VISTAS articles are made available for historical reference only and are presented "as is." ACA does not guarantee or represent that the information is current, accurate or indicative of the original or intended quality. These materials are not maintained or updated and may contain outdated or incomplete information. Readers should exercise discretion and verify information independently before relying on it. We assume no responsibility for the use or interpretation of this content.

Article 13

Sand Play Therapy With U.S. Soldiers Diagnosed With PTSD and Their Families

Poppy K. Moon

Download PDF

“War! Huh! Good god ya’ll! What is it good for? Absolutely nothing!” Edwin Starr howls in his 1970s hit War. Unfortunately Starr stands to be corrected. War is good for one thing: giving hundreds of thousands of American soldiers PTSD. PTSD, or posttraumatic stress disorder, is a psychiatric disorder that results from experiencing or witnessing events that are extremely traumatic or life threatening. Soldiers in Iraq, who experience firsthand military combat and terrorist threats, are especially at risk for developing this disorder. According to a study published in the New England Journal of Medicine (Hoge et al., 2004), 15% to 17% of returning veterans are suffering from posttraumatic stress disorder. This means that literally thousands of American soldiers are returning to the United States with a serious mental disorder that not only affects the soldier, but his or her family system as well. Now more than ever, counselors need to educate themselves about PTSD treatment and be prepared to offer innovative individual and family therapy to military families. One treatment option that shows particular promise in the treatment of PTSD is sand tray therapy.

What Is PTSD?

Posttraumatic stress disorder is listed in the in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-R; American Psychiatric Association, 2000) as an emotional disorder that results from experiencing an event that elicits a severe stress reaction. Individuals suffering from PTSD relive the traumatic event(s) over and over in their minds, through nightmares and flashbacks. These thoughts can become so realistic and severe that the individual begins to dissociate, becomes estranged from friends and family members, and experiences reduced functioning in daily life. PTSD is comorbid with other illnesses, such as depression, physical and mental problems, and substance abuse. The family system is often disrupted due to relationship issues, marital problems, and parenting concerns.

PTSD is not a new disorder; it has affected people since the beginning of human civilization. Symptoms of PTSD have been recorded as early as 490 BCE by the Greek historian Herodotus in his writings on the battle of Marathon. Other historians noted similar symptoms among soldiers in Greek, Egyptian, and Roman wars (Bentley, 2005). PTSD is not a disorder that is only related to war. Any traumatic experience can cause PTSD. The diary of Samuel Pepys depicts the horror of the Great Fire of London in 1666. The townspeople were unable to put out the fire, save their possessions, or protect their homes. He wrote, “A most horrid, malicious, blood fire…so great was our fear….it was enough to put us out of our wits” (Bentley, 2005). Even though his home was not destroyed, Pepys reported feelings of anger, nightmares, and flashbacks for several months following the incident. Other historical accounts describe PTSD symptoms occurring after natural disasters, physical and sexual abuse, motor vehicle accidents and violent personal assault.

How PTSD Affects Soldiers and Their Families

Once the soldier returns home, there is a honeymoon period. This is a great time of joy when the family celebrates the return of their loved one. Once life settles back into its normal routine, the family may notice that the veteran is feeling and acting differently than he or she did before the deployment. These new ways of feeling and acting are directly related to the trauma of war. The veteran may notice that he or she is having problems with nightmares and sleeping, increased anxiety and panic, unwanted memories and distressing thoughts, irritability and anger, emotional numbing, and substance abuse. All of these symptoms indicate PTSD.

Bowen’s family systems theory (Kerr & Bowen, 1988) postulates that when one member of a family begins to change, the other members will be either positively or negatively affected. In the case of PTSD, these symptoms are often severe and can cause major disruptions to the family system. These disruptions occur as family members react to the veteran’s symptoms. Family members react in many different ways when a loved one is traumatized, such as sympathy, depression, fear and worry, avoidance, guilt and shame, anger, negative feelings, drug and alcohol abuse, sleep problems, and health problems. Without proper intervention and treatment, the soldier’s personal trauma can end up traumatizing the entire family.

The family is the primary source of practical and emotional support for the returning soldier who is coping with internal PTSD stressors. The family can monitor the veteran’s emotional state, provide companionship and a sense of belonging. Family members can confront the veteran if he or she is showing signs of withdrawal, depression, or substance abuse. Families can also monitor each other to ensure that other members are not developing problematic reactions. If PTSD symptomology becomes apparent within the veteran or other family members, treatment is necessary to deal with these issues.

Treatment for PTSD

PTSD treatment usually begins with a detailed assessment of the veteran and his or her presenting problems. Families are encouraged to participate in treatment, especially if the family unit is being affected by PTSD symptoms. During the assessment phase, individual and family treatment plans are created by the therapist, the veteran, and the family. These treatment plans focus on educating the veteran and family about PTSD, teaching coping skills to deal with stress, anger, anxiety, and guilt; revisiting traumatic experiences (exposure therapy) in order to reduce fear; medication management (antidepressants, antianxiety); and other interventions specifically tailored to the family’s particular needs (Department of Veterans Affairs, n. d.).

Sand Play Therapy

Counselors who are working with soldiers and their families may find that talk therapy is not effective as a treatment method. This may be due to the fact that the horrors of war cannot be adequately expressed through words. Veterans and family members may find that they need more tangible ways to express their thoughts and emotions. Sand play therapy is a therapeutic tool that allows the client to create a three- dimensional picture in a sand box with toy miniatures. This method can be used with either children or adults and is done in the presence of a trained therapist (Sandplay Therapists of America, n. d.). The value of sand play therapy is that it allows clients to express themselves without speaking, thus creating an environment for healing.

Paul: A Case Study

Paul came to me for PTSD treatment following his return from Iraq. His fiancée urged him to seek treatment because he no longer could express affection or emotion. Our first four sessions were punctuated with long silences. Despite my best efforts our sessions seemed stagnant. Paul would discuss trivial issues; however, he seemed unable to go any deeper than the surface level. During one session I offered him the use of my sand tray and miniatures. The mood of the session changed instantly. He immediately began to touch the sand, feeling the texture and weight as it slipped through his fingers. Then he collected all my military figures and started to create several busy scenes. At the end of the session I asked him if he wanted to share with me anything about the tray. He pointed to a section of the tray where five children laid facedown in the sand, dead, unmoving under several army trucks. He said that these tiny bodies had been plowed over by American army supply trucks on a mission in Iraq. The children had been part of a human barrier preventing supplies from reaching our troops. Despite the fact that they were children, the orders were clear: “Deliver the goods at all costs.” He wiped a tear from his eye and looked at me across the sand tray. He stared at the image, strangely detached and unemotional. Through the sand tray, he was able to describe to me the horrors of war that he had previously unable to share with me verbally.

Several sessions followed. During each session he would work at the tray for most of the session. I would sit silently, observing him as he worked. We did not speak until the end of the sessions, when he would tell me about the various scenes. Some scenes he would not describe, perhaps because they were too painful. Even though he did not discuss these scenes, simply recreating them appeared to have the necessary therapeutic effect. Eventually Paul stopped using the tray. At this point in therapy he was able to vocalize his problems during the sessions. Had he not had the tray to express himself, I doubt that we would have moved forward in his treatment.

The Sand Play Method

Historically, the sand tray is a rectangular box approximately 28 x 19 x 3 (or 57 x 72 x 7 cm), painted or colored blue on the bottom and sides (Amatruda & Simpson, 1997). Traditional sand play uses two boxes, one for dry and one for wet sand. Wet sand seems to elicit more emotions and feelings than dry sand. When working with emotionally charged issues, such as war, therapists should choose dry sand until they are sure the client is ready to delve deeper into his or her psyche. Sand tray miniature collections include “everything that is in the world, everything that has been, and everything that can be” (Amatruda & Simpson, 1997, p. 8). The general collection to be used consists of several pieces from the following categories: animals, insects, birds, sea creatures, half- human/half-animal figures, reptiles and amphibians, monsters, eggs and food, fantasy figures, plants, rocks, shells and fossils, mountains, caves and volcanoes, buildings, barriers, vehicles, people, fighting figures, and spiritual figures. Figures can be purchased online (from Web sites such as www.sandplay-toys.com and www.e-archetypes.com).

According to Amatruda and Simpson (1997), the figures should be arranged per the organization in the chart below.

Sand play sessions are 50 to 60 minutes on length, with 35 to 40 minutes dedicated to creating the tray. The remaining time is spent discussing the tray, noting its meaning for the creator and recentering the client. After the client leaves the tray should be photographed. The photographs can later be revisited by the client and therapist and serve as a record of client progress. It is important that the therapist dismantle the tray after the client leaves. Most sand play therapists agree that the tray is a sacred creation that should never be destroyed by the creator. In not allowing the client to take their tray apart, it shows the client that his or her work is important and valued. When the figures are removed, they should be placed back in the exact same position on the shelves. This creates a semblance of permanence and safety in a constantly changing world.

Family Sand Play

The sand play method can be used individually or with an entire family. Photographs of individual trays can be brought to family therapy sessions and shared with other family members. During family sessions, individual members can create a tray with the entire family watching. If this is done, it is important that during the creation of the tray the other family members stay silent and supportive, even if they disagree, are disturbed, or are otherwise affected by the contents of the tray. The therapist should remind the family that the tray represents personal feelings that need to be dealt with in the session. Group trays can be created by the entire family. All members can work together to create a tray that is ripe with family meaning and symbolism.

Resources

Counselors who are interested in using the sand play method are encouraged to visit the Sandplay Therapists of America site (http://www.sandplay.org). There are many excellent books available on the subject of sand play. These include the following:

Amatruda, K., & Simpson, P. (1997). Sandplay, the sacred healing. Novato, CA: Trance Sand Dance.

Boik, B., & Goodwin, E. (1999). Sandplay therapy. New York: Norton.

Friedman, H., & Mitchell, R. (1994). Sandplay: Past, present, future. San Francisco: Routledge.

Turner, B. (2005). The handbook of sandplay therapy. Cloverdale, CA: Temenos Press.