We got so many fantastic questions during the AVATAR2 Trial Launch that we couldn't answer them all live. Here, the team answer all the questions we couldn't get to on the day.
Q: Do you plan to follow up with participants to see if any changes have been sustained over time and if so, how often would this take place?
A: We will be completing follow-up assessments with participants at the end of therapy (16 weeks post-randomisation) and 3 months later (28 weeks post-randomisation).
Q: What is the neurological theory as to why AVATAR therapy may work to reduce distress and frequency?
A: There are neurological theories of voice hearing, but we will not currently be exploring the neurological basis of the voice hearing experience or AVATAR therapy in AVATAR2, although there is potential to do so in the future.
Q: Do you routinely refer trial's participants to the hearing voices network?
A: The trial is separate from the person's clinical care which is managed by their mental health team and so we do not routinely do onward referrals. However, we recognise the important and meaningful contribution the Hearing Voices Network (HVN) and the groups in particular have made to the lives of people who hear voices. If someone participates in a HVN group, then they can be referred to AVATAR2.
Q: Is there any specific training to administer Avatar or can we put into practice the knowledge based on "CBT therapy for psychosis" by Philippa Garety once we will have the software?
A: Yes, there is specific training. AVATAR therapy shares significant commonalities with CBTp, for example (but not limited to) the therapeutic target of increasing the voice-hearer’s perceived power and control over the voice. As such a grounding in CBTp approaches is considered helpful in learning to deliver the therapy. However, the explicitly relational approach and novel experiential aspects (e.g. voicing the avatar and facilitating the dialogue) require therapy-specific training and supervised practice. The current research trial will be seeing whether the skills can be effectively taught, and the level of competence required of therapists.
Q: Is there a way people can utilise avatar therapy as a self-help therapy? After using it with a therapist perhaps.
A: Not directly (in the sense of a meaningful real time dialogue in the absence of the therapist). However, participants are given recordings of the sessions and encouraged to keep these and listen to them whenever the voices are troubling. In the future (and outside of the AVATAR2 trial) we are also interested in exploring ways in which we can promote generalisation of gains to real world contexts.
Q: Do the effects and confidence-building of the Avatar trial wear off over time? Do participants need 'refresher' treatment?
A: We do not know. The studies so far have only followed up participants for 6 months. These studies suggest that many but not all participants maintain the benefit of the therapy to this point. In the new trial we will be interested to see whether the extended version of therapy confers any benefit in terms of sustained improvement over time.
Q: What would happen if a participants' voice isn't associated with any physical representation? Would they still be asked to choose physical characteristics for the avatar?
A: We would usually ask them to choose a face that they think might represent the voice or to choose one from the initial set up that they feel comfortable talking with.
Q: How sensitive to success of the therapy is the nature of the voice?
A: We have not shown any difference in outcomes according to the nature of the voice. In the current trial we are interested to see whether the degree to which the voice is experienced as a characterised social entity might influence treatment outcome.
Q: Do clients typically have a clearly defined personification of their voices in mind when the treatment begins, or are they defined in collaboration with the therapist?
A: Some do (about a third very much so) while others report a less clear representation/characterisation of the voice. When creating the avatar the therapist and participant work together to make as close a representation as possible in an iterative manner until the participant says the avatar has achieved a very close match in terms of image and voice. The therapist in enacting the voice also tries to take account of the ascribed personal characteristics of the person's voice, including for example, cultural background.
Q: How do therapists/researchers achieve 'buy in' from patients to interact with avatar in first instance? I.e., how do they overcome issues like belief/level of conviction that their 'voice' is a live personal persecutor? Have you had people say at end of session, e.g. ‘That was fine; but that was just a computer-generated figure. It wasn't my voice'?
A: The process of creating the avatar and realistic enaction using verbatim 'voice' comments helps with this. We have had several comments such as 'you are the first person to really hear/understand what I hear'. Our experience is that while interacting with the avatar, most people are highly immersed, interacting with the avatar as though with their usual voice. This sense of presence was maintained across all therapy sessions. A small number of people did find the set up unconvincing as you say. However, in these instances there can still potential opportunities to make the dialogues helpful e.g., building self-esteem/ encouraging positive self-talk.
Q: I think this work has greatly impacted on the insights into the anorexic voice in individuals with anorexia and I was wondering if the elements of externalising the voice via AVATAR and fostering a compassionate synthesis between self and voice could be applicable to this client group?
A: We absolutely agree. We are involved in ongoing work aimed at adapting AVATAR therapy for the eating disorder voice which is highlighting important commonalities e.g., the nature of the relationship with voices (feelings or entrapment, powerlessness and coercion) can be mirrored in an eating disorder context. The compassionate synthesis of voice with self (likely to be central in AVATAR therapy for ED) is also relevant to people with psychosis- however the common attribution of the voice to an external source adds an extra consideration. We always work collaboratively with the person, respecting their personal understanding of their voice- for some, through dialogue, the voice comes to be viewed as an aspect of the self; for others, the voice remains external to the self but (we hope) a less threatening and distressing presence.
Q: Hi, just to be clear, is the therapist speaking as the avatar and what effect if any does this have on the therapeutic relationship?
A: Yes, the therapist is speaking as the avatar. S/he is clear from the outset that while the enactment must be as close to what the participant usually experiences from their 'voice', the therapist is there as a support and guide, helping the participant to stand up to the voice, taking greater power and control. The therapeutic relationship was not formally assessed, although ratings of 'empathy' reported by participants were high. Working alliance will be assessed in the current trial. Our sense as a team isthat the delivery set-up ensures that we, as clinicians, connect with the lived experience of the voice - participants have reported a positive sense that "finally someone else can hear what I hear". The direct use of content allows us to understand aspects of the experience (e.g., communicative implications of key distressing content) that might be easily missed otherwise. While we always approach use of verbatim content with sensitivity and care, we are mindful of therapist avoidance which can inadvertently reinforce a person's sense of shame around their experiences.