You’re sitting across from your client, who’s narrating an epic battle in their favorite video game. Their character—an archer—is dodging dragons, leaping from cliffs, and working with a team to conquer an enemy fortress. There’s a spark in their eyes as they describe the strategy, the team dynamics, the feeling of triumph. You know that this moment is bigger than pixels on a screen—this is where your client is practicing problem-solving, decision-making, and maybe even working on their social anxiety.

In that moment, you think to yourself, This is exactly why I love being a therapist. But then, a small voice creeps in: How in the world am I going to translate this into a progress note that insurance will understand? And suddenly, that dragon-slaying victory feels a little less victorious.

Sound familiar? Don’t worry, you’re not alone in this struggle. Many of us in the therapy world find ourselves balancing the magic of creative interventions—whether it’s through games, tarot, or even Dungeons & Dragons—with the clinical language required for insurance documentation. The good news is that it’s entirely possible to weave these creative moments into structured, goal-oriented documentation without losing the essence of the work.

The Magic of Creative Therapy

Let’s be honest: traditional talk therapy isn’t for everyone, and that’s where the real beauty of creative interventions comes in. When clients immerse themselves in a game or draw meaning from tarot cards, they’re not just “playing” or looking at random symbols—they’re processing emotions, practicing life skills, and connecting deeply with their experiences. As therapists, these are golden moments. They allow us to meet clients where they are, through what excites or comforts them.

But here’s the catch: insurance companies don’t care about how a client embodied a wizard in their D&D campaign. They care about seeing progress toward treatment goals, framed in clinical terms that match up with diagnoses and outcomes. So, how do we bridge these worlds without letting the creative spark die? Let’s explore.

Translating Play into Progress

Creative therapy works best when we, as therapists, can balance the play with a purpose. Whether it’s a board game or video game, each intervention should always tie back to the client’s treatment goals. And yes, it’s entirely possible to document a game of Sorry! as a therapeutic tool for emotional regulation or a tarot reading as an exercise in exploring life transitions. The key? Be specific about how the activity aligns with the client’s progress.

Here’s how you can document some common creative approaches:

1. Board Games & Emotional Regulation

• In Session: You’re locked in a game of Uno, and your client is learning how to handle frustration and manage impulses when the draw-four card gets played on them.

• Documentation Example: “Client participated in a structured card game to practice emotional regulation, specifically managing frustration when faced with setbacks. The intervention focused on enhancing coping strategies for dealing with impulsivity and practicing patience, aligned with treatment goals related to frustration tolerance.”

2. Tarot & Life Transitions

• In Session: Your client pulls the Death card, which sparks a conversation about the metaphorical death of their old job as they transition into a new career.

• Documentation Example: “Client engaged in metaphorical exploration using tarot imagery to process feelings of loss and renewal associated with a recent job change. Intervention facilitated cognitive reframing of client’s perspective on change, aligning with treatment goals related to managing anxiety and life transitions.”

3. Video Games & Social Skills

• In Session: Your client recounts a Fortnite mission where they coordinated with a team to defeat an enemy. Through this, they explore leadership and communication skills.

• Documentation Example: “Client utilized narrative from video gameplay to analyze team dynamics and practice social interaction skills, focusing on leadership and communication. This session supported treatment goals of improving peer relationship dynamics and enhancing teamwork abilities.”

The Importance of Anchoring in Evidence-Based Frameworks

As creative and playful as these tools might be, it’s crucial to remember that every intervention needs to be grounded in a solid, evidence-based theoretical framework. Why? Because while tarot cards and role-playing games can open doors to powerful insights and emotional growth, they need to have a clear, therapeutic direction. It’s not just about engaging clients—it’s about ensuring that these tools are effective, supported by research, and connected to broader therapeutic goals.

Think of it like this: Creative tools are the vehicle, but evidence-based frameworks are the GPS. Without the guidance of frameworks like Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Therapy (CBT), or Dialectical Behavior Therapy (DBT), the intervention might be fun but won’t have the structure necessary to help your client reach their destination.

For example:

• ACT: Using creative tools like tarot or role-playing helps clients increase psychological flexibility, allowing them to experience thoughts and emotions without being trapped by them. Drawing a card or choosing a game action can serve as a metaphor for values-based decision-making.

