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Department of Psychology, Universidad de Chile, Santiago, Chile

This paper presents the results of a qualitative study on the use of sandplay, or sand tray therapy, in the psychotherapeutic process of children who have been sexually abused. A longitudinal study was carried out with seven participants between the ages of 7 and 10 years old. Data was produced during observation of the therapeutic activity over the course of three different phases of treatment, using a rubric created especially for this observation. Three sandplay sessions were recorded: one at the start of therapy, one at the 3-month mark, and the third and final session after 6 months of treatment. Sessions were then transcribed for later analysis. A rubric was developed in order to help researchers identify central themes, behaviors and content of creative play, as well as the therapeutic relationship. Transcribed sessions and observation rubrics were evaluated using qualitative content analysis, and information was categorized according to verbal and behavioral characteristics of the game. Results of the present study reveal common and transversal forms of playful expression among this group of children shown by their engagement with sandplay. During this activity, participants elaborate personal stories that feature violence as a central theme, often involving aggression between two or more individuals. They also express their need for care and protection and work to resolve conflicts using fantasy. The shifting dynamics of sandplay at each stage of therapeutic treatment is an important finding that reveals the progress made during psychotherapy. In the third phase of treatment, sandplay encouraged movement among children, allowing them to act out meaningful scenarios and create structured situations with positive outcomes. Finally, the value of sandplay as an important therapeutic tool is discussed, primarily its role in supporting processes of change and allowing participants to assign new meanings to traumatic experiences. Its application to the field of clinical psychology, particularly when working with victims of sexual abuse, is also explored.

Introduction

Child sexual assault is a serious issue which has drawn increasing international attention in recent years. Studies show that nearly 150 million girls and 73 million boys under 18 years have experienced sexual abuse ( United Nations Children's Fund [UNICEF], 2006). In Chile, studies show that around 7% of boys and girls between 11 and 17 years old have suffered from sexual abuse at some point in their lives ( Ministerio del Interior [Home Office], 2013). These statistics have prompted debates from diverse sectors of society on how to best analyze and strengthen legislation toward eradicating child abuse.

In psychotherapy with children who have been sexually assaulted, therapeutic approaches must constantly adapt and adjust to the patient's own rhythm-incorporating and reaffirming his or her needs while also adhering to the goals of treatment ( Cattanach, 2004). Inside this, play is regarded as a key therapeutic activity for children because it stimulates communication and the symbolization of lived experiences using non-verbal methods of expression. This is especially important when working with victims of sexual assault who may find it difficult to speak about their experiences ( Gil, 2006; Esquivel y Ancona et al., 2007). Play also supports general development and creativity in children ( West, 2000; Cattanach, 2004); it provides a safe and protected space where children may experiment with different ways of acting and understanding the world and articulate and integrate traumatic experiences ( West, 2000; Oaklander, 2001).

Sand tray therapy, a symbolic mode of play, is commonly applied within clinical settings. Here, children use a sand tray to create their own fantasy worlds. Through the use of different figurines (miniature animals, people and plants, among other items), children depict their understanding of the world and aspects of their reality ( Amman, 1991; Dale and Lyddon, 2000), providing the clinician with a symbolic representation of their inner world ( Cunningham and Macfarlane, 1996). This playful approach provides children with a contained and protected space for where they may share facets of their experience ( Labovitz and Goodwin, 2000).

During the sandplay it is important to pay attention to both behaviors as well as the content of the game, which provides a deeper understanding of the activity for further analysis an therapeutic use. Such observations may include how children handle sand, the number of miniatures utilized, the ways in which children engage in play, as well as any changes or revisions made to the game. Content refers to emerging themes played out in the fantasy world and any connections between them ( Sjolund and Schaefer, 1994).

In this way, a number of authors have shown the benefits of sand tray therapy, or sandplay, in young patients' progress during psychotherapeutic treatment ( O'Connor and Schaefer, 1994; Oaklander, 2001). In particular, research on the use of sandplay with child victims of sexual assault ( Grubbs, 1994; Dripchak, 2007) reveals that by using sandplay children may externalize conflict and take control over negative experiences, opening the possibility to portray, manipulate, alter and destroy facets of the traumatic experience. These are all crucial to psychotherapeutic work in the sense that they allow individuals to resignify events ( Labovitz and Goodwin, 2000).

Few studies employ methodologies that allow for a deeper analysis of aspects of play therapy and their progression over the course of psychotherapy ( Mathis, 2001; Herane, 2005). In one case, Mathis (2001) analyzes the progression of sand tray therapy among children during 10 months of treatment. Results show a positive change in how children engage in sand play.

Considering all these, limited research on the topic of therapeutic treatment with victims of sexual assault, particularly play therapy and children, demonstrates the need for further qualitative studies concerned with the subjectivity of participants involved in treatment. The present study therefore seeks to analyze characteristics of play during therapy among child victims of sexual assault between the ages of 7 and 10. Three particular moments of the therapeutic process are observed using sand tray therapy.

Methodology

Sample

The research sample consists of children between 7 and 10 years old. Participants were selected using inclusion criteria of both girls and boys who have suffered from sexual abuse and who, at the time of study, were enrolled in psychotherapeutic treatment in a specialized center for the treatment of child sexual assault. The sample was obtained at the Center for the Treatment of Sexual Abuse (CAVAS), an organization affiliated with the Policía de Investigaciones de Chile (Civil Police Department) which serves child victims of sexual assault in the city of Santiago, Chile.

In order to obtain and establish the sample, authorization was secured by the Institute of Criminology which oversees CAVAS, specifically by the project team coordinator which provided researchers with access to clinical records of the children who agreed to participate in the study.

Therapists were asked to present the option of participating in the study to patients and their legal guardians. They were then informed of the research study, as well as ethical implications of participating voluntarily and anonymously. After agreeing to participate, the parents or legal guardians were asked to sign an informed consent form, and children's verbal assent was obtained by the therapist once they confirmed their desire to participate. The total number of participants was determined using the criterion of data saturation ( Rodríguez et al., 1999), which considers participants until all information has been sufficiently collected. Cases of sexual abuse among the sample population were either extra- or intrafamilial and differ in terms of incidence and duration, particularly in terms of chronic and repeated exposure. This criteria is consistent with literature on sexual assault and the cases share similar characteristics ( Finkelhor, 1994; Cantón and Cortés, 2004; Pereda et al., 2009). In addition, differential criteria were included, specifically regarding gender and participants with varied symptomatology. It is important to note that cases involving serious psychological disorders, such as psychosis and organicity, were omitted from the sample. Accordingly, the primary characteristics of the sample population are presented in Table 1.

All children participating in the study had completed psychodiagnostic phase, which identifies clinical indicators of sexual abuse prior to starting treatment, and were in the beginning stages of psychotherapy. Participants attended sessions on a regular basis and, according to information reported by therapists for each case, children had no contact with the perpetrators.

With regards to the treatment method, sand tray therapy was used prior to the study in order to familiarize participants with the activity, but wasn't the only technique used in therapy. It is important to note that the type of sand tray and miniatures utilized in the present study are consistent with the technical references established by specialists ( Cunningham and Macfarlane, 1996; Gil, 2006).

On the other hand, about the sample of therapists, one selection criteria in the present study was that therapist uses implementation of a constructivist approach to psychotherapy. Therapists were also expected to have had previous experience or prior training with sand tray therapy in a clinical setting. This was important for standardizing the application of techniques and interventions employed in the study. Finally, a total of six psychologists participated in the study, all of whom took part in a theoretical and practical training course on standardizing criteria related to the application and engagement with sand tray therapy.

It is relevant to note that the present study was an investigation carried out in the context of a Master of Clinical Psychology Program at the University of Chile ( Tornero, 2014). Thus, the ethical aspects of this research, along with other aspects, was fully assessed, reviewed, and approved by a specialized review committee at this Program, which uses guidelines of the Ethics Committee for the Investigation in Social Sciences and Humanities of the University of Chile.

Techniques

One of the main methods for collecting qualitative data was observation. This involves the detailed and systematic description of behaviors, artifacts, and events in the social setting under study ( Marshall and Rossman, 1989; Banister et al., 2004) in order to record both verbal and non-verbal behaviors of the subject in his or her specific context ( Banister et al., 2004). Observation, when paired with play therapy, provides insight into this phenomenon because it looks specifically at narrative and behavioral components of creative play. This is consistent with the key objectives of the present study.

Observation is beneficial in cases where subjects have difficulty expressing themselves verbally and emotionally, thereby allowing researchers to access a variety of topics, unlike other techniques ( Rodríguez et al., 1999). It is a minimally invasive method of study for this specific sample population, which requires an approach that is attentive to the psychological impact of sexual assault and protects the psychosocial well-being of participants.

Moreover, this technique draws on recording methods that help to structure and guide the process and specify the content and length of time under observation ( Banister et al., 2004). In the present study, observation was structured using two primary methods: video recordings and an observation rubric or assessment.

Prior to beginning, a rubric was developed in order to provide a framework with which to observe and evaluate behaviors, content of the activity and the therapeutic relationship. A theoretical review of the literature on sand tray therapy was conducted and relevant aspects of the activity and the relationship between therapist and patient were identified and systematized in the rubric. Behaviors and content of sandplay served as a primary focus for understanding the various activities and narratives developed during the activity. With regards to the therapeutic relationship, verbal and non-verbal interactions, as well as displays of emotion and exchanges between patient and therapist, were considered. This was a way to essentially grasp the relational context within which sandplay was developed, providing an additional perspective in order to advance understanding of this therapeutic tool. Within each of these three aspects (content, behavior, and relationship), more precise aspects of observation were identified. Nonetheless, for the purpose of this article, only behaviors and content of sandplay are explored.

It is important to note that the observation rubric was reviewed by a professional psychologist specialized in psychotherapy with child victims of sexual abuse, and all suggestions were incorporated. Similarly, the rubric was applied to a pilot case independent of this study, allowing researchers to make changes prior to implementation. This rubric has the objective of guiding observation (for example, to observe use of sand, story development, etc.) and not to code behaviors.

In the second phase of study, therapeutic sessions for seven children receiving treatment at CAVAS were videotaped. Video recordings are essential for analyzing the actions and interactions of participants, and they allow researchers to observe a situation more than once ( Secrist et al., 2002). Moreover, a photo digital camera was used to obtain a visual image of the sand tray and the final product. Images are not analyzed in the present study, however, they are used as an example.

Video Recordings were taken at three different points in time during the psychotherapeutic process: in the beginning, after 3 months of treatment and finally, after 6 months of treatment. This allowed for a span of six to nine regular sessions between each activity, which complied with long-term treatment goals while also minimizing the number of sessions between recordings. The timeline was implemented at the start of treatment, as clinical manifestations of the activity in the beginning stages of treatment were shown to provide key information on the progression and psycho-affective state of each child. At the same time, the activity was recorded during the initial session and in two other points of treatment in order to gauge the activity's progression (see Table 2).

It should be noted that during the research process, some cases withdrawn from the study. As a result, there are seven recordings from the first phase, seven from the second and five from the third and final phase.

Recordings were scheduled together with the therapist, informing to the child and legal guardians of this prior to the session. Practice recordings were performed in order to ensure proper positioning of the camera without interfering with the session. In between recordings, participant's progress (attendance and general emotional state) was monitored by the therapist as to determine the best time to schedule a future video recording of the sandplay session. In this way, the researcher was able to access relevant information about the therapeutic process and the child's own history, and to gain a deeper understanding of the particular case.

Therapeutic sessions were approximately 50 min long, and the duration of the activity itself ranged anywhere from a fraction of the time allotted to the full session. Recordings were taken of the entire session, regardless of the time spent on the activity, in order to ensure the normal order of the psychotherapeutic session. The sand tray was photographed prior to disassembly. Finally, observations were made by researchers using recordings of therapeutic sessions, the transcription of the videos and the observation rubric. All steps of the process were repeated for each phase.

Analysis

Data gathered through observation was analyzed using qualitative content analysis, one research method concerned with subjective interpretation. This is important given the present study's focus on play as a form of expression among children. Content analysis is used for textual material produced by a number of data gathering methods, thereby allowing the researcher to access content of any communicative act. It also outlines a set of procedures for organizing both verbal and behavioral information ( Abela, 1998; Pérez Serrano, 1998).

Content analysis was employed using guidelines proposed by Strauss and Corbin (1990). This method involves selecting relevant parts of a text and identifying primary units of meaning which are related to phenomena under study. These units of meaning are then qualitatively coded and categorized using specific criteria (shared characteristics and meanings) in order to later develop an interpretive understanding of data, making comparisons of theoretical information while further developing the research question ( Strauss and Corbin, 1990; Hernández et al., 2006).

In the present study, videos and their transcriptions were observed using the rubric. Given the variety of data sources in terms of both digital and analog language, it was key to develop a form of qualitative coding which would allow the research to carry out a detailed analysis and consistently work with information in order to clarify observations. Coding was done identifying portions of the text, that were selected and grouped according to thematic criteria presented in the rubric (for example, identifying feelings in the play, which were of anger, fear, etc.). These were directly related to the objectives of the present study, and some were eventually designated as categories.

In the second stage, a cross-sectional analysis was carried out for each phase of sand tray therapy. Results led to the development of a conceptual map for interpreting content, and a document, or memo, was developed for each of the phases. In the third and final stage, and once the conceptual map was created for phase, characteristics of categories present in the transcriptions were examined and compared. Categories were evaluated and reformulated based on emerging meanings in order to identify similarities and differences between phases. It is important to note that two researchers were involved in reviewing recordings and defining categories, using intersubjectivity in order to verify observations and analysis, presenting generally, important similarities in the analysis. Thus, the triangulation of data analysis among researchers was a significant criteria of rigor in this study.

Results

Results are organized according to the behaviors and content of sandplay observed in psychotherapeutic sessions. In the first section of each content or behavior, commonly observed aspects which appear at different phases of treatment are presented. Differences between the three phases are then identified. Main results are shown in Tables 3, 4. Excerpts from video recordings as well as photographs of the sand tray help to illustrate aspects described in the categories of analysis and provide concrete examples of elements described in the paper, while respecting the confidentiality of all participants at all times.

Play Behavior

Use of Sand

Sand plays an important role in all three phases of treatment, particularly in the development of a story's setting. Four characteristic behaviors were observed among participants: shaping, pouring, burying or hiding, and digging.

Participants initially shape sand in order to even out the surface of the sand tray, which they can then use to construct elements resembling their natural environment or structures, such as mounds or hills. The act of pouring sand is primarily a sensory activity (especially in children with risk-taking behaviors), and registers different levels of intensity depending on whether sand is moved with force or lightly sprinkled. Participants may bury objects or parts of the body (hands or fingers) partially or completely only to later reveal them. Finally, digging in the sand allows participants to create small furrows in the sand with their hands or objects, which serve as waterways (lagoons, rivers, the ocean), hiding or storage places or spaces to bury fallen soldiers.

During the more advanced phases of treatment, changes in behavior include prolonged contact with objects, which grows in intensity when participants expresses sadness over one aspect of game. This may manifest, for example, in an altercation between two people within the game who threaten or hurt each other or exhibit distress.

Categories Employed in the Activity

In order to create their own worlds out of sand, participants drew on human miniatures, fantasy characters and animals of different sizes and species with varied identities, abilities, and duties. Moreover, one important observation was the repeated use of certain categories in all three phases of treatment.

Humans employed in the activity were often family members (grandparents, men, women, teenagers, and young children), public servants (police) and service members (soldiers, warriors, or fighters). Fantasy characters were mostly male and rarely female. While heterogeneous in form, fantasy characters generally possessed special powers and were engaged in fighting. In particular, superheroes and magicians had a dominating presence and were able to exercise control over others.

