280

The
British
Psychological
British Journal of Clinical Psychology (2012), 51, 280–291
C 2011 The British Psychological Society
Society

www.wileyonlinelibrary.com

An investigation of adult attachment

and the nature of relationships with voices

Katherine Berry∗ , Alison Wearden, Christine Barrowclough,

Lauren Oakland and Jonathan Bradley
School of Psychological Sciences, University of Manchester, UK

Objectives. The study investigated associations between adult attachment and voice
hearing. We hypothesized associations between insecure attachment, severity of voice
hearing, and distress in relation to voices. We also hypothesized associations between
attachment and the nature of relationships with voices.
Method. Seventy-three participants with a diagnosis of schizophrenia spectrum
disorders completed measures of anxiety and avoidance in attachment relationships
and we coded experiences of voice hearing from interviews.
Results. There were modest but significant positive associations between attachment
anxiety and both severity and distress in relation to voice hearing, but no associations
between attachment avoidance and these dimensions. We found evidence of predicted
associations between attachment avoidance and themes of rejection, criticism, and
threat in relationships with voices. Contrary to predictions, there were no significant
associations between anxious attachment and the theme of control in relationships with
voices and no association between anxious attachment and the theme of threat.
Conclusions. The study is promising in demonstrating some associations between
attachment and the nature of relationships with voices. This suggests that the assessment
of attachment styles may be a useful contribution in developing formulations of voice
hearing.

Cognitive models of voice hearing propose that distress arising from voices can be
understood with reference to the individual’s beliefs about voices, which are, in turn,
influenced by past and current relationship experiences (Birchwood & Chadwick, 1997;
Chadwick & Birchwood, 1994). In support of these models, Chadwick and Birchwood
(1994) found that when individuals believed voices were malevolent they were resisted
and evoked avoidance, anger, and despair; whereas when individuals believed voices
were benevolent they were courted and often evoked amusement. There is also evidence
that distress in relation to voices is associated with social and interpersonal cognitions

∗ Correspondence should be addressed to Dr Katherine Berry, School of Psychological Sciences, University of

Manchester, 2nd Floor Zochonis Building, Brunswick Street, Manchester M13 9PL, UK (e-mail: katherine.
berry@manchester.ac.uk).

DOI:10.1111/j.2044-8260.2011.02027.x
 Attachment and relationships with voices 281

