Aaron came to his social skill’s group early each week so he could get Sasha’s undivided attention. “Can I bring in the cage and hold Sasha for a while? She is so cute,” bellows Aaron as I entered the building. “Sure, why not,” I replied. What he did not realize is that my eyes never left him as he carried in my small gerbil, sat down in the classroom and let her out of the cage. Here is a ten-year-old child diagnosed with ADHD, sitting and giggling and smiling, as Sasha crawls over his legs. So as not to frighten her, he sits calmly—something that is hard for him to do. He eventually begins to stroke her and tells her how beautiful she is. “You are a sweetheart, Sasha. I love you,” he whispers, with a proud smile.
At these times, Aaron acts like a different child. Around Sasha he slows down, and she has a calming effect on him. Her nature seems to transform him. Perhaps it is her size. He does not want to overpower her, so he moves slowly and talks gently. She reciprocates, by snuggling and allowing his tender touch. Over the course of the program, I often brought Sasha to Aaron so that he can learn to gage his own activity level and perhaps be in more control (Fine and Eisen, 2008, p. 7).
This case study occurred over 30 years ago. Sasha eventually was to become my first therapy animal. Those preliminary observations helped develop my early understanding of the value of animal-assisted interventions. In particular, I began to appreciate how the integration of an animal into therapy promoted a more nurturing and safer environment for clients.
As has been articulated throughout this book, the value of the human/animal bond has been seriously investigated over many decades. Furthermore, popular culture reflects the bond between humans and animals as is seen in the popular press and the film industry. Most recently, various films in our pop culture have portrayed the importance of the human/animal bond as well as the impact of the bond. There has also been a proliferation of books focusing on the importance of wildlife to humans as a recognition of the positive impact that animals have on the lives of people: Olmert (2009) Made for each Other; Becker et al. (2005) Chicken Soup for the Dog Lover’s Soul; Chernak-McElroy (1996) Animals as Teachers and Healers; Von Kreisler (1997) The Compassion of Animals; and Grogan (2005) Marley and Me. It seems a logical next step that mental health professionals try to incorporate the human/animal bond connections, when applicable, into their practices where applicable. As Bern Williams once stated: “There is no psychiatrist in the world like a puppy licking your face.”
10.2 The need for research
Despite positive anecdotal examples, the reader needs to recognize that there is limited empirical support and research validating the overall effectiveness of AAT (Fine, 2002, 2003, 2008; McCulloch, 1984; Serpell, 1983). Voelker (1995) noted that the biggest challenge facing advocates of animal-assisted therapy can be summed in two words. “Prove it” (p. 1,898). Voelker (1995) stresses that the major difficulties in obtaining outcome data in animal-assisted therapy is that many of the professionals applying these strategies do not see the necessity of conducting outcome research or, possibly, they do not take the time to validate outcomes. This lack of documentation and thorough investigation leaves a large void in demonstrating the efficacy of this approach. It seems that most clinicians persevere and incorporate the modality primarily on qualitative impressions that have been observed or heard about. However, a lack of empirical evidence may continue plaguing the acceptance of AAI, especially as many become more concerned about evidence-based forms of psychotherapy.
Barak et al. (2001) notes that research is also needed to identify the underlying mechanisms of AAT that produce therapeutic changes. The findings from these studies would be valuable to understand how the interventions work, so that the best practice procedures can be implemented. Unfortunately, many outsiders have a limited awareness of how AAI is applied and there is a need to demystify the process. In addition, there also needs to be a more appropriate bridge between clinical practice and best practice research. Practitioners are encouraged to pay closer attention to the need for program evaluation and documentation. All of these efforts should assist the scientific community with the needed research priorities.
Many have pointed out that although the utilization of animals may be highly appealing, it needs to be understood that just because an interaction with an animal is enjoyable, does not imply that the procedure is therapeutic (Katcher, 2000; Serpell, 1983).
Fine, in an interview with Kale (1992), pointed out that animals could have a therapeutic impact on children when the approach was integrated with other strategies. “To say that the therapeutic changes occur solely in isolation would perhaps be quite misleading.” Fine (2005) explains that it is important to understand how animal-assisted interventions can be integrated alongside traditional psychotherapeutic approaches. Attention in future research must address this concern.
