Reduction of cortisol levels and participant responses during artmaking

Abstract

This quasi-experimental study investigated the impact of visual art making on the cortisol levels of 39 healthy adults. Participants provided saliva samples to assess cortisol levels before and after 45 minutes of art making. Participants also provided written responses about the experience at the end of the session. Results indicate that art making resulted in statistically significant lowering of cortisol levels. Participants' written responses indicated that they found the art-making session to be relaxing, enjoyable, helpful for learning about new aspects of self, freeing from constraints, an evolving process of initial struggle to later resolution, and about flow/losing themselves in the work. They also reflected that the session evoked a desire to make art in the future. There were weak associations between changes in cortisol level and age, time of day, and participant responses related to learning about one's self and references to an evolving process in art making. There were no significant differences in outcomes based on prior experiences with art making, media choice, or gender.

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Art Therapy
Journal of the American Art Therapy Association
ISSN: 0742-1656 (Print) 2159-9394 (Online) Journal homepage: http://www.tandfonline.com/loi/uart20
Reduction of Cortisol Levels and Participants'
Responses Following Art Making
Girija Kaimal, Kendra Ray & Juan Muniz
To cite this article: Girija Kaimal, Kendra Ray & Juan Muniz (2016) Reduction of Cortisol Levels
and Participants' Responses Following Art Making, Art Therapy, 33:2, 74-80
To link to this article: http://dx.doi.org/10.1080/07421656.2016.1166832
Published online: 23 May 2016.
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Reduction of Cortisol Levels and Participants’Responses
Following Art Making
Girija Kaimal, Kendra Ray, and Juan Muniz
Abstract
This quasi-experimental study investigated the impact of
visual art making on the cortisol levels of 39 healthy adults.
Participants provided saliva samples to assess cortisol levels
before and after 45 minutes of art making. Participants also
provided written responses about the experience at the end of
the session. Results indicate that art making resulted in
statistically significant lowering of cortisol levels. Participants’
written responses indicated that they found the art-making
session to be relaxing, enjoyable, helpful for learning about new
aspects of self, freeing from constraints, an evolving process of
initial struggle to later resolution, and about flow/losing
themselves in the work. They also reflected that the session
evoked a desire to make art in the future. There were weak
associations between changes in cortisol level and age, time of
day, and participant responses related to learning about one’s
self and references to an evolving process in art making. There
were no significant differences in outcomes based on prior
experiences with art making, media choice, or gender.
Introduction
Efforts have been underway in the past decade to exam-
ine the biological substrate of creative self-expression
(Pennebaker, 1997; Smyth, Hockmeyer, & Tulloch, 2008).
In particular, salivary cortisol has been examined as a nonin-
vasive biomarker and a proxy measurefortheexperienceof
stress in humans (Smyth et al., 1997; Smyth et al., 1998).
Cortisol is a glucocorticoid hormone and one of the most
widely studied markers of stress (Staufenbiel, Penninx,
Spijker, Elzinga, & van Rossum, 2013). The hypothalamic-
pituitary-adrenal axis (HPA axis) regulates reactions to stress
and HPA axis dysfunction is associated with physiological
stress in the body (Engelmann, Landgraf, & Wotjak, 2004).
Measurement of cortisol levelsisindicativeofHPAdysfunc-
tion and a stress response is typically associated with increases
in cortisol levels.
