Dr. Alexander (Alex) Esterhuyzen is member of the Royal College of Psychiatrists. He worked as a consultant psychiatrist in psychotherapy with the NHS in the UK for many years and is also a senior psychoanalyst with the Independent Group of Analytical Psychologists (IGAP, London). Most pertinent to the context of this conversation, he is a Sandplay therapist and Teaching member of both the British and Irish Sandplay Society (BISS) and the International Society for Sandplay Therapy (ISST). In addition Dr. Esterhuyzen was the President of ISST, a worldwide therapeutic body, for several years.

Dr. Esterhuyzen was president of ISST when the interview took place.

Note: All references to ‘sandplay’ refer to the therapeutic method as devised by Dora Kalff and based on the psychology of C. G. Jung. This method is also sometimes abbreviated to ‘Jungian sandplay’.

Maeve: Alex I am delighted to introduce you to the readers of Inside Out. You and I already know each other as we are members of the British and Irish Sandplay Society (BISS) which is a regional Society member of the International Society for Sandplay Therapy (ISST). That said, you have left British shores in recent years and now live in Hong Kong. There you have been very involved in training sandplay therapists and setting up an ISST regional Society, alongside your work as the current President of ISST. Perhaps Alex you might let our readers know a little about you, your involvement in sandplay and your role as the President of ISST.

Alex: Like any good psychodynamic psychotherapist I trace my current interests and situation back to my past. I was born and raised in central Africa in an extremely multicultural and ethnically diverse country. I grew up close to nature and the indigenous people, where intellect and words were secondary to a more primal experience, a way of seeing the world and of communicating. Professionally, my interest in sandplay dates back almost 40 years to when I was a young medical student. I was already interested in Jung and engaged in dream work using a Jungian approach, when I attended a conference that included a presentation by Cecil Burney, a Jungian analyst and sandplay therapist from the USA and one of the founding members of ISST. The symbolic approach that was used to give meaning to the sandplay images seemed natural and profoundly effective. In my youthful enthusiasm, I determined immediately that I would one day become a sandplay therapist. It was a considerable number of years later that I finally completed my studies and became an ISST certified sandplay therapist. Subsequently I became involved in the organisational work of the Society, partly because it seemed to have a unique role in promoting and maintaining professional standards in this method across many countries and cultures. ISST seemed to be able to engage many ethnic and cultural groups with clarity and flexibility. Given my experience in other professional circles it was refreshing to find an organisation that seemed to have a passion for keeping alive the values and attitudes of its method. Rather than prioritising legalistic requirements for professional membership with a deadening bureaucracy. Having said that, ISST certification is a substantial demand and in many ways best suits professionals who are interested in the journey more than in the endpoint.

The International Society has its domicile in Zürich, Switzerland. It is an umbrella Society operating through a number of regional Societies spread throughout the world. Currently there are 15 regional ISST Societies. A region (in some cases a single country or in others, two or more countries working together…’ as is the case with the British and Irish Sandplay Society) requires a minimum number of individual members before they can apply to become a regional Society. In addition, there are developing groups in a further 20 countries. ISST is managed by a Board which is comprised of one representative from each regional Society. I have great admiration for the Board members – each acting as a rib that holds the span of the ‘umbrella’ – because they have to continually balance their own Society’s needs and interests, with those of the global, umbrella organisation. This is also my role in the Society and it is necessary for me, as far as possible to be aware of and in tune with what the key issues are in any particular region.

Maeve: That sounds like quite a commitment from everyone involved. Interestingly it also evokes the idea of holding the tension of opposites, embodying an important tenet of analytical psychology itself. Alex, I really like the way you talk about ‘the journey more than the endpoint’ there. Can you continue to say more about your experience and understanding of sandplay as a therapeutic journey?

Alex: At a superficial level sandplay might seem to be a type of projective technique, but here again I have to say it is more than this. Rather than starting from the position of having to articulate and explain something from a rational or cognitive perspective, sandplay is based in the body and in immediate experience. As the client engages with the sand and subsequently the miniatures in creating an image they spontaneously lose many of the inhibitions and defences that in verbal therapy, can consciously and unconsciously inhibit their expression of what is happening in their internal worlds. They enter a world of playfulness, curiosity and an attitude of experimenting with possibilities. Soon their deepest inner conflicts, potentials, blocks and possible solutions can begin to appear in the trays. Of course, one has to understand the language of symbolism to be able to read these spontaneous and unconscious expressions of the client’s inner world. In ISST, sandplay is very much a non-directive therapy where the client is provided with a ‘free and protected space’ (Kalff, 1980) within which the individual can meet their authentic selves with their own particular challenges and unique possibilities. This does not mean that the therapist is a passive observer. Like an attuned mother watching her child engaged in creative play, the therapist accompanies the client with an active attunement. There are also moments before and after the play, when the client will have time to speak about whatever they may need to. There is never a direct interpretation to the client of images at the time they are made. The images may inform the direction the therapist takes in the verbal part of the therapy because, from the image they may have additional information about what stage in the therapy the client is at, and what the particular issues are or may be brewing below the surface. The ISST board came up with the following definition that attempts to describe what sandplay is:

“It is a therapeutic method developed by Dora M. Kalff, in Zollikon, Switzerland. It is based on the psychological principles of C.G. Jung. Sandplay is a creative form of therapy using the imagination, “a concentrated extract of the life forces both physical and psychic.” (C. G. Jung). It is characterized by the use of sand, water and miniatures in the creation of images within a “free and protected space” of the therapeutic relationship and the sand tray. A series of Sandplay images portrayed in the sand tray create an ongoing dialogue between the conscious and the unconscious aspects of the client’s psyche, which activates a healing process and the development of the personality. This therapeutic method may be successfully applied to individual work with both adults and children”

(International Society for Sandplay Therapy, 2018).

Maeve: There is a real ‘journeying’ feel in how you describe the process there. Can you say more about the particular approach of Dora Kalff?   How did she come to develop sandplay?

Alex: Dora Kalff was a student of C. G. Jung who, himself, was a pioneer of psychoanalysis and founder of the school of Analytical Psychology, now a large, worldwide organisation with which ISST is officially affiliated (International Association for Analytic Psychology, 2016). She also studied with Margaret Lowenfeld, a pediatrician who became a pioneer of child psychology and psychotherapy. Lowenfeld’s interest in how children grow and develop and think began, when as a recently qualified doctor she worked with children affected by the first world war. She wondered what enabled some children to survive and flourish despite their traumatic experiences. Her outstanding contributions sprang from her recognition that play is an important activity in children’s development and that language is often an unsatisfactory medium for children to express their experiences. She consequently invented non-verbal techniques that enabled children to convey their thoughts and feelings without having to resort to, or depend on, words – in particular the well known Lowenfeld ‘World Technique’ which used a sandbox and miniatures (Lowenfeld, 1979). Dora Kalff adapted and developed the World Technique by using sand boxes approximately the size of the visual field and applying analytical psychology to further understand and work with the meaning of the images created by children and later applied this with adults also.

Maeve: Developing a new therapeutic method alone is quite an achievement in a lifetime, but Dora Kalff, who I believe was fluent in four languages including English, also managed to set up a world container for her method in the form of ISST. The question ‘how does one person do all of that?’ may flicker in people’s minds. Perhaps you can tell us how this came to be?

Alex: Yes Dora Kalff was indeed multi-lingual, and widely travelled, teaching sandplay not only in Europe, but in America and Japan also. She established ISST together with a group of thirteen founding members. They were from Switzerland, Italy, Germany, Japan, England and the United states. Initially they simply met to share the clinical experiences of using her method. However, with time, there arose a need to provide a more formal structure for the study and practice of sandplay therapy, in order to protect, develop and spread its practice. It is a unique quality of ISST as a professional organisation of therapists, that from the beginning it benefitted from a shared enthusiasm and interest in this work from various parts of the world. Its foundation and development lies in the experience and practice of professionals stemming from a variety of cultural environments. In this way the history of ISST is testimony to an archetypally grounded common human essence which helps to transcend cultural differences. Today, many people use these sandboxes and miniatures as a therapeutic tool, but what is unique about people who train in Kalff’s method through ISST, is that they are trained to engage in and understand the method using depth psychology, and in the container of the multicultural organisation that originated the method. If one understands that analytical psychology is based on the study of individual psychology in the context of society, culture and anthropology, it is then easy to see why it has an essential role in understanding the creation of images in sandplay. It holds the key to understanding symbols that have transpersonal meaning. Creating images has been part of human evolution since the beginning of time. Our early ancestors had a need to create images on cave walls. We dream in images (not simply words or numbers). Sandplay requires less technical ability than say, painting. By spontaneously creating sandplay images in the ‘free and protected space’ of the therapeutic relationship, the individual begins to relate to their own inner world and imagination. These images can help both the therapist and client begin to see and relate to the psychological conflicts and potentials that were, previously, not available to the conscious mind of the creator of the image.

Maeve: You mention the multicultural nature of ISST and the value of this to the practice of sandplay, however I imagine that such differences also naturally bring up difficulties at times. I wonder how these are metabolised within a world body such as ISST, without resulting in rupture. In relation to this I’m also thinking of our Irish context, and in particular how difficult and complex it has been to find resolution to conflict in governance issues, in Northern Ireland. Does socio political difference manifest within ISST? If so how is containment held? Does it have an impact on the practice and understanding of sandplay?

Alex: Since its inception ISST and its Board has held the difficult task of maintaining professional standards and the authenticity of the method, while also honouring cultural and geographical differences. This is not as cool or as smooth as it may sound! Much of its success so far has been because of an attitude of respect for difference and openness to learn from this. There is also a Swiss organisational structure that attempts to provide a container for a way of making decisions that will affect all the membership. Ultimately decisions are made by a General Assembly comprising the entire professional membership. For example, the ISST Board and ultimately the General assembly, agree the minimum basic requirements for membership. While local Societies contribute to these, they are also able to add additional requirements and procedures to suit their local circumstances. In many ways, so far, the ISST organisation has tried to avoid becoming just another bureaucratic regulating organisation. The method is contained in the consulting room of the individual therapeutic relationship, they are similarly contained and held by the regional Society and these in turn by ISST through it’s representative Board. Awareness, respect for boundaries and clear definition are key. We also recognise that the method is not a cure-all and can also be damaging if used inappropriately or used by inadequately trained individuals. It is the clear task of ISST to provide a safe container for certified practitioners of the method. In order to support successful ongoing holding of this containment, ISST co-ordinates a Bi-annual International Congress. Our next one will be in Europe, in Berlin on August 5-9, 2019. Adding to this support, we also have an active Research group who are connecting research throughout the world and are collating a database of published research relevant to sandplay. Regional ISST Societies often host their own local conferences and provide training opportunities. I believe the British and Irish Sandplay Society (BISS) have a training cycle running currently and are also holding a conference in Scotland next June. I suppose you could say that while the focus of containment is ISST, with protection of standards being essential – much latitude is entrusted to the dynamic and inclusive participation of members and regional Societies, who also feed back into ISST through their Board representative.

Maeve:   As you talk there about different events and developments being set up and run by regional Societies including the initiatives of British and Irish Society, I start to wonder about us as therapists in the 21^st century. We have access to great resources for international learning – apart from the ease of travelling, there is the internet which alone can provide so much learning and communication access. Might this lessen the benefits or the need for an international body like ISST or indeed the need for structured training programmes, particularly when it comes to those in the postgraduate space, such as sandplay?

Alex: Increasingly the internet has become an indispensable tool for learning and accessibility to resources and information. This is profoundly useful, but it remains a ‘tool’. It is a tool that can be used wisely or unproductively, perhaps at times destructively. In essence our method is relational. It requires the presence, and use of the therapist themself in a relationship. So, in sandplay there are the three: the client, the therapist and the sandplay collection (which includes the sand trays). Conscious and unconscious dynamics occur in relation to all three. This is why training as an ISST sandplay therapist requires an actual, physical relationship between client, therapist and materials. No amount of book (or internet) learning can substitute for this. Increasingly, theoretical and applied learning about sandplay and analytical psychology can be accessed on the internet. These are important resources but there are elements that require a physical shared experience. This is also one of the reasons why ISST requires a therapist to undergo their own personal sandplay process with an ISST certified therapist, as part of the training for certification. Some online supervision is permitted for certification in the context of the supervisor and supervisee having met and having some working knowledge of each other before embarking on internet supervision.

Similarly, at an organisational level it is vital to have person to person contact to get a real sense of cultural value and difference. This requires considerable investment in time and resources, but has proved invaluable in creating and maintaining an organisation that strives to sustain a unique method of engaging with psyche, personal and collective.

Maeve: I have been very taken by many of the recent findings from Neuroscience and how they are building a model of the physiology of psychological change that in so many respects, parallels Jungian understanding of development. This has drawn significant attention to non-verbal expression as key to the integration of fractured experiences, which are often imbedded in implicit memory and thus outside of conscious memory. From your own experience and awareness of practice around the world, is sandplay as a non-verbal therapeutic method able to place itself in this context?

