Attentional capacities (ACs) allow the subject to process all perceptual information to which he or she is subjected to. They are comprised of three sub-systems described by Posner and Petersen (25). Sustained attention allows the subject to stay focused on a percept or cognitive task for a given time (ibid.). Divided attention allows the subject to distribute his attentional functions over several cognitive percepts or tasks at the same time (ibid.). Finally, selective attention allows focusing on a percept or a task while inhibiting surrounding percepts considered to be irrelevant (ibid.). Nowadays, it is considered that attentional control capacities belong to working memory and that they act in computational synergism with other cognitive functions such as executive functions (26, 27). In individuals with schizophrenia, ACs are considered one of the most impaired cognitive functions (28). This impairment is sometimes increased by treatments, motivation (29), negative or positive psychotic dimensions, and psychoaffective symptomatology (30). With regard to functional impairment, it affects the processing capacities and cognitive functions computationally associated with AC (26). The functional incidence of an AC impairment has a strong impact on the success of a life project driven by a PSR approach.

Defined as the speed with which various cognitive operations are performed, processing speed (PS) is one of the most affected cognitive functions in instances of schizophrenia (28, 31). This impairment is also increased by drug treatments, motivation (29) and psychotic symptoms (30). At the functional level, PS has an influence on encoding, the use of adaptive strategies and decision-making processes. Despite ongoing debate regarding the type of cognitive model and psychometric assessment associated with processing speed (32), it appears that PS primarily interacts with working memory and executive functions (33, 34). Thus, while cognitive remediation enables an improvement in PS, it is acknowledged that the latter is predictive of an improvement in functional abilities (35).

Memory is comprised of five subsystems (procedural memory, perceptive memory, semantic memory, episodic memory (EM) and working memory (WM)) allowing for the processing and maintenance of information (36, 37). Sparsely studied in patients with schizophrenia since they are relatively well-preserved (21), perceptive memory (sensory information), procedural memory (motor tasks) and semantic memory (facts, ideas, concepts, states of meaning and vocabulary) are not particularly considered as main key dimensions in PSR programs.

Conversely, working memory is generally affected in schizophrenic patients and more specifically in IDSPMI (27). Classically considered as a component of executive control, WM is a temporary storage and processing space with limited capacity allowing the performance of complex tasks such as understanding or reasoning (38). It is based on three subsystems (the phonological loop, the visuospatial sketchpad and the episodic buffer ensuring dialogue with the EM) coordinated by a central administrator (ibid.). The central executor is responsible for executive attentional control and for the processing and retrieval of information (38, 39). The phonological loop (which is linked to memory span) is used for the temporary storage of acoustic and vocal elements. A saturation of the phonological loop can hence generate interactional difficulties such as hindering the recording of verbal instructions. Finally, the visuospatial sketchpad allows the temporary storage of visual and spatial information (38).

As a part of declarative memory (episodic memory + semantic memory), episodic memory (EM) allows the recovery of previous experiences associated with a spatio-temporal context and an authentic subjective experience involving a capacity for self-apprehension (36, 37). In IDSPMI (31), as in patients with deficit schizophrenia (40), EM is often altered. This alteration is linked to the encoding and retrieval conditions, particularly when the individual is subjected to a high cognitive demand involving control and connectivity functions (41). At the functional level, EM difficulties strongly hamper social and professional adaptation, but also rehabilitation and reeducation work (42). Improvement in EM skills in IDPMSI can be expected with cognitive remediation (35).

Executive functions (EF) are high-level cognitive processes (Inhibition, Cognitive flexibility, WM updating and Planning) involving the fronto-cingulo-parietal network (43). They have an influence on lower cognitive processes and allow individuals to regulate and organize their thoughts and actions according to a behavioral goal (44). Although these four cognitive processes are presented separately, some can act synergistically in the functioning of a more complex process (e.g. planning) (ibid.). Currently, a deficit in executive functions commonly observed in IDSPMI (28) can lead to organizational and adaptability difficulties impeding the construction of adaptive strategies and self-empowerment. These difficulties must therefore be understood to guide the choice of the working axes in cognitive rehabilitation and training in social abilities considered as beneficial on EF (45).

