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Playing with the sand tray

sandcastle-insideWe used to have two gorgeous handmade wooden sand trays at our agency but when our boss left she naturally took her toys with her and that included the sand trays. I knew they were leaving but didn’t think much of it because I figured we’d get out the old Rubbermaid boxes we used to use and I thought, well, they aren’t as lovely but what the heck, they’ll work just fine.

Funny thing, though — they don’t work nearly as well.

An official sand tray is wooden and is painted blue inside (to symbolize water). They come in different sizes (and some of them are round) but the standard size is around 24″ x 30″ and about 3″ to 4″ deep. The reason they’re so big is they’re meant to hold an entire world. The reason they’re not even bigger is that they’re meant to hold that world in a space small enough that the child can see all of it without turning her head.

The Rubbermaid containers are smaller and they’re not as pretty. The small size matters because the kids who are used to the bigger trays are annoyed to find the worlds they make are now all cramped up. And the prettiness matters because the toys we use are our means to communicate with our clients and the better our tools, the more we are conveying our respect for what they have to say. I believe that the respect that comes with working in a solid, lovely sand tray makes a difference in how welcomed the child feels in our sessions together and the Rubbermaid fix — while workable — doesn’t have that same gravity and consideration.

I didn’t have a sand tray for my private practice because I was holding out for a good one and they’re not cheap. I kept thinking about giving in and buying something makeshift but I didn’t want to compromise. Once I saw the difference our switch to the Rubbermaid containers made in my sessions at the agency, I became even more determined to wait until I could get a good, solid, wooden tray.

Then I found these instructions for making your own. Hurray!

Now I’m not handy so I knew that I wasn’t up for the task but when I was talking to my father-in-law about it he volunteered to make me one. And he did and it is beautiful and I am thrilled.I’m still working on building up my miniature collection and exploring ways to display it to make it accessible (right now it’s a jumble). I’m thinking about using molding to create shelves for the figures but want to make sure that they’re not prone to tumbling off before I start drilling holes in the wall.

I love using the sand tray with my clients. It’s such a great way for a less verbal child to communicate with me and it calms down the sensory seekers like nothing else (except maybe play dough). Children who are feeling shy about choosing toys in the playroom will generally dive into sand tray work much more quickly and then it seems once they’ve established their place in the sand then they are able to transfer that sense of ownership over to the rest of the toys.

It’s also a useful way to get a better understanding of relationships since families can create trays together. Watching two brothers negotiate a world together gives me a glimpse of how they work together (or don’t) at home.

A sand tray is an important investment for anyone doing play therapy and getting a good one is definitely worth the time or money. (I tried to talk my father-in-law into making himself available for building one for local friends but he said that while it was an easy project, it’s not something he’s rushing to do again. But he does encourage the handy among you not to be afraid of trying to build your own.)

Musical Offices

shutterstock_2448579At the community mental health agency where I work part-time people are assigned offices on the basis of hours. The more clients you see, the more permanent your office. Full-time people have their own offices (although they share with the rest of us), which they can decorate and personalize and then we contract workers play catch as catch can. Because my hours were lowest among the Family Program staff, I was used to not being sure which office I’d be in until I arrived for my shift and checked the big white board behind the front desk. Now that I’ve increased my client load I get the same office every time, which has made my life a lot easier and likely has made life easier for my clients, too.

Especially for the kids, moving offices depending on the day and time of the appointment can be disconcerting. There are some children on my client roster who have seen me in four different offices, some more child-friendly than the others. I keep toys in the trunk of my car but rotating around sometimes caught me off-guard. I’d show up with playdough only to find out I was in an office without a table where we could work with it or I’d wrangle the marble run out of my trunk and up the stairs on the day when I was in a fully-stocked office and didn’t need it.

Now I know where I am every time, I know which toys I have available and which I’ll need to bring from my private practice and things are so much easier.

Still I didn’t mind my time moving around. Working in different offices decorated by people with different sensibilities (and in offices that were under- or over-furnished as full-time clinicians moved in and out) gave me the chance to see how space impacts the therapeutic hour. I learned how to get creative when the toys were missing or space was inadequate. I learned how to recognize when clients felt off-kilter in our space, how to address it and how to figure out ways to make the room feel more comfortable by moving a table, a chair or turning lights on and off.

Other things I learned:

  • A big office isn’t necessarily better than a small office. Furniture placement and lack of clutter makes a bigger difference than size.
  • The quality of toys matters more than quantity.
  • A visible clock for both my client and me makes life oh so much easier. I’m pretty good at knowing when our time is up but not enough to go entirely clock-free.
  • It’s nicest being in the offices where we don’t have to sit too close to the door since clinicians and their clients are sometimes chatty in the halls.

I also learned how much easier it is to do therapy when you’re not fighting against your environment so as much as I valued my time jumping offices, I’m happier knowing where I’m hanging my hat every shift.

A Diagnosis Discussion

toomuchthink-insideAt the community mental health center where I work every single person I see gets a diagnosis. There’s a preliminary diagnosis after the first session, which I may write without even seeing the client. (When we do an intake on a child we see the parents without the child for that first diagnostic assessment so the preliminary diagnosis is based on the parents’ report.) The preliminary diagnosis isn’t set in stone; it’s considered a starting point. Clients at the clinic use insurance or Medicaid to get services and they require a diagnosis to open the case so we give one based on the information that we have.

