Centre, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany. .,Department of Health Service and Population Research, Institute of Psychiatry, King's College London, Psychology & Neuroscience, London, UK.
| | - Nils Ehrbar
- grid.5570.70000 0004 0490 981XMental Health Research and Treatment Centre, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Thomas Ward
- grid.13097.3c0000 0001 2322 6764Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,grid.37640.360000 0000 9439 0839South London & Maudsley NHS Foundation Trust, London, UK
| | - Clementine Edwards
- grid.13097.3c0000 0001 2322 6764Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,grid.37640.360000 0000 9439 0839South London & Maudsley NHS Foundation Trust, London, UK
| | - Mark Huckvale
- grid.83440.3b0000000121901201Speech, Hearing and Phonetic Sciences, Division of Psychology and Language Sciences, University College London, London, UK
| | - Jennifer Walke
- grid.13097.3c0000 0001 2322 6764Department of Health Service and Population Research, Institute of Psychiatry, King’s College London, Psychology & Neuroscience, London, UK
| | - Philippa Garety
- grid.13097.3c0000 0001 2322 6764Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK ,grid.37640.360000 0000 9439 0839South London & Maudsley NHS Foundation Trust, London, UK
| | - Tom Craig
- grid.13097.3c0000 0001 2322 6764Department of Health Service and Population Research, Institute of Psychiatry, King’s College London, Psychology & Neuroscience, London, UK ,grid.37640.360000 0000 9439 0839South London & Maudsley NHS Foundation Trust, London, UK
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Garety P, Edwards CJ, Ward T, Emsley R, Huckvale M, McCrone P, Rus-Calafell M, Fornells-Ambrojo M, Gumley A, Haddock G, Bucci S, McLeod H, Hardy A, Peters E, Myin-Germeys I, Craig T. Optimising AVATAR therapy for people who hear distressing voices: study protocol for the AVATAR2 multi-centre randomised controlled trial. Trials 2021; 22:366. [PMID: 34034792 PMCID: PMC8145186 DOI: 10.1186/s13063-021-05301-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 04/28/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND AVATAR therapy is a novel intervention targeting distressing auditory verbal hallucinations (henceforth 'voices'). A digital simulation (avatar) of the voice is created and used in a three-way dialogue between participant, avatar and therapist. To date, therapy has been delivered over 6 sessions, comprising an initial phase, focusing on standing up to a hostile avatar, and a second phase in which the avatar concedes and focus shifts to individualised treatment targets, including beliefs about voices. The first fully powered randomised trial found AVATAR therapy resulted in a rapid and substantial fall in voice frequency and associated distress that was superior to supportive counselling at 12 weeks. The main objective of this AVATAR2 trial is to test the efficacy of two forms of AVATAR therapy in reducing voice-related distress: AVATAR-brief (standardised focus on exposure, assertiveness and self-esteem) and AVATAR-extended (phase 1 mirroring AVATAR-brief augmented by a formulation-driven phase 2). Secondary objectives include the examination of additional voice, wellbeing and mood outcomes, the exploration of mediators and moderators of therapy response, and examining cost-effectiveness of both forms of therapy compared with usual treatment (TAU). METHODS This multi-site parallel group randomised controlled trial will independently randomise 345 individuals to receive AVATAR-brief (6 sessions) plus TAU or AVATAR-extended (12 sessions) plus TAU or TAU alone (1:1:1 allocation). Participants will be people with a diagnosis of schizophrenia spectrum and other psychotic disorders who have heard distressing voices for more than 6 months. The primary outcome is the PSYRATS Auditory Hallucinations Distress dimension score at 16 and 28 weeks, conducted by blinded assessors. Statistical analysis will follow the intention-to-treat principle and data will be analysed using linear mixed models. Mediation and moderation analyses using contemporary causal inference methods will be conducted as secondary analyses. Service costs will be calculated, and cost-effectiveness assessed in terms of quality-adjusted life years accrued. DISCUSSION This study will clarify optimal therapy delivery, test efficacy in a multi-site study and enable the testing of the AVATAR software platform, therapy training and provision in NHS settings. TRIAL REGISTRATION ISRCTN registry ISRCTN55682735 . Registered on 22 January 2020. The trial is funded by the Wellcome Trust (WT).
