Hearing distressing voices in the absence of external stimuli has always been an equally fascinating and challenging topic in health care. On a phenomenological level, a recent study on a large sample of voice hearers identified four clusters of voice hearing (McCarthy-Jones et al. 2014
). Specifically, these were (1) repetitively speaking commanding and commenting voices, (2) “own thought voices” that speak in the first-person and vocalize memories/thoughts, (3) “nonverbal voices” vocalizing words that don’t make any sense, and (4) “replay voices” that reiterate a memory of heard speech. Most patients experience voices from multiple clusters, with the commanding and commenting voices being the most prevalent form (86%). Research efforts have long focused on the neural basis of voice hearing in terms of neurofunctional deficits in signal-detection and intentional inhibition (Waters et al. 2012
). In recent years, however, the increasing dissemination of cognitive behavioral therapy (CBT) for psychosis and service user guided therapies for voice hearing has also facilitated the exploration of the psycho-social causal factors (e.g., childhood trauma; Daalman et al. 2012
) that can precipitate voice hearing and of the individual meaning of the voices in terms of underlying emotional conflicts involving anger, shame, or low self-esteem or in terms of the identity of the voice (Corstens and Longden 2013
While hearing voices has traditionally been linked mostly to psychotic disorders such as schizophrenia, recent research has found voice hearing to be common across many mental disorders (Waters and Fernyhough 2017
) and also in the general population (Larøi et al. 2012
), with the latter group exhibiting no need for help. In light of these results, contemporary conceptions of clinically relevant hallucinations have been gradually extended to include the impact of voice hearing such as voice related distress as a core element—rather than focusing on the phenomenon of hearing voices in and of itself (Greenwood et al. 2010
; Thomas et al. 2014
). This lead to the emergence of a new “wave” of symptom-targeted psychological interventions for voice hearing aimed at reducing distress due to hearing voices (e.g., Hayward et al. 2017
), reducing the compliance with harmful command hallucinations (e.g., Birchwood et al. 2014
), or facilitating mindful disengagement from distressing voices (e.g., Strauss et al. 2015
). To further improve on these efforts, we require a deeper understanding of mechanisms that underlie a distressing voice hearing experience and the key variables that facilitate or predict these mechanisms.
Based on the idea that voice hearing bears similarity to relating to other people, etiological research and new approaches to therapy have adopted a relational framework. Research on the relational framework continues to generate evidence linking social schema (Paulik 2012
) with functional and dysfunctional relating behavior (Hayward et al. 2020
; Sorrell et al. 2010
) and the positive or negative impact of voice hearing. Among the therapies based on this framework, cognitive therapy for command hallucinations focuses on the voice hearers’ perception of their voices as superior in social rank and seeks to modify beliefs about the voices’ power and control (Birchwood et al. 2014
). At least three other therapies are based on the relating framework and included behavioral elements, either by facilitating a constructive ‘live’ dialogue between the voice hearer and the voice (Voice Dialogue approach; Corstens et al. 2012
), by practicing how to respond more assertively to difficult voices in a simulated setting (AVATAR therapy; Craig et al. 2018
), or by means of experiential role-plays (Relating therapy; Hayward et al. 2017
). With RCT findings providing preliminary evidence on the efficacy of these therapies, the relating framework has become a promising approach to understanding the mechanisms maintaining distress due to voice hearing.
Focusing on functional compared to dysfunctional relating as a core mechanism to explain voice distress, a previous study by Hayward et al. (2016
) hypothesized gender to be a key predictor for an increased risk of dysfunctional relating and increased distress due to voice hearing. This hypothesis was based on the premise that relating to voices mirrors relating to others and is consequently affected by the same gender differences that are found in interpersonal behavior. For instance, we may assume that relating to a voice characterized by dominance, intrusiveness and negative content directed at the voice hearer corresponds closely to a social situation of bullying victimization. Consequently, gender differences found in coping with bullying, such as women showing more avoidance and less assertiveness (Jóhannsdóttir and Ólafsson 2004
) should also be found in relating to voices. Adding to this theoretical plausibility, gender differences in voice hearing have repeatedly been found. For example, female participants in general population samples show higher rates of auditory hallucinations (Murphy et al. 2010
). When comparing male and female patients with a schizophrenia diagnosis and auditory hallucinations, gender differences were predominantly found in the emotional impact of voice hearing, with female participants reporting more negative feelings of shame, guilt, and anxiety due to voices (Toh et al. 2020
). Finally, Hayward et al. (2016
) found that female voice hearers prefer more distance when relating to their voices and reported more avoidant behavior and negative emotions due to their voices. In sum, previous research already points to gender differences in voice distress and voice relating, which suggests a possible connection between these variables. To date, however, no study has explored whether differences in relating can explain differences in the impact of negative voices.
