Illness management and recovery

1. Introduction

Version followed: SAMHSA Illness Management and Recovery Evidence-Based Practices KIT (HHS Pub. No. SMA-09-4462, 2009; 10 topics plus Orientation), especially Training Frontline Staff and Practitioner Guides and Handouts. Where it helps, differences from the 2003 first toolkit (9 modules), the Mueser et al. (2006) pilot version, and the Hazelden third edition (Gingerich & Mueser, 2011; 11 modules, including an optional Healthy Lifestyles module and DSM-5 updates) are noted.

Illness Management and Recovery (IMR) is a curriculum-based programme for adults with serious mental illness, mainly schizophrenia-spectrum, bipolar and major depressive disorders. It teaches people to manage their illness so they can pursue goals they themselves define. Mueser and Gingerich built it during the US National Implementing Evidence-Based Practices Project (2000–2002) by packaging five self-management strategies that already had research support: psychoeducation, cognitive-behavioural approaches to medication use (behavioural tailoring), relapse prevention planning, social skills training to strengthen social support, and coping skills training for persistent symptoms. It is a manualised package, not a new single therapy. [source: Mueser et al. 2006; SAMHSA KIT Training Frontline Staff; APA Div 12 entry]

Core idea of change. The model rests on the stress-vulnerability model: symptoms and relapse come from biological vulnerability interacting with stress, and coping buffers the effect. People change outcomes by lowering vulnerability (informed medication use, reducing alcohol and drugs), reducing or anticipating stress, and coping better. A motivational frame drawn from the transtheoretical model runs throughout. The client defines recovery and sets personal goals, and the work is tied to those goals, so the near-term aim (self-management skills) serves the longer-term aim (functioning, meaning, hope). [source: Mueser et al. 2006; Training Frontline Staff Module 3]

2. Framework

Format. Sessions are weekly, or biweekly where agreed, for roughly 3 to 10 months. Individual sessions run about 45–60 minutes. Groups run 45–90 minutes, and the fidelity scale caps them at 8 participants. For people with limited attention, the KIT suggests shorter sessions (20–30 minutes) held two or three times a week. Each client keeps an IMR binder of handouts, with the goal chart at the front, and brings it to every session. Fidelity standards are at least 3 months of weekly sessions (or equivalent), at least 8 of the 10 topics covered, and handouts given to everyone. [source: Training Frontline Staff Modules 1–2; Practitioner Guides and Handouts, Orientation; Evaluating Your Program (IMR Fidelity Scale)]

Phase A: Referral, engagement and orientation (usually 1–3 sessions).

Goals: explain what IMR is and how it is structured, clarify the roles of client and practitioner, agree expectations (regular attendance, collaboration, practising skills, home practice), and learn about the person.
Run the Knowledge and Skills Inventory as a strengths-focused, conversational assessment, not an interview. One or two further sessions may be used to get to know the person.
Move on when the person agrees to take part and has a first sense of how IMR could serve something they want. [source: Practitioner Guides, Orientation; Training Frontline Staff Module 2]

Phase B: The curriculum (10 topics, taught in order by default). The KIT gives typical session counts for some topics. Where it does not, the counts below are from the group version reported in Mueser et al. (2006, Table 1).

Topic (KIT 2009)	Core goal	Typical sessions
1. Recovery Strategies	Define recovery personally; choose 1–2 goals; plan steps	2–4 (group: 4)
2. Practical Facts About Mental Illnesses (2a schizophrenia, 2b bipolar, 2c depression, 2d stigma)	Accurate knowledge of diagnosis, symptoms, course; counter self-blame and stigma	2–4 (group: 4)
3. The Stress-Vulnerability Model and Treatment Strategies	Understand the model and the options it implies	~3 [uncertain: pilot figure]
4. Building Social Supports	Evaluate supports; places to meet people; conversation and closeness skills	2–4 (2003 workbook); 7 in pilot group
5. Using Medication Effectively (5a–5e)	Informed decisions about medication; side-effect coping; behavioural tailoring	~4 [uncertain]
6. Drug and Alcohol Use	Explore effects of substance use; decide on change	not given [uncertain]
7. Reducing Relapses	Learn relapse is often predictable; write a relapse prevention plan	~4 [uncertain]
8. Coping with Stress (8a relaxation)	Recognise stress signs; prevent and cope with stress	~5 [uncertain]
9. Coping with Problems and Persistent Symptoms	Step-by-step problem solving; coping strategies for persistent symptoms	~6 [uncertain]
10. Getting Your Needs Met by the Mental Health System	Know the services and benefits; self-advocacy	~3 [uncertain]

The Drug and Alcohol topic was added after the pilot and is usually taught between medication and relapse prevention. The Hazelden third edition adds an optional Healthy Lifestyles module. The pilot ran about 40 sessions over about 9 months. [source: Mueser et al. 2006; Gingerich & Mueser 2011 Implementation Guide sample]

Tailoring the order. Follow the order unless there is reason not to. For example, teach persistent-symptom coping early if a symptom is very distressing. For individuals, use only the diagnosis-specific Topic 2 handouts that fit them. The I-IMR adaptation keeps Recovery and Stress-Vulnerability first in all cases. [source: Training Frontline Staff Module 2; Pratt et al. I-IMR manual]

Moving between topics. The KIT gives no formal mastery test. In practice, move on once the person:

can answer the topic's review questions in their own words (the KIT supplies review questions per topic);
has completed at least one practice step from the topic, or a scaled-down version of one;
has the topic's product written down where there is one: a goal plan (Topic 1), a list of supports (Topic 4), a medication cue plan (Topic 5), a relapse prevention plan (Topic 7), or chosen coping strategies (Topics 8–9).

