General discussion 197 implementation requirements are met including the sample size, (number of) outcome measures, control group, and number of measurement time points. The quality of IMR implementation includes fidelity, completion, and organizational conditions. In addition, future longitudinal research is required to replicate the association between improvements in illness self-management and personal recovery. In our RCT (Chapter 5), we performed measurements at three time points: baseline, after treatment at one year, and a follow-up measurement 1.5 years after baseline. Despite the extra work required, future research might consider adding an additional time point after six months, halfway through the treatment. This could facilitate measurement of goal attainment and longitudinal data analyses. We propose that future research should assess IMR cost-effectiveness and collect cost data using the Trimbos Institute and the Institute of Medical Technology Assessment Questionnaire for Costs Associated with Psychiatric Illness (TiC-P) (34). Goal setting and the follow-up of individual goals are important components of IMR. However, to our knowledge, the impacts of progress on goals and goal achievement on IMR outcomes have not yet been quantitatively assessed. Therefore, future studies should address this issue. However, assessing progress in achieving goals may be challenging. One reason for this is goal shifting within shorter or longer periods, which is not always related to goal achievement. Additional teaching by trainers to support IMR participants in goal setting and follow-up goals could be helpful. The Boston University Approach to Psychiatric Rehabilitation has developed methodologies to support the setting, acquisition, and maintenance of personal goals (35). In future research, closer monitoring of progress toward goals may be required. With respect to IMR model fidelity, the IT-IS was designed to rate the fidelity of clinicians to the IMR program based on observations of treatment sessions (either live, audio recorded, or video recorded) (22, 36). However, the logistics of organizing multiple recordings per IMR group and subsequent assessments were not feasible in the context of our RCT. Therefore, in our fidelity study, the IT-IS assessment procedure was adapted based on the IMR Fidelity Scale protocol (13) (Chapter 6). In this way, we suggest that all IT-IS items could be assessed, and a good picture of IMR competency within each group was obtained. Therefore, for future research, we propose comparing the results obtained using the originally proposed IT-IS protocol with those obtained using the IT-IS protocol as applied in this study. If the results are comparable, there could be substantial efficiency gains
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