Then a few more sessions in we write the actual diagnosis. By then we’ve seen the client, we have a fairly full history and we can make a full five axes diagnosis. We base that diagnosis on the client’s symptoms and history and when we write the treatment plan we refer back to it and it all works very nicely.

The reasons behind diagnosis are pretty clear — when we make a diagnosis we are creating a picture of the client for ourselves, for other clinicians who might work with her, and for the client herself. As we design treatment plans and measure progress we can refer to the diagnosis to get a better understanding of the work we’re doing together. When we case consult at our clinical meetings we can use diagnosis to better communicate the issues for our client in order to get appropriate feedback to improve her care.

That’s all good, right? Usually it is good. But sometimes it’s frustrating.

Diagnosis is an imperfect art. You know that old joke about rabbis? Here, I’ll tell it to you: What do you get when you have three rabbis? Four opinions. Same goes for therapists. Sometimes a person is experiencing such clear symptoms that it’s very easy to say, “Ahh, yes! Recurrent, persistent and intrusive thoughts? Behaviors meant to neutralize these thoughts? Repetitive hand washing, counting and rules about light switches meant to stave off distress? That’s 300.3 Obsessive-Compulsive Disorder!” Easy-peasy. Everyone gets it.

But other times you can have a client and it’s not nearly as clear for lots of reasons. Like clients may not really know their own history. They may exaggerate or understate the length of time they’ve had symptoms or the severity of those symptoms. Sometimes I get a client’s records and find out she’s had several different diagnoses (this is especially true for children). This speaks to the fact that it is all open to interpretation.

A diagnosis doesn’t just exist in the clinical setting; our clients live with it. I’m not talking about the symptoms or history that lead to the diagnosis; I’m talking about the label. The diagnosis doesn’t just live in her file, all nice and neat and detached from real life. The diagnosis lives in her experience of herself.

Part of working with a client around her diagnosis is helping understand that she isn’t her label. She is not “a depressive” or even a “depressed woman;” she is a “woman with depression.” Even if her illness dictates some of her choices (medication, counseling, etc.) it is not HER. But it can be hard, particularly when I have a client who has been living under the shadow of a diagnosis for some time.

This is especially important when it comes to teenagers. Teens are already trying to figure out who the heck they are and getting a diagnosis in the middle of that can be heady stuff. A diagnosis can be used like a shield to protect her from expectations, to excuse herself when she hangs back, and to rationalize her failures. She may become her diagnosis, reading information on the internet and shaping herself to fit the criteria.

I have a lot of clients who come in with a self-diagnosis based on reading magazines, talking to friends or just a general understanding of what a label actually means. (Lots of clients use words like “anxious” and “panic attack” and “bipolar” without understanding their clinical definition.) They sometimes feel very defensive when I tell them that they don’t actually meet criteria. Feeling sad about a pet dying is not clinical depression; it’s appropriate grief. Feeling nervous about going on a first date is not social anxiety disorder; most of us are nervous before a first date. Feeling happy one day and sad the next is not bipolar disorder; it’s part of the human condition. Our sadness and our fears and our struggles do not need labels to be real.

When I give a client her diagnosis I first give her a rundown about how we got to it. I explain that a diagnosis is a label for a cluster of symptoms and that our focus will be on addressing symptoms. I tell them that a diagnosis is just a way for us all to communicate with each other and it’s not more real than what they’re actually experiencing. It’s a tool, I say, OUR tool, THEIR tool and we own our tools; our tools do not own us.

I don’t take insurance in my private practice and one reason is that it allows me the freedom to give or not give a diagnosis. A diagnosis should serve the client and sometimes I think a client is best served by not being given one.

My Counseling Office Journey So Far

calmempty-insideI’ve been spending the last few months looking for counseling office space to launch my private practice. I had one lined up, a shared office in a very nice location. But I work with kids as well as with adults, which means I need somewhere to store play therapy toys and a waiting room that’s welcoming to children.

Unfortunately the shared office wasn’t going to cut it. I realized this when I came by to talk to the owner and took a closer look at the waiting room, which I’d noted was bright and sunny and spacious but neglected to recognize the safety issue of having an open landing to the stairs.

Office space is interesting. You have to get a good location, of course, and ample parking. You want to find a place with character and appropriate square footage and a decent lay-out. If you’re lucky you’ll get a view and natural lighting and clean carpet. But unless your budget is limitless (mine isn’t) you have to make compromises and figuring out how and where to compromise has been my challenge. It’s certainly been fun looking and imagining; it’s a little like house-hunting but it feels a lot less stressful.

I think I found the right place. It has a lot going for it, most particularly the location. It’s on the bus line and very near shops and eateries and the library. The downsides (no view and on the lower-level) are liveable. I’m very pleased that there will be room for all the toys and even enough square-footage to run small groups or workshops.

Another advantage to going out on my own is that I won’t be restricted by someone else’s hours. I want to be able to be flexible while I figure out what works for me and for my clients.

Now the fun will be to set it up just the way I like it or at least as close to how I would like it. It will take time to figure out exactly what I need and then I can’t afford every little thing I’d like (one day I want to have two counseling rooms — one for play therapy and one just for adults but for now it’ll be all in one space). But even if space is a little tight, it will be nice to have a chance to use the tools I’ve been gathering over the years in preparation for my own practice.

Once I’ve moved in and set it up I’ll be having an open house and I hope you locals will come by and take a peek. (You can subscribe to the newsletter to get a heads up!) I’ll also be sure to post pictures. Right now I’m enjoying myself by looking at paint chips and room lay-outs and getting ridiculously excited!

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