Therapy through Art

This essay explores the therapeutic modality of the House-Tree-Person Test (HTP) in assessing the psychological state of individuals. It discusses the search strategy, keywords, and database selection used in the research. The literature review highlights the importance of HTP and identifies research gaps for future studies.

Running head: THERAPY THROUGH ART
Therapy through Art
Name of the Student
Name of the University
Author Note

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Table of Contents
Introduction................................................................................................................................3
About HTP.............................................................................................................................4
Search Strategy...........................................................................................................................5
Keyword Selection.................................................................................................................5
Selection of the database........................................................................................................6
Inclusion and Exclusion Criteria............................................................................................6
Search Outcome (PRISMA)...................................................................................................8
A statement on the state of literature..........................................................................................9
Literature Review.......................................................................................................................9
Research Gap.......................................................................................................................12
Conclusion................................................................................................................................13
References................................................................................................................................14

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Introduction
According to Hartley, Frank and Goldenson (2013), children’s drawing have a naiveté
and freshness which are lost quickly as defensiveness, conformity and sophistication take
over it. It is during this tenure of freshness and openness that children tell their adult care
givers must about themselves and about their human condition. The pioneer in the
psychological interpretation of the art in disturbed childhood was Bender and Despert.
Anastasi and Foley have done early exhaustive survey on the literature centring the artistic
behaviour in the abnormal. Alschuler and Hattwick have contributed towards giving proper
recognition to child’s painting (Hartley, Frank and Goldenson 2013). Raven was one who
have successfully described that the imaginative technique of a child is reflected through his
or her drawings and thereby helping to get an overview of the developmental and deviant
characteristics of a child. Multiple aspects of the human figures drawn by a child apart from
scenery also holds immense value in studying the mental development of child between the
age group of five to twelve years (Hartley, Frank and Goldenson 2013). The following essay
is a literature review which is based on the importance of the House-Tree-Person Test (HTP)
or House Tree-Person Activity. HTP is a projective art therapy drawing technique which was
first developed by John Buck (Burns 2014). In this review, the therapeutic modality of HTP
will be studied. The therapeutic modality of the HTP will be accessed based on the
application of the HTP in assessing the psychological state of a person. In doing so, the essay
will initiate will a detailed description of the search strategy and the keywords used along
with the pattern of the electronic database search. This will be followed a detailed narrative
review of the selected studies along with finding of the research gap for future research. At
the end, the review summary will conclude via highlighting the main points gathered from
the review.

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About HTP
The HTP activity was introduced in the mid to late 1940 by John Buck. It is used as a
substitute to the IQ test, which is used to analyse the level of human intelligence and is also
used to access the personality of the individuals (Leibowitz 2013). Oster (2016) are of the
opinion that the stimulating ability of the House, Tree and Person provides emotionally
restrained clients the possibility, sovereignty and provision in order to express their feelings
while providing strategic benefits within the clinical background. In HTP, house is the sense
of self and ego. The size of the house is proportional with the controlled atmosphere or ego of
the individuals. The position of the house of the paper or the lines of the house specifies the
ego strength. Similarly, the tree trunk, the doors and the windows of the house, the walk away
from the house, the branches of the tree, the height and the posture of the person also
signifies several aspects of a person’s ego, there underlying thoughts and the present
relationship status (Leibowitz 2013). The HTP activity is used to access the aspect of well-
being and the mental health of children, adolescents and adults. The aspect of well-being is
associated with various psychological construct like identity, emotion, cognition, personal
goals, personality, coping skills, values, spiritualty and social skills (Schmitt et al., 2014).
House-Tree-Person assessment is a broad-based yet uneven investigation of
psychotherapy. The three factors which restricts the overall validity of the House-Tree-Person
clinical values are (i) literature on HTP is largely associated to psychiatric entities as the
standardisation and development of the assessment are mainly concentrated over the
abnormal patients in the psychiatric care; (ii) all the three drawings (hose, tree and person)
are drawn on here separate papers and thus there can be no direct connectivity or actions
between the illustrations; (iii) the data or the symbols are verified under the Freudian matrix
(Oster 2016). According to Fairbairn’s postulate, as stated in 1946, the Freud’s conception of
identity and ego is not clear. Freud emphasize that identity is unstructured energy and the ego

