The effects of restricted group sandplay therapy on interpersonal issues of college students in China

The Arts in Psychotherapy 38 (2011) 281–289

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The Arts in Psychotherapy

The effects of restricted group sandplay therapy on interpersonal issues of college students in China Zhang Wen, Ph.D. a , Zhang Risheng, Ph.D. b,∗ , Darryl R. Haslam, Ph.D., LCSW, RPT c , Jiang Zhiling, M.D. b a b c

School of Children’s Development & Education, China Women’s University, Beijing, China Institute of Developmental Psychology, Beijing Normal University, Beijing, China School of Social Work, Missouri State University, Springfield, MO, United States

a r t i c l e

i n f o

Keywords: Restricted group sandplay therapy Interpersonal difficulties in college students Anxiety issues in adults

a b s t r a c t This study explored the outcomes of restricted group sandplay therapy (RGST) on college students in China with interpersonal difficulties and self image issues. The study involved nine students at a university in Beijing identified with social distress and avoidance issues who participated in an eight session group therapy intervention using the RGST approach. Participant outcomes were measured using both objective and subjective measures. Objective measure involved the Social Avoidance and Distress Scale (SAD) at pretest and posttest to measure the social avoidance and distress participants felt before and after the group. The subjective means involved examining the sandtray creations of the group each session to observe overall changes in the group’s attitudes and reactions toward each other; and by evaluating participants’ self image as reflected by their choice of sandtray miniatures to represent themselves at pretest and posttest.. The results suggested noticeable improvements in both participants’ SAD scores and self-image representations The group process also showed marked improvement in the amount of social awareness and coordination experienced by group members through the RGST intervention. Although the results must be regarded as tentative due to a low sample size and lack of regression statistical analyses, the group appeared to show promising findings for the use of the RGST in future social skills groups. © 2011 Elsevier Inc. All rights reserved.

In recent years, the frequency of cases involving college students’ behavior problems caused by psychological problems has increased (Wang, 2004). Researchers in China appear to have begun to pay increased attention to Chinese college students’ psychological health problems. A survey of 114 million national college students in China indicated that 17% of the students had different levels of mental disorders (Fan, Ma, Lin, & Wang, 2001). Many college students were also shown to have had deficits in interpersonal communication despite having a need to use it in fundamental ways in their daily lives. These deficits were noted to be mostly in the practice or implementation of sound communication (Wang, 2004). One researcher pointed out that mental health may be the main factor in social difficulties of college students (Li, 2002). As such, it appears there is a connection between social difficulties and the mental health of college students that needs to be studied further in research and addressed in psychotherapy. The existing scholarly literature on college students suggests that college students’ interpersonal issues can be expressed

∗ Corresponding author. E-mail addresses: [email protected] (W. Zhang), [email protected] (R. Zhang). 0197-4556/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2011.08.008

in different forms, including negative emotional distress, social behavioral avoidance, and lack of communicative competence (Li, 2002). Due to these findings, researchers have begun exploring therapies for improving interpersonal relationships of college students in China (Wang, 2004). Among this segment of young adults, group therapy has become a popular and effective therapy among them (Li, Liu, & Zhang, 2005). There are many types of focus for group therapy in terms of interpersonal issues, such as self development, social skills training, and role playing. These types of groups are mainly based on verbal communication and cognitive and behavioral training (Li et al., 2005; Wang, 2004; Yang & Wang, 2008). However, in Taiwan, some researchers have used art therapy or music therapy for improving social difficulties, which also showed good results (Guo, 2000; Lin, 2002). Notwithstanding, there is still much more to explore in the use of nonverbal methods such as play or sandplay approaches in this context of group therapies. Group sandplay as an approach to therapy was created and developed by De Domenico in the 1980s (De Domenico, 1988). Professor Zhang Risheng introduced sandplay therapy to China in 1998 and developed a new form of sandplay called Restricted Group Sandplay Therapy (RGST), based on years of clinical experience in the development of sandplay therapy in China and on research done

