Integration of Augmented Reality in Expressive Art Therapy for Borderline Personality Features
Condition: Self Destructive Behavior; Mood Disturbance; Self Esteem
MeSH terms: Borderline Personality Disorder; Self-Injurious Behavior
Study type: Interventional

Summary: 
      From the last decades, applied approach for the use of augmented reality on clinical and
      health psychology has grown exponentially. Hence, the present study is aimed to examine the
      effectiveness of augmented reality for the treatment of borderline personality features in
      young adults. For the purpose, it is hypothesized that (i) borderline personality features of
      experimental groups will be reduced in posttest followed by the integration of augmented
      reality in expressive art therapy (ii) Borderline personality features of experimental group
      will decrease significantly as compared to control group in the post test followed by the
      integration of augmented reality in expressive art therapy (iii) Borderline personality
      feature of self-destruction will be reduced in posttest followed by the integration of
      augmented reality in expressive art therapy (iv) Borderline personality feature of affect
      regulation will be reduced in posttest followed by the integration of augmented reality in
      expressive art therapy and (v) Borderline personality feature of negative self-perception
      will be reduced in posttest followed by the integration of augmented reality in expressive
      art therapy. For the present purpose, a total of 20 subjects experiencing symptoms of
      Borderline personality features will be screened and recruited from the Umeed e Nau clinics
      of the Institute of Professional Psychology Bahria University Karachi Campus by initial
      screening of the subjects. Participants will be monitored through pre and post-screening of
      Borderline Symptoms Checklist assigned to an experimental (treatment group) and control
      (waiting list) group using convenient sampling. The experimental group will receive the
      Management plan; which will be comprised of total 14 sessions. The effectiveness of the
      intervention plan will be measured via quantitative measure (the latest version of SPSS).
    

Detailed description: 
      The final sample consisted of 20 participants (aged 18-36, males n=5, and females n=15). Half
      of the sample was assigned to the intervention group, while the other half was assigned to
      the control group as per convenient sampling method. The intervention group participants were
      provided with a total of fourteen psychotherapy sessions at Umeed-e-Nau clinic at the
      Institute of Professional Psychology.

      Assemblr Studio: Easy AR Maker (android version 4.1.7) Assemblr studio was used to make
      augmented reality within the sessions. It is a free android application for turning 2-D and
      3-D images into augmented reality. The application was designed by Assemblr (2018) and
      consists of a marker less based type of augmentation. Rather it uses basic templates and
      camera picture upload options, transforming a simple image into augmented reality format. It
      also provides drag and drop options and does not require any coding.

      3-D Pen/ Doodling pen A digital 3-D pen was used to contrast art in the sessions. It was a
      portable and handheld type of machine.

      Procedure Approval to conduct this research was taken from the board of the Institute of
      Professional Psychology, Bahria University, Karachi Campus. The participants were then
      approached via advertisement on social media platforms highlighting awareness regarding
      borderline personality features and the objectives of the present research. The sample frame
      consisted of 36 individuals which were then screened for the inclusion criteria using the
      Borderline symptoms list. The final 20 participants were then randomly divided into two equal
      groups, namely the treatment group and the control waiting-list group. The final 20
      participants were all made privy to the details and purpose of the research and their consent
      was taken. Confidentiality was maintained and the participants retained the right to withdraw
      their participation at any point in the study, as well as remain able to decide not share
      details of specific traumatic or hurtful life events. Moreover, the researchers took all
      necessary steps to ensure safety of the participants' wellbeing.

      The experimental group's treatment plan for augmented reality-based art therapy interventions
      comprised of 14 weekly individual standard sessions. Each session was of approximately 90
      minutes, duration of which was divided into 5 minutes initial check-in to reflect
      participant's outer world, 30 minutes for making art, 30 minutes for discussing the art, 10
      minutes to wrap up the session, and 5 minutes final check-out to reflect on the session's
      interventions, explorations, and learning.

      The treatment plan was divided into three levels. Level one comprised of three primary
      intervention-based sessions designed to help build rapport and have the participants get
      familiar with intervention's concept. Level two, lasting from session four to session twelve,
      dealt with gradually evolving the participants' perceptual continuum to a developmental
      continuum where the individual would the be able to make desired changes and recreate their
      thoughts, feelings, and behaviors. The third and final level included sessions thirteen,
      fourteen, and the consequent follow-ups. Its purpose was to reflect upon the participants'
      learning so far and to sum up the termination phase of therapy. The follow-up session took
      place three weeks after the unilateral termination of the regular sessions. Here the
      participants were required to complete the Borderline Symptoms List (Bohus et al., 2007), and
      if it was assessed that a participant needed further therapeutic help, they were provided
      with referrals to professionals. The control group participants were also assessed for
      post-test borderline symptoms at this point of time.

      After the completion of the study, the results were coded and analyzed using SPSS version
      22.0.

      Session Plan Session 01 - GROW (The Kitchen Table Classroom, 2019). The aim of this session
      was to develop rapport with the participant through semi structured interview and goal
      setting. The objective of the session was to explore the concept of personal change in
      clients via art medium where they drew the word GROW and self-reflected from their onwards.

