The Minnesota Model for Treatment — Rationale


Description of the counselling approach as used by premium priced primary rehabilitation centres worldwide:





1.1 General description of approach



It was developed by the University of Minnesota and is typically characterized by a thorough and ongoing assessment of all aspects of the addict and of multimodal therapeutic approaches. Its is used by the majority of rehabilitation centres worldwide including the most well known in South Africa. It includes group and individual therapy, family education and support, and other methods. A multidisciplinary team of professionals (e.g., counsellor, psychologists, nurses) plan and assist in the treatment process for each client. Each member of the team meets individually with the client to conduct an interview, review the client's test results, and review the questionnaire that the client completes. After the addict is seen by each team member, the team meets without the client to discuss the findings and form a treatment plan that includes individualized goals and objectives. The assumption is that abstinence is the prerequisite. Treatment provides tools and a context for the client to learn new ways of living without alcohol and other drugs. This type of treatment can be employed on an inpatient or outpatient basis. The philosophy of the Minnesota Model is based on Alcoholics Anonymous (AA). The patient does need to be able to read and write and so this does pose a major problem in dealing with the masses of addicts and alcoholics in South Africa.


1.2 Goals and objectives of approach


The primary goal is lifetime abstinence from alcohol and other mood-altering chemicals and improved quality of life. This goal is achieved by applying the principles of the 12-step philosophy, which include frequent meetings with other recovering people and changes in daily behaviours. The ultimate goal is personality change or change in basic thinking, feeling, and acting in the world. Within the model, this change is referred to as a spiritual experience.


1.3 Theoretical rationale/mechanism of action


This approach works by changing an addict's beliefs about his or her relationship to others and to self. This changed perspective occurs by attending meetings, by self-reflection, and by learning new coping skills. Through this process, the addict's understanding about himself or herself in relationship to the self and to others is transformed.


1.4 Agent of change


The main agent of change is group affiliation and practice of behaviours consistent with the 12 steps of AA. The treatment assignments that the counsellor gives each client help the client connect with the group and provide opportunities for practicing behaviour changes.


1.5 Conception of drug abuse/addiction, causative factors


Chemical addiction is seen as a primary, chronic, and progressive disease. It is primary because it is an entity in itself and not caused by other factors, such as intra-psychic conflict. It is chronic because a client cannot return to "normal" drinking, drugging or behaviour once an addiction is established. It is progressive because symptoms and consequences continue to occur with increasing severity as use continues.




2.1 Most similar counselling approaches


The most similar counselling approaches are cognitive-behavioural therapy, education/rehabilitation from a physical health disorder (e.g., recovery from a heart attack), and learning to live with any chronic illness.


2.2 Most dissimilar counselling approaches


Methadone maintenance and psychoanalysis are dissimilar counselling approaches.




3.1 Modalities of treatment


Approximately 80 to 90 percent of the treatment occurs in groups; the remainder is in individual sessions. Group treatment may offer therapy focusing on seeing a broader reality; overcoming denial and gaining greater acceptance of personal responsibility and hope for change; learning about the disease and related factors; orienting to 12-step philosophy and groups (e.g., AA, Narcotics Anonymous [NA], or Cocaine Anonymous [CA]); looking at special issue groups; focusing on topics specific to clients who have special characteristics (e.g., women, elderly persons, those with dual disorders, incest survivors); and participating in recreation groups, meditation groups, work task groups, groups for individuals to tell their stories and receive feedback, and groups where members review their behavioural homework assignments.


Individual sessions are used for reviewing progress and addressing issues that may be too sensitive or unique to be dealt with routinely in a group setting.


Typically, the counsellor schedules individual meetings one to three times a week, more frequently toward the beginning of treatment and less frequently toward the end of treatment. The counsellor helps the client integrate all of his or her group experience and individual work, teaching the client how this knowledge applies to the 12-step philosophy. Individual sessions are used to review the treatment assignments with the client and to give new assignments.


For example, after the treatment team has established the client's goals and methods, the client and counsellor meet. Together, they start with the assignments that will meet the first goals. During the next individual session, the counsellor and client may review those assignments to determine whether they were helpful and whether the goal was met. If so, they move to the next set of assignments to work on the next goal. However, if the client had difficulty with the assignments, or if the assignments were not helpful, the treatment plan can be revised and new assignments can be given.


Unscheduled individual sessions are conducted to resolve difficulties the client may have in the treatment setting or with external issues (e.g., family, legal system). For the client whose functioning level is low because of cognitive or emotional impairment, the counsellor may meet more frequently with the individual for short sessions (e.g., 15 minutes) to help the client stay on track with simple daily goals and to re-evaluate status.


3.2 Ideal treatment setting


The ideal treatment setting is residential, as this environment most easily conveys dignity and respect for the individual and provides grounds and physical space for solitude and reflection. This model can, however, be applied in any setting including a clinical hospital environment.


3.3 Duration of treatment


In a residential setting, the typical length of stay is 22 to 28 days. On an outpatient basis, the typical length of treatment is 5 to 6 weeks of intensive therapy (3 to 4 nights a week, 3 to 4 hours a session) followed by 10 or more weeks of weekly aftercare sessions.


3.4 Compatibility with other treatments


This approach is compatible with psychotropic medication monitoring, individual psychotherapy, family therapy and auricular acupunture therapy.


3.5 Role of self-help programs


Involvement in self-help groups (AA, NA, CA) is considered critical for long-term abstinence. In some cases, involvement in related self-help groups (e.g., women groups) may be acceptable. During primary treatment, the goal is to expose clients to 12 step programmess so they can begin to see how they function and to feel comfortable in them. After primary treatment, frequency of meetings depends on the individual. If a client is functioning relatively well and has a good support system, attendance one to two times a week may be recommended; for those whose hold on recovery is more tenuous, daily meetings may be recommended. Clients are urged to join groups that are most specific to their drug of choice.




4.1 Educational requirements


A bachelor's degree is required, but some treatment programs accept a counsellor who has a high school diploma, certification, and experience. Ideally, a counsellor will have a master's degree in psychology, social work, or a closely related field.


4.2 Training, credentials, and experience required


The minimum requirement for a counsellor is registration witn S.A.P.A. i.e. the South African Pastoral Care givers Association. Chemical addiction counsellor should take a state credentializing examination and receive certification. A drug counsellor course is recommended also as a minimum which are offered by the more reputable rehabilitation centres in S.A.


4.3 Counsellor's recovery status


The ideal counsellor is in an active program of recovery from a chemical addiction. Understanding and practicing the 12-step philosophy (e.g., self-help group attendance, AA/NA, Al-Anon, CA) in personal life are essential. All counsellor must demonstrate good chemical health. Non-recovering counsellor can also do quite well.


4.4 Ideal personal characteristics of a counsellor


A counsellor should:


· Be tolerant and non-judgemental of client diversity.

· Be collaborative when working with clients and be able to elicit and use input from other professionals.

· Be flexible in accepting job responsibilities (e.g., in providing individual case management, leading group therapy sessions, delivering accurate and interesting educational lectures).

· Have good verbal and written communication skills.

· Have personal integrity.

· Convey compassion to clients.


4.5 Counsellor's behaviours prescribed


· The counsellor must be able to:

· Assess a client's addiction.

· Compile and synthesize information about a client from other professionals, referents, and family members.

· Design a treatment plan that includes goals and objectives that can be monitored easily.

· Assign goals and objectives and periodically evaluate progress toward them by observation and discussion.

· Point out a client's strengths and barriers to recovery.

· Describe observed progress toward goals.

· Elicit client commitment and behaviours toward change.

· Trust a client's ability to change and convey information.

· Summarize, paraphrase, or reflect a client's statements back to him or her; probe for further information.

· Listen to where a client is in the process of recovery and employ treatment or counselling methods accordingly.

· Offer personal disclosure within appropriate boundaries (e.g., recovery status).


4.6 Counsellor's behaviours proscribed


The counsellor must not:

· Break confidentiality

· Provide any medications, even over-the-counter types.

· Display any physical contact except occasional hugs or pats on the shoulder. (This limited physical contact should occur only with the client's permission or request and be conducted in a public place).

· Confront a client unnecessarily (i.e. no bullying, shaming, or humiliating).

· Establish a personal relationship outside the treatment setting.

· Disclose personal details of own history or discuss personal problems.


4.7 Recommended supervision


The counselling model is established so that ongoing supervision is naturally obtained from the supervisor and colleagues during the multidisciplinary team meetings. Clients are discussed and reviewed on a weekly basis, and each counsellor receives ongoing feedback about his or her work. Ideally, the counsellor receives individual supervision at least monthly, where patterns of types of clients and any problems the counsellor has can be discussed.




5.1 What is the counsellor's role?


The counsellor's role might best be described as that of educator and coach. The relationship seems to work best when a client perceives the counsellor as an ally in the work toward recovery. In other words, the counsellor is an important resource in the client's recovery, not the one who is responsible for the recovery.


5.2 Who talks more?


It depends on the goal of the session. Generally, the client talks more than the counsellor does. However, if the counsellor is giving goals and objectives, the counsellor will do most of the talking.


5.3 How directive is the counsellor?


A good counsellor will be more or less directive, depending on client characteristics and stage of treatment. This form of treatment is more directive than many types of therapy (e.g., client-centred therapy), but it is no longer as indiscriminately confrontive as it was once characterized. The counsellor will typically be direct in stating "this is what I see about you," but usually not until he or she has elicited the client's perception and built a rapport. The counsellor typically chooses the topic of the session and keeps the focus on that subject.


There is a misconception that the Minnesota Model is, or needs to be, hard-hitting confrontation. This is unfortunate, as the method of direct or harsh confrontation may in fact be detrimental to some clients, particularly those whose self-esteem is already compromised. This is often true for elderly persons, women, people who are depressed, and people who are just realizing they are alcoholic/addicted and are feeling the painful consequences. Shaming clients and using punitive treatment methods do not have a place in the Minnesota Model.


5.4 Therapeutic alliance


In this model, the counsellor is seen as a colleague or partner in the recovery process, the one who has expertise. The counsellor aligns with the client: listening, retaining confidentiality, demonstrating knowledge, observing the client without judgment or shaming, and offering encouragement and support. A therapeutic alliance (TA) can be poor if the client perceives the counsellor as an authority figure and rebels. The counsellor typically attempts to avoid a power struggle and intentionally places responsibility for behaviour on the client.


Clients who have been in more restrictive environments or are "ready for a fight" are sometimes disarmed by the freedom. The environment must say, "We assume you are responsible, competent human beings; if you want to leave, you may." If the client focuses anger or blame on the counsellor for his or her alcoholism/addiction or need for treatment, the counsellor may choose to keep a lower profile or play a background role in the client's recovery. In this case, treatment assignments would have the client gather information from family, friends, or staff whom they choose to trust, rather than from the counsellor (if that is where the rebellion is placed). Usually this approach defuses the issue.


A poor TA can also occur if a client becomes overly dependent on the counsellor, placing his or her success in the counsellor's hands. In this case, the client may claim to be unable to stay sober without constant attention from the counsellor and may have repeated crises. If the counsellor attempts to set limits, the client may "triangulate" the staff by going to other staff members. The counsellor is likely to work toward improving this TA by:


· Talking directly to the client about his or her neediness and ways to work together to help the client feel more secure in the recovery process.

· Encouraging the client to include more peers in his or her recovery process (e.g., using the homework assignments to help the client make these connections).

· Referring the client for psychological consultation to see if he or she is becoming too overwhelmed by emotional issues that are arising as chemicals are leaving his or her system.

· Continuing to offer support and reinforcement for even small successes so the client begins to "own" his or her recovery process.




6.1 Addicts best suited for this counselling approach


The following individuals are well suited for this approach:


· Adolescents or adults who have transient intellectual impairment at most.

· People with average or better intellectual ability and at least sixth-grade reading ability.

· Alcoholics or poly drug users.

· People who are dually diagnosed if the psychiatric disorder is stable or not predominant in the clinical picture.

· People who have or develop at least moderate motivation and willingness to change. (Although many come to treatment with some resistance, most will be able to engage in the treatment process within 5 to 10 days. If they cannot, they may be discharged.)


6.2 Clients poorly suited for this counselling approach


Those not suited for this approach include the converse of the above, as well as individuals who are seeking methadone maintenance, those with poor reading ability or memory impairment, and those not motivated to change. People who have a dual diagnosis.




The initial assessment generally takes 5 to 7 days. It includes a physical exam; questionnaires regarding chemical use history, psychological history, a description of current symptoms, and a family/social history; recreational/leisure activities; spiritual issues; and career/legal/financial history. The client should also given MMPI, Shipley, Hartford, and Beck evaluations. Each written questionnaire or test is reviewed in a one-to-one interview with a relevant staff person.


Assessment during treatment is done by reviewing homework (written), by conducting interviews, and by observing the client. Homework assignments are a critical part of the treatment process. Depending on the client's needs, assignments may include activities like reading a pamphlet or chapter in a book and discussing it with a peer, holding a small group discussion on a topic, keeping a journal, asking a peer for help in any way, spending enjoyable time with peers, writing a detailed history of personal drug use and consequences, answering questions that help personalize the 12 steps, and so forth.


