Utilising sandplay therapy to support children with intellectual disabilities and complex mental health needs in China’s child welfare institutions: a case study

Abstract

Sandplay therapy (SPT) has demonstrated significant effectiveness for children with intellectual disabilities, autism, and other challenges. This case study explores its impact on emotional regulation, sexual psychology, and behavior in orphaned children with significant functional limitations residing in Chinese welfare institutions. Utilizing Jungian psychology, the child’s development was assessed through 26 SPT sessions and four interviews with simulated family members. The findings showed improvements in emotional functioning, self-care capabilities, and the management of sexual energy and emotions. Furthermore, interpersonal relationships within the simulated family improved, thereby achieving the counseling goals. SPT, with its focus on the unconscious and symbolic representation, offers unique advantages in addressing the emotional and behavioral challenges experienced by children with severe functional impairments in welfare environments.

Introduction

Orphaned children and those with disabilities constitute a significant global social issue. In China, the care and upbringing of these children not only reflect the level of national welfare—which includes social care and services for vulnerable groups such as children, the elderly, single-parent families, individuals with disabilities, and those with chronic mental illnesses—but also profoundly impact social harmony. Since the initiation of China’s reform and opening-up policy, the country has seen rapid economic and social development, leading to gradual improvements in the social security system. Consequently, the protection for the rights and interests of orphaned children and those with significant support needs has steadily increased. As of the end of 2020, there were 1217 child welfare institutions in China. The total number of orphans was 193,000, consisting of 134,000 scattered orphans and 59,000 residing in child welfare institutions. ‘Scattered orphans’ refers to minors under 18 who cannot locate their biological parents and have not been legally adopted, including children raised by relatives, such as grandparents or other family members, after losing both parents. According to the Ministry of Civil Affairs of the People’s Republic of China, most children in China’s welfare homes are orphans who have lost their parents due to natural disasters or other unforeseen events. These institutions also act as guardians for children with severe mental and physical disabilities or those abandoned due to serious illnesses. The children under the care of these institutions are predominantly those who are critically ill or have significant support needs. These orphaned children and those with significant support needs were abandoned and sent to welfare homes at an early age by public security officials or other well-intentioned individuals due to congenital disabilities (Huan 2012). Typically, children who reach the age of 18 and possess a normal range of intelligence leave the welfare institution, whereas those with physical disabilities and serious diseases require much longer stays (Deng et al. 2020).

The ability to care for a child with a disability in China presents distinct challenges. Due to the high costs of medical care and prevalent poverty in many rural areas, abandonment may be seen as the only option for securing institutional care of any quality for these children, despite the problems associated with orphanages. Many children require surgery, which is prohibitively expensive in China (James 2008). In recent years, the ongoing development of China’s economy and society has spurred efforts to enhance guardianship and welfare provisions for orphaned children and those with disabilities. The number of child welfare institutions and the professionalism of service personnel in China have steadily increased (Zhou and Zheng 2019). Concurrently, China has initiated rehabilitation and training programs for children with disabilities, improving the relevant relief and service systems to benefit more vulnerable children. Currently, guardianship and rearing methods for these children in China are categorized into five main types: institutional care, voluntary assistance, temporary foster care, family foster care, and simulated family care. Although adoption is also available, the proportion of children adopted is very small. For instance, in 2020, China processed 11,000 adoption registrations, including 31 cases from Hong Kong, Macao, Taiwan, or by overseas Chinese, and 63 by foreigners. The upbringing of orphaned children and those with disabilities in China is primarily conducted by welfare institutions through collective care.

Simulated family mode and research questions

In recent years, an increasing number of Chinese child welfare institutions have adopted the simulated family model (Fang and Chen 2017), a caregiving approach that combines aspects of family foster care, nursing, and education to foster a sense of ‘belonging’ for children without a traditional ‘home’. Unlike traditional institutional care, this model employs a full-time mother and a working father, who are publicly recruited and trained by the government to become the primary caregivers for children with disabilities. A simulated family typically comprises two parents and between four to six children, providing some familial functions and addressing the children’s psychological and social development needs. Research indicates that, compared to children with significant support needs raised in institutional care, those from simulated families demonstrate higher levels of interpersonal interaction, enhanced feelings of belonging and security, and improved physical development (Luo 2015). Additionally, children with significant support needs in simulated families exhibit notable improvements in physical fitness, as measured by height, weight, head circumference, and IQ, compared to their peers with disabilities in general institutional care (Deng et al. 2020).

Although children with significant support needs in China’s child welfare institutions receive substantial funding and material assistance, ongoing attention and research are essential to address the psychological challenges these children face during their development. Research has shown that these children experience a range of psychological distress, including emotional disturbances such as tearfulness, irritability, and social withdrawal. They also face daily life challenges, including sleep disorders, frequent bedwetting, and skin scratching, as well as exhibiting abnormal behaviors like tantrums and destruction of daily necessities (Deng et al. 2020; Fu 2011). These psychological issues complicate the possibility of these children eventually leaving the welfare homes.

