Documenting Play Therapy Notes: Best Practices for Therapists
As play therapists, our work extends far beyond the playroom. Each session is a journey into a child's world, full of rich narratives, powerful emotions, and transformative moments. But how do we capture these experiences? How do we hold onto the threads of progress, the emerging themes, the shifts in behavior, and the effectiveness of our interventions? The answer lies in our play therapy notes.
Our notes are more than just a professional requirement or a way to communicate with others involved in the child's care. They are, in many ways, a conversation with ourselves. They are our roadmap guiding us through our therapeutic journey with each child. They help us remember, understand, and plan. They allow us to reflect on our work, see patterns, celebrate successes, and adjust our strategies when needed.
Each note we write is a snapshot of a moment in time, preserving the rich tapestry of interactions, expressions, and emotions that unfold in the playroom. They are our silent partners, helping us stay focused, organized, and mindful of our therapeutic goals.
Our play therapy notes mirror our work and are a compass guiding our future interventions. They are an integral part of our practice, a tool for enhancing our understanding of our clients, and a resource for informing our next steps. As we delve deeper into note-taking in play therapy, we'll explore making this process as meaningful and effective as possible.
Key Elements to Include in Play Therapy Notes
Documenting play therapy notes is a nuanced process requiring objectivity, empathy, and clinical insight. Here are some key elements that can help structure your notes and ensure they capture the essence of each session.
Start with the basics. Include the client's name, age, date, and session number. This information helps to organize your notes and provides context for each session.
Clearly state the goals of therapy. These could be broad, long-term goals or, more specifically, short-term objectives. They provide a roadmap for the therapy process and a benchmark for assessing progress.
A description of the session is the heart of your note. Describe the child's play, their interactions with you, and any significant behaviors or statements. Remember to stay objective, focusing on what you observed rather than interpreting the child's actions or emotions.
Note the child's responses to your interventions or any changes in their behavior during the session. Client response can provide valuable insights into what strategies are effective and how the child is progressing towards their therapy goals.
Document the interventions you used during the session. This part of the note could include specific play therapy techniques, questions you asked, or any changes you made to the play environment. Writing the interventions used helps you track your practice and records what approaches you have tried.
Reflect on the child's progress toward their therapy goals. Progress might involve:
- Comparing their behavior in this session to previous sessions.
- Noting any new skills or behaviors.
- Discussing any challenges that arose.
Plan for Next Session
End your note with a plan for the next session. The plan could include:
- Any interventions you plan to use.
- Themes you want to explore.
- Skills you want to work on.
The plan section helps to keep the therapy process focused and ensures that each session builds on the last.
Remember, while it's important to be thorough, your notes should be concise and easy to read. Use clear, straightforward language and avoid jargon where possible. And most importantly, always write your notes with the understanding that they may be read by others, including the child's parents or other professionals involved in their care.
Different Types of Therapy Notes
In play therapy, therapists can use several types of notes to document their sessions. Each type has its structure and focus, and the best choice often depends on the therapist's style, the setting in which they work, and the child's specific needs. Here are four commonly used types of therapy notes.
SOAP stands for Subjective, Objective, Assessment, and Plan. This format is widely used in the medical field and can also be effective for play therapy.
- Subjective: This section includes the therapist's observations of the child's mood, statements, and behaviors.
- Objective: Here, the therapist records factual information about the session, such as the child's actions and emerging play themes.
- Assessment: The therapist interprets the session professionally, including progress toward therapy goals.
- Plan: The therapist outlines their strategy for future sessions, including any interventions they plan to use or issues they want to address.
DAP stands for Description, Assessment, and Plan. This format is similar to SOAP but leaves out subjective observations.
- Description: The therapist provides a detailed session account, including the child's behaviors, interactions, and play themes.
- Assessment: The therapist offers their professional interpretation of the session, including any progress or changes they observed.
- Plan: The therapist outlines their plan for the next session, including any interventions or strategies they plan to use.
Narrative notes are less structured than SOAP or DAP notes. They allow the therapist to write a detailed session narrative, including their observations, thoughts, and interpretations. This format can be useful for capturing the richness and complexity of play therapy, but it can also be time-consuming to write and difficult to skim key information.
