Reducing Anxiety Through Art Therapy in Nature: Bernadine ...

ART THERAPY IN NATURE 1

Reducing Anxiety Through Art Therapy in Nature:

A Heuristic Arts-Based Study

Bernadine Lieske

A Thesis Submitted in Partial

Fulfillment of the Requirement

for the Master of Arts in Art Therapy Degree

Department of Art Therapy in the Graduate Program

Saint Mary-of-the-Woods College

Saint Mary-of-the-Woods, Indiana

June 6, 2021


ABSTRACT

The purpose of this study was to evaluate the effectiveness of an art intervention to reduce

symptoms of anxiety for individuals living with Generalized Anxiety Disorder (GAD). The study

also investigated how creativity can increase coping skills for those with the disorder, and

ultimately increase the quality of life for individuals with GAD. Using an arts-based heuristic

inquiry, the study utilized a modified short form of Spielberger’s STAI (state-trait anxiety

inventory) and reflective journaling to evaluate the effect of mindfully creating nature mandalas

on anxiety symptoms. The results of the data analysis revealed themes of: (a) connection, (b)

coping, and (c) perspective.

Keywords: art therapy, generalized anxiety disorder, mandalas, nature, mindfulness


TABLE OF CONTENTS

ABSTRACT ...........................................................................................................................1

LIST OF FIGURES ...............................................................................................................5

I. INTRODUCTION ..............................................................................................................6

Problem Statement .....................................................................................................6

Research Question .....................................................................................................7

Basic Assumptions .....................................................................................................7

Statement of Purpose .................................................................................................7

Definition of Terms....................................................................................................7

Justification of the Study ...........................................................................................8

II. LITERATURE REVIEW ..................................................................................................9

Anxiety in the United States ......................................................................................9

Challenges for Individuals with GAD .......................................................................10

Biological Challenges ....................................................................................11

Psychosocial Challenges ................................................................................11

Emotional Challenges ....................................................................................12

Protective Factors for Individuals with GAD ............................................................12

Spirituality......................................................................................................13

Relationships ..................................................................................................13

Connection .....................................................................................................14

Perspective .....................................................................................................15

Attachment Theory ....................................................................................................16

Current Treatment ......................................................................................................16

Cognitive Behavioral Therapy .......................................................................17

Alternatives to CBT .......................................................................................17

Pharmacological Treatments ..........................................................................18

Barriers to Treatment .....................................................................................18

Coping with GAD ..........................................................................................19

Art Therapy ................................................................................................................20

Mandalas .......................................................................................................21

Mindfulness and Art Therapy ........................................................................22

Nature-based therapy ................................................................................................23

Summary ....................................................................................................................24

III. METHODOLOGY ..........................................................................................................26

Participant .................................................................................................................26

Research Design ........................................................................................................26

Heuristic Research .....................................................................................................27

Research Instruments .................................................................................................28

STAI assessment ............................................................................................28

Reflective Journaling .....................................................................................28

Nature Mandalas ............................................................................................29

Data Collection .........................................................................................................29

Data Analysis .............................................................................................................29


Validity and Reliability .............................................................................................30

Ethical Implications ..................................................................................................31

Researcher Bias ..........................................................................................................31

IV. RESULTS .......................................................................................................................33

Connection .................................................................................................................33

Nature .............................................................................................................33

Self .................................................................................................................34

Others .............................................................................................................34

Spirituality......................................................................................................35

Time ...............................................................................................................36

Coping ........................................................................................................................37

Mindfulness....................................................................................................37

Anxiety ...........................................................................................................38

Meaning-Making............................................................................................39

Relaxation ......................................................................................................40

Emotional Awareness ....................................................................................41

Repetition .......................................................................................................42

Perspective .................................................................................................................42

Aesthetics .......................................................................................................43

Awareness ......................................................................................................43

Symbolism .....................................................................................................44

Processing ......................................................................................................45

Summary ....................................................................................................................46

V. DISCUSSION ...................................................................................................................47

Connection .................................................................................................................47

Coping ........................................................................................................................48

Perspective .................................................................................................................50

Limitations ................................................................................................................51

Recommendations and Future Studies .......................................................................52

Conclusion .................................................................................................................52

REFERENCES ......................................................................................................................54

APPENDICES .......................................................................................................................74

APPENDIX A: Results of the Pre- and Post-STAI Assessment ...........................................74


LIST OF FIGURES

Figure 1. Thematic Analysis ......................................................................................29

Figure 2. Water mandala ............................................................................................33

Figure 3. Sunflower mandala .....................................................................................34

Figure 4. Ouroboros mandala ....................................................................................35

Figure 5. Clover mandala ...........................................................................................39

Figure 6. Stick and berry mandala .............................................................................40

Figure 7. Cicada mandala ..........................................................................................41

Figure 8. Flower mandala ..........................................................................................42

Figure 9. Garden mandala ..........................................................................................43

Figure 10. Radiate mandala .......................................................................................45

Figure 11. Shells mandala ..........................................................................................46


CHAPTER I

Introduction

In her early 30s, the researcher was diagnosed with Generalized Anxiety Disorder (GAD)

and was presented with the challenge of developing personal coping skills and discovering ways

to soothe and treat her chronic worry and anxiety symptoms. The researcher experienced relief

that sometimes comes with a diagnosis and wondered how to shift gears at this particular stage in

her adult life and not let this disorder derail her life and plans. The researcher began to notice

certain activities and elements in her life that lead to a decrease in her overall anxiety levels and

symptoms. These elements included being in nature, practicing mindfulness, and making

mandalas. This heuristic research study was designed upon those practices and examined how

mindfully creating nature mandalas can affect symptoms of anxiety in individuals with GAD.

Problem Statement

GAD affects 6.8 million Americans yearly (Anxiety and Depression Association of

America, n.d.). GAD involves chronic worrying (Hirsch et al., 2018), and it affects overall

quality of life, mental functioning, productivity at work, and social activity (Carl et al., 2020).

Ruscio et al. (2017) reported that GAD has a lifetime prevalence of 3.7% in over 25 different

countries. Adult-onset GAD was common, and individuals reported facing a number of barriers

when seeking mental health treatment for GAD (Goetter et al., 2020). Increasing effective and

affordable treatment options was essential to continue to meet the needs of those individuals with

GAD (Hebert & Dugas, 2019). Art therapy, mandala creation, and mindfulness practices all

show some potential to be effective in reducing anxiety symptoms (Abbing et al., 2018; Lee,

2018; Schumer et al., 2018). There was a lack of research studies that combine all three of these

practices to address the needs of individuals with anxiety and GAD, and filling this gap in the

literature was a main objective of this study.


Research Question

The researcher conducted an arts-based heuristic inquiry into the experience of living

with GAD by mindfully creating mandalas from items found in nature. This study was guided by

the question, how does mindfully making nature mandalas affect symptoms of GAD?

Basic Assumptions

The researcher’s basic assumptions for this study were that engaging in art-making could

contribute to a decrease in anxiety (King et al., 2019). Additionally, the researcher's basic

assumptions were that exposure to nature results in a reduction of anxiety symptoms (Neill et al.,

2019). It was also assumed that anxiety symptoms would decrease as a result of mindfulness as

well (Hofmann et al., 2017). The study assumed that the combination of these elements can help

to decrease symptoms of anxiety.

Statement of Purpose

The purpose of this study was to evaluate the effectiveness of an art intervention to

reduce symptoms of GAD. The study also investigated how creativity can increase coping skills

for those with the disorder, and ultimately increase the quality of life for individuals with GAD.

The results of this study may be used to inform the development of an art therapy support group

or nature group with participants diagnosed with GAD.

Definition of Terms

GAD

The diagnosis of generalized anxiety disorder requires an individual to meet the

following criteria: excessive anxiety and worry about several events or activities that the

individual finds difficult to control and occurs more days than not for at least six months (APA,

2013). Three of these six symptoms must be present: restlessness, fatigue, difficulty

concentrating or mind going blank, irritability, muscle tension, and sleep disturbance. The


individual must be experiencing significant distress or impairment in areas of functioning due to

symptoms, and the anxiety was not caused by substance use, a medical condition, or other

medical disorder (APA, 2013).

Mandala

In the fourteenth century, a Buddhist teacher named Longchenpa defined a mandala as

“an integrated structure organized around a unifying center” (Shkreli, 2016, p. 143). Mandalas,

derived from the Sanskrit word for “circle,” have spiritual roots in Buddhism and Hinduism.

