SAMHSA's National Mental Health Information Center

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About the Toolkits

Illness Management and Recovery

Assertive Community Treatment

Family Psychoeducation

Supported Employment

Co-occuring Disorders: Integrated Dual Diagnosis Treatment

Feedback Form

Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Illness Management and Recovery Fidelity Scale

Protocol: Item Definitions and Scoring

Initial Questions:

Which practitioners are providing IMR training? Which consumers have you identified as receiving IMR? The fidelity assessment refers only to these practitioners and consumers.

Note: The program leader identifies who is defined as the IMR sample. The fidelity ratings will be influenced by the definition of the target population of consumers receiving the IMR interventions. If the definition is inclusive, the site will have a high penetration rate but possibly a low fidelity rating. Conversely, if the group is restricted to a small number, the site will have a low penetration rate but possibly a high fidelity rating.

In the questions below, the wording of the program leader interview should be modified, prefaced with the phrase, “Do the practitioners you supervise in providing IMR…”

1. # People in a Session or Group

Definition: IMR is taught individually or in groups of 8 or less consumers.

Rationale: IMR can be taught using either an individual or group format, each of which has its advantages. The main advantages of the individual format include individualized pacing of the teaching and increased attention. Group format, on the other hand, provides consumers with more sources of feedback, support, role models, and may be more economical; however, if the group size exceeds 8 consumers, individualized attention and participation by all consumers are likely to be compromised.

Sources of Information:

a) Program leader and practitioner interviews.

“Do you teach IMR both individually and in a group format?” [If yes] “On what condition do you provide individual sessions?”
“How many consumers were in the largest group you have taught in the last 6 months?”

b) Consumer interview.

“Do you attend individual or group IMR sessions? Did you have a choice between the two formats?”
“How many consumers were in the largest group you have ever attended?”

Item Response Coding: If all IMR sessions are taught individually or in groups of 8 or less consumers, the item would be coded as a “5”. In some programs more than one practitioner may co-instruct a large group session. In such a case, the rating depends on the amount of individual attention given during the session. For example, if 3 practitioners break up a class of 15 consumers into smaller groups of 5 for discussion and/or exercises, then the item would be coded as a “5”.

2. Program Length

Definition: Consumers receive at least 3 months of weekly IMR sessions or an equivalent number of IMR sessions (e.g., biweekly for at least 6 months).

Rationale: In general, between 3 and 6 months of weekly sessions are required to learn the information and skills in the modules of IMR, depending on the frequency/duration of sessions, the consumer’s prior knowledge and level of skills, and the presence of cognitive impairment or symptoms that may slow the learning process. Following completion of all modules, consumers may also benefit from booster sessions or support groups aimed at using and expanding skills.
Note: Fidelity assessors should rate the scheduled duration of the training as planned by the practitioner. Consumers who drop out prematurely should be excluded from consideration of
program length.

Sources of Information:

a) Chart review for consumers who completed the program.
Look for frequency of sessions and program length per consumer.

b) Program leader and practitioner interviews.

“How long and how often are your IMR sessions?”
“On average, how long does it take for a consumer to complete your IMR program?”
“Do you find that some consumers only require a couple of sessions of IMR?”

c) Consumer interview.

“How often do you attend the IMR sessions here? How long is a session?”
“How long have you been with this program?” [If less than 3 months] “How long do you plan to continue with this program?”

Item Response Coding: If = or > 90% of IMR consumers receive weekly or an equivalent number of sessions for at least 3 months, the item would be coded as a “5”.

3. Comprehensiveness of the Curriculum

Definition: Curriculum materials for each of the following nine topic areas are available for IMR practitioners to use in their sessions:

Recovery strategies
Practical facts about mental illness and treatment
The stress-vulnerability model (i.e., an illness results from an enduring
Predisposition that interacts with environmental stress to cause illness)
Building social support
Effective use of medication
Reducing relapses
Coping with stress
Coping symptoms
Getting needs met in the mental health system

Rationale: Studies of professionally based IMR training programs have identified these 9 areas as key topics. The more comprehensive the curriculum, the more beneficial the program is to the participating consumers.

Sources of Information:

a) Program leader and practitioner interviews.

“What kinds of topics are covered in the IMR sessions?”
“Is there an established curriculum for the IMR sessions?” [If yes] Request a copy for review. “Who developed the curriculum?”
[To Program leader] “Do you provide practitioners with training on the curriculum? How do you make sure that the practitioners follow it?”
[To practitioners] “Have you received training on the curriculum?”

b) Educational curriculum and handouts review.

