Next Level Play Therapy: A Podcast for Play Therapy Excellence

What is Best Practice in Play Therapy Clinical Decision-Making

• Cathi Spooner, LCSW, RPT-S • Episode 83

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How does being trained to use a specific play therapy model influence clinical decision-making vs clinical decision-making of child/adolescent therapists using play in therapy?

 

Hmmmmm.  What the heck does that question even mean?

 

Essentially clinical decision-making involves our expertise and training in a play therapy model and how play therapists engage in the decision-making process to get excellent treatment results for their clients.

 

Is the clinical decision-making skill level of play therapists who are trained to use specific play therapy models better than child/adolescent therapists not trained who are using play in sessions?

 

A study by Baker-Ericzen, Jenkins, Park, and Garland (2015) explored the quality of clinical decision-making for child/adolescent therapists who were trained in an evidence-based treatment model (EBT) versus therapists who were not.

 

This study, Clinical Decision-Making in Community Children’s Mental Health: Using Innovative Methods to Compare Clinicians With and Without Training in Evidence-Based Treatment, 👇🏼

 

Had some interesting results.

 

Join me for this week's podcast episode, I’ll discuss the findings of their study and how it relates to play therapy. 

 

There are several play therapy models considered to be EBT models, so this study provides some interesting points for child and adolescent therapists to consider when working with children using play.

 

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Cathi Spooner:

Welcome to Next Level Play Therapy. A weekly podcast dedicated to supporting the next generation of child and adolescent therapists to provide exceptional play therapy services. We'll explore all things play therapy to elevate your work with children and adolescents using the therapeutic powers of play. I'll discuss practical tips and ideas so you can provide a transformative experience for your young clients and make a real difference in their lives. So get ready to take your play therapy skills to the next level and make a lasting impact in the lives of children, adolescents, and families. Hey there. Good morning. So today I wanna talk about, um, what the research is saying. One of the things that I like to do when I am working on creating a course, and I'm pulling a course together these days on case conceptualization in play therapy, which to my, in my mind also includes clinical decision making. So one of the things that I like to do when I'm pulling together a new course is to go through and look at what the current research says. And so I ran across this study and what took, what, what struck me about the study is that it was using clinical decision making regarding mental health treatment for children. And it was set in community mental health settings. Typically, community health, typically, not always for on an outpatient basis, you tend to have some of the more higher acuity families, and so in my mind, clinical decision making with some of these higher acuity families definitely requires some, uh, expertise, experience. These, they, they can be challenging. I work in, uh, over the years, have worked in community mental health and some of the more, uh, like residential treatment and working in homeless shelters. So in my mind, when we're using play therapy, it would be really good to know what the research says about clinical decision making. And so in the last couple of livestream episodes, like last week and the week before, I talked about what is clinical decision making? What are, um, some of the things to keep in mind about clinical decision making and play therapy. So if you're interested in learning more about what the heck is clinical decision making, then I would definitely recommend that you go back and, and listen to or watch some of my live replays and if so. I stream live every week into Instagram. I live stream into my Facebook group for child adolescent therapists using play an expressive arts therapy. If you're interested in that group and you're on Facebook. Um, and you meet that criteria, that group is called Play and Express. Its Play and Expressive Arts, Therapy Playground. You do have to answer all the questions, like there's are several questions. That's one of the things that people regularly don't do, so they don't get in the group. Um, so you do have to answer all the questions. And then I stream into my YouTube channel and also LinkedIn. So if you're on Instagram and you wanna watch some of the replays, you can just go into my grid, I think, and you should find them all there. In my Facebook group. Click in the featured section, or the easiest place to find it is hop over to my YouTube channel, Cathi Spooner, Renewing Hearts Consulting, and uh, click on the live tab and then you'll see all my live streams there. But the last couple weeks I have talked about clinical decision making. And so if you wanna know more about that, you can hop over there and watch the replays. So I'm Cathi Spooner. I'm a licensed clinical social worker and a registered play therapist supervisor here in the United States with over 30 years experience working with children, adolescents, and families. And I love using play therapy and expressive arts play therapy. I use expressive arts uh, with a play therapy lens. And so I find that's a really, really effective way to engage children, especially family play therapy. It's a really effective way to get siblings of different developmental stages to engage in the, in the change process and have parents in there, caregivers. So, um, today what I do wanna talk about is this study that I ran across and I'll post a link in the con, I'll not the link, I'll post the study citation. So those of you who have access to university libraries. If you wanna check it out, you can check it out. So the name of the study is Clinical Decision Making and Community Children's Mental Health, using innovative methods to compare Clinicians with and without training in evidence-based treatment. I have my notes, I have to read that off my notes. Um, and so what, so the purpose of this study is, what was, um, they wanted to look at kind of looking at some of the gaps in quality mental health services for children because one of the things that they found is through, through the current data is there's not a lot of really good access to evidence-based treatment or, um, quality treatment for children that's gonna help them overcome whatever mental health challenges they're experiencing. And to me, this is especially important. Even post pandemic because what we're finding in children's mental health and adolescent mental health is that children and adolescents and families are still struggling. Um, so, access to good quality mental health care for children is really important, and if you live in an area where access to mental health services is kind of limited, then what we're even finding now is trying to figure out ways to get quality mental health services to children in those more rural areas or areas where there isn't a lot of good access. And so for that reason, I thought, well, it would be good to look at what the research says about clinical decision making. I have not found, I haven't found any information in the play therapy arena about clinical decision making. I think sometimes it, um, kind of gets in there, um, without necessarily talking about it directly. I think whenever you're learning a specific play therapy model, part of what you're learning is how do you, especially, you get the training and then you have the supervision or the consultation. I think a lot of what good consultation will do is help you take that theory, that play therapy theory, and how are you going to use your clinical decision making to apply the theory for each of your clients.'Cause they're gonna be different nuances and you're gonna be hitting kind of different barriers, sometimes a little roadblocks. Roadblocks. How do you navigate through that? And so. I don't think we necessarily directly talk about clinical decision making in and of itself. And so when I found this research, I got really excited. Um, and so in this, I'm gonna read a quote. This is the research. It's actually a lot of pages, so I wanna read a quote from the study about kind of the overview of what this study was trying to accomplish and the issues that they were trying to address. So the authors say to compliment, so