The Arts in Psychotherapy 41 (2014) 409412

Contents lists available at ScienceDirect

The Arts in Psychotherapy

Visually transforming artwork and guided imagery as a way to reduce

work related stress: A quantitative pilot study
Ephrat Huss , Orly Sarid 1
Spitzer Dept. of Social Work, Ben-Gurion University of the Negev, P.O.B 653, Beer-Sheva 84105, Israel

a r t i c l e

i n f o

Article history:
Available online 23 July 2014
Keywords:
Work related stress
SUDS
Stress regulation

a b s t r a c t
This paper explores ways of transforming stress related visual images for health care professionals who
are exposed to stressful images in their work. Transformation of these images is conducted using changes
of compositional elements such as shape, color, size and texture through harnessing the power of creativity and imagination to transform an image that is drawn or imagined. We hypothesize that subjective
discomfort levels (SUDS) will be reduced by visually transforming their images. We also assume that
similar elements of color, size shape and texture will be drawn and imagined. Thirty-six health professionals participated in a ve hours workshop that took place in two consecutive days. SUDS levels were
calculated and were found to be reduced following image transformation in both art and imagery. On a
comparative level, the elements of shape size and color, were highly used in both techniques and did
not differ statistically signicantly.
The compositional elements used to transform images are discussed as a theoretical base for reducing
work related stress.
2014 Elsevier Ltd. All rights reserved.

Introduction
This paper suggests that it is a timely moment to search for a
short term and self-initiated arts based technique of stress reduction that will access health professionals creative recourses as an
antidote to stress at work.
Health care professionals are often exposed to disturbing
visual images in their work (Laws, 2001; Rubino, Luksyte, Perry,
& Volpone, 2009) and thus using the arts to deal with stress
related visual images would seem to be an appropriate method to
reduce work stress related stress. To elaborate, previous studies
have shown that visual images, which contain emotional content, are encoded in memory more rapidly and intensely than
images devoid of emotional content (Bocanegra & Zeelenberg,
2009; Phelps, Ling, & Carrasco, 2006). Thus, visual images are
an accessible source for retrieval of experiences (Sarid & Huss,
2010). Retrieval of these images enables their continuous recreation and thus re-interpretation by adjusting their meaning and
signicance through verbal and visual techniques. Numerous studies focus on the hermeneutic and semantic meaning that images

Corresponding author. Tel.: +972 86428136.

E-mail address: ehuss@bgu.ac.il (E. Huss).
1
Tel.: +972 86428136.
http://dx.doi.org/10.1016/j.aip.2014.07.004
0197-4556/ 2014 Elsevier Ltd. All rights reserved.

initiate (Huss, Sarid, & Cwikel, 2010; Kaye & Bleep, 1997; Malchiodi,
2012; Huss & Sarid, 2012). This process of image transformation includes observation of the content and composition of the
image and encouragement of alternative and varying interpretations. This is in accordance with additional arts conceptualizations,
such as the theory of art therapy, visual culture, and guided
imagery (Eisner, 1997; Harrington, 2004; Johnson, 1999; Shank,
2005).
Health care professionals mental stress is documented as a
major issue for the individual practitioner and for the organization 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 short
term exposure to patients distress and pain can provoke occupational 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 longterm, such responses can cause disease of a physical, psychological
or behavioral nature (Bourbonnais et al., 2011).
Reduction of health care professionals mental stress is generally addressed by integrating occupational health and safety,
health promotion, and psychosocial intervention (Hall, Doran,
& Pink, 2008). Psychological interventions mainly consist of
occasional educational programs (Krasner et al., 2009), and
cognitivebehavioral interventions that focus on attenuating

