Fidelity and clinical competence in providing IMR 155 (involvement of significant others, cognitive-behavioral techniques, behavioral tailoring for medication, relapse prevention training, coping skills training (all five assessed with both scales), IMR goal follow-up (only assessed with the IMR Fidelity Scale), weekly action planning, and action plan review (only assessed with the ITIS)). These results suggest that both scales should be used to obtain a complete picture of IMR implementation. In implementing IMR, three core teaching principles (motivational, educational, and cognitive-behavioral strategies) should be used every session by the trainers to enable skills training for promoting illness self-management (3, 6). Although motivational and educational strategies were sufficiently implemented in this study, cognitive-behavioral strategies were not. The implementation of all eight poorly implemented IMR elements especially requires competence in the cognitivebehavioral techniques of role-playing, modeling, and using home assignments (6). However, these techniques were rarely applied. Relative value of the IT-IS to the standard IMR Fidelity Scale Both instruments aim to assess IMR fidelity. Regarding the different IMR elements assessed by both scales, there is considerable overlap because eight IMR elements are measured by both scales. However, five elements are only assessed by the IMR Fidelity Scale, and eight other elements are only assessed by the IT-IS. There is more overlap because the IT-IS item “goals” combines the items “IMR goal-setting” and “IMR goal follow-up” from the IMR Fidelity Scale. However, separate scoring of these items in the IMR Fidelity Scale seems beneficial, as it is practically relevant to know if "goal setting” is better realized than “goal follow-up,” as it was in the current study. However, despite the observed overlap and high correlation, the description and operationalization of the items, as well as the focus of both scales, are quite different. The IMR Fidelity Scale is considered a more global program-level measure (38), while the IT-IS is a more detailed clinician-level measure. The more detailed operationalization of the IT-IS items appears to have added value because it provides precise direction for scoring and therefore may be used for advanced training and supervision. Furthermore, the IMR Fidelity Scale was developed much earlier (34) and is used more often, which improves comparability across studies (23). To date, in four of the RCTs on IMR, results for the IMR Fidelity Scale were reported (9, 10, 14, 15, 17); and in two RCTs on IMR, the IT-IS was applied (12, 17). In this study, we found that the mean overall score of the IT-IS was 0.65 (16%) lower than the mean overall score of the IMR Fidelity Scale. This appears to be partly due
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