Using the Draw-a-Story Drawing Test to Predict Perceived Stress, Military Life Adjustment, and Resilience

Round 1

Reviewer 1 Report

Dear authors, 

thanks for giving me the possibilty to review the paper named : "Using the Draw-a-Story drawing test to predict perceived stress, military life adjustment, and resilience". I hope you and your family are safe and well in this particular period. 

I read twice your paper and I really appreciate it for the idea and method. 
I only suggest to improve a little your literature with https://doi.org/10.15866/irece.v11i3.19025 . I find it very rigorous even if on a different field. Please include it. 

For the rest congratulations!

Author Response

: Thanks for your kind comment. The thesis mentioned is cited in the text as follows.

 

LINE# 261-262.

Resilience is psychological strength that allows people to endure adverse situations; it is a dynamic process that involves positive adaptation [27-30, 47].

 

References

47. Di Nardo, M.; Clericuzio, M.; Murino, T.; Madonna, M. An adaptive resilience approach for a high capacity railway. INT REV CIVIL ENG, 2000, 11(3), 98-105. https://doi.org/10.15866/irece.v11i3.19025

Author Response File: Author Response.pdf

Reviewer 2 Report

The authors present an interesting study on perceived stress in the military. In order for this work to be published, in my opinion the authors should improve the following aspects:
a) The authors should present theoretically supported hypotheses that they could subsequently test.
b) In the data analysis they indicate that they calculate the descriptive data for the sample, but they do not present them. Therefore, I do not know if any variable such as gender or age (this is made clear in the limitations of the study, 21-year-old males) or level of education or any other variable could moderate perceived stress.
c) The authors show a series of scales and check the reliability through Crombach's alpha, but they should check the validity of the scales. Prior to making correlations. 
d) They should explain how DAS drawing is done. 
e) They should strengthen the discussion.
f) Conclusions are limited to one paragraph. I think they should be clearly. improved. Defining what are the main implications/advantages that are achieved thanks to the DAS.
h) Include the scales questionnaire used in an annex.
i) They should use more updated bibliography as far as possible.Two citations from 2021, 0 from 2019, 3 from 2018, 2 from 2017, 0 from 2016.
e) They should strengthen the discussion.
f) Conclusions are limited to one paragraph. I think they should be clearly. improved. Defining what are the main implications/advantages that are achieved thanks to the DAS.
h) Include the scales questionnaire used in an annex.
i) They should use more updated bibliography as far as possible.Two citations from 2021, 0 from 2019, 3 from 2018, 2 from 2017, 0 from 2016.
Two citations from 2021, 0 from 2019, 3 from 2018, 2 from 2017, 0 from 2016.
j) In my opinion there are a large number of references to Korean journals and reports. 7 citations from Korean J ART THER.  Also cited, if not exhaustive: Korean J COUNS PSYCHOTHER, J Korean ACAD NURS, J Korean ACAD PSYCHIAT MENTAL HEALTH NURS..., among the many reports from Korea. 

Author Response

Response to Reviewer 2

 

Question a) The authors should present theoretically supported hypotheses that they could subsequently test.

Answer a) We supplemented the research hypothesis as follows.

Line # 77-96:

The purpose of this study was to determine the effectiveness of a drawing assessment as a method of evaluating and predicting soldiers’ mental states. We chose to examine Silver’s Draw-a-Story (DAS) test. This drawing test is testee-friendly because it provides stimulus drawings that it asks subjects to refer to as they draw their own pictures [1, 4, 31]. For this reason, the DAS is not difficult even for those who say they don’t know what to draw. The DAS has been implemented to examine a variety of people, including firefighting officials [32], subway engineers who experienced accidents on duty [33], North Korean defectors [34], and burn victims [35]. A previous study that administered the DAS to soldiers found that it can be used to effectively determine depressive status [36]. Another study found that DAS can be used to assess depression and suicidal ideation levels in soldiers [37]. Based on this theoretical background, we set out to examine how effectively the DAS test predicts conscript soldiers’ military service stress, military life adjustment, and resilience. To achieve this goal, we established the following research hypothesis.

Hypothesis 1. The DAS scales will show significant correlations with military service stress, military life adjustment, and resilience of soldiers.

Hypothesis 2. The emotional content scale in the DAS will predict military service stress, military life adjustment, and resilience, respectively.

Hypothesis 3. The self-image scale in the DAS will predict military service stress, military life adjustment, and resilience, respectively.

