Interpersonal complementarity in responses to ... - Wiley Online Library

Copyright © The British Psychological Society Reproduction in any form (including the internet) is prohibited without prior permission from the Society

411

The British Psychological Society

British Journal of Clinical Psychology (2009), 48, 411–424 q 2009 The British Psychological Society

www.bpsjournals.co.uk

Interpersonal complementarity in responses to auditory hallucinations in psychosis Neil Thomas1*, Hamish J. McLeod2 and Chris R. Brewin3 1

Monash University, Melbourne, Australia University of Wollongong, Wollongong, Australia 3 University College London, London, UK 2

Objectives. Models of interpersonal relating have proposed that people are drawn to respond to others according to a principle of complementarity, whereby perceived hostility elicits reciprocal hostility and perceived dominance elicits submission. This study examined interpersonal appraisals and responses to auditory hallucinations, to determine whether this principle predicts how patients respond to hallucinated voices. Design and methods. Thirty-five participants with schizophrenia or schizoaffective disorder rated their internal ‘relationship’ with their auditory verbal hallucinations using the Structural Analysis of Social Behaviour, in addition to completing measures of voicerelated distress and depression. Results. Participants were able to ascribe almost the full range of interpersonal relating behaviours to their voices reliably, with some notable exceptions for voices’ ‘responses’ to being directly addressed. Appraisals of voice hostility very strongly predicted reciprocal hostile responses, but perceptions of voice control were only weakly associated with submission to voices. Perceived voice hostility was also associated with voice-related distress and perceived voice control was associated with depression. Conclusions. Individual differences in responses to auditory hallucinations appear to reflect normal interpersonal responses to appraisals of voice hostility and affiliation. However, voice hearers do not readily submit to voice control and other factors may be of importance in determining this response.

Auditory hallucinations are one of the most common symptoms of schizophrenia, usually characterized by the person hearing one or more voices, talking directly to or about them (Nayani & David, 1996). The particular stimulus of hearing human speech referring to oneself would ordinarily be encountered in the context of everyday social interaction, so it seems likely that this hallucinated experience may be interpreted in similar, interpersonal, terms. Indeed, patients readily explain their hallucinations in

* Correspondence should be addressed to Dr Neil Thomas, Monash Alfred Psychiatry Research Centre, Level 1, Old Baker Building, The Alfred, Commercial Road, Melbourne 3004, Australia (e-mail: [email protected]). DOI:10.1348/014466509X411937


412 Neil Thomas et al.

terms of real others interacting with them (Chadwick & Birchwood, 1994), and may respond to these voices as they would do within the context of ordinary social relationships (Hayward, 2003). A growing literature has examined the interpersonal appraisals made by hallucinators about the voices they hear, proposing that these are important in determining the person’s emotional and behavioural responses. Chadwick and Birchwood (1994) highlighted the importance of perceptions of voices’ identity, intent, and power, which are often imposed upon hallucinatory experience. A number of studies using their Beliefs About Voices Questionnaire (BAVQ; Chadwick & Birchwood, 1995; Chadwick, Lees, & Birchwood, 2000) have found that appraisals of voices as malevolent as opposed to benevolent predict levels of voice-related distress (BeckSander, Birchwood, & Chadwick, 1997; Birchwood & Chadwick, 1997; Van der Gaag, Hageman, & Birchwood, 2003). In addition, voices are frequently appraised as holding great power over the voice hearer (Chadwick & Birchwood, 1994). The experience of being subjugated by a voice that is dominant as well as hostile may compound related distress, as well as being related to depressive symptomatology (Gilbert et al., 2001). Accordingly, appraisals of voice power and dominance have been found to relate to both distress and depression (Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000; Gilbert et al., 2001; Vaughn & Fowler, 2004). Chadwick and Birchwood (1994) also proposed that interpersonal appraisals are of importance in understanding behavioural responses to hallucinatory experience. The BAVQ includes two scales measuring the person’s behavioural responses to their voices: the first, termed ‘resistance’, includes responses such as telling the voice to leave the person alone and trying to stop it from talking, and the second, ‘engagement’, includes responses such as willingly listening to and seeking out the voice. A very consistent finding has been that appraisals of voice malevolence elicit resistance, whereas benevolence elicits engagement (Beck-Sander et al., 1997; Birchwood et al., 2004; Birchwood & Chadwick, 1997; Chadwick & Birchwood, 1995; Chadwick et al., 2000; Van der Gaag et al., 2003). However, to date, there has been little examination of the interpersonal aspects of hallucinatory experience with reference to broader models of interpersonal relating. Indeed, the concepts of benevolence and malevolence concern appraisals of suspected voice ‘intent’, and the concept of voice power relates to factors such as perceived ability to harm, knowledge and superiority (Chadwick & Birchwood, 1994). These mainly concern mental states and abilities ascribed to the voice rather than perceptions of interpersonal relating per se. Similarly, the constructs of ‘resistance’ to and ‘engagement’ with voices have not been articulated within broader models of interpersonal relating. A small number of studies have asked voice hearers to make ratings of their hallucinations using measures developed for everyday interpersonal relationships (Benjamin, 1989; Hayward, 2003; Vaughn & Fowler, 2004), to more directly assess the interpersonal meaning attributed to hallucinatory experience and the hearer’s corresponding responses. However, whilst confirming that participants are able to describe their hallucinations and their own responses to them using an interpersonal framework, these studies have not examined predictions made by interpersonal theories. In particular, it is unclear how much voice hearers respond to their hallucinations in a manner congruent with the interpersonal meaning they have imposed upon this experience. Elements of interpersonal relating are often represented as points around a circular array, referred to as a circumplex. The original ‘Interpersonal Circle’ (Freedman, Leary,


