The role of expressive art therapy and neurofeedback assessments in improving clinical hypnosis adherence among anxiety sufferers

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The copyright © of this thesis belongs to its rightful author and/or other copyright owner. Copies can be accessed and downloaded for non-commercial or learning purposes without any charge and permission. The thesis cannot be reproduced or quoted as a whole without the permission from its rightful owner. No alteration or changes in format is allowed without permission from its rightful owner.

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THE ROLE OF EXPRESSIVE ART THERAPY AND NEUROFEEDBACK ASSESSMENTS IN IMPROVING CLINICAL HYPNOSIS ADHERENCE

AMONG ANXIETY SUFFERERS

By

KOOKIANYONG

Thesis Submitted to College of Arts and Sciences

Universiti Utara Malaysia,

in Fulfillment of the Requirement for the Degree of Doctor of Philosophy

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Permission to Use

In presenting this thesis in fulfilment of the requirements for a postgraduate degree from Universiti Utara Malaysia, I agree that the University Library may make it freely available for inspection. I further agree that permission for the copying of this thesis in any manner, in whole or in part, for scholarly purpose may be granted by my supervisor(s) or, in their absence, by the Dean of Awang Had Salleh Graduate School of Arts and Sciences. It is understood that any copying or publication or use of this thesis or parts thereof for financial gain shall not be allowed without my written permission. It is also understood that due recognition shall be given to me and to Universiti Utara Malaysia for any scholarly use which may be made of any material from my thesis.

Requests for permission to copy or to make other use of materials in this thesis, in whole or in part, should be addressed to:

Dean of Awang Had Salleh Graduate School of Arts and Sciences UUM College of Arts and Sciences

Universiti Utara Malaysia 06010 UUM Sintok

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Abstrak

Walaupun terdapat tumpuan dari seluruh dunia mengenai kebimbangan, langkah- langkah pencegahan dalam industri kesihatan awam, masih tidak mencukupi. Antara isu yang dibangkitkan hasil daripada penyelidikan sebelum ini adalah kepatuhan

terapeutik sebagai komponen penting yang didapati meningkatkan keberkesanan rawatan penghidap kebimbangan. Intervensi berfokus pada teori polyvagal dicadangkan untuk dijadikan pendekatan yang efektif menangani isu kepatuhan berkaitan dengan kebimbangan berdasarkan perspektif biopsikososial yang luas.

Penyelidikan ini bertujuan untuk menghasilkan garis panduan terapeutik yang berfokus kepada polyvagal sesuai dengan penghidap kebimbangan. Penyelidik menggunakan intervensi terapi seni ekspresif dan penilaian neurofeedback berdasarkan teori polyvagal dalam kajian ini bagi mengatasi isu kepatuhan dalam kalangan penghidap kebimbangan. Secara empirikal, proses dan hasil intervensi diteliti sama ada membantu ataupun tidak. Intervensi yang membantu atau tidak mempengaruhi keputusan terhadap hypnosis klinikal yang dikaji. Penyelidikan ini menggunakan kaedah kualitatif dengan pendekatan grounded theory. Sampel kajian yang mendapat skor sama ada 8 dalam subskala Anxiety atau 15 dalam subskala Stress of Depression, Anxiety, dan Stress Scale-21 (DASS-21) telah dipilih sebagai responden dengan mengikuti kaedah persampelan bola salji. Sampel telah dianalisis selepas intervensi melalui temubual semi-struktur yang mendalam bagi tujuan pengumpulan data. Seramai 45 peserta telah terlibat dalam kajian ini. Hasilnya, kepatuhan terapeutik dapat diperbaiki dengan rangka kerja garis panduan terapeutik yang berfokus kepada polyvagal yang dibina dalam kajian ini. Kajian ini telah mengenal pasti bahawa terapi seni ekspresif, neurofeedback, dan hipnosis klinikal merupakan rawatan yang sesuai untuk menyelesaikan masalah kebimbangan. Selanjutnya, penyelidik juga mencadangkan garis panduan terapeutik hipnosis klinikal untuk individu yang mengalami masalah kebimbangan. Implikasi kajian ini berpotensi menawarkan pendekatan inovasi yang berguna untuk pembangunan panduan terapeutik dalam meningkatkan kepatuhan penghidap kebimbangan melalui intervensi (dari peringkat pencegahan awal) agar petanda kebimbangan yang serius dapat dikurangkan.