The KIT supplies the review questions and the rule of following topics in order. Applying them as gates for moving on is [synthesis].

Phase C: Ongoing goal pursuit (runs through every session). Use the Goals Set in the IMR Program chart. Follow up goals every session (in groups, rotate two or three members each session), revise them, and set new goals when old ones are met. Fidelity standards: at least 90% of clients have a documented, measurable personal goal, and at least 90% have documented collaborative follow-up. [source: Training Frontline Staff Module 2; Fidelity Scale]

Phase D: Completion. The KIT does not set a formal ending protocol. The Hazelden edition includes certificates, and the I-IMR adaptation has an End of Treatment Goal Progress Review. Suggested ending: review goals, consolidate the relapse prevention plan and the coping toolkit with supporters, celebrate, and arrange booster or follow-on contact. [synthesis; source for certificates: Gingerich & Mueser 2011 sample; I-IMR manual]

Standard session structure (all topics).

Step	Individual (min)	Group (min)
1. Informal socialising; check for major problems	1–3	1–3
2. Review previous session	1–3	1–3
3. Review home practice (praise effort, solve obstacles)	3–5	5–10
4. Follow up goals	1–3	5–10 (2–3 members)
5. Set agenda	1–2	1–2
6. Teach new material or review, with practice	30–40	20–25
7. Agree new home practice	3–5	5–10
8. Summarise progress	3–5	3–5

[source: Training Frontline Staff Module 2; Practitioner Guides, Orientation]

Infrastructure. Write an IMR progress note after every session, recording goals, the motivational, educational and cognitive-behavioural strategies used, skills taught and home practice. Attend weekly supervision with the IMR leader. The team reviews fidelity every 6 months. [source: Training Frontline Staff Module 2]

3. Guiding principles

The KIT's six practice principles [source: Training Frontline Staff Module 1]:

Recovery is defined by the individual. Ask what recovery means to this person before you teach anything, and keep their wording.
Education is the foundation of informed decision-making. Give facts so the person can choose, not so they comply.
The stress-vulnerability model is the blueprint. Explain every topic as lowering vulnerability, lowering stress, or raising coping.
Collaboration with professionals and supporters helps recovery, and involving supporters is the client's choice. Invite supporters every time; never contact them without consent.
Relapse prevention planning reduces relapses and rehospitalisations. Every client should leave with a written plan; the fidelity scale checks charts for one.
People can learn new strategies for symptoms, stress and quality of life. Expect learning. Teach skills actively; information alone is not enough.

Core values and stance [source: Training Frontline Staff Modules 1, 3, 4]:

Build hope. Say plainly that people with these illnesses lead productive lives, and use real examples from the handouts.
The client is the expert on their own experience. Ask before you explain, and adopt their words for symptoms and problems.
Personal choice. Offer options and pros and cons; the person decides.
Collaborative, non-hierarchical partnership. Set agendas and home practice together, not by prescription.
Respect beliefs, including disagreement about the diagnosis. Do not argue about diagnosis. Find common ground, such as distress, staying out of hospital, or a goal.
From compliance to informed decision-making. Talk about medication as a choice the person weighs.
Validate grief, anger and despair rather than reading them as symptoms. Reflect the feeling first, then turn to what the person can do.
Never assume motivation. Link every topic to a personal goal before teaching it.
Interactive, not didactic. Pause often, ask for reactions, avoid yes/no checks, and avoid rapid-fire questions.
Strengths-based assessment. Ask about past coping and accomplishments of any size.
Flexible, not a cookbook. The mix of motivational, educational and cognitive-behavioural strategies varies by person, but all three should appear regularly (the fidelity standard is each in at least 50% of sessions).
Shaping and small steps. Break every goal and skill into steps achievable in a week or two, and praise each one.

[source: Training Frontline Staff; Fidelity Scale; I-IMR manual for the 1–2 week step size]

4. Intervention inventory

The inventory has two parts. Part A covers the cross-cutting teaching techniques used in every topic. Part B covers the topic-specific interventions. The KIT calls clients "consumers". All example language is illustrative wording written for this guide, not text from the manual. Do not reproduce the KIT handouts or worksheets beyond what your licence allows: SAMHSA KIT materials are public-domain US government publications, but the Hazelden edition is copyrighted. [source: Training Frontline Staff Module 4; Mueser et al. 2006]

Part A. Cross-cutting techniques

A1. Linking material to personal goals (motivational)

Purpose / when: At the start of every topic and whenever engagement drops. The KIT tells practitioners never to assume motivation.
Steps:
1. Before teaching a topic, recall the person's recovery goal from the goal chart.
2. Ask how the topic might help or hinder that goal.
3. Restate the link in the person's words.
4. Return to the link when you summarise the session.
Example language (illustrative): "You said getting back to your part-time job matters most. Stress has knocked you off track before. Shall we look at whether today's ideas could protect the job?"
Watch for: Polite agreement without any personal link. Ask what would be different for them if the skill worked. Working well: the person starts connecting topics to their goals unprompted.
[source: Training Frontline Staff Module 4; Practitioner Guides, Topic 1]

A2. Pros and cons of change (decisional balance / payoff matrix)

Purpose / when: Ambivalence about goals, medication, substance use, social contact, or changing a support network. The Hazelden edition adds a Payoff Matrix tool for this.
Steps:
1. Name the behaviour or decision.
2. Elicit the advantages of staying the same, without judging them.
3. Elicit the disadvantages of staying the same.
4. Elicit the advantages and disadvantages of changing.
5. Summarise all four sides.
6. Ask what stands out. Let the person draw the conclusion.
Example language (illustrative): "What are the good things about how things are now? ... And the not-so-good things? ... If you did change it, what might be better, and what might be harder?"
Watch for: Practitioner "righting reflex": arguing the change side. If the person defends the status quo harder, step back to reflecting. Working well: the person voices reasons for change themselves.
[source: Practitioner Guides Topic 1; 2003 Workbook Ch. 5; Gingerich & Mueser 2011 sample; Mueser et al. 2006 (MI emphasis)]

