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Reduction of Cortisol Levels and Participants' Responses Following Art Making

Reduction of Cortisol Levels and Participants' Responses Following Art Making Cortisol is a glucocorticoid hormone and one of the most This quasi-experimental study investigated the impact of widely studied markers of stress (Staufenbiel, Penninx, visual art making on the cortisol levels of 39 healthy adults. Spijker, Elzinga, & van Rossum, 2013). The hypothalamic- Participants provided saliva samples to assess cortisol levels pituitary-adrenal axis (HPA axis) regulates reactions to stress before and after 45 minutes of art making. Participants also and HPA axis dysfunction is associated with physiological stress in the body (Engelmann, Landgraf,&Wotjak,2004). provided written responses about the experience at the end of Measurement of cortisol levelsisindicativeofHPA dysfunc- the session. Results indicate that art making resulted in tion and a stress response is typically associated with increases statistically significant lowering of cortisol levels. Participants’ in cortisol levels. written responses indicated that they found the art-making Several clinical studies have reported reductions in session to be relaxing, enjoyable, helpful for learning about new salivary cortisol levels after behavioral interventions to aspects of self, freeing from constraints, an evolving process of reduce stress (Aboulafia-Brakha, Suchecki, Gouveia-Pau- initial struggle to later resolution, and about flow/losing lino, Nitrini, & Ptak, 2014; Galvin, Benson, Deckro, themselves in the work. They also reflected that the session Fricchione, & Dusek, 2006; Miluk-Kolasa, Obminski, evoked a desire to make art in the future. There were weak Stupnicki, & Golec, 1993). Specifically, saliva contains associations between changes in cortisol level and age, time of free, biologically active cortisol as opposed to total corti- day, and participant responses related to learning about one’s sol present in serum or plasma. Importantly, the concen- self and references to an evolving process in art making. There tration of cortisol in saliva is independent of the salivary were no significant differences in outcomes based on prior flow rate and is strongly correlated with serum cortisol experiences with art making, media choice, or gender. concentrations (Bozovic, Racic, & Ivkovic, 2013). Sali- vary cortisol levels increase 5 minutes after an increase in plasma levels and are strongly correlated with plasma lev- Introduction els (Lucassen & Cizza, 2012). Expressive writing has been found to be related to long-term improvements in Efforts have been underway in the past decade to exam- health (Pennebaker, 1997) and lowered stress levels ine the biological substrate of creative self-expression (Smyth et al., 2008). Like expressive writing, evidence (Pennebaker, 1997; Smyth, Hockmeyer, & Tulloch, 2008). suggests that music and art are two interventions that In particular, salivary cortisol has been examined as a nonin- may have a positive effect on psychological states and on vasive biomarker and a proxy measurefor theexperienceof biomarkers (Chanda & Levitin, 2013; Lai & Li, 2011; Stuckey & Nobel, 2010). Patients with serious health © 2016 Girija Kaimal, Kendra Ray, and Juan Muniz. issues have used art as a therapeutic approach to help This is an Open Access article distributed under the terms reduce stress and anxiety and express emotions (Reynolds of the Creative Commons Attribution-NonCommercial-NoDeriva- & Lim, 2007). In a randomized controlled trial, individ- tives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), uals with breast cancer displayed improved well-being which permits non-commercial re-use, distribution, and reproduc- through the reduction of negative emotions and the tion in any medium, provided the original work is properly cited, enhancement of positive emotions using art (Puig, Lee, and is not altered, transformed, or built upon in any way. Goodwin, & Sherrard, 2006). In a qualitative study, Girija Kaimal is Assistant Professor in the Department of Creative Arts Therapies; Kendra Ray is a doctoral student in the researchers provided descriptive accounts of how care- Department of Creative Arts Therapies; and Juan Muniz is Assis- givers used art to lessen symptoms of compassion fatigue tant Teaching Professor in the Department of Nutrition Sciences, and reduce their stress (Samoray, 2006). For patients all at Drexel University, Philadelphia, PA. Correspondence con- with chronic illness, art has aided in improving overall cerning this article may be addressed to the first author at health and well-being by distracting individuals from [email protected] thoughts of illness, improving self-identity, and providing The authors thank Dr. Joshua Smyth, Ms. Adele Gonzaga, a social network (Reynolds & Prior, 2003). and Dr. Stella Volpe for helping with various aspects of the study There are a small number of studies indicating including providing expertise on biomarkers, access to the data reduced stress resulting from visual art making. Artistic analysis lab, and transportation of samples. expression appears to lower stress in various health settings Color versions of one or more of the figures in this article can be found online at www.tandfonline.com/uart. for both patients and family caregivers. For example, 74 KAIMAL / RAY / MUNIZ 75 Lawson et al. (2012) found in their wait-list control study Method (pretest/posttest crossover design) that 1 hour of art mak- ing, which consisted of using brushes and paint to deco- Participants rate a tile under the supervision of a student volunteer, Participants included 39 students, staff, and faculty decreased cortisol levels and helped to reduce feelings of ages 18 to 59 years, (M D 38.88, SD D 12.69) from a large sluggishness and improve concentration in people receiv- university in an urban area. There were 33 women and 6 ing blood and marrow transplants. In another pilot study, men. The racial/ethnic makeup of the participants was Walsh, Radcliffe, Castillo, Kumar, and Broschard (2007) African American (n D 2), Asian American (n D 13), White tested the effects of an art-making class on family care- (n D 13), and multiracial (n D 3). There were 18 partici- givers (N D 69) of patients diagnosed with various forms pants who reported that they had limited prior experience of cancer. Their quasi-experimental pretest/posttest study with art making, 13 who reported some experience, and 8 employed a 2-hour art class. The results, although not sta- who reported extensive experience. tistically significant, did show a reduction in stress as mea- sured by levels of salivary cortisol. Research shows promise for studying art making Materials and Procedures with cortisol as a biological indicator to measure changes in stress response in patients and their caregivers. Most The Institutional Review Board of the University studies, however, have tested art activities (Lawson et al., approved the study. After receiving this approval, we 2012; Mercer, Warson, & Zhao, 2010; Walsh et al., recruited participants using both an e-mail sent to univer- 2007) and used a specific art task or directive that may sity listservs and printed flyers posted around campus. The have influenced the outcomes. Thus it is unclear how flyer described the study as examining the health outcomes structuring the session for free creative self-expression, of visual self-expression, and participants were invited to