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Susan M. Knell, PhD - Guest
Susan M. Knell, Ph.D. is a psychologist who received her Ph.D. in Clinical Psychology from Case Western Reserve University and did her internship and NIMH Postdoctoral Fellowship at The Neuropsychiatric Institute (NPI), UCLA, specializing in clinical child psychology and developmental disabilities. She is currently Adjunct Assistant Professor in Psychology at Case Western Reserve University, maintains a private practice, supervises graduate students in training, and is the author of the book, “Cognitive-Behavioral Play Therapy” (Jason Aronson, 1993). Susan was the first to study and write about the application of cognitive-behavioral therapy with young children. In addition to her book, she has published many chapters in edited books on play therapy, with recent chapters on creative applications of CBPT and treating young children with anxiety and phobias. She lectures throughout the country and internationally on Cognitive-Behavioral Play Therapy with preschool and early school-age children. Most recently, Susan has been working with Maria Angela Geraci, Ph.D., Meena Dasari, Ph.D. and colleagues, as part of the Cognitive Behavioral Play Therapy Institute, in Rome, Italy. The Institute will be disseminating relevant research and providing online training in CBPT. Online training is available through the institute website: www.cognitivebehavioralplaytherapy.com. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton, Psy.D: (00:21)
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of The Institute for The Advancement of Psychotherapy. Today I'll be speaking with Susan M. Knell, who is a psychologist who received her Ph.D. in clinical psychology from Case Western Reserve University. She did her internship at the National Institute of Mental Health, and a postdoctoral Fellowship at the Neuropsychiatric Institute at UCLA, where she specialized in clinical child psychology and developmental disabilities. She's currently an adjunct assistant professor in psychology at Case Western Reserve University, maintains a private practice, supervises graduate students in training, and is the author of the book Cognitive Behavioral Play Therapy. Susan was the first to study and write about the application of cognitive behavioral therapy with young children.
Dr. Keith Sutton, Psy.D: (01:17)
In addition to her book, she has published many chapters in edited books on play therapy with recent chapters on creative applications of CBPT and treating young children with anxiety and phobias. She lectures throughout the country and internationally on cognitive behavioral play therapy with preschool and early school-age children. Most recently, Susan has been working with Maria Angela Geraci, Ph.D., Meena Dasari, Ph.D., and colleagues, as part of the Cognitive Behavioral Play Therapy Institute in Rome, Italy. The institute will be disseminating relevant research and providing online training in CBPT. Online training is available through the institute's website at www.cognitivebehavioralplaytherapy.com. Let's listen to the interview. Well, hi, Susan. Welcome. Thanks for joining us.
Susan M. Knell, Ph.D.: (02:03)
Hi. It's great to be here. Thank you.
Dr. Keith Sutton, Psy.D: (02:06)
So, I was really interested in talking to you and talking about your work. So, I do CBT myself and I also work with children and incorporate play techniques. There was actually a little conversation on one of our local CBT network listservs about somebody asking for a play therapy referral and somebody was writing, “That's not CBT, but maybe not appropriate for our lister here.” And so there was kind of a whole conversation about play and CBT and I looked up and found some of your work and some research around CBT and play. So, I’d love to hear about all of this. And, before we even get there, I'd love to hear about kind of how you got to do what you're doing, the evolution of your thinking here.
Susan M. Knell, Ph.D.: (02:51)
So, my training is as a clinical psychologist, and I always knew that I wanted to work with kids, so I really focused a lot on child clinical in my Ph.D. program. Even though I've worked with adults and all age ranges over the years, I knew that I wanted to focus on kids. During my training, a lot of the supervision was very psychodynamic, some family-oriented stuff, and I gravitated to play with kids. But it was extremely frustrating because I would find that like a child might bring his anger into the playroom and he'd punch the punching bag or he'd, you know, angrily deal with something in the playroom. But from the supervision, I was getting as a graduate student internship postdoc and, as a young professional, mostly what I was learning was to reflect back the anger and to deal with what might be making him angry.
Susan M. Knell, Ph.D.: (03:55)
And, there was this whole range of things that I think were very important, but I never really felt like I was helping the child to cope with, and I'm using him as an example. It wasn't always boys, but helping the child to cope with his situation. So I remember very clearly this little boy that came in, he was very upset that there was a new baby at home. The baby was crying and messing in his diaper and all of that, and the kid just kept punching the punching bag and punching the punching bag. And I really just, it was like this aha moment when I felt like I need to give him some skills. I can't just reflect the anger. I can't just talk about, how upsetting it is to have a baby at home and have the attention that it's taking away from him and his parents being busy.
Susan M. Knell, Ph.D.: (04:44)
And all of that was important, but I just felt like I needed to give him some skills. And about the same time, I was learning a lot more about cognitive behavior therapy with adults and older, like older adolescents. And I was using it with adults, and I was using it with like my older adolescent population. And as I followed the literature, I was seeing that it was just gradually going downwards. You know, it was first with adults and then with older adolescents, but don't try it with younger adolescents and then younger adolescents. And it seems like around 8, 9, 10 years old, it was like, you just can't go below that. And at that time, I read an article, maybe I won't mention who wrote it. I read an article by a developmental psychologist who said, you cannot use cognitive behavior therapy with kids who were younger than, you know, I think it was eight at the time.
Susan M. Knell, Ph.D.: (05:42)
And I think what happened was like just I ran into a wall thinking I'm gonna find a way to do this. It was like a challenge and that's kind of where it all started. Like, how do I bring CBT, which really can't be used with young kids and how do I bring that to this younger population to help them? And I think the important part, there are a lot of important parts of CBT, but what that reflected for me at the time was I could teach a kid some coping skills and I could teach them ways of thinking about things differently. And I need to find a way to bring this to this younger population. And what clicked for me was play because I did a lot of play therapy and play is what makes sense with younger kids. It's a language of children.
Dr. Keith Sutton, Psy.D: (06:32)
Oh, that's great. Well, wonderful. So tell me about how you think about CBT and play and kind of translating it to younger children.
Susan M. Knell, Ph.D.: (06:46)
So the way I've thought about it over the years, this has been a work in progress. I mean, the very first work was over 30 years ago, but it's really been a work in progress. And the way I think about it is younger they just can't do CBT the way we're trained to do CBT with adolescents and adults. So that author was correct. You can't do CBT with young children. But the way I think about it is I'm trying to find ways to make it developmentally appropriate, sensitive to the child and the child's needs, and to make it such that it's not relying on a lot of complex language skills because CBT can be kind of heavy linguistically and cognitively.
Susan M. Knell, Ph.D.: (07:39)
And how can I bring that to the play therapy room and capitalize on the child's strengths, not just what the child isn't that good at, which would be more complex cognitive abilities and language.
Susan M. Knell, Ph.D.: (07:54)
And what the model has really, as I said, it's a work in progress, but the thing that's been there since the beginning is modeling. And that's probably the most important part of this, is that we're modeling through play the things that we can't explain linguistically.
Susan M. Knell, Ph.D.: (08:16)
And that might be modeling with puppets or other toys, or it could be books, it could be movies, or songs. There are just so many ways in which we can model for young children, but it's integrated into the play.
Dr. Keith Sutton, Psy.D: (08:30)
Can you give me an example?
Susan M. Knell, Ph.D.: (08:33)
Okay. So, a child is playing and let's say is playing out some scenarios from home. Mom and Dad are fighting and they're yelling at the kids. And, the child is hovering in a corner and kind of dealing with it. And the child is playing this all out through her play, let's say. So what I can do is bring into that play another voice. Like I can be a puppet who says, “Gee, when my mom and dad fight that way, you know, I also kind of wanna go in the corner.” And then likely the kid, the kid in therapy is going to say, “Oh, yeah, I'm always hiding in the corner.” And then my puppet could say something like, “Oh, it's so hard to hear your parents fight that way. You know, here are some things that I might do. I might sing a song to myself, or I might find a book that comforts me.” Or, you know, so that would be, I mean, that's not the only way to do it, but that would be one example of how I could bring it into the play.
Dr. Keith Sutton, Psy.D: (09:37)
So kind of like using the puppet in that sense as like, kind of another child or something, sharing their experiences and kind of how they deal with those situations to kind of help. Kind of relate to that or potentially take that in.
Susan M. Knell, Ph.D.: (09:51)
Or I might read a book with the child about, you know, fighting parents and things, there might be some coping skills in there, or we might create a book. You know, there isn't a manual, there's not one size fits all. And it's really trying to figure out how you model good coping skills and the things that the child needs to learn basically.
Dr. Keith Sutton, Psy.D: (10:16)
Ok, great. And I think that there's been some research done on your work, is that right?
Susan M. Knell, Ph.D.: (10:21)
Yes. Can you say, you know, where we are right now, it's sort of an interesting place to be. There are approximately 28 to 30 published case studies, but they're just case studies. And, you know, kind of getting more of a sense of what population this works best with and those sorts of things. But since they're just case studies, there are a couple of things that are happening right now. One is that there's a growing body of research on what's called CBPI, which stands for Cognitive Behavioral Play Interventions, and that's not therapy. But it's an intervention, cognitive behavioral play interventions that are being used in a research setting. So for kids with diabetes or sleep disorders or other situations where they're not coming for therapy, but they're doing empirical studies on using those techniques with these essentially non-clinical populations.
Dr. Keith Sutton, Psy.D: (11:25)
To try and like convey information?
Susan M. Knell, Ph.D.: (11:28)
I'm sorry?
Dr. Keith Sutton, Psy.D: (11:28)
To like, convey information or help them kind of better understand?
Susan M. Knell, Ph.D.: (11:33)
Yes. So some psychoeducation, some teaching coping skills, modeling, and other ways that they could deal with the situation. So what's kind of nice about that research is that it's really empirically testing out many of these interventions, but it's testing them out with a nonclinical population around a specific symptom or problem. So when I say nonclinical, I mean non-psychologically clinical.
Dr. Keith Sutton, Psy.D: (11:59)
Happening in for depression or anxiety or so on. Right?
Susan M. Knell, Ph.D.: (12:02)
Right.
Dr. Keith Sutton, Psy.D: (12:03)
Ok.
Susan M. Knell, Ph.D.: (12:04)
So that's an interesting direction that it's going in. And that was all based on a dissertation that all started from a dissertation that, Beth Pearson did at Case Western Reserve, and I was on her dissertation committee. So she was trying to find a way to test some of these interventions, but with a non-clinical population, because this is about 14 years ago, and she'd probably still be in graduate school if she was trying with a clinical population.
Dr. Keith Sutton, Psy.D: (12:31)
Yeah, I'm sure.
