Day Treatment Group Programme for Eating Disorders: Reasons for Drop-out

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1 European Eating Disorders Review Eur. Eat. Disorders Rev. 12, (2004) Day Treatment Group Programme for Eating Disorders: Reasons for Drop-out Ute Franzen*, Herbert Backmund and Monika Gerlinghoff Treatment Center for Eating Disorders, Max Planck Institute of Psychiatry, Munich, Germany This study was designed to identify clinical variables and personality factors that could predict the completion or noncompletion of a day treatment group programme for patients with eating disorders. Patients (n ¼ 125) were subdivided into those who had completed a 4-month day treatment programme (n ¼ 106) and those who had dropped out (n ¼ 19). All the patients had been assessed with regard to eating psychopathology, general psychopathology and personality features at the beginning of the programme. At presentation, 50.4 per cent fulfilled DSM-IV criteria for anorexia nervosa, 39.2 per cent for bulimia nervosa and 10.4 per cent for an eating disorder not otherwise specified. Non-completion of therapy was associated with more severe bulimic symptoms, high levels of aggression and extraversion and low levels of inhibitedness. Assessment of these characteristics could be used to improve the therapy programme and to help those patients at increased risk of dropping out. Copyright # 2004 John Wiley & Sons, Ltd and Eating Disorders Association. Keywords: day treatment programme; drop-out; cognitive-behavioural therapy INTRODUCTION * Correspondence to: Dr U. Franzen, Therapie-Centrum für Essstörungen (TCE), Schleißheimer Str. 67, München, Germany. The most intensive form of outpatient treatment is a day hospital which incorporates treatment components found to be effective in both inpatient and outpatient settings (Piran & Kaplan, 1990). A day hospital programme has the advantage of encouraging patient responsibility and autonomy while, at the same time, offering an intensive therapeutic programme (Gerlinghoff & Backmund, 1995; Piran, Langdon, Kaplan, & Garfinkel, 1989a; Piran et al., 1989b). It involves lower total costs per patient compared with inpatient hospitalization and is able to accommodate a large number of patients. The effectiveness of recently developed intensive outpatient programmes has not yet been sufficiently established and the specific indications for this form of treatment still have not been fully explored (Gerlinghoff, Backmund, & Franzen, 1998). As yet, there is no way of knowing which patients will complete these programmes and which ones will drop out of therapy prematurely. Early identification of patient characteristics which predict noncompletion of therapy would improve treatment planning and selection of patients. For patients with bulimia nervosa who are taking part in outpatient cognitive-behavioural groups the average drop-out rate is 24 per cent (Blouin et al., 1995). Nearly half the bulimic patients treated with less structured, eclectic group therapy drop out Copyright # 2004 John Wiley & Sons, Ltd and Eating Disorders Association. Published online in Wiley InterScience ( DOI: /erv.515

2 154 U. Franzen et al. halfway through the programme (Dixon & Kiecolt- Glaser, 1984; Roy-Byrne, Lee-Benner, & Yager, 1984). There are very few studies of non-completion of group day treatment programmes for anorexia nervosa and bulimia nervosa. A Canadian research group studying a cognitive-behavioural group therapy programme reported a drop-out rate of 17 per cent at a preliminary spot-check. These drop-outs had more often than not been directly transferred from an inpatient unit and had significantly higher values on the Fear Questionnaire (Piran et al., 1989a). The purpose of our study was to investigate predictors of