Question 1

Dear Susan,
I am a newly registered educational psychologist. I am interested in learning more about using CBT with students in an inclusive context where one-on-one therapy is not an option. Any thoughts/pointers will be appreciated.  Thanks

Susan Knell · Accepted Answer

Welcome to the field of Psychology, and thank you for your interest in CBPT. If you are looking for training in CBPT, I would recommend registering for the online training available through the CBPT Research Institute (https://www.cognitivebehavioralplaytherapy.com/). 
There are also numerous articles and chapters in edited books about CBPT.

I am not entirely sure what you mean by an “inclusive context” and am wondering if you are talking about using CBPT in groups or possibly directly in the educational setting? I will respond to your question with the assumption that you are talking about using Cognitive Behavioral interventions in the school setting but not using CBPT with individual children.

Given that you cannot do one-on-one therapy with students in your setting, I might recommend that you review the literature on Cognitive Behavioral Play Interventions (CBPI). 
This is not psychotherapy, per se, but uses the techniques of CBPT in settings where CBPT is not possible. It has been used to date largely in medical facilities for things like sleep problems and diabetes, but many other populations might be helped by CBPI. The original research was in a school setting; a doctoral dissertation (see attached, Pearson, B. (2008) Effects of CBPI on Children’s hope and school adjustment) and has not been published yet. Here are some articles/references for you:

Attached: Fehr, K., Russ, S., & Levers-Landis, C. (2016). Treatment of sleep problems in young children: A case series report of a cognitive-behavioral play intervention.

Attached: Fehr, K., Chambers, D., & Ramasami, J. (2021). The impact of anxiety on behavioral sleep difficulties and treatment in young children: A review of the literature.

For purchase: Russ, S., & Fehr, K. (2016). The use of pretend play to overcome anxiety in school age children. In A. Drewes & C. Schaefer (Eds.) Play Therapy in Middle Childhood (pp. 77-95). American Psychological Association. https://doi.org/10.1037/14776-005

Fehr, K., Russ, S., Anderson, J., Leigh Josie, K., & Cousino, M. (2017, November). Application of a cognitive-behavioral play intervention to pediatric populations: A pilot study for siblings of children diagnosed with cancer. In C. Sieberg (Chair), Behavioral interventions for pediatric health conditions: Results from prospective studies. Symposium presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, San Diego, CA.

I hope that this is helpful.

Question 2

What sort of problems can CBT help kids with and what are its limitations?

Susan Knell · Accepted Answer

This is an important question. Cognitive Behavior Therapy (CBT) can be used with children of all ages. Cognitive Behavioral Play Therapy (CBPT) is the adaptation of CBT for younger children since it would be difficult to use CBT, as used with adults and older children/adolescents. CBT without play relies on language abilities that are typically beyond young children.

I will answer your question specifically about CBPT. CBPT is designed for use with children from ages 2 ½ to 8. The upper age limit is approximate, as play can be incorporated into therapy for older kids, as well.   We have adapted CBT into play therapy so that the Cognitive Behavioral interventions can be introduced to children in developmentally sensitive, appropriate ways. 
Most of this is through modelling in play. We have used CBPT with a wide range of problems, including but not limited to anxiety, depression, fears and phobias, selective mutism, encopresis, as well as children who have experienced traumatic life events, such as parental conflict or abuse.

I believe that CBPT is particularly useful for “control” issues and other concerns where the child needs to be an active participant in treatment. We know that there are excellent behavioral management programs where an adult, usually a parent, works directly to help the child. For example, there are programs for parents to treat their child’s non-compliance and other behavioral problems. However, with many of these programs, the child is responding to rewards (and sometimes consequences) for his/her behavior.

Motivation to change in these cases may come from the child’s responses to the management program. However, when the child is IN treatment, such as with CBPT, then the child is actively involved in the treatment, and change can also come from within, in addition to via reinforcement. Behavioral interventions from the parents can clearly be helpful, and in many cases, it may be enough to help the child successfully change maladaptive behaviors. We are gathering more and more information about what situations would be better served by CBPT alone or CBPT in combination with a parent-implemented treatment.

CBPT will be most effective if parents can bring a child to regularly scheduled sessions and can support the work that the therapist is doing with the child. In many cases of CBPT, the therapist will also be working with the parents, and if behavioral management programs are needed, the therapist is relying on the parent(s) to be able to work with the child on the program recommended by the therapist.

Success in CBPT will be limited if parents are unable or unwilling to follow treatment recommendations. Sometimes clinicians question if CBPT will be effective for non-compliant and/or aggressive and acting out children. My clinical opinion is that it can be effective because play is a universal language for children, and if the therapist is clinically astute, he/she will find a way to make the CBPT work for that particular child. Many times, children who are non-compliant or acting out will need a parent-implemented program as well. Thus, the parent involvement, as noted above, will be critical.

The question of which kids can be helped by CBPT is an important one, and we are beginning to have a better understanding of its best uses and limitations. 
Much more research is needed to have clearer answers to these questions.

Question 3

Does CBT for kids depend on parent support and involvement outside the clinical setting?

Susan Knell · Accepted Answer

In a word, YES, but this will vary depending on the nature of the problem and the situation. CBPT will be most effective if parents can support the work that the therapist is doing with the child. In many cases of CBPT, the therapist will also be working with the parents, and if behavioral management programs are needed, the therapist is relying on the parent(s) to be able to work with the child on the program recommended by the therapist. Success in CBPT will be limited if parents are unable or unwilling to follow treatment recommendations. Children can make great strides in CBPT, but if their new, more adaptive behaviors are not supported in the outside environment (and that would usually mean school, as well as home), then their behaviors are unlikely to generalize to the environment outside of therapy. If they do generalize, they may not be maintained if the supportive environment is not actively working to encourage and reinforce more adaptive behaviors.

So, the best answer to your question is, yes, CBT depends on parent support and involvement. However, this is not to say that progress cannot be made without that support and involvement. In many situations, the parents can be helped to be more involved and supportive. In other cases, there are significant others, such as grandparents, caregivers, or teachers, who may provide that adult support.

Question 4

How can CBT play therapy help my 8 year old child feel less anxious?

Susan Knell · Accepted Answer

The good news is that there is a wealth of information about CBT with anxious children, and we are finding many ways to bring those treatments to younger and younger children.  At 8, your child is probably falling somewhere between needing more play-based CBPT and more language-based CBT.  A CBPT who is used to working with children at this age should be able to find the right mix for your child, and figure out what interventions are going to be most useful.  There are some wonderful Cognitive Behaviorally based workbooks for Anxious children (the one that I use often is from APA, “What to do when you worry too much”).  https://www.amazon.com/dp/1591473144

There are many others.  There are also some great books for parents that are based on a CBT model, that help the parents know how best to respond to their child’s anxiety.  One suggestion is:  Helping your Anxious Child by Ronald Rapee (https://psychwire.com/ask/profiles/1otbauk/ronald-rapee) and colleagues (https://www.amazon.com/Helping-Anxious-Child-Step-Step/dp/145877189X).

CBPT can help anxious children in a wide range of ways.  As a parent of an anxious child, you have probably found that you are constantly reassuring your child, and it doesn’t make things better.  Or, you might find that you are walking on eggshells, making things “easier” for the child but not necessarily helping the child learn to cope.  Anxious children can disrupt the family system in such a way that everyone feels that they are spending lots of energy so that the child feels safe/calm.  It can be very hard for siblings who are not anxious.  CBPT helps the anxious child learn to contain the anxiety, to keep it more manageable.

It helps the child externalize the anxiety, as if the anxiety were a bully telling the child what to do and controlling the child’s life.  It helps the child learn skills to “talk back to the bully” and find a more peaceful balance.

It can help the child learn skills to manage the anxiety, from relaxation skills to distraction skills, as well as more positive self-statements and other thoughts that are more adaptive and less debilitating.

You want to find someone who understands children and CBT, and hopefully someone who integrates play into his/her treatment.

Question 5

How much does CBPT allow for unstructured play?

Susan Knell · Accepted Answer

There is quite a bit of unstructured play in CBPT, and it is one of the questions that I get asked frequently. Many people assume that CBPT is all structured, which it is not. The unstructured play is where the child is bringing in spontaneous play, behaviors, emotions, verbalizations. It provides a wealth of information for the therapist and is a critical piece of CBPT.   If the play was completely structured, the therapist would lose this rich source of clinical information. The structured play is what I use to communicate/model interventions. CBPT is both structured and unstructured, and ideally, they should be so seamless that one can’t necessarily identify what is happening in therapy. If you watch a CBPT session, you shouldn’t be seeing sections of each, but rather, structure being brought into the unstructured time in a smooth, flowing, flexible way.

So, for example, let’s say the child is playing out something that happens at home. 
They may not have identified the family characters as their family, but it is clear that they are re-enacting things that they have seen and heard. I might want to bring some structure in, for example, by having a child character model different ways of responding to the parents. So, if the child client typically tantrums at home, I might have the child puppet make positive statements, use calming techniques, or find ways to tell the parents how upset she is. Depending on the child’s reaction to this, I might change what I have the child puppet do next. I might have one child who tantrums, and another who uses some of these coping skills, and perhaps have the puppet who has tantrums, watch the puppet who is trying to cope as a way to learn how to manage such a difficult situation. So, clearly, it isn’t like 5 minutes of structured play and 5 minutes of unstructured. It is more like the structure, in the form of various interventions that are modelled, is interwoven into the play.

Question 6

What are the differences/similarities between CBT play therapy and traditional play therapies?

