Computer-assisted cognitive remediation (CACR) as a recovery-oriented intervention for schizophrenia: a randomized controlled trial

Abstract

Background

Recovery-oriented care focuses on empowering individuals with schizophrenia to live meaningful lives despite persistent challenges. Schizophrenia often involves cognitive impairments and reduced participation in purposeful activities, contributing to poor psychosocial outcomes. Although computer-assisted cognitive remediation (CACR) is a well-established method for improving cognitive function, its potential to enhance recovery-related outcomes remains underexplored.

Objectives

This study investigated the impact of CACR on personal recovery, psychological needs satisfaction, self-esteem, and occupational engagement in individuals with schizophrenia.

Methods

In a double-blind randomized controlled trial, 54 outpatients with schizophrenia were allocated to either CACR (n = 27) or an active control condition (n = 27). The CACR group completed 30 sessions of computerized cognitive training using four CANTAB tasks (visual attention, memory, and planning) under therapist supervision, incorporating feedback and meta-cognitive reflection. The control group participated in matched sessions of computerized leisure activities without cognitive training or therapist guidance. Outcomes included the Recovery Assessment Scale–Domains and Stages (RAS-DS), Engagement in Meaningful Activities Survey (EMAS), Basic Psychological Needs Satisfaction in General Scale (BPNSG-S), Rosenberg Self-Esteem Scale (RSES), and General Health Questionnaire-12 (GHQ-12), assessed at baseline, post-intervention, and 3-month follow-up.

Results

CACR group experienced significant improvements in personal recovery, autonomy, competence, self-esteem, and engagement in meaningful activities (all p < 0.05). Psychological well-being also improved at follow-up. However, no significant changes were observed in relatedness. The control group demonstrated only transient or non-significant fluctuations across outcomes.

Conclusions

These findings suggest that CACR can support key elements of recovery, offering a person-centered intervention beyond cognitive improvement. CACR may serve as a valuable adjunct to standard care in schizophrenia by promoting recovery-oriented outcomes such as autonomy, self-esteem, and meaningful activity engagement. However, the findings should be interpreted with caution given the relatively small sample size and short follow-up period. Future studies with larger and more diverse samples, and longer observation, are needed to confirm and extend these results.

Clinical trial number

The study was registered with www.irct.ir: IRCT20180317039116N2, on 2023/01/28. Prospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12888-025-07747-7.

Background

In recent decades, mental health care has undergone a paradigm shift from symptom-focused treatment toward recovery-oriented care. This approach emphasizes the individual’s right to pursue a meaningful, self-directed life, even while managing persistent symptoms of mental illness [1, 2]. Recovery is not merely the absence of psychosis but the presence of hope, empowerment, identity, autonomy, social connection, and participation in valued activities [3]. As such, recovery-oriented care prioritizes outcomes like self-agency, well-being, and functional engagement, often overlooked in traditional clinical models.

This shift is particularly important in the context of schizophrenia, a complex disorder characterized not only by positive symptoms (e.g., hallucinations, delusions) but also by negative symptoms and profound cognitive impairments [4]. While antipsychotic medications effectively manage acute psychotic symptoms, they have limited impact on long-term functioning and cognitive capacity [5]. Cognitive deficits particularly in attention, working memory, and executive functioning, are persistent and highly predictive of poor social, vocational, and daily life outcomes [6].

These cognitive impairments are not only persistent but also resistant to pharmacological intervention, prompting interest in non-medication-based strategies that align with recovery-oriented goals. One such approach is Computer-Assisted Cognitive Remediation (CACR) that uses interactive, computer-based exercises to improve cognitive domains through structured, repetitive practice [7]. A recent systematic review and meta-analyses confirms that cognitive remediation produces reliable improvements in cognition and functioning, with benefits moderated by treatment intensity and therapist involvement [8].

Contemporary consensus further emphasizes that effective cognitive remediation integrates therapist guidance, strategy coaching, and real-world transfer opportunities [9]. Nonetheless, ongoing debate continues regarding the distinct contribution of computerized formats and their capacity to engage motivation and learning mechanisms [10]. Beyond cognitive gains, CACR is increasingly recognized for its potential to promote psychosocial and recovery-oriented outcomes, including self-efficacy, and motivation [7].

