Digital Therapy Stops Auditory Voices

A new preprint analysis of the AVATAR1 clinical trial provides the first evidence for why a digital therapy for auditory verbal hallucinations works. The study identifies that reducing a voice’s perceived omnipotence and increasing a person’s assertiveness are the mechanisms that reduce voice severity and distress. This has direct relevance for understanding distressing internal auditory experiences.

How AVATAR Therapy Works: Two Core Mechanisms

The research team, led by Dr. Miriam Fornells-Ambrojo and colleagues, performed a mediation analysis on data from the AVATAR1 trial. This trial involved 150 participants who heard persistent and distressing auditory verbal hallucinations. They were randomly assigned to receive either AVATAR therapy or supportive counselling. The new analysis aimed to find out why AVATAR therapy was more effective than counselling, by testing which factors changed during therapy to drive the positive outcomes.

AVATAR therapy is a relational therapy. A patient works with a therapist to create a digital representation (an avatar) of their most distressing persecutory voice. In structured dialogues, the therapist—voicing the avatar—initially matches the voice’s hostility and power. The patient is then coached to stand up to the avatar. Over time, the avatar’s character is altered by the therapist to become less hostile and more conceding, shifting the perceived power dynamic.

Voice Omnipotence and Assertiveness Are Key

The researchers tested whether improvements were mediated by changes in six specific areas: beliefs about voice omnipotence, voice malevolence, perceived power differential, self-esteem, anxiety, and assertiveness toward the voice.

The results were clear. Across two different statistical approaches, only two factors consistently emerged as significant mediators. “Reductions in perceived voice omnipotence and increased assertiveness in relation to voices emerged as consistent mediators of AVATAR therapy on reductions in overall severity, frequency and distress,” the authors wrote. When patients came to see their voices as less all-powerful and felt more able to confront them, their symptoms improved.

Other factors did not mediate the treatment effect. Changes in how malevolent the voice seemed, the perceived power gap between voice and hearer, general self-esteem, and anxiety levels did not explain why AVATAR therapy worked better than counselling.

Implications for Hearing-Related Distress

While AVATAR therapy was developed for auditory verbal hallucinations in conditions like schizophrenia, the findings have broader relevance for tinnitus, misophonia, and hyperacusis. These conditions all involve a problematic, distressing relationship with sound or auditory perception.

The study identifies “agency, voice omnipotence and acceptance as intervention targets.” This suggests that therapies for tinnitus or misophonia may benefit from focusing not just on sound perception, but directly on a person’s perceived powerlessness against the sound and their ability to assert control within the relationship. The exploratory finding that increased acceptance and autonomy also played a role supports established approaches like tinnitus acceptance therapies, providing a potential mechanism for their effect.

This mechanistic understanding moves the field from simply knowing a therapy works to knowing which parts of it are essential for change. This can help refine and improve therapeutic approaches for a range of auditory disturbances.

Study Limitations and Preprint Status

This is a preprint, meaning the analysis has not yet undergone peer review. The conclusions require independent validation before being fully accepted into the scientific literature. The study itself has limitations. It analyses mediators only at the end of a 12-week therapy, making the precise timing of changes unclear. The supportive counselling control was an active therapy, which strengthens the findings, but the specific mediators might differ if compared to a different control condition or treatment as usual.

Finally, the participants had a primary diagnosis associated with auditory verbal hallucinations. Direct research is needed to test if these mechanisms—reducing perceived omnipotence of a sound and increasing assertiveness—translate to idiopathic tinnitus, misophonia, or hyperacusis populations.

Source:
AVATAR therapy for distressing auditory hallucinations: mediators of change in AVATAR1, a single blind randomised control trial with supportive counselling as active control (medRxiv preprint, 2026-08-13)