non-completion of a highly structured day hospital group treatment programme for patients with anorexia nervosa and bulimia nervosa. Symptoms of the eating disorder, general psychopathology and personal characteristics were investigated. METHOD Subjects In total, 125 patients were analysed on admission to the Treatment Centre for Eating Disorders day treatment programme between May 1995 and February Only one patient was male. Using the criteria outlined in the 4th edition of the Diagnostic and statistical manual of mental disorders (DSM-IV; American Psychiatric Association, 1994), five patient groups were identified: anorexia nervosa restrictive type (AN-R; n ¼ 32); anorexia nervosa bingeing/purging type (AN-BP; n ¼ 31); bulimia nervosa purging type (BN-P; n ¼ 45); bulimia nervosa non-purging type (BN-NP; n ¼ 4); and eating disorder not otherwise specified (EDNOS, n ¼ 13). The average length of day treatment was 122 days (range: days). All patients were initially assessed in a diagnostic interview. Patients judged to be at acute suicidal risk and those with substance dependence or psychotic symptoms were referred to the appropriate inpatient setting. The subjects were subsequently divided into two groups: those who had completed the 4- month day treatment programme (n ¼ 106, 84.8 per cent) and those who had not (n ¼ 19, 15.2 per cent). Procedure On admission patients took part in a semi-structured interview covering demographic factors, family history, previous in- and outpatient treatment and detailed questions on specific eating disorder psychopathology (including frequency of bingeing, vomiting and laxative or alcohol abuse). Specific behavioural and cognitive aspects of eating disorders were evaluated using the Eating Disorder Inventory (EDI; Garner, Olmsted, & Polivy, 1983), a self-report measure. Three of the scales relate directly to eating psychopathology, addressing restriction of intake (Drive for Thinness), body image (Body Dissatisfaction), and bulimic tendencies (Bulimia). General psychiatric symptoms (somatization, depression and anxiety) were assessed by the use of self-rating scales: the SCL- 90-R (Derogatis, 1977) and the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). In each case, higher scores indicate more severe symptoms. For the evaluation of personality the Freiburger Personality Inventory, Revised Form was used (FPI-R; Fahrenberg, Hampel, & Selg, 1994). This well-standardized German instrument can be used to describe patients in treatment situations (Fahrenberg et al., 1994) and consists of 10 scales of items each (for example: life satisfaction, social orientation, archievement orientation, inhibitedness, impulsiveness, aggressiveness, strain, somatic complaints, health concerns, frankness, extraversion, emotionality). The Treatment Centre for Eating Disorders in Munich, Germany, has been providing intensive outpatient care since 1989 in the form of a four-phase treatment programme (Gerlinghoff & Backmund, 1995). It consists of an outpatient motivation phase (duration 4 weeks), a 4-month day hospital phase, an outpatient follow-up treatment phase (4 12 months), and a 6-month self-help phase. A key aspect of the therapeutic strategy is the promotion of patient motivation by bringing patients from all treatment phases together with the aim of moving systematically towards self-help and autonomy (Kanfer, Reinecker, & Schmelzer, 1991). This study focuses on the 4-month day treatment programme. The centre admits three cohorts of patients (AN, BN, EDNOS) per year, with a fixed date of admission for each cohort. Patients attend the day hospital 7 days a week from to hours. All patients take part together in the treatment programme which follows a detailed timetable. Invasive methods such as naso-gastric or intravenous feeding are avoided and medication is not used during the treatment programme. Psychotherapeutic methods include behaviouralcognitive, psychoeducational and interpersonal interventions and the therapy is conducted exclusively in a group setting. Operant behavioural methods are not used. Instead, group support, confrontation within the group and social pressure are employed to promote change (Piran et al.,

