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Hafner Mateja, Ihan Alojz:
PREBUJANJE: Psiha v iskanju izgubljenega Erosa – psihonevroimunologija
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Animal-assisted therapy

Animals and humans have shared a special relationship since pre-historic times. Cave paintings indicate that the earliest human-animal relationships may have occurred between wolves and cavemen. Archaeologists suggest that, over 10,000 years ago, the wolf/dog was the first animal to be domesticated. The dog played a large role in hunting and carrying loads, but there is little doubt that real human-dog relationships began the first time a dog responded to a pat on the head with a wagging tail.

Man has shared significant relationships with many types of animals and has experienced physical and emotional benefits because of them. For example, the Ancient Greeks used hippotherapy (i.e., physical therapy on horseback) to rehabilitate injured soldiers. Then, about 5,000 years ago, Egyptians tamed African tabby wildcats to hunt mice and rats. Cats went on to be pampered and worshipped. They were known to eat from the same plate as their owners, wear valuable jewelry, and be well taken care of medically. In fact, ancient Egyptians believed that cats were immortal and would make special efforts to preserve cats’ bodies after death so their souls would have a place to return to. Oftentimes, after death, the cat was embalmed and put in a coffin that contained food for the cat’s soul. The coffin was then buried in a sacred vault along the banks of the Nile (Dale-Green, 1963). A story is told of how a Persian army once won victory over Egyptians by taking advantage of their reverence for cats. The Persians were besieging an Egyptian fort when their king had the brilliant idea of ordering his soldiers to throw live cats over the walls. The defending troops apparently allowed the city to be captured, rather than risk injuring the animals they knew to be sacred and which they suspected to be divine.
The belief that animals, because they are rational and know the difference between right and wrong, could be held accountable for their acts was prevalent in the ancient world. This belief continued into the Middle Ages. During this time, animals were entitled to the same legal protection as human beings (Hyde, 1956), but a distinction was made between domestic animals, which were tried in the ordinary criminal courts, and wild noxious animals such as rats, which were tried by the ecclesiastical courts. Both courts could impose the death penalty. In 1497 there was an interesting trial of a sow that murdered and then ate her piglet. She was found guilty and was hanged (Hyde, 1956). As late as 1906, a dog was sentenced to death in Switzerland.

The emotional bond that develops between humans and animals, however, can be very powerful. Although many stories cannot be confirmed, it is fascinating to hear tales of incredible love and devotion between humans and animals.

History of Animal-Assisted Therapy
The first recorded use of animals in a therapy setting appears to have occurred at York Retreat in England (Levinson, 1965). This retreat was founded by the Society of Friends in 1792 and often incorporated animals into the treatment of patients with mental illness in an effort to “reduce the use of harsh drugs and restraints.” The idea that pet animals could serve a socializing and/or therapeutic function for people with mental health concerns became popular during this time and by the 19th century the introduction of animals to institutional care facilities was widespread. For example, the use of animals in therapy was recorded in 1867 at Bethel, a residential treatment center for persons with epilepsy (McCulloch, 1983). In North America, one of the earliest recorded uses of animals in a therapeutic setting was at St. Elizabeth’s Hospital in Washington, D.C. in 1919. Here, dogs were introduced as companions for residents in psychiatric care. Unfortunately, however, these early and preliminary uses of AAT were soon replaced due to the discovery of psychotropic medications during the early part of the 20th century. There were no more substantial medical discussions of the value of animals as therapeutic adjuncts until 1944, when Dr. James Bossard published a paper which discussed the therapeutic value of owning an animal. Based on case studies and his own personal experiences, he discussed the many roles that the family pet may play (e.g., source of unconditional love; outlet for people's desire to express love; social lubricant; companion and teacher of children in areas such as toilet training, sex education, and responsibility). This article was reprinted by veterinary journals, animal welfare publications and several newspapers.

Since the early 1960s, there has been an increase in the number of professional therapists who recognize and value animals as therapeutic tools. In the State Mental Hospital in Lima, Ohio, the positive effect animals could have on people was discovered after a patient found an injured sparrow. Without any direction or approval, he began to care for the injured bird. Other patients, usually detached and withdrawn, began working together to help in caring for the little bird. Staff recognized the positive change in these inmates and soon incorporated animals into their treatment plans. Today, the hospital in Ohio is home to a wide variety of animals (e.g., dogs, cats, parrots, goats, deer, and snakes). The hospital also conducted a year-long study to determine the effects animals had on the patients. Interestingly, it was found that patients on wards with animals present used only half the amount of medication that was used on wards without animals. The study also demonstrated a reduction in violence and significantly fewer suicide attempts amongst patients who were on wards with animals, compared to other wards (Lee, 1984).

Two of the most significant events in the history of modern pet therapy were the 1969 publication of “Pet-Oriented Child Psychotherapy” and the 1972 publication of “Pets and Human Development” by Dr. Boris Levinson. His study of the therapeutic use of animals in treatment began quite by accident in 1953 upon a young patient’s first visit to see him. The boy arrived early for his appointment and met and embraced Levinson’s dog, Jingles, who was in the office that day. The dog helped Levinson develop rapport with the boy and facilitated a bond between them. Levinson recognized the powerful impact that the dog had, and thus began his future specialization in the human-animal bond.

In the 1970s, Sam and Elizabeth O’Leary Corson established a dog ward in their psychiatric hospital at Ohio State University to research animal behaviour in various settings. They believed that this would provide them with insight into the behaviour of children and adolescents placed in similar circumstances. The ward housing the dogs was not soundproof and, consequently, the patients in the adolescent ward could hear the dogs barking. Surprisingly, many patients began to break their self-imposed silence to ask if they could see or help take care of the dogs. The response of the patients towards the dogs inspired the Corsons to conduct a research project to determine the effects dogs had on psychiatric patients who had not responded to a variety of other treatment methods. The incredible result of this pilot study was a dramatic improvement in twenty-eight out of thirty subjects (Corson, Corson & Gwynne, 1974).

