What factors influence failure to engage in a supervised self-help programme for bulimia nervosa and...

European Eating Disorders ReviewEur. Eat. Disorders Rev. 12, 178–183 (2004)

What Factors Influence Failureto Engage in a Supervised Self-helpProgramme for Bulimia Nervosaand Binge Eating Disorder?

Lorraine Bell* and Kathryn NewnsEating Disorders Team, Park Way Centre, Havant, Hampshire, UK

The study investigated factors influencing failure to engage amonga group of bulimic and binge eating disordered clients referred to asupervised self-help programme. A total of 125 patients referred toa supervised self-help programme for people with bulimia andbinge eating disorder were grouped into those who were seen intreatment (n¼ 85), and those who failed to engage i.e. did notattend their initial appointment ( n¼ 40). Diagnosis, age, genderand waiting times of the two groups were compared. Diagnosis,age and gender were not significantly different between the twogroups. The only significant factor measured was the length oftime that they had waited between being referred to the serviceand their appointment date. Clients who waited less than 4 weekswere 2.4 times more likely to attend their appointment. For everyweek that lapsed between referral and appointment date, the oddsof attending were reduced by 15% (p¼ 0.002). The results arediscussed in light of the importance of maximizing engagement intreatment. Copyright # 2004 John Wiley & Sons, Ltd and EatingDisorders Association.

Keywords: failure to engage; waiting times; bulimia nervosa and binge eating disorder

INTRODUCTION

A significant minority of patients in all services donot keep their initial appointments. This phenom-enon is variously described as pretreatment drop-out, ‘no shows’ or failure to engage (FTE). Rates ofFTE range from 14 to 28% in eating disorder services(Burket & Hodgin, 1993; Coker, Vize, Wade, &Cooper, 1993; Waller, 1997) and 21 to 57% in generalmental health services (see e.g. Burgoyne, Acosta, &Yamamoto, 1983; Freund, Russell, & Schweitzer,1991; Livianos-Aldana, Vila-Gomez, Rojo-Moreno,& Luengo-Lopez, 1999; Loumidis & Shropshire,

1997; Maclean, Greenough, Jorgensen, & Couldwell,1989; Piancentini, Rotheram-Borus, Gills, & Graae,1995). FTE therefore contributes to a substantialwaste of health resources—administrative and clin-ical—as well as unnecessarily extending waitinglists. It is of particular concern in the field of bulimianervosa (BN) as only a small minority of patients arereferred for treatment (Hoek, 1993). Further, BN is achronic or relapsing condition in the medium term(Fairburn, 2000). Despite this, rates of FTE are rarelyreported in published eating disorder studies (Bell,2001).

For the purposes of this study, FTE is defined asnever attending an appointment i.e. not commencingtreatment. Clearly the reasons for failing to engagein treatment may be different from those for drop-ping out of treatment at a later date. Patients who failto engage have not yet had contact with a service

Copyright # 2004 John Wiley & Sons, Ltd and Eating Disorders Association.

Published online 4 March 2004 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/erv.554

* Correspondence to: Dr L. Bell, Eating Disorders Team, ParkWay Centre, Park Way, Havant, Hampshire PO9 1HH, UK.Tel: 023 92 499224. Fax: 023 92 498291.E-mail: [email protected]

(although they may have had a preliminary screen-ing assessment from a generic service as in our studyand therefore gleaned some impression of the ser-vice, whether accurate or inaccurate). FTE mayresult from negative expectations of the service orissues in the client’s own personal circumstancesor levels of motivation. There may be similar factorswhich contribute to FTE and drop-out, notably lowreadiness for change, pessimism about treatment,fluctuating symptoms and the perceived need forhelp, or difficulty trusting others (Mahon, 2000).Alternatively, positive factors may contribute to anindividual’s decision not to attend an initial appoint-ment. Some clients may no longer need help, havesought help elsewhere or feel more able to addresstheir problem independently of professional care.This may explain the results of a study by Waller(1997; see Table 1), who found that patients whofailed to attend reported better family functioningand may have felt they had more support. Howeverthose who FTE in treatment for bulimic disordersmay have more severe problems (see Table 1)and are therefore unlikely to recover withouttreatment.

