The 7 – Dimension Intervention – A Holistic Diathesis-Stress Approach to Stress-Management
Developing a Systematic Psychosocial Stressor Assessment Process utilizing the 7-Dimensional Psycho-social Stressor Inventory (7D-PSI)
Can stress alone cause us to develop physical and mental disorders?
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 vulnerabilty 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.
So then experiencing psycho-social stressors may not be a sufficient cause to develop disorders, but the two added together – genetic predisposition and/ or adverse childhood experience plus (+) current stressors are sufficient causes for the development of diseases, disorders, and abnormal behavior in general. Since vulnerabilities and stressors may exist on a continuum, for example ranging from one (1) low to ten (10) high, individuals that have high levels of vulnerabilities may only need low levels of current stressors in their life to develop disorders. Likewise, individuals with high levels of psycho-social stressors may only need low levels of diatheses (adverse childhood experiences and/ or genetic predispositions) for certain disorders to develop.
This article will introduce the 7 Dimension Intervention – a unique stress-management assessment process. It will discuss the utilization of the following three instruments – to systematically document and assist a client with visualizing their childhood vulnerabilities, current life stressors, and current positive activities that they are participating in 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. 7 Dimensional – Psycho-social Stressor Inventory (7D-PSI)
3. 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.
The ACE Study findings suggest that these experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. Progress in preventing and recovering from the nation’s worst health and social problems is likely to benefit from the understanding that many of these problems arise as a consequence of adverse childhood experiences.
What’s an ACE score? Growing up experiencing any of the following conditions in the household prior to age 18 identifies your ACE score (1 point for each one):
Recurrent physical abuse
Recurrent emotional abuse
Contact sexual abuse
An alcohol and/or drug abuser in the household
An incarcerated household member
Someone who is chronically depressed, mentally ill, institutionalized, or suicidal
Mother is treated violently
One or no parents
Emotional neglect
Physical neglect
The ACE score can be used to quantify your childhood adverse experiences and vulnerabilities, and the score can be documented on the “Wheel of Life,” to visualize a client’s stress tolerance zone.
What is the significance of the ACE study?
Because adverse childhood experiences (ACEs) are very common, and ACEs are strong predictors of health risks and disease from adolescence to adulthood – the combination of these findings makes ACEs one of the leading, if not the leading determinant of the health and social well-being of our nation.
Identifying Psych-social Stressors
“The DSM-IV-TR informs us that Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders delineated on Axes I and II. A psychosocial or environmental problem may be a negative life event, an environmental difficulty or deficiency, a familial or other interpersonal stress, an inadequacy of social support or personal resources, or other problem related to the context in which a person’s difficulties have developed. When a individual has multiple psychosocial or environmental problems, the clinician may note as many as are judged to be relevant,” (DSM-IV-TR, p. 31).
Unfortunately, clinicians rarely conduct a multi-dimensionally comprehensive systematic investigation of their client’s psychosocial stressors to document those stressors that may be significant to the diagnosis and treatment planning process. The 7D – PSI was developed specifically for this purpose.
7 Dimensional – Psycho-social Stressor Inventory (7D-PSI)
The 7 – Dimensional Psychosocial Inventory (7d-PSI) is an effective and efficient 170-item psychosocial stressors tool that facilitates the comprehensive and systematic evaluation of an individual’s stressful life experiences. The purpose of identifying as complete a list as possible, of an individual’s psychosocial stressors, is so that a treatment plan can be developed that will address the most important of those factors. This method enhances the use of resources. It also can assist with and enhance the DSM-IV-TR, Axis IV (Psychosocial Stressor) diagnosis. The 7D-PSI targets the adult population, but it can be modified to be used with adolescents. The 170 items can easily be assessed within 15 minutes. It is easily scored, and the results can be quickly integrated into a 7 – Dimensional Wheel of Life to be viewed by the client as a motivational enhancement. In addition to the 7 D – PSI’s effectiveness in targeting the most important psycho-social stressors needing attention, it has the potential to identify differential primary diagnoses for further evaluation. The 7 D – PSI’s brevity, ease of administration and scoring make it highly useful for research applications. Based on independent interviews by a mental health professional, this inventory administered by primary care practitioners’ demonstrated good accuracy (sensitivity and specificity) for identifying psycho-social stressors significant to diagnosis and treatment planing. Treatment outcome studies are presently in process (Slobodzien, 2005).
