Introducing a Multidimensional Public Health Approach for Poly-behavioral Addictions By James Slobodzien, Psy.D., CSAC |
The sun was thought to revolve around the earth for 1500 years. It wasn’t until a European astronomer named - Nicolaus Copernicus first formulated a modern heliocentric theory of the solar system that we began to change our thinking. This insight ultimately ushered in a major paradigm shift in astronomy and physics.
Every model or viewpoint for recovery maintains the integrity and importance of its own position, often to the exclusion of other explanations. For example, there are recovery models and theories for: biological, psychological, social, cultural, and spiritual viewpoints that can all explain human behavior. Unfortunately, these viewpoints may thus “blind” their adherents to alternative interpretations until some new insight is achieved that resolves the problems left unsolved. This article describes a public health model that could possibly be a step towards a “Copernicus” type paradigm shift.
The Unitary Syndrome Healthcare Model (The Problem)
Our present healthcare system is set up to focus on acute care rather than chronic illnesses (e.g., obesity, high blood pressure, heart disease, and addictions, etc.). An acute illness is sudden and severe and an immediate response is needed for events like heart attack, stroke, or violent injury. Acute disease is episodic, relatively brief and often fatal.
Acute care focuses on a Unitary Syndrome model in which the sole marker of treatment response or success is specific symptom-reduction, rather than a multi-dimensional approach that can address the multitude of risk factors and contributory causes.
A chronic illness is defined as a disease that is ongoing, rarely cured, afflicts young and old, varies in severity, and typically lasts more than a year. The goals of treatment for chronic disorders and diseases are to preserve body function, minimize symptoms, ensure the best quality of life possible and maximize a patient's independence.
In 1990, 50 percent of the mortality (over 1-million deaths annually) in the United States from the 10 leading causes of death were linked to chronic addictive behaviors such as tobacco use, poor dietary habits, alcohol misuse, illicit drug use, and risky sexual practices, (McGinnis and Foege, 1994). The term “Poly-behavioral Addiction,” will be used in this article to categorize the combination of substance and chronic behavioral (lifestyle) addictions (e.g., pathological gambling, food addiction, sex addiction, and other potentially obsessive-compulsive behavioral patterns such as exercise, shopping, internet, and religion, etc.). If the goal is to eliminate or at least reduce alcohol, substance abuse, and other poly-behavioral addictions in the United States and the rest of the world, then a major shift in thinking will be required. We will need to expand our efforts not only in treating these disorders, but also in preventing them through early (multi-dimensional) interventions (Foley & Hochman, 2006).
The Public Health Model (7 Dimensions)
In the 1990s, the U.S. Congress directed the National Institute of Mental Health (NIMH) to work with the Institute of Medicine (IOM) to develop a Public Health Model that encompasses the following 7 strategies for the prevention, treatment, and maintenance of emotional problems that include addictions (Dozois & Dobson, 2004).
1. Universal Interventions: Efforts aimed at influencing the general population.
2. Selective Interventions: Efforts aimed at specific subgroups of the population that are considered at risk for developing problems, such as adolescents or ethnic minorities.
3. Indicated Interventions: Efforts directed toward high-risk groups of individuals who are identified as having minimal symptoms but do not meet the criteria for a clinical diagnosis.
4. Case Identification: Efforts aimed at screening, assessing, and diagnosing high-risk individuals.
5. Short-term Treatment: Efforts aimed at utilizing standard approaches to treat individuals.
6. Long-term Treatment: Efforts aimed at assisting individuals with the compliance of their long-term treatment goals to reduce relapse and recurrence.
7. Aftercare: Efforts aimed at maintaining gains including rehabilitation.
The 7 Dimensions Addiction Treatment Model
According to a recent (2010), addendum published by the American Society of Addiction Medicine (ASAM), concerning the criteria for preventing and managing the relapse of addictions - patients now being referred to treatment are presenting with much greater complexity of pathology and chronicity of relapse behaviors.
Early treatment for Alcoholism patients was modeled on the philosophy of the Twelve Steps of Alcoholics Anonymous, and they underwent “rehabilitation,” that is they had already acquired the skills to function effectively, but their drinking interfered with the application of these skills. Later, as the field broadened its scope, patients required “habilitation,” with treatment focused on the acquisition of skills to function effectively for the first time.