Recent studies suggest that CACR, particularly when integrated with personalized goal setting and therapist support, may enhance motivation, self-efficacy, and engagement in psychosocial services [11, 12]. These outcomes align closely with Self-Determination Theory (SDT), which posits that human well-being depends on the fulfillment of three basic psychological needs: autonomy, competence, and relatedness [13]. For individuals living with schizophrenia, these needs are often unmet due to the compounded effects of stigma, social exclusion, and internalized self-doubt [14]. CACR may help address these challenges by creating structured opportunities for mastery and progress, thereby restoring a sense of agency and purpose.

As mental health systems increasingly adopt person-centered approaches [15], it is essential to assess how interventions like CACR can bridge the gap between cognitive enhancement and lived recovery. Instead of focusing on symptom or cognitive outcomes, the current study evaluates CACR’s impact using recovery-aligned tools, offering a more holistic perspective on intervention efficacy. Building on these perspectives, the present study explores the role of CACR as a recovery-oriented intervention. Specifically, it investigates whether CACR contributes to improvements in personal recovery, psychological need satisfaction, self-esteem, general well-being, and participation in meaningful daily activities. By situating CACR within a holistic model of psychiatric rehabilitation, this research moves beyond symptom-based outcomes to examine its potential to foster personal growth, engagement, and autonomy among individuals with schizophrenia.

Methods

This study received ethical approval from the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Approval Code: IR.USWR.REC.1401.199) and was registered with the Iranian Registry of Clinical Trials under registration number IRCT20180317039116N2. It employed a randomized, double-blind clinical trial design with equal group allocation (1:1), incorporating a pretest-posttest structure and a three-month follow-up period. The study adhered to the CONSORT reporting standards, and all procedures complied with the ethical principles outlined in the Declaration of Helsinki. Prior to participation, written informed consent was obtained from all individuals. The data were drawn from the same double-blind RCT described in Fathi Azar et al. (2025) study [16]. While that publication analyzed cognitive and usability outcomes, this study presents a secondary analysis focused on recovery, psychological needs, and meaningful activity engagement. Data were collected concurrently but not reported in the earlier publication.

Design and participants

Participants were selected from three outpatient departments of psychiatric hospitals in Tehran, using random sampling methods. Eligibility criteria included: (1) age between 18 and 60 years; (2) a clinical diagnosis of schizophrenia according to DSM-IV criteria, confirmed by a psychiatrist; (3) a Mini-Mental State Examination (MMSE) score above 18 to ensure adequate cognitive functioning; and (4) provision of written informed consent. Exclusion criteria included: (1) recent changes in medication regimen (within one month before or during the study); (2) chronic neurological conditions such as Epilepsy, Parkinson’s disease, or Alzheimer’s disease; (3) upper limb musculoskeletal impairments; and (4) below-average intellectual functioning, defined as a documented diagnosis of intellectual disability in the participant’s clinical record.

A priori power analysis was conducted using G*Power (3.1.9.7) for a two-tailed independent samples t-test, with a significance level of α = 0.05, power (1–β) = 0.80, and a moderate effect size (Cohen’s d = 0.5). A moderate effect size was selected because this value is commonly used as a conventional benchmark in behavioral and clinical research when prior evidence does not indicate very small or very large effects. Specifically, Cohen (2013) defines d = 0.5 as a “medium” effect representing a meaningful difference detectable in applied psychological and clinical settings [17]. In addition, previous systematic reviews of cognitive and behavioral outcomes in schizophrenia populations have reported small-to-moderate effects, supporting the rationale for assuming a moderate effect size [8, 18]. The power analysis indicated a required sample size of 64 participants (32 per group). Due to recruitment, financial, and logistical constraints, the final sample comprised 54 participants (27 per group), which still provides adequate power for detecting moderate-to-large effects [17, 19].

Participants meeting the inclusion criteria were randomly assigned to either the CACR group or the control group using a computer-generated randomization sequence (Random.org; [20]). Allocation was concealed using sealed, opaque envelopes prepared by an independent researcher not involved in data collection or intervention delivery. Both participants and outcome assessors were blinded to group assignments throughout the study to reduce bias.

Intervention

Participants in the intervention group received a structured cognitive training program using the Cambridge Neuropsychological Test Automated Battery (CANTAB) software. The training was delivered in clinical outpatient settings across three psychiatric hospitals in Tehran. Sessions were administered by trained therapists with backgrounds in psychology or occupational therapy. The intervention consisted of 30 individualized sessions over 10 weeks, with three sessions per week. Each session lasted approximately 80 min, including two 30-minute training blocks separated by a 20-minute break.

