Interpersonal Trauma, Shame and Hearing voices
Research type
Research Study
Full title
Understanding the Impact of Traumatic Experiences Throughout the Lifespan and Feelings of External Shame on the Experience of Hearing Voices.
IRAS ID
334076
Contact name
Amy Lewins
Contact email
Sponsor organisation
Research and Development Department, Oxford Health NHS Foundation Trust
Clinicaltrials.gov Identifier
n/a, n/a
Duration of Study in the UK
0 years, 7 months, 30 days
Research summary
Summary of Research
The experience of hearing voices which others can not is common in both people with mental health difficulties, as well as in the general population. For some, this experience can be distressing and frightening. We are hoping to understand a little more about experiences that may be associated with people developing voice-hearing and what factors influence the types of voices people hear, for example whether they hear a kind, compassionate voice or an authoritative, scary voice.
We are hoping that people who have experienced hearing a voice, or multiple voices, will answer some online questionnaires about themselves and their personal experience of hearing voices. We hope that by getting a better understanding of the experience of hearing voices, we can suggest some changes that mental health services can make to the support they provide for people who are distressed by voices they hear.
Participants will be asked to answer a series of online questionnaires about their experience of hearing voices, including what the voice(s) sound like, or used to sound like, and what they say or said. Participants will be asked about their current mental health and wellbeing, and past life experiences, including some questions about difficult past experiences. The questionnaires are likely to take no more than 5-10 minutes to complete.
Summary of Results
Study 1: Exploring the Relationship Between External Shame and Perceived Social Rank in People Who Hear Voices
Background
According to evolutionary models, shame can be understood as an adaptive emotion that developed to act as a social threat detection system (Gilbert, 1997), functioning by alerting individuals to negative appraisals from others and potential for ostracization from the group. Shame can be delineated into two subtypes: internal and external. External shame involves the perception of being negatively evaluated by others and may lead people to assume a low “social rank” (Gilbert, 2000).
People who hear voices often feel high levels of shame and while some authors believe that this is explained by the fact that the experience of hearing voices itself is shaming (Woods et al., 2015), others believe that predisposing high levels of shame may increase the likelihood of voice hearing in those who have experienced childhood trauma (Bortolon et al., 2022; McCarthy-Jones, 2017).
Given that voice hearing is a social experience, largely reflecting person-to-person relationships (Bell, 2013; Woods, 2017), our study aimed to understand whether heightened external shame leads voice hearers to adopt a subordinate role, assigning their voices higher social rank. Secondly, our research aimed to explore whether critical voice content mediates the relationship between external shame and perceived social rank.
Methods
Participants with experience of voice-hearing were recruited via social media and NHS services. They were asked to complete online questionnaires related to their experience of hearing voices, feelings of external shame and perceptions of themselves and the dominant voice heard in terms of social rank or positioning. Demographic information and control variables were also measured.
Results
58 participants took part in the study. High levels of external shame were predictive of participants perceiving themselves to have low social rank compared with the dominant voice heard. This was the case even when controlling for other variables which may have explained perceived low social rank, including age, duration of voice hearing, anxiety and low mood.
Contrary to the second hypothesis, the content of the voices heard did not appear to mediate the relationship between feelings of external shame and a perceived low social rank, relative to the voice.
Research Implications
Further research implementing longitudinal designs is required to establish temporality and directionality. Future studies could expand on this study by measuring external shame and social rank in voice hearers across multiple time points. Furthermore, a measure designed with experts by experience to more accurately assess voice content could be a logical next step for research in this field. Finally, intervention studies, such as case reports or pilot studies, focusing on shame reduction and its impact on social rank, would contribute meaningfully and necessarily to the evidence base.
Clinical Implications
Results from this study suggest that reducing shame in therapy, using models such as Compassion Focused Therapy, may be an effective way to improve the ways in which patients view themselves socially, relative to the voice(s) they hear and also to others in society. Patients may also feel more able to resist commands given by the voice(s). Though voice content was not found to play a mediating role, it was significantly associated with feelings external shame. It is possible, therefore, that focusing on shame reduction early in therapy may have an impact on the tone and content of voices. Voice content should be assessed and measured throughout therapy to evaluate whether this is the case.Study 2: An investigation of the relationship between voice-hearing distress and frequency, and interpersonal traumatic experiences in childhood, while controlling for adulthood interpersonal trauma, mood and anxiety.
Introduction
Voice-hearing is a common symptom associated with many mental health diagnoses, including psychosis. Hearing voices is the most common symptom of psychosis and in psychosis specifically, voices are often particularly distressing. For many years psychosis and symptoms such as voice hearing were understood from biological and genetic perspectives. Such models placed emphasis on the stress-diathesis model, however they were criticised due to their lack of consideration of psychosocial factors. Traumatic experiences, particularly, were overlooked and much research has identified strong links between psychosis, voice-hearing and childhood interpersonal trauma, leading to multiple perspectives on this relationship.
The traumagenic neurodevelopmental theory of psychosis is one theory that attempts to explain why childhood trauma specifically, is related to the later development of psychosis and symptoms including voice-hearing. The model suggests that extreme stress experienced during trauma during critical developmental points in childhood leads to the cognitive and perceptual biases associated with later psychosis. A limitation of the model is that not all those who experience trauma develop psychosis and vice versa, and the authors suggest that dissociation may be a factor that mediates this relationship.
The relationship between interpersonal trauma experienced in adulthood and psychosis and voice-hearing has also been well established. Most studies exploring traumatic experiences and voice-hearing have not controlled for the different ages of trauma, and therefore the specificity of trauma occurring in childhood, as proposed by the traumagenic neurodevelopmental model, is unclear.Research Questions
This study aimed to investigate the relationship between childhood interpersonal trauma and voice hearing, while controlling for adulthood interpersonal trauma, mood and anxiety.
Additional research questions included exploring the relationship between adulthood trauma and voice hearing while controlling for childhood traumatic experiences. Dissociation was also explored as a mediating factor for the relationship between traumatic experiences and voice hearing.Methods
Adults over 18 who reported hearing distressing voices were recruited for this study. Participants were recruited from NHS services, charities, and via social media. All participants took part in an online survey which included questions and questionnaires about their voices, traumatic experiences, dissociation, mood, anxiety and demographics.Key Findings
A total of fifty-five participants took part in this research. The study found that when controlling for adulthood interpersonal traumatic experiences, childhood interpersonal traumatic experiences were not significantly associated with distressing voices. Similarly, adulthood trauma was not significantly predictive of voice-hearing when controlling for childhood traumatic experiences. However, when adulthood trauma was not accounted for, childhood interpersonal trauma was significantly predictive of voice hearing.
Only childhood interpersonal traumatic experiences were significantly associated with dissociative experiences. However, dissociation did not mediate either trauma age’s relationship to voice-hearing. The sample comprised of mostly White females with high educational attainment.
Implications and Limitations
The findings of this study did not support the traumagenic neurodevelopmental theory of psychosis, as it found no significant association between childhood interpersonal trauma and later voice hearing. Importantly, this was found only when adulthood trauma was controlled for. Most existing research into the relationship between childhood trauma and voice hearing has not controlled for adulthood trauma, and therefore the current research suggests that the established relationship between childhood trauma and voice hearing may have been overstated in the evidence base.
A limitation of the current study is that research suggests that neurodevelopment finishes at age 25, however adults over 18 were included in this study. Future research needs to further unpick the intricacies in the relationship between traumatic experiences and voice hearing.REC name
South East Scotland REC 01
REC reference
24/SS/0048
Date of REC Opinion
17 Jun 2024
REC opinion
Further Information Favourable Opinion