Chapter 6 160 the training and supervision of IMR trainers to improve the quality of IMR implementation. In addition, we were able to determine the relative value of the IT-IS to the standard IMR Fidelity Scale. During the execution of this study, IMR had become a part of routine mental healthcare in both institutions. For this study, there were only limited changes in routine mental health care in each institution. Therefore, the results may be generalizable to other sites. Generalization might also be supported by the similarities in outcomes between this study and two other studies that examined IMR fidelity at the item level (McGuire et al., 2012; McGuire et al., 2016a). However, 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. In addition to other elements, both scales measure eight of the same IMR elements. The two scales were scored sequentially per assessor. Therefore, scoring on two scales of the same IMR elements could have influenced each other. However, the elements were scored with the two scales from a different perspective. Moreover, two different manuals were applied, and scores were discussed separately for each scale by the two assessors. The rating of both scales may have been limited by only including one observational session. However, the manual of the IMR Fidelity Scale specifies that after interviews and chart review, only one session must be observed. Conversely, the ITIS rating should be based on observations of IMR sessions (live or based on audio or audiovisual recordings). Therefore, in this study, we adapted the IT-IS rating procedure based on the IMR Fidelity Scale rating procedure and used extended interviews. We thus suggest the results of this study are relevant. Finally, realization of organizational conditions is critical to successful IMR implementation (21, 39, 43, 44). In this study, however, we chose to focus on adherence to the IMR model and the fidelity of the competencies of IMR trainers. Conclusions Adequate fidelity in IMR implementation is important for many reasons, one of which is the impact on IMR outcomes. Proper IMR implementation requires trainers with a broad set of advanced knowledge and specific clinical skills. The majority of IMR elements appeared sufficiently implemented. However, for most IMR trainers, eight relevant IMR elements regarding clinical skills were found to be difficult to implement. Some cognitive-behavioral skills, especially using role-play, modeling,
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