**1. Introduction**

Since the onset of the Al-Aqsa Intifida in September of 2000, Israeli society has been witnessing continual terrorist attacks by Hamas and other terrorist organisations, including suicide bombings, drive-by shootings, knife and gun attacks, and missile attacks in urban settings launched from the Gaza strip. Hamas's ongoing threat against Israeli civilians has led to several military operations. The current study was conducted during Operation "Protective Edge", also known as the 2014 Gaza conflict. This operation was launched in the summer of 2014 in response to the substantial increase in Hamas's rocket attacks against Israeli communities, firing on an almost daily basis [1].

During Operation "Protective Edge", which lasted 50 days, more than 4500 rockets were launched towards Israel from Gaza. This operation and the period immediately preceding it represented an intense period of rocket and mortar fire against Israel's civilian population. Although the range of these rockets covered more than 70% of Israel's civilian population, those residing in communities near the Gaza Strip were most affected, having only 15 seconds to seek shelter. During this time, six civilians and 67 soldiers in Israel were killed, more than 1600 civilians were harmed, and an estimated 10,000 civilians evacuated their homes. In the Gaza Strip, approximately 2,125 Palestinians were killed [1].

Mental health professionals (MHPs) are among the first responders to address the needs of traumatized people following exposure to large-scale disasters, including terrorist attacks and wars. In the southern region of Israel, which has been subject to missile attacks from Gaza since 2001, MHPs encounter a double exposure to war-related trauma as community members and as professionals providing service to terror victims [2]. This situation in which MHPs are coping with the same traumatic event as their clients is referred to as "shared trauma," "shared tragedy," or "shared traumatic reality" [3–5]. Shared traumatic situations typically occur in communal disasters, such as natural disasters and war [6]. MHPs working in shared traumatic situations face multiple levels of vulnerability to traumatization, including direct, secondary, and vicarious traumatization [3].

The negative consequences of shared reality situations have been well documented. These consequences may include emotional distress during a traumatic event [6], as well as immediately after a traumatic event and up to a year later [5]. Cohen et al. [7], who interviewed therapists working with traumatized children following the shared traumatic reality of the Second Lebanon War, found high levels of anxiety, stress, and symptoms of posttraumatic stress disorder (PTSD) among the therapists. Similar findings emerged from Finklestein et al.'s [8] study of MHPs working in areas affected by repeated rocket attacks from the Gaza Strip, indicating that MHPs were at risk for both PTSD and vicarious trauma (VT) symptoms. Those who lived in the more affected area were at even greater risk for developing PTSD and VT symptoms. Additional studies have shown similar associations among level of exposure to terror attacks, PTSD symptoms, and emotional distress [6,9], providing further support for an incremental dose effect [6]. However, other studies have not found an association between exposure levels and emotional distress [10,11]. Increased levels of PTSD symptoms also have been reported among physicians and nurses exposed to a shared war-related reality in Israel [10,12,13] and in Gaza [14,15].

Work under shared reality conditions exposes MHPs to the blurring of boundaries between professional and personal lives [4,16,17], including boundaries between work and family loyalties [5,18]. Research also points to the blurring of boundaries between MHPs and their clients [5], manifested in their difficulty separating their personal experience from that of their clients [19].

Several studies on the effects of working in a shared war reality have reported a decrease in perceived professional competence among MHPs [5] and a sense of being deskilled [3]. However, other studies reveal a strong perception of professional competence [19] and high levels of professional confidence [9] among these MHPs.

Work in a shared traumatic reality also has been associated with positive consequences. These consequences may include a sense of growth, both personal and professional [4,10,16,19], and a sense of resilience [19]. Post-traumatic growth also has been reported among nurses working in a shared war–related reality in Israel [10] and in Gaza [15]. Positive consequences also can include heightened intimacy in the therapeutic relationship [4,20], a strong therapeutic alliance [19], a high level of work satisfaction, and a sense of agency and helpfulness [7].

The overall picture that emerges from studies of MHPs exposed to a shared traumatic reality stresses the importance of interventions designed to alleviate their emotional distress, particularly among those operating in areas highly exposed to armed conflicts and terror attacks. Interventions for MHPs in traumatic events mainly consist of group support [21,22], individual or group supervision [7], and debriefing sessions [7,9]. Research findings, however, have called into question the effectiveness of debriefing methods in alleviating symptoms of stress among MHPs and disaster workers [9,23]. One possible explanation for the ineffectiveness of debriefing methods is that MHPs view participation and sharing as integral to the organizational culture of mental health services, rather than as a unique intervention tailored to alleviate their war-related stress [9]. Another plausible explanation is that emotional turmoil and thoughts related to traumatic experiences do not lend themselves to easy verbalization [24]. The inadequacy of conventional verbal methods in the context of disasters points to the need to search for alternative methods of self-care for MHPs in shared war situations. To address this need, Huss, Sarid, and Cwikel [25] developed an art-based intervention model for stress reduction and self-care for social workers operating in a war zone during the Iron Cast Operation (2008). They based this intervention model on the use of a single drawing in a single group session. In the first stage of the intervention, social workers were asked to draw one image of their war experience as social workers. They were then instructed to identify the sources of their stress and their stress reactions within the artwork and to change their artwork by adding sources of coping and resilience. Allowing the social workers to change their artwork helped them to gain a sense of control over diffuse sources of anxiety. Huss and Sarid [26] have found that transformation of stressful visual images through drawing and in the imagination is linked to decreased levels of work-related stress among health care professionals. These findings demonstrate the efficacy of transforming a stressful image without extensive verbalization for stress reduction.

This article focuses on a CB-ART (cognitive behavioral and art-based) intervention for distress reduction that was developed based on these earlier findings. This intervention was implemented with MHPs who shared war-related experiences and distress with their clients during Operation "Protective Edge".