Susan M. Knell, Ph.D.: (12:33)
So that's one piece of it. And then the other piece of it is that there's growing research in trying to test the actual clinical applications of CBPT.
Dr. Keith Sutton, Psy.D: (12:46)
And part of it is there's a coping skills aspect that you're modeling and so on. How about the thoughts or the schema, or is there any kinda way that you think of that with children and kind of in the cognitive interventions?
Susan M. Knell, Ph.D.: (13:07)
So, you know, any of the cognitive interventions can really be modeled for kids through play. I’m trying to think of some examples where, you know, things are like changing. I tend not to think of them as rational thoughts. I mean, that's what the literature talks about with young children. I tend to think of them more as maladaptive thoughts because I think that developmentally that makes sense. I'm gonna go off on a little bit of a tangent to answer your question, but I'll get to it.
Dr. Keith Sutton, Psy.D: (13:38)
Go for it.
Susan M. Knell, Ph.D.: (13:39)
So, you know, you have a child who's learning toileting behaviors. And one of the things that I've seen many times over the years in my practice is kids are afraid they're gonna fall in the toilet. They're afraid they're gonna get flushed down the toilet. They hear their parents being all positive about, you know, the stuff that goes in the toilet and gets flushed, but, you know, they don't wanna get flushed down the toilet. And I tend to think that's not really an irrational thought. It would be irrational, obviously, as adults if we had that thought. But for children, it's maladaptive. It's really not functional, it's not good to think you're gonna get flushed down the toilet or you could fall in or whatever. And the reason why it's not irrational, per se, is that the child doesn't really have the learned history to know it's not possible. The child doesn't understand. No, they can't fall in, No, they can't get flushed down. That's adult understanding. That's not child, little child understanding.
Dr. Keith Sutton, Psy.D: (14:47)
It reminds me of when Steven Hayes talked about how we come to our beliefs honestly. So that, you know, it's not that these irrational thoughts are somehow we came to them through our experience, or like in this situation developmentally haven't had the alternative experiences to shift that thinking.
Susan M. Knell, Ph.D.: (15:06)
Right. So, with a child, for example, we can really deal with those maladaptive beliefs that they're not gonna get flushed down and they're not gonna fall in. And there are lots of ways that we can model that for children but that would be dealing with the cognitive piece of it. So I might have a puppet who's sitting on the toilet and saying, “I was kind of scared of this, but I know I can sit on the toilet. I know that I'm gonna be okay. I know that I'm safe and I know I'm not gonna fall in.” And that's modeling that maladaptive belief that they're changing for the child to hear.
Dr. Keith Sutton, Psy.D: (15:44)
Wonderful. Yeah, I remember watching with my own kids in potty training watching Elmo's potty time, several times over and over, just seeing that modeling of being comfortable with the toilet and so on.
Susan M. Knell, Ph.D.: (15:59)
That's great. And we know from the literature that coping modeling is way more effective than master remodeling. So I wouldn't just have a puppet sit on the toilet and say, “Great, I did it. It's fine. It's over.” I would, you know, shape it and have that child see how a puppet or a toy starts to deal with that over time.
Dr. Keith Sutton, Psy.D: (16:21)
Okay, great. My original training was in narrative therapy and then later I got deeper into cognitive behavioral therapy. So I've kind of used some of those in externalizing the different emotions and sometimes using stuffed animals to represent the anxiety or the anger or whatever it might be. And then kind of really helping the kids sometimes kind of talk to those parts in that way and kind of that relationship. Which has been kind of a fun way to kind of talk about and also kind of bring up those automatic thoughts, but in a way of; what is the anger saying, you know, what's it want you to do? And, all those kinds of things to kind of get that, you know, mindfulness and kinda metacognition.
Susan M. Knell, Ph.D.: (17:07)
The other quick example, which actually is from a very psychodynamic place is Selma Fraiberg's The Magic Years, which I think is such an important book for understanding. It's very psychodynamic, but it was one of the first books that I read about preschool-aged children, and she uses the example of a little kid who was getting closer and closer to a family vacation and getting more and more worried about it. And then at one point, he said, “I can't go to Eurp.” Eurp was what he called Europe. And the family said, “Why?” And he said, “I don't know how to fly yet.”
Susan M. Knell, Ph.D.: (17:46)
And it's just a perfect example of that kind of, is that irrational, or is that just learned history that he didn't know that he didn't have to fly?
Dr. Keith Sutton, Psy.D: (17:54)
Yeah. Not having that information yet, but that's not how you get there.
Susan M. Knell, Ph.D.: (17:58)
Right.
Dr. Keith Sutton, Psy.D: (17:59)
Yeah, so much of that I think is so exploratory and kind of figuring out what is going on. And sometimes I think of myself, you know, and working with children as kind of almost like mining for the gold and then kind of passing it over to the parents. I also do a lot of family work and grounded in family systems, but kind of helping to kind of unearth what's going on and then helping them communicate that to the parents and teaching parents tools and techniques and play therapy eventually put me out of a job.
Susan M. Knell, Ph.D.: (18:29)
And I do a lot of work with the parents too. It's not just family work or child work but I do, you know, the mining for the gold is real. I mean, to me, that's what you get with play therapy, as long as you're not, I think the trick to CBPT is if you are too structured then you are not going to get to the gold. But if you're just letting the child spontaneously keep digging you're not only not going to really get the gold, but you're also not gonna be able to intervene.
Dr. Keith Sutton, Psy.D: (19:06)
Yeah. It's kind of I think sometimes with psychodynamics it's a lot of listening and exploring, but not necessarily, then what do we kind of do about it? So kind of bridging that gap between kind of understanding and eliciting and drawing out what's going on in the internal world, but then actually translating that. Like you're saying to skills and shifting cognitions and work.
Dr. Keith Sutton, Psy.D: (19:32)
So what do you think is important for folks that do CBT to kind of think about in working with children?
Susan M. Knell, Ph.D.: (19:43)
Well, I think it's important to really understand that, I mean, first of all, I don't think that if you approach this, like I've worked with older kids. Somebody says, “I've worked with older kids now I wanna do this with little kids.” But they don't have any experience in play therapy, and they don't really understand developmentally at that age. I think it's important to kind of have the whole package. You need to understand the developmental issues, you need to have some experience with play. So really the way I think about it is learning how, if you know, CBT and play, you're learning how to integrate them. But it's not, I don't think it would be so easy to just learn it all at the same time.
Dr. Keith Sutton, Psy.D: (20:26)
Definitely, and I think that I was even kind of talking about this in the discussion on our lister that I think there is a belief for folks that play therapy equals non-directive psychodynamic. Or, rather than play can be CBT or other parts of development or treatment.
Susan M. Knell, Ph.D.: (20:54)
Absolutely.
Dr. Keith Sutton, Psy.D: (20:55)
That it's separate or different or not evidence-based or whatever it might be.
Susan M. Knell, Ph.D.: (21:00)
No, I absolutely agree with you. I think that a lot of people just think play has to be either sort of Freudian, psychodynamic, you know, like sort of the beginning hundreds of over hundred years ago of how play was used, or there is such a strong movement for child-centered play therapy, sort of client-centered play therapy. But with kids, and I can tell you an interesting story about that, which just sort of tickles me to this day. About four years ago I was presenting a workshop to the Pennsylvania Play Therapy Association and there were about a hundred people there. And I was presenting on CBPT for a whole day and I usually start by finding out who my, you know, I think most people do this, who's my audience, not just disciplines, but orientations. And when I got about 98 out of a hundred people raised their hand, that they were child-centered. I took a really deep breath and thought, this is gonna be really interesting. Because I've actually found over the years, for a wide variety of reasons that presenting to more psychodynamically oriented therapists is easier in terms of presenting CBPT. It's easier than presenting to client-centered or child-centered.
Dr. Keith Sutton, Psy.D: (22:23)
Interesting.
Susan M. Knell, Ph.D.: (22:24)
And I think the reason for that is there are more similarities between, I mean, except for the directiveness of it. There are more similarities between CBPT and psychodynamically oriented therapy. When I have a chart where I look at the differences between CBPT and other play therapies and CBPT and child-centered pretty much don't match any place. I mean they match in terms of using play as a means of communication and, you know, communicating that it's a safe place for the child, but they really don't match on any of the other variables. So about 98 individuals in this room raised their hands and said that they were client-centered or child-centered. And I really felt like, oh boy, I got a hole of a day ahead of me and there was one particular person sitting in the front row who was, I felt like he was glaring at me through the whole day.
Susan M. Knell, Ph.D.: (23:21)
So, you know, I was doing all my own cognitive interpretations of what was going on. And I asked them if they could just be open-minded, and clearly, this is how they were trained and thought, and I was gonna ask them again at the end of the day. And I asked them again at the end of the day, how many of them thought that they could do this kind of work, and everybody, but that guy in the front row raised their hand that they thought that they could do it. And boy, I was really puzzled at that point, and I thought, I don't know what's going on here. But they were really in the question-and-answer period and afterward telling me that this made sense to them, and it was countered to a lot of what they'd learned, but it made sense to them. Well, this guy actually came up to talk to me, and what he said to me was, not at all what I was expecting to hear. What he said to me was, “I don't think I could ever do this, because you have to be really playful and creative and imaginative.”
Susan M. Knell, Ph.D.: (24:24)
And I stepped back and I thought, well, first of all, to do play therapy with a child, no matter what your theoretical orientation is, you have to be playful and creative. I think, you know, and he was basically telling me, I don't think I can do this because it doesn't fit my personality. And I was kind of thinking, why are you a play therapist? But, you know, I was able to sort of say to him, “Look, if you wanted to learn how to do this work, get some good CBPT supervision, and you could do it if you really wanted to.” Even though that other narrative was going on in the back of my head.
Dr. Keith Sutton, Psy.D: (25:02)
And I found even for myself, I originally went into the field interested in working with adolescents. And in my training, also worked with children. I felt comfortable with children, but again, had that idea that we're just kind of playing and it's non-directive. And I had spent a year at a Head Start preschool doing, you know, my first-year practicum. We were just supposed to do kind of pride of the PCIT where you're praising and reflecting and so on. Which was great, but it kind of felt like, you know, a bit repetitive after a while. Then, you know, later on learning more about how we can kind of incorporate some of these, you know, with CBT having that direction and having those goals and kind of figuring out.
Susan M. Knell, Ph.D.: (25:48)
Well, PCIT has a, I went through the training myself, and there's just a lot of similarities. Obviously, it's not CBPT, but I see PCIT is extremely helpful for families and parents.
Dr. Keith Sutton, Psy.D: (26:01)
I was just, we were just practicing that one little technique, so it wasn't even working with the family, it was just basically kind of like a structure for non-directive. But yeah, no, PCIT is great and helps direct the parents in the moments with the kids. One client I was working with, a four-year-old with a dog phobia, you know, and trying to think about how do I even translate kind of this and anxiety. And so I found out what movie that she liked and it was Rapunzel at the time. So this was before I had kids. So I watched it and then was able to kind of use the metaphor, the mom and telling Rapunzel, don't go out there. Everything's scary, you know, everything is bad and scary out there. And then talked about, did she listen to her mom and didn't. And then kinda talk about the fear that was telling her that dogs are scary and so on.
Susan M. Knell, Ph.D.: (26:54)
That's great. I mean, my experience with dog phobias with kids is that most of the time I've got to leave the playroom and go out and do in vivo work and work with them in the community. And, you know, I just recently did one with a little boy where we started with the smallest little dogs that are really far away, and we did systematic desensitization. And he's like a dog fanatic now.
Dr. Keith Sutton, Psy.D: (27:20)
That's what we ended up doing. And I have a dog in my office, so it was like a nice way to kind of like, slowly kind of do some work and kinda do that exposure to have that different experience.
Susan M. Knell, Ph.D.: (27:32)
In terms of Rapunzel, you know, the other thing that if kids like musical theater kinds of things, maybe this is for kids a little bit older. But I whistle a happy tune from The King and I, where it's basically, I don't have the words right in front of me, but basically, I can do this. And even though I'm afraid and I just keep putting one foot in front of the other and I got it, and kids really like that.
Dr. Keith Sutton, Psy.D: (27:58)
Oh, nice. Kind of using those playful engaging ways of kinda translating this information. I know I'm not totally familiar with trauma-focused CBT, but I know that that even goes down to three years old in the work that they're doing there.
Susan M. Knell, Ph.D.: (28:16)
I think Drewes and Cavett have taken the trauma-focused CBT and have introduced play in a way that Cohen's work, the trauma-focused work with older kids didn't really incorporate the play in a play therapy kind of way. I mean, the thing to me that's a really important distinction is that play can be therapeutic. A lot of people use play with older kids and even with adolescents. So play can be therapeutic, but there's a difference between play being therapeutic and CBPT where it's actually the therapy.
Dr. Keith Sutton, Psy.D: (28:51)
Yeah. Say more about where the therapeutic play versus it's the actual therapy. How do you mean?
Susan M. Knell, Ph.D.: (29:00)
Well, I mean like I've had adolescents to get to my office, you have to walk through my playroom and I have this big bucket of puppets that's kind of right on the way into my office. And a lot of times an adolescent will just grab a puppet on the way into my office, and they don't wanna do therapy with the puppet. They don't want me to do anything with the puppet. They got the puppet on their lap and they occasionally may do something silly with it and we may be playful about it. So to me, that's sort of play being therapeutic, but that's not play therapy.
Dr. Keith Sutton, Psy.D: (29:34)
Got it. So that's kind of having something that's making it a little more comfortable, but not necessarily like, kind of a medium of the change.
Susan M. Knell, Ph.D.: (29:42)
Sure, yeah.
Dr. Keith Sutton, Psy.D: (29:44)
I don't know if you also incorporate art. I know so many play therapists, you know, incorporate art into their work. Can you talk a little bit about that?
Susan M. Knell, Ph.D.: (29:54)
I do, I have a big whiteboard in my office. I have a lot of construction paper and drawing paper and coloring books if a kid doesn't want to create on their own, lots of times we make a book. One of the ways that I use art a lot is kind of in a systematic desensitization way where a child might be drawing pictures, like a child who's experienced abuse or some kind of trauma. They may not be able to deal with that trauma right away, but they can draw pictures kind of getting closer and closer to the trauma. The street or the house or the room or the people, and using their drawing in that way. I'm supervising a graduate student who, this is a kid who's a little bit older, but who said, “you know, she's spending so much time on her art and I feel like I'm not getting.” and I'm like, “no, stop.” You know, art is so important because that's the way the kids communicate, especially the younger kids.
Dr. Keith Sutton, Psy.D: (30:58)
Yeah, and I think what I'm hearing is that is kind of having some direction, like kind of using that play and like you're saying, like drawing things that are related to the trauma. So there may be that prompt and then letting the kids kind of do the play in that direction. And so kind of that, it almost reminds me of motivational interviewing where there's somewhat of a non-directed. But then there's also kind of a direction that we're kinda going in or kind of pointing towards, although it's not rigidly making the kid go in a certain direction.
Susan M. Knell, Ph.D.: (31:33)
Sure, and you know, sometimes the art will be, I'll have them make a book about their life and, you know, if they're not a child who's writing yet or they don't wanna write, they'll dictate it and I'll write it out and then they'll illustrate it. And the pictures can sometimes be very helpful to figure out what we should say next and sometimes those books are a combination of the child's spontaneous discussion and my adding things.
Dr. Keith Sutton, Psy.D: (32:01)
Yeah, kinda in weaving that in there and I think too that with the art is always nice for, you know, drawing out feelings or so on or kind of with that Dan Siegel kind of connecting the upstairs and the downstairs brain. And helping the kids, you know, put their emotions into language and drawing them out and, and kinda connecting that ability to communicate and help with that affect regulation. Or always like the one kind of drawing, like a gingerbread person and then kind of drawing the different places where you feel the anger or the nicer.
Susan M. Knell, Ph.D.: (32:37)
And, you know, in terms of putting the CBT spin on it, lots of times what I feel like I'm doing with those kinds of situations is I'm shaping the appropriate expression of feelings. You know, so like, I had this kid where there was a puppet and he was learning to use the toilet and kind of making it close to the child's experience. And the child was drawing things and he was really angry at this puppet cuz the puppet was kind of getting it but he didn't feel like he was getting it. And what I could do when he was angry at the puppet or like wanting to hurt the puppet, or crossing out the pictures that he drew of the puppet is start to shape those feelings. I think you're angry because maybe the puppet is kind of learning how to use the toilet and you're kind of frustrated that you're not. And that's, you know, pure shaping of feelings. Expression of feelings.
Dr. Keith Sutton, Psy.D: (33:37)
Yeah, through that reflection amd kind of helping bring that more to awareness or kind of putting words to the experience. And then how about Sand Tray? Do you use any kind of sand tray work in any of the work that you've done.
Susan M. Knell, Ph.D.: (33:55)
I don't. I really never got trained in it. And, one of the playrooms that I worked in many years ago did have a sand tray and so we used it, but I did not use it in terms of knowing the techniques.
Dr. Keith Sutton, Psy.D: (34:09)
Well, because I know there's one technique of just kind of non-directive and seeing what the kid does and kind of reflecting what they're doing and exploring it. I found it a nice way to use it too is even just having the kid kind of put a scene together of something that happened recently. Then sometimes ask about the different characters and what they were thinking or feeling and then having them do the scene again. How they would've liked to have that situation go with their mom or their dad or their parents.
Susan M. Knell, Ph.D.: (34:40)
And I might do exactly the same thing, but just with the house and all the characters there without the sand.
Dr. Keith Sutton, Psy.D: (34:46)
Oh yeah, it's like a doll house or something.
Susan M. Knell, Ph.D.: (34:49)
Yeah.
Dr. Keith Sutton, Psy.D: (34:50)
Great, so it seemed like with the CBT work again it's, you know, kind of having this direction or idea like you're saying, translating in vivo exposure into play and kind of addressing some of those thoughts, or through the modeling and such. Tell me about modeling and it sounds like that's an area of focus that you're most interested in, or one of your top mediums. Can you talk about your thoughts on that.
Susan M. Knell, Ph.D.: (35:19)
So, you know, basically I'm trying to figure out where is a child is and where I wanna get the child to. And you know, it's obviously quite different from working with an adult where an adult comes in and maybe says, “I wanna be able to do X, Y, Z.” You know, many times whatever the family's concerned about with the child, the child may not be concerned about. So most of the time children aren't gonna say to me, gee, I'm still pooping my pants and I don't wanna be doing that. Or, if they're selectively mute, they're not gonna say to me, I don't wanna talk. But yeah many times their goals are not what my goals might be, particularly as I'm pulling in what the parent's goals might be.
Susan M. Knell, Ph.D.: (36:05)
So modeling I think is a huge way and I don't know how to communicate strongly enough that there's not just one way to model. There are so many ways that I would bring modeling into a session, and I think it's just a way that, you know, we talked before about communicating maybe some coping skills, some things like that but it's a way of modeling almost everything. You know, modeling another individual who might have similar experiences or another individual who might be dealing with it totally different,or it's a way of modeling some of those maladaptive thoughts the child might be having difficulty communicating but I'm really hearing through their play. So I guess my bottom line thought about it is that there's nothing you can't model.
Susan M. Knell, Ph.D.: (37:04)
As I said before, it isn't always, I mean, I talk a lot about puppets because I do find that a lot of kids gravitate to the puppets but I've had a bunch of kids who don't like the puppets. They go maybe straight to my big container of toys and sort of, what was that movie Cars, I think it was.
Dr. Keith Sutton, Psy.D: (37:24)
Yeah. Cars.
Susan M. Knell, Ph.D.: (37:25)
You know,Cars had all the characters have names and the kids will bring that into the playroom and I can do the same thing with a toy car that I can do with a puppet.
Dr. Keith Sutton, Psy.D: (37:35)
You can kind of give it a voice and have it model different things.
Susan M. Knell, Ph.D.: (37:40)
You know, and then there are all the books, the from Imagination Press. Which is now an imprint of APA that What to Do When You Worry Too Much and What to Do When You Dread Your Bed and, you know, a whole slew of those books, which are all based on a CBT model. I do use those with the older kids, but with the younger kids, I can pull some of that into the play and it can be something. I wouldn't sit and read it with a child with most children, it'd just be too wordy but the workbook pieces of it can definitely be used.
Dr. Keith Sutton, Psy.D: (38:16)
Do you have any examples of those?
Susan M. Knell, Ph.D.: (38:19)
Yeah, I've got lots of them.
Dr. Keith Sutton, Psy.D: (38:23)
Kinda using that with a child with the play.
Susan M. Knell, Ph.D.: (38:26)
Yeah, for example, in the What to Do When You Worry Too Much book, there's a place where you draw, I don't know if you're familiar with the book, but you draw your worry monster.
Dr. Keith Sutton, Psy.D: (38:38)
Yes.
Susan M. Knell, Ph.D.: (38:39)
And the kids, you know, will draw these scary monsters and you know, like you imagine when you see this picture what's going through their head right about their worry monster. And then towards the end of the book, it asks you to show how you feel without the worry monster on your shoulder, which is where they're talking about, you know, pushing the worry monster off your shoulder. I have lots of examples where the kids then draw that picture and the monster, which was huge. And the first picture is teeny tiny, or there was this kid who drew a picture of himself stomping on the worry monster who was about an inch tall.
Dr. Keith Sutton, Psy.D: (39:23)
Wow. Very cool.
Susan M. Knell, Ph.D.: (39:25)
So, you know, there are lots of ways to bring those workbook pieces into play and sometimes I bring them into play. I've got kids who wanna play school all the time so I can bring them into play by having the teacher say, “Hey, let's learn about worry monsters.”
Dr. Keith Sutton, Psy.D: (39:43)
Oh, nice.
Susan M. Knell, Ph.D.: (39:45)
Or, I have a couple of examples of children that when I got to something that was kind of upsetting for them, they weren't interested, so they disappeared to the other side of the playroom. And I'm often asked, well, how do you model stuff if the kid isn't interested? And what I've found is that kids, I have this vivid memory of this child who had been abused and we were going through this book and he's just like, “no, I'm not gonna do it.” And he went to the other side of the room and I said, “well, I'm just gonna take a couple of minutes and read the book to this puppet.” And that child sat on the other side of the room, listened to every word I was saying, and kept telling the puppet what to tell me. Don't tell her that. Tell her this. And essentially what he was doing was interacting with me even though he didn't think he was. He was interacting with the puppet, telling the puppet everything that was in his experience, but even if I invited him to come closer, he wasn't interested.
Dr. Keith Sutton, Psy.D: (40:53)
Well, it's so great because I think oftentimes kids can communicate or kind of with some distance, whether it be talking about a character in a book or a movie or something, rather than maybe talking about their direct experience or like you were saying. Talking to the puppet but not talking directly to you.
Susan M. Knell, Ph.D.: (41:12)
And, for some kids, you know, even in the play where they're interacting with me, they don't necessarily think that they're telling me what they think. You know, here's this toy character that's my age, has my name, and looks just like me, but that's not what I really think.Oftentimes what I hear from the kids.
Dr. Keith Sutton, Psy.D: (41:33)
Exactly, kind of totally separate. Not at all about me. The worry monster was interesting too as you were talking about it because I was just thinking about just even putting that out there and kind of thinking about sharing it right in and of itself, you know, kind of shrinks the monster. It’s a way from being this scary kind of thing that one's alone with and kind of putting it out there and seeing that it's not so big or whatever it might be. And also reminds me of the technique of laying the monster in EMDR where the kids will draw the picture, and then they will, you know, kind of cross it out left and right or rip, or so on and then draw it again. And oftentimes it's very different after they kinda do the second drawing.
Susan M. Knell, Ph.D.: (42:16)
Because they're taking some power. You know, I think I like the whole concept of sort of the worried monster or the worried bully sometimes they call it. Because a lot of kids, even if they haven't had experience with bullies, know somebody's trying to mess with them or somebody's trying to kind of bully them. They know what that means and I give them, and I think the book gives them permission to talk back. And I'll say to kids, you know, these may be words you're not allowed to use at home, but it's okay when you're talking back to the worry bully to use words that, you know, that's okay because it's just here and it's safe.
Dr. Keith Sutton, Psy.D: (42:55)
Yeah, and that's also incorporated into the evidence-based treatment with children in OCD, you know, the OCD is the bully and kind of externalizing it and kind of creating this not listening to the bully or giving it a name.
Dr. Keith Sutton, Psy.D: (43:10)
The Bully says don't touch that and you're like, and then defy the bully. Like, I'm gonna touch that anyway. Right, kinda helping them to position themselves, you know, externalizing that symptom over it.
Susan M. Knell, Ph.D.: (43:22)
I think even just giving the bully a name sometimes is very powerful, you know? I’ve had kids say, “shut up Charlie,” you know, “Just go away, get lost .”
Dr. Keith Sutton, Psy.D: (43:31)
Yeah. I had one kid, her anxiety she named it Gertrude, sorry, Gertrude's out there. But she associated Gertrude with somebody with the kind of wagging their finger at them and telling them what to do.
Susan M. Knell, Ph.D.: (43:42)
I think that might have a sort of connotation of an old older person's name or something, you know, Gertrud.
Dr. Keith Sutton, Psy.D: (43:48)
Exactly, well yeah, so this is so great and it's great that there are so many different ways that you can translate, you know, and kind of using the theoretical grounding of CBT and what we know from coping skills and doing exposure work and also kind of eliciting thoughts, beliefs, and getting to core schemas and then being able to have interventions to help shift that. Whether through, you know, talking about it or talking back to the bully using coping thoughts or like you're saying kind of playing that out and modeling a child kind of using coping thoughts to use the toilet whatever it might be. And tell me about the parents. What kind of stuff are you doing with the parents? You're mentioning that there's some incorporation there.
Susan M. Knell, Ph.D.: (44:41)
Sure. Well, you know, I've always at the beginning trying to figure out if this more parent, you know, I should be doing parent work. Is this child work? Is this a combination? And, you know, clinically I'm trying to figure out who am I working with here. And there are certainly cases where the child was of play therapy age and the parents might have come to me originally for play therapy for the child. But I feel like if I can work with the parents if I really can identify that the parents can do the core of the work, I'm more inclined to say, “let's try this first and see how far we get.” And then we can always bring the child and we can always do play therapy, but I'm not going to jump on, you have to bring the child in because sometimes I just work with the parents and that's enough.
Susan M. Knell, Ph.D.: (45:29)
Sometimes I do both. Sometimes I'm working with the parents and working with the child sort of combined. And what makes that tricky, especially in-person work is that you know, I might not need a whole session with the parents and a whole session with the child, but if the child is brought by a parent, it's often very tricky. Can I talk to the parent while the child is playing? I don't wanna be talking to the parent in front of the child, but how do I do this? How do I juggle this? And I don't think there's ever one size fits all but, you know, sometimes the parents will both come and take turns hanging out with the kids. Sometimes I'll ask them to bring like a sitter or older kid who can play or, you know, there are multiple ways of dealing with it but it's not always smooth.
Dr. Keith Sutton, Psy.D: (46:23)
Yeah, exactly. Sometimes that is one of the benefits of online work is that you can do a little with the kids and then send them out and bring the parents in for a little bit and bring them together and enough work in those different, Are you doing online work?
Susan M. Knell, Ph.D.: (46:37)
Not with kids this young. I mean, the problem really is that I have done some, I'm mostly doing online work now. Kids that I've seen before in play therapy in my playroom at my office are a little bit easier to transition to online but it's still difficult. I think they have to kind of prep the family to have certain supplies available there and I have the same supplies. It doesn't translate very well.
Dr. Keith Sutton, Psy.D: (47:09)
Yeah, it's so interesting. So, I've talked to so many different people that some like really love the online work and can really do with the kids. Some have a tough time with the online work and really prefer the in-person and, you know, I think so much there's part of the the therapist. The way they work and kind of what their personality is as well as the kids and kinda makes it going on.
Susan M. Knell, Ph.D.: (47:31)
And I would guess of the people that you're talking to, they're probably not doing online work with the much younger kids, I'm guessing.
Dr. Keith Sutton, Psy.D: (47:38)
Sure not like a three or four-year-old or so on. That's gonna be a lot harder. But if you're also doing a lot of work with the family too, kind of incorporating that, not just more of a mostly kid session or so on, that would beeally tricky. That is really helpful and it's really great to hear about the work that you're doing and the way that you're kind of thinking about CBT and kind of translating that into the language of play with children. And it sounds like you also do training. Is that what you were mentioning too?
Susan M. Knell, Ph.D.: (48:11)
Yeah, and what's really interesting about the pandemic and one of the positive things that came out of it is that a lot of places that might have only thought about doing, you know, like paying to have me or whoever come out to do training or now doing these Zoom things. So yeah, in the past couple years, I've done training for therapists in Turkey and China and Hong Kong, and I've forgotten someplace, but a couple of countries and what this has led into, which is I'm really excited about. So I wanna talk about it a little bit, you know, over time different therapists will contact me and they'll want me to comment on their dissertation or this idea or that idea. And I always sort of take a deep breath because oftentimes they use the term CBPT, but it bears no resemblance to anything that I think of as CBPT. So that's always difficult but I was contacted by a therapist, a psychologist in Italy who, to make a very long story short, was really doing CBPT and very interested in it. And we have developed the CBPT Institute in Rome, Italy.
Dr. Keith Sutton, Psy.D: (49:29)
Yeah.
Susan M. Knell, Ph.D.: (49:30)
Did you take a look at the website?
Dr. Keith Sutton, Psy.D: (49:32)
I was looking at it. I think that's how I ended up actually finding you. I was like, oh, perfect.
Susan M. Knell, Ph.D.: (49:37)
So, they actually have a researcher on board who's gonna be implementing in collaboration with a researcher, Carla Fair, who's in Illinois doing some CBPT research. And we're been taping training, so the trainings are gonna be available to people online and there'll be a CBPT certificate. And it's really kind of exciting to me because I'm, you know, I'm getting towards the end of my career. And even though the book came out 30 years ago, I just don't see myself traveling all over the world, although I'd like to do training. So it's wonderful to be able to say, Hey, take a look at this online training.
Dr. Keith Sutton, Psy.D: (50:20)
Yeah, having that resource there for people that maybe can't make it to one of your trainings live or whatever it might be. Oh, that's perfect. Do you know when that's kinda coming out?
Susan M. Knell, Ph.D.: (50:31)
Well, some of it is already out. I mean, you'll see from the website that some of the training can be bought at this point. Some of it is still a work in progress. I was actually in Italy, Florence, and Rome, in the beginning of November where we presented a symposium at the first national CBT conference. And I think the whole notion of CBPT in Italy is, you know, maybe it's also an issue for the people that you were interacting with on the blog. But it's definitely an issue there because it's very client-centered there and, you know, it's like hard to know. It was pretty well received given the nature of I think in Italy, it's not just that CBPT isn't that widely understood, but play therapy itself is not necessarily considered something that psychologists and mental health professionals do.
Dr. Keith Sutton, Psy.D: (51:30)
Oh, interesting.
Susan M. Knell, Ph.D.: (51:31)
I think there's more of a thought about play, you know, and that play therapy piece as a psychological is just beginning to sort of gain some momentum there, which was kind of interesting.
Dr. Keith Sutton, Psy.D: (51:45)
Yeah, wonderful. And your book, what's the name of your book? Just to mention for our audience.
Susan M. Knell, Ph.D.: (51:51)
Cognitive Behavioral Play Therapy.
Dr. Keith Sutton, Psy.D: (51:53)
Perfect. Well, thank you so much for your time today. It was great to learn about your work and we'll link to the online trainings as well as your books so people can learn more about it. Thank you very much. I really appreciate it.
Susan M. Knell, Ph.D.: (52:08)
Thank You. It was great. It's always fun to bring this to new audiences.
Dr. Keith Sutton, Psy.D: (52:11)
Definitely. Take care.
Susan M. Knell, Ph.D.: (52:13)
Okay. You too.
Dr. Keith Sutton, Psy.D: (52:14)
Thank you for joining us. If you're wanting to use this podcast or continuing education credits, please go to our website at therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for The Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco bay area. IAP provides training for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to SFIAP.com or call 415-617-5932. Also, we really appreciate the feedback. If you have something you're interested in, something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of The Institute for The Advancement of Psychotherapy. Today I'll be speaking with Susan M. Knell, who is a psychologist who received her Ph.D. in clinical psychology from Case Western Reserve University. She did her internship at the National Institute of Mental Health, and a postdoctoral Fellowship at the Neuropsychiatric Institute at UCLA, where she specialized in clinical child psychology and developmental disabilities. She's currently an adjunct assistant professor in psychology at Case Western Reserve University, maintains a private practice, supervises graduate students in training, and is the author of the book Cognitive Behavioral Play Therapy. Susan was the first to study and write about the application of cognitive behavioral therapy with young children.
Dr. Keith Sutton, Psy.D: (01:17)
In addition to her book, she has published many chapters in edited books on play therapy with recent chapters on creative applications of CBPT and treating young children with anxiety and phobias. She lectures throughout the country and internationally on cognitive behavioral play therapy with preschool and early school-age children. Most recently, Susan has been working with Maria Angela Geraci, Ph.D., Meena Dasari, Ph.D., and colleagues, as part of the Cognitive Behavioral Play Therapy Institute in Rome, Italy. The institute will be disseminating relevant research and providing online training in CBPT. Online training is available through the institute's website at www.cognitivebehavioralplaytherapy.com. Let's listen to the interview. Well, hi, Susan. Welcome. Thanks for joining us.
Susan M. Knell, Ph.D.: (02:03)
Hi. It's great to be here. Thank you.
Dr. Keith Sutton, Psy.D: (02:06)
So, I was really interested in talking to you and talking about your work. So, I do CBT myself and I also work with children and incorporate play techniques. There was actually a little conversation on one of our local CBT network listservs about somebody asking for a play therapy referral and somebody was writing, “That's not CBT, but maybe not appropriate for our lister here.” And so there was kind of a whole conversation about play and CBT and I looked up and found some of your work and some research around CBT and play. So, I’d love to hear about all of this. And, before we even get there, I'd love to hear about kind of how you got to do what you're doing, the evolution of your thinking here.
Susan M. Knell, Ph.D.: (02:51)
So, my training is as a clinical psychologist, and I always knew that I wanted to work with kids, so I really focused a lot on child clinical in my Ph.D. program. Even though I've worked with adults and all age ranges over the years, I knew that I wanted to focus on kids. During my training, a lot of the supervision was very psychodynamic, some family-oriented stuff, and I gravitated to play with kids. But it was extremely frustrating because I would find that like a child might bring his anger into the playroom and he'd punch the punching bag or he'd, you know, angrily deal with something in the playroom. But from the supervision, I was getting as a graduate student internship postdoc and, as a young professional, mostly what I was learning was to reflect back the anger and to deal with what might be making him angry.
Susan M. Knell, Ph.D.: (03:55)
And, there was this whole range of things that I think were very important, but I never really felt like I was helping the child to cope with, and I'm using him as an example. It wasn't always boys, but helping the child to cope with his situation. So I remember very clearly this little boy that came in, he was very upset that there was a new baby at home. The baby was crying and messing in his diaper and all of that, and the kid just kept punching the punching bag and punching the punching bag. And I really just, it was like this aha moment when I felt like I need to give him some skills. I can't just reflect the anger. I can't just talk about, how upsetting it is to have a baby at home and have the attention that it's taking away from him and his parents being busy.
Susan M. Knell, Ph.D.: (04:44)
And all of that was important, but I just felt like I needed to give him some skills. And about the same time, I was learning a lot more about cognitive behavior therapy with adults and older, like older adolescents. And I was using it with adults, and I was using it with like my older adolescent population. And as I followed the literature, I was seeing that it was just gradually going downwards. You know, it was first with adults and then with older adolescents, but don't try it with younger adolescents and then younger adolescents. And it seems like around 8, 9, 10 years old, it was like, you just can't go below that. And at that time, I read an article, maybe I won't mention who wrote it. I read an article by a developmental psychologist who said, you cannot use cognitive behavior therapy with kids who were younger than, you know, I think it was eight at the time.
Susan M. Knell, Ph.D.: (05:42)
And I think what happened was like just I ran into a wall thinking I'm gonna find a way to do this. It was like a challenge and that's kind of where it all started. Like, how do I bring CBT, which really can't be used with young kids and how do I bring that to this younger population to help them? And I think the important part, there are a lot of important parts of CBT, but what that reflected for me at the time was I could teach a kid some coping skills and I could teach them ways of thinking about things differently. And I need to find a way to bring this to this younger population. And what clicked for me was play because I did a lot of play therapy and play is what makes sense with younger kids. It's a language of children.
Dr. Keith Sutton, Psy.D: (06:32)
Oh, that's great. Well, wonderful. So tell me about how you think about CBT and play and kind of translating it to younger children.
Susan M. Knell, Ph.D.: (06:46)
So the way I've thought about it over the years, this has been a work in progress. I mean, the very first work was over 30 years ago, but it's really been a work in progress. And the way I think about it is younger they just can't do CBT the way we're trained to do CBT with adolescents and adults. So that author was correct. You can't do CBT with young children. But the way I think about it is I'm trying to find ways to make it developmentally appropriate, sensitive to the child and the child's needs, and to make it such that it's not relying on a lot of complex language skills because CBT can be kind of heavy linguistically and cognitively.
Susan M. Knell, Ph.D.: (07:39)
And how can I bring that to the play therapy room and capitalize on the child's strengths, not just what the child isn't that good at, which would be more complex cognitive abilities and language.
Susan M. Knell, Ph.D.: (07:54)
And what the model has really, as I said, it's a work in progress, but the thing that's been there since the beginning is modeling. And that's probably the most important part of this, is that we're modeling through play the things that we can't explain linguistically.
Susan M. Knell, Ph.D.: (08:16)
And that might be modeling with puppets or other toys, or it could be books, it could be movies, or songs. There are just so many ways in which we can model for young children, but it's integrated into the play.
Dr. Keith Sutton, Psy.D: (08:30)
Can you give me an example?
Susan M. Knell, Ph.D.: (08:33)
Okay. So, a child is playing and let's say is playing out some scenarios from home. Mom and Dad are fighting and they're yelling at the kids. And, the child is hovering in a corner and kind of dealing with it. And the child is playing this all out through her play, let's say. So what I can do is bring into that play another voice. Like I can be a puppet who says, “Gee, when my mom and dad fight that way, you know, I also kind of wanna go in the corner.” And then likely the kid, the kid in therapy is going to say, “Oh, yeah, I'm always hiding in the corner.” And then my puppet could say something like, “Oh, it's so hard to hear your parents fight that way. You know, here are some things that I might do. I might sing a song to myself, or I might find a book that comforts me.” Or, you know, so that would be, I mean, that's not the only way to do it, but that would be one example of how I could bring it into the play.
Dr. Keith Sutton, Psy.D: (09:37)
So kind of like using the puppet in that sense as like, kind of another child or something, sharing their experiences and kind of how they deal with those situations to kind of help. Kind of relate to that or potentially take that in.
Susan M. Knell, Ph.D.: (09:51)
Or I might read a book with the child about, you know, fighting parents and things, there might be some coping skills in there, or we might create a book. You know, there isn't a manual, there's not one size fits all. And it's really trying to figure out how you model good coping skills and the things that the child needs to learn basically.
Dr. Keith Sutton, Psy.D: (10:16)
Ok, great. And I think that there's been some research done on your work, is that right?
Susan M. Knell, Ph.D.: (10:21)
Yes. Can you say, you know, where we are right now, it's sort of an interesting place to be. There are approximately 28 to 30 published case studies, but they're just case studies. And, you know, kind of getting more of a sense of what population this works best with and those sorts of things. But since they're just case studies, there are a couple of things that are happening right now. One is that there's a growing body of research on what's called CBPI, which stands for Cognitive Behavioral Play Interventions, and that's not therapy. But it's an intervention, cognitive behavioral play interventions that are being used in a research setting. So for kids with diabetes or sleep disorders or other situations where they're not coming for therapy, but they're doing empirical studies on using those techniques with these essentially non-clinical populations.
Dr. Keith Sutton, Psy.D: (11:25)
To try and like convey information?
Susan M. Knell, Ph.D.: (11:28)
I'm sorry?
Dr. Keith Sutton, Psy.D: (11:28)
To like, convey information or help them kind of better understand?
Susan M. Knell, Ph.D.: (11:33)
Yes. So some psychoeducation, some teaching coping skills, modeling, and other ways that they could deal with the situation. So what's kind of nice about that research is that it's really empirically testing out many of these interventions, but it's testing them out with a nonclinical population around a specific symptom or problem. So when I say nonclinical, I mean non-psychologically clinical.
Dr. Keith Sutton, Psy.D: (11:59)
Happening in for depression or anxiety or so on. Right?
Susan M. Knell, Ph.D.: (12:02)
Right.
Dr. Keith Sutton, Psy.D: (12:03)
Ok.
Susan M. Knell, Ph.D.: (12:04)
So that's an interesting direction that it's going in. And that was all based on a dissertation that all started from a dissertation that, Beth Pearson did at Case Western Reserve, and I was on her dissertation committee. So she was trying to find a way to test some of these interventions, but with a non-clinical population, because this is about 14 years ago, and she'd probably still be in graduate school if she was trying with a clinical population.
Dr. Keith Sutton, Psy.D: (12:31)
Yeah, I'm sure.
Susan M. Knell, Ph.D.: (12:33)
So that's one piece of it. And then the other piece of it is that there's growing research in trying to test the actual clinical applications of CBPT.
Dr. Keith Sutton, Psy.D: (12:46)
And part of it is there's a coping skills aspect that you're modeling and so on. How about the thoughts or the schema, or is there any kinda way that you think of that with children and kind of in the cognitive interventions?
Susan M. Knell, Ph.D.: (13:07)
So, you know, any of the cognitive interventions can really be modeled for kids through play. I’m trying to think of some examples where, you know, things are like changing. I tend not to think of them as rational thoughts. I mean, that's what the literature talks about with young children. I tend to think of them more as maladaptive thoughts because I think that developmentally that makes sense. I'm gonna go off on a little bit of a tangent to answer your question, but I'll get to it.
Dr. Keith Sutton, Psy.D: (13:38)
Go for it.
Susan M. Knell, Ph.D.: (13:39)
So, you know, you have a child who's learning toileting behaviors. And one of the things that I've seen many times over the years in my practice is kids are afraid they're gonna fall in the toilet. They're afraid they're gonna get flushed down the toilet. They hear their parents being all positive about, you know, the stuff that goes in the toilet and gets flushed, but, you know, they don't wanna get flushed down the toilet. And I tend to think that's not really an irrational thought. It would be irrational, obviously, as adults if we had that thought. But for children, it's maladaptive. It's really not functional, it's not good to think you're gonna get flushed down the toilet or you could fall in or whatever. And the reason why it's not irrational, per se, is that the child doesn't really have the learned history to know it's not possible. The child doesn't understand. No, they can't fall in, No, they can't get flushed down. That's adult understanding. That's not child, little child understanding.
Dr. Keith Sutton, Psy.D: (14:47)
It reminds me of when Steven Hayes talked about how we come to our beliefs honestly. So that, you know, it's not that these irrational thoughts are somehow we came to them through our experience, or like in this situation developmentally haven't had the alternative experiences to shift that thinking.
Susan M. Knell, Ph.D.: (15:06)
Right. So, with a child, for example, we can really deal with those maladaptive beliefs that they're not gonna get flushed down and they're not gonna fall in. And there are lots of ways that we can model that for children but that would be dealing with the cognitive piece of it. So I might have a puppet who's sitting on the toilet and saying, “I was kind of scared of this, but I know I can sit on the toilet. I know that I'm gonna be okay. I know that I'm safe and I know I'm not gonna fall in.” And that's modeling that maladaptive belief that they're changing for the child to hear.
Dr. Keith Sutton, Psy.D: (15:44)
Wonderful. Yeah, I remember watching with my own kids in potty training watching Elmo's potty time, several times over and over, just seeing that modeling of being comfortable with the toilet and so on.
Susan M. Knell, Ph.D.: (15:59)
That's great. And we know from the literature that coping modeling is way more effective than master remodeling. So I wouldn't just have a puppet sit on the toilet and say, “Great, I did it. It's fine. It's over.” I would, you know, shape it and have that child see how a puppet or a toy starts to deal with that over time.
Dr. Keith Sutton, Psy.D: (16:21)
Okay, great. My original training was in narrative therapy and then later I got deeper into cognitive behavioral therapy. So I've kind of used some of those in externalizing the different emotions and sometimes using stuffed animals to represent the anxiety or the anger or whatever it might be. And then kind of really helping the kids sometimes kind of talk to those parts in that way and kind of that relationship. Which has been kind of a fun way to kind of talk about and also kind of bring up those automatic thoughts, but in a way of; what is the anger saying, you know, what's it want you to do? And, all those kinds of things to kind of get that, you know, mindfulness and kinda metacognition.
Susan M. Knell, Ph.D.: (17:07)
The other quick example, which actually is from a very psychodynamic place is Selma Fraiberg's The Magic Years, which I think is such an important book for understanding. It's very psychodynamic, but it was one of the first books that I read about preschool-aged children, and she uses the example of a little kid who was getting closer and closer to a family vacation and getting more and more worried about it. And then at one point, he said, “I can't go to Eurp.” Eurp was what he called Europe. And the family said, “Why?” And he said, “I don't know how to fly yet.”
Susan M. Knell, Ph.D.: (17:46)
And it's just a perfect example of that kind of, is that irrational, or is that just learned history that he didn't know that he didn't have to fly?
Dr. Keith Sutton, Psy.D: (17:54)
Yeah. Not having that information yet, but that's not how you get there.
Susan M. Knell, Ph.D.: (17:58)
Right.
Dr. Keith Sutton, Psy.D: (17:59)
Yeah, so much of that I think is so exploratory and kind of figuring out what is going on. And sometimes I think of myself, you know, and working with children as kind of almost like mining for the gold and then kind of passing it over to the parents. I also do a lot of family work and grounded in family systems, but kind of helping to kind of unearth what's going on and then helping them communicate that to the parents and teaching parents tools and techniques and play therapy eventually put me out of a job.
Susan M. Knell, Ph.D.: (18:29)
And I do a lot of work with the parents too. It's not just family work or child work but I do, you know, the mining for the gold is real. I mean, to me, that's what you get with play therapy, as long as you're not, I think the trick to CBPT is if you are too structured then you are not going to get to the gold. But if you're just letting the child spontaneously keep digging you're not only not going to really get the gold, but you're also not gonna be able to intervene.
Dr. Keith Sutton, Psy.D: (19:06)
Yeah. It's kind of I think sometimes with psychodynamics it's a lot of listening and exploring, but not necessarily, then what do we kind of do about it? So kind of bridging that gap between kind of understanding and eliciting and drawing out what's going on in the internal world, but then actually translating that. Like you're saying to skills and shifting cognitions and work.
Dr. Keith Sutton, Psy.D: (19:32)
So what do you think is important for folks that do CBT to kind of think about in working with children?
Susan M. Knell, Ph.D.: (19:43)
Well, I think it's important to really understand that, I mean, first of all, I don't think that if you approach this, like I've worked with older kids. Somebody says, “I've worked with older kids now I wanna do this with little kids.” But they don't have any experience in play therapy, and they don't really understand developmentally at that age. I think it's important to kind of have the whole package. You need to understand the developmental issues, you need to have some experience with play. So really the way I think about it is learning how, if you know, CBT and play, you're learning how to integrate them. But it's not, I don't think it would be so easy to just learn it all at the same time.
Dr. Keith Sutton, Psy.D: (20:26)
Definitely, and I think that I was even kind of talking about this in the discussion on our lister that I think there is a belief for folks that play therapy equals non-directive psychodynamic. Or, rather than play can be CBT or other parts of development or treatment.
Susan M. Knell, Ph.D.: (20:54)
Absolutely.
Dr. Keith Sutton, Psy.D: (20:55)
That it's separate or different or not evidence-based or whatever it might be.
Susan M. Knell, Ph.D.: (21:00)
No, I absolutely agree with you. I think that a lot of people just think play has to be either sort of Freudian, psychodynamic, you know, like sort of the beginning hundreds of over hundred years ago of how play was used, or there is such a strong movement for child-centered play therapy, sort of client-centered play therapy. But with kids, and I can tell you an interesting story about that, which just sort of tickles me to this day. About four years ago I was presenting a workshop to the Pennsylvania Play Therapy Association and there were about a hundred people there. And I was presenting on CBPT for a whole day and I usually start by finding out who my, you know, I think most people do this, who's my audience, not just disciplines, but orientations. And when I got about 98 out of a hundred people raised their hand, that they were child-centered. I took a really deep breath and thought, this is gonna be really interesting. Because I've actually found over the years, for a wide variety of reasons that presenting to more psychodynamically oriented therapists is easier in terms of presenting CBPT. It's easier than presenting to client-centered or child-centered.
Dr. Keith Sutton, Psy.D: (22:23)
Interesting.
Susan M. Knell, Ph.D.: (22:24)
And I think the reason for that is there are more similarities between, I mean, except for the directiveness of it. There are more similarities between CBPT and psychodynamically oriented therapy. When I have a chart where I look at the differences between CBPT and other play therapies and CBPT and child-centered pretty much don't match any place. I mean they match in terms of using play as a means of communication and, you know, communicating that it's a safe place for the child, but they really don't match on any of the other variables. So about 98 individuals in this room raised their hands and said that they were client-centered or child-centered. And I really felt like, oh boy, I got a hole of a day ahead of me and there was one particular person sitting in the front row who was, I felt like he was glaring at me through the whole day.
Susan M. Knell, Ph.D.: (23:21)
So, you know, I was doing all my own cognitive interpretations of what was going on. And I asked them if they could just be open-minded, and clearly, this is how they were trained and thought, and I was gonna ask them again at the end of the day. And I asked them again at the end of the day, how many of them thought that they could do this kind of work, and everybody, but that guy in the front row raised their hand that they thought that they could do it. And boy, I was really puzzled at that point, and I thought, I don't know what's going on here. But they were really in the question-and-answer period and afterward telling me that this made sense to them, and it was countered to a lot of what they'd learned, but it made sense to them. Well, this guy actually came up to talk to me, and what he said to me was, not at all what I was expecting to hear. What he said to me was, “I don't think I could ever do this, because you have to be really playful and creative and imaginative.”
Susan M. Knell, Ph.D.: (24:24)
And I stepped back and I thought, well, first of all, to do play therapy with a child, no matter what your theoretical orientation is, you have to be playful and creative. I think, you know, and he was basically telling me, I don't think I can do this because it doesn't fit my personality. And I was kind of thinking, why are you a play therapist? But, you know, I was able to sort of say to him, “Look, if you wanted to learn how to do this work, get some good CBPT supervision, and you could do it if you really wanted to.” Even though that other narrative was going on in the back of my head.
Dr. Keith Sutton, Psy.D: (25:02)
And I found even for myself, I originally went into the field interested in working with adolescents. And in my training, also worked with children. I felt comfortable with children, but again, had that idea that we're just kind of playing and it's non-directive. And I had spent a year at a Head Start preschool doing, you know, my first-year practicum. We were just supposed to do kind of pride of the PCIT where you're praising and reflecting and so on. Which was great, but it kind of felt like, you know, a bit repetitive after a while. Then, you know, later on learning more about how we can kind of incorporate some of these, you know, with CBT having that direction and having those goals and kind of figuring out.
Susan M. Knell, Ph.D.: (25:48)
Well, PCIT has a, I went through the training myself, and there's just a lot of similarities. Obviously, it's not CBPT, but I see PCIT is extremely helpful for families and parents.
Dr. Keith Sutton, Psy.D: (26:01)
I was just, we were just practicing that one little technique, so it wasn't even working with the family, it was just basically kind of like a structure for non-directive. But yeah, no, PCIT is great and helps direct the parents in the moments with the kids. One client I was working with, a four-year-old with a dog phobia, you know, and trying to think about how do I even translate kind of this and anxiety. And so I found out what movie that she liked and it was Rapunzel at the time. So this was before I had kids. So I watched it and then was able to kind of use the metaphor, the mom and telling Rapunzel, don't go out there. Everything's scary, you know, everything is bad and scary out there. And then talked about, did she listen to her mom and didn't. And then kinda talk about the fear that was telling her that dogs are scary and so on.
Susan M. Knell, Ph.D.: (26:54)
That's great. I mean, my experience with dog phobias with kids is that most of the time I've got to leave the playroom and go out and do in vivo work and work with them in the community. And, you know, I just recently did one with a little boy where we started with the smallest little dogs that are really far away, and we did systematic desensitization. And he's like a dog fanatic now.
Dr. Keith Sutton, Psy.D: (27:20)
That's what we ended up doing. And I have a dog in my office, so it was like a nice way to kind of like, slowly kind of do some work and kinda do that exposure to have that different experience.
Susan M. Knell, Ph.D.: (27:32)
In terms of Rapunzel, you know, the other thing that if kids like musical theater kinds of things, maybe this is for kids a little bit older. But I whistle a happy tune from The King and I, where it's basically, I don't have the words right in front of me, but basically, I can do this. And even though I'm afraid and I just keep putting one foot in front of the other and I got it, and kids really like that.
Dr. Keith Sutton, Psy.D: (27:58)
Oh, nice. Kind of using those playful engaging ways of kinda translating this information. I know I'm not totally familiar with trauma-focused CBT, but I know that that even goes down to three years old in the work that they're doing there.
Susan M. Knell, Ph.D.: (28:16)
I think Drewes and Cavett have taken the trauma-focused CBT and have introduced play in a way that Cohen's work, the trauma-focused work with older kids didn't really incorporate the play in a play therapy kind of way. I mean, the thing to me that's a really important distinction is that play can be therapeutic. A lot of people use play with older kids and even with adolescents. So play can be therapeutic, but there's a difference between play being therapeutic and CBPT where it's actually the therapy.
Dr. Keith Sutton, Psy.D: (28:51)
Yeah. Say more about where the therapeutic play versus it's the actual therapy. How do you mean?
Susan M. Knell, Ph.D.: (29:00)
Well, I mean like I've had adolescents to get to my office, you have to walk through my playroom and I have this big bucket of puppets that's kind of right on the way into my office. And a lot of times an adolescent will just grab a puppet on the way into my office, and they don't wanna do therapy with the puppet. They don't want me to do anything with the puppet. They got the puppet on their lap and they occasionally may do something silly with it and we may be playful about it. So to me, that's sort of play being therapeutic, but that's not play therapy.
Dr. Keith Sutton, Psy.D: (29:34)
Got it. So that's kind of having something that's making it a little more comfortable, but not necessarily like, kind of a medium of the change.
Susan M. Knell, Ph.D.: (29:42)
Sure, yeah.
Dr. Keith Sutton, Psy.D: (29:44)
I don't know if you also incorporate art. I know so many play therapists, you know, incorporate art into their work. Can you talk a little bit about that?
Susan M. Knell, Ph.D.: (29:54)
I do, I have a big whiteboard in my office. I have a lot of construction paper and drawing paper and coloring books if a kid doesn't want to create on their own, lots of times we make a book. One of the ways that I use art a lot is kind of in a systematic desensitization way where a child might be drawing pictures, like a child who's experienced abuse or some kind of trauma. They may not be able to deal with that trauma right away, but they can draw pictures kind of getting closer and closer to the trauma. The street or the house or the room or the people, and using their drawing in that way. I'm supervising a graduate student who, this is a kid who's a little bit older, but who said, “you know, she's spending so much time on her art and I feel like I'm not getting.” and I'm like, “no, stop.” You know, art is so important because that's the way the kids communicate, especially the younger kids.
Dr. Keith Sutton, Psy.D: (30:58)
Yeah, and I think what I'm hearing is that is kind of having some direction, like kind of using that play and like you're saying, like drawing things that are related to the trauma. So there may be that prompt and then letting the kids kind of do the play in that direction. And so kind of that, it almost reminds me of motivational interviewing where there's somewhat of a non-directed. But then there's also kind of a direction that we're kinda going in or kind of pointing towards, although it's not rigidly making the kid go in a certain direction.
Susan M. Knell, Ph.D.: (31:33)
Sure, and you know, sometimes the art will be, I'll have them make a book about their life and, you know, if they're not a child who's writing yet or they don't wanna write, they'll dictate it and I'll write it out and then they'll illustrate it. And the pictures can sometimes be very helpful to figure out what we should say next and sometimes those books are a combination of the child's spontaneous discussion and my adding things.
Dr. Keith Sutton, Psy.D: (32:01)
Yeah, kinda in weaving that in there and I think too that with the art is always nice for, you know, drawing out feelings or so on or kind of with that Dan Siegel kind of connecting the upstairs and the downstairs brain. And helping the kids, you know, put their emotions into language and drawing them out and, and kinda connecting that ability to communicate and help with that affect regulation. Or always like the one kind of drawing, like a gingerbread person and then kind of drawing the different places where you feel the anger or the nicer.
Susan M. Knell, Ph.D.: (32:37)
And, you know, in terms of putting the CBT spin on it, lots of times what I feel like I'm doing with those kinds of situations is I'm shaping the appropriate expression of feelings. You know, so like, I had this kid where there was a puppet and he was learning to use the toilet and kind of making it close to the child's experience. And the child was drawing things and he was really angry at this puppet cuz the puppet was kind of getting it but he didn't feel like he was getting it. And what I could do when he was angry at the puppet or like wanting to hurt the puppet, or crossing out the pictures that he drew of the puppet is start to shape those feelings. I think you're angry because maybe the puppet is kind of learning how to use the toilet and you're kind of frustrated that you're not. And that's, you know, pure shaping of feelings. Expression of feelings.
Dr. Keith Sutton, Psy.D: (33:37)
Yeah, through that reflection amd kind of helping bring that more to awareness or kind of putting words to the experience. And then how about Sand Tray? Do you use any kind of sand tray work in any of the work that you've done.
Susan M. Knell, Ph.D.: (33:55)
I don't. I really never got trained in it. And, one of the playrooms that I worked in many years ago did have a sand tray and so we used it, but I did not use it in terms of knowing the techniques.
Dr. Keith Sutton, Psy.D: (34:09)
Well, because I know there's one technique of just kind of non-directive and seeing what the kid does and kind of reflecting what they're doing and exploring it. I found it a nice way to use it too is even just having the kid kind of put a scene together of something that happened recently. Then sometimes ask about the different characters and what they were thinking or feeling and then having them do the scene again. How they would've liked to have that situation go with their mom or their dad or their parents.
Susan M. Knell, Ph.D.: (34:40)
And I might do exactly the same thing, but just with the house and all the characters there without the sand.
Dr. Keith Sutton, Psy.D: (34:46)
Oh yeah, it's like a doll house or something.
Susan M. Knell, Ph.D.: (34:49)
Yeah.
Dr. Keith Sutton, Psy.D: (34:50)
Great, so it seemed like with the CBT work again it's, you know, kind of having this direction or idea like you're saying, translating in vivo exposure into play and kind of addressing some of those thoughts, or through the modeling and such. Tell me about modeling and it sounds like that's an area of focus that you're most interested in, or one of your top mediums. Can you talk about your thoughts on that.
Susan M. Knell, Ph.D.: (35:19)
So, you know, basically I'm trying to figure out where is a child is and where I wanna get the child to. And you know, it's obviously quite different from working with an adult where an adult comes in and maybe says, “I wanna be able to do X, Y, Z.” You know, many times whatever the family's concerned about with the child, the child may not be concerned about. So most of the time children aren't gonna say to me, gee, I'm still pooping my pants and I don't wanna be doing that. Or, if they're selectively mute, they're not gonna say to me, I don't wanna talk. But yeah many times their goals are not what my goals might be, particularly as I'm pulling in what the parent's goals might be.
Susan M. Knell, Ph.D.: (36:05)
So modeling I think is a huge way and I don't know how to communicate strongly enough that there's not just one way to model. There are so many ways that I would bring modeling into a session, and I think it's just a way that, you know, we talked before about communicating maybe some coping skills, some things like that but it's a way of modeling almost everything. You know, modeling another individual who might have similar experiences or another individual who might be dealing with it totally different,or it's a way of modeling some of those maladaptive thoughts the child might be having difficulty communicating but I'm really hearing through their play. So I guess my bottom line thought about it is that there's nothing you can't model.
Susan M. Knell, Ph.D.: (37:04)
As I said before, it isn't always, I mean, I talk a lot about puppets because I do find that a lot of kids gravitate to the puppets but I've had a bunch of kids who don't like the puppets. They go maybe straight to my big container of toys and sort of, what was that movie Cars, I think it was.
Dr. Keith Sutton, Psy.D: (37:24)
Yeah. Cars.
Susan M. Knell, Ph.D.: (37:25)
You know,Cars had all the characters have names and the kids will bring that into the playroom and I can do the same thing with a toy car that I can do with a puppet.
Dr. Keith Sutton, Psy.D: (37:35)
You can kind of give it a voice and have it model different things.
Susan M. Knell, Ph.D.: (37:40)
You know, and then there are all the books, the from Imagination Press. Which is now an imprint of APA that What to Do When You Worry Too Much and What to Do When You Dread Your Bed and, you know, a whole slew of those books, which are all based on a CBT model. I do use those with the older kids, but with the younger kids, I can pull some of that into the play and it can be something. I wouldn't sit and read it with a child with most children, it'd just be too wordy but the workbook pieces of it can definitely be used.
Dr. Keith Sutton, Psy.D: (38:16)
Do you have any examples of those?
Susan M. Knell, Ph.D.: (38:19)
Yeah, I've got lots of them.
Dr. Keith Sutton, Psy.D: (38:23)
Kinda using that with a child with the play.
Susan M. Knell, Ph.D.: (38:26)
Yeah, for example, in the What to Do When You Worry Too Much book, there's a place where you draw, I don't know if you're familiar with the book, but you draw your worry monster.
Dr. Keith Sutton, Psy.D: (38:38)
Yes.
Susan M. Knell, Ph.D.: (38:39)
And the kids, you know, will draw these scary monsters and you know, like you imagine when you see this picture what's going through their head right about their worry monster. And then towards the end of the book, it asks you to show how you feel without the worry monster on your shoulder, which is where they're talking about, you know, pushing the worry monster off your shoulder. I have lots of examples where the kids then draw that picture and the monster, which was huge. And the first picture is teeny tiny, or there was this kid who drew a picture of himself stomping on the worry monster who was about an inch tall.
Dr. Keith Sutton, Psy.D: (39:23)
Wow. Very cool.
Susan M. Knell, Ph.D.: (39:25)
So, you know, there are lots of ways to bring those workbook pieces into play and sometimes I bring them into play. I've got kids who wanna play school all the time so I can bring them into play by having the teacher say, “Hey, let's learn about worry monsters.”
Dr. Keith Sutton, Psy.D: (39:43)
Oh, nice.
Susan M. Knell, Ph.D.: (39:45)
Or, I have a couple of examples of children that when I got to something that was kind of upsetting for them, they weren't interested, so they disappeared to the other side of the playroom. And I'm often asked, well, how do you model stuff if the kid isn't interested? And what I've found is that kids, I have this vivid memory of this child who had been abused and we were going through this book and he's just like, “no, I'm not gonna do it.” And he went to the other side of the room and I said, “well, I'm just gonna take a couple of minutes and read the book to this puppet.” And that child sat on the other side of the room, listened to every word I was saying, and kept telling the puppet what to tell me. Don't tell her that. Tell her this. And essentially what he was doing was interacting with me even though he didn't think he was. He was interacting with the puppet, telling the puppet everything that was in his experience, but even if I invited him to come closer, he wasn't interested.
Dr. Keith Sutton, Psy.D: (40:53)
Well, it's so great because I think oftentimes kids can communicate or kind of with some distance, whether it be talking about a character in a book or a movie or something, rather than maybe talking about their direct experience or like you were saying. Talking to the puppet but not talking directly to you.
Susan M. Knell, Ph.D.: (41:12)
And, for some kids, you know, even in the play where they're interacting with me, they don't necessarily think that they're telling me what they think. You know, here's this toy character that's my age, has my name, and looks just like me, but that's not what I really think.Oftentimes what I hear from the kids.
Dr. Keith Sutton, Psy.D: (41:33)
Exactly, kind of totally separate. Not at all about me. The worry monster was interesting too as you were talking about it because I was just thinking about just even putting that out there and kind of thinking about sharing it right in and of itself, you know, kind of shrinks the monster. It’s a way from being this scary kind of thing that one's alone with and kind of putting it out there and seeing that it's not so big or whatever it might be. And also reminds me of the technique of laying the monster in EMDR where the kids will draw the picture, and then they will, you know, kind of cross it out left and right or rip, or so on and then draw it again. And oftentimes it's very different after they kinda do the second drawing.
Susan M. Knell, Ph.D.: (42:16)
Because they're taking some power. You know, I think I like the whole concept of sort of the worried monster or the worried bully sometimes they call it. Because a lot of kids, even if they haven't had experience with bullies, know somebody's trying to mess with them or somebody's trying to kind of bully them. They know what that means and I give them, and I think the book gives them permission to talk back. And I'll say to kids, you know, these may be words you're not allowed to use at home, but it's okay when you're talking back to the worry bully to use words that, you know, that's okay because it's just here and it's safe.
Dr. Keith Sutton, Psy.D: (42:55)
Yeah, and that's also incorporated into the evidence-based treatment with children in OCD, you know, the OCD is the bully and kind of externalizing it and kind of creating this not listening to the bully or giving it a name.
Dr. Keith Sutton, Psy.D: (43:10)
The Bully says don't touch that and you're like, and then defy the bully. Like, I'm gonna touch that anyway. Right, kinda helping them to position themselves, you know, externalizing that symptom over it.
Susan M. Knell, Ph.D.: (43:22)
I think even just giving the bully a name sometimes is very powerful, you know? I’ve had kids say, “shut up Charlie,” you know, “Just go away, get lost .”
Dr. Keith Sutton, Psy.D: (43:31)
Yeah. I had one kid, her anxiety she named it Gertrude, sorry, Gertrude's out there. But she associated Gertrude with somebody with the kind of wagging their finger at them and telling them what to do.
Susan M. Knell, Ph.D.: (43:42)
I think that might have a sort of connotation of an old older person's name or something, you know, Gertrud.
Dr. Keith Sutton, Psy.D: (43:48)
Exactly, well yeah, so this is so great and it's great that there are so many different ways that you can translate, you know, and kind of using the theoretical grounding of CBT and what we know from coping skills and doing exposure work and also kind of eliciting thoughts, beliefs, and getting to core schemas and then being able to have interventions to help shift that. Whether through, you know, talking about it or talking back to the bully using coping thoughts or like you're saying kind of playing that out and modeling a child kind of using coping thoughts to use the toilet whatever it might be. And tell me about the parents. What kind of stuff are you doing with the parents? You're mentioning that there's some incorporation there.
Susan M. Knell, Ph.D.: (44:41)
Sure. Well, you know, I've always at the beginning trying to figure out if this more parent, you know, I should be doing parent work. Is this child work? Is this a combination? And, you know, clinically I'm trying to figure out who am I working with here. And there are certainly cases where the child was of play therapy age and the parents might have come to me originally for play therapy for the child. But I feel like if I can work with the parents if I really can identify that the parents can do the core of the work, I'm more inclined to say, “let's try this first and see how far we get.” And then we can always bring the child and we can always do play therapy, but I'm not going to jump on, you have to bring the child in because sometimes I just work with the parents and that's enough.
Susan M. Knell, Ph.D.: (45:29)
Sometimes I do both. Sometimes I'm working with the parents and working with the child sort of combined. And what makes that tricky, especially in-person work is that you know, I might not need a whole session with the parents and a whole session with the child, but if the child is brought by a parent, it's often very tricky. Can I talk to the parent while the child is playing? I don't wanna be talking to the parent in front of the child, but how do I do this? How do I juggle this? And I don't think there's ever one size fits all but, you know, sometimes the parents will both come and take turns hanging out with the kids. Sometimes I'll ask them to bring like a sitter or older kid who can play or, you know, there are multiple ways of dealing with it but it's not always smooth.
Dr. Keith Sutton, Psy.D: (46:23)
Yeah, exactly. Sometimes that is one of the benefits of online work is that you can do a little with the kids and then send them out and bring the parents in for a little bit and bring them together and enough work in those different, Are you doing online work?
Susan M. Knell, Ph.D.: (46:37)
Not with kids this young. I mean, the problem really is that I have done some, I'm mostly doing online work now. Kids that I've seen before in play therapy in my playroom at my office are a little bit easier to transition to online but it's still difficult. I think they have to kind of prep the family to have certain supplies available there and I have the same supplies. It doesn't translate very well.
Dr. Keith Sutton, Psy.D: (47:09)
Yeah, it's so interesting. So, I've talked to so many different people that some like really love the online work and can really do with the kids. Some have a tough time with the online work and really prefer the in-person and, you know, I think so much there's part of the the therapist. The way they work and kind of what their personality is as well as the kids and kinda makes it going on.
Susan M. Knell, Ph.D.: (47:31)
And I would guess of the people that you're talking to, they're probably not doing online work with the much younger kids, I'm guessing.
Dr. Keith Sutton, Psy.D: (47:38)
Sure not like a three or four-year-old or so on. That's gonna be a lot harder. But if you're also doing a lot of work with the family too, kind of incorporating that, not just more of a mostly kid session or so on, that would beeally tricky. That is really helpful and it's really great to hear about the work that you're doing and the way that you're kind of thinking about CBT and kind of translating that into the language of play with children. And it sounds like you also do training. Is that what you were mentioning too?
Susan M. Knell, Ph.D.: (48:11)
Yeah, and what's really interesting about the pandemic and one of the positive things that came out of it is that a lot of places that might have only thought about doing, you know, like paying to have me or whoever come out to do training or now doing these Zoom things. So yeah, in the past couple years, I've done training for therapists in Turkey and China and Hong Kong, and I've forgotten someplace, but a couple of countries and what this has led into, which is I'm really excited about. So I wanna talk about it a little bit, you know, over time different therapists will contact me and they'll want me to comment on their dissertation or this idea or that idea. And I always sort of take a deep breath because oftentimes they use the term CBPT, but it bears no resemblance to anything that I think of as CBPT. So that's always difficult but I was contacted by a therapist, a psychologist in Italy who, to make a very long story short, was really doing CBPT and very interested in it. And we have developed the CBPT Institute in Rome, Italy.
Dr. Keith Sutton, Psy.D: (49:29)
Yeah.
Susan M. Knell, Ph.D.: (49:30)
Did you take a look at the website?
Dr. Keith Sutton, Psy.D: (49:32)
I was looking at it. I think that's how I ended up actually finding you. I was like, oh, perfect.
Susan M. Knell, Ph.D.: (49:37)
So, they actually have a researcher on board who's gonna be implementing in collaboration with a researcher, Carla Fair, who's in Illinois doing some CBPT research. And we're been taping training, so the trainings are gonna be available to people online and there'll be a CBPT certificate. And it's really kind of exciting to me because I'm, you know, I'm getting towards the end of my career. And even though the book came out 30 years ago, I just don't see myself traveling all over the world, although I'd like to do training. So it's wonderful to be able to say, Hey, take a look at this online training.
Dr. Keith Sutton, Psy.D: (50:20)
Yeah, having that resource there for people that maybe can't make it to one of your trainings live or whatever it might be. Oh, that's perfect. Do you know when that's kinda coming out?
Susan M. Knell, Ph.D.: (50:31)
Well, some of it is already out. I mean, you'll see from the website that some of the training can be bought at this point. Some of it is still a work in progress. I was actually in Italy, Florence, and Rome, in the beginning of November where we presented a symposium at the first national CBT conference. And I think the whole notion of CBPT in Italy is, you know, maybe it's also an issue for the people that you were interacting with on the blog. But it's definitely an issue there because it's very client-centered there and, you know, it's like hard to know. It was pretty well received given the nature of I think in Italy, it's not just that CBPT isn't that widely understood, but play therapy itself is not necessarily considered something that psychologists and mental health professionals do.
Dr. Keith Sutton, Psy.D: (51:30)
Oh, interesting.
Susan M. Knell, Ph.D.: (51:31)
I think there's more of a thought about play, you know, and that play therapy piece as a psychological is just beginning to sort of gain some momentum there, which was kind of interesting.
Dr. Keith Sutton, Psy.D: (51:45)
Yeah, wonderful. And your book, what's the name of your book? Just to mention for our audience.
Susan M. Knell, Ph.D.: (51:51)
Cognitive Behavioral Play Therapy.
Dr. Keith Sutton, Psy.D: (51:53)
Perfect. Well, thank you so much for your time today. It was great to learn about your work and we'll link to the online trainings as well as your books so people can learn more about it. Thank you very much. I really appreciate it.
Susan M. Knell, Ph.D.: (52:08)
Thank You. It was great. It's always fun to bring this to new audiences.
Dr. Keith Sutton, Psy.D: (52:11)
Definitely. Take care.
Susan M. Knell, Ph.D.: (52:13)
Okay. You too.
Dr. Keith Sutton, Psy.D: (52:14)
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