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

The Minnesota Model in the Management of 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, methodological criticisms of these studies indicate the need for further research incorporating control or 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 number of therapeutic elements known or suspected to be of value in the management 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

Despite extravagant claims of success, there appear to be few serious follow-up studies of patients graduating from Minnesota-type programmes. Most information exists for the Hazelden Foundation, which has gone to some lengths both to evaluate its own programmes, 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 Hospital In 1955 and 1956 all patients living in rural areas
* The first part of this review was published in British Journal of Addiction (1988) 83, pp. 625-634 Qune issue).

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 agencies 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 conducted 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 eight male alcoholics, representing a 12% sample of all admissions, were traced after a mean follow-up

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Christopher C. H. Cook (ii) Hazelden Laundergan (1982), evaluated discharges over a 2.5 year period from 1973 to 1975. Gilmore (1985) summarizes data from 1978, 1980 and 1983. (a) 1973-75: Methodology. All patients who gave consent, 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 somewhat by definition of a 'study population' on the basis of three inclusion criteria: (1) Completion of treatment by successfully meeting the programme objectives and being discharged 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 problems 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, withholding of consent and not being sent a form (through error or design) as well as failure in tracing or 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 dependent. However, 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 sociodemographic characteristics (high socio-economic status, employment, marital status, etc.), which he admits are known indicators of good prognosis, but his evidence that they are not infiuential is based

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 co-operating agencies outside the state of Minnesota. The authors present some evidence 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 not assessed); 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 longest period of abstinence by 6 months or more. However, 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 within self, sibling relations, budgeting, employment, 'harmony at work', and income. Patients continuously abstinent since discharge showed improvement 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 behavioural improvement occurred in all groups, regardless of drinking behaviour. While these studies show valuable and impressive results, they are methodologically deficient. No account was taken of any other treatments obtained by patients between discharge and follow-up. No control or comparison group of patients was included. (A comparison of patients who 'dropped out' with those who completed treatment showed a statistically insignificant advantage for the latter group in improved behavioural indices. Drinking data were not reported for this comparison.) The 'behavioural areas' examined by Rossi, Stach & Bradley appear highly subjective and operational definitions of them are not given.

The Minnesota ModelPart II upon comparison between court referrals and other patients at Hazelden. Other differences between these groups (e.g. motivation) may have offset any effect of socio-demographic factors. (3) It is difficult to believe Laundergan's argument that the 11.5% of patients who fail to attend after arranging admission are insignificant as a source of sampling bias. (4) Laundergan himself remarks that exclusion from follow-up of patients dropping out after less than 5 days of treatment 'may be criticized as an intentional sampling bias'. It is therefore apparent that the 'study population' represents a select group of patients with not inconsiderable commitment to treatment. Adjustment is made for deaths, untraced patients, and return during follow-up for further treatment. Of these groups, 50%, 75% and 100% respectively are considered as treatment failures. Michael Patton, in an appendix to Laundergan's book, comments that the questionnaires are representative of patients who complete treatment, but not of the total population since a high proportion of non-responders dropped out of treatment. Acceptable figures are presented for reliability (internal consistency and response stability over time) as well as validity (based on comparison with questionnaires completed by 'significant others'). These figures are only applied to drinking data and the validity figures strictly apply only to the 1166 patients (out of a study population of 1652) for whom significant others returned questionnaires. The psycho-social outcome measures employed by Laundergan (with the exception of AA attendance) were not subject to the same reliability and validity studies as drinking behaviour. Similar psycho-social indices of outcome were used in a study of the Hazelden family programme (Williams et al, 1981). One of these indices, 'General Physical Health', was rated as 'Much Improved' or 'Somewhat Improved' by 45% of participants in the latter study. These subjects were family members of alcoholics or addicts and not patients themselves (although an unspecified minority recognized a chemical dependency problem in themselves as a result of the programme). It is difficult to see how such a large improvement in physical health could genuinely be mediated. Respondent bias may, therefore, account for a significant percentage of apparent improvement in at least one of these measures. The study may also be criticized for the employment of self report questionnaires rather than interview, and for the lack of a comparison group of

