By: Valerie J.
Slaymaker, Kirk J. Brower and Mike Crawford
Several interesting and informative publications document the historical development of the Minnesota Model of treatment. Interested readers are referred to Anderson (1981), Anderson et al. (1999), McElrath (1987), Spicer (1993), and White (1998) for thorough descriptions from which the following early historical material was gleaned.
Several interesting and informative publications document the historical development of the Minnesota Model of treatment. Interested readers are referred to Anderson (1981), Anderson et al. (1999), McElrath (1987), Spicer (1993), and White (1998) for thorough descriptions from which the following early historical material was gleaned.
The Minnesota Model’s beginnings can be traced to a state psychiatric hospital in
Willmar, Minnesota in the early 1950s where Nelson
Bradley, a Canadian physician, and Dan Anderson, a psychologist, began to
revolutionize addiction
treatment. At the time, alcoholics (or ‘inebriates’ as they were known) were
detoxified and institutionalized with the chronically mentally ill. Many languished. In
an effort
to learn more about alcoholism, Bradley and Anderson began to attend local
A.A. meetings that were springing up around the state. They quickly developed
personal relationships
with A.A. attendees who urged the pair to examine two new and innovative treatment
programs in Minnesota that were based on the A.A. philosophy: Pioneer House and
Hazelden.
Pioneer House was founded in 1948 in an effort to treat alcoholic men with families
and thereby reduce the cost of welfare payments. The
program was based entirely on the A.A. philosophy, involved lectures and informal
discussions, and residents were required to complete the first five of the Twelve Steps
before leaving. Almost simultaneously, Hazelden was founded in 1949 as an
alcoholism treatment
center for professionals. Following on the A.A. philosophy, the program
included lectures, groups, informal discussions and recreational activities.
Based on what they learned from these programs, Bradley and Anderson developed
a comprehensive philosophy of alcoholism treatment. They shunned the traditional
psychoanalytic approach
and instead conceptualized alcoholism as a biological, psychological, social,
and spiritual disease
that was a primary, progressive, and chronic illness. To best address these multiple
dimensions, Bradley and Anderson convened a group of professionals into a
multidisciplinary team of physicians, psychologists, nurses, social workers, and spiritual
care providers. They turned traditional treatment on its head by separating
alcoholics from
the mentally ill, unlocking the doors, and bringing in recovering alcoholics to
interact with the patients. For the first time, recovering people obtained paid positions
as counselors
and participated fully on the treatment team of professionals.
In the 1960s, Bradley and colleagues left Willmar State Hospital while Anderson
accepted a position at Hazelden where he later became
President. It was at Hazelden that the Minnesota Model continued to take shape and grow. Eventually, a cohesive
model of alcoholism treatment emerged and is known even today as the ‘Minnesota
Model.’ The
Minnesota Model has developed into a comprehensive, evidence-based, integrated
treatment strategy that recognizes addiction as a chronic biopsychosocial and
spiritual disease
oftentimes complicated by other medical and psychiatric disorders. Treatment is approached in
a holistic
way, working with mind, body and spirit as components of a healthy life.
Consistent with the model’s origins at Willmar State Hospital, treatment is
delivered by
a team of professionals including substance abuse/ addiction counselors, nurses,
physicians, psychologists and psychiatrists, spiritual care professionals, and
fitness and
recreation specialists.
Abstinence from alcohol and drugs is the goal for ongoing recovery from substance dependence. Consistent with early Hazelden programming, the Twelve Steps are a foundation and guideline for living and are fully integrated into the treatment process and care plan. The steps are an integrated core of the program, applied systematically, that provide a framework to examine substance dependence, mental health, physical health, emotional wellbeing, relationships, spirituality, and more. Cognitive behavioral strategies are consistently employed to identify and restructure the ‘‘stinkin’ thinkin’’ associated with substance use. Contrary to its image as a ‘‘confrontational’’ approach, the model emphasizes treating all patients with dignity and respect. To this end, ‘‘hot seat’’ or other confrontational methods are not implemented. Instead, motivational enhancement approaches are used to facilitate problem recognition and subsequent engagement in treatment.
Programming consists of structured activities including thorough clinical assessment
and evaluation, individual counseling, group
therapy, and peer interaction. Care is tailored to the individual and may involve specialty
groups such as relapse
prevention, anger, eating issues, dual disorders, women’s issues, men’s issues,
assertiveness, Twelve Step group study,
trauma survivors, and other topics. To address co-occurring disorders, integrated mental health care is
provided and may involve specialized assessments (e.g. gambling, post-traumatic
stress disorder, ADHD),
therapy, and medication management. Motivational lectures by clinical staff and alumni
educate clients
on a broad range of topics including psychological, medical, social, spiritual
issues, and Twelve-Step work. Family and parent programs are also available.
Treatment is provided in
residential, outpatient, extended care and halfway house settings.