Checklist or Template Notes
Some therapists prefer to use a checklist or template for their notes. This can include a list of common play themes, behaviors, or interventions that the therapist can check off or rate on a scale. This format can be quick and easy to use but may not capture a play therapy session's full depth and nuance.
Each format has pros and cons; many therapists use a combination of styles depending on the situation. The key is to find a method that works for you and meets your client's needs.
Tips for Streamlining Play Therapy Notes
Documenting play therapy sessions is crucial to our work as therapists but can also be time-consuming. Here are some tips to streamline your note-taking process without compromising on the quality or depth of your notes.
Know Your Theory
Understanding the theoretical framework that guides your practice can help you focus your notes. Whether working from a psychodynamic, cognitive-behavioral, or humanistic perspective, your theory will guide what you pay attention to and how you interpret it. Keep your theoretical lens in mind as you write your notes.
Include the “What” and “How”
When describing the session, include what happened (the child's actions, words, and play themes) and how it happened (the child's tone, affect, and interaction style). This information will give a fuller picture of the session and provide valuable insights into the child's experiences and coping strategies.
Get Clear on Your Top Interventions and Techniques
As a play therapist, you likely have a toolbox of interventions and techniques you use regularly. Get clear on these and ensure you're documenting them consistently in your notes. This can help you track which interventions are most effective and provide a record of your therapeutic approach.
Keep It Simple, Keep It Short
While it's important to be thorough, your notes should also be concise and easy to read. Avoid jargon and use clear, straightforward language. Others may read your notes, including parents and other professionals, so they should be understandable to non-specialists.
Use a Template or Checklist
Using a template or checklist can help streamline your note-taking process. A template can ensure that you're consistently documenting all the necessary information and can save you time by providing a clear structure for your notes.
Remember, your notes aim to provide a clear, accurate, and useful record of each play therapy session. By keeping these tips in mind, you can streamline your note-taking process and make your notes a more effective tool for your therapeutic work.
Utilizing a Comprehensive Template for Play Therapy Notes
A comprehensive template for play therapy notes can be a game-changer in your practice. It provides a structured format that ensures you capture all the necessary information while allowing for the flexibility and depth needed to reflect the therapeutic process accurately. Let's explore how to utilize this template effectively.
Mental Status Exam and Observations
At the beginning of your note-taking, it's crucial to document your observations of the child's mental status and behavior. This provides a snapshot of the child's state during the session and can help track changes.
Here are the key areas to focus on:
- Appearance: Note the child's physical appearance, clothing, hygiene, and any noticeable changes since the last session.
- Speech: Observe the child's speech patterns. Are they speaking clearly and coherently? Is their speech fast or slow, loud or soft?
- Eye Contact: Document the level and appropriateness of eye contact. Are they making regular eye contact, avoiding eye contact, or is their eye contact overly intense?
- Attention: Assess the child's level of focus and concentration. Are they easily distracted, or do they remain focused on their play?
- Delusions: If applicable, note any delusions or false beliefs the child may express during the session.
- Perceptual Abnormalities: Document any abnormalities in the child's perception, such as auditory or visual hallucinations.
Next, focus on the child's mood, affect, body posture, activity level, and orientation:
- Mood / Affect: Note the child's emotional state. Are they happy, sad, anxious, angry, or displaying any other significant emotions? Is their affect congruent with their stated mood?
- Body Posture: Observe the child's body language. Are they relaxed, tense, engaged, withdrawn, or displaying any other notable postures?
- Activity Level: Assess the child's level of activity. Are they highly energetic, moderately active, or low in activity? Do they display any fidgety behavior or tics?
- Orientation: Determine if the child is oriented to person, place, time, and object. Document any signs of disorientation.
By carefully observing and documenting these aspects, you can comprehensively understand the child's mental and emotional state during each play therapy session. This information is invaluable for tracking the child's progress and adjusting your therapeutic approach as needed.
In play therapy, a critical aspect of the safety assessment is documenting any potential risks of harm to the child or others, as reported by caregivers or observed outside of sessions. This includes recording any statements made by the child indicating self-injury, suicidal ideation, or harm to others, as well as any concerning behaviors noted during sessions or reported by other significant individuals in the child's life.
