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Is There a Biofeedback Response to Art Therapy? A Technology-Assisted Approach for Reducing Anxiety and Stress in College Students:

Is There a Biofeedback Response to Art Therapy? A Technology-Assisted Approach for Reducing... College students are exposed to daily stressors throughout their academic careers, which can have lasting consequences to their health and well-being. Mindfulness practices, art therapy, and the simple act of manipulating clay have independently demonstrated positive effects on stress and anxiety, but there is little research on the feasibility of incorporating these into an online resource for students to proactively address their mental health. In this pilot study, full-time university students (N = 15) were randomly assigned to a mindfulness-based art therapy (MBAT) program that used clay for all art directives or an unstructured, undirected neutral clay-manipulating task (NCT) for 10 weeks. Anxiety symptoms, salivary cortisol concentrations, and perceived levels of stress were assessed. Within-group analysis demonstrated significant decreases in anxiety symptoms and cortisol concentrations for MBAT participants, with no significant decrease in perceived stress. NCT participants experienced a significant decrease in cortisol concentrations on Week 1 but not on Week 10, with no other statistical significance in outcomes detected. Between-group analysis generated no significant interactions between variables. Based on these results, the structure of a therapist-directed online MBAT program using clay has the capacity to elicit anxiety-reducing benefits and may produce a trained biofeedback response for combating stress, offering a feasible strategy for addressing the mental health crisis on college campuses. Keywords art therapy, mindfulness, clay, anxiety, stress, college students issues, and half (50%) of those who dropped out never Introduction accessed mental health services or support (National Alliance To address the ever-growing prevalence of mental health on Mental Illness [NAMI], 2012). issues, researchers across the globe are looking into feasible Unmanaged anxiety and stress can have devastating con- strategies for enhancing individuals’ access to services. Web- sequences to a student’s academic career, as depression and based interventions are increasing in popularity and impor- anxiety have strong correlations with lower grade point aver- tance as digital natives are coming of age and making up a age and increased risk of dropout (Eisenberg, Golberstein, & larger part of the affected demographic. Hunt, 2009; López-Bárcena, González-de Cossío Ortiz, Data collected from 86 institutions’ counseling centers Avila-Martínez, & Teos-Aguilar, 2009; NAMI, 2012), but (CCs) from 2010 through 2015 reflected a significant consequences extend beyond academic success. Being in a increase in college students reporting symptoms of general- state of chronic stress can have a severe negative impact on a ized anxiety, depression, and overall distress (Xiao et al., person’s overall well-being. The stress response is a natural, 2017). CC utilization increased by 30% over the course of those 5 years, while institution enrollment only increased by Department of Art Education, Florida State University College of Fine 5.5%, suggesting that the stigma surrounding mental health Arts, Tallahassee, USA is declining. However, many students still prefer to seek sup- 2 Department of Biomedical Sciences, Florida State University College of port from peers or family rather than through formal clinical Medicine, Tallahassee, USA counseling services (Eisenberg, Hunt, Speer, & Zivin, 2011). Corresponding Author: Even with the influx in students using university counseling Megan E. Beerse, Research Assistant, Department of Art Education, Florida State services, 64% of college dropouts in a 2012 survey stated University, 1033 William Johnston building, Tallahassee, FL 32306-1232, USA. their reason for dropping out was related to mental health Email: meb15k@fsu.edu Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open biological mechanism that is integral to survival. Stress hor- Scale 10-item (PSS-10) and the Generalized Anxiety mones like cortisol and adrenaline allow the body to remain Disorder 7-item (GAD-7) were used to assess psychological alert in dangerous situations. When daily stressors induce outcomes while concentrations of the stress hormone cortisol this stress response on a regular basis, preventing the indi- in saliva samples were tested, as reductions in concentrations vidual from returning to homeostasis, they begin to shift the have been observed in mindfulness and art therapy research mental and physical health statuses of that individual (Brand, Holsboer-Trachsler, Naranjo, & Schmidt, 2012; (McEwen, 2006; Sterling & Eyer, 1988). Chronic stress can Kaimal, Ray, & Muniz, 2016). lead to the development of anxiety, depression, and suicidal ideation (Sareen et al., 2005; Schneiderman, Ironson, & Method Siegel, 2005). It can also elevate blood pressure, increase risk of cardiovascular disease (Cohen, Edmondson, & Overview of Intervention Program Kronish, 2015), lead to the development of an autoimmune disease, or even exacerbate the symptoms of a preexisting Art therapy is a mental health profession that integrates the disease like rheumatoid arthritis or multiple sclerosis creative process with applied psychological theory (American (Schneiderman et al., 2005). Art Therapy Association, 2017). Art therapists are trained Web-based interventions and online programs are being psychotherapists with more specified training in the thera- explored with other populations that are experiencing peutic properties of art materials and creative processes. Art heightened levels of stress. A web-based holistic stress therapy researchers are gaining a better understanding that in reduction intervention was piloted with certified nurse- addition to the therapist–client relationship and the directives midwives, who are at risk of secondary traumatic stress, used in session, the art material itself can affect a client down posttraumatic stress disorder, and burnout. Participation in to neurological and physiological levels (Kaimal et al., 2017; holistic exercises 4 times a week for 4 weeks effectively Kaimal et al., 2016; Kimport & Robbins, 2012; Kruk, improved their stress levels and coping (Wright, 2018). In Aravich, Deaver, & deBeus, 2014; Lorenzo de la Peña, 2016; Switzerland, Germany, and Austria, a therapist-guided Sandmire, Gorham, Rankin, & Grimm, 2012; Scholt & online stress management program was offered to newly Gavron, 2011). Findings from previous studies suggest that diagnosed cancer patients to help them with the psychologi- the material properties of clay complement mindfulness cal distress that comes with adjusting to a cancer diagnosis. practices, as even brief clay sculpting is associated with The 8-week program consisted of self-directed stress man- increased gamma and theta power, brain waves linked to agement modules and patients received guidance from a information-processing and deep meditative states, respec- trained psychologist in the form of weekly feedback and tively (Budzynski, 2006; Kruk et al., 2014). In addition, clay individual support through a secure chat function. Program tasks can facilitate expression of emotions (Scholt & Gavron, participants experienced improved quality of life and sig- 2011) and promote stress reduction (Kimport & Robbins, nificant decreases in distress when compared with the wait- 2012). list-control group, further supporting this concept of The research exploring the therapeutic properties of clay web-based minimal contact mental health support (Grossert offers a promising role in anxiety and stress reduction among et al., 2016; Urech et al., 2018). college students. Noticeably, if clay manipulation alone Technologies like HIPAA (Health Insurance Portability could elicit sufficient positive psychological and physiologi- and Accountability Act)-compliant web servers have made cal outcomes, then the most feasible program for college stu- the digital streamlining of psychological screenings and dents would be a campaign to get clay in the hands of each assessments possible, changing components of mental health entering freshman. We set out to determine whether clay services. And now, news articles like Top 25 Best Mental alone was indeed sufficient to produce positive outcomes, or Health Apps of 2018 (Shelton, 2018) suggest that mental if more structure and direction is needed. health apps have become commonplace, but many profes- The program was developed as a mindfulness-based art sionals stress that these apps do not serve as an alternative to therapy (MBAT) program using clay that can be facilitated therapy. Instead, they can be used as a supplement, or at least over an online platform with a minimal contact approach provide a space for people who are still reluctant to seek tra- from the art therapist/researcher. It is made up of one “chal- ditional mental health support, or perhaps lack the resources lenge” that the researcher facilitates, in-person, with partici- to get to face-to-face therapy. pants on the first and last week of the program, and eight Few of the apps have been validated by peer-reviewed “self-care challenges.” These self-care challenges are brief, studies, and online programs such as the ones mentioned 15-min, MBAT directives. The directives are each made up above solely rely on self-report measures to evaluate effi- of a brief mindfulness practice like yoga or meditation with a cacy. Therefore, we developed a research design to assess complementary clay-based art directive. The meditation both psychological and physiological outcomes, to fortify audio files in the program were adapted by Dr. Sean Sullivan study results and acknowledge the strong relationship from Limbix, Inc.© and were free for our use. The first between mental and physical health. The Perceived Stress author produced all the yoga sequence videos. Beerse et al. 3 Table 1. Breakdown of Mindfulness-Based Clay Art Therapy Modules. Module title Description Face-to-Face Meetings Protocol Yoga sequence facilitated by researcher and complementary art directive Module 1: Introduction Audio introduction to meditation with complementary clay-based art directive Module 2: Using Yoga Yoga video with complementary clay-based art directive Module 3: Releasing Stress and Anxiety Audio meditation + art directive Module 4: Harnessing Gratitude Audio meditation + art directive Module 5: Revisiting Yoga Yoga video + art directive Module 6: Rejuvenating Anytime Audio meditation + art directive Module 7: Restoration Yoga video + art directive Module 8: Building Focus Audio meditation + art directive Procedure Participants This study was reviewed and approved by the university’s Students with a full-time enrollment status at the university institutional review board. The researchers used an experi- were recruited through posted advertisements, classroom mental-comparison research design with a convenience sam- announcements, and social media. Inclusion criteria were 18 ple of college students enrolled at a public university full-time. to 65 years old with a full-time enrollment status at a public Participants were randomized into the experimental MBAT university. Smokers were excluded from this study because group condition or a neutral clay-manipulating task (NCT), nicotine can compromise the salivary cortisol data. which served as the comparison group condition. The study A total of 25 students expressed interest in participating, was conducted over the course of 10 weeks within a single 17 qualified for the study, and 15 attended their first face-to- academic semester and used a minimal contact, technology- face meeting (N = 15). Informed written consent was assisted approach. Both group conditions were asked to com- obtained by all participants at the first meeting. Eleven par- plete a brief self-care task once a week; these techniques were ticipants identified as female (73%), three identified as male dubbed “self-care challenges” and were designed to only take (20%), and one participant preferred not to disclose (7%). 15 min. The experimental group’s self-care challenges con- Participants’ ages ranged from 18 to 23 years old (M = 19.87 sisted of a 5-min mindfulness practice and 10 min of inten- years, SD = 1.51). Sixty percent of participants identified as tional art making with earth-based clay. Table 1 provides a White, 14% as Hispanic or Latino, 13% as Black or African brief overview of the modules. The NCT group’s self-care American, and 13% identified themselves as more than one challenges were identical from week to week, and consisted race. It was required in the inclusion criteria that participants of a NCT, where they were given the same clay as experimen- were enrolled full-time at the university. Participants were tal participants and told to “manipulate the clay in any way enrolled in at least 12 and up to 16 credit hours (M = 13.67 you wish for 15 minutes.” The primary researcher met with credit hours; SD = 1.45 hr). They were randomized into the the groups separately on Weeks 1 and 10, during which time experimental (n = 7) and comparison group (n = 8) quantitative data were collected in the form of self-report conditions. measures and pre- and post-challenge saliva samples. For the 8 weeks in between face-to-face meetings, participants Data Analysis checked in through the study’s online platform, a learning management system, to complete the self-care challenges. Generalized Anxiety Qualtrics© was used to administer the self-report assessments remotely. To demonstrate their continued participation in the To measure severity of general anxiety symptoms, the study, participants were asked to upload images of their art- GAD-7 self-report measure was used. The GAD-7 is brief work each week within the online platform. and able to distinguish symptoms of anxiety from depressive The procedure of this study (see Figure 1) was informed symptoms (Spitzer, Kroenke, & Williams, 2006). Scores can by the research question: can MBAT, facilitated to college range from 0 to 21 and cutoffs are 5, 10, 15, and 21 for deter- students using a minimal contact technology-assisted mining whether anxiety is insignificant, mild, moderate, or approach, decrease cortisol levels, decrease levels of per- severe, respectively. It has a sensitivity score of 89% and ceived stress, and reduce symptoms of anxiety more effec- specificity of 82% for diagnosing generalized anxiety disor- tively than an unstructured and undirected clay task? The der. It has been found to be valid and reliable for the general researchers hypothesized that participants of the experimental population (Lowe et al., 2008; Spitzer et al., 2006), making it group condition would experience statistically significant a relevant instrument for the sample of this study. All data decreases in all three measures while the comparison group analysis was conducted using GraphPad Prism 7.01 data would not. analysis software. Within-group paired-samples t tests were 4 SAGE Open Figure 1. Sequence of procedures. Note. MBAT = mindfulness-based art therapy; GAD-7 = Generalized Anxiety Disorder 7-item; PSS-10 = Perceived Stress Scale 10-item. conducted to compare severity of anxiety from the first week pretest–posttest design of its administration was used to to the 10th week and determine whether any significant assess whether any of the self-care challenges in the experi- changes were observed. Between-group comparison of mental program were more effective than others and ana- scores from Week 1 to Week 10 was conducted using a two- lyzed by conducting within-group paired-sample t tests. way analysis of variance (ANOVA) to evaluate any signifi- Within-group paired-sample t tests of Week 1 prechallenge cant interaction between group condition and week of scores and Week 10 postchallenge scores were also con- assessment. ducted to determine whether any overall change in per- ceived stress was observed from the beginning to the end of the study. Perceived Stress Perceived stress levels were assessed pre- and post-self-care Salivary Cortisol Concentrations challenges each week using the Sheldon Cohen PSS-10. The PSS-10 is a 10-item questionnaire with a two-factor struc- A physiological measure of stress was also collected through ture measuring perceived helplessness and perceived self- saliva samples and processed as enzyme-linked immunosor- efficacy and is both valid and reliable with U.S. college bent assays (ELISA). The ELISA samples measured the con- students (Roberti, Harrington, & Storch, 2006). The weekly centration of the stress hormone cortisol in the participants’ Beerse et al. 5 saliva. This biological measure provides an additional facet to determine optical density. From these data, the researcher of empirical data that is harder to manipulate compared with computed the percentage of cortisol bound and conducted a self-report measures. Collecting saliva samples before and regression analysis to establish cortisol concentrations. after the tasks on Weeks 1 and 10 also provided the research- Cortisol concentrations were measured in micrograms per ers with the ability to measure rate of change in cortisol con- deciliter (μg/dL) and used to run the two-way ANOVA and centrations to assess for any possible biofeedback response. within-group paired-sample t tests. A two-way ANOVA was conducted to analyze the variance between the MBAT group’s pre- and postchallenge cortisol Additional questionnaires. Information collected through concentrations from Week 1 to Week 10. In addition to two- questionnaires was not used for formal analysis, but used to way ANOVA, the researcher also conducted paired-sample t understand the characteristics of the study sample and their tests of each group’s pre- and postchallenge cortisol concen- overall experience as research participants. Qualtrics© was trations for Weeks 1 and 10, independently. This was done to used to administer several questionnaires created for the pur- determine whether any within-group significance took place. pose of this research study. Students who contacted the pri- Saliva samples were analyzed using the Salimetrics© mary researcher with interest in participating were asked to Expanded Range High Sensitivity Salivary Cortisol Enzyme complete an online preliminary screening through Qual- Immunoassay Kit (Item No. 1-3002 [Single] 96-Well Kit; trics© to determine their eligibility. A brief demographic 1-3002-5 [5-Pack] 480 Wells). Participants were asked to questionnaire was administered at Week 1 meeting to gather avoid alcohol consumption for 12 hr and to not consume demographic data, average hours of sleep a night, caffeine food for at least 1 hr prior to sample collection. Water was intake, exercise routine, and last day of menstruation for provided to participants to rinse their mouths thoroughly 10 female participants, as menstruation can affect the produc- min before each saliva sample was collected. Saliva samples tion of the stress hormone cortisol. were collected by unstimulated passive drool. Participants Participants who attended the Week 10 meeting also had were instructed to tilt their heads forward, allowing the saliva the option to take an anonymous exit survey. In this exit sur- to pool on the floor of the mouth and then pass the saliva vey, participants were asked questions regarding whether through their lips into a collection vial. Time and date of they found it helpful, whether it was convenient and easy to sample collections were recorded, and samples were col- use, and they had the opportunity to provide open-ended lected between 7:30 a.m. and 8:30 a.m. due to the diurnal comments/feedback about their overall experience. variation in cortisol levels. Samples were immediately placed on wet ice and then transported to the lab within 3 hr of col- Results lection and frozen below –20°C. On days of assays, saliva samples were thawed completely, Retention vortexed, and centrifuged at 1500g for 15 min using the Of the initial sample size of 15, nine participants attended Model TJ-6 Centrifuge to remove mucins and other particu- both face-to-face meetings (MBAT, n = 4; NCT, n = 5), but late matter. Twenty-five microliter of standards, controls, and only five students completed all 10 self-care challenges triplicates of saliva samples were pipetted into appropriate (MBAT, n = 2; NCT, n = 3). The researcher used the n = 9 wells on a 96-well microtiter plate and 25 µL of assay diluent data set of retained participants for data analysis to maximize was pipetted into two wells to serve as the zero and two non- sample size. The researchers acknowledge that these results specific binding (NSB) wells. Conjugate solution was pre- are measurement estimates due to the small sample size, and pared by diluting the enzyme conjugate 1:1600 into the assay need to be investigated further with a larger sample. diluent and 200 µL of the solution was added to each well using a multichannel pipette. The plate was covered, rotated for 5 min at 500 rpm, and then incubated for 1 hr at room Generalized Anxiety temperature. After incubation, the plate was washed by add- Within-group paired-sample t tests showed that the MBAT ing 200 µL of 1× Wash Buffer to each well, discarding the group (n = 4) demonstrated a statistically significant liquid over the sink, and then thoroughly blotted with paper decrease in anxiety from Week 1 to Week 10, t(4) = 6.789, towels. This wash process was repeated 4 times. After the p = .006, while the NCT group (n = 5) did not demonstrate plate was washed and blotted dry, 200 µL of TMB substrate any statistical significance from Week 1 to Week 10, solution was added to each well using a multichannel pipette. t(4) = 1.783, p > .05. Although the NCT group did not have The plate was then covered, rotated for 5 min at 500 rpm any statistically significant difference in GAD-7 scores from again, and incubated in the dark at room temperature for 25 Week 1 to Week 10, it did exhibit a general decrease in aver- min. Fifty microliter of stop solution was added to each well age scores (see Figure 2). Two-way ANOVA (Table 2) using the multichannel pipette before being covered and showed no statistical interaction was identified between mixed on the plate rotator for 3 min at 500 rpm. The bottom group condition and week of assessment: F(1, 14) = 0.046, of the plate was wiped with a water-moistened Kimwipe and p > .05. Sample sizes were small, making data analysis far read at 450 nm using Gen 5 1.11 Microplate reading software 6 SAGE Open Figure 2. Average GAD-7 scores with standard deviation bars of MBAT and NCT groups from Week 1 to Week 10. Note. GAD-7 = Generalized Anxiety Disorder 7-item; MBAT = mindfulness-based art therapy; NCT = neutral-manipulating clay task. Table 2. Two-Way ANOVA Between-Group Comparison of MBAT and NCT Group GAD-7 Scores From Week 1 to Week 10 demonstrating no significant interactions between groups and time periods. Table analyzed GAD-7 results MBAT vs. NCT Two-way ANOVA Ordinary α .05 Source of variation % of total variation p value p value summary Significant? Interaction 0.2721 .8334 ns No Group 0.0912 .9030 ns No Time period 16.73 .1149 ns No ANOVA table SS (Type III) df MS F (dfn, dfd) p value Interaction 1.003 1 1.003 F(1, 14) = 0.04595 .8334 Group 0.3361 1 0.3361 F(1, 14) = 0.0154 .9030 Time period 61.67 1 61.67 F(1, 14) = 2.826 .1149 Residual 305.5 14 21.82 Number of missing values 2 Note. ANOVA = analysis of variance; MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task; GAD-7 = Generalized Anxiety Disorder; SS = sum of squares; MS = mean squares; dfn = degrees of freedom numerator; dfd = degrees of freedom denominator. from conclusive, but results from within-group paired-sam- stress. The normal distribution of PSS-10 scores for 18- to ple t tests do suggest that MBAT has some anxiety-reducing 29-year-olds is a mean of 14.2 with a standard deviation of benefits when compared with a NCT condition. 6.2, based on a normed sample of N = 645. A score of at least 20 is considered high levels of perceived stress. For the MBAT group, paired-sample t-tests generated no statistically Perceived Stress significant difference in Week 1 prechallenge scores and Participants were asked to complete the Sheldon Cohen PSS- Week 10 postchallenge scores: t(3) = 1.809, p > .05. The 10 as their pre- and postchallenge assessment of perceived same conclusion was made for the NCT group, as they did Beerse et al. 7 Figure 3. Average PSS-10 scores with standard deviation bars from Week 1 to Week 10 with pre- and postconditions comparing MBAT and NCT groups. Note. PSS-10 = Perceived Stress Scale 10-item; MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task. the retained subjects data set to maximize sample size and minimize a Type I error. Only Week 8 (see Figure 4), “Restoration,” demonstrated a statistically significant reduc- tion in PSS-10 scores pre- and post-self-care challenge, t(2) = 10, p = .009. The paired-sample t test of Week 5, Module 4: “Harnessing Gratitude,” PSS-10 scores pre- and postchal- lenge generated a nearly statistically significant decrease in perceived stress: t(3) = 2.611, p = .0796 (see Figure 5). The small sample size prohibits any conclusions being made from such results, but they suggest that certain modules may be more effective at reducing levels of perceived stress than others. Cortisol Analysis Regression analysis of optical density and percent bound was conducted using a four-parameter nonlinear regression curve fit to generate cortisol concentrations (µg/dL) of stan- dards, high and low controls, and saliva samples. The r Figure 4. MBAT participants’ plotted PSS-10 scores before and obtained for Plate 1 was 99.15% (R = .992) and 99.23% for after Module 7: Restoration. Plate 2 (R = .992), ensuring accuracy of cortisol data. Two Note. MBAT = mindfulness-based art therapy; PSS-10 = Perceived Stress saliva samples collected were too low to analyze and had to Scale 10-item. be excluded from analysis. A two-way ANOVA between the MBAT group’s pre- and postchallenge cortisol concentra- not demonstrate any statistical difference between Week 1 tions from Week 1 to Week 10 and the NCT group’s concen- pre- and Week 10 postchallenge scores either: t(4) = 1.757, trations was conducted. There was no significant interaction p >.05 (see Figure 3). between group condition and salivary cortisol collection Weekly paired-sample t tests were run using all of the period on cortisol concentration: F(1, 14) = 0.012, p = .915 MBAT participants’ PSS-10 scores from each week, not just (see Table 3). 8 SAGE Open one somewhat disagreed, and three neither agreed nor dis- agreed. Seven out of nine participants found the online plat- form convenient and easy to use while two participants somewhat disagreed, explaining that “the [online] app glitched often and made it frustrating to submit photos” and “the . . . page wasn’t set up in the best way.” Other feedback received through the exit survey included suggestions for changing the day of the week that self-care challenges were “due” from Saturday night to Sunday night, as most respondents explained it was difficult to remember to complete them before a Saturday deadline. Respondents also described positive outcomes from participating. One respon- dent “enjoyed the study” and “learning new techniques.” Another respondent said, “I loved the challenge, and found myself practicing the breathing exercises even outside of the study. I love the clay too, really fun.” Overall, participants were open to providing honest feedback of their experience and offered valuable suggestions for altering the research design to enhance usability and retention rates in the future. Figure 5. Demonstration of near statistical significance in plotted PSS-10 scores for MBAT participants before and after Discussion Module 4: Harnessing Gratitude. Note. PSS-10 = Perceived Stress Scale 10-item; MBAT = mindfulness- This study’s purpose was to address an elemental gap in based art therapy. research relating to proactive mental health programs for college-level students. Perceived stress, generalized anxiety, and salivary cortisol concentrations of participants were Paired-sample t tests (see Figure 6) of each group’s pre- measured and compared. Within-group and between-group and postchallenge cortisol concentrations for Weeks 1 and 10 analysis was conducted to test the effectiveness of each produced inverse results for each group condition. The group condition. MBAT group showed no statistical difference in cortisol con- centrations from before the challenge to after on Week 1, t(4) = 0.272, p = .799, but did show a statistically signifi- MBAT and Its Impact on Anxiety cant decrease in cortisol concentrations on Week 10, The hypothesis that the MBAT group would experience more t(3) = 13.01, p = .001. The opposite happened for the NCT significant reduction in GAD-7 scores from Week 1 to Week group, as they experienced a statistically significant decrease 10 was accepted. The MBAT group had a statistically signifi- in cortisol on Week 1, t(7) = 3.208, p = .015, but not on cant reduction in GAD-7 scores from Week 1 to Week 10 Week 10, t(4) = 0.132, p = .902. while the NCT group did not. The average GAD-7 score of the retained subjects from the MBAT group on Week 1 was Exit Surveys M = 9.0 and the average for the retained subjects of the NCT Participants who attended the second meeting (Week 10) had group was M = 9.2. This reinforces that the significant the option to complete an anonymous exit survey. All nine decrease in scores on Week 10 for MBAT participants is participants opted into completing it at the conclusion of the unlikely attributable to more severe initial symptoms of anx- final meetings. The survey asked them five questions regard- iety but rather to the group condition itself. ing satisfaction with participating, level of helpfulness with The initial GAD-7 scores of participants supported a high their own stress and anxiety, convenience and usability, and prevalence of anxiety among college-level students. Ninety- an open-ended component for any comments and/or feed- three percent of the research participants had GAD-7 scores back relating to their experience. Eight out of nine partici- of at least mild levels of generalized anxiety, and 47% scored pants (89%) either agreed or strongly agreed that they were moderate or severe levels. It is possible that we do not yet very satisfied with their experience as a participant in the truly understand the extent to which college students are study and one participant somewhat disagreed. Six out of affected by anxiety and stress. Participants who scored high nine participants found it helpful with reducing levels of per- on the GAD-7 were monitored throughout the study and ceived stress, one person somewhat disagreed, one disagreed, would be referred to additional mental health support if and one neither agreed nor disagreed. Four out of nine par- decreases in anxiety were not observed. The inflated preva- ticipants somewhat agreed that the study was helpful in lence among the sample size of this study could be influ- reducing their levels of anxiety, one participant disagreed, enced by the phenomenon of self-selection, as potential Beerse et al. 9 Table 3. Two-Way ANOVA of Group Conditions and Saliva Collection Period Interaction With Cortisol Concentration (µg/dL) demonstrating no significant interactions between groups and time periods. Salivary cortisol concentrations Table analyzed (µg/dL) MBAT vs. NCT Two-way ANOVA Ordinary α .05 Source of variation % of total variation p value p value summary Significant? Interaction 0.2882 .9908 ns No Group 0.2587 .7581 ns No Time period 2.708 .7994 ns No ANOVA table SS (Type III) df MS F (dfn, dfd) p value Interaction 0.004599 3 0.001533 F(3, 36) = 0.03574 .9908 Group 0.004129 1 0.004129 F(1, 36) = 0.09628 .7581 Time period 0.04322 3 0.01441 F(3, 36) = 0.336 .7994 Residual 1.544 36 0.04289 Number of missing values 20 Note. ANOVA = analysis of variance; MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task; SS = sum of squares; MS = mean squares; dfn = degrees of freedom numerator; dfd = degrees of freedom denominator. Figure 6. Pre- and postchallenge cortisol concentrations with standard deviation bars for MBAT and NCT group conditions Week 1 and Week 10. Note. MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task. participants knew that the study’s focus was about address- produced a statistically significant decrease from Week 1 to ing anxiety and stress. Week 10, but the NCT group condition had near-statistically significant decrease in scores pretest to posttest on Week 10 (p = .071), coinciding with literature that identifies clay work as Perceptions of Stress having stress-relieving benefits (Kimport & Robbins, 2012). The hypothesis that the MBAT group would experience Weekly PSS-10 scores, however, suggest some of the greater reductions in perceived levels of stress on Week 10 challenges were more effective at lowering levels of per- compared with the NCT group was rejected. Neither group ceived stress than others. Week 8’s self-care challenge, 10 SAGE Open “Restoration,” elicited statistically significant reduction in emphasizes that it is the ongoing practice of mindfulness that PSS-10 scores for the MBAT group participants: t(2) = 10, enhances physical and mental benefits (Brand et al., 2012; p = .0099. This challenge consisted of a simple yoga Henderson et al., 2013; Hofmann, Sawyer, Witt, & Oh, 2010; sequence of three poses followed by a mindful art-making Kabat-Zinn, 2003; Prazak et al., 2012; Schure, Christopher, session where participants were asked to create a clay work & Christopher, 2008), while a brief single-session clay task response to how they were feeling in the present moment. can affect cortisol concentrations (Kaimal et al., 2016). The Week 5 challenge, “Harnessing Gratitude,” elicited reductions in PSS-10 scores that were near statistical signifi- Accessibility and Feasibility cance: t(3) = 2.611, p = .0796. Gratitude, which constitutes having “a more positive and appreciative outlook toward Participants had access to the research facilitator through life” (Wood, Maltby, Gillett, Linley, & Joseph, 2008, p. 854), email and cell phone while they were completing Weeks 2 has been identified as having a lasting protective effect through 9, remotely. Some participants took advantage of against stress and depression among college-level students this and communicated with the researcher when they had (O’Leary & Dockray, 2015). Gratitude also requires some questions, issues with the online platform, or missed a dead- awareness of the present moment, similar to mindfulness and line. This allowed the researcher to support participants as likely complements the characteristics of this study. In the needed even though they were not meeting face-to-face each Week 5 MBAT challenge, participants listened to a brief week. Participants who did reach out throughout the study guided meditation about gratitude and were then asked to chose text messaging or email as their method of communi- create an art piece representing the thing they were grateful cation with the researcher; no participants chose to call the for through the meditation. researcher, suggesting that college students feel more com- fortable communicating through digital avenues. Regarding the online platform, some participants found it Cortisol Concentrations confusing while others liked that they already regularly The hypothesis that the MBAT group would experience accessed the web-based application, which is also the univer- reductions of salivary cortisol concentrations pretest to post- sity’s adopted learning management system, and therefore test at a faster rate than the NCT group by Week 10, indicating they found it convenient. It is possible that using the same the presence of a biofeedback response, was rejected. The platform that students use to turn in assignments, check MBAT group did experience a statistically significant reduc- grades, and communicate with their professors made the tion in salivary cortisol concentrations on Week 10 after expe- self-care challenges feel more like homework rather than riencing no significant reduction on Week 1, but there was no self-care. Each self-care challenge would go live on the web- statistical significance when compared with the NCT group. site/app for a week at a time, starting at midnight on Saturdays The NCT group experienced the opposite of the MBAT and they would be due the following Saturday at midnight. group. The NCT group demonstrated statistically significant Most participants completed their self-care challenges late reductions in salivary cortisol concentrations on Week 1 pre- on Saturday evenings, and the inconvenient “due dates” test to posttest, but not on Week 10. The significant reduction could have contributed to the high attrition rate of the study. in the NCT group’s concentrations on Week 1 could be Results of this study imply that further research is needed attributed to the natural reduction in cortisol concentrations on the concept of using MBAT through an online platform as that occurs when just sitting quietly (Pawlow & Jones, 2005), a proactive mental health program for college-level students but there are several other variables that can affect salivary and that current findings are reassuring. The differences in cortisol concentrations. Potential contributing factors to sali- effects of the two group conditions support the current vary cortisol concentrations range from differences in sex, research on mindfulness practices, art therapy, and the intrin- food and alcohol intake, genetic predispositions, environ- sic therapeutic benefits of working with an art medium. The mental factors, menstruation, caffeine intake, exercise activ- high attrition rate, in spite of the minimal time requirement ity, medication, and more (Clements, 2012; Stephens, asked of participants, suggests that there is less of an issue of Mahon, McCaul, & Wand, 2016). It is recommended for students lacking access to mental health resources but rather future research that data on these possible variables be col- that the student population fails to use such resources. Further lected more vigorously while also incorporated into analysis. research into understanding how students are motivated to While some of these data were collected with the initial proactively address their mental health is necessary for the demographic questionnaire, corresponding posttest data development of a university program that is not only evi- were not collected at the end of the study to assess the pres- dence-based, but also maximizes student involvement. ence of any additional benefits to participation, such as sleeping patterns, caffeine intake, or exercise routines. Limitations Notwithstanding the other variables, the results of the cor- tisol paired-sample t tests align with research regarding There are several significant limitations of this study. The mindfulness, meditation, and working with clay. Research small sample size of nine retained participants prevents any Beerse et al. 11 generalizations to be made about the results. In addition, the Funding study sample was a majority of female participants and The author(s) disclosed receipt of the following financial support therefore not reflective of the general student population. for the research, authorship, and/or publication of this article: This Another limitation of the study was the issue of self- project was supported by the Florida State University Council on screening. The researcher used a convenience sample and Research and Creativity (Project ID 041680). relied on students to respond to recruitment flyers. It appears that students who already identify themselves as more ORCID iD stressed and anxious are more likely to express interest in a Megan E. Beerse https://orcid.org/0000-0003-4388-8030 study such as this one. The average PSS-10 score pre-chal- lenge at the first face-to-face meeting was M = 19.53 References (SD = 7.367), closer to the higher range of perceived stress American Art Therapy Association. (2017). About art therapy. rather than the normed average score of M = 14.2. Similarly, Retrieved from https://arttherapy.org/about-art-therapy/ the average GAD-7 score of all participants on Week 1 was Brand, S., Holsboer-Trachsler, E., Naranjo, J. R., & Schmidt, S. M = 10.87 (SD = 4.96), which is considered a moderate (2012). Influence of mindfulness practice on cortisol and sleep level of generalized anxiety. The participants of this study in long-term and short-term meditators. Neuropsychobiology, were not necessarily displaying subclinical levels of anxiety 65, 109-118. doi:10.1159/000330362 and stress, but moderate levels that needed addressed and Budzynski, T. (2006). The clinical guide to sound and light. Retrieved from https://web.stanford.edu/group/brainwaves/ may not be reflective of the general student population at 2006/theclinicalguidetosoundandlight.pdf large. Clements, A. D. (2012). Salivary cortisol measurement in develop- mental research: Where do we go from here? Developmental Conclusion Psychology, 55, 205-220. doi:10.1002/dev.21025 Cohen, B. E., Edmondson, D., & Kronish, I. M. (2015). State of Future studies can expand on this research by facilitating the art review: Depression, stress, anxiety, and cardiovascular the program with a much larger sample size, and efforts are disease. American Journal of Hypertension, 28, 1295-1302. already under way to replicate this study at the same insti- doi:10.1093/ajh/hpv047 tution on a larger scale. Alternative outcome measures Eisenberg, D., Golberstein, E., & Hunt, J. B. (2009). Mental health could also be incorporated into future studies to gather dif- and academic success in college. The B.E. Journal of Economic ferent information. Acceptance and participation could be Analysis & Policy, 9(1), 1-35. Eisenberg, D., Hunt, J., Speer, N., & Zivin, K. (2011). Mental considered, as well as other physiological measures or health service utilization among college students in the United external variables, like the program’s effect on academic States. The Journal of Nervous and Mental Disease, 199, 301- performance, sleeping habits, exercise routine, and 308. doi:10.1097/NMD.0b013e3182175123 sociability. Grossert, A., Urech, C., Alder, J., Gaab, J., Berger, T., & Hess, Reviewers of the preexisting mental health apps have V. (2016). Web-based stress management for newly diag- noted that the best apps will have mental health professionals nosed cancer patients (STREAM-1): A randomized, waitlist taking on active roles to ensure safety and support for their controlled intervention study. BMC Cancer, 16, Article 838. consumers (Shelton, 2018). The structured and directed doi:10.1186/s12885-016-2866-0 nature of the program’s self-care challenges was more effec- Henderson, V. P., Massion, A. O., Clemow, L., Hurley, T. G., tive than the simple nondirected task of manipulating clay, Druker, S., & Hebert, J. R. (2013). A randomized controlled trial coinciding with this ideal of a therapist-directed program. of mindfulness-based stress reduction for women with early- stage breast cancer receiving radiotherapy. Integrative Cancer The program, facilitated by an art therapist through a mini- Therapies, 12, 404-413. doi:10.1177/1534735412473640 mal contact approach, could offer college students a place to Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The learn skills for managing stress and experience anxiety effect of mindfulness-based therapy on anxiety and depression: reduction, all while the ongoing practice impacts them down A meta-analytic review. Journal of Consulting and Clinical to the physiological level. Psychology, 78, 169-183. doi:10.1037/a0018555 Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Acknowledgment Past, present, and future. Clinical Psychology, 10, 144-156. doi:10.1093/clipsy.bpg016 A sincere thank you to Lisa Anderson of the Stanwood Lab for her Kaimal, G., Ayaz, H., Herres, J., Dieterich-Hartwell, R., Makwana, contributions to the project and to Jonathan Sockell, Dr. Sean B., Kaiser, D. H., & Nasser, J. A. (2017). Functional near- Sullivan, and the rest of the Limbix© team for providing the medi- infrared spectroscopy assessment of reward perception based tation audio files incorporated into the MBAT modules. on visual self-expression: Coloring, doodling, and free draw- ing. The Arts in Psychotherapy, 55, 85-92. doi:10.1016/j. Declaration of Conflicting Interests aip.2017.05.004 The author(s) declared no potential conflicts of interest with respect Kaimal, G., Ray, K., & Muniz, J. (2016). Reduction of cortisol to the research, authorship, and/or publication of this article. levels and participants’ responses following art making. Art 12 SAGE Open Therapy: Journal of the American Art Therapy Association, Schure, M. B., Christopher, J., & Christopher, S. (2008). Mind- 33, 74-80. doi:10.1080/07421656.2016.1166832 body medicine and the art of self-care: Teaching mindfulness Kimport, E. R., & Robbins, S. J. (2012). Efficacy of creative clay to counseling students through yoga, meditation, and qigong. work for reducing negative mood: A randomized controlled Journal of Counseling & Development, 86, 47-56. trial. Art Therapy: Journal of the American Art Therapy Shelton, J. (2018, April 24). Top 25 best mental health apps: Association, 29(2), 74-79. doi:10.1080.07421656.2012.680048 An effective alternative for when you can’t afford therapy? Kruk, K. A., Aravich, P. F., Deaver, S. P., & deBeus, R. (2014). Retrieved from https://www.psycom.net/25-best-mental- Comparison of brain activity during drawing and clay sculpt- health-apps ing: A preliminary qEEG study. Art Therapy: Journal of the Spitzer, R. L., Kroenke, K., & Williams, J. B. W. (2006). A brief American Art Therapy Association, 31(2), 52-60. doi:10.1080/ measure for assessing Generalized Anxiety Disorder: The 07421656.2014.903826 GAD-7. Archives of Internal Medicine, 166, 1092-1097. López-Bárcena, J., González-de Cossío Ortiz, M., Avila-Martínez, doi:10.1001/archinte.166.10.1092 I., & Teos-Aguilar, O. (2009). Epidemiological health fac- Stephens, M. A. C., Mahon, P. B., McCaul, M. E., & Wand, G. tors and their relationship with academic performance during S. (2016). Hypothalamic-pituitary-adrenal axis response to first year of medical school. Study of two generations. Gaceta acute psychosocial stress: Effects of biological sex and circu- Medica de Mexico, 145, 81-90. lating sex hormones. Psychoneuroendocrinology, 66, 47-55. Lorenzo de la Peña, S. (2016). 2D expression is intrinsic. In D. E. doi:10.1016/j.psyneuen.2015.12.021 Gussak & M. L. Rosal (Eds.), The Wiley handbook of art ther- Sterling, P., & Eyer, J. (1988). Allostasis: A new paradigm to apy (pp. 146-153). West Sussex, UK: John Wiley. explain arousal in pathology. In S. Fisher & J. Reason (Eds.), Lowe, B., Decker, O., Muller, S., Brahler, E., Schelberg, D., Herzog, Handbook of life stress, cognition and health (pp. 629-649). W., & Herzberg, P. Y. (2008). Validation and standardization New York, NY: John Wiley. of the Generalized Anxiety Disorder screener (GAD-7) in the Urech, C., Grossert, A., Alder, J., Scherer, S., Handschin, B., general population. Medical Care, 46, 266-274. doi:10.1097/ Kasenda, B., . . . Hess, V. (2018). Web-based stress manage- MLR.0b013e318160d093 ment for newly diagnosed patients with cancer (STREAM): McEwen, B. S. (2006). Protective and damaging effects of stress A randomized, wait-list controlled intervention study. mediators: Central role of the brain. Dialogues in Clinical Journal of Clinical Oncology, 36, 780-788. doi:10.1200/ Neuroscience, 8, 367-381. JCO.2017.74.8491 National Alliance on Mental Illness. (2012). College students Wood, A. M., Maltby, J., Gillett, R., Linley, P. A., & Joseph, S. speak: A survey report on mental health. Arlington, VA: (2008). The role of gratitude in the development of social sup- Printing Office. port, stress, and depression: Two longitudinal studies. Journal O’Leary, K., & Dockray, S. (2015). The effects of two novel grati- of Research in Personality, 42, 854-871. doi:10.1016/j. tude and mindfulness interventions on well-being. The Journal jrp.2007.11.003 of Alternative and Complementary Medicine, 21, 543-245. Wright, E. M. (2018). Evaluation of web-based holistic stress reduc- doi:10.1089/acm.2014.0119 tion pilot program among nurse-midwives. Journal of Holistic Pawlow, L. A., & Jones, G. E. (2005). The impact of abbreviated Nursing, 36, 159-169. doi:10.1177/0898010117704325 progressive muscle relaxation on salivary cortisol and salivary Xiao, H., Carney, D. M., Youn, S. J., Janis, R. A., Castonguay, immunoglobulin A (sIgA). Applied Psychophysiology and L. G., Hayes, J. A., & Locke, B. D. (2017). Are we in crisis? Biofeedback, 30, 375-387. doi:10.1007/s10484-005-8423-2 National mental health and treatment trends in college counsel- Prazak, M., Critelli, J., Martin, L., Miranda, V., Purdum, M., & ing centers. Psychological Services, 14, 407-415. doi:10.1037/ Powers, C. (2012). Mindfulness and its role in physical and ser0000130 psychological health. Applied Psychology: Health & Well- Being, 4, 91-105. doi:10.1111/j.1758-0854.2011.01063.x Author Biographies Roberti, J. W., Harrington, L. N., & Storch, E. A. (2006). Further Megan E. Beerse (MS, 200-RYT) is a 2018 graduate of the FSU psychometric support for the 10-item version of the perceived master of Science Art Therapy program and a 200-hour Registered stress scale. Journal of College Counseling, 9, 135-147. Yoga Teacher with the Yoga Alliance. Her research interests Sandmire, D. A., Gorham, S. R., Rankin, N. E., & Grimm, D. R. include interdisciplinary frameworks, mindfulness-based art ther- (2012). The influence of art making on anxiety: A pilot study. apy, and proactive mental health strategies. Art Therapy: Journal of the American Art Therapy Association, 29(2), 68-73. doi:10.1080/07421656.2012.683748 Theresa Van Lith (PhD, ATR-BC, AThR) is an associate profes- Sareen, J., Cox, B. J., Afifi, T. O., de Graaf, R., Asmundson, G. J. G., sor and clinical professor of Art Therapy at Florida State University. ten Have, M., & Stein, M. B. (2005). Anxiety disorders and risk She is an associate editor of Art Therapy: Journal of the American for suicidal ideation and suicide attempts: A population-based Art Therapy Association and is a board member of the Research longitudinal study of adults. Archives of General Psychiatry, and Multicultural Committees for the American Art Therapy 62, 1249-1257. doi:10.1001/archpsych.62.11.1249 Association. Van Lith has published widely on the implementation Schneiderman, N., Ironson, G., & Siegel, S. (2005). Stress and of evidence-based service delivery models using art therapy for health: Psychological, behavioral, and biological determinants. various mental heatlh, developmental and sociocultural issues. Annual Review of Clinical Psychology, 1, 607-628. Scholt, M., & Gavron, T. (2011). Therapeutic qualities of clay- Gregg D. Stanwood (PhD) is a neuroscientist and pharmacologist work in art therapy and psychotherapy: A review. Art Therapy: whose laboratory focuses on the neural circuits that underlie mental Journal of the American Art Therapy Association, 23(2), 66- health disorders. He is particularly interested in gene-environment 72. doi:10.1080/07421656.2006.10129647 interactions during sensitive periods of brain development. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png SAGE Open SAGE

Is There a Biofeedback Response to Art Therapy? A Technology-Assisted Approach for Reducing Anxiety and Stress in College Students:

SAGE Open , Volume 9 (2): 1 – Jun 2, 2019

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Abstract

College students are exposed to daily stressors throughout their academic careers, which can have lasting consequences to their health and well-being. Mindfulness practices, art therapy, and the simple act of manipulating clay have independently demonstrated positive effects on stress and anxiety, but there is little research on the feasibility of incorporating these into an online resource for students to proactively address their mental health. In this pilot study, full-time university students (N = 15) were randomly assigned to a mindfulness-based art therapy (MBAT) program that used clay for all art directives or an unstructured, undirected neutral clay-manipulating task (NCT) for 10 weeks. Anxiety symptoms, salivary cortisol concentrations, and perceived levels of stress were assessed. Within-group analysis demonstrated significant decreases in anxiety symptoms and cortisol concentrations for MBAT participants, with no significant decrease in perceived stress. NCT participants experienced a significant decrease in cortisol concentrations on Week 1 but not on Week 10, with no other statistical significance in outcomes detected. Between-group analysis generated no significant interactions between variables. Based on these results, the structure of a therapist-directed online MBAT program using clay has the capacity to elicit anxiety-reducing benefits and may produce a trained biofeedback response for combating stress, offering a feasible strategy for addressing the mental health crisis on college campuses. Keywords art therapy, mindfulness, clay, anxiety, stress, college students issues, and half (50%) of those who dropped out never Introduction accessed mental health services or support (National Alliance To address the ever-growing prevalence of mental health on Mental Illness [NAMI], 2012). issues, researchers across the globe are looking into feasible Unmanaged anxiety and stress can have devastating con- strategies for enhancing individuals’ access to services. Web- sequences to a student’s academic career, as depression and based interventions are increasing in popularity and impor- anxiety have strong correlations with lower grade point aver- tance as digital natives are coming of age and making up a age and increased risk of dropout (Eisenberg, Golberstein, & larger part of the affected demographic. Hunt, 2009; López-Bárcena, González-de Cossío Ortiz, Data collected from 86 institutions’ counseling centers Avila-Martínez, & Teos-Aguilar, 2009; NAMI, 2012), but (CCs) from 2010 through 2015 reflected a significant consequences extend beyond academic success. Being in a increase in college students reporting symptoms of general- state of chronic stress can have a severe negative impact on a ized anxiety, depression, and overall distress (Xiao et al., person’s overall well-being. The stress response is a natural, 2017). CC utilization increased by 30% over the course of those 5 years, while institution enrollment only increased by Department of Art Education, Florida State University College of Fine 5.5%, suggesting that the stigma surrounding mental health Arts, Tallahassee, USA is declining. However, many students still prefer to seek sup- 2 Department of Biomedical Sciences, Florida State University College of port from peers or family rather than through formal clinical Medicine, Tallahassee, USA counseling services (Eisenberg, Hunt, Speer, & Zivin, 2011). Corresponding Author: Even with the influx in students using university counseling Megan E. Beerse, Research Assistant, Department of Art Education, Florida State services, 64% of college dropouts in a 2012 survey stated University, 1033 William Johnston building, Tallahassee, FL 32306-1232, USA. their reason for dropping out was related to mental health Email: meb15k@fsu.edu Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open biological mechanism that is integral to survival. Stress hor- Scale 10-item (PSS-10) and the Generalized Anxiety mones like cortisol and adrenaline allow the body to remain Disorder 7-item (GAD-7) were used to assess psychological alert in dangerous situations. When daily stressors induce outcomes while concentrations of the stress hormone cortisol this stress response on a regular basis, preventing the indi- in saliva samples were tested, as reductions in concentrations vidual from returning to homeostasis, they begin to shift the have been observed in mindfulness and art therapy research mental and physical health statuses of that individual (Brand, Holsboer-Trachsler, Naranjo, & Schmidt, 2012; (McEwen, 2006; Sterling & Eyer, 1988). Chronic stress can Kaimal, Ray, & Muniz, 2016). lead to the development of anxiety, depression, and suicidal ideation (Sareen et al., 2005; Schneiderman, Ironson, & Method Siegel, 2005). It can also elevate blood pressure, increase risk of cardiovascular disease (Cohen, Edmondson, & Overview of Intervention Program Kronish, 2015), lead to the development of an autoimmune disease, or even exacerbate the symptoms of a preexisting Art therapy is a mental health profession that integrates the disease like rheumatoid arthritis or multiple sclerosis creative process with applied psychological theory (American (Schneiderman et al., 2005). Art Therapy Association, 2017). Art therapists are trained Web-based interventions and online programs are being psychotherapists with more specified training in the thera- explored with other populations that are experiencing peutic properties of art materials and creative processes. Art heightened levels of stress. A web-based holistic stress therapy researchers are gaining a better understanding that in reduction intervention was piloted with certified nurse- addition to the therapist–client relationship and the directives midwives, who are at risk of secondary traumatic stress, used in session, the art material itself can affect a client down posttraumatic stress disorder, and burnout. Participation in to neurological and physiological levels (Kaimal et al., 2017; holistic exercises 4 times a week for 4 weeks effectively Kaimal et al., 2016; Kimport & Robbins, 2012; Kruk, improved their stress levels and coping (Wright, 2018). In Aravich, Deaver, & deBeus, 2014; Lorenzo de la Peña, 2016; Switzerland, Germany, and Austria, a therapist-guided Sandmire, Gorham, Rankin, & Grimm, 2012; Scholt & online stress management program was offered to newly Gavron, 2011). Findings from previous studies suggest that diagnosed cancer patients to help them with the psychologi- the material properties of clay complement mindfulness cal distress that comes with adjusting to a cancer diagnosis. practices, as even brief clay sculpting is associated with The 8-week program consisted of self-directed stress man- increased gamma and theta power, brain waves linked to agement modules and patients received guidance from a information-processing and deep meditative states, respec- trained psychologist in the form of weekly feedback and tively (Budzynski, 2006; Kruk et al., 2014). In addition, clay individual support through a secure chat function. Program tasks can facilitate expression of emotions (Scholt & Gavron, participants experienced improved quality of life and sig- 2011) and promote stress reduction (Kimport & Robbins, nificant decreases in distress when compared with the wait- 2012). list-control group, further supporting this concept of The research exploring the therapeutic properties of clay web-based minimal contact mental health support (Grossert offers a promising role in anxiety and stress reduction among et al., 2016; Urech et al., 2018). college students. Noticeably, if clay manipulation alone Technologies like HIPAA (Health Insurance Portability could elicit sufficient positive psychological and physiologi- and Accountability Act)-compliant web servers have made cal outcomes, then the most feasible program for college stu- the digital streamlining of psychological screenings and dents would be a campaign to get clay in the hands of each assessments possible, changing components of mental health entering freshman. We set out to determine whether clay services. And now, news articles like Top 25 Best Mental alone was indeed sufficient to produce positive outcomes, or Health Apps of 2018 (Shelton, 2018) suggest that mental if more structure and direction is needed. health apps have become commonplace, but many profes- The program was developed as a mindfulness-based art sionals stress that these apps do not serve as an alternative to therapy (MBAT) program using clay that can be facilitated therapy. Instead, they can be used as a supplement, or at least over an online platform with a minimal contact approach provide a space for people who are still reluctant to seek tra- from the art therapist/researcher. It is made up of one “chal- ditional mental health support, or perhaps lack the resources lenge” that the researcher facilitates, in-person, with partici- to get to face-to-face therapy. pants on the first and last week of the program, and eight Few of the apps have been validated by peer-reviewed “self-care challenges.” These self-care challenges are brief, studies, and online programs such as the ones mentioned 15-min, MBAT directives. The directives are each made up above solely rely on self-report measures to evaluate effi- of a brief mindfulness practice like yoga or meditation with a cacy. Therefore, we developed a research design to assess complementary clay-based art directive. The meditation both psychological and physiological outcomes, to fortify audio files in the program were adapted by Dr. Sean Sullivan study results and acknowledge the strong relationship from Limbix, Inc.© and were free for our use. The first between mental and physical health. The Perceived Stress author produced all the yoga sequence videos. Beerse et al. 3 Table 1. Breakdown of Mindfulness-Based Clay Art Therapy Modules. Module title Description Face-to-Face Meetings Protocol Yoga sequence facilitated by researcher and complementary art directive Module 1: Introduction Audio introduction to meditation with complementary clay-based art directive Module 2: Using Yoga Yoga video with complementary clay-based art directive Module 3: Releasing Stress and Anxiety Audio meditation + art directive Module 4: Harnessing Gratitude Audio meditation + art directive Module 5: Revisiting Yoga Yoga video + art directive Module 6: Rejuvenating Anytime Audio meditation + art directive Module 7: Restoration Yoga video + art directive Module 8: Building Focus Audio meditation + art directive Procedure Participants This study was reviewed and approved by the university’s Students with a full-time enrollment status at the university institutional review board. The researchers used an experi- were recruited through posted advertisements, classroom mental-comparison research design with a convenience sam- announcements, and social media. Inclusion criteria were 18 ple of college students enrolled at a public university full-time. to 65 years old with a full-time enrollment status at a public Participants were randomized into the experimental MBAT university. Smokers were excluded from this study because group condition or a neutral clay-manipulating task (NCT), nicotine can compromise the salivary cortisol data. which served as the comparison group condition. The study A total of 25 students expressed interest in participating, was conducted over the course of 10 weeks within a single 17 qualified for the study, and 15 attended their first face-to- academic semester and used a minimal contact, technology- face meeting (N = 15). Informed written consent was assisted approach. Both group conditions were asked to com- obtained by all participants at the first meeting. Eleven par- plete a brief self-care task once a week; these techniques were ticipants identified as female (73%), three identified as male dubbed “self-care challenges” and were designed to only take (20%), and one participant preferred not to disclose (7%). 15 min. The experimental group’s self-care challenges con- Participants’ ages ranged from 18 to 23 years old (M = 19.87 sisted of a 5-min mindfulness practice and 10 min of inten- years, SD = 1.51). Sixty percent of participants identified as tional art making with earth-based clay. Table 1 provides a White, 14% as Hispanic or Latino, 13% as Black or African brief overview of the modules. The NCT group’s self-care American, and 13% identified themselves as more than one challenges were identical from week to week, and consisted race. It was required in the inclusion criteria that participants of a NCT, where they were given the same clay as experimen- were enrolled full-time at the university. Participants were tal participants and told to “manipulate the clay in any way enrolled in at least 12 and up to 16 credit hours (M = 13.67 you wish for 15 minutes.” The primary researcher met with credit hours; SD = 1.45 hr). They were randomized into the the groups separately on Weeks 1 and 10, during which time experimental (n = 7) and comparison group (n = 8) quantitative data were collected in the form of self-report conditions. measures and pre- and post-challenge saliva samples. For the 8 weeks in between face-to-face meetings, participants Data Analysis checked in through the study’s online platform, a learning management system, to complete the self-care challenges. Generalized Anxiety Qualtrics© was used to administer the self-report assessments remotely. To demonstrate their continued participation in the To measure severity of general anxiety symptoms, the study, participants were asked to upload images of their art- GAD-7 self-report measure was used. The GAD-7 is brief work each week within the online platform. and able to distinguish symptoms of anxiety from depressive The procedure of this study (see Figure 1) was informed symptoms (Spitzer, Kroenke, & Williams, 2006). Scores can by the research question: can MBAT, facilitated to college range from 0 to 21 and cutoffs are 5, 10, 15, and 21 for deter- students using a minimal contact technology-assisted mining whether anxiety is insignificant, mild, moderate, or approach, decrease cortisol levels, decrease levels of per- severe, respectively. It has a sensitivity score of 89% and ceived stress, and reduce symptoms of anxiety more effec- specificity of 82% for diagnosing generalized anxiety disor- tively than an unstructured and undirected clay task? The der. It has been found to be valid and reliable for the general researchers hypothesized that participants of the experimental population (Lowe et al., 2008; Spitzer et al., 2006), making it group condition would experience statistically significant a relevant instrument for the sample of this study. All data decreases in all three measures while the comparison group analysis was conducted using GraphPad Prism 7.01 data would not. analysis software. Within-group paired-samples t tests were 4 SAGE Open Figure 1. Sequence of procedures. Note. MBAT = mindfulness-based art therapy; GAD-7 = Generalized Anxiety Disorder 7-item; PSS-10 = Perceived Stress Scale 10-item. conducted to compare severity of anxiety from the first week pretest–posttest design of its administration was used to to the 10th week and determine whether any significant assess whether any of the self-care challenges in the experi- changes were observed. Between-group comparison of mental program were more effective than others and ana- scores from Week 1 to Week 10 was conducted using a two- lyzed by conducting within-group paired-sample t tests. way analysis of variance (ANOVA) to evaluate any signifi- Within-group paired-sample t tests of Week 1 prechallenge cant interaction between group condition and week of scores and Week 10 postchallenge scores were also con- assessment. ducted to determine whether any overall change in per- ceived stress was observed from the beginning to the end of the study. Perceived Stress Perceived stress levels were assessed pre- and post-self-care Salivary Cortisol Concentrations challenges each week using the Sheldon Cohen PSS-10. The PSS-10 is a 10-item questionnaire with a two-factor struc- A physiological measure of stress was also collected through ture measuring perceived helplessness and perceived self- saliva samples and processed as enzyme-linked immunosor- efficacy and is both valid and reliable with U.S. college bent assays (ELISA). The ELISA samples measured the con- students (Roberti, Harrington, & Storch, 2006). The weekly centration of the stress hormone cortisol in the participants’ Beerse et al. 5 saliva. This biological measure provides an additional facet to determine optical density. From these data, the researcher of empirical data that is harder to manipulate compared with computed the percentage of cortisol bound and conducted a self-report measures. Collecting saliva samples before and regression analysis to establish cortisol concentrations. after the tasks on Weeks 1 and 10 also provided the research- Cortisol concentrations were measured in micrograms per ers with the ability to measure rate of change in cortisol con- deciliter (μg/dL) and used to run the two-way ANOVA and centrations to assess for any possible biofeedback response. within-group paired-sample t tests. A two-way ANOVA was conducted to analyze the variance between the MBAT group’s pre- and postchallenge cortisol Additional questionnaires. Information collected through concentrations from Week 1 to Week 10. In addition to two- questionnaires was not used for formal analysis, but used to way ANOVA, the researcher also conducted paired-sample t understand the characteristics of the study sample and their tests of each group’s pre- and postchallenge cortisol concen- overall experience as research participants. Qualtrics© was trations for Weeks 1 and 10, independently. This was done to used to administer several questionnaires created for the pur- determine whether any within-group significance took place. pose of this research study. Students who contacted the pri- Saliva samples were analyzed using the Salimetrics© mary researcher with interest in participating were asked to Expanded Range High Sensitivity Salivary Cortisol Enzyme complete an online preliminary screening through Qual- Immunoassay Kit (Item No. 1-3002 [Single] 96-Well Kit; trics© to determine their eligibility. A brief demographic 1-3002-5 [5-Pack] 480 Wells). Participants were asked to questionnaire was administered at Week 1 meeting to gather avoid alcohol consumption for 12 hr and to not consume demographic data, average hours of sleep a night, caffeine food for at least 1 hr prior to sample collection. Water was intake, exercise routine, and last day of menstruation for provided to participants to rinse their mouths thoroughly 10 female participants, as menstruation can affect the produc- min before each saliva sample was collected. Saliva samples tion of the stress hormone cortisol. were collected by unstimulated passive drool. Participants Participants who attended the Week 10 meeting also had were instructed to tilt their heads forward, allowing the saliva the option to take an anonymous exit survey. In this exit sur- to pool on the floor of the mouth and then pass the saliva vey, participants were asked questions regarding whether through their lips into a collection vial. Time and date of they found it helpful, whether it was convenient and easy to sample collections were recorded, and samples were col- use, and they had the opportunity to provide open-ended lected between 7:30 a.m. and 8:30 a.m. due to the diurnal comments/feedback about their overall experience. variation in cortisol levels. Samples were immediately placed on wet ice and then transported to the lab within 3 hr of col- Results lection and frozen below –20°C. On days of assays, saliva samples were thawed completely, Retention vortexed, and centrifuged at 1500g for 15 min using the Of the initial sample size of 15, nine participants attended Model TJ-6 Centrifuge to remove mucins and other particu- both face-to-face meetings (MBAT, n = 4; NCT, n = 5), but late matter. Twenty-five microliter of standards, controls, and only five students completed all 10 self-care challenges triplicates of saliva samples were pipetted into appropriate (MBAT, n = 2; NCT, n = 3). The researcher used the n = 9 wells on a 96-well microtiter plate and 25 µL of assay diluent data set of retained participants for data analysis to maximize was pipetted into two wells to serve as the zero and two non- sample size. The researchers acknowledge that these results specific binding (NSB) wells. Conjugate solution was pre- are measurement estimates due to the small sample size, and pared by diluting the enzyme conjugate 1:1600 into the assay need to be investigated further with a larger sample. diluent and 200 µL of the solution was added to each well using a multichannel pipette. The plate was covered, rotated for 5 min at 500 rpm, and then incubated for 1 hr at room Generalized Anxiety temperature. After incubation, the plate was washed by add- Within-group paired-sample t tests showed that the MBAT ing 200 µL of 1× Wash Buffer to each well, discarding the group (n = 4) demonstrated a statistically significant liquid over the sink, and then thoroughly blotted with paper decrease in anxiety from Week 1 to Week 10, t(4) = 6.789, towels. This wash process was repeated 4 times. After the p = .006, while the NCT group (n = 5) did not demonstrate plate was washed and blotted dry, 200 µL of TMB substrate any statistical significance from Week 1 to Week 10, solution was added to each well using a multichannel pipette. t(4) = 1.783, p > .05. Although the NCT group did not have The plate was then covered, rotated for 5 min at 500 rpm any statistically significant difference in GAD-7 scores from again, and incubated in the dark at room temperature for 25 Week 1 to Week 10, it did exhibit a general decrease in aver- min. Fifty microliter of stop solution was added to each well age scores (see Figure 2). Two-way ANOVA (Table 2) using the multichannel pipette before being covered and showed no statistical interaction was identified between mixed on the plate rotator for 3 min at 500 rpm. The bottom group condition and week of assessment: F(1, 14) = 0.046, of the plate was wiped with a water-moistened Kimwipe and p > .05. Sample sizes were small, making data analysis far read at 450 nm using Gen 5 1.11 Microplate reading software 6 SAGE Open Figure 2. Average GAD-7 scores with standard deviation bars of MBAT and NCT groups from Week 1 to Week 10. Note. GAD-7 = Generalized Anxiety Disorder 7-item; MBAT = mindfulness-based art therapy; NCT = neutral-manipulating clay task. Table 2. Two-Way ANOVA Between-Group Comparison of MBAT and NCT Group GAD-7 Scores From Week 1 to Week 10 demonstrating no significant interactions between groups and time periods. Table analyzed GAD-7 results MBAT vs. NCT Two-way ANOVA Ordinary α .05 Source of variation % of total variation p value p value summary Significant? Interaction 0.2721 .8334 ns No Group 0.0912 .9030 ns No Time period 16.73 .1149 ns No ANOVA table SS (Type III) df MS F (dfn, dfd) p value Interaction 1.003 1 1.003 F(1, 14) = 0.04595 .8334 Group 0.3361 1 0.3361 F(1, 14) = 0.0154 .9030 Time period 61.67 1 61.67 F(1, 14) = 2.826 .1149 Residual 305.5 14 21.82 Number of missing values 2 Note. ANOVA = analysis of variance; MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task; GAD-7 = Generalized Anxiety Disorder; SS = sum of squares; MS = mean squares; dfn = degrees of freedom numerator; dfd = degrees of freedom denominator. from conclusive, but results from within-group paired-sam- stress. The normal distribution of PSS-10 scores for 18- to ple t tests do suggest that MBAT has some anxiety-reducing 29-year-olds is a mean of 14.2 with a standard deviation of benefits when compared with a NCT condition. 6.2, based on a normed sample of N = 645. A score of at least 20 is considered high levels of perceived stress. For the MBAT group, paired-sample t-tests generated no statistically Perceived Stress significant difference in Week 1 prechallenge scores and Participants were asked to complete the Sheldon Cohen PSS- Week 10 postchallenge scores: t(3) = 1.809, p > .05. The 10 as their pre- and postchallenge assessment of perceived same conclusion was made for the NCT group, as they did Beerse et al. 7 Figure 3. Average PSS-10 scores with standard deviation bars from Week 1 to Week 10 with pre- and postconditions comparing MBAT and NCT groups. Note. PSS-10 = Perceived Stress Scale 10-item; MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task. the retained subjects data set to maximize sample size and minimize a Type I error. Only Week 8 (see Figure 4), “Restoration,” demonstrated a statistically significant reduc- tion in PSS-10 scores pre- and post-self-care challenge, t(2) = 10, p = .009. The paired-sample t test of Week 5, Module 4: “Harnessing Gratitude,” PSS-10 scores pre- and postchal- lenge generated a nearly statistically significant decrease in perceived stress: t(3) = 2.611, p = .0796 (see Figure 5). The small sample size prohibits any conclusions being made from such results, but they suggest that certain modules may be more effective at reducing levels of perceived stress than others. Cortisol Analysis Regression analysis of optical density and percent bound was conducted using a four-parameter nonlinear regression curve fit to generate cortisol concentrations (µg/dL) of stan- dards, high and low controls, and saliva samples. The r Figure 4. MBAT participants’ plotted PSS-10 scores before and obtained for Plate 1 was 99.15% (R = .992) and 99.23% for after Module 7: Restoration. Plate 2 (R = .992), ensuring accuracy of cortisol data. Two Note. MBAT = mindfulness-based art therapy; PSS-10 = Perceived Stress saliva samples collected were too low to analyze and had to Scale 10-item. be excluded from analysis. A two-way ANOVA between the MBAT group’s pre- and postchallenge cortisol concentra- not demonstrate any statistical difference between Week 1 tions from Week 1 to Week 10 and the NCT group’s concen- pre- and Week 10 postchallenge scores either: t(4) = 1.757, trations was conducted. There was no significant interaction p >.05 (see Figure 3). between group condition and salivary cortisol collection Weekly paired-sample t tests were run using all of the period on cortisol concentration: F(1, 14) = 0.012, p = .915 MBAT participants’ PSS-10 scores from each week, not just (see Table 3). 8 SAGE Open one somewhat disagreed, and three neither agreed nor dis- agreed. Seven out of nine participants found the online plat- form convenient and easy to use while two participants somewhat disagreed, explaining that “the [online] app glitched often and made it frustrating to submit photos” and “the . . . page wasn’t set up in the best way.” Other feedback received through the exit survey included suggestions for changing the day of the week that self-care challenges were “due” from Saturday night to Sunday night, as most respondents explained it was difficult to remember to complete them before a Saturday deadline. Respondents also described positive outcomes from participating. One respon- dent “enjoyed the study” and “learning new techniques.” Another respondent said, “I loved the challenge, and found myself practicing the breathing exercises even outside of the study. I love the clay too, really fun.” Overall, participants were open to providing honest feedback of their experience and offered valuable suggestions for altering the research design to enhance usability and retention rates in the future. Figure 5. Demonstration of near statistical significance in plotted PSS-10 scores for MBAT participants before and after Discussion Module 4: Harnessing Gratitude. Note. PSS-10 = Perceived Stress Scale 10-item; MBAT = mindfulness- This study’s purpose was to address an elemental gap in based art therapy. research relating to proactive mental health programs for college-level students. Perceived stress, generalized anxiety, and salivary cortisol concentrations of participants were Paired-sample t tests (see Figure 6) of each group’s pre- measured and compared. Within-group and between-group and postchallenge cortisol concentrations for Weeks 1 and 10 analysis was conducted to test the effectiveness of each produced inverse results for each group condition. The group condition. MBAT group showed no statistical difference in cortisol con- centrations from before the challenge to after on Week 1, t(4) = 0.272, p = .799, but did show a statistically signifi- MBAT and Its Impact on Anxiety cant decrease in cortisol concentrations on Week 10, The hypothesis that the MBAT group would experience more t(3) = 13.01, p = .001. The opposite happened for the NCT significant reduction in GAD-7 scores from Week 1 to Week group, as they experienced a statistically significant decrease 10 was accepted. The MBAT group had a statistically signifi- in cortisol on Week 1, t(7) = 3.208, p = .015, but not on cant reduction in GAD-7 scores from Week 1 to Week 10 Week 10, t(4) = 0.132, p = .902. while the NCT group did not. The average GAD-7 score of the retained subjects from the MBAT group on Week 1 was Exit Surveys M = 9.0 and the average for the retained subjects of the NCT Participants who attended the second meeting (Week 10) had group was M = 9.2. This reinforces that the significant the option to complete an anonymous exit survey. All nine decrease in scores on Week 10 for MBAT participants is participants opted into completing it at the conclusion of the unlikely attributable to more severe initial symptoms of anx- final meetings. The survey asked them five questions regard- iety but rather to the group condition itself. ing satisfaction with participating, level of helpfulness with The initial GAD-7 scores of participants supported a high their own stress and anxiety, convenience and usability, and prevalence of anxiety among college-level students. Ninety- an open-ended component for any comments and/or feed- three percent of the research participants had GAD-7 scores back relating to their experience. Eight out of nine partici- of at least mild levels of generalized anxiety, and 47% scored pants (89%) either agreed or strongly agreed that they were moderate or severe levels. It is possible that we do not yet very satisfied with their experience as a participant in the truly understand the extent to which college students are study and one participant somewhat disagreed. Six out of affected by anxiety and stress. Participants who scored high nine participants found it helpful with reducing levels of per- on the GAD-7 were monitored throughout the study and ceived stress, one person somewhat disagreed, one disagreed, would be referred to additional mental health support if and one neither agreed nor disagreed. Four out of nine par- decreases in anxiety were not observed. The inflated preva- ticipants somewhat agreed that the study was helpful in lence among the sample size of this study could be influ- reducing their levels of anxiety, one participant disagreed, enced by the phenomenon of self-selection, as potential Beerse et al. 9 Table 3. Two-Way ANOVA of Group Conditions and Saliva Collection Period Interaction With Cortisol Concentration (µg/dL) demonstrating no significant interactions between groups and time periods. Salivary cortisol concentrations Table analyzed (µg/dL) MBAT vs. NCT Two-way ANOVA Ordinary α .05 Source of variation % of total variation p value p value summary Significant? Interaction 0.2882 .9908 ns No Group 0.2587 .7581 ns No Time period 2.708 .7994 ns No ANOVA table SS (Type III) df MS F (dfn, dfd) p value Interaction 0.004599 3 0.001533 F(3, 36) = 0.03574 .9908 Group 0.004129 1 0.004129 F(1, 36) = 0.09628 .7581 Time period 0.04322 3 0.01441 F(3, 36) = 0.336 .7994 Residual 1.544 36 0.04289 Number of missing values 20 Note. ANOVA = analysis of variance; MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task; SS = sum of squares; MS = mean squares; dfn = degrees of freedom numerator; dfd = degrees of freedom denominator. Figure 6. Pre- and postchallenge cortisol concentrations with standard deviation bars for MBAT and NCT group conditions Week 1 and Week 10. Note. MBAT = mindfulness-based art therapy; NCT = neutral clay-manipulating task. participants knew that the study’s focus was about address- produced a statistically significant decrease from Week 1 to ing anxiety and stress. Week 10, but the NCT group condition had near-statistically significant decrease in scores pretest to posttest on Week 10 (p = .071), coinciding with literature that identifies clay work as Perceptions of Stress having stress-relieving benefits (Kimport & Robbins, 2012). The hypothesis that the MBAT group would experience Weekly PSS-10 scores, however, suggest some of the greater reductions in perceived levels of stress on Week 10 challenges were more effective at lowering levels of per- compared with the NCT group was rejected. Neither group ceived stress than others. Week 8’s self-care challenge, 10 SAGE Open “Restoration,” elicited statistically significant reduction in emphasizes that it is the ongoing practice of mindfulness that PSS-10 scores for the MBAT group participants: t(2) = 10, enhances physical and mental benefits (Brand et al., 2012; p = .0099. This challenge consisted of a simple yoga Henderson et al., 2013; Hofmann, Sawyer, Witt, & Oh, 2010; sequence of three poses followed by a mindful art-making Kabat-Zinn, 2003; Prazak et al., 2012; Schure, Christopher, session where participants were asked to create a clay work & Christopher, 2008), while a brief single-session clay task response to how they were feeling in the present moment. can affect cortisol concentrations (Kaimal et al., 2016). The Week 5 challenge, “Harnessing Gratitude,” elicited reductions in PSS-10 scores that were near statistical signifi- Accessibility and Feasibility cance: t(3) = 2.611, p = .0796. Gratitude, which constitutes having “a more positive and appreciative outlook toward Participants had access to the research facilitator through life” (Wood, Maltby, Gillett, Linley, & Joseph, 2008, p. 854), email and cell phone while they were completing Weeks 2 has been identified as having a lasting protective effect through 9, remotely. Some participants took advantage of against stress and depression among college-level students this and communicated with the researcher when they had (O’Leary & Dockray, 2015). Gratitude also requires some questions, issues with the online platform, or missed a dead- awareness of the present moment, similar to mindfulness and line. This allowed the researcher to support participants as likely complements the characteristics of this study. In the needed even though they were not meeting face-to-face each Week 5 MBAT challenge, participants listened to a brief week. Participants who did reach out throughout the study guided meditation about gratitude and were then asked to chose text messaging or email as their method of communi- create an art piece representing the thing they were grateful cation with the researcher; no participants chose to call the for through the meditation. researcher, suggesting that college students feel more