General introduction 17 clients learn self-management strategies and pursue their personal goals, which is a major part of IMR. Theoretical foundation of IMR The theoretical foundation of IMR relies on two models, the trans-theoretical and stress-vulnerability models (56, 84, 85). The trans-theoretical model holds that people are more motivated to acquire new behaviors if the types of intervention are adjusted to their current stage of change. This makes it easier for individuals to become aware of their problems, make decisions, and implement and sustain changes (86, 87). In line with the stress-vulnerability model, IMR trainers teach participants the basics of illness (self-) management, enabling them to reduce substance use, improve adherence to medication, increase coping and social support, and become involved in meaningful activities. This may improve illness outcomes such as symptoms, relapse, and hospitalization (short-term goals). Then, through the combination of pursuing personal goals and improving illness selfmanagement, the long-term goal of IMR is to help clients progress toward recovery, including objective (e.g., community functioning, social relationships, work) and subjective (e.g., sense of purpose, hope, confidence) recovery. The working mechanisms underlying IMR have been combined in a hypothetical conceptual framework, indicating that changes over time in illness selfmanagement skills are associated with changes in personal and functional recovery, mediated by changes in clinical recovery (56), see Chapters 3, 4 and 7, and Figure 1. Guidelines for IMR implementation are given in the IMR toolkit (88, 89), a guide to IMR implementation (90), several IMR implementation papers (58, 59, 91, 92), and three IMR fidelity scales: the IMR fidelity scale (93), IMR Treatment Integrity Scale (IT-IS) (94), and IMR General Organizational Index (GOI) (95). For the implementation of IMR in Bavo-Europoort Rotterdam in 2008-2009 (now merged into ANTES), an extensive implementation trajectory was followed after a visit to the United States (96) (see Chapters 2 and 5). This thorough initial implementation process included drafting an implementation plan; holding plenary meetings with all outpatient practitioners and members of the client council; forming a steering, implementation, and training committee; editing translated handouts and workbooks; holding a two-day training for trainers and supervisors; setting up supervision groups; starting six IMR groups; and launching a pilot study (97) (Chapter 2).
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