Avoiding Clinical Drift

Learning how to use CARE with your clients

David Bricker, Mark Glat, and Sherri Stover
Magazine Issue
January/February 2007
Avoiding Clinical Drift

Q: Lately, some of my therapy sessions are feeling less focused–more like friendly conversations and reviews of the week’s events. How can I better organize my work and keep therapy moving toward objective, recognizable goals?

A: Getting unstuck in your therapy requires a good “clinical toolbox”–a set of useful, empirically informed ideas about therapy and human behavior that are easy to remember, easy to access, and foster “clinical mindfulness.” Being an effective therapist requires not only being empathic, but having concrete skills that help make a difference in the lives of our clients.

The toolbox we use has four compartments that correspond to the areas most clients must address in therapy:

* Cognitions–all the words, ideas, and concepts that shape a client’s way of seeing the world;

* Actions–behaviors and activities that structure experiences inside and outside of the consulting room;

* Relaxation–that’s shorthand for the importance of managing bodily responses, especially anxiety, in clinical work;

* Emotional Expression–the role that feelings play in all forms of psychotherapy.

Keeping the acronym of CARE in mind (as both an idea and a mantra) will help your practice become more focused and effective.


Since identifying clinical drift isn’t always easy, a good strategy is to periodically ask yourself whether your treatment is working on one or more of the CARE elements. Chances are if you’re having trouble answering the question, it’s time to take out the CARE toolbox.

To help a client develop new point of view, you can begin by distinguishing the cognitions that are shaping his or her perspective of the problem. Of course, there are a variety of ways of doing this. Roadmaps for cognitive restructuring include thought logs, feeling diaries, and checklists. Other CBT tools discussed by Aaron Beck or David Burns that may also be helpful here.

At the same time that you’re facilitating a new understanding of a situation and different goals, the Action compartment of our toolbox reminds us that behaviors have both obvious and subtle connections to the problem at hand. Templates and roadmaps for establishing new patterns of behavior as well as extinguishing unwanted ones abound within the CBT tradition. Some make use of the tried and true principles of learning and operant conditioning, others employ social-skills training, while still others combine elements of both of these with motivational strategies designed to identify a client’s values, beliefs, and willingness to change.

Whether you call it reinforcement or secondary gain, the cycle of choosing short-term relief while perpetuating long-term pain and chaos is one with which clinicians of all orientations are a familiar. Clients who are anxious avoid confronting the situations that they need to deal with to have a full and productive life. In doing so, they deprive themselves of the opportunity to develop the skills needed to cope with similar situations in the future. This is a breeding ground for drift and despair on both sides of the clinical relationship. This is where Relaxation and other techniques like positive imagery, mindfulness, and acceptance strategies come in.


Because feelings are central to psychotherapy, CARE can’t occur without Emotional Expression. Negative feelings, such as anger and resentment, may be difficult to express. We encourage the client to look for the other feelings underneath the anger and to consider what they might signify. Our toolbox has templates and roadmaps to help a client see, for instance, that a negative feeling of inadequacy is actually only one side of a two-sided coin–the other side of which is a desire to be effective and whole. We have numerous templates to identify the goals and motivations behind seemingly untoward and unhelpful feelings.

To get a better feel for how CARE works, consider the following situation. Your client is a woman in her early forties with three children aged 12, 9, and 6. She’s engaged in a bitter divorce from a man she perceives as selfish, withholding, manipulative, and hostile. Her history is notable for the loss of her father when she was 12 and what she describes as her mother’s long history of depression and bitterness following this loss. This made her daughter feel criticized and judged. The client never completed college, but was fully supportive and involved in her husband’s business successes during the course of the marriage. She herself acknowledges her own anger, low self-esteem, feelings of victimization, and vulnerability to depressed moods.

Suppose you notice that when you gently challenge her version of what the conflict of the moment is with her estranged husband or suggest how her reactions to her children are reminiscent of how her own mother treated her, your client’s anger and frustration can be intense. When you “back off” and settle into a more neutral stance of unconditional acceptance, the client becomes increasingly frustrated with the lack of meaningful change that she’s experiencing in and out of therapy. In this situation, anxiety, powerlessness, frustration, and defeat are likely to emerge on both sides of the clinical equation.

Here’s when the CARE mantra can be most useful to pull you out of clinical drifting.


Cognition. Look for long-term patterns in the moment to moment thoughts. These are likely to work with a client whose life is full of challenges, but who also is able to see beyond these stressors to what she can commit to and do for herself. But remember, emotional enlightenment doesn’t necessarily bring emotional relief. Behaviors must also change. There’s more work to be done.

Action. Try assertiveness training and solution-focused problem solving. These will expand her behavioral repertoire and also serve to remind her of times in her life when she’s been effective. However, action is less likely if she is crippled by anxiety and agitation. You need to dig into your toolbox again.

Relaxation. To address the corrosive influence of chronic distress and agitation, use simple relaxation-training exercises and meditation, and support naturally occurring activities, such as running, to promote healthy distraction and stress reduction. Keep in mind that you’re putting a lot on your client’s plate. The trick is doing this without making her feel even more burdened and criticized.

Emotional Expression. Try using emotional-validation strategies. This would help her express the hurt and sadness she’s feeling. These experiences will also help her to see the “wisdom” of her anger, which is a recognition of what she really wants (security and justice) and what she needs to do to get them.

Harry Stack Sullivan, the renowned American psychiatrist, once said, “Therapy is a discussion between two people, one of whom is more anxious than the other, and it’s not always clear who that is.” That’s clinical drift. We think that what transforms talking into therapy and anxious feelings into clinical data is a good clinical toolbox that promotes therapeutic mindfulness, focus, and flexibility.

David Bricker, Ph.D., is adjunct clinical supervisor at Albert Einstein College of Medicine in the Bronx, New York. He’s the coauthor of A Client’s Guide to Schema-Focused Cognitive Therapy. Mark Glat, Ph.D., Psy.D, is president and cofounder of Group Interactions, a clinical services development firm with a core expertise in the application of group methodologies in a variety of clinical and business settings. Sherri Stover, Psy.D., is vice president and cofounder of Group Interactions. She’s served as director of internships in psychology and group therapy services at the Carrier Clinic in Belle Meade, N.J.