By identifying these risks, therapists can collaborate with the child, caregivers, and other professionals to develop a safety plan, which may involve additional therapeutic interventions, referral to a psychiatrist, or coordination with the school to ensure the child's safety.
Progress Notes: Documenting Session Entry and Stage of Therapy
Progress notes play a pivotal role in documenting a play therapy session. They offer a detailed record of the child's engagement with the therapy process and their progression over time. Here are the key components to include:
Client's Entry into Session:
Begin by noting how the client entered the session. This can provide insights into the child's feelings towards therapy and their willingness to engage.
Here are some examples:
- Willingly: The child entered the session without hesitation, ready to engage in play therapy.
- Hesitantly: The child showed some reluctance or uncertainty upon entering the session.
- Resistant: The child displayed resistance or opposition to participating in the session.
- Only if accompanied by a caregiver: The child was willing to enter the session only if accompanied by a trusted adult.
- Eagerly: The child showed enthusiasm and eagerness to start the session.
Stage of Therapy:
Documenting the stage of therapy the child is in can help track the child's progress over time. This can be particularly useful when reviewing the therapy process, planning future sessions, or communicating with parents or other professionals about the child's progress.
Some possible stages to include in your conceptualization:
- Acclimation: The child is getting used to the therapy environment and the therapist.
- Exploration: The child explores their feelings, thoughts, and behaviors through play.
- Testing: The child is testing boundaries and the therapist's reactions.
- Dependency: The child depends on the therapist for support and guidance.
- Growth / Working: The child is actively working through their issues in therapy.
- Resolution: The child is resolving their issues and preparing to end treatment.
- Termination: The therapy process ends, and the child is preparing for closure.
You can create a comprehensive record of the child's therapy journey by carefully documenting these aspects in your progress notes. This can be invaluable for evaluating the effectiveness of the therapy, planning future interventions, and communicating the child's progress to caregivers and other professionals.
Qualities and Urgency of Play
Understanding the nature of a child's play is a key aspect of play therapy. It can provide valuable insights into the child's inner world and the issues they are working through. Here are the key elements to document:
Qualities of Play:
Note the distinctive characteristics of the child's play. These characteristics can help you understand the child's emotional state, their coping mechanisms, and the themes they are exploring. Some examples include:
- Fantasy: The child uses imaginative play to explore different scenarios or roles.
- Dissociative: The child disconnects from the reality of their play, possibly indicating trauma or distress.
- Regressive: The child engages in play typical of younger children, which may suggest a need for comfort or safety.
- Trauma: The child reenacts traumatic events or experiences through their play.
- Expressive: The child uses play to express their feelings, thoughts, or experiences.
- Cathartic: The child uses play to release strong or pent-up emotions.
- Empowering: The child uses play to gain control or mastery.
- Integrative: The child uses play to make sense of different experiences or feelings.
- Transformative: The child uses play to explore change and growth.
Urgency of Play:
Assess the intensity or urgency of the child's play. The urgency of play can indicate the child's level of engagement and the importance of the themes they are exploring. For example:
- High: The child demonstrates energetic and intense play, characterized by rapid movement, active exploration, and frequent shifts in themes or materials.
- Medium: The child shows moderate activity and engagement in play.
- Low: The child displays low activity levels, appearing passive, disinterested, or withdrawn in play.
Toys Used in Play Therapy
The choice of toys used in a play therapy session can provide significant insights into the child's emotional state, interests, and the themes they are exploring. Here are some examples of toys and their potential interpretations:
- Doctor/Medical: Toys related to medical experiences can help children explore healthcare themes, process medical experiences, or express concerns about health and body issues.
- Board Games: Interactive games can promote social skills, cooperation, and problem-solving. They can also provide a structured way for children to express themselves and interact with the therapist.
- Sand Tray: Sand tray play can offer a non-threatening medium for children to express their feelings and experiences. It can also encourage creativity and imagination.
- Sensory Play Materials: Textured objects, fidgets, playdough, and other sensory materials can provide sensory exploration and help self-regulation.