Today, the Delta Society is considered to be the leading North American organization in AAT. The Delta Society was founded as a non-profit organization in 1977 with a mission to promote mutually beneficial relationships between animals and people, in order to help people improve their health, independence, and quality of life.

According to the Delta Society, AAT is a goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. The organization stresses that AAT should be administered by an appropriately trained healthcare professional, in normal practice, and should seek to accomplish pre-determined, quantifiable objectives. The Delta Society differentiates between AAT and Animal-Assisted Activity (AAA). Although both methods seek to bring about improvement in physical, social, or emotional function, AAT is always administered by a trained health professional and is goal-directed, with measurable objectives. In contrast, Animal-Assisted Activities (AAAs) are less formal opportunities for interaction with animals.

Experimental Studies of Animal-Assisted Therapy

It is known that descriptive or anecdotal studies contribute to our knowledge of clinical phenomena, but they are not designed to quantify effectiveness or define causal relationships. Experimental studies that use control groups, however, are constructed to test hypotheses, to prove or disprove causal relationships, and to quantify the existence or magnitude of effect.

The concept of involving animals in therapy has only been investigated academically since the mid-1960s. Although AAT was pioneered by explorative and descriptive work (Levinson, 1965), the field has grown in size and depth and does include some studies of an experimental nature. Investigators have attempted to link animal interaction with a number of health benefits, including survival rates (Freidmann, Katcher, Lynch, & Thomas, 1980). Researchers have measured changes in indicators of physiological arousal (Baun, Bergstrom, Langston, & Thoma, 1984; Katcher, Segal, & Beck, 1984; Harris, Rinehart, & Gerstman, 1993; Wilson, 1991), levels of neuroendocrine chemicals that correlate with bonding behaviour and improved mood (Odendaal, 2000), and have also found some support for transient, yet significant, physical effects of interaction with animals.

Several experimental studies have also examined the effects of AAT in mental health settings (see Chapter 5 of this manual for a review). Critical reviews of the field of AAT have indicated that most of the experimental studies conducted to date have lacked appropriate sample sizes, thus providing insufficient power for statistics and limiting the potential for comparison with normal populations. Thus, there is a need for well-designed studies on AAT to build a scientific foundation that supports the use of this innovative therapeutic technique.

Current Animal-Assisted Therapy is largely a volunteer-based field that involves volunteers and their animals in a variety of therapeutic settings (e.g., physical therapy, speech therapy, occupational therapy, group therapy). It is believed that the volunteer nature of the field is a factor in the limited amount of quantitative research on AAT. As mentioned in Chapter 1 of this manual, the plethora of qualitative and anecdotal research clearly describes the benefits animals have on humans, but does not provide a great deal of detail about the field of AAT itself. Even the quantitative research that has been published does not provide much detail about what the animals actually do to aid in the therapeutic process. Currently, the only real way to learn about AAT is to participate in it and to experience it first-hand, but this is easier said than done.

Example goals and strategies to develop rapport and foster relationships.

Deepen trust with therapist (transference).Permit the client to hold or pet the companion animal while interacting with the therapist or the therapy group.
Develop rapport with therapist. 
• The animal may be a common interest between the therapist and client and, thus, can create a bond and foster discussion.
 Increase social interaction skills. • Encourage the client to talk to the animal rather than the therapist. The client’s focus on the animal may result in easier articulation of thoughts and words because animals are sympathetic listeners and cannot tell secrets.
• Transfer the improved social interaction skills to family and peers.
 Increase socialization and participation (individual or group). 
• Prepare a scrapbook of photos, information, or articles about a specific dog breed and share the information with others.
• Document attendance in therapy groups to determine if it increases when an animal is present.
Improve relationships with peers.
• Use the relationships between the handler and the animal and between the therapist and the animal as a metaphor for human relationships.
• Work at transferring this experience to peers.
 Increase amount of eye contact with people.  
• Work with the human-animal team to develop appropriate eye contact.
• Work at transferring that skill to other relationships.
 Improve appropriateness of voice tone with people. 
• Work with the human-animal team to develop appropriate voice tone when training the animal.
• Work at transferring this skill to other relationships.

Improve socialization, communication.
• Practice teaching an animal something new.  
Information obtained from: The Therapy Dog Training Institute (1999), Utilizing therapy dogs in mental health settings; The DELTA SOCIETY (1996), The Human-Animal Health Connection, Standards of practice for animal-assisted activities & therapy; and The DELTA SOCIETY (1997), Therapeutic Interventions.

Many people in therapy may have attachment disturbances or may have difficulty trusting someone enough to bond with them. In many cases, their life experiences have taught them to expect to be hurt by those they love and depend on. These people often feel that it is dangerous to get close to another person and so they avoid any relationship that could put them in a potentially vulnerable situation (Mayes, 1998). An animal can be a safe living thing that these people can bond to. The person can benefit from giving affection to, or receiving affection from an animal. They can also experience predictable interactions from the animal that may help them learn about themselves and others.

Because animals can provide a non-judgmental ear and unconditional acceptance, children often turn to animals for social support (McIntosh, 2002). Studies have shown that children regularly confide in their pets when they have a problem, and play with their pet when feeling stressed (Covert, Whiren, Keith, & Nelson, 1985). This is true for adults as well. According to an annual national survey conducted by the American Animal Hospital Association, almost half of the 1252 respondents indicated that they are emotionally dependent on their pet. Furthermore, 83% said they would be likely to risk their own life for their pet, 89% believe their pet understands all or some of what they say, and about 30% said they spend more time with their pet than with family or friends (Interactions, 1998).

A Catalyst for Emotion
Many people have difficulty expressing their emotions. Oftentimes, persons with mental health concerns have been told that their feelings are wrong and that they should not feel the things they do. They may also have learned that others regard their feelings as unimportant. This can lead to confusion or guilt when certain emotions recur and, consequently, suppression of these emotions. Interacting with or observing an animal can help individuals realize that it is normal to have emotions.

