Schizophrenia is a mental disorder that has as one of its distinctive features the presence of difficulties associated with poorer social functioning (1), fewer social relationships, and poorer quality of life (2, 3). People with schizophrenia often become socially isolated, showing less initiative and motivation toward activities, especially social activities, than they did before the onset of the illness. They suffer from social isolation because they find it difficult to make contact with other people and to maintain a conversation. They have difficulty functioning normally under stressful conditions, partly because of their difficulties in social skills and problem solving (4, 5).

Couture et al. (6) concluded that there are clear and consistent relationships between aspects of functional outcome and social cognition. However, methodological issues remain unresolved (7–9) on the recognition of facial affect as a mediator between cognitive and social functioning in psychosis.

Since the 2000s, interest in Social Cognition (SC) has been growing after it was shown that participants with Severe Mental Disorder (SMD) with problems in this type of tasks presented worse social functioning (3) and poorer social relationships (10). SC includes the perception of emotions, both in people’s faces and voices (11, 12), social perception (6, 13) and life perception (14–16). During the last decade, there have been improvements on the development of rehabilitation tools focused on SC which have proven that these deficits are restorable and that their improvement contributes to functional recovery (17–21), theory of mind (ToM) (22, 23) and attributional style (AS) (24–27).

Different work teams have suggested an alternative to group training using computerized training which would allow virtually universal accessibility (28). e-Motional Training® (ET) is an online self-training program for the SC rehabilitation of participants with SMD such as schizophrenia. This program was initially developed and tested by the Psychiatry Service of the Complexo Hospitalario de Ourense. The first version of the program started developing in 2011, being operational in 2013. The results of the initial unblinded controlled pilot study demonstrated statistically significant improvements in both Emotion Recognition (ER) and ToM (29). The version 1.0 has proven its efficacy in a multicenter randomized clinical trial (RCT) (30) and version 2.0 of the program, developed since 2013, is now available (31). ET 2.0 increased the number of different models with photographs, the number of games and a new movie was included with actors called “The Surprise.” In addition, a first prosodic training game VOICES, a mime training game and a video game for ToM (Second Chance) was included.

Currently there are some SC training programs that have reported promising results in cognitive and functional outcomes (32, 33). These encouraging results are limited in a practical sense because their application requires complex clinical settings, with specially trained and skilled medical teams for their implementation, resulting in higher costs that limit their accessibility to the entire target population. ET arises from this need, with the objective of developing an easy to apply tool in Spanish, with the possibility of being self-administered by the patient and that is also versatile for the rehabilitation of social cognition.

Employment is another concern that has become apparent in the scientific literature in recent years (34). The high unemployment rates of people with schizophrenia have led to strategies that have been systematically evaluated. One of these strategies is Individual Placement and Support (IPS), developed in the US by Becker and Drake (35), which establishes that incorporation into competitive employment should occur as quickly as possible, followed by support and training in the job. The person with SMD must be integrated into the workplace in the same way as another person without a mental disorder, with the purpose of emphasizing the social integration of the patient, reinforcing the significance of his role as a citizen and making him an essential participant in his therapeutic recovery process (36). There is strong evidence, both in Europe and in the US, that the IPS model is more effective for people with SMD to obtain competitive employment than programs based on pre-vocational training such as the “Train-Place” (37, 38). In addition, the IPS presents better results than pre-vocational training, considering both the number of hours and weeks worked competitively, and the number of hospital admissions (36–38).

The focus of this study is to analyze the impact of the ET intervention on social competence in people with schizophrenia who use the IPS employment strategy.

All participants had a diagnosis of schizophrenia, with a mean age of 44.1 ± 6.7 years. Twenty-four percent were female to 76% who were male. The marital status of most of the sample components, 94%, was single or divorced. The educational level of 48% of the participants was primary school, 20% were secondary school, 18% had higher education, 8% were high school graduates and 6% were university graduates. At the beginning of the study, 64% of the participants were unemployed and 36% were working. Mean duration of schizophrenia diagnosis of all participants was 20.8 ± 7.9 years. Finally, 36% of participants had not had any admission prior to the resource, 36% had been admitted once, 20% had been admitted twice and 8% had been admitted three or more times. Regarding the data related to the sociodemographic characteristics of the participants (Table 1A), no significant differences were found between the control group and the intervention group, thus evidencing that both groups are quite homogeneous at the sociodemographic level due to the characteristics related in this regard.

The comparison of the pre-values between participants who continue the study (carry out the post-test) and those who do not, is included in Table 1B. No significant differences were observed between the variances of these two groups in any of the variables evaluated. Nor are significant differences observed in the means, except for the emotion Fear, with a slight deterioration in the group that does not continue (p = 0.049) and, in Hinting Total 1, with a slight improvement in the group that does not continue (p = 0.040).

