Please contact Dr. Freedle if you would like to discuss her research or yours. You may also find her on Research Gate.
The effects of sandplay therapy on the limbic system and prefrontal cortex in women with generalized anxiety disorder (GAD)
Abstract: Generalized Anxiety Disorder (GAD) is a common disorder characterized by psychological and neurophysiological impairments. Previous studies show that Jungian Sandplay Therapy (SPT) effectively improves anxiety symptoms in individuals with GAD. This study explores whether clinical symptom improvement from using SPT also involves changes in brain functioning. The study focused on the brain regions implicated in GAD, including the hippocampus, amygdala, thalamus, and prefrontal cortex (PFC). Magnetic resonance spectroscopy was used to target these brain regions to measure metabolite changes, specifically in the N-Acetylaspartate to creatine (NAA/Cr) ratio—a measure of neuronal viability. A within-subject pre-post design was utilized with adult females from Indonesia diagnosed with GAD (n = 6, ages 21 to 40). Thirty sessions of SPT were provided weekly. Results from both clinical measures of anxiety (HAM-A and GAD-7) indicated mean pretest scores in the clinical range, with average posttest scores below the clinical range for GAD. Likewise, the NAA/Cr ratio mean scores for the hippocampus, amygdala, and PFC were outside the healthy range before and trended toward or into the healthy range after treatment. The NAA/Cr ratio mean scores in the thalamus were in the healthy range before treatment and remained in the healthy range after treatment. This study concludes that SPT effectively improves clinical anxiety symptoms in individuals with GAD and may also improve metabolic brain functioning in the limbic system and PFC. Limitations, implications, and further research are discussed.
Citation: Foo, M. & Freedle, L. R. (2024). The effects of sandplay therapy on the limbic system and prefrontal cortex in women with generalized anxiety disorder (GAD). The Arts in Psychotherapy, 88(2024), 102145. https://doi.org/10.1016/j.aip.2024.102145.
Sandplay Therapy: An evidence-based treatment
Abstract: There is a substantial and growing body of evidence demonstrating the efficacy and effectiveness of sandplay therapy in the treatment of children and adults with a wide variety of clinical presentations. This article briefly defines evidence-based treatment and provides an overview of the research base for sandplay therapy in this context. In an era where high value is placed on scientifically-proven psychotherapies, this article is beneficial for sandplay therapists, clients, collaborating professionals, payers, and policy makers alike.
Citation: Freedle, L. R. (2022). Sandplay Therapy: An evidence-based treatment. Journal of Sandplay Therapy, 31(1), 129-36. https://doi.org/10.61711/jst.2022.31.1.898
A Meta-analysis of Sandplay Therapy Treatment Outcomes
Abstract: Sandplay therapy is a cross-cultural, psychodynamic, non-directive, multi-sensory psychotherapy method founded by Dora Kalff. Sandplay is used with children and adults with a range of mental health problems. Despite sandplay’s growing popularity, its empirical evidence base is less developed than more well-known therapies. This international study provides a meta-analysis of the available quantitative outcome studies in order to summarize the growing evidence base of sandplay. The meta-analysis specifically examined emotional and behavioral outcome measures of treatment with sandplay therapy. The initial search identified 1715 potential records from over sixteen countries. After screening, 40 studies from eight countries representing 1284 participants met the inclusion criteria. Mean effect sizes were calculated using a random effects model with the Comprehensive Meta-Analysis program (CMA). The overall effect size was large (Hedges’ g= 1.10). Large effect sizes were maintained for internalizing, externalizing and attention-deficit/hyperactivity (ADHD) symptoms. Improved effect sizes were associated with individual treatment over the group format. These results suggest that sandplay therapy is an effective treatment method for children and adults with a wide variety of mental health concerns. Limitations and suggestions for further research are discussed.
Citation: Wiersma, J. K., Freedle, L. R., McRoberts, R., & Solberg, K. B. (2022). A meta-analysis of sandplay therapy treatment outcomes. International Journal of Play Therapy, 31(4), 197-215. https://doi.org/10.1037/pla0000180
The lava ate my school: The use of group sandplay to reduce anxiety and post-traumatic stress in displaced elementary school students
Abstract: Children impacted by natural disasters are vulnerable to developing mental health problems including anxiety and post-traumatic stress disorders. This field-based study explores the use of group sandplay with students whose lives were disrupted by a volcanic eruption in their community. Participants (n=12) included first graders, ages 6-7 whose school had been recently consumed by lava. Using a mixed-method, pre-post design, data were collected during a school-based outreach project. The Revised Children’s Manifest Anxiety Scale–Second Edition (RCMAS-2) Short Form and the Child Report of Post-traumatic Symptoms (CROPS) were administered before and after a series of five group sandplay sessions and analyzed using paired samples t-tests. Qualitative data were also collected, including interviews with school staff and analysis of archetypal sandplay themes. Findings indicated a significant reduction in ratings for anxiety and post-traumatic symptoms with each measure showing a large effect size (d= 1.25 for anxiety; d= 1.40 for post-traumatic symptoms). Themes indicated movement toward integration, balance, and access to internal resources, despite the continued presence of threat. Interviews with school staff supported the findings and showed that children enjoyed group sandplay, and were more calm and better able to talk about the event. Implications and limitations are discussed.
Citation: Freedle, L. R., McGee, M., Blechman, S., Souza, J. & Zandbergen, D. L. (2021). The lava ate my school: The use of group sandplay to reduce anxiety and post-traumatic stress in displaced elementary school students. Journal of Sandplay Therapy, 30(2), 129-147. https://doi.org/10.61711/jst.2021.30.2.323
The effect of sandplay therapy on the thalamus in the treatment of generalized anxiety disorder: A case report
Abstract: Generalized anxiety disorder (GAD), a common, debilitating condition, involves psychological and physiological dysfunction. Sandplay therapy (SPT), a multisensory treatment modality, has been successfully utilized to reduce anxiety ratings for individuals suffering from GAD using the Hamilton Anxiety Rating Scale (HAM-A) and the General Anxiety-7 (GAD-7). Since GAD involves sensory processing alterations in the thalamus, which may also be implicated in SPT, it would be beneficial to accompany evaluation with a physiological measurement targeting the thalamus. Using an A-B single-subject design, this case study explores whether clinical improvement in a GAD patient treated with SPT is associated with brain metabolite changes, specifically the NAA/Cr ratio (a measure of neuronal viability) in both thalami using proton magnetic resonance spectroscopy (MRS). With no improvement during the waiting period, after eighteen sessions of SPT, the participant (female, age 23) showed clinically significant improvement in symptoms of anxiety as measured by the HAM-A and GAD-7, and also showed improved NAA/Cr ratio to the healthy range in the right and left thalamus. The effectiveness of SPT in reducing symptoms of anxiety in this study is consistent with previous findings. The results also suggest an association between clinical improvement and metabolite changes in the thalamus, and may underscore the multisensory aspects of SPT as an essential mechanism of change. Future studies regarding interpretation of the NAA/Cr ratio are recommended. Limitations are discussed.
Citation: 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.apa.org/doi/10.1037/pla0000137
The added value of sandplay therapy with emerging adults in an outdoor behavioral healthcare program
Abstract: Using a mixed-method quasi-experimental design this study explores the added value of sandplay therapy with emerging adults (age 18-24) in a residential outdoor behavioral healthcare (OBH) treatment program. Participants were divided into two groups: One group (n=29) received sandplay therapy during OBH treatment. A comparison group (n=29) was randomly selected from those who received OBH treatment without sandplay during the same time period. The Outcomes Questionnaire (OQ® 45.2) was administered at admission and discharge. Open-ended surveys were also conducted and analyzed using grounded theory. Findings indicate that compared to OBH treatment as usual, adding sandplay therapy resulted in a greater clinically and statistically significant reduction in distress. Both groups evidenced a very large effect size. Adding sandplay therapy to OBH treatment appeared to be particularly beneficial for those who presented with higher levels of distress upon admission. Therapists reported using sandplay therapy for clients with notable trauma, difficulties with self-expression, and tendencies toward over-intellectualization, and/or when other methods weren’t working. Seven themes emerged with participants noting that sandplay enabled access to deep emotions and memories; facilitated somatic connections; stimulated creativity and expression; was playful and fun; felt safe and relaxing; was met with initial skepticism turned into appreciation; and provided insight and new perspectives. The value of adding sandplay to an already robust treatment program is discussed, along with implications for further research.
Citation: Freedle, L.R., Goodwin-Downs, D., Souza, J. & Cipponeri, A. (2020). The added value of sandplay therapy with emerging adults in an outdoor behavioral healthcare program. Journal of Sandplay Therapy, 29(1), 129-144. https://doi.org/10.61711/jst.2020.29.1.405
Making connections: Sandplay therapy and the Neurosequential Model of Therapeutics
Abstract: This article explores how sandplay works using the conceptual framework of Bruce Perry’s Neurosequential Model of Therapeutics® (NMT). The work of neuroscientist Antonio Damasio on the development of “self processes” is also reviewed in this context, along with the author’s research and practice involving “Sandplay’s Sensory Feedback Loop” and the neuropsychology of sandplay and trauma. Recent neuroimaging studies on sandplay therapy are presented that show promise for the involvement of “top-down” and “bottom-up” mechanisms of change. Exploring how the brain functions and develops, along with therapeutic activities that promote neurodevelopment advances understanding of the sandplay process. Moreover, the manner in which a child or adult engages in sandplay therapy may provide valuable information regarding what activities may be beneficial outside of the sandplay session to optimize development.
Citation: Freedle, L.R. (2019). Making connections: Sandplay therapy and the Neurosequential Model of Therapeutics. Journal of Sandplay Therapy, 28(1), 91-109. https://doi.org/10.61711/jst.2019.28.1.747
Trauma, Innocence, and the Self-Care System: Implications for sandplay therapy
Abstract: The article describes Jungian Analyst, Donald Kalsched’s model of the dissociating psyche, called the Self-Care System (SCS) and its applications to sandplay therapy. The SCS often appears in the material of trauma-survivors as a type of “core complex” of the traumatized psyche. First, Dr. Kalsched discusses this dynamic system and the unconscious archetypal “powers” that defend a sacred, innocent core of the whole personality from further violation. Next, Dr. Lorraine R. Freedle shares the sandplay process of a young man “Howard” that involves sensory play, regression, the recovery of a core of lost innocence and vulnerability, and the capacity for embodied emotion following trauma. Dr. Kalsched then offers an analysis of the theory and practice related both to the model of the dissociating psyche and the clinical case. The information in this article was presented during the keynote address at the 2018 STA National Conference in Albuquerque, NM.
Citation: Kalsched, D. & Freedle, L.R. (2019). Trauma, Innocence, and the Self-Care System: Implications for sandplay therapy. Journal of Sandplay Therapy, 28(1), 7-32. https://doi.org/10.61711/jst.2019.28.1.710
Healing trauma through sandplay therapy: A neuropsychological perspective
Abstract: This chapter explores how sandplay therapy heals trauma from a neuropsychological perspective. It reviews four aspects of sandplay therapy that promote neural integration including relational safety, somatosensory engagement, symbolic expression of the trauma narrative, and mindful participation. The chapter provides a brief overview of the basic principles of neurodevelopment; Jung’s conceptualization of the psyche and the process of individuation; and neural integration, as defined in the field of interpersonal neurobiology. In sandplay, encounters with the Self play an essential role in facilitating psychological healing and transformative growth. In sandplay therapy, the trauma narrative is expressed and re-processed over time through symbols in the presence of the attuned therapist. Symbols play an essential role in stimulating interactions between brain and psyche in sandplay. As awareness expands through the senses, sandplay calls for mindful participation. A neuropsychological perspective on Sandplay recognizes the dynamic interplay between brain and psyche that brings forth neural integration and psychological healing.
Citation: Freedle, L. R. (2017). Healing trauma through sandplay therapy: A neuropsychological perspective. In B. Turner, (Ed.), The Routledge International Handbook of Sandplay Therapy, (pp. 190- 206). Routledge. https://doi.org/10.4324/9781315656748
Application of the Neurosequential Model of Therapeutics (NMT) in an integrative outdoor behavioral healthcare program for adolescents and young adults.
Abstract: This article explores the application of the Neurosequential Model of Therapeutics® (NMT) at an integrative outdoor behavioral healthcare program that uses horticultural therapy and other experiential modalities to treat adolescents and young adults with a variety of emotional and behavioral problems. In this nature-assisted approach to whole person wellness, the neurosequential model provides an empirical basis for therapeutic garden design, clinical interventions, and program structure.
First, key terms are defined. Next, an overview of the integrative clinical practice model is provided. Lastly, applications of NMT are presented with a particular focus on the horticultural component of the program, including the therapeutic gardens.
Citation: Freedle, L. R. & Slagle, T. (2018). Application of the Neurosequential Model of Therapeutics (NMT) in an integrative outdoor behavioral healthcare program for adolescents and young adults. In E. Perry, G. Griffin, M. Maikoetter, S. Graner, J. Rosenfelt, & B. Perry (Eds.), (pp. 20- 26). Proceedings of the 2nd International Neurosequential Model Symposium: Banff, Alberta Canada. 2016. The ChildTrauma Academy Press. ASIN: B07D34S68C
Restraint and critical incident reduction following introduction of the Neurosequential Model of Therapeutics (NMT)
Abstract: Children with developmental trauma are at risk for severe and complex behavioral problems, often requiring long-term residential and day treatment. The Neurosequential Model of Therapeutics (NMT) is a developmentally sensitive approach to clinical work with a capacity-building component focusing on attachment, the impact of maltreatment and trauma, and emerging concepts in developmental psychology, neuroscience and traumatology. Research has demonstrated its effectiveness with trauma-exposed populations. NMT training may help providers working with trauma-exposed youth prevent critical incidents and reduce restraints. Restraint and critical incident data were obtained from 10 organizations providing residential and/or day-treatment services following exposure to, or certification in, the NMT. Data from the Pre-NMT Introduction period through to the Maintenance phase of NMT Certification were used to examine changes in restraints and critical incidents across phases of NMT exposure/certification. Multilevel logistic regression models suggested that NMT exposure and/or certification was associated with significant reductions in restraints and critical incidents. Reductions were sustained throughout the Maintenance phase. Estimates of potential staff hour and financial savings associated with these reductions are discussed. Implementation of the NMT in residential and day-treatment settings may result in staff, behavioral health provider, and organization-level changes that reduce critical incidents and restraint use.
Citation: Hambrick, E.P., Perry, B.D., Wang, E., DeMarco, T., Capparelli, C., Grove, T., Maikoetter, M., O’Malley, D., Paxton, D., Freedle, L., … & Polales, C. (2018). Restraint and critical incident reduction following introduction of the neurosequential model of therapeutics (NMT), Residential Treatment for Children & Youth, DOI: 10.1080/0886571X.2018.14
The role of sandplay therapy in the treatment of adolescents and young adults with co-occurring substance use disorders and trauma
Abstract: This study explores the effectiveness of the Bonding through Experiential Adventures in Recovery (BEAR) program and the role of sandplay therapy in addressing the complex needs of youth (ages 14-24) with co-occurring trauma and substance use disorders. BEAR included sandplay therapy, adventure therapy, art therapy and recovery-oriented support in addition to the evidence-based, 16-week Matrix Model intensive outpatient treatment program. A mixed methods quasi-experimental design was utilized to evaluate the program. Data was collected through questionnaires at approximately 2-month intervals—admission, midway through treatment, and at discharge. Separate focus groups were held with youth, parents, and staff with their responses evaluated using grounded theory. Results demonstrate that the youth who participated in BEAR significantly improved daily functioning at home, school, and in their community, and reduced the severity of their substance use problem and symptoms of distress associated with trauma exposure. Sandplay therapy positively impacted engagement in treatment with youth endorsing sandplay as the most helpful part of the program. The role of sandplay therapy in the treatment of trauma and addictions is discussed, along with implications for further research.
Citation: Freedle, L.R., Altschul, D.B., & Freedle, A.M. (2015). The role of sandplay therapy in the treatment of adolescents and young adults with co-occurring substance use disorders and trauma. Journal of Sandplay Therapy, 24(2), 127-145. https://doi.org/10.61711/jst.2015.24.2.167
Sandplay therapy with brain injured adults: An exploratory qualitative study
Abstract: Employing a collective case study qualitative approach, sandplay therapy (sandplay) was utilized to study the phenomenological experiences of four adults with moderate to severe Traumatic Brain Injury (TBI) and to explore the process of individuation as defined by Carl Jung in these individuals. Participants ranged in age from 22 to 36, completed 12 to 18 sand trays, and were seen in an outpatient neurorehabilitation center. Results indicated that the participants could express themselves through sandplay in ways previously unavailable to them verbally. The contents of psychotherapy for all of the participants centered on their TBI experiences and its devastating impact on their lives, as well as a quest for deeper psychological goals such as wholeness, purpose, connection to life, and acceptance. Furthermore, a Sandplay Sensory Feedback Loop was developed to describe how these four participants progressed through seven phases of psychological development. The process that emerged was likened to an individuation journey wherein unconscious contents are made conscious, there is confrontation of shadow material, and the Self is manifested. Implications for using multi-sensory forms of psychotherapy with persons with TBI, and for applying similar
research designs in future studies of sandplay and the individuation process are discussed.
Citation: Freedle, L. R. (2007). Sandplay therapy with brain injured adults: An exploratory qualitative study. Journal of Sandplay Therapy, 16 (2), 115-133. https://doi.org/10.61711/jst.2007.16.2.573
Eseʻs Emancipation
Abstract: In this intensive case study, the author highlights the sandplay process of a 16-year-old, gang-involved youth who was transitioned from a group home for troubled teens to living on his own with very little support. His use of sandplay reconciles the despair of his abusive and neglectful childhood, to disengage from an identity centered around violence and antisocial behavior, and to launch into adulthood with newfound protection.
Citation: Freedle, L. R. (2006). Ese’s emancipation. Journal of Sandplay Therapy, 15(1), 93-107. https://doi.org/10.61711/jst.2006.15.1.144
Sandplay therapy and the individuation process in adults with moderate to severe traumatic brain injury: An exploratory qualitative study. (Dr. Freedle’s Dissertation)
Abstract: Employing a collective case study qualitative approach, sandplay therapy (sandplay) was utilized to study the phenomenological experiences of four adults with moderate to severe Traumatic Brain Injury (TBI) and to explore the process of individuation as defined by Carl Jung in these individuals. Participants ranged in age from 22 to 36, completed 12 to 18 sand trays, and were seen in an outpatient neurorehabilitation center. Results indicated that the participants could express themselves through sandplay in ways previously unavailable to them verbally. The contents of psychotherapy for all of the participants centered on their TBI experiences and its devastating impact on their lives, as well as a quest for deeper psychological goals such as wholeness, purpose, connection to life, and acceptance. Furthermore, a sandplay sensory feedback loop was developed to describe how these four participants progressed through seven phases of psychological development. The process that emerged was likened to an individuation journey wherein unconscious contents are made conscious, there is confrontation of shadow material, and the Self is manifested. Implications for using multisensory forms of psychotherapy with persons with TBI, and for applying similar research designs in future studies of sandplay and the individuation process are discussed.
Citation: Freedle, L. R. (2006). Sandplay therapy and the individuation process in adults with moderate to severe traumatic brain injury: An exploratory qualitative study. Doctoral Dissertation, Fielding Graduate University, Santa Barbara, CA.