Cognitive-behavioural play therapy

1. Introduction

Version followed: Susan M. Knell's cognitive-behavioural play therapy (CBPT), as she describes it in her Beck Institute article, her published answers to clinicians' questions and the abstract of her 2015 Handbook of Play Therapy chapter. Knell's four stage names (Section 2) come from that abstract, and the bibliographic details of her chapters from published reference lists. Her book Cognitive-Behavioral Play Therapy (Jason Aronson, 1993; later printings by Aronson, 1995, 288 pp., and Rowman & Littlefield, 2004) and her chapters in Foundations of Play Therapy (2011) and the Handbook (2015) are cited from publisher and reference-list details only. The publisher describes CBPT as structured, goal-oriented and directive [source: Torrossa publisher page]. What each stage contains, session counts and criteria for moving on are therefore not confirmed from Knell's own text [uncertain]; Section 2 marks what is drawn from others. For anxiety work the guide follows Knell & Dasari (2009), as a practitioner presentation reports it [uncertain: secondary report of the chapter]. Later developments by others (Drewes & Cavett; Remey; Geraci) are used only to fill gaps and are labelled.

CBPT is a play therapy that delivers cognitive-behavioural therapy through play for young children, roughly 2½ to 8 years old. Knell developed it from the late 1980s (Knell & Moore, 1986 poster on encopresis; Knell, 1993) in answer to the view that young children were too concrete, egocentric and language-limited for CBT. Her position is that CBT can work for them when it is developmentally sensitive and engaging. [source: Knell, Beck Institute article; Knell, Psychwire Q&A; Univ. of Patras library record]

How change happens: the child takes part directly in their own change. This is unlike parent-run behavioural programmes alone. Modelling and behavioural rehearsal through puppets and toys stand in for the verbal reasoning adult CBT relies on. The child watches a character with a problem like theirs learn coping thoughts and actions, copies them in play, and then practises them in real life. Parents and other adults reinforce the gains at home and school. Knell's stated targets are lower physiological arousal, coping with maladaptive thoughts and behaviours, emotion regulation, and better relationships with peers and caregivers. [source: Knell, Beck Institute article; Knell, Psychwire Q&A]

Professional frame. CBPT is a theoretical approach within play therapy, not a separate regulated profession. Only clinicians already qualified and licensed for child mental health work (psychologists, counsellors, social workers, child psychotherapists) should use it, and only after training in both child CBT and play therapy. In the United States, the Association for Play Therapy (APT) awards play-therapy credentials such as RPT and RPT-S. In the UK, BAPT and PTUK register play therapists. Knell runs webinars for Beck Institute youth-CBT trainees [source: APT parents' page (shows RPT-S); Beck Institute article]. There is also an online course site, course.cbpt.org (cbpt-institute.teachable.com redirects to it), with courses titled "CBPT Guidelines", "CBPT Basic Theoretical Model" and "Roadblocks in CBPT with children". Who runs it, what it teaches and whether it carries continuing-education credit are unverified. The cbpt.org domain hosts a poster by Maria A. Geraci (Centro Ricerca CBPT, Rome), so do not assume these are Knell's own courses [uncertain]. Credential requirements are [uncertain]. Do not use the anxiety exposure or encopresis components without supervised training in child CBT [synthesis].

Related guides: 157 Child-centred play therapy for reflective responding and limit-setting, 168 Prescriptive play therapy for matching CBPT to presenting problems, and 170 Trauma-focused integrated play therapy for trauma work. [synthesis]

2. Framework

Knell names four stages: "introductory/orientation, assessment, middle, and termination" [source: Knell 2015, Handbook of Play Therapy chapter abstract]. A single-case study that followed the phases of "the S. Knell model" lists the same four [source: Geraci poster]. The abstract also says the chapter covers the physical space, how often and how long treatment runs, initial assessment and treatment planning, and that planning aims at generalisation and relapse prevention. The chapter text is not reported here, so the goals, steps and move-on criteria below are put together from other sources and labelled; anything not traced to Knell is marked. Drewes & Cavett, writing in APT's magazine, call CBPT a "component approach" with no fixed length [source: Drewes & Cavett 2019]. A related Italian variant, "further refined by M.A. Geraci", uses five phases instead: orientation, evaluation, conceptualisation, intervention and conclusion [source: Geraci & D'Angelo 2025 abstract].

Format. Individual sessions with the child in a playroom, run alongside parent sessions. The therapist plays actively and works toward specific goals. Structured, directive segments are woven into unstructured play rather than run in fixed blocks. Goals come from the child and the therapist, often with parent input. [source: Knell, Psychwire Q&A]

Age fit. About 2½ to 8 years in Knell's Q&A; her 2015 chapter abstract says 3 to 8. Around age 8, mix play-based CBPT with language-based CBT to suit the child. [source: Knell, Psychwire Q&A; Knell 2015 abstract]

Stage 1: Introductory/orientation. This is Knell's first stage [source: Knell 2015 abstract]. The child gets used to the therapist, the room and how sessions run. Use unstructured play to gather clinical information and build the relationship [source: APT parents' page; Knell, Psychwire Q&A]. Drewes & Cavett put three things at the outset: setting goals with measurable objectives (the child helps set them through play), starting psychoeducation, and building a positive therapeutic relationship [source: Drewes & Cavett 2019]. What Knell's own text puts in this stage, and whether parent or child is seen first, were not verified [uncertain].

