Abstract

The Minnesota Model blends a philosophy and a transtheoretical treatment approach that addresses the core, fundamental issues of the complex, multifactorial disease of addiction. Existential and spiritual issues are conceptualized as being at the root cause of addiction, formative in the development of client-centered therapy, and foundational to the principles of AA and the treatment philosophy of the Minnesota Model. The concept of worldviews is intimately linked to the core philosophy inherent in the model. The implementation of the assessment of worldviews is proposed as a unifying construct for enhancing the quality of recovery services. A phased approach is outlined across various levels of the organization. Individualization of care, professional competency, and patient outcomes are expected to improve. The construct allows for the evolution of recovery programs and services so as to maximize opportunities to meet the changing needs of an increasingly diverse customer population.

TABLE OF CONTENTS
Introduction
Theory of Addiction

• Biopsychosocial Elements
• Addiction as a Family Disease
• Spiritual and Existential Dimensions

• Individual, Client-Centered Therapy
• Relationship Between Client-Centered Therapy and Existential Thought
• Existential Approach of Alcoholics Anonymous
• Group Therapy
• Multicultural Counseling

• The Construct of Worldviews
• Assessment of Worldviews
• The Utility of Worldviews in Counseling

• Methods
• Discussion

• A - Implementation Timeline
• B - Proposed Budget
• C - Strategic Alignment

INTRODUCTION

Alcohol and other drug addiction is a complex, multifactorial disease encompassing biological, psychological, sociological, and spiritual elements. Addiction not only impacts the individual but also extends to and perpetuates itself within the context of the entire family system. Recognizing the complexity of the disease, a holistic approach is advocated that allows for individualization of treatment based upon the assessed needs of the individual and an appreciation of their uniqueness and individual worldview.

The Minnesota Model is a comprehensive, abstinence-oriented approach to the treatment of alcohol and drug addictions (Cook, 1988a). The model denotes both a philosophy and a methodology of delivering care to individuals suffering from the disease of addiction (McElrath, 1997). One of the characteristic features of the model is that it embraces the practice and philosophy of the Twelve Step approach of Alcoholics Anonymous as a foundation for therapeutic change (Stinchfield & Owen, 1998). Having grown from the legacy of Alcoholics Anonymous, the Minnesota Model is inherently existential in nature and incorporates an individualized, client-centered approach to treatment. It is suggested that drug and alcohol addiction is primarily a spiritual disease from which the sufferer lacks subjective meaning in life (Koster, 1991). The Minnesota Model is therefore highly successful as it blends a philosophy and a transtheoretical treatment approach that address the core, fundamental existential issues of the disease of addiction.

The construct of worldviews offers a global and holistic perspective of individualized treatment. We all possess a worldview that affects how we perceive and evaluate situations and how we determine appropriate actions (Sue & Sue, 1999). The concept of worldviews encompasses one's total outlook on life and has been described as a 'filter' through which phenomena are perceived and comprehended (Koltko-Rivera, 2000). This thesis presents a proposal for implementing the assessment of worldviews as a unifying construct for enhancing the quality of recovery services provided to the customers of Hazelden. It is anticipated that the implementation of this proposal will translate into an enhancement of the individualization of treatment and improved patient outcomes. This is consistent with Hazelden Foundation's vision to lead the way in the development of innovative products and services that help build recovery in the lives of those affected by addiction (Hazelden Foundation, 2002).

THEORY OF ADDICTION

Biopsychosocial Elements

Addiction is a complex, multifactorial disease including biological, psychological and sociological elements (Leukefeld, 1999). Family, twin and adoption studies demonstrate that addiction has a biogenetic basis that is transmitted within families (Blum, Braverman and Holder, 2000). The core of the predisposition is a set of genes that are responsible for the feeling of reward derived in the mesolimbic system of the brain. Individuals with an inherited hypodopaminergic functioning are more prone to seek substances or behavior that stimulate dopamine release and thus provide reward. Recognition of addiction as an inherited, reward deficiency disease provides a biological basis of understanding and helps to alleviate social stigma.

Acknowledging that a positive family history of alcoholism elevates one's risk for alcohol abuse, Finn, Sharkansky, Brandt and Turcotte (2000) conducted research designed to elucidate the mechanisms that lead from increased risk to alcohol abuse. They found evidence of two distinct personality-related pathways that suggest different bio-psychosocial mechanisms. Firstly, proneness for social deviance or antisociality was directly associated with alcohol problems suggesting that addiction is a manifestation of a general difficulty in regulating behavior. This personality trait was significantly associated with a family history of alcoholism. Secondly, excitement/ pleasure-seeking was found to be a basic approach tendency that promoted increased drinking, which, in turn, leads to alcohol problems. However, it could also be argued that alcohol use can promote impulsive, excitement-seeking behavior. This raises the question of whether the expressions of such genetic traits are shaped by the environment.

Jang, Vernon, Livesley, Stein and Wolf (2001) addressed this question. They examined genotype-environment correlations to better understand the extent to which individuals are exposed to environments as a function of their genetic predispositions. Alcohol abuse was correlated with environments that activate or maintain the expression of the underlying genetic liability for alcoholism. Specifically, decreases in family moral-religious emphasis, family cohesion, and increased organization (strictness) were associated with pathological alcohol use. While there is clearly a genetic predisposition, environmental factors seem to significantly affect the likelihood of the expression of the disease.

