Bringing the “self” into focus: conceptualising the role of self-experience for understanding and working with distressing voices

“The reflective self, also referred to as the core self (Damasio, 1999), self-as-object (James, 1890) or objectified self (Sedikides and Skowronski, 1997) refers to a primitive cognitive representation of the self as the invariant and persisting subject pole of experience and action (Parnas, 2003).”

“Specifically, parallel developments in the fields of phenomenological psychiatry and cognitive psychology suggest that these disturbances in self-experience might well: (a) underlie the emergence of and adaptation to voice hearing; (b) contribute to additional distress/disruption in those who hear…”

“At any one time, only a subset of self-schema are accessed and invoked, depending on both the self-motives being served and the particular demands and affordances of the immediate social situation (Markus and Wurf, 1987).”

“…clarity, in combination with a tendency toward experiences of aberant salience (i.e., in which stimuli that ordinarily would not seem significant become much more salient and important; Kapur, 2003), is associated with an increased risk of psychotic-like experiences (Cicero et al., 2013).”

“The two-chair method provides an opportunity for clients to explore the interactions between newly elaborated positive and negative self-schema, allowing their eventual integration within a new metacognitive model of self as complex and changing (Chadwick, 2006; Dannahy et al., 2011).”

“…this field would be aided by the use of dismantling approaches to determine the impact of existing techniques within multi-component interventions (Kazdin, 2007), and Frontiers in Psychology | www.frontiersin.org August 2015 | Volume 6 | Article 112911 interventionist-causal approaches (Kendler…”

“However, modifying negative schematic content might not always be possible, as this content may be stored in memory in a way that is not easily amenable to change (Hayes, 2004; Brewin, 2006; Longmore and Worrell, 2007).”

“Interventions can alternatively aim to target disturbances of self consciousness proposed to underlie or reinforce disrupted selfexperience, such as hyper-reflection and impaired metacognitive processing (see The Reflective Self).”

“…6 | Article 11293 Whilst anomalous self-experiences are acknowledged to be an important pre-disposing factor in cognitive models of psychosis (Garety et al., 2001; Paulik, 2012), little attempt has been made to fully integrate these higher and lower-level conceptualisations of self in…”

“In line with this view, people with a diagnosis of schizophrenia have been found to experience trait like deficits in the ability to form and use complex metacognitive selfrepresentations (Lysaker and Dimaggio, 2014), and reduced metacognitive capacity to comprehend one’s own mental states has been…”

“Compassion-focused therapy (CFT; Gilbert, 2009) does not directly aim to alter self-schematic content but rather attempts to enhance self-soothing and to dampen activation of the threat system through compassion-focused exercises.”

“One reason for doing so is the evidence of a close relationship between selfconcept clarity and state self-esteem (Campbell, 1990; Nezlek and Plesko, 2001), which might have important implications for how to target low self-esteem in voice hearers.”

“The present framework takes as its basis Parnas’s (2003) description of the structure of the self, which is founded on insights from phenomenological investigations of self-experience within both healthy individuals and those with a diagnosis of schizophrenia (Sass and Parnas, 2003).”

“A number of key research questions can be identified.”

“These concepts have been explored predominantly within the paranoia and persecutory delusions literature (e.g., Bentall et al., 2001; Freeman et al., 2002; Tiernan et al., 2014).”

“These concepts have been explored predominantly within the paranoia and persecutory delusions literature (e.g., Bentall et al., 2001; Freeman et al., 2002; Tiernan et al., 2014).”

“Whilst the stored schematic representations described previously make up the knowledge component of the self (i.e., what people believe about themselves), the evaluative component comprises constructs such as self-esteem (i.e., how people feel about what they believe about themselves; Maddux and…”

“…monitoring deficits (which result in difficulty identifying self-generated events, and are proposed to result in the misattribution of inner speech; Bentall, 1990), whilst operative hyper-reflexivity correlates with compromised memory-prediction processes (which promote excessive attention to…”

“This is not surprising, since cognitive behavioral approaches are typically reliant on processes of conscious self-reflection to foster insight and facilitate change (Chadwick, 2006).”

“…in the ability to form and use complex metacognitive selfrepresentations (Lysaker and Dimaggio, 2014), and reduced metacognitive capacity to comprehend one’s own mental states has been found to predict increased severity of auditory hallucinations in people with psychosis (Lysaker et al., 2005).”