When used in art therapy, a mandala is a design created by an artist within a circle and the

creation of mandalas promotes repetitive movements (Stinley et al., 2015). Symmetry and

geometric shapes were design elements commonly used in mandalas.

Justification of the Study

Anxiety has become prevalent in our modern world and individuals continue to seek

treatment for their mental, emotional, and physical symptoms of anxiety. This study was

important to the researcher because of her career choice of art therapist and of her desire to

understand how art therapy can be used to treat anxiety in a mindful way, for herself and for

others. The researcher was ultimately interested in increasing treatment options to complement

the diversity of the populations who experience anxiety. Additionally, there was limited research

on incorporating nature-based therapy with art therapy to treat anxiety. This study was important

because it aimed to contribute to research of GAD and how mindful art-making can impact

anxiety symptoms. This study intended to add to that body of literature and to connect

mindfulness, art therapy, and nature exposure with the treatment of anxiety.


CHAPTER II

Literature Review

When examining the effects of making nature mandalas on symptoms of GAD, there

were a number of components involved--anxiety itself, treatment and coping of anxiety, art

therapy and anxiety, mindfulness, mandalas, and nature-based therapy. Anxiety affects millions

of Americans, creating biological, psychosocial, and emotional challenges. Treatment may

involve both psychotherapy and medication, including Cognitive Behavioral Therapy (CBT) and

mindfulness approaches. There has been limited research on how alternatives to CBT such as art

therapy, the use of mandalas therapeutically, and nature-based therapy can affect symptoms of

GAD.

Anxiety in the United States

Forty million American adults have been affected by anxiety disorders every year, and

6.8 million Americans experience GAD (Anxiety and Depression Association of America, n.d.).

GAD involves chronic worrying about future events (Hirsch et al., 2018), and it affects overall

quality of life, mental functioning, productivity at work, and social activity (Carl et al., 2020).

Individuals with GAD may perceive their worries as irrational, though their chronic worry does

cause distress and is difficult for the individual to control (Navarro-Haro et al., 2019). Worry

behaviors associated with GAD can include avoidance of events that an individual may be

worried about, excess preparation for future events, procrastination in decisions or behaviors due

to worries, and repetitive assurance seeking behaviors (Brown & Tung, 2018). Though more

common in depression, rumination was also a symptom, and was usually focused on the past

(Hirsch et al., 2018). Perseverative thought—or repetitive, negative thought intrusions—has also

emerged as a symptom and emotional challenge for those with GAD, and was similarly common

in those with depression (Ruscio et al., 2011).


Executive functioning can also be affected by GAD, and issues with executive

functioning may lead to increased risk for social anxiety and difficulty with inhibition for those

with GAD (Hallion et al., 2017; Sandmire et al, 2012). This study examined over 600 Canadians

aged 18-84 years old, some with major depressive disorder, some with GAD, some individuals

with both disorders, and some with neither. The researchers explored the temperamental

differences in these individuals. That same study also found that increased levels of neuroticism

were associated with GAD (Trofimova & Sulis, 2018).

One study found variance of the type anxiety throughout the lifespan—given the same

severity of anxiety, individuals older than 60 years of age with GAD experienced higher levels of

distress overall but reported lower levels of fatigue than younger individuals, and younger

individuals (ages 20-39 years old) experienced more worry about social issues (Correa & Brown,

2019). Older individuals also noticed they worried more about community or worldwide issues

and the health of themselves (Correa & Brown, 2019). In another study, older adults over 65

years of age reported more sleep disturbances and higher and more severe rates of depression

than reported by younger adults under 45 years of age (Altunoz et al., 2018).

The economic burden of GAD results from such factors as a decrease in productivity and

an increase in health care utilization (Gajic-Veljanoski et al., 2018). The reliability of a GAD

diagnosis was lowest among all the anxiety disorders, possibly due to overlap of diagnostic

criteria with other anxiety disorders and covert descriptions of symptoms (Brown & Tung,

2018). Some researchers wish to change the GAD diagnosis, like Tyrer (2018), who suggested

thinking of GAD as an adjustment disorder--where anxiety flares up due to a major life event,

though the client may be prone to anxiety in the first place.

Challenges for Individuals with GAD


The ongoing struggle with chronic worry can often create more problems and challenges

for those with GAD. Challenges for individuals with GAD can include biological challenges,

psychosocial challenges, and emotional challenges. These challenges range from chronic

headaches to increased economic burdens to parenting challenges.

Biological Challenges

A variety of bodily symptoms were associated with GAD, such as muscle pain, nausea,

shaking, tingling sensations, gastrointestinal complications, sweating, and respiratory symptoms

(Tyrer, 2018). Biologically, individuals with GAD have showed increased inflammation in the

body, increased activity in the amygdala, and an increase in hypothalamic activity related to the

pituitary and adrenal glands (Baykan et al., 2019). Not only do individuals with GAD experience

increased physical discomfort such as chronic headaches and irritable bowel syndrome, they also

report physical discomfort more distressing compared to those without GAD (MacDonald et al.,

2015). Heart rate variability has been found to be significantly lower in individuals with an

anxiety disorder, which can increase cardiovascular health risks (Chalmers et al., 2014). A pilot

study also demonstrated a relationship between individuals with GAD and certain neuropeptide

levels in their plasma (Baykan et al., 2019).

Psychosocial Challenges

Individuals living with GAD often face many challenges beyond biological ones.

Increased healthcare costs and decreased productivity have been associated with GAD

(Greenburg et al., 1999). Anxiety disorders cost the American economy and healthcare system

between $42.3 billion and $46.6 billion every year, and these costs amount to about one-third of

total costs for mental illnesses in America (Devane et al., 2005). GAD has been associated with

higher use of emergency departments (Jones et al., 2001). Some college students with GAD find

that demand for services within college-based counseling centers are often high, and resources


are sometimes low, so not all individuals were able to access the care available there (Watkins et

al., 2012).

Quality of life and psychosocial functioning has been showed to be impaired for many

individuals with GAD (Barrera & Norton, 2009; Revicki et al., 2012). One study suggested

individuals with comorbid GAD and major depressive disorder consistently fail to meet their

role-specific standards, thus finding less satisfaction in their roles (Thompson et al., 2020). GAD

has been association with lower cognitive and attentional flexibility, and also can result in a

negative outlook on problem solving (Malivoire et al., 2019). One study aiming to differentiate

GAD from other anxiety disorders suggested that another symptom of GAD was “social-verbal

fatigue,” which was defined as withdrawing socially and a decreased volume of speech

(Trofimova & Sulis, 2018, p. 14).

Emotional Challenges

Many individuals with GAD face emotional challenges in their lives as well. Those with

GAD may fear they may be unable to control their emotions (Roemer et al., 2005). Individuals

with GAD can also experience more intense emotions, less understanding, and decreased ability

to regulate their emotions (Mennin et al., 2005). Individuals with GAD experience increased

worry, and Borkovec et al. (2002) postulated that this increase in worrying serves an avoidance

function which can complicate interpersonal problems. Chronic worry can create a barrier to

positive and rewarding emotional experiences for individuals with GAD, as worry was often

reinforced by the experience of previously anticipated negative emotions (Renna et al., 2018).

One study showed that individuals with GAD may face additional parenting challenges related to

their children’s emotional experiences (Arellano et al., 2018).

Protective Factors for Individuals with GAD


Protective factors were associated with the lower likelihood of negative outcomes or

reduce the effects of GAD. For those with GAD, protective factors can include spiritual well-

being, positive relationships, increased feelings of connection, and a positive or new perspective.

Spirituality

Spirituality has been found to have a positive impact on mental health and can promote

effective coping strategies when dealing with stress and existential issues (Amjad & Bokharey,

2015). Spirituality-based therapeutic interventions have shown efficacy when addressing GAD

symptoms (Khodayarifard & Fatemi, 2013). Amjad and Bokharev (2015) stated that spiritual

well-being leads to a positive sense of connectedness, increased acceptance, and promotes

feelings of hope. Coping strategies directed by spirituality can encourage development of an

internal locus of control amidst worry and stress (Hefti, 2011). Feelings of meaninglessness may

lead to psychopathology, though spirituality can counteract feelings of meaninglessness by

creating meaning and defining purpose (Cornah & Ryrie, 2006; Frankl, 1964; Maslow, 1964;).

A number of studies have examined the interaction between spirituality and GAD

symptoms. A small pilot study by Koszycki et al. (2014) found that a multifaith or

nondenominational spiritually based intervention showed greater efficacy in reducing GAD

symptoms in comparison to a control of supportive psychotherapy. Individuals in this study using

the spirituality-based intervention also reported greater spiritual well-being. A 2013 study by

Brown et al. involving 121 graduate and undergraduate students reported that higher levels of

spiritual well-being and involvement in religion may correlate with reduced mental illness. A

survey of 238 adults in 2017 by Steiner et al. reported that an individual’s spiritual well-being

predicted over 39% of an individual’s state anxiety and over 37% of trait anxiety.


Relationships

Protective factors for individuals with anxiety include positive parent and family

relationships, as well as social support in the form of high-quality social relationships (Sax

Institute, 2019). A systematic review found that social support was a protective factor for anxiety

disorders among adults (Zimmerman et al., 2019). Social support was reported to predict higher

treatment satisfaction for anxiety in one study of older adults (Hundt et al., 2013). A 2013 study

by Khodayarifard and Fatemi found that the role of families can support treatment of GAD,

particularly when used in conjunction with family cognitive-behavioral therapy. A study of

adolescents in Ghana found low parental involvement to be a risk factor and self-esteem to be a

protective factor with GAD (Ahulu et al., 2020). For college students dealing with anxiety during

the COVID-19 pandemic, increased social support was suggested to be a protective factor

against unhealthy coping mechanisms including increased alcohol consumption (Lechner et al.,

2020).

Connection

Anxiety has been associated with feelings of disconnection and social loneliness

(DiTommaso & Spinner, 1997), and a study by Hyland et al. (2019) suggests that higher quality

social connections are important for reducing anxiety. Gupta (2020) suggests that therapeutic art-

making can increase feelings of connectedness with humanity for individuals experiencing

isolation. Connection to spirituality and divine presence can also lead to a positive sense of

connectedness and improved mental health for those with anxiety (Amjad & Bokharev, 2015).

Increased connection to and expression of emotions was found to be a protective factor

associated with lower anxiety symptoms for individuals who experienced childhood adversity

(Sax Institute, 2019). Positive connection to self and high self-esteem was also found to be a

protective factor for anxiety within a variety of youth populations (Sax Institute, 2019). Among


civilians exposed to war trauma, one study found that low self-esteem in individuals with GAD

were at a higher risk for dissociative experiences or reduced connection to the individual’s

memory, consciousness, and identity (Weinberg et al., 2015). Additionally, some individuals in

one study reported that an increased sense of personal connection within the therapeutic setting

led to higher motivation to adhere to treatment (Wells et al., 2020). Reflective journaling may

increase feelings of self-expression and connection to self and personal experience, though

students in particular may find journaling to be more of a chore instead of a path to reconnection

to self (Mills, 2008; Oxendine, 1988).

Perspective

Individuals with GAD may benefit from maintaining a positive perspective or exploring

new perspectives. Sax Institute (2019) suggested that a positive perspective was a protective

factor for mental well-being for some youth. Additionally, Sax Institute (2019) also reported that

positive perception of belonging were associated with less mental health issues. Focusing on an

aesthetic perspective through mindful art-making or coloring has been shown to reduce anxiety

for some individuals (Abbing et al., 2019; Bi & Liu, 2019; Duong et al., 2018). One study by van

Der Heiden (2013) found that addressing the beliefs and viewpoints behind worrying through

metacognitive therapy was more effective than focusing on the worrying itself with cognitive-

behavioral therapy, thus altering the perspective of worry.

In a study examining snake imagery created by an individual with GAD, Khodarahimi

(2010) posited that symbols such as snakes can contribute to personal transformation as symbolic

imagery can reveal new associations and perspectives. Snakes have been seen as symbols of

transcendence, mystery, instinct, fertility, death, and rebirth (Khodarahimi, 2010). Engaging with

symbols and metaphors may contribute to exploration of new associations and perspectives for

individuals with GAD. Additionally, mindfulness can be used to address symptoms of GAD


(Daitch, 2018). Increasing awareness of an individual’s experiences and space is often a goal of

mindfulness, with mindfulness leading to an altered perspective of one’s environment for some

(Iani et al., 2019). Ponton (2020) discusses how creatively engaging with one’s environment can

ultimately lead to psychological security and a sense of safety.

Attachment Theory

Bowlby (1973) explored a possible relationship between insecure attachment in

childhood and the development of anxiety disorders. Insecure attachment in childhood can result

from inconsistent responses from parents or parents that were unresponsive to their child’s

emotional needs, and Bowlby theorized this can lead to anxiety disorders in adulthood. Cassidy

et al. (2009) found adult GAD was associated with insecure attachment styles in childhood and

suggested this may stem from feeling uncertain in childhood that a caregiver was available to

protect them when needed. In addition to insecure/avoidant attachment styles, GAD has been

associated with anxious-ambivalent attachment. Muris et al. (2001) found ambivalent attachment

to be associated with GAD. Brown and Whiteside (2008) found chronic worry—the defining

trait of GAD—to be associated with anxious-ambivalent attachment in children.

In a longitudinal study by Warren et al. (1997), infants exhibiting anxious-ambivalent

attachment were twice as likely to develop GAD in adolescence as infants exhibiting secure or

avoidant attachment. A small study by Newman et al. (2016) found that specifically maternal

insecure attachment predictive of GAD. Bowlby theorizes that inconsistent tending to a child’s

emotional needs or unresponsive parenting can lead to insecure attachment, and Draisey et al.

(2020) noted that anxiogenic parenting styles, negative life events and ongoing childhood

adversity can impair emotional maturation and can lead to the development of childhood anxiety

disorders.

Current Treatment


Individuals with GAD can explore a few different treatment options. Treatment for

anxiety typically involves psychotherapy and/or medication, although research suggested that

patients prefer psychological treatment over medication (Carl et al., 2020). Psychotherapy for

GAD often involves Cognitive Behavioral Therapy (CBT), though there are an increasing

number of alternatives to CBT. Barriers to treatment can involve financial barriers, shame,

stigma, and logistical barriers and coping with GAD can reduce the effects of GAD or involve

harmful behaviors such as binge drinking (Dyer et al., 2019; Goetter et al., 2020; Zimmerman et

al., 2019). Those with GAD often do not receive treatment for about two years after symptoms

first appear, and without treatment, these individuals experience distress, psychosomatic issues,

and decreased quality of life (Blackwelder & Bragg, 2016; Goetter et al., 2020).

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy (CBT) was a primary treatment for individuals with GAD,

with about 50% of individuals seeing significant improvements (Muir et al., 2019; Nordahl et al.,

2018). CBT was structured, time-limited, and symptom focused, and rated high on cost

effectiveness, though it was unclear whether group therapy or individual therapy were more cost

effective (Gajic-Veljanoski et al., 2018). CBT has also been shown provide lasting benefits for

older adults with GAD when delivered by nonexpert lay providers supervised by licensed mental

health professionals (Freshour et al., 2016). Using primarily home-based online sessions, one

study demonstrated a positive effect of cognitive modifications on anxiety to reduce ruminations

and repetitive negative thoughts (Hirsch et al., 2018). When added to CBT, motivational

interviewing has been shown to reduce worrying, improve interpersonal problems, and reduce

resistance to treatment and change for those with GAD, in contrast with just CBT alone as

treatment (Muir et al., 2019).

Alternatives to CBT


There were other options for treatment of GAD besides CBT. Interpersonal therapy was

also recommended for GAD (Gajic-Veljanoski, 2018). One study showed metacognitive therapy

as more effective than CBT for GAD, even after 2-years post-treatment (Nordahl et al., 2018).

Timulak (2018) argues for humanistic-experiential therapy options for individuals with GAD,

such as emotion-focused therapy. There was limited but promising research showing

mindfulness-based interventions to be effective for GAD (Navarro-Haro et al., 2019). However,

individuals with GAD may be distracted by their worries and show attention deficits, which may

inhibit mindfulness training (Navarro-Haro et al., 2019). Zainal and Newman (2019)

recommended increased focus on perseverance and optimism as part of treatment for GAD.

Pharmacological Treatments

Pharmacological treatment for management of GAD may include selective serotonin

reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors, tricyclic antidepressants,

benzodiazepines and other anxiolytics (Gajic-Veljanoski et al., 2018). Patients may sometimes

stop medication use due to side effects, low results, dependency concerns or even stigma (Gajic-

Veljanoski et al., 2018). Side effects of pharmacological treatments for GAD can include

drowsiness, sexual dysfunction, weight gain, memory and sleep disturbances, impaired

psychomotor function, headaches and nausea (Baldwin et al., 2011).