Addiction as a Family Disease
There is a growing body of research focused on the dynamics of addiction within the context of family relationships. Drinking parents have profound and lasting effects on their children's physical, social, and psychological development. Children of alcoholic parents are twice as likely as those with non-alcoholic parents to experience inadequate supervision, neglect, physical abuse, and imprisonment (Barber and Gilbertson, 1999). Offspring of drinkers are more impulsive, less likely to delay gratification, and prone to aggression and hyperactivity. They report low self-esteem, high social anxiety, tend to be depression-prone and are prone to develop drug-misuse problems. Children of alcoholics drink more, show more symptoms of alcohol dependence, report more frequent use of other drugs, and display more drug-related negative consequences. Parental inconsistency is the most significant factor, adversely affecting emotional development and placing the child at greater risk of drug abuse. The family cycle of addiction is perpetuated by these family dynamics, affecting not only the addict but also all those who care about the addict (Brown and Lewis, 1999).

Partners of addicted individuals suffer from the disease. Hurcom, Copello, and Orford (2000) present a psychosocial perspective of the effects of alcoholism on spouses. This view combines preexisting aggressive personality difficulties and environmental stress factors. Wives of problem drinkers report significant levels of stress. The use of ineffective coping mechanisms, including avoidance, care taking, and rescuing of others, impairs self-worth and increases the risk of suffering depression and abusing drugs or alcohol.

The effects of addiction extend to the entire family system (Hurcom, Copello, and Orford, 2000). For example, family violence, incest, separation and divorce have all been linked to parental drinking. Alcohol abuse is hypothesized to skew the balance of growth and stability within the family, resulting in a rigid, inflexible system. Rather than maintaining healthy regulatory behaviors such as routines, rituals, and problem solving, the alcoholic family's system begins to revolve around alcohol. For the family to retain a sense of "stability", the use of alcohol is perpetuated. In this way, the more alcohol becomes an integral part of the family dynamics, intergenerational transmission of the disease is increased.

The negative parenting characteristics and familial discord often associated with having an addicted parent are particularly harmful (Ross & Hill, 2001). Alcohol misuse is more likely in alcoholic homes where parents tend to be unpredictable, uninvolved, rejecting and abusive. Parental unpredictability is a central factor. Children exposed to this environment develop a basic belief system and worldview that the world and the people in it are unpredictable. This increases risk taking in general, including substance abuse.

In addition to parenting influences, the manifestation of an addictive predisposition in adolescents is strongly influenced by peers. Peer pressure is positively associated with adolescent smoking and drinking (Simons-Morton, Haynie, Crump, Eitel and Saylor 2001). In contrast, teens whose parents were involved, had high expectations for their behavior, and held them in high regard were less likely to initiate drug use. Similarly, Pidcock and Fisher (1998) found that the risk of intergenerational transmission is decreased when addicted parents enter recovery.

Addiction is therefore a multifactorial disease that expresses and perpetuates itself within the context of family systems. Understanding addiction conceptually as a family disease encourages the counselor to approach patient care from an individualized, holistic view that factors the worldview orientation of the patient and encompasses the entire family.

Spiritual and Existential Dimensions
The Alcoholic's Anonymous program of recovery is based upon spiritual principles (Alcoholics Anonymous, 1995). Empirical evidence substantiates the relationship between faith, spirituality, and addiction recovery (Jarusiewicz 2000). Significantly greater spirituality, defined as a "positive relationship with self, others, and with God or the universe, as evidenced by tolerance, gratitude, release, and humility" (p. 106), was measured for those successful in recovery for at least two years, compared to those who continued to relapse.

Existential issues of meaninglessness, death, isolation and freedom are conceptualized as being at the root of addiction and central to the philosophy and subsequent success of the Minnesota Model. According to Frankl, humans are basically striving to find and fulfill meaning and purpose in life (1966). One can actualize only by fulfilling a meaning in the world and relating to and being directed by something or someone other than oneself. The experience of a sense of futility and emptiness, a feeling of meaninglessness, an inner void, is referred to as "existential vacuum" (Frankl, 1966, p. 252; 1972, p. 85) and can lead to addiction (Koster 1991). The alcoholic lives in an existential vacuum; life is seen as empty, absurd and fruitless (Johnson, Griffin-Shelley & Sandler, 1987). The active addict or alcoholic lives life in a state of primitive denial against the reality of death, another of the existential issues of life. This failure to confront the inevitability of death is, at least in part, responsible for the addict's spiritual problem. According to Frankl, meaning can be gained from experiencing even negative aspects of existence including death (1966). Through their addiction, many patients experience the reality of death.

Additionally, existential isolation plagues addicted individuals. This involves the realization that a gap exists between one's self and others and that we are uniquely alone in the world. Most alcoholics are conflicted about isolation and, by contrast, about intimacy and love. A crucial aspect of recovery, then, is the acceptance of feelings of separateness and individualization while developing a capacity to love and share.

The healthy, growing person faces freedom by building bridges with others to make contributions to the world (Nicholson, Higgins, Turner, James, Stickle, & Pruitt, 1994). Unhealthy mechanisms to avoid the anxiety and responsibility that freedom brings include compulsive acts such as drinking or drug use and denial of responsibility (Kurtz, 1982; Johnson, Griffin-Shelley & Sandler). Addicted individuals have compulsively denied and displaced responsibility for their lives to avoid the anxiety of free choice. They become masters of rationalization, projection and avoidance. It is only through existentially feeling the fear that the addict can begin to recognize life's aloneness and take responsibility for his or her own destiny. Through this experience, the alcoholic gains the freedom to not-drink, as opposed to surrendering freedom to drink.

TREATMENT APPROACHES

Individual, Client-Centered Therapy
The common roots of client-centered therapy and existential approaches become evident when one examines the life experience and personality of Carl Rogers. Roger's struggles during life with fundamental existential issues shaped his personality and led him to develop the principles of the client-centered approach. Roger's approach is particularly relevant to the treatment of addiction as his formative life experiences in many ways parallel those of many alcoholics.