Cognitive remediation was delivered through the Computer-Assisted Cognitive Remediation (CACR) program using the CANTAB platform, which provided four adaptive subtests targeting distinct cognitive domains: Match to Sample Visual Search (visual attention and scanning), One Touch Stockings of Cambridge (planning and problem-solving), Pattern Recognition Memory (visual memory), and Delayed Matching to Sample (short-term recognition memory). The tasks were administered in a fixed sequence within each session, and for equal duration per session. The only adaptive component was the automated adjustment of task difficulty based on individual performance to maintain an optimal challenge level and promote engagement, consistent across both groups.

Each session was conducted individually under the supervision of trained clinical psychologists or occupational therapists who were present throughout. Their role extended beyond technical oversight to include motivation, clarification of task instructions, observation of engagement, and immediate performance feedback. Therapists encouraged participants to reflect on strategies that improved task performance, fostering awareness of cognitive processes and promoting the application of these strategies to daily activities, thereby supporting meta-cognitive development and functional generalization. This structure positioned CACR as a therapist-assisted intervention delivered through a computerized platform, consistent with established cognitive remediation frameworks [9, 21]. The same protocol has previously demonstrated efficacy in improving cognitive skills in individuals with schizophrenia [16]. Building on evidence that cognitive remediation can support psychological and functional recovery through mechanisms of cognitive enhancement, motivation, and self-efficacy [7, 9, 21], the current study focused on evaluating its downstream recovery-related outcomes. Analyses of the relationships among cognitive and psychosocial changes observed in this study will be reported in a separate publication using the current dataset. Participants assigned to the control group attended the same number of sessions (30 over 10 weeks), on the same schedule, and in the same clinical settings as the intervention group. Sessions were led by the same therapists to control for therapeutic contact time and setting. The control activities consisted of low-cognitive-demand computer games and leisure-based digital tasks, including: A simple naming game, Adult digital coloring tasks, and Chance-based games (e.g., virtual dice rolls). These activities were selected to control for participant engagement, screen exposure, and therapist interaction, while avoiding targeted cognitive stimulation. In the control group, no performance feedback or instruction was given, apart from general encouragement to complete the tasks.

All participants continued to receive standard psychiatric care, including antipsychotic medication, occupational therapy, and psychological support, in accordance with Iran’s public mental health care protocols. Both groups were required to attend at least 80% of the scheduled sessions to be included in final analyses. Outcome assessments were conducted at three time points: before intervention (T0), after intervention (T1), and at three-month follow-up (T2). Participants received a small financial reimbursement for each completed assessment and intervention session to acknowledge their time and contribution.

Outcome measures

In alignment with the principles of personal recovery, which emphasize meaning, autonomy, self-worth, and well-being beyond symptom reduction [2], this study utilized outcome measures that capture both functional engagement and subjective experience of recovery. All assessment tools used were either validated in Persian or culturally adapted and translated accordingly. Questionnaires were administered in paper format, and results for individual subscales are presented where relevant.

Outcomes included recovery-related constructs and engagement in meaningful daily activities. All participants completed the Persian version of the Engagement in Meaningful Activities Survey (EMAS) [22], the Persian Recovery Assessment Scale – Domains and Stages (P- RAS-DS) [23, 24], the Basic Needs Satisfaction in General Scale (BPNSG-S) [25], the General Health Questionnaire (GHQ-12) [26], and the Rosenberg Self-Esteem Scale (RSES) [27].

EMAS reflects the “meaning” and “empowerment” dimensions of recovery. It measures perceived engagement in meaningful daily occupations through 12 items focused on value, enjoyment, and personal relevance [22]. The RAS-DS is a self-report questionnaire designed to measure personal recovery in individuals with mental illness. It consists of 38 items, each rated on a 4-point Likert scale, yielding a total score range of 38 to 152 [23]. The RAS-DS aligns with multiple domains of recovery model such as “connectedness”, “hope”, “identity”, “meaning”, and “empowerment”. The RAS-DS has been culturally adapted and psychometrically validated in Persian, showing excellent internal consistency (α = 0.940) and test–retest reliability (ICC = 0.941), and can be used in Iranian society [24].

The BNSG-S assesses autonomy, competence, and relatedness that are all central to recovery. It aligns with the “empowerment” and “connectedness” domains of recovery, and has 21-item that evaluates the satisfaction of basic psychological needs [25]. Higher scores in both EMAS, RAS-DS, and BNSG-S indicate higher levels of engagement, recovery, and satisfaction of needs.

