The “pretend mode” is one of the so-called “pre-mentalizing modes of thinking”, which were first introduced by Target and Fonagy over 20 years ago. In a series of papers about play and reality, “pretend mode” thinking was understood as a mode of pre-mentalizing thinking which is typical in the early years, but which can reappear in a more problematic way in adults. Although the concept of pretend mode was first introduced in a developmental context, as a clinical term it has primarily been discussed in the context of adult or adolescent psychotherapy. This paper suggests that the pretend mode is a valuable clinical concept for therapists working with school-age children, but that its use in this context needs some clarification. After reviewing how pretend mode has been understood as a normal part of early development, this paper goes to demonstrate the various roles of pretend mode in clinical work with school-age children and sets out a number of clinical strategies that may be used in therapeutic work.