As the model developed at Hazelden in the 1960s, word quickly spread about the new
approach to addiction treatment. Anderson, Hazelden alumni, visiting
professionals and
Hazelden’s own publishing activities facilitated the spread of information. As a
result, Hazelden expanded and community and hospital based treatment programs emulating the Minnesota
Model sprang up around the country. As the years progressed, treatment centers
across the country adopted a
Minnesota Model approach to treatment, basing programming on the principles of the Twelve-Steps of A.A. Due
to a lack of nationwide best practices or governance, the quality and type of
treatment provided from one center
to another varied greatly.
Boundaries between Minnesota Model care and what became known as ‘milieu
therapy’ were sometimes blurred. Because use of
the descriptor ‘Minnesota Model’ is widespread and unregulated, the Hazelden Foundation has recently begun to
refer to its model and philosophy of treatment as the ‘Hazelden Model,’ nomenclature
originally used in the 1960s (Anderson et
al., 1999). Within the research arena,
programs offering Minnesota Model care are sometimes referred to as Twelve-Step based
programs. Unfortunately, this tends to confuse comprehensive, professionally
delivered, integrated treatment with the mutual- and self-help provided in A.A.
Twelve-Step-based
professional treatment is not A.A.; conversely, A.A. is not Twelve-Step-based treatment. Care must be made to
distinguish the two when searching and reviewing literature related to outcomes.
To confuse the matter even further, Twelve-Step-based treatment (a.k.a. Minnesota or
Hazelden Model) was manualized in the early-1990s in order to be subjected to a
multi-site, highly
controlled study called Project MATCH. The resulting manualized program was titled, ‘Twelve-Step Facilitation’
(TSF; Nowinski et al.,
1992). The authors sought the assistance of several Hazelden employees,
including Dan Anderson
himself, who provided their expertise, suggestions and feedback during the
development of the TSF manual.
While the manualization of Twelve-Step-based
professional treatment helped to address fidelity and issues of variation from one
center to another in the course of
a clinical trial, Twelve-Step Facilitation is sometimes mistaken as an entirely
different treatment approach than
the Minnesota or Hazelden Model. Addressing this issue, Nowinski & Baker (2003), authors of the TSF
manual for Project MATCH, note that TSF is ‘‘. . . informed
by and consistent with what is more generally known as the Minnesota Model .
. .’’ (p. xxviii) and add ‘‘.
. . TSF, as well as the treatment program
offered at
Hazelden, are well-developed, structured approaches, with specific goals and
objectives’’ (p. xxix). When reviewing literature, it is helpful to keep in mind that the
phrases
‘‘Twelve-Step-based treatment’’ and ‘‘Twelve-Step Facilitation’’ are used
interchangeably with ‘‘Minnesota’’ or ‘‘Hazelden Model’’ treatment programming.
The Minnesota Model of care is historically one of the most commonly used treatment
approaches in the United States (Fuller, 1989;
Institute of Medicine, 1990), and its use has spread to other parts of the world (Cook, 1988; Keso & Salaspuro, 1990).
Because this complex model is composed of multiple components, the extent to which
it has been fully
incorporated into treatment programs around the world has not been
measured. However, data from the National
Treatment Improvement Evaluation Study (Center for Substance Abuse Treatment, 1997)
provide information on the utilization of several of its components. In a
survey of 519 outpatient, residential, and specialty care facilities
receiving grant funding from the Centers for Substance Abuse Treatment in the early
1990s, 71%
of programs indicated they placed ‘moderate’ to ‘great’ therapeutic emphasis
on the Twelve Steps. Other components included supportive individual counseling
(89%), supportive group
counseling (86%), and spirituality (51%), among others.
Due to advances in research on this model, its position as an effective treatment for
alcohol dependence is recognized at the national level. Perhaps the strongest
commendatory statement has come from the National Institutes of Health. In the 10th special
report to the U.S. Congress in 2000, the National Institute on Alcohol Abuse and
Alcoholism (2000b)
recognized the empirical support for Twelve-Step-based professional treatment and
concluded, ‘‘Professional treatments based on 12-step approaches can be as effective
as other therapeutic approaches and may
actually achieve more sustained abstinence’’ (p. 448). The Department of Veterans
Affairs, in their detailed
clinical practice guidelines for the management of substance use disorders,
specifies, ‘‘Consider addiction-focused psychosocial interventions with the most consistent empirical support,’’ and includes
Twelve Step-based professional treatment in the list of equally acceptable interventions for
the treatment of substance dependence (Veterans
Health Administration Office of Quality & Performance, 2001).
The Minnesota Model’s efficacy as a treatment approach for youth is also recognized.
The Substance Abuse and Mental Health Services
Administration’s Center for Substance Abuse Treatment provides direction on
delivering Twelve-Step based treatment to adolescents in Treatment
Improvement Protocol #32: Treatment of adolescents with substance use disorders
(U.S. Department of Health and Human Services, 1999).
References
Peter
Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in
Psychiatry, Cambridge University Press 2008.
Read Also
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Treatment of co-occurring psychiatric and substance use disorders
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