Introduction
Auditory verbal hallucinations (AVHs: hearing voices) are often, but not always, distressing experiences (McCarthy-Jones, Reference McCarthy-Jones2012). Whilst the beliefs a person holds about their voices impacts on the ensuing levels of distress they experience (Peters, Williams, Cooke and Kuipers, Reference Peters, Williams, Cooke and Kuipers2012), recent work has begun to explore how the relationships people have with their voices contribute to distress levels. One framework that has been used to analyse such relationships is Birtchnell's theory of relating (Reference Birtchnell1996). Using this framework, Vaughan and Fowler (Reference Vaughan and Fowler2004) found that Voice Dominance (the voice relating to the person in a dominant, insulting manner) and Hearer Distance (the hearer avoiding communication with the voice) were associated with greater levels of distress in hearers, and argued that it is not a hearer's beliefs about the voice's power per se that leads to distress, but the way in which the voice is perceived to use its power, for example by being domineering and bullying. A later study by Sorrell, Hayward and Meddings (Reference Sorrell, Hayward and Meddings2010) found that Voice Dominance, Hearer Distance, and Voice Intrusiveness (the voice imposing itself on the hearer) were all significantly positively correlated with levels of distress, but that when levels of malevolence and omnipotence were controlled for, these correlations became non-significant. Sorrell et al. concluded that it is a combination of both relating styles and beliefs about voices (specifically malevolence and omnipotence) that determines distress, with beliefs about voices either moderating (influence the strength of the relationship) or mediating the association between relating styles and distress.
To date, almost all such work has been cross-sectional, with only one study directly exploring how beliefs about voices change over time. This study by Csipke and Kinderman (Reference Csipke and Kinderman2006) investigated change in beliefs about voices’ intent, for clinical hearers over a 6-month period (N = 16), finding that the frequency and severity of voices decreased significantly but not finding significant changes in beliefs about the malevolent or benevolent intent of voices. This offered support for the proposal that beliefs about voices are enduring and stable, irrespective of immediate frequency and severity of voices, and do not change without a specific intervention. The first aim of our study was to attempt replication of these findings in a 12-month longitudinal study, using a more psychometrically reliable measure of beliefs about voices’ benevolent or malevolent intent and including a measure of perceived voice-power. We hypothesized that beliefs about voices’ malevolence, benevolence and omnipotence, as assessed by the Beliefs about Voices Questionnaire-Revised (BAVQ-R; Chadwick, Lees and Birchwood, Reference Chadwick, Lees and Birchwood2000), would remain stable over a 12-month period, irrespective of changes in the severity of voices, as assessed by the Psychotic Symptoms Rating Scale-Auditory Hallucinations Scale (PSYRATS-AH: Haddock, McCarron, Tarrier and Faragher, Reference Haddock, McCarron, Tarrier and Faragher1999).
We also aimed to examine whether relationships with voices change over time. Previous research has found that over time hearers have increasing levels of intimacy with their voices and more detailed dialogues with them (Nayani and David, Reference Nayani and David1996), with Chin, Hayward and Drinnan (Reference Chin, Hayward and Drinnan2009) finding developments in the relationship over time were evident for all participants in their study. These findings suggest that relating styles may change over time, with voice-hearers becoming closer to their voices. To investigate this we examined whether voice-hearers’ relations with their voices, as assessed by the Voice and You scale (VAY; Hayward, Denney, Vaughan and Fowler, Reference Hayward, Denney, Vaughan and Fowler2008), changed over a 12-month period.
Method
Participants
Inclusion criteria were being over 18 years of age, in receipt of mental health services, and having heard voices for at least 6 months. Exclusion criteria were participants' voice-hearing being a likely consequence of substance misuse or organic illness, currently experiencing acute psychosis or distress that meant they were not able to give informed consent, or lacking sufficient English language skills. As this was an exploratory study, we designed the study to be able to detect large (and hence clinically relevant) effect sizes. G*Power was used to calculate the necessary sample size to detect, with 80% power, a large effect size (Cohen's d = 0.8) at an alpha of .05. This indicated for a repeated-measures t-test that a sample size of 15 would be required.
