Consistent with early definitions of schizophrenia as marked by a fragmentation of thought, emotion and desire¹, psychosis is currently understood as involving deep disturbances in the sense that persons have of themselves and their connection with the world². Though endemic across psychosis³, it has remained unclear how to operationalize and measure the processes which underlie and sustain these alterations in self-experience.

One challenge for empirical research is that the sense anyone has of him/herself, given its intimacy, immediacy and elusiveness, is not easily measured. Validated assessments, for example, of the oddness of thinking, thought disorder, reasoning biases, or the inaccuracy of judgments do not capture how people amidst psychosis experience their purposes, possibilities, and life trajectories differently⁴.

Nevertheless, it is possible to evaluate processes that underlie the subjective disturbances that characterize psychosis. The sense anyone has of him/herself is enabled by the integration of experience. A sense of oneself in the world is made possible by the active synthesis of discrete experiences into a larger sense in which the relationship of those discrete experiences lends meaning to one another².

One line of research has proposed that metacognition is a process whose disruption could result in alterations of self-experience in psychosis². Metacognition, across disciplines, refers to the awareness of one’s own thoughts and behaviors, and the ability to therefore monitor and alter behavior⁵. Applied to subjective experience in psychosis, an integrative model has conceptualized metacognition as a spectrum of activities that range from awareness of discrete cognitive, emotional and embodied experiences to the synthesis of those experiences into a broader awareness of the self, others and one's place in the community⁴.

Metacognition, in this integrated model, extends beyond isolated judgments, and involves processes that enable awareness of and reflection upon experience in socially situated and intersubjective contexts⁶. It allows for persons to have available, in a given moment, the kind of sense of self, others, and emergent challenges necessary to adaptation and cooperation with others².

Applied to psychosis, this model has offered several significant advances. First, it has been accompanied by the development of a tool for measuring metacognitive capacity as a continuous variable: the Metacognitive Assessment Scale Abbreviated (MAS-A)⁴. The MAS-A differentiates metacognitive capacity according to its focus on the self, others, one’s community, and the use of metacognitive knowledge. It provides subscales corresponding to these four dimensions. Higher scores on each subscale reflect a sense which involves greater levels of the integration of information, while lower scores quantify more fragmented experiences⁴.

With adequate psychometric properties, the MAS-A has allowed for quantitative studies of subjective experience in psy­chosis internationally^{2, 4, 6}. Relatively greater metacognitive def­icits have been detected in adults diagnosed with multiple phases of psychosis compared to healthy controls, people with non-psychiatric medical adversity, and others with less severe psychopathology.

Illuminated in these studies are qualities of how individuals experience themselves as they seek to make sense of what has happened to them and what they need. Results of these studies indicate, for example, that many individuals with psychosis are able to identify discrete embodied, cognitive and emotional states, but struggle to form a coherent sense of self in which these experiences are cohesively related to one another. Thus, we are afforded a chance to dimensionally measure the experience of fragmentation which may compromise chances of the experience of oneself as an active agent in the world with coherent possibilities and purposes.

The link of these alterations to disturbances in daily life are confirmed empirically by findings that graver metacognitive deficits within psychosis are linked to concurrent and prospective decrements in psychosocial functioning, including social behaviors, negative symptoms, and relatedly intrinsic motivation. Research has also found that changes in metacognition accompany changes in other aspects of function².

This work may offer an even more substantial advance as it goes beyond the recognition of a new variable affecting psychosocial functioning in psychosis. Contemporary research has affirmed that complex arrays of social and biological factors create and sustain psychosis⁷. Metacognition not only allows for the study of psychosis as multidetermined, but it offers a view of an underlying process that links social, biological and psychological phenomena in a fluidly interacting network which culminates in any number of possible outcomes.

As supported in a recent network analysis⁸, metacognitive capacity may act as a central node in a complex array of heterogenous neurocognitive domains and symptoms in psychosis. In such a network, metacognitive capacity may deeply influence outcome, not only directly, but also via its influence as a node connecting and affecting the relationships among different biopsychosocial elements. Metacognition thus allows for a larger nuanced picture of the forces which shape psychosis, moving from genetics and basic brain function to socio-political issues, to phenomenology of the unique suffering, history and possibilities of a person diagnosed with psychosis.

Finally, maybe most plainly, if deficits in metacognition leave persons unable to make sense of and manage experiences that accompany psychosis, then treatment which ameliorates these deficits may open unique paths to recovery. Here, there are implications for both the general principles of recovery-oriented management as well as the development of unique treatment approaches.

Concerning the common elements of recovery-oriented management, metacognitive research suggests that, in order to promote a personal awareness and approach to managing psychosis, treatment has to be intersubjective in nature and emphasize joint meaning making rather than primarily offering clinician-directed approaches to symptom reduction and skill acquisition².

One intervention specifically developed on the basis of this work, metacognitive reflection and insight therapy (MERIT)⁹, is an integrative treatment which is responsive to patients’ level of metacognitive capacity and explicitly seeks to promote the growth of this capacity over time⁶. With promising initial empirical support⁹, this operationalized treatment stands as an example of an innovation that may uniquely address the loss of persons’ sense of themselves and promote self-directed recovery.

