J. Psychosoc. Rehabil. Ment.

Health (2021) 8:109–123

https://doi.org/10.1007/s40737-020-00204-6

ORIGINAL ARTICLE

Cognitive Enhancement Therapy in Early Schizophrenia:

A Qualitative and Quantitative Case Series of Patients’
Experiences
Chelsea Noël . Feng Gu . Leighanne Ormston . Samantha Tingue .
Alexandra Tucci . Patrizia Pezzoli . Shezal Padani . Luis Sandoval .
Jessica A. Wojtalik . Shaun M. Eack . Matcheri S. Keshavan . Synthia Guimond

Received: 8 July 2020 / Accepted: 6 October 2020 / Published online: 28 October 2020
Ó Springer Nature India Private Limited 2020

Abstract Evidence shows that cognitive remedia- questionnaires and participated in semi-structured
tion therapy improves cognition in individuals with focus groups or in an individual interview about their
schizophrenia. However, its broader impact on experience with CET. Four deductive themes were
patients’ lives remains unclear. Furthermore, little is assessed when analyzing responses: (1) perceived
known about the motivational factors influencing impact, (2) motivational facilitators, (3) motivational
treatment engagement. This quantitative and qualita- barriers, and (4) suggestions to improve CET. All
tive case series study identified factors that influence participants reported that CET was helpful, and the
patients’ experiences while receiving cognitive majority enjoyed participating in CET. Most partici-
enhancement therapy (CET). Nine individuals with pants reported high satisfaction with their work and
schizophrenia who received CET completed two school, but lower satisfaction with their social life.
Results also indicated perceived improvements in
negative symptoms, neurocognition, and confidence
Electronic supplementary material The online version of following CET. Participants identified extrinsic,
this article (https://doi.org/10.1007/s40737-020-00204-6) con-
tains supplementary material, which is available to authorized intrinsic, and program-specific facilitators and barriers
users.

C. Noël
F. Gu
A. Tucci
P. Pezzoli
S. Guimond S. M. Eack

Department of Psychiatry, The Royal’s Institute of Mental School of Social Work and Department of Psychiatry,
Health Research, University of Ottawa, Ottawa, ON, University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA,
Canada USA

L. Ormston
S. Tingue
S. Padani
L. Sandoval
M. S. Keshavan
S. Guimond

M. S. Keshavan
S. Guimond Department of Psychiatry, Harvard Medical School,
Department of Psychiatry, Beth Israel Deaconess Medical Boston, MA, USA
Center, Massachusetts Mental Health Center Division of
Public Psychiatry, Boston, MA, USA S. Guimond
Department of Psychoeducation and Psychology,
A. Tucci
S. Guimond University of Quebec in Outaouais, Gatineau, QC, Canada
Department of Psychology, Carleton University, Ottawa,
ON, Canada M. S. Keshavan (&)
BIDMC-Mass. Mental Health Center, 75 Fenwood Road,
J. A. Wojtalik Boston, MA 02115, USA
Jack, Joseph and Morton Mandel School of Applied e-mail: [email protected]
Social Sciences, Case Western Reserve University,
Cleveland, OH, USA