Children in these welfare homes generally experience relatively high levels of loneliness and social anxiety, exhibit weak self-awareness, and tend to display more aggressive behaviors (Ai 2015). Most orphaned children and children with disabilities in China’s child welfare homes suffer from physical, mental, and intellectual disabilities. Many experienced extreme pain shortly after birth and before they developed language skills, leaving deep emotional scars. Due to their physical conditions and the trauma of abandonment, these children may face severe mental health challenges later in life (Fu 2011). Disability policies advocate that individuals with all types of disabilities should be supported to develop and maintain meaningful lives with socially inclusive outcomes (Wilson et al. 2015). However, currently in China, there is a lack of a systematic intervention model to provide psychological support to orphaned and critically ill children with significant support needs in welfare institutions. The psychological health issues of orphaned and disabled children in welfare institutions should receive adequate attention from both the institutions and society at large. Efforts should be made to introduce various psychological counseling interventions into welfare institutions to provide references and support for establishing systematic, standardized, and replicable psychological intervention methods in these institutions in the future.

This study selected a 16-year-old orphaned and critically ill child with significant support needs, who lived in a simulated family within a welfare institution, as the participant for a case study. Considering the background of growing up in welfare institutions as an orphan with disabilities, and the unique trauma characteristics associated with these conditions, a professional assessment and analysis were conducted. Subsequently, sandplay therapy (SPT) was utilized as an intervention method, aiming to explore the effectiveness of SPT to promote the psychological well-being of orphaned children and children with disabilities who reside in simulated families created by China’s child welfare institutions.

Why and what is the Sandplay Therapy?

As each group possesses a unique background, living environment, and state, it is essential to consider the growth background of orphaned children and children with disabilities, as well as the characteristics of their trauma, when developing psychological interventions for children in welfare institutions. SPT offers a valuable approach for addressing the trauma experienced by orphaned children and children with disabilities. SPT is a widely utilized psychotherapeutic approach for working with children, adolescents, and adults. The origins of SPT can be traced back to 1911, when British author H.G. Wells published two books: Floor Games (1911) and Little Wars: A Game for Boys (1913). Wells recognized that through play, children could develop broad thinking patterns and resolve conflicts and contradictions. Inspired by Wells, Margaret Lowenfeld incorporated toys, models, and trays for sand and water into her child clinic, naming her approach the ‘World Technique’. Dora Maria Kalff, influenced by H.G. Wells and Margaret Lowenfeld, integrated Jungian psychoanalytic theory with Eastern philosophical concepts to develop SPT. She formally introduced the concept of ‘Sandplay Therapy’ at the International Analytical Psychology Conference in 1962 and founded the International Society for SPT in 1985, marking the establishment of the SPT framework. In the early 1990s, Professor Shen Heyong and his team introduced SPT to China, publishing the first Chinese professional paper and monograph on the subject. Over the past two decades, SPT has become a widely accepted method and technique in China, having a significant impact. Numerous scholars have conducted extensive clinical applications, utilizing SPT for children with Attention Deficit Hyperactivity Disorder (Wang et al. 2010), psychological rehabilitation for children with cerebral palsy (Yang et al. 2011), and preschool children with Autism Spectrum Disorder (Wang et al. 2019). Currently, the professional societies of SPT in China are among the largest in the field of psychotherapy worldwide.

Sandplay Therapy is a form of ‘non-verbal psychotherapy’ in which clients use a variety of miniature figures to create three-dimensional scenes in a tray filled with sand. The tray’s blue interior symbolizes the sky or water, and clients can add water to shape the sand or create lakes and rivers (Shen and Gao 2012, 11–12). In this therapy, unconscious content is expressed through imagery, allowing internal emotional content to be transformed into visual representations. This transformation can directly influence and alter clients’ inner thoughts and feelings, aiding in the reconstruction of their internal worlds and establishing order (Shen, Chen, and Gao 2005). SPT provides a ‘free and protected space’ where clients use sand, water, and miniatures to create imagery that facilitates a dialogue between the conscious and unconscious parts of the psyche. This interaction promotes psychological healing and personal development (Shen and Gao 2012, 36). The therapy involves significant work at the unconscious level, with therapists ensuring a safe and protected environment. According to Kalff, this ‘free and protected space’ is essential for SPT, serving as a container for the non-verbal and symbolic expression of the client’s inner experiences during play, which includes the therapeutic relationship (Roesler 2019). SPT’s unique advantages include its symbolic, non-verbal nature and its appeal to children. It facilitates the expression of children’s experiences, feelings, expectations, needs, and desires during the therapy process. Additionally, it integrates consciousness with the unconscious and body with mind, enhancing clients’ self-control and promoting both personal growth and the comprehensive development of their personality.

SPT has been employed in counseling environments worldwide for several decades, primarily with children (Foo et al. 2020; Liang et al. 2021). Many orphaned children and those with significant support needs in welfare institutions struggle to engage in psychological interventions through verbal means due to impaired intelligence and limited language abilities. As a non-verbal technique, SPT may offer the most effective treatment strategy, minimizing the risk of re-traumatization. There is substantial evidence supporting SPT's ability to provide an accurate representation of a client’s inner world and to identify elements of the client’s psychopathology (Roesler 2019).

The functions of SPT are manifested on several levels: limbic and pre-symbolic, graphic, memorial, symbolic, and linguistic (Turner, Unnsteinsdottir, and Armstrong 2015). Younger children with Down syndrome are more prone to maladaptive behaviors such as agitation, aggression, sleep disturbances, inattention, impulsivity, rigid and repetitive behaviors, oppositional behavior, and reciprocal social impairment (Esbensen et al. 2017). This case study describes the application of SPT to a child with Down syndrome and intellectual disability, thereby providing a reference for using SPT as an intervention for emotional and behavioral problems among children with disabilities.

Case study

In this case study, a critically ill child with significant support needs from a child welfare institution in Guangdong Province was the focus. The study utilized sandplay games as a psychological intervention, underpinned by the Garden of Heart and Soul project, initiated in 2007 by Chinese professors Shen Heyong and Gao Lan. By the end of 2023, the project had established 90 workstations nationwide, with city-level welfare homes and orphanages comprising more than 61.5% of these locations. Children in welfare homes typically possess unique psychological conditions, often feeling insecure and displaying self-protective mechanisms that make them wary of relationships. If the psychological counseling relationship is not well-maintained, it can be more detrimental than beneficial to these orphaned children and children with disabilities. Thus, psychological interventions for these children demand strict adherence to the capacity, attitudes, and professionalism of counselors, and follow a rigorous protocol that encompasses the initiation, progression, and conclusion of the consultation. The Garden of Heart and Soul project adopts psychological counseling as its foundational framework, conducting one-to-one interventions with children. Sessions occur weekly, and each critically ill child with significant support needs is treated for at least one academic year (two semesters, excluding winter and summer breaks), with sandplay games serving as the primary therapeutic tool.

Background

Ben (not his real name, to protect his privacy), a 16-year-old boy, was a third-grade student at a special school in a city in China. Shortly after birth, Ben was abandoned and subsequently placed by the police in a local child welfare home where he was diagnosed with Down syndrome and raised institutionally. In 2016, Ben became one of the first group of orphaned children and children with disabilities to be raised in a simulated family within the city’s child welfare institution. Each simulated family comprises an adult couple and four children with significant support needs of the same gender. The female caregiver of Ben’s simulated family enrolled him in SPT. She reported that Ben’s mood was unstable and fluctuating, and he sometimes exhibited strong aggressiveness and stubbornness. In addition, Ben often scratched his skin (thereby damaging the skin), touched his genitals in public and performed other inappropriate behaviours. Therefore, his female caregiver believed that he would benefit from a psychological intervention.

Our initial impression and evaluation of Ben were as follows: When Ben first attended the consultation, he was 16 years old but appeared to be about 10 years old, standing only 145 cm tall. After being admitted to a welfare institution, he was diagnosed with Down syndrome by a local pediatric hospital. His primary symptoms include intellectual disabilities, delayed physical growth, and distinctive facial features. In terms of motor skills, his overall development is behind that of his peers, and he exhibits weaknesses in both gross and fine motor abilities, resulting in a hemiparetic gait. Although he can perform basic self-care tasks such as eating, using the restroom, and dressing, he lacks initiative in managing daily activities. Additionally, he has scabs on his face and other exposed areas of skin, particularly on his forearms.

Ben’s cognitive abilities are limited; he can recognize common objects and engage in basic picture matching activities. In terms of communication, he demonstrates basic awareness, understanding simple instructions from a therapist and responding with simple ‘humming’ sounds. Additionally, he uses gestures to express his basic needs and communicate.

Ben’s living environment is relatively restricted, primarily consisting of life within the welfare institution and attendance at a special school. In social interactions, he sometimes exhibits aggressive behavior, such as grabbing objects, particularly when faced with situations he dislikes or when he is reluctant to follow teachers’ instructions, which leads to emotional outbursts.

Method

The case study method was employed to gather descriptive data for analysis. Key aspects of SPT were analyzed, and the intervention’s effectiveness was evaluated. Research on SPT has extensively examined the characteristics of symbols and patterns in sandplay images associated with specific psychological syndromes and disorders (Sim and Jang 2013). The SPT process involves a series of sessions during which the client addresses psychological issues by creating a sequence of images. Often, certain elements and symbols recur in these images repeatedly, though their arrangement may evolve throughout the course of therapy (Roesler 2019).

