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

TY - JOUR

T1 - Clinical Correlates of Compliance, Appeasement, and Resistance in Command Hallucinations: A Systematic Review

AU - Medas, Mia

AU - Georgiades, Anna

PY - 2026/2/18

Y1 - 2026/2/18

N2 - Objective: 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. Method: A systematic review was conducted to synthesise the existing evidence regarding the clinical correlates of compliance, appeasement, and resistance to CHs. Results: 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, greater attentive awareness), relational factors (social rank, voice identity, voice familiarity), emotional drivers (anger, obligation), behaviours (impulsivity, 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, concurrent suicidal ideation), voice topography factors (high intrusiveness/frequency/volume, and low authoritativeness), alongside childhood trauma factors (interpersonal adversities, fearful attachment). Conclusion: 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 command hallucinations.

AB - Objective: 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. Method: A systematic review was conducted to synthesise the existing evidence regarding the clinical correlates of compliance, appeasement, and resistance to CHs. Results: 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, greater attentive awareness), relational factors (social rank, voice identity, voice familiarity), emotional drivers (anger, obligation), behaviours (impulsivity, 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, concurrent suicidal ideation), voice topography factors (high intrusiveness/frequency/volume, and low authoritativeness), alongside childhood trauma factors (interpersonal adversities, fearful attachment). Conclusion: 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 command hallucinations.

M3 - Review article

SN - 1063-3995

JO - Clinical psychology & psychotherapy

JF - Clinical psychology & psychotherapy

ER -