Stage 2: Assessment. Knell's 2015 chapter covers initial assessment and treatment planning [source: Knell 2015 abstract]. Goal: a formulation, not just a diagnosis [source: Halpin presentation, secondary]. The steps come from other sources:

• Parent interview on development, current functioning and the presenting problem.
• A separate child session with free play and a wide range of materials.
• Observation across settings, standardised measures and a look at family patterns that keep avoidance going.

A spontaneous play re-enactment of home events tells you where to aim interventions. Drewes & Cavett also assess developmental (especially cognitive) level, what maintains the problem, the child's coping strengths and weaknesses, and peer, caregiver and school influences. They keep reassessing progress and revise goals with the caregiver, child and teacher [source: Drewes & Cavett 2019]. Move on when you have a working formulation and goals agreed with the parents and, at the child's level, with the child [synthesis]. [source: APT parents' page; Halpin presentation drawing on Knell & Dasari 2009; Knell, Psychwire Q&A]

Stage 3: Middle. This is Knell's name for the working stage [source: Knell 2015 abstract]. Goal: teach and rehearse coping thoughts and behaviours. Drewes & Cavett open each working session with an agenda and a homework review, and set homework at every stage so skills carry over to other settings (see 4.30) [source: Drewes & Cavett 2019]. For anxiety, the reported order is:

1. Psychoeducation linking events, thoughts, feelings and behaviour.
2. Somatic management (relaxation).
3. Cognitive restructuring at the child's level.
4. Building a graded hierarchy and coping skills, then active exposure.

Parent work runs in parallel: support at home and, where needed, a parent-run behaviour programme. Move on when the child uses the coping skills in session without prompting and parents report the first gains outside [synthesis]. [source: Halpin, after Knell & Dasari 2009; Knell, Psychwire Q&A]

Generalisation and relapse prevention (across the middle and termination stages). This is not one of Knell's four stages. Her 2015 abstract says treatment planning aims at generalisation and relapse prevention [source: Knell 2015 abstract]. Steps: name triggers, plan coping for any return of symptoms, review progress and skills, and practise solving future problems with toys. Gains may not last unless home and school support the new behaviour. [source: Halpin, after Knell & Dasari 2009; Knell, Psychwire Q&A]

Stage 4: Termination. This is Knell's final stage [source: Knell 2015 abstract]. Drewes & Cavett end treatment when skills are in place, negative feelings or problem behaviour have decreased and goals are met. Child, caregiver and therapist decide together, and the ending is framed as a "graduation" [source: Drewes & Cavett 2019]. Expect a brief return of symptoms around the ending. Mark the end with a review book or a graduation event that includes parents [source: APT parents' page; Halpin presentation]. Knell's own termination criteria are [uncertain].

Session count and length. Knell's 2015 chapter discusses how often and how long treatment runs, but the abstract gives no figures [source: Knell 2015 abstract]. A secondary claim that Knell (2015) specifies 8 weekly 60-minute sessions is unconfirmed; do not plan around it [uncertain: secondary, unverified]. Drewes & Cavett say CBPT has no fixed length [source: Drewes & Cavett 2019]. Two published cases show the range:

• Emotional dysregulation (Geraci, Rome): 15 CBPT sessions over 6 months, after 12 child-centred play therapy sessions meant to give the child a safe climate and acceptance; follow-up at 30 months [source: Geraci poster].
• Separation anxiety in a girl aged 4½ (Geraci & D'Angelo 2025): 25 sessions over 9 months, plus parent training, with follow-ups at 3 and 6 months [source: Geraci & D'Angelo 2025 abstract].

These are single cases, not norms. APT notes that phases can pass in three or four sessions or last several months [source: APT parents' page]. A practical default is weekly sessions of about 45–50 minutes, plus regular parent sessions, reviewed against goals every 6–8 sessions [synthesis].

3. Guiding principles

• Developmental sensitivity. Fit every CBT method to the child's cognitive and language level; for example, swap verbal disputing for modelling [source: Knell, Beck Institute article].
• CBT delivered through play. Turn each CBT component into a play activity, not a talk [source: Knell, Beck Institute article].
• The child is an active agent. Work directly with the child, not only through the parents [source: Knell, Beck Institute article].
• A directive component. In Knell's words, "CBPT is a form of play therapy, but it has a directive component." Have a goal for each session and take part in the play [source: Knell, Psychwire Q&A].
• The full range of play. Use structured and unstructured, directive and nondirective play; leaving any of it out weakens treatment [source: Knell, Beck Institute article].
• Seamless structure. Bring structure into free play "in a smooth, flowing, flexible way". Join the child's story instead of stopping the play to teach [source: Knell, Psychwire Q&A].
• Unstructured play is data. Watch spontaneous play for re-enactments, beliefs and patterns, and plan the next intervention from them [source: Knell, Psychwire Q&A; Remey, Beck Institute].
• Modelling in place of verbal language. Show coping through a character before you ask the child to do it [source: Knell, Beck Institute article].
• Psychoeducation is built in. Teach new skills and alternative behaviours explicitly [source: Knell, Psychwire Q&A].
• Collaborative goals. Agree aims with the child and parents and revisit them [source: Knell, Psychwire Q&A].
• Deliberate praise and differential attention. Praise the adaptive behaviour you want and pay less attention to the maladaptive kind; praise "communicates to the child which behaviors are appropriate" [source: Knell, Psychwire Q&A].
• Make connections. Gently link the play to the child's real situation, much as interpretation works in psychodynamic therapy [source: Knell, Psychwire Q&A].
• Responsive adjustment. Watch how the child reacts to each modelling sequence and change the next step to match [source: Knell, Psychwire Q&A].
• Parent involvement is essential, and generalisation is planned. Engage parents, teachers or other caregivers so that home and school reinforce gains [source: Knell, Psychwire Q&A].
• Positive collaborative relationship. Treat the alliance as the vehicle for the work [source: Remey 2024].
• Thoughts show up in story and symbol. Find and change the cognitions as they appear in the play, without requiring self-report [source: Remey, Beck Institute].
• Formulation drives treatment. Use the formulation, not the diagnosis, to choose interventions [source: Halpin presentation, secondary].
• Use the child's interests. Borrow vocabulary from the child's favourite characters to name thoughts and skills [source: Halpin presentation, secondary].
• Safety and rights frame (applies throughout). Get parental consent and the child's assent, follow safeguarding and mandatory-reporting law, keep clear touch boundaries and use safe materials (see Section 5) [synthesis].

