∗ , Cynthia Chandler † , Karen Schaffer ‡ , Teri Pichot § , Julia Gimeno ∗
∗California State Polytechnic University
†University of North Texas
‡New Mexico State University
§Jefferson County Department of Health and Environment
An overview of AAI as an aspect of therapy
Aubrey H. Fine, Dana O’Callaghan, Cynthia Chandler, Teri Pichot
11.1 Introduction
The primary purpose of this chapter is to provide the reader with a better understanding of the multitude of therapeutic options on how animals can be incorporated effectively. The chapter is divided into three major themes. The first section of the chapter provides an overview of the applications of animal-assisted interventions (AAI) in various disciplines and provides a discussion highlighting the numerous ways in which AAI can be integrated and applied. The second section builds on this information and provides useful techniques and strategies for AAI with children and adults. Finally, the chapter concludes with specific information on the application of equine therapy.
In the course of the past 40 years, the utilization of therapy animals in health care has increasingly gained much attention. Originally AAI were incorporated sporadically by a few professionals; AAI is now becoming more recognized as a potential alternative in numerous health care disciplines. Professionals in various mental health disciplines, speech and language therapists, psychotherapists, occupational therapists, physical therapists, and nurses are but a few of the disciplines incorporating animals as part of their therapeutic regime. Fine (2008) and Fine and Mio (2006) point out that the greatest challenge that advocates for AAI now face is to document not only how AAI makes a difference, but also the specific protocols that are followed. It is clear that the interventions are in need of a stronger set of evidence-based findings. Protocols need to be evaluated and articulated so there will be more opportunities for replication. For AAI to advance as a more reputable intervention there needs to be more rigorous research to document its efficacy.
Unfortunately, the literature on AAI is filled with glamorous anecdotal comments on the value of AAI, but many questions continue to be left unanswered. Regrettably, the methods of how one applies AAI with various populations are very poorly understood and best practice options have not been readily established and clarified. One of the earliest studies examining the use of animals in psychotherapeutic settings identified some of the therapeutic purposes for utilizing animals. Rice et al. (1973) found that respondents included animals as a source of comfort, as a reward in behavior modification framework and, in addition, from a gestalt perspective as a way of exploring the meaning of touch, smell, and warmth. Rice’s study, however, did not identify specific techniques utilized with animals in psychotherapy. O’Callaghan (2008) investigated the various animal-assisted interventions incorporated by mental health professionals as part of their therapeutic regime as well as the various therapeutic purposes intended with each technique. Participants were recruited nationally from various AAI/AAT for mental health providers. O’Callaghan postulated from a review of the literature that there were about 18 animal-assisted therapy techniques and ten therapeutic intentions that were identified as the primary reasons why clinicians utilized AAI. Results from O’Callaghan’s study did explore how mental health professionals incorporated a variety of animal-assisted techniques for various therapeutic intentions. She found that the vast majority of mental health counselors reported using AAT to build rapport in the therapeutic relationship. They often did this by reflecting on the client’s relationship with the therapy animal, encouraging the client to interact with the therapy animal, and sharing information about the therapy animal. O’Callaghan also found that therapy animals provided therapeutic benefits solely from their presence and without any direct intervention from the mental health professional. For instance, therapists did not encourage or guide an interaction between client and therapy animal. The animal’s existence in a therapy environment provided benefits. This finding seems consistent with much of the literature describing the use of animal-assisted therapy interventions. Corson and Corson (1980) were also early pioneers in the study of AAT. They performed one of the first controlled studies involving animals as adjuncts in the therapeutic process. They reported that patients in a hospital setting displayed increased verbalization when therapy animals were included in psychotherapy treatment. Corson and Corson noted that the therapy animal was included in a non-directive fashion. Participants indicated that enhancing trust and facilitating feelings of safety in the therapeutic environment were also some of the therapeutic benefits of incorporating therapy animals. Table 11.1 describes the findings from O’Callaghan’s study reviewing the top five reported therapeutic techniques and reported intentions of each technique of the subjects involved in her research.
