Illness Management and Recovery
Kim Mueser, PhD1 and Sally MacKain, PhD2
The CMHS National GAINS Center
May 2006 Updated August 2008
Illness Management and Recovery (IMR) is a set of specific evidence-based practices for teaching people with severe mental illness how to manage their disorder in collaboration with professionals and significant others in order to achieve personal recovery goals. Learning about the nature and treatment of mental illness, how to prevent relapses and rehospitalizations, and how to cope effectively with symptoms gives consumers greater control over their own treatment and over their lives. The practices included in IMR are often referred to by a variety of other names, such as wellness management and recovery and symptom self-management.
Research reviews have identified five specific evidence-based practices included in IMR, each supported by multiple controlled studies.
Psychoeducation is teaching information about mental illness and its treatment using primarily didactic approaches, which improves consumers’ understanding of their disorder and their capacity for informed treatment decision-making.
Behavioral tailoring is helping consumers fit taking medication into daily routines by building in natural reminders (such as putting one’s toothbrush by one’s medication dispenser), which improves medication adherence and can prevent relapses and rehospitalizations. Relapse prevention training reduces the chances of relapse and rehospitalization by teaching consumers how to recognize situations that trigger relapses and the early warning signs of a relapse, and developing a plan for responding to those signs in order to stop them before they worsen and interfere with functioning.
Coping skills training bolsters consumers’ ability to deal with persistent symptoms by helping them identify and practice coping strategies, which can decrease distress and the severity of symptoms.
Social skills training helps consumers strengthen their social supports and bonds with others by practicing interpersonal skills in role plays and real life situations, resulting in more rewarding relationships and better illness management.
A variety of standardized programs have been developed to help consumers learn how to manage their mental illness more effectively. These programs overlap with one another, but
each contains unique features, and consumers may benefit from participating in more than one program:
Although evidence supports teaching illness self-management in hospitals and communities, little is known about the effects of such programs in the criminal justice system. Four published studies in the mental health or criminal justice literature identify programs that utilized IMR evidence based practices. Two programs, one at the California Medical Facility at Vacaville (MacKain & Streveler, 1990) and one at Brown Creek Correctional Institution in North Carolina (MacKain & Messer, 2004) used the SILS modules as a primary focus of treatment. The programs were delivered on acute care and day treatment units that provided multi-level, continuous care. Inmates who received at least 18 sessions of medication management training scored higher on a test of knowledge and skill than those with less exposure to the modules. The inmates at Brown Creek showed improvement in knowledge about their own medications and in their understanding of information and skills taught in the module. The gains in personal medication knowledge were maintained after transfer to other prison units, but the more generalized medication management knowledge and skills deteriorated following transfer, perhaps due to the lack of opportunities for continued practice.
The Mental Health Program at McNeil Island Corrections Center in Washington offers psychoeducational classes such as symptom recognition and relapse prevention (Lovell et al., 2001a). In one study, comparisons of pre-program and post-program behavior in inmates with at least 3 months of treatment showed reductions in symptom severity, behavioral infractions, and assignments to higher levels of care (Lovell et al., 2001b). Former participants also had higher rates of job and school assignments and lower levels of symptom severity when transferred or released, compared to their level at treatment entry. At follow-up, 70 percent of the transferred inmates maintained their level of functioning and were housed among the general population of inmates.
Despite the lack of controlled research on IMR-related programs in criminal justice settings, evidence supporting their use in other contexts suggests that they can be adapted to an offender with mental illness in a variety of settings. Different illness self-management programs complement one another in focus and approach. Components of IMR, SILS, and WRAP can all be adapted to meet the unique demands across institutional and community settings:
Jails. Considering the brief to intermediate length of time individuals may spend in jail, this setting is most appropriate for mental health screening, educating consumers about the basic facts of mental illness and its treatment, and fostering motivation for learning illness self-management skills. Subsequent work on formulating personal recovery goals and competence at illness self-management can be accomplished in either outpatient mental health or prison settings.
Prisons. IMR-related programs can be implemented in prison settings, with the combined focus on articulating personal long-term goals and learning the rudiments of illness self management.
As described in the previous section on the evidence base for IMR-related programs in criminal justice settings, longer sentences in prison and the ready access to consumers facilitate the engagement of inmates in group or individual work aimed at improving illness self-management
skills.
Community Corrections/Community Mental Health. IMR related programming can be implemented with individuals or groups in these settings, other transitional programs, or FACT teams. Topic areas emphasizing skills such as building social support, using medications effectively, coping with stress, and getting one’s needs met in the mental health system are most relevant when offered within the consumer’s own residence or community. Peers are important partners in helping consumers with criminal justice system involvement develop the motivation and IMR-related skills to avoid incarceration or for those leaving jail or prison to adjust to life outside institutions and avoid re-incarceration.
The Bronx Mental Health Court started in 2001 using a deferred sentence model for diverting individuals with serious mental illness who had committed felonies to community-based treatment. In 2005 when the court was preparing to add a track for misdemeanor charges, it engaged experts in IMR to help adapt the practice for justice-involved individuals. The practice was modified to fit with the court-ordered treatment plans of the mental health court participants and additional modules were developed to address the effects of prison and jail cultures on thinking and behavior. The clinical modifications resulted in modules added to the front end of the curriculum as a means of preparing participants for general modules (i.e., building social support, coping with stress). These add-on modules addressed:
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 (pp. 395- 424). New York: Norton.
Illness Management & Recovery program materials website: www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/default.asp.
Lovell, D., Allen, D., Johnson, C., & Jemelka, R. (2001a). Evaluating the effectiveness of residential treatment for prisoners with mental illness. Criminal Justice & Behavior, 29, 83 – 104.
Lovell, D., Johnson C., Jemelka, R., Harris, V., & Allen, D. (2001b). Living in prison after residential mental health treatment: A program follow-up. Prison Journal, 81, 473-490.
MacKain, S. J., & Messer, C. (2004). Ending the inmate shuffle: An intermediate care program for inmates with a chronic mental illness. Journal of Forensic Psychology Practice, 4, 87-100.
MacKain, S.J. & Streveler, A. (1990). Social and independent living skills for psychiatric populations in a prison setting: Innovations and Challenges. Behavior Modification, 14, 490-518.
Mueser, K. T., Corrigan, P. W., Hilton, D., Tanzman, B., Schaub, A., Gingerich, S. et al. (2002). Illness management and recovery for severe mental illness: A review of the research. Psychiatric Services, 53, 1272-1284.
Rotter, M. and Boyce, K.O. (2007, September 6). Bronx mental health court/illness management and recovery. Presentation at the CMHS National GAINS Center Expert Panel on Adapting Evidence-Based Practices to Criminal Justice Settings in Bethesda, MD.
Social and Independent Living Skills (SILS) program materials website: http://www.psychrehab.com.
Wellness Recovery and Action Plan (WRAP) program materials website: http://www.mentalhealthrecovery.com.
Acknowledgements: Special thanks are due to the attendees of the GAINS Center’s Expert Panel Meeting on Illness Management and Recovery held in Bethesda, MD, on October 18, 2005, where an earlier version of this paper was presented and discussed.
1 New Hampshire-Dartmouth Psychiatric Research Center - Dartmouth Medical School - 105 Pleasant Street, Main Building - Concord, NH 03301
2 University of North Carolina Wilmington - 601 South College Road - Wilmington, NC 28403-5612
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