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July 2019

Behavior Contracts – the good, the bad and how to move away from them; Surpises about food and the environment

In SAVVY, we focus on the advantages and disadvantages of Behavior Contracts.
In SKILLS, I invite you to delete Behavior Contracts from your clinical toolkit.
In SOUL, I was shocked to learn that that a quarter of the world’s greenhouse gas emissions come from putting food on the table.


“Written documents called “contracts” are appearing with increasing frequency in clinical practice and the medical literature.” (1)  “Healthcare providers can use behavior contracts as a technique to improve patient adherence and address problematic patient behaviors.” (2)
“Behavior contracts” are used for participants In some addiction and mental health treatment programs, especially residential levels of care, and in some drug court treatment programs. The following may trigger a behavioral contract:
  • Clients who “break program rules”
  • Inconsistent attendance
  • Angry or impulsive outbursts
  • Other “inappropriate” and antisocial behavior
Consider the advantages and disadvantages of using Behavior Contracts
  • The contract spells out clearly what behaviors you expect from the client, as well as behavior they can expect from you and your staff.
  • The contract’s goal is to encourage the client to adhere to their treatment plan.
  • The hope is that it will help resolve or manage inappropriate or disruptive behaviors.
  • Because it is a “contract”, there has to be consequences for violating the contract terms. Such a mindset and approach to behavior problems works against a collaborative treatment environment that encourages learning from mistakes.
  • What “makes a contract different from an agreement is that contracts are intended to be enforced. So turning informal agreements into formal documents emphasizes the consequences of breach, whether explicit or implied.” (1)
  • “Do certain factors – such as intellectual immaturity, limited health literacy, or comorbidities – inhibit the patient from understanding that the behavior is hindering an effective relationship?” (2)
  • “Is the problematic behavior objectively documented in the patient’s health record as it occurs? Does the documentation avoid disparaging remarks and subjective statements? Are quotes used when possible?” (2)
I have concerns about behavior contracts and am not a fan. The last paragraph of the Lancet article (1) summarizes well what I believe, not just for physicians but all clinicians and counselors who use behavior contracts:
In sum, “contract” is a misleading term for documents which are increasingly used in a wide variety of clinical situations, with myriad purposes and uncertain effectiveness. Although the aims of contracting may be sound, physicians need to understand the limits of contracts and the ways they can be misunderstood, to the detriment of the patient-physician relationship. Whenever possible, written agreements should be bilateral, tailored to the patient, and presented in a way that signals ongoing commitment. Otherwise we risk alienating patients and damaging the therapeutic alliance.” (1)
1. Michael L. Volk, Sarah R. Lieber, Scott Y. Kim, Peter A. Ubel, and Carl E. Schneider (2012): “Patient Contracts in Clinical Practice”. Lancet. 2012 Jan 7; 379(9810): 7-9.
Published online 2011 Apr 14. doi: 10.1016/S0140-6736(11)60170-0
2. “Using Behavior Contracts To Improve Patient Adherence and Address Behavioral Issues” MedPro Group. Fort Wayne, IN


I invite you to delete “behavior contracts” from your clinical toolkit and get back to:
  • The therapeutic alliance (agreement on goals; agreement on methods/strategies within a mutually respectful, safe and trusting relationship) and
  • A collaborative treatment plan tailored to the needs and strengths of the client.
How to move from away Behavior Contracts to improving the Treatment Plan
  • Instead of seeing rule breaking, poor attendance, angry outbursts and other antisocial attitudes as behaviors to be controlled; view them as learning opportunities to try new ways of thinking, feeling and being.
  • Instead of looking to enforce a behavior contract, focus on linking such behaviors to an accountable treatment plan.
Try these steps to help the participant discover their self-defeating patterns and create an improved treatment plan:
Explanatory Notes:
1. Identify what are the behaviors that “break the rules”, demonstrate antisocial or criminal thinking.
2. Rather than “punish” the behavior and invoke “loss of privileges”, set the client back a phase or sanction the participant, explore whether the participant recognizes what they are doing. Do they connect how such thoughts, attitudes and behavior have set them back in their life before and limited getting what they want in their life?
3. If they see a connection between how they are acting here and now and previous life problems, are they interested in exploring that more? Are they open to discovering how they have limited getting what they want e.g., getting their children back, or getting people ‘off their back’ by continuing such attitudes, thoughts and behaviors?
4. If they are ambivalent about exploring more, check whether they are even engaged in treatment or are just “doing time”.
5. If they do see a connection, identify how to name the problem or priority in their treatment plan e.g., “When I have angry outbursts, it pushes people away from wanting to help me”; “When I am late to sessions often, it makes people think I am unreliable and not trustworthy”
6. Link the problems/priorities identified to which assessment dimensions (ASAM Criteria) are a priority. e.g., “When I have angry outbursts, it pushes people away from wanting to help me” (Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications)
7. Change the treatment plan to incorporate the newly identified issue to focus on.
8. Determine the best level of care to provide this updated treatment plan.
Bottom line: Clients and participants are in treatment to work on attitudes, thoughts, feelings and behaviors that keep them entangled in addiction and mental health programs, criminal justice and child protective services; and limit realizing their full personal and social potential.
Behavior contracts focus on negative behaviors, violations, enforcing consequences and compliance to treatment. This significantly impacts the therapeutic alliance and decreases the chance for good outcomes.


I used to think that cars, trucks and other gas-guzzling transportation accounted for the major part of greenhouse gas (GHG) emissions. So I dutifully bought a Prius Prime, partial electric car to do my part for the environment.
Then I was listening to the July 12, 2019 edition of Science Friday on National Public Radio (NPR) and was shocked to hear that a quarter of the world’s greenhouse gas emissions come from putting food on the table. “From the fossil fuels used to produce fertilizers, to the methane burps of cows, to the jet fuel used to deliver your fresh asparagus, eating is one of the most planet-warming things we do.”
Ira Flatow interviewed science writer, Amanda Little. Here are some of the nuggets (not chicken nuggets) that got my attention:
  • Many of us meat-eaters generate more planet-warming emissions from eating than we do from driving or flying.
  • Food production accounts for about a fifth of total greenhouse gas emissions annually, with agriculture contributing more than any other sector, including energy and transportation, to climate change.
  • Compare beef to fossil fuels: if you give up one 5-ounce steak and eat beans instead, that’s the equivalent of saving about 2/3 of a gallon of gas.
If you eat plant-based proteins, it is more sustainable and humane than conventional meats. A University of Michigan study compared the production of Beyond Burger to a ¼ lb. US beef burger.
  • It took 99 percent less water, 93 percent less land, and about half the energy.
  • Production of that ‘fake’ burger emits 90 percent fewer greenhouse gas emissions.
Not interested in being a vegetarian?
Beef and lamb result in the highest carbon emissions. “Substituting chicken or pork for beef is, from a carbon perspective, almost as good as substituting a plant food.”
Not interested in giving up beef and lamb?
Then know that food waste is another significant problem-40% of food goes wasted in the USA. Before all the vegetarian and vegan people become too self-righteous:
  • Darby Hoover of the Natural Resources Defense Council (NRDC), who worked on the NRDC’s Wasted report on food waste says: “Food waste is riddled with unexpected contradictions, and one of them is that healthier diets tend to be the most wasteful diets.”
  • This is because healthy, fresh foods are also the most likely to perish.
  • Also if your asparagus, broccoli and other fruits and vegetables were air-freighted, that’s not healthy for the environment.
Interested in at least tackling food waste?
I’m not ready to give up my beef and lamb yet, so here are some tips from Science Friday:
  • When produce begins to wilt, use it for soups and blended drinks
  • Freeze fruits and vegetables if you can’t eat them all before spoiling
  • Buy more frozen fruits and vegetables if fresh produce tends to go wasted in your house
  • Store your leftovers in glass rather than plastic containers, to extend the life of your food and preserve its flavor
  • Finally: Don’t forget to eat your leftovers!
These tips will save you money……..and the environment.
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