Currently considered to be the central node component of biopsychosocial functioning (46), metacognition is the ability of ‘‘thinking about thinking’’, to have an integrated sense of self through the knowledge and awareness of our cognitive processes (47). Metacognition is divided into two groups of processes: metacognitive knowledge and metacognitive regulation (48). Metacognitive regulation encompasses reflexive awareness (self-awareness), the awareness of others as well as the ability to decenter (47–49). Metacognitive knowledge is knowledge related to the behavior of others, of oneself and of cognitive functioning in itself (ibid.). One of the characteristics of all metacognitive processes is that they are described as hierarchical. This functioning hence implies the notion of using lower level metacognitive knowledge to build other more complex knowledge, so-called higher-level metacognitive knowledge (ibid.). Finally, it is considered that metacognition appears and evolves within an intersubjective context (47). In practice, metacognition allows access to a knowledge of Self and of others, but above all, to use this knowledge to adapt to contextual and environmental changes (47). In the literature, numerous studies have shown the presence of metacognitive deficits in schizophrenic subjects generating numerous difficulties in their everyday life (ibid.). Lastly, it has been shown that an improvement in metacognitive abilities promotes the recovery process (ibid.), notably owing to an improvement over time in cognitive and social cognition skills (46).

Social cognition (SC) defines ‘‘the mental operations that underlie social interactions, including perceiving, interpreting and generating responses to the intentions, dispositions, and behaviors of others’’ (50). Four sub-dimensions are commonly associated with SC (51): 1) the perception/management of emotions allows identifying and recognizing emotions, but also to manage and regulate the latter (ibid.); 2) social perception which consists of interpreting contextual social information and achieving judgments regarding the behavior of others in order to deduce their social and cultural belonging (ibid.); 3) attributional style that echoes the manner in which an individual interprets, explains and understands the negative and positive social elements to which he is subjected (ibid.); 4) the theory of mind/ToM which allows to represent the mental states of others by making inferences on the intentions and beliefs of others (ibid.). Inferences can be of the first order (representations of the mental states of a third party) or second order (representations of the representations of others). Finally, the differentiation of an emotional and cognitive aspect of ToM allows a relevant association with models integrating the notion of affective and cognitive empathy (52, 53). It is well recognized that individuals with schizophrenia display deficits in SC (54) in terms of emotion perception/processing (particularly in identifying emotions), of social perception and theory of mind (55). These elements lead to numerous functional repercussions that impede social adjustment (52, 55). However, they remain stable according to age (56) and can be improved by an increase in metacognitive abilities (46). Given that IDPMSI are directly impacted by these deficits (potentially increased by institutionalization, its codes, and the lack of social interactions), it is therefore imperative to properly assess these components.

There are several psychoaffective elements associated with the subject’s personality and personal experience that can hamper the success of a psychosocial rehabilitation/housing support program in IDPMSI. Although regularly mentioned by clinicians, there is currently no empirical work studying the impact of psychoaffective components on the success of psychosocial rehabilitation programs. Among others, the ability to engage in a therapeutic alliance, transference and countertransference processes, previous experiences, acting out and ability to accept group interactions (particularly for housing support programs) are known to have a significant influence on PSR projects of IDSPMI (23, 57, 58).

The last selected dimension refers to the historical, clinical, social, and interpersonal background of the patient. Indeed, a growing body of knowledge currently shows that family support, the presence of past professional experiences, a positive financial situation, a recognition of citizenship/individual rights and a supportive social network are considered as factors facilitating the recovery process (59, 60). Similarly, prior clinical information, existing comorbidities and former treatments also represent an important dimension to be collected (61). It is therefore necessary to integrate these aspects in the assessment of IDSPMI willing to enter in a PSR program.

