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Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study

  • Julian Leff (a1), Geoffrey Williams (a2), Mark A. Huckvale (a3), Maurice Arbuthnot (a4) and Alex P. Leff (a4)...



One in four patients with schizophrenia responds poorly to antipsychotic medication, continuing to hear persecutory auditory hallucinations. Patients who are able to sustain a dialogue with their persecutor feel much more in control.


To develop a computerised system that enables the patient to create an avatar of their persecutor. To encourage them to engage in a dialogue with the avatar, which the the rapist is able to control so that the avatar progressively yields control to the patient.


Avatar therapy was evaluated by a randomised, single blind, partial crossover trial comparing the novel therapy with treatment as usual (TAU). We used three main outcome measures: (a) the Psychotic Symptom Rating Scale (PSYRATS), hallucinations section; (b) the Omnipotence and Malevolence subscales of the Revised Beliefs About Voices Questionnaire (BAVQ-R); and (c) the Calgary Depression Scale (CDS).


The control group showed no change over time in their scores on the three assessments, whereasthe novel therapy group showed mean reductions in the total PSYRATS score (auditory hallucinations) of 8.75 (P = 0.003) and in the BAVQ-R combined score of omnipotence and malevolence of the voices of 5.88 (P = 0.004). There was no significant reduction in the CDS total score for depression. For the crossover control group, comparison of the period of TAU withthe period ofavatar therapy confirmed the findings of the previous analysis. The effect size of the therapy was 0.8.


Avatar therapy represents a promising treatment for medication-resistant auditory hallucinations. Replication with a larger sample is required before roll-out to clinical settings.

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Corresponding author

Julian Leff, c/o The Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG, UK. Email:


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See editorial, pp. 394-395, this issue.

Declaration of interest




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Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study

  • Julian Leff (a1), Geoffrey Williams (a2), Mark A. Huckvale (a3), Maurice Arbuthnot (a4) and Alex P. Leff (a4)...


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Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study

  • Julian Leff (a1), Geoffrey Williams (a2), Mark A. Huckvale (a3), Maurice Arbuthnot (a4) and Alex P. Leff (a4)...
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Psychosis / Dissociation - a rose by any other name

Paul W. Miller
18 May 2014

Despite over 100-years experience only a minority of individuals withschizophrenia make a full recovery. The burden includes: legal problems, stigma and reduced life expectancy, which can be reduced by between 11 and20 years. As we are not aiming for cure, it is important to weigh-up long-term consequences: tardive dyskinesia in the first-generation and metabolic syndrome in the second-generation antipsychotics. The Roscommon Family Study observes that the diagnostic boundaries of schizophrenia haveexpanded and contracted from the time of Kraepelin (1). Scharfetter invites us to 'repatriate' schizophrenia into the spectrum of disorders that he argues it was associated with when it was first conceptualised, "those which can be interpreted by a dissociation model" (2). Upon exploring the research around the time of the naming of schizophrenia, (2)argue that the core concepts of Bleuler's schizophrenia have a stronger relationship with dissociation theory paralleling the work of Janet and Paulhan (2) rather than with the work of Freud. It is notable that at thetime Bleuler coined the term 'the schizophrenias' there were in existence 4 other terms that all drew explicitly on the dissociation model: Wernicke's -- 'dissociation psychosis', Otto Gross's - 'insanity of dissociation', Stransky's - 'process of dissociation' and Zweig's - 'insanity of dissociation'.

Ross(3) looks at the challenge for the clinician in respect to psychosis verses dissociation and states, "The overlap between the core features of dissociative identity disorder (DID) & schizophrenia cannot be reduced to a problem of comorbidity because the two are not discrete & separate categories. They cannot be comorbid with each other as they are too often and too much the same thing." He raises the issue of how diagnostic labelling has a real-world effect on what treatment is made available to the client, "Many people in treatment for schizophrenia could benefit from psychotherapy for DID. There is very little chance that their diagnoses will be revised to DID if they are being treated for schizophrenia and very little chance that they will be offered intensive psychotherapy if they continue to receive the diagnosis of schizophrenia." In the field of trauma and dissociation talking to and listening to the voices has been a stock and trade of therapy for some time.