viewed as similar as possible to an actual therapy situa- schedule a time to take part in the study led by an art ther- tion and facilitated by an art therapist, would lower the apy faculty member. The study was described as including stress response. In addition, the role of media, theoreti- a 1-hour session that included approximately 45 minutes of cally identified as ranging from structured to unstruc- art making and an additional 15 minutes for consent and tured and having differential effects (Lusebrink, 1990), data collection before and after the session. Data were col- has not yet been examined empirically. With the limited lected over a 4-month time period in a dedicated art-ther- understanding of the physiological and concurrent psy- apy studio space in one of the university buildings. Given chological changes that result from art making, these that this was a pilot study, a sample of 35 was identified as gaps demonstrate a need for further research using bio- the minimum number of participants required for a markers as a measure of stress. In addition, given that medium effect size. there are some potential emergent differences between Each participant first completed procedures for artists’ and non-artists’ physiological responses to art informed consent. Previous levels of art-making experience making (Belkofer, Van Hecke, & Konopka, 2014), there were determined by verbally requesting this information is a need to better understand the role of prior experien- prior to the intervention. Responses were coded as limited ces with art making on stress-related outcomes following or no art-making experience, some prior art-making experi- art making. ence, or extensive prior art-making experience. Participants The purpose of this study was to examine the out- also provided a small sample of saliva using the Sarstedt comes of art making in the context of making art with a Salivette saliva collection tool prior to art making. facilitating art therapist who was also the primary After the completion of these pretest procedures, par- researcher. The first author provided the structure of ticipants were invited to make art using collage materials, time and art materials and participants were free to create modeling clay, and/or markers. Participants were told that imagery of their choice. The study design was a quasi- they had the option of creating any kind of imagery using experimental (pretest/posttest with no control group) the three media choices individually or in combination. study. The hypotheses guiding our study were that art They were also told that there was no expectation of creat- making would result in reduced cortisol levels; greater ing a final artwork but that they were welcome to work changesincortisolreduction forthose with priorart- with the materials as they chose. Most participants created making experience; and greater changes in cortisol reduc- their own artwork without any directive but the first author tion for participants who used art media such as clay was available to provide any assistance and followed the compared with participants using more structured media lead of the participants regarding the level of conversation such as collage or markers. We also collected brief writ- and interaction they sought while making art. For example, ten responses from participants in order to better under- if participants chose to talk during the session, the first stand their individual subjective experiences related to art author responded in conversation and if they chose to work making. These narrative responses were collected as the silently, the first author remained quietly present. Similarly qualitative component of the study in order to determine if they requested help with executing an idea for their work, whether and how the subjective experiences might relate the first author helped them and, if not, stayed present and to changes in cortisol levels. available. After they had completed their work, participants 76 CORTISOL were invited to share any aspect of their work and/or experi- ences verbally. After the art-making experience a second saliva sample was collected, using the same procedure, and participants then were asked to share a brief (one to two line) written description of their experience with the art making and the imagery in their art. The study’s pretest and posttest saliva samples were then transported on ice to a certified lab at the university where they were analyzed using the ELISA kit method. The data from the lab analysis of the saliva were available in unit measures of ng/ml (nanograms/milliliter). To further ensure against any potential bias in the analysis, the analyst in the lab was blind to the source of the samples and did not know whether they were pre or posttest data. The samples were also analyzed in duplicate in order to reduce any errors in single sample analysis. Figure 1. Average Salivary Cortisol Levels Before (Dark Grey) and After (Light Grey) Art Making Data Analysis 25.00 ng/ml to 5.01 ng/ml at posttest. See Figure 1 for The data from cortisol levels and participant demo- graphics were entered into an Excel file and imported for the changes in mean cortisol levels before and after art making. analysis into SPSS. The data were first summarized using descriptive statistics. Next, the mean pretest and posttest As can be seen in Figure 1, the mean cortisol levels were significantly lower after art making, even though data cortisol values were compared using a paired samples t test. The changes in cortisol levels were also examined in the change was not consistent across participants. The relation to participants’ self-reported levels of expertise with levels were lowered more for some than for others. The art making and media choice using a one-way ANOVA. An area graph in Figure 2 reveals the changes in cortisol independent t test was performed to compare changes in levels as they varied across all participants. The pretest cortisol based on gender. Correlations were also computed and posttest levels were, however, strongly correlated, r to assess changes related to age of participants and time of D 0.61, p < .001. This indicates that overall those with day. higher pretest cortisol levels had higher posttest scores The written responses were compiled in response to the and similarly those with lower pretest scores also had lower posttest scores. Overall, the cortisol levels were question, “What was it like to make art during this session?” These were collected and entered into a textual document lowered after art making for approximately 75% of the sample. Cortisol levels stayed unchanged or were ele- and analyzed using Riessman’s (2008) method for thematic analysis. The narratives were coded independently for open vated for about 25%. Figure 3 highlights this range in codes by the first and second authors. The codes generated change of cortisol levels with an area graph showing were compared and those that were similar were combined. changes across all participants. Those that differed were resolved through discussion and As can be seen in Figures 2 and 3, there was consider- combined into a mutually agreed upon set of codes. The able variation across participants even though the overall first and second authors then coded the responses again and results indicated a statistically significant reduction in identified seven distinct themes. Once the responses were coded, each theme was attributed a dichotomous numerical value (1 D theme present or 0 D theme not present) for each participant. The qualitative responses were thus con- verted into numeric data and then entered into the quanti- tative database to examine how and to what extent the narrative responses related to changes in cortisol levels. Results Changes in participants’ pretest/posttest stress levels were measured via salivary cortisol (measured in nano- grams/milliliter). A paired-sample t test indicated signifi- cant reductions in cortisol following the intervention. Mean scores for cortisol levels pretest (M D 17.85, SD D 5.11) and posttest (M D 14.77, SD D 5.06), t(38) D 4.54, p < .01, differed significantly. Cortisol levels ranged Figure 2. Individual Salivary Cortisol Levels Before (Dark from 32.40 ng/ml to 5.05 ng/ml at pretest and from Grey) and After (Light Grey) Art Making KAIMAL / RAY / MUNIZ 77 multiracial, M D¡5.40, SD D 4.13, on changes in cor- tisol levels, F(3, 35) D 1.08, p D .37. Gender The relationships between gender and change in corti- sol levels for men (M D¡3.86, SD D 2.12) and women (M D¡2.93, SD D 4.83) were examined using an inde- pendent t test. The results indicated that there were no sig- nificant differences based on gender on changes in cortisol, t(37) D .456, p D .65. Age The relationship between age and changes in cortisol levels was examined using a bivariate correlation. Results indicated that there was a weak positive correlation between age and changes in cortisol levels, r(37) D 0.22, p D .18. This indicates that younger participants were more likely to Figure 3. Range of Changes in Salivary Cortisol Levels demonstrate lowering in cortisol levels compared with older Across Participants as a Result of Art Making participants. The relationship was very weak so this differ- ence needs to be interpreted with caution. cortisol. We further sought to examine whether these differ- ences between participants might be related to other varia- Time of Day bles like age, gender, race/ethnicity, time of day, prior experience with art-making, or type of art media used. Because cortisol levels tend to be highest in the morning and steadily decline throughout the day (Debono et al., 2009; Lupien,King, Meaney,&McEwen,2000), we wanted to Prior Experience With Art Making determine the influence of time, if any, on relationships The relationship between prior experience with art between variables. Time of day was coded using a continuous making and cortisol levels was examined using a one-way scale mapped onto the 24-hour day (e.g., 1 pm was coded as ANOVA. Results indicated that there were no significant 13, 2 pm as 14, etc.). Using a bivariate correlation, we found differences based on prior experiences (limited experience, that there was a moderate positive relationship between the M D¡2.43, SD D 3.91; some experience, M D¡4.24, time of day that cortisol was collected and difference in cortisol SD D 5.59; and extensive experience, M D¡3.0, scores before and after art making, r(39) D .29, p D .038. SD D 3.99) on cortisol levels, F(2, 36) D 0.64, p D .53. Taken together these findings indicate that changes in cortisol levels were seen across demographic characteristics and were not related to age, gender, or race/ethnicity. In Media Choice addition, changes in cortisol levels were also unrelated to par- Participants had the option of using collage, model ticipants’ prior experiences with art making or media choice. magic clay, fine-tip markers, or any combination thereof. Given these, 13 participants used collage, 9 used clay, 6 Participant Responses to Art Making used markers, 4 used a combination of markers and clay, 3 used a combination of collage and clay, 3 used a combina- In order to assess whether the individual level variation tion of collage and markers, and 1 used a combination of all in the changes in cortisol levels could be explained further media. The relationship between media choice and change based on participants’ narrative responses, the data were in cortisol was examined using a one-way ANOVA. Results examined for content related to the self-reported perceived indicated that there were no significant differences based on impact of art making. The written responses indicated that media choice on change in cortisol level, F(7, 31) D 0.47, participants’ perceptions of the art-making experience were p D .85. varied. Some referred to it as relaxing, a stress reliever dur- ing a busy work day; others referred to it as being fun and enjoyable, a form of distraction, and a reminder of child- Race/Ethnicity hood. Several participants reflected on the absence of art in The relationship between race and ethnicity and their adult lives and how the experience reminded them of change in cortisol was examined using a one-way a time when they had last made art as a child. Seven themes ANOVA. Results indicated that there were no signifi- emerged from analysis of participants’ responses to art mak- cant differences between race/ethnicity, Asian American, ing: feeling relaxed (n D 19); feeling pleasure/enjoyment M D¡2.51, SD D 4.47; African American, M D 1.45, (n D 19); learning something new about one’s self SD D 8.41; White, M D¡3.53, SD D 4.26; and (n D 15); feeling free from constraints (n D 13); 78 CORTISOL Figure 4. Artwork Made Using Modeling Clay, Collage Materials, and Markers Figure 6. Artwork Made Using Magazine Images for Collage experiencing an evolving process of change in art making from initial struggle to later resolution (n D 12); feeling a everything flowed naturally and freely. I actually went from sense of flow/losing themselves in the work (n D 11); and perceiving too much to feeling like time moved too fast.” having a desire to make art in the future (n D 3). Some nar- He went on to say: “My imagination was fully engaged by ratives included more than one theme. the end.” A 29-year-old Asian American woman created To examine whether responses could be related to Figure 5, which she described by writing, “This is my changes in cortisol levels, we attributed a numeric value for representation of City Hall. I see it every day on my way to the occurrence of each theme and checked for correlations work,” going on she said, “I found the experience of making with individual changes in cortisol levels. This indicated this piece to be enjoyable and ‘liberating’ in that I didn’t that themes were not strongly correlated with changes in have to be restricted by rules or procedures.” A 38-year-old cortisol levels. Controlling for time of day, two themes cor- African American woman created Figure 6, which she said related with changes in cortisol: evolving process, r(39) D was about the idea of homes/homelessness. She described 0.27, p D .11], and learning about one’s self, r(39) D 0.22, the art-making experience as follows: “It was very relaxing. p D .19. Participants who reported going through a process After about 5 minutes, I felt less anxious. I was able to of initial struggle to later creating something they liked and obsess less about things that I had not done or need[ed] to those who reported learning about self through the process get done. Doing art allowed me to put things into of art making were slightly more likely to demonstrate low- perspective.” ering of cortisol levels. Images and titles of three participants’ artwork are pro- Discussion vided in Figures 4, 5, and 6. Figure 4 depicts artwork cre- ated by a 24-year-old White man, which he titled The Our main hypothesis, that there would be a lowering of Evolution of a Seed of an Idea. Referring to the art-making salivary cortisol as a result of visual art making, was sup- experience, he said, “I was tentative and careful at first, but ported by the results. Additional hypotheses were not sup- once I found my concept in the magazine materials ported: Those with prior levels of experience with art making or who used less structured media did not show greater reductions in cortisol. Also, there were no associa- tions between reduction of cortisol and age, gender, or race/ethnicity. We found weak correlations between changes in cortisol levels and age of participants and time of day. Controlling for age and time of day, weak positive correla- tions were found between changes in cortisol levels and the themes of evolving process and learning about self. Results indicate that a brief experience of art making produced physi- ological changes in most participants, indicating that art mak- ing can lower cortisol levels regardless of prior experience with art, media type, or demographics. Previous studies have demonstrated some change in cor- tisol levels as a result of an art task (Lawson et al., 2012; Walsh et al., 2007). To the best of our knowledge, this is Figure 5. Artwork Made Using Modeling Clay the first study to demonstrate reductions in cortisol levels in KAIMAL / RAY / MUNIZ 79 healthy adults as a result of art making in a format struc- might also consider assessing levels of salivary alpha amy- tured to be similar to an art therapy session. We also exam- lase, a biomarker increasingly being considered a more ined participants’ written responses to the experience, which accurate measure of short-term changes in stress levels allowed for a more complete understanding of its impact. (Nater & Rohleder, 2009). Further research is also needed Written responses indicated that some themes (evolving pro- to better understand the differences in outcomes between cess and learning about self) were associated with greater psychological and physiological measures, differences lowering of cortisol than other themes, though the correla- related to type of media, differences in outcomes based on tions were weak. These results have to be viewed with cau- art making with and without an art therapist, and differen- tion because of this, together with the small sample size. ces with clinical populations. Art making is an enjoyable or relaxing experience for There are several limitations of this study to consider. some, whereas for others it is associated with freedom of The primary limitation was the absence of a control group. expression, evokes a flow experience, stimulates insight, and Thus it is hard to determine at present which factors in the provides a way to learn about one’s self. Further research is session (art making, interactions with the researcher, or needed to better understand how these experiences are something else) contributed to the lowering of cortisol. related to changes in cortisol levels and stress reduction. Moreover, participants varied in their level of interaction Although results overall were statistically significant, with the researcher and need for structure during art mak- reductions in cortisol levels were not consistent for all partici- ing, which again made each experience somewhat variable. pants. Levels were lowered for about 75% of the sample The study also used a healthy (nonclinical) sample and thus (n D 30). This does not seem to have been related to the it is not clear if the same patterns would be seen in clinical type of media used or to gender. There was a weak correla- groups. In many of the between-group analyses, the sub- tion with age such that younger participants demonstrated a groups were not very large. Therefore results in these cases greater lowering of cortisol than older participants. This must be interpreted with caution. Lastly, 85% of the partic- might be because older individuals may have a more prac- ipants were women and nearly 80% had moderate to high ticed response to their stress levels and are able to tap into levels of experience with art making, which further limits problem-solving strategies more readily compared with youn- the generalizability of the findings. ger individuals. In addition, lowering of cortisol levels was Our pilot study provides preliminary evidence for the more likely to be seen earlier in the day, rather than later, use of art making for lowering cortisol, a proxy measure of which has implications for the timing of studies of these stress, among healthy adults. To the best of our knowledge kinds of interventions, as well as for patient interventions. this is the first study to demonstrate lowering of cortisol lev- It is of note that for a little less than 25% of the sample els after a short session of art making structured to be simi- (n D 9), cortisol levels stayed about the same or actually lar to an art therapy situation. In our sample, reduction of went up by a few ng/ml after art making. The narrative cortisol was not related to gender, type of media used, race/ responses of these individuals did not indicate any negative ethnicity, or prior experience with art making, although it reflections about the art-making process. This finding raises was related slightly to age and time of day. There were several questions. It could be that art making resulted in a weak to moderate correlations between the lowering of cor- state of arousal and/or engagement, which resulted in tisol and the narrative response themes of learning about higher stress for this small group. This might not necessarily self and the evolving process of art making. It is of note that be a problem, because arousal may lead to increased self- cortisol levels were lowered for most participants but not awareness or new learning. In fact, we did find some corre- all, indicating a need to further explore stress reduction lations between changes in cortisol and participants’ narra- mechanisms. tive experiences. Those who spoke about an evolving process from initial struggle to later resolution and those Funding who reported learning about self were slightly more likely to demonstrate a decrease in cortisol. It is also possible that This study was funded through a grant to the first author 45 minutes of art making was not adequate time for some from the Office of Faculty Development and Equity at to experience reduced stress or notice any benefits. In addi- Drexel University. tion, for a few participants, the art making was possibly stressful and/or stimulating; and as a result, their cortisol went up instead of down even though their narrative response suggested a positive experience. It is also possible References that given the small sample size and the nature of the ses- Aboulafia-Brakha, T., Suchecki, D., Gouveia-Paulino, F., Nitrini, sions, participants were reluctant to report negative R., & Ptak, R. (2014). Cognitive-behavioural group therapy responses. Another likely reason for the lack of a relation- improves a psychophysiological marker of stress in caregivers of ship between many of the themes and the changes in corti- patients with Alzheimer’s disease. 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Amer- doi:10.1016/j.aip.2009.12.003 ican Journal of Public Health, 100(2), 254–263. doi:10.2105/ AJPH.2008.156497 Miluk-Kolasa, B., Obminski, Z., Stupnicki, R., & Golec, L. Walsh, S. M., Radcliffe, S., Castillo, S., Kumar, A., & Broschard, (1993). Effects of music treatment on salivary cortisol in D. (2007). A pilot-study to test the effects of art-making classes patients exposed to pre-surgical stress. Experimental and Clini- for family caregivers of patients with cancer. Oncology Nursing cal Endocrinology, 102, 118–120. doi:10.1055/s-0029- Forum, 34,E9–E16. doi:10.1188/07.ONF.E9-E16 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Art Therapy Pubmed Central

Reduction of Cortisol Levels and Participants' Responses Following Art Making

Kaimal, Girija; Ray, Kendra; Muniz, Juan
Art Therapy , Volume 33 (2) – May 23, 2016
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Abstract

Cortisol is a glucocorticoid hormone and one of the most This quasi-experimental study investigated the impact of widely studied markers of stress (Staufenbiel, Penninx, visual art making on the cortisol levels of 39 healthy adults. Spijker, Elzinga, & van Rossum, 2013). The hypothalamic- Participants provided saliva samples to assess cortisol levels pituitary-adrenal axis (HPA axis) regulates reactions to stress before and after 45 minutes of art making. Participants also and HPA axis dysfunction is associated with physiological stress in the body (Engelmann, Landgraf,&Wotjak,2004). provided written responses about the experience at the end of Measurement of cortisol levelsisindicativeofHPA dysfunc- the session. Results indicate that art making resulted in tion and a stress response is typically associated with increases statistically significant lowering of cortisol levels. Participants’ in cortisol levels. written responses indicated that they found the art-making Several clinical studies have reported reductions in session to be relaxing, enjoyable, helpful for learning about new salivary cortisol levels after behavioral interventions to aspects of self, freeing from constraints, an evolving process of reduce stress (Aboulafia-Brakha, Suchecki, Gouveia-Pau- initial struggle to later resolution, and about flow/losing lino, Nitrini, & Ptak, 2014; Galvin, Benson, Deckro, themselves in the work. They also reflected that the session Fricchione, & Dusek, 2006; Miluk-Kolasa, Obminski, evoked a desire to make art in the future. There were weak Stupnicki, & Golec, 1993). Specifically, saliva contains associations between changes in cortisol level and age, time of free, biologically active cortisol as opposed to total corti- day, and participant responses related to learning about one’s sol present in serum or plasma. Importantly, the concen- self and references to an evolving process in art making. There tration of cortisol in saliva is independent of the salivary were no significant differences in outcomes based on prior flow rate and is strongly correlated with serum cortisol experiences with art making, media choice, or gender. concentrations (Bozovic, Racic, & Ivkovic, 2013). Sali- vary cortisol levels increase 5 minutes after an increase in plasma levels and are strongly correlated with plasma lev- Introduction els (Lucassen & Cizza, 2012). Expressive writing has been found to be related to long-term improvements in Efforts have been underway in the past decade to exam- health (Pennebaker, 1997) and lowered stress levels ine the biological substrate of creative self-expression (Smyth et al., 2008). Like expressive writing, evidence (Pennebaker, 1997; Smyth, Hockmeyer, & Tulloch, 2008). suggests that music and art are two interventions that In particular, salivary cortisol has been examined as a nonin- may have a positive effect on psychological states and on vasive biomarker and a proxy measurefor theexperienceof biomarkers (Chanda & Levitin, 2013; Lai & Li, 2011; Stuckey & Nobel, 2010). Patients with serious health © 2016 Girija Kaimal, Kendra Ray, and Juan Muniz. issues have used art as a therapeutic approach to help This is an Open Access article distributed under the terms reduce stress and anxiety and express emotions (Reynolds of the Creative Commons Attribution-NonCommercial-NoDeriva- & Lim, 2007). In a randomized controlled trial, individ- tives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), uals with breast cancer displayed improved well-being which permits non-commercial re-use, distribution, and reproduc- through the reduction of negative emotions and the tion in any medium, provided the original work is properly cited, enhancement of positive emotions using art (Puig, Lee, and is not altered, transformed, or built upon in any way. Goodwin, & Sherrard, 2006). In a qualitative study, Girija Kaimal is Assistant Professor in the Department of Creative Arts Therapies; Kendra Ray is a doctoral student in the researchers provided descriptive accounts of how care- Department of Creative Arts Therapies; and Juan Muniz is Assis- givers used art to lessen symptoms of compassion fatigue tant Teaching Professor in the Department of Nutrition Sciences, and reduce their stress (Samoray, 2006). For patients all at Drexel University, Philadelphia, PA. Correspondence con- with chronic illness, art has aided in improving overall cerning this article may be addressed to the first author at health and well-being by distracting individuals from [email protected] thoughts of illness, improving self-identity, and providing The authors thank Dr. Joshua Smyth, Ms. Adele Gonzaga, a social network (Reynolds & Prior, 2003). and Dr. Stella Volpe for helping with various aspects of the study There are a small number of studies indicating including providing expertise on biomarkers, access to the data reduced stress resulting from visual art making. Artistic analysis lab, and transportation of samples. expression appears to lower stress in various health settings Color versions of one or more of the figures in this article can be found online at www.tandfonline.com/uart. for both patients and family caregivers. For example, 74 KAIMAL / RAY / MUNIZ 75 Lawson et al. (2012) found in their wait-list control study Method (pretest/posttest crossover design) that 1 hour of art mak- ing, which consisted of using brushes and paint to deco- Participants rate a tile under the supervision of a student volunteer, Participants included 39 students, staff, and faculty decreased cortisol levels and helped to reduce feelings of ages 18 to 59 years, (M D 38.88, SD D 12.69) from a large sluggishness and improve concentration in people receiv- university in an urban area. There were 33 women and 6 ing blood and marrow transplants. In another pilot study, men. The racial/ethnic makeup of the participants was Walsh, Radcliffe, Castillo, Kumar, and Broschard (2007) African American (n D 2), Asian American (n D 13), White tested the effects of an art-making class on family care- (n D 13), and multiracial (n D 3). There were 18 partici- givers (N D 69) of patients diagnosed with various forms pants who reported that they had limited prior experience of cancer. Their quasi-experimental pretest/posttest study with art making, 13 who reported some experience, and 8 employed a 2-hour art class. The results, although not sta- who reported extensive experience. tistically significant, did show a reduction in stress as mea- sured by levels of salivary cortisol. Research shows promise for studying art making Materials and Procedures with cortisol as a biological indicator to measure changes in stress response in patients and their caregivers. Most The Institutional Review Board of the University studies, however, have tested art activities (Lawson et al., approved the study. After receiving this approval, we 2012; Mercer, Warson, & Zhao, 2010; Walsh et al., recruited participants using both an e-mail sent to univer- 2007) and used a specific art task or directive that may sity listservs and printed flyers posted around campus. The have influenced the outcomes. Thus it is unclear how flyer described the study as examining the health outcomes structuring the session for free creative self-expression, of visual self-expression, and participants were invited to viewed as similar as possible to an actual therapy situa- schedule a time to take part in the study led by an art ther- tion and facilitated by an art therapist, would lower the apy faculty member. The study was described as including stress response. In addition, the role of media, theoreti- a 1-hour session that included approximately 45 minutes of cally identified as ranging from structured to unstruc- art making and an additional 15 minutes for consent and tured and having differential effects (Lusebrink, 1990), data collection before and after the session. Data were col- has not yet been examined empirically. With the limited lected over a 4-month time period in a dedicated art-ther- understanding of the physiological and concurrent psy- apy studio space in one of the university buildings. Given chological changes that result from art making, these that this was a pilot study, a sample of 35 was identified as gaps demonstrate a need for further research using bio- the minimum number of participants required for a markers as a measure of stress. In addition, given that medium effect size. there are some potential emergent differences between Each participant first completed procedures for artists’ and non-artists’ physiological responses to art informed consent. Previous levels of art-making experience making (Belkofer, Van Hecke, & Konopka, 2014), there were determined by verbally requesting this information is a need to better understand the role of prior experien- prior to the intervention. Responses were coded as limited ces with art making on stress-related outcomes following or no art-making experience, some prior art-making experi- art making. ence, or extensive prior art-making experience. Participants The purpose of this study was to examine the out- also provided a small sample of saliva using the Sarstedt comes of art making in the context of making art with a Salivette saliva collection tool prior to art making. facilitating art therapist who was also the primary After the completion of these pretest procedures, par- researcher. The first author provided the structure of ticipants were invited to make art using collage materials, time and art materials and participants were free to create modeling clay, and/or markers. Participants were told that imagery of their choice. The study design was a quasi- they had the option of creating any kind of imagery using experimental (pretest/posttest with no control group) the three media choices individually or in combination. study. The hypotheses guiding our study were that art They were also told that there was no expectation of creat- making would result in reduced cortisol levels; greater ing a final artwork but that they were welcome to work changesincortisolreduction forthose with priorart- with the materials as they chose. Most participants created making experience; and greater changes in cortisol reduc- their own artwork without any directive but the first author tion for participants who used art media such as clay was available to provide any assistance and followed the compared with participants using more structured media lead of the participants regarding the level of conversation such as collage or markers. We also collected brief writ- and interaction they sought while making art. For example, ten responses from participants in order to better under- if participants chose to talk during the session, the first stand their individual subjective experiences related to art author responded in conversation and if they chose to work making. These narrative responses were collected as the silently, the first author remained quietly present. Similarly qualitative component of the study in order to determine if they requested help with executing an idea for their work, whether and how the subjective experiences might relate the first author helped them and, if not, stayed present and to changes in cortisol levels. available. After they had completed their work, participants 76 CORTISOL were invited to share any aspect of their work and/or experi- ences verbally. After the art-making experience a second saliva sample was collected, using the same procedure, and participants then were asked to share a brief (one to two line) written description of their experience with the art making and the imagery in their art. The study’s pretest and posttest saliva samples were then transported on ice to a certified lab at the university where they were analyzed using the ELISA kit method. The data from the lab analysis of the saliva were available in unit measures of ng/ml (nanograms/milliliter). To further ensure against any potential bias in the analysis, the analyst in the lab was blind to the source of the samples and did not know whether they were pre or posttest data. The samples were also analyzed in duplicate in order to reduce any errors in single sample analysis. Figure 1. Average Salivary Cortisol Levels Before (Dark Grey) and After (Light Grey) Art Making Data Analysis 25.00 ng/ml to 5.01 ng/ml at posttest. See Figure 1 for The data from cortisol levels and participant demo- graphics were entered into an Excel file and imported for the changes in mean cortisol levels before and after art making. analysis into SPSS. The data were first summarized using descriptive statistics. Next, the mean pretest and posttest As can be seen in Figure 1, the mean cortisol levels were significantly lower after art making, even though data cortisol values were compared using a paired samples t test. The changes in cortisol levels were also examined in the change was not consistent across participants. The relation to participants’ self-reported levels of expertise with levels were lowered more for some than for others. The art making and media choice using a one-way ANOVA. An area graph in Figure 2 reveals the changes in cortisol independent t test was performed to compare changes in levels as they varied across all participants. The pretest cortisol based on gender. Correlations were also computed and posttest levels were, however, strongly correlated, r to assess changes related to age of participants and time of D 0.61, p < .001. This indicates that overall those with day. higher pretest cortisol levels had higher posttest scores The written responses were compiled in response to the and similarly those with lower pretest scores also had lower posttest scores. Overall, the cortisol levels were question, “What was it like to make art during this session?” These were collected and entered into a textual document lowered after art making for approximately 75% of the sample. Cortisol levels stayed unchanged or were ele- and analyzed using Riessman’s (2008) method for thematic analysis. The narratives were coded independently for open vated for about 25%. Figure 3 highlights this range in codes by the first and second authors. The codes generated change of cortisol levels with an area graph showing were compared and those that were similar were combined. changes across all participants. Those that differed were resolved through discussion and As can be seen in Figures 2 and 3, there was consider- combined into a mutually agreed upon set of codes. The able variation across participants even though the overall first and second authors then coded the responses again and results indicated a statistically significant reduction in identified seven distinct themes. Once the responses were coded, each theme was attributed a dichotomous numerical value (1 D theme present or 0 D theme not present) for each participant. The qualitative responses were thus con- verted into numeric data and then entered into the quanti- tative database to examine how and to what extent the narrative responses related to changes in cortisol levels. Results Changes in participants’ pretest/posttest stress levels were measured via salivary cortisol (measured in nano- grams/milliliter). A paired-sample t test indicated signifi- cant reductions in cortisol following the intervention. Mean scores for cortisol levels pretest (M D 17.85, SD D 5.11) and posttest (M D 14.77, SD D 5.06), t(38) D 4.54, p < .01, differed significantly. Cortisol levels ranged Figure 2. Individual Salivary Cortisol Levels Before (Dark from 32.40 ng/ml to 5.05 ng/ml at pretest and from Grey) and After (Light Grey) Art Making KAIMAL / RAY / MUNIZ 77 multiracial, M D¡5.40, SD D 4.13, on changes in cor- tisol levels, F(3, 35) D 1.08, p D .37. Gender The relationships between gender and change in corti- sol levels for men (M D¡3.86, SD D 2.12) and women (M D¡2.93, SD D 4.83) were examined using an inde- pendent t test. The results indicated that there were no sig- nificant differences based on gender on changes in cortisol, t(37) D .456, p D .65. Age The relationship between age and changes in cortisol levels was examined using a bivariate correlation. Results indicated that there was a weak positive correlation between age and changes in cortisol levels, r(37) D 0.22, p D .18. This indicates that younger participants were more likely to Figure 3. Range of Changes in Salivary Cortisol Levels demonstrate lowering in cortisol levels compared with older Across Participants as a Result of Art Making participants. The relationship was very weak so this differ- ence needs to be interpreted with caution. cortisol. We further sought to examine whether these differ- ences between participants might be related to other varia- Time of Day bles like age, gender, race/ethnicity, time of day, prior experience with art-making, or type of art media used. Because cortisol levels tend to be highest in the morning and steadily decline throughout the day (Debono et al., 2009; Lupien,King, Meaney,&McEwen,2000), we wanted to Prior Experience With Art Making determine the influence of time, if any, on relationships The relationship between prior experience with art between variables. Time of day was coded using a continuous making and cortisol levels was examined using a one-way scale mapped onto the 24-hour day (e.g., 1 pm was coded as ANOVA. Results indicated that there were no significant 13, 2 pm as 14, etc.). Using a bivariate correlation, we found differences based on prior experiences (limited experience, that there was a moderate positive relationship between the M D¡2.43, SD D 3.91; some experience, M D¡4.24, time of day that cortisol was collected and difference in cortisol SD D 5.59; and extensive experience, M D¡3.0, scores before and after art making, r(39) D .29, p D .038. SD D 3.99) on cortisol levels, F(2, 36) D 0.64, p D .53. Taken together these findings indicate that changes in cortisol levels were seen across demographic characteristics and were not related to age, gender, or race/ethnicity. In Media Choice addition, changes in cortisol levels were also unrelated to par- Participants had the option of using collage, model ticipants’ prior experiences with art making or media choice. magic clay, fine-tip markers, or any combination thereof. Given these, 13 participants used collage, 9 used clay, 6 Participant Responses to Art Making used markers, 4 used a combination of markers and clay, 3 used a combination of collage and clay, 3 used a combina- In order to assess whether the individual level variation tion of collage and markers, and 1 used a combination of all in the changes in cortisol levels could be explained further media. The relationship between media choice and change based on participants’ narrative responses, the data were in cortisol was examined using a one-way ANOVA. Results examined for content related to the self-reported perceived indicated that there were no significant differences based on impact of art making. The written responses indicated that media choice on change in cortisol level, F(7, 31) D 0.47, participants’ perceptions of the art-making experience were p D .85. varied. Some referred to it as relaxing, a stress reliever dur- ing a busy work day; others referred to it as being fun and enjoyable, a form of distraction, and a reminder of child- Race/Ethnicity hood. Several participants reflected on the absence of art in The relationship between race and ethnicity and their adult lives and how the experience reminded them of change in cortisol was examined using a one-way a time when they had last made art as a child. Seven themes ANOVA. Results indicated that there were no signifi- emerged from analysis of participants’ responses to art mak- cant differences between race/ethnicity, Asian American, ing: feeling relaxed (n D 19); feeling pleasure/enjoyment M D¡2.51, SD D 4.47; African American, M D 1.45, (n D 19); learning something new about one’s self SD D 8.41; White, M D¡3.53, SD D 4.26; and (n D 15); feeling free from constraints (n D 13); 78 CORTISOL Figure 4. Artwork Made Using Modeling Clay, Collage Materials, and Markers Figure 6. Artwork Made Using Magazine Images for Collage experiencing an evolving process of change in art making from initial struggle to later resolution (n D 12); feeling a everything flowed naturally and freely. I actually went from sense of flow/losing themselves in the work (n D 11); and perceiving too much to feeling like time moved too fast.” having a desire to make art in the future (n D 3). Some nar- He went on to say: “My imagination was fully engaged by ratives included more than one theme. the end.” A 29-year-old Asian American woman created To examine whether responses could be related to Figure 5, which she described by writing, “This is my changes in cortisol levels, we attributed a numeric value for representation of City Hall. I see it every day on my way to the occurrence of each theme and checked for correlations work,” going on she said, “I found the experience of making with individual changes in cortisol levels. This indicated this piece to be enjoyable and ‘liberating’ in that I didn’t that themes were not strongly correlated with changes in have to be restricted by rules or procedures.” A 38-year-old cortisol levels. Controlling for time of day, two themes cor- African American woman created Figure 6, which she said related with changes in cortisol: evolving process, r(39) D was about the idea of homes/homelessness. She described 0.27, p D .11], and learning about one’s self, r(39) D 0.22, the art-making experience as follows: “It was very relaxing. p D .19. Participants who reported going through a process After about 5 minutes, I felt less anxious. I was able to of initial struggle to later creating something they liked and obsess less about things that I had not done or need[ed] to those who reported learning about self through the process get done. Doing art allowed me to put things into of art making were slightly more likely to demonstrate low- perspective.” ering of cortisol levels. Images and titles of