Dolliver (1995) provides an insightful reflection of the life of Rogers. From early childhood, Rogers struggled with doubts that someone could love him and with feelings of loneliness and pain; he struggled to be "fully functioning" (p. 114) and became socially isolated. The expression of strong feelings, especially negative emotions, was not permitted in Roger's childhood home. As a result, he had life-long struggles with expressing anger. He never felt safe to share personal thoughts or feelings with his parents for fear of being judged. Overall, Rogers struggled with issues of authority, self-acceptance, emotional expression, and the nature of interpersonal relationships. Through his life experiences, he was able to transcend these issues and develop a remarkably sensitive and effective approach to helping people much like himself. His personality theories are in many ways the antithesis of what he experienced as a child. He specified three core conditions as being necessary and sufficient for therapy to occur: unconditional positive regard, empathy, and congruence or genuineness. The most important aspect of Rogers therapeutic approach is the relationship in which the client is valued, respected, and validated as a whole, worthy individual (Glauser & Bozarth, 2001).

Relationship Between Client-Centered Therapy and Existential Thought

Upon review of client-centered and existential approaches, it becomes apparent that they are based on similar tenants and originate from common roots. Recognizing that a person's existence is an individual core issue, neither approach prescribes what existence is, should be, or how it should be changed. Both reject the unconscious as perceived by Freud but rather focus on what Rogers referred to as "Conscious Existence" (Milton, 1993, p. 243). Clients need to fully experience and understand their feelings to enable them to accept them and to move on to other phases of existence (Rogers, 1995; Milton).

Similarly, existentialists and client-centered therapists give precedence to the individual's subjective meaning of their life (Frankl, 1966; Rogers, 1995; Milton, 1993). In existentialism, this view includes the fixed, biological 'givens' of life and death, but recognizes that different people's understandings of, and reactions to, these givens can vary depending upon the meaning attributed to them by the individual. From a client-centered approach, Rogers emphasizes the importance of the therapist striving to understand the client's world and meaning. From both points of view, meaning is seen in terms of the individual's unique and subjective view of their own life. These worldviews are existential in nature and strengthen the concept of a philosophical link between client-centered therapy and existentialism.

Having stemmed from a similar phenomenological philosophy, the methodology employed by the two approaches is similar. In an attempt to accurately perceive the world of the client rather than project his own meaning to the client's subjective world, Rogers tended to divest of himself and limit his perceptions to checking perception, reflecting feelings, and clarifying the client's words. Rogers stated that he "found it of enormous value when [he] can permit [himself] to understand another person, ... to enter thoroughly and completely and empathetically into his frame of reference" (p. 11).

Rogers (1995) learned that it was therapeutic to understand and accept others as individuals. He emphasized the importance of active listening and seeking an understanding and acceptance of another person's world of feelings as a mutually rewarding experience. It is within this type of relationship that the client's capacity for healthy self-development grows and allows a greater congruence between their unique concept of self and actual experience (Milton, 1993).

Both approaches are holistic in that the client is treated as a whole person (Bohart & Tallman, 1996). The therapist facilitates the process by which the whole person ultimately finds personally meaningful resolution to the dysfunction they may experience, which is a result of their own actions and choices in life. Rogers was of the opinion that persons have a basically positive direction that they tend to move toward when they are sensitively understood and accepted as separate individuals (1995). The therapist merely offers the client a safe space and time where they can be listened to, think and feel, techniques that serve as tools for the client to explore their own experience and work through their problems, and an interactive presence that invites thinking, experiencing and exploration (Bohart & Tallman, 1996; Milton, 1993; Johnson, Griffin-Shelley & Sandler, 1987). It is the whole person of the individual client who generates the processes and solutions that create intrapersonal change.

Existential Approach of Alcoholics Anonymous
Existential philosophy has been conceptualized as a framework for understanding the disease of addiction and as a foundation for the development of client-centered therapy. We now consider to what extent these same underpinnings have woven into the fabric of the movement of Alcoholics Anonymous (AA). Recognizing an existential vacuum, the drug abuser experiences unhappiness and, as a maladaptive response, turns to drugs or alcohol for relief of emotional pain (Nicholson, Higgins, Turner, James, Stickle & Pruitt, 1994). In the tradition of AA, it is through the recounting of life stories that the addict learns how to interpret their past in a way that gives meaning to the past and hope for the future (Flores, 1988). From a phenomenological perspective, the past is relived, interpreted and created in the present experience of an AA meeting, and becomes a model for creation of the future. The telling of stories provides a different structure and logic that helps the individual understand and accept his or her being as an alcoholic.

The regular introduction of oneself as an alcoholic at meetings is another important element of the AA program (Flores, 1988). This proclamation reminds the member that they are just one drink away from losing the newly recovered self they have become, and that they are powerlessness over alcohol. Powerlessness, as referred to in the First Step, brings the focus of the program on the alcoholic as one who is essentially limited (Kurtz, 1982).

Essential limitation and finitude are core concepts of existential philosophy (Kurtz, 1982). Finitude concerns limitations such as what one cannot do or be. The AA member who states he is alcoholic embraces the existential insight of essential limitation. Having confronted the choice of abstinence or insanity, the alcoholic becomes aware of the reality of the fact that some limitation has become absolutely inevitable.

The acceptance of limitation is key to the healing dynamic of AA (Flores, 1988; Kurtz, 1982). These concepts are pervasive throughout the program and fellowship as exemplified by the mottoes, "First Things First", "One Day at a Time", and Progress Rather than Perfection" (Kurtz, p. 46). The acceptance of limited control is well summed up by the Serenity Prayer; the "can" and "cannot" of the prayer eloquently integrate the existential concepts of limited control and limited dependence. Thus, the AA member gains his freedom to not-drink as opposed to surrendering freedom to drink.

