The involvement of the child in treatment is an important predictor of treatment outcome (Chu & Kendall, 2004; Braswell et al., 1985). Most clinicians who treat youth believe that some level of play therapy, or play within a therapy, is necessary in order to engage youth in what is traditionally a more verbal endeavor and CBT is no exception. Play facilitates the involvement of youth, particularly young youth, in the key interventions of CBT. For example, an engaged and involved child is more likely to benefit from the graduated exposures that are central to the effective treatment of OCD, or a depressed child is more like to benefit from pleasant activity scheduling if the child is engaged in this task and the treatment process, in general.

At the same time, there are key differences between the way play is viewed and conducted in CBT versus traditional play therapy. In traditional play therapy, the therapist is a neutral observer of the child’s psychological process and resists directing or influencing the child. Traditional play therapists view direction as a form of control and non-acceptance of youth and believe that youth will work through, without direction or influence, their problems via the play itself. Therefore, the play therapist does not praise, teach, or educate youth directly as the therapist views these actions as controlling youth and the psychological process. In CBT, on the other hand, the therapist utilizes play to actively guide youth through the tasks and stages of the treatment process. Praise, rewards, psychoeducation, and actively teaching youth skills are central tasks of CBT and play facilitates the implementation of these tasks. That is, in traditional play therapy, play is the therapy, whereas in CBT, play engages the child in the tasks and goals of the therapy.

Play is important in all phases of CBT, including assessment, psychoeducation, as well as treatment strategies, such as exposure tasks and relapse prevention. For example, during the assessment phase, the therapist might ask young youth to use a puppet to disclose their troubling or embarrassing thoughts rather than asking youth to disclose this information directly to the therapist. During the relapse prevention phase, the youth and therapist might write a poem or story or draw a picture that clarifies the important lessons learned from the therapy.

Building rapport. The quality of the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the particular psychotherapeutic approach {McLeod, 2011 #2848}{McLeod, 2014 #2744}. Furthermore, research suggests that the value of a strong therapeutic alliance may be more important in behavioral versus nonbehavioral therapies {Shirk, 2011 #2849}. Interpersonal factors, such as the therapist’s warmth, caring, and genuineness result in a positive client-therapist alliance. Play facilitates the formation of a strong positive therapeutic alliance, in part, because an adult who is willing to crow like Peter Pan at the child’s successes demonstrates directly to the child that therapy can be fun and therapists can be warm and funny.

Play is a great ice breaker. Playing a get-to-know-you game, such as the “Answer Game,” whereby therapist and child take turns answering questions on cards (e.g., “What is your favorite food?” or “How many brothers and sisters do you have?”) is an easy game in which both the youth and therapist share information about themselves. Similarly, simple games, such as, “With my little eye, I spy,” or charades provide a simple, non-challenging way to break the ice. At the same time, we recommend therapists explain the role of play in treatment during these first rapport building sessions. This is particularly true for children who enter CBT from traditional play therapy and therefore may expect CBT to be similar to the nondirective, free-form play that they experienced in the past.

Engaging youth in the tasks and goals of therapy. Youth seldom refer themselves for treatment. They are referred to treatment by parents, teachers, pediatricians, and mental health professionals. In a sense, youth are mandated into treatment and the therapist may expect that youth, particularly adolescents, may not be as engaged as adults who seek treatment themselves. Therefore, it is essential that clinicians find ways to engage youth in the treatment process.

Fun is contagious. A therapist who is comfortable with play and is willing to do it likely has more fun too and because of this, both therapist and youth are more fully engaged in the treatment process. In fact, we believe that a creative and playful therapist may do more to encourage and engage a child in treatment than a tangible reward, such as a sticker or pencil.

Play is particularly important when striving to engage a youth in a tedious task, such as psychoeducation, or developing an exposure hierarchy. For example, during the engagement phase, the therapist may wish to educate the child regarding the treatment process and goals. Together, therapist and child could read a Victory Book in which children who completed treatment with the therapist wrote a note (signed anonymously or with only a first name) to future children who enter treatment with the therapist. The Victory Book is a fun way to normalize the condition for the child, to re-moralize the child who is hopeless and believes that nothing can be done to help them, and to reassure the child regarding the treatment process itself.

Teaching skills. Play engages young children in the process of learning new skills. When working with a child with OCD, the therapist uses play to teach resistance to urges to engage in compulsions, the child and therapist can first develop a list of boss-back talk (e.g., “You’re an old meanie and I don’t have to do what you say.” “No one likes you, so go away and leave me alone.”).  Then, the therapist and child play a version of red-light green-light. The child covers his eyes with his hands and counts to three. The therapist plays the mean OCD and slowly walks toward the child. When the child reaches three, he opens his eyes and bosses back the therapist with his boss-back talk. The therapist grimaces, snarls, but backs away. As you might imagine, young children love this.