Numerous handbooks and manuals are available to systematically interpret symbols, images, and structures in sandplay pictures (e.g. Von Gontard 2007). Ramos and de Matta (2008) developed a standardized method for classifying and categorizing sandplay pictures for use in research and data analysis. Building upon previous research, this study conducted a comprehensive and in-depth analysis of Ben’s sandplay. It involved a detailed listing of all known modes of expression in sandplay creation, focusing on patterns of change from one sandtray to the next, including an analysis of the thematic content of each scene. The analysis of the sandplay intervention was primarily based on our detailed notes on Ben’s sandtray process and sandplay pictures, interviews with members of simulated families, and feedback from two members of the International Society for SPT (based on Ben’s sandplay pictures). In our interviews, we collected data on the critically ill child with significant support needs and the changes observed before and after the consultation and interviews. We also obtained clinical records and growth information from the nursing staff and the child welfare home.

Counselling setting and research ethics

SPT in the case study was conducted in the sand table room of a city-level child welfare home. The study spanned from February 2019 to early January 2020, excluding winter and summer vacations. In alignment with the schedule of the local children’s welfare institution, our intervention work was paused during the children’s winter and summer breaks. Consequently, 26 counseling sessions were conducted throughout the year. The structure of the counseling sessions was consistent, with interventions occurring weekly at predetermined times in designated classrooms, each lasting 50 min. The intervention primarily consisted of sandplay games. A total of 26 sessions were held, including one drawing psychological consultation and 25 sandplay game consultations. Additionally, interviews with parents from four simulated families were conducted during the intervention. Before finalizing this article, written consent was obtained from the visiting guardian (the head of the local welfare institution), who reviewed a preliminary version of this study and agreed to its publication in both Chinese and English versions. After reviewing the first draft, the guardian expressed that the study had provided him with a new perspective on the situation of these children. He expressed a hope that more attention would be given to these children with significant support needs and that the research findings would be widely disseminated.

Goals

The following goals were established for the treatment: to develop Ben’s ability to regulate his emotions; to reduce his aggressive behaviors in daily life, such as spitting at people; to understand his stages of sexual psychological development and the reasons for its obstruction from the perspective of Jungian analytical psychology, thereby alleviating Ben’s sexual impulses and attacks during SPT; to enhance Ben’s connection with his body and encourage him to accept it; and to decrease the severity and frequency of Ben’s skin scratching.

Analysis of SPT intervention and its Key stages

During the sandplay intervention, Ben’s changes occurred in four main stages. Due to space constraints, we have included only selected sandtray images from each stage in this study.

The first stage: emergence of problems and establishment of the therapeutic relationship (sessions 1–5)

In this stage, the therapist aimed to create a safe, free, and protected space for Ben and establish a connection with him. The relationship between client and therapist is a crucial factor in successful psychotherapy (Akimoto et al. 2021). The simulated family’s aunt mentioned that Ben had undergone SPT twice a year earlier but was unwilling to return to the sandplay room after those sessions. Therefore, during the first meeting, the therapist did not prompt Ben to engage in sandplay. Instead, Ben spontaneously used the sandplay figures on the shelf. He did not remain seated on the bench but preferred to move around the sand tray, occasionally glancing at me as if to confirm that I was attentively observing and accompanying him. It appeared that he needed constant eye contact to ensure the therapist’s presence. In SPT, the initial sand picture is crucial, as it often reveals the client’s core issues and offers clues for healing (Li et al. 2018).

Ben’s sand pictures during this stage may illustrate his issues with sexual energy (Figure 1, Top panel). In the initial consultation, he placed animal-shaped miniatures in the sandtray, positioning them almost face-to-face with himself. Animals represent various human instincts and convey the significance of these instincts from different perspectives (Kalff 2014). Ben appeared to be aware of the symbolic meaning of the miniatures. For instance, while placing the ‘tiger’ in the sandtray, Ben made clawing motions with his hands and exclaimed ‘wow’. When the therapist asked, ‘Are you mimicking a tiger?’ Ben nodded in affirmation. Ben frequently caused two animals to collide, producing a whining sound. These animal miniatures may symbolize Ben’s sexual impulses and attacks, reflecting his unconscious and instinctive mental state.

Figure 1.

Examples of Ben’s sand pictures (taken by the first author in 2019).

During the sessions, Ben occasionally scratched his genitals and then glanced at the therapist before resuming the sandplay. Due to Ben’s impaired physical and intellectual development, his sexual physiology had progressed normally, but his sexual psychology had developed more slowly. He experienced physiological sexual desire but lacked an understanding of sexual morality. Children with intellectual disabilities are more likely than their peers without such disabilities to exhibit unclear sexual psychology and overt sexual behavior (Li et al. 2018), which presents additional challenges for educators. At the age of 16, Ben was unaware of how to manage his sexual urges and inner aggression. The aunt in the simulated family reported that he frequently touched his genitals at home and school, and sometimes displayed a strong interest in grasping the genitals of other boys living with him. Ben’s troubles were presented in the sandtray several times (Figure 1).