The acceptance of limitation is most stark when an individual faces an existential predicament or limiting situation. Alcoholics face this decision when pushed to their personal limit situation referred to in AA as "hitting bottom" (Alcoholics Anonymous, 1996, p. 21). They must either continue on their present path leading to death, or change their life by surrendering to the First Step. If the alcoholic is able to do this and integrate this experience, a more meaningful, authentic life ensues.

The feelings of alienation and loneliness arise not from the sense of limitation, but from the refusal to accept essential limitation when faced with a personal "bottom" (Kurtz, 1982). Rather than trying to control the limitation, the alcoholic is urged to gain perspective, which involves facing fear and pain. Frankl maintained that people grow through pain and suffering (1972). A fresh human perspective is gained, not by conquering and controlling, but by acceptance and surrender.

In addition to the AA core elements of telling one's story, admitting powerlessness, and acceptance of hitting bottom, sharing and the pursuit of happiness foster personal growth. During Frankl's horrific wartime experiences in a Nazi concentration camp, he realized that the survivors were those prisoners who put their suffering within some meaningful context through faith, belief or hope (Flores, 1988). In a similar fashion, AA members, as prisoners to alcohol, share their "kinship of common suffering" (p. 83). The sharing of common suffering within AA teaches the alcoholic "that to be fully human is to need others" (Kurtz, 1982, p. 55). The alcoholic learns to be more self-aware and more honest with self and others. Once these existential issues are faced, patients can experience a sense of purpose or meaning in life, and shift the focus of their attention to the action stage of change involving behavior modifications (Ford, 1996; Prochaska, DiClemente & Norcross, 1992).

Group Therapy
Group therapy is complementary to, but distinct from participation in Twelve Step groups (Freimuth, 2000). Through the group process, growth is facilitated, isolation is reduced, and the concept of sobriety as an interpersonal experience is fostered. Indeed, group therapy is frequently considered the treatment of choice for addiction, allowing for positive peer interactions, improvement in communication skills, mutual support, confrontation of ego defenses and an overall substitution of the euphoric state of intoxication with the elation of the group (Straussner, 1997).

Change is facilitated through interactional group dynamics as described by Yalom (Flores, 1997, chap. 4). Yalom suggests that we are uniquely influenced by our interpersonal relationships and that group therapy can provide a corrective emotional experience by acting as a social microcosm of our interpersonal world in the here and now. As such, personal issues, conflicts, doubts or fears will emerge within the group. Through process illumination in which the leader and group members comment on specific behaviors and interpersonal communications, augmented by self-reflection, individuals are able to learn to understand the impact of their behavior on others and how they are perceived. Cyclical growth and change are the result of, and emanating from, self-exploration within the microcosm of the group.

The leader's role includes giving feedback, gently confronting, keeping the group in the here and now, and establishing a genuine, therapeutic relationship with the members (Corey, 2000). Clarification and confrontation are utilized as means of pointing out and explaining the contradictions in behavior between what people say and do (Straussner, 1997). Through the modeling of confrontative, yet empathetic responses, the leader helps the member connect cause-and-effect behavior and increase their self-nurturing. Behavioral approaches such as communication and problem solving skills and assertiveness training can also be incorporated.

Conceptualizing addiction as a relationship hunger, treatment within a group setting allows for a shift in attachment or dependency from a drug to others (Winship 1999). Group therapy offers the addicted individual the opportunity to recreate their individual concept of self in terms of their human emotions. Negative feelings of sadness, loss and separation can be dealt with in small doses through therapeutic encounters of groups of individuals.

Multicultural Counseling
Multicultural counseling has traditionally been conceptualized in terms of a counseling relationship where the counselor is Euro American and the client is a member of a racial or ethnic minority group (Speight, Myers, Cox & Highlen, 1991). Multicultural training was initiated to assist counselors in understanding those who are "culturally different" from themselves. The assumption is that when counselors have learned all of the characteristics of the variety of cultural and ethnic groups, they will possess the skills to be effective multicultural counselors. The concern is that lists of characteristics are often difficult to distinguish from stereotypes. Implicit in this view is the assumption that counselors and clients who culturally match one another will achieve better therapeutic outcomes. However, the problem is that individuals cannot be categorized so simply.

Given the current trend toward diversification in the United States, we can no longer afford to consider only those who are "culturally different" (Sue, Arredondo & McDavis, 1992). We are fast becoming a multiracial and multicultural society. It is projected that, by 2010, what have been traditionally viewed as "ethnic minorities" will become the majority. The profession has been challenged to recognize that all forms of counseling are cross-cultural; race, culture, and ethnicity are functions of everyone and not limited to "just minorities" (Sue & Sue, 1999).

Multiculturalism has been conceptualized over time from a variety of fragmented viewpoints (Jackson & Meadows, 1991). Prior to the 1950's, multiculturalism was defined in terms of patterns of behavior and customs whereas during the 1960's the focus began to shift to ethnographic variables (e.g., nationality, ethnicity, shared history). Sole focus on ethnographic variables ignored the uniqueness of individuals. During the 1980's, the social systems focus acknowledged the complexity of individuals and cross-cultural interactions of all people. Surface level aspects of culture were taken into account including demographic, status, affiliation and ethnographic variables. Understanding of culture from this perspective continued to be fragmented in that the values that give meaning to behavior were ignored.

More recently, the shift has been toward viewing culture as an integrated whole by which themes and associated behaviors are observed within groups of people and individuals. This worldview notion consists of assumptions individuals hold about the makeup of their world, which in turn determine how we think, behave and make decisions. The worldview orientation provides an optimal view of multiculturalism in that it amalgamates these various fragmented elements into an integrated, holistic view of all individuals. Ibrahim (1991) argues that all counseling is multicultural and understanding a client's worldview leads to more effective, ethical, sensitive and client-specific counseling.