Failure to Engage in Mental Health Services

Studies have examined factors associated with FTEin treatment in a variety of mental health services. Arange of variables have been identified includingage, ethnicity and socioeconomic differences butwaiting time is the most consistent and robust factorpredicting FTE. Three studies found there was anoptimum waiting time period i.e. the relationshipbetween waiting time and FTE was non-linearalthough this varies depending on the type of ser-vice. Orme and Boswell (1991) found attendance ina community mental health team was higher forappointments sent within 3 days or after 10 days.Hicks and Hickman (1994) found less than 2 weeksor greater than 12 weeks were associated with FTE

in relationship counselling. Foreman and Hanna(2000) found too short a wait (less than 4 weeks)and too long a wait (over 30 weeks) was associatedwith FTE in a child and adolescent mental healthservice. These findings suggest there are subgroupsof people who FTE.

Loumidis and Shropshire (1997) examined theeffects of waiting time on appointment attendancewith clinical psychologists. FTEs had waited anaverage of 6 weeks longer than those who didattend. The probability of attending for patientswho waited 6 months was 0.53, for 1 year 0.41 andfor over 1 year 0.23.

Patients whose problems are egosyntonic, many ofwhom are in the pre-contemplative stage of change,may be less likely to keep appointments unless theyare seen relatively quickly. For example, patientswith drug dependence are more likely to keep initialappointments if seen within 24 h (Festinger, Lamb,Kirby, & Marlowe, 1996).

Failure to Engage in Eating DisorderedPopulations

Two small studies found that weight dissatisfaction,features of depression and laxative abuse were asso-ciated with increased risk of FTE for clients withbulimia nervosa (Burket & Hodgin, 1993; Cokeret al., 1993; see Table 1). Coker et al. also found thatlonger duration, a history of substance misuse andlow self-esteem were associated with FTE. Two stu-dies (Coker et al., 1993; Waller, 1997) found that adiagnosis or features of borderline personality dis-order were more common in patients who failed toengage in services for bulimic disorders. Waitingtime was not examined in any of these studies.

Whilst numbers in these studies are small, theyconsistently suggest that patients who FTE in treat-ment for an eating disorders may have severe pro-blems, both in terms of eating pathology andborderline features.

Table 1. Studies examining factors associated with failure to engage in eating disorders

Sample Sample Factors Association foundsize assessed

Burket and Hodgin (1993) Mixed EDs 20/72 Various Laxative abuse; weight dissatisfactionWaller (1997) Bulimic disorders 7/50 Various Borderline pathology, more severe

perceived bulimic characteristics, reporthealthier family functioning

Coker et al. (1993) BN 6 /25 Various Longer history; higher rate of laxativeabuse, depressive features, dissatisfactionwith body weight, history of substanceabuse; history of self harm; lowerself-esteem; BPD

Failure to Engage in a Supervised Self-help Programme 179

Copyright # 2004 John Wiley & Sons, Ltd and Eating Disorders Association. Eur. Eat. Disorders Rev. 12, 178–183 (2004)

The aim of this study was to examine whetherdemographic and clinical features (age, diagnosis,gender) or waiting time for appointment predictedfailure to engage in a supervised self-help pro-gramme for adults with bulimic disorders.

METHOD

Participants

A total of 125 patients were referred to a supervisedself-help programme for clients with bulimia ner-vosa and binge eating disorder over a 2-year period.Referrals to the programme were made by a varietyof disciplines working in community mental healthteams. All patients are required to have a mentalhealth assessment so those who FTE in the self-helpprogramme have kept this appointment, demon-strating some interest in change.

Four (3.2%) of the patients referred were male, 121(96.8%) were female. The average age of patientsreferred was 29.6 (SD 9.99) with a range of 17 to 58years. A total of 98 (78.4%) patients were diagnosedby their referrer as having Bulimia Nervosa and 27(21.6%) were diagnosed with Binge Eating Disorder.The location for appointments was local for thepatient, usually in the same building where theyreceived their mental health assessment.