In Ben’s initial consultation, he placed a police car miniature in the lower right corner of the sandtray. In SPT, vehicles often symbolize functional roles, such as police cars for law enforcement, firefighting trucks for emergency responses, and garbage trucks for waste collection (Kalff 2014). According to Ben’s clinical records and growth data from the child welfare home, he had been abandoned and subsequently placed in the welfare home by the police, we learned that he had been abandoned and sent to the welfare home by the police, so maybe the police car had unique significance for him. By positioning the police car close to the therapist, Ben may have been expressing a form of positive empathy towards the therapist. During previous sessions, it had been challenging for the therapist to conclude the consultations on time. Whenever Ben arranged the animals, the therapist would state the names of the animals, signifying acknowledgment and response to his gaze and actions. As the session approached its end, Ben would throw sand and spit at the therapist, reflecting his difficulties with maintaining stable relationships. The therapist would repeatedly tell him, ‘We will see each other again next week’. Ben often needed to take a sand toy with him to be willing to end the session, which he would bring back at the subsequent consultation. The therapeutic relationship between the therapist and the client encompasses both experiential states and feelings that operate at both conscious and unconscious levels (Cunningham 2013). In SPT, establishing a trusting relationship with the therapist is essential for facilitating regression and reworking developmental phases, allowing for the expression, conscious experience, and alleviation of grief and rage (Beavers, Private, and Folsom 2015).

The second stage: development of the therapeutic relationship (sessions 6–12)

In the second stage, the relationship between the therapist and Ben grew closer. At this stage, Ben was still reluctant to end the sessions on time, hoping to extend his time in the consultation room with the therapist. A turning point seemed to occur during the tenth session, on an exceptionally hot day. Ben noticed the therapist continuously wiping sweat during the session. When the therapist reminded him that their time was almost up in the final minutes, Ben immediately ran out of the room. While the therapist was documenting the session in the consultation room, Ben suddenly ran in and handed the therapist a bottle of water, gesturing for her to drink. After this incident, the relationship between the therapist and Ben appeared to grow closer. Ben became more engaged and seemed more secure during the sand tray activities. He no longer delayed the end of sessions or acted aggressively towards the therapist, no longer spitting or throwing sand, seemingly no longer worried that the therapist might not return for the next session. During the sand tray activities, Ben’s placement of the animal miniatures in the sandtray started to simulate sexual intercourse between them, it seems that the original sexual impulse was released to a certain extent. Additionally, Ben began to place trees in the sandtray. The growth of trees is often metaphorically associated with the human life cycle, and the concept of the Tree of Life holds significance in many cultures. Trees provide refuge under their shade and sustenance from their fruit, symbolizing a protective and nurturing role akin to that of a maternal figure (Kalff 2014).

The most notable feature of this stage was Ben’s preoccupation with a repetitive theme: pouring sand from one container to another (Figure 2) until the sand overflowed. The theme of the sandplay is a summary of the symbolic meanings represented by the models in the sand tray, encompassing the dominant ideas and intentions presented in the sand, as well as their symbolic significance. The ‘theme’ informs us of the fundamental meanings expressed or conveyed by the client during the sandplay. It also serves as a barometer for the process of sandplay analytical therapy, indicating changes in the client’s internal emotional journey (Shen and Gao 2012, 152). The sandtray itself symbolizes the space and container for the transformation of the psyche, with the therapist acting as the guardian of this ‘container’. Within this safe and nurturing environment, Ben was able to establish a mother–child connection with the therapist. The process of pouring sand served as a self-protective mechanism, allowing him to cultivate an inner sense of peace within the psychological space (Castellano, Private, and Red 2021). Ben also began filling other containers with sand. This repetitive action symbolized communication and connection, as sand was poured in and out of various containers. The essence of life’s continuity is embedded in repetition, representing the experience of returning to a sacred origin (Liang et al. 2021).

Figure 2.

Examples of Ben’s sand pictures (taken by the first author in 2019). Top panel (left): The theme of containers (in the sixth session). Top panel (right): The presence of trees (in the 10th session).

Ben gradually developed a clearer understanding of his relationship with both himself and the therapist throughout this process. Notably, he began to establish more eye contact and a deeper inner connection with the therapist once he was assured of the therapist’s consistent presence. When Ben encountered difficulties stabilizing animal figurines or when planted trees toppled over, he would use nonverbal cues such as eye contact and gestures to solicit the therapist’s assistance. After successfully resolving these issues together, Ben would look at the therapist, give a thumbs-up, and say ‘Good’, to which the therapist would respond in kind. Ben required repeated interactions and affirmations of this nature within a single consultation session. Consequently, there was a marked increase in interaction and collaboration between Ben and the therapist. The simulated family parents reported that Ben’s behavior had become more positive and sociable both at school and within the simulated family environment, earning praise from his teachers. During his play, Ben appeared satisfied and relaxed, as if his sense of emptiness had been addressed and the elements that once eluded him felt preserved and stabilized. The Garden of the Heart and Soul project has demonstrated that many children abandoned in their early years can, in their own way, reconnect with their nature (Deng et al. 2020). Through SPT, they can nourish themselves and achieve an internal sense of satisfaction. As SPT analysts, it is essential not only to perceive, recognize, and understand the symbolic meanings expressed by the themes in the SPT but also to engage with the visitors during the practical sessions of the sandplay therapies, feeling and absorbing the positive significance contained within these themes (Shen and Gao 2012, p.165).

