Assessing the Difference and Effectiveness of Art and Sand-play Therapy in Treating Post-traumatic Stress Disorders Among Syrian Refugee Children in Jordan

Post-traumatic stress disorder (PTSD) involves severe symptoms like re-experiencing trauma, avoidance, and hyperarousal, lasting more than a month and causing significant distress or functional impairment. Common treatments include EMDR and TF-CBT, but over 30% of patients do not benefit, especially those with complex trauma or poor verbal memory. Sand-play therapy is a nonverbal psychotherapeutic technique where clients create a "sand-world" using miniatures in a sandbox. Developed by Margaret Lowenfeld and later expanded by Dora Kalff, it offers therapeutic value through its multidimensional nature, narrative potential, access to preverbal memories, and accessibility without requiring special skills. It allows individuals to express internal experiences symbolically, supporting emotional healing in a safe, non-judgmental environment. Sand-play therapy uses a sand-tray and miniature objects like people, animals, buildings, and natural elements to help children express their inner experiences nonverbally. The process typically has two stages. First, the child creates a "sand-world" in silence, without any input from the therapist, allowing for personal, unconscious expression. Therapists avoid interpretations at this stage, respecting that each object can have unique meaning to the child.

In the second stage, the child may choose to explain the story behind their creation, helping them clarify emotions and gain insight. This encourages the release of negative feelings and memories stored in the unconscious. While some therapists interpret symbols based on the child's background, interpretation remains debated. Many believe that imposing meaning is unnecessary, as healing can occur naturally through the child's self-expression.

Furthermore, while counselors practicing from a Jungian perspective commonly use interpretation of children's pictures as a component of the therapeutic process, others argue that interpretation is not only unnecessary but also inappropriate. It is suggested that symbols are arbitrary and have unique meanings for individuals and, as such, their subjective nature must be respected. It is also noted that because sand-play allows issues to be resolved on an unconscious level, interpretation is seldom needed. Thus, for the purposes of this research we refrain from analyzing and interpreting the children's sandboxes to devote the counseling sessions just to the therapeutic value of sand-play therapy.

Overall, the counselor's primary role is to provide a safe and emotionally permissive environment for the child's expression of feelings and experiences. The child should be encouraged to express whatever he or she is experiencing with the freedom to determine how materials are used and what scenes are created in the sand. Hence, sand-play therapy can be considered as a form of play therapy and its basis in play is one factor that makes it particularly worthy of consideration for use in school contexts. It is suggested that this innate inner healing mechanism can reveal those things that need to be remembered, felt, released, or integrated and, as such, children are viewed as being capable of actively directing the resolution of their own concerns.

It is known that play is the singular central activity of childhood and is a spontaneous, enjoyable, voluntary and non-goal directed activity. It gives concrete form and expression to children's inner worlds and provides them with a symbolic language for self-expression, which is what is experienced when the child undergoes sand-play therapy. It has been suggested that in a counseling context, play is to the child, what verbalization is to the adult and literature pertaining to the use of therapeutic play with children frequently describes play as their language and toys as their words. It is known that in traditional counseling approaches, when children experience enormously complex feelings and thoughts in relation to the events in their lives, they often have difficulty trying to communicate these verbally in the counseling context. Using therapeutic techniques that are based in play provides the most natural and non-threatening means for children to communicate and act out sensitive material related to frightening and difficult situations.