I remain an advocate for therapists to engage in their own therapeutic work. I am proffering this article here to further highlight why we need to dig deep within ourselves to better serve our clients. The bulk of this piece was initially published in the journal of the Association for Play Therapy (June 2019). I’ve made minor edits for clarity, and added more photos. I reiterate that both these vignettes present the work of highly trained and exceptionally qualified therapists. I remain grateful for their willingness to be vulnerable, and for their permission to share their journeys with you.
As play therapists we know the healing and transformative powers of play. Yet how often do we directly engage the tools for ourselves that we use routinely in our professional practice? The inherent nature of working with distressed people, particularly children and trauma victims, exposes therapists to vicarious traumatization or compassion fatigue, risking potential burn out. Miller states, “special stresses are attendant to working with traumatized children” (Miller, 1998, p. 250). The neurobiology of human connection indicates that “our nervous systems are constructed to be captured by the nervous systems of others, so that we can experience others as if from within their skin, as well as from within our own” (Stern, 2004, p.76, italics in original). From an attachment perspective, Schore (2003) asserted this mirrored connection functions therapeutically as a psychobiological regulator, because therapeutic communication from the right hemisphere of the brain “nonverbally communicates its unconscious states to other right brains that are tuned to receiving these communications” (Schore, 2003, p. 49, italics in original). Even when therapists believe that they are consciously addressing countertransference issues, unconscious material continues to be transmitted.
In the formation of this deep-rooted empathetic life-to-life bond, both the resources and the deficits of the therapist may manifest. As therapists intensively use their own lives in this manner, providing a safe container for clients, they face a fundamental risk to their ability to contain their own experiences. Symptoms of vicarious traumatization may include “sleep disturbance, … depression, confusion, fear, anxiety, irritability, anger, rage, or horror. Clinicians may become over-identified with or detached from their client” (Berthold, 2011, p. 50). Unaddressed therapist distress places clients in jeopardy. Accordingly, self-care is an ethical issue that requires vigilance and action on our part.
I encourage therapists’ use of the Sandtray method for self-care based on Margaret Lowenfeld’s pioneering play research. Lowenfeld’s (2012) research with children formed her belief that the sand tray functioned as a “cipher language” (p. 7) in which the therapist’s understanding of the client’s meaning of the objects arranged becomes essential to the therapist’s understanding of the core of the client’s life. Sandtray is multisensory, and evokes the vague, inchoate, and indescribable elements of life as well as those that are accessible. Sandtray offers a way to bypass a judging intellect to uncover authentic experience. This method provides three brain-changing factors enhancing neuroplasticity: “focused attention, …novelty, and emotional arousal” (Siegel, 2010, p. 84). Sandtray affords a way to identify, negotiate, and resolve intense reactions therapists may have in response to highly distressed clients. Therapists can use Sandtray to metabolize counter-transference reactions and to learn to recognize and enhance personal resources. Sandtray also offers the opportunity to explore and heal issues that arise from therapists’ own past experiences when they are evoked by clinical work.
Clients benefit from less-verbal and nonverbal work and therapists can gain from such modalities. For humans, the consensually agreed upon system of symbols that is language tends to be removed from our profound idiosyncratic experiences. By its very nature language tends to be inaccurate and falls short when we want to share a deeply individual viewpoint. The sand tray also communicates to the person who forms it, not just to the witness. Sandtray spans the gaps between an individual’s “unconscious,” or less actively accessible aspect of mind, and their more readily available “conscious” aspect of mind. Siegel’s interpersonal neurobiology research supports Lowenfeld’s 90-year-old view, and has particular relevance for therapists:
“We must keep in mind that only a part of memory can be translated into the language-based packets of information people use to tell their life stories to others. Learning to be open to many layers of communication is a fundamental part of getting to know another person’s life” (Siegel, 1999, p. 43).
The following vignettes illustrate how effective Lowenfeld’s Sandtray methods can be for therapists in processing their own personal unease. Both women are experienced therapists with previous sand tray training and an existing safe relationship with the author as consultant. Both trays were spontaneous and not directed. The information presented is from my session notes and photographs, not an interpretation.
Sara’s Story:
A busy mental health professional, Sara (pseudonym) requested a sand tray session because she was feeling somewhat overwhelmed by her work. She normally felt a rich satisfaction from providing trauma treatment. When Sara began to notice consistently less eagerness as she prepared for work, she accurately considered it a red flag and requested consultation.
Sara began by creating a hill-like form with sand in the center of her tray. On its top she placed a group of figures holding hands in a circle around a candle. She then stated: “The world is so crazy it needs some harmony.” Quickly she lit the candle (Figure 1).
Sara then placed items that she described as “abuse,” “torture,” “evil,” and “war.” Sara spoke of the impoverished state of humanity in today’s world. She referred to “evil atrocities in our world,” such as rape, the training of child soldiers, devastating natural disasters, and the rise of warlords in many regions. Sara spoke intermittently as she formed her sand tray (Figure 2).
Later in the session, Sara focused on the small, black, and hunched over devil as it crept towards the group of figures holding hands around their light. She characterized this devil as the “creeping…seeping of evil” towards her circle of “harmony and peace.” She then placed a broken red heart as a barrier between these two, pushed the heart into the sand, stating that the heart was so “tattered the evil is likely to get through” (Figure 3).
Sara eventually became able to recognize the connections between her globally-focused observations and her personal stressors. She also realized that she had become increasingly more over-sensitive and less modulated in her responses to her traumatized clients. Like the miniature group of people in the center of her sand world, Sara felt assaulted by evil and negativity. She said that she was “feeling overwhelmed” by the graphic and intense images of abuse that she dealt with in her psychotherapy practice with teens.
