Publications about Avatar Therapy

These are papers by the Avatar Therapy team. Click here for publications by other authors.


  • Leff, J., Williams, G., Huckvale, M., Arbuthnot, M., & Leff, A. P. (2013). Silencing voices: a proof-of-concept study of computer-assisted therapy for medication-resistant auditory hallucinations. British Journal of Psychiatry. View Abstract
  • Background One in four patients with schizophrenia responds poorly to antipsychotic medication, continuing to hear persecutory auditory hallucinations. Patients who are able to sustain a dialogue with their persecutor feel much more in control. Aims To develop a computerised system that enables the patient to create an avatar of their persecutor. To encourage them to engage in a dialogue with the avatar, which the therapist is able to control so that the avatar progressively yields control to the patient. Method Avatar therapy was evaluated by a randomised, single blind, partial crossover trial comparing the novel therapy with treatment as usual (TAU). We used three main outcome measures: (a) the Psychotic Symptom Rating Scale (PSYRATS), hallucinations section; (b) the Omnipotence and Malevolence subscales of the Revised Beliefs About Voices Questionnaire (BAVQ-R); and (c) the Calgary Depression Scale (CDS). Results The control group showed no change over time in their scores on the three assessments, whereasthe novel therapy group showed mean reductions in the total PSYRATS score (auditory hallucinations) of 8.75 (P = 0.003) and in the BAVQ-R combined score of omnipotence and malevolence of the voices of 5.88 (P = 0.004). There was no significant reduction in the CDS total score for depression. For the crossover control group, comparison of the period of TAU withthe period ofavatar therapy confirmed the findings of the previous analysis. The effect size of the therapy was 0.8. Conclusions Avatar therapy represents a promising treatment for medication-resistant auditory hallucinations. Replication with a larger sample is required before roll-out to clinical settings.
  • Huckvale, M., Leff, J., & Williams, G., (2013) Avatar Therapy: an audio-visual dialogue system for treating auditory hallucinations, Interspeech 2013, Lyon, France. View Abstract
  • This paper presents a radical new therapy for persecutory auditory hallucinations (“voices”) which are most commonly found in serious mental illnesses such as schizophrenia. In around 30% of patients these symptoms are not alleviated by anti-psychotic medication. This work is designed to tackle the problem created by the inaccessibility of the patients' experience of voices to the clinician. Patients are invited to create an external representation of their dominant voice hallucination using computer speech a technology. Customised graphics software is used to create an avatar that gives a face to the voice, while voice morphing software realises it in audio, in real time. The therapist then conducts a dialogue between the avatar and the patient, w view to gradually bringing the avatar, and ultimately the hallucinatory voice, under the patient’s control. Results of a pilot study reported elsewhere indicate that the approach has potential for dramatic improvements in patient voices after a series of only six short sessions this paper is on the audio-visual speech technology which delivers the central aspects of the therapy.


  • Leff, J., Williams, G., Huckvale, M., Arbuthnot, M., & Leff, A. P. (2014). Avatar Therapy for persecutory auditory hallucinations: What is it and how does it work?. Psychosis: Psychological, Social and Integrative Approaches. View Abstract
  • We have developed a novel therapy based on a computer program, which enables the patient to create an avatar of the entity, human or non-human, which they believe is persecuting them. The therapist encourages the patient to enter into a dialogue with their avatar, and is able to use the program to change the avatar so that it comes under the patient’s control over the course of six 30-min sessions and alters from being abusive to becoming friendly and supportive. The therapy was evaluated in a randomised controlled trial with a partial crossover design. One group went straight into the therapy arm: “immediate therapy”. The other continued with standard clinical care for 7 weeks then crossed over into Avatar therapy: “delayed therapy”. There was a significant reduction in the frequency and intensity of the voices and in their omnipotence and malevolence. Several individuals had a dramatic response, their voices ceasing completely after a few sessions of the therapy. The average effect size of the therapy was 0.8. We discuss the possible psychological mechanisms for the success of Avatar therapy and the implications for the origins of persecutory voices.


