Illness Management and Recovery

1. Illness Management and Recovery Implementation of the IMR Program Kim T. Mueser

2. Organizational Structure for Implementing IMR

3. Should IMR be Implemented by all Clinicians / Case Managers? IMR involves extensive set of skills, useful for all clinicians, but requires time to implement for everyone Substantial burden of supervision needed if all clinicians / case managers trained Probably need multiple supervisors per agency, and also IMR Program Leader More rapid dissemination of IMR, but probably slower to reach high fidelity

4. Should IMR be Implemented by IMR Specialists? Allows training to focus on selected clinicians who develop IMR expertise IMR specialists can be drawn from broad range of services provided by agency IMR specialists educate other mental health workers about IMR, integration of recovery goals into treatment planning, etc. Allows training resources to be concentrated on fewer clinicians, permitting more rapid attainment of fidelity, but at cost of slower penetration rate

5. Concept of the “IMR Team” An IMR team is a group of clinicians, supervisors, and administrators who are responsible for implementing IMR services at an agency The clinicians and supervisor on a team meet regularly for IMR supervision Other responsibilities include educating other staff members, consumers, and family members about IMR program IMR services can be implemented at an agency by forming a single IMR team or multiple teams

6.  Members of IMR Team IMR Clinicians IMR Consumer Providers (optional) IMR Supervisor IMR Coordinator/Program Leader (may be same person as supervisor) Agency Director

7. IMR Clinicians and IMR Consumer Providers 3-8 per treatment team (depending on number of consumers served by the team) 2 days initial training & 1-2 days follow-up Are expected to work with at least 3-5 consumers (or lead 2-3 groups) in the first year Have protected time for providing IMR and attending supervision

8. IMR Clinicians and IMR Consumer Providers, continued Receive weekly supervision focused on IMR Receive consultation from experienced IMR clinician (when possible) Start working with consumers within 4 weeks of 2-day IMR training Have accountability for providing IMR (e.g., part of job description)

9. IMR Coordinator/Team Leader Coordinating IMR is in job description Specific proportion of his or her time is designated and protected for providing and coordinating IMR Receives IMR training and works with some consumers using IMR Provides IMR supervision (may oversee other IMR supervisors in large agency with multiple IMR teams)

10. IMR Coordinator/Team Leader, continued Establishes and monitors IMR referral process Assures that referred consumers receive IMR Monitors the quality and quantity of IMR services delivered at the agency Reports to the agency director and meets regularly with him or her

11. Agency Director Shows Interest and Support by: Attending training Attending some supervision sessions Meeting regularly with IMR Coordinator/Team Leader Troubleshooting obstacles to IMR

12. Supervision/Consultation Weekly group supervision by agency IMR supervisor, not more than 8 clinicians Review cases Discuss goals, share treatment formulations, troubleshoot problems Role play challenging situations Structure regular case consultations

13. Supervision/Consultation, cont’d Selected teaching of core skills Evaluate engagement of consumers, integration of IMR with team, involvement of significant others Twice monthly the IMR trainer will provide phone consultation during the regular supervision time (optional)

14. Implementation of IMR in Acute Care & State Hospital Settings Different organizational structure required In long-term settings, importance of building support staff into overall IMR team concept to ensure transfer of skills In acute care settings, breaking of IMR curriculum into briefer subtopics that can be covered simultaneously Long-term potential to integrate inpatient & outpatient IMR by employing same language & continuous work towards consumers’ goals

15. Other Issues Regarding the Implementation of IMR

16. Example of Training Outline 2-day initial IMR foundation training 1-day training in motivational interviewing (3-6 months later, but can precede foundation training) 1-day training in CBT (6-9 months later) 1-day advanced training (12-15 months later; also addresses train-the-trainer) Biweekly telephone phone consultation with IMR trainer (min. 6 months)

17. Consumers as Providers Consumer-practitioner team model Developed by Michelle Salyers (currently under evaluation) Implemented on ACT teams Consumers can provide IMR given same training and supervision as practitioners Most experience with consumers as providers has been in the context of mental health agencies rather than peer support

18. Distinctions Between Wellness Recovery Action Plan (WRAP) & IMR WRAP almost always delivered by consumer; IMR most often provided by mental health professional IMR designed to incorporate specific empirically supported strategies for improving illness self-management (psychoeducation, behavioral tailoring for medication, relapse prevention, coping skills training, social skills training); WRAP limited mainly to relapse prevention & recommending coping skills WRAP provides no information about “mental illness” (term is eschewed); IMR provides information about major mood disorders & schizophrenia-spectrum disorders

19. Distinctions Between WRAP & IMR, continued Primary teaching approach in WRAP is providing information & inspiration provided by teacher; IMR employs educational, motivational, & cognitive-behavioral teaching strategies IMR organized around consumer identifying goals related to personal vision of recovery, & striving towards achieving those goals; WRAP assumes that consumers know what they want & is not aimed at helping consumers work towards personal goals WRAP relatively short-term, compared to longer-term IMR IMR & WRAP compliment each other, with some but not much overlap in content

20. Group vs. Individual IMR Agencies recommended to be able to provide group & individual IMR Each format has its own unique advantages Group IMR more economical, consumers benefit from mutual support & role modeling, can be conducted on rotating curriculum basis (recovery strategies done individually & the remaining topics covered in group on a rotating basis with new consumers joining at beginning of a module) Individual IMR better for some severe impaired consumers, people who are difficult to engage in groups, when conducting outreach, in rural areas Practical plan: offer IMR in groups first, then provide individually if consumer can’t be engaged; in rural areas, individual may be primary choice

21. Challenges in Implementing IMR *Protected time to identify consumers, prepare for IMR sessions & conduct them, & attend supervision (time requirements for preparation decline significantly after first year) Lack of clear expectations on clinicians providing IMR regarding minimal # of IMR cases treated following initial training, resulting in slower than desirable acquisition of skills *Expanding # of cases treated with IMR by clinicians after they are experienced in IMR (e.g., 5-15 cases, depending on other clinical roles) Fitting IMR into clinicians’ regular routines Paperwork challenges trying to get goals set in IMR to match up with treatment goals Setting goals that are both personally meaningful & have been broken down into specifically, behaviorally defined steps *Lack of prior experience among clinicians with motivational interviewing and CBT approaches