“However, modifying negative schematic content might not always be possible, as this content may be stored in memory in a way that is not easily amenable to change (Hayes, 2004; Brewin, 2006; Longmore and Worrell, 2007).”

“…complementary aspects (Sass, 2014): diminished selfaffection (a weakened sense of existing as a subject of awareness or agent of action) and operative hyper-reflexivity (a non-volitional tendency for focal attention to be directed toward processes and phenomena that are normally tacit or implicit).”

“…aim to target lower-level constructs, such as the content, meaning, accessibility and impact of positive and negative self schema, and/or to influence the way in which these lower-level self representations interact to produce higher-level constructs such as self-esteem, self-concept and identity.”

“Given the demonstrated links between negative self-schema and voices (Close and Garety, 1998; Birchwood et al., 2000, 2004; Barrowclough et al., 2003; Fox et al., 2004; Smith et al., 2006), such treatment approaches might be expected to influence the content, appraisal and impact of voice hearing…”

“However, modifying negative schematic content might not always be possible, as this content may be stored in memory in a way that is not easily amenable to change (Hayes, 2004; Brewin, 2006; Longmore and Worrell, 2007).”

“Whilst many researchers within the cognitive behavioral tradition have investigated the relationship between voices and elements of self-experience such as self-schema and self-esteem, Beck, Bentall, Chadwick and colleagues are amongst the few who have attempted to integrate these constructs within…”

“…of perspectives, the majority appear to assume that there is some elementary form of order, structure, or “essence” to our experience (or “sense”) of self, which remains relatively consistent both within and between individuals (Markus and Wurf, 1987; Damasio, 2003; Gallagher and Zahavi, 2012).”

“…a central role of self-disturbance in the development of voice hearing experiences in schizophrenia (Sass and Parnas, 2003; Raballo and Larøi, 2011; Larøi et al., 2012; Perona-Garcelán et al., 2015), and cognitive models of psychosis emphasize the role of anomalous self-experiences and beliefs…”

“These will each be described in turn, and evidence for their role in relation to the emergence of and adaptation to voice hearing experiences examined.”

“Whilst this idea demonstrates clear parallels with the cognitive notion that the meaning and impact of anomalous experiences are mediated by beliefs (Chadwick et al., 1996; Garety et al., 2001), the phenomenological conception goes further to suggest that anomalous pre-reflective self-experience…”

“Finally, approaches that enhance self-compassion are showing promise for people experiencing psychosis in reducing distress and social marginalization (Braehler et al., 2013), with benefits also found specifically for people hearing voices (Mayhew and Gilbert, 2008).”

“…in the ability to form and use complex metacognitive selfrepresentations (Lysaker and Dimaggio, 2014), and reduced metacognitive capacity to comprehend one’s own mental states has been found to predict increased severity of auditory hallucinations in people with psychosis (Lysaker et al., 2005).”

“…is one of the defining features of schizophrenia (it has been estimated that approximately 60% of those receiving this diagnosis hear voices; Slade and Bentall, 1988), it is possible that disturbances in self-experience are in some way related to the emergence of and adaptation to voice…”

“Finally, addressing the content and meaning of voice hearing experiences within a broader life narrative is likely to be an important element of therapy, a perspective that is emphasized by approaches associated with the Hearing Voices Movement (e.g., Corstens et al., 2008; Longden et al., 2012).”

“Randomized controlled trials (RCTs) are consistent in demonstrating evidence for beneficial but modest effects of CBTp on global measures of voice hearing experiences (van der Gaag et al., 2014).”

“…evidence (naturally occuring evidence as well as evidence gathered through behavioral experiments) as to the accuracy of negative self-schemas (Padesky, 1993) and/or to strengthen positive self beliefs, such as beliefs about personal power and status relative to voices (Trower et al., 2004).”

“Given the demonstrated links between negative self-schema and voices (Close and Garety, 1998; Birchwood et al., 2000, 2004; Barrowclough et al., 2003; Fox et al., 2004; Smith et al., 2006), such treatment approaches might be expected to influence the content, appraisal and impact of voice hearing…”

“Finally, approaches that enhance self-compassion are showing promise for people experiencing psychosis in reducing distress and social marginalization (Braehler et al., 2013), with benefits also found specifically for people hearing voices (Mayhew and Gilbert, 2008).”

