The Minnesota Model in the Management of Addiction BrJAdd 1988

7/28/2019 The Minnesota Model in the Management of Addiction BrJAdd 1988

http://slidepdf.com/reader/full/the-minnesota-model-in-the-management-of-addiction-brjadd-1988 1/15

British Journal of Addiction (1988) 83, 735-748

The Minnesota Model in the Managementof Drug and Alcohol Dependency:miracle, method or myth?Part II. Evidence and Conclusions'^

CHRISTOPHER C. H. COOK, B.Sc, M.R.C.Psych

Lecturer in Drug & Alcohol Dependence, Academic Department of Psychiatry, University

College & The Middlesex Hospital School of Medicine, Wolfson Building, The Middlesex

Hospital, London, WIN 8AA, United Kingdom \

Summary

Claims of impressive outcome figures for the Minnesota Model find some support in published studies, with as

many as two thirds of admissions apparently achieving a genuinely good outcome at 1-year follow-up.

However, m ethodological criticisms of these studies indicate the need for further research incorporating controlor comparison treatment groups, longer follow-up, more rigorous assessment procedures, and clearly defined

diagnostic/outcome criteria. The powerful ideology of the programme provokes criticism but is apparently

central to its success . It incorporates a numb er of therapeutic elements known or suspected to be of value in the

managem ent of drug/alcohol dependence. While some clients or patients and professionals alike may react

against this treatment model we all have much to learn from it, and many are undoubtedly helped by it.

Follow-up Studies of the Minnesota Model

Desp ite extravagant claims of success, there appearto be few serious follow-up studies of patients

graduating from Minneso ta-type programmes. Most

information exists for the Hazelden Foundation,

which has gone to some lengths both to evaluate its

own pro gram mes , and also to advise other centres in

evaluating theirs (Spicer & Barnett, 1980). A brief

review of outcome studies published to date will

demonstrate the great need for further research.

( i) Willmar State HospitalIn 1955 and 1956 all patients living in rural areas

were followed up by a counsellor who interviewed

the patients themselves and a variety of other

informants (including probate judges, sheriffs,

county attorneys, police departments, welfare agen-

cies and AA groups) in order to gain some measure

of the programme's effectiveness. In 1957 a 20%

sample of patients was similarly followed up. The

authors conclude that "at best, the program has

about 45% effectiveness".

Rossi, Stach & Bradley (1963) published a more

detailed study condu cted about 5 years after the first

follow-up in 1955, and the authors suggest that it

shows no appreciable change in effectiveness of

their programme over this period. Two hundred and



736 Christopher C. H. Cook

period of 21.3 months. Personal interviews were

conducted with the patients by the research team or

'specially trained county social workers' in most

cases. Others were seen by trained volunteers or

social workers and c o-operating agencies outside the

state of Minnesota. The authors present someevidence of inter-rater reliability across this large

team of interviewers, which used a five-step rating

scale of drinking behaviour (however, the validity

of this rating scale was no t asse ssed); 83% of the

study population were traced.

Eleven patients were institutionalized and 13

had died at follow-up. Of the 149 patients located

in the community 49 (24% of the original sample)

had been abstinent from alcohol for 6 months or

more, and of these, 35 (17% of the original

sample) had improved on their previous longestperiod of abstinence by 6 months or more. How-

ever, only 14 had been continuously abstinent

since discharge. Those found to be drinking with

mild effects at follow-up were subjected to a

further follow-up 1 year after the first. Of these

45 patients, only one was continuing to drink with

'mild effects' and only three had stopped drinking.

The remaining 41 were by that time suffering

serious effects as a result of their continued

drinking.

Rossi, Stach & Bradley (1963) also looked at 20

other 'behavioural areas' including such items as

'self questioning attitude', 'believes problem with-

in self, sibling relations, budgeting, employment,

'harmony at work', and income. Patients continu-

ously abstinent since discharge showed improve-

ment in 16 out of these 20 areas, while those

drinking with 'mild effects' improved in only 11

areas. Patients drinking with 'serious effects'

showed an even poorer outcome, but some behav-

ioural improvement occurred in all groups, regard-

less of drinking behaviour.

While these studies show valuable and impres-

sive results, they are methodologically deficient.

No account was taken of any other treatments

obtained by patients between discharge and fol-

low-up. No control or comparison group of pa-

tients was included. (A comparison of patients

who 'dropped out' with those who completed

treatment showed a statistically insignificant ad-

vantage for the latter group in improved behav-

ioural indices. Drinking data were not reported for

this comparison.) The 'behavioural areas' exam-ined by Rossi, Stach & Bradley appear highly

(ii) Hazelden

Laundergan (1982), evaluated discharges over a 2.5

year period from 1973 to 1975. Gilm ore (1 985 )

summarizes data from 1978, 1980 and 1983.

(a ) 1973-75: Methodology. All patients wh o gaveconsent, and who stayed in treatment 5 days or

more, were sent a postal questionnaire at 4,8 and 12

months after discharge. Those who did not respond

were contacted by telephone where possible. The

study period included all patients discharged

between June 1, 1973 and December 31, 1975

(w=3638). However, analysis is confused some-

what by definition of a 'study population' on the

basis of three inclusion criteria:

(1 ) Com pletion of treatm ent by successfully

meeting the programme objectives and being dis-

charged with a medallion (regularly discharged

patients are presented with a medallion in a full

group meeting in their treatment unit, usually 24

hours before leaving Hazelden).

(2 ) Classification as having problem s with either

alcohol or alcohol and drugs at the time of

treatment, as reported in response to the 4-month

questionnaire.

(3) Return of the questionnaire at 4, 8 and 12

months.

Additionally, patients were excluded who either

returned to treatment at Hazelden or entered

'extended care treatment' at Hazelden. Together

these criteria reduce the study population to only

1652 patients.

Response rates to the questionnaires were high as

a percentage of the study population, but left nearly

half of the total patient population unrepresented.

Reasons for 'non-response' included death, with-

holding of consent and not being sent a form

(throug h error or design) as well as failure in tracingor response.