Her heart was “ragged and torn” in her attempts to hold onto her own “safe place,” while being present with her clients’ suffering. After summarizing this tray together, Sara acknowledged not only feeling bombarded by her everyday work world and the “big world,” but also by some personal family issues. This awareness was acknowledged between us and the focus turned to how Sara could nurture and strengthen herself.
As our processing continued, Sara placed the “Do Not Enter” and “Stop” signs in the tray. She moved the “Do Not Enter” sign toward the “devil’s path” and “other evils” as a way to protect her “harmony and peace” group (Figure 4). In the end, her peaceful circle conquered evil. Sara expressed a deeper commitment to strengthen herself to deal with her difficulties more effectively, creating a specific plan to do so.
Latika’s Story:
Latika (pseudonym) requested a consultation after she was notified of the shocking death of her infant client, Ian (pseudonym). She worked in an agency serving high-risk families with preschool age children and infants. Latika had just closed this case to transfer to a supervisory position. Ian and his mother had progressed well in their treatment.
Mother’s interactions with her son had become very responsive and she demonstrated good parenting skills. Latika expressed feeling a “delightful intimacy” working with this pair, and deep satisfaction in their excellent progress. She felt considerable grief for Ian, for his mother’s loss of him, and the end of their hope-filled future. Latika recognized that Ian’s death triggered memories from her own past losses. Her goals included maintaining professional yet compassionate boundaries with Ian’s mother, and managing her own sadness in the workplace. Latika expected that she may have to deal with some aspects of her childhood to resolve her distress.
On arrival Latika reported that she had not slept well since learning of Ian’s death. She stated that she was “emotional” all week and that her grief was “leaking out” at work. Latika struggled with the question, “How could I have made this not happen?” She was beginning to doubt her own professional abilities, just as she was taking on more responsibilities. Her fourth visit was after Ian’s memorial service and Latika’s own interview by the state’s child death investigator.
In the sand tray, Latika formed rock walls with the stone woman inside. Next, she set out a tiny baby on its back with a heavy, blue, round object on top of it (Ian was found on his back), and a police figure nearby (Figure 5). Then Sacajawea with her baby was placed, and the rock figure with its hand on its head. Next, she placed the woman with her hand on her head, the baby in the coffin, and the owl. Latika then placed some other babies, pushing many of them forcefully face down in the sand.
As her witness I shook with intense feeling, and I thought, “This is the death of her own childhood,” which gave me a hypothesis to use in a later aspect of the session. Subsequently, Latika placed the empty crib, the turned over cradle, and the open hand. Lastly, she placed a screaming woman (Figure 6).
Latika described the white block within the rock woman’s “hiding place” as a shower. She then blurted out, “I just keep taking showers, but it doesn’t help!” Later, Latika was able to make direct links between this mother’s bereavement, the loss of her own hope for them, and her own early deprivation (Figure 7).
Latika revealed that she was permanently separated from her birth mother when very young. She had an adoption disruption and was then placed in an abusive family where she grew up. Using the sand tray in front of her, Latika shared how the stone woman wants to hide in her world, and not face Ian’s death or her own loss of a joyful and receptive parent. Despite the two layers of walls (“to help keep feelings out”), and the shower (“to purify and wash away pain and grief”), the woman in the sand knows her losses. Latika began to weep openly. She expressed her grief for the “death of [her] own childhood.” In exploring the figure of Sacajawea holding her infant near the owl and the open hand, Latika began to connect to her capacity for self-compassion. She identified this group of miniatures as “my spirit guides,” (Figure 8).
During the subsequent four sessions, Latika formed a deeper self-compassion, consistent self-care, and managed her grief in a manner that did not interfere with her job. She increased her compassion for Ian’s mother, even prior to the release of the coroner’s report confirming SIDS as Ian’s cause of death. Latika became clearer about her authentic attachment to clients and how to have appropriate boundaries with them. Latika reported that her sand worlds better equipped her to serve her supervisees and future families by strengthening empathy and boundary-setting skills. She was no longer haunted by her sorrow and intense doubts about her professionalism. Latika shared a sense of healing when she reviewed her story for publication.
These vignettes reveal the power of Lowenfeld’s Sandtray method to aid therapists in resolving countertransference evoked by clinical work. Both therapists manifested unconscious aspects of their experiences that heightened their personal resources. Both women improved their professional functioning, thereby protecting their clients. Latika came to consultation with a specific triggering event. By contrast, Sara, came with only a vague sense of unease. Both therapists displayed a strong ethical commitment towards their clients and the willingness to face their own contributions to the disharmony they experienced. Sara changed her perspective and created a restorative plan after a single session. Latika suffered a sudden shock with ongoing triggering events, such as the memorial service and the legal investigation. Each therapist found Sandtray beneficial as both a reparative and a wellness practice to protect both themselves and their clients.
References:
Berthold, S. M. (2011). Vicarious trauma and resilience. CME Resource, 136, 44-87
Lowenfeld, M. (1993). Understanding children’s sandplay: Lowenfeld’s world technique. Cambridge, UK: Margaret Lowenfeld Trust.
Miller, L. (1998). Shocks to the system: psychotherapy of traumatic disability syndromes. New York: Norton.
Rae, R. (2013). Sandplay: playing to heal, recover, and grow. Maryland: Jason Aronson.
Schore, A. N. (2003). Affect regulation and repair of the self. New York: Norton
Siegel, D. (1999). The developing mind. New York: Guilford Press.
Siegel, D. (2010). Mindsight. New York: Bantam Books.
Stern, D. (2004). The present moment in psychotherapy and everyday life. New York: Norton.
