Conceptualizing Play Therapy Treatment … A Standard for Excellence

What's the foundation for excellent play therapy treatment? Clinical case conceptualization.

Any really great therapist will tell you that one of the foundational elements of providing excellent psychotherapy is ...

Clinical case conceptualization.

Are you having flashbacks to graduate school and rolling your eyes at me as you read this?  

Well, hang in there with me for a minute.  I LOVE, LOVE, LOVE , LOVE clinical case conceptualization.  It’s like being a psychotherapy detective aka – super sleuth. Yes, that’s my guilty pleasure – watching detective shows. I love a good “who dunnit.” As a psychotherapy super sleuth, you begin an investigation to figure out what's going on underneath those symptoms and how to help your clients get better.

Here’s why case conceptualization is the backbone… (full disclosure – I’m passionate about this because I see it go wrong so often) … 

…it’s the way in which you conceptualize what’s going on with your clients and then formulate a plan to help your clients overcome the problem they were seeking you to resolve.  The same is true for play therapy and expressive arts.  How you conceptualize the presenting problem determines how you plan to help your client overcome it. So, you need to be a good psychotherapy super sleuth because if you conceptualize the presenting symptoms erroneously then your treatment approach may take you and your client in the wrong direction. Being a good mental health super sleuth is the difference between being a mediocre (at best) and an excellent therapist.

What is clinical case conceptualization?

It’s the way in which you conceptualize what the presenting symptoms mean and how you’ll treat those symptoms.  Clinical case conceptualization helps you figure out your road map or GPS for treatment – aka your treatment plan.   Your clinical case conceptualization is based on collecting information about the frequency, duration, and intensity of the presenting symptoms in order to identify a diagnosis (even a non-DSM diagnosis of the problem) which allows you to determine what treatment modality to use and what type of interventions are needed. The way in which you conceptualize the presenting issues guides you to figure out how you'll pace the sessions, aka – the frequency of sessions.  You’ll also understand who needs to participate in treatment and what you’ll address with parents/family members.

Tips for developing your clinical conceptualization

Gathering a thorough history using a bio-psycho-social-spiritual-cultural assessment provides the information needed to fully understand what are the factors contributing to the presenting issue as well as the extent of the problem.  Using a genogram framework allows you to identify all the various nuances of the generational family system and relationship patterns.  For example, is there a family history of trauma, attachment, addiction, and/or mental health problems?  The longer the problems have existed through the generations typically means the issue is more entrenched systemically.  

Since play therapists work with children it’s important to understand them within the context of family, school, social network, and culture.  When you’re gathering information from parents/caregivers, and when appropriate the child/adolescent, it’s important to gather information about the presenting symptoms frequency, duration, and severity. How often do the symptoms occur, how long does the problematic behavior last, and how severe are the symptoms? I often ask clients to rate the severity of the symptom using a Likert scale of 0- 10 with “0” meaning no problem to “10” as the most severe. Having my clients rate the severity of their problem gives me information to see the problem through their eyes so I can get a better sense of how parents/caregivers and the child experience the problem. These are the clues I need for my detective lens that allows me to better identify what’s going on with my client.

It’s also very important to ask about the child’s developmental and school history because this information gives clues to identify a potential learning problem or other developmental delays that may be impacting symptoms.  It also assists you to get a sense of your client’s ability to manage stressors during significant transitions, such as the transition to school for kindergarten, middle school, and high school. These are big transition periods and it’s important to get a sense of how your young clients adjust to changes in their life. For example, the transition from elementary school to middle and middle school to high school can be problematic, and gathering this information may provide clues as to when problems began to get worse.  You can ask parents/caregivers if their child’s behavior began to gradually and steadily get worse or if there was an event that seemed to have activated the problematic behavior.  

Frequency, duration, and severity of symptoms

Using a really good genogram framework to gather information about family history and family relationships allows you to collect information about the broader context of the presenting symptoms and identifying resiliency resources.  This provides information about potential genetic predispositions such as ADHD, learning problems, depression, anxiety, trauma, addiction, and other significant mental health challenges like bipolar disorder.  It’s also critical to identify potential resources to support positive growth and resiliency. Gathering information about the quality of family relationship patterns provides clues about parenting abilities and attachment patterns.  

As play therapists, part of our treatment focus is to help parents/caregivers develop skills for supporting their child long after treatment ends.  You need to build therapeutic rapport with parents/caregivers.  Gathering information about family history and relationship patterns gives you clues about the acuity level of the family system in which your young client lives.  All of this information provides clues to help you identify the “roots” of the presenting symptoms and conceptualize the treatment plan needed to help your client overcome their challenges.

What happens if you miss key components because you are not gathering “clues”?

Your roadmap, or GPS system, will likely go to the wrong "destination" or you may get lost in treatment if you don’t have enough information to fully understand what is underneath (roots) your client’s presenting problems.  For example, if you don’t gather information about school performance and school transitions, then you may miss a potential learning disability that warrants further evaluation by a clinical psychologist.  Undiagnosed learning problems can often manifest as defiance, depression, anxiety, and poor self-esteem that may later contribute to substance misuse and/or dropping out of school.  Perhaps you’ve gathered information about a traumatic event your client experienced but you didn’t gather a thorough family history and/or information about generational family attachment patterns.  

Children heal best within the context of their relationships because they need their parents/caregivers to help them navigate their world and their emotions. So, why would you leave parents out of the treatment process since they’re a significant part of the solution? Gathering information about family history, culture, spirituality, and family relationship patterns provides information about parent/caregiver capacity.  Caregiver capacity refers whether parents/caregivers can effectively (and confidently) meet the social, emotional and physical needs of their children.  Exploring caregiver capacity allows you to determine what type of support and interventions are needed to help parents meeting needs of their children, including attachment needs.  It helps you to figure out if a parent/caregiver has the ability and capacity to be a healthy part of the child’s healing process. If you fail to accurately identify the roots of the problem and positive resources available, the interventions you choose may not be effective because you didn’t identify what are the potential “roots” of the problem and how to effectively address those roots.  

Here’s the thing … we don’t always get it right in the beginning because our clients are complex and it takes time to fully understand what are the factors contributing to the presenting problems.  However, you do need to make sure you have a mindset of mental health super sleuth so that you're regularly looking for clues to the problem. You need to use that information for your clinical decision-making and adjust the treatment approach as needed throughout the play therapy process.  This is critical to effectively help your clients and their families overcome their challenges. 

Here’s the recap:

  • Clinical case conceptualization is the way in which you identify what are the roots of the symptoms and conceptualize what treatment approach is needed. It forms the basis for your treatment roadmap or GPS system.
  • Gathering a thorough bio-psycho-social-spiritual-cultural assessment helps you identify the roots of the symptom frequency, duration, and intensity as well as identifying the severity of the problem within the context of the child’s life.'
  • If you miss key components you’ll be trying to figure out why your client may not be making progress and your roadmap will miss the mark for its effectiveness.  
  • We don’t always get it right.  You may need time to gather enough information and get to know your clients and their family.  The key is that you need to ensure you're using your mental health super sleuth lens so you can accurately identify the roots of the problem.  You also need to figure out how you’re going to integrate parents/caregivers into the treatment process.

Categories: Neuroscience of attachment