410

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

pathological symptoms (Sarid, Berger, Eckshtein, & SegalEngelchin, 2012; Shapiro et al., 2005). The emerging eld of arts
and health care as well as guided imagery may be helpful directions, because they utilize recalled visual images and their creative
transformation (Huss et al., 2010; Kaye & Bleep, 1997; Malchiodi,
2012; Sarid et al., 2012).
Following on these ndings, this study hopes to deepen the
focus on the transformation of images rather than their verbal
elaboration, as exemplied by our inborn visual ability to change
composition, by quickly separating a threatening element from its
background (Barrett, 2005; Haijiang, Saunders, Stone, & Backus,
2006; Lang & Bradley, 2010).
The process of transforming an image includes recalling a stressful visual image, reecting on the elements that comprise this
image and then working on changing these compositional elements. For example, this process of change can include separating,
uniting or differently organizing shapes and colors. In art, this process is conducted using art materials and the visual elements of a
disturbing image are thus transformed within the art work. Compared to this, in guided imagery, a disturbing image is recalled and
its elements are adjusted within the mind (Huss and Sarid, 2012).
According to guided imagery theory (Bandler, 1985) then, transforming of images links to transforming of subjective emotional
states. The above described process of image transformation can
provide an alternative and more enabling emotional state that is
not linked to the original stress (Huss & Sarid, 2012; Kaye & Bleep,
1997; Rubin, 2001; Silver, 2005). The plastic arts help to concretize
this process.
This paper will explore the above described less semantic and
a more visual approach. The focus of our technique is to adjust
elements that comprise the image. This includes compositional elements such as shape, size, color, texture and placement of objects
(Huss & Sarid, 2010, 2012). The use of these basic elements can
occur in both an imagined and a concrete image. However, we
expect to nd certain elements that will differentiate between
image transformation on the paper and in the mind. For example,
we assume that addition and omission of objects is more easily
done on the paper than in the mind. In a previous qualitative study,
working with visual images on the paper was an effective technique for reducing occupational stress among social workers in
war time (Huss et al., 2010). In the current study health professionals comprise the target population in need and the method of
image transformation is comparatively explored through drawing
and imagining.
Understanding these differences can further elucidate how people can transform their stressful images and can be of practical help
in choosing the most appropriate intervention. It also may help to
conceptually connect between art therapy and guided imagery.
Thus, the rst of aim of this study is to compare how elements
of shape, size, color and texture are used in the mind as compared
to in a drawing. The second aim is to enquire which technique is
most effective in reducing subjective work related stress.

Methods
This is an intervention evaluation study. Thirty-ve practicing
health professionals participated in the current study. They were
recruited through offering a free voluntary enrichment workshop
in Ben-Gurion University of the Negev, department of social work.
Attending two free ve hours workshop on images was conditioned
in return for using the data in research. Upon their arrival participants received an explanation of the studys procedure and decided
if they are willing to continue. Oral informed consent was provided,
with the possibility of quitting the study at any stage. All participants continued their participation throughout the study. A similar

Table 1
A compositional elements scale.
Compositional elements
Shape
Size
Color
Texture
Addition of objects
Omission of objects

procedure was reported by Huss and colleagues (2010). The study

was approved by an ethics committee.
Sample
The majority of the participants were women 84.7% (30), age
ranged between 3055 years with a mean of 32 (SD = 4) years. More
than half of the participants 58% (20) were married, 25.7% (9) were
single and 16.3% (6) were divorced. All the participants spoke, read
and wrote uently in Hebrew. Thirty percent of the participants
were physicians, 30% were nurses and 40% were social workers in
health and mental health agencies.
Procedure
Upon arrival to the workshop all participants were presented
with 2 h of educational preparatory lecture that introduced general
background of occupational stress, distress eliciting images, and
elements that comprise an image. Similar procedure is reported in
another interventional study (Huss et al., 2010; Sarid et al., 2012).
It is important to note that the lecture was theoretical in nature
and did not teach specic techniques for intervening in images.
The participants were then randomly assigned to either art therapy
or guided imagery workshops in the rst day and switched in the
second day of the two days workshop.
Both workshops started with the participants asked to retrieve
a visual distressing image from their work. In art therapy they then
depicted it visually on a page (A-4 size) with soft pastel crayons,
and in guided imagery, they recalled and held the image in their
mind. In the next stage, the participants were asked to note the
level of their discomfort toward the stressful image using Subjective Units of Discomfort Scale (SUDS) level (Wolpe, 1991). Following
this, the participants were prompted to change elements in the picture or their mind as a method to create an image that felt more
comfortable. Participants were asked to ll in a scale of compositional elements (see Table 1) that noted the elements that they
had changed. Finally, the participants SUDS were re-measured to
determine subjective experience of discomfort in the end of the
intervention.
Measures
A compositional elements scale based on the compositional elements outlined in diagnostic art therapy literature (Silver, 2005)
and on comparative compositional analysis as described by Huss
and Sarid (2012). The scale denes the elements that can be transformed in the participants images (see Table 1). Each element was
marked according to did or did not use.
Subjective Units of discomfort Scale (SUDS, Wolpe, 1991). A selfassessment scale was used to measure the intensity of subjective
discomfort experienced by the participants. It is an 11-point scale
where 10 reects the highest level of distress and 0 the lowest level
or absence of distress. The SUDS rating scale was used to assess the
levels of stress at the beginning and at the end of each intervention.
The use of SUDS has been reported in numerous studies (Benjamin

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

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

Drawing
percentages (n)

Imagery
percentages (n)

2 (df = 1)

Shape
Size
Color
Texture
Addition of objects
Omission of objects

71.4 (25)
71.4 (25)
91.4 (32)
40.0 (14)
40 (14)
28.6 (10)

82.4 (28)
71.4 (25)
71.4 (25)
40.0 (14)
14.3 (5)
14.3 (5)

0.85
0.15
0. 52
0.28
8.61*
7.56**

*
**

p = 0.03.
p = 0.04.

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

Scalzo, 1996)
Data analysis
Descriptive statistics including frequencies and percentages of
compositional elements which were used in image transformation
was calculated. Statistical differences between the uses of each element in imagery versus drawing were analyzed using 2 tests. At
the individual level, mean values and standard deviations were calculated and paired t-tests were conducted to assess the average use
of each element in imagery and drawing.
SUDS mean values were calculated before and after each intervention. Effect size was calculated using Cohen d.
Results
The rst aim of the study was to compare which compositional
elements were used when transforming an image in the mind and
in the drawing. From Table 2 we can see that in both techniques
the elements of shape, size and color had high frequency of
usage and the element of texture has a relatively low usage of
about 40%. The use of the above elements did not differ statistically signicantly between the two interventions. It is interesting
to note, that the elements of addition of objects and omission of
objects were used statistically signicantly more in drawing than
in imagery (2 = 8.61 (df = 1), p = 0.03, and 2 = 7.56 (df = 1), p = 0.04,
respectively).
At the individual level the average use of each compositional element was compared between drawing and imagery using paired
t-test (see Table 3). No statistically signicant differences were
found in the average use of shape, size, color and texture
between the two interventions. However, participants who had
higher mean values of addition of objects and omission of objects
in their drawing had lower mean values of these elements in their
imagination (t-test = 3.27 (df = 1), p = 0.03, and t-test = 2.03 (df = 1),
p = 0.04, respectively).
The second aim of this study aimed to compare between
the overall effectiveness of transforming compositional elements
within guided imagery versus drawing in reducing subjective work
Table 3
Average use of elements: drawing versus imagery (means (SD), Student t-test).
Compositional elements

Drawing mean
(SD)

Imagery mean
(SD)

t-test (df = 1)

Shape
Size
Color
Texture
Addition of objects
Omission of objects

0.67 (0.47)
0.73 (0.44)
0.28 (0.45)
0.40 (0.49)
0.42 (0.49)
0.88 (0.32)

0.82 (0.38)
0.70 (0.46)
0.14 (0.35)
0.37 (0.45)
0.11 (0.32)
0.68 (0.47)

1.3
0.37
1.96
0.27
3.27*
2.03**

*
**

p = 0.03.
p = 0.04.

411

related stress. In drawing, the SUDS mean values taken before the
intervention were 7.0 (SD = 0.5). After transforming the picture, the
SUDS mean values were reduced to 3.0 (SD = 0.5). Effect size, calculated using Cohen d, was large (0.97). In imagery, the SUDS mean
values taken before the intervention were 8.0 (SD = 0.5). After transforming the image in the mind the SUDS mean values were reduced
to 4.0 (SD = 0.5). Effect size, calculated using Cohen d, was large
(0.97). From these ndings we can see that transforming compositional elements within a drawing and in the mind reduced SUDS
levels by four units.