“This level of self is widely understood to presuppose the pre-reflective and reflective selves (Sedikides and Skowronski, 1997; Damasio, 1999; Nelson et al., 2014), and to rely on the reflective self, in addition to a capacity for encoding and retrieving episodic–autobiographical memories…”

“…2009), Acceptance and Commitment Therapy (Gaudiano et al., 2010) and Person Based Cognitive Therapy (Chadwick, 2006), and may be particularly helpful for voice hearers given evidence that the intensity of voice hearing decreases during active engagement in leisure activity (Delespaul et al., 2002).”

“…synthetic metacognition (see The Reflective Self) may result in difficulties at each of these levels (Dimaggio et al., 2010; Lysaker et al., 2012; Lysaker and Dimaggio, 2014) resulting in the disturbances in self-coherence and self-identity described in the psychosis literature, including an…”

“…representations and voice content (Close and Garety, 1998; Barrowclough et al., 2003), appraisals of voice power (Birchwood et al., 2000, 2004; Thomas et al., 2015), and emotional and behavioral responses to voices such as distress (Birchwood et al., 2004; Smith et al., 2006) and compliance…”

“However, such approaches are still reliant on traitmeasures of selfexperience and voices, and there is good evidence that both voices and self-experiences are likely to vary within-person (i.e., they are state variables; Nezlek and Plesko, 2001; Thewissen et al., 2011).”

“Contemporary dialogical theories agree that processes such as hyper-reflexivity and hyper-reflection contribute to basic problemswith self-recognition of thoughts and emotions (Lysaker et al., 2012), but they posit that these issues are further compounded by additional metacognitive deficits, which…”

“…robust findings in Frontiers in Psychology | www.frontiersin.org August 2015 | Volume 6 | Article 11294 relation to hallucinations; for example, Waters et al. (2012b) have presented meta-analytic evidence that source monitoring/selfrecognition is impaired in patients with schizophrenia, and…”

“…appraisals about the identity, power, knowledge and intent of voices, as these are proposed to determine the degree Frontiers in Psychology | www.frontiersin.org August 2015 | Volume 6 | Article 11291 of distress and interference with functioning experienced by the hearer (Thomas et al., 2014).”

“…life and through behavioral tasks) and mental rehearsal can be used to strengthen conviction in and accessibility of positive schema (Tarrier, 2001; Hall and Tarrier, 2003), including self-efficacy beliefs such as “I have some control even when voices are around” (Morrison et al., 2004; Chadwick,…”

“Indeed, the negative or disordered higher level self-representations which have been described may develop in reaction to more fundamental, pre-reflective disturbances in experience of self (Nelson et al., 2014; Stanghellini and Rosfort, 2015).”

“…(Perona-Garcelán et al., 2008); findings that voice hearing experiences share some of the pragmatic properties of communication between people (Leudar et al., 1997); and finally, evidence that the relationship between the person and his or her voices is similar to the relationship between…”

“…demonstrated association between these phenomenological disturbances and deficits in attention, sensory processing and source monitoring, and it has been suggested that neurocognitive remediation therapies targeting these mechanisms may be beneficial (Nelson et al., 2014a,b; Postmes et al., 2014).”

“…about voice hearing experiences specifically, experiencing the self as “ontologically vulnerable” could serve to reinforce appraisals of voice power, proposed by cognitive models to be an important factor in determining voice-related distress (Birchwood et al., 2000, 2004; Gilbert et al., 2001).”

“…(Kazdin, 2007), and Frontiers in Psychology | www.frontiersin.org August 2015 | Volume 6 | Article 112911 interventionist-causal approaches (Kendler and Campbell, 2009; Freeman, 2011), in which specific aspects of self-experience are targeted experimentally in order to determine whether…”

“Whilst attempts have been made to directly target higher-level concepts such as self esteem (Lecomte et al., 1999), it has been suggested these constructs may be more helpfully viewed as treatment outcomes (or intermediaries between target and Frontiers in Psychology | www.frontiersin.org August…”

“However, whilst a recent trial targeting a specific type of voice appraisal (voice power beliefs) in people experiencing command hallucinations found a significant reduction in compliance behavior, again, no significant treatment effect was found on voice-related distress (Birchwood et al., 2014).”

“A number of key research questions can be identified.”

“…aim to target lower-level constructs, such as the content, meaning, accessibility and impact of positive and negative self schema, and/or to influence the way in which these lower-level self representations interact to produce higher-level constructs such as self-esteem, self-concept and identity.”

