*Edited by Mohammad Saber Fallah Nezhad*

This book is an introduction to the mathematical analysis of Bayesian decision-making when the state of the problem is unknown but further data about it can be obtained. The objective of such analysis is to determine the optimal decision or solution that is logically consistent with the preferences of the decision-maker, that can be analyzed using numerical utilities or criteria with the probabilities assigned to the possible state of the problem, such that these probabilities are updated by gathering new information.

ISBN 978-1-78923-092-5

New Insights into Bayesian Inference

Published in London, UK © 2018 IntechOpen © Patrick Hendry / unsplash


**3. Microcontingential system**

**2. Contingential analysis**

24 Behavior Analysis

Contingential analysis is a methodology developed for psychologists' professional work which enables analysis and modification of individual human behavior. It was developed by Ribes et al. [1], based on Ribes and López's [2] work, who developed an interbehavioral theory based on Kantor's work [3]. This theory presents a naturalistic behavior approach which

The subject matter of the interbehavioral approach, also known as the field model, is interbehavior, understood as a series of interdependent relationships—of varying degrees of complexity between specific elements of the environment and of the organism that are built in the ontogenetic history. This approach's specific premises and characteristics make it different from others.

From this perspective and using a functional criterion, all of an individual's interactions with his/her environment comprise different elements that can be grouped into three specific categories: the stimulus-response function, dispositional factors, and the means of contact.

Generally, it is important to mention that the stimulus-response function refers to the response and stimulus segments that make contact. This can take place at different qualitative levels.

Dispositional factors refer to the series of events conducive to certain types of interactions by facilitating or inhibiting the same. Such factors include situational and environmental factors (temperature, objects, places, and organisms, among others), the interbehavioral history (stimulus evolution and reactive biography), and the organism's conditions (diseases, ail-

Finally, the physical-chemical, biological, and regulatory means of contact refer to the condi-

These elements constitute the interbehavioral field, which is *a conceptual representation of an interaction segment of the individual organism with its environment* ([2], p. 42). In this field, elements are interrelated synchronously, establishing contingencies between events, in other

Based on this model, Ribes and López [2] developed a taxonomy of the different levels of behavior organization mainly based on two parameters: (1) *mediation*, which is the process by which different factors of a psychological event relate through the critical element, which is the mediating element [2] and (2) the functional *detachment*, which refers to the possibility of an organism to respond in a relatively autonomous manner to the physical-chemical properties of the environment, in other words, its capacity to interact with objects, events, or absent

**a.** In a specific context, the relationship between the stimulus and response functions repre-

**b.** The behavioral approach is naturalistic—the relationships between elements of the person or people with their environment never refer to entities, phenomena, or supernatural

Thereby, some of this theory's basic characteristics are briefly described hereunder:

ments, deprivation fullness, drug effects, or tendencies).

words, establishing mutual dependencies between them.

tions that enable a specific interaction [2, 3].

people in the here and now [2].

sents the psychological analysis unit.

is radically different from the dualistic conceptions that permeate our discipline.

The microcontingential system refers to the series of relationships that a person establishes with objects, people, circumstances, or environmental events [5], in which any of these elements structures the form in which such relationship occurs (mediating element). It is limited according to the conventionally defined situation of interest, family relationship, work relationship, upbringing, and love relationships, among others. It consists of four elements: behavior morphologies, situations, other people's behavior, and effects. Each one is explained herein.

his/her partner, he/she repeats these types of behaviors. To be jealous is a tendency, in other

Contingential Analysis: Interbehavioral Methodology for the Applied Field

http://dx.doi.org/10.5772/intechopen.74464

27

The situations that give a context to a relationship comprise different elements with a possible dispositional function. Some of them refer to specific components of the person's interbehavioral history, whereas others refer to certain environmental characteristics. Thereby, the subcategories that correspond to situations are (1) social circumstance, (2) place or places, (3) objects or physical events, (4) socially expected behaviors, (5) competencies and incompetences to carry out what is socially expected, (6) inclinations and propensities, and (7) tendencies [5].

**a.** Social circumstance: the type of circumstance in this category is identified according to conventional criteria, in which the behavior that is going to be studied is presented. Examples of these circumstances are family circumstances, couple relationships, and work

**b.** Place or places: a physical space can have a dispositional function for a certain behavior,

**c.** Objects or physical events: in this category the possible dispositional function of objects or physical events that are part of the physical context is identified. For example, hot weather can facilitate people wearing light clothing or abundant food, for a person to overeat. **d.** Socially expected behaviors: in all social circumstances there are tacit or explicit demands for people. These demands have a dispositional function. What a person or a group of people expects from another can make a behavior more or less likely. For example, in a family relationship, children are regularly expected to behave respectfully with their parents, whereas in a peer relationship what can be expected is for peers to bully each other.

**e.** Competencies or incompetences to do what is socially expected: this category refers to a dispositional factor related to the history of the person whose behavior is studied. It refers to the ability or inability of this person to meet what is expected of him/her in a specific situation. For example, a person is expected to study, pass his/her exams, and do his/her homework in an academic situation. If this person does not have an effective studying method and does not understand the texts, his/her lack of competency is a factor that

**f.** Inclinations, propensities, and motives: these categories fall within the broadest tendency category, although they have more specific characteristics. Inclinations refer to tastes and preferences; propensities refer to short-term temporary states, particularly states of mind/ moods (sadness, happiness, infatuation), to emotional shocks (intense short-term emotions such as rage, elation, anger, fear, etc.), and to biological conditions (such as a headache, drug or alcohol intake, different diseases, sexual deprivation); on the other hand, motives refer to tendencies linked with short-, medium- and long-term possible consequences. It should be noted that these concepts are the ones used the most in a dualistic form as categories that "explain" behavior when from this perspective are a part of the behavior that will be explained. According to the specific analysis of each case, inclinations, propensities, and motives may have a dispositional function and would be a part

makes it less likely for him/her to pass his/her exams and get good grades.

words, a dispositional factor.

relationships, among others.

for example, a school can facilitate the habit of studying.


**3. Anxiety**

#### **3.1. Anxiety and coronary heart disease**

Anxiety has been characterized as a future-oriented, negative affective state with a component of fear, resulting from the perception of threat and the individual's perceived inability to predict, control, or obtain the desired results in upcoming situations. Somatic manifestations are tachycardia, hyperventilation, sweating, psychological manifestations are feelings of apprehension, nervousness, restlessness, and may also cause changes in sleeping pattern [13]. Pathophysiological background by which anxiety influences outcome in ischemic heart disease is largely unknown. An increased incidence of ECG QT interval prolongation has been demonstrated among patients with anxiety, which increases the occurrence of ventricular arrhythmia [14]. Patients with anxiety have been shown consistently to have sympathetic nervous system upregulation, with excessive catecholamine production [15]. Furthermore, impaired vagal control, manifest as an impaired baroreflex response and a decrease in heart rate variability has been noted in patients with anxiety. Impairment of the baroreflex response and decreased heart rate variability are each thought to be sensitive markers for abnormalities in autonomic cardiovascular regulation and are independent risk factors for sudden cardiac death [16, 17, 18]. Patients with anxiety and CAD often show an exaggerated systemic response to stress, characterized by an abnormally increased production of catecholamines, which can result in increased myocardial oxygen demand due to elevations in heart rate, blood pressure, and the rate of ventricular contraction [19]. In addition to the biological risks of anxiety, the additive effects of adverse behavioural risk factors (e.g., excessive nicotine and perhaps caffeine) in anxious patients have also be taken into account [20]. Anxiety is very common in patients with myocardial infarction, with an inhospital occurrence rate of 30% to 40% [21]. Studies with coronary patients suggest that anxiety disorders may be associated with greater mortality, particularly sudden cardiac death, and greater cardiovascular morbidity. Higher levels of anxiety have been associated with poorer prognosis and greater recurrence of cardiac events after myocardial infarction [22]. In a cohort study the relative importance of depression, anxiety, anger, and social support in predicting 5-year cardiac-related mortality following a myocardial infarction was investigated. Higher level of anxiety predicted greater cardiacrelated mortality in a sample of nearly 900 patients with myocardial infarction, but this effect was non significant following adjustment for disease severity [23]. The first meta-analysis on the association of anxiety and coronary heart disease showed a consistent association between anxiety and impaired prognosis after myocardial infarction, with a 36% increased risk for mortality (cardiac and all-cause) and for cardiac events. Limitation of the result was the pooled odds ratios for cardiac death, because it was based on only four studies [21].

