Exploring the relationship between external shame and perceived social rank in people who hear voices

OBJECTIVES: People who hear voices commonly experience high levels of shame. This study builds on evolutionary theories by investigating how feelings of shame are associated with the nature of the voice-person relationship. Researchers aim to understand whether increased feelings of external shame are associated with voice-hearers adopting a subordinating relationship to the voice(s), assigning the voice a higher social rank. The research also explored whether voice content, operationalized as the ways in which voices address the person (e.g. making requests, demands, forbidding actions, asking questions), is associated with this relationship as a potential mediator. METHODS: The study implements a cross-sectional design, using an online survey. Fifty-six voice-hearers completed a series of questionnaires related to voice-hearing, external shame and perceived social rank, along with additional control variables online or via the telephone. RESULTS: After controlling for confounders, external shame was significantly associated with perceived social rank, with higher levels of external shame corresponding to a lower perception of one's own social rank compared with the voice. Results did not suggest that voice content mediates this relationship. CONCLUSIONS: Findings align with evolutionary theories on shame in voice-hearers and build on previous research by offering greater specificity in understanding the relationship between external shame and social rank, suggesting that interventions targeting external shame may be relevant, while future longitudinal research is needed to clarify the direction of the association. However, the cross-sectional study design precludes conclusions about directionality or causality, and self-selecting recruitment may limit the generalizability of results.