'There is No Room for Stigma' in Addiction Treatment

By Dr. Richard Juman 08/13/15

How a prominent clinician developed “Carefrontation” in his work with patients.

Harris Stratyner
Dr. Harris Stratyner Photo via

Dr. Harris Stratyner, PhD is a licensed ​psychologist and an internationally recognized expert on addiction, with a particular specialty in co-occurring disorders. He is the Vice President and New York Regional Clinical Director of Caron Treatment Center and Clinical Associate Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai. Dr. Stratyner​ also​ maintains a private practice in New York​. He is the co-author of the PDR Guide to Pediatric and Adolescent Mental Health​.

His treatment approach, in contrast to those that rely on confrontation when patients fail to adhere to prescribed behaviors, holds them to a single standard, that they strive to become experts about their illness and devise a treatment plan that will set them on a road to stable recovery. 

Richard Juman: You are perhaps best known for utilizing the “Carefrontation” approach to working with addictive disorders. Just in case some of our readers are unfamiliar with the concept, would you give a brief history and summary of the approach? 

Harris Stratyner: Carefrontation came about in the early '80s and has continued to grow, particularly as an approach to primarily treating individuals with co-occurring disorders (psychiatric issues and substance abuse). In my case, I noticed very early on, when I started one of the first MICA (Mentally Ill Chemical Abuse) programs in the country, at Rockland Psychiatric Center's outpatient division in New York, that folks with psychiatric illnesses were being stigmatized, but they in turn were stigmatizing individuals with addiction issues! And I would see that even some of the staff were taking a moral approach to these people—using strong confrontation in an effort to break through defense mechanisms. But I found that these techniques usually only made things worse. 

Around this time, I became aware of the work of Bernie Siegel, MD. He originally practiced general medicine and pediatric surgery but pioneered a caring approach to empowering individuals to deal with illnesses, like cancer, that threatened their mortality. It was an approach that encouraged and assisted patients who were “stuck” to take action by letting them know, as they worked with their doctors, that they could work on themselves through meditation and insight. He encouraged them to approach themselves with care and love, and he himself grew as a caring practitioner. 

So as I was learning about this approach, I realized that the concept of “carefrontation” might have a place in the work that I was doing with co-occurring individuals. I saw the logic of empowering people to take action through a gentle, loving approach, but at the same time holding them responsible for their treatment. Don't try to knock people down—like so many therapeutic communities (TCs) were doing at the time—just be supportive and understanding, but let folks know that they first and foremost must take responsibility for their illness or illnesses.

In my studies of addiction and work with patients it was clear that so many of these individuals also had some form of major psychiatric clinical syndromes and/or personality issues. To blame or shame them was not the answer! Instead, it made much more sense to use an evidence-based approach that focused not on shaming or blaming the patients for having an illness, but instead on caringly holding them responsible for their own care. My focus was to help people take control by taking medication if necessary, utilizing professional counseling and self-help groups, taking whatever steps they could to deal with their diseases(s) and live healthy, productive lives. It is important to always remember that addiction is indeed a brain disease—it is primary, progressive and chronic. And if it is not addressed, it’s potentially fatal—so there is no room for stigma.

By this time, my career and doctoral work had moved on, and I was working at Four Winds Hospital, a private psychiatric facility in New York. I began studying the work of James Prochaska and colleagues, as well as the work of Rotter, and later Achterberg and Lawlis. So suddenly I had the tools to bring about readiness to change and belief in oneself in my patients: the Transtheoretical Model of Change, and Internal and External Locus of Control, respectively. I found that when I worked in a caring manner to motivate people to change, as opposed to shaming and stigmatizing them, the results were impressive and people could become sober and healthy.

You’ve been working with a Carefrontation framework for many years now. How have your ideas about Carefrontation evolved over the years? 

I’ve always continued to be impressed by the power of Carefrontation: Regardless of someone's diagnosis (severity), they always should be treated with respect and dignity, and their efforts to take responsibility for their own health and treatment should be modeled and reinforced.

Over time, I began to incorporate the work of several other clinicians into my approach, such as Roger's Person-Centered approach and Frieda Fromm-Reichmann's understanding of the importance of Therapeutic Alliance in treating symptoms as metaphors. I also studied Bosgang's Benevolent Transformation, with an eye towards being flexible and always erring on the side of empathic understanding. That led to my concept of fixed but fluid boundaries, which helps soften the person I may represent to the patient who is, in one way, taking away what Khantzian would refer to as the patient's self-medicating behavior. I would do this by sharing something personal that is appropriate with a patient—such as a picture or a piece of music, or recommending a book or perhaps a movie that almost serves as a transitional or comfort object in a way that is somewhat related to Winnicott's concept. 

In keeping with this, my patients always have phone access to me, but they also clearly understand the difference between a sponsor and a therapist. I find that this tends to foster a positive transference. Of course, I rely heavily on the aforementioned Transtheoretical Model of Change and the Model of Internal and External Locus of Control, which Achterberg and Lawlis referred to as Health Attribution Locus of Control, with their further breakdown of external locus of control into two parts—belief in powerful others, and fate and spirituality. 

Often people are surprised that a cognitive motivational therapist has strong roots in psychoanalytic theory and object relations. I believe that a good therapist needs to use whatever tools can benefit his patient, just as Prochaska and colleagues outlined with their "10 processes of change." 

I believe that the ideal goal in the treatment of addiction is complete abstinence, but it doesn’t come about overnight. The clinician must be mindful of this and meet the patient where he or she is at—otherwise patients vote with their feet and leave treatment. While I am not a strong believer in true moderation management, I believe it is every clinician's duty to use harm reduction and to realize that clinical progress, as Miller and Rollnick point out, comes in stages.

It is widely accepted that addiction is a family disease and I work with families to educate and accept, but not enable the patient. However, this does not mean throwing patients out of their lives but rather reinforcing their treatment without using the threats that are so often seen in confrontation.

I want to highlight that I continually use the word "patient," and not "client." That is because I want to reinforce that I am a doctor of psychology who is there to address the individual’s illness; I have actually found this to be ego-syntonic, because the patients come to realize that they are not their illness.

As Carefrontation has evolved over many years I have also gone on my own journey, so to speak, and use mindfulness meditation both in my life and with my patients. I am in no way a "new age" therapist, but I am spiritual in an effort to be grounded, and find the work of Kabat-Zinn to be well-documented and effective.

So Carefrontation is motivational, rooted in developmental theory, supportive, and spiritual. I never judge my patients, whether I am working on a chemical or process addiction, and I suppose I would have to use that catch-all phrase "eclectic." I always support the use of medication, if warranted, as evidenced by my co-authoring the PDR Guide to Pediatric and Adolescent Mental Health (2009), and I reinforce choices for patients. I believe that one size does not fit all, which I describe as "selective autonomy." I suggest the levels of care an individual might need, but reinforce their autonomy in making those choices. Like Linehan, I use individual and group work, and have always seen myself as a coordinator of services.

In this day and age of evidenced-based practice, I believe in utilizing only those methodologies that have been well-studied. Patients have a right to be well-informed and discuss their needs and concerns, and again this comes back to the foundation of Carefrontation—respect and dignity with reinforcement and teaching the patient to take responsibility for their treatment. 

I would imagine that some of your patients, particularly those who have been involved in more traditional forms of treatment that can be heavy-handed or even punitive, might be taken aback by your "carefrontational" approach. Does that happen? 

One of my favorite sayings with my students and colleagues is this: "never look for univariate answers to multivariate questions." There are multivariate reasons why patients respond the way they do, be it positive or negative, to Carefrontation. Those who respond positively do so because they finally feel like someone understands them. 

For example, a male patient with both schizophrenia and alcohol use disorder (under the model of Carefrontation one is never simply referred to by his or her diagnosis) who has delusions or hallucinations involving God might have an aversion to 12-step meetings. He might be the last person who wants to hear the concept of God in a 12-step meeting if he believes that God is punishing him. When he sees that I understand that and meet him where he’s at, it moves the therapeutic bond and the treatment forward. By the same token, if an anti-social person has a history of manipulating staff members in a punitive programs, and now there is no need to, they may be thrown off by that. Some of their primitive defense mechanisms, like projective identification, simply fall on deaf ears. 

I always treat my patients like students. I discuss brain chemistry with them, synergistic combinations of legal and illicit drug use, medications and why a psychopharmacologist might be helpful. Treated in this way, patients begin to feel a sense of belonging and partnership. Their defenses go down and their positive transference increases.

Interestingly, it is not uncommon to see that it’s the family members who become defensive about this approach. They may be used to being told that “tough love” is the answer by more confrontative programs. They want to buy into this but often can't, and sometimes feel like they are being talked down to by clinicians who have the attitude of "it's their way or the highway." Interestingly, when they come to see me, they are at their most defensive and struggle with an intellectual approach that searches for logical treatment solutions. I hear things like, "he is too much like a friend—our son will eat him alive," or "he is too nice." I always remind these individuals that the word is Carefrontation, and that the "frontation" is all about having patients take responsibility—there is no room for enabling!

Richard Juman—a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings—is also former President of the New York State Psychological Association. [[email protected]] Find him on twitter—@richardjuman

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.