Interpersonal responses to hallucination

413

Ossorio, & Coffey, 1951) was a conceptual model, with different facets of interpersonal relating organized as segments of a circle, each adjacent to the segments which were conceptually most similar, and with four main ‘poles’ of love, hate, dominance, and submission. Since then, the circumplex has been regarded as a testable statistical structure, in which the magnitude of inter-item correlation decreases from positive to negative as a function of the distance between items around the circle. A number of such models have been proposed including adaptations of the original Interpersonal Circle (Kiesler, 1983; Lorr & McNair, 1963; Strong et al., 1988; Wiggins, 1979) and the structural analysis of social behaviour (SASB; Benjamin, 1974). The ordering and definition of different interpersonal behaviours has varied between models, but agreement has converged upon the ‘poles’ of hostility, affiliation, dominance, and submission. These poles correspond to the interpersonal aspects of hallucinatory experience highlighted in research to date. A key application of these models is the principle of interpersonal complementarity (Carson, 1969), which proposes that certain interpersonal behaviours tend to elicit complementary responses in others. The principle states that, in the course of an interaction, hostility tends to elicit reciprocal hostility, and affiliation tends to elicit affiliation, whereas control and submission have a tendency to elicit each other. Support for this comes both from experimental studies in which participants are observed responding to confederates role playing different interpersonal styles (e.g. Strong et al., 1988; Tracey, 1994) and from observations of naturally occurring interactions (e.g. Markey, Funder, & Ozer, 2003; Sadler & Woody, 2003; Tracey, 2005). Similarly, within an interpersonal relationship, made up of many interactions, people are likely to adopt characteristic ways of interacting with each other that are complementary. Accordingly, complementarity has been found in participant ratings of various interpersonal relationships, including with parents (e.g. Gurtman, 2001; Tracey, Ryan, & JaschikHerman, 2001), friends (e.g. Tracey et al., 2001), and roommates (e.g. Ansell, Kurtz, & Markey, 2008; Markey & Kurtz, 2006). A particularly comprehensive circumplex-based model of interpersonal relating is the SASB (Benjamin, 1974, 1996), which defines 72 different interpersonal behaviours. These are presented as points around two separate circumplex planes of 36 items each. The two planes correspond to whom the focus of the interaction is upon: the first for how the participant addresses the other person, and the second for how they respond when the other person addresses them. Items are arranged so that corresponding points across the two planes are complementary and should elicit each other in a given interaction. Although the 36 items are presented as equally spaced around the plane, for ease of presentation, they are usually segmented into eight labelled ‘clusters’ of interpersonal behaviours at 458 intervals around the plane (see Figure 1). Points are arranged around a horizontal axis representing affiliation versus hostility and a vertical axis which represents autonomy versus control/submission. The SASB allows interpersonal relationships to be profiled by rating the frequencies of different interpersonal behaviours shown by each person towards the other. Studies have found that in ratings of relationships, items intercorrelate on each plane according to the predicted ordering (Benjamin, 2000), and between planes according to the complementarity principle (Gurtman, 2001). Further details of the SASB model are available in a review by Benjamin, Rothweiler, and Critchfield (2006). Benjamin (1989) explored whether people with auditory hallucinations would be able to use a questionnaire based on the SASB to rate relationships with their voices. Asking 30 participants with a range of diagnoses to do this, she found ratings of voices often



Figure 1. SASB cluster model.

corresponded above chance to predefined profiles of relating often encountered in everyday relationships. However, a specific analysis of complementarity has not been conducted. The present study uses the SASB model to examine whether ratings of the ‘internal’ relationship between the voice hearer and their voices conforms to the same principles as ratings of ‘external’ relationships. Specifically, it will examine whether interpersonal appraisals of hallucinations predict corresponding responses according to the complementarity principle. In addition, the study will examine the extent to which interpersonal appraisals of voice hostility and dominance predict distress and depressive symptoms as proposed by cognitive models (e.g. Chadwick & Birchwood, 1994; Gilbert et al., 2001).

