{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T08:04:07Z","timestamp":1785485047737,"version":"3.56.0"},"reference-count":44,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2023,3,15]],"date-time":"2023-03-15T00:00:00Z","timestamp":1678838400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Le Fonds de recherche du Qu\u00e9bec\u2014Sant\u00e9 (FRQS)"},{"name":"Otsuka Canada Pharmaceutical Inc."},{"name":"Chaire Eli Lilly Canada de recherche en schizophr\u00e9nie"},{"name":"Fondation Pinel"},{"name":"Services et recherches psychiatriques AD"},{"name":"Fonds d\u2019excellence en recherche Apog\u00e9e Canada (Institut de la Valorisation des Donn\u00e9es IVADO)"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>(1) Background: Very little is known about the inner therapeutic processes of psychotherapy interventions for patients suffering from treatment-resistant schizophrenia. Avatar therapy (AT) is one such modalities in which the patient is undergoing immersive sessions in which they interact with an Avatar representing their main persistent auditory verbal hallucination. The aim of this study is to identify the most prevalent dyadic interactions between the patient and the Avatar in AT for patient\u2019s suffering from TRS. (2) Methods: A content analysis of 256 verbatims originating from 32 patients who completed AT between 2017 and 2022 at the Institut universitaire en sant\u00e9 mentale de Montr\u00e9al was conducted to identify dyadic interactions between the patients and their Avatar. (3) Results: Five key dyads were identified to occur on average more than 10 times for each participant during the immersive sessions across their AT: (Avatar: Reinforcement, Patient: Self-affirmation), (Avatar: Provocation, Patient: Self-affirmation), (Avatar: Coping mechanisms, Patient: Prevention), (Patient: Self-affirmation, Avatar: Reinforcement), and (Patient: Self-appraisal, Avatar: Reinforcement). (4) Conclusion: These dyads offer a first qualitative insight to the interpersonal dynamics and patient-avatar relationships taking place during AT. Future studies on the implication of such dyadic interactions with the therapeutic outcome of AT should be conducted considering the importance of dyadic relationships in psychotherapy.<\/jats:p>","DOI":"10.3390\/jcm12062299","type":"journal-article","created":{"date-parts":[[2023,3,16]],"date-time":"2023-03-16T02:40:11Z","timestamp":1678934411000},"page":"2299","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":7,"title":["Dyadic Interactions of Treatment-Resistant Schizophrenia Patients Having Followed Virtual Reality Therapy: A Content Analysis"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4868-0928","authenticated-orcid":false,"given":"Alexandre","family":"Hudon","sequence":"first","affiliation":[{"name":"Centre de Recherche de l\u2019Institut Universitaire en Sant\u00e9 Mentale de Montr\u00e9al, Montr\u00e9al, QC H1N 3J4, Canada"},{"name":"Department of Psychiatry and Addictology, Faculty of Medicine, Universit\u00e9 de Montr\u00e9al, Montr\u00e9al, QC H3T 1J4, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonathan","family":"Couture","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, Department of Medicine, Campus Montr\u00e9al, Universit\u00e9 de Montr\u00e9al, Montr\u00e9al, QC H3T 1J4, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8262-130X","authenticated-orcid":false,"given":"Laura","family":"Dellazizzo","sequence":"additional","affiliation":[{"name":"Centre de Recherche de l\u2019Institut Universitaire en Sant\u00e9 Mentale de Montr\u00e9al, Montr\u00e9al, QC H1N 3J4, Canada"},{"name":"Department of Psychiatry and Addictology, Faculty of Medicine, Universit\u00e9 de Montr\u00e9al, Montr\u00e9al, QC H3T 1J4, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0169-8055","authenticated-orcid":false,"given":"M\u00e9lissa","family":"Beaudoin","sequence":"additional","affiliation":[{"name":"Centre de Recherche de l\u2019Institut Universitaire en Sant\u00e9 Mentale de Montr\u00e9al, Montr\u00e9al, QC H1N 3J4, Canada"},{"name":"Department of Psychiatry and Addictology, Faculty of Medicine, Universit\u00e9 de Montr\u00e9al, Montr\u00e9al, QC H3T 1J4, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3113-9104","authenticated-orcid":false,"given":"Kingsada","family":"Phraxayavong","sequence":"additional","affiliation":[{"name":"Services et Recherches Psychiatriques AD, Montr\u00e9al, QC H1C 1H1, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1624-378X","authenticated-orcid":false,"given":"St\u00e9phane","family":"Potvin","sequence":"additional","affiliation":[{"name":"Centre