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motivating their participation in the program. Sugges- neurocognitive and social-cognitive outcomes. Tradi-
tions to improve CET included changes to treatment tionally, the acceptability of cognitive interventions is
design and content. Altogether, these results indicate inferred by the number of missed sessions [50], in lieu
that the perspective of CET end users can provide of directly asking participants. Along with generally
useful information on the factors influencing treatment low adherence to homework across cognitive remedi-
engagement, satisfaction, and perceived impact. ation studies [6], a meta-analysis of cognitive reme-
diation therapies for schizophrenia indicated a pattern
Keywords Schizophrenia
Cognition
Cognitive of difficulty with engagement similar to issues faced in
remediation
Cognitive enhancement therapy
other psychotherapies, with attrition rates that can be
Motivation as high as 47.5% [62]. Where reported, the attrition
rate for CET has been comparable to other cognitive
remediation trials [23].
Beyond attrition rates as an indicator of subjective
Background experience, the field has yet to examine personal
factors that might influence engagement in cognitive
Schizophrenia is a chronic and severely disabling remediation, as well as its effectiveness. Subjective
mental health disorder characterized by positive awareness of neurocognitive improvement (i.e. per-
symptoms, negative symptoms, and cognitive deficits ceived competence) has shown to increase engage-
[4, 32, 40]. Since cognitive deficits are a strong ment, task persistence, and learning among
predictor of poor functional capacity and quality of individuals with schizophrenia [16]. Moreover, factors
life, they represent a critical treatment target [7, 32]. such as task relevance, task interest and the amount of
Furthermore, although pharmacological treatments for control or autonomy individuals have in learning
schizophrenia are effective in treating positive and, to situations contribute to motivation to engage in
some extent, negative symptoms [58], cognitive cognitive remediation [12, 31]. A prosocial treatment
deficits tend to persist [41]. This has led to the setting has also shown to foster intrinsic motivation for
development of alternative interventions such as treatment, retention, and positive transfer effects in
cognitive remediation, which aim to improve cogni- psychiatric samples, including individuals with
tive and daily functioning in individuals with schizophrenia [15, 42, 54]. Nevertheless, qualitative
schizophrenia [7]. Numerous studies have supported research on the factors that motivate participation and
the efficacy of cognitive remediation programs for completion of cognitive remediation programs is
improving cognitive and functional outcomes in limited [17, 62]. A better understanding of subjective
schizophrenia [9, 43, 62]. One approach to cognitive factors contributing to cognitive remediation engage-
remediation is Cognitive Enhancement Therapy ment could aid in the development of more engaging
(CET) [35]. In addition to neurocognitive domains cognitive treatments and reduce attrition rates [28].
such as attention, memory, and problem-solving, CET Mixed qualitative and quantitative methods have
specifically targets social cognition [21, 29, 36, 37]. been suggested as a potential useful tool to identify
During CET, individuals complete 18 months of critical information which could be used to improve
neurocognitive training exercises in pairs with the engagement to cognitive interventions [5]. Hence, the
aid of a CET therapist/coach, along with structured current quantitative and qualitative case series study
social-cognitive group sessions relevant to individual aimed to investigate patients’ experience of CET using
participant recovery goals [21, 29, 36, 37]. two questionnaires, two semi-structured focus groups,
Several studies have shown that CET leads to and one individual interview in a sample of nine
improvements in neurocognitive, social-cognitive, individuals with schizophrenia who underwent CET
and functional outcomes, which persist following treatment. Using a thematic content analysis, we
treatment (e.g. [20–23, 25, 36]. However, there is analyzed responses related to four deductive themes:
limited research on participants’ subjective experi- (1) perceived impact, (2) motivational facilitators, (3)
ences during CET and other cognitive remediation motivational barriers, and (4) suggestions to improve
treatments, as well as their broader impact on partic- CET. We hypothesized that participants would report
ipants’ lives, beyond routinely measured positive levels of satisfaction with the CET program in

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terms of helpfulness and enjoyment, as well as for up to 18 months. CET program content has been
perceived improvements in life satisfaction and cog- described in detail in previous reports [20, 35–37].
nitive functioning following CET. Moreover, we Participants’ clinical symptoms severity, neurocog-
expected to identify factors motivating or hindering nitive and socio-cognitive outcomes as well as life
participants’ engagement and satisfaction with CET, satisfaction was assessed at baseline, 9-month and
as well as useful suggestions for CET improvement. 18-month follow-up. Treatment responses on those
outcomes are reported in the full intent-to-treat sample
(n = 102) in Wojtalik et al. [61, in revision]. Follow-
Methods ing their participation in CET, participants from
BIDMC were then invited to complete two satisfaction
Study Design and Participants questionnaires and to participate in either a focus
group or an individual interview about their experi-
This study was embedded within a large-scale multi- ence with CET.
site randomized-controlled trial [61, in revision] (NCT
#01561859). The participants included in the current Baseline Assessments
study were 9 individuals referred to the Beth Israel
Deaconess Medical Center (BIDMC) in Boston, Neurocognitive and socio-cognitive functioning were
Massachusetts by programs specialized in treating assessed using composite scores corrected for age and
early-course schizophrenia. A total of 8 of these sex from the Measurement and Treatment Research to
participants were randomized in the clinical trial, Improve Cognition in Schizophrenia (MATRICS)
while one received CET after being initially random- [30]. Participants’ level of life satisfaction was also
ized to the EST group. Therefore, this participant was assessed using overall composite scores of The World
excluded from the assessments and analyses of the Health Organization Quality of Life (WHOQOL
larger trial, but was still invited to participate in the Group [60]) across domains of psychological health,
focus group session. The BIDMC Institutional Review social relationships and environment. Participants’
Board approved all procedures, and all participants negative and positive symptoms were assessed using
provided written informed consent. Participants were the total scores of the Scale for the Assessment of
also asked to provide additional verbal consent before Negative Symptoms (SANS) [2], and the Scale for the
participating in the in-person interview or focus Assessment of Positive Symptoms (SAPS) [1],
groups. Eligibility criteria for the study are outlined respectively.
in the Supplementary Methods section of the Online
supplement. Questionnaires