A3. Reframing the past as strength; recalling accomplishments

Purpose / when: The person dwells on setbacks, feels hopeless, or says recovery is impossible.
Steps:
1. Acknowledge past problems with empathy.
2. Ask what they did to get through them.
3. Name the strengths this shows (persistence, resourcefulness).
4. Ask about accomplishments of any size: household tasks, parenting, school, managing money.
5. Shift focus to the future.
Example language (illustrative): "You've been through three hospital stays and you're still here, still wanting your own flat. What kept you going?"
Watch for: Premature cheerleading that invalidates grief. Working well: the person describes themselves with less self-blame.
[source: Practitioner Guides, Orientation and Topic 1; Training Frontline Staff Module 3]

A4. Conveying hope and confidence

Purpose / when: Throughout, especially when motivation fluctuates.
Steps:
1. State your confidence that the person can learn the skill.
2. Point to evidence from their own progress.
3. Use the handout examples of people living productive lives with the same illness.
4. Support self-efficacy by attributing gains to the person's own effort.
Example language (illustrative): "That plan worked because you followed it on a hard day. That's your skill, not luck."
Watch for: Hope that sounds scripted. Tie it to specifics.
[source: Training Frontline Staff Module 4; Practitioner Guides, Topic 2]

A5. Interactive psychoeducation (educational techniques)

Purpose / when: Teaching any handout content.
Steps:
1. Summarise a handout section in plain language, or take turns reading aloud. Never force anyone to read.
2. Present small chunks at a comfortable pace, simplifying key points for people with cognitive difficulties.
3. Pause after each chunk to ask for reactions and the person's own experience.
4. Check understanding with open questions, asking the person to explain the point in their own words. Avoid yes/no checks.
5. Leave time for in-handout exercises, and offer help with reading, spelling or writing.
6. Invite them to circle points or quotes that matter to them.
7. Begin each session by reviewing the last, prompting recall, and linking old material to new.
8. Use the topic's review questions at the end.
Example language (illustrative): "In your own words, what does this say about how stress and symptoms are linked?" / "Does that match what happened to you?"
Watch for: Lecturing, or rapid-fire questions that feel like interrogation. Working well: the person paraphrases accurately and adds examples from their own life.
[source: Training Frontline Staff Module 4; Practitioner Guides, Orientation]

A6. Positive reinforcement

Purpose / when: After any effort or step, including partial ones.
Steps:
1. Notice the effort.
2. Give specific praise, interest or enthusiasm promptly.
3. Point out the relief the person has gained, such as less anxiety or no hospital stay. The KIT calls this negative reinforcement and notes it is not punishment.
4. In groups, applause, certificates or small tokens can mark goal steps.
Example language (illustrative): "You made the call even though you were nervous. How did it feel afterwards?"
Watch for: Generic praise. Be specific about the behaviour.
[source: Training Frontline Staff Modules 2, 4]

A7. Shaping

Purpose / when: Ambitious goals, complex skills, or "all or nothing" thinking.
Steps:
1. Break the goal or skill into small successive steps, each achievable in about 1–2 weeks.
2. Start where success is likely.
3. Praise each step.
4. Raise the step size only after success.
Example language (illustrative): "Rather than 'get a job', what's a first step you could manage this week? Looking at one job site?"
Watch for: Steps that are too big, which lead to repeated non-completion. If a step fails, halve it.
[source: Training Frontline Staff Module 4; Practitioner Guides Topic 1; I-IMR manual]

A8. Modelling

Purpose / when: Before the person practises any skill.
Steps:
1. Describe the skill.
2. Demonstrate it. For private, cognitive skills such as relaxation or self-talk, think aloud: say what you notice, what you decide, then do it.
3. Ask for feedback on what they saw.
Example language (illustrative): "I'll show you. Say I notice my shoulders are tight and I'm thinking 'I can't cope.' I'll tell myself 'This is stress, I can slow down', then breathe slowly. What did you notice I did?"
Watch for: Long demonstrations. Keep them short and concrete.
[source: Training Frontline Staff Module 4]

A9. Role-play / behavioural rehearsal (the KIT's nine steps)

Purpose / when: Any interpersonal or step-by-step skill: inviting a friend, a job interview, responding to stigma, telling a prescriber about side effects, carrying out a relapse plan.
Steps:
1. Elicit reasons the skill would help.
2. Discuss the steps of the skill.
3. Demonstrate it in a role-play and ask for feedback.
4. The person role-plays the same situation.
5. Give positive feedback first.
6. Give one corrective suggestion, gently and generalised.
7. Repeat the role-play.
8. Give further feedback.
9. In groups, rotate other members through steps 4–8.
Example language: For corrective feedback the KIT models a generalising phrase such as "Most of us find it hard to make eye contact at first." [source: Training Frontline Staff Module 4]. Illustrative: "That was clear and friendly. One thing to try: say what you'd like at the start. Let's run it again."
Watch for: Shy group members. Offer individual practice. More than one correction at a time overloads people. Working well: the second run improves on the targeted point.
[source: Training Frontline Staff Module 4]

A10. Home practice ("homework", or "recovery action steps")