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Affiliation(s)
- Philippa Garety
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Clementine J Edwards
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
- South London & Maudsley NHS Foundation Trust, London, UK.
| | - Thomas Ward
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Richard Emsley
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | | | - Mar Rus-Calafell
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
| | - Miriam Fornells-Ambrojo
- University College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Andrew Gumley
- University of Glasgow, Glasgow, UK
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Gillian Haddock
- University of Manchester and the Manchester Academic Health Sciences Centre, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust and the Manchester Academic Health Sciences Centre, Manchester, UK
| | - Sandra Bucci
- University of Manchester and the Manchester Academic Health Sciences Centre, Manchester, UK
- Greater Manchester Mental Health NHS Foundation Trust and the Manchester Academic Health Sciences Centre, Manchester, UK
| | - Hamish McLeod
- University of Glasgow, Glasgow, UK
- NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Amy Hardy
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Emmanuelle Peters
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | | | - Thomas Craig
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
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O'Brien C, Rus-Calafell M, Craig TK, Garety P, Ward T, Lister R, Fornells-Ambrojo M. Relating behaviours and therapeutic actions during AVATAR therapy dialogue: An observational study. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2021; 60:443-462. [PMID: 33949726 DOI: 10.1111/bjc.12296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 04/08/2021] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Conan O'Brien
- Research Department of Clinical, Educational and Health Psychology, University College London, UK.,East London NHS Foundation Trust, London, UK
| | - Mar Rus-Calafell
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany.,Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Tom Kj Craig
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Philippa Garety
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK.,South London & Maudsley NHS Foundation Trust, UK
| | - Thomas Ward
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK.,South London & Maudsley NHS Foundation Trust, UK
| | - Rachel Lister
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | - Miriam Fornells-Ambrojo
- Research Department of Clinical, Educational and Health Psychology, University College London, UK.,North East London NHS Foundation Trust, UK
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Ward T, Lister R, Fornells-Ambrojo M, Rus-Calafell M, Edwards CJ, O'Brien C, Craig TKJ, Garety P. The role of characterisation in everyday voice engagement and AVATAR therapy dialogue. Psychol Med 2021; 52:1-8. [PMID: 33827728 PMCID: PMC9811344 DOI: 10.1017/s0033291721000659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 02/05/2021] [Accepted: 02/08/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Voices are commonly experienced as communication with a personified 'other' with ascribed attitudes, intentionality and personality (their own 'character'). Phenomenological work exploring voice characterisation informs a new wave of relational therapies. To date, no study has investigated the role of characterisation in behavioural engagement with voices or within psychological therapy for distressing voices. METHODS Baseline characterisation (the degree to which the voice is an identifiable and characterful entity) of the dominant voice was rated (high, medium or low) using a newly developed coding framework, for n = 60 people prior to starting AVATAR therapy. Associations between degree of characterisation and (i) everyday behavioural engagement with voices (The Beliefs about Voices Questionnaire-Revised; n = 60); and (ii) interaction within avatar dialogue [Session 4 Time in Conversation (participant-avatar); n = 45 therapy completers] were explored. RESULTS Thirty-three per cent reported high voice characterisation, 42% medium and 25% low. There was a significant association between characterisation and behavioural engagement [H(2) = 7.65, p = 0.022, ɛ2 = 0.130] and duration of participant-avatar conversation [F(2,42) = 6.483, p = 0.004, η2 = 0.236]. High characterisation was associated with increased behavioural engagement compared with medium (p = 0.004, r = 0.34; moderate effect) and low (p = 0.027, r = 0.25; small-moderate effect) with a similar pattern observed for the avatar dialogue [high v. medium: p = 0.008, Hedges' g = 1.02 (large effect); high v. low: p = 0.023, Hedges' g = 1.03 (large effect)]. No differences were observed between medium and low characterisation. DISCUSSION Complex voice characterisation is associated with how individuals interact with their voice(s) in and out of therapy. Clinical implications and future directions for AVATAR therapy and other relational therapies are discussed.
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Affiliation(s)
- Thomas Ward
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Rachel Lister
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Miriam Fornells-Ambrojo
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Mar Rus-Calafell
- Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-Universität Bochum, Bochum, Germany
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Clementine J. Edwards
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Conan O'Brien
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Tom KJ Craig
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Philippa Garety
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- South London & Maudsley NHS Foundation Trust, London, UK
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