The Hearing Voices challenge
Psychotic conditions such as schizophrenia affect approximately 1.5% of people over the age of 18. Many sufferers are tormented by auditory hallucinations (‘voices’) that are abusive, persecutory or command them to harm themselves and other people. Yet despite drug and psychological treatments, these persecutory experiences persist for many years in up to a third of sufferers, with profound impact on their ability to work, maintain relationships and manage everyday living tasks.
AVATAR therapy: a promising new approach
AVATAR therapy was first created by Julian Leff and Mark Huckvale at University College London (UCL) and was further developed through collaboration with King’s College London (KCL) with the support of the Wellcome Trust. In AVATAR therapy, computer software is used to create a visual and auditory representation (‘avatar’) of the hallucinated voice. The client sits in front of a computer on which the avatar appears while the therapist, sitting apart from the client, speaks as him/herself or as the avatar (using software to transform the sound of his speech) encouraging the voice hearer to enter into a dialogue with the avatar. Over 7 sessions the therapist shapes this dialogue in response to the client’s efforts. The power of AVATAR was shown by a marked reduction in the frequency of hallucinations and reductions in distress in a small pilot study. These striking results were then replicated in a fully powered randomized controlled trial at KCL funded by the Wellcome Trust which compared AVATAR therapy to supportive counselling among people who had experienced unremitting voices for at least a year despite adequate medical treatment. This study showed statistically and clinically significant benefit that was substantially greater than that obtained by the existing gold-standard cognitive behavioural therapy for psychosis.
AVATAR therapy is a step change in the treatment of a particularly pernicious symptom of psychosis. It is also eminently scalable. The equipment is modest (a laptop, a headset and a tablet connected to the internet) and can be delivered by the existing workforce. In our current clinical trial which explores the cost-effectiveness of brief and extended delivery of the therapy we have successfully trained psychologists, psychiatrists and nurses and further developed the system to enable remote therapy during Covid-19 lockdown. Thus we can readily envisage the therapy being a routine provision within specialist psychosis services including early intervention.
Therapists have been trained
Voice Hearers have received therapy
Therapy sessions have been completed
Information for Therapists
What is the Avatar Therapy product?
The Avatar Therapy software facilitates Avatar Therapy through the provision of a computer-generated and animated avatar (an artificial 3D computer graphics persona) that can be customised by the client and used in a dialogue between therapist and client. The avatar is created by the therapist and client together in an initial enrolment session. The face and voice of the avatar can be chosen from a range of pre-existing models, or can be manipulated using software controls. The customised avatar is then stored as a combination of a voice transform and a 3D head model to be used in subsequent therapy sessions. The Avatar Therapy system manages the enrolment of avatars and the delivery of therapy sessions and keeps records of accounts, users and clients in a central database. Avatar Therapy Ltd will partner with clinical sites to deliver training courses for therapists to make the best use of Avatar Therapy.
What is an Avatar Therapy session?
During a therapy session, the avatar system runs on two computers in two separate locations communicating through a computer network. The therapist operates one copy of the system and can speak through the system to the client at the other location. The therapist can speak to the client in their normal voice or in the chosen avatar voice which is a modified version of their normal voice. In another location, which may be local or remote, the client can see the avatar and can hear the therapist’s voice or the chosen avatar voice. When the clinician is speaking in the modified voice the mouth movements of the avatar are synchronized to the converted speech to create the illusion that it is the avatar speaking. The speech of the client and the image of the client are also communicated back through the system to the therapist. After each session, a recording of the dialogue between therapist, client and avatar can be provided to the client so that they can listen again to the conversation outside the therapy session (using for example, a personal music player).
How does Avatar Therapy help the Voice Hearer?