Method Participants were recruited from the adult psychiatry services of a UK Mental Health NHS Trust. All people with a schizophrenia-spectrum disorder treated by the Trust’s



415

psychiatric in-patient services and a locality community mental health team during a 4-month period were considered for the study. Inclusion criteria were (a) a chart diagnosis of schizophrenia or schizoaffective disorder, (b) identified by the treating team as currently experiencing auditory verbal hallucinations, (c) confirmation by participant report of auditory verbal hallucinations within the last week, and (d) sufficient command of English to complete interview and questionnaires. For the purposes of the study, auditory verbal hallucinations were defined as hearing speech, with a similar perceptual quality to other auditory perceptions; perceived references to self from persons in the immediate environment were not included. Of 84 participants meeting these criteria, 15 were excluded because they were considered too disabled by symptoms to meaningfully participate in the interview, and five were discharged before they could be assessed. Of the remaining 64 participants, 35 (55%; 22 male, 13 female) agreed to participate and completed measures. The mean age of participants was 34.9 years (range: 19–54, SD ¼ 8:43), and all had heard voices for at least 1 year (M ¼ 10:6 years, SD ¼ 8:98, range: 1–31 years). Eighteen were White British and 17 were from other ethnic backgrounds. Thirty had a diagnosis of schizophrenia, and five had a diagnosis of schizoaffective disorder.

Measures Structural analysis of social behaviour The long form of the Intrex (Benjamin, 2000), a checklist based upon the SASB model, was given to participants to rate how their voices acted towards them, and how they responded to their voices. The Intrex consists of a series of items relating to each of the 72 points defined on the two circumplex planes within the SASB, e.g. ‘X gives in to Y, yields and submits to Y’ (item in the ‘submit’ cluster). Items were worded to correspond to interpersonal behaviours of (a) the voice in relation to the hearer (e.g. ‘The voice gives in to me, yields and submits to me’) and (b) the hearer in relation to the voice (e.g. ‘I give in to the voice, yield and submit to it’). The inventory comprised the 72 voice items, in random order, followed by the 72 hearer items, in random order. Each item was rated on a scale of 0–100 with the anchors 0 ¼ ‘does not apply at all’ and 100 ¼ ‘applies always, perfectly’. Participants were asked to rate one of the voices which they heard most often or that otherwise stood out from the rest and were given a copy of the questionnaire to follow while the interviewer read out each question. The long form Intrex shows test–retest reliabilities ranging from .82 to .94 for ratings of different relationships by psychiatric patients (Benjamin, 2000), and factor analysis has confirmed the relative positioning of the eight clusters within two-dimensional space (Benjamin, 2000; Lorr & Strack, 1999; Pincus, Gurtman, & Ruiz, 1998). There is convergent validity with measures of related constructs such as the Interpersonal Circle, Five Factor Model of personality and adult attachment style (Pincus, Gurtman, & Ruiz, 1998; Pincus, Dickinson, Schutt, Castonguay, & Bedics, 1999).

Emotional response to voices Distress in response to hallucinations was assessed using an adapted version of the Profile of Mood States (POMS; McNair, Lorr, & Droppleman, 1992). The POMS is a wellestablished measure consisting of a checklist of a series of words relating to different emotional states, which are rated according to how intensely they are felt. The POMS was adapted so that participants were asked to rate how they usually felt in response to



hearing voices. In order to shorten the questionnaire, only items for the depression, tension, and anger scales were included. The POMS scales used have good reliability and validity and, although not previously used to rate responses to auditory hallucinations, have frequently been used to measure responses to other stimuli (McNair et al., 1992). As a check of the concurrent validity of this adaptation of the POMS, participants also completed the distress item from the questionnaire developed by Hustig and Ha¨fner (1990). This uses a five-point scale anchored as follows: (1) very distressing, (2) fairly distressing, (3) neutral, (4) fairly comforting, and (5) very comforting. Depression The Calgary Depression Scale for Schizophrenia (CDSS; Addington, Addington, & Tyndale, 1993) was used as a measure of depressive symptoms. This is an interviewbased measure designed to assess depressive symptoms in people with schizophrenia, independent of levels of positive and negative symptomatology. Nine items are rated by the interviewer on four-point scales. The CDSS shows good inter-rater reliability and correlates highly with measures of depressive symptoms whilst showing low correlations with measures of psychotic symptoms. In line with data presented by Addington et al. (1993), a cut-off score of seven or more was used to classify the presence of depressive symptoms. Participants were also asked how often they currently experienced voices, with hallucinations occurring at least every hour of the day classified as continuous auditory hallucinations. The measures were completed in the above order in a single session lasting approximately 1 hour.