The GHQ-12 is used to assess current mental well-being by evaluating whether the respondent has recently experienced certain symptoms or behaviors [26]. The RSES is a widely used instrument for assessing global self-worth by measuring both positive and negative feelings about the self. Self-esteem is closely linked to the “identity” domain in recovery. The scale consists of 10 items [27]. Both GHQ-12 and RSES are rated on a 4-point Likert scale. Lower scores on the GHQ-12 and higher scores on RSES reflect better mental health and higher self-esteem.

Statistical analysis

All statistical analyses were conducted using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize the data, with continuous variables presented as means ± standard deviations (SD) and categorical variables as frequencies and percentages. The normality of continuous variables was assessed using the Shapiro–Wilk test. Baseline comparisons between groups were performed using independent samples t-tests for normally distributed variables and Mann–Whitney U tests for non-normally distributed variables. Categorical variables were compared using chi-square test.

To assess both within-group changes over time and between-group differences across the three time points (pretest, posttest, and 3-month follow-up), repeated-measures ANOVA was used for normally distributed outcomes, and Generalized Estimating Equations (GEE) were used for non-normally distributed outcomes. Post hoc comparisons were conducted with Bonferroni correction where applicable. All statistical tests were two-tailed, and a p-value < 0.05 was considered statistically significant.

Results

Baseline characteristics

Participant recruitment was conducted between October 2022 and November 2023. There were no significant differences between the CACR and control groups in demographic or baseline clinical variables, including age, sex, duration of illness, MMSE scores, or PANSS subscales. The mean age was 41.78 years in the CACR group and 40.67 years in the control group. Females made up 40.7% and 37% of the CACR and control groups, respectively. The average duration of illness was approximately 4.6 years in both groups. Most participants had education below diploma level and were either single or divorced. Full baseline characteristics are available in Supplementary Table 1. Moreover, the CONSORT flow diagram is presented in supplementary Fig. 1. These characteristics have been previously reported in an earlier publication [16] using the same trial sample and are included here to support interpretation of the current findings. There were no dropouts in either the intervention or control groups, and all participants completed assessments at baseline, post-intervention, and follow-up.

Main outcomes

Engagement in meaningful activities (EMAS)

Repeated-measures ANOVA revealed a significant main effect of time (F (2, 104) = 63.17, p < 0.001, η² = 0.548) and a time × group interaction (F (2, 104) = 5.80, p = 0.004, η² = 0.100), indicating greater improvement in the CACR group. While both groups improved post-intervention, gains were more pronounced in the CACR group (T1: M = 40.29) than controls (T1: M = 38.33). Scores declined slightly at follow-up in both groups, but remained above baseline, especially in the CACR group. There was no significant main effect of group overall (p = 0.375) (Tables 1 and 2).

Table 1.

Results of Mixed-Design ANOVA for EMAS and BPNSG-S

Variable	Source	Type III SS	df	Mean Square	F	p	Partial η²
EMAS	Time	588.000	2	294.000	63.17	< 0.001	0.548
	Time × Group	53.975	2	26.988	5.80	0.004	0.100
	Group	5.191	1	5.191	0.80	0.375	0.015
Autonomy*	Time	10.253	1.39	7.401	31.97	< 0.001	0.381
	Time × Group	1.901	1.39	1.372	5.93	0.010	0.102
	Group	3.348	1	3.348	8.45	0.005	0.140
Competence	Time	4.074	2	2.037	14.24	< 0.001	0.215
	Time × Group	1.095	2	0.548	3.83	0.025	0.069
	Group	1.529	1	1.529	6.67	0.013	0.114
Relatedness	Time	0.465	2	0.233	0.76	0.468	0.014
	Time × Group	0.254	2	0.127	0.42	0.660	0.008
	Group	0.144	1	0.144	0.30	0.584	0.006

ANOVA: Analysis of variance; EMAS: Engagement in meaningful activities scale; BPNSG-S: Basic needs satisfaction in general scale

* Greenhouse-Geisser correction was applied due to violation of the sphericity assumption

Table 2.

