Listening to and believing derogatory and threatening voices
Keywords: assessment measures
auditory hallucination
distress
cognitive models
structural equation modelling
voices

Background: An appraisal account has been important in understanding and treating the distress of people who hear voices. Over the past 25 years, a substantial body of research has accumulated that supports the view that appraisals concerning malevolence and omnipotence of voices have significant associations with voice-related distress. Each type of appraisal explains approximately a fifth of the variance in distress. Substantial variance in voice-related distress is therefore left unexplained. The aim of this thesis is to extend the appraisal account by focusing on one common presentation of voices: derogatory and threatening voices (DTVs). A cognitive framework is developed to understand a paradox: patients know that these voices intend to upset them, and yet they typically listen to and believe the threats and criticisms heard. Specifically, the objectives were to develop a grounded theory of reasons for listening to and believing DTVs, produce assessment measures to assess key constructs in the approach, test associations between listening to and believing DTVs and distress, and between the reasons and the degree of listening to and believing DTVs and lastly to develop an initial understanding of factors other than appraisals that might lead to greater listening to and believing DTVs.
Method: A lived experience advisory panel collaborated on all aspects of the research programme. In the thesis two National Health Service (NHS) mental health service patient cohorts were recruited: a group of 15 adult patients with non-affective psychosis and daily DTVs was recruited for a qualitative interview study (Chapters Two and Four), and a group of patients who heard DTVs at least once per week (N=591) took part in a cross-sectional observational study (Chapters Three and Five). The qualitative study obtained data via semi-structured interviews, which were analysed using a grounded theory approach to develop the framework of reasons for listening to and believing DTVs (Chapter Two). A systematic search revealed that there were no existing assessment measures for listening to and believing DTVs, or the reasons for doing so. Hence a psychometric study with 591 patients hearing DTVs was conducted. Two new measures were developed: Listening and Believing – Assessment, and Listening and Believing – Reasons. The participant group was made up of two parts for the purpose of exploratory (part A n=308) and confirmatory factor analysis (part B n=283). A sub-group of 42 part B participants completed test-retest reliability for both measures. Associations between listening to and believing DTVs and distress were tested. Listening and believing DTVs was individually regressed onto each factor (sub-scale) of the reasons for listening to believing DTVs questionnaire. In order to identify the most important reasons for listening to and believing DTVs, accounting for shared variance, structural equation modelling was carried out. Listening to and believing DTV factors (subscales) were together regressed onto the latent factors of the reasons for listening to and believing DTVs questionnaire. A secondary analysis of the qualitative interview study took place using thematic analysis to learn about the patient experience of social connection (Chapter Four) and its relationship with listening to and believing, because this was a prominent theme across the accounts. Lastly, a sub-group of part B participants (n=140) from the cross-sectional observational study completed questionnaires assessing psychological problems that could plausibly contribute to listening to and believing (e.g. boredom, low self-confidence, insomnia). Mediation models assessed whether these psychological problems were associated with listening to and believing DTVs via the reasons for listening to and believing.
Results: Patient interviews identified 21 reasons for listening to and believing DTVs, grouped into six higher order categories: i) to understand the voices (e.g. what is their motive?); ii) to be alert to the threat (e.g. prepared for what might happen); iii) a normal instinct to rely on sensory information; iv) the voices can be of known people; v) the DTVs use strategies (e.g. repetition) to capture attention; and vi) patients feel so worn down it is hard to resist the voice experience (e.g. too mentally defeated to dismiss comments) (Chapter Two). Listening and believing formed four factors: active listening, passive listening, believing, and disregarding DTVs (Chapter Three). 58% (n=332) of participants passively listened to their voices very often, and 52% (n=307) believed their DTVs very often. Actively listening out for voices was less common, occurring very often for a third of patients. Higher levels of believing, active listening, and particularly passive listening, were associated with higher levels of anxiety, depression, and voice-related distress. Passive listening explained approximately one-quarter of the variance in depression and anxiety, and believing DTVs explained approximately a fifth of the variance. Reasons for listening to and believing formed seven factors: to better understand the threat; being too worn down to resist; to learn something insightful; being alone with time to listen; voices trying to capture attention; voices sounding like real people; and voices sounding like known people (Chapter Three). Each type of reason was associated with active listening, passive listening, and believing. The structural equation model (SEM) explained 70% of the variance in passive listening, 52% in believing, and 46% in active listening. The SEM showed that feeling worn down in particular accounted for listening to and believing DTVs. Test-retest reliabilities of both measures (Listening and Believing - Assessment, and Listening and Believing – Reasons) were excellent. The secondary analysis of the qualitative interviews showed that withdrawing from people was a common response to hearing DTVs, but also a time of vulnerability for listening to and believing the voices (Chapter Four). Ten reasons were outlined why hearing DTVs led to lower social connection, including voices leading to difficulties during conversations (e.g. the concentration required is hard), negative expectations of interactions (e.g. fearing judgement from others), and difficulties sharing experiences of hearing voices (e.g., people will be hurt or upset if I tell them about the voices). A sub-group of participants had found ways to reconnect with people and noted the benefits on the experience of DTVs. The sub-group analysis of the cross-sectional study identified additional common psychological problems for people experiencing DTVs: very strongly held negative self-beliefs, high levels of inactivity, insomnia, and weekly nightmares occurred in at least two-thirds of the participant group. Worn-down appraisals mediated the individual cross-sectional relationship between insomnia, boredom, negative self-beliefs, and listening to and believing DTVs.
Conclusions: Listening to and believing DTVs is a new framework for extending the understanding of voice distress. Listening to and believing DTVs was found to be a common occurrence, a problem that patients identified with, and was associated with higher levels of emotional distress. The motivations to listen to and believe DTVs were readily elicited from patients. Seven groups of reasons each predicted the degree of listening to and believing DTVs, and hence could act as treatment targets for a psychological intervention drawing on the framework. Appraisals related to being worn down might be particularly important to target. Limitations of the research are that listening to and believing each accounted for only a minority of the variance in emotional distress. Hence the majority of variance in distress for people hearing DTVs remains unexplained. It is possible that listening to and believing DTVs are associated with other unmeasured negative outcomes (e.g. confusion from voices, and paranoid thoughts). The second substantial limitation is the cross-sectional design which meant that it was not possible to determine the direction of pathways between either listening and believing and distress, or between the appraisals and listening and believing. Further work is required to investigate whether the variance in distress that is explained by the new framework is shared with existing appraisal measures (e.g. malevolence and omnipotence), or whether the new framework explains additional unique variance. A clear next step is to develop psychological treatment techniques that target the seven appraisal groups and assess whether these can be changed and whether this leads to a lessening of the degree of listening to and believing DTVs.