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For people who hear voices, interacting with a virtual avatar that embodies that voice might be key to a speedy reduction in the power it has over them and the distress it causes.

That鈥檚 according to the first large trial of avatar therapy 鈥� the creation of a computerised avatar that is voiced by a therapist.

Between 5 and 28 per cent of people聽will hear voices that no one else hears聽at some point. While not everyone is distressed by them, or has a mental health condition, 70 per cent of people with a schizophrenia spectrum diagnosis experience auditory verbal hallucinations (AVH). Persistent voices can be detrimental to quality of life as they are often derogatory or threatening, leading to low self-esteem, anxiety and depression.

Anti-psychotic drugs only work in about 75 per cent of cases. Cognitive behavioural therapy (CBT) can be helpful, but time-consuming 鈥� taking several months to have a significant effect.

A team led by and at Kings College London have tested an alternative聽option. They allocated 150 people who had experienced persistent AVH despite drug treatment to either six sessions of avatar therapy or six sessions of emotional counselling.聽On average the participants had聽experienced voices for 20 years.

The avatar group built a digital representation of the entity they believed was the source of their main voice,聽choosing its聽gender, vocal characteristics and facial features. The therapist, from another room, could choose to speak聽to the participant in their own voice or via the avatar.

In the first few sessions they had the avatar say its usual derogatory things but encouraged the participant to stand up to it. For example, if the avatar said, 鈥淚 know exactly what you鈥檙e thinking and you鈥檙e completely finished鈥�, the participant might be supported to respond: 鈥淵ou have no right to talk to me like that鈥�. In later sessions, the therapist gradually shifted the balance of power, making the avatar more conciliatory, for example, by having it acknowledge the person鈥檚 new-found assertiveness.

Regaining control

The experience could be extremely frightening, says Garety, with some people initially whispering or unable to look at the computer screen. Joe, for example, says he sometimes found the sessions intimidating 鈥渟itting in front of a computer which seemed to know my every thought鈥�.聽As the sessions went on, most people鈥檚 anxiety dropped. Another participant, Richard, says 鈥淏efore [the sessions] I felt passive, afterwards I felt in control.聽I don鈥檛 have a sense of guilt anymore, because I could explain to the voices why their accusations were wrong鈥�.

At the end of each session, a recording of the interaction was given to the participant to listen to over the following week. The people in the emotional counselling group recorded a positive message each week.

A few weeks after the sessions ended, the voices of the people who had avatar therapy were assessed as being significantly less severe than those who had received counselling. They heard their voices less often, perceived them as being less powerful and were less distressed by them. What鈥檚 more, the reduction in severity was greater than , and the effects lasted when the participants were reassessed three months later.

The fact that the effect is larger than that seen in trials of CBT, says Garety. 鈥淚f it proves effective more widely, it should be one of the options for the psychological treatment of voices in the future鈥�.

People previously thought it was counterproductive to interact with hallucinated voices, that there was nothing to be gained by understanding what they say and how they made them feel, says聽, a psychologist at the University of Durham.聽鈥淲hat avatar therapy shows, is that at least for some people it is possible to have that interaction and have some kind of therapeutic change as a result鈥�, he says.