Purpose / when: End of every session, to carry skills and goal steps into daily life.
Steps:
1. Agree the assignment collaboratively. It may be reviewing a handout section, finishing an exercise, practising a skill, taking a goal step, or discussing material with a supporter.
2. Make sure the person is confident with the skill first.
3. Specify what, for how long, which days, what time, where, with whom, and what is needed.
4. Anticipate obstacles and solve them in advance.
5. Write it down.
6. Tailor it to skill and confidence, scaling it down as needed.
7. Next session: praise effort, ask what was and was not done, ask for a demonstration rather than only a description, and explore what to do differently.
8. If it was not done, identify the obstacles and make the assignment smaller.
Example language (illustrative): "So: Tuesday and Thursday after lunch, ten minutes of the breathing exercise in your room. What might get in the way?"
Watch for: The word "homework" putting people off; rename it. Working well: completion rates rise and the person starts proposing their own assignments.
[source: Training Frontline Staff Modules 2, 4; I-IMR manual; Gingerich & Mueser 2011 sample (Home Practice Sheets)]

A11. Involving significant others (supporters)

Purpose / when: From orientation onward, for reviewing material, practising skills, goal steps, and the relapse prevention, coping and stress plans. The fidelity standard is supporter involvement for at least 50% of clients.
Steps:
1. Ask who supports the person: family, friends, peers, self-help leaders, case managers, faith community members.
2. Explain the roles a supporter could take.
3. Get consent, and agree what will be shared.
4. If the person is uncomfortable reaching out, offer to make contact with their permission.
5. Keep supporters informed by phone or by sharing handouts.
6. Assign home practice that includes the supporter.
7. Optionally, run a monthly group for clients and supporters.
Example language (illustrative): "Would it help if your sister knew the early signs we listed? You could show her, or I could call her with you."
Watch for: Pressure to involve people. The decision belongs to the client. Mueser et al. (2006) report that supporter collaboration happened for only a minority of clients, so invite repeatedly.
[source: Training Frontline Staff Module 2; Fidelity Scale; Mueser et al. 2006]

A12. Group-format procedures

Purpose / when: Running IMR as a group.
Steps:
1. Agree group guidelines at the start: confidentiality (the KIT's phrase is "what is said in the room stays in the room"), respect for members and property, and regular attendance.
2. Use the group timing (Section 2).
3. Rotate goal follow-up among 2–3 members per session.
4. Use the combined Topic 2 handout. Several sessions per topic may be needed.
5. Address minor guideline breaches by reminding the whole group and asking for recommitment. Handle serious breaches privately.
6. Use two leaders where possible (the Dutch implementation used two trainers per group).
Watch for: Members with no goal update for weeks. Keep a rotation log.
[source: Training Frontline Staff Module 2; Practitioner Guides; Roosenschoon thesis (Dutch format)]

Part B. Topic-specific interventions

Source coverage. The full KIT Practitioner Guides are drawn on for Orientation and Topics 1–2 only, plus the 2003 workbook guide for Topic 4. Guidance for Topics 3 and 5–10 comes from Training Frontline Staff and Mueser et al. (2006), which describe the core techniques (stress-vulnerability teaching, behavioural tailoring, relapse prevention, coping skills training, cognitive restructuring) but not each topic's handout content or session plans. Those gaps are marked. [uncertain]

B1. Orientation and Knowledge and Skills Inventory

Purpose / when: First 1–3 sessions.
Steps:
1. Explain what IMR is, its topics, the session format, the binder, and the length (several months of weekly or biweekly sessions).
2. Explain both roles: the client attends, collaborates, practises and does home practice; the practitioner teaches, supports and follows the client's goals.
3. Ask what interests them and how IMR could help with something they want.
4. Reframe past struggles as strengths (A3).
5. Complete the Knowledge and Skills Inventory conversationally, focusing on strengths and not insisting on every question.
6. Ask about supporters who might join.
7. Close with the Orientation review questions.
Example language (illustrative): "This is less like a class and more like a workshop on managing things your way. What would you most want to get out of it?"
Watch for: An interrogation feel; slow down. Working well: the person can say in their own words what IMR involves and why they might come.
[source: Practitioner Guides, Orientation; Training Frontline Staff Module 2]

B2. Exploring recovery and recovery strategies (Topic 1)

Purpose / when: First topic. Builds hope and a personal definition of recovery.
Steps:
1. Introduce the idea that recovery is personal and ongoing, and can include setbacks.
2. Ask what recovery means to them; have them write it down.
3. Review the kinds of things that help people in recovery: self-help, activity, support, physical health, environment, leisure, creativity, spirituality, treatment.
4. With the Strategies for Recovery exercise, note what they already use and one strategy to try.
5. Plan when, where and with whom to try it.
Example language (illustrative): "Some people say recovery means having fewer symptoms; others say it means having a life they value even with symptoms. What would it mean for you?"
Watch for: Messages from others that they will never reach goals. Explore those messages and offer alternative views. Working well: a written, personal definition, and one strategy tried.
[source: Practitioner Guides Topic 1; Training Frontline Staff Module 3]

B3. Life-areas satisfaction review and goal identification (Topic 1)

Purpose / when: To find goal areas, especially if the person "has no goals".
Steps:
1. Use the Satisfaction with Areas of My Life exercise. Rate satisfaction across domains such as friends, family, living situation, money, work or school, health, leisure, spirituality and symptoms.
2. Discuss what they like and dislike in low-rated areas.
3. Ask what they would want different.
4. If stuck, ask about daily routine, relationships, pre-illness dreams and activities once enjoyed, then explore current versions of those.
5. Pick one or two meaningful goals.
Example language (illustrative): "Before you got ill, what did you picture yourself doing? Is any part of that still interesting?"
Watch for: Goals set to please the practitioner. Ask "Who wants this most, you or others?"
[source: Practitioner Guides Topic 1; E-IMR Module 1 preview]

B4. Goal setting, step planning and goal follow-up

Purpose / when: End of Topic 1, then every session.
Steps:
1. Turn the goal into a specific, measurable goal.
2. Use Working on Goals to break a long-term goal into short-term goals, then into steps achievable in 1–2 weeks.
3. Write it on the Goals Set in the IMR Program chart (Hazelden: Goal-Tracking Sheet).
4. Choose the first step as home practice.
5. Each session, review the step, praise effort, solve obstacles, and set the next step.
6. Revise goals that no longer fit. Revisiting goals every few months is an I-IMR addition.
7. Set new goals when old ones are met.
Example language (illustrative): "Your long-term goal is a volunteer job. A short-term goal could be finding two places that take volunteers. Step one this week: ask at the library on Monday."
Watch for: Very ambitious goals. Do not discourage them; shape them into smaller first versions. Working well: steps completed, and the chart visibly updated.
[source: Practitioner Guides Topic 1; Training Frontline Staff Module 2; I-IMR manual]

B5. Step-by-step problem solving and goal achievement

Purpose / when: When a goal step stalls (Topic 1), and as a core coping skill for problems (Topic 9).
Steps (KIT exercise named "Step-by-Step Problem-Solving and Goal Achievement"; the step names below are the standard sequence and are not quoted from it) [uncertain on exact wording]:
1. Define the problem or goal specifically.
2. Brainstorm possible solutions without judging them.
3. Weigh the advantages and disadvantages of each.
4. Choose one or a combination.
5. Plan the steps: who, what, when, resources, possible obstacles.
6. Set a date to review.
7. Review; praise effort; if it did not work, return to the list.
Example language (illustrative): "Let's write every idea first, even odd ones, before we judge any."
Watch for: Jumping to the first solution. In groups, involve members in brainstorming.
[source: Practitioner Guides Topic 1 (exercise named); Mueser et al. 2006 (problem solving in Module 8)]

B6. Practical facts about the person's illness (Topic 2a–2c)

Purpose / when: Topic 2, in individual work using the diagnosis-specific handout.
Steps:
1. Explain how diagnosis is made (clinical interview; no blood or imaging test diagnoses these illnesses, though tests may rule out other causes).
2. Cover how common the illness is, typical onset, and episodic course.
3. Walk through the symptom groups (for schizophrenia: hallucinations, delusions, thought disorder, disorganised behaviour, negative symptoms, cognitive difficulties; for mood disorders: mania, depression, psychosis).
4. Have the person mark the symptoms they have had and give their own examples. The KIT includes symptom exercises for this.
5. Discuss causes using the stress-vulnerability model, and stress that it is no one's fault.
6. Review examples of people living productive lives with the illness.
7. Practise describing symptoms to a supporter or the treatment team.
Example language (illustrative): "When you heard the voices last spring, what were they like? That's one example of what this handout calls hallucinations."
Watch for: Non-acceptance of diagnosis. It is not required; use the person's terms ("stress problems", "nerves") and link the material to a valued goal. If the person already knows a lot, review quickly.
[source: Practitioner Guides Topic 2; Training Frontline Staff; I-IMR manual]

B7. Positive self-statements against self-blame

Purpose / when: Self-blame or shame about illness (Topic 2 and beyond).
Steps:
1. Identify the self-blaming thought.
2. Agree an accurate alternative. The KIT's example is "No one is to blame for mental illnesses." [source: Practitioner Guides Topic 1/2]
3. Model saying it.
4. Have the person practise it aloud, then silently.
5. Plan when to use it as home practice.
Example language (illustrative): "When the 'it's my fault' thought shows up this week, what will you say back to it?"
Watch for: Statements the person does not believe. Make them more accurate and less positive. Working well: the person reports using it spontaneously.
[source: Practitioner Guides Topics 1–2; I-IMR manual]

B8. Responding to stigma (Topic 2d)

Purpose / when: Experienced or anticipated stigma, and self-stigma.
Steps:
1. Define stigma and self-stigma.
2. Review four response options, each with trade-offs: (a) educate yourself and consider a support group; (b) correct misinformation without disclosing; (c) selectively disclose after weighing risks and benefits, possibly with a supporter; (d) know your legal rights (in the US, the ADA and Fair Housing Act; substitute local law elsewhere).
3. Have the person record strategies they have used.
4. Model a response to a stigmatising remark.
5. Role-play the person's own situation.
Example language (illustrative): "If your cousin says people with schizophrenia are dangerous, what could you say that you'd feel OK with, without telling him your diagnosis?"
Watch for: Disclosure decisions made under pressure. Weigh them carefully. In non-US settings the legal content must be localised [synthesis].
[source: Practitioner Guides Topic 2]

B9. Teaching and personalising the stress-vulnerability model (Topic 3)

Purpose / when: Topic 3, and whenever explaining why a strategy matters.
Steps:
1. Explain that episodes arise from biological vulnerability plus stress.
2. Explain the kinds of stressors: major negative events, major positive changes, and daily hassles.
3. List factors that raise susceptibility (poor sleep, hunger, isolation, pessimism) and lower it (rest, nutrition, social support, exercise, optimism).
4. Map the person's own last relapse or hospitalisation onto the model.
5. Derive the treatment options from the model: lower vulnerability (informed medication use, working with the prescriber, avoiding alcohol and drugs); reduce exposure to stressors (anticipate them, e.g. rent problems); break positive changes such as a new flat or job into graduated steps; and cope with stress better.
6. Optionally list personal protective and risk factors (an I-IMR worksheet).
Example language (illustrative): "Looking back at last winter: losing the flat, not sleeping, drinking more. Which of these pushed things over the edge?"
Watch for: Hearing "vulnerability" as blame. Frame it like diabetes or asthma. People who deny illness often accept talking about stress. Working well: the person explains their own episode using the model.
[source: Training Frontline Staff Module 3; I-IMR manual; KIT Topic 3 handout content: uncertain]

B10. Building social supports: evaluating supports and meeting people (Topic 4)

Purpose / when: Topic 4. Social support buffers stress and strengthens relapse prevention.
Steps:
1. Explain the benefits of support, linked to the person's goal (e.g. friends who do not drink, if cutting down is a goal).
2. Evaluate current supports and past positive relationships.
3. Weigh the pros and cons of keeping or changing the support network.
4. Identify places to meet people: clubs, classes, faith groups, volunteering, peer groups.
5. Plan the practical steps to get there (transport, timing, a companion).
6. Set home practice to research or visit one place.
Example language (illustrative): "You enjoy music. Where are people who like music, near you?"
Watch for: Unpleasant past experiences. Explore what went wrong and identify better strategies.
[source: 2003 Workbook Ch. 5 (Handout #4 guidelines); Mueser et al. 2006]

B11. Conversation and closeness skills, levels of disclosure (Topic 4, social skills training)

Purpose / when: Topic 4, when the person wants more or closer relationships.
Steps:
1. Teach starting, maintaining and ending a conversation using the role-play sequence (A9).
2. Use the handout checklists "Things You Can Say to Increase Closeness" and "Things You Can Do to Increase Closeness" to choose one or two to try.
3. Teach the "Levels of Disclosure in Relationships" checklist: share personal information gradually, matched to how close the relationship is.
4. Shape: begin with small steps (smiling, saying hello, a short note to an estranged relative).
5. Set home practice, for example starting two conversations, or trying one closeness behaviour with a chosen person.
Example language (illustrative): "Let's practise how you'd start chatting with someone at the art class. I'll be the other student."
Watch for: Shyness, so begin very small and consider a dedicated social skills group. Moving too fast, so teach gradual pacing and reading the other person's interest.
[source: 2003 Workbook Ch. 5]

B12. Informed decision-making about medication (Topic 5)

Purpose / when: Topic 5. The KIT shifts the aim from compliance to informed choice. Subtopics: 5a antipsychotics, 5b mood stabilisers, 5c antidepressants, 5d anti-anxiety and sedative medicines, 5e coping with side effects. This guide gives no dosing.
Steps:
1. Explore the person's experience with and beliefs about medication without arguing.
2. Use pros and cons (A2) of taking versus not taking medication as prescribed.
3. Teach what the person's class of medication is meant to do, and its common side effects, from the relevant handout.
4. Identify side effects they experience. Plan coping strategies and how to raise them with the prescriber.
5. Role-play telling the prescriber about benefits, side effects and concerns (A9).
6. If the person decides to take medication, move to behavioural tailoring (B13).
Example language (illustrative): "What has medication done for you, good and bad? ... What would you want your doctor to know about the drowsiness?"
Watch for: Covert agendas to secure adherence, which damage trust. A practitioner rather than prescriber giving medication advice beyond the handout scope; refer clinical questions to the prescriber. Working well: the person speaks up in prescriber appointments.
[source: Training Frontline Staff Modules 1, 3, 4; Mueser et al. 2006. KIT Topic 5 handout content: details of 5a–5e uncertain]

B13. Behavioural tailoring for medication

Purpose / when: The person wants to take medication but forgets or finds it hard. This is a fidelity item: all practitioners should know it and use it regularly.
Steps:
1. Explore daily routines (meals, hygiene, coffee, TV).
2. Pick an existing routine to attach medication-taking to.
3. Create a physical cue, e.g. keep the medication container next to the toothbrush so it is taken before brushing.
4. Simplify where possible: discuss with the prescriber whether the schedule can match routines; pill organisers [synthesis].
5. Model the routine, then have the person rehearse it in session.
6. Assign it as home practice.
7. Involve a supporter if wanted, and follow up with a home visit if possible.
8. Praise each step.
Example language (illustrative): "What's something you do every morning without fail? Could your tablets sit right beside that?"
Watch for: Tailoring imposed on someone who has not decided to take medication; go back to B12. Working well: the person self-reports fewer missed doses, or supporters notice.
[source: Training Frontline Staff Module 4; Fidelity Scale; Mueser et al. 2006]

B14. Exploring drug and alcohol use (Topic 6)

Purpose / when: Topic 6, usually taught between medication and relapse prevention, for everyone (screening), with depth matched to use.
Steps (built from IMR's motivational stance and the stress-vulnerability rationale) [uncertain]:
1. Ask openly about use, without labels.
2. Explore the reasons people use (socialising, coping with symptoms, sleep, pleasure).
3. Explain how substances interact with vulnerability (worsening symptoms, triggering relapse, interacting with medication), linked to the stress-vulnerability model.
4. Use pros and cons (A2) of using versus cutting down or stopping, linked to the person's goals.
5. If ready, set a goal (reduction or abstinence, by the person's choice) with steps.
6. Plan for high-risk situations; build non-using supports (B10) and alternative activities.
7. Refer to integrated co-occurring treatment where indicated.
Example language (illustrative): "What does cannabis do for you? ... And how does it fit with getting back to college?"
Watch for: A confrontational tone, which raises defensiveness. Stage of change: the KIT outcome set tracks stage of substance abuse treatment.
[source: Mueser et al. 2006 (module added, placement); Training Frontline Staff Module 3; Evaluating Your Program (outcome list); steps [synthesis]]

B15. Relapse prevention planning (Topic 7)

