Can sandplay therapy change the brain as it reduces anxiety? A case study using neuroimaging

Sandplay therapy is a nonverbal, multisensory, psychodynamic treatment method for children and adults. With roots in play therapy, the theories of C. G. Jung, and Eastern contemplative practices, sandplay has been growing in popularity worldwide. Research has shown sandplay to be effective in reducing anxiety as measured by rating scales that focus on clinical symptoms.

A recent article in the International Journal of Play Therapyopens in new window by Mariana Foo, Lorraine Freedle, Riryn Sani, and Grace Fonda assesses the effect of sandplay therapy on symptoms and brain metabolite changes in the thalamus of a 23-year-old female patient with general anxiety disorder (GAD). What’s new about this study is that it explores whether the improvement in clinical symptoms from the use of sandplay therapy also involves neurophysiological change.

This single-case study looks at symptom improvement using the Hamilton Anxiety Rating and General Anxiety-7 scales. Building on prior studies that used neuroimaging to examine GAD, the authors used proton magnetic resonance spectroscopy to measure brain metabolites with a particular focus on the ratio of N-Acetylaspartate to creatine—a measure of how well neurons in the brain are able to function.

Along with the therapeutic relationship, the multisensory aspects of sandplay therapy are an important and underlying mechanism for change. The authors chose the thalamus as the targeted brain region of this study because it has an essential role in processing sensory input. It also has interconnections with the amygdala and the limbic system, which are known to be implicated in GAD.

The study began with a 45-day wait to establish the baseline. Next, the 23-year-old participant received 18 one-hour sessions of sandplay therapy over 9 weeks conducted by a qualified sandplay therapist. Her anxiety showed no improvement during the waiting period; however, after treatment with sandplay therapy, her symptoms on both anxiety scales dropped from the severe range to the normal range. Imaging showed that the participant’s ratios of N-Acetylaspartate to creatine in both the right and left thalamus were below the healthy range during the baseline period and increased to within the normal range after treatment. It is possible that sandplay not only reduces clinical symptoms of GAD but also promotes brain health and function, particularly in subcortical systems.

The authors were particularly interested in subcortical brain systems, because these systems not only regulate safety, sensory input, and the stress response but also play a critical role in supporting the “thinking brain.” People with GAD may experience both clinical and neurophysiological improvement with sandplay therapy that could affect how they think, feel, and react to stressors in their lives. More research is needed and is currently underway.

Note: This article is in the Clinical Psychology topic area. View more articles in the Clinical Psychology topic area.

Foo, M., Freedle, L.R., Sani, R. & Fonda, G. (2020). The effect of sandplay therapy on the thalamus in the treatment of generalized anxiety disorder: A case report. International Journal of Play Therapy, 29 (4), 191-200. https://doi.org/10.1037/pla0000137opens in new window

Mariana Foo, PhDopens in new window is an internationally certified sandplay therapist (ISST), play therapist, counselor, and the director of Perhati Counseling and Care Center in Jakarta, Indonesia. In her practice, Dr. Foo works with individuals, families, and groups to treat mental, behavioral, and emotional problems. Dr. Foo’s research interests focus on anxiety disorders.

Lorraine R. Freedle, PhD, ABPdN is a clinical psychologist, pediatric neuropsychologist, and internationally certified sandplay therapist and teacher (STA/ISST). She is on faculty at Southwestern College in Santa Fe, New Mexico and maintains a private practice, Black Sand Neuropsychological Services in Hilo, Hawaii. Dr. Freedle has numerous publications in the areas of sandplay, neuropsychology, and trauma and currently serves as president of the Sandplay Therapists of America and research editor for the Journal of Sandplay Therapy.

Riryn Sani, MPsi is a clinical psychologist who works with clients with various psychological issues, ranging from daily stress, depression, and anxiety symptoms, bipolar disorder, to personality disorder. She serves on faculty at Pelita Harapan University, Tangerang, Indonesia. Her research interests focus on clinical psychology and working together with experts in neuropsychology, psychotherapy, and psychometry to provide integrative studies of the mind and behavior.

Grace Fonda, MD is a graduated medical doctor from Pelita Harapan University who currently practices as a general physician in a private hospital in Jakarta, Indonesia. Dr. Fonda’s research interests focus on neuroscience.