“Social and occupational engagement are emphasized by a number of exisiting interventions, for example Social Recovery Focused Cognitive Therapy (Fowler et al., 2009), Acceptance and Commitment Therapy (Gaudiano et al., 2010) and Person Based Cognitive Therapy (Chadwick, 2006), and may be…”

“…problemswith self-recognition of thoughts and emotions (Lysaker et al., 2012), but they posit that these issues are further compounded by additional metacognitive deficits, which can result in an inability to see one’s own thoughts processes as subjective and fallible (Dimaggio and Lysaker, 2015).”

“Stanghellini and Lysaker (2007) outline four general principles of phenomenonologically-informed therapy; (i) highlighting disturbances of intersubjectivity; (ii) aiming at achieving a shared partnership, (iii) focusing on the here-and-now, youand-I relationship, and (iv) pointing to shared…”

“However, it is widely acknowledged that stored knowledge and evaluations are only one aspect of self-experience (Sedikides and Skowronski, 1997; Damasio, 2003), and much more fundamental disturbances of self are also characteristic of psychosis (Moe and Docherty, 2014; Nelson et al., 2014).”

“Interventions can alternatively aim to target disturbances of self consciousness proposed to underlie or reinforce disrupted selfexperience, such as hyper-reflection and impaired metacognitive processing (see The Reflective Self).”

“To date, there has been less of a focus on the role of self-efficacy beliefs (another aspect of the evaluative component of the self-concept) in voice hearing, although this is frequently stated as a target for psychological therapy (e.g., Chadwick, 2003; Hayward et al., 2009).”

“…that voice hearing experiences share some of the pragmatic properties of communication between people (Leudar et al., 1997); and finally, evidence that the relationship between the person and his or her voices is similar to the relationship between individuals in a social context (Hayward, 2003).”

“Finally, addressing the content and meaning of voice hearing experiences within a broader life narrative is likely to be an important element of therapy, a perspective that is emphasized by approaches associated with the Hearing Voices Movement (e.g., Corstens et al., 2008; Longden et al., 2012).”

“Social and occupational engagement are emphasized by a number of exisiting interventions, for example Social Recovery Focused Cognitive Therapy (Fowler et al., 2009), Acceptance and Commitment Therapy (Gaudiano et al., 2010) and Person Based Cognitive Therapy (Chadwick, 2006), and may be particularly helpful for voice…”

“…Nelson et al., 2014), and to rely on the reflective self, in addition to a capacity for encoding and retrieving episodic–autobiographical memories (Gallagher, 2003; Prebble et al., 2013), for the development, consolidation, and refinement of its content, structure and functions (Sedikides and…”

“The two-chair method provides an opportunity for clients to explore the interactions between newly elaborated positive and negative self-schema, allowing their eventual integration within a new metacognitive model of self as complex and changing (Chadwick, 2006; Dannahy et al., 2011).”

“…in Psychology | www.frontiersin.org August 2015 | Volume 6 | Article 112911 interventionist-causal approaches (Kendler and Campbell, 2009; Freeman, 2011), in which specific aspects of self-experience are targeted experimentally in order to determine whether changes in voice experience…”

“Varese et al. (2011) have demonstrated using the experience sampling method (ESM) that patients with auditory hallucinations are more vulnerable to dissociative states (an example of disrupted self experience) in response to daily life stress compared to non-hallucinating patients and healthy…”

“…in the ability to form and use complex metacognitive selfrepresentations (Lysaker and Dimaggio, 2014), and reduced metacognitive capacity to comprehend one’s own mental states has been found to predict increased severity of auditory hallucinations in people with psychosis (Lysaker et al., 2005).”

“Furthermore, Perona-Garcelán et al. (2008) demonstrated a positive correlation between self-focused attention and dissociative experiences in patients with hallucinations, but not in patients with psychoses who have never experienced hallucinations.”

“…aim to target lower-level constructs, such as the content, meaning, accessibility and impact of positive and negative self schema, and/or to influence the way in which these lower-level self representations interact to produce higher-level constructs such as self-esteem, self-concept and identity.”

“However, it is widely acknowledged that stored knowledge and evaluations are only one aspect of self-experience (Sedikides and Skowronski, 1997; Damasio, 2003), and much more fundamental disturbances of self are also characteristic of psychosis (Moe and Docherty, 2014; Nelson et al., 2014).”

“These concepts have been explored predominantly within the paranoia and persecutory delusions literature (e.g., Bentall et al., 2001; Freeman et al., 2002; Tiernan et al., 2014).”