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by De Domenico (e.g., De Domenico, 1988). In a nutshell, RGST involves that members follow certain rules to make a sandplay world and in so doing process their thoughts and emotions based on what was created in the sandplay world (Zhang, 2006). Details on how RGST was implemented in this study are described below. Some research has shown that RGST can promote mental growth of adolescents effectively (J. Chen, 2005; S.S. Chen, 2005), relieve test anxiety of students (J. Chen, 2005; S.S. Chen, 2005), increase group cohesion of a team (Zhang, 2006), evaluate ways of communication in families or couples (Mason, 1987), and improve communication and understanding between family members (Karla, Kathy, & Gail, 1997; Xu & Zhang, 2007). However, the approach has not been studied in terms of improving interpersonal difficulties of individual adults. Purpose of current study The aim of this study was to explore the process and effects of restricted group sandplay therapy (RGST) on college students with interpersonal difficulties. In this study, the researchers wanted to investigate outcomes of RGST for students with social difficulties through exploratory quantitative and qualitative measures. In addition, the researchers wanted to gather detailed information on what changes would occur in the group process for this type of group and what stages or shifts participants may go through during the group therapeutic process. According to the literature, previous researchers who used sandplay therapy in couples or group therapy may not have used an approach as systematic and defined by rules and regular instruction as RGST. Therefore, this study targeted the impact of this approach on group sandplay therapy. As a result, it is hoped that this new approach to sandplay therapy can be investigated and highlighted through additional study. Methods Participants and sample procedures The initial sample involved 120 college students selected randomly from the same university in Beijing, China. All of them were asked to complete the Social Avoidance and Distress Scale (SAD; Watson & Friend, 1969). According to the scores of the scale, the 20 highest scoring students on the SAD were selected to take part in face-to-face interviews with the group leaders. These interviews were designed to investigate the prospective participants’ history of using mental health services, their motivation for improving their social issues and their willingness to participate in a therapy group using the RGST approach. Finally, nine students were selected for the therapy group who presented with serious social difficulties, an earnest motivation to seek assistance for these issues and with no therapy experience prior to entering the group. The final number of participants for the sample was intentionally kept low in order to create a manageable number of members for a therapy group using the RGST approach. Sample characteristics and demographics As far as sample characteristics, four of the nine participants were female (44.4%), the other five being male. All of the participants were sophomores in the same university but majored in different areas. Their scores on the SAD showed that they have significant difficulties in social interaction and their interview results showed that they would be a good match for an RGST group. None of them had past therapeutic experience, but they were all open to the experience of being involved in a sandplay therapy group.

Measures Two categories of measures were used in this study. The first was the SAD and second involved evaluations based on the content of sandplay therapy scenes created by the participants and of the group dynamics generated by the sandplay approach. The first was quantitative in nature while the second one was more qualitative in nature. Social Avoidance and Distress Scale (SAD) The SAD was used in this study to examine the level of social avoidance and social distress found in the participants at pretest and posttest intervals. The scale contains a total of 28 items, 14 evaluating social avoidance and the other 14 items measuring one’s social distress. All the items are assessed as true/false. The correlation coefficient between the mean value and instrument items in the scale is 0.77. As far as norms, the mean value for college students taking the exam is 9.1 with a standard deviation of 8.0 (Watson and Friend, 1969). There is a high correlation between the score of SAD and other scales about social anxiety and shame (r > 0.75; Jones, Briggs, & Smith, 1986) Lastly, the scale was tested for its validity with Chinese students and was found to be a sound measure with this population (Chun, Xiao, & Luo, 2003). Sandplay therapy measures and procedures The group leaders also evaluated scenes created in sandplay therapy sessions as measures of the participants’ progress during the treatment regimen. The specifications and procedures of the sandplay interventions were conducted as described herein. A standard sandtray filled with sand was used for the treatment sessions. The sandtray was 57 cm × 72 cm × 7 cm inner dimensions and the inner wall of the box was blue and half full of clean sand at the beginning of each session. The therapeutic items used included miniatures of people, animals, plants, buildings, furniture, articles for daily use, vehicles, food, fruits, stones, and so on. These items were used by the participants to create scenes in the sandtrays that represented their inner experiences or expressions. Finally, a digital camera was used to take photos of the sandtrays both as documentation of the session content and for later research purposes. At the time the group sessions were conducted, the two group leaders were both graduate students majoring in clinical psychology with professional training in sandplay therapy, clinical counseling and psychotherapy. One of them was the group leader, in charge of designing and carrying out the group therapy. The other one was a recorder with no direct direction and participation in the therapy. The entire clinical process used in the study was supervised by a clinically licensed professor, Zhang Risheng, who is introduced sandplay therapy to China and developed RGST. The sandtray medium and its associated items were used for measure purposes in two different ways. First, the sandtray miniatures were used to test the participants’ self image at pretest and posttest. The method used for this involved each group member selecting a sandtray item that represented their self image in social context before and after the group. In addition, verbal statements made by each participant were recorded at the self-image posttest in order to get information related to the rationale behind their choices and/or the meaning behind the change for them personally. Both the symbolic nature of the participants’ choices between pretest and post-test was evaluated qualitatively, as well as the comments made by them at the posttest. Second, changes in the group dynamics over the course of the intervention were examined qualitatively by the group leaders. Information related to the events and interactions between group members during each session was recorded and analyzed. Details on the findings of these recordings are presented in the results section.

W. Zhang et al. / The Arts in Psychotherapy 38 (2011) 281–289 Table 1 Detailed description of session procedures in RGST. Step of RGST session

Content of therapeutic activity

Announce rules

Therapist announces instruction and rules of RGST. Determine the order or participation by drawing Let group members put their hands in the sand together or by order, close their eyes, and feel the temperature and the character of the sand, as well as their own feelings. They can touch the sand at will, and experience the feeling of the sand flow Group members make the sandplay world individually. Therapist will not guide or order them, just observe and note the process briefly Invite group members to appreciate their work from different angles separately, and experience the feelings brought about by their work. This process does not allow talking, and all participants should concentrate on his or her own feelings and views Group members can talk and share the meanings of the miniatures they had placed in the sand box, their thoughts during the process and their own understanding for the miniatures placed by other members. Therapist acts as a client-center group leader, listening and reacting but not directing or explaining. Lastly, each member will name the sandtray respectively and select a common theme together During the creation and discussion phase, the therapist needs to note the process and significant performance of the members according to the RGST record form When the sandtray photo is taken, all the members are asked to remove the miniatures from the sandtray and place them back on the shelf During the therapeutic process, group members are asked to submit self-state reports as the feedback from each session

Feel sand

Make the sandplay world

Experience the sandplay world

Complete discussion

Record

Remove miniatures

Write report

General description and rules of restricted group sandplay therapy (RGST) In order to provide better understanding about RGST as a therapeutic approach, a basic description will be provided. Typically, 6–10 participants are allowed to play in one sandtray simultaneously in each session, following certain rules that were developed for the use of sandplay therapy in China. These rules or parameters are key factors in the group sandplay therapy and are the reason the approach was called “restricted group sandplay therapy.” Usually the group leaders would provide specific instructions for the group members in each RGST session. For this particular group, the protocol first included the group determining the sequence of turns at the beginning of each session. Next, each member would make one sandtray addition or alteration in turns. This process constitutes the primary creation phase for the sandtray activity for that session. During this creation phrase, each member can only take one action on the sandtray scene each round, including shaping the sand and placing one kind of miniature. It is permitted to move

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a miniature in the tray, instead of placing a new one, but it is not permitted for any member to take them away from the box. Verbal or nonverbal communication between members during the activity is also forbidden. Finally, when the creation phase is complete, the group moves into the discussion phase. Members are invited to “experience” the sandtray and share all their feelings and thoughts about the process. During this phase of the session, it is allowed, and even encouraged, for members to express themselves verbally and respond to others. Finally, each member names the sandtray respectively and then the group selects a common theme together. Details on the group process and rules are found in Table 1. Some key restrictions on the group dynamics are interwoven in the group process of RGST. Since group members are limited to one move per turn, (whether that involves picking a new item and placing it into the sandtray or moving another person’s item or alter the sandtray scene in some way), they must make careful decisions about what they do each turn. Many members must face the dilemma: select an item for themselves or change another’s and risk the social consequences of that choice. These decisions are viewed as replicating decisions that must be made in common social situations in people’s lives and is thereby influential in helping the group members with social skills detect deficits in them. In addition, since members are forbidden to communicate verbally or nonverbally to each other, each person must balance between being considerate to other members (as they perceive it) and in depending on themselves to make independent social choices. This again is seen creating important milieu that allows participants to practice their social skills and improve their “emotional intelligence.” Finally, when the play is over for the session and the group moves into the discussion phase, they can share their thoughts, observations, feelings, questions and reactions to each other based on what occurred during the creation phase. This phase provides an opportunity for them to share their inner worlds with each other openly and come to know each other better. In RGST, the therapist’s job is to create a safe and protected space for members to conduct their creations and then process them. This includes clearly stating the rules to the group members in every session, taking notes during the creation and discussion phases without providing directions, and facilitating the group members to share and discuss their thoughts and feelings without providing detailed explanations. Stages of RGST implementation For the purposes of this study, the RGST group was structurally broken up into three different stages: the Preparatory Stage, Treatment Stage and Post-therapy stage. In many other sandplay papers, other different kinds of stages division are seen, such as three stages, four stages and so on. Many stage divisions are built on the unique process of each client or group. A brief description of the main components of each stage from a research process perspective is provided. The preparatory stage In the initial stages of group treatment, the group leaders organized a pre-group meeting of the nine subjects before the formal group therapy process started. The purpose of this meeting was to let group members know each other, confirm the goal of the group counseling, and make a contract together to provide some ground rules for the group. This meeting had a set structure starting with a warm up activity involving the responding to questions asked by participants of each other. The group then discussed the exact content of group contract and reviewed the conditions of confidentiality to participate in the group. According to the group contract,

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30

15

25 20

10

15

pre-therapy

10

post-therapy

pre-therapy post-therapy

5

5 0

1

2

3

4

5

6

7

8

0

9

Fig. 1. Total scores of SAD in pre-therapy and post-therapy.

1

2

3

4

5

6

7

8

9

Fig. 2. Social avoidance scores of SAD in pre-therapy and post-therapy.

15

the group decided to meet twice a week for 2 h every session. The whole therapeutic process lasted for four weeks with a total of eight sessions.

10 pre-therapy post-therapy

5

The treatment stage In the treatment stage, the main group process was implemented, consistent with the rules and procedures of the RGST approach. The group leaders explained the rules of RGST to the group members and provided them sufficient time to complete a group sandtray world (or scene). There were no directions or suggestions provided from the therapists. While in session, the therapists would only observe the process and take notes, as necessary. During the discussion phase in each session, the group leaders would organize the process but again allowed the group members to be open in their expressions. During each subsequent session, a similar format was followed. Table 1 includes details on how each portion of the sandplay sessions were conducted. At the beginning of the treatment stage, a step was included designed to help group members get acquainted with the sand medium. In traditional individual sandplay therapy, the initial sandtray is very important because it could present inner psychological problems of the client (Person & Wilson, 2001). This is the same for RGST and the first time the members experienced the sandtray, they are instructed to feel the sand and observe the miniatures in order to build comfort and familiarity with them.

0

1

2

3

4

5

6

7

8

9

Fig. 3. Social distress scores of SAD in pre-therapy and post-therapy.