of social power and rank (Birchwood, Meaden, Trower, Gilbert, & Plaistow, 2000;
Birchwood et al., 2004). Interpersonal strategies in social relationships have also been
shown to have a direct association with strategies for relating to voices. Using Birtchnell’s
(2002) theory of interpersonal relating, Hayward (2003) found significant associations
between relating socially and relating to voices in terms of the dominant and submissive
forms of power and over dependence. These findings were independent of beliefs about
voices and mood-linked appraisals.
There is now a substantial body of evidence to support associations between
interpersonal traumas and the experience of voice hearing (Read, van Os, Morrison,
& Ross, 2005). A number of studies have investigated the way in which trauma may
be related to voices. A recent study found associations between traumatic life events,
including childhood sexual abuse and negative beliefs about voices (Andrew, Gray, &
Snowden, 2008). Trauma may also influence the content of voices, as several studies
have found that the content of the voices is related thematically to the nature of trauma
experienced (Hardy et al., 2005; Read, Agar, Argyle, & Aderhold, 2003; Read & Argyle,
1999).
Bentall, Fernyhough, Morrison, Lewis, and Corcoran (2007) argue that consistent
evidence of associations between interpersonal experiences and psychosis highlights the
potential value of theories of normal psychological development to the understanding
of symptoms (Bentall et al., 2007). Attachment theory is both a theory of interpersonal
relationships and a lifespan developmental theory (Bowlby, 1980). According to Bowlby
(1980), earlier interpersonal experiences influence future interpersonal functioning and
methods of regulating distress via ‘working models’, or cognitive representations about
the self and others in relationships. If caregivers are responsive and sensitive to distress,
the individual is hypothesized to develop a secure attachment style that is associated with
a positive self-image, a capacity to manage distress, and comfort with both autonomy
and in forming relationships with others. Inconsistently responsive or overly intrusive
care giving in attachment relationships is hypothesized to result in insecure-anxious
attachment that is associated with negative beliefs about the self, hypervigilance to
signs of rejection, and a tendency to be overwhelmed by negative affect. Consistent
neglect or criticism in attachment relationships is hypothesized to result in insecure-
avoidant attachment that is associated with negative beliefs about others, an inhibition of
affect, and avoidance of relationships (Crowell & Treboux, 1995; Shaver & Mikulincer,
2002). However, it is important to note that individuals with a range of adverse and
negative early-care experiences can and do develop secure attachments; and individuals
with positive parenting and care experiences throughout their childhood can develop
attachment insecurity (Hesse, 1999).
Several studies have investigated associations between attachment and schizotypy,
and there is some evidence of associations between attachment and symptoms of
psychosis in clinical samples. Berry, Wearden, Barrowclough, and Liversidge (2006)
found that both attachment avoidance and anxiety were positively associated with
subclinical hallucinatory phenomena (Berry et al., 2006). In a similar study, MacBeth,
Schwannauer, and Gumley (2008) found that hallucinatory phenomena were predicted
by latent constructs representing interpersonal dependence and avoidance strategies.
The authors argue that these constructs depict a disorganized pattern of attachment,
whereby the individual fears both rejection and being controlled or dominated (MacBeth
et al., 2008). A further study by Pickering, Simpson, and Bentall (2008) also found
evidence of associations between hallucinations and attachment, but these findings were
not maintained when controlling for co-morbidity between paranoia and hallucinations
282 Katherine Berry et al.

(Pickering et al., 2008). Ponizovsky, Nechamkin, and Rosca (2007) investigated rela-
tionships between severity of symptoms and attachment in a clinical sample and found
associations between both attachment anxiety and positive symptoms and attachment
avoidance and positive symptoms (Ponizovsky et al., 2007). Berry, Barrowclough, and
Wearden (2008) confirmed findings of associations between attachment avoidance and
positive symptoms, but associations between attachment anxiety and positive symptoms
failed to reach significance (Berry et al., 2008). However, neither of these studies
specifically investigated associations between attachment and voice hearing.
This study aims to investigate the relationship between attachment and the expe-
rience of voice hearing. We specifically focused on the concept of attachment in the
context of relationships in adulthood, as there is evidence to suggest attachment styles
can change over the life span, particularly if the individual experiences interpersonal
traumas (Weinfield, Sroufe, & Egeland, 2000). Research with people with a diagnosis
of psychosis, does, however, suggest that insecure attachment styles in adulthood
are associated with reports of lower parental care and abuse by significant others in
childhood (Berry, Barrowclough, & Wearden, 2009).
Previous research shows associations between insecure attachment and subclinical
hallucinations and associations between insecure attachment and positive symptoms
of psychosis. We therefore hypothesized positive correlations between severity of and
distress in relation to voices and both insecure-anxious attachment and insecure-avoidant
attachment. We also hypothesized associations between attachment and the nature of
relationships with voices. There are currently no well-validated schemes for categorizing
themes in voice hearing and studies have used different coding systems (Hardy et al.,
2005; Read & Argyle, 1999; Read et al., 2003). Voices in our study were classified as:
(a) controlling; (b) rejecting or critical; and (c) threatening. This coding frame was
developed by authors based on clinical experience, pilot work, and existing literature
(Hardy et al., 2005; Read & Argyle, 1999; Read et al., 2003). Given Bowlby’s (1980)
hypothesis that overly intrusive care giving predicts the development of insecure-anxious
attachment, we hypothesized that individuals reporting voices that were controlling
would have higher levels of insecure-anxious attachment than those not reporting
voices with this theme. Given Bowlby’s (1980) hypothesis that neglect and criticism in
attachment relationships predicts insecure-avoidant attachment, we hypothesized that
individuals reporting voices that were rejecting or critical would have higher levels of
insecure-avoidant attachment than those not reporting voices with these themes. Feeling
threatened in the context of attachment relationships is likely to have particularly adverse
effects on the individual’s attachment system and psychological development (Liotti &
Gumley, 2008). We therefore hypothesized that individuals reporting voices that were
threatening would have higher levels of both insecure-anxious and insecure-avoidant
attachment than those not reporting voices with this theme.

