The acute care psychiatric setting present concept of self and environ- strument was developed in 1948 by
requires that the occupational thera- ment as well as his emotional self: Buck, a psychologist, primarily as a
pist comes to an early decision re- It has been considered that the ex- test of intelligence. However, as
garding client treatment. In order to pression of ideas and feelings which more exact tests of intelligence were
do this, the occupational therapist are not completely understood by developed, it ceased to be used for
needs to have available efficient, re- the individual or currently accept- this purpose. Rather, its secondary
liable and valid evaluation tools. able to the individual is possible use, the identification of personality
Projective techniques have often traits and factors, predominated. In
been used in occupational therapy a formalized manner, the client is
for evaluation. Symbols are felt to The H.T.P. data were asked to draw first a house, then a
uncover the ideas and feelings of an tree and finally a person. This is
individual. Rosenfeld (1982) wrote
being used to develop an followed by the `post-drawing inter-
that projective tests help in the es- O. T. problem list and to rogation' consisting of 64 specific
tablishment of the individual's select O. T. treatment questions and a follow-up of any
leads resulting from the answers to
strategies. these questions. The drawings, to-
Helen Polatajko, PhD., OT(C), is an Associate gether with their responses to the
Professor, in the Department of Occupational questions, are then interpreted to
Therapy, Faculty of Applied Health Sciences, through the use of symbols (Mosey, provide data concerning the per-
cross appointment to Department of Educa- 1968). Unfortunately, at the present ceived developmental, traumatic or
tional Psychology — Faculty of Education, time, none of the projective tests
University of Western Ontario, London, environmental problems of the
Ontario. developed specifically for the use in client. Jones (1981) has provided a
Ethel Kaiserman, B.O.T., OT(C), is an occupational therapy, are standard- manual to guide these interpreta-
Occupational Therapist, with Community ized or well researched. tions.
Occupational Therapy Associates, Toronto, The House-Tree-Person Projec- The H-T-P has been in use by
Ontario. At the time of the study she was the
tive Technique (H-T-P) provides an occupational therapists at University
Senior Occupational Therapist, Psychiatry,
Occupational Therapy Services, University instrument with a well-standardized Hospital, London, Ontario, as part
Hospital, London, Ontario. system of administration. This in- of an assessment procedure with
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CJOT — Vol. 53 — No. 4
acute psychiatric clients. The thera- ingly accepted than other items, as a variety of patient populations. For
pists felt that the information col- objects for drawing by subjects of all example, Gording and Match (1968)
lected had implications for occupa- ages; and c) stimulated more frank reported on a preliminary study
tional therapy treatment. Thus, and free verbalization than did other using the techniques of free-hand
H-T-P data were being used to items. figure drawings of a house, tree and
develop an occupational therapy As Hammer (1978) describes, the person (H-T-P) to investigate per-
problem list and to select occupa- house, as a dwelling place, has been sonality changes in 33 contact lens
tional therapy treatment strategies. found to arouse within the subject wearers. Ernst, Beran, Badashi, Ko-
Subjectively, the therapists found associations concerning home life sovsky and Kleinhauz (1977) used
the use of the H-T-P to be an enjoy- and intra-familial relationships. The the H-T-P with elderly people with
able and beneficial process giving drawing of the house may reflect the a diagnosis of "chronic brain syn-
them greater insight into their subject's domestic situation in rela- drome", to investigate the effects of
clients' problems and facilitating tionship to his spouse or the child- bi-weekly sensory stimulation and
rapport. It was also felt to provide hood relationship to parental figures group therapy over a period of three
a forum for the establishment of a may still be apparent as residual months. Perkins and Wagemaker
consensus between therapist and attitudes. The drawing of the tree (1977) administered the H-T-P four
client regarding further assessment appears to reflect the subject's relati- times to a chronic schizophrenic un-
and the treatment program. Howev- vely deeper and more unconscious dergoing hemodialysis. Platzer
er, the literature provided no empir- feelings about himself, whereas the (1976) used the H-T-P in pre/post
ical evidence to support the use of drawn person becomes the vehicle test fashion with 40 subjects with
the H-T-P in this manner. The pur- for conveying the subject's closer-to- deficits in gross-motor skills and
pose of the study was to investigate conscious view of himself and his self-concept, randomly assigned to
the validity of the H-T-P in identify- relationship with his environment. experimental and control groups to
ing functional problems. In this manner, a picture of the determine program effectiveness.
