Question

Alicia, a 16-year-old high school student, was diagnosed with anorexia nervosa 2 years ago. Over those 2 years, she has required multiple hospital admissions for dehydration, malnutrition, and electrolyte imbalance. During these hospitalizations, it was established that Alicia has a history of self-starving and also exercising excessively to reduce her weight to less than 75% of her normal weight. According to her mother Joan, Alicia has always been “harder on herself than anyone should be.” She has always been an overachiever who is dissatisfied with anything less than perfect. Joan says that unlike her other children, Alicia is “wound very tight, almost obsessive, and has to do everything herself.”

                  Last week, Alicia was hospitalized again after she fainted during gym class. Since her admission, she has worked with a psychotherapist to identify some healthier coping strategies and behaviors. The therapist suggested that Alicia sign a contract, agreeing that she will follow certain agreed-upon behaviors. Now that she is about to be released from the hospital, an advanced practice nurse, Eileen, is brought in to plan her after-care. The first thing Eileen suggests is that she and Alicia create a contract.

Alicia is frustrated. “Another contract?” she says. “This is so stupid! I already did a contract in the hospital! Why should I have to start over again?”

“You’re not starting over,” Eileen says. “This is a new contract for a new phase of your ongoing wellness plan.”

“All this controlling structure,” Alicia says. “I feel like I’m being babied.” She sits back in her chair, looking miserable.

1. What sort of “contract” do you think Eileen wants Alicia to sign at this time? What would it include?

1. Alicia complains that having a contract is “controlling.” Do you think an eating contract is an effective treatment intervention for Alicia? Why or why not? Considering what you have read about Alicia’s personality, how might establishing a contract with her be particularly valuable?

Answer 1

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.

Treatment Contracts Includes

1. 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.
• How this treatment schedule can change. Any change in the treatment plan will be discussed with the patient and/or patient’s significant others prior to implementation
• Treatment participation expectations. “Patient is expected to attend all treatment sessions. Should the patient need to reschedule or cancel an appointment, it is her/his responsibility to contact the provider in advance. A pattern of failed or canceled appointments will result in a treatment team meeting to evaluate barriers to participation.”

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

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

• A timeline for achieving each weight range is documented. Here is an example for weight gain
• The benefits of achieving a weight goal should be based on the patient’s requests as much as possible.
• The providers’ response to the patient should not meet a weight goal is described in detail.

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

• How family members will communicate with the treatment team.
• Treatment recommendations and requirements for family members.
• Treatment recommendations and requirements for the patient and family members

5. 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.

Based on Alicia's personality eating contract may help her if it is monitored regularly and modify it if required. As mentioned, she already had signed more treatment contract earlier, the compliance to the treatment is very important. The first goal is to create an insight into her mind, with the help of cognitive-behavioral therapy,  psychodynamic psychotherapy, motivational enhancement therapy, and family interventions are helpful to improve Alicia's condition

There is no specific treatment for anorexia nervosa, some modification might be needed in each stage of treatment. In Alicia's case treatment or eating contract alone may not work, because she already had a history of noncompliance to the contract. A multisectoral approach with different teams and regular follow up needed for her condition.

If the condition worsens, it may progress to fatal stages unless if failed to identify, therefore a well planned nutritional or diet needed. Nutritional guidance focuses on healthy food intake and regaining the energy needed to resume activities. Although calorie counting is important, it generally should not be discussed with the patient. Daily menus should include three full meals and a structured snack schedule that is monitored by parents or the school nurse. A multivitamin plus vitamin D and calcium supplements are recommended.