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is structured which is deprived of energy. However, Fairbairn is of the opinion that all these
are dynamic with variations in the energy sources (Birtles and Scharff 2018).
Search Strategy
Keyword Selection
In the systematic review of the literature, the main aspect is search of the relevant
articles in the electronic databases. According to Mcintosh-Scott et al. 2014), proper
identification of the keywords help to search authentic articles that fall within the scope of the
study. Polit and Beck (2014) stated that during the initiation of online search of the articles, it
is mandatory to select the keywords. The selection of the keywords should be done in a
manner that covers the main concepts of the research. The table below highlights the
keywords which were used for the search of the scientific articles in the electronic databases.
Table for Keywords
1. House-Tree-Person Test OR House-Tree-Person OR House-Tree-Person Assessment OR House-
Tree-Person Activity
AND
2. Mental state assessment OR Psychological Assessment OR Emotional Assessment
AND
3. Young adults AND Children AND Adolescents
Source: Created by the Author
A broad range of the target population was selected in the keywords (Young adults
AND Children AND Adolescents). This is because, increase the span of the population will

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help to increase the overall search hits. The use of the children or the infants alone might
decrease the overall relevant search results.
Selection of the database
According to the data published in the book of Parahoo (2014), the online databases
helps to access a huge lot of information from the recently published literature. The online
databases which are used for the search of the scientific articles online include MedLine,
Ovide, Cinhal, Cochrane.
Inclusion and Exclusion Criteria
Aveyard (2014) stated that having a proper plan for doing a search of the scientific
articles online means that the pattern of the data search is a specific focus on the aim of the
search and no extra time is wasted in scrolling through the irrelevant data. Coughlan et al.
(2013) opined that this approach helps to set specific boundary for the online search of the
articles. Moreover, the selection of the inclusion and the exclusion criteria for the article
selection must be justified. The detailed of the inclusion of the inclusion criteria is listed
below in the table
Initial Inclusion and Exclusion Criteria
Articles published during 2013 to 2019 Articles published before 2013
Articles based strictly on all the three aspects of
the HTP test
Articles based on different aspects of HTP test
separately
Source: Created by author
The use of this inclusion and the exclusion criteria in the database search leads to
negligible to no significant results online. This signified that no specific studies conducted on
HTP test during the tenure of 2013 to 2019. Hence the inclusion and the exclusion criteria

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were broadened. According to Parahoo (2014), selection of the exclusion criteria which are
too specific might lead to side-passing of the important information which is relevant for the
research.
Final and Modified Inclusion and Exclusion Criteria
Articles published during 2010 to 2019 Articles published before 2010
Articles based on different aspects of HTP test
separately
Source: Created by author

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Search Outcome (PRISMA)
A statement on the state of
literature
The main statement of the state of the literature is, the implication of the HTP can be
used for the accessing the mental health condition of a children and adolescents of the young
adults. The main thesis statement will be guided by the motion that HTP is an important tool
Records identified by database
search
(n=71)
Studies included (n=3)
Duplicates removed (35)
Records screened
(n=35)
Full text articles excluded
(n=2)
Not covering HPT assessment
as primary intervention (n= 2)
Full-text articles assessed
(n=5)
Records excluded based on title only
(n=25); Records removed based on
abstract (n=5) Identification
ScreeningEligibility
Included
Medline
(n=19)
Cinhal
(n=20)
Ovid
(n=15)
Cochrane library
(n=17)

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for getting a rough overview of the mental state under the concept of the psychological
therapy through the application of art.
Literature Review
According to Crawford et al. (2012), when children use their drawing skills under
clinical contexts, the clinician or the mental health professionals mainly depends on the use
of the colour by the children in order to make inferences about their emotional association
with the drawing. The main aim of the research was to elucidate whether the use of the colour
by the children can be used to display emotions in their drawings. In the experiment, the
children were asked to show their colour preferences in HTP paintings. They were mainly
asked to colour the outlines of figures characterised as either nice or nasty. Children were
also asked to draw multi-coloured pictures in relation to either some happy or sad
experiences. In experiment two, the children who are hospitalized are drawn about being
scared or tensed in hospital about their positive experiences. In both the experiments, the
study was conducted in order to analyse the relationship between the children’s colour use
and the colour of their preferences when they are asked to paint HTP diagrams sketched by
them (Crawford et al. 2012). The analysis of the results highlighted that the three to then
years old children used their preferred colours in order to colour the nice outlines. However,
they were more likely to use non-preferred colours to paint the nasty outlines. Moreover, a
mixture of both preferred and non-preferred colour was used to paint the nasty outline. When
the drawings are presented by both the hospitalized and the normal children in the domain of
both positive and negative events, there was no significant relation with choice of the colours
by the children and their colour preferences. Children mainly used their preferred colours in
order to fill their diagrams. Thus the interpretation of the data mainly highlighted that it will
be the role of the mental health professionals to exercise with caution while interpreting the

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meaning of the colours in the children’s drawing. Thus the study lead to the elucidation that
the use of the HTP, more precisely, use of the colours in the HTP sketches can be used to
access the state of mind of the children and their under psychology in connecting or relating
with the colours (Crawford et al. 2012). However, the article has few limitations like it has
not specified that whether the children who are hospitalized are suffering from any kind of
mental health complications or physical health complications, this will help in the assessment
of their comprehensive mental health state.
The study conducted by Li et al. (2014) was directly based on the Kinetic-House-
Tree-Person (KHTP) drawing test in order to validate its scoring system and its psychometric
properties over a group of individuals who have psychiatric disorder. Mainly college students
were used for the assessments who are suffering from psychiatric disorders. Each of the
participants were asked to completed KHTP test. Half of the participants with mental health
complications complete KHTP again following tenure of 2 weeks. The KHTP scoring system
had 54 items representing characteristics of drawing. The drawing were analysed by two
independent reviewers and accordingly scores for the drawing were given while keeping the
validity and reliability of the KHTP scoring system. The overall results revealed both validity
and reliability of the KHTP scoring system thus demonstrating the acceptable reliability of
the test. The intra-class correlation co-efficient of the scoring system’s inter-rater reliability
was found to be 76. This showed a significant statistical difference between the KHTP scores
of the college students and the individuals with psychiatric disorders. From the interpretation
of the results, the authors concluded that the KHTP scoring system has an acceptable level of
construct validity, inter-rater reliability along with test-retest reliability. Li et al. (2014)
further stated that because the drawing tests have an additional advantage of expressing the
non-verbal characteristics, the overall scoring system must prove to be useful for those
individuals who are unwilling or are unable to communicate verbally. Thus the study

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conducted by Li et al. (2014) provides important information for the clinical application in
the domain of psychiatric rehabilitation professions. The study however, only focused on the
young adults who are the college students who are suffering from the psychiatric disorders, a
different aspect of the reliability and validity of the HTP test can be achieved if the test was
conducted among the children below the age of 18.
Picard and Lebaz (2010) are of the opinion that use of the drawing activity can be
defined as a medium in order to access the intellectual’s ability of the children along with
personal and present emotional state. The study conducted by Picard and Lebaz (2010) was
used to test whether, under free (colouring and drawing) conditions among the children and
the young adults are varied in the domain of size and colour and the same can be used to
interpret their underlying emotional consequences. For the conduction of the study, Picard
and Lebaz (2010) selected 80 different French children and adults who have no known mood
disorders. This group of children was divided into four different groups like group of 5-year
old, group of 7-year old, group of 11-year old and the adults. Each of the group contained 10
female and 10 make participants. The participants were observed individually under a quite
room setting in their school or college premises. They were provided with a sheet of paper, a
regular grey pencil and nine different colours namely black, brown, red, blue, purple, orange,
yellow, and green and pink. They are asked to draw a tree as a baseline drawing and then a
happy and a sad tree. The entire session lasted for about 10 minutes. The drawing were
measured on the domain of height of the tree and the use of the colours over the baseline
drawings. The frequency of the use of the colours was also accessed in order to explore the
drawing type. The analysis of the results highlighted that the free drawing and colouring
conditions showed increased size of the drawings among the children who falls under the age
group of 7. The size of the drawings reduced in case of sad tree. The group who are 5-year
old, the variation in the size was not significant. The symbolic use of the colours was also

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reflected like the participants tend to use dark hue of colours in order to represent the sad
version of the tree paintings. Thus the dark colours mainly represented negative emotions. It
was also elucidated that the irrespective of the age of the participants, the use of the colours
was done in a visually realistic manner. The main implication of the study is, it helps in
accessing the psychological state of a person. However, the symbolic use of the characters
must be taken under deep consideration.
One of the limitations of the study is, their analysis was mainly restricted to single
topic that is tree drawing. The following the task instructions are used in the study, did not
ensured that the children and the young adults were showing their mood symbolically as
opposed to simply showing their image of sad or happy tree. Thus, further evidence for the
symbolic use of the size (but not the colour) under the free drawing settings by involving
trees and other different topics like the house and the person would be important for both
healthy control and assessment of other mental or clinical mood disorder conditions.
Research Gap
The review of the literature mainly highlighted how the use of the colour and the
length of the sketches in the HTP test or activity can be used for the assessment of the mental
health state that is happy or sad. This was mainly done by the use of the colours. Thus the
future prospect of the research will mainly be guided by the validation and the overall
effectiveness of the HTP in accessing the psychological development of child. This can be
done via comparing the results obtained by HTP with any other psychological assessment
tests. According to Upadyaya and Salmela-Aro (2013), the mental health development of a
child is mainly guided by their ego, self esteem and their level of confidence. Upadyaya and
Salmela-Aro (2013) are of the opinion that the children who have higher level of self-esteem
and higher level of the self-confidence are more susceptible in having a successful career in
life going forward.

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Conclusion
The review of the literature highlighted that use of the different aspects of the HTP
activity of test might be helpful in getting a rough overview of the state of the mind of the
individuals and his or her perspective in viewing things positively and negatively. This can be
gauged from the size of the tree draw through the HTP test of the pattern of the lines and the
use of the colours. Mainly the colours which are assumed to be favourite by one individual
are used to draw a happy image, whereas the darker or the black colours can be used to
portray bad interpretation of the images. These results are consistent irrespective of the age of
the individuals between the age group of 5 to 18 years. Moreover, the review of the literature
also highlighted that the validation process which are used in the process of reviewing the
diagrams is also reliable and consistent.
Thus from the above discussion, it can be concluded that although HTP is popular
clinical assessment and a huge amount of data along with interpretation is available in the
literature, the overall validity and reliability is potentially poor. However, art therapy
development is significantly funded by the application of HTP. Further research are required
to be undertaken in order to access the application of the HTP in accessing the ego, self-
esteem and the level of confidence and the surrounding atmosphere in which the children is
raised and its effect on their development and this is required to be done via performing a
comparative analysis with other established mental health assessment tool.

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References
Aveyard, H., 2014. Doing a literature review in health and social care: A practical guide.
McGraw-Hill Education (UK).
Birtles, E.F. and Scharff, D.E., 2018. From instinct to self: the evolution and implications of
WRD Fairbairn’s theory of object relations. In Fairbairn and the Object Relations
Tradition (pp. 5-25). Routledge.
Burns, R.C., 2014. Kinetic House-Tree-Person Drawings: KHTP: An Interpretative Manual.
Routledge.
Coughlan, M., Cronin, P. and Ryan, F., 2013. Doing a Literature Review in Nursing, Health
and Social Care: SAGE Publications. Sage.
Crawford, E., Gross, J., Patterson, T. and Hayne, H., 2012. Does children's colour use reflect
the emotional content of their drawings?. Infant and Child Development, 21(2), pp.198-215.
Hartley, R.E., Frank, L.K. and Goldenson, R., 2013. Understanding children's play.
Routledge.
Leibowitz, M., 2013. Interpreting projective drawings: A self-psychological approach.
Routledge.
Li, C.Y., Chung, L., Hsiung, P.C., Chen, T.J., Liu, S.K. and Pan, A.W., 2014. A
psychometric study of the Kinetic-House-Tree-Person scoring system for people with
psychiatric disorders in Taiwan. Hong Kong Journal of Occupational Therapy, 24(1), pp.20-
27.
McIntosh-Scott, A., Mason, T., Mason-Whitehead, E. and Coyle, D., 2013. Key concepts in
nursing and healthcare research. Sage.

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Oster, G.D., 2016. Using Drawings in Clinical Practice: Enhancing Intake Interviews and
Psychological Testing. Routledge.
Parahoo, K., (2014). Nursing research: principles, process and issues. Palgrave Macmillan.
Picard, D. and Lebaz, S., 2010. Symbolic use of size and color in freehand drawing of the
tree: myth or reality?. Journal of Personality Assessment, 92(2), pp.186-188.
Polit, D.F. and Beck, C.T., 2008. Nursing research: Generating and assessing evidence for
nursing practice. Lippincott Williams & Wilkins.
Schmitt, M.T., Branscombe, N.R., Postmes, T. and Garcia, A., 2014. The consequences of
perceived discrimination for psychological well-being: a meta-analytic review. Psychological
bulletin, 140(4), p.921.
Upadyaya, K. and Salmela-Aro, K., 2013. Development of school engagement in association
with academic success and well-being in varying social contexts: A review of empirical
research. European Psychologist, 18(2), p.136.