conflicts and defenses as set in the All of the above investigators
hierarchy of the subject's personality reported changes due to treatment,
Literature Review structure is provided. having confidence in the test-retest
Initially, much of the work on the The research evidence to support reliability of the H-T-P. However,
H-T-P dealt with its use as a test of the validity and reliability of the these data cannot clearly be inter-
intelligence. However, as indicated H-T-P in its use in the identification preted as support for the instru-
above, with the advent of more valid of personality factors or stress factors ment's test-retest reliability. Such
intelligence tests, its use and subse- is scant and can be easily criticized. data is difficult to obtain due to the
quently the research in this area Nevertheless, based on research nature of both the instrument and
decreased a good deal (Kuhlman & available at the time the last review- its intended use (Haworth, 1965).
Bieliauskas, 1976; Kline & Svaste, er of the H-T-P for the Mental Mea- A number of studies have used the
1981). This literature is not of inter- surements Year Book concluded that H-T-P to identify differences in per-
est here and will not be discussed. the H-T-P is a valuable tool: sonality between various groups.
Of interest here is the use of the The H-T-P is now, and no doubt will Wildman, Wildman and Smith
H-T-P as a method of identifying continue to be, used as a rewarding (1967) asked hospital ward person-
stress factors and personality char- clinical technique in work with both nel to select 30 extroverted patients
adults and children. The amount of and 30 introverted patients. Both
acteristics and its use in psychiatric meaningful projective data to be
occupational therapy. groups were asked to draw same sex
derived from the drawings (and the
As with many projective tech- drawings according to H-T-P test
inquiry, if used) will depend on the
niques, the H-T-P received its impe- experience and o rientation of the cli- instructions. Extroverts did not make
tus from psychoanalytical theory nician. The test can se rve as a non- significantly larger drawings than
and evolved from empiricism and threatening `opener' before more for- introverts. Even when extreme cases
practical clinical observations mal testing (Haworth, 1965, p. 436). of expansiveness or constriction were
(Robin & Haworth, 1971). Symboli- It should be noted that this review used, the predictions of the H-T-P
cally potent concepts such as house, is quite old. This is reflective of the were only slightly above chance.
tree and person are thought to be evolution of projectives in general, Davis and Hoopes (1976) com-
saturated with the emotional and i.e., there was a loss of interest in pared the H-T-P drawings of a
ideational experiences associated such tests for a period of time due matched sample of 80 deaf and 80
with the personality's development, to the difficulty encountered in es- hearing, 7-10 year olds to assess
the drawing of these images compel- tablishing rigorous evidence of the differences related to the handicap,
ling projection on the part of the reliability and validity of such tests and the capacity of the H-T-P to
drawer (Hammer, 1978). In regard (Robin and Haworth, 1971). distinguish between children rated
to his choice of the specific items, There have been some studies by their teachers as poorly adjusted
Buck (1981) considered that the concerning the H-T-P in the more and those rated well adjusted. No
house, tree and person: a) were items recent past. A number have used the differences were found between deaf
familiar to all; b) were more will- H-T-P as a measure of change with and hearing children in the drawing
of the ear or mouth of the human tween the groups being contrasted. H-T-P's ability to assist in the identi-
figure, although there were signifi- Three of the studies found some fication of characteristics. However,
cant differences in the drawing of the differences (Davis et al. 1975; they do not substantiate this, partic-
branch structure of the tree. Also, no Gasparrini et al. 1980; and Blain et ularly since these studies used the
differences were found in the num- al. 1981). In all three studies the H-T-P in conjunction with a number
bers of indicators of disturbance be- groups being contrasted were credi- of other instruments and no clear
tween the drawings of the subjects bly different in some way, thus one indication is given of the relative
rated as more and less well adjusted. could assume the findings to support contribution of the individual tests
Kuhlman and Bieliauskas (1976) the H-T-P as a valid indicator of or the correlation between the tests.
