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Recovery Model: Mental Health Recovery Model Applied to Severely Mentally Ill; JH Rick Massimino MD

Individual Treatment Contract (c)

 Individual Treatment Contract (ITC):  A powerful and innovative copyrighted contract protocol.

The John Henry Model© relies on developing and implementing an “Individual Treatment Contract (ITC)” with each patient tailored to the specific clinical challenges which have contributed to relapse behavior in the past.


The Individual Treatment Contract (ITC) is agreed to prior to admission between patient/resident and treating facility. It clearly specifies and outlines a treatment plan consistent with the objectives of relapse prevention and rehabilitative growth for each individual.  Each resident, their authorized representative and the facility agree to each Individual Treatment Contract voluntarily and in writing.  It also provides a mechanism for navigating through the very complex and difficult tensions, which exist between a patient’s right to refuse treatment and be ill (ultimately becoming psychotic and/or dangerous to self or others) versus a patient’s right to be healthy and safe and society’s right to be safe from out of control mental illness.  The Individual Treatment Contract represents a mechanism under which a mentally ill patient can receive the necessary comprehensive treatment services they require while residing in an outpatient non-medical residential setting.


Under normal circumstances when a citizen exercises certain rights it does not result in any immediate consequences.  For example a citizen may freely come and go from their home without consequence.  Should a seriously mentally ill person with disorganized delusional thinking and impaired judgment freely come and go from their home?  A typical Individual Treatment Contract (ITC) clarifies that a mentally ill person with disorganized delusional thinking and impaired judgment needs assistance during this period of increased symptoms and should only leave with another responsible person or stay at home until improved.  The resident’s impaired condition and judgment is made healthier by the better judgment of another person i.e. the treatment setting.  The mentally ill resident through their signed ITC can agree to receive this specific and necessary assistance and not exercise their right to come and go freely.  Similarly, any clinical challenge which benefits from the needed temporary curtailment of a specific Right, would be incorporated into the Individual Treatment Contract (ITC). The result is that every decision made is always a best interest decision instead of an expressed interest (I want what I want) decision. The process of building on best interest thinking which results in improved individual responsibility leads to maximal Rights without conflict. The ITC is a fluid and flexible contract which is constantly modified according to resident growth or clinical needs. By cooperating with treatment and seeking wellness, a seriously mentally ill person who is clear thinking and accountable for their behavior can then exercise any patient right without limitation.

All seriously mentally ill patients have statutory rights.  Often patients have exercised their right to refuse treatment, smoke, engage in conduct likely to cause relapse, use drugs and alcohol, eat candy bars while diabetic, ignore hygiene, etc. without any immediate limitation or restriction on their conduct and decisions.  These statutory rights are made available and protected for seriously mentally ill people assuming competence in decision making even when an obvious impairment exists.  If one is competent to exercise a right, then one is competent to understand the consequence of a decision and resultant behavior. Therefore, one is competent to enter into a contract such as the Individual Treatment Contract (ITC).  The John Henry Model© supports the retention of all statutory rights by chronically mentally ill people who are cooperative to treatment and understand and accept the need for help when they become symptomatic.  The John Henry Model© also believes that cooperative and stable seriously mentally ill people deserve the same opportunities and rewards enjoyed by all citizens. This equality of opportunity and reward can only be accomplished through medical stability and personal accountability. 

The Individual Treatment Contract offers the remedy for when a resident chooses to engage in a relapse behavior. The treating facility will immediately act to remedy the situation by providing the necessary assistance.  A typical ITC when used by a skilled facility makes it possible to identify these relapse behavior events early enough in the illness process to allow the resident to successfully accept the assistance needed for correction.  Each resident understands that by refusing to accept required assistance they violate their Individual Treatment Contract.  Every resident is therefore motivated to listen and cooperate with offered assistance because the consequence may be termination of the residential relationship or more serious loss of Rights (if court ordered into treatment then a return to custody may result). A resident who is given the privilege and opportunity to enter into an Individual Treatment  Contract  (for treatment success, personal and societal health and safety and maximal statutory rights) accepts greater responsibility for their life and is the fundamental uniqueness of  the Individual Treatment Contract.

Applying necessary temporary limitations on a patient Right for just cause and best interest  is one of the most confusing, contradictory, seemingly illogical,  and combative issues in this country.  These issues have created divisive conflicts between doctors, providers, patients, families, police, courts, judges, and advocates on both sides. This issue ultimately helped create the largest mental health care system for the seriously mentally ill in this country, our prisons.  The John Henry Model© through the Individual Treatment Contract (ITC) provides the framework and mechanism for addressing these issues and concerns while simultaneously offering the necessary treatment services.