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Animal Assisted Therapy

Animal-Facilitated Therapy in Various Patient Populations

By: Sarah Matuszek, MSN, RN, Lourdes College, Sylvania, Ohio  August 2012

With a soaring trend of the incorporation of complementary therapies into the mainstream of health care, animal-facilitated therapy has become a popular interest for the health care team to integrate into a patient’s plan of care. This systematic literature summarizes the current research on the use of animal therapy in several patient populations and provides nursing implications for practice.

The use of pet therapy in nursing is now known as animal-facilitated therapy, which is an umbrella term that covers animal-assisted activities (AAA) and animal-assisted therapy (AAT). Animal-facilitated therapy has existed since the 1800s, when Florence Nightingale made substantial discoveries, especially regarding animal therapy. She once recommended that animals are good companions for the infirmed. Since Nightingale’s suggestions and from past discoveries, the profession of nursing recently began implementing the use of animals as therapeutic interventions; the use of dogs has been used to assist patients’ emotional, psychological, and physical well-being. Such benefits of therapy dogs include a decrease in loneliness, stress, blood pressure, and heart rate, which all contribute to the improvement of patient outcomes. Animal therapy uses animals, mostly dogs, to aid in healing patients holistically. Dogs have an overwhelming gratitude and exuberance for life and this effect on people is astounding. Furthermore, animal-facilitated therapy has been researched and its effectiveness on patients’ outcomes and healing is documented, yet it continues to be a standing controversial topic in nursing and health care.

SIGNIFICANCE TO NURSING

Regardless of when a therapy dog steps on a hospital ward, it is irrefutable that the majority of the staff and patients develop a smile in interest. Nurses who utilize a therapy animal in their practice recognize this and consider a smile or act of engagement a success. In a meta-analyses performed by Souter and Miller, the 5 articles they analyzed showed that AAA/AAT had positive effects on depression. However, they also noted that the implementation of animal-facilitated therapy in nursing created various legitimate concerns and controversies. Skepticism of therapy dogs revolves around fear of animal transmitted diseases to humans and the risks of dog bites and scratches. The therapeutic purpose of using animals by nurses in health care is considered complementary therapy. Complementary medicine is based on the paradigm of whole systems. The belief is that people are more than physical in nature, rather their well-being is composed of many components such as mental, emotional, and spiritual. These all interact with each other and are part of a force of life. Much complementary therapy is inherited from Eastern medicine and has joined the Western culture. AAA/AAT is becoming one of many new complementary therapies that are used in nursing to assist patients with their infirmities and deficits. In nursing, the use of AAA/AAT is increasing; however, the research on the effectiveness of this therapy in various health care settings continues to lag behind.

WHAT IS ANIMAL-FACILITATED THERAPY?

Animal-facilitated therapy involves using any animal for the purpose of providing emotional support only. Dogs, cats, guinea pigs, rabbits, and horses are some of the kinds of animals that have been used as therapy for humans. The most common therapy animal is a therapy dog. Therapy dogs are strenuously trained and evaluated on special commands and good behavior. Therapy dogs must know commands to sit, stay, lie down, and come. Once a dog is sufficiently trained, the dog can then be evaluated by a licensed evaluator. The dog must pass a series of commands and tasks in order to become certified by the American Kennel Club (AKC) as a therapy dog. Therapy dogs are used by the health care team as a therapeutic modality in order to gain insight into thought and emotional/ behavioral patterns.

Therapy dogs help improve the social, mental, and physical conditions of patients. Once a dog is certified, proper vaccination and health requirements must be completed. After the paperwork is processed, the therapy visits can begin. Several rules and regulations must be adhered to as a therapy dog owner. For example, prior to any visit, the dog must be bathed within 24 hours and must have clean teeth, trimmed nails, and clean ears. This ensures that the dogs are in proper hygienic condition to make a visit. Several other rules exist that must be followed as well.

