Introduction

Mental health services have been criticized for inadequately using effective treatment programs for people with severe mental illness (SMI) (Girlanda et al., 2017). In recent years, an increasing proportion of mental health services have implemented evidence-based practices (EBPs). Despite a growing acceptance of EBPs (Huffman et al., 2004; Walrath et al., 2006), their effective implementation continues to be a significant challenge (Moullin et al., 2019). Professionals have voiced a range of concerns about implementing them in mental health services (Hunsley, 2007), including the dehumanization of services, the loss of professional autonomy, the subordination of professionals to special interests and theoretical orientations, and the inadequacy of the research base underlying EBPs.

In the implementation of new practices in mental health services, professionals play a crucial role (Egeland, 2018). Far from being passive recipients, they actively engage with the practices as they experiment with, evaluate, find meaning in, challenge, gain experience with, improve, and innovate them to suit the tasks that they need to perform (Greenhalgh et al., 2004). Thus, knowledge about professionals’ perspectives toward using new practices is crucial to understanding their readiness to implement EBPs and enhance implementation strategies to increase demand for them (Aarons et al., 2012).

Illness Management and Recovery (IMR) is an evidence-based psychosocial treatment program developed to empower people with SMI to manage their conditions, identify personal recovery goals, and obtain the knowledge and skills needed to make informed decisions about their treatment (Mueser et al., 2006; SAMSHA, 2009b). Developed in 2000–2002 as part of the U.S. National Implementing EBP Project, IMR is based on a comprehensive review of teaching self-management strategies to people with SMI (Mueser et al., 2002) and packaged in an “Implementation Resource Kit” to facilitate dissemination. The kit includes, among other things, information on developing a training structure, recruiting staff, the basic principles and skills of IMR, and how to monitor fidelity and outcomes (SAMSHA, 2009a, 2009b). The primary rule for becoming a certified IMR therapist is completing a two-day course with a basic introduction to the use of IMR and one year of practice with guidance. IMR is organized into 11 modules, each covering a different topic and incorporating five empirically supported strategies: psychoeducation, cognitive–behavioral therapy, relapse prevention planning, social skills training, and coping (Mueser et al., 2002; Egeland, 2018). In addition, to motivate people to better manage their illness and move forward in their lives, IMR begins by exploring what recovery means to each participant and identifying personal recovery goals for them to work toward while attending the program. Usually IMR sessions are held weekly over a 9-month period, either individually or as a group (Färdig et al., 2011).

Numerous implementation frameworks—for example, the exploration–preparation–implementation–sustainment framework (Aarons et al., 2010), the framework on core implementation components (Fixsen et al., 2013), and the dynamic sustainability framework (Chambers et al., 2013)—propose different stages and factors as being important when new practices are to be implemented. When implementing new practices in mental health services, the goal is to make them sustainable over time (Egeland, 2018). In this study, sustainability was defined as “the extent that interventions can continue to be delivered over time, institutionalized within settings, and have necessary capacity built to support their delivery” (Chambers et al., 2013, p.118). Simplified, sustainability denotes the process of maintaining a practice beyond its implementation (Bond et al., 2012). In terms of its long-term sustainability as a program, IMR has shown low rates. At 6 years follow-up, Bond et al. (2012) observed that only 25% of IMR programs had demonstrated long-term sustainable practice, whereas 58% had been discontinued and restarted, and 17% had been discontinued entirely. Therefore, knowledge about making IMR sustainable in mental health services is needed.