Protective Factors
Protective factors in childhood or influences that may modify a child’s reaction or response to a stressor must also be considered in the equation. These protective factors such as having a family environment in childhood in which at least one one parent was supportive and a good attachment relationship between parent and child was developed can protect against the harmful effects of an abusive parent (Masten & Coatsworth, 1998). Other childhood protective factors that can protect against a variety of stressors include having an easygoing temperament, high self-esteem, high intelligence, and school achievement (Masten, 2001; Masten & Coatsworth, 1998; Rutter, 1987).
Building Resiliency
So, what is a person to do if they should fall in the category of having high levels of childhood vulnerabilities (diatheses); having had low levels of childhood protective factors; and currently having high levels of psycho-social stressors in their life. How do people cope with serious illnesses, the loss of a job, the death of a loved one, or other life challenging events and/ or traumatic experiences? Should you just give up and give into the symptoms that you are already developing. Is it inevitable or just fate that you will develop these disorders, or is their something that you can start doing for yourself now to decrease your risk?
Since stress is defined by some experts as the response or experience of an individual to demands that he or she perceives as taxing or exceeding his or her personal resources (Folkman & Moskovitz, 2004; Lazarus, 1993; Taylor & Stanton, 2007), it is logical to consider that we could increase our personal resources to build resiliency in all the dimensions of our lives – to decrease the risk of developing these disorders and their harmful consequences. Resilience is the ability to recover from or adjust easily to change or misfortune. To be resilient means to be flexible, elastic, and springy. In other words, when bad things happen to you, you are considered to be resilient when you are able to bounce back and adapt successfully to very difficult circumstances.
There is increasing evidence that if a child’s fundamental systems of adaptation (such as intelligence and cognitive development, ability to self-regulate, motivation to achieve mastery, effective parenting, and well-functioning neurobiological systems for handling stress) are operating normally, then most threatening circumstances will have minimal impact on him or her (Masten, 2001). Problems may arise when a serious stressor damages one or more of these systems or when the level of challenge far exceeds human capacity to adapt (e.g., exposure to chronic trauma in war or chronic maltreatment in abusive families (Cicchetti, 2004; Cicchetti & Toth, 2005; Masten & Coatsworth, 1998). Resilience is not a personality trait that people are born with. It is an ability that can be learned and developed in anyone. Resilience can be systematically built multi-dimensionally into many areas of your life by developing a holistic health and wellness plan. The following Therapeutic Activity Survey can be utilized to assess an individuals current behaviors/ activities related to decreasing stress, building resiliency, and improving over-all wellness.
7 Dimensional – Therapeutic Activity Survey (7D-TAS)
The 7D-TAS is a 21 question survey that can identify specific therapeutic activities in the following seven life-functioning dimensions:
1. Medical/ Physical Stress – Dimension
2. Self-regulation/ Impulse Control Stress – Dimension
3. Educational/ Occupational Stress – Dimension
4. Social/ Cultural Stress – Dimension
5. Financial/ Legal Stress – Dimension
6. Mental/ Emotional Stress – Dimension
7. Spiritual/ Religious Stress – Dimension
The following three questions are asked:
1. Are you currently participating in activities that will decrease stress, build resiliency, and improve your overall wellness in in each of the 7 dimensions?
2. If Yes – What specific activities are you participating in for at least 30 minutes per day?
3. How many days per month are you participating in these activities?
Six of the seven dimensions are common to most health and wellness models, but the second dimension: Self-regulation/ Impulse Control may require some explanation, so I will list the following second dimension questions for consideration:
Self-regulation/ Impulse Control Dimension:
1. Are you currently maintaining a balanced lifestyle by avoiding alcohol/ drug abuse and/ or other addictive/ high-risk behaviors (e.g., gambling, sexual compulsive behaviors, food – binging/ purging, obsessive religious practices, risky/ dangerous behaviors – speeding/ reckless driving, and/ or assaults/ violence/ self-harm, excessive – internet use shopping, exercise, work activities, etc.). Yes/ No
2. If Yes – Circle the following activities that you are participating in: self-monitoring, daily journaling, talk to family members/ friends, sponsor/ peer coach, read self-help books, attend support groups (religious meetings, Alcoholics Anonymous), individual/ group counseling/ therapy, etc. Other: _____________
3. If Yes – Circle the amount of Days per Month: 0 — 5 — 10 — 15 — 20 — 25 — 30
Total percentage (%) scores are then tallied and can then be documented on a “Wheel of Life” to be visualized to emphasize the cognitive dissonance between what you (or your client) are actually doing to improve your life at this time and what you think you may be doing.
