29 October 2024
AVATAR therapy has shown significant promise in reducing the frequency and impact of distressing voices for those with a diagnosis of schizophrenia. Working extensively with people with lived experience of hearing voices, researchers at King’s have unveiled encouraging results from a large, multi-site clinical trial, providing hope for voice hearers. Now, the National Institute for Health and Care Excellence (NICE) has endorsed AVATAR therapy under its Early Value Assessment, paving the way for wider NHS implementation.
Around 60 to 70 per cent of people who have schizophrenia experience distressing voices. For at least a quarter of these people, the voices persist after medication and many would like help with how they respond to them.
Over the last decade, researchers at the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London have worked with collaborators around the UK to test AVATAR therapy – a new therapy in which voice hearers create and then have a dialogue with an animated digital representation of the main distressing voice they hear (the ‘avatar’).
Although Cognitive Behavioural Therapy for psychosis (CBTp) is helpful for people who experience voices, it is lengthy and research has shown the effects can be limited. By bringing the voice to life on a computer, AVATAR therapy enables voice hearers to take control through dialogue with the voice. This also allows the therapist to hear what the voice sounds like and guide the voice’s utterances to support this process of empowerment.
A large proportion of people with schizophrenia continue to experience distressing voices despite lengthy treatment, so it was crucial that we began looking at newer, more effective and shorter forms of therapy.
Professor Thomas Craig, Emeritus Professor of Social Psychiatry at King's IoPPN and AVATAR1 Principal Investigator
AVATAR therapy uses customised computer-generated avatars to represent the voices experienced by people with psychosis. The purpose of the therapy is to help the voice hearer stand up to the voice and take control in a courageous and confident way.
Before starting treatment, the person who hears voices works with the therapist to create their own avatar, which looks and sounds like the main voice they hear. Therapy involves a three-way conversation between the voice hearer, therapist and avatar, with the therapist speaking as themselves as well as voicing the avatar using voice conversion software.
There are two versions of AVATAR therapy: Brief, which takes place over six sessions, and Extended, which takes place over 12 sessions. In both versions, the voice hearer spends 10-15 minutes of each session speaking face-to-face with the avatar, practising standing up to it, correcting any misconceptions it had about them, and being more in control of the conversation. For the remainder of each session, the therapist and voice hearer begin to discuss broader aspects of the voice hearer’s life, aiming to reduce anxiety and increase sense of power through dialogue. In AVATAR Extended, the additional sessions allow more time for the person to share their earlier life experiences and relationships to explore how the voice might mirror these.
Over the course of both versions of the therapy, the avatar comes to recognise the voice hearer’s strengths and good qualities, becomes less hostile, and concedes power to them.
AVATAR therapy was invented in 2008 by Professor Julian Leff at UCL. Initial work took place at UCL over the next five years, during which Professor Leff worked with Professor Mark Huckvale to build a voice conversion system which transforms the therapist’s voice into the avatar’s voice in real-time, enabling realistic conversation with the avatar.
In 2013, Professor Leff and colleagues published the first pilot of the therapy with 26 participants with a diagnosis of schizophrenia, 14 of whom received AVATAR therapy and 12 received their usual treatment, before receiving AVATAR therapy seven weeks later. Over half of the participants had heard voices for more than 10 years upon starting the therapy.
They found that those who received AVATAR therapy showed a significant reduction in the frequency of the voices and associated distress compared to pre-therapy. Remarkably, the voices ceased completely for three participants, and this was sustained three-months later.
Professor Leff had demonstrated in a pilot study that he could deliver AVATAR therapy effectively. Professors Thomas Craig and Philippa Garety, long-time colleagues of Professor Leff during his 20 years at the IoPPN, led the first fully-powered randomised controlled clinical trial of AVATAR therapy (AVATAR 1) in 2018 with funding from Wellcome and the National Institute for Health and Care Research (NIHR) Maudsley Biomedical Research Centre.
They recruited 150 participants who had had a diagnosis of schizophrenia for approximately 20 years and heard three-to-four voices on average. Of these, 75 people had AVATAR therapy and the other 75 people had a form of supportive counselling designed for the study as a control.
After just six sessions of AVATAR therapy, researchers found a rapid and substantial fall in the frequency and associated distress of voices.
I remember walking home from that session with a smile on my face. Something had shifted… my confidence began to grow. I was also able to start putting some boundaries in place with my voices in my daily life.
Patient and Public Involvement consultant who received AVATAR therapy
Since its invention, researchers at King’s have been refining and optimising the therapy into the Brief and Extended versions, while Avatar Therapy Ltd has improved the software to align it with the latest technology. These changes are designed to support the therapy to be more easily scaled-up, make it more usable for busy clinicians, and optimise its effectiveness for people who hear voices.