It became clear that to offer effective treatment, the field must expand its set of tools to include psychosocial interventions to improve life functioning skills to overcome problems with living conditions, housing, education, employment, job skills, childcare, and transportation , etc.
“Increasingly, our appreciation of addiction as a chronic, relapsing disorder - reflects scientific advances in our understanding of the structure and function of the brain, the genetics of addiction, and the pharmacology of motivation and behavior,” (ASAM, 2010).
Healthcare consumers are increasingly advocating for a Multidimensional Healthcare model that takes into account an array of life-functioning domains that influence patient treatment progress. Evidenced-based meta-analysis studies purport the prognostic power of life-functioning variables to predict outcome as well as their importance for treatment planning over a Unitary Syndrome Healthcare model that has had little empirical support.
Accurate diagnosis is also dependent on a thorough multidimensional assessment process along with the possible help of a multidisciplinary treatment team approach. Behavioral Medicine practitioners have come to realize that although a disorder may be primarily physical or primarily psychological in nature, it is always a disorder of the whole person – not just of the body or the mind.
In 2005, the "Addictions Recovery Measurement System (ARMS)," was published - describing the following 7 life-functioning therapeutic activity dimensions for progress outcome measurements.
The 7 Life-functioning Dimensions of Wellness:
1. Medical/ Physical Dimension 2. Self-regulation/ Impulse-control Dimension 3. Educational/ Occupational Dimension 4. Social/ Cultural Dimension 5. Financial/ Legal Dimension 6. Mental/ Emotional Dimension 7. Spiritual/ Religious Dimension
Each of the 7 Dimensions of wellness encompasses the following individualized criteria:
I. Medical/ Physical Dimension
A. The Medical/ Physical Dimension of wellness includes the following combination of attitudes and behaviors:
1. Building endurance, strength, flexibility, and fitness through adequate exercise,
2. Eating a variety of healthy foods to maintain proper nutrition and diet,
3. Maintaining healthy sleep patterns to acquire a restful nights sleep,
4. Having the ability to identify symptoms of disease, and taking personal responsibility for minor illnesses and self-care such as getting regular medical checkups.
5. Pursuing an active lifestyle on a daily basis to maintain consistent health,
6. Understanding the importance of the relationship between nutrition, activity, performance and health, and
7. Monitoring your stress levels to get through your daily activities without feeling fatigued or physically stressed.
II. Self-regulation/ Impulse Control Dimension
A. The Self-regulation/ Impulse Control Dimension of wellness includes the following combination of attitudes and behaviors:
1. Recognizing that by replacing unhealthy habits with healthy habits - we can attain the psychological benefits of enhanced self-esteem, self-control, determination and a sense of direction,
2. Avoiding excessive alcohol consumption: Drinking no more than 4 drinks in a sitting, not drinking and driving, avoiding risky behaviors and situations while drinking, and choosing non-alcoholic, non-caffeine, and low sugar beverages,
3. Avoiding nicotine and tobacco products that are unsafe and that can potentially cause cancer. Also avoiding second-hand exposure to tobacco smoke that is very dangerous and that can cause cancer,
4. Avoiding the use of illegal drugs, non-prescribed drugs, addictive substances and/ or abusing over-the-counter drugs, and choosing a drug free life-style,
5. Avoiding excessive sexual compulsive behaviors, practicing safer sex, if you are sexually active, by using condoms and dental dams that can greatly reduce your risk of contracting sexually transmitted diseases,
6. Avoiding behavioral addictions, such as excessive gambling, food - binging/ purging, (control meal portions) obsessive religious practices, and excessive internet use, shopping, exercise and work activities,
7. Avoiding high-risk and dangerous behaviors, such as speeding/ reckless driving, and/ or assaults/ violence/ self-harm, and by proactively using seat belts, helmets, and other protective equipment.
