Behavioral Health Types Of Therapy
Sand Tray Therapy
Sand tray therapy is a therapeutic intervention that uses sand, toy figures, and sometimes water to create a person’s inner world in miniature. Sand play is often nonverbal and is considered play therapy, although it is used in adjunct along with talk therapy. Sand Tray Therapy refers to the overarching use of sand trays in therapy, however, there are specific methods that have developed, such as Sandplay therapy which have more of a solid basis in theory.
Sand Tray Therapy development
Margaret Lowenfield first pioneered sand tray work in the 1920s, primarily using a method called the World technique, where clients build a safe ‘world’ which is assumed to represent their inner world. Through this creation, work on healing trauma and processing difficulties is completed.
Dora Klaff is the founder of andplay therapy. She modified Margaret Lowenfield’s work and combined multiple techniques and schools of thought to come up with sand tray therapy based on a Jungian model and an Eastern belief system. Jung is reported to have posited: “Often the hands know how to solve a riddle with which the intellect has wrestled in vain.” Sandplay therapy falls perfectly in line with this sentiment.
Sandplay was introduced in the United States and Europe and began with children, but as the therapy has evolved, it has grown to include adults. The International Society for Sandplay Therapy began in the 1980s with Klaff and experts from around the world with the goal of training therapists in Sandplay and promoting its therapeutic benefits.
Sand Tray Therapy setting and tools for sand tray work
Sandplay is deeply rooted in Jungian therapy, where symbols are the language of the psyche. The World Technique developed by Margaret Lowenfield is less based on symbols but has very similar requirements for settings and tools.
Either method of therapy occurs in the office with two trays filled with sand; one is dry, one is damp, and a myriad of miniatures can be placed in the trays to build the client’s world.
The client is encouraged to create their experience in the tray and have the abilities to express and proceed with the world in a way that bypasses the thinking brain and accesses the unconscious. Since a number of symbols, as well as a safe space, are provided, healing comes not only from the interpretation of the image but in the expression of the image itself.
It is important that the client feels safe and identifies the tray as a safe space to explore. At the same time, the sand is the grounding medium that allows for connection, and the miniatures are the representatives of the inner world brought to life in the world of the tray.
Who benefits from Sand Tray Therapy
While Sandplay was initially designed and developed with children in mind as a way to help in a nonverbally focused way, the process has proven to be beneficial for adults as well.
Sand tray work is especially helpful for young children who cannot express their feelings in words, but as any seasoned therapist can attest to, young children are not the only individuals who struggle with verbal expression. Teens and adults with trauma or suffering from the remnants of emotional abuse may not be confident in expressing themselves.
Additionally, sand work can benefit those with:
- Autism Spectrum Disorder
- Attention Deficit Disorders
- Learning difficulties, including expressive language disorder
- Depression or anxiety symptoms
Sand work can help develop a strong rapport between therapist and client and is a great way to encourage expression when something seems to be blocking it.
Sand therapy techniques
There are a few different techniques used by sand tray therapists based on different theories and perspectives of therapeutic work.
The World technique is the original process developed by Lowenfield. In this technique, clients are provided with dry and wet sand, toys, and tools to build their world with. The clients are encouraged to build a safe world using their imagination and subconscious mind. The therapist uses this to understand the processes going on in the client’s mind and work through trauma or other difficulties the client is experiencing.
Humanistic therapists see the client as individuals who have the capacity to use their own inner skills to develop. The emphasis is on the client as an individual in the process of self-actualization. This process emphasizes the client’s ability to discover and work through their own problems using creative play processes.
Sandplay is the process developed by Dr. Dora Kalff based on Jungian theory and eastern philosophical principles. Sandplay focuses on symbol expression and the process of creative expression using archetypes and the integration of the conscious and unconscious. Sandplay places an emphasis on freedom from emotional repression as an important component of growth.
Sand Tray Therapy effectiveness
Sand tray therapy works by helping the client to understand the connection between their inner world and what they have built in the sand. Additionally, by being encouraged to make changes in the world they create in the sand, individuals can find the confidence to make changes in the real world.
Sandplay has been studied and found to be effective in helping those with trauma process through and take control of their experience in order to move to a healthier concept of themselves with the trauma integrated.
Sandplay has also been shown to help reduce anxiety and behavioral problems. Sandplay has its own dedicated peer-reviewed journal, which has been presenting studies and cases for the past 31 years about the efficacy and various uses of Sandplay called the Journal of Sandplay Therapy.
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Downsides of Sand Tray Therapy
All therapies have limitations, and sand tray therapy is no different. Adults may be resistant to the idea of sand play therapy as they may think they aren’t creative enough, or they may incorrectly believe it to be something they are too ‘grown-up’ to do.
Additionally, sand tray therapy is grounded in theory and clinical evidence, but few studies have been conducted to validate the approach scientifically. The interpretation of symbols and scenes can also be ambiguous or vague.
Billing for Sand Tray Therapy
Sand tray therapy doesn’t currently have a specific CPT code for use. However, because sand play could be considered similar to other ‘tools’ that therapists use, like games, then most therapists bill under regular coding for psychotherapy 90837 for a 60-minute session, 90834- for a 45-minute session, and 90832 for a 30-minute session. Especially considering that sand tray therapy is often used in adjunct with more traditional talk therapy with older children or adults or other play therapies with children, this billing would be the most appropriate code for most therapists to use.
At the same time, others use code 90899 Other Psychiatric Services or Procedures - to report psychiatric services or procedures that do not have a specific code. In the notes, therapists should indicate information referring to specific art techniques used and the client's response to the treatment.
Some specific insurance companies do have their own billing codes to designate various modalities. Always consult information received upon credentialing with specific insurance boards for best billing practices.
Sand tray training for therapists
Sand tray therapy is used by many therapists because there are multiple different ways to utilize sand play in therapy, and there are multiple routes to receiving the training needed to become proficient in the process.
The first step is to be a licensed psychotherapist, which typically requires a minimum of a Master’s degree in psychology, social work, or counseling as well as the necessary work postgraduate school to attain licensure status. However, some therapists may train in and use sand tray therapy while still under supervision if their supervisor is amenable to the idea.
As a caveat, sand tray work may be completed in different settings by speech therapists, school counselors, and even teachers, but therapeutic work such as what is done in Sandplay requires a psychotherapy license.
Training varies widely, so it is important to identify first how you would like to use sand tray therapy in your practice. Continuing education courses offered through accredited providers may be sufficient if you wish to use a sand tray as an adjunct to play therapy or as a tool to help clients begin to open up. However, if you want to be recognized as a Sandplay therapist, then they have their own requirements and courses that you will need to take, which include gaining familiarity with Jungian therapy as well as training about symbols and the sand play process.
The International Society for Sandplay Therapy has a lot of information for therapists, including information about research, training, and resources. The ISST also has links to other associations based on country location for more localized resources in the international community.
The Sandplay Therapists of America offers training opportunities as well as a variety of helpful links and ways to learn about Sandplay. You can also look through their directory to find a therapist to work with
Another great resource for finding a therapist is the directory at Psychology Today where you can filter by your location and the type of therapy you would like to utilize.
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