Procedure The CET satisfaction questionnaire addressed partic-

ipants’ level of satisfaction regarding perceived help-
Cognitive Enhancement Therapy fulness and enjoyment of CET components (i.e.
individual coaching, computer sessions, group lec-
During CET, participants met with the trained coach in tures, group activities) as well as their perceived
weekly individual sessions to create co-developed neurocognitive improvement. Participants were told
treatment plans complementary to personal recovery that CET is designed to be helpful and enjoyable and
goals. Participants were assigned to pairs and com- that choosing ‘‘not at all’’ or a ‘‘a little’’ to describe the
pleted approximately 60 h of a computer-assisted level of helpfulness and enjoyment of CET had
neurocognitive training (weekly 1-h sessions) in negative implications. Moreover, they were told that
attention, memory, and problem solving. Further, choosing ‘‘neutral’’ implied that their experience was
participants were enrolled in forty-five weekly social- neither negative nor positive. This questionnaire also
cognitive group sessions facilitated by the CET allowed them to provide open-ended feedback. The
coaches involving 6–8 participants (one and a half life satisfaction questionnaire addressed participants’
hours per week). Participants were treated with CET level of satisfaction with their social life, occupation,
and recovery. Questionnaires were filled in during the

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focus group or interview sessions and are presented in as well as transcripts of the focus groups and the
the Supplementary Methods section of the Online individual interview [45].
supplement. A mixed analysis grid was used. More precisely, an
initial coding framework was developed based on the
Focus Groups and Individual Interview themes initially identified in the interview guide (i.e.
perceived impact, motivational facilitators, motiva-
Two semi-structured focus groups (n = 8) and one tional barriers, and suggestions to improve CET) to
individual interview (n = 1) were conducted to iden- perform the deductive analysis. As there is a lack of
tify factors influencing participants’ experience with qualitative data regarding this type of intervention, the
CET. These qualitative assessments were conducted themes of the coding framework were minimal and
by a researcher who has experience working with broad in order to maximise the generation of cate-
individuals with schizophrenia (S.G.) and guided by a gories and codes reflecting the participants’ experi-
semi-structured interview (see Supplementary Meth- ences [27]. Thus, an inductive analysis was also
ods section of the Online supplement). The questions performed to identify emergent themes, categories,
in the semi-structured interview were selected to and codes. No new emergent themes were identified,
highlight factors suggested to be related to motivation but several categories (e.g. improved neurocognition)
and engagement in cognitive remediation in the and sub-categories (e.g. focus/memory, thought orga-
literature and were divided in four predetermined nization and problem-solving) that emerged were
themes: (1) perceived impact, (2) motivational facil- included in the final categorization.
itators, (3) motivational barriers, and (4) suggestions First, coders familiarized themselves with the data
to improve CET. The focus groups and interview were collected through questionnaires, focus groups, and
video-recorded and transcribed into anonymized ver- the interview. Data were then summarized into smaller
batim transcripts by L.O and S.T. Two other Authors fragments of meaningful information that were first
(S.G., S.P) collected field observations and comments, descriptive (paraphrases of participants’ words) and
and verified the accuracy of transcriptions. then interpretative (words chosen by coders as most
representative of underlying concepts, called codes).
Data Analysis Codes reflecting similar meaning were grouped
together under one category or sub-category, and
Quantitative Analysis categories were grouped in themes, within the themes
of the coding framework [45, 46]. Co-coding and team
Quantitative data were analyzed in R version 3.5.2. meetings were used to agree on the coding scheme and
We used descriptive statistics including frequencies final categorization.
and measures of central tendencies to describe the Corresponding sample quotations for themes, cat-
sample in terms of sex, age, ethnicity, clinical egories, and sub-categories describing perceived
diagnosis, education, number of CET sessions com- impact, motivational facilitators, barriers, and sugges-
pleted and treatment completion. We also reported the tions to improve CET are identified in the Supple-
neurocognitive and socio-cognitive performance, mentary Results section of the Online supplement and
level of life satisfaction, and level of symptoms frequencies (the number of participants who raised
severity at baseline for each participant in Table 1. ideas related to certain themes, categories and sub-
Lastly, frequencies for the quantitative responses to categories) are highlighted in Tables 2, 3, 4 and 5.
the CET and life satisfaction questionnaires were
tabulated to assess participants’ experience of CET.
Results
Qualitative Analysis
Demographic Results
A thematic content analysis was performed with
NVivo12 [10, 45]. A cross-sectional analysis was Participants were 9 individuals (n = 1 female, n = 8
conducted to identify consensus and divergence male) who met diagnostic criteria for schizophrenia
through open-ended responses to the questionnaires (n = 6) or schizoaffective disorder (n = 3) (mean age:

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Table 1 Baseline clinical and demographic information

Participants
Variable 1 2 3 4 5 6 7 8 9

Sex M M M M M F M M M
Age 22 27 22 26 28 27 22 24 22
Ethnicity Asian African Other Caucasian Caucasian Other Caucasian Asian Caucasian
American
Diagnosis SZ SZ SZ SZ SZ SA SA SZ SA
Education Some Completed Some Completed Some Completed Some Some N/A
college college college post college college college college
graduate
education
Completed No Yes No Yes Yes Yes No Yes No
treatment
(Yes or no)
# of CET 56 116 65 132 149 110 107 72 N/A
sessions
completed
Neurocognition 48 47 38 49 41 45 48 47 N/A
Social 41 35 26 60 25 32 57 55 N/A
cognition
Quality of life 84 79 54 N/A 61 86 94 69 N/A
Negative 21 28 28 32 43 20 36 28 N/A
symptoms
severity
Positive 3 0 7 1 39 18 15 0 N/A
symptoms
severity
M = Male; F = Female; Age = Age when consent to participate in CET was provided; SZ = Schizophrenia; SA = Schizoaffective
disorder; Some college = Attended but did not complete college receiving a degree. Neurocognition = Measurement and Treatment
Research to Improve Cognition in Schizophrenia (MATRICS) overall composite t scores corrected for age and gender. Social
cognition = MATRICS social cognition composite t scores corrected for age and gender. Life Satisfaction = The World Health
Organization Quality of Life (WHOQL) composite mean scores across life domains of psychological health, social relationships, and
environment. Positive symptoms severity = total overall score of the Scale for the assessment of positive symptoms (SAPS).
Negative symptoms severity = total overall score of the Scale for the assessment of negative symptoms (SANS). N/A = Information
unavailable

Table 2 Perceived impact of CET

Theme Category Sub-category

Perceived impact Decreased negative symptoms of schizophrenia (1)

Decreased self-blame/guilt (1)
Improved social cognition (5)
Improved neurocognition (4) Focus/memory (3)
Thought organization (1)
Problem-solving (1)
Improved confidence and helped to attain recovery goals (8)
The number of participants who raised ideas related to each category and sub-category is shown in parentheses

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Table 3 Motivational facilitators for CET

Theme Category Sub-category

Motivational facilitators (extrinsic) Family support (2)

Cost (1)
Incentives (5) Monetary compensation (4)
Food (i.e. Pizza) (1)
Motivational facilitators (intrinsic) Desire to overcome cognitive symptoms
(2)
Motivational facilitators (program- Quality of program delivery (8) Positive relationship with coach (5)
level) Coach feedback reinforced learning (4)
Peer feedback reinforced learning (4)
Overall program content (7) Positively challenging (1)
Prompted a perception of improvement in
cognition (6)
Group session content (8) Relevant to recovery goals (5)
Socially engaging (4)
Fun and engaging (4)
Computerized session content (5) Fun and engaging (5)
The number of participants who raised ideas related to each category and sub-category is shown in parentheses

Table 4 Motivational barriers for CET

Theme Category Sub-category

Motivational barriers (intrinsic) Lack of intrinsic motivation (1)