Results Reliability of interpersonal appraisals of hallucinations The SASB items were distributed across four separate circumplex planes, corresponding to the participant’s perceptions of (1) how the voice addresses them (voice acts, VA), (2) their corresponding responses to the voice (hearer reacts, HR), (3) how they address the voice (hearer acts, HA), and (4) the voice’s corresponding responses to their actions (voice reacts, VR). In order to examine whether the full range of interpersonal concepts could be applied reliably to auditory hallucinations, items were grouped into each plane’s eight clusters, which each comprise either four or five items. Cronbach alpha coefficients were calculated for each cluster (see Table 1). On the two planes that correspond to the voice’s actions towards the hearer (VA) and the hearer’s responses (HR), the obtained Cronbach alpha coefficients were in the range .60–.88. This is consistent with the range (.59–.90) reported by Lorr and Strack (1999) for 182 participants’ ratings of their childhood relationships with their mothers. A similar range was found for when the participant addressed the voice (HA). However, three of the clusters on the plane for the voice’s corresponding responses (VR) appeared to be unreliable, with alpha coefficients below .60: ‘sulk’, ‘separate’, and ‘protest’. Dimensions of control and hostility By weighting item scores according to their position relative to the horizontal and vertical axes, two dimension scores can be calculated for each plane, representing affiliation versus hostility and autonomy versus control/submission (Pincus, Newes,



417

Table 1. Internal consistencies of SASB item clusters Cluster (acts plane/reacts plane)

Number of items

Control/submit Protect/trust Active love/reactive love Affirm/disclose Emancipate/separate Ignore/wall-off Attack/protest Blame/sulk

VA plane

5 4 5 4 5 4 5 4

HR plane

.66 .81 .68 .73 .60 .88 .87 .80

.80 .84 .70 .76 .60 .71 .82 .75

HA plane .82 .66 .81 .73 .60 .74 .86 .82

VR plane .74 .79 .84 .77 .00 .64 .50 .47

Note. VA, voice acts; HA, hearer acts; HR, hearer reacts; VR, voice reacts.

Dickinson, & Ruiz, 1998). Scores for these dimensions were calculated using the formulas described by Benjamin (2000), to produce scales with a possible range from 2 210 to þ 210. For ease of discussing results, polarities have been reversed, with positive scores representing hostility or control/submission. With two dimensions across four planes, this produces a total of eight dimension scores. Scores were normally distributed on all eight dimensions. Means and standard deviations for these and the other main variables are presented in Table 2. The means close to zero on the hostility– affiliation dimensions suggest that hostile relationships were as common as affiliative relationships, in contrast to in everyday relationships where the mean is much closer to the affiliative pole (Benjamin, 2000). Table 2. Means and standard deviations of main variables Variable

Mean

VA hostility (þ) versus affiliation (–) VA control (þ) versus autonomy (–) VR hostility (þ) versus affiliation (–) VR submission (þ ) versus autonomy (–) HA hostility (þ ) versus affiliation (–) HA control (þ) versus autonomy (–) HR hostility (þ ) versus affiliation (–) HR submission (þ ) versus autonomy (–) POMS depression POMS tension POMS anger POMS overall CDSS depressive symptoms

þ3.4 þ 22.6 –29.1 –25.1 –22.5 –32.4 þ1.3 –7.1 1.96 1.81 1.03 1.87 4.94

SD 105.2 45.2 66.8 41.5 76.6 41.1 87.8 58.4 1.16 0.99 0.62 0.99 5.36

Note. VA, voice acts plane of SASB; VR, voice reacts plane; HA, hearer acts plane; HR, hearer reacts plane; POMS, adapted version of Profile of Mood States; CDSS, Calgary Depression Scale for Schizophrenia. SASB dimensions range from negative to positive with a midpoint of zero.

On exploring correlations between the interpersonal dimensions and the number of years participants reported they had heard voices for, the only statistically significant correlation was with submission to voices (HR submission, r ¼ :37, p ¼ :04).



Complementarity The complementarity principle predicts that the affiliation–hostility and autonomy– interdependence dimensions should be intercorrelated on corresponding planes. In other words, in relationships where the voice expresses hostility and control towards the hearer (on the VA plane), it would be expected that the hearer would respond with hostility and submission (on the HR plane); a similar pattern would be predicted when the focus of the interaction is towards the voice (on the HA and VR planes). Because the two dimension scores on each plane had been derived from the same set of items, partial correlations were calculated between dimension pairs, controlling for the two other dimensions on the planes being compared. For example, the partial correlation between VA hostility and HR hostility controls for VA control and HR submission. The obtained intercorrelations are presented in Table 3. This shows that there was a very strong relationship between the dimensions of hostility. The relationship between dimensions of control and submission was weaker, with the correlation between VA control and HR submission just failing to reach statistical significance. Table 3. Partial correlations between complementary SASB dimensions Dimensions Voice addressing hearer (VA and HR planes) VA hostility 2 HR hostility VA control 2 HR submission Hearer addressing voice (HA and VR planes) HA hostility 2 VR hostility HA control 2 VR submission

Partial r

p

.91 .31

p , .001 p ¼ .08

.87 .44

p , .001 P ¼ .01

Note. Partial correlations control for the other two interpersonal dimensions on the two planes being compared. VA, voice acts plane of SASB; VR, voice reacts plane; HA, hearer acts plane; HR, hearer reacts plane.