An acknowledgement of the link between trauma, dissociative mechanisms and the disorder of schizophrenia is important in opening up the psychotherapies as possible treatments for these patients and Leff et al. (4) underline this point in their recent work. By acknowledging the dissociative mechanisms of schizophrenia the application of psychotherapy including EMDR makes sense(5). Treating schizophrenia by formulating it within a trauma paradigm allows the application of one of the current international gold standard psychotherapies for PTSD: EMDR, with good outcome.

1.Kendler KS, Maguire M, Gruenberg AM, Aileen O'Hare ea. The Roscommon Family Study I. Methods, Diagnosis of Probands, and Risk of Schizophrenia in Relatives. Archives of General Psychiatry. 1993; 50(July): 527-39.2.Moskowitz A, Schafer I, Dorahy MJ. Psychosis, trauma, and dissociation : emerging perspectives on severe psychopathology. Wiley-Blackwell, 2008.3.Ross CA. Schizophrenia : innovations in diagnosis and treatment. Haworth Maltreatment and Trauma ; Northam : Roundhouse, 2004.4.Leff J, Williams G, Huckvale MA, Arbuthnot M, Leff AP. Computer-assisted therapy for medication-resistant auditory hallucinations: proof-of-concept study. British Journal of Psychiatry. 2014; 202: 428-33.5.Kim DC, Joonho; Kim, Seok Hyeon; Oh, Dong Hoon; Park, Seon-Cheol; Lee,Sun Hye.* A Pilot Study ofBrief Eye Movement Desensitization and reprocessing(EMDR) for Treatment ofAcute Phase Schizophrenia. 2010; 17(2): 93-101.

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Conflict of interest: I have a current contract with Springer Publications for a book on EMDR for Psychosis

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Avatar therapy for refractory AVH

James Paul Pandarakalam, Locum Consultant Psychiatrist
06 January 2014

James Paul Pandarakalam, Locum Consultant Psychiatrist, 5 Boroughs Partnership NHS Foundation Trust.

Computerized voice therapy (C. V. T.) proposed by Leff et al is a deviation from the conventional remedial measure of drug treatment for persistent auditory verbal hallucinations (AVH) (1) and is highly welcoming. More cognizance of psychological treatments are warranted for this distressing symptom. Analytically oriented therapists even talk to the hallucinatory voices of their clients to extract information and reassure them. For such committed therapists, it is quite encouraging to have developed a computerized voice therapy (C.V.T) to treat refractory AVH. AVH is a dynamic and emotionally charged experience, perhaps an epiphenomenon of a deeper psycho-physiological and psycho-dynamic process.Schizophrenia suffers feel like abstract entities and the AVH may be due to morbid "objectification" of inner dialogue (worded thoughts) (2). AVH is like an acoustic hologram of inner speech. Most voice hearers declare that their experiences are more real than the material reality.

In physics, material and physical can have different meaning (a tableis material and physical whereas electromagnetism is physical, but not material). Computer programes are physical whereas hard text is material. Most often, voice hearers tend to attribute their experiences to disembodied spirits which in theory is a non physical reality: anything spiritual/invisible is viewed with suspicion and can be perceived as powerful and superior. The cybernetic physical reality is seemingly the personification (Avatar) of the ostensibly omnipotent pseudo spiritual reality which in turn is challenged and depowered. Apparently, C.V.T involves hypnotherapeutic principles in a harmless manner without the shortcoming of intense mental exercise- all forms of hypnotherapy is contraindicated in psychotic conditions. C.B.T. works better with higher intelligent patients and likewise, C.V.T. might also work better with intelligent and technically minded patients.