Therefore, it is strongly emphasized that over the next decade a concentrated effort be initiated to demonstrate the efficacy of this modality. The findings from quality designed studies will help clinicians as well as researchers answer a variety of questions, including:
Under what conditions are animal-assisted interventions (AAI) most beneficial?
With what special groups do AAI appear to work the best?
Under which theoretical orientation (e.g. humanistic, cognitive, behavioral) does the incorporation of animals seem the most therapeutically effective?
10.2.1 Objective of the chapter
The objective of this chapter is to provide the reader with practical insight into how animals may be incorporated into a therapeutic practice. Within this context, the author will also provide suggested guidelines to assure quality control for the client’s and animal’s safety. Case studies will be incorporated to illustrate how the interventions can be applied logically.
10.3 The role of animal-assisted therapy in psychotherapy: is there such a thing as an AAT Rx?
As previously discussed, one of my greatest reservations in recommending AAT has been the lack of published protocols. There is a definite lack of clarity of how a treatment regime can be replicated. Unfortunately, this lack of clarity makes it difficult to develop a clear cut Rx for AAT. One should not look at AAT in isolation, but rather how the animals support and augment the clinician’s ability to work within his/her theoretical orientation (Fine, 2005, 2008). Fine (2005) has suggested that there are several basic tenets to consider when one incorporates animals into therapeutic practice. Therapists should consider utilizing a simple problem-solving template as they plan on applying AAT interventions with their various patients. The following three questions should be considered:
What benefits can AAT/AAI provide this client? The clinician needs to consider the benefits animals will have in the therapy. What benefits will the animals provide in the clinical intervention? Should therapists only expect the animals to act as social lubricants to promote a safer environment, or can the animal’s involvement be more deeply integrated within the clinical efforts?
How can AAT strategies be incorporated within the planned intervention? A clinician must begin to conceptualize the vast array of opportunities that the therapy animals can provide. Several of these alternatives will be discussed later in the chapter. A plan must be formulated so the outcome will not be purely serendipitous.
How will the therapist need to adapt his/her clinical approach to incorporate AAT? This perhaps is the most critical aspect to consider. A clinician must take into account how incorporating animals into therapy may alter his/her clinical orientation. Therapists must also mull this over (even if being an animal lover) if they are comfortable practicing psychotherapy co-jointly with their animals. If the animal’s presence does not match the style of therapy practiced, it may cause more dissidence and become ineffective.
In a similar vain, Chandler (2005) points out that the therapist should design interventions to involve a therapy animal in ways that will move a client toward treatment goals. The decisions regarding if, when and how a therapy animal can or should be incorporated into counseling depends on: (1) the client’s desire for AAI along with the appropriateness of the client for AAI (which may be prohibited by such things as animal allergies, animal phobias, or client’s aggressive tendency); (2) the counselor’s creative capacity to design AAI consistent with a client’s treatment plan; and (3) the therapy animal’s ability to perform activities that assist in moving a client in a direction consistent with treatment goals (Chandler, 2005).
To assist in better understanding how to apply AAT in traditional clinical practices, the following section briefly describes basic foundation strategies that should be considered.
10.4 Consideration 1—why clinicians may find animals therapeutically beneficial
10.4.1 Animals as a social lubricant for therapy
Parish-Plass (2008) suggests that AAT is based on the very strong emotional connection and evolving relationship between the therapist, client and animal. She points out that an animal’s presence in the environment contributes to the perception of a safe environment. She also believes that the client’s perceptions that the therapist makes the therapy animal feel safe contribute to the client’s impression that s/he will feel safe as well. Early research investigating the incorporation of animals within outpatient psychotherapy was somewhat limited. Nevertheless, Rice (1973) conducted a study to evaluate the extent to which animals were used by psychotherapists in the USA as a whole. The study also attempted to classify the ways in which animals served in psychotherapeutic roles. One hundred and ninety members (64% of the sample) of APA Division 29 (Division of Psychotherapy) responded to the survey. The findings of the study suggested that 40 clinicians (21%) indicated that they used animals or animal content in conjunction with their psychotherapy.
