Exploration of the dialogue components in Avatar Therapy for schizophrenia patients with refractory auditory hallucinations: A content analysis

Abstract

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.

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“…Similar to the Avatar Project, virtual reality–assisted therapy for schizophrenia often encourages patients to engage with the voices they hear through the use of an AI avatar. Initial studies found that the therapy could help in developing therapeutic targets [24] and also in particularly difficult cases of schizophrenia [25]. Another study found improvements in auditory visual hallucinations, symptoms of depression, and overall quality of life following therapy sessions for treatment-resistant schizophrenia patients [26].…”

One-year randomized trial comparing virtual reality-assisted therapy to cognitive–behavioral therapy for patients with treatment-resistant schizophrenia

“…The therapy may therefore help reduce cognitive avoidance of fear-relevant information (i.e., the voice and its content) and reduce anxiety as a result of exposure 61,62 . A usual therapy experience for patients who engage with the approach generally involves some early anxiety followed by a reported sense of relief, achievement, power, and liberation 56,63,64 . It has been speculated that distressing AVH with negative content may directly impact mood, and low mood may in turn make a patient more vulnerable to further AVH 65 .…”

“…Although this study was not conducted with the aim of further understanding the therapeutic elements of the interventions, future research should aim to understand the components of psychotherapies that leads to efficacy over simply conducting efficacy trials. There is indeed emerging work into understanding the therapeutic components that lead to AT's and VRT's large efficacy on AVH and other facets of the illness 63,64 . More research is necessary to establish which components of AT/VRT make it efficacious and to determine which patients may respond better to the intervention.…”

Exploring the Benefits of Virtual Reality-Assisted Therapy Following Cognitive-Behavioral Therapy for Auditory Hallucinations in Patients with Treatment-Resistant Schizophrenia: A Proof of Concept

“…Higher order themes were in line with key therapeutic processes of the interventions. For CBT, these themes were based on the topics discussed during the intervention (e.g., normalization of voices, coping strategies) and for VRT, the themes were based on prior qualitative analyses (e.g., emotion regulation, self-perceptions) [ 34 , 35 ].…”

“…On the other hand, VRT is among a newer wave of dialogical approaches that aim to ameliorate the voice-hearer relationship by encouraging assertive interactions with voices and by negotiating new ways of relating. VRT focusses on repetitive practice in real-time in an emotional-inducing VR environment where patients may dialogue with their distressing voices [ 28 , 29 , 30 , 34 , 35 ]. Although these two therapies overlap in common practice, to our knowledge, no one has integrated both these models to draw on their strengths.…”