Peer-Mediated Cognitive Enrichment in First-Episode Psychosis: A Pilot Feasibility Study Using the Feuerstein Approach

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Data may be preliminary. 17 October 2025 V1 Latest version Share on Peer-Mediated Cognitive Enrichment in First-Episode Psychosis: A Pilot Feasibility Study Using the Feuerstein Approach Authors : Ana Olivia Fonseca 0000-0002-0104-9485 [email protected] , July Silveira Gomes , Maria Eva de Miranda Alves Rodrigues , Ary Gadelha , and Cristiano Noto 0000-0002-2706-9118 Authors Info & Affiliations https://doi.org/10.22541/au.176072409.93151942/v1 244 views 128 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background : Translating cognitive remediation gains into everyday functioning remains limited in schizophrenia. We evaluated a peer-mediated Feuerstein Instrumental Enrichment (FIE) approach, grounded in mediated learning principles, in individuals in the early phase of illness. The FIE approach utilizes small-group sessions, mediator oversight, and explicitly guided transfer strategies to promote metacognitive reflection and strengthen real-world generalization. Objective : This pilot study aimed to assess the feasibility and acceptability of a peer-mediated FIE program in first-episode psychosis (FEP) and to generate preliminary signals of its effect on patient-centered functional outcomes. Methods : In this open-label, single-arm pilot study, 16 individuals with FEP participated in a 10-week, group-based FIE program. Outcomes were assessed at baseline (T0), post-intervention (T1), and 6-month follow-up (T2). The primary outcome was patient-centered functioning, measured by the Goal Attainment Scale (GAS). Secondary outcomes included cognitive domains (MCCB) and symptom severity (PANSS). Change over time were analyzed using the non-parametric Friedman test. Results : The intervention demonstrated excellent feasibility, with 100% participant retention. Significant and sustained improvements were observed in patient-defined functional goals (GAS; χ2(2)=24.43, p<.001). Additionally, preliminary cognitive gains emerged in Processing Speed, as measured by the Coding subtest (χ2(2)=10.47, p<.005), and in Verbal Working Memory, assessed by the Letter–Number Span (χ2(2)=10.34, p<.006), suggesting domain-specific enhancement of cognitive efficiency and working memory manipulation. Furthermore, significant reductions were noted in positive, general, and total PANSS scores, while negative symptoms remained stable. Conclusions : Peer-mediated FIE is a highly feasible and acceptable intervention for individuals with FEP. The promising preliminary signals on patient-centered functioning and specific cognitive domains strongly support the need for a large-scale randomized controlled trial with an active control group to definitively establish efficacy. Peer-Mediated Cognitive Enrichment in First-Episode Psychosis: A Pilot Feasibility Study Using the Feuerstein Approach Ana Olivia Fonseca1, MSc; July Silveira Gomes1,2, PhD; Maria Eva de Miranda Alves Rodrigues1, BSc; Ary Gadelha1, PhD; Cristiano Noto1, PhD ¹Early Intervention in Psychosis Program (GAP), Schizophrenia Program, and Clinical Neuroscience Lab, Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil. ²Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil. Corresponding Author: Ana Olivia Fonseca, MSc Rua Major Maragliano, 241 CEP: 04017-030 São Paulo, SP, Brazil Email: [email protected] ABSTRACT Background : Translating cognitive remediation gains into everyday functioning remains limited in schizophrenia. We evaluated a peer-mediated Feuerstein Instrumental Enrichment (FIE) approach, grounded in mediated learning principles, in individuals in the early phase of illness. The FIE approach utilizes small-group sessions, mediator oversight, and explicitly guided transfer strategies to promote metacognitive reflection and strengthen real-world generalization. Objective : This pilot study aimed to assess the feasibility and acceptability of a peer-mediated FIE program in first-episode psychosis (FEP) and to generate preliminary signals of its effect on patient-centered functional outcomes. Methods : In this open-label, single-arm pilot study, 16 individuals with FEP participated in a 10-week, group-based FIE program. Outcomes were assessed at baseline (T0), post-intervention (T1), and 6-month follow-up (T2). The primary outcome was patient-centered functioning, measured by the Goal Attainment Scale (GAS). Secondary outcomes included cognitive domains (MCCB) and symptom severity (PANSS). Change over time were analyzed using the non-parametric Friedman test. Results : The intervention demonstrated excellent feasibility, with 100% participant retention. Significant and sustained improvements were observed in patient-defined functional goals (GAS; χ2(2)=24.43, p<.001). Additionally, preliminary cognitive gains emerged in Processing Speed, as measured by the Coding subtest (χ2(2)=10.47, p<.005), and