administered the H-T-P to 30 black personality factors. However, it must Only a few studies looked at the
and 30 white adolescents, matched be remembered that unless there are identification of stress factors using
for sex, age, intelligence and socio- other external indicators of such dif- the H-T-P. Cooper and Caston
economic level. No significant dif- ferences, the findings remain equiv- (1969) studied the size of human
ferences were found between the two ocal. figure drawings before and after
groups on either the H-T-P, IQ mea- Similarly, for the studies that stress, (the stress being the an-
sures or the adjustment ratings. failed to show differences between nouncement of impending heart sur-
Hoover (1978) attempted to con- groups it cannot be determined, gery). They found a trend for post-
struct a composite personality profile from these studies, if differences did stress drawings to be larger than
for skydivers. Eighteen active ' sky- indeed exist or if the findings were pre-test drawings. Peyru and De
divers (median age 24-6 years), were valid. Pastrana-Borrero (1977) proposed a
administered the Rorschach,'' the psychotherapeutic method centred
Hand, the H-T-P and Draw-A=Per- on the evaluation of changes in the
son tests. No statistically significant In some instances the patients central oedipal conflict.
differences were found between the They used a battery of psychological
skydivers and a matched group of
H. T.P. missed problems tests administered at regular inter-
controls. while in others it vals during the course of therapy;
Gasparrini, Shealy and Walters identified unique the H-T-P, the Bender-Gestalt Test,
(1980) administered the H-T-P to 17 the Rorshach and the Phillipson
right hemisphere brain-damaged
problems not noted by Test, to identify stress in the form
patients, 19 left hemisphere brain- nursing or O. T. of a focal oedipal conflict.
damaged patients and 23 non brain- Finally one study was found which
damaged medical patients. Statisti- looked at the significance of a partic-
cal analyses revealed significant Still other studies used the H-T-P ular symbol. Devore and Fryrear
differences between groups in size to investigate the characteristics of (1976) compared the H-T-P draw-
and spatial placement of drawings. a specific population. Doorbar ings of 1,844 juvenile delinquents
Blain, Bergner, Lewis and Gold- (1967) used the Wechsler Adult In- and a sample of the adolescents who
stein (1981) conducted a study to telligence Scale, the Thematic Ap- drew the tree with a hole or scar to
determine whether the H-T-P might perception Test (TAT) and the 76 adolescents who drew a tree with
be used as a means to identify physi- H-T-P with 34 transexuals. no hole or scar. The two groups were
cally abused children. Protocols of Tropauer, Franz and Dilgard (1970) compared with respect to 22 vari-
32 abused children, 32 nonabused studied 20 children with cystic fibro- ables, including age, sex, urban or
but disturbed children and 45 ap- sis and 23 mothers of such children rural residence, total number of si-
parently well-adjusted children. (ages using psychiatric interviews and the blings, reading placement and 8
5-12 years) were examined for the H-T-P. Ullman, Moore and Reidy MMPI scales. The two groups dif-
presence of 15 objectively scorable (1977) compared the performance of fered significantly on two variables:
items that emerged as good potential 10 adult subjects with chronic atopic IQ and the mania scale of the
discriminators from an earlier pilot eczema with matched controls on the MMPI. Subjects who drew a tree
study. Results of several statistical MMPI, H-T-P, selected TAT cards with a hole were significantly more
analyses indicate that (1) items taken and an open-ended psychiatric in- intelligent and scored lower on the
individually discriminated strongly terview. Seligman (1979) examined mania scale.
between abused and well-adjusted personality and cognitive charac- As is evident from the above liter-
subjects, but not between abused teristics of black foster children using ature, the summary of the H-T-P
and non-abused but disturbed sub- the Bender Gestalt Test, the H-T-P, literature by Haworth in 1965 still
jects; and (2) the 6 most discrimi- the Wide Range Achievement Test, applies. The studies that exist have
nating individual items, discrimi- the Rorschach, a specially designed a number of methodological flaws,
nated reasonably well between sentence completion inventory, the many of which are inherent to the
abused subjects and both of the Weschler Intelligence Test and an investigation of projective tech-
other groups. extensive interview. niques. Consequently, little or no
In the six studies above, the inves- These studies indicate the confi- external validation exists for charac-
tigators assumed differences be- dence of their investigators in the teristics or problems identified by the
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CJOT — Vol. 53 — No. 4
Method
The purpose of this study was to
determine if the H-T-P could validly
and efficiently identify a problem list
for occupational therapy treatment.
