What is the rationale for developing a written or verbal contract with a patient to maintain motivation for behavior change?

Rationale for Developing Contracts with Patients to Maintain Motivation for Behavior Change

Contracts serve as collaborative tools that increase patient ownership and commitment to treatment by establishing explicit agreements on specific behaviors and timelines, while simultaneously functioning as diagnostic "probes" to assess the patient's actual capacity to implement change. 1

Primary Mechanisms of Action

Collaborative goal-setting combined with self-monitoring is the fundamental mechanism through which behavior-change contracts produce positive health outcomes. 2 This approach works by:

• Fostering concrete, achievable targets that patients help create, which increases their sense of responsibility for health improvements 2
• Enhancing self-efficacy through positive experiences of meeting small, consecutive goals that build confidence for future change 2
• Providing explicit structure for tracking progress and maintaining motivation through the combination of self-monitoring with goal-setting 2

Contracts function as assessment tools to evaluate whether patients and families can effectively identify precipitants and problem-solve to prevent recurrence of problematic behaviors—this diagnostic function is actually the beginning of treatment itself. 1

Evidence of Effectiveness

Within the 5 A's framework (Assess, Advise, Agree, Assist, Arrange), the "Agree" step—where clinicians co-create action plans with patients—is among the three most impactful components for successful behavior change, yet it remains frequently underused in clinical practice. 2

• Research demonstrates that patients who sign behavioral contracts achieve greater beneficial health changes than non-contractors, with those who fully meet contract obligations experiencing the greatest health benefit (such as lowered cholesterol or decreased exercising heart rate). 3
• Patient-practitioner agreement on problems requiring follow-up is associated with greater problem resolution as judged by both practitioners and patients, regardless of problem severity. 4
• Contracts embedded within the full 5 A's framework maximize effectiveness, particularly when the "Assist" and "Arrange" steps connect patients to intensive behavioral interventions. 2

Critical Implementation Requirements

Contracts must be used as collaborative tools within a therapeutic alliance; coercive use damages the patient-provider relationship and encourages deceit rather than genuine commitment. 1, 2

Essential Prerequisites:

• Patient-centered communication using open-ended questions and reflective listening to help patients identify their own personal motivations for change 2
• Adequate patient understanding and developmental capacity to comprehend the commitments being made 1
• Use as adjuncts to comprehensive treatment plans, never as substitutes for other necessary interventions 1, 2

Specific Contract Elements:

• Written contracts are preferred over verbal agreements for moderate- and high-risk patients, as they specify criteria necessary for ongoing clearance and ensure shared understanding of how clinical status will be followed. 1
• Contracts should include: specific behaviors to be changed, defined timelines, treatment goals coordinated with multidisciplinary team members, frequency of visits, and expectations for each team member. 1
• The team physician reviews recommendations with the patient, answers questions, and both parties sign the written contract after discussion. 1

Integration with Motivational Interviewing

Contracts work synergistically with motivational interviewing principles to maximize patient autonomy and intrinsic motivation:

• Ask patients to rate their likelihood of following the plan on a 1-10 scale and use motivational interviewing to explore barriers when the rating is low 2
• Resist the "righting reflex"—avoid telling patients what to do, as this generates resistance; instead, help them articulate their own reasons for change 5, 6
• Use the "elicit-provide-elicit" technique as a nonconfrontational approach to giving advice that allows patients to express feelings about change and helps assess readiness 5
• Employ reflective listening to identify and mirror back statements the patient makes supporting change, highlighting their own reasons 5

Critical Pitfalls and Contraindications

"No-suicide contracts" specifically lack proven efficacy and may erode therapeutic trust—they should be avoided. 1 The American Academy of Child and Adolescent Psychiatry explicitly states there have been no empirical studies evaluating the efficacy of such contracts. 1

Specific Contraindications:

• Never rely on contracts when there is disturbance of mental state 1
• Use only with patients at low risk who have sufficient cognitive capacity 1, 2
• Avoid coercive language (e.g., "unless you promise not to attempt suicide, I will keep you in the hospital")—this encourages deceit and defiance 1, 2

Potential Harms:

• Contracts can unintentionally reduce patients' willingness to disclose distress if they fear punitive consequences for breaking the agreement 1, 2
• May lessen communication of stress and dysphoria, decrease potential for developing therapeutic alliance, and impair risk management 1
• Even when patients agree to contracts, risk may persist—contracts should not create false reassurance 1

Supporting Long-Term Behavior Change

Recognize that changing lifelong habits is difficult; gradual, sustained modifications are more durable than rapid changes. 2

• Progress in small, consecutive steps prevents negative experiences that lower self-efficacy and leads to sustained long-term behavior change 2
• Treatment compliance improves with definite, closely spaced follow-up appointments, flexible crisis scheduling, and telephone or note reminders about next appointments 1
• If appointments are missed, contact the patient and parent immediately 1
• For hopeless and depressed patients who cannot commit to lengthy treatment, offer short-term treatment plans with defined intervention goals 1

Evidence Limitations

Systematic reviews indicate insufficient high-quality, large-scale evidence to routinely recommend contracts as a standalone intervention—they should be viewed as one component of a broader behavior-change strategy. 2, 7

• A Cochrane review of 30 trials (4,691 participants) found limited evidence that contracts can potentially contribute to improving adherence, but insufficient evidence from large, good quality studies to routinely recommend them. 7
• Effects on adherence were not detected when measured over longer periods 7
• The specific contract elements that most improve compliance remain unclear, necessitating individualized assessment for each patient 2
• Ethical concerns about power dynamics and potential damage to the therapeutic relationship must be carefully considered, especially when contracts are used to manage "difficult" patients rather than to support genuine behavior change 2