The few studies that have explored mental health professionals’ experiences with implementing IMR (Egeland et al., 2019, 2017; Salyers et al., 2008; Whitley et al., 2009) have shown that a high degree of fidelity among participants does not equal successful implementation. Supportive and engaged leaders, however, are important to IMR’s success (Egeland et al., 2019). When Salyers et al. (2008) explored facilitators and barriers involved in implementing IMR in assertive community treatment, the most important facilitators were training, IMR materials, coworkers and supervisors, the agency or administration, and consumers’ involvement, whereas the critical barriers were patients’ lack of motivation, patients’ nonattendance, insufficient agency or administration (e.g., policy and philosophy), IMR materials, and inadequate time for staff. The following year, Whitley et al. (2009) examined factors that promoted or hindered IMR’s successful implementation in 12 community mental health centers and found that leadership, organizational culture, training and staff, and supervision determined the success or failure of implementation. Since then, drawing from interviews with recovery coordinators and local IMR experts, McGuire et al. (2014) have highlighted inadequate time for staff, lack of basic knowledge about IMR, and lacking employees experienced with IMR from other locations as major barriers to implementation. However, to the best of my knowledge, no studies have examined mental health professionals’ perspectives on what is needed to make IMR sustainable as a practice in specialized mental health care. In this study, I therefore explored the perspectives of mental health professionals who work at sites that have offered IMR for at least 6 years regarding what they perceive as being crucial for sustaining IMR program. The research question was as follows: What do professionals perceive as being crucial to sustainably providing IMR?

Methods

This study was based on data from the Norwegian qualitative study “Illness Management and Recovery in Specialized Mental Healthcare: Experiences of Professionals.”

Setting

In Norway, the healthcare system is characterized by universal and comprehensive coverage that is funded and owned by the state. The central government has overall managerial and financial responsibility for the hospital sector, while Norway's four regional health authorities control the provision of specialized healthcare services (Norwegian Medicines Agency, 2023). Of the sites included in this study, three are public, while two are private with government subsidies.

Norway has a two-tier healthcare system with primary and secondary levels. In the context of the study, the secondary level, titled “specialized mental healthcare”, involved treatment provided by professionals in psychiatric hospitals and district psychiatric centers (DPS).

Recruitment and sampling

To gain an overview of sites in Norway that deliver IMR, the Norwegian IMR Network was contacted. The network aims to promote the implementation and development of the IMR program and since 2017 has been a national arena for anyone interested in IMR (The Norwegian IMR-Network, 2022). Among the 21 sites the Norwegian IMR network identified that delivered IMR, five were selected. The sites were selected based on how long they provided IMR and the degree of experience with individual and group treatment. Furthermore, a geographical spread of sites was sought.

Then, communication with the management at the respective sites in specialized mental health care was established. The management provided information about the study to their staff and booked meeting rooms for the interviews. To be included, participants had to be employed as mental health professionals in outpatient or inpatient mental health care (i.e. in mental hospitals or district psychiatric centers) and have experience delivering IMR.

At five IMR sites (see Table 1), seven focus groups with professionals were conducted. A total of 36 professionals participated—27 women and 9 men, all of various mental health professions (see Table 2)—13 of whom were working in outpatient services (i.e., psychosis outpatient clinic, aftercare outpatient clinic, Flexible Assertive Community Treatment, and day care clinic), whereas the other 23 were working in inpatient services (i.e., general psychiatric units, rehabilitation units, and specialist psychiatric units for psychosis).

Table 1 Studied sites providing IMR
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Table 2 Professional background of participants
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Among the 36 participants, 30 actively ran IMR groups. Of these, 10 also offered individual IMR sessions. Two participants offered only individual sessions and four ran neither individual nor group sessions but justified this by being in management positions. All participants had previously hosted group sessions in IMR. Some, particularly those working in outpatient services, held weekly group sessions in fixed groups over a period of 9–10 months. Participants who were working in inpatient services, by comparison, held group sessions several times a week, usually with open, flexible groups in which the facilitators were liable to differ from session to session. In services in which patients were hospitalized for 3 months or more, patients were likely to complete the entire program during their stay. When lengths of admission were shorter, the inpatient staff selected two to four modules (i.e., partial IMR) to alternate between; however, all patients had to complete the first module individually before entering group sessions. In the first module, the concept of recovery is discussed, and patients are encouraged to identify an overall recovery goal, short-term goals, and the steps needed to work toward those goals. Patients introduced to IMR upon admission and who wanted to complete the entire program were referred to fixed or closed IMR groups in the outpatient clinic or municipal health service.

In advance of the focus groups, an interview guide was prepared. To encourage participants to share and speak freely about their experiences, interrupting and steering the conversations were avoided to the greatest extent possible. Instead, themes and questions that could be explored later were jotted down in a notebook. Before each focus group interview, the participants were given written and oral information about the study, and all participants signed their informed consent to participate before the interview.

The focus groups consisted of two to eight participants each, all with different professional backgrounds and experiences. The interviews were open-ended and lasted 81–98 min, with an average length of 88 min. All interviews were audio-recorded and transcribed verbatim in Norwegian by a professional transcriber. To ensure anonymity, the participants’ names were changed to participant numbers (P1, P2, P3, etc.) and the sites’ names were changed to site numbers (S1, S2, S3, etc.).

Data analysis

To explore the professionals’ experiences of what is crucial to ensure the sustainability of IMR, Braun and Clark’s (2019, 2021) reflexive thematic analysis was conducted in six steps: (1) becoming familiar with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing this article. Identified themes were presented to and discussed with an “expert group” of three people with firsthand experience with IMR and recovery-oriented practices as patients, clinicians, and/or researchers. In the final phases of the analysis, the author refined the themes based on discussions with colleagues in the research groups, (1) Mental Health and (2) Equitable Community Participation and Marginalized Groups.

Ethical considerations

The Norwegian Centre for Research Data gave the study ethical approval (No. 2021/200019), and the study was conducted in accordance with the principles of the Declaration of Helsinki (World Medical Association, 2013). Participation was voluntary and based on written informed consent, and participants were informed that they could withdraw from the study at any time for any or no reason.

Limitations

The research has some limitations. First, the sample can be seen as too diverse as it includes both individual and group IMR sessions and full and partial IMR. Second, few specialists, such as psychiatrists and psychologists were represented; nor did our sample include many social workers. At the same time, it is important to point out that nursing today is one of the professions most represented in Norwegian specialized mental healthcare.

Findings

Factors essential to promoting sustainable implementation emerged in three themes in the data. Despite overlap between the themes, they are presented separately in what follows for ease of comprehension.

Anchoring in the organization

At all five sites, participants highlighted that anchoring in the organization was necessary for implementing the IMR program. From 2011 to 2015, the management at the various sites was introduced to IMR through the Internet, at conferences, and/or on study trips in Norway or abroad. According to the participants, managers at the various sites such as themselves have long sought effective treatment programs that are evidence-based, can inspire staff, and promote quality of life and coping among patients.

The participants offered examples of previous failed attempts to implement treatment methods in mental health services. In recounting those experiences, they highlighted anchoring as a necessity for sustainable implementation; otherwise, the methods were largely doomed to fail. To facilitate anchoring, participants emphasized the importance of systematically implementing the IMR program throughout the organization, not only among individuals who are supposed to run the treatment:

P16: It’s important that everyone employed, from the head of the department or chief of psychiatry to the entire staff, has ownership over the IMR program, that they have this feeling that “we’ve chosen to do this at our department, we decided this.” I think it’s quite important that not only three employees make plans that everyone has to follow, because that rarely succeeds. (S2)

Likewise, the participants also underscored the importance of working to build a sense of “we-ness” when new treatment methods are implemented and that leaders play a particularly central role in that work:

P31: To speak positively about IMR is central, that it’s something that we believe in [both at the management and specialist level]. ... It’s essential that everyone becomes “we,” something that we all believe in.

P30: Yeah, that [Implementation of IMR] has to come from the management level. It’s something that we invest in. In fact, organizations that have succeeded [in implementing such methods] are the ones with people in management who have knowledge about IMR. Otherwise, there’ll only be two passionate employees in the organization, and they’ll eventually get tired and bored and lose motivation. (S4).

In one dialogue, two professionals, one of whom was in management, elaborated upon the importance of management’s having knowledge about the treatment program and recognizing the professionals’ daily work with IMR:

P15: Initially, it was important for me as a leader to be aware of what was going to happen that day and know who was going to have the IMR group—you know, mentioning the group, asking whether everything was okay, and figuring out whether the professionals had everything that they needed. I always went back to the professionals afterward to ask how they had experienced the day’s group session. I believe that such affirmations were important.

P18: We [professionals] got support and recognition from management. In the beginning, that was particularly important, because we were trying to figure out how to [run the program]. At that time, some support from the management was crucial, and I really felt that we got that from you [P15 in management]. (S3)

In this study, the professions who usually ran IMR groups were mental health professionals with bachelor’s degrees in nursing or social work and who had completed additional clinical courses, programs, and/or graduate schooling. Generally, that arrangement was considered to be positive because staff members were given clearer, more important roles in the treatment of people with SMI, especially in the wards. However, that specialists in medicine and psychology were only slightly represented among IMR therapists was pointed out as being a limitation, particularly for the visibility and recognition of IMR throughout the organization:

P32: I think that our specialists should have been more involved and worked in a similar way. I think that’s important. ... Now, it’s like, “What are you doing?” and that’s not good.

P33: Do you think that it will do anything to the quality of IMR?

P32: No, but ...

P33: In relation to competence?

P32: For us, it’s about being visible [in the organization].

I: But does that mean that if there were more specialists in psychology [doing IMR], do you think that ...?

P32: Then it [IMR] will be more visible [in the organization].

P33: Do you think about receiving recognition?

P32: Yes, I think so. Previously, we had a director who was very knowledgeable about IMR. At that time, we were seen. Now, we’re less seen. ... So, there’s a danger that it [IMR] could simply die, as other programs have done before, right?

P33: At the same time, we shouldn’t hide under the chair just because we’ve had a very challenging situation in terms of handling specialist tasks in our unit. In recent years, we’ve cut to the bone and had to make hard decisions about prioritizing how to use the specialists, and that’s also anchored in the organization. (S5)

Overall, the professionals needed more than mere positive confirmation that they were implementing a new treatment method. They also underscored the importance of organization-wide anchoring that makes all employees part of the implementation process. Particularly, having some specialists in medicine or psychology with great knowledge and/or training in IMR was seen as being vital. In addition, maintaining the program was described as requiring knowledge, involvement, and attention from management.

Access to training and guidance

All participants emphasized the importance of receiving training and guidance when implementing a new treatment program. However, the extent to which they had been able to access such training and supervision, as well as of how systematic and comprehensive the training has been, has varied greatly over time. Participants who received training in the program’s early years received thorough instruction and guidance from an externally certified IMR therapist, including at least two days of training and one year of guidance by phone, with the possibility of an additional year of follow-up:

P34: When we started, all professionals at district psychiatric centers and hospitals in Norway who were going to implement IMR received training from the same person from abroad. We received weekly guidance, which included recordings of the group sessions and getting feedback on the methods that we used. (S5)

As the years went by and the participants gained more experience in IMR, several become certified IMR trainers and could thus offer training to their colleagues. Nevertheless, they stated that even within the same organization, differences in access to training and guidance among staff have been vast, especially between inpatient and outpatient services. Participants in outpatient services largely described extensive IMR training and guidance, whereas participants who delivered IMR in inpatient services reported differences in both type and form of training and guidance. Some had received training while working in an outpatient services, while others had worked in a 24-h service but were given the opportunity to run one or more IMR groups in the organization’s outpatient service in order to maintain their IMR skills. Some had received close follow-up internally by more experienced IMR colleagues and had run full-scale IMR groups in their organizations, whereas others had only received an introductory course to IMR and tried to master the practice on their own through trial and error.

The participants employed in inpatient services, however, disagreed about what training is required to implement IMR. Their perspectives ranged from experiencing that training would be more sustainable if it were based on learning by doing to observing that all staff need systematic training in order to be able to deliver high-quality treatment:

P7: I think that the strategy of our leaders has been crucial. They just started and expected everyone to stick to it. Because if you thought that we needed a certain kind of room or to sit in this or that way, that the employees needed a certain kind of education and had to know this and that before we were ready to start, I don’t think we would have been able to implement it [the IMR program]. The essential thing is gathering people into a group.

P5: I think it’s quite demanding when you have colleagues who don’t want to lead the IMR groups.

P3: But they should do that. ... If not, then this isn’t the right place for them to work.

P5: Yeah, but usually it’s about fear, and they should be allowed to have fear.

P3: I hope there aren’t many of those employees.

P5: You [P7 and another IMR resource person] are constantly nagging that there’s no point in making a big deal about it [doing the IMR groups], that we should instead take it easy.

P7: Yes, I think that’s the trick. For there are some colleagues who come up with arguments such as, “If I don’t have enough knowledge about IMR, then I don’t have anything to offer the patients. It’s not okay for the patients to get punished as a result of my lack of knowledge about practicing IMR.” Some argue that they’re not provided with sufficient training, but the real training is practicing IMR in the group and relying on each other. Employees shouldn’t place excessive demands on themselves. (S2)

Although there was an expectation among the participants that all staff in inpatient services should run IMR groups, several felt that they had not received systematic training. For years, those participants had experienced being thrown into the program without specific training or guidance. Even so, some described changes in that practice a result of their request for more systematic follow-up by so-called resource personnel—that is, employees on-site who are certified trainers in IMR:

P9: It [IMR] wasn’t in place when you [another participant] and I started. ... We were kind of thrown out on the ice. ... Fortunately it’s now been made into a system. People who are experts in IMR certify us. We go through every module together, and they attend some group sessions when we’re teaching. (S2)

Professionals who had received significant training and guidance during the IMR program’s implementation in their organizations highlighted the importance of continuing to facilitate access to guidance even when employees become experienced IMR therapists. To prevent the discontinuation of IMR in their organizations, they underscored the continuous need for booster training and guidance, especially in relation to maintaining motivation and being innovative in teaching self-management skills:

P33: It [IMR] isn’t something new in our organization anymore. People have maintained their motivation and have become self-sufficient over time. However, to make us willing to continue, particularly during periods when it might be difficult, we really need a place to vent, receive new input, and get encouraging words. We don’t need much to regain motivation and energy to continue our work.

P32: We don’t have high demands.

P34: To stay motivated to continue doing IMR, it might be important to invest in supervision and provide staff with some extras [incentives]. (S5)

While experienced IMR therapists in the outpatient services already had access to arenas where they could share experiences with others, participants affiliated with inpatient services called for access to peer-to-peer learning. They underscored the importance of giving experienced IMR therapists the opportunity to provide training and supervision to less experienced colleagues, which, though challenging, was crucial to ensuring IMR’s sustainability:

P25: There are resource personnel in our organization who could share their knowledge with colleagues. Usually, they run IMR groups in outpatient services in order to keep their IMR skills sharp.

P23: But I think it’s quite difficult for them, too. They really want to supervise and follow up on colleagues, but when are they supposed to do that if they’re not provided the time to?

P22: COVID-19 has not helped [opportunities to give and receive guidance] either. We [IMR therapists in the full-scale groups in outpatient services] have been part of an IMR peer network with staff from the municipality. We’ve exchanged ideas ... . It’s been quite interesting, and we’ve learned a lot from each other ... .

P23: But why can’t you [staff from inpatient services] be with us?

P25: Because then there’s nobody left in the unit [to follow up on patients] ... .

P22: I really hope that you could be included, because it gives so much extra inspiration to hear how people think, feel, and have solved similar challenges: a lot of good tips. ... I see now that I’ve been really lucky. For me, it’s worked well, both the IMR training and the follow-up with peers. But I see that you’re in quite a different situation. I definitely think that you can learn IMR by yourself. I have no doubt, but it’s nice to have time for training and guidance and to get professional replenishment. (S3)

At one of the sites, participants had experienced that previous colleagues with training in IMR had left the organization without being replaced by new professionals, even despite the fact that management had initially decided to implement IMR in the organization. Without a team of a certain size, it becomes a risk to run IMR groups:

P2: We no longer have IMR groups.

P1: There are only two of us [IMR therapists] with education in IMR. Previously, there were three or four more professionals with such training. Then, we had an IMR team, where we could discuss how to run the program efficiently and guide each other (S1)

The participants emphasized the importance of receiving training and guidance early on in the implementation of the program, if not from the beginning. Although they gradually gained experience and competence in running IMR groups, they stressed the value of continuing to have the opportunity to receive guidance, be supervised, and engage in peer-to-learning and sharing, all of which were viewed as being crucial to sustaining the motivation for IMR practice.