Laundergan produces various arguments to refute

the possibility of distortion by sampling bias:

(1 ) He argues that diagnosis is carefully assessed

and that less than 1% of patients are found not to be

chemically de pend ent. H ow ever, he does not specify

diagnostic criteria, nor does he attempt to make any

quantitative assessment of the level of drinking or

alcohol dependence prior to admission.

(2) He argues against the infiuence of socio-

demographic characteristics (high socio-economic

status, employment, marital status, etc.), which he






Table 1. Outcome at 1 year after Treatment for P atients Discharged from Hazelden between June 1, 1973an d December 31, 1975

All patients respondingPatients completing treatment

Study populationAdjusted for deaths, untraced

patients and patients re-entering

treatment*

Calculated, adjusted, outcome

for all discharges*

n

189915981246

3236(402 still

excludedfrom study)

3638

Abstinent

50.050.954.6

39.3

37.8

Improved

17.618.318.0

10.3

9.2

Not improved

32.430.827.4

50.4

53.1

* See text.

Table 2. Alcohol and Drug Use at 1 year Po llow-upfor Patients with Alcohol and Drug Use Problemsat Admission to Hazelden (and discharged June 1 to Decemb er 31, 1975). Laundergan (1982)

Alcohol Use

AbstinentImproved

Not improvedNo response

Total

Drug UseAbstinentImproved

Not improvedNo response

Total

n

18846

95113

442

122175

41104

442

(% )

42.510.4

21.525.6

27.639.6

9.323.5

Adjusted*

(% )

57.114.0

28.9

36.151.8

12.1

Re-adjusted*

(% )

48.910.4

40.7

33.539.6

26.9

* See text.

Stability of drinking behaviour over time is also in that study responded to follow-up. On the basis

considered. Th e figures are complicated by artifacts that patients who are difficult to trace may have a

of questionnaire categories and an increasing num - poor outcome (M oos & Bliss, 1978; M acKe nzie etber of non-responders. However, it is clear that the al., 1987), it seems unwise to conclude that d rinking

abstinent group is more stable than the other two after discharge facilitates eventual abstinence. It is

outcom e categories and there is some evidence for clear tha t longer follow-up perio ds are required in

increasing stability of the group as a whole over future studie s.

time. Of those patients who changed outcome Psycho-social indicators of outcom e show that

categories between 4 and 8 mon ths post discharge, 'ability to handle prob lem s', 'self image function-

similar num bers moved in the directions of more or ing ', and 'general enjoyment of life' were improved

less drinking. How ever, of those who moved categ- at 1 year follow-up in the majority of patients in all

ories between 8 and 12 m onth s, 61.8% moved in the outcome groups. Improvem ent was greater in 'absti-

direction of more drinking, and 38.1% moved in the ne nt' than 'impro ved' patients and greater in

direction of less drinkin g/abstin ence. Another study 'impro ved' than 'not impro ved' patien ts. The seof Hazelden patients (Brissett et al., 1980) sug- findings raise two issues. First, the authors apply



The Minnesota Model—Part II 739

However, this is unsurprising for a treatment

modality that encourages patients towards, and

prepares them for, total abstinence. Secondly, as

with the early Willmar State Hospital programme,

there appear to be benefits obtainable from treat-

ment which are independent of drinking outcome.

Frequency of AA attendance was positively

correlated with abstinence as weU as with a variety

of indicators of psycho-social functioning. The

latter included 'job performance' and 'participation

in community affairs', increased contact and im-

proved relationship with a 'Higher Power', and

relationships with relatives/friends (but not

spouse).

Other psycho-social outcome measures employed

in this study included 'general physical health',

ability to accept and give help, 'ability to manage

finances', and 'acceptance of need for abstinence'.

All 12 of the psycho-social indices employed were

significantly related to abstinence.

Despite the criticisms of methodology and data

analysis, this study represents a detailed evaluation

of the Minnesota Model. It shows that almost half

the patients discharged are either abstinent or

drinking less at 1 year follow-up. A ll patients appear

to have gained some therapeutic benefit from their

admission in psycho-social terms. These achieve-ments are not to be ignored, and they warrant

further research.

(c ) 1978, 1980, 1983. Methodology of the

evaluation condu cted over these years appears to be

essentially similar to the 1973-5 evaluation.

Outcome at 12 months follow-up as presented by

Gilmore (1985) is summarized in Table 3. How-

ever, her figures exclude patients to whom que stion-

naires were not sent (because of discharge before 5

days of treatment, transfer to another treatmentcentre, refusal to participate in foUow-up and

death) , patients who failed to respond by mail or

telephone, and patients who made inadequate re-

plies. Th is is justified by the au thor on ground s of a

high response rate of 75% to 78% (which also fails to

account for between 13.2% and 18% of patients to

whom questionnaires were not sent), and similarity

of respondents to the total (1983) population.

However, the areas of similarity considered are

mainly socio-demographic and no account is taken

of possible differences in pre-treatment alcohol/drag use. Again, outcome is likely to be poorer

the 1973-5 study. This is arbitrary and of debatable

validity but does draw attention to the possibility of

distortion in the results. Re-calculations on this

basis considerably reduce the near 100% success

rates quoted by Gilmore (1985) (see Table 3). I t

seems a pity that impressive figures have beenapparently biased in this unnecessary fashion. If the

adjusted 'success' rates are at all realistic, they show

that about two-thirds of patients achieve a good

outcome for alcohol use, and a simUar proportion

for drag use.

Issues of quality of life and AA attendance are

also discussed by Gilmore (1985) but the comments

made for the 1973-5 study remain essentially

applicable.

Laundergan (1981) compared outcome of pa-

tients who had received treatment for chemical

dependency in the 2 years before admission to

Hazelden in 1978 with those who had not. Both

groups showed improvem ent at 1 year follow -up,

but those who had received previous treatment were

not as improved as those who had not.

(d ) Other outcome studies at Hasdelden. Willi-

am s et al. (1983) describe a study of participants in

the Hazelden family programm e in 1979. Pro -

gramme activities were rated as helpful at 6 monthfoUow-up, and indices of'psychosocial growth' were

improved.