3 Day Treatment Programme a). A multidisciplinary team approach is used. Group sessions are theme-centred, with topics focusing on psychological, social and eating-related issues. There is a strict balance between the degree of professional help given and the degree of patient autonomy encouraged, with the emphasis on allowing the patients as much responsibility as possible at each stage of therapy. Work with families and partners is conducted through regular meetings to exchange information and multiple family therapy sessions. Analyses The aim of the study was the identification of factors predicting the probability of non-completion of treatment. We therefore compared completers and non-completors with respect to eating disorder symptoms (drive for thinness, body dissatisfaction, bulimic symptoms), general psychopathology (depression, anxiety, somatization) and personal characteristics. Statistical comparison between groups was performed using contingency tables for non-continuous variables. For continuous variables, Mann Whitney tests were used. RESULTS Clinical characteristics Table 1 gives an overview of the demographic and clinical features of the sample. The sample had a mean age of 22.7 ( 4.4) years. More than 90 per cent of patients were unmarried and the largest group (56 per cent) were in school or further education; 42 per cent were still living with their parents. There were no significant differences in demographic characteristics between the two groups. The non-completers tended to be younger and to have a longer duration of illness but neither difference reached statistical significance (Mann Witney Z ¼ 1.27, p ¼ 0.20; Z ¼ 0.56, p ¼ 0.56). Regarding the symptoms of the eating disorder, the Table 1. Demographic and clinical features at presentation All patients Completers Non-completers Significance (n ¼ 125) (n ¼ 106) (n ¼ 19) Age (years) 22.7 (4.4) 22.9 (4.4) 21.6 (4.3) n.s. Marital status n.s. No partner 76 (60.8%) 67 (63.2%) 9 (47.4%) Unmarried, with partner 40 (32.0%) 32 (30.2%) 8 (42.1%) Married 9 (7.2%) 7 (6.6%) 2 (10.5%) Occupation n.s. Working 45 (36.0%) 39 (36.8%) 6 (31.6%) In school or studying 70 (56.0%) 58 (54.7%) 12 (63.2%) Other 10 (8.0%) 9 (8.5%) 1 (5.3%) Living situation n.s. With parents 53 (42.4%) 44 (41.5%) 9 (47.4%) Flat sharing 21 (16.8%) 19 (17.9%) 2 (10.5%) With partner/own family 22 (17.6%) 18 (17.0%) 4 (21.1%) Alone 29 (23.2%) 25 (23.5%) 4 (21.1%) Clinical variables Illness duration (years) 7.0 (4.6) 7.0 (4.7) 7.3 (4.0) n.s. BMI 18.9 (4.5) 18.8 (4.5) 19.1 (4.8) n.s. Laxative abuse 27 (21.6%) 24 (22.6%) 3 (15.8%) n.s. Weekly binges 5.7 (8.8) 4.5 (6.2) 12.7 (15.9) Weekly vomiting 7.6 (15.1) 6.2 (14.5) 15.3 (16.7) Diagnosis (DSM-IV) AN 63 (50.4%) 56 (52.8%) 7 (36.8%) n.s. BN 49 (39.2%) 38 (35.8%) 11 (57.9%) EDNOS 13 (10.4%) 12 (11.3%) 1 (5.3%) Pretreatments Outpatient 74 (59.2%) 65 (61.3%) 9 (47.4%) n.s. Inpatient 46 (36.8%) 36 (34.0%) 10 (52.6%) AN, anorexia nervosa; BN, bulimia nervosa; EDNOS, eating disorder not otherwise specified; BMI, Body-Mass-Index (ratio of weight in kilograms to the height in meters squared); n.s., non-significant. Values are expressed as the mean (SD) or as the percentage of the number of subjects in each group. Statistical comparison between groups was performed using contingency tables for non-continnous variables. For continnous variables Mann Whitney tests were performed.

4 156 U. Franzen et al. Table 2. Differences between completers and non-completers in eating-disorder symptoms (EDI), general psychopathology (SCL-90-R, BDI) and personality traits (FPI-R) Scales All subjects Completers Non-completers Significance (n ¼ 125) (n ¼ 106) (n ¼ 19) EDI Drive for thinness 12.1 (5.6) 11.9 (5.5) 13.2 (5.9) n.s. Bulimia 7.4 (6.2) 6.6 (6.0) 11.0 (5.7) Body dissatisfaction 16.4 (7.4) 16.5 (7.3) 15.8 (7.9) n.s. SCL-90-R Somatization 1.0 (0.6) 1.0 (0.7) 1.2 (0.6) n.s. Depression 1.8 (0.8) 1.8 (0.8) 1.8 (0.7) n.s. Anxiety 1.1 (0.6) 1.1 (0.6) 1.1 (0.6) n.s. BDI 22.7 (9.5) 22.6 (9.8) 23.1 (8.0) n.s. FPI-R Life satisfaction 2.6 (2.3) 2.6 (2.3) 2.6 (2.3) n.s. Social orientation 7.5 (2.5) 7.7 (2.5) 6.6 (2.4) n.s. Achievement orientation 5.7 (2.6) 5.6 (2.6) 6.2 (2.7) n.s. Inhibitedness 7.4 (3.2) 7.7 (3.2) 6.0 (2.7) Impulsiveness 8.5 (2.6) 8.5 (2.5) 8.6 (3.2) n.s. Aggressiveness 4.0 (2.3) 3.7 (2.2) 5.3 (2.3) Strain 7.9 (2.4) 7.7 (2.4) 8.4 (2.4) n.s. Somatic complaints 6.0 (2.5) 5.9 (2.5) 6.8 (2.5) n.s. Health concern 3.1 (2.2) 3.0 (2.0) 3.6 (3.1) n.s. Frankness 7.6 (2.6) 7.6 (2.7) 7.9 (2.0) n.s. Extraversion 5.7 (3.4) 5.3 (3.3) 7.7 (3.5) Emotionality 10.5 (2.5) 10.4 (2.6) 10.9 (2.2) n.s. Values are expressed as the mean (SD). Statistical comparison between groups was performed using Mann Whitney tests. non-completers reported more binges per week (Z ¼ 3.09, p ¼ 0.002) and more episodes of selfinduced vomiting per week (Z ¼ 3.07, p ¼ 0.002) prior to admission. When comparing the diagnostic groups (AN, BN, EDNOS) no significant differences were found in terms of non-completion of therapy. However, if a comparison is made between those subgroups with bulimic symptoms (AN-BP, BN-P, BN-NP) and those without (AN-R), only 5.6 per cent of the noncompleters fulfilled the criteria for anorexia nervosa restrictive type ( 2 ¼ 5.56, df ¼ 1, p < 0.05). Hardly any significant differences in eating disorder symptoms were found between the patient groups as measured by the EDI (Table 2). However, the completers had, on average, a lower value on the bulimia subscale (Z ¼ 2.79, p ¼ 0.005). The stronger drive for thinness (Z ¼ 1.01, p ¼ 0.30) of the noncompleters (Z ¼ 0.49, p ¼ 0.62) compared with the completers did not reach statistical significance. The results on the SCL-90-R showed a slight tendency to somatization in the non-completers but his was not statistically significant (Z ¼ 1.32, p ¼ 0.18). There was no difference in depression scores (BDI) between the two groups (Z ¼ 0.27, p ¼ 0.78). Results on the FPI-R indicated that noncompleters were distinctly less socially inhibited (Z ¼ 2.27, p ¼ 0.02) and showed a higher tendency to aggressive (Z ¼ 2.49, p ¼ 0.012) and extrovert behaviour (Z ¼ 2.71, p ¼ 0.006) than the completers. DISCUSSION The non-completion rate of 15.2 per cent for our 4- month day treatment programme is a little below that of the Canadian day hospital (Piran et al., 1989a), which offers a comparable therapy programme for patients with anorexia nervosa and bulimia nervosa. The specific aspects of our day treatment programme can be summarized as follows: emphasis on self-management and taking responsibility for oneself (Gerlinghoff & Backmund, 1995), a strongly structured and intensive therapy programme, and a group of patients who begin and end the therapy together. In our experience, the intensive group work has a very positive effect on the motivation of each individual patient. This type of therapy does not allow the patient to go through the therapy

5 Day Treatment Programme 157 passively (for example proving to herself and her family that no-one can help) or to avoid necessary change permanently. Comparing this type of therapy to weekly, shortterm, behavioural group therapy for bulimia nervosa, the drop-out rate in this study is surprisingly low. Like our day treatment programme, these short-term outpatient programmes are clearly structured, of limited length and voluntary. Blouin et al. (1995) report a drop-out rate of 28.7 per cent from a 10-week outpatient cognitive-behavioural group programme for bulimia nervosa. One possible reason for our comparatively low drop-out rate is the preliminary motivational phase consisting of four 2-h group meetings. These sessions, which take place before the start of the day treatment programme, are a prerequisite for admission into the programme. They provide information, encourage motivation and