‘Avatar therapy’ aims to help those who hear voices

The voices in Keris Myrick’s head are “in the kitchen,” she says.

She’s not referring to where food is cooked. The term “kitchen,” she said, is how many black women describe the nape of the neck “where our hair is curly and wavy; some people might use the term ‘kinky.’”

“The hair might look very pretty on top, but underneath, it could be a frizzy mess – and that’s where the voices reside,” she said. “They’re not up front bothering me or taking my attention away. They just hang out in that frizzy place.”

Myrick, now in her 50s, started hearing voices in her early 20s. They sprung up in the grocery store, telling her the food was poisoned. She stopped eating for months and was diagnosed with an eating disorder. It took years before doctors considered that her disorder might fall on the schizophrenia spectrum.

“The stigma kept me from being fully forthcoming, so how could they give me an accurate diagnosis?” asked Myrick, a former president of the National Alliance on Mental Illness, who also ran a large peer-led organization for people living with mental illness.

“I was embarrassed by it,” she said. “I thought that people would think I was the C-word: crazy.”

Face to face

For Myrick, the voices in the grocery store were nondescript, neither male nor female. She thinks the idea of poisoned food came from something much more everyday.

She remembers how her mother would reach back into the shelves, looking for groceries with later expiration dates. “Don’t take the first thing on the shelf,” her mother would say.

“I thought the voice represented something that was familiar in the way that we do things, not that it was a person … I could identify.”

But for many people, the voices they hear sound distinct – maybe even recognizable, like someone they know.

A group of UK researchers hopes to tackle those kinds of voices head-on, using technology to help patients whose auditory hallucinations won’t go away, even with medications and other treatments. Their method, invented in 2008, is known as “avatar therapy.”

Using a computer program, patients build a face to match one of their voices – moving sliders to thicken eyebrows, add blush to cheeks, reshape an avatar’s face and even change its race.

Sitting in another room, a therapist speaks through the avatar, using the software to change the pitch of their voice to match what the patients hear in their heads. Occasionally, the therapist chimes in with their own voice, offering words of encouragement.

Over six sessions, patients gradually stand up to their voices and try to build self-esteem. Meanwhile, the voice gradually surrenders.

“It’s not for everyone,” said Tom Craig, a professor of social psychology at King’s College London who conducts and researches avatar therapy. “Some people find it a bit too frightening to take the therapy on board.”

But some patients who choose to go this route have seen their symptoms improve: They had less frequent and less distressing auditory hallucinations 12 weeks later, according to a study published Thursday in the journal Lancet Psychiatry.

“You can’t have a dialogue or a conversation with a disembodied voice,” said Craig, the study’s lead author. He likened the therapy to a video game, which must be sufficiently “real” to get patients immersed “but modified enough to make it as safe as possible.”

“You can challenge that (avatar) much more than you can a voice that’s just in the air somewhere,” he said. “The face makes it work.”

After avatar therapy, patients also found the voices to be less “omnipotent” than they were at baseline, the researchers found.

“It’s essentially a rescripting … of the way that the person responds” to the voices they hear, said Paul Grant, an assistant professor at the University of Pennsylvania’s Perelman School of Medicine who has developed versions of cognitive therapy for people living with schizophrenia.

Grant, a faculty member of the school’s Aaron T. Beck Psychopathology Research Center, was not involved in the new study.

Though intrigued by avatar therapy, Grant said that more research is needed to show what about it seems to work, how well it holds up against other therapies and who might benefit from it.

For example, it may be the novelty of the technology that keeps people engaged, he said, rather than how avatar therapy structures the patients’ dialogues with their voices. “You could do the same thing low-tech if you role-play the voice,” Grant added.

Myrick, a self-proclaimed “geek,” can see the appeal of avatar therapy, though she’s unlikely to pursue it herself.

