# Clinical Correlates of Compliance, Appeasement and Resistance in Command Hallucinations: A Systematic Review

## TL;DR

This review identifies factors influencing compliance, appeasement, and resistance to command hallucinations in psychosis, offering insights to improve therapy.

## Contribution

The paper systematically reviews clinical correlates of responses to command hallucinations, providing a novel framework for cognitive behavioral therapy.

## Key findings

- Compliance with command hallucinations is linked to cognitive, emotional, and developmental factors.
- Appeasement is associated with perceived danger and behaviors like avoiding provocation.
- Resistance is tied to beliefs about voice malevolence and voice intrusiveness.

## Abstract

Command hallucinations (CHs) are a subtype of auditory hallucination commonly observed in psychosis and are strongly associated with harmful behaviours towards the self and others. Despite their clinical relevance, no review has synthesised the clinical variables associated with compliance, appeasement and resistance.

A systematic review was conducted to synthesise the existing evidence regarding the clinical correlates of compliance, appeasement and resistance to CHs.

Fifty‐six studies were eligible for inclusion. Compliance was associated with cognitive factors (benevolence, omnipotence and omniscience beliefs, perceived consequences of disobedience, perceptions of future compliance and greater attentive awareness), relational factors (social rank, voice identity and voice familiarity), emotional drivers (anger and obligation), behaviours (impulsivity and social isolation), childhood trauma, substance use and overall symptom severity. Appeasement was associated with cognitive factors (perceived dangerousness) and behaviours (avoiding provocation, obeying milder commands or self‐harm to protect others). Resistance was associated with cognitive factors (malevolence and omnipotence beliefs, perceived control over the voice and concurrent suicidal ideation) and voice topography factors (high intrusiveness/frequency/volume and low authoritativeness), alongside childhood trauma factors (interpersonal adversities and fearful attachment).

These findings highlight the need for clinical formulations of CHs to attend closely to the factors driving compliance and appeasement, given their strong association with risk. Targeting the cognitive, relational, emotional, behavioural and developmental influences that sustain these responses—and strengthening resistance‐promoting factors—may enhance cognitive behavioural therapy for psychosis (CBTp). To support clinical practice, this review also provides Socratic questions to guide the assessment, formulation and intervention of CHs.

Compliance is associated with cognitive, relational, emotional, behavioural, developmental and substance‐related factors, as well as overall symptom severity.
Appeasement is associated with cognitive and behavioural factors and represents a risk profile comparable to that of full compliance, underscoring its importance in routine clinical assessment.
Resistance is associated with cognitive factors, voice topography and childhood trauma.Interventions targeting modifiable clinical correlates of compliance and appeasement (e.g., cognitive, relational, emotional, behavioural and substance‐related factors), alongside strengthening modifiable resistance factors (e.g., cognitive factors), may help reduce risk.The Cognitive Model of Compliance, Appeasement, and Resistance to Command Hallucinations enables the development of longitudinal and idiosyncratic case formulations regarding command hallucinations, which would enhance current CBTp practices.

Compliance is associated with cognitive, relational, emotional, behavioural, developmental and substance‐related factors, as well as overall symptom severity.

Appeasement is associated with cognitive and behavioural factors and represents a risk profile comparable to that of full compliance, underscoring its importance in routine clinical assessment.

Resistance is associated with cognitive factors, voice topography and childhood trauma.

Interventions targeting modifiable clinical correlates of compliance and appeasement (e.g., cognitive, relational, emotional, behavioural and substance‐related factors), alongside strengthening modifiable resistance factors (e.g., cognitive factors), may help reduce risk.

The Cognitive Model of Compliance, Appeasement, and Resistance to Command Hallucinations enables the development of longitudinal and idiosyncratic case formulations regarding command hallucinations, which would enhance current CBTp practices.