Several clinical studies have reported reductions in
salivary cortisol levels after behavioral interventions to
reduce stress (Aboulafia-Brakha, Suchecki, Gouveia-Pau-
lino, Nitrini, & Ptak, 2014; Galvin, Benson, Deckro,
Fricchione, & Dusek, 2006; Miluk-Kolasa, Obminski,
Stupnicki, & Golec, 1993). Specifically, saliva contains
free, biologically active cortisol as opposed to total corti-
sol present in serum or plasma. Importantly, the concen-
tration of cortisol in saliva is independent of the salivary
flow rate and is strongly correlated with serum cortisol
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-
els (Lucassen & Cizza, 2012). Expressive writing has
been found to be related to long-term improvements in
health (Pennebaker, 1997) and lowered stress levels
(Smyth et al., 2008). Like expressive writing, evidence
suggests that music and art are two interventions that
may have a positive effect on psychological states and on
biomarkers (Chanda & Levitin, 2013; Lai & Li, 2011;
Stuckey & Nobel, 2010). Patients with serious health
issues have used art as a therapeutic approach to help
reduce stress and anxiety and express emotions (Reynolds
& Lim, 2007). In a randomized controlled trial, individ-
uals with breast cancer displayed improved well-being
through the reduction of negative emotions and the
enhancement of positive emotions using art (Puig, Lee,
Goodwin, & Sherrard, 2006). In a qualitative study,
researchers provided descriptive accounts of how care-
givers used art to lessen symptoms of compassion fatigue
and reduce their stress (Samoray, 2006). For patients
with chronic illness, art has aided in improving overall
health and well-being by distracting individuals from
thoughts of illness, improving self-identity, and providing
a social network (Reynolds & Prior, 2003).
There are a small number of studies indicating
reduced stress resulting from visual art making. Artistic
expression appears to lower stress in various health settings
for both patients and family caregivers. For example, Law-
son et al. (2012) found in their wait-list control study
(pretest/posttest crossover design) that 1 hour of art mak-
ing, which consisted of using brushes and paint to deco-
rate a tile under the supervision of a student volunteer,
decreased cortisol levels and helped to reduce feelings of
sluggishness and improve concentration in people receiv-
ing blood and marrow transplants. In another pilot study,
Girija Kaimal is Assistant Professor in the Department of
Creative Arts Therapies; Kendra Ray is a doctoral student in the
Department of Creative Arts Therapies; and Juan Muniz is Assis-
tant Teaching Professor in the Department of Nutrition Sciences,
all at Drexel University, Philadelphia, PA. Correspondence con-
cerning this article may be addressed to the first author at
gk27@drexel.edu
The authors thank Dr. Joshua Smyth, Ms. Adele Gonzaga,
and Dr. Stella Volpe for helping with various aspects of the study
including providing expertise on biomarkers, access to the data
analysis lab, and transportation of samples.
Color versions of one or more of the figures in this article can
be found online at www.tandfonline.com/uart.
74
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Walsh, Radcliffe, Castillo, Kumar, and Broschard (2007)
tested the effects of an art-making class on family care-
givers (ND69) of patients diagnosed with various forms
of cancer. Their quasi-experimental pretest/posttest study
employed a 2-hour art class. The results, although not sta-
tistically significant, did show a reduction in stress as mea-
sured by levels of salivary cortisol.
Research shows promise for studying art making with
cortisol as a biological indicator to measure changes in stress
response in patients and their caregivers. Most studies, how-
ever, have tested art activities (Lawson et al., 2012; Mercer,
Warson, & Zhao, 2010; Walsh et al., 2007) and used a
specific art task or directive that may have influenced the
outcomes. Thus it is unclear how structuring the session for
free creative self-expression, viewed as similar as possible to
an actual therapy situation and facilitated by an art thera-
pist, would lower the stress response. In addition, the role
of media, theoretically identified as ranging from structured
to unstructured and having differential effects (Lusebrink,
1990), has not yet been examined empirically. With the
limited understanding of the physiological and concurrent
psychological changes that result from art making, these
gaps demonstrate a need for further research using bio-
markers as a measure of stress. In addition, given that there
are some potential emergent differences between artists’
and non-artists’physiological responses to art making
(Belkofer, Van Hecke, & Konopka, 2014), there is a need
to better understand the role of prior experiences with art
making on stress-related outcomes following art making.
The purpose of this study was to examine the outcomes
of art making in the context of making art with a facilitating
art therapist who was also the primary researcher. The first
author provided the structure of time and art materials and
participants were free to create imagery of their choice. The
study design was a quasi-experimental (pretest/posttest with
no control group) study. The hypotheses guiding our study
were that art making would result in reduced cortisol levels;
greater changes in cortisol reduction for those with prior
art-making experience; and greater changes in cortisol
reduction for participants who used art media such as clay
compared with participants using more structured media
such as collage or markers. We also collected brief written
responses from participants in order to better understand
their individual subjective experiences related to art making.
These narrative responses were collected as the qualitative
component of the study in order to determine whether and
how the subjective experiences might relate to changes in
cortisol levels.
Method
Participants
Participants included 39 students, staff, and faculty
ages 18 to 59 years, (MD38.88, SD D12.69) from a large
university in an urban area. There were 33 women and 6
men. The racial/ethnic makeup of the participants was
African American (nD2), Asian American (nD13), White
(nD13), and multiracial (nD3). There were 18 partici-
pants who reported that they had limited prior experience
with art making, 13 who reported some experience, and 8
who reported extensive experience.
Materials and Procedures
The Institutional Review Board of the University
approved the study. After receiving this approval, we
recruited participants using both an e-mail sent to univer-
sity listservs and printed flyers posted around campus. The
flyer described the study as examining the health outcomes
of visual self-expression, and participants were invited to
schedule a time to take part in the study led by an art ther-
apy faculty member. The study was described as including
a 1-hour session that included approximately 45 minutes of
art making and an additional 15 minutes for consent and
data collection before and after the session. Data were col-
lected over a 4-month time period in a dedicated art-ther-
apy studio space in one of the university buildings. Given
that this was a pilot study, a sample of 35 was identified as
the minimum number of participants required for a
medium effect size.
Each participant first completed procedures for
informed consent. Previous levels of art-making experience
were determined by verbally requesting this information
prior to the intervention. Responses were coded as limited
or no art-making experience, some prior art-making experi-
ence, or extensive prior art-making experience. Participants
also provided a small sample of saliva using the Sarstedt
Salivette saliva collection tool prior to art making.
After the completion of these pretest procedures, par-
ticipants were invited to make art using collage materials,
modeling clay, and/or markers. Participants were told that
they had the option of creating any kind of imagery using
the three media choices individually or in combination.
They were also told that there was no expectation of creat-
ing a final artwork but that they were welcome to work
with the materials as they chose. Most participants created
their own artwork without any directive but the first author
was available to provide any assistance and followed the
lead of the participants regarding the level of conversation
and interaction they sought while making art. For example,
if participants chose to talk during the session, the first
author responded in conversation and if they chose to work
silently, the first author remained quietly present. Similarly
if they requested help with executing an idea for their work,
the first author helped them and, if not, stayed present and
available. After they had completed their work, participants
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
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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.
Data Analysis
The data from cortisol levels and participant demo-
graphics were entered into an Excel file and imported for
analysis into SPSS. The data were first summarized using
descriptive statistics. Next, the mean pretest and posttest
data cortisol values were compared using a paired samples t
test. The changes in cortisol levels were also examined in
relation to participants’self-reported levels of expertise with
art making and media choice using a one-way ANOVA. An
independent ttest was performed to compare changes in
cortisol based on gender. Correlations were also computed
to assess changes related to age of participants and time of
day.
The written responses were compiled in response to
the question, “What was it like to make art during this
session?”These were collected and entered into a textual
document and analyzed using Riessman’s (2008)
method for thematic analysis. The narratives were coded
independently for open codes by the first and second
authors. The codes generated were compared and those
that were similar were combined. Those that differed
were resolved through discussion and combined into a
mutually agreed upon set of codes. The first and second
authors then coded the responses again and identified
seven distinct themes. Once the responses were coded,
each theme was attributed a dichotomous numerical
value (1 Dtheme present or 0 Dtheme not present)
for each participant. The qualitative responses were thus
converted into numeric data and then entered into the
quantitative database to examine how and to what
extent the narrative responses related to changes in corti-
sol levels.
Results
Changes in participants’pretest/posttest stress levels
were measured via salivary cortisol (measured in nano-
grams/milliliter). A paired-sample ttest indicated signifi-
cant reductions in cortisol following the intervention.
Mean scores for cortisol levels pretest (MD17.85, SD D
5.11) and posttest (MD14.77, SD D5.06), t(38) D
4.54, p<.01, differed significantly. Cortisol levels ranged
from 32.40 ng/ml to 5.05 ng/ml at pretest and from
25.00 ng/ml to 5.01 ng/ml at posttest. See Figure 1 for
the changes in mean cortisol levels before and after art
making.
As can be seen in Figure 1, the mean cortisol levels
were significantly lower after art making, even though
the change was not consistent across participants. The
levels were lowered more for some than for others. The
area graph in Figure 2 reveals the changes in cortisol
levels as they varied across all participants. The pretest
and posttest levels were, however, strongly correlated, r
D0.61, p<.001. This indicates that overall those with
higher pretest cortisol levels had higher posttest scores
and similarly those with lower pretest scores also had
lower posttest scores. Overall, the cortisol levels were
lowered after art making for approximately 75% of the
sample. Cortisol levels stayed unchanged or were ele-
vated for about 25%. Figure 3 highlights this range in
change of cortisol levels with an area graph showing
changes across all participants.
As can be seen in Figures 2 and 3, there was consider-
able variation across participants even though the overall
results indicated a statistically significant reduction in corti-
sol. We further sought to examine whether these differences
between participants might be related to other variables like
age, gender, race/ethnicity, time of day, prior experience
with art-making, or type of art media used.
Figure 1. Average Salivary Cortisol Levels Before (Dark
Grey) and After (Light Grey) Art Making
Figure 2. Individual Salivary Cortisol Levels Before (Dark
Grey) and After (Light Grey) Art Making
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Prior Experience With Art Making
The relationship between prior experience with art
making and cortisol levels was examined using a one-way
ANOVA. Results indicated that there were no significant
differences based on prior experiences (limited experience,
MD¡2.43, SD D3.91; some experience, MD¡4.24,
SD D5.59; and extensive experience, MD¡3.0,
SD D3.99) on cortisol levels, F(2, 36) D0.64, pD.53.
Media Choice
Participants had the option of using collage, model
magic clay, fine-tip markers, or any combination
thereof. Given these, 13 participants used collage, 9
used clay, 6 used markers, 4 used a combination of
markers and clay, 3 used a combination of collage and
clay, 3 used a combination of collage and markers, and
1 used a combination of all media. The relationship
between media choice and change in cortisol was exam-
ined using a one-way ANOVA. Results indicated that
there were no significant differences based on media
choice on change in cortisol level, F(7, 31) D0.47,
pD.85.
Race/Ethnicity
The relationship between race and ethnicity and
change in cortisol was examined using a one-way
ANOVA. Results indicated that there were no signifi-
cant differences between race/ethnicity, Asian American,
MD¡2.51, SD D4.47; African American, MD1.45,
SD D8.41; White, MD¡3.53, SD D4.26; and mul-
tiracial, MD¡5.40, SD D4.13, on changes in cortisol
levels, F(3, 35) D1.08, pD.37.
Gender
The relationships between gender and change in corti-
sol levels for men (MD¡3.86, SD D2.12) and women
(MD¡2.93, SD D4.83) were examined using an inde-
pendent ttest. The results indicated that there were no sig-
nificant differences based on gender on changes in cortisol,
t(37) D.456, pD.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) D0.22, pD.18.
This indicates that younger participants were more likely to
demonstrate lowering in cortisol levels compared with older
participants. The relationship was very weak so this differ-
ence needs to be interpreted with caution.