Self-regulation is one of the major executive functions of the human brain and is a centrally important process and life-functioning dimension. Not only does it hold important keys to self theory, but it also has extensive pragmatic applications. Indeed, the majority of personal and social problems faced by modern Western citizens – addiction, violence and crime, debt, sexually transmitted diseases, underachievement, unwanted pregnancy, obesity, failure to exercise, gambling, failure to save money, and others – are rooted in failures of self-regulation (Higgins, E. T., 1996).
Putting It All Together
Guidelines for implementing a 7 Dimension Intervention:
1. Start the interview with the “Open question” technique to elicit as much detailed information as possible from the client, prior to administering any questionnaires or checklists (Utilize reflective listening skills, etc.).
2. Administer the ACE questions and calculate the ACE score.
3. Administer the 7D – PSI and calculate scores.
4. Administer the 7D – TAS and calculate scores and plot all scores on the Wheel of Life to visualize the diathesis levels, current psycho-social stressor levels, and the current efforts to decrease stress and build resiliency.
5. Administer the “Stages of Change” question: On a scale of 1 to 10 – with 10 representing the highest motivation for change that you have at this time, how motivated are you?
Pre-contemplation Stage = 1 – 3
Contemplation Stage = 4 – 5
Preparation Stage = 6 – 7
Action Stage = 8 – 9
Maintenance Stage = 10
6. Provide a “Motivational Interviewing” session with your client discussing the “Stages of Change.” The brevity of this article does not allow for an overview of this session (Tomlin, K. & Richardson, H., 2004)
7. Develop a holistic multidimensional health and wellness plan and a comprehensive individualized treatment plan if necessary along with a case management and treatment monitoring system.
7 – Dimensional Model
In the “Addictions Recovery Measurement System (ARMS),” (Slobodzien, J. 2005), the following seven life-functioning therapeutic activity dimensions for progress outcome measurements include the 7D-PSI. Each of the seven dimensions has individualized assessment criteria:
1. Medical/ Physical Stress – Dimension
2. Self-regulation/ Impulse Control Stress – Dimension
3. Educational/ Occupational Stress – Dimension
4. Social/ Cultural Stress – Dimension
5. Financial/ Legal Stress – Dimension
6. Mental/ Emotional Stress – Dimension
7. Spiritual/ Religious Stress – Dimension
The 7 – Dimension model was initially designed to measure patient progress by assessing therapeutic life-functioning activities, however research 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.
Psycho-social stressors may affect many domains of an individual’s functioning and require holistic health and wellness planning along with multi-modal treatment. Goals of treatment include reduction in multi-dimensional stress, and simultaneous improvement in multi-dimensional functioning. Real progress requires time, commitment, and discipline in thinking about it, planning for it, working the plan, and monitoring the successes made to increase resilience. 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 building resilience incorporates the interaction between many background factors (e.g., family history, social support, and co morbid psychopathology), physiological states, cognitive processes (e.g., self-efficacy, motivation, outcome expectancies), and coping skills. 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’ 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.”
Conclusion
A rapidly growing body of evidence supports the relationship between adverse childhood experiences and physical/ mental disorders. Clinical research investigating this relationship concludes that psychosocial stressors in childhood combined with current stressors can be both a cause and a consequence of mental disorders. Furthermore, recent data have shown that health and wellness planning to decrease stress and build resiliency might reduce the symptoms that lead up to mental disorders.
Unfortunately, the influence of psychosocial stressors upon mental disorders remains underrecognized compared to traditional genetic-biologic causes. Mental health providers should perform systematic screening for psychosocial stressors to recognize potential symptoms for further diagnosis and treatment planning. Considerations should be given to developing unique interventions to assist patients with becoming aware of the connections between their lifestyle activities and future mental health disorders. The combination of screening devices discussed in this article to help patients visualize their childhood vulnerabilities, current stressors, and current therapeutic activities have successfully motivated patients to implement positive therapeutic activities to target specific stressors affecting particular dimensions of their lives to decrease stress, build resiliency, and improve their overall wellness. The 7 Dimension Intervention has been particularly useful in patients with substance abuse disorders occurring with other chronic diseases.
The time has come for mental health providers to recognize the impact of a seven dimensional approach to mental health. The 7 – Dimensions Model is not claiming to be the panacea for the ills of all mankind, 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 more info see: Poly-Behavioral Addiction and the Addictions Recovery Measurement System (ARMS) at:
by James Slobodzien, Psy.D.
References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000, p. 787 & p. 731.
Cicchetti, D. (2004), An odyssey of discovery: Lessons learned through three decades of research on child maltreatment. Amer. Psychol., 731-41
Cicchetti, D., Toth, S.L. (2005). Child maltreatment, Annual Review of Clinical Psychology, 1 (1), 409-38.
