Art therapy for students academic stress

Deborah C. Escalante

The aims of this study are as follows:

  1. 1.

    To examine the psychological and physiological differences between an Mindfulness-based Art Therapy (MBAT) intervention, its components as isolated Art-Only (NCT) and Mindfulness-Only (MO) interventions, and a non-intervention control using a minimal contact, web-based approach with students in Generation Z.

Hypothesis 1

MBAT, NCT, and MO will produce distinguishable differences in participant outcomes related to anxiety and stress symptomology, protective factors against chronic stress, and the biological stress response compared to a non-intervention control.

  1. 2.

    To evaluate how these interventions affect participants’ responses to an acute academic stress simulation using the TSST paradigm.

Hypothesis 2

Results of self-report assessments and saliva samples collected during the acute academic stress simulation will produce distinguishable differences between group conditions, suggesting that the art-based interventions engage unique mechanisms of change compared to the Mindfulness-Only intervention.

  1. 3.

    To determine which intervention produces the greatest participant satisfaction and acceptance.

Hypothesis 3

Participants of the MBAT and NCT interventions will report higher levels of study engagement, overall study satisfaction, and intervention acceptance compared to participants of the MO intervention and non-intervention control group conditions.

Participants and eligibility criteria

This study will enroll a total of 120 students from Florida State University. To be eligible for the study, individuals must be enrolled in an academic program and fit within generation Z’s age category (18–26). Exclusion criteria for the study include (1) regular smoking (smoking is significantly associated with increased daily salivary cortisol release and (2) being over the age of 26.

Recruitment

Participants will be recruited via emails to several departments within the university, associated social media and traditional flyers posted on campus. Participants will be informed of the eligibility criteria as required by the university’s Human Subjects Institutional Review Board (IRB). Interested students will be emailed a brief summary of the study and a consent form. Following confirmation of a signed consent, participants will be scheduled for an introductory in-person session wherein the study requirements will be explained.

Procedure

Participants will be randomized into the experimental MBAT group condition, a neutral clay-manipulating task (NCT), a mindfulness only group (MO), or a control group condition. The study will be conducted over the course of 10 weeks within two academic semesters and used a minimal contact, technology assisted approach. The MBAT, NCT and MO groups are asked to complete a brief self-care task twice a week; these techniques were dubbed “self-care challenges” and were designed to only take 15 min. The MBAT group’s self-care challenges consisted of a 5-min mindfulness practice and 10 min of intentional art making with earth-based clay. The NCT group’s self-care challenges were identical from week to week, and consisted of a NCT, where they were given the same clay as experimental participants and told to “manipulate the clay in any way you wish for 15 min.” The MO group’s self-care challenges consisted of the same 5-min mindfulness practice as those in the MBAT group. The control group will participate in no self-care challenges during the 5 weeks. The study coordinator will meet with the individuals separately before Week 1 during which time quantitative data are collected in the form of saliva samples and a self-report questionnaire packet. For the 5 weeks in between face-to-face meetings, participants will check in through the study’s online platform, a learning management system, to complete the self-care challenges. Qualtrics© is used to administer the self-report assessments remotely. To demonstrate their continued participation in the study, participants assigned to the MBAT and NCT groups will upload images of their artwork each week within the online platform.

BACA JUGA:   Relaxing art therapy/stress buster art/art for relaxation

Each of the 10 modules is designed to take approximately 15–20 min and they are provided over the course of five weeks, a direct replication of our second pilot study, when preliminary data was gathered. From our first pilot study to our second, intervention delivery was condensed from once a week for 10 weeks to twice a week for five weeks, doubling our retention rate. All MBAT modules include a brief mindfulness practice of meditation, guided imagery, or yoga with a complementary clay-based art directive. The MO modules consist of only the mindfulness practices from the MBAT intervention. The NCT modules consist of an open-ended art-making exercise, with minimal direction. The NCT intervention is designed as an ‘art for art’s sake’ intervention with the focus on the art-making and less on outcome or product. All modules are completed through the online platform. Each of the MBAT modules are described in detail:

Modules 1 and 10

The first module is replicated on Week 5 to limit variables affecting biological outcome measures. Prior to the first meeting, participants will review and sign the consent form, register on the online platform, and filling out a demographic questionnaire and self-report assessments electronically. Clay kits with unique participant identification tags are distributed to participants of the MBAT and NCT groups as they arrive, which consist of a three-pound ball of natural clay in a sealed bag and instructions for caring for the clay.

Brief yoga sequence

Following the first face to face meeting, participants will follow along with the online five-minute light yoga sequence, where asanas (yoga postures) are cued with breath. Yoga, for the purposes of the study, is explicitly defined to participants as the unity of breath with body movement. Poses were chosen based on their accessibility to a variety of body types and abilities, and chosen because they are documented to aid in grounding, increased haptic awareness, lowered levels of stress and anxiety, and restoration.

Clay art directive

Following getting the participants more mindful of the present moment and bodily sensations through the yoga sequence, participants are asked to pull their ball of clay out and spend ten minutes creating a form from the clay to visually express their experience in the present moment. They are reassured that the final product of the art making will in no way be interpreted or judged; it is solely an exercise in mindfulness. Participants are then instructed to take a photograph of their art piece and upload the image to Canvas.

This same MBAT directive is facilitated through Qualtrics for module 10.

Module 2: introduction

Participants are asked to listen to the ‘Introduction’ meditation clip from Limbix©, which introduces the concept of mindfulness and meditation. Next, participants are asked to respond and spend 10 min creating a form from the clay that reflects the way they conceptualize mindfulness.

Module 3: using yoga

The ABM directive for week three consists of a four-minute yoga video practicing the ‘Breath of Joy’ yoga sequence that is commonly used for depression, anxiety, and stress. Next, the participants are asked to respond, being given the following instruction: “For the next 10 min, create a form out of your clay that reflects how your body feels right now.”

Module 4: releasing stress and anxiety

For this self-care challenge, participants are asked to begin with art making: “Create a piece out of your clay that represents what your stress and anxiety look/feel like (five minutes).” Next, they are to listen to the Limbix© meditation video titled “Releasing Stress and Anxiety.” After listening to the clip, they are asked to revisit their clay piece: “Did the breathing technique address your stress and/or anxiety? In what way(s)? Spend five minutes changing the piece based on your experience.”

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Module 5: harnessing gratitude

Participants listen to the “Cultivate Gratitude” Limbix© video where they are directed to focus their attention on one specific thing for which they are grateful. For the art response, participants are asked to “create an art piece representing the specific thing you are grateful for.”

Module 6: revisiting yoga

For the second yoga video of the study, participants are guided through body alignment and a short yoga sequence consisting of extended mountain pose, forward fold to ragdoll, back up to extended mountain pose, ending in traditional mountain pose. Following the yoga video, they are asked to complete the art response: “For the next 10 min, create a form out of your clay that reflects how your body feels right now.”

Module 7: rejuvenate anytime

Participants listen to the Limbix video “Rejuvenate Anytime” for three minutes and then are asked to create an art response: “For the next 10 min, create a form out of your clay, keeping your attention on noticing how it feels in your hands.”

Module 8: restoration

Participants are provided a restorative yoga sequence consisting of a supported Viparita Karani, also known as ‘legs-up-the-wall pose,’ followed by supine twists. Participants are then asked to complete an art response: “For the next 10 min, create a form out of your clay that reflects how you feel right now.”

Module 9: build focus

For the module 9, participants are asked to begin with art making: “Create a form out of your clay reflecting how you are feeling right now.” After the art making, participants are to “Focus on [their] created form while listening to the [Limbix© “Build Focus”] clip.”

At the end of the 5-week intervention period, all participants will complete a final face to face meeting. During this session participants will go through an acute academic stress simulation- the Trier Social Stress Test (TSST) protocol. Trier Social Stress Test (TSST) is a validated paradigm to induce psychological stress in participants in a laboratory setting. It consists of 3 components. The first is an anticipation period of 10 min, where participants will prepare a speech for 3 judges that are part of the research team. The next two test components consist of delivering the prepared speech and completing a mental arithmetic exercise for the judges. The TSST will be used to experimentally induce a stress response and measure differences in reactivity, anxiety, and activation of the hypothalamic–pituitary–adrenal axis. The TSST has reliably produced heightened cortisol levels, above baseline levels [12]. Saliva will be collected at baseline on Week 1 of the intervention, before and twice immediately after the TSST. It will be analyzed for multiple potential biological mediators including cytokines, inflammatory markers, and stress hormones. Following the simulation, participants provide two final saliva samples and are given access to an exit survey and offered the opportunity to provide subjective feedback on their perception of the program’s effectiveness, user-friendliness, and any open-ended comments they would like to provide.

The self-report measures will be administered again 6 weeks later as a follow-up to allow us to discern whether beneficial effects are maintained. For full study procedures, please see Fig. 1.

Measures

Questionnaire packet

Participants will complete a packet of questionnaires 3 times during this study. They will be given after the initial in-person session, immediately upon completion of the intervention modules and 6 weeks post intervention. The measures included are as follows:

Individual characteristics of participants including age, gender, ethnic background, major, and year in school will be collected via a demographic assessment administered after the initial in-person meeting via Qualtrics. In this demographic assessment, female participants will be asked the date of their last menstrual cycle to make sure 5th week cortisol sampling pairs with a similar timeline, as hormone concentrations are affected by menstruation cycles and can alter cortisol results.

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Generalized Anxiety Disorder 7-item (GAD-7) is a self-report measure used to assess symptoms related to generalized anxiety during the past 2 weeks. Items assess the severity of symptoms including feelings of restlessness, excessive worry, trouble relaxing and nervousness/irritability on a 4-point Likert-type scale where a higher sum indicates severe anxiety.

Perceived Stress Scale 10-item (PSS-10) is a self-report measure of an individual’s levels of stress through assessing lack of control, unpredictability and overload over the past month. Items are on a 5-point Likert-type scale with high scores indicating higher perceived stress.

Patient Health Questionnaire 9-item (PHQ-9) is a brief self-report measure of depression severity. Scores range from 0 (not at all) to 3 (nearly every day) for items describing common symptomology associated with depression over the past two weeks. A sample item is “how often have you been bothered by little interest or pleasure in doing things”. Total scores indicate a range from minimal to a severe level of depression.

Somatic Symptom Scale (SSS-8) is a self-report measure of somatic symptom burden. Items are clustered into four categories: gastrointestinal, pain, cardiopulmonary and fatigue. Items are rated on a 5-point Likert-type scale and refer to symptomology over the past week.

Oldenburg Burnout Inventory (OLBI) is a self-report measure used to assess job burnout. This scale was adapted by the authors to assess academic burnout. This scale uses a two-factor structure to measure burnout through scores of disengagement and exhaustion, wherein higher scores indicate higher levels of burnout.

Five Facet Mindfulness Questionnaire-Short Form (FFMQ-SF) is a 24-item scale used to measure various aspects of mindfulness. An example item is “I find myself doing things without paying attention.” Each item is rated on a scale ranging from 1 to 5. This questionnaire uses a five-facet structure that includes non-reactivity, observation, description, acting aware and non-judgement. These scores are summed to create an overall mindfulness score.

Pittsburgh Sleep Quality Index (PSQI) is a 19-item self-report measure of sleep quality over the past month. This measure consists of seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. These component scores can be summed to create an overall sleep quality score ranging from 0 to 21 with higher scores indicating poor sleep quality.

Biological measures

Human Interleukin-6 and cortisol saliva samples will be collected in adherence to the Salimetrics© saliva specimen preparation protocol. Participants will be asked to avoid alcohol consumption for 12 h and not to consume food for at least 1 h prior to sample collections. Water will be provided to participants to rinse their mouths thoroughly 10 min before each saliva sample is collected. Saliva samples will be collected by unstimulated passive drool.

Participants will be instructed to tilt their heads forward, allowing the saliva to pool on the floor of the mouth and then pass the saliva through their lips into a collection vial. Time and date of sample collections will be recorded, and samples will be collected at controlled times due to the diurnal variation in cortisol levels. Samples will be immediately placed on wet ice in a portable biohazardous cooler and then transported to the lab within three hours of collection and frozen at − 80 °C. Circulating interleukin-6 is a validated biomarker of generalized anxiety disorder.

Data plan

Data will be analyzed by repeated measures ANOVA with time as a repeated measure and treatment arm as a between-subjects factor. Power analysis and previous experience indicates that sample size will be sufficient to reveal medium-sized effects (f = 0.3, power = 0.8). We expect the MBAT intervention will reduce severity of these reports from baseline to week 10 (after 5 weeks of intervention), particularly for the GAD-7 and PSS10 (based on preliminary data). We also predict that the MBAT intervention will diminish the impact of the TSST on anxiety and stress. Data obtained through the SSS-8 may be of particular interest in determining if the intervention improves systemic function, including anxiety-related gastrointestinal, cardiovascular, and musculoskeletal related systems. Our follow-up 6 weeks later, at approximately the same time in the semester as the initial measurements, will allow us to discern whether the expected beneficial effects of the intervention are persistent.

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