With regards to the use of animals, participants employed both wild and domestic creatures in families, with each individual carrying out a particular function. From the second phase onward, many participants began to employ reptiles, particularly snakes-a threatening and dangerous element of the game. In the same vein, the incorporation of mythological creatures such as dragons, which play a prominent role in participants' stories, is suggestive as they represent both power and evil.

Characteristics of the Activity

Generally, throughout the treatment process, participants developed a symbolic game involving complex story lines that integrate aspects of reality and fantasy. Here, there are two primary modes of playing. The first involves selecting and arranging figures within the sand tray until a scene is completed. These figures remain in a fixed position throughout the game (see Figure 1).

The second mode involves movement or action, whereby the development of a story line is coupled with movements. Here, scenes are active and accompanied by speech, emotional responses, and sounds (see Figure 2).

In the initial phase of treatment, participants demonstrated stagnant play, whereby objects are arranged in a static manner despite changes in the story. This contrasts with the later stages of treatment, which were dominated by dynamic play, whereby miniatures and their respective personalities interact with each other and move in different directions, even extending beyond the limits of the sand tray with the development of the story.

Use of Time

Participants dedicated a majority of their time to constructing physical aspects of the play world and then spent the remaining time developing a storyline. These moments were clearly demarcated and communicated to the therapists. In addition, the presence of delays or interruptions is one important aspect of sandplay and was a central component observed among participants in this study. This is associated with a number of interrelated factors, such as content of the game and moments of introspection in response to therapeutic interventions.

Interruptions during play were common and particularly recurrent in the first two phases of treatment, while in the third phase, interruptions were more sporadic. The following excerpt shows the relationship between a desire to pause the game and one's own biological functions. Here, the child expresses her need to use the restroom and physically remove herself from the space. This may be related to emerging feelings of anxiety based on the progression of the game: The child turns toward the box, searching for new objects and says: N: "I have to go to the bathroom" -using a quiet voice (V-V1).

Composition

With regards to the composition of the sand tray, participants organized their worlds in two ways: first, developing meaningful and consistent scenarios where miniatures and other elements in the sand tray are directly implicated in the child's story and second, progressively creating a scenario that becomes more chaotic, disorganized and filled with toys. In the second case, stories began to lose their logical sequence, making them difficult to understand. This is shown by the following excerpt, or observation of this type of disorganization:

T: "Ok, what is the story of this world you've created?" N: "it has to do with, um, with a birthday" N: "both of their birthdays" - she takes up the princess and moves its closer to the prince, then turns to face the sand tray N: "Ah!" - she says, taking the duck out of the sand and quickly placing it on the edge of the sandbox, which represents the ocean - N: "the duck was leaving, I don't know" (W-V3).

In contrast, phase three of treatment is generally marked by more composed scenarios and coherent and meaningful worlds.

Content

Emerging Topics

Among the many topics that emerged during sandplay, violence served as a key organizing theme. Here, content related to experiences of victimization referred to both individuals and groups of people who act in ways that cause physical, psychological, and social harm. Violence in its various forms serves as a guide for the stories that participants develop throughout the course of treatment, whether it be widespread or an individual act that threatens the welfare of others.

During these scenes of aggression, the position of victim and perpetrator are clearly defined, sometimes shifting as the child's story develops. The perpetrator appears as a powerful and all-knowing figure who uses a variety of strategies in order to subdue the victim, using trust as a manipulation tactic, as well as physical harm, deceit, and persecution. The victim, however, suffers from physical harm by others, feeling defenseless and fearful as a result.

With regards to the wide range of negative interactions observed during sandplay, participants referred to three specific types of asymmetrical relationships: aggressive, abuse, and degrading. These relationships are interrelated and marked by an attack on part of the perpetrator, who employs both verbal and physical violence such as killing, hitting, and biting. This is demonstrated in Figure 3, where one participant develops a scenario in which an aggressor (characterized as a spider) kills a man by the venom of its bite.

During play sessions, participants' stories often allude to serious offenses toward female figures or between male figures and others who are typically the most vulnerable due to their size, gender (men-women), stage of development (children-adults) and category (animals-humans). For example, the following excerpt provides insight into the aggressive interaction between a father and his daughter, involving both physical and psychological violence: N: "And she started to cry" T: "mmm" N: "honey, don't cry" -sound of hitting N: "don't cry" - another hit - N: "don't cry, he was hitting her" T: "And why?" N: "because he didn't want her to cry (...) you're stupid" - sounds of fighting (F-V2).

The third phase of treatment shows marked changes in the ways in which violence is presented, mainly the shift from widespread violence to particular violent interactions or behaviors. In some cases, miniatures that were previously used to attack or defend against others do not engage in violence. In addition, stories feature more positive interactions involving collaboration, care and safety. These are often intended to protect characters from violence or to provide support to characters that have been hurt.

Additional emerging themes in participants' stories include threatening environments (hostile and dangerous surroundings), safety measures (to defend against threats or danger), social control (authority and public order), transformation (characters that shift from bad to good or that die and are reborn), family (dynamics and social roles) and nourishment (feeling full or hungry).

Character Identity

In general, throughout all phases of treatment, participants' stories involve plot lines where evil and good are central to identifying characters in the game. On the one hand, "good" individuals are characterized by their ability to protect and provide aid to others in the face of aggressors or dangerous situations. For example, a policeman reports and imprisons those who commit crimes. On the other hand, "bad" individuals are identified by their unlawful behaviors and violent actions toward others, such as physical attacks, theft, destruction of property and harassment.

Environmental Conditions and Personal Needs

Environmental conditions present in the participants' stories are typically dangerous and hostile, and involve various forms of threat and aggression on part of animals, humans, and natural disasters. In particular, tornados and tsunamis appear to create chaos and destruction, resulting in death and material losses and negatively impacting the community. The following excerpt provides an example of the destruction and fatalities caused by a natural disaster: N: "I am searching for survivors!" T: Survivors from what? "N: The tsunami" T: Ahh N: Instead of water there was only sand and all the sand swelled up" T: And the monkeys that were there (...) N: "buried" (V-V3).

In the third phase of treatment, stories draw on environmental conditions that while still threatening and harmful, are noticeably more organized and less destructive than in previous phases. In addition, there is the presence of safe zones, where characters may take shelter or access personal resources that allow them to continue on with their life.

With regards to personal needs, children refer to a lack of protection and care in their stories and draw on feelings of insecurity in the wake of environmental disaster. Here, individuals within their immediate circle (family or friends), as well as law enforcement, play an important role. Moreover, during the third phase of treatment, children's stories involve characters whose needs are met either by themselves or by others. For example, a character's need for protection is met with a safe space to stay, or a character is rescued from danger.

Feelings and Emotional Atmosphere

Participants' stories developed through sandplay at different stages of the therapeutic process are dominated by feelings of fear. Here, characters experience fear when they come into contact with external, hurtful events that are out of their control. As a result, the characters develop a number of psycho-affective and physical responses which vary, even including loss of consciousness and fainting:

N: "she got scared because a girl was walking by with her grandmother" T: "and what happened with the girl and her grandmother?" N: "they fainted" T: they fainted! N: "yes, because the car drove by really fast" T: "mmm, so they got scared." N: "Yes" (I-V2).

Furthermore, feelings that emerge while playing include anger, confusion, sadness, self-reproach, shame, loneliness, hopelessness, and anxiety, all of which refer to catastrophic thinking. Physical feelings of illness and pain related to bodily injury are also present. With the progression of therapeutic treatment, participants' stories involve more circumscribed, positive feelings associated with particular interactions, most notably affection, happiness and trust, which are grounded by an emotional connection to their environment.

In terms of the consequences of sexual assault, or traumagenic dynamics articulated by Finkelhor and Browne (1985), feelings of defenselessness and fear are present in participants' stories. These are often associated with a lack of control over harmful external events. In some cases, characters in the story struggle to remain safe and protected. Despite their search to find a place to hide, threats from their immediate environment are overwhelming: T: "some are trying to steal, others want to raze the building" N: Over there, the girls are hiding (...) N: "There are bad people everywhere" (V-V2).

On the one hand, betrayal appears as a theme in the first and second phases of treatment. Participants' stories speak to a feeling of mistrust between individuals, which is characterized by low credibility, hostility and aggression and which acts as survival mechanisms (fight or flight) in their interactions.

On the other hand, traumatic sexualization is observed in phases two and three of treatment in some participants' stories. This involves an eroticized interpersonal relationship between figures of the same or opposite sex. Some children who suffered from sexual assault at the hands of someone in their immediate family acted out abusive and humiliating moments between characters. In these cases, individuals were treated as commodities or objects to be exchanged and were seduced (particularly through gift-giving) by another individual. This is reflected in the following excerpt:

N: "I'll give you my little duck from ule if you dance with me" T: (laughs) "but you already told him that you would go to the dance with him" N: (laughs) "I'll give you, I'll give you to my girl cousin" T: "How are you going to give me to your cousin?" N: "I'll give you to her" T: "You can't give me to another person" N: "I'll give you to, I'll give you to my boy cousin" (W-V2).

In phase one, stigmatization is present only in the cases of children who have suffered from sexual assault committed by individuals outside of the family (acquaintances). Throughout the course of therapy, however, an increasing number of participants (the majority of children) allude to stigma in their stories in phases two and three. Contents of the play session include characters that are isolated and have feelings of inadequacy, shame, and social exclusion. For example, one child says N: " it feels bad because it's different from all the other animals" (M-V1).

Story Development

In the majority of cases, participants create a fantasy world with atypical and eccentric features. Accompanying stories are often ambiguous and incomplete, ultimately lacking an end or a final close. For example, Figure 4 illustrates one imaginative turn in the story where a flying child appears, without any relation to the prior storyline.

In phase three of treatment, changes in story development were positive in most of the participants: threats were taken under control and protagonists of the stories were able to find a safe space. At the same time, the development of support networks among characters signaled a shift in the ways in which characters behaved. Originally faced with social isolation, characters received help by others in order to move elsewhere or reach their own goals.

Conclusion

The present study explores the topic of creative play in therapy with child victims of sexual assault. In particular, it examines their therapeutic progress through the use of sandplay, or sand tray therapy, using a qualitative approach. These allows us to explore how children narrate and rewrite their lived experiences and how therapists serve as co-participants in the process of metaphorical reconstruction ( Dale and Lyddon, 2000). Key findings show a common set of behaviors during play that are related to violence: characters involved in the game act in an aggressive manner, they require care and safety and act out imaginative endings to conflict. Moreover, there are marked differences in the different stages of treatment, showing a gradual progression toward the third stage, where the activity involved mobile play and the creation of meaningful worlds with more organized environments and an overall positive outcome.

Results are consistent with international studies on the subject ( Cunningham and Macfarlane, 1996; Zinni, 1997; Homeyer and Landreth, 1998). Specifically, the use of digging or hiding objects while playing with sand has been widely observed among children who have suffered from sexual abuse, which serves as a metaphorical representation of the secrecy surrounding such experiences ( Cunningham and Macfarlane, 1996; Homeyer and Landreth, 1998). Nevertheless, it is important to analyze the specific meanings assigned by each child.

Creative materials employed during sandplay include people, fantasy figures and animals, all of which have been described by other authors during the use of therapy with child victims of sexual assault, specifically wild and domesticated animals, boyfriends, magicians, and superheroes ( Cunningham and Macfarlane, 1996). In the present study, participants predominantly referred to male figures in their games, which may refer to an association between masculinity and authority or power. This is one aspect that may be explored in future studies.

One of the most relevant miniatures employed during the activity is the snake, which was progressively incorporated in child's narratives over the course of treatment. This has been detailed in previous studies on the symbolism of animals in therapeutic treatment of child victims of sexual assault ( Cunningham and Macfarlane, 1996). During play sessions, snakes carry the connotation of causing harm and generating fear, and they are incorporated and taken away throughout the game. From an analytical perspective, the snake may be a phallic symbol over which the individual assumes control ( Bettelheim, 2010). On this basis, and considering the presence of the snake as a prominent character in the third phase of therapeutic treatment under study, we may speculate that children begin to symbolically address sexualized aspects and feelings associated with experiences of abuse. Here, disassociated memories may emerge through metaphors employed during play once the child feels that the therapeutic space is safe and contained ( Colombo and Beigbeder, 2005).

The composition of the game, which gradually becomes less chaotic over time, is similar to other experiences in past research on the presence of disorganization in sandplay with victims of sexual assault ( Zinni, 1997). In these cases, the development of chaotic worlds reveals distortions in how children perceive their reality during an emotional crisis caused by a traumatic experience - a topic that would benefit from further analysis ( Sjolund and Schaefer, 1994). In the present study, it is important to note that the composition of sandplay becomes more organized as treatment progresses.

Additional behaviors present during sandplay include sustained contact with the sand, particularly during the advanced phases of treatment. When children become distressed, handling sand may serve as a control mechanism for their emotions as they act out conflicts in the game. Many authors have regarded sandplay as a way to provide children with a sensorial experience that has therapeutic benefits by promoting relief and relaxation ( Oaklander, 2001; Gil, 2006). Results of the present study as well as past research may speak about the important role that sand plays in the therapeutic process of children who have suffered from sexual assault. Sand provides them with a contrasting tactile experience where they may reconnect with their own body and experience positive and pleasurable sensations that promote physical and psychological wellbeing. Moreover, this activity allows children to freely build and destroy their own creations, providing them with a sense of control that was taken away from them as a result of sexual abuse ( Gil, 2006). Finally, the therapist may serve as both an observer and supportive figure, guiding the child in his or her own search for meaning.

With regards to game or play content, the topic of violence plays a central role in participants' stories. This has been also shown by previous studies ( Zinni, 1997; Herane, 2005; Sandoval, 2005). Moreover, these findings are consistent with other studies using projective techniques, specifically Rorschach, which suggest that violence plays a central role for sexual abuse victims, affecting their inner world ( Armstrong and Loewenstein, 1990; Kamphuis et al., 2008; Scimeca et al., 2015). These studies show that victims of sexual abuse tend to experience intrusion of traumatic memories into consciousness, as well as a negative perception of the world. They also tend to show a more disorganized perception of causality in the understanding of human relationships ( Armstrong and Loewenstein, 1990; Kamphuis et al., 2008; Scimeca et al., 2015). Thus, it is possible to think that both, sandplay and projective techniques for personality assessment, share the common characteristic of allowing individuals to freely reproduce their inner world.

Similarly, the worlds that children create during sandplay invoke both fear and distress; the emotional atmosphere is reflected in content of the game, which reveals a traumagenic dynamic of defenselessness associated with experiences of sexual abuse ( Finkelhor and Browne, 1985). As a result, children draw on the need for protection and care in their stories, and authority figures such as law enforcement (police) play a vital role, which is consistent with other research studies ( Homeyer and Landreth, 1998).

Moreover, when taken together, results of the present study on behaviors and content are consistent with those presented in the literature on post-traumatic play-a ludic form of therapy observed with child victims of sexual assault ( Terr, 1990; Cunningham and Macfarlane, 1996; Gil, 2006, among others). In this way, it is clear that traumatic events associated with violence are reproduced during treatment in terms of the level of engagement with certain topics and play objects, as well as stories associated with feelings of risk and threat, or more generally, an emotional state of fear and defenselessness. Unpleasant emotions experienced during the game, such as anxiety, are accompanied by analog movements such as delays, silences, and interruptions. These findings are consistent with clinical descriptions of post-traumatic play, and they underscore the value of monitoring and providing follow-up to ludic processes in a rigorous and systematic way ( Terr, 1990) in order to promote approaches that respond to the changing needs of children.

At the same time, differences across categories in all three stages of the process provide insight into the evolution or progression of post-traumatic play over the course of psychotherapeutic treatment for child victims of sexual assault. Content of sandplay reveals a shift in terms of violence; in later phases, worlds developed during sandplay feature safer and more organized environments, as well as individuals who have the capacity to confront threats in their environment and arrive to a positive conclusion. Behavioral aspects of the game include mobile play and the development of meaningful and coherent worlds. Fewer disruptions demonstrate a more integrated and less fragmented game.

These results are consistent with previous studies by scholars such as Gil (2006), who argue that the transition from stagnant to dynamic play is representative of a child's ability to slowly integrate emotions and thoughts affiliated with a traumatic experience and assign meaning to and assimilate the experience. While conflict and unpleasant emotions may still be present despite these transformations, the progression of post-traumatic play is clear. The game becomes more dynamic and encourages the child to approach the topic in a symbolic manner, empowering and providing him or her with an emotional release.

In general, while children may experience the pain and consequences of sexual abuse in different ways, study results show that there are certain common ludic expressions among child victims, which are demonstrated through sandplay at various points in time during psychotherapy. These expressions are consistent with findings from previous studies, and are representative of the primary challenges faced by this population. In addition, there are certain characteristics of sandplay which evolve over the course of psychotherapy, and which demonstrate key changes in play that may support children in redefining and assigning new meaning to their experiences.

The present study contributes to the literature by providing new insights on the application of sandplay as a therapeutic tool for child victims of sexual assault, opening up new lines of work on the process of overcoming abuse. In this sense, it is a major contribution to research which foregrounds children's perspectives and means of expression.

Findings of the present study reaffirm the value of therapeutic play in cases of sexual abuse, which can provide rich insight into the psychological resources of children that help to facilitate a positive emotional change. In this way, it may help the therapist to delve into the meanings that children develop and assign to their experiences and monitor their engagement with symbolic elaboration. Since the present study follows participants during 6 months of treatment and not necessarily to completion, future studies are needed to explore the evolution of creative play in terms of the entire psychotherapeutic process. Additional studies may benefit from a comparative analysis of the characteristics of sandplay in both the initial and concluding phases of treatment.

In methodological terms, the present study employs a longitudinal research approach to therapeutic treatment. Here, the researcher had direct access to medical records. It presents a focus the evolution of creative play and the value of exploring changes in play throughout the course of treatment, which is a research design that may be explored in more detail in future study. By conducting a general analysis of heterogeneous cases, researchers were unable to explore the particularities of each case in depth, which is considered to be a limitation of the present study. In addition, employing a conceptual framework such as sexual trauma may present a bias when interpreting results, thereby limiting understanding of different traumatic experiences or developmental challenges made visible through sandplay. Here, further study is needed. Moreover, the utilization of cameras in the therapeutic space was met with mixed reactions. It would valuable to further analyze the use of recordings as both a research tool and a therapeutic technique. Future research may draw on mixed methodologies (including verbal reporting) to complement results obtained by sandplay, and also evaluate other ludic techniques. It is also possible to explore this phenomenon at different developmental stages with children who have experienced other types of abuse and emotional distress in order to identify similarities and differences that provide greater insight into the phenomenon of creative play.

With regards to the practical implications of study results in clinical practice, sand tray therapy emerges as a useful tool for the treatment of child victims of sexual assault. In this study, it promotes an in-depth analysis of cases over an extended period of time, thereby providing clinicians with a tool that could give insight into how children resignify their experiences and transform and overcome sexual abuse. Finally, we may hypothesize that the creative potential of sand tray therapy is reached once a therapeutic bond is established - a hypothesis that should be addressed in future studies.

Author Contributions

The work was developed by MT and supervised by CC. CC also contributed to the process of analysis and triangulation of information and the article writing.

Funding

The authors acknowledge that the present study was partially funded by CONICYT Project Fondecyt N°11140049.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Footnotes

In the excepts presented here, "N" is used to identify the child or participant's response, while "T" is used for the therapist's response. Hyphens signal observations or clarifications to the text. Finally, at the end of the excerpt, a series of letters is used to identify the participant, which corresponds to the participants identification presented in Table 2. Videos are marked "V" and are followed by a number (1, 2, and 3) depending on the phase of treatment.

References

# data[].attributes.attachment_link.title
Change during Psychotherapy through Sand Play Tray in Children That Have Been Sexually Abused

# data[].attributes.attachment_link.description
This paper presents the results of a qualitative study on the use of sandplay, or sand tray therapy, in the psychotherapeutic process of children who have been sexually abused. A longitudinal study was carried out with seven participants between the ages of 7 and 10 years old.

# data[].attributes.attachment_link.readable_text
Judan Tan , Huaying Yin , Tuo Meng , Xiaoli Guo ,

Department of child health in Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
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Department of child health in Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
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Corresponding Author

Department of child health in Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
Correspondence
Huaying Yin, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Department of Child Healthcare, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China.

Email: sarah6524@126.com
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Department of child health in Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Children's Hospital of Chongqing Medical University, Chongqing, P.R. China
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First published:

Funding information:
The authors disclosed receipt of the following financial support for the research, authorship and publication of this article: this work was supported by the Demonstration of Technology Innovation and Application of Chongqing Science and Technology Commission (general project of social livelihood), China. Project No.: cstc2018jscx-msybx0065

[Correction added on 8 September 2021 after first online publication: some values inside the text and group names in table 6 have been updated in this version]

Abstract

Purpose

Children with chronic diseases exhibit a higher incidence of emotional-behavioural problems. Though sandplay therapy is a universally recognized psychological treatment method, experimental evidence for this form of therapy is lacking. Our aims were to examine the effectiveness of sandplay therapy in reducing emotional and behavioural problems in school-age children with chronic diseases as well as anxiety and depression in their caregivers.

Design and methods

A total of 60 children and their caregivers were enrolled in the present study between January and October 2019. A randomized controlled trial was conducted at the Children's Hospital of Chongqing Medical University, China. Participants were divided into an intervention and a control group. Both groups received regular treatment, and the intervention group received additional sandplay therapy. Four behavioural rating scales were used to evaluate the differences between the two groups. The children's scores on the Child Behavior Checklist (CBCL), Eysenck Personality Questionnaire (EPQ), Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) before and after the intervention were compared using the Mann-Whitney test. The Wilcoxon signed rank test was also employed to compare the median results before and after treatment.

Results

The total scores for CBCL, anxiety and depression, withdrawal, and social behavioural problems for children in the intervention group were all lower than the corresponding scores for those in the control group ( p < .05). The EPQ scores for emotional stability and psychosis in the intervention group were both lower than those in the control group ( p < .05). The SAS and SDS scores for the caregivers of children in the intervention group were also lower than the corresponding scores for those in the control group ( p < .05).

Conclusion

Sandplay therapy can reduce anxiety, withdrawal, and social behavioural problems in school-age children with chronic diseases, as well as relieve anxiety and depression symptoms in their caregivers. Our study provided evidence for the clinical application of sandplay therapy and highlights the importance of offering and integrating psychological treatment in clinical nursing care.

1 INTRODUCTION

Children with chronic diseases have complex health conditions. Consequently, they exhibit a higher incidence of emotional-behavioural problems, which is four times greater than that among their physically healthy peers (Hysing et al., 2007). Children are still undergoing cognitive and psychological development and their immature coping strategies in response to adverse external stimuli (chronic pain, poor physical conditions, etc.) make them more prone to chronic diseases (Zeltzer et al., 2008). Though children do not necessarily develop psychological illnesses, they constantly grapple with emotional-behavioural problems (Douma et al., 2018). Delfos and Gempel divided emotional-behavioural problems into two categories: externalizing and internalizing problems. The former includes oppositional defiant disorder, conduct disorder and situational attention deficit disorder, while the latter refers to mood disorder, anxiety disorder and attention deficit disorder (Gimpel & Hollard, 2003; Martine, 2004).

Chronic diseases influence the emotional and behavioural expressions of children in many ways. Changes in normal bodily functions (physical limitations, long-term pain, etc.), the need to adapt to special diet restrictions and enduring the side effects of treatment or medication bring about negative emotions including worry, distress and anxiety (LeBovidge et al., 2003). Restrictions to participation in different activities, reduced social identity and a lack of normal peer interactions in daily life also result in a negative self-concept and greater self-consciousness in children. Such situations can make children feel ashamed about their physical defects, cause psychological behavioural problems (social withdrawal, aggression) (Blackman & Gurka, 2007), detrimentally affect treatment coordination and increase the risk of negative long-term health outcomes (Kongkaew et al., 2014). Chronic disease is also a stressor to family members, especially caregivers. Families of patients with chronic diseases face a heavier financial burden and more daily organizational problems (Sawin et al., 2003). For instance, isolation, immobilization, frequent hospitalization and restrictions of normal activities, which sometimes persist after the end of treatment, result in emotional disturbance in parents (Lemos et al., 2020; Schepers et al., 2018). In addition to their children's medical regimen, parents also worry about their children's adherence to treatment, long-term prognosis and current and future levels of independence (Mullins et al., 2007). Therefore, the psychological stresses experienced by parents can be roughly divided into two types: personal and parental. Personal stress refers to psychological stress including depression, anxiety and posttraumatic stress symptoms, while parental stress refers to an indirect emotional strain (frustration or guilt) stemming from the demands of parenthood (Deater-Deckard et al., 2015; Norberg & Boman, 2008). These stresses can last as long as 5-10 years after the completion of treatment and put parents, children and other caregivers at risk for adverse outcomes (Vrijmoet-Wiersma et al., 2010).

China has nearly two hundred million children with chronic diseases (Zheng & Zheng, 2015). Leukaemia and chronic kidney disease are two of the most common chronic diseases in China and share characteristics such as recurrent pain and restrictions in daily life activities. Sandplay is a useful adjunct for the mainly cognitive and behavioural techniques commonly used by school guidance counsellors. Several studies have examined the effects of sandplay on children with cerebral palsy (Wang et al., 2015) and on children with separation anxiety (Hamideh & Zohreh, 2015), but there is still insufficient research on the effectiveness of sandplay at reducing emotional-behavioural problems in children with chronic diseases in China. Due to the shortage of paediatric psychologists, filling the gap with nursing practitioners has been proposed (Schwartz et al., 2017). Therefore, integrating emotional and behavioural treatments into traditional nursing care is a priority.

In this study, we used the sandplay theory as a theoretical framework. Sandplay therapy is a psychological therapy method created by Dora Kalff, a Swiss analytical psychologist, in the 1950s. Kalff used Jung's analytical psychology as the foundation for sandplay therapy, borrowed Margaret Lowenfeld's "The world technique," and integrated them with Eastern thoughts and philosophies. In contrast to the prevailing interpretation of psychoanalysis at the time, Lowenfeld pioneered the idea that sandplay was a natural interest for children and correlated play with psychological development in children. Inspired by the concept, Kalff integrated the theory with Jung's analytical psychology. She retained the original methodological system, upgraded the miniature toys provided for the play session and named the new therapy "sandplay" (Chiesa, 2012). Half a century later, a standard sandplay therapy session requires an independent, quiet room with basic equipment including (1) a sandbox: a sandbox with a size of 57 × 72 × 7 centimetres with the bottom painted blue to reflect water or the sea; (2) sand: water should also be provided so that the children have a choice of both wet and dry sand (Chiesa, 2012); (3) miniature objects: the objects should be organized in categories including animals and plants, every-day and cartoon figures, buildings, military machineries, transportation and miscellaneous (Plotts et al., 2008).

As a form of play therapy, sandplay is an effective intervention for children. The main advantage of sandplay is the unconditional admissive environment created. During sandplay therapy, children can express their emotions freely using sand, water and miniature objects, which promotes nurse-child interactions. Richards et al. ( 2012) stated that school children can externalize their trauma due to the safe environment created in sandplay therapy, effectively reducing their social withdrawal level. Sandplay therapy requires little language skill and allows children to express themselves or respond nonverbally through sandplay creations. Lu et al. ( 2010) applied sandplay to school children with autism spectrum disorder. The results suggested that sandplay successfully increased the children's language expression levels, their participation in social activities and their symbolic, voluntary and creative play performance. Furthermore, sandplay therapy can help children construct an idealized world to express their demands and expectations for the future or reconstruct distressing experiences in the past to relieve their emotions. Mariefrance ( 2007) applied sandplay therapy to immigrant and refugee preschoolers and found that sandplay offered the children a chance to express sentiments derived from a combination of past and present experiences and helped them develop suitable coping strategies.

Sandplay is widely utilized by mental health workers and is especially suitable for paediatric nurses. Regardless of the therapists' orientation, sandplay therapy provides a special and progressively organized approach that helps children better engage in the therapeutic process (Hamideh & Zohreh, 2015).

With a growing number of children becoming more vulnerable to long-lasting physical health problems and emotional trauma across their lifetime, it has become more difficult for paediatric nurses to respond (Wise, 2007). Sandplay therapy is an effective technique that enables children to express their emotions, reveal traumas, and develop safe relationships and self-actualization. However, the efficacy of sandplay therapy in children with chronic diseases remains undetermined. Therefore, in the present study, we set up sandplay treatment rooms in the Nephrology and Hematology wards (each room was equipped with a set of standard sandplay equipment purchased from professional companies) to examine the clinical effectiveness of sandplay therapy in school-age children with chronic diseases who have emotional and behavioural problems.

2 METHOD

2.1 Design

A two-armed parallel randomized controlled trial was used to examine the effectiveness of sandplay therapy for children with chronic diseases. The caregivers of the children completed the Child Behavior Checklist (CBCL), the Zung Self-Rating Depression Scale (SDS), and the Zung Self-Rating Anxiety Scale (SAS) while the children completed the Eysenck Personality Questionnaire (EPQ) before and after the sandplay therapy (see Diagram 1).

A two-armed parallel randomized controlled trial was used to assess the effectiveness of sandplay therapy for children with chronic diseases between January and October 2019. The entire therapeutic procedure consisted of six sessions of sandplay therapy, performed 1-2 times a week for 60-90 min each, and the total treatment lasted about 2 months. Eligible children and their caregivers in both groups were instructed to complete the CBCL, EPQ, SAS, and SDS in a private room after providing consent. All questionnaires were completed before and after the sandplay therapy procedure. The follow-up diagram is presented in Diagram 2.

2.2 Setting

Our research was conducted at the Children's Hospital of Chongqing Medical University, China. The sandplay treatment rooms were set up in the Nephrology and Hematology wards, and we ensured the rooms were relatively independent, quiet, and sufficiently bright. Each room was equipped with a set of standard sandplay equipment purchased from professional companies. The size of the sand table was 57 × 72 × 7 cm. The interior and bottom of the table were both painted blue to simulate the colour of the sky and sea and to encourage the children to relax. Soft sand was added to the table. The miniatures used consisted of animals, flowers, every-day figures, religious figures, buildings, military machinery, vehicles, etc., totalling more than 2,000 pieces. Potted plants, tables, chairs and sofas were set up in the sandplay treatment rooms to create a safe, relaxing and warm treatment environment.

Sandplay therapists were required to have a Chinese National Grade III Psychological Consultant Certification and to undergo professional sandplay therapy training. After passing the subsequent assessment, the sandplay therapists conducted therapy procedures under the guidance of an experienced psychotherapist with regular supervision.

2.3 Participants

The participants were children receiving long-term treatment at the Children's Hospital of the Medical University and one of their main caregivers. According to the order of hospital admittance for children with chronic diseases, participants were recruited based on the following inclusion criteria: (1) children aged 6 to 12 with a diagnosis that met the criteria for leukaemia or chronic kidney disease; (2) a total score on the CBCL questionnaire that exceeded the Chinese norm; and (3) children and their caregivers were all Chinese speaking and able to complete the questionnaires. The exclusion criteria were as follows: (1) children and primary caregivers were unable to communicate well with the researchers; (2) the disease condition of the children was in a critical stage; and (3) refusal to participate in the study.

According to previous research (Maoqun et al., 2016), the sample size required to detect a Cohen's d effect size of 0.6 from sandplay therapy in the intervention and control groups was calculated. Twenty-five cases each were deemed sufficient to observe an effect of at least 80% power at a 5% level of significance, in consideration of an attrition rate of up to 15%. Thirty participants each were therefore enrolled in the intervention and control groups. The enrolled children and their caregivers were informed about the study and its purpose. Those who agreed to participate signed an informed consent form.

2.4 Randomization

After signing the informed consent form, the children eligible to undergo sandplay therapy were numbered by the order of enrolment in the study. The children randomly selected an opaque envelope containing a group identifier (intervention or control) prepared in advance by an independent statistician. The ratio of assignment to the intervention and control groups was 1:1.

2.5 Control group: Regular nursing care

Children in the control group received regular nursing care without sandplay therapy. Regular nursing care consisted of routine disease care and daily expressions of consolation and encouragement by the medical staff.

2.6 Intervention group: Sandplay therapy

The main theme and topic of each sandplay therapy session were set according to the sandplay model suggested by Margaret Lowenfeld (see Table 1), which follows a standard procedure and can be adjusted according to the therapy situation (Hamideh & Zohreh, 2015). To ensure the session was effective, only one child was admitted to the sandplay room at a time. Before the session began, the therapist led the child through a strict hand hygiene procedure and introduced the settings of the sandplay treatment room with a soft and gentle voice. After the child became familiar with the environment, the therapist guided the child to touch the sand and take five deep breaths to relax. The therapist particularly emphasized that the sandplay creation could be anything and that the child would not be judged. While the child engaged in sandplay, the therapist recorded the child's behaviour and the miniatures used. The therapist adopted a "silent witness" approach, accepted, appreciated and accompanied the child, and created a safe, tolerant and supportive atmosphere so that the child could devote themselves wholeheartedly to the process of making sandplay creations. After the treatment session, according to the psychological state of the child, the therapist asked the child to introduce their sandplay creations, communicated with the child, and guided them to appreciate and explore their inner world. After the sandplay therapy session, the therapist took pictures with the child's permission and saved the images as files, then guided the child to repeat the hand hygiene procedure.

Goals: Establishing emotional and friendly relationship with children and building trust in children

First

Goals: Simulating the environment of school and home, expressing interest in the two main environment

Second

Goals: Trying to reduce children's emotional and behaviour problems

Third

Goals: Proposing now pedagogical strategies and trying to playing a role in this process

Forth

Goals: Gradual recovery, enthusiasm or calm children's negative emotion or behaviour

Fifth

Goals: Disappearance of all symptoms of children's emotional and behaviour problems

Sixth

2.7 Primary outcome measures

2.7.1 The emotional-behavioural problems

The CBCL for ages 6-18 (CBCL/6-18) is widely used to assess emotional-behavioural problems in children and contains 113 items. The responses are rated with a three-point scale and parents or caregivers select the most appropriate rating (0 = never, 1 = sometimes, 2 = very often or always) based on their children's behaviours in the preceding 6 months. Higher scores indicate more emotional-behavioural problems. The questionnaire is broadly divided into two categories: introversion factors (depression, social withdrawal and poor communication) and extraversion factors (hyperactivity, aggression and disciplinary behaviour). These categories are more specifically divided into eight aspects: Anxiety/Depression, Somatic complaints, Attention problems, Rule-breaking behaviour, Aggressive behaviour, Withdrawal, Social problems and Thought problems. The upper limits for the Chinese norm are 40-42 for boys and 37-41 for girls. A CBCL score reductive ratio (rate of difference in scores before and after intervention) ≥25% is regarded as effective. The retesting reliability of the scale was reported to be 0.950, and the Cronbach's report for internal consistency was 0.93 (Zuoji, 2005).

The parental scale was used in this study.

2.7.2 The personality of the children

The EPQ, compiled by Eysenck H.J, a professor of psychology, is one of the most widely used personality questionnaires. In this study, the EPQ (Chinese version) revised by Yaoxian Gong was used. This version of the EPQ contains a total of 88 questions and the possible responses for all questions are "yes" or "no." The EPQ uses the factor analysis method to evaluate four main dimensions of personality: Neuroticism (N), Extraversion (E), Psychoticism (P) and Lie (L). The Chinese version has been confirmed to have adequate internal consistency for the four subscales (0.70-0.88) (Yaoxian, 1986).

2.7.3 Secondary outcome measures

The SDS and SAS are self-evaluation questionnaires used to assess anxiety and depression. Each contains 20 items and uses a four-point rating system (1 = none or seldom, 2 = sometimes, 3 = usually, 4 = always or most of the time). The total scores range from 20 to 80 and lower scores indicate a lower severity of anxiety/depression. The standard scores can be stratified into three levels: mild (53-62), moderate (63-72) and extreme (72 or higher). The Cronbach's α values for the Chinese versions of the SAS and SDS are 0.862 and 0.931, respectively, showing good reliability (Liu et al., 1995).

2.7.4 Sociodemographic characteristics

The social and demographic characteristics of the participants, including the sex and current age of the children, educational level of the caregivers and other important descriptors, were collected using a questionnaire created in-house in accordance with the research target.

2.7.5 Data collection and analysis

Essential disease-related data (initial diagnosis, disease duration, treatment procedure, etc.) were collected from the medical records of the children. Data were analysed by means of the Statistical Package for the Social Sciences software (version 25.0). Mean ± standard deviation was used to describe the average ages of the children, frequencies were used to present the sociodemographic characteristics, and median (p25, p75) was used for the statistical description of the assessment scores (CBCL, EPQ, SAS and SDS). The average ages of the children in the intervention and control groups were compared using the t test. The CBCL, EPQ, SAS and SDS scores before and after the intervention were compared with the Mann-Whitney test. The Wilcoxon signed rank test was also used to compare the median scores before and after the treatment. The children's gender, diagnosis, and illness duration were compared with the chi-squared test. A two-sided test significance level of p < .05 was used in all statistical analyses.

3 RESULTS

3.1 Sociodemographic and clinical characteristics of participants

A total of 62 children and their caregivers were enrolled in the present study between January and October 2019. Two children failed to complete the entire sandplay therapy procedure because they transferred to other hospitals and the rest completed the full procedure. Therefore, the data for a total of 60 children and their caregivers were analysed, with 30 participants in each group. There were 15 boys and 15 girls in the intervention group and 16 boys and 14 girls in the control group. The ages of the children in each group ranged from 6 to 12 years, with mean ages of 9.30 ( SD 1.58) and 8.97 ( SD 1.33), respectively, and no statistical difference ( t = 0.886, p = .380). The sex, type of disease and duration of the illness for the children were not statistically significant either (χ ² = 0.067, p = .796; χ ² = 0.069, p = .793; χ ² = 2.584, p = .108). Other data were comparable and are presented in Tables 2 and 3.

Group

Gender

Age

Diagnosis

Duration of diagnosis

CBCL (p25-p75)

Male

Female

(x ± S)

Chronic kidney disease

Leukaemia

Within one year

One year or over

Intervention

15

15

9.30 ± 1.58

12

18

22

8

65 (57.25-70)

Control

16

14

8.97 ± 1.33

13

17

16

14

59.5 (52.75-65.25)

Test statistics

χ ² = 0.067

t = 0.886

χ ² = 0.069

χ ² = 2.584

Z = 1.415

p values

.796

.380

.793

.108

.140

Note

Analysis using t test, Mann-Whitney test and chi-square test.

Abbreviation: CBCL, child behavior checklist.

Characteristics

Control (n = 30)

Intervention (n = 30)

χ²

p

Sex of the child

Accompanied by

Highest education attainment of the accompanied family

Disease of the child

First diagnose

Duration of illness

3.2 Changes in CBCL scores

The effective rate was 53% according to the CBCL score reductive ratio. No significant differences in the total and subscales scores were noted between the control and intervention groups before the intervention. In contrast, significant differences between the scores before and after the sandplay therapy in the control and intervention groups were found in the total scores ( z = 6.320, p = .00), anxiety ( z = 6.016, p = .00), attention problems ( z = 3.571, p = .00), aggressive behavior ( z = 6.138, p = .00), withdrawal ( z = 4.680, p = .00) and social problems ( z = 4.594, p = .00). The control group showed no significant difference in the total and subscales scores after treatment. However, there were statistically significant difference in the total scores ( z = 4.784, p = .00), anxiety ( z = 4.633, p = .00), attention problems ( z = 3.830, p = .00), aggressive behaviour ( z = 4.797, p = .00), withdrawal ( z = 4.638, p = .00) and social problems ( z = 4.555, p = .00) in the intervention group (see Table 4).

[Correction added on 5 October 2021 after first online publication: all z value in the preceding paragraph have been updated in this version]

Group

Time

Total score, Median (IQR)

Anxious, Median (IQR)

Somatic complains, Median (IQR)

Attention problems, Median (IQR)

Rule-breaking behaviour, Median (IQR)

Aggressive behaviour, Median (IQR)

Withdrawn, Median (IQR)

Social problems, Median (IQR)

Thought problems, Median (IQR)

p

.000**

.000**

.196

.341

.110

.053

.000**

.003**

.377

Note

Analysis using Mann-Whitney test and Wilcoxon signed rank test.

Abbreviations: CBCL, child behavior checklist; IQR, interquartile range (25th centile-75th centile).

**:P < 0.05

3.3 Changes in EPQ scores

The distribution of changes in personality showed in the N scales and P scales (see Table 5). There were significant differences in the N ( z = 3.952, p = .000) and P ( z = 3.829, p = .000) scales in the intervention group as well as between the control and intervention groups before and after the sandplay therapy ( z = 3.790, p = .000; z = 2.275, p = .000). In the E scale, there was a statistical difference between the two groups before and after sandplay therapy ( z = 2.391, p = .017; z = 2.189, p = .029) (see Table 6). The total distribution of changes in personality.

[Correction added on 5 October 2021 after first online publication: all z value in the preceding paragraph have been updated in this version]

Before (N = 60)

After (N = 60)

Note

Analysis using McNemar test.

Group

Time

EPQ-E, Median (IQR)

EPQ-N, Median (IQR)

EPQ-P, Median (IQR)

EPQ-L, Median (IQR)

p

.017*

.686

.454

.632

p

.029*

.000**

.000**

.133

Note

Analysis using Mann-Whitney test and Wilcoxon signed rank test.

Abbreviations: E, extraversion; EPQ, Eysenck personality questionnaire; IQR, interquartile range (25th centile-75th centile); L, lie; N, neuroticism; P, psychoticism.

**:P < 0.05

3.4 SAS and SDS scores of the caregivers of children with chronic disease

The SAS and SDS scores of the caregivers of children in the intervention group showed statistically significant differences before and after the sandplay therapy ( z = 4.270, p = .001; z = 4.680, p = .000). The comparison of the two groups after the intervention was also statistically significant ( z = 2.847, p = .004; z = 3.580, p = .000) (see Table 7).

[Correction added on 5 October 2021 after first online publication: value for z and p in the preceding paragraph have been updated to correspond with Table 7]

Group

Time

SAS, Median (IQR)

SDS, Median (IQR)

Z (two groups before intervention)

0.910

0.710

p

.363

.478

Z (two groups after intervention)

2.847

3.580

p

.004**

.000**

Z (two groups changes before and after)

−3.543

−5.109

p

<.001

<.001

Note

Analysis using Mann-Whitney test and Wilcoxon signed rank test.

Abbreviations: IQR, interquartile range (25th centile-75th centile); SAS, self-rating anxiety scale; SD, standard deviation; SDS, self-rating depression scale.

**:P < 0.05

4 DISCUSSION

A previous study examined the effects of sandplay therapy on children with emotional-behavioural problems (Richards et al., 2012). Our study aimed to expand the scope of application for this form of therapy. Overall, children with chronic diseases who received sandplay therapy exhibited significantly fewer emotional-behavioural problems than those who did not.

Limited mobility, chronic pain and special restrictions (food, clothing, housing and transportation) all affect children with chronic diseases to varying degrees. Previous studies have shown that these children had 1.5 times more behavioural problems than normal children, including antisocial behavioural, hyperactivity and social withdrawal/peer conflict (Blackwell et al., 2019; Wise, 2007). Li et al. ( 2008) investigated emotional problems in 203 children aged 8 to 16 with chronic diseases and found that 43.8% had anxiety, 30.0% had depression, and 26.1% had both anxiety and depression. However, methods to reduce emotional-behavioural problems in children with chronic diseases in China have received insufficient attention.

4.1 Effects of sandplay therapy on emotional-behaviour problems

The positive results in the present study support the effectiveness of sandplay therapy as the scores for anxiety, withdrawal and social problems in the intervention group were lower after sandplay therapy. Analysis of children's actions during sandplay revealed that the sandplay process can be roughly divided into two stages: the first stage consisted of trauma presentation and conflict intensification, while the second stage consisted of transformation and healing. As the intervention progressed, the traumatic elements gradually decreased and the themes of healing and hope became more apparent.

At the beginning of sandplay, the children often exhibited obvious resistance, impulsiveness and restlessness because they had a limited understanding of the procedure. The safe and empathic environment created by the therapist helped reduce the children's resistance to the medical staff, loosen their self-restraint and encourage them to gradually express their inner world. Through guidance, the children began to express their traumatic experiences and negative emotions by selecting miniatures, creating a sand world and symbolic narrations. As the sandplay progressed, the children manifested internal conflict and questioning of their abilities by destroying and rebuilding the scene, destroying old creations and recreating them. A possible explanation for this behaviour is that through the three-dimensional environment for expression provided by sand in the visual and kinesthetic channels (including movement and touch), the children could gradually release themselves from a state of avoidance and resistance, transforming from the role of a victim in previous experiences to the creator of new experiences and gaining more initiative. During this stage, the therapist employed positive transference therapy to reduce inappropriate emotional regulation methods (aggression or self-injury) as well as promote and consolidate positive behaviours to help the children enter the next transformation stage.

In the second stage, as the duration of the disease increased, low social desire and negative emotions caused by limited activities and pain from the disease gradually emerged (Harding et al., 2002). Anxiety and depression cause withdrawal and avoidance during medical treatment. Traumatic themes in the sandplay creations decreased and a hesitation in self-cognition became apparent as well as the desire for school activities, family and a normal social life. Treatment at this stage was focussed on active communication and interactions between the therapist and child. The therapist adopted an inclusive attitude and provided affirmations to help the child increase their emotional stability, strengthen their self-identity, balance the nurse-child interpersonal relationship and establish an appropriate level of self-awareness.

4.2 Effects of sandplay therapy on children's personality

School age is an important period for personality formation and psychological development in children. This period is also an important stage for children to develop their self-identity and a healthy personality (Lizhu, 2015). Though personality is comprised of a combination of psychological characteristics with certain tendencies and is relatively stable, it is influenced by heredity, age and environment (Berg et al., 2016). As a serious negative stimulus, chronic diseases strongly influence the formation and improvement of children's personalities.

Consistent with previous studies (Hovens et al., 2016; Jinxiang et al., 2018), the children's scores for emotional stability (N scale) and psychosis (P scale) in the Eysenck personality assessment significantly decreased after the intervention. A likely explanation is that by providing a safe, relaxed and unlimited protective environment, sandplay therapy can alleviate children's negative emotions, enabling them to adjust their emotions and reduce the frequency of strong reactions when faced with a serious stimulation (pain, activity limitation). In addition, the unconditional attention and positive feedback the children receive from the therapist and parents during sandplay therapy can increase prosocial behaviours, reduce their resistance to the external environment and benefit the process of socialization. Consequently, the children's mental quality scores decreased.

4.3 Effects of sandplay therapy on caregiver's emotional problems

The results of the present study showed that the anxiety and depression scores of the caregivers decreased after sandplay therapy. When parents are faced with long-term negative stimuli due to chronic diseases, they experience multiple stressors such as medical procedures, instability of family roles and lack of social support, often resulting in emotional overreactions, such as irritability, anxiety and depression (Cousino & Hazen, 2013; Haverman et al., 2013). These negative emotions not only affect the mental health of the parents, but also affect their social interactions, marital relationships, careers and other aspects of their lives. These situations usually trigger polarized responses such as overprotection or over-neglect due to difficulties balancing the two extremes. Overprotective parents may lead to low levels of dependence and self-efficacy in the children, while over-neglect may lead to low self-esteem and self-denial.

In the present study, two sessions of family sandplay therapy were conducted after individual therapy, which promoted the connection between the medical staff and the family and alleviated negative emotions in the caregivers. According to our clinical observations, family sandplay strengthened the communication between the caregivers and their children, which is conducive to improving family interactions and helping caregivers discover their children's potential abilities. It also helps the children feel more positive about the support and care they receive from their family, find an outlet to vent emotions, balance their inner world, and foster trust between the family and medical staff.

5 LIMITATIONS

One of the limitations of the current study was that children and their caregivers were recruited from one hospital; hence, the generalizability of the results may be limited. Additionally, the lack of blinding may be a primary source of bias. However, due to the nature of sandplay therapy, it is difficult to blind the children, caregivers and therapists. Despite knowing they are undergoing an intervention, children are unlikely to change their behaviours (Silva et al., 2017). To minimize the potential bias, we chose a series of objective questionnaires to evaluate the effectiveness of the sandplay therapy on children with emotional-behavioural problems, and the assessors who collected the data (the scores for questionnaires, children's clinical data and sociodemographic) were blinded. Finally, other undetected factors may be responsible for the results such as the functioning of the family, the rearing style of the parents or the coping strategy of the children. Further studies should take these factors into account and include the family's condition.

6 CONCLUSION

Paediatric nurses, as evaluators of children's problems, implementers of nursing measures, collaborators with other professionals and educators of children and their families, are indispensable in influencing the mental health of children with chronic diseases. In 2010, the International Council of Nurses (ICN) proposed the theme "nurses dominate chronic disease management" to highlight the leading role of nurses in chronic disease management. The impact of chronic diseases in children usually manifests in their behaviours and emotions; thus, it is important to help children reduce these negative influences.

Sandplay therapy is a universal psychological method that is suitable for adoption in medical settings, as supported by our findings. China has the largest population of children with chronic diseases. Though many studies have highlighted the importance of offering and integrating psychological help into standard clinical nursing care, the topic has not received enough attention. Our findings provide positive empirical evidence that sandplay therapy can effectively reduce anxiety, withdrawal and social problems in children with chronic diseases as well as anxiety and depression in their caregivers. Furthermore, our findings will contribute to the development of a comprehensive and quality paediatric care system, improving patient satisfaction, increasing the trust of children and their families in the medical staff and society, improving nurse-child interactions and expanding the scope of the nursing profession in China.

CONFLICTS OF INTERESTS

None declared.

ETHICAL STATEMENTS

This study was approved by the Institutional Review Board of Children's Hospital of Chongqing medical University, China. File No.: 2018-116.

PATIENT CONSENT

Parental/guardian consent obtained.

The data that support the findings of this study are available on request from the corresponding author, Huaying Yin. The data are not publicly available due to their containing information that could compromise the privacy of research participants.

Abstract

Purpose

Children with chronic diseases exhibit a higher incidence of emotional-behavioural problems. Though sandplay therapy is a universally recognized psychological treatment method, experimental evidence for this form of therapy is lacking. Our aims were to examine the effectiveness of sandplay therapy in reducing emotional and behavioural problems in school-age children with chronic diseases as well as anxiety and depression in their caregivers.

Design and methods

A total of 60 children and their caregivers were enrolled in the present study between January and October 2019. A randomized controlled trial was conducted at the Children's Hospital of Chongqing Medical University, China. Participants were divided into an intervention and a control group. Both groups received regular treatment, and the intervention group received additional sandplay therapy. Four behavioural rating scales were used to evaluate the differences between the two groups. The children's scores on the Child Behavior Checklist (CBCL), Eysenck Personality Questionnaire (EPQ), Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) before and after the intervention were compared using the Mann-Whitney test. The Wilcoxon signed rank test was also employed to compare the median results before and after treatment.

Results

The total scores for CBCL, anxiety and depression, withdrawal, and social behavioural problems for children in the intervention group were all lower than the corresponding scores for those in the control group ( p < .05). The EPQ scores for emotional stability and psychosis in the intervention group were both lower than those in the control group ( p < .05). The SAS and SDS scores for the caregivers of children in the intervention group were also lower than the corresponding scores for those in the control group ( p < .05).

Conclusion

Sandplay therapy can reduce anxiety, withdrawal, and social behavioural problems in school-age children with chronic diseases, as well as relieve anxiety and depression symptoms in their caregivers. Our study provided evidence for the clinical application of sandplay therapy and highlights the importance of offering and integrating psychological treatment in clinical nursing care.

1 INTRODUCTION

Children with chronic diseases have complex health conditions. Consequently, they exhibit a higher incidence of emotional-behavioural problems, which is four times greater than that among their physically healthy peers (Hysing et al., 2007). Children are still undergoing cognitive and psychological development and their immature coping strategies in response to adverse external stimuli (chronic pain, poor physical conditions, etc.) make them more prone to chronic diseases (Zeltzer et al., 2008). Though children do not necessarily develop psychological illnesses, they constantly grapple with emotional-behavioural problems (Douma et al., 2018). Delfos and Gempel divided emotional-behavioural problems into two categories: externalizing and internalizing problems. The former includes oppositional defiant disorder, conduct disorder and situational attention deficit disorder, while the latter refers to mood disorder, anxiety disorder and attention deficit disorder (Gimpel & Hollard, 2003; Martine, 2004).

Chronic diseases influence the emotional and behavioural expressions of children in many ways. Changes in normal bodily functions (physical limitations, long-term pain, etc.), the need to adapt to special diet restrictions and enduring the side effects of treatment or medication bring about negative emotions including worry, distress and anxiety (LeBovidge et al., 2003). Restrictions to participation in different activities, reduced social identity and a lack of normal peer interactions in daily life also result in a negative self-concept and greater self-consciousness in children. Such situations can make children feel ashamed about their physical defects, cause psychological behavioural problems (social withdrawal, aggression) (Blackman & Gurka, 2007), detrimentally affect treatment coordination and increase the risk of negative long-term health outcomes (Kongkaew et al., 2014). Chronic disease is also a stressor to family members, especially caregivers. Families of patients with chronic diseases face a heavier financial burden and more daily organizational problems (Sawin et al., 2003). For instance, isolation, immobilization, frequent hospitalization and restrictions of normal activities, which sometimes persist after the end of treatment, result in emotional disturbance in parents (Lemos et al., 2020; Schepers et al., 2018). In addition to their children's medical regimen, parents also worry about their children's adherence to treatment, long-term prognosis and current and future levels of independence (Mullins et al., 2007). Therefore, the psychological stresses experienced by parents can be roughly divided into two types: personal and parental. Personal stress refers to psychological stress including depression, anxiety and posttraumatic stress symptoms, while parental stress refers to an indirect emotional strain (frustration or guilt) stemming from the demands of parenthood (Deater-Deckard et al., 2015; Norberg & Boman, 2008). These stresses can last as long as 5-10 years after the completion of treatment and put parents, children and other caregivers at risk for adverse outcomes (Vrijmoet-Wiersma et al., 2010).

China has nearly two hundred million children with chronic diseases (Zheng & Zheng, 2015). Leukaemia and chronic kidney disease are two of the most common chronic diseases in China and share characteristics such as recurrent pain and restrictions in daily life activities. Sandplay is a useful adjunct for the mainly cognitive and behavioural techniques commonly used by school guidance counsellors. Several studies have examined the effects of sandplay on children with cerebral palsy (Wang et al., 2015) and on children with separation anxiety (Hamideh & Zohreh, 2015), but there is still insufficient research on the effectiveness of sandplay at reducing emotional-behavioural problems in children with chronic diseases in China. Due to the shortage of paediatric psychologists, filling the gap with nursing practitioners has been proposed (Schwartz et al., 2017). Therefore, integrating emotional and behavioural treatments into traditional nursing care is a priority.

In this study, we used the sandplay theory as a theoretical framework. Sandplay therapy is a psychological therapy method created by Dora Kalff, a Swiss analytical psychologist, in the 1950s. Kalff used Jung's analytical psychology as the foundation for sandplay therapy, borrowed Margaret Lowenfeld's "The world technique," and integrated them with Eastern thoughts and philosophies. In contrast to the prevailing interpretation of psychoanalysis at the time, Lowenfeld pioneered the idea that sandplay was a natural interest for children and correlated play with psychological development in children. Inspired by the concept, Kalff integrated the theory with Jung's analytical psychology. She retained the original methodological system, upgraded the miniature toys provided for the play session and named the new therapy "sandplay" (Chiesa, 2012). Half a century later, a standard sandplay therapy session requires an independent, quiet room with basic equipment including (1) a sandbox: a sandbox with a size of 57 × 72 × 7 centimetres with the bottom painted blue to reflect water or the sea; (2) sand: water should also be provided so that the children have a choice of both wet and dry sand (Chiesa, 2012); (3) miniature objects: the objects should be organized in categories including animals and plants, every-day and cartoon figures, buildings, military machineries, transportation and miscellaneous (Plotts et al., 2008).

As a form of play therapy, sandplay is an effective intervention for children. The main advantage of sandplay is the unconditional admissive environment created. During sandplay therapy, children can express their emotions freely using sand, water and miniature objects, which promotes nurse-child interactions. Richards et al. ( 2012) stated that school children can externalize their trauma due to the safe environment created in sandplay therapy, effectively reducing their social withdrawal level. Sandplay therapy requires little language skill and allows children to express themselves or respond nonverbally through sandplay creations. Lu et al. ( 2010) applied sandplay to school children with autism spectrum disorder. The results suggested that sandplay successfully increased the children's language expression levels, their participation in social activities and their symbolic, voluntary and creative play performance. Furthermore, sandplay therapy can help children construct an idealized world to express their demands and expectations for the future or reconstruct distressing experiences in the past to relieve their emotions. Mariefrance ( 2007) applied sandplay therapy to immigrant and refugee preschoolers and found that sandplay offered the children a chance to express sentiments derived from a combination of past and present experiences and helped them develop suitable coping strategies.

Sandplay is widely utilized by mental health workers and is especially suitable for paediatric nurses. Regardless of the therapists' orientation, sandplay therapy provides a special and progressively organized approach that helps children better engage in the therapeutic process (Hamideh & Zohreh, 2015).

With a growing number of children becoming more vulnerable to long-lasting physical health problems and emotional trauma across their lifetime, it has become more difficult for paediatric nurses to respond (Wise, 2007). Sandplay therapy is an effective technique that enables children to express their emotions, reveal traumas, and develop safe relationships and self-actualization. However, the efficacy of sandplay therapy in children with chronic diseases remains undetermined. Therefore, in the present study, we set up sandplay treatment rooms in the Nephrology and Hematology wards (each room was equipped with a set of standard sandplay equipment purchased from professional companies) to examine the clinical effectiveness of sandplay therapy in school-age children with chronic diseases who have emotional and behavioural problems.

2 METHOD

2.1 Design

A two-armed parallel randomized controlled trial was used to examine the effectiveness of sandplay therapy for children with chronic diseases. The caregivers of the children completed the Child Behavior Checklist (CBCL), the Zung Self-Rating Depression Scale (SDS), and the Zung Self-Rating Anxiety Scale (SAS) while the children completed the Eysenck Personality Questionnaire (EPQ) before and after the sandplay therapy (see Diagram 1).

A two-armed parallel randomized controlled trial was used to assess the effectiveness of sandplay therapy for children with chronic diseases between January and October 2019. The entire therapeutic procedure consisted of six sessions of sandplay therapy, performed 1-2 times a week for 60-90 min each, and the total treatment lasted about 2 months. Eligible children and their caregivers in both groups were instructed to complete the CBCL, EPQ, SAS, and SDS in a private room after providing consent. All questionnaires were completed before and after the sandplay therapy procedure. The follow-up diagram is presented in Diagram 2.

2.2 Setting

Our research was conducted at the Children's Hospital of Chongqing Medical University, China. The sandplay treatment rooms were set up in the Nephrology and Hematology wards, and we ensured the rooms were relatively independent, quiet, and sufficiently bright. Each room was equipped with a set of standard sandplay equipment purchased from professional companies. The size of the sand table was 57 × 72 × 7 cm. The interior and bottom of the table were both painted blue to simulate the colour of the sky and sea and to encourage the children to relax. Soft sand was added to the table. The miniatures used consisted of animals, flowers, every-day figures, religious figures, buildings, military machinery, vehicles, etc., totalling more than 2,000 pieces. Potted plants, tables, chairs and sofas were set up in the sandplay treatment rooms to create a safe, relaxing and warm treatment environment.

Sandplay therapists were required to have a Chinese National Grade III Psychological Consultant Certification and to undergo professional sandplay therapy training. After passing the subsequent assessment, the sandplay therapists conducted therapy procedures under the guidance of an experienced psychotherapist with regular supervision.

2.3 Participants

The participants were children receiving long-term treatment at the Children's Hospital of the Medical University and one of their main caregivers. According to the order of hospital admittance for children with chronic diseases, participants were recruited based on the following inclusion criteria: (1) children aged 6 to 12 with a diagnosis that met the criteria for leukaemia or chronic kidney disease; (2) a total score on the CBCL questionnaire that exceeded the Chinese norm; and (3) children and their caregivers were all Chinese speaking and able to complete the questionnaires. The exclusion criteria were as follows: (1) children and primary caregivers were unable to communicate well with the researchers; (2) the disease condition of the children was in a critical stage; and (3) refusal to participate in the study.

According to previous research (Maoqun et al., 2016), the sample size required to detect a Cohen's d effect size of 0.6 from sandplay therapy in the intervention and control groups was calculated. Twenty-five cases each were deemed sufficient to observe an effect of at least 80% power at a 5% level of significance, in consideration of an attrition rate of up to 15%. Thirty participants each were therefore enrolled in the intervention and control groups. The enrolled children and their caregivers were informed about the study and its purpose. Those who agreed to participate signed an informed consent form.

2.4 Randomization

After signing the informed consent form, the children eligible to undergo sandplay therapy were numbered by the order of enrolment in the study. The children randomly selected an opaque envelope containing a group identifier (intervention or control) prepared in advance by an independent statistician. The ratio of assignment to the intervention and control groups was 1:1.

2.5 Control group: Regular nursing care

Children in the control group received regular nursing care without sandplay therapy. Regular nursing care consisted of routine disease care and daily expressions of consolation and encouragement by the medical staff.

2.6 Intervention group: Sandplay therapy

The main theme and topic of each sandplay therapy session were set according to the sandplay model suggested by Margaret Lowenfeld (see Table 1), which follows a standard procedure and can be adjusted according to the therapy situation (Hamideh & Zohreh, 2015). To ensure the session was effective, only one child was admitted to the sandplay room at a time. Before the session began, the therapist led the child through a strict hand hygiene procedure and introduced the settings of the sandplay treatment room with a soft and gentle voice. After the child became familiar with the environment, the therapist guided the child to touch the sand and take five deep breaths to relax. The therapist particularly emphasized that the sandplay creation could be anything and that the child would not be judged. While the child engaged in sandplay, the therapist recorded the child's behaviour and the miniatures used. The therapist adopted a "silent witness" approach, accepted, appreciated and accompanied the child, and created a safe, tolerant and supportive atmosphere so that the child could devote themselves wholeheartedly to the process of making sandplay creations. After the treatment session, according to the psychological state of the child, the therapist asked the child to introduce their sandplay creations, communicated with the child, and guided them to appreciate and explore their inner world. After the sandplay therapy session, the therapist took pictures with the child's permission and saved the images as files, then guided the child to repeat the hand hygiene procedure.

Goals: Establishing emotional and friendly relationship with children and building trust in children

First

Goals: Simulating the environment of school and home, expressing interest in the two main environment

Second

Goals: Trying to reduce children's emotional and behaviour problems

Third

Goals: Proposing now pedagogical strategies and trying to playing a role in this process

Forth

Goals: Gradual recovery, enthusiasm or calm children's negative emotion or behaviour

Fifth

Goals: Disappearance of all symptoms of children's emotional and behaviour problems

Sixth

2.7 Primary outcome measures

2.7.1 The emotional-behavioural problems

The CBCL for ages 6-18 (CBCL/6-18) is widely used to assess emotional-behavioural problems in children and contains 113 items. The responses are rated with a three-point scale and parents or caregivers select the most appropriate rating (0 = never, 1 = sometimes, 2 = very often or always) based on their children's behaviours in the preceding 6 months. Higher scores indicate more emotional-behavioural problems. The questionnaire is broadly divided into two categories: introversion factors (depression, social withdrawal and poor communication) and extraversion factors (hyperactivity, aggression and disciplinary behaviour). These categories are more specifically divided into eight aspects: Anxiety/Depression, Somatic complaints, Attention problems, Rule-breaking behaviour, Aggressive behaviour, Withdrawal, Social problems and Thought problems. The upper limits for the Chinese norm are 40-42 for boys and 37-41 for girls. A CBCL score reductive ratio (rate of difference in scores before and after intervention) ≥25% is regarded as effective. The retesting reliability of the scale was reported to be 0.950, and the Cronbach's report for internal consistency was 0.93 (Zuoji, 2005).

The parental scale was used in this study.

2.7.2 The personality of the children

The EPQ, compiled by Eysenck H.J, a professor of psychology, is one of the most widely used personality questionnaires. In this study, the EPQ (Chinese version) revised by Yaoxian Gong was used. This version of the EPQ contains a total of 88 questions and the possible responses for all questions are "yes" or "no." The EPQ uses the factor analysis method to evaluate four main dimensions of personality: Neuroticism (N), Extraversion (E), Psychoticism (P) and Lie (L). The Chinese version has been confirmed to have adequate internal consistency for the four subscales (0.70-0.88) (Yaoxian, 1986).

2.7.3 Secondary outcome measures

The SDS and SAS are self-evaluation questionnaires used to assess anxiety and depression. Each contains 20 items and uses a four-point rating system (1 = none or seldom, 2 = sometimes, 3 = usually, 4 = always or most of the time). The total scores range from 20 to 80 and lower scores indicate a lower severity of anxiety/depression. The standard scores can be stratified into three levels: mild (53-62), moderate (63-72) and extreme (72 or higher). The Cronbach's α values for the Chinese versions of the SAS and SDS are 0.862 and 0.931, respectively, showing good reliability (Liu et al., 1995).

2.7.4 Sociodemographic characteristics

The social and demographic characteristics of the participants, including the sex and current age of the children, educational level of the caregivers and other important descriptors, were collected using a questionnaire created in-house in accordance with the research target.

2.7.5 Data collection and analysis

Essential disease-related data (initial diagnosis, disease duration, treatment procedure, etc.) were collected from the medical records of the children. Data were analysed by means of the Statistical Package for the Social Sciences software (version 25.0). Mean ± standard deviation was used to describe the average ages of the children, frequencies were used to present the sociodemographic characteristics, and median (p25, p75) was used for the statistical description of the assessment scores (CBCL, EPQ, SAS and SDS). The average ages of the children in the intervention and control groups were compared using the t test. The CBCL, EPQ, SAS and SDS scores before and after the intervention were compared with the Mann-Whitney test. The Wilcoxon signed rank test was also used to compare the median scores before and after the treatment. The children's gender, diagnosis, and illness duration were compared with the chi-squared test. A two-sided test significance level of p < .05 was used in all statistical analyses.

3 RESULTS

3.1 Sociodemographic and clinical characteristics of participants

A total of 62 children and their caregivers were enrolled in the present study between January and October 2019. Two children failed to complete the entire sandplay therapy procedure because they transferred to other hospitals and the rest completed the full procedure. Therefore, the data for a total of 60 children and their caregivers were analysed, with 30 participants in each group. There were 15 boys and 15 girls in the intervention group and 16 boys and 14 girls in the control group. The ages of the children in each group ranged from 6 to 12 years, with mean ages of 9.30 ( SD 1.58) and 8.97 ( SD 1.33), respectively, and no statistical difference ( t = 0.886, p = .380). The sex, type of disease and duration of the illness for the children were not statistically significant either (χ ² = 0.067, p = .796; χ ² = 0.069, p = .793; χ ² = 2.584, p = .108). Other data were comparable and are presented in Tables 2 and 3.

Group

Gender

Age

Diagnosis

Duration of diagnosis

CBCL (p25-p75)

Male

Female

(x ± S)

Chronic kidney disease

Leukaemia

Within one year

One year or over

Intervention

15

15

9.30 ± 1.58

12

18

22

8

65 (57.25-70)

Control

16

14

8.97 ± 1.33

13

17

16

14

59.5 (52.75-65.25)

Test statistics

χ ² = 0.067

t = 0.886

χ ² = 0.069

χ ² = 2.584

Z = 1.415

p values

.796

.380

.793

.108

.140

Note

Analysis using t test, Mann-Whitney test and chi-square test.

Abbreviation: CBCL, child behavior checklist.

Characteristics

Control (n = 30)

Intervention (n = 30)

χ²

p

Sex of the child

Accompanied by

Highest education attainment of the accompanied family

Disease of the child

First diagnose

Duration of illness

3.2 Changes in CBCL scores

The effective rate was 53% according to the CBCL score reductive ratio. No significant differences in the total and subscales scores were noted between the control and intervention groups before the intervention. In contrast, significant differences between the scores before and after the sandplay therapy in the control and intervention groups were found in the total scores ( z = 6.320, p = .00), anxiety ( z = 6.016, p = .00), attention problems ( z = 3.571, p = .00), aggressive behavior ( z = 6.138, p = .00), withdrawal ( z = 4.680, p = .00) and social problems ( z = 4.594, p = .00). The control group showed no significant difference in the total and subscales scores after treatment. However, there were statistically significant difference in the total scores ( z = 4.784, p = .00), anxiety ( z = 4.633, p = .00), attention problems ( z = 3.830, p = .00), aggressive behaviour ( z = 4.797, p = .00), withdrawal ( z = 4.638, p = .00) and social problems ( z = 4.555, p = .00) in the intervention group (see Table 4).

[Correction added on 5 October 2021 after first online publication: all z value in the preceding paragraph have been updated in this version]

Group

Time

Total score, Median (IQR)

Anxious, Median (IQR)

Somatic complains, Median (IQR)

Attention problems, Median (IQR)

Rule-breaking behaviour, Median (IQR)

Aggressive behaviour, Median (IQR)

Withdrawn, Median (IQR)

Social problems, Median (IQR)

Thought problems, Median (IQR)

p

.000**

.000**

.196

.341

.110

.053

.000**

.003**

.377

Note

Analysis using Mann-Whitney test and Wilcoxon signed rank test.

Abbreviations: CBCL, child behavior checklist; IQR, interquartile range (25th centile-75th centile).

**:P < 0.05

3.3 Changes in EPQ scores

The distribution of changes in personality showed in the N scales and P scales (see Table 5). There were significant differences in the N ( z = 3.952, p = .000) and P ( z = 3.829, p = .000) scales in the intervention group as well as between the control and intervention groups before and after the sandplay therapy ( z = 3.790, p = .000; z = 2.275, p = .000). In the E scale, there was a statistical difference between the two groups before and after sandplay therapy ( z = 2.391, p = .017; z = 2.189, p = .029) (see Table 6). The total distribution of changes in personality.

[Correction added on 5 October 2021 after first online publication: all z value in the preceding paragraph have been updated in this version]

Before (N = 60)

After (N = 60)

Note

Analysis using McNemar test.

Group

Time

EPQ-E, Median (IQR)

EPQ-N, Median (IQR)

EPQ-P, Median (IQR)

EPQ-L, Median (IQR)

p

.017*

.686

.454

.632

p

.029*

.000**

.000**

.133

Note

Analysis using Mann-Whitney test and Wilcoxon signed rank test.

Abbreviations: E, extraversion; EPQ, Eysenck personality questionnaire; IQR, interquartile range (25th centile-75th centile); L, lie; N, neuroticism; P, psychoticism.

**:P < 0.05

3.4 SAS and SDS scores of the caregivers of children with chronic disease

The SAS and SDS scores of the caregivers of children in the intervention group showed statistically significant differences before and after the sandplay therapy ( z = 4.270, p = .001; z = 4.680, p = .000). The comparison of the two groups after the intervention was also statistically significant ( z = 2.847, p = .004; z = 3.580, p = .000) (see Table 7).

[Correction added on 5 October 2021 after first online publication: value for z and p in the preceding paragraph have been updated to correspond with Table 7]

Group

Time

SAS, Median (IQR)

SDS, Median (IQR)

Z (two groups before intervention)

0.910

0.710

p

.363

.478

Z (two groups after intervention)

2.847

3.580

p

.004**

.000**

Z (two groups changes before and after)

−3.543

−5.109

p

<.001

<.001

Note

Analysis using Mann-Whitney test and Wilcoxon signed rank test.

Abbreviations: IQR, interquartile range (25th centile-75th centile); SAS, self-rating anxiety scale; SD, standard deviation; SDS, self-rating depression scale.

**:P < 0.05

4 DISCUSSION

A previous study examined the effects of sandplay therapy on children with emotional-behavioural problems (Richards et al., 2012). Our study aimed to expand the scope of application for this form of therapy. Overall, children with chronic diseases who received sandplay therapy exhibited significantly fewer emotional-behavioural problems than those who did not.

Limited mobility, chronic pain and special restrictions (food, clothing, housing and transportation) all affect children with chronic diseases to varying degrees. Previous studies have shown that these children had 1.5 times more behavioural problems than normal children, including antisocial behavioural, hyperactivity and social withdrawal/peer conflict (Blackwell et al., 2019; Wise, 2007). Li et al. ( 2008) investigated emotional problems in 203 children aged 8 to 16 with chronic diseases and found that 43.8% had anxiety, 30.0% had depression, and 26.1% had both anxiety and depression. However, methods to reduce emotional-behavioural problems in children with chronic diseases in China have received insufficient attention.

4.1 Effects of sandplay therapy on emotional-behaviour problems

The positive results in the present study support the effectiveness of sandplay therapy as the scores for anxiety, withdrawal and social problems in the intervention group were lower after sandplay therapy. Analysis of children's actions during sandplay revealed that the sandplay process can be roughly divided into two stages: the first stage consisted of trauma presentation and conflict intensification, while the second stage consisted of transformation and healing. As the intervention progressed, the traumatic elements gradually decreased and the themes of healing and hope became more apparent.

At the beginning of sandplay, the children often exhibited obvious resistance, impulsiveness and restlessness because they had a limited understanding of the procedure. The safe and empathic environment created by the therapist helped reduce the children's resistance to the medical staff, loosen their self-restraint and encourage them to gradually express their inner world. Through guidance, the children began to express their traumatic experiences and negative emotions by selecting miniatures, creating a sand world and symbolic narrations. As the sandplay progressed, the children manifested internal conflict and questioning of their abilities by destroying and rebuilding the scene, destroying old creations and recreating them. A possible explanation for this behaviour is that through the three-dimensional environment for expression provided by sand in the visual and kinesthetic channels (including movement and touch), the children could gradually release themselves from a state of avoidance and resistance, transforming from the role of a victim in previous experiences to the creator of new experiences and gaining more initiative. During this stage, the therapist employed positive transference therapy to reduce inappropriate emotional regulation methods (aggression or self-injury) as well as promote and consolidate positive behaviours to help the children enter the next transformation stage.

In the second stage, as the duration of the disease increased, low social desire and negative emotions caused by limited activities and pain from the disease gradually emerged (Harding et al., 2002). Anxiety and depression cause withdrawal and avoidance during medical treatment. Traumatic themes in the sandplay creations decreased and a hesitation in self-cognition became apparent as well as the desire for school activities, family and a normal social life. Treatment at this stage was focussed on active communication and interactions between the therapist and child. The therapist adopted an inclusive attitude and provided affirmations to help the child increase their emotional stability, strengthen their self-identity, balance the nurse-child interpersonal relationship and establish an appropriate level of self-awareness.

4.2 Effects of sandplay therapy on children's personality

School age is an important period for personality formation and psychological development in children. This period is also an important stage for children to develop their self-identity and a healthy personality (Lizhu, 2015). Though personality is comprised of a combination of psychological characteristics with certain tendencies and is relatively stable, it is influenced by heredity, age and environment (Berg et al., 2016). As a serious negative stimulus, chronic diseases strongly influence the formation and improvement of children's personalities.

Consistent with previous studies (Hovens et al., 2016; Jinxiang et al., 2018), the children's scores for emotional stability (N scale) and psychosis (P scale) in the Eysenck personality assessment significantly decreased after the intervention. A likely explanation is that by providing a safe, relaxed and unlimited protective environment, sandplay therapy can alleviate children's negative emotions, enabling them to adjust their emotions and reduce the frequency of strong reactions when faced with a serious stimulation (pain, activity limitation). In addition, the unconditional attention and positive feedback the children receive from the therapist and parents during sandplay therapy can increase prosocial behaviours, reduce their resistance to the external environment and benefit the process of socialization. Consequently, the children's mental quality scores decreased.

4.3 Effects of sandplay therapy on caregiver's emotional problems

The results of the present study showed that the anxiety and depression scores of the caregivers decreased after sandplay therapy. When parents are faced with long-term negative stimuli due to chronic diseases, they experience multiple stressors such as medical procedures, instability of family roles and lack of social support, often resulting in emotional overreactions, such as irritability, anxiety and depression (Cousino & Hazen, 2013; Haverman et al., 2013). These negative emotions not only affect the mental health of the parents, but also affect their social interactions, marital relationships, careers and other aspects of their lives. These situations usually trigger polarized responses such as overprotection or over-neglect due to difficulties balancing the two extremes. Overprotective parents may lead to low levels of dependence and self-efficacy in the children, while over-neglect may lead to low self-esteem and self-denial.

In the present study, two sessions of family sandplay therapy were conducted after individual therapy, which promoted the connection between the medical staff and the family and alleviated negative emotions in the caregivers. According to our clinical observations, family sandplay strengthened the communication between the caregivers and their children, which is conducive to improving family interactions and helping caregivers discover their children's potential abilities. It also helps the children feel more positive about the support and care they receive from their family, find an outlet to vent emotions, balance their inner world, and foster trust between the family and medical staff.

5 LIMITATIONS

One of the limitations of the current study was that children and their caregivers were recruited from one hospital; hence, the generalizability of the results may be limited. Additionally, the lack of blinding may be a primary source of bias. However, due to the nature of sandplay therapy, it is difficult to blind the children, caregivers and therapists. Despite knowing they are undergoing an intervention, children are unlikely to change their behaviours (Silva et al., 2017). To minimize the potential bias, we chose a series of objective questionnaires to evaluate the effectiveness of the sandplay therapy on children with emotional-behavioural problems, and the assessors who collected the data (the scores for questionnaires, children's clinical data and sociodemographic) were blinded. Finally, other undetected factors may be responsible for the results such as the functioning of the family, the rearing style of the parents or the coping strategy of the children. Further studies should take these factors into account and include the family's condition.

6 CONCLUSION

Paediatric nurses, as evaluators of children's problems, implementers of nursing measures, collaborators with other professionals and educators of children and their families, are indispensable in influencing the mental health of children with chronic diseases. In 2010, the International Council of Nurses (ICN) proposed the theme "nurses dominate chronic disease management" to highlight the leading role of nurses in chronic disease management. The impact of chronic diseases in children usually manifests in their behaviours and emotions; thus, it is important to help children reduce these negative influences.

Sandplay therapy is a universal psychological method that is suitable for adoption in medical settings, as supported by our findings. China has the largest population of children with chronic diseases. Though many studies have highlighted the importance of offering and integrating psychological help into standard clinical nursing care, the topic has not received enough attention. Our findings provide positive empirical evidence that sandplay therapy can effectively reduce anxiety, withdrawal and social problems in children with chronic diseases as well as anxiety and depression in their caregivers. Furthermore, our findings will contribute to the development of a comprehensive and quality paediatric care system, improving patient satisfaction, increasing the trust of children and their families in the medical staff and society, improving nurse-child interactions and expanding the scope of the nursing profession in China.

CONFLICTS OF INTERESTS

None declared.

ETHICAL STATEMENTS

This study was approved by the Institutional Review Board of Children's Hospital of Chongqing medical University, China. File No.: 2018-116.

PATIENT CONSENT

Parental/guardian consent obtained.

The data that support the findings of this study are available on request from the corresponding author, Huaying Yin. The data are not publicly available due to their containing information that could compromise the privacy of research participants.

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Effects of sandplay therapy in reducing emotional and behavioural problems in school‐age children with chronic diseases: A randomized controlled trial

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Judan Tan , Huaying Yin , Tuo Meng , Xiaoli Guo , Department of child health in Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing Key Laboratory of Translational Medical Research in Cognitive Development and Learning and Memory Disorders, Chongqing Key Laboratory of Child Health and Nutrition, Children's Hospital of Chongqing Medical University, Chongqing, P.R.

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The Use of Sandplay Therapy in Urban Elementary Schools as a Crisis Response to the World Trade Center Attacks-David Publishing Company

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Christine J. Yeh, Sara M. Aslan, Violeta E. Mendoza, Mio Tsukamoto University of San Francisco, San Francisco, USA We evaluated the use of sandplay therapy with a sample of 32 elementary school students, who were evacuated from school during the World Trade Center Attacks of September 11, 2001.

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Abstract

In this time of increasing globalization, it is not uncommon to practice counseling in a context with native speakers of multiple languages seeking therapy with a practitioner in a shared language that is not their own. Providing therapeutic counseling across cultures can be a complicated endeavor. Sand tray is an expressive therapy, which allows significant non-verbal and pre-verbal material to be shared. This can be especially valuable when working in a cross-cultural, or language learner context. The sand tray allows the therapist to become a "visitor" to the inner world of the client, and literally see their interpretation of events and relationships without the limiting constraints of vocabulary and culture based assumptions. It provides a cultural window for insight in assessment and diagnosis and a bridge for the use of therapy techniques within the cultural context. In this paper, the sand tray method is discussed with regards to multicultural communication. The discussion includes a brief history of sand tray therapy development, and the sand tray method used. Case study examples of cross-cultural work done in Kosovo illustrate the effective use of sand tray as a medium for therapeutic intervention. The possibility of future research in the exploration of sand tray therapy as a cross-cultural means of counseling assessment and intervention are discussed.

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Windows and Bridges of Sand: Cross-cultural Counseling Using Sand Tray Methods

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In this time of increasing globalization, it is not uncommon to practice counseling in a context with native speakers of multiple languages seeking therapy with a practitioner in a shared language that is not their own. Providing therapeutic counseling across cultures can be a complicated endeavor.

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Sandplay Therapy_Ene Livia si Popescu Aurora_PCCPP an I (2)

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Sandplay Therapy_Livia Ene si Popescu Aurora_eseu

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Teorie

Nisipul este pamantul aflat chiar la granita dintre profunzimile inconstiente, nevazute ale marii si patrunderile constiente ale tarmurilor. Nisipul marcheaza urmele timpului. Marcheaza legaturile cosmice, acea miscare intre fiinta dinamica si nemiscarea vida. Castelele de nisip au prins imaginatia copiilor si adultilor de cand oamenii au populat tarmurile.

Psihicul este o experienta vie in sandplay - ideea nu impietreste, ci devine vizibila in expresie tridimensionala. Acest lucru, permite un nou potential, acela ca, dupa ce identificarea cu sandplay poate sa conduca spre material arhetipal arhaic sau regresia spre starea preistorica a psihismului, procesul retrograd sa fie reinnoit de constientizarea din cand in cand a intelesurilor relative la viata proprie a individului respectiv. Acest gen de experiente par sa reinnoiasca starea dinamica ulterioara a psihicului.

Cand apare o submergere (a se scufunda) spre instinct, rezistenta la haosul ei dinamic este compensata de nevoia de forma si ordine. Sandplay da posibilitatea unei schimbari rapide si flexibile pe dimensiunea haos - ordine.

Psihicul celui care lucreaza creeaza simbolul care exprima cel mai bine spectrul dinamic care elibereaza libidoul legat de inconstient. Simbolul incearca de fiecare data sa indice eliberarea din aceste legaturi de energii prinse in cursa si sa elucideze partial.

Imaginea fanteziilor copilariei si ulterioara proiectie a arhetipului copilului in imaginile sale constiente cer implinirea si integrarea in adult odata cu utilizarea sandplay-ului.

Fanteziile adesea anticipa evenimente umbrite in inconstient. C. G. Jung vorbeste adesea despre simbolul care vindeca, - si care apare din locul de unde nimeni nu se asteapta. De aceea, atitudinea cea mai importanta si corecta este de a nu te lansa in nici un fel de presupuneri anticipative cand construiesti un sandplay.

Jocul cu nisip simbolic este o cale de mijloc in care opusele pot curge impreuna intr-o noua miscare, astfel ca functii care au fost inerte pana acum tind sa vina la viata, elemente reprimate si subevaluate intra in jocul cu nisip prin cea mai putin valorizata functie a vietii constiente. Psihicul blocat curge din nou indepartandu-se de chemarea abisului maternal.

Descriere si administrare

Tehnica sandplay include folosirea a doua cutii standard cu nisip sterilizat, a unui aparat polaroid de fotografiat si a unei colectii de miniaturi. Spatiul de lucru este o incapere separata de camera de consultatie analitica.

Descrierea instrumentelor

Dimensiunile cutiei: - 43.2 cm, 55.2 cm, 8.4 cm. In interior este vopsita in albastru azuriu rezistent la apa. Cutia este pusa pe o masa si umpluta cu nisip pana la jumatatea inaltimii.

O cutie cu nisip uscat, o a doua cu nisip ud, pacientul urmand sa aleaga pe cea care, in prezent, o prefera.

Cupe cu apa pentru udat nisipul la nevoie.

Figurile miniaturale sunt asezate pe rafturi de-a lungul peretilor incaperii.

Figurile sunt mici ca dimensiune si reprezinta viata umana, animale, plante si minerale.

Cladiri pentru orice tip de utilitate, pentru cat de multe culturi posibile. Animale fantastice, preistorice. Figuri culturale, istorice, simbolice din cultura estica sau vestica. Vehicule pentru apa, uscat, aer.

Inregistrarea pe diapozitive sau film color a seriei de imagini realizate de fiecare pacient. Fotografiile se fac dupa plecarea pacientului, inainte ca terapeutul sa reaseze lucrurile.

Teoria Nisipului

Nisipul este mediul de baza pentru aceasta modalitate terapeutica, cea mai simpla si comuna cu pamantul. Alegerea nisipului ca fundament pentru sandplay nu a fost intamplatoare, mai degraba a fost un fenomen natural. Legatura omului cu pamantul este fundamentala. Conectandu-ne cu pamantul, simtim legatura cu spiritul interior si creatia din exterior.

Nisipul are si calitatea de a readuce istoria. Un fir de nisip poate calatorii mii de km si mii de ani inainte de a gasi un loc de odihna. Nisipul este produs de forte naturale diverse.

Multe forte intervin si la nivelul vietii omului - unele din familia de origine, altele care tin de factorii sociomediului, altele din crizele traversate si traumele resimtite. Deformarea interioara a firului de nisip vorbeste metaforic de durerea intrapsihica adusa cu ei de multi dintre pacientii cabinetului de terapie. Nisipul este un produs al istoriei sale, la fel ca noi insine.

Legatura terapeutica si procesarea zbuciumului emotional adanc inradacinat nu sunt doar asistate de utilizarea nisipului. Chiar nisipul este cel care creeaza liantul, puntea, cararea. Nisipul este mijlocul princare pot fi exprimate sentimente - emotii puternice pentru ca poate fi aruncat, tasat, modelat, sapat si mangaiat, si datorita acestui fapt pot fi exprimate in mod concret simboluri, Eichoff, 1952.

Nisipul este astfel mai mult decat un mediu terapeutic - este un mijloc de exprimare a chiar miezului a ceea ce suntem. Actul jocului cu nisip permite pacientului sa se apropie de propria sa totalitate, Dora Kalff, 1980.

Joc si terapie

Jocul este, la fel ca nisipul, terapeutic prin sine insusi. Atribute unice ale jocului :

jocul este prin natura sa voluntar si, intr-o lume plin de reguli, jocul reimprospateaza si da sentimentul de libertate;

jocul nu cere evaluare si judecare, deci poti face in siguranta greseli fara sentimentul esecului;

jocul incurajeaza fantezia si utilizarea imaginatiei, dand posibilitatea controlului fara competitie;

jocul creste implicarea personala si interesul;

jocul incurajeaza dezvoltarea sinelui personal (eul), Caplan & Caplan, 1974.

Terapia prin joc implica mai mult decat aplicarea terapiei traditionale dublata de un mediu de joc. Definitie, Landreth, 1991, jocul ca relatie interpersonala dinamica intre materiale de joc selectate si faciliteaza dezvoltarea unei relatii de siguranta pentru ca pacientul sa-si exprime total si sa-si exploreze fiinta (sentimente, ganduri, trairi, comportamente) prin intermediul mediului natural de comunicare al copilariei, nisipul.

Tehnica Jocul cu nisip - sandplay - implica o relatie interpersonala dinamica.

Indiferent de specificul fundalului teoretic prin care se abordeaza acest tip de terapie, cruciala este tocmai relatia copil - adult, precum si terapeutul format pentru acest tip de proceduri terapeutice care furnizeaza evolutia si dezvoltarea unei relatii interpersonale dinamice.

D. Kalff, considera important ca terapeutul sa creeze un loc liber si protejat. Doar dragostea terapeutului poate crea un astfel de spatiu. Din acest motiv principal, acest gen de terapie cere formare in procedurile de sandplay, formare care include atat experienta proprie a jocului cu nisip, fundalul teoretic dar si experienta personala cu supervizare. De exemplu, selectarea miniaturilor si prezentarea lor nu este nici intamplatoare, nici lipsita de ordine. Clientul poate fi confuzionat de o colectie dezorganizata, inundat de emotii de o colectie nelimitata, sau prea restrans de o colectie limitata.

Terapeutul trebuie sa faciliteze, nu sa directioneze experienta terapeutica. Copiii, familiile intra in procesul terapeutic cu sentimentul de a fi covarsiti si lipsiti de control. Aceasta calitate de facilitare este descrisa de Siegelman, 1990 - a fi un participant, - observator in momentul cand un pacient inspaimantat si constrans simte suficienta siguranta pentru a face primul pas in taramul jocului simbolic -, este a fi o moasa pentru nasterea capacitatii de a da sens, inteles.

Facilitarea astfel inteleasa creeaza pacientului posibilitatea de a-si exprima si explora deplin fiinta. Auto-exprimarea si auto-explorarea sunt cruciale pentru procesul de consiliere si fundamentale in sandplay.

Ultimul aspect al definitiei lui Landreth se aplica in particular procesului din sandplay. Jocul este mai mult decat un mediu natural de comunicare al copilariei. Este un mediu expresiv natural de comunicare pentru pacientul in criza.

Legatura dintre terapie de familie si terapia prin sandplay este fireasca - angajeaza creativ si dinamic terapeutul, dar si participarea familiei intr-un mod dinamic, fie prin intensificarea, fie prin inlocuirea comunicarii verbale.

Permite o includere activa si intentionata a copilului. Nathan Ackerman, 1979, fara angajarea copilului intr-un schimb cu sens de-a lungul generatiilor, nu poate fi vorba de o terapie de familie.

Nisipul creeaza o punte pentru interschimbari cu sens, continutul sandplay-ului furnizeaza o amprenta metaforica pentru alianta de familie, stadiile personalitatii si modelele de intergeneratii. Permite accesarea unei informatii care nu poate fi dezvaluita verbal, si posibilitatea de a observa climatul emotional al familiei.

Fragmente din Introducere in tehnici proiective - Mihaela Minulescu

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Teorie Nisipul este pamantul aflat chiar la granita dintre profunzimile inconstiente, nevazute ale marii si patrunderile constiente ale tarmurilor. Nisipul marcheaza urmele timpului. Marcheaza legaturile cosmice, acea miscare intre fiinta dinamica si nemiscarea vida. Castelele de nisip au prins imaginatia copiilor si adultilor de cand oamenii au populat tarmurile.

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Mulți părinți au auzit despre rezultatele uimitoare pe care le oferă terapia cu nisip pentru sănătatea și dezvoltarea copiilor. Dar mulți nu știu ce este această metodă și cum să o folosească. În acest articol vom vorbi despre esența și principiile, indicațiile și contraindicațiile, precum și învățăm pe mamele și tații să efectueze sesiuni de terapie cu nisip pe cont propriu.

Terapia cu nisip este o metodă de influențare a psihicului și a comportamentului unui copil prin vizualizarea lumii sale interioare. Metoda este o manipulare arbitrară simplă a nisipului purificat și fin, diverse figuri, obiecte mici. Într-o tavă specială, puteți avea figuri, cochilii și orice lucruri mici, după cum doriți, în orice ordine, oriunde pe tavă cu nisip. Puteți construi diapozitive și castele cu nisip folosind apă și apoi să demolați realitatea nisipului construit și să începeți să construiți unul nou.

Creșterea și distrugerea lumii iluzorii și fragile a nisipului, copilul folosește "I" -ul interior profund. Potrivit psihologilor și psihoterapeuților, creând un peisaj fantastic arbitrar, care arată destul de tridimensional, copilul își exprimă temerile, resentimentele, mânia și iritabilitatea subconștientului, iar aceste sentimente acționează de obicei distructiv asupra psihicului și sănătății copiilor de toate vârstele. Sentimentele și emoțiile negative vin cu modele și turle de nisip.

Metoda este una dintre cele mai populare tipuri de terapie artistică, împreună cu terapia muzicală, terapia de basm și isoterapia. Desigur, nu este folosită în fiecare grădiniță sau școală, cum ar fi desenul sau modelarea, dar acest lucru nu o face mai puțin eficientă și interesantă.

Metoda este utilizată pe scară largă în psihologia și psihoterapia copilului, folosind această metodă:

pentru a diagnostica încălcările stării de personalitate, factorii stresanți și traumatizanți, precum și motivele comportamentului neobișnuit sau ciudat al copilului sau adolescentului;

ușurează tensiunea, stresul, anxietatea crescută, instabilitatea emoțională;

ajuta copilul să se dezvolte mai armonios;

facilitarea contactului în cazul în care copilul nu comunică din cauza naturii sau a bolii (pentru autism);

ajuta dezvoltarea generală, socializarea copiilor cu dizabilități.

Metoda, care este considerată o metodă de psihoterapie logică, este folosită și în psihiatrie, deoarece contribuie la o diagnoză mai precisă a anumitor tulburări mintale, precum și la procesul de adaptare a copilului în timpul tratamentului.

Primele zone de nisip pentru meditație și relaxare sunt menționate în literatura și istoria Chinei antice, dar numai oamenii nobili, călugării și războinicii eminenți ar putea să tragă cercuri pe nisip și să pună pietre pe ele. O astfel de divertisment nu era disponibil pentru mase. Karl Jung este considerat fondatorul metodei de terapie cu nisip, el a creat baza teoretică care explică transferul intern al exteriorului. A fost la începutul secolului al XX-lea și apoi numai leneșii nu erau dependenți de psihologie și psihanaliză. Nu este surprinzător faptul că mulți adepți, discipoli și fani ai lui Jung au luat rapid bastonul.

Karl jung

În 1930, la Londra, Margaret Lovenfeld inventează o metodă în care jucării și figuri mici sunt plasate într-o anumită substanță - apă, nisip, lut etc.Jocul devine numele "Lumea" și devine incredibil de popular atât cu oamenii obișnuiți cât și cu psihiatrii, care urmăresc îndeaproape modul în care pacienții lor creează lumi și trag concluzii.

La mijlocul secolului trecut, Margaret Lowenfeld preia bastonul la Dora Kalff. Ea a elaborat o metodă pentru o explicație destul de distinctă a picturilor de nisip pe care adulții și copiii le creează. Ea a fost cea care a fost prima care a conectat direct subconștientul și straturile profunde ale conștiinței copilului cu ceea ce el portretizează din nisip.

Margaret Lowenfeld

Dora Kalff

În vremurile sovietice, nisipurile erau în fiecare curte și sute și mii de copii au jucat în fiecare zi. Jocuri de nisip de astăzi sunt, de asemenea, populare cu copii de toate vârstele.

Observați, dacă este posibil, adulții care se toarnă cu nerăbdare nisip în palme pe plajă, care, gândindu-se, adună nisip într-un tobogan. Toate acestea reprezintă o manifestare a unui "copil interior" profund ascuns, cu temerile și experiențele, bucuriile și visele.

Terapia cu nisip poate fi practicată la orice vârstă, de îndată ce copilul începe să se bucure de joc în nisip. Este clar că până la un an copilul nu va putea să-și modeleze lumea într-o cutie de nisip sau o tavă cu nisip, dar în 2-3 ani o va face cu plăcere. Crede-mă, chiar și un adolescent dificil, în vîrsta de 14-16 ani, nu va refuza, în timpul liber, să dăruiească cu nisip moale și plăcut, în care este atât de interesant să-și scufunde mâinile.
Metoda principală este recomandată pentru următoarele categorii de copii:

copiii care se confruntă cu crize legate de vârstă (3 ani, 6-7 ani, 13-15 ani);

copii care au suferit pierderi grave, traume psihologice sau fizice, violență, agresiune, umilire, dezastre naturale, moartea celor dragi;

copiii cu dificultate în exprimarea emoțiilor (reticenți și secreți, necomunicativi);

copiii cu boli congenitale și tulburări vizuale dobândite, autism, anumite forme de schizofrenie, copii cu deficiențe de auz, vorbire;

copiii care suferă de discursul întârziat, dezvoltarea psihomotorie sau psihofizică, CRA - retard mental;

copii cu boli ale sistemului nervos;

copii cu tulburări ale sistemului musculo-scheletic;

copiii prea activi și impresionați, neurasthenicii care suferă de isterie;

tuturor tipilor în situații dificile de viață, într-o stare de stres.

Există afecțiuni și boli în care, prin utilizarea terapiei cu nisip, se recomandă să așteptați până la comenzile speciale ale medicului curant. Aceste contraindicații includ:

tulburare de deficit de atenție;

epilepsia, însoțită de frecvente crize de pierdere a conștienței și convulsii;

sindromul mișcărilor obsesive, în care copilul nu poate crea liber, mișcările involuntare repetate vor interfera și vor mânca copilul;

alergic la praf și nisip, astm bronșic în formă severă;

tuberculoza;

tulburări psihice grave, însoțite de idiotă completă, debilitate profundă, incapacitate și nedorința de a intra în contact cu oamenii și obiectele din jurul vostru;

vârsta copiilor până la 1,5-2 ani.

Acțiunea terapiei cu nisip este complexă.

În primul rând, copilul atinge nisipul cu mâinile. Este plăcut și util, deoarece particule mici de nisip stimulează terminațiile nervoase ale palmelor, vârfurile degetelor. Se dezvoltă motilitatea, creierul primește semnale constante de receptori nervoși în zonele responsabile pentru cunoaștere, memorie, analiză.

În al doilea rând, nisipul este un material slăbit și, prin urmare, copilul creează din el aproape inconștient, împrăștiind și colectându-l exact așa cum "ia mâna". Acest fapt este considerat important pentru diagnosticarea stării interne a copilului sau adolescentului.

Se demonstrează că exercițiile sistematice de tratament prin nisip îi permit copilului să creadă în el însuși, să scape de experiențele și amintirile negative, să-și realizeze mai clar propria personalitate, să devină mai calm și mai echilibrat, mai independent.

Cel mai viu efect al terapiei cu nisip se manifestă în cazul copiilor care au cursuri combinate cu alte metode de artă, de exemplu, au inclus muzica clasică în timpul lecției, au povestit un basm sau o fabulă în același timp, citeau poezii.

Recunoscută ca cea mai reușită utilizare a terapiei cu nisip în terapia lingvistică, în dezvoltarea integrată a prescolarilor, în activitățile menite să întărească memoria, atenția, dezvoltarea discursului și abilităților intelectuale ale copilului, diagnosticul problemelor psihologice ale preșcolarului, școlii și adolescenței, reabilitarea și educarea copiilor cu dizabilități sănătate limitată).

Psihoterapeuții în munca lor încearcă să folosească truse gata făcute. Sunt alcătuite dintr-o cutie cu dimensiunile de 50x70x8 cm. Nisipul este, de obicei, realizat din plastic ecologic, jantele interioare sunt vopsite pe perimetru în albastru, iar fundul albastru. Nisipul alege o fracțiune mică, galben sau alb, special pre-curățată.

Există un mic container de apă în set, deoarece unele jocuri necesită umectare cu nisip. Există, de asemenea, seturi de figuri miniatură sub formă de persoane (adulți, bebeluși, bătrâni), clădiri și structuri, mașini, nave, animale (atât interne, cât și sălbatice). Setul combină întotdeauna miniaturile care provoacă simpatie copilului și figuri neplăcute pentru el, de care îi este frică.

Este important ca setul să conțină elemente care pot reprezenta "valoare" în înțelegerea copiilor, simbolizând comorile și bogățiile găsite, visele și obiectivele - cutii mici, cufere, cochilii, pietre prețioase din sticlă. Un set de profesioniști este completat cu litere și numere din plastic, steaguri, simboluri religioase, pietre și conuri, precum și obiecte create de om - șuruburi și piulițe.

Costul setului final poate fi destul de impresionant, totul depinde de cât de bine este finalizat. De obicei, cifrele și miniaturile sunt vândute separat pe subiect. Dar nu este necesar să cumpărați un set profesionist costisitor. Mai jos vom descrie modul de a crea singur.

Pentru ca copilul să poată crea lumi tridimensionale, adulții încep să explice că partea albastră din lateral este cerul, nisipul este pământul, iar acoperirea albastră a fundului nisipului este apa. Acum, bebelușul are toate elementele și dimensiunile de bază pentru a crea compoziții uimitoare, basme, universuri și planete întregi.

La începutul oricărei activități, copilul trebuie să-și aleagă personaje miniatură, obiecte, "comori", etc. Cu cât colecția ta este mai diversă, cu atât va avea mai multă alegere copilul. Întreabă-l justifică alegerea de ce nu prefera figuri de oameni, ci dinozauri mici sau pisoi, de ce a luat mai multe numere, de ce avea nevoie de scoici sau butoane. Aceasta va fi prima sarcină. Psihologii cred că obiectele selectate simbolizează starea psihologică a micuțului sau adolescentului în momentul actual al vieții.

specifica, ce și de ce creează sau demolează în lumea sa nisipoasă - va ajuta la stabilirea contactului și va deschide o mulțime de lucruri interesante despre viziunea asupra lumii, experiențele și factorii stresanți. Atitudinea atentă la nisip și figurine este cea de-a treia sarcină pe care trebuie să o insuflați în copilul dumneavoastră încă de la început. Nu ar trebui să le împrăștie, să-și piardă.

După încheierea sesiunii de tratament, va trebui să returnați cifrele în locurile lor, să le aranjați în ordinea inițială.

Jocurile pot fi:

phonemic - însoțită de pronunția sunetelor individuale pentru a-și asigura pronunția;

dezvoltarea și învățarea (citirea, numărarea);

proiecție (copilul se asociază cu o singură figură și își construiește propria lume);

corectivă (trebuie să creați o lume care să fie plină de creaturi înfricoșătoare și înfricoșătoare, situații teribile, copilul trebuie să-și ilustreze temerile);

familie (când atât copilul, cât și membrii familiei sale construiesc lumea în același timp).

Pentru copii cu tulburări de vorbire și întârzierea dezvoltării vorbirii jocurile de direcție fonemică - tigrii ("rr-r"), cocoșul ("ku-ka-re-ku") etc sunt mai potrivite. le.

Pentru copiii cu autism și copiii cu dificultăți de comunicare jocuri de familie potrivite și proiecție. Proiecția asupra lor înșiși este, de asemenea, necesară pentru copiii care au fost victime ale violenței, au suferit o pierdere gravă, un stres sever. În stadiul de tratament, sarcinile de proiecție sunt treptat transferate sarcinilor corecționale pentru a descoperi temeri și probleme profunde.

Copii cu retard mintal educaționale și educative vor beneficia. Aceeași categorie de sarcini este potrivită pentru toți prescolarii și elevii de școală primară.

Clasele și exercițiile sunt individuale și grupate. Pentru ca acasă să practice terapia cu nisip, părinții vor trebui să facă o cutie care să se potrivească dimensiunilor specificate în lățime și înălțime (dimensiunile indicate mai sus). Clătiți nisipul în mai multe ape și uscați bine. Dacă nu există dorință sau capacitate de a cumpăra seturi de cifre, colectați toate elementele miniaturale care, în opinia dvs., ar putea fi de interes pentru construirea unei noi lumi - butoane, coșuri de nuci, nuci, dopuri, capace metalice, oase de piersici și cont de copii, margele mari, conuri și semințe, jucării mici (de exemplu, din ouă de ciocolată).

Înainte de începerea orelor de curs, mama trebuie să decidă în ce direcție să construiască sesiuni de tratament, pentru asta aveți nevoie desfășurați un joc de proiecție pentru diagnosticare. Copilul ar trebui să atragă pe nisip orice semne și cifre cu degetele, ceea ce va ajuta cel puțin să înțeleagă esența problemelor sale. Cum să le descifrăm, vom spune mai jos.

Dacă nu este posibil să diagnosticați în mod independent problemele psihologice ale copilului, consultați un psiholog. O mulțime de cunoștințe utile vor fi oferite mamei mele prin cartea "Minunile în nisip" de T. Zinkievich-Evstigneeva.

Unele clădiri și semne de nisip comune ale copiilor în nisip ajutați părinții să înțeleagă mai bine ce simte copilul și ce are nevoie:

castele de nisip sau case, garduri și pereți cu ziduri groase - nu este suficientă siguranța, nesiguranța, frica și nevoia de protecție;

haosul haotic, confuzia în simboluri și semne - haos și confuzie în interiorul copilului însuși;

lipsa figurilor umane cu posibilitatea alegerii lor - dorința de a se izola de oameni, de a le răni, de teamă și de durere;

cercurile trase pe nisip - dorința de schimbare, lipsa de iubire și de îngrijire;

spirale - lipsa de comunicare, oboseală, coșmaruri;

colțuri ascuțite și linii sfâșiate - conflicte interne, gelozie, furie.

Potrivit părinților, terapia cu nisip deja după câteva săptămâni, beneficiul devine vizibil - copilul îmbunătățește somnul și apetitul, mai puține ori există izbucniri de furie sau isterie. Exercițiile sistematice cu nisip cel puțin de două ori pe săptămână contribuie la creșterea performanțelor școlare.

Tehnica este simplă și ușor de înțeles pentru toți și, prin urmare, feedback-ul despre aceasta este în mare parte doar pozitiv.

Veți afla mai multe despre terapia cu nisip și beneficiile sale în următorul videoclip.

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Terapia cu nisip pentru copiii preșcolari: beneficii, clase pentru copii de 2-3 ani, recenzii ale tratamentului cu nisip

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Ce este terapia cu nisip pentru copii și cum este util? Există contraindicații? Cum să conduci clasele în mod independent pentru copiii de vârstă preșcolară și școlară și care ar trebui să fie baza pentru cursurile pentru copiii de 2-3 ani? Cum de a corecta bolile cu ajutorul terapiei cu nisip?

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Sandplay reprezinta o abordare terapeutica eficienta si accesibila de vindecare a persoanei in intregul ei. Bazandu-se pe vaste cunostinte de mitologie si folclor, dar mai cu seama pe dezvoltarile analizei jungiene, autoarea explica felul in care imaginile in nisip contribuie la autoreglarea psihicului, iar interpretarea simbolurilor spatiale ajuta la clarificarea si depasirea blocajelor interioare. La fel ca pictura, analiza viselor sau imaginatia activa, modelarea in nisip are meritul de a aduce intr-un spatiu imaginar procese inconstiente si emotii nespuse, care sunt mult mai greu de accesat in urma unei simple „cure prin vorbire". Prin coimplicarea trup si suflet in jurul cutiei cu nisip, analistul si pacientul obtin o imagine concreta a evolutiei relatiei terapeutice, dar mai ales descatuseaza capacitatea pacientului de autovindecare.

Volumul include o serie de istorii de caz, dar si ilustratii fotografice si sfaturi practice pentru psihologii care sunt tot mai interesati de metoda sandplay. Pe langa virtutile sale vindecatoare, terapia prin jocul cu nisip serveste si diagnosticarii, putand fi utilizata atat pentru adulti, cat si pentru copii.

Tehnica jocului cu nisip i se potriveste lui Ruth Ammann ca o manusa. (Verena Kast)

Ruth Ammann, analista jungiana, s-a format sub indrumarea Dorei Kalff, creatoarea terapiei prin jocul cu nisip. Este formatoare la Institutul Jung din Zurich. A mai publicat carti despre simbolistica gradinii si casei.

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Terapia prin jocul cu nisip - Sandplay - Ruth Ammann

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Sandplay reprezinta o abordare terapeutica eficienta si accesibila de vindecare a persoanei in intregul ei. Bazandu-se pe vaste cunostinte de mitologie si folclor, dar mai cu seama pe dezvoltarile analizei jungiene, autoarea explica felul in care imaginile in nisip contribuie la autoreglarea psihicului, iar interpretarea simbolurilor spatiale ajuta la clarificarea si depasirea blocajelor interioare.

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Sandplay therapy - jocul cu nisip ca metodă terapeutică

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Materiale video despre sandplay limba engleză

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Materiale video despre sandplay limba engleză

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"Sand" - An example of its use in Play Therapy

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May 25, 2013 - Psychology In Seattle Podcast - Episode: Sandplay Therapy - 2008-12-22 - Hosted by Kirk Honda

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Daniela Neagu - Presedintele Asociatiei Romane pentru terapia cu nisip

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Daniela Neagu - Presedintele Asociatiei Romane pentru terapia cu nisip