clarify expectations of what therapy will entail. In our experience, an average of approximately per cent of patients will drop out during the motivational phase. This mandatory phase at the beginning of an intensive and expensive treatment seems to be economical for the health care system. In addition, it appears to be important to patients because interruption of an intensive programme of therapy, once it has started, can have an adverse affect on their self-confidence. In contrast to most outpatient programmes, our programme treats anorexia nervosa and bulimia nervosa patients together in one group. No differences could be found between patients with anorexia nervosa and those with bulimia nervosa with regard to non-completion rates. With regard to the diagnostic subgroups it seems, however, that the presence of bulimic symptoms plays a large role in the therapy drop-out rate. Our analysis shows that patients with frequent episodes of bingeing and vomiting tend to drop out. The unfavourable prognosis for such patients is consistent with the published literature (Davis, Olmsted, & Rockert, 1992; Lee & Rush, 1986). In previous studies of the group therapy process, the ability to integrate oneself into the group, openness and dealing with one s own aggression have been found to be the most important personality characteristics determining the completion or noncompletion of therapy (Mackenzie, 1990; Yalom, 1985). In the context of cognitive-behavioural group therapy with bulimic patients, high levels of depression, frequent episodes of bingeing/vomiting (Lee & Rush, 1986) and problems with close relationships (Lee & Rush, 1986; Olmsted et al., 1991) are recognized as risk factors for dropping out. Our analysis also found that non-completers reported more frequent severe bulimic symptoms prior to therapy. These patients were socially less inhibited, more aggressive and more extroverted than those who completed the programme. In other words noncompleters showed a higher level of impulsiveness and excessive behaviour which obviously makes it more difficult to co-operate in the therapeutic process (Waller, 1997). In contrast to other published studies, we found that neither the level of depression (Kirkley, Schneider, Agras, & Bachman, 1985; Lee & Rush, 1986) nor that of anxiety (Piran et al., 1989a) predicted dropping out. The more socially inhibited patients tended to complete treatment. An explanation for this could be the high level of structure and predictability which the therapy provided. These elements might have been regarded as being especially helpful by the socially more inhibited patients. On the other hand, patients who tend to be more aggressive, hostile and socially extroverted might find it more difficult to accept the rules of the programme and to integrate themselves into the patient group (Blouin et al., 1995). Therefore it is very important to explain the rules in detail beforehand and make the therapeutic strategies as transparent as possible for the patient. Kirkley et al. (1985) also found the degree of expressed anger to be the most important predictor of dropping out from outpatient group therapy for bulimia nervosa. Olmsted et al. (1991) and Blouin et al. (1995) reported that the extent of the patient s interpersonal difficulty is especially relevant to non-completion of group therapy. If patients with strong interpersonal difficulties also have problems in reducing their more severe bulimic symptoms, they are likely to be confronted by increasing group pressure and may consider dropping out. As already confirmed in outpatient group therapy for bulimia nervosa (Coker, Vize, Wade, & Cooper, 1993; Olmsted et al., 1991; Waller, 1997), it is possible that patients showing characteristics of borderline personality disorder also tend to drop out of day treatment. However, in this study, the diagnosis of borderline personality disorder was not fully considered and needs to be evaluated in further studies. Additional therapeutic methods are needed to support those patients with interpersonal difficulties and a higher degree of impulsiveness. The integration of treatment strategies for borderline patients (Linehan, 1993) into the day treatment setting might be helpful. Nevertheless, a very low drop-out rate in the treatment of patients with eating disorders will remain an unrealistic goal.

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