Command hallucinations are strongly associated with self-harm and harm to others. While full compliance is of clear clinical concern, appeasement—or partial compliance—has been relatively overlooked despite its potential to cause harm. This review synthesises the clinical correlates of compliance, appeasement, and resistance, supporting the development of personalised formulations and targeted interventions in Cognitive Behaviour Therapy for psychosis, thereby enhancing risk management and fostering client recovery.
Dr Anna Georgiades, Lecturer in Early Intervention in Psychosis and corresponding author on the study
17 March 2026
New review examines responses to command hallucinations in individuals with psychosis
Researchers looked at the evidence for why some people comply, appease or resist command hallucinations, and the clinical variables associated with these responses.
A new systematic review from the Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s College London has examined the evidence behind the three main distinct responses of individuals with psychosis to command hallucinations: compliance, appeasement and resistance.
Command hallucinations (CH) are a subtype of auditory hallucination. They are common in psychosis, manifesting as voices instructing people to act, and frequently involve self harm, or harming others. The review, published in Clinical Psychology & Psychotherapy synthesised data from 56 studies examining why some individuals comply with, appease, or resist CH. Researchers explored overlapping as well as distinct aspects driving people to these responses and their implications for developing clinical practice, risk management strategies and targeted intervention.
Multiple factors (including cognitive, behavioural, patient history, etc) were shown to drive the responses to CH. Compliance was associated with beliefs that the voice is powerful, all-knowing, or benevolent, fears about consequences of disobedience, emotional drivers such as anger or obligation, impulsivity, social isolation, childhood trauma, substance use, and overall symptom severity.
Appeasement—partial compliance intended to reduce perceived threat—was associated with beliefs about the voice’s dangerousness and behaviours aimed at preventing escalation, including self-harm to protect others. Resistance was associated with perceived control over the voice, certain beliefs about its intent, specific voice characteristics (e.g., intrusiveness), and developmental factors such as interpersonal trauma and fearful attachment patterns.
The research findings highlighted the importance of detailed psychological formulation in assessing risk. As CH can involve dangerous acts, suicidal behaviour and distress, even appeasement (ie, partial acts) can lead to detrimental outcomes. Targeting the cognitive, relational, emotional, behavioural, and developmental factors that drive compliance and appeasement—while strengthening those driving resistance—may enhance Cognitive Behavioural Therapy for psychosis (CBTp).
The review also developed an aid comprising practical Socratic questions to guide clinical assessment and intervention.
Clinical Correlates of Compliance, Appeasement and Resistance in Command Hallucinations: A Systematic Review (Medas & Georgiades) (doi.org/10.1002/cpp.70246)
In this story
Lecturer in Early Intervention in Psychosis, Deputy Director, MSc Early Intervention in Psychosis