Results Social Avoidance and Distress Scale (SAD) As shown in Table 2, notable improvements were observed in most participants’ scores on the SAD from the beginning of the group to the end. In the pretest, the mean overall score for participants was 18.2 (SD = 5.9), with Social Avoidance and Social Distress subscale mean scores a 9.6 (SD = 2.3) and 8.7 (SD = 4.3), respectively. In the posttest, the mean overall score for participants was 7.4 (SD = 6.7), with Social Avoidance and Social Distress subscale mean scores a 3.6 (SD = 3.5) and 3.9 (SD = 3.9), respectively. Figs. 1–3 provide graphic comparisons on the total SAD scores, Social Avoidance subscale scores and Social Distress subscale scores at pretest and posttest. No linear regression analyses to compare the means of these scores were conducted.

The post-therapy stage After the eight sessions of RGST, the group members were asked to complete the SAD as a post-test. There was also a final, postgroup meeting for group members and therapists together to share their feelings and thoughts about the whole therapeutic process. They also conducted the posttest on self-image by selecting a sandtray item representing themselves again. After this meeting, all the materials including the SAD scale scores, self-reported statements and items, photos of the sandtray and process notes were analyzed by the researchers in qualitative and quantitative ways.

Results from the RGST intervention The results from qualitative evaluations of the RGST intervention first involved a representation of each participant’s self image before and after the group, as evidenced by the type of item they used to describe themselves. The second were the changes in group process that were observed as the sessions progressed. These shifts in group dynamics provided key information on changes in and evolutions of the members as a group.

Table 2 Participants’ overall scores on the SAD at pretest and posttest. Participant #

Pre-therapy test Total

1 2 3 4 5 6 7 8 9

22 22 18 24 25 9 14 10 20

Post-therapy test Avoidance 10 10 10 13 12 9 8 5 9

Distress 12 12 8 11 13 0 6 5 11

Total 7 5 4 2 24 9 3 9 4

Avoidance 2 1 2 1 11 8 2 3 2

Distress 5 4 2 1 13 1 1 6 2

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Table 3 Changes in self-images of the group members. Subject

Description of sandplay item chosen

Paraphrased comments of participants

Self-image pre-therapy

Self-image post-therapy

1

A self-abased child with head hanging down

A smiling face

2

A lonely girl

3

A small, low-pitched, unicolor house

A bear with a red heart in its arms A lovely red house

4

Big temple

Small temple

5

A crooked house

A little doctor

6

A bear

Two bears

7

A stone

A lovely tiger

8

A cup full of sand

A beautiful flower

9

A child in swaddling clothes

Santa Claus with a bag full of gifts

Self-image Table 3 shows details on the item chosen by each participant at the beginning and end of the group. As can be seen, many of the group members initially picked figures that expressed feelings of social isolation or conflict related to their self image. Many of these items also seemed to suggest low perceptions of themselves. In contrast, the items picked to express their self images at posttest seemed more frequently to show themes related to social harmony and/or positive views of self (i.e., strong, courageous, etc.) or of relationships in general. Group process In understanding changes in clients’ behavior and attitudes through the group sandplay interventions, it is important for the clinicians to pay close attention to the dynamic variation in the overall process of the group, such as what is happening in the therapeutic process as a whole and how the specific shifts in the dynamics affect the therapeutic effects in the study (Hou, 2005). The group leaders should investigate what the clients have been experiencing during the therapeutic process, both emotionally and cognitively, and how this compares with other times in their lives where such feelings and thoughts may have occurred. There were different obvious stages in eight sessions of RGST, which also reflected the development of the group. Considering other research about sandplay stages (Sun, Zhang, & Xu, 2008; Zhang, 2006), the group leaders divided the eight sessions into three stages, based on the clinical dynamics of the group. These were: conflict presenting stage, learning from each other stage, and mutual understanding stage. These stages assisted the group leaders in the clinical implementation and interpretation of the group process from one session to the next. Key events in the sessions are highlighted for each stage, which provide key information on the

“I was self-abased before and afraid of social interaction. Now I am confident and likely to show my smile to others” “I used to be alone, I had no friends and I didn’t trust anyone. Now I would like to treat my friends around me with my heart and trust others” “Only 8 sessions of therapy is hardly enough to change a person, but it is enough to change one’s attitude toward life. Now my life is more colorful and I am more confident and staunch than before” “Once I was an arrogant person; I hardly considered the feelings of others and did what I wanted to do. Now I have learned how to be a modest man and to respect others, not just force my will on others” “I have achieved much from this group. I know that we must use our wisdom and art in social interaction, not to express ourselves selfishly” “I used to be alone, and didn’t like to interact with others. Now I know the importance of friends, and I am not alone any more. . .” “I used to be a bland stone and no one knew me. I once lived in the corner quietly but now I am a lively tiger, embracing my life positively” “My heart is full but I don’t know how to express it. I am afraid of hurt and misunderstanding. Now I know I must serve as a foil to others like a small flower and bring sweet scents to others” “I used to be nervous when I spoke to others. I was not mature, just like a kid. Now I am growing up. The gifts represent the things I learned from the group”

results of the group intervention and in particular on the changes in the group process that were observed. Stage #1: conflict presenting stage (Sessions 1–4) In this stage, many conflicts between group members’ actions in the sandtrays were observed. Although all members knew the rules, when they begin making the sandtray scenes, they often forgot or ignored them, showing indications of their social problems and avoidant personal characteristics. Although there is a level of awkwardness in the relationships between group members in all therapeutic groups, this effect seemed to be magnified by the restricted rules of the RGST. As such, many members expressed themselves more individually at first and rarely considered others. Several members often broke rules by moving miniatures frequently, picking up too many miniatures or doing more than one thing in one round. Even in the discussion phase in the initial ses-

Fig. 4. Final group sandtray in Session 1.