“This idea of putting a face to or personifying a voice, it doesn’t sound that odd to me,” she said. “I don’t know that I would like to do that in particular, but for some people, it’s super important.”

“Me in particular, I don’t care to explore what (the voices) are about,” Myrick said. “They’re hanging out in the kitchen. I don’t really need to know why they’re there, who they are or why they want to persecute me.”

‘Living a nightmare’

“It was like talking to a part of myself,” wrote one 40-year-old participant in the avatar study who answered CNN’s questions on the condition of anonymity. Having trained as a lawyer, he would often hear the voices of judges.

He said that hearing voices was “like a living nightmare” and that talking to his digital avatar – a round-faced man with long, wavy brown hair – helped him “wake up.”

Though patients in the avatar trial saw improved symptoms after 12 weeks, another group of patients caught up by the 24-week mark. They had received supportive, face-to-face counseling by psychologists that didn’t focus on directly addressing the voices. By 24 weeks, the researchers found no significant differences between the two groups. A handful of people in both groups stopped hearing the voices altogether during that time.

The study, which initially enrolled 150 participants and gathered 12-week data from 124, did not have a third group who continued only therapy as usual. No adverse events, such as self-harming or hospitalizations, could be linked to the avatar treatment itself.

Grant and Myrick wonder how the study’s results translate to the patients’ ability to thrive and engage with the world around them.

“They’ve always been focused on symptoms,” Grant said. “Symptoms can be there, or they can not be there. It doesn’t matter if you’re not in the life you want.”

Craig said that his study was neither big nor lengthy enough to show more definitive changes in how people lived their lives.

“Did anybody get a job? Did anybody go back to school? Did anybody get a boyfriend?” Myrick asked. “Hearing voices is one thing. Having a life is a whole different matter.”

Even for those who might benefit from avatar therapy, experts say, cost could be a barrier – both to patients who seek it and to therapists who must be trained and overseen.

“The UK has a universal kind of care, and we don’t in the US,” said Myrick, who nevertheless is encouraged that researchers are pushing forward with new mental health treatments.

Craig said it’s “not a cheap therapy at this stage” in that it’s being administered by a small cadre of highly trained professionals. On the other hand, the treatment comprises only six therapy sessions, and “there’s nothing in the therapy that I feel couldn’t be delivered by someone much earlier on in the course of their career,” he said.

When angels sing

Grant works with patients with severe forms of schizophrenia, but he said he focuses less on the voices they hear.

Whereas avatar therapy aims to suppress the voices in order to improve patients’ lives, Grant aims to change how they live their lives – and perhaps the voices will change as a result.

For some people, as they find a new job or build relationships, “the voice becomes less negative. And sometimes, it even becomes positive,” Grant said. “The voice is largely coming from beliefs that people have about themselves.”

Focusing on living life and staying occupied is partly how mental health advocate Myrick lives with her diagnoses, not by addressing the voices directly.

“I find that really focusing in on work and things that keep my mind super busy, engaged, challenged is far more beneficial for me,” she said.

The avatar treatment is not for everyone, as Craig said. For example, a number of people who have symptoms for the first time will no longer hear voices after conventional treatment, he said. The patients in his study had had symptoms for about 20 years on average.

Moreover, people must want to get rid of their voices – and many don’t, experts say. Sometimes, voices can be pleasant or helpful. Sometimes, a voice can be that of a loved one who died.

Myrick remembers one experience that changed the way she thought about the voices. Sitting in work one day, she began to hear angels singing. This was new, so she called her psychiatrist.

“It wasn’t distracting, but it definitely wasn’t in the kitchen,” she said.

Her psychiatrist asked why she was calling him. “Because I’m hearing angels,” she said.

“Are they bothering you?” he asked. Not at all. In fact, they were singing quite prettily, she told him.

If it wasn’t bothering Myrick, hearing voices wasn’t a problem on its own, he said.

Her psychiatrist recommended she hang up the phone and get back to work. Let the angels sing.