The Arts in Psychotherapy 41 (2014) 409412

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The Arts in Psychotherapy

Visuall gework r

Ephrat HSpitzer Dept. of

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Article history:Available onlin

Keywords:Work related sSUDSStress regulati

ing srworape, cn imaucedand trkshced fape

tran

2014 Elsevier Ltd. All rights reserved.

Introductio

This papshort termtion that wantidote to

Healthvisual imag& Volpone,related visureduce worhave showtent, are enimages dev2009; Phelan accessib2010). Retration and tsignicanceies focus on

CorresponE-mail add

1 Tel.: +972

http://dx.doi.o0197-4556/n

er suggests that it is a timely moment to search for aand self-initiated arts based technique of stress reduc-ill access health professionals creative recourses as anstress at work.care professionals are often exposed to disturbinges in their work (Laws, 2001; Rubino, Luksyte, Perry,2009) and thus using the arts to deal with stress

al images would seem to be an appropriate method tok stress related stress. To elaborate, previous studiesn that visual images, which contain emotional con-coded in memory more rapidly and intensely thanoid of emotional content (Bocanegra & Zeelenberg,ps, Ling, & Carrasco, 2006). Thus, visual images arele source for retrieval of experiences (Sarid & Huss,ieval of these images enables their continuous recre-hus re-interpretation by adjusting their meaning andthrough verbal and visual techniques. Numerous stud-the hermeneutic and semantic meaning that images

ding author. Tel.: +972 86428136.ress: ehuss@bgu.ac.il (E. Huss).86428136.

initiate (Huss, Sarid, &Cwikel, 2010; Kaye&Bleep, 1997;Malchiodi,2012; Huss & Sarid, 2012). This process of image transforma-tion includes observation of the content and composition of theimage and encouragement of alternative and varying interpreta-tions. This is in accordance with additional arts conceptualizations,such as the theory of art therapy, visual culture, and guidedimagery (Eisner, 1997; Harrington, 2004; Johnson, 1999; Shank,2005).

Health care professionals mental stress is documented as amajor issue for the individual practitioner and for the organi-zation as well as for the quality of care received by patients(Bourbonnais, Brisson, & Vzina, 2011; Shapiro, Astin, Bishop,& Cordova, 2005). Previous studies suggest that even the shortterm exposure to patients distress and pain can provoke occupa-tional stress related symptoms such as elevated blood pressure,anxiety and depressive symptoms, among health professionals(Figley, 2002; Rabin et al., 2011; Rubino et al., 2009). Over the long-term, such responses can cause disease of a physical, psychologicalor behavioral nature (Bourbonnais et al., 2011).

Reduction of health care professionals mental stress is gen-erally addressed by integrating occupational health and safety,health promotion, and psychosocial intervention (Hall, Doran,& Pink, 2008). Psychological interventions mainly consist ofoccasional educational programs (Krasner et al., 2009), andcognitivebehavioral interventions that focus on attenuating

rg/10.1016/j.aip.2014.07.0042014 Elsevier Ltd. All rights reserved.y transforming artwork and guided imaelated stress: A quantitative pilot study

uss , Orly Sarid1

Social Work, Ben-Gurion University of the Negev, P.O.B 653, Beer-Sheva 84105, Israel

e i n f o

e 23 July 2014

tress

on

a b s t r a c t

This paper explores ways of transformare exposed to stressful images in theiof compositional elements such as shativity and imagination to transform adiscomfort levels (SUDS) will be redsimilar elements of color, size shapesionals participated in a ve hours wocalculated and were found to be reducomparative level, the elements of shnot differ statistically signicantly.

The compositional elements used towork related stress.ry as a way to reduce

tress related visual images for health care professionals whok. Transformation of these images is conducted using changesolor, size and texture through harnessing the power of cre-ge that is drawn or imagined. We hypothesize that subjectiveby visually transforming their images. We also assume thatexture will be drawn and imagined. Thirty-six health profes-op that took place in two consecutive days. SUDS levels wereollowing image transformation in both art and imagery. On asize and color, were highly used in both techniques and did

sform images are discussed as a theoretical base for reducing

410 E. Huss, O. Sarid / The Arts in Psychotherapy 41 (2014) 409412

pathological symptoms (Sarid, Berger, Eckshtein, & Segal-Engelchin, 2012; Shapiro et al., 2005). The emerging eld of artsand health care as well as guided imagery may be helpful direc-tions, because they utilize recalled visual images and their creativetransforma2012; Sarid

Followinfocus on thelaborationcompositiobackground2006; Lang

Theprocful visual iimage andments. For euniting or dcess is conddisturbing ipared to thiits elementAccording tforming ofstates. Theprovide annot linked t1997; Rubinthis process

This papa more visuelements thments such(Huss & Saoccur in boexpect to image transwe assumedone on theworking wnique for rwar time (Hsionals comimage transand imagin

Understple can tranin choosingconceptuall

Thus, thof shape, sito in a drawmost effect

Methods

This is ahealth profrecruited thin Ben-GuriAttending tin return fopants receivif they arewwith the popants contin

Table 1A compositional elements scale.

Compositional elementsShape

eon ofion of

ure wprov

majbetw

alf ofand 1rotehysiand

ure

n arh of eoundts thr intportd norticiped imday

h wol disted itguidIn thf theits ofe parthe

rtabll eleangeinentio

res

mpooutlcom

rid (2in t

d accjectivent scale was used to measure the intensity of subjective

fort experienced by the participants. It is an 11-point scale10 reects the highest level of distress and 0 the lowest levelnce of distress. The SUDS rating scale was used to assess thef stress at the beginning and at the end of each intervention.

e of SUDS has been reported in numerous studies (Benjamintion (Huss et al., 2010; Kaye & Bleep, 1997; Malchiodi,et al., 2012).g on these ndings, this study hopes to deepen thee transformation of images rather than their verbal, as exemplied by our inborn visual ability to changen, by quickly separating a threatening element from its(Barrett, 2005; Haijiang, Saunders, Stone, & Backus,

& Bradley, 2010).ess of transforming an image includes recalling a stress-mage, reecting on the elements that comprise thisthen working on changing these compositional ele-xample, this process of change can include separating,ifferently organizing shapes and colors. In art, this pro-ucted using art materials and the visual elements of amage are thus transformed within the art work. Com-s, in guided imagery, a disturbing image is recalled ands are adjusted within the mind (Huss and Sarid, 2012).o guided imagery theory (Bandler, 1985) then, trans-images links to transforming of subjective emotionalabove described process of image transformation canalternative and more enabling emotional state that iso the original stress (Huss & Sarid, 2012; Kaye & Bleep,, 2001; Silver, 2005). The plastic arts help to concretize.er will explore the above described less semantic andal approach. The focus of our technique is to adjustat comprise the image. This includes compositional ele-as shape, size, color, texture and placement of objects

rid, 2010, 2012). The use of these basic elements canth an imagined and a concrete image. However, wend certain elements that will differentiate betweenformation on the paper and in the mind. For example,that addition and omission of objects is more easilypaper than in the mind. In a previous qualitative study,

ith visual images on the paper was an effective tech-educing occupational stress among social workers inuss et al., 2010). In the current study health profes-prise the target population in need and the method offormation is comparatively explored through drawinging.anding these differences can further elucidate howpeo-sform their stressful images and can be of practical helpthe most appropriate intervention. It also may help toy connect between art therapy and guided imagery.e rst of aim of this study is to compare how elementsze, color and texture are used in the mind as compareding. The second aim is to enquire which technique is

ive in reducing subjective work related stress.

n intervention evaluation study. Thirty-ve practicingessionals participated in the current study. They wererough offering a free voluntary enrichment workshopon University of the Negev, department of social work.wo freevehoursworkshopon imageswas conditionedr using the data in research. Upon their arrival partici-ed an explanation of the studys procedure and decidedilling to continue. Oral informed consentwas provided,ssibility of quitting the study at any stage. All partici-ued their participation throughout the study. A similar

SizeColorTexturAdditiOmiss

procedwas ap

Sample

Therangedthan hsingleand wwere phealth

Proced

Upowith 2backgrelemenanotheIt is imand diThe paor guidsecond

Bota visuadepictand inmind.level otive Unthis, thture orcomfositionahad chdeterminterve

Measu

A comentsand onand Saformedmarke

Subassessmdiscomwhereor abselevels oThe usobjectsobjects

as reported by Huss and colleagues (2010). The studyed by an ethics committee.

ority of the participants were women 84.7% (30), ageeen 3055 yearswith amean of 32 (SD=4) years.Morethe participants 58% (20) were married, 25.7% (9) were6.3% (6) were divorced. All the participants spoke, readuently in Hebrew. Thirty percent of the participantscians, 30% were nurses and 40% were social workers inmental health agencies.

