Using Virtual Reality Social Environments to Promote Outcomes' Generalization of AVATAR Therapy for Distressing Voices: A Case Study.

AVATAR therapy (AT) works by facilitating a 'face-to-face' dialog between the person and a digital representation (avatar) of their persecutory voice. Although there is cumulative evidence of this way of working with voices, enhancing the therapeutic focus on improved confidence and a sense of control of the voices in social situations represents a promising way to boost the generalization of therapy gains into social contexts. This paper presents a descriptive clinical case example of AVATAR_VRSocial therapy, a new augmented version of AT incorporating immersive Virtual Reality to help the person deal better with their voices in daily situations. "Laura" is a woman who was hearing a very distressing, threatening voice. She felt anxious and distressed when anticipating hearing it and would engage in safety-seeking behaviors to prevent hearing the voice. Laura was supported to stand up to her avatar and regain power over it by using assertive responses, both in active avatar dialog and when exposed to the avatar voice in VR scenarios, which turned into reduced distress when hearing the voice in her everyday life. Laura's dialog with her avatar evolved into a more explicit exploration of the meaning and the purpose of the voice in relation to previous trauma and personal relationships. The additional work in VR appeared to facilitate exposure to social situations while hearing the distressing voice, without performing seeking-safety behaviors, and to allow for practicing strategies to reduce the voice's interference, which evolved from the dialogic sessions with the personalized avatar.