Sandplay therapy for OCD

At the Integrative Centre for OCD Therapy we are integrative in our approach, meaning we integrate two or more therapies together. Our core therapies across our therapists are Exposure and Response Prevention therapy (ERP), often being called the gold standard of OCD treatment, and Acceptance and Commitment Therapy (ACT). Our therapists then bring in their own wealth of trainings and expertise along side these two core therapies for OCD treatment. One therapy in particular I bring in with some of my child and adolescent clients with OCD is Sandplay therapy. Please note, Sandplay therapy is also used with adults - although currently no one at our centre working with adults uses it.

I will explain Sandplay in more detail including what it is, and how it may be helpful for children and adolescents dealing with OCD. But in short, here are the benefits I see in my practice:  

• For younger children it can be calming, as playing with the sand is sensory.

• Sandplay does not require speech, so for younger children it takes some of the pressure off.

• It allows for the unknown to be shown through the use of symbols in the sandtray.

• It allows for the scary or shameful thoughts and feelings to be displayed.

• It opens up a lot of discussion.

Please read on for my explanation of these points.

“The world of pretend play is one in which children can be free to express themselves, their ideas, their emotions, and their fantastic visions of themselves, of other people, and of the world.” - Dr Sandra Russ (Psychologist)

A brief introduction to Sandplay: What is it?

Sandplay is a therapy rooted in Jungian depth psychology, and created by Dora Kalff. Sandplay is a non-verbal, hands-on therapy where the child, adolescent or adult selects symbols (or miniatures) using their intuition and puts them in the sand where ever feels appropriate or most potent. The child does not need to have a plan, or idea, the goal is to go with the flow of the process. It does not need to make sense. As the child plays in the sand the belief is that unconscious processes are revealed through the symbols (or figures). As they create worlds in the sand across sessions they are playing out their inner worlds, making sense of them, and putting them in order or healing something. Sandplay figures are called symbols because they represent and symbolise things that have been viewed this way across many cultures and across many years. For example, a castle may symbolise safety or imprisonment, an owl could symbolise wisdom, intelligence or protection, a shark may symbolise honesty and destruction, and a wizard may symbolise truth and intuition. The key role of the therapist is to provide a free and protected space for the young person to explore their psyche in the sandtray. Although the process of Sandplay is non-verbal, once the tray is created I will explore with the young person what is in the tray, and aim to make sense of it. However, if no sense is made that is ok. What is revealed in the sand may not be ready to be understood.

 “Often the hands will solve a mystery that the intellect has struggled with in vain.” - Carl Jung

Sandplay for OCD: Research

I only found one study with several participants in it (n=3). I found one other study, published in Japan I believe. Due to language barriers I was unable to read this paper, however it appeared to involve only one participant.

The main study (Matta & Ramos, 2020) I found did weekly therapy with 3 children aged 6-8 years of age. The therapy lasted between 2 years and 3 months, to 3 years and 2 months. The 3 children rated on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS – the main scale for measuring OCD severity) as 1 moderate and 2 severe cases. At the end of the study all 3 children were subclinical on the scale, meaning they no longer met the criteria for OCD. However, in a semi structured interview with the parents, the parents still reported noticing obsessions and compulsions. The study also highlights some key changes in the themes showing up in the sand trays from the beginning to the end which could be interpreted as improvements. A criticism of this study is that they used the Y-BOCS which is the adult version of the measure, when they should have used the Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) which was adapted for children. They did not measure progress throughout the study which would have been helpful. The main practical issue though is that it took 2-3 years to get subclinical. In this time many external factors could have been at play to help the children reduce their symptoms. But all that being said, it’s an interesting study and it is great that these researchers conducted this research as it shows there may be some ability for Sandplay to reduce symptom severity for children with OCD.

The benefits and potential benefits I see

For younger children it can be calming, as playing with the sand is sensory.

Creating a world within the sand can be soothing, as the child runs their hands through the sand, and molds it how they wish. When working on OCD it can be upsetting and the content of thoughts can be challenging. The sensory play can help ground the child in their physical senses, and keep them out of their head. Which is less time ruminating, which is a compulsion. The grounding can also help them regulate their emotions if feeling overwhelmed.

Sandplay does not require speech, so for younger children it takes some of the pressure off.

For younger children, their verbal communication skills and rational thought is still developing. Sometimes making sense of cognitive principles in ERP may feel hard to understand. Now I do believe the psychoeducaiton of ERP in a child friendly way is very important, but introducing Sandplay can reduce the mental load of some sessions, and help them engage in play. A natural way children make sense of their worlds.

“Birds fly, fish swim, and children play.” ― Garry L. Landreth, Play Therapy: The Art of the Relationship

It allows for the unknown to be shown through the use of symbols in the sandtray.

Sometimes children, or anyone coming to therapy, may not have yet made the unconscious conscious. For example, not truly be able to formulate and make sense of their difficulties. Especially if they have gone on for a long time. Playing out in the sand can allow for meaning making to occur and making sense of difficulties in a contained way.

It allows for the scary or shameful thoughts and feelings to be displayed.

OCD can be very unsettling. The thoughts can be very scary to the child and if thoughts are taboo in nature they can bring a lot of shame. Sometimes children or young people don’t want to reveal their thoughts, or will hold back certain ones. The sand tray can offer a safer place to reveal these and understand them, without fear of judgement.

It opens up a lot of discussion.

The sand tray often opens up areas of discussion that had not previously been discussed during therapy. After the child or young person finishes creating in the tray, we discuss it. This can often bring up ideas and understandings that were previously unknown to themselves and me. These conversations can be fruitful, and where possible I look for someway to feed that into ERP or ACT, if applicable.

How this could be integrated into ERP?

The main way I currently use Sandplay with my clients is to allow them to explore what’s in their mind, and open up conversation about what’s in the tray. However, for some client’s selecting some of the symbols may itself be an exposure to a feared stimuli i.e. someone with a fear of harm, could select the skull, baseball bat, or ‘poisen’ to name a few. Someone with religious OCD can select from a range of God statues.

Sandplay is non-directive, with the clients mainly doing free trays which simply means they follow their senses or intuition when creating the tray, however when integrating we could give a prompt such as, create a tray around your OCD worries, or create a tray around ways of working on your OCD.

Once trays are discussed the post-conversation often brings up links to their OCD, or how they are feeling currently. This can offer ways of linking any learning back to the existing work around ERP or ACT.

Conclusion

This was an introduction to Sandplay and how it may add something to the already strong suite of therapies applicable to OCD. Does Sandplay need to be a part of therapy for OCD? Absolutely not, however it may be a nice addition bringing a different angle to therapy. In some way, Sandplay may offer a non-directive sensory way to explore the unknown, the unknown being a key factor in the uncertainty people with OCD experience. 

“It is in playing, and perhaps only in playing, that the child is free to be creative.” - Donald Woods Winnicott

Sandplay symbols at our office in Farnham