Allocating time for preparation and reflection

Regardless of whether the participants were employed in an outpatient or inpatient service, they experienced busy workdays when the work tasks were many and required balancing available working time. However, the participants also stressed the importance of prioritizing time to prepare for IMR, because when they felt hurried, there was a risk that preparation would be sidelined. Therefore, several participants highlighted the need to strictly adhere to scheduled meetings and to avoid rescheduling, shortening, or canceling sessions:

P2: We’ve needed to set that time aside. We haven’t allowed double-booking our joint preparation time. You can’t say, “No, I have to go to a course or another meeting.” It’s our shared time, so the person will simply have to find another time for their other tasks. At least for us, such discipline has been crucial, because if someone starts slipping, then the rest of the team starts slipping, too. (S1)

In highlighting the need to allocate time in advance of group sessions, the participants added that the lack of adequate joint preparation created uncertainty about what material to use and how to present it in group sessions, which risked poor treatment quality. The challenge, on the other hand, was that time was perceived as being increasingly scarce:

P22: Preparation is important for us to be mentally present during group sessions and to avoid merely reading the IMR manual in groups. Can you imagine anything more boring? We need to be sufficiently prepared so that we can free ourselves from the manual and convincingly convey the content to the participants in the group.

P21: In the beginning, we tried to prepare. It was nice. ... Nowadays, we have limited time to prepare, at least planned time. I would really like to have that possibility again, because it makes it [the group sessions] so much easier. (S3)

Although participants tried to avoid being unprepared for group sessions, they demonstrated how they had experienced sessions where they lacked time to prepare properly.

P28: “Shit, it’s just two minutes until we start the group session. Do you remember where we ended our last session? What are we really doing?” That’s not okay for us or for the IMR participants. We need to tune in, which involves both planning our session in general and what we need to ask each participant more specifically about. If we’re able to remember exactly what we talked about in the last session and what each participant’s goals are, then the participants will experience being seen by us. Otherwise, we’ll start like this: “Shit, we have to find the right page [in the manual].” Preparation is key.

P29: Yes, it’s crucial. (S4)

Even experienced IMR staff reported needing time to “tune in” to group sessions. When they were confident with the material and had an overview of the session, then they had more flexibility while interacting with patients:

P33: There’s a difference when I’ve had time to prepare well from when it’s been impossible to do so. I’ve noticed that I’m more relaxed. If I have an overview of what’s going to happen in the session, then it’s much easier to accept and handle things that come up. (S5)

According to the participants, when possible, they prioritized reflecting on how they had experienced the group sessions. At the same time, they revealed that they often did not complete reflections on sessions immediately afterward due to time pressure:

P1: Usually, we’ve scheduled the half-hour afterward to reflect on what we did. What techniques did we use? Did we use motivational interview? Role-play? What happened in the group? Was the session perceived as being useful for the participants? Had they done their assignments? Had they progressed in some way? What happened when you…? It was quite useful, especially in relation to what we as therapists did in the sessions. We discovered, for example, “Okay, no role-play this time.” Then, we realized that we weren’t good enough and planned how to use role-play in the next session. (S1)

To continue offering group-based IMR, participants stressed that their organizations need to facilitate sufficient time to prepare. Because being an IMR therapist involves more than participating in group sessions, a lack of sufficient preparation before and some reflection afterward poses a real barrier to IMR’s long-term sustainable implementation.

Discussion and Conclusions

This study revealed several factors that are crucial for maintaining IMR in specialized mental health care services. Based on the professional perspectives of the participants, those factors seem to be interrelated. In the following, some tensions related to the factors are discussed and situated among the findings of other research in the field.

First, the findings show that anchoring IMR broadly in the institution is important. Such anchoring means that everyone in the organization, regardless of level, function, and profession, has knowledge of the IMR program, even if they do not perform the treatment themselves. To the participants, broad anchoring in the institution made the IMR program less vulnerable to illness and turnover among staff because other professionals were thus available to step in during short- or long-term absence. Because turnover usually is high in health and welfare services and challenges the institutions in terms of sustainability (Bond et al. 2009), broad anchoring can help to prevent the discontinuation of the IMR program.

