No abstract

The gold-standard cognitive–behavioral therapy (CBT) for psychosis offers at best modest effects. With advances in technology, virtual reality (VR) therapies for auditory verbal hallucinations (AVH), such as AVATAR therapy (AT) and VR-assisted therapy (VRT), are amid a new wave of relational approaches that may heighten effects. Prior trials have shown greater effects of these therapies on AVH up to a 24-week follow-up. However, no trial has compared them to a recommended active treatment with a 1-year follow-up. We performed a pilot randomized comparative trial evaluating the short- and long-term efficacy of VRT over CBT for patients with treatment-resistant schizophrenia. Patients were randomized to VRT (n = 37) or CBT (n = 37). Clinical assessments were administered before and after each intervention and at follow-up periods up to 12 months. Between and within-group changes in psychiatric symptoms were assessed using linear mixed-effects models. Short-term findings showed that both interventions produced significant improvements in AVH severity and depressive symptoms. Although results did not show a statistically significant superiority of VRT over CBT for AVH, VRT did achieve larger effects particularly on overall AVH (d = 1.080 for VRT and d = 0.555 for CBT). Furthermore, results suggested a superiority of VRT over CBT on affective symptoms. VRT also showed significant results on persecutory beliefs and quality of life. Effects were maintained up to the 1-year follow-up. VRT highlights the future of patient-tailored approaches that may show benefits over generic CBT for voices. A fully powered single-blind randomized controlled trial comparing VRT to CBT is underway.

Objective: Because the therapeutic processes of Avatar Therapy remain equivocal, the current study aims to further extend our previous findings by analysing the evolution of the avatars' and patients' speech and changes in patient responses as sessions progressed.Design: Eighteen patients with treatment-resistant schizophrenia were selected from two clinical trials on Avatar Therapy. Three coders analysed both the avatars' and patients' discourse during immersive therapy sessions using content analysis methods.Results: Our analyses enabled the categorization of the avatar discourse into confrontational techniques (e.g., provocation) and positive techniques (e.g., reinforcement). Patients responded to these utterances using coping mechanism or by expressing emotions, beliefs, self-perceptions or aspirations. Through identification of mutual changes in the interaction between the patient and their avatar, a shift was observed over the sessions from confrontation to a constructive dialogue.Assertiveness, emotional responses and prevention strategies seemed to be central to the therapeutic process, and these usually occur in response to positive techniques. Conclusion:Investigating AT's therapeutic process may help to identify components to achieve positive outcomes and can enable the development of more effective treatments. Further studies should explore the association between these themes and therapeutic response to help predict which patients will better respond to Avatar Therapy.

Auditory verbal hallucinations are hallmark symptoms of schizophrenia and are amongst the most disturbing symptoms of the disorder. Although not entirely understood, the relationship between the voice hearer and their voices has been shown to be an important treatment target. Understanding voice hearers' standpoints through qualitative analysis is central to apprehend a deeper comprehension of their experience and further explore the relevance of interpersonal interventions. Compared with other dialogical intervention, virtual reality-assisted therapy (Avatar Therapy) enables patients to be in a tangible relation with a representation of their persecutory voice. This novel therapy has shown favourable results, though the therapeutic processes remain equivocal. We consequently sought to begin by characterizing the main themes emerging during the therapy by exploring the hearer's discussion with their avatar. The therapy sessions of 12 of our referrals were transcribed, and the patients' responses were analysed using content analysis methods. Five themes emerged from data saturation: emotional responses to the voices, beliefs about voices and schizophrenia, self-perceptions, coping mechanisms, and aspirations. All patients had at least one element within each of these themes. Our analyses also enabled us to identify changes that were either verbalized by the patients or noted by the raters throughout therapy sessions. These findings are relevant as they allowed to identify key themes that are hypothesized to be related to therapeutic targets in a novel relational therapy using virtual reality. Future studies to further explore the processes implicated within Avatar Therapy are necessary.

Background: Combining cognitive behavioral therapy (CBT) for psychosis with another psychosocial intervention comprising virtual reality (VR)-assisted therapy (VRT) may improve targeted outcomes in treatment-resistant schizophrenia patients. Methods: Ten participants having followed CBT were part of our comparative clinical trial comparing VRT to CBT and were selected at the end of the study as they desired to continue to achieve improvements with VRT (CBT + VRT). Clinical assessments were administered before/after treatments and at follow-ups. Changes in outcomes were examined using linear mixed-effects models. To gain a more in depth understanding on CBT + VRT, therapists’ notes, and open interviews on a sub-group of patients were qualitatively analyzed. Results: Findings showed that the sequence of both interventions was appreciated by all patients. Several significant improvements were found throughout time points on auditory verbal hallucinations, beliefs about voices, depressive symptoms, symptoms of schizophrenia and quality of life. Although most of these improvements were in similar range to those observed in our comparative trial, effects of CBT + VRT on depressive symptoms and symptoms of schizophrenia were larger than those found for either intervention alone. Conclusion: This proof of concept is the first to merge gold-standard CBT with VRT for treatment refractory voices and to suggest a certain synergistic effect.