THE MINNESOTA MODEL OF RECOVERY

The Minnesota Model is "inextricably interwoven with the program, practice and philosophy of Alcoholics Anonymous (AA)" (McElrath, 1997, p. 141). The AA movement conferred the belief that alcoholism is a physical, mental and spiritual illness and developed the Twelve Steps, which outline a spiritual solution, and the concept of a fellowship where recovery can take place.

Two long-term treatment goals of the Minnesota Model are total abstinence from all mood-altering substances and an improved quality of life (Cook, 1988a; Stinchfield & Owen, 1998). Consistent with the philosophy of AA, the objectives for the individual are to grow in transcendental, spiritual awareness, to recognize personal choice and responsibility, and to develop peer relationships. The resources for recovery, then, lie primarily within the addict with treatment providing the opportunity to discover and use those resources and the therapeutic atmosphere conducive to change. This approach is by nature client-centered.

Much of the work done by patients toward achieving those goals is done within the context of group therapy (Cook, 1998a). Engaging with counselors and members of the peer group, the client is encouraged to develop meaningful relationship experiences and clarify feelings and definitions of reality. Success of the process is characterized by relief, peace, increased sense of self worth, acceptance by self and the group, and the existential restoration of meaning to life (Cook, 1988b).

The success of the Minnesota Model stems from it addressing the fundamental existential issues of addiction. Common to AA, it is rooted in existential philosophy and incorporates a treatment philosophy and treatment approach that addresses the core issues of addiction. This existential philosophy allows for a caring, nurturing, client-centered environment where the Twelve Steps provide direction and patients suffering from addiction can find healing. Patients with co-morbid mental health conditions receive concomitant treatment for both conditions within a co-therapy concept. A common mental health diagnosis among chemically dependent patients is borderline personality disorder (BPD), a pervasive pattern of instability of interpersonal relationships, self-image, and affect along with impulsivity (Soloff, 2000). Up to 43% of chemically dependent subjects are also diagnosed with BPD (Daley & Moss, 2002). Those with BPD seem especially prone to the use of substances in order to cope with unwanted affective states (Trull, Sher, Minks-Brown, Durbin & Burr, 2000). The frequent co-occurrence of addiction with other mental health problems is of relevance and importance to the chemical dependency (CD) counselor (Stone, 2000). For example, patients with BPD are likely to evoke strong and often negative responses among CD professionals (Horsfall, 1999). There is a risk that patients presenting with symptoms of BPD may be negatively stereotyped and treated inappropriately. There may be the tendency for staff to describe the patient in vivid and dramatic terms that can set negative expectations even before the patient arrives on the treatment unit. There may be a tendency to react to self-harming or suicidal acts with horror and/or anger. The CD counselor needs to understand this behavior in the context of the patient's underlying pain and distress and their inability to express or process those feelings. Counselors need to be educated to understand the etiology and manifestations of disorders such as BPD in order to appreciate the worldview of patients with dual disorders and enhance empathy and respect shown all patients.

ETHICAL CONSIDERATIONS

Codes of ethics and standards of practice are set forth by professional associations such as the American Counseling Association (ACA, 2001) and the National Association of Alcoholism and Drug Abuse Counselors (NAADAC, 2001). Such codes define principles of ethical behavior required by the profession. Additionally, the Hazelden Foundation defines requirements for employees designed to ensure consistent ethical behavior across the organization (Hazelden, 2001). However, practicing as a professional also requires judgment, ethical decision-making, and regular introspection and clarification of a personal code of ethics.

Parsons (1995) states that the effective helper is one who has a sense of self-awareness, an investigative approach, a desire to strive for competence, emotional objectivity, and facilitative attitudes and values. Self-awareness refers to a counselor having insight into who they are, what is important to them, their unique gifts, and limitations they bring into a helping relationship. From a Twelve Step perspective, this involves a regular, Step Ten, personal inventory (Alcoholics Anonymous, 1995). The counselor needs to be cognizant of the power differential in the counselor: patient relationship and "avoid actions that seek to meet personal needs at the expense of clients" (ACA, ¶ A.5)

To be effective, the counselor must take regular stock of their attitudes and values. Employees of Hazelden are required to provide "fair and just practices" and to treat all patients with "dignity and respect" (Hazelden, p.1). As a professional member of ACA and NAADAC, the counselor is commitment to "avoid imposing (their) own values on clients" (ACA, ¶ A.5) and to "espouse objectivity and integrity" (NAADAC, ¶ 2). This means practicing patience, tolerance, and unconditional regard for each individual client and being cognizant of personal views, which, in many cases, are shaped by a Euro-American, protestant, middle-class, traditional, nuclear family cultural experience.

This is especially important as counseling is rooted in and reflects the dominant values of the larger society, thus reflecting a primarily Eurocentric worldview (Sue & Sue, 1999). As a result, treatment has the potential to represent cultural oppression and cause harm to clients. In 1991, the Association for Multicultural Counseling and Development called upon the counseling profession to minimize this risk by adopting ethical standards that would encourage the development of competencies in multicultural counseling (Sue, Arredondo & McDavis, 1992). The present Code of Ethics of the National Association of Alcoholism and Drug Abuse Counselors stipulates that the counselor not discriminate against clients based on race, religion, age, gender, disability, national ancestry, sexual orientation, or economic condition (NAADAC, 2001). While the standard is clear, the competencies required to fulfill the expectation are less so. The lack of clarity is exemplified by, and due in part to, the inconsistent and confusing terminology such as culturally appropriate, multicultural, ethnically sensitive, and cultural diversity (Resnicow, Soler, Braithwaite, Ahluwalia & Butler, 2000). A unifying construct is required for conceptualizing the problem at an individual level and for identifying and implementing solutions.