Purpose / when: Topic 7, and for anyone with a history of relapse. This is a fidelity item: plans should appear in charts.
Steps:
1. Discuss past relapses and their consequences.
2. Discuss the advantages of preventing or minimising future relapses, linked to goals.
3. Explain that relapses often build gradually, with early warning signs, and that triggers can be identified.
4. Review the most recent relapse in detail: what stressors came before it, and what changed first (sleep, mood, suspiciousness, withdrawal, other personal signs).
5. Select the most prominent warning signs to monitor.
6. Decide on steps for each sign, e.g. contacting the treatment team, increasing coping strategies, reducing stress, involving a supporter.
7. Write the plan down with names and phone numbers of the people to contact.
8. Role-play using it, and refine it.
9. Home practice: rehearse it, and share it with supporters (with consent), so they know the signs and their role.
10. Review it after any warning-sign episode.
Example language (illustrative): "Looking back, what was the very first thing that changed before you went into hospital? ... Who noticed?"
Watch for: Plans too vague to act on, and signs only others notice (involve supporters). Working well: earlier help-seeking, or shorter and milder episodes.
[source: Training Frontline Staff Modules 1, 4; Fidelity Scale; Mueser et al. 2006]

B16. Coping with stress: recognising signs, preventing and coping (Topic 8, 8a relaxation)

Purpose / when: Topic 8, and for stress linked to symptoms or goals.
Steps (topic aims from Mueser et al. 2006 and KIT titles) [uncertain]:
1. Help the person identify their personal stressors (life events and daily hassles) and their own signs of stress. The KIT flags that some people struggle to recognise their stress signs.
2. Prevention: plan around known stressors, set realistic expectations, keep healthy routines, and break positive changes into steps (from Topic 3).
3. Coping: review strategies already used and how well they worked; add new ones (talking to supporters, positive self-talk, relaxation, exercise, hobbies, spirituality).
4. Relaxation (8a): model a technique by thinking aloud, then practise it in session. Typical options are slow breathing, muscle relaxation, and imagining a calm scene. The KIT 8a technique list is not drawn on [uncertain].
5. Make a written personal stress plan, and practise it as home practice.
Example language (illustrative): "What does stress look like in you before you notice it in your head: tight jaw, short temper, poor sleep?"
Watch for: Relaxation that increases anxiety or triggers dissociation in some people. Offer alternatives such as eyes open or activity-based options [synthesis]. Working well: the person notices stress earlier and uses a strategy.
[source: Training Frontline Staff Module 4 (modelling example, closing exercise); Mueser et al. 2006; I-IMR manual (stress strategies list)]

B17. Coping skills training for problems and persistent symptoms (Topic 9)

Purpose / when: Topic 9, or earlier if a persistent symptom (voices, low mood, anxiety, sleep problems, low motivation) is very distressing. This is a fidelity item.
Steps:
1. Identify one problem or persistent symptom.
2. Do a behavioural analysis of when and where it is most distressing, and what happens before and after.
3. Identify coping strategies the person has used before.
4. Evaluate how well each worked.
5. Increase use of the effective ones.
6. Identify one or two new strategies to try.
7. Model and rehearse them in session.
8. Practise at home, ideally with a supporter.
9. Get feedback on effectiveness, and tailor the strategies.
Example language (illustrative): "When are the voices worst? ... What have you tried? ... Humming helped a bit? Let's plan when to use it, and add one new thing to test."
Watch for: Expecting elimination of a symptom; the aim is less distress and interference. Working well: lower distress ratings, more activity despite symptoms. The pilot found the largest gains in self-reported coping.
[source: Training Frontline Staff Module 4; Mueser et al. 2006. Symptom-specific strategy lists in the Topic 9 handout: uncertain]

B18. Cognitive restructuring

Purpose / when: Distressing beliefs linked to symptoms, stress, self-stigma or depression. It can be used informally in the moment, or taught as a coping skill.
Steps:
1. Describe the situation or symptom that led to the feeling.
2. Identify the feeling and the thought behind it.
3. Weigh the evidence for and against the thought.
4. If the thought is not supported, develop a more accurate one.
5. If it is supported, make an action plan. This branch comes from the I-IMR version.
6. Teach common thinking traps: overgeneralising, jumping to conclusions, black-and-white thinking, catastrophising, selective attention.
Example language (illustrative): "You thought 'Everyone at the centre thinks I'm useless.' What evidence fits that? What doesn't?"
Watch for: Fixed delusional beliefs. Avoid confrontation; work on distress and evidence gently. If the thought is accurate, problem-solve instead.
[source: Training Frontline Staff Module 4; I-IMR manual]

B19. Getting needs met in the mental health system; self-advocacy (Topic 10)

Purpose / when: Topic 10, usually last.
Steps [uncertain]:
1. Review the services available locally (community mental health, crisis, housing, employment, peer support, benefits).
2. Identify the person's unmet needs.
3. Plan steps to get one need met.
4. Role-play advocating for oneself, e.g. requesting a service or raising a concern with staff (A9).
5. Consider advance or crisis planning tools and rights information where available [synthesis].
Example language (illustrative): "Let's practise asking your care coordinator about the work scheme: what do you want to say first?"
Watch for: Content written for the US system needs localising [synthesis].
[source: Mueser et al. 2006 (module aims: services, benefits, self-advocacy); KIT topic title]

B20. Healthy Lifestyles (optional; Hazelden 3rd ed. only)

Purpose / when: An optional module added in 2011 to address physical health. The I-IMR variant expands this with medical-illness modules.
Steps: The primary source is not drawn on [uncertain]. Use the IMR format: link to goals, pros and cons, choose one health step, make a specific plan with a confidence rating, and follow it up. Set no specific weight, diet or exercise targets; individualise with the person's medical team [synthesis].
Watch for: Shame about weight or habits; keep the focus on the person's own reasons.
[source: Gingerich & Mueser 2011 Implementation Guide sample; I-IMR manual]