  • Craig, T., Rus-Calafel, M., Ward, T., Fornells-Ambrojo, M., mcCrone, P., Emsley, R., Garety, P. (2015). The effects of an Audio Visual Assisted Therapy Aid for Refractory auditory hallucinations (AVATAR therapy): study protocol for a randomised controlled trial. Trials (2015) 16:349. View Abstract
  • Background Psychological interventions which adopt an explicitly interpersonal approach are a recent development in the treatment of distressing voices. AVATAR therapy is one such approach which creates a direct dialogue between a voice-hearer and a computerised representation of their persecutory voice (the avatar) through which the person may be supported to gain a sense of greater power and control. The main objective of the trial is to test the clinical efficacy of this therapy to reduce the frequency and severity of auditory verbal hallucinations (AVH). Secondary objectives of the study are to explore explanatory mechanisms of action and potential moderators, to carry out a qualitative evaluation of participants’ experience and to conduct an economic evaluation. Methods/Design The AVATAR randomised clinical trial will independently randomise 142 participants to receive either 7 sessions of AVATAR therapy or supportive counselling (SC). The study population will be individuals with schizophrenia spectrum and other psychotic disorders who report hearing persistent distressing voices, for more than 12 months, which are unresponsive or only partially responsive to antipsychotic medication. The main hypotheses are that, compared to SC, AVATAR therapy will reduce the frequency and severity of AVH and will also reduce the reported omnipotence and malevolence of these voices. Assessments will occur at 0 weeks (baseline), 12 weeks (post-intervention) and 24 weeks (follow-up), and will be carried out by blinded assessors. Both interventions will be delivered in a community-based mental health centre. Therapy competence and adherence will be monitored in both groups. Statistical analysis will follow the intention-to-treat principle and data will be analysed using a mixed (random) effects model at each post treatment time point separately. A formal mediation and moderator analysis using contemporary causal inference methods will be conducted as a secondary analysis. The trial is funded by the Welcome Trust (WT). Discussion AVATAR therapy showed promising effects in a pilot study, but the efficacy of the approach needs to be examined in a larger randomised clinical trial before wider dissemination and implementation in mental health services.
  • Rus-Calafell M, Garety P, Ward T, Williams G, Huckvale M, Leff J, Craig TK., "Confronting Auditory Hallucinations Using Virtual Reality: The Avatar Therapy", Stud Health Technol Inform. 2015;219:192-6. [PMID:26799906] View Abstract
  • The AVATAR therapy is a computer-based intervention which aims to reduce the frequency and severity of voices. The approach is based on computer technology which enables each patient to create an avatar of the entity (human or non-human) that they believe is talking to them. The therapist promotes a dialogue between the patient and the avatar in which the avatar progressively comes under the patient's control. Using real-time voice conversion delivery software, the therapist can modify the relationship between the patient and his/her voice. The innovation of this new intervention is discussed in the present paper as well as the advantages of using a computer based system. The subjective view of the technology from a participant's point of view is also presented.


  • Craig T, Ward T, Rus-Calafell M., "AVATAR Therapy for Refractory Auditory Hallucinations", In: Pradhan B, Pinninti N, Rathod S, editors. Brief Interventions for Psychosis: A Clinical Compendium. London: Springer; 2016. Chapter 4. [PMID:27386617] View Abstract
  • While attempts to understand voice hearing need to acknowledge the complexity and diversity of the experience (Woods et al. 2014), the majority of hearers describe voices that take the form of a characterized “other” with whom a personally meaningful relationship develops (Beavan 2011); McCarthy-Jones et al. 2014). AVATAR therapy is part of a new and exciting wave of therapies which adopt an explicitly relational and dialogic approach to working with the distressing voices. To understand the AVATAR approach, it is important to consider its position in the evolution of psychological interventions for distressing voices.