The most powerful finding from this study pertained to the specific uses of the animal within the therapeutic setting. The researchers reported that some therapists found some utility in actually having animals present in therapy, while others utilized animals in a conceptual manner. Common commentaries about the utilization of real animals pertained to employing an animal as a vehicle for cultivating or modeling the positive nature of interpersonal relationships. Most of the responders pointed out that animals were used to ease the stress of the initial phases of therapy to establish rapport. The researchers also reported isolated uses of animals such as suggesting that a patient obtain a pet as a means of introducing practical caretaking responsibilities. The conceptual use of animals by most reporting clinicians was most frequently symbolic. Therapists often incorporate animal content to formulate interpretations of patient’s fantasies or underlying themes in their discussions.
Mallon (1992) points out that the animals should not be considered as substitutes for human relationships but as a complement to them. It has been noted that animals appear to decrease the initial reservations that may develop from initially entering therapy. Arkow (1982) suggested that the animal may act as a link in the conversation between the therapist and the client. He called this process a rippling effect. Others such as Corson and Corson (1980) describe this process as a social lubricant. It appears that the presence of the animal allows the client a sense of comfort, which then promotes rapport in the therapeutic relationship.
Box 10.1 Case study
Fine and Eisen (2008) described how a gentle golden retriever aided a young girl with selective mutism into feeling more comfortable in therapy. “For years Diane’s parents had told themselves their daughter was shy. But after her first week at kindergarten, the teacher called the parents into school for a conference where they were told that Diane needed professional help. In school she was not only unwilling to speak, but she cowered with fright when approached or spoken to. Diane’s parents, concerned and upset by this evaluation, tried to work with Diane to overcome her selective mutism and fear when away from her home. Yet, nothing they said or did made any impression on Diane. She refused to talk and, at times, seemed incapable of speech, as though she physically either could not hear or speak.
I first met Diane and her parents on a weekday in the afternoon. When I introduced Puppy and myself, Diane didn’t respond. She gave no indication that she had even heard me. Instead, like Charles, she began to pet Puppy’s head, running her hands over Puppy’s ears, nose and muzzle. Although she never changed her body posture, she was smiling and enjoying her interaction with Puppy.
I turned towards the girl and called Puppy’s name quietly. When Puppy looked up at me, I gave her a hand signal to come towards me and then continued back into the inner office. As Puppy walked away, I watched Diane’s face fall and her eyes take on a sad and disappointed look. I told her, “Oh, I’m sorry. I didn’t realize you wanted Puppy to stay with you. All you have to do for her to come back is to say, ‘Puppy, come.’”
Diane’s parents stared at me, with a look of skepticism on their faces. Then, in a low voice, she called, “Puppy, come, please come, Puppy.” The parents in awe gazed at their daughter. I gave Puppy the signal to go and she ran over to Diane, who slid off of her chair and began hugging Puppy tightly.
Sitting on the floor beside Puppy and Diane, I began to talk to her. I told her that I knew how hard it was for her to talk to people she didn’t know and how happy I was that she was brave enough to call for Puppy. Hoping to build on this small first step, I asked her what she liked about Puppy. She hesitated a moment and then answered, “She is so soft and cuddly.” As we talked, Puppy sat beside Diane who leaned against her and laced her fingers through Puppy’s fur.
When the session ended, I asked Diane to say goodbye to Puppy. She hugged the dog again and said, “Goodbye.” Her voice was soft, but it was clear. Puppy reciprocated with a head nudging and a huge lick on her arm. She had made a remarkable breakthrough and was about to begin her journey towards interacting with the world outside her home.
Over the course of the next five months, Diane, Puppy and I developed a wonderful relationship. Our simple first session eventually changed her life. For Diane, her whole world opened up and she eventually developed the confidence to talk and interact with others (p. 9).
Kruger et al. (2004) and Beck et al. (1986) suggested that a therapist who conducts therapy with an animal being present may appear less threatening and, consequently, the client may be more willing to reveal him/herself. A gentle animal helps a client view the therapist in a more endearing manner. This perception was also found by Peacock (1986), who reported that in interviews in the presence of her dog, children appeared more relaxed and seemed more cooperative during their visit. She concluded that the dog served to reduce the initial tension and assisted in developing an atmosphere of warmth. There have been numerous studies which have elicited similar findings. Odendaal and Meintjes (2003) suggested that animals appear to have a calming effect on humans and reduce arousal. In their study, the data linked tactile contact with a dog with experimentally induced low blood pressures.
