Play Therapy Note

Client Information

• Client Name: Lucas Vance
• Provider Name: Dr. Sarah Jenkins, MD
• Date of Service: 24/10/2023
• Session Duration: 45 mins

Subjective

Presentation

• Chief Complaint: Increased separation anxiety and school refusal x 3 wks following recent parental separation.

Objective

• Type Of Play: Non-directive, child-centered play therapy.
• Materials Used: Sand tray, miniature animal figures, wooden blocks, toy rescue vehicles.
• Play Narrative And Symbolic Themes: Pt constructed two separate enclosures in the sand tray using wooden blocks, placing baby animal figures in one and parent figures in the other. Repeatedly buried and dug up the baby animals, stating they were "lost in a storm." Introduced a toy helicopter to move figures between enclosures. Themes of separation, instability, and desire for rescue/reconnection were prominent.

Assessment

Progress And Response

• Response To Treatment: Engaged readily in play without parental presence in the room after brief initial hesitation. Beginning to externalize internal distress regarding family restructuring through symbolic play.
• Specific Examples Or Instances: Separated easily from mother in waiting room today (required 10 mins of coaxing last session). Verbalized "the little bear is scared to be alone" during sand tray activity, demonstrating emerging emotional identification.
• Challenges To Progress: Inconsistent routine between maternal and paternal homes exacerbating baseline anxiety.
• Therapist Observations And Reflections: Pt utilizes control over the play environment to process feelings of helplessness related to parental divorce. Affect was initially constricted, brightening mid-session during rescue narratives.

Plan

Discussed Goals

• Goal 1:
  • Goal Description: Decrease morning school drop-off distress and transition into the classroom independently.
  • Metrics: Reduce crying/clinging episodes at drop-off from 5 days/wk to ≤ 2 days/wk per parent/teacher report.
  • Attainability: High, given intact cognitive skills and positive response to transitional objects.
  • Relevance: Directly addresses chief complaint of school refusal and separation anxiety.
  • Time Frame: 6 weeks.
  • Quote (Goal): Mother stated, "I just want him to be able to walk into his classroom without panicking every morning."
• Barriers To Achieving Goals: High parental conflict during custody exchanges on Wednesday and Friday mornings.

Follow Up Actions And Plans

• Homework: Mother and father to implement a consistent, brief goodbye ritual at school drop-off and utilize a matching "pocket stone" transitional object with pt.
• Plan For Future Session: Introduce directive play activity ("Color Your Heart") to further facilitate identification and verbalization of somatic anxiety symptoms.
• Plans For Continued Treatment: Continue weekly 45-minute individual play therapy sessions; schedule biweekly 15-minute parent check-ins.
• Coordination Of Care: Obtain ROI to consult with school counselor (Ms. Davis) regarding morning transition support.