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untreated patients or of patients randomly assigned to alternative treatment centres. Drinking behaviour at follow-up is categorized relative to pre-treatment levels. Absolute, quantitative, estimates of alcohol/ drug intake or dependence pre- and post-treatment are not given. (b) 1973-75: Outcome. Outcome in terms of drinking behaviour is summarized in Table I. Incomplete and unusable questionnaires reduce the number of patients in each category. The most complete estimate provided by Laundergan, is the 'adjusted category' where deaths, untraced patients and patients re-entering treatment are allocated, in the proportions described above, to 'abstinent' or 'not-improved' outcome. Even this set of figures omits 402 patients, described as 'excluded from the study'. Presumably these represent the 268 patients who denied permission for follow-up and the 134 to whom the forms were 'not sent', at 12 months after treatment. It is difficult to understand why these patients were not allocated to outcome groups in the same way as untraced patients (i.e. 75% to 'not improved' and 25% to 'abstinent'). If such a calculation is made, this produces a combined abstinent/improved outcome of 47% (see Table 1). Consideration was also given in this study to use of drugs other than alcohol during follow-up. Data is limited since patients misusing only drugs other than alcohol were excluded from the study population. Ninety-three cases are also missing from the study population due to lack of drug use information. However, 69.7% of the remainder of the study population (w=1153) were abstinent from drugs other than alcohol, 25.4% were 'improved' and 4.9% were 'not improved'; 40.9% were abstinent from drugs and alcohol. Analysis of the 442 patients misusing drugs and alcohol at the time of admission is summarized in Table 2. Laundergan's 'adjusted' column appears to represent an equal allocation of patients giving no response between the 'abstinent', 'improved' and 'not improved' outcome categories. This is not discussed in the text and appears incongruous with the earlier 75%: 25% division between 'not-improved' and 'improved' when discussing the untraced patients' drinking behaviour at follow-up. A similar allocation here would result in an overall abstinent/improved outcome of 59.3% for alcohol use and 73.1% for drug use (see Table 2). Figures are not provided to allow calculation of total abstinence from drugs and alcohol in this group.

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Christopher C. H. Cook Table 1. Outcome at 1 year after Treatment for Patients Discharged from Hazelden between June 1, 1973 and December 31, 1975 Abstinent Improved 17.6 18.3 18.0 10.3 Not improved 32.4 30.8 27.4 50.4

n
All patients responding Patients completing treatment Study population Adjusted for deaths, untraced patients and patients re-entering treatment* Calculated, adjusted, outcome for all discharges* * See text. Table 2. Alcohol and Drug Use at 1 year Pollow-upfor Patients with Alcohol and Drug Use Problems at Admission to Hazelden (and discharged June 1 to December 31, 1975). Laundergan (1982) Adjusted* (%) 57.1 14.0 28.9 Re-adjusted* (%) 48.9 10.4 40.7 1899 1598 1246 3236 (402 still excluded from study) 3638 50.0 50.9 54.6 39.3

37.8

9.2

53.1

n
Alcohol Use Abstinent Improved Not improved No response Total Drug Use Abstinent Improved Not improved No response Total * See text. 188 46 95 113 442

(%) 42.5 10.4 21.5 25.6

122 175 41 104 442

27.6 39.6 9.3 23.5

36.1 51.8 12.1

33.5 39.6 26.9

Stability of drinking behaviour over time is also in that study responded to follow-up. On the basis considered. The figures are complicated by artifacts that patients who are difficult to trace may have a of questionnaire categories and an increasing num- poor outcome (Moos & Bliss, 1978; MacKenzie et ber of non-responders. However, it is clear that the al., 1987), it seems unwise to conclude that drinking abstinent group is more stable than the other two after discharge facilitates eventual abstinence. It is outcome categories and there is some evidence for clear that longer follow-up periods are required in increasing stability of the group as a whole over future studies. time. Of those patients who changed outcome Psycho-social indicators of outcome show that categories between 4 and 8 months post discharge, 'ability to handle problems', 'self image functionsimilar numbers moved in the directions of more or ing', and 'general enjoyment of life' were improved less drinking. However, of those who moved categ- at 1 year follow-up in the majority of patients in all ories between 8 and 12 months, 61.8% moved in the outcome groups. Improvement was greater in 'abstidirectionof more drinking, and 38.1% moved in the nent' than 'improved' patients and greater in direction of less drinking/abstinence. Another study 'improved' than 'not improved' patients. These of Hazelden patients (Brissett et al., 1980) sug- findings raise two issues. First, the authors apply gested that those who drank in the 1.5 years this as evidence against a possible return to'normal' following treatment may still have a good outcome drinking (in combination with evidence for instabilat 3.5 years. However, only 149 out of 323 patients ity of reduced drinking behaviour over time).

The Minnesota ModelPart II 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 treatment 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 improved 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. All patients appear to have gained some therapeutic benefit from their admission in psycho-social terms. These achievements are not to be ignored, and they warrant further research. (c) 1978, 1980, 1983. Methodology of the evaluation conducted 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. However, her figures exclude patients to whom questionnaires were not sent (because of discharge before 5 days of treatment, transfer to another treatment centre, refusal to participate in foUow-up and death), patients who failed to respond by mail or telephone, and patients who made inadequate replies. This is justified by the author on grounds 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 among non-respondents. It seems not unreasonable to consider dividing the patients unaccounted for on a 75%: 25% 'poor':'good' outcome as described in

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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). It seems a pity that impressive figures have been apparently 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 patients 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 improvement 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. Williams et al. (1983) describe a study of participants in the Hazelden family programme in 1979. Programme activities were rated as helpful at 6 month foUow-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 & Kammeier (1979) compared outcome of court referrals and other patients admitted to Hazelden over a 12-month period during 1974-5. Despite sociodemographic differences, 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 the Hazelden model (Spicer & Bamett, 1980). Criticisms of the methodology employed are similar to those above. Thus, 1 year follow-up of patients admitted during 1977 revealed that 77.8% were

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Christopher C. H. Cook

Table 3. Hazelden Outcome Figures for 1978, 1980, 1983 with Re-calculation to Estimate Outcome of Patients Unaccounted Por 1978 Total patients discharged Study period/sample Total study discharges Total questionnaires not sent/not returned Inadequate replies Alcohol data Dmg data Gilmore, 1985 Alcohol Use 'Good' outcome (%)' 'Poor' outcome (%)^ Drug Use 'Good' outcome (%)' 'Poor' outcome (%)^ 89 11 96 4 1558 Full year 1278 599 35 18 Adjusted* Gilmore, 1985 91 9 96 5 1980 1579 8 months (alternate patients) 448 144 18 28 Adjusted* Gilmore, 1985 97 4 100 1 1983 1687 3 months 437 169 20 73 Adjusted*

63 37 68 32

67 33 69 32

66 35 59 42

' 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 months. 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 successfully completed treatment. Treatment drop-outs are presumably not included and no indication is given of how many patients actually do complete treatment, 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 March-April, 1985 of patients who had successfully completed 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 'employment' 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 described and neither are the socio-demographic or drug/alcohol use patterns of the pre-treatment patient population (except that 61% were unemployed). Further comment is therefore withheld, except to

(v) Comparisons with other Treatment Centres A true comparison of the results of the Minnesota Model with those of other treatment programmes is not possible until a prospective study employing random allocation of patients is conducted. Comparison 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 treatment and advice given to alcoholics revealed 26 patients with a 'good' outcome at 2 years, out of 65 patients for whom complete follow-up data were available (from an original sample of 100). There was no significant difference between outcome following 'treatment' or 'advice'. Ten year follow-

The Minnesota ModelPart II up of this group showed that 18 had died, 27 achieved 'good' outcome, 32 were drinking in an 'uncontrolled' way, and 13 were of'equivocal' status (Edwards et al., 1983). However, the majority of these patients fiuctuated between abstinence, 'troubled', and 'controlled' drinking (but mainly the former two of these three categories). Only 20% were consistently drinking in a 'troubled' way, 4% were consistently abstinent, 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 & Melotte (1977) traced 87 out of the first 100 patients admitted to a British 'Concept' based therapeutic community. Seventeen per cent were abstinent, 12% sporadically using drugs, 23% regularly 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 Family', 'Quadrant', 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. Thirty-nine per cent were not using other illegal drugs. Only patients from Quadrant were significantly 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 criminal convictions and were more likely to be employed or at school at follow-up compared with the withdrawal 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.

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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; Kammeier, 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) studied 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 spirituality was a profound enough experience for them to comment about it frequently. These findings provide an interesting indication of what patients at Hazelden subjectively felt was important in contributing to their recovery. However, this does not necessarily mean that these items were the ones which exerted any therapeutic effect that was obtained. Although confidential, the questionnaires 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 questionnaire, it is possible that different patients may have understood the questions differently. For example, some may have reported items of emotional importance, and others items which they considered therapeutically important. (b) Laundergan (1982) conducted a more elaborate study based upon the follow-up questionnaires used in his outcome studies. At 12 months post discharge, patients returned a self report questionnaire which included data on post-treatment alcohol/drug use, post-treatment AA attendance, a range of indicators of social/psychological function-

How Does it Work? Therapeutic Mechanisms in the Minnesota Model A useful overall review of the drug abuse treatment

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Christopher C. H. Cook 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 select group 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) The questionnaires employed were of a selfreport 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) Alcohol/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 relationship is not proven for any correlations demonstrated. Measures of treatment 'helpfulness' or 'effectiveness' were retrospective, subjective, and unsupported by any objective evaluation. Confounding variables such as motivation were not excluded.

ing, and a rating of how helpful/effective treatment 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 findings: (i) Post-treatment abstinence at 12 month follow-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 treatment 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 was predicted in the regression analysis by increased 'Higher Power contact' (8.48% of the variance), favourable rating of group-related treatment activities (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 posttreatment 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 the variance 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 Power and AA attendance. This relationship is important 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 improvement" [his emphasis]. He goes on to say that, "The importance of increased prayer and meditation in the post-treatment recovery process strongly reinforces the spiritual emphasis of the Minnesota Model treatment approach and the way that the spiritual part of recovery complements frequent AA attendance with its direct recovery benefits."
' Increased post-treatment prayer and meditation.

(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 Anonymous and Narcotics Anonymous. As an important element of the Minnesota Model, it may be argued that AA and NA provide the therapeutic ingredient responsible for its success. Unfortunately, despite a widely held clinical impression of the value of AA, reviews of the literature suggest that its efficacy remains unproven. This is largely owing to the enormous methodological obstacles (Bebbington, 1976; Glaser & Ogborne, 1982). Similarly, further research is needed concerning the therapeutic mechanisms of AA/NA. Edwards (1987) identifies a list of essential processes through which AA may operate. These include: 'coherent fiexible ideas' (an ideology), 'an action programme' (the 12 steps), 'rewards of sobriety', and, 'possibility of recovery'. Alibrandi (1985) identifies 100 activi-

The Minnesota ModelPart II 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 awakening'. In a later paper (Tiebout, 1961) he identifies four hypothetical elements to the effective psychological events which make possible the maintenance of sobriety; 'hitting bottom', 'surrender', 'ego reduction' and 'maintenance of humility'. AA is, of course, a part of the self help movement; 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 characteristics of self-help groups described by Killilea (1976): 'common experience of members', 'mutual help and support', 'the helper principle', 'differential 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 Minnesota programme by use of ex-addict/ex-alcoholic lay counsellors. Levy (1979) identifies behavioural and cognitive processes which provide an explanation 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 tenets of AA: the nature of alcoholism, 'hitting bottom', the Higher Power, the moral inventory and 'twelfth-stepping'. Finally, he describes three experiences of self characteristic of alcoholism (the omnipotent self, the embattled self

743

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) The 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 which are beyond his conscious effort. It thus counteracts the three alcoholic characteristics described 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 the disease concept of alcoholism (Davies, 1974; Douglas, 1986). However, the benefits described above are real enough even if it is theoretically invalid. Many of the suggestions that it may be countertherapeutic 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 applicable 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 curative 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). Blume (1977), in a more recent review, lists seven advantages of such counsellors:

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Christopher C. H Cook The above elements of the Minnesota model 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 as being 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.