Voice-related distress The main measure of voice-related distress was the adapted POMS. The three POMS scales were noted to be highly intercorrelated (depression–tension: r ¼ :82, p , :001; depression–anger: r ¼ :72, p , :001; tension–anger: r ¼ :63, p , :001), so were combined to produce an overall distress score, represented by the mean of all items. The internal consistency of this overall POMS score was high (a ¼ :96). This scale differentiated between those participants who regarded their voices as distressing and those who rated them as neutral or comforting (t ¼ 3:54, df ¼ 33, p ¼ :001), supporting the validity of using the POMS in this way. The POMS overall score was not associated with frequency of hallucination or number of years hearing voices, but was associated with the presence of depression on the CDSS (t ¼ 2:471, df ¼ 33, p ¼ :02). As predicted, the overall POMS score showed bivariate correlations with both voice hostility (VA hostility; r ¼ :65, p , :001) and control (VA control; r ¼ :37, p ¼ :03). A multiple regression analysis was conducted with the POMS overall score as the dependent variable. The presence of depression according to the CDSS was entered as a first independent variable (R2 change ¼ :156, Fð1; 33Þchange ¼ 6:107, p ¼ :02), and then VA control and VA hostility were entered as a second block of predictors (R2 change ¼ .299, Fð2; 31Þchange ¼ 8:492, p ¼ :001). The model explained 46% of



419

variance in POMS distress scores (R 2 ¼ :455, Fð3; 31Þ ¼ 8:621, p , :001). The only significant predictor of distress was voice hostility (VA hostility; b ¼ 0:591, t ¼ 3:839, p ¼ :001). Voice control (VA control; b ¼ 2 0.011, t ¼ 0:064, p ¼ :95), and depression (CDSS: b ¼ 0:184, t ¼ 1:192, p ¼ :24) did not show independent effects. The proportion of variance explained by the model was not significantly improved by the addition of the voice hearer’s responses to the voice (HR hostility and HR submission) or any of the other interpersonal dimensions. Depression The association between interpersonal perceptions of voices and depressive symptoms was also examined. Nine of the 35 participants were identified as depressed on the CDSS using the cut-off score of seven or above. The presence of depression on the CDSS was associated with both VA hostility (t ¼ 2.263, df ¼ 33, p ¼ .03) and VA control (t ¼ 3.201, df ¼ 33, p ¼ .003). A logistic regression using VA hostility and VA control as predictor variables (likelihood ratio test: x2 ¼ 11.486, df ¼ 2, p ¼ .003) showed that VA control was a statistically significant predictor (Odds Ratio (OR) ¼ 1.034, 95% CI 1.003–1.067, p ¼ .03), but VA hostility was not (Odds Ratio (OR) ¼ 1.006, 95% CI 0.995–1.016, p ¼ .29). Depression was not related to submission to voices (HR submission; t ¼ 0.660, df ¼ 33, p ¼ .51), but did show an association with hearers reacting to voices with hostility (HR hostility; t ¼ 2.147, df ¼ 33, p ¼ .04). Entering these two variables as a second block did not improve the fit of the regression model (increase in likelihood ratio: x2 ¼ 0.024, df ¼ 2, p ¼ .99).

Discussion This project adds to a growing number of studies suggesting that models of interpersonal relating can be meaningfully applied to auditory verbal hallucinations. Most clusters within the SASB model could be applied to hallucinated voices as reliably as has been found in interpersonal relationships. The principle of interpersonal complementarity could be used to predict rated responses to hallucination and distress was predicted by the interpersonal appraisals made. These findings support the proposal that voice hearers impose interpersonal meaning on their hallucinatory experience, and this may influence their emotional and behavioural responses. This is the first published study to explicitly examine whether a wide range of interpersonal relating patterns can be mapped on to the experience of auditory hallucinations. Internal consistency was used as a basic index of the applicability of different interpersonal concepts to voice hearer’s ‘internal’ relationship with their voices. Using this index, 29 of the 32 interpersonal behaviour ‘clusters’ described by the SASB could be applied to voices as reliably as has been reported in conventional interpersonal relationships. Internal consistency only provides an initial test of the applicability of each of these concepts, with further validation required, but these data are consistent with there being a wide range of interpersonal concepts which can be meaningfully imposed upon hallucinatory experience. Nonetheless, it is worth considering why some areas did not appear as readily applicable to hallucinatory experience. Of course, hallucinated voices are mentally generated phenomena, not expected to ‘behave’ in the same manner as real persons. Indeed, voice content typically has particular themes: most commonly instructions to



