AVATAR therapy for voices (Leff, Craig)

Domain IX · Biomedical, neuro & digital · Julian Leff, Craig · 2013

What it is

AVATAR therapy is a blended digital psychological therapy for people with psychosis who hear distressing voices (auditory verbal hallucinations), usually voices that have persisted despite antipsychotic medication. With the therapist, the person builds a computerised face and a matched voice (the…

Format

• Who it is for (trial criteria, the best available indication of suitability). Adults (18 and over) under a specialist mental health team, with frequent, distressing voices for at least 6 months (AVATAR2; at least 12 months and medication-unresponsive or partly responsive in AVATAR1), and a…
• Format. Individual sessions, weekly, about 45 to 60 minutes, typically in a clinic; the person and therapist sit in separate private rooms linked by the AVATAR software, with the therapist seeing the person by webcam. In AVATAR2, 87% received in-person treatment; a bespoke end-to-end encrypted…

Who practises it, and how they are trained or regulated

• This is a licensed, software-based treatment, not a technique that can be improvised. Its software (the Avatar Therapy System) is described by the AVATAR2 authors as registered as a Class 1 medical device, and NICE says the technologies in its 2024 early value assessment must be delivered or supported by a mental health professional trained in the technology. A psychotherapist wanting to start needs access to the…
• Regulatory and evidence status (as of October 2026 per the NICE HTE17 recommendations page and the KCL AVATAR-RW project page):
• NICE early value assessment HTE17 (reported in March 2024) says AVATAR Therapy can be used in the NHS for adults with psychosis to help manage auditory verbal hallucinations as an option while more evidence is generated, for 3 years; conditions include delivery or support by a trained mental health professional, appropriate regulatory approval including NHS England's DTAC (Digital Technology Assessment Criteria),…

Evidence status, as the guide reports it

• Evidence, attributed: AVATAR1 (150 participants, South London and Maudsley; versus supportive counselling) found a larger reduction in overall voice severity (PSYRATS auditory hallucinations total) at 12 weeks, reported by the authors as a large effect (d = 0.8), with the between-group difference…

Questions to explore with your client

• What drew you to it, and what are you hoping it will change?
• Does it involve any substance, plant preparation, remedy or supplement? Has your doctor or prescriber been told, especially about any medication you take?
• Does it involve intense or unusual breathing? Have you been told about the medical conditions for which that is not advised?
• Is it a group, retreat or community? How do they respond if someone wants to leave or raises a concern?
• How do you and the practitioner understand what is happening, in spiritual or cultural terms? Is that a source of comfort, worry, or both?
• Who runs it, and what training or registration do they hold?
• What actually happens in a session or meeting, and how often?
• What does it cost, and is there pressure to commit to more?
• How do you feel afterwards, in the hours and days that follow?
• Does it fit with, or clash with, the work we do here?

What practitioners of it watch for

• planned changes being too large; set small, specific steps.
• goals that are other people's rather than the person's own.
• ending on an attack when time runs out; protect time for the win.
• contact replacing sessions, or signs of deterioration in messages.
• the therapist's own cultural assumptions; let the person define their identity.

When to involve someone else

• New or worsening physical symptoms, or advice to stop or change prescribed medication: involve the client's doctor or prescriber.
• Signs of coercion, isolation from family and friends, escalating costs or secrecy: discuss openly and consider safeguarding.
• A crisis or thoughts of suicide: follow your crisis protocol. In the US, call or text 988; in the UK and Ireland, Samaritans on 116 123.

Drawn automatically from the guide's own sections. Stay curious: neither endorse nor dismiss what the client values, and check anything that matters against the full guide and its sources. Not medical advice.