Spicer, Nyberg & McKenna (1981) compared

client characteristics and outcome of the Hazelden

Inpatient and Outpatient programmes. Inpatients

were found to have more severe alcohol-related

problems and symptoms, and generally greater

psychopathology as demonstrated by the Minnesota

Multiphasic Personality Inventory. There was no

difference between the two groups in terms of

outcome at 1 year foUow-up.Laundergan, Spicer & Kamm eier (1979) com -

pared outcome of court referrals and other patients

admitted to Hazelden over a 12-month period

during 1974-5. Despite sociodemographic differ-

ences, outcome for the two groups was similar.

(iii) St Joseph's Hospital Chemical Dependency

Centre

St Joseph's Hospital Chemical Dependency Centre

in St Paul, Minnesota has been subject to an

outcome evaluation programme based upon theHazelden model (Spicer & Bamett, 1980). Criti-




Table 3. Hazelden Outcome Figures for 1978, 1980, 1983 with Re -calculation to Estimate Outcom e of Patients

Unaccounted P or

1978 1980 1983

Total patients dischargedStudy period/sample

Total study dischargesTotal questionnaires

not sent/not returnedInadequate replies

Alcohol dataDmg data

1558Full year

1278

599

3518

15798 months

(alternate patients)

448

144

1828

16873 months

437

169

2073

Gilmore,

1985

Adjusted* G ilmore,

1985

Adjusted* Gilm ore,

1985

Adjusted*

Alcohol Use'Good' outcome (%)''Poor' outcome (%)^

Drug Use

'Good' outcome (%)'

'Poor' outcome (%)^

8911

964

6337

6832

919

965

6733

6932

974

1001

6635

5942

' Combined 'Not used'/'Not as much' categories.^ Combined 'About as much'/'More' categories.^ Combined 'Not used'/'For medical reasons'/ 'Not as much' categories.* See text. (Based on Gilmore, 1985.)

abstinent from alcohol, but only 55.4% had been

abstinent for 11 to 12 mo nths. Out of a total of 472

admissions, 12 month follow-up data was available

for only 176 (37%) and its significance is therefore

questionable.

note that the figures apply to patients who success-

fully completed treatment. Treatment drop-outs are

presumably not included and no indication is given

of how many patients actually do complete treat-

ment, or of what treatment 'completion' actually

means.

( iv) Clouds House

The 'Life Anew Trust' and Clouds House have

produced figures from a survey carried out in

M arch -Ap ril, 1985 of patients who had successfullycompleted treatment from April, 1983 to May,

1984; 54% were reported to be abstinent from

alcohol and mood-altering drugs, and 14% were

reported to be abstinent following only one relapse.

Improvement in 'lifestyle', 'self-confidence',

'health', 'new interests', 'relationships' and 'employ-

ment' are also all quoted as indices of more general

therapeutic benefit. Sixty-nine per cent of patients

were attending AA/NA once per week or more

often.

The methodology of this study is not describedand neither are the socio-demographic or drug/alco-

(v ) Comp arisons with other Treatment Centres

A true comparison of the results of the Minnesota

Model with those of other treatment programmes isnot possible until a prospective study employing

random allocation of patients is conducted. Com-

parison of Minnesota Model results with those of

other, separately conducted, studies at other centres

is invalidated by differences of patient population

and methodology. However, follow-up studies at

other treatment centres do provide a context to the

Minnesota Model outcome studies quoted above.

Orford & Edwards' (1977) classic comparison of

treatm ent and advice given to alcoholics revealed 26

patients with a 'good' outcome at 2 years, out of 65patients for whom complete follow-up data were



The Minnesota Model—Part II 74 1

up of this group showed that 18 had died, 27

achieved 'good' outcome, 32 were drinking in an

'uncon trolled' w ay, and 13 were of'equ ivoc al' statu s

(Edwards et al., 1983). However, the majority of

these patients fiuctuated between abstinence, 'trou-

bled', and 'controlled' drinking (but mainly the

former two of these three categories). Only 20%

were consistently drinking in a 'troubled ' way, 4%

were consistently abstin ent, and one patient claimed

consistent social drinking over the follow-up period

(Taylor et al, 1985).

Turning to the treatment of drug dependence,

Gossop et al. (1987) found that (although many

relapsed soon after treatment) 47% of their opiate

addicts were opiate free at 6 month follow-up.

Ogborne & M elotte (1977 ) traced 87 out of the first100 patients admitted to a British 'Concept' based

therapeutic community. Seventeen per cent were

abstinent, 12% sporadically using drugs, 23% regu-

larly using oral drugs, and 44% regularly injecting

drugs. The 'majority' of these patients had been

discharged for more than 6 months at the time of

follow-up.

Bale et al. (1984) prospectively compared three

North American therapeutic communities ( 'The

Fam ily', 'Quadra nt', and 'Satori') with a 'withdrawal

only' group in the treatment of narcotic addiction.At 2-year follow-up one-third of the withdrawal

only group were not using heroin and were not in

jail. Thirt y-n ine p er cent were not using other illegal

drugs. Only patients from Quadrant were signifi-

cantly more likely to be off heroin at follow-up, and

this difference disappeared when a parallel variable

('ever narcotic free after first daily use of heroin')

was controlled for in the analysis. Only patients

from Satori were significantly less likely to be using

other illegal drugs at follow-up. Patients from both

the Family and Satori sustained fewer criminalconvictions and were more likely to be employed or

at school at follow-up compared with the with-

drawal only group.

Thus, the Minnesota Model outcome figures

appear to be equivalent to or even better than those

of other treatment programmes for drug and alcohol

dependence. However, they also illustrate the need

for future studies to include comparison treatment

groups and/or a withdrawal only group, and the

need for longer follow-up periods.

process literature is provided by Allison & Hubbard

(1985). There appear to be no studies of treatment

process in the Minnesota Model apart from those

conducted by its proponents (Laundergan, 1982;

Kam meier, Lucero & Anderson, 1973). There is, of

course, a vast literature on certain elements of the

Minnesota Model (e.g. AA or group therapy), and

on processes of attitude change or persuasion

generally.