Alex: This is a very exciting development. Our growing understanding of neuroscience makes it possible for us to conceptualise, at least in part, the mechanism through which sandplay therapy works, in bringing about the profound growth and changes that we see in individuals who engage with it. To put it very simplistically and briefly: Most verbal therapy is worked in a ‘top-down’ fashion. That is to say that we start in the cerebral cortex with formulating words and concepts and from here work down to the midbrain, the centre of emotions and memories. In this way we attempt to reconnect aspects of experience that have become fragmented or dissociated due to trauma (not only a traumatic event, but the developmental trauma of continuous exposure to mis-attunement that many individuals experience in their early development). We also endeavour to help the client to effect better emotional regulation in this way. However, we now know that the midbrain is also influenced from the bottom up. That is to say that lower centres that have to do with sensation and regulation of basic body functions (breathing, heart rate, balance, physical orientation) also connect with and influence the midbrain. It is here, in this ‘bottom-up’ influence that sandplay has a particular role to play. Sandplay is a profoundly sensory experience. With this particular approach sensory experience is related to the symbolic process involved in creating an image which expresses unconscious material. In this way it influences the midbrain regions from both directions; bottom-up and top-down.

Maeve: Alex can you give us a picture of the efficacy of sandplay as a method of therapy? Is there a difference in its use, popularity, uptake and efficacy around the world?

Alex: There is an enormous body of case-based evidence of how sandplay therapy changes people’s lives, their perspective of themselves and others. How it can help to address an enormous range of problems in self-image, ability to self-regulate, relationships, mood disorders and existential issues, particularly in relation to meaning in life. There is also a growing body of quantitative research, including small randomised control studies, which evidences the positive change that sandplay therapy brings about particularly in mood disorders such as anxiety and depression. Dr. Lorraine Freedle, a USA based neuropsychologist and ISST sandplay therapist, has included sandplay therapy in her research on working with adolescents with addiction problems and found that out of a number of therapeutic modalities sandplay therapy played a central role in engaging this client group in treatment and keeping them in treatment (Freedle, L., Altschul, D., and Freedle, A., 2015). Readers may be well aware that young people with addictions are notoriously difficult to engage and keep in treatment. She recently gave a delightful, informal interview to a local TV station and this video clip is available on YouTube for those who are interested. In this clip she also eloquently describes for a lay audience how she understands the neurological mechanism through which sandplay works (ThinkTeck Hawaii, 2017).

Interestingly much of the quantitative research is coming from the East (in China where sandplay is included in many university curricula providing PhD students with ample material to scientifically explore the method, also in South Korea, Japan, Taiwan and Indonesia). This also reflects a profound and growing interest in sandplay therapy in the East. In spite of (or perhaps because of) the fact that many people in the East have become focused on excellence in academic study, emphasising science and technology, the population of professionals and clients alike are deeply attracted to this symbolic experiential way of engaging in therapy. It is the fastest growing region for ISST and indeed for analytical psychology through the International Association for Analytic Psychology (IAAP). In China and South Korea it is not unusual for 500 people to turn up when I speak at public events there. Similarly, regular ongoing theoretical teaching of ISST sandplay attracts over 100 students who attend training every month.

Maeve: This is very interesting as I believe Dora Kalff herself was very interested in Eastern philosophy and made many trips to the Orient throughout her life, particularly Japan. The development of sandplay has thus been strongly influenced by the Eastern and Buddhist approaches, including an emphasis on being with/meeting experience more than trying to define and shape it. A different curiosity comes to my mind now Alex, as apart from being a Jungian analyst and sandplay therapist you are a psychiatrist. Is sandplay suited to working with people who have a profound medical diagnosis such as a psychosis?

Alex: You could say that any psychodynamic psychotherapist is constantly doing a risk assessment with the client in the sense that they use their training experience and supervision to continually assess when and how far to open up sensitive areas in the client’s internal world. This is particularly so with clients who have a serious mental illness, including psychosis. During a psychotic state the individual’s ego is overwhelmed by his/her unconscious, thus the ego’s ability to function is severely impaired. Consequently, when working with clients who have a history of psychosis, there is a constant need to monitor and support ego functioning. When using sandplay as one of the modalities of engaging with this particular client group the same caution applies. It has been common practice to use the creation of images, such as in art therapy, as part of the treatment for this client group. However, this is usually only used during the recovery phase, rather than the acute phase, of the illness. And always with the support of a well structured and communicating system around the client. There is always psychiatric medical treatment and other resources as part of that supporting system. In this context sandplay therapy can be very helpful to the client in that the sensory experience of working with the sand itself often helps the client to improve their reality orientation. I have seen sandplay therapy used with great benefit in day hospital settings, with clients recovering from psychotic episodes. However, each individual needs to be closely monitored because sandplay can cause an unhelpful regression with some clients struggling with reality orientation (one of the functions of the ego). Sandplay can be useful in monitoring the client’s mental state and ego functioning if the therapist has sufficient training and experience in working with serious mental illness. In this way the therapist can work collaboratively with the client and their psychiatrist in supporting and maintaining the client’s recovery. Because of the symbolic language used in understanding sandplay images, it can be possible to see the client’s struggle to emerge from the mists of their overwhelming unconscious, back into connecting with outer reality and the world around them.