In this study, only professionals at one of the sites (i.e., S1) had experienced that their IMR team had deteriorated, particularly when several IMR therapists left the institution and no plan was in place to replace them. Because it takes at least a year before professionals feel comfortable running IMR, the need for long-term planning related to recruitment is crucial (SAMSHA, 2009a). Patras and Klest (2016) have posited that clustering therapists together in groups of at least three makes evidence-based programs less vulnerable. Thus, establishing an IMR team that always consists of at least three IMR therapists could make the program sustainable, namely at the abovementioned site, where the team deteriorated upon having fewer than three IMR therapists. Having only two IMR therapists seems to be too risky, for there would be no one else to discuss the program with or to step in when either team member is absent.

At the same time, it is possible that not only the number of team members determines the program’s sustainability but also whether the trained staff fit into the program. According to SAMSHA (2009a), professional background is secondary to the professional’s understanding of SMI and the inherent belief that the group of people can live full, productive lives in the community. That staff members also possess qualities such as being warm and empathetic and have good listening skills is also crucial (SAMSHA, 2009a).

According to our participants, although such broad anchoring provided the potential for developing a strong “we culture” and a recovery-oriented environment throughout the institution, it also challenged professionals’ ability to achieve a clinical understanding of IMR and refine the strategies and skills needed to deliver effective treatment. Particularly in inpatient services, the ambition of broad anchoring undermined the possibility for all staff to receive high-quality training and effectively refine and/or improve their skills. Most of the participants’ institutions had not managed to create adequate structures for systematic training and guidance for all. SAMSHA (2009a) recommends that IMR teams should not exceed eight therapists in order to ensure that the IMR leader can properly supervise them. If the team exceeds eight members, then it should be split into two or more teams (SAMSHA, 2009a). In that light, it is interesting that most participants who provided IMR for inpatients did not experience being part of an IMR team whatsoever and seemed to be at risk of having limited access to valuable resources related to continuous training and guidance.

Second, the findings showcase the importance of affording staff access to training and guidance. That observation is consistent with the results of past research highlighting that training and guidance are important in the process of implementing the IMR program (Bartholomew & Kensler, 2010; Fixsen, 2005). According to Fixsen (2005), such training usually addresses various topics, including the history, theory, philosophy, and rationale of the program, as well as imparts skills and abilities needed to carry out the program’s components and practices. This study shows that it is not enough to simply read through the IMR manual and implement the strategies without becoming familiar with the program’s background, philosophy, and rationale and without being given the opportunity to work with strategies and techniques. Training and guidance from experienced IMR therapists should consist of both discussions and feedback on recordings from group sessions, on strategies and skills utilized, and on strategies and skills that group members are reluctant to use.

When professionals in this study lacked training and guidance, it seemed to lead to insecurity and uncertainty while running the IMR program. According to Bartholomew and Kensler (2010), clinical training and guidance reduce anxiety among staff and simultaneously increase professionals’ skills. More recently, Egeland et al. (2019) have stated that having professionals with a minimum amount of initial briefing on the content of IMR is not unusual but might make them feel overwhelmed by the workload. They also found that training and guidance appeared to be important tools for ensuring the safety and quality of the work performed in the IMR program. In that light, it may be necessary to ask institutions whether they plan for staff training and guidance beyond the implementation period. In this study, all sites had prioritized training and guidance for selected professionals in the initial years, and some had also provided initial briefing to a larger group of professionals. Nevertheless, how training and guidance should be put into daily operation for a long-term sustainability seemed less planned, particularly when a large group of staff was tasked with handling the program.

Although professionals on full-scale IMR teams seemed more content with recruitment, training, and guidance, in everyday practice they were given limited space and time to prepare and reflect on sessions and to give peer-to-peer guidance to less experienced IMR therapists. It appeared that the institutions did not take into account the time needed to afford continuous training and guidance after the program’s initial implementation. As other research has shown, additional costs associated with training staff are regarded as a critical issue in health care services, where turnover rates are usually high (Aarons et al., 2010, p.16). Considering all of the participants’ experiences, setting time aside for training and peer guidance after the implementation phase has ended (i.e., 2–4 years) seemed random, which is unfortunate given how crucial it could be for staff members’ well-being, motivation, continued learning, and skills refinement.

