Can Gender Differences in Distress Due to Difficult Voices Be Explained by Differences in Relating?

Participants for this study were drawn from a large sample of 402 participants (37.6% female, age: M = 40.47, SD = 13.40) recruited from inpatient units and community mental health teams in 14 Mental Health Trusts within the National Health Service (NHS) in England for the validation of a relating to voices questionnaire (Hayward et al. 2020). Inclusion criteria for the initial study were: age of at least 18 years, voice hearing for six months or longer, and sufficient English language skills to complete the questionnaires. For the purpose of the present study, we only included participants from the original sample who reported hearing voices at least once within the week prior to the research assessment.

A subsample was drawn using a pairwise-matching procedure. Pairs of male and female voice hearers were matched according to (1) age (no more than two years of age difference) and (2) education level (equal level of education or one step above/below). Furthermore, participants were matched (3) by self-reported primary diagnosis if possible (i.e. preferred matching of pairs with the same diagnosis; if no match was possible, participants were matched based on a broader criterion, comparing those with psychotic disorder vs. other diagnosis). This resulted in a sample of 248 participants consisting of 124 matched pairs, with 75% of the participants (n = 93 pairs) being matched by primary diagnosis. Demographic and clinical data on the male and female participants included in this study are summarized in Table 1.

Participants who met the inclusion criteria were recruited and informed about the study by clinicians within the participating inpatient units and community mental health teams. For the study, participants were invited to meet with a member of the research team. At the start of this meeting, the participant information sheet was reviewed and any questions about the study were answered. Participants were advised that they could end their participation at any point without giving a reason and without their care being affected. Written informed consent was obtained from all participants.

Next, several measures were completed in line with an assessment protocol (for a more detailed description, see: Hayward et al. 2020). First, participants provided demographic data—including the diagnosis they had received. Next, they started with the first half of the Approve questionnaires (either the Approve Voices or Approve Social), followed by clinical outcome questionnaires including the HPSVQ and the DASS-21. Finally, participants answered the second half of the Approve questionnaire. The Approve questionnaires were split and presented in a random order for the purpose of more conservative testing in the original validation study (Hayward et al. 2020) from which the data for this study was extracted. Following the assessment, participants were able to provide written feedback on the questionnaires.

All procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. All procedures involving human subjects/patients were approved by an NHS Research Ethics Committee (reference 18/LO/0046) and the NHS Health Research Authority.

All data analyses were carried out using R 3.6.1 (R Core Team 2019). In a first step, we compared the mean scores of male and female participants for all variables of interest (voice severity, voice distress, relating scores, and general mental health parameters) using two sample t tests. To account for alpha error inflation, the tests were corrected using the Bonferroni correction for the significance level (i.e. for a global significance level of α = 0.05, the threshold for each of the 11 individual t tests was α = 0.0045). Additionally, Cohen’s d was calculated for all tests to compare the total size of gender differences on all variables (small effect size: 0.20 ≤ d < 0.50, medium effect size: 0.50 ≤ d < 0.80, large effect size: d ≥ 0.80). Finally, all of the aforementioned group comparisons were repeated while controlling for diagnosis by calculating linear regression models of the outcome-variables with gender and diagnosis entered as predictors.

Next, we tested the hypothesis that gender differences in voice distress are mediated by relating to voices. We carried out structural equation modeling to calculate separate mediation models for each relating factor that showed significant gender differences. The indirect effect (ab) comprising the path from gender to the respective relating factor (a) and the path from the relating factor to voice distress (a) was tested for significance. Additionally, to double-check whether the hypothesized pathway from gender to relating to voice distress emerges from the data, we performed a network analysis with a graphical lasso (glasso) based optimization of the covariances. A model including gender and all HPSVQ and Approve factors with significant gender differences was initially calculated to explore whether the partial correlation matrix would include pathways between gender and voice distress via relating to voices and whether this was the strongest pathway in terms of correlation size (“Relating to Voices”-network model). Finally, mental health parameters were added in an “Extended Mental Health” network model to explore whether connections between gender and voice distress remained stable when global psychopathology markers were controlled for.

Gender differences in all variables of interest are summarized in Table 3. T tests showed significant between-group differences in relating to voices and others. Female voice hearers responded less assertively and more passively to voices. They showed a similar tendency in passive responding to other people. However, this difference was non-significant under the Bonferroni-corrected alpha level. Furthermore, female participants rated their voices to be significantly more distressing, had higher voice severity scores, and showed higher levels of anxiety and stress. All results remained unchanged when diagnosis was controlled for—with the sole exception of passive relating to others, for which the uncorrected results became non-significant (b = 0.488, SE = 0.32, T = 1.55, p_uncorr = 0.123).