what they're talking about is evidence-based treatment. What the, what these researchers did is they, they were wanting to compare the quality of, uh, clinical decision making in clinicians who had been trained in evidence-based therapy versus clinicians who had not been claimed in evide, uh, who have not been trained in evidence-based treatment. And to me this is relevant for play therapy because there are play therapy models that are considered evidence-based. And the other thing is that play therapy is based in theory. And the theory dictates how you're gonna help your clients access those therapeutic powers of play. And so it's, it's grounded in theory. And then you have to do your clinical decision making about how you are going to apply and implement the theory with each one of your clients and within their family context. And so maybe not every single play therapy model is considered evidence-based treatment by samhsa, but they're all grounded in a theoretical model and the model that takes how you're going to apply the theory. So I thought it was, I thought it was relevant for play therapy, the play therapy community to think about clinical decision making. And if you and child and adolescent mental health therapist, so maybe you don't consider yourself a play therapist. And so we're looking at even if, like what evidence-based models are you using that are geared towards children? Um, so here's the quote and, um, to compliment the individual treatment protocol training model, some reachers researchers propose greater attention to a trans treatment model and suggesting that empirically supported treatments share identifiable elements across several different protocols. So I kind of looked at this as, um, so I love using attachment theory. There are lots of different attachment theory models that you can use with children and children and their parents. If you're using attachment theory there are a lot of similar elements across all the attachment models. They're gonna kind of, I call it, package 'em a little differently and then apply them even in play therapy, there are lots of similar elements in the play therapy, um, in, in play therapy models and then they're just kind of utilized differently. So, so what this is talking about, the way that I read it is there are similarities across all of these different ev evidence-based models, and so they were proposing kind of doing more of like a trans treatment, um, protocol, which, you know, in any of us in the mental health, like most of us use an integrated approach. So in my mind this was kind of even more interesting, um, the idea of using clinical decision making, if you're using more of an integrated approach, how do you look at some of those common elements across all the different play therapy models? And so here's what they said. A major commo component of the common elements approach is the use of clinical decision making, and I a hundred percent agree with that, which involves the use of an algorithm type approach to guide decisions. So basically you are kind of, using like decision trees in your head, well if this happens and I go this way, or if this happens, I need to try this way. And they're all gonna be based on whatever your theoretical model is that you're using. So one of the things that, that some of the researchers are talking about and maybe something to think about, I think, um. Um, the article brings up, the research study brings up is using those common elements to do your clinical decision making and what would quality decision making look like. Excuse me. All right. So this type of clinical skill development may involve the growth of metacognitive skills involved in clinical decis decision making and that, and that can be used across problem areas to improve the effectiveness of treatment while reducing training demands. With the larger evidence-based framework, clinical decision making plays a crucial role. And I would 100% agree with that. Because evidence-based treatment is grounded in a theoretical model. And then that model is gonna require decision making to help you determine how you're going to apply it. So I thought this was really, really interesting research. Um, and so what the, so the results of the study, so in this study, let me back up a little bit. So in this study, they took 48 clinicians. And they divided them into two groups. There were, there were 14 clinicians who were in the evidence-based treatment trained, uh, group, and then 34 were in the non evidence-based treatment trained group. And so the way that the research worked was they were given, each of the clinicians in both groups were given the same case vignettes. Um, the case vignettes were about children with disruptive behavior, and the therapists had to verbalize their so out loud, they had to verbalize their clinical decision making process and their treatment. Uh, their treatment planning. So what we know is, um, when we're using case conceptualization, we're also using clinical decision making. And if you're interested in learning more about case conceptualization in play therapy, that was a few live stream episodes before as well, so you may wanna go hop over easiest places to hop over to my YouTube channel, and you should be able to find them there in the live tab. If you're in my Facebook group, you can find them in the featured section. So what they did was they had the, so what we know is clinical decision making is important in the, in the case conceptualization process. And part of that is treatment planning. Like I'm doing treatment formulation, I take this information and I use it to help me develop my plan of action for treatment. But we also know as clinicians in the mental health field that we are doing clinical decision making all and a bit of, and we're using that to kind of, um, navigate our case conceptualization from beginning to end of treatment. So again, clinical decision making and our ability to use quality decision making is really important for the treatment outcomes that you get. And so that's what the study was focused on. The, they used what they call, there's a naturalist natural naturalistic decision making theory, and they used that theory, the coder, uh, the researchers used that theory to code the verbalizations and the decision making process. And essentially this naturalistic decision making theory is focused on using decision making more in a realistic kind of real world setting and looking at specific set of criteria for that decision making and how they're doing that evolving kind of dynamic, um, process to basically figure things out clinically. And so this NMD naturalistic decision making model essentially dis differentiates expert and novice decision making based on some operationalized criteria that accesses, assesses that decision making process. So here's what they found that, so that's a, that's