(i) they provide a 'living example of hope' (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 exalcoholics offer a special expertise which cannot be provided by psychiatrists or other professionals. The present author would add also the advantage that 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 histories 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 approaches 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. However, there is doubt as to the value of family therapy in alcoholism, and divided opinion on exactly how families should best encourage an alcoholic to seek ueatment (Madden, 1984).

(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 religious revivalism and thought reform share important common features with psychotherapy (Frank, 1961). (a) Conversion. William James defines conversion 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 its firmer 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 achieve abstinence through involvement with AA (Tiebout, 1944; Tiebout, 1961). C. G. Jung believed

The Minnesota ModelPart II 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 an unstable condition of disrupted 'group-system relationships', induced in this case by the psycho-social (and medical) complications of drug/alcohol abuse. 'Conversion', as described above, is seen as adoption by the subject of AA philosophy and standards. 'Cult formation' is represented by continued membership of AA (or NA) confirming the individual's new found security. (b) Persuasion. Mahon (1973), discussing the concept based therapeutic communities (and not the Minnesota model), shows that these institutions closely parallel the techniques of're-socialization' 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 of'resocialization' 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.

745

forces (the 'Higher Power') which are contingently benevolent. The relationship between persuader and sufferer is characterized by investment of great effort on the part of the former to induce change in the attitudes of the latter. There is characteristically emotional arousal, often to the point of exhaustion, but occurring in a context of hope and potential support from the persuader (and/or his group). The 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 representing the 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 prerequisite for susceptibility to these procedures. He concludes this section of his book by stating that: "Thought reform and revivalism highlight the importance of a person's immediate social milieu in sustaining or shaking his self image and world view. They also underline the function 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 attitude modification." Thus Frank's comparative study of psychotherapy, religious revivalism and thought reform enables us to postulate that the 'religious' and dogmatic aspects of the Minnesota ideology combine 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 abstinence from mood altering chemicals.

(c) "Persuasion and healing". Jerome Frank (1961) considers elements common to the influencing processes of religious revivalism, thought reform, 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 Minnesota Model. The 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 (in this case the therapist, counsellor, or AA 'sponsor') and his group (the treatment centre or AA) represent an 'infallible', comprehensive and persuasive world view, incorporating supremely powerful

Lessons from the Minnesota Model The Minnesota Model illustrates well the value of a 'comprehensive' or 'multi-professional' approach to

746

Christopher C. H. Cook community, utilizing lay therapists who are themselves 'in recovery' from alcoholism or drug dependence. 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 which are of known or suspected therapeutic value for the treatment of drug/alcohol dependence. Perhaps its most powerful 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 environment of AA/NA are associated 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 may antagonize professionals. However, the present writer hopes to have shown that while some may view this ideology as 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.

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 group therapy, by the emphasis on sharing life histories, by providing written assignments, and by encouraging (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 problem'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 of the 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 treatment 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 is far from 'normal'. However, attendance at AA meetings and socialization 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 occupations in the wider community.

Acknowledgements I am grateful to Dr M. S. Lipsedge and Dr C. Feinmann for their constructive criticism and encouragement during the preparation of this paper.

References
ADLER, H . M . & HAMMETT, Y . B . O . (1973) Crisis,

Conclusions
The 'Minnesota Model' has been shown to refer to a treatment programme for alcoholism and drug dependence, which has a specific ideology related to the 12 steps of AA and NA. It includes a comprehensive and multi-professional approach but the emphasis is that of a self-help therapeutic

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 of
alcoholics anonymous, in: S. ZINBERG, J. WALLACE & S.

B. BLUME (Eds) Practical Approaches to Alcoholism Psychotherapy, 2nd edn, ch. 13, pp. 239-256 (New York, Plenum). ALLISON, M . & HUBBARD, R. L . (1985) Drug abuse

The Minnesota ModelPart II

treatment process: a review of the literature, International Journal of the Addictions, 20, pp. 1321-1345. ANDERSON, D . (1944) The place of the lay therapist in the treatment of alcoholics. Quarterly Journal of Studies on Alcohol, 5, pp. 257-266. ANTZE, P . (1979) Role of ideologies in peer psychotherapy
groups, in: M. A. LiEBERMAN, L. D. BORMAN, P. ANTZE

747

JAMES, W . (1902) The Varieties of Religious Experience (New York, Longmans Green).
KAMMEIER, M . L . , LUCERO, R . J. & ANDERSON, D . J.

(1973) Events of crucial importance during alcoholism treatment, as reported by patients. Quarterly Journal of Studies on Alcohol, 34, pp. 1172-1179. KiLLiLEA, M. (1976) Mutual help organisations: interpretations in the literature, in: G. CAPLAN & M. KILLILEA

et al. (Eds) Self Help Groups for Coping with Crisis, ch. 12, pp. 272-304 (San Francisco, Jossey-Bass).
BALE, R . N . , ZARCONE, V. P., VAN STONE, W . W . , KuLDAU, J. M., ENGELSING, T . M . J. & ELASHOFF, R .

(Eds) Support Systems and Mutual Help: multidiscipUnary explanations (New York, Grune & Stratton).
LAUNDERGAN, J. C , SPICER, J. W. & KAMMEIER, M . L .

(1979) Are Court Referrals Effective? Judicial CommitM. (1984) Three therapeutic communities. A prospecment for Chemical Dependency in Washington County tive controlled study of narcotic addiction treatment: Minnesota (Center City, MN, Hazelden). process and two year follow-up results. Archives of LAUNDERGAN, J. C. (1981) The Outcomes of Treatment: General Psychiatry, 41, pp. 185-191. the relationship between previous treatment and client BEBBINGTON, P . E . (1976) The efficacy of Alcoholics outcome (Center City, MN, Hazelden). Anonymous: the elusiveness of hard data, British LAUNDERGAN, J. C. (1982) Easy Does hi Alcoholism Journal of Psychiatry, 128, pp. 572-580. Treatment Outcomes, Hazelden and the Minnesota BLUMB, S. B. (1977) Role of the recovered alcoholic in the Model (Center City, MN, Hazelden). treatment of alcoholism, in: B. KissiN & H. BEGLEITER (Eds) The Biology of Alcoholism, Vol. 5, Treatment & LEACH, B . & NORRIS, J. L. (1977) Factors in the development of Alcoholics Anonymous (AA), in: B. Rehabilitation of the Chronic Alcoholic, ch. 12, pp. KissiN & H. BEGLEITER (Eds) The Biology of Alcohol545-565 (New York, Plenum). ism, Vol. 5, Treatment and Rehabilitation of the Chronic BRISSETT, D . , LAUNDERGAN, J. C , KAMMEIER, M . L . & Alcoholic, ch. 11, pp. 441-543 (New York, Plenum). BlELE, M. (1980) Drinkers and non-drinkers at three and a half years after treatment: attitudes and growth, LEVY, L . H . (1979) Processes and activities in groups, in: M. A. LEIBERMAN, L . D . BORMAN, P. ANTZE et al. (Eds) Journal of Studies on Alcohol, 41, pp. 945-952. Self Help Groups for Coping with Crisis, ch. 11, pp. BROWN, J. A. C. (1963) Techniques of Persuasion 234-271 (San Francisco, Jossey-Bass). (London, Penguin). DAVIES, D . L . (1974) Alcoholism as a disease [editorial]. LiEBERMAN, M. A. (1979) Analyzing change mechanisms in groups, in: M. A. LIEBERMAN, L . D . BORMAN, P. Psychological Medicine, 4, pp. 130-132. ANTZE et al. (Eds) Self Help Group for Coping with DOUGLAS, D . B . (1986) Alcoholism as an addiction: the Crisis, ch. 10, pp. 194-233 (San Francisco, Jossey-Bass). disease concept reconsidered. Journal of Substance LiEBERMAN, M. A., BORMAN, L. D., ANTZE, P. et al. Abuse Treatment, 3, pp. 115-120. (1979) Self Help Groups for Coping with Crisis (San DUMONT, M. p . (1974) Self-help treatment programs, Francisco, Jossey-Bass). American Journal of Psychiatry, 131, pp. 631-635.
EDWARDS, G . , DUCKITT, A., OPPENHEIMER, E . , SHEEHAN, MACKENZIE, A., FUNDERBURK, F . R . , ALLEN, R . P. &

