A group therapy adaptation with in-patient eating disorder patients

Authored by: Thomas Brecht

The Routledge International Handbook of Sandplay Therapy

Print publication date:  January  2017
Online publication date:  February  2017

Print ISBN: 9781138101692
eBook ISBN: 9781315656748
Adobe ISBN: 9781317325970




Over the last few decades, psychotherapy groups have enjoyed an ever-increasing popularity, at least in part, due to the fiscal restraints implemented by health insurance companies as a means to contain costs. The depth psychology approaches, which have largely depended on individual therapy, face a challenge in this changing mental health scene. This chapter provides a description of my attempt to adapt what has generally been an individual therapy approach to a group application. The chapter is meant to be informative and descriptive and assumes that the reader has some prior knowledge of the Sandplay technique and of Jungian psychology. This account is applied and not theoretical in nature, with the intention of sharing the group sand tray work I did with the patients, while working at the clinic. My practice and the Eating Disorder Clinic functioned within a traditional, psychiatric medical model context which is reflected by some of the terminology used in the chapter.

 Add to shortlist  Cite


Over the last few decades, psychotherapy groups have enjoyed an ever-increasing popularity, at least in part, due to the fiscal restraints implemented by health insurance companies as a means to contain costs. The depth psychology approaches, which have largely depended on individual therapy, face a challenge in this changing mental health scene. This chapter provides a description of my attempt to adapt what has generally been an individual therapy approach to a group application. The chapter is meant to be informative and descriptive and assumes that the reader has some prior knowledge of the Sandplay technique and of Jungian psychology. This account is applied and not theoretical in nature, with the intention of sharing the group sand tray work I did with the patients, while working at the clinic. My practice and the Eating Disorder Clinic functioned within a traditional, psychiatric medical model context which is reflected by some of the terminology used in the chapter.

Some years ago I was asked by a newly established Eating Disorder Clinic to add some form of non-verbal, expressive therapy, such as art therapy, to the treatment modalities being offered. The one stipulation was that it needed to be a group in nature. I considered developing a modification of the Jungian Sandplay approach for use with groups. At that time, I was unable to find any information on using Jungian Sandplay therapy in a group setting. Thus, I reached back to Margaret Lowenfeld’s (1979) work in the 1930s to the London Child Guidance Clinic for an example. Her approach involved a large room in which each child was assigned an individual therapist and a sand tray. All the children in the room had mutual access to common drawers and shelves with a large selection of figurines. After reviewing her method, and after some contemplation of the specific clinic parameters in which I had to function, I decided on the following model.

I decided to describe my approach as sand tray therapy to distinguish it from the traditional, individual therapy Sandplay approach of Dora Kalff (1980/2003). One of my first considerations concerned what figurines to obtain for an Eating Disorder Clinic. Besides the typical items that one would purchase for a sand tray shelf, rational considerations seemed to suggest the following items: skeletons, obese and skinny people, toilets, mirrors, fake vomit and poop, whales, elephants, refrigerators, food items, among others. As the patients began to matriculate through the clinic, they made requests for inclusion of new figurines. Some of the items requested give some insight into the eating disorder dynamics. Lengths of chain were requested, since some eating disorder patients feel chained by their pathology. Cages were also asked for, because the patient felt caged by their disorder. Fishing nets and spider webs were other commonly desired items. Requests for female sports figures such as softball players, runners, soccer players, tennis players, and golfers were made. This was related to various means that eating disorder patents use to burn calories. Requests for ballerinas were also made – ballet activity being another way to consume calories. At times there never seemed to be enough mirrors available for participants, so several extra purchases of mirrors were made over the months. Witches and other negative female archetypal figures were often used. This would be in accord with the traditionally held professional belief that eating disorders develop from the patient’s relationship to a dominating mother figure. One surprise was the multiple requests for father figure figurines. It appears that there is a subgroup of eating disorder patients where a relationship with an emotionally or physically distant father appeared to be the source of their problems (Jenkins, Meyer, & Blissett, 2013).