“This “re-living” involves imagining these positive experiences whilst adopting a congruent posture and facial expression and (sub) vocalizing a congruent positive selfstatement (van der Gaag et al., 2012).”

“…to have conscious access to selfrepresentations that are context-relevant; (iii) the ability of different self-representations to be aware of each other and engage in a “dialogue” (achieved via inner speech) during inter- and intra-personal exchanges; (iv) the ability of the person to adopt a…”

“…specific therapeutic targets and processes (e.g., Thomas et al., 2014), we will now briefly consider what therapeutic methods may be suited to targeting self-experience, with reference to potential applications of components of current interventions that have been described in the literature.”

“…frequency have been observed in individual case studies (Salvatore et al., 2012a), and it is likely that such an approach would facilitate interventions aimed at restoring processes of narrative self-construction (described in see Targeting Higher-level Constructs: Self Esteem and Self…”

“…of; (i) selfconcept clarity (i.e., the degree to which one’s beliefs about one’s attributes are clear, confidently held and cognitively accessible; Stinson et al., 2008); (ii) self complexity (i.e., the number and distinctiveness of accessible self-representations; Linville, 1987); (iii) the…”

“…can such an approach be helpful toward identifying key targets for psychological therapy, but given the suggestion that a disturbance of the basic sense of self is a phenotypic trait marker of psychotic vulnerability, might also inform future strategies for early intervention (Nelson et al., 2009).”

“…self representations and voice content (Close and Garety, 1998; Barrowclough et al., 2003), appraisals of voice power (Birchwood et al., 2000, 2004; Thomas et al., 2015), and emotional and behavioral responses to voices such as distress (Birchwood et al., 2004; Smith et al., 2006) and compliance…”

“Stanghellini and Rosfort (2015) elaborate on this idea, suggesting that “self-disorder, being at the core of the vulnerability to schizophrenia, is refracted through the prism of the person’s background of values and beliefs that determine what things and events in the world mean for us” (p. 4).”

“…clarity, in combination with a tendency toward experiences of aberant salience (i.e., in which stimuli that ordinarily would not seem significant become much more salient and important; Kapur, 2003), is associated with an increased risk of psychotic-like experiences (Cicero et al., 2013).”

“This is the level at which themajority of cognitive behavioral research in psychosis has been conducted (see Current Conceptualisations of “self ” in CBT for Frontiers in Psychology | www.frontiersin.org August 2015 | Volume 6 | Article 11295 Psychosis).”

“…the demonstrated links between negative self-schema and voices (Close and Garety, 1998; Birchwood et al., 2000, 2004; Barrowclough et al., 2003; Fox et al., 2004; Smith et al., 2006), such treatment approaches might be expected to influence the content, appraisal and impact of voice hearing…”

“Other recommended treatment approaches include those which encourage gradual engagement in activities and social interaction, thereby promoting a sense of immersion in present activity (Nelson and Sass, 2009).”

“…and through behavioral tasks) and mental rehearsal can be used to strengthen conviction in and accessibility of positive schema (Tarrier, 2001; Hall and Tarrier, 2003), including self-efficacy beliefs such as “I have some control even when voices are around” (Morrison et al., 2004; Chadwick, 2006).”

“…aim to target lower-level constructs, such as the content, meaning, accessibility and impact of positive and negative self schema, and/or to influence the way in which these lower-level self representations interact to produce higher-level constructs such as self-esteem, self-concept and identity.”

“…are dependent upon interpersonal experience (Markus and Wurf, 1987), behavioral approaches which promote social and occupational engagement (e.g., Hodgekins and Fowler, 2010) or target assertiveness and communication skills (Hayward et al., 2009) could all potentially contribute to the…”

“…(2003) and Chadwick (2006) in the cognitive literature that the accessibility and dynamic interactions between different self-representations is as important as the content of these representations in determining functional adaptation to anomalous experiences (Lysaker and Lysaker, 2002, 2004).”

“…referred to as minimal, ecological, basic, or proto self, selfhood or self-assubject; James, 1890; Gibson, 1986; Damasio, 1999; Nelson et al., 2014; Stanghellini and Rosfort, 2015) constitutes the foundational level of selfhood on which other levels of self-experience are built (Nelson et al.,…”

“Adapted mindfulness practice, metaphors and experiential exercises can be used to further facilitate re-appraisal of the status, rather than the content, of negative self-schema (Chadwick, 2006; Thomas et al., 2013).”

