Beyond Eating Disorder Contracts: From High School to University

It’s common for individuals who have been in eating disorder treatment to sign a treatment contract. These documents set out the criteria for remaining in treatment or accessing specific privileges (e.g. a day pass with family during an inpatient stay). While contracts have shown to be effective in intensive settings, they can also hinder patient care and raise ethical concerns for clinicians.

The primary issue is that traditional contracts focus heavily on medical compliance and treatment plan adherence. While this can be life-saving in an inpatient hospital setting, bringing them into outpatient and private treatment – as a young adult moves into university or the workforce – can feel punitive. 

For example, these contracts often centre on strict weight targets for individuals with anorexia nervosa, attaching harsh consequences if goals aren’t met (e.g. conditioning tuition or expense support on gaining four pounds per week). Parents frequently use financial support as leverage for weight maintenance.

Shifting to Internal Motivation

By the time my clients transition to university or work, they have usually moved from externally motivated recovery (e.g. using weight to motivate change) to internally motivated recovery (e.g. pursuing what matters to them outside the eating disorder), even if only by a small margin.

At some point during therapy, I ask clients to create a circle chart: this is a visual representation of what occupies space in their daily lives. At the beginning of therapy, their circle is filled almost entirely with body- and food-related activities. 

As we work together, we build out other areas of their life. When we repeat this exercise later, they can visually see how their world has expanded. We then use these meaningful life areas as internal motivators for recovery.

Co-Created Health Plans for Eating Disorder Recovery 

Once a client stabilizes medically and psychologically, I recommend co-creating a health plan for the university or work transition, rather than a contract. The focus shifts away from strict compliance rules and toward collaborative goals and strategies designed to guide them through the change – focusing on skills they have already practiced in therapy for months.

This approach functions like a Recovery Plan, Relapse Prevention Plan or Cope-Ahead Plan. Its purpose is to provide structured support during an overwhelming time without resorting to ultimatums; it is a safety net if they falter, not a punishment if they struggle.

Rather than rules to follow or break, the plan outlines their go-to coping strategies, triggers, personal motivators, and non-weight markers that indicate whether they are thriving or starting to struggle. This helps young adults shift away from relying on a scale to measure recovery, establishing meaningful and psychological benchmarks instead. 

Most of my clients print their health plan to keep in a private spot in their new room, while keeping a digital version on their phone for quick access when needed. 

Why I Co-Create a Health Plan Instead of a Contract

This document should ultimately be created by and for the young person. The goal is to foster empowerment and self-efficacy, not forced compliance. Contracts are too often written to reduce parental anxiety while keeping their child hyper-focused on weight. 

Flexibility is essential. Recovery occurs in stages, and support must adapt accordingly. Consider your child’s level of transparency: if they are consistently honest with their care team about eating disorder thoughts and behaviour, the plan should reflect and celebrate that. If transparency is still a struggle, more structured check-ins and weigh-ins (for restrictive-type eating disorders) may be necessary.

Reflect on where your child is right now and what will support them best. While online templates offer a good starting point, co-creating the plan directly with your child (or their therapist) yields the highest chance of long-term success. 

FAQ: Developing a Health Plan for the University Transition

• When should we start the conversation?

  Beginning about six months before high school graduation is ideal. This timeline allows ample room for thorough discussion, adjustments and collaborative feedback between everyone involved. 

• What should we consider based on diagnosis?

  Anorexia Nervosa: When weight has been stable for less than six months, weigh-ins and medical monitoring are typically included. However, because clients often struggle with weight goals recommended by their treatment team, the approach must be gentle. If your child has previously experienced contingency contracts with punitive clauses, encountering rigid language can again trigger resistance. Framing the document as a collaborative health plan helps reduce anxiety. 

  ARFID: The focus is usually on maintaining the consistent nutritional intake achieved over the preceding six months, alongside practical backup options for high-stress days (e.g. supplemental nutritional drinks or bars when eating feels too difficult). 

  Bulimia Nervosa & Binge Eating Disorder: The plan emphasizes proven coping skills, trigger management and a protocol for increasing therapeutic support if relapse signs appear (which are often self-identified by the individual).

• What key elements should be included?

  Parent Check-Ins: Define the frequency, format and structure of communication. This can range from quick text messages confirming they’ve eaten their meal/snack to a longer video call every few evenings.

  Medical Monitoring: Determine the appropriate level of clinical oversight. If the individual has been stable for less than six months, regular medical check-ins (monitoring vitals, bloodwork and weight) remain necessary. If stability has been maintained for over six months, psychological indicators can serve as primary metrics (e.g. an increase in urges to restrict/binge/purge indicates the need for more support). Medical reviews can then be scheduled during academic breaks (e.g. winter, spring and summer breaks).  

  Therapy Schedule: Establish a clear therapy plan, such as weekly sessions leading up to and through the first few months of campus life. This can be adjusted as needed, but booking these appointments once the student receives their class schedule creates immediate structure. 

  Relapses vs. Setback Protocols: Frame relapses as possible without treating them as inevitable, making clear a distinction between a minor setback and a full relapse. Outline tiered action steps based on severity. For example, an increase in eating disorder thoughts might indicate the need for increased therapy; whereas significant weight changes or severe overwhelm might indicate that taking a week to decompress and regroup at home might be the best course of action.  

• If weight isn’t the primary focus, is it still monitored?

  Yes, but often less frequently than during intensive therapy. Prior to university, the client will have practiced coping with weight checks and processing their emotional response. At this stage, weigh-ins are typically phased out gradually, shifting from weekly to bi-weekly, then monthly, and eventually to academic breaks 3-4 times per year. The exact frequency is always decided on a case-by-case basis.

• How do you know when your child is truly ready?

  Readiness is evaluated individually, but clinicians frequently look for a minimum of six months of continuous stability. If your child has reached this milestone, moving away for school can be realistically considered. If not, alternative pathways – such as attending a local college while living at home for the first year, or taking a gap year to work part-time while continuing therapy – can provide a safer bridge to independence. 

• Who should draft the first version of the health plan?

  I recommend that the client drafts the initial version with their therapist before sharing it with parents for feedback, the opposite to how traditional contracts are written. This sequence gives the young adult time to evaluate their recovery, identify lingering triggers, reaffirm coping skills they are using regularly and consider upcoming challenges.

  Presenting the draft to their parents gives them true ownership of their recovery. When clients lead the process, parents are often pleasantly surprised by how thoroughly their young adult has anticipated the transition.

References

Fiester, A., & Yuan, C. (2023). Ethical Issues in Using Behavior Contracts to Manage the “Difficult” Patient and Family. The American Journal of Bioethics, 23(1), 50–60.

Henry, L. (2026). Occupation-centred practice using psychotherapeutic approaches: Sharing a favourite exercise to support people with eating disorders. Occupational Therapy Now, 2(29).

Murphy, K.E. (2026) Between Care and Compliance: A Mixed-Methods Examination of Social Workers’ Perspectives on Behavior Contracts in Healthcare. Social Work Doctoral Dissertations, 52.

Ziser, K., et. al. (2018). Contingency Contracts for Weight Gain of Patients with Anorexia Nervosa in Inpatient Therapy: Practice Styles of Specialized Centers. Journal of clinical medicine, 7(8), 215.