#### **3.2. Anxiety and CABG**

Tully PJ. The role of depression and anxiety symptoms in hospital readmissions after cardiac surgery.

468 Artery Bypass

226 Hospital readmissions after coronary artery bypass graft surgery were assessed.

**Figure 1.** Figure showes significant difference in depression (BDI points) between survivors and non survivors preoper‐

Anxiety has been characterized as a future-oriented, negative affective state with a component of fear, resulting from the perception of threat and the individual's perceived inability to predict, control, or obtain the desired results in upcoming situations. Somatic manifestations are tachycardia, hyperventilation, sweating, psychological manifestations are feelings of apprehension, nervousness, restlessness, and may also cause changes in sleeping pattern [13].

**Table 1.** Some important studies about depression and CABG

atively, after discharge and in both intervals.

**3.1. Anxiety and coronary heart disease**

**3. Anxiety**

When analyzed as continuous variables in multivariable analyses, preoperative anxiety and

postoperative depression predicted readmissions independent of medical covariates. In multivariable analyses with dichotomized anxiety, depression and stress, more than two-fold increase in readmission risk was attributable to preoperative anxiety and postoperative depression, independent of

covariates.

Anxiety is especially high for CABG patients while they are on the waiting list with an unknown surgery date [24]. The patients have fear of dying before, rather than during surgery, and this fear influenced strongly their level of anxiety. Anxiety also manifests as an activator of sympathetic and parasympathetic nervous systems and cardiovascular excitation that can exacerbate CAD symptoms. After surgery, while anxiety may decrease to below pre-operative level, the severity of anxiety does not necessarily remit to below sub-clinical levels and may warrant intervention [25]. In the Post-CABG Trial the presence of anxiety symptoms was significantly associated with a higher incidence rate of death or myocardial infarction after a median follow-up time of 4.3 years following CABG. After controlling for the presence of depressive symptoms and other covariates (age, gender, race, treatment assignment and years since CABG surgery), a significant dose-response relationship persisted between anxiety and mortality. The observed dose-response relationship between level of anxiety and risk of death or myocardial infarction underlines the importance of even lower levels of anxiety. The risk of death or myocardial infarction in those with both depressive and anxiety symptoms was what would be expected from the combination of the independent effects [26]. In a study of our workgroup trait anxiety was associated with increased mortality and cardiovascular morbidity. In our population trait anxiety remained an independent predictor for postdischarge cardiovascular events and 4 year mortality. Moreover, post-discharge 6th month trait anxiety scores were more predictive for cardiovascular events compared to the preoper‐ ative values. Although anxiety and depression were positively and highly correlated in these patients, only anxiety was associated with increased mortality and morbidity. In addition trait anxiety was significantly higher in patients hospitalized with arrhythmia, congestive heart failure or myocardial infarction during a 4 year period after cardiac (CABG and valve) surgery [27]. In another study of our workgroup depression, anxiety, education, social isolation and mortality together were investigated 7.5 years after cardiac surgery. Our results have suggest‐ ed that the assessment of psychosocial factors, particularly anxiety and education may help identify patients at an increased risk for long-term mortality after cardiac surgery (Figure 2.) [13]. Anxiety was also reported to be associated with twofold risk for fatal CHD and more than fourfold risk for sudden death [28]. In a retrospective study 17,885 discharge records of patients after primary CABG surgery were identified. In the sample of rural patients the prevalence of anxiety disorder was 27%. Anxiety was a significant independent predictor of both length of hospital stay and non routine discharge [29]. In a prospective study on cardiac-related readmission within 6 months of CABG postoperative anxiety was identified as both a uni‐ variate risk factor and a multivariate risk factor for CHD and surgery-related readmission both with and without adjustment for covariates [30].

Frasure-Smith N. Depression and other psychological risks following myocardial

Koivula M. Fear and anxiety in patients at different timepoints in the coronary artery

Rosenbloom JI. Self-reported anxiety and the risk of clinical events and atherosclerotic progression among patients with Coronary Artery Bypass

Székely A. Anxiety predicts mortality and morbidity after coronary artery and valve surgery--a 4-year follow-up

study.

bypass process.

Grafts (CABG).

896 Beck Depression Inventory, state scale of

myocardial infarction.

171 CABG patients completed questionnaires

Anxiety Inventory.

1317 CABG patients were randomized to either

Anxiety Inventory (STAI)

180 Patients who underwent cardiac surgery

using cardiopulmonary bypass were prospectively studied and followed up for 4 years. Anxiety (Spielberger State-Trait Anxiety Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI), living alone, and education level along with clinical risk factors and

while awaiting surgery at home, in hospital the evening before surgery and 3 months later. The Bypass Grafting Fear scale was developed to measure fear. Anxiety was measured using State-Trait-

aggressive or moderate lipid lowering and to either warfarin or placebo. Patients were followed up for clinical end points and coronary angiography was conducted at enrollment and after a median followup of 4.3 years. Anxiety symptoms were assessed at enrollment using the state portion of the Spielberger State-Trait

version of the General Health Questionnaire, Modified Somatic Perception Questionnaire, Anger Expression Scale, Perceived Social Support Scale, number of close friends and relatives, and visual analog scales of anger and stress were assessed to predict 5-year cardiac-related mortality following a

the State-Trait Anxiety Inventory, 20-item

Short and Long Term Effects of Psychosocial Factors on the Outcome of Coronary Artery Bypass Surgery

The Beck Depression Inventory (P<0.001), the State-Trait Anxiety Inventory (P =0.04), and the 20-item version of the General Health Questionnaire (P = 0.048) were related to outcome, but only depression remained significant after adjustment for cardiac disease severity (hazards ratio per SD, 1.46; 95% confidence interval, 1.18-1.79) (P<0.001). There was also a covariate-adjusted trend between negative affectivity scores and outcome (P = 0.08). Furthermore, residual depression scores (P =0.001) and negative affectivity scores (P = 0.05) were linked to cardiac-related mortality after adjustment for each other and cardiac covariates.

http://dx.doi.org/10.5772/54622

471

The highest levels of fear and anxiety were measured in the waiting period to coronary CABG. Compared with the waiting period, fear and anxiety levels dropped in hospital and 3 months later. Female gender was related to change in

STAI score "/> or =40 was positively associated with risk of death or myocardial infarction (MI) (OR 1.55, 95% CI 1.01-2.36, P =0.044). This association was attenuated slightly when depressive symptoms were included in the model, but lost statistical significance (P = 0.11). There was a dose-response relationship between STAI score and risk of death or myocardial infarction. There was no association between self-reported anxiety and atherosclerotic progression of grafts.

Average preoperative STAI-T score was 44.6 +/- 10. Kaplan-Meier analysis showed a significant effect of preoperative STAI-T "/>45 points (p =0.008) on mortality. In multivariate models, postoperative congestive heart failure (OR: 10.8; 95% confidence interval [CI]: 2.9-40.1; p =0 .009) and preoperative

fear and anxiety.

infarction

of death or myocardial infarction in those with both depressive and anxiety symptoms was what would be expected from the combination of the independent effects [26]. In a study of our workgroup trait anxiety was associated with increased mortality and cardiovascular morbidity. In our population trait anxiety remained an independent predictor for postdischarge cardiovascular events and 4 year mortality. Moreover, post-discharge 6th month trait anxiety scores were more predictive for cardiovascular events compared to the preoper‐ ative values. Although anxiety and depression were positively and highly correlated in these patients, only anxiety was associated with increased mortality and morbidity. In addition trait anxiety was significantly higher in patients hospitalized with arrhythmia, congestive heart failure or myocardial infarction during a 4 year period after cardiac (CABG and valve) surgery [27]. In another study of our workgroup depression, anxiety, education, social isolation and mortality together were investigated 7.5 years after cardiac surgery. Our results have suggest‐ ed that the assessment of psychosocial factors, particularly anxiety and education may help identify patients at an increased risk for long-term mortality after cardiac surgery (Figure 2.) [13]. Anxiety was also reported to be associated with twofold risk for fatal CHD and more than fourfold risk for sudden death [28]. In a retrospective study 17,885 discharge records of patients after primary CABG surgery were identified. In the sample of rural patients the prevalence of anxiety disorder was 27%. Anxiety was a significant independent predictor of both length of hospital stay and non routine discharge [29]. In a prospective study on cardiac-related readmission within 6 months of CABG postoperative anxiety was identified as both a uni‐ variate risk factor and a multivariate risk factor for CHD and surgery-related readmission both