      Session 02 - Scribble zoom in and out (Khat & Macklin, 2019). The aim of the session was to
      facilitate the process of catharsis, and have the client engage in and explore their
      impulsivity and curiosity. Moreover, childhood insecurities and traumas were explored in this
      session as well and the artwork was used to discuss the participant's self-perception of
      change.

      Session 03 - Blind Contour Drawing (Hu et al., 2021). The aim of the session was to
      psychoeducate the participant with the primary goal of using blind contour drawing to draw
      attention towards differences of perceptions and conceptualization of information. The
      objective of this intervention was to help the participant become aware of their own
      judgmental reactions in different life circumstances.

      Session 04 - Self-Awareness via Johari's window (Batool, 2018). The aim of the session was to
      introduce the concept of thought modification via developing insight through blind spots, in
      a nonjudgmental and nonthreatening manner. The objective of the session's activity was to
      help the participant become self-aware and to bring positive change in self-development.

      Session 05 - My Life Outline (Batool, 2018). The aim of the session was to address
      self-harming behavior in session by identifying distressing elements in the participant's
      life, and to learn to better cope with these distressing elements in a nonjudgmental manner.
      The objective was to have the participant become able to identify different distressing and
      pleasant moments in their life, eventually leading to development of insight and stability in
      mood regulation.

      Session 06 - Free Flow Writings without stimulus (Batool, 2018). The aim of the session was
      to channel emotional distress, negative thoughts, and self-destructive behavior. It was based
      upon the presumption that, while everybody has something to say and the ability to say it,
      the mental wellspring may be blocked by apathy, self-criticism, resentment, anxiety about
      deadlines, fear of failure or censure, or other forms of resistance. Objective was to explore
      and discuss features of personality malfunctions.

      Session 07 - Draw what you hear (Chowdhury, 2019). The aim of the session was to provide the
      participant with cathartic medium to anchor their self, with respect to emotional distress
      and mood regulation. The objective was that via this integration of the self, the participant
      would then be able to regulate their free affirmative emotions.

      Session 08 - Draw your breath (Batool, 2018). The aim of the session was to strengthen
      self-awareness, which eventually helped the participant to maintain mood, regulate
      self-image, and possibly reduce self-harm. Objective was to help the participant feel relief
      by the end of the session.

      Session 09 - Body Healing in Ink (Batool, 2018). The aim of the session was to reduce the
      participant's aggressive and suicidal impulses, thus, helping them better cope with their
      self-destructive behavior. In this manner, the objective of the session was to utilize and
      project participant's aggression in making art in a nonjudgmental manner.

      Session 10 - Paint inside a Heart (Khat & Macklin, 2019). The aim of the session was to
      provide the participant with a nonthreatening and nonjudgmental medium through which they may
      process the emotions being experienced in that moment. The objective of the session was to
      bring into awareness the participant's own emotional burdens and help them create a positive
      self-image.

      Session 11 - Sculpture of Anger (Godfrey, 2008). The aim of the session was to have the
      participant become aware of their emotional distress and the ways in which they manage that
      distress. To attain this goal, the participant was asked to create an art form sculpture that
      most resembled their anger in real life. By the end of session, the participant was then able
      to become self-aware of their aggression and frustration, which automatically led to a
      reduction in tendency to self-harm and helped them better regulate their mood.

      Session 12 - Words of Mind Haiku (Stephenson & Rosen, 2015). The aim of the session was to
      provide the participant with a unique way to become mindful of their progress, enabling them
      to manage their borderline personality features in healthy way. The objective of the session
      was to have the participant self-reflect and then accept their self-image. By the end of the
      session, the participant was able to write their creative thoughts in form of poems, helping
      them to understand compassion and self-regulation.

      Session 13 - Recollection of Moments (Filmore, 2019). The aim of the session was to reflect
      upon the growth and improvement observed by the participant as well as the therapist. In the
      session, progress exhibited by the participant was discussed and goals of the therapy process
      were reviewed. At last, one final objective was to ready the participant for termination of
      therapy.

      Session 14 - What I Have. Aim of the session was to talk about the developmental continuum of
      the participant, to explore their awareness and acceptance of recreational thoughts while
      taking examples from their real-life scenarios. Therapy was terminated and closure was
      provided.

      Follow-up session. It took place three weeks after the termination session. In the follow-up
      session, the participants completed formal post-Intervention assessment of the Borderline
      Symptoms List (Bohus et al, 2007). Moreover, if required, further referrals and psychiatric
      consultations were made for the participant with their agreement.

      Statistical Analysis The pre- and post-intervention assessments of the treatment group and
      the control group for the Borderline Symptoms List (Bohus et al., 2007) was scored. The
      results were coded and exported to SPSS, version 22.0. The data was then analyzed with paired
      sample analysis to explore the possible significant differences between scores of BSL of
      treatment group as compared to control group.
    

Intervention name(s): Art based Augmented Reality
Intervention type(s): Behavioral
Intervention description(s): The participants will be provided 14 sessions management plan
Other intervention name(s): Psychotherapy
Allocation: Non-Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment