丁俊贵之《论“房树人”绘画投射的艺术治疗》

论文标题：栖居的隐喻：基于“房树人”绘画投射的艺术治疗对医院实习护生环境适应不良的干预研究

摘要：

本研究旨在探讨融合哲学心理学视角的“房树人”绘画测验艺术治疗技术，对缓解医院驻点班实习护生环境适应不良的有效性。研究以存在主义哲学“在世之在”与道家“天人合一”思想为理论透镜，将适应不良重新定义为个体与医疗环境“意义世界”联结的断裂。研究采用混合方法设计，对60名存在中度及以上环境适应不良的实习护生进行随机对照试验。量化结果表明，实验组（接受为期6周、每周一次的团体艺术治疗）在《护生环境适应量表》与《症状自评量表-焦虑/抑郁维度》上的后测得分显著优于对照组（p<0.01），其绘画作品中的“空间开放性”、“根系稳固性”及“人物互动性”隐喻指标亦呈现积极演进。质性分析结合荣格“积极想象”与王阳明“心即理”的阐述，揭示了治疗过程如何通过象征性表达，促进护生内在心理图式与外部医院环境的重新整合，化“他者之地”为“意义之乡”。本研究为护理人文教育与心理支持提供了兼具东方心性哲学与西方深度心理学根基的创新型干预范式。

关键词： 房树人测验；艺术心理治疗；实习护生；环境适应不良；存在主义；投射技术；量化研究

引言

医院，作为生、死、病、痛交汇的独特场域，对初入临床的实习护生而言，不仅是技能实践的物理空间，更是一个充满情感张力与存在挑战的“意义环境”。环境适应不良，常表现为高焦虑、情感耗竭、疏离感及职业认同动摇，已成为影响护生身心健康与职业发展的关键问题。超越行为主义式的压力应对训练，从哲学心理学视角审视，此“不适”本质是个体（护生）与世界（医院环境）的意向性关系出现了障碍，即海德格尔所言“栖居”感的丧失，个体无法在繁忙、冰冷的医疗体系中安顿其“此在”。

艺术治疗，尤其是“房树人”绘画测验，作为一种非语言的投射技术，为触及并转化这种深层的存在性不适提供了桥梁。它根植于弗洛伊德与荣格关于无意识与象征的理论，认为绘画中的房、树、人并非客观再现，而是个体内在世界与外部环境关系的隐喻性表达。本研究创新性地融合了东西方哲学心理学智慧：一方面，借鉴存在主义与现象学，关注护生在医疗环境中“被抛入”的体验及其意义建构；另一方面，汲取中国道家“身国同构”与心学“在事上磨炼”的思想，视适应为内外和谐的动态过程。研究旨在通过严谨的量化与质性分析，验证这一整合性艺术治疗模式的有效性，并阐释其内在疗愈机制。

理论框架与文献综述

1. 哲学心理学根基：

（1）西方存在-现象学视角

雅斯贝尔斯强调“临界境遇”对人格塑造的推动力。医院实习正是一种“临界境遇”，护生被迫直面生命有限性。梅洛-庞蒂的“身体现象学”指出，身体是我们感知世界的媒介，护生的身体不适（如疲惫）常是心理不适的体现。艺术治疗通过创造（绘画）这一身体化行动，使无形的适应压力得以“具身化”并被审视。

（2）东方心性哲学视角

《庄子·齐物论》中“天地与我并生，而万物与我为一”的境界，指向一种主客交融的适应状态。王阳明提出“心外无物，心外无理”，强调意义由心而生，非由外铄。治疗的核心是帮助护生在其“心”上，与医院环境达成新的“理”的和谐，而非单纯改变外部行为。

（3）深度心理学视角

荣格的“集体无意识”与“原型”理论认为，“房子”可视为“自我”原型的象征，“树”连接着生命与成长，“人”则代表当下的自我认知。绘画过程是一种“积极想象”，能激活自性化的潜能，促进心理整合。

2. “房树人”作为治疗媒介：

巴克发展的“房树人”测验，因其结构简单、内涵丰富，被广泛用于评估人格与关系。在治疗情境中，它从评估工具转化为对话媒介。画纸成为护生内心世界与外部环境之间的“过渡性空间”（温尼科特），在此空间内，对环境的恐惧、疏离、期待得以安全地外化与重构。

研究方法

1. 研究设计： 采用随机对照前测-后测设计，并嵌入质性个案研究。

2. 参与者： 从某三甲医院驻点实习的240名护生中，采用《护生环境适应量表》进行筛查，选取得分处于后25%（表明存在中度及以上适应不良）的60人，随机分为实验组（n=30）与等待对照组（n=30）。两组在年龄、性别、前测得分上无显著差异。

3. 干预方案（实验组）：

形式： 封闭式团体艺术治疗，每周1次，每次90分钟，共6周。

主题进阶：

第1-2周：“初识之地”——绘制“我初来乍到的医院”，侧重情绪表达。

第3-4周：“局内之眼”——绘制“我所在病区的一角与我”，侧重关系探索。

第5-6周：“重构之乡”——绘制“我期望中能给予我支持的医院环境”，侧重意义重构与资源挖掘。

治疗师角色： 遵循“非指导性但促进性”的原则，运用现象学式提问（“你能多告诉我一些关于这棵树的感觉吗？”），结合道家“无为而治”的思想，鼓励成员自我诠释与团体共鸣，避免权威解读。

4. 测量工具：

量化工具：

（1）《护生环境适应量表》：包含人际关系、工作负荷、角色认同、环境控制感4个维度，共20条目，Cronbach‘s α=0.87。

（2）《症状自评量表》的焦虑与抑郁分量表。

（3）绘画隐喻指标量化表（自编）： 由3名不知分组情况的艺术治疗师对“房树人”作品进行独立评分（0-5点Likert量表），评估：

空间开放性： 画面布局是否局促压抑 vs. 流动开放。

根系稳固性： 树木根基是否虚弱漂浮 vs. 扎实深入。

人物互动性： 人物是否孤立背对 vs. 与环境或他人有互动。

质性资料： 治疗过程记录、部分参与者的深度访谈、系列绘画作品。

5. 数据分析： 采用SPSS进行协方差分析，比较两组后测得分差异。对绘画指标评分进行组间比较。对质性资料进行主题分析。

结果

1. 量化结果：

协方差分析（控制前测分数）显示，实验组在《护生环境适应量表》总分及各维度后测得分上均显著高于对照组（F=28.43, p<0.001；各维度p<0.01）。SCL-90焦虑、抑郁分量表得分显著低于对照组（p<0.01）。

实验组绘画作品的“空间开放性”、“根系稳固性”、“人物互动性”三项隐喻指标的后测评分显著高于本组前测及对照组后测（p<0.01），且评分者间一致性高（ICC>0.80）。

2. 质性发现与经典案例分析：

以成员小A（化名）为例。前测绘画中，其“房”（医院）巨大、门窗紧闭，位于画纸边缘；“树”细小无叶，根系悬空；“人”背对画面，尺寸渺小。这生动隐喻了其被环境吞噬、孤立无根的状态。她自述：“我感觉自己像个透明人，在走廊里飘，碰不到任何实在的东西。”

治疗过程中，小A在第三次绘画时，为“医院”添加了一扇带有门把手的小侧门（“也许有一个我可以悄悄进入的出口”）。第五次绘画，她画了一棵扎根在病床旁的树，树上系着代表祝福的千纸鹤，一名护士（自己）正与病床上的患者共同望向窗外夕阳。她分享道：“我好像明白了，支撑感不是环境给我的，是我在照顾病人的那一刻，自己心里长出来的。医院不再只是一个‘地方’，它开始有了一些我和病人共同的‘时刻’。”

此案例印证了治疗如何促进从“被抛入的客体”到“主动参与的主体”的转变，即从海德格尔的“沉沦”转向“本真能在”，亦暗合了阳明心学“事上磨练，乃见真体”的实践智慧。

讨论

本研究证实，以哲学心理学为纲的“房树人”艺术治疗，能有效改善实习护生的环境适应不良。其疗效机制可能在于：

1. 象征性外化与具身化

将抽象、弥漫的适应压力转化为具体、可视的象征意象（如紧闭的门、无根的树），使其成为可被观察、思考和对话的“对象”，打破了焦虑的循环反刍。

2. 意义重构与叙事整合

通过系列绘画，护生无意识中完成了对环境体验的“再叙事”。从最初的“威胁性故事”，逐步过渡到包含挑战、资源与微小联结的“复杂性故事”，乃至最终生成带有个人意义的“成长性故事”。这实现了维克多·弗兰克尔意义治疗所倡导的“对不可改变之环境的态度的转变”。