Methods Results

During a median follow-up of 7.6 years (25th to 75th percentile, 7.4 to 8.1 years), the mortality rate was 23.6% (95% confidence interval [CI] 17.3-29.9; 42 deaths). In a Cox regression model, the risk factors associated with an increased risk of mortality were a higher EUROSCORE (points; Adjusted Hazard Ratio (AHR):1.30, 95%CI:1.07-1.58)), a higher preoperative STAI-T score (points; AHR:1.06, 95%CI 1.02-1.09), lower education level (school years; AHR:0.86, 95%CI:0.74-0.98), and the occurrence of major adverse cardiac and cerebral events during follow up (AHR:7.24, 95%CI: 2.65-19.7). In the postdischarge model, the same risk factors remained.

180 Anxiety (Spielberger State-Trait Anxiety

patients.

Inventory, STAI-S/STAI-T), depression (Beck Depression Inventory, BDI) and the number and reason for rehospitalizations were assessed each year in cardiac surgery

with and without adjustment for covariates [30].

patients

First author and title Number of

Cserep Z. The impact of preoperative anxiety and education level on long-term mortality after cardiac

surgery.

470 Artery Bypass

**Figure 2.** Figure showes significant difference in STAI-T (State-Trait Anxiety Inventory) between survivors and non sur‐

Short and Long Term Effects of Psychosocial Factors on the Outcome of Coronary Artery Bypass Surgery

http://dx.doi.org/10.5772/54622

473

Self-rated health (SRH) is measured with a simple question "How do you rate your health in general?" There are five possible responses: very good, good, fair, poor and very poor [31]. Self rated health has been shown to be a potent predictor of mortality and morbidity, functional decline, disability and utilization of health care even after controlling for several sociodemo‐ graphic and health indicators The association can be explained by three ways: (1) SRH is a more comprehensive and sensitive measure of health status than the other psychosocial covariates in the analyses; (2) SRH measures individual optimistic or pessimistic disposition, that as such, may be associated with survival; or (3) SRH also measures characteristics other than health status itself, such as family history, health behaviour, and social and psychological resources [32]. In a review SRH was described as an active cognitive process that is independ‐ ent from formal definitions of health. Self rated health covers bodily sensations that are directly available only to the individuals. These sensations may reflect important physiological dysregulations, such as inflammatory processes. SRH is an individual and subjective concep‐ tion that is related to death, and builds a connection from the social world and psychological to the biological world. Therefore the answer to the SRH question may summarize the dimensions of health that are most important and determinant to each individual [33]. SRH has been described as one of the most important health outcomes available and recommended as a tool for disease risk screening, as an outcome indicator in the primary care, and standard part of clinical trials [34]. Several studies in different field confirmed the importance of SRH, one of them described that good self health 3 months after PCI predicted good clinical outcome

vivors preoperatively, after discharge and in both intervals.

**4. Self rated health**

**Table 2.** Some important studies about anxiety and CABG

**Figure 2.** Figure showes significant difference in STAI-T (State-Trait Anxiety Inventory) between survivors and non sur‐ vivors preoperatively, after discharge and in both intervals.


*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*


**6. Problems with conventional surfactants in foam stability**

The creation of spume, alone, is not a serious problem; the highlighted ones are quality of spume, formation of spume and its balance is particularly when it is in contact with oil. The surfactants used for spume creation have low endurance with salinity and result in extreme adaption on rocks of carbonate. With reference to stability of foam, the surfactants of non-ionic are lesser but the problem is their stability at high temperatures. Usually, a foam that absorbs on the rock matrix becomes worse over time, and has a higher decay at increased temperatures if present with oil. These problems become worse when the CO2 gas is present. This phenomena was particularly created to produce fresh surfactants with an affinity for CO2 gas under controlled conditions and to defeat the problems linked with surfactants that is conventional. The surfactants of novel can produce much balance foam at an increased temperature and in the existence of oil with lesser adaption problems.