In order to do this, a comparative
study using blinded procedures was
carried out.
Sample:
All the clients referred to occupa-
tional therapy between September,
1983 and April, 1984, were consid-
ered for the study. Criteria for
inclusion were: (1) admission to the
psychiatric unit at University Hospi-
tal in London; (2) referral to
occupational therapy; and (3) signed
tion for the duration of the testing. test and then both the senior and
informed consent. Criteria for exclu-
All testing was done in the late the RO were videotaped administer-
sion were: (1) acute psychosis; (2) ing the H-T-P. These tapes were used
afternoon. The testing took approxi-
second admission during the tenure to establish inter-rater agreement.
mately 40 minutes. After the testing,
of the study; (3) research officer's Each viewed the other's video and
the RO scored and interpreted the
vacation schedule precluding testing then scored the H-T-P independent-
H-T-P using Jolies' manual (1981).
at designated time for specific ly. In total, four H-T-P's were ad-
Finally, the RO generated the H-T-P
clients; (4) marked motor impair- ministered in this fashion. Once 80%
problem list using the H-T-P dic-
ment. agreement was achieved, data col-
tionary (see below for description)
The resulting sample consisted of
to translate the H-T-P terms into lection started. Halfway through
40 clients, 10 males, 30 females, be-
occupational therapy terms. The data collection inter-rater agreement
tween the ages of 17 and 73 (X =
H-T-P protocols and the H-T-P was again evaluated in the same
37.68; SD = 15.42) with a variety
problem lists were kept in a place manner described above. In all in-
of occupations (see Table 1). The
where the case occupational thera- stances, inter-rater agreement was
average length of stay was 4 to 5
pist did not have access to the results above 80% ranging from 81% to
weeks (X = 34.68 days; SD =
in order to keep the process blind. 100%.
17.14). The number of admissions
ranged from 1 — 10 with this being Furthermore, only code numbers
appeared on all protocols. Occupational Therapy Assessment:
the first admission for 15 clients and
The RO was a qualified occupa-
the second for nine. The clients suf-
tional therapist with experience in Concurrently, but independently,
fered from a variety of psychiatric
psychiatry. She was trained in the the occupational therapist assigned
conditions with depression being the
administration and interpretation of to the case administered the occupa-
most frequent psychiatric diagnosis
the H-T-P by the senior occupational tional therapy assessment to the
(see Table 2).
therapist on the unit. The training client. In all cases the occupational
proceeded as follows: (1) The RO therapist was one of the two occupa-
Procedures:
familiarized herself with selected tional therapists assigned to the psy-
H-T-P: Each subject was adminis- material available on the adminis- chiatric unit, one of whom was the
tered the H-T-P by a trained re- tration and interpretation of the H- senior mentioned above.
search officer (RO) within the first T-P, i.e. Bieliauskas, 1980; Buck, The occupational therapy assess-
two weeks of referral to occupational 1981; Hammer, 1981; Jolles, 1981; ment consisted of three parts: (1)
therapy. The H-T-P was adminis- Wenck, 1981, and then worked inte rv iew, (2) concrete task (tile tri-
tered as outlined in Buck's manual through these with the senior, iden- vet), and (3) abstract task (collage).
(1981), in any available space in the tifying issues and discussing prob- It should be noted that this was a
occupational therapy department lems. (2) Subsequently, the RO dynamic assessment process, i.e., it
where there would be no interrup- watched the senior administer one did not preclude therapeutic input
..,v u Jt. 2
.. .. :'.5c.am g -s
esn..Josa
...r'CS v_.e,..
scr,;.zoïyped pe1çoiiü;: ^ y
.4.n.=j diagnosis
l l.i:.^!l pV!iK;Yi.`'.oc.
during the assessment. All parts of grout so that they could finish their and glue them on paper in any man-
the assessment were administered on task. Throughout, discussion be- ner they chose. Again, there was
a one-to-one basis in a setting similar tween the occupational therapist and discussion throughout, focusing on
to that in which the H-T-P was ad- client centred on the choice of color the theme, the reason for the theme
ministered, although in this instance, and pattern, any difficulties exhibit- and pictures chosen, their signifi-
this was not always a private space. ed, and the relationship of these cance to the client and any difficul-
The assessment was administered at difficulties to home and work. ties in task performance.
various times during the working At the end of this process, the
day, in four separate sessions lasting occupational therapist generated an
for a total of approximately five occupational therapy (OT) problem
hours. list and placed it on the client's chart.