The elaboration of the FIPRACS begins with a collection of clinical case history (anamesis) and social (life course evaluation) data referring to the key ‘‘Historical, interpersonal, clinical and social dimensions of the subject’’ dimension. It requires coordination and information sharing between the teams historically involved with the subject, and the current user himself/herself (so as not to dwell on the representations of previous teams involved with the subject). Generally carried out by a paramedical professional (nurse or nursing assistant), the anamnesis is presented as a reconstruction of the medical and social history underlying the reason for follow-up support (61). It encompasses «the chronology of onset of the disorders and the evolutive course of the signs and symptoms» (ibid., p. 5), the presence of personal history (prior hospitalizations, previous diagnoses, addictions, etc.) and familial antecedents (proposed diagnoses, symptomatic similarity, etc.), the presence of somatic comorbidities, but also the functional consequences of the disorders on the adaptation of the individual (ibid.). As part of the FIPRACS, the anamnesis must include a reflection dedicated to the presence of possible cognitive disorders by allocating particular attention to academic and professional history, the presence of learning difficulties or the ability to maintain acquired skills. Lastly, by including the etiology of the disorders within the history of the subject, the anamnesis allows orienting the diagnostic reflection, thereby enabling considering several potential prognoses as well as different care support modalities.

Concomitantly with the anamnesis, the “life course evaluation” focuses on past and present social aspects (previous life projects, social integration, financial data, family ties, places of living, former professions, etc.), and allows shedding light on the social adaptation of the subject (62). Associated with an updated collection of social data, the presentation of the “life course” is generally carried out by a social worker or a specialized educator who provides insight on the construction of projects. Finally, it generates self-empowerment when constructed in conjunction with the patient and helps in the selection of the PSR program or the housing support modalities for LTHIDSPMI.

First, among the tools proposed by the literature for attention assessment ( Supplemental Data 2, Table 1 ), we retained the Test of Everyday Attention (TEA) (63). Despite its length, TEA is the most complete and adjusted tool for IDSPMI. It also allows complementing other function evaluations.

Second, for the assessment of processing speed, these are mainly based on tools aimed at performing a certain number of cognitive tasks during a given time frame ( Supplemental Data 2, Table 2 ). For the FIPRACS, we selected the Stroop test (64) for its speed, adequation and ease of use with IDSPMI (33). In addition, the conducting of the Stroop test allows assessing other cognitive elements such as inhibition (enabling to reduce the access time of IDSPMI). We also strongly recommend that the examiner assess the delays associated with the use of strategies (caution, verification, inhibition, etc.) on PS (65).

Third, the memory skills assessment principally focuses on working memory and episodic memory tools ( Supplemental Data 2, Table 3 ). In WM, the central executor is not evaluated since it is studied via the attention, procedural speed, long-term memory and executive functions assessment. The selected tool to assess phonological loop is the WAIS IV ‘Backward digit recall’ subtest (66) for its simplicity, ease of use and adequation with IDSPMI. Particular attention must be given to omissions, intrusions, inversions and to any differences greater than two elements between the forward and backward memory span tasks. The chosen assessment tool for the visuospatial sketchpad is the Rey-Osterrieth Complex Figure Test (67, 68). This tool has been selected for its ease of execution, speed and capacity to assess other cognitive elements. Moreover, our clinical investigations evaluated its utilization as particularly adapted to IDSPMI. However, it is necessary to combine the Rey-Osterrieth Complex Figure Test with a clinical evaluation of the possible influence of other cognitive functions such as executive functions, but also of the influence of psychotic symptoms (69). Lastly, the tool for accessing episodic memory is the RL-RI 16 test (70). Its ability to dissociate encoding, storage and retrieval processes provides a strong asset for the memory evaluation of IDSPMI. We also recommend being alert to intrusions, perseverance, repetitions and strategies facilitating memorization (ibid.). Finally, since RL-RI 16 does not capture autobiographical memory which is often deficient in IDSPMI (71), it is useful to associate clinical questioning on this topic.