Statistical Analysis

All analyses were carried out using SPSS (version11.0). A univariate analyses was first carried outcomparing attendees to non-attendees with regardto age, diagnosis, gender and waiting time forappointment. As both age and waiting time exhib-

ited skewness, a Mann Whitney U-test wasemployed. For categorical variables, diagnosis andgender, the Chi-square test or Fisher’s Exact testwere used. Multivariate analysis using binary logis-tic regression was then undertaken in which bothage and waiting times were dichotomized into‘low’ or ‘high’ groups. Goodness of fit was examinedusing the Hosmer–Lemeshow test.

RESULTS

The univariate comparison is presented in Table 2below.

We found no significant difference between atten-dees and non-attendees with regard to age, genderand diagnosis. Attendees, however, had shorterwaiting times for their appointments on average.When adjusted for other variables, waiting timewas found to be the only significant predictor ofFTE. When waiting time was categorized as ‘short’(equal to or less than 4 weeks) or long (equal to ormore than 5 weeks), the odds ratio of attending anappointment was 2.4 times greater for those withshort waiting times. Figure 1 indicates that for clientswho waited over 10 weeks, the likelihood of enga-ging in treatment was greatly reduced.

As waiting time is a continuous variable it is usefulto be able to predict the likelihood of FTE at anygiven point in time. We fitted a logistic regressionmodel in which waiting time (in weeks) was enteredas a continuous variable. The resultant model sug-gested that the odds of attendance at an appoint-ment falls by 15% per week (odds ratio¼ 0.85, 95%confidence interval, 0.770 to 0.945, p¼ 0.002). TheHosmer–Lemeshow test provided no evidence to

Table 2. Univariate analyses

Variables Cases seen in Cases failed to Test statistic,treatment engage p-value

Number 85 40Age

Median (range) 28.00 (17–58) 26.5 (18–55) 1447.00, p¼ 0.638*Diagnosis

BN 65 (76%) 33 (82%)BED 20 (24%) 7 (18%) 0.584, p¼ 0.445y

Waiting timeMedian (range) 4.00 (1–22) 6.00 (1–20) 1040.00, p¼ 0.000*

GenderFemale 82 (96%) 39 (98%) 1.000z

*Mann Whitney U-test.yChi square.zFisher’s Exact test.

180 L. Bell and K. Newns


suggest that the model provided a poor fit to ourdata (p¼ 0.497).

DISCUSSION

This study examined whether a small range of fac-tors influenced the likelihood of patients attendingtreatment for bulimia nervosa and binge eating dis-order. FTE in clients with bulimic disorders has beenlargely overlooked and few studies have examinedthe effects of waiting times on commencement oftreatment. In this study, age, BMI, referrer and diag-nosis were not significant predictors of FTE. Thefinding that the waiting time for an initial appoint-ment significantly predicted FTE is consistent withresearch among other client groups and confirmsthat this phenomenon is maintained in an eating dis-ordered population.

Clients who waited less than 4 weeks were 2.4times more likely to attend their appointment. Thissuggests that to minimize FTE, clients should ideallystart treatment within 4 weeks of their assessmentand at the most within 10 weeks to ensure greatestlikelihood of attendance. Much effort has been putinto the development of cost-effective treatmentsfor bulimia nervosa and engaging clients who maybe pre-contemplative of change (Treasure, Troop,& Ward, 1996). However, a significant minority ofclients who have presented for help with their eatingdisorder never receive treatment as they do notattend their initial or subsequent appointments.Given that these clients may have severely disor-dered eating or borderline features, engaging intreatment is a service priority. Maximizing their

chances of this lends indirect support for two devel-opments in the eating disorders field—firstly, theneed for cost effective abbreviated interventionswhich can reduce waiting times for treatment andsecondly, the role of motivational enhancement tomaintain engagement (see Ward, Troop, Todd, &Treasure, 1996) and minimize the risk of drop-out.Most of these clients are adults who have elected togo to their GP and (in our study) kept an initialappointment in the community mental health ser-vice. They therefore have a potential interest inaddressing change and maximizing their engage-ment in treatment is an important service goal.When clients with bulimic disorders first presentwith their symptoms they may be at a motivationaljuncture and delaying their appointment on a treat-ment programme may mean that by the time theirappointment is due, they are less ready to addresschange. (It is recognized that stage of readiness forchange fluctuates across time in response to a num-ber of factors).

