Contingency Contracts for Weight Gain of Patients with Anorexia Nervosa in Inpatient Therapy: Practice Styles of Specialized Centers

Abstract

The treatment of patients with anorexia nervosa (AN) is often challenging, due to a high degree of ambivalence towards recovery and weight gain these patients often express. One part of the multimodal treatment is the utilization of treatment contracts (i.e., contingency contracts) that aim to motivate patients to gain weight by applying positive and negative consequences for the (non-)achievement of weight goals. The main aim of this study is to assess and analyze current standards of contingency contracts’ utilization in German eating disorder centers. n = 76 mental health professionals of twelve specialized university centers in Germany that are currently or were formerly treating patients with AN in an inpatient setting participated. Most experts use contingency contracts in their clinic with weekly weight goals ranging between 500 and 700 g. Overall effectiveness and significance of contingency contracts for the inpatient treatment of patients with AN was rated high. Typical characteristics of a contingency contract in specialized German university hospital centers, such as the most frequent consequences, are described. The survey results assist the planning of further studies aiming to improve the multimodal treatment of patients with AN. For clinical practice, using external motivators such as contingency contracts as well as targeting internal motivation (e.g., by using motivational interviewing) is proposed.

Identifying and Managing Eating Disorders in Persons Presenting for Addiction Treatment

“…129 Treatment of SUD and ED is often difficult due to ambivalence towards recovery and decreased engagement and adherence to treatment. 127,130 ED behaviors are often ego-syntonic, making change difficult. 131 MI and CM have been found useful in these situations.…”

“…131,136 Similarly, CM has good evidence for SUD, increasing abstinence, although effects decrease over time. 137 CM is often employed for AN around weight gain in inpatient settings, where providers rate the significance and effectiveness as high, 130 although empirical data is limited to short-term weight gain, with more mixed results long-term. 138 Both MI and CM thus may be suited for comorbid ED and SUD patients, especially early on, although trial data is currently lacking.…”

Experiences of parents and patients hospitalised in a child psychiatric unit for anorexia nervosa after reorganisation of care imposed by the COVID-19 Pandemic in France: a qualitative study—The QUALICOVID study

“…Otherwise, a rehospitalisation was planned at the end of lockdown. This was an external motivator and contingency contracts are frequently used in clinical practice [ 34 , 35 ]. Moreover, during their hospitalisation, patients may have improved their motivation to change (internal motivation) through specific cares as motivational interviewing [ 36 ].…”

Discordant conceptualisations of eating disorder recovery and their influence on the construct of terminality

“…Individuals with EDs may be at risk of being subject to involuntary treatment, pressured to accept 'voluntary' treatment under coercion to maintain greater freedoms that may be afforded with voluntary patient status [101,102], or be paradoxically refused treatment due to the perceived intractability or severity of their ED. ED treatment programs or clinicians often use authoritarian treatment protocols; for example, the use of ultimatums and pseudo-contracts or 'contingency contracts' as a method of coercing individuals into accepting a HLOC and as a strategy for setting expectations of treatment reward, punishment, and behavioural change [6,103,104]. People with EDs are inordinately subjected to coercive or compulsive treatment methods [103] such as involuntary nasogastric tube feeding under restraint (actual or threatened), seclusion, and physical, mechanical, and/or chemical restraint [105,106].…”