The Model Maker

The Model Maker: After a half-century of treating alcoholics and drug addicts, Hazelden is still the world’s most influential recovery center. But critics claim its much-imitated ‘Minnesota Model’ should be retired.

By John Rosengren

After a half-century of treating alcoholics and drug addicts, Hazelden is still the world's most influential recovery center. But critics claim its much-imitated "Minnesota Model" should be retired.

Alcoholism nearly destroyed Steve McNally. When his boss confronted the salesman about his drinking, McNally quit. For the next nine months he rarely left his Minneapolis apartment except to go to the bank, the grocery store, and the liquor store. To get up the strength to deal with traffic and wait in lines, he gobbled the anti-anxiety drug Xanax and chugged vodka. Leaving his apartment became increasingly difficult. He disconnected the phone and kept the shades drawn. Sometimes after a binge he passed out for a day and a half. His girlfriend of two years gave up on him. He bloated up to 250 pounds and started running out of money. McNally figured he would end up on the streets, then in a psych ward, and eventually dead like his uncle, who died of cirrhosis at 35. By that reckoning, McNally had five years to go.

One day after vomiting blood, he looked in the mirror and didn't see his reflection. "I had this feeling, if this is what I'm seeking, I've found it and don't want it anymore." Several days later, he called the Hazelden treatment center in Center City. "I drove up and turned myself in."

Today, McNally is sober, healthy, married with two small children, once again a successful salesman--and grateful to be alive. "I consider what happened to me a miracle," he says, thoughtfully watching the ice on Lake Calhoun break up on a warm spring day. "At Hazelden, I learned to be human again."

With five years of sobriety under his belt, McNally is one of those who escaped the clutches of alcoholism with the help of a chemical dependency treatment program. Sadly, stories like his are the exception rather than the rule. There are few long-term follow-up studies, but one published in the New England Journal of Medicine in 1985 reported that five years after treatment at hospital-based programs, fewer than 10 percent of the patients remained clean and sober. For many, treatment becomes a revolving door--70 percent of those admitted to chemical dependency treatment programs in Minnesota last year reported they'd been treated at least once before. Those who don't wind up back in treatment often end up as McNally feared he would: on the streets, incarcerated, or dead.

Such low success rates leave chemical dependency treatment centers vulnerable to criticism and the field itself rife with dissension over its methods. Hazelden, the venerable grandfather of treatment centers that coined the term "chemical dependency," stands at the center of the controversy. Since its founding in 1949, then a group of Twin Cities businessmen purchased the Hazelden Farm in Center City as a tranquil atmosphere to treat alcoholic male professionals, the organization has treated more than 100,000 alcoholics and drug addicts using the "Minnesota Model," which blends the 12 steps of Alcoholics Anonymous with multidisciplinary therapy. Critics claim the model has outlived its usefulness, has failed to evolve with the times, is too dependent upon Alcoholics Anonymous, and dwells unnecessarily upon the shame of the past. Yet, at the ripe old age of 50, the Hazelden Foundation is thriving, even expanding, when the industry itself is shrinking.

Hazelden is to chemical dependency treatment what McDonald's is to hamburgers or Hallmark is to greeting cards. Here in Minnesota, Hazelden enjoys 85 percent name recognition; around the country, one-fifth of the population can identify Hazelden as a chemical dependency treatment center. Its reputation attracts clientele from all over the world, celebrities included. Ringo Starr, Eric Clapton, Calvin Klein, David Kennedy, Liza Minnelli, Don Johnson, Matthew Perry, and Tommy Kramer are just a handful of those rumored to have checked into Hazelden's Center City facility, though Hazelden publicly defends the confidentiality of all admissions, refusing to deny or confirm rumors.

Many end up staying in Minnesota to be close to the roots of their recovery. They start restaurants, like Michael Morse of Cafe un deux trois, or run baseball teams, like Mike Veeck of the St. Paul Saints, or latch onto Hazelden itself, like William Cope Moyers, the foundation's director of public policy. They come for treatment, and they stay for the state's famous sober community.

St. Mary's Hospital and the Johnson Institute share credit with Hazelden for pioneering new understanding and treatment of alcoholism and other drug addictions, making Minnesota the mecca of recovery since the '70s. But Hazelden alone emerged as the industry leader. While still based in Center City, the Hazelden Foundation operates treatment and support facilities in St. Paul, Plymouth, and New Brighton, as well as in Chicago, New York, West Palm Beach, and Dallas. Its public policy division is a powerful player in the political arena. Its publishing division sells more than 3 million books, pamphlets, videos, training curricula, and other products annually around the world. The non-profit organization had 1998 revenues of over $59 million and runs on an annual operating budget of $65.3 million. In its half-century of existence, Hazelden has firmly established itself as the world's wealthiest and most influential treatment center.

Back in 1949, when "inebriates" were warehoused behind locked doors in the snake pits of state hospitals, they were seen as hopeless. Physicians, social workers, psychologists, and clergymen all attempted in their own fashion to treat them, but without success.

Enter Dan Anderson. As a colleague of physician Nelson Bradley at Willmar State Hospital, the dumping ground for inebriates, Anderson's charge was to find a humanitarian and successful method of treatment. In 1951, Anderson and Bradley decided alcoholism was a physical disease in its own right, not a result of some primary psychiatric condition--radical thinking in those days--and a multifaceted illness that needed a multidisciplinary staff to deal with it. They advocated treatment that was not only physical, social, psychological, but also spiritual, another radical idea borrowed from the Alcoholics Anonymous program.

"The prevailing psychoanalytical theory of the day was that alcoholics had a pregenital oral fixation--well, what are you going to do with that?" says Anderson, now 78. "We skipped trying to get at the underlying causes and decided to treat the presenting problem: addiction."

When Anderson began working part-time at Hazelden in 1957, he imported his method, which was initially known as the Willmar Model in the '50s, the Hazelden Model in the '60s, and eventually, as it gained wider acceptance in the '70s, the Minnesota Model. By the mid-'80s, with the chemical dependency treatment industry booming, Time magazine reported 96 percent of treatment centers nationwide used the model.

The Center City campus sits on 488 wooded acres about 45 miles northeast of the Twin Cities. A cluster of single-story tan brick buildings overlook South Center Lake. While the setting is short of breath-taking, and the particle board furniture looks like it could be on loan from a Holiday Inn, it's pleasant enough--certainly a lot nicer than most hospitals. Many alumni attest that the serene setting provided the environment they needed to come to terms with their addiction.

The first stop for new admissions is Ignatia Hall, the medical center where they undergo detox (many show up high) and have their vital signs monitored. Patients are then assigned to one of five units segregated by gender but connected by a maze of cinder block hallways. In the past, the hallways bore no signs--newcomers had to ask directions as a means of learning to ask for help, one of the basic tenets of recovery. Days are regimented into group therapy, lectures, relaxation exercises, physical therapy, and AA meetings. Lengths of stay very from the traditional 28 days to as long as two years in the extended care unit.

Recovery, as promoted by Hazelden, is more than mere abstinence; it involves a complete change of behavior. Patients might be given an assignment to initiate social interactions or a medication to deal with dyslexia, the idea being to treat the individual on all dimensions. The 12 steps of AA are used as a guide to dealing with the past and committing oneself to a spiritual lifestyle. "One of the biggest pieces we offer as a model of change is we help people make a change in their lifestyle," ways Mike Schiks, executive vice president of Hazelden's national recovery services. "One of the reasons we're still here is because we're still effective in helping people make those changes."

Steve McNally, for one, agrees, "Without the confinement, structure, and education at Hazelden," he says, "I wouldn't have gotten the tools I needed to get started in recovery."

There is not a lot of reliable research to support or condemn the efficacy of the Minnesota Model. The most common measure of success in follow-up studies is abstinence over a defined period: most commonly, six months or a year after treatment. True success is usually defined as someone who is able to stay abstinent and improve relationships, perform responsibly at work, and reduce related health and legal problems, but these variables are even harder to track.

In its own study published in 1998, Hazelden found that 53 percent of more than 1,000 men and women admitted to its program between 1989 and 1991 self-reported abstinence from alcohol and other drugs one year after completing the program. However, more than 29 percent of the sample did not respond. If it is assumed that all of the non-respondents returned to using, the abstinence rate drops to 37 percent. A recent independent study funded by the National Institute on Alcoholism and Alcohol Abuse that compared three different treatment models concluded that the 12-step approach to treatment Hazelden uses is as successful as other methods, though none can guarantee recovery.

Proponents of the Minnesota Model contend that success rates for the treatment of chemical dependency are not low when compared to successful treatment of other terminal illnesses, such as cancer, AIDS, or heart disease. (The American Medical Association has recognized alcoholism and other drug addictions as a disease for more than 30 years. Addiction is also considered a terminal illness in the sense that left unchecked, it usually ends in premature death.) "If I had a 53 percent--or even 33 percent--recovery rate for AIDS, I'd probably win some sort of prize," says Schiks, a large, bearded man, alternately gruff and gentle, and an alumnus himself with 22 years of sobriety. "But am I satisfied? No, we're never satisfied. I use outcomes to talk to the staff about how we can get better."

