Advanced Sandtray Therapy: Digging Deeper into Clinical Practice [1 ed.] 0367554828, 9780367554828

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“From the opening poem, this book is an invitation into the mysteries of making healing worlds in the sand. Linda Homeyer and Marshall Lyles blend meticulous research about the effcacy and process of sandtray therapy with a poetic love affair with sand and miniatures, clients, and clinicians. Embracing therapists from many theoretical orientations who support a beautiful diversity of people, the authors provide solid ground for the advanced practice of this sacred healing art.” —Bonnie Badenoch, PhD, LMFT, cofounder of Nurturing the Heart with the Brain in Mind and author of The Heart of Trauma “This is a book that flls a huge gap regarding the deeper practice of sand therapy. Reading it I thought of three symbols: 1) A star for illumination of what is not visible; 2) an anchor, for grounding in theory and history; and 3) a compass, for a reliable guide to knowing where we are and fnding our way when uncertain or lost. Linda Homeyer and Marshall Lyles are a great team and I applaud this wonderful contribution to our growth using this approach we love so dearly.” —Eliana Gil, PhD, LMFT, RPT-S, ATR, founder of The Gil Institute for Trauma Recovery and Education, LLC “Homeyer and Lyles talk about ‘digging deeper’ into the world of sandtray therapy and defnitely deliver on that promise. In the sandtray therapy world, which is diverse in thought and application—and, sometimes not as theoretically and technically deep as need be—this is a refreshing addition. This book is a welcome companion to Homeyer and Sweeney’s text and deserves to be on the shelves of both practitioners and educators.” —Daniel Sweeney, PhD, professor and director of the NW Center for Play Therapy Studies at George Fox University and coauthor of Sandtray Therapy: A Practical Manual

ADVANCED SANDTRAY THERAPY Advanced Sandtray Therapy deepens mental health professionals’ abilities to understand and apply sandtray therapy. Chapters show readers how to integrate clinical theory with sand work, resulting in more focused therapeutic work. Using practical basics as building blocks, the book takes a more detailed look at the ins and outs of work with attachment and trauma, showing therapists how to work through the sequence of treatment while also taking into account clients’ trauma experiences and attachment issues. This text is a vital guide for any clinician interested in adding sandtray therapy to their existing work with clients as well as students in graduate programs for the mental health professions. Linda E. Homeyer, PhD, LPC-S, RPT-S, is a play therapist, sandtray therapist, author, and distinguished professor emerita at Texas State University. After thirty years of practice she is now semi-retired but continues to write and play in the clay in Texas. Marshall N. Lyles, MA, LMFT-S, LPC-S, RPT-S, is an EMDRIA-approved consultant and has 20 years of experience as a trainer, author, and clinician in Austin, Texas, where he owns and manages The Workshop.

ADVANCED SANDTRAY THERAPY Digging Deeper into Clinical Practice Linda E. Homeyer and Marshall N. Lyles

First published 2022

by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2022 Linda E. Homeyer and Marshall N. Lyles The right of Linda E. Homeyer and Marshall N. Lyles to be identifed as authors of this work has been asserted by them in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identifcation and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Homeyer, Linda, author. | Lyles, Marshall N., author. Title: Advanced sandtray therapy : digging deeper into clinical practice / Linda E. Homeyer and Marshall N. Lyles. Description: New York, NY : Routledge, 2022. | Includes bibliographical references and index. Identifers: LCCN 2021013629 (print) | LCCN 2021013630 (ebook) | ISBN 9780367554828 (hardback) | ISBN 9780367554811 (paperback) | ISBN 9781003095491 (ebook) Subjects: LCSH: Sandplay--Therapeutic use. Classifcation: LCC RC489.S25 H65 2022 (print) | LCC RC489.S25 (ebook) | DDC 616.89/1653--dc23 LC record available at https://lccn.loc.gov/2021013629 LC ebook record available at https://lccn.loc.gov/2021013630

ISBN: 978-0-367-55482-8 (hbk) ISBN: 978-0-367-55481-1 (pbk) ISBN: 978-1-003-09549-1 (ebk) DOI: 10.4324/9781003095491 Typeset in Times LT Std

by Deanta Global Publishing, Services, Chennai, India

To colleagues and clients who have taught me so much about playing in the sand and have become woven into my life to shape the person I am. And to God for His presence in a long, playful life. Linda To Heather, Janell, and Isaac whose love has opened my eyes so that I better see the unfolding world. Marshall

Contents Figures.......................................................................................xv Tables ......................................................................................xvii Acknowledgements ..................................................................xix About the Authors ....................................................................xxi Preface................................................................................... xxiii Digging Deeper.......................................................................xxv

Part One

Digging Deeper into Sandtray Therapy Essentials

1

Chapter 1 History in the Making: Past and Present................3 The Wonder Box! ...................................................4 Paths to the Future................................................ 13 In Closing ............................................................. 15 References ............................................................ 15 Chapter 2 Validating the World ............................................ 17 Sandtray Therapy with Refugees and Immigrants ........................................................... 18 Sandtray Therapy for Military Combat Trauma .................................................... 21 Sandtray Therapy with Abused and Neglected Children...............................................22 Structurally Induced Trauma with Intergenerational or Historical Trauma ................24 Sandtray Therapy for those with Neurological Changes ..........................................25 Sandtray Therapy for Autism Spectrum Disorder (ASD) ....................................27 References ............................................................29 Chapter 3 Deeper Exploration of Sand Tray Materials ...................................................... 31 The Sand Tray ...................................................... 31 Sizes and Shapes .............................................. 31 Placement of the Tray ......................................34 With or Without a Ledge.................................. 35 The Sand...............................................................36 The Neurobiological Benefts of Sand .............36 Types of Sand...................................................37 ix

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Contents

Non-sand Substitutes........................................39 Colors of Sand..................................................39 Working “Sandless” .........................................40 The Water ............................................................. 41 Messy Wet-work............................................... 41 The Miniature Figures and Images ......................42 Impact of Guiding Clinical Theory ................. 43 Clinical Issues ..................................................44 Typical Figures for Various Ages.....................44 Symbols and Metaphors...................................45 Organization and Displaying ...........................49 Sand Tray Add Ons .............................................. 51 Back Drops....................................................... 51 Sky Hooks........................................................ 52 References ............................................................54 Chapter 4 Importance of Clinical Theory and Integrating Developmental Theories .................... 57 Importance of Clinical Theory............................. 57 Developmental and Other Theories Informing Sand Therapy Treatment .....................62 Developing Clinical Theory-specifc Treatment Plans....................................................66 Case Studies ......................................................... 67 Case Study One: Adolescent with Anxiety .................................................... 67 Case Study Two: Adult with Childhood Trauma ...........................................72 Case Study Three: Pre-adolescent Adoptee....... 77 In Closing .............................................................82 References ............................................................82 Chapter 5 Person-of-the-Therapist and Use of the Protocol ............................................................. 85 Origin of Person-of-the-Therapist Concept.................................................................86 Information from Lowenfeld and Kalff................89 Person-of-the-Sandtray-Therapist (POST) ........... 91 Marshall’s Journey ...............................................93 Cultural Humility in Sand Work ..........................98 Sandtray Therapy Session Protocol......................99 Step 1: Room Preparation ..............................100 Step 2: Introduction to The Client, The Prompt ....................................................100

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Contents

Step 3: Creation in the Sandtray..................... 101 Step 4: Post-creation....................................... 102 Step 5: Sandtray Cleanup ............................... 102 Step 6: Documenting the Session................... 103 In Closing ........................................................... 104 References .......................................................... 106

Part Two Digging Deeper into Clinical Application

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Chapter 6 Neurodiversity in the Sand Tray......................... 111 Sandtray Therapy and Erikson’s Psychosocial Stages............................................ 112 Very Young Children ..................................... 113 Preschoolers ................................................... 113 Elementary Students ...................................... 114 Middle Schoolers ........................................... 114 Adolescents .................................................... 114 Young Adulthood ........................................... 115 Middle Adulthood.......................................... 115 Late Adulthood .............................................. 115 Additional Stage: Stage 9 ............................... 115 Neurotypical and Neurodiverse Groups ............. 116 Gifted Children and Adolescents................... 116 Autism Spectrum Disorder (ASD) ................. 118 Dementia ........................................................ 119 Working with the Neurotypical in Non-clinical Settings .......................................... 122 In Education: University Level ...................... 122 In Education: Elementary and Secondary School Level.................................124 In Business ..................................................... 128 In Social Science Research ............................ 129 Working toward Understanding ..................... 129 In Closing ........................................................... 130 References .......................................................... 130 Chapter 7 Attachment in the Sand Tray.............................. 133 Attachment Theory Concepts............................. 134 Sandtray Therapy and Attachment Theory ........ 143 Secure Base.................................................... 145 Safe Haven ..................................................... 147 Narrative Coherence ...................................... 149

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Mentalization/Refective Functioning............ 150 In Closing ........................................................... 151 References .......................................................... 152 Chapter 8 Trauma in the Sand Tray .................................... 155 Brief History of Trauma Theory ........................ 155 Trauma and Neuroscience .................................. 158 Sandtray Therapy and Trauma Treatment .......... 162 Sandtray Therapy Session Protocol.................... 165 Step 1: Room Preparation .............................. 166 Step 2: Introduction to the Client, The Prompt .................................................... 166 Step 3: Creation in the Sandtray..................... 167 Step 4: Post-creation....................................... 168 Step 5: Sand Tray Cleanup ............................. 169 Step 6: Documenting the Session................... 170 Sandtray Trauma Treatment Planning and Advanced Methods............................................. 171 References .......................................................... 175 Chapter 9 Resilience in the Sand Tray ................................ 177 Defning Resilience ............................................ 178 Research on Resilience....................................... 179 Neuroscience and Resilience.............................. 181 Using the Sand Tray to Identify Resilience ........ 183 Research in China .......................................... 183 Research in South Africa ............................... 184 Research in the United States ........................ 185 Using the Sand Tray to Enlarge Capacities ........ 185 Person-of-the-Sandtray Therapist and Resilience ........................................................... 190 In Closing ........................................................... 191 Our Journey Concludes … for the Moment ....... 191 References .......................................................... 192 Closing Moments................................................................... 195 1 Sand Trays and Sand ...................................... 197 John Burr 2 Selecting Sand for Your Sand Tray—Characteristics to Consider .................200 Jerry Bergosh 3 Use of the Sand Tray with Children with ASD........................................................202 Robert Jason Grant

Contents

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4 How Sand Tray Brings Safety for Trauma Healing..............................................205 Eliana Gil 5 Sand Tray Adaptations for Elders...................207 Sandi Peters 6 Attachment in the Sand Tray.......................... 210 Bonnie Badenoch Appendices............................................................................. 211 Appendix A: Resources for Sand Trays, Sand, and Miniature Figures ................................... 213 Appendix B: Documentation Cues and Clues .................... 217 Appendix C: Exercises for the Sandtray Witness...............223 Appendix D: Sandtray Prompts for Working with the Person-of-the-Sandtray-Therapist ................225 Appendix E: Annotated Bibliography.................................229 Index....................................................................................... 237

Figures 1.1 Lowenfeld’s First Play Therapy Room. ..............................6 1.2

Dora Kalff’s Sandplay Room. .......................................... 10

1.3 VSA and Lowenfeld’s Original Sand Tray at PlayWell Exhibition..........................................................12 3.1 Trays on the Wall of The Workshop.................................34 3.2 Sand Tray with Ledge and Sky Hook .............................. 35 3.3

Microscopic Views of Three Sands..................................38

3.4 Warrior Protector .............................................................48 3.5 Back Drop ........................................................................ 52 3.6 Sand Landscape................................................................ 52 3.7

Sky Hook with Weather ................................................... 53

4.1

Kosanke’s Sandtray Therapy Model.................................58

4.2

Aspen’s Adlerian Sandtray ...............................................69

4.3

Aspen’s Solution-focused Sandtray ..................................70

4.4 Aspen’s Satir Method Sandtray ........................................72 4.5 Terry’s Adlerian Sandtray ................................................73 4.6 Terry’s Solution-focused Sandtray.................................... 75 4.7

Terry’s Satir Method Sandtray.......................................... 76

4.8 Angel’s Adlerian Sandtray................................................ 78 4.9 Angel’s Solution-focused Sandtray...................................80 4.10 Angel’s Satir Method Sandtray ........................................ 81 5.1 Create a World Where it is Easy to Know What Safe Is ......................................................94 5.2 Create a World Where it is OK to be Seen.......................94 5.3

Create a World of Belonging ............................................95

5.4

Create a World about an Inner Judgement........................96

5.5 Create a World Where Strength and Weakness Work Together.................................................96 5.6

Create a World Putting an Action to Fear ........................97

5.7 Create a World about Your Unfnished Story......................97 xv

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Figures

7.1 Nesting Dolls as Metaphor ............................................ 149 8.1 Kosanke’s Sandtray Therapy Model............................... 163 9.1

Genogram Blocks ........................................................... 188

9.2 Greatness Sticks ............................................................. 189 9.3

Greatness Cards in a Sand Tray ..................................... 189

Tables 4.1

The Neurosequential Model and Sandplay Therapy ........64

4.2 Implications for Sand Tray according to Piaget’s Cognitive Development Levels.........................................65 4.3

Aspen’s Adlerian Treatment Plan.....................................68

4.4 Aspen’s Solution-focused Treatment Plan ........................70 4.5 Aspen’s Satir Method Treatment Plan.............................. 71 4.6 Terry’s Adlerian Treatment Plan ......................................73 4.7

Terry’s Solution-focused Treatment Plan.......................... 74

4.8 Terry’s Satir Method Treatment Plan ............................... 76 4.9 Angel’s Adlerian Treatment Plan .....................................78 4.10 Angel’s Solution-focused Treatment Plan .........................79 4.11 Angel’s Satir Method Treatment Plan............................... 81

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Acknowledgements A wonderful, generous group of colleagues helped us meet the vision we had for this book. Special thanks to the Lowenfeld Trust for permission to use the photo of Margaret Lowenfeld’s frst play room, and to Martin Kalff for providing a current picture of Dora’s sandplay room. Tricia Antoniuk and Elizabeth Hartwig graciously contributed to our case study section. Many areas we wanted to address had little or no published materials. So, we invited colleagues to help with that. Several ‘personal communications’ resulted to provide the reader with new, dynamic information and we are grateful to all of those contributors. Many of those contributors also provided a longer written statement, which can be found in the Closing Moments section. These include: Bonnie Badenoch, Jerry Bergosh, John Burr, Eliana Gil, Robert Jason Grant, and Sandi Peters. Thanks to Mandi Meléndez for her informative interview. A fnal thanks goes to Caleb Matthews, a sandtray therapist and photographer. He took many of our photos as you will see and all the photos at the beginning of each chapter. Special thanks to him! You will see these and more scattered throughout the book. We thank each of you for your work in your specifc area of expertise and allowing us to share it more widely with our readers! Linda & Marshall

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About the Authors Linda E. Homeyer, PhD, LPC-S, RPT-S After over 30 years of work as a play therapist, sandtray therapist, and university professor, Linda is semi-retired. She continues to write, provide professional consultations, and plays in the clay in Canyon Lake, Texas. She most recently directed the Door of Hope Counseling Center in New Braunfels, Texas, where she also provided play therapy and sandtray therapy trainings and supervision. In addition to keynotes and conference presentations in the United States, Linda has enjoyed traveling the globe and has taught play therapy, sandtray therapy, and clinical supervision in Turkey, Lebanon, Jordan, South Africa, Australia, Mexico, Canada, Great Britain, Ireland, Taiwan, Denmark, and even on a cruise ship! Her publications include Sandtray Therapy: A Practical Manual (3rd ed.), The Handbook of Group Play Therapy, Play Therapy in Malaysia, and numerous book chapters and journal articles. Her work has been translated into Turkish, Chinese, Russian, Korean, and Spanish. Linda is a distinguished professor emerita of Professional Counseling at Texas State University. The Association for Play Therapy named Linda as a director emerita and awarded her their Lifetime Achievement Award. Marshall Lyles, LMFT-S, LPC-S, RPT-S, EMDRIA Approved Consultant Marshall Lyles has over 20 years of practice in family and play therapy. He owns The Workshop, a training venue in Austin, Texas. Drawing on lessons learned from working with attachment trauma in a variety of mental health settings, Marshall regularly teaches on trauma, expressive therapies, and attachment-informed family work around the globe. In addition to maintaining a small clinical practice, Marshall also conducts supervision and consultation sessions with counseling professionals who are pursuing EMDR certifcation and RPT status, often with a particular focus on the use of sandtray therapy. Marshall has published in professional journals and magazines and contributed to the books Counseling Families: Play-Based Treatment and EMDR with Children in the Play Therapy Room: An Integrated Approach.

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Preface It was Istanbul. Marshall and I had just fnished a day of teaching in our week-long seminar on Advanced Sandtray Therapy. As is our custom, we were enjoying some downtime and musing over our day. “This would make a great book,” Marshall commented. And here we are! This has been a wonderful journey over a period of time of collecting a sampling of our clinical, teaching, and learning experiences. We are excited to share it with you. We chose a writing style to be a blend of those experiences. It is a more casual style supported with, we hope, suffciently robust academic underpinnings to fulfll those needs in our readers, who like us, want to have sources and a careful review of the literature. However, we also want it to be reader friendly. We hope you feel like you are in Istanbul (or elsewhere) with us, enjoying the moment, enjoying the energy developed with many curious, interactive, playful therapists in the room. This is an advanced book. We are ‘digging deeper’ into how to use sandtray therapy. The assumption is that the reader will have already had some experience using the sand tray and other materials with clients. You will have a working knowledge of the basics. We see this book picking up where Linda and Daniel Sweeney’s book, Sandtray Therapy: A Practical Manual, has already positioned you; or other initial training and supervised sandtray or sandplay therapy experiences. A background in expressive arts and play therapy is immensely helpful. There certainly are many areas of conceptual and practical overlaps. Years of experience in providing any kind of mental health therapy offers a wealth of client understanding. However, our caveat is this: working in the sand tray requires its own unique skill set. We implore you to have training and supervision/consultation in its use. Sand therapies are wonderfully inclusive of so many clinical theories and approaches. Marshall and I both encourage a deep, working understanding of a clinically sound approach to facilitating therapy in the sand. Sandplay therapists adhere to the Kalffan approach. We highly respect them, and they are a model for the rest of —understanding an approach deeply and thoroughly. We hope this book, however, provides information for the general feld of sandtray therapists. We do acknowledge that we share so much in common as sand therapists, though: the tray, sand, water, miniature fgures/symbols, the deep appreciation for how clients use their experience in the sandtray, and with us, to make therapeutic progress.

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Preface

We hope you enjoy and are brought to moments of curiosity as you journey through the book, digging deeper along the way. Marshall and I are honored to bring this to you and share the journeys in our lives that have brought us to this point to be here with you. Linda

Digging Deeper By Marshall Lyles

There is room for you here Room for your joys, your fears Room for your victories and your doubts This is your world for the making Each world deserves witness Every story worth hearing The pages we turn together Reveal this very moment began long ago Connecting to sand and water Balance arrives Allowing images to show the way To any possibility Questions join as guide By not needing an answer Direction does not depend On perfect knowing Your guide is true Not because of a life pain free But because woundedness made way For compassionate curiosity Seeds of difference sowed Brought a harvest of strife So we return to ground and water To remember sweet sensitivity’s gift In the stillness we hear Whispers of relationships past And you fnd freedom to choose If there is room for them in this world

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Digging Deeper

Reclaiming power over world Where terror once landed shakes the soul But we reimagine story’s art Even if words arrive on delay In this world you create Fueled by mystery and light You fnd your inner witness That delights as you bravely dig deeper

Part One Digging Deeper into Sandtray Therapy Essentials

History in the Making

1

Past and Present There is room for you here Room for your joys, your fears Room for your victories and your doubts This is your world for the making History—what an intriguing concept—the moment after you read this, the present becomes history. History is facts, but it is also context. What historical events formed the thoughts and creativity of those who developed our feld? While pondering what infuenced the developers in our feld, how does that context fnd itself in what is created, and how that is laying a stepping stone for the next step in our feld, and then the next? Each day is built on the previous, each advance becomes the basis for the next. So, let’s time travel along on a journey through sand therapy history. “It’s like what we do in our sessions. I lower the bucket, we pull it up, dump it out, the slimy, gross, dark stuff. Once we deal with it all, I go back for another bucket,” shared the adult client as she processed with me about the meaning of the fgure of the wishing well positioned in the corner of her tray. This statement energized Linda’s wonderment with sandtray therapy! The client had experienced a great deal of trauma throughout her life and had signifcant attachment issues. She was a hard-working and motivated client. Her work in the sand tray was so helpful to her, and to Linda. As a doctoral student in the early 1990s, already trained in play therapy, Linda began working in the sand. The above client was one of her very frst clients to use the sand tray. Linda was reading everything she could fnd on sandtray therapy. At that time, there was not a lot. There were plenty of sandplay therapy publications, but she was not Jungian nor psychodynamic in her clinical work. So, Linda began searching the history of sand therapy to expand DOI: 10.4324/9781003095491-1

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Sandtray Therapy Essentials

her understanding and knowledge. Linda continued that journey as a practitioner, academic, and lifelong learner. Along the way, she has continued to be intrigued by this marvelous method of working with clients and colleagues. She has “met” creative and thoughtful individuals who have shaped this intriguing use of such ordinary elements: sand, tray, water, and small fgures. Come join this journey with me. (Fair warning, Linda loves the backstories!)

THE WONDER BOX! . . . sticks, beads, small toys, paper shapes, matchboxes, and such, placed the items in a simple shoebox; this became what the children soon identifed as the Wonder Box.

We begin our journey in London. It is 1928, and Margaret Lowenfeld has just opened her frst clinic. Her early professional experiences included a curiosity about how young adolescent boys, aged 10–14, could resolve war trauma. She now wanted to discover a way to apply that to children in Great Britain (Lowenfeld, n.d.; Lowenfeld, 1979). Linda, too, had become curious about how foster children on her Child Protective Services caseload had apparently been able to resolve their own traumatic, abusive experiences. That began her quest regarding play therapy, and subsequently, sandtray therapy. Born in 1890, Margaret Lowenfeld’s professional work began in 1914 as a medical doctor. As such, she worked as a part of the British Typhoid Unit and the Prisoner of War Departments in eastern Europe after the European War of 1914–1918 and while the Russo-Polish War still raged (Lowenfeld, 1979, p. 1; Lowenfeld, n.d., p. 1). This impact of working in prisoner of war camps, with the many related diseases, was profound. Additionally, because her family were landowners in Poland, she served with the European Student Relief project to help feed and clothe thousands of Polish students just back from serving in the war. Aware of the personal trauma experienced by these young adults she served in Poland, she visited some of these young men once again two years later. Lowenfeld noted most of them were “cheerful and normal” and that it “seemed to me to demand an explanation” to how the apparent recovery had occurred. She was curious if something similar could be created for the children in Great Britain (Lowenfeld, n.d., pp. 1–2). Again in London, in 1925, we see Lowenfeld, now working in pediatrics and determined to gain experience in both child development and child psychology she continued her interest in the “emotional conditions of childhood” (1979, p. 4). While training in clinical research and assisting in a research project on children’s emotional conditions (Lowenfeld, 1939), she realized that language was inadequate in the attempt to study children. She was curious if having children use objects rather than words might be

History in the Making: Past and Present

5

a more productive way to understand them. She remembered having read H. G. Well’s Floor Games (Wells, 1911) as a young adult, so she began collecting sticks, beads, small toys, paper shapes, matchboxes, and such, and placed the items in a simple shoebox; this became what the children soon identifed as the Wonder Box. After providing these objects to children, she reported, “the children understood at once and responded with a naturalness that has persisted throughout the investigation. With this experiment, a door came open and I found the children and myself in contact with one another” (Lowenfeld, 1979, p. 2). Later adding tin trays with sand and a growing selection of items, this soon became known as the World Technique. Documentation of this term’s frst use was in case notes of March 6, 1929 (Lowenfeld, 1979, p. 280; Mitchell & Friedman, 1994). Lowenfeld opened her frst clinic in Notting Hill, The Children’s Clinic for the Treatment and Study of Nervous and Diffcult Children. Unlike her psychoanalytic contemporaries, Anna Freud and Melanie Klein, Lowenfeld intentionally did not develop her work with a specifc theory in mind; instead, she desired to make direct contact with children without interference from the adult (Lowenfeld, 1979, p. 4). Lowenfeld wrote, “I had at that date no theory of the mind and was determined to “avoid” making or accepting one until I should have achieved objective records from which a theory could be built or checked” (1979, p. 3). Lowenfeld provided what she called apparatus: a metal tray which measured 29.5″ × 20″ × 2.75″; half-flled with sand; some implements like shovels, funnels, sieve; unstructured items like rubber tubes, plasticine, tin, pieces of wood; and “oddments of any kind.” She had a nearby drawer cabinet containing miniature objects organized by categories of “living creatures, phantasy and folk-lore, scenery, transport, equipment,” and additional miscellaneous objects: The Wonder Box (1979, pp. 4–5). Lowenfeld used the World Technique and other play materials and approaches, including water play, art materials, movement, and music, to develop the frst play therapy (1979). Lowenfeld also began using the World with adults, stating it was “welcomed by adult patients as an aid to their understanding of themselves and to communicate with their therapist” (1979, p. 5). On our journey, we are startled to observe a mass exodus of children out of London. It was just before the London Blitz in World War II, and over 100,000 never returned because their families either died in the war or could not be located (Prest, 2011). The children were not told of the reason for their having to leave, and parents were told it was in the child’s best interest not to do so. Operation Pied Piper, in 1939, shipped all of London’s children into the countryside for their protection. After the war, some

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children did not want to return, as their unoffcial foster families were the only parents they remembered, having left London when they were so young. Other children reported mistreatment and abuse while in these temporary placements. Think of all the resulting attachment disruptions. Lowenfeld’s clinic moved during the war when the clinic’s space was commandeered by the Kensington Fire Service. Lowenfeld continued her work elsewhere as The Children’s Clinic. After the war, she reopened her clinic, now named, The Institute for Child Psychology (ICP), in a larger space as the children began returning home to their families and a war-torn city (Lowenfeld, n.d; Figure 1.1). As Lowenfeld’s work became more widely known, others became curious about it. Remember, this was a time of profound and pivotal developments in the entire feld of psychotherapy, especially with children. Contemporaries of Lowenfeld included Margaret Mead, Donald Winnicott, Jean Piaget, Anna Freud, Melanie Klein, Susan Isaacs, Alfred Adler, and John Bowlby. Many collaborative interactions occurred as a variety of professionals explored and infuenced each other’s work. Let’s quickly journey to the University of Vienna, where in 1935 we fnd Charlotte Bühler, a child development researcher. Bühler has also become aware of the World Technique (Turner, 1991). While visiting Lowenfeld, Bühler was intrigued by the cross-cultural aspects of children’s work in the created Worlds. Lowenfeld also shared that she had noticed differences in those children’s Worlds who had emotional problems and those who did not. Intrigued, Bühler developed a system similar to the World Technique for researching normal and clinical children’s “scene

FIGURE 1.1

Lowenfeld’s First Play Therapy Room.

Lowenfeld Trust. Used with Permission.

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development.” Bühler standardized a research protocol using 160 miniature fgures, which she labeled “elements,” and had children build scenes on foors or tables, without trays or sand, called The World Test, later renamed the Toy World Test. She researched subjects in several countries and found signifcant differences in the worlds constructed by clinical and non-clinical subjects (Bradway et al., 1981; Bühler, 1951a; Bühler, 1951b). To read more about her fndings, read her original work, or a summary and application in Homeyer and Sweeney’s Sandtray Therapy: A Practical Manual. Let’s stay a bit in Austria, where Hedda Bolgar and Liselotte Fischer are developing the Little World Test in the mid-1930s. Bolgar studied at the University of Vienna with Bühler and was aware of the World Test. Also used for diagnosing and as a psychoanalytic projective technique, they found the Little World Test also could differentiate the non-clinical person from the clinical population. They used a standardized set of 232 fgures on a large table, without sand (Friedman & Mitchell, 1994; Homeyer, n.d.). In 1938 Bolgar and Fischer fed Austria when the Nazis invaded and relocated to the United States. They had planned to standardize and publish the Little World Test in the United States, but that never occurred (Friedman & Mitchell, 2008). Bolgar was only 28 years old when she came to the United States. She went on to have a long professional life, still seeing clients at 102 years of age (Persch, 2011). Our journey in the sand therapy movement takes us next to Sweden. In 1942, after studying with Lowenfeld in 1933, Hanna Bratt modifed the World Technique. Developed for therapeutic and diagnostic purposes, she named her version The Sandtray (Sjolund, 1981; Nelson, 2011). Goesta Harding, a Swedish psychiatrist, inspired by Bratt’s work, also studied with Lowenfeld in 1949. She further developed The Sandtray into the Erica Method (Mielcke, 2005). Harding subsequently developed a detailed, standardized manual for diagnostic and therapeutic purposes at the Erica-Institute in Stockholm (Sjolund, 1981). The materials were standardized as well: 360 miniature toys, organized on shelves with 12 specifc compartments, and two trays, one of dry sand, the other with wet sand (Sjolund, 1981). The Erica Method is still widely used in Sweden. Our journey now crosses the ocean to the United States. We fnd Erik Homburger (who later changed his name from that of his stepfather, Homburger, to Erikson when receiving American citizenship in 1938). Homburger/Erikson, raised in Germany, experienced bigotry as the child of a non-Jewish Dane father and a Jewish Dane mother (Coles, 1970). He fed his homeland in 1933 with his Canadian American wife and two young children, not

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. . . the use of the sand increased the richness of expression, added more information to the analysis of the production, and gave an added dimension to the experience of creating the World. Laura Ruth Bowyer

Sandtray Therapy Essentials

wanting to raise their children in Nazi Germany. Erikson’s life was a series of challenging and traumatic experiences, undoubtedly impacting his creation of the psychosocial human development theory for which he became so well known. In 1938, Homburger/Erikson was part of a large research study at Harvard. For this research, he developed the Dramatic Productions Test. This research used a consistent set of small human fgures and other small toys that college students used to construct a dramatic scene on a square table. The results of the created scene and accompanying story frequently revealed early childhood trauma. Homburger/Erikson stated it was as if the students “picked-up” the traumatic story of their childhood, expressing it in the created scene (Homburger, 1938). Erikson later used this same Dramatic Production Test in a longitudinal developmental study at the University of California at Berkeley. In the Berkeley study, Erikson saw similar childhood trauma themes, along with scenes of family confict. It also appears that he was unaware of Lowenfeld and others’ work in the World Technique or the World Test and developed the Dramatic Production Test without that infuence. Still in the United States on our journey, we fnd Lowenfeld is visiting. She visited three times in the 1950s to participate in cross-cultural projects (Mead, 1974). While on her speaking tour, she observes that there are many adaptations of her World. Some of these adaptations, she noticed, excluded the use of sand and even of trays. Lowenfeld stated she had “considerable anxiety” that “my whole research and therapeutic method should not be misunderstood or distorted when part of the equipment is borrowed and adapted to a different purpose.” She further states that she did not disapprove of the materials being used for testing, nor restrict its use (1950, p. 325). It appears she was not opposed to the continuing development and expansion of her original work, but that it be clearly identifed and recognized as different from the World. Back in Great Britain, Laura Ruth Bowyer, on faculty at the University of Bristol and later the psychology department at the University of Glasgow in Scotland, published her research on Lowenfeld’s Worlds in 1956. This research focused on the developmental and normative study of created Worlds in the sand. Bowyer wanted to see if the use of sand was important, because, as we have seen on our journey, many had stopped using it. She reports “the use of the sand increased the richness of expression, added more information to the analysis of the production, and gave an added dimension to the experience of creating the World” (cited in Mitchell & Friedman, 1994, p. 33; Homeyer, n.d.). With Lowenfeld’s blessing, Bowyer also wrote

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the comprehensive history and uses of the World Technique in the book The Lowenfeld World Technique: Studies in Personality, published in 1970. She also published under her married name, Ruth Pickford. As we journey along, visiting the 1950s, we see Dora Kalff in Zurich and London. A Swiss Jungian child analyst, Kalff was told of Lowenfeld’s speech at the International Congress of Mental Health in Paris in 1937. Carl Jung, who attended this conference, had heard Lowenfeld speak, and knowing of Kalff’s interest in working with children, encouraged Kalff to contact Lowenfeld. At Emma Jung’s (also a Jungian Analyst and wife of Carl Jung) request, Michael Fordham, and friend and colleague of Lowenfeld’s, arranged the meeting (Mitchell & Friedman, 1994). Subsequently, we fnd Kalff in London studying with Lowenfeld in 1956. Returning to Switzerland, Kalff adapted the method, “infusing a symbolic, archetypal orientation” to “the sand tray as a means of contacting and expressing preverbal levels in the unconscious, thus activating regenerative energies” (Mitchell & Friedman, 1994, p. 34). Kalff (1971) acknowledged Lowenfeld’s signifcant contribution: “She understood completely the child’s world and created with ingenious intuition a way which enables the child to build a world—his world—in a sandbox” (p. 32). According to Martin Kalff, sharing from his practice in Zollikon, Switzerland, “… my mother recognized that the creations of the children in the sand correspond to the inner psychic processes of individuation described by C. G. Jung. She developed her method for working with these patterns of individuation in the children’s work, and in agreement with Margaret Lowenfeld, she called this method Sandplay” (Kalff, 2004, p. vii; Homeyer, n.d.). See Dora’s Kalff’s sandplay room as seen in 2020, Figure 1.2. We can also follow Kalff to California in the 1960s as she begins presenting lectures to the Jungian community there. Her Sandplay spread beyond the United States, initially to Italy and Japan. The International Society of Sandplay Therapy (ISST) co-founded by Dora’s son, Martin, continues to expand her work worldwide. If we were to journey to the places where there are now international Sandplay societies, we would have quite the trip: Brazil, Britain/Ireland, Canada, China, Germany, Hong Kong, Israel, Italy, Japan, Latvia, Netherlands, South Korea, Switzerland, United States, and Taiwan (ISST, 2018). ISST maintains the sound teaching and clinical implementation of Kalff’s Jungian approach. The Society’s standards continue to provide the professional community precisely what Sandplay is and what to expect from those who profess to practice this approach. As we will see in the continuation of our historical journey, knowing who is doing what soon becomes complicated. If we were to jump

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Sandtray Therapy Essentials

FIGURE 1.2 Dora Kalff’s Sandplay Room. Photographer, Martin Kalff. Used with Permission.

ahead in history, we would also fnd the Association for Sandplay Therapy founded in the United States in 2015. It was formed to refect Dora Kalff’s values of loving, kindness, clarity, and humility (www.sandplayassociation.com, 2020; Homeyer, n.d.). Returning to California in the mid-1980s we fnd Gisela De Domenico developing Sandtray-Worldtray Therapy (ST-WP). She studied with John Hood-Williams of the Lowenfeld Institute and notes the additional infuences of Lowenfeld and Kalff (De Domenico, 1986). De Domenico (2002) states that ST-WP is “rooted in noninterpretive, client-psyche centered, hermeneutic, and phenomenological traditions” (pp. 1–2). De Domenico (1986) completed phenomenological research of normal preschool children through nondirected sandtray therapy. Many clinicians studied with De Domenico, and her impact is still apparent in the sand therapy world. A quick trip to Australia in the mid-1980s also fnds Mark Pearson and Helen Wilson developing a therapeutic approach termed Emotional Release Counselling (ERC). Their form of sandplay is used to support various ERC modalities. Both Pearson and Wilson studied at the Living Water Centre in the Blue Mountains in Australia, where Jung’s and Kalff’s theories were combined with transpersonal and Gestalt psychology experiential modalities. They adapted Perls’ Gestalt role-play and dreamwork into symbol work, identifying that as part of the processing of a completed sandtray (Pearson & Wilson, 2001).

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Back to the United States, over the next few decades others continue to formulate their own approach to sand therapy. The use in family therapy is identifed and described by several sand therapists, including Lois Carey (1999), Dottie HigginsKlein (2013), and Eliana Gil (2014). Others write about working with specifc clinical theories: Dee Preston-Dillon, Narrative Sand Therapy©; Terry Kottman, Adlerian Sandtray; and Steve Armstrong, Humanistic Sandtray Therapy. While looking in on London, we see Lara Kasa developing SandStory Therapy® (Homeyer, n.d.). As we continue with our journey through history and across the world, we will continue to fnd other clinicians and researchers interested in helping clients. Just as Lowenfeld desired to fnd a way to facilitate growth in mental health for traumatized and “diffcult and nervous children” (Lowenfeld, 1979), clinicians through the decades aspire to do the same. This journey pauses now: the year 2020, in which the global COVID-19 pandemic changed how all forms of mental health services were delivered. Creative sand therapists pivoted many ways to continue their work through telehealth. This included allowing clients via telehealth to direct the sandtray therapist to select miniature fgures and place them in the tray. This allows clients to retain creative control even if the tray was physically with the therapist. Other therapists delivered a small tray and collection of miniature fgures to the client’s home, allowing the client the chance to still touch and interact with the materials. Many other creative experiences and adaptations were developed out of the necessity of delivering services through telehealth. One application, Virtual Sandtray App®© (VSA), developed by Christopher Ewing and Jessica Stone, was already available. Let’s listen to Stone share about creating a sand tray work that is so very different and yet the same. The Virtual Sandtray App® © (VSA) was created in 2011 out of immense respect for traditional therapeutic sandtray work. With foci both on preserving the fundamental tenets of therapeutic sand work and on accessibility, the VSA intends to expand the use of sand work for the people with whom and the places within which the traditional sandtray is not possible. Additionally, digital natives, or those who have always known digital tools to be a part of life, frequently include digital devices, tools, and interaction styles in their identifed culture. As therapists, including and respecting client culture is of great importance. In response to COVID-19, additional features such as screenshare and remote connection have been created within the VSA. Much consideration has been given to achieving a balance between preserving the therapeutic process—including the

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intentional digging, building up, painting, model placement, and alterations, all with the hands—and working to reach as many clients as possible through remote means. One is left with exploring what components of the sand work are ultimately therapeutic and therefore need to be preserved while adapting to a new medium. The VSA has always held these therapeutic components in the forefront. There is an intentional process of creating a traditional sandtray, and there is an intentional process in creating a Virtual Sandtray. Digging down, building up, burying, moving, and so much more—it is a process, it’s not an instant click. When using the VSA, one can experience and feel the intention of the action, the kinesthetic experience of the layers of sand you are moving around, the model placement one by one, the intentional orientation; one can easily become immersed and engaged in the creative process. Create … slow down … peruse the models/images/ items … see things you didn’t even realize would speak to you. Listen and breathe and be. Sandtray takes time to know. (J. Stone, personal communication, September 30, 2020).

No doubt, as the future unfolds, there will be more theoreticallysound approaches and applications to sandtray therapy. The feld needs innovation and growth.

FIGURE 1.3 Exhibition.

VSA and Lowenfeld’s Original Sand Tray at PlayWell

Photograph by Jessica Stone. Used with Permission.

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We will end this journey through history back in London. Between October 2019 and extended by popular demand to April 2020, the Wellcome Collection held the Play Well exhibit (Strainer, 2020). It included Lowenfeld’s World Trays and Stone’s Virtual Sandtray App®© (VSA). Figure 1.3 provides a delightful refection of the beginning and the current state of sand therapy work!

PATHS TO THE FUTURE As a feld grows and develops, more variety ensues. This is essential. Lowenfeld stated, “It is a welcome sign of the life of the ideas embodied in this technique that other workers are now experimenting with modifcations of it” (cited in Bowyer, 1970, p. 16). As more published writings occur and the feld fourishes, words begin to be used in many different and inconsistent ways. We humbly suggest these following usages of words and terms, especially when writing and training, with the hopes of bringing clarity to this ever-growing and expanding feld. ◾ Sand Therapy, sand therapy: The broadest umbrella term that encompasses and is inclusive of all therapeutic interventions using a tray, sand, and small toys/miniatures/ images/fgures and materials. ◾ World Technique: Lowenfeld’s original approach, is always capitalized. ◾ Kalffan Sandplay Therapy: Clearly refers specifcally to Dora Kalff’s method. Using this term initially would be helpful in publications; then the simpler use of sandplay, as many writers are currently implementing. Harriet Friedman and Rie Rogers Mitchell (2021), also use the term Kalffan-Jungian Sandplay Therapy to clearly identify the method then use sandplay. ◾ Sandtray Therapy, sandtray therapy: A generic term inclusive of all non-Kalffan approaches to sand therapy; the collective use of all the typical materials for a session: tray, sand, water, miniature fgures for therapeutic purposes; initially developed by Margaret Lowenfeld. ◾ Sandplay Therapy, sandplay therapy, Sandplay, sandplay: Also refers specifcally to Dora Kalff’s Jungian approach. It is frequently cited that Friedman, a founding member of Sandplay Therapists of America (STA) and a certifed member of the International Society of Sandplay Therapy (ISST), stated that the KalffanJungian Sandplay method should be identifed with a capital “S” (cited in Boik & Goodwin, 2000). However,

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◾

◾ ◾

◾

◾

It is a welcome sign of the life of the ideas embodied in this technique that other workers are now experimenting with modifcations of it. Lowenfeld

since that time she and Mitchell switched using capitalization to lowercase as indicated in their 2008 and 2021 books. The Journal of Sandplay Therapy uses lowercase. STA also uses lower case (L. Freedle, personal communication, February 18, 2021). Sandtray Counseling: refers to sandtray therapy when in settings where the term “therapy” is inappropriate or discouraged, such as schools. Sandtray Play Therapy: Refers to the use of sandtray therapy within the play therapy process. sand tray: Using two words when referring to the tray only, of various sizes and shapes, typically (but not necessarily) blue inside. sandtray: The therapeutic use of the tray during a session. It comprises the client’s work/creation in the tray, refers to a completed or to be completed scene or experience and the sand. miniature fgures/toys/images/symbols: The small items used to create a scene in the sand.

As already noted in the history section, as will continue to happen in the now and in the future, other approaches to sand therapy have and undoubtedly will continue to occur. These are carefully identifed and labeled by their creators. This allows all practitioners in the feld to understand the method or approach that is being discussed. It provides us all a common language to understand and share the work. It is also encouraged that authors use consistent terms in publications. This is particularly important when reporting research. Of concern is the expanded use of the term “sandtray therapy” to include a wide variety of activities and materials, which more appropriately might be identifed as expressive arts. These may be viable, therapeutically sound, and clinically useful. However, these are outside of sand therapy. Where that line is can seem ambiguous. For example, because a client cannot tolerate sand and works without it, does this disqualify the use of the term sandtray therapy? Likely not, as adaptations are being made to meet the therapeutic beneft for a specifc client. Finally, on the subject of core competencies, there are currently no widely held, acknowledged or identifed competencies in sand therapy. To develop a set of broad enough competencies to apply comprehensively to various sand therapy theories and approaches is a daunting task. An agreed-upon set of competencies would assist in further establishing sand therapy and its use. Turner, Schoeneberg, Ray, and Lin (2020), completed a Delphi study on play therapy competencies. They stated the importance

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of such research provides “the foundational conceptualization of play therapy and the specialized knowledge and skills required for effective practice of the scaffolding upon which professional identity in play therapy is built” (p. 177). This holds true for sand therapies as well. The World Association for Sand Therapy Professionals (WASTP) is currently undertaking researching competencies. Watch their website for updates on that research, www.WorldSandTherapy.org.

IN CLOSING History is dynamic and living! As we learn about our sand therapy history it provides a basis for confdence in our work. It provides an understanding of the many rich and diverse ways in which it was and is being used. With this understanding comes responsibility, a responsibility to be well-grounded, well-trained, wellsupervised, and sandtray therapy-literate. Linda and Marshall hope that this book will be a part of that process.

REFERENCES Association for Sandplay Therapy (2020). Equality statement. https://sandplayassociation.com/equality-stat ement/ Boik, B. L., & Goodwin, A. (2000). Sandplay therapy: A step-by-step for psychotherapists of diverse orientations. W. W. Norton & Company. Bowyer, R. (1970). The Lowenfeld World Technique: Studies in personality. Pergamon Press. Bradway, K., Signell, K. A., Spare, G. H., Stewart, C. T., Stewart, L. H., & Thompson, C. (1981). Sandplay studies: Origins, theory, and practice. C. G. Jung Institute. Bühler, C. (1951a). The world test, a projective technique. Journal of Child Psychiatry, 2, 4–23. Bühler, C. (1951b). The world test, a projective technique. Journal of Child Psychiatry, 2, 69–81. Carey, L. J. (1999). Sandplay therapy with children and families. Jason Aronson. Coles, R. (1970). Erik H. Erikson: The growth of his work. Souvenir Press. De Domenico, G. (1986). The Lowenfeld world apparatus: A methodological contribution towards study and analysis of the sandtray play process [Unpublished doctoral dissertation]. Pacifc Graduate School of Psychology, Menlo Park, CA. UMI #8717059. wwwlib.umi.com.libproxy.txstate.edu/dissertations/fullc it/8717059 De Domenico, G. (2002). Weaving together dream, image, and relationship: Moving from anger to fear, to love. International Journal of Play Therapy, 11(1), 1–18. Friedman, H. S., & Mitchell, R. R. (2008). Supervision of sandplay therapy. Routledge. Friedman, H. S., & Mitchell, R. R. (2021). Sandplay wisdom. Routledge. Gil, E. (2014). Play in family therapy. Guilford Press. Higgins-Klein, D. (2013). Mindfulness-based play-family therapy: Theory and practice. W. W. Norton & Company. Homburger, E. (1938). Dramatic productions test. In H. Murray (Ed.), Explorations in Personality (pp. 554– 582). Oxford University Press. Homeyer, L. (n.d.). History of sand therapy. World Association of Sand Therapy Professionals. https://worldsa ndtherapy.org/history-of-sand-therapy Homeyer, L., & Sweeney, D. (2017). Sandtray: A practical manual (3rd ed.). Routledge. International Society for Sandplay Therapy (2018). https://www.isst-society.com/node/4 Kalff, D. (1971). Sandplay: Mirror of a child’s psyche. C. G Jung Institute. Kalff, D. (2004). Sandplay: A psychotherapeutic approach to the psyche (The Sandplay Classics Series). Temenos Press.

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Lowenfeld, M. (n.d.). The Institute of Child Psychology. Margaret Lowenfeld Trust. Lowenfeld, M. (1939). The world pictures of children: A method of recording and studying them. British Journal of Medical Psychology 18(1), 65–101. (Paper delivered to the Medical Section of the British Psychological Society, March 23, 1958.) Lowenfeld, M. (1950). The nature and use of the Lowenfeld World Technique in work with children and adults. The Journal of Psychology, 30, 325–331. http://dx.doi.org: 10.1080/00223980.1950.9916070 Lowenfeld, M. (1979). Understanding children’s sandplay: Lowenfeld’s World Technique. George Allen & Unwin. Mead, M. (1974). Margaret Lowenfeld 1890–1973. Journal of Clinical Child Psychotherapy, 3(2), 56–57. http: //dx.doi.org:10.1080/15374417409532580 Mielcke, J. (2005). The Erica method sand tray assessment. In C. Schaefer, J. McCormick & A. Ohnogi (Eds.), International handbook of play therapy (pp. 177–194). Jason Aronson. Mitchell, R. R., & Friedman, H. S. (1994). Sandplay: Past, present & future. Routledge. Nelson, K. Z. (2011). The Sandtray technique for Swedish children 1945–1960: Diagnostics, psychotherapy and processes of individualisation. Paedagogica Historica, 47(6), 825–840. http://dx.doi.org/10.1080 /00309230.2011.621204 Pearson, M., & Wilson, H. (2001). Sandplay & symbol work: Emotional healing & development with children, adolescents and adults. Australian Council for Educational Research. Persch, J. A. (2011, November 14). At age 102, this therapist is still psyched. Today News. https://web.archive. org/web/20161130191755/www.today.com/id/45287411/ns/today-today_news/t/age-therapist-still-psyc hed/#.WD5E9_krLIU#.WD5E9_krLIU Prest, D. (2011). Evacuees in World War Two—The True Story. BBC. www.bbc.co.uk/history/british/britain _wwtwo/evacuees_01.shtml Sjolund, M. (1981). Play diagnosis and therapy in Sweden: The Erica-Method. Journal of Clinical Psychology, 37(2), 322–325. http://dx.doi.org/10.1002/1097-4679(198104) Strainer, H. (2020, March 20). Play well. https://hazelstainer.wordpress.com/tag/margaret-lowenfeld/ Turner, B. (1991). An evaluation of the effectiveness of training in subjective immersion analysis as an analytic tool in Jungian sandplay therapy. Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol. 59(8-B), pp. 4490. ProQuest Information & Learning. Turner, R., Schoeneberg, C., Ray, D., & Lin, Y.-W. (2020) Establishing play therapy competencies: A Delphi study. International Journal of Play Therapy, 29(4), 177–190. http://dx.doi.org/10.1037/pla0000138 Wells, H. G. (1911). Floor games. Arno Press. (Originally published in England. First U.S. edition, 1912, Boston, MA.)

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Each world deserves witness Every story worth hearing The pages we turn together Reveal this very moment began long ago Research studies in sandtray therapy are increasing. This is a very welcome and essential occurrence. Developing credibility as a mental health treatment approach is based on an established, long-lasting clinical history (as documented in Chapter 1), generating a body of literature (which has also grown exponentially in the last several decades), and validation based on published, peer-reviewed research. Research began alongside Lowenfeld’s development of sandtray therapy nearly 100 years ago. The frst published play therapy research (Dukes, 1938) studied children who participated in play therapy at Dr. Lowenfeld’s Institute of Child Psychology between 1930 and 1938. Lowenfeld’s clinics included sand trays for the World Technique, as well as other play materials, collectively referred to play therapy. This research, therefore included a sandtray therapy experience. One review of the sandtray therapy research can be found in Homeyer and Sweeney’s Sandtray Therapy: A Practical Manual (3rd ed.) (2017) and another is in Mitchell and Friedman’s Sandplay: Past, Present, and Future (1994). A current meta-analysis of sandplay research has just been completed. Wiersma et al. (2021) reviewed 1,715 studies, with only 40 meeting all the requirements to be included in the metaanalysis. This included a screening to be sure that the original study was, in fact, Kalffan Sandplay Therapy (J. Freedle, personal communication, February 3, 2021). The 40 studies represented 8 countries. The overall effect size was an amazingly very large, Hedge’s g=1.10! A very large effect size was also found for other domains, for the treatment of internalizing, externalizing, and ADHD symptoms. This is such exciting news! While, as Marshall and Linda indicate throughout this book, sandplay therapy adheres to one clinical approach, Kalffan-Jungian, it is also DOI: 10.4324/9781003095491-2

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These results [of the meta-analysis] suggest that sandplay therapy is an effective treatment method with children and adults across a variety of mental health disorders including those with internalizing externalizing, and ADHD symptoms. Wiersma et al., 2021

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Sandtray Therapy Essentials

one of the sand therapies. Many commonalities of the use of sand tray and materials provide all sand therapists encouragement for our work. This meta-analysis is a huge boon to our feld. Here we will look at subsequent research with attention to trauma and attachment. A caveat here. When reading research, it is diffcult to assess it when terms are not used consistently or defned within the publication. This is refected by the researchers involved in the metaanalysis cited above. Often the use of the word sandplay occurs. Even when statements about it being Kalff’s form of sand therapy are given, there may be no concepts or terms used to indicate that perspective when reading the treatment/intervention, results, and discussion. It raises the question if the researchers were, in fact, using Kalff’s approach to sand therapy. It does not invalidate the research fndings, of course. However, it does confuse the reader and complicates attempts at replicating the research or implementing the treatment. Also, most research reviewed here does not identify the training and experience of those providing sand therapy treatment/intervention. That information assists in understanding the validity of results. For the feld to continue to be empirically recognized, attention to these areas will be helpful.

SANDTRAY THERAPY WITH REFUGEES AND IMMIGRANTS With increased attention to refugees and migration worldwide, both in refugee camps and those who have become immigrants, some thought-provoking studies have been completed. In 2018, Kronick, Rousseau, and Cleveland indicated that “while global advocacy is beginning to focus on this vulnerable group, children’s own experiences of detention up to now have been largely underrepresented” (p. 242). Stauffer (2008) articulates the attachment, trauma, and mental health issues inherent in the prefight, fight, and resettlement phases. Several international studies using sand therapy have occurred, and some of them are reported here. You will read that two of these studies are written out of a single Canadian research project. It is interesting to see the unique research questions which can be addressed from the same subject-group. This is a wise use of resources and use of the data collected. And it reveals such rich information. This kind of research is not unusual, and it is interesting to highlight it here. An exploratory study with immigrant families to Canada from West and Central Africa and Algeria was completed by Measham and Rousseau (2010). The curiosity was directed at why some children were coping with and managing their war experience

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more successfully than others. This study focused on the different ways a family talked about war trauma experiences and how it related to their children’s play. The study compared a general population group and the clinical group to explore if the children’s play differed (p. 86). The researchers collected data from directed sandtrays and subsequent storytelling with the children and interviews with the parents. Twenty-one children, ages 5–13, from 15 families, participated in the research. All the children had experienced traumatic stress. Each child made ten trays with each tray being prompted by a Thematic Apperception Test (TAT) card. Once completed, the tray was processed with the children using questions regarding what led up to what was happening in the story in the tray, what is happening in the tray, what might occur in the future, and what each character was thinking and feeling. Structure codes were used for the qualitative analysis of the completed sandtrays: fexible, organized, over-organized, disorganized, and empty (p. 88). The fndings indicated that children who could better manage in their daily life created narratives that displayed fexibility. Even though all trays had a theme of violence, all narratives ended either favorably or partially favorably (p. 88). Families who were able to establish a feeling of safety to discuss their experiences, allowing the children the opportunity to process those experiences, appeared to be able to better regulate their behavior. The researchers offered implications for treatment: it may be hypothesized that a therapeutic goal for children who have experienced war trauma may be not so much what a parent discloses to a child about trauma, but rather what particular aspects should be disclosed, how, and when. As a result, disclosure or nondisclosure of traumatic events may not in and of itself be protective or pathology inducing. Instead, the timing and manner of disclosure is important (p. 94).