Look to see if the curriculum and handouts adequately cover the 9 areas.

Do handouts reflect program philosophy and critical ingredients of IMR?

Item Response Coding: If the IMR curriculum materials cover 8 or more topic areas, the item would be coded as a “5”.

4. Provision of Educational Handouts

Definition: All consumers participating in IMR receive IMR handouts.

Rationale: An educational handout summarizes the main teaching points in plain language and includes useful forms and exercises. These handouts can be reviewed in the session as well as outside the session (e.g., for homework assignments). In addition, consumers can share the handouts with significant others to inform them about IMR.

Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of provision of educational handouts.

b) Educational curriculum and handouts review.

Look to see if the cu16rriculum and handouts adequately cover the 9 areas.

Do handouts reflect program philosophy and critical ingredients of IMR? Are they written in simple language, tailored to both consumers and their significant others (i.e. information specifically for consumers as well as information specifically for significant others), and visually effective (e.g. information is presented in an attractive and organized way)?

c) Program leader and practitioner interviews.

“Do you provide consumers with educational materials? [If yes] Request a copy for review. “Who developed them?”
“Do all IMR consumers receive them? When do you provide them (e.g. upon admission, in class)? How do you use them in the session?”
“What do you provide for consumers who cannot read?”

d) Consumer interview.

“Do you use an educational handout/text in the IMR sessions?”
“When did you get the handout/text?
“How do you use the handout/text inside and outside the session?”

Item Response Coding: If = or > 90% of IMR consumers receive written (or alternative) educational materials, the item would be coded as a “5”.

5. Involvement of Significant Others

Definition: Significant others refer to family members, friends, or any other individual in the consumer’s support network excluding professionals. “Involvement” is defined here as at least one IMR-related contact in the last month between the practitioner and the significant other OR the significant other’s involvement with the consumer in pursuit of goals identified in the IMR plan, such assisting the consumer with homework assignments.

Rationale: Research has shown that social support has been found to help people generalize information and skills learned in sessions to their natural environment, leading to better social functioning. Social support also plays a critical role in reducing relapse and hospitalization in persons with SMI. Because developing and enhancing natural support is one of the goals of IMR, consumers are encouraged to identify significant others with whom they can share the handout materials and who will support them in applying newly acquired skills. However, the decision to involve significant others is the consumer’s choice.

Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of involvement of significant others.

b) Practitioner interviews.

Go through the entire roster of IMR consumers. For each consumer, ask if a significant other(s) has had a least one contact with IMR staff in the last month or worked with consumer to attain IMR goals.

“In what way do you involve consumers’ significant others? Then probe for specifics, e.g., frequency of contact, frequency of homework assignments that require participation of significant others.
“What do you do if a consumer refuses to involve his/her significant others?”

c) Consumer interview.

“Are your family members or friends involved in your treatment?” [If yes]
“In what way?”
“Do they help you with your homework?”
“Have they attended the sessions with you?”
“Do they have regular contact with your practitioners?”
“What has the program done to get them involved?”
“Do you want them to be more involved?”

Item Response Coding: If = or > 90% of IMR consumers involve significant others (i.e., at least monthly contact reported by the practitioner, or involvement reported by the consumer), the item would be coded as a “5”.

6. IMR Goal Setting

Definition: Practitioners help consumers identify realistic and measurable goals. The goals should be pertinent to the recovery process and can be very individualized, but there should be linkage between the goal and the IMR plan.
Rationale: One of the objectives of the IMR program is to help consumers establish personally meaningful goals to strive towards. In addition to being teachers, practitioners are collaborators in helping the consumers learn how to cope with their illness and make progress towards their goals.

Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of IMR goal(s) and collaborative goal setting process. (Examples are given in the IMR practitioner workbook).

b) Program leader and practitioner interviews.

“Please describe the process of IMR goal setting.”

c) Consumer interview.

“What are your goals for IMR? Did your practitioner ask what your goals were?”Item Response Coding: If = 90% of IMR consumers have at least 1 measurable personal goal(s), the item would be coded as a “5”.

7. IMR Goal Follow-up

Definition: Practitioners and consumers collaboratively follow up on goal(s) identified in Item 6.

Rationale: A core value of IMR is to facilitate consumers’ pursuit of their goals and progress in their recovery at their own pace. Therefore, the goals and the steps to be taken toward the goals need ongoing evaluation and modification.

Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of follow-up on IMR goal(s) (Examples are given in the IMR practitioner workbook).

b) Program leader and practitioner interviews.