do things, criticism, threats, and commentary on what the person is doing or thinking (Nayani & David, 1996). Each of these content themes is self-referent, likely reflecting the internal origins of hallucinatory material. In terms of the SASB model, such selfreferent content places the focus of the interaction upon the voice hearer, represented by the VA and HR planes. All clusters of interpersonal behaviour appeared reliable on these two planes. The other two planes of the SASB correspond to when the focus of the interaction is upon the voice. This would apply when the voice hearer actively directs or questions the voice (HA plane) and the voice responds to this or spontaneously talks about itself (VR plane). Whilst all clusters were reliable on the HA plane, the three clusters that showed poor reliability were all located on the VR plane. Hence, whilst it seemed that participants could consider the full range of interpersonal behaviours in how they addressed their voices (HA plane), it did not appear that the full range of interpersonal concepts were applicable to the voices’ corresponding responses (VR plane). This is similar to findings reported by Vaughn and Fowler (2004) using a different measure of relating, the Couples Relating to Each Other Questionnaire (CREOQ). They noted that participants’ ratings of voice distancing (similar to separation on the SASB) and voice submission showed poor internal consistency. A possible interpretation of this is that hallucinatory experience does not completely mimic normal interpersonal interaction, with voices not showing the same range of responses to the hearer as would a person in the external social world. An implication of this would be that voices may not ‘respond’ in a congruent manner when addressed by the voice hearer. This study also examined whether the principle of interpersonal complementarity could be used to predict the person’s responses to their hallucinations. Perceptions of voice hostility as opposed to affiliation very reliably predicted reciprocal hostile or affiliative responses in line with this principle. This mirrors the observations of perceived voice malevolence predicting resistance, and benevolence predicting engagement. Considering this within an interpersonal framework illustrates that these responses might be understood as normal interpersonal reactions to perceiving being related to by a hostile or friendly other. However, the observed associations between the dimensions of control and submission were less strong, with submission to voices showing only a trend to be predicted by voice control. This suggests that submission does not reliably arise as a reciprocal response to voice dominance, and that other factors are likely to be important in determining this reaction. An unexpected observation was that submission showed a trend to be associated with the number of years voices had been heard for, raising the possibility that voice hearers may initially resist submitting to voices, but may adopt increasingly submissive responses after hearing voices over a prolonged period. It is likely that other appraisals influence submission to voices, rather than perceived voice control alone. Studies on command hallucinations have found that compliance with hallucinated commands may be associated with beliefs about the voice’s power to harm the hearer and apparent superiority, together with beliefs the person holds about their own social rank in relationships in general (Birchwood et al., 2000; Chadwick & Birchwood, 1994; Fox, Gray, & Lewis, 2004). These appraisals may moderate submission as an interpersonal response beyond the effect of perceived voice control. The study also provided an opportunity to examine the predictions that voice hostility and dominance are important in determining emotional adjustment to voice hearing (Gilbert et al., 2001). The prediction that voices characterized as hostile and dominating would be associated with both voice-related distress and depressive symptomatology was partly supported. However, a dissociation emerged, with



421

voice-related distress being most strongly associated with appraisals of voice hostility, and depressive symptoms only showing an association with voice control. This is the first time the association between perceived voice hostility and voice related distress has been assessed using a measure other than the BAVQ, confirming this observation using an independent measure. However, the finding that distress was more strongly related to voice hostility than voice dominance is in contrast to findings by Vaughn and Fowler (2004), who measured voice dominance using the upperness scale of the CREOQ, designed to measure excessively domineering interpersonal relating in everyday relationships. They found that this measure of voice dominance was a stronger predictor of ratings of voice-related distress than BAVQ malevolence. However, malevolence and upperness were themselves very highly intercorrelated (r ¼ .88) which raises doubts about the extent to which separate constructs had been measured. Given that both the present study and that of Vaughn and Fowler (2004) have employed relatively small samples for conducting multivariate analysis, further study is required to clarify the relative importance of voice dominance and hostility. Following previous studies (Birchwood et al., 2004; Gilbert et al., 2001), depressive symptomatology was additionally examined as a potential correlate of interpersonal appraisals of hallucinations. The correlation between depression and voice dominance, rather than voice hostility alone, supports proposals that perceptions of low power and social rank may be of particular importance in understanding depressive responses (Gilbert et al., 2001). However, as depression was not additionally associated with submission to voices, it seems unlikely that perceived subjugation by voices is causal in this association. Indeed, a path analysis conducted by Birchwood et al. (2004) suggested that depressive symptoms and appraisals of voices as dominant (powerful and of high status) may both arise from beliefs relating to one’s social rank in general. Hence appraisals of voices as dominating may reflect broader interpersonal schemas that may themselves predispose to depressive symptoms. The influence of broader interpersonal schemas on the extent to which one may adopt complementary submissive responses to dominating voices is a subject for further investigation. This study had several limitations. The sample size was small, which, although not precluding finding a number of predicted associations, prevented more detailed statistical analysis (e.g. of circumplex structure). There was a high refusal rate. It was also a relatively chronic sample of voice hearers, having experienced hallucinations for an average of 10 years, so it is unclear whether these results would generalize to a first episode population. We cannot determine from these data how long it may take for the suggested pattern of reciprocal relating to form with hallucinated voices. The observed associations between interpersonal perceptions of voices and emotional and behavioural responses were not examined in the context of broader individual difference variables. Hence it is not clear the extent to which ratings made of the ‘relationship’ between voice hearer and voice reflected voice content, other dimensions of hallucination (e.g. loudness, location), other appraisals of voices, perceptions of interpersonal relationships in general, personality, and psychotic symptoms which might influence interpersonal relating (e.g. paranoia, grandiosity). It would have been valuable if participants completed ratings of real life relationships as well as voices as this would also have provided data for examining how the structure of relating with voices compares to other relationships. The study may also have benefited from the inclusion of measures such as insight and severity of illness, which potentially moderate the impact of interpersonal perceptions of voices, and of standardized measures of hallucination phenomenology. The POMS has not previously been validated for the purpose of rating



