Authored by Christine Manville*
Abstract
This study examined the impact of Mandalynth tracing as a mindfulness-based training technique. It investigated whether the act of tracing had an influence on an individual’s physiology and self-perception of anxiety, and their perceived ability to participate in meaningful activities. This descriptive, mixed-methods study used interview responses, the Beck Anxiety Inventory, and pulse-oximeter readings to obtain data. While this study was not statistically significant, researchers concluded anxiety has a negative impact on individual perception of participation. Though additional research is needed to confirm the efficacy of Mandalynth tracing, the use of this tool decreased physiological symptoms of anxiety and promoted self-reported relaxation and calming effects.
Introduction
According to the World Health Organization (WHO) [1], mental health is defined as, “a state of well-being in which each individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. By this definition, mental health can be understood as a continuum. An individual’s specific location on this continuum can fluctuate depending on a variety of internal and external variables, which can include stressors, anxiety, or physiological changes. The WHO has identified mental health as “a growing cause of disability worldwide and predicts that in the future, mental illness...will be the top cause of disability”.
According to the National Alliance on Mental Illness (NAMI) [2], one in five adults in the United States experiences mental health issues in a given year. Individuals living with serious mental health issues have an increased risk of chronic medical conditions and live an average of twenty-five years less than other Americans [2]. Anxiety is a common co-occurring symptom with mental health disorders and has both mental and physical implications for an individual [3-5]. Symptoms of anxiety can interfere with one’s ability to engage in a range of chosen occupations and affects perception of abilities [6,7]. Research has revealed a variety of techniques that can be used to help individuals cope with anxiety and stress [8]. Among the professions who work toward this goal with clients are occupational therapists. The goal of occupational therapy is to empower others to “achieve health, well-being, and participation in life” [9] through engagement in occupations. Activities and strategies which reduce symptoms of mental illness and promote participation can potentially reduce anxiety and enable individuals to have a better quality of life.
Complementary and Alternative Medicines (CAMs), among many other interventions, have promising outcomes for decreasing symptoms of mental illness [10]. CAMs are defined as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine” [11]. A key responsibility of occupational therapy practitioners is to teach clients who are experiencing mental illness “strategies for managing symptoms to enhance occupational performance” [6], of which CAMs can play an important role [12]. The CAMs currently being used include guided imagery, massage, meditation, yoga, behavioral relaxation training, and mindfulness practices.
One component of CAMs relates to channeling mindfulness. Mindfulness is described as a “purposeful, non-anxious, reflective practice” [13] and can be a means to gain self-acceptance and cope with anxiety, stress, anger, and other negative emotions [14]. Mindfulness-based interventions have been shown to benefit individuals with a variety of mental health issues, including anxiety, depression, and schizophrenia spectrum disorders [15]. These interventions have also been shown to boost mood [16], increase one’s sense of well-being [17], and reduce perceived stress and rumination [18].
Research suggests mindfulness techniques can be effective in empowering adolescents with mental health issues to self-soothe and relieve emotional distress [19]. Mindfulness techniques encourage focused attention on the present moment, which has been shown to reduce symptoms of anxiety and mental illness [20]. Tracing and drawing are considered mindfulness techniques because they have calming effects shown to decrease an individual’s perceived anxiety and stress. Mandalynth tracing is a similar kinetic activity, involving the use of a continuous pattern to evoke a flow of uninterrupted movement. There is a need for evidence concerning the use of Mandalynth tracing and its effects on anxiety.
Utilizing Mandalynth tracing as a mindfulness-based tool, this study investigated the influence of Celtic Art Mandalynths on anxiety levels and perception of participation through changes in pulse rate, oxygen saturation, and qualitative interviews. The Mandalynths used in this study were created by artist Erin Rado, who states that Mandalynth tracing simulates mindfulness through focus on intricate patterns (2016). The Mandalynth designs selected for this study were inspired by Celtic knots, and consisted of an assortment of continuous patterns, which varied in difficulty level based on the tightness or openness of the loops.
Methods
All participants in this mixed-methods study were receiving residential services in the local community through Park Center [21], a local community agency which has been providing services to individuals in recovery for over thirty years. In order to qualify for these services, individuals must have met the following criteria:
• be between the ages of 18 and 24,
• have a documented diagnosis of severe and persistent mental illness, and
• have a history of mental health hospitalization or adolescent foster care, and/or were currently experiencing homelessness, and
• the participants could not be a registered sex offender or have a history of acting out with sexual behaviors.
Ethical approval for this study was granted by an Institutional Review Board (IRB). All residents were invited to an initial meeting to discuss the research plan, their possible participation in this study, and any additional questions or concerns they may have. Individuals who wished to participate in the study signed a consent form and completed a demographic form. In total, seven residents chose to participate in the study; however, one participant dropped out of the study after the first session due to an exacerbation of psychotic symptoms.