WORLDVIEWS AS A MEDIATING VARIABLE IN COUNSELING

The Construct of Worldviews
In a broad sense, worldview can be defined as how a person perceives his or her relationship to the world and is highly correlated with a person's cultural upbringing and life experiences (Sue & Sue, 1999). It is composed of our attitudes, values, opinions and concepts, and affects how we think, define events, make decisions and behave. Trevino (1996) suggests that a worldview is formed out of personal experience through interaction with members of an individual's culture. Worldviews evolve from both shared cultural experiences and unique experiences that are particular to our personal and family histories (Terrell, 1996).

Worldviews are organized within individuals into systems of thought (Trevino, 1996) and may be perceived as value orientations, as postulated by Kluckhohn (1951). These involve abstract, core understandings of the world, involving broad aspects of life such as views on human nature, interpersonal relationships, nature and time. Value orientation is a fundamental concept that incorporates normative cognitive, directional, and affective elements (Carter, 1991).

Worldviews may also be thought of as a set of assumptions that define what can be known in the world, how it can be known, and what can be done or accomplished (Koltko-Rivera, 2000). In the face of existential uncertainty, humans form constituted worlds that create a sense of one's reality. Reality is viewed as though through a lens of assumptions, a lens that constitutes a worldview. Worldview assumptions regarding human nature include issues of moral orientation and variability. Worldviews encompass beliefs about other existential questions such as the meaning of life and whether life is worthwhile.

Sue and Sue (1999) suggest that an understanding of the worldviews is critical in order to be an effective, culturally competent counselor. A culturally skilled counselor is aware of his or her own assumptions about human behavior, values, biases and preconceived notions and actively attempts to understand, and accept as legitimate, the worldview of the client (Sue, Arredondo & McDavis, 1992). Given that all counseling is multicultural in nature, and that each individual has their own unique worldview which is inextricably interwoven with the etiology and manifestation of their addiction as well as the Minnesota Model of recovery, this then raises the question as to how to practically and reliably assess the worldview of patients in order to ensure addiction counseling competency.

Assessment of Worldviews
Trevino (1996) suggests that an effective assessment of worldview must be comprehensive, capturing a broad range of human experience, be applicable across cultural groups, and be relevant to counseling. Sue first proposed a subjective worldview model consisting of two independent dimensions, locus of control and locus of responsibility (Ibrahim, 1991; Ibrahim and Kahn, 1987). These two dimensions, when placed on a continuum to intersect provide four quadrants yielding four specific worldviews.

Acknowledging the importance of the worldview construct, Ibrahim (1991) proposed a broader conceptualization based on the value orientation theory of Kluckhohn and Strodtbeck (1961). Five existential questions relating to a person's orientation to time and activity, relationship with others and nature, and human nature were developed (Ponce, 1995). Based on this schema, Ibrahim developed the Scale to Assess World Views instrument, a 45-item scale inventory of value orientation statements (Mahalik, Worthington & Crump, 1999; Hickson, Christie & Shmukler, 1990; Ibrahim, 1991). Although this instrument has been used in descriptive research, it is yet unpublished and fails to fully assess all aspects of Kluckhohn's original model (Koltko-Rivera, 2000).

Lyddon and Adamson (1992) studied the ability of worldview assessments to predict clients' preferences for counseling approaches. Support was found for the notion that persons prefer a counseling approach that is congruent with their philosophical worldview. For example, individuals assessed as being mechanistic (orderly, conforming, passive) preferred behavioral counseling. This indicates that the assessment of worldview has the potential to add value and maximize therapeutic processes and outcomes.

Optimal theory suggests moving from a fragmented and segmented view to a more holistic view of individuals (Speight, Myers, Cox & Highlen, 1991). Optimal theory assumes the unity of spirit and matter with individuals conceptualized as unique manifestations of spirit. In a more integrated approach, individual worldviews are thought to be influenced and shaped by cultural specificity, individual uniqueness, and human universality.

Koltko-Rivera (2000) recently developed such an integrated worldview assessment instrument (WAI) which assesses selected components of worldview belief systems that are deemed to be relevant to counseling. Six dimensions of worldview were selected for psychometric scale development including beliefs concerning mutability of human nature, agency (voluntarism; determinism), locus of responsibility, relation to authority, relation to group (individualism; collectivism), and metaphysics (spiritualism; materialism). A 54-item Likert scale instrument was developed, evaluated and published. The instrument was found to fulfill accepted standards of reliability and validity to support its use as a worldview assessment tool.

The Utility of Worldviews in Counseling
Worldview assessment can serve as a mediating variable that can help operationalize client constructs that relate to personal identity in a number of ways. Studies of the worldviews of different ethnic groups suggest that ethnicity can affect patient expectancy, engagement in treatment, and attrition rates (Pena & Koss-Chioino, 1992; Belgrave, Townsend, Cherry, & Cunninghan, 1997; Odenweller, 1998; Moore, 1992). Cultural matching in terms of worldviews and cultural identity has been suggested as a means to facilitate the process of establishing a trusting therapeutic relationship.

Trevino (1996) developed a model of how worldviews can enhance the therapeutic process. He conceptualized that many people in need of counseling have some specific aspect of their worldview that has not been functioning effectively. During the initial stage of counseling, the counselor strives to achieve congruence with his or her client's worldview as a basis for enhancing the therapeutic relationship. During the intervention phase, exploring specific discrepancies and possible solutions facilitates change. There is a need for an effective and efficient worldview assessment instrument in order to operationalize this model.