Pairwise comparisons between time points for EMAS and BPNSG-S (Autonomy and Competence)

Variable	Time Comparison	Mean Difference	Standard Error	p-value	95% CI
EMAS	Before vs. After	-4.333	0.445	< 0.001	-5.434, -3.233
	Before vs. Follow- up	-0.667	0.360	0.210	-1.558, 0.224
	After vs. Follow- up	3.667	0.435	< 0.001	2.590, 4.743
Autonomy	Before vs. After	-0.559	0.088	< 0.001	-0.776, -0.343
	Before vs. Follow- up	-0.504	0.090	< 0.001	-0.727, -0.280
	After vs. Follow- up	0.056	0.045	0.648	-0.055, 0.166
Competence	Before vs. After	-0.385	0.065	0.001	-0.547, -0.223
	Before vs. Follow- up	-0.146	0.076	0.176	-0.334, 0.041
	After vs. Follow- up	0.238	0.077	0.009	0.049, 0.428

EMAS: Engagement in meaningful activities scale; BPNSG-S: Basic needs satisfaction in general scale

Basic needs satisfaction in general scale (BPNSG-S)

Autonomy showed significant effects of time (F (2, 104) = 31.97, p < 0.001), group (F (1, 52) = 8.45, p = 0.005), and interaction (F (2, 104) = 5.93, p = 0.004), with CACR participants reporting stronger and more sustained improvements. Competence also improved over time (F (2, 104) = 14.24, p < 0.001), with significant group (p = 0.013) and interaction effects (p = 0.025). Gains were larger in the CACR group and partially maintained at follow-up. Relatedness showed no significant effects for time, group, or interaction (all p > 0.46), suggesting no notable changes in this domain (Tables 1 and 2). Group means over time for EMAS and BPNSG-S are shown in 3 Table 3.

Table 3.

Group means over time for EMAS and BPNSG-S

Variable	Time	Intervention Mean (SD)	Intervention 95% CI	Control Mean (SD)	Control 95% CI
EMAS	T0	34.630 (0.506)	33.911, 35.349	35.333 (0.506)	34.614, 36.052
	T1	40.296 (0.735)	39.253, 41.340	38.333 (0.735)	37.290, 39.377
	T2	35.556 (0.611)	34.689, 36.422	35.741 (0.611)	34.874, 36.607
Autonomy	T0	3.399 (0.150)	3.187, 3.610	3.405 (0.150)	3.193, 3.617
	T1	4.141 (0.127)	3.961, 4.321	3.781 (0.127)	3.602, 3.961
	T2	4.160 (0.122)	3.987, 4.333	3.650 (0.122)	3.478, 3.823
Competence	T0	3.213 (0.091)	3.084, 3.343	3.229 (0.091)	3.100, 3.358
	T1	3.799 (0.122)	3.626, 3.972]	3.413 (0.122)	3.240, 3.587
	T2	3.474 (0.123)	3.301, 3.648	3.261 (0.123)	3.087, 3.435
Relatedness	T0	3.772 (0.137)	3.577, 3.967]	3.629 (0.137)	3.434, 3.824
	T1	3.571 (0.170)	3.331, 3.812	3.618 (0.170)	3.378, 3.859
	T2	3.621 (0.181)	3.366, 3.877	3.539 (0.181)	3.283, 3.795

Recovery assessment scale- domains and stages (RAS-DS)

A generalized estimating equations analysis was conducted to examine the effects of group (intervention vs. control), time (pre, post, follow-up), and their interaction. The results indicated a significant main effect of time (χ² (2) = 11.55, p = 0.003), and a significant group × time interaction (χ² (2) = 6.26, p = 0.044). The main effect of group approached significance (χ² (1) = 3.67, p = 0.055).

Pairwise comparisons revealed that the intervention group improved significantly from pre- to post-intervention (p = 0.005). This improvement was partially maintained at follow-up, though the difference between T0 and T2 scores did not reach significance (p = 0.095). A significant between group difference was observed at post-intervention (p = 0.030), favoring the intervention group. However, this difference was not significant at follow-up (p = 0.295), suggesting a potential convergence of scores between groups over time (Table 4). Figure 1 presents the estimated marginal means over time for all variables.

Table 4.

The result of GEE model analysis and effect sizes

Variable		Time	Groups, Mean (SD)			GEE (time × group interaction)			Effect sizes
			Intervention (N = 27)		Control (N = 27)	Df	Wald Chi-Square	P-Value
RAS-DS		T0	129.48 (2.09)	125.81 (2.02)		2	6.256	0.044
		T1	134.19 (1.79)	127.11 (2.14)					0.69
		T2	132.22 (1.85)	127.30 (2.14)					0.47
GHQ-12		T0	18.59 (0.32)	19.11 (0.33)		2	4.187	0.123
		T1	18.48 (0.50)	18.89 (0.31)					0.66
		T2	17.33 (0.26)	18.89 (0.28)					0.45
RSES		T0	20.48 (0.25)	20.26 (0.27)		2	6.487	0.039
		T1	22.78 (0.26)	21.30 (0.20)					0.94
		T2	20.70 (0.27)	20.41 (0.23)					0.43

RAS-DS: Recovery assessment scale-domains and stages; GHQ-12: General health questionnaire; RSES: Rosenberg’s self-esteem scale

Fig. 1.