- Baby Doll/Caretaker: Toys for nurturing, caregiving, and exploring parental roles can help children process attachment issues and familial relationships.
- Puppets: Puppets can facilitate role-play, storytelling, and the expression of feelings and experiences.
- House/People: These toys can be used for role-playing and exploring relationships and daily life. They can help children create small worlds and explore family dynamics.
- Dolls and Action Figures (including heroes, villains, and Transformers): These toys can facilitate imaginative play and storytelling. They can also help children explore power, control, and morality themes.
- Blocks/Building: Construction toys can promote creativity, problem-solving, and spatial skills development. They can also provide a sense of mastery and control.
- Computer/Video Games: These can engage children in a familiar activity while observing their problem-solving skills and reactions to success or failure.
- Kitchen/Food: Toys for cooking, nurturing, and exploring domestic roles can help children process familial roles and daily routines.
- Books/Stories: These can facilitate storytelling, expression of feelings, and exploration of different scenarios or roles.
- Tools: Toys representing tools can promote exploration, problem-solving, and mastery. They can also help children process themes of control and competence.
- Animals and Animal Figures: Toys representing animals can help children explore instincts, emotions, and relationships.
- Expressive Materials: Art supplies for visual expression (crayons, markers, paint, clay) can provide a non-verbal medium for children to express their feelings and experiences.
- Other / Elaboration: Always note any toys that don't fit into these categories and elaborate on how the child used them in play.
By documenting the toys used in each session, you can track changes in the child's interests and themes over time. Reporting toys can provide valuable insights for your therapeutic interventions and help communicate the child's progress to caregivers and other professionals.
Themes and Interpretation
Identifying the themes that emerge during a child's play can provide valuable insights into their emotional world and the issues they grapple with. Here are some common themes and what they might indicate:
- Victim: The child may be processing experiences of victimization or injustice. Victim play could be related to bullying, abuse, or other traumatic experiences.
- Perpetrator: The child may be exploring feelings of guilt or shame or trying to understand the perspective of someone who has harmed them.
- Violation: This theme could indicate experiences of boundary violations or invasions of privacy.
- Trauma: The child may be reenacting traumatic events or expressing trauma-related feelings.
- Danger: This could indicate feelings of fear or insecurity or experiences of threat or harm.
- Fear: The child may express concerns about specific situations or more general anxieties.
- Hopelessness/Despair: This theme could indicate sadness, grief, or despair.
- Competency: The child may explore their abilities and strive for mastery and achievement.
- Inadequacy: This could indicate low self-esteem, self-worth, or fear of failure.
- Confusion: The child may try to understand confusing experiences or complex emotions.
- Anxiety: This theme could indicate worry, nervousness, or unease.
- Failure: The child may be grappling with experiences of failure or disappointment.
- Anger: The child may be expressing anger or frustration.
- Protection: This theme could indicate a need for safety and security or a desire to protect oneself or others.
- Security: The child may be seeking reassurance and stability.
- Boundaries: The child may be exploring personal boundaries and personal space issues.
- Empowerment: The child may be seeking a sense of control or power.
- Power & Control: The child may explore the dynamics of power and control or express a need for autonomy.
- Revenge: This theme could indicate resentment or a desire for retribution.
- Attachment: The child may be exploring relationships and attachment figures.
- Nurturing: The child may express a need for care and nurturing or explore caregiving roles.
- Assurance: The child may be seeking validation and reassurance.
- Attention: The child may be expressing a need for attention or recognition.
- Loneliness: This theme could indicate feelings of isolation or loneliness.
- Loss: The child may be processing experiences of loss or grief.
- Separation: The child may be exploring feelings related to separation or abandonment.
- Death: The child may be grappling with death or dealing with grief.
- Change: The child may try to understand changes in their life or feelings.
- Adjustment: The child may be dealing with transitions or adjustments.
- Choices: The child may explore decision-making and the consequences of different options.
- Reality: The child may distinguish between fantasy and reality or express their perception of reality.
- Grounding: The child may be seeking a sense of grounding or stability.
- Truth: The child may be exploring concepts of truth and honesty.
- Lies: The child may be dealing with issues of deceit or dishonesty.
