Based on the information about Abby and the interventions below, what are four supported intervention components to consider as part of a treatment plan for Abby?Abby
Abby, a 42-year-old woman, spent the entire time of a wedding reception in the company of food. She started off eating a generous portion of food but still wanted more. She spent the next five hours eating, at first trying to graze among the guests, but then, when shame set in, she retreated to dark corners of the room to take frantic, stolen bites. Abby stuffed herself with crackers, cheeses, breads, chicken, turkey, pasta, and salads, but all that was a prelude to what she really wanted--sugar. She ate two pieces of cake, then two more, then ate directly from the serving tray. Witnessing her lack of control, Abby began to cry. This event marked the beginning of a 6-month period of binge eating two or three time per week. Abby was very afraid of becoming fat because her sense of worth was very influenced by her shape and weight. So after the binges she was driven to "get rid" of the calories by incessant exercise, walking 4 or 5 hours at a time, dragging her bicycle up and down six flights of stairs, and biking for miles.
DAVE: So how have things been since our last session?

TOM: I think they've been a lot better.

DAVE: How so?

TOM: Well, Danielle has worked off her plateau, and she's gained a few more pounds.

DAVE: Joan, what's your impression?

JOAN: The same. A few weeks ago, I didn't think she was getting enough calories. But over the past few weeks, she has been taking bigger portions, and without us even having to ask her to.

DAVE: You've been monitoring her eating and calorie intake closely?

JOAN: Oh, yeah.

DAVE: Good. You too, Tom?

TOM: Yes. We've been giving Danielle a little more choice in how much she eats, and she's been eating well.

DAVE: Good. I'm glad to hear that. So why did you decide to let Danielle have more choice?

JOAN: Well, Danielle asked us to, but also because she's doing better. And yet sometimes she gives us that look, like we're prison guards watching over the prisoner.

DAVE: Do you feel like a prisoner, Danielle?

DANIELLE: Sometimes. It's like-- I don't know. I just feel like they think I'm not going to do what I'm supposed to, like they don't trust me.

DAVE: Is that your concern? You don't trust her?

TOM: No. We just want her to be able to succeed.

JOAN: Yeah. We just don't want this thing to take control again. I mean, it's not her. It's the anorexia.

DAVE: How do you feel about that, Danielle?

DANIELLE: I know that. It's just that I feel like I can do this now. I don't need them to watch everything I do.

DAVE: OK. Well, this treatment program moves in phases. In the beginning, the parents take primary responsibility for ensuring that eating patterns are stable and sufficient to allow weight to be gained. That's because of the health risks involved. But at some point we make the transition to having Danielle take more responsibility in that area again. Danielle, it sounds like you think you're ready to begin that.

DANIELLE: I do.

DAVE: So what makes you think so?

DANIELLE: Well, I think I'm doing well. I mean, the doctor said so.

DAVE: That's good. I saw that in the doctor's report. Besides the doctor telling you that your health is improving, what else have you noticed in yourself that makes you feel you're ready?

DANIELLE: Well, I'm eating larger portions. I'm doing that myself. And I'm taking my calcium every day. I didn't like hearing about how my bones could get that brittle, and like it's going to take a while for them to get strong again.

DAVE: You're more concerned about the health risks, and that's motivating you more than it used to.

DANIELLE: Yeah. I always kind of knew about them, but I guess when it actually happened to me, it was different. I'm feeling better, and I can see it's because I'm eating.

DAVE: That's different than when you first started treatment.

DANIELLE: Yeah. When I first heard that I was gaining weight, it was kind of scary. But after a while, it didn't bother me as much.

DAVE: Is it still a struggle?

DANIELLE: Not like it used to be. I think I'm doing a lot better, just focusing on getting healthier and getting my life back. I feel like I'm ready to get my life back.

DAVE: I can see that. So how do you guys feel about handing over some of the responsibility to Danielle? Are you ready? Do you think she's ready?

JOAN: I think so. I still want to know how she's doing.

TOM: I'm thinking we can try it.

DAVE: So how can we hand some of this responsibility back to Danielle and also feel assured that she's continuing her success?

TOM: What about the doctor's report? I mean, if they continue to be good, then we know she must be doing well. If not, I guess we're just going back to what we were doing.

