Cognitive Behavioral Therapy & Play Therapy: Three Appraoches

Cognitive Behavioral Therapy is an umbrella term. 
 
Cognitive Behavioral Therapy (CBT) is a form of therapy that focuses on thoughts, feelings, and behaviors and has been found to be effective in treating mental health diagnoses such as anxiety, ADHD, depression, separation anxiety, trauma, phobias, and the list goes on! 
 
Overall CBT believes: 

• Psychological difficulties are a product (in part) of unhelpful thinking patterns
• Psychological difficulties are a product (in part) of learned patterns of unhelpful behavior 
• People with psychological difficulties and problems can:
  • Learn better ways of coping (shifting thinking patterns and altering behavior) 
  • Can relieve symptoms and become more effective in their lives 

 
Dr. Aaron Beck is widely recognized as the Father of Cognitive Behavioral Therapy and founded, with Dr. Judith Beck the Beck Institute.  Check out this quick introduction to Cognitive Behavioral Therapy.

There are other types of CBT that shift to focus more on thinking and theories such as Rational Emotive Behavioral Therapy developed by Dr. Albert Ellis.  These models were developed as talk therapy approaches, which…well… doesn’t work great for kids.  
 
The awesome news is that there have been many adaptations of Cognitive Behavioral Therapy approaches and techniques to integrate play to make it more developmentally appropriate (and effective) for children.  
 
I wanted to share three types of Cognitive Behavioral Therapy I think are essential in any child therapy practice:
 
Cognitive Behavioral Play Therapy:
 
Okay this one is a given and definitely my default when working with children! Cognitive Behavioral Play Therapy was developed by Susan Knell in 1998 who drew on influences of Dr. Aaron Beck, Dr. Albert Ellis, and Dr. Albert Bandura.

Phases include introduction and orientation, assessment, the middle (or working) stage, and termination. Susan Knell developed the model to have both structured and goal oriented activities and unstructured activities to allow for the child’s spontaneity to emerge and allows the gathering of essential information about the child’s world.  Knell notes that the focus of CBPT is on “directions and goals, choice of play materials and activities, play as educational, and the importance of making connections between the child’s behavior and thoughts”.  Techniques include modeling, role play, direct and indirect approaches, and classical and operant conditioning. 
 
Want to add some Cognitive Behavioral Play Therapy tools to your toolbox?  Check out these interventions, activities, and downloads here:  

• A bibliotherapy intervention and free downloadable worksheet for shifting cognitions 
• 4 calming crafts to make in your office 
• Free downloadable cards for adaptive self statements 
• 5 Bibliotherapy techniques for emotional regulation 
• 3 Play Therapy activities with bubbles (including popping maladaptive thoughts) 
• Exploring the Cognitive Triangle with Giraffes Can’t Dance (free download included) 
• Shifting cognitions with Big Feeling Eaters 
• Teaching emotional literacy and expressing thoughts and feelings with Play Dough Feeling Faces 

 
Dialectical Behavioral Therapy:  

Dialectical Behavioral Therapy (DBT) was developed by Marshal Linehan in the late 1980’s for adults with intense emotions. Four modes of standard outpatient DBT include individual psychotherapy, DBT Skills training, in-the-moment phone coaching, and DBT Consultation Teams for therapists.  Skills foundations include mindfulness, distress tolerance, interpersonal effectiveness, and emotional regulation. 
 
Dialectical Behavioral Therapy has been adapted for children in DBT-C for pre-adolescent children with severe emotional dysregulation and corresponding behavioral discontrol and requires formal DBT-C training to implement the model with fidelity.

DBT-C includes four main categories including: 

• Decrease risk of psychopathology in the future
  • Life-threatening behaviors of a child
  • Therapy-destroying behaviors of a child
  • Therapy-interfering behaviors of parents
  • Parental emotion regulation
  • Effective parenting techniques

• Targeting the parent-child relationship
  • Improve the parent child relationship 

• Target the presenting issues 
  • Risky, unsafe, and aggressive behaviors
  • Quality-of-life-interfering problems
  • Skills training
  • Therapy-interfering behaviors of a child

One of the foundations of this model is teaching parents all the skills their child learns as well as effective contingency management techniques, focus on parent modeling of adaptive behaviors, reinforcement of skill use, ignoring maladaptive responses, validation, and acceptance.  Overall this model is used to help children and families create a life worth living while validating distress as well as pushing for change.  
 
While official training is necessary and ethical to carry out the DBT-C model with fidelity, if your agency and practice does not have the training you can use and teach the DBT skills by incorporating these skills into Play Therapy techniques.  
 
Check out some ways to incorporate DBT skills into your Play Therapy practice HERE: 

• Rainbow meditation and deep breathing 
• 4 alternatives to deep breathing for emotional regulation and distress tolerance 
• 30 Day Gratitude Challenge (free download) 
• 5 playful ways to teach deep breathing 
• Bibliotherapy gratitude technique 
• Mindfulness, gratitude, and emotional regulation scavenger hunt (free download) 

Reality Play Therapy: 

I learned about Reality Therapy in my grad school program and was instantly hooked!  It is described as a brief counseling approach and a client centered form of Cognitive Behavioral Therapy.  
 
Reality Therapy was developed by Dr. William Glasser and is based on Choice Theory. Choice Theory is based on the premise that we only have the power to control ourselves and limited power to control others. 
 
The goals of reality therapy are to help increase positive connections with others, meet our 5 basic needs, and overall help the client discover alignment or disconnect between satisfying Quality World, needs, and behaviors. 
 
Reality Therapy believes that all behavior is purposeful to meet needs. The 5 basic needs include survival, love and belonging, power, freedom, and fun.

​Distress comes when there is a disconnect between our Quality World (where we store mental pictures or representations of wants including people, places, things, values, and beliefs that are important to you) and your perceived world (our experience of the real world that comes through our five senses).  Our perceived world is passed through our Total Knowledge Filter, which is a representation of everything you know or have experienced in life. 
 
Reality Therapy has been combined with Play Therapy in research starting in 2011 with Eric Davis who combined the WDEP technique in Reality Therapy with drawing.  Since then the has been research and integration of Reality Therapy and Play Therapy in a model called Reality Play Therapy.   
 
And there you have it! Three types of Cognitive Behavioral Therapy you can integrate into your practice with children!  
 
Drop a comment below to let me know if you use any of these theories and techniques in your practice OR if anything here makes you want to learn more! 

Looking for a deeper dive into Reality Play Therapy complete with tons of interventions and downloadable workbook?  Check out this training HERE! ​

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