The thrust of the therapist's challenge is that the beliefs are reasonable and understandable reactions to, and attempts to make sense of, the auditory hallucinations. The therapist reviews evidence and inconsistency, and plans tests, with the aim always of evaluating two possible meanings: that the beliefs are true, a discovery, or that they are reasonable and understandable, but mistaken. As ever, it is vital that the therapist really practises Socratic questioning and works collaboratively. This involves drawing out patients' own doubts, puzzlement, double-awareness, critical faculty, etc., rather than forcing a contradiction on them.
The major piece of evidence for the delusional beliefs is always the actual voices, especially their content—these are, after all, the activating events that the delusions are invoked to explain. The role of beliefs is critical because individuals usually attribute voices with a power and knowledge that goes well beyond what they have actually said. Several examples of challenging follow.
It is really quite common for beliefs about compliance (e.g. 'If I don't do what my voice says I will be punished') not to fit patients' experiences, and perhaps it is only their emotional impact which prevents patients from abandoning them. Kate, for example, believes 'If I drop my guard the voices will kill me', but in fact she has dropped her guard on many occasions without consequence. This might be pointed out as follows. 'Kate, you say that the voices have the power to kill you and you must be on your guard constantly. I certainly appreciate the fear that this must create. What puzzles me though is that your guard is often down, like when you are asleep. How is it that they have not succeeded in all these years?'
The appearance of being all knowing (omniscience) is a vital aspect of many voices (22) and often features as a key piece of evidence that the identity of the voice is superhuman. It leaves individuals feeling exposed and vulnerable and very prone to guilt and shame. Alice believes that her voice is a prophet endowed with the ability to foretell the future. In particular, the voice anticipates exactly the arrival of her husband home from work each day. To begin the process of questioning she was asked: 'Let's suppose for a moment that the voice cannot foretell the future; can you think of any other possible explanations for last night's prediction?' One such possibility was that the voice was making a very safe guess.
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