We introduce a Multi-dimensional Addiction Recovery Measurement Model for Addicts.
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. It is my hope that the 7 – Dimensions model for addictions recovery measurement is a step towards a “Copernicus” type paradigm shift.
Because human behavior is so complex, an attempt to understand the reasons individuals continue to use, and/ or abuse themselves with substances and/ or maladaptive behavioral addictions to the point of developing self-defeating behavior patterns and/ or other life-style dysfunctions or self-harm is enormously difficult to achieve. Many researchers therefore prefer to speak of risk factors that may contribute, but not be sufficient to cause addictions. They point to an eclectic bio-psychosocial approach that involves the multi-dimensional interactions of genetics, biochemistry, psychology, socio-cultural, and spiritual influences. Risk Factors / Contributory Causes / Influences:
1. Genetics (family history) – is known to play a role in causing susceptibility through such biological avenues as metabolic rates and sensitivity to alcohol and/ or other drugs or addictive behaviors.
2. Biochemistry – the discovery of morphine-like substances called endorphins (runners high, etc.) and the so-called “pleasure pathway” – the mesocorticolimbic dopamine pathway (MCLP). This is the brain center or possible anatomic site underlying addictions at which alcohol and other drugs stimulate to produce euphoria – which then becomes the desired goal to attain (tolerance – loss of control – withdrawal).
3. Psychological Factors – developmental personality traits, vulnerability to stress, and the desire for tension and symptom reduction from various mental health problems and traumatic life experiences.
Our present healthcare system is set up to focus on acute care rather than chronic illnesses. It focuses on a Unitary Syndrome model in which the sole marker of treatment response or success is specific symptom-reduction. Healthcare consumers are increasingly advocating for a multidimensional model that takes into account an array of life-functioning domains that influence patient treatment progress. Evidenced-based meta-analysis studies also purport the prognostic power of life-functioning variables to predict outcome as well as their importance for treatment planning over a unitary 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.
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. ASAM developed the following six dimensions specifically for the addictions field with the intent to provide clinicians with decision-making guidelines for patient placement of care:
1. Acute Intoxication and/ or Withdrawal Potential
2. Biomedical Conditions and Complications
3. Emotional/ Behavioral Conditions and Complications
4. Treatment Acceptance / Resistance
5. Relapse / Continued Use Potential
6. Recovery Environment
The ASAM dimensional delineations were developed to assess severity of illness (alcoholism/ drug addiction). The severity of illness level is then used to determine the match to type and intensity of treatment to help guide placement into one of four levels of care. The dimensional assessments would 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.
Seven Dimensions Model
In 2004, the Addictions Recovery Measurement System (ARMS), was published – describing the following seven life-functioning therapeutic activity dimensions for progress outcome measurements. As can be seen below, the ASAM (Severity of Illness) dimensions do not compete with the seven “Life-functioning” dimensions, but rather add depth in describing the Abstinence/ Relapse – 7th Dimension. Each of the seven dimensions has individualized assessment criteria:
1. Social/ Cultural – Dimension
2. Medical/ Physical - Dimension
3. Mental/ Emotional - Dimension
4. Educational/ Occupational - Dimension
5. Spiritual/ Religious - Dimension
6. Legal/ Financial - Dimension
7. Abstinence/ Relapse - Dimension
a. Acute Intoxication and/ or Withdrawal Potential
b. Biomedical Conditions and Complications
c. Emotional/ Behavioral Conditions and Complications
d. Treatment Acceptance / Resistance
e. Relapse / Continued Use Potential
f. Recovery Environment
Note: These seven dimensions have been delineated in the book entitled, Poly-behavioral Addiction and the Addictions Recovery Measurement System (Slobodzien, 2005).
The 7 – Dimension recovery model is not based upon an expanded version of the ASAM dimensions. As noted above, it was initially designed to measure patient progress by assessing therapeutic life-functioning activities. Researched may prove it to be effective as a generalized model for recovery, from all pathological diseases, disorders, and disabilities. It’s multidimensional assessment/ treatment process includes the internal interconnection of multiple dimensions from biomedical to spiritual - taking into account the effects of feedback and the existence of each dimension mutually influencing each other simultaneously. Because of the complexity of human nature, treatment progress needs to be initially tailored and guided by an individualized treatment plan based on a comprehensive bio-psychosocial assessment that identifies specific problems, goals, objectives, methods, and timetables for achieving the goals and objectives of treatment.