DAVE: Joan, how does that strike you?

JOAN: That sounds good.

DAVE: Danielle, do you have a problem with what your mom and dad are suggesting, that you take control over how much you eat, use the doctor's report, and talk here?

DANIELLE: No, I know I can do it.

DAVE: OK, good. Let's just talk more specifically about what this eating pattern will look like over the next week and the targets we'd like to see in the doctor's report.

JONGSMA: Well, in this particular vignette, we're starting to see the transition here. And it starts with the parents being in control in Phase One. And Dave is trying to move them into Phase Two here, and getting all of the data that he needs to make that decision.

BRUCE: Yeah, he's going to have some criteria he's looking for to see if it's met. So how do the parents feel about it? How's the adolescent feeling? And I liked that he was asking questions to get at that information, but doing it in a way where they felt like they were part of that decision-making process.

JONGSMA: He gets the perspective of all the different family members here. And that's good for him to make a decision to help them move into adolescent control.

BRUCE: Absolutely.

JONGSMA: And he also looks for what basis they have for moving to Stage Two. He asks that of each one of those particular family members, huh?

BRUCE: Yeah. And I think in this therapy, if you look at the training manuals and the book that's been written on it, the nature of the therapist's style is serious and concerned because this is a potentially dangerous disorder.

And here you're also at the same time not trying to make all these decisions for everyone. You're trying to get them to make those and keep those criteria in mind. So they want to see a certain amount of weight loss. And I thought he did a good job of saying, all right, how are we going to make this transition but still be accountable, still be able to see if things start to turn for the worse?

JONGSMA: And if weight loss happens, it's time to return to more control on the part of the parents.

BRUCE: Back to Phase One.

JONGSMA: Yep. So the specifics of the change to Phase Two and what will be involved in that were also kind of outlined. And he draws that from the parents. What is it going to mean to be in Stage Two here?

BRUCE: Yeah, I thought that was good.

JONGSMA: And then there's a section where he talks about, well, what will it mean to be successful in Phase Two? And those are identified. How will we know we're doing well?

BRUCE: Mm-hmm, very good. Kind of identifying their objectives, their goals--

JONGSMA: The role of the doctor, the physician, is brought out.

BRUCE: Yeah. Yeah, excellent. And I think this demonstrates what this therapy is about. It's one little transition, but you can see it's a family unit being treated as a family unit. And as they move down, they're going to work toward communication and problem-solving as a family unit, and so on.

JONGSMA: Yeah, good job. BRUCE: The following vignette shows various scenes representing progressive phases of CBT for bulimia, including psychoeducation, coping skills training, addressing common fears, and planning for high-risk situations. Let's take a look at these.

DAVE: So given what we've discussed and what you've read, what's your take on this cycle?

CLIENT: Well, it seems like when I try dieting, it eventually makes me want to binge. And I feel bad, afraid I'm going to gain weight, so I purge. And it just repeats over and over.

DAVE: And how do you feel after purging?

CLIENT: Well, honestly I feel good and bad.

DAVE: How so?

CLIENT: Well, good in that I feel like I won't gain weight, but bad because, well, I feel like I can't control myself.

DAVE: So by restricting your diet, it actually drives your urge to binge. Then binging leads to fears of gaining weight and makes you want to purge. You feel better temporarily, but then you start to feel guilty, like you don't feel in control. Then the cycle repeats itself the next time around.

CLIENT: Yeah, that sounds like me.

DAVE: Binging does this to everyone. Does it make sense to you that if you could break this cycle, it'll help you reach your goals?

CLIENT: Yeah, but I haven't been able to.

DAVE: I understand. Let's talk about the first step in breaking the cycle, regulating when you eat.

CLIENT: Okay. I understand about trying to get on a regular eating pattern. But if I stop skipping meals to help reduce the urge to binge, won't I just gain a bunch of weight?

DAVE: Well, remember, we agreed that our first goal is to reduce the binging and purging. Having said that, most people don't gain a bunch of weight when they make this transition. In fact, most people find that their weight fluctuates more down and up when they're not on a regular schedule.

CLIENT: Really?

DAVE: Yeah. Part of this is because we are regulating when you eat, not how much or what you eat. Establishing a regular pattern reduces urges to binge, so your overall calories don't necessarily have to be more. It depends on the types of meals and snacks you have.