the research in a nutshell. And it was kind of quasi experimental. If you're into those things, you wanna know those things. Um. So here were the re results of this study, and what they found was that evidence-based trained clinicians displayed cognitive processes more closely aligned with the expert decision making than non EBT trained that non EBD, eBT evidence-based treatment approach. They were more aligned with the expert novice decision making process. Hey, Carla. Carla, so glad. Oh, that's awesome. I'm glad you could join us. Hey, which reminds me, I totally forgot to say, if you're watching, feel free to. Uh, post your name. I would actually really love to know who's here, what population you work with, um, which play therapy and expressive arts modalities that you're using, what questions you have about, uh, the decision making process and play therapy. Feel free to post those in the comments. Thank you, Carla. When I saw your post, I realized, Ooh, I forgot to ask people that or tell people to do that. Feel free to join the conversation. So, um, the results of the study, so, so the, the clinicians who were trained in an, uh, evidence-based treatment model, their decision making was much more aligned with expert decision making quality. And so what they found was with these EBT trained clinicians, they, they used reasoning that focused on relevant information, and their questioning was more focused when they were gathering information. And they, they used about half the questions that the non EBT trained clinicians used because they were, they were much more focused. And what they, they found was, uh, one of the reasons that's helpful to know is that the EBT trained clinicians tended to organize and synthesize the information more efficiently to conceptualize what the diagnosis is and what the treatment plan needed to be. So, and there were significant variations between the EBT trained clinicians and the non EBT trained clinicians on how they attended to the information in these case vignettes and how they made decisions based on that information. So I thought I would read out of the results. I would read a little bit, I read a quote from the study that kind of highlights this, um, information. So novices would be, um, uh, the, the ones that are not necessarily very proficient in doing that clinical decision making making process. So Carla's asking, what does EBT mean? EBT stands for evidence-based treatment. So it's treatment that's been researched and found to be effective. So it's got evidence behind it that it's a very effective model. Like one of, uh, like a in play therapy, evidence-based treatment models would be child-centered play therapy. It would be Filial Therapy, um, which is SLU the gurney version of adding parents. The Gary Landreth version would be Child Parent Relationship Therapy. That's another evidence-based. Adlerian therapy play Therapy and Thera play. Those are considered evidence-based by samhsa. They've had a lot of research behind them. Um, like a really common one pretty much a lot of people know is Cognitive Behavioral Therapy, DBT therapy. They've con they're considered evidence-based because there's a lot of research to back it up. So, um, so here's my other thing about that. Like, even in play therapy that like Gestalt play therapy or Jungian play therapy, they, at this point they probably don't have enough research, maybe because there's not enough funding for it or they don't have a big university organization behind it doing the research. So that's kind of one of my thing. It's nice evidence-based treatment I think it's good to know. The other thing about that is there's some really good models out there that maybe haven't had the research, they haven't had funding or whatever, um, to kind of get that done. That's just my little caveat and my opinion. So here's the quote that I thought would be info, um, about the, the findings. Novices are described as not having sufficient, sufficient knowledge and skills to discriminate between salient and non salient cues, which appear to occur with non EBT trained clinicians, based on the increased number of diagnoses and factors attended to for V vignettes that included parent and family factors. The findings suggests that non EBT um, trained clinicians may have more difficulty organizing large amounts of information like child, parent, and family-based, given the complexity of families seeking services in community-based mental health settings, including a high frequency of multiple parent and child conte contextual risk factors. Which is basically the meaning they have they have higher acuity families, they have FI families who have more complex. They are. Um, usually lots of generations of trauma addiction and attachment issues that they've been struggling with mental health through a, a few generations. So that's higher acuity. Hey, uh, I. I hope I pronounced your name right. Ro Aya from South Africa. I'm so glad you're joining us. Thank you for breaking down the study. So well, the study highlights and supports, again, the importance of using evidence-based practices. I agree. Um, and at and at least practices that are theory based and the theory apply determines how you apply it. But the other piece is, what they're highlighting here is that training in the clinical decision making process.'Cause you can go to a training, you can get trained. But the the effectiveness of the out of the treatment, and the, the quality of the outcomes is gonna based on clinician competency. The clinician's ability to apply it, which is going to require that clinical decision making process. It also in is gonna include your case conceptualization. They go hand in hand. Um, so what, what it says is, so just kind of finishing the, the quote here, A clinician's ability to meaningfully synthesize case information and create an accurate case conceptualization, including a diagnosis and treatment plan in an efficient manner can be qua critical to delivering optimal care. And I 100% agree with that. And I, I have, um, that's one of the things that we focus on in my, when I, any of my consultation and supervision that I do. I think it's really important for clinicians to develop case conceptualization and clinical decision making skills. Then that includes in play therapy. And so I have Play Therapy Academy, which is basically we do online consultation groups couple times a month. And then in Play Therapy Academy, I have additional trainings. These are the ones I'm in the process of developing. I have one out now, which is getting grounded in Play Therapy Foundations. That's available if you're not in Play Therapy Academy, it's still available. I'll talk a little bit more about that. I'll talk a little bit more about play Therapy Academy as well. But right now I'm in the process of developing these, it's called Getting Grounded in Play Therapy