Echoes of others: A path analytic examination of an interpersonal–cognitive model of voice‐related distress

Objectives Cognitive models propose that levels of distress associated with auditory verbal hallucinations (‘voices’) are influenced by the hearers' beliefs about their voices (perceived malevolence and omnipotence), their negative beliefs about themselves and others and their attachment style. This study aims to test a comprehensive model of the relationship between these variables in order to identify distal and proximal interpersonal and cognitive factors contributing to voice‐related distress. This interpersonal–cognitive model of voices proposes that attachment anxiety/avoidance drive negative beliefs about self and others, which in turn lead to persecutory (malevolent/omnipotent) beliefs about voices, which in turn increase levels of voice‐related distress. Design/Methods Path analysis was used to test the interpersonal–cognitive model in a sample of 180 people currently hearing voices (57% self‐reported schizophrenia‐spectrum diagnoses; 90% some form of self‐reported mental health diagnosis). Results Path analysis provided support for a model in which there were direct pathways from attachment anxiety and avoidance to negative beliefs about self and others; direct pathways from negative beliefs about self and others to persecutory beliefs about voices; and a direct path from persecutory beliefs about voices, and negative beliefs about self, to voice distress. Conclusions Findings add support to the suggestion that voice‐related distress occurs in the context of an insecure attachment style and negative core beliefs about self/others. A therapeutic focus on beliefs about voices, attachment style and core beliefs about self/others may be important to minimize voice‐related distress. Further tests of this model that can establish causal relationships between variables are now needed. Practitioner points Distress associated with auditory verbal hallucinations (‘voices’) is highly variable. This study tests a comprehensive interpersonal–cognitive model of voice distress using path analysis with 180 participants. The model tested in the current paper shows that attachment style predicts negative beliefs about self and others, which in turn predicts negative beliefs about voices, which in turn predicts voice‐related distress. Findings support the suggestion that voice‐related distress occurs in the context of an insecure attachment style and negative core beliefs about self and others. In addition to focusing on beliefs about voices, a therapeutic focus on attachment style and core beliefs about self and others may be important in order to minimize voice‐related distress.