in Verbal Working Memory, assessed by the Letter–Number Span (χ2(2)=10.34, p<.006), suggesting domain-specific enhancement of cognitive efficiency and working memory manipulation. Furthermore, significant reductions were noted in positive, general, and total PANSS scores, while negative symptoms remained stable. Conclusions : Peer-mediated FIE is a highly feasible and acceptable intervention for individuals with FEP. The promising preliminary signals on patient-centered functioning and specific cognitive domains strongly support the need for a large-scale randomized controlled trial with an active control group to definitively establish efficacy. Keywords: Schizophrenia; First-Episode Psychosis; Cognitive Remediation; Feuerstein Instrumental Enrichment; Functionality; Goal Attainment Scale Introduction First-episode psychosis (FEP), which marks the initial emergence of psychotic symptoms within the schizophrenia-spectrum disorders, is a period marked by pronounced cognitive vulnerability and variable clinical trajectories [1–4]. Robust cognitive deficits in domains such as executive functioning, processing speed, attention, and working memory are core features of schizophrenia [5–7]. These challenges often persist despite early treatment, creating significant difficulties in real-world functioning and highlighting FEP as a critical window for interventions aimed at improving long-term outcomes [1-2, 8]. Although cognitive remediation can improve cognition, the transfer of these gains to daily life remains a significant hurdle, particularly when interventions are delivered without integrated psychosocial support [9–11]. Feuerstein Instrumental Enrichment (FIE) is a distinct, ¨top-down¨ cognitive intervention, designed to address this gap. Grounded in the principles of Mediated Learning Experience (MLE) and Structural Cognitive Modifiability (SCM) [12,14], FIE focuses on training transferable cognitive processes rather than specific skills. While FIE has shown benefits in chronic schizophrenia, its application in FEP samples is limited, especially using a peer-mediated group format [12-15]. This peer-based approach is theoretically well-suited for the FEP population, as it directly targets common challenges like social withdrawal and amotivation. By encouraging structured verbalization, reciprocal feedback, and goal-focused discussions (”bridging”), peer mediation may enhance engagement and the metacognitive reflection necessary for generalizing skills to daily life [11-12, 14]. Accordingly, this pilot study was designed to evaluate the feasibility and acceptability of a peer-mediated FIE program for individuals with FEP. The primary objective was to generate preliminary data on patient-centered functioning, as measured by the Goal Attainment Scale (GAS) - a validated, individualized outcome that captures clinically meaningful change [12, 16-18]. Secondary exploratory outcomes included cognitive performance on the MATRICS battery and clinical symptomatology. This work was explicitly designed as a pilot study to assess feasibility and generate hypotheses for a future randomized controlled trial (RCT) with an active control group, rather than to draw definitive conclusions about efficacy [9, 19–20]. Methods 2.1. Study Design and Participants This open-label, single-arm pilot study evaluated the feasibility and preliminary effects of the Feuerstein Instrumental Enrichment (FIE) program in individuals with first-episode psychosis (FEP). The primary outcome was patient-centered functionality, assessed at baseline (T0), immediately post-intervention (T1), and at a six-month follow-up (T2). The study received approval from the Ethics Committee of the Universidade Federal de São Paulo (protocol A00951289489) and was preregistered in the Brazilian Registry of Clinical Trials (RBR-4gzhy4s). All participants provided written informed consent before enrollment. The research adhered to the principles of the Declaration of Helsinki and Good Clinical Practice, with all data coded to ensure confidentiality. Participants were recruited between February 2022 and February 2024 from the Early Intervention Program at the Universidade Federal de São Paulo and through referrals from affiliated outpatient psychiatric clinics. Trained clinicians and neuropsychologists conducted all screening and eligibility assessments to confirm diagnostic criteria and clinical stability. Inclusion criteria required participants to be: (1) aged 18 and 40 years; (2) diagnosed with a schizophrenia-spectrum disorder according to DSM-5 criteria [21], confirmed using the Structured Clinical Interview for DSM-5 – Research Version (SCID-5-RV) [22]; (3) clinically stable for at least four weeks prior to enrollment; (4) within two years of their first psychotic episode; (5) have an estimated IQ of 70 or higher, based on the Wechsler Adult Intelligence Scale short form [23]; and (6) proficient in Portuguese. Exclusion criteria were: (1) a history of neurological or systemic conditions known to affect cognition; (2) a substance use disorder (excluding nicotine) within the past six months; (3) sensory impairments that would prevent test administration; and (4) concurrent participation in other formal cognitive or psychosocial interventions. Attrition criteria was defined as missing more than 20% of sessions. 