10.4.2 The benefits of animals as an extension to a therapist: a method for rapport building
Animals are known for the zealous greetings they provide to visiting clients they encounter. Levinson (1965), in a seminal article on the use of pets (in the treatment of children with behavior disorders), implies that bringing in the animal at the beginning of therapy assisted frequently in helping a reserved client overcome his/her anxiety about therapy. Many therapy dogs are more than willing to receive a client in a warm and affectionate manner. Imber-Black (2009) points out that animals in therapy provide healthy support for spouses being yelled at by their partners and shy children who are anxious to attend therapy.
For example, in most cases, animals can become an extension of the therapist. Personally, the animals that work with me are very responsive to greeting visitors. Children look forward to seeing and interacting with Fine’s therapy animals (PJ and Magic—golden retrievers, Tikvah—a bare eyed cockatoo and Ozzy—a bearded dragon). The dogs eagerly walk over to the children encouraging attention. These initial encounters ease the tension at the beginning of every meeting. The animals are instrumental in regulating the emotional climate.
Boris Levinson (1964), a pioneer of utilizing animals in therapeutic relationships, suggested that the animals may represent a catalyst in helping a child make more progress in a clinician’s setting. It seems evident that the animals’ presence may make the initial resistance easier to overcome. Furthermore, as suggested by Fine and Mio (2006) (and in an updated chapter later in this volume) as well as by Parish-Plass (2008), the AAI acts as an adjunctive therapy that supports the clinicians’ abilities to work on the client’s cognitive, social and behavioral issues. As Parish-Plass (2008) states, “the animal is the tool, and the client is the focus” (p. 12).
Box 10.2 Case study
Several years ago, a 15-year-old boy, who was diagnosed as being depressed, was referred to my office. When he entered the waiting room he became very intrigued with the fish tanks. It seemed that over the years he had developed a strong interest in tropical fish. This common interest appeared to enhance our therapeutic rapport quickly. Over the next six months, our common interest went beyond talking about and observing the fish to a higher level of involvement. After careful consideration and planning, we both believed that putting together a 60-gallon salt water tank would be therapeutically beneficial for him. Indirectly and directly, his involvement and efforts in helping select the fish, plants, scenery, and rocks not only enhanced our bond but definitely appeared to uplift his sense of demoralization. Jeff had something to look forward to. His drive to fight off his lethargy and helpless thoughts seemed to be impacted by the sight of a new environment which he helped design and build. He frequently stopped at the office to check on the fish, taking pride in his accomplishments. Although Jeff continued to battle with his depression, he continued to find refuge and support in the tank he established. The partnership we established in developing the tank was a definite asset to our working relationship.
10.4.3 A therapeutic benefit of animals in therapy: a catalyst for emotion
Fine and Beiler (2008) point out that, for many clients, the mere presence of an animal in a therapeutic setting can stir emotions. Simply interacting with an animal in a therapeutic setting can lighten the mood and lead to smiling and laughter. Animals may also display emotions or actions that may not be professionally appropriate for therapists to display. For example, the animal might climb into a client’s lap or sit calmly while the client pets him. Holding or petting an animal may soothe clients and help them feel calm when exploring difficult emotions in treatment that might be overwhelming without this valuable therapeutic touch.
Animals within therapeutic settings can also elicit a range of emotions from laughter to sorrow. Often in the literature on animal-assisted therapy more attention has been given to the softer emotions, which the human/animal bond instills. Nevertheless, recognition that animals can exhibit humorous behaviors is relevant. Norman Cousins (1989) in his premier writing of Head First: The Biology of Hope has emphasized for decades that humor was not only beneficial in improving an individual’s mental state, but also his/her physical constraints. Laughter and joy are two ingredients which positively impact a person’s quality of life. It seems apparent that not only do animals promote warmth within a relationship, but they may also bring joy and a smile.
There are numerous examples that can be applied to illustrate this phenomenon. For example, a playful cockatoo or a puppy getting itself into mischief can always garner a smile. There have been numerous occasions where the animals incorporated therapeutically get themselves in comical/playful situations. It seems that when this occurs, the laughter generated has therapeutic value.