III. Educational/ Occupational Dimension
A. The Educational/ Occupational Dimension of wellness includes the following combination of attitudes and behaviors:
1. Creating a vision for your future career that will be meaningful, enjoyable and rewarding,
2. Exploring a variety of career options that are consistent with your personal values, interests, and beliefs,
3. Choosing educational/ vocational goals to pursue a career that suits your personality, interests, and talents,
4. Visiting a career planning/placement office and using the available resources to make you marketable in your field, 5. Being open to change and learning new skills to balance your work, family and leisure time activities,
6. Preparing and making use of your gifts, skills and talents in order to gain purpose, happiness and enrichment in your life, and
7. Maintaining a positive attitude in your place of employment.
IV. Social/ Cultural Dimension
A. The Social/ Cultural Dimension of wellness includes the following combination of attitudes and behaviors:
1. Establishing and maintaining positive relationships with family, friends and co-workers,
2. Learning social skills to develop a good support system and deep, meaningful relationships,
3. Developing good communication and listening skills by practicing empathy and compassion as well as caring for others to generate more satisfying and meaningful relationships,
4. Interacting with people of other cultures, backgrounds, and beliefs by cultivating healthy relationships, sharing your talents and skills, contributing to your community, and communicating your thoughts, ideas and feelings to others,
5. Living in harmony with fellow human beings, seeking positive interdependent relationships with others, and developing healthy interpersonal behaviors,
6. Being involved in socially responsible activities to protect the culture and environment such as: conserving water and other natural resources; reducing, reusing, recycling, minimizing your exposure to chemicals, and renewing your relationship with the earth,
7. Promoting health measures that improve the standard of living and quality of life in the community, including laws and agencies that safeguard the physical environment.
V. Financial/ Legal Dimension
A. The Financial/ Legal Dimension of wellness includes the following combination of attitudes and behaviors:
1. Contemplating your personal beliefs concerning: security, peace of mind, economic freedom and choice to determine your concept of financial/ legal health and wellness,
2. Assessing your debt-to-income ratio, your savings rate and your ability to respond to a financial emergency,
3. Creating, planning, managing, monitoring, and conserving your money and assets,
4. Avoiding spending more than you’re earning, and sticking to a budget to keep debt in check,
5. Seeking advice from a reputable financial planner,
6. Buying the necessary health, auto, and life insurance,
7. Obeying the law, complying with rules and regulations, and becoming a community role-model.
VI. Mental/ Emotional Dimension
A. The Mental/ Emotional Dimension of wellness includes the following combination of attitudes and behaviors:
1. Learning, problem-solving and creative pursuits as well as reading, writing and other mentally-stimulating and challenging activities,
2. Striving to improve your intellect and your creative spark by: taking a course or workshop, learning a foreign language, reading for personal enjoyment, seeking out persons who challenge you intellectually, and/ or taking up a hobby,
3. Cultivating optimism, self-esteem, self-acceptance, and the ability to share your feelings by tuning-in to your thoughts and feelings, seeking and providing support to others and accepting and forgiving yourself,
4. Understanding yourself and coping with the challenges of life by acknowledging and sharing your feelings of anger, fear, sadness, stress, hope, love, joy and happiness in a productive manner,
5. Coping with normal life stressors, relationships with others, job satisfaction and success as well as quality of life and happiness,
6. Assessing your limitations, developing your autonomy, and being aware of your personal limitations and understanding the value of seeking support and assistance from others,
7. Expressing feelings freely, managing feelings effectively and learning to accept a wide range of feelings in yourself and others.
VII. Spiritual/ Religious Dimension
A. The Spiritual/ Religious Dimension of wellness includes the following combination of attitudes and behaviors:
1. Possessing a unique set of guiding beliefs, principles, values or spiritual guidelines that help give direction to your life,
2. Establishing peace and harmony in your life by developing congruency between your values and your actions,
3. Seeking meaning and purpose in life through meditation, religion, music, art, literature, nature and through connections with loved ones and other people in your community,
4. Exploring your spiritual core, being inquisitive and curious, listening to your heart and following your principles, and allowing yourself and others around you the freedom to be who they are,
5. Having a sense of selflessness and empathy for others, and a commitment to a higher, greater power,
6. Being able to ponder the meaning of life and being tolerant of the beliefs of others instead of being close minded and intolerant, and
7. Being mindful, appreciative and accepting of the opportunities for growth in the challenges that life brings you.
The “7 Dimensional” Public Health Model Components
The 7 Dimension Addiction Treatment Model has various components that can be incorporated into the public health models' focus on the individual within the psychosocial environment in the following ways:
1. Universal Interventions: Public education and prevention campaigns can promote the 7 Dimension Health and Wellness Programs (See the 7 University Campaigns below).