Animal-assisted activities and animal-assisted therapy

AAA and AAT can be separated from each other on the basis of the intent and goal of each. AAA is defined as “…the casual ‘meet and greet’ activities that involve pets visiting people. The same activity can be repeated with many people, unlike a therapy program that is tailored to a particular person or medical condition.” For example, a pet that visits a patient in the hospital without a specific goal would be considered an AAA.

On the other hand, AAT is defined as “…a goal-directed intervention directed and/or delivered by a health/human service professional with specialized expertise, and within the scope of practice of his/her profession. AAT is designed to promote improvement in human physical, social, emotional, and/or cognitive functioning.”.  Thus, the patient’s goal should be monitored and progress should be documented when AAT is used as an intervention.

Both of these animal therapy components can provide positive outcomes for a patient. Regardless of whether AAA or AAT is used, the use of animals can be beneficial and supplemental to a patient’s plan of care.

Animal Assisted Therapy (AAT)

In the helping profession, especially the field of counseling, no one method or therapeutic technique is appropriate for every client. For this reason, a holistic treatment method that could serve as a valuable tool in a veteran’s recovery is AAT. This method has been shown to be effective for a number of diverse populations.  Additionally, the benefits of AAT have been demonstrated with individuals in various age ranges and with a wide number of psychological disorders (Sockalingam et al., 2008).

Chandler (2005) defined AAT as the incorporation of animals into the counseling process as therapeutic agents. The animal often but not always belongs to the therapist and can be included in group and individual counseling sessions. Interactions with the animal can be structured or unstructured depending on a variety of factors, such as the abilities of the client or the purpose of therapy (Walsh, 2009).

Walsh (2009) provided support for AAT by addressing the benefits of the treatment. It was determined that much can be learned about a patient or client by observing his or her interactions with an animal. Patterns or behaviors and ways of coping can be seen in a natural and unobtrusive manner. During sessions, the animal will act as a metaphor for the underlying concerns of the client or clients. Stress and anxiety are often eliminated simply by having an animal present in both individual and group therapy. This is purported to be due to the fact that the ability to physically touch an animal reduces symptoms of hyper arousal and helps to calm the individual, both emotionally and physically (Becker, 2002). Walsh stated that “animals act as a catalyst for a release and discussion of deep emotions and suffering” (p. 495). The benefits that animals can offer ought to encourage further discussion and research by clinicians about this therapy.

A variety of animals have been used in conjunction with therapy such as dogs, cats, birds, rabbits, and horses, but dogs are most often used due to their simple training, temperament, and the fact that less individuals have allergic reactions to dogs as compared to cats  (Sockalingam et al.). Larger animals, such as horses, are also used in therapy. When horses are used, the therapy is called equine-assisted therapy (EAT) (Macauley, 2006). This form of therapy allows clients to work through unfinished business, relieves psychological distress, and correct dysfunctional patterns of behavior (Klontz, Bivens, Leinart, & Klontz, 2007). Another term for EAT is known as hippotherapy. As with other forms of AAT, hippotherapy involves addressing a person’s physical, psychological, cognitive, social, and behavioral problems.

In EAT or hippotherapy, the horse acts as a metaphor for developing personal empowerment by overcoming large obstacles and stressful life situations. A balance must be achieved between strength and control, both with the animal and with outside life, making therapy with horses as well as other animals a unique mode of healing and development (Becker, 2002). Animals may also serve a purpose in helping to reduce clients’ resistance to treatment (Lefkowitz, Paharia, Prout, Debiak, & Bleiberg, 2005).

This is especially important to consider for mandated clients whom might demonstrate strong opposition to therapy. Populations. For victims of trauma, AAT has been shown to offer some relief for related symptoms. Lefkowitz and colleagues (2005) found that AAT was helpful for victims of assault by decreasing anxiety and improving the therapeutic relationship. The authors stated that for women, trauma most often involves sexual assault. For these victims, trust in others is often broken, thus requiring special attention to how to best treat the individual in a safe and comfortable environment in which the client is at ease with the therapist. An animal may act as a tool to encourage security within the therapeutic relationship. This is especially important to note because of the fact that often, the strength of the therapeutic relationship has been linked to a better outcome in treatment (Sockalingam et al., 2008).

As for mental illness, AAT has been documented as helpful for individuals with mood disorders and schizophrenia. For those with mood disorders, especially depression, improved mood and increased optimism were reported following AAT sessions (Becker, 2002; Sockalingam et al., 2008). Additionally, anxiety levels were decreased and motivational levels increased. Among individuals with schizophrenia, increased levels of domestic and health activities were present after AAT sessions (Kovacs, Kis, Rozsa, & Rozsa, 2004), thus improving aspects related to one’s quality of life.

The number of patients’ social interactions also increased. As the clients began to understand the animals, they also began to better relate to each other. In the elderly population, AAT has been shown to offer not only cognitive but also emotional and social benefits. Kawamura and colleagues (2007) demonstrated that AAT helped to improve the mental functions of elderly adults dealing with a gradual loss of cognitive skills due to age. Banks and Banks (2002) found that AAT reduced widespread feelings of loneliness in elderly adults, especially those without strong social support networks.

Decreased apathy has also been noted among elderly patients who received AAT sessions (Motomura, Yagi, & Ohyama, 2004). Becker (2002) observed that animals often increase their owner’s quality of life by providing a source of support, trust, and companionship, especially for the elderly.

Finally, other individuals with whom AAT has shown some promising results are children and people with developmental disabilities. Developmental levels among children vary and for those who have not yet fully developed communication skills, AAT can offer a more age-appropriate form of therapy. Parish-Plass (2008) concluded that in children, AAT has been shown to provide additional “tools” that children may lack, especially concerning language or coping mechanisms. For children, interactions with animals can facilitate better self-control and improve their abilities to understand the feelings of others by first understanding and caring for an animal (Flom, 2005).

Additionally, for those with mental retardation, AAT offers help by aiding the healing process for individuals who might not possess the cognitive skills necessary in traditional “talk therapy” (Becker, 2002). Another example of the effectiveness of AAT was documented by Macauley (2006) who found that AAT was helpful for individuals with limited speech due to stroke and aphasia. Not only was AAT found to be as effective as traditional therapy, but patients also demonstrated more emotions during sessions and looked forward to sessions in which the animal was present. Communications between members improved and clients were less likely to be hindered by their limited vocal abilities. This example serves as further evidence for why AAT could be useful in treating veterans who might otherwise be silent or unengaged in therapy.

AAT and Veterans

Because of the effectiveness of AAT with other populations plagued by trauma, mental illness, or loneliness, the potential benefits of this form of treatment for veterans should be explored. Walsh (2009) stated that animals have the unique ability to help individuals during times of stress and crisis and to facilitate coping, recovery, and resilience.

Bonds with animals can offer unconditional affection, comfort, and security. This is especially true for military families. During times of separation or relocation, such as deployments, animals provided support and stability for their owners (Walsh). The healing that pets and animals can facilitate offers hope for veterans who might otherwise feel excluded and doomed to forever suffer from mental illness.

For veterans who have been traumatized by their combat-related experiences, AAT might prove helpful in aiding the development of trust such as is the case with civilians who have been traumatized in some manner. Physical and emotional trauma may occur as a result of combat but for female veterans, the trauma often involves rape and sexual assault. Fitzpatrick (2010) reported that 22% of women seeking treatment at VA clinics have been sexually assaulted. They are nine times more likely to experience symptoms of PTSD than those without sexual trauma.

Because of such severe and possibly debilitating trauma, it seems appropriate to consider the possibility of AAT because of how successful the treatment has been with civilian victims of trauma, especially women (Lefkowitz et al., 2005).

Because a large number of veterans currently suffer from mental illness (Tanielian & Jaycox, 2008) it is imperative to consider other treatments, such as AAT, when past treatