This single-case study examined changes in emotion regulation, symbolic processes, and attachment–relationship dynamics in a 12th-grade female student with a history of self-harm and suicide attempts who received Sandplay therapy in a clinical counseling setting following school-based identification as high risk. The client, who presented with escalating emotional distress related to university entrance examinations and family/interpersonal stressors, had made two suicide attempts using a rope and engaged in repeated non-suicidal self-injury. After being identified as a high-risk student in the school counseling office, she was referred to a community counseling center, where she received 22 sessions of individual sandplay therapy, three sessions of verbal counseling, pre–post psychological assessments, and follow-up contacts. Data sources included quantitative measures of depression (CES-DC), trait anxiety (TAIC), suicidal ideation (SIQ-JR), and recent non-suicidal self-injury episodes, as well as qualitative materials such as a sentence completion test (SCT), drawing tests (K-HTP, K-KFD), sandplay images and therapist process notes for each session, and collateral information from the homeroom teacher and the client’s parent. Pre–post comparisons showed decreases in depression and suicidal ideation scores, and the number of non-suicidal self-injury episodes in the previous month decreased from six to zero. Projective measures indicated a shift from themes of isolation, rigid boundaries, and vulnerability in relation to others toward increased connection with everyday life, community, and family relationships. Across the course of sandplay therapy, the client’s symbolic expressions moved from “safe isolation” motifs—such as islands, forests, deserts, and fenced spaces—through mid-phase scenes dominated by intrusion, surveillance, and time/movement symbols, and finally toward late-phase scenes depicting apartment complexes, parks, streets, graduation and college entry, and a central tree and cats as self-representations. This symbolic trajectory suggests that the emotion-regulating functions previously served by self-harm and suicidal behavior were progressively replaced by symbolic expression within the sand tray, contributing to a reduction in emotional collapse and a reorganization of attachment and relationship experiences. The findings highlight the clinical potential of Sandplay therapy as a crisis-intervention modality for high-risk adolescents in the context of school-based identification and referral to clinical counseling settings, while also underscoring the methodological limitations of single-case research and the need for further studies.
Lee et al. (Sun,) studied this question.