# The Impact of AVATAR Therapy on Voice Hearing in Everyday Life: ESM Outcomes of the AVATAR2 Trial

## TL;DR

AVATAR therapy, especially the extended version, reduces distress and negative beliefs about hearing voices in daily life, according to a multi-site trial.

## Contribution

First study to report real-life outcomes of AVATAR therapy using experience sampling method across multiple timepoints.

## Key findings

- AV-EXT therapy reduced momentary voice-related distress at 16 and 28 weeks compared to TAU.
- AV-EXT therapy reduced appraisals of voice control at 16 weeks when the voice was present or not.
- Both AV-BRF and AV-EXT reduced voice power appraisals when the voice was on participants' minds.

## Abstract

AVATAR therapy involves facilitated dialogs between a voice hearer and a digital embodiment of their distressing voice (“the avatar”). We conducted a multi-site single-blind randomized controlled trial to evaluate the efficacy of brief (AV-BRF) and extended (AV-EXT) forms of AVATAR therapy, compared with treatment as usual (TAU) alone (AVATAR2). This study reports the data from experience sampling method (ESM) assessments conducted at baseline, end of therapy (16 weeks), and follow-up (28 weeks). The research questions focused on whether those in the AV-BRF or AV-EXT arms experienced less voice-related distress, anxiety, and beliefs as measured by ESM, compared to TAU. Separate mixed-effects models were fitted for each research question. The final sample (n = 200) completed approximately 40% of questionnaires across all timepoints. Participants who received AV-EXT therapy, but not AV-BRF, reported reduced momentary voice-related distress at 16 (P = .022) and 28 weeks (p = .029). Appraisals of voice control were also reduced in the AV-EXT arm at 16 weeks when the voice was present (P = .002) or not (P = .008). Voice power appraisals were reduced (P < .035) in both arms when the voice was “not present but on my mind” at all timepoints. There were no changes in the frequency of voice hearing, appraisals of voice intent, or assertive responding. These findings from everyday life, reported for the first time, provide evidence of the impact on the primary AVATAR therapy treatment targets, including appraisals of voice power and control. The weight of evidence favors the AV-EXT protocol in the further development and implementation of AVATAR therapy.