*2.3. Measures*

#### 2.3.1. Distress Level

Participant distress level was measured using the Subjective Units of Distress Scale (SUDS) [34]. Respondents were asked to assess their level of distress on an 11-point scale ranging from 0 (absence of distress) to 10 (extreme level of distress). The SUDS has been used in previous studies that evaluated the efficacy of art-based interventions in reducing stress [26,35].

#### 2.3.2. Compositional Elements

We used a compositional element scale, based on the compositional analysis of image transformation [26,36], to examine the compositional elements of the stressful image and its transformed elements within the integrated drawing. This scale covered five compositional elements: object, color, placement, size, and background. Participants were asked to fill in this scale for both the stress drawing and the integrative drawing.

#### 2.3.3. Statistical Analyses

To investigate whether significant changes occurred in participant distress levels following the intervention, in a first step, we employed a paired sample *t*-test to compare pre–post SUDS scores. In a second step, we used descriptive statistics to analyze the compositional elements of the three drawings. Statistical tests for examining differences in these characteristics were not carried out because of the constraint of small cells. In a third step, we used independent sample *t*-tests to examine whether transformations in the compositional elements of the stress drawing within the integrated drawing were related to a greater reduction in SUDS scores. For this purpose, we computed a variable based on the difference between the SUDS score at (t2) and the SUDS score at (t1) (referred to here as *SUDS-di*ff*erence score*). We then examined three types of transformations within the integrated drawing: (1) object transformation (e.g., addition versus change in or omission of objects), (2) color transformation (e.g., number and types of colors used), and (3) size transformation (e.g., reduction versus non-reduction of the stressful image size).

An independent samples *t*-test was also used to examine whether the selected format for the integrated drawing (e.g., a new sheet of paper, addition of elements to the stress drawing, or addition of elements to the resources drawing) was related to a greater reduction in the SUDs scores. Because only three participants drew the integrated drawing on the resources drawing, we created two categories: the first comprised those who added elements from the resources drawing to the stress drawing, whereas the second comprised participants who either drew a new picture or added elements from the stress drawing to their resources drawing.

#### **3. Results**

#### *3.1. Pre–Post SUDS Scores*

Table 2 presents the results of the paired sample *t*-tests conducted to examine differences in MHP SUDS scores between the beginning and end of the intervention. As Table 2 shows, the scores significantly decreased after the intervention, suggesting efficacy of the process. The mean difference was 1.51 (on a 0–10 scale).


**Table 2.** Pre–post Subjective Units of Distress Scale (SUDs) scores (*N* = 51).

#### *3.2. Compositional Characteristics of the Mhps' Drawings and Their Explanatory Narratives*

The second aim of the study was to explore the compositional characteristics of the three drawings and their explanatory narratives. Here we present the descriptive statistics of the compositional characteristics of the three drawings, followed by two illustrative examples of drawings and explanatory narratives.

As Table 3 shows, there were substantial differences among the three drawings in the compositional elements. Almost half of the stress drawings (49%) had no background, compared to only a little more than a third of the resources drawings (37.3%), and less than a third of the integrative drawings (29.4%). A quarter of the stress drawings (25.5%) were composed of a single object, and in 37.3% of the drawings, the stressful image was placed at the center. In contrast, less than 10% of the resources drawings (7.8%) and of the integrative drawings (9.8%) were composed of a single object, and a considerably smaller percentage of these drawings had their image placed at the center of the drawing (19.6% and 13.7%, respectively). More than half of the stress drawings (54.9%) and of the resources drawings (54.9%) consisted of medium and large objects, compared to 45.1% of the integrated drawings. Additionally, in almost half of the stressed drawings (47.1%), black emerged as the dominant or only color, compared to only 3.9% of the resources drawings and 21.6% of the integrated drawings. A similar pattern was observed with regard to the dominant use of grey within the stress drawings (11.8%), compared to its dominant use within the resources drawings (2.0%) and the integrated drawings (5.9%). In contrast, in about a third of the resources drawings and the integrated drawings, green emerged as the dominant or only color, compared to only 7.8% of the stress drawings.

**Table 3.** Descriptive statistics of the compositional characteristics of the three drawings (*N* = 51).



**Table 3.** *Cont*.