Based on the differences reported above, we tested whether (1) assertive relating and (2) passive relating to voices mediated the association between gender and voice distress. For assertive relating, no significant indirect effect was found due to a low association between assertive relating and voice distress (Fig. 1, mediation model 1). Passive relating, by contrast, mediated 33.73% of the total effect of gender on voice distress (Fig. 1, mediation model 2).

The initial “relating to voices” network model including the variables of gender, passive relating and assertive relating to voices, voice severity, and voice distress showed no direct connection between gender and voice distress; instead, two separate pathways connected both variables (see Fig. 2, left). One pathway included voice severity, with female gender being associated with higher levels on the voice severity scale, which in turn was associated with increased voice distress. The other pathway included assertive relating to voices, with female gender being associated with decreased levels of assertive relating. Assertive relating, in turn, was negatively correlated with passive relating. Passive relating, finally, was associated with higher levels of voice distress. Lastly, there was a connection between both pathways, with more passive relating being connected with higher voice severity. Notably, while a mediated pathway from gender to voice hearing via relating was found in this network, partial correlation coefficients connecting gender and relating were somewhat lower than the partial correlation between gender and voice severity.

When global levels of anxiety and stress were added to the network (Fig. 2, “extended mental health network”), no direct connections between gender and voice distress involving any of the newly added parameters emerged. Furthermore, the “voice severity” pathway remained unchanged. However, the “relating” pathway was extended and now included both stress and anxiety as intermediary variables that connected passive relating and voice distress.

Strengths of this study include the matching of the samples which reduces the chance of biased results. Furthermore, the relatively large sample size can be considered a strength as it allows for the detection of medium and small differences and increases the precision of estimates. A limitation is that diagnoses were self-reported. This could have led to reduced accuracy of diagnostic status, especially since there is evidence that mental health professionals are sometimes reluctant to share the exact diagnosis with their patients (Perkins et al. 2018). Secondly, relating and voice hearing were measured by self-report questionnaires. Possibly, self-reports of affect and behavior lead to an overestimation of gender differences in the direction of gender-role conforming behaviors, especially since there are results from other areas of research that show larger differences in self-reported behavioral tendencies than in objectively assessed behavior (Allen 1995), or instances where self-reported symptom intensity shows the opposite effect when compared to objective parameters (e.g., pain perception vs. physiological parameters; Etherton et al. 2014). Whereas voice severity eludes a truly objective assessment, physiological parameters to quantify voice distress and behavioral assessment of relating could be implemented in future research to further elucidate the extent of gender differences. Finally, the current study focuses on negative voices (i.e., when voices become difficult). As there is some evidence for differences in voice valence (with male voice hearers experiencing more benevolent voices, e.g., Toh et al. 2020), we need to interpret our findings in a larger context of potential gender differences in voice hearing.

Our results show that relating to voices and subsequent voice distress is connected to gender. Future studies could extend on these findings and explore to what degree these differences are the result of external causes (e.g. more frequent experience of abuse) and whether non-assertive relating amplifies gender differences in voice severity and distress over time. In terms of practical implications, this research may ultimately inform efforts to optimize CBT and relating therapies. Specifically, potential applications could be (1) scanning for gender-typical differences during case-formulation (2) including gender in individual case models when working with male and female participants (3) acknowledging that gender roles may have impacted negatively on relational aspects of voice hearing (in female patients) and utilizing the topic of gender role conformity when working with beliefs about oneself. Moreover, it may be possible to (4) build on any existing gender-typical resources a patient may bring to therapy. In male participants, this could mean fostering gender-role conforming assertiveness. For female patients, this may include broadening the range from which an assertive response is chosen. Rather than focusing on confrontational assertiveness (i.e., hearing what they are saying but also presenting and defending my own view), an assertive response rooted in mindfulness (e.g., notice the voices, notice your own reaction to it, and allow both of it to be) or even in Acceptance and Commitment Therapy (e.g., notice the voices but make responding a deliberate choice) might be more suitable if a female patient conforms to gender norms in society—especially since some trials have found both of these methods to be more effective in women (Gobin et al. 2019; Katz and Toner 2013). Finally, (5) practical implications of our results could also entail acknowledging that – for reasons yet unknown—women can experience voices more intensely and subsequently have more difficulties relating assertively to them. In sum, this study highlights the importance of including gender differences into our understanding of a relational framework and points to a research topic that could become highly relevant to practical application of voice hearing therapies.