Time of Day
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),wewantedto
determine the influence of time, if any, on relationships
between variables. Time of day was coded using a continuous
scale mapped onto the 24-hour day (e.g., 1 pm was coded as
13, 2 pm as 14, etc.). Using a bivariate correlation, we found
that there was a moderate positive relationship between the
time of day that cortisol was collected and difference in cortisol
scores before and after art making, r(39) D.29, pD.038.
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
addition, changes in cortisol levels were also unrelated to par-
ticipants’prior experiences with art making or media choice.
Participant Responses to Art Making
In order to assess whether the individual level variation
in the changes in cortisol levels could be explained further
based on participants’narrative responses, the data were
examined for content related to the self-reported perceived
impact of art making. The written responses indicated that
participants’perceptions of the art-making experience were
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-
hood. Several participants reflected on the absence of art in
their adult lives and how the experience reminded them of
a time when they had last made art as a child. Seven themes
emerged from analysis of participants’responses to art mak-
ing: feeling relaxed (nD19); feeling pleasure/enjoyment
(nD19); learning something new about one’s self
(nD15); feeling free from constraints (nD13); experienc-
ing an evolving process of change in art making from initial
struggle to later resolution (nD12); feeling a sense of flow/
losing themselves in the work (nD11); and having a desire
Figure 3. Range of Changes in Salivary Cortisol Levels
Across Participants as a Result of Art Making
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to make art in the future (nD3). Some narratives included
more than one theme.
To examine whether responses could be related to
changes in cortisol levels, we attributed a numeric value for
the occurrence of each theme and checked for correlations
with individual changes in cortisol levels. This indicated
that themes were not strongly correlated with changes in
cortisol levels. Controlling for time of day, two themes cor-
related with changes in cortisol: evolving process, r(39) D
0.27, pD.11], and learning about one’s self, r(39) D0.22,
pD.19. Participants who reported going through a process
of initial struggle to later creating something they liked and
those who reported learning about self through the process
of art making were slightly more likely to demonstrate low-
ering of cortisol levels.
Images and titles of three participants’artwork are pro-
vided in Figures 4, 5, and 6. Figure 4 depicts artwork cre-
ated by a 24-year-old White man, which he titled The
Evolution of a Seed of an Idea. Referring to the art-making
experience, he said, “I was tentative and careful at first, but
once I found my concept in the magazine materials every-
thing flowed naturally and freely. I actually went from per-
ceiving too much to feeling like time moved too fast.”He
went on to say: “My imagination was fully engaged by the
end.”A 29-year-old Asian American woman created Fig-
ure 5, which she described by writing, “This is my repre-
sentation of City Hall. I see it every day on my way to
work,”going on she said, “I found the experience of making
this piece to be enjoyable and ‘liberating’in that I didn’t
have to be restricted by rules or procedures.”A 38-year-old
African American woman created Figure 6, which she said
was about the idea of homes/homelessness. She described
the art-making experience as follows: “It was very relaxing.
After about 5 minutes, I felt less anxious. I was able to
obsess less about things that I had not done or need[ed] to
get done. Doing art allowed me to put things into
perspective.”
Discussion
Our main hypothesis, that there would be a lowering of
salivary cortisol as a result of visual art making, was sup-
ported by the results. Additional hypotheses were not sup-
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
the first study to demonstrate reductions in cortisol levels in
healthy adults as a result of art making in a format struc-
tured to be similar to an art therapy session. We also exam-
ined participants’written responses to the experience, which
Figure 4. Artwork Made Using Modeling Clay, Collage
Materials, and Markers
Figure 5. Artwork Made Using Modeling Clay
Figure 6. Artwork Made Using Magazine Images for
Collage
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allowed for a more complete understanding of its impact.
Written responses indicated that some themes (evolving pro-
cess and learning about self) were associated with greater
lowering of cortisol than other themes, though the correla-
tions were weak. These results have to be viewed with cau-
tion because of this, together with the small sample size.
