The newly developing Avatar therapy has been hailed by many as ground-breaking, a fantastic break-through, an alternative to drug treatment where the drugs aren't working. On the other hand the biological believers (people who think schizophrenia is a biological disease that needs biological interventions) look on sceptically; pointing to the small scale of the research. It must be a bit of a shock to many conventional schizophrenia researchers because it’s actually a psychological approach that is getting attention; not a gene discovery or a wonder drug. Meanwhile those in the hearing voices movement (including me) also ask questions; suspicious of scientists - posing as voices - getting a lot of attention for a snazzy-looking role-play. So what is all the fuss about?
The initial pilot study created computer generated images -avatars - designed to look like each person's voice. The therapist sat in another room and said aggressive things via the avatar and the person was encouraged to stand up to their voice and gradually the avatar voice became more friendly. In a BBC News health article by Lorna Stewart, Julian Leff said:
"I encourage the patient, saying; 'you mustn't put up with this, you must tell the avatar that what he or she is saying is nonsense, you don't believe these things, he or she must go away, leave you alone, you don't need this kind of torment'... The avatar gradually changes to saying, 'all right I'll leave you alone, I can see I've made your life a misery, how can I help you?' And then begins to encourage them to do things that would actually improve their life."
The research started off with 26 voice hearers but by the end of the six 30 minute sessions only 16 had completed the course. For the people who completed the course the results seem promising. For nearly all the last 16 there was a reduction in frequency and severity of the voice hearing and three of the participants stopped hearing voices altogether. It’s reported that that the reason 10 did not complete the course is because they were bullied by the voices into stopping.
O.K., I need to admit something here; I am confused! Why? Because I personally have had a very mixed reaction to this Avatar therapy news that includes fear, jealousy, excitement and hope.
I am jealous of the attention this research is getting! Not only did Avatar therapy get good publicity but there is 1.3 million pounds being put into the follow-up research (by the Wellcome Trust), this time with 142 participants. Why has this research generated such interest? Usually society does not want to know about therapies for voice hearing. In our culture there is a massive fear of hearing voices other people can't hear. These are the demons of our nightmares, and psychiatry's attempt to deal with them with sedating drugs and disease terminology does not seemed to have helped increase our understanding.
I wonder if the invisibility of voices makes them more scary and, by putting a face to the experience, people are able to be more interested. In Hearing Voices groups we have done something similar; not with computer-generated images but with finger puppets of people's voices. For example; you can make constructive voices finger puppets and get them to dialogue with the aggressive ones.
But finger puppets don't have the same science fiction appeal, so I won't get my hopes up for a million-pound research project into finger puppet therapy. But maybe this is the beginning of more open-minded approaches in the mainstream... Maybe I should get off my 'holier than thou' horse and offer to collaborate. I guess I would love for Hearing Voices groups, and the dialogic approaches I and others use, to start getting such interest.
I am worried at how the researchers and the media equate aggressive voice-hearing with schizophrenia. There are huge problems with the diagnosis of schizophrenia. It lacks scientific validity and presupposes long-term chronicity and biological abnormality. A growing proportion of psychologists in the U.K. no longer use the term schizophrenia because it disguises the unique and complex psychological confusion people are experiencing. The diagnosis itself creates a sense of hopelessness and a lack of curiosity about the meaning of people's experiences.
Yet the media ignores these problems, as do funders of therapy research. There is growing evidence that hostile and controlling voices are linked to traumatic childhood experience, so it is worrying that researchers at UCL are not making these links. I appreciate the dilemmas researchers are in; they want to do innovative research but they are framed by the parameters of the dominant ideology. Perhaps they feel that if they do not use concepts like ‘treatment-resistant schizophrenia’, or mention trauma, they won't get the funding.
