A Case Report on Sandplay Therapy for a 3-Year-11-Month-Old Child with Post-Traumatic Stress Disorder ()
*Co-first author.
#Co-corresponding author.
1. Introduction
Post-traumatic stress disorder (PTSD) is a psychiatric disorder characterized by delayed and persistent mental disturbances resulting from sudden, threatening, or catastrophic life events [1] . PTSD in individuals after trauma is manifested by three main factors: hyperarousal symptoms, intrusive symptoms, and avoidance symptoms [2] . Children’s reactions to trauma often include fearfulness, sleep disturbances, lack of interest in academics, regression or behavioral problems such as fighting, physical symptoms like headaches and abdominal pain [3] . Previous studies have identified several common symptoms in children following disasters, including nightmares, fear of the dark, lack of a sense of safety, anxiety, deliberate avoidance of anything related to the disaster, sleep disturbances, hypersensitivity to sounds, and potential development of psychosomatic symptoms [4] . Research progress on childhood PTSD emphasizes the importance of early identification and intervention, utilizing a combination of psychological and pharmacological treatments, with a preference for psychological therapy [5] . Given the limited language expression abilities in young children, game therapies such as doll play, board games, sandplay, and collage therapy can be used to address childhood post-traumatic stress disorder [6] . Sandplay therapy is well-suited for children with post-traumatic stress disorder (PTSD) and has been shown to alleviate symptoms of post-traumatic stress disorder, ultimately leading to healing effects [7] . In this report, we present a case of sandplay therapy applied as a psychological intervention for a 3-year-11-month-old child with post-traumatic stress disorder, demonstrating positive treatment outcomes.
2. Case Report
The patient is a 3-year-11-month-old male who was crushed by a neighbor’s white car on his upper body two months ago. After receiving medical treatment for two months, his physical health recovered. However, psychological issues were observed, including timidity, reluctance to cross the road or touch toy cars, nightmares, clenching fists in fear during sleep, hiding behind his mother when encountering strangers, and limited speech. On November 30, 2020, the patient visited our clinical psychology department, where the symptoms were assessed according to the DSM-5 diagnostic criteria [8] . The child’s symptoms corresponded to those experienced by children with post-traumatic stress disorder following a disaster, including nightmares, fear of the dark, lack of a sense of safety, anxiety, deliberate avoidance of anything related to the disaster, and sleep disturbances. As the traumatic event had occurred over two months ago and the child’s symptoms persisted, a diagnosis of post-traumatic stress disorder was established.
Treatment Tools Sand Tray: One sand tray measuring 57 cm * 72 cm * 7 cm, with the inside coated in blue symbolizing water, filled with fine sand. Toys: Several toys representing people, animals, plants, buildings, etc. Camera: Used to photograph the sandplay creations made by the child. Record form: Documenting the characteristics of the creations (theme, arrangement of toys, spatial configuration, etc.) and content discussed during the sandplay sessions.
Treatment Procedure: The sandplay therapy process includes individual sand tray construction, experiencing the creations, dialogue about the creations, and dismantling the creations. The specific procedures are outlined in Table 1.
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Table 1. Sandplay therapy procedure.
Sandplay Therapy Process and Outcome: Establishing a good therapeutic relationship with the child’s family was the initial step, aimed at understanding the child’s current condition and history. Upon engaging with the child, efforts were made to establish a positive therapeutic relationship. Once the child was able to relax in the presence of the therapist, the therapist signaled for the child’s parents to sit quietly on the nearby couch. The child began arranging the sand tray during the subsequent session. Below is a description of the sand tray presented by the child during the first visit. During the first therapy session, the primary goal is to establish a good rapport with the child’s family and gain an understanding of the child’s current condition and history. When meeting the child, it is important to establish a positive therapeutic relationship. The specific process is as follows: First, communicate with the mother and ask the father to wait with the child in the waiting room. From the mother, you learn that the child was run over by a white car from the upper body two months ago. The physical injuries have healed through medical treatment, but there are psychological shadows. The child has become timid, afraid to cross the road or touch their toy car, and clenches their fists in fear at night while sleeping. They also exhibit fear and seek refuge behind the mother when encountering strangers, and they speak noticeably less than before.
Next, invite the father to bring the child into the counseling room. The child appears fearful and clings to the mother’s clothing, hiding behind her, with fear evident in their eyes. At this point, the therapist approaches the child, crouches down, and says, “Look, what is this? It’s called a sand tray. Have you ever played with sand before?” The mother leads the child to the sand tray while the therapist continues to crouch and says, “Come, use your little hands to touch the sand.” The therapist takes the visitor’s hand and walks towards the sand tray, pointing at the miniatures, saying, “Look! There are toys here, all kinds of toys. There are little people, animals, houses, flowers, trees, and various vehicles like cars, planes, and boats… Do you play with toys at home?” The child nods. The therapist continues, “Come, you can arrange these toys in the sand tray. You can arrange them however you want, just follow your own sense of safety. Create your world. It’s your world, and you’re in charge. How do you want to arrange them? It’s up to you. Okay? Let’s get started!” With the therapist’s presence and support, the child relaxes and starts arranging the sand tray. The therapist then signals for the child’s parents to sit on the nearby sofa and remain quiet. Throughout the child’s sandplay process, the therapist actively observes and assists, lifting the child when they cannot reach the miniatures, enabling them to access them comfortably. Figure 1 shows the sand tray arranged by the child during their first session.
One week later, the child attended therapy again with their mother. The mother reported significant progress over the past week. The child willingly crossed the road with their family and was no longer afraid of cars or toy car models. The child’s current state had largely returned to pre-trauma levels. Below is a description of the sand tray created by the child during the second session. Throughout the entire treatment process, the child was happy, relaxed, and no longer sought refuge behind their mother. The final element in the child’s sand tray was placing a tiger on the bridge, with fences on both sides. The police officer, originally on the bridge, was placed outside the fence. The child explained, “The police officer locked the tiger up with the fence on the bridge, but the police officer also got hurt. The fence keeps the tiger inside, preventing it from harming people anymore.” The child introduced their sand tray, saying, “On the left is the zoo, there are fruits here, and the little boy sitting on the chair can eat delicious food.” The child also placed a bed next to the police officer, stating, “The police officer can sleep on the bed when they are tired.” (Figure 2).
One week later, a follow-up was conducted. The child’s mother reported a complete recovery to the state prior to the car accident. The child’s nighttime sleep was sound, their temperament was cheerful, fear of transportation and related toy models was no longer present, and their interaction with strangers was positive, with a significant reduction in avoidance behaviors.
3. Discussion
Sandplay therapy integrates the essence of Jungian analytical psychology and Eastern philosophical culture, combining game elements with psychological counseling theories. For children, sandplay therapy is a natural form of expression. By arranging miniatures and shaping the sand within the confines of the sand tray, they create a world that corresponds to their inner state. Under the guidance of the therapist, they engage in full self-expression and exploration, thus achieving optimal growth and development. For young children with post-traumatic stress disorder (PTSD), sandplay therapy provides a space where they can freely express themselves and reshape traumatic events in their own way. They can release negative emotions, resolve internal conflicts, and deeply repair their personality structures. This awakening of the individual’s subconscious and somatic sensations helps alleviate and release symptoms of post-traumatic stress disorder, promoting the healthy development of the child’s personality.
This case demonstrates symptom improvement in a child with post-traumatic stress disorder (PTSD) through two sessions of sandplay therapy. The sand tray and toys used in sandplay therapy help individuals express unconscious content, increase self-awareness, and provide a symbolic and playful way to present and express themselves, thereby reducing psychological defenses and facilitating acceptance and transformation [9] . In the free, unrestricted, and harmonious therapeutic environment provided by sandplay, the child’s mind and body relax, allowing for the release of tension and anxiety, leading to the healing of post-traumatic stress disorder. As the sandplay therapy progresses, the child actively enhances their confidence, strength, and adaptability to the external environment [10] .
4. Conclusion
This successful case with only two sessions of sandplay therapy can be attributed to the following three factors. First, a good therapeutic relationship was established with the child and their family, creating an environment where the child felt relaxed, safe, and supported, enabling them to engage in therapy quickly. Second, due to the young age of the child and their relatively weak defense mechanisms, combined with their favorable physical and emotional development prior to the trauma, the child was able to easily express their emotions in the sandplay sessions. The child successfully released their emotional experiences related to cars during sandplay therapy. Third, the treatment was timely, as the traumatic event had occurred two months prior, and the child’s parents promptly noticed the child’s abnormal emotional and behavioral reactions after their physical recovery and sought timely treatment. This case report underscores the importance of timely identification and treatment of traumatic stress disorder, particularly in individuals with limited expressive abilities, especially young children. Early identification, intervention, and treatment for childhood traumatic stress disorder can lead to favorable treatment outcomes.