Discussion
Our participants were asked to recall two distressing visual
images which relate to their work setting. They altered compositional elements of one distressing image through imagery and
the compositional elements of another distressing image through
drawing. We found that while the stressful images were linked
to rather high SUDS levels, transformed images were linked to
decreased levels of SUDS. These ndings point to the effectiveness
of transforming an image of stress without extensive verbalization
as is common in many therapeutic interventions. A possible explanation for the reduction of subjective distress through transforming
an image may be due to the sense of control achieved through the
active nature of managing a distressing image as compared to the
lack of control that working in an environment of continuous stress
evokes (Bandura, 1991). The sense of control and resourcefulness in
transforming the image does not necessarily need verbal elaboration. The transformed image may constitute a concrete prompt for
a calmer emotional state that can be self-activated and accessed
at need rather than ruminating on the negative image. Further
research could help to elucidate these proposed processes.
The above ideas may have clinical implication as to the effectiveness of altering stress related images in a work related setting,
as this technique can be employed in the short term, even immediately within a stressful situation, when the image is still not
consolidated within the memory (Nelson & Fivush, 2004; Pan &
Soto, 2010; Huss & Sarid, 2012). This may be of particular relevance to health professionals who do not have time or resources
to verbally elaborate on the continuous high impact stress that
they experience within their work milieu (Krasner et al., 2009;
Tulchinsky & Varavikova, 2010; Turner, 1996).
From our ndings we can see that in the drawing and in the
imagination the compositional elements such as shape, size,
color, and texture were transformed. This nding corroborates
previous studies showing that basic compositional elements are
involved in the alteration of distressful images (Torralba & Oliva,
2003; Ullman, Vidal-Naquet, & Sali, 2002). A possible explanation
for this similarity is that an intimidating situation demands the
quickest and most immediate reorganization through size, shape
and color so as to distinguish between a potentially threatening gure and its background regardless of the form that the image takes
(Lang & Bradley, 2010; Ullman et al., 2002). The literature points
to the fact that when high distress is predominant a more elaborate or detailed perception may not be accessible (OCallaghan,
2008; Tosey, Mathison, & Michelli, 2005). At the same time our
ndings point to some differences in the use of compositional elements between drawing and imagining. Addition and rubbing out
of objects were more prevalent in drawing. A possible explanation
is that from a practical point of view drawing enables to concretely
omit or add objects and thus creates a larger repertoire of possible
transformations of a stress related image. These compositional differences between guided images and drawn images, point to the
ease in which health professionals can be taught to actively utilize
the most common 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-regulate

their stress. The differences between the two methods point to the
usefulness of a drawn image that enables more manipulations. On
the other hand, art demands colors and paper and overcoming of
fear of drawing, while images in the mind are always accessible
and less threatening. Another point may be that beyond the simple methods of image transformation, more complex uses (such as
shading, texture, perspective, etc.) can be taught and generalized to
enable a more nuanced method of stress reduction. Future studies
could develop these ideas.
The preliminary nature of this study is its limitation, as it measures reduction in perceived stress on a general level. The study
demands more replication and evaluation. At the same time, the
ndings point to interesting directions concerning the difference
between real versus imagined images, and concerning greater
understanding how people can harness visual compositional elements, rather than verbal elaboration to stress reduction. This, in
different work settings can have direct implications for the wellbeing of professions that experience high levels of occupational
stress of a visual nature.
References
Bandler, R. (1985). Using your brain for a change. Moab, UT: Real People Press.
Bandura, A. (1991). Self-regulation of motivation through anticipatory and self-reactive
mechanisms. Perspectives on motivation: Nebraska symposium on motivation (Vol.
38) Lincoln: University of Nebraska Press.
Barrett, H. C. (2005). Adaptations to predators and prey. In D. Buss (Ed.), The handbook
of evolutionary psychology. Hoboken, NJ: Wiley.
Benjamin, C., ONeil, K., Crawley, S., Beidas, R. S., Coles, M., & Kendall, P. C. (2010). Patterns and predictors of subjective units of distress in anxious youth. Behavioral
and Cognitive Psychotherapy, 38(4), 497504.
Bocanegra, B. R., & Zeelenberg, R. (2009). Emotion improves and impairs early vision.
Psychological Science, 20(6), 707713.
Bourbonnais, R., Brisson, C., & Vzina, M. (2011). Long-term effects of an intervention on psychosocial work factors among healthcare professionals in a hospital
setting. Occupational and Environmental Medicine, 68, 479486.
Eisner, E. (1997). The promises and perils of alternative forms of data representation.
Educational Researcher, 26(6), 420.
Figley, C. R. (2002). Compassion fatigue: Psychotherapists chronic lack of self-care.
Journal of Clinical Psychology, 58, 14331441.
Haijiang, Q., Saunders, J. A., Stone, R. W., & Backus, B. T. (2006). Demonstration of cue
recruitment: Change in visual appearance by means of Pavlovian conditioning.
Proceedings of the National Academy of Sciences of the United States of America,
103(2), 483488.
Hall, L., Doran, D., & Pink, L. (2008). Outcomes of interventions to improve hospital
nursing work environments. Journal of Nursing Administration, 38(1), 4046.
Harrington, A. (2004). Art and social theory: Sociological arguments in aesthetics. London: Polity Press Ltd.
Huss, E., & Sarid, O. (2012). Using imagery in health care settings: Addressing physical
and psychological trauma. In K. Malciodi (Ed.), Art therapy and healthcare (pp.
136145). NY: Guilford Publications.
Huss, E., Sarid, O., & Cwikel, J. (2010). Using art as a self-regulating tool in
a war situation: A model for social workers. Health & Social Work, 35(3),
201209.