Barriers to Treatment

Most individuals experience anxiety differently, and treatments often need to be adapted

to each individual to maximize efficacy (Duong et al., 2018). For individuals with GAD, while

they may be motivated to reduce their anxiety symptoms, they also may be resistant, as they

experience their chronic worry as a motivator to be prepared and stay in control (Muir et al.,

2019) Individuals with GAD have identified various barriers to utilizing mental health treatment,

including shame, stigma, and logistical and financial barriers (Goetter et al., 2020). Other factors


such as severity of symptoms, knowing where to start looking for treatment, racial discrimination

and cultural norms all can contribute to individuals not seeking treatment for GAD (Goetter et

al., 2020). Once symptoms appear, individuals with anxiety often do not start treatment for up to

two years (Blackwelder & Bragg, 2016). Without treatment, individuals with GAD can

experience serious distress, lowered quality of life, and medical problems (Goetter et al., 2020).

Coping with GAD

A systematic review found that coping in general was a protective factor for anxiety

disorders among adults (Zimmerman et al., 2019). Some individuals with GAD turn to

psychotherapy and CBT in order to developing coping skills (Nordahl et al., 2018). Employment

can at times benefit those with GAD by increasing access to resources used to cope with

symptoms and challenges (Sax Institute, 2019). Mindfulness can increase the use of relaxation as

a coping skill for addressing GAD as well (Navarro-Haro et al., 2019).

Body-focused repetitive behaviors were used to cope with anxiety; however, relief was

temporary and these repetitive behaviors can lead to reduced quality of life and significant

distress (Solley & Turner, 2018). Nuttall and Pelletier (2020) noted that repetition compulsion

has been theorized as an attempt to master and deal with trauma through increasing a sense of

control and regulate anxiety symptoms. One study has proposed that increased use of self-

compassion as a coping skill can reduce repetitive negative thinking or rumination, a symptom of

anxiety (Wadsworth et al., 2018). Coping strategies for physical discomfort might include

increased visits to the emergency room for individuals with GAD (MacDonald et al., 2015).

Alcohol use has also been reported as a method of coping for those with GAD, including

frequent drinking, binge drinking, and harmful drinking (Dyer et al., 2019). Some individuals

turn to religious-focused coping and focusing on spiritual wellness to cope with anxiety


symptoms (Amjad & Bokharey, 2015). There was a wide range of coping mechanisms and skills,

some more effective than others, and some more harmful than others.

Art Therapy

Abbing et al. (2018) suggested that firm conclusions could not be drawn concerning the

effectiveness of art therapy on anxiety symptoms, and that more studies were needed to examine

the potential effectiveness of art therapy on anxiety. Abbing et al. utilized a systematic review of

randomized controlled trials on art therapy to address anxiety for adult populations. This review

only found three publications that fulfilled inclusion criteria, with 162 patients in total and a

reported high risk of bias. Even though Abbing et al. (2018) reported a lack of randomized

controlled trials, King et al. (2019) found significant anecdotal data supporting art therapy as an

aid to meeting goals in treatment, with an increase in recent quantitative findings supporting

links between art-making and measures of anxiety, though the mechanism of change are not well

represented in the literature. King et al. (2019) stated that components of art therapy such as

creative expression and various materials and methods contribute to regulation of emotions and

emotional processing. King et al. provides a general overview of current neuroscience research

in art therapy and the understanding of mechanisms by which art therapy effects change.

However, a randomized controlled trial by Abbing et al (2019) demonstrated a decrease in

anxiety symptoms as a result of art therapy. This study used a randomized controlled trial design

and compared three months of art therapy with a three-month waiting list for women ages 18-65

with moderate to severe anxiety. There were 60 participants in total, with 30 in each group, and

art therapy took place in private practice in the Netherlands. Abbing et al. suggested this

decrease of anxiety was a result of improvement of executive functioning such as emotion

regulation.


One example of a randomized controlled trial was a pilot study on the influence of art-

making on anxiety on undergraduate students (Sandmire et al., 2012). Sandmire et al. suggested

that art-making may significantly decrease anxiety an individual was experiencing. Additionally,

a study by Cross and Brown (2019) demonstrated that participating in a 15-minute art activity

may promote positive psychological effects.

Williams (2018) stated that engaging with art-making and materials can promote

emotional regulation and expression. Art therapy can enhance clients’ sense of safety and

validation, which contributes to the regulation of the parasympathetic nervous system—a system

that acts to reduce the stress response and bring a sense of calm in the body and the mind (Hass-

Cohen et al., 2014). Anxiety symptoms show up both mentally and as somatic symptoms, so a

reduction in both types of symptoms can be beneficial (Hass-Cohen et al., 2014). The researchers

suggested that through art therapy, clients may be able to see an optimistic view of the future,

and thus calming an individual through their parasympathetic nervous system. Additionally,

results of study by Kaimal et al. (2016) indicated that art making can lower stress hormone

levels.

Mandalas

Mandala comes from the Sanskrit words for center (“manda”) and accomplishment (“la”)

and using mandalas has been associated with self-integration and authenticity, addressing

existential concerns, and centering the self (Kim et al., 2017). Jung saw the mandala as a symbol

of wholeness of the Self (Jung, 1963). Anxiety can often manifest as a desire for resolution, and

the natural resolution of a circle--a complete form--could be seen as relaxing for those

experiencing anxiety. The curricular form also mimics forms seen in the natural world, and

nature has been shown to be calming for some people (King et al., 2019). Babouchkina and

Robbins (2015) suggested that the circular shape of the mandala can contribute towards


enhancing an individual’s mood. Mandalas have the potential to be therapeutically integrated

with mindfulness, and mandalas have even been described as a mindfulness or meditative tool

(Duong et al., 2018).

Coloring mandala patterns was shown to increase hope in psychiatric patients (Kim et al.,

2017), reduce anxiety more than coloring a plaid design or on a blank page for psychology

students (van der Vennet & Serice, 2012), decrease anxiety in veterans with PTSD (Rodak et al.,

2018), have been used successfully as an anxiety reduction tool with Chinese undergraduate

students (Lee, 2018), and were effective in reducing state anxiety for undergraduate students

(Campenni & Hartman, 2019). Painting on pre-drawn mandalas was shown to reduce school

anxiety in Russian adolescents (Kostyunina & Drozdikova-Zaripova, 2016). Creating a mandala

within a circular template was shown to reduce negative mood for adults, mostly undergraduate

students (Babouchkina & Robbins, 2015). A randomized controlled trial by Stinley et al. (2015)

suggested a decrease anxiety in pediatric patients when dealing with acute pain. This study had

40 participants with the mean age of 12.3 years, with 20 of those in the control group who were

receiving the standard care treatment. Additionally, Schrade et al. (2011) demonstrated in a study

with 15 participants that mandala making was effective at reducing stress for adults with

intellectual disabilities, but no more effective than the control.

Mindfulness and Art Therapy

Mindfulness has been shown to affect individuals with GAD in a variety of ways,

including decreasing worry (Hoge et al., 2015), improving relationships (Millstein et al., 2015),

improving occupational functioning (Hoge et al., 2017), improving stress reactivity and coping

(Hoge et al., 2013), and overall was an effective intervention for treating anxiety (Bolognesi et

al., 2014; Hofmann et al., 2010). Despite these studies, Khusid and Vythilingam (2016) found a


lack of adequate data supporting mindfulness-based interventions for GAD due to design of

studies and controls provided in trials that were analyzed.

When examining the interaction between mindfulness and art therapy, Kalmanowitz

(2016) suggested that mindfulness and art therapy work together to help clients separate

themselves from overwhelming emotions and use non-linear thinking to encourage creative

problem solving. Both mindfulness and art therapy have been shown to contribute to increased

feelings of calmness, and the combination may be a powerful neurological tool for addressing

anxiety and stress as well (Peterson, 2015). This calmness often extends past the mind to the

body, encouraging psychophysiological self-regulation and repair (Ando et al., 2016). A study by

Beerse et al. (2020) suggested that mindfulness and art therapy together can lead to reductions of

anxiety and perceived stress. The existing literature revealed a need for more research overall,

including research for new mindfulness and art therapy interventions. Mindfulness and art

therapy have been shown in preliminary research to work together to focus clients in the present

moment to reduce anxiety (Monti et al., 2012).

