Chapter 5 130 group cohesion and thus attendance. In addition, to promote completion, the two respective RCTs on IMR that had the highest percentages of completers selected participants based on earlier treatment adherence (23, 24) and applied the total IMR curriculum using home-visits (28). However, choosing one or more of these options will not be preferred or feasible at all practices and centers. Although our study demonstrated positive results, the observed effects were small. We observed a statistically significant effect on illness self-management within the client version of the IMR scale (p = 0.048). Although we found effects on personal recovery, there were limited effects on other secondary outcome measures in the current study. These limitations could be attributed to several potential reasons. First, IMR training may not be sufficiently specific for generating statistically significant effects on the separate components of illness self-management. This limitation may be associated with the multiplicity of IMR objectives, as shown in the previously published conceptual framework for IMR (3). Second, participants in both experimental conditions showed improvement in five domains over time as follows: clinician-rated overall illness management, social support, clinical and functional recovery, and self-stigma. These findings may be attributed to the positive effects of CAU, given that many clinicians in the Netherlands have been trained in psychiatric rehabilitation methodologies, including the Boston University Approach to Psychiatric Rehabilitation (69). Additionally, standard outpatient treatment and care have evolved into the FACT model. FACT (Flexible ACT) is a rehabilitation-oriented clinical case management model; a flexible version of ACT (70). Third, in our study, most of the IMR practitioners (community mental health nurses and social workers) had no specific training in the empirically supported strategies underlying IMR, including cognitive behavioral approaches and skills training. Thus, while the facilitators may have had training in rehabilitation skills and attitudes, other specific clinical skills required for the successful implementation of IMR were often insufficient. Moreover, with respect to IMR group training, it may be challenging to provide these EBPs based on the required protocols. This challenge was partly reflected in the observed fidelity scores. Our study observed improved outcomes in only one of the eleven secondary outcomes in the intervention group. Sensitivity analyses for completers revealed improved outcomes in the intervention group for four of the eleven secondary outcomes. These effects were not observed following Benjamini-Hochberg correction for multiple testing. However, multiple adjustment methodologies have been criticized within the statistical, epidemiological, and medical literature (63, 71). For example, some researchers have indicated that multiple correction methodologies mechanize, and therefore trivialize, interpretative problems. In
RkJQdWJsaXNoZXIy MjY0ODMw