An appreciation of worldviews can help counselors better understand themselves and their clients (Hichson, Christie, and Shmukler, 1990; Sue, 1978). It makes values, beliefs, and assumptions explicit and can facilitate the agreement on treatment goals and processes appropriate to the client. It is therefore important to assess the client's worldview during the initial screening process, and to tailor the counseling approach to be congruent with the worldview of the client. Persons are inclined to prefer and respond more favorably to a counseling approach that is congruent with their cultural and philosophical orientations (Lyddon & Adamson, 1992).

It is important to consider alignment of worldview orientations across various systems within a treatment facility. Consideration must be given to the collective orientations of the organization, treatment units, staff, and patients. The effectiveness of treatment is enhanced when there is reasonable congruence across these cultural group systems (Ponce, 1995). This allows for individualization of treatment planning such as the incorporation of nature walks for someone with a strong harmony with nature orientation. In addition to diagnostic and therapeutic applications, such profiling can augment the discharge planning process. For example, a more complete understanding of the client's relationship worldview would help clarify whether aftercare recommendations should involve independent living versus family or structured care environments.

In addition to worldview assessments offering an opportunity to enhance the therapeutic process, ethical obligation requires the profession to implement solutions to ensure professional competency (Sue, Arredondo & McDavis, 1992; Burn, 1992). From a position of dominant power in the therapeutic relationship, the organization and counselors have an ethical obligation to protect the welfare of the client and take whatever steps necessary to enhance the potential to positively impact treatment outcomes. Incorporation of the construct and application of worldview assessment into counselor training and continuing education programs is recommended. The construct of worldview assessment provides tools and a reasonable framework for conceptualizing individualized treatment based on the view of the world of all people from differing backgrounds and experiences. It our ethical obligation to take proactive measures to continue to enhance the competency of the programs and services offered to Hazelden clients.

PROPOSAL

From this review of the literature it becomes apparent that patients suffering from addiction stand to benefit from the incorporation of the worldview construct into treatment practices. While published authorities on the subject espouse the notion of considering the worldview of the client, and recent research indicates the positive outcome of doing so, there seems to be a virtual absence of the practical application of the construct throughout an organization. It is proposed that Hazelden lead the way by taking the bold and innovative step of implementing the clinical utilization of worldview assessments as a foundational step in the provision of recovery services.

A multilevel systems approach is proposed whereby the assessment of worldview would involve the organization at a broad, systemic level, the treatment units at a treatment program level, and counselors and patients at the individual level. A phased approach is recommended as a means of introducing the construct and gradually evolving programs and services over time. In this way, change management issues will be minimized and allow for the tailoring and optimization of services to meet the changing needs of customers.

The worldview assessment instrument (WAI) as developed and validated by Koltko-Rivera (2000) is recommended for implementation. This instrument would allow for the assessment of each patient's worldview during the intake process. Assignment to treatment units would be individualized based on a matching system designed to find the best fit between patient and unit concept. Once assigned to a unit, the treatment team would factor the assessment into assigning the most appropriate focal therapist based on degree of congruence with the various worldview dimensions of the patient. This would enhance the development of a therapeutic relationship and provide a framework for customizing all aspects of treatment and aftercare planning.

On an ongoing basis, regular monitoring of patient-unit fit is recommended. Over time, the units have tended to evolve spontaneously, developing unique customs, traditions and practices. To date, this evolution has been somewhat random and likely primarily influenced by the training, personalities, and preferred treatment styles and approaches of the treatment staff. Utilization of data from this instrument would allow Hazelden to evaluate the current extent of these differences across units, and assess the degree to which the various worldviews of patients are accommodated. Based upon ongoing internal research, unit practices could be further differentiated so as to maximize the potential to tailor unit assignment to meet the needs of the present population. With ongoing monitoring, as the patient population shifts with time, so too can unit practices.

Utilization of this construct also allows for customization of Hazelden's marketing and outreach programs. This would require assessments of the worldview of Hazelden as an organization and of the customer base. A determination of the congruence between the organization's worldview and those of current customers would facilitate the tailoring of programs and marketing messages for expanding the current customer base. Additionally, the assessment of the worldview spectrum of the general population of individuals suffering from addiction would allow for the identification of target populations currently not well served by Hazelden. This would represent areas of market growth potential that would facilitate growth strategies of the organization. Overall, this model conceptualizes the evolving alignment of the worldview orientations of the organization, treatment units, staff and patients.

Methods
A phased in approach is recommended (see Appendix A for implementation timeline). The initial phase involves the testing and customization of the WAI. A series of fifty patients would be asked to participate in research to validate and customize the instrument for use at Hazelden. Hazelden specific norms would be established and incorporated into what we will refer to as the Hazelden-WAI, and assessment descriptions would be incorporated into the scoring key and interpretive guide.

Following the initial phase, a pilot study would be carried out to determine the feasibility and impact of assigning patients to treatment units based upon worldview alignment. As a first step, the staff of one unit would be requested to participate in a team process of creating a worldview assessment of their unit. This assessment would weigh input from the results of worldview assessments of all members of the treatment team as well as individual and team assessments of the traditions, practices and norms of the unit. A series of one hundred patients would be asked to participate in the pilot study. During the intake process, while on the Ignatia medical unit, patients would be asked to complete the Hazelden-WAI. Those patients determined to best fit the profile of the trial unit would be assigned to that unit for treatment. The remaining patients would be randomly assigned to treatment units as per usual practice. Following treatment, outcome assessments would be performed on all one hundred participants by telephone contact at 3, 6 and 12 months. A full range of outcome measures would be assessed including treatment retention, abstinence rates, and compliance with aftercare recommendations. It is the hypothesis of this proposal that those who were assigned to treatment based upon a worldview assessment will do better during treatment and achieve more positive outcomes. If a positive impact is determined, it is recommended that the program proceed to full implementation.

