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Using Sandtray in Clinical Consultation

Once a month I facilitate a consultation group for play therapists. Last year we shared a process over a series of months that illustrated many complex dynamics within supervisory/ consultation relationships, as well as the ones between clinician and client.  The evolution and outcome of that process, what it indicated about our group community and the individuals within it, and how it provided a clear example of using expressive means for clinical consultation excited me so much that I asked permission to write it up, and invited collaboration. Two members contributed their reflections and insights, which added additional depth of meaning to the overall experience. 

Once written, it was submitted to the magazine Play Therapy, whose December issue would be focusing on supervision. A new format and discipline for my writing practice- learning proper APA citation, third person voice, headings, and working with editors. There was, admittedly, some initial grumbling before the full delight of editorial guidance was realized. 

Thanks to Kira Maritano and Whitney Sullivan who encouraged the use of “recycling & reusing” thoughts across audiences.  This month’s offering is the published article from Play Therapy Volume 14, Issue 4, December 2019. 

Structure, Symbol, and Countertransference in Group Sandtray Consultation
Authors: Heather Maritano, LCSW, RPT-S, Cheryl Mansell, LCSW, and Lynda Ransburg, LCSW, RPT-S.

This article describes the use of an expressive modality to address countertransference issues within a clinical consultation group and to clarify the dynamics of the case being presented.
 
Distinguishing Supervision and Consultation
Supervision is a relationship with legal implications regarding the chain of liability, access to clinical information, and authority to insist on a course of action. A consultation relationship is a voluntary process motivated by one’s own desire for professional development, clinical enhancement, and peer support without explicit authority. A supervisor has criteria which must be assessed and tended; during consultation, though, a consultee primarily sets the agenda for the session. Persons providing supervision and/or consultation should be knowledgeable about the legal ramifications and responsibilities of the service provided and use the proper terms accordingly. In this article, we use the words interchangeably to describe processes used, not roles defined.   
 
Structure and Symbol in Group Consultation: Developing a Learning Community
Stewart and Echterling (2008) discuss the supervisory relationship as one of a learning community. They describe ways in which rituals and routines enhance the overall experience by increasing collective identity, providing predictability that allows for risk taking, and ultimately evolves toward the members making the group uniquely theirs.

The intentional use of symbolic expression deepens the reflective process and expands communication (Luke, 2008). Our opening ritual of selecting a miniature to share what we are bringing within us as we start our process, provides a bridge from our day-to-day experiences to the work of exploring our professional selves. In using the expressive means to “arrive” with one another, we increase group cohesion and begin to experience potential transference and countertransference material that may emerge in our clinical explorations for that session. Generally speaking, transference occurs when feelings one has are unconsciously redirected to someone else; countertransference moves in the opposite direction, as a reaction to transference (Social Work Degree Guide, 2019; Tudor & Merry, 2006a, 2006b).
 
Within this particular group, all of us have sandtray training. This ritual continues to reinforce the power of symbolic means of expression, ensuring that we practice with the tools we rely on in our work. Heather, as supervisor, consultant and presenter, tries to weave nurturing and mindfulness into the overall learning process. A goal of this experience is for supervisees to be nourished while learning to be attentive and slowing down. The this end, the group shares a healthy home-baked treat and uses a colored liquid times to re-settle ourselves between case presentations, closing one story before beginning another.
 
In group, the time is divided among the participants that wish to present. Members are asked to prepare in advance and to present an intention, such as a case-related goal or other professional issue. Although the topics can be broad, the expectation is that each person arrives prepared to get the most from the process. Clarity about the goals and desired feedback is helpful for all parties. 
 
Resolving Confusion and Countertransference: A Case Example
 3 months in a row Lynda, an RPT-S with over 20 years of experience, brought the same case for consultation: a young adolescent with significant physical and cognitive impairment. It was a client she had been working with for a long time and for whom treatment had evolved over time. Lynda struggled to articulate her question or concern, and even to provide the most basic case conceptualization material. The identified client and treatment goals seemed to constantly shift; we could not keep track of them.  Everyone in the group struggled with how to be most helpful, as we could see her spinning.
 
Cheryl described how “each time Lynda presented the case, I got more and more confused, I think she did too, on what it was she was looking for from supervision. It seemed that the confusion that emerged from her shifting details generated frustration in the group.  We did not know how to help her, and only added further confusion when we tried.”
 
Lynda indicated feeling guilty in the group because “My way of explaining isn’t working, and I’m trying to fit into their way of understanding, I want to help them help me. I’m such an internal processor, I’m struggling to bring it out”
 
As the group facilitator, Heather was becoming keenly aware of the countertransference energies pulsating in the group. The subjective experience of each member was being received loud and clear, flooding the small space. Heather felt a wide range of intense feelings and the pressure of assuming the facilitator role in a group of experienced play therapists with whom long-term connections and overlapping relationships have been developed. Trust in herself began to waiver. How does the supervisor productively hold all that there is to hold toward some fruitful outcome for all involved? How could she best handle her own feelings of anxiety and frustration? Heather had known Lynda the longest, and the personal-professional boundaries between them were the most diffuse in the group. Heather’s familiarity with Lynda’s process added fuel to the countertransference fire. Shame spirals were on the horizon.
 
Linda Cunningham (2013) addressed contemporary understandings of countertransference through a positive and productive lens wherein there is “an emphasis on its information function rather than on its interference in the therapeutic endeavor. Its value lies in the fact that is may be a tremendously helpful healing tool.” (Cunningham, 2013, p. 2).  Gil and Rubin (2008) offered that therapeutic play in the context of clinical supervision may help address countertransference responses to inform and enhance self-awareness.
 
Sandtray as a Means of Self-Expression
 Clearly, the reliance on verbal means was not working. We needed to try a different avenue. Stewart and Echterling (2008) suggested that supervisors explore instructional approaches that offer structure, meaning, and connectivity to their supervisee’s experience. Through her comments, Lynda had indicated that a visual process might be more effective in meeting her needs. Sandtray came to my mind and made sense to implement in this group of sandtray-trained therapists.
 
Several authors identified the benefits of sandtray for addressing many of the issues we were struggling with: difficulty articulating verbally, countertransference, intense emotions, and lack of clarity (Morrison and Homeyer, 2008; Rubin & Gil, 2008, Stewart and Echterling, 2008). Morrison and Homeyer (2008) state that “advanced supervision often requires supervisees to process intra- and interpersonal difficulties, sand tray provides opportunity to explore these types of issues nonverbally” p. 233).
 
In our group, although we always start with experiential process, we often defer to talking about our cases for the bulk of our consultation time. We overly rely on cognitive and abstract means wherein we are not maximizing the use of what we all supposedly value: play and expressive means. We should be facilitating consultation in a method more congruent with our own clinical practices.
 
In the next session, we altered our standard format and give Lynda an hour to present this case in a Sandtray to give the group a larger range of material for gaining insight into the case and to give Lynda a better sense of herself within that context. Our rituals and routines have helped to establish security and connection. We know from attachment theory that it is from a secure base that greater risks can be taken and new learning derived.
 
Additionally, because everyone in this particular group had training and experience with Sandtray, we were not introducing a powerful foreign process into an already vulnerable situation. There was enough cohesion within the group and comfort with Sandtray to make this a responsible suggestion. As facilitator, Heather has extensive training in Sandtray and access to her own consultants, if needed. As supervisors/ consultants, it is essential to maintain our own on-going consultation relationships, as well.
 
Our Sandtray Process and Results
 At the next session, Lynda arrived early and began moving trays into position in a line. Although Heather’s immediate impulse was to set a limit of using only one tray in order to provide containment of what was already being experienced as overwhelming, Lynda requested five trays. We compromised at three. The group acknowledged Lynda’s expressed need for multiple trays, though everyone remained concerned about continuing to replicate the confusion we were trying to address through sandtray containment.
 
Lynda laid out the three trays in a line, and the remainder of the group sat along the sides. She began to gather images, mostly human figures. Having done trays with Lynda before, Heather noted that the more concrete representational figures were a departure from her usual way of working in the sand. She set them up in the various trays. There was not much in the way of landscaping or metaphor, these trays felt more like a genogram using figurines.
 
After setting up the trays, Lynda began to talk about the various characters depicted and her relationship to each.  She began ruling out characters as periphery to her work with her identified client, and began to see some of the ways in which her focus had gotten lost in extraneous details and relationships. While a full assessment is important, she was holding too much information in the forefront.
 
Cheryl, a group participant, wrote the following summary of the process,  
 
“when Lynda began with three trays it continued to be overwhelming but helped to understand why it was she was struggling with the case, and what she needed.  She had many connections to all the participants and I feel their various agendas clouded what her and the child’s goal was for treatment. 
 
