The Role of Sense of Voice Presence and Anxiety Reduction in AVATAR Therapy

Abstract

AVATAR therapy offers a unique therapeutic context that uses virtual reality technology to create a virtual embodiment of the voice-hearing experience, enabling the person to visualize their persecutory voice and engage in real-time “face-to-face” dialogue. The present study explores, for the first time, the contribution of sense of voice presence, together with session-by-session reduction of anxiety and paranoid attributions about the avatar, to changes in primary outcomes following AVATAR therapy. Data from 39 participants, who completed AVATAR therapy and attended a 12-week follow-up assessment, were analysed. Mid- to high-levels of sense of voice presence were reported across the therapy sessions, along with significant reductions of anxiety levels and paranoid attributions about the avatar. The interaction of sense of voice presence and reduction of anxiety was associated with two of the significant therapy outcomes: PSYRATS total and frequency of voices. The findings suggest that improvements in voice severity and frequency at post AVATAR therapy may be influenced by the combination of feeling less anxious in the context of a realistic simulation of the voice, while voice-related distress may involve additional cognitive and relational processes.

The role of characterisation in everyday voice engagement and AVATAR therapy dialogue

“…Clearly a crucial question is whether the influence of voice characterisation on engagement in AVATAR dialogue leads to improvement in the actual distressing voices. Rus-Calafell et al (2020) have demonstrated that the interaction between sense of voice presence (i.e. virtual embodiment of the 'voice as avatar') and reduction of anxiety predicted improvement in two of the Psychological Medicine 5 significant AVATAR therapy outcomes: PSYRATS (Haddock, McCarron, Tarrier, & Faragher, 1999) total and frequency of voices.…”

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

“…Distressing voices are typically characterized by negative content and affective consequences (Beavan & Read, 2010; Close & Garety, 1998; Nayani & David, 1996). AVATAR therapy provides a realistic simulation of the persecutor’s voice heard by the person during everyday life, which seems to be crucial to important therapy outcomes (Rus‐Calafell et al., 2020). Although direct use of abusive verbatim voice content presents challenges, accurately representing voice content provides an opportunity for validation of experiences and may facilitate habituation (Rus‐Calafell et al., 2020; Ward et al., 2020).…”

Optimising AVATAR therapy for people who hear distressing voices: study protocol for the AVATAR2 multi-centre randomised controlled trial

“…Delivery of AVATAR Therapy in this recent trial resulted in an evolution in our understanding of the core therapy processes and how these might, in principle, differ between a standardised phase 1 focusing on exposure and assertiveness, and a formulation-driven phase 2 incorporating a broader range of treatment targets [ 14 ]. Data from the previous trial suggest that anxiety reduction is especially prominent during phase 1, but that other processes during phase 2, including changes in the perceived omnipotence and malevolence of the voice, may contribute to improved treatment outcomes, at least for some participants [ 17 ]. The new trial develops these insights and aims to make progress towards increased availability of AVATAR therapy in routine mental health care.…”

“…As described above, AVATAR therapy as delivered in the previous trial comprises two phases. The trial therapists noted that phase 1 in itself was a powerful intervention for a sizeable number of people, which was supported by evidence within the AVATAR therapy arm of significant anxiety reduction during sessions 1–3 [ 17 ]. On the other hand, for some people, anxiety reduction alone may be insufficient to produce optimally effective lasting change, and therefore an approach including both phases may be necessary (see the ‘ Introduction ’ section).…”

“…Whilst sense of voice presence remained consistently high across all sessions, there was a significant reduction in anxiety which was driven by a rapid change during sessions 1–3 (phase 1). Notably, improvements in voice frequency and overall severity at follow-up were predicted by an interaction between overall anxiety reduction and sense of voice presence [ 17 ]. Allied to clinical reports of significant early improvements [ 14 ], this raises the question as to whether a consistent phase 1 focus on exposure and assertiveness to a valid representation of the voice might be sufficient for some individuals; for example, where distress is closely linked to fear, anxiety and relational submissiveness.…”