The role of social schema in the experience of auditory hallucinations: a systematic review and a proposal for the inclusion of social schema in a cognitive behavioural model of voice hearing

Abstract

The interpersonal nature of the voice-hearing experience has been highlighted in recent studies investigating whether social processes (or 'schemas') that guide interpersonal interactions also govern the relationship between voice hearer and voice. A systematic literature review of relevant studies was undertaken, including those that investigated how social processes interact with appraisals of voices, as well as affective and behavioural responding to voices. The review included 13 studies published between 2000 and 2010. Two well-replicated findings emerged from the review. First, voice hearers who perceive themselves to be of low social rank (inferior) relative to others also feel inferior in relation to their voice and behave accordingly. Second, responding to voices from a position of closeness/dependency is associated with least distress. The review advocates for an extension of the Chadwick and Birchwood cognitive behavioural model of voices to include the mediating role of social schemata in explaining the affective and behavioural responses to voices. Only two interventions have yet targeted social schema variables utilizing different therapeutic approaches, both with some success. These clinical studies, as well as clinical implications drawn from the reviewed literature, will be discussed.

Key practitioner message: Social processes governing relationships in the real world are also at play in the relationship between voice hearer and voice. Social schemas also shape beliefs about-and responses to-voices and thus are important to target in therapy. Voice hearers may be able to develop a more equal, and thus less distressing, relationship with their voice by improving their perceived social rank relative to others. This may be achieved through assertiveness training, social skills training and/or self-esteem work. Cognitive behavioural therapy techniques can be instrumental in helping an individual to consider the beliefs they hold about their voices and the way in which they respond and relate to them. Addressing how past traumatic experiences have influenced the voice hearer's relationships with others and their voices in therapy is recommended.