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Psychiatry and group therapy
For the treatment of mental illness, psychiatric science has tried various treatment methods such as group camps, personal analysis, sleep therapy, electro-shock therapy, treatment communities, psychodrama and medication over the past centuries. (Shorter, 1997/2009, pp.377-389). Freud (1995) emphasized the importance of groups in his research ‘an analysis of group psychology and self’. There is always someone involved in the individual’s mind, and the basis of individual psychology is the beginning of collective psychology at the same time (Freud 1995). Group therapy has different therapeutic values from individual psychotherapy.
Bierer (1980) attempted group therapy for inpatients at a public psychiatric hospital in London in 1938. He established the principle of group therapy, which patients decide on their own and insight, and called it “community therapy.” This is the beginning of group therapy that began in the UK (Bierer 1980). Since then, group therapy has been active in various ways in schools as well as hospitals, correctional facilities, and social welfare facilities for numerous patients and specific groups (Scheidlinger & Schamess, 1992).
Group therapy for patients complaining of similar symptoms simultaneously delivers information and has the efficiency to treat many subjects in a short time with limited number of therapists and efforts (MacKenzie, K. R., 1994). In addition, the effect of group therapy is not much different from individual therapy, and depending on the patient, group therapy is more effective than individual therapy (Dies, 1992).
Sand play and group therapy
In 1931, Lowenfeld first reported the world technique using sand, water, toys and boxes to children suffering from neurosis. Based on Lowenfeld’s World Technique, Kalff integrated Jung’s analytical psychology with oriental meditation and named it ‘sandspiel’ (Kalff, 1980/2003, pp.1-17). Sand play therapy (SPT) has been introduced to many countries around the world for more than 90 years and has been applied to mental health problems of adults as well as children in various environments such as schools and hospitals (Roesler, 2019; Ahn et al., 2021; Lee & Jang, 2015; Wiersma et al., 2022, Zhou et al., 2009; Enns et al., 2003).
Studies on SPT have historically focused on theoretical and qualitative exploration that emphasizes case studies and multi-case study designs.
However, a number of academic research on group therapy began to be reported in the 1990s (Okada, 1991; Carmichael, Echols, & Warren, 1997; James, & Martin, 2002; Domenico, 2002). Compared to individual case studies, SP group therapy facilitates psychological and psychiatric-based psychological research (Ahn, 2021). In addition, it is highly useful as a mental health program in a structured environment such as school (Ahn et al., 2020; Kwak et al., 2020).
In the case of Korea, studies that outline Korea’s SPT research trends have been introduced since 2010 (Kang & Lee, 2010; Lee & Jang, 2015; Ahn et al., 2020; Ahn et al., 2021; Park & Seo, 2022). Lee and Jang (2015) conducted meta-verification of SPT effects in Korea to analyze the therapeutic effects of group therapy and individual therapy, while Ahn et al. (2022) investigated research trends of SP group therapy in Korea and analyzed the research and treatment methods of group therapy. Roesler (2019) reviewed an overview of the evidence-based in SPT studies in many countries around the world, and confirmed the significant improvement of SPT through the magnitude of moderate effects on child and adult mental health problems. However, there was no separate distinction between group therapy and individual therapy. According to a Korean SPT treatment effect meta-study, there is a difference in the effect size (cohen’s d = 1.093) of individual therapy (cohen’s d = 1.596) and group therapy (cohen’s d = 1.032) or group therapy combined with individual and group (Lee, 2015). However, it was not considered that there were fewer treatment sessions for group therapy than individual therapy. Through meta-analysis of SPT studies in more than 16 countries, Wiersma et al. (2022) presented the greatest improvement in treatment methods in 50-60 minute sessions twice a week.
However, group therapy shares therapeutic factors applied to SP individual therapy such as ‘play, transfer, meditation, and symbolic experience’ (Ahn, 2021), but includes therapeutic factors unique to group therapy, such as ‘expectation and opening’ and ‘sympathy and acceptance’ in which participants show each other’s works. Since SP group therapy has different treatment methods and therapeutic values from individual therapy, it is time for a separate study on SP group therapy. In this way, SP group therapy has different treatment methods and therapeutic values from individual therapy.