• CBT: Board games or video games can offer real-time practice in cognitive restructuring. A client can challenge automatic negative thoughts in a game and learn to replace them with more adaptive thinking, applying the same skills outside of the session.

• DBT: Creative interventions can serve as a platform for practicing distress tolerance or mindfulness skills, helping clients engage with intense emotions in a manageable and structured way.

When these creative tools are anchored in a framework, you’re not just playing—you’re guiding clients through a meaningful therapeutic process that aligns with proven techniques.

Expanding the Creative Toolkit: More Approaches to Enrich Your Therapy Sessions

While board games, tarot, and video games offer dynamic ways to connect with clients, there are countless other creative interventions that can enhance therapy sessions and align beautifully with therapeutic goals. Let’s explore a few more approaches that fit well within this framework, keeping therapy both engaging and clinically rigorous.

Drama Therapy: Stepping Into New Roles

Imagine your client is struggling with assertiveness, unsure how to navigate difficult conversations in their personal life. In session, you ask them to role-play a scenario where they need to set a boundary. Suddenly, they’re not just talking about their challenges—they’re living them, rehearsing responses, and building confidence in real time.

• In Session: You engage your client in a role-play exercise using Drama Therapy where they practice assertiveness in a conversation with a family member.

• Documentation Example: “Client participated in a role-play scenario to practice assertiveness and boundary-setting. The intervention focused on emotional regulation and communication skills, supporting treatment goals related to improving self-confidence and interpersonal effectiveness.”

Art in Therapy: Unlocking Emotions Through Creativity

When words fail, art can speak. With art in therapy, clients can express complex emotions through drawing, painting, or even sculpting. These creative expressions can unlock deep emotional processing, particularly for clients who struggle with verbal communication or have experienced trauma.

• In Session: Your client creates a series of abstract paintings to express their feelings about a recent life transition.

• Documentation Example: “Client engaged in art in therapy, using abstract imagery to process and express emotions related to a recent divorce. The intervention supported treatment goals of improving emotional expression and processing grief.”

Music in Therapy: Tuning Into Emotions

Music has the unique ability to access and express emotions that are often difficult to verbalize. Whether a client is creating music, listening to their favorite songs, or using rhythms to regulate their mood, music therapy can be a powerful tool for emotional expression and emotional regulation.

• In Session: Your client shares a playlist of songs that reflect their current emotional state, discussing how each piece resonates with their mood.

• Documentation Example: “Client utilized music in therapy intervention, selecting and discussing music that reflects their emotional state. The session supported treatment goals of improving emotional awareness and coping strategies for mood regulation.”

Ecotherapy: Nature as a Healing Space

For clients who feel overwhelmed by traditional office settings, ecotherapy can provide a breath of fresh air—literally. Whether it’s walking in nature or incorporating nature-based elements into the therapy room, this approach helps clients connect with their environment to manage stress and enhance mindfulness.

• In Session: You and your client take a walk in a local park while discussing stressors and practicing grounding techniques.

• Documentation Example: “Client engaged in ecotherapy, participating in a nature walk to practice mindfulness and grounding techniques. The intervention focused on reducing anxiety and building coping skills, aligning with treatment goals of managing stress.”

Dungeons & Dragons and Role-Playing Games (RPGs): Exploring Identity Through Play

Beyond video games, RPGs like Dungeons & Dragons provide an immersive experience where clients can explore their identity, navigate complex social dynamics, and practice decision-making in a low-stakes environment. Clients might create characters that represent aspects of themselves, using gameplay to process personal challenges and practice social skills.

• In Session: Your client assumes the role of a powerful sorcerer in a Dungeons & Dragons campaign, learning how to navigate group dynamics and resolve conflicts.

• Documentation Example: “Client participated in a role-playing game to practice social skills and conflict resolution, exploring leadership and decision-making in a fantasy narrative. The intervention supported treatment goals of improving interpersonal relationships and building confidence in decision-making.”

Sand Tray Therapy: Building Narratives in the Sand

For clients who find it difficult to express emotions directly, sand tray therapy offers a tactile and symbolic way to process experiences. Clients use miniature figures and objects to create scenes in a sandbox, representing their internal world or key life events. This is particularly effective for trauma survivors or children.