Fourth, in terms of tools selected for executive functions assessment ( Supplemental Data 2, Table 4 ), the Stroop test previously used to assess PS ( Supplemental Data 2, Tables 1 and 2 ) already allows studying inhibition and attentional control (64). We did not retain any assessment pertaining to WM update considering it is measured by the tools assessing EM and WM. Cognitive flexibility is conversely preferentially studied through the Wisconsin Card Sorting Test (WCST) developed by Grant & Berg in 1948 (72). It is notably important to determine the rate of persevering responses and the number of rankings (73). The ability of the WCST to assess other cognitive processes in IDSPMI (ibid.) and its playful aspect (particularly appealing to our target population) were determining factors in our selection. To assess planning abilities, we retained the Behavioral Assessment of the Dysexecutive Syndrome (BADS) battery (74, 75). While this battery presents a reduced speed of use compared to other tools assessing executive function, we noted its ability to assess other functions and its particular adequation with the clinical particularities of IDSPMI. This ecological test thus allows a complete and closer assessment of day-to-day life issues (ibid.).

Fifth, among the tools available to assess social cognition ( Supplemental Data, Table 5 ) the Facial Emotions Recognition Test (TREF) was selected to evaluate the processing of emotions in the FIPRACS (76). This decision was taken given the accuracy of the test, its ease of use, and the recency of its pictures largely appreciated by the IDSPMI. Likewise, we selected Theory Of Mind-15 (TOM-15) proposed by Desgranges et al. in 2012 (77) and the French version of the Interpersonal Reactivity Index (F-IRI) (78) to assess ToM and empathy. In instances where clinical observation is insufficient, social perception abilities can then be assessed with the Mini Profile of Nonverbal Sensitivity (MiniPons) (79). On the other hand, we did not retain a specific tool for attributional style considering that the available tools do not provide additional elements to that of clinical observation. There are also several batteries in French for social cognition (BICS, ClaCoS, EVACO, PECS-B) (20). These were not selected for the FIPRACS because their use was associated with a loss of focus and motivation for IDSPMI. Nonetheless, the fact that EVACO integrates an assessment of mental handicap as well as a tool pertaining to the capacity to accept assistance (80) leads us to mention the latter as the most suited battery for our target population.

Finally, for metacognition assessment ( Supplemental Data 2, Table 6 ), we estimated that the existing questionnaires do not provide additional information to those obtained with clinical interviews and observations. We nonetheless consider that, in addition to clinical evaluation and clinical assessment of insight, the addition of two instructions to the conducting of the WCST proposed by Koren et al. (81) allows a quick and relevant estimation of metacognitive abilities. These instructions are: «Between 0 and 100, at what number do you estimate your success in this test?» and «Do you want your answer to count towards the total score». This complementary assessment was integrated in the FIPRACS for its ease of use.

Within the FIPRACS, the evaluation of psychoaffective elements is based on the Rorschach projective test. This choice is firstly based on the notion that combining psychodynamic and neurocognitive assessments can facilitates the comprehension of clinical and institutional difficulties (82, 83). Furthermore, the Rorschach Assessment Comprehensive System is considered valid for certain psychoaffective aspects owing to a recent meta-analysis (84). Similarly, certain Rorschach indicators using the R-Optimized method have been associated with certain cognitive and social impairments in schizophrenic subjects (85). The model used in the present assessment (psychodynamic model of the Paris school), meanwhile, is currently being validated and features French adult norms (86). The choice of this tool and method was based on the adequacy of the non-figurative material with IDSPMI, its comprehensiveness and the adequacy of the clinical assessments of the subjects observed during our monthly exchanges. The procedure for conducting the Paris school model is based on the enunciation of a non-inductive instruction (ex: What could that be? ») followed by the enunciation of the subject’s responses to the ‘‘choices and rejection test’’ followed by the ‘‘localization of responses’’ phase (86, 87).

The interpretation of the Rorschach test is firstly based on a quantitative analysis supported by the psychogram and its underlying rating: Locations, Determinants, Contents, Qualitative section (88). This analysis is based on the French standards published by Tychey et al. (86). More specifically, the F^% (number of F responses/total number of responses × 100) and the F^+% (number of F⁺ responses and F^+/− responses divided by 2, divided by the total of F × 100) assess the link to concrete reality or conversely to the invasion of the imaginary (86–88). These two indicators allow pinpointing the anchoring and adaptation ability to be anchored in real life of a subject (ibid.). Thereafter, a high A^% (number of animal-type responses (A and Ad)/total number of responses × 100) and a high number of trivial responses (Ban) are considered as a sign of preserved socialization abilities, of social conformism and a social adaptability useful for therapeutic commitment (ibid.). The AI^% (number of Hd + sex + blood responses × 100/number of responses), when greater than 12%, allows determining the presence of disabling anxiety for the subject (ibid.). Other indicators such as the variety of contents or the variety of Locations attest to the flexibility of psychic functioning (ibid.) whereas the presence of kinesthetics (movement, posture, relationship) is synonymous with relational capacities (86, 89). Lastly, the number of “shock” responses (Choc R, Choc N, Choc M, Choc au blanc, Eq choc) allows pinpointing putative traumatic traces or deep psychological impairments depending on the latent content of the card (86, 88).

In terms of qualitative analysis, the use of a self-representation grid (89, 90) attests to the narcissistic foundations and the integrity of the subject’s body image (86). Thereafter, the identification of the object relation modalities of the subject provides insight on the relational valences and potential psychic conflicts (depending on the latent content of the card) that the subject can unfold (91). The ensuing study of the type of anxiety and the identification of the defense mechanisms allow enlightening the team on the subject’s psychoaffective strategies (88). In addition, the sequence of responses (progredient or regredient processes) allows ascertaining the presence of an instability or decompensation of the subject and his/her restoration capacities in the event of psychoaffective difficulties (ibid.).

The final assessment axis encompasses the subject’s pulsionality and its transformation (92). Based on the vibrancy of the imaginary (number of responses, number of kinesthetics, F^% and F^+%, the variety of gaps and contents, etc.), on mentalization capabilities (successful affect-representation associations obtained by a combination of drive and formal determinants) and the quality of symbolization (qualitative analysis of the responses according to phallic, feminine and aggressive symbolism), it is possible to propose an estimate of the subject’s mentalization and symbolization capacities (93). These capabilities allow facing new situations or to demonstrate the ability to develop. In addition, this indicator provides additional light on the presence of operative functioning, the possibilities of acting out as well as certain obstacles to therapeutic development. Lastly, the sensitivity to latent content and the representations of parental images (86) shed insight on the subject’s interactions with the team and his/her social environment.

The last axis of the FIPRACS combines a psychiatric evaluation including the clinical data, the diagnostic elements, the possible reflections pertaining to medication incidence as well as an assessment of clinical and psychosocial elements carried out by the care team, partners and sometimes by family members or loved ones. This collection of observations is furthermore enhanced when supplemented by precise elements stemming from the daily life of the subject. This approach also allows ascertaining the functional repercussions originating from the psychoaffective register, but also to estimate the functional repercussions of the neurocognitive disorders (61). It also benefits from supplementation with the Functional Repercussion Scale (FRS) thus allowing adapting PSR support to the difficulties of daily life of the accompanied individuals (94). Upon completion, this collection allows the emergence of exchanges between the assessing team and the subject being evaluated regarding his/her difficulties and the desired areas for improvement.