“Do you review the consumers’ progress towards achieving their IMR goal(s) on a regular basis?” [If yes] “How often? Please describe the review process.”
“What do you do if a consumer would like to change his/her IMR goal(s)?”

c) Consumer interview.

“Do you and your practitioner together review your progress toward achieving your personal goal(s)? [If yes] How often? Please describe the review process.”

Item Response Coding: If =90% of IMR consumers have documentation of continued follow-up on their goal(s), the item would be coded as a “5”.

8. Motivation-Based Strategies

Definition: Practitioners regularly use motivation-based strategies, which include:

Helping the consumer see how learning specific information and skills could help him/her achieve short and long-term goals
Helping the consumer explore the pros and cons of change
Helping the consumer put past experiences in more positive perspectives
Instilling hope and increasing self-efficacy (i.e., belief that the consumer can achieve the goal).

Rationale: Motivation-based strategies reflect the understanding that a therapeutic relationship must be established before attempting to address IMR. Furthermore, unless consumers view learning specific information or skills as being relevant to their own needs or desires, they will not be motivated to invest the necessary effort in learning.

Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of motivation-based strategies used in a session.

b) Practitioner interview.

For each of the motivation-based strategies checked in the recent progress/session notes, probe for details by asking open-ended questions, e.g., “I notice you checked ‘explore pros & cons of change’ in 6 of 10 sessions. Could you describe the process you used with the consumer to ‘explore pros & cons of change’ in your most recent session.”

c) Consumer interview.

For each of the motivation-based strategies checked in the recent progress/session notes, probe for details using a layperson’s language. For example, if the majority of the progress/session notes reviewed indicate ‘instilling hope & self-efficacy’ as a common practice, ask, “Do the practitioners make you feel hopeful [confident]? Please describe how they made you feel that way in your most recent session.”

Item Response Coding: If = or > 50% of IMR sessions use at least 1 motivation-based strategies, the item would be coded as a “5”.

9. Educational Techniques

Definition: Practitioners embrace the concept of and regularly apply educational techniques, which include:

Interactive teaching: Frequently pausing when presenting information to get the consumer’s reaction and perspective, talking about what the information means, and clarifying any questions that may arise.
Checking for understanding: Asking consumers to summarize information in their own language rather than asking yes or no questions, such as, “Did you understand?”
Breaking down information: Providing information in small chunks
Reviewing information: Summarizing previously discussed information (both by the practitioner and the consumer)

Rationale: Educational techniques are the pillars in teaching basic information and ensuring that consumers understand. For example, interactive teaching not only makes learning an interesting and lively activity, but also conveys to consumers that they have important contributions to make to the learning process and that the practitioner is interested in what they have to say.

Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of educational techniques used in a session.

b) Practitioner interview.

For each of the educational techniques checked in the recent progress/session notes, probe for details by asking open-ended questions, e.g., “I notice you checked ‘interactive teaching’ in 6 of 10 sessions. Could you please describe the ‘interactive teaching’ in your most recent session.”

c) Consumer interview.

For each of the educational techniques checked in the recent progress/session notes, probe for details using a layperson’s language. For example, if the majority of the progress/session notes reviewed indicate ‘checking for understanding’ as a common practice, ask, “Do the practitioners check your understanding of the material covered during the session? Can you think about your most recent session and describe how they made sure you understood what was covered in the session.”

Item Response Coding: If = or > 50% of IMR sessions use at least 1 educational technique, the item would be coded as a “5”.

10. Cognitive-Behavioral Techniques

Definition: Practitioners regularly use cognitive-behavioral techniques to teach IMR information and skills, which include:

Positive reinforcement: Positive feedback following a skill or behavior designed to increase it or to encourage a consumer’s efforts to use a skill.
Shaping: Reinforcement of successive approximations to a goal. The practitioner recognizes the multiple steps and individualized pacing necessary for consumers to learn complex skills, and provides frequent reinforcement as they progress toward the goal.
Modeling: Demonstration of skills.
Role playing: A simulated interaction in which a person practices a behavior/skill.
Cognitive restructuring: Practitioners help the consumer describe the situation leading to the negative feeling, make a link between the negative emotions and the thoughts associated with those feelings, evaluate the accuracy of those thoughts, and, if they are found to be inaccurate, identify an alternative way of looking at the situation that is more accurate.
Relaxation training: Teaching strategies to help consumers relax.

Rationale: There is strong evidence for the efficacy of cognitive-behavioral techniques in helping consumers to develop and maintain social skills, use medication effectively, develop coping strategies for symptoms, and reduce relapses.
Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of cognitive-behavioral techniques used in a session.

b) Practitioner interview.

For each of the cognitive-behavioral techniques checked in the recent progress/ session notes, probe for details by asking open-ended questions, e.g., “I notice you checked ‘cognitive restructuring’ in 6 of 10 sessions. Could you describe the ‘cognitive restructuring’ in your most recent session.”

c) Consumer interview.

For each of the motivation-based strategies checked in the recent progress/session notes probe for details using a layperson’s language. For example, if the majority of the progress/session notes reviewed indicate ‘role playing’ as a common practice, ask, “Do you get to practice new skills with others in the session [or as a homework]? How often? Could you give us examples from your most recent session?”

Item Response Coding: If = or > 50% of IMR sessions use at least 1 cognitive-behavioral technique, the item would be coded as a “5”.

11. Coping Skills Training

Definition: Practitioners embrace the concept of, and systematically provide, coping skills training that includes:
Exploring the coping skills currently used by the participant;
Amplifying the current coping skills and/or teaching new coping strategies;
Behavioral rehearsal of the coping skill;
Evaluating the effectiveness of the coping skill; and
Modifying the coping skill as necessary.

Rationale: Coping skills training is used to improve the ability of consumers to cope with persistent symptoms.
Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of coping skills training in a session.

b) Practitioner interview.

For each practitioner who checked coping skills training in the recent progress/ session notes, probe for details by asking open-ended questions, e.g., “I notice you checked ‘coping skills training’ in 6 of 10 sessions. Could you describe the ‘coping skills training’ methods you used in your most recent session?”

c) Consumer interview.

If coping skills training is indicated in the recent progress/session notes as a common practice, probe for specific components using a layperson’s language, e.g., “Have you talked about or learned new coping skills in your recent sessions? Could you give me some examples?”

“Do you feel more confident today in your ability to cope with symptoms?”

Item Response Coding: If all practitioners are familiar with and regularly practice coping skills training, the item would be coded as a “5”.

12. Relapse Prevention Training

Definition: Practitioners embrace the concept of and systematically apply relapse prevention training that include:

Identification of environmental triggers;
Identification of prodromal signs;
Stress management;
Ongoing monitoring;
Rapid intervention when indicated

Rationale: Studies have shown that training in relapse prevention strategies is effective in reducing symptom severity, relapses, and rehospitalization.

Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of relapse prevention training in a session.

b) Practitioner interview.

For each practitioner who checked relapse prevention training in the recent progress/ session notes, probe for details by asking open-ended questions, e.g., “I notice you checked ‘relapse prevention training’ in 6 of 10 sessions. Could you describe the ‘relapse prevention training’ methods you used in your most recent session?”

c) Consumer interview.

If relapse prevention training is indicated in the recent progress/session notes as a common practice, probe for specific components using a layperson’s language, e.g., “Have you discussed ways that you can avoid going back to the hospital your recent sessions? What kind of things did you learn about relapse prevention?”

“Do you feel more confident today in your skills in preventing relapse?”

Item Response Coding: If all practitioners are familiar with and regularly practice relapse prevention training, the item would be coded as a “5”.

13. Behavioral Tailoring for Medication

Definition: Practitioners embrace the concept of and use behavioral tailoring for medication. Behavioral tailoring includes developing strategies tailored to each individual’s needs, motives and resources (e.g., choosing medication that requires less frequent dosing, placing medication next to one’s toothbrush so it is taken always before brushing teeth).

Rationale: Behavioral tailoring is especially effective in helping consumers manage their medication regime as prescribed.
Sources of Information:

a) Chart review (especially IMR progress/session notes).

Look for documentation of behavioral tailoring in a session.

b) Practitioner interview.

For each practitioner who checked behavioral tailoring for medication in the recent progress/session notes, probe for details by asking open-ended questions, e.g., “I notice you checked ‘behavioral tailoring for medication’ in 6 of 10 sessions. Could you describe the ‘behavioral tailoring for medication’ methods you used in your most recent session?”

c) Consumer interview.

If behavioral tailoring for medication is indicated in the recent progress/session notes as a common practice, probe for specific components using a layperson’s language, e.g., “Sometimes we miss taking medication and regret it later. Have you and your practitioner discussed what you can do at home to prevent that? Could you give us some examples of the strategies?”

“Do you feel more confident today in taking medication as prescribed?”

Item Response Coding: If all practitioners are familiar with and regularly practice behavioral tailoring, the item would be coded as a “5”.

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