Within the AVATAR therapy approach, the person’s relationship with their voice is viewed in the context of their current and previous significant relationships. The possible role of early trauma is sensitively addressed from the first meeting and unresolved social and emotional issues that may be relevant to the person’s experience of voice hearing are considered throughout the therapy. The nature of the relationship with voice as it varies along dimensions of interpersonal power and proximity also influences the evolving dialogue. While all AVATAR dialogues (particularly early sessions) involve negotiation of a transfer of power and control from voice/avatar to hearer, voice relationships characterized by a withdrawal by the hearer require an initial “turning to face” the previously avoided experience, while relationships in which the hearer clings to the voice typically necessitate a process of disengagement. Following the initial assertiveness phase, the avatar’s character gradually changes to become conciliatory or even helpful. This initiates a second phase which focuses on issues of self-esteem and identity, work that is consistent with other recent approaches emphasizing the importance of self-esteem and self-compassion in working with distressing voices. [text adapted from Craig et al 2016]
Information for Voice Hearers
AVATAR therapy offers a new approach to working with distressing voices (auditory hallucinations). It involves innovative use of digital technology to allow ‘face-to-face’ dialogue between the voice-hearer and a computerised representation of their voice (the avatar), with a therapeutic focus on increasing power and control over the voice.
The digital technology allows us to bring the person’s experience of hearing the voice into therapy in a new and potentially powerful way. Listen to one voice hearer's experience of Avatar Therapy.
For more general information about hearing voices, the Understanding Voices website contains over 100 pages of information on different ways of understanding voices and supporting those who are struggling to cope with their experiences.
Avatar Therapy was invented by Julian Leff (1938-2021) at University College London.
The current team are honoured to have worked with Julian to realise his vision for a new therapy for persecutory voices.
Mark is Emeritus Professor of Speech Science in the Division of Psychology and Language Sciences at UCL. He designed the original software for supporting avatar therapy and continues to develop and support the computing and business sides of AVATAR.
CEO Avatar Therapy Ltd
Tom is Emeritus Professor of Social Psychiatry at the IoPPN at Kings College London whose research and clinical career has been dedicated to improving the care of people with severe mental illness. Tom was principal investigator for the AVATAR1 clinical trial
Philippa is Professor of Clinical Psychology at the IoPPN at Kings College London and researches digitally supported psychological treatments for psychosis. Philippa is principal investigator for the AVATAR2 clinical trial
Sam is principal consultant and director of SQMS Ltd, and works with medical device start-ups, helping them to create and implement their Quality Management System in accordance with the requirements of ISO 13485, associated standards and regulations. With over 30 years experience in quality and regulatory compliance across many different types of medical device, Sam now specialises in Software as a Medical Device (SaMD) products.
Consultant on Medical Device Regulations
Avatar Therapy Ltd is grateful for the support of the following organisations:
AVATAR therapy is funded by Wellcome
Wellcome supports science to solve the urgent health challenges facing everyone. We support discovery research into life, health and wellbeing and we are taking on three worldwide health challenges: mental health, infectious disease and climate and health.
AVATAR therapy Ltd was supported by the SimDH accelerator programme for health technology
SimDH is co-funded by London South Bank University and the European Regional Development Fund.
University College London
UCL Psychology and Language Sciences
Kings College London
KCL Institute of Psychiatry, Psychology & Neuroscience
Frequently Asked Questions
If you have a question about Avatar Therapy you would like answered here, email firstname.lastname@example.org.
When will Avatar Therapy be ready for general use?
Avatar Therapy is being evaluated within a multi-centre clinical trial funded by the Wellcome Trust which will end in the Summer of 2023. Details of this trial can be found at avatartherapytrial.com.
Once the results of that trial are complete, and the therapy shown to be safe and effective, the therapy will start to be available at a number of specialist centres in the U.K.
What computer hardware is needed to deliver Avatar Therapy?
The Avatar Therapy software is an internet application that only requires a web browser to use. To run an avatar session, the therapist needs to have a desktop or laptop computer equipped with a headset and a webcam. To take part in an avatar session, the client needs to have a device suitable for taking part in a video call, for example a laptop or tablet. Connection between the two participants can be performed with any video conferencing software that can share screens, for example Zoom or Teams.
If you have questions about Avatar Therapy, please contact us on the links below.
Please note that we are unable to give advice to voice hearers on obtaining therapy.
If you are a clinician interested in receiving training in the delivery of Avatar Therapy to your clients, please complete the contact form below and we will send you details about training courses when these are available.