Kronick, Rousseau, and Cleveland (2018) studied sandplay narratives of 35 children, aged 3–13 years, in Canadian detention centers. The sandplay method used in this qualitative methodology of narrative inquiry was based in Kalff, Lowenfeld, and Bühler’s work and modifed for use with refugee children (p. 425). The children were offered a single sand tray 20″ × 12″ and a box containing objects including representations of various cultural and geographic backgrounds. The children were invited to “create a world” in the tray. Once fnished, the children shared a narrative of what they created. Three broad themes were identifed: confnement and surveillance, loss of protection, and human violence (p. 427). The researchers also noted signifcant fgures and

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themes which were not present in the trays: teachers or school scenes, friends, or symbols of friendship, and use of “magic” to overcome diversity. Lacroix et al. (2007), studied 75 immigrant and refugee preschoolers aged 4–5 in a Montreal, Canada school to examine the impact of extensive media exposure of trauma on children with a history of trauma. The children’s country of origin varied widely, including Pakistan, Sri Lanka, India, Bangladesh, Ghana, Morocco, and Tunisia. The children “created their world” in a sand tray. Two children worked in a single tray, with a divider to designate individual space. The children could choose to remove the partition and create together in one scene. The fgures included multicultural items related to their countries of origin, including fags, houses of worship, deities, different housing types, and clothing. Once done creating the sandtray, the children were invited to tell their story. An art therapist conducted the sessions; the research report did not indicate the therapist’s training or experience in sandplay. The sessions with children began two weeks after the Indian Ocean’s 2004 tsunami, off Sumatra’s coast. This occurrence was not planned, of course, as part of the research. Although all these children lived in Canada, 29% represented the tsunami in their trays (p. 102). It refects the possible distress transmitted to the children by their parents’ worries about the event and the exposure to watching television’s reports of the event (p. 103). In the Western world, it is generally thought that children living in families with sound communication systems and having the opportunity and ability to freely express their feelings about loss will be in a better position to make sense of their experiences (Melvin & Lukeman, 2000). In other cultures, community and parental transmission of experiences (fliation), if they can be worked through in various ways, can be very positive at different developmental stages (Rousseau, Drapeau, & Corin, 1998). For immigrant children, host society institutions, particularly schools, play a key role in external transmission (affliation). (Lacroix et al., 2007, p. 111)

Secondary traumatic stress and vicarious trauma are essential considerations of which to be aware. Many mental health practitioners observed this in the United States, for example, after the World Trade Towers attack on September 11. Children who have lived through fash foods in the Texas Hill Country also reenact foods in their play when there is a heavy rain event. There are many such examples available. Clients may present thematic or concrete content in their trays, which appear incongruent with the presenting issue. However, being alert to other environmental

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factors and world events that inform our work is crucial and may be readily apparent, as described in the research above. Other times it might be very idiosyncratic. Cambra (2019) conducted a meta-analysis of the effectiveness of expressive therapies with refugee children and adolescents. Cambra found a medium effect size (g=0.58) in the pre-post fndings and a small effect size (g=0.32) for between-group data. One of the 17 studies included in the meta-analysis used sandtray therapy with refugee children in Canada (Rousseau et al. 2009). See the discussion of that research next. Rousseau et al., in 2009, reported their research, which was part of a larger project with other researchers (Lacroix et al. 2007; see description earlier in this section). The research project occurred in a school with kindergarteners in a French-Canadian school with a high concentration of recently arrived immigrant and refugee families (p. 744). One-hundred fve children, aged 4–6, in 10 different school classes participated in the study. Half of the classes were randomly assigned to either an experiential or control group. The Strengths and Diffculties Questionnaire (SDQ) completed by both parents and teachers was used to collect pre-post data. The parents’ SDQ responses showed a signifcant symptom reduction in the intervention group; no signifcant change was found in the control group. Cohen’s effect size was small to moderate (total score, d = .36; emotional symptoms, d = .43; relational symptoms, d = .48). The teachers’ reports showed interesting results: no change for the experiential group, but the control group’s symptoms showed a signifcant increase in emotional and behavioral symptoms (d = −.31). The researchers surmised that the sandplay program appears to prevent the increase in emotional and behavioral symptoms for the school setting. Parent focus groups after the posttest revealed that the sandplay was very acceptable to them, as they felt it coincided with some of their cultural traditions and did not feel threatened or stigmatized by it. The teachers were very enthusiastic about the workshops, which helped them to get to know and understand their pupils better. They were, however, quite surprised by how much adversity was expressed in the children’s stories and sand tray pictures. (p. 748)

SANDTRAY THERAPY FOR MILITARY COMBAT TRAUMA A phenomenological study competed by Popejoy, Perryman, and Broadwater (2020) used sandtray therapy for a neuro-integrative approach to process military combat trauma. The researchers

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Sandtray Therapy Essentials

sought to identify military service members’ observed experience while engaging in sandtray therapy to process combat trauma (p. 1). Popejoy et al. included the concept of moral injury with combat trauma, which may result in post-traumatic stress disorder (PTSD). The authors state unanticipated moral decisions may result in intense guilt or shame once returning to civilian life. The four research participants were veterans experiencing PTSD symptoms after exposure to combat trauma. Three were upper enlisted men, one held offcer rank; two served in the Army, one each in the Marine Corps and the Air Force, all identifed as White. Two researchers provided sandtray therapy. One researcher was the spouse of a former military member, counselor educator, and counselor practitioner; the second researcher was a counselor educator with a background in neuroscience and sandtray therapy (p. 4). They practiced sandtray sessions with each other before beginning working with the participants to ensure their approach was the same. All sessions were held in the same sandtray therapy room, were video-recorded, and lasted 1.5 to 2 hours in length. Each session began with a breathing exercise to relax and ground the participant. The prompt was to ‘tell their story in the sand.’ The tray was then verbally processed from a frst-person storytelling perspective. At the end of that sharing, they were asked if they would like to change the story in any way or provide a different ending, including adding additional fgures to the tray. The tray was also rotated, so together, the researcher and participant could view the tray from all perspectives. The researchers believed this enhanced the visceral reaction to what had been created in the tray. Finally, each participant was offered the opportunity to give a fnal refection on the re-storied tray. The researchers coded the session transcriptions and found two primary categories of themes: Sandwork and Emotional Processing. Subthemes were also identifed in the fndings. Sandwork included conveying literal specifcs, reactions to the tray, and restorying the trauma. In emotional processing, they identifed attachment and connection, identity, responsibility, death and destruction, order and upheaval, and betrayal and injustice (p. 6). During a follow-up interview, all the participants reported that the session was “cathartic and benefcial to their emotional wellbeing” (p. 12). The researchers stated that their fndings “demonstrate a clear distinction, but also symbiosis, between the physical sandwork and the verbal-emotional processing” (p. 12).

SANDTRAY THERAPY WITH ABUSED AND NEGLECTED CHILDREN Four Malaysian girls, aged 10–17, who resided in a Malaysian shelter home for abuse and neglect victims, participated in this

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research project. The researchers, Ismail et al. (2019), collected data through direct observation of a single sandtray therapy session. The session was the beginning of the girls’ ongoing counseling. This descriptive, qualitative study analyzed verbal and nonverbal communication in the session, the session documentation, and the tray’s pictures. The researchers stated that the experience assisted the girls’ ability to “go straight to the main issue,” and “a combination of multi senses during the therapy also helped the children to stay focused during and after they had completed their sandtray” (p. 669). The description of the trays and the girls’ discussion had noteworthy components. All the girls had common themes of unhappiness at the shelter home and the feeling of “living a lifeless life, with no aspiration and reason that they could hold on to” (p. 669). The girls reported a lack of relationship with peers and distrust, even fear, of their warden at the shelter home. This insight assisted the girls’ counselors to focus their ongoing treatment. It’s also noted that even with common themes, each girl constructed her tray differently: one was singing and took her time selecting fgures; two selected fgures quickly, one imitating the sounds of the fgures she chose, the second made no sounds; and fnally, the fourth girl moved slowly and deliberately with a happy face. This serves as a reminder that children with disrupted attachment and a history of trauma may present differently in the sandtray process. Children in another shelter home, this time in Nepal, were studied by Maharjan, also in 2019. This research was a multiple case study, qualitative design. Sandplay had been used in these shelter homes since 2006. Barbara Turner, an internationally known sandplay therapy trainer, served as an ongoing consultant for fdelity. The participants were 3–16 years of age and had ten sandplay sessions each. The intervention was provided by two counselors, each of whom had fve participants with traumabased behavioral problems. Six major themes were identifed: 1). the signifcant role of the nonverbal aspects of sandplay; 2). the role of the movement within the psyche in the sandplay; 3). the role of resiliency in the children’s sandtrays; 4). the role of cultural aspects in the children’s sandtrays; 5). the role of the kinesthetic aspects of sandplay; and 6). the role of the nondirective presence of the therapist (pp. 175–176). Additionally, all ten children demonstrated resiliency skills required to overcome trauma symptoms (p. 195). In southern California, a pilot comparison study by Cunningham, Fill, and Al-Jamie (2000) comprised three groups of fve boys each, aged 6–11 years. One group of boys who had experienced protracted sexual abuse; the second group of boys who had experienced medical trauma (chronic or terminal illness

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Sandtray Therapy Essentials

with lengthy hospitalization); and a control group with no known trauma. The boys were Caucasian, Black, Asian, and Hispanic. The sand tray materials were presented similarly to each group, with a large rectangular sand tray and 150 miniature fgures. The medical group used cornmeal rather than sand to lower respiratory risk. Participants were invited to create a picture in the tray. Distinct differences were found: the sexual abuse group averaged 9.3 fgures, the medical group had 9.2, while the non-traumatized control group averaged 46.1 (p. 200). The smaller number of fgures used by all the traumatized participants is theorized by the researchers to be due to their isolation and depression. The control and medical trauma group participants displayed the ability to plan, structure, and integrate the fgures into a single picture. This was not seen in the group of sexually abused participants. The researchers did not fnd any meaningful inference with the types of miniature fgures used. One exception, noted with caution given the small number of participants, was every boy in the sexually abused group used a snake in their tray. Thematically, confict and violence were present in all trays regardless of the group. (One should be reminded that trays by the typical boy of this age show confict; Homeyer & Sweeney, 2017). The hospitalized group had a lower level of aggression, perhaps because of the boys’ lower energy levels when building their scene (Cunningham et al., 2000). The participants who experienced sexual abuse did not show any confict resolution, no justice, and the antagonistic character remained unchanged (p. 201).

STRUCTURALLY INDUCED TRAUMA WITH INTERGENERATIONAL OR HISTORICAL TRAUMA Rural children in South Africa frequently experience structurally induced trauma with intergenerational or historical trauma. Ayres (2016) was interested in exploring the possibility of the assessment value of a single sandtray to screen for trauma in a cross-cultural setting (p. 61) and used a qualitative approach with an interpretivist paradigm using a single clinical case study. The participant was a female student in Grade 9. The fndings indicated that the creation of a single tray was successful in identifying trauma symptoms. The study results include multiple symptoms consistent with other trauma symptoms found in sandplay, sandtray therapy, and play therapy literature. These are too lengthy to report here. One interesting fnding was this one participant built her tray from the short side of the tray. Ayres writes

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that this position of the builder “frequently has to do with discomfort in the physical body and can indicate illness, wounding, or physical intrusion and trauma that the person has experienced” (p. 81).

SANDTRAY THERAPY FOR THOSE WITH NEUROLOGICAL CHANGES Authors have posited that the multi-sensory experience of working in the sand activates various parts of the brain (Badenoch, 2008; Homeyer & Sweeney, 2017; Kestly, 2014). A beginning collection of published research proves an effect in the brain when subjects participate in sand therapy. While this book focuses on sandtray therapy, the research, thus far, uses sandplay. Given the multi-sensory commonalities of the sand therapies, including the tray, sand, water, miniature fgures, creating the tray, etc., this cutting-edge research is vital to highlight here. Another study, built upon the results of a pilot study by Akimoto et al. in 2004 (available only in Japanese) with braindamaged elderly. This second study by Akimoto et al. (2018), showed sandplay resulted in brain changes in the surface areas of the cerebral hemisphere. Using Near-infrared Spectroscopy (NIRS), they found that sandplay “triggered many correlations between multiple brain regions in both hemispheres” and “enabled the retrieval and reprocessing of memories with an optimal amount of executive control” (p. 193). The second study involved a live, real-time short sandplay session, while the young adult male sandplayer created in the sand tray and was connected to the NIRS, was an intriguing method through which the beginning of understanding just what happens in the brain. The NIRS measures cerebral blood fow that is coupled with neuronal activity. The research fndings show a correlation with both the left and right hemispheres working in cooperation. Analyzing the NIRS signals and the video behavior of the sandplayer, suggests that the temporal area and inferior frontal gyrus (IFG) work together. These areas are associated with creative productivity. Also, the temporal regions belong to the default mode network (DMN). The DMN activates in the absence of external commands and activity. It is also activated when people are more internally focused with tasks like autobiographical memory retrieval, envisioning the future, and taking perspectives of others (p. 81). All of these are activities which sand therapists hope clients will be activating and accessing during sessions. (Also see reference to the DMN below in the work with dementia and elders.)

Sandplay triggered many correlations between multiple brain regions in both hemispheres” and “enabled the retrieval and reprocessing of memories with an optimal amount of executive control. Akimoto et al. 2018, p. 193

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Additional observations by Akimoto et al. are that some factors involved in sandplay therapy, such as the sand as a sensorimotor stimulus in the sandbox, the blue color of the bottom of the box, and the therapist, trigger the DMN as well as the executive network (ECN). It could be the dynamic coupling of these two networks that brings about an optimally controlled expression of images. (2018, p. 82)

Finally, let’s allow these researchers to say in their own words some of the conclusions of this important sandplay-brain research: we measured brain activity in the superior temporal cortices and prefrontal cortices during a naturalistic, simulated sandplay session, using NIRS. The real-time measurement has suggested that bilateral (left > right) prefrontal and temporal regions worked in cooperation to retrieve memories and reconstruct them in the sandbox. The experiment has demonstrated that sandplay involves both the left and the right hemispheres of the brain, and some specifc cognitive processes may be involved in sandplay. The dynamic coupling of the prefrontal region and the temporal region, or the frontotemporal network, may play a major role in retrieving memories (i.e. images) and reconstructing them in the sandbox. Furthermore, this dynamic interplay of the memories (the unconscious), and cognitive processes of the conscious mind may be at the heart of sandplay. (2018, p. 82)

Foo et al. (2020) built on this research and studied sandplay therapy’s effect on the thalamus of a 23-year-old female with Generalized Anxiety Disorder (GAD). Using an A-B singlesubject design, the female client received 18 Sandplay Therapy (SPT) sessions in 9 weeks. The sandplay therapist was certifed in play therapy with an additional 350 hours of sandplay training with the International Society of Sandplay Therapy (ISST). The participant was assessed at three points in the research project: Phase A, before the baseline period, Phase B, after the baseline period and before beginning treatment, and Phase C at the end of treatment (p. 194). The Hamilton-Anxiety Rating Scale (HAMA; Hamilton, 1959) and the GAD-7 (Spitzer et al., 2006) were used to collect data regarding anxiety symptoms and completed by the research participant. The thalamus’ scans occurred using a proton magnetic resonance spectroscopy (MRS) quantitively measuring biochemical data in localized brain areas (p. 193). This is a noninvasive technique; the results were interpreted by a radiologist. The sandplay therapist invited the participant to “create a picture” in the sand tray. If the participant chose to share a story of the created scene, the therapist listened to but did not interpret it (p. 194). The fndings on both the HAM-A and the

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GAD-7 found changes from the clinical range for both Phase A and B scores to normal scores at Phase C. The MRS results were reported as an NAA/CR ratio (a measure of neuronal viability). “The NAA/CR ratios for the participant in both the right and left thalamus were below the healthy range during the baseline period and increased into the normal range after treatment” (p. 196). This is an important fnding because the thalamus serves an essential role in processing sensory input from the primary sensory cortices and has reciprocal connection with the amygdala in the limbic system … Thus, it is possible that one way that SPT improves symptoms of anxiety is through thalamo-limbic neural pathways. (p. 196)

Foo and Freedle (2021) completed another study to explore sandplay and the treatment of GAD, expanding on the brain regions measured. This study “explores whether clinical symptom improvement from the use of SPT also involves changes in brain functioning. This study focused on the brain regions implicated in GAD including the hippocampus, amygdala, thalamus and prefrontal cortex” (Abstract). As with the study above, the results showed change from the clinical range to the normal, or trending toward the normal range. The exception is the thalamus was in normal range before and after the sandplay intervention. “This study concludes that SPT is effective in improving clinical symptoms of anxiety in individuals with GAD, and may also result in improvements in neuronal functioning in the limbic system and Pfc” (Foo & Freedle, 2021, Abstract). This research used the same measures as Foo et al. (2020) and has a subject pool of six adult females. The continuation of the brain research continues to be intriguing. It also provides scientifc basis for understanding how the sandtray process works.

SANDTRAY THERAPY FOR AUTISM SPECTRUM DISORDER (ASD) There is very little research with this population, but two studies using sand therapy with children with autism are described here. A case study in Australia with a 7-year-old boy showed remarkable results (Parker & O’Brien, 2011). One session of sandplay occurred weekly for 12 weeks. The baseline behavior logged between 35 and 40 incidents of problematic behavior. These were grouped into visits to the lunch detention room, refusal to participate in class, hitting or biting other children, and classroom tantrums. At the end of 12 weeks, the total score was

SPT is effective in improving clinical symptoms of anxiety in individuals with GAD, and may also result in improvements in neuronal functioning in the limbic system and Pfc. Foo & Freedle, 2021 Abstract

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0–5 total incidents of problem behavior (p. 85). Although the research report does not indicate the training or experience of the researcher with sandplay, several citations in the research article indicate the infuence of Pearson and Wilson (see discussion of their approach to sandplay in Chapter 4). Lu et al. (2010) studied 25 elementary school children in special education classes in Montreal, Canada. Each session began with an opening ritual of 5–10 minutes that included rhythm and movement activities followed by a sandplay session (p. 56). They studied the impact of these interventions to stimulate communication, social interaction, and symbolic play. Their adaptation of sandplay included “a semi-structured child-centered approach, employing techniques like narrating the child’s play, mirroring, and offering fgurines to draw out the play, while remaining sensitive to the child’s reactions” (p. 57). The sessions also used concepts from Greenspan’s Floortime, to “encourage observing, following the child’s lead, opening and closing circles of communication, so that children can elaborate on their self-initiated gestures in order to expand on their ideas and imagination. The aim of using a relational approach in this intervention was to help support the development of imaginative play” (p. 57). Research fndings report: Children responded to this semi-structured sandplay activity with initial tentative involvement, yet over the course of the 10 weeks the increased engagement and investment in the activity supported their developmental skills in communication, socialization, and symbolic elaboration. Children tended to work in a spiral rather than a linear fashion, staying with the same themes and building and expanding, with growing fexibility upon their play capacities over the course of the program. Children could address their particular limitations pertaining to the foundations of relating, communicating, and thinking (Greenspan & Wieder, 2006) that had not been previously mastered, such as sensory exploration, engaging and relating, sharing attention, and purposeful emotional interaction. (p. 63)

Teachers also introduced story structure through creative writing for some children to assist them in organizing their sandtray narrative. After 10 weeks of weekly sessions the children demonstrated “increased verbal expression, engaged and sustained social interaction, and increased symbolic, spontaneous, and novel play” (p. 56). This is an excellent article with much more detail than reported here. For those readers working with ASD clients, you might be interested in reading the full article. For all those in the feld of sand therapy and those working with ASD clients, it is interesting to see the success of using sand

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therapy with clients with ASD. See Chapter 6 for some initial guidelines on using sandtray therapy with ASD clients. It is exciting to read about the positive results found in these research studies. The wide variety of presenting issues, the numerous international settings, and by many different practitioners/researchers further show the effectiveness of sand therapy. The neurobiological studies to provide a scientifc understanding of how the brain interacts with the builder of the sandtray is at its beginning and building. Continued research will build the scientifc underpinning to further validate this work. Having a working knowledge of effective sand therapy research adds to our professional identity.

REFERENCES Akimoto, M., Furukawa, K., & Ito, J. (2018). Exploring the sandplayer’s brain: A single case study. Archives of Sandplay Therapy, 30, 73–84. Ayres, K. (2016). Indicators of trauma in a single sand tray scene of a rural school youth [Unpublished doctoral dissertation]. University of Pretoria. Badenoch, B. (2008). Being a brain-wise therapist. W. W. Norton & Company. Cambra, B. K. (2019). The effect of expressive therapies on refugee children and adolescents: Meta-analytic fndings [Unpublished doctoral dissertation]. Liberty University. Cunningham, C., Fill, K., & Al-Jamie, L. (2000). Sandtray play with traumatized children. Journal of Aggression, Maltreatment & Trauma, 2(2), 195–205. http://dx.doi.org: 10.1300/J146v02n02_09 Dukes, E. (1938). Play-therapy for “problem” children. The British Medical Journal, 213–215. Foo, M., & Freedle, L. (2021). The effects of Sandplay therapy on the limbic system and prefrontal cortex with patients with Generalized Anxiety Disorder. [Submitted for publication]. Foo, M., Freedle, L., Sani, R., & Fonda, G. (2020). The effect of sandplay therapy on the thalamus in the treatment of Generalized Anxiety Disorder: A case report. International Journal of Play Therapy, 29(4), 191–200. http://dx.http://dx.doi.org.org/10.1037/pla0000137 Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32, 50–55. http://dx.doi.org/10.1111.j.2044-8341.1959.tb00467.x Homeyer, L., & Sweeney, D. (2017). Sandtray: A practical manual (3rd ed.). Routledge. Ismail, M. R., Amat, S., Johari, K. S. K., & Mahmud, Z. (2019). Sandtray therapy for young girls in a shelter home. Proceedings of the 1st Progress in Social Science, Humanities and Education Research Symposium (PSSHERS 2019). http://dx.doi.org.org/10.2991/assehr.k.200824.151 Kestly, T. (2014). The interpersonal neurobiology of play: Brain-building interventions for emotional wellbeing. W. W. Norton & Company. Kronick, R., Rousseau, C., & Cleveland, J. (2018). Refugee children’s sandplay narratives in immigration detention in Canada. European Child Adolescent Psychiatry, 27, 423–437. https://http://dx.doi.org.org/ 10.1007/s00787-017-1012-0 Lacroix, L., Rousseau, C., Gauthier, M., Singh, A., Gurere, N., & Lemzoudi, Y. (2007). Immigrant and refugee preschoolers’ sandplay representations of the tsunami. The Arts in Psychotherapy, 34, 99–113. https://ht tp://dx.doi.org.org/10.1016/j.aip.2006.09.006 Lu, L., Petersen, F., Lacroix, L., & Rousseau, C. (2010). Stimulating creative play in children with autism through sandplay. The Arts in Psychotherapy, 37(1), 56–64. https://doi.org/10.1016/j.aip.2009.09.003 Maharjan, C. L. (2019). Sandplay therapy for children with trauma living in a residential facility in Nepal: A multiple case study. Publication No. 27669449 [Doctoral dissertation, California Institute of Integral Studies]. ProQuest. Measham, T., & Rousseau, C. (2010). Family disclosure of war trauma to children. Traumatology, 16(4) 85–96. http://dx.doi.org/10.1177/1534765610395664 Mitchell, R. R., & Friedman, H. (1994). Sandplay: Past, present & future. Routledge.

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Parker, N., & O’Brien, P. (2011). Play therapy-reaching the child with autism. International Journal of Special Education, 26(1), 80–87. Popejoy, E. K., Perryman, K., & Broadwater, A. (2020). Processing military combat trauma through sandtray therapy: A phenomenological study. Journal of Creativity in Mental Health. http://dx.doi.org/10.1080 /15401383.2020.1761499 Rousseau, C., Benoit, M., Lacroix, L., & Gauthier, M. F. (2009). Evaluation of a sandplay program for preschoolers in a multiethnic neighborhood. Journal of Child Psychology and Psychiatry and Allied Disciplines, 50(6), 743–750. Spitzer, R. L., Kroenke, K., Williams, J. B. W., & Lowe, B. (2006). A brief measure for assessing generalized anxiety disorder. European Archives of Psychiatry and Clinical Neuroscience, 261, 303–307. http://dx. doi.org/10.1001/archinte.166.101092 Stauffer, S. (2008). Trauma and disorganized attachment in refugee children: integrating theories and exploring treatment options. Refugee Survey Quarterly, 27(4) 150–163. Wiersma, J. K., Freedle, L. R., McRoberts, R., & Solberg, K. (2021). Meta-analysis of sandplay therapy outcomes research. [Manuscript submitted for publication].

Deeper Exploration of Sand Tray Materials

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Connecting to sand and water Balance arrives Allowing images to show the way To any possibility On the one hand, the materials needed for sandtray therapy appear simple: a tray, sand, water, and a collection of miniature fgures. Most therapists begin with a single, standard tray (perhaps a plastic one), play sand from the local home big-box store, some water in a spray bottle, and several fgures from each category. As the therapist continues this journey of using sandtray therapy, we fnd different clients bring various needs. We become more established in our practices and upgrade our materials: A wooden tray with painted interior, add additional sizes and shapes of trays. We might have some of these new trays contain a different color or texture of sand, or maybe a sand alternative. This chapter will explore all of this and a bit more, digging deeper into the elements of sandtray therapy.

THE SAND TRAY The tray is a critical part of our materials that allow us to do sand therapy. Lowenfeld called the sand tray part of her world apparatus (1991). It was more elegantly referred to by Ruth Ammann as a soul garden (1994). Whatever we choose to call it, the tray is the contained space in which our clients do their therapeutic work.

Sizes and Shapes The Lowenfeld and Kalff sand trays were approximately the same size: 28.5″ × 19.5″ × 3″ (Mitchell & Friedman, 1994, p. 53). This size has become what is referred to today as the standard tray DOI: 10.4324/9781003095491-3

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for sand work. These 556 square inches allows suffcient space for a complex, detailed world to be created. The client has room to create one scene, multiple smaller sub-scenes, before and after sections, comparison scenes, and such. It provides the space that allows the client and therapist to visually take in the tray’s entire creation without moving their head, allowing for one complete visual picture or gestalt. The standard tray typically is painted blue on the interior, simulating water and sky. Painting the interior has been adapted by some for specifc therapeutic issues and client work. If able to paint one’s own tray, an art therapist, Lenore Steinhardt, suggests: . . . the optimum size and shape of the tray will probably be found to vary in different countries and should be in harmony with the proportions of notebooks, typing paper, etc. Lowenfeld 1950, p. 327

A darker blue color encourages depth work, but Steinhardt cautions against the use of too dark a hue, which can bring on grief responses. Equally, too light a shade of blue for the sky-line on the sides of the tray may have the effect of no longer containing the work within the tray. According to Walkes (cited in Steinhardt, 1997), the color blue triggers neurotransmitters which calms the entire body; lowers blood pressure, providing the ability to handle threatening material; the pulse rate slows and breathing deepens, eliminating the fight or fright response (p. 52). Steinhardt uses a medium cerulean-blue in her dry trays; a darker cobalt-blue in the wet tray. (1997, p. 461; Homeyer & Sweeney, 2017, p. 23)

Other sand therapists custom paint their trays’ interiors with colors such as black and red. John Burr, LCSW and Utah play therapist (personal communication, November 23, 2020), shared in his experience that matching colored sand can also be added to further intensify specifc work. Burr shared that black and white sand trays allow clients to work on light and shadow, especially when the trays are placed next to one another. A black tray with black sand is used for facilitating going into the abyss. “The elemental sand trays were designed to invoke each element’s energy and symbol that we experience and are used in work with Native Americans. Children love the gold sand tray with the jeweled bottom as it invokes the experience of fnding a hidden treasure” (J. Burr, personal communication, November 23, 2020; see longer statement by John in Closing Moments at the end of this book). De Domenico (2002) states that when working with trauma, trays that are too small can become “overly charged”; instead, she recommends larger sand trays for trauma work, even 34″ × 35″ × 4.″ This size might also be a useful size to be used with couples and families. De Domenico also indicates that a 5–6foot tray helps some clients who need an even larger space to integrate fragmented life experiences. Because integrating fragmented right-brain memories into a left-brain trauma narrative is

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integral for trauma treatment, this larger tray might also become the standard-of-care for such work. Larger trays for family and group work are helpful. Linda has a 3′ × 3′ × 4″ tray. It can sit on the foor or on two tables placed side by side. It has collapsible wooden sides, and the interior is draped with blue cloth to hold the sand. This makes it portable and easily stored. A large, more permanent custom-made tray might be useful for those who frequently do family and group work. Kestly (2010) used a large round tray for groups with children in elementary school. Smaller trays might also serve us well. School counselors may use small trays, so every classroom student can have their own tray during classroom guidance experiences. Group and family work might begin with each person working in their own individual smaller tray, with later work shifting to one larger communal tray. Other clients may choose to use one or two smaller trays rather than one large tray. The client might, for example, desire to clearly separate or contain parts of their story or work. If smaller trays are offered with various colors or types of sand, a client might include such a tray near, on, or within the standard tray. This can also include various shapes of trays. Square trays are also an option. De Domenico (1998) shares that the nearly square form “may facilitate both the depiction of oppositional and conficting states and the slow integration of the quaternity through the process of centering” (p. 9). For those who fnd work in the center of the tray meaningful, a square tray allows the client to display a more balanced creation, with the edges are more equally distant from the center (De Domenico, 1998). Round trays, even if sourced in garden centers from plant saucers of various sizes, may evoke centering, unity, and mandalas’ construction. For directive experiences, such as building a family constellation by Adlerian therapists or a social atom by Solutionfocused therapists, the round trays may help that process along. Round trays can be custom-made or found by specialty sand tray vendors. De Domenico (1998) found that round trays were especially benefcial for “anxious, agitated, extremely ambivalent, and angry clients” (p. 13). She also indicated that perceived conficts and dualities, when moved from the rectangular tray to the round tray, often then revealed connectedness. This held true during a meditative event hosted by Marshall. Participants were given the choice of approximately 14-inch rectangular, round, or octagonal trays (see Figure 3.1). Every participant chose the round or nearly-round octagonal trays. Thoughtful, introspective creations were observed in all these trays. De Domenico earlier stated that clients using smaller round trays displayed more refective work,

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FIGURE 3.1

Sandtray Therapy Essentials

Trays on the Wall of The Workshop.

Photograph by Caleb Matthews. Used with Permission.

as was shown in this event. She also indicated larger round trays lent toward more exploratory work (1998). Other shapes may also enhance the therapeutic intent. Marshall, who does marriage and family work and attachment work, has a house-shaped tray (see Figure 3.1) available for clients.

Placement of the Tray The optimal sand tray placement in the room, to effectively facilitate the client’s work, allows the client to move around all sides of the tray at their discretion. Some clients will want to view their creations from various perspectives. Others might build from only one side or end. Having the tray on a wheeled table or cart also provides the therapist and client the ability to sit side by side and rotate the completed tray, viewing it from all sides. More on the purpose of that later. Having the tray waist level is also optimal (De Domenico, 2002; Lowenfeld, 1950; Mitchell & Friedman, 1994). Some sand therapists have several tables of different heights to accommodate the client’s age and height. When doing family therapy with young children, having a larger sand tray on the foor accommodates the youngest family member. De Domenico believes that the tray on the foor also encourages placement of miniature items outside the tray and might encourage younger clients to climb into the tray (1998). The tray’s placement on the foor may also encourage regressive

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play, so take this into account when planning your session (De Domenico, 1998). A tray built into a coffee table, or sitting on a low table, allows several people or family members to construct simultaneously while keeping the workspace elevated off the foor. The decision of the placement of the tray is a clinical one, of course. Like all clinical decisions, it should be an informed and intentional one.

With or Without a Ledge A sand tray with ledges is not typical. However, again, a therapist might decide that it is helpful. Clients experiencing impulsivity and attention diffculties often fnd it challenging, particularly early in therapy, to maintain the tray’s boundaries. Clients living in a chaotic environment may express that with items spilling out over the tray in equally unruly ways. Very young children typically create scenes fowing over the edges of the tray. Having the tray with an approximately 3-inch ledge provides the client with a space to extend their work. Ron’s Sandtray (Figure 3.2) has a sand tray with a ledge (or as he labels it, a side entry shelf). This includes room outside the tray, and yet, visually, it is still part of the creative picture. It also may be a purposeful part of the client’s work, such as a spot for angels or other spiritual items, or a place for impending danger or doom, such as dragons or evil images.

FIGURE 3.2

Sand Tray with Ledge and Sky Hook.

Photograph by Brittney Ferguson. Sand tray by Ron’s Sandtrays. Used with Permissions.

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Placing the tray on a table wider than the tray offers similar additional workspace. Some clients simply like to have a place to set miniature fgures they no longer want to use rather than return them to the shelves. Sandtray therapists report neurodiverse clients frequently place miniature fgures outside the tray. Having a ledge or placing the tray on a table (or the foor) might be best practices in these situations.

THE SAND Sand is clearly essential to sand therapies. The very essence of sand is of the earth, the ground. Both actual, symbolic, and metaphoric. Working in the sand can help clients to stay grounded and regulated. Staying suffciently regulated is critical for clients to be able to work on diffcult issues. The metaphorical components of sand allow the client to “go deep.” Lowenfeld began her work in 1925 with the Wonder Box and briefy without sand (Bowyer, 1970, Lowenfeld, 1939). However, once the sand was added in 1929, it became a permanent and standard part of her World work. Her later disagreement with Charlotte Bühler’s research included Bühler’s lack of use of sand. Bühler did not use sand it in her developmental studies. Others had also begun to work without sand (Bowyer, 1970). Bowyer’s later research identifed many benefcial uses of sand and found that constructive use of sand (i.e., the movement of the sand by the client in order to build a creative product) added important dimensions: increased the richness of expression, expanded available information for analysis of the production, and gave added depth to the experience of creating the World. The medium of sand provided the opportunity for subjects to experience and express a large range of emotion through pouring, burying, and hitting the sand … deepened and enriched both the experience and interpretation. (Mitchell & Friedman, 1994, p. 69)

The Neurobiological Benefts of Sand The “added depth of experience” (Mitchell & Friedman, 1994, p. 69) is an earlier acknowledgement about what we now understand is linked to the neurobiological activation of touch and working in the sand. Activating the nervous system is a considerable beneft of sandtray therapy. The tactile quality of the miniature fgures as they are held and then visually observed in the tray, with the meaning-making occurring in our mind, is profound. This is the process of integrating the brain. The use of the sand immediately does the same. Bonnie Badenoch, a marriage and family therapist

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and renowned author in the area of Interpersonal Neurobiology, writes: In my experience, patients who fnd sandplay a natural medium immediately begin to partake of its integrative power as soon as their fngers touch the sand. How might that happen? Imagine plunging your hands into either moist or dry sand. What do you notice? There is an immediate connection between body, feeling, and (sometimes) thought. We can picture the sensation of the sand fowing up the arms to the thalamus, and then to the parietal lobe of the brain, which processes touch. In addition, the occipital lobe will soon be activated for sight. This confuence of sensory streams may partially account for the immediate richness of the experience. (Badenoch, 2008, p. 221)

Linda recalls, in particular, a 10-year old boy, referred to therapy because of anxiety. He spent the frst couple of sessions standing next to the tray, moving both hands back and forth in the sand while being easily engaged in talking. It was clear his tactile sand play was a regulating factor. All of us who have used sandtray therapy know how soothing it is to simply have one hand randomly moving through the sand while sharing more about the created scene or other seemingly tangential verbal work.

Types of Sand There are so many choices of sand! Multiple factors go into the decision making regarding the selection of sand. Many therapists choose sand based on cost. This is very realistic and pragmatic. Most therapists have limited offce space and can only have one, or perhaps two, sand trays, so they may use the same sand for practical purposes. Other sand therapists select their sand based on touch and feel. The grit, or the size of the sand particles, is a therapeutic consideration. Lowenfeld provided the client with a choice of medium coarseness or extra fne sand (Bowyer, 1970; Lowenfeld, 1950). Understanding the therapeutic infuences of the differences, therapists may offer clients a sand texture or grit choice. People may be aware of sandpaper grit—the smaller the grit, the fner the sandpaper. Gardeners may know of the importance of coarser or larger grit, sand for planting succulents and cactus or improving the soil. Boik and Goodwin (2000) state the “fner grits are usually soothing and tend to evoke deeper altered states than the coarser grits” (p. 33). Sand, such as Jurassic Sands’ River Bed Sand®, has coarser grit or grains described as a “rounded, multi-earth-colored sand with a ‘crunchy texture’” (Jurassic Sands, 2020). This sand could provide a metaphorical foundation in the tray of a problematic or “rocky” life-scene.

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Garnet crystal sand, gemstone sand with large grain size, may evoke a magical, fairy-tale landscape. Glass sand, which has a very fne, rounded grain, is almost slippery in feel, might be used by a client to communicate their inability to fnd frm ground on which to build their life. The white smoothness might also evoke other-worldliness or a snowy, icy atmosphere. Given these examples of possibilities, clients’ opportunities to select the type of sand may enhance their therapeutic expression and experience. Geologist Jerry Bergosh, who founded Jurassic Sands, identifes each of their sands in both geological and tactile terms. For instance, their Sparkly White Jurassic StarDust Therapy Sand® geologically is “pure frosted quartz crystals, creamy-white in color, fne-to-very fne grain size, sub-rounded” as well as in tactile terms, “soft, satin, silky and velvety soft pure glass crystals; sparkles and fows like liquid when dry” (Jurassic Sands, 2020). Most sand is formed naturally by wind and water over hundreds of thousands of years. Other sand is made by grinding and crushing rocks, resulting in a rougher, sharper feel, and results in dust as well. Bergosh shares that, grain that is sharp and angular, like those created when rock is crushed and pulverized, will have a rough and coarse feel when stroked by your fngers. Bigger grains also have more texture - a granular feel that is distinct to larger grain sizes. Rounded sand grains typically occur naturally in deserts, oceans, and rivers where wind, wave, and water action have eroded off the sharp edges. The grains are blown and rolled around for eons, and the rounded shape sends the tactile impression of softness and silkiness to the person feeling the sand. Grain size also plays an important role; the smaller the rounded grain is, the softer, more and more silky it feels. (Personal communication, November 23, 2020; See his full statement in Closing Moments)

When possible, sand therapists enjoy the opportunity to provide their clients with options. Linda offers a standard size tray with a terra-cotta colored sand. Slightly smaller trays with white (Stardust®), beige, and garnet sand are available for clients to

FIGURE 3.3

Microscopic Views of Three Sands.

Photographs by Jurassic Sands. Used with Permission.

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select. Clients might place a smaller tray completely inside the standard tray. One client rested the smaller tray flled with white sand on one corner and identifed it as heaven. Options permit diverse possibilities for creativity and expression. See Figure 3.3.

Non-sand Substitutes There may be instances when the use of sand is not practical, possible, or is counter-therapeutic. For example, hospital settings may not allow sand but might allow the glass sand, which can be more easily sanitized. Therapists who travel may fnd the ground corncob material lighter and more easily carried in and out of client homes. KnotSand®, from Jurassic Sands (2020), is made from grinding up the inside core of corn cobs and has a “rough texture, bigger grain size than sand, and pleasing all-natural golden grain color. While dry use is recommended, we know water doesn’t affect it.” Others have used cornmeal (Cunningham et al., 2000) for work in hospitals and clients with respiratory issues. Individuals with sensory processing issues may fnd an alternative within their limits of tolerance, such as rice. Some children, including neurodivergent kids, may be prone to eat the material, so some therapists report using dry oatmeal. Robert Jason Grant (personal communication, January 22, 2021) indicates there are also non-food items which can also be used, such as straw, shredded paper, soap foam, and beads. While for some sand therapists, any alternative is objectionable, the ability to use the symbolic, nonverbal work in the tray overrides the use of an alternative to sand.

Colors of Sand Similar to the above discussion of a variety of sand is the option of colors of sand. Optionally, it would be unmodifed sand, as found in nature. This does, of course, provide many options. Depending on the source, colors may be the beige-gray on Texas beaches; white on beaches in Tahiti, Playa Paraiso, Malaysia; black, found on beaches of Hawaii, Iceland, the Canary Islands; red-orange in deserts of Jordan and Mojave, to name just a few. While traveling the world to collect our favorite sand would be fantastic, some vendors make these available. Bergosh shares, Color is always mentioned by geologists when a sand is described to a sand and play therapist. It is important to note that Mother Nature creates a wide range of minerals of different colors, from purple-pink garnets to the warm terra-cotta color of the US Southwest and many neutral colors in-between. And this naturally occurring color is part of the fabric of the rock and

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diffcult-to-impossible to remove by human means. (Personal communication, November 23, 2020; see his full statement in Closing Moments.)

Lowenfeld offered three sand colors; the two sand textures provided two brown shades, with the fne sand being lighter in color (Bowyer, 1970). She also offered silver sand (Davis, 1992), also identifed as white sand (Lowenfeld, 1991). Silver sand was and continues to be a colloquial label and a gardener’s name for fne white sand used in gardening. It consists largely of quartz particles that are not coated with iron oxides (Sonia Murray, Play Therapist in Great Britain, personal communication, November 14, 2020). Artifcially colored sands are also available at aquarium and craft stores. A middle-school school counselor conveyed her decision to obtain a collection of colored sand. Frequently using sandtray therapy with her students, one shared with her that if she had sand that went along with the emotions in the Walt Disney movie Inside Out, it would help him express himself more easily. She found offering a selection of small plastic trays, each with a different color of sand, along with the Inside Out characters (which had already been in her collection), was a great hit with her students. A word of caution: colored sand purchased at craft stores may be water-soluble, so a client adding water to it will release the dye. Colored sand made for aquariums, of course, should be safe with added water. Burr (personal communication, November 23, 2020) states that he has a large clinical space and has ten different colors (natural and artifcial) of sand and trays. Knowing others do not have such a large space for use, Burr indicates if he could only have one colored sand, he would choose white. He also states, Black sand is used a great deal by teenagers. The shadow aspect of the black color seems to be a draw to them as this is part of what they are dealing with developmentally. The red sand is often used as fre. One client told his offender that the red sand was “a stop sign. You see the red, and it says stop, don’t touch this.” Sometimes a client will choose a colored sand because of its texture, and other times, the color invokes something within the client. The most important aspect of using colored sand is to make sure you do not have a preset meaning to the color. The meaning must always come from the client. (Personal communication, November 23, 2020; also see his full statement in Closing Moments.)

Working “Sandless” While it seems counter-intuitive that one would practice sand therapy without sand, there are valid reasons to do so. Some

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veterans who saw combat in desert regions may not be able to tolerate the use of sand. One therapist taped off a designated space on the foor in which the veterans could work. She and her veteran-client sat on the foor and proceeded to hold effective sessions. Hospitals or other health care settings may not allow sand trays into their facilities regardless of the offer to use a sand alternative. Patients can still beneft signifcantly from the use of miniature fgures and the creating of scenes.

THE WATER Water in various forms is vital to the client’s sand tray experience. It might come in the illusion of the sand tray’s blue-painted bottom to actual water poured into the sand. Other water representations were used as early as Lowenfeld providing mirrors, tin lids, colored paper, or shallow bowls in which to pour water (Bowyer, 1970).

Messy Wet-work An awareness issue here. Some sand therapists report not being able to tolerate the messiness of the exceptionally sloppy, messy nature of lots of water and sand. If this sounds familiar to you, we suggest you take some time and play in the wet, soggy sand. If you live near a beach, go and play in the sand just inside the water’s edge. Let the waves flow in and out over your sand play. Get wet, get sandy, get messy. If not near a beach, get a pan with some sand in the bottom and pour in lots and lots of water. Play joyfully! Sit with the various emotions and sensory responses which are evoked. Tune into yourself. This will allow you to stay attuned to the client who does messy wet play in session. Our clients will only go where we allow them the contained comfort and safety to go, maintaining their ability to perceive felt safety. While witnessing a client playing in the wet sand, the therapist’s mind adds personal meaning based on the therapist’s own prior experience of those sensations. The therapist will then nonverbally, and typically out-of-awareness, communicate that possible discomfort to their client. This is especially true if the felt-sense of the therapist is incongruent with the therapist’s statements. The client’s mirror neurons and neuroception pick up our sense of “icky-ness,” then they may be repulsed from it as well. We must be able to contain their work, just as does the tray. Younger children often engage in messy play, as do clients exhibiting regressed behaviors. It will occur, and we must be ready to delight in it.

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THE MINIATURE FIGURES AND IMAGES . . . your aim is to bring forth all which is a vital aspect of the collective, individual, racial, cultural, historical, spiritual, physiological and emotional heritage of humanity and the planet. De Domenico, 1998, p. 45

A frequent inquiry is how many miniature fgures are needed? Can there be too few? Too many? What is the minimum number required to express oneself? At what point is the client overwhelmed? There is, as well, the infuence of the sand therapist who loves to keep collecting. And collecting. And collecting. Everywhere one goes, we see items that can be added to the collection: a walk on the beach (seashells, sea glass); a walk in the park (leaves, acorns, rocks); truck stops (fgures on keychains, small collectibles); our own children’s play areas (they will never miss those items); well, everywhere! Then there are all the vendors at professional conferences! And the Internet! Oh, dear! So many new and unusual things. Sometimes we cannot be restrained! Linda, somewhat playfully, informs her students that one might need their own 12-step group, as it verges on addictive behavior! De Domenico (1998) reminds us to “select as many objects that are aversive as are attractive to you” (p. 35). Amatruda and Helm (1997/2013) share that the “ideal (and impossible) collection contains everything that is in the world, everything that has been, everything that can be” (p. 11). So, we can see why we keep collecting. Perhaps some guidelines would be helpful. Lowenfeld (1950) stated there should be a suffcient number of choices, fve or six examples of each, so a “wholeness” is provided while not being overwhelmed by a “multiplicity of choices.” Also, she wrote to use a “large collection of small objects, representing the ordinary people and objects found in the world around” (p. 327). Ruth Pickford (1992) stated Lowenfeld’s collection numbered 200–300 items. Kalff (2003/1980) suggests having “hundreds of small fgures of every conceivable type” (p. 9). Joel Ryce-Menuhin (1992), Sandplay therapist in London, writes that his collection numbers about 1,000. Bonnie Badenoch (2008) reminds us that although she now has thousands of miniature objects, she started with plastic trays and “fve drawers of carefully chosen objects, [her] patients still did profound work” (p. 220). Early developers of sand tray’s use as an assessment and therapeutic tool varied in the size of their standardized sets: ◾ 160 (diagnostic), 300 (therapeutic) items for Bühler’s World Toy Test (Bühler, 1951b) ◾ 232 items for Bolgar & Fischer’s Little World Test (Mitchell & Friedman, 1994) ◾ 360 items for Harding’s Erica Method (Sjolund, 1981) Online vendors offer basic sets containing about 75 fgures to premium sets of about 165.

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There are no research studies regarding the optimal size of a set of miniature fgures. A general guideline is to have a foundational number of fgures in each of the categories. Then, the sand therapist can add to the collection to add variety and depth. The sand therapist who works in schools and serves a classroom full of students would beneft from a more extensive set. Those working with groups and families would also want multiple miniature fgures and larger collections. Self-awareness on the sand therapist part will assist in guiding when a set is suffcient for their practice. However, we do want to encourage sand therapists that they do not have to have thousands of miniatures to facilitate effcacious therapy.

Impact of Guiding Clinical Theory The sand therapist’s guiding clinical theory is also a lens to use when selecting miniature fgures. Thinking about how you will be interacting with your clients from that perspective informs possible options you might want to provide your clients. Here are a few possibilities to engage your curiosity about how you work with your clients. Adlerian sandtray therapy provides for both directive and nondirective prompts (Kottman & Meany-Walen, 2018). Some of the more directive prompts will help the sand therapist assess and facilitate the following concepts: ◾ Family constellation: people and family fgures, pets, animal families ◾ Social interest: peers, various aged people fgures ◾ Life tasks: working/school fgures, spiritual, occupations Gestalt therapists work primarily from a nondirective stance. When contemplating that clinical theory’s concepts, one will want plenty of fgures to express: ◾ Opposites and polarities: trees, barren and leafed; fre and ice; sun and moon; baby and skeleton ◾ Boundaries, rigid and permeable: fences, a variety of types; rocks, vegetation ◾ Representations of being “stuck”: rocks, towers, suffcient sand for fgures to be substantially pushed in (e.g., a person buried up to the waist in sand) Family system therapists will fnd many family fgures helpful to complete: ◾ Genograms: various aged people, Genogram Blocks™, representations of death, estrangement, divorce, multiple types of fences

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◾ Family subsystems: babies, children, adolescents, adults of various ages; twins, animal families Solution-focused therapists will beneft from fgures that assist in implementing their particular constructs playfully (Hartwig, 2021): ◾ Scaling: numbered blocks ◾ Successes: trophy, gold medal ◾ Internal resources: heart, star, sun, person with muscles, dancing person, tree, bridge, dragon, tiger, lioness, rainbow ◾ External resources: family fgures, spiritual symbols, fairy godmother

Clinical Issues Also, the effective sand therapist will have a high level of awareness of their clinical population. That may also inform additional selection of fgures. For example, a special education high school counselor served students in the juvenile justice system. She found her adolescent clients needed several police cars, policemen and policewomen, and handcuffs. She also discovered they desired to have jails and judges. Career counselors fnd the need for graduates, various occupational fgures, and human fgures of different ages. Also, having bridges, connectors, and barriers, to express the ability or lack of, get from “here” to “there.” Those working with trauma fnd a wide variety of containers—lots and lots of containers—and fencing, both permeable and invincible, very helpful.

Typical Figures for Various Ages Developmental studies provide us with miniature fgures used by various non-clinical or typical age groups (Amatruda & Simpson, 1997/2013; Bühler, 1951a, 1951b; Bowyer, 1970; Glasse, 1995; Jones, 1986). Some research studies that compare clinical to nonclinical groups also provide insight when looking at fgures used in the non-treatment, non-clinical groups. The list below indicates miniature fgures typically used by these age groupings. These items would be in addition to a well-balanced, basic collection. Age 2–7 years: ◾ Houses, people, trees, fences, animals ◾ More use of animal fgures than humans

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◾ Babies, parents, houses ◾ Bathroom fxtures Age 7–11 years: ◾ Increased number of trees ◾ Farm scenes ◾ Cars, wedding, fre, knights, soldiers Age 11 years and up: ◾ Suffcient fgures to build a town or village including school and place of worship ◾ Landscaping, including trees, bridges ◾ Mythic fantasy, dungeons, princesses Age 21–65 years: ◾ Houses, trees ◾ Places of worship; wedding items, couples Late Adulthood: ◾ Spiritual fgures, fgures of mystery and the unknown

Symbols and Metaphors Beyond the use of miniature fgures as of that which they concretely are, the symbolic and metaphorical use of fgures is where the exquisite, captivating, breathtaking, and healing work of sandtray therapy occurs. Miniature fgures, regardless of our clinical theory approach, are used by clients in their own unique creative ways. Clients develop symbols and metaphors to assist in communication. Sometimes, the client may not be aware of what a symbol or metaphor means, but states that the miniature fgure “just has to be in there.” Typically, the meaning is later revealed to and by the client. This occurs in a variety of ways, from increased client self-awareness to processing with the sandtray therapist. A symbol is a specifc item that represents something else, for example, when a dove symbolizes peace or a fag represents a country. In a sandtray, a client might put a fag amongst a gathering of soldiers to symbolize the soldiers’ allegiance and belonging to one another. The symbol is defned in context and can represent a wide range of ideas. This is why letting the client share the meaning of the symbol is critical. The sandtray therapist might have a clinical hunch on what it might mean, but it is

When the sandplay fgurines become symbols they begin to express the language of our unconscious. Connection to what is unconscious in us supports emotional healing and personal development. Pearson & Wilson, 2001, p. 1

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the client’s symbol, not ours. When the sandtray therapist is attuned with the client during the metaphor’s development and discussion, both have a felt-sense of being understood and understanding. This results in the desired integration (Badenoch, 2008; Dunn-Fierstein, 2013; Kestly, 2014). Linda and Marshall acknowledge those who practice Kalffan Sandplay Therapy view a symbol differently. They see a symbol as an active function of the psyche, serves a transcendent function (Turner, 2005) and is imbued with archetypal meaning. This defnition and use of the symbol are theory-specifc to Jungian and the Kalffan form of sand therapy. A metaphor uses symbolism to express two things that are not alike yet still have something in common, such as giving someone “the cold shoulder.” The metaphor embodies thought and places that thought in a living context (McGilchrist cited in Haen, 2020) or, in the case of sandtray therapy work, within the tray. Metaphors are “vivid descriptors that activate mental imagery and support the representation nature of fantasy and projection” (Haen, 2020, p. 44). Metaphors are developed in the right hemisphere, the intuitive, emotional hemisphere, which also holds our implicit memories, abstract concepts rooted in the body (Lakoff & Johnson cited in Haen, 2020). Once in the tray, metaphors become the bridge to the verbal, rational, logical, linguistic left hemisphere (Dunn-Fierstein, 2013). As the client observes and processes the tray, the right and left-hemisphere integration occurs, from imagery to words. The usefulness of metaphors is to integrate fragmented memories which are held in the left hemisphere, or “simply not integrated fully into the client’s awareness, so the psyche used metaphor to be able to digest it, one piece at a time” (Dunn-Fierstein, 2013, p. 136). Dunn-Fierstein (2013) states clients of all ages may use metaphors in the tray for the following reasons: (a) “to express ideas or process information that is not fully understood yet,” (b) “to express something that is not yet fully conscious but is trying to break through to consciousness;” (c) “to express issues that they are not ready to bring to consciousness,” and (d) “to communicate something more comfortably that is diffcult to say” (pp. 135– 136). Identifying which of these reasons the client may be using will help the sandtray therapist know how to process and use the metaphor with the client. These comments and interaction are what is referred to as staying in the metaphor. Verbally processing the metaphor in the sandtray activates the brain. Research completed by Lai et at. (2019) notes: Several neuroimaging studies provided evidence for the involvement of the concrete domain, by demonstrating sensory-motor activations during metaphor comprehension. Reading tactile

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metaphors (e.g., a rough day) or taste metaphors (e.g., a sweet girl) activates sensory regions responsive to touch and taste (Lacey et al., 2012; Citron and Goldberg, 2014). Reading metaphors with action content (e.g., grasp an idea) activates motor regions involved in motor perception and planning. (Desai et al., 2011, Boulenger et al., 2012, Lauro et al., 2013, Desai et al., 2013, p. 202)

Linda acknowledges that discussing the visual metaphor with the client is not “reading” in the traditional sense; however, we are, in fact, “reading” the visual images, just as reading is observing visual images, also known as words, is a parallel process. Sometimes, sitting quietly and nonverbally in attunement and resonance with the client who is not yet prepared or ready to share the metaphor is the best therapeutically productive choice. Regardless of the verbal or nonverbal level of interaction, when the interpersonal relational system is activated, and there is resonance, “the middle prefrontal regions are active in both of us, increasing the integrative possibilities” (Badenoch, 2008, p. 223). Additionally, Badenoch states that talking about the “emerging meaning of the tray at this stage [after the completion of the building of the tray] can help foster connection between the hemispheres by adding words to the rich experience that has unfolded nonverbally” (2008, p. 224). Novel metaphors are those created by clients and are idiosyncratic. Novel metaphors are alterable, offering their use in therapy signifcant. Terr, as cited in Haen, states “… the metaphor hits the child on two levels—on the ‘story’ level and on his own, more internal level. Highly visualized language, after all, is probably the real language of psychic trauma” (2020, p. 47). The novel metaphor, being changeable, provides the option to make meaning, provide more effective choices and outcomes, and understand and remove activators and triggers. Metaphors are discussed in speech and writing literature as both a way of poetic writing and creative speaking. Novel metaphors, or newly coined metaphors, were studied, and fndings indicated that: conventionalization of novel metaphors specifcally tunes activity within bilateral inferior prefrontal cortex, left posterior middle temporal gyrus, and right postero-lateral occipital cortex. These results support theoretical accounts attributing a role for the right hemisphere in processing novel, low salience fgurative meanings, but also show that conventionalization of metaphoric meaning is a bilaterally-mediated process. (Cardillo et al. 2012, p. 3212)

We suggest that many of the metaphors created by clients in the sandtray are indeed novel metaphors. Unique to their situation, and not part of the conventional metaphors already found in our usage.

Novel metaphors are those created by clients and are idiosyncratic.

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Novel metaphors allow for extended moments of practiced neural integration. Holding these emerging metaphors in mind, especially within a larger narrative, asks multiple domains of the mind to be involved (Wheeler & Dillman Taylor, 2016) and engaging different mental systems encourages cooperation and communication within one’s mental processes. A client-created novel metaphor becomes a gentle opportunity for the client to become refective and metacognitively aware without falling into judgment as easily as one might when disclosing some personal aspect of self more directly, allowing more space for fexible exploration and mindful connection to parts of self needing attention. Clients tend to hold these novel metaphors in their mind and ponder them. This assists in “extending” and deepening the work in the session to that time between sessions. As the novel metaphor is held, deeper meanings emerge, and self-refection is engaged. Linda has mentioned in previous writings an adult female client who created the novel metaphor of a horse in a fenced enclosure (Homeyer & Sweeney, 2017). This novel metaphor had great meaning for the client which unfolded into a more complex understanding of self and therapeutically useful content. Here are two examples of symbols embedded in a novel metaphor: ◾ An adult female places a horse in her tray. At the time, she does not know what it means (Homeyer & Sweeney, 2017). Later, she indicates it is symbolic of horses that are “broken” by men, although the horse is meant to run free

FIGURE 3.4

Warrior Protector.

Photograph by Caleb Matthews. Used with Permission.

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and wild. Then, adding the metaphoric level, she indicates she is like that horse, also broken by men, through their sexual assaults. Understanding the metaphor at two levels increases neural integration. ◾ Another adult female puts a warrior princess fgure in the tray (Figure 3.4). She identifes this as a self-fgure, symbolizing herself as a powerful woman. Placed with Eeyore (from Winnie the Pooh) representing a family member and soldier symbolizing danger, her self-fgure became part of the novel metaphor of her taking the role as the protector and avenger of a family member’s battle with chronic illness.

Organization and Displaying Housed in a set of drawers to reduce the chance the client would be overwhelmed by the number of items, Lowenfeld believed that it was “important that the factor of suggestions be reduced to a minimum … therefore the most satisfactory form of storage is a cabinet with drawers” (Lowenfeld, 1950, p. 328; Bowyer, 1970; Lowenfeld, 1979). Conversely, Kalff preferred shelves of items so the client could easily view them (2003, p. 8). Harding’s Erica Method (Sjolund, 1993) displayed the fgures in a unit of cubbies/shelves with four columns by three rows by category: 1. Column One: Aggressive a. Row One: Vehicles: Airplanes b. Row Two: People and Animals: Soldiers, Cowboys, Native Americans c. Row Three: Static Objects: Fire, Explosions, Cannons 2. Column Two: Peaceful a. Row One: Vehicles: Trains b. Row Two: People and Animals: People c. Row Three: Static Objects: Houses, Churches, Trees 3. Column Three: Peaceful a. Row One: Vehicles: Cars b. Row Two: People and Animals: Farm Animals c. Row Three: Static Objects: Dollhouse Furniture 4. Column Four: Aggressive a. Row One: Vehicles: Boats b. Row Two: People and Animals: Wild Animals c. Row Three: Static Objects: Fences, Traffc Signs

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This is an interesting display cabinet organization, informed for the purposes of developing the Erica Method assessment. It provides us with a perspective which may inform our own. It also may spark curiosity for the thought process for why we place miniature fgures where they are in our own collections. Barbara Turner (2005, p. 360) shared a method of organizing her collection using general developmental ranges: ◾ Highest shelves: (Adults) death fgures ◾ High shelves: (Adults) spiritual and religious fgures ◾ Middle shelves: (Elementary age) soldiers, military vehicles, horses ◾ Lower shelves: (All ages) animals, people, common household furnishings, cartoon and fairy-tale fgures ◾ Lowest shelves: (All ages) archetypal, earthy items: rocks, trees, shells Linda suggests what she calls a world arrangement, beginning with miniature items out of, or above, this world and moving on to what’s in the world. Beginning at the top left shelf of the collection and moving down the shelves: ◾ Spiritual and mystical fgures, including treasure chests, jewels, crystals, Bibles, rosary, etc. ◾ Cartoon and fantasy items ◾ Living things (animate): humans and soldiers, followed by animals (domestic then wild—including dinosaurs), birds (up in the air), sea creatures (going down into the water) ◾ Living things (inanimate): vegetation, such as trees and plants ◾ Things made: vehicles (air, land, water), buildings, fences and signs, landscaping (such as park benches, playgrounds, mailboxes, trash cans, etc.) ◾ Small baskets are placed on the foor, containing household furniture and items, food, etc., such as a more extensive military (soldiers & vehicles) collection. Some smaller baskets or containers may be on the shelves to contact small items, such as coins, marbles, polished rocks, shells, etc. An additional thought is tied to the visual tracking of our collections by our clients. Those cultures who read left to right have a visual bias to look at the top left of a collection and then scan down. Those cultures with Hebrew and Arabic languages, and

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others who read right to left, have a visual bias to visually scan beginning at the bottom right and then scan up. This might infuence where one places the aggressive versus non-aggressive items. Therapeutically, to help establish a safe environment, having clients view neutral or non-aggressive items frst may help. Bonnie Badenoch discusses another way to think about arrangement of fgures that embraces a more right hemisphere way of thinking. “There is something to say for a more organic arrangement with relationships between the pieces themselves and between the therapist and the fgures taking center stage. It seems like this kind of arrangement may invite people into a more right hemisphere relationship with the fgure” (personal communication, February 16, 2021). It is valuable to attempt to view our miniature fgure collection display from a client’s perspective. Is it sensitive to their culture? Their view of cultural differences? Age differences? It may be benefcial to have a friend or colleague come and view your sand therapy space: does it feel welcoming? Do they connect with, or are they put off by the fgures they frst see? Do they feel diminished or marginalized by what they see represented in your collection? Or are they validated and honored? Finally, Turner shares a piece of wisdom, “It takes some doing to fnd our own comfortable way of being with the collection. This is all part of sandplay containment” (2005, p. 360). Given the shelves’ various confgurations in different offces over time, Linda has needed to change her typical plan from time to time and place to place. The changing makeup of Linda’s clientele also expanded her collection in specifc categories to provide the words and symbols they might need. Whatever choices Linda made, it was thoughtful and purposeful, but most of all, it just feels right and is a comfortable way of being.

SAND TRAY ADD ONS Back Drops Clients can also create a back drop to help more fully develop their sandtray creation. Taken from the theatre, back drops add the desired background for the scene created in front of it. Clients might draw the scene themselves, making it uniquely personal. Or, the client can use greetings cards, postcards, magazine pictures, or such (Figure 3.5). Sand Landscapes, available from Sand Therapy Creations, are also called photographic symbols (Figure 3.6). (See Appendix A for their website.) Linda recently had a 9-year-old male client who put words on a long strip of paper that became the back drop for his tray about

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FIGURE 3.5

Back Drop.

FIGURE 3.6

Sand Landscape.

Photograph by Caleb Matthews. Used with Permission.

his parent’s divorce. He wrote feeling words about how he felt regarding the divorce. It was placed in the sand, along the back side of the tray with his created scene in front.

Sky Hooks Linda frst came across this concept when Ron Marincic, of Ron’s Sandtrays, developed the Hang-It. The Hang-It also came with clouds, a rainbow, sun, moon, etc., that could be hung from it.

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He no longer makes or sells them (personal communication, November 23, 2020). He has developed a Sky Hook specifc to a newly added tray to his offerings (look back at Figure 3.2). Linda has this new tray and had an 8-year-old boy carefully balanced a jet plane, and later a helicopter, on the Sky Hook, over a battle scene (similar to Figure 3.2). A 10-year-old girl used a chenille stick to hang a phoenix over her scene. Linda also has clients draw their own weather or other celestial bodies or creatures found in the air (Figure 3.7). One technique is to have the client draw what the current weather would be in their scene; then change it for what they would like it to be. For example, dark thunderstorm changed to a sunny day. It is particularly useful when working with cognitive distortions (CBT), misbeliefs (Adlerian), and self-talk (many theories). A client can draw a thought-bubble and write on it all their current thoughts and beliefs. A second thought-bubble can be made after processing those, which contains more functional, adaptive, cognitive beliefs. Clients could also write out what they hear in their home, school, or work; the words that fll their environment. Clients are often in a toxic environment, and to be able to express in writing what they hear all the time helps to communicate, understand, then dispute and process it. Sky hooks can also be made from ornament holder stand or plastic card holders that forists use in plants or bouquets. While these options don’t actually hang something in the sky, a similar effect can be created. Creative therapists also develop “add ons” in their practices, out of needs and usefulness with their clients. For example, Marshall,

FIGURE 3.7

Sky Hook with Weather.

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a marriage and family therapist, developed Genogram BlocksTM. Clients can write on the blocks, organize the genogram in the sand tray, positioning miniature fgures on the blocks. See examples in Chapter 9, Figure 9.1. Tammi Van Hollander developed Greatness Sticks and Cards (see Figure 9.2 and 9.3 in Chapter 9). She uses these in several different ways. You can check that on her website (See Appendix A). Other clinicians have also developed creative additions for use in the tray! Sand trays and the materials we use in them are simple, and on another hand, quite complex. Where we practice infuences and informs our selection and implementation of the sand and water. Our offering of materials to our clients provides for a wide range of expression and therapeutic use. The miniature fgures, with resulting concrete, symbolic and metaphoric work, enrich their self-awareness and self-exploration. This can occur with remarkably small collections and a single tray. The wonder of this work is the human creativity and seeking to understand self and others.

REFERENCES Amatruda, K., & Simpson, P. H. (2013). Sandplay—the sacred healing: A guide to symbolic process. Trance*Sand*Dance Press. (Original work published 1997.) Ammann, D. M. (1994). The sandtray as a garden of the soul. Journal of Sandplay Therapy, IV(1), 46–65. Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to Interpersonal Neurobiology. W. W. Norton & Company. Boik, B. L., & Goodwin, A. (2000). Sandplay therapy: A step-by-step for psychotherapists of diverse orientations. W. W. Norton & Company. Bowyer, L. R. (1970). The Lowenfeld World Technique: Studies in personality. Pergamon Press. Bühler, C. (1951a). The World Test: projective technique. Journal of Child Psychiatry, 2, 4–23. Bühler, C. (1951b). The World Test: projective technique. Journal of Child Psychiatry, 2, 69–81. Cardillo, E., Watson, C., Schmidt, G., Kranjec, A., & Chatterjee, A. (2012). From novel to familiar: Tuning the brain for metaphors. NeuroImage, 59, 3212–3221. http://dx.doi.org:10.1016/j.neuroimage.2011.11.079 Cunningham, C., Fill, K., & Al-Jamie, L. (2000). Sandtray play with traumatized children. Journal of Aggression, Maltreatment & Trauma, 2(2), 195–205. http://dx.doi.org: 10.1300/J146v02n02_09 Davis, M. (1992). Play symbolism in Lowenfeld and Winnicott. Dr. Margaret Lowenfeld Trust. De Domenico, G. S. (1998). Sand tray world play: A comprehensive guide to the use of sand tray play in therapeutic transformational settings. Vision Quest into Reality. De Domenico, G. (2002). Sandtray-WorldplayTM: A psychotherapeutic and transformational sandplay technique for individuals, couples, families, and groups. Sandtray Network Journal, 6(2). Dunn-Fierstein, P. (2013). Metaphorical language in sandplay therapy. Journal of Sandplay Therapy, 22(1), 133–143. Glasse, C. (1995). Sandplay in the classroom: Teacher’s guide (Rev. ed.). Author. Haen, C. (2020). The roles of metaphor and imagination in child trauma treatment. Journal of Infant, Child, and Adolescent Psychotherapy, 19(1), 42–55. https://doi.org/10.1080/15289168.2020.1717171 Hartwig, E. K. (2021). Solution-focused play therapy: A strengths-based clinical approach to play therapy. Routledge. Homeyer, L., & Sweeney, D. (2017). Sandtray therapy: A practical manual (3rd ed.). Routledge. Jones, L. E. (1986). The development of structure in the world of expression: A cognitive-developmental analysis of children’s “sand worlds” [Doctoral dissertation]. Pacifc Graduate School of Psychology, Menlo Park, CA. Dissertations Abstracts International, University Microflms Number 83–03178.

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Jurassic Sand (2020, October). Jurassic knot therapy sand. https://www.jurassicsand.com/collections/therapy -play-sand/products/jurassic-knot-therapy-sand Kalff, D. (2003/1980). Sandplay: A psychotherapeutic approach to the psyche. Temenos Press. Kestly, T. A. (2010). Group sandplay in elementary schools. In A. Drewes, L. Carey, and C. Schaefer (Eds.), School-based play therapy (pp. 257–281). John Wiley & Sons. Kestly, T. A. (2014). The interpersonal neurobiology of play: Brain-building interventions for emotional wellbeing. W. W. Norton & Company. Kottman, T., & Meany-Walen, K. (2018). Doing play therapy: From building the relationship to facilitating change. Guilford Press. Lai, V. T., Howerton, O., & Desai, R. H. (2019). Concrete processing of action metaphors: Evidence from ERP. Brain Research, 1714, 202–209. doi:10.1016/j.brainres.2019.03.0053 Lowenfeld, M. (1939). The world pictures of children: A method of recording and studying them. British Journal of Medical Psychology, 18(1), 65–101. (Paper delivered to the Medical Section of the British Psychological Society, March 23, 1938.) Lowenfeld, M. (1950). The nature and use of the Lowenfeld world technique in work with children and adults. The Journal of Psychology, 32, 325–331. Lowenfeld, M. (1979). Understanding children’s sandplay: Lowenfeld’s World Technique. George Allen & Unwin. Lowenfeld, M. (1991). Play in childhood. Cambridge University Press. Mitchell, R. R., & Friedman, H. S. (1994). Sandplay therapy: Past, present & future. Routledge. Pearson, M., & Wilson, H. (2001). Sandplay & symbol work: Emotional healing & development with children, adolescents and adults. Australian Council for Educational Research. Pickford, R. (1992). The sand tray update1970–1980. British Journal of Projective Psychology, 37. Ryce-Menuhin, J. (1992). Jungian sandplay: The wonderful therapy. Routledge. Sjolund, M. (1981). Play diagnosis and therapy in Sweden: The Erica-Method. Journal of Clinical Psychology, 37(2), 322–325. http://dx.doi.org/10.1002/1097-4679(198104) Sjolund, M. (1993). The Erica Method: A technique for play therapy and diagnosis, a training guide. Carron Publishers. Steinhardt, L. (1997). Beyond blue: The implications of blue as the color of the inner surface of the sandtray in sandplay. The Arts in Psychotherapy, 245(5), 455–469. https://doi.org/10.1016/S0197-4556(97)00043-9 Turner, B. (2005). The handbook of sandplay therapy. Temenos Press. Wheeler, N., & Dillman Taylor, D. (2016). Integrating interpersonal neurobiology with play therapy. International Journal of Play Therapy, 25(1), 24–34.

4

Importance of Clinical Theory and Integrating Developmental Theories Questions join as guide By not needing an answer Direction does not depend On perfect knowing

We all have a lens through which we see our world: our worldview. It organizes my world, embodies my culture, my understanding of others’ cultures, explains how life works, makes meaning of my life experiences, and brings all aspects into focus. As a therapist, having a clinical lens is equally as important. We have the advantage of viewing, or knowing, several clinical theories from which we can organize our understanding of our clients, their issues, and their world. The clinical theory or approach from which we work must be congruent with our own beliefs; otherwise, we begin our therapeutic relationships from an incongruent stance. For many of us, the selection of our clinical theory was established early in our careers. For some, our approach has changed, morphed, and developed over time. For others, the importance of a clinical theory never occurred to you. However, to do advanced work, we believe that this is the foundation upon which we continue to build throughout our professional life.

IMPORTANCE OF CLINICAL THEORY In sandtray therapy, particularly, we know the importance of “holding” our clients’ work. But what holds us? Clinical theory. Garjana Kosanke (2013) developed a clinical model for sandtray therapy work with adult trauma survivors (Figure 4.1). This model resulted from her thematic content analysis of the professional literature regarding sandtray therapy with adult trauma survivors. DOI: 10.4324/9781003095491-4

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FIGURE 4.1

Sandtray Therapy Essentials

Kosanke’s Sandtray Therapy Model.

Used with Permission.

The application of Kosanke’s model will be discussed in more detail in Chapter 8 “Trauma and Sandtray Therapy.” For now, however, Linda and Marshall suggest it can also apply to sandtray therapy work in general. Note that Kosanke identifed clinical theory as holding the therapist, who in turn, holds the therapeutic work in the sand tray. The concept of holding is multi-leveled: the sand tray, the sandtray therapist, and the clinical theory. Graduate school introduces us to numerous personality and counseling theories. We are also infuenced by the perspective of the graduate school we attended and, quite possibly, signifcant professors. Some programs stress an in-depth study of the seminal theories beginning with Sigmund Freud. Others may emphasize post-modern theories or social justice. Some graduate programs stress the importance of identifying one theory to align with and from which to work. Others may not. There is also variation based on mental health disciplines: counseling, marriage and family, social work, psychology, and psychiatry. So much to sort out! And so much to be aware of! The importance of selecting a clinical theory with which to most closely align is to understand our client and the work to be done. It provides the framework for conceptualizing our client, a metacognitive synopsis. How do we talk about the client with other mental health professionals (in supervision or consultation)? It provides the intention and purpose of what we do in a

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session, our role as the therapist, and what we believe must occur for the client to become functional and mentally healthy. Let’s begin with how we select our clinical theoretical approach that is congruent with our personal belief system. Kevin Fall et al. (2017) suggest that we already have a counseling theory embedded within our existing personal belief system. you already have beliefs about what causes people to be as they are and what they need in order to continue in their development; in the process of living, you already have begun to develop your own fedgling guidebook. (p. 9)

There are four categories of questions whose answers can lead a clinician to the best match for a counseling/clinical theory once articulated. What do you believe about human nature? Do you believe people are basically positive, negative? Neither? How much, if any, of a personality is innate? Is it biologically, genetically determined, or infuenced by epigenetics? Are we a unifed whole or several parts that work together? How do our life experiences impact our personality development? How important is the parenting style? Attachment style? Nurturing vs. neglectful early childhoods impact on neural development? Healthy, caring childhood environment? What about the continuing infuence of the social environment and personal relationships as the person ages? What explains function vs. dysfunction? What do you believe about how a person develops mentally healthy? Conversely, what happens for dysfunction or mental unhealth to occur? What about trauma, and when it occurred during our development? Developmental trauma? Chronic trauma? Adverse childhood experiences? What needs to happen for change to occur? How does a person move from unhealth to health? Dysfunction to function? Are there specifc conditions that need to be met? Are these necessary or suffcient? Is insight needed? Can a person change on their own? What is the person’s level of responsibility for the change? (Adapted from Fall et al., 2017.) Matching these beliefs with a clinical theory requires a working knowledge of various theories’ concepts. A full discussion of theories is beyond the scope of this book. It is, after all, one or more courses in graduate school. Marshall and Linda recommend

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a review of textbooks or other publications to get a comprehensive survey of clinical theory options. See the Recommended Readings list at the end of the book. However, here are a few thoughts to stimulate some thinking and perhaps inspire further exploration for more details.

It is perfectly clear that, confronted with this material [creations in the tray] anyone who will be able to read into these “World” representations components derived from his personal conviction [referring to clinical theories], and that not merely as a result of wish fulflment, but because they are almost certainly to be present there. Lowenfeld 1979, p. 7

◾ Carl Rogers, Person-centered, believed experiencing the six core conditions are suffcient to result in self-actualization. ◾ Albert Ellis, Rational Emotive Behavior, believed that given a choice, the person will demonstrate distorted thinking; the primary goal of life is enjoyment. ◾ Alfred Adler, Individual Psychology/Adlerian, saw people as creative and with a need to belong. He identifed dysfunction as existing in a highly discouraged person; insight is required for change, as is social interest development. ◾ Fritz Perls, Gestalt, believed in the importance of experiencing the “here-and-now” to bring into awareness polarities and providing healthy boundary contact experiences. ◾ Steve de Shazer, Solution-focused, believed people socially construct their reality; focus is on problem-solving and expanding on identifed resources and positive attributes. ◾ Michael White and David Epston, Narrative Therapy, viewed people as having the skills and expertise to change their own lives; able to identify and construct more preferred or alternate personal storylines (narratives). ◾ Virginia Satir, Satir Method (Family Systems), believe people are good and are able to connect in positive, loving ways; family problems result from how individuals attempt to cope with problems. Explore the thought that a therapist will interact and do clinical planning differently if the therapist believes the client is, at the core, able to be creative and is unique and can self-actualize; or if the therapist thinks the client will default to irrational thoughts and must be taught how to dispute distorted thinking. These are essential beliefs to sort out. The role of the therapist also infuences the selection of a clinical theory. This usually focuses on the level of involvement of the therapist in the session. This has led to long discussions regarding Directive vs. Nondirective approaches. Often thought of as a view of theories, it is more about the therapist. Refecting on our personal interactions, are we more directive? Are we the take

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charge, offer opinions, “get on with it,” list-making for decision making, type of person? Or are we more refective, introspective, encouraging, helping others fgure things out? Some personal traits will suggest to us how we will be most comfortable working with clients. Each clinical theory has a corresponding role of the therapist on the directive-nondirective continuum. Some are variable, depending on the phase, and offer appropriate moments for both approaches. Techniques will be the fnal component of a clinical theory that we will look at. This is the way the therapist engages the client to bring about therapeutic change and growth. Adlerians use a wide variety of techniques, both directed by the therapist and self-directed by the client, to help them move through the four phases. Solution-focused and CBT therapists will use specifc techniques with specifc therapeutic intent. Person-centered therapists don’t use techniques but prefer to focus on the therapeutic skills required to provide the core conditions of change. Once again, self-awareness on the part of the person-of-the-therapist will assist in the best-ft of a counseling theory. Just a note here. For this book’s purposes, Marshall and Linda are using the term clinical theory to identify a counseling theory that includes personality development. As seen by the discussion above, a clinical theory explains how personality is formed, dysfunction occurs, and the elements needed for change. Approaches do not have the personality development component. For example, an integrative approach allows the clinician to select the techniques and methods of working from several clinical theories to address the client’s progress through the therapeutic process. Integrative play therapy (Drewes et al., 2011) is one such well-articulated approach. Or it might be a clinically based approach of a way of working with clients that have proven successful for a given clinical population. Dialectical behavior therapy (DBT) is an approach that began with treating suicidality in women and expanded to borderline personality disorders (Chapman, 2006). The prescriptive approach (Kaduson et al., 2020) proposes identifying the client’s therapeutic need and then “prescribing”’ the clinical theory approach. For example, one client with relationship issues might beneft from person-centered or child-centered theory. Another client with impulsivity issues might be better served with a cognitive behavioral theory. The clinician who practices a prescriptive approach is aware of the outcome research to know which clinical theory or approach is most effcacious for specifc mental health diagnoses. Of course, this requires the prescriptive therapist to be skilled in providing many clinical theories. So much to know and understand.

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Once a clinical theory is selected, adaptations will naturally occur as we make it our own and our unique way of working with clients. Adding sandtray therapy provides the opportunity to “translate” skills and techniques into a sand tray experience. These then become well grounded and theoretically sound. The clinical theory holds us, as we hold the client, and the tray holds the work.

DEVELOPMENTAL AND OTHER THEORIES INFORMING SAND THERAPY TREATMENT Other dynamics impact the person of the client, which the therapist needs to be able to understand and integrate. These affect the client’s functioning and inform the therapist in working with the client, the family, and the caretakers in child and adolescent cases. Child development (asymmetrical; neurodiverse—neurotypical and neurodivergent) consists of many components: brain development, attachment rhythms, trauma history, and medical issues, to name a few. Neurobiology informs us of how early childhood experiences shape our brains, bodies, and ability to interact with life. Bruce Perry is an infuential voice in the area of trauma and brain development. Human beings become a refection of the world in which they develop. If that world is safe, predictable, and characterized by relationally and cognitively enriched opportunities, the child can grow to be self-regulating, thoughtful, and a productive member of family, community, and society. In contrast, if the developing child’s world is chaotic, threatening, and devoid of kind words and supportive relationships, a child may become impulsive, aggressive, inattentive, and have diffculties with relationships. That child may require special educational services, mental health or even criminal justice intervention. (Perry, 2005)

Perry’s Neurosequential Model of Therapeutics (NMT) highlights the asymmetrical development. A NMT functional review provides “estimates of which neural systems and brain areas are involved in the various neuropsychiatric symptoms and the key strengths of the child” (Perry & Hambrick, 2008, p. 40). The NMT identifes 32 areas of development tied to the four parts of the brain, including self-regulation, sensory integration, relational and cognitive areas. Perry’s work provides the understanding of asymmetrical development and the impact on a given individual. Interventions which may be accomplished in the sand tray

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include tactile play (sand and manipulating fgures); self-soothing (manipulating the sand, co-regulating with therapist); large and fne motor skills (building in the tray); storytelling (processing the sandtray creation). Lorraine Freedle, a pediatric and school neuropsychologist and a certifed sandplay therapist (STA/ISST) is well published in the area of Kalffan Sandplay Therapy. She interacts frequently with Bruce Perry and developed a table for her article Making Connections: Sandplay Therapy and the Neurosequential Model of Therapeutics (2019). Table 4.1 is an adaptation of that table. Cognitive development is state-dependent. Louis Cozolino (2020) discusses how nature-nurture (genetics-experience) work together through epigenetics to shape our brains and minds, becoming one person different from even those in the same family. The individual develops from both organic and interactional experiences. Neurons and genes are different forms of coded information that remain fexible for the purpose of adaptation. Together, they build our brains, minds, and bodies while modifying them in ways that help us cope with the environment and social challenges we face during development. (Cozolino, 2020, p. 272)

As neurodiverse brain development occurs, so does cognitive development. Jean Piaget’s (1932/1965) four stages of cognitive development are still the standard for understanding neurotypical expectations. When working as a teacher, Cherie Glasse (1995) applied Piaget’s three school-age levels to her students’ work in the sand tray in her classroom. Each student had an assigned weekly time when they had access to the sand tray and could build a scene as they wished. Once completed, Glasse invited them to tell a story of the scene. Glasse noticed some notable academic changes in her students, particularly those who had a diffcult home life. After several years of observation and noting academic changes, Glasse tied what she observed in the sand tray with Piaget’s cognitive levels as shown in Table 4.2. Using Glasse’s (1995) work can help the sandtray therapist assess the client’s cognitive developmental level at the moment. Remember, the client’s work can have many clinical and developmental implications. However, it does provide a point of information to consider. Steve Porges’ (2011) Polyvagal Theory provides understanding of the autonomic nervous system that describes, in part, the elements involved in fght, fight, faint, collapse. Awareness of how safe relationships and secure attachment reside in the ventral vagal arm of the parasympathetic nervous system (PNS) helps the

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TABLE 4.1 The Neurosequential Model and Sandplay Therapy Neurosequential Model of Therapeutics ® Brain Region

Clinical Symptoms

Functional Domain

Examples of Sandplay Therapy Activities/ Themes

Brainstem & Diencephalon

• Trauma Core Symptoms (brainstem) • Depressive and Affect Symptoms (diencephalon)

“Regulate” Sensory Integration & Self-Regulation

• sensory play • massaging the sand, touching, smoothing • rhythmic, bilateral movements • placing stones or mosaics one-by-one • molding, watering, sifting, constructing • pounding, dumping, fooding, destroying • posttraumatic play, “implicit surges” • use of creepy crawlers, snakes, monsters (devouring or protective aspects)

Limbic System

• Relational Diffculties • Alcohol, Substance Abuse

“Relate” Relational Functioning

• creative play • symbolic expression • therapeutic relationship, cotransference • emotions, desires • attachment themes (e.g., nurturing, feeding, abandonment, neglect) • use of animals (instincts, emotions, companions)

Neocortex

• Guilt and Shame

“Reason” Cognitive Problem Solving

• • • • • • •

storytelling, language journey trays refection, self awareness, discovery meaning making, insight abstract, spiritual families, social groups use of humans (roles in everyday life, connections to self, others, and world)

Source: Adapted from Freedle, L. R. (2019). Making connections: Sandplay therapy and the neurosequential model of therapeutics. Journal of Sandplay Therapy, 28(1). Used with permission.

therapist develop an approach for creating a safe therapeutic environment through accessing the social engagement system. The sympathetic nervous system (SNS) seeks to protect the client and moves the client into dysregulation. Therapists who know how to watch for clues that the SNS has come online will be prepared to meet clients in their place of self-protectiveness. As clients understand their own polyvagal system, they also come to appreciate the reasons behind their own dysregulation and their ability to access regulation. Dan Seigel’s (1999) Window of Tolerance (WOT) is a model to explain autonomic arousal. Siegel “proposes that between the extremes of sympathetic hyperarousal and [dorsal vagal]

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TABLE 4.2 Implications for Sand Tray according to Piaget’s Cognitive Development Levels Category

Preoperational/Intuitive 4–7 years

Concrete 8–12 years

Formal 12 years and above

Use of Sand

1–2 small bodies of water, small pond, partial river Vehicle tracks; Roads with an unclear destination Patted mounds; Bury/ unbury

Medium lake, more than 2 bodies; river, top-to-bottom Clear roads; hills & mountains, islands Volcanoes, sand walls Figures, faces drawn, footprints

Ocean, rivers side-to-side (could be diagonal) Roads with destinations, connections Cliffs, pits, dens, tunnels, land bridges Pyramids, castles, mines, graves

Sand as Boundaries

Primitive quality and lack of clarity Incomplete paths, ponds, lakes

Not completely delineated boundaries Goal lines, furrows, canals, hills, mountains, etc.

Clearly delineated and unusual formations that create clear boundaries that also unite the world Oceans, roads, combinations of bodies of water, hills, stairs, etc.

Groupings of Figures

Very simple line of soldiers, people, fowers

Relationship of fgures

Dyad, human or animal By age 5, includes small constructions (house, fenced with people & trees)

Complex grouping: unifed relationship forming boundaries, can both unify & separate, allows complex to be parts of the whole Complex and clear relationships; both separated and unifes complex parts Whole human/animal communities Clearly defned & integrated

Anomalies

Creates scattered effect or disrupt theme Example: house in a river Suggestion of differentiated perspectives One underdeveloped theme; or several unrelated themes 4–8 years, makes sounds (brumm-m-m for car motors)

Well-coordinated groups that are complex Obvious connections Appropriate use: signs, fences, paths/roads defned by rocks, hedges, bridges, etc. Parts of community (neighborhoods, bands) Opposing forces: Cowboy/ Indian; soldiers Dramatic action is obvious On top of another Inside, seated, lying fat Does not seriously intrude, but are intrusive Parts are more complex, still a scattered step-bystep quality Sets of objects groups Simple concrete, single theme Number of items uses increases with age Includes lots of trees

Coherent, symbolic/abstract realistic world Humor or spirituality unites parts Single, clearly recognizable theme; united complex parts

World View: Level of Complexity Coherence of Theme Number of Figures

Source: Adapted from Cherrie Glasse, 1995.

Nothing abnormal

No dramatic play, but may show dramatic movement Frequently includes trees Constructed scene of town with school, church; human settlement within landscape

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But to the extent to which each therapist prescribes procedure . . . will naturally depend on his or her general therapeutic viewpoint. For it needs emphasizing here that Sandplay, however useful and exciting, is not a treatment in itself but an adjunct to treatment, and the approach to it must vary with the individual therapist. In my opinion we cannot remind ourselves of this often enough. Thompson, 1990 p. 11

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parasympathetic hypoarousal is a ‘window’ or range of optimal arousal states in which emotions can be experienced as tolerable and experience can be integrated” ( Corrigan et al., 2011, p. 17). The WOT is easily taught to a client in the sand tray. The therapist frst explains the concept to the client, then invites the client to divide the tray into three parts. Each part refects the clients’ own perception of how much time they spend in each area: hypoarousal, optional arousal zone, and hypoarousal. The client can then place in each area miniature fgures that relate to that area. Finally, what helps them move back into the optimal arousal zone. This is an effective psychoeducational experience in the sand tray to explain the autonomic nervous system and the polyvagal theory. Read more about using the Window of Tolerance when working with trauma in Chapter 8. Jaak Panksepp (2010) helps us understand the seven basic emotional circuits in the sub-cortical regions of the brain: SEEKING, LUST, CARE, PLAY, RAGE, FEAR, GRIEF. “Emotional feelings (affects) are intrinsic values that inform animals how they are faring in the quest to survive” (p. 533). Panksepp’s work provides insight into therapeutic application. For example, separation anxiety, he purposes, is a GRIEF reaction to unmet CARE needs and thwarted SEEKING. Activating the SEEKING circuits with the provision of CARE can neurobiologically reduce the GRIEF/separation anxiety response. Panksepp (2010) states that increased therapeutic approaches which promote “social CARE and PLAY systems may increase treatment options that could yield better outcomes than existing therapies” (p. 545). Certainly, playing in the sand in the presence of a caring therapist could be one of those options.

DEVELOPING CLINICAL THEORYSPECIFIC TREATMENT PLANS Pulling this all together to write treatment plans can be a challenge. The clinical theory provides what needs to happen to assist the client in moving toward health, thus, showing up in the treatment plan. The client’s developmental history inform the therapist of possible neurodivergent issues integral to working with a specifc client. The sand tray provides the space in which the sandtray therapist can meet all parts of the client and offer experiences for the therapeutic process to occur. Treatment plans include the current symptoms (which may become, or lead to, the DSM diagnosis), the goal of symptom change for treatment to be determined as successful, and fnally, interventions that will assist in the desired change. Most

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sand therapists use the sandtray experience as one of several modalities. Both Lowenfeld and Kalff utilized other therapeutic experiences. Clients at Lowenfeld’s clinics had art, water/ messy play, nature play, and movement (Lowenfeld, nd). For the purpose of this book, sample treatment plans will include only sand therapy interventions. To assist in demonstrating how therapists aligning with different clinical theories might work, three treatment plans will be suggested. Each case consists of a brief conceptualization of the client according to the clinical theory, a treatment plan with a couple of sample interventions, and a brief statement regarding how this client might use the sandtray experience during the treatment process. Finally, an imagined sandtray that might have been created by the client during one of the interventions. Each case study is developed from the Adlerian, Solution-focused, and Satir Method (family systems) perspectives. Linda did the Adlerian versions of the case studies, Elizabeth Hartwig did the Solution-focused version, and Tricia Antoniuk the Satir Method. Note the differences in the layout of the treatment plans. This is another example of unique ways mental health professionals implement conceptualizing their work. Linda’s (Adlerian) format is written with listing the Symptomatic Behavior frst, then moving to the Goals (third column) as the client (or client’s caregivers) identify desired outcomes. Then, the Interventions go in the middle column, as in working the plan it is the interventions that get treatment to the goals. Elizabeth decides on Interventions after setting goals with clients. So, Elizabeth’s treatment plan order is: Symptomatic Behavior, Goal, and Intervention. Elizabeth provides this explanation as the way she (and SFT practitioners) goes about treatment planning with clients.

CASE STUDIES Case Study One: Adolescent with Anxiety Aspen is 14 years old. Aspen is an only child in an intact family. Both parents are professionals and have high hopes for Aspen’s future. During the initial parent consultation, there appeared to be intergenerational security in both families. Aspen has high academic grades and a few friends. Aspen was in an automobile accident two years prior; Aspen’s mother was driving and at fault; no one in either car was hurt. No other trauma was reported. Aspen fears airplane travel, which is the initial focus of treatment, as the family plans holiday travel. Parents also report increased startle response and heightened concern when either leaves the house to run errands.

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Adlerian Theory Case Conceptualization

Aspen’s goal of misbehavior is control of self. Aspen’s private logic: I am not able to control my life in the moment, nor in the future; the world is out of my control, scary events happen that grownups either cause or cannot protect me from; therefore, I must seek to control everything that I can. Aspen has an appropriate level of social interest and belonging. Aspen is developmentally on task, even perhaps a bit neurodivergent in high academic achievement. Aspen’s fight aspect of the sympathetic nervous system appears frequently activated, as demonstrated by hypervigilant behavior. See treatment plan, Table 4.3. Intention of Sandtray Work with This Client with These Interventions

Aspen is well attached and socially embedded. Nondirective prompts to “show me your world” created in the sand tray will likely display age-typical use of miniature fgures. When building anxiety-provoking scenes, for example of the car accident, Aspen will probably show reduced cognitive skills as the Window of Tolerance’s optimal arousal zone is left, and hypoarousal is activated. Awareness to watch for this and help Aspen ‘work the edges’ of the window while holding the symbol work, emotions, and thoughts will provide the safe space in which to make meaning of the event: A corrective emotional experience. Sandtray experiences such as this will help Aspen develop insight as the theme of control vs. loss of control is revealed in the trays. See the sandtray, Figure 4.2

TABLE 4.3 Aspen’s Adlerian Treatment Plan Symptomatic Behavior

Intervention

Goal

Dysregulation: as demonstrated with the need to be with a family member almost constantly

Phase One: Developing Egalitarian Relationship Individual sand tray sessions, with prompts such as: “Create a fantasy world with a powerful creature/ person; Build a scene where you are in charge,” etc. Phase Three: Gaining Insight Family sand tray sessions, with prompts such as: “build a scene of the whole family doing something together; Create a scene of the family on vacation,” etc.

Ability to co-regulate, as demonstrated by the ability to play and do homework independently 70% of the time

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Therapist Prompt: “Build a scene in the sand of a time when you felt out of control.”

FIGURE 4.2 Aspen’s Adlerian Sandtray. Photograph by Brittney Ferguson. Used with Permission.

Solution-focused Therapy Case Conceptualization

Aspen comes to counseling with numerous strengths and resources that can support her in working towards a clinical goal. Aspen’s individual strengths include having good grades and some friends. Her external resources include having two parents who are hopeful for her future. Aspen has also demonstrated that despite being in an auto accident two years prior, she has been able to be transported by vehicles to school, appointments, and other places and to be away from her parents while at school. Aspen also demonstrates concern for her safety and her parent’s safety. Developmentally, Aspen is capable of doing directive and nondirective interventions and can process sandtray work from a formal operations cognitive level, meaning she can think abstractly and metaphorically. During an initial parent/client consultation, the solutionfocused practitioner will explore with Aspen and her parents the following topics: what they have already tried to address the presenting issues, times when Aspen doesn’t have anxiety when parents are not around (e.g., not in the same room or outside), her strengths and hobbies, what goals Aspen would most like to work on frst, and if Aspen and her parents would be willing to do some family sessions in addition to individual sessions. See the treatment plan, Table 4.4. Intention of Sandtray Work with This Client with These Interventions

Aspen has strengths and coping skills that help her to manage fears and anxiety. The Finding Exceptions prompt encourages

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TABLE 4.4 Aspen’s Solution-focused Treatment Plan Symptomatic Behavior Fear of airplane travel

Increased anxiety when parents leave the house

Goal

Intervention

To explore two coping skills that Aspen already has and can use to manage anxiety or fear. To identify what Aspen would be doing different if the problem didn’t exist.

Finding Exceptions – Sandtray prompt: “Create a scene in the sand of times when you have felt some anxiety or fear and were able to work through it.” Miracle Question – Ask Aspen to imagine that a miracle happened overnight and the next morning she did not have any anxiety when her parents left the house. Sandtray prompt: “Create a scene of what you would be doing if you didn’t feel anxious when your parents left the house?”

Aspen to consider times when she has felt anxious but has been able to work through those feelings. Examples might include meeting new friends, getting through the first day of school, and being a passenger in a vehicle. As Aspen identifies these exceptions, she can start to connect what coping skills she currently has to what skills she can use to address the presenting issues. The Miracle Question prompt helps Aspen to envision a future in which she doesn’t have anxiety when her parents leave the house and what she would do differently if this anxiety didn’t exist. This allows Aspen to consider how her life might be different if she could have more control over this anxiety. We can then start to brainstorm what small steps Aspen would be willing to take to work toward this future. See the sandtray, Figure 4.3 Therapist Prompt: “Create a scene in the sand of times when you have felt some anxiety or fear and were able to work through it.”

FIGURE 4.3

Aspen’s Solution-focused Sandtray.

Photograph by Elizabeth Hartwig. Used with Permission.

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Satir Method Case Conceptualization Hypothesis: The automobile accident has heightened Aspen’s sense that the world is not safe and is unpredictable. She may have had pre-existing anxiety regarding airplane travel and even regarding losing her parents, but her current symptoms are likely an attempt to fx a problem she is experiencing in herself and/or her family system.

Aspen’s inner experience involves the following: ◾ Aspen may feel anxious, afraid, overwhelmed and/or sad. ◾ Her feelings may be overwhelming, and she doesn’t know how to calm herself. ◾ She may believe that her parents aren’t comfortable with her anxiety and fear, so she may try to suppress them. Or she may believe that relying on her fear is the only way to survive. ◾ She may have internalized beliefs that the world is not safe, that she has to be in control or bad things will happen, or that her feelings are so overwhelming that she will not be okay if something happens. ◾ She may have expectations that she should be able to prevent bad things from happening, that others think she shouldn’t feel so afraid, or that others shouldn’t take so many risks. She also understands that her parents have “high hopes” for her future, which may feel like pressure to perform. ◾ Her yearnings may be for safety, for connection, for unconditional acceptance, or for acknowledgement. See treatment plan, Table 4.5 and sandtray Figure 4.4.

TABLE 4.5 Aspen’s Satir Method Treatment Plan Symptomatic Behavior Fear of airplane travel. Anxiety and hypervigilance, especially regarding parents leaving the house.

Intervention

Goal

Work with impacts of feeling out of control or overwhelmed. Explore the protective intent of anxiety, as well as the cost. Are there other parts of self that can connect with the anxiety in a helpful way? What would feeling safe look like in the sand tray? Explore expectations of self and expectations of others. Consider family sandtray sessions to address any anxiety held in the system and to support moving away from a family organization around the anxiety.

Increase sense of safety and experience her own resourcefulness. Even though many things in life are out of our control, we have options in how we respond to what happens. Help Aspen experience choices and options available to her that help her feel empowered and less responsible for parents’ safety.

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Therapist Prompt: “Connecting to your sense of fear or anxiety, show me what that looks like in the sand.”

FIGURE 4.4 Aspen’s Satir Method Sandtray.

Case Study Two: Adult with Childhood Trauma Terry is 40 years old and single. Terry, an only child, experienced early childhood neglect, which largely contributed to her dismissive presentation. Terry also has early childhood amnesia. Terry was unable to connect with peers throughout life. Terry revealed several traumatic events as both a young adolescent and young adult, including sexual assault. The presenting issue at intake was suicidality, having no purpose in life, and no meaningful relationships. Terry had experienced success and satisfaction when part of the military, but that was no longer an option. Terry currently works as a tutor, being brilliant in the area of mathematics. Adlerian Theory Case Conceptualization

Terry’s personality priority is control. Terry’s private logic: I am unworthy of existing; the world is a place without pleasure or relationships; therefore, I must keep myself safe by retreating. Terry developed misbeliefs during neglectful childhood (unmet CARE and thwarted SEEKING), negatively impacting Terry’s ability to make connections or feel a sense of belonging. Terry’s asymmetrical development is revealed with Terry’s advanced cognitive skills (mathematics) and emotional delays and low social skills (dismissive/avoidant attachment style). See treatment plan, Table 4.6.

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TABLE 4.6 Terry’s Adlerian Treatment Plan Symptomatic Behavior Suicidality: Daily thoughts of self-harm and killing herself

Lack of ability to express emotions

Intervention Phase 1: Developing Egalitarian Relationship Joint sandtrays to develop our relationship; spontaneity and creativity; and joy in interactions. Phase 4: Reorientation & Re-education Directive sandtray experiences to practice emotional expression: Prompts such as: “Create a tray that shows your happiest time in the last week; when you experienced frustration when working with someone you tutor,” etc.

Goal No suicidality. Ability to recognize sadness and other diffcult feelings without moving into suicidal thoughts. Expand emotional expression as measured by being able to identify and express three emotions within the therapy sessions.

Intention of Sandtray Work with This Client with These Interventions

Terry will beneft initially from activating the social engagement system and PLAY circuit by creating joint sandtrays. Prompts will be nonthreatening and seek no self-awareness, so Terry can experience relaxing and enjoy being in a nonevaluative, nurturing relationship. This will help strengthen her parasympathetic nervous system, providing the neurological foundation for social engagements and relationships. Once Terry can internalize the resulting self-worth, suicidality will be reduced. Terry’s emotional development halted, and the SEEKING circuit deactivated, Therapist Prompt: “Create a tray that shows your happiest time in the last week.”

FIGURE 4.5

Terry’s Adlerian Sandtray.

Photograph by Brittney Ferguson. Used with Permission.

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during the neglectful childhood. Throughout the therapeutic intervention, every opportunity is taken to assist Terry in engaging emotional expression through engagement of the PLAY circuit (social joy). In the fnal phase, directive sand activities provide Terry opportunities to safely practice emotional expression. See sandtray, Figure 4.5. Solution-focused Theory Case Conceptualization

Terry has experienced numerous challenges in life and yet still has come to counseling for support and guidance. Terry’s personal strengths include the success and satisfaction she experienced as a member of the military, her ability to work as a tutor, and her intelligence in the area of mathematics. While Terry has struggled in connecting with peers, she has been able to work as part of a team in the military and provide tutoring to others. Terry has considered suicide, but has not attempted or completed suicide, which demonstrates that she has the ability to keep herself safe. She also has the courage to make a counseling appointment to get help. During the initial session, the solution-focused practitioner will explore with Terry the following topics: what she has already tried to address her trauma experiences and suicidal ideation, times when Terry feels more hopeful about life, her support system, and her strengths and hobbies. See treatment plan, Table 4.7. Intention of Sandtray Work with This Client with These Interventions

The Solution-Focused Safety Scale (SFSS; Lutz, 2019) provides a vehicle for Terry to consider how much confdence she has that she TABLE 4.7 Terry’s Solution-focused Treatment Plan Symptomatic Behavior

Goal

Intervention

Suicidal ideation

To increase client’s confdence that she can keep herself safe.

Lack of social support network and meaningful relationships

To identify one potential meaningful relationship.

Scaling – Use the Solution-Focused Safety Scale (SFSS; Lutz, 2019) in the sand. Sandtray prompt: “Create a scale in the sand from 0 to 10 by choosing fgures that represent no confdence (0) to high confdence (10) that you can keep yourself safe.” Ask Terry to also choose a fgure that represents where she is on that scale. Discuss what she is doing to get to that point on the scale and celebrate those actions. Presupposing Change – Tell Terry you’re going to ask her to think outside the box today. Sandtray prompt: “Suppose that you woke up tomorrow morning and you had a meaningful relationship with someone else. Create a scene of you and that person doing something together.”

Source: Lutz, A. B. (2019). Cope is one letter away from hope: Solution-Focused Safety Assessment (SFSA). https://solutio nfocused.net/2019/05/03/cope-is-one-letter-away-from-hope-solution-focused-safety-assessment-sfsa/

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Therapist Prompt: “Suppose that you woke up tomorrow morning and you had a meaningful relationship with someone else. Create a scene of you and that person doing something together.”

FIGURE 4.6 Terry’s Solution-focused Sandtray. Photograph by Elizabeth Hartwig. Used with Permission.

can keep herself safe and what she’s doing to have that confdence. This intervention is benefcial to do in the sand, because Terry can choose fgures that serve as metaphors for having no, some, or high confdence that she can keep herself safe. As we engage in the SFSS intervention, we will also explore what Terry knows she will need to keep herself safe, what has kept her from acting on suicidal thoughts in the past, and what resources (e.g., support system, medication, pets) might be helpful to her in the future. The Presupposing Change prompt encourages Terry to consider what kind of meaningful relationship she would like to have (e.g., friend, family member, signifcant other) and what they might do together. Part of building a social support network is to start small and develop one meaningful relationship. It’s possible that this relationship is with someone Terry already knows or may be with someone Terry doesn’t know yet. As Terry envisions this meaningful relationship, she can begin to consider what small steps she can take to develop this relationship. See sandtray, Figure 4.6. Satir Method Case Conceptualization

Feeling suicidal is the “solution” to an inner world of feeling alone and disconnected. Hypothesis: Terry feels deep sadness and inner pain. She has not experienced self as valued and unique. Relationships have not felt safe in the past, so relationships probably feel scary and unsafe.

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TABLE 4.8 Terry’s Satir Method Treatment Plan Symptomatic Behavior Suicidality Lack of purpose No meaningful relationships

Intervention Work with impacts of childhood neglect, loneliness, and traumatic events. How do these experiences still have an impact on how Terry experiences the world today? Can Terry connect to self differently today than she was able to in the past, bringing perspective, awareness, appreciation, and compassion? Can the therapist help her connect to inner wisdom and inner resources that she has not been aware of? Explore new possibilities and introduce hope based on Terry’s successes, uniqueness, and yearning for purpose. Consider prompting a sandtray experience that explores listening to the positive messages of familiar feelings. Explore how therapist’s use of self could show up in the creation of therapist-client joint tray to relationally facilitate movement through felt connection.

Goal Healing sense of self; being able to acknowledge self as valued and resourceful.

Inner experience: ◾ Terry may feel sad, hurt, angry, afraid and hopeless. ◾ She has probably experienced that her feelings are dismissed by others and by self. ◾ She may have decided that her anger or her sadness are not okay, and hopelessness feels like the only option. ◾ She may have internalized beliefs that she doesn’t matter, that she is “too much” or “not enough,” or that her life doesn’t have value.

Therapist Prompt: “Connecting to that sense of loneliness, show me what that would look like in the sandtray.”

FIGURE 4.7

Terry’s Satir Method Sandtray.

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◾ She may have expectations that she should be different, that she shouldn’t expect anything from others, or that she should know what to do. ◾ Her yearnings may be for love, for connection, for acknowledgement, for belonging, for purpose and/or for meaning. See treatment plan, Table 4.8 and sandtray, Figure 4.7.

Case Study Three: Pre-adolescent Adoptee Angel is a 10-year-old child adopted into an American family from an international country. In Angel’s biological family, there were no known other children, but Angel is the youngest of four in the adoptive family. Angel was with at least one biological parent for 6 months before being placed in a group care facility for 18 months. When Angel met adoptive parents at age 2, there were many moments of diffculty being soothed after becoming dysregulated along with extreme separation anxiety symptoms. These struggles intensifed after starting school, and Angel has been in and out of therapy for the last four years. Adlerian Theory Case Conceptualization

Angel’s goal of misbehavior is proving inadequacy. Angel’s private logic: I am overlooked, not noticed, and unwanted; the world seems to go on without me, but I don’t understand emotions or how to belong in it; therefore, I need to others to rescue me; I cannot rescue myself. Angel’s early life did not provide the environment for secure attachment or the Crucial C’s to be met (capable, count, connect, courage). There were some SEEKING needs met as Angel appears to have social interest, but it remains underdeveloped. Angel’s adoptive parents and siblings must be a critical part of the treatment intervention for Angel to experience belonging. See treatment plan, Table 4.9. Intention of Sandtray Work with This Client with These Interventions

Individual sand tray sessions provide the opportunity for Angel to develop courage and being capable. The therapist will offer high levels of encouragement and returning responsibility. The therapist will use interactions in the sandtray work to activate the SEEKING and PLAY circuits. Helping Angel co-regulate with the therapist is a critical part of Phase One interventions. Involving the family in group sand tray, provides Angel a sense of connecting and counting to the family unit and an experience of social embeddedness. Instructing the parents and siblings (all of whom

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TABLE 4.9 Angel’s Adlerian Treatment Plan Symptomatic Behavior

Intervention

Goal

Dysregulation: as demonstrated with the need to be with a family member almost constantly

Phase One: Developing Egalitarian Relationship Individual sand tray sessions, with prompts such as: “Create a fantasy world with a powerful queen; Build a scene where you are in charge,” etc. Phase Three: Gaining Insight Family sand tray sessions, with prompts such as: “build a scene of the whole family doing something together; Create a scene of the family on vacation,” etc.

Ability to co-regulate, as demonstrated by the ability to play and do homework independently 70% of the time

Therapist Prompt: “Build a scene of the whole family doing something together.”

FIGURE 4.8

Angel’s Adlerian Sandtray.

Photograph by Brittney Ferguson. Used with Permission.

are older and understand the importance of interpersonal concepts) to use self-esteem building refections, encouragement, and co-regulation will facilitate the family sessions. Also, instruct family members to increase self-and-other awareness and selfregulation. See sandtray, Figure 4.8. Solution-focused Theory Case Conceptualization

Angel comes to play therapy with several strengths and resources. Angel was adopted from a group care facility when he was two into a large family with two parents and three siblings. Angel attends school and has participated in therapy over the past four

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years. While Angel struggles with separation anxiety, Angel has been able to stay in school for four years. Given that Angel has attended school for four years, he has the language and cognitive capacity to participate in both nondirective and directive interventions. During an initial parent/client consultation, the solutionfocused practitioner will explore with Angel and his parents the following topics: what they have already tried to address the dysregulation and separation anxiety, times when Angel is able to regulate his brain and body, Angel’s strengths and hobbies, what goal Angel would most like to work on frst, and if Angel and his family would be willing to do some family sessions in addition to individual sessions. See treatment plan, Table 4.10. Intention of Sandtray Work with This Client with These Interventions

As a systemic approach, Solution-focused Therapy encourages members of a client’s system, such as the entire family, to participate in counseling to promote change in the system, not just one client (i.e., Angel). The goal focuses on increasing regulation skills for the whole family. The Family Regulation prompt allows all family members to learn and practice regulation strategies. This gives Angel, his parents, and his siblings some new coping skills and helps them to role model these skills and support Angel when he struggles with dysregulation and separation anxiety. Having all family members practice regulation skills encourages systemic growth of the family. See sandtray, Figure 4.9. Discuss brain regulation with the family. Ask about things they do to regulate their brain. Next, ask all family members to practice some brain regulation skills with the sandtray—feel the sand, take deep breaths, and choose a calming song to listen to as they touch the sand. Ask each family member to “identify one

TABLE 4.10 Angel’s Solution-focused Treatment Plan Symptomatic Behavior Dysregulation

Goal To identify and practice three regulation skills with the family.

Intervention Family Regulation—Facilitate a family sandtray session. Discuss brain regulation with the family. Ask about things they do to regulate their brain. Next, ask all family members to practice some brain regulation skills with the sandtray—feel the sand, take deep breaths, and choose a calming song to listen to as they touch the sand. Ask each family member to identify one fgure that helps them to regulate their brain and body—or speaks to them as you discuss regulation and mindfulness. Discuss the fgures and their experience of practicing regulation.

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Therapist Prompt: “Each of you select a fgure that helps you regulate your brain and body and place them in the tray as a family.”

FIGURE 4.9

Angel’s Solution-focused Sandtray.

Photograph by Elizabeth Hartwig. Used with Permission.

fgure that helps them to regulate their brain and body—or speaks to them as they discuss regulation and mindfulness.” Discuss the fgures and their experience of practicing regulation. Satir Method Case Conceptualization Hypothesis: Angel did not experience safe attachment in the frst two years of her life and is easily overwhelmed. She needs support to learn how to experience her own fear and pain in a safe and contained way, while remaining connected to parents during her current developmental stage.

Inner experience: ◾ Angel may feel overwhelmed, afraid, angry, terrifed, and/or sad. ◾ Her feelings are overwhelming, and she doesn’t know how to calm herself. ◾ Overwhelming feelings continue to reinforce the experience that life is out of control. ◾ Angel has had lots of experiences that indicate that the world is unsafe, and that life is unpredictable. Many of these experiences were preverbal, so Angel has little ability to express or understand her experience. ◾ Her yearnings may be for safety, for belonging, for connection and/or for peace, but she does not yet know how to tolerate being with such needs. See treatment plan, Table 4.11 and sandtray, Figure 4.10.

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TABLE 4.11 Angel’s Satir Method Treatment Plan Symptomatic Behavior Extreme separation anxiety; Becomes dysregulated (overwhelmed, everything feels out of control).

Intervention

Goal

Bringing safety though presence, gentleness, curiosity and patience. Staying grounded and calm in the presence of Angel’s pain allows her to begin to be able to tolerate her own pain and fear. Expressing her overwhelming feelings in the sand tray allows them to be externalized and processed safely. Allowing parents, who will be prepared ahead of time, to serve as co-creators and witnesses in some sand tray sessions may support connection.

Help Angel experience safety and presence with the therapist so her feelings and experiences are shared and do not feel so overwhelming or unsafe. Safe connection allows healing, even if the fear and pain originated in preverbal experience. The sand tray can allow new possibilities for expression and soothing to emerge once safety has been established.

Therapist Prompt: “Create a world in the sand.”

FIGURE 4.10 Angel’s Satir Method Sandtray.

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Documentation, or writing sessions notes, also considers the clinical theory as well as presenting issues and interaction of therapist-client. Appendix B: Documentation Session Notes: Cues and Clues may be a helpful reference form for you as you write up your notes. Clues and Cues will include information from the subsequent chapters.

IN CLOSING The therapist’s journey is made easier by having a consistent lens through which to work with their clients. The use of a consistent clinical theory or approach provides this lens. Through it we can integrate the client’s unique developmental and life issues. The clinical theory or approach provides us the means to create a treatment plan and specifc interventions, including use of the sand tray. A sandtray therapist who is in touch with how they make meaning will be better equipped to support clients as they embrace their own meaning-making, creating space for dynamic worlds to be made in the sand.

REFERENCES Chapman A. L. (2006). Dialectical behavior therapy: Current indications and unique elements. Psychiatry, 3(9), 62–68. Corrigan, F. M., Fisher, J. J., & Nutt, D. J. (2011). Autonomic dysregulation and the Window of Tolerance model of the effects of complex emotional trauma. Journal of Psychopharmacology, 25(1), 17–25. doi:10.1177/0269881109354930 Cozolino, L. (2020). Neuroscience for clinicians. W. W. Norton & Company. Drewes, A., Bratton, S., & Schaefer, C. (2011). Integrative play therapy. John Wiley & Sons. Fall, K., Miner Holden, J., & Marquis, A. (2017). Theoretical models of counseling and psychotherapy (3rd ed.). Routledge. Glasse, C. (1995). Sandplay in the classroom: Teacher’s guide (Rev. ed.). Author. Kaduson, H., Cangelosi, D., & Schaefer, C. (2020). Prescriptive play therapy. Guilford Press. Kosanke, G. C. (2013). The use of sandtray approaches in psycho-therapeutic work with adult trauma survivors: A thematic analysis [Master’s dissertation]. Auckland University of Technology, Auckland, New Zealand. http://aut.researchgateway.ac.nz/handle/10292/5592 Lowenfeld, M. (n.d.). The Institute of Child Psychology. Dr. Margaret Lowenfeld Trust. Lowenfeld, M. (1979). Understanding children’s Sandplay: Lowenfeld’s World Technique. George Allen & Unwin. Lutz, A. B. (2019). Cope is one letter away from hope: Solution-Focused Safety Assessment (SFSA). https:// solutionfocused.net/2019/05/03/cope-is-one-letter-away-from-hope-solution-focused-safety-assessment -sfsa/ Panksepp, J. (2010). Affective neuroscience of the emotional BrainMind: Evolutionary perspectives and implications for understanding depression. Dialogues in Clinical Neuroscience, 12(4), 533–545. https://doi .org/10.31887/DCNS.2010.12.4/jpanksepp Perry, B. (2005). Maltreatment and the developing child: How early childhood experience shapes child and culture. The Margaret McCain Lecture Series. https://7079168e-705a-4dc7-be05-2218087aa989.flesusr .com/ugd/aa51c7_1052a376f51b40219ac48304da3af5ed.pdf Perry, B., & Hambrick, E. (2008). The neurosequential model of therapeutics. Reclaiming Children and Youth, 17(3), 38–43.

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Piaget, J. (1932/1965). The moral judgment of the child (M. Gabain, trans.). Free Press. Porges, S. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, self-regulation. W. W. Norton & Company. Siegel, D. J. (1999). The developing mind. Guilford Press. Thompson, C. (1990). Variations on a theme by Lowenfeld: Sandplay in focus. In K. Bradway et al. (Eds.), Sandplay studies: Origins, theory and practice (pp. 5–20). Sigo Press.

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Person-of-the-Therapist and Use of the Protocol Your guide is true Not because of a life pain free But because woundedness made way For compassionate curiosity

The observer effect tells us that the simple act of observation changes the thing (or person) being observed. In therapy, we could go a step further and say that the specifc person of the one doing the observing changes how and what and who is being observed. As therapists, our very persons infuence each moment of therapy even when sitting in complete silence! This means that any two sandtray therapists, even if they have the same demographic information, hometown, personality type, professional training, clinical theory, etc., would impact the client’s creation and meaning-making of a sand world in such a manner that there could be dramatically different endpoints. Allan Schore (2019) says this exists, at least in part, because “rapid communications between the right-lateralized “emotional brain (‘right mind’) of each member of the therapeutic alliance allows for moment-to-moment, right brain-to-right brain ‘self-state sharing,’ a co-created, organized, dynamically changing dialogue of mutual infuence” (Schore, 2019, p. 26). Mutual infuence. What a lovely and overwhelming responsibility! It’s these sorts of thought experiments and neuroscientifc ponderings that Marshall delights in as he contemplates the importance of working with the person-of-the-sandtray-therapist (POST). Considering how consequential this construct seems, very little has been written on the subject. The self of the therapist has been explored in multiple approaches and modalities, just not much in sandtray literature. Schore (2019) goes on to say that “right brain interactions ‘beneath the words’ nonverbally communicate essential, DOI: 10.4324/9781003095491-5

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nonconscious, body-based affective relational information about the inner world of the patient (and therapist)” (p. 26). Since sandtray therapy emphasizes a nonverbal, expressive/projective, and sensory rich approach to exploring the inner worlds of clients, the lack of exploration of the person-of-the-therapist seems like a critical omission! This chapter will look at the origin of the person-of-the-therapist concept before moving to exploring the POST as relevant to each of the six steps in the sandtray therapy protocol (Homeyer & Sweeney, 2017). All of this will hold a particular bent toward considering attachment and trauma infuences consistent with the rest of the book.

ORIGIN OF PERSON-OF-THETHERAPIST CONCEPT It always seems like treacherous territory to address the history of a therapeutic construct in a manner that is thorough enough to honor those who moved an idea forward while remaining succinct enough to get to application of those concepts! With that being said, this section will briefy overview some of the thought leaders who prominently contributed to thinking of the therapist’s “self.” The therapist’s use of self (or interference of self) has long been addressed in clinical theories. Beginning with Freud, and then further articulated by many who followed, trainee therapists were taught to be aware the potential dangers of their own unresolved issues manifesting in sessions with vulnerable clients; this is largely why therapists were asked to spend such lengthy times in their own treatment (Satir, 2013). While it remains important for therapists to practice self-care, including seeking their own clinical support when needed, early awareness of the self of the therapist was primarily discussed as a risk needing to be mitigated. This risk management mindset traditionally assumed that therapists have a personal self and a professional self. These two “selves” were meant to be kept separate for the protection of clients. Beginning with the origin of psychoanalysis, countertransference was introduced as a clinical theory staple for this reason. As clinical thought and therapist training evolved, some clinicians appeared on the scene who challenged the strict duality approach to considering therapists’ use of self. Theorists such as Murray Bowen and Virginia Satir emphasized the need for therapists to integrate their personal selves and professional skills

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(Baldwin, 2013) instead of continuing with a forced separation point of view. Satir said, when I am in touch with myself, my feelings, my thoughts, with what I see and hear, I am growing toward becoming a more integrated self. I am more congruent, I am more ‘whole,’ and I am able to make greater contact with the other person. (2013, p. 25)

Even before the beneft of modern relational neuroscience, some pioneers in the feld were beginning to acknowledge the inevitability of therapist’s “personal self” being present in client sessions because a person cannot segment out aspects of self on command. And even if it were possible, Satir indicates it would not be advantageous to therapeutic relationships! The idea of intentionally instructing clinicians in a manner that welcomes exploration of personal parts of self while learning professional clinical theory and skills originated in the Person-of-the-Therapist Training model (POTT) developed by Harry Aponte (Aponte, 1992; Kissil & Niño, 2018). Originally applied to training therapists in the structural family therapy model (Aponte, 1992), this broadened to become a trans-theoretical approach. Here is a description of POTT from Aponte and Kissil: The main thrust of the POTT model has to do with a use of self that emanates from the personal depths of the individual who is conducting the therapy. This is more than a strategy about how therapists use themselves. This is about us, as clinicians developing a conscious, purposeful and disciplined access to our humanity within our professional role in the therapeutic relationship. This means that as therapists we view the therapeutic process, at its core, as a person-to-person human encounter. The POTT approach assumes that the more of both therapist and client are experientially present in this living process of therapy, the greater the access the therapist has to self and to client to do the work of therapy. POTT’s concept of being “present” in the therapeutic relationship implies a professionally purposeful personal engagement with the client (individual, couple or family) that lends clarity of insight, depth of sensitivity and potency of effectiveness to the therapist’s clinical performance. (2017, Abstract)

The POTT model emphasizes the importance of a therapist listening to their personal parts of self and learning to responsibly use these parts in session. For sandtray therapists, this requires exploring these ideas in the same modality offered to clients. Much more will offered later in encouraging this approach! One specifc component of POTT training invites therapists to get to know their “signature themes.” Signature themes are

This embracing of inherent vulnerability, consistent with a wounded healer mindset, asks and allows clinicians to make therapeutic use of self a relational mindset.

Working with a sandtray therapy consultant who is familiar with POTT can allow for making caring contact with signature themes in the sandtray; and seeking consultation in this manner has been linked with increased self-awareness on the part of the therapist.

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“defned as the patterns of feeling, thinking, and relating that are rooted in our woundedness, and are experienced by the person as both pervasive and challenging” (Niño & Zeytinoglu-Saydam, 2020, p. 3). When training in the POTT model, the goal is not necessarily to overcome signature themes, but to know and understand those parts of self more fully. This embracing of inherent vulnerability (Kissil & Niño, 2017), consistent with a wounded healer mindset, asks and allows clinicians to make therapeutic use of self a relational mindset. Since “signature themes are the lifelong struggles shaping the person’s relationships with self and others” (Aponte & Kissil, 2014, p. 4), therapists deserve supportive environments and containing modalities for exploring these, just as clients do! Working with a sandtray therapy consultant who is familiar with POTT can allow for making caring contact with signature themes in the sandtray; and seeking consultation in this manner has been linked with increased self-awareness on the part of the therapist (Kissil, Carneiro, & Aponte, 2018)! What ethical behavior, too, for a therapist to review their own personal narratives while considering how these could be interacting with various clients! Let’s hear from Aponte and Kissil (2014) one more time as the POTT signature theme gets even more specifcally explored: These specifc qualities and circumstances, as they manifested in the past and do today in our lives allow for the ability of therapists to identify with and differentiate from their clients’ themes at more context specifc levels. Aponte et al., 2009, pp. 155-156

We all live with our very unique-to-each person signature struggles with ourselves and with life. The signature theme has an underlying core, such as the need for control or fear of vulnerability or fear of rejection or feelings of low self-esteem. These themes are universal enough to enable therapists to identify and empathize with most clients. However, the signature theme has another level more specifc to the individual that has to do with how the underlying dynamic surrounding the core theme gets played out habitually in the various contexts of that person’s life. This is at the level of the specifc qualities and circumstances of the person’s life. Our biology, our family histories, our gender, race, ethnicity, culture and spirituality, along with the effects of the choices we have made in life, all shape who we are today. Woven into these life experiences are hurts, deprivations, failures and losses that form the core of each person’s lifelong personal emotional vulnerabilities (Aponte et al., 2009). At this operational level, people’s personal issues inevitably are active factors that tend to get triggered or played out in thematically predictable forms in the various contexts of the drama of life, such as people’s family relationships and jobs, which for therapists would include their relationships with clients—individuals and families. These specifc qualities and circumstances, as they manifested in the past and do today in our lives allow for the ability of therapists to identify with and differentiate from their clients’ themes at more context specifc levels. (pp. 155–156)

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To both “identify with and differentiate from” beautifully captures the complexity of therapists’ holding space for the sometimes messy work of learning to use self well in client sessions. The feld of therapy has evolved dramatically in the decades since it became a profession; the concept of person-of-the-therapist is one of the areas where this is especially true. And it is an important shift. In the words of Satir (2013), “The person-ofthe-therapist is the center point around which successful therapy revolves. The theories and techniques are important … but I see them as tools to be used in a fully human context” (p. 25). Now let’s see how sandtray therapists, in particular, can use their tools to ensure the work is indeed being done in a fully human context.

INFORMATION FROM LOWENFELD AND KALFF As with all clinical theories, approaches, and modalities, sandtray therapy came to existence within a certain context. One of those contextual factors is the reality that all clinicians were trained in psychoanalytic theory or beginning to push away from it. Either way, the constructs from psychoanalysis were heavily infuential. Lowenfeld herself was a trained psychoanalyst. While she wanted the World Technique (sandtray’s original iteration) to stand independent of theory (Lowenfeld, 1979), Lowenfeld still had to work with the only language available to therapists. Regarding therapists’ use of self, she primarily used language around countertransference in early writings about the World Technique. The therapeutic relationship was not fully discussed by Lowenfeld in her writings (Urwin & Hood-Williams, 2014). It is reported, that in Lowenfeld’s clinic, clinicians frequently changed which children they were seeing, all clinicians dressed alike and rarely were called by name so that the therapists might be seen as one blended group (Urwin & Hood-Williams, 2014). It seems the role of therapist as an emotional presence in the therapeutic relationship was dramatically de-emphasized in the early days of sand therapy. Lowenfeld, similar to most clinicians of her day, initially discussed the need to minimize transference and countertransference. “In therapy itself the emphasis was less on using the emotional relationship between child and therapist than on enhancing the child’s ability to organize and make sense of his or her own experience” (Urwin & Hood-Williams, 2014, chapter 1, para. 13). Regarding transference and countertransference, Lowenfeld stated it was diffcult to observe and study such concepts. Being a keen scientist who put much faith in the powers of observation,

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Rae (2013) reports that Lowenfeld later realized that “the therapeutic bond is formed in a manner that precludes the therapist’s neutrality” (p. 28).

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this made such concepts unreliable, but not necessarily unimportant, in her eyes (Urwin & Hood-Williams, 2014). However, there are descriptions of her evolving in later years to a different way of thinking about therapeutic relationship in sandtray therapy. Rae (2013) reports that Lowenfeld later realized that “the therapeutic bond is formed in a manner that precludes the therapist’s neutrality” (p. 28). This shift represents a way of thinking closer to the conceptualizations of relational neuroscience and person-of-the-therapist in current professional literature. It makes Marshall wonder if all those years of intensely recording and reviewing worlds created in the sand, deepening “her sensitivity to what she was observing rapidly led her to the emotional life of the child” (Urwin & Hood-Williams, 2014, chapter 1, para. 13) were part of this reported relational shift. Lowenfeld did write in one of her papers that when working with withdrawn children, the focus of the therapist must be on showing complete acceptance and approval (Urwin & Hood-Williams, 2014). Regardless of where the modality began in relation to this topic, it does seem Lowenfeld uncovered some sense of therapists’ use of self as a needs-meeting opportunity for clients as important. When Dora Kalff took her sand studies with Lowenfeld and merged that information with her Jungian beliefs, she moved the conversation about the self of the therapist to a new place. Keeping in mind that Kalff’s sandplay model represents a single theory’s point of view, she deserves mentioning about how she acknowledged therapists’ infuence on the process of sand therapy with clients. Kalff (2003) says that “the therapist represents the protector, the space, the freedom and at the same time, the boundaries” (p. 7). Furthering this line of thinking, she emphasized that therapists must fully accept their clients as they risk the stressful prospect of growth; “it is the role of the therapist to perceive these possibilities and, like the guardian of a precious treasure, protect them” (Kalff, 2003, p. 7). It is for this reason that the sandplay therapists were tasked with creating a space that feels “free and protected” (Kalff, 2003, p. 7). In order to be appropriately understanding of the client’s vulnerable processes, sandplay therapists needed to be able to imagine themselves in clients’ created worlds (Kalff, 2003). From a sandplay perspective, “In the person-of-the-therapist, we are contained until we trust not only in the therapist but in the sense of inner guidance from the Self” (Steinhardt, 2013, p. 62). There are many aspects of this thinking that are congruent with the attachment and trauma-sensitive approaches advocated for in later parts of this book. There is at least one more important point to be made about sandplay’s contribution to therapists’ learning

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how to appropriately bring and use self in client sessions. They do their own therapy in the sand! Sandplay trainees are required to do an individual and play process with a certifed sandplay therapist before going on to study sandplay theory, as the only way to really understand the power, depth, and creative unpredictability of work with the symbols put forth by the unconscious. (Steinhardt, 2013. p. 181)

PERSON-OF-THE-SANDTRAYTHERAPIST (POST) Now that we have looked both at a brief overview of therapist’s use of self and how sandtray therapy originally grappled with this, we will turn our attention to how we might intentionally begin to work with the person-of-the-sandtray-therapist (POST). As a believer in the “vulnerability and healing power present in both healer and patient” (Miller & Baldwin, Jr. 2013, p. 81), Marshall teaches that expressive and play therapists bear quite a responsibility in monitoring and cultivating their POST. “Playing is an experience that reaches into zones of experience and thought out of reason’s reach, and the spontaneity of play gives access to the mysterious and the unspoken in human experience” (Keith, 2013, p. 216). Since expressive and play therapists spend intentional, nonverbal time “out of reason’s reach” and immersed in clients’ inner worlds, there is a responsibility for being about to offer dual attention to our own inner worlds inevitably touched by clients’ right hemispheric deep dives. For a place of beginning, sandtray therapists need to have a sense of ease in their sand space (Rae, 2013). This ease comes, in part, from monitoring beliefs about what might happen in this free and open space. The worlds created by clients, and therapists, in the sand need to be free of the pressure to assign quick meaning for the sake of the therapeutic holy grail of a “breakthrough.” Meaning is to be made gently and in the client’s time, which means sandtray therapists will have to tolerate many moments of ambiguity and uncertainty. This is vital to the process. “When Witnesses [meaning therapists] release any need to know about the meaning of what is being created, the Creator is freer to play. Witnesses are helpful when they are curious and interested but should not allow their own inquisitiveness to lead” (Rae, 2013, p. 82). Also see additional suggestions for exercises for the sandtray therapist from Rae in Appendix C: Exercises for the Sandtray Witness.

All sand therapists have something to learn from remembering that treating this therapy as sacred asks that we step into the same sand tray we offer to others.

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Rae (2013) goes on to add that desirable qualities needed in a sandtray therapist in order to offer this kind of presence include: ◾ The willingness to enter a felt, lived experience with the Creator. ◾ A facility for authentic, attuned interaction. ◾ The capacity to tolerate silence and uncertainty. ◾ Compassion, kindness, empathy, fexibility, and respect. ◾ The ability to observe one’s self and the Creator in the process. ◾ A willingness to serve the Creator’s needs frst. ◾ The ability to set clear boundaries and be reliable. ◾ An ability to set aside personal judgments, interpretations, and meanings. ◾ The capacity to explore the sandtray with an imaginative or playful state of mind (p. 68).

Sandtray therapists deserve to be ever seeking to increase selfcompassion so that it keeps up the other many discoveries awaiting us in the sand.

To maintain such a demanding energetic posture, the sandtray therapist must possess “more than knowledge and interpersonal skill” (Rae, 2013, p. 69); it is about creating internal space for an evolving and invited self-awareness to occupy. All of this presents as prerequisites for deep and solid, right brain to right brain, sustained connection. The sandtray therapist simply must be familiar with their own right brain processes. Madeleine De Little, a clinician trained in the Satir model who has incorporated relational neuroscience into her sand therapy approach, says “authentic presence” requires such a need to have ongoing monitoring of the therapist’s self (2019). It is one of the great opportunities that come with being a sandtray therapist: that doing the work required in monitoring the POST reaps tremendous professional and personal benefts. It can also feel like one of the greatest burdens in doing this work. It can be tiring and painful to attend to inner lives. When beginning to ponder how one might monitor the POST, Gil and Rubin (2005) have suggestions about how play therapists can use their sand trays to help. They recommend a way of making worlds in the sand that explore dynamics that have arisen after relationally-intense sessions. Clinicians should prepare themselves to make their countertransference tray by making sure they will be free of interruptions, by giving themselves permission to take time without internal pressure to rush, and by making the environment as quiet and comfortable as possible. The directive is simple: ‘Allow yourself to check in and see what thoughts, feelings, and responses you have about the work you’ve just completed with … [a specifc client

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or over a specifc period of time]. Then review the miniatures in front of you and use as few or as many as you like and place them in the sand box.’ Once clinicians feel that they have completed the task, they are encouraged to explore their reactions as they stand back and observe the sand scenario they have created. (p. 96)

Another way to work with POST is to use the sand tray as a personal journal where the sandtray therapist’s own lived experiences can be explored, even outside of issues directly touched in client sessions. As mentioned before, the POTT model asks therapists to work with signature themes that have journeyed alongside their woundedness. The following section is a snapshot from some of Marshall’s personal work in the sand in such a manner.

MARSHALL’S JOURNEY Often asked to teach on attachment theory and trauma work integrated with sandtray therapy, Marshall arrived at a place where he felt the need to enter into a season of exploring his own signature theme(s) in personal sand tray journaling based on prompts that moved through increasingly vulnerable contact with points of pain in his personal narrative. These pictures and journal entries were processed in personal therapy and with colleagues. Many colleagues joined in the journey on social media and created their own worlds in response to the prompts Marshall was using. The following shows a few of the discoveries made in the sand and Marshall and Linda hope it can provide encouragement for other sandtray therapists to fnd ways to work with signature themes regarding person-ofthe-therapist in the sand! You will fnd the prompt, a picture of Marshall’s created world, and a brief corresponding journal entry for each. Attachment theory helps us know that relationally wounded people deserve to have space to contemplate safety. I know that I have many times needed to imagine what security could feel like before risking stepping into that potential security. My neuroception deserves to be honored before it is asked to incorporate new information about how perception of safety could be updated. I pause here to offer that honor. See Figure 5.1. Once you start to feel confdent that there are internal and external resources you can rely on, it will become a little easier to imagine yourself risking being really seen by others. I have discovered that if I cultivate invisibility, then no one ever really knows me. If I don’t feel known, then I can’t feel cared for. See Figure 5.2.

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FIGURE 5.1 Create a World Where it is Easy to Know What Safe Is. Photograph by Caleb Matthews. Used with Permission.

FIGURE 5.2

Create a World Where it is OK to be Seen.

Photograph by Caleb Matthews. Used with Permission.

We all crave belonging. That’s because we all need to know we belong. This is a complicated need, but my step toward belonging today involves meditating on the opportunity that diversity brings. I can be more relational and inclusive by simply acknowledging that I want to honor those different from me and by maintaining a posture of humility. I should not try to make others more like me in order to create safe belonging. That’s a selfsh kind of safety that only benefts me … and, in truth, it does not even really beneft me. See Figure 5.3.

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FIGURE 5.3

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Create a World of Belonging.

Photograph by Caleb Matthews. Used with Permission.

Having spent two weeks looking at the inner resources I have been blessed with, I now start to look at what those resources can help me overcome. Attachment theory helps me to know that my mind has been shaped by my experiences … and I need to be able to refect on how I came to perceive myself based on those experiences. We all pick up judgments about ourselves along the way. From a place of strength, I want to look at those self-judgments. It’s hard to replace lies with truth without frst recognizing the lies. So, today’s sandtray prompt was to “create a world about an inner judgment.” I will sit in curiosity about the layers of meaning in the metaphors. If my curiosity turns to judgment, I will let my mind meditate on the strengths I have been previously contemplating. And I believe that if I can allow truth and judgment to sit close to one another, truth will prevail. Understanding will bring gentleness. That’s good for me and those I love. See Figure 5.4. Being able to hold seemingly incongruous ideas together develops internal qualities needed for high level attachment work, but judgments that we have about others or ourselves don’t allow for multiple possibilities to exist. We need moments of stretching ourselves to see beyond our self-protective reactions where one “truth” is privileged at the cost of seeing any other perspective. As I have been working through one self-judgment this week, my mind is opening to the option that strength and weakness are far more cooperative than competitive. See Figure 5.5.

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FIGURE 5.4 Create a World about an Inner Judgement. Photograph by Caleb Matthews. Used with Permission.

FIGURE 5.5 Create a World Where Strength and Weakness Work Together. Photograph by Caleb Matthews. Used with Permission.

As I get to know the specifcs of my inner world of fear, patterns emerge. Early life events created predispositions and then I spent many years trying to confrm the reasons for my anxious instincts. Meanwhile, I missed seeing the self-fulflling prophecy of it all. By fxating on what I was worried about, I was contributing to the likelihood of it becoming true, not preventing it. Self-fulflling prophecy (at least for me) puts a lot of energy in predicting how the world is destined to treat me. This one is harder for me to spend time on, so I didn’t get much of a world built. I did get an action represented and it speaks loudly to me.

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FIGURE 5.6

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Create a World Putting an Action to Fear.

Photograph by Caleb Matthews. Used with Permission.

FIGURE 5.7

Create a World about Your Unfnished Story.

Photograph by Caleb Matthews. Used with Permission.

Imagining fear as an action does help me see how it uses power and what actions I can take to counter it. So, ironically, that same fear that once kept people at a distance can now be what builds bridges. Be gentle with yourself. And then give that same gentleness to others. See Figure 5.6. When I’m living as if pain is all of what’s true about the world, my thoughts about my unfolding narrative refect that. My personal story sounds fatalistic. The characters’ faws are exaggerated. It’s very gloom and doom. However, when pain and joy are held together, I am open to more possibilities. Each next moment feels like an opportunity. The story

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doesn’t have to feel like a fairy tale in order to have meaning that is full of hope. That is today’s tray … a view of my unfnished story based in acceptance and appreciation of right now. There is no way to know exactly where my story is headed, but how I live today is shaping it. See Figure 5.7. Linda appreciates Marshall’s transparency and sharing of such personal work and insights. This is what POST is all about. Linda and Marshall both challenge everyone to do their own exploration in the tray. We, and our clients, will be the better for it. Now, for a shift, we move into the next section. See Appendix D: Sandtray Prompts for Working with the Person-of-the-Sandtray-Therapist.

CULTURAL HUMILITY IN SAND WORK Due to the deep right brain to right brain work involved in sandtray therapy, “the therapist’s blind spots, biases, and unrecognized emotional needs may result in inappropriate emotional and behavioral responses, intolerance, need to be liked by the client, and attempts to change the client” (Gil & Rubin, 2005, p. 88). While this is true and needs to be monitored in all therapies, there is a special burden sandtray therapists, and other expressive arts practitioners, take on when inviting clients to access deeply rooted, wordless places with the promise of safely handling those vulnerabilities, especially when working with one from a community, or communities, often impacted by oppression and misuses of power. In the sandtray room, there is need to focus on what offce décor, arrangement, and selection of miniatures communicate to all clients who walk in the door (Fountain & Lyles, 2021), but there is just as great a need to focus on biases and prejudices existing in the heart and mind of the POST. They do exist; denying them helps no one. Clients deserve to work with a clinician who continues to address how to maintain a culturally humble POST. Cultural humility as a core value refects an openness on the part of the therapist to privilege the client’s experience of culture as most important, moving away from a focus on cultural “knowing” on the part of the therapist that the traditionally-taught concept of cultural competence emphasized (Fountain & Neal, 2020). Yolanda Fountain, a colleague of Linda and Marshall’s who regularly teaches and writes on these subjects, has contributed signifcantly to the felds of sandtray and play therapy, especially in the area of contemplating cultural humility. Fountain (2019) emphasizes these steps toward growing one’s cultural humility:

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1. Acknowledge incompetence; 2. Be proactive in cultural application; 3. Make a lifelong commitment to introspection and humility. Since cultural humility “involves an individual’s recognition of gaps in knowledge about a particular culture” (Abbott et al., 2019, p. 170), there could be signature themes hindering the development of a culturally humble attitude (Fountain & Lyles, 2021). This returns us to the importance of a sandtray therapist using their own materials to make worlds exploring how their signature themes may be impacting their comfort with cultural humility. It is also important for sandtray therapists to step into the shoes of the client and attempt to make worlds with the materials on hand and to ask clients if there are miniatures not represented that could aid their individualized explorations in the sand. Here are additional recommendations: ◾ Seek paid consultation with someone versed in culturally humble practices, especially a clinician who represents the communities served. ◾ Read a variety of materials from a range of authors on the subjects related to culture and anti-oppressive and anti-racism practices. These are critical to maintaining a healthy and socially-aware POST. A sandtray therapist must embrace the lifelong journey of “personalized explorations of culture, power, privilege, and prejudice” (Patallo, 2019, p. 231). It’s ok to be uncomfortable, but it’s not ok to do nothing about it.

SANDTRAY THERAPY SESSION PROTOCOL So much therapy education focuses on the client and rightfully so! Therapists read books and attend trainings on applying clinical theory, addressing common client issues, executing treatment strategies, and the list goes on and on. However, the most attachment- and trauma- (and human-) sensitive therapy focuses on being rather than doing. This goes for sandtray therapy, too! And focusing on how to be with clients in the sand requires attending to the POST through every aspect of a sandtray therapy session. There six steps in sandtray process, according to Homeyer and Sweeney (2017): “1. Room preparation 2. Introduction to the client

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3. Creation in the sandtray 4. Post-creation 5. Sand tray cleanup 6. Documenting the session” (p. 42). The POST cannot be divorced from any of these moments and the following sections address how to maintain contact with the POST during each step.

Step 1: Room Preparation The sand tray, sand, and miniature fgures are an extension of the therapist. When getting a sandtray therapy room in order by emptying the tray, smoothing the sand, and arranging fgures on shelves, the therapist is not simply doing chores; they are connecting to the materials that a client will use to make contact with tender parts of self. This room, and the therapist’s connection to all parts of it, make way for a client to begin to sense safety. Sandtray therapists can beneft from spending time with their materials outside of client sessions. Meditate while moving hands through the sand. Sit in the “client’s chair” and take in the different view. Get to know the textures and dimensions of the miniatures. Make worlds. These materials are partners in healing and a client can best feel all their parts are welcome when a sandtray therapist has made room for them. In so doing, the sandtray therapist will “provide a deeply safe and protected healing environment” (Webber & Mascari, 2008, p. 7) because those materials will become a more fuid part of the POST.

Step 2: Introduction to The Client, The Prompt Delivering a sandtray therapy prompt to a client is an invitation. This invites the client to explore their inner world, not knowing exactly what will be found. The POST needs to be able to offer a prompt for creating a sand tray world, be it nondirective or directive, without expectation or agenda for its unfolding. Whatever the client hears and wherever the client goes with their world must be handled with care and treated as valuable. For the invitation to truly be an invitation, there must be no attachment to the outcome and complete attachment to the creator. Intentionality, connected to clinical theory, assists the therapist in staying congruent throughout the therapeutic process. This congruence is also sensed by the client. This also emphasizes why the POST needs to offer a succinct prompt. Being organized in the offering of a prompt allows the sandtray therapy client a clean entry into their inner world. When a prompt is unclear or too wordy, the client’s implicit world becomes entangled in confusion before creation has begun. A clear mind from the POST, rooted in awareness of self, the other,

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and the process, facilitates the best chance of a secure launching for exploration.

Step 3: Creation in the Sandtray After being prompted, the client begins to gather miniature fgures for the creation of a world. These are often the most quiet moments of sandtray witness and creator being together. The quiet allows for the creator to enter into their right hemisphere as they interact with the sensations and images available to them. The POST can fall out of attunement in the quiet if silent witnessing is not comfortable or practiced in maintaining strong connection without words. Rae (2013) calls this the “Silent Reverie” (p. 92), stating that the silence can allow, if the POST can stay engaged, for the implicit world between client and therapist and the created sand tray world, to become alive. Webber and Mascari (2008) offer these thoughts for the POST to remain connected to self and other during the often silent creation phase: Stand or sit so that the entire building process and tray can be viewed. Notice the client’s development of the sand tray. Which fgure is placed frst? What items are moved? Does the creator engage the fgures in action? Does the creator narrate the action or speak for the fgures? Observe the client’s contact with the sandbox and self-soothing with sand. Does the creator move the sand with his/ her hands or a tool? Moisten the sand? Place fgures under the sand? Work outside the tray? (p. 7)

And if the mind of the POST wanders, they are best served by noticing the distraction and returning to their witnessing role gently and without self-judgment. It is human to struggle with focused attention; however, self-compassion for these tendencies will help the sandtray therapist effciently return to tracking the creator’s work instead of becoming stuck in perceived inadequacies. While the POST’s internal awareness across clinical theories would remain the same, the interactive process may differ, of course. For the Adlerian sandtray therapist, who is co-creating in the tray, there will likely be a high level of verbal and physical interaction, movement of both individuals around the tray and interacting with the miniature fgures. Likewise, the Solutionfocused therapist may be using a directed prompt to do a scaling experience, where problem-solving and interaction is consistent with this clinical theory. A family therapist might have the entire family working in the tray and may encourage verbal interaction to assess and develop communication. This is an example why

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understanding one’s clinical theory, which includes the role of the therapist and the techniques that will be used to attain clinical goals, is foundational.

Step 4: Post-creation It is often at this step that the POST can get most excited or overwhelmed. Many sandtray clinicians feel a pressure to “see something” extraordinary in a created world. Remember, though, the POST serves the creator of the world best by remaining attuned, following close and offering refections, pacing open-ended questions with a sense of ease, and allowing meaning to unfold (not be forced). There is no “right” kind of sand world. Some are crowded; some are sparse. Some are peopled; some are not. Some are energized; some are slow moving. None of these dynamics alone determines if processing will go smoothly. The POST who remains ready and aware and invested can help any creator fnd the sacred in any creation. And when working with one whose trauma is showing, these competent holding patterns from the POST become even more vital. Hold back from giving interpretation, meaning, or names to the client’s sand tray. Respect the pace of sand tray construction and the client’s need for repetition in reconstructing the trauma story. Do not rush the process. Recognize, with the client’s stories, the potential personal impact of vicarious trauma. (Webber & Mascari, 2008, p. 7)

Quite simply, the POST who can trust the sandtray process will allow meaning to come in waves as the relationship between witness and creator can support what is being discovered. Patience, sincerity, and humility are good friends to the POST while processing a completed world with its brave creator. Similar to the prompt and building of the scene, the therapist’s clinical theory will impact how this step unfolds. A Gestalt therapist may have miniature fgures interact with and “talk” to each other. The noticing of polarities in the tray may be identifed by the Gestalt sandtray therapist, inviting the client to explore those more fully. Knowing fully the purpose of this step and how one’s clinical theory supports this part of the session is crucial.

Step 5: Sandtray Cleanup Of course, different theories and clinicians handle the dismantling of a created world in various manners. Regardless of who

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empties the tray and when they empty it, the POST will need to be as thoughtfully invested in these moments as in the creation. There is often a beauty in what has been created; sometimes there is great harshness in the created world. Either way, something important was witnessed and treating the cleanup with respect matters. When possible, the POST can offer a blessing over each fgure as it is returned to its resting place. If the creator of the world is involved, model gratitude to the materials as they are removed from the world. It can be an experience of supporting the work that has been done in the tray and modeling appropriate relational interactions. The shift from processing, of whatever type, to this “taking apart” is still part of the therapeutic holding. Even if the creator is not present, the POST can fnd peace in these moments if they remember that they are not just “tidying toys,” but are instead handling soul speech that are being tenderly cleared to make room for another spirit to be witnessed.

Step 6: Documenting the Session Documentation is rarely a therapist’s favorite part of their job, but even in documenting a sandtray session, there is important space for contemplating the POST. Session notes for so many reasons focus rather exclusively on the experience of the client. However, a sandtray clinician needs to monitor their own ongoing involvement in their client’s work. Take a moment during this step to close eyes and allow for the experience of witnessing the tray to be strongly noticed. The sandtray therapist does not necessarily need to include this in the client’s documentation, but this step provides a moment to give attention to the POST. Beware of judgment sneaking in. If moments of struggle occurred during the session, treat those memories with curiosity and compassion. Ask: What do I as therapist need as a result of being a part of this session? Then get that need met outside of client work. Also, notice if any moments might have led to a rupture with the client and contemplate what repair might look like. Mindfully tending to self will serve the client because the sandtray therapist’s half of the relationship will be ready for what’s next. Lowenfeld had therapists draw pictures of the clients’ worlds with the clients’ guidance (Urwin & Hood-Williams, 2014). While technology developments have allowed the sandtray therapy world to move to photographing worlds as part of documentation, there is still room for involving the client in this documentation step. Seeing the client witness their tray through a

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lens and a picture wakes up a different part of the POST. There is a “meta” moment where perspectives get another chance to be practiced during this new moment of noticing. And try, just try, drawing that picture from time to time. Who knows what it might awaken? Another experience is to take a moment and add back in the tray a few of the miniature fgures that were prominent in the meaning of the client’s tray. How do those speak to you as you recall key components of the work of the session? This may be seen as a luxury, in our time rushed days. Linda has found this helpful when struggling with attuning with a specifc client, or specifc session.

IN CLOSING Undoubtedly, being a sandtray therapist asks for one to accept many responsibilities: to be prepared for supporting clients through moments of surprise revelations, to hold competently all that clients are verbally and nonverbally bringing to and through their created worlds, to remain constantly curious without stepping into interpretations or judgments, to trust in the power of metaphor. However, under all of these critical roles, lies the responsibility to maintain contact with the POST, and to handle gently all personal awareness that unfolds while engaged in such expressive work. As part of a multi-day sandtray therapy training that Linda and Marshall led in Istanbul, Turkey, a lovely therapist named Layza volunteered to be a sand tray creator as part of a demonstration. Here are her POST refections on the importance of engaging in such an experience: I feel more than lucky to be able to do a sandtray with Marshall Lyles and it was in sandtray training with 30-35 participants. In trainings, as a therapist, experiencing what the client will feel is very important. And also experiencing how the therapist can contain the client is so informative. As the tray seems to be the concrete container, the therapist is the container of the soul, the scene, the feelings; and the safe accompaniment for the hope and the road that will open new paths for the client. In my experience, with 30-35 participants watching what miniatures I will pick, knowing they will offer unexpected meanings, here comes the importance of the attachment with the container (the tray itself) and the therapist (dear Marshall). I felt connection with my inner self; the silent talking to my inner self became perceivable, touchable, smellable and changeable with the help of the miniatures and with the attached therapist. As doing my sandtray during the training, I learnt how important

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it is to pay attention to the eyes of the client rather than looking into the tray; as the sandtray does, my therapist Marshall made me experience to that very important concept that I might miss during a training. So, knowing is not enough; I needed to experience that feeling. That I will never forget to resonate and attune with the client in that sense. As therapists, doing our sandtrays, it is even more important to stay connected to ourselves. As Marshall said in some specifc part for my tray ‘going deeper is also going forward. As you are going deeper in the sand, a pile somewhere is getting higher. As you lower, the pile gets higher’. Such powerful metaphors make the client ‘move’ forward in this trip of life. Layza Ovadya, MA, Clinical Psychologist, Play and EMDR Therapist, Turkey personal communication, December 19, 2020)

Working with the POST presents as a critical element in doing effective sandtray therapy with clients. Each therapist’s chosen clinical theory will offer more about the role the therapist is meant to play in therapy, but every defned role will still be executed by very human sandtray therapists. Schore (2009) wrote this comment inspired by Karen Maroda, from my experience there are more therapists who have painfully sat on their emotions, erroneously believing that they were doing the right thing. For these therapists, the prospect of using their emotional responses constructively for the patient is a potentially rewarding and mutually healthy experience … perhaps we can explore the therapeutic nature of affect, freeing both our patients and ourselves. (Schore, 2009, p. 140)

Using sandtray therapy to facilitate healing in attachmentwounded and traumatized clients does require that the POST is monitored for the clients’ sake, but it also good for the heart and mind of the sandtray therapist! Our hope is that sandtray therapists will more and more personally beneft from the sandtray therapy tools at their fngertips. The rich connection between therapist and their materials will beneft countless others in the future. “We started out knowing that the person-of-the-therapist could be harmful to the patient. We concentrated on ways in which the use of self can be of positive value in treatment” (Satir, 2013, p. 26). This applies to every step of the sandtray therapy process. Bring your whole, monitored self to each moment of the work because “this therapy tool can be as creative and imaginative as the therapist who uses it” (Bainum et al., 2006, p. 43). Here are closing words from Eliana Gil that beautifully capture the heart of this idea:

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Over decades of supervising and mentoring, I can say with confdence that the person-of-the-therapist issues are critical to identify, address, and keep working with over time. Far from a sprint, this works tends to be a marathon of self-evaluation, refection, compassion, and action. It’s simply absolutely compelling for the therapist to continue his or her own work throughout their clinical development in order to provide the very best relational opportunities to our clients. I believe one such aspect is counter transferential work, and most importantly, making time for it. How much time do you spend after a session concludes, allowing yourself to “be with” the experience you just had with a client? Can you move from one client to another without taking the time to calm your mind, check in with your heart, listening to what your body needs? I think therapists need to prioritize taking the time to explore themselves and their responses because these are responses gleaned by being with the client. I have often found myself whispering, feeling uneasy, even feeling irritable or angry after a session. Unless I stop long enough to register those feelings and externalize them, I will just carry them from one client session to another, and the weight can become heavier throughout the day. So fnding a way to release and compartmentalizing will be a lot healthier than simply suppressing or compartmentalizing your responses. We all bring a unique set of experiences to the work we do. Those experiences guide our interest in working with specifc target groups, or specifc situations. It is not coincidental for example, that Margaret Lowenfeld, who was bilingual, found this silent, nonverbal experience of sand tray to be so compelling, evocative, deep and gratifying. Knowing the reasons why we gravitate to specifc ways of working is a most useful journey, necessary for offering ourselves to others in the most responsible and genuine ways. (Eliana Gil, personal communication, December 18, 2020; Her full statement to us can be read in Closing Moments, later in the book.)

REFERENCES Abbott, D. M., Pelc, N., & Mercier, C. (2019). Cultural humility and the teaching of psychology. Scholarship of Teaching and Learning in Psychology, 5(2), 169–181. https://doi.org/10.1037/stl0000144 Aponte, H. J. (1992). Training the person of the therapist in structural family therapy. Journal of Marital and Family Therapy, 18(3), 269–281. Aponte, H. J., & Kissil, K. (2014). “If I can grapple with this I can truly be of use in the therapy room”: Using the therapist’s own emotional struggles to facilitate effective therapy. [Abstract]. Journal of Marital and Family Therapy, 40(2), 152–164. Aponte, H. J., & Kissil, K. (2017). The person of the therapist training model. In A. Chambers & D. C. Breunlin (Eds.), Encyclopedia of couple and family therapy. Springer. https://doi.org/10.1007/978-3-319-15877-8 _544-1 Bainum, C. R., Schneider, M. F., & Stone, M. H. (2006). An Adlerian model for sandtray therapy. Journal of Individual Psychology, 62(1). Baldwin, M. (Ed.). (2013). The use of self in therapy. Routledge. De Little, M. M. (2019). Where words can’t reach: Neuroscience and the Satir Model in the sand tray. Friesens. Fountain, Y. N. (2019). Cultural dynamics in play therapy. [PowerPoint presentation]. Roswell, GA: Play Wellness LLC.

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Fountain, Y. N., & Lyles, M. (2021, January 26). Creating a culturally humble space in sand and play therapy. [Live virtual continuing education training]. World Association for Therapy Professionals’ 2021 Inaugural International Conference. Fountain, Y. N., & Neal, S. (2020). Developing cultural humility through clinical consultation. Play Therapy, 15(4), 4–7. Gil, E., & Rubin, L. (2005). Countertransference play: Informing and enhancing therapist self-awareness through play. International Journal of Play Therapy, 14(2), 87–102. https://doi.org/10.1037/h0088904 Homeyer, L. E., & Sweeney, D. S. (2017). Sandtray therapy: A practical manual (3rd ed.). Routledge. Kindle Edition. Kalff, D. M. (2003). Sandplay: A psychotherapeutic approach to the psyche. Temenos Press. Keith, D. V. (2013). “I” is rising: Parallel play, transcendence, irony, and jouissance. In M. Baldwin (Ed.), The use of self in therapy (pp. 216–225). Routledge. Kissil, K., Carneiro, R., & Aponte, H. J. (2018). Beyond duality: The relationship between the personal and the professional selves of the therapist in the Person of the Therapist Training. Journal of Family Psychotherapy, 29(1), 71–86. https://doi.org/10.1080/08975353.2018.1416244 Kissil, K., & Niño, A. (2017). Does the Person‐of‐the‐Therapist Training (POTT) promote self‐care? Personal gains of MFT trainees following POTT: A retrospective thematic analysis. Journal of Marital and Family Therapy, 43(3), 526–536. https://doi.org/10.1111/jmft.12213 Kissil, K., & Niño, A. (2018). The Person-of-the-Therapist Training’s state of affairs: Evaluating research and implementation of the model. Journal of Family Psychotherapy, 29(4), 318–335. https://doi.org/10.1080 /08975353.2018.1477383 Lowenfeld, M. (1979). Understanding children’s sandplay. George Allen & Unwin. Miller, G. D., & Baldwin, Jr, D. C. (2013). The implications of the wounded-healer archetype for the use of self in psychotherapy. In M. Baldwin (Ed.), The use of self in therapy (pp. 81–96). Routledge. Niño, A., & Zeytinoglu-Saydam, S. (2020). Helping supervisees use their self in their clinical work: The person-of-the-therapist training model (POTT) in supervision. Journal of Family Psychotherapy, 1–18. https ://doi.org/10.1080/08975353.2020.1804799 Patallo, B. J. (2019). The multicultural guidelines in practice: Cultural humility in clinical training and clinical supervision. Training and Education in Professional Psychology, 13(3), 227–232. https://doi.org/10 .1037/tep0000253 Rae, R. (2013). Sandtray: Playing to heal, recover, and grow. Rowman & Littlefeld. Satir, V. (2013). The therapist story. In M. Baldwin (Ed.), The use of self in therapy (pp. 19–27). Routledge. Schore, A. N. (2009). Right-brain affect regulation: An essential mechanism of development, trauma, dissociation, and psychotherapy. In D. Fosha, D. J. Siegel, & M. F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development & clinical practice (pp. 112–144). W. W. Norton & Company. Schore, A. N. (2019). Right brain psychotherapy (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Steinhardt, L. (2013). On becoming a Jungian sandplay therapist: The healing spirit of sandplay in nature and in therapy. Jessica Kingsley Publishers. Urwin, C., & Hood-Williams, J. (2014). Child psychotherapy, war and the normal child: Selected papers of Margaret Lowenfeld. Sussex Academic Press. Webber, J. M., & Mascari, J. B. (2008, March). Sand tray therapy and the healing process in trauma and grief counseling. Based on a program presented at the ACA Annual Conference & Exhibition, Honolulu, HI. Retrieved June 27, 2008, from http://counselingoutftters.com/vistas/vistas08/Webber.htm

Part Two Digging Deeper into Clinical Application

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Seeds of difference sowed Brought a harvest of strife So we return to ground and water To remember sweet sensitivity’s gift Sandtray therapy offers inner and outer world exploration and healing to a wide range of ages, as well as to both clinical and non-clinical populations. This is primarily due to the immense fexibility of use and the symbolic and unfolding nature inherent to the modality. Understanding sand tray work with various age groups and neurodiverse presentations, and how this may impact clients’ choice of miniature fgures and the approach to processing the created worlds may increase effectiveness. The terms neurodiverse, neurotypical, and neurodivergent are now being used more frequently in education, human development, and mental health felds. The word neurodiverse was developed in the 1990s by sociologist Judy Singer (1998), who is on the autism spectrum. She encouraged its use as an alternative for the pathological, medical model view when referring to those issues often seen as defcits, disorders, or impairments. Nick Walker (2014, 2020), a professor, wrote about clarifying the following terms and usage: ◾ Neurodiversity is a biological fact. It is not a trait that any individual possesses; it is a trait possessed by a group. ◽ Usage example: Our school offers multiple learning strategies to accommodate the neurodiversity of our student body. ◾ Neurotypical means having a style of neurocognitive functioning that falls within the dominant societal standards of “normal.”

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◽ Usage example: He’s neurotypical or She’s a neurotypical ◽ Opposite of neurodivergent ◾ Neurodivergent (and neurodivergence) means having a brain that functions in ways that diverge signifcantly from the dominant societal standards of “typical.” ◽ Usage example: Our school aims to be inclusive of students who are Autistic, dyslexic, or otherwise neurodivergent. “Neurodiversity: Some Basic Terms & Defnition” section ◽ Can be largely or entirely genetic and innate ◽ Can be largely or entirely produced by brain-altering experiences ◽ Can arrive from a combination of the two (such as trauma, long-term medication practice) ◽ Multiple divergent is a person whose neurocognitive function diverges from dominant societal norms in multiple ways. (Adapted from Walker, 2014, 2020) As has been identifed throughout this book, understanding terms and using them correctly is important. Too often, new terms and concepts are misunderstood or misused. So, the above is an introduction (or review) for the sandtray therapist as you read this chapter.

SANDTRAY THERAPY AND ERIKSON’S PSYCHOSOCIAL STAGES Erik Erikson’s (1963) Psychosocial Stages of Development is a classic part of mental health professionals’ training programs. Because these are well known and identify lifespan tasks related to an individual’s maturation of psychological and social interactions, it provides one of several ways to assess and identify a point of engagement with our clients. Understanding how neurotypical individuals respond to sand tray activities offers us the insight to identify and most effectively serve the neurodivergent client. Viewed through our current knowledge of neurodevelopment, the psychosocial stages are based on brain development and integration. Amatruda and Simpson (2013) wrote from this perspective in Sandplay: The Sacred Healing. A client often presents in our offces with a variety of levels of developmental states. This happens for multiple reasons. These delays may have many sources, including childhood abuse and neglect, trauma, and attachment disruptions (Perry, 2006). Young children, for example, often present with uneven, out-ofsync, or asymmetrical development. Linda recently worked with

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a mother with a 3-year, 10-month-old son who had varying levels of cognitive and emotional development, resulting in a shifting ability to regulate behavior. This is quite neurotypical, although distressing for his parents. Building on already effective parenting, some parent education, and implementing Child-Parent Relationship Therapy (CPRT, Bratton & Landreth, 2020) and other parenting adjustments, the parents helped their son improve his behavior. However, Linda also had a middle-aged woman client who had superior cognitive skills in mathematics but behaved emotionally like a pre-teen. She functioned and interacted with others at a much earlier psychosocial stage than her chronological age. Indeed, she had a history of early childhood neglect, attachment disruption, and sexual assault. This neurodivergent client engaged quickly with the sand tray, other expressive techniques, and talk therapy. Her emotional capacity and ability for social engagement grew as she worked on resolving her trauma history. Awareness of the following information that integrates the psychosocial stages with a neurotypical presentation may also provide informal assessment opportunities as a client creates in the tray. The sandtray therapist will still need to decide the source or origin of a neurodivergent presentation to design a treatment plan to meet individual therapeutic goals.

Very Young Children Children three and under are dealing with the tasks of Trust vs. Mistrust (birth to 12 months) and Autonomy vs. Shame and Doubt (years 1–3). These very young children do not contain their play within the tray. The sandtray therapist verbally tracks the ongoing process of active, dynamic play, similar to play therapy tracking. Young children of this age range most typically use sharks, monsters, babies, parents, or anything they can reach on the shelves (Amatruda & Simpson, 2013).

Preschoolers Children at age 3–5 are dealing with the Initiative vs. Guilt developmental tasks. Using the term loosely with this age, tray organization is about ordering (grouping miniature fgures by color or families) and disruptions. These children continue to have active, dynamic play, so play therapy tracking is still the appropriate interaction. The miniature fgures often line the edges of the tray. (These children would fnd the tray-with-a-ledge helpful in their work.) They are drawn to farm animals, family fgures, and houses (Amatruda & Simpson, 2013).

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Children at age 6 begin dealing with Industry vs. Inferiority developmental tasks. Tray organization continues to be about ordering, but begins to develop magical stories. They are drawn to fantasy fgures, babies, and houses (Amatruda & Simpson, 2013).

Elementary Students Children ages 7 and 8 continue to deal with Industry vs. Inferiority developmental tasks. Tray organization continues to display growing storytelling ability and appear busier. These children will shift from pausing to story tell and then continue dynamic play. The sandtray therapist’s ability to stay attuned and be fuid in response and following the child’s play is a necessary skill. They are drawn to cars, weddings, fantasy, ego fgures, and the setting of fres (Amatruda & Simpson, 2013). Children ages 9–10 are continuing to deal with Industry vs. Inferiority. Tray organization continues with more advanced storytelling, adding elaborate sequencing and beginning to use abstract images. They are now drawn to knights, soldiers, horses, fgures to build family constellations (Amatruda & Simpson, 2013). Linda notices that girls of this age use a lot of horses and arrange very concrete neighborhoods; boys typically use many soldiers in adversarial arrangements.

Middle Schoolers Preadolescents aged 11–14 are dealing with Identify vs. Role Diffusion developmental tasks. Tray organization reveals a shift in the storytelling to the beginning of journeys, with a sense of the possibly ominous. They are now drawn to mythic fantasy, including dungeons and princesses. This would include dragons, heroes and villains, those needing rescue and those in need of rescue (Amatruda & Simpson, 2013).

Adolescents Adolescents are dealing with Identify vs. Role Diffusion tasks. Tray organization begins to shift toward more typical adult arrangements while still showing journeys. Miniature fgures selected are more abstract in nature, matching adolescents’ higher cognitive functioning (Amatruda & Simpson, 2013). Social justice is a dynamic for this age, so fgures that may express this topic would be facilitative.

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Young Adulthood Young adults (ages 20–39) are dealing with the tasks surrounding Intimacy vs. Isolation. Tray organization continues to show journeying but adds gatherings and centering. As the story and depictions become more elaborate, ego fgures become important, symbolizing gender representations, temples, wedding items, couples/partners (Amatruda & Simpson, 2013).

Middle Adulthood Middle adulthood (ages 40–59) issues are dealing with the tasks surrounding Generativity vs. Stagnation. Tray organization continues to show journeying and gatherings, adding mounds and voids. Figures surrounding parenthood and families are essential, babies, children, mother and child, father and child, families, eggs, gardens, treasures (Amatruda & Simpson, 2013).

Late Adulthood Late adulthood (ages 60 and above) issues are dealing with the tasks surrounding Ego Integrity vs. Despair. Tray organization continues to show journeys and quests, centering, meeting of the ego and the divine, and obstacles and scarcity. Figures focusing on the unknown, hidden spiritual fgures, and mystery, are now used in the tray (Amatruda & Simpson, 2013). Also, items representing death, loss, and grief are useful in this stage.

Additional Stage: Stage 9 Joan Erikson, wife of Erik and codeveloper of the psychosocial stages, added the ninth stage (J. Erikson, 2013). Once she entered her 90s, she shared that she and Erik may not have fully understood the aging process’s nuances when developing the psychosocial stages while in their 50s. After Erik’s death in 1994, Joan introduced Stage 9 as a time to revisit the earlier stages. If successfully managed, this leads to gerotranscendence (E. & J. Erikson, 1997; J. Erikson, 2013; Peters, 2020). In this phase, individuals are still neurotypical, including age-related cognitive decline, alongside the physical changes that typically accompany advancing age. Sandtray therapy can help assist these elders in dealing with aging changes and diffculties as well as dementia. See more details later in this chapter.

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NEUROTYPICAL AND NEURODIVERSE GROUPS Gifted Children and Adolescents

Twice exceptional (2E) is the term for a gifted person who also has a learning disability or mental health diagnosis. M. Melendez, personal communication, January 8, 2021

Gifted children and adolescents are usually identifed by school offcials as functioning at academically advanced levels. These children are then placed in at least some advanced scholastic classes. Gifted children and adolescents may have various issues, including perfectionism, dealing with high expectations, peer relationships, and others. Parents may also feel unequipped to parent their gifted child or teen. Some gifted children and adolescents in non-public school educational settings may not have been formally tested and identifed but may still deal with some of these issues. Gifted individuals are noted for their asynchronistic developmental patterns (Dabrowski, 1967; Parker & O’Brien, 2011). This often results in others, particularly adults, shaming and not understanding them. Their behavior often results in misdiagnosis because over-excitability mimics pathology, such as ADHD and Anxiety Disorders. These individuals will have a variety of a combination of areas of over-excitability and possibly another area of neurodivergence. A play therapist and counselor, Mandi Meléndez, specializes in work with gifted children and adolescents. She provided the following information (personal communication, November 20, 2020). Frequently these neurodiverse clients often process shaming messages in the tray—also, the duality of both the positives and negatives of being gifted. Meléndez states many clients express that it is “NOT a gift!” and use their work in the tray to communicate and resolve their reaction to who they are. There are fve areas of overexcitability (Dabrowski, 1967). These have special considerations for using the sand tray (M. Meléndez, personal communication, November 20, 2020). 1. Intellectual: These individuals may initially be skeptical of the sand tray. They will ask for explanations on how it works and are concerned about how you will be interpreting what they do in the tray. Meléndez states that she often tells them, “I use this so you can learn about yourself, not for me to learn about you.” 2. Sensory/Sensual: These individuals are often misdiagnosed with Sensory Integration Disorders, so you will notice sensory aversions and seeking behaviors. Some clients will not tolerate the sand and will work more effectively without it. Some will prefer coarser sand or

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a sand alternative. Meléndez fnds many of her clients prefer the texture of the StarDust Therapy Sand™ by Jurassic Sands because the smooth roundness is preferred to the sharper edges of regular sand. Some clients also are sensitive to the materials from which the miniature fgures are made. For example, some cannot tolerate plastic fgures, indicating they smell bad and don’t like the plastic texture; or wooden items, they are concerned about the rough texture and getting slivers. For these clients offering materials to make their own fgures is a must. Some clients like painting rocks to make fgures. Water can also be tricky. Meléndez suggests allowing the client to try out sand and water in a smaller container before using it in the large sand tray. 3. Psycho-motor: These clients are highly active. Having the sand tray in the middle of the room to provide ample opportunity for movement is extremely helpful. They will also be very dynamic and active while creating their trays, not building a static scene and sitting and talking about it. One technique that is also helpful is having the client move their body like the fgure that they are adding to the tray would move. Some clients that are also sensory seekers fnd that having sessions in the standard play therapy room allows them to get into the sandbox sitting on the foor while building the scene, providing high levels of both sensory and psychomotor needs. 4. Emotional: These clients are over-attached to their emotional response. The emotional attribution given to miniature fgures can be extreme. Meléndez fnds it is easier for these clients to have fewer fgures from which to choose. She will pull out fgures with strong emotional meaning and attributes, leaving those with more neutral, less emotional charges. Clients will still imbue these with strong emotional connotations. These clients often also over amplify emotions during the processing of their sandtrays. Be prepared to help the clients stay regulated; the therapist being merely neutral in communication while staying empathetic regarding their concerns can be suffcient. 5. Imaginational: These clients engage in sand tray easily. They love the opportunity for storytelling and accessing the right-brain imagination. Serving gifted clients and their parents is most effective (as with other populations) when the therapist understands their specifc needs and strengths.