At the same time I am excited because the researchers use the term 'dialogue' quite a bit. Now I think the type of dialogue Julian Leff seems to be encouraging is a little simplistic and hostile, i.e.; 'be nice to me or go away'. But its a start. I teach people to be assertive but non-aggressive to the voices. Once the person is able to stand up to the voice we also try to get a sense of the emotional life of the voice itself. I have found once the voice has the experience of having its feelings and needs listened to it very often starts to become more constructive. I feel encouraged that Julian Leff and his colleagues seem to be encouraging this constructive relationship to emerge by acting it out in the role-play they do via the avatar.
In the media coverage of this there is a lot of talk of 'controlling voices', 'silencing voices' and 'taming them'. One of the researcher talks about 'shifting' them. Much is being made of the fact that 3 of the participants’ voices stopped altogether. In my experience some voices are fairly simple replays of abusive characters from the past. I have found that if the person learns to confront the memories - e.g.; through confronting the original person in a role-play - these voices do disappear. I think this is probably what happened for 3 of the participants.
However many voices appear to be more complicated parts of consciousness, with their own personalities, and in my view we should not try to get rid of them. Rather we should seek to set boundaries with them (as the study does) but also, if they persist, it is often very helpful to dialogue with them.
This means dialoguing not with an avatar but directly with the voice. We call this approach 'voice dialogue' or 'talking with voices'. Therapists or supporters can help the person learn new ways to to relate to the voice; being assertive, but also friendly and compassionate.
We have this macho approach in the West to conquer, and control; I think it’s misguided. Aggressive voices seem to be messengers about emotional conflicts in the person's life. We can see them as separated-off parts of the person that are carrying painful emotions. While we want to empower the person to be assertive we also need to acknowledge the voices’ painful feelings. This is not something that can be done in 6 brief sessions. So I am worried if Avatar therapy is seen as a quick fix. Ideally I want us to help all people who hear voices so I am interested in the 10 people who dropped out. Confronting terrorising parts of your mind is really tricky and you need a lot of support. I hope the researchers become interested in creating safe-enough spaces that allow more people to try to learn to change the power relationship with their voices.
Aggressive voices are often protecting terrifying memories the person has dissociated from. So when the person learns to confront the voices they then often need to confront difficult emotions and memories. We need to give people the opportunity to do this integrative work and very often it needs significant time and space. It’s well worth doing because it can take people out of a dis-empowered and passive role in their lives. However; resources are needed that are not just 'brief therapy interventions' if we want to make the psychological benefits sustainable.
In some ways the Avatar therapy reminds me of the Wizard of Oz. Initially, the Wizard seems to be all powerful, but his huge head turns out to be an illusion conjured by this little ordinary man. By acting out voices using avatars or puppets we can make the experience less scary. I think it’s a great beginning to learning to face our fears and our voices. I guess I would like the principle of role-playing voices (or other difficult relationships) to be something that is not seen as a sophisticated therapy, that only highly trained professionals can do. After all; children do it with their teddy bears.
In the film Avatar, the indigenous Na'vi turn out to have a wisdom about life that humans can learn from. At present the Avatar therapy's main aim seems to be to make the person more assertive and to try to control the voices. My hope is that it develops to not only strengthening the person but also learning from the voices. In the film Jake is struggling to breathe without a respirator on the planet Pandora and by connecting with the Tree of Souls he is transformed so he can breathe. Previously humans were trying to destroy the Tree of Souls to exploit the planet's resources. Aggressive voices seem to have their social origins in an atmosphere of violence and denial.
I think if we connect with the energy of voices non-judgementally we can participate in a healing process that is transformative for the people involved. People can reclaim their fighting spirit and have buried truths acknowledged. I have found that supporting people in this integrative and respectful approach to voices is a powerful and humanising process for me, as well. It puts me in touch with my unheard and buried energies. So it’s important to move away from therapy warfare - against voices and each others’ different approaches - and come back to a non-aggressive approach to our experiences because that is where the life energy truly is.
I think Avatar therapy is encouraging because it is trying to simulate and understand voice hearing. Where voices endure I would like the researchers to strengthen their intention to support dialogue with the voices (or beings) people are living with. I would also like the researchers at University College London to perhaps be clearer on the philosophy behind their approach. Are they trying to silence voices or are they trying to learn from the voice hearing experience?