Method
Measures
Attachment
We measured adult attachment using the Psychosis Attachment Measure (PAM; Berry
et al., 2008). Items were derived from existing self-report attachment measures (Brennan,
Clark, & Shaver, 1998), but there were no items referring specifically to romantic
 Attachment and relationships with voices 283

relationships. The measure has advantages over existing attachment measures, as items
are rated on simple and anchored, four-point Likert scales, and unlike the majority
of other self-report attachment questionnaires, it is applicable to people who do not
currently have or have not recently had a romantic partner. The fact that the measure
assesses attachment in terms of the two dimensions of attachment, anxiety and avoidance
that have been shown to underlie existing self-report measures facilitates comparisons
with previous and future studies (Brennan et al., 1998). Total scores were calculated for
each dimension by averaging individual item scores, with higher scores reflecting higher
levels of insecure attachment. The PAM has been shown to have good reliability and
validity in non-clinical (Berry, Band, Corcoran, Barrowclough, & Wearden, 2007; Berry
et al., 2006) and clinical (Berry et al., 2008) samples. Alphas in the present study were
.83 for the anxiety subscale and .78 for the avoidance subscale.

Voice hearing
We measured experiences of voice hearing using the hallucinations item from the
Positive and Negative Syndrome Scale (PANSS; Kay, Fiszbein, & Opler, 1987) and the
hallucinations subscale from the Psychotic Symptom Rating Scales (PSYRATS; Haddock,
McCarron, Tarrier, & Faragher, 1999). The PANSS is a clinical interview designed to
assess a range of psychiatric symptoms and each item is rated on a seven-point scale
with higher scores indicating higher levels of psychopathology. As part of the PANSS
interview, the researchers were trained to ask participants about whether they heard
noises or voices when there was no one about and nothing to explain the experience,
and if so, the identity, characteristics, and content of the voice(s), followed by their
beliefs about the experiences. The PSYRATS consists of 11 items that ask participants
about their experiences of auditory hallucinations over the past week. The scale assesses
frequency, intensity, distress, and interference associated with psychotic experiences
on four-point scales and a total for hallucination subscales that we used as a measure
of overall severity. This study focused on measures of distress, in line with the view
that voice hearing can be a positive experience and may only be problematic for the
individual if he/she experiences distress (Romme & Escher, 1989). Measures of distress in
relation to voice hearing were taken from two items assessing the intensity and amount
of distress experienced. Both the PANSS and the PSYRATS have good psychometric
properties in samples of people with a diagnosis of psychosis (Haddock et al., 1999; Kay
et al., 1987).
A summary of the nature of the participant’s hallucinations was recorded verbatim on
a ‘symptom summary sheet’ by the researcher during the interviews and this information
was later used to classify the nature of the participant’s relationship with voices.
Researchers were asked to record as much detail as possible regarding the nature of
the person’s experiences, including number of voices, voice gender, and beliefs about
voices. We developed three categories of ‘control’, ‘rejection or criticism’, and ‘threat’
for classifying voices, as insecure attachment has been associated with interpersonal
experiences of this nature (Crowell & Treboux, 1995). Categories were developed on
the basis of the authors’ (KB and CB) clinical experience in working with people with
voices and on pilot work, which involved reviewing and provisionally grouping different
types of voice hearing experiences recorded as part of the studies. Definitions for each
category were then derived from previous research investigating thematic associations
between trauma and psychotic experiences (Hardy et al., 2005) and criteria from the
Five Minute Speech Sample (FMSS; Magana et al., 1986), which is a measure that has
284 Katherine Berry et al.

been used to assess the nature of relationships between people with a diagnosis of
psychosis and significant others. Voices were rated as controlling if there was evidence
of interference and attempted control of the participant. This category included voices
that told the participant what to do. Voices were rated as critical or rejecting if there was
evidence of negative comments about the person’s behaviour or personality or comments
that they were not liked by other people. This category included voices that suggested
that the participant’s actions were ‘wrong’ or ‘stupid’ or that the participant is or other
people think he or she is ‘stupid’, ‘ugly’, or ‘evil’. Voices were rated as threatening if
the person thought that they or someone else might be killed or injured. This category
included voices that told the participant that he or she would be harmed if he or she
went out or that his or her family would be attacked. Given the potentially delusional
interpretation of speech–content, often evident in people with psychosis, the decision
was made to categorize voices on the basis of the content of what was actually said as
opposed to the participants’ perceptions of control, rejection, criticism, and threat. The
presence or absence of each category was coded by two independent raters (KB & LO)
using information from ‘symptom summary’ sheets. Good levels of inter-rater reliability
were obtained (all Kappas > .80, p <.001) and where there was disagreement, this was
resolved through discussion. Categories were not mutually exclusive, so participants’
experiences of voices could meet criteria for more than one category and the raters
were told to assign participants to as many categories as appropriate. In cases, where
participants heard more than one voice each voice hearing experience was categorized
separately.

Participants and procedure

Patients were recruited from community and inpatient psychiatric services across
Greater Manchester, and were all participating in a larger study investigating associations
between adult attachment and therapeutic relationships in people with a diagnosis of
psychosis (Berry et al., 2008) or in a Medical Research Council funded trial of Motivational
Interventions for Drug and Alcohol Misuse in Schizophrenia (MIDAS). Patients were
eligible for inclusion in the aforementioned research if they had a documented DSM-
IV diagnosis of schizophrenia or related psychoses (American Psychiatric Association,
1994), were able to give informed consent, and were English speaking. Additional criteria
for the present study were a score of three or above on the PANSS for hallucinations.
Patients with a significant history of organic factors implicated in the aetiology of
psychotic symptoms were excluded. Following consent, measures were administered
with participants and medical records were reviewed to verify current diagnosis. Medical
records were also used to obtain demographic information and information about illness-
related experiences, such as age of onset defined in terms of first contact with services
for psychosis and number of in-patient admissions.

Data analysis
Data sets were normally distributed and there were no significant outliers. Associations
between attachment and dimensions of voice hearing were assessed using Pearson’s
correlations. Associations between attachment and themes in voice hearing were
assessed using independent groups t tests and multiple regression analyses. Data were
analysed using Statistical Package for the Social Sciences (SPSS) version 15.
 Attachment and relationships with voices 285

Results
Sample characteristics
Data were analysed for 73 participants, which included 28 participants from the original
Berry et al.’s (2008) study and 45 participants from the MIDAS trial. The majority of the
sample was male (82.8%; n = 59) and White British (95.9%, n = 70). The remaining
three participants were classified as Mixed Race, Black Other, and Other. A total of
79.5% of the sample had a diagnosis of schizophrenia (n = 58), 9.6% had a diagnosis
of schizoaffective disorder (n = 7), and 11% were diagnosed with a psychotic episode
(n = 8). All participants from the MIDAS trial had a co-morbid diagnosis of substance
misuse. The mean age of the group was 39.1 years (SD = 11.3), the mean duration of
illness was 13.7 years (SD = 10.7), and the median number of hospital admissions was
4 (range = 0–20). The mean PANSS total score was 62.42 (SD = 14.58) and the mean
PSYRATS total score was 25.61 (SD = 9.94). There were significantly more females in
the sub-sample of participants from Berry et al.’s (2008) study compared to the MIDAS
study (␹ 2 , df = 1, p = .015), but the groups did not differ significantly in terms of age,
illness duration, hospital admissions, symptom scores, or attachment.

Voice characteristics
A total of 63% of the sample were rated as having voices that were critical or rejecting
(n = 46), 43.8% were rated as having voices that were controlling (n = 32), and 31.5%
were rated as having voices that were threatening (n = 23). A total of 4.1% participants’
voices met criteria for all categories (n = 3), 17.8% voices met criteria for both criticism
and control (n = 13), 9.6% met criteria for both control and threat (n = 7), and 21.9% met
criteria for both criticism and threat (n = 16). A total of 24.7% of participants (n = 18)
reported positive relationships with voices, in addition to controlling, critical, rejecting,
or threatening voices.

Is adult attachment associated with voice hearing dimensions?

We predicted positive associations between insecure attachment and severity of voices
and positive associations between insecure attachment and distress experienced in
relation to voices. There were significant positive associations between attachment
anxiety and severity and distress, but no significant associations between avoidant
attachment and dimensions of voice hearing (see Table 1).

Table 1. Associations between attachment and severity and distress in relation to voices

Attachment anxiety Attachment avoidance

N = 73 r p r p

Severity of voices .29 .014 .22 .065

Distress in relation to voices .32 .005 .20 .086

Note. Pearson’s correlation coefficient.

286 Katherine Berry et al.

Is adult attachment associated with control, rejection, criticism, or threat from

voices?
We predicted that patients who reported the theme of control in relationships with
voices would report higher levels of insecure-anxious attachment than those who did not
report this theme. Contrary to predictions, participants who reported controlling voices
did not have significantly higher levels of insecure-anxious attachment. We predicted that
participants who reported themes of rejection or criticism in relationships with voices
would report higher levels of insecure-avoidant attachment than those who did not report
such themes. As predicted, participants who reported critical or rejecting voices had
significantly higher levels of attachment avoidance than those who did not report these
themes. We predicted that participants who reported the theme of threat in relationships
with voices would report higher levels of both insecure-anxious and insecure-avoidant
attachment than those who did not report this theme. As predicted, participants who
reported threatening voices had significantly higher levels of attachment avoidance than
those who did not report this theme in voice hearing, but contrary to predictions, these
groups did not differ significantly in terms of attachment anxiety (see Table 2).
We carried out a multiple regression analyses to assess the independent contributions
of distress in relation to voice hearing and voice categories to both attachment anxiety
and attachment avoidant. Attachment anxiety and avoidance were the dependent
variables and distress and themes were independent variables. The regression model
for attachment anxiety was not significant (Adjusted R2 = .06; F = 2.14, df = 4, 68,
p = .09). Consistent with univariate analyses, distress was a significant independent
predictor (␤ = .32, p = .007), but themes of control (␤ = .07, p = .569), criticism or
rejection (␤ = .08, p = .526), and threat (␤ = –.03, p = .791) were not. Consistent with
the above univariate analyses, the overall regression model for attachment avoidance
was significant (Adjusted R2 = .37; F = 11.44, df = 4, 68, p <.001). Both themes of
criticism or rejection (␤ = .33, p = .002) and threat (␤ = .52, p <.001) were significant
independent predictors, but the theme of control (␤ = .09, p = .401) and distress ratings
(␤ = .16, p = .095) were not.

Table 2. Group differences in attachment anxiety and attachment avoidance for control, rejection and
threat in relation to voices. Means and standard deviations.

Control No control
(n = 32) (n = 41) t df p Cohen’s d

Attachment anxiety 1.25 (.63) 1.21 (.77) .24 71 .815 .06

Attachment avoidance 1.50 (.55) 1.68 (.55) −1.34 71 .185 −.33

Rejection or No rejection or
criticism (n = 46) criticism (n = 27) t df p

Attachment anxiety 1.29 (.70) 1.12 (.73) 1.03 71 .306 0.24

Attachment avoidance 1.75 (.54) 1.35 (.48) 3.14 71 .002 0.78

Threat No threat
(n = 23) (n = 50) t df p

Attachment anxiety 1.20 (.74) 1.24 (.70) −0.22 71 .830 −.01

Attachment avoidance 2.03 (.49) 1.41 (.46) 5.25 71 ⬍.001 1.35
 Attachment and relationships with voices 287

Discussion
We found predicted associations between severity and distress in relation to voices
and insecure-anxious attachment, but there were no significant associations between
these dimensions and insecure-avoidant attachment. We found evidence of predicted
associations between attachment avoidance and the themes of rejection, criticism, and
threat in relationships with voices. Contrary to predictions, there were no significant
associations between attachment anxiety and the theme of control in relationships with
voices and no association between attachment anxiety and the theme of threat.
Associations between anxious attachment and severity of and distress in relation to
voices are consistent with previous research showing relationships between attachment
anxiety and subclinical hallucinations (Berry et al., 2006; MacBeth et al., 2008; Pickering
et al., 2008). These findings lend support to cognitive models of psychosis and
previous research, which highlights the influence of past and current relationship
experiences in voice hearing (Andrew et al., 2008; Chadwick & Birchwood, 1994;
Hayward, 2003; Read et al., 2005). There were, however, no significant associations
between attachment avoidance and either severity of voices or levels of distress. These
findings are inconsistent with previous evidence of relationships between avoidant
attachment and the positive symptoms of psychosis (Berry et al., 2008; Ponizovsky
et al., 2007). One possible explanation of this discrepancy is that individuals with
avoidant attachment tend to under-report distress in relation to symptoms. Dozier and Lee
(1995) found that individuals with deactivating or avoidant attachment patterns reported
less psychiatric symptoms than individuals with hyperactivating or anxious attachment
patterns. However, both interviewers and case managers rated avoidant participants as
experiencing higher levels of symptoms, including hallucinations. Therefore self-report
measures of symptoms and distress may not be sufficiently sensitive to detect associations
between voice hearing and attachment avoidant.
We found significant relationships between avoidant attachment and themes of
rejection, criticism, and threat in voice hearing, with large effect sizes. We predicted
relationships between avoidant attachment and themes of rejection or criticism, as
insecure-avoidant attachment is hypothesized to arise from experiences of neglect and
criticism in relationships with caregivers (Bartholomew, 1997; Shaver & Mikulincer,
2002). Attachment anxiety is hypothesized to arise from experiences of inconsistency
in caregiver responsiveness or caregiver over control. However, we found no significant
relationship between the theme of control and attachment. Attachment theory may
therefore provide a less useful framework for understanding the experience of being
controlled by voices. Previous studies suggest that themes of submission and dominance
in social relationships may be more relevant to experiences of being controlled by voices
(Birchwood et al., 2004; Hayward, 2003).
We predicted relationships between the theme of threat in voice hearing and both
insecure-anxious and insecure-avoidant attachment, given the potentially toxic effects of
threat in attachment relationships (Liotti & Gumley, 2008). In line with these predictions,
we found significant relationships between attachment avoidance and threat, but there
were no relationships between attachment anxiety and threat. Attachment avoidance
may therefore play a more important role in understanding threat in voice hearing
relationships than attachment anxiety.
There are a number of limitations that must be considered in interpreting our
findings. Although statistically significant group comparisons for themes in voices
produced relatively large effect sizes, correlations between attachment anxiety and
288 Katherine Berry et al.

severity of voices and correlations between attachment anxiety and distress in relation
to voice hearing were small in magnitude. As the study is cross-sectional, the direction
of relationships between variables cannot be ascertained and the influence of third
variables, such as negative affect or anxiety, cannot be ruled out. However, research
investigating associations between attachment and schizotypy has found that significant
relationships are maintained when negative affect is controlled (Berry et al., 2006).
Our hypotheses assumed a linear and causal relationship between early experiences
and adult attachment. Evidence relating to people who have negative experiences of
caregiving and secure attachment and likewise people who have had good enough
caregiving experiences but have insecure attachment suggests that the processing and
internationalization of experiences may be as important in the development of adult
attachment as the nature of early attachment experiences themselves (Hesse, 1999).
Given the finding that interpersonal events can lead to changes in attachment styles,
it is also possible that the experience of voice hearing has the potential to influence
the individual’s attachment patterns in other social relationships (Berry, Barrowclough,
& Wearden, 2007). The Adult Attachment Interview (AAI; 1984) was developed on
the principle that individual differences in attachment relate to the organization of
representations of earlier attachment figures and assess attachment states of mind on
the basis of the discourse properties of the individual’s narrative in describing parenting
experiences, rather than the content of what is said. The AAI provides a measure of
attachment-related unconscious processes and does not assume a linear relationship
between earlier caregiving experiences and adult attachment. It also has the advantage
of classifying a disorganized pattern of attachment that is associated with earlier trauma,
lack of affect regulation, and psychopathology (Hesse, 1999). Both self-report measures
and the AAI have unique value in the investigation of the function and operation of the
attachment system and should be used to study associations between adult attachment
and voice hearing (Shaver & Mikulincer, 2002). More extensive interviewing or more
specific questioning regarding relationships with voices might also have provided more
sensitive measures of control, rejection, criticism, or threat. We choose to categorize
voices according to the content of what was actually said, as opposed to the participants’
perceptions of control, rejection, criticism, and threat. However, it is possible that it is
the person’s perceptions that determine what they view as their relationship with their
voices, rather than merely what the voices say.
Findings may not generalize to more diverse samples with a higher proportion of
female participants, a wider range of diagnoses, ethnic groups, and illness durations.
Relatively few participants reported positive experiences of voices and those that did
tended to report a mixture of both positive and negative experiences. Future studies
should investigate whether voices can function as attachment figures for people with
psychosis, particularly if wider social networks have diminished. Finally, a substantial
number of participants were categorized as having voices with two themes, and in the
case of three participants all three themes. This overlap between categories compromises
our analyses of independent relationships between themes and attachment. Future
studies with larger samples of participants might incorporate more people reporting
single themes, thus providing sufficient power to test for more specific relationships
between different types of attachments and types of voices.
Despite these limitations, the findings of the study are consistent with the emerging
literature on associations between individuals’ psychological characteristics and expe-
riences of voice hearing. The study is unique in demonstrating associations between
attachment and voice hearing and the nature of relationships with voices. These
 Attachment and relationships with voices 289

associations now need to be tested in larger, more diverse samples with more detailed
measures of positive and negative relationship experiences with voices. Future research
investigating attachment and voice hearing should also include measures of beliefs about
the omnipotence and malevolence of voices and methods of coping with voices given
the importance of these concepts to models of voices hearing. Furthermore, given
associations between experiences of trauma and voice hearing, and the potential impact
of interpersonal traumas on the attachment system, future studies investigating the role
of attachment in voice hearing should incorporate measures of trauma (Liotti & Gumley,
2008).
Findings of associations between attachment and voice hearing suggest that psy-
chological distress associated with hallucinations might be better understood if a
psychosocial perspective were given more emphasis in working with this group. This
highlights the importance of assessing attachment styles in developing formulations of
symptoms (Hayward, 2003). Psychological interventions for voices should also target
cognitive interpersonal schemata and interpersonal behavioural strategies associated
with insecure attachment patterns (Gumley & Schwannauer, 2006).

Acknowledgements
We thank all participants who took part in the studies from the NHS trusts and all the NHS staff
who helped with recruitment. This research was supported by the Medical Research Council
(MIDAS trial grant number – G0200471) and a Medical Research Council PhD studentship.

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Received 8 February 2010; revised version received 23 September 2011

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