‘There is No Room for Stigma’ in Addiction Treatment

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

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.


Read more via The Fix: ‘There is No Room for Stigma’ in Addiction Treatment