The Sanskrit expression 'Avatar' borrowed by the Hollywood film industry, means Divine incarnation in Vedic philosophy. The term invokes utmost mystical feelings in the oriental culture and has a unique semantichalo. Avatar therapy, while trying to demystify AVH may be misconstrued asmystifying the hallucinatory experience. Avatar can mean direct (full reincarnation of the Sacred) and indirect avatar (Higher reincarnation) inVedic philosophy. The concept of injecting human intelligence/ consciousness into a remotely located biological body as depicted in the Avatar film is the basis of dubbing the computerized voice therapy as Avatar therapy. Critical observers of reincarnation research fear that thesame concept may also be used for the ultimate experiment of reincarnationresearch (the forbidden fruit of parasciences); transferring the consciousness of a dying person into a foetal body. Therapists may trivialize the hallucinatory voices without trivializing the Sublime. A term with a spiritual connotation can also prompt schizophrenia sufferers who are already preoccupied with philosophical and spiritual ideas to delve more into spiritual dimensions. The concrete thinking of schizophrenia warrants discouraging such an endeavor. In this respect, theinappropriate usage of this sacred term may be avoided.

Of note, another development in voice therapy is the use of tinnitus control instrument (TCI) in treating refractory AVH. Kaneko et al report successful intervention of two cases of refractory AVH with sound therapy using TCI alongside antipsychotic medications (3).Similar to AVH, subjective tinnitus is defined s the false perception of sound in the absence of acoustic stimuli. As it is observed that tinnitus and AVH coexist in many of the schizophrenia sufferers, a common neuro-mechanism for both tinnitus and AVH has been proposed (4). The two cases Kenaeko etal treated with TCI alongside atypical anti-psychotics claimed to have full remission of AVH after 17 and 30 months respectively (3). Like Avatartherapy, more case trials are warranted in this research arena. In an observational study of a single case, I have found that TCI reduced the intensity and frequency of AVH along with anti-psychotics and C.B.T. Even such an outcome could be useful to aid C. B. T. in challenging the belief that the voices are all powerful (because they can be tampered with by a mechanical device).


1.Leff J,Williams G, Huckvale MA, Arbuthnot M, Leff AP. Computer assisted therapy for medication-resistant auditory hallucinations; proof-of-concept study.Br J. Psychiatry 2013;202:428-33.

2.Stanghellini Giovanni. Disembodied Spirits and de-animated Bodies. Oxford: Oxford University Press, 2004.

3.Kaneko Y,Oda Y,Goto F. Two cases of intractable auditory hallucination successfully treated with soun

4.Dolberg D, Schaaf H, Hesse G. Tinnitus in primarily schizophrenia patients.HNO 2008; p56:719-26.

Dr James Paul Pandarakalam, 5 Boroughs Partnership NHS Foundation Trust,Locum Consultant Psychiatrist, Hollins park Hospital, Warrington WA2 8WA, UK. Email:

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Conflict of interest: None declared

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Avatar assisted relational therapy for persecutory voices?

James A Rodger
05 July 2013

Concealed beneath the implausibly insentient nature of intervention implied by the study title is in fact a highly relational therapeutic approach for voice hearers of potentially Copernican significance! An example of the kind of paradigm shift in both research and clinical practice recently advocated in several recent BJP editorials (e.g. Brackenet al. 2012; Priebe et al. 2013)

While only a 'proof of concept' study, it is predicated on a very different understanding of psychopathology than conventionally argued for in the pages of this journal. Not only does the study shun conventional diagnoses in favour of 'symptom groups' as Tyrer points out in the journal's editorial coda, but it revives the concept of psychotic symptomsas relational phenomena - both in terms of aetiology and intervention, that our group has recently further argued for (1).

While a large scale phase III study is clearly warranted, the early impression of an evidently useful shift in the framing of psychosis, potentially opens up readers of this journal to more serious considerationof a wider range of relationally-orientated aetiological factors and therapies already advocated for psychosis and psychotic-symptoms in several 'lower impact' journals - which as Kingdon points out in his related editorial, have historically proved to be the principle hotbed of past game changers in psychiatric practice.