In another version of teaching the child to resist compulsive urges, the therapist and child write boss-back talk on index cards and place the cards on the floor. Then child and therapist take turns tossing a bean bag toward the cards. When a bean bag lands on a card, the child or therapist shout the boss-back talk on the card. The therapist and child can use puppets to model adaptive responses (i.e., boss-tack talk) or to model effective problem-solving, or any number of skills. Arts and crafts are a terrific way to engage young children in learning skills.

When treating anxious youth in general, the child and therapist during an early session can convert a shoe box into a Strong and Brave box for the child to store the things he or she makes during CBT sessions. The child and therapist can then make a fear thermometer of colored construction paper with colored glitter to denote degrees of fear while the therapist teaches the child how to use this to report subjective units of distress (SUD); or, the therapist can ask the child to draw the worry bully or to draw a map that denotes how much land the worry bully rules and how much the child rules.

When working with depressed youth, therapist and child can make and decorate a hope box and fill it with poems, photos, reminders, games, that remind youth to counter hopelessness and orient the youth toward managing depressive episodes.

Reinforce therapeutic tasks and facilitate learning. An engaged child is more likely to learn from therapeutic tasks than a disengaged child and play is central to engagement. Furthermore, exposure tasks are difficult for youth and yet these tasks are critical to the effective treatment of emotional disorders, such as anxiety and depressive disorders. Play that is fun and engaging can help the child not only benefit from the treatment but also to remember therapy as a positive experience, and thereby increase the child’s willingness to return to CBT if psychological symptoms return.

For example, a child with OCD who has contamination obsessions can play board games (e.g., checkers, Chutes and Ladders) with “contaminated” game pieces as an ERP task. Similarly, the therapist and child can play with “contaminated” molding clay or learn to juggle “contaminated” balls. Packaging exposure tasks as play is limited only by the creativity of the therapist. For example, M&M candies are a favorite of children and therapists. Once, one of us worked with a child with intense “need to know” obsessions. The child was simply unable to wait or let go of the doubts that he did not understand something correctly or completely. He would repeatedly interrupt his teacher, interrupt conversations with friends, interrupt meal times at home, and continue these questions regardless of the consequences that friends, teachers, and parents gave him. The child and therapist agreed to work on this and the exposure task was for the child to close his eyes and selected a colored M&M from the bowl, pop the M&M into his mouth and suck on the candy. Then, the therapist asked the child to sit and think about the color of his tongue while he held a hand mirror but to resist the urge to check the color of his tongue. Was it coated in red, in blue, in green? Child and therapist waited and monitored the intensity of the urge.  After the urge subsided, the therapist asked the child to drink water (to wash away the color) and then to repeat the process. Eventually, the child learned that the urges subsided and willingly agreed to practice this exposure task at home.

Reinforce adherence with the goals and tasks of the therapy. The goals and tasks of CBT are explicit and straightforward and the success of the treatment depends on the child engaging in the therapeutic tasks that are central to the stated goal of decreasing the child’s psychological symptoms. At the same time, psychotherapy is not necessarily fun or pleasurable and often boring for young children. To reinforce adherence with the therapeutic tasks as well as attending to the tasks and the therapist, the therapist can invite the child at the conclusion of the therapy session to select a play activity. Free and unstructured play then reinforces effective work in the session. Furthermore, at the end of the session, the therapist can invite the child to select an inexpensive reward (pencils, bracelets, rubber balls) from the treasure chest with explicit praise, “Nice work today. You listened carefully while I told you about the worry bully and you did a super job building your fear thermometer.”

Shift parent-youth relationship. In order for a child to fully benefit from the treatment process, it is essential that the child engage in between-session therapeutic homework tasks. Typically, this involves the parent prompting and assisting the child to begin and complete the therapeutic tasks, such as exposure or engaging in a pleasant activity, that child, parent, and therapist devised. However, by the time parents bring the child to treatment, the relationship is often quite strained, which can undermine the child’s willingness to engage in between-session therapeutic tasks with the parent. Play can help to moderate this strain and rebuild trust and a sense of fun again in the child-parent relationship. For example, the therapist can teach the parents the boss-back game and ask them to practice with the child, or demonstrate the M&M task and ask the parents to practice with the child the task therapist and child completed in session. The fun and whimsy that is inherent in play can reconnect the child and parents in a common goal and make the condition and treatment a bit less overwhelming and burdensome.