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Fig. 5. Final group sandtray in Session 2.

sions, many members seemed to care more about themselves and than the others in the group. This type of conflict increased in the second through fourth sessions. In the third round of the second session, Participant #4 placed two big green chairs into the sand box, which made Participant #8 feel so bad that she inserted several plants to cover the chair. Moreover, Participant #8 moved a miniature which Participant #4 had\put down from the water to the land, which made Participant #4 feel uncomfortable, offended and even a bit angry. In the 4th session, Participant #7 ruined the whole sandtray by knocking over the items in the sandtray, which caused the other group members to feel “destroyed.” The members then attempted to repair the tray from memory and recreate the items as they were. Once the last item was replaced by Participant #3, completing the repair process, the group members felt “reborn.” Figs. 4–7 show the photos of the completed group sandtray scenes at the end of sessions one through four, respectively. Fig. 4 shows the final sandtray following the first session. The participants expressed a range of emotions while doing it the first time, such as being excited, cautious and at times caring more about their own perceptions than those of others. However, the sandtray did appear to look a little crowded but still harmonious overall. In the second session, conflict appeared to be present this time, especially between Participant # 4 and Participant #8. One can see in the photograph (Fig. 5) the two big green chairs in the right side of sandbox, which were placed in the middle at first and then were removed to the right side due to the conflict. Fig. 6 shows the final standtray following the third session. Several animals were placed in the sandtray together, showing some possible coordination, or at least awareness, of each other in the placement of their items. Still, a few participants continued to concentrate on their own inner world, such as the items in the top left corner of the sandtray created by Participant #5 (see Fig. 6). Lastly, in the fourth session, the sandtray fell victim to the heated conflict between participants which culminated in the whole sandtray scene being destroyed by Participant

Fig. 6. Final group sandtray in Session 3.

Fig. 7. Final group sandtray in Session 4.

#7 in the final round of the session, resulting in all the miniatures knocked down or turned back. The photo in Fig. 7 shows the sandtray after Participant #3 replaced the items from the memory.

Stage #2: learning from each other stage (Sessions 5 and 6) In this stage, members began to learn how to coordinate with each other and seem to make the sandtray under a more mutually beneficial principle. Building on lessons learned from the conflict experienced in the previous stage, and the communication and open feedback they had given each other, group members seemed to learn to introspect and discern their own issues more, and appeared to make changes in themselves that facilitated effective communication they learned from other people. When they made sandtray scenes together, they seemed to begin to think about others and respect their needs more. Overall, members appeared to become more cooperative, and show more concern about each other and less conflict-causing behavior than was observed in the previous stage. In addition, members showed an increase in their ability to listen to each other attentively in the discussion stages, and rarely interrupted other members or distract from their comments. For example, Participant #4 was no longer the one who made trouble intentionally in the group. Instead, he was more likely to put miniatures smaller in size or do simple modifications rather than large ones. With Participant #5, he was initially introverted and seldom expressed himself in the group; however, after a series of sessions, he learned from Participant #7 to place some unexpected miniatures such as a figure called “the naughty boy” in the sandbox. Participant #8 no longer placed plants across the sandtray in order to change others’ creations. Instead, she was more likely to choose smaller miniatures in order to be more modest in her expressions. Participant #3 no longer made creations by himself in an independent corner of the sandbox, but instead began to show increase concern about others and cooperation with them. Finally, Participant #2 seemed more likely to choose the coupled miniatures, and not be “lonely” in her expressions anymore, as she had previously done. All of these group process changes seemed to reflect changes in the quality of individual group member’s social interactions. Figs. 8 and 9 show the photos of the completed group sandtrays at the end of sessions five and six, respectively. Fig. 8 shows the final sandtray following the fifth session. Participants appeared to begin to learn from each other and care more about others, as shown by the selection of relatively smaller miniatures (instead of bigger ones) to provide other group members more space to express themselves. This was seen by the group leaders as showing more cooperative behavior as a group. In the sixth session, a river was made in the middle of sandbox and participants showed enthusiasm to place items along the banks almost as if joining the “grand meeting” (see Fig. 9). Participant #2 chose more couple-oriented

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Fig. 8. Final group sandtray in Session 5.

Fig. 10. Final group sandtray in Session 7.

miniatures instead of a single one, stating that she did not feel as lonely as she had been.

Figs. 10 and 11 show the photos of the completed group sandtrays at the end of sessions seven and eight, respectively. In Fig. 10, the formation of the miniatures seemed to show a more centralized pattern than previous sandtrays. Members tended to place their items in the middle of sandbox with a river all around, which suggested a more group-wide identity in their creations. The group leaders also observed participants beginning to be more accepting of the miniatures others chose and their individual contributions. Fig. 11 shows the final sandtray following the eighth and final session. In this sandtray, Participant #7 chose the big green chairs again to show his friendship toward Participant #4, who was unreceptive to such behaviors in the beginning.