three participants’ artwork are pro- Discussion vided in Figures 4, 5, and 6. Figure 4 depicts artwork cre- ated by a 24-year-old White man, which he titled The Our main hypothesis, that there would be a lowering of Evolution of a Seed of an Idea. Referring to the art-making salivary cortisol as a result of visual art making, was sup- experience, he said, “I was tentative and careful at first, but ported by the results. Additional hypotheses were not sup- once I found my concept in the magazine materials ported: Those with prior levels of experience with art making or who used less structured media did not show greater reductions in cortisol. Also, there were no associa- tions between reduction of cortisol and age, gender, or race/ethnicity. We found weak correlations between changes in cortisol levels and age of participants and time of day. Controlling for age and time of day, weak positive correla- tions were found between changes in cortisol levels and the themes of evolving process and learning about self. Results indicate that a brief experience of art making produced physi- ological changes in most participants, indicating that art mak- ing can lower cortisol levels regardless of prior experience with art, media type, or demographics. Previous studies have demonstrated some change in cor- tisol levels as a result of an art task (Lawson et al., 2012; Walsh et al., 2007). To the best of our knowledge, this is Figure 5. Artwork Made Using Modeling Clay the first study to demonstrate reductions in cortisol levels in KAIMAL / RAY / MUNIZ 79 healthy adults as a result of art making in a format struc- might also consider assessing levels of salivary alpha amy- tured to be similar to an art therapy session. We also exam- lase, a biomarker increasingly being considered a more ined participants’ written responses to the experience, which accurate measure of short-term changes in stress levels allowed for a more complete understanding of its impact. (Nater & Rohleder, 2009). Further research is also needed Written responses indicated that some themes (evolving pro- to better understand the differences in outcomes between cess and learning about self) were associated with greater psychological and physiological measures, differences lowering of cortisol than other themes, though the correla- related to type of media, differences in outcomes based on tions were weak. These results have to be viewed with cau- art making with and without an art therapist, and differen- tion because of this, together with the small sample size. ces with clinical populations. Art making is an enjoyable or relaxing experience for There are several limitations of this study to consider. some, whereas for others it is associated with freedom of The primary limitation was the absence of a control group. expression, evokes a flow experience, stimulates insight, and Thus it is hard to determine at present which factors in the provides a way to learn about one’s self. Further research is session (art making, interactions with the researcher, or needed to better understand how these experiences are something else) contributed to the lowering of cortisol. related to changes in cortisol levels and stress reduction. Moreover, participants varied in their level of interaction Although results overall were statistically significant, with the researcher and need for structure during art mak- reductions in cortisol levels were not consistent for all partici- ing, which again made each experience somewhat variable. pants. Levels were lowered for about 75% of the sample The study also used a healthy (nonclinical) sample and thus (n D 30). This does not seem to have been related to the it is not clear if the same patterns would be seen in clinical type of media used or to gender. There was a weak correla- groups. In many of the between-group analyses, the sub- tion with age such that younger participants demonstrated a groups were not very large. Therefore results in these cases greater lowering of cortisol than older participants. This must be interpreted with caution. Lastly, 85% of the partic- might be because older individuals may have a more prac- ipants were women and nearly 80% had moderate to high ticed response to their stress levels and are able to tap into levels of experience with art making, which further limits problem-solving strategies more readily compared with youn- the generalizability of the findings. ger individuals. In addition, lowering of cortisol levels was Our pilot study provides preliminary evidence for the more likely to be seen earlier in the day, rather than later, use of art making for lowering cortisol, a proxy measure of which has implications for the timing of studies of these stress, among healthy adults. To the best of our knowledge kinds of interventions, as well as for patient interventions. this is the first study to demonstrate lowering of cortisol lev- It is of note that for a little less than 25% of the sample els after a short session of art making structured to be simi- (n D 9), cortisol levels stayed about the same or actually lar to an art therapy situation. In our sample, reduction of went up by a few ng/ml after art making. The narrative cortisol was not related to gender, type of media used, race/ responses of these individuals did not indicate any negative ethnicity, or prior experience with art making, although it reflections about the art-making process. This finding raises was related slightly to age and time of day. There were several questions. It could be that art making resulted in a weak to moderate correlations between the lowering of cor- state of arousal and/or engagement, which resulted in tisol and the narrative response themes of learning about higher stress for this small group. This might not necessarily self and the evolving process of art making. It is of note that be a problem, because arousal may lead to increased self- cortisol levels were lowered for most participants but not awareness or new learning. In fact, we did find some corre- all, indicating a need to further explore stress reduction lations between changes in cortisol and participants’ narra- mechanisms. tive experiences. Those who spoke about an evolving process from initial struggle to later resolution and those Funding who reported learning about self were slightly more likely to demonstrate a decrease in cortisol. It is also possible that This study was funded through a grant to the first author 45 minutes of art making was not adequate time for some from the Office of Faculty Development and Equity at to experience reduced stress or notice any benefits. In addi- Drexel University. tion, for a few participants, the art making was possibly stressful and/or stimulating; and as a result, their cortisol went up instead of down even though their narrative response suggested a positive experience. It is also possible References that given the small sample size and the nature of the ses- Aboulafia-Brakha, T., Suchecki, D., Gouveia-Paulino, F., Nitrini, sions, participants were reluctant to report negative R., & Ptak, R. (2014). Cognitive-behavioural group therapy responses. Another likely reason for the lack of a relation- improves a psychophysiological marker of stress in caregivers of ship between many of the themes and the changes in corti- patients with Alzheimer’s disease. 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Art Therapy – Pubmed Central

Published: May 23, 2016

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