Additionally, SP group therapy shares therapeutic factors with traditional group therapy. MaCormick (2019) randomly assigned 169 addicted patients to SP group therapy (SGT) and cognitive behavioral (CBT) group therapy, and administered the Therapeutic Factors Inventory (TIF) to participants and observers. According to MaCormick, the sand play group received significant scores in all four therapeutic factor categories, including ‘hope-raising’, ‘emotional expression’, ‘interpersonal relationships’, and ‘social learning’, compared to the cognitive-behavioral group.
Modern SPT (sand play therapy) is evolving from individual psychotherapy based on empiricist psychology to group therapy based on evidence-based psychology. However, there is no systematic literature study on SP(Sand Play) group therapy, and recent reviews of SPT also did not systematically distinguish between group therapy and individual therapy. Therefore, this study systematically reviewed the literature on SP group therapy, which is developing into evidence-based psychology based on empiricist psychology, and explored the development process of group therapy. According to Homes (2000), in the treatment process, group therapy focuses more on focusing on others and self and relationships, while individual therapy focuses more on emotional awareness and insight. However, in the case of SP group therapy, it implements unique therapeutic value and function in that it interacts with sand play works based on the therapeutic factor of SP individual therapy, ‘free and protected space.’As such, SP group therapy is developing various treatment methods and unique therapeutic values, and therefore, it is time to systematically review the development process of SP group therapy. This study is significant in that it is the first group therapy overview study that analyzes SP group therapy in various countries around the world based on the time of presentation, research content, and treatment method.
Methods
Overseas academic papers were searched using electronic information services such as Google Scholar (https://scholar.google.co.kr) and PUBMED (https://pubmed.ncbi.nlm.nih.gov/) to analyze overseas research trends on SP group therapy. Search keywords were ‘sand play, group’, ‘sandplay, group’, and ‘sand tray, group’. By reviewing the titles and abstracts of the searched academic journal papers, the original text was collected from papers believed to correspond to group therapy research, and 195 original texts were secured.
Since SPT was actively distributed in East Asia such as Korea, Japan, and China (Rolser, 2019), Chinese and Japanese academic journals were separately searched. In addition, papers from Chinese and Japanese academic journals, which are difficult to search electronic information, were separately collected with the help of SPT researchers in the country.
Papers and dissertations that do not correspond to group therapy, such as individual therapy and overview research, were excluded. Roesler (2019) presented as the basis for evidence-based research whether at least 15 study subjects, at least 5 treatment sessions were applied to the individual or group environment, and whether objective measurement of treatment effect was reported. However, after reviewing the text, this study ruled out studies that did not suggest that two or more participants in the group or that did not describe how sand play was performed as group therapy. For example, in the study of Roesler (2019), the study of Han et al. (2017) was classified as group therapy, but in this study, it was excluded for the above reasons.
In addition, in the case of studies with less than 15 participants and less than 5 treatment sessions, studies that applied group interaction around sand boxes in the treatment method (HMT) and appreciation method were selected as group therapy studies. The studies with less than 5 treatment sessions include Zheng et al. (2019), 4 sessions and Yahaya et al. (2019), 4 sessions. Zheng et al. (2019) applied the interaction of group therapy to produce and appreciate sand boxes as a variable of interpersonal relationships as a treatment method. Yahaya et al. (2019) also conducted repeated measurement variance analysis (MANOVA) with randomized controlled trial (RCT) of 16 experimental groups and 16 control groups, but it was a short-term treatment in four sessions. However, a group therapy method was implemented in which group members appreciated each other’s sand works, and it was considered that youth participants with low self-esteem applied a treatment method of sand play group therapy to appreciate and communicate with each other.
The 40 papers selected for the study were analyzed for the published research content and treatment methods, and based on these, they were divided into three periods. The contents of the study were analyzed based on research designs such as research subjects, variables, research methods, measurement tools, and statistical analysis. The treatment method was analyzed based on the basics such as treatment session (S) and treatment time (T), how group members make sand works (HMT=How to Make sandtray), tray size (TS), and whether to present a structured group program table (PT=Program Table). The timing classification was divided into three periods based on the research content and the presence or absence of treatment methods.
Results
International academic research on SP group therapy is classified by ‘year of publication, research content, and treatment method’ as follows.
<Table 1> is the literature of the ‘first phase, explorer’. Bader and Miller (1980) considered SP group therapy as a therapeutic factor that could provide an opportunity to safely share the participants’ inner world with others, and introduced logos, an intellectual approach, and erotic method that does not interpret the work. The therapist creates a free and safe environment during the group therapy process, and is responsible for the group’s atmosphere and the interaction of the participants.
Okada (1991) introduced a method of group therapy in which one participant brings props in one box in order, and the rest of the participants accept the meaning in silence. Through this method, he considered that the experience of appreciating and empathizing with the work could be induced through the interaction that occurs in the process of producing a single sand work together. He suggested that empathy and acceptance through work would be useful as a training method for therapists.
The first phase, ‘the time to explore’, can be referred to as an “exploratory period” in which theoretical and methodical studies for conducting SPT in the form of a group, such as the theoretical concept of conducting group therapy for couples and families (Carmichael et al., 1997; Domenico, 2002) and the usefulness of student counseling in schools (Kestly, 2001). Researchers in ‘The time to explore’ explored the therapeutic potential of SP group therapy. The possibility of applying SP individual therapy as group therapy in clinical settings was explored, and the therapeutic characteristics of SP group therapy and treatment methods of group therapy were explored.
<Table 2> is the literature of the ‘second phase, qualitative research period’. James et al. (2002) introduced the therapeutic value of SP group therapy in a safe communication method to the parent-child relationship problem of addicted adolescents, and Draper (2003) suggested that group therapy is useful in achieving developmental goals in need of relationship improvement and social skills. In addition, the session of group therapy was structured as a treatment method.
Noriko (2003) revalued the meaning of creating a “free and protected space” suggested by Kalff in group therapy through the introduction and interviews of the participants’ works. SP group therapy includes therapeutic factors such as creating a safe space, mutual motivation through sand works, cohesion formed in the group over and over sessions, and acceptance of others and oneself. These therapeutic factors are activated through images of sand works that are not expressed in language.
Lacroix et al. (2007) qualitatively analyzed the contents of sand works of preschoolers who suffered a disaster, Tsunami, and observed the process of safely expressing and accepting trauma. Spooner et al. (2007) applied SP group therapy as an auxiliary intervention technique in the group treatment of sexually addictive patients. They considered the way that participants can express their own meaning without right or wrong in sand works, group therapy can appreciate sand works together, and accept meaning through this non-verbal communication method as a therapeutic factor. As a qualitative research method that introduces the treatment process of group therapy participants through sand works, it was reported that the reproduction of symbolic trauma was accepted through group empathy.
The “second phase” is meaningful in that SPT began to be applied as a treatment technique in the clinical field as specific treatment methods such as treatment sessions and time were attempted to various subjects such as children, adolescents, college students, and families. The ‘qualitative research period’ is characterized by the fact that SP group therapy began to be used as a psychotherapy technique in actual clinical settings and that it presented a method to vividly convey the process of group therapy through qualitative research methods.
<Table 3> is the literature of the ‘third stage, evidence-based research period’. Flahive et al. (2007) performed group therapy for a total of 10 times and 45 minutes once a week to 28 experimental groups and 28 control groups, evaluated BASC (Behavior Assessment System for Children) to participants, teachers, and parents, and presented ANCOVA statistical analysis and treatment effects (Cohen’s D). This is the beginning of a study based on sand play group therapy. However, the interaction of the group that creates and appreciates sand works by the group members is not presented.
* Treatment Method : S= Session, W= Number of sessions per week, T= Minutes per session, SGN = Small Group Number, TS= sand Tray Size [0= 72*57*7cm, ?=Unknown, S= small tray], HMT= How to Make SandTray.[1T1= one tray with 1 client, 1T4=clients share one tray, t=clients turn in one tray, ex; 1T4t = In one sand tray, four clients make it one by one in order. PT= Presence or absence of Program Table [0=Presence, ?=Unknown, X=absence]
* Measures: BASC;Behavior Assessment System for Children, CSES;Core Self-Evaluation Scale, CSI-4;Child’s morbid signs questionnaire, ERS;Ego-resilience scale, GEQ-34;Grief Experience Questionnaire, IIP-C;Inventory of Interpersonal Problems Circumplex Scales, ITS;Interpersonal Trust Scale, PSQI;Pittsburgh sleep quality index, RFQ;Risk factor questionnaire, SIAS;Social Interaction Anxiety Scale, SPPC;Harter’s Self-Perception Profile for Children, SECS;self-expression classification scale, STAS;State-Trait Anxiety Scale, SPCAS;Spence Preschool Children ‘s Anxiety Scale, SDQ:Strengths and Difficulties Questionnaire, SAD;Social Avodandce and Distress Scale, SCSQ; Simplified Coping Style Questionnaire, SRS;Social Responsiveness Scale, SRQ;Self-reflection questionnaire, SQI;Pittsburgh sleep quality index, PUPI;University personality inventory.
Meanwhile, studies from the “ground-based research journal” began to be introduced to the field of global medical science as they were published in the Science Citation Index (SCI). When searching for sand play group therapy studies in PUBMED run by the United States National Library of Medicine (NLM), five sand play group therapy studies were introduced from 2019.
Three of these studies (Li et al., 2019; Liu et al., 2019; Wang et al., 2020) have been applied to Asperger syndrome, social interaction of autistic children, and social atrophy and emotional cognitive treatment in hospitals in China. As a treatment method, after five individual therapies, five group therapy for two people and five group therapy for three people with ordinary children were performed, and the Okada method was performed in which participants placed props in order in one sand box.
The remaining two scientific citation index (SCI) studies were conducted as school mental health programs in schools in Korea (Ahn et al., 2020; Kwak et al., 2020). The two studies were conducted on 284 elementary school students and 70 high school students using the ‘School Sand play’ technique conducted in schools. The “School Sandplay” technique by Kwak et al. (2018) and Ahn et al. (2017), Kwak et al. (2020), and Ahn et al. (2020) systematized Kalff’s “free and protected space” into a series of sand works in one sand box (72*57*7cm) and systematized the appreciation method of respecting and listening to other people’s works. In addition, the meditative appreciation presented in the attitude of the therapist in individual treatment was implemented in group therapy. This is meaningful in safe structuring that promotes therapeutic factors such as ‘participation, universality, appreciation, empathy, acceptance, and symbolic experience’ in the process of SP group therapy without undermining the therapeutic factors of traditional SP individual therapy. Unlike previous periods, studies in the evidence-based research period used standardized psychological testing tools such as BASC, SCL-90 and MMPI (Flahive et al., 2007; Ahn et al., 2020; Yu et al., 2021), group treatment was conducted on a large group of over 70 people (Sun et al., 2018; Kwak etl al., 2020; Ahn et al., 2020), Paired t-tests Statistical techniques such as parametric statistics began to be used. The ‘evidence-based research period’ presents the research content and treatment methods in detail according to the researcher, and has the characteristic of more scientifically verifying the clinical effects of group therapy on subjects of various psychiatric symptoms and ages.
Discussion and Conclusion
This study is the first to investigate trends in SP group therapy research conducted in many countries around the world. The development process of group therapy based on the research contents and treatment methods was divided into “the beginning period, the qualitative research, and the evidence-based research period” of 40 literature subjects. Timing can help systematically understand the process of events and predict the direction of universality and development (Jeong, 2004).
The characteristics of overseas research trends of group therapy by period are as follows. SPT researchers began exploring the possibility of SP group therapy in the 1980s. The first phase, ‘the time to explore’, was from the 1980s to 2002, and research designs such as treatment targets, number of experimental groups, variables, measurement tools, and statistical analysis, as well as treatment methods such as number of sessions, treatment time, and group operation, were not presented in academic research during this period. However, this is a period of theoretical exploration in which the possibility of applying SPT, an individual therapy, as a group therapy in the clinical field, usefulness as a treatment tool, and treatment methods are introduced.
The second phase, ‘qualitative research period’, has been from 2002 to the present, and group therapy has begun to be applied to clinical subjects with various symptoms in the clinical field. Unlike the “first phase”, the studies in the “second phase” began to report specific treatment methods such as the subject of study, the number of treatments, sessions, and time. Like a case study of individual therapy, it was a phenomenological qualitative study that analyzed the subject of sand works or analyzed interviews of observers and participants.
Group therapy was applied as a therapeutic technique to various subjects and environments such as substance abuse adolescents, alternative school adolescents, disaster trauma children, sex addiction patients, and bereaved families. (James et al., 2002; Draper et al., 2003; Lacroix et al., 2007; Green & Connollyl, 2009); 2014 (Noric, 2015). Studies of this period are significant in that group therapy began to be used as a psychotherapy technique in actual clinical sites, and that it presented qualitative research methods such as subject analysis, observation interviews, and surveys of sand works. The “qualitative research period” can be seen as a transitional period between the “ the time to explore” and the “ground-based research period,” but it is of separate value in that it presented a way to vividly convey the process of group therapy through qualitative research methods.
