This study suggests that the power imbalance between the individual and his persecutor(s) may have origins in an appraisal by the individual of his social rank and sense of group identification and belonging. The results also raise the possibility that the appraisal of voice frequency and volume are the result of the appraisal of voices' rank and power. Theoretical and novel treatment implications are discussed.

Background. Auditory hallucinations in psychosis often contain critical evaluations of the voice-hearer (for example, attacks on self-worth). A voice-hearer's experience with their dominant voice is a mirror of their social relationships in general, with experiences of feeling low in rank to both voices and others being associated with depression. However, the direction of the relationship between psychosis, depression and feeling subordinate is unclear.Method. Covariance structural equation modelling was used with data from 125 participants diagnosed with schizophrenia to compare three ‘causal’ models: (1) that depression leads to the appraisal of low social rank, voice power and distress; (2) that psychotic illness leads to voice activity (frequency, audibility), which in turn leads to depression and the appraisal of voices' power; (3) our hypothesized model, that perceptions of social rank and social power lead to the appraisal of voice power, distress and depression.Results. Findings supported model 3, suggesting that the appraisal of social power and rank are primary organizing schema underlying the appraisal of voice power, and the distress of voices.Conclusions. Voices can be seen to operate like external social relationships. Voice content and experience can mirror a person's social sense of being powerless and controlled by others. These findings suggest important new targets for intervention with cognitive and social therapy.

The results support the efficacy of cognitive therapy for CTCH.

Conceptualizing aspects of depressed and psychotic thinking as relating to evolved mental mechanisms, which are role serving, but can internally play off against each other, may open new ways of investigating certain aspects of severe pathologies.

UK Medical Research Council and the National Institute for Health Research.

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