Julian Leff, Institute of Psychiatry
Schizophrenia is normally treated with medicines such as antipsychotics in combination with talking therapies like cognitive behavioural therapy. But now Institute of Psychiatry, London, researcher Julian Leff has discovered that asking patients to create a cartoon representation, or avatar, of the voices they hear can enable them to regain control over the condition and in some cases achieve freedom from these hallucinations altogether, as he explained to Chris Smith...
Chris - Tell us about your strategy; which involves cartoon avatars on computers.
Julian - Well, we know that most patients who hear these voices like Louise find it very difficult to confront them. Partly because the voices are quite vicious and they will say, “If you start talking to me, I will harm you or your family.” It’s very frightening and so, they recede into the background and don’t tackle them. But it turns out that a few people who are able to start a dialogue with the voices will overcome that fear, actually feel much more in control. And so, that was the start point for my work, trying to enable the patient to actually create a dialogue with this invisible entity. No one can see it, not even the patient, but they do have some idea of who it is. So, with my colleagues, two speech scientists that Geoffrey Williams and Mark Huckvale, we developed a computerised programme that enables a patient to choose the face that they thought belong to the person talking to them and also, the voice which was actually my voice as a therapist morphed into variety of forms and they chose the one that was closest to the voice they heard and then that was all put together in a programme so that you had the face, and the voice, and the lips of the face were synchronised with the voice.
Chris - And you would go and hide somewhere else so that you could communicate with them as though you were that avatar on that screen they were seeing.
Julian - That's right, yes. The patient will be in one room looking at a monitor on which their avatar appeared, the avatar they’ve created. I’d be in another room, which they couldn’t see it and didn’t know I was there, and I could speak in two different ways. I could speak through the avatar with my morphed voice and be the horrible persecutory avatar and then I could switch in a second to being the therapist speaking in my own voice by just having a click on a screen, one way or the other. So, I would say to the patient for example, “You're horrible. You don’t deserve to live. Punch yourself in the face.” And then immediately, I would switch to my own voice and say, “Don’t listen to the avatar. It’s horrible. It’s telling you lies. You’ve got to tell the avatar to go away and leave you alone.”
Chris - Did they believe you? Did they engage with this avatar?
Julian - Out of the 16 patients who receive this therapy, only 2 didn’t respond to the avatar, as though it was a real representation of the voice they heard. Only 6 sessions were given to each patient. Out of the 16, 14 of them accepted that this was the voice that they heard outside of the experimental session.
Chris - How do you evolve what the voice says to the patient over the course of the 6 sessions? You presumably don’t persecute them all the way through the treatment course.
Julian - No, not at all. The idea was first of all, to give the patients a sense that they could overcome the avatar and also, the avatar changes over the course of the 6 sessions from being persecutory and horrible and vicious to actually becoming friendly and offering to help the patient. So, there's a real sea change in the avatar’s persona and at the same time, the avatar agrees not to torment the patient anymore and to leave the patient in peace.
Chris - Does it work?
Julian - That’s the extraordinary thing. I was quite surprised by how well it did work. They were able to stand up to the voices, as opposed to the avatar when they're out in the real world. Furthermore, they were able to feel that they were controlling the avatar. One patient said to me, “They’ve stopped talking to me because they know I will answer them back.”
Chris - So, it does appear that it sort of hands control to the patient without ever having to dissuade them that the voices they hear aren't real because that’s the big thing that I think Louise displays, that she remains absolutely convinced that these are sounds coming from outside her head that are a third party.
Julian - You're absolutely right about that and one of the issues in this is that I’d take what the patient say at face value. I don’t say, “No. This is nonsense. This is your imagination.” I say, “Yes, you are hearing these voices. Now, I can hear them. Because you’ve created the avatar, I can both hear and see the person who’s persecuting you.” And that validates the patient’s experience so they no longer feel freakish. I'm sharing their experience with them.
Chris - What fraction of the 16 patients got some degree of improvement through doing this?
Julian - Virtually, all of them. Not the 2 who didn’t recognise that the avatar was the voice. They didn’t have any success at all, but the other 14 improved in various ways. There were highly significant reductions in what they perceived as the frequency and intensity of the voices and there was also a significant decrease in the persecutory nature of the voice, the fact that it was malevolent, dropped very considerably. Three of the patients to my utter astonishment stopped hearing the voice altogether.
Chris - Is there any possibility that this could represent a subgroup of people with Schizophrenia? Were they a certain select group of individuals who had a certain manifestation of the disorder or do you think this treatment could generalise to people with Schizophrenia at large and be a very effective, very cheap way to intervene?
Julian - All the patients that I admitted to my trial had to have had voices for at least 6 months that had not responded to the adequate doses of medication. In fact, all the patients but 2 were still on their medication. The 3 people who lost the voice, one had been hearing the voices for 16 years, another one for 13 years, and another for 3 ½ years. All of them lost the voice during the course of the therapy, and 3 months after the therapy had been completed the voices were still absent. But there were other patients in the trial who couldn’t tolerate the experimental situation. They couldn’t bear to hear the avatar saying these horrible things to them and they dropped out and others couldn’t concentrate on the avatar because they were hearing multiple voices that were talking very loudly over the avatar. So, it clearly will not work for everybody. It works best for people who hear one dominant voice. If there were 2 or 3 voices, I ask the patient, “Which one would you most like to be rid of?” And then we concentrate on that one voice. As we did with Louise, I mean, she was hearing voices from all over the place. But nevertheless, concentrating on one voice and getting her to feel in control of that one voice actually generalised to her, not hearing those voices anymore.