Susan Knell · Accepted Answer

This is one of my favorite questions, as people are often surprised by my answers. First, in regard to similarities, the therapeutic relationship between therapist and child client is critical in all forms of play therapy. If there is not a strong therapeutic relationship, it is not likely that the CBPT will be effective. The child has to trust the therapist and feel positive about the interaction. Another similarity between CBPT and other types of play therapy is that much of the communication happens via play; the therapist and child are communicating with each other through play and words. Finally, in all types of Play therapy, the therapist is trying to make therapy a safe place and for the child to feel safe in that environment. It is unlikely that any communication (via play or words) will take place if the child does not feel safe. If the child feels that he/she will be criticized, hurt, or misunderstood in any way, they are unlikely to trust the therapist.

In terms of differences, there are many, and I will discuss them in regard to different characteristics of play therapy. I will also use Client Centered Play Therapy (CCPT) and Psychodynamically (PD) oriented play therapy as the main types of Play Therapy besides CBPT. Clearly, there are others, but these two orientations probably capture the theoretical bent of most Play therapists who do not identify with being CBPT oriented.

First, in terms of Direction and Goals. Neither the CCPT nor PD therapist develop direction of goals. Both theories rely on the child for direction and goals. In CBPT, direction and goals come from both the child and the therapist. Often the therapist is working with parents to help determine goals.

In terms of play materials and activities, in CCPT and PD, these are chosen by the child and never by the therapist. In CBPT, play materials and activities can come from both the child and the therapist.

In regard to education, neither PD nor CCPT include any form of education, as they do not consider therapy as a place to educate the child. In CBPT, education is considered part of the therapy. The therapist is teaching new skills and alternative behaviors, and by definition, CBPT is psychoeducational in nature.

We consider interpretations and connections. In PD, interpretation is the ultimate goal. In CCPT, the therapist is not making connections or interpretations for the child, but rather those are presumed to come from the child. So in CCPT, they would not be discussed until the child introduces them. In this way, CBPT is more similar to PD, in that interpretations (more commonly referred to as connections, so that one is not implying “interpretation” in the psychoanalytic use of the word), are introduced by the therapist. The therapist is going to bring conflict into verbal expression for the child and help the child understand and make connections.

Finally, the use of praise is not considered appropriate in either PD or CCPT. IN CBPT, praise is a critical component because we know that praising communicates to the child which behaviors are appropriate and reinforces the child for these behaviors.

In summary, CBPT is similar to other play therapies in its use of play, communicating through play, creating a safe environment for the child, and on its reliance and importance of the therapeutic relationship. It is different in that it provides direction, goals, therapist involvement in play activities and materials, psychoeducation and connections.

Question 7

What does cognitive behavior play therapy look like?

Susan Knell · Accepted Answer

CBPT is a form of play therapy, but it has a directive component, and the interventions are modelled through play. The therapist needs to be flexible, concrete when necessary, and oftentimes a structure has to be part of the treatment. We do not rely on language per se, but we can show the child through various characters/puppets/toys who model thoughts, emotions and behaviors for the child. We try to capitalize on the child’s strengths, not weaknesses. If someone were observing a CBPT session, they might not immediately see how it differs from other types of play therapy.

What makes it different is that the therapist is working towards specific goals, with suggestions that there are directions towards those goals, that the therapist and the child are actively involved in the play, that the therapist will be modelling many interventions through toys/puppets/play materials, and that there is a component of psych-education that is integral to the play. So, the therapist will be interacting with the child, oftentimes around something that the child has chosen, and is then integrating movement towards the goals in the play.

What does this actually look like? Here is an example. A child is in therapy for aggressive behavior towards a sibling. In playing with people characters, the therapist may help establish parents and children, with one child character who is aggressive towards a sibling. The therapist will then model both the presenting problem (aggressive behavior) and gradually model skills that will help the child find more adaptive ways to interact with the sibling. The therapist may voice the thoughts, “My brother makes me so angry I feel like hitting him”, but begin to articulate other thoughts, “I am angry at my brother, but it helps if I go in my room and cool down”. Through the play, the therapist will reinforce the characters for more adaptive behaviors and decrease attention for maladaptive behaviors. The child will be watching this, and often interacting with the characters, which will help guide the therapist’s interventions.

If you are interested in a chapter that provides a transcript of CBPT, as well as explanations for the therapist’s choices, I would recommend:

Knell, S.M. (1993). To show and not tell: Cognitive-Behavioral Play Therapy in the Treatment of Elective Mutism.  In T. Kottman & C. Schaefer (Eds.). Play Therapy in Action:  A Casebook for Practitioners. (pp. 169-208). New Jersey: Jason Aronson. https://www.amazon.com/Play-Therapy-Action-Casebook-Practitioners/dp/1568210582

Another chapter that would help clarify what CBPT looks like is:
Knell, S.M. & Dasari, M (2009). CBPT:  Implementing and integrating CBPT into Clinical Practice. In A. Drewes (Ed.). The Effective Blending of Play Therapy and Cognitive Behavioral Therapy:  A convergent approach.   (321-352). NY:  Wiley. https://www.amazon.com/Blending-Play-Therapy-Cognitive-Behavioral/dp/0470176407

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