The inte rv iew, based on the Occu-
The H.T.P. is an efficient The RO did not have access to the
pational Therapy Services Initial In- and useful tool, charts at this point in the study.
terview was always given first. (N.B. particularly if it is
This document, as other non-
published materials mentioned in augmented by a work
Nursing Evaluation:
this paper are available from the assessment.
authors). This was followed by the This evaluation was carried out
concrete task. In this task, the clients within 48 hours of the admission of
were told where the tiles were and the client to the unit. The evaluation
asked to choose the color and design Lastly, the clients were asked to was always carried out on a one-to-
for their trivet. They were then given produce a collage. They were given one basis by the nurse assigned to
the glue and trivet and asked to glue the necessary equipment and asked the client. She/he did a nursing his-
the tiles onto the trivet. After a to pick a theme and pictures that tory and then generated the nursing
period of at least 24 hours (time for represented that theme. They were problem list which was placed on the
the glue to dry ) they were given then asked to cut these pictures out client's chart at that time.
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CJOT — Vol. 53 — No. 4
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203
CJOT — Vol. 53 — No. 4
0e: -
e
vs _
The percentage agreement and missed 12 times compared to nurs- OT assessment, taking 3+ hours less
percentage accounted for appear in ing. These misses were comprised of to complete. Of particular impor-
Table 6. As can be seen, in all cases, 4 different problems. Work problems tance here is the finding that this
the percentage accounted for is the were identified 17 times in the H-T-P gain in time is not accompanied by
greater. Also, both percentage but were missed 21 times when com- a great loss of information. The
agreement and the percentage ac- pared to the OT lists. There were 6 H-T-P identified 75.19% of the prob-
counted for between OT and the different problems which were lems identified by the OT assess-
H-T-P were higher than for nursing. missed repeatedly. ment. Given that OT typically only
identified four problems, this means
The nature of the problems iden- The H-T-P proved to be a consid- that only one problem was missed.
tified by the H-T-P spanned all the erably more efficient tool compared If this is counter-balanced with the
functional categories set out at the to the OT assessment. The average observ ation that the H-T-P typically
creation of the dictionary as did the time taken to administer the H-T-P, identified two additional problems
nature of the problems unique to the including the post-drawing interro- over the OT list, it suggests that the
H-T-P and the nature of missing gation was 40 minutes. The interpre- H-T-P is as proficient at identifying
problems. In the majority of cases tation of the projective material and problems as is the OT assessment.
the missing problems appeared in- the answers to the questions took
frequently (see Table 7). approximately another 50 minutes In terms of the unique problems,
per client, for a total of 90 minutes it must be remembered that there
Of interest in Table 7 are the for the complete administration of was no method available to assess
category specific discrepancies be- the H-T-P. The OT assessment took the validity of these problems. How-
tween H-T-P and Nursing and OT approximately 5 hours (300 minutes) ever, the observation that many of
problems. Namely, sexual problems to complete per client. the unique problems were sexual
were identified 30 times by the problems and, indeed, only 2 of the
H-T-P and 28 of these were unique 30 sexual problems identified by the
to the H-T-P. Likewise, 14 of the 39 Discussion H-T-P were identified elsewhere
self-concept problems were identi- suggests that the unique problems
fied by the H-T-P alone. Alternati- The H-T-P is clearly a more effi- may be indicative of areas where the
vely, mood/affect problems were cient method of evaluation than the H-T-P is more proficient.