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Autism Spectrum Disorder (ASD) Neurodiverse individuals identifed on the autism spectrum may be served with sand therapies. Robert Jason Grant shares he uses sand tray with ASD clients after careful assessment of the client and then using appropriate adaptations (personal communication, November 28, 2020). Children with autism often do not understand symbolic and pretend play skills that interfere with their social interactions with peers. Sandtray therapy can assist in the development of these skills. The following intervention protocol for Symbolic Play Time is adapted from Grant (2017). The therapist instructs the child that they are going to have some symbolic and pretend play time. The therapist explains the concept of symbolic and pretend play and introduces the child to the sand tray and the miniature fgures that will be used in the symbolic/pretend play time. Pretend Play—“This is a type of play where we might use a toy and pretend that it is something that it is not. We might take a car miniature and pretend like it is alive and can talk and think.” Symbolic Play—“This is a type of play where we might take a toy and use it to be or represent something else. We might take a penguin miniature and say this miniature represents my mom because she likes penguins.” The therapist might start with an example saying, “I’m going to pick two miniatures to be two kids at a school, and they are having an argument.” The therapist picks a car and says, “This is Michael,” and picks a dog miniature and says, “This is John.” The therapist then places the miniatures in the sand tray and has Michael and John have an argument about Minecraft. The therapist then picks a tree miniature and says, “This is the teacher at the school.” The tree/teacher comes into the sandtray and tells the boys to stop arguing. The therapist can create any example they like to show the child what symbolic and pretend play looks like. It is important the therapist begins by role modeling and showing the child examples. The therapist might want to provide a few different examples. After role modeling a few examples, the therapist then begins incorporating the child into the decision making. The therapist will continue with examples but try to involve the child by having the child take on the role of one of the characters or having the child introduce a new character into the sandtray story as much as possible. The therapist can periodically switch to different miniatures and create other symbolic play examples. Once the child seems to be comfortably participating in the symbolic/pretend play, the therapist can introduce a directive tray for the child to try and complete.

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Some example prompts include: 1) Create an original story using some of the miniatures. 2) Pick a couple of miniatures and turn them into original characters. 3) Pick a miniature to represent you and each person in your family. Try not to use people. 4) Pick a miniature that describes a feeling you are having right now. 5) Pick one miniature that describes your home and one miniature that describes your school. Try not to pick a building. 6) Make a sandtray, using the miniatures, that describes things you like. 7) Make a sandtray, using the miniatures, that describes things you don’t like. (p. 80). The therapist should always be looking for opportunities to have the child make decisions and engage in and lead the way in the symbolic/pretend play. The ultimate goal would be to have the child complete a directive symbolic tray and displaying a signifcant level of understanding in symbolic and pretend play.

Grant is an expert on working with this neurodivergent population. Linda and Marshall appreciate his input on this section of this chapter. Please see his statement to us in full in the Closing Moments section at the end of the book.

Dementia Dementia is a category of neurodivergent, neurocognitive disorders. The most common is Alzheimer’s Disease and includes Lew’s Body, Parkinson’s, Huntington’s, and vascular dementia. Those with dementia have progressive memory loss. This results in the neurotypical individual moving to neurodivergence. With the resulting short-term memory loss, social relationships are affected, and eventually, there is a loss of social controls. Sandi Peters (2018) believes this loss of social controls over retained and still accessible long-term memory occurs when elders (Peters’ term) can no longer manage intrusive memories. Unresolved diffcult, scary, painful memories make their way into conscious thought, no longer able to be kept at bay. It is the reaction to these diffcult intrusive memories that results in problem behavior and inappropriate verbalization. Peters shares the use of sandplay with what she terms as “both non-compromised and compromised elders” (2018, p. 182), using miniatures fgures and symbols as the nonverbal expression of self. “When cognitive capacity wanes, what is left is the symbolic” (p. 184). Peters posits that even though the elder’s cognitive capacity may no longer be present, it may be possible for them to do inner work; the elder can express and even resolve early distressful experiences through the symbolic work in the tray. For those in the early stages of memory loss, sandtray therapy helps the elder express

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their reaction to realizing their increasing loss of cognitive and physical functioning. Neuroscience informs us about the default mode network (DMN; Buckner, 2013), which may be the location of this inability to manage unpleasant memories. Peters (2020) references the DMN as the gatekeeper for what comes into conscious awareness. The DMN, located in the brain’s frontal region, is involved in a wide variety of cognitive functions including semantic processing, thinking about oneself, imagining one’s future, encoding and retrieving episodic memories, retrieving autobiographical memories, considering the world from the perspective of another person and thinking creatively about a problem. (adapted from Konishi et al., 2015, p. 2) Whether living with memory loss or simply the visages of aging, when given the opportunity to connect with an inner state and manifest it in the exterior world, each elder experienced something compelling. Peters, 2018, p. 192

The DMN is more prominent when the individual ceases focused, active tasks, decreasing when the individual is busily focused on some task. DMN functioning also decreases as memory loss increases (Pollan, 2019). As elders begin to shift to less activity and have more extended periods of quiet, the DMN naturally becomes more prominent. Additionally, when dementia decreases the DMN’s ability to function, elders are increasingly unable to manage emotions and disregard social cues. Long forgotten and repressed memories resurface. This may be why some elders repeat stories of what happened earlier in their life; their DMN is no longer able to maintain its gatekeeper duties (Peters, 2020). The process of doing sandtray therapy with elders with dementia varies depending on individual capabilities as dementia progresses. Here are some guidelines: ◾ Cognitively intact elders residing at home, in assisted living, or nursing home (for reasons other than dementia): ◽ The session is set up like a typical one: the client selects fgures from the collection and places them in a tray. There may need to be adaptations for choosing miniature fgures because the elder has limitations in movement or visual ability. If there are no issues, then the elder can select from the regular collection of miniature fgures. If not, preselecting a few from every category would help reduce stress and embarrassment. A verbal discussion could occur based on what is seen and shared. ◾ Early stage dementia elders can also participate in a typical session: ◽ The interaction between the elder and therapist is often one of increased: connection, bonding, and nurturance.

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◽ A tray created with an empty center may represent the elder’s lack of sense of internal cohesion, connection, and emptiness. ◽ Miniature fgures are more frequently placed in the tray’s left side, interpreted by psychodynamic therapists as the unconscious, instinctual area, indicating these symbols are more evident based on the reduced functioning of the DMN. ◾ Early part of fnal-stage dementia in elders. These individuals may no longer be mobile or have diffculty with mobility and balance: ◽ Preselect fgures for the elder, place in a basket on the elder’s lap; the therapist selects the items based on knowledge of the elder, possibly previously elderelected items. Remember to include items for death and grief. ◽ Allow the elder to place in the tray, as possible. ◽ Elders may not be able to verbally process the tray. However, we know that the act of being creative and expressing self in the tray may bring relief and internal resolution. ◽ Working with those who can do some verbal processing, one must balance both the story being told and directing them to place items in the tray. ◽ Empower the elder as much as possible to place items and share as much story as they can (Adapted from Peters, 2020). Other considerations in working with elders in a sand tray: ◾ Most elders prefer dry sand ◾ Use larger miniature fgures, as elders may have diffculty handling smaller items. Include a few miniature fgures from each typical category, being sure to include items about grief and death items. (S. Peters, personal communication, December 10, 2020; See Peters’ handout in Closing Moments section at the end of the book.) A Gestalt application of sandtray with clients with dementia suggests that it offers joy and creativity, which is experienced in the here and now. Katrina Siawpani (2013) uses small everyday objects with clients in both initial and advanced stages of Alzheimer’s. Her experience is that the elderly are often resistant to being invited to “play” in the sand because they are resistant to being treated like children. Sadly, this condescending approach to working with elders with dementia is a common occurrence.

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Siawpani indicates men, in particular, are resistant to being invited to “play”; they state they are not children anymore and do not want to play. Therefore, she uses the prompt, “place objects on the sand tray to create a setting or a story” (p. 39). Elders are provided a selection of small familiar, everyday objects and a sand tray. Siawpani often works in groups and does individual work as needed. She clearly enjoys her work with elders with dementia, stating: If there is something I can contribute to their lives, it is the happiness and creativity the “here and now” can offer, even when the human brain ceases to have the faculties it once had. Sandplay therapy often brings a person back to childhood memories. The connection between sand and the self through the use of personal objects helps one return to the point that needs healing (p. 56).

This is very encouraging for the well-being of elders. This population deserves a fresh look for those providing them with mental health services (Suri, 2012). As we know, the elder population in the United States is growing. The Rural Health Information Hub (2020) indicates that there are currently 46 million adults aged 65 or older in the United States. Between 2020 and 2030, it’s anticipated there will be almost 18 million more of those 65 and older, or 1 in 5! Internationally, the number of people aged 65 or older is projected to grow from an estimated 524 million in 2010 to nearly 1.5 billion in 2050 (World Health Organization, 2020). All sandtray therapists can beneft from staying connected to developing research on how to best serve this vulnerable population.

WORKING WITH THE NEUROTYPICAL IN NON-CLINICAL SETTINGS The sand tray is most frequently used with clinical populations, including a broad grouping of neurodiverse individuals. The sand tray is also used in non-clinical settings, with neurotypical individuals. These settings include schools, universities, business settings, and, as noted above, with elders. The purpose for use varies in focus. Several such examples will be explored below.

In Education: University Level Public administration graduate students at Brigham Young University were already participating in the recent addition of biographical refectivity and critical refectivity to the curriculum. Experiences in journal work, group work, guided

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imagery, and meditation were used to facilitate these refective goals. Mayes (2001) believed that the spiritual component was lacking, so he added spiritual refectivity to the course work. A sandplay experience was chosen to use to meet this goal. The facilitators were faculty and clinicians who regularly used sandplay in their clinical practices. The prompt used with the graduate students was: “What is your vision of yourself as an administrator?” (Mayes et al., 2004, p. 258). Their research project on this added course work consisted of seven frst-year cohort students and six fnal-year cohort students, eight males and fve females, and all members of the Church of Jesus Christ of Latter-day Saints (LDS). A single sandtray was constructed in the presence of the researcher who had the most extensive experience in sandplay. All the researchers met and analyzed the trays, and the written fndings were sent to the participants for any edits. A follow-up interview with the incoming cohort participants occurred three weeks later. The interview’s purpose was to see if their responses correlated to their respective trays’ thematic material. The fndings indicate that using a sand tray experience offers insight into a prospective school principal’s motivational aspects. Spirituality was found to be more important to the females, especially for those at the elementary school level. The fndings also helped the participants understand themselves more fully, including the impact of spiritual functionality, and informed the graduate program on what areas to address more thoroughly in their course work. A sand tray was used in the Spirituality and Communication undergraduate course at a major university (Webster et al., 2006). The university developed this course in response to students’ desire for the university to take an increased role in their emotional and spiritual development. The course activities provided the opportunity to examine spirituality in a mainstream (non-religious) context. The course is limited to 25 students to provide opportunities for a variety of interactive, sharing activities. Working in the sand tray is one of three such experiences for this course. Each student was asked to bring a large shoebox with sand to class. The faculty provided a selection of miniature fgures. After contemplating the prompt of thinking about their “spiritual paths, obstacles and strengths,” the students had 15 minutes to build their scene. It was then shared with a peer who asked open-ended questions. Two key spiritual themes that emerged from the sand tray activity were values and meaning. For instance, one student created two separate paths in her box. One was dictated by society with a road,

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a controlling wizard, and demanding people. This path was not appealing to the student, but was the most direct path to the person representing the student in the box. The other path depicted what she wanted to do. The second path was not a straight one and she described it as not easy. Further, it was blocked off by a roadblock that was described by the student as an indication that this path would be hard to take because it was not the typical high- earning career after college. When the student started moving the toys around, she removed the roadblock and decided that she would need faith and courage to move that roadblock in her real life. (Webster et al., 2006, p. 5)

Students reported that their intimate relationships improved after this sandtray experience; they had learned more about themselves personally and developed more insight into their future paths. At Texas State University, in the Professional Counseling Graduate Program, Linda has used sand tray as an end-of-semester experience. Used in various courses, students built together in a large sand tray to provide the opportunity to create a collective, group tray. This 3′ × 3′ tray is set on two classroom tables, placed side by side, to hold the tray. An extensive teaching collection of sand tray miniature fgures provides a plethora of choices for the students. A simple prompt, such as “create together what this semester has been like for you,” offers suffcient focus for the closure experience. Watching students’ various approaches to the task is interesting and insightful. Also, noting their interaction and collaboration, often along with laughter and spontaneous discussions about each other’s additions to the tray seems to preclude the need for a formal time processing the tray. Similar uses of sand tray might help a wide variety of university programs, regardless of degree, to increase student self-awareness, while exploring specifc issues, personal and professional traits.

In Education: Elementary and Secondary School Level Elementary and secondary schools have been the sites for sand tray use for quite some time (Blalock, 2021; Carmichael, 1994; Flahive & Ray, 2007; Kestly, 2010; Shen & Armstrong, 2008; Rousseau et al., 2005; Zarzaur, 2004). In addition to the expected use in school counseling, sandtray experiences are also used in classroom guidance activities. Linda has provided clinical supervision for several school counselors who also provide classroom guidance curriculum. Classroom experiences are for all the students, a neurodiverse group.

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A handy set-up for classroom experiences: ◾ a wheeled cart with shelves ◾ small individual sand trays which can be easily stacked with sand ◽ plastic take-out meal boxes, or ◽ 6” to 8” round plant saucers ◾ miniature fgures organized in fsherman’s tackle boxes ◽ the smaller trays will reduce the number needed for each student ◽ special attention to types of miniature fgures, based on ages of students served, will assist in students’ communication through the tray’s scene Intentional use of the prompt is developed from the curriculum’s content. For example: “Build in the tray an example of what bullying might look like,” followed with, “How might the scene change to help?” There are many creative ways to use the individual sand trays within the classroom experience. A fun side story here. When Linda taught at Texas State University, she had a counseling student who took a sand tray and a small collection of miniature fgures on a job interview for a school counselor position. Linda thought she was incredibly brave to do so. After all, what might a committee member reveal that they might then be embarrassed about unintentionally revealing!? How well could the student explain the importance of play and how it works into the school counseling curriculum? Well, the committee loved her sharing how she would use it with students in the classroom and in counseling. They were taken with the experience of doing it themselves. Yes. She got the job! The use of a sand tray in the classroom for academic improvement has been written about by Cherrie Glasse (1994), Mary Noyes (1981), and Kristin Unnsteinsdóttir and Barbara Turner (2015). These four individuals developed similar approaches for the use of a sand tray experience to enhance educational development. Frank Wilson, neurologist (cited in Unnsteinsdóttir & Turner, 2015), has studied the link between hand movement, storytelling, and language skills. He noted that “moving or playing with objects with the hands creates brain activity that parallels the basic elements of a story … as the hands move, the brain creates a cognitive story line” (p. 41). Unnsteinsdóttir and Turner stated that hand movement is linked to language skills, “moving hands through the sand stimulates and strengthens these neural connections and reinforces language development” (p. 41). Noyes stated that the “use of the right brain allows the child to make the

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leaps of insight necessary to become a ‘top down’ reader” and “meaning is constructed from the head down rather than more slowly and sequentially from the printed page up” (1981, p. 232). In the 1980s, Mary Noyes, a reading teacher, began using a sand tray experience with her students (1981). The Sand Tray Technique, as she named it, was similar to Glasse’s approach. The students had a private place in the classroom to build in a sandtray. She used a green plastic bag over a cardboard box flled with beach sand. Noyes was typically present during the building, later writing down the story and other student comments, along with taking a photograph of the completed sandtray. In closing her article, Noyes shares: I am convinced that the teacher who uses Sandplay as one technique in a remedial reading program will not only bring students farther along the academic road but will also provide them with a unique opportunity to get in touch with their inner feelings, to make a connection with the core of their being, and to work out some of their conficts about themselves and others. (1981, p. 237)

Also as an educational experience, Glasse (1995) began using sandplay in the classroom. She set up a sand tray with a collection of miniature fgures. These were placed in a relatively visually protected space in the classroom to provide some privacy for the student when working in the tray. Each student had an assigned specifc time each week when they could work in the tray. They did so alone, and when completed, invited Glasse over to hear their story of the created scene. Glasse wrote the story as it was narrated to her. There was no processing. With a neurodiverse group of students, as one would expect in a classroom, she found a wide variety of how her students used the tray. She also stated: Creating sandworlds and allowing me to share their story is the only classroom activity I have found that makes a difference—a difference that is observable in improved student behavior, some test scores, and a difference also in my empathy and awareness of the student’s world. (p. 10).

Sandtray Play in education was developed by Kristin Unnsteinsdóttir and Barbara Turner (2015). Although based on sandplay, they are clear that Sandtray Play is not used as a psychotherapy intervention but as creative play in an educational setting: In addition, creative play is a primary vehicle through which children resolve the often worrisome or overwhelming feelings that attend their normal growth and development. When children

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tackle stressful feelings that burden them in their creative play an oscillation is created between different regions of the brain. This initiates understanding and resolves tension, resulting in a strong self-image. (Unnsteinsdóttir & Turner, 2015, p. 10)

Unnsteinsdóttir invites up to fve children at a time into the school’s learning center. The learning center has a long table with several sand trays, placed suffciently apart to give each child a sense of privacy. The room also has an extensive collection of sand tray miniature fgures. Unlike Glasse’s work above, Unnsteinsdóttir believes it is essential to be present, although quiet and not interactive, while the children create their trays and to be available to manage any challenging or disruptive child interactions. This needed presence is well-rooted in sandplay therapy. Unnsteinsdóttir states the teacher’s presence is critical to maintaining a safe place for the child to explore. Like Noyes and Glasse, she listens to the child’s story and records it for the child. The child can then build a book with photographs of the tray and the typed narratives created by the child. Although there may be up to fve students in the room simultaneously, the process is seen as an individual experience, not a group one. Noyes’ (1981) record-keeping of the students’ standardized testing revealed that typical students gained 8–9 months of improvement during a school year. At one school, those involved in the Sandtray Technique averaged twice that, a 1-year-6-month improvement. Noyes taught sixth-grade students who made more remarkable improvement at another school, with the smallest gain being two years improvement, and six years the largest gain; all within one academic year. Glasse (1994) stated she conducted research in California schools from 1982 to 1990. She recorded their growth on standardized testing as well. She had mixed results, but those who benefted the most from sandplay were below-average students (1994, p. 11). Unnsteinsdóttir (2012) reports research on Sandtray Play in her school in Iceland. She found positive outcomings on her research question: “Can Sandplay and storytelling on a regular basis affect learning skills, self-image and mental wellbeing of pupils with poor selfimage, learning diffculties and/or emotional problems” (p. 328). Signifcant improvement occurred in many academic areas, including perception and verbal comprehension (measured by the WISC). Findings led to a discussion of the correlation between strength in perception and reading diffculties. Fourteen participants scored average or better on the posttest; 11 of these had displayed considerable reading diffculty on the pretest, and of these, 6 were diagnosed with dyslexia (p. 332). In 2014–2017, Unnsteinsdóttir continued to research Sandtray Play in Ireland

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and Romania. She is now retired and no longer teaching on this subject (K. Unnsteinsdóttir, personal communication, January 7, 2021). The academic setting is an area rich with possibilities for increasing student success. Continued research would help establish this as an adjunctive experience in educational settings.

In Business Sandtray is also used in the business world. Britni Mueck, a regional mental health services agency supervisor, used a sand tray for a team-building experience. Here is Mueck in her own words: As a new supervisor, I found sand tray to be very effective for my team and during my individual supervisions for a new mixture of staff members. For the set-up, I used a larger than a traditional sand tray, as I lead a team building for 10 team members. The miniatures were placed near the tray in their respective categories. As several staff had no previous experience with sand tray, I introduced the tray very simplistically, modeling how they can move the sand around to build hills and valleys. And additionally, introducing the miniatures in their categories for which they will use to create a scene: people, animals, mode of transportation, natural items, and fences and bridges. Since we were a relatively new—and rather incohesive—team, I asked each member to create a scene in the sand that describes or introduces themselves. I gave them approximately 20 minutes to explore the miniatures and build their scene. Not by my surprise, everyone created a small scene in their sand separate from each other; however, their demeanors changed through the experience of processing their individual scenes. Staff grew excited when they found commonalities between each other, which lead to questions and conversations about their similar items. During one staff member’s explanation of her scene, she surprised herself; she built a scene of herself in the corner of the tray with several items around her. As she processed her scene, she stated something like “wow, this is much like my life; I very much close everyone off and only let a few people in.” It is important to note that I struggled to motivate this staff prior to this activity, and she struggled with communicating with me. From that moment forward, as her supervisor, I knew I had to be more patient with building rapport with her. To this day, this staff member and I laugh at how this activity was the preceding moment in peeling back the layers of her “onion”; we now have an excellent working relationship! For the group, after this team building activity, I noticed a drastic increase in collaboration and communication between team members. And quantitatively, our productivity numbers drastically increased. (Personal communication, Britni Mueck, January 4, 2021.)

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In Social Science Research Social science research: Julie Matthews and Parlo Singh (2009) used a sand tray as a variety of visual methods to explore the relationship of the refugee experience to the local education experience. Their research focused on young African people who involuntarily migrated. They were unaware of the sand tray being used in any previous social sciences research projects. Those using the sand tray produced a collaborative story, and we found that it stimulated discussion in small groups with limited communication skills in English. Sand has a tactile attraction and participants liked to run it between their fngers and move it around the tray, the fgures were able to stand for a broad range of matters, and discussions about what they could or should represent were insightful (p. 62).

The fndings included that “visual methods enabled refugee young people to demonstrate their resilience, their enjoyment of their new lives, and their capacity to appropriate youth culture to their own ends” (p. 60). Study of resilience: Netsai Gwata’s (2018) research question was: “How do young adults from Leandra explain their resilience in the context of drought?” (p. 3). Gwata used visual and narrative data collection methods, such as draw-and-write techniques, timelines, body-maps, and “sand-tray” work (p. 7). The participants also provided narratives of their work. Sandtray work was done in groups with prompts such as: “What does it mean for a young person to be OK when there is drought?” “What/ who makes it possible for young people to be OK when there is drought?” (p. 48). The researchers also identifed themes which included the individual, family, and community settings.

Working toward Understanding Jewish and Arab Israeli group facilitator trainees participated in an experiential sandtray workshop. The Gaza War, however, had fractured the group for several months. Ariel Katz (Katz & Marzouk 2010) was asked to facilitate an experience to get through some of the impasses the war had created. Katz selected a sand tray for the two-hour experience. Arab-Jewish dyads shared a sand tray, which was symbolic of the land over which there was confict. To promote a spirit of equality and facilitative movement, each person, taking alternate turns, selected three fgures (p. 116). They were then prompted to “build your world” and instructed they could add as many as they wanted and had 20 minutes to build. “Subjects in this experience identifed with

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the ideals of co-existence, but their actual operation refected struggles over power and control, domination and submission, acquiescence over political correctness, and some instances of evolving ideas of sharing” (p. 126).

IN CLOSING Experiences in the sandtray are helpful for a wide range of neurodiversity. Whether the neurodivergent individual is also identifed as gifted, on the autism spectrum disorder, or impacted by dementia, experienced trauma, or identifed with an attachment disorder, sand therapies are useful during therapeutic interventions. The neurotypical population setting also shows the sand tray’s value in non-clinical settings, such as educational, business settings, and research projects. Sandtray can even be used to deepen understanding between people of conficting nations. The effectiveness of using a sand tray and miniature fgures can be, indeed, applicable for a wide range of settings and people.

REFERENCES Amatruda, K., & Simpson, P. H. (2013). Sandplay – the sacred healing: A guide to symbolic process. Trance*Sand*Dance Press. Blalock, B. (2021) School-Based sandtray counseling on a shoe string, Journal of Creativity in Mental Health. Advance online publication. https://doi.org/ 10.1080/15401383.2021.1928575 Bratton, S., & Landreth, G. (2020). Child-parent relationship therapy (2nd ed.). Routledge. Buckner, R. (2013). The brain’s default network: Origins and implications for study of psychosis. Dialogues in Clinical Neuroscience, 15(3), 351–358. https://doi.org/10.31887/DCNS.2013.15.3/rbuckner Carmichael, K. D. (1994). Sand play as an elementary school strategy. Elementary School Guidance and Counseling, 28(4), 302–307. Dabrowski, K. (1967). Personality-shaping through positive disintegration. Little, Brown & Company. Erikson, E. (1963). Childhood and society. W. W. Norton & Company. Erikson, E., & Erikson, J. (1997). The life cycle completed: Extended version. W. W. Norton & Company. Erikson, J. (2013). On old age 1: A conversation with Joan Erikson at 90. Davidson Films. Flahive, M. W., & Ray, D. (2007). Effect of group sandtray therapy with preadolescents. Journal of Specialists in Group Work, 32(4), 362–382. Glasse, C. (1995). Sandplay in the classroom: Teacher’s guide (Rev. ed.). Author. Grant, R. J. (2017). Play-based interventions for autism spectrum disorders and other developmental disabilities. Routledge. Gwata, N. (2018). Resilience of young adults in a context of drought [M.Ed Dissertation]. University of Pretoria, Pretoria. http://hdl.handle.net/2263/70105 Katz, A., & Marzouk, R. (2010). Israeli Arab-Jewish sandtray group work: Creating a world together. Psychotherapy and Politics International Psychotherapy Politics. International, 8(2), 113–127. https:// doi.org/10.1002/ppi.218 Kestly, T. (2010). Group Sandplay in elementary schools. In A. Drewes, L. Carey, and C. Schaefer (Eds.), School-based play therapy (pp. 257–281). John Wiley & Sons. Konishi, M., McLaren, D. G., Engen, H., & Smallwood, J. (2015). Shaped by the past: The Default Mode Network supports cognition that is independent of immediate perceptual input. PLoS ONE, 10(6), 1–18. https://doi.org/10.1371/journal.pone.0132209

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Matthews, J., & Singh, P. (2009) Visual methods in the social sciences: Refugee background young people. The International Journal of Interdisciplinary Social Sciences, 4(10), 59–70. Mayes, C. (2001). A transpersonal model for teacher refectivity. Journal of Curriculum Studies, 35(2), 56–70. Mayes, C., Blackwell Mays, P., Williams, E. (2004). Messages in the sand: Sandtray therapy techniques with graduate students in an educational leadership program. International Journal of Leadership in Education, 7(3), 257–284. https://doi.org/10.1080/13603120410001694540 Noyes, M. (1981). Sandplay imagery: An aid to teaching reading. Academy Therapy, 17(2), 231–237. Parker, N., & O’Brien, P. (2011). Play therapy-reaching the child with autism. International Journal of Special Education, 26(1), 80–87. Perry, B., & Szalavita, M. (2006). The boy who was raised as a dog. Basic Books. Peters, S. (2018). Using Sandplay to explore inner states. Journal of Religion, Spirituality & Aging, 30(2), 179–194. https://doi.org/10.1080/15528030.2017.1289141 Peters, S. (2020). Aging with agency: Building resilience, confronting challenges, and navigating eldercare. North Atlantic Books. Pollan, M. (2019). How to change your mind. Penguin Books. Rousseau, C., Drapeau, A., Lacroix, L., Bagilishya, D., & Heusch, N. (2005). Evaluation of a classroom program of creative expression workshops for refugee and immigrant children. Journal of Child Psychology and Psychiatry, 46(2), 180–185. Rural Health Information Hub (2020, December). Demographic changes and aging population. https://www .ruralhealthinfo.org/toolkits/aging/1/demographics Shen, Y., & Armstrong, S. A. (2008). Impact of group sandtray therapy on the self-esteem of young adolescent girls. The Journal for Specialists in Group Work, 33(2), 118–137. Siawpani, K. (2013). Incorporating Sandplay therapy into Gestalt therapy in the treatment of dementia. Gestalt Review, 17(1), 35–58. https://doi.org/10.5325/gestaltreview.17.1.0035 Singer, J. (1998). Why can’t you be normal for once in your life? From a “problem with no name” to the emergence of a new category of difference. In M. Corker & S. French (Eds.), Disability Discourse. Open University Press. Suri, R. (2012). Sandplay: An adjunctive therapy to working with dementia. International Journal of Play Therapy, 21(3), 117–130. 137. https://doi.org/10.1080/01933920801977397 Unnsteinsdóttir, K. (2012). The infuence of Sandplay and imaginative storytelling on children’s learning and emotional-behavioral development in an Icelandic primary school. The Arts in Psychotherapy, 29, 328–332. Unnsteinsdóttir, K., & Turner, B. (2015). Sandtray play in education: A teacher’s guide. Tenemos Temenos Press. Walker, N. (2014, September 27). Neurodiversity: Some basic terms & defnitions. Neurocosmopolitanlism. https://www.neurocosmopolitanism.com/neurodiversity-some-basic-terms-defnitions/ Walker, N. (2020, November 26). Neurodiversity: Some basic terms & defnitions. Planet Neurodivergent. https ://www.planetneurodivergent.com/neurodiversity-and-neurodivergent-basic-terminology/ Webster, S. M., Curran, J., Greathead, L., & Lemieux, K. (2006). Spirituality in mainstream academia: Three transformative activities. Journal of College and Character, 7(6), 1–6. https://doi.org/10.2202/1940 -1639.1210 World Health Organization. (2020, December). Global health and aging. https://www.who.int/ageing/publicat ions/global_health.pdf Zarzaur, M. (2004). The effectiveness of sandtray therapy versus classroom behavior management on the improvement of school behavior of kindergarten through fourth-grade students [Master’s thesis]. The University of Memphis, Dissertation Abstract International, AAT 3153961.

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In the stillness we hear Whispers of relationships past And you fnd freedom to choose If there is room for them in this world “Psychotherapy is about changing the meaning people make about themselves in the world” (Tronick, 2009, p. 86). This begs the questions: How do people make meaning? And how can sandtray therapy support this goal? Attachment theory has much to say on the subject of meaning-making and bringing these ideas into client’s sand tray work can make for powerful co-created moments between therapists and clients. Attachment theory has been strongly infuential on the feld of therapy for decades. Marshall remembers reading about Bowlby’s original concepts while in graduate school and feeling like the world around him came into focus. Since then, developments in the relational neurosciences have made knowledge of attachment theory a virtual requirement for mental health professionals desiring to remain relevant; the mental health feld has become aware that the quality of an individual’s attachment impacts how they sense, think, feel, and act (Green et al., 2013). That’s the whole person! Sandtray therapists across the globe attempt to integrate attachment theory concepts into the modality of sandtray therapy, not to mention their chosen clinical theories. These therapists deserve support in order to understand how their sand materials and processes connect to attachment theory’s constructs. While overviewing seminal attachment theory concepts, like safe haven, secure base, and narrative coherence, this chapter will articulate methods for bringing these ideas and others into felt contact with the sandtray client. As we explore the overlap between these two therapeutic staples, attention will be given to honoring clients’ DOI: 10.4324/9781003095491-7

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needs as taught to us by attachment theory. We will then look at how work in the sand tray can support clients in updating their meaning-making matrices based on present day realities.

ATTACHMENT THEORY CONCEPTS Sandtray therapy and attachment theory were born in a shared season and location and that is just the beginning of their commonalities. Both focus on the relationship between a caretaker and a creation, hoping that exploration of interpersonal and intrapersonal dynamics feels secure as it unfolds within contained parameters. Attachment theory brought new energy to how we think about making meaning. What an important and relevant concept for therapists attempting to hold space for clients who are creating worlds in the sand in an attempt to explore their minds’ inner worlds! Every situation we meet with in life is constructed in terms of the representational models we have of the world about us and of ourselves. Information reaching us through our sense organs is selected and interpreted in terms of those models, its signifcance for us and for those we care for is evaluated in terms of them, and plans of action conceived and executed with those models in mind. On how we interpret and evaluate each situation, moreover, turns also how we feel. (Bowlby, 1980, as cited in Collins et al., 2004, p. 196)

These words come to us from John Bowlby. Just a few years behind Lowenfeld, Bowlby, often regarded in our present time as the father of attachment theory, made his professional entry into the mental health feld. Robert Karen (1998) quoting Victoria Hamilton, a long-time colleague of Bowlby’s, describes him as having “‘penetrating but responsive eyes beneath raised eyebrows which to me expressed both interest and a slight air of surprise and expectation’” (p. 29). His physical appearance seemed to prepare others for the affective experience soon to come. Often praised for his stance of intellectual curiosity and scientifc exploration, Karen added that Bowlby himself was sometimes described as relationally distant and guarded about his own inner world. He seemingly devoted his career to uncovering nuances of relationship that often eluded him. John Bowlby was born in London on February 26, 1907 (Holmes, 1993). Coming from an upper-class English family, Bowlby’s father was surgeon to the king’s household. Bowlby’s caregivers were primarily nannies until he was sent to boarding school at the age of 7 or 8 (there is disparity in the literature).

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At a very young age, the nanny to whom Bowlby was most connected left his family’s employment. These early life experiences tremendously impacted Bowlby and most believe these led to his investigation into familial environments (Karen, 1998; Mooney, 2009). It makes Marshall wish Bowlby could have benefted from creating some worlds in the sand, to fnd care for that younger self by bypassing intellectual attempts at making meaning of early life moments. Bowlby entered young adulthood with so much intellectual capability. Like Lowenfeld, he trained in medicine and psychoanalysis, and was greatly impacted by working with young people while war and its effects gripped society (Bowlby, 1988). Bowlby’s professional observations focused on caregiver–child dynamics, formulating a theory that the quality of the affectual bond between baby and caregiver had long-term implications on the child’s development. As hard as it might be to believe, Bowlby’s ideas about considering the quality of external relationships as important were controversial (Mooney, 2009). Psychoanalytic wisdom of the time did not acknowledge how caregiver state of mind and caregiving patterns might infuence the child’s development. Bowlby felt existing theories of human development either overemphasized biological programming or what is learned from the environment; he proposed that understanding what shapes human behavior required holding these concepts in balance (Bowlby, 1988). Disputing much of the conventional wisdom in child welfare during his early career, Bowlby believed it was prejudicial to simply believe a home environment was suitable or not based on physical provisions alone; he thought that the emotional atmosphere in the family was far more impactful on child development (Karen, 1998). Bowlby went even further by suggesting that the child’s appraisal of caregiver availability was key in the attachment process. John Bowlby’s pioneering work in attachment theory advanced an evolutionary model of human bonding. In contrast to the psychoanalytic drive theories of the time, he proposed that human infants attach to their caregivers because they come into the world wired for relationships, and that moment-to-moment interactions within those relationships support the child’s learning and adaptation to the environment, and enhance survival. Bowlby was convinced that children’s actual relationship experiences, not just their fantasies, shaped their emotions, thinking, and behavior and, bit by bit, created in them automatic patterns of thinking, feeling, and relationship behavior. (Whelan & Stewart, 2015, p. 114)

Bowlby was convinced that children’s actual relationship experiences, not just their fantasies, shaped their emotions, thinking, and behavior and, bit by bit, created in them automatic patterns of thinking, feeling, and relationship behavior.

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Bowlby further broke new ground by attending to the emotional qualities in shared experiences between caregiver and child: A feature of attachment behaviour of the greatest importance clinically, and present irrespective of the age of the individual concerned, is the intensity of the emotion that accompanies it, the kind of emotion aroused depending on how the relationship between the individual attached and the attachment fgure is faring. If it goes well, there is joy and a sense of security. If it is threatened, there is jealousy, anxiety, and anger. If broken, there is grief and depression. (Bowlby, 1988, p. 4)

In a caregiving relationship, attachment theory emphasizes that relational opposites of moving toward and pulling away from a needs source is required for optimal growth and development. “A child’s ability to rely on his or her attachment fgure as a safe haven in times of need and as a secure base from which to explore the environment are key components of well-functioning attachment bonds” (Cooper et al., 2004, p. 439); patterns emerge quickly in a child’s behavior based on their caregiver’s ability to hold these “opposites” while focusing on the child’s expression of need. Without intervention, these early life patterns carry forward into all the future relationships the person might have, including a therapeutic relationship (Bowlby, 1988). Bowlby called this internalized representational model the Internal Working Model. This model incorporates the beliefs that either (a) one is worthy of love and that the world is a predictable and positive place (i.e., secure attachment), or (b) one is unlovable and exists in a world that is unpredictable and untrustworthy (i.e., insecure attachment). (Green et al., 2013)

Over time, Mary Ainsworth and Mary Main were able to develop instruments for measuring aspects of the Internal Working Model for children and adults, respectively (Wallin, 2007). As these hypotheses became researchable, names for certain patterns of attachment organization were able to come forward, broadly arranged to a model that is either based in internalized security or resulting from internalized insecurity about whether their needs will be validated and met consistently. Secure attachment does not imply perfection; it means that attunement was present enough in caregiving for children to come to befriend their own neediness. When needs and feelings are regularly attuned to by secure caregivers, children are able to tolerate noticing the resulting relational rupture and move toward available repair experiences with those wounds. Again, this need

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does not need to exist perfectly in an infant’s life for them to fnd security, which is a relief since it would be impossible. It just needs to occur enough for there to be an expectation developed that someone would usually care enough to engage in safe relationship. And as far as sandtray therapy goes, internalized security will show up in a variety of manners. In security, there is a fresh quality to narratives being shared, that each moment can be one of discovery versus only allowing the same patterns of speech long ago established to echo forward with no openness to awareness of the moment. There is also a “fuidity and freedom” in relation to play (Holmes, 2020) that will be transparent, assuming the client is not playing out a more recent trauma. For those who did not get the beneft of secure caregiving or substantial healing experiences later in life, patterns entrenched in insecurity will be alive. Some will have developed hyperactivating strategies that have been informed by anxious/preoccupied caregiving experiences, often resulting in a felt hopelessness about emotional experiences of being cared for; “Rather than actively searching or changing their environment, sufferers remain passive in the face of loss, confict, or trauma” (Holmes, 2020, pp. 60–61). Others live with more deactivating emotional survival strategies. These clients protect themselves through dismissing contact with their own attachment systems, informed by an early life of avoidance. Those with this Internalized Working Model are particularly vulnerable to trauma and stress due to a long season of diffculty learning from or recovering from painful emotions (Holmes, 2020). The third insecure attachment pattern emerging from attachment research described a disorganized inner world. Those who struggle in this way often come from backgrounds of painful abuse or neglect and benefted from no modeling of mentalizing from caregivers. As a result, their strategy for survival was cycling between hypervigilance and dissociation with neither extreme settling into a predictable way of taking in the world. “In all three patterns of insecure attachment, appropriate complexity is sacrifced for the sake of security” (Holmes, 2020, p. 62). Talia and colleagues fnd that the specifc categories of attachment predict how clients speak and manage dialogue in their psychotherapy sessions. Secure–autonomous clients’ talk is characterised by attentive turn-taking, leading to mutually generated new formulations and solutions to their diffculties. By contrast, dismissive individuals’ dialogue resists new perspectives, downplaying or retracting emerging emotions and efforts at restructuring. Anxiously attached clients tend to spin confusing monologues in which therapists fnd it diffcult to fnd, engage or initiate reciprocal dialogue. The course of true therapy never runs smooth.

Secure attachment does not imply perfection; it means that attunement was present enough in caregiving for children to come to befriend their own neediness.

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The majority of patients coming for help will manifest various forms of insecure attachment … insecure dialogic styles refect a top-down strategy in which the need for a modicum of security restricts exploration and innovation. Therapeutic skill depends on being able to turn the impasse created by these insecure dialogic patterns into a conversational focus (Holmes, 2020, pp. 67–68). The goal of attachmentsensitive therapy includes assisting a client in becoming aware of thoughts, feelings, and behaviors connected to caregiving experiences (that are often out of awareness) and supporting clients in making meaning of new experiences without automatic infuence of earlier life patterns.

Implicit features of working models often reveal themselves through nonverbal communication and “projective tasks that can be used to infer unconscious thoughts and feelings” (Collins, et al., 2004, p. 208). While sandtray therapy techniques have not formally been shown to reveal attachment tendencies, these general patterns from research suggest that sandtray therapy presents as the type of tool that would invite attachment dynamics forward. Continuing in this chapter, there will be references to the following concepts: attachment strategies can, and often will, be revealed in the sand; all humans can and will have memories whose emotional encoding are consistent with all the various strategies; all people deserve sustained, compassionate contact from an attuned healer who can competently hold the manifestation of these rhythms in the sand tray, regardless of “classifcation.” One of the most tragic consequences of living within an insecure stream of attachment is that these dear people “fnd unbearable what at some deep level they crave, to love and be loved” (Music, 2018, p. 40). Moving away from the historic use of the word “attachment,” let’s explore ways to view all relational wounding that impacts a client’s internal world. Badenoch shares this broader perspective, Sometimes the word ‘attachment’ means only the experiences we have with our primary people in early life. Here, honoring the primacy of our system’s ongoing capacity for attaching, it will apply to the many signifcant connections we have throughout our lives that shape and reshape our relational circuitry and experience. (Badenoch, 2017, p. 242)

Different relational moments may awaken any of a number of attachment streams internalized from earlier relationships; these varying internalized relationships, whether involving early life caregivers or not, lead to multiplicity of mind and we want to be open to how all relationships have been involved in the formation of the client’s inner community as we share space in the sand (Badenoch, 2017). The goal of attachment-sensitive therapy includes assisting a client in becoming aware of thoughts, feelings, and behaviors connected to caregiving experiences (that are often out of awareness)

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and supporting clients in making meaning of new experiences without automatic infuence of earlier life patterns. The therapist’s primary role in this endeavor is “to provide the patient with a secure base from which he can explore both himself and his relationships with all those with whom he has made, or might make, an affectual bond” (Bowlby, 2005, p. 172). Similar to parents’ role when secure attachment is being initially created, an attachment-sensitive therapist focuses on the atmosphere being created in therapy so that the client has the option of growth. “Bowlby’s project was to bring together systematic observations of parent–offspring interaction with psychoanalytic ideas about the origins of mental pain and the ways that the mind defends itself against disruption” (Holmes, 2020, p. 59). As these defenses began to be known and studied, Bowlby’s idea of the ways therapists can maintain the secure base offering evolved. He described that attachment therapy creates “a setting in which the patient’s distress comes into focus, is given voice, regulated, refected upon, and in which new meanings spontaneously emerge and begin to be co-constructed” (Holmes, 2020, p. 9). “In the absence of an external or internal secure base, exploration, physical and psychological, is curtailed” (Holmes, 2020, p. 60). Bowlby felt that clients deserved help in getting access to new information and that a therapist’s job requires them to be able to help clients scaffold toward being able to tolerate accessing the source of pain while gaining access to new perspectives (2005). While Marshall can fnd no mention of sandtray therapy in Bowlby’s writings, the opportunities this modality provides seem to be a good ft within Bowlby’s desired constructs for therapeutic methodology. Bowlby believed therapy works when clients feel safe to explore their inner worlds. Sandtray therapy presents as an ideal choice for this type of attachment work! Attachment-sensitive therapy is about stepping into the internal dialogue clients are already experiencing and introducing a secure base for new meaning-making. For a sandtray therapist, this occurs in all phases of sandtray work, including the welcoming of a client into the process and the quiet moments of the creating a world, not just in moments of making a narrative. Clients will reveal their inner dialogues, typically occurring outside of their conscious awareness, with their bodies and their words while engaging the sandtray materials. While not mentioning sandtray therapy specifcally, David Wallin (2007) has synthesized attachment theory research and formed a clinical model for supporting attachment repair that is quite congruent with sandtray therapy processes. In so doing, he has:

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identifed three fndings that appear to have the most profound and fertile implications for psychotherapy: frst, that co-created relationships of attachment are the key context for development; second, that preverbal experience makes up the core of the developing self; and third, that the stance of the self toward experience predicts attachment security better than the facts of personal history themselves. (p. 1)

Sandtray therapy, without relying on words alone and while privileging attuned co-construction of meaning, allows clients to feel the safety of a regulated therapist while coming to see how self orients to story.

He goes on to say, “By virtue of the felt security generated through such affect-regulating interactions, the therapeutic relationship can provide a context for accessing disavowed or dissociated experiences within the patient that have not-and perhaps cannot-be put into words” (2007, p. 3). Sandtray therapy, without relying on words alone and while privileging attuned co-construction of meaning, allows clients to feel the safety of a regulated therapist while coming to see how self orients to story. In response to describing a client who journeyed through a healing vision quest in the sand, Badenoch states, We might ask what role relational neuroscience plays in these kinds of experiences. For me, it begins with the body. Cultivating an understanding-and most importantly, a felt sense-of these neural pathways helps us attune body to body with our people as they enter these deeper, more challenging realms. Through resonance, our capacity to attend to our bodies while remaining in a ventral state gradually becomes theirs. (2017, p. 308)

Neurobiology is designed to interfere with holding a state of curiosity about self and others if “trust is turned off” internally (Jurist, 2018, p. 129). Attuning to clients’ bodies will serve to create a map of their neural pathways and automatic meanings so that sandtray therapists can meet clients in their movements and introduce a new regulating rhythm. In addition to attuning to what client’s bodies are revealing about their inner worlds during sandtray sessions, therapists also get insight into the lived experiences of clients through their narratives. The Adult Attachment Interview (AAI; George et al., 1985) emphasizes how language patterns can be a window into the inner world, revealing patterns and levels of coherence that invite awareness of attachment streams; clinicians who learn to “listen” in this way can begin to offer care to original sources of pain (Ammaniti et al., 2008). Listening for moments of idealization of others, preoccupied anger, rumination, as well as recovery, met needs, and free-fowing fresh perspectives will offer invitations into deeper knowing of implicitly-held, relationallyinformed pain and potential.

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When painful events cause clients to become attachmentwounded, they not only hold the stored pain, they also lose mentalization capacity. Mentalization “is the process by which we realize that having a mind mediates our experience of the world” (Fonagy et al., 2018, p. 3). With less ability to refect on thought and feeling, the trapped woundedness loses the option of coming to incorporate new meanings so a safe therapeutic relationship needs to feature of a sharing mentalization moments until recovery allows the client more ease of access to the injured parts of self (Holmes & Slade, 2017). Holmes and Slade state, Mentalizing starts from the capacity to be able to put oneself in another’s shoes; entails the ability to see and evaluate oneself and one’s feelings from the outside and those of others from the inside; differentiations feelings about reality from reality itself; is a graded rather all-or-nothing; is related to arousal; determines responsiveness; is enhanced by the presence of a secure soothing partner. (p. 66)

It can be daunting to enter into awareness of all that mentalization offers after a lifetime of self-protection informed by relational woundedness; actually, it can be quite overwhelming. Sandtray therapy, with its nonverbal-privileging, imageryexternalizing, and distance-optional approach, allows clients to wade into awareness in their own time, experimenting with noticing inner parts while being relationally supported to make new meanings. Sandtray therapists need to maintain awareness that clients in an insecure stream of attachment struggle to tolerate versions of surprise; attachment-sensitive therapists need to be prepared to hold these moments of new sightedness with ample regulation (Holmes, 2020). When we recognize an enactment and make the implicit explicit by putting it into words, we communicate to the patient that behavior has a graspable psychological meaning-a context of feeling, thought, and desire within which it can be seen to make sense. Further, when we explore the enactment, we awaken or deepen the patient’s awareness of unconscious mental models, enabling the patient to become more aware of the existence and impact of the representational world. In these ways, for therapist and patient alike, enactments provide a context within which to exercise the refective function. (Wallin, 2007, p. 290)

We have a mechanism in sandtray therapy to help clients listen to their own stories through creative exploration, making this a great modality for improving refective functioning. Refective functioning refers to the mental capacities needed to notice states

Sandtray therapy, with its nonverbal-privileging, imagery-externalizing, and distance-optional approach, allows clients to wade into awareness in their own time, experimenting with noticing inner parts while being relational supported to make new meanings.

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of mind as they interact with one another (Fonagy et al., 2018). Creating worlds in the sand allow clients a contained space for exploring locked away parts of self while coming into contact with increasing understanding and empathy, resulting in greater capacity for trust of self and others (Green et al., 2013). As metaphors arise and take root in the sandtray therapy session, mental processes will change with them. New metaphors have the power to create a new reality. This can begin to happen when we start to comprehend our experience in terms of a metaphor, and it becomes a deeper reality when we begin to act in terms of it. If a new metaphor enters the conceptual system that we base our actions on, it will alter that conceptual system and the perceptions and actions that the system give rise to. (Lakoff & Johnson, 2008, pp. 144–145)

The relationship with early caregivers creates patterns intrapersonally, not just interpersonally. The multiple states of mind created in response to needs being met or not informs how our inner world pieces and parts relate to one another (and how we express those relationships) across time (Cooper et al., 2004). So clients of all ages, in order to heal attachment wounds, need safe opportunities for exploration and care receiving (Feeney & Collins, 2004). The combined sense of safety, freedom from anxiety, and excitement generated via attunement provides the affective background for the feeling of vitality and spontaneous expression (Cozolino, 2017, p. 205).

“Psychotherapy is memory work-remembering, unlearning, and relearning” (Cozolino, 2020, p. 13); sandtray therapists and clients must be able to detect memories that are coming alive through whole body “listening.” Affective states in need of regulation during these “memories coming alive” moments may need to be reduced, maintained or intensifed (Fonagy et al., 2018) while in the presence of an attuned other. The therapist moves with the client while always offering a regulated return of the energy being expressed. This is the frst step to new meaning creation. What does it mean to make meaning? We may use a term like understand or make sense of to capture the idea, but these words imply conscious thought in the form of language … The still-face research revealed that people make meaning well before they have the ability to put those meanings into words … The information they incorporate in their relationships with others is composed of multiple layers of sensations, movements, and emotional experiences. (Tronick & Gold, 2020, p. 42)

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We then bring these meanings formed in old relationships into new experiences with others; among other needs, clients will need ways to experience repair and learn to tolerate uncertainty of developing experiences. Again, that’s where the response fexibility supported by creating worlds and experimenting with narratives offer healing potential. All meaning is informed by internal reactions to the presence or absence of felt love; we will see this in the tray time and time again. Bruner has said that humans are meaning makers. They make meaning to gain a sense of their self in relation to their own self, and in relation to the world of things and other people. These meanings are held in the individual’s state of consciousness … Some meanings are known and symbolizable, some are unknown, implicit but with “work” can become known, and some may be unknowable … The meanings contained in a state of consciousness organize individuals’ presence, way of being in the world … When meanings are dyadically organized, a dyadic state of consciousness emerges between the individuals and contains new cocreated meanings, which in turn can be appropriated by each individual into his or her state of consciousness. Successful self-or self-and-other creation of new meanings leads to an expansion of the complexity and coherence of the individual’s state of consciousness. (Tronick, 2009, pp. 87–88)

Secure caregiving that has offered such coherent states between parent and child contains elements that also need to be present in attachment-sensitive therapy: arousal, proximity, tolerance of silence, contingent lead taking, and play (Holmes & Slade, 2017). As we transition into looking at specifc ways sandtray therapy can support the involvement of the preceding concepts, keep in mind those processes. Clients deserve to feel supported as their nervous systems wake up while being in the sand. Sandtray therapists remain close and tolerate moments of quiet, remembering that meaning-making is happening in all moments of the session. And never forget that playfulness is possible while still doing such heavy emotional work!

SANDTRAY THERAPY AND ATTACHMENT THEORY Staying with Homeyer and Sweeney’s (2017) defnition of sandtray therapy, the attachment-sensitive elements of this modality immediately come into view. “Sandtray therapy is an expressive and projective mode of psychotherapy involving the unfolding

Working in the sand invites the implicit world, home of our earliest attachment wounds, to take symbolic form. Badenoch, 2008, p. 220

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and processing of intra and inter-personal issues through the use of specifc sandtray materials as a nonverbal medium of communication, led by the client or therapist and facilitated by a trained therapist [emphasis added]” (p. 6). Let’s take a closer look at the italicized words. As an expressive modality, sandtray therapy allows for projective material to foat forward. For those with attachment wounds, their minds and bodies have rightfully created many self-protective internal mechanisms to guard these memories laced with pain. Without being intrusive or bypassing mechanisms of consent, sandtray helps to support clients in overcoming these defenses (De Little, 2020) while embracing the secure base offered by the therapist. The projective elements of sandtray therapy lead naturally to the unfolding nature of the work. “To get any value out of the material the user must fnd his way to understanding of the possibilities of the material and gradually come to ‘fnd himself’ in the medium, if it is to yield a really rich harvest” (Lowenfeld, p. 6, 1993). As attachment-sensitive sandtray therapists, the emphasis is on the idea of this knowing of “self” occurring at a rate determined by the client. The gradually unfolding nature of sandtray allows therapy to move at a rate that can keep clients connected to the co-regulation of the sandtray therapist, providing the pace and safety needed for making gentle contact with implicitly-held pockets of information. “Working in the sand invites the implicit world, home of our earliest attachment wounds, to take symbolic form” (Badenoch, 2008, p. 220). The symbolic nature of the work emphasizes indirect access to these implicit places and this can feel safer while exploring making new meanings (Turns et al., 2020). The rhythm between intrapersonal and interpersonal exploration inherent to the sandtray-based therapeutic journey provides a critical element for attachment healing. The separation between the intrapersonal and interpersonal can be arbitrary as they are ever present in one another, but sandtray therapy clients will fow in and out of their dialogue about relationships between their internal parts and relationships in their external world. Ultimately, clients increasing in security will be able to see the connection between these concepts. Theresa Kestly (2014) points out that Margaret Lowenfeld faced opposition as she tried to convince the feld that babies do indeed “think”; they just do so nonverbally. Since Lowenfeld’s early days of work, therapeutic research and practice has come to new understandings of the importance of honoring the role of nonverbal communication. As established earlier in this chapter, attachment-informed exploration of self must privilege the

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nonverbal and sandtray therapy and other expressive arts are uniquely positioned to accomplish this by involving such sensory and image-rich opportunities. Research on early attachment and brain development is beginning to inform psychotherapy of the value of expressive therapies. Expressive therapies, particularly dance, art, and play therapies, may be useful in reestablishing and encouraging healthy attachments through sensory experiences, interactions, movement, and hands-on activities. These modalities may be helpful in repairing and reshaping attachment through experiential and sensory means and may tap early relational states before words are dominant, possibly allowing the brain to reestablish new, more productive patterns. (Malchiodi, 2005, p. 12)

“Sand tray offers opportunity for clients to explore, communicate, and make meaning of internalized and non-verbalized experiences, including less accessible information” (Rogers et al., 2020, p. 2). The implicit often feels less accessible, yet clients are playing out patterns stored implicitly every day. Sandtray therapy’s honoring of the nonverbal provides a gateway to the implicit. Ana Gomez (2013) says, “Due to the symbolic nature of sandtray work, it is one of the forms of treatment that allows various levels of distance and a gentle access route to the ‘implicit’ self and the right hemisphere” (p. 193). Gomez goes on to discuss that attachment wounds are not always able to be disclosed or acknowledged by clients, but “the use of symbols and fgures utilized in sandtray work allow the distance” (p. 193) needed to process without becoming overwhelmed.