While the BJP has itself recently published several articles acknowledging childhood maltreatment to be significant risk factors for psychosis possibly meditated by changes in the H-P-A axis and downstream effects on dopamine systems (e.g. Collip et al. 2013), the idea that hallucinatory phenomena may themselves represent 'echoes' of past abuse, brings us closer to dissociative concepts of such phenomena, which by definition points towards relational solutions. Indeed outside the pages of this journal the once confident distinction between dissociative phenomena and psychosis has been challenged on various counts, including:

1) Experimental studies which have shown that psychological measures of dissociation and psychosis are highly correlated and do not have convincing differential construct validity (4).

2) Historical analysis of changing diagnostic trends, demonstrating awaning in the popularity of Multiple Personality Disorder at the time thatthe diagnosis of Schizophrenia began to gain ascendance is argued to be nocoincidence (5). That childhood abuse is now suggested by some studies to have a 'dose-dependent' relationship with later risk of psychotic symptomdevelopment, in particular hallucinations (6), also weakens the basis for any presumed aetiological distinction between the two.

3) Psychological modelling of how child maltreatment and trauma may give rise to psychotic symptoms (including negative symptoms). Presumed differences between traumatic flashbacks and 'hallucinations' may be basedmore on whether insight into a link between trauma and symptom is acknowledged by the patient (and psychiatrist) (6). This becomes harder still when the 'hallucination' is symbolic rather than simply echoic or thematic.

If such a model is correct then we can begin to take more seriously the claims of such relational therapies as the Open Dialogue family therapy model for early psychosis in Finland which claims to have reduced the transformation of new onset psychosis to chronic schizophrenia to a remarkable degree (7). We might also take seriously the ideas of relating therapy for voices and even the more radical, direct voice dialogue advocated by some (8). The implications for wider practice are also substantial - after all the difference between voice elimination/repression and integration/transformation cannot be overstated, although clearly some patients are likely to still favour a 'sealing off' recovery style.

Julian Leff's team and the editorial board of the BJP are to be congratulated for the publication of this paper. Greater insight into how the therapist learns to convincingly embody the patients persecutory voice, through the avatar, would however be welcome.

1. Bracken P, Thomas P, Timimi S, Asen E, Behr G, Beuster C, et al. Psychiatry beyond the current paradigm. Br. J. Psychiatry. 2012 Dec 1;201(6):430-4.

2. Priebe S, Burns T, Craig TKJ. The future of academic psychiatry may be social. Br. J. Psychiatry. 2013 May 1;202(5):319-20.

3. Collip D, Myin-Germeys I, Wichers M, Jacobs N, Derom C, Thiery E, et al. FKBP5 as a possible moderator of the psychosis-inducing effects of childhood trauma. Br. J. Psychiatry. 2013 Apr 1;202(4):261-8.

4. Moskowitz AK, Barker-Collo S, Ellson L. Replication of dissociation-psychosis link in New Zealand students and inmates. J. Nerv. Ment. Dis. 2005 Nov;193(11):722-7.

5. Rosenbaum M. The Role of the Term Schizophrenia in the Decline of Diagnoses of Multiple Personality. Arch Gen Psychiatry. 1980 Dec 1;37(12):1383-5.

6. Read J, Os J, Morrison AP, Ross CA. Childhood trauma, psychosis and schizophrenia: a literature review with theoretical and clinical implications. Acta Psychiatr. Scand. 2005;112(5):330-50.

7. Seikkula J, Alakare B, Aaltonen J. The Comprehensive Open-DialogueApproach in Western Lapland: II. Long-term stability of acute psychosis outcomes in advanced community care. Psychosis. 2011;3(3):192-204.

8. Corstens D, Longden E, May R. Talking with voices: Exploring what is expressed by the voices people hear. Psychosis. 2012;4(2):95-104.

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Conflict of interest: None declared

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