AVATAR therapy is a structured, computer-assisted psychotherapy designed for people with persistent, distressing auditory hallucinations that have not fully responded to medication. It was developed in the UK by Julian Leff and refined by Tom Craig and colleagues, and it has now been tested in two large randomised trials. The premise is simple, almost startling: instead of describing the voice in the abstract, the patient creates a digital face and a synthesised voice that match their internal experience as closely as possible. Then they speak to it.
AVATAR therapy is a brief, computer-mediated intervention in which a clinician voices a digital character matched to the patient's persecutory voice, helping the patient confront, contradict, and ultimately reduce its perceived power.
Where the idea came from
Many people with schizophrenia hear voices that make threats, give commands, or run a relentless commentary. Standard CBT for voices, described in our CBTp for voices guide, often makes a real difference — but a substantial minority of patients do not respond. AVATAR therapy was conceived as a more direct intervention. The idea was that talking back to a "voice" you can see is fundamentally different from rehearsing what you would say with a therapist. The avatar makes the abstract visible.
How a session is set up
The first session is technical. With the therapist's help, the patient designs the face and voice of their dominant persecutor on a screen. They adjust gender, age, ethnicity, expression, and pitch until the avatar feels close enough to the experience to be uncomfortable. Many patients find this stage emotional in itself; they have never seen the voice before.
From the next session onward, the therapist sits in a separate room with software that lets them speak through the avatar in real time. The patient sees and hears the avatar on a monitor; the avatar's mouth moves as the therapist's voice plays through the synthesiser. The therapist begins by voicing the kinds of things the patient has reported the voice saying — and then, gradually, lets the avatar concede, soften, and back down as the patient asserts themselves.
The arc of the work
AVATAR is brief — typically six sessions, sometimes extended. The therapist's coaching and the avatar's behaviour follow a deliberate arc:
- Sessions 1–2. Building a tolerable confrontation. The avatar repeats what the voice has said. The patient practises responding rather than listening passively.
- Sessions 3–4. The avatar starts to give ground when the patient pushes back firmly, modelling that the voice can be answered.
- Sessions 5–6. The avatar begins to acknowledge positive qualities the patient has, and the dialogue shifts from confrontation toward the patient setting limits the avatar respects.
Sessions are recorded, and the patient takes the recording home. Listening between sessions is part of the work — and is itself an exposure.
What the trials show
The AVATAR1 trial published in The Lancet Psychiatry in 2018 compared AVATAR therapy to supportive counselling in 150 adults with persistent voices. The AVATAR group showed a meaningful reduction in voice-related distress at 12 weeks, with effect sizes substantially larger than typical CBTp benchmarks. The follow-up AVATAR2 trial, published in 2024, replicated the work across multiple UK sites and tested a longer 12-session version. The shorter and longer protocols both reduced distress; the longer version had additional benefit on subordination beliefs about the voice. NIMH lists computer-assisted therapies of this kind as part of the active research landscape in voice-hearing.
Why it seems to work
Researchers do not yet have a single mechanistic explanation, but several effects are commonly described:
- The patient's sense of relative power over the voice rises. They have been talked at; now they are talking back.
- The avatar provides a predictable, finite version of the voice — it ends when the session ends.
- Confronting an external representation reduces the sense that the voice is omnipresent and omniscient.
- The recordings allow rehearsal between sessions, which generalises the new responses into daily life.
Who it is designed for
- People with persistent voices that medication has not silenced
- People who are willing to engage with a computer-based intervention
- People who have one or two dominant voices rather than a chorus
- People with reasonable reality-testing about the avatar — i.e., who can hold both that the avatar is a digital simulation and that it represents something distressing
Who it is not designed for (yet)
- People in an acute psychotic episode with very poor reality-testing
- People at high suicide risk who would not be safe with the rehearsal of voice content
- People for whom the voices are predominantly positive or longed-for
Practical caveats
AVATAR therapy is not yet widely available outside research and specialist clinics. Where it is offered, training is restricted; it is not the same as just letting a patient build an avatar in a videoconferencing tool. The therapist's pacing, the avatar's gradual concession, and the safety wrap around each session are essential. People interested in this therapy can ask their early intervention service or specialist psychosis clinic whether it is being trialled in their area, and can read the NICE schizophrenia guideline for context on where psychological therapies sit alongside medication.
If working with voice content in any format — therapy, journaling, role-play — increases thoughts of self-harm or harm to others, stop and contact your clinician or call 988.
Where it fits in the bigger picture
AVATAR therapy is not a replacement for medication or for broader CBTp. It is a focused tool for one specific, common, and disabling problem. Combined with maintenance treatment, peer support like the Hearing Voices Network, and a relapse plan, AVATAR can give people a felt experience of agency over a symptom that has often defined their lives for years.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.