A novel treatment using computer-generated avatars, developed by UCL researchers, is an effective way of helping people with psychosis who hear distressing voices, according to a new study.
AVATAR therapy is a series of guided therapy sessions during which voice hearers are able to have a conversation with an animated digital representation of their distressing voice. The research, published in Nature Medicine and led by King's College London researchers, found that AVATAR therapy is an effective means of helping participants to feel less distressed by the voice and more empowered in daily life.
Before the therapy, participants work with a therapist to create a computerised visual representation of the voice that they hear (the avatar). Therapy involves a three-way conversation between the voice hearer, therapist and avatar, with the therapist speaking as themselves as well as voicing the avatar using voice conversion software. Over several sessions, participants learn to stand up to the voice and take control.
The therapy was first created by the late Professor Julian Leff at UCL, and the voice conversion system was built by Emeritus Professor Mark Huckvale (UCL Psychology & Language Sciences). AVATAR therapy's development was supported with patent filings by UCL Business, and the researchers continued to refine it in a collaboration with King's College London, supported by Wellcome.
Professor Huckvale said: "The results of this trial confirm the value of AVATAR therapy for the reduction in the frequency and the distress of persecutory voices in psychosis, and open the door to providing the therapy within clinical practice."
The researchers recruited 345 participants from eight clinical settings in four centres linked to the Universities of Glasgow, Manchester, UCL and King's. They were randomly assigned to receive either AVATAR Brief (six sessions of therapy), AVATAR Extended (12 sessions of more personalised therapy), or continue with their usual support. The researchers conducted follow up interviews at the end of therapy (16 weeks) and three months after therapy concluded (28 weeks) to assess the effectiveness of the intervention across several measures, investigating the long-term impact on the related distress, severity and frequency of voices, as well as participant mood and wellbeing.
Researchers found that, at the 16-week follow-up, participants in both the Brief and Extended versions of the therapy showed statistically significant improvements in voice-related distress, voice severity, empowerment, mood and wellbeing compared to those who did not receive the therapy. Participants who received AVATAR Extended also saw a reduction in the frequency of distressing voices.
While AVATAR's effects on distress did not differ significantly at the 28-week mark, compared to those receiving their usual support, researchers did find that AVATAR Extended was an effective means of reducing the frequency of distressing voices and increasing participants' empowerment and wellbeing over the longer-term.
Professor Emerita Philippa Garety (King's College London Institute of Psychiatry, Psychology and Neuroscience) and the study's lead author, said: "People who hear voices rarely only hear one. In an interesting development, the Extended version of the therapy proved effective at reducing voice frequency in total, despite participants only creating one avatar for one voice.
"To our knowledge, this is the first therapeutic intervention that has a direct and sustained impact upon the frequency with which people hear voices. This is an extremely important finding, as it is a clear priority for voice hearers, and hearing fewer voices, less often, or voices going away altogether can have a hugely positive impact on their day-to-day lives."
Nick, a former trial participant, said: "I was hearing 40 to 50 abusive voices a day. With the help of AVATAR therapy, that went down to four or five. I felt like I was taking back control of my life."
The research team are now investigating how AVATAR therapy could be rolled out across England, as well as conducting further research with mental health teams across the world. In March 2024, the National Institute for Health and Care Excellence (NICE) conducted an Early Value Assessment (EVA) for medical technology and have since recommended the therapy be used in the NHS while researchers continue evaluation.
Dr Thomas Ward, Research Clinical Psychologist at King's IoPPN, Clinical Lead for AVATAR therapy and one of the study's co-senior authors, said: "Our latest findings have demonstrated the effectiveness and feasibility of AVATAR therapy across multiple sites. With these results and the NICE Early Value Assessment recommendation, we hope to see AVATAR therapy available in several NHS Trusts in 2025."
Professor Miranda Wolpert, Director of Mental Health at Wellcome and Professor of Evidence Based Practice and Research at UCL, commented: "It is very exciting to see the emergence of a powerful new digital therapy that could be life changing for people who hear voices. This study builds on more than a decade of pioneering research. AVATAR therapy has been shown to reduce the distress people experience from auditory hallucinations and the frequency with which they hear them. This is a striking example of how mental health science can drive forward cutting-edge treatments, providing new ways to intervene early to help improve and resolve symptoms."
This research was possible thanks to funding from Wellcome, with support provided by the National Institute of Health and Care Research (NIHR) Maudsley Biomedical Research Centre (BRC), NIHR Manchester BRC and NHS Research Scotland.