2. Selective Interventions: The 7 Dimension Health and Wellness Program can be targeted at specific subgroups (College students, Military members, etc.).
3. Indicated Interventions: The 7 Dimensional Intervention can be utilized to screen and assess high-risk individuals (See below for a brief description of this intervention).
4. Case Identification: The 7 Dimension Diagnostic Classification system can be utilized to diagnose patients without labeling or stigmatization (A Prototype Model for the Alcohol/Substance Dependence diagnosis has been developed and proposed for DSM-V).
5. Short-term Treatment: Standardized 7 Dimensional treatment plans can be utilized.
6. Long-term Treatment: The 7 Dimensional Tracking Team can be utilized to assist with treatment compliance.
7. Aftercare: 7 Dimensional Treatment progress reports can be utilized to assist with acquiring outcome measures.
Note: These seven dimensional program components have been delineated in the book entitled, Poly-behavioral Addiction and the Addictions Recovery Measurement System (Slobodzien, 2005), and also in the article entitled: The 7 - Dimension Intervention - A Holistic Diathesis-Stress Approach to Stress-Management
The 7 Dimension Intervention
The Diathesis-Stress Model
The 7 Dimension Intervention is a unique stress-management assessment process that is based on the Diathesis-Stress Model. Researchers have proposed that many disorders are believed to develop when some kind of stressor affects a person who already has a vulnerability or diathesis for that disorder (Ingram & Luxton, 2005; Meehl, 1962; Monroe & Simons, 1991). The diathesis or vulnerability which could be a genetic predisposition or adverse childhood experience is not generally sufficient to cause the disorder itself, but it is a contributory factor. For example, a child who experiences the death of a parent would be at a higher risk to develop depression as an adult. In this case the vulnerability itself was a childhood stressor.
The 7 Dimension Intervention utilizes the following three instruments - to systematically document and assist a client with visualizing their childhood vulnerabilities, current life stressors, and current positive activities on a “Wheel of Life.” The goal is to decrease stress, build resiliency, and improve their overall wellness to hopefully motivate them to develop and monitor a health and wellness plan for their lives:
1. Adverse Childhood Experiences (ACE) Questionnaire 2. The 7 Dimensional - Psycho-social Stressor Inventory (7D-PSI) 3. The 7 Dimensional - Therapeutic Activity Survey (7D-TAS)
What is the ACE Study?
The Adverse Childhood Experiences (ACE) Study is one of the largest investigations ever conducted on the links between childhood maltreatment and later-life health and well-being. As a collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente's Health Appraisal Clinic in San Diego, Health Maintenance Organization (HMO) members undergoing a comprehensive physical examination provided detailed information about their childhood experience of abuse, neglect, and family dysfunction. Over 17,000 members chose to participate. To date, over 50 scientific articles have been published and over 100 conference and workshop presentations have been made (Slobodzien, 2009).
For more information see the article: The 7 - Dimension Intervention - A Holistic Diathesis-Stress Approach to Stress-Management (Slobodzien, 2009).
The 7 Dimensional Hypothesis
The 7 - Dimensions hypothesis acknowledges that there is a multidimensional synergistically negative resistance that individual’s develop to any one form of treatment to a single dimension of their lives, because the effects of an individual’s addiction have dynamically interacted multi-dimensionally. Having the primary focus on one dimension is insufficient. Traditionally, addiction treatment programs have failed to accommodate for the multidimensional synergistically negative effects of an individual having multiple addictions, (e.g. nicotine, alcohol, cocaine and sex, etc.).