Animals within therapeutic settings help to elicit a range of emotions from laughter to sorrow. Although entertainment is not often the focus in AAT literature, there are many reports of therapy animals getting into comical and/or playful situations (McCulloch, 1984; Fine, 2000). Human expressions of laughter and joy can be therapeutic in that they are known to reduce stress and to positively impact a person's quality of life, even if just for a moment (Cousins, 1989).

Animals are in a unique situation to display emotions and behaviours that may not be deemed professionally appropriate for mental health therapists. For example, even though “touch” is a basic need in human development, we live in a society where people often avoid touching each other. The appropriateness and safety of touch is something that is often debated without resolve. Thus, many mental health professionals try to avoid all physical contact with their clients. Contact with companion animals, however, is a safe way that individuals can experience the physical and emotional benefits of touch. The warmth and security of a dog who is sitting beside you or who has its head in your lap provides a touch that is lacking in many clients’ lives. For example, when Sharon Smith studied interactions between ten dogs and their family members, she found that the pets provided both men and women with a socially acceptable outlet for touching, rubbing, scratching, patting, or stroking (Smith, 1983). These are behaviours that most American men are reluctant to engage in. Thus, holding or petting an animal during therapy may provide physical comfort and soothe all clients, irrespective of gender, in difficult sessions.

Having an animal present in therapy sessions may also help clients gauge excessive behaviours or emotions. The animals seem to regulate the emotional climate of the room (Fine, 2000). For example, there are numerous reports of clients (of all age groups) regulating their reactions during disputes when an animal was present in the session. Many clients appear to respect the animal’s presence and do not wish to create uneasiness in the animal. Clients who do display excessive reactions will see an immediate response from the animal and will often quickly calm themselves down. The response of the animal to various emotions can be a valuable teaching/discussion tool.

Furthermore, studies have indicated that animals may be an important source of emotional support for children. For example, while preschoolers to grade one children viewed their pets as playmates and protectors, children in grades three to five viewed their pets as confidants and sources of emotional support (Triebenbacher 1994). In addition, Salomon (1995) found that nine to thirteen year olds with higher scholastic performance reported seeking more emotional support from animals when they suffered with internal discomfort or felt lonely, compared to those with lower scholastic performance.

A study conducted by Levine and Bohn (1986) found that children who live in homes where a pet is considered to be a member of the family were more empathetic than children in homes where there was no such pet. Another study found that children’s scores on an empathy scale increased after attending a year-long animal humane education program in an elementary school (Ascione, 1992). Importantly, these more humane attitudes (towards animals and people) were still present in the experimental group one year after the program was complete. It has also been found that children will often quickly regard an animal as their peer, even if they do not have their own animal. Thus, teaching individuals to be empathetic with an animal may be easier than teaching them to be empathetic with a human because animals don't play games with feelings the way that some humans do. With time and experience, empathy will develop and may transfer from animals to humans (Levinson, 1965; Nebbe, 1994).

Self-Esteem Building:
Many clients in therapy suffer from low self-esteem. The ability of animals to provide positive regard and to not discriminate against people makes them a unique medium for increasing self-esteem. An animal’s acceptance of a person is non-judgmental and uncomplicated by the psychological games that humans may play. For example, humans will often withhold love and approval automatically, even unconsciously, from those who do not measure up socially. Animals, however, do not care whether you are able to speak "normally" or whether your hand shakes when you reach to pet them. Animals don’t care about how much money you have in the bank, what kind of job you do, or what kind of car you drive. They love you for who you are inside.

Children who have regular contact with animals have been shown to have higher levels of self-esteem. One study, for example, showed significantly increased self-esteem scores in children when an animal was added to their classroom for a period of nine months. Interestingly, children who had lower self-esteem scores in the pre-test demonstrated the most improvement (Bergesen, 1989). Similarly, using a sample of 300 families, Covert et al. (1985) found that adolescents who owned pets had higher self-esteem scores and Melson (1990) found a positive association between attachment to pets and self-esteem in kindergarteners.

Enhancing Personal Growth and Development:
Many young children, and some adults, see animals as peers. When people are taught to be kind to animals and to treat them with respect, they also learn to be kind and to respect other people. A study by Melson (1990) indicates that kindergarten children with a family pet have fewer behavioural problems when transitioning to public school.

Personal development, such as speech and communication skills, can be enhanced by partnership with a therapy animal. For example, giving a command, saying the animal’s name, or describing feelings while holding a therapy animal are simple, but often effective ways to encourage an individual to talk and communicate with others. Contact with animals is also thought to be beneficial for a child’s cognitive development (Poresky, 1996).

Providing a Sense of Control:
AAT offers a realistic basis for control therapy, whether focusing on internal-, external-, or self-control (Nebbe, 1994). The clients can be taught to respect the self-control of animals, but they may also have the opportunity to exhibit control in subtle ways (i.e., having the animal perform obedience commands or tricks). Manipulation tactics or bullying does not work with most animals (as demonstrated in the case examples above) and this can be used as a teaching tool for individuals who have little self-control. On the other hand, individuals may find it very empowering to have an animal respond to them after they have taken time to gain the animal’s respect and then to teach it something. This may be especially rewarding for someone who has low self-esteem and perceives that they have no control.

Reducing Abusive Behaviours or Tendencies:
"At risk" youth may especially benefit from AAT because many of these youth are abusive (or have potential to be abusive) to animals as a result of their dysfunctional or abusive family history. Cruelty to animals was first included in the Diagnostic and Statistical Manual (DSM) in 1987 and has been found to be one of the earliest symptoms of conduct disorder to appear in childhood. In fact, it is estimated that approximately 25% of conduct disorder cases include a history of abuse to animals. The significance of these findings led the American Psychiatric Association (APA) to cite animal cruelty as a diagnostic criterion for conduct disorder in the DSM-IV (APA, 1994). The inclusion of animal cruelty in the DSM-IV has renewed attention to animal abuse as being a potential precursor to human mental health problems.

A chance to observe and to work with animal teams demonstrating kindness, compassion, and a reverence for life, may provide “at risk” youths with a strong role model and the realization that they have choices (Nebbe, 1994; Sue McIntosh, personal communication, 2002).

Psychological Benefits:
We all have basic psychological needs to be loved, respected, useful, needed, accepted, and trusted. An animal may fulfill these psychological needs by filling roles such as companion, friend, servant, dependant, admirer, confidante, scapegoat, mirror, trustee, and defender. An animal may also satisfy his human friend’s need for loyalty, trust, respectful obedience, and even submission (Levinson, 1961). Thus, caring for or interacting with an animal can mean the difference between loneliness and fulfillment for many people.

Animals are employed extensively in a variety of therapeutic settings. A large number of respondents to a survey conducted in the U.S. indicated that in psychotherapeutic settings, anxiety disorder is one of the diagnoses with which AAT is most effective (Mason & Hagan, 1999). Animals appear to have a calming effect on persons with anxiety, and the simple act of touching or petting an animal reduces anxiety in many (Barker & Dawson, 1998; Wilson, 1991).

Many anecdotal or case reports claim that AAT is beneficial for an extensive range of mental health illnesses. For example, a study of 612 primary school children in Slavonia, a region heavily affected by war, found that students with a dog or cat expressed emotions, sought social support and problem-solved more than those without animals, and demonstrated more differentiated coping strategies. This proved to be helpful in reducing post-traumatic stress reactions in these children (Arambasic & Kerestes, 1998).

Valuable Roles Animals Can Play in Therapy
While animals are far more than "tools" in therapy, their innate natures are often ideally suited to promote therapeutic disclosures and to enhance therapeutic progress. The Person Centered Counselling approach mentions three conditions that must be present in order for therapeutic growth to occur: 1) genuineness; 2) unconditional positive regard; and 3) empathy. Animals provide these emotions freely and without judgment, in a manner that human counselors can only strive to achieve (McIntosh, 2002).

Assessment Tool
Individuals in therapy may be unwilling to disclose information about their past because they feel the need to protect those who have hurt or wronged them. In other cases, they may feel guilty about past events or feel that they are to blame for the bad things that have happened to them. An animal in therapy can provide a valuable assessment tool. By observing the person’s interactions and comments to or about the animal, the therapist may gather a lot of information about the client’s thoughts and experiences. The client may also inadvertently show the therapist how they have been treated and what they have learned through their life experience.

Projective Tool
Many people find it easier to express feelings, issues, and fears indirectly rather than directly. These people may find it helpful to express their thoughts through a companion animal.

Tool for Storytelling and Metaphor
Individuals may also benefit from hearing stories of the animal's experiences that parallel their own issues. Some examples may include the therapist telling stories about how the animal was separated from its parents and siblings, travelled to a new home, was forced to live with a complete stranger, went to see the veterinarian, or went to obedience school ─ and also about how the owner helped the animal adjust to the new surroundings and made them feel safe and loved. There are numerous other instances that could be drawn upon, depending on the circumstances of the particular client (Mayes, 1998; Fine, 2000).

Role Modeling Tool
Having an animal present in therapy may indirectly benefit the client as a result of observing the interaction between the therapist and the animal. Many people will unconsciously compare these interactions with their own personal relationships. The scenarios between the animal and handler that occur during a therapy session can be used to demonstrate to the client appropriate interactions and responses to behaviours. For example, there will be many times during therapy sessions in which boundaries will need to be placed on the animal. Therapists can use these times to model appropriate methods to discipline the animal and to problem-solve when the animal does not respond. Discussions about managing behaviour, setting boundaries on behaviour, or appropriate ways of interacting may then be initiated as a result (Mayes, 1998; Fine, 2000).

Teaching Tool
Instruction can be therapeutic for people who are insecure or afraid due to insufficient knowledge about the things they fear. Therapists should take advantage of teachable moments and learning opportunities that arise during therapy. Discussing and observing animals and their interactions with the handler and with the client will provide the client with knowledge that can then be transferred to their own lives.

Alternative Ways to Utilize the Human-Animal Bond

Have an Animal Present
In some cases, just having an animal present in a therapy session may be therapeutic. There are numerous anecdotal reports in the literature to indicate that the simple presence of an animal during a session can be revitalizing and therapeutic for clients.

Use the Person’s Relationship with Their Own Pet
If a client has their own pet at home, then the therapist could use the client’s relationship with their animal in the therapeutic process (Mayes, 1998). If appropriate, the client could bring their pet to therapy or the therapist could have the client do specific assignments with their pet between therapy sessions. This would allow the therapist to use the bond that the client has already established with their animal to help the client during difficult times.

In addition to benefits of AAT already noted in this chapter, bringing animals to work can also result in fringe benefits. For example, therapists who employ their animals as co-therapists indicate they have increased job satisfaction (Mason & Hagan, 1999). In addition, the animal serves to create an office with a homier atmosphere, making the therapist appear more approachable. This could ultimately result in lower cancellation rates and increased business. Therapist Betty Hodnefield relates that her canine co-therapist, Bernard, is quite a local attraction. He can often be seen sitting in the front window of the social services building that they work out of, much like “that doggy in the window” of a pet store. Betty believes that Bernard helps reduce the stigma of going to a “social services” building. In fact, clients have actually brought their spouses or their animal friends in to see Bernard and other people will come in just to see him and ask questions about him. (B. Hodnefield, personal communication, 2002)
Despite the numerous potential advantages of AAT, it is important to realize that the quality and effectiveness of AAT will vary according to the knowledge, skill, and experience of the therapist, and the different training, temperament, and aptitude of the companion animal. It is also important to note that, no matter how much we love and value our animals, not all clients are animal people and some may not respond to the inclusion of an animal in therapy. However, for those that do respond, the therapeutic partnership with an animal may be limited only by one's imagination.

In this manual, you have read many accounts of positive therapeutic results being achieved by working with an animal. But how do you measure these effects? This chapter will briefly describe some techniques you can use to help evaluate your AAT program.

Performance Indicators
Performance indicators are measurement tools used to help determine if programs meet our expectations, by acting as guides to monitoring and evaluating aspects of a program that affect client outcomes. The development of performance indicators can help therapists focus on those things that are really important to them and to their clients. It may be helpful for therapists to plan, up front, how they will decide if their AAT program is a success. This will also help determine what they need to measure in order to know how well the program is doing. Some key questions may include:

• Which activities are appropriate and effective?
• Which activities are efficient and how efficient are they?
• Which processes need to be improved?
• What evidence is there that client outcomes have improved?
Examples of performance indicators that may begin to address these questions include:
• Number and percent of clients who agree to include an animal in the therapy session;
Man is a dog's idea of what God should be. -- Holbrook Jackson
• Number and percent of clients who come to their scheduled appointment (if possible, compare AAT clients with non-AAT clients);
• Number and percent of clients who are on concurrent medication for their mental health illness (if possible, compare AAT clients with non-AAT clients);
• Length of time clients are seen, prior to discharge (if possible, compare AAT clients with non-AAT clients);
• Number and percent of clients who achieve therapeutic gains and are discharged;
• Number and percent of clients who have increased knowledge about animal care; and
• Number and percent of clients who report satisfaction with the AAT program.
Of course, the information that is obtained will ultimately depend on what data is routinely collected and available.
Outcome Measures
After the performance indicators are established, the measures to be used to monitor the success of the program will be easier to select. Much of the data may come from routine program statistics (e.g., admissions, discharges, length of stay, wait time). However, client-related outcome data may be obtained for individual clients using any of the following:
1) Standardized psychological instruments that are administered on a regular basis;
2) Direct observation and documentation of specific behaviours;
3) Surveys or questionnaires that capture specific, but subjective information; or
4) Therapist progress notes.

These measures can provide information about the client’s therapeutic progress. However, in most cases, the data will not help determine why or how the change occurred. In other words, the data will not necessarily provide evidence that the client’s progress (or lack of progress) is the direct result of AAT. Thus, regardless of what outcome measures are chosen to evaluate an AAT program, it must be recognized that unless the presence of the animal in the therapy session is controlled for, it is not possible to make unequivocal claims about an animal's impact in therapy. The outcome measures used for the Chimo Project are described below to provide an example of an AAT program evaluation strategy.

Several outcome measures are being monitored for clients involved in the Chimo Project. Therapists involved in the project are asked to create specific goals for each client on a session-by-session basis. At the end of each session, the therapist and the client fill out a questionnaire. The therapist’s questionnaire (see Appendix C) addresses specific information from that particular session and, if an animal was present, the therapist's feelings about the helpfulness of the animal. In addition, the therapist is asked to indicate what the goals of the session were and whether, in their opinion, the goals were attained. The client’s questionnaire (see Appendix D) asks specific questions about the
therapy they received in the session and, if an animal was present, the client's feelings about the presence of the animal. The questionnaires take five to ten minutes to complete following each session. Because there is a paucity of empirical investigation into the efficacy of AAT, itself, instruments assessing its efficacy are unavailable. As a result, the questionnaires mentioned above were developed by the Chimo Project. Although the questionnaires do not have established psychometric properties, they are designed to quantify anecdotal information. In addition to these subjective data sources, therapists are also asked to provide case studies, where possible.

Experimental Studies of Animal-Assisted Therapy
As mentioned in Chapter 1 of this manual, the Delta Society defines AAT as a goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. The Delta Society differentiates between AAT and Animal-Assisted Activity (AAA). Although both forms seek to bring about improvement in physical, social, or emotional function, AAT is always administered by a trained health professional and is goal-directed, with measurable objectives. In contrast, Animal-Assisted Activities are less formal opportunities for interaction with animals.
Before reviewing the experimental studies in the literature, it should be noted that the practical application of AAT takes a variety of forms and that many forms do not follow the strict definition set out by the Delta Society. In addition, confusion often arises when trying to compare studies in the literature, which use different therapeutic techniques and varied methodologies. For example, AAT can be practiced in individual or group therapeutic settings by professionals with different educational backgrounds or treatment philosophies, and using a variety of animal species and breeds. The animals can be incorporated in diverse programs that vary from infrequent visitation to full-time companionship, as part of the treatment strategy for patients with an assortment of medical or psychiatric conditions with a range of severity. As mentioned, it is difficult to make comparisons between such varied methodological approaches.

The following is a review of the impact of AAT on mental health by examining those studies where experimental design and inclusion of control groups have been attempted. Studies are categorized by the type of human-animal interaction involved, including ownership, visitation within the home, and visitation in institutional settings.

One of the earliest studies, and one of the most meticulous experimental designs to date, was conducted by Mugford and M’Comisky in 1974. Using a pre-post methodology, investigators compared the performance of four experimental groups and one control group on a standardized questionnaire assessing attitudes towards self and others. Elderly subjects living in their own homes were assigned to one of the following groups in which they were allowed the following things in their home: 1) Budgie and TV, 2) Begonia and TV, 3) Budgie and no TV, 4) Begonia and no TV, and 5) Control group with neither a budgie or a begonia, but half were allowed a TV and half had no TV. After five months, the researchers were able to report a generally positive effect for the groups who had budgies, but were unable to provide proper statistical analysis due to an inadequate sample size (n = 17 divided into 5 groups) caused by high rates of subject mortality or relocation prior to the end of the study. Although lacking in conclusive results, the study demonstrates that quantitative research in the area of human-animal interaction is possible if investigators use a large enough sample size to guard against subject loss.