By observing the client and reviewing his or her assignments, the counsellor can obtain information about the client's ability to progress in recovery. Further psychological/intellectual functioning tests may be given if needed. Major domains assessed depend on the individual. Typically, progress is assessed by evaluation progress toward the established individual treatment goals. After treatment, clients should typically be sent evaluation questionnaires at 1 month, 6 months, and 12 months. Major domains assessed are chemical use, self-help attendance, and quality of life.




8.1 Format for a typical session


Session structure depends to some degree on each counsellor's style. In general, the counsellor:


· Elicits any new information about progress from the client (e.g., review of homework assignments, discussion of changes in behaviours or thinking).

· Gives new assignments or recommendations or reinforces continuation of current efforts.


8.2 Several typical session topics or themes


In the first several sessions, the theme is assessment. The counsellor determines the topic and basic structure and then reviews, with the client, the written information the client has provided about an aspect of his or her life. The purpose of these sessions is to clarify and expand on the information given to provide a more thorough assessment.


In the goal-setting session, the counsellor tells the client the goal that has been recommended for him or her, based on the information he or she has provided in the assessment phase. The counsellor begins to assign homework; the quantity depends on the functioning level of the client.


During progress review sessions, the counsellor continues to meet with the client periodically to review progress and give new assignments.


During client-initiated sessions, the client typically requests one or more sessions with the counsellor to ask for help in dealing with issues that arise during the course of treatment. These are typically problem solving sessions.


The counsellor and client discuss plans for discharge during aftercare planning sessions, including living situation, return to work, referrals to AA and other community resources, and ongoing goals the client will continue to work on.


8.3 Session structure


Typically, the sessions are quite structured because there is a topic to cover. Client-initiated sessions tend to be less structured.


8.4 Strategies for dealing with common clinical problems


The problem behaviour is pointed out to the client. When applicable, the problem is put in the context of the 12-step philosophy for possible resolution. For example, a client may be asked, "I know you are working on your anger and need to control. Does this situation relate to that?" Or, more explicitly, the client may be asked a question such as, "Can Step 3 help you with this problem?" Depending on the nature and severity of the problem, the responsibility for change is given to the client (e.g., "What do you need to do to get here on time?"). If the client is unable or unwilling to describe methods for change, the counsellor may say, "How would it work if you did _________?" If the client still cannot commit to making the changes, the counsellor may recommend that he or she talk to peers about the problem and elicit recommendations for change. If the client is unwilling to do the above, or if the problem behaviour continues, the client is seen by the counsellor's supervisor or the clinic director. Other sources of the problem may be explored (e.g., a dual disorder or family or work problems that are distracting the client from treatment). If the problem cannot be resolved, the client may be discharged with recommendations or transferred to a different counsellor or treatment setting.


8.5 Strategies for dealing with denial, resistance, or poor motivation


Typically, the counsellor will identify these as bona fide treatment issues with individualized goals rather than simply viewing them merely as barriers to progress. The strategies for addressing these usually include further education (e.g., reading, reflecting, and writing; talking with peers). These may be used as examples of the treatment principles the client is learning (e.g. Step 1).


8.6 Strategies for dealing with crises


The counsellor responds as any therapist would, by meeting with the client to determine the nature and extent of the crisis and proceeding accordingly. The client may be referred to another type of treatment instead of or in addition to the current treatment. In addition, the client will be encouraged to turn to peers for support to serve as practice and reinforcement for learning new ways of coping without chemicals. This may be used as an example of the treatment principles the client is learning (e.g. Step 3).


8.7 Counsellor's response to slips and relapses


First, the client would be taken to detox if still under the influence. Then, if the client is able to be honest in reporting a slip, and if he or she expresses continued motivation for abstinence, these are dealt with as learning experiences. The counsellor may use these to illustrate the power of addiction (Step 1) and will work with the client to identify triggers for relapse and how to cope with them. In severe cases, the client may need to go back to detox and return to treatment to focus on a revised treatment plan. If the client continues to relapse and expresses no motivation to change, the counsellor would assess (or refer for assessment of) undiagnosed co-morbidity (e.g., depression, organicity). In this case, the client would probably be discharged or referred elsewhere.




At the beginning of treatment, family members are asked to fill out a detailed questionnaire about the client's alcohol and other drug use and the resulting consequences. The counsellor will probably have one or more discussions with family members during the assessment phase to gather more information. The family is invited to come to a separate family program where they will learn more about addiction and what changes they can begin to make in their lives. Toward the end of treatment, there may be a family conference where the counsellor, the client, and the client's family meet to discuss outstanding issues and review goals for discharge. For many families this is just the beginning, as they will be referred to marital/family counselling after treatment. Family and friends are always referred to Al-Anon.

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