 

 

 

 

Question b) In the data analysis they indicate that they calculate the descriptive data for the sample, but they do not present them. Therefore, I do not know if any variable such as gender or age (this is made clear in the limitations of the study, 21-year-old males) or level of education or any other variable could moderate perceived stress.

Answer b): As you pointed out, we supplemented participants’ general characteristics in Table 1.

 

Line # 98-104:

2.1. Participants

The A total of 280 Korean conscript soldiers participated in this survey. After excluding four incomplete questionnaires, we used 276 responses in our analysis. The participants were all male, their average age was 20.96 year (S.D. = 1.27, Min. = 19.0, Max. = 27.0), and their average service period was 11.19 months (S.D. = 5.48). Other demographic characteristics of the participants were presented in Table 1.

Table 1. Participants’ General Characteristics (N = 276)

Variable		Frequency	%
Sex	male	276	100.0
	female	0	0
Marital status	married	2	0.7
	unmarried	274	99.3
Education level	Graduated from high school	64	23.2
	enrolled in college	204	73.9
	Graduated from college	8	2.9
Socioeconomic status	Upper class	9	3.3
	Upper middle class	26	9.4
	Middle class	216	78.3
	Working class	20	7.2
	Poor	5	1.8

 

 

 

Question c) The authors show a series of scales and check the reliability through Crombach's alpha, but they should check the validity of the scales. Prior to making correlations. 

 

Answer c) We reported on the validity of the scales as follows.

Line # 117-141:

2.3. Measures

2.3.1. The Perceived Stress Scale

We used the Perceived Stress Scale developed by Hyun and Lee [6] to measure soldiers’ perceived stress levels. The scale comprises 26 items rated on five-point Likert scales (1 = strongly disagree, 5 = strongly agree). The final score is the average of response scores, and higher averages indicate higher levels of stress. Hyun and Lee demonstrated that the soldiers' perceived stress is closely related to the stress response, thus indicating that the construct validity of this scale is appropriate. The reliability coefficient of this scale was 0.90 in Hyun and Lee’s study and 0.95 in this study.

2.3.2. The Military Life Adjustment Scale

Stouffer et al. [38] originally developed the Military Life Adjustment Scale; Shin [39] reconstructed it for Korean military settings and Koo [40] later modified it. It comprises 26 items, rated on five-point Likert scales. The higher the final average scores, the greater the soldiers’ adjustment levels. Shin proved the criterion validity by revealing that the correlation analysis between the military life adaptation sub-factors was significant. The reliability coefficient of this scale was 0.93 in Koo’s study and 0.94 in this study.

2.3.3. The Connor-Davidson Resilience Scale – Korean Version

We used the Connor-Davidson Resilience Scale (Korean version) to evaluate soldiers’ resilience levels. Connor and Davidson [41] originally developed this scale and Baek et al. [42] translated it into Korean and validated it. It consists of 25 items rated on five-point Likert scales. The higher the average scores, the better the levels of resilience. Baek et al. proved that the construct validity was appropriate through correlation analysis between this scale and the Rosenberg Self-Esteem Scale, Beck Depression Inventory, Perceived Stress Scale, and Impacted of Event Scale-Revision. The researchers reported a Cronbach’s α of 0.93, and we found a Cronbach’s α of 0.95 in this study.

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Silver [4] demonstrated the validity of the DAS test was sufficient by revealing differences in the DAS scale between those who are clinically depressed and those who are not depressed.

The DAS scoring was performed separately by two art therapists who had no information other than the pictures. They both had more than 7 years of experience conducting drawing tests. We calculated the degree of concordance between the individual graders by sampling 40 of the total 276 pictures, and found the correlation coefficient between them to be 0.95.

Question d) They should explain how DAS drawing is done. 

 

Answer d) In the method section, we added the DAS implementation method as follows. Additionally, we introduced the DAS directive in the appendix.

As a supplementary note, we did not introduce the picture stimulus used in DAS due to copyright issues. We found that none of previously published DAS papers presented a picture stimulus.

e.g.

34. Jue, J.; Kim, H. Draw-a-Story response characteristics of young North Korean defectors. ARTS PSYCHOTHER, 2014, 41(5), 504-510. https://doi.org/10.1016/j.aip.2014.08.007
35. Park, C.H.; Kim, G.S. A Validation Study on DAS in the Prediction of Suicidal Risk for Adolescents. ARTS PSYCHOTHER, 2013, 40(2), 108-114. https://doi.org/10.1016/J.AIP.2012.11.006

However, we included the stimulus drawing here.

  

 

 

Line # 142-155:

 

2.3.4. The Draw-a-Story Drawing Test

Silver [31] developed the Draw-a-Story (DAS) drawing test to assess individuals’ internalized psychological problems including depression and aggression. The tools of DAS include stimulus pictures, drawing paper, pencils, and erasers. The conditions for this test are not strict: there is no time limit, and it can be conducted individually or in a group. The examiner asks a testee to draw a picture using provided stimulus drawings and to write the story. The specific implementation method is as follows: The DAS provides 14-stimulus pictures, asks testees to choose two stimuli and to imagine something happening between them, and then asks them to draw a picture showing their imagined stories. Testees can add or change the original stimuli in their own drawings. The stimuli include a man with a hat, a man with glasses smoking a pipe, a boy, a woman with a bridal veil, a person with a parachute, a snake, a cat, a dinosaur, a chick, a mouse, a tree, a knife, an erupting volcano, and a castle. This art assessment is used to evaluate the emotional states of testees based on the stories and drawings they compose.

 

 

Line # 453-458:

Appendix D. The Draw-a-Story Drawing Test

Instruction: The stimulus pictures provided show pictures of people, animals, places, and objects. Choose two of these and imagine the story of what is going on between them. Now draw your story. You can change parts of the stimulus picture or add your ideas when you draw. When you have finished drawing, please write your story in the blank space.

 

 

Question e) They should strengthen the discussion.

Answer e) We expanded the discussion even further on areas where we found no meaningful results.

Line # 277-320:

The DAS self-image scale is used to evaluate the strength of the objects identified by the individuals who draw the pictures. In this study, we found no significant relationship between self-image and perceived stress or adjustment to military life. Although our analysis of the self-image scale showed a significant correlation between it and resilience, we ultimately excluded it from the regression analysis because it did not increase significantly when administered as an independent variable. These results have important implications in predicting whether conscript soldiers might have difficulties adjusting in the military by conducting drawing tests. In other words, it is vital to consider the whole picture to estimate the psychological state of the subject. It might be dangerous to draw a hasty conclusion from only a part of the picture.

Self-image is a partial element compared to emotional content. Therefore, in studies analyzing the effects of self-images, we find inconsistent reporting: Some studies of DAS self-images have produced significant results, but others have not. Examining the relationship between depression and the DAS self-images of conscript soldiers, Byeon and Lee [36] reported that higher levels of depression were associated with more helpless or unfortunate self-images. Other researchers have reported that the higher the DAS self-image score, the higher the psychological well-being of college students [50]. Meanwhile, adolescents who perpetrated school violence showed more of their pathological fantasies in their self-images [51]. Among subway train drivers suffering from post-traumatic stress, more negative DAS self-images were associated with more severe the post-traumatic stress [33]. Young north Korean defectors have more fragile self-images [34].

In contrast, a previous study found no relationship between the DAS self-images of male juvenile delinquents and anger or physical/verbal aggression [52]. The fact that the 5 self-image points in the self-image scale include both positive and negative content likely explains why it is less effective than the emotional content scale. For example, if one draws a person who makes others happy, the self-image score is 5. However, if one draws a person threatening or attacking his or her opponent, the self-image score can also be 5. For this reason, researchers have suggested that studies should separate positively strong self-images and negatively strong self-images, which are all 5 points [52-55]. Our self-image results may have been insignificant because the 5 self-image points reflected mixed positive and negative self-image scores.

There is another possible reason why the analysis result of the self-image scale was not significant: Did the self-image used in the analysis truly symbolize the person’s self? In this study, we assumed that the subjects of written sentences are testees’ symbolized selves. What if the objects projected and identified with themselves were something else in the testees’ drawing? Or what if there was no such object? In such cases, the analysis result of the self-image scale would inevitably become insignificant. Therefore, defining the testees’ identified self-image will determine the applicability of this scale in the future.

In this study, we analyzed using only two measures suggested by Silver [31]. However, there are other ways to analyze pictures: one can explore the degree of space usage in drawings; after providing colored media, one can examine the types and number of colors used. Although such a method is not the standard analysis method of DAS, it would be meaningful to try various analysis methods to obtain significant results.

 

 

 

Question f) Conclusions are limited to one paragraph. I think they should be clearly. improved. Defining what are the main implications/advantages that are achieved thanks to the DAS.

Answer f) We further supplemented our conclusions as follows.