The third stage: the continuous deepening of the relationship and the transformation of behaviors (sessions 13–18)

At this stage, Ben would display happiness upon seeing the therapist, waving to greet her from a distance. He also appeared joyful when the therapist visited his home. The aunt from the simulated family reported that Ben now enjoys greeting people. Additionally, the skin bleeding caused by Ben’s scratching has decreased, as has his genital scratching in public. Instead, his emotions became more stable, and he became more proactive in assisting the aunt with household chores. Ben has shown some different behaviors in the sand tray as well. He still enjoys the sandplay, but unlike before, where he would circle around the tray, he now sits on a stool and plays with the sand, becoming more engaged and focused throughout the process. Ben began to touch the sand with his hands—a behavior that had rarely occurred in previous consultations, where he had always used tools to interact with the sand. In human development, individuals initially experience life through tactile interaction with tangible objects, transitioning to abstract understanding and mastery (Amman 2012, 1). The power of SPT derives from the potential energy created by using real sand, water, and sand tools collaboratively (Bradway and McCoard 2023, 11). In SPT, by feeling and touching the sand with hands, a bridge is formed between our internal and external worlds. Within a free, safe, and protected space, individuals are able to freely create their own worlds in the sand, allowing their inner psyche to manifest in symbolic forms. This enables the full mobilization of an individual’s inner creative energies, facilitating the healing of the psyche and the comprehensive development of the personality. Additionally, through Ben’s clinical records and growth information at the children’s welfare home, it is noted that he was institutionally reared in the welfare home before 2016. In the group care model of the welfare home, caregivers had to attend to many children simultaneously. During their first three years, these children spent most of their time in cribs with protective rails. Consequently, as Ben was growing up, few people were available to mirror, appreciate, and accept his body, making it difficult for him to affirm his identity through his surroundings. The gentle touch of dry sand can induce relaxation and evoke memories of childhood games. It may also remind individuals of the tender and affectionate caresses received from their mothers or other loved ones (Amman 2012).

In the third stage, Ben began to leave fingerprints and other marks in the sand (Figure 3) as he paddled with his hands in the sandtray. In SPT, the act of using both hands mobilizes an individual’s creative energy, initiating a comprehensive process of healing and personality transformation (Amman 2012, 1). SPT places importance on both the physical and psychological aspects, emphasizing the expression of the ‘body’ and ‘hands’. When clients place their hands in the sand tray or gently touch the sand, they are ‘speaking’ in a way that simultaneously engages both the body and mind in feeling and expressing. The concept of ‘self’ became clearer, indicating that Ben had begun to connect more deeply with his body. Additionally, Ben’s sandtray included new elements, such as scales and pots, symbolizing deeper nourishment. This represents a metaphorical connection to cooking, embodying the primal image of a nurturing mother providing protection and sustenance (Amman 2012).

Figure 3.

Examples of Ben’s sand pictures (taken by the first author in 2019). Top panel (left): Handprints in the sand picture (in the 13th session). Top panel (right): The appearance of new elements such as scales and pots (in the 15th session).

Additionally, the sandtray contained elements such as cars and road-building materials. During the sand tray activities, Ben began to experiment with constructing roads by piecing together road-themed sand tools. Initially, he sought the therapist’s assistance to assemble the pieces, but over time, he became increasingly proficient at constructing the roads on his own. Road building is a realistic process of destruction and reconstruction, symbolizing the processes of bodily reconstruction, repair, and exploration. Ben’s sandtray experiences centered on creating his own path, with road construction reflecting the awakened forces within him. Discovering one’s path is a universal task; it is only when inner energy is liberated that new tasks can be accomplished (Kalff 2014). Concurrently, as the counseling relationship deepened, Ben’s behaviors, particularly his skin function, began to change. The development of a secondary skin function involves bodily defenses and auto-sensory behaviors that help manage unbearable affects often triggered by separation and abandonment. When the skin evolves as a boundary between internal and external realms, individuals can experience living within their own skin, separate yet interconnected with significant others (Brian 2020).