CLIENT: I see. I guess I'm worrying about the weight issue again, huh? It's just hard to weigh myself once a week.

DAVE: I know. Do you mind if we talk a little more about that, weight, health, and how these two things relate to one another? Then maybe we can start to look at what your meals and snacks could be, when and where you're going to eat, and the like. Does that sound okay?

CLIENT: Okay. I know I need to get used to feeling full as being normal and not a sign that I've over-eaten. That's hard.

DAVE: What's hardest about it for you?

CLIENT: The urges, how to deal with them.

DAVE: Okay, let's talk about that. One of the first things to know in coping with urges is that if you can ride them out some, they will decrease. The urges get weaker.

CLIENT: I read that in the workbook. I guess I've never really waited to see, but the workbook did have a graph.

DAVE: That's right. The urge actually does something like this. It goes up to a point, and then it comes down. Our goal is to get you past that hump.

CLIENT: Looks like a wave.

DAVE: Exactly. Some people call this surfing the urge.

CLIENT: Surfing the urge, huh? Never surfed before.

DAVE: Let's talk about how to surf, then. What do you say?

CLIENT: Alright.

DAVE: So you're worried about this thing coming up on Friday night.

CLIENT: Yeah. I'm sure some people are going to bring snacks and stuff, and I don't want to fall off the wagon.

DAVE: OK, so let's problem-solve like we've done with the others. First, let's define the problem specifically. We know the situation. So what's your goal?

CLIENT: I don't want to overeat snacks at the party, I suppose.

DAVE: That's good. That's specific. I want to prevent myself from overeating snacks at the party. Let's move to options that might help us to do this. Can you think of any?

CLIENT: I was thinking I would take my own snack, and limit the amount I eat that way.

DAVE: Just eat what you bring?

CLIENT: Yeah. If anyone asks, I could just say my snack sits better with me or something.

DAVE: OK. We'll wait to evaluate that option. Any other options?

CLIENT: I was thinking of taking some sugar-free tea with me to keep me satisfied so I don't feel like drinking high-calorie stuff that will tempt me to purge.

DAVE: OK. Let's look at some more options, and then we'll evaluate the pros and cons of all of them.

JONGSMA: I thought he made good use of psychoeducation. And he's integrating that throughout the session, not just at the beginning. But he's always teaching some of the method here.

BRUCE: Yeah. One of the phrases we've used in treatment planning is there's initial and ongoing psychoeducation. Because it's kind of like once you start something, you continue to integrate it, and he demonstrates that here.

JONGSMA: And we talk about relationship skills and how they need to be important in terms of applying a technique. He used good reflective listening skills here to make the person feel understood.

BRUCE: You can see they have a good therapeutic relationship there. And here's a patient who hasn't talked about this, and there's a lot of shame around these things. He's creating an environment where she can do that.

JONGSMA: And then the urges. He's talking about the urges and how they need to be coped with. And so he begins to develop coping skills to deal with those.

BRUCE: Surfing the urge.

JONGSMA: Yes.

BRUCE: Right, which comes out of substance abuse treatment, right.

JONGSMA: Yes, right.

BRUCE: It's kind of a staple of CBT to look at, okay-- you're making these positive changes. What are some of the risks out there, and how can we manage some of the things that you find challenging?

JONGSMA: He identifies high-risk situations, I make a note here. And he identified specifics of those. What are they? Let's say them clearly and identify them clearly and behaviorally.

BRUCE: And then he goes into, what's the scale we're going to use to try to manage those? He takes that into problem-solving and applying problem-solving with a relevant, real-life, high-risk situation. And they're going to do that with anticipated future high-risk situations as well.

JONGSMA: And I like how he draws options for dealing with these high-risk situations out of the client rather than saying, well, here's three things you could do.

BRUCE: He's trying to empower her.

JONGSMA: He draws them out of the client very nicely.

BRUCE: Yeah. He wants her to be able to do this. Essentially, in CBT the therapist is trying to put themselves out of business.

JONGSMA: Multiple CBT techniques integrated into one session here, not just one.

BRUCE: Representing cross-sections of time in the therapy, yeah.

JONGSMA: Very good.