*3.3. SUDS-Di*ff*erence Scores by the Selected Format of the Integrated Drawing and Compositional Transformations*

In the current study, we also sought to determine which of selected formats and the transformed compositional elements of the stressful image within the integrated drawing are associated with greater SUDS reduction. Table 4 presents the SUDS-difference scores by the selected format for the integrated drawing and transformed compositional elements. As shown in Table 4, we found statistically significant differences with regard to size transformation within the integrated drawing and to the selected format of the integrated drawing. Participants who reduced the initial size of the stressful image within the integrated drawing had a greater SUDS-difference score (−1.87 [1.22]) than those who maintained the initial size of the stressful image (−1.13 [1.48]). Additionally, participants who drew the integrated drawing on either the resources drawing or on a new sheet of paper had a higher SUDS-difference score (−1.73 [0.15]) than participants who drew the integrated drawing on the stress drawing (−0.92 [0.86]).


**Table 4.** SUDS-difference scores by the selected format of the integrated drawing and compositional transformations: stress-drawing versus integrated drawing (*N* = 51).

\* *p* < 0.05.

#### **4. Discussion**

This study focused on a CB-ART intervention implemented with MHPs who shared war-related experiences and distress with their clients during the 2014 Gaza conflict. Results indicate that MHPs' levels of distress significantly decreased after the intervention, suggesting its efficacy. Further evidence of the efficacy of a CB-ART intervention in reducing disaster-related distress is derived from Segal-Engelchin et al.'s [35] study of Nepalese students living in Israel during the 2015 Nepal earthquake, who were indirectly exposed to the disaster that struck their country. A plausible explanation for the decline in MHPs' levels of distress at the completion of the intervention may be that drawing and identifying the war-related stressors as well as personal and social resources increased their sense of control in the war situation. Transforming the compositional elements of the stress drawing within the integrated drawing may have also enhanced MHPs' sense of control. Previous studies on art-based interventions suggest that the active management of a stressful image leads to an enhanced sense of control [25,26]. Additionally, it may be that modifying the compositional elements of the stress image within the integrated drawing allowed the MHPs to modify its emotional content into a more enabling meaning [32]. This possibility is reflected in the explanatory narrative ascribed by the MHP in Example 1 to her integrative drawing, in which the image of war-related stress was modified, indicating that the drawing mirrored the lessened feelings of emotional turmoil. Another possible explanation lies in the integrated drawing, in which the stressful image and the coping resources were simultaneously displayed. This depiction may have enabled the MHPs to view war-related stressors and coping resources at their disposal as two interrelated entities of their war experience. This, in turn, may have led them to perceive the war-related stressors as less threatening and more manageable. The use of arts as a tool that enhances manageability has been reported by Huss and Samson [37] in their study of a group of recovering cancer patients.

One aim of the study was to explore participants' narratives of the three drawings (e.g., stress, resources, and integrated drawings) and their compositional characteristics. Their narratives of the stressful image, as demonstrated in the above two examples, reflected their emotional turmoil, feelings of extreme distress, and concern about the safety of their loved ones and their clients. A further prominent theme in their narratives, which was also evident in the narratives of the other participants, was the emotional burden that stemmed from assisting their clients while coping with their own anxieties and caring for their family members. These narratives corroborate findings of previous studies indicating high levels of anxiety and emotional distress among MHPs in shared trauma situations [6–9] as well as the blurring of boundaries between work and family loyalties [5,18,25].

Two major resources that enabled better coping with stressful situations emerged from the narratives of the resources drawing. One was the family and home environment, and the other was related to social-leisure activities, such as listening to music and going to the beach. Previous studies indeed indicate that family is an essential source of support for MHPs in shared war realities [5]. Their narratives of the integrated drawing reflect lessened feelings of emotional turmoil as well as a perceived ability to better cope with the shared war reality.

The different narratives ascribed to the three drawings are also expressed in the different compositional characteristics of these drawings. Our quantitative findings revealed substantial differences among the three drawings in the compositional elements, as illustrated in the two examples given. The stress drawings were generally characterized by a single, predominantly black, large–medium-sized object, placed at the center of the drawing, with no background. In contrast, both the resources and integrative drawings were typically characterized by the use of several mixed-sized objects and lighter optimistic colors, scattered all over the drawing. The use of single large objects and intense black lines to depict war-related stressors have been reported previously [25], and comparable compositional characteristics of stressful images also have been found in a study of children with cancer [38]. The use of the color black is associated with stress and depression in the diagnostic art therapy literature [39–42]. While diagnostic analyses of color is based on universal measures, other art therapy directions point to the cultural significance of specific colors [43]. On an Israeli cultural level, the color black is also associated with negative experiences such as mourning, a situation in which people wear black clothes, and negative moods, which are described as "black".