de Recherche de l\u2019Institut Universitaire en Sant\u00e9 Mentale de Montr\u00e9al, Montr\u00e9al, QC H1N 3J4, Canada"},{"name":"Department of Psychiatry and Addictology, Faculty of Medicine, Universit\u00e9 de Montr\u00e9al, Montr\u00e9al, QC H3T 1J4, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4480-0064","authenticated-orcid":false,"given":"Alexandre","family":"Dumais","sequence":"additional","affiliation":[{"name":"Centre de Recherche de l\u2019Institut Universitaire en Sant\u00e9 Mentale de Montr\u00e9al, Montr\u00e9al, QC H1N 3J4, Canada"},{"name":"Department of Psychiatry and Addictology, Faculty of Medicine, Universit\u00e9 de Montr\u00e9al, Montr\u00e9al, QC H3T 1J4, Canada"},{"name":"Services et Recherches Psychiatriques AD, Montr\u00e9al, QC H1C 1H1, Canada"},{"name":"Institut National de Psychiatrie L\u00e9gale Philippe-Pinel, Montr\u00e9al, QC H1C 1H1, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,3,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1097\/HRP.0000000000000165","article-title":"Psychotherapy over the Last Four Decades","volume":"25","author":"Weissman","year":"2017","journal-title":"Harv. Rev. Psychiatry"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"460","DOI":"10.3389\/fpsyg.2019.00460","article-title":"Psychotherapy: A World of Meanings","volume":"10","author":"Locher","year":"2019","journal-title":"Front. Psychol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1023\/A:1022678622119","article-title":"Psychotherapy: Definitions, mechanisms of action, and relationship to etiological models","volume":"26","author":"Brent","year":"1998","journal-title":"J. Abnorm. Child Psychol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1111\/jopy.12012","article-title":"Self-Regulation and Mechanisms of Action in Psychotherapy: A Theory-Based Translational Perspective","volume":"81","author":"Strauman","year":"2013","journal-title":"J. Pers."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"565800","DOI":"10.3389\/fpsyg.2022.565800","article-title":"Therapists\u2019 Views of Mechanisms of Change in Psychotherapy: A Mixed-Method Approach","volume":"13","author":"Shalev","year":"2022","journal-title":"Front. Psychol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"118","DOI":"10.1002\/cpp.792","article-title":"Clients\u2019 and Therapists\u2019 views of the therapeutic alliance: Similarities, differences and relationship to therapy outcome","volume":"20","author":"Bachelor","year":"2013","journal-title":"Clin. Psychol. Psychother."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1521\/bumc.2017.81.2.167","article-title":"Transference and countertransference: A review","volume":"81","author":"Parth","year":"2017","journal-title":"Bull. Menn. Clin."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"293","DOI":"10.7326\/0003-4819-113-4-293","article-title":"Transference Phenomena in Medical Practice: Being Whom the Patient Needs","volume":"113","author":"Zinn","year":"1990","journal-title":"Ann. Intern. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"13","DOI":"10.1111\/j.1744-6163.2004.00013.x","article-title":"Transference and countertransference","volume":"40","author":"Jones","year":"2004","journal-title":"Perspect. Psychiatr. Care"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2129","DOI":"10.2147\/PRBM.S369294","article-title":"Managing Transference and Countertransference in Cognitive Behavioral Supervision: Theoretical Framework and Clinical Application","volume":"15","author":"Prasko","year":"2022","journal-title":"Psychol. Res. Behav. Manag."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"496","DOI":"10.1037\/pst0000189","article-title":"Countertransference management and effective psychotherapy: Meta-analytic findings","volume":"55","author":"Hayes","year":"2018","journal-title":"Psychotherapy"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"189","DOI":"10.5507\/bp.2010.029","article-title":"Transference and countertransference in cognitive behavioral therapy","volume":"154","author":"Prasko","year":"2010","journal-title":"Biomed Pap. Med. Fac. Univ. Palacky Olomouc. Czech Repub."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"210","DOI":"10.3389\/fpsyt.2019.00210","article-title":"Treatment-Resistant to Antipsychotics: A Resistance to Everything? Psychotherapy in Treatment-Resistant Schizophrenia and Nonaffective Psychosis: A 25-Year Systematic Review and Exploratory Meta-Analysis","volume":"10","author":"Polese","year":"2019","journal-title":"Front. Psychiatry"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/j.schres.2013.05.028","article-title":"Definition and description of schizophrenia in the DSM-5","volume":"150","author":"Tandon","year":"2013","journal-title":"Schizophr. Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1016\/j.tins.2018.12.004","article-title":"Schizophrenia, Dopamine and the Striatum: From Biology to Symptoms","volume":"42","author":"McCutcheon","year":"2019","journal-title":"Trends Neurosci."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1016\/j.biopsych.2016.03.2104","article-title":"Pathway-Specific Dopamine Abnormalities in Schizophrenia","volume":"81","author":"Weinstein","year":"2016","journal-title":"Biol. Psychiatry"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"519","DOI":"10.2147\/NDT.S225643","article-title":"Negative Symptoms in Schizophrenia: A Review and Clinical Guide for Recognition, Assessment, and Treatment","volume":"16","author":"Correll","year":"2020","journal-title":"Neuropsychiatr. Dis. Treat."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1016\/j.psc.2016.01.006","article-title":"Treatment-Resistant Schizophrenia","volume":"39","author":"Elkis","year":"2016","journal-title":"Psychiatr. Clin. N. Am."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.jpsychires.2014.07.001","article-title":"New therapeutic approaches for treatment-resistant schizophrenia: A look to the future","volume":"58","author":"Miyamoto","year":"2014","journal-title":"J. Psychiatr. Res."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"104257","DOI":"10.1016\/j.nbd.2018.08.016","article-title":"Treatment resistant schizophrenia: Clinical, biological, and therapeutic perspectives","volume":"131","author":"Nucifora","year":"2019","journal-title":"Neurobiol. Dis."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"279","DOI":"10.1017\/ipm.2018.47","article-title":"Treatment resistant schizophrenia\u2014Review and a call to action","volume":"36","author":"Lally","year":"2018","journal-title":"Ir. J. Psychol. Med."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"354","DOI":"10.1080\/00332747.2019.1616658","article-title":"Integrated Psychological Therapy and Treatment-Resistant Schizophrenia: Initial Findings","volume":"82","author":"Rakitzi","year":"2019","journal-title":"Psychiatry"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1","DOI":"10.3310\/hta23070","article-title":"Cognitive\u2013behavioural therapy for clozapine-resistant schizophrenia: The FOCUS RCT","volume":"23","author":"Morrison","year":"2019","journal-title":"Health Technol. Assess."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1016\/S2215-0366(18)30184-6","article-title":"Cognitive behavioural therapy in clozapine-resistant schizophrenia (FOCUS): An assessor-blinded, randomised controlled trial","volume":"5","author":"Morrison","year":"2018","journal-title":"Lancet Psychiatry"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"874","DOI":"10.1176\/appi.ps.201300213","article-title":"Cognitive-Behavioral Therapy for Medication-Resistant Psychosis: A Meta-Analytic Review","volume":"65","author":"Burns","year":"2014","journal-title":"Psychiatr. Serv."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1080\/17522439.2013.773457","article-title":"Avatar therapy for persecutory auditory hallucinations: What is it and how does it work?","volume":"6","author":"Leff","year":"2014","journal-title":"Psychosis"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1016\/S2215-0366(17)30427-3","article-title":"AVATAR therapy for auditory verbal hallucinations in people with psychosis: A single-blind, randomised controlled trial","volume":"5","author":"Craig","year":"2018","journal-title":"Lancet Psychiatry"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1016\/j.schres.2018.02.031","article-title":"Virtual reality therapy for refractory auditory verbal hallucinations in schizophrenia: A pilot clinical trial","volume":"197","author":"Potvin","year":"2018","journal-title":"Schizophr. Res."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1038\/s41537-021-00139-2","article-title":"One-year randomized trial comparing virtual reality-assisted therapy to cognitive\u2013behavioral therapy for patients with treatment-resistant schizophrenia","volume":"7","author":"Dellazizzo","year":"2021","journal-title":"NPJ Schizophr."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1002\/cpp.2322","article-title":"Exploration of the dialogue components in Avatar Therapy for schizophrenia patients with refractory auditory hallucinations: A content analysis","volume":"25","author":"Dellazizzo","year":"2018","journal-title":"Clin. Psychol. Psychother."