Behavioral addictions interact negatively with each other and with strategies to improve overall functioning. They tend to encourage the use of tobacco, alcohol and other drugs, help increase violence, decrease functional capacity, and promote social isolation. Most treatment theories today involve assessing other dimensions to identify dual diagnosis or co-morbidity diagnoses, or to assess contributing factors that may play a role in the individual’s primary addiction. The 7 Dimensional Theory
Many healthcare consumers of addiction recovery services have a genetic pre-dispositional history for addiction. They have suffered and continue to suffer from past traumatic life experiences (e.g. physical, sexual, and emotional abuse, etc.) and often present with psychosocial stressors (e.g. occupational stress, family/ marital problems, etc.) leaving them with intense and confusing feelings (e.g. anger, anxiety, bitterness, fear, guilt, grief, loneliness, depression, and inferiority, etc.) that reinforce their already low self-esteem. The complex interaction of these factors can leave the individual with much deeper mental health problems involving self-hatred, self-punishment, self-denial, low self-control, low self-respect, and a severe low self-esteem condition, with an overall (sometimes hidden) negative self-identity.
The standardized performance-based 7 Dimension Addiction Treatment philosophy incorporates a bio-psychosocial disease model that focuses on a cognitive behavioral perspective in attempting to alter maladaptive thinking and improve a person’s abilities and behaviors to solve problems and plan for sustained recovery.
The 7 Dimensions’ theory promotes a synergistically positive effect that can ignite and set free the human spirit when an individual’s life functioning dimensions are elevated in a homeostatic system. The reciprocity between spirituality and multidimensional life functioning progress, establish the deepest intrinsic self-image and behavioral changes.
The 7 Dimension “Long-term Goal”
The long-term goal is the health-consumer’s highest optimal functioning, not merely the absence of pathology or symptom reduction. The short-term goal is to change the health care system to accommodate and assimilate to a multidimensional health care perspective. The 7 Dimensions model addresses the low self-esteem - “addiction - common denominator” by helping individuals establish values, set and accomplish goals, and monitor successful performance.
Additionally, when we consider that addictions involve unbalanced life-styles operating within semi-stable equilibrium force fields, the 7 Dimension philosophy promotes that there is a supernatural-like spiritually synergistic effect that occurs when an individuals’ multiple life functioning dimensions are elevated in a homeostatic human system. This bilateral spiritual connectedness reduces chaos and increases resilience to bring an individual harmony, wellness, and productivity.
Other Evidenced Based Multi-dimensional Models
Diagnostic and Statistical Manual of Mental Disorders (DSM)
It was suggested that the DSM-IV Classification be organized following a dimensional model rather than the categorical model used in DSM-III-R. A dimensional system classifies clinical presentations based on quantification of attributes rather than the assignment to categories and works best in describing phenomena that are distributed continuously and that do not have clear boundaries.
A joint committee of the American Psychiatric Association and the National Institute of Mental Health charged with identifying pressing issues for the DSM – Fifth Edition (DSM-V) concluded that: ‘there is a clear need for dimensional models to be developed and for their utility to be compared with the existing typologies.'
American Society of Addiction Medicine (ASAM)
The American Society of Addiction Medicine’s (2003), “Patient Placement Criteria for the Treatment of Substance-Related Disorders, 3rd Edition”, has set the standard in the field of addiction treatment for recognizing a multidimensional, bio-psychosocial assessment process. These dimensional assessments involve asking if the patient’s daily living activities were significantly impaired to interfere with or distract from abstinence, recovery, and/ or stability treatment goals and efforts.
The Community Reinforcement Approach (CRA)
CRA is a comprehensive behavioral program for treating substance-abuse problems. It is based on the belief that environmental contingencies can play a powerful role in encouraging or discouraging drinking or drug use. Consequently, it utilizes social, recreational, familial, and vocational reinforcers to assist consumers in the recovery process. Its goal is to make a sober lifestyle more rewarding than the use of substances. Oddly enough, however, while virtually every review of alcohol and drug treatment outcome research lists CRA among approaches with the strongest scientific evidence of efficacy, very few clinicians who treat consumers with addictions are familiar with it.
Comprehensive Soldier Fitness (CSF)
CSF a multi-dimensional holistic fitness program for Soldiers, families, and Army civilians implemented in 2009 in order to enhance performance and build resilience.