2.2. Intervention Participants engaged in a 10-week group-based Feuerstein Instrumental Enrichment (FIE) program, attending two 60-minute sessions per week. The intervention was delivered in small groups of two to three participants, each guided by a certified FIE mediator. FIE is a structured cognitive intervention based on the principles of Mediated Learning Experience (MLE) and Structural Cognitive Modifiability (SCM) [12]. The core of this approach is the mediator, who actively guides participants to develop metacognitive awareness by reflecting on their reasoning, verbalizing problem-solving strategies, and explicitly generalizing these cognitive principles to real-world situations. A key adaptation in this study was the use of a peer-mediated format, designed to address the specific challenges of early psychosis, such as social withdrawal and amotivation. Within the group, participants were encouraged to verbalize their thought processes and provide constructive, goal-oriented feedback to one another under the mediator’s supervision. This dynamic was intended to foster social engagement, enhance metacognitive reflection, and reinforce the transfer of cognitive strategies to daily life. The protocol utilized three instruments from the FIE Standard Program I, each targeting distinct cognitive functions: • Organization of Dots : This task required participants to identify and connect dispersed dots to form geometric figures, targeting planning, systematic scanning, and executive control. • Orientation in Space I : This instrument focused on strengthening spatial orientation and comparative reasoning by having participants solve problems using relative coordinates and directional cues. • Analytic Perception: This exercise fostered selective attention and analytic reasoning by requiring participants to mentally deconstruct and reconstruct figures from their component parts. Each session followed a structured, three-stage process: (1) Introduction , where the mediator activated prior knowledge, and set learning objectives; (2) Task execution , where participants worked collaboratively on the instrument while the mediator provided graded prompts to encourage metacognitive awareness; and (3) Bridging, where the session concluded with a guided discussion on applying the learned cognitive principles to specific real-world challenges, such as managing daily routines or improving communication. All sessions were delivered by a coauthor (M.E.D.M.A.R.), a certified FIE practitioner trained by the Feuerstein Institute. To ensure procedural fidelity, the mediator attended weekly supervision meetings with the research team. A structured checklist was used to monitor adherence to core MLE principles, including the promotion of peer verbalization, use of graded prompts, explicit bridging to daily life, and maintenance of a psychologically safe environment. Any deviations were discussed and corrected in real-time to ensure consistent delivery across all groups. 2.3. Outcome Measures All outcomes were assessed at baseline (T0), immediately post-intervention (T1), and at a six-month follow-up (T2) by trained neuropsychologists who were blinded to the study’s hypotheses to minimize assessment bias. Primary Outcome: Patient-Centered Functionality The primary outcome was patient-centered functionality, measured with the Goal Attainment Scale (GAS). The GAS is a validated, individualized metric designed to capture progress on personally meaningful goals. Following the SMART framework (Specific, Measurable, Achievable, Relevant, Time-bound), participants collaborated with an evaluator to define up to three functional goals. Achievement for each goal was rated on a five-point scale ranging from -2 ( much less than expected ) to +2 ( much more than expected ), with 0 representing the expected outcome. A standardized T-score (mean = 50, SD = 10) was then calculated to allow for comparisons across time points. This measure was chosen for its ecological validity and its sensitivity to clinically significant changes that may not be captured by traditional symptom scales or cognitive assessment. Secondary outcomes focused on cognitive performance, assessed using the Brazilian standardized version of the MATRICS Consensus Cognitive Battery (MCCB). The MCCB evaluates seven domains critical to schizophrenia: speed of processing, attention/vigilance, working memory, verbal learning, visual learning, reasoning and problem-solving, and social cognition. Based on psychometric findings from the Brazilian standardization study, the social cognition subtest (MSCEIT) was excluded from all analyses due to its limited validity in the local adaptation [19]. Additional, secondary outcomes included clinical symptom severity, measured with the Positive and Negative Syndrome Scale (PANSS), which provides a total score and scores for positive, negative, and general psychopathology [28]. The remaining MCCB domains were also analyzed on an exploratory basis to identify any broader cognitive signals. 