Adjusted average scores over time

General mental health (GHQ-12)

GEE revealed significant effects for group (χ² (1) = 8.09, p = 0.004) and time (χ² (2) = 6.09, p = 0.048), though the interaction was not significant (p = 0.123). No group differences emerged at baseline or post-intervention, but the CACR group reported significantly better mental health at follow-up (p = 0.001), indicating delayed emotional benefits.

Rosenberg self-esteem scale (RSES)

Aa presented in Table 4, GEE results for self-esteem showed significant main effects of group (χ² (1) = 10.88, p = 0.001) and time (χ² (2) = 43.04, p < 0.001), as well as a significant time × group interaction (χ² (2) = 6.48, p = 0.039). At baseline (T0), self-esteem scores were comparable between groups. Post hoc comparisons revealed that the intervention group showed a significant increase from baseline to post-intervention (T1) and maintained these gains at follow-up (T2). At T2, the intervention group had significantly higher self-esteem scores compared to the control group (p < 0.001), with a moderate effect size. These findings indicate that the CACR intervention contributed to sustained improvements in self-esteem over time.

A summary figure (Fig. 2) illustrates the effect sizes and p-values across all outcome measures, providing a concise overview of the magnitude and significance of intervention effects.

Fig. 2.

Summary of outcomes across measures at T1

Discussion

This randomized trial provides additional evidence that computer-assisted cognitive remediation (CACR) can contribute to recovery-oriented change in schizophrenia. The concept of recovery extends beyond symptom reduction or cognitive improvement to encompass broader psychological, social, and functional dimensions, including hope, identity, autonomy, competence, and participation in meaningful activities [1, 2, 28]. Framing the findings within this perspective, the present results indicate that CACR fostered gains across several interconnected aspects of recovery such as personal empowerment, satisfaction of psychological needs, and engagement in valued occupations.

Recent advances in cognitive remediation research have shifted the field from a narrow focus on cognitive outcomes toward a more integrated understanding of recovery-oriented processes. While cognitive enhancement remains an important therapeutic target, emerging studies emphasize that recovery also involves subjective and relational experiences of agency, motivation, and self-efficacy [8, 9]. Participants experienced notable gains in autonomy, competence, and self-esteem, alongside stronger involvement in meaningful activities. These changes suggest that CACR may serve as a pathway for restoring a sense of capability and purpose rather than simply improving cognitive performance.

Improvements in personal recovery, engagement, and self-esteem likely reflected both the adaptive task design and the therapist’s facilitative role. Individualized difficulty provided achievable challenges, while therapists offered feedback, encouragement, and strategy coaching to sustain motivation and reinforce competence. These interactions helped participants internalize success as personal mastery, consistent with self-determination theory [29]. Thus, the observed psychological gains were likely shaped not only by cognitive enhancement but also by the therapeutic process that supported confidence, agency, and intrinsic motivation [9, 30].

The therapeutic context of the CACR intervention extended beyond computerized training. Each session was therapist-facilitated, providing encouragement, clarification, and feedback to sustain motivation. This supportive structure fostered collaboration, positive reinforcement, and individualized pacing, key elements that distinguish CACR from simple “brain training”. The therapist’s active role, opportunities for reflection, and shared goals likely contributed to improvements in recovery-related outcomes, aligning with Wykes et al. (2024), who view cognitive remediation as a relational and goal-oriented intervention rather than a purely neurocognitive exercise [31].

Consistent with the consensus definition of cognitive remediation (Bowie et al., 2020), the CACR program incorporated therapist involvement and meta-cognitive strategy development to promote real-world transfer [9]. However, it lacked structured transfer elements such as role-plays or integration within a broader rehabilitation program. Embedding CACR within multidisciplinary frameworks may enhance functional generalization and sustain gains.

Participants who received CACR demonstrated significant improvements in personal recovery, engagement in meaningful activities, perceived autonomy and competence, and self-esteem. As they progressed through the cognitive exercises, they likely gained a sense of accomplishment and confidence, which contributed to greater personal empowerment. These findings align with growing literature suggesting that, beyond improving neurocognition, CACR can foster empowerment and personal agency, which are key drivers of psychological recovery and, in turn, contribute to enhanced well-being [7–9]. Our results extend these outcomes to encompass core personal recovery domains (Connectedness, Hope, Identity, Meaning, and Empowerment (CHIME)) that are central to recovery-oriented frameworks [1]. This positions CACR not merely as a cognitive intervention, but as a catalyst for meaningful psychological change aligned with the principles of recovery-oriented mental health care.