3. 主客关系的哲学性调和

治疗过程暗合了从主客二分到主客交融的东方哲学路径。护生不再视医院为纯粹的、异己的“客体”，而是通过自身的情感投入与创造性行动，将其逐步转化为承载个人实践与意义的“生活世界”的一部分，从而恢复“栖居”感。

结论与启示

本研究将“房树人”绘画测验从一种评估工具，深化为一种根植于东西方哲学心理学深厚传统的艺术治疗干预。它不仅为缓解实习护生环境适应不良提供了实证有效的“术”，更启发了护理人文关怀的“道”——即关注护生作为完整“人”在与医疗环境相遇时的存在性体验与意义建构。

未来研究可延长随访时间，检验疗效的持续性，并探索该模式在其他高压力职业群体环境适应中的应用。教育者与临床管理者可考虑将此整合性艺术治疗模块纳入护生岗前培训与持续支持体系，培育更具心理弹性与人文深度的护理人才。

参考文献

[1]Heidegger, M. Being and Time. (Trans. J. Macquarrie & E. Robinson). Harper & Row, 1962.

[2]王阳明. 传习录. 中州古籍出版社, 2008.

[3]Jung, C. G. The Archetypes and the Collective Unconscious. Princeton University Press, 1969.

[4]Buck, J. N. The House-Tree-Person Technique. Western Psychological Services, 1948.

[5]梅洛-庞蒂. 知觉现象学. 姜志辉, 译. 商务印书馆, 2001.

[6]Frankl, V. E. Man's Search for Meaning. Beacon Press, 2006.

翻译英文全文如下：

Title: The Metaphor of Dwelling: An Intervention Study on Art Therapy Based on the House-Tree-Person Drawing Projection for Nursing Interns' Maladjustment to the Hospital Environment

Abstract:

This study aimed to investigate the effectiveness of an art therapy technique integrating the House-Tree-Person(HTP) drawing test from a philosophical psychology perspective in alleviating environmental maladjustment among nursing interns stationed at hospitals. Using the existential philosophical concept of "being-in-the-world" and the Daoist idea of "the unity of heaven and humanity" as theoretical lenses, maladjustment is redefined as a rupture in the connection between the individual and the "world of meaning" within the healthcare setting. A mixed-methods design was employed, conducting a randomized controlled trial with 60 nursing interns exhibiting moderate or higher levels of environmental maladjustment. Quantitative results indicated that the post-test scores of the experimental group (receiving 6-week, once-weekly group art therapy) on the Nursing Intern Environmental Adaptation Scale and the anxiety/depression subscales of the Symptom Checklist-90 were significantly better than those of the control group (p<0.01). The metaphorical indicators of "spatial openness," "rootedness stability," and "figure interaction" in their drawings also showed positive progression. Qualitative analysis, incorporating Jung's "active imagination" and Wang Yangming's concept of "the mind is principle," revealed how the therapeutic process facilitated the reintegration of interns' internal psychological schemas with the external hospital environment through symbolic expression, transforming the "land of the other" into a "home of meaning." This study provides an innovative intervention paradigm grounded in both Eastern philosophy of mind and Western depth psychology for nursing humanities education and psychological support.

Keywords: House-Tree-Person Test; Art Psychotherapy; Nursing Interns; Environmental Maladjustment; Existentialism; Projective Technique; Quantitative Research

Introduction

The hospital,as a unique field where life, death, illness, and pain converge, is not merely a physical space for skill practice for novice nursing interns, but also a "meaningful environment" full of emotional tension and existential challenges. Environmental maladjustment, often manifested as high anxiety, emotional exhaustion, a sense of alienation, and动摇 professional identity, has become a key issue affecting the physical and mental health and career development of nursing interns. Moving beyond behaviorist stress-coping training, and examining this "discomfort" from a philosophical psychology perspective, its essence lies in a disruption of the intentional relationship between the individual (the intern) and the world (the hospital environment)—a loss of the sense of "dwelling" as described by Heidegger, where the individual cannot settle their "Dasein" within the busy, impersonal medical system.

Art therapy, particularly the HTP drawing test, serves as a bridge to access and transform this deep-seated existential discomfort as a non-verbal projective technique. Rooted in Freudian and Jungian theories of the unconscious and symbolism, it posits that the house, tree, and person in the drawing are not objective representations but metaphorical expressions of the relationship between the individual's inner world and the external environment. This study innovatively integrates Eastern and Western philosophical psychology wisdom: on one hand, drawing on existentialism and phenomenology to focus on the interns' "thrownness" experience and meaning construction within the medical environment; on the other hand,汲取 Chinese Daoist ideas of "the isomorphism of body and state" and the Neo-Confucian concept of "tempering through affairs," viewing adaptation as a dynamic process of internal-external harmony. The study aims to validate the effectiveness of this integrated art therapy model and elucidate its inherent healing mechanisms through rigorous quantitative and qualitative analysis.