Stage #3: mutual understanding stage (Sessions 7 and 8) In this stage, members seemed to become more tacit and harmonious. As the RGST approached neared its completion, the relationship between group members also seemed to change from a “stranger” stage to a “familiar” stage. After having a series of sessions together, members began to realize that standing in another’s place is very important in social activities. Both in the creation and discussion stages of each of these final sessions, all of them showed an ability to care about others in the group and to express themselves more properly in relation to the group. Additionally, they expressed feeling more valued and appreciated by each other. As a group, the sandplay worlds seemed to become more integrated and dynamic. There were fewer occurrences of disruptive or isolative behavior from group members and all seemed to act in a more helpful way toward each other in the sandtray. Most members expressed feeling the group was like a family, and they increasingly became more real and open with each other. They stated that they liked to share their happiness and troubles with each other in order to get more support and courage from other members, thus helping them better face challenges in real life. The themes of the sandtrays in this stage were mainly about “dreams” and “love”. Participant #4 expressed having learned much from Participant #9 (who was the most popular member in the group) and could act in cooperation with others while expressing himself. Participant #1 gave up the opportunity to go first to Participant #7, who had wanted to be the first for a long time, demonstrating an apparent act of consideration and generosity. Participant #6 seemed to no longer try to escape from dilemmas and began to face the world on her own. Participant #7 put the two green chairs, which once set off a conflict, to express his acceptance and support of Participant #4. Participant #6 put two little girls on the chairs to show her cooperation. Finally, Participant #4 chose a little temple instead of a bigger one to symbolize himself.

Fig. 9. Final group sandtray in Session 6.

Discussion While this was an exploratory study with a small sample of participants, the results found among group members suggest promising outcomes for RGST to be used with individuals experiencing social distress and/or avoidance difficulties. As far as the SAD scores, all but two group members showed notable improvements (see Table 2). Across the nine participants, the mean total scores decreased by nearly 60% over the course of the group intervention (from 18.2 to 7.4). Social avoidance scores decreased by 62.8% (from 9.6 to 3.6) and social distress scores decreased by 55.1% (from 8.7 to 3.9). These findings suggest that RGST appeared to improve the social interaction abilities of these group members effectively and adds to studies supporting the RGST as a structured group sandplay therapy. At the same time, it is recognized that these results must be stated tentatively for two reasons. First, there was no control group in the available research design, which prevents the researchers from comparing the improvements with a similar group who did not experience the intervention. Second, no quantitative statistical analyses were performed to test changes in means between pretest and posttest empirically. Ideally, conducting linear regres-

Fig. 11. Final group sandtray in Session 8.

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sion analysis to compare the means of the SAD scores (i.e., T-test) would have been provided better support for the research findings. However, due to the limited sample size, such analyses proved to be unproductive. As a result, significant effects in the findings cannot be identified with complete confidence. Notwithstanding, as an exploratory study of using RGST in this manner, the changes in mean scores observed seem notable and to suggest possible positive outcomes with this approach in future clinical settings. Regarding changes in self-image, improvements in group members also seemed apparent. Before discussing these findings in detail, it is important to note that the self-image as expressed in the sandtray generally is typically the inner projection of the client, and represents different sides of the client’s personality (Xu, Zhang, & Zhang, 2008). The change in self-image via a series of sandtrays partly reflects the change and development of the individual’s inner ego. This can help identify key shifts in one’s inner thoughts and feelings, which thereby affects one’s behavior. In this study, the group leaders chose to test the self-images of the nine participants before and after the eight sessions of RGST in order to provide some information on how their inner worlds changes as a result of the RGST intervention. While no objective rating or scoring system was used to rate the changes in the participants’ symbols of their self image, the qualitative evaluations of the researchers in this study recognized that positive shifts were seen for most participants in their self image from pretest to posttest. As noted above, there appeared to be a qualitative shift in the themes that participants used for their post-group representations, chosing symbols that showed a more positive outlook toward social relationships, an increased desire for social interaction and more positive views of one’s self in the context of social interactions. What added to the certainty of positive changes noted by the researchers were the participants’ comments about how the group affected their social self images (see Table 3 for details). For example, Participant #1 chose a self-abased child with its head hanging down before the group but then chose a smiling face as her self-image at the end. This suggests a much happier symbol of self than the initial one. Her comment made at the time confirms this interpretation, “I was self-abased before and afraid of social interaction. Now I am confident and likely to show my smile to others.” Participant #3 chose a small, low-pitched unicolor house before the group but afterwards chose a lovely, red house, suggesting a more positive and broad range of inner feelings; the person’s comments also confirmed this interpretation by saying, “Now my life is more colorful and I am more confident and staunch than before.” Participant #6 chose one bear before the group but afterwards chose two bears, suggesting a more social and relationship-oriented attitude. The person commented about this, saying, “I used to be alone, and didn’t like to interact with others. Now I know the importance of friends, and I am not alone any more. . ..” Finally, Participant #9 chose a child in swaddling clothes before the group but afterwards chose a figure of Santa Claus with a bag full of gifts. This suggests a release from possible bonds in social situations and the receiving of positive benefits from social interaction. The person’s comment seems to confirm this, “I used to be nervous when I spoke to others. I was not mature, just like a kid. Now I am growing up. The gifts represent the things I learned from the group.” As such, the changes in the participants’ self-images before and after therapy seemed to indicate that through the eight RGST sessions, the group members received successful self-development, and their inner egos became healthier and stronger. Finally, as a group, the nine participants who began the RGST sessions with some identified trouble in social interaction, seemed to move from conflict to harmony with the help of the sandplay group. The creation stage seemed to dramatize social interac-