Line # 321-349:

5. Conclusions

We conducted this study to determine whether the DAS test that Silver developed to examine depression and aggression can predict soldiers’ stress, military life adaptation, and resilience. Our findings indicate that the emotional content scale of the DAS picture test can predict such variables. The three research hypotheses established in this study were partially adopted and partially rejected as follows. The first hypothesis was that the DAS scale would correlate significantly with military service stress, military life adjustment, and resilience of soldiers. We adopted this hypothesis. The emotional content scale of the DAS showed significant correlations with all of the variables we examined in the study. The second hypothesis was that the emotional content scale of the DAS would predict military service stress, military life adjustment, and resilience, respectively; we also adopted this hypothesis. Finally, we rejected the third hypothesis. Based on the regression analysis results, the self-image scale of the DAS could not predict military service stress, military life adjustment, or resilience, respectively.

In summary, we found that the DAS emotional content was helpful as a tool to evaluate the psychological state of soldiers, but the DAS self-image was not. These results suggest that it is necessary to consider the overall contents when using and interpreting drawing assessments rather than focusing only on a partial picture. A carefully used drawing test can provide a primary indicator for measuring the soldiers’ stress or resilience concerning military adaptation. In addition, we propose that by using picture tests to evaluate soldiers’ stress, adaptation, and resilience, practitioners can increase the likelihood of preventing problems in the military.    

             The limitations of this study and our suggestions for future research are as follows. First, this study only considered male conscripted soldiers in their early twenties. Thus, we cannot generalize these findings to female soldiers or those in other age groups. Second, we conducted a cross-sectional survey at a specific point in time and did not track the results longitudinally. Future studies should therefore consider investigating the relationship between DAS test results and subsequent adaptation to military life or related difficulties.

 

 

 

Question h) Include the scales questionnaire used in an annex.

Answer h) As you have pointed out, we have presented the questionnaire in the appendix.

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Appendix A. The Perceived Stress Scale

Please read each of the following questions and choose from 1 to 5 points that best represents your thoughts. (1 = strongly disagree, 5 = strongly agree)

 

1. I get stressed because of the inconvenience of facilities (e.g., toilet, bathroom).
2. I get stressed because of the lack of leisure life.
3. I get stressed because meals are poor.
4. I get stressed because the quality of supplies is not as good as expected.
5. I get stressed because My sleeping place is narrow and uncomfortable.
6. I get stressed because I don't have any feedback for my work.
7. I get stressed because what I have to do now doesn't make sense.
8. I get stressed because the life around me is confusing.
9. I get stressed when I have to do something contrary to my beliefs.
10. I get stressed because I don't know what to do.
11. I get stressed because of the rude words and behaviors of people around me.
12. I get stressed because of conflicts with people around me.
13. I get stressed because I don't have as much privacy as needed.
14. I get stressed because of unfair demands from people around me.
15. I get stressed because of excessive work.
16. I get stressed because the assigned task doesn't fit to my aptitude.
17. I get stressed because I lack the skills and experiences to do my job.
18. I get stressed because of the conflict over following instructions.
19. I get stressed because of the risk of accidents at work.
20. I get stressed because the work orders given to me are not clear.
21. I get stressed because my daily work is boring and unchanged.
22. I get stressed because my personal time (e.g., after work hours) is not guaranteed.
23. I get stressed because vacations or overnight stays are unreasonably carried out.
24. I get stressed because of my family problems.
25. I get stressed because of my lover.
26. I get stressed because I am anxious about the future after my release.

Appendix B. The Military Life Adjustment Scale

Please read each of the following questions and choose from 1 to 5 points that best represents your thoughts and feelings. (1 = strongly disagree, 5 = strongly agree) 

 

1. In general, daily life in the unit is cheerful.
2. I try to spend my free time in the military for my personal development.
3. My physical health is very good.
4. In battle, I want to fight for my country as a combatant rather than an administrative soldier.
5. If the country is in crisis, I will extend my service period.
6. When a battle occurs, I will go to the battlefield immediately.
7. If a war breaks out, I want to go to a unit on the front line.
8. My current position is very satisfactory compared to other positions.
9. If I were given the opportunity to change my position, I would not change it.
10. My job in the military is very valuable
11. In general, there are many opportunities to demonstrate my abilities in the military.
12. I think my position is very important for the military to carry out its combat mission.
13. I am doing my best in the military service.
14. Our unit's training and military conditions are very good.
15. My job in the military is interesting.
16. I think the military is very good in all respects these days.
17. Our unit's administration (e.g., reward, vacation, overnight stay, outing) is fair.
18. Work, training, and office hours in the military are meaningful.
19. In terms of mission performance, the levels of our unit's non-commissioned officers are excellent.
20. The officers keep what they once promised their subordinates to the end.
21. I have a lot of non-commissioned officers whom I want to be together in battle.
22. All officers in our unit care about their subordinates.
23. I think the current system of promotion in the order of seniority is a very good system.
24. Even when I receive an unfair order or instruction from my boss, I am not bothered.
25. I believe the military is doing its best for soldiers’ welfare.
26. I will have a good impression of the military when I am discharged.

Appendix C. The Connor-Davidson Resilience Scale

Looking back over the past one month, and please choose from 1 to 5 points that best represents how you think or feel. (1 = strongly disagree, 5 = strongly agree)

 

1. I am able to adapt to change.
2. I have close and secure relationships.
3. Sometimes fate or God can help.
4. I can deal with whatever comes.
5. Past success gives me confidence for new challenges.
6. I see the humorous side of things.
7. Coping with stress can strengthen me.
8. I tend to bounce back after illness or hardship.
9. Things happen for a reason.
10. I give my best effort no matter what.
11. I can achieve my goals despite obstacles.
12. When things look hopeless, I don’t give up.
13. I know where to turn for help.
14. Under pressure, I can stay focused.
15. I prefer to take the lead in problem solving.
16. I am not easily discouraged by failure.
17. I think of myself as a strong person.
18. I can make unpopular or difficult decisions.
19. I can handle unpleasant feelings.
20. Sometimes I have to act on a hunch.
21. I have a strong sense of purpose.
22. I am in control of my life.
23. I like challenges.
24. I work to attain my goals.
25. I have pride in my achievements.

Appendix D. The Draw-a-Story Drawing Test

Instruction: The stimulus pictures provided show pictures of people, animals, places, and objects. Choose two of these and imagine the story of what is going on between them. Now draw your story. You can change parts of the stimulus picture or add your ideas when you draw. When you have finished drawing, please write your story in the blank space.

 

 

 

Question i) They should use more updated bibliography as far as possible. Two citations from 2021, 0 from 2019, 3 from 2018, 2 from 2017, 0 from 2016.

 

Answer i) Thank you for your valuable point. As you said, we tried to cite the most up-to-date references. Followings are newly supplemented references.

References

10. Ha, J.H.; Jue, J.; Jang, Y. The relationship between army soldiers’ perceived stress and army life adjustment: Focusing on the mediating effect of stress response and the moderating effect of cohesion. MIL MED, 2020, 185(9-10), e1743-e1749. https://doi.org/10.1093/milmed/usaa114

 

17. Kimhi, S.; Eshel, Y.; Bonanno, G.A. Resilience protective and risk factors as prospective predictors of depression and anxiety symptoms following intensive terror attacks in Israel. PERS INDIV DIFFER, 2020, 159(1), 109864. https://doi.org/10.1016/j.paid.2020.109864

 

19. Song, Y.; Ha, J.H.; Jue, J. Examining the relative influences of the risk factors and protective factors that affect firefighter resilience. SAGE OPEN, 2020, https://doi.org/10.1177/2158244020982610

 

25. Afek, A.; Ben-Avraham, R.; Davidov, A.; Cohen, N.B.; Yehuda, A.B.; Gilboa, Y.; Nahum, M. Psychological resilience, mental health, and inhibitory control among youth and young adults under stress. FRONT PSYCHIAT, 2021, 11, 608588. https://doi.org/ 10.3389/fpsyt.2020.608588

 

30. Yoon, S.; Maguire-Jack, K.; Knox, J.; Ploss, A. Socio-ecological predictors of resilience development over time among youth with a history of maltreatment. CHILD MALTREATMENT, 2020, 26(2), 162-171. https://doi.org/10.1177/1077559520981151

 

Question i) In my opinion there are a large number of references to Korean journals and reports. 7 citations from Korean J ART THER.  Also cited, if not exhaustive: Korean J COUNS PSYCHOTHER, J Korean ACAD NURS, J Korean ACAD PSYCHIAT MENTAL HEALTH NURS..., among the many reports from Korea. 

 

Answer j) As you pointed out, Korea published many of the cited references. Although the subject of our thesis is mainly from studies in Korea, we hope that researchers from other countries will also be interested in this subject. We believe publishing our research in Sustainability, an internationally renowned journal, will enable more active academic exchanges in the future.

We look forward to seeing international research on this subject.

Author Response File: Author Response.pdf