与早期对精神分裂症的定义一致，精神分裂症以思想、情感和欲望的分裂为标志¹，目前精神病被理解为涉及人对自身及其与世界的联系的深层困扰²。尽管在精神病中很普遍³，但目前仍不清楚如何操作和衡量这些自我体验改变的基础和维持过程。

实证研究面临的一个挑战是，任何人对自己的感觉，由于其亲密性、直接性和难以捉摸性，是不容易测量的。例如，对思维的奇怪性、思维障碍、推理偏见或判断不准确的有效评估并不能反映精神病患者如何以不同的方式体验他们的目的、可能性和生活轨迹⁴。

然而，评估精神病特征的主观干扰的过程是可能的。任何人对自己的感觉都是通过经验的整合来实现的。通过将离散的经验积极地综合成一种更大的意义，使这些离散的经验之间的关系赋予彼此意义，从而使一种自我意识成为可能²。

一项研究提出，元认知是一个过程，其破坏可能导致精神病中自我体验的改变²。跨学科的元认知是指对自己的思想和行为的认识，以及因此监控和改变行为的能力⁵。应用于精神病的主观体验时，综合模型将元认知概念化为一系列活动，范围从对离散认知、情感和具体体验的认识到将这些体验综合为对自我、他人和自己在社会中的地位的更广泛的认识。社区⁴ .

在这个综合模型中，元认知超越了孤立的判断，并涉及能够意识到和反思社会情境和主体间背景中的经验的过程⁶。它允许人们在特定时刻拥有自我意识、他人意识以及适应和与他人合作所必需的紧急挑战²。

该模型应用于精神病，取得了一些重大进展。首先，伴随着一种用于测量连续变量元认知能力的工具的开发：缩写元认知评估量表（MAS-A）⁴。MAS-A 根据其对自我、他人、社区的关注以及元认知知识的使用来区分元认知能力。它提供了与这四个维度相对应的子量表。每个分量表上的较高分数反映了涉及更高水平的信息整合的感觉，而较低的分数则量化了更多碎片化的体验⁴。

凭借足够的心理测量特性，MAS-A 允许在国际范围内对精神病的主观体验进行定量研究^{2, 4, 6}。与健康对照者、患有非精神病性医疗逆境的人和其他精神病理学不太严重的人相比，在被诊断患有多阶段精神病的成年人中发现了相对更大的元认知缺陷。

这些研究揭示了个体在试图理解发生在自己身上的事情和需要什么时如何体验自己的品质。例如，这些研究的结果表明，许多患有精神病的人能够识别离散的体现、认知和情绪状态，但难以形成一种连贯的自我意识，其中这些经历彼此紧密相关。因此，我们有机会在维度上衡量碎片化的体验，这可能会损害自己作为世界上具有连贯可能性和目的的积极行动者的体验的机会。

这些改变与日常生活障碍之间的联系得到了实证研究的证实，即精神病中更严重的元认知缺陷与社会心理功能的同时和未来的下降有关，包括社会行为、阴性症状和相关的内在动机。研究还发现，元认知的变化伴随着功能其他方面的变化²。

这项工作可能会带来更实质性的进步，因为它超出了对影响精神病心理社会功能的新变量的认识。当代研究已经证实，一系列复杂的社会和生物因素会造成并维持精神病⁷。元认知不仅允许对精神病进行多决定性的研究，而且还提供了一种潜在过程的观点，该过程将社会、生物和心理现象联系在一个流动的相互作用的网络中，最终导致许多可能的结果。

正如最近的网络分析所支持的⁸，元认知能力可能充当一系列复杂的异质神经认知领域和精神病症状的中心节点。在这样的网络中，元认知能力不仅可以直接影响结果，还可以通过其作为连接和影响不同生物心理社会要素之间关系的节点的影响力来影响结果。因此，元认知可以更全面、更细致地描绘塑造精神病的力量，从遗传学和基本大脑功能到社会政治问题，再到被诊断患有精神病的人的独特痛苦、历史和可能性的现象学。

最后，也许最简单的是，如果元认知缺陷使人们无法理解和管理伴随精神病的经历，那么改善这些缺陷的治疗可能会开辟独特的康复之路。在这里，对以恢复为导向的管理的一般原则以及独特治疗方法的开发都有影响。

关于以恢复为导向的管理的共同要素，元认知研究表明，为了促进个人意识和管理精神病的方法，治疗本质上必须是主体间性的，并强调共同意义的制定，而不是主要提供临床医生指导的症状治疗方法减少和技能获取²．

在这项工作的基础上专门开发的一项干预措施，元认知反思和洞察疗法（MERIT）⁹，是一种综合治疗，它对患者的元认知能力水平做出反应，并明确寻求随着时间的推移促进这种能力的增长⁶。凭借有希望的初步实证支持⁹，这种可操作的治疗方法成为创新的一个例子，可以独特地解决人们自我意识丧失的问题并促进自我导向的康复。