M. & TAYLOR, C . (1983) What happens to alcoholics?. Lancet, ii, pp. 269-271. EDWARDS, G . (1987) Alcoholics Anonymous, in: The Treatment of Drinking Problems, 2nd edn, ch. 16, pp. 257-265 (Oxford, Grant Mclntyre). FRANK,J. (1961) Persuasion fie/fea/iw^ (Baltimore,Johns Hopkins Press). FREUDENBERGER, 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 Treatment Program: 1985 profile and 'Patient outcome' (Center City, MN, Hazlden). GLASER, F . B . & OGBORNE, A. C. (1982) Does AA really work?, British Journal of Addiction, 77, pp. 123-129. GLATT, M . M . (1976) Alcoholism disease concept and loss of control revisited, British Journal ofAddiction, 71, pp. 135-144. GLATT, M . M . (1986) Kick heroin [book review], BriltsA Journal of Addiction, 81, p. 839.

STEFAN, R. L . (1987) The characteristics of alcoholics frequently lost to follow-up. Journal of Studies on Alcohol, ii,,^^. 119-123. MADDEN, J. S. (1984) A Guide to Alcohol and Drug Dependence (Bristol, Wright). MAHON, T . (1973) Therapy or brainwashing. Drugs & Society, 2, pp. 7-10. Moos, R. & BLISS, F . (1978) Difficulty of follow-up and outcome of alcoholism treatment. Journal of Studies on Alcohol, 39, pp. 473-490.
OGBORNE, A. C. & MELOTTE, C . (1977) An evaluation of a

therapeutic community for former drug users, British Journal of Addiction, 72, pp. 75-82. ORFORD, J. & EDWARDS, G . (1977) Alcoholism, Institute of Psychiatry, Maudsley Monographs No. 26 (Oxford University Press). ROBINSON, D . (1978) Self help groups, British Journal of Hospital Medicine, 20, pp. 306-311. ROBINSON, D . (1979) Talking Out ofAlcoholism (London, Croom Helm). Rossi, J. J., STACH, A. & BRADLEY, N . J. (1963) Effects of Gossop, M., GREEN, L . , PHILLIPS, G . & BRADLEY, B . treatment of male alcoholics in a mental hospital. (1987) What happens to opiate addicts immediately Quarterly Journal of Studies on Alcohol, 24, pp. 91-98. after treatment: a prospective follow-up study, British SPICER, J. & BARNETT, P. (1980) Hospital-based Chemical Medical Journal, 294, pp. 1377-1380. Dependency Treatment: a model for outcome evaluation HILL, S. Y. (1985) The disease concept of alcoholism: (Center City, MN, Hazelden). a review. Drug & Alcohol Dependence, 16, pp. 193SPICER, J., NYBERG, L . R . & MCKENNA, T . R . (1981) 214.

748

Christopher C. H. Cook
Alcoholics Anonymous, American Journal of Psychiatry, 100, pp. 468-473. TlEBOtrr, H. M. (1961) Alcoholics Anonymous: an experiment of nature. Quarterly Journal of Studies on Alcohol, 22, pp. 52-68.
WILLIAMS, T . , SCHROEDER, M . R . , SPICER, J., LALINDER-

Apples and Oranges. A Comparison of Inpatient and Outpatient Programmes (Center City, MN, Hazelden). STANTON, M . D . (1979) Family treatment approaches to drug abuse problems: a review. Family Process, 18, pp. 251-280.
TAYLOR, C , BROWN, D . , DUCIUTT, A., EDWARDS, G . ,

OPPENHEIMER, E . & SHEEHAN, M . (1985) Patterns of

outcome: drinking histories over 10 years among a group of alcoholics, British Journal of Addiction, 80, pp. 45-50. TIEBOUT, H . M . (1944) Therapeutic mechanisms of

GAN, J. C. & JONES, D . R. (1981) Families in Crisis (A Study of the Hazelden Family Programme) (Center City, MN, Hazelden). YALOM, I. D. (1975) The Theory and Practice of Group Psychotherapy, 2nd edn (New York, Basic Books).