tions and dillemmas in their real lives in a powerful way, they having to discern other people’s problems as well as their own in an actual social activity. This gave them a real-time experience in working out issues and implementing new solutions in social interaction situations. It seems like a verbal-only group may not have achieved the same level of intensity or benefits. In the discussion phase, group members were able to discuss these impressions and receive information to confirm, refute or clarify them. Overall, positive effects appeared evident by the changes in group dynamics observed by the group leaders through the three clinical stages identified for the group (the conflict presenting stage, learning from each other stage, and mutual understanding stage). In the conflict presenting stage, interpersonal conflict seemed common. Members were evidently aloof from each other and show awkwardness in their actions related to each other. While such dynamics are not uncommon for most therapeutic groups in their initial stages of development, this level of conflict, detachment and awkwardness seemed more prominent and intense given the participants’ identified difficulties in social interaction and by the restrictions imposed by the RGST approach. However, in time this conflict seemed to decreased through the interaction provided by the RGST approach. In the interpersonal conflict stage, there appeared to be more coordination and resolution between members than before. This suggests the presence of learning and the application of key social skills that may not have been gained or used previously. Finally, in the mutual understanding stage, members seemed to reach a higher level of harmony, discernment and consideration for each other that seemed a stark contrast from the beginning of the group. This stark contrast is especially remarkable in the context that the nine participants of the group scored in the highest twenty scores of social distress and avoidance among over 120 college students who took the survey. As such, the level of social harmony and coordination achieved by this group seemed a significant thing to achieve for these group members. Therefore, based on the observations of this level of evolution in the group, and the marked transition in the behavior of individual group members, the RGST approach’s effect on the group as a whole, and individually, seemed to be notable and positive. At the post-group meeting, the group leaders also generated group member feedback via asking the clients to submit a report on the sandplay group process after every session, which provided information on clients’ perceptions of RGST from another method. One member wrote: This was a wonderful family, where whoever did anything could be accepted, and we communicated with each other sincerely, confidingly and all of us were accepting and considerate. This process changed my passive outlook on life and helped me to get over a gloomy and difficult time in my life. I was very happy to know so many friends in my life. We had to say farewell to each other in this group, but I think it was a new beginning instead of an ending. Another member stated, “This group was like a family, which was warm, kind, safe, happy, and relaxed. In the beginning, I didn’t like to communicate with people around me, but the series of group activities changed me gradually. Now I begin to take the initiative in my daily life even if it’s just a smiling face.” These comments reflect again the significant shifts in thoughts and emotions created by the RGST group approach. See Table 4 for detailed discription on the therapeutic mechanism of RGST. Limitations of the study This research was carried out in the student counseling center (SCC) in a university setting. The group leaders and developers had

W. Zhang et al. / The Arts in Psychotherapy 38 (2011) 281–289 Table 4 Detailed description on the therapeutic mechanism of restricted group sandplay therapy (RGST). Introduction RGST derives directly from sandplay and group therapy, which has the traditional benefits of individual sandplay therapy and group therapy. Meanwhile, as a unique therapy, RGST also has its own advantages and therapeutic mechanism, especially for the people with social difficulties. Key points a. In RGST, clinicians use the traditional setting of sandplay therapy, such as tray, sand and miniatures, which provides a unique therapeutic space for the group members to express themselves in a free, creative, and symbolic way. In addition, there are many other protective factors: boundary of the sandbox, restricted rules, and unconditional acceptance and positive attention from the therapist b. Restricted rules are analogies of real life, as we are not freewheeling in our daily lives and should act by different kinds of rules. People living in the world should learn how to adjust to social life and get along with each other without hurting one another, which is not an easy task and may cause many mental disorders. RGST gives people a chance to learn how to deal with social matters and improve their emotional intelligence In RGST, group members’ social difficulties could be c. presented visually based on the creation process and miniatures’ symbolic meanings, which reflects every member’s personal social problems and clues to healing. The therapist gives no directions and allows them to express themselves freely in order to let themselves understand all the problems they have. A group setting gives them a chance to learn from others and imitate good behavior and skills d. In RGST, the therapist has a multidimensional appraisal system to evaluate group members’ social problems and group dynamic relationship. During the creation and complete discussion phase, the therapist can observe members’ role-playing, special characteristics of each member, methods of communication and personal problems reflected by sandplay, then deal with them in groups, which will be better than individual therapy e. Play itself can arouse inner energy and creativity in the group, and provide a chance for group members to repair their “child ego”. Members can express their emotions and feelings appropriately by making the sandtray, which is symbolic but natural. It is better and safer than verbal communication. For those who are lack of emotions expressing or over rationalistic, sandplay can help them to sympathize with others well. In addition, play can reduce therapeutic resistance and quitting