The significant improvements observed in both P-RAS-DS and EMAS scores underscore the multifaceted impact of CACR on personal recovery and engagement in meaningful activities among individuals with schizophrenia. However, the non-significant difference in P-RAS-DS scores at follow-up suggests that these recovery gains may diminish over time without continued intervention or support. This study uniquely demonstrates enhancements in meaningful activity engagement, a construct distinct from general daily functioning [22]. While many cognitive remediation studies report improvements in everyday performance or functional capacity, our use of the EMAS allowed us to assess how participants experience value, purpose, and satisfaction in their daily occupations. This focus on the subjective sense of meaning reflects an important dimension of recovery that extends beyond observable functioning.

In line with this, recent evidence highlights that cognitive remediation and improvements in specific cognitive skills, such as visual learning, are closely associated with progress toward personally valued goals [32–34].

Doroud et al. (2021) explored how everyday activities support recovery among people with mental illness, emphasizing that recovery unfolds through engagement in meaningful, self-directed occupations that foster momentum, identity, and self-worth [35]. In the present study, CACR led to improvements in both engagement in meaningful activities and personal recovery, suggesting that cognitive remediation may indirectly facilitate recovery by enhancing individuals’ capacity and motivation for occupational participation.

Taken together, these findings suggest that CACR could serve as a cornerstone for fostering broader recovery processes, operating directly through psychological empowerment and indirectly through increased engagement in meaningful activities. The observed improvements in EMAS and P-RAS-DS are unlikely to stem from cognitive enhancement alone. Rather, they may reflect a process through which participants internalized their success during CACR sessions, developing a more capable self-concept and belief in their ability to lead meaningful lives, an outcome that aligns closely with the core principles of the CHIME model [2].

Improvements in autonomy and competence, as assessed by the BPNSG-S, provide additional insight into CACR’s recovery potential. Participants in the intervention group reported significant and sustained improvements in autonomy that is a critical ingredient in fostering self-determination and perceived control. Competence also improved, though slightly declined by follow-up, suggesting that while CACR may boost initial confidence, maintaining perceived efficacy might require ongoing reinforcement or real-world application. Both findings are consistent with Self-Determination Theory, which posits that autonomy and competence are foundational for intrinsic motivation and personal growth [13, 25]. These results support the idea that CACR fosters not just skill acquisition, but also a subjective sense of progress, mastery, and self-direction.

In contrast, no significant changes were observed in relatedness. This may reflect the largely individual nature of the intervention, which offered limited opportunities for interpersonal interaction or social connection. Prior research has suggested that relatedness may be more sensitive to group-based interventions [36] or those explicitly designed to enhance social cognition [37]. Group-based CACR delivery models, collaborative problem-solving formats, or integrated peer-support components could be explored in future iterations to better target this need. Addressing relatedness is especially important for individuals with schizophrenia, for whom social isolation and interpersonal disconnection often represent significant barriers to recovery [37].

The results of this study highlight CACR’s potential to improve self-esteem over time. Self-esteem showed a marked and lasting improvement following the intervention and at follow-up. These gains are consistent with prior research indicating that participation in cognitively challenging, goal-oriented tasks can enhance self-worth and a sense of agency [11, 12]. The structured, feedback-driven nature of CACR likely provided participants with clear experiences of success, reinforcing personal competence and a more positive self-concept. The results of the present study differ from an earlier cognitive remediation trial that reported non-significant changes in self-esteem, depression, and quality of life despite improvements in social and occupational functioning [38].

Possible explanations for the stronger self-esteem outcomes in the current study include the structured, performance-contingent design of the CANTAB platform, which maintained optimal cognitive challenge and provided participants with a sense of progress, and the therapist’s active facilitation, including motivational support, clarification of strategies, and guided reflection that enhanced participants’ sense of competence and autonomy. These combined factors may have contributed to the sustained improvement in self-esteem observed here.

The superior improvements observed in autonomy, competence, and self-esteem among participants receiving CACR, compared with the control group, likely reflect the therapeutic mechanisms inherent to structured cognitive remediation. Unlike general computer games, which primarily offer entertainment and transient engagement, CACR tasks are explicitly designed to challenge specific cognitive domains while reinforcing mastery through structured feedback and therapist support. While both conditions involved computerized activities, only CACR provided targeted cognitive challenges, adaptive feedback, and therapist-facilitated strategy reflection, elements known to promote mastery and intrinsic motivation [9, 10]. In contrast, the control activities, although engaging, lacked cognitive progression and did not explicitly foster meta-cognitive awareness or goal-related reinforcement. This difference aligns with evidence that cognitive remediation produces functional and psychological benefits when embedded in a learning framework emphasizing feedback, guided problem-solving, and opportunities for success [7, 8]. Collectively, these factors likely explain why self-esteem, competence, and autonomy increased to a greater extent in the CACR group than in the control condition.

In terms of general mental health, significant improvements were observed only at the 3-month follow-up, suggesting that the emotional benefits of CACR may emerge over time as individuals begin to apply enhanced cognitive and motivational capacities to real-life challenges. This delayed trajectory can be explained by the time required for cognitive gains to translate into meaningful psychosocial outcomes. As individuals gain confidence in their cognitive abilities, they may gradually re-engage with daily activities, social roles, and goal-directed behavior, which in turn fosters improved emotional well-being [39].

Strengths and limitations

Key strengths include the randomized, double-blind design, active control, and validated recovery-aligned measures. The small sample size may have limited power to detect some effects, particularly relatedness and general health. The absence of goal-specific measures restricts understanding of how cognitive gains translate into personally meaningful outcomes. Future studies should include longer follow-ups, goal-centered tools such as the Canadian Occupational Performance Measure (COPM), and mixed-methods designs to capture lived experience. Furthermore, it should be noted that participants were financially compensated for completing intervention sessions, which may have influenced treatment adherence and self-reported motivation. This represents a potential confounding factor when interpreting the observed outcomes.

Finally, although the CACR program included therapist-guided reflection, it lacked structured components to facilitate the generalization of cognitive gains to everyday contexts, such as goal-setting discussions or social-cognition exercises. The lack of explicit transfer components may have hindered the carryover of cognitive improvements to daily functioning, consistent with Bowie et al. (2020) [9].

Conclusion

Overall, this study supports CACR as a recovery-oriented intervention that enhances personal recovery, self-esteem, psychological needs satisfaction, and engagement in meaningful activities among individuals with schizophrenia. These findings expand understanding of CACR’s benefits beyond cognitive improvement, highlighting its capacity to strengthen the psychosocial dimensions essential to well-being. Integrating CACR into multidisciplinary rehabilitation programs may advance client-centered care by promoting autonomy, purpose, and personal growth.

Although the study was conducted with a relatively stable outpatient sample, this limits the generalizability of the findings to individuals in acute phases. The results underscore CACR’s potential as a valuable complement to medication and psychosocial interventions. The delayed but sustained improvements suggest that continued engagement is critical and that CACR is most effective when embedded within comprehensive, recovery-focused care. As a structured, goal-oriented approach, CACR can empower individuals, reinforce therapeutic outcomes, and foster meaningful functional gains.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

CACR

Computer-Assisted Cognitive Remediation

CR

Cognitive Remediation

RCT

Randomized Controlled Trial

CONSORT

Consolidated Standards of Reporting Trials

RAS-DS

The Recovery Assessment Scale-Domains and Stages

EMAS

Meaningful Activities Survey

BPNSG-S

Basic Psychological Needs Satisfaction in General Scale

GHQ-12

General Health Questionnaire-12

RSES

Rosenberg Self-Esteem Scale

MMSE

Mini-Mental State Examination

CANTAB

Cambridge Neuropsychological Test Automated Battery

SDT

Self-Determination Theory

CHIME

Connectedness, Hope, Identity, Meaning, Empowerment (recovery model framework)

COPM

Canadian Occupational Performance Measure

Author contributions

E.F: Conceptualization, Methodology, Writing – Original Draft, Project Administration. S.O.B: Conceptualization, Writing– Original Draft, Writing – Review & Editing. S.M: Visualization, Writing – Review & Editing. H.M: Methodology, Writing – Review & Editing, Supervision and funding acquisition HA.H: Resources, Writing – Review & Editing.

Funding

This study was supported by a grant from University of Social Welfare and Rehabilitation Sciences for the research expenses.

Data availability

Data are available upon reasonable request from first author/ corresponding author.

Declarations

Ethics approval and consent to participate

The study was approved by the ethics committee of the University of Social Welfare and Rehabilitation Sciences (ethics’ code IR.USWR.REC.1401.199). Each participant was informed of the purpose and requirement of the study. Consent was obtained as written approval on the ethical informed consent form. The procedures used in this study adhere to the tenets of the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.