How often have you clicked into your inbox and opened up some variation of this email:
I wanted to check in before our next session. I don't want to take up too much time during the appointment. I was hoping you could find some time for a quick phone call before tomorrow.
With so much going on in your therapy practice (and life) I wanted to give you one quick tip on how to help with the stress and struggle with documenting goals in play therapy!
Now, did you know that setting goals is so much more valuable than the plan you have on file in case you get audited by the insurance company or someone requests records? Check out this post HERE about why setting goals is like GOLD for the rest of your therapy relationship!
If you casually flip through all 110,723,302 pages of documentation I have created in my child therapy career there is one thing you will never see.
This is also one of the things I never recommend to anyone who has ever been in any of my consultation or supervision groups. It is also something that I (thankfully) learned really early in my career.
And it all started with this one sentence “You are not the custody evaluator”.
Figuring out what exactly needs to go into a progress note can be intimidating.
AND that intensifies when your progress notes include Play Therapy. So… how do you communicate in your progress notes that you are not “just playing” with a client but you are actually engaging in therapeutic play therapy interventions and techniques?
How do you clarify that you weren’t “just playing doctor for fun” but that you were working on goals and themes related to nurturing, support, and family?
I am not kidding when I say everything goes in the file.
If I take a time machine back to my early days of practicing therapy (before the world thankfully went digital) files could be huuuuuge. Some clients (depending on the presenting concern, need for records, and how long they had been seen) could have 2 or 3 files as part of their file set.
When you think of a board report in the world of mental health therapy what comes up for you?
Well….besides a little bit of panic-heart-racing-sweaty feelings?
One of the most important questions I ask on nearly every individual or group consultation session after I learn more about the symptoms, struggles, and stuck points is “what are your goals for this client”?
This question is quickly followed by “what was the baseline when they came into therapy?”.
Sometimes when the play therapy door closes you think “what exactly just happened there”?
You know those sessions - maybe you weren’t quite sure what themes were coming up for a child and if it was play therapy or “just playing” (get more support on that HERE!). Maybe you spent the entire session listening to the middle school gossip and struggled to balance maintaining rapport and shifting it back to their goals. Other times it might look like glares, loooong periods of silence, and “I don’t know” seems to be the response to every question.
Play therapy sessions are intended to have a specific theory or framework that determines exactly what to do and when during your play therapy sessions.
And after the playroom door shuts you go to your computer to type up the progress notes, which are meant to demonstrate… well… progress!
So, how often do you think “what did we actually DO”? It’s pretty rare for a client to demonstrate significant and miraculous progress each and every session until termination. And that’s because life isn’t linear - and neither is the road to healing.
One thing I LOVE to share most when working on documentation with fellow therapists is this one simple shift in creating goals.
And just what is this shift?
I'm Ann Meehan, an LPCC,