  • Craig, T., Rus-Calafell, M., Ward, T., Leff, J., Huckvale, M., Howarth, E., Emsley, R., Garety, P. (2018). AVATAR therapy for auditory verbal hallucinations in people with psychosis: a single-blind, randomised controlled trial. The Lancet Psychiatry 5 p31-40. View Abstract
  • Background A quarter of people with psychotic conditions experience persistent auditory verbal hallucinations, despite treatment. AVATAR therapy (invented by Julian Leff in 2008) is a new approach in which people who hear voices have a dialogue with a digital representation (avatar) of their presumed persecutor, voiced by the therapist so that the avatar responds by becoming less hostile and concedes power over the course of therapy. We aimed to investigate the effect of AVATAR therapy on auditory verbal hallucinations, compared with a supportive counselling control condition. Methods We did this single-blind, randomised controlled trial at a single clinical location (South London and Maudsley NHS Trust). Participants were aged 18 to 65 years, had a clinical diagnosis of a schizophrenia spectrum (ICD10 F20–29) or affective disorder (F30–39 with psychotic symptoms), and had enduring auditory verbal hallucinations during the previous 12 months, despite continued treatment. Participants were randomly assigned (1:1) to receive AVATAR therapy or supportive counselling with randomised permuted blocks (block size randomly varying between two and six). Assessments were done at baseline, 12 weeks, and 24 weeks, by research assessors who were masked to therapy allocation. The primary outcome was reduction in auditory verbal hallucinations at 12 weeks, measured by total score on the Psychotic Symptoms Rating Scales Auditory Hallucinations (PSYRATS–AH). Analysis was by intention-to-treat with linear mixed models. The trial was prospectively registered with the ISRCTN registry, number 65314790. Findings Between Nov 1, 2013, and Jan 28, 2016, 394 people were referred to the study, of whom 369 were assessed for eligibility. Of these people, 150 were eligible and were randomly assigned to receive either AVATAR therapy (n=75) or supportive counselling (n=75). 124 (83%) met the primary outcome. The reduction in PSYRATS–AH total score at 12 weeks was significantly greater for AVATAR therapy than for supportive counselling (mean difference −3·82 [SE 1·47], 95% CI −6·70 to −0·94; p<0·0093). There was no evidence of any adverse events attributable to either therapy. Interpretation To our knowledge, this is the first powered, randomised controlled trial of AVATAR therapy. This brief, targeted therapy was more effective after 12 weeks of treatment than was supportive counselling in reducing the severity of persistent auditory verbal hallucinations, with a large effect size. Future multi-centre studies are needed to establish the effectiveness of AVATAR therapy and, if proven effective, we think it should become an option in the psychological treatment of auditory verbal hallucinations.
  • Hall, J, Rus-Calafell, M, Omari-Asor, L, Ward, T, Emsley, R, Garety, P & Craig, TKJ. (2018) Assessing the subjective experience of participating in a clinical trial (AVATAR). Psychiatry Research, vol. 263, pp. 82-87. View Abstract
  • This study assessed the subjective experience of participating in a clinical trial, specifically positive and negative experiences and the experience of audio recording assessment sessions. The study was cross-sectional from a single blinded randomised controlled trial. Forty participants with a primary diagnosis of non-organic psychosis completed baseline and 12-week follow-up questionnaires assessing their experiences. Participants rated research interviews as moderately helpful in facilitating their therapy and talking to the interviewer as moderately helpful at baseline and 12-week follow-up. Self-report ratings of the degree of self-realisation promoted by the research questionnaires were significantly higher at 12-week follow-up compared to baseline. Participants adjusted quickly to being audio recorded and rated interviews as not at all disruptive and not at all to slightly intrusive. On average there were neutral emotional reactions, positive gains and minimal inconveniences as a result of participation. The main reasons for taking part were: ‘To help myself’, ‘I was curious’ and ‘To help others’. The findings offer support to previous research reporting that individuals with mental health problems find participating in clinical trials a beneficial experience. This may alleviate concerns that participation in similar studies may be personally intrusive or harmful.