Though Hazelden's approach has stood the test of time, critics contend it hasn't changed with the times. "The Minnesota Model has not kept up with what science is teaching us," claims Joan Mathews Larson, Ph.D., who founded Health Recovery Center in Minneapolis in 1981 to treat alcoholics and addicts with an approached based in body chemistry. "I want to challenge the field to move on."

Larson takes issue with the talk-therapy approach of 12-step programs. "The cause of the disease is primarily physical in nature, but (traditional) treatment has never offered to fix what's broken," she says. "They only want to talk about the behavior that results. That's why treatment success rates have not changed in 30 years and have remained woefully inadequate."

One of the people whom traditional treatment failed was Larson's son. Rob Mathews completed St. Mary's Hospital's inpatient program and a halfway house stay as a teenager but continued to experience wild mood swings. Though sober, he killed himself at 17. Convinced the cause of her son's malaise and eventual suicide was a chemical imbalance--specifically, hypoglycemia--that hadn't been addressed at St. Mary's, Larson (who was working on her certification as a chemical dependency counselor) directed her efforts to researching and developing a treatment method that would address what she perceived as the root of addiction. She completed her doctorate in nutrition and started Health Recovery Center, which has treated several thousand alcoholics and addicts with its biochemistry stabilizing approach.

The physiological approach works for some where the traditional approach failed. Kelly, a 40-year old woman who asked that her last name not be used, came to Health Recovery Center in January as a last resort. Drunk and depressed when she had sought treatment at Hazelden four years earlier, she'd been dual-diagnosed as chemically dependent and mentally ill, with a multiple personality disorder, and referred to a trauma center in Santa Fe. For four years she bounced around from treatment centers to psych wards, unable to stay sober or sane. At the time she checked into Health Recovery Center's outpatient program, she was taking nine different medications and could barely walk two blocks. She arrived with lethal doses of mood stabilizers, anti-depressants, and sleeping pills, prepared to kill herself if the program didn't work.

At Health Recovery Center, Kelly was diagnosed with pyroluria, a condition defined in alternative medicine circles as one where the brain can't maintain adequate levels of B6 and zinc, causing anxiety and depression. She stopped taking her medications, and instead began taking mega-doses of 22 different vitamins, minerals, amino acids, and essential fatty acids. For eight weeks, she also attended support groups based on rational-emotive therapy, which is based on the premise that feelings and emotions are reflections of one' s thought processes. As Kelly started to feel better physically, her psychological problems lessened. She no longer felt depressed and anxious. Three months later, she reported that she was in the best health she could remember. Her moods had stabilized, her memory had improved, and she was able to work again as a receptionist. Granted, it has only been three months, but her turnaround thus far has been dramatic. "Now that I've been through Health Recovery Center, I don't know what good other treatment centers do other than keep you sober during the time that you're there," she says.

In her book Seven Weeks to Sobriety: The Proven Program to Fight Alcoholism through Nutrition, Larson boasts that 75 percent of the alcoholics and addicts treated at Health Recovery Center recover. Yet her study in the early '80s, which located 95 of 100 patients one and a half to three and a half years after treatment, is statistically questionable because of its small sample. And some physicians (particularly those with an allegiance to more traditional treatment methods) dismiss her methods as unscientific.

"Her theories of biochemistry and physiology make no sense medically," says Dr. Gregory Amer, medical director of Minneapolis-based Fairview Behavioral Services, the state's second-largest chemical dependency treatment provider and a Minnesota Model program. "There's no basis for abnormal glucose tolerances and nutritional deficiencies. You can come up with a proposal, say, to wear a string of garlic around your toe for three weeks and see if you stop drinking. Even if you quoted a 75 percent success rate, the method still doesn't make any sense."

While Larson's program treats addiction by replacing chemicals already found in the body, the National Institute of Drug Abuse (the federal agency in charge of addiction-research funding) has been pushing the limits of science to find other drugs that can be used to treat chemical dependency. One of the researchers whose work is funded by the institute is Marilyn Carroll, Ph.D., a professor of psychiatry and neuroscience at the University of Minnesota. Carroll has administered various medications to her collection of alcohol- and drug-addicted rhesus monkeys and rats, but has not found any that reliably reduce cravings or drug abuse.

"None of the medications have proven to be very successful," she says. "Researchers are trying to find new drugs, but I don't think they will work because the brain is able to get around any kind of modification we're able to make. You have to get at the behavior rather than one or two specific changes in the brain."

Carroll has, in fact, had more success with experiments that combine medication and behavior modification. Her monkeys and rats aren't working the steps or discussing their cravings over a cup of coffee, but when she offers them more food or water sweetened with Saccharine as an alternative to sips of alcohol or hits off a crack pipe, half choose the alternative. When she combines the alternative reinforcer with medication, the incidence of alcohol or drug use is reduced by 80 to 90 percent, though she's not exactly sure why the combination works so well.