Nature-Based Therapy

Nature-based therapy encompasses a wide range of therapeutic practices that integrate

with nature (Corazon et al., 2012). Spending time in and connecting to nature has been shown to

positively affect mood and well-being (Neill et al., 2018), improve mental health (Jordan, 2014),

and counteract feelings of anxiety (Softas-Nall & Woody, 2017). Research into ecotherapy and

ecopsychology indicated a decrease in anxiety associated with nature-based therapy (Chun et al.,

2017; Kamitsis & Simmonds, 2017; King, 2019). Jordan (2014) considered the effects of moving

psychotherapy to an outdoor setting, and Chun et al. (2017) thought that nature-based therapy

could be useful with patients who were difficult to treat with standard treatments, such as

pharmacological treatments. Berger and Tiry (2012) suggested that nature-based therapy can be


used to empower those coping with anxiety, and also by reconnecting to nature, individuals can

better reconnect to themselves. A pilot study revealed that forest environments increase positive

feelings and decrease negative feelings, in addition to significantly increasing parasympathetic

nervous activity (Lee et al., 2011). Also included in nature-based therapy, research on gardening

as a mental health intervention suggests reduced anxiety as a result (Clatworthy et al., 2013).

Corazon et al. (2012) believed that nature also had the potential to be integrated with

mindfulness in a therapeutic manner. The researchers referred to the mindfulness associated with

nature as resembling fascination, relaxation and present awareness (Corazon et al., 2012).

Regarding the intersection of art therapy and nature-based therapy, there has been little research

concerning the use of both simultaneously. However, because nature positively benefits mood,

the therapeutic integration of art and nature invites exploration (King et al., 2019).

Summary

Millions of Americans experience chronic worry and other symptoms of GAD (Anxiety

and Depression Association of America, n.d.). GAD affects quality of life and carries an

economic burden as well (Carl et al., 2020; Devane et al., 2005). Individuals with GAD may

struggle with emotional, psychosocial, and interpersonal challenges (Arellano et al., 2018;

Borkovec et al., 2002; Revicki et al., 2012). Current treatment for anxiety typically involves

psychotherapy and/or medication. Art therapy may be effective in reducing anxiety for those

with GAD, but more research is needed (King et al., 2019). Research has shown that mandalas

can reduce anxiety, and mindfulness has also been shown as effective treatment for anxiety

symptoms (Bolognesi et al., 2014; Campenni & Hartman, 2019). Studies also suggest that

spending time in nature decreases feelings of anxiety (Softas-Nall & Woody, 2017). In

conclusion, there were many elements to consider when treating individuals diagnosed with

GAD. A research study by Lindsey et al. (2018) suggests that mindfulness, journaling, and art


therapy can work together as coping strategies for managing anxiety. Jordan (2014) suggested a

view of therapy that includes fluid boundaries of psychotherapy and may include being in nature,

in contrast to a reductionist approach of therapy occurring only on the therapist’s couch.


CHAPTER III

Methodology

This arts-based heuristic study examined how the utilization of art therapy and mandala

creation affects symptoms of GAD. It also explored how art-making and creativity might lead to

increased coping skills and improved quality of life for individuals with GAD. The researcher

created nature mandalas to explore the effects of mindful art making on generalized anxiety

symptoms. The researcher measured anxiety levels before and after the art-making session with a

short-form anxiety assessment.

Participant

The participant was a 33-year-old white American female. She was diagnosed with

Generalized Anxiety Disorder in the spring of 2019—two years prior to the study. She also had

celiac, an autoimmune disease triggered by ingesting gluten. At the time of the study, she lived

in Tennessee and was a graduate student at Saint Mary-of-the-Woods college in Indiana. Saint

Mary-of-the-Woods College provided an institutional review approval required when using

human subjects while conducting research.

Research Design

The researcher engaged in creating mandalas in nature over a period of four weeks for

one and half hours a day for approximately three days a week. At the beginning of each session,

the researcher filled out a pre-session assessment using the short-form anxiety assessment. The

researcher then engaged in five minutes of mindful deep breathing while she focused on

centering herself. This was followed by 30 minutes of collecting natural materials for the

mandala near and around the researcher’s house. These materials included branches, leaves,

berries, bugs, stones, and flowers. The researcher then spent 30 minutes creating a mandala in a

designated space within her house or yard. She took a photo to record her mandala after it was


completed. Following the mandala making, the researcher spent 15 minutes for reflective

journaling and answered four guiding prompts: (a) discuss your choice of materials today, (b)

discuss your process today, (c) what does this mandala mean to you, and (d) do you feel this

session helped you deal with anxiety today, and if so, discuss why. Journaling was followed by a

post-assessment—again using the short-form anxiety assessment. The researcher ended each

session with mindful deep breathing with the intention of grounding and letting go of anything

she may have still been carrying from the session.

Heuristic Research

The researcher analyzed and explored the art-making process by employing Moustaka’s

(1990) six phases of heuristic inquiry. This included:

1. Initial engagement where the researcher explored what interests felt most important to her

personally, as well as those interests that felt meaningful in a social context.

2. Immersion included identifying a specific research question and engaging wholly with

the topic. The researcher set aside an hour and half, three days a week for four weeks to

mindfully create nature mandalas and journaled about the experience after each session.

The researcher was able to increase her understanding and comprehension of the research

question.

3. Incubation was where the researcher stepped back from the immersive experience,

limiting additional thoughts and feelings about the experience, in order for existing

understanding to develop and grow. This phase encouraged “insight, understanding, and

integration” (Sultan, 2019, p. 11).

4. Illumination involved breakthroughs, awakenings, discoveries, intuitive knowledge, and

increased awareness concerning the researcher’s topic of inquiry.


5. Explication involved the process of examining and expressing what has been discovered

throughout the process and required organization and presentation of themes.

6. Creative synthesis occurred when the researcher integrated and expressed the reflective

journaling, quantitative, and arts-based data in an intuitive and personal manner

(Moustakas, 2015).

Research Instruments

Quantitative data was collected through STAI pre- and post-assessments to measure

anxiety before and after each mandala making session. Qualitative data was collected through

reflective journaling in response to specific prompts regarding meaning and coping with anxiety.

Visual data was also collected through photographs of mandalas at the end of each session.

STAI Assessment

In 1992, Marteau and Bekker developed a six-item short form of Spielberger's state-trait

anxiety inventory (STAI, Spielberger et al., 1970) featuring six of the original 40 items. The

inventory asks the individual to rate how they were feeling in the present moment on a scale

from one to four--calm, tense, upset, relaxed, content, and worried. This modified version of

Spielberger’s STAI was used for the pre- and post-assessment. Kruyen et al. (2013) concluded

this short form was acceptable for research purposes, and Buela-Casal and Guillén-Riquelme

(2017) also found it reliable, valid, and useful when needing a shorter assessment.

Reflective Journaling

Ortlipp (2008) discussed how reflective journaling is methodologically an accepted

practice from many research perspectives and enhances self-reflection about the research process

itself. Whittemore et al. (2001) noted how reflective journaling can be used to indicate validity

within qualitative research. The researcher wrote about her perceived levels of anxiety and

experience of the creative process through reflective journaling after engaging in the


interventions during the session. Data was gathered from the pre- and post-reflections and

examined to analyze the similarities and differences of the researcher’s perceived levels of

anxiety and related feelings.

Nature Mandalas

The mandalas were made by the researcher from items found in nature and photographed

at the end of each session. Betts and Deaver (2019) suggested the researcher determine the most

appropriate documentation method for their research process, including photographic

documentation of impermanent art. Poveda et al. (2018) explored how the use of photographs in

qualitative research has evolved, providing an accessible tool for gathering reflexive data from

the participant’s point of view that generates data that can be examined on its own or in

combination with other forms of data.

Data Collection

The research spent time gathering materials from nature and creating a new mandala each

session. She followed the art-making with reflective journaling in response to specific prompts.

Each mandala was unique, some more complex that others, with additional layers and materials.

Many mandalas had a defined center, were organized and employed repetition within the design,

integrating various colors and found objects. The researcher used natural elements symbolically

and aesthetically. Some mandalas were made with intention; others were made with no plan at

all. Data was collected digitally and stored in a Google Drive account that had been properly

configured to protect confidentiality.

Data Analysis

Thematic analysis of the qualitative data was used to discover and determine overarching

themes from the study (Creswell, 2018). This qualitative data came from reflective journaling


completed by the researcher after each artmaking session. The researcher worked to uncover

universal themes that embodied her experiences during the study (Moustakas, 2015). Steps to


Figure 1

Thematic analysis

thematic analysis that were taken included classifying and coding data using categories,

identifying themes, and then looking for meaning within the patterns (Creswell, 2018). The

researcher employed manual color-coding techniques using a digital word processing program

and inductive coding to determine codes based on the qualitative data, rather than looking for

predetermined codes. Creswell (2018) also stated that thematic analysis of a heuristic study may

include analysis of significant comments and the development of an essence description.

