This is The Guardian. Today, Avatar Therapy, the sci-fi treatment for psychosis that really works.
Hello, I'm Jonathan Friedland from the Politics Weekly America podcast. Donald Trump has started his second term. It's going to be a turbulent period and the Guardian will be here, covering it all. We have no billionaire owners or shareholders pulling at the purse strings. So if you can afford it, please do support us. Every contribution powers our independent journalism. Do click the link in the episode description.
A quick warning before we start, this episode discusses suicide and self-harm, but I would really urge you to listen if you can because it's ultimately an extremely uplifting story.
When I think back, sometimes were quite hard. I had some traumatic experiences early on. One of my parents was an alcoholic and had serious mental health issues as well. They all suffered quite badly, but I didn't act out when things happened to me. I just carried on and I don't think anybody noticed really that I was struggling.
This is Claire. I had quite a lot of friends and I did alright at school, I did quite well, but then things just continue to be pretty bad.
I was just turned 10 and I was in my bedroom. It was a summer, late spring, summer evening. And I obviously was feeling quite low. And this male voice just spoke to me out of nowhere and told me to jump out of my window.
The first voice kept returning, always when she was alone in her room. Sometimes I actually sat on the ledge and it would be saying go on, go and do it, do it. But the more pushy he got, I kind of reacted to it and thought, no, I won't do it. But I was tempted.
Claire didn't know it then, but she was experiencing psychosis, which caused us sufferers to lose contact with reality, hearing or seeing things that don't exist. The older I got the worse they got, they started threatening people I cared about. They would tell me to kill myself as well, and I did make attempts on my life. Psychosis affected every aspect of Claire's life, making it impossible to hold down a job or a relationship.
And then, after decades of lonely torment, she took part in a clinical trial that changed her life. From the Guardian, I'm Helen Pitt. Today in focus. How computer games inspired a radical new treatment for psychosis, allowing patients to confront their demons.
Claire, you told us about that terrifying experience when you were just 10 years old, and you heard a voice telling you to jump out of a window. What did you think that you were hearing? I didn't really have an explanation of it. You'd think you'd be frightened, but I wasn't. Maybe it was because I was a child as well. You fear things more when you're older, I think.
It was actually external, it was actually into my ear rather than in my head. You can sense the presence of them as well. It's not just a voice out of nowhere.
Right. Okay. I think it's hard for people to understand who haven't experienced that. So I think it's really important that you've clarified that. And how did this evolve from the age of 10? So you initially had this male voice. Did other voices come and talk to you as well? So it happened on several occasions, only when I was on my own in my bedroom. And then I heard a second voice when I was 13. And that was being very abusive towards me.
What sort of things were they saying to you? It was just torment, really. They were telling me to kill myself, to harm myself, name calling, putting me down. I was actually on a school holiday and was bullied there, and I think that's obviously why it came. And I sort of said, oh, shut up, out loud, and people laughed and said, there's no one there, Claire. And then I knew I couldn't tell anybody.
In fact, I didn't tell anybody until my early-to-mid-thirties that I heard voices. Really? Hmm. It was to be incredibly isolating and you said that you weren't telling anybody about this for decades. Yeah. And in terms of the impact that it had on your life,
What did it do to your relationships, your ability to work and study and lead a kind of normal life? I just wasn't able to. I did manage to go to university, but I had to leave after my second year. I couldn't complete my course and I couldn't hold down a job really.
not really been able to have a relationship. I had friends but I was so worried about them finding out. I was afraid people wouldn't want to know me anymore or friends wouldn't want me to see their children and things like that because of the stigma. That was to felt very lonely. Were there times in your life when you ended up in psychiatric care? Were you ever sectioned?
Yes, I first saw a psychiatrist when I was about 20 where I broke down at university. And then my first day, I was about 25. I wasn't sectioned then. But as time went on, yes, I've been sectioned quite a few times and also by the police who found me in a distressed state. Did you know what it was? Did you have a diagnosis for yourself at that point?
Yeah, I've had many diagnoses, sort of ranging from depression, mood disorders, and then obviously where I did eventually open up to hearing the voices, it was a psychotic depression and some other diagnoses with psychosis.
And what sort of treatment did you receive? Did any of it help with the voices? Just medication really, antidepressants and then other mood stabilizers, antipsychotics and talking therapy as well, which was helpful for the trauma and things like that, but it never helped with the voices.
Jenny Kleeman, you're a journalist who specializes in exploring how technology can affect our lives for better and for worse. And you wrote a really fascinating long read for The Guardian about a truly exciting new treatment for people suffering from psychosis. We've just heard from Claire about how she suffered with psychosis and it was clearly very distressing and lonely for her. Can you allow him for us what causes psychosis?
Psychosis is when your experience of reality is interrupted by hallucinations or delusions and for a lot of people it means hearing voices without any external evidence of those voices but it can also be visual hallucinations and it can also be a sort of sense of a felt presence
And it's surprisingly common around two or 3% of people experience psychosis. And when people do hear voices quite often, the voices can be saying some quite distressing things, quite often really persecutory, degrading, sexually shaming, you know, racist content, horrible, horrible things. Like the worst stuff that you could ever hear is what these people hear on a daily basis. It's an incredibly unpleasant thing to be living with.
And is it a condition in itself or is it a symptom of other psychiatric disorders like schizophrenia, for example? Psychosis is an umbrella term. So people with schizophrenia experience psychosis. It's a symptom of schizophrenia, but it can also be a symptom of severe depression. You can also hear voices or have hallucinations without any other mental health diagnosis. And do we know what triggers it?
There are different schools of thought about what causes psychosis. It's an interplay of lots of different factors. There are hereditary factors that if you have a parent who's experienced psychosis or has schizophrenia, you're more likely to be diagnosed with it yourself. There are environmental factors, for example, if you
take drugs and have a horrific drugs experience that can trigger something if you have a predisposition to it and there's no consensus about the extent to which trauma can trigger psychosis but I think it's fair to say there is a widespread belief that there is a correlation between trauma and psychosis and people who have gone through trauma like abuse or being severely bullied or having gone through a
incredibly frightening experience that's shaken their sense of self, that that can trigger psychosis. But the point is nobody really knows what causes psychosis.
Yeah, Claire told me that she suffered a lot of childhood trauma, and it seems very likely that that would have played a role in her developing psychosis, and she did receive quite a bit of treatment over the years, she was sectioned multiple times, but nothing seemed to make the voices go away. How has psychosis traditionally been treated?
There are pharmacological approaches, medicines, and there are psychological approaches, and no approach is perfect. Since the mid 20th century, there was a kind of revolution in antipsychotic medication, and it was found that certain kinds of medicines could stop people from having psychotic episodes. But these medicines come with really serious side effects.
weight gain, sexual dysfunction, bed wetting, exhaustion, all sorts of really horrible side effects potentially. And they also only work for a certain subset of people. They don't solve the problem for everybody. And then there are psychological approaches, things like cognitive behavioral therapy for psychosis,
which can also be effective for some people, but there is still a really significant number of people for whom nothing really works and the voices persist. Okay, so traditional treatments don't seem to help everybody, including Claire, but you've been following closely the development of a new and some would say radical form of treatments called avatar therapy. What is it?
I first heard about it in 2013. So when I first started trying to get access to this story, I had no children. And now I've got an 11 year old child. So that's how long the gestation of this story has been. I heard about the results of the pilot study conducted by Julian Leff, who passed away a few years ago. He's the man who came up with the idea of avatar therapy when he was watching his children play around with computer games and choose avatars.
And that's what made him think, ah, what if I can actually manifest the voices that people hear in their heads and experience them as real external voices and having something they could face whilst being next to their therapist, because this is something that has been real only to them. And I thought this really sounds like my kind of thing, because I write a lot about the kind of intersection of really difficult human problems and technology.
And I always wanted to follow somebody going through this therapy because it sounded like something incredibly human that is only being enabled by a piece of digital technology.
And how does this kind of therapy work exactly? Talk us through it. The principle is that you sit down with your therapist and design the avatar. And I had an insight into the avatar design process. It's quite amazing. You have to first choose whether or not the voice that you're manifesting in digital form is a human or a non-human entity. And if it's human, you get to choose is it male or female? Is it old or young?
what's its ethnicity, and then you can change the shape of the nose, the eyes, the mouth. You can style its hair, all sorts of different things. If it's a non-human entity, you have to choose, be very specific. Is it a devil? Is it an alien? Is it a monster? All sorts of different possibilities. And then you have to pick the voice, and the voice is the really important thing, not so much the face.
you choose what kind of voice it is. Is it male, female, high or low, rough or smooth? And whilst the actual image of the avatar, I mean, when I was looking at it, it was good, but it would be difficult for me to suspend disbelief that I was talking to a real person. For the patients that I listened to, it didn't really matter if the face didn't look quite right. It was the voice that really jolted them into believing that they were listening to the voice in their head.
So once the patient has created their avatar, what happens next? Can you give us a sense of how these conversations unfold? The therapist is in one room and the patient is in the other and the therapist can watch.
the patient in the other room over webcam. And the therapist plays two roles. In one respect, using their own voice, they are the therapist. They're to guide the patient and help them. But a click of a mouse and they become the voice of the avatar. They're a kind of puppeteer of the avatar. So the avatar's mouth moves in sync with the therapist's voice. And the patient and the therapist will have had a discussion beforehand about the kinds of things that the avatar is going to say.
and how the patient might want to respond to it. And in the first few sessions, that is what the therapist through the avatar will be saying to the patient. Yeah, I looked up an old clip online of somebody demonstrating how it works, because I was really curious to hear what one of these avatars sounded like. You're lifeless. You're a waste of space. You're a life-staring murderer.
During the avatar therapy, the therapist can always switch into their own voice and coach the patient, guide them, advise them, give them possibilities of how they might respond to the avatar. I want you to talk back to the avatar as strongly as you can. No, it's not true. I'm not worthless and I don't have to listen to you saying that.
And then the dynamic changes over the course of these 12 sessions. And the avatar gradually becomes more submissive as the patient becomes more empowered. There's lots of good things about me. I don't have to listen to you saying I'm worthless. I'm a good person. And the things you're saying I'm true. I did the shopping for my mom. That's a good thing to do.
That's really good, Owen. You keep going and telling the cool little things that you've done. I've come here to do this, to speak to you, and it's not fair, you're saying that I'm worthless. And by the end of the session, the avatar and the patient will have come to a kind of understanding and an agreement on how they're going to interact going forward in a way that isn't so distressing for the patient. I'm saying I'm having a stretch here.
You've done some things to think about me.
And one of the most interesting things is a principle behind all of this is that you never break the fourth wall. The therapist and the patient at all times must treat the avatar like it is an entirely real external being. And the avatar, because it's not the therapist, can do outrageous things. The avatar can say things that are lies, can say things that are wrong. The avatar can even suggest self-harm.
If there is a clinical benefit in the patient answering back and saying, no, I don't want to end it. I have a good life. People love me. And I think on balance, I want to live here. I want to be alive.
That sounds potentially quite dangerous. It sounds really dangerous. And when I first heard it, it was when I was listening to the recordings of these sessions, and Tom Ward, he's an extremely experienced psychologist and a clinical lead on the trial, was doing the therapy. And he suggested to this young man who had interviewed and spent a lot of time with, through the avatar, he said, you should end it.
And he said, you know, you would never use that on the first session. You would only use it when you'd done a risk assessment to know that the risk of suicide was minimal and that there was real benefit in getting the patient to articulate their reasons for wanting to stay alive. And presume the aftercare is really important after these sessions.
Well, I mean, in the immediate aftermath of the sessions, the sessions themselves are not long. They're about 10, 15 minutes each. And there's a lot of leading up to the sessions. There's a lot of debrief after the sessions. And I think in the trials that kept in touch with the patients for quite a long time, because it's pretty strong stuff. People do drop out. They did drop out of the of the trial. They said it was too much for them, but none of them have had any serious deterioration in their condition as a consequence of having had avatar therapy.
And at what point during that trial did the researchers start to see we're onto something here? This could be actually a really powerful clinical therapeutic tool.
So the first trial was a pilot trial on 16 patients, all of whom had had persistent voices that were treatment resistant. So they had been on drugs, they had had all the talking therapies possible, and they still heard voices for years. And Julian left found that for three of the 16 patients,
After a few sessions of avatar therapy, the voices went away entirely, which was not what he was expecting. He was expecting people to feel less distress, but not for the voices to disappear. And these are people who have never been alone with their own thoughts or haven't been alone with their own thoughts for decades, suddenly being in peace and quiet. For most people, the voices remained, but they were much easier to manage and they could go on with their daily lives. They could hold down jobs, all the rest of it. Incredible.
So after this pilot trial, there was the Avatar One trial, which was a way of seeing, was the pilot study just a consequence of Julian Leff's magic touch as a therapist, because he was a very, very experienced clinician, and 150 patients were involved in that trial.
And Tom Ward and Tom Craig conducted the therapy. And Tom Craig told me, and he is somebody who was also a very, very experienced psychiatrist, had been working with people who hear voices for decades. And he said, within the first one or two sessions, it was just incredibly clear that they were dealing with something really powerful and transformative.
And then the Avatar 2 trial, which is the one that I had access to, you needed to be somebody who had heard voices for at least two years. And they accepted a wide range of people, think nearly 350 people eventually were on the trial. Seeing whether or not the therapy could work if it was rolled out in different locations around the country and a wide range of therapists were trained to deliver the therapy. So it wasn't just
very, very experienced psychologists and psychiatrists. It was people at all sorts of different stages of the career. And the point of that being is they're trying to see whether or not this could be an NHS treatment. Is this something that you could have in centers all around the country?
to see if it's kind of scalable. Yeah, absolutely. Yeah. So the Avatar 2 trial results were published at the end of October and they were remarkable. They showed that Avatar therapy is more effective in reducing distressing voices than any other non-pharmacological treatment available.
The vast majority of people involved in this trial, it made their voices more manageable. It meant that they could get on with their lives. For a significant number, the voices went away, but that was not the objective of the treatment. The objective of the treatment was to make life better for people who are living with these very distressing voices.
And the other treatments available CBTP cognitive behavioral therapy for psychosis takes a lot longer. It involves more sessions. It involves a year of working with a patient. Avatar therapy is just 12 weeks. So potentially here is something that could be cheaper and more effective than all existing psychological therapies at the moment for psychosis.
Claire, you were accepted on the Avatar 2 trial. How old were you at this point? I was actually 50. So you'd been struggling with this for 40 years? Yes. Can you talk us through the process of creating this digital Avatar?
Did you have a very clear idea in your mind what the voice looked like? For me, I had a clearer picture of what this voice looked like. So it's mid forties with very dark eyes and dark hair and dark beard as well. You look frightening. And once you had worked to create this avatar, was it convincing? What was it like for you to look at this?
creation. It wasn't 100%, but it was the voice that hit me like a jolt. I knew that was right. That must have been quite a moment when you heard that. Yeah, it startled me and I think my therapist knew. She knew she'd got the right one as well.
And what happens next? You've created the avatar. How does the session play out? So you sit with the therapist for a while and come up with what you would like to say back, being assertive, well, trying to be. And the first session was
Yeah, I was terrified, really. And it was only about five minutes, the first session. But something had changed because I did answer back. They were telling me to stop my medication. And then I just said, well, it's not a good idea to just stop. And he said, who says? And I said, well, everybody really, everybody else. And apparently that was a big breakthrough. Never spoken back to them like that.
And it just kind of grew from there, really. And how many sessions did you have in total? I had 12. I had the extended version. And at what point did you realise that it was helping? Well, probably the sixth session about halfway, they started to reduce and then buy about, yeah, a couple more weeks have disappeared completely.
And what was it like, you know, for the first time in 40 years, being alone in your thoughts and not having any of these voices talking to you? Very, very weird, very weird, but in a good way. I actually felt the loss because I'd had them for so long, 40 years. And at times it was, it was also a sort of company. So it was quite sad, but positive as well.
And tell me about that final session. Well, we planned it so that I was able to say goodbye and wish them well. And he said that they would be there alongside me, but it's a distance. And that sort of meant that I know they're in the background protecting me, but they're not there, really.
It's very interesting hearing you say that because I think a lot of people might imagine that you would want to say good riddance. Be gone with you. I never want to hear from you ever again. So to kind of wish them well, it's quite something. Well, now I know they were my survival self, gone haywire.
because they wanted to protect me from all the hurt and pain and what's the best way but to not be around anymore. Even though it's so violent and abusive, what they were asking me to do to myself, it was still protection.
And tell us about your life now, four years on after undergoing avatar therapy. Well, everything's just so different without the voices. Working now, it's only part time, but, you know, I'm getting there and...