4. Intervention inventory

The first 16 entries (4.1 to 4.16) come from Knell's own writing. The rest (4.17 onward) come from secondary sources that draw on Knell, mainly a practitioner presentation based on Knell & Dasari (2009) that does not attribute each item; those are labelled. All example language is illustrative unless it is quoted and cited. Where steps go beyond what a source says, they are marked [synthesis].

4.1 Puppet or character modelling of coping

• Purpose: The central CBPT method. A puppet, doll or figure with a problem like the child's shows the problem and then, step by step, more adaptive thoughts, feelings and actions. It replaces verbal instruction. Use it for fears, anger, tantrums, sibling aggression and other target behaviours. [source: Knell, Beck Institute article; Knell, Psychwire Q&A]
• Steps:
  1. Choose a character the child likes and give it a problem that echoes the child's own but is not identical (for example, a puppet afraid of dogs).
  2. Act out the problem first so the child sees it recognised.
  3. Over this session and the next few, have the character try coping statements and actions: a calming breath, a brave self-statement, a small approach step.
  4. Have a second character praise the coping.
  5. Invite the child to help or to play the character.
  6. Carry the practice into real situations outside the playroom.
  [source: Knell, Beck Institute article; Knell, Psychwire Q&A] Pacing over several sessions [synthesis].
• Example language (illustrative): "Bear sees a dog and his tummy goes tight. Bear says, 'I can take a big breath. That dog is on a lead.' Let's see what Bear does next."
• Watch for: Does the child copy the character's words or actions on their own? Do they reject the scene (too close to home) or ignore it (too far)? Adjust the next sequence to their reaction, for instance by having one character just watch another cope. It is working when the child produces the coping words unprompted in play, and later at home. [source: Knell, Psychwire Q&A]

4.2 Behavioural rehearsal and role play

• Purpose: Practise a target skill until it is fluent before trying it in real life. Examples: asking a peer to play, sorting out a disagreement, telling a parent how upset you feel. [source: Knell, Beck Institute article; Knell, Psychwire Q&A; Remey, Beck Institute]
• Steps:
  1. Name the situation in the child's words.
  2. Model it once with puppets.
  3. Have the child act it with a puppet, and give specific praise.
  4. Add small challenges, such as the peer puppet saying no.
  5. Replay until it runs smoothly.
  6. Plan one real try with the parent.
  [synthesis, built on cited examples]
• Example language (illustrative): "Your puppet wants to join the block game. What could she say? Let's try it, and I'll be the other kid."
• Watch for: Rehearsal that stays scripted and never happens outside. Ask parents and teachers what they see.

4.3 Positive (coping) self-statements

• Purpose: Replace maladaptive self-talk with short, concrete coping statements a young child can say. [source: Knell, Beck Institute article; Knell, Psychwire Q&A]
• Steps:
  1. Listen for the worried or angry thought in the child's play.
  2. Have a character say a brief alternative.
  3. Help the child choose or invent their own phrase.
  4. Practise it in play scenes.
  5. Write or draw it on a card to take home.
  [source: Knell (statements via characters); Halpin presentation (coping cards)] Order of steps [synthesis].
• Example language (illustrative): "What could Bunny tell herself? Maybe 'I can do hard things'? Or would you pick different words?"
• Watch for: Statements that are too long, or that deny real danger. They should be believable, brief and specific to the situation.

4.4 Externalising the problem ("anxiety is a bully")

• Purpose: Separate the child from the anxiety, then teach them to resist it. Knell describes treating anxiety as a bully the child learns to "talk back" to. [source: Knell, Psychwire Q&A]
• Steps:
  1. Have the child name or draw the worry as a character.
  2. Act out how it bosses the child around.
  3. Model talking back with a puppet.
  4. Have the child practise talking back with relaxation and coping statements ready.
  5. Get parents to cue the same phrase at home.
  [synthesis around the cited core]
• Example language (illustrative): "The Worry Bully says, 'You can't go to the party.' What can we say back to him?"
• Watch for: A bully character that becomes frightening. Keep it silly and small; see 4.22.

4.5 Relaxation training

• Purpose: Lower physiological arousal, which is one of Knell's stated targets. Teach this before exposure. [source: Knell, Beck Institute article; Knell, Psychwire Q&A; Halpin presentation]
• Steps:
  1. Teach one concrete method, such as slow breathing or tensing and relaxing muscles.
  2. Use a sequence of "see one, do one, teach one": the child watches the puppet do it, does it with you, then teaches the puppet.
  3. Use props to make it visible, such as a balloon to show holding worry in versus letting it out.
  4. Practise briefly every session.
  5. Give parents a home routine.
  [source: Halpin, after Knell & Dasari 2009]
• Example language (illustrative): "Can you teach Puppy to breathe out slowly, like blowing out birthday candles?"
• Watch for: Children who feel more anxious when they attend to their breathing. Switch to an active method, such as tensing and relaxing muscles or movement play.

4.6 Distraction

• Purpose: A short-term coping tool for anxiety, named by Knell alongside relaxation and self-statements. [source: Knell, Psychwire Q&A]
• Steps: Build a small menu with the child (counting colours, a song, a fidget). Rehearse using it in a play scene of the feared moment. [synthesis]
• Example language (illustrative): "When the worry starts, what's one thing you could count?"
• Watch for: Distraction turning into avoidance during exposure. Use it to cope, not to escape the exposure step [synthesis].

4.7 Psychoeducation through play

• Purpose: Teach the child and parents, in concrete terms, how events, thoughts, feelings and behaviour link. Knell treats psychoeducation as integral to CBPT. [source: Knell, Psychwire Q&A; Halpin presentation]
• Steps:
  1. Use a story or puppet scene to show event, thought, feeling and action.
  2. Help the child spot their own body signals.
  3. Give parents a matching explanation.
  [synthesis]
• Example language (illustrative): "When Lion thought 'everyone will laugh', his face got hot and he hid. What if he thought something else?"
• Watch for: Lecturing. Keep it short and inside the play.

4.8 Cognitive change (restructuring) adapted for young children

• Purpose: Reduce maladaptive thoughts and add adaptive ones. Knell names cognitive restructuring as adaptable for young children. [source: Knell, Beck Institute article]
• Steps:
  1. Draw helpful and unhelpful thought bubbles on a whiteboard for a character.
  2. With children old enough, play "detective": look for evidence for and against a thought. This has limits with younger children.
  3. With younger children, lean on modelling (4.1) and self-statements (4.3) instead.
  [source: Halpin presentation, secondary]
• Example language (illustrative): "Detective time: has Fox ever got lost at school before? What clues do we have?"
• Watch for: Abstract reasoning beyond the child's stage. If the child is confused, go back to modelling.

4.9 Systematic desensitisation and graded exposure through play

• Purpose: Reduce fear and avoidance by approaching feared situations step by step while using coping skills. Knell names systematic desensitisation and exposure as adaptable to CBPT. [source: Knell, Beck Institute article; Halpin presentation]
• Steps:
  1. Build coping skills first (4.5, 4.3).
  2. Make a concrete hierarchy with the child: drawings or toys placed on a "stairway", with reward symbols on the steps.
  3. Do imaginal exposure by acting out each step with toys while the child's character uses coping talk.
  4. Move to real-life (in vivo) steps outside the playroom, with the parent present or doing the practice.
  5. Climb a step only when the one below feels manageable.
  [source: Halpin, after Knell & Dasari 2009; Knell, Beck Institute article]
• Example language (illustrative): "Step one is looking at a picture of a dog. Ready to put your brave puppet on step one?"
• Watch for: Distress that stays high, or flooding. Never force a step. Get the parent's informed consent and the child's assent for each real-life step. Check for medical or trauma factors before starting (see Section 5). [synthesis]

4.10 Exposure and response prevention (ERP)

• Purpose: For compulsive or ritualised behaviour, approach the trigger while holding off the ritual. Knell names ERP as adaptable; no cited source describes how to deliver it in play [uncertain].
• Steps: [synthesis] Externalise the urge as a character (4.4), set up a graded ladder (4.9), and have a puppet model resisting the ritual for a set time. Then the child does a short practice with coping talk. Coach parents to reduce accommodation (4.14).
• Example language (illustrative): "The Washing Monster says wash again. Can Teddy wait until the sand timer runs out?"
• Watch for: Hidden rituals, and family accommodation. Refer to OCD-specialist child CBT if progress stalls [synthesis].

4.11 Deliberate praise and differential attention in session

• Purpose: Strengthen adaptive behaviour and weaken maladaptive behaviour inside the play. Knell sets this against client-centred and psychodynamic approaches, which avoid praise. [source: Knell, Psychwire Q&A]
• Steps: Praise specific coping acts, by the child or a character, right after they happen. Give little attention to minor misbehaviour that is safe to ignore. Have characters praise each other. [source: Knell, Psychwire Q&A] Specific wording [synthesis].
• Example language (illustrative): "You used your calm-down breath when the tower fell. That was really strong."
• Watch for: Generic praise, and praise that comes to feel controlling. Ignoring is never used for unsafe behaviour.

4.12 Making connections

• Purpose: Help the child link the play to their own life and understand conflicts. Knell compares this to interpretation in psychodynamic work. [source: Knell, Psychwire Q&A]
• Steps: After a play theme repeats, offer one tentative link and let the child accept or wave it away. [synthesis]
• Example language (illustrative): "I wonder if Baby Doll gets cross like that when her big sister takes her toys, a bit like at your house?"
• Watch for: The child shutting down. Go back into the metaphor.

