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Articles    H3'ed 9/1/13

Avatars and Hearing Voices Therapy

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   Today I'm at the 30th year of the annual conference for the Society for the Scientific Study of Shamanism, which I have attended around 20 times.   I've just come from the biannual conference of the ISPS, which is the International Society for Psychotherapy and Social Therapies of Psychosis.   I wanted to write about some recent work by Julian Leff and colleagues at University College, London, who wrote a recent paper called, "Avatar Therapy for persecutory auditory hallucinations: What is it and how does it work?"

   In my observation, the voices that torture people are the mean, persecuting ones, telling them how worthless they are and commanding them to kill themselves, hurt themselves, or do something cruel to someone else.   I've written before about our young man who has believed he was the reincarnation of Adolf Hitler and heard the voices of two Ascended Masters, who urged him to kill his parents, so he would go to prison where he could be appropriately tortured for the rest of his life.   The people who suffer the most feel helpless. Dialogue with invisible entities is difficult. Leff wrote, "Hearing a disembodied voice abusing you in stereotyped phrases taxes your resources as a social human being. Furthermore, because the entity is invisible there are none of the usual cues of facial expression and non-verbal communication by which we signal agreement with, attention to, and turn-taking with the speaker."

We frequently help people to feel more sense of agency by dialoguing with their voices.   To accomplish this, we use puppets, masks, other people, guided imagery, and so on.   The idea is to give body to the voices, to see the voices.   What we can see is not as frightening.   Once we see it, we can go further, as Harry Potter did in one of the movies, and make the being of the voice appear ridiculous.   We can put that being in long clown shoes, ridiculous costumes, and otherwise turn the frightening into the hilarious.  

I find that these approaches work very well for those who will do them, but not everyone will.   Leff and colleagues devised a new and creative method for facilitating dialogue between the voice hearer and the entity speaking to them using a computer-generated avatar. Their aim was to facilitate the dialogue so that the person would learn to stand up to their avatar and eventually control it.

They developed two commercial programs in a package in conjunction with a voice-morphing program. The voice hearer uses the software to construct the avatar, choosing a face and a voice for the entity they hear. The voices from which the patient chooses are produced by alterations of the therapist's voice. Then the facilitator can speak to the voice hearer through the avatar in real time using the selected voice. Voice hearers then pick a face for that voice.   In my experience, this is harder for clients, almost as if the connections with the visual system are disturbed.   We do something similar by giving voice hearers a limited number of puppets form which to choose, which is a kind of forced choice method, which is probably less overwhelming.

    In Leff's system, the voice hearer sits in a room and faces a monitor on which the avatar is shown. The software synchronizes the avatar's lip movements with its speech. The facilitator sits in an adjacent room and views a screen. Clicking on the right side of the screen allows the facilitator to speak to the patient through the avatar using the voice selected by the voice hearer for the persecutory voice. Clicking on the left side of the screen enables the facilitator to speak to the patient in a normal voice.

The voice hearer is prompted by the facilitator to enter into a dialogue with the avatar and encouraged to oppose it. The facilitator controls the avatar so that it progressively comes under the voice hearer's control over six weekly sessions of 30 minutes duration. Over the course of the therapy the avatar progressively becomes more appreciative and supportive. Each session is digitally recorded and the audio file is transferred to a personal media player given to the voice hearer to use at any time to use at any time to remember and reinforce control over the persecutory voice'   

Leff and colleagues compared avatar therapy to treatment as usual in a randomized controlled trial with a cross-over of the control group from treatment as usual into avatar therapy after an initial seven week block. The duration of hearing voices ranged from four years to more than thirty years, the median being more than ten years.   To assess success, they used the Psychotic Symptom Rating Scale's hallucinations score a hearing voices scale score on omnipotence and malevolence, and a depression scale.

Twenty-six voice hearers began the study, 16 interacted with avatars, and benefitted from significant reductions in the frequency and intensity of the voices and in the disturbance to their life. The perceived malevolence and omnipotence of the voices also dropped. At the three-month follow-up, further reductions in the frequency and intensity of the voices occurred. A full account of this study appeared in the June, 2013, issue of the British Journal of Psychiatry.

Leff described the most dramatic effects among three voice hearers who had been hearing voices constantly for 16 (A), 13 (B), and 3-1/2 years (C). A had stopped taking medication three years previously, while B and C took adequate antipsychotic medication regularly. Voice hearers A and C stopped hearing their persecutory voice after the second session, while Voice hearer B's "voice' stopped after the 5th session. These persecutory voices were still gone at three months follow-up for all three people.

Dr. Julian Leff was the sole therapist in this study and found very low self-esteem to be a common factor among the voice hearers. It was not effective to schedule a set time to listen to their voices or to tell the voice that the voice hearer would only listen when the voice said pleasant things. If the voice hearer believed the voice was real (had full ontological status), Dr. Leff accepted that and dealt with the voice on that basis. We do the same in our work.  

In one of his papers, Dr. Leff gives an example of his work:


An example is the elderly man (C) who had been a senior executive in a large company. Several years before he was inducted into the trial, he began to be woken every morning at 5 a.m. by the voice of a woman, also a senior company executive. She held business meetings from that early hour until nightfall, so that he heard her discussing business matters with her subordinates throughout the entire day, although she never addressed him directly. He was completely convinced of the reality of this woman, but had not developed an explanation for her disembodied voice. JL accepted the patient's experience as real and advised him that the woman was behaving unprofessionally, and that he should tell the avatar to confine her meetings to business hours. Furthermore she was betraying her organisation by letting him hear her discussions. In the first session with the avatar C was polite, spoke in a soft voice and remained calm and quiet throughout the session which was ended after 15 minutes. One week later he arrived for the second session and reported that her voice was quieter, as were the voices of her subordinates. Also they started at 8 a.m. instead of 5 a.m. In this session C was more forceful and told the avatar that he did not want to hear her plans, saying, "It's treason. Keep it to yourself'. He told her to confine her meetings to the afternoon, after 2 p.m. He said, "I don't want to hear you at 8 a.m. I have a lot to do in the mornings and you disturb me.' In general he was much more assertive than in the first session. When C. arrived for the next session he reported that he was sleeping until 7 a.m. and that the woman's voice had gone entirely, "as though she left the room.' At a follow-up one week later the woman's voice was still absent, and had not resumed at a three month follow-up.


This is impressive work, considering that only one hour of contact was required to get this result.   It reminds me of a client with whom I worked who was hearing the devil all night long.   She could only sleep when the sun was up, because the sun kept the devil at bay.   We made masks of the devil, the sun, and some audience members.   I facilitated a dialogue with the sun and the devil.   We alternated who played the sun and who played the devil.   That helped reduce the intensity and severity of the voice during the day, but it did nothing at night.   We needed a new character that could oversee the night.   I told my client about the words of an elder who told me that the night spirits took over from the day spirits when the sun disappeared into his home in the West.   Traditionally the dog warriors guarded the camp at night and others in the day.   We brainstormed about who could manage the devil at night.   I liked the moon, but my client feared that the voice would take over as the moon waned.   I asked about a dog warrior, and we settled upon one of my favourite characters, Coyote, though I hadn't imagined Coyote as a candidate for the job.   We made a coyote mask and repeated the work of taking turns playing Coyote and the Devil.   When I thought we were ready, I asked my client to invite her friends to a session to play the audience.   Then we would expel the devil and announce to the Sun and the Moon, her triumph over the devil.   We performed the dramatic enactment in a two-hour session, and the voice came under control.   However, this took significantly more time than Dr. Leff's procedure.   I hope to obtain his software and try his approach with my own clients who suffer from persecutory voices.

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Lewis Mehl-Madrona graduated from Stanford University School of Medicine and completed residencies in family medicine and in psychiatry at the University of Vermont. He is the author of Coyote Medicine, Coyote Healing, Coyote Wisdom, and (more...)
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