Theoretical Framework and Literature Review

1. Philosophical Psychology Foundations:

    *  Western Existential-Phenomenological Perspective:Jaspers emphasized the motivating force of "boundary situations" for personality formation. Hospital internship constitutes such a "boundary situation," forcing interns to confront human finitude. Merleau-Ponty's "phenomenology of the body" points out that the body is our medium for perceiving the world; physical discomfort (e.g., fatigue) in interns is often an embodiment of psychological discomfort. Art therapy, through the embodied action of creation (drawing), allows intangible adaptive stress to be "embodied" and examined.

    *  Eastern Philosophy of Mind Perspective:The state described in Zhuangzi·Discussion on Making All Things Equal—"Heaven and earth were born at the same time as I was, and the ten thousand things are one with me"—points towards a state of adaptation characterized by subject-object fusion. Wang Yangming proposed that "there are no things outside the mind, and there is no principle outside the mind," emphasizing that meaning arises from the mind, not from external imposition. The core of therapy is to help interns achieve a new harmony of "principle" within their "mind" regarding the hospital environment, rather than merely changing external behaviors.

    *  Depth Psychology Perspective:Jung's theories of the "collective unconscious" and "archetypes" suggest that the "house" can be seen as a symbol of the "Self" archetype, the "tree" connects life and growth, and the "person" represents current self-perception. The drawing process is a form of "active imagination" that can activate the potential for individuation and promote psychological integration.

2. The HTP as a Therapeutic Medium:

The HTP test developed by Buck is widely used for assessing personality and relationships due to its simple structure and rich connotations.In a therapeutic context, it transforms from an assessment tool into a dialogical medium. The drawing paper becomes a "transitional space" (Winnicott) between the intern's inner world and the external environment, within which fears, alienation, and expectations towards the environment can be safely externalized and reconstructed.

Methods

1. Research Design:A randomized controlled pretest-posttest design was used, embedded with qualitative case studies.

2. Participants:From 240 nursing interns stationed at a tertiary hospital, 60 scoring in the bottom 25% on the Nursing Intern Environmental Adaptation Scale (indicating moderate or higher maladjustment) were selected and randomly assigned to an experimental group (n=30) or a wait-list control group (n=30). The two groups showed no significant differences in age, gender, or pretest scores.

3. Intervention Protocol (Experimental Group):

    *  Format:Closed-group art therapy, once per week for 90 minutes, over 6 weeks.

    *  Thematic Progression:

        *  Weeks 1-2:"The Land of First Encounter" – Drawing "The Hospital When I First Arrived," focusing on emotional expression.

        *  Weeks 3-4:"The Eye Within" – Drawing "A Corner of My Ward and Me," focusing on relationship exploration.

        *  Weeks 5-6:"Reconstructed Home" – Drawing "The Hospital Environment I Hope Can Support Me," focusing on meaning reconstruction and resource identification.

    *  Therapist Role:Adhering to a "non-directive but facilitative" principle, employing phenomenological questioning (e.g., "Can you tell me more about the feeling of this tree?"),结合 the Daoist idea of "governing by non-action," encouraging self-interpretation and group resonance, and avoiding authoritative interpretation.

4. Measurement Tools:

    *  Quantitative Tools:

1.  Nursing Intern Environmental Adaptation Scale: Contains four dimensions: interpersonal relationships, workload, role identity, and environmental control, 20 items total, Cronbach's α=0.87.

2.  Anxiety and Depression subscales of the Symptom Checklist-90 (SCL-90).

3.  Drawing Metaphor Indicator Quantification Scale (Self-developed): Three art therapists, blind to group allocation, independently scored the HTP drawings on a 0-5 point Likert scale, assessing:

            *  Spatial Openness:Whether the composition is cramped/oppressive vs. flowing/open.

            *  Rootedness Stability:Whether tree roots are weak/floating vs. solid/deep.

            *  Figure Interaction:Whether the human figure is isolated/back-turned vs. interacting with the environment or others.

    *  Qualitative Data:Therapy process notes, in-depth interviews with selected participants, series of drawings.