With further funding from Wellcome, the researchers, led by Professor Philippa Garety at the IoPPN, introduced AVATAR therapy in eight clinical settings across the UK in centres linked to King’s, UCL and the Universities of Glasgow and Manchester. In 2024, they published the results of the largest randomised controlled trial of the therapy (AVATAR2), demonstrating that both Brief and Extended versions of AVATAR therapy were effective across more geographically diverse settings.
345 participants were randomly assigned to one of three treatment groups – AVATAR Brief, AVATAR Extended and their usual treatment. 16 weeks after therapy was completed, participants who received both versions of the therapy showed statistically significant improvements in the severity of the voice itself and related distress, compared to those who received their usual treatment.
Participants who received AVATAR Extended also saw a sustained reduction in the frequency of distressing and a wide range of other benefits in wellbeing, recovery and empowerment.
In this large multi-centre study, we have replicated previous trial findings, demonstrating that AVATAR therapy is linked with a rapid reduction in voice-related distress. For the first time, we have shown that an extended version of the therapy also leads to a sustained reduction in the frequency of voices and improvements in other voice-related experiences and wellbeing. This is very encouraging and points the way forward for an innovative therapy, which can alleviate distress and improve everyday life for many voice hearers.
Professor Philippa Garety, Professor of Clinical Psychology at King's IoPPN and AVATAR2 Principal Investigator
Results from this most recent and largest clinical trial suggest that AVATAR therapy is an effective intervention to reduce the frequency and associated distress of voices for people with psychosis. The researchers have recommended that the AVATAR Extended protocol should guide the planned implementation in routine care settings for people with psychosis.
Both AVATAR therapy clinical trials were conducted with leading methodologists and statisticians in the Mental Health & Neuroscience Clinical Trial Statistics Group, part of King’s Clinical Trials Unit.
Patient and Public Involvement (PPI) has been at the forefront of the AVATAR Therapy trials. The team has been working with a diverse group of people with lived experience of psychosis, family members and carers to inform staff and participant recruitment, develop accessible resources, co-produce research, and guide public dissemination.
Nicola received AVATAR therapy during the first trial and then became part of the AVATAR therapy research team as a PPI consultant. Hear her story below:
Throughout the AVATAR trials, many PPI consultants have shared their journey through a series of blog posts, including poetry, and a podcast episode.
Being a part of the Patient and Public group has been a great experience as someone who has used mental health services for all of their adult life. Having researchers and psychologists willingly hold themselves accountable to the people they are meant to be helping, and willingly so, is so refreshing and bold.
Patient and Public consultant in Glasgow
In March 2024, AVATAR therapy received a National Institute for Health and Care Excellence (NICE) recommendation as part of their Early Value Assessment MedTech initiative (NICE-EVA). This means that AVATAR therapy is recommended for use within the NHS while researchers continue to gather evidence of its effectiveness in the ‘real world’ of everyday clinical practice.
Through the NICE-EVA process, the team has already identified the real-world evidence that is needed to enable a wider roll-out within the NHS. The team is now working with a number of centres in the UK to seek funding for a project which will generate this evidence.
Our latest findings have demonstrated the effectiveness of AVATAR therapy across multiple sites. With these results and the NICE Early Value Assessment recommendation, we hope to see AVATAR therapy available in several NHS Trusts in 2025.
Dr Thomas Ward, Research Clinical Psychologist at King's IoPPN and AVATAR Clinical Lead
Researchers, led by Dr Thomas Ward at the IoPPN, are now embarking on a new project, also funded by Wellcome. The project will establish AVATAR therapy Implementation and Training Hubs in Ethiopia and India, working in collaboration with partners at each site to test the feasibility of training and delivering therapy in languages spoken by over half a billion people.
Meanwhile, in the UK, the team will test automation of avatar dialogues using Artificial Intelligence (AI)-powered conversational agents (“AVATAR-AI”). Using technology which is similar to virtual assistants such as Alexa or Siri, these agents generate human-like responses to language, enabling users to have meaningful conversations with them.
This represents a world first, and could hold the key to ensuring AVATAR therapy becomes more widely available in the future.
Professor of Clinical Psychology
Emeritus Professor of Social Psychiatry
Research Clinical Psychologist & Clinical Lead AVATAR and SloMo therapy teams
Wellcome ECA Fellow/Research Clinical Psychologist
Statistician
Professor of Clinical Psychology & PICuP Director
Senior Lecturer
NIHR Research Professor
A large proportion of people with schizophrenia experience distressing voices, which are often insulting and threatening. An...