In this study, we aimed to replicate previous findings on gender differences in voice distress and relating to voices, utilizing a newly developed questionnaire that assesses typical relating styles when interacting with difficult voices. Furthermore, we hypothesised that female gender would predict increased voice distress due to gender differences in relating to voices.
In this study, we tested whether gender differences in voice hearing experiences can be explained by differences in relating to voices. Our results replicated previous findings that female voice hearers tend to have more severe voice hearing experiences (Murphy et al. 2010
), report more negative emotions and distress due to voice hearing (Toh et al. 2020
), and tend to relate less functionally (Hayward et al. 2016
) when compared to male voice hearers. In general, significant effect sizes were small to medium (0.37 ≤|d|≤ 0.59). To translate this range of effect sizes into more understandable terms of overlapping variance (Magnusson 2020
): There is an increased chance (i.e., 64.4–72.2%) that a randomly selected female voice hearer shows more distress and less functional relating than a randomly selected male voice hearer. Overall, however, the within gender variances in individual voice hearing experiences still overlap considerably (i.e., 77.2–85.3% overlap). Therefore, while population-wide trends for gender-differences exist, the individual voice hearing experience varies from person to person. In clinical practice, the knowledge of the gender differences can help to inform the diagnostic process and lines of inquiry when initially meeting patients. But at the same time, we need to remain curious about individual differences and avoid over-generalization when delivering person-centered therapy.
Of importance, our findings extend previous results by offering some evidence for a pathway from gender to voice distress via increased levels of passive relating. This is in line with the hypothesis that relating differences drive gender differences in voice hearing. Additionally, using network analysis, we found an extended pathway between gender and voice distress via assertive relating and passive relating. This could point towards an interdependence of the relating styles, where the passive reaction to the voice is the result of reduced assertiveness. In sum, these associations between assertive relating, passive relating and distress corroborate the basic tenets of the relating therapy approach that improving assertive relating can help to reduce less functional responses to voices and thereby reduces distress.
Additionally, in order to further refine our underlying assumptions that gender differences in relating to voices correspond to global differences in social relating, a closer inspection of the Approve Voices scales and the Approve Social scales adds helpful information. By descriptive values, women responded less assertively and more passively to both voices and other people. However, effect sizes for social relating (assertive: d = − 0.24, passive: d = 0.25) were notably lower than for relating to voices (assertive: d = − 0.38, passive: d = 0.47), and only relating to voices yielded consistently significant results when accounting for alpha-error inflation. However, a comparison of our effect-sizes to previous studies on gender differences in relating [i.e., responding to bullying with assertiveness: d = − 0.28, and with avoidance: d = 0.35, transformed from R2
reported in Jóhannsdóttir and Ólafsson (2004
)] shows that our effect sizes regarding social relating correspond to previous findings. Conversely, it seems that gender differences in relating to voices constitute an amplification of gender-role conforming differences in social relating. At this point, however, further research is needed to replicate this pattern of results and explore the factors that drive this translation of social relating styles to relating to voices.
Finally, while relating accounted for some of the gender differences in voice distress, network analysis also yielded a pathway that involved gender differences in voice severity. Possibly, women tend to experience more distress due to voices and relate more passively to them because they hear voices more frequently, more loudly, and for longer periods than men. The matching procedure utilized for this study makes it unlikely that this difference can be explained by differences in diagnosis or illness duration (see Table 1
) or demographic variables. However, since we have no data on medication or treatment history, we cannot determine to what extent gender differences in voice severity stem from etiological differences or differences in treatment, e.g. differences in prescription practice (Rothbard et al. 2003
), efficacy (Usall et al. 2007
), and pharmacodynamics of antipsychotic drugs (Seeman 2004
). On a related note, the composition of our sample prevented us from examining the role of gender differences across different cultures. It stands to reason that the aggressive-assertive-passive relating continuum is as likely to be affected by cultural norms and the cross-cultural variation in gender norms as it is by gender. To test this hypothesis, future studies will need to collect more ethnically diverse samples. Furthermore, since our data is cross-sectional, we cannot exclude reverse causal effects of passive relating and distress exacerbating voice severity in the long term. At present, the question of what drives the gender difference in voice severity remains open. To further optimize the fit between client and therapeutic approach, future research needs to explore the working mechanisms of gender differences in voice severity.
Strengths and Limitations
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.
Practical Implications and Future Directions
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.
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