Sandplay Therapy in Vulnerable Communities

A Jungian Approach

Eva Pattis Zoja

• Publisher: Routledge
• Year: 2011
• eBook ISBN: 9781136732768
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Sandplay Therapy in Vulnerable Communities offers a new method of therapeutic care for people in acute crisis situations such as natural disasters and war, as well as the long-term care of children and adults in areas of social adversity including slums, refugee camps and high-density urban areas.

This book provides detailed case studies of work carried out in South Africa, China and Colombia and combines practical discussions of expressive sandwork projects with brief overviews of their sociohistoric background. Further topics covered include:

• the social aspect of psychoanalysis
• the importance of play
• pictographic writing and the psyche.

Providing the reader with clear, practical instructions for carrying out their own sandwork project, this book will be essential reading not only for psychotherapists involved with sandplay therapy but also for those with an interest in cross cultural psychotherapy, as well as all professionals working with those in situations of social adversity.

Chapter 1

The social aspect of psychoanalysis

Freud’s polyclinic

…to mix some alloy with the pure gold of analysis…¹

Although the First World War had not yet come to an end, the city of Vienna had largely already lost its sheen of a cultural and political metropolis. The Viennese saw themselves facing a future of historical insignificance. Esteemed psychiatrist Sándor Ferenczi’s suggestion to hold the Fifth International Congress on Psychoanalysis in Budapest met with agreement because life was thought to be safer there than in Vienna. Ferenczi, the son of a radical journalist and publisher, belonged to a circle of progressive Hungarian intellectuals and artists including György Lukács and Béla Bartók.

The psychoanalysts whom Freud had once assembled around himself in Vienna had been dispersed across Europe since the beginning of the war, because many of them had had to do military service for their own countries. Each of them knew that he might one day have to face friends and colleagues in the enemy’s lines. Many of them experienced the war’s psychological consequences, in the form of posttraumatic stress disorder (as we call it today), at close range. The main purpose of the conference was to discuss the psychological costs of war and to try to find methods of treating war neuroses. Official representatives of the Central Powers were attending the congress, and were interested in establishing psychiatric wards according to new criteria. They had high expectations of psychoanalysis: the psychological damage that this war had caused was to be repaired.²

It is surely thanks to psychoanalysis that this psychological damage received a general description for the first time in the history of war. According to the German army’s official medical report, ³ between 1914 and 1918, a total of 613,047 soldiers had been treated in military hospitals for ‘nervous afflictions’. This equalled almost 10 per cent of an estimated 6.5 million soldiers. The official term of the time was ‘war hysteria’,⁴ and electric shocks were the usual form of treatment in military hospitals. There was obviously a big challenge awaiting psychiatry and especially psychoanalysis, which had already proven that it was able to leave its consultation rooms and make its knowledge available to the general public. It was time ‘to make the psychoanalytic healing method available to wider parts of the population’.⁵

The time was right for Sigmund Freud’s and Sándor Ferenczi’s idea of universal access to psychotherapy, which was voiced for the first time at this congress, to meet with strong approval.⁶ In his talk, Freud said: ‘The poor man should have just as much right to assistance for his mind as he now has to the life-saving help offered by surgery’.

One circumstance in particular, which also had to do with the political events of the time, paved the way for this suggestion’s acceptance. The years of war had led to a shortage of patients in Vienna. Freud’s entire fortune had fallen victim to inflation. His separation from Swiss psychiatrist C.G. Jung had happened four years ago. He could now devote all of his attention to developing psychoanalysis according to his own ideas. These included the founding of training institutes. Over the past years, several questions had started arising in psychoanalyst circles: ‘How does one become a psychoanalyst? Where should training institutes be founded? How should supervision be governed? Could lay analysts (psychoanalysts without a degree in medicine) be trained?’ In any case, future trainees would certainly require a large number of patients. Given the entire population’s current precarious psychological state, patients would no longer come only from Europe’s highest social classes. Therefore, the idea of a clinic in which patients could be treated without charge seemed attractive from this point of view as well.

But Freud’s proposal was also an expression of a special historical moment of socio-political reformation in which liberal and social ideas were poised to overcome conservative, monarchist and clerical attitudes.

Then institutions and out-patient clinics will be started, women who have nearly succumbed under the burden of their privations, children for whom there is no choice but running wild or neurosis, may be made capable, by analysis, of resistance and efficient work. Such treatments will be free.⁷

Freud’s idea met with great approval. It took root in the psychoanalysts’ minds and was soon to become reality.

In February 1920, Ernst Simmel and Max Eitingon opened the first polyclinic for psychoanalysis at Schloss Tegel sanatorium in Berlin. The cultural programme for the opening ceremony reflected the spirit of the time: Karl Abraham gave the opening speech, Ernst Simmel read from Rainer Maria Rilke’s Book of Hours, and there was music by Chopin, Schubert and Schönberg. Everyone was filled by a spirit of optimism. The list of psychoanalysts who agreed to devote a fifth of their working time to the free clinic reads like an index of pioneers in this field: Karl Abraham, Paul Federn, Therese Benedek, Otto Fenichel, Edith Jacobson, Karen Horney, Erich Fromm, Helene Deutsch, Hanns Sachs, Sándor Radó, Wilhelm Reich, Annie Reich and Melanie Klein. From the start, the clinic was so popular that its founders decided against further promotion and advertising.

In the first two and a half years alone, 700 patients had sought admittance: ‘from the 6-year-old child to the 67-year-old man, from workers and maids to generals’ daughters’.⁸ Psychoanalytical treatment was indicated for about half of the patients. Analysis was free of charge if patients declared that they could not pay for the treatment. Otherwise they were to pay ‘as much or as little as they can or think they can’.⁹ Proper financial support for the clinic was found eventually. Ernst Simmel wrote to the relevant ministry at the time that the very group of patients who needed treatment most were usually also the ones without resources, precisely because of their psychoneurosis.

Regarding a clinic in Vienna, Freud was sceptical at first: he had not considered Vienna to be a suitable city for a clinic in which people in need could be treated free of charge. He would have preferred Budapest. Indeed, the initiative had met with resistance for the longest time. The medical association expressed their concern that such a clinic could damage the status and image of doctors. But the atmosphere in Vienna under the influence of the social-democrats was favourable. In 1922, Eduard Hitschmann, Helene Deutsch and Paul Federn founded the Vienna Ambulatorium, which was integrated into the university clinic at Pelikangasse 18. Just as had been the case in Berlin, there was no form of funding at first. The patients were treated in the rooms of the cardiology ward, which were empty during the afternoons. The couch was a narrow, unpadded treatment table for heart patients, which was so high that the patients had to reach it with the help of a stool. Nevertheless, from the start it was barely possible to deal with the rush of patients. Craftsmen, civil servants, nuns, factory workers, housemaids, lawyers and students all came to the ambulatorium. Between 1920 and 1931, hundreds of patients of all ages, many of them welfare cases, were treated for psychosomatic illnesses, depression and phobia.¹⁰ The most common diagnosis was hysteria; the second most common was neurotic compulsion. Anna Freud, Wilhelm Reich, Siegfried Bernfeld, August Aichhorn, Willi Hofer and Grete Bibring were among the psychoanalysts who were active there. They saw the ambulatorium itself as an instrument for social reform. The psychoanalysts were convinced that they would be able to bring about a change in society towards greater social justice. Free services were extended to the analysts as well. Specifically, Pappenheim recalled that ‘every training analyst in Vienna was obligated to train two students for free’.¹¹

Treatment of children and adolescents was one of the ambulatorium’s priorities.

Vienna’s focus on children’s needs and rights increased in parallel with the emergence of new scientific studies of child development and treatment techniques, and a developing interest in early education. Child analysis itself emerged from the social context of radicalism and service.¹²

Anna Freud held a series of seminars on the relation between psychoanalysis and upbringing. August Aichhorn, a former teacher and director of a municipal kindergarten, developed a psychoanalytical model of social help for disturbed or delinquent adolescents.¹³

At the Berlin Polyclinic, up to 10 per cent of patients treated every year were children of school age. They first underwent a general medical and neurological examination and were then entrusted to a psychoanalyst. Sessions took place three times a week, as they did for adults.

An outpatient file from 1921 titled ‘Case History and Diagnosis’ bears a comment by Max Eitingon:

Brought from the youth office in Wilmersdorf. Petty thieving (broke into a school cupboards led by [?] another boy) and sexual aggression towards little girls. Very difficult environment; appears to have been encouraged to steal from a very early age by a sister. Cries when asked if he knows he has done something that is not allowed. Speaks very little the first time, is visibly intimidated, despite otherwise having many characteristics of the uninhibited suburban child. Has difficulty learning, but gives no impression of being intellectually backward.¹⁴

Suggested therapy for the boy was: Attempted analysis: Frau Klein.¹⁵ The young patient was asked to lie down on the couch and to associate freely – both requests apparently always met with his resistance.¹⁶ Though more sessions had been intended (three sessions weekly), only fourteen of them took place (from April 1921 until the last session on 9 June), because – as Melanie Klein says – ‘his foster mother did all she could to keep him away from me’.¹⁷ The analyst’s resentment is hard to miss in this statement.¹⁸ This was one of Melanie Klein’s first child analyses, and she began by interpreting the boy’s associations according to Freud’s Oedipus complex. She tried to understand the boy with the help of S. Freud’s essay ‘Verbrecher aus Schuldbewusstsein’ (1916).¹⁹ But she also made a note of everything that did not necessarily fit this concept. In the seven pages of session notes there are two mentions of the boy’s ‘fantasies of the electric’. The ‘electric’ (the tram) would derail on the way home from his therapy session, and the conductor would not give the passengers tickets to board another tram.

The boy’s fear of derailing (in German this word is also used for immoral behaviour in particular) and the impossibility of making reparations for lack of a positive fatherly authority (the conductor), are obvious to us today. The second time that Melanie Klein remarks on this fantasy, she adds that the boy is also ‘preoccupied with elevators whose ropes could tear’.

Later, the analyst remarks on ‘the boy’s completely new interest in metalwork and the exact construction of elevators.’ It is easy to imagine that the boy had begun to draw hope at this point, and that new, inner-psychological dynamics were becoming activated inside him.

The boy’s pictographic associations on the couch could have taken a similar form if he had been sitting at a table with paper and colour pencils – or at a sandtray with toys: he could have, for example, let a miniature train derail. Perhaps he might have shown less initial resistance to the sessions if this had been the case. It might have made the situation a little easier for both parties. (Later in life, Melanie Klein developed a form of treatment for children with miniature toys.) But there is an important difference between the two approaches, which influences their respective ways of expressing unconscious content. In his freely associated fantasies on the couch, the boy himself is sitting in the tram when it derails. If, however, he is playing with a miniature train and makes it derail, he keeps the event at a certain distance. Naturally, this has advantages and disadvantages for the therapy’s progress.

The psychoanalysis of this boy from Berlin’s suburbs could not be successfully completed. Melanie Klein reported that ‘the boy didn’t commit a single offence during his highly sporadic analysis’, but that he ‘became delinquent once more during the interruption and was immediately admitted to a reformatory.’²⁰ This interruption lasted a few months and was due to the analyst’s ‘absence from Berlin for personal reasons’, as she put it. Later, she lamented: ‘All of my attempts at bringing him back to analysis, after my return, were in vain. In view of all circumstances, I do not doubt in the least that he pursued a career in crime.’ There is no way that we can know if Melanie Klein’s view was too pessimistic. However, if we consider what reformatories for youths were still like in Germany of the 1920s, we probably must share her fears.

After more than a hundred years of psychoanalysis, there is no lack today – and maybe also back then – of analytical understanding, empathy or techniques of treatment. What was known as ‘free association’ then is essentially still the core of depth-psychological treatment today, even if we have developed a whole spectrum of different methods for evoking unconscious content in the mean time, as well as diverse theoretical systems for understanding the same. Far more, our therapeutic approach today – and in 1920 – seems to suffer from the fact that the transforming and healing effect of the therapeutic relationship is underestimated, especially by therapists themselves. The therapist’s simple presence, as a person with his or her own thoughts and feelings about the child, is experienced by the child as being symbolic for the child’s own complete and fundamental acceptance or rejection in the world. The therapist, who is reliably present during every session, becomes a surface for projection: he or she is made to represent outwardly the parental roles that are laid out in the child’s psyche. Whether the child will be able to compensate for the shortcomings in the environment depends on the therapist’s ability to let him or herself be used as such a ‘primary object’ within the therapeutic relationship. Too long an interruption – as was for example the case in Melanie Klein’s analysis – and the glimmer of hope, which was awakened in the child, will go out.

By no means does it merely depend on the therapists and their training if children find their way to therapy in the first place, and whether these therapies are interrupted too easily or not. The cultural and societal connections go further and lie deeper. In the end it depends on the adults’ abilities to perceive consciously ...

Table of contents

• Cover
• Halftitle
• Title
• Copyright
• Contents
• Acknowledgements
• Introduction
• 1. The social aspect of psychoanalysis
• 2. The cross-cultural aspect of analytical psychology
• 3. Margaret Lowenfeld’s World Technique and Dora Kalff’s Sandplay
• 4. Psychotherapy in precarious situations
• 5. Trauma and ‘newly contained time’
• 6. Expressive Sandwork
• 7. Expressive Sandwork in South Africa
• 8. Expressive Sandwork in China
• 9. Expressive Sandwork in Colombia, Latin America
• 10. Practical instructions for an Expressive Sandwork project
• Notes
• Bibliography
• Plates
• Index