Using a similar longitudinal research design, Serpell (1990), administered a series of questionnaires to seventy-one adults who had recently acquired pets (dogs and cats) and to an unmatched control group of twenty-six non-owners. Data was collected at baseline, and after one, six, and ten months. Upon analysis, significant changes in a number of areas emerged. Pet owners reported fewer minor health problems in the first month (p<0.001). Dog owners exhibited a significant (p<0.01), but transient improvement in general health, while the control group did not show this change. Serpell reports that the positive effects are stronger and longer lasting for dog owners than for cat owners. For example, dog owners experienced a significant and prolonged increase in physical exercise due to walking of their dogs. Although, the study incorporates a large sample, repeated measures and an awareness of potential confounds, the researchers disclose that there are significant differences between the experimental and control groups, even at baseline. These differences are likely due to a lack of exclusionary or inclusionary criteria.

A recent project (Cole & Gawlinski, 2000) examined the effects of animal ownership by providing each patient in an intensive care unit with their own fish tank. In a single group design, ten patients awaiting orthotopic heart transplants were given fish tanks and then scored on the Multiple Affect Adjective Checklist-Revised (MAACL-R) at baseline and post-treatment. The test, designed to assess levels of anxiety, depression, hostility, sensation-seeking, and positive affect, did not detect any significant change on any measure. The authors cite the small sample size as a possible explanation for the lack of significant results.

Visitation within the Home
AAT, through regular visitation, has been applied in a number of different settings. From private homes to psychiatric hospitals, the technique has been employed with varied success. Francis, Turner, and Johnson (1985), using a relatively simple and inexpensive methodology, introduced six SPCA puppies to twenty-one older, chronic mentally ill residents of a community adult home in three-hour weekly group sessions for eight weeks. Utilizing a pre-post design and a control group of a matched population at a separate adult home, investigators measured nine variables using seven standardized tests. Analysis showed statistically significant improvement in the animal visitation group on measures of social interaction, psychosocial function, life satisfaction, mental function, depression, social competence, and psychological well-being (p< 0.03). Although an improvement in life satisfaction was observed in the control group, no other variable demonstrated significant change.

A similar program was developed where volunteers and their animals visited homebound elderly (Harris, Rinehart, & Gerstman, 1993). Sixteen elderly homebound clients participated in the research study. Four non-experimental visits conducted by the nurse coordinator preceded four experimental visits where a volunteer and a dog accompanied the coordinator. Researchers made measurements of systolic and diastolic blood pressure, pulse and breathing rates, and asked half the participants to complete the General Well-Being Scale at the beginning and end of each visit. Investigators found significant decreases in blood pressure and pulse rate with a visit from the pet and volunteer (p<.05), and similar significant differences in pulse and respiration following a control visit. The General Well-Being Scale revealed no significant differences. There are some grounds for criticism in this study. As is the case with many investigations in the field of AAT, the sample size is insufficient to be representative of a normal population. Furthermore, there was little control over the nature of the control visits versus the experimental visits. A nurse conducted control visits and no mention is made of diversionary activities being incorporated. Instead, the control visits contained discussions of the patients’ current circumstances and loss of previous pets; discussions of an emotional nature may have affected physiological indicators of emotional state, thereby potentially skewing comparative results.

Visitation in Institutional Settings:
Perhaps the most common paradigm for AAT or AAA is visitation within an institutional setting, such as a nursing home or psychiatric ward. Walsh, Mertin, Verlander, and Pollard (1995) examined the effects of introducing animals to an institutional setting. In this study, a dog was introduced to a group of seven dementia patients on a psychiatric ward. The dog visited the ward twice each week for three-hour sessions during which he and his handler would visit each patient independently. A group of patients with less severe dementia in an adjacent ward served as the control group. The study found no significant difference on the London Psycho-Geriatric Scale, the Brighton Clinic Adaptive Behaviour Scale, or diastolic or systolic blood pressure between the experimental and control groups. Investigators did note that a substantial, but not enduring, reduction in ward noise levels occurred during and after the dog’s visit (not significant) and that patients in the experimental group experienced a significant reduction in heart rate (p=0.021). A larger sample size in a replicate study would add credibility to the results.

Recognizing the need for adequate sample sizes, Zisselman, Rovner, Shmuely, and Ferri (1995) introduced pets to fifty-eight geriatric psychiatry inpatients as an adjunct to traditional phamaco- and psychotherapy. Group sessions consisted of a one-hour visit with dogs for five consecutive days. A control group participated in an exercise session while the experimental group visited with the dogs. Analysis showed no significant differences between or within groups on the Multidimensional Observation Scale for Elderly Subjects (MOSES) or its subscales. This investigation included one of the largest subject groups and, with the exception of other concomitant treatments, made provisions for controlled conditions.
Barker and Dawson (1998) examined the effect of animal interaction on anxiety ratings of psychiatric in-patients. The animal-assisted activity used in this study was of a recreational nature and was directed by volunteers and not by a trained healthcare professional. The researchers involved 230 patients in a pre-post crossover design that allowed patients to participate in a single session with animals and/or a single session of recreational therapy. Fifty subjects completed a pre- and post-treatment measure for both activity types. The State-Trait Anxiety Inventory was administered before and after each session to determine the patients’ levels of anxiety. While only patients with mood disorders experienced a significant decline in anxiety scores after attending recreational activities (p<.001), among patients who participated in AAA, those with psychotic, mood, and “other” disorders all experienced significant declines in levels of anxiety (p<.026). Despite these within-group improvements, the study found no significant differences between groups in anxiety level changes.

A similar approach focused on the introduction of a dog into two wards in a psychiatric hospital (Haughie, Milne & Elliot, 1992). A total of thirty-six patients participated in a repeated measures design across three conditions: 1) baseline, 2) dog and visitor, and 3) visitor with photographs of dog. The activity described in the study was intended to relieve anxiety and boredom. The authors employed a Patient Interaction Observation scale that monitored various social behaviours, and a nurses’ rating scale that catalogued similar measures, but from a more clinical perspective. One-minute observations were made according to a strict rotation procedure during the visit, while nurses were asked to complete the rating instrument two hours after each visit. A total of eight visits were completed for each condition. Haughie reports greater significant increases in mean interaction during the dog condition than in either the baseline (p<-.05) or photograph condition (p<.05). The author also suggests that the improvements were generalizable across psychiatric conditions, across settings (i.e., in both wards), and across behaviour types. The study gives considerable attention to controlling for confounding variables and the implementation of methodological guidelines; it would be instructive to use a similar design to measure a greater range of dependent variables.

Many articles assessing the effects of AAT involve older participants, diagnosed with various psychiatric conditions and housed in institutional settings. In a crossover design, Jendro, Watson and Quigley (1983) introduced twenty-two geriatric patients with severe mental illness to four weekly sessions of interaction with three or four puppies. Participants were divided into two groups; each group was exposed to both AAA and a control condition of no AAA, but in opposite sequence. Investigators found no significant differences on the Nurse’s Observational Scale for Inpatient Evaluation (NOSIE), the Stockton Geriatric Scale (SGRS), or the Ward Behavior Characteristics Instrument (WBCI). Statistically significant increases in purposeful behaviours before AAA (p<.001) and during the sessions with the puppies (p<.001) were reported. The authors interpret these results with caution, as an observer who was obviously not blind to experimental conditions collected the data. No enduring treatment effects were found.

Kongable, Buckwalter, and Stolley (1989) reported an increase in the number of social behaviours in 12 Alzheimer’s clients in a Veterans’ Home. In a within-subject repeated measures design, various social behaviours including smiles, looks, and touches, were tallied in the absence, temporary placement, and permanent placement of a dog in the home. The subjects were observed for five-minute intervals in individual and group sessions. Investigators report a significant increase in social behaviours in the presence of the animal (p<.001); however, they did not find a significant difference between temporary or permanent placement. Like many other studies in its field, this investigation is hampered by an inadequate and heterogeneous sample; only twelve patients were included and the severity of dementia and other impairments was not controlled. The observations fail to discriminate between positive and negative social behaviours and are limited in number and duration. In group sessions, individuals were not observed simultaneously but instead were monitored on a rotating basis, leaving substantial potential for error due to novelty effects, or change in activity type or level during the session.

Another study, examining the impact of animal interaction on patients with Alzheimer's disease, found a significant (p=0.05) decrease in agitation and an increase in socialization during sundown hours, a time reputed to be of high distress for many patients (Churchill, Safaoui, McCabe, & Baun, 1999). The dog and a researcher visited with twenty-eight patients in a group setting while another researcher made periodic video tapings of behaviours for later analysis. Unfortunately, this methodology suffers from the same limitations as the study mentioned previously, in that periodic observations made on a rotating basis may not achieve representative results. Furthermore, as only two sessions occurred (one with the dog and one without), there is no control for novelty.

The dog is man's best friend. He has a tail on one end. Up in front he has teeth. And four legs underneath. -- Ogden Nash - An Introduction to Dogs
Most of the studies mentioned previously concentrate on the effect of AAT on observable social behaviours, as opposed to assessing direct clinical outcome. In contrast to the typical investigative paradigm, one study, conducted as part of a thesis program (Hagmann, 1997), measured the effect of animal interaction on measured levels of anxiety and/or depression using the Beck Anxiety Inventory (BAI) and the Beck Depression Inventory (BDI) – two instruments with established psychometric properties. In the initial phase of the study, a total of eighty participants, split into two groups, completed both the BAI and the BDI. The first group had participated in visits with animals for an average of 8.4 years, with visits occurring no less than four times per month. The second group had never received any form of AAT. The study found no significant difference in the levels of measured anxiety reported by members of the experimental group and the control group. In contrast, the level of depression was significantly higher in the control group (p<.05). In a second phase of the study, Hagmann studied a much smaller sample of volunteers from the original experimental (n = 9) and control (n = 13) groups, in order to determine if two weeks of AAA would have an effect on BDI and BAI scores. Interestingly, the results show a significant increase in depression in the experimental group while levels of anxiety and depression drop among members of the control group (significance not reported). The small sample size in the second phase of the study and non-randomized method of selection (volunteer) for all participants suggest that the sample is not representative of a normal population. Furthermore, as participants were selected from twelve separate institutions in different cities, environmental conditions could not be adequately controlled. In addition, the visits occurred over different periods of time, were conducted by different volunteers and animals, and occurred at frequencies varying from four visits per month to fifteen visits per month. This degree of variation threatens the validity of the results. Although the study requires greater variable control, it demonstrates the feasibility of utilizing standardized psychometric instruments in the study of clinical outcome in AAT.

There are many animal-interaction programs operating under the label of AAT; however, it is clear that some patients are participating in a social activity rather than structured, directed therapy. While AAA may be beneficial, it is important to differentiate between the two forms of interaction. Below, are summaries of studies where animal visitation is incorporated into regular, supervised therapy sessions.

Thompson, Kennedy, and Igou (1983), endeavoured to quantify improvement among a group of twenty chronic psychiatric patients. Animals were introduced as part of a normal therapy program administered by a professional, and provisions were made for objectives and outcome measures. The patients were screened for inclusion in the study, randomly selected, and divided between a locked or open ward. The investigators used the Physical and Mental Impairment of Function (PAMIE) and the Mini-mental State Questionnaire administered by staff blind to subject assignment. Subjects in the pet-facilitated psychotherapy group participated in three-hour group therapy/pet education sessions for six weeks. Control group participants took part in similar sessions and activities, but without exposure to pets. The pre-post design found a statistically significant (p<.05) improvement on the total PAMIE score in patients who were members of the experimental group and had an “intermediate” level of impairment. This difference was not observed until three subjects who scored very high or very low on the PAMIE were removed from the sample. These outlier subjects, removed during analysis, further reduced the sample size to seventeen and allowed differences between groups to become apparent. There was no significant difference on any measure for any individual subject.

As part of a program designed for psychiatric inpatients at risk for substance abuse, animals were introduced into therapy sessions (Marr, French, Thompson, Drum, Greening, Mormon, Henderson & Hughes, 2000). Researchers compared a daily traditional therapy group to a daily AAT group and observed social behaviours according to an observational guide of pro-social behaviours, over a period of four weeks. Both groups were identical, except for the use of AAT in the experimental group. The investigators report that patients in the AAT group engaged in greater social interaction with other group members than did patients in the control group (p=0.022). This increased socialization effect continued over the four-week period. The study does provide support to the hypothesis that the effects of AAT can be studied using rigorous experimental design.

Clark Brickel (1984) studied the impact of animal-assisted psychotherapy in the nursing home. Fifteen male members of a nursing home unit were divided into three groups: 1) regularly scheduled traditional therapy, 2) dog present during regularly scheduled therapy sessions, 3) casual meetings with therapist, but no active therapy. Following two 45-90 minute sessions every week for a duration of four weeks, a significant improvement in depression was observed in both treatment groups (using pre-post Zung Self-Rating Depression Scales p<.05). Brickel also describes an increase in social interaction in the AAT sessions, over those where the animal was not present. In addition, a greater pre-post difference was reported for the AAT group, but this difference was not reported to be significantly greater than that for traditional therapy. Although this experimental design is commendable, a substantial increase in sample size would be essential in order to demonstrate true effect.

Beck, Seraydarian, and Hunter (1986) conducted a pre-post test design comparing two matched groups of psychiatric inpatients. Seventeen patients were to voluntarily attend daily therapy sessions for a period of eleven weeks. The patients were assigned to two groups: the first group would attend sessions held in one room, while the second group met in an identical room with four caged finches.

Considerable care was taken to ensure random assignment and controls for the two groups. Measures of attendance, participation, standardized scales [Nurse’s Observation Scale for Inpatient Evaluation (NOSIE) and the Brief Psychiatric Rating Scale], and discharge status were compared between groups. The results indicated that attendance was significantly greater for the bird group (p<.008); members of the bird group contributed to discussion more frequently (p<.05); and that, at the conclusion of the study, the members of the bird group were less hostile than those in the control group (p<.05). No significant variation was found on the NOSIE total score or any of the subscales. Interestingly, 50% of the patients in the bird group were discharged by the end of the study, while all of the non-bird group remained in treatment. It is unfortunate that such a carefully controlled study was undermined by a small sample size.

Acknowledging the need to quantify the effects of AAT using appropriate measures, one team focused on the development of a standardized rating instrument for use in evaluation of AAT. Draper, Gerber, and Layng (1990), a Canadian research team, monitored the behaviour of ten patients participating in three twenty-minute one-on-one therapy sessions in a psychiatric hospital. The team categorized activity according to displays of appropriate or inappropriate affect or communication, approach or avoidance movement, and whether the patient’s attention was directed at the animal or the therapist. The researchers were able to achieve high inter-rater correlations, but found no significant changes for affect, communication, or movement across sessions. A non-significant trend towards increasing attention to therapist and decreasing attention to animal was observed, indicating that perhaps the animal was serving to strengthen the therapeutic bond and communication with the therapist. Although the sample size was small, and the animal used in therapy sessions was not consistent, the study does serve as a starting point for the development and subsequent validation of appropriate measurement instruments.

While many studies have been conducted on the effects of AAT in institutionalized psychiatric or geriatric populations, few have examined the consequences of AAT on young people residing in the community. One study introduced college students who had scores indicative of depression on the Beck Depression Inventory to either AAT alone (n = 12), traditional group psychotherapy with adjunctive AAT (n = 9), and a control condition that received neither treatment (n = 27) (Folse, Minder, Aycock, & Santana, 1994). The study failed to find a difference between the psychotherapy group and the control, while, surprisingly, a significant decrease in depression was found in the AAT-only- group compared to the control group (p value not reported). The authors admit that these results should be interpreted with caution for a number of reasons. First, subjects were not randomly assigned and post-hoc examination of depression levels showed distinct differences between groups. Second, there were substantial variations between treatment groups. For instance, group sessions were directed by two separate moderators with different qualifications (therapist vs. grad student), and different animals were used in the two types of sessions. Furthermore, the treatment groups were quite small, while the control group was twice the size of either treatment group. Because AAT research using younger participants is uncommon, further research with greater attention to controls, would be of interest.

Summary of Experimental Studies
Although variable in design and research paradigm, the studies cited above all address the effects of human-animal interaction in either therapeutic or social settings. Upon conducting a systematic analysis of the investigations available, it is felt that more research, of a rigorous experimental nature, is still required. It is especially evident, upon review, that most of the studies conducted to date have lacked appropriate sample sizes, thus providing insufficient power for statistics and limited ability to compare to normal populations.

In addition to the need for thorough experimental research, the field of animal interaction in therapeutic settings may benefit from incorporating more structure into existing programs and practices. For example, agreement as to what constitutes therapy as opposed to recreation, and clear delineation of the roles of the patient, therapist, and animal in AAT would allow for further development of the field and also assist in the training of AAT professionals. In order to gain acceptance as a legitimate technique, the domains of therapy and recreation need to be made distinct. Furthermore, it is believed by many that validated standards for selecting and training therapy animals, as well as universal guidelines for the implementation of AAT programs, would greatly enhance the efficacy and safety of this treatment modality.

Clinicians and researchers, alike, express the intuitive conclusion that AAT is effective in reducing anxiety, alleviating depression, and improving the self-esteem and socialization of their patients. However, while some of the studies published to date have been able to show some increases in social interaction, improvements in clinical condition have not been clearly quantified. It is hoped that further research, incorporating sound experimental design, adequate samples, and standardized measures will provide the scientific foundation to support continued utilization of this innovative technique.

The Chimo Project, 2003
Liana J. Urichuk with Dennis Anderson: Improving mental health through animal-assisted therapy

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