4.13 Weaving structure into unstructured play

• Purpose: Keep the child engaged and keep the information that free play gives, while still delivering CBT content. [source: Knell, Psychwire Q&A; Knell, Beck Institute article]
• Steps: Let the child lead. Spot a moment in their story that fits the goal (a character gets scared or angry). Bring in the coping model inside that story. Then hand the lead back. [source: Knell, Psychwire Q&A] Steps [synthesis].
• Example language (illustrative): "Oh no, the dinosaur is stomping because his brother took his food! What could help him calm down?"
• Watch for: Too much steering, so the child stops playing, or none at all, so no skills are taught.

4.14 Parent work: guidance, home support and reducing accommodation

• Purpose: Make sure gains generalise and keep. Knell answers "YES" to whether CBPT depends on parent involvement, though how much varies by problem. [source: Knell, Psychwire Q&A]
• Steps:
  1. Hold regular parent sessions.
  2. Explain the skills the child is learning and give a home practice routine.
  3. Help parents stop over-reassuring an anxious child and stop "walking on eggshells".
  4. Bring in teachers, grandparents or other carers when parents cannot take part.
  [source: Knell, Psychwire Q&A]
• Example language (illustrative): "When she asks the same worry question again, try once: 'You know what to tell the worry.' Then help her use her card."
• Watch for: Parental distress or conflict that blocks the work. Consider separate parent support.

4.15 Parent-implemented behaviour management programmes

• Purpose: For non-compliant or aggressive children, run a parent-led behaviour programme alongside CBPT, since these children often need one. [source: Knell, Psychwire Q&A]
• Steps: [synthesis] Agree one or two target behaviours, set up a simple reward chart and consistent consequences, and review it each parent session. Mirror the targets in play, for example a puppet earning stickers.
• Example language (illustrative): "This week let's reward just one thing: using words instead of hitting."
• Watch for: Programmes that are too complex or that punish; inconsistent use at home.

4.16 Play-based assessment and ongoing observation

• Purpose: Gather clinical information from spontaneous play and from how the child responds to modelling. [source: Knell, Psychwire Q&A]
• Steps: Offer free play with varied materials. Note themes, re-enacted home events and the child's thinking styles. Add a parent interview, observation across settings and standardised parent and teacher measures. [source: Knell, Psychwire Q&A; Halpin presentation; APT parents' page]
• Example language (illustrative): "You can play with anything here. I'll be right here with you."
• Watch for: Over-reading play. Play themes are hypotheses for the formulation, not diagnostic evidence of abuse or disorder [synthesis].

4.17 The child coaches the anxious puppet

• Purpose: Put the child in the expert role to strengthen skills and self-efficacy. This builds on Knell's example of one puppet watching another cope. [source: Halpin presentation (secondary); Knell, Psychwire Q&A]
• Steps:
  1. Bring in a puppet with the child's fear.
  2. Ask the child to teach it a skill they have learned.
  3. Have the puppet "forget" a step so the child has to correct it.
  [synthesis on the cited core]
• Example language (illustrative): "Owl is scared about sleeping alone. What should we teach him first?"
• Watch for: A child who cannot coach yet. Model the coaching again first.

4.18 Body tracing for feelings

• Purpose: Build awareness of where feelings sit in the body, as part of psychoeducation and somatic work. [source: Halpin presentation (secondary)]
• Steps:
  1. Trace round the child on large paper, only with the child's assent.
  2. Ask the child to draw or colour where worry, anger and calm live.
  Offer to trace round a doll or use a printed outline instead if the child does not want their own body traced [synthesis].
• Example language (illustrative): "Where does the worry go in your body? Pick a colour for it."
• Watch for: Discomfort with lying down or with body focus, especially after trauma. Tracing needs no touch at all (see 5.9).

4.19 Calming and exciting play (arousal awareness)

• Purpose: Help the child notice their arousal levels and practise bringing them down. [source: Halpin presentation (secondary)]
• Steps:
  1. Alternate active play (a ball game, a chase in a safe space) with quiet play (colouring, building bricks).
  2. Have the child rate their "engine" before and after.
  3. Practise moving from fast to calm on cue.
  [source: Halpin; rating step synthesis]
• Example language (illustrative): "Is your engine fast or slow right now? Let's see if we can slow it down."
• Watch for: Over-arousal you cannot settle. Keep the room safe and set clear limits.

4.20 Coping cards, strengths cards and brave props

• Purpose: Make the skills concrete and portable. [source: Halpin presentation (secondary)]
• Steps:
  1. The child decorates a card with their coping statement and makes a separate card listing their strengths.
  2. Use role models the child admires ("What would your hero say?").
  3. Use props such as a brave hat, helmet or cardboard sword to practise pretending to be brave.
• Example language (illustrative): "Put on the brave helmet. What does Brave-You say to the worry?"
• Watch for: Props used to avoid the feared step rather than to approach it.

4.21 Role play with helpful thoughts

• Purpose: Practise helpful thinking in action. [source: Halpin presentation (secondary)]
• Steps:
  1. Act out the target situation with toys.
  2. Pause at the hard moment.
  3. Have the toy say the helpful thought aloud before acting.
  4. Swap roles with the child.
• Example language (illustrative): "Freeze! What helpful thought could Robot say right now?"
• Watch for: Thoughts that stay at the level of words. Check them against real behaviour.

4.22 Making the fear silly (dominating the fear)

• Purpose: Reduce the threat value of an externalised fear and give the child a sense of mastery. [source: Halpin presentation (secondary)]
• Steps: Let the child give the fear character something absurd to wear or do, such as a tutu or roller skates. Then have the child's character tell it what to do. [source: Halpin]
• Example language (illustrative): "What silly thing should the Scary Dog wear today?"
• Watch for: Mocking a real danger, or a real person. Use this only for exaggerated fears, not for traumatic events or actual abusers [synthesis].

4.23 Strengths shield

• Purpose: Gather the child's strengths, coping skills and supports into one symbol for the end of treatment. [source: Halpin presentation (secondary)]
• Steps: The child decorates a cardboard shield with emblems for strengths, skills and the people who help them. Review it at relapse-prevention sessions. [source: Halpin; review step synthesis]
• Example language (illustrative): "Which picture shows who helps you when you're scared?"
• Watch for: A child who cannot name any supports. That is a safeguarding and social-support cue (see 5.8).

4.24 Future problem-solving with toys (relapse prevention)

• Purpose: Prepare for setbacks and practise generalising skills. [source: Halpin, after Knell & Dasari 2009]
• Steps:
  1. Set up likely future triggers with toys, such as a new school or a new dog.
  2. Have the child's character work out which skills to use.
  3. Rehearse it.
  4. Make a short plan with the parents.
• Example language (illustrative): "What if the worry comes back when Bunny starts big school? What would she do first?"
• Watch for: A belief that worry must never come back. Normalise lapses.

4.25 Co-created therapy storybook and bibliotherapy

• Purpose: Strengthen learning through narrative. A storybook made with the child reviews the work, and published children's books can teach coping. [source: Halpin presentation (secondary); Remey 2024 (bibliotherapy)]
• Steps:
  1. Over the final sessions, build a page-by-page book about the child's journey, using drawings or photos with consent.
  2. Add a closing page about the future.
  3. Separately, read a coping-themed children's book together and practise the skill it shows.
• Example language (illustrative): "This page is about the day you were brave at the park. What should we write?"
• Watch for: Photos of the child: get the parent's consent and agree who keeps the book [synthesis].

4.26 Metacognitive bravery story

• Purpose: Present bravery as acting while still feeling worried, not as the worry going away. [source: Halpin presentation (secondary)]
• Steps: Tell or make up a story, such as a firefighter who feels scared but goes in anyway. Then link it to the child's next step. [source: Halpin; linking step synthesis]
• Example language (illustrative): "The firefighter's heart was racing and she still climbed the ladder. That's what brave means."
• Watch for: Stories in which the hero takes unsafe risks.

4.27 Nurturing play and co-regulation via a doll

• Purpose: Practise self-soothing by soothing someone else, and bring out separation fears. [source: Remey, Beck Institute (later development)]
• Steps: In home-corner or kitchen play, notice when the child's doll is scared or alone. Model calming statements to the doll, then invite the child to comfort it. Make a link to the child's own fears (4.12) if it fits. [source: Remey, Beck Institute; steps synthesis]
• Example language (illustrative): "Baby is scared when Mummy goes. What can we tell her?"
• Watch for: Play themes that suggest something has actually happened. Do not interpret these as evidence; follow safeguarding procedures (see 5.8).

4.28 CBPT in the sand tray

• Purpose: A later integration by Remey: the sand tray as a medium for CBT work such as psychoeducation, coping self-talk and enacting problems. [source: Remey 2024]
• Steps: Use the child's tray scene to find the problem and the thoughts in it. Have a figure model coping self-talk. Let the child change the scene to show a coping outcome. [source: Remey 2024; steps synthesis]
• Example language (illustrative): "What is this little figure thinking? What could help it?"
• Watch for: Sand hygiene and dust (see 5.10). This is not part of Knell's original account.

4.29 Graduation ceremony

• Purpose: Mark the end of treatment, consolidate gains and include parents. [source: Halpin presentation (secondary)]
• Steps: Hold a short ceremony with the child, therapist and parents. Give a certificate naming the skills learned, and review the shield or storybook. [source: Halpin; content synthesis]
• Example language (illustrative): "Today we celebrate everything you learned. Can you show Mum your best calm-down trick?"
• Watch for: Sadness or a return of symptoms around ending. That is common and usually brief. [source: APT parents' page]

4.30 Session agenda, homework and behavioural contract

• Purpose: Give the middle stage a predictable CBT structure and carry skills into home and school. Drewes & Cavett list these among CBPT components: an agenda and homework review at the start of each session, homework at every stage, contingency contracts made by child, therapist and caregiver, behavioural shaping, and teaching caregivers positive reinforcement and time out [source: Drewes & Cavett 2019]. Knell's own pages cited here do not list these [uncertain].
• Steps [synthesis around the cited components]:
  1. Open with a short picture agenda of two or three items, one of them free play.
  2. Review last week's practice with the child and parent, and praise any attempt.
  3. Agree one small home task linked to the session's skill.
  4. For a behaviour goal, draw up a simple contract with the child and parent: one target behaviour, a reward the child picks, and how it will be recorded.
  5. Shape the behaviour: reward closer and closer approximations, then raise the bar.
  6. Coach parents in specific praise and, if used, brief non-punitive time out. Review both at each parent session (see 4.15).
• Example language (illustrative): "Today we have three things: your brave chart, a puppet game, then your choice. What did you try this week?"
• Watch for: Agendas that crowd out play; contracts with too many targets or rewards the family cannot keep up; time out used harshly, or used for an anxious child's avoidance. It is working when the child brings back home-practice reports and contract targets go up steadily [synthesis].