( i) Research at Hazelden

(a ) Kammeier, Lucero & Anderson (1973) s tud-

ied self reports from 482 inpatients at Hazelden who

wrote down, in their own words, (a) 'the most

important or significant event or thing of that day'and (b) 'why it was significant or important' at the

end of each day in treatment. The most salient

findings were that (i) the most important events

involved the daily lectures with resultant insight,

(ii) one to one conferences with staff members were

also reported as significant and meaningful, (iii)

visitors, telephone calls and mail were frequently

reported by patients as meaningful, and (iv) for

many patients a return to previously acquired

religious beliefs or an awakening interest in spiritu-

ality was a profound enough experience for them tocomment about it frequently.

These findings provide an interesting indication

of what patients at Hazelden subjectively felt was

important in contributing to their recovery. How-

ever, this does not necessarily m ean that these items

were the ones which exerted any therapeutic effect

that was obtained. Although confidential, the ques-

tionnaires do not appear to have been anonymous.

There would thus be considerable pressure upon

patients in treatment to conform and to provide the

answers that they thought staff were looking for.Specific figures for the frequency of reported items

are not given. Finally, being a self-report question-

naire, it is possible that different patients may have

understood the questions differently. For example,

some may have reported items of emotional impor-

tance, and others items which they considered

therapeutically important.

(b ) Laundergan (1982) conducted a more elabo-

rate study based upon the follow-up questionnaires

used in his outcome studies. At 12 months post

discharge, patients returned a self report question-



742 Christopher C. H. C ook

ing, and a rating of how helpful/effective treatm ent

activities during admission had been. This data was

subjected to a range of statistical analyses, including

factor analysis, multiple regression analysis, and

path analysis. The following were the major find-

ings:

(i) P ost-trea tme nt abstinence at 12 mo nth fol-

low-up was predicted in the regression analysis by

frequent AA attendance (6.09% of the variance),

lack of post-treatment hospitalization (5.24% of the

variance), assessment of group and individual

activities in treatm ent as helpful (2.42 % and 2.9% of

the variance respectively), better education (1.14%

of the variance), and 'Higher Power contact ' '

(0.42% of the variance).

(ii) AA attendance at 12 month follow-up waspredicted in the regression analysis by increased

'Higher Power contact ' (8.48% of the variance),

favourable rating of group-related treatment activi-

ties (2.9% of the variance), better education (1.52%

of the variance), married status (1.26% of the

variance), and female sex (0.86% of the variance).

(iii) Four strong predictors of improved post-

treatment social/psychological functioning at 12

month follow-up emerged from the regression

analysis: favourable rating of group and individual

activities in treatment (15.9% and 6.16% of thevariance respectively), increased 'Higher Power

contact ' (6.13% of the variance), and abstinence

(6.99% of the variance).

(iv) In the path analysis:

"The strong relationship identified is between

Higher Pow er and AA attendance. This relation-

ship is imp ortant because it is part of a path from

the Higher Power variable to frequent AA

attendance to abstinence, to improvement in

social/psychological functioning. In other words,

the Higher Power variable emerges in the path

analysis as the principal variable, both directly

and indirectly in explaining functioning improve-

ment" [his emp hasis].

He goes on to say that,

"The importance of increased prayer and medita-

tion in the post-treatment recovery process stron-

gly reinforces the spiritual emphasis of the

Minnesota Model treatment approach and the

way that the spiritual part of recovery comple-ments frequent AA attendance with its direct

recovery benefits."

A number of criticisms must be made concerning

this study:

(i) Response rates to questionnaires, inclusion

criteria for the study, and other factors, confine the

applicability of the findings to a relatively selectgroup of patients.

(ii) Response to questionnaires may be biased by

a desire to please or impress those seen by patients

'in recovery' as the providers of the means of that

recovery.

(iii) Th e questionnaires employed were of a self-

report nature and may have been understood

differently by different patients. Apart from the

drug/alcohol use, and AA attendance items, these

questionnaires do not appear to have been validated

or subjected to reliability studies.(iv) Alcoho l/drug use, relationships, 'Higher

Power', and other items were rated in relation to

pre-treatment levels, and no absolute measure of a

quantitative nature was provided.

(v) Despite the path analysis, a causal relation-

ship is not proven for any correlations demon-

strated. Measures of treatment 'helpfulness' or

'effectiveness' were retrospective, subjective, and

unsupported by any objective evaluation. Con-

founding variables such as motivation were not

excluded.

(ii) Therapeutic Mechanisms of Specific Elements in

the Minnesota Programme and Philosophy

We shall consider here, briefly, the literature

relating to AA/NA, the disease concept, group

psychotherapy, the role of ex-addict/ex-alcoholic

counsellors, and family therapy.

(a) Alcoholics Anonymou s and Narcotics Anony-

mous. As an important element of the MinnesotaModel, it may be argued that AA and NA provide

the therapeutic ingredient responsible for its suc-

cess. Unfortunately, despite a widely held clinical

impression of the value of AA, reviews of the

literature suggest that its efficacy remains unp roven .

This is largely owing to the enormous methodologi-

cal obstacles (Bebbington, 1976; Glaser & Ogborne,

1982).

Similarly, further research is needed concerning

the therapeutic mechanisms of AA/NA. Edwards

(198 7) identifies a list of essential processes throughwhich AA may operate. These include: 'coherent

fiexible ideas' (an ideology), 'an action program me'



The Minnesota Model—Part II 74 3

ties (or 'tools') employed by members of AA. He

found these to be 'semantically organized and to

vary systematically over the time phase of the

newcomers sobriety'. Tiebout (1944) considers the

importance of a 'religious or spiritual awak ening'. In

a later paper (Tiebout, 1961) he identifies fourhypothetical elem ents to the effective psychological

events which make possible the maintenance of

sobriety; 'hitting bottom', 'surrender' , 'ego reduc-

tion' and 'maintenance of humility' .