Given that Csipke and Kinderman's (Reference Csipke and Kinderman2006) 6-month longitudinal study had an attrition rate of 65%, in order to attempt to achieve our desired sample size we assessed 32 participants (19 male) at baseline, recruited from local adult mental health services. All were currently taking antipsychotic medication. We were able to reassess 18 of these participants at 12-month follow-up. Reasons for attrition included participants withholding their consent to be re-contacted, the researchers being unable to make contact with the participant, and participants being in hospital or unwell. The mean age of the 18 participants was 39.39 years (SD = 9.95); all were of White British ethnicity, and they had been hearing voices for a mean of 16.50 years (SD = 9.46). Nine participants reported their predominant voice was male, four female, and five unknown. Eight had voices that they personified as real people, seven as unknown people, and three as supernatural entities. Ethical approval was received for this study from the South West Surrey Local Research Ethics Committee.
Procedure
Participants were interviewed face-to-face. Follow-up interviews were conducted as close as possible to 12 months (range 10–14 months) following the original interview date. The following measures were completed at baseline and 12-month follow-up. During the course of the 12 months, 10 (56%) participants attended Hearing Voices Groups (peer-support groups for people who hear voices), 2 (11%) underwent formal individual psychotherapy, and 7 (39%) changed medication.
Measures
Voice and You (VAY; Hayward et al., Reference Hayward, Denney, Vaughan and Fowler2008) is a 28-item, self-report measure of a person's assessment of themselves in relation to their predominant voice, with four subscales: Voice Dominance (e.g. “My voice tries to get the better of me”); Voice Intrusiveness (e.g. “My voice does not let me have time to myself”); Hearer Dependence (e.g. “My voice helps me make up my mind”); and Hearer Distance (e.g. “I don't wish to spend much time listening to my voice”).
Psychotic Symptoms Rating Scale - Auditory Hallucinations Scale (PSYRATS-AH; Haddock et al., Reference Haddock, McCarron, Tarrier and Faragher1999) is an 11-item scale, administered by the researcher, that assesses characteristics of voices such as frequency, duration, severity, loudness, location, degree of negative content and controllability. It also assesses the impact of the voice upon the hearer in terms of distress caused, beliefs about origin of voices, and disruption caused to the hearer's life.
Beliefs about Voices Questionnaire-Revised (BAVQ-R; Chadwick et al., Reference Chadwick, Lees and Birchwood2000) is a 35-item questionnaire with a number of sub-scales; however, we only report here on the key subscales of beliefs about the voice's malevolence, benevolence and omnipotence.
Results
We adjusted conventional significance levels to take into account the multiple tests performed. As Bonferroni corrections have been argued to be overly conservative (Narum, Reference Narum2006), we employed the correction suggested by Benjamini and Yekutieli (Reference Benjamini and Yekutieli2001). As a total of 16 tests were performed (Table 1), this corresponded to a corrected significance level of p = .015, with a trend towards significance for this study being defined as .015< p < .10.
Table 1. Changes in relevant variables over a 12-month period
Notes: a Difference between means divided by the pooled standard deviation times the square root of 1 minus the correlation (r) between scores at baseline and at 12m follow-up; b Due to missing data, n = 16; c Due to missing data, n = 17; d Due to missing data, n = 12. * Trend towards significance, as per paper's statistical criterion, i.e. .015 < p < .10
To test our first hypothesis, we examined whether beliefs about voices’ malevolence, benevolence and omnipotence changed over time. As can be seen from Table 1, at baseline assessment BAVQ-R scores indicated that participants mostly perceived their voice to have malevolent intent, to have omnipotence and low benevolence. As Table 1 also shows, at the corrected significance level there was no significant change in malevolence or omnipotence over time, despite there being a trend towards a reduction in both the amount of voice-related distress and voice-related disruption. However, there was a trend towards a reduction in beliefs about the voices’ benevolence.
To evaluate our second hypothesis, we tested whether scores on the VAY changed significantly over time. As indicated in Table 1, there were no significant changes in VAY scores. Descriptive statistics indicated that both at baseline and follow-up participants typically perceived their voice to relate to them primarily from a position of dominance, perceived themselves relating to their voice from a position of distance, with the voices being intrusive (with average scores on both these scales being closest to the “Quite often true” response). Participants had low levels of dependence on their voice (with average scores on this scale being “Sometimes true”), both at baseline and at follow-up.
We also undertook two re-performances of our analyses. First, we re-analysed our data using the Wilcoxon Signed-Rank test, as some of our variables were non-normally distributed. Second, as two participants had undergone formal individual psychotherapy over the course of the 12-month follow-up period, we re-performed our analyses excluding these individuals. Neither of these re-analyses changed our original pattern of findings, with the same variables (benevolence, amount of voice-related distress and voice-related disruption) continuing to show trends towards significance (.015 < all p’s <.10).
Discussion
This study examined whether participants’ beliefs about their voices, and their interrelating styles with their voices, changed over time, in the absence of specific interventions aiming to change these. At baseline, participants predominantly believed their voice to have malevolent intent, to be highly omnipotent and to have low levels of benevolence. At 12-month follow-up there was no significant change in beliefs about malevolence or omnipotence, despite there being a trend towards a reduction in both the amount of voice-related distress and voice-related disruption. This finding is consistent with the findings of Csipke and Kinderman (Reference Csipke and Kinderman2006) who also found that, in the absence of a specific intervention, beliefs about voices are enduring and stable, irrespective of changes in the severity of voices. However, unlike Csipke and Kinderman we found a trend for beliefs in the benevolence of voices to decrease. Whilst it is possible that improvements in the amount of voice-related distress and voice-related disruption were due to the majority of participants attending a Hearing Voices Group (Ruddle et al., Reference Ruddle, Livingstone, Huddy, Johns, Stahl and Wykes2012) or changes in some participants’ medications, it is unclear why beliefs about the benevolence of voices decreased.
At baseline, participants typically perceived their predominant voice to relate to them from a position of dominance, related to their voice from a position of distance, and found the voices intrusive. There was no significant change in this situation at 12-month follow-up, despite a trend towards a reduction in both the amount of voice-related distress and voice-related disruption. This suggests that the short-term course of interrelating between voice and hearer in clinical populations is relatively stable and enduring, without the use of specific interventions.
Our study had a number of limitations. First, it was only powered to detect large effect sizes and the pattern that emerged in our data was of typically small to medium effect sizes. Changes in hearers’ voices at the level of large effect-sizes may not be found in routine clinical services. It was also notable that difficulties were encountered in recruitment, in part due to mental health professionals’ belief that talking about voices represented “collusion” and was therefore unhelpful. This concern still remains to be evidence-based. Another limitation of the study was that the majority of participants were attending Hearing Voices Groups. These participants therefore possibly represent a specific subset of voice-hearers, skilled at thinking and talking about their voices, and our findings hence lack generalizability to all voice-hearers in clinical services. A focus on the hearers’ predominant voice may also have been a limitation as several participants reported that they heard multiple voices. Some participants reported that their voices were quite different and therefore focusing on one voice may have discounted or distorted important information.
The results of the current study suggest that styles of interrelating between voice and hearer are relatively stable and enduring, as are beliefs about the voices’ malevolent intent and power, in the absence of specific interventions. Our findings suggest that negative relating patterns and beliefs about malevolence and omnipotence may serve as ongoing vulnerability factors for distress. Thus, any re-emergence of voices is likely to be understood and responded to within this enduring framework, with consequent negative emotional and behavioural reactions. Therefore, psychotherapeutic interventions may be useful even in periods where a person is not currently experiencing voices.
When combined with the findings of Csipke and Kinderman (Reference Csipke and Kinderman2006), this lack of change in the absence of specific interventions highlights the need for interventions that specifically attempt to change voice-hearers’ beliefs about the malevolence and omnipotence of their voices, as well as interventions that attempt change in voice-hearers’ interpersonal relationships with their voices. Although manualized cognitive behaviour therapy (CBT) has shown some promise in changing the omnipotence of voices (e.g. Trower et al., Reference Trower, Birchwood, Meaden, Byrne, Nelson and Ross2004), it has not demonstrated an ability to alter the perceived malevolence of voices (Peters et al., Reference Peters, Williams, Cooke and Kuipers2012; Trower et al., Reference Trower, Birchwood, Meaden, Byrne, Nelson and Ross2004), and is not designed to specifically alter voice-hearers’ interpersonal relations with their voices. This highlights the need for the employment of novel therapeutic techniques that attempt to change voice-hearers’ relations with their voices, such as Relating Therapy (e.g. Hayward, Overton, Dorey and Denney, Reference Hayward, Overton, Dorey and Denney2009), and the need for the development of new techniques to specifically reduce the malevolence of voices, with the use of psychotherapeutic techniques based on biographical formulation potentially being of help (e.g. Longden, Corstens, Escher and Romme, Reference Longden, Corstens, Escher and Romme2012).
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