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AVATAR therapy, conducted on a two-dimensional computer screen and its adaptation virtual reality-assisted therapy (VRT), using three-dimensional virtual reality (VR), have shown promise. Despite the potential of VRT, research exploring how specific VR characteristics can simulate voices experiences and affect therapy outcome remains scarce. Addressing this gap is key to refining VRT for persistent voices.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>This qualitative substudy of the CHALLENGE trial explored patient perspectives on modified VRT versions (VRT-Emotions, VRT-Environment, and VRT-Whiteboard) and their therapeutic impact, with the aim to inform intervention refinement and development.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Semistructured interviews were conducted with 15 participants with SSD and persistent voices after undergoing the modified therapies. Data were analyzed within a pragmatist-critical realism orientation, with a hybrid deductive-inductive approach to thematic analysis. Reflexive team dialogues supported analytical rigor.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      One overarching theme:\n                      <jats:italic toggle=\"yes\">A challenging yet transformative therapy,<\/jats:italic>\n                      and three subthemes, corresponding to the specific modifications, were generated:\n                      <jats:italic toggle=\"yes\">Emotional connection with voice<\/jats:italic>\n                      ,\n                      <jats:italic toggle=\"yes\">Recognizability builds resistance,<\/jats:italic>\n                      and\n                      <jats:italic toggle=\"yes\">The power of the written word.<\/jats:italic>\n                      The modifications were generally perceived to enhance therapeutic experience and effectiveness, albeit participants\u2019 perspectives varied and sometimes contrasted.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Findings suggest that refining VRT for persistent voices may involve improving avatar's facial expressions, tailoring therapy to voice experiences, and using recognizable VR environments with gradual exposure and selective visual tools. While controlled studies are needed to establish efficacy, these insights offer practical guidance for VRT refinement and development.\u2009\u2009<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/20552076251411033","type":"journal-article","created":{"date-parts":[[2026,1,21]],"date-time":"2026-01-21T19:09:53Z","timestamp":1769022593000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Patient perspectives on modified virtual reality-assisted therapy for persistent auditory verbal hallucinations: A qualitative substudy of the CHALLENGE randomized clinical trial"],"prefix":"10.1177","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-3137-7265","authenticated-orcid":false,"given":"Katrine","family":"Rasmussen","sequence":"first","affiliation":[{"name":"VIRTU Research Group, Mental Health Center Copenhagen, Copenhagen University Hospital \u2013 Mental Health Services CPH, Hellerup, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5096-2281","authenticated-orcid":false,"given":"Ditte Lammers","family":"Vernal","sequence":"additional","affiliation":[{"name":"Aalborg University Hospital"},{"name":"Department of Clinical Medicine, Aalborg University, Aalborg, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-4448-6152","authenticated-orcid":false,"given":"Lise Sandvig","family":"Mariegaard","sequence":"additional","affiliation":[{"name":"VIRTU Research Group, Mental Health Center Copenhagen, Copenhagen University Hospital \u2013 Mental Health Services CPH, Hellerup, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6297-4746","authenticated-orcid":false,"given":"Gry","family":"J\u00f8rgensen","sequence":"additional","affiliation":[{"name":"VIRTU Research Group, Mental Health Center Copenhagen, Copenhagen University Hospital \u2013 Mental Health Services CPH, Hellerup, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0960-3310","authenticated-orcid":false,"given":"Fatime","family":"Zeka","sequence":"additional","affiliation":[{"name":"VIRTU Research Group, Mental Health Center Copenhagen, Copenhagen University Hospital \u2013 Mental Health Services CPH, Hellerup, Denmark"},{"name":"Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5231-7750","authenticated-orcid":false,"given":"Lisa Charlotte","family":"Smith","sequence":"additional","affiliation":[{"name":"VIRTU Research Group, Mental Health Center Copenhagen, Copenhagen University Hospital \u2013 Mental Health Services CPH, Hellerup, Denmark"},{"name":"Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4895-7023","authenticated-orcid":false,"given":"Merete","family":"Nordentoft","sequence":"additional","affiliation":[{"name":"Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark"},{"name":"Copenhagen Research Center for Mental Health (CORE), Mental Health Center Copenhagen, Copenhagen University Hospital - 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