• In Session: Your client creates a scene in the sand that reflects their childhood home, exploring past trauma through symbolic play.

• Documentation Example: “Client engaged in sand tray therapy, using symbolic figures to explore unresolved childhood trauma. The intervention supported emotional processing and insight, in alignment with treatment goals related to trauma recovery.”

Mindfulness-Based Practices: Grounding in the Present Moment

Mindfulness can be a simple yet profound tool in therapy, helping clients slow down, tune into the present, and manage overwhelming thoughts or emotions. Guided meditation, breathwork, or even simple grounding techniques can help clients regulate anxiety and stress.

• In Session: You guide your client through a short mindfulness exercise, helping them focus on their breath to manage stress.

• Documentation Example: “Client participated in a mindfulness-based intervention, using breath awareness to reduce stress and increase present-moment awareness. The session supported treatment goals related to anxiety reduction and emotional regulation.”

These additional creative approaches offer even more ways to engage clients in meaningful therapeutic work, all while staying rooted in evidence-based practices. By incorporating techniques like drama therapy, ecotherapy, or RPGs into your sessions, you can further individualize your approach to meet clients where they are—whether they’re battling dragons, painting their inner world, or walking through nature’s healing spaces.

Tying Medical Necessity to Creative Interventions and Documentation

When incorporating creative approaches like board games, tarot, and video games into therapy, it’s essential to ensure that every intervention is linked to the diagnosis being treated and the concept of medical necessity. Insurance companies require that services provided are directly related to a client’s diagnosis and treatment goals, so even the most playful and engaging interventions must serve a clear therapeutic purpose.

Here’s how to ensure your creative approaches meet the standards of medical necessity:

1. Link the Intervention to the Diagnosis

Whether you’re treating anxiety, depression, trauma, or social skills deficits, be explicit in how the intervention addresses symptoms. For example:

• For Anxiety: “Client engaged in a board game focused on decision-making to practice coping strategies and reduce avoidance behaviors, in alignment with treatment goals for managing anxiety.”

• For Depression: “Client used narrative in video gameplay to explore social interactions and practice cognitive restructuring, supporting treatment goals for improving mood and social engagement.”

2. Ground in Therapeutic Goals

Every creative intervention must be tied to a treatment plan goal. The intervention is not just for engagement—it’s for progress. Be specific about how these activities help the client meet their treatment goals:

• “Client engaged in a symbolic tarot reading to process recent life changes, helping them gain insight and reframe negative thinking patterns related to their depression diagnosis.”

3. Use Clinical Language to Justify the Approach

Even though the interventions may be playful or creative, use clinical language to ensure the intervention is justified. This ensures medical necessity is met:

• “Participation in role-playing during a Dungeons & Dragons campaign allowed the client to practice assertiveness and leadership, directly addressing deficits in social skills and communication as identified in the treatment plan for ASD.”

4. Document Progress Related to the Diagnosis

Finally, document how the client’s symptoms are impacted by these interventions. Highlight any improvements or continuing struggles related to the diagnosis:

• “Client demonstrated reduced social anxiety during collaborative board game play, showing increased comfort in peer interactions and aligning with treatment goals for social phobia.”

By clearly linking creative interventions to the diagnosis, treatment plan goals, and clinical progress, you can ensure your sessions not only foster engagement but also meet the necessary criteria for insurance documentation and medical necessity.

Avoiding the Pitfalls

As magical as creative therapy can be, there are a few common pitfalls when it comes to translating that magic into documentation. It’s easy to get too caught up in the fun, only to realize your note doesn’t reflect the therapeutic purpose. Here are a couple of pitfalls to watch for—and how to avoid them.

• Pitfall 1: Getting Too Playful in Documentation

It’s tempting to write about how your client vanquished a dragon, but insurance companies won’t appreciate the narrative. They want to know about progress, not battle scenes.

• Solution: Focus on the therapeutic outcomes of the activity. Instead of “client played a game,” try “client engaged in role-playing to practice assertiveness in decision-making, aligned with treatment goals of building self-confidence.”

• Pitfall 2: Losing the Treatment Goals in the Fun

If the activity doesn’t tie back to a treatment goal, your documentation can look disconnected from the client’s progress.

• Solution: Use clear language like “in alignment with treatment goals of…” or “intervention supported progress toward…” to ensure every session links back to the client’s therapeutic objectives.

Crafting the Perfect Script (Without Losing Authenticity)

In session, the last thing you want to do is break the flow by suddenly shifting into clinical mode. Fortunately, you don’t have to. With a few well-placed scripts, you can maintain authenticity while subtly guiding the session toward therapeutic goals that will be easier to document later.

• For board games: “As we play, think about how you’re handling the frustration when things don’t go your way. What strategies can you use here that you might also use in real life?”

• For tarot: “Let’s look at this card as a symbol of change. How does this apply to what’s happening in your life right now? What can you learn from it?”

• For video games: “Tell me about how you worked with your teammates in that mission. What worked well, and how could those skills help in your relationships outside of the game?”

These moments allow you to stay in sync with the client’s experience while setting the stage for meaningful documentation.

Connecting Creativity to Theoretical Frameworks

Even though you might be pulling out a tarot deck or setting up a board game, the work you’re doing still ties into well-established theoretical frameworks like Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT).

• ACT: Creative interventions like tarot cards or role-playing games help clients build psychological flexibility, as they practice noticing thoughts and feelings without judgment and making choices that align with their values.

• CBT: Board games or video games can serve as a playful way to practice cognitive restructuring. When a client faces a challenge in a game, they have an opportunity to challenge negative thoughts and replace them with more adaptive ones, just like in life.

Reflection Questions to Enhance Your Practice

Creative therapy approaches can feel like uncharted territory, even for seasoned therapists. To deepen your work, consider reflecting on these questions:

• “What creative approaches have I used that resonated with clients? How can I more clearly connect them to treatment goals?”

• “How can I document these sessions in a way that honors both the creativity and the clinical rigor needed for insurance?”

• “What other creative interventions could I try with clients to enhance their engagement?”

Making the Magic Work for Insurance

It’s possible to document creatively while still satisfying insurance requirements—it just takes a little intentionality. Your notes don’t have to strip away the magic of the session; they just need to show how that magic aligns with clinical progress.

For example:

• In Session: Your client is knee-deep in a D&D campaign, making decisions about how to lead their group.

• Documentation Example: “Client engaged in narrative role-playing to practice leadership skills, decision-making, and assertiveness, in alignment with treatment goals of improving self-confidence in group dynamics.”

How Storm Haven Counseling & Wellness Can Support You

At Storm Haven Counseling & Wellness, we believe that creative therapy is an art form. Whether you’re looking for guidance on documentation or support in crafting interventions that work for your clients, we’re here to help you bridge the gap between creativity and clinical care.

Try incorporating one of these creative interventions in your next session, and let us help you document it in a way that reflects both the artistry and science of therapy. Ready to roll the dice?

By weaving the storytelling of creative interventions into the clinical framework of documentation, you’ll not only engage your clients but also satisfy the demands of rigorous insurance standards—all while keeping the magic of therapy alive.

Explore More: Continue the Series

If you enjoyed this blog and want to expand further on the subject, be sure to check out the rest of our series:

• Part One: The Art of Translating Real Talk into Professional Therapy Documentation

• Part Two: Unlocking the Magic of Therapy: Creative Approaches to Documentation

Together, these posts offer deeper insights into blending creativity with professional documentation. Dive in to continue refining your practice and balancing the art and science of therapy!

Written by Jen Hyatt, a licensed psychotherapist at Storm Haven, Counseling & Wellness in Temecula, California. 

Disclaimer: The content in this blog post is intended for informational and educational purposes only and is not a substitute for professional advice, diagnosis, or treatment. All therapeutic techniques and approaches discussed should be used in accordance with relevant legal, ethical, and clinical guidelines, including ensuring medical necessity for insurance purposes. Please consult with a licensed mental health professional or your supervisor before implementing new interventions or approaches in your practice. Storm Haven Counseling & Wellness assumes no responsibility for any outcomes related to the use of these techniques without proper supervision and adherence to local regulations.