AA is, of course , a part of the self help m ovem ent;

indeed it is seen by many as the paradigm of it

(Dumont, 1974). The characteristics and processes

of self-help groups are reviewed by Robinson

(1978) and Lieberman et al. (1979). Robinson

(1979) identifies in AA the seven core character-

istics of self-help groups described by Killilea

(1976): 'common experience of members' , 'mutual

help and support', 'the helper principle', 'differen-

tial association', 'collective willpower and belief,

'importance of information' and 'constructive action

toward shared goals'. Robinson points out that

'importance of information' may be a feature more

characteristic of groups other than AA. It is

therefore of interest to note that this function (the

provision of greater factual information about the

problem) is well provided for by the lectures

incorporated into the Minnesota programme. The'helper principle' refers to the benefits received by

the helper from his efforts to help others with

problems similar to his own. This is fundamental to

AA and receives additional provision in the Minne-

sota programme by use of ex-addict/ex-alcoholic

lay counsellors. Levy (1979) identifies behavioural

and cognitive processes which provide an explana-

tion for the efficacy of self help groups.

Antze (1979) considers the role of ideology in

peer psychotherapy and self help groups with

application to AA. First he identifies four structural

characteristics which make these groups persuasive:

they are 'fixed communities of belief; they engage

active participation of members by making them

share their experience; they attract members with

common attributes and experience, thus increasing

group cohesion; they comprise people with extreme

or terrifying conditions whose lives are in disarray

and who are thus ready to embrace a new system of

ideas promising comfort or relief. He then identifies

five ideological ten ets of AA: the na ture of alcoho l-

ism, 'hitting bottom', the Higher Power, the moralinventory and 'twelfth-stepping'. Finally, he de-

and the accountable self) and shows how the five

ideological tenets provide a 'cognitive antidote'

which acts to contradict these experiences or

attitudes. In conclusion he states that the benefits

conferred by peer therapy groups are closely linked

with the systems of meaning they generate. The

corollary of this is that tampering with the ideology

of AA, or by extrapolation the Minnesota Model,

endangers their therapeutic efficacy.

(b ) Th e disease concept. The therapeutic efficacy

of the disease concept derives partly from its

ideological importance (Antze, 1979). It lifts the

alcoholic's guilt and forces him to put his trust in

forces w hich are beyond his conscious effort. It th us

counteracts the three alcoholic characteristics de-

scribed above. It encourages him to take the easier

step of resisting the temptation to take the first

drink rather than the second, third or subsequent

drink (Glatt, 1976). It alters the attitudes of family

and others in a way which may encourage them to be

more supportive by removing blame and stigma

(Glatt, 1976). Paradoxically, in the form employed

by AA (and the Minnesota Model), the disease

concept increases the sense of responsibility and

participation that the alcoholic must adopt to ensure

his own recovery (Hill, 1985).

There are many criticisms of the validity of thedisease concept of alcoholism (Davies, 1974; Doug-

las, 1986). However, the benefits described above

are real enough even if it is theoretically invalid.

Many of the suggestions that it may be counter-

therapeutic have been met by Glatt (1976).

(c ) Group therapy. A review of therapeutic

mechanisms in group psychotherapy is beyond the

scope of this paper. However, Yalom's 'curative

factors in group psychotherapy' are worthy of

mention (Yalom, 1975). Items such as 'universality

of expeience', 'instillation of hope', 'altruism' and

'imitative behaviour' are clearly particularly appli-

cable in a setting where all patients are drug/alcohol

misusers, where patients are encouraged to help

each other and where 'role models' exist in the form

of ex-addict/ex-alcoholic counsellors. These cura-

tive mechanisms have also been applied to the study

of self-help groups (Lieberman, 1979).

(d ) Ex-addict/ex-alcoholic counsellors. As early

as 1944, Dwight Anderson published a paper

outlining the place of ex-alcoholics as counsellors

in the treatment of alcoholism (Anderson, 1944).



744 Christopher C. H Cook

(i) they provide a 'living example of hop e'

(ii) they offer a 'role model'

(iii) they can communicate better by virtue of

'speaking the same language'

(iv) they may be more 'patient and tolerant' and

'less prone to moralistic judgement'(v) they are harder to fool or 'con'

(vi) personal experience in handling practical

day-to-day problems associated with abstinence in a

drinking society

(vii) an understanding of the AA programme.

Blume does not include 'scarcity of trained

professionals' as an advantage on the basis that ex-

alcoholics offer a special expertise which cannot be

provided by psychiatrists or other professionals.

The present author would add also the advantagethat the patient can identify with his counsellor and

is denied the opportunity of saying 'you don't

understand my problem'!

Blume also refers to problems associated with the

use of recovered alcoholics as counsellors:

(i) 'competition' and 'conflict' with professional

staff members

(ii) overcompensation for lack of professional

training

(iii) identification with the patient, leading to

hasty or incorrect assumptions

(iv) a drinking episode by a counsellor (which

Blume considers to be very rare)

(v) interference with the personal help derived

by the counsellor from AA meetings.

Freudenberger (1986) describes three case histo-

ries of 'burnout' among ex-alcoholic/ex-addict

counsellors and usefully demonstrates that this

syndrome may express itself in ways other than a

relapse of drug/alcohol use.

(e) Family therapy. Family treatment ap-

proaches to drug abuse problems are reviewed by

Stanton (1979) who reaches optimistic conclusions

as to their value. While it is not possible to review

these issues fully here, there are two main benefits

to the involvement of the family in therapy for

alcoholism (or drug dependence) (Madden, 1984).

First, the family of the alcoholic may themselves

benefit from emotional support and practical advice

on how to cope with an alcoholic in the family.

Secondly, they may provide a valuable source of

help to the patient. H owever, there is doubt as to thevalue of family therapy in alcoholism, and divided

The above elements of the Minnesota m odel were

chosen for discussion here by virtue of their

emphasis in the programme, and the existence of a

significant literature examining the processes by

which they operate. There is, as yet, no data to

support any one element or group of elements asbeing most, therapeutically, important. Some items

not discussed in detail (e.g. therapeutic assignments

and lectures) may be of equal, or even greater,

importance. However, they demonstrate that there

are a variety of ways in which the Minnesota Model

could operate to produce a 'successful' outcome for

its patients.