<Table 3> is the literature of ‘the period of evidence-based research’. First, the “third phase” literature systematically presents research subjects, variables, research methods, measurement tools, and statistical analysis methods in the research conten(Li et al., 2019; Liu et al., 2019; Wang et al., 2020). Second, the treatment method of group therapy is specifically presented by researchers(Ahn et al., 2020; Kwak et al., 2020). The issue of the treatment method of ‘production and appreciation method’ of sand works has been presented since the beginning of group therapy. Compared to individual therapy, group therapy has various and complex methods. The treatment method is a specific method of implementing treatment factors in the treatment process, and acts as a variable that affects the treatment effect. Of the 21 evidence-based studies, 16 (76%) specifically suggest the production and appreciation of sand works in treatment methods. This can be said to be the development of a “ground-based research machine” not only for research content but also for treatment methods.
However, depending on the researchers, the introduction or concept definition of the treatment methods was inconsistent, and the presentation method was not systematic.
Lowenfeld and Kalf’s SPT are applied to clinical sites as a treatment technique. SPT has been developed mainly on individual therapy and qualitative research (Dale & Lydon, 2000). However, as seen in this study, group therapy began to appear in the 1980s, which is being applied as a treatment technique in countries around the world. In addition, several SPT overview studies have scientifically presented the basis for SPT and the therapeutic effect (Lee & Jang, 2015; Rolser, 2019, Wiersma et al., 2022). The background of the scientific verification of SPT is in company with the development of the basis for group therapy.
Group therapy has a variety of and complex treatment methods compared to individual therapy. In the case of most SPT overview studies, the therapeutic value and action of individual and group therapy are included together without distinguishing them (Rosler, 2019; Wiersma et al., 2022). However, as seen in this study, SP group therapy researchers present the therapeutic value of SP group therapy through concerns about the therapeutic principles and treatment methods of group therapy (Kwak et al., 2020; Mccormick, 2019; Bader & Miller, 1980; Okada, 1991; Noriko, 2003). Group therapy includes therapeutic factors such as ‘play, transference, meditation, and symbols’ of individual therapy, while at the same time having therapeutic factors unique to group therapy (Ahn, 2021). In group therapy, there are therapeutic characteristics of participants’ interactions that make boxes together, open works, and share them, and methodical characteristics of programs that structure topics or orders within limited sessions. In the case of the therapeutic characteristics of group therapy, such as the “interaction of production, opening, and appreciation” around the sand box, it can be said that it is still a research task that remains whether it conflicts with the treatment principle of “free and safe space” proposed by Kalff.
This study is meaningful as it is the first study to review the beginning and development process of group therapy for studies around the world of SP group therapy. In the future, we look forward to new studies on the therapeutic characteristics and therapeutic value of SP group therapy alone. This study utilized an electronic information service to investigate previous research on international SP group therapy between 1980 and 2021. However, this study had the following limitations. There were limitations in collecting studies whose research literature had not yet been registered in electronic literature. In addition, in the case of neighboring countries where SPT is actively distributed, such as Japan, and China, literature was collected separately with the help of researchers in those countries. However, this was limited to being only the help of an individual researcher and not a complete survey of the country’s literature. In Western countries such as Europe and the United States, where SPT was popular, there were limitations in investigating literature that was not registered as electronic literature. In addition, compared to other mental health group treatments, SP group therapy requires a lot of furniture and toys to create a treatment room environment, which has limitations in terms of cost and difficulty in establishing a treatment room. This study has a limitation in that it failed to present systematic data on the physical composition of this treatment environment.
This study reviewed the development direction of modern SPT, which is evolving from individual psychotherapy based on empiricist psychology to group therapy based on evidence-based psychology. SP group therapy based on evidence-based psychology can provide clients with more scientific and standardized psychological treatment for psychiatric disorders with various symptoms. However, as discussed above, the treatment methods of SP group therapy are largely divided into treatment methods in which several clients create sand works in one sandbox and treatment methods in which one client creates sand works in one sandbox. Additionally, when a client created a sand work, the degree of the therapist’s intervention was different, such as whether the therapist presented a program such as a ‘topic’ or ‘theme’ for the sand work. However, there was no scientific verification of the effect of the treatment method on the treatment effect and the treatment mechanism. Therefore, we look forward to various scientific reviews on standardized therapeutic methods of SP group therapy in the future.