  • Ward T, Rus-Calafell M, Ramadhan Z, Soumelidou O, Fornells-Ambrojo M, Garety P, Craig TKJ. "AVATAR Therapy for Distressing Voices: A Comprehensive Account of Therapeutic Targets", Schizophr Bull. 2020 May 6;46(5):1038-44. doi: 10.1093/schbul/sbaa061. Online ahead of print. [PMID:32372082] View Abstract
  • AVATAR therapy represents an effective new way of working with distressing voices based on face-to-face dialogue between the person and a digital representation (avatar) of their persecutory voice. To date, there has been no complete account of AVATAR therapy delivery. This article presents, for the first time, the full range of therapeutic targets along with information on acceptability and potential side effects. Interest in the approach is growing rapidly and this report acts as a necessary touchstone for future development.
  • Rus-Calafell M, Ward T, Zhang XC, Edwards CJ, Garety P, Craig T., "The Role of Sense of Voice Presence and Anxiety Reduction in AVATAR Therapy" J Clin Med. 2020 Aug 25;9(9):2748. doi: 10.3390/jcm9092748. [PMID:32854387] View 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.


  • Garety, P., Edwards, C., Ward, T., Emsley, R., Huckvale, M., McCrone, P., Rus-Calafell, M., Fornells-Ambrojo, M., Gumley, A., Haddock, G., Bucci, S., McLeod, H., Hardy, A., Peters, E., Myin-Germeys, I., Craig, T. "Optimising AVATAR therapy for people who hear distressing voices. Study protocol for the AVATAR2 multi-centre randomised controlled trial", Trials, 2021. View Abstract
  • Background AVATAR therapy is a novel intervention targeting distressing auditory verbal hallucinations (henceforth ‘voices’). A digital simulation (avatar) of the voice is created and used in a three-way dialogue between participant, avatar and therapist. To date, therapy has been delivered over 6 sessions, comprising an initial phase, focusing on standing up to a hostile avatar, and a second phase in which the avatar concedes and focus shifts to individualised treatment targets, including beliefs about voices. The first fully powered randomised trial found AVATAR therapy resulted in a rapid and substantial fall in voice frequency and associated distress that was superior to supportive counselling at 12 weeks. The main objective of this AVATAR2 trial is to test the efficacy of two forms of AVATAR therapy in reducing voice-related distress: AVATAR-brief (standardised focus on exposure, assertiveness and self-esteem) and AVATAR-extended (phase 1 mirroring AVATAR-brief augmented by a formulation-driven phase 2). Secondary objectives include the examination of additional voice, wellbeing and mood outcomes, the exploration of mediators and moderators of therapy response, and examining cost-effectiveness of both forms of therapy compared with usual treatment (TAU). Methods This multi-site parallel group randomised controlled trial will independently randomise 345 individuals to receive AVATAR-brief (6 sessions) plus TAU or AVATAR-extended (12 sessions) plus TAU or TAU alone (1:1:1 allocation). Participants will be people with a diagnosis of schizophrenia spectrum and other psychotic disorders who have heard distressing voices for more than 6 months. The primary outcome is the PSYRATS Auditory Hallucinations Distress dimension score at 16 and 28 weeks, conducted by blinded assessors. Statistical analysis will follow the intention-to-treat principle and data will be analysed using linear mixed models. Mediation and moderation analyses using contemporary causal inference methods will be conducted as secondary analyses. Service costs will be calculated, and cost-effectiveness assessed in terms of quality-adjusted life years accrued. Discussion This study will clarify optimal therapy delivery, test efficacy in a multi-site study and enable the testing of the AVATAR software platform, therapy training and provision in NHS settings.