Table 2 shows the comparison of the variables measured with the different tests between the pre and post values for each of the groups. In the last column of this table, the pre values between groups were also compared, not showing significant differences. In Ekman’s 60-item test, a significant improvement is perceived in the total score of the intervention group (p = 0.009), but not of the control group (p = 0.187), mainly due to the improvement in the emotions fear, sadness and disgust (p = 0.041, p = 0.021 and p = 0.038, respectively, Figure 2). An improvement in the Total 1 score (equivalently a reduction in the Total 2 score) of the Hinting test was also observed in both groups (control: p = 0.049, intervention: p < 0.001, Figure 3). In the Faux Pas FP-FP test, a similar effect was also shown, a greater improvement in the intervention group than in the control group (control: p = 0.046, intervention: p < 0.001). Finally, the Faux Pas C-C test shows a tendency toward improvement that is close to significance (p = 0.061). The comparison of whether the evolution over time of the different scores varied between the groups is shown in Table 3 (group*time column). Indeed, it showed a significant improvement in the intervention group compared to the control group (p < 0.001) in the Ekman test, due to a better performance on the emotion fear (p = 0.003), sadness (p = 0.009) and close to significance in disgust (p = 0.063). In the case of the Hinting test, a significant improvement (score reduction) in the Total 2 score is observed, being higher in the intervention group than in the control group (p = 0.011) and an improvement close to significance (p = 0.080), was higher in the Total 1 score of the intervention group. For the rest of the variables, no significant differences were found in the evolution of the two groups.

To measure the internal consistency (reliability) of all the pre and post variables, we performed the Cronbach’s alpha coefficient and obtained α = 0.522. In the case of the post variables, the Cronbach’s alpha value was 0.687.

Cognitive therapy in people with schizophrenia is primarily aimed at improving global social functioning (52). Social cognition programs can help the general functioning of people with psychosis, in addition neurocognition-based programs. Due to the need for a tool in Spanish for the rehabilitation of SC, a research team from the University of Santiago de Compostela designs the ET program showing its feasibility in a pilot study (29). Subsequently, this same research team conducted the first randomized controlled trial of this program, showing it to be a promising tool for treating SC deficits in schizophrenia (30).

In the Canary Islands, more specifically on the island of Tenerife, this study was replicated with a research team specialized in mental health in an attempt to accommodate the needs of this type of population. In conclusion, the results found in this study were very similar to those found by the Santiago team (30).

Recently, in 2021, Lahera et al. (53) compared in a group of 100 participants with schizophrenia the efficacy of using Training in Affect Recognition (TAR) and Social Cognition and Interaction Training (SCIT) on the performance of facial recognition of affect, ToM, AS and social functioning before, after treatment and 3 months later. They found that the entire sample, who received either TAR or SCIT, showed improvements in ToM, AS, clinical symptoms, and social functioning. However, the TAR intervention was more effective than the SCIT program in improving facial emotion recognition (ER).

With regard to the ER, the intervention group showed a significant improvement in the Ekman 60 Faces Test in the same way as in the Santiago research (30). These results are consistent with previous interventions (54, 55). Regarding the ToM, our intervention group showed significant improvements in the Hinting Task and Faux Pas Recognition Test as in the previous study by Maroño-Souto et al. (30). Evidencing in this way that both progresses did not reach the level of competence of the population without schizophrenia, which differs from those found in other previous interventions (56, 57).

In short, ET is an interactive online program that has proven to be effective for training the domains of social cognition. Compared to other programs available for SC rehabilitation (58), ET allows self-training and online follow-up by therapists. Thus becoming one of the intervention tools within the Spanish SMD community. The creation of this computerized tool enables a new approach where participants can practice social skills in a safe environment before facing society.

Our study has a series of limitations centered mainly on the sample size. Due to the COVID-19 pandemic, it was difficult to carry out an adequate follow-up of the study, as we have already mentioned, so the adequacy of the sample had to be reduced. In particular, the initial statistical power of 90% was reduced to 41.7%, which may be masking results that do not show significant differences between groups that do. On the other hand, all participants in the study at the time of the investigation were stabilized, which means that our results can be applied with caution to the general population with schizophrenia. 76% of the study participants were men, although the existence of sex difference in the risk of developing schizophrenia is well known (59), these percentages may vary depending on the bibliography consulted. The fact that the control group has not received any type of treatment, except that of the IPS, is also a limitation of this work.

Future lines of research on the topic should include more study about emotions and theory of mind in people with schizophrenia.

The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author.

The studies involving humans were approved by Research Ethics Committee University Hospital Complex of the Canary Islands. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

FR (principal investigator), NC and EG designed, conducted and supervised the study and interpreted the results. EG also contributed to the statistical analyses. AG provided all standardised tests and supervised the design and execution of the study. MH, SL and PV searched for and selected participants. CL conducted the pre- and post-tests as a blinded researcher and assisted in data collection and extraction. FR, NC and EG drafted the manuscript. All authors have had full access to the study data.