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205
CJOT - Vol. 53 - No. 4
In terms of the missing problems, fled by the H-T-P. The percentage Doorbar, R.M. (1967). Psychological testing
a similar phenomenon is suggested. accounted for was considerably of transsexuals: a brief report of results
from the Wechsler Adult Intelligence
The H-T-P only identified work higher. Since this parameter is not Scale, The Thematic Apperception Test,
problems in 17 instances but missed affected by unique problems, it is and the House-Tree-Person Test. Transac-
21 occurrences of the work problems considered to be more meaningful. tions of the New York Academy of Sciences,
identified by OT. This again could It is important to remember that the 29, 455-462.
be interpreted as a statement on the latter is true only if the unique prob- Ernst, P., Beran, B., Badash, D., Kosovsky,
relative areas of proficiency of the lems identified by the H-T-P are true R. & Kleinhauz, M. (1977). Treatment of
the aged mentally ill: further unmasking
two instruments. problems. If not, then percentage of the effects of a diagnosis of chronic brain
Thus, it would appear that the agreement is a more accurate reflec- syndrome. Journal of the American Geria-
H-T-P is an efficient and useful tool tion of the performance of the HT- trics Society, 25, 466-469.
relative to the OT assessment, par- P. This study was not intended to Gasparini, B., Shealy, C. & Walters, D. (1980).
ticularly if it is augmented by a work verify whether unique problems Differences in size and spatial placement
assessment. of drawings of left versus right hemisphere
were true or false. However, since brain-damaged patients. Journal of Con-
In comparison to the nursing eval- the unique problems were largely in sulting Clinical Psychology, 48, 670-672.
uation, again the H-T-P seems to one area, it seemed to reflect the Gording, E.J. & Match, E. (1968). Personality
account for a substantial proportion differences in the orientation of the changes of certain contact lens patients.
of the problems identified (66.42%) instruments (e.g., sexual problems). Journal of the American Optometric Associ-
typically missing no problems. (It Thus, the percentage accounted for ation, 39, 266-269.
should be noted that the low per- may indeed be the more significant Hammer, E.F. (1978). The Clinical Applica-
tion for Projective Drawings. Charles C.
centage agreement relative to a parameter. Thomas. Springfield.
mode of zero for missing problems In summary: The problems iden-
Hammer, E.F. (1981). The House-Tree-Person
is more reflective of the small num- tified by the H-T-P were the same (H-T-P) clinical research manual. Los An-
bers being dealt with here than of as those identified by nursing and geles. Western Psychological Se rv ices.
poor agreement). The area most fre- OT in 66.4% and 75.2% of the cases Haworth, M.R. (1965). H-T-P: House-Tree-
quently having missing problems respectively. In some instances, the Person Projective Technique. In O.K.
was mood/affect. This occurred in H-T-P missed problems while in Buros (Ed). The Sixth Mental Measure-
ments Yearbook. Highland Park, N.J.:
12 instances although there were others it identified unique problems Gryphon Press, 6:214, 434-436.
only 4 different problems. Since the not noted by nursing or OT. There-
Hoover, T.O. (1978). Skydivers: Speculations
H-T-P did identify 34 mood/affect fore, for a thorough assessment, all of Psychodynamics. Perceptual & Motor
problems, 8 of which were unique, three procedures should be used. Skills, 47, 629-630.
it suggests that the H-T-P is not However, given the high percentage Jokes, 1. (1981). A catalog for the qualitative
deficient in this area but that specific of OT problems accounted for by the interpretation of the House-Tree-Person
problems should be looked at - such H-T-P, if a quick assessment is re- (H-T-P). Los Angeles. Western Psycholo-
an analysis was beyond the scope of quired, the H-T-P alone would be gical Services.
this paper. appropriate - taking special care to Kline, P. & Svaste, X.B. (1981). The House,
Tree, Person Test (HTP) in Thailand with
In interpreting the results of this look for work-related problems. 4 and 5 year old children: A comparison
research and in considering the im- of Thai and British results. British Journal
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Cooper, L. & Caston, J. (1969). Size of figures Perkins, C.F. & Wagemaker, H. (1977). Art
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Nursing and H-T-P and between OT Devore, J.E. & Fryrear, J.L. (1976). Analysis Platzer, W.S. (1976). Effect of perceptual
of juvenile delinquents' hole drawing motor training on gross motor skill and
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Résumé
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