Secure Base In the realm of holding space for allowing clients to experience the healing rhythm of dancing through contact with their relational needs, being a therapeutic secure base makes way for this exploration. Exploration of the sand and the miniatures or images parallels clients exploring their inner lives that are made up of long-held beliefs about self and others that were relationally implanted. “Sandtray therapy can help clients recognize new insights into their problems and how they function in their relationships. It is an opportunity to communicate internal frustration with common external symbols” (Turns, 2020, p. 79). This must be accomplished with awareness of the courage clients will display when turning inward to compassionately confront those parts of self. Even in the quiet moments of a sandtray session, clients can sense if their therapist has remained attuned; they need to feel

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they are not left alone in the journey of discovery. Also, a competent sandtray witness refects and mirrors creator’s words and nonverbals, withholding judgments or interpretations (Rae, 2013). The mindful connection keeps the relationship alive enough that clients can “feel felt” through the sandtray therapist’s spoken and unspoken judgment-free refections. Paradoxically, one important step for maintaining a secure base posture in the sandtray room is to offer permission for taking breaks at any point that emotions are becoming too overwhelming or thoughts too confusing. Knowing that interrupting these dysregulating moments are an option allows the sandtray creator a moment of assurance that they are held by an agenda-less witness (Badenoch, 2008). The sandtray therapist can introduce early in the process the option of having a stop signal (Parnell, 2013) or calling a pause (Badenoch, personal communication, March 14, 2019) whenever needed. Feeling in control of the pacing allows for more confdent entry into exploration. Another critical aspect of a sandtray creator internalizing their therapist as a secure base involves how ruptures are noticed and repaired. When wandering into internal territory, clients need to sense the presence of a supportive other as somewhat constant in order to risk making new meanings out of familiar pain. Clients can feel “dropped” in the sandtray room in so many ways: feeling an image they needed wasn’t available, fnding buried artifacts from another in the sand, sensing a distracted witness, hearing an unwelcome interpretation and so on. At times, clients may be able to articulate this sense of being left alone, but it is often occurring outside of conscious awareness. The attachment-aware sandtray therapist will track these moments and discern how to move toward relational repair. It could be a quiet attunement correction, a verbal offering of humble acknowledgement, or remembering to have a needed item available at a following session. Clients may even need to use the sand tray to refect on dynamics they are perceiving in the therapeutic relationship, especially when a rupture has occurred (Green et al., 2013). In order to move into the deep work of inner world exploration, clients may need clear moments of connection so they can feel the secure base before receiving a prompt. Working in the sand alone can provide a sensory rich experience that can serve as a connection to a younger version of self where original attachment patterning is held (Jeppsen, 2012). The sandtray therapist can invite clients’ hands into the empty tray for connection to self; the therapist can even mirror the sand play in their own tray as rhythms can start to synchronize. Since “Sandtray is a practical way to animate and explore narratives in art and imagery while conversely providing a way into

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images from a narrative or drama,” (Huckvale, 2011, p. 39) the exploration work will often pick up intensity as miniatures and stories begin to emerge. Regardless of theory or prompt, a secure base sandtray therapist holds reverence for the sacred elements at play and prepares for regulated entry into moments of stuckness that can arise during this exploration. Having some techniques for limiting or expanding the search for meaning can be benefcial as long as the techniques serve the relationship. Laurel Parnell, an EMDR author who discusses incorporating attachment sensitivity into treatment planning, has methods for welcoming supportive fgures into such moments. Parnell (2013), who endorses sandtray therapy but doesn’t necessarily describe sand application of all her concepts, says the four most important resources for creating an adequate therapeutic container that communicates a secure base are: resourcing an imagined peaceful place, welcoming connection with nurturing fgures, fnding protector fgures when appropriate, and establishing inner wisdom fgures that can step into moments of confusion (Parnell, 2013). All of these can be easily facilitated through prompts or just welcoming additional fgures into diffcult sand worlds. Parnell advocates that having connection to such resources provides clients with a sense of control that helps maintain contact with security. Another idea for facilitating dialogue and exploration with attachment-wounded parts of self while connected to a secure base comes from Clair Mellenthin, a play therapist who specializes in attachment-focused play therapy (2019). She designed a play and art activity for sending “mail” to communicate with a caregiver as needed during play sessions; this idea easily transfers to the sand tray. Having a mailbox miniature in the collection would allow the sandtray therapist the option to suggest the introduction of this image any time a client is needing to move through a stuck place. Simply referencing the mailbox image and asking if there is any message needing to be shared or received can facilitate moments of movement while still remaining a solid witness who doesn’t interpret their way into a client’s inner world. In short, a sandtray therapist is being a secure base when they remember clients need to leave session with an increased capacity for making meaning, not with having a meaning made for them.

Safe Haven Safe haven moments come as clients make contact with pain during their inner exploration and need to return to needs-meeting interactions with a caregiver. Sandtray therapists will get many clues that clients are needing contact with a safe haven.

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As clients make contact with pain, their eyes will direct the sandtray witness to a point of need.

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Eyes reveal the inner world so the attachment-sensitive sandtray therapist needs to track their clients’ eyes throughout all parts of the session, always remembering to be more invested in the creator than the creation. As clients make contact with pain, their eyes will direct the sandtray witness to a point of need. The therapist’s eyes need to communicate care and regulation as they take in the client and their created world. Therapist tone of voice, prosody of voice, and facial expression, along with their eyes, really matter during these attachment-repairing experiences (Cozolino, 2017). When clients feel met in their pain by a safe haven, earlier life pain gets what it originally needed. Most of this can be offered through attunement alone; this is the force that drives healing. Sandtray therapists can borrow concepts from other attachmentfocused authors as inspiration for remaining connected to safe haven principles. Brown and Elliott (2016) describe a process where clients internalize an Ideal Parent Figure (IPF). The imagined contact with an ideal caregiver is meant to offer repair for misattuned early life relational issues. The technique focuses on moving to a mindful inner place, connecting to younger child state, and fully interacting with an imagined ideal parent. The attachment-sensitive therapist holds awareness of their client’s attachment history while guiding the client through the IPF. At any point in this process, beginning, middle, or end, could provide space for a sandtray prompt. Another sandtray therapy opportunity that emphasizes safe haven dynamics would be creating a world that is a safe place for baby/younger self (Wesselmann et al., 2014). This can facilitate the client accessing aspects of self that need, and have needed, care while maintaining contact with the attuned therapist. Wesselmann et al. (2014) also emphasize working with nesting dolls to bring attention to various ages of self that have varying needs. Marshall recommends having nesting dolls in different categories of miniatures (spiritual, human, animals, trees, etc.) so that clients are able to access the metaphor of the nesting dolls while have the amount of emotional distance they would need to stay with the metaphor. See Figure 7.1. Joan Lovett (2015) discusses a “slaying the monsters” art activity where clients are able to cross out moments of intense pain in order feel empowered in its presence. In the sand, clients can accomplish the same task by burying or removing items from the tray that are preventing contact with safe haven. Lovett coaches clients to add words such as, “I’m taking my power back,” “It’s over,” “I’m stronger now,” “I know what I need and who I can trust” while taking action to overcome the “monsters.” If clients fnd their way to their own empowered expression, the sandtray therapist can encourage the client to repeat

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Nesting Dolls as Metaphor.

Photograph by Caleb Matthews. Used with Permission.

their own words and allow the action or words to sink into the place that deserves the care. Green et al. (2013) say clients can be encouraged: to express themselves and their world in less threatening ways to the play [sandtray] therapist. Through these sand worlds and other creative expressions, adolescents [clients] come to understand (a) that their feelings have value, (b) they are supported by caring adults who do not judge them, and (c) attention to their inner emotional landscape is a vital key to their ongoing psychological development. (p. 99)

Sandtray therapy is a great tool for welcoming safe haven experiences.

Narrative Coherence When attachment wounding has been a signifcant part of someone’s lived experience, they lose coherent sense of their overall narrative. This can leave one feeling misunderstood as their wounded internal elements interfere with seeing the whole of self. Sue Richardson (2020) writes about creating room for the fve Cs in therapy to help combat disorganization: compassion, communication, cooperation, connection, co-consciousness. Each of these concepts needs to carry through all sandtray therapy moments, starting from assessment. In the assessment sessions, the trauma and attachment relationships are explored using sand tray techniques. In such sessions, the child used miniatures to build a sand world, and then explained the world in a story told to the therapist and the caregiver. The child’s cognitions were assessed this way, as many younger children do not have the cognitive capacity to answer

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direct questions or participate in traditional talk-listen therapy. (Stauffer, 2008, p. 161)

As attachment wounds heal, sandtray therapists will see peace and organization enter into the sand worlds.

Even older clients with attachment wounding will need these same opportunities as the younger self needs the sandtray therapist to remain sensitive to it. A client’s level of coherence will become seen even as the therapist observes the physicality in the client’s relationship to the sand itself. Is sand being smoothed rigidly or excessively? Is this client unaware of sand fying out of the tray? The interaction in the sand will often be revealing. So, a client’s sense of narrative coherence will emerge not just from the story added to the selected miniatures. All parts of engaging the sand materials can reveal inner world dynamics that invites the therapist into sharing an understanding of an incoherent place; as the sandtray therapist meets the client there, through regulated and organizing energy, the client has the chance to embody a new part of an emerging narrative (Huckvale, 2011). As attachment wounds heal, sandtray therapists will see peace and organization enter into the sand worlds; handle these with careful refection (Badenoch, 2017). Theresa Kestly (2014) recommends having clients lay out pictures of previous sand trays and allow a “meta moment” of unifying a greater story (Kestly, 2014). The client’s narrative heals in parts through multiple moments in the sand and then integrates into more complex meanings over several sessions (Lyles & Homeyer, 2015).

Mentalization/Refective Functioning Regarding Margaret Lowenfeld’s hope for how creating worlds in the sand can offer healing, Urwin and Hood-Williams (2014) write, “what World-making does is to take the patient to a point at which refective contemplation of the mind’s products is possible” (chapter 11, para. 6). Mentalization and refective functioning, referenced earlier in the chapter, refer to the processes involved in seeing how experiences have impacted various states of mind. Sandtray therapy’s natural embrace of silence (Rae, 2013) and amplifying metaphors without interpreting them (Gil, 2014) set the stage for experimenting with these cognitive capacities. Sand worlds can invite awareness into the internal working model even if clients cannot directly verbalize the stored thoughts and feelings (Stauffer, 2008). Sandtray therapists can offer clients chances into deeper connection with the materials as multiple meanings and possibilities are explored. As therapists notice the quality of touch when miniatures are individually handled, they can highlight slight shifts in these contacts, as well as in

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tray organization over time (Sachs, 1992). Sandtray therapists can also watch for inconsistencies in narratives or for unacknowledged miniatures (Sachs, 1992); refecting these moments back to the client allows for both to interact with refecting functioning through curiosity about what the body and spoken words are introducing into the session. Another simple technique for perspective taking involves asking the client switch seats with the therapist for a moment or for the entirety of the session (Rae, 2013). Seeing the world from different points-of-view makes room for narrating the world from yet to be privileged voices. This small shift allows for safe refective practice.

IN CLOSING “The depth and fexibility that attachment theory presents makes its integration distinctively valuable to other theories that are more narrowly focused and technique oriented” (Stauffer, 2008, p. 156). Attachment theory gets therapists in touch with the forces that informed client’s original meaning-making. What an honor! Past experiences, often in childhood, lead to creative adjustments. When they continue as part of our being, we react to the present as if it were the past … Awareness plus Connection leads to growth … Issues surface through externalization, metaphor and a safe relationship with the therapist. The story unfolds in the contained world of the box of sand, in the creation of scenes, through the choices of fgures, and the dialoguing between therapist and client. (Pernet & Caplan, in press)

Bonnie Badenoch offers the perfect words for wrapping up this chapter on how sandtray therapy, informed by attachment theory, provides a depth of healing clients have long deserved. Our early attachment experiences have no words. They are deeply felt in the body and shape our interior landscape for the rest of our lives. When we approach sand and miniatures, these right-hemisphere-based feelings translate fuidly into images and particularly into relationships that spontaneously emerge. The more we let go and respond to both the sand and beings on the shelves as though our body itself is doing the choosing, the more these early experiences appear, to be held and warmed and cared for by the sand tray person and his/her attentive witness. Our inner world begins to shift in the light of this beholding. It is a powerful process that one might imagine could be disruptive. Instead, the tray itself becomes a boundaried sanctuary for what is being allowed into the light while the human witness also provides the safety of presence. (Personal communication, December 19, 2020; see her complete statement to us in Closing Moments later in the book.)

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REFERENCES Ammaniti, M., Dazzi, N., & Muscetta, S. (2008). The AAI in a clinical context: Some experiences and illustrations. In H. Steele & M. Steele (Eds.), Clinical applications of the adult attachment interview (pp. 236–269). Guilford Press. Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Badenoch, B. (2017). The heart of trauma: Healing the embodied brain in the context of relationships (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. Basic Books. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. Basic Books. Bowlby, J. (2005). The making and breaking of affectional bonds. Routledge. Brown, D. P., & Elliott, D. S. (2016). Attachment disturbances in adults: Treatment for comprehensive repair. W. W. Norton & Company. Collins, N. L., Guichard, A. C., Ford, M. B., & Feeney, B. C. (2004). Working models of attachment: New developments and emerging themes. In W. S. Rholes & J. A. Simpson (Eds.), Adult attachment: Theory, research, and clinical implications (pp. 196–239). Guilford Press. Cooper, M. L., Albino, A. W., Orcutt, H. K., & Williams, N. (2004). Attachment styles and intrapersonal adjustment: A longitudinal study from adolescence into young adulthood. In W. S. Rholes & J. A. Simpson (Eds.), Adult attachment: Theory, research, and clinical implications (pp. 438–466). Guilford Press. Cozolino, L. (2017). The neuroscience of psychotherapy: Healing the social brain (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Cozolino, L. (2020). The pocket guide to neuroscience for clinicians (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. De Little, M. M. (2020). Using the sand tray in the context of the latest research in neuroscience to transform clients’ defences. Canadian Journal of Counselling & Psychotherapy/Revue Canadienne de Counseling et de Psychothérapie, 54(3), pp. 259–285. Feeney, B. C., & Collins, N. L. (2004). Interpersonal safe haven and secure base caregiving processes in adulthood. In W. S. Rholes & J. A. Simpson (Eds.), Adult attachment: Theory, research, and clinical implications (pp. 300–338). Guilford Press. Fonagy, P., Gergely, G., & Jurist, E. L. (Eds.). (2018). Affect regulation, mentalization and the development of the self. Routledge. George, C., Kaplan, N., & Main, M. (1985). The Adult Attachment Interview. [Unpublished manuscript]. University of California at Berkeley. Gil, E. (2014). Creative use of metaphor in play and art therapy with attachment problems. In C. A. Malchiodi & D. A. Crenshaw (Eds.), Creative arts and play therapy for attachment problems (pp. 159–177). Guilford Press. Gomez, A. M. (2013). EMDR therapy and adjunct approaches with children: Complex trauma, attachment, and dissociation. Springer Publishing Company. Green, E. J., Myrick, A. C., & Crenshaw, D. A. (2013). Toward secure attachment in adolescent relational development: Advancements from Sandplay and expressive play-based interventions. International Journal of Play Therapy, 22(2), 90–102. https://doi.org/10.1037/a0032323 Holmes, J. (1993). John Bowlby and attachment theory. Psychology Press. Holmes, J. (2020). The brain has a mind of its own: Attachment, neurobiology, and the new science of psychotherapy. Confer Books. Holmes, J., & Slade, A. (2017). Attachment in therapeutic practice. Sage. Homeyer, L. E., & Sweeney, D. S. (2017). Sandtray therapy: A practical manual (3rd ed.). Routledge. Kindle Edition. Huckvale, K. (2011). Alchemy, sandtray and art psychotherapy: Sifting sands. International Journal of Art Therapy, 16(1), 30–40. https://doi.org/10.1080/17454832.2011.570272 Jeppsen, M. L. (2012). Sand tray therapy: Utilizing indigenous objects with traumatized Haitian orphans. Regent University. Jurist, E. (2018). Minding emotions: Cultivating mentalization in psychotherapy. Guilford Press. Karen, R. (1998). Becoming attached: First relationships and how they shape our capacity to love. Oxford University Press. Kestly, T. A. (2014). The interpersonal neurobiology of play: Brain-building interventions for emotional wellbeing. W. W. Norton & Company.

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Lakoff, G., & Johnson, M. (2008). Metaphors we live by. University of Chicago Press. Lovett, J. (2015). Trauma-attachment tangle: Modifying EMDR to help children resolve trauma and develop loving relationships. Routledge. Lowenfeld, M. (1993). Understanding children’s sandplay: Lowenfeld’s world technique. Drake International Services. Lyles, M., & Homeyer, L. E. (2015). The use of sandtray therapy with adoptive families. Adoption Quarterly, 18(1), 67–80. https://doi.org/10.1080/10926755.2014.945704 Malchiodi, C. A. (2005). Expressive therapies: History, theory, and practice. In C. Malchiodi (Ed.), Expressive therapies (pp. 1–15). Guilford Press. Mellenthin, C. (2019). Attachment centered play therapy. Routledge. Mooney, C. G. (2009). Theories of attachment: An introduction to Bowlby, Ainsworth, Gerber, Brazelton, Kennell, and Klaus. Redleaf Press. Music, G. (2018). Nurturing children: From trauma to growth using attachment theory, psychoanalysis and neurobiology. Routledge. Parnell, L. (2013). Attachment-focused EMDR: Healing relational trauma. W. W. Norton & Company. Pernet, K, & Caplin, W. (forthcoming). The here and now of sandtray therapy: Sandtray therapy meets Gestalt therapy. In P. Cole (Ed.), Together in the therapeutic process: Exploring the relational feld of Gestalt therapy. Routledge. Rae, R. (2013). Sandtray: Playing to heal, recover, and grow. Rowman & Littlefeld. Richardson, S. (2020). Internal attachment relationships: The fve Cs versus the two Ds. Attachment, 14(1), 99–106. Rogers, J. L., Luke, M., & Darkis, J. T. (2020). Meet me in the sand: Stories and self-expression in sand tray work with older adults. Journal of Creativity in Mental Health, 1–13. Sachs, R. G. (1992). An introduction to sandtray therapy for adult victims of trauma. Dissociative Disorders Fund. Stauffer, S. (2008). Trauma and disorganized attachment in refugee children: Integrating theories and exploring treatment options. Refugee Survey Quarterly, 27(4), 150–163. https://doi.org/10.1093/rsq/hdn057 Tronick, E. (2009). Multilevel meaning making and dyadic expansion of consciousness theory: The emotional and the polymorphic polysemic fow of meaning. In D. Fosha, D. J. Siegel, & M. F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development & clinical practice (pp. 86–112). W. W. Norton & Company. Tronick, E., & Gold, C. M. (2020). The power of discord: Why the ups and downs of relationships are the secret to building intimacy, resilience, and trust. Little, Brown Spark. Turns, B., Springer, P., Eddy, B. P., & Sibley, D. S. (2020). “Your Exile is Showing”: Integrating Sandtray with Internal Family Systems Therapy. The American Journal of Family Therapy, 1–17. https://doi.org/10.1 080/01926187.2020.1851617 Urwin, C., & Hood-Williams, J. (2014). Child psychotherapy, war and the normal child: Selected papers of Margaret Lowenfeld. Sussex Academic Press. Kindle Version. Wallin, D. J. (2007). Attachment in psychotherapy. Guilford Press. Wesselmann, D., Schweitzer, C., & Armstrong, S. (2014). Integrative team treatment for attachment trauma in children: Family therapy and EMDR. W. W. Norton & Company. Whelan, W., & Stewart, A. L. (2015). Attachment security as a framework in play therapy. In D. A. Crenshaw, & A. L. Stewart (Eds.), Play therapy: A comprehensive guide to theory and practice (pp. 114–128). Guilford Press.

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Trauma in the Sand Tray Reclaiming power over world Where terror once landed shakes the soul But we reimagine story’s art Even if words arrive on delay

BRIEF HISTORY OF TRAUMA THEORY The Greek word for trauma translates as “wound” (merriam -webster.com). While originally referring to physical injury, this powerful word “trauma” has come to be equally, or more so, associated with wounded memories and their impact on the ever-developing mind. The mental health feld has a storied history with how trauma and its effects were viewed and treated. Understanding a bit about this lineage can empower sandtray therapists to continue their own exploration into honoring how trauma wounds show up in sandtray sessions, as well as how they want to treatment plan with clients around this tender subject. Before beginning the path into a brief overview of the history of trauma conceptualization, it is important to let you know where this journey will arrive. Bonnie Badenoch (2017) defnes trauma as “any experience of fear and/or pain that doesn’t have the support it needs to be digested and integrated into the fow of our developing brains” (p. 23). This succinct, rich defnition captures the biological, emotional, and relational aspects of trauma. Holding all of these parts together while offering trauma-sensitive clinical care through the sandtray will be the goal of this chapter. As sandtray therapists, we work in a modality that implicitly invites this material into clients’ created sand worlds, so we need to be prepared to handle that with appropriate care. Now let’s explore some of the historical context for how the feld arrived at this modern understanding. Although there is some documentation of trauma symptoms in mental health literature dating back to the mid-1850s under names such as “hysteria,” “lightning neuroses,” “shell shock,” DOI: 10.4324/9781003095491-8

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and “soldier’s heart,” trauma was not regularly treated as a serious mental health consideration until the late 1900s (van der Kolk et al., 1994). This occurred despite pioneers such as Jean-Martin Charcot and Pierre Janet attempting to raise awareness around the impact of unresolved, painful memories much earlier, even documenting ideas regarding the existence of the subconscious, the unconscious, and dissociation that would be later validated (Walusinski & Bogousslavsky, 2020). Sigmund Freud, who greatly infuenced the direction of mental health treatment for decades, originally agreed with Charcot and Janet’s assertions on ideas related to trauma and dissociation. However, he later changed some of his clinical beliefs and moved to advocating that repression, and not dissociation, was a primary struggle for those with painful past experiences (van der Kolk et al., 1994). Freud did contribute helpful ideas in his own right, even describing the experience of trauma as an event “surpassing the stimulus barrier” (Cozolino, 2020, p. 230) and advocating that the goal of therapeutic relief was not perfection but decreasing symptoms’ intrusive intensity. Sandor Ferenczi, in 1933, wrote about sexual trauma in children by stating that abuse is experienced as trauma when a child is not met with understanding and healthy communication about the painful nature of the event (Haynal, 2018). Healing, according to Ferenczi, occurred through a client’s recall and verbalization of the trauma, and then through repetition of transference experiences with a psychoanalyst. Ferenczi initially split with Freud on how he viewed the nature of trauma. He wrote about the need to understand the amount of terror in trauma victims, connecting this to the importance of exploring identifcation with aggressors and providing clients with a healing experience contrary to their trauma. However, the complicated relationship between the two men eventually pulled Ferenczi into alignment with Freud and psychoanalysis primarily followed Freud’s line of thinking (Haynal, 2018). It is diffcult to know, but Ferenczi’s ideas on trauma seemed to have afforded the early psychoanalytic community a more empathic connection to traumatized clients. Marshall likes to imagine that he would have made a wonderful sandtray therapist with his sensitivity to the unfolding and repetitive stories of clients! When Abram Kardiner, a psychoanalyst in New York, began writing about traumatic neuroses around the beginning World War II, he defned traumatic symptoms as primarily involving departure from typical functioning, fxation on the unresolved event, disrupted dream life, and the atypical presence of irritability/hostility. This was based on his observations after treating trauma victims impacted by World War I. His work actually

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dictated the categories of symptoms for PTSD when it eventually appeared in the DSM III in 1980. Kardiner felt trauma should be defned “as an externally imposed situation that overwhelms the host’s defenses to manage an unmanageable situation” (van der Kolk et al., 1994, p. 589). His infuence is still felt in modern trauma treatment. In the 1980s, Lenore Terr began to document post-traumatic play occurring in children. Her longitudinal study of trauma is well documented in Too Scared to Cry (1990). She also noticed that some children showed trauma symptoms even when the upsetting event was distant or indirect, such as in viewing the Challenger explosion on television (Terr et al., 1999). Her work furthered the curiosity about how and why people have traumatic stress symptoms. Therapeutically, Terr values play in many different forms. She states, whatever their choice, the opportunity for traumatized young people to express themselves and to form meaningful relationships with us very frequently lives and breathes in their play. The chance to enter their worlds of fear and pain exists in our ability to join in. (2015, p. xi)

Judith Herman published her book Trauma and Recovery in 1992. This work quickly became a guiding light for trauma clinicians. Herman was vocal about shifting blame away from sufferers of trauma symptoms who had historically been seen as weak in the clinical world. She also felt the nature of how trauma became rooted in a victim was largely due to the societal context around them when the trauma occurred. Seeing all trauma as rooted in internalized terror, Herman articulated that traumatic stress symptoms were biological reactions that simply expressed the body’s instinctive response to such threat. Advocating for the need for clinical treatment to be rooted in safety, much of Herman’s trauma theory (rooted around exploring hyperarousal, intrusion, and constriction) was soon confrmed by developments in neuroscience (Zaleski et al., 2016). This will be further discussed in the next section. In 1998, a landmark research study known as the Adverse Childhood Experiences Study (ACES) brought quantitative proof to the impact of early life struggles on long-term physical, emotional, and relational health (Felitti et al., 1998). Original data was gathered by sending questionnaires to Kaiser Health Plan patients in southern California who had medical evaluations between August and November of 1995 and between January and March of 1996, yielding around 23,000 responses. This was done again in 1997 yielding about the same effect. Questions on

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the survey asked about the childhood presence of abuse, exposure to substance abuse and domestic violence, mental illness in the family, and criminal behavior in the family. Results showed that the presence of four or more risk factors in childhood dramatically increased the presence of signifcant health struggles in adulthood. This study helped to move the feld of trauma work to one that embraced the need to look at preventative elements, and not just reactive treatments, in order to be of best service to the public. There are known limitations to the ACES study that have warranted much follow-up in professional literature. For example, the original research sample did not include adequate representation of vulnerable communities and the surveyed risk factors did not include experienced racism, household poverty, or a look into intergenerational trauma. Additionally, the original research did not evaluate for protective and resiliency factors (McEwen & Gregerson, 2019), but these will be explored in a later chapter of this book. In the last few decades, new clinical approaches have emerged that are wholly dedicated to promoting understanding and healing of trauma. Models such as Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen et al. 2012), Eye Movement Desensitization and Reprocessing (EMDR; Shapiro, 2017), and Somatic Experiencing (SE; Levine & Frederick, 1997) are just a few of those with a substantial presence in professional literature. In fact, many of these models have been explored through integration with sandtray therapy (Gerayeli, 2019; Gomez, 2012; Lyles, 2021; Taylor, 2020).

TRAUMA AND NEUROSCIENCE Modern mental health practitioners exist in an information rich season regarding deeper understanding of how the woundedness of trauma shows up in the nervous system. The ever-developing relational neurosciences have shaping what aspects of trauma theory’s legacy were headed in productive directions and which parts should be released. As trauma study in the last 20 years has heavily relied on advances in neuroscience, the overwhelming result is a more connected way to discern what clients’ bodies, words, behaviors, and created works are communicating about their experiences and therapeutic needs. Going further into how neuroscience is shaping the intersection of expressive approaches and trauma treatment, Counselors must understand brain functioning and the effects of trauma in order to choose the most effective methods for working with clients. Creative arts therapies offer a nonthreatening

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way for clients to access and express their trauma, creating a corrective experience in the brain. Activities that incorporate body movement can be particularly helpful by providing a corrective emotional experience for those clients with an immobilized response to a traumatic event. (Perryman et al., 2019, p. 80)

As sandtray therapists, it has become imperative to stay responsibly aware of what neuroscience is revealing about trauma treatment. Many neuroscience authors have brought vital data to the clinical world, and there is only space to honor a few. Those whose voices offer much beneft to sandtray therapy application are featured below. Bessel van der Kolk (2015) wrote a paradigm-shifting work now present on most therapists’ bookshelves called The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. Inspired by collaboration with a team of trauma healers from various clinical backgrounds and practicing in different body-honoring approaches, van der Kolk brought together attachment understanding with neuroscience to highlight how traumatic memories stored in the mind interact with the body. In his offering, trauma therapists are encouraged to remain fexible as they listen to how clients’ bodies communicate safety needs from moment to moment. (In sandtray therapy, this highlights the necessity of staying connected to the creator of a sand world while exploring their creation.) Louis Cozolino (2020) writes about the evolutionary and attachment-specifc processes underlying humans’ reactions to and recovery from extreme stress and trauma. His perspective offers insight into what prevents traumatically-stored memories from being integrated into the rest of a person’s experience and perspective. Primarily defned in terms of amygdala-mediated hyperarousal, Cozolino discusses how neurobiology keeps someone vigilant enough to stay alive during threat, but also how getting stuck in that arousal, or collapsed, neurobiological state prevents the memory from getting updated as life moves forward. He also discusses how co-regulated, sensory-based retrieval of the trauma memory’s impact on a client’s sense of their story can provide opportunity for that memory to integrate into the rest of the mind. What great news for sandtray therapists! Another giant in the feld of trauma-informed neuroscience is Bruce Perry. Perry has highlighted the need to broaden understanding of the domains of development in order to accurately understand trauma’s impact and the client’s evolving treatment needs. During early childhood, the organizing neural networks that are developing require touch, sight, sound, smell and movement in order to develop normally. Absent experiences of sufficient

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duration or quality, some of the genetic potential of the individual will be lost. (Perry, 2013) Honoring trauma healing in the sand means reshaping a narrative long told to self through image and story making.

Creative arts activities offer a nonthreatening avenue for the discovery and processing of an embedded traumatic experience. Perryman et al., 2019, p. 81

His sensitivity to the impact of developmental trauma has brought much attention to the need for somatosensory-based treatment approaches. Polyvagal theory, brought forward by Stephen Porges, has its roots in the 1960s when Porges became curious about the interactions between physiology and behavior. However, it wasn’t until the 1990s that Porges began to discover and articulate the now well-known role of the vagus nerve in hierarchical, self-protective autonomic nervous system functioning (Porges, 2011). As the autonomic nervous system takes on the critical role of telling our minds and bodies “how we are” (Dana, 2018, p. xvii) faring in each moment of life, it has much to say in traumatic situations. “Trauma interrupts the process of building the autonomic circuitry of safe connection and sidetracks the development of regulation and resilience” (Dana, 2018, p. xvii). This is why people with histories of unresolved trauma struggle with staying present and regulated and relationally open; their bodies, informed by the vagus nerve, are conditioned to privilege staying alive over staying connected to others. From a polyvagal theory point of view, trauma practitioners know that trauma survivors’ minds made meaning of the trauma only after the autonomic nervous system responded. So, “story follows state” (Dana, 2018, p. 6). This has many implications for trauma-sensitive sandtray therapy treatment planning and some of those will be explored in a following section of this chapter. A preview, though, would be to remember Dana’s (2018) words, “Because we humans are meaning-making beings, what begins as the wordless experiencing of neuroception drives the creation of a story that shapes our daily living” (p. 8). Honoring trauma healing in the sand means re-shaping a narrative long told to self through image and storymaking. Daniel Siegel has brought substantial awareness to the experience-dependent nature of the developing brain (Siegel, 1999). As such, his writing often highlights how the experience of trauma interrupts vertical integration within the brain. Energy required for self-protection from harm keeps the lower, more primitive regions of the brain overactive and fooded with stress hormones, resulting in states of dysregulation. Contact with safe, consistent relationship is required for those lower regions to resume communication with the rest of the brain and return to a holistic, regulated way of perceiving the world. Shifting from a focus on the healing elements required for vertical integration in the brain to awareness of the need to tend to horizontal, hemispheric integration, the journey through

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neuroscience-informed perspectives on trauma brings us to Allan Schore. Schore (2019), along with many others like Iain McGilchrist (2019) and Bonnie Badenoch (2017), advocate for trauma therapists to understand the important role of the right hemisphere of the brain in storing and healing trauma. Processes that encourage laterality are emphasized, honoring the need to be sensory aware, somatically grounded, and emotionally attuned during trauma therapy. Neuroscience has highlighted the relational, sensory, and somatic nature in which trauma is embedded into the nervous system. It also calls forward the need for trauma treatment to be healing in manners that are relational, sensory, and somatic. Art therapy, along with the other right-brain–activating creative arts therapies (music, dance/movement, drama, poetry therapy), along with play therapy and sand tray therapy, utilize the brain’s integrative capacity (Jones, 1994). Activation of the right hemisphere offers access to the stored physical and emotional traumatic memories, internal sensations, feelings, and thoughts that can then be expressed in visual form. (Chapman, 2014, p. xxiv)

While the feld of trauma therapy has evolved in many ways, sandtray therapy has been fairly consistent in honoring these elements from Lowenfeld’s early iterations. “Sand therapy boldly professes the unspoken by allowing the neocortex (thinking brain) to more deeply understand the subcortical brain’s needs in collaborative sacred space whereby trauma experienced can receive the fresh air needed to transform into growth and healing” (Y. Fountain, personal communication, December 21, 2020). The words of Eliana Gil seem a ftting way to hold all of this information as we transition to the elements of the chapter that serve to illustrate how to execute the sacred role of sandtray therapist, holder of traumas: The most basic factor in all trauma is the person’s perceived sense of helplessness. In addition, traumatized clients can feel a wide range of emotions that include confusion, distrust, anticipatory anxiety, fear, shame, and isolation. Their attempts to make sense of their experiences can cause them to develop untrue narratives that they caused the abuse, that there is something inherently wrong with them, and that they deserve whatever happened to them. The response to trauma is a corrective and reparative experience that includes novel information to counteract traumatic responses. Thus, a therapist focuses frst on allowing the client to develop a sense of safety and trust, and becomes trustworthy to the client so that the therapy relationship becomes one that offers comfort, respect of boundaries, limit-setting, visibility,

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and acceptance. As clients settle into a warm and safe relationship, they can explore, make choices, set the pace, and access strengths and feelings of mastery. (E. Gil, personal communication, December 18, 2020; See her complete statement to us in Closing Moments later in book.)

SANDTRAY THERAPY AND TRAUMA TREATMENT Given the complexity of trauma’s impact on the mind and body, no one approach will ever be suffcient for all clients’ unique needs. However, creative and expressive therapies offer substantial hope for many. As a starter, “Creative arts activities offer a nonthreatening avenue for the discovery and processing of an embedded traumatic experience” (Perryman et al., 2019, p. 81). Creativity provides clients an option for gentle exploration of stored pain. Remaining in this metaphor-based approach honors the many protections and defenses clients’ inner systems have created to keep traumas sealed away. After having a safe approach in place for accessing trauma, the important work of embodiment, care receiving, and integration can begin. Referencing Cathy Malchiodi in Perryman et al. (2019), we agree “that the use of creative arts helps the client reconnect implicit (sensory) and explicit (declarative) memories of trauma, as these therapies provide a less threatening way for clients to tell their stories” (p. 83). The expressive arts allow these stories to be told through images, movement, and language. Using sensation and imagination as guides, clients get to introduce new information into frequently rehearsed and often entrenched trauma narratives (Malchiodi, 2020). Throughout the process of trauma healing, clients need to stay grounded in the present and in their bodies. This is to support the process of remembering over reliving (Frewen & Lanius, 2015). Clients who stayed anchored to the here and now are more able to allow all of their present day resources to be introduced into the pain-captive memory networks. Frewen and Lanius say that successful trauma workers accomplish this by supporting clients to maintain sensory awareness, fnd their way to embodied representations of themselves into complex narratives, and make the present reality explicit while remembering the traumatic episodes. The following paragraphs will illustrate how sandtray therapy, in particular, presents as a powerful tool for accomplishing these processes. When clients stay grounded while working through past pain in the sand tray, they develop deeper mentalization abilities,

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which allows for the holding of intersubjective states of mind. This makes the present self stronger (Badenoch, 2008). Garjana Kosanke (2013) conducted thematic analysis research into how clinicians across different therapeutic approaches have written about effective use of sand therapy when working with adult clients who have experienced trauma (Figure 8.1). Kosanke discovered that clients generally move from wounded representations in the sand tray toward healing representations over time, but that both of these elements are also always present in created worlds. This process is embedded within three wide themes: ◾ Safety offered by a trauma-sensitive clinician ◾ Communication, combating the speechless terror (van der Kolk, 2015) associated with trauma ◾ Active work (involved in active reconstruction of the narrative containing embedded trauma). Kosanke’s image showing her conceptual framework as to how sandtray therapy can support trauma healing highlights how a sandtray therapist, grounded in theory and connected to themselves, can work with a client to gradually make room in their created worlds for noticing their innate healing potential. See Figure 8.1.

FIGURE 8.1 Kosanke’s Sandtray Therapy Model. Used with Permission.

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Another way to conceptualize the healing power of the sand tray while staying connected to the responsibility of a trauma clinician lies in engaging the window of tolerance (Siegel, 1999; Ogden et al., 2006). The window of tolerance is a metaphor for describing the highly individualized amount of stress someone can experience before their body moves toward neurobiologically programmed self-protection, through hyperarousal or hypoarousal. When someone is “in their window,” they are regulated and open. In order to do effective trauma work in the sand, clients need to remain regulated, even co-regulated by borrowing from the clinician’s capacity for holding pain. “Utilizing creative arts techniques offers the potential to increase the counselor’s ability to maintain the window of tolerance” (Perryman et al., 2019, p. 85). Because what fres together wires together on a neurobiological level (Hebb, 1949; Siegel, 2012), sandtray therapists need to be aware of what meaning clients assign to moments of being emotionally overwhelmed while in our presence. Feeling unsafe by making too much contact with pain in the tray and feeling disconnected from the therapist may cause the client to pair pain with working in the sand tray. This could contaminate the client’s faith in the containment potential of the tray. The window of tolerance is compatible with Herman’s conceptualization of the sequence for trauma healing (Zaleski et al., 2016; Zaleski, 2018). Moving through trauma healing with safety as the shared priority between therapist and client asks the sandtray therapist to remain keenly aware of where each exists in their individual (and joint) windows of tolerance. Sandtray therapy, as previously mentioned, is compatible with many trauma approaches that build on Herman’s theory while honoring current awareness of neurobiological realities. In an attempt to bring Herman’s language on phased trauma healing into contact with more recent neurobiological understanding about trauma and common therapeutic approaches, Zaleski et al. (2016) unifed this content to see side by side comparisons. Zaleski (2018) then updated the information to add even more nuance. Here is a summary of that work which Zaleski titled Triphasic Model of Healing: ◾ Phase 1: Safety ◽ Herman emphasized trust and connection as necessary focus with the therapist establishing self as a capable witness. ◽ Neurobiology emphasizes the role of the parasympathetic branch of the nervous system during this phase.

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◽ Models such as EMDR, SE, SP, and DBT all focus on mindful and body-based interventions to facilitate establishing felt safety in this phase; psychoeducation may also be prominent. ◾ Phase 2: Remembrance and Mourning ◽ Herman discusses the need to reconnect to feelings/ sensations in order to access the traumatic memory. ◽ Neurobiology discusses the work of horizontal and vertical integration happening in the brain during this delicate work. ◽ Trauma approaches usually emphasize working with a narrative, in various manners, as connections are now made in the presence of safety instead of the meanings originally made during a time of threat. ◾ Phase 3: Reconnection ◽ Herman talks about moving with the trauma survivor to a place of creating a vision of a thriving future. ◽ Neurobiology describes the efforts of neuroplasticity working for the mind has the prefrontal cortex is now more involved in creating a post-trauma self. ◽ Common trauma approaches start emphasizing future template work and possibly engaging relationships/ systems in the therapeutic process to help with reentry. Taking this multifaced conceptualization a step further, sandtray therapists can invite clients to create metaphorical representation of their window of tolerance in the sand (Lyles, 2021). Having the three zones of the window of tolerance shown in image form can help clients be in relationship with their own nervous system while providing the safe distance of symbols for therapists to reference in future moments of experienced dysregulation, evening widening the client’s capacity for holding stress as they make more contact with inherent resilience.

SANDTRAY THERAPY SESSION PROTOCOL The effective sandtray therapist maintains window of tolerance awareness through all six steps in sandtray process: 1. Room preparation 2. Introduction to the client 3. Creation in the sandtray 4. Post-creation 5. Sand tray cleanup 6. Documenting the session (Homeyer & Sweeney, 2017, p. 42). Here is a trauma-sensitive approach to monitoring the window of tolerance in all parts of the sandtray therapy session:

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The therapist remains the most important of the sand tray “materials”; connecting to the sand and images in a regulating manner presents a more embodied healer the client in opening moments of the sandtray session, while preparing the therapist to be in an open state of mind for tracking well the body language, tones, gestures, and words that will be the passageway to attuning to clients’ inner world of feeling and thought.

Digging Deeper into Clinical Application

Step 1: Room Preparation Sandtray therapy materials lead the way to trauma healing by creating sensory rich environments that begin promoting integrating experiences early in therapeutic work. In fact, clients may be able to develop safe relationships with our materials before they can with us (Badenoch, 2008). Just being in the sandtray therapy room with displayed images keeps the right hemisphere involved in the healing work and a “rich relationship with the sand often unfolds” (Badenoch, 2008, p. 221). With such importance on maintaining connection to the materials, this makes room preparation a critical aspect in setting up a safe, pro-social experience into which the client can step. Refer to Chapter 3 for recommendations on setting up the sandtray therapy room. As the sandtray therapist, it can be helpful to transition the preparing of the room from being seen as a chore to viewing it as the frst contact with a waiting window of tolerance. Smoothing the sand and checking the placement of miniatures on the shelves becomes a frst act of creating safety for the next client, whose trauma has likely kept them in a state of anticipation for this appointment. In addition to preparing the room, this is an opportunity for the trauma-sensitive sandtray therapist to prepare self. Setting up the sand tray space gives a moment to embrace the recalibration of one’s own window of tolerance. The therapist remains the most important of the sand tray “materials”; connecting to the sand and images in a regulating manner presents a more embodied healer the client in opening moments of the sandtray session, while preparing the therapist to be in an open state of mind for tracking well the body language, tones, gestures, and words that will be the passageway to attuning to clients’ inner world of feeling and thought.

Step 2: Introduction to the Client, The Prompt Introducing the chance to create a world in the sand is typically referred to as “the prompt.” However, the moment of stating the prompt needs to be immediately followed by the client beginning to create their world. So there is some pre-prompt work to do before getting that invitation. Clients may need an anchor in the room, especially if their trauma history has left them vulnerable to dissociation. Early in treatment, invite the client to fnd an anchoring object or sensation in the room. It could be a stuffed animal, a blanket, a fgure, scented oil, etc. Then, practice using the anchor for grounding, enhancing safety through sensory focusing (Malchiodi, 2020).

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This can become useful in maintaining regulation if profound pain is touched in processing completed worlds. Another pre-prompt experience that can support a client staying within their window of tolerance lies in offering a moment of mindful connection. There are many grounding guided imageries available to the sandtray therapist. It is a chance to establish connection to body, heart, and mind that is rooted in strength and openness. Here is sample option: Spend a moment connecting to breath and body, sensing where comfort or attention is needed. Place a hand anywhere that needs connection and fnd a moment of stillness, noticing we are sitting in this shared space. Feel your feet on the ground, fnding connection with the earth that is capable of holding and centering all energy. Slowly move awareness up your legs, through your core, noticing your heart and breath on the way. Check in with your shoulders and neck and give attention where it is needed. When ready, let your eyes fnd the miniatures on the shelves. Your heart and mind can come to agreement to not judge the instincts invited by your eyes’ curiosity and your hands’ choices.

And now to the prompt. Confusion and complexity can compromise a trauma client’s connection to regulation. The prompt needs to be delivered with clarity, warmth, succinctness. Remember to prompt with intention, but without agenda. The client has freedom to explore whatever arises in them. Whether “nondirective” or “directive,” the prompt offers a moment of aligned goals for therapist and client, where each moves toward curiosity and remains open to the unfolding nature of a sandtray therapy session.

Step 3: Creation in the Sandtray As clients receive the sandtray prompt, whether collaboratively established or therapist led, they move quickly to moments of inner exploration as images begin to call for a place in the waiting world. For those with a trauma history, this can be a powerful experience and powerful can be cathartic or powerful can be overwhelming. Sandtray work does not begin with processing the narrative of a created world; it is already well under way by the creation stage. All clients, especially those with trauma histories, deserve profound and felt attunement during the quiet moments of creation. Observe the client’s nonverbal expressions during their gathering of images. Track behaviors and choices in your mind; refect emotions internally as they come into awareness. These will be clues as to where clients are in their windows of tolerance and offer quiet support in the already-occurring meaning-making processes.

Sandtray work does not begin with processing the narrative of a created world; it is already well under way by the creation stage.

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When clients suggest they have fnished their creations, check in to give them another moment to evaluate completion. Given the chance, clients may hear the invitation as permission to return to connection, which can offer a fresh set of regulated eyes from which to view the blossoming world. “Then there often comes a moment when the energy in the room will suddenly ‘relax.’ That seems like the right word for the feeling of satisfaction that comes as the last piece fnds its necessary place” (Badenoch, 2008, p. 223).

Step 4: Post-creation As clients enter into the part of a sandtray session when they have the option of adding words, there are new possibilities and responsibilities for monitoring their windows of tolerance. Does the story making feel oriented or confused? Are parts of the world unincorporated into the narrative and how does the client respond when attention is given to it? Does tone of voice and pacing of speech change at any point in the narrative? How are certain fgures described—any upsetting, disparaging or intense language? All of these answers reveal aspects of regulation (or dysregulation) and inform what a client needs from their sandtray therapist. It’s not the talking, as much as coming to a shared witnessing, that offers healing energy to our clients. As sandtray therapists, the desire is for clients to “work the edges” while remaining in the window of tolerance. The narrative piece of a sandtray session allows the movement of up and down regulating energy needed in trauma memories that have been held in isolation from other aspects of self so that they come into contact with any unmet need waiting for care and attention. In order to be an effective witness, it is important to check in with clients about feeling, both in body and emotion. Even by offering the opportunity for expression in these areas, the healing work of integration can be approached with gentle understanding.”We don’t want to catalyze a leap from right-toleft-hemisphere processes, but rather open the highway for the right to offer itself to the left” (Badenoch, 2008, p. 224). If clients begin to experience dysregulation during this step of the process, here are some ideas for supporting sustained connection: ◾ Step away from words and ask the client to return to tracking sensation, even with the opportunity to communicate this awareness nonverbally. ◾ Invite the client to shift their posture, possibly matching the pose of a chosen sandtray miniature.

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◾ Ask the client if a certain miniature needs to be re-rooted in the sand, moved, or replaced with a different image. ◾ Invite a vulnerable fgure into a safer place, even if that place is outside of the tray, or add another miniature to help keep it safe. ◾ Invite the client to pause their use of words and move their hands over the tray until their body knows the direction and speed needed for the fow of processing. ◾ Return to the use of metaphor language if a client has moved into frst-person discussions about their world. Clients will communicate in a variety of ways their return to regulation and internalization of the therapist’s co-regulation. There is a felt presence that re-enters the room and “Even in a profoundly painful trays, there is often a sense of rightness that brings a kind of regulating joy amidst the tears. We then just sit together and hold the tray between us, allowing interpersonal warmth and resonance to continue doing their integrative work” (Badenoch, 2008, p. 223).

Step 5: Sand Tray Cleanup Just as it is important to begin a sandtray session mindfully connected to self and each other, there also is the need to close a session with focus on grounding and containment. Clients with trauma backgrounds deserve every minute of a session to be honoring of their support need regarding window of tolerance monitoring. As sessions end, clients re-enter their external worlds with this fresh dose of sandtray-illuminated meaning-making, needing to be integrated into their present day lived experiences. There are many ways to close a session in ways that emphasizes grounding. Since we have been focused on monitoring windows of tolerance closely throughout the session, this should not be a new goal. However, clients will be separating from therapists as live co-regulators and moving to relying on an internalized version of the memory of being co-regulated. Generally, sandtray therapists want to be certain that clients are connected to their bodies, to time, and to their inner world of thought and feeling. This could be achieved by asking what awareness from the sandtray world wants to move into the next portion of the client’s day with them. As they close their eyes or turn away from the created world, clients can describe where they feel this awareness housed internally (connecting to body) and how that can show up in upcoming specifc moments (connecting to time). As clients describe this, the sandtray therapist can monitor that there is coherence in client’s descriptions (monitoring thought life) and

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refect important emotions. Add some shared breath work and clients will have experienced a shared grounding moment. Containment refers to the process of having a safe internal place to hold stirred aspects of self until there is time to safely and relationally access the evolving themes related to trauma again. If clients are needing containment support, here are a few options for achieving this in the sandtray room while moving to putting away the world: ◾ Cover any part of the world with a lid for the tray or piece of fabric as a transitional closing moment (something Marshall has learned Ana Gomez also does). ◾ Have a “holding tray” (something Marshall learned from Bonnie Badenoch) where fgures that might not feel safe being left alone in the created world can move. ◾ Use a real container (box with lid, treasure box, bottle with cork, etc.) where client can place a written note identifying anything that felt unfnished and needs to be acknowledged. ◾ Invite client to trace the walls of the tray and notice that this world can symbolically remain in the tray as they leave the room. It can also be important to remind clients that others use the tray and materials so that the items in the world will be put away before another person enters the room (Homeyer & Sweeney, 2005). This both helps the client to know that their stories are protected and prevent clients from being surprised that their created world is not still intact when they return. Also, as the trauma-sensitive sandtray therapist puts the fgures away, whether one’s clinical point of view makes this a therapist responsibility or shared experience, it needs to be done in a manner that acknowledges the sacred work that occurred. The therapist can have a moment of gratitude or blessing for the meanings that each symbol brought to the healing process, in whatever manner feels natural for the therapist.

Step 6: Documenting the Session Many times, sandtray therapists, and all therapists, can forget that the documentation step provides another window of tolerance opportunity. When sitting to complete any documentation requirements for session, the therapist is necessarily holding the client in mind. If documentation is done with dread, frustration, or overwhelm, as has happened to all of us, then we are pairing those states with the memory of the client. That energy can

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carry forward unintentionally to future contacts. All humans, but especially clients with trauma, are sensitive to how it feels to be seen by another. As much as possible, sandtray therapists can care for their clients’ windows of tolerance by mindfully holding the client in gratitude and strength as often as they come to mind, including during documentation tasks. When writing session notes, acknowledge the courage displayed by clients, even if it occurs only internally and not in written form; however, it is diffcult to see the downside to capturing both moments of strength and struggle in documentation. As the photo is being taken of the client’s sand world, take that as another moment to see the different angles and points-of-view. Being mindful of refective functioning during these moments will expand the therapist’s window of tolerance in relation to the subject matter explored and the client’s presence in it. That increased capacity will directly beneft the returning client. Appendix D provides Documentation Cues and Clues. This might be helpful in writing notes. It includes “clues and cues” inclusive of the material in this book.

SANDTRAY TRAUMA TREATMENT PLANNING AND ADVANCED METHODS ”Because sand tray play involves both the sensory experience of moving sand and the motor experience of manipulating tiny toys and fgures with small fngers, it is a marvelous vehicle for healing trauma” (Levine & Kline, 2006, p. 384). This beautiful expressive tool is indeed marvelous, but it also needs to be treated as powerful. As clients make contact with some of their most wounded parts of self, as well as burgeoning strength, they are reliant on their therapist to competently hold space and move with them through the healing process. “During a sandtray session the therapist is both witness and guide, creating space for the builder to bring to awareness what they have created. The therapist creates safety through presence and empathic curiosity” (Pernet & Caplin, in press). So the therapist needs to have enough faith in where the process is headed to communicate safety without stepping into creating expectations and agendas. In trauma healing, we can defer to Herman’s original fow now repeated in many clinical approaches: safety frst and safety throughout. Eliana Gil (2017) describes well the frst phase for play with children being treated for trauma. Clients will explore different externalizing play behaviors that puts their trauma into the therapeutic space. Clients will also be observing the capability of

Sand tray invites traumatized children into a world of creative imagination, of release, of control, and of interacting with an unconditional witness.

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the play therapist for adequately containing their traumatic material. The early trays are often focused on testing how strong is the safety net. This is likely not conscious on the part of the client. Sand tray invites traumatized children into a world of creative imagination, of release, of control, and of interacting with an unconditional witness. These are the elements of healing that children need and desire, especially when they occur within the safe and protected space of sand therapy. The boundaries of the tray and the soft, cool sand provides cues to the nervous system that suggest that it will be possible to relax and soothe. The small objects allow children to bring forth that which is encumbering their mind and heart. When children externalize with small miniatures, they tell their stories, ask their questions, express their dilemmas in their own unique way, without having to interact with the demand to use words, or explain themselves to others. Once objects are selected and externalized into picture images or stories, children can direct the content and manifest their most basic needs. Working with them in metaphor, as well as accepting their spontaneous verbal communication, will allow children to feel powerful and lean into having personal control. Sand tray is one of the expressive therapies well suited to traumatized children and adults as a beginning externalization or as a deepening process of understanding and developing self-empathy, as well as challenging the narratives of responsibility for the trauma. The end result is that children can work along the continuum of unsafely/safety and distrust/trust, experience a corrective reparative relationship, and have renewed feelings of personal control and mastery, all the while learning to manifest gradual exposure, and affective tolerance. (E. Gil, personal communication, December 18, 2020)

As sandtray therapist and client learn one another’s rhythms, the sand tray becomes a place in the early sessions for experimentation with fnding safety in co-constructed meaning-making. The therapist will need to remember to be more invested in the creator of the sand world than the creation. Clients also need to reconnect to their own nervous systems, which have sometimes been overwhelmed by long-held trauma. Dana (2018) says it is the therapist’s sacred role to support clients to befriend their adaptive responses to trauma and recommends remembering the four R’s: ◾ ◾ ◾ ◾

“Recognize the autonomic state. Respect the adaptive survival response. Regulate or co-regulate into a ventral vagal state. Re-story” (p. 7).

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She also reminds sandtray therapists: The kinesthetic experience of working in the sand offers another way of seeing and sensing autonomic states. Sand trays offer your clients a way to visualize their autonomic response patterns through objects and metaphor and, through the story in the sand, are a way for you to enter a client’s autonomic nervous system with them. (Dana, 2018, pp. 85–86)

Dana goes on to discuss inviting clients to represent their nervous system states in the sand as this provides a regulated offering for being with all parts of the nervous system. She also mentions that clients can be invited to add a new miniature whenever they sense a nervous system shift in themselves during the processing of any created world. This is a useful awareness for establishing and maintaining safety throughout the treatment arc of trauma healing in the sand. When clients begin to internalize the felt safety of exploring self in the sand with a co-regulating therapist, beautiful work emerges! Old narratives open to new meanings and identity gets updated to include the courageous nature of the one doing the healing. However, there can be moments of stuckness and sandtray therapists need to be prepared to infuse fresh doses of security into the process. Below are some techniques for such moments: ◾ Clients can be invited to bring “advisors” into created worlds, which are miniature fgures that may have ideas how to connect back to a place of moving through story and through hard emotions (Gomez, 2012). ◾ Stauffer (2021) describes using a superhero activity to help empower clients toward moving through traumatic play when they reach a place of stuckness. Clients can accomplish this through the addition of new fgures or even holding a superhero pose while viewing their world. ◾ Clients may need to turn away from the activating sand world and focus on their anchoring object or the sandtray therapist. This can re-establish regulation and provide greater access to fnding new connections and meaning when returning to the sand world. ◾ Inviting the client to choose which fgures may need to move to a separate tray, especially a differently shaped tray, can provide added containment. There are so many creative, trauma-knowledgeable sandtray therapists doing innovative work, combining their respective

Sand trays offer your clients a way to visualize their autonomic response patterns through objects and metaphor and, through the story in the sand, are a way for you to enter a client’s autonomic nervous system with them.

