How a prominent clinician developed “Carefrontation” in his work with patients.
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. Read more “the fix”…