to consider more about the reality and needs of the SCC than of the research itself. This resulted in many insufficiencies in research design and observational-tracking. As such, the study only involved one group of nine clients without a control group or more sample support. This prevents the findings being interpreted with high confidence and decreases the ability of the researchers to generalize positive outcomes of RGST to broader samples of clients or client populations. Due to limitations in the size and number of groups involved in the study, the group leaders focused on the outcomes of the process of RGST for this group of clients, and not a comparison with other therapeutic methods. Although the researchers gathered detailed information of each client and analyzed it in a deep and qualitative way, the application and extensibility of research conclusions needs more testing in the future. In addition, the lack of quantitative analyses or rigorous qualitative analytical methods again limits the utility and confidence of the findings. Given the highly interpretative nature of sandplay

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methods in general, more objective and scientific techniques must be used to test effects empirically. Notwithstanding, the amount of information that was generated, both in terms of the SAD scores and via sources related to the sandplay medium itself (i.e., self image item test, sandplay group dynamics, verbal statements by participants), provide support that suggests promising outcomes for further uses of the RGST in the future. Conclusion and future directions As stated earlier, RGST is widely used in couple therapy, family therapy, and Employee Assistance Program (EAP) training programs. Due to its highly visual and symbolic nature, it help users of it to express their inner world and experience with complex feelings with the safe buffer of the sand medium. Due to RGST’s special rules, it also provides a valuable approach for dealing with interpersonal problems and social difficulties of clients in many clinical situations. The RGST approach could help clients with interpersonal issues learn how to communicate with others and express themselves suitably, which also promotes their self-development. References Chen, J. (2005). An intervention study of group sandplay therapy for behavior problem of children. Unpublished master’s thesis, School of Educational Science of South China Normal University, Guangzhou, Guangdong, China. Chen, S. S. (2005). A study on effectiveness of sandplay therapy on intervention for test anxiety of junior high school students. Unpublished master’s thesis, School of Educational Science, Hebei University, Baoding, Hebei, China. Chun, P., Xiao, F., & Luo, L. (2003). The validity and reliability of social avoidance and distress scale in Chinese students. Chinese Journal of Clinical Psychology, 11(4), 279–281. De Domenico, G. S. (1988). Sand tray world play: A comprehensive guide to the use of sand tray play in therapeutic transformational settings. Oakland, CA: Vision Quest Into Reality. Fan, C. X., Ma, S. B., Lin, H. S., & Wang, H. S. (2001). A stepwise regression analysis of psychological health status of college students and its influencing factor. Chinese Journal of School Health, 22(3), 215–216. Guo, X. Y. (2000). A study of effect of developmental orientation art therapy guidance on emotional disturbance and Self-Concept of elementary school children. Unpublished master’s thesis, National Education Institute, Tainan Normal College, Taiwan. Hou, Z. J. (2005). A study of counseling and psychological therapy—What to do and how to do. Chinese Mental Health Journal, 19(1), 65–67. Jones, W. H., Briggs, S. R., & Smith, T. G. (1986). Shyness conceptualization and measurement. Journal of Personality and Social Psychology, 51, 629–639. Karla, D. C., Kathy, L. E., & Gail, G. W. (1997). Using sandplay in couples counseling. Counseling and Therapy for Couples and Families, 5(1), 32–36. Li, Q. C. (2002). The status quo and countermeasure of college students’ interpersonal relationship. Chinese Journal of School Health, 23(1), 47–48. Li, Y., Liu, A. S., & Zhang, S. C. (2005). Effect of group psychological guidance on interaction anxiety of college students. Heath Psychology Journal, 13(4), 252–256. Lin, S. Q. (2002). The counseling research of music therapy activities on attack and interpersonal issues of primary four to six grade children. Unpublished master’s thesis, Psychological Counseling Education Institute of Ping Dong, Normal College, Taiwan. Mason, L. (1987). Assessing couple interaction with the sandplay method. Dissertation Abstracts, 47, 3531–3532. Person, M., & Wilson, H. (2001). Sandplay and symbol work. Sydney, Australia: Australian Council for Educational Research. Sun, F. F., Zhang, R. S., & Xu, J. (2008). Sandplay therapy with an abused boy. Studies of Psychology and Behavior, 6(1), 17–22. Wang, Y. (2004). A study on the role of group counseling in enhancing college students’ intercourse skills. Psychological Science, 27(5), 1254–1256. Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and Clinical Psychology, 33, 448–457. Xu, J., & Zhang, R. S. (2007). The theoretic basis and clinical practice of sandplay applied to family therapy. Psychological Science, 30(1), 151–154. Xu, J., Zhang, R. S., & Zhang, W. (2008). Process and effect of an ADHD boy’s sandplay therapy. Chinese Journal of Clinical Psychology, 16(4), 440–445. Yang, S., & Wang, Y. (2008). A study on group counseling for personalcommunication of undergraduates. China Journal of Health Psychology, 16(2), 140–143. Zhang, R. S. (2006). Sandplay therapy. Beijing, China: People’s Education Press.