Behavioral contracting in a burn care facility: a strategy for patient participation

Behavioral contracting is a valuable tool for resolving persistent behavioral problems interfering with the treatment and recovery of severely burned patients. Coercive bidding of the patients for more control occurs in an environment where they experience extreme forms of loss of control and associated enforced regression. The ensuing conflicts between patient and staff often lead to breakdown in mutual cooperation, with deleterious effects on patient-staff morale. Staff experience highly ambivalent feelings toward a problem patient and may wish to withdraw from him, feeling threatened in their image of themselves as competent professionals. Beyond reducing disruptive conflicts on the ward, behavioral contracting aims to mobilize patient and staff around common and explicit goals, and to maximize patient cooperation and productive control in the recovery process. Contracts are valuable because: 1) they facilitate productive communication about issues which underlie patient-staff conflict; 2) they facilitate solutions to problem interactions between patients and staff; 3) they afford both patients and staff a sense or self-control. We provide a rationale for behavioral contracting and discuss the indications for initiating contracts with hospitalized burn patients, and describe methods for developing, implementing, and managing behavioral contracts in order to improve communication and effectiveness in patient-staff interactions.