Chapter 8 190 recovery. For completers, on the client version of the illness self-management scale, the effect size was 74% greater (d =.59), and now the clinician version of the IMR scale also showed an effect (d =.62). Moreover, an effect was found on overall personal recovery measured using the Mental Health Recovery Measure (MHRM), a composite measure of personal recovery (d =.34). These results support the impact of IMR on illness self-management and on personal recovery (Chapter 5). Fidelity and clinical competence Providing all 20 IMR elements adequately requires a variety of advanced clinical skills of IMR-practitioners In 15 IMR groups, the implementation of IMR elements was measured using both the IMR Fidelity Scale and the IMR Treatment Integrity Scale (IT-IS). Twelve IMR elements (60%) were adequately implemented. However, eight IMR elements (40%) were insufficiently implemented: the involvement of significant others, cognitive-behavioral techniques, behavioral tailoring for medicine, relapse prevention training, coping skills training, IMR goal follow-up, weekly action planning, and action plan review. Though motivational and educational skills were sufficiently implemented, cognitive-behavioral skills were not, including the critical techniques of role-playing, modeling, and giving home assignments. The IT-IS appeared to have added value because the more detailed operationalization of the IT-IS items provided a more precise and stricter direction for scoring than the IMR Fidelity Scale. Moreover, IT-IS includes some relevant additional items, such as action plan review, weekly action planning, and structure/efficient use of time. Therefore, IT-IS seems well suited for use in advanced training and supervision (Chapter 6). Exploring the working mechanisms of IMR Our findings provided only partial support for the IMR conceptual framework The working mechanisms underlying IMR have been suggested in a conceptual framework indicating that changes in illness self-management skills over time are associated with changes in personal and functional recovery mediated by changes in clinical recovery (Chapter 1). A cross-sectional analysis using baseline data showed support for this framework because coping appeared to be a determinant of all three types of recovery, and social support was a determinant of functional recovery. Coping and social support are components of illness management. However, in contrast to this framework, direct associations between coping and
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