com- fortable communicating through digital avenues. Regarding the online platform, some participants found it Cortisol Concentrations confusing while others liked that they already regularly The hypothesis that the MBAT group would experience accessed the web-based application, which is also the univer- reductions of salivary cortisol concentrations pretest to post- sity’s adopted learning management system, and therefore test at a faster rate than the NCT group by Week 10, indicating they found it convenient. It is possible that using the same the presence of a biofeedback response, was rejected. The platform that students use to turn in assignments, check MBAT group did experience a statistically significant reduc- grades, and communicate with their professors made the tion in salivary cortisol concentrations on Week 10 after expe- self-care challenges feel more like homework rather than riencing no significant reduction on Week 1, but there was no self-care. Each self-care challenge would go live on the web- statistical significance when compared with the NCT group. site/app for a week at a time, starting at midnight on Saturdays The NCT group experienced the opposite of the MBAT and they would be due the following Saturday at midnight. group. The NCT group demonstrated statistically significant Most participants completed their self-care challenges late reductions in salivary cortisol concentrations on Week 1 pre- on Saturday evenings, and the inconvenient “due dates” test to posttest, but not on Week 10. The significant reduction could have contributed to the high attrition rate of the study. in the NCT group’s concentrations on Week 1 could be Results of this study imply that further research is needed attributed to the natural reduction in cortisol concentrations on the concept of using MBAT through an online platform as that occurs when just sitting quietly (Pawlow & Jones, 2005), a proactive mental health program for college-level students but there are several other variables that can affect salivary and that current findings are reassuring. The differences in cortisol concentrations. Potential contributing factors to sali- effects of the two group conditions support the current vary cortisol concentrations range from differences in sex, research on mindfulness practices, art therapy, and the intrin- food and alcohol intake, genetic predispositions, environ- sic therapeutic benefits of working with an art medium. The mental factors, menstruation, caffeine intake, exercise activ- high attrition rate, in spite of the minimal time requirement ity, medication, and more (Clements, 2012; Stephens, asked of participants, suggests that there is less of an issue of Mahon, McCaul, & Wand, 2016). It is recommended for students lacking access to mental health resources but rather future research that data on these possible variables be col- that the student population fails to use such resources. Further lected more vigorously while also incorporated into analysis. research into understanding how students are motivated to While some of these data were collected with the initial proactively address their mental health is necessary for the demographic questionnaire, corresponding posttest data development of a university program that is not only evi- were not collected at the end of the study to assess the pres- dence-based, but also maximizes student involvement. ence of any additional benefits to participation, such as sleeping patterns, caffeine intake, or exercise routines. Limitations Notwithstanding the other variables, the results of the cor- tisol paired-sample t tests align with research regarding There are several significant limitations of this study. The mindfulness, meditation, and working with clay. Research small sample size of nine retained participants prevents any Beerse et al. 11 generalizations to be made about the results. In addition, the Funding study sample was a majority of female participants and The author(s) disclosed receipt of the following financial support therefore not reflective of the general student population. for the research, authorship, and/or publication of this article: This Another limitation of the study was the issue of self- project was supported by the Florida State University Council on screening. The researcher used a convenience sample and Research and Creativity (Project ID 041680). relied on students to respond to recruitment flyers. It appears that students who already identify themselves as more ORCID iD stressed and anxious are more likely to express interest in a Megan E. Beerse https://orcid.org/0000-0003-4388-8030 study such as this one. The average PSS-10 score pre-chal- lenge at the first face-to-face meeting was M = 19.53 References (SD = 7.367), closer to the higher range of perceived stress American Art Therapy Association. (2017). About art therapy. rather than the normed average score of M = 14.2. Similarly, Retrieved from https://arttherapy.org/about-art-therapy/ the average GAD-7 score of all participants on Week 1 was Brand, S., Holsboer-Trachsler, E., Naranjo, J. R., & Schmidt, S. M = 10.87 (SD = 4.96), which is considered a moderate (2012). Influence of mindfulness practice on cortisol and sleep level of generalized anxiety. The participants of this study in long-term and short-term meditators. Neuropsychobiology, were not necessarily displaying subclinical levels of anxiety 65, 109-118. doi:10.1159/000330362 and stress, but moderate levels that needed addressed and Budzynski, T. (2006). The clinical guide to sound and light. Retrieved from https://web.stanford.edu/group/brainwaves/ may not be reflective of the general student population at 2006/theclinicalguidetosoundandlight.pdf large. Clements, A. D. (2012). Salivary cortisol measurement in develop- mental research: Where do we go from here? Developmental Conclusion Psychology, 55, 205-220. doi:10.1002/dev.21025 Cohen, B. E., Edmondson, D., & Kronish, I. M. (2015). State of Future studies can expand on this research by facilitating the art review: Depression, stress, anxiety, and cardiovascular the program with a much larger sample size, and efforts are disease. American Journal of Hypertension, 28, 1295-1302. already under way to replicate this study at the same insti- doi:10.1093/ajh/hpv047 tution on a larger scale. Alternative outcome measures Eisenberg, D., Golberstein, E., & Hunt, J. B. (2009). Mental health could also be incorporated into future studies to gather dif- and academic success in college. The B.E. Journal of Economic ferent information. Acceptance and participation could be Analysis & Policy, 9(1), 1-35. Eisenberg, D., Hunt, J., Speer, N., & Zivin, K. (2011). Mental considered, as well as other physiological measures or health service utilization among college students in the United external variables, like the program’s effect on academic States. The Journal of Nervous and Mental Disease, 199, 301- performance, sleeping habits, exercise routine, and 308. doi:10.1097/NMD.0b013e3182175123 sociability. Grossert, A., Urech, C., Alder, J., Gaab, J., Berger, T., & Hess, Reviewers of the preexisting mental health apps have V. (2016). Web-based stress management for newly diag- noted that the best apps will have mental health professionals nosed cancer patients (STREAM-1): A randomized, waitlist taking on active roles to ensure safety and support for their controlled intervention study. BMC Cancer, 16, Article 838. consumers (Shelton, 2018). The structured and directed doi:10.1186/s12885-016-2866-0 nature of the program’s self-care challenges was more effec- Henderson, V. P., Massion, A. O., Clemow, L., Hurley, T. G., tive than the simple nondirected task of manipulating clay, Druker, S., & Hebert, J. R. (2013). A randomized controlled trial coinciding with this ideal of a therapist-directed program. of mindfulness-based stress reduction for women with early- stage breast cancer receiving radiotherapy. Integrative Cancer The program, facilitated by an art therapist through a mini- Therapies, 12, 404-413. doi:10.1177/1534735412473640 mal contact approach, could offer college students a place to Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The learn skills for managing stress and experience anxiety effect of mindfulness-based therapy on anxiety and depression: reduction, all while the ongoing practice impacts them down A meta-analytic review. Journal of Consulting and Clinical to the physiological level. Psychology, 78, 169-183. doi:10.1037/a0018555 Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Acknowledgment Past, present, and future. Clinical Psychology, 10, 144-156. doi:10.1093/clipsy.bpg016 A sincere thank you to Lisa Anderson of the Stanwood Lab for her Kaimal, G., Ayaz, H., Herres, J., Dieterich-Hartwell, R., Makwana, contributions to the project and to Jonathan Sockell, Dr. Sean B., Kaiser, D. H., & Nasser, J. A. (2017). Functional near- Sullivan, and the rest of the Limbix© team for providing the medi- infrared spectroscopy assessment of reward perception based tation audio files incorporated into the MBAT modules. on visual self-expression: Coloring, doodling, and free draw- ing. The Arts in Psychotherapy, 55, 85-92. doi:10.1016/j. Declaration of Conflicting Interests aip.2017.05.004 The author(s) declared no potential conflicts of interest with respect Kaimal, G., Ray, K., & Muniz, J. (2016). Reduction of cortisol to the research, authorship, and/or publication of this article. levels and participants’ responses following art making. 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Applied Psychophysiology and L. G., Hayes, J. A., & Locke, B. D. (2017). Are we in crisis? Biofeedback, 30, 375-387. doi:10.1007/s10484-005-8423-2 National mental health and treatment trends in college counsel- Prazak, M., Critelli, J., Martin, L., Miranda, V., Purdum, M., & ing centers. Psychological Services, 14, 407-415. doi:10.1037/ Powers, C. (2012). Mindfulness and its role in physical and ser0000130 psychological health. Applied Psychology: Health & Well- Being, 4, 91-105. doi:10.1111/j.1758-0854.2011.01063.x Author Biographies Roberti, J. W., Harrington, L. N., & Storch, E. A. (2006). Further Megan E. Beerse (MS, 200-RYT) is a 2018 graduate of the FSU psychometric support for the 10-item version of the perceived master of Science Art Therapy program and a 200-hour Registered stress scale. Journal of College Counseling, 9, 135-147. Yoga Teacher with the Yoga Alliance. Her research interests Sandmire, D. A., Gorham, S. R., Rankin, N. E., & Grimm, D. R. include interdisciplinary frameworks, mindfulness-based art ther- (2012). The influence of art making on anxiety: A pilot study. apy, and proactive mental health strategies. Art Therapy: Journal of the American Art Therapy Association, 29(2), 68-73. doi:10.1080/07421656.2012.683748 Theresa Van Lith (PhD, ATR-BC, AThR) is an associate profes- Sareen, J., Cox, B. J., Afifi, T. O., de Graaf, R., Asmundson, G. J. G., sor and clinical professor of Art Therapy at Florida State University. ten Have, M., & Stein, M. B. (2005). Anxiety disorders and risk She is an associate editor of Art Therapy: Journal of the American for suicidal ideation and suicide attempts: A population-based Art Therapy Association and is a board member of the Research longitudinal study of adults. Archives of General Psychiatry, and Multicultural Committees for the American Art Therapy 62, 1249-1257. doi:10.1001/archpsych.62.11.1249 Association. Van Lith has published widely on the implementation Schneiderman, N., Ironson, G., & Siegel, S. (2005). Stress and of evidence-based service delivery models using art therapy for health: Psychological, behavioral, and biological determinants. various mental heatlh, developmental and sociocultural issues. Annual Review of Clinical Psychology, 1, 607-628. Scholt, M., & Gavron, T. (2011). Therapeutic qualities of clay- Gregg D. Stanwood (PhD) is a neuroscientist and pharmacologist work in art therapy and psychotherapy: A review. Art Therapy: whose laboratory focuses on the neural circuits that underlie mental Journal of the American Art Therapy Association, 23(2), 66- health disorders. He is particularly interested in gene-environment 72. doi:10.1080/07421656.2006.10129647 interactions during sensitive periods of brain development.

Journal

SAGE OpenSAGE

Published: Jun 2, 2019

Keywords: art therapy; mindfulness; clay; anxiety; stress; college students

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