People have really noticed the change in me as well. I'm more confident. I wouldn't have done anything like this. It would have been hidden away. I think my friendships have got better as well and I've been able to get involved with further research as psychological research, as someone with lived experience. So I'm able to help other people and hopefully help them to promote avatar therapy.
It's just transformed my life, really, for the better.
I'm really, really happy to hear it. And I understand that all patients on the avatar trail get the avatar to take home. I don't know if that's all on a CD-ROM or a tape. Is that in a drawer somewhere locked away? No, it's not locked away. It was in a drawer, but I can listen to it whenever I want. And I listened to some of the earlier sessions a few days ago.
And I could just feel how hard it was for me. I could sell the strain, you know. But I can see it with different eyes now as well. I'm not back in that place where I was hearing them. And some people might find it very surprising that you would want to listen back years on, that that could have the danger of opening up old wounds. It sounds like you find the opposite.
Yeah, the opposite. It shows how far I've come. Coming up, what does the future of Avatar therapy look like?
Hello, I'm Jonathan Friedland from the Politics Weekly America podcast. Donald Trump has started his second term. It's going to be a turbulent period and the Guardian will be here, covering it all. We have no billionaire owners or shareholders pulling at the purse strings. So if you can afford it, please do support us. Every contribution powers our independent journalism. Do click the link in the episode description.
Denny, it's quite remarkable hearing the impact that this therapy has had on Claire's life. And I'm curious, what happens next? Is this gonna be something that's available for more people?
So, NICE hasn't approved it for use on the NHS yet. There's going to be a kind of pilot study to see if it works in NHS settings. That's happening. But there's now going to be an Avatar 3 trial, which is really, really interesting. There's two parts of the Avatar 3 trial. The first is to check whether or not it works in a context
outside Australia, Canada and Europe, which is where these trials have happened so far. So they have pilots taking place in India and I think Ethiopia to look at sort of different cultural contexts as well. And the other thing the Avatar 3 trial is investigating is whether or not you could use a fully digital avatar voiced by an artificial intelligence to have the dialogues.
what are the implications of using that? Because, of course, if you could have a fully digital avatar, then you could roll this out very, very quickly and very widely. And that kind of made the hair on my next stand up a little bit, the idea of... Yes, I blanched when you just said that. Yeah, because, you know, it's, would you want
the most sensitive content in the world to be delivered to you by a machine. And of course, that's why they need to explore this. I was told that a human being would always be involved in the process, supporting the patient and also making sense of what was happening in the dialogues. But yes, it was something that instinctively made me feel uncomfortable. And is there a sense yet whether this kind of therapy could be broadened out and used to help people with other psychological conditions or the mental health conditions?
That's what's really exciting. There are some pilot studies that have shown that avatar therapy can be used for eating disorders, avatars used to embody the anorexic voice. And that's really important because eating disorders are among the most lethal of all mental health conditions.
But they're also seeing whether or not this therapy could work with severe depression, with obsessive compulsive disorder. It's an entirely new approach. And so far, the results have been encouraging, but they need to be investigated more fully.
It sounds really exciting and it's quite refreshing actually to have a conversation about technology and AI potentially that isn't dystopian and doesn't make, I mean, I am unsettled by hearing what you're saying, but it does seem to be quite refreshingly optimistic.
So much so. I mean, I have, for a large part of my career, I have focused on the implications of dystopian technology. And this was something that I found so incredibly encouraging and positive. And I guess that's because it's using digital tools.
to do something incredibly human, which is to have dialogues and negotiate and to feel empowered by talking about things. And, you know, it's not often that I see a new technology and just feel incredible hope. Jenny, thank you very much. Thanks so much for having me.
That was Jenny Kleeman. I really recommend you read her long read on avatar therapy at TheGuardian.com. It's headlined, you tried to tell yourself I wasn't real. What happens when people with acute psychosis meet the voices in their heads? Thanks to her and to Claire in particular for sharing her experiences with us. Claire, by the way, is not her real name.
And that is all for today. This episode was produced by Eli Block and presented by me, Helen Pitt. Some design was by Hannah Varrell and the executive producers were Elizabeth Cassin and Homer Khalili will be back tomorrow. This is The Guardian.
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