Sandtrays, Fables, and Expressive Arts: Story-telling Adventures with the CANS

By: Ritchie Rubio, PhD

We were fortunate enough to have Dr. Rubio present at the 15th Annual TCOM Conference earlier this month. In his post below he shares more on using the CANS and story-telling to promote client wellness.

Listening to, reading, or sharing a good story is something most if not all of us enjoy. One of the check-in activities I love to use when facilitating CANS training workshops is to ask participants to share the kinds of stories they are drawn to. What I notice is an immediate spark of energy in the room, as participants share about their interests in folktales; myths; children’s stories and fairytales; news stories; stories of resilience; autobiographies; psychological thrillers; celebrity gossip; science fiction; and many more.

Stories and story-telling is not new to TCOM. In fact, John Lyons (see One Person, One Story, One CANS/ANSA, 2019) has always talked about how the goal of the CANS is to “represent a commonly understood story that integrates the perspectives of all story tellers.”  With story-telling as the overarching theme in the most recently concluded TCOM Conference, Dr. Farahnaz Farahmand (interim director of our Children, Youth, and Families system of care) and I took this as an opportunity to share the story of our work at the San Francisco Department of Public Health, and highlight our Data Reflection to Innovate and Revitalize Effectiveness (DRIVE) Initiative. Our data reflection processes have strengthened the story-telling aspects of the CANS while promoting practices that are trauma-informed and culturally-appropriate.

I routinely bring CANS data to clinicians and mental health providers. Our mantra has been, “to be data effective, we need to be data reflective.” My hope is that they will enthusiastically reflect on the data and use their reflections to improve their clinical practices. Easier said than done. Many times, when I open discussions on CANS data with clinicians, I am met with a seemingly ‘deer in headlights’ standstill. We gradually changed this by shoring up story-telling approaches to encourage clinicians to reflect on data with the same engagement and pleasurable feelings like being in a ‘story time’ circle. These approaches have been informed by: (1) narrative data visualization (e.g. Segel & Heer, 2010); (2) neuroscience findings that many areas of the brain are activated more by stories than data (e.g. Zak, 2014); and (3) mathematical mindset development as a means to visually approach numerical data and help heal math trauma (see Boaler, 2019).      

CANS Story-telling with our Community Mental Health programs

We have used story-telling approaches to motivate an effective and meaningful use of CANS data among our clinical and data personnel. One approach is to ask reflection participants to look at data as a storyboard. When we look at data, we tend to approach it by asking questions such as, ‘What do the numbers mean?’ or ‘Where are the statistically significant improvements?’ Using a Storyboard Approach, one can instead ask questions that we customarily use around stories: ‘What’s the story here?’, ‘Who are the protagonists in this story?’, ‘Are there antagonists?’, ‘What are the conflicts in this story?’, ‘What are the resolutions to the conflicts?’ or ‘How does the story end?’ Another approach is to integrate the use of sandtray therapy, in itself an expressive arts story-telling intervention used by many clinicians who work with children and youth. Using a Sandtray Approach, one can look at the data as if it were a sandtray story, and ask sandtray processing questions such as: ‘What is the title of this story?’, ‘What is happening in here?’, ‘Are you, your client, or your program in this scene? Can you show me where?’, ‘Where is the energy here?’ or ‘What has the most power in here?’ I have noticed that using these approaches have augmented the engagement of many of our clinicians around CANS data.

CANS Story-telling with our Clients

Stories of our clients often include a number of actionable needs in their CANS. When this happens, it is important to engage in case formulation to be able to organize our understanding of a client’s needs and strengths, to inform what we prioritize for treatment (see John Lyons’ Treatment Planning with a Communimetric Tool). Using this approach, we generated our CANS Case Formulation and Treatment Planning Worksheet. This worksheet helps clinicians arrange the story of a client in such a way that it reflects a story mountain or narrative arc: reason for referral and background needs (introduction and rising action); priorities for treatment needs and strengths (rising action and climax); and interventions/activities and anticipated outcomes (falling action and resolution).

In the past decade, there was a paradigm shift to make our assessment processes more collaborative and therapeutic for our clients (Finn et al., 2012). Creative platforms have also been recommended as a means to engage children and youth in collaborative assessment feedback that is both meaningful and developmentally appropriate. One of those methods is the use of fables (Tharinger et al., 2008), which uses the realm of fantasy and metaphor to assist children and youth in processing their story or re-authoring their story, without overburdening their emotional capacities or raising their defenses. You can see in Figure 1 some pages of a fable co-authored with Lian (not her real name), a 4-year old Chinese girl who presents with traumatic grief and severe anxiety following the death of her maternal grandmother, who became a primary attachment figure. Many of the CANS items that were prioritized for her treatment (both needs and strengths) were integrated into the fable. Through this story, Lian was able to understand her story and collaborate in re-authoring it for constructive change.

Figure 1: Therapeutic fable with CANS items prioritized for treatment

Many stories are shared and processed verbally, such as the use of the worksheet and fable above. However, many children and youth have difficulty verbalizing their most painful experiences. Especially when children/youth have experienced trauma, self-protection involves difficulty in talking about them. Such experiences are often not readily available to be communicated through language but may be available through the use of expressive arts and other experiential activities (Malchiodi, 2015). As such, trauma-informed approaches like the use of sandtray therapy, art therapy, and play therapy can be used to translate the CANS assessment into a therapeutic intervention that maximizes the engagement of children and youth. For example, in Figure 2, you can see an example of how Lian represented her CANS story in the sand. Story-telling art therapy approaches can also be used such as journey sticks, mandalas, dioramas, comic strips, and others.         

Figure 2: Sandtray story with CANS items represented as miniatures

Stories and story-telling are innate and central to our human experience. It is my hope that we continue to explore and share creative and adventurous ways of strengthening our CANS storytelling. In our work with diverse clients, story-telling is truly a powerful culturally- and trauma-informed approach to promoting our clients’ wellness and recovery.


Some useful references:

Boaler, J. (2019). Developing mathematical mindsets: The need to interact with numbers flexibly and conceptually. American Educator, 28-40.

Finn, S. E., Fischer, C. T., & Handler, L. (Eds.). (2012). Collaborative/therapeutic assessment: A casebook and guide. Hoboken, NJ: Wiley.

Segel, E., & Heer, J. (2010). Narrative visualization: telling stories with data. IEEE Transactions On Visualization And Computer Graphics, 16(6), 1139–1148.

Tharinger, D. J., Finn, S. E., Wilkinson, A., DeHay, T., Parton, V. T., Bailey, K. E., & Tran, A. (2008). Providing psychological assessment feedback to children through individualized fables. Professional Psychology: Research and Practice, 39(6), 610–618.

Zak, P. J. (2014). Why Your Brain Loves Good Storytelling. Harvard Business Review Digital Articles, 2–4.

2 Comments on “Sandtrays, Fables, and Expressive Arts: Story-telling Adventures with the CANS

  1. This is a truly fascinating look at both the assessment process, as well as communimetric items. Communimetric measures work analytically by their ability to atomize the narrative nature of a person’s experience, but in this assessment approach we see narrative breathed back in through contextualizing the items in various ways. Truly fascinating approach. Research on the impact of such approaches on actionability rates would be interesting to see.

    • Thank you for your feedback and very useful recommendation Dan. And yes, as much many of these approaches augment engagement of clients in the therapeutic assessment process, it will be very meaningful to see how they impact client outcomes.

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