rival to the workshop all participants were presentedducational preparatory lecture that introduced generalof occupational stress, distress eliciting images, and

at comprise an image. Similar procedure is reported inerventional study (Huss et al., 2010; Sarid et al., 2012).ant to note that the lecture was theoretical in naturet teach specic techniques for intervening in images.antswere then randomly assigned to either art therapyagery workshops in the rst day and switched in the

of the two days workshop.rkshops started with the participants asked to retrieveressing image from their work. In art therapy they thenvisually on a page (A-4 size) with soft pastel crayons,ed imagery, they recalled and held the image in theire next stage, the participants were asked to note their discomfort toward the stressful image using Subjec-Discomfort Scale (SUDS) level (Wolpe, 1991). Followingticipantswere prompted to change elements in the pic-ir mind as a method to create an image that felt moree. Participants were asked to ll in a scale of compo-ments (see Table 1) that noted the elements that theyd. Finally, the participants SUDS were re-measured tosubjective experience of discomfort in the end of then.

sitional elements scale based on the compositional ele-ined in diagnostic art therapy literature (Silver, 2005)parative compositional analysis as described by Huss012). The scale denes the elements that can be trans-

he participants images (see Table 1). Each element wasording to did or did not use.e Units of discomfort Scale (SUDS, Wolpe, 1991). A self-

E. Huss, O. Sarid / The Arts in Psychotherapy 41 (2014) 409412 411

Table 2Elements used within drawing versus imagery percentages (frequency), 2.

Compositional elements Drawingpercentages (n)

Imagerypercentages (n)

2 (df = 1)

Shape 71.4 (25) 82.4 (28) 0.85Size 71.4 (25) 71.4 (25) 0.15Color 91.4 (32) 71.4 (25) 0. 52Texture 40.0 (14) 40.0 (14) 0.28Addition of objects 40 (14) 14.3 (5) 8.61*

Omission of objects 28.6 (10) 14.3 (5) 7.56**

* p=0.03.** p=0.04.

et al., 2010; Lee & Drummond, 2008; Sharpley, Montgomery, &Scalzo, 1996)

Data analys

Descriptcompositiowas calculament in imthe individuculated andof each elem

SUDS mvention. Eff

Results

The rstelements win the drawthe elemenusage andabout 40%.cally signito note, thaobjects wein imagery (respectively

At the inment was ct-test (seefound in thbetween thhighermeain their draimaginationp=0.04, res

The secthe overallwithin guid

Table 3Average use of

Composition

ShapeSizeColorTextureAddition of oOmission of

* p=0.03.** p=0.04.

related stress. In drawing, the SUDS mean values taken before theintervention were 7.0 (SD=0.5). After transforming the picture, theSUDS mean values were reduced to 3.0 (SD=0.5). Effect size, calcu-lated using Cohen d, was large (0.97). In imagery, the SUDS meanvalues takeforming theto 4.0 (SD=(0.97). Fromsitional elemlevels by fo

Discussion

Our parimages wh

l elepos

g. Wer hsed lsformmmfor thge mnatucont(Banrminhe traer emd rath coabo

ss oftechwit

idate010;to heally

xpersky

m ouationand

us std in

Ullms simst anlor sod its& Brafactr deToseis

ive statistics including frequencies and percentages ofnal elements which were used in image transformationted. Statistical differences between the uses of each ele-agery versus drawing were analyzed using 2 tests. Atal level,mean values and standard deviationswere cal-paired t-testswere conducted to assess the average useent in imagery and drawing.

ean values were calculated before and after each inter-ect size was calculated using Cohen d.

aim of the study was to compare which compositionalere used when transforming an image in the mind anding. From Table 2 we can see that in both techniquests of shape, size and color had high frequency ofthe element of texture has a relatively low usage ofThe use of the above elements did not differ statisti-cantly between the two interventions. It is interestingt the elements of addition of objects and omission ofre used statistically signicantly more in drawing than2 =8.61 (df = 1), p=0.03, and2 =7.56 (df = 1), p=0.04,).dividual level theaverageuseof eachcompositional ele-ompared between drawing and imagery using pairedTable 3). No statistically signicant differences weree average use of shape, size, color and texturee two interventions. However, participants who hadn values of addition of objects and omission of objectswing had lower mean values of these elements in their(t-test = 3.27 (df = 1), p=0.03, and t-test = 2.03 (df = 1),

pectively).ond aim of this study aimed to compare betweeneffectiveness of transforming compositional elementsed imagery versus drawing in reducing subjectivework

elements: drawing versus imagery (means (SD), Student t-test).