Excellence Skills, because what I found is in the play therapy community, we don't necessarily have a lot of training for some of these, what the research would call common elements. Some of these elements that in play therapy that are, that are common among all the different play therapy models. For example, clinical decision making and case conceptualization. So your play therapy model is gonna determine how you apply it. That being said, you still need to formulate that case conceptualization and use your clinical decision making to get all the way through the process. Which is, you know, when I, when I do any of these courses and I'm developing them, I always like to go to the research and see what the research says and include that in the training because I think it's really important to make sure that we've got the most up-to-date information in when we're doing our trainings 'cause we're passing that along. And so, um, to me that's really important in the, in the treatment that we're, I mean, the training that we're providing. So I'll talk a little bit more at the end about these, these two programs. One, which is the Play Therapy Academy, that's the consultation, which also has some training in the program. But also if you, if you're not in Play Therapy Academy and maybe you're, you're not in need of, uh, of play therapy, supervision, consultation program, or you're already in with somebody else, uh, but you still want access to the courses, they're available as well. So I'll, I'll talk a little bit more about that. Um, but I do think this is important for play therapists to have these kinds of trainings to kind of hone, hone our skills. And this, this is probably one of my superpowers'cause I love a structure. I get lost without a structure. And early on in my play therapy career, I realized I have got to develop a structure, a way of thinking about and, and navigating these cases, um, in order to be effective.'Cause the goal is for them to, um, be able to successfully complete play therapy in the shortest amount of time, getting the most optimal benefits. That's the goal. Um, so what does that mean for play therapy? So I've kind of already talked about that a little bit, but here, uh, the thing is just to kind of a kind of tie in the the study with play therapy. Play therapy has evidence-based models and they have some non-evidence based models. The thing is, across play therapy, if you're using play therapy, you've been trained in a specific play therapy model, like child-centric play therapy or um, Adlerian play therapy, or Gestalt play therapy, or Jungian play therapy, or Filial play therapy or therapy play. You're, you're gonna use, um. When you're learning these models, you wanna make sure that you're learning the principles and how they're applied. Because one of the things that I notice happens a lot, and I've been doing, um, consultation and supervision for about 15 years now. One of the biggest things that I find happening is that clinicians are not thinking about how the model is applied. And practicing and becoming proficient at, okay, maybe I wanna use, um, Jungian play therapy. What is Jungian theory and how is that applied with this particular client at this particular time where they are in the treatment process? All of that's decision making. So e so you're basing your decision making and you're conceptualizing your treatment based on your theoretical model. But there are still ways in which you need to go about gathering the data, using your theoretical model to understand and conceptualize the problem, figure out what the diagnoses is, and then use that for your treatment planning. That's gonna be true across all your play therapy models, and it's important to really hone and develop your clinical decision making skills and your case conceptualization skills. That's an important part of the process, and for that reason, that's why I came up with, and I'm developing these, these courses that I talked about in the Getting Grounded and Play therapy Foundation courses. All the courses are gonna be self-paced. They're gonna be online. You could take 'em in your own time zone whenever it's convenient for you. I wanted to make them really, really, really accessible. So just to recap for today, um, play the study provides useful information to understand the role of quality clinical decision making when providing mental health treatment to children, adolescents and families. And clinicians who are trained in an evidence-based model, and I, and, and I would say the evidence-based model is really about using the theoretical model. And how does that, how does that, how do you apply that with each of your clients? So your, your evidence, it, your model that you're using is grounded in a theory and theory drives the application, and that's the important piece. You're not just kind of making things up from session to session, not really grounded in any kind of theoretical model and just kinda, or even if you're working with children, you're not using an adult model. That developmentally is geared towards adults. You're not using that with children. And then thirdly, play therapy is based in a theoretical model that guides children's ability to access those therapeutic powers of play for healing. So simply learning a play therapy model is not gonna be sufficient. You've got to learn how to apply that model with each of your clients who are showing up in your practice, and that's where the clinical decision making process is really, really important. So that is it for today. I am so glad you were able to join. If you're watching on the replay, I would love to know, um, your name, where, what population you work with, where you work. So feel free to post in the replay. I would love to know what play therapy models you are using. So go ahead and post those in the comments as well, and I'll see you next week. Bye. Thank you for joining me on this episode of Next Level Play Therapy. I hope you found the discussion valuable and gained new insights and ideas to support your work helping children, adolescents, and families heal. If you enjoyed this episode, be sure to subscribe to the podcast and leave a review. Your feedback helps to improve and reach more people who can benefit from this information. Remember, play therapy is a powerful tool for healing and growth. Whether you're a new play therapist or experienced, I encourage you to continue your learning journey to unlock the potential of play in your own work in relationships. If you have any questions or topics, suggestions for future episodes. I'd love to hear from you. Connect with me on social media and visit my website at Renewing Hearts Play Therapy Training to stay updated on upcoming episodes, trainings, and resources. Thank you once again for listening to Next Level Play Therapy. Until next time, keep playing, learning and growing.