(iii) Overall Hypotheses of How the Minnesota

Model may Operate: conversion and persuasion

The Minnesota Model, with its strong emphasis

upon AA and a spiritual component to treatment,

has a distinctly religious fiavour. The apparently

dramatic change seen in some patients, who may

even have been initially hostile, is akin to a

'conversion' experience. Critics of other therapeutic

communities for drug addicts have also drawn a

parallel with so-called 'brainwashing' (Mahon,

1973). While these comparisons may be seen as

criticisms, the American pioneer of psychotherapy

research, Jerome Frank, has shown that religiousrevivalism and thought reform share important

common features with psychotherapy (Frank,

1961).

(a) Conversion. William James defines conver-

sion thus:

"The process, gradual or sudden, by which a self

hitherto divided, and consciously wrong, inferior

and unhappy, becomes unified and consciously

right, superior and happy, in consequence of itsfirmer hold upon religious realities" (James,

1902).

If the spiritual principles, relating to the 'higher

power' of AA, be taken to represent the 'religious

realities' described by James, then we may see that

many successful graduates of the Minnesota Model

have undergone a conversion experience. In any

case. Brown points out that conversions need not be

in relation to religion at all, and goes on to quote

Leuba's examples of "drunkards conversion to total

abstention" (Brown, 1963). Tiebout also describes a

conversion experience in the lives of alcoholics who



The Minnesota Model— Part II 74 5

that a genuine conversion experience may provide

the only hope of recovery for some alcoholics (see

Leach & Norris, 1977).

Adler & Hammett (1973) postulate a common

therapeutic process of 'Crisis, Conversion and Cult

Formation', which they apply to AA. Crisis is anunstable condition of disrupted 'group-system rela-

tionships', induced in this case by the psycho-social

(and medical) complications of drug/alcohol abuse.

'Con versio n', as described abov e, is seen as adoption

by the subject of AA philosophy and standards.

'Cult formation' is represented by continued mem-

bership of AA (or NA) confirming the individual's

new found security.

(b ) Persuasion. Mahon (1973), discussing theconcept based therapeutic communities (and not the

Minnesota model), shows that these institutions

closely parallel the techniques of're-so cializatio n' or

'brain-washing' used by China and North Korea on

prisoners-of-war. He identifies in these treatment

programmes for drug addicts the six elements o f'r e-

socialization' listed by Selznick: Total control over

the individual, suppression of past status, denial of

moral worth of the old self, participation of the

individual in his own re-socialization, extreme

sanctions and intensification of peer group pressure

and support. Apart from the use of sanctions (which

tend not to be extreme) and control over the

individual (which is not total) these elements are

represented in the Minnesota model. Mahon is

critical of the failure of these programmes to

prepare their residents for life in the outside world

and suggests that their techniques fail to produce

enduring change.

(c ) "Persuasion and healing". Jerome Frank

(1961) considers elements common to the influenc-

ing processes of religious revivalism, thought re-

form, miracle cures, and religious healing. He

identifies features in the 'sufferer', 'persuader',

'relationship' and 'activities' of these processes

which have relevance to our analysis of the Minne-

sota Model.

T he sufferer (in our application the drug addict or

alcoholic) tends to be in a state of emotional

distress, and estrangement or isolation from his

usual sources of group support. The persuader (i n

this case the therapist, counsellor, or AA 'sponsor')and his group (the treatment centre or AA)

forces (the 'Higher Power') which are contingently

benevolent.

T he relationship between persuader and sufferer

is characterized by investm ent of great effort on the

part of the former to induce change in the attitudes

of the latter. There is characteristically emotionalarousal, often to the point of exhaustion, but

occurring in a context of hope and potential support

from the persuader (and/or his group).

T he activities engaged in require participation of

the sufferer (and persuader/group). They are

frequently highly repetitive, requiring the sufferer

to review and re-evaluate his past life, leading to

guilt, confession and penance. Frank goes on to say

that "This serves to detach him from his former

patterns of behaviours and social intercourse and

facilitates his acceptance by the group representingthe ideology to which he becomes converted".

Success of the process is accompanied by relief,

peace, joy, increased sense of self worth and

identity, diminution of confusion and conflict,

harmony with, and acceptance by, the group and

restoration of meaning to life. Frank also considers

some degree of emotional involvement to be a pre-

requisite for susceptibility to these procedures. He

concludes this section of his book by stating that:

"Thought reform and revivalism highlight theimportance of a person's immediate social

milieu in sustaining or shaking his self image

and world view. They also underline the func-

tion of detailed review of the sufferer's past

history, with special emphasis on guilt arousing

episodes, followed by opportunity for confession

and atonement, as a means of producing atti-

tude modification."

Thus Frank's comparative study of psycho-

therapy, religious revivalism and thought reform

enables us to postulate that the 'religious' anddogmatic aspects of the Minnesota ideology com-

bine with the various programme elements (e.g. life

history review, confession, role model counsellors,

etc.) and the emotional state of the drug addict or

alcoholic in order to set the scene for a profound

attitude change or 'conversion experience'. This

experience appears to be closely related to the

accompanying behavioural changes including absti-

nence from mood altering chemicals.

Lessons from the Minnesota Model




the management of the addictions. In particular, the

value of ex-alcoholic or ex-addict counsellors has

been greatly neglected by some other treatment

programmes. It is particularly effective at engaging

its patients actively in their own treatment: by a

therapeutic community approach utilizing grouptherapy, by the emphasis on sharing life histories,

by providing written assignments, and by encour-

aging (supervised) peer evaluation. Further the

Minnesota Model demonstrates that the goal of

abstinence, with associated psycho-social and

medical benefits, is achievable, at least for some

patients.

Perhaps the most important lesson from this

treatment approach is that of the need for a

rationale which is comprehensible to the patient

and which deals with all aspects of his prob-

lem—'spiritual', psychological, social and medical;

past and future. This rationale must cater not only

for the short-term treatment process but also for

longer-term recovery and rehabilitation within a

new social system. AA and NA provide a new set

of attitudes to one's self and to life in combination

with an extensive system of social support which

fills the void left by rejection of a drug-centred

lifestyle.