Indeed, some of the patients in this subgroup felt that their fathers wanted a boy child and the female child attempted to oblige him by denying her femaleness by maintaining an athletic bodily physique. Edvard Munch’s (1893) painting of The Scream, in figurine form was also requested. Some eating disordered patients felt they are not heard by others. Often their screams for help are non-verbal and are represented by their eating disorder behaviors and the resulting body physique. Another interesting request was for shark figurines. The sharks were used by patients to represent their binging behavior, which, in its shark form, is described as a “feeding frenzy.” Often, an orca or alligator figurine was used to represent the same theme.

Another interesting request was for a vomitorium. Historically, a vomitorium was a separate room in some Roman households. It was utilized during eating orgies as a place to go to regurgitate food, allowing the participant to vacate his stomach in order to return to the party and continue to binge. After some deliberation, I designed a rectangular trough with the word “vomitorium” on it and had it especially made by a local artist.

During the group therapy hour, we would read myths pertinent to the patients’ issues. This resulted in requests for statuettes of Persephone, Cerberus, and of pomegranates. The later addition of the Hansel and Gretel fairytale resulted in requests for these figures as well. The patients noted that the fairytale contained the witch who sets up the two children for an eating binge on sugar. There was also an anorexic theme of the caged Hansel who offered the witch a thin stick as opposed to his finger as a sign that he had not gained any weight. Also represented in this story is an ineffectual father, unable to protect his young children from a witch-like step-mother figure.

The sand tray group met weekly as a part of the Eating Disorder Clinic’s regular treatment program. I functioned as the leader of the group. My function was to explain the sand tray process and to be the witness to that process. Group members were assigned individual sand trays and had access to common selves, on which were a large variety of figurines. Group members were asked to remain silent during the sand tray construction, unless they had a specific question related to the process. Group members were provided with a form upon which they could record any particular theme the sand tray presented, or other comments they may have in terms of feelings or thoughts. The group hour ended with the reading of one of three myths or fairytales. Jung (1977) commented on the need for the unconscious to have a large repertoire of symbols to facilitate the psychic healing process. I included these readings to assist in that process. The group members then left the group room. I took pictures of the trays for future reference, then disassembled the sand trays without the group members being present. Several days after the construction of the sand trays, another group session occurred where I gave each group member a photograph of the tray he or she had constructed. Unlike the traditional Jungian Sandplay approach in which discussion is delayed until after the completion of the final tray, each group member was encouraged to comment upon the tray they had completed. Other group members also made supportive comments or queries.

Such an approach has been observed in primitive societies, such as with the Iroquois, who traditionally shared their dreams (Irwin, 1996). I encouraged group members to keep their sand tray pictures in chronological order for a final debriefing at discharge from the clinic, and for their future reference. The author is aware of the concern that some Sandplay therapists have regarding discussing Sandplay themes with the patient prior to the final Sandplay session. If this did result in some form of coaching that influenced subsequent sand tray productions, it seemed minimal. However, some patients did use certain figurines in subsequent sand tray presentations, but that did not seem to be at any higher frequency than what is observed with individual Sandplay patients. As noted above, one of three stories was read after the completion of the sand trays and before the ending of the group process. I chose the myth of Persephone, since many Jungian and Freudian analysts consider it the classic myth concerning eating disorders. As I gained more experience with the eating disorder sand tray group, the myth of Echo and Narcissus seemed an appropriate addition. After some months, one of the group members suggested the addition of the fairytale, Hansel and Gretel to the reading list. So over a period of three weeks the group members would have heard all three stories, adding new symbols to their repertoire. The reading of the stories out loud was a shared exercise among the group members and the group therapist. Of course, in time, some of the symbols from these stories began to show up in the sand trays in terms of figurines chosen.

The question may arise on how such an aberration in a long-standing traditional treatment approach fared in terms of patient acceptance and therapeutic efficacy. Most patients involved in the Eating Disorder Clinic completed approximately a dozen sand trays during their stay. The preponderance of patient’s comments was positive about their sand tray experience. In the eight-year existence of the clinic, several hundred people were involved constructing sand trays. Some commented that they preferred sand tray over the art therapy, which was also offered as a treatment module by the clinic, since the patients felt they could not draw or paint well. Those few patients who responded negatively to the sand tray were allowed an alternative for that particular hour. These patients felt that the sand tray approach ran contrary to their religious beliefs, since myths and fairytales were discussed, and some of the figurines were images of pagan gods. Some few had a sense that constructing a sand tray somehow gave the group leader special knowledge about the patient that apparently they did not want to reveal.

In a further effort to introduce the patients to as many symbols as possible, I used selected episodes from Fraser Boa’s (2008) The Way of the Dream. This is a rich series of film interviews where Boa has eminent Jungian analyst, Marie Louise von Franz, analyze dreams he has collected from around the world. The eating disorder patients particularly found the episode on Marilyn Monroe of interest. Also the episodes involving the dreams themes of the Old Testament were popular. This popularity was due in part to the clinic being located in the Deep South (USA) where many people have had some exposure to Sunday school or Vacation Bible School as children.

Patients coming through the clinic often had another diagnosis along with their eating disorder diagnosis. Common diagnoses included: major depression, anxiety disorders, bipolar disorder, and borderline personality disorder, and other personality disorders. During the time spent at the Eating Disorder Clinic the existence of these other diagnoses often complicated the treatment approach. The weekly sand trays often gave the clinical staff an early warning of impending psychological deterioration in the patient’s mental status. We would see this in a weakening of meaningful relationships in the trays. There were occasions where bipolar patients entering a manic phase would demonstrate an increase quality of activity in their sand tray for that week. These trays often had an intensely pressured feel about them. They were very busy, overcrowded, overly sparkly, etc. Individuals developing psychotic features, or loosening of ego boundaries, would, at times, manifest difficulty with containment of the figurines within the boundaries of the sand tray. On one occasion the figurines were literally spilling over the sides of the sand tray on to the supporting table.

The clinical staff was quite positive about the inclusion of sand tray therapy in the clinic’s offerings. The staff showed particular interest in the first sand tray produced by an incoming patient. Traditionally, the first sand tray creation has been considered a statement of the problem and the resources the client has to address those issues (Turner, 2005). Indeed, that was often the case with patients attending the Eating Disorder Clinic, giving clinicians some early insight into the case. Also there was significant interest among the clinical staff in the final sand tray production prior to discharge in terms of insight into the patient’s therapeutic progress.

Although the author observed an accord between the improvement demonstrated by the patients’ progress through the Clinic and similar positive characteristics in the sand tray themes, such could be considered self-serving. Of particular concern was how the group context could affect the transference on to the sand tray.

After about a year of experience with this group technique, I engaged an outside consultant of international reputation in Sandplay therapy to give her impressions. The above description of the group regimen was provided to her, along with photographs of the sand tray group room. Most importantly, one of the group participants gave us permission to share her sequence of trays with the consultant. The final impression was that, indeed, there was therapeutic movement noted in the sequence of sand trays, but not at the depth of what is seen in the traditional individual sand tray procedure. This conclusion was in accord with the author’s impression as well.

In summary, it appears feasible to modify the traditional individual Sandplay approach into a viable group therapy modality. The preponderance of patients seemed to respond positively to the sand tray group. The clinical staff found it to be a valuable addition to the treatment regimen. Outside assessment of the approach validated its therapeutic efficacy.

Sand trays from the eating disorder groups

I have chosen six trays from the eating disorder groups to share as examples of their work in the Clinic.