The fourth stage: the transformation and elimination of problematic behaviors (sessions 19–26)

During this phase, Ben became more engaged in the sandplay activities. The simulated family’s mother also reported improvements in his behavior at home and school, with almost no instances of him scratching his skin until it bled. Additionally, Ben’s involvement in schoolwork increased, and he showed greater interest and enthusiasm in participating in various activities organized by the welfare home. In the final stage of the consultation, the image of the ‘breast’ repeatedly appeared in the sandtray (Figure 4). According to Bion, the breast symbolizes the mind, with the mother providing not only love and nourishment but also her own thinking self (Margot 2022). Fordham (1985) posits that the mother’s breast is the infant’s first symbol, emerging as the infant struggles with its physical absence. The recurring presence of the breast image in the sandtray suggests that Ben was attempting to form a sensory image of the breast or nipple to retain in his memory. As Ben experienced consistent and reliable maternal care, and as a relationship of empathic attunement developed between the therapist and Ben, he began to internalize the image of a nurturing breast that comforted, soothed, calmed, and provided essential nutrients. Through these experiences of connection and separation, a symbolic space was created that facilitated thinking and reflection (Brian 2020). This may indicate that Ben was re-experiencing the crucial original mother-child attachment (Li et al. 2018). In the healing factors of psychotherapy, the most crucial is the quality of the therapeutic relationship, which can create a sacred space (Stein 2023, 38). At this stage, he was able to express his feelings, expectations, needs, and aspirations within the free and protected environment established by the therapist.

Figure 4.

Ben’s sand pictures (pictures taken by the first author in 2019). Top panel (left): The imagery of breasts (in the 22nd session). Top panel (right): Wet sand and shaping (in the 26th session).

Simultaneously, he began to engage in more creative play with water in the sandtray. During the process of using water in SPT, individuals often require more ‘hands-on’ involvement or participation through physical activities. Through the manipulation by hands, the psychic energy between water and sand takes shape. Jung wrote extensively about the similarities between alchemy and the psychotherapeutic process. The connection between alchemy and SPT lies in their shared attempt to establish a link between the conscious mind and the unconscious world. Edinger referred to the ashes left after burning in alchemy as ‘white earth’, which corresponds to the ‘sand’ in SPT. The melting process in alchemy parallels the element of ‘water’ in the sand tray. Edinger stated: ‘Concepts and abstractions do not coalesce… It is the images of dreams and active imagination that coalesce, bridging the internal and external worlds… thereby consolidating the elements of the psyche. Our moods and emotions leave us unsettled unless they can coalesce into something tangible and visible, allowing us to make an objective connection’ (Edinger 1958, 100). SPT provides a space for ‘dissolution and coalescence’. Through the processes of playing with sand, smoothing it, molding it, and sprinkling water, Ben is able to create within the sand tray. This activity allows his inner self to gradually settle and coalesce. When sand is wet, it becomes solid enough to be shaped like soil. Similar to the inner life of the psyche, sand embodies both the energy of movement and the energy of stillness (Amman 2012).

In this process, Ben regained the ability to nourish his mind and achieved a greater integration of body and psychology. According to the results from interviews with the simulated family, Ben’s scratching behavior was significantly reduced, and he rarely scratched his genitals in public. Additionally, his emotional functioning improved; his aggressive behavior diminished, he became better tempered, and he no longer threw things impulsively. Remarkably, Ben also developed a heightened sensitivity to the feelings of those around him and began to take the initiative to care for others. For instance, after a consultation, he noticed the rainfall outside and reminded the therapist to take an umbrella before leaving. This may indicate that Ben has developed a more complete sense of his self and capacity, making him more sensitive to his own emotions and those of the people around him.

Result

The findings can be categorized into three main themes: (1) Sandplay Game Theme: As previously noted, Ben’s process involved several themes, including animal intercourse and repeated sand-dumping. Additionally, throughout the intervention, almost all sandtrays featured containers that held Ben’s emotions and unconscious desires. This observation highlights the importance of providing a container—a free and protected space—for orphaned children and children with disabilities. Such a space serves as a place to contain and manage emotions, helping children gradually restore their internal order and establish new, healthy relationships with the outside world. (2) Synergistic Development of Psychology and Physiology: Ben engaged with the sand on a sensory level, which is crucial in the symbolic experience of sandplay games. The tactile sensation of sand under his palms provided an embodied, symbolic experience with a self-regulating effect on his body. This experience contributed to the maturation of Ben’s integrated psycho-physical system. Moreover, Ben demonstrated the ability to classify and arrange objects in the sandplay game, placing sandtray tools and animal miniatures in an organized manner. This improvement was also reflected in his enhanced hand-eye coordination and fine motor skills in daily life. (3) Realistic Feedback and Change: Ben’s self-care abilities and emotional functioning in daily life improved significantly. Children in simulated families demonstrated increased independence in dressing, eating, and using the toilet. Additionally, they proactively engaged in simple household tasks, such as picking vegetables and collecting clothes. These changes led to reduced emotional fluctuations and aggressive behaviors, facilitating better interactions with their peers.

Discussion

In this study, SPT interventions were applied to address issues of emotional regulation, sexual psychology, and behavior in orphaned and disabled children at a child welfare institution. Using the unique advantages of sandplay, Ben was able to express and process his emotions. The entire sandplay process, his external behaviors, and feedback from related staff suggest that SPT contributed positively to improvements in his emotional state and motor coordination. This efficacy is linked to the nonverbal nature of SPT, which enables children to articulate their emotional and mental states without the need for adults to interpret them, thereby accessing preverbal experiences (Roesler 2019). This indicates that individual interventions using SPT are effective, warranting further extensive and in-depth research.