5. Data Analysis:Analysis of covariance (ANCOVA) using SPSS to compare post-test score differences between groups, controlling for pretest scores. Inter-group comparison of drawing indicator scores. Thematic analysis for qualitative data.

Results

1. Quantitative Results:

    *  ANCOVA(controlling for pretest scores) showed that the experimental group's post-test scores on the total score and all dimensions of the Nursing Intern Environmental Adaptation Scale were significantly higher than those of the control group (F=28.43, p<0.001; all dimensions p<0.01). Scores on the SCL-90 anxiety and depression subscales were significantly lower than the control group (p<0.01).

    *  The post-test ratings for the three metaphorical indicators—"spatial openness,""rootedness stability," and "figure interaction"—for the experimental group's drawings were significantly higher than both their own pretest ratings and the control group's post-test ratings (p<0.01), with high inter-rater consistency (ICC > 0.80).

2. Qualitative Findings and Classic Case Analysis:

Taking participant Xiao A(pseudonym) as an example. In the pretest drawing, her "house" (hospital) was huge with closed doors/windows, located at the edge of the paper; the "tree" was small, leafless, with悬浮 roots; the "person" was背对 the viewer, diminutive in size. This vividly metaphorized her state of being engulfed by the environment, isolated and rootless. She stated: "I feel like a透明 person, floating in the corridor, unable to touch anything solid."

During therapy,in her third drawing, Xiao A added a small side door with a handle to the "hospital" ("Perhaps there is an exit I can quietly enter"). In the fifth drawing, she depicted a tree rooted beside a hospital bed, with paper cranes representing blessings tied to it. A nurse (herself) and a patient in bed were looking together towards the setting sun outside the window. She shared: "I seem to understand, the sense of support isn't given by the environment; it grows from within me the moment I care for a patient. The hospital is no longer just a 'place'; it's starting to have 'moments' shared between me and the patients."

This case印证 how therapy facilitated a shift from"thrown object" to "active participant," i.e., from Heideggerian "fallenness" to "authentic potentiality-for-being," also暗合 the practical wisdom of Wang Yangming's "true substance is revealed through tempering in affairs."

Discussion

This study confirms that HTP-based art therapy,guided by philosophical psychology, can effectively improve environmental maladjustment in nursing interns. Its therapeutic mechanisms may lie in:

1. Symbolic Externalization and Embodiment:Transforming abstract, diffuse adaptive stress into concrete, visible symbolic imagery (e.g., closed doors, rootless trees), making it an "object" that can be observed, contemplated, and dialogued with, breaking the cycle of anxious rumination.

2. Meaning Reconstruction and Narrative Integration:Through a series of drawings, interns unconsciously complete a "re-narration" of their environmental experience. This progresses from an initial "threatening story" to a "complex story" containing challenges, resources, and微小的 connections, and ultimately to generating a "growth story" with personal meaning. This achieves the "change in attitude towards unalterable circumstances" advocated by Viktor Frankl's logotherapy.

3. Philosophical Reconciliation of Subject-Object Relations:The therapeutic process暗合 the Eastern philosophical path from subject-object dichotomy to subject-object fusion. Interns no longer view the hospital as a purely alien "object," but gradually transform it, through their own emotional investment and creative action, into part of a "lifeworld"承载 personal practice and meaning, thereby restoring a sense of "dwelling."

Conclusion and Implications

This study deepens the HTP drawing test from an assessment tool into an art therapy intervention rooted in the profound traditions of both Eastern and Western philosophical psychology.It not only provides an empirically effective "technique" for alleviating nursing interns' environmental maladjustment but also inspires the "way" of nursing humanistic care—namely, focusing on the existential experience and meaning construction of interns as whole "persons" encountering the medical environment.

Future research could extend follow-up periods to test the durability of effects and explore the application of this model to other high-stress occupational groups facing environmental adaptation challenges.Educators and clinical managers may consider incorporating this integrated art therapy module into pre-service training and ongoing support systems for nursing interns, cultivating nursing professionals with greater psychological resilience and humanistic depth.

References

[1]Heidegger, M. Being and Time. (Trans. J. Macquarrie & E. Robinson). Harper & Row, 1962.

[2]Wang, Y. Instructions for Practical Living and Other Neo-Confucian Writings. (Trans. W. T. Chan). Columbia University Press, 1963.

[3]Jung, C. G. The Archetypes and the Collective Unconscious. Princeton University Press, 1969.

[4]Buck, J. N. The House-Tree-Person Technique. Western Psychological Services, 1948.

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