BRIEF

Plasma fluphenazine levels would have been useful in assessing the drug interactions in this case, and we hope to pursue the phanmacokinetics of the depot agents in the future. The presence of clonus and equivocal toe signs in this case is unusual, but it is known that in non-drug-induced parkinsonian syndromes pyramidal tract signs may occasionally be seen. Since no other concomitant neurologic disorder can be substantiated in this individual, we assume that the clonus was related to the overall disturbance.

cases order.

The

Summit-

BY

I1I1\EY

The

author

(preferably

Annotated %. ROSENSTOCK,

describes nonpsvchotic.

Contract

Technique

is atypical,

severe

I. Chien C, Cole JO: Depot phenothiazine sis: a sequential comparative study. I973 2. Rifkin A, Quitkin zinc for non-chronic chiatry 3. Hollister

5.

We feel that the frequent administration of depot phenothiazine agents to patients whose probable level of postdischange cooperation will be poor is hazardous. It is hoped that investigators studying depot preparations will continue to follow up their patients and to monitor the incidence of delayed neurologic symptoms. Possibly this paper will also prompt the reporting of cases from other centers hitherto unreported in the literature. Emergency room physicians should suspect phenothiazine effects in

there

neurologic

dis-

REFERENCES

4. CONCLUSIONS

in which

COMMUNICATIONS

Am

treatment in acute psychoJ Psychiatry 13&.13-18,

F, Carrillo C, et al: Very high dose of fluphenatreatment-refractory patients. Arch Gen Psy-

25:398-403, L: The

1971 Clinical

Use

of

Psychotherapeutic

Drugs.

Springfield. Ill, CharlesC Thomas, 1973, p35 Ayd FJ Jr: Side effects of depot Iluphenazines. Compr Psychiatry 15:277 284, 1974 Donlon P. Tupin JP: Rapid “digitalization” of decompensated schizophrenic patients with antipsychotic agents. Am J Psychiatry 131:310-312,

6. 7. 8. 9. 10.

1974 T, Mutalipassi LR. Malkin MD: Phenothiazine-induced decompensation. Arch Gen Psychiatry 30:102-105, 1974 Ayd FJ Jr: The depot fluphenazines: a reappraisal after 10 years’ clinical experience. Am J Psychiatry 132:491-500, 1975 Chien C, DiMascio A, Cole JO: Antiparkinsonian agents and depot phenothiazine. Am J Psychiatry 13 1:86-90. 1974 Davidson K: Possible effects of combining phenothiazines (ltr to ed). Am J Psychiatry 131:1408, 1974 Mason AS: Basic principles in the use of antipsychotic agents. Hosp Community Psychiatry 24:825-829, 1973

Van

for

Putten

Hospitalized

Adolescents

\I.I).

a techniquefor acting-out

use with patients)

adolescents in the

terminal phase ofpsvchiatric hospitalization. Patient. parents. and therapist have a sunimit meeting during which they write a contract which is a prerequisite of the patient’s discharge. The document. which allparties sign. specifies conditions of the patient’s return to family life. A case report, including a contract, illustrates the use of the technique.

IT SEEMS WE 1.1. ESTABLISHED that one of the most crucial issues of adolescence is the question of identity and the renavigation of the separation-individuation phase (1). These developmental tasks prove temporarily overwhelming for many adolescents and exceed the coping abilities of the entire nuclear family. In such cases psychiatric hospitalization may be necessary. It is for these

patients that the summit-annotated contract technique I will describe has proved extremely effective. In individual psychotherapy, group psychotherapy, and milieu therapy the groundwork is laid for the patient to meet with his parents (the “summit”) with the express purpose of negotiating a written contract between patient and parents to outline the conditions of his return to the family. A number of individual preparatory sessions with the patient and with his parents occur before the summit. The anticipation of the summit enhances its impact and significance-as does the fact that discharge from the hospital is contingent on the actual writing of the contract.

Dr. Rosenstock is Assistant Clinical Professor of Psychiatry at Baylor College of Medicine and at the University of Texas Medical School, Houston, Tex. He is also Director, Adolescent Center & Children’s Center, Houston International Hospital. and is in private practice at the Hauser Clinic, 4126 Southwest Freeway, Houston, Tex. 77027.

AmJ

Psychiatry

132.7,July

1975

745

BRIEF

COMMUNICATIONS

OF

CONTENT

TIlE

CASE

CONTRACT

REPORT

The contract is a written agreement between the patient and the parents on expectations for the posthospital period. It is time limited, going into effect immediately after it is signed and ending on a specific date, usually six months after discharge. The contract is limited to an understanding of the major problem areas of the patient, and the questions under negotiation are usually listed in order of increasing levels of conflict. The contract is written positively-there are no penal-

A 15-year-old girl was hospitalized for treatment following a one-week elopement from home. Involvement with illicit drugs, sexual encounters, and a seemingly increasing loss of a sense of family responsibility were critical areas at presentation. The patient was treated with individual, group. and milieu therapy over a three-month period, during which time concurrent psychotherapeutic work was undertaken with her parents on a weekly basis. The patient was gradually able to recognize that the sexual acting-out was related to parental anger and that

ties

determined and related in part to her resentment at being treated like a child. It was noted that her drug involvement (pri-

for

failure

to comply.

The

adolescent

who

adheres

to

contractual obligations is rewarded not only by privileges delineated in a given contract but by a sense of accomplishment. He has earned his discharge from the hospital and he returns to a home climate that is comparatively free of harassment. The adolescent who continues to make gains in specific areas such as school performance is rewarded not only by higher levels of academic performance and improved social relatedness but also by the right to negotiate a new contract from a position of accomplishment. By listing in the contract only areas of achieved agreement, there is less provocation (except in cases of sociopathic patients) for the adolescent to challenge the potential penalties for failure to comply. (There may of course be an implicit threat that global failure may result in rehospitalization.)

flaunting

manly

disrespect

marijuana

for

the

family

smoking)

rules

generally

was

followed

in

fact

family

over-

alterca-

tions.

The patient began to communicate more clearly with her parents and developed an increasing sense of family loyalty. She asked for more and more pass time with her parents and seemed to spontaneously take an increased interest in household affairs. When it became clear that discharge considerations

were

in order,

the

patient

and

the task of preparing a list of principal they had reached some understanding. meeting was arranged and the contract resulted.

her

parents

were

given

issues on which they felt A one-hour summit presented in appendix I

DISCUSSION

Not all adolescent patients are candidates for summits and contracts. The technique seems most useful with nonpsychotic, nonorganic, acting-out adolescents, including those who fit Masterson’s diagnostic criteria of the “borderline adolescent” (2). The method is more successful in the termination phase of hospitalization, although it can be adapted to an office practice. The rap sessions and small-group therapy experiences that are available on many adolescent inpatient services lend themselves to the preliminary work that is necessary before a summit can be arranged. The hospitalized patient is able to test his positions with peers and staff prior to negotiation with his parents. At the Adolescent Center of the Houston International Hospital, making arrangements for presummit meetings has become synonymous with the termination phase of hospitalization. The contract technique appeals to the patient’s sense of increasing autonomy in that it is binding not only on him but on his parents as well. The parents are obligated to limit their demands to those specifically delineated in the contract and to attend and participate in any conference calls to deal with new crises. Thus, a mechanism for continued dialogue between adolescent and parents is an integral pant of the contract. The contract technique encourages the evolution of what has been seen as the second separation-individuation (I). A sense of fairness is an integral part of the contract and seems to be promoted by the fact that the therapist, who by this time has an established rapport with the patient. serves as mediator and

Follow-up experience with this technique has been limited-only a few of the first 20 adolescents treated are approaching the six-month mark. However, the response thus far has been quite favorable. The adolescents treat the contract as a viable entity and refer to it frequently in outpatient follow-up visits, acknowledging that they are adhering to their contractual agreements. Patients do not hesitate to point out to their parents any lack of adherence to the contract. Both parents and adolescent seem more receptive to criticism when either strays from a written agreement. ln many instances, families have used the contract as a model for their own private contracts with other members of the nuclear family, and some have recommended the technique to relatives. In two instances, family friends have successfully adopted the technique for their own use. Writing down the contents of the treatment contract has also proven to be of clinical value vis-#{224}-vis the patient-therapist relationship. The patient seems to acquine a definite sense of purpose in coming to his posthospital therapy sessions. He understands his obligations more clearly and uses therapy time more efficiently. In the few instances in which family conferences have been called at critical times as provided by the contract, the previous written understandings facilitated the successful conclusion of the meetings and, in two instances to date, helped avert immediate rehospitalization. The elucidation of reciprocal expectations between adolescent and parents and the written acknowledgment of areas of agreement-sufficient in scope for hospital discharge-resemble the marriage contract described by Sager and associates (3). Hospital therapists have also re-

signs

as a witness.

peatedly

746

Am

WITH

WHOM

AND

WIlY

J Psychiatry

[)OIS

THE

TE(’IINIQUE

132:7, July /975

WORK’?

emphasized

the

need

for

total

family

in-

BRIEF

volvement and the setting of reachable goals and workable tasks (4). This is especially applicable to the presummit family conferences. Problem-oriented and goal-di nected verbally con summated contracts have been known since Biblical times. The many types of individual and group psychotherapies freely incorporate similar principles. The summit-annotated contract technique isjust another adaptation of this concept. In order to further evaluate the clinical effectiveness of this technique, studies are planned for longer term follow-up with families who have participated in the summit contract sessions.

ment

Center

TELEPHONE

Erikson E: Childhood and Society. New York, WW Norton & Co. I964 2. Masterson JF: Treatment of the Borderline Adolescent: A Developmental Approach. New York, Wiley-Interscience, 1972 3. Sager C. Kaplan H, Gundlach R, et al: The marriage contract. Family Process 10:3 1 I 326. 1971 4. Ferber A, Ranz J: How to succeed in family therapy: set reachable goals, give workable tasks, in Progress in Group and Famil Therapy. Edited by Sager C. Kaplan H. New York, Brunner/Mazel. l9’/2,pp3’46 375

with repre-

USAGE

I. Gladys caught

up and

agreed

upon

agrees

that

until

such

by Gladys

telephone

2. Calls

I.

only

should

until time

her schoolwork

is completely

as she is academically

and her parents

stable

as

she will use between the hours of4:00 p.m. and 10:00 and ad lib until l&.00 p.m. on Saturdays

p.m. on weekdays and Sundays.

ENCES

contact

sentatives ofeither place. 2. Acknowledging that marijuana smoking constituted an act of anger, Gladys agrees not to smoke marijuana or to take other illicit drugs but reserves the option to call for family conferences at any time to deal with controversies. 3. The signature parties obligate themselves to participate in all urgently called family conferences.

the REFER

and not to in any way make

COMMUNICATIONS

be limited

to no longer

together,

than

45 minutes

at

one time. this

3. Once section

REGARDING I

.

Gladys

conditions of paragraph can be renegotiated. JOHN

I in this

section

are

met,

way make

con-

DOE

agrees

not to call or in any other

tact

with the above-listed individual. 2. The signature parties acknowledge ship has been mutually destructive.

that

such

relation-

SOCIALIZING

APPENDIX Contract

I

I. Gladys agrees that any new friends will be discussed with her parents and that, after prior agreement to do so, she will arrange for her parents to meet the new friends. 2.

PARTIES

This

is an agreement

and Mrs.

Gladys

S. and

her

parents,

Mr.

S.

DURATION

This

between

OF

POSTHOSPITAL

CONTRACT

agreement

is to become

effective

immediately

upon

sig-

nature and will terminate on June 1, 1975, after which it may be renegotiated by unanimous written agreement of the signature parties. HOUSEHOLI)

CHORES

Understanding participation

that in family

sibility,

being a member of the family implies activities and the assumption of respon-

in the kitchen

assisting with the dishes. 2. To be solely responsible 3. To keep her room neat

I.

AREAS

Recognizing

relationships

will be by mutual

consent

away

from

home

with in

FOLLOW-UP

I . Gladys agrees to participate in group therapy on an outpatient basis. 2. Gladys and her parents are each allowed the option of individual orjoint consultation with the therapist. AMENDMENTS

Gladys agrees: I. To help out daily

OFF-LIMIT

Continuing

parents. 3. Gladys agrees to account for time advance, i.e., with approval by parents.

AND

that

ILLICIT

by setting

for the care and to make

the table

of her dog. her own bed

I . Any additions or deletions by unanimous written agreement

locations

be made

parties.

Gladys daily.

S.

Mr. S. Mrs.

in certain

must

by the signature

and

1)RUGS

attendance

to this contract

S.

has

proven to be detrimental to her relationship with members of the family, as well as with many of her peers, Gladys agrees not to frequent the Ajax Billiards Quad and Bob’s Entertain-

Witness

(Therapist)

Date:

AmfPsychiatry

132.7.July

/975

747