  • Rus-Calafell, M., Ehrbar, N., Ward, T., Edwards, C., Huckvale, M., Walke, J., Garety, P., Craig, T., Participants' experiences of AVATAR therapy for distressing voices: a thematic qualitative evaluation, BMC Psychiatry (2022) 22:356. View Abstract
  • Background: AVATAR therapy is an innovative therapy designed to support people with distressing voices. Voice hearers co-create a digital representation of their voice and engage in dialogue with it. Although it has been successfully tested in a powered randomised controlled trial (ISRCTN65314790), the participants’ experience of this therapy has not been yet evaluated. We aimed to explore enablers and barriers to engagement with the therapy and potential for real-world impact on distressing voices. Methods: Thirty per cent of those who completed AVATAR therapy (15 people in total) and 5 who dropped out from therapy within the main AVATAR RCT were invited to participate in a semi-structured interview, which was audio-recorded and subsequently transcribed. Results: Fourteen therapy completers (28% of the full sample) and one person who dropped out of therapy after 1 active session, were interviewed. Thematic analysis was used to explore the interviews. A total of 1276 references were coded, and five overarching themes identified: AVATAR therapy set-up; voice embodiment and associated emotions; working in a safe space (supported by the therapist); learning new ways of relating to the voices; impact of therapy on everyday life. Overall, the therapy set-up, with its digital components and its distinctive features as compared with common face-to-face talking therapies, was satisfactory. The inclusion of technology was well accepted as both a means to deliver the therapy and a tool to create a digital representation of the person’s distressing voice. The co-creation of the avatar and the enactment of the relationship between the person and the voice were perceived as a very helpful process to promote the therapeutical dialogue. Participants reported engaging well with the therapist and feeling supported and identified specific learnt strategies to deal with the voices and how they have had an impact on everyday life. Conclusions: AVATAR therapy is acceptable and provides benefit for participants with psychosis. Our results high-lighted the enablers and challenges of working dialogically with distressing voices using a digital representation and dealing with highly demanding emotional, cognitive, and relational processes linked to the experience. Our analysis also identified the core strategies learnt by participants and how these were generalised to their daily life resulting into a positive change in different domains, and in particular broader social relationships.


  • Edwards C., Oliver, O., Lucy, M., Hassan, J., Emsley, R., Rus-Calafell, M., Craig, T., Clancy, M., McLeod, H., Fornells-Ambrojo, M., McDonnell, J., Montague, A., Huckvale, M., Bucci, S., Haddock, G., Garety, P., Ward, T. The voice characterisation checklist: psychometric properties of a brief clinical assessment of voices as social agents, Frontiers in Psychiatry, 14 2023. View Abstract
  • Aim: Aim: There is growing interest in tailoring psychological interventions for distressing voices and a need for reliable tools to assess phenomenological features which might influence treatment response. This study examines the reliability and internal consistency of the Voice Characterisation Checklist (VoCC), a novel 10-item tool which assesses degree of voice characterisation, identified as relevant to a new wave of relational approaches
  • Thompson, A., Calissano, C., Treasure, J. et al. A case series to test the acceptability, feasibility and preliminary efficacy of AVATAR therapy in anorexia nervosa. J Eat Disord 11, 181 (2023). View Abstract
  • Summary: People with anorexia nervosa often struggle with connecting to their identity beyond the illness. They tend to relate to the eating disorder from a powerless and submissive position. The aim of this study was to test AVATAR therapy for anorexia nervosa. The goal of the intervention was to help patients to assert themselves, their identity, will, power and desires, when confronted with the “voice” of the illness. Twelve patients with anorexia nervosa were recruited and 10 completed one assessment session and five to seven therapy sessions. During the assessment session, patients were guided by the therapist to create a representation of their illness (“the avatar”) by manipulating visual and auditory characteristics through a computer software. During treatment, they were supported by the therapist to assert themselves over the illness, responding to the abusive and critical comments of the eating disorder delivered by “the avatar”. Patients’ qualitative feedback indicated that the therapy was meaningful to them, and that it helped to recognise their own voice as distinct from the illness. The distress perceived in relation to the eating disorder voice decreased over time, and feelings of self-compassion increased at the end of therapy. Findings point towards the acceptability and usefulness of AVATAR therapy for anorexia nervosa. Larger studies are needed expand these results.