Life-style addictions may affect many domains of an individual's functioning and frequently require multi-modal treatment. Goals of treatment include reduction in the use and effects of substances or achievement of abstinence, reduction in the frequency and severity of relapse, and improvement in psychological and social functioning. Real progress requires time, commitment, and discipline in thinking about it, planning for it, working the plan, and monitoring the successes made to prevent relapse. It also requires appropriate interventions and motivating strategies for each progress area of an individual’s life.
7 - Dimensions is a nonlinear, dynamical, non-hierarchical model that focuses on interactions between multiple risk factors and situational determinants similar to catastrophe and chaos theories in predicting and explaining addictive behaviors and relapse. Multiple influences trigger and operate within high-risk situations and influence the global multidimensional functioning of an individual. The process of relapse incorporates the interaction between background factors (e.g., family history, social support, years of possible dependence, and co morbid psychopathology), physiological states (e.g., physical withdrawal), cognitive processes (e.g., self-efficacy, cravings, motivation, the abstinence violation effect, outcome expectancies), and coping skills (Brownell et al., 1986; Marlatt & Gordon, 1985). To put it simply, small changes in an individual’s behavior can result in large qualitative changes at the global level and patterns at the global level of a system emerge solely from numerous little interactions. The clinical utility of the 7 – Dimensions recovery model is in its ability to assist health care providers to quickly gather detailed information about an individual’s personality, background, substance use history, affective state, self-efficacy, and coping skills for prognosis, diagnosis, treatment planning, and outcome measures.
The 7 - Dimensions hypothesis is 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, and obesity, 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 Dimensions’ theory is that a multidimensional treatment plan must be devised addressing the possible multiple addictions identified for each one of an individual’s life dimensions in addition to developing specific goals and objectives for each dimension.
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 underlying 7 - Dimensions theory purports that the combination of an individuals’ elevated and balanced multiple life-functioning dimensions can produce a synergistically tenacious, resilient, and spiritually positive individual homeostasis. Just as the combination of alcohol and drugs (for example valium) when taken together produce a synergistic effect (potency effects are not added together, but multiplied), and can develop into an addiction or unbalanced life-style, positive treatment effectiveness and successful outcomes are the result of a synergistic relationship with “The Higher Power.”
The 7 – Dimensions model acknowledges that family genetics, and bio-psychosocial, historical, and developmental conditioning factors are difficult and sometimes impossible to be changed within individuals. The standardized performance-based Addictions Recovery Measurement System 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. 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 7 – Dimensions model combines a multidimensional force field analysis of an individual’s unique problems to identify positive strength prognostic factors, with behavioral contracting, and a token-“like”- economy point system to accomplish this task. Force field analysis is a process whereby an individual’s behavior is assessed to determine which are the key forces driving the addictive behaviors and which are the key forces restraining the addictive behaviors. A plan is implemented to identify the positive strength restraining factors to somehow manipulate those forces in order to increase the likelihood of moving an individual’s behavior in a pro-social recovery direction. Kurt Lewin (1947) who originally developed the Force Field Theory argued that an issue is held in balance by the interaction of two opposing sets of forces – those seeking to promote change (driving forces) and those attempting to maintain the status quo (restraining forces). Any given social event occurs at a given frequency in a given social context, and the frequency of the event is dependent upon forces acting to increase the event as well as forces acting to decrease the event. At any given point in time, there is a “semi-stable equilibrium” whereby the frequency of the social event will remain the same so long as there is neither change in the number or strength of the forces acting to increase the social event nor any change in the forces acting to decrease the event. Equilibrium is altered in either direction by increasing the frequency or intensity of the driving or the restraining forces and thereby creating a corresponding increase or decrease in the rate of an individual’s “addictive” behaviors.
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 - Dimensions 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. The ARMS takes an objective perspective on spirituality by assessing an individual’s positive and/ or negative spiritual/ religious dimension with the Religious Attitudes Inventory (e.g., the RAI is capable of identifying extremely unhealthy cult-like spirituality with the rigid, and intolerant religious and militant orthodoxy, practiced by some terrorists, etc.). RAI test results are also integrated into the prognostication scoring system.
The 7 – Dimensions model also promotes Twelve Step Recovery Groups such as Alcoholics and Narcotics Anonymous along with spiritual and religious recovery activities as a necessary means to maintain outcome effectiveness. The National Institute of Alcohol Abuse and Alcoholism’s most recent research findings regard such active involvement with AA/ NA as the crucial factor responsible for sustained recovery
The seven – 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 embed a system that will standardize their assessment procedures and treatment programs. .