responses to hallucinations, although in this sample it did correlate with self-rating of the degree of voice distress, supporting the validity of its use in this way. Clinically, the study suggests the value of considering interpersonal aspects of hallucinatory experience when working with people with schizophrenia. In particular, behavioural responses to voices, traditionally conceptualized as coping responses to a stressor (Farhall, Greenwood, & Jackson, 2007), might also be thought of as reciprocal interpersonal responses to the perceived actions of hallucinated others. A possible therapeutic application of this is to help the voice hearer to examine the usefulness of responding to voices in a reciprocal manner, such as responding with hostility to voices perceived as critical or threatening. In people who regard their voices as real others, analogies with normal interpersonal interactions might be used (e.g. considering the helpfulness of ‘arguing’ with voices). The belief that hallucinated voices should be dealt with in the same way as others in the person’s external social world could also be targeted for modification. This might involve drawing contrasts between internal relationships with voices and external relationships, or by modifying underlying beliefs that voices have a will of their own, which could complement existing approaches targeting beliefs about voice power (e.g. Chadwick & Birchwood, 1994; Trower et al., 2004). People with greater insight could be directly helped to recognize when they are being drawn into reacting to voices as if they were literally another person. Additionally, acceptance and mindfulness-based approaches (e.g. Bach & Hayes, 2002) may also provide skills and techniques that might help to disentangle voice hearers from dysfunctional relationships with their voices.

References Addington, D., Addington, J., & Tyndale, E. M. (1993). Assessing depression in schizophrenia: The Calgary Depression Scale. British Journal of Psychiatry, 163(Suppl. 22), 39–44. Ansell, E. B., Kurtz, J. E., & Markey, P. M. (2008). Gender differences in interpersonal complementarity within roommate dyads. Personality and Social Psychology Bulletin, 34, 502–512. Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70, 1129–1139. Beck-Sander, A., Birchwood, M., & Chadwick, P. (1997). Acting on command hallucinations: A cognitive approach. British Journal of Clinical Psychology, 36, 139–148. Benjamin, L. S. (1974). Structural analysis of social behavior. Psychological Review, 81, 392–425. Benjamin, L. S. (1989). Is chronicity a function of the relationship between the person and the auditory hallucination? Schizophrenia Bulletin, 15, 291–310. Benjamin, L. S. (1996). A clinician-friendly version of the interpersonal circumplex: Structural analysis of social behaviour. Journal of Personality Assessment, 66, 248–266. Benjamin, L. S. (2000). SASB Intrex users manual for short, medium and long form questionnaires. Salt Lake City, UT: University of Utah. Benjamin, L. S., Rothweiler, J. C., & Critchfield, K. L. (2006). The use of the structural assessment of social behaviour (SASB) as an assessment tool. Annual Review of Clinical Psychology, 2, 83–109. Birchwood, M., & Chadwick, P. (1997). The omnipotence of voices: Testing the validity of a cognitive model. Psychological Medicine, 27, 1345–1353. Birchwood, M., Gilbert, P., Gilbert, J., Trower, P., Meaden, A., Hay, J., et al. (2004). Interpersonal and role-related schema influence the relationship with the dominant ‘voice’ in schizophrenia: A comparison of three models. Psychological Medicine, 34, 1571–1580.