Secondly, SPT is a typical nonverbal approach. The distinctiveness of SPT, compared to other nonverbal art therapies, lies in its primary material: sand. By interacting with the sand, the client’s playful imagination is stimulated, initiating a dynamic process of sand ‘play’ that evolves over time. The sand also links the body and mind through both tactile and visual senses, providing a potent healing force. The therapist, observing this interaction, is also influenced by the power of the sand through sight, creating a shared creative space (Akimoto et al. 2021). In this study, communication barriers existed between Ben and the therapist, with Ben only able to respond using simple language. Nevertheless, he greatly enjoyed the sandplay game and consistently engaged with the sandtray during nearly every counseling session. Previous research has demonstrated that children with intellectual disabilities often prefer games based on nonverbal expression (Li et al. 2018). This also suggests the potential for further promotion of SPT in psychological intervention work at children’s welfare institutions in China.

This study’s intervention process is based on the theories of sandplay and analytical psychology, with the most crucial aspect being the creation of a free, safe, and protected space for Ben, which is vital for the counseling relationship. It includes the spontaneous synchronization of frontal cortical tissue oxygenation occurs between dyads participating in sandplay (Akimoto et al. 2021). In the safe and protected environment created by the therapist, SPT allows for nonverbal communication and the expression of the client’s inner world through images and symbols in the medium of sand. By transforming emotional content into a sandtray representation, clients can directly alter and adjust their inner thoughts and emotions, thereby restructuring their inner world and establishing order. Through sandtray activities, Ben showed improvements in his emotional and affective functioning, along with effective release and management of his sexual and aggressive impulses. This process contributed to an enhancement of Ben’s self-identity and the development of a positive self-concept.

Conclusions

Although further research is warranted, the current evidence underscores the potential benefits of SPT in clinical practice. Sandplay, as a nonverbal therapeutic approach, possesses an internal mechanism that is universally applicable across cultures. This mechanism allows orphaned children and those with disabilities to communicate their experiences independently through the play process, thereby enhancing their coping abilities and reducing feelings of insecurity or anxiety. Before the sandplay intervention, Ben exhibited unstable emotions and sometimes strong aggression. Through SPT, Ben was able to freely express and release suppressed emotions during the counseling process. This intervention helped him visualize difficult-to-articulate feelings, conflicts, and psychological barriers, thereby deepening his self-awareness, enhancing his emotional regulation abilities, reducing aggression, and improving his physical coordination. SPT offers substantial advantages for orphaned children and those with intellectual disabilities in welfare institutions, allowing them to engage with sand at a sensory level. This interaction helps them connect with their own bodies and activate their internal creative energy.

Ben’s case study provided insights into sandplay data involving a young child with Down syndrome and intellectual disabilities. Overall, Ben’s actions and content in sandplay displayed certain repetitiveness and monotony. Compared to normal children’s sandplay activities, Ben’s actions during sandplay were relatively simple, lacking variety and complexity. This may be related to his developmental level in cognitive skills, imagination, and thinking abilities, making it difficult for him to construct complex and creative scenes. Therefore, this also suggests that during sandplay interventions, it is crucial to consider the individual differences and developmental levels of different children, devise personalized intervention plans, and conduct ongoing observation and evaluation.

Limitations and future research

Although Ben’s case study revealed inspiring changes and developments, it is important to acknowledge that his psychosocial progress was influenced by multiple factors, including the simulated family environment, the education provided by his school, and the various services offered by the welfare institution. Consequently, assessing the true effectiveness of sandplay-based interventions in addressing emotional, affective, and behavioral issues in children with intellectual disabilities is complex, and the generalizability of these results is somewhat limited.

To provide more scientific and effective psychological support services for orphaned and abandoned children, future research should focus on the psychological characteristics of these children in Chinese welfare institutions and the specifics of SPT. It is recommended to conduct a comprehensive review and summary of SPT cases at 90 workstations across China, known as the 'the Garden of Heart and Soul’ project. Many of these children are treated differently due to congenital defects and even abandonment, and their traumatic experiences need to be better recognized and addressed. Future studies could expand the sample size and perform coding and thematic analysis of the sand pictures created by these children. This would offer clinical guidance and theoretical support for the psychological assessment and case conceptualization of orphaned and abandoned children, and attempt to develop a model of psychological development for these children based on clinical practice and an in-depth study of Jungian theory. Particularly in light of the challenges faced during the past three years of the pandemic, the Garden of Heart and Soul project within the Welfare Institution has encountered significant difficulties. Since January 2023, our efforts have gradually returned to normalcy. Moving forward, our objective will be not only to guide these children towards brighter futures as an instrumental goal but also to protect and nurture the intrinsic light within their lives. Every life has inherent value, and that light belongs to them.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Disclosure statement

No potential conflict of interest was reported by the authors.

Data availability statement

The datasets generated and analyzed during this study are not publicly available due to the sensitive nature of the information. Privacy and ethical restrictions prevent the disclosure of this data.