In phase I of implementation, the remaining unit staff would participate in the process of profiling their units. Organizational intake and admission processes would undergo a series of rapid process improvement exercises to facilitate the implementation of the Hazelden-WAI for all new patients. Phase II would require the design, beta testing, refinement and implementation of customized computer software to facilitate rapid and accurate scoring of WAI scores, and integration with the admission process and RMIS system. Once implemented, all patients would be assigned to treatment units based upon best fit of their worldview. As part of Hazelden's ongoing commitment to outcome measurement, all patients would be followed with comparison of outcomes being made against historical controls over time.

Phase II implementation involves training and engagement of staff. Temporally overlapping with phase I, treatment staff would participate in educational sessions to acquire new information and skills required to incorporate the use of worldview assessments into treatment and aftercare planning. In terms of change management, training sessions would also serve to engage the staff in the process of change. Counselors would undergo personal worldview assessments and participate in the process of evaluating the worldview of Hazelden and the individual units. Regular inservice sessions would be part of an ongoing evaluation process and evolution of individual and unit treatment practices. Counselors would be provided with exercises such as role-playing for internalizing and integrating their learning.

The final stage of implementation involves the integration of the worldview construct into the strategic framework and operational procedures of the organization. This includes the incorporation of worldview assessment and outcome data into market research as well as outreach and communication programs.

The main costs of piloting and implementing this initiative involve staff salaries (see Appendix B for budget proposal). Additional costs include software development and inservice education programs. Once implemented, ongoing operational integration and staff development would be handled through the ongoing operating budget of the organization.

Discussion
This proposal presents Hazelden with an exciting opportunity to enhance the professional competency of recovery services and the therapeutic outcomes of patients. By acting now, Hazelden can lead the way in developing a new and innovative approach that treats the whole person and provides a framework for evolving core programs and services to align with the needs of present and future patients.

There are many advantages to this proposal. It utilizes an instrument that has been designed for use in counseling which has been shown to be reliable and valid. By introducing the use of this instrument in a phased approach, minimal disruption of current processes is anticipated. Furthermore, the change process is one of evolution, rather than revolution or reengineering. Current unit practices and traditions serve as a baseline for implementing the program. Unit practices and treatment procedures will evolve only as indicated by reliable, internal research, and involve the staff in the change process. Through better alignment of the worldviews of the organization, treatment unit, counselor staff and patients, it is anticipated that Hazelden will improve the retention of patients for full courses of treatment and improve health outcomes.

Sponsorship of the initiative is suggested at the level of the Executive Director of Recovery Services as a means of garnering executive support, ensuring strategic alignment (see Appendix C for strategic alignment), and facilitating the change management process.

The implementation of this proposal not only enhances compliance with ethical standards of professional practice, but it is well aligned to Hazelden's strategic framework, thus positively impacting the potential of the organization to achieve its vision as the leader in developing innovative services for those suffering from addiction (Hazelden Foundation, 2002).

CONCLUSION

Addiction has been understood to be a complex, multifactorial disease impacting the entire family system. As such, a holistic approach is advocated that allows for individualization of treatment based upon an appreciation of each individual patient's unique situation and worldview. Hazelden's Minnesota Model has been successful because it incorporates a treatment philosophy and approach that address the core issues of addiction while fostering an individualized approach to treatment. Existential issues are seen to be at the root of addiction and formative in the life and work of Carl Rogers. Many of the phenomenological perspectives that are common between Roger's client-centered approach and existential therapy are also seen to be foundational to the philosophy and practice of the AA movement. Common to AA, the Minnesota Model incorporates an existential philosophy and provides a caring, nurturing, client-centered environment where patients can find healing. In this context, the recovering addict gains insights into the meaning of life, the implications of essential limitation, and learns to accept life's mutuality's. Through individual and group experiences, the addict gains insights into the relationship between their private and public selves and learn ways to successfully adapt to the essential conflicts of life.

It is proposed that the assessment of worldviews be introduced as a unifying construct for further individualizing and enhancing the quality of services offered to the patients of Hazelden. Embracing worldviews as a unifying construct links to the core fundamental philosophy of the Minnesota Model which is inherently existential and client centered, accepting the individual's subjective meaning of their life. The notion of worldview is inextricably interwoven with the etiology, manifestation, and Minnesota Model treatment approach of addiction.

Worldview assessment would provide a mechanism for the alignment of the patient with treatment unit, counselor and treatment approach. It is anticipated that the implementation of this customer-focused proposal will improve the quality of recovery services, enhance counselor multicultural competency, and improve patient outcomes. Implementation of the construct aligns with Hazelden's strategic direction and allows for integration with the operating procedures of the organization. This proposal offers Hazelden a unique opportunity to enhance counselor competency and to lead the way in developing innovative programs and cutting-edge research capabilities. Over time, this integrated strategic approach has the potential to shape future programs and services that improve the effectiveness and quality of treatment services so as to better meet the needs of the evolving and increasingly diversified customer population.

APPENDIX A

Implementation Timeline

Initial Phase

• Instrument testing (50 patients)
• Hazelden customization

Pilot Study

• Feasibility trial involving profiling of one treatment unit (100 patients)
• Outcome measures at 3,6 & 12 months

Phase I Implementation

• Profile remaining units
• Phased in unit assignment of all patients
• Rapid process improvement of intake and admission processes

Phase II Implementation

• Computer software development & implementation
• Staff training & engagement

APPENDIX B

Proposed Budget

Expenses		Estimated costs ($)
Project Manger (0.25 FTE @ $50/hr. for 2 years)		$52,000
Research Specialist (0.5 FTE @ $12/hr. for 1 year)		$12,500
Computer Software Development		$20,000
Inservice Sessions (3 sessions @ $5K each)		$15,000
TOTAL		$99,500

APPENDIX C

Strategic Alignment

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