Self-Experience in Schizophrenia: Metacognition as a Construct to Advance Understanding

In our original piece (Hamm et al. 2015), we suggested that contemporary phenomenological models of schizophrenia such as the ipseity-disturbance model emphasize perceptual and cognitive elements of self-disturbances, potentially neglecting the presence and central importance of painful affect in the experience of schizophrenia. We concluded that integrating affect within developing phenomenological models would offer not only a theoretical advance but also a possible path to more effective recovery-oriented treatment. In response, Phillips (2015) agrees there is incontrovertible evidence of painful affect central to the experience of schizophrenia. He expresses concerns though about a danger in falsely reducing schizophrenia to one cardinal essence and, in the tradition of Jaspers’s claims of ununderstandability (1963), challenges the view that the experience of schizophrenia “can be understood and described” (Phillips 2015, 210). Turning more keenly to the issue of future research, Stanghellini (2015) calls for additional exploration of a range of aspects of schizophrenia and self-disturbance, and suggests that one impediment to date to advancing research in this area has been the difficulty in operationalizing aspects of these self-experiences.

In response to these comments, our first remarks concern the reflections of Phillips. We agree that there is a need to avoid an overly essentialist and rationalist view of schizophrenia (Phillips 2015) and also agree that available research does not suggest that there is a core categorical experience underneath schizophrenia. Like Phillips (2015), we reject the idea that schizophrenia can be reduced to one essence, and also reject that the self-experience of person with schizophrenia is categorically different from self-experience of persons without schizophrenia. Our own view is consistent with other contemporary descriptions of (van Os et al. 2009) a dimensional, rather than categorical, view of psychotic experiences that position such states as part of the continuum of human experience. We would also contend that the richness of self-experience can be considered to vary along a continuum. This is to say that some persons with schizophrenia may experience varying levels of severity in disruptions in self-experience with presumably higher levels of disturbance tied to other kinds of poor outcomes. In this regard, the study of self-disturbance in schizophrenia can avoid essentialism if it takes a dimensional view.

We support Stanghellini’s (2015) call for additional exploration of a range of aspects of schizophrenia and self-disturbance, and agree that difficulties in operationalizing aspects of these self-experiences has to date been one impediment to advancing research in the areas highlighted. Accordingly in the remaining space of this reply we offer at least one method of assessing these aspects of self-experience that is quantitative in nature and which we assert avoids the problems of essentialism. Specifically, we point to a paradigm that incorporates cognitive, social, and emotional processes through which persons form, reflect on, and evolve mental representations of self and others. This paradigm uses the term metacognition to refer to the spectrum of activities which allow persons to integrate information into more or less complex and evolving representations of self and others (Lysaker et al. 2013; Semerari et al. 2003).

In persons with schizophrenia, metacognition has been studied by separately measuring the complexity of representations of self, others, the larger world and the ability to use that knowledge to respond to psychosocial challenges within personal narratives. Using the Metacognition Assessment Scale Abbreviated (MAS-A) (Lysaker et al. 2005), different authors (Hasson-Ohayon et al. 2015; Lysaker, Vohs, et al. 2014; Massé and Lecomte 2015; Nicolò et al. 2012; Vohs et al. 2014) have found that persons with schizophrenia struggle to recognize and distinguish different events within their own minds and overall tend to not articulate nuanced emotional experience, or to perceive thoughts, feelings, and intentions as interacting with one another within specific life events. They also demonstrate limited awareness of the subjectivity of others, and a diminished ability to use insights about self and others to solve psychological problems. Measured dimensionally with the MAS-A, these deficits have...