No perceived instant payoff (1)
Motivational barriers (program-level) Issues with group content (5) Content heavy (binder) (2)
Disorganized binder (3)
Mundane or tiresome (3)
Issues with computerized session content (5) Content is too difficult to understand (4)
Purpose of training is unclear (3)
Mundane or tiresome (1)
The number of participants who raised ideas related to each category and sub-category is shown in parentheses

24.39, SD =2.74) (see Table 1). Participants identified Quantitative Results

as Caucasian (n = 4), Asian (n = 2), African Ameri-
can (n = 1) or other (n = 2) with an average duration Baseline Assessments
of illness of 4.13 years (SD =2.08). Participants
completed between 56 and 149 CET sessions and 4 Baseline scores for neurocognitive functioning,
out of nine participants were considered non-com- social-cognitive functioning, satisfaction across all
pleters of CET. Participants were considered com- domains of life, negative and positive symptom
pleters if they completed the entire 18-month protocol severity are reported in Table 1 for each participant.
of CET, based on data from the release termination
report and clinician report.

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Table 5 Suggestions to improve CET

Theme Category Sub-category

Suggestions for improvement Coaching (1) Increased guidance with recovery plan (1)
Group sessions (4) Breakdown/streamline binder content (4)
Computer sessions (3) Modernize exercises (2)
Lengthen training (1)
CET environment (2) Increase lighting/Increase room size (2)
CET purpose and design (6) Change binder content format (4)
Include more interactive activities and content (1)
Explain benefits and purpose of CET (3)
Explain structure of CET (3)
Involve participants in CET design (3)
The number of participants who raised ideas related to each category and sub-category is shown in parentheses

Perceived Neurocognitive Improvement Perceived Life Satisfaction

Figure 1 shows that most participants reported per- Most participants reported high satisfaction with their
ceived neurocognitive improvements post CET, espe- current work or school situation (5 out of 9 very
cially in the domains of attention (a good amount: 6 satisfied) as well as with their recovery (5 out of very
out of 9), problem-solving (a good amount: 6 out of 9), satisfied; see Fig. 2) following CET. However, most
as well as in the ability to act wisely in social situations (6 out of 9) reported having only being ‘‘a bit’’ satisfied
(a good amount: 6 out of 9) and self-understanding of with their current social life (see Fig. 2).
skills and setbacks (a good amount: 5 out of 9). Most
(6 out of 9) also indicated that CET improved their Self-Reported Experience of CET
ability to think clearly. In comparison, fewer partic-
ipants reported feeling that CET improved their As shown in Fig. 3, participants reported positive
memory (neutral: 4 out of 9) and organization (neutral: participatory experiences with individual coaching
4 out of 9). (5 out of 9 helped a lot; 6 out of 9 enjoyed a lot),
computer sessions (4 out of 9 helped a lot; 4 out of 9

Fig. 1 Participants’ perceived neurocognitive improvements following CET. Note: One response was missing for problem solving

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Fig. 2 Participants’ self-reported level of satisfaction with their life following CET

Fig. 3 Participants’ self-reported level of helpfulness and enjoyment of CET

enjoyed a lot), group lectures (5 out of 9 helped a lot; 5 Motivational Facilitators and Barriers to Cognitive
out of 9 enjoyed a lot) and group activities (5 out of 9 Enhancement Therapy
helped a lot; 4 out of 9 enjoyed a good amount).
Motivational facilitators are specified in Table 3.
Qualitative Results Participants reported that successful attendance of
CET was motivated by external factors such as family
Perceived Impact support. Some participants also appreciated that CET
was provided at no cost, whereas others were moti-
A summary of perceived impacts is identified in vated by compensation. Some participants were
Table 2. Participants reported that CET had positive intrinsically motivated to receive CET by their desire
impacts including (1) decreased negative symptoms, to relieve neurocognitive symptoms associated with
(2) improved neurocognitive skills like focus, mem- their condition, while others reported a lack of
ory, and problem solving, (3) improved social cogni- intrinsic motivation and instant payoff as a barrier to
tion, (4) increased self-confidence, and (5) enhanced pursuing CET.
ability to attain recovery goals.