There are also, of course, criticisms to be made ofthe Minnesota treatment approach. Dogmatism that

it alone has the answers has been offensive and has

antagonized professionals (e.g. Glatt, 1986). It has

become associated strongly with the private sector

so that it is seen as an elite treatmen t available only

to the privileged few (although a number of

'assisted' places now exist in this country). The

disease concept, while therapeutically advantageous,

is open to considerable criticism on a theoretical

basis. Finally, it may be said that the lifestyle of

graduates from this programme isfar

from 'normal'.However, attendance at AA meetings and socializa-

tion with ex-addicts/alcoholics are a small price to

pay for freedom from dependence upon drugs. In

any case, many patients are subjectively happier

with their lives and many return to useful occupa-

tions in the wider community.

ConclusionsThe 'Minnesota Model' has been shown to refer to a

treatment programme for alcoholism and drugdependence, which has a specific ideology related to

community, utilizing lay therapists who are them-

selves 'in recovery' from alcoholism or drug depen-

dence. Despite exaggerated claims of success, it

appears to have a genuinely impressive 'track

record' with as many as two-thirds of its patients

achieving a 'good' outcome at 1 year after discharge.More research is needed upon outcome in patients

exposed to this programme.

On close analysis, it is not surprising that the

Minnesota Model is effective. It includes a number

of 'methods' in its programme w hich are of known or

suspected therapeutic value for the treatment of

drug/alcohol dependence. Perhaps its most power-

ful tool, however, is its comprehensive and dogmatic

ideology. This acts to counter the pathological

cognitive tendencies of the chemically dependent

patient while providing release from past guilt and

tangible hope of future recovery. Isolation from the

subculture of alcohol or drugs and immersion in the

social environm ent of A A / N A areassociated with a

profound attitude change which closely parallels

religious conversion experiences. The outcome for

many, if not all, patients is not simply abstinence

from mood altering chemicals but rather a new way

of life. The conviction of infallibility, the disease

concept, and the religious emphasis m ay antagonize

professionals. However, the present writer hopes to

have shown that w hile some m ay view this ideologyas a 'myth' it has provided a 'miracle' of hope for

many patients who were drug/alcohol dependent.

We serve these people better by learning to

understand how they have been helped rather than

trying to tell them why they are wrong.

Acknowledgements

I am grateful to Dr M. S. Lipsedge and Dr C.

Feinmann for their constructive criticism and en-

couragement during the preparation of this paper.

ReferencesA D LER , H. M. & HAMMETT, Y. B. O. (1973) Crisis,

conversion and cult formation: an examination of a

common psycho-social sequence, American Journal of

Psychiatry, 130, pp. 861-864.

AuBRANDI, L. A. (1985) The folk psychotherapy ofalcoholics anonymous, in : S. ZINBERG, J. WALLACE & S.

B. BLUME (Eds) Practical Approaches to Alcoholism



The Minnesota Model—Part II 747

treatment process: a review of the literature, Interna-tional Journal of th e Addictions, 20, pp. 1321-1345.

A N D E R S O N , D . (1944) The place of the lay therapist in thetreatment of alcoholics. Quarterly Journal of Studies on

Alcohol, 5, pp. 257-266.A N T Z E , P . (197 9) R ole of ideologies inpeer psychotherapy

groups, in : M. A. LiEBERMAN, L. D. B O R M A N , P . A N T Z E

et al. (Eds) Self Help Groups for Coping with Crisis, ch.

12, pp. 272-304 (San Francisco, Jossey-Bass).B A L E , R. N. , Z A R C O N E , V. P., VAN S T O N E , W. W. ,

KuLDAU, J. M., E N G E L S I N G , T. M . J. & E L A S H O F F , R.

M . (1984) Three therapeutic commu nities. A prospec-tive controlled study of narcotic addiction treatment:

process and twoyear follow-up results. Archives of

General Psychiatry, 41, pp. 185-191.BE BBINGT ON, P. E. (1976) The efficacy of A lcoholics

A nonymous: the elusiveness of hard data, British

Journal of Psychiatry, 128, pp. 572-580 .BL U M B, S . B . (1977) Role of the recovered alcoholic in the

treatment ofalcoholism, in: B. KissiN & H. BEGLEITER

(Eds) Th e Biology of Alcoholism, Vol. 5, Treatment &Rehabilitation of the Chronic Alcoholic, ch. 12, pp.

545-565 (N ew York, Plenu m).B R I S S E T T , D., L A U N D E R G A N , J. C , K A M M E I E R , M . L. &

BlELE, M. (1980) D rinkers and non-drinkers at threeand a half years after treatment: attitudes and growth,Journal of Studies on Alcohol, 41, pp. 945-952.

B R O W N , J. A. C. (1963) Techniques of Persuasion

(London, Penguin) .D A V I E S , D . L. (1974 ) A lcoholism as a disease [editorial].

Psychological Medicine, 4, pp. 130-132.D O U G L A S , D . B. (1986 ) A lcoholism as an addiction: the

disease concept reconsidered. Journal of Substance

Abuse Treatment , 3, pp. 115-120.D UM O N T , M. p. (1974) Self-help treatment programs,

Ame rican Journal of Psychiatry, 131, pp. 631-635.E D W A R D S , G. , D U C K I T T , A., O P P E N H E I M E R , E., S H E E H A N ,

M . & T AYL OR, C . (1983) W hat happens to alcoholics?.

Lancet, ii, pp . 269-271.E D W A R D S , G. (1987) A lcoholics A nonymous, in: The

Treatment of Drinking Problems, 2nd edn, ch. 16, pp.

257-265 (O xford, Grant M clntyre) .F R A N K , J . (1961) Persuasion fie/fea/iw^ (B altimore,John s

Hopkins Press) .F R E U D E N B E R G E R , H . J. (1986) The issues of staff burnout

in therapeutic communities. Journal of Psychoactive

Drugs, 18, pp. 247-251.GiLMORE, K. M. (1985) Hazelden Primary Residential

Treatme nt Program: 1985 profile and 'Patient outcome'

(Center Ci ty , M N , Hazlden).GL ASE R, F . B . & O G B O R N E , A . C. (1982) D oes AA really

work?, British Jou rnal of Addiction, 77, pp. 123-129.GL AT T , M . M . (19 76) A lcoholism disease concept and loss

of control revisited, British Journal of Addiction, 71 , pp .