sitionathe comdrawinto rathdecreaof tranas is conationan imaactivelack ofevokestransfotion. Ta calmat neeresearc

Thetiveneas thisdiatelyconsolSoto, 2vanceto verbthey eTulchin

Froimagincolor,previoinvolve2003;for thiquickeand coure an(Langto theorate o2008;al elements Drawing mean(SD)

Imagery mean(SD)

t-test (df = 1)

0.67 (0.47) 0.82 (0.38) 1.30.73 (0.44) 0.70 (0.46) 0.370.28 (0.45) 0.14 (0.35) 1.960.40 (0.49) 0.37 (0.45) 0.27

bjects 0.42 (0.49) 0.11 (0.32) 3.27*

objects 0.88 (0.32) 0.68 (0.47) 2.03**

ndings poments betwof objects wis that fromomit or addtransformaferences beease in whithe most conbefore the interventionwere8.0 (SD=0.5). After trans-image in themind the SUDSmean valueswere reduced0.5). Effect size, calculated using Cohen d, was largethese ndings we can see that transforming compo-ents within a drawing and in the mind reduced SUDS

ur units.

ticipants were asked to recall two distressing visualich relate to their work setting. They altered compo-ments of one distressing image through imagery anditional elements of another distressing image throughe found that while the stressful images were linkedigh SUDS levels, transformed images were linked toevels of SUDS. These ndings point to the effectivenessing an image of stress without extensive verbalization

on in many therapeutic interventions. A possible expla-e reductionof subjectivedistress through transformingay be due to the sense of control achieved through there of managing a distressing image as compared to therol thatworking in an environment of continuous stressdura, 1991). The sense of control and resourcefulness ing the image does not necessarily need verbal elabora-nsformed image may constitute a concrete prompt forotional state that can be self-activated and accessed

her than ruminating on the negative image. Furtheruld help to elucidate these proposed processes.ve ideas may have clinical implication as to the effec-altering stress related images in a work related setting,nique can be employed in the short term, even imme-hin a stressful situation, when the image is still notd within the memory (Nelson & Fivush, 2004; Pan &Huss & Sarid, 2012). This may be of particular rele-alth professionals who do not have time or resourceselaborate on the continuous high impact stress that

ience within their work milieu (Krasner et al., 2009;& Varavikova, 2010; Turner, 1996).r ndings we can see that in the drawing and in thethe compositional elements such as shape, size,

texture were transformed. This nding corroboratesudies showing that basic compositional elements arethe alteration of distressful images (Torralba & Oliva,an, Vidal-Naquet, & Sali, 2002). A possible explanationilarity is that an intimidating situation demands thed most immediate reorganization through size, shapeas to distinguish between a potentially threatening g-

background regardless of the form that the image takesdley, 2010; Ullman et al., 2002). The literature pointsthat when high distress is predominant a more elab-tailed perception may not be accessible (OCallaghan,y, Mathison, & Michelli, 2005). At the same time ourint to some differences in the use of compositional ele-een drawing and imagining. Addition and rubbing outere more prevalent in drawing. A possible explanationa practical point of view drawing enables to concretelyobjects and thus creates a larger repertoire of possible

tions of a stress related image. These compositional dif-tween guided images and drawn images, point to thech health professionals can be taught to actively utilizemmon and simple methods of image transformation,

412 E. Huss, O. Sarid / The Arts in Psychotherapy 41 (2014) 409412

using shape, color and size, to transform images and to self-regulatetheir stress. The differences between the two methods point to theusefulness of a drawn image that enables more manipulations. Onthe other hand, art demands colors and paper and overcoming offear of drawing, while images in the mind are always accessibleand less threatening. Another point may be that beyond the sim-ple methods of image transformation, more complex uses (such asshading, texture, perspective, etc.) can be taught and generalized toenable a more nuanced method of stress reduction. Future studiescould develop these ideas.

The preliminary nature of this study is its limitation, as it meas-ures reduction in perceived stress on a general level. The studydemands more replication and evaluation. At the same time, thendings point to interesting directions concerning the differencebetween real versus imagined images, and concerning greaterunderstanding how people can harness visual compositional ele-ments, rather than verbal elaboration to stress reduction. This, indifferent work settings can have direct implications for the well-being of professions that experience high levels of occupationalstress of a visual nature.

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Visually transforming artwork and guided imagery as a way to reduce work related stress: A quantitative pilot studyIntroductionMethodsSampleProcedureMeasures

Data analysisResultsDiscussionReferences