All patients waiting for mental health care arepotentially at risk of failing to engage. It may be thatthe more precontemplative of change the clientgroup or the more egosyntonic their disorder, theshorter treatment delay (i.e. waiting time) isrequired to increase FTE. The waiting times neededto significantly increase FTE will vary on a conti-nuum of client groups (see Table 3).

Further studies of FTE in eating disordered popu-lations and other groups with egosyntonic disordersare needed to confirm this hypothesis. If this is thecase, it may mean for example, that patients withBED, which is more egodystonic, could toleratewaiting times more than patients with BN. Accuratecomparison across studies and clinical groups willnecessitate a common measure such as the oddsratio at weekly intervals for non-crisis services.

What can services do which cannot maintain wait-ing lists below 4 weeks? A number of studies havedemonstrated that reducing waiting times improvesattendance at initial appointments (Festinger, Lamb,Marlowe, & Kirby, 2002; Festinger et al., 1996;

Figure 1. Attendance or failure to engage by weekswaiting between referral and appointment

Table 3. Waiting times likely to increase FTE

Type of service Waiting time

Mental health crises and substance 24 hoursmisuse servicesCommunity mental health teams 7–15 daysSpecialist eating disorders services 4 weeksGeneric counselling and therapy 4 weeks or longerservices



Grieves, 1973; Miyake, Chemtob, & Torigoe, 1985).Other studies improved initial attendance by tele-phoning patients 1 or 2 days prior to their appoint-ment to remind them of their appointment (Garitiet al., 1995; Hochstadt & Trybula, 1980; Ritchie,Jenkins, & Cameron, 2000; Shivack & Sullivan,1989; Turner & Vernon, 1976). This may be necessaryeven if the delay is as short as 2 weeks (Levy & Cla-varall, 1997). However, this may not reduce FTE ifthe appointment delay is too long (Stasiewicz &Stalker, 1999). These findings may be an artifact—patients with telephones may be more likely toattend (Burgoyne et al., 1983). Contact by lettershould be considered for those who cannot bephoned as any contact appears to increase atten-dance rates (Deane, 1991; Kourany, Garber, &Tornusciolo, 1990).

Preparation for waiting by referrers can also ame-liorate the negative impact of treatment delay. In thereport by Freund et al. (1991) patients consented to a4-week wait in writing and those who FTE did notreport this had contributed to their reasons forFTE. Kluger and Karras (1983) halved the FTE rateby sending an ‘orientation’ letter with the initialappointment which described what would occur atthat appointment. Similarly, Swenson and Pekarik(1988) significantly reduced FTE by sending an‘orientation letter’ received 1 day before an appoint-ment. Sending such information with the initialappointment is cost-effective compared to telephon-ing patients and can reach all clients, not only thosewith telephones. MaClean et al. (1989) found atten-dance improved after sending any of four differentletters but was improved further if the patient wasasked to return a form. Presumably this facilitatesthe patient making a commitment to treatment andmaking an initial engagement before waiting to starttreatment.

CONCLUSION

Only a minority of patients with bulimic disordersare referred for treatment and bulimia nervosa islikely to run a persistent course in the medium tolong term if untreated. Therefore an important ser-vice goal is to minimize FTE as well as drop-out. Thisstudy identified waiting times as a significant factorinfluencing FTE, with a significant increased risk ofFTE at 4 and 10 weeks. Patients need to be preparedfor waiting times by those who refer them to the ser-vice. If treatment is delayed beyond this, contact bythe service by telephone or letter may reduce the riskof FTE. Patients with egosyntonic disorders such as

eating disorders may be at earlier risk of FTE thanother patients if treatment is delayed.

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