I also feel it brought to light her struggles with her own boundaries, her role in the treatment process, and not to be the everything to everyone that is involved. I think the sand narrowed her focus to where it needed to be, helped her let go of those extended families (trays), and move back to the original client and goal for treatment.  
 
I think the use of sand tray was very helpful for us to see her jumbled brain, help us to understand it better, and be able to help move the focus to the “one tray”.
 
After this session, Lynda stated, “I was so entangled, putting it all in the sandtrays helped me disentangle it”.  She reflected that she needed the space of multiple trays to express what felt too chaotic for her to contain in one tray. Her right brain knew what she needed, even if all the left brains in the room logically thought fewer trays would be clearer. By expanding the systems across three trays, Lynda became able to articulate how entwined the mother and child were, and the ways in which she had conflated them as well. She had trouble identifying the needs of her child client because the needs of the child’s mother were difficult to extricate.  “I needed space to see the lack of space between the mother and child.”
 
Lynda reported back to the group that after the Sandtray session, she altered her work with the client significantly. Her biggest shift was to focus individually on the needs of the client, to see them in sessions without either of their parents. She gave them their own space to experience self and the therapy relationship outside the conflicting energies of all the other characters in their life. Lynda began to see and appreciate this young person, to access their capabilities which had been so diminished by everyone else. The Sandtray process restored Lynda’s confidence and creativity, and her delight was evident in the radiant smile on her face as she shared the new ways she was working, and the progress being made.
 
 References
 A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful: Techniques for child and play therapist supervisors. Lanham, MD: Jason Aronson.    

Bratton, S., Ceballos, P., & Sheely, A. (2008). Expressive Arts in a Humanistic Approach to Play Therapy Supervision. In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful: Techniques for child and play therapist supervisors (pp.211-232). Lanham, MD: Jason Aronson.    

Counselling Tutor, ltd. (2019). Retrieved from https://counsellingtutor.com/transference-and-countertransference 

Cunningham, L (2013). Sandplay and the Clinical Relationship. (pp. 2). San Francisco, CA: Sempervirens Press.

 
Gibbs, K. & Green, E. (2008). Sanding in Supervision, A Sand Tray Technique for clinical Supervisors. In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful:  Techniques for child and play therapist supervisors (pp.27-38). Lanham, MD: Jason Aronson.    
 
Lukes, M. (2008). Supervision: Models, Principles, and Process Issues. In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful:  Techniques for child and play therapist supervisors (pp.7-27). Lanham, MD: Jason Aronson.    
 
Morrison, M. & Homeyer, L. E. (2008). Supervision in the Sand. In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful:  Techniques for child and play therapist supervisors (pp.233-248). Lanham, MD: Jason Aronson.    
 
Rubin, L & Gil, E. (2008). Countertransference Play, Informing and Enhancing Therapist Self-Awareness through Play.  In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful: Techniques for child and play therapist supervisors (pp.249-267). Lanham, MD: Jason Aronson.    
 
Social Work Degree Guide. (2019). Derived from: https://www.socialworkdegreeguide.com/faq/what-is-countertransference/
 
Stewart, A., & Echterling, L. G. (2008). Playful supervision: Sharing exemplary exercises in the supervision of play therapists. In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful:  Techniques for child and play therapist supervisors (pp.281-307). Lanham, MD: Jason Aronson.    
 
About the Authors
 Heather Maritano, LCSW, RPT-S developed a small group practice from which she provides therapy, training, and consultation. She’s committed to serving her professional and personal communities in a variety of ways, with a focus on social justice issues. Heather regularly practices her belief in the healing powers of play and is particularly fond of dancing.
 
Cheryl Mansell, LCSW, is the founder of New Outlook Counseling Center, Inc.  She has worked in a variety of facilities cultivating her skills and abilities as a therapist. She has been through the Foundational and the Advanced Intensive DBT training, received her certificate in Collaborative Divorce Training, taken Level 1 of Theraplay, has been trained in play therapy and recently submitted the application to receive her credential as a Registered Play Therapist.
 
Lynda Ransburg, LCSW, RPT-S  works in private practice, and has many years experience working in different agencies where she provided treatment for individuals, families and groups across the lifespan. She has been a supervisor for masters level students, as well as to those pursuing becoming play therapists. She served on the Indiana Association for Play Therapy Board for 6 years, and for the past decade has been a member of the Bloomington Task Force for Perinatal Mood Disorders.