Last, the professionals in this study argued that leadership was important for the sustained use of the IMR program. Although they primarily emphasized the importance of a committed, supportive first-level leader, having a top manager familiar with the IMR program was also highlighted as pivotal to enabling sustainable practice, as has become clear at one of the sites. There, when top management with good knowledge of IMR was replaced with management with limited knowledge of the program, professionals experienced being less recognized and more uncertain about IMR’s viability. Past studies have shown that leadership is crucial to the sustainability of evidence-based programs once active implementation has ended (Aarons et al., 2012; Egeland et al., 2019; Whitley et al., 2009).

According to Whitley et al. (2009), leadership is especially important for new practices such as IMR, for effective leadership can facilitate access to critical resources within the institution, including supplementary training, consultation, and high-quality guidance. In this study, leaders were important gatekeepers of access to the institutions’ scarce resources. Sound knowledge of the IMR program among leaders can also contribute to a greater understanding of professionals’ needs for preparation and reflection and the need for the further development of the program. Despite having leadership with a positive attitude toward the implementation of the IMR program and interest in innovation (Whitley et al., 2009), most professionals in this study indicated the challenge of balancing their existing duties along with their IMR duties. That predicament is consistent with what Egeland et al. (2019) found, namely that professionals, despite having high autonomy when it comes to following up with their patients, were torn between IMR work and other responsibilities in their institutions. Continuously dealing with priority dilemmas might result in deprioritizing IMR more than desired. In that sense, a lack of time for staff can be a real barrier to sustainable practice (McGuire et al., 2015), and it is important that leaders be made aware of that reality.

In sum, several interrelated factors are crucial to ensuring sustainable IMR practice. Beyond that, all of them can be understood in light of Fixsen et al.’s (2013) implementation framework of implementation drivers, including competence drivers, organization drivers, and leadership drivers, all highlighted as components of successfully implemented programs. Based on the professionals’ perspectives on what is needed to sustain the IMR program, all of the types of implementation drivers mentioned by Fixsen et al. (2013) are present in their organizations. For one, competence drivers appear in the form of training and guidance for staff who run the IMR program in the organization. By contrast, organizational drivers include developing a shared vision for the program, creating clear structures for staff recruitment, providing ongoing training and guidance, and having a long-term financing plan in place in order to operate and develop the program after implementation. Last, leadership drivers are present in that top- and first-level leaders have knowledge of the program, provide support and recognition of the IMR therapists’ work, and allocate access, time, and space for preparation, self-reflection, and participating in peer-to-peer learning and sharing. To ensure sustainability, it is therefore crucial that professionals, leaders, and their organization as a whole work together in the same direction. To keep professionals motivated to continue IMR, access to skills development and sufficient time and space to plan, implement, and reflect on the IMR program are essential.

Implications

This study has shown that providing training and guidance to IMR therapists only once is not enough to sustain the IMR program. Because there always are new professionals being hired and because skilled professionals and well-trained staff might leave the organization, a plan for recruitment, ongoing training, and guidance is needed. Further, without sufficient training in IMR teaching strategies and adequate time to prepare, it is a risk that IMR sessions become more didactic. In addition, the findings highlight the importance of providing experienced IMR therapists the time and space to facilitate colleague-based peer-to-peer learning and sharing.

More research on the sustainability of EPBs is also necessary. A replication of Bond et al.’s (2012) study, for example, in which rates of sustainability and factors associated with sustainability 6 years after full implementation in five evidence-based programs are examined, could provide knowledge about whether IMR still shows low sustainability after implementation has ended and examine why or why not. It would also be interesting to map how many institutions have started with IMR on the national level, if not the international level, and to examine in greater detail the sites that have discontinued their IMR practice in order to learn more about why they were discontinued and what professionals at those sites perceive to be necessary to restart the IMR program. Finally, this study suggests that the use of focus groups where professionals can share their experiences about the factors needed to sustain the provision of IMR could be an important next step for exploring the sustainability of other EBPs.