Fidelity and clinical competence in providing IMR 143 Introduction Illness Management and Recovery (IMR) is a structured psychosocial intervention developed to support people with serious mental illnesses (SMI). IMR aims to provide support in coping with the physical, social, and emotional consequences of these illnesses (1, 2). In addition, it is designed to help people set and achieve personal goals. Thus, the overall objective of IMR is to facilitate recovery (3). Based on an empirical review of the research literature concerning teaching illness selfmanagement (4), five strategies were integrated into the IMR program: psychoeducation to promote knowledge of SMI and its treatment; behavior modification for medication adherence; relapse prevention training; social skills training to increase social support; and coping skills training for controlling persistent symptoms (3). IMR training consists of 11 modules, manuals, and handouts for the participants. The modules include recovery strategies, basic facts about mental illness, the stress vulnerability model, building social support, effective use of medication, drug and alcohol use, relapse reduction, coping with stress, managing persistent symptoms, meeting mental health needs, and maintaining a healthy lifestyle (5). IMR trainers, i.e., clinicians providing IMR, apply three core teaching principles that should be used in every session (3, 6). These include educational, motivational, and cognitivebehavioral strategies, which are applied in weekly IMR sessions lasting approximately one year. IMR can be conducted in a group or individually. In a group, the session structure includes all participants focusing on the topics of the modules; additionally, during each session, two or three participants follow up on their personal goals on a rotating basis (6, 7). IMR is currently used in several countries across North America, Europe, and Asia. The IMR program is based on a combination of multiple evidence-based practices (EBPs) (4, 8). However, as the results of seven randomized controlled trials (RCTs) on IMR are inconsistent, the effectiveness of the IMR program does not appear evident (9-17). In our recently published RCT, patients who were receiving IMR demonstrated statistically significant improved self-reported overall illness management (the primary outcome), as compared with usual care. In addition, they showed improvement in self-esteem, a component of personal recovery. No effects were found in other domains, including clinical and functional recovery. IMR completion was associated with stronger effects. In addition, high IMR fidelity was found to be associated with self-esteem (17). Altogether, in the mentioned RCTs on IMR, most evidence has been found in overall illness self-management, as measured by IMR scales (9-11, 16, 17). Variations in results may be due to
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