Validity and Reliability

According to McNiff (2010), the researcher’s immediate and intimate experience of their

own creative process and motivations results in an increase of validity of the data which is being

researched. McNiff (1998) also discussed aesthetic criteria to measure validity in heuristic

research, such as moments of intense awareness, enlightenment, and meaningful discovery.

Bloomgarden and Netzer (1998) stated that the verification involved in Moustakas’ six-phase


model of heuristic research tests and refines the validity of the researcher’s intuition. The pre-

and post- standardized assessment used in this study added validity, and the use of reflective

journaling as a response to consistent guiding prompts increase reliability (Pyrczak & Bruce,

2017).

Ethical Implications

The American Art Therapy Association (AATA, 2013) stated that researchers must

adhere to regulations and industry pertaining to conducting research and must obtain institutional

review approval when using human subjects and follow appropriate protocol throughout

research. Saint Mary-of-the-Woods College provided my institutional review approval. The

researcher expected that this arts-based heuristic study posed minimal risk to her well-being. The

anticipated risks included unfavorable responses to increasing her focus on personally

challenging subject matter. During the study, the researcher met with her personal therapist who

was a licensed professional counselor with mental health service provider designation. This

aided in the resolution of unfavorable responses brought up during the study. The researcher

worked with her therapist to obtain objective distance from her feelings and thoughts that arise

during the study, increasing the validity of the data as well.

Researcher Bias

The researcher acknowledged that her training to become an art therapist, her belief that

art-making would benefit individuals with anxiety, and her personal experience making art

potentially presented a bias for the study. The researcher’s personal expectations for the study

may also have contributed to potential bias within this heuristic inquiry.


CHAPTER IV

Results

An analysis of the data indicated three major themes relating to the participant’s response

to artmaking. These included (a) connection, (b) coping, and (c) perspective. The subthemes for

connection include connection to nature, self, others, spirituality and time.

Connection

The participant found that mindfully making nature mandalas increased feelings of

connection. Increased connection with nature was a prominent theme that was reflected in

repeated comments in the reflective journal, often as a result of both collecting materials as well

as arranging them into a mandala design. Other feelings of connection were reflected as similar

to feelings of reconnection, such as with the self and a connection to spirituality.

Nature

Connection to nature can be evidenced by sensitive and detailed interactions with natural

materials in order to create the nature mandalas. The participant noted how she noticed that bugs

and birds had eaten parts of the leaves and seeds she was collecting and responded this increased

her awareness “…not in a bad way, but more about how connected everything in nature is, how

it is affected and dependent on itself in so many ways.” Connection to nature can also be seen in

reflection on natural cycles and seasons. For example, Figure 2 displays a mandala made in a

small puddle of water by the participant’s house. After making this, she wrote “I feel like

working in the water gave me a sense of peace and contentedness, and I felt more connected to

nature and the cycles of life.” The participant also reported increased awareness of natural

materials in her environment and a sense of feeling as though nature was more integrated into her

inner world than before.


Figure 2

Water mandala

Self

Connection to self was observed in the study through data from the participant’s

reflective journal. The participant discussed personal emotions, thoughts, fears, hopes, dreams,

preferences, and other personal matters as a response to mandala making. The participant

described herself as an introvert, and time spent alone in nature during the sessions increased

feelings of connection to self. The participant discussed her relationship with herself and

suggested that relationship benefitted from the sessions. For example, the participant said that

while participating in one session that “I could give myself permission to not worry about

anything else for the 30 minutes [when] I’m making the mandala.” The data also revealed a

connection to deeper personal concerns such as the participant’s level of acceptance of her own

mortality.

Others

In addition to feeling an increased connection to self, the participant also reported feeling

an increased to connection to others—specifically loved ones, such as friends and family. At


times, it was a specific connection to another person, such as her husband. The participant stated,

while reflecting on a mandala she had made in that session, that “I feel like this design is

connected to my prayer for them,” referring to two friends she was concerned about. Figure 3

shows a mandala made that symbolized a concern for another troubled friend—the participant

stated she felt more connected to the friend after making this mandala. Other times, the

participant discussed feeling connected to the whole of humanity, as evidenced by the quote: “I

began to remember all the times I had felt life was important, we are all connected and a part of

this existence.”

Figure 3

Sunflower mandala

Spirituality

Connection to spirituality was another subtheme found in the data. The participant talked

about art as a form of prayer, labeling a number of mandalas she made as prayers. For example,


Figure 4 contains a mandala made by the participant that she reported was a prayer for her future

children—the snake eating its tail in the mandala represents the ouroboros, which is a symbol for

fertility. She stated “I often see my art as a form of prayer, so this piece was a prayer for fertility

and children.” She also reported an increased connection to her spirituality as a result of

spending time in her garden at her home. This connection to spirituality is also demonstrated by

the following quote: “So being able to make art and pray about it was very soothing and I felt in

touch with God, it felt like a spiritual experience.”

Figure 4

Ouroboros mandala

Time

The data revealed an increased connection to and awareness of time for the participant.

This involved feelings of connection to both the present and the future, with connection to the

present evidenced by the quote: “I guess this whole study helps bring me back to the present.”

The participant also noted a desire for more time during sessions, which was expressed


numerous times. Another way the participant appeared to feel connected to time was feeling an

increased connection to the quality of the time spent during the sessions, and how she noticed

how much value the time spent during the sessions brought to her life. For example, she stated,

“I felt like I have been so busy and just taking an hour to poke around the yard, examining the

plants, do a little digging with the shovel and make a mandala gave me space and time to process

some of the things I’ve been thinking about.” Additionally, when asked how one of the sessions

helped her deal with anxiety, the participant acknowledged how the time that was spent making

mandalas did help her deal with anxiety in her own way: “I think it gave me space to think about

things and time to organize my thoughts.”

Coping

Coping and coping skills were another theme the researcher discovered in the data. The

subthemes for coping include mindfulness, anxiety, meaning-making, relaxation, emotional

awareness, and repetition. The subthemes for perspective include aesthetics, awareness,

symbolism, and processing. Mindfulness was an anticipated form of coping, due to the design of

the study. Anxiety was also anticipated as related to coping, and the participant discussed her

experience of anxiety and coping with it frequently in her reflective journal. Relaxation as a

coping skill was a noticeable result derived from the STAI assessment as well as the reflective

journal. Emotional awareness included awareness of anxiety and increased awareness of self.

Repetition was reported as soothing, as was found repeatedly in mandala designs through the

study.

Mindfulness

A mindful component was included in the study design, with two five-minute sessions of

mindful breathing occurring before and after each session. Mindfulness showed up in different

areas of the study outside of the breathing exercises, including both the collection of materials


and designing the mandala. The following quote illustrated that point: “I noticed how focused I

was on the colors and details of the materials while I was picking out material and making the

mandala.” The researcher found mindfulness was also being practiced by intentionally noticing

interesting textures and various shapes of natural materials. For example, the participant reflected

on specific features of mushrooms she was working with one day: “I love the mushrooms--they

are so sensitive and soft, and their texture is fascinating.” Being more present was a result of

mindfulness the researcher noticed as well, as evidenced by the statement from the participant’s

journal: “I also noticed how much my mind wanders to the future during the mindful breathing,

so I feel like that is really helpful for me to be more aware of my thoughts, practice mindfulness

and bringing myself back to the present.”

Anxiety

As seen through the STAI assessment data, the participant demonstrated increased coping

with symptoms of anxiety. The STAI assessment revealed an overall decrease in worry and

feelings of tension after the sessions. Data from the STAI pre- and post-assessment showed

changes in 5 out of 6 measures that suggested a decrease in anxiety symptoms (see Appendix A).

Over the 12 sessions, the participant reported feeling more relaxed, calmer and more content on

average after the session. The participant reported feeling less tense and less worried on average

after the session. The data did not reveal a significant change in feeling more or less upset after

each session.

An increase in coping with anxiety symptoms was also seen through the reflective data.

One prompt in the reflective journal was “Do you feel this session helped you deal with anxiety

today?” The participant responded positively 10 out of 12 times that the session did help her to

cope with anxiety in some way. The expression of anxious thoughts and concerns were also

revealed through the mandala designs. The researcher felt this expression was another coping


skill for anxiety.

Meaning-Making

The subtheme of making meaning within the session and through the reflective journal

was found as a form of coping. The subtheme is related to the symbolism and spirituality

subtheme as well, as the participant at times found spiritual meaning in symbolism within a

mandala design. For example, the participant’s last session felt meaningful to her and she wanted

to find something unique to mark that mandala as different. She found a four-leaf clover, which

is a symbol in her personal life, and she commented on how positively she felt after creating

meaning in that way: “I’m really glad I found a four-leaf clover for the center of my last one,

somehow it seems to be more meaningful and personal that way.” Figure 5 shows the referenced

Figure 5

Clover mandala

mandala, with the four-leaf clover in the middle. The participant stated that she “felt it helped me

gain some closure and find meaning in the process of making them,” in reference to making the

mandalas. The research data revealed a search for meaning within nature during collection of


materials as well.

Relaxation

When consider the STAI assessment data, an increase in relaxation after sessions was

found to be the most significant result (see Appendix A). In addition to increased relaxation, the

STAI assessment data also reported an increase in feelings of calm following mandala-making

sessions. The reflective journaling data showed an increase in relaxation as well, predominantly

as a result of mandala making, but also due to collection of natural materials. For example, the

participant stated in her reflective journal: “This mandala felt relaxing to me. I love the little

berries I found, the roundness of them replicated the circular mandala shape and that felt very

satisfying and relaxing.” This quote was in reference to the Stick and Berry mandala, found in

Figure 6. The setting of the session may have contributed to relaxation, as the participant

reported, “I felt more relaxed after spending time in the garden by myself.”

Figure 6

Stick and berry mandala


Emotional Awareness

The participant increased emotional awareness throughout the study as evidenced by

reflective journaling data and STAI assessment data. The STAI assessment required increased

emotional awareness from the participant concerning current anxiety symptoms and levels of

contentment and calm, and further inspection of emotional state during reflective journaling.

There was a significant amount of data disclosing the participant’s emotional state, including

feeling anxious, positive emotional states such as feeling hopeful, and negative emotional states

like feeling depressed. The reflective journal contained quotes such as “I was drawn to the

flowers and felt pretty content today,” and “I didn’t feel like I had much anxiety, but I was

dealing with some depression.” At times, emotional awareness was increased by reflection on

mandala design. For example, Figure 7 shows a mandala with a dead cicada at the center. The

participant was not aware of underlying concerns about mortality until engaging in reflective

journaling and reflecting on her focus on a dead bug during the session.

Figure 7

Cicada mandala


Repetition

All of the mandala images featured repetition of materials. For example, Figure 8 shows

repetition of found flowers and berries. The participant stated that while making this mandala “I

let myself repeat shapes and patterns, focusing on the repetition and slight variation in form and

color.” Repetition was practiced during natural material collection as evidenced by material seen

in the mandalas. The participant responded to a prompt about material collection during the

session that “I am more drawn to the repetition.” Feeling soothed was often linked with a

repetitive action by the participant, as evidenced in the following quote: “I liked picking some of

the white petals off of the flowers individually, it was repetitive and soothing.”

Figure 8

Flower mandala

Perspective

The researcher noted a theme of increased perspective throughout the data. The subtheme

aesthetic reflects an increased aesthetic perspective. Awareness was another subtheme, and refers


to a renewed awareness of space, particularly the environment and personal property of the

participant. The subtheme of symbolism through artmaking provided a new perspective as well.

Processing was another subtheme within perspective. The researcher found data that conveyed

“that the time spent making the mandala was helpful as it gave time and space to process

thoughts and feelings, thus gaining a new perspective instead of ruminating on unprocessed

thoughts and feelings. This is evidenced in the following quotes: “I think this time spent alone

and making this art helped me process some things, since I usually try to distract myself when I

feel anxious, or stay really busy,” and “I think it gave me space to think about things and time to

organize my thoughts.”

Aesthetics

The data indicates that, at times, the participant was focused on aesthetic during the

mandala making session. This is in contrast to focusing on worries or life events or maintaining a

process-oriented approach. This aesthetic perspective created a different state of being for the

participant at times. In the quote: “I felt like I was not being mindful, and just wanting the

mandala to look good,” the participant raises awareness about her aesthetic focus concerning

Figure 9--the garden mandala. Data was found in the reflective journal about textures, colors,

shapes, compositions, lighting, and other aesthetic elements. “I really love the stark white color,

and they matched the white tiny pumpkin I found growing in the compost,” the participant

stated, and “It also wasn't a circle, more of an organic oval shape.” At times, the participant was

highly aware of how the mandala looks and concerned how will it photograph. For example, the

participant wrote about wanting the photos of one of the mandalas: “I also took a few photos and

changed the mandala around a bit, as I’m not sure which configuration I like the most.”

Awareness

The participant reported increased awareness within the session and outside of each


Figure 9

Garden mandala

session. This raised awareness created a different perspective for the participant, as evidenced by

the following statements: “I was noticing different things in my yard than yesterday,” and “I also

was very aware of the bites the bugs had taken out of the leaves and the seeds the birds had eaten

from the sunflower heads.” By engaging in collection of and art-making with natural materials

found near her home, the participant noticed a resulting awareness of the flora that had before

gone unnoticed. This awareness differed from mindfulness in that the awareness was more

sensory and body based, and mindfulness involved sensory awareness though felt more

integrated with mental processes.

Symbolism

The participant reported a change in perspective through use of symbolism. The data

showed the participant frequently employed symbolism when discussing what the mandala


design meant to her. She used archetypal symbols as well as assigning symbols with personal

meaning. For example, one mandala design was made in an empty garden bed that had recently

been installed. The participant made the mandala in the bed, then raked in natural materials and

covered them in soil. She discussed how her intentionality symbolized her dreams for her

garden: “This mandala represents my hope for my garden.” Figure 10 shows a mandala the

participant made where she stated that the Virginia Creeper plant leaves symbolized drug use in

her family.

Figure 10

Radiate mandala

Processing

The data suggested that the participant found new perspective after increased cognitive

and affective processing during the sessions. The participant stated numerous times that the large

amount of time spent dedicated to the mandala making session was beneficial in that it supported

and gave a space for processing anxious thoughts and feelings. For example, the participant

stated: “I think this time spent alone and making this art helped me process some things, since I


usually try to distract myself when I feel anxious, or stay really busy.” Additionally, the data

revealed that time spent in the garden area during sessions resulted in a perceived increase of

emotional and mental processing. Figure 11 shows a mandala made on a rock in the center of the

garden.

Figure 11

Shells mandala

Summary

Results of the thematic analysis revealed themes of connection, coping, and perspective.

Many of these themes are connected, such as connection with self and increased emotional

awareness. Symbolism, meaning-making, and spirituality were woven together throughout the

data—distinct subthemes but related. The subthemes of mindfulness, connection to time, and

increased awareness also shared commonalities. Each of these themes and subthemes contributed

to the participant’s experience, mandala collection, mandala design and making, and her relation

to her anxiety symptoms.


CHAPTER V

Discussion

The heuristic study was conducted over a period of four weeks and included

mindfulness, pre- and post-STAI assessments, creation of nature mandalas, and reflective

journaling. The results of the data analysis of this study indicated three overarching themes.

These included: (a) connection, (b) coping, and (c) perspective.

Connection

Several forms of connection came through in this heuristic study including connection to

nature, self, others, spirituality, and time. The participant found that mindfully making mandalas

with natural materials promoted connection to nature by increased interactions with natural

materials and increased awareness of natural cycles and seasons. Gathering and using natural

materials when making mandalas led to feeling connected to nature as the participant noticed

details about nature that she would have otherwise overlooked. The participant gathered and used

multiples of most of the materials for her mandalas, which led to comparing and contrasting

materials and increased connection with natural materials as she gained understanding and

appreciation for differences and similarities in materials. King et al. (2019) suggested there may

be therapeutic potential when combining art-making and connection with nature. Berger and Tiry

(2012) believed that interaction with nature can lead to reconnection with self. Gathering of

materials, the art-making process and reflective journaling demonstrated an increased connection

to self by revealing personal hopes and dreams of the participant and increasing levels of self-

acceptance. Reflective journaling can allow individuals to express, clarify, and examine their

personal experience (Oxendine, 1988). However, Mills (2008) found that many students may

experience reflective journaling as mere busy work.


The participant felt an increased connection to others such as friends and family members

during and after making mandalas as evidenced by increased thoughts of loved ones and overall

feelings of connectedness to humanity. Feelings of isolation are common among those with GAD

(Ditommaso & Spinner, 1997). However, Gupta (2020) explores how art-making can lead to

increased feelings of connection and solidarity with others during times of isolation. Art-making

also seemed to increase the participant’s connection to spirituality in this study as the participant

reported art-making became a form of prayer for her. Connection to divinity and spirituality can

increase feelings of overall connectedness (Amjad & Bokharev, 2014). Additionally, the

participant found an increased connection to time through feelings of connection to the present

and to the future through art-making and reflective journaling. Duong et al. (2018) described

mandalas as a tool for increasing present awareness.

Coping

Several coping strategies came through in this heuristic study including increased

mindfulness, reduction in anxiety, increased meaning-making, relaxation, emotional awareness,

and repetition. These coping strategies enhanced the participant’s ability to minimize or tolerate

anxiety and resulting symptoms. Mindfulness was used intentionally to open and close each

session, but the participant also found herself incorporating mindfulness into other parts of the

sessions such as collection of materials. Art-making and spending time in nature seemed to

bolster the effects of mindfulness during the study, as each element encouraged the researcher to

increase present awareness. King et al. (2019) suggested that the circular forms derived from

natural materials and the circular mandala design can lead to feelings of calm and mindfulness.

Duong et al. (2018) stated that mandalas can be used as a means to experience mindfulness.

Mindfully making mandalas with natural materials helped to reduce anxiety levels in this study

as demonstrated by pre- and post-STAI assessment data and comments made by the participant


through reflective journaling. Additionally, meaning-making through spiritual engagement was

used as a coping tool to reduce symptoms of anxiety. Mandala making has been demonstrated to

reduce symptoms of anxiety in various populations (Campenni & Hartman, 2019; Lee, 2018;

Rodak et al., 2018; van der Vennet & Serice, 2012). Mindfulness was reported to reduce anxiety

symptoms in a meta-analysis by Hofmann et al. (2010). Preliminary research by Monti et al.

(2012) suggested that art therapy and mindfulness can work in tandem to increase focus in the

present moment to reduce anxiety. Interaction with nature has also been associated with a

reduction in anxiety symptoms (Berger & Tiry, 2012).

During many art-making sessions, the participant used the natural materials to create

meaning through symbolism and spirituality. Frankl (1964) observed that a sense of

meaninglessness could lead to psychopathology, and Maslow (1964) stated that spirituality can

reduce feelings of meaninglessness. The intersection of connection through spirituality and

coping through meaning-making found in this study pointed to spirituality as a compelling

coping strategy and protective factor for the participant. For many individuals with GAD,

chronic worry may result in feelings of fear due to lack of control (Navarro-Haro et al., 2019;

Roemer et al., 2005). However, when spiritually directed or meaning-making coping strategies

were implemented, this can result in development of an internal locus of control, or sense of

control over one’s life and future (Hefti, 2011). Additionally, the participant consistently

experienced feelings of relaxation following most mandala making sessions and time spent in a

mindful state. One session, in contrast, did not result in feelings of relaxation, as the participant

encountered a negative experience involving seed ticks while gathering natural materials.

Corazon et al. (2012) found that mindfulness associated with time spent in nature increased

feelings of relaxation. Navarro-Haro et al. (2019) found that mindfulness can also increase the

use of relaxation as a coping skill for addressing GAD.


The participant observed that increasing emotional awareness by increasing acceptance

and reducing avoidance of emotions became an effective coping skill for addressing intense

emotional states. Increased acceptance of emotions can lead to greater self-compassion, and self-

compassion has been reported to be an effective coping skill for reducing repetitive negative

thinking or rumination (Wadsworth et al., 2018). Repetition was also identified within the coping

theme, as the participant used repetition consistently when making and designing mandalas.

Some individuals with anxiety and GAD use body-focused repetitive behaviors to cope with

anxiety, though relief was temporary and more often these behaviors cause distress (Solley &

Turner, 2018). However, the researcher noted the use of repetition through art-making during the

study as an effective coping strategy for anxiety with no harmful ramifications. Nuttall and

Pelletier (2020) noted that repetition compulsion has been theorized as an attempt to master and

deal with trauma through increasing a sense of control and a way to regulate anxiety symptoms.

Perspective

Several variations in perspective came through in this heuristic study including increased

perspective of aesthetics, expanded awareness of personal environment, new symbolism

discovered through art-making, and increased cognitive and affective processing. An increased

focus of perspective on aesthetics of natural materials increased the participants focus on the

present experience. The participant’s reflective journaling demonstrated a shift to an aesthetic,

and perhaps external, perspective. A number of studies showed an increased aesthetic

perspective as a result of mindful art-making (Abbing et al., 2019; Bi & Liu, 2019; Duong et al.,

2018). Mindfulness and gathering natural materials in their found environment resulted in

expanded awareness of the participant’s personal space and environment. Within the study, the

increased awareness of the participant’s personal environment and the use of mindfulness


seemed to support each other. Iani et al. (2019) found that mindfulness can lead to increased

awareness of personal space and altered perspective of environment.

During the study, the researcher discovered new perspectives through symbolism and

meaning-making through art-making, often represented in the mandala artwork and discussed in

her reflective journaling. According to Jung (1963), the mandala is a symbol for the wholeness

of self. Symbolism may also be a tool for personal transformation that integrates meaning-

making, spirituality, and expanded perspective (Khodarahimi, 2010). For example, the

participant explored meaning and symbolism when using a snakeskin in a mandala design during

one session which she viewed as a symbol of fertility and new life. Khodarahmi also suggested

that snakes have been seen as a symbol of fertility, rebirth, and even transcendence.

The participant felt that the time spent making the mandala was quite valuable for her, as

this was the time during which she was able to process thoughts, feelings, and worries. This led

to gaining of a new perspective instead of rumination on unprocessed thoughts and feelings.

King et al. (2019) reported that elements of therapeutic art-making such as creative expression

and use of various materials can enhance emotional processing, though the mechanisms of how

this occurs requires more research.

Limitations

The researcher was aware of the limitations of this heuristic study, including the sample

size of one individual, and, thus, this study cannot be generalized to a larger population. The

researcher has been diagnosed with generalized anxiety disorder, and her experience of the

disorder and specific symptoms may vary widely from other individuals with the same diagnosis.

The researcher also had previous experience using art-making effectively as a coping skill for

anxiety. Practical limitations also included weather patterns, seasonal availability of foliage,


seasonal and plant allergies, and natural hazards such as a ticks and poison ivy that may be

present when foraging for materials.

Recommendations and Future Studies

This study could be replicated with a larger and more diverse sample size and also within

an art therapy group or individual setting. This study may also find effectiveness with other

anxiety disorders, such as social anxiety, or with individuals experiencing high stress or

adjustment disorder. Adults, adolescents, and even children may find a reduction of anxiety as a

result of art therapy that incorporates natural elements and settings. This might include making

mandala collages from natural materials or images of natural materials and settings. The

researcher also recommends future studies investigate the effects of art therapy in nature for

adults dealing with chronic diseases and health issues. Additionally, future studies may examine

or integrate spiritual connections associated with mandala making and nature-based therapy.

Cross and Brown (2019) noted that even a 15-minute self-initiated art-making session can help to

promote a reduction in anxiety symptoms and increased positive mood. Mindful mandala making

with natural materials may also be used as a coping skill for individuals with anxiety to use in a

shorter session or even outside of a therapy session.

Conclusion

This heuristic arts-based study evaluated the effectiveness of mindful art-making in

nature on generalized anxiety disorder symptoms. The literature review reveals some support for

each of these elements individually in reducing anxiety including the effectiveness of art therapy

for anxiety symptoms (Bolognesi et al., 2014; Hass-Cohen et al., 2014; Softas-Nall, & Woody,

2017). The results of this heuristic study indicated increased connection, altered perspectives,

and increased coping including a reduction in anxiety symptoms as a result of mindfully making

mandalas using materials gathered in nature. Although this heuristic study cannot be generalized


to a larger population, the combination and synthesis of art-making, mindfulness, and nature-

based therapy may reveal a greater efficacy for treating anxiety (King et al., 2019, Peterson,

2015). The arts-based intervention from this study could be used in an individual or group

therapy setting to increase treatment options for the diverse population who experience

generalized anxiety disorder symptoms, lending further validation to the field of art therapy by

providing new and effective forms of addressing anxiety. This study advances the field of art

therapy by supporting the use of mandalas, nature-based therapy, and mindfulness with art to

increase feelings of relaxation and connection and suggesting coping strategies for individuals

with anxiety.


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APPENDIX A

Results of the Pre- and Post-STAI Assessment

Average change in anxiety assessment from pre- to post-session

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