“In individuals with a diagnosis of schizophrenia, low self-concept clarity has been found to predict higher levels of positive symptoms, lower subjective quality of life and increased risk of perceived exposure to stigmatization (Weinberg et al., 2012; Noyman-Veksler et al., 2013).”

“…agree that processes such as hyper-reflexivity and hyper-reflection contribute to basic problemswith self-recognition of thoughts and emotions (Lysaker et al., 2012), but they posit that these issues are further compounded by additional metacognitive deficits, which can result in an inability…”

“…evidence from the delusions literature suggests that similarmetacognitive training approaches can be used to promote insight into the cognitive biases serving to maintain unusual beliefs (Kumar et al., 2014), whichmay serve to augment cognitive behavioral interventions for voice hearing.”

“In line with this, Kim et al. (2010) have found a significant association between anomalous self-experiences and voice hearing (but not delusions) in patients with schizophrenia, and Raballo and Larøi (2011) present evidence from first-person accounts that anomalous self-experiences could prelude…”

“…between operations occurring at the different levels of self is consistent with recent neurocognitive models of voice hearing (Waters et al., 2012a; Aleman and Vercammen, 2013), which propose that auditory hallucinations are caused by a blend of distorted input from bottom-up sensory information…”

“At the highest levels of self-reflectivity, the therapist aims to work alongside the client to consider the fallibility of their thinking, take a step back from firmly held ideas, and begin to consider alternative world views.”

“As with the phenomenological approach, reflections in the secondperson are thought to be useful since these reflections implicitly treat clients as participants in their lives, recognizing that they are more than passive observers (Lysaker and Lysaker, 2011).”

“One reason for doing so is the evidence of a close relationship between selfconcept clarity and state self-esteem (Campbell, 1990; Nezlek and Plesko, 2001), which might have important implications for how to target low self-esteem in voice hearers.”

“Contemporary cognitive models emphasize the significance of recognizing the complex and dynamic nature of the self-concept (Bentall, 2003; Chadwick, 2006).”

“…focused on only two elements of self-experience in voice hearing; negative self-schema and self-esteem, largely neglecting significant advances in the understanding of selfexperience from research in phenomenological psychiatry and cognitive and social psychology (García-Montes et al., 2012).”

“In addition, there is preliminary evidence suggesting that both negative beliefs about voices [20,26] and the self [52] contribute to emotional distress in BPD who experience AVH, and could, thus, become the target for psychological therapies, such as cognitive behavioral therapy or interventions addressing the self-e…”

“Potentially fruitful connections might also be drawn with recent work that has focused on the relationship between voices and broader aspects of self – including self-concepts and self-schemas – particularly as they play out in functional recovery (Fielding-Smith et al., 2015; Thomas, Farhall, & Shawyer, 2015).”

“…to absorption rather than the more cognitive mechanisms of psychosis may suggest that value of approaches that focus on embodied states (or the embodiment of emotions), mindfulness and awareness of self and world (Fielding-Smith et al., 2015; Stanghellini & Lysaker, 2007; Lysaker & Dimaggio, 2014).”

“Since negative beliefs about hallucinated voices(96,97) and self-image(98) contribute to emotional distress in BPD, hallucinations themselves could become targets for psychological interventions such as cognitive behavioural therapy or narrative-based self-experience interventions (Thomas et al 2014, Fielding-Smith et…”

“…(Bürgy, 2008; Fuchs, 2010; Sass et al., 2011; Henriksen and Parnas, 2012; Parnas, 2012; Akroyd, 2013; Nelson et al., 2014; Parnas and Henriksen, 2014; Sass, 2014; Fielding-Smith et al., 2015; Irarrázaval, 2015; Stanghellini and Rosfort, 2015; Maiese, 2016; Stanghellini and Aragona, 2016).”

“…targets the mechanisms known to maintain the distress that can be experienced when hearing voices, such as negative beliefs about the self (Fielding-Smith et al., 2015), beliefs about the omnipotence and malevolence of voices (Chadwick and Birchwood, 1994), and negative patterns of…”

“This aligns with research suggesting that disruptions in self-experience in psychosis may arise from a breakdown in reflective capacity and the ability to engage in internal dialogue (Fielding-Smith et al., 2015; Lysaker & Lysaker, 2002).”

“It is thus unsurprising that inconsistent self-experience has been associated with deleterious effects on “self-coherence, self-identity, and self-esteem” (Fielding-Smith et al., 2015, p. 1129).”