5. Handling problems

From the sources [source: Practitioner Guides, Orientation and Topics 1–2; Training Frontline Staff Modules 2–4; 2003 Workbook Ch. 5]

Reluctance to talk about recovery. The person may have been told they will never reach their goals. Explore those messages, empathise, and offer other views of the future. Gently redirect repeated focus on past setbacks toward what is possible next.
Cannot identify goals. Ask about their living situation, routine, relationships, pre-illness dreams and activities once enjoyed. Then explore current versions of them, or start from a low-rated life area (B3).
Very ambitious goals. Do not discourage them. Shape them into small first steps (A7).
Does not accept the diagnosis. Acceptance is not required to take part. Use the person's language ("problems with stress", "nervous condition"), find common ground (distress, staying out of hospital, a goal), and link each topic to that.
Already knows the material. Review quickly, using the handout to check and organise what they know.
Home practice not done. Praise any effort, identify obstacles, and shrink the task. Make sure they were confident in the skill and had a specific time, place and partner. Rename "homework" if the word puts them off.
Feels interrogated or lectured. Make it conversational, do not require every question to be answered, and ask for reactions rather than testing.
Shy about role-play in a group. Offer individual practice. Start with them watching others. Keep correction to one point.
Attention or cognitive difficulties. Smaller chunks, simplified points, more frequent review, and shorter sessions two or three times a week.
Strong emotions (grief, anger, despair). Validate rather than treat as symptoms, then turn to what the person can do.
Social difficulties (Topic 4). After a bad past experience, analyse what went wrong and plan differently. With shyness, start with very small steps and consider a social skills group. With moving too fast, teach gradual disclosure.
Group guideline breaches. For minor ones, remind the whole group and ask for recommitment. Handle serious ones privately.
Practitioner drift. As caseloads grow, practitioners drift from the model without noticing. Use weekly supervision, progress notes, first-year consultation and six-monthly fidelity reviews.

Additional guidance not stated in the sources [synthesis]

Stuck client (no progress over 4–6 weeks). Check that the goal is still theirs (revisit it), that steps are small enough, and that a symptom, substance use or a life crisis is not blocking progress. Switch temporarily to the most relevant topic (e.g. Topic 9 for intrusive symptoms) and return to the curriculum later.
Overwhelm in session. Pause the teaching. Use a brief grounding or relaxation step (B16), shorten the remaining agenda to one point, and agree a lighter home practice.
Paranoid or suspicious group members. Give them seats near the door. Keep processes transparent: explain note-taking and what supervisors see. Offer individual sessions alongside the group.
Irregular attendance. Use brief contacts between sessions (calls or texts with consent), send handouts home, and use make-up individual sessions. The UNC Institute notes that groups suit settings where attendance is irregular [source for the latter: UNC IMR/WMR page].
Ruptures (e.g. after pushing medication, or after a mandated admission). Name the rupture and ask for the person's view without defending yourself. Acknowledge your part, and return to their goals and choices. If you have acted as an adherence enforcer, step back to informed decision-making (B12).
Acute relapse during IMR. Activate the relapse prevention plan and the treatment team. Pause the curriculum, keep brief supportive contact, and on return review what the plan caught or missed and revise it (B15).
Suicidal ideation or self-harm. Respond according to your service's standard risk-assessment protocol: ask directly, assess current ideation, intent, plans, history and protective factors, and involve the treatment team. Collaborate on a safety plan, and do lethal-means counselling (safe storage or removal of means with supporters' help). Build warning signs of suicidal crises into the relapse prevention plan. IMR sessions are not a substitute for crisis care.
Substance use undermining progress. Do not make continued attendance depend on abstinence. Integrate Topic 6 earlier, use the pros and cons tool, and coordinate with integrated co-occurring disorder treatment.
Literacy or language barriers. Read handouts aloud together, use pictures, larger fonts and coloured modules (as the Australian pilot site did), and translated materials where available (e.g. the KIT's Spanish brochure).
Trauma-related distress triggered by material (e.g. hospital memories, stigma discussions). Slow down, offer choice over what to discuss, and refer for trauma-focused treatment if indicated.
Supporter conflict (critical or over-involved family). Involve supporters only by the client's choice. Consider separate family psychoeducation, and keep confidentiality boundaries explicit.
Ending. Plan it early. Review the goal chart and the written plans, hand plans to supporters with consent, and offer booster sessions or a peer or self-help link.

Sources

Sources:

Books and papers cited:

Substance Abuse and Mental Health Services Administration (2009). Illness Management and Recovery: Evidence-Based Practices (EBP) KIT (HHS Pub. No. SMA-09-4462). Rockville, MD: CMHS, SAMHSA.
Mueser, K. T., Meyer, P. S., Penn, D. L., Clancy, R., Clancy, D. M., & Salyers, M. P. (2006). The Illness Management and Recovery program: Rationale, development, and preliminary findings. Schizophrenia Bulletin, 32(Suppl 1), S32–S43.
Gingerich, S., & Mueser, K. T. (2011). Illness Management and Recovery: Personalized Skills and Strategies for Those with Mental Illness (3rd ed.). Center City, MN: Hazelden. Only the sample is drawn on.
Gingerich, S., & Mueser, K. T. (2005). Illness management and recovery. In R. E. Drake, M. R. Merrens & D. W. Lynde (Eds.), Evidence-Based Mental Health Practice: A Textbook. New York: Norton.

Further reading (not drawn on): the PubMed Central, Europe PMC, Wayback Machine, Connecticut DMHAS and SAMHSA store pages. The full KIT practitioner guides for Topics 3 and 5–10 are not drawn on; the affected content is marked [uncertain].

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