*The Current Study*

The conceptual framework used in this study was based on the Stress and Coping Model (SCM) [27] and on the "art as therapy" orientation, which highlights the healing qualitaties of art making [28–31].

The aims of the current study were (1) to examine whether significant changes occurred in distress levels among MHPs at the end of the intervention; (2) to explore the narratives of the three drawing (e.g., stress, resources, and integrated drawings) and their compositional characteristics; (3) to determine which compositional elements of the stressful image that were transformed within the 'integrated drawing' were associated with greater distress reduction; and (4) to determine which of the selected formats for the 'integrated drawing' (e.g., a new sheet of paper, 'stress drawing,' or 'resources drawing') were associated with greater distress reduction.

#### **2. Methods**

Three CB-ART workshops were implemented with MHPs in southern Israel during the 2014 Gaza conflict at the social work department in Ben-Gurion University of the Negev. MHPs were recruited through advertisements on the university website, emails sent after the war began to health and social service agencies in the community, and through a snowball sampling technique. All participants were employed in health or social services agencies and were both working and living in the war zone.

Before the workshop began, the authors described the objective and procedure of the study and emphasized that participation in the workshop did not require participation in the study. All MHPs who participated in the workshops chose to take part in the study. They were asked to note their level of distress at the beginning and end of the workshop. At the end of the workshop, they also were asked to note the compositional elements that they used in the 'stress drawing' and to describe the transformations that they had made in the compositional elements of the stressful image within the 'integrated drawing.' To enable pre–post comparisons on an individual level, MHPs were asked to provide the last four digits of their national ID number on both the questionnaire and the three drawings. They were told that this information was needed for statistical purposes and would not be used to identify them.

The research was approved by the departmental ethics committee at Ben-Gurion University of the Negev. All participants signed consent forms agreeing to have their drawings and questionnaire used in research.

#### *2.1. CB-Art Intervention Description*

The two-hour workshop started with a short introductory lecture on stress responses to disasters and the debilitating effect of a negative distressing image, symptom, or memory on negative mood states. We explained how drawings can be analyzed by both the narrative attached to them and their compositional elements, such as shape, size, colors, and placement of the images on the paper [32,33].

In the first phase of the intervention, participants were asked to draw their current emotions and thoughts relating to the war situation (referred to here as the *stress drawing*). They were then asked to write a short description of their artwork on the back of their drawing. Participants presented their drawings within the group setting, describing what they had drawn, and shared their narrative. The group then discussed the compositional characteristics of each drawing. The aim of this phase was to enable MHPs to identify the sources of their war-related stress as well as the compositional elements that characterized their stressful image.

After drawing about their current condition, participants were asked to draw a new picture that reflected on their personal and social resources that could enable them to better cope with stressful situations (referred to here as the *resources drawing*). Again, they were asked to write a short description of their artwork on the back of it. Drawings were shared within the group setting and their compositional elements noted. The aim of this phase was to enable MHPs to identify coping resources at their disposal as well as the compositional elements that characterized their resources drawing.

In the last phase of the intervention, participants were asked to draw a picture that integrated the stressful image and the resources drawing (referred to here as the *integrated drawing*). Participants had the option to draw a new picture or to add elements to either the stress drawing or the resources drawing. The integrated drawings were shared within the group setting and their compositional elements discussed and compared to those of the stress and resources drawing. The purpose of the integrated drawing was to enable participants to learn how to "build bridges" between their resources and their distress image, symptom, or memory. The drawings in all three phases described above were created on A-4 paper with oil pastels.

#### *2.2. Sample*

To ensure the homogeneity of the sample, participants in the three workshops were compared by their demographic variables. Chi-square tests revealed no significant differences in gender, marital status, country of birth, education level, religion, degree of religious observance, or perceived financial situation. For this reason, we pooled the three groups into one. Table 1 presents the demographic characteristics of the pooled sample. The average age was 37 years, and most were female (86%) and Israeli born (82% ), were married or lived with a partner (63%), and had children (52%). Almost all participants were Jewish (96%), and most defined themselves as secular (72%). About half of the participants (52% ) viewed their financial situation as fair.

Participants included: 45 (88.2%) social workers, 5 (9.8%) psychologists and one psychiatrist (1.9%). All participants drew the three drawings included in the CB-ART intervention described above. With regard to the selected format for the integrated drawing, 21 participants chose to draw a new picture; 3 participants chose to add elements to the stress drawing; and 27 participants chose to add elements to the resources drawing.


**Table 1.** Demographic characteristics of study participants (*N* = 51).


**Table 1.** *Cont*.
