Contracting and Session Structure

Contracting is the negotiation at the start of a session about what it is for. It takes two or three minutes and determines whether the next forty are useful, because a counselor who has not asked what the patient came for will answer a question they were not asked. It is the single highest-return habit in the encounter and the one most often skipped under time pressure.

• Contracting is mutual, not an agenda announcement. The counselor states what they can offer and asks what the patient hopes for, and the session plan is built from both. Reciting a plan is not contracting.
• Elicit the patient's agenda first. "What are you hoping to get out of today?" and "What is your main concern?" routinely surface something absent from the referral. Referral reasons are written by referring clinicians, not by patients.
• Assess prior understanding before explaining anything. What the patient already believes determines what you need to say, and it is frequently wrong in a specific way that generic explanation will not touch.
• Name the structure. Telling someone the session will cover family history, then the condition, then testing options, then decisions, lets them locate themselves and hold their question until its slot rather than losing it.
• Set boundaries and expectations explicitly: how long the session runs, what can be answered today, when results will return, and what is outside the scope. Unstated expectations are the main source of disappointment.
• Note the practicalities: who else is present and their role, whether an interpreter is needed, whether the patient consents to a student, and whether anyone is joining remotely.
• Recontract when the session turns. If a patient introduces something that changes the purpose, the plan needs renegotiating rather than pushing through the original agenda.
• Closing is the other half. Summarize what was covered, confirm the plan, state who does what next and by when, and check that the patient's original question was answered. A session that runs out of time rather than closing leaves people uncertain what happens next.
• Documentation follows the contract. The note should record the reason for referral, the patient's own stated concern where different, and the agreed plan.

• A woman is referred for hereditary cancer risk assessment. Asked what she is hoping for, she says she wants to know whether her daughter should be worried. The referral was about her; the session she came for is about her daughter. Contracting surfaced this in one question, and without it the counselor would have spent forty minutes answering the wrong question well.
• A couple is referred after an abnormal prenatal screen. Asked what they already understand, they say they were told the baby has Down syndrome. They were told the screen was positive. The entire session has to start from correcting that, which the counselor would not have known to do without asking.
• Midway through a session about carrier screening, a patient mentions she is being pressured by her partner. The counselor stops, names that this seems more important than the panel details, and recontracts around it.
• A session runs long and the counselor closes by summarizing, confirming that the sample will be drawn today, stating that results take three weeks and will come by phone, and asking whether the patient's original question about her daughter was answered. She adds one more question, which is why the check exists.

• Do not skip contracting when time is short. It is what prevents the session from being spent on the wrong thing, so it saves more time than it costs.
• Do not assume the referral reason is the patient's reason. They are frequently different, and only one of them is why the patient came.
• Do not explain before assessing understanding. Explanation aimed at a blank slate misses the specific misunderstanding the patient actually holds.
• Do not let the session end rather than close it. Summary, plan, and responsibility are what the patient takes home.
• Do not treat the contract as fixed. When the purpose changes, renegotiate rather than completing the original plan.