‘It felt good to be able to say that out loud’: A peer research qualitative study exploring voice content work and the therapeutic alliance in AVATAR therapy

Background: AVATAR therapy is a novel psychological therapy which aims to reduce distress associated with hearing voices. The approach involves a series of therapist- facilitated dialogues between a voice-hearer and a digital embodiment of their main distressing voice (the avatar), which aim to reduce distress and increase self-empowerment. Extending previous qualitative work on treatment acceptability, this study explored therapeutic processes which are unique to AVATAR therapy, including direct early work with voice content and the role of the therapist in dialogue enactment. Methods: People with lived experience relating to psychosis (peer researchers) contributed to each stage of the study. Peer researchers led semi-structured interviews which were conducted with nineteen participants who received AVATAR therapy as part of the AVATAR2 trial, including three participants who dropped out of therapy. Data were analysed using Interpretative Phenomenological Analysis (IPA; n=5) and template analysis (n=14). Results: Participants described the initial challenges of experiential work with distressing voice content; however, most reported a meaningful increase in power and control over the avatar and improvements with voices in daily life. Strong therapeutic alliance was experienced by all participants, including those who chose to discontinue therapy, often mitigating the discomfort associated with initial challenges by enhancing their sense of safety. Several important themes relating to individual engagement were highlighted, such as participants’ open-minded attitudes, determination and the emotional intensity of the therapy experience. Those who decided not to continue with therapy described challenges with the realism of working dialogically with a digital representation of their distressing voice.Conclusions: This study has provided a deeper understanding of the experience of engaging in AVATAR therapy, in particular the challenges and opportunities of direct work with voice content. The importance of therapeutic alliance and establishing a sense of voice presence has been emphasised. Implications for the planned optimisation and wider implementation of AVATAR therapy in routine care settings are discussed.