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Feedback from peers and coaches emerged as an program could be beneficial to increasing motivation
important program-level motivator, and a positive and improving participants’ experience in future trials.
relationship with coaches reinforced motivation to
learn. Overall, participants indicated that CET was
positively challenging and that this motivated them to Discussion
participate, alongside perceived neurocognitive
improvement. Relevant content motivated them to Overall, findings from this quantitative and qualitative
actively engage in the group sessions. Similarly, some case series study indicate some improvements in
participants highlighted that computerized sessions neurocognition, negative symptom severity, and life
were ‘‘fun and engaging’’. satisfaction after CET. Participants also reported
Motivational barriers are shown in Table 4. overall positive levels of satisfaction with CET.
Regarding program-level motivational barriers, some Moreover, participants identified interrelated extrin-
participants noted that the group session curriculum sic, intrinsic, and program-specific facilitators and
was dense, and that binder content was disorganized. barriers to participating in CET, and they provided
Others noted that binders were difficult and cumber- valuable insight to improve future trials.
some to transport to group sessions which affected
their motivation to come to the sessions. Some Impact of CET
mentioned that activities and lectures during group
sessions were mundane and tiresome. Computerized Our quantitative and qualitative analyses revealed
content was also described as too difficult to under- perceived improvements in neurocognitive function-
stand and some participants noted that the purpose of ing following CET in most participants. During the
computerized neurocognitive training was unclear. focus groups and individual interview, 4 out of 9
participants identified improved neurocognition in
Suggestions for Improvement domains of focus and memory, thought organization
and problem-solving. Furthermore, most (6 out of 9)
A summary of suggestions for improvement from CET reported perceived neurocognitive improvements in
end users is presented in Table 5. Participants indi- domains of attention, problem-solving, their ability to
cated that having more help with their recovery plan act wisely in social situations, and their ability to think
via one-on-one coaching would be beneficial to clearly through the CET satisfaction questionnaire.
delineate and accomplish their recovery goals. All Fewer reported improvements in memory and organi-
participants suggested that the CET binder covered in zation (4 out of 9 through the CET satisfaction
group sessions could be broken down and streamlined questionnaire) and most but fewer (5 out of 9) reported
to improve the CET program content. They also improvements in self-understanding of skills and
recommended summarizing the binder content, adding setbacks). While, in most cognitive remediation
a table of contents, and providing access to it online. studies, cognitive outcomes are investigated with
Moreover, participants suggested that having more standardized assessment batteries only [52], addition-
interactive activities during the group sessions would ally recording participants’ accounts of their experi-
increase their motivation to participate in CET. ence with CET provided us with an important piece of
Modernization and lengthening of computerized evidence in support of its efficacy from the end user
training were also raised as suggestions to improve point of view.
CET. Specifically, participants noted that computer Our qualitative results also highlighted a subjective
graphics were outdated and that they would have liked relationship between treatment outcomes and feeling
more time to complete the exercises. Participants also of self-efficacy. Specifically, most participants
suggested that having a larger, well-lit room would reported that CET-induced improvements increased
improve the CET environment. Finally, many partic- their confidence and ability to attain personal recovery
ipants suggested that discussing the structure, content, goals. For example, participants noted that CET’s
and benefits of CET would motivate them to be more ‘‘positively challenging’’ environment helped them
engaged with the program. They particularly high- overcome defeatist beliefs and negative symptoms. In
lighted that being involved in the design of the turn, this fostered a greater sense of self-efficacy

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regarding their neurocognitive capacity and functional Motivational Facilitators to CET

improvement. Thus, consistent with prior schizophre-
nia research on cognitive remediation [17, 50] and Among extrinsic motivational facilitators, participants
CET specifically [20, 36], treatment effects extended highlighted external incentives such as monetary
beyond specific cognitive treatment targets to sec- compensation. Importantly, they also emphasized the
ondary recovery factors. These findings are in line importance of receiving social support and feedback
with previous reports of the efficacy of CET in from family, peers, and coaches. They reported that
schizophrenia for promoting self-esteem [33, 34], self- having a supportive family encouraged them to attend
competency, self-efficacy [20, 36], and negative and actively participate in treatment sessions. This is
symptoms [24]. Future research should examine the in line with extensive research on the benefits of
persistence of these secondary recovery factors after family support in mental health care [19]. For
treatment and clarify whether they concur with example, families can provide support in setting
improved neurocognitive and functional outcomes treatment and recovery goals, which can result in
[26]. more tailored interventions and better outcomes [19].
In line with previous studies [22, 26], most Social support has been shown to be critical for
participants reported high satisfaction with their work treatment outcomes among individuals with
and school situation, as well as with their recovery schizophrenia [51] and our study underlines that this
following CET. Nonetheless, most of them were only also applies to CET. Thus, an interesting possibility
‘‘a bit’’ satisfied with their social life. Accordingly, in for future research would be to combine CET with
other samples of individuals with schizophrenia, family interventions and measure their joint impact on
objective cognitive assessments have been found to functional recovery.
correlate poorly with self-reported functional recovery Participants also indicated peer feedback and peer
[3, 13, 38, 44]. Therefore, perceived social functioning support as key motivational facilitators. Peer support-
in everyday life is a treatment target that requires ers in therapy can draw upon their lived experiences to
further investigation [17, 52, 56]. The perceived empathize, share insights, serve as role models, impart
limited transfer of social-cognitive improvements into hope, and engage others in treatment activities [14].
real-life settings may reflect the limited ecological Beyond typical psychiatric rehabilitation groups, CET
validity of current cognitive remediation interventions includes partnered activities and small-group discus-
[8, 49]. More naturalistic approaches might improve sions [20], potentially creating an ideal environment
transfer of social-cognitive gains into daily life for peer support. In addition to being a motivator for
[29, 49]. treatment, performing neurocognitive training with a
peer has been associated with better neurocognitive
Participatory Experience and Satisfaction outcomes than when those exercises were performed
with CET alone [53], thus contributing to the overall efficacy of
CET.
Quantitative analyses of questionnaire data revealed Furthermore, participants emphasized the impor-
positive participatory experiences in terms of per- tance of receiving supportive, adaptive, and instruc-
ceived helpfulness and enjoyment. Clinical measures tive coaching, as noted in previous studies [17, 26, 50].
also revealed that life satisfaction improved following CET coaching involves collaborative completion of
CET. This is in line with previous studies where homework, goal-setting, encouragement, and support
individuals with schizophrenia also reported that with decision-making [26]. This type of therapeutic
cognitive remediation was helpful [48] and enjoyable relationship has been associated with greater neu-
[12, 17]. Believing that cognitive remediation can help rocognitive improvements relative to cognitive reme-
in achieving recovery goals has been shown to predict diation without human guidance [39] and has been
active engagement in treatment [11], a vital factor for shown to facilitate empowerment and recovery [47].
its success [18]. Similarly, satisfaction with cognitive One possible factor underlying the importance of
remediation therapy has been shown to predict its coaching is ongoing feedback on performance, which
efficacy [52]. may facilitate participants’ ability to detect improve-
ments [57]. Therefore, our results contribute to

