20 ,May, 2019

The Rehab model foundered on Therapeutic Communities  (TC’s) & overlaid by various versions of the Minnesota Model and its progeny the 12 Step Facilitation Model (TSF) is fundamentally flawed and is delivering extremely modest outcomes.

 Here in Australia it is impossible to get any evidence based statistics from these facilities. That said having spoken to a number of people in the Industry the figure that consistently comes up is somewhere between 30% and 35% maintain abstinence for any extended period ( 6-12 months ), post their residential stay.

The history of TC’s is well documented in a July 2015 article by the National Institute on Drug Abuse. Historically, TCs have seen themselves as a mutual self-help alternative to medically oriented strategies to address addiction.

As the TC’s started to flourish in the USA during the 1950’s and 60’s they turned to the Minnesota Model which was foundered on the 12 Steps of Alcoholics Anonymous (AA) as the preferred program for their clients.

It is important to understand the early teachings of AA were foundered on a one size fits all solution and members were dogmatic in the extreme in passing on their message of recovery. Some of the slogans from these days exemplify this dogma.

i. “Pills are for dills”

ii. “There are only two types of alcoholics male and female”

iii. “Take the cotton wool out of your ears and stick it in your mouth”

iv. “It’s AA or Amen”

The Minnesota Model placed and still does place a huge emphasis on Steps 6 & 7 of the 12 Steps of Alcoholics Anonymous. This emphasis has transferred into many of the TSF programs being implemented in TC’s today.  

   Step 6 Were entirely ready to have God remove all these defects of character.

   Step 7 Humbly asked Him to remove our shortcomings.

During a client’s stay in a TC utilizing the Minnesota Model they would be required to confront their shortcomings, learn to be humble and obey the rules of the TC. Failure to comply was met with disciplinary action and corresponding penalties.

Unfortunately, this paradigm of “boot camp” type treatment still exists today in the vast majority of TC’s that now utilize the TSF program (or variations thereof). Clients who breach TC rules such as being late for a meal or a group session are often required to write a 300 word “Awareness” or endure some form of recrimination for their transgression. These penalties are often displayed on community notice boards for other clients to see.

I am not suggesting that amongst the treatment options for people with substance abuse issues this model does not have a place. It does. However, the negative impact on the individual and the TC group of the constant implementation of penalties and hierarchical discipline creates a negative pall over the community and dramatically impacts the level of engagement and buy in of many of the community.

People arrive at Treatment facilities for many reasons. Some have hit “rock bottom” and will do anything to improve their lives, some are there to appease their partner/family/or boss, others arrive to mitigate an up-coming court appearance and some because they realise they need help. Whatever the reason they all come from different backgrounds,

a. backgrounds,

b. home environments

c. types of substance usage

d. mental health issues

e. personal relationships e.g. married, single, children, age of children

f. educational qualifications

g. work skills and employment

h. length of substance abuse

i. previous attempts to address their substance abuse issues

j. etc. etc. etc.

Another fundamental flaw of the TC/TSF model of treatment is that it is foundered on days abstinent not what the client learns in the time they are in residential treatment.

The success of this model requires repetition, repetition, repetition and is reinforced by nightly meetings of AA or NA. When little or no progress is seen in a client comments such as this flow,

i. You need to go to more meetings

ii. You need to become more humble

iii. You need to go back and do the steps again.

This repetition is further reinforced by the duration of the programs they offer, 30 days, 60 days, 90 days. Why are days 30, 60 or 90 so pivotal? Why does a person who completes 30 days automatically need another 30 days? Perhaps they might only need a further 17 days.

Given the variety of factors which are found in any group of clients in a “rehab” it is impossible for the one size fits all approach of the TC/TSF paradigm to produce anywhere near acceptable outcomes.

When it comes to substance abuse issues a one size fits all model such as the TC/TSF model is fundamentally flawed.