General introduction 21 Research questions This study had four major aims: (1) to explore the effectiveness of IMR; (2) to explore the impact of IMR fidelity and the level of IMR exposure (completion) on IMR efficacy; (3) to comprehensively explore the implementation of the clinical skills of IMR practitioners; and (4) to explore the working mechanisms of IMR based on a conceptual framework. The remainder of this paragraph describes the research questions. The pilot study (Chapter 2) aimed to explore the feasibility of an RCT in the former Bavo-Europoort, a psychiatric institute in Rotterdam (now part of ANTES). To that end, our primary objective in the pilot study was to evaluate support for implementing IMR on a broader scale. Therefore, we examined participant recruitment, client outcomes, and client and clinician satisfaction. The secondary objectives were to evaluate fidelity, trainers’ training, and supervision, and to explore program duration, IMR dropout, and client characteristics related to dropout. Chapter 3 describes the study protocol for the RCT performed as part of this study (Chapter 5). In this multicenter, single-blind RCT, we aimed to compare the effects of IMR plus treatment as usual with treatment as usual alone for outpatients with SMI. We investigated whether IMR leads to better illness self-management, fewer symptoms, fewer relapses (clinical recovery), and better personal and functional recovery. The primary outcome measure was the client version of the IMR Scale, which measures overall illness (self-) management. Secondary outcome measures were the clinician’s version of the IMR scale, measures of illness (self-) management components, and measures of different types of recovery. We also investigated the impact of fidelity and completion on IMR efficacy. Measurements were taken before randomization and at 12 and 18 months after randomization. In Chapter 4, baseline data were used to cross-sectionally analyze the possible associations described in the IMR theoretical model (Figure 1). Our rationale lies in the interrelations among these concepts, as suggested by the IMR conceptual framework. The research questions were as follows: (1) are higher illness management component scores associated with higher clinical recovery scores, (2) are higher clinical recovery scores associated with higher functional and personal recovery scores, and alternatively, (3) are higher illness management scores associated with higher functional and personal recovery scores?
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