| Top five techniques | Top intention for each technique, reported by respondents |
| 1. Therapist reflects or comments on client’s relationship with therapy animal | building rapport in the therapeutic relationship |
| 2. Therapist encourages client to interact with therapy animal by touching or petting therapy animal | building rapport in the therapeutic relationship |
| 3. Information about therapy animal’s family history (breed, species, and so forth) is shared with client | building rapport in the therapeutic relationship |
| 4. History related to therapy animal is shared with client | building rapport in the therapeutic relationship |
| 5. Animal stories and metaphors with animal themes are shared with client by therapist | facilitating insight |
(From O’Callaghan, 2008)
Given this diversity within AAI approaches, it would seem that an understanding of how therapy animals are incorporated into the therapeutic regime of a clinician is critical in elevating the status of AAI as a complementary treatment modality. LaJoie (2003) in her dissertation proposed a classification system in order to better organize the literature in this field. She noted that to complicate matters worse, various terms were used to describe the roles of animals as therapeutic tools.
11.2 Understanding the magnitude of AAI from an interdisciplinary perspective
11.2.1 The role of AAI in speech and language, occupational and physical therapy and education
Over the past 40 years, numerous health care disciplines have incorporated AAI into their work place. It is apparent that, to most practitioners, AAI on a superficial level uses the animals to captivate their clients and to enhance their rapport. Disciplines such as physical therapy, occupational therapy, speech therapy, nursing, mental health, and education are some of the disciplines where animals are now being used as an aspect of treatment. For example, during a hospital physical therapy session, the act of petting or grooming the dog can be used to target muscles in the hand, arm, or shoulder. Patients frequently are willing to engage in a repetitious task for longer periods of time when they are engaged with a dog (Pichot, 2009). The dog’s presence takes the patient’s mind away from the discomfort of the exercise and adds a more casual feel (Fick, 1993; Steed and Smith, 2002).
In reviewing the literature, it is apparent that AAI has also been adopted by various speech and language therapists. However, there is little research or information describing how AAI is incorporated into the treatment process. Macauley (2006) cited six studies investigating the effects of AAT in speech and language treatment, all of the studies involved children as the recipients of treatment. One pilot study involved the incorporation of canines in speech and language treatment with preschoolers with speech delay (Macauley et al., 2002). An additional case study (Adams, 1997) examined the enhancement of speech therapy by also involving canines. The remaining studies incorporated the use of hippotherapy as a treatment modality in the field of speech and language treatment.
Macauley (2006) investigated the effectiveness of AAI in speech and language therapy for persons with aphasia. Although no significant differences were found in Macauley’s study, participants noted some of the differences during AAT speech and language sessions. Participants reported more motivation when the therapy dog was incorporated into the session. In some cases, participants were asked to direct their statements to the dog, resulting in more effort in their conversations according to outside observers. In addition, participants also stated they felt less tension in their visit when the therapy dog was present. Oftentimes when therapy animals were part of a therapy session, the animals may have engaged in spontaneous moments undirected or unscripted by the therapist. According to Macauley (2006), participants spontaneously verbalized statements directed toward the therapy dog more so during AAT speech and language sessions compared to traditional speech and language sessions.
On the other hand, Mullett (2008) described a unique application of utilizing an animal in therapy. Mullett (2008) noted how a therapy dog named Pita would respond with a bark when she heard the words “cow” and “squirrel.” For one patient, witnessing Pita’s response provided motivation for that patient to verbalize these words more easily. Mullett explains that, for some patients, a therapy dog can offer the right amount of entertainment, distraction and pleasure to the therapy process, which seems to motivate the clients to work harder. Fine (2006, 2008) has also observed similar outcomes in mental health and occupational therapy.
AAI is now quite commonly practiced in the field of occupational therapy as an adjunct to therapy. The United States Department of Labor describes the role of occupational therapists as helping patients improve their tasks in living and working environments (Bureau of Labor and Statistics, 2009). Occupational therapists apply treatments to develop, recover, or maintain the daily living skills and work skills of their patients. For example, the occupational therapists at St. Mary’s Hospital for Children, in Bayside New York, developed an animal-assisted therapy occupational therapy program in the winter of 1998 (Oakley and Bardin, n.d.). Oakley and Bardin describe animal-assisted occupational therapy as a process where the “occupational therapist conducts the therapy session using the dog as a modality to facilitate the development of skills needed by the child to achieve independent functioning in the areas of self-help, play and learning.” As a child learns or relearns daily tasks such as grooming, a therapy dog can become part of that learning process. Oakley and Bardin describe a possible technique:
For example, a child recovering from a traumatic brain injury experiences considerable difficulty dressing and grooming him/herself due to the loss of function in one arm. The therapist may ask the child to reach out with the weak arm to pet, brush or even feed the dog. The therapist may add a wrist weight to the weak arm in order to develop strength, or use an adapted brush with a special handle to assist the child in holding the brush. The child becomes motivated and excited to participate in treatment; thus helping to achieve treatment goals quicker and easier.
As has been witnessed in many disciplines, the therapy animal acts as a catalyst of discussions including motivating the patients to talk about previous pets they owned. This seems to be a simple bridge to the therapy animal and perhaps the patient’s personal interest in animals. In a paper by Velde et al. (2005), they described how occupational therapists may incorporate therapy animals into their practice. Velde et al. examined three different qualitative case studies utilizing animal-assisted therapy in occupational treatment. Each case study revealed different themes that emerged when incorporating a therapy animal into treatment. Ferrese et al. (1998, as cited in Velde et al.) reported that patients were able to tolerate treatment for longer periods of time when a therapy animal was present, as well as increasing patient’s positive affect. They observed more smiles and increased verbalizations from the patients. Specifically related to occupational treatment goals, Ferrese et al. also noted that therapists report patients’ physical benefits such as increased range of motion. The second case study investigated the incorporation of therapy animals with hospice patients. Garland et al. (1997, as cited in Velde et al.) also reported similar results, themes related to remotivation, and cognition including memory as well as tolerance for activities. In both case studies, reports indicated that the animals’ presence seemed to distract the patients from the arduousness of the tasks and motivated them to work harder. Herbert and Greene (2001) found similar results when a therapy animal accompanied senior citizens in their walking program, compared to times when the senior citizens walked alone. They suggested that the dogs had the potential to improve physical conditioning for senior citizens at an assisted living facility. This perception has also been documented by Johnson in her work with the elderly.
Finally, it is also clear that AAI has found a role in the education of children. The presence of a therapy animal has the possibility to provide a calming and supportive atmosphere to children in the classroom, thus influencing children’s performance in academic settings. Jalongo et al. (2004) stated that “Animal-assisted therapy is founded on two principles: children’s natural tendency to open up in the presence of animals and the stress-moderating effect of an animal’s calm presence” (p. 10). Within San Diego’s Unified School District in San Diego, California, a therapy dog named Sunny assists students through adaptive physical education (ARAcontent, n.d.). Teacher Andrea Bazer co-works with Sunny and about 45 preschool to sixth grade children with disabilities at five different schools. Part of Sunny’s role is to play fetch and other interactive games. While some school districts are welcoming therapy animals onto campuses, other therapy animal teams are finding alternative ways of bringing animal-assisted therapy to school children. Therapy Dogs United (2008), a non-profit organization based in PA, has created a traveling program bringing therapy dogs to various schools. Therapy Dogs United’s ACE (Animal Care for Exceptional Children and Adults) program is designed to help children and young adults with social, emotional, physical and developmental challenges achieve positive outcomes. Their weekly visits are conducted with a therapy animal, handler, and counselor or trained therapist.
The authors will now address how various philosophically trained mental health providers utilize AAI in their practices. This dialogue will be followed with a more lengthy discussion of the various clinical applications of AAI by various disciplines.
11.2.2 Integrating AAI into psychotherapy
When psychotherapists are contemplating adding a therapy animal as a tool in their practice, it is most helpful to begin by making a list of key principles upon which their underlying guiding theory relies. By becoming clear regarding one’s theoretical approach, therapists can determine if incorporating a therapy animal is compatible. Once this crucial step is in place, the therapy animal then becomes a valuable tool in the work prescribed by the guiding approach.
Chandler et al. (n.d., under review) demonstrate the versatility of AAT as various techniques are applied in ways consistent with several different counseling theories, including person-centered, cognitive-behavioral, behavioral, psychoanalytic, gestalt, and solution-focused brief therapy (see Tables 11.2 and 11.3).
Table 11.2 Sample psychotherapeutic animal-assisted interventions
| Psychotherapeutic theory | Animal-assisted intervention (AAI)∗ | AAI intention | Case scenario |
| Person-centered | Therapist reflects upon client’s feelings while client pets and hugs therapy dog during spontaneous client therapy/animal interaction | Increase client’s sense of safety and trust | After a spontaneous intervention with a counselor and her therapy dog a female adolescent lowers her defenses and becomes much more cooperative in an initial intake interview with a probation officer in a juvenile detention facility |
| Cognitive-behavioral | Therapist facilitates clients performing tricks with a therapy animal | Challenge client’s irrational beliefs, enhance frustration tolerance, and increase self-confidence | An adolescent male in a juvenile detention facility tried unsuccessfully a few times to get a therapy dog to do a trick and then gave up quickly out of frustration stating he could not do it. Following processing of self-defeating thoughts with a therapist and some brief coaching and encouragement the juvenile tried again until after several more attempts he and the dog succeeded with the trick |
| Behavioral | Therapist facilitates clients teaching obedience commands to therapy animals | Experiential lessons for clients on impulse control, behavioral learning, behavioral modification, and generalization (from dogs to juveniles) of positive benefits of change in behaviors | A group of adolescent males in a juvenile detention facility learn to modify their own behaviors while teaching unadoptable dogs good manners and obedience so the dogs can be adopted into good homes instead of being euthanized |
| Psychoanalytic | Therapist facilitates client insight from client interaction with a therapy animal serving as a transitional object | Uncover unconscious anxiety of client to make it conscious so the client can better resolve an anxiety | Ten-year-old male described by school counselors as at risk for academic and social failure begins group equine therapy and experiences his horse to be very nervous and anxious around him but the horse is not this way around his same age and gender therapy partner. The therapist learns from the client that the client believes the horse acts this way because the horse does not like him. The therapist encourages him to spend the next week pondering why he thinks the horse does not like him. The following week the client exclaims that he has figured it out—that the horse does not like him because he does not like himself. After processing why he does not like himself the client achieves new personal insight and support and encouragement from the therapist and other members of the therapy group. The client is now able to approach and interact with the therapy horse without the horse becoming nervous or anxious around the client |
| Gestalt | Therapist facilitates client group to achieve a task together with a therapy animal | Uncover self-defeating personal beliefs, limited thinking styles, and dysfunctional communication and interaction patterns that impair authentic living | Clients must cooperate together to move a horse over a low obstacle in a large arena. The only rules are: during the task clients may not speak words out loud or touch or bribe the horse. But, clients may speak to one another during infrequent timeouts called by the therapist. Though not revealed to the group until the end of the task, success relies on (1) how well the group works together in respectful ways, and (2) clients’ ability to initiate creative problem solving |
| Solution-focused brief therapy | Therapist changes the client’s therapeutic environment and activities to include equine-assisted therapy | To provide the type of therapeutic environment and activities that will facilitate client personal growth and development | An adolescent male in a juvenile detention facility was withdrawn and introverted for many months until he participated in group therapy with horses, a therapy environment where he thrived though he had no previous exposure to horses. Successes with the horses brought him out of his shell and he developed self-confidence. The support from his therapist and the respect he received from his peers in his equine group facilitated his development as a compassionate leader of his group |
∗ The sample AAI are not meant to suggest that certain AAI are limited only to certain theories, rather it is meant to demonstrate that AAI is versatile enough to be incorporated into a variety of theoretical approaches. | |||
(briefly summarized from Chandler et al., n.d., under review)
Table 11.3 Principles of solution-focused based therapy and AAI (Pichot and Dolan)
| 1. If something is working, do more of it | When working with a therapy dog, it becomes immediately clear who likes dogs and who is interested in receiving a visit. A solution-focused therapist using a therapy dog is always cognizant of these moments, and takes the time whenever possible to allow the clients to have the desired interaction |
| 2. If it is not working, do something different | Adding a therapy dog as a tool can be just the something “different” that works. A therapy dog can provide just the needed distraction to allow client and therapist alike to discover a different path that might be more effective |
| 3. Small steps lead to large changes | When observing a therapy dog and professional in action, it soon becomes clear that each tiny act adds upon another, building upon something special deep within the client, resulting in something powerful |
| 4. The solution is not necessarily directly related to the problem | This approach believes that the clients’ solutions to their problems oftentimes have nothing to do with what originally caused the clients’ problems. In the end, the therapy dogs make a difference to each client in very different ways |
| 5. The language requirements for solution development are different than those needed to describe a problem | Because animals do not speak, clients are forced to use a different way of communicating when interacting with a therapy dog |
| 6. No problem happens all the time. There are always exceptions that can be utilized | Solution-focused therapy suggests helping the clients change their focus onto times in which the problem is not occurring or is not as severe. Animals excel at this technique, for they do not analyze problems |
General AAI techniques for children and adults
Aubrey H. Fine, Dana O’Callaghan, Karen Schaffer, Teri Pichot, Julia Gimeno
In the previous chapter, several general tenets of the various applications of AAI were discussed in great detail. These tenets appear to be the strongest reasons why most clinicians apply animals in their work regardless of their professions and theoretical orientation. Before we add to this list and discuss some unique approaches, a brief review will be incorporated. Table 11.4 lists the four major tenets that Fine discusses in the previous chapter. The readers are encouraged to review these principles as a foundation for the information discussed within this chapter.
Table 11.4 Tenets of animal-assisted therapy
| Tenet 1: Animals acting as a social lubricant |
| Tenet 2: A catalyst for emotion |
| Tenet 3: Animals as teachers |
| Tenet 4: Adjuncts to clinicians and animals changing the therapeutic environment |
Many benefits of AAI have been demonstrated in AAT research and some of the most notable benefits include, but are not limited to: (a) increasing client motivation to attend sessions (Lange et al., 2006/2007); (b) contributing to unconditional acceptance of a client and facilitating client/therapist rapport and trust (Lange et al., 2006/2007; Reichert, 1994, 1998); (c) increasing client focus and attention during sessions (Fick, 1993; Heindl, 1996; Limond et al., 1997; Martin and Farnum, 2002; Richeson, 2003); and (d) providing nurturance, growth and healing of a client through client/therapy animal play, petting and other appropriate interactions (Cole et al., 2007; Fine, 2006; Friedmann et al., 1983; Odendaal, 2000; Wilkes et al., 1989).
When therapists initially learn about the power of integrating a therapy animal into a psychotherapy session, an exciting chapter in the clinician’s professional life unfolds. Once the nascent excitement begins to fade and reality begins to set in, therapists soon begin to wonder, “What do I do with the therapy animal in the session? What is the animal’s role?” The therapist is the one who must decide if, when and how a therapy animal is to be incorporated into the therapy process. The therapy animal can best be described as an “adjunct tool” (Chandler, 2005, p. 89; Fine, 2006) in therapy, meaning the therapy animal works as an assistant to the therapist.
11.3 General therapeutic approaches for children and adults
11.3.1 Therapeutic use of metaphors and stories
Mallon (1994) discovered that animals have been symbols of power and nurturance. The metaphors of flight with birds and strength of horses can be used therapeutically by therapists to help their clients uncover internal concerns. McMullen (in press), McMullen and Conway (1996), Close (1998), Battino (2003), Barker (1996) and Argus (1996) point out that metaphors are extensively utilized by clients in their conversations with therapists. Their research suggests that the incorporation of metaphor themes throughout the course of therapy may actually represent a productive indicator of the therapeutic relationship. Kopp (1995) pointed out that metaphors are similar to mirrors in their ability to reflect inner images within people. Metaphor therapy resides on the position that people, in general, structure their reality metaphorically. Both the client and the clinician can apply metaphors as a method of discovering and understanding client’s concerns. The imagery generated from the metaphors can be used to help the client uncover how s/he is coping or feeling. For example, a client could be talking to a therapist about feeling overwhelmed about her daily life. When asked what she plans to do about it, the client responds quickly by stating “I really don’t want to open that can of worms right now.” The metaphor of the “opening of the can of worms” may represent the client’s unwillingness to scramble and try to clean up the mess that she is in right now (rushing around trying to prevent the mess that would be made when the worms squirm out). She does not want to face the formidable task of putting her life in order. The metaphor helps to accentuate that position.
Probably the most effective metaphors and stories about birds pertain to their grace in flight. Therapeutic discussions range from the majestic eagle soaring freely to the beauty in the flight of a flock of birds. Equally as beneficial are the sad metaphors that can be applied to a clipped (wings) or grounded bird.
Additional metaphors may include feeling chained or leashed, smothered or being in a cocoon. Clients may develop therapeutic gains when the metaphors applied may also suggest a resolution. For example, the entire process of metamorphosis is an excellent example, which illustrates a transformation. The caterpillar goes through the arduous task of spinning its cocoon that initiates the metamorphosis from its present state to the magnificent butterfly. For months the caterpillar leads its sheltered existence as its body is transformed. Therapeutically, the process of metamorphosis can be valuable in explaining two challenges. Numerous insightful dialogues can be developed on either of these two themes. Some clients will benefit from a discussion of the process of transformation, while others may gain some insight into themselves while discussing the sheltering of a being in a protective environment. Furthermore, the short-lived life of a butterfly can also be related to the price that some will take for the outcome.
11.3.2 Storytelling
Deshazer (1994) and Combs and Freedman (1990) imply that embellishing a client’s thoughts through storytelling stems from the narrative psychotherapy tradition. From this approach, insights suggest that meaning is given to our lives and movement occurs in therapy when we have transformational stories which help put our lives in a new context. The narrative approach to therapy suggests that some clients appear to be stuck in their lives and the new stories generated help them gain a better understanding of their life conditions. Furthermore, the various stories may also lend credible approaches and insight for possible resolution. It seems that for some clients, the previous stories they rehearse in their heads to cope with their challenges are not effective any longer or lose their meaning. Therapeutic storytelling that takes advantage of thematic concerns can integrate narratives that directly pertain to the client’s concerns.
Experientially, since the author’s practice incorporates animals, he also applies metaphors and uses stories with animals to help clarify certain positions to his clients. Freeman (1991) points out that stories are appropriate in different manners at all stages of life. A clinician’s ability to care for and maintain effective communication between his/her patients can be augmented and enhanced by the stories we hear and share. The use of tales can be utilized as a source of support and expression as a child or an adult works through a specific concern. The story may reflect a specific dilemma that the individual is attempting to confront and provide some insight on methods for resolution. Fine et al. (in press) suggests that stories help us see the world from the inside perspective of other people. Through stories, outcomes and consequences of decisions are illustrated. Stories of events concerning people or animals can be an inspiring approach to apply with our clients. The stories can therapeutically illustrate and uncover specific concerns and issues, and also help our clients unravel their concerns from other perspectives.
11.3.3 Walking therapy
Biophilia is a fundamental human need to affiliate with other living organisms (Kahn, 1997). The Kahn (1997) research reveals that children have an abiding affiliation with nature. Combining the therapeutic usage of animals along with nature exploration could be a powerful approach with some clients. A natural outcome of having a therapy animal is to walk the animal. While walking, one has the opportunity not only to engage in discussion, but also to experience the surroundings. At times, the serendipitous observations may enhance or stimulate the ongoing conversation between the clinician and the client. Fine (2006) has found walking a productive part of therapy in some cases. When working with clients whose concerns are non-threatening, the walk may put the client at ease. While working with children, most do not appear to become distracted while on a walk, but rather engage in discussions freely. While taking a walk, many life examples may be illustrated. For example, if the dog needs to relieve itself, the client must learn to be patient and understanding. Furthermore, the clinician can model responsible behavior and bring materials to clean up the mess.
While walking, children seem to display a great sense of pride leading the animal. In fact, on numerous occasions I stop the walk and make a point out of how important the child appears leading the animal. This redirection emphasizes the importance of the special bond. They are periodically stopped by a pedestrian who may ask them a question about the animal, and in most cases, the interactions are quite pleasant. Combining utilizing the natural environment, along with the animals, seems to be an added benefit in strengthening the rapport with the child.
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