‘It felt good to be able to say that out loud’: A peer research qualitative study exploring therapeutic alliance and processes in AVATAR therapy

<b>Background: </b>AVATAR therapy is a novel psychological therapy which aims to reduce distress associated with hearing voices. The approach involves a series of therapist-facilitated dialogues between a voice-hearer and a digital embodiment of their main distressing voice (the avatar), which aim to increase coping and self-empowerment. Extending previous qualitative work on treatment acceptability, this study explored therapeutic processes which are distinctive to AVATAR therapy, including direct early work with voice content and the role of the therapist in dialogue enactment.<br/><br/><b>Methods: </b>People with lived experience relating to psychosis (peer researchers) contributed to each stage of the study. Peer researchers led semi-structured interviews which were conducted with nineteen participants who received AVATAR therapy as part of the AVATAR2 trial, including three participants who dropped out of therapy. Data were analysed using Interpretative Phenomenological Analysis (IPA; n=5) and template analysis (n=14).<br/><br/><b>Results: </b>Participants described the initial challenges of experiential work with distressing voice content; however, most reported a meaningful increase in power and control over the course of dialogues and improvements with voices in daily life. Strong therapeutic alliance was experienced by all participants, including those who chose to discontinue therapy, often mitigating the discomfort associated with initial challenges by enhancing their sense of safety. Several important themes relating to individual engagement were highlighted, such as the emotional intensity of the experience and the importance of participants’ determination and open-minded attitudes despite initial doubts. Those who decided not to continue with therapy described challenges with the realism of working dialogically with a digital representation of their distressing voice.<br/><br/><b>Conclusions: </b>This study has provided a deeper understanding of the experience of engaging in AVATAR therapy, in particular the challenges and opportunities of direct work with voice content. The importance of therapeutic alliance and establishing a sense of voice presence has been emphasised. Implications for the planned optimisation and wider implementation of AVATAR therapy in routine care settings are discussed.<br/><br/><b>Trial registration: </b>ISRCTN registry ISRCTN55682735 (Registration date: 22/01/2020)