5. Handling problems

5.1 Skills show up in play but not at home or school. Knell warns that gains may not generalise or last without active support at home and school. Steps:

• Bring parents, and with consent teachers, into planning.
• Give them the same cue words and coping cards.
• Set a few small real-life practice steps each week.
• Review them at the start of each child session.

[source: Knell, Psychwire Q&A; steps synthesis]

5.2 The child resists directive play or ignores the modelling. Go back to child-led, unstructured play. Then bring the structure in inside the child's own story, smoothly and flexibly. Make the model character less like the child, for distance, or have it simply watch another character cope. [source: Knell, Psychwire Q&A] Shorten the structured parts and use the child's favourite characters [synthesis].

5.3 Non-compliant, aggressive or acting-out children. Knell says CBPT can work with these children when it is tailored to the child, and that a parent-run behaviour programme is often needed alongside it (4.15). In session, set clear safety limits. Praise calm behaviour right away. Model angry and then calmer characters. Consider whether the parent programme should come first. [source: Knell, Psychwire Q&A; limits and sequencing synthesis]

5.4 Overwhelm during exposure or a frightening scene. [synthesis]

• Stop moving up the hierarchy.
• Step out of the scene: put the puppet down and say it is pretend.
• Do a practised relaxation skill together.
• Go back one step on the ladder.
• Re-check the child's assent before going on.
• Tell the parent what happened at the end of the session.

Do not do graded exposure until coping skills are in place [source: Halpin, after Knell & Dasari 2009]. Contraindications for exposure that need a medical or specialist check first: an untreated medical cause of the symptom; current abuse or an unsafe home, where the fear may be realistic; acute trauma symptoms; and a parent who cannot support the plan [synthesis].

5.5 Parent non-adherence, over-reassurance or accommodation. Knell notes that parents may need help to stop over-reassuring or "walking on eggshells" around an anxious child. Steps:

• Explain how accommodation keeps fear going.
• Agree on one change at a time.
• Role-play the parent's response in session.
• Keep home tasks to a few minutes a day.

If parents cannot take part, involve other caregivers or teachers. Look for parental anxiety or depression that needs its own referral. [source: Knell, Psychwire Q&A; steps synthesis]

5.6 Ruptures with the child (anger at the therapist, refusing to come) or with parents. The APT notes that children may go through a negative-reaction phase in which symptoms briefly worsen and they resist attending. Steps: name the feeling in play, ease the demands, and repair through child-led play. With parents, re-agree the goals and explain that a dip is expected. [source: APT parents' page; responses synthesis]

5.7 Older or more verbal children (about 8 and up). Blend in more language-based CBT, such as talking through thought records and evidence for and against a thought, while keeping play as the vehicle. [source: Knell, Psychwire Q&A; Halpin presentation]

5.8 Safeguarding, disclosure, consent and assent. [synthesis, except where cited]

• Consent and assent. Get informed consent from whoever holds parental responsibility, and check the custody arrangements. Explain CBPT, parent involvement, the limits of confidentiality and the plan for any exposure. Get the child's assent at their level at the start and before each exposure step, and accept a "no" as information, not defiance.
• Confidentiality with parents. Agree in advance what you will share with parents (themes and progress, not word-for-word play) and what you must share (risk).
• Disclosure or concern. If a child discloses harm, or play, words or physical signs raise concern:
  • Stay calm.
  • Do not ask leading questions or re-stage the event in play.
  • Write down the child's words exactly, with the date and time.
  • Follow your service's safeguarding procedure.
• Mandatory reporting. Whether you must report, to whom, and how fast varies by country, state and profession. Check your local law and professional code, and discuss with your safeguarding lead or supervisor. Never wait to gather "proof" from play.
• Play is not evidence. Play themes (aggressive or sexualised scenes, nurturing play about being left alone) are hypotheses. Never present them as diagnostic evidence of abuse. Forensic interviewing is a separate, specialist role.

5.9 Touch boundaries. [synthesis] No cited CBPT source addresses touch.

• Keep touch minimal and child-initiated: a high-five, or help with a costume.
• Never touch the genitals, buttocks or chest, and never touch in any sexual way.
• Do not restrain except under your service's emergency policy.
• Body tracing (4.18) and relaxation need no touch; use a doll or an outline instead if the child prefers.
• Ask before any touch, respect refusals, and keep the door or a window open as your service requires.
• Take extra care with traumatised children and different cultural norms.
• Tell parents what touch, if any, can happen in session.

5.10 Play materials safety. [synthesis] CBPT starts at about 2½ years, so:

• Avoid small parts, magnets, button batteries, balloons left within reach (supervise balloon use in 4.5), and long cords.
• Use non-toxic, age-labelled art materials.
• Avoid sharp scissors and props for young children; cardboard swords and shields only.
• Check for latex and food allergies before using balloons or food in play.
• Clean puppets, dolls, sand and toys regularly. Replace or sieve sand, and keep it damp to limit dust.
• Keep the room hazard-free for active play (4.19).