Johnson, D. (1999). Essays on the creative arts therapies. New Haven, CT: Charles
Thomas Publisher.
Kaye, S., & Bleep, M. (1997). Arts and healthcare. London: Jessica Kinsley.
Krasner, M. S., Epstein, R. M., Beckman, H., Suchman, A. L., Chapman, B., Mooney, C. J.,
et al. (2009). Association of an educational program in mindful communication
with burnout, empathy, and attitudes among primary care physicians. JAMA,
302, 12841293.
Lang, P. J., & Bradley, M. M. (2010). Emotion and the motivational brain. Biological
Psychology, 84(3), 437450.
Laws, T. (2001). Examining critical care nurses critical incident stress after in hospital cardiopulmonary resuscitation (CPR). Australian Critical Care, 14(2), 7681.
Lee, C. W., & Drummond, P. D. (2008). Effects of eye movement versus therapist
instructions on the processing of distressing memories. Journal of Anxiety Disorders, 22(5), 801808.
Malchiodi, C. (2012). Introduction to art therapy in health care settings. In C. Malchiodi (Ed.), Art therapy and health care (pp. 112). NY: The Guilford press.
Nelson, K., & Fivush, R. (2004). The emergence of autobiographical memory: A social
cultural developmental theory. Psychological Review, 111(2), 486511.
OCallaghan, C. (2008). Object perception: Vision and audition. Philosophy Compass,
3(4), 803829.
Pan, Y., & Soto, D. (2010). The modulation of perceptual selection by working
memory is dependent on the focus of spatial attention. Vision Research, 50(15),
14371444.
Phelps, E. A., Ling, S., & Carrasco, M. (2006). Emotion facilitates perception and potentiates the perceptual benets of attention. Psychological Science, 17(4), 292299.
Rabin, S., Shorer, Y., Nadav, M., Guez, J., Hertzanu, M., & Shiber, A. (2011).
Burnout among general hospital mental health professionals and the Salutogenic approach. Israeli Journal of Psychiatry and Related Science, 48(3), 175181.
Rubin, J. (2001). Approaches to art therapy. Philadelphia: Brunner-Rutledge.
Rubino, C., Luksyte, A., Perry, S., & Volpone, S. (2009). How do stressors lead to
burnout? The mediating role of motivation. Journal of Occupational Health Psychology, 14, 289304.
Sarid, O., & Huss, E. (2010). Trauma and acute stress disorder: A comparison between
cognitive behavioral intervention and art therapy. Arts in Psychotherapy, 37(1),
812.
Sarid, O., Berger, R., Eckshtein, R., & Segal-Engelchin, D. (2012). Are
cognitivebehavioral interventions effective in reducing occupational
stress among nurses? Applied Nursing Research, 25(3), 152157.
Silver, R. (2005). Aggression and depression assessed through art. New York: BrunnerRutledge.
Shank, M. (2005). Transforming social justice: Redening the movement: Art
activism. Seattle Journal for Social Justice, 3, 531535.
Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based
stress reduction for health care professionals: Results from a randomized trial.
International Journal of Stress Management, 12(2), 164176.
Sharpley, C. F., Montgomery, J. M., & Scalzo, L. A. (1996). Comparative efcacy of
EMDR and alternative procedures in reducing the vividness of mental images.
Cognitive Behaviour Therapy, 25(1), 3742.
Tosey, P., Mathison, J., & Michelli, D. (2005). Mapping transformative learning: The
potential of neuron-linguistic programming. Journal of Transformative Education,
3(2), 335352.
Torralba, A., & Oliva, A. (2003). Statistics of natural image categories. Network, 14(3),
391412.
Tulchinsky, T., & Varavikova, E. (2010). What is the New Public Health? Public Health
Reviews, 32, 2553.
Turner, F. (Ed.). (1996). Social work treatment: Interlocking theoretical approaches.
New York: The Free Press.
Ullman, S., Vidal-Naquet, M., & Sali, E. (2002). Visual features of intermediate complexity and their use in classication. Nature Neuroscience, 5, 682687.
Wolpe, J. (1991). The practice of behavior therapy (4th ed.). New York: Pergamon
Press.