Art making is an enjoyable or relaxing experience for
some, whereas for others it is associated with freedom of
expression, evokes a flow experience, stimulates insight, and
provides a way to learn about one’s self. Further research is
needed to better understand how these experiences are
related to changes in cortisol levels and stress reduction.
Although results overall were statistically significant,
reductions in cortisol levels were not consistent for all par-
ticipants. Levels were lowered for about 75% of the sample
(nD30). This does not seem to have been related to the
type of media used or to gender. There was a weak correla-
tion with age such that younger participants demonstrated
a greater lowering of cortisol than older participants. This
might be because older individuals may have a more prac-
ticed response to their stress levels and are able to tap into
problem-solving strategies more readily compared with
younger individuals. In addition, lowering of cortisol levels
was more likely to be seen earlier in the day, rather than
later, which has implications for the timing of studies of
these kinds of interventions, as well as for patient
interventions.
It is of note that for a little less than 25% of the sample
(nD9), cortisol levels stayed about the same or actually
went up by a few ng/ml after art making. The narrative
responses of these individuals did not indicate any negative
reflections about the art-making process. This finding raises
several questions. It could be that art making resulted in a
state of arousal and/or engagement, which resulted in
higher stress for this small group. This might not necessarily
be a problem, because arousal may lead to increased self-
awareness or new learning. In fact, we did find some corre-
lations between changes in cortisol and participants’narra-
tive experiences. Those who spoke about an evolving
process from initial struggle to later resolution and those
who reported learning about self were slightly more likely
to demonstrate a decrease in cortisol. It is also possible that
45 minutes of art making was not adequate time for some
to experience reduced stress or notice any benefits. In addi-
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
that given the small sample size and the nature of the ses-
sions, participants were reluctant to report negative
responses. Another likely reason for the lack of a relation-
ship between many of the themes and the changes in corti-
sol might be that we did not use the appropriate
psychological parallels for this biomarker. In future studies,
participants could be administered a psychological measure
of stress which might be more closely related to cortisol
change rather than narrative responses. Future research
might also consider assessing levels of salivary alpha amy-
lase, a biomarker increasingly being considered a more
accurate measure of short-term changes in stress levels
(Nater & Rohleder, 2009). Further research is also needed
to better understand the differences in outcomes between
psychological and physiological measures, differences
related to type of media, differences in outcomes based on
art making with and without an art therapist, and differen-
ces with clinical populations.
There are several limitations of this study to consider.
The primary limitation was the absence of a control group.
Thus it is hard to determine at present which factors in the
session (art making, interactions with the researcher, or
something else) contributed to the lowering of cortisol.
Moreover, participants varied in their level of interaction
with the researcher and need for structure during art mak-
ing, which again made each experience somewhat variable.
The study also used a healthy (nonclinical) sample and thus
it is not clear if the same patterns would be seen in clinical
groups. In many of the between-group analyses, the sub-
groups were not very large. Therefore results in these cases
must be interpreted with caution. Lastly, 85% of the partic-
ipants were women and nearly 80% had moderate to high
levels of experience with art making, which further limits
the generalizability of the findings.
Our pilot study provides preliminary evidence for the
use of art making for lowering cortisol, a proxy measure of
stress, among healthy adults. To the best of our knowledge
this is the first study to demonstrate lowering of cortisol lev-
els after a short session of art making structured to be simi-
lar to an art therapy situation. In our sample, reduction of
cortisol was not related to gender, type of media used, race/
ethnicity, or prior experience with art making, although it
was related slightly to age and time of day. There were
weak to moderate correlations between the lowering of cor-
tisol and the narrative response themes of learning about
self and the evolving process of art making. It is of note that
cortisol levels were lowered for most participants but not
all, indicating a need to further explore stress reduction
mechanisms.
Funding
This study was funded through a grant to the first author
from the Office of Faculty Development and Equity at
Drexel University.
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