5.11 Return of symptoms at ending. Expect it (APT), plan termination gradually, and use the relapse-prevention work (4.24) and the storybook (4.25). Offer a booster session rather than restarting full treatment. [source: APT parents' page; booster synthesis]

5.12 The child's problem has a medical side (for example, encopresis, an early CBPT application). Make sure a physician has assessed and treated any physical cause before behavioural work. CBPT supports medical care and does not replace it. [source: Knell & Moore 1986 poster, cited by title only in the Beck Institute article; guidance synthesis]

5.13 The approach is not working after a fair trial. [synthesis]

• Re-check the formulation: is the problem mainly in the family system or the parenting?
• Consider shifting the weight toward parent-led treatment.
• Look for comorbidity (developmental, language or trauma).
• Refer on to specialist child CBT or other services.

Sources

Online sources:

• Cognitive Behavioral Play Therapy (CBPT): A developmentally informed integration of cognitive behavioral therapy and play therapy (Susan M. Knell, Beck Institute)
• Cognitive-behavioral play therapy: Q&A with Susan Knell (Psychwire)
• Susan Knell profile (Psychwire)
• Cognitive behavioral play therapy: library record, University of Patras
• Bridging cognitive behavior therapy and play therapy (Lisa Remey, Beck Institute)
• Remey, L. (2024). Cognitive Behavioral Play Therapy in the Sand. World Journal for Sand Therapy Practice, 2(1)
• Halpin, S. Incorporating play into CBT for children (Australian Psychological Society presentation)
• What to Expect in a Play Therapy Session (Association for Play Therapy)
• Ab Razak, N. H., et al. (2018). General Review on Cognitive Behavior Play Therapy on Children's Psychology Development. IJARPED, 7(4) (minimal content used)
• CB play therapy workshop description (Everleaf / PathLMS) (minimal content used)

Further online sources:

• Knell, S. M. (2015). Cognitive-Behavioral Play Therapy, Handbook of Play Therapy chapter: abstract (ResearchGate record)
• Drewes, A., & Cavett, A. (2019). Cognitive behavioral play therapy. Play Therapy, 14(3), 24–26 (Association for Play Therapy)
• Geraci, M. A. Poster: Cognitive Behavioral Play Therapy (CBPT) and emotional dysregulation: a single case study (cbpt.org)
• Geraci, M. A., & D'Angelo, F. R. (2025). Application of cognitive behavioral play therapy in a case of separation anxiety in a 4.5 year old girl. Psicologia clinica dello sviluppo, 29(2), 303–313 (abstract)
• Remey (2024), reference list (used to verify Knell chapter details)
• Bookseller listing: Cognitive-Behavioral Play Therapy (Jason Aronson, 1995)
• Knell, S. M. Cognitive-Behavioral Play Therapy (Jason Aronson, 1995 printing): publisher listing and description (Torrossa)
• Drewes, A. A., & Remey, L. (Eds.). Cognitive Behavioral Play Therapy: A Comprehensive Guide to Theory and Practice (Bloomsbury Academic, 2026): ebook listing (Perlego)

Books and chapters cited (details as given in the pages above):

• Knell, S. M. (1993). Cognitive-Behavioral Play Therapy. Northvale, NJ: Jason Aronson. Later printings: Aronson, 1995; Rowman & Littlefield, 2004 (per Remey 2024, a bookseller listing and the Torrossa publisher page, which gives 288 pp. for the 1995 printing).
• Knell, S. M., & Moore, D. J. (1986). Cognitive-behavioral play therapy in the treatment of encopresis. Poster presentation.
• Knell, S. M., & Dasari, M. (2009). CBPT: Implementing and integrating CBPT into clinical practice. In A. A. Drewes (Ed.), Blending Play Therapy with Cognitive Behavioral Therapy (pp. 297–318). Wiley (details per Remey 2024's reference list). An earlier version of this guide placed the 2009 anxiety chapter in Kaduson & Schaefer's Short-Term Play Therapy for Children; that placement is unconfirmed, and which chapter the Halpin presentation drew on is [uncertain].
• Knell, S. M. (2011). Cognitive-behavioral play therapy. In C. E. Schaefer (Ed.), Foundations of Play Therapy (2nd ed., pp. 313–328). Wiley (per Remey 2024).
• Dasari, M., & Knell, S. M. (in preparation). Cognitive Behavioral Play Therapy: Helping Young Children with Anxiety and Beyond. Guilford.
• Drewes, A. A., & Remey, L. (Eds.) (2026). Cognitive Behavioral Play Therapy: A Comprehensive Guide to Theory and Practice. Bloomsbury Academic. [ebook listing]

Further Knell chapters (details from reference lists; the 2015 chapter also from its abstract):

• Knell, S. M. (2015). Cognitive-behavioral play therapy. In K. J. O'Connor, C. E. Schaefer & L. D. Braverman (Eds.), Handbook of Play Therapy (2nd ed., pp. 119–133/134). Wiley. doi:10.1002/9781119140467.ch6
• Knell, S. M. (2022). Cognitive behavioral play therapy. In R. D. Friedberg & E. V. Rozmid (Eds.), Creative CBT with Youth. Springer.
• Knell, S. M., & Dasari, M. (2011). Chapter in S. W. Russ & L. N. Niec (Eds.), Play in Clinical Practice (cited in Geraci poster; title not verified) [uncertain].