7 Dimension Health and Wellness Campaigns
The following 7 Universities/ Colleges have instituted 7 Dimensional Health and Wellness Programs:
1. University of California, Riverside 2. Ball State University, IN 3. University of North Dakota 4. North Dakota State University, Fargo 5. Illinois State University 6. University of Wisconsin - Stevens Point 7. Salem College, North Carolina
The 7 – Dimensions Model is not claiming to be the panacea for the ills of addictions treatment progress and outcomes, but it is a step in the right direction for getting clinicians to change the way they practice, by changing treatment facility systems to incorporate evidence-based research findings on effective interventions. The challenge for those interested in conducting outcome evaluations to improve their quality of care is to incorporate a system that will standardize their assessment procedures, treatment programs, and clinical treatment practices. By diligently following a standardized system to obtain base-line outcome statistics of their treatment program effectiveness despite the outcome, they will be able to assess the effectiveness of subsequent treatment interventions.
For further information see the following books:
1. Poly-Behavioral Addiction and the Addictions Recovery Measurement System (ARMS) at:
2. Hawaii and Christian Religious Addiction: A Survey of Attitudes Toward Healthy Spirituality and Religious Addiction Within Christianity
3. Christian Psychotherapy & Criminal Rehabilitation: An Integration Of Psychology And Theology For Rehabilitative Effectiveness
For more info see: 7dimensions.net
Books: Published Articles:
1. Contemplating a 7 - Dimensional Theory of Everything 2. Ancient Mysteries of the Seven Dimensions 3. The 7 Dimensional God and Ancient Mystery Religion 4. 2012 And the 7 Dimension End Time Prophecies 5. Spirituality 101 (Part-1) 6. Spirituality 101 (Part 2 - Religion) 7. The Pope and the "Holy War"
James Slobodzien, Psy.D., CSAC, is a Hawaii licensed psychologist and certified substance abuse counselor who earned his doctorate in Clinical Psychology. He is credentialed by the National Registry of Health Service Providers in Psychology. He has over 25-years of mental health experience primarily working in the fields of alcohol/ substance abuse and behavioral addictions in hospital, prison, and court settings. He is an adjunct professor of Psychology and also maintains a private practice as a mental health consultant.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 787 & p. 731. American Society of Addiction Medicine’s (2003), “Patient Placement Criteria for the Treatment of Substance-Related Disorders, 3rd Edition, Retrieved, June 18, 2005, from: http://www.asam.org/ Arthur Aron, Ph.D., professor, psychology, State University of New York, Stony Brook; Helen Fisher, research professor, department of anthropology, Rutgers University, New Brunswick, N.J.; Dozois, D. J. A., & Dobson, K. S. (Eds.). (2004). The prevention of anxiety and depression: Theory, research, and practice. Washington, D.C: American Psychological Association. Foley, G. M. & Hochman, J. D. (2006), Mental health in early intervention: Achieving unity in principles and practice.: Baltimore Brooke Publishing. Kessler, R.C., (1994), Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the national comorbidity survey. Arch. Gen. Psychiat., 51, 8-19. Paul Sanberg, Ph.D.,professor, neuroscience, and director, Center of Excellence for Aging and Brain Repair,University of South Florida College of Medicine, Tampa; June 2005, the Journal of Neurophysiology Gorski, T. (2001), Relapse Prevention In The Managed Care Environment. GORSKI-CENAPS Web Publications. Retrieved June 20, 2005, from: http://www.tgorski.com Lienard, J. & Vamecq, J. (2004), Presse Med, Oct 23;33(18 Suppl):33-40. Monroe, S.M., & Simons, A.D. (1991). Diathesis-stress theories in the context of life stress research: Implications for the depressed disorders. Psychol. Bull., 110, 406-25. Morgan, G.D.; and Fox, B.J. Promoting Cessation of Tobacco Use. The Physician and Sports medicine. Vol 28- No. 12, December 2000. Slobodzien, J. (2005). Poly-behavioral Addiction and the Addictions Recovery Measurement System (ARMS), Booklocker.com, Inc., p. 5. U.S. Department of Health and Human Services. Healthy People 2010 (Conference Edition). Washington, DC: U.S. Government Printing Office; 2000.
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