Fidelity and clinical competence in providing IMR 157 other involvement—were among the seven elements with the lowest fidelity in the present study (36). In another study, results regarding the lower scoring items on the IT-IS were also quite similar (32). However, in the overview of elements in this study, data for the three optional items were excluded. The similarities between the results of these three studies appear to support generalization. This provides direction for improvement efforts in the future. However, it should be noted that comparing the IT-IS ratings in this study with those from previous research that also used this scale should be done with caution considering differences in how the instrument was used. Relevance and interrelationship of the poorly implemented elements Providing IMR requires mastery of a variety of advanced clinical skills (36). In our view, the reasons for the poor implementation of the eight IMR elements might be interrelated, as most of these elements involve cognitive-behavioral skills. This is outlined in the following two sections, using a guide to IMR implementation (6). Setting and follow-up on personal goals are central elements of IMR (3, 6, 32, 36). At the start of the curriculum in IMR Module 1, individual goals are set to work on the IMR training. Supporting participants in following up on goals (1) by using goal charts should be a routine part of every IMR session (6). This goal follow-up involves action planning (2), wherein goals are broken down into smaller, intermediate goals, allowing one to work step by step toward achieving the goals as home assignments between sessions. This facilitates the evaluation of progress in the action plan review (3) every session. Achieving personal goals is more successful when there is close cooperation among participants, trainers, and significant others (4) (6). In coping skills training (5), after modeling by the trainer, newly selected coping strategies are practiced during the IMR session. Subsequently, a home assignment is developed with the participant to practice the coping skill independently (6, 40). This may also include coping skills training to respond to a trigger of relapse or early warning signs, as part of the implementation of a relapse prevention plan (6). In such a plan, significant others may be quite important to include because they may help identify those signs and triggers. Home assignments regarding taking medications may be linked to participants’ recovery goal. It may include reviewing the benefits and side effects of medications with a significant other. If a participant has decided to take medication, they could make an action plan to use behavioral tailoring of medication (7) or practice talking to the doctor in a role-play. Central to the implementation of all these IMR elements should be the use of cognitive-behavioral techniques (8), especially techniques for behavioral
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