135-144.GLATT, M . M . (1986) Kick heroin [book review], BriltsA

Journal of Addiction, 81 , p. 839.

Gossop, M., G R E E N , L. , P H I L L I P S , G. & B R A D L E Y , B.

(1987) W hat happens to opiate addicts immediatelyafter treatment: a prospective follow-up study, British

Medical Journal, 294, pp. 1377-1380.HILL, S. Y. (1985) The disease concept of alcoholism:

JAMES, W . (1902) The Varieties of Religious Experience(N ew York, Longmans Green) .

K A M M E I E R , M. L. , L U C E R O , R. J. & A N D E R S O N , D . J.

(1973) Events ofcrucial importance during alcoholismtreatment, as reported bypatients. Quarterly Journal ofStudies on Alcohol, 34, pp. 1172-1179.

KiLLiLE A , M. (1976 ) M utual help organisations: interpre-tations in the literature, in: G. CA P LA N & M. KILLILEA

(Eds) Support Systems and M utual He lp: multidiscipU-

nary explanations (N ew York, Grune & St ra t ton) .

L A U N D E R G A N , J. C, S P I C E R , J. W. & K A M M E I E R , M. L .

(1979) Are Court Referrals Effective? Judicial Commit-ment for Chem ical Dependency in Washington CountyMinnesota (Center City, MN, Hazelden) .

LAUNDERGAN, J. C. (1981) The Outcomes of Treatment:

the re lationship betwe en previous treatm ent and clientoutcome (Center Ci ty , M N , Haze lden) .

L A U N D E R G A N , J. C. (1982) Easy Does hi AlcoholismTreatment Outcomes, Hazelden and the MinnesotaModel (Center Ci ty , M N , Haze lden).

L E A C H , B. & N O R R I S , J. L. (1977) Factors in thedevelopment of A lcoholics A nonymous (AA), in: B.KissiN & H. BEGLEITER (Eds) The Biology of Alcohol-ism, Vol. 5, Treatment and Reh abilitation of the Ch ronicAlcoholic, ch. 11, pp. 441-543 (N ew York, Plenum).

LEVY, L . H. (1979) Processes andactivities in groups, in:

M. A. L E I B E R M A N , L. D . B O R M A N , P. A N T Z E et al. (Eds)

Self Help Groups for Coping with Crisis, ch. 11, pp.

234-271 (San Francisco, Jossey-Bass).

LiEBERMAN, M. A. (1979 ) A nalyzing change mechanismsin groups, in: M. A. L I E B E R M A N , L. D. B O R M A N , P.

A N T Z E et al. (Eds) Self Help Group for Coping withCrisis, ch . 10, pp. 194-233 (San Francisco, Jossey-Bass).

LiEBERMAN, M. A., BORMAN, L. D., A N T Z E , P. et al.(1979) Self Help Groups for Coping with Crisis (San

Francisco, Jossey-Bass).M A C K E N Z I E , A., F U N D E R B U R K , F. R., A L L E N , R. P. &

S T E F A N , R . L. (1987) The characteristics of alcoholics

frequently lost to follow-up. Journal of Studies on

Alcohol, ii,,^^. 119-123.

M A D D E N , J. S. (1984) A Guide to Alcohol and Drug

Dependence (Bristol , W right) .M A H O N , T. (1973) Therapy or brainwashing. Drugs &

Society, 2, pp. 7-10.

M o o s , R. & BLISS, F . (1978 ) D ifficulty of follow-up and

outcome of alcoholism treatmen t. Journal of Studies on

Alcohol, 39, pp. 473-490.O G B O R N E , A . C. & M E L O T T E , C . (1977) An evaluation of a

therapeutic community for former drug users, British

Journal of Addiction, 72, pp. 75-82.

O R F O R D , J . & E D W A R D S , G . (1977) Alcoholism, Institute of

Psychiatry, M audsley M onographs No. 26 (O xford

U niversity P ress) .R O B I N S O N , D . (1978) S elf help groups, British Journal of

Hospital Medicine, 20, pp. 306-311.

R O B I N S O N , D . (1979) Talking Out of Alcoholism (London,

Croom Helm).

R ossi , J . J., STACH, A . & BRADLEY, N . J. (1963) Effects of

treatment of male alcoholics in a mental hospital.

Quarterly Journal of Studies on Alcohol, 24, pp. 91-98.

SPICE R, J. & B A R N E T T , P. (1980) Hospital-based ChemicalDependency Treatment: a mode l for outcome evaluation



748 Christopher C. H.Cook

Apples and Oranges. A Comparison of Inpatient and

Outpatient Programmes (Center City, MN, Hazelden) .

S T A N T O N , M . D . (1979) Family treatment approaches to

drug abuse problems: a review. Family Process, 18, pp.

251-280.

T A Y L O R , C , B R O W N , D. , D U C I U T T , A., E D W A R D S , G. ,

OPPENHEIMER, E. & SHEEHAN, M. (1985) Patterns ofoutcom e: drinking histories over 10 years among a groupof alcoholics, British Journal of Addiction, 80, pp.

45-50.T IE BOUT , H. M. (1944) T herapeutic mechanisms of

A lcoholics Anonymous, American Journal of Psychiatry,

100, pp. 468-473.T lEBOtrr, H. M. (1961) A lcoholics A nonymous: an

experiment of nature. Quarterly Journal of Studies on

Alcohol, 22, pp. 52-68.W I L L I A M S , T. , S C H R O E D E R , M. R., S P I C E R , J., LA LINDER-

GAN, J. C. & JONES, D . R. (1981) Families in Crisis (AStudy of the Hazelden Family Programme) (CenterCity, MN, Hazelden) .

YALOM, I. D. (1975) The Theory and Practice of GroupPsychotherapy, 2nd edn (New York, Basic Books).



Documents

The Minnesota Model in the Management of Addiction BrJAdd 1988