423

Birchwood, M., Meaden, A., Trower, P., Gilbert, P., & Plaistow, J. (2000). The power and omnipotence of voices: Subordination and entrapment by voices and significant others. Psychological Medicine, 30, 337–344. Carson, R. C. (1969). Interaction concepts of personality. Chicago, IL: Aldine. Chadwick, P., & Birchwood, M. (1994). Challenging the omnipotence of voices: A cognitive approach to auditory hallucinations. British Journal of Psychiatry, 164, 190–201. Chadwick, P., & Birchwood, M. (1995). The omnipotence of voices II: The Beliefs About Voices Questionnaire (BAVQ). British Journal of Psychiatry, 166, 773–776. Chadwick, P., Lees, S., & Birchwood, M. (2000). The revised Beliefs About Voices Questionnaire (BAVQ-R). British Journal of Psychiatry, 177, 229–232. Farhall, J., Greenwood, K. M., & Jackson, H. (2007). Coping with hallucinated voices in schizophrenia: A review of self-initiated strategies and therapeutic interventions. Clinical Psychology Review, 27, 476–493. Fox, J. R. E., Gray, N. S., & Lewis, H. (2004). Factors determining compliance with command hallucinations with violent content: The role of social rank, perceived power of the voice and voice malevolence. Journal of Forensic Psychiatry and Psychology, 15, 511–531. Freedman, M. B., Leary, T. F., Ossorio, A. G., & Coffey, H. S. (1951). The interpersonal dimension of personality. Journal of Personality, 20, 143–161. Gilbert, P., Birchwood, M., Gilbert, J., Trower, P., Hay, J., Murray, B., et al. (2001). An exploration of evolved mental mechanisms for dominant and subordinate behaviour in relation to auditory hallucinations in schizophrenia and critical thoughts in depression. Psychological Medicine, 31, 1117–1127. Gurtman, M. B. (2001). Interpersonal complementarity: Integrating interpersonal measurement with interpersonal models. Journal of Counseling Psychology, 48, 97–110. Hayward, M. (2003). Interpersonal relating and voice hearing: To what extent does relating to the voice reflect social relating. Psychology and Psychotherapy: Theory, Research and Practice, 76, 369–383. Hustig, H., & Ha¨fner, R. (1990). Persistent auditory hallucinations and their relationship to delusions and mood. Journal of Nervous and Mental Disease, 178, 264–267. Kiesler, D. J. (1983). The 1982 interpersonal circle: A taxonomy for complementarity in human transactions. Psychological Review, 90, 185–214. Lorr, M., & McNair, D. M. (1963). An interpersonal behavior circle. Journal of Abnormal and Social Psychology, 67, 68–75. Lorr, M., & Strack, S. (1999). A study of Benjamin’s eight-facet structural analysis of social behaviour (SASB) model. Journal of Clinical Psychology, 55, 207–215. Markey, P. M., Funder, D. C., & Ozer, D. J. (2003). Complementarity of interpersonal behaviors in dyadic interactions. Personality and Social Psychology Bulletin, 29, 1082–1090. Markey, P. M., & Kurtz, J. E. (2006). Increasing acquaintanceship and complementarity of behavioral styles and personality traits among college roommates. Personality and Social Psychology Bulletin, 32, 907–916. McNair, D. M., Lorr, M., & Droppleman, L. F. (1992). Manual for the profile of mood states. San Diego, CA: Educational and Industrial Testing Service. Nayani, T. H., & David, A. S. (1996). The auditory hallucination: A phenomenological survey. Psychological Medicine, 26, 126–141. Pincus, A. L., Dickinson, K. A., Schutt, A. J., Castonguay, L. G., & Bedics, J. (1999). Integrating interpersonal assessment and adult attachment using SASB. European Journal of Psychological Assessment, 15, 206–220. Pincus, A. L., Gurtman, M. B., & Ruiz, M. A. (1998). Structural analysis of social behavior (SASB): Circumplex analyses and structural relations with the Interpersonal Circle and the Five-Factor Model of personality. Journal of Personality and Social Psychology, 74, 1629–1645. Pincus, A. L., Newes, S. L., Dickinson, K. A., & Ruiz, M. A. (1998). A comparison of three indexes to assess the dimensions of structural analysis of social behavior. Journal of Personality Assessment, 70, 145–170.


424 Neil Thomas et al. Sadler, P., & Woody, E. (2003). Is who you are who you’re talking to? Interpersonal style and complementarity in mixed-sex interactions. Journal of Personality and Social Psychology, 84, 80–95. Strong, S. R., Hills, H. I., Kilmartin, C. T., DeVries, H., Lanier, K., Nelson, B., et al. (1988). The dynamic relations among interpersonal behaviours: A test of complementarity and anticomplementarity. Journal of Personality and Social Psychology, 54, 798–810. Tracey, T. J. G. (1994). An examination of the complementarity of interpersonal behavior. Journal of Personality and Social Psychology, 67, 864–878. Tracey, T. J. G. (2005). Interpersonal rigidity and complementarity. Journal of Research in Personality, 39, 592–614. Tracey, T. J. G., Ryan, J. M., & Jaschik-Herman, B. (2001). Complementarity of interpersonal circumplex traits. Personality and Social Psychology Bulletin, 27, 786–797. Trower, P., Birchwood, M., Meaden, A., Byrne, S., Nelson, A., & Ross, K. (2004). Cognitive therapy for command hallucinations: Randomised controlled trial. British Journal of Psychiatry, 184, 312–320. Van der Gaag, M., Hageman, M. C., & Birchwood, M. (2003). Evidence for a cognitive model of auditory hallucinations. Journal of Nervous and Mental Disease, 191, 542–545. Vaughn, S., & Fowler, D. (2004). The distress experienced by voice hearers is associated with the perceived relationship between the voice hearer and the voice. British Journal of Clinical Psychology, 43, 143–154. Wiggins, J. S. (1979). A psychological taxonomy of trait-descriptive terms: The interpersonal domain. Journal of Personality and Social Psychology, 37, 395–412. Received 21 December 2007; revised version received 28 December 2008