2.4. Clinical and Cognitive Assessments All clinical and cognitive assessments were conducted in a controlled setting by trained psychiatrists and neuropsychologists who were independent of the intervention team. Clinical symptomatology was evaluated using the Positive and Negative Syndrome Scale (PANSS) [23, 29]. All raters were trained clinicians who achieved and maintained interrater reliability above 0.80 through calibration sessions prior to and during data collection. Functional outcomes were assessed using the Goal Attainment Scale (GAS) [16-18], as previously described. For each participant, up to three personally meaningful goals were collaboratively defined and operationalized according to the SMART framework at baseline and reassessed at each subsequent time point. Cognitive performance was assessed with the Brazilian version of the MATRICS Consensus Cognitive Battery (MCCB) consistent with the Brazilian standardization study [19], the social cognition domain (MSCEIT) was excluded from analyses due to its limited local psychometric adequacy. Raw scores were used for all analyses. A priori, particular attention was given to domains theoretically aligned with the FIE intervention, specifically Processing Speed (as measured by the Coding and Category Fluency subtests) and Verbal Working Memory (Letter–Number Span). Finally, estimated intellectual functioning was assessed for screening purposes only (inclusion criterion IQ ≥70) using two subtests from the WAIS-III: Vocabulary and Matrix Reasoning. 2.5. Statistical Analysis All statistical analyses were conducted to assess changes across the three time points: baseline (T0), post-intervention (T1), and six-month follow-up (T2). The primary analysis for change over time was performed using the nonparametric Friedman test, with statistical significance set at p<.05 (two-tailed). Consistent with the signal-detection purpose of a pilot study, the main focus was on the overall omnibus test. However, to better contextualize the observed trajectories and to help generate hypotheses for a future randomized controlled trial, exploratory pairwise comparisons were also conducted using the Conover post-hoc test. For these multiple comparisons, the Holm–Bonferroni correction was applied to control for Type I error, and the indicated p-values reflect these adjustments. Results 3.1. Baseline Characteristics The final sample included 16 participants diagnosed with a schizophrenia-spectrum disorder (DSM-5). The mean age was 27.1 years (SD = 5.03), and the sample was predominantly male (n = 11; 68.8%). All participants were within two years of their first psychotic episode and had been clinically stable for at least four weeks prior to enrollment. A key indicator of the intervention’s feasibility and acceptability was the 100% retention rate, with no participants lost during the 10-week intervention or at the six-month follow-up. Table 1 presents the detailed baseline demographic and clinical characteristics. Table 1. Baseline Demographic and Clinical Characteristics (N = 16) Demographics Age (years), M (SD) 27.11 (5.03) Sex, n (%) Male 11 (68.8%) Female 5 (31.2%) Estimated IQ¹ 90.62 (10.71) Clinical Characteristics (PANSS Baseline) Positive Scale, M (SD) 11.62 (5.19) Negative Scale, M (SD) 16.20 (5.67) General Psychopathology Scale, M (SD) 29.87 (9.96) Total Score, M (SD) 58.13 (17.39) 1 Note: Estimated IQ was used for screening purposes (inclusion criterion IQ ≥70). M = Mean; SD = Standard Deviation; PANSS = Positive and Negative Syndrome Scale. 3.2. Clinical, Cognitive, and Functional Outcomes The primary outcome, patient-centered functionality, showed marked and sustained improvement. Scores on the Goal Attainment Scale (GAS) increased significantly from baseline to post-intervention and remained elevated at the six-month follow-up (χ2(2)=24.43,p<.001). Consistent with this functional progress, significant reductions were observed in clinical symptoms, including the PANSS Positive (χ2(2)=7.74,p<.02), General Psychopathology (χ2(2)=14.60,p<.01), and Total scores (χ2(2)=13.62,p<.01). Negative symptoms, however, remained stable over time. In the cognitive domain, exploratory analyses of the MCCB battery revealed selective signals of improvement. Specifically, significant gains were found in Processing Speed (χ2(2)=10.47,p<.005) and Verbal Working Memory (χ2(2)=10.34,p<.006). No significant changes were observed in the other cognitive domains. Table 2. Changes in Functional, Clinical, and Cognitive Outcomes Across Time Points (N = 16) Functionality Goal Attainment Scale (GAS) 35.79 (1.86) 49.46 (6.49) 53.77 (9.88) 24.43 <.001 Clinical Symptoms PANSS Positive 11.62 (5.19) 8.73 (3.15) 8.27 (1.98) 7.74 <.02 PANSS General Psychopathology 29.87 (9.96) 24.13 (6.05) 22.13 (5.59) 14.60 <.01 PANSS Total Score 58.13 (17.39) 46.87 (9.28) 42.13 (10.10) 13.62 <.01 Cognitive Performance MCCB – Processing Speed (Coding) 41.69 (12.70) 44.94 (12.43) 46.06 (14.70) 10.47 <.005 MCCB – Verbal Working Memory (LNS) 12.19 (2.66) 13.81 (2.99) 13.81 (2.74) 10.34 <.006 Trail Making Test 41.40 (15.78) 35.49 (9.28) 35.41 (19.58) 3.58 0.17 Verbal Learning 21.81 (2.74) 21.31 (4.69) 22.50 (5.15) 0.44 0.82 Visual Working Memory 15.19 (3.94) 16.25 (4.47) 15.94 (3.32) 0.98 0.61 Mazes 17.13 (7.67) 17.38 (6.17) 18.81 (5.88) 3.61 0.16 Visual Learning 23.88 (7.06) 26.25 (5.99) 25.63 (7.17) 5.63 0.06 Verbal Fluency 19.13 (6.11) 21.81 (6.41) 20.00 (4.60) 2.43 0.30 Attention 1.96 (0.94) 2.09 (0.70) 2.21 (0.66) 2.93 0.23 Note: M = Mean; SD = Standard Deviation; T0 = Baseline; T1 = Post-Intervention; T2 = 6-Month Follow-up. Statistics reflect the Friedman test (χ²) . Discussion This pilot study was designed to assess the feasibility and acceptability of a peer-mediated Feuerstein Instrumental Enrichment (FIE) program for individuals with first-episode psychosis (FEP). The intervention proved to be highly feasible and acceptable, all participants completing the program and follow-up assessments. Furthermore, the study generated promising improvements in patient-centered functioning, specific cognitive domains, and clinical symptoms, providing a strong rationale for a future, large-scale randomized controlled trial (RCT). The field of cognitive remediation is undergoing a critical paradigm shift, moving from restorative drill-and-practice exercises toward integrated, ”top-down” approaches that explicitly target metacognition—the ability to reflect on one’s own thinking [10-11,20]. Seminal work by leaders such as Wykes, Bowie, and Eack has established that for cognitive gains to translate into functional outcomes, interventions must cultivate higher-order skills like cognitive insight and a sense of self-agency. [9-11, 20] Our application of Feuerstein Instrumental Enrichment (FIE) is uniquely positioned within this modern metacognitive framework. Rather than simply training cognitive skills, FIE’s core mechanism of Mediated Learning Experience (MLE) and its emphasis on ”bridging” are inherently designed to make participants aware of their own problem-solving strategies, directly fostering metacognitive awareness and self-reflection. Furthermore, by delivering the intervention in a group format, our peer-mediated approach extends this into the realm of social cognitive remediation, using structured interaction to provide real-time practice in perspective-taking and social reasoning. This group-based format aligns with growing support for social cognition training in FEP, where group dynamics are explicitly leveraged to enhance social engagement and functional outcomes, a strategy used successfully in other cognitive remediation paradigms [11-12, 14, 26-27]. The most prominent finding was the significant and sustained improvement in patient-defined functional goals, measured by the Goal Attainment Scale (GAS). These gains, which persisted six months post-intervention, align with the theoretical foundation of FIE, which emphasizes the transfer of cognitive principles to real-world contexts through Mediated Learning Experience (MLE). While this result is highly encouraging, the open-label, single-arm design precludes causal inference. It is plausible that non-specific factors, such as structured therapeutic contact and peer support, contributed to the observed functional changes. This critical question must be addressed by including an active-control condition in the subsequent RCT [9,12,14,16]. In our secondary analyses, we identified selective improvements in Processing Speed (Coding) and Verbal Working Memory (Letter–Number Span), cognitive domains strongly linked to functional competence and responsiveness to remediation [5, 20]. Within a mediation-based framework, it is plausible that the enhanced strategic monitoring and graded prompting inherent to FIE support these gains. However, these findings must be interpreted with caution. Notably, there was no significant change in problem-solving (Mazes), the domain theoretically most aligned with the FIE intervention’s goals. This pattern, where signals were observed in procedural domains but not the primary theoretical target, suggests that practice effects from repeated MCCB administration may be the most parsimonious explanation for the observed cognitive gains and underscores the need for a control group in future research. Regarding clinical symptoms, the reductions in PANSS Positive and General dimensions may reflect indirect benefits of improved cognitive regulation and social engagement. Alternatively, these changes could stem from the natural course of illness and ongoing antipsychotic