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clinical theory perspectives with innovative sand-based techniques. Remaining connected to the continually emerging trauma literature will provide security to the sandtray therapist looking to ground their instincts in current and reliable information. However, knowledge will never trump relationship. Sandtray therapists looking to create space for trauma healing will be well served by remembering the power of connection in the face of addressing traumatic pain. In the words of Dottie Higgins-Klein (2013), “Healing occurs when the therapist and child together descend into their respective places of inner stillness” (p. xxii). This is needed, and deserved, for clients of all ages. “And the day came when the risk to remain closed tightly in a bud became more painful than the risk it took to blossom.” Some say this quote is by Anais Nin and others say Elizabeth Appell. While the attribution may be up for debate, the sentiment speaks a calming truth about the process of overcoming the aloneness of trauma. So many times, sandtray therapists get to witness the moment when this truth fnds its home inside a client’s heart and the courage of opening to a new way of being in the world manifests. It is awe-inspiring each and every time. Judith Rubin writes in the foreword of Carey’s (2006) book, Today, through neuroscience, we can better understand why the arts are so therapeutic-that in order to master trauma, it is necessary frst to access the nonverbal right hemisphere (through images, sounds, and movements); and the to enable it to communicate with the left in order to gain cognitive and affective mastery. (p. 12)

Sandtray therapy is one of the remarkable tools where the neurobiological need to overcome trauma symptoms through increasing integration can be achieved, always within a solidly secure therapeutic relationship that offers co-regulation all along the way. When clients stay grounded while working through past pain in the sand tray, they develop deeper mentalization abilities, which allows for the holding of intersubjective states of mind. This makes all aspects of the present self stronger and welcomes the younger self into new and dynamic dialogue. In the words of Badenoch (2008), “Grounded in the body, Sandplay unfolds through the limbic region and cortex, and spans both hemispheres as the symbolic unfolds into words” (p. 220). What a privilege to be a participant in this life-giving process.

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REFERENCES Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Badenoch, B. (2017). The heart of trauma: Healing the embodied brain in the context of relationships (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Carey, L. (2006). Expressive and creative arts methods for trauma survivors. Jessica Kingsley Publishers. Chapman, L. (2014). Neurobiologically informed trauma therapy with children and adolescents: Understanding mechanisms of change (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Cohen, J. A., Mannarino, A. P., & Deblinger, E. (Eds.). (2012). Trauma-focused CBT for children and adolescents: Treatment applications. Guilford Press. Cozolino, L. (2020). The pocket guide to neuroscience for clinicians (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Dana, D. A. (2018). The Polyvagal theory in therapy: Engaging the rhythm of regulation (Norton series on Interpersonal Neurobiology). W. W. Norton & Company. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749–3797(98)00017–8 Frewen, P., & Lanius, R. (2015). Healing the traumatized self: Consciousness, neuroscience, treatment (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Gerayeli, S. V. (2019). The importance of embodiment in psychotherapy with an emphasis on Sandplay therapy [Doctoral dissertation]. Pacifca Graduate Institute. Gil, E. (2017). Posttraumatic play in children: What clinicians need to know. Guilford Press. Gomez, A. M. (2012). EMDR therapy and adjunct approaches with children: Complex trauma, attachment, and dissociation. Springer. Haynal, A. E. (2018). Disappearing and reviving: Sándor Ferenczi in the history of psychoanalysis. Routledge. Hebb, D. O. (1949). The organization of behavior: A neuropsychological theory. Wiley. Higgins-Klein, D. (2013). Mindfulness-based play-family therapy: Theory and practice. W. W. Norton & Company. Homeyer, L. E., & Sweeney, D. S. (2005). Sandtray therapy. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 162–182). Guilford Press. Homeyer, L. E., & Sweeney, D. S. (2017). Sandtray therapy: A practical manual (3rd ed.). Routledge. Kindle Edition. Kosanke, G. C. (2013). The use of sandtray approaches in psycho-therapeutic work with adult trauma survivors: A thematic analysis [Doctoral dissertation]. Auckland University of Technology. Levine, P. A., & Frederick, A. (1997). Waking the tiger: Healing trauma: The innate capacity to transform overwhelming experiences. North Atlantic Books. Levine, P. A., & Kline, M. (2006). Trauma through a child’s eyes: Awakening the ordinary miracle of healing. North Atlantic Books. Lyles, M. (2021). Room for everyone: Family-based play therapy in the sandtray. In A. Beckley-Forest & A. Monaco (Eds.), EMDR with children in the play therapy room: An integrated approach (pp. 75–108). Springer. Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. Guilford Press. McEwen, C. A., & Gregerson, S. F. (2019). A critical assessment of the adverse childhood experiences study at 20 years. American Journal of Preventive Medicine, 56(6), 790–794. McGilchrist, I. (2019). The master and his emissary: The divided brain and the making of the western world. Yale University Press. Ogden, P., Minton, K., & Pain, C. (2006). Trauma and the body: A sensorimotor approach to psychotherapy (Norton series on interpersonal neurobiology). W. W. Norton & Company. Pernet, K., & Caplin, W. (forthcoming). The here and now of sandtray therapy: Sandtray therapy meets Gestalt therapy. In P. Cole (Ed.), Together in the therapeutic process: Exploring the relational feld of Gestalt therapy. Routledge.

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Perry, B. D. (2013). Brief: Refections on childhood, trauma and society. The ChildTrauma Academy Press. Kindle Edition. Perryman, K., Blisard, P., & Moss, R. (2019). Using creative arts in trauma therapy: The neuroscience of healing. Journal of Mental Health Counseling, 41(1), 80–94. https://doi.org/10.17744/mehc.41.1.07 Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Schore, A. N. (2019). Right brain psychotherapy (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Shapiro, F. (2017). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures. Guilford Press. Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. Guilford Press. Siegel, D. J. (2012). Pocket guide to interpersonal neurobiology: An integrative handbook of the mind (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Stauffer, S. D. (2021). Overcoming trauma stuckness in play therapy: A superhero intervention to the rescue. International Journal of Play Therapy, 30(1), 14–27. https://doi.org/10.1037/pla0000149 Taylor, O. (2020). Evaluation and update of Trauma-Focussed Cognitive Behavioural Therapy with sensory approaches for the treatment of Post-Traumatic Stress Disorder in maltreated children [Doctoral dissertation]. Auckland University of Technology. Terr, L. (1990). Too scared to cry. Basic Books. Terr, L. C., Bloch, D. A., Michel, B. A., Shi, H., Reinhardt, J. A., & Metayer, S. (1999). Children’s symptoms in the wake of Challenger: A feld study of distant-traumatic effects and an outline of related conditions. American Journal of Psychiatry, 156(10), 1536–1544. https://doi.org/10.1176/ajp.156.10.1536 Terr, L. (2015). Foreword. In N. Boyd-Webb (Ed.), Play therapy with children and adolescents in crisis (4th ed., pp. xi). Guilford Press. van der Kolk, B. A., Herron, N., & Hostetler, A. (1994). The history of trauma in psychiatry. Psychiatric Clinics of North America, 17(3), 583–600. https://doi.org/10.1016/S0193–953X(18)30102–3 van der Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books. Walusinski, O., & Bogousslavsky, J. (2020). Charcot, Janet, and French models of psychopathology. European Neurology, 83(3), 333–340. Zaleski, K. L., Johnson, D. K., & Klein, J. T. (2016). Grounding Judith Herman’s trauma theory within interpersonal neuroscience and evidence-based practice modalities for trauma treatment. Smith College Studies in Social Work, 86(4), 377–393. https://doi.org/10.1159/000508267 Zaleski, K. L. (2018). Understanding and treating military sexual trauma (2nd ed). Springer.

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In this world you create Fueled by mystery and light You fnd your inner witness That delights as you bravely dig deeper The knight, fully armored and ready for battle, stood in the center of the tray. The knight is encircled with every dragon from the miniature fgures collection, at least a dozen, perhaps more. This was 10-year-old Skyler’s frst tray about his physical assault by bullies at his afterschool care program. The knight, identifed as himself, was entirely surrounded, and alone, but not without important resources: a warhorse, sword, and armor. His risks and resources are symbolically displayed in his sandtray; his resilience has shown up. Lowenfeld observed the resilience of the young men resettled in Poland after serving in World War I (1979; Lowenfeld, n.d.). After about two years of being back in Poland, she observed them closely, and their apparent normalcy is part of what piqued her curiosity regarding children’s mental health. Southwick et al. (2014) report that for children, “perhaps the most effective way to enhance resilience is to provide a safe, stable and loving environment that allows the child’s natural protective systems to emerge, and to foster healthy brain, cognitive, emotional and physical development” (Enhance resilience section, para. 3). These young men had developed a stable life after the war and Lowenfeld’s observations may be that of those natural protective systems producing resilience. While hurt and pain are common human experiences, so is fnding strength in previously unknown or unidentifed parts of self. In sandtray therapy, there is tremendous beneft in exploring both struggle and endurance, risk and protective factors. This chapter will review the complexity of defning resilience, recent DOI: 10.4324/9781003095491-9

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fndings from resilience research, how sandtray therapy is used to assess resilience, and dive into the many opportunities for enlarging clients’ capacities for overcoming hardships that sandtray therapy provides. Final thoughts on using sand tray materials to bring resilience to the person-of-the-therapist will be offered to encourage sandtray professionals.

I can be changed by what happens to me. But I refuse to be reduced by it. - Maya Angelou

DEFINING RESILIENCE American Psychological Association (APA) defnes resilience as “the process of adapting well in the face of adversity, trauma, tragedy, threats, or signifcant sources of stress” (2020). It involves bouncing back and can involve immense personal growth (Ackerman, 2012). APA states there are four core components— connection, wellness, healthy thinking, and meaning. There are other defnitions and perspectives of resilience. Positive psychology views it as a core concept and it is seen as a personality trait related to positive outcomes that can be improved (Ackerman, 2012). Helen Herrman et al. (2011) say “fundamentally, resilience refers to positive adaptation, or the ability to maintain or regain mental health, despite experiencing adversity” (p. 259). In another perspective, Ann Masten, who studies resilience in children, states that resilience is a dynamic system with the capacity to adapt when situations threaten its viability, function, and development (Southwick et al., 2014). Steven Southwick et al. (2014) state it is important to not think of resilience as present or absent and to identify whether it is being viewed as a trait, a process, or an outcome. As the reader may have already deduced, there is no consistent, universally agreed-upon defnition of resilience (Herrman et al., 2011). Herrman and her colleagues attempt to bring clarity to this issue through a review of professional literature on the defnition of resilience. These defnitions together acknowledge two points: various factors and systems contribute as an interactive dynamic process that increases resilience relative to adversity; and resilience may be context and time specifc and may not be present across all life domains. Accordingly, there are multiple sources and pathways to resilience, which often interact, including biological, psychological, and dispositional attributes, and social support and other attributes of social systems (family, school, friends, and community). Despite the lack of consensus on an operational defnition of resilience, most defnitions use similar domains as evidence of resilience. (Herrman et al., 2011, p. 260)

Herrman et al. (2011, p. 261) list the resiliency factors they have identifed. They note that resilience is interactive with

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environmental risk factors and overcoming stress or adversity. Therefore, resiliency is different from positive mental health (p. 262). The Adverse Childhood Experiences (ACE; Felitti et al., 1998) research is familiar to most readers. The original, and subsequent, research provides information on the impact of ACEs. This information informs the therapist in case conceptualization and management. Other researchers have explored resiliency for those who have experienced ACEs. Resiliency—the ability to “bounce back” or positively adapt despite adversity—can be developed by cultivating protective factors (Luthar 2006; Pizzolongo and Hunter 2011). ACE researchers highlight three interrelated “core protective systems” associated with positive adaptation: the person’s individual capacities, attachment to a nurturing caregiver and sense of belonging with caring and competent people, and a protective community, including faith and cultural processes. (Sciaraffa et al., 2018) Neuroscience authors now conclude that although the left hemisphere is specialized for coping with predictable representations and strategies, the right predominates not only for organizing the human stress response (Wittling, 1995), but also for coping with and assimilating novel situations (Podell et al., 2001) and ensuring the formation of a new program of interaction with a new environment (Ezhov & Krivoschekov, 2004). Indeed, the right brain possesses special capabilities for processing novel stimuli … Right-brain problem solving generates a matrix of alternative solutions, as contrasted with the left brain’s single solution of best-ft. This answer matrix remains active while alternative solutions are explored, a method suitable for the open-ended possibilities inherent in a novel situation. (Schutz, 2005, p. 13) Recall that resilience in the face of stress and novelty is an indicator of attachment security. Therapeutic changes in the patient’s internal working model, encoding strategies of affect regulation, refect structural alterations within the right brain (Schore, 2009, pp. 143–144).

Next will be a review of some resilience research.

RESEARCH ON RESILIENCE Ji Hee Lee et al. (2013) completed a meta-analysis of 31,071 research participants in 33 studies from several countries regarding the relationship of psychological resilience and relevant variables. They looked specifcally at protective factors: life satisfaction, optimism, positive affect, self-effcacy, self-esteem, social support; and risk factors: anxiety, depression, and negative affect. They found the largest effect size for resilience was the

Herrman et al.’s Resiliency Factors 1. 2. 3. 4. 5. 6. 7. 8.

Nurturance Personal Biologic-Genetic Environmental Family-friends Social-economic Cultural-Spiritual Community policy

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protective factors, with the strongest positively related variable was self-effcacy. Medium effect size was found with the risk factors; depression was the strongest negatively related variable. In conclusion, they indicated, The results of this meta‐analysis further imply that resilience could be part of a protective process active against depression, anxiety, PTSD, and other psychiatric disorders, and it is strongly associated with positive affect and optimism, which in turn are positively related to self‐effcacy and self‐esteem. Resilience can be thought of as a dynamic process that both protects an individual in adverse situations and enhances his or her therapeutic outcomes against risk factors [emphasis added] (e.g., depression and anxiety; Tusaie & Dyer, 2004). (Lee et al., 2013, p. 275)

They also suggest that counselors in individual therapy sessions be empowered to maintain an optimistic outlook by identifying clients’ potential talents and enhancing prominent traits (p. 275). The researchers remind us that, although resilience is seen as universal, individual and cultural differences impact a meta-analysis that merges studies from a wide range of countries. Netsai Gwata (2018) studied South African young adults’ ability to be resilient in the face of experiencing persistent drought and the inherent risk factors. Her research found three systems enabling resilience for these young adults: individual (religious engagement, exercising agency, positive persona characteristics of optimism and altruism, keeping busy to avoid stress, regulating water use habits), family (protective parenting), and community pragmatic initiatives and connectedness. Seiler and Jenewein (2019) conducted research to look at resilience in patients diagnosed with cancer. They found that patients were able to draw on resiliency factors to accomplish post-traumatic growth through their treatment, but that there were two paths to growth. One path was “direct” and showed resiliency was informed by social supports, positive personality traits, good coping skills, etc. The second path involved patients who did not have these “skills” as naturally available to them; however, they still found their way to a meaning-making experience that showed similar growth, but through a different process. Even in times characterized by signifcant loss in multiple domains, such as during the COVID-19 pandemic, systems have shown they have the ability to impact individuals’ perceptions of their resiliency both positively and negatively (Walsh, 2020). Sandtray therapists who address systemic issues impacting a client’s perception of their having the strength to survive struggle will be helping to move clients forward even during complex times; meaning-making can be shifted so that the client can claim

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an identity rooted in overcoming. The following brief section on neuroscience will help develop this idea further.

NEUROSCIENCE AND RESILIENCE Due to all that is being learned about neural plasticity, therapists get to be neurologically optimistic about how a client’s actual brain can shift as a result of healing. Especially when a client feels safe with a clinician who enthusiastically believes that their offered therapy can be effective, the client’s brain seems to become more open to moving away from a closed, self-protective stance back to the dynamic, resilient rhythms (Cozolino, 2017). Healing happens and, in beautiful ways, clients get to have a further empowered sense of self as a result of experiencing the beneft of their own neural plasticity. Relational neuroscience has also aided in bringing awareness to how positive experiences in care receiving serve to increase a felt-sense of resilience. When intergenerational relational experiences are mutually enjoyable, the joy reaction that comes from delighting and being delighted in foods the brain with strengthbuilding neurochemicals that facilitate greater internal neurological growth as well as belief in the power of relationships. As this builds from generation to generation, the genetic momentum moves toward a lineage of resilience (Cozolino, 2020). Therapists can beneft from this knowledge by remembering to draw on clients’ families legacies of survival and thriving, being careful to acknowledge that not all systems have gifted future generations with only resilience factors regarding care legacies; and not all societies have given all people groups the same freedom to experience intergenerational empowerment. All of this can be explored in the sand, both legacies of empowerment and legacies of survival. Resilience is not just a byproduct of joy and positivity, though. Ed Tronick and Claudia Gold (2020) suggest that people move toward a belief that they can thrive in life by being supported through countless small, and sometimes large, moments of struggle. The rupture-repair cycle that comes with feeling “dropped” or misunderstood or alone followed by someone helping to make these moments right builds in greater capacity for handling future moments of hardship. Tronick and Gold refer to the relationallydriven and brain-enlivening process as regulatory scaffolding. Attuned sandtray therapists will notice moments of rupture and move to an offering a relational repair, thus supporting more contact for the client with relationally-informed inner strength. Theresa Kestly (2014) describes how sandtray therapy’s emphasis on witnessing clients’ created worlds in the sand, without

Attuned sandtray therapists will notice moments of rupture and move to an offering a relational repair, thus supporting more contact for the client with relationallyinformed inner strength.

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That is the sandtray therapist’s task: to caringly provide the tools necessary for seeing personal gifts while bringing coherent meaning making processes to waiting memory networks.

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trying to teach or correct and while using voice and nonverbals to refect back emerging metaphors, contributes to improved client development. As the rhythm of image and story come alive, supported by the safe distancing element of metaphor, clients get much-needed space for practicing neurobiological processes that support integration, leading to more of an identity rooted in resilience. At a memory level, fnding the way to embrace inherent resilience requires tapping into the strength to revisit unresolved moments from the past without allowing them to overtake present resources (van der Kolk, 2015). This does not happen in isolation. Diana Fosha says, “The roots of resilience … are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned, and self-possessed other” (van der Kolk, 2015, p. 105). Being truly present and supporting others in becoming increasingly refective, all the while bringing energy to a growing capacity for insight, empathy, and coherence, builds resilience through accessing memory networks with the intention of fnding strength, not just struggle (Siegel, 2016). That is the sandtray therapist’s task: to caringly provide the tools necessary for seeing personal gifts while bringing coherent meaning-making processes to waiting memory networks. Even those people existing in insecure streams of attachment, due to a catalog of memories featuring unmet needs, found their way to these insecure places because of resilience (Holmes & Slade, 2017). The defensive strategies developed to live in less than ideal relational environments were done so for the sake of survival. Learning to work with these righteous protectors, while allowing a new sense of strength rooted in relational understanding, is critical for a sandtray therapist looking to support clients in a move toward a strength-based identity. Building on this theme, Southwick et al., (2014) states that: humans are endowed with great potential to weather adversity and to change or adapt when necessary, but they need basic social and material resources to do so. One of the most important ways to foster resilience is to promote healthy family and community environments that allow the individual’s natural protective systems to develop and operate effectively. (Enhance resilience section, para. 5)

Attuned connection while engaging in creative exploration of past struggles provides the environment the nervous system needs for reconnecting to forward-moving resilience (Hass-Cohen, 2016). This will often mean that the sandtray therapist is asking the

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client’s mind to engage in updating messages stored in the nervous system that say self-protection is the only way to survive; ideally, the relationship between sandtray therapist and sandtray creator, through the use of safe and engaging materials, will help move the client toward an identity rooted in thriving, not just surviving.

USING THE SAND TRAY TO IDENTIFY RESILIENCE Interest in the sand tray as a way to assess or diagnose individuals began with Margaret Lowenfeld’s World Technique. Key initial researchers were Charlotte Bühler (1951a, 1951b) and Laura Ruth Bowyer (1970); Bowyer also documented many other researchers’ work (1970). Rie Rogers Mitchell and Harriet Friedman (1994) additionally reviewed those who did so. These researchers worked throughout various countries. Linda had a graduate student, Leslie Petruk, who did original research on the ability to differentiate between clinical and non-clinical children in their initial sandtrays (1996). This curiosity continues today. The feld is all the better for it. Here we look at some research done specifcally regarding identifying resilience in the sand tray.

Research in China Development of an instrument to identify and score a person’s resilience, done in an initial sandtray session, was undertaken by Dan Wang and Adam John Privitera, psychology faculty in China (2019). Based in a sandplay perspective this research sought to discover an alternative way to measure resilience other than the currently used as self-report instruments. This research resulted in the Sand Tray Test of Resilience (STR; 2019). The developers of the STR characterize the three indicators through a sandplay therapy lens: ◾ Vitality: ◽ Symbolic meaning: energetic, positive, and healthy status of a person ◽ Includes number and type of life forms: animal, human, and plant. ◾ Type of Water: ◽ Symbolic meaning: inner energy, growth, nourishment, creativity, and the downward exploration of self-potential and resources ◽ Includes number of three types of water formed in tray: 1) stream, pond, or well, 2) river or lake, 3) a sea.

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◾ Relationship: ◽ Presented through concrete interactions between animals or humans rather than symbolic meanings ◽ Includes number and type of relational activities in the tray, cooperative, constructive, and secure (adapted from Wang & Privitera, 2019, p. 65). For those researchers reading this, you may want the information that the interrater reliability of the three indicators was 0.94 (vitality), 0.92 (type of water), and 0.96 (relationship) (Wang et al., 2017). The criterion-related validity established by the developers of the STR may provide the basis for all sand therapy therapists to experience as helpful. Wang and Privitera acknowledge limitations of STR, including that it is a short test with only three indicators. This might lead to low test sensitivity (2019, p. 66). Wang and Privitera report that comparing the STR with the self-report instruments resulted in statistically signifcant criterion-related validity. However, there remains the need to establish validity and reliability with more populations and cultures. Wang indicated no further work has been to validate this instrument (personal communication, February 9, 2021). Even with this update and these caveats, the information is interesting and may provide therapists with a new lens through which to view sandtrays when searching for signs of resilience.

While staying true to their sandplay therapy approach, other clinical theories and approaches may also fnd meaning in the sand creations by clients. Lowenfeld also indicated, it is perfectly clear that, confronted with this material [creations in the tray] any one who will be able to read into these “World” representations components derived from his personal conviction [referring to clinical theories], and that not merely as a result of wish fulflment, but because they are almost certainly to be present there. (Lowenfeld, 1979, p. 7)

Research in South Africa Liesel Ebersöhn et al., professors of educational psychology, studied the use of an initial sandtray to identify risk and resilience in rural South African youth (2017). Their working defnition of resilience was “the ability to develop normally in the face of risk using protective resources” (p. 15). The researchers also desired to fnd a more multicultural, indigenized assessment tool for use in a South African context, given that most current measurements are Eurocentric.

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They used the frst created sandtray of 25 students, aged 13–19 years, as the qualitative assessment tool. The sand tray was chosen because it is a “bridge between the conscious reality and unconscious truth of the client’s life experience” (p. 147). They found the participants showed resilience by being aware of their challenges and ability to recognize and appreciate protective resources. They identifed three protective resources displayed in the sandtray: 1. Spirituality, belief in a higher power beyond physical/ material world (p. 151) 2. Fulflled needs, access to things important to survival and development; movement toward self-actualization, resources to assist in meeting own needs (p. 151) 3. Belonging to a family, peer group, a community and contributing to others in that community with a reciprocal sense of responsibility (p. 153). These researchers found that despite living with internal and external risk factors, protective resources are identifable which led to identifcation of resilience. “The clients therefore not only showed resilience by being aware of their challenges, but also seemed to recognize and appreciate their resources” (2017, p. 155).

Research in the United States Linda Hart (2017) studied homeless high school students in south central Texas who experienced academic success. Engaging in a phenomenological study, she used the sandtrays created by her six participants as the source of her data. The participants included four Hispanics, two Caucasians; four females and two males. The prompt included instructing them to use as many or as few fgures that they wanted to use to show their experience as a homeless student, their motivation for fnishing high school, and what it was like to be accepted to a university. Hart focused on motivating factors contributing to this academic resilience and success. She found fve themes in the analysis of her sandtray-based data: “(a) isolation, (b) confusion, (c) faith, (d) determination, and (e) academic achievement” (p. 66).

USING THE SAND TRAY TO ENLARGE CAPACITIES Cathy Malchiodi (2020) says resilience is not a superpower, but instead ordinary magic that all have inside them. As a sandtray

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therapist, the responsibility is to provide opportunities through world making to access that magic. This is done through getting to contemplate on and listen to parts of self that have been welcomed into conversation because of the safety of refecting through metaphor. Approaches, like sandtray therapy, that emphasize refective and metaprocessing moments within session allow for greater integration of the material being processed; integration allows for being more connection to capacity, strength, and inherent resilience (Brown & Elliott, 2016). Furthermore, sandtray therapy works through accessing the body early in each session, which can provide vital opportunities for accessing and maintaining regulation, which is critically needed for remaining connected to resilience. That said, a direct, exclusive, or even primary focus on emotional processing can initially present diffculties in working with those patients who typically experience an overwhelming food of emotions, a lack of emotion, or the same emotion over and over. Direct attention to emotions in such instances may exacerbate dysregulation and/or reinforce maladaptive emotional patterns. Affect might be best regulated, rather, through an exclusive focus on bottom-up or sensorimotor processing interventions that challenge these tendencies, promote stabilization, and pave the way for future effcacious processing of emotions. (Ogden, 2009, pp. 204–205)

Group sand therapy presents another relational pathway to engaging connection to self and others; group sandplay was used to develop resilience in college students in one study (Wang et al., 2017). The social support experienced in the group setting, and development of self-esteem, were viewed as reasons for resilience development. The nonverbal aspects of the group sandplay was also an element for increased resilience. Sandplay provides three layers of protection for clients: the frst layer is the closed, quiet, and cozy group counseling room; the second layer is the sand-tray; and the third layer comes from the parent-child unity therapeutic relationship shaped between the therapist and the clients. (p. 193)

Wang et al. (2017) report using The Sandplay Test of Resilience (see earlier in this chapter, in previous publication by the same author, it was labeled Sand Tray Test of Resilience.) Group tray work provides expansive opportunities for harnessing the power of community in connecting to a shared sense of resilience. Individual sandplay sessions were found to develop resilience in Mexican farmworker women (Mejia, 2004). Through four sandplay sessions, improvement was identifed and three factors:

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social support, children, and religious beliefs (p. 83). Ximena Mejia also noted that future interventions “should include a conceptualization of resilience that encompasses their culture’s emphasis on familism, collectivist values, and affliation” (p. 84). This research demonstrates the ability of working in a primarily nonverbal process can provide the opportunity to expand resilience. Many have offered practical methods for enhancing resilience by connecting to mind and body, as the body is especially important in learning one’s way back to experiencing self as resilient (Malchiodi, 2020). For example, Rick Hanson (2009) discusses how meditating on strength, specifcally attending to the shifts in physiology noticed during the meditation, reinforces that sense of strength and makes it easier to access in the future. In the sandtray, this could be as simple as prompting a world about strength or being watchful for strength to spontaneously show up in any prompted world. It will most certainly be there. Once strength is found, ask the client to say a little more about that. Then inquire about what they notice in their body when describing strength. Staying with those moments a bit longer allows more time for integration and, involving the body in that meditative moment, is critical. Another critical element in supporting an expressive arts client in gaining access to their sense of resilience requires working with the concept of self-compassion (Malchiodi, 2020). Trauma and sandtray therapist, Nancy Simons, asks clients to see the sandtray as a container made of self-compassion, prompting clients to attend to the inside of their container as featuring selfkindness, mindfulness, and common humanity (Kristen Neff’s components of self-compassion); then clients are asked them to gather images that support these concepts (personal communication, February 8, 2020). Simons says, The Self Compassion Container exercise is a manifestation of our inner landscape, a landscape that holds the qualities of selfkindness, acceptance and shared humanity. These qualities guide us to wellness. The sand tray becomes the physical expression of this inner landscape. Its rectangular form is the container and the inner landscape of sand, blueness and fgurines becomes the personal expression of a self-compassionate being. (N. Simons, personal communication, February 17, 2021)

Tammi Van Hollander, another talented and innovative sandtray clinician, prompts clients toward Greatness Trays through use of specifc products she has created, bringing focused attention on positive character traits:

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When working with a family, each person is asked to pick a miniature that represents themselves and the other people in their family, and each member is separated into quadrants. Greatness Sticks or Greatness Cards are all laid out on a big table, or whatever works best. Then, one at a time, each person goes around and frst picks a greatness card or stick for each family member, stating how they possess that quality and putting it in the family member’s quadrant. Next, they pick one for themselves and put it in their own space for a recognition for how they possess that quality. Other people can be prompted to chime in and give more evidence to why this is true. Each person then picks the quality they wish the family member was more of and a quality they wish they were more of. This is a fantastic assessment activity because the family is identifying strengths and challenges that can turn into treatment goals … If a stick or card is not available, the client just makes one and adds to the tray. The sandtray prompt is, “Pick a miniature that represents each person in the family or other important people in your life and put a greatness stick/card next to the miniature.” (personal communication, December 20, 2020)

Genograms, as previously discussed in the book, provide entry into insight about intergenerational dynamics (McGoldrick et al., 2008). While every family tree has pain fowing through the generations, there is also strength to access in every family history. Genograms can be conducted in the sand tray with the specifc mission of fnding inspiration, a legacy of determination, and hope, without ignoring the struggles that are also present. Marshall has developed the Genogram BlocksTM (see Figure 9.1). The client can be invited to add a miniature or a Greatness Stick (Figure 9.2; see Tammi Van Hollander in Appendix A: Resources) that highlights discovered strengths uncovered during genogram processing. As before, invite the client to take a moment to connect with that intergenerational resource and locate a body sensation that corresponds with it (Figure 9.3).

FIGURE 9.1 Genogram Blocks. Photograph by Caleb Matthews. Used with Permission.

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FIGURE 9.2

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Greatness Sticks.

Photograph by Caleb Matthews. Used with Permission.

FIGURE 9.3

Greatness Cards in a Sand Tray.

Photograph by Caleb Matthews. Used with Permission.

Sandtray therapist-sandtray creator relationship allows for practicing security and care receiving (Rae, 2013) in a variety of ways that enhance a sense of resilience. When there are not obvious family legacies or external relationships to rely on in sandtray therapy sessions, the therapeutic relationship can do more of the heavy lifting. The sandtray therapist, during the processing of a client’s tray, can simply validate the courage shown by the client in taking a risk to explore self through a created world (Sachs, 1992). That refection alone highlights a seen and demonstrated capacity for overcoming struggle in relationally-attuned, carefocused manner. Marshall has taken this one step further with many clients. When a sandtray creator cannot fnd their way to seeing their inner light and strength, he will ask them to “borrow” his vision and try to look into their created world with his eyes. Clients will often be willing to experiment with seeing their goodness and grit when stepping into the shoes of an attuned and caring other. They may not initially believe the words they say, but they were able to momentarily practice noticing and embodying these traits.

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One fnal sandtray processing opportunity for moving from stuckness in an identity of struggle to experiencing self as an overcomer involves the use of two differently shaped trays. Most often, Marshall’s clients and supervisees, create worlds in rectangle trays. If a narrative gets fxated on brokenness or suffering, after spending all the time needed to offer much-needed care, Marshall prefers to close session with clients connecting to some positive aspect of self that can be trusted. He has experienced success in helping others to shift to this vision of the world by inviting them to move their same chosen miniatures to a round tray. The same images, but now in a new relationship, might be what the client needed to try on a new, strengths-based perspective.

PERSON-OF-THE-SANDTRAY THERAPIST AND RESILIENCE In order to see the resilience clearly in others, sandtray therapists must be able to recognize their own.

In order to see the resilience clearly in others, sandtray therapists must be able to recognize their own. This profession features sitting with people in some of their darkest moments, serving as witnesses in both visual and auditory manners of these experienced hardships. All of these pain-laced narratives can take a toll. (However, it is important to remember that sandtray therapists not only sit in voluntary view of others’ pain, but they also get to delight in the demonstrated strengths of others.) Still, to best see those strengths in others with ease, sandtray therapists may need to take moment to inventory their own positive traits and welcome the body into connection with them. Marshall has asked many sandtray training groups to meditate on the qualities of self they can trust to show up in hard sessions, whether it be compassion, wisdom, protectiveness, etc. He then asks them to locate a body sensation that accompanies the experience of connecting to this quality. From there, the therapists choose a sandtray miniature that is a metaphorical representation of the trait and then sit in meditative noticing of and dialogue with this fgure. Finally, the therapists spend time bringing to mind people and events that have contributed to the cultivation of this reliable strength. The gratitude inherent to this step helps to anchor the quality in a grounded manner that can welcome it into a more lasting and coherent sense of self as therapist. Another technique that uses sandtray and genogram concepts again, but this time to root the person-of-the-sandtray-therapist (POST) in a legacy of competence, asks therapists to make a professional genogram in the sand. Linda frequently uses an experience she calls “professional genograms” in her supervision trainings. After having the participants place a self-fgure in the center of

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the tray, they are prompted to “place around your professional-self those activities, experiences, and people, who have contributed to who you are today.” This provides an opportunity for refection of infuencers in one’s professional life. Participants frequently share how this experience is rewarding on many levels. Primarily, that deep sense of gratitude for and the awareness of the internalization of these infuencers has been rewarding. It’s always a notable visualization of seeing how being part of a larger, nurturing, professional community has impacted the POST. Marshall has led many person-of-the-sandtray-therapist (POST) groups that allow clinicians a chance to experience the support of other therapists while exploring self in the sand tray. These rooms are flled with encouragement, informed by shared understanding and an ease in seeing the goodness in each other, even when self-judgment is present. These groups can work with all nondirective prompting or directive prompting around exploring signature themes and future aspirations. Consistently, clinicians seem to fnd success in seeing self through a lens of resilience when they are doing the same for others in the room. The created worlds in the sand that come from these groups are often dynamic and moving as clinicians encounter their own POST as capable of holding pain and strength simultaneously.

IN CLOSING From prompting sand worlds that feature exploration of strengths and self-compassion to fnding these spontaneously while processing other types of prompted worlds, sandtray therapy allows for the space to access mind and body while welcoming a whole self-embrace of resiliency. The experience of watching clients, who have been wounded by relationships and life circumstances, fnd aspects of self that helped them survive is a sacred responsibility. Then, the act of witnessing someone, through use of metaphor, image, and narrative, shift from a survival state to an identity of thriving seals in this honor. It also gives the POST the chance to grow in their conviction that this modality can help clients connect to their resiliency. That increased confdence will continue to pay forward future clients who need to borrow from this atmosphere of belief.

OUR JOURNEY CONCLUDES … FOR THE MOMENT You have reached the end of this journey of digging deeper into sandtray therapy. We hope that the journey has brought deeper

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appreciation for its history and research; new insights; fresh thoughts; new-found ways of working with clients; a deeper understanding of yourself, as POST; and especially a curiosity of continuing the journey. Appendix E, an Annotated Bibliography, is also available for further digging! Enjoy! We will join you along the way!

REFERENCES Ackerman, C. E. (2012, January 9). What is resilience and why is it important to bounce back? PositivePsychology. https://positivepsychology.com/what-is-resilience/ American Psychological Association (2020). Building your resilience. https://www.apa.org/topics/resilience Bowyer, R. (1970). The Lowenfeld world technique: Studies in personality. Pergamon Press. Brown, D. P., & Elliott, D. S. (2016). Attachment disturbances in adults: Treatment for comprehensive repair. W. W. Norton & Company. Bühler, C. (1951a). The world test, a projective technique. Journal of Child Psychiatry, 2, 4–23. Bühler, C. (1951b). The world test, a projective technique. Journal of Child Psychiatry, 2, 69–81. Cozolino, L. (2017). The neuroscience of psychotherapy: Healing the social brain (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Cozolino, L. (2020). The pocket guide to neuroscience for clinicians (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Ebersöhn, L., Nel, M., & Loots, T. (2017). Analysing risk and resilience in the frst sand tray of youth at a rural school. The Arts in Psychotherapy, 55, 147–157. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V., Koss, M., & Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. Gwata, N. (2018). Resilience of young adults in a context of drought. [Unpublished dissertation]. University of Pretoria. Hanson, R. (2009). Buddha’s brain: The practical neuroscience of happiness, love, and wisdom. New Harbinger Publications. Hart, L. M. (2017). Factors contributing to academic resilience of former homeless high school students: A phenomenological study [Abstract]. [Doctoral dissertation]. Sam Houston State University. ProQuest. Hass-Cohen, N. (2016). Secure resiliency: Art therapy relational neuroscience trauma treatment principles and guidelines. In J. L. King (Ed.), Art therapy, trauma, and neuroscience: Theoretical and practical perspectives (pp. 100–138). Routledge. Herrman, H., Stewart, D. E., Diaz-Granados, N., Berger, E. L., Jackson, B., & Yuen, T. (2011). What is resilience? The Canadian Journal of Psychiatry, 56(5), 258–265. https://doi.org/10.1177/07067437110 5600504 Holmes, J., & Slade, A. (2017). Attachment in therapeutic practice. Sage. Kestly, T. A. (2014). The interpersonal neurobiology of play: Brain-building interventions for emotional wellbeing. W. W. Norton & Company. Lee, J. H., Nam, S. K., Kim, A. R., Kim, B., Lee, M. Y. & Lee, S. M. (2013). Resilience: A meta‐analytic approach. Journal of Counseling & Development, 91(3), 269–279. https://doi.org/10.1002/j.1556-6676 .2013.00095.x Lowenfeld, M. (n.d.). Institute of child psychology. The Margaret Lowenfeld Trust. Lowenfeld, M. (1979). Understanding children’s sandplay. George Allen & Unwin. Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. Guilford Press. McGoldrick, M., Gerson, R., & Petry, S. S. (2008). Genograms: Assessment and intervention. W. W. Norton & Company. Mejia, X. E. (2004). An investigation of the impact of Sandplay on mental health status and resiliency attitudes in Mexican farmworker women. Electronic Theses and Dissertations, 2004–2019, 108. https://stars .library.ucf.edu/etd/108

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Mitchell, R. R., & Friedman, H. S. (1994). Sandplay: Past, present & future. Routledge. Ogden, P. (2009). Emotion, mindfulness, and movement: Expanding the regulatory boundaries of the window of affect tolerance. In D. Fosha, D. J. Siegel, & M. F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development & clinical practice (pp. 204–231). W. W. Norton & Company. Petruk, L. (1996). Creating a world in the sand: A pilot study of normative data for employing the sand tray as a diagnostic tool with children [Unpublished master’s thesis]. Southwest Texas State University. Rae, R. (2013). Sandtray: Playing to heal, recover, and grow. Rowman & Littlefeld. Sachs, R. G. (1992). An introduction to sandtray therapy for adult victims of trauma. Dissociative Disorders Fund. Schore, A. N. (2009). Right-brain affect regulation: An essential mechanism of development, trauma, dissociation, and psychotherapy. In D. Fosha, D. J. Siegel, & M. F. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development & clinical practice (pp. 112–144). W. W. Norton & Company. Sciaraffa, M., Zennah, P., & Zennah, C. (2018). Understanding and promoting resilience in the context of adverse childhood experiences. Early Childhood Education, 46, 343–353. https://doi.org/10.1007/s 10643-017-0869-3 Seiler, A., & Jenewein, J. (2019). Resilience in cancer patients. Frontiers in Psychiatry, 10, 208. Siegel, D. J. (2016). Mind: A journey to the heart of being human (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Southwick, S. M., Bonanno, G. A., Masten, A. S., Panter-Brick, C., & Yehuda, R. (2014). Resilience defnitions, theory, and challenges: interdisciplinary perspectives. European Journal of Psychotraumatology, 5. https://doi.org/10.3402/ejpt.v5.25338 Tronick, E. & Gold, C. M. (2020). The power of discord: Why the ups and downs of relationships are the secret to building intimacy, resilience, and trust. Little, Brown Spark. van der Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books. Walsh, F. (2020). Loss and resilience in the time of COVID‐19: Meaning making, hope, and transcendence. Family Process, 59(3), 898–911. https://doi.org/10.1111/famp.12588 Wang, D., Nan, J. K.M., & Zhang, R. (2017). Structured group Sandplay to improve the resilience of college students: A pilot study. The Arts in Psychotherapy, 55, 186–194. https://doi.org/10.1016/j.aip.2017.04 .006 Wang, D., & Privitera, A. J. (2019). Beyond self-report methods: Sand tray used in resilience evaluation. The Arts in Psychotherapy, 63, 60–67. https://doi.org/10.1016/j.aip.2019.03.001

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1 SAND TRAYS AND SAND John Burr Personal Communication 11/23/2020

Sand Trays Over the past several years, I have been experimenting with painting both the inside and outside of sand trays. I have sand trays that have symbols to represent the four elements of earth, air, fre, and water; a gold sandtray with a treasure jewel bottom; as well as an all-black and all-white sand tray. The black and white sand trays have allowed clients to work on light and shadow with the trays placed next to each other. The black tray with black sand is often used for the experience of going into the abyss. The elemental sand trays were designed to invoke each element’s energy and symbol that we experience and are used in work with Native Americans. Children love the gold sand tray with the jeweled bottom as it invokes the experience of fnding a hidden treasure. I have not found any particular meaning or symbol for the type, color, size of sand, of a sand tray. No symbol has the same meaning for everyone. The importance for me is to have sand and trays available to help in the healing process no matter who comes into my offce. I fnd all the sands and all sand trays are used by all different ages, ethnic and cultural backgrounds.

Sand Most, if not all, of us, have a variety of personal experiences with sand. We are drawn to sand. Sand hypnotically invites us into a relationship. Something seems to magically happen to us when we touch sand. A child client once said when she touched the sand, “ooh, this feels like my teddy bear,” and another child said, “this feels like water. I could play in this sand forever.” Yet, others’ experience with sand can be quite painful when the grain of sand is sharp and angular. I have over ten colors and textures of sand available for clients to use in my sandtray offce. The colors range from tan, white, black, red, green, brown, or blue. Most of the sand I use is naturally colored, while a few sands are dyed. The texture or grain can be soft, almost fuid (glass bead sand), to hard and granular. If I only had space for a couple of sandtrays, I would only use white sand in my sandtrays. The white sand has no specifc

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meaning or symbol attached to it and creates a table rasa for the client. It would be a mistake to only have orange sand or black sand available to your client. Having a variety of colors and textures is like having a variety of tools available for a project but not the main tools you would use. Black sand is used a great deal by teenagers. The shadow aspect of the black color seems to be a draw to them as this is part of what they are dealing with developmentally. The red sand is often used as fre. One client told his offender that the red sand was “a stop sign. You see the red, and it says stop, don’t touch this.” Sometimes a client will choose a colored sand because of its texture, and other times, the color invokes something within the client. The most important aspect of using colored sand is to make sure you do not have a preset meaning to the color. The meaning must always come from the client. I have had many clients who have used a sharp angular hard sand, refecting that the sand refects their own diffculties and experience with attachment. Children seem to especially be drawn to the glass bead sand. The texture can be quite soft and soothing. Blue sand is almost always used as water. Ways have I used sandtray in my work with clients: Couple sandtray can be very powerful. I fnd it very helpful in getting the couple to “see” and “experience” each other through the sand tray and increase understanding and ways to communicate and validate each other. A caution here is to make sure you are trained in working with couples as this method can easily get out of hand. Do not underestimate the power of a symbol.

I have used sandtray effectively with clients of all ages and with a variety of issues and diagnosis. Sand tray can be used with individuals, couples, groups, businesses, and families. I have used sandtray therapy with issues of grief, loss, sexual abuse, depression, anxiety, gender identity, divorce, complex trauma, abuse, sexual orientation, family dysfunction, ptsd, indifelity, premarital therapy, forgiveness, employment problems, spiritual and religious issues, etc. Sandtray therapy with victims and offenders can be quite powerful and healing. I have asked victims to create sandtrays of their experience of having been sexually abused. I have asked their parents or other secondary victims to create trays of their feelings toward the offender. I once had eight family members create sandtrays for the offender of their children and grandchildren. These trays are helpful in creating empathy for the offender and giving the victims a voice that is deeper than words. I have found it to be a useful method to have an offender create a clarifcation

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sandtray and a forgiveness sandtray instead of the traditional letter to the victim which tends to be void of feelings and emotions (in my experience). Children and teens have used sandtray to work through divorce issues, especially in going back and forth between the homes. I often bring both parents of divorce into the session together so their children can share his/her experience of divorce with both parents present. Parents have been able to make signifcant changes as they see through the eyes of their children in their sandplay how they are experiencing divorce I have used sand tray in helping clients create vision boards for their companies and to problem solve complex company problems that were not understood until it was seen and experienced through the use of images and sand.

2 SELECTING SAND FOR YOUR SAND TRAY—CHARACTERISTICS TO CONSIDER Jerry Bergosh, Chief Geologist, Jurassic Sands Personal Communication, November 23, 2020 Sand for your sand tray is available from two general sources— either natural locations like deserts, beaches, and riverbed sandbars or sand and gravel pits which manufacture it for home improvement and big-box stores or landscape centers. The properties of sand from each of these sources are discussed, and the features and benefts related to using it in your sand tray. Texture and grain size are two of the most common features we describe to play therapists because they are key elements to your sensory satisfaction. Texture is best visualized by the shape of a sand grain. A grain that is sharp and angular, like those created when rock is crushed and pulverized, will have a rough and coarse feel when stroked by your fngers. Bigger grains also have more texture—a granular feel that is distinct to larger grain sizes. Rounded sand grains typically occur naturally in deserts, oceans, and rivers where wind, wave, and water action have eroded off the sharp edges. The grains are blown and rolled around for eons, and the rounded shape sends the tactile impression of softness and silkiness to the person feeling the sand. Grain size also plays an important role; the smaller the rounded grain is, the softer, more and more silky it feels. Purity is another critical factor when selecting sand for your sand tray. A fundamental geology principle related to purity is material of the same density will group together when exposed to excessive wind or water action. Gold nuggets and fakes are the best-known examples—miners knew to look for telltale pockets along sandbars where eddy currents collected the gold. That same process occurs in the desert and along beaches where pure deposits of one mineral can be found under the right circumstances. These high quality, pure deposits are most prized for use by sandtray therapists and play therapists. Purity can be compromised by the locale where it is mined and how the sand is processed. A good example is sand from a typical sand and gravel pit deposit. When this material is dug up, it will consist of whatever is in the soil—this could include rocks of different sizes and compositions, clay and silt, sand, roots of plants,

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organic matter like leaves, and even dust that has been blown in from far away. As with any material, more impurities mean a lower sand quality, which can affect your satisfaction with your sand’s performance. Sand from a sand and gravel pit is ‘manufactured’ by crushing and pulverizing rock and soil and then screening it to the desired sizes. The unintended consequence of this crushing is the creation of dust in the sand, which is diffcult to remove by the washing process. Whether from the beach or desert, natural sand has had the dust removed by the winnowing action of wind, water, or wave action. This activity results in a naturally pure material. Color is always mentioned by geologists when a sand is described to a sand and play therapist. It is important to note that Mother Nature creates a wide range of minerals of different colors, from purple-pink garnets to the warm terra-cotta color of the US Southwest and many neutral colors in-between. And this naturally occurring color is part of the fabric of the rock and diffcult-to-impossible to remove by human means. On the other hand, brightly colored manufactured sands typically rely on dye or paint to ‘color’ a clear or frosted sand grain, and the degree of permanence is a function of how often you wet the sand in your tray. Dye and paint do not stand up to prolonged wetness very well and may eventually come off on hands and clothes over time. Some colorizing agents are hydrophobic, which means they repel water and prevent the sand from sticking together to make shapes in the sand tray. A fnal word on the cost and volume of sand; the cost of regular sand can range from $5 per 50 lb. bag at the local home improvement store to $50 per ton at the local sand and gravel pit or landscape center. Specialty sands available online that are dust-free and higher purity can range from $1 to $2 per pound plus shipping. The standard-sized sand tray requires 50 pounds to fll it to the midpoint. Your budget, your and your clients’ sensitivity to dust allergies while working indoors, and other considerations like asthma or sensory issues all need to be taken into account when determining which sand to use in your sand tray.

3 USE OF THE SAND TRAY WITH CHILDREN WITH ASD Robert Jason Grant Personal Communication, November 28, 2020 Children with autism spectrum disorder (ASD) have been noted as having trouble using pretend or symbolic play defned as “the capacity to purposefully engage in imaginative activity or advanced pretense” (Wolfberg & Schuler, 2006, p. 185). Traditional sandtray therapy approaches typically rely on a symbolic and pretend processes which children with ASD may lack the skills to perform. Autism is a wide spectrum of manifestation and some children with ASD may be capable of participating in a sandtray therapy approach at the same level as their neurotypical peers. There has been limited research on the use of traditional sandtray therapy approaches with children with autism. Parker and O’Brien (2011) highlighted the results of using a more traditional sandplay therapy process with a child with ASD which showed the child’s play moved through four stages common in sandplay therapy (chaos, battles, the rise of a hero fgure, and play with an apparently secondary or deeper meaning). At the same time signifcant differences in the child’s classroom and playground behavior were noted by their teachers and were evident in school behavior records. Lu et al. (2010) worked with a group of 25 students diagnosed with ASD using traditional sandplay therapy and produced positive results including increased verbal expression, engaged and sustained social interaction, and increased symbolic, spontaneous, and novel play. Children with autism who lack he skill ability to understand symbolic and pretend play skills can beneft from sandtray therapy approaches. Grant (2017) proposed that sandtray therapy can be effective in helping children with autism improve symbolic and pretend play skills, which are often primary and important components of social interactions with same age peers. The therapist should move at the child’s pace of understanding and not push the child beyond what they are capable of understanding. The therapist will take on a psychoeducational role and will need to teach the child what symbolic and pretend skills are and provide role modeling and examples. This will likely be a repetitive process that will span several therapy sessions. The following

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intervention protocol (Symbolic Play Time) is highlighted from Grant (2017). Play-Based Interventions for Autism Spectrum Disorder: Using a sandtray and miniatures. The therapist instructs the child that they are going to have some symbolic and pretend play time. The therapist explains the concept of symbolic and pretend play and introduces the child to the sandtray and the miniatures that will be used in the symbolic/pretend play time. Pretend Play—“This is a type of play where we might use a toy and pretend that it is something that it is not. We might take a car miniature and pretend like it is alive and can talk and think.” Symbolic Play—“This is a type of play where we might take a toy and use it to be or represent something else. We might take a penguin miniature and say this miniature represents my mom because she likes penguins.” The therapist will start my giving the child an example. The therapist might start with saying “I’m going to pick two miniatures to be two kids at a school and they are having an argument.” The therapist picks a car and says, “This is Michael” and picks a dog miniature and says, “This is John.” The therapist then places the miniatures in the sandtray and has Michael and John have an argument about Minecraft. The therapist then picks a tree miniature and says, “This is the teacher at the school.” The tree/teacher comes into the sandtray and tells the boys to stop arguing. The therapist can create any example they like to show the child what symbolic and pretend play looks like. It is important the therapist begins by role modeling and showing the child examples. The therapist might want to provide a few different examples. After role modeling a few examples, the therapist then begins incorporating the child into the decision making. The therapist will continue with examples but try to involve the child by having the child take on the role of one of the characters or having the child introduce a new character into the sandtray story as much as possible. The therapist can periodically switch to different miniatures and create other symbolic play examples. Once the child seems to be comfortably participating in the symbolic/pretend play, the therapist can introduce a directive tray for the child to try and complete Some examples include: 1) Create an original story using some of the miniatures. 2) Pick a couple of miniatures and turn them into original characters. 3) Pick a miniature to represent you and each person in your family. Try not to use people. 4) Pick a miniature that describes a feeling you are having right now. 5) Pick one miniature that describes your home and one miniature that describes your school. Try not to pick a building. 6) Make a sandtray, using the miniatures, that describes things you like. 7) Make a sandtray, using the miniatures, that describes things you don’t like. (p. 80)

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The therapist should always be looking for opportunities to have the child make decisions and engage in and lead the way in the symbolic/pretend play. The ultimate goal would be to have the child complete a directive symbolic tray and displaying a signifcant level of understanding in symbolic and pretend play.

Due to the wide variance of autism, sandtray therapy approaches with children with ASD should be a mindful consideration for the therapist. It is critical to understand the child’s ASD manifestations and skill ability regarding participation in a sandtray therapy processes. Some children will require little to no modifcation while others will need a more structured and role modeled guide from the therapist. When the therapist is cognizant of the child, the process being implemented, goals to be achieved, and the modifcations that may be necessary, a sandtray therapy process can hold benefts for children across the autism spectrum.

REFERENCES Grant, R. J. (2017). Play-based interventions for autism spectrum disorders and other developmental disabilities. Routledge. Lu, L., Peterson, F., Lacroix, L., & Rousseau, C. (2010). Stimulating creative play in children with autism through sandplay. The Arts in Psychotherapy, (37), 56–64. Parker, N., & O’Brien, P. (2011). Play therapy reaching the child with autism. International Journal of Special Education, 26, 80–87. Wolfberg, P. J., & Schuler, A. L. (2006). Promoting social reciprocity and symbolic representation in children with autism spectrum disorders: Designing quality peer play interventions. In T. Charman & W. Stone (Eds.), Social and communication development in autism spectrum disorders: Early identifcation, diagnosis, and intervention (pp. 180–218). Guilford Press.

4 HOW SAND TRAY BRINGS SAFETY FOR TRAUMA HEALING Eliana Gil Personal Communication, December 18, 2020 The most basic factor in all trauma is the person’s perceived sense of helplessness. In addition, traumatized children can feel a wide range of emotions that include confusion, distrust, anticipatory anxiety, fear, shame, and isolation. Their attempts to make sense of their experiences can cause them to develop untrue narratives that they caused the abuse, that there is something inherently wrong with them, and that they deserve whatever happened to them. The response to trauma is a corrective reparative experience that includes novel information to counteract traumatic responses. Thus, a therapist focuses frst on allowing the child to develop a sense of safety and trust, and becomes trustworthy to the child so that the therapy relationship becomes one that offers comfort, respect of boundaries, limit-setting, visibility, and acceptance. As children settle into a warm and safe relationship, they can explore, make choices, set the pace, and access strengths and feelings of mastery. Sand tray invites traumatized children into a world of creative imagination, of release, of control, and of interacting with an unconditional witness. These are the elements of healing that children need and desire, especially when they occur within the safe and protected space of sand therapy. The boundaries of the tray and the soft, cool sand provides cues to the nervous system that suggest that it will be possible to relax and soothe. The small objects allow children to bring forth that which is encumbering their mind and heart. When children externalize with small miniatures, they tell their stories, ask their questions, express their dilemmas in their own unique way, without having to interact with the demand to use words, or explain themselves to others. Once objects are selected and externalized into picture images or stories, children can direct the content and manifest their most basic needs. Working with them in metaphor, as well as accepting their spontaneous verbal communication, will allow children to feel powerful and lean into having personal control. Sand tray is one of the expressive therapies well suited to traumatized children and adults as a beginning externalization or as a deepening process of understanding and developing

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self-empathy, as well as challenging the narratives of responsibility for the trauma. The end result is that children can work along the continuum of unsafely/safety and distrust/trust, experience a corrective reparative relationship, and have renewed feelings of personal control and mastery, all the while learning to manifest gradual exposure, and affective tolerance.