Structure and Procedures
Researchers met with participants for thirty minutes once a week for four sessions. During these sessions, a pre-tracing pulse oximeter measurement was recorded in order to establish a baseline for each participant’s heart rate and oxygen saturation levels. The participants selected a Mandalynth design from one of eight different potential patterns and then spent five minutes tracing with their index finger on their dominant hand. Post tracing, a second measurement was taken with the pulse oximeter, recording their heart rate and oxygen saturation level. At the end of each session, participants engaged in a six-question interview about their feelings and thoughts before and during the tracing and their self-perception of ability to perform meaningful activities. During the first and fourth week, the participants also completed a written Beck Anxiety Inventory (BAI). In the final session, participants completed six additional questions encouraging reflection on selfperception of anxiety and how they felt their anxiety changed over time, if at all.
Evaluation Procedures
The BAI is a twenty-one item self-report measure in which participants rate their perceived levels of anxiety. The BAI was used twice, once before the study began to establish a baseline level of anxiety and again at the end of the study to allow for comparison to see if any changes had occurred. The BAI uses a Likert scale for self-report, rating how often they experienced common physical symptoms of anxiety, such as: tingling, trembling hands, sweating or an inability to relax. Beck, et al. [22] report the test-retest reliability for the BAI as 0.75. The BAI scale was selected because of its simple rating system and non-leading questions, which facilitate unbiased responses to feelings and thoughts about anxiety.
The interview questions were created using a triangulation method. The content validity of the questionnaire was enhanced by drawing information from a review of the literature on mindfulness, participation, quality of life, and anxiety. The questions were reviewed by administrators from the residential program and a licensed occupational therapy practitioner, with ten years of experience in mental health. To provide face validity, interview questions were pilot- tested by members of another program who were not research participants who also had a diagnosis of mental illness.
Researchers measured physiological symptoms of anxiety using a pulse oximeter. In stressful situations, the body releases the hormone adrenaline, which will bring about an increase in heart rate and blood pressure [23]. Heart rate and oxygen saturation were measured before and after each session to evaluate whether Mandalynth tracing had an effect on these physiological manifestations of anxiety.
Analysis of the Data
Individual structured pre and post interviews with participants were transcribed, and the data collected during each interview was analyzed using the coding system NVivo. In order to increase validity, multiple researchers worked to code the data and compare results, looking for emerging themes and patterns.
Both parametric and non-parametric methods were used to analyze the quantitative data. Measures of central tendency, variability, and dispersion were calculated for ordinal data in the interview questions as well as pre and post oxygen saturation and heart rate levels. This data was then analyzed using the Friedman Test. This test was used because of the study’s small sample size and to compare changes in the participant’s’ physiological symptoms week to week. The BAI was analyzed using the Wilcoxon Two-Tailed Signed Rank Test, to compare participant’s anxiety levels at the beginning and end of the study.
Results
The physiological results of pre- and post-tracing were not statistically significant; however, there were trends in the data. The lines depicting each individual’s pre- and post-session pulse values are portrayed. While median values for the group decreased during weeks one (-4.5), three (-7.0), and four (4.0), the difference in the amount of change among the four sessions was not statistically significant (Friedman test, Χ2 = 3.24, p = 0.356). The Friedman test was used for the nonparametric data to analyze the difference between the pre- and post-test for each of the weeks for individual participants. Changes in oxygen saturation levels within sessions are displayed similarly. Minimal changes were detected in any session (median values: week 1=-1.0, week 2 = -1.0, week 3 = 1.0, week 4 = 0.0) and the difference in the amount of change among the four sessions was not statistically significant (Friedman test, Χ2 = 5.86, p = 0.119). During the four weeks of research, the majority of the participants’ pulse and oxygen saturation levels decreased after the Mandalynth tracing was completed.
Due to small sample size and variable physiological information, qualitative data is more revealing of the participants’ lived experience. Self-report data from the Beck Anxiety Inventory generally followed a similar pattern to the physiological data. The median change in Beck score from session one to session four was -2.0 yet was not statistically significant (Wilcoxon Signed-Rank test, z = 1.21, p = 0.225). The Wilcoxon Signed-Rank test was used to analyze the difference between the nonparametric pre- and posttests between the participants. As shown, five of the six participants displayed some level of decrease in self-reported anxiety over the study period. Based on the results of the BAI, there was a general trend of decreased anxiety over time.
Answers from interview questions were coded in NVivo. The most commonly used words from the interview responses were “good,” “calm,” and “blank.” Half of the participants experienced a positive or calming change in thoughts and feelings while completing the Mandalynth tracing, and reported feeling “relaxed,” or “focused.” Some participants fluctuated between feeling calm and having no effect at all. During one particular session, participant six felt, “nervous anxious trying to do it fast enough”.
During the final interview, the participants were asked what aspects of the Mandalynths were meaningful or helpful to them personally. Four of the six participants reported the Mandalynth tracing had calming, relaxing, and focusing effects. Participant four used Mandalynth tracing as a coping strategy on a daily basis and stated, “When I started to get frustrated, I traced engravings in a table at work when I didn’t have a Mandalynth.” One of the participants noted the Mandalynth tracing was only helpful for approximately an hour, and another participant did not feel the tracing was helpful at all.
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