Treatment Contracts

Treatment contracts serve many useful purposes for eating disorders patients, their families, and the treatment team. For example, contracts are helpful when working with patients or family members who are chaotic or who have not been able to collaborate with treatment team members. Contracts can be drawn when treatment has stalled and new therapy options need to be clearly introduced. For treatment team members with minimal experience with eating disorders, contracts can serve as a guide for monitoring and goal setting. Contracts can also be helpful for conveying treatment plans to health maintenance organizations and insurance companies.

Treatment contracts are particularly helpful for adolescent patients, and with larger treatment teams, and when family members are more involved in treatment. Finally, the detailed information developed with a treatment contract can be very helpful to send to managed-care organizations to document the seriousness of an eating disorder.

Where to Begin

The health professionals on the treatment team initially draft the treatment contract. Each provider contributes to the document until all team members agree upon the goals and plan of action. The contract is then presented to the patient and family members for review and addition of their goals.

The contract is revised until all involved parties agree on the document. When a consensus is reached, each party signs the final contract.

What Is Included in a Treatment Contract?

The structure is flexible, but typically includes the following:

Treatment participation: A description of the current treatment plan:

• The name and role of each team member and a description of the client’s appointments with that practitioner. For example, “Dr. Jones (physician) – vitals check once a week on Mondays, at 4:00 pm. Electrolytes monitored every two weeks.” If necessary, the vitals check can be described in detail, such as what and how measurements will be taken; e.g., “Weight will be taken on office A’s scale with the patient wearing a gown and panties.”
• How this treatment schedule can change. For example, “The above appointments may be increased or decreased in frequency, as recommended by Dr. Jones. Any change in the treatment plan will be discussed withpatient and/or patient’s significant others prior to implementation.”
• Treatment participation expectations. “Patient is expected to attend all treatment sessions. Should patient need to reschedule or cancel an appointment, it is her/his responsibility to contact the provider in advance. A pattern of failed or cancelled appointments will result in a treatment team meeting to evaluate barriers to participation.”

Treatment component descriptions: As needed, individual treatment components are described in detail to clarify goals and provider/patient interactions.

• Here is an example of a nutrition component description: “Patient and Tami Lyon will work together to develop a ‘safe’ and nutritionally adequate meal plan of 1800 calories/day by February 20, 2000. Patient will inform Tami of any substitutions and modifications that she makes to this meal plan by discussing them during nutritional counseling sessions. Patient will complete a food diary that will be reviewed by patient and Tami during sessions.”

Achieving a healthy weight: All pertinent goal weight ranges are addressed, including hospitalization, medical stability, and exercise and target weight ranges.

• A time line for achieving each weight range is documented. Here is an example for weight gain: “Patient will achieve her exercise weight of 100 lb or more by March 1, 2000.”
• The benefits of achieving a weight goal should be based on the patient’s requests as much as possible. For example, “The patient may participate in three physical education classes per week as long as she maintains a weight of 100 lb or more. If this weight is maintained for 6 consecutive weigh-ins, then the patient can reduce her vital checks with Dr. Jones to once every other week.”
• The providers’ response to the patient should she not meet a weight goal is described in detail. For example, “If patient’s weight is less than 100 lb on March 1, 2000, all extracurricular activities, including all individual and group events that expend energy will be suspended until the goal weight of 100 lb is attained. Vitals checks with Dr. Jones and nutrition appointments with Tami Lyon will increase to twice a week until the weight goal is met. ”
• The providers’ response to weight loss after the weight goal is achieved. For example, ” If patient’s weight is less than 100 lb for two or more vital checks during a four- week period, the following will occur: immediate restriction of all extracurricular activities, including walking for transportation and pleasure, attendance of any social functions that include any activity and twice-a-week weigh-ins with Dr. Jones.”

Participation of family members: The level of involvement of family members is described in detail.

• How family members will communicate with the treatment team. For example, “Patient’s parents will meet with Dr. Hayes once a month for 55 minutes.”
• Treatment recommendations and requirements for family members. For example, “Patient’s parents will start couples therapy by March 1, 2000.”
• Treatment recommendations and requirements for the patient and family members. For example, “Patient and patient’s parents will attend family therapy on a weekly basis beginning March 1, 2000.”

Effective dates: The dates that the contract will begin and end are documented. This typically includes a mid-contract review of progress meeting for all those involved in treatment.

A treatment contract documents treatment goals and how the treatment team will support the patient and family members in achieving the goals. The process of drafting the document can take several weeks and may have an impact on the treatment process. It is important that the patient and family members feel included in the creation of the contract, and that the final document contains input from everyone affected by the agreement.

— Tami J. Lyon, MS, RD, CDE

(Note: For the past 10 years, Tami Lyon has offered practical, real-life solutions to nutrition and eating disorders issues in “Nutrition Notes.” With the next issue, Tami will take a well-deserved rest, and this column will continue with a series of guest contributors. Tami will remain on the Editorial Advisory Board.)