AVATAR: a digital therapy that could help people who hear voices

AVATAR therapy is for people who hear voices, also known as auditory hallucinations.

Its success could be particularly life-changing for people with psychosis, a mental health condition that is characterised by feeling disconnected from reality.

Results from the latest trial show it can reduce the voices heard by an individual, and the distress these voices can cause. 

In AVATAR therapy, the person who hears voices works with a therapist to build an avatar – a digital representation of the voice inside their head. The avatar is programmed to sound and look like the voice inside their head.

A therapist can then communicate through this avatar – speaking the same things the voice may typically say. Individuals, supported by a therapist, can also speak with their avatar. They can stand up to the negative statements they hear and take control of the conversation.

After speaking with their avatar, individuals can reflect on the conversation they had with their therapist. The sessions are designed to help people take back power from the voice they hear and reduce the distress they experience hearing it.

AVATAR therapy was first developed by Professor Julian Leff from University College London in 2008 and tested in a pilot study in 2013.

Researchers from King’s College London then ran a randomised controlled trial in 2017. The trial, funded by Wellcome, showed that AVATAR therapy was more effective than counselling at reducing the distress experienced by people who hear voices.

In 2019, we funded a second trial called AVATAR2. The goal was to test the efficacy of AVATAR2 therapy further across multiple National Health Service (NHS) sites in England and Scotland. The research was carried out with the involvement of people with lived experience of mental health problems. Their expertise has helped to inform the trials at every stage – from recruitment to producing resources and research.

As part of AVATAR2, 345 participants were randomly assigned to one of three treatment groups:

• AVATAR Brief, which provided six sessions of therapy
• AVATAR Extended, which provided 12 sessions of therapy including a more personalised stage based on the voice hearer’s life history
• treatment as usual, for example antipsychotic medication, contact with a mental health worker and outpatient psychiatric appointments

To assess the effects of the therapy, the research team conducted interviews at 16 weeks and 28 weeks. They looked at several factors including the distress caused by voices, the frequency of voices heard and the participant’s wellbeing and mood.

The results, published in October 2024, once again demonstrated the effectiveness of the therapy. Participants who received the Brief or Extended versions of the therapy saw significant improvements in the severity of the voices heard and the distress caused by it, compared to those who received treatment as usual. Additionally, the Extended version of the therapy delivered stronger and more sustained effects over time, with participants seeing a greater reduction in the occurrence of the voices heard.

Mental health problems affect millions of people around the world. Digital interventions, like AVATAR therapy, could provide better ways to intervene early and help improve and resolve symptoms.

Lynsey Bilsland, Head of Mental Health Translation at Wellcome, says: “Current treatments for psychosis don’t work for everyone, and may not resolve hearing voices. It’s fantastic to see AVATAR therapy confirmed as a real contender to have an impact on people’s lives by reducing the distress associated with these voices.”

Following the success of AVATAR2, we’re now funding a follow-on study until 2027 to culturally adapt and test the feasibility and acceptability of the technology in Ethiopia and India. The findings of this study could provide a template for global roll-out of the therapy.

Alongside this, we’re supporting the development of a version that uses artificial intelligence to provide automated dialogues in English. This could increase the scalability of AVATAR by reducing the training requirements for people to deliver it.

The therapy has also been recommended by the National Institute for Health and Care Excellence (NICE) for use in the UK’s National Health Service (NHS). The project team will now continue to collect real-world evidence of how it can be implemented in routine NHS settings. They hope this will position AVATAR therapy for wide-spread rollout in the NHS within the next five years.