treatment, which are common in early psychosis care. The lack of significant change in negative symptoms is also noteworthy and consistent with literature indicating that such symptoms often require more targeted psychosocial or motivational interventions [11, 24-25]. Building on this metacognitive framework, the peer-mediated format may uniquely amplify FIE’s core principles of intentionality, reciprocity, and transcendence. Reciprocal feedback among peers promotes intentional strategy use, the pursuit of shared goals strengthens reciprocity, and guided ”bridging” discussions foster the transcendence of skills from the task to daily life. By leveraging social interaction to catalyze metacognition, this peer-based approach may enhance ecological transfer in FEP more effectively than individually delivered formats. [11-12, 14, 26-27]. This study must be interpreted under some existing limitations. The primary constraints are its open-label, single-arm design and small sample size, which limits generalizability and prevents conclusions about efficacy. A critical limitation stems from the sample selection itself: recruiting patients already engaged in an Early Intervention Program (GAP) may have introduced a selection bias, as these individuals are likely more motivated and have already received comprehensive treatment. These limitations, however, are instructive and directly inform the design of the planned active-controlled RCT, highlighting the need for comprehensive data collection to model potential confounders. In conclusion, this pilot study successfully demonstrates a peer mediated FIE program is a feasible and high acceptable intervention for individuals with FEP. The study generated promising, hypothesis-forming signals of improvement in patient-centered functionality, processing speed, and verbal working memory. While efficacy cannot be inferred from this design, these findings provide a compelling warrant for a definitive randomized controlled trial to establish the causal effects of this innovative intervention. Acknowledgments The authors wish to thank the neuropsychological and psychiatric team from the Grupo de Atenção às Psicoses Iniciais (GAP) for their valuable collaboration in discussing the assessment protocol. This research was funded by the Brazilian Federal Agency for Support and Evaluation of Graduate Education (CAPES), funding code 001. No artificial intelligence was used in the writing of this manuscript. The authors acknowledge the use of artificial intelligence tools (ChatGPT, Gemini) to assist with language editing and stylistic refinement. All content was verified by the authors, who take full responsibility for the accuracy and integrity of the manuscript. No AI tools were used to generate, analyse, or interpret data. Data Availability Statement The data that support the findings of this study are not publicly available due to privacy and ethical restrictions stipulated by the approving ethics committee. Data may be available from the corresponding author upon reasonable request and pending approval from the Universidade Federal de São Paulo Ethics Committee. Conflicts of Interest AG has been a consultant or advisor to or has received honoraria from Cristalia, Lundbeck, Ache, Daiichi-Sankyo, Teva, and Janssen. CN has been a consultant or advisor to or has received honoraria from Ache, Daiichi-Sankyo, Teva, and Janssen. Noother conflicts of interest were declared concerning the publication of this article. The other authors AOF, JSG and MEDMAR have no conflicts of interest to declare concerning the publication of this article. Author Contributions AOF: Conceptualization, Investigation, Writing – Original Draft, Writing – Review & Editing. JSG: Investigation, Writing – Review & Editing. MEDMAR: Investigation, Methodology. AG: Supervision, Writing – Review & Editing. CN: Conceptualization, Supervision, Writing – Review & Editing. REFERENCES 1. Lally J, Ajnakina O, Stubbs B, et al. 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Keywords cognitive remediation feuerstein instrumental enrichment first-episode psychosis functionality schizophrenia Authors Affiliations Ana Olivia Fonseca 0000-0002-0104-9485 [email protected] Universidade Federal de Sao Paulo - Campus Sao Paulo View all articles by this author July Silveira Gomes Universidade Federal de Sao Paulo - Campus Sao Paulo View all articles by this author Maria Eva de Miranda Alves Rodrigues Universidade Federal de Sao Paulo - Campus Sao Paulo View all articles by this author Ary Gadelha Universidade Federal de Sao Paulo - Campus Sao Paulo View all articles by this author Cristiano Noto 0000-0002-2706-9118 Universidade Federal de Sao Paulo - Campus Sao Paulo View all articles by this author Metrics & Citations Metrics Article Usage 244 views 128 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Ana Olivia Fonseca, July Silveira Gomes, Maria Eva de Miranda Alves Rodrigues, et al. 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