Susan M. Knell, PhD, Adjunct Faculty
The treatment of 5-year-old Little Hans (Freud, 1909) is often considered to mark the beginning of child psychotherapy, but Freud had little interest in working directly with children. Other psychoanalytically oriented therapists, such as Anna Freud and Melanie Klein, understood the importance of such direct work. Later, Carl Rogers developed Client Centered Psychotherapy for adults, which was soon adapted for work with children, by his student, Virginia Axline. Her work is now known as Child-Centered Play Therapy (CCPT). Axline’s writings (Play Therapy, 1947; Dibs in Search of Self, 1964) are on the bookshelves of many child therapists, and for many years CCPT was the primary theoretical approach to play therapy.
As the years passed, other theoretical approaches to play therapy emerged, but even with a broader range of theoretical backgrounds, there continued to be great skepticism about play therapy. It was often dismissed as lacking scientific credibility.
Recently, play therapy has received more attention. Play therapy research has continued to show that the therapeutic powers of play are effective in improving young children’s internalizing and externalizing symptoms. At present, play therapy is not one single approach, but rather a psychotherapy for very young children informed by a specific theoretical orientation. Currently, there are eight seminal theories of play therapy (Crenshaw, Stewart & Ray, 2025).
Why Young Children Were Once Considered Unable to Benefit from CBT
One of these, Cognitive Behavioral Play Therapy (CBPT) emerged in the late 1980s, around the time that Cognitive Behavior Therapy (CBT) was gaining greater acceptance (Knell & Moore, 1986, Knell, 1993). CBT was increasingly moving towards becoming an empirically supported treatment for school-age children; however, CBT with younger children remained undeveloped. In large measure, developmentalists noted the many reasons why young children were unlikely to engage in or benefit from CBT. From a Piagetian perspective, young children were too egocentric, concrete, linguistically challenged, and unable to think rationally or flexibly. Any efforts to introduce CBT to preschool-age children were likely sidelined by this developmental understanding of the young child.
Yet, the need for a developmentally informed treatment approach based on the CBT model was sorely needed. CBPT began in part as an effort to introduce psychoeducation and goals into the therapy. Over time, it became clearer that CBT could be introduced to children if the psychotherapy was developmentally sensitive and engaging. CBT provides both the framework and theory for this therapeutic approach. CBPT is based on CBT principles (J. Beck, 2021) and integrates these in a developmentally appropriate way (Dasari & Knell, in preparation). CBPT helps children decrease physiological arousal, cope with maladaptive thoughts and behaviors, regulate their emotions, and improve their relationships with peers and caregivers.
How CBPT Adapts CBT Techniques for Young Children
Today, CBPT has evolved into an integration of CBT and play therapy, with CBT delivered through play and adapted to the child’s level and needs. In place of verbal language, modeling and behavioral rehearsal are often used. For example, a puppet can struggle with a fear of dogs but with the therapist’s help, can learn positive self-statements and coping skills. As children watch and interact with the puppet model, they often copy and imitate the puppet, especially if they find it appealing and believable. Then, in real life, outside the playroom, the child can practice interacting with dogs of various sizes, activity levels, and perceived danger. The child can overcome fears, increase adaptive behaviors, and decrease maladaptive thoughts. Children can be part of the change and participate directly, rather than indirectly as is often the case with parent-implemented behavioral programs.
In our experience, any CBT technique can be adapted for use in CBPT. For example, systematic desensitization, exposure and response prevention, and cognitive restructuring are all CBT techniques that can be successfully adapted with young children. The nature of structure or direction in treatment are important variables. The dimension of unstructured versus structured refers to the organization of the play whereas the dimension of nondirective versus directive refers to the level of therapist guidance. More traditional play therapies, such as CCPT, are typically unstructured and nondirective. CBPT is known for being structured and directive, but it also includes play that is unstructured and nondirective. One of the important aspects of CBPT is that it includes a full range of play, to optimize treatment.
Play therapy has become an increasingly respected discipline and the growth of CBPT is offering child therapists an opportunity to use CBT in a developmentally informed way to help young children with a wide variety of problems.
References:
Beck, J. (2021). Cognitive Behavior Therapy: Basics and Beyond, 3rd ed. Guilford.
Daari, M. and Knell, S.M. (in preparation). Cognitive Behavioral Play Therapy: Helping Young Children with Anxiety and beyond. Guilford.
Knell, S.M. (1993). Cognitive-Behavioral Play Therapy. New Jersey: Jason Aronson.
Knell, S.M. & Moore, D.J. (1986, December). Cognitive-Behavioral Play Therapy in the Treatment of Encopresis. Poster presented at the Rivendell Conference for Clinical Practitioners, Memphis, TN.
If you work with children and adolescents, we hope you will learn more about our CBT certification program for clinicians working with youth. By earning certification, clinicians not only strengthen their own practice—they contribute to raising the standard of care for youth mental health everywhere.
Trainees who are enrolled in Beck Institute Certification (both adult and youth tracks) are eligible to enroll in a free webinar from Dr. Knell. CEs are available!
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