COGNITIVE BEHAVIORAL PLAY THERAPY

What is Play Therapy and How does it works? 

Cognitive Behavioral Play Therapy is a psychotherapy approach aimed at children, including pre-schoolers, and their parents and represents a possible psychotherapy path to intervene in emerging psychological distress. Specifically, it uses therapeutic play to help the child learn how the world works, learn how to relate to others, understand how to deal with difficulties and find possible solutions.

The psychotherapist, who uses this model, aims to directly involve the child with different problems, in the therapeutic process and integrates cognitive and behavioral techniques  within play therapy. Playful activity, as well as nonverbal forms of verbal communication, are used to promote the development of problem-solving skills.

Therefore, Cognitive Behavioral Play Therapy proposes a conceptual framework based on the principles of cognitive behavioral therapy, and making them adapted to the  developmental level of the child.

Knell (1998) further developed the approaches of Beck (1976), Ellis (1971), and Bandura (1977) and other theorists, using play to work with children. Knell used structured approach, being directive and goal-oriented, to teach children to think of a new way to play, solve their problems, and build relationships. The application of CBPT includes the assessment and introduction of a customized intervention tailored to “increase behavioral competence” (p. 30). The therapist creates scenes from the child’s life and uses models, role-playing games, desensitization and other techniques to help the child change their behavior (Knell, 1998). 

According to Knell (1993a, 1993b, 1994, 1997, 1998), CT could be applied to children if presented in a way accessible to them. Puppets, stuffed animals, books and other toys can be used to model children’s cognitive strategies, verbalizing the ability to solve problems or find possible solutions to a problem similar to the child’s.

CBPT, as conceptualized by Knell (1993a, 1993b, 1994, 1997, 1998, 1999, 2000; Knell & Moore, 1990; Knell & Ruma, 1996, 2003; Knell & Beck, 2000, Knell & Dasari, 2006) was developed for use with children between 2½ and 8 years and is based on cognitive, behavioral and traditionally therapies. CBPT is sensitive to developmental issues and emphasizes the empirical validation of effectiveness of interventions.

For children, play is a natural and developmentally appropriate means of communication. So, children can use toys as their words and play as communication/language.

CBPT is divided into several phases, described as introductory/orientation, assessment, middle, and termination stages.

• Introductory/orientation
  During the initial interview, the therapist must help the parents understand how best to prepare the child for their first session and what explanation may be most developmentally suitable for him. So, can be recommended books such as “A Child’s First Book About Play Therapy” (Nemiroff & Annunziato, 1990).
• Assessment
  The aim of assessment is to define the targets and a treatment plan. In addition to a parent interview, it is important to provide a observation of familiar play and observation of child spontaneous play. In summary, the assessment includes parent report inventories (e.g., Child Behavior Checklist, Achenbach, 1991), familiar and children play assessment, The Puppet Sentence Completion task (Knell, 1992; Knell, 1993a; Knell, 2018, Knell & Beck, 2000) or therapist-created measures.
• Middle
  The therapist develops a treatment plan and the therapy focuses on increasing and reinforcement of the child’s self-control, sense of accomplishment, and learning more adaptive responses to deal with specific situations. Depending on the presenting problem, the therapist chooses the most appropriate cognitive and behavioral interventions using specific play techniques, to which the child responds most. The interventions must be evaluated carefully, with as much specificity as possible related to the intervention and the child’s specific problems/concerns.
• Termination  
  During this phase, the child and the family are prepared for the end of therapy. As the treatment nears its end, the child deals with the reality of termination and faces the feelings connected to it.

For a more complete description of these stages in CBPT, see Knell (1999).

In CBPT, the balance between structured and goal-oriented activities and unstructured activities in which child’s spontaneity emerges is fundamental.. Unstructured and spontaneous information is critical because it allows the therapist to obtain many clinical information, that the child feeling in a safe context has the opportunity to bring out.

The child expresses his needs through play and the therapist in recognizing them gives him all the expressive space without intervening and interpreting, but accepting and recognizing the precious moment of communication. Thanks to this space, structured therapy can plan an intervention that involves teaching more adaptive behaviors and strategies.

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• Knell, S.M. (2018).  Puppet Sentence Completion Task.  In A.A. Drewes & C.E. Schaefer  (Eds.).  Puppets in Play Therapy:  A Practical Guidebook. (pp. 59-73). Routledge Press.
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