- Deceit: The child may be exploring themes of trickery or manipulation.
- Trickery: The child may be expressing a sense of being tricked or fooled or exploring the concept of trickery.
- Other: Always note any emerging themes during the child's play, and provide your interpretation.
By identifying and interpreting these themes, you can better understand the child's experiences and emotional world. Themes can also guide your therapeutic interventions and help you communicate the child's progress to caregivers and other professionals.
Keeping track of the interventions used during a play therapy session can provide valuable insights into the most effective techniques for the child. Here are some interventions you might use:
- Non-directive play therapy techniques allow the child to lead the play, expressing themselves freely and exploring their feelings at their own pace.
- Directive play therapy techniques involve more guidance from the therapist, directing the child's play toward specific therapeutic goals.
- Tracking: This involves narrating the child's play, reflecting on their actions and feelings to validate their experiences and help them understand their emotions.
- Coregulation techniques: These techniques help the child manage their emotions and behavior, teaching them self-regulation skills.
- Limit Setting: Set boundaries for the child's behavior to create a safe, structured therapeutic environment.
- Emotion Naming: This technique involves naming the emotions the child expresses in their play, helping them identify and understand their feelings.
- Metacommunication involves communicating about the communication process and helping the child understand their communication patterns and behaviors.
- Encouragement: This involves providing positive reinforcement to the child, boosting their confidence and self-esteem.
- Mirroring: This technique involves reflecting the child's emotions and behaviors to them, helping them gain self-awareness.
- Therapeutic storytelling involves using stories to explore therapeutic themes, helping the child understand and process their experiences.
- Sandplay Therapy: This involves using sand and miniature figures to create scenes, providing a non-verbal medium for the child to express their feelings and experiences.
- Therapeutic Games: These games are designed to help the child explore their feelings, develop social skills, and work towards therapeutic goals.
- Creative Arts: This involves using art materials to allow the child to express themselves creatively, providing another medium to explore their feelings and experiences.
- Other: Always note any other interventions you used during the session.
How a play session ends can provide insights into the child's feelings towards the therapy process and their readiness to end it. Here are some things you might note:
- Uncooperative: The child may resist ending the session, indicating a need for more time or difficulty with transitions.
- Secure: The child may end the session calmly and confidently, indicating a sense of security and trust in the therapeutic process.
- Residual Activity: The child may continue to engage in play activity after the session has ended, indicating a high level of engagement in the play process.
- Insecure: The child may show signs of anxiety or distress at the end of the session, indicating a need for additional support or reassurance.
- Rebellious: The child may resist ending the session or act out, indicating a need for more structure or limit-setting.
- Cooperative: The child may end the session willingly and follow the therapist's directions, indicating a positive engagement with the therapy process.
- Grounded: The child may end the session in a calm and centered state, indicating a successful use of grounding or self-regulation techniques.
- Other: Always note any other observations about the child's behavior at the end of the session.
By documenting the interventions used and the child's behavior at the end of the session, you can assess the effectiveness of your techniques and plan for future sessions.
Plan and Collateral Contact
Finally, outline your plan for the next session, including any interventions you plan to use, themes you want to explore, or skills you want to work on. Also, document any collateral contact, such as the next scheduled appointment, treatment plan updates, support persons, or referrals. This helps to keep the therapy process focused and ensures that each session builds on the last.
A comprehensive template like this can streamline your note-taking process, capture all the necessary information, and provide a valuable tool for reflecting on your therapeutic work. Remember, the goal is not to fill in every box for every session but to use the template as a guide to help you document the most relevant and important information.
I hope this article has shed some light on the importance and intricacies of documenting play therapy notes. It's more than just a professional requirement – it's a way for you, as a therapist, to reflect on each session, understand your clients better, and plan your future strategies. Every child you work with is unique, and their therapeutic journey should be captured in a way that reflects this. Yes, it might seem like a lot of work sometimes, but trust me, the insights and progress you'll see will make it all worthwhile. Remember, every note you take is a piece of the puzzle that is the child's therapeutic journey. So, keep observing, keeping notes, and growing alongside your clients. Here's to your incredible work helping children heal and thrive!