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1002\/cpp.2556","article-title":"The therapeutic processes of avatar therapy: A content analysis of the dialogue between treatment-resistant patients with schizophrenia and their avatar","volume":"28","author":"Beaudoin","year":"2021","journal-title":"Clin. Psychol. Psychother."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"581","DOI":"10.3233\/THC-151014","article-title":"Social interactions in virtual reality exposure therapy: A proof-of-concept pilot study","volume":"23","author":"Morina","year":"2015","journal-title":"Technol. Health Care"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Hudon, A., Beaudoin, M., Phraxayavong, K., Dellazizzo, L., Potvin, S., and Dumais, A. (2022). Implementation of a machine learning algorithm for automated thematic annotations in avatar: A linear support vector classifier approach. Health Inform. J., 28.","DOI":"10.1177\/14604582221142442"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1177\/1754073915590622","article-title":"Interpersonal Affect Dynamics: It Takes Two (and Time) to Tango","volume":"7","author":"Butler","year":"2015","journal-title":"Emot. Rev."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"112391","DOI":"10.1016\/j.socscimed.2019.112391","article-title":"Interpersonal trust in doctor-patient relation: Evidence from dyadic analysis and association with quality of dyadic communication","volume":"235","author":"Petrocchi","year":"2019","journal-title":"Soc. Sci. Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"152","DOI":"10.1080\/10503307.2012.747013","article-title":"Transference, countertransference, emotional expression, and session quality over the course of supportive expressive therapy: The raters\u2019 perspective","volume":"23","author":"Markin","year":"2013","journal-title":"Psychother. Res."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"20170155","DOI":"10.1098\/rstb.2017.0155","article-title":"Traits of empathy and anger: Implications for psychopathy and other disorders associated with aggression","volume":"373","author":"Blair","year":"2018","journal-title":"Philos. Trans. R. Soc. B Biol. Sci."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1176\/ajp.150.4.589","article-title":"Schizophrenic patients\u2019 sensitivity to social cues: The role of abstraction","volume":"150","author":"Corrigan","year":"1993","journal-title":"Am. J. Psychiatry"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1007\/s00406-016-0705-6","article-title":"Restricted attention to social cues in schizophrenia patients","volume":"266","author":"Nikolaides","year":"2016","journal-title":"Eur. Arch. Psychiatry Clin. Neurosci."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1016\/j.psychres.2014.08.041","article-title":"Safety-seeking behaviours and verbal auditory hallucinations in schizophrenia","volume":"220","author":"Chaix","year":"2014","journal-title":"Psychiatry Res."},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Bisso, E., Signorelli, M., Milazzo, M., Maglia, M., Polosa, R., Aguglia, E., and Caponnetto, P. (2020). Immersive Virtual Reality Applications in Schizophrenia Spectrum Therapy: A Systematic Review. Int. J. Environ. Res. Public Health, 17.","DOI":"10.3390\/ijerph17176111"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1159\/000363144","article-title":"Coping with delusions in schizophrenia and af-fective disorder with psychotic symptoms: The relationship between coping strategies and dimensions of delusion","volume":"48","author":"Gentner","year":"2015","journal-title":"Psychopathology"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"577","DOI":"10.1521\/jscp.2009.28.5.577","article-title":"Personality Traits and the Working Alliance in Psychotherapy Trainees: An Organizing Role for the Five Factor Model?","volume":"28","author":"Chapman","year":"2009","journal-title":"J. Soc. Clin. Psychol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"291","DOI":"10.1002\/wps.20666","article-title":"Toward a personalized approach to psychotherapy outcome and the study of therapeutic change","volume":"18","author":"Barber","year":"2019","journal-title":"World Psychiatry"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/6\/2299\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:56:09Z","timestamp":1760122569000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/6\/2299"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,3,15]]},"references-count":44,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2023,3]]}},"alternative-id":["jcm12062299"],"URL":"https:\/\/doi.org\/10.3390\/jcm12062299","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,3,15]]}}}