The University of Vermont in Burlington has adapted Carroll's environment-enriching behavior modification approach to treating human heroin addicts by offering money vouchers instead of food to patients when they submit clean urine samples. The vouchers can be redeemed for rent, tuition, theater tickets, or ski passes. As one might expect, the costs of such a program are high, but Carroll says the early results are encouraging. A handful of other treatment programs around the country are adopting the Vermont model.

"This behavioral strategies program is probably one of the best things that's come along in a long time," Carroll says. "I see this as the way of the future. The way of the post hasn't worked. There is such a very low success rate to 12-step, traditional methods that we've got to try something else."

Mike Schiks bristles at the suggestion that Hazelden is stuck in the past. "We are not just an icon of the Old World," he says. "There seems to be an investment in categorizing Hazelden as an old model, but we are changing every day." He points to the way Hazelden has expanded services over the years to include after-care, support groups for special needs (such as physical and sexual abuse), codependency treatment, a licensed mental health clinic and, most recently, a smoking cessation program. Hazelden is also exploring the use of acupuncture and biofeedback and possible uses of its model to treat eating disorders, gambling addiction, and stress. "This is an innovative model," Schiks insists, "not a dinosaur."

Industry gadfly Bob Muscala acknowledges that Hazelden has made changes over the years, but insists the organization is still too dogmatic in its adherence to a 12-step-based program. "The very notion that the 12-step program is the only program that works is like the Mayo Clinic saying Prozac is the only method to use to treat depression," says Muscala. "Hazelden has this prefabricated notion of how people are supposed to get well within the AA community."

Muscala Chemical Health Clinic in Minneapolis, an outpatient program Muscala founded 20 years ago, treats about 75 patients annually with a variety of approaches. Muscala does not believe abstinence is a prerequisite to recovery, nor does he believe in the disease concept, having coined 25 years ago the term "chemical health," a corollary to mental health implying that there's a continuum of healthy and unhealthy chemical use. He supports and refers clients to a host of recovery groups that have sprung up as alternatives to AA, such as Women for Sobriety, Rational Recovery, Smart Recovery and Moderation Methods. Most of these programs--like Muscala's--reject AA's foundation upon spiritual principles. Muscala is especially critical of what he perceives as a symbiotic relationship between AA and Hazelden. "AA is like the dental hygienist for the dentist--it does all of Hazelden's follow-up work," says Muscala, whom Hazelden has threatened to sue in the past over critical comments he has made.

Muscala's biggest criticism of the Minnesota Model is that it is a shame-based program. He's not alone in this regard. Joan Mathews Larson thinks that the emphasis on looking at old mistakes, particularly as required by AA's Fourth Step ("a fearless and thorough moral inventory"), leaves patients mired in the past. "The way back is not exclusively to sit in groups and review one's guilt and shame," she says. "The treatment of cancer or any other physical disease doesn't insist that someone focus on their mistakes in order to recover."

Of course, AA adherents look at it differently. Sharing one's story isn't shame, they argue; it's fellowship. Hazelden's program relies heavily on this fellowship aspect for recognition of one's addiction and support in recovery. "When one alcoholic sits down, looks another alcoholic in the eye, and says, 'You're telling my story'--after all that isolation of addiction, the alcoholic starts to make connections," Schiks says. "It's what the Big Book [AA's basic text] calls 'our common peril.'"

Alcoholics Anonymous has endured criticism for its spiritual foundation since it began in 1935. Heavily influenced in its early philosophy by the Oxford Group, a conservative Christian movement, AA has been called everything from a religion to a cult. Its insistence on a belief in God--which it nicknames a Higher Power--is summed up by an old AA parable Mike Schiks tells: "A guy walked into a meeting looking like he'd been dragged by a truck and said he'd found the answer to spirituality and the Higher Power that everyone could agree upon. The other members of the group sat up in their chairs eager to hear what he had to say. His answer: 'I'm not Him.'" Schiks pauses. "How can anyone help me if I always say I know best?"

He admits that there are zealots about AA just as there are zealots about the Bible, Taoism, or Buddhism, but he claims that rigid fundamentalism does not reign at Hazelden. "There is room for a range of what works," he says. "The beauty in my mind of the 12-step program is that people have the freedom to believe what they believe."

Dan Anderson, architect of the Minnesota Model, admits addiction is still a mystery that no one has solved. "All we're trying to do is tame the beast a little bit," he says. "We haven't slaughtered it. Some people seem to think we should be able to shoot it right in the heart, but we can't do that."

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