Selectively, animals are in a unique situation to display emotions and behaviors that may not be deemed professionally appropriate for a human service provider. For example, in difficult periods within therapy, a client may be in need of comforting and reassurance. The presence of an animal may become that catharsis. The holding of an animal or the petting of an animal (be it a cat, dog, or a bunny) may act as a physical comforter and soothe many patients. The touching of the animal and the proximity to the animal may also represent an external degree of safety within many clients.
Moreover, an additional benefit of the animals may be their contribution in helping clients gage excessive emotion and reactive behavior. On numerous occasions, the author has witnessed that when a dispute would take place, the animal’s presence seemed to lend some comfort and stability to the environment. The adults seemed to regulate their reactiveness, possibly because they were aware of the animal’s presence. Furthermore, in working with children who are quite active and impulsive, it is amazing to observe how large birds (cockatoos and macaws) seemed to help promote a decorum for what is or is not considered acceptable behavior. It seems that most children gave tremendous respect to the birds’ presence (possibly some unconscious intimidation) and the reduction to their disruptiveness was evident. Most children seemed to realize that their escalated behaviors would cause uneasiness in the birds, which they did not want to cause. In addition to this one benefit, as a follow-up to the child’s outbursts and the bird’s ability to help reduce the tension, discussions on self-control and behavioral regulation were introduced.
10.4.4 Animals acting as adjuncts to clinicians
Mallon (1992) emphasizes in his paper that the animals must be considered as adjuncts in the establishment of a therapeutic relationship and bond. Hoelscher and Garfat (1993) suggest that when relating to a therapist with an animal, people with difficulties sometimes find the animals the catalyst for discussion, which previously may have been blocked. For example, several years ago, an eight-year-old girl visited the office. She was very intrigued with the birds she saw and wanted to hold a few of the small lovebirds. Without asking if she could hold the bird, she eagerly put her hand towards the animal. To her dissatisfaction, the bird hissed at her. Shortly after this experience, I explained to the girl that she needed to ask the bird’s permission (and mine) to touch the animal. Ironically, this was followed by a powerless response of “I know what you mean.” Her response to my statement piqued my attention, since she was referred for depressive symptoms. I picked up the lovebird and began to scratch her head. I told the girl that the bird was very sensitive to touch, and there were certain spots that she did not like to be touched. At this point, the girl became very teary eyed and responded by saying once again (very sadly this time) “I know what you mean.” Shortly after, she began to reveal a history of sexual abuses by one of her grandparents. It was apparent the serendipitous use of the bird acted as a catalyst to promote a discussion on feelings that she had buried. Over the course of her treatment, we used the example of the bird to help her gain insight on the importance of giving people permission to embrace you, and how you have the right to tell people that your body is private.
10.4.5 The use of the relationship with animals vicariously—role modeling
A valued benefit of incorporating animals clinically is the vicarious outcomes that a client may develop as a consequence of the interaction between the clinician and the animals. For example, the loving relationship between the animal and the therapist may explain by example to the client some of the caring traits of the clinician. This outcome may enhance the development of the therapeutic relationship and alliance. Personally, over the years, this writer has been amazed with the comments he has received from clients observing his interaction with the animals. The most common response pertains to the interaction with the animals and how some clients compare these interactions with their own child/parent relationships (since most of his clients are children and their parents). Other clients comment on how well the animals are treated, including the elements of compassion, consistency, firmness, and love. These scenarios can be used to demonstrate to the client appropriate interactions and responses to behaviors.
Experienced clinicians will attest to the numerous occasions (during sessions) that boundaries need to be placed on the animals. This demonstration of limit setting should be a valuable teaching tool for the clients. The therapist can use these episodes as opportunities to model specific discipline or problem-solving strategies. For example, within my office, one of the many therapy birds that I use is an umbrella cockatoo. She periodically has a tremendous need for attention, and one approach that she uses is to screech. Parents are always amazed with my approach and the explanation that I give to them. The most common approach applied is extinction, and the eventual reinforcement of the appropriate behavior when it is demonstrated (verbal praise and petting the bird). The outcome to this interaction eventually leads to an informal discussion on behavior management, which may have implications to their own child rearing practices.
As can be seen, there are numerous episodes that a clinician could draw upon. It is of utmost importance that the therapist takes advantage of teachable moments and learning opportunities. Discussions with adults on boundary setting, the need to be loved and admired and appropriate ways of interacting are all relevant.
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