The Person-of-the-Therapist Over decades of supervising and mentoring, I can say with confdence that the person-of-the-therapist issues are critical to identify, address, and keep working with over time. Far from a sprint, this works tends to be a marathon of self-evaluation, refection, compassion, and action. It’s simply absolutely compelling for the therapist to continue his or her own work throughout their clinical development in order to provide the very best relational opportunities to our clients. I believe one such aspect is counter transferential work, and most importantly, making time for it. How much time do you spend after a session concludes, allowing yourself to “be with” the experience you just had with a client? Can you move from one client to another without taking the time to calm your mind, check in with your heart, listening to what your body needs? I think therapists need to prioritize taking the time to explore themselves and their responses because these are responses gleaned by being with the client. I have often found myself whispering, feeling uneasy, even feeling irritable or angry after a session. Unless I stop long enough to register those feelings and externalize them, I will just carry them from one client session to another, and the weight can become heavier throughout the day. So fnding a way to release and compartmentalizing will be a lot healthier than simply suppressing or compartmentalizing your responses. We all bring a unique set of experiences to the work we do. Those experiences guide our interest in working with specifc target groups, or specifc situations. It is not coincidental for example, that Margaret Lowenfeld, who was bilingual, found this silent, nonverbal experience of sand tray to be so compelling, evocative, deep and gratifying. Knowing the reasons why we gravitate to specifc ways of working is a most useful journey, necessary for offering ourselves to others in the most responsible and genuine ways.

5 SAND TRAY ADAPTATIONS FOR ELDERS Sandi Peters Personal Communication, December 12, 2020 This handout was prepared by Sandi Peters and adapted by Linda Homeyer. Location: ◾ Choose a quiet, non-distracting space with good lighting ◾ If working in a facility, make sure you are able to secure your miniatures in a safe place when you are not doing a sand tray or are away. The Tray: ◾ It’s preferable for trays to be large enough to allow for selected miniatures without crowding. ◾ Small trays that can be placed on a table with wheelchair access may be needed. Sand: ◾ Most elders prefer dry sand. ◾ Use various colors and grains/textures, including ground corncob which is made from corn husk and is easily transportable. Miniature Figures: Start with a small collection and add as you can but make sure you have a few items in each of the following categories to begin. Larger fgures work well because it’s diffcult for elders to see and manipulate small ones. Human fgures (men, women, children of both sexes; look for variety of occupations and include other races & ethnicities) Fantasy and religious fgures Animals (having a large variety of this category both domesticated and wild as these are frequently used) Natural items (trees, rocks, dried fowers, etc.) Transportation/Vehicles Buildings of various kinds, including fences

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CONSIDERATIONS WHEN DOING SANDTRAY WITH AN ELDER Visual Ability: Is the elder able to see? If the person cannot see well enough to make out the differences in the fgures, this adds another level of stress and complicates the possibility of doing a sand tray with them. Motor Capacity: Does the elder have limited range of motion? Does the elder have contractures? Is the elder ataxic (presence of abnormal, uncoordinated movements)? You will need to accommodate these limitations. Cognitive ability: What is the cognitive capacity of the elder? ◾ If the elder is fairly intact cognitively, s/he can be exposed to your entire collection (if it is large!) ◾ If the elder’s is compromised by dementia, it is advisable to choose a few fgures that may resonate with their history/interests as well as something from each category. Present these to him/ her rather than risk overwhelm by too much choice. Personality: What is the personality of this elder? The answer to this question tells you how you might best approach an invitation as: ◾ an opportunity to help you out with a project you’re initiating at the facility ◾ a chance to spend some time together ◾ a chance to play together Be creative! Be fexible! Dementia: With elders who are cognitively compromised: ◾ Put items you have pre-selected (based on the known interests of that elder plus a few unknowns thrown in, including grief, death items) in a basket and put the basket on their lap. The closer you can bring their attention to this project, the more successful you will be. ◾ Pay attention to: ◽ Balancing between going along with whatever story is present for them vs returning repeatedly to the task of directing them in the choosing/placing process ◽ Determining a satisfactory method that allows them maximum choice in positioning of objects in the sand

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BASIC INSTRUCTIONS FOR FACILITATING A SANDTRAY 1. Invite the elder with whatever approach best matches the elder’s personality. 2. When you get to the sandtray, invite the elder to put his/ her hand in the sand and move it around. If s/he does not, then you do so and show the elder that it’s possible to move the sand exposing the blue bottom to make a lake, river, stream. 3. Show the elder the fgures and introduce each of the categories, e.g., here we have men, then women, wild animals, etc. 4. Invite the elder to choose whatever is interesting to him/ her; whatever “pops out,” including fgures that are not too appealing, e.g., scary, ugly, etc. 5. Remain fully present to what the elder is doing. Be attentive to a possible need for help with reaching/placing an item. If you’re working with someone who has dementia and is having diffculty choosing, notice where the elder’s eye goes, pick that item up, show it to him/her and ask if s/he would like to use this piece. It is helpful to take some notes to jog your memory paying attention to the order in which fgures are chosen and any accompanying comments. 6. Be fully present to what is happening inside of YOU as the process unfolds. What are your thoughts, associations, feelings, body sensations? Note them and at what point you experienced them. 7. Follow the lead of the elder regarding conversation. If the elder talks about what s/he is doing, help them amplify their creation. For those with dementia, there is often a running commentary. This commentary is as important as the creation of a tray. Engage them in the memories, associations, etc. that come up while also keeping in mind the hope of completing a tray. If the elder seems more engaged with the conversation, however, than you may need to let go of the desire to complete a tray. 8. When it seems the scene is complete, ask the elder if s/he would like to give a title to the work; if s/he would like to make any comments about what they created. Write these down. Finally, ask if s/he would like to do this again. 9. Take a photograph of the completed tray. You can give a copy to the elder the next time you see him/her and discuss further if that seems appropriate.

6 ATTACHMENT IN THE SAND TRAY Bonnie Badenoch Personal Communication, December 19, 2020 Our early attachment experiences have no words. They are deeply felt in the body and shape our interior landscape for the rest of our lives. When we approach sand and miniatures, these righthemisphere-based feelings translate fuidly into images and particularly into relationships that spontaneously emerge. The more we let go and respond to both the sand and beings on the shelves as though our body itself is doing the choosing, the more these early experiences appear, to be held and warmed and cared for by the sand tray person and his/her attentive witness. Our inner world begins to shift in the light of this beholding. It is a powerful process that one might imagine could be disruptive. Instead, the tray itself becomes a boundaried sanctuary for what is being allowed into the light while the human witness also provides the safety of presence.

Appendices

Appendix A Resources for Sand Trays, Sand, and Miniature Figures SAND TRAYS Child Therapy Toys www.childtherapytoys.com Sand trays: wooden, plastic, various sizes Miniature fgures Starter and intermediate kits (sand tray, sand, miniature fgures) Sand

Play Therapy Supply www.playtherapysupply.com Sand trays: wooden, plastic, various sizes Portable sand tray & starter kit Miniature fgures Starter and intermediate kits (sand tray, sand, miniature fgures)

Ron’s Trays Sand trays: rectangular “standard” and octagon Carts with shelves Shelves www.sandtrays.com 707-894-4856

Play Therapy Outlet www.playtherapyoutlet.com Sand trays, sand, and miniatures

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SAND Jurassic Sands www.JurassicSand.com Dust-free, asthma & allergy-friendly sands Natural sand of various colors and textures

Play Therapy Supply www.playtherapysupply.com Sandtastik—several colors Sand trays Books

MINIATURE FIGURES Bell Pine Art Farm www.bellpineartfarm.com Handmade clay items

Georgia Mann Archetypal Sculptures www.georgiamann.com 406-360-8003 Handcrafted glazed pottery sculptures

Kennedy’s Sandplay Mini’s www.kennedysminis.etsy.com 3-D and epoxy fgures

Marshall’s Miniatures www.marshalllyles.com Miniature subscription box (monthly shipments of theme curated items) Miniature store—internationally sourced and in-house pottery

Momma Owls Minis www.mommaowlsminis.com Handcrafted and unique art pieces

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Self Esteem Shop www.selfesteemshop.com Miniature fgures Sandtray therapy and sandplay therapy books

Stones for Therapy from Ukraine https://www.facebook.com/groups/812311415643268 or search for Facebook group “Stones for Therapy from Ukraine” Hand-painted stones for sandtray work

Beth Richey www.bethricheycounseling.com Miniature fgures and play therapy supplies

MoonShadow Minis www.etsy.com/moonshadowminis Handmade ceramic miniatures

SW Therapy Supplies www.etsy.com/shop/SWTherapySupplies 3D printed miniatures

Playfully Connected Games www.playfullyconnectedgames.com Sandtray miniatures and therapy supplies

OTHER ITEMS—ADD ONS Main Line Play Therapy www.mainlineplaytherapy.com/shop Tammi Van Hollander Greatness Sticks & Greatness Cards

Marshall’s Miniatures www. marshallsminiatures.com Genogram BlocksTM

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Sand Therapy Creations www.sandtherapycreations.com John Anthony Sand Landscapes

Appendix A: Resources

Appendix B Documentation Cues and Clues While documenting sessions, it may be helpful to have a handy sheet of reminders about what to notice in a created world in order to assist with clinical insights. Here are a few suggestions of items to notice in clients’ trays but remember to keep any stated narratives about the items used in mind as well. These are only potential clues, not certain interpretations. Please feel free to add your own thoughts to make these uniquely applicable to your work and your settings. Some are clinical theory-specifc, others are not. Most of the items below are in the book. So, if you have a question about a term or usage, please refer back to the appropriate chapter.

SIX-STEP PROTOCOL Step 1: Room Preparation ◾ ◾ ◾ ◾

Room: Scents? Music? Candle? Other? Sand trays: Use a special shape? More than one? Sand: Colored? Alternative? Texture? Add ons: Genogram blocks? Back drop? Sky hook? Other?

Step 2: Introduction to The Client, The Prompt ◾ Did client select grounding item? (pillow, blanket, miniature fgure, scented oil/beads) ◾ Did you begin with a mindfulness exercise?

Step 3: Creation in the Sand Tray ◾ Use of table around the tray? Use of a ledge? Sky Hook? Back drop? Other? ◾ Window of Tolerance: Able to remain in Optimal Zone? Hyperaroused? Hypoaroused? ◾ If dysregulation occurred what was used to down regulate, up regulate? ◾ Interaction with therapist: Joint tray? ◾ Verbalization? Conversation?

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Step 4: Post-creation ◾ Window of Tolerance: Able to remain in Optimal Zone? Hyperarousal? Hypoarousal? ◾ Use of symbol work? ◾ Metaphor? Novel metaphor?

Step 5: Sand Tray Cleanup ◾ Did client(s) help deconstruct sandtray? If so, who initiated: therapist or client? ◾ Photograph: By therapist? Client? Both?

Step 6: Documenting the Session Themes to notice, see below:

NEURODIVERSITY: NEUROTYPICAL— NEURODIVERGENT Neurotypical/Neurodivergent Concepts ◾ Gifted Children/Adolescents Overexcitability categories: ◽ Intellectual—skeptical about using sand tray ◽ Sensory/sensual—may use sand alternative, fgures not tolerate touching, issues with use of water ◽ Psychomotor—dynamic and active play, tray placed providing for extra physical movement, sensory seeking ◽ Emotional—reduced number of fgures based in strong emotional responses, instilling fgures with excessive emotional meaning, needed assistance in regulating ◽ Imaginational—easily engage in sand tray, easily story tell, accesses right-brain imagination ◾ Clients with Autism Spectrum Disorder ◽ Pretend play—able to join in ◽ Symbolic play—able to initiate ◽ Used sand alternative: rice, corn cob, confetti, other ◽ Places miniature fgures outside the tray as part of creation? Lines the tray? ◾ Clients with Dementia; Elders ◽ Modifed sand tray arrangement

Appendix B: Documentation

◽ ◽ ◽ ◽

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Pre-selected fgures for client in a basket Placed fgures in the tray for the elder Ability of elder to verbally process the sandtray Level of visual ability

ATTACHMENT Attachment Concepts ◾ Safe haven, secure base, narrative coherence ◾ Mentalization/refective functioning

Attachment Woundedness Themes as Seen in the Sandtray ◾ Use of baby humans or animals in insecure manners ◾ Caregiving fgures are absent, neglectful, or harsh ◾ Withholding food, medicine, etc. (or resources being out of reach) ◾ Fences, barriers, or boundaries separating fgures when resources need to be shared ◾ Use of nesting dolls to depict stages or levels of struggle ◾ Houses being isolated/buried/broken ◾ Emotions moving to hyperactivation or deactivation ◾ Treatment of sand/fgures becoming haphazard as client loses body awareness ◾ Narrative moves to judgment or rigidity and away from fexibility ◾ Pockets of grief/despair in the narrative become overpowering ◾ Stories/phrases begin to feel rehearsed/scripted ◾ Insisting that a vulnerable fgure is at fault for “weakness” ◾ Preoccupying anger or rumination enters narrative ◾ Figures are idealized despite their destructive tendencies ◾ Client (or a fgure) has sudden loss of memory

TRAUMA Trauma Concepts ◾ ◾ ◾ ◾ ◾

Terror, hyperarousal, intrusion, constriction Fragmentation, integration Activators, triggers (sound, touch, sight, smell, movement) Memory: Implicit? Explicit? Making meaning: Linking sequential events narrative (left hemisphere) with embodied limbic memories

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◾ Who do you see showing up in the tray? ◽ Traumatized client, resourceful client, wounded client, healing client ◾ Containment: activity needed at end of session for client’s containment support? ◾ Adaptive trauma responses: autonomic state, adaptive survival response, regulate/co-regulate to ventral vagal state, re-story

Trauma Themes as Seen in the Sandtray ◾ Use of rescue/escape fgures (frst responders, helicopter, ladder, Pegasus, etc.) still in process of trying to help ◾ Use of inadequate containers ◾ Adding ominous or threatening fgures, especially when placed in relation to a vulnerable fgure (like a larger aggressive animal near an unsuspecting, defenseless animal) ◾ Excusing an aggressive fgure for its impact, even as it is being disparaging ◾ Depicting a vulnerable fgure as isolated or exiled ◾ Created world becomes marked with terrifed/terrorizing fgures ◾ Figure waiting to be rescued; theme of helplessness is evident ◾ Figures in world have nightmares or intrusive, troubling beliefs ◾ Figures are trapped or not allowed into the world/tray (rejection theme) ◾ Uninvolved onlookers watch vulnerable fgures in a world featuring struggle ◾ Natural elements used for destruction (fre, water, tornado, etc.) become overpowering ◾ Items critical to narrative are buried in the sand ◾ Client suddenly loses speech or moves to pressured speech ◾ Disintegrated elements in world or narrative are prominent ◾ Confusion enters into the narrative ◾ Painful part of a story begins to loop without moving to mastery ◾ Client, or a fgure, leaves their window of tolerance ◾ Struggle to hold moments of positive affect or safety in the tray ◾ Client prematurely ends work in the sand; turns away from tray

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RESILIENCE Resilience Concepts ◾ Connection, wellness, healthy thinking, meaning ◾ Nurturance, personal, biologic-genetic, environmental, family-friends, social-economic, cultural-spiritual ◾ Relational rupture, relational repair

Protective Resources as seen in the Sandtray ◾ Spirituality ◽ Shown with as butterfies, stars, religious items, items of light, magical helpers ◾ Fulflled Needs ◽ Movement to self-actualization (vehicles of any type) ◽ Meeting own needs (food, household implements) ◽ Giving water to plants, water well to humans or animals ◽ Providing strong shelter, blankets, etc. ◾ Belonging—people or animals in benefcial relationships ◽ Family ◽ Peer group ◽ Community ◽ Assisting—caring for self / others ◽ Figures banding or working together ◾ Connecting parts of created world with pathways, bridges ◾ Having capable containers holding or ready to hold other fgures/thoughts ◾ Figures overcoming obstacles in their story ◾ Finding a creative solution to a problem ◾ Highlighting a specifc skill, talent, positive character quality ◾ Client shifting body to a posture of strength/ determination Sandtray Test of Resilience Items (adapted from Wang & Privitera, 2019): ◾ Vitality: energetic, positive, and healthy status of a person ◽ Life forms: animal, human, and plant ◾ Water: inner energy, growth, nourishment, creativity ◽ Stream, pond, or well; river or lake; a sea

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◾ Relationships ◽ Interaction between animals or humans, rather than symbolic meanings ◽ Relational activities in tray, cooperative, constructive, and secure (number/type)

Appendix C Exercises for the Sandtray Witness The following content was taken from Roxanne Rae’s book (Rae, 2013, pp. 201–202), but is so well suited for this publication that we sought permission to reproduce her Appendix C here. Rae’s book is a valuable contribution to the feld of sand therapy and we recommend adding it to your library. Two exercises that referenced earlier parts of her book and needed these earlier sections for context were removed from this list. Much thanks to Roxanne for granting us permission to use this information. Allow yourself the gift of time to play, to refect on your process, and to take photographs and notes. I recommend ninety minutes to two hours if you are working alone. Another option is to play with another therapist working in a Creator and a Witness dyad with each person taking a turn at each role. These exercises may also be conducted in a small group. With group members playing in parallel, each person records his or her own observations and, perhaps, shares these with the others. Each participant can bring ffteen items to share with others. The important elements for learning are to allow yourself to play freely, to observe, and to record your process. Experiment with these exercises by repeating them at intervals and observing your reaction to overtime. The following ideas are designed to get you started. ◾ Play in dry sand alone. Notice the sand’s qualities, including the sound, smell, feel, and energy that it takes you to move it. Try this with your hands and with tools. ◾ Play in wet sand with your hands and a variety of tools. Notice it’s qualities as above. Discover how wet the sand needs to be to make good shapes and molds; observe what occurs when the sand is to dry, and when it is too wet. Finish by fooding the tray and playing in it for a while. Discover the properties of “soupy” sand. ◾ Choose one object to play with for at least 30 minutes. Then add any other items and see what happens. You can do this exercise repeatedly, beginning with the fgure from a different category of miniatures each time. ◾ Play with any single category of items, not allowing objects from other groups. You may choose your category or make this activity random. A random experience may be provided 223

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◾ ◾ ◾ ◾

by preparing a list of options on paper, cutting them apart, and then choosing one from a container. Play as above with three to fve categories. Create a Sandtray using only objects from nature. Form a sand world solely using plastic items. Start with a single miniature of your choosing. After ten minutes of Sandtray play with it alone, choose another. Allow an additional ten minutes to play with these two fgures. At intervals, add one other item at a time, observing how each new object comes into the world and relates to the sand and other miniatures present. How does each item change as it enters and relates to what is already present? How is each new object perceived by those miniatures proceeding it? Remember always to take a note of your observations.

REFERENCE Rae, R. (2013). Sandtray: Playing to heal, recover, and grow. Rowman & Littlefeld.

Appendix D Sandtray Prompts for Working with the Personof-the-Sandtray-Therapist The following sandtray prompts are written in a pattern that allows for moving through attachment- and trauma-informed concepts. Sandtray therapists can use these to “journal” on their own, but they are encouraged to have an outlet for processing: by meeting with their own therapist, by meeting with an experienced consultant to process POST issues that arise, or by meeting with a POST group. Pace yourself slowly enough to integrate what arises, making sure to allow for the receiving of needed care. Of course, feel free to craft your own prompts. Trusting your own sense of what is needed next, while listening to the constructs of your chosen clinical theory, is always important.

RESOURCING 1. Create a world in the sand. 2. Create a world where it is easy to know what is safe. 3. Create a world full of caring. 4. Create a world that is fully protected. 5. Create a world that shows a source of wisdom. 6. Create a world of delight. 7. Imagine yourself surrounded by gratitude and build that world. 8. Create a world where it is OK to be seen. 9. Create a world of belonging. 10. Create a world where you can experience calm. 11. Create a world that highlights your strengths. 12. Create a world of safety. 13. Create a world all about empowerment. 14. Create a world of compassion. 15. Create a circle of inner helpers.

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SELF AND METACOGNITIVE MONITORING 16. Create a world about an inner judgment. 17. Create a world about last tray’s inner judgment, but from your inner child’s point of view. 18. Create a world where strength and weakness work together. 19. Create a world that focuses on what you want to believe about yourself. 20. Create a world that represents how you feel about needing others. 21. Create a world of mutuality in relationships. 22. Create a world that shows what you need from others today. 23. Create a world about an important need that went unmet in a relationship. 24. Create a world where righteous warriors show up.

FEAR 25. Create a world exploring fear. 26. Part 2: Add one object of protection to your previous world about fear. 27. Create a world for conversation between your fearful past and secure present. 28. Create a world putting an action to fear. 29. Create a world about perfectionism. 30. Create a world about the progression of your inner self.

GRIEF 31. Create a world exploring grief. 32. Create a world about your grief’s call to action. 33. Create a world of grief and hope. 34. Create a tray allowing grief to be integrated into your new world. 35. Create a world about joy’s relationship with grief.

SHAME 36. Create a world about your upstairs brain vs. downstairs brain when experiencing shame. 37. Create a world about overcoming past humiliation. 38. Create a world where there is room for self-forgiveness.

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39. Create a world about a force stronger than shame. 40. Create a world exploring where your shame learned to be shame. 41. Create a world about forgiveness of self. 42. Create a world that separates forgiveness and trust.

FOCUSING ON INTEGRATION AND FUTURE POSSIBILITIES 43. Create a world of balanced involvement. 44. Create a world refecting on the experience of your adult self getting to know your child self. 45. Connect an object to a memory that inspires regulation. 46. Create a world of inspiration. 47. Create a world about your unfnished story. 48. Create a tray that is a blessing for the world. 49. Choose a fgure that represents change and build a world where it can belong. 50. Create a world about what your journey has taught you.

Appendix E Annotated Bibliography Below is a list of books we have found important and relevant to the writing of this book. We provide this annotated bibliography to help inform you of possible places to continue your professional development in some of the key areas addressed in earlier pages. While reading any of the books below, consider highlighting phrases that impact you; they could become future sandtray prompts for yourself or for a client. Enjoy!

THE WORLD TECHNIQUE AND SANDTRAY THERAPY Bowyer, R. (1970). The Lowenfeld World Technique: Studies in personality. Pergamon Press. A classic in the sandtray therapy feld. Ruth Bowyer completed this book with the encouragement of Margaret Lowenfeld. Bowyer follows the various iterations of the World Technique. For those history buffs this is full of details and information. Homeyer, L. E., & Sweeney, D. S. (2017). Sandtray therapy: A practical manual (3rd ed.). Routledge. Kindle Edition. Linda and Daniel have now brought us three editions of this impactful text. Clinicians all over the world have used this book to learn the basics of sandtray therapy. It is not only an immensely helpful read, but it will also become a frequent practical reference in your sandtray therapy work. Lowenfeld, M. (2008). Play in childhood. Sussex Academic Press. (First published in 1935 by Victor Gollanez; 1991 by Mac Keith Press.) Margaret provides us a wonderful insight into her development of understanding children. Details are given about how to observe children’s play, setting up the playroom including the World Technique, mentions of outdoor/garden play, and rhythm/movement. Many case examples are included. Lowenfeld, M. (n.d.). Understanding children’s sandplay: Lowenfeld’s World Technique. This has been published at various times with various publishers: 1979, George Allen & Unwin; 1999, Margaret Lowenfeld Trust; 229

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Cambridge University Press & Mac Keith Press, 1991; Science Editions, 1967. Written by Margaret Lowenfeld we have her account of her personal history which led to her development of the World Technique. The primary part of the book is case examples. Additional papers by Lowenfeld are available from the Dr. Margaret Lowenfeld Trust. You can read them at: www. Lowenfeld.org Rae, R. (2013). Sandtray: Playing to heal, recover, and grow. Rowman & Littlefeld. Grounded in treating sandtray as truly sacred, Roxanne Rae offers much practical advice for mindfully deepening sandtray work with clients. She understands Lowenfeld’s original purposes in creating this modality and takes those concepts further into right-hemisphere application without sacrifcing the best parts of the discipline already established. This is a great read for sandtray therapists of all levels.

OTHER TOPICS COVERED Attachment Badenoch, B. (2008). Being a brain-wise therapist: A practical guide to interpersonal neurobiology (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Bonnie’s book beautifully invites readers into a deep understanding of how attachment patterns, and their interaction with internal neurobiology, lead to the development of complex inner communities. Bonnie provides deeply relational guidance for working with these sometimes-complicated members of the inner community in relationally-sensitive ways. She has a chapter on how sand therapy fts with this approach that is truly phenomenal. Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. Basic Books. It is so important to read original sources from felds we follow whenever possible. This is one of Bowlby’s books where he articulates why he felt the tenets of attachment theory needed to be introduced, how his early observations developed into this unifed theory, and what the therapist’s attachment responsibilities are with clients. A sandtray therapist will be able to get a sense of their attachment-sensitive role from the originator’s own words.

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Brown, D. P., & Elliott, D. S. (2016). Attachment disturbances in adults: Treatment for comprehensive repair. W. W. Norton & Company. This book is weighty; it provides a comprehensive understanding of how different streams of attachment come to show up in a person’s relational patterns and how to effectively meet the needs of these different presentations. Due to the dense amount of important material, this book could be more easily digested if sandtray therapists read it as a group study and allowed space to create trays for integration’s sake. Cozolino, L. (2017). The neuroscience of psychotherapy: Healing the social brain (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Cozolino is a gem; he takes complex concepts and makes them approachable and relevant to the practice of therapy. In this book, he helps connect neuroscience to attachment theory to psychotherapy. It is critically helpful for sandtray therapists trying to integrate these areas into their practice. Holmes, J. (1993). John Bowlby and attachment theory. Psychology Press. Every once in a while, it helps to more deeply connect a therapist to their discipline if they read some history of their profession or a biography of a pioneer. This book brings John Bowlby’s personal story into contact with the development of attachment theory. The personal touches might help to bring concepts from theory more to life for the sandtray therapist. McGoldrick, M., Gerson, R., & Petry, S. S. (2008). Genograms: Assessment and intervention. W. W. Norton & Company. Genograms were referenced a few times throughout this book, so we wanted to offer you a resource for going deeper with this valuable therapeutic tool. There are so many possibilities for enlarging healing potential by accessing intergenerational aspects of families. This book might be the pre-eminent text on understanding use of the genogram. And they work wonderfully in the sand! Mellenthin, C. (2019). Attachment centered play therapy. Routledge. Mellenthin contributes a much-needed text on how to welcome attachment theory into play therapy. For those sandtray therapists who might serve young children with play therapy, this is a must read. Many of the ideas are easily translatable to sandtray therapy.

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Tronick, E., & Gold, C. M. (2020). The power of discord: Why the ups and downs of relationships are the secret to building intimacy, resilience, and trust. Little, Brown Spark. From the originator of the Still Face Experiment, Ed Tronick, and co-author Monica Gold, bring a fresh take on what it takes to maintain relational and emotional health. The focus on supporting others to be able to better tolerate moments of discord, mismatch, and uncertainty will have direct payoffs for sandtray therapists as they hold space for unfolding worlds. Wallin, D. J. (2007). Attachment in psychotherapy. Guilford Press. Perhaps the most comprehensive book on walking through attachment theory history and arriving at helpful clinical implications, Wallin provides many key concepts that can unlock potential attachment healing. This book is a treasure trove for hunting possible wording for sandtray prompts that are attachment relevant.

Elders/Dementia Peters, S. (2020). Aging with agency: Building resilience, confronting challenges, and navigating eldercare. North Atlantic Books. Sandi Peters has years of work with elders and the use of sandplay therapy with them. Although this book does not have her wealth of sandplay information, it is full of information about working with elders, including application of Maslow’s and Eriksons’ work; gerotranscendence; and perspectives on memory loss.

Relational Neurosciences Cozolino, L. (2020). The pocket guide to neuroscience for clinicians (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. In this more science-heavy book from Cozolino, sandtray therapists will beneft from his casual use of metaphors that help explain complicated principles of neuroscience. Dana, D. A. (2018). The polyvagal theory in therapy: Engaging the rhythm of regulation (Norton series on Interpersonal Neurobiology). W. W. Norton & Company. As a senior therapist herself, Dana provides a practical explanation of how polyvagal theory will show up in counseling sessions, emphasizing methods for meeting well all nervous systems states that arise. Sandtray therapy even gets a couple of mentions as

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a helpful approach for incorporating into nervous system understanding for the client. Kestly, T. A. (2014). The interpersonal neurobiology of play: Brain-building interventions for emotional well-being. W. W. Norton & Company. This is a wonderfully concise book that weaves together various neurobiology authors’ information. It is an easy read for those who get overwhelmed with the more detailed parts-of-the-brain books. Very understandable and applicable. Every play therapy and sand therapist should have this on their bookshelves, and read, too! Teresa is also a well-respected sandtray therapist and trainer as well. McGilchrist, I. (2019). The master and his emissary: The divided brain and the making of the western world. Yale University Press. In Bonnie Badenoch’s book Being a Brain-wise Therapist: A Practical Guide to Interpersonal Neurobiology, she emphasizes the integrating nature of sandtray therapy as this modality welcomes both hemispheres of the brain into processing. This seminal text by McGilchrist will deepen the sandtray therapist’s understanding of the relationship between the right and left hemispheres. Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and selfregulation (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Another deep-dive book. For all you want to know about polyvagal theory and more! A wonderful in-depth seminal book. Schore, A. N. (2019). Right brain psychotherapy (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. As an expressive modality, sandtray therapy engages the right brain in a deeply felt manner. Allan Schore is masterful at bringing further understanding into why working with the right hemisphere is a necessity in therapy. Both deeply scientifc and incredibly applicable, the sandtray therapist will feel encouraged about their chosen professional practice. Siegel, D. J. (2012). Pocket guide to interpersonal neurobiology: An integrative handbook of the mind (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Dan Siegel has been a staple on therapist’s bookshelves for years. In this text, he walks through the science of his created branch

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of relational neuroscience that is interpersonal neurobiology. Focusing on the power of relationships in shaping brain development, Siegel’s work has much to say on achieving increased vertical integration in the mind. The sandtray therapist will fnd encouragement and support in hearing how supporting the refective capacity of clients can support healing of the mind.

Trauma Badenoch, B. (2017). The heart of trauma: Healing the embodied brain in the context of relationships (Norton Series on Interpersonal Neurobiology). W. W. Norton & Company. Bonnie returns to offer this game-changing text on how to invite embodied connection into trauma healing. As a practitioner of sand therapy herself, Bonnie knows the work we do and there are many gems in this text for the expressive therapist in particular. It is both fully acknowledging of the heartache of the work of trauma healing, while offering life-giving inspiration and encouragement. This is another great one to read with a group of other sandtray therapists. Gil, E. (2017). Posttraumatic play in children: What clinicians need to know. Guilford Press. Eliana has been a treasure in the feld of family play and expressive therapies for many years. This work, informed by a nuanced understanding of trauma theory, and years of experience, helps practitioners recognize patterns in trauma play so as to determine if a child’s play patterns are facilitating trauma healing or intensifying the trauma memory in problematic ways. Full of case examples and pragmatic advice, this book is a staple in the feld. Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. Guilford Press. Cathy Malchiodi has been a leading contributor in the expressive arts therapy feld for many years; this recent book speaks eloquently to the needs of trauma survivors and the many ways expressive arts therapists can hold supportive space for their healing. Offering much to readers about the neurobiology of trauma and how expressive arts work can positively impact a traumatized nervous system, this book provides the therapeutic community with a powerfully pragmatic resource. Terr, L. (1990). Too scared to cry. Basic Books. A classic in the feld of child trauma. Terr follows the lives of the children of Chowchilla who had been kidnapped, buried alive

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in the school bus, and ultimately rescued. Her insights of about trauma continue to inform our feld. It’s an interesting read for anyone focusing on trauma in children, or those adults traumatized at children. Van der Kolk, B. A. (2015). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin Books. Quite simply, this is a must read. Van der Kolk brings so much awareness to how trauma is stored in the body and how to sensitively work with it. Sandtray therapy is such a somatosensory approach that the wisdom in this book will help highlight the potential and responsibilities in harnessing such a tool.

Person-of-the-Therapist Baldwin, M. (Ed.). (2013). The use of self in therapy. Routledge. With so much focus on the person-of-the-therapist in this book, we wanted to offer you something that might allow your exploration of the use of the therapeutic self to go further. Baldwin has brought together a variety of voices on the subject to offer a wellrounded view on the ways therapists may bring elements of who they are into the therapy room.

Index Page numbers in italics refer to fgures. Page numbers in bold refer to tables. abused and neglected children 6, 22–24; counseling 23; medical trauma 23–24; nonverbal aspects 23; protracted sexual abuse 23–24; psyche 23; qualitative design 23; verbal and nonverbal communication 23 academic resilience and success 185 adaptations 62, 178–179 ADHD (attention defcit hyperactivity disorder) 116 Adler, A. 6, 60 Adlerian therapists 33 adolescent with anxiety: Adlerian theory 68, 68, 69; Satir method 71, 71, 72; Solution-Focused therapy 69–70, 70, 70 Adult Attachment Interview (AAI) 140 adult with childhood trauma: Adlerian theory 72–74, 73, 73; Satir method 75–77, 76, 76; SolutionFocused theory 74, 74–75, 75 Adverse Childhood Experiences (ACE) 179 Adverse Childhood Experiences Study (ACES) 157–158 adversity 21, 178–179, 182 affliation 20, 187 age-related cognitive decline 115 aggressive vs. non-aggressive items 51 Ainsworth, M. 136 Akimoto, M. 25–26 Al-Jamie, L. 23 Alzheimer’s Disease 119 Amatruda, K. 42, 112 American Psychological Association (APA) 178 Ammann, R. 31 amygdala 27, 159 anti-racism practices 99 anxiety 8, 37, 116, 179–180 anxiously attached clients 137–138 anxious/preoccupied caregiving experiences 137 Aponte, H. 87 apparatus 5, 31 Appell, E. 174 Arabic language 50–51 Arab-Jewish dyads 129 artifcially colored sands 40 art therapist 20 attachment-sensitive therapy 138–139, 143 attachment theory 133; aware sandtray therapist 146; behaviour feature 136; concepts 134–143, 219; disruptions 112; focused play therapy 147; insecure 137; mentalization/refective functioning 150–151; narrative coherence 149–150; repairing experiences 148; safe haven 147–149; sandtray therapy and 143–151; secure base 145–147; sensitive sandtray therapists 139, 141, 144; woundedness themes 219; wounds heal 150 attuned sandtray therapists 181 autism spectrum disorder (ASD) 27–29, 202–204

autobiographical memory retrieval 25 autonomic nervous system 160, 173 awareness 101 Ayres, K. 24–25 back drops 51–52, 52 Badenoch, B. 36–37, 42, 51, 138, 140, 151, 161, 174, 210 behaviors connected to caregiving experiences 138–139 Bergosh, J. 38–39, 200-201 biographical refectivity 122–123 black sand 32, 40, 197–198 blue sand 198 Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, The 159 Boik, B. L. 37 Bolgar, H. 7 bonding 120, 135 Bowen, M. 86–87 Bowlby, J. 6, 134–136, 139 Bowyer, L. R. 8, 183 Bratt, H. 7 British Typhoid Unit 4 Broadwater, A. 21–22 Brown, D. P. 148 Buhler, C. 6, 183 Burr, J. 32, 40, 197-199 Cambra, B. K. 21 CARE 66 career counselors 44 caregiver: availability 135; child dynamics 135; nannies 134–135; nurturing 179; secure 137 Carey, L. 11, 174 cerebral blood fow 25 Charcot, J. M. 156 childhood: abuse and neglect 112; trauma themes 8 Child-Parent Relationship Therapy (CPRT) 113 Child Protective Services 4 child centered approach, semi-structured 28 children: abused and neglected 22–24; child-centered theory 61; cognitions 149–150; counseling 23; development and child psychology 4–5; medical trauma 23–24; natural protective systems 177; nonverbal aspects 23; protracted sexual abuse 23–24; psyche 23; qualitative design 23; verbal and nonverbal communication 23 Cleveland, J. 18 clinical theory 57–62; adaptations 62; child-centered theory 61; concepts 43; dialectical behavior therapy (DBT) 61; integrative play therapy 61; Kosanke’s Sandtray Therapy Model 58; mental health professionals 58–59; personal belief system 59; personality and counseling theories 58; questions categories 59; treatment plans 66–67

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co-consciousness 149 co-constructed meaning-making 172 cognitive distortions 53 cognitive skills 72 Cohen’s effect size 21 colored sand 40 communication 28, 149, 163 compassion 92, 103, 106, 149 complexity 89, 137, 143, 162, 167, 177 confusion 100, 147, 161, 167, 185, 220 connection 120–121, 149 consciousness 46, 143 containment 170 cooperation 25–26, 149 coping skills 69–70 core protective systems 179 counselors, trauma and neuroscience 158–159 countertransference 86, 89 couple sandtray 198 Cozolino, L. 63, 159 creation in sandtray 101–102, 167–168, 217 creator 91–92, 101–104, 146 criterion-related validity 184 critical refectivity 122–123 cross-cultural projects 8 cross-cultural setting 24 crunchy texture sand 37–38 culture/cultural: and anti-oppressive practices 99; application, proactive in 99; aspects in the children’s sandtrays 23; differences 51; humility in sand work 98–99 Cunningham, C. 23 Dana, D. A. 172–173 DBT see dialectical behavior therapy (DBT) De Domenico, G. 10, 32, 42 default mode network (DMN) 25, 120 dementia 119, 121, 122; stages, early 120; fnal 121 dementia, sandtray with elder 208 depression 179–180 De Shazer, S. 60 developmental skills in communication 28 dialectical behavior therapy (DBT) 61 dialogic styles 138 directive vs. nondirective approaches 60 disorganized inner world 137 documentation 103–104, 170–171, 218 Dramatic Productions Test 8 dual attention 91 Dunn-Fierstein, P. 46 dysregulation 68, 78–79 Ebersohn, L. 184 educational psychology 184 ego integrity vs. despair 115 elders, compromised 119 Elliott, D. S. 148 Ellis, A. 60 emotion/emotional 186; attribution 117; and behavioral symptoms 21; capacity 113; conditions of childhood 4; interaction 28; problems 127; relationship, child and therapist 89; and spiritual development 123; wellbeing 22

Index

Emotional Release Counselling (ERC) 10 emptiness 121 Epston, D. 60 Erica Method 7 Erikson, E. 112 Erikson, J. 115 Erikson’s psychosocial stages 112–115; adolescents 114; elementary students 114; late adulthood 115; middle adulthood 115; middle schoolers 114; preschoolers 113–114; Stage 9 115; young adulthood 115 European Student Relief project 4 European War of 1914–1918 4 Ewing, C. 11 exercises for sandtray witness 223–224 experiences: community and parental transmission of 20; intergenerational relational 181 expressive modality 144 expressive therapies, effectiveness 21 Eye Movement Desensitization and Reprocessing (EMDR) 158 faith and cultural processes 179 Fall, K. 59 family: 114; system therapists 43; therapy 11 family constellations 43, 114 fear 66, 226 feelings 138–139; alone and disconnected 75; of safety 19; unsafe 164 Ferenczi, S, 156 fgures of mystery 45 fliation 20 Fill, K. 23 fnal-stage dementia 121 fner grits 37 Fischer, L. 7 Floor Games 5 Foo, M. 26–27 Fordham, M. 9 Fosha, D. 182 Fountain, Y. 98–99 free and open space 91 free and protected feeling 89 Freedle, L. 27, 63 Freud, A. 5–6 Freud, S. 58, 156 Friedman, H. 183 frosted quartz crystals 38 GAD-7 26–27 garnet crystal sand 38 Gaza War 129 Generalized Anxiety Disorder (GAD) 26 generativity vs. stagnation 115 Genogram BlocksTM 43, 54, 188, 188 genograms 188 gerotranscendence 115 Gestalt application of sandtray 121 Gestalt sandtray therapist 43, 102 Gil, E. 11, 92, 161, 171–172, 205-206 Glasse, C. 63, 125–127 glass sand 38 global advocacy 18

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Gold, C. 181 Gomez, A. 145 Goodwin, A. 37 grain size, sand 38 Grant, R. J. 39, 118–119, 202–204 Greatness Cards 188, 189 Greatness Sticks 188, 189 Green, E. J. 149 grief 66, 226 group sand therapy 186 Gwata, N. 129, 180

Isaacs, S. 6 Ismail, M. R. 23

Hamilton-Anxiety Rating Scale (HAMA) 26–27 Hanson, R. 187 Harding, G. 7 Harding’s Erica Method 49 Hart, L 185 Hebrew language 50–51 Herman, J. 157; language on phased trauma healing 164; trauma theory 157 Herrman, H. 178–179 Higgins-Klein, D. 11, 174 history 3–13 Hollander, T. V. 54, 187 Holmes, J. 141 Homburger, E. 7 Homeyer, L. E. 7, 99–100, 143–144 Hood-Williams, J. 10 hopelessness 137 host society institutions 20 Humanistic Sandtray Therapy 11 humanity 187 Huntington’s Disease 119 hypervigilance 137 hysteria 155–156

Kaiser Health Plan 157–158 Kalff, D. 9, 42, 67, 89–91 Kalffan-Jungian Sandplay method 13 Kalffan Sandplay Therapy 13, 17, 46, 63 Kardiner, A. 156–157 Karen, R. 134 Kasa, L. 11 Katz, A. 129 Kensington Fire Service 6 Kestly, T. A. 33, 144, 150, 181–182 Klein, M. 5–6 Kosanke, G. 57, 163 Kosanke’s Sandtray Therapy Model 58, 163 Kottman, T. 11 Kronick, R. 18

Ideal Parent Figure (IPF) 148 identify vs. role diffusion tasks 114 imaginational overexcitability 117 individual sandplay sessions 186–187 industry vs. inferiority 114 inner guidance 89–90 inner psychic processes of individuation 9 insecurity, internalized 136–137 Inside Out (movie) 40 Institute for Child Psychology (ICP) 6 integrative play therapy 61 intellectual capability 135 intellectual curiosity 134 intellectual overexcitability 116 intentionality 100 internal cohesion 121 Internalized Working Model 137 Internal Working Model 136 international Sandplay societies 9 International Society of Sandplay Therapy (ISST) 9, 13, 26 Interpersonal Neurobiology 36–37 intimacy vs. isolation 115 intra and inter-personal issues 144 introduction to client, sandtray therapy session 100–101, 166–167, 217 introspection and humility, lifelong commitment to 99

Janet, P. 156 Jenewein, J. 180 Journal of Sandplay Therapy 14 judgment-free refections 146 Jung, C. 9 Jungian community 9 Jurassic Sands 37–38, 117 juvenile justice system 44

Lacroix, L. 20 Lai, V. T. 46 Latter-day Saints (LDS) 123 learning diffculties and skills 127 Lee, J. H. 179–180 Lew’s Body 119 life: satisfaction 179–180; tasks 43 lightning neuroses 155–156 Lin, Y.-W. 14–15 Little World Test 7 longitudinal developmental study 8 Lovett, J. 148 Lowenfeld, M. 9, 31, 37, 42, 67, 89–91, 134, 144, 177, 184; clinic 5; First Play Therapy Room 6; as medical doctor 4; in pediatrics 4–5 Lowenfeld World Technique: Studies in Personality, The 9 Lu, L. 28, 202 lust 66 magnetic resonance spectroscopy (MRS) 26 Main, M. 136 Malchiodi, C. 185–186 Marshall, N. 119, 188 Mascari, J. B. 101 Masten, A. 178 Matthews, J. 129 Mayes, C. 123 McGilchrist, I. 161 Mead, M. 6 meaning-making matrices 134 media exposure of trauma 20 medical trauma 23–24 medicine and psychoanalysis 135 medium effect size 180 Mejia, X. 187

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Melendez, M. 116 Mellenthin, C. 147 memory loss 120 mentalization 141; abilities 174; capacity 141; refective functioning 150–151 mental wellbeing 127 messy wet-work 41 metaphors 46; bilaterally-mediated process 47; clientcreated novel 48; conventionalization 47; symbols embedded in 48 military combat trauma 21–22; categories of themes 22; counselor educator 22; counselor practitioner 22; moral decisions 22; moral injury 22; posttraumatic stress disorder (PTSD) 22 mindfulness 187 miniature fgures 45, 121; clinical issues 44; guiding clinical theory 43–44; and images 42–51; organization and displaying 49–51; resources 214–215; symbols and metaphors 45–49; toys/ images/symbols 14; for various ages 44–45 misbehavior 77 misbeliefs 53 mistreatment 6 Mitchell, R. R. 183 monitoring beliefs 91 motor capacity, sandtray with elder 208 Mueck, B. 128 multiplicity of choices 42 mutual infuence 85 mystery 115 NAA/CR ratio 27 Narrative Sand Therapy© 11 narratives, inconsistencies in 151 Near-infrared Spectroscopy (NIRS) 25 needs and strengths 117 neural networks 159–160 neural plasticity 181 neurobiology 140 neurodivergence/neurodivergent 111–112, 116; individuals 118; kids 39; population 119 neurodiversity: Erikson’s psychosocial stages 112–115; neurotypical and neurodiverse groups 116–122, 218–219; neurotypical in non-clinical settings 122–130 neuro-integrative approach 21–22 neurological changes, sandtray therapy for those with 25–27 neuronal viability 27 neuroscience 179, 181–183 neurotransmitters 32 neurotypical people 111–112; autism spectrum disorder (ASD) 118–119; in business 128; concepts 218–219; dementia 119–122; in education, elementary and secondary school level 124–128; in education, university level 122–124; experiential sandtray workshop 129; gifted children and adolescents 116–117; and neurodiverse groups 116–122; in non-clinical settings 122–129; in social science research 129 Nin, A. 174 non-compromised elders 119

Index

nondirective presence of therapist 23 non-sand substitutes 39 nonverbal aspects, abused and neglected children 23 nonverbal communication 138, 144–145 Noyes, M. 125–127 nurturance 120 O’Brien, P. 202 obstacles and strengths 123 optimism 179–180 over-excitability, mimics pathology 116 paid consultation 99 Panksepp, J. 66 parent–offspring interaction 139 parents’ role, secure attachment 139 Parker, N. 202 Parkinson’s Disease 119 Parnell, L. 147 past experiences, creative adjustments 151 patient, distress of 139 Pearson, M. 10, 28 perception and verbal comprehension 127 Perls, F. 60 Perry, B. 62–63, 159 Perryman, K. 21–22 personal belief system 59 personal communication 51, 116 personal emotional vulnerabilities 88 personality: and counseling theories 58; sandtray with elder 208; trait 178 personal self 87 person-of-the-sandtray-therapist (POST) 91–93, 190–191, 225 person-of-the-therapist concept 206; attachment theory 93; cultural humility in sand work 98–99; Lowenfeld and Kalff information 89–91; Marshall’s journey 93–98, 94–97; neuroception 93; origin 86–89; resourcing 225; sandtray therapy session protocol 99–104; self and metacognitive monitoring 226; self-awareness 88; signature themes 87–88; thrust 87 person-of-the-sandtray-therapist (POST) 91–93 person-of-the-therapist training model (POTT) 87 person, individual capacities of 179 Peters, S. 119–120, 207–209 Petruk, L. 183 photographic symbols 51 physical injury 155 Piaget, J. 6, 63 Pickford, R. 42 PLAY 66 Play-Based Interventions for Autism Spectrum Disorder 203 playing 91 play therapy 4, 14–15 polyvagal theory 160 Popejoy, E. K. 21–22 Porges, S. 63, 160 positive affect, resilience 179–180 POST see person-of-the-sandtray-therapist (POST)

Index

post-creation, sandtray therapy session 102, 168–169, 218 POTT see person-of-the-therapist training model (POTT) pre-adolescent adoptee: Adlerian theory 77–78, 78, 78; Satir method 80–82, 81, 81; Solution-Focused theory 78–80, 79, 80 Preston-Dillon, D. 11 pretend play time 118, 203 primary sensory cortices 27 Prisoner of War Departments 4 Privitera, A. J. 184 problem-solving and interaction 101 professional genograms 190–191 protracted sexual abuse 23–24 psyche 23; abused and neglected children 23; active function 46 psychiatric disorders, resilience 180 psychoanalysis/psychoanalytic 86; contemporaries 5; theory 89 psychodynamic therapists 121 psychoeducational role 202 psychological and social interactions 112 psychology 178 psychosocial human development theory 8 psychosocial stages 113 Psychosocial Stages of Development 112 psychotherapy 6, 133, 140, 142; expressive and projective mode 143–144; intervention 126 PTSD, resilience 180 publications 3 Rae, R. 90–92 RAGE 66 Ray, D. 14–15 reading tactile metaphors 46–47 real-time short sandplay session 25 refective functioning 141–142 refugees and immigrants 18–21; art therapist 20; Cohen’s effect size 21; community and parental transmission of experiences 20; emotional and behavioral symptoms 21; expressive therapies, effectiveness 21; feeling of safety 19; host society institutions 20; media exposure of trauma 20; qualitative methodology 19; secondary traumatic stress 20; Strengths and Diffculties Questionnaire (SDQ) 21; structure codes 19; Thematic Apperception Test (TAT) 19; thinking and feeling 19; vicarious trauma 20 regional mental health services agency 128 relational and cognitive areas 62–63 relational neuroscience 140, 181 representational model, internalized 136 resilience/resiliency: capacities 185–190; in children’s sandtrays 23; in China 183–184; concepts 221; defning 178–179; neuroscience and 181–183; person-of-the-sandtray therapist and 190–191; protective resources 221–222; research on 179–181; sand tray use to identify 183–185; skills 23; in South Africa 184–185; in United States 185 resources 44, 213–216 Richardson, S. 149

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River Bed Sand® 37 Rogers, C. 60 room preparation, sandtray therapy session 100, 166, 217 round trays 33 Rousseau, C. 18, 21 Rubin, J 174 Rubin, L. 92 Rural Health Information Hub (2020) 122 Russo-Polish War 4 Ryce-Menuhin, J. 42 safe haven moments 147–149 sand 36–41, 38, 197–199; characteristics 200–201; colors 39–40, 201; constructive use 36; dye and paint 201; landscapes 51, 52; neurobiological benefts 36–37; non-sand substitutes 39; purity 200–201; resources 214; texture and grain size 200; therapist’s guiding clinical theory 43; therapy 13; types 37–39; working sandless 40–41; worlds, internal working model 150–151 sandpaper grit 37 Sandplay Room 10 Sandplay Therapists of America (STA) 13 sandplay therapy 13–14; brain research 26; kinesthetic aspects of 23; lens, indicators 183–184; sessions, Mexican farmworker women 186–187; trainees 91 Sandplay: The Sacred Healing 112 SandStory Therapy® 11 sand therapy movement 7 sand therapy treatment, developmental and theories 62–66; brain, sub-cortical regions 66; child development 62; cognitive development 63; emotional feelings 66; neurodiverse brain development 63; neurons and genes 63; Neurosequential Model of Therapeutics (NMT) 62–63, 64; parasympathetic nervous system (PNS) 63–64; Piaget’s Cognitive Development Levels 65; Polyvagal Theory 63–64; Window of Tolerance (WOT) 64–66 sand tray 7, 14, 31–34, 34, 197; attachment in 210; back drops 51–52; cleanup 102–103, 169–170, 218; counseling 14; miniature fgures and images 42–51; with or without a ledge 35, 35–36; play therapy 14; resources 213; sand 36–41; sky hooks 52–54; therapists 100, 146; therapistsand tray creator relationship 189; tray placement 34–35; water 41 Sand Tray Technique 126 Sand Tray Test of Resilience (STR) 183 sandtray therapy 14; adaptations for elders 207–209; attachment in 210; creation in sandtray 101–102, 167–168, 217; defnition 143–144; documentation 103–104, 170–171, 218; introduction to client 100–101, 166–167, 217; post-creation 102, 168–169, 218; room preparation 100, 166, 217; sand tray cleanup 102–103, 169–170, 218; session protocol 217–218; with victims and offenders 198–199 Sandtray Therapy: A Practical Manual 7, 17 Sandtray-Worldtray Therapy (ST-WP) 10 Sandwork and Emotional Processing 22

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Satir, V. 60, 86–87 scaling 44 Schoeneberg, C. 14–15 Schore, A. 85, 105, 161 secure–autonomous clients’ talk 137 Seigel, D. 64–65 Seiler, A. 180 self 86; -actualization 185; -awareness 43, 45, 54, 92, 124; -care 86; -compassion 187; -effcacy 179–180; -empathy 172; -esteem 179–180; -exploration 54; -fulflling prophecy 96–97; -image 127; -judgment 191; -kindness 187; -protective autonomic nervous system 160; -protective internal mechanisms 144; -regulation 62–63; -talk 53 Self Compassion Container exercise 187 semi-structured sandplay activity 28 sensory/sensual matters: exploration 28; integration 62–63; motor activations 46; overexcitability 116–117; sensorimotor processing interventions 186 sexual abuse 23 sexual trauma in children 156 shame 226–227 shell shock 155–156 Siawpani, K. 121–122 Siegel, D. 160 Silent Reverie 101 silver sand 40 Simons, N. 187 Simpson, P. H. 112 Singh, P. 129 sky hooks 52–54 Slade, A. 141 social care and play systems 66 social controls 119 social engagement ability 113 social interactions 28, 202 social interest 43 socialization 28 social justice 114 social science research, neurotypical in non-clinical settings 129 social support 179–180 soldier’s heart 156 solution-focused therapists 44 Somatic Experiencing (SE) 158 somatosensory-based treatment approaches 160 soul garden 31 Southwick, S. M. 177, 178, 182 Sparkly White Jurassic StarDust Therapy Sand® 38 spirituality/spiritual 123, 185; fgures 45, 115; paths 123; refectivity 123 square trays 33 Stauffer, S. D. 18, 173 Steinhardt, L. 32 Stone, J. 11 strengths 69–70, 177, 187 Strengths and Diffculties Questionnaire (SDQ) 21 stress 179 structural family therapy model 87 structurally induced trauma with intergenerational or historical trauma 24–25

Index

structure codes 19 successes 44 suicidal ideation 74 Sweeney, D. 7, 99–100, 143–144 symbolic elaboration 28 symbolic play 28, 118, 203 Symbolic Play Time 118 symptomatic behavior 71 taste metaphors 47 temporal area and inferior frontal gyrus (IFG) 25 Terr, L. 157 terror, internalized 157 thalamo-limbic neural pathways 27 thalamus 27 Thematic Apperception Test (TAT) 19 therapeutic skill 138 thoughts 138–139 Too Scared to Cry (1990) 157 Toy World Test 7 traditional talk-listen therapy 150 transference 89 trauma 112; approaches 89–90; clinical care 155; clinician 163; concepts 155, 219–220; defnition 155, 157; healing 160, 164, 205–206; history of 155–158; informed neuroscience 159; intergenerational or historical 24–25; knowledgeable sandtray therapists 173–174; neuroscience and 158–162; neuroses 156–157; pain-captive memory networks 162; response to 161–162; sandtray therapist 170; sandtray therapy 162–165; sandtray therapy session protocol 165–171; stress 20; themes as seen in sandtray 220; theory, history of 155–158; treatment 33, 171–174 Trauma and Recovery 157 Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) 158 tray: organization 114; placement 34–35; see also sand tray Triphasic Model of Healing 164–165; reconnection 165; remembrance and mourning 165; safety 164–165 Tronick, E. 181 Turner, B. 23, 50, 125–126 Turner, R. 14–15 unconscious mental models, patient’s awareness 141 unconscious thoughts and feelings 138 Unnsteinsdottir, K. 125–127 Van der Kolk, B. 159 vascular dementia 119 verbalization/verbal 119; communication 172; discussion 120; emotional processing 22; expression 28; and nonverbal communication, abused and neglected children 23; nonverbal level of interaction 47 vicarious trauma 20 video behavior of sandplayer 25 Virtual Sandtray App® © (VSA) 11, 12 visual ability, sandtray with elder 208 vulnerability and healing power 91

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Index

Walker, N. 111 Wallin, D. 139 Wang, D. 184 water 41 Webber, J. M. 101 Well, H. G. 5 Wesselmann, D. 148 White, M. 60 Wiersma, J. K. 17 Wilson, F. 125 Wilson, H. 10, 28 Winnicott, D. 6

witnesses 91 Wonder Box 5 Wonder Box 5–13 world arrangement 50 World Association for Sand Therapy Professionals (WASTP) 15 World Technique 5–7, 13 World Test 7 wound 138, 141, 150, 155 Zaleski, K. L. 164