An additional objective of the current study was to determine which of the transformed compositional elements of the stressful image within the integrated drawing was associated with greater SUDS score reduction. The results indicate that size transformation of the stressful image within the integrated drawing was the only transformed compositional element significantly associated with greater SUDS score reduction. This finding can be interpreted in two ways. MHPs who experienced greater distress reduction after identification of their war-related stressors and coping resources in the framework of the first two phases of the intervention tended to decrease the size of the stressful image within the integrative drawings. It could also be, however, that the greater distress reduction resulted from the size transformation of the stressful image rather than being the cause of the size transformation. It is possible that the size modification of the stressful image and its proportion relative to the objects symbolizing various coping resources enabled MHPs to feel an increased sense of control and competence, resulting in their greater SUDS score reduction. Further research is needed to determine the direction of causality between SUDS score reduction and size transformation of the stressful image.

Of interest, we found an association of selecting the resources drawing or a new sheet of paper for the integrated drawing with significantly greater SUDS score reduction. This finding suggests that in the process of transforming the stressful image, attention should also be given to the context where the stressful image is placed, in addition to the transformed compositional elements. The placement of the stressful image in a new context that encompasses MHPs' personal and social resources may lessen its threatening features, resulting in an enhanced sense of agency. It is also possible that the selection of a new context for the stressful image is an indication of reduced levels of distress. Further investigation may shed light on the causal relationship between the format selected for the integrative drawing and SUDS score reduction.

Several limitations of the current study should be acknowledged. The first is related to the cross-sectional design that does not allow for determination of the long-term impact of the CB-ART intervention. Follow-up studies are needed to investigate the long-term effectiveness of this intervention. The second limitation is related to the lack of a control group. This limitation is inherent to this type of quick-response intervention in times of disaster, where the evaluative research must be conducted rapidly and with regard for the well-being of all the people involved. A third limitation is the relatively small sample size, which precluded rigorous statistical tests to examine the differences among the various compositional elements of the three drawings. Future studies using larger samples may enrich our understanding of the role that compositional elements play in shaping participants' perception of stressful images, resource images, and integrated images. Further research is also needed to examine the contribution of the different components of the intervention (e.g., each of the three different drawings and the group setting) to stress reduction.

#### **5. Conclusions**

The current study marks the first attempt to examine the effectiveness of a CB-ART intervention implemented with MHPs under actual wartime conditions. In this study, the concepts presented in the Stress and Coping Model [SCM, 27] served as a framework to examine the ways that a CB-ART intervention, based on drawing, can help MHPs to express their stress as well as to acknoewledge their coping strategies, and integrate these two elements in the context of war. Within the drawing process, the identification of the compositional elements of the three drawings and the creation of manipulations within the integrated drawing enabled participants to actively appraise which compositional transformations decreased their distress and enhanced their adjustment and coping [44,45]. Our findings suggest that participants' conscious cognitive processing of the compositional transformations altered their interpretation of the stressful images, which in turn decreased their distress levels.

The study findings make an initial contribution to understanding the ways that stressful images and resource images are integrated on the paper using compositional transformations, as well as the ways in which this process assists in reducing MHP distress levels when they are operating in a shared war reality. The findings add to the art therapy literature on positive psychology and on the healing qualitaties of art making as in " art as therapy" orientations [28–31].

On a practical level, this study offers an easily implemented tool for distress reduction among MHPs in shared trauma situations. The CB-ART intervention provided MHPs an opportunity to depict their war-related stressors as well as their coping resources on the page and to discuss both images and access new thoughts and understanding regarding ways to manage stress in extremely stressful situations. As such, the CB-ART intervention not only may have enriched their coping resources but also have become a coping resource in itself, which they can use in traumatic situations in the future as a self-care strategy.

**Author Contributions:** Conceptualization, D.S.-E. and O.S.; Formal analysis, N.A. and O.S.; Investigation, D.S.-E., E.H. and O.S.; Methodology, D.S.-E. and O.S.; Writing—original draft, D.S.-E.; Writing—review & editing, O.S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*
