As I climbed 15-feet on a wooden ladder to the top of an old platform, next to this wall of leathery gray flesh, I caught a good whiff of fresh animal dung that immediately cleared my sinuses. Attempting to hide my fear from my wife with a poker face, and already feeling a little queasy, we were then advised by an old man who held a hammer in his right hand, to step into a shaky bamboo cradle seat atop of this seemingly gentle 8000 lb mammoth giant. As the sweat dripped off my forehead, I knew there was no turning back from the plunge into the humid jungle while perched on an elephants’ back that we had so enthusiastically planned. At last, we were elephant trekking in Thailand. Apart from the slow bumpy ride, and my thighs being chafed on the course sides of this enormous peaceful beast, the serene walk through the forest with its’ beautiful and unique flora on top of one of the strongest ancient animals alive, was an unforgettably pleasant experience for both of us.
Recently, as I was daydreaming about elephant trekking in Thailand, I began to think about an old video that is used in the addictions’ field entitled, “The Elephant in the Living Room.” This is a rather silly story of a family that pretended to function normally with a real life elephant walking around in their living room. It exemplifies the dynamics of the co-dependent, dysfunctional family that continues to enable the alcoholic family member and deny the presence of alcoholism in the family.
Try to imagine having some quality family time – conversations, watching television, or just relaxing all together when the elephant continues to tramp around the living room, bumping into things and knocking them over. It smells bad, eats a ton of hay and bananas daily, it takes up half the living room space, and it makes loud trumpet noises all day long. Then try to imagine convincing your children, friends, and other family members to keep it a secret, or that the elephant does not really exist. The idea is that if you just pretend long enough that it’s not really there, and it’s not really an elephant, that it may just go away by itself. Some things like the common cold, poison ivy, and stress headaches usually due subside with time. Chronic diseases and life-style addictions (e.g., alcoholism, drug addiction, obesity, gambling, etc.) on the other hand continue to progress with time. Just ignoring a chronic problem rarely makes it go away for good, because of the continued negative consequences that effect everyone involved.
My initial purpose in writing this article is not only to proclaim that the elephant is real, but that it won’t be ignored despite our best efforts to do so. Lying about it makes the elephant bigger and stronger, and it will continue to dominate the house. If we admit and acknowledge its’ existence, we can take the first step out of denial and onto the road to recovery. The “it” that I am referring to is what I call “Poly-Behavioral Addiction.” Secondly, I want to introduce the Addictions Recovery Measurement System (ARMS) as a progress tracking measurement tool for clinicians. In a sense, this system simulates the old elephant masters’ steering instructions to me. “Dig your heels into the elephants’ neck, and hold on to its forehead, kick right to go right and left to go left, and if the elephant stops to eat bananas, you must use the hammer on his head, because with his thick skin, nothing else will get his attention.”
Behavior medicine experts and health psychologists must take into account the biological, psychological, and socio-cultural influences when considering an individual’s health. They have long emphasized the role that multidimensional life experiences (e.g. traumatic life events, the negative effects of stress on the immune, endocrine, gastrointestinal, and cardiovascular systems, unhealthy/ hazardous life-styles, and poor health choices in regards to adherence to preventive regiments, etc.), play in the occurrence, maintenance, and prevention of physical illness. In 1990, 50 percent of the mortality (over 1-million deaths annually) in the United States from the 10 leading causes of death was linked to addictive behaviors such as tobacco use, poor dietary habits and activity, alcohol misuse, illicit drug use, and risky sexual practices, (McGinnis and Foege, 1994).
Some experts in the medical field are presently purporting that America’s number one health problem is no longer heart disease or cancer, but a deadly condition labeled “Syndrome X”. This condition is described as a combination of several metabolic problems such as being overweight, having high blood pressure, being insulin resistant, and/ or having abnormal cholesterol levels that are all related to a poor diet and a lack of exercise. The sum is greater than the parts in this syndrome. Each metabolic problem is a risk for other diseases separately, but together they multiply the chances of life-threatening illness such as heart disease, cancer, diabetes, and stroke, etc. They indicate that up to 25% of adults presently have Syndrome X, and the ranks are growing considering for example that 30.5% of our Nations’ adults suffer from morbid obesity, (100lbs., or more above ideal weight, or BMI = 30 >), and that two thirds or 66% of adults are overweight (BMI = 25>). Considering that the U.S. population is now over 290,000,000, some estimate that up to 73,000,000 Americans would benefit from some type of education awareness and/ or treatment for a behavioral addiction. This fact does not take into account the 25% addicted to nicotine, the 13.4 % (NIMH) with alcoholism, and the multiple millions of others who are addicted to mind-altering substances, and other behavioral addictive disorders such as pathological gambling, pornography, and extreme religious addictions, etc.
To compound this healthcare crisis, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and the Commission on Accreditation of Rehabilitation Facilities (CARF) both continue to seek verification of quality healthcare, as healthcare disciplines typically have no common ruler that standardizes outcome measures. The outcome measurement research data in their comprehensive medical center inspections therefore, remain a primary focus. In many states, outcome evaluations are legislatively mandated with future appropriations tied to the demonstration of treatment program effectiveness. To add to the confusion, there are differences in the definition of outcome that relate to two paradigms:(1) 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.(2) 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.
My goal in writing this article is not only to educate and make others aware of these complex issues, but also to offer strategies and practical tools for clinicians to utilize in attacking these problems.
The Addictions Recovery Measurement System (ARMS) was developed in an effort to help healthcare providers to:
1. Provide the highest quality of patient care that improves patients’ overall health
2. Document health risk reduction effectiveness and medical care cost reductions
3. Comply with the U.S. Preventive Services Task Force’s evidence-based prevention assessments and recommendations for early detection of diseases
4. Support the U.S. Department of Health’s Healthy People 2010 national initiatives
5. Comply with JCAHO and CARF standards for outcome measurements
6. Help change the current health care system from a traditionally symptom-reduction focused model to a holistic multi-dimensional prevention model
7. Maintain treatment efficacy and integrity for healthcare program viability
The ARMS is a standardized multidimensional integrative program that offers a combination of twelve primary clinical and innovative assessment and measurement tools to assist providers and consumers of healthcare services with the following seven objectives: Initial Intervention Diagnosis Prognosis Treatment Level of Care Recommendations Progress Management Discharge Determination and Outcome Measurement. The ARMS patient progress tracking system also includes a performance based holistic health and wellness non-confrontational point system. It provides a uniform administrative device to impartially screen, monitor, and re-assess a patients’ initial bio-psychosocial medical condition for prognostic indicators, treatment progress indicators, and subsequent treatment outcome indicators. This motivational measurement system can track patient progress in six (PD) Progress Dimensions from admission to discharge to coordinate continuity of care given to the patient by multiple providers simultaneously. The ARMS incorporates a comprehensive prognostication system of instruments with a treatment progress and outcome measurement system that visually displays a patient’s journey from enrollment to recovery. The goal of treatment outcome measurement is to yield more effective, targeted, and clinically validated treatments to match individual patient needs through continued research.
The Addictions Recovery Measurement System is equipped with an arsenal of assessment tools and prognostic, progress, and outcome measurement instruments to help you fight the War on poly-substance and behavioral addictions. We must consider that over 440,000 Americans are dying each year from nicotine addiction alone, (e.g., that’s 1205 daily, etc.), costing $75 billion in direct medical costs. We must consider that 300,000 adults a year are dying from obesity (e.g., that’s 822 daily, etc.), with $117 billion we spend on obesity related diseases annually, (National Health and Nutrition Examination Survey, 1994). We must also consider the 100,000 deaths annually related to alcohol use (e.g., that’s 274 daily, etc.), with the 184.6 billion we spend for this problem, (Tenth Special Report to the U.S. Congress, June 2000). Just these three lifestyle addictions mentioned alone are causing 840,000 deaths annually (e.g., that’s 2301 daily, etc.), with total costs of $376.6 billion annually to the U.S. taxpayer. We must conclude that we can no longer afford to ignore the “elephant in America’s living room,” – the multidimensional problems related to individuals suffering from multiple behavioral addictions. A call to “ARMS” is in order to fight and stop the top killer of Americans: Poly-behavioral Addiction.
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 20-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.