Maeve: Clearly it requires quite a skillful and experienced awareness along with grounded confidence in working with such a presentation. In relation to a different aspect, sometimes sandplay is used in a group setting. Is this is a different application, or do you also see sandplay as having a group application in the ISST context?

Alex: Traditionally sandplay therapy in the tradition of Dora Kalff and ISST has been used primarily for individuals. In this approach each sand tray/sandplay image represents the inner world of the client creating it. It is clear in these circumstances that conflicts, potentials and emerging psychic forces seen in the tray belong to that particular client and the therapeutic relationship that holds the process. When groups engage in making trays together it can be confusing and much more difficult to understand the unconscious communications in the trays and, indeed, between the individuals making the trays. For example, there are unconscious (sibling) rivalries between members of any group. These can often be denied in favour of an idealised “togetherness” which compensates for the shadow or more “negative” aspects of any individual and their relationships. This seems to me to avoid the purpose of therapy; to deal with our painful struggles to be whole persons in whole relationships. By whole I mean all of oneself, positive and negative, and to be able to take that into the therapeutic relationship for growth and integration. In a group the therapist conducting the group (either as a therapeutic or as a training experience) needs to be very clear about their objectives and not confuse them with those of individually based sandplay which focuses much more on understanding the inner and unconscious world of the individual making the tray. If the objective is clear and not confused with the deep unconscious personal work aimed for in ISST sandplay therapy, using sandboxes and miniatures in a group setting can be helpful. I have supervised sandplay therapists working with groups interested in exploring re-conciliation (for example groups of individuals from the Arab Israeli context). In this example the therapists had considerable ISST training and were clear about the differences between the approach and use of sandplay in the traditional contexts, and the work of helping groups to understand themselves and their unconscious collective prejudices and conflicts. In addition, in situations where a group is undergoing training in ISST sandplay therapy, using sandboxes and miniatures can be a helpful experiential exercise. For example the group might be divided into subgroups of three people with one person playing the role of ‘client’, another the role of ‘therapist’ and a third as an observer. This can be a useful exercise in terms of exploring certain aspects of sandplay; for example reflecting on the difference in the individuals experience of wet sand and of dry sand. But we need to be clear about differentiating this kind of experiential exercise from the profound ongoing process that happens in personal work, involving the client, a therapist and the sandplay materials.

Maeve: For us here in Ireland training in the ISST approach currently means travelling to London. While the training programme is modular to facilitate travel from Ireland and the farther reaches of Britain, it still adds extra logistics and expense for people who might be interested but find that too much. Are there other options for people who may be interested to train towards ISST membership?

Alex: I believe it is extremely helpful to have a systematic structured training container such as that provided by BISS in the British and Irish context. This provides scaffolded learning that progresses from a clear foundation. The alternative might be to invite visiting teachers from time to time which can be interesting and stimulating. However there is no opportunity for students to develop systematically under the guidance of a group of trainers who are there to support their individual development over a period of time. Other opportunities are; attending conferences such as the forthcoming BISS conference in Glasgow next June or the ISST International Congress in Berlin in August 2019. These events give an opportunity to sample the depth and breadth of sandplay therapy. Just as importantly, they also give an opportunity to connect with a community of people interested in symbolic work in the tradition of Dora Kalff and based on the psychology of C.G. Jung. The board members of ISST are required by the constitution to meet annually for a board meeting. On alternative years, when there is no ISST International Congress directly following this meeting, a number of the board members remain on to offer an intensive training week. Bearing in mind that the board members are representatives from each regional ISST society, this training experience is profound in the richness of knowledge and cultural perspectives on sandplay therapy that it provides. The next event will take place in Malta in early August 2018 (see www.isst-society.com/isst-events for details).

Maeve: Unfortunately Alex we must now conclude our conversation. Thank you very much for sharing some of your insights into the dynamics of sandplay, from the consulting room to the Board room.  

Alex: It’s been lovely to have this opportunity to connect back in with Ireland and Irish psychotherapists. I believe that there is growing interest and enthusiasm there for sandplay. I would absolutely encourage people to contact the regional Society of BISS if they have any queries or are interested in finding out more. Bye for now.