General discussion 199 to facilitate attendance (8). For example, to promote the efficient use of available places at our study sites, the current study had rolling admissions into IMR groups; however, peer support and thus participation may be promoted if groups have a closed enrollment format (8). At one site in our study, the IMR groups had lunch together at each meeting to promote group cohesion and thus attendance. Realization of organizational conditions is critical The realization of organizational conditions is critical for successful IMR implementation (37-41). For example, each IMR practice should have a coordinator/program leader who is given time to perform their duties. This includes establishing and monitoring methods for referring clients to IMR and providing or arranging for the supervision and training of practitioners(41). In addition, the program leader should be empowered and accountable to senior management/a director (38). Practitioners stressed the relevance of their leaders as being positive and involved in IMR and having clear aims and visions for intervention (37). Conclusions Our findings suggest that IMR is an effective intervention for improving generic illness self-management. This is consistent with the findings of most other RCTs on IMR. For this reason, in line with a review and meta-analysis (2) this study supports the relevance of self-management interventions such as IMR. These mental health services deserve more attention and should be part of standard mental health care for people with SMI. Future IMR research is needed to determine whether our effects on personal recovery can be confirmed and to examine causality in the association between improvement in illness self-management and improvement in personal recovery. Future research is also needed to examine the effectiveness of IMR on symptoms, which was found in three of five earlier RCTs. This study may have underestimated the effectiveness of IMR due to challenges in IMR fidelity, IMR completion, and study design. Based on the findings of the current research, we propose a more comprehensive initial and continuing education for IMR trainers to improve high-fidelity IMR implementation, as well as an emphasis on new and innovative strategies focusing on promoting IMR completion. Our results only partially supported the operation of IMR, as suggested in the conceptual framework described by Mueser et al. (1). A possible new variant of the
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