Fidelity and clinical competence in providing IMR 147 curriculum is applied (i.e., coping skills training, relapse prevention planning, and behavior modification for medication); two items are only scored if IMR is taught in groups (i.e., involvement of group members and mutual support between group members) (7). Unlike the IMR Fidelity Scale, the scoring system of the IT-IS includes so-called indicators of excellence, which reflect both characteristics of the use of the element (e.g., for recovery orientation, the provider maintains a “non-judgmental” attitude) or specific techniques (e.g., “shaping” for cognitive-behavioral techniques) (36). Often, the explanation of the indicators of excellence in IT-IS is quite detailed. For example, the explanation for shaping is “the reinforcement of successive approximations to a skill or a goal.” An example of one of the seven indicators of cognitive-behavioral techniques regarding cognitive restructuring is “helping the client describe the situation leading to the negative feeling, make a link between the negative emotions and the thoughts associated with those feelings, evaluate the accuracy of those thoughts, and, if they are found to be inaccurate, identify an alternative way of looking at the situation that is more accurate” (7). Another example is that for motivational enhancement strategies, indicators of excellence are listed concerning seven IMR principles: evocation, development of discrepancy, collaboration, autonomy/support, rolling with resistance, direction, and empathy. Moreover, for each principle, examples of proficient execution and a violation are provided (7). More than the IMR Fidelity Scale, the IT-IS protocol indicates that specific aspects of an element must be present in practice for it to achieve certain scores. For example, “note that the client must have completed the action plan for there to be evidence for the last two indicators; the action plan integrated material into their recovery and goals, and had an obvious positive effect on recovery” (in action plan follow-up) (7). In scoring, raters should even penalize for missed opportunities to apply cognitive-behavioral techniques (7). Therefore, it is the presence or absence of a clinician’s behavior that must be scored. Psychometric analysis of the IT-IS has demonstrated excellent inter-rater reliability, good factor structure validity, and acceptable internal consistency and discriminant validity (32). Procedures The principal investigator and one of the two co-auditors conducted IMR fidelity assessments during one-day visits to each of the 15 IMR groups. Both assessors scored independently following a standard procedure and manuals (24). In case of
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