An auditory hallucination (AH) is the subjective experience of hearing sounds, commonly voices, that are not actually occurring in the environment. While often considered to be synonymous with schizophrenia, AHs actually occur across a range of psychotic and non-psychotic conditions. Present in between 64 and 80 percent of individuals with schizophrenia, they are very common in dissociative disorders (DDs), especially dissociative identity disorder, in complex PTSD, and in certain substance-induced mental states. They are sometimes reported in mood disorders, especially bipolar disorder, as well as borderline personality disorder, and in non-clinical conditions such as bereavement.
Differences Between Schizophrenic and Dissociative Auditory Hallucinations
Hearing auditory hallucinations can be very distressing, especially in schizophrenia and the dissociative disorders. However, there are significant clinical differences between the AHs heard by individuals with schizophrenia and those heard by someone with a dissociative disorder. Hallucinatory voices in schizophrenia are usually perceived as coming from outside of the person and typically are commanding, demanding, critical, or threatening. The number and source of the voices are often ambiguous and often associated with delusions about their origin—e.g., that they come from someone who is broadcasting their thoughts, or from CIA-directed radio waves. Schizophrenic patients frequently do not have insight into their hallucinatory nature, but regard their AHs as real.
Dissociative disorder auditory hallucinations are more often experienced as internalized voices, with distinct and persistent identities and personality attributes (e.g., children, persecutory voices, comforting voices). They often have distinctive speech patterns, a strong central affect, and age and gender attributes (e.g., the hateful old lady who tells me to kill myself, the frightened child who tells me to hide). DD patients frequently have insight into their AHs, recognizing that they are hallucinations. DD hallucinations are frequently trauma-related, which is less true of schizophrenic AHs. Unfortunately, DD hallucinations are frequently misdiagnosed as psychotic symptoms, leading to inappropriate and ineffective treatment with antipsychotic medications.
How Are Schizophrenic Auditory Hallucinations Treated?
As distressing symptoms, schizophrenic AHs are frequently treated with antipsychotic medications. However, about 30 percent of schizophrenic patients’ AHs are resistant to medication. In many other cases, the medication reduces but does not eliminate schizophrenic AHs, which remain distressing.
A variety of adjunctive psychological treatments have been added to the pharmacological treatments of schizophrenic AHs. These psychological approaches include: 1) Focusing therapies, including self-monitoring and directed attention; 2) Cognitive behavioral techniques such as thought-stopping; 3) Distraction techniques using competing auditory stimuli such as music, vocal/motor tasks, and even earplugs; and increasingly 4) computerized and virtual reality-based interventions (Shergill et al., 1998).
A recent random-effects meta-analysis compared five main psychological approaches to distressing AHs in schizophrenic patients (Fässler et al., 2026). Outcome measures were the severity, frequency, and distress of AHs plus other psychiatric symptoms (delusions, depression, and anxiety). Avatar therapy (AT) emerged as the clear favorite, showing the largest and most consistent positive effects and outperforming all other psychological and cognitive approaches. Adverse side effects were rare. and dropout rates were similar between intervention groups and controls, indicating good acceptability.
What Is Avatar Therapy?
In avatar therapy, introduced in 2013 by Leff et al., patients collaborate with their therapists to create a digital or virtual representation (an “avatar”) of the voice(s) that they hear (Fässler et al., 2026). This avatar is given a face and a computer voice that closely matches the patient’s experience. The therapist controls the avatar’s responses, gradually shifting the avatar’s tone and content from hostile or distressing to more supportive and constructive comments. The patient engages in structured, therapist-guided dialogues with the avatar designed to reduce the negativity and distress associated with the AHs. Avatar therapy integrates CBT techniques, such as cognitive restructuring, AH-challenging strategies, and emotional regulation. The AHs don’t disappear so much as transform from hostile and derogatory to friendlier and more supportive voices.
How Are Dissociative Auditory Hallucinations Treated?
The overall gold standard for treating trauma-related disorders is based on the trauma-focused, phase-oriented psychotherapy model first described by Dr. Judith Herman for complex PTSD (Herman, 1992). More recent randomized clinical trials are finding that an adjunctive, structured psychoeducational and skills-building curriculum emphasizing grounding, containment of traumatic intrusions, safety, emotion regulation, and increased collaboration among DID identity-states is yielding significant improvements in objective and subjective measures of posttraumatic and dissociative symptoms (Brand et al., 2025).
Similarities in Therapeutic Approaches to Auditory Hallucinations
Direct therapeutic interactions with the DID patient’s identity-states, in particular, are important in reducing the hostile relationships among these identity-states, which contribute to dysfunctional and self-destructive behaviors. In many cases, therapists work directly with DID identity-states to build positive internal communications among internal identity states, and to reduce self-sabotaging and distracting interactions, such as self-pejorative AHs and self-harm. The ultimate expression of this approach is the “integration” of DID identity-states into a more harmonious, cooperative, and less conflicted “personality system.”
Hallucination Essential Reads
Avatar therapy, as applied to schizophrenic AHs, seems to be accomplishing a similar detoxification process by “personifying” the AHs with a face (and perhaps a name) and gradually ramping down the AHs’ hostility and intrusiveness, replacing them with AHs that are supportive and nonthreatening. It appears that therapeutically interacting directly with schizophrenic AHs as if they are independent entities, rather than ignoring them or explaining them away as “tricks of the mind,” is proving to be a common denominator across both schizophrenic and dissociative AHs. This is a very different approach from what is currently taught in most training programs.
Implications of Avatar Therapy
Talking with schizophrenic patients’ AHs, which was originally discouraged lest it “reinforce” them, is currently being replaced by a willingness to relate directly with the voices, as if they were entities that can be modified by therapeutic interpersonal interactions. This is a radical change in approaches to schizophrenic AHs that needs to be investigated much further before it becomes a standard practice. It suggests, however, that schizophrenic and dissociative disorder auditory hallucinations, despite their phenomenological differences, may share a common underlying mechanism that is amenable to psychological interventions rather than just medication.