Kata-kata Kunci: Kepatuhan terapeutik, Hipnosis klinikal, Terapi seni ekspresif, Neurofeedback, Kebimbangan

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Abstract

Despite worldwide concern on anxiety, preventive measures in public health industries remain scarce. Among the issues raised by previous research, therapeutic adherence is a vital component that increases the treatment efficacy of anxiety sufferers. The polyvagal theory-focused intervention is suggested to effectively deal with the adherence issue associated with anxiety concerns by addressing the broad biopsychosocial perspectives. This research intended to generate polyvagal-focused therapeutic guidance in line with anxiety sufferers. The researcher uses polyvagal theory informed expressive art therapy and neurofeedback assessment. The assessment identifies issues among anxiety sufferers. These interventions may be helpful or not helpful to the processes as well as the empirically examined outcomes of the intervention. In addition, it examined both the beneficial and the unhelpful moderating factors of intervention impacting clinical hypnosis adherence. This research utilised the qualitative method with the grounded theory approach. Study samples scored either 8 in the Anxiety subscale or 15 in the Stress subscale of Depression, Anxiety and Stress Scale-21 (DASS-21). The respondents were selected through the snowball sampling method and analysed through semi-structured in-depth interviews for data collection after the intervention. About forty-five participants were involved in generating the outcome of this study. The findings showed that therapeutic adherence enhanced by this study's polyvagal-focused therapeutic guideline framework. This study also identified that expressive art therapy, neurofeedback, and clinical hypnosis are helpful interventions in improving anxiety. Furthermore, the researcher proposes the therapeutic clinical hypnosis guideline protocol for individuals with anxiety sufferers.

The study's implications potentially offer a practical, innovative approach to therapeutic guidance development for enhanced anxiety sufferers' adherence through interventions (from early preventive stages) to deter full-fledged anxiety intricacies.

Keywords: Therapeutic Adherence, Clinical Hypnosis, Expressive Art Therapy, Neurofeedback, Anxiety

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Acknowledgement

Special thanks to my supervisor and mentor, Dr Azizah Binti Abdullah who guided me throughout the process and empowering me to be the best version of myself.

Thanks to my parents, my loved one, my friends, my colleagues and examiners who keep supporting throughout the journey of my life.

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List of Tables

Table 1.1 AMHS Tier System ... .5 Table 2.1 Summarised Themes of Change Model Stages... 71 Table 2.2 Summarised Themes of Helpful Processes in Expressive Art Therapy and Neurofeedback Assessment ... 82 Table 2.3 Summarised Themes of Unhelpful Processes in Expressive Art Therapy

and Neurofeedback Assessment ... 95 Table 2.4 Summarised Themes of Helpful Outcomes in Expressive Art Therapy as an Assessment ... 100 Table 2.5 Summarised Themes of Helpful Outcomes in Neurofeedback as an Assessment ... 106 Table 2.6 Summarised Themes of Unhelpful Outcomes in Expressive Art Therapy as an Assessment ... 112 Table 2.7 Summarised Themes of Unhelpful Outcomes in Neurofeedback as an Assessment ... 117 Table 2.8 Summarised Themes of Helpful Moderating Factors in Expressive Art Therapy Assessment... 123 Table 2.9 Summarised Themes of Helpful Moderating Factors in Neurofeedback Assessment ... 133 Table 2.10 Summarised Themes of Helpful Moderating Factors in Clinical Hypnosis ... 139 Table 2.11 Summarised Themes of Unhelpful Moderating Factors in Expressive Art Therapy Assessment... 145 Table 2.12 Summarised Themes of Unhelpful Moderating Factors in Neurofeedback Assessment ... 149 Table 2.13 Summarised Themes of Unhelpful Moderating Factors in Clinical

Hypnosis ... 153 Table 4.1 Descriptive Statistics of Study Respondent Gender 237 Table 4.2 Descriptive Statistics of Respondent Age ... 238 Table 4.3 The Study DASS-21 and Modified DAI-10 Scores and Interview Rating ... 239 Table 4.4 Summary of Categories under Developing a Therapeutic Context ... 241

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Table 4.5 Summary of Categories under Attaining from the Process of Expressive Art Therapy and Neurofeedback Assessment ... 254

Table 4.6 Summary of the Categories under the Negative Impacts of the Therapeutic Context ... 262 Table 4.7 Summary of Categories under Negative Effects from Expressive Art Therapy and Neurofeedback Assessment Processes ... 270 Table 4.8 Summary of Categories under Enhancing Motivation ... 273 Table 4.9 Summary of Categories under Lowering Motivation ... 290 Table 4.10 Summary of Categories under Fostering a Healthy Belief towards Clinical Hypnosis ... 296 Table 4.11 Summary of Categories under Positive Satisfactory Feedback ... 303 Table 4.12. Summary of Categories under Negative Satsfactory Feedback ... 308

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List of Figures

Figure 1.1. CBHI ... 52

Figure 2.1. Framework of adherence phenomenon sensitising concept ... 154

Figure 3.1. Research framework ... 175

Figure 3.2. Procedure of data collection protocol ... 190

Figure 4.1. Frequency of interview rating on CBHI ... 240

Figure 5.1. Conceptual framework based on current study findings ... 378

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List of Appendices

Appendix A: Ethical Clearance Application Form ... 418

Appendix B: International Institutional Review Board Ethical Approval Letter .. 430

Appendix C: Informed Consent ... 434

Appendix D: Online Video-Conferencing Consent and Guideline ... 436

Appendix E: Data Collection Application Letter ... 438

Appendix F: Questionnaire Sample ... 439

Appendix G: Interview Questions ... 441

Appendix H: An Example of the Interview Transcript ... 443

Appendix I: Review and Feedback from Supervisor, External Auditor, Peer Debriefer, Experts in the Field and Participants ... 445

Appendix J: Manual of Creative Brain Health Intervention Protocol... 454

Appendix K: Video Transcript of Introduction about Clinical Hypnosis ... 459

Appendix L: Presentations and Works to Create Awareness for the Innovation of this Study ... 461

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CHAPTER ONE INTRODUCTION

1.1 Introduction

Individuals in developed and industrialised cultures are currently undergoing anxiety- oriented complexities at an alarming rate. Specifically, anxiety involved perpetual impulsiveness and despair against an integrated lifestyle (Kalat, 2014). In this vein, anxiousness is a primarily social and mental health issue. Following much scholarly attention on anxiety management, extensive studies have been performed on anxiousness from various viewpoints (Arango et al., 2018). Despite commonly and widely obtainable anxiety screening instruments, specific self-labelling (mild, moderate, or severe anxiety sufferers) possibly established more social stigma and hesitance towards psychological therapies (Kalat, 2014).

Given that psychiatrists primarily treated clinically diagnosed patients with mental disorders, past studies generally demonstrated that certain risk elements linked to mental disorders could not be solely addressed by psychiatrists (Arango et al., 2018).

For example, psychiatrist involvement primarily aimed to prevent progression into disability-oriented states (tertiary prevention). Notwithstanding, mental disorders were preventable with individuals’ risk element minimisation and coping mechanism enhancement in different mental health prevention stages. Although tertiary prevention occurred with psychiatrist engagement, the primary counterpart should be highlighted for minimal mental health disorder occurrence rates. In this vein, the public would generally comprehend the essentiality of psychological well-being and

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The role of expressive art therapy and neurofeedback assessments in improving clinical hypnosis adherence among anxiety sufferers

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CHAPTER ONE INTRODUCTION

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