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converging evidence that coaching is a valuable so that 80% or greater success rates are achieved,
component for CET’s acceptability. while maintaining challenge in support of cognitive
Lastly, participants indicated that they were moti- growth. In prior cognitive remediation studies, this
vated to participate in CET because it was positively approach has been shown to promote self-efficacy and
challenging, the group session content was relevant, motivation to initiate and complete learning tasks [16].
and the computerized sessions prompted a perception Finally, some participants noted that the content of the
of improvement in neurocognition. This is consistent group sessions was disorganized, lengthy, mundane,
with other cognitive remediation studies indicating and heavy, which undermined their motivation. As a
that mastering cognitively challenging exercises can countermeasure, they suggested breaking down and
be intrinsically rewarding [50]. Thus, our results streamlining binder content (e.g. converting it to
support previous evidence suggesting that intrinsic online format) and including more interactive and
motivation increases when learning tasks are salient engaging group activities. A summary of relevant
and success is experienced [55]. suggestions to build in motivators and to attenuate
motivational barriers to CET is highlighted in Table 6.
Motivational Barriers and Suggestions to Improve
CET
Limitations
Participants reported both intrinsic and extrinsic
motivational barriers to CET. As intrinsic motiva- This study involved a small sample of individuals with
tional barriers, they mentioned a lack of perceived early course schizophrenia. Hence, while our findings
improvement or ‘‘instant payoff’’ and confusion highlight important factors influencing perceived CET
surrounding the goal of CET. To improve their experience of these participants, they are limited in
experience, they suggested providing them with the their generalizability. Furthermore, our small sample
opportunity to learn about the scope of CET, as well as does not allow us to conduct comparative statistics,
to contribute to its design and implementation. Thus, nor draw inferences about causality or efficacy of
to promote intrinsic motivation and engagement, CET. Hence, qualitative research involving larger
future CET studies should involve people with samples and individuals with enduring symptoms of
schizophrenia in the development of the program. schizophrenia is needed to perform more comprehen-
This would facilitate personalization of the CET sive analyses of participants’ experiences with CET,
learning material in line with recovery goals [59], as and to be able to generalize our study findings. Our
well as contextualize the cognitive exercises in real- recruitment may also have suffered from selection bias
world situations relevant to the individual [55]. Then, and this should be considered while interpreting the
peer support and coaching could be planned more current findings, given that only a portion of a larger
often throughout the intervention to allow participants sample of participants receiving CET agreed to answer
to continuously monitor their improvements, as well questionnaires and participate in focus groups or an
as the adherence to their pre-established recovery interview. Our results might also be biased by these
goals. This finding also highlights the need for coaches differing methods of data collection. For instance,
to follow the CET training manual and ensure that participants may have been more willing to share their
participants are aware of CET benefits and goals. thoughts during an interview than a focus group due to
With respect to extrinsic motivational barriers, social pressure presented by their peers. In order to
some participants noted that content was too difficult minimize the risk of social desirability, besides
for them. Difficult content might represent a motiva- informing participants that their response would be
tional barrier because it limits the opportunities to completely confidential, interviews were conducted
demonstrate competency [16], potentially increasing by a neutral interviewer (S.G.) who had not provided
frustration [52]. As noted above, individuals with any intervention or assessment in the original clinical
schizophrenia benefit especially from interventions trial. Further, while participants were told that
that promote self-efficacy [16]. Thus, one approach to describing CET as ‘‘not at all’’ or a ‘‘a little’’ helpful
mitigate perceived difficulty could be to titrate the or enjoyable implied having a negative experience
complexity of CET exercises in a personalized fashion with CET, the CET satisfaction questionnaire could

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Table 6 Synthesis of recommendations for future CET studies and clinical services
Recommendations for future CET studies and similar clinical services Intended outcome

Implement ecological approaches focusing on participants’ community goals Improved transfer of social-cognitive gains into
daily life
Involve people with lived experience in the development of the program Personalization of the learning material in line with
recovery goals
Plan peer support and coaching more often throughout the intervention Adherence to pre-established recovery goals and
enhanced self-monitoring
Titrate the complexity of computerized exercises in a personalized fashion so Promotion of self-efficacy and motivation to initiate
that 80% or greater success rates are achieved, while maintaining challenge and complete learning tasks
in support of cognitive growth
Ensure coaches are following the training manual and that participants are Increased clarity regarding the goal of the
aware of the purpose and possible benefits of the intervention intervention and perception of improvement
Break down and streamline content related to the intervention (e.g. converting Promoted motivation to engage with and attend the
the CET binder to online format) and include more interactive and engaging intervention
group activities

have positively biased their ratings. Future studies of the manuscript, helped by AT and PP. LS, JW, and MSK also
regarding CET may benefit from scales that permit provided valuable expertise on cognitive enhancement therapy
throughout the study. All authors contributed to the writing and
participants to provide clearer negative ratings for its approval of the final manuscript.Funding This work was
components and allow for the triangulation of qual- funded by an operating Grant from NIMH MH 92440; MSK, PI,
itative findings and descriptive survey results. Impor- Clinicatrials.gov #NCT01561859). SG was supported by a
tantly, despite this limitation, focus group interviews postdoctoral training fellowship from the Fonds de recherche du
Québec – Santé and by an Emerging Research Innovators in
and the individual interview provided us with a Mental Health award.
nuanced understanding of participants’ perceived
experience of CET. Availability of Data and Material The datasets generated
during and/or analysed during the current study are available
from the corresponding author on reasonable request.

Conclusion Compliance with Ethical Standards

Overall, our quantitative and qualitative case series Conflict of interest The authors declare that they have no
study provides additional evidence that CET is an conflict of interest.
acceptable intervention that can lead to self-reported
improvements in cognition and functional recovery.
We also identified several motivational facilitators
that could be leveraged in future studies and factors References
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