Tray 1

Of particular interest in this sand tray is the representation of the obese person looking into the mirror in the far left hand corner. Through her psychotherapy, this patient discovered the tendency for an anorexic to look in the mirror and see a fat person, where objective others see her as overly thin. The placement of the figure suggests the beginning of some insight into her pathology. Also in this corner we see objects involved in her struggle: the toilet, food, and a razor used for self-mutilation. A tombstone is also in this corner, representing her recognition of the ultimate end, if she is unable overcome her pathology. A silver mask lies near which is the manifestation of her persona that hides her eating disorder from the view of family and friends. A brief introduction to Jungian psychology was a part of the program at the Eating Disorder Clinic, and the patient had a conscious awareness of the meaning of the mask, as a face, or persona, shown to others. The turtle suggests a slow but steady recuperation, which is preferred to a fast but shallow recovery. Such rapid recovery is often subject to major setbacks. Opposite the turtle, in the far right corner, is the figure of a nurse, an intra-psychic helper in her recovery. Also of note is the cowboy and handcuffs in the center of the tray. This may represent the sense of restraint and imprisonment that is experienced by many patients. Note that the cowboy is a male figure, and that he is also holding an instrument of restraint, the lasso. Perhaps this symbolically carries energies of the control issues surrounding her father figure in years past. Some success in dealing with the eating disorder is implied by the cowboy lying down, and not standing up. The handcuffs have been unlocked by the key, which represents her new attitude and positive thinking. The bridge may be the transition from a life dominated by the eating disorder, to her more positive goals in life. This includes going back to school and becoming a nurse, as well as having a family. This is suggested by the presence of schoolbooks, a graduation ring, a school house, and a home, in the near right corner of the tray, opposite the corpulent figure gazing into the mirror. With the school house and books, she may be learning about her growing awareness of the distortion in her body image. The tiger in this tray reflects the courage it will take to overcome her pathology and move in a positive direction. Symbolically, the tiger also carries powerful feminine energies that do what needs to be done.

Case example, Trays 1–6

Figure 3.1   Case example, Trays 1–6

Tray 2

This sand tray is a classic example of the use of chains that many eating disorder patients use. Note the web-like pattern in the way the chains are laid out. Perhaps this represents the web she has woven in her thinking and behavior that keeps her trapped in her eating disorder. Also of interest is the placement of the mirror. The mirror dominates the sand tray just as her focus on her body image dominates her psyche. The narcissistic positioning of the larger mirror in the far center of the tray is bolstered by two large boulders, upon which stand cannons ready at the defense. The mirror looks down upon the evergreen tree, where any attempt at new growth is strangled by the rope twined around it. This entire drama occurs behind a persona, suggested by the silver mask at the foot of the tree. Also of interest are the circular furrows that the patient made in the sand. This suggests a need and a willingness to probe the deeper issues by digging down into the unconscious. It may have to do with cultivating the earth for something new to grow. It may also concern digging deeper into the body of the earth/sand, or beginning to get in touch with her own body. Perhaps it involves touching Mother Earth as a way of beginning to heal her own childhood deprivations. By seeking the archetypal mother within her own psyche, perhaps she will be led to her release from the bonds manifesting as the eating disorder that currently constrains her. The seven white stones also make a powerful presence in the front of the scene. Symbolically, the number seven is the combination of the numbers three, the heavens, the masculine energy, with the four, the earth, the feminine energy. Coming together as seven, the three and the four carry energies of completeness, wholeness, an integration of formerly disassociated elements of psychic qualities into a meaningful whole. That they are white stones is symbolically significant, as well. Stones are solid; they endure. They form a firm place upon which to stand. This recalls to mind the phase in the Western Bible where it is told to “build your house upon a rock” (Matthew 7:24–25 English Standard Version).

Everyone then who hears these words of mine and does them will be like a wise man who built his house on the rock. And the rain fell, and the floods came, and the winds blew and beat on that house, but it did not fall, because it had been founded on the rock.

As we clearly see in this tray, the issues that bind and strangle this patient are present, along with the psyche’s solution and resources to individuate and develop a meaningful life. The profound level of insight and understanding that emerges through the pre-verbal work in the sand tray cannot be accessed through the traditional more rational, cognitive interventions. By being able to work symbolically, the patient’s psyche accesses its inherent wisdom to guide her healing and transformation.

Tray 3

Here we have another common theme seen in sand trays of eating disorder patients, the jail, prison, or cage. There is a skunk in the jail with her, representing the big stink her illness has caused her. A basin and a black heart in front of the jail are representations of the negative behavior and feelings she attempts to leave behind. The history book, leaning up against the outside bars of the jail, suggests she is moving away from the jail, which is now past history for her. She begins to be released from the chains by a re-engagement with her spirituality, represented by the menorah. She moves forward with the help of her doctor. The young children and the rainbow indicate that a new life is now in sight. The rainbow appears after the storm. A tray of cookies and a red crystal heart indicate that she is developing a more positive feeling toward food. Notice the use of the hearts to suggest a tension on the feeling continuum: a black heart to represent negative feelings at one end; and a red at the other end of the continuum, representing positive feelings as her therapy progresses. This opposition appears to indicate the possibility of a coming integration of these opposite poles, which will lead to the birth of a new way of seeing herself and her experiences.

Tray 4

In this sand tray we also see the common use of mirrors. Unique to this tray is that the mirrors are back to back! One mirror reflects the various personas that this patient displays to the outside world in an effort to hide her eating disorder, while the other mirror reflects a rather confused internal picture of where she thinks she would like to be. Unfortunately, her therapeutic progress was complicated by what we might call a “Wendy” complex, named for the Wendy figure from J. M. Barrie’s (1911) novel, Peter Pan and Wendy. Wendy is a young girl on the brink of adolescence, who initially has a fear of becoming an adult. She did not want to become like the pompous, angry man her father proved to be. Taken away to Neverland by Peter Pan, the boy who never wanted to grow up, Wendy acts as mother to Peter’s tribe of lost boys, caring for them at the expense of her own needs. This is a common theme seen with anorexics. Some will stay in the kitchen for hours preparing elaborate meals, taking care of others, and looking after the nutritional needs of others, while neglecting their own nourishment. Often this is taken to the point of preparing meals for others and not eating any of the cuisine they have prepared. In the Peter Pan novel, this is an underlying theme of Wendy’s ambivalent relationship to her father, as well as her hesitant feelings toward entering her teenage years. These are also common themes with many eating disorder patients who have father figure issues and body image concerns (Thelen, Lawrence, & Powell, 2013; Johnson, Cohen, Kasen, & Brook, 2014).

Tray 5

Here we have a good example of the use of a multiplicity of mirrors. I found that this frequently suggests narcissistic qualities to the patient’s personality, which are intertwined with the eating disorder. Eating disorder patients will often use exercise to burn calories in an effort to maintain a thin physique. In the current picture a runner figurine is placed at the front of the tray. This patient used excessive running as a means of keeping weight down. Running can take on a pathological quality, to the point of causing physical damage to the body. In the tray, the runner appears to be ready to run the gauntlet of mirrors. The final destination appears to be yet another mirror, in front of which has been placed a question mark. This suggests identity issues. In addition, there is a chain just behind, and to the right of the runner. As we have seen before, this is a quite common theme in the sand trays of the eating disorder patient. It is as if the runner was attempting to sprint away from the eating disorder chain, only to discover that he must run a narcissistic gauntlet of mirrors with no real improvement in terms of identity to be found at the end of the ordeal. Two keys appear in the sand tray with the word “success” written upon them. It appears that the patient gauges success by the amount of running that occurs. However, what lies ahead of the runner indicates this will prove to be a false success.

Importantly, behind the final mirror is an unstable character that appears to be about ready to lose his balance and fall. To the left and right of the person who is losing his footing is a dragon and cherub, respectively. Perhaps this suggests an interesting combination of the dominating mother, the fiery dragon, and Eros, the classic god of love, desire, and procreation. This may indicate an ambivalent relationship with the mother figure, which is common with some eating disorder patients. In the far right corner is an empty treasure chest. It appears that the patient is empty when it comes to any emotional or psychological reserves. In the near right corner sits a large golden sun. Generally, such suns are reminiscent of Apollo, the god of enlightenment, order, rationality, and authority. One would expect such a large figure to dominate the sand tray scene. However, here it lies at an angle against the side of the sand tray, and its noble effect is diminished. Further, there appears to be the potential for some diagonal tension between the sun and the dragon in the far left corner. However, in this case the dragon appears to be in the dominant position, while the sun is in a declining stance. Perhaps this indicates an ongoing struggle between emotional submission to a smothering mother figure, versus an attempt to think more clearly and “keep things in the light of day.” Finally, there are several masks in the sand, just in front of the sun. Perhaps this patient is able to present a competent and confident persona. In short, one of having his act together. However, the person behind the mirror, in the upper center of the sand tray presents a picture of a far less balanced psyche.

Tray 6

This sand tray presents an eating disorder patient whose symptomology is in remission, and is ready for discharge from the Eating Disorder Clinic. Our view first focuses on a rather grounded, confident looking woman, situated in the center of the sand tray. The common eating disorder patient mirror motif reappears here, however, there is a twist. The patient has achieved clarity in her perception of body image. She now views her body with objectivity and acceptance. Her clarity in thinking is represented by a brain, while the red heart represents her positive feelings toward herself. This newfound clarity is literally spelled out in letters across the near front of the tray, just in case her progress was not clear to others. The use of plastic letters of the alphabet was another common occurrence among a subgroup of eating disordered patients. It appeared to be a concrete attempt to be heard. Finally, we observe that the negative black heart and persona masks of a previous sand tray have been moved behind the mirror. This appears to be a positive movement, but does suggest some potential issues, if these problems are not kept in awareness.


The effectiveness of the adaptation of Jungian Sandplay to the group setting at the Eating Disorder Clinic is evident in the examples cited, and in the work we have reviewed. Most of the patients enjoyed their sand tray work, and appreciated how working with the images, instead of thoughts and words, allowed them to explore and discover aspects of themselves and their illness that they might otherwise have not seen. The group discussions that followed the construction of the sand trays allowed them to share their discoveries and to be seen and heard in their authenticity. Overall, the combination of mythic literature and the opportunity to create in the sand trays greatly enhanced the patients’ healing experiences and proved to be a highly beneficial addition to the treatment program at the Clinic.


Barrie, J. M. (1911). Peter Pan and Wendy. London: Hodder & Stoughton.
Boa, F. (Director). (2008). The way of the dream: Marie-Louise von Franz in conversation with Fraser Boa. Canada: Windrose Films.
Irwin, L. (1996). The dream seekers: Native American visionary traditions of the great plains (The Civilization of the American Indian Series). Norman: University of Oklahoma Press.
Jenkins, P. E. , Meyer, C. , & Blissett, J. M. (2013). Childhood abuse and eating psychopathology: the mediating role of core beliefs. Journal of Aggression, Maltreatment & Trauma, 22(3), 248–261.
Johnson, J. G. , Cohen, P. , Kasen, S. , & Brook, J. S. (2014). Childhood adversities associated with risk for eating disorders or weight problems during adolescence or early adulthood. American Journal of Psychiatry, 159(3), 394–400.
Jung, C. G. (1977). Symbols of transformation ( G. Adler & R. F. C. Hull , Trans.) Princeton, NJ: Princeton University Press.
Kalff, D. (2003). Sandplay: A psychotherapeutic approach to the psyche. Cloverdale, CA: Temenos Press. (Original work published 1980).
Lowenfeld, M. (1979). The world technique. London: George Allen & Unwin.
Munch, E. (1893). The scream (painting). Retrieved from
Thelen, M. H. , Lawrence, C. M. , & Powell, A. L. (2013). Body image, weight control, and eating disorders among children. In J. H. Crowther , D. L. Tennenbaum , S. E. Hobfoll , & M. A. Parris Stephens (Eds.), The etiology of bulimia nervosa: The individual and familial context (pp. 81–102). New York: Hemisphere Publishing Corporation.
Turner, B. A. (2005). The handbook of Sandplay therapy. Cloverdale, CA: Temenos Press.
Search for more...
Back to top

Use of cookies on this website

We are using cookies to provide statistics that help us give you the best experience of our site. You can find out more in our Privacy Policy. By continuing to use the site you are agreeing to our use of cookies.