Table 3 Emerging themes and sub-themes of the thematic analysis
Themes | Sub-themes | Quote example | Percentage of participants |
|---|---|---|---|
1. AVATAR therapy set-up | Concerns about technology | “And you all can find these (avatars) creeping onto the internet. It might not be anything to do with us, but somebody else will think of an avatar…” | 7 (50%) |
“I was not concerned. No, not really” | |||
Satisfaction with software | “It (the software) was kind of basic, but it kind of did the job, ?, I think. I don’t think it should be too complicated to be honest. I think it was just about right.” | 11 (79%) | |
MP3 usage | “Eventually, I started, I started listening to it more, at the beginning I didn’t feel monitored, you know.” | 14 (100%) | |
“I was using it around 3–4 times a week when …; at the moment I’m not using it, I don’t have my voices this much” | |||
“I have enough with my voices when their troubling me, why listen to it when there not troubling me.” | |||
2. Voice embodimenta and associated emotions | Strong emotional reaction (anxiety, fear, embarrassment) | “I was frightened of getting retaliation from my voice” | 9 (64%) |
“The emotion of fear was one of the greatest, I say fear” | |||
Sense of voice presence & realism | “It shook me, you know what I mean, wow. I thought wow, you know. Erm… That’s very close to the bone, do you understand what I mean?” | 11 (79%) | |
“Very real yeah….definitely. It used to make me jump when it first came on screen and talk to me it was like (giggles)…” | |||
Reactivation of memories/re-experience of trauma | “It made me think (of) what happened to me and I was thinking maybe I might not come again because of what happened and because the session made me remember what happened to me before.” | 6 (43%) | |
“AVATAR (therapy) with me started off when I got ill, it went back in time, and I think that shook me with memories of the past.” | |||
Working with only one voice | “I think it was sensible to only work with one… otherwise I would get confused as well.” | 6 (43%) | |
“I thought that was a good idea, to actually explore the voice, the main protagonist voice a little bit, and see what we could do with it.” (1310) | |||
3. Safe space facilitated by therapist support | Feeling supported by the therapist | “He seemed to listen, he seemed to listen quite well and he seemed to be… And he gave me a lot of positive reinforcement and told me how well I was doing, and stuff like that, which was nice. Erm, so yeah, he was quite supportive throughout the whole process, yeah” | 14 (100%) |
Feeling anxious when talking to the avatar | “I used to just babble you know, just babble. Just try and say anything, because I had already forgotten what the therapist said to me, you know.” | 13 (93%) | |
“It was hearing the horrible words that was speaking back to me. I didn't like it. I didn't like it at all.” | |||
Therapy expectations (hopes/fears for therapy) | “Exceeded them” | 9 (64%) | |
“No, I didn’t have any expectations at all, no. No idea, no. I just thought it was an interesting idea” | |||
4. Learning new ways of relating to the voices | Confident standing up to the voice | “Because the avatar started backing off, because as I started confronting it, the voice started backing off and getting less powerful, so I started getting more power over it as the sessions progressed” | 10 (71%) |
“It was really great, really really helpful. Because ever since I started the avatar and even when I stopped seeing my therapist, the avatar has really helped me in the way of talking back (to my voice)” | |||
Disengage from the voice | “I’m trying to get out about a bit more, because I can get a bit trapped in my own flat sometimes and everything gets too much” | 4 (29%) | |
“Actually, (what I) mostly did is try to ignore the voices or thinking you know, not giving back, but you know, give it a reason, you know” | |||
Reduction of fear/anxiety linked to the voice | “(After the therapy) You’re not getting distressed, you’re not getting into panic, you’re not being irritated by your voices.” | 7 (50%) | |
“When I’m out socially and stuff, the voice, it’s a bit… it’s a lot more, erm, less stressful, like buying, shopping or going on the buses and stuff like that.” | |||
Making sense of the voices | “… I suppose it’s challenged the whole idea, because one part of me says oh it’s not real, it’s just your own imagination, doing all this. But it happens all the time, and I’ve kind of begun to accept it a bit more and just get on with my life, rather than it being a problem.” | 10 (71%) | |
“I think afterwards I’m more watching myself. Trying to be aware of exactly what’s going on. Try to see them as less critical, yeah, and not, erm, just random voices.” | |||
“I guess I am different because I now see the voices as…how do I put it? as an entertainer, that I don’t really pay that much attention to. Before I was seeing them as annoying, I was seeing them as a problem but now I don’t see them as a problem. I just see them as ‘oh you’re here again, your welcome, what can I do for you?’ just something to keep me busy.” | |||
Building up self-confidence | “I’m a bit more in control, I feel a lot more confident | 12 (86%) | |
“It’s made me stick up for myself a bit more, erm… And a bit more generally in my everyday life, as well. Just… not just with the voices, just it’s given me a bit more confidence generally” | |||
Understanding relationship between my mood and the voices | “Because it usually gets me when I’m, yeah, when I’m down or vulnerable still, but I’m kind of almost expecting it now, so I’m kind of ready for it.” | 4 (29%) | |
“Before, if the voice was there, my mood was low; I just wanted to be on my own or probably sleep. But now I just pick up my MP3, listen to it and that- lifts up my spirit.” | |||
5. Impact of therapy on everyday life | (Confidence to) Engage socially with others | “Helped me get out and reconnect with people and stuff like that” | 6 (43%) |
“Socially, it has had an impact, yeah, because I feel a lot more comfortable and it kinda like… it feels like a lot of, being outside is a lot easier” | |||
No perception of harmful events | “It’s certainly a good idea and erm more (sessions) of it won’t harm us, there’s more research information about it” | 12 (86%) | |
“No, because of the way it was done, like I said, because my anxiety was lessened through the sessions because, like I said, the avatar was backing off, erm, I felt safer as the sessions… I think it was quite cleverly done, the way the avatar was backing off as I was getting stronger, kind of thing. So I don’t think there’s any danger… There wasn’t, I didn’t feel like I was under danger or under threat really” | |||
Reduction in frequency of the voices | “Before I had the avatar I used to hear them every day, throughout the whole day. Since I’ve done the avatar, sometimes I don’t hear them for the whole day, for a few days and then might hear them, like, throughout the day, but very, very quiet, can hardly hear.” | 11 (79%) | |
“There have been four or five days, or six and seven days without hearing anything at all” | |||
Effects on other voices | “(It worked) With all the voices. Though mostly I hear the male one but a few times about three or four of them speaks at the same time” | 6 (43%) | |
“I think they’re a bit quieter, you know” | |||
“It hasn’t changed the other voices at all.” | |||
Recommendable to others hearing distressing voices | “It’s helped me, so probably it can help other people. And just give it a try, because it can help, it can benefit your life, I’d say.” | 14 (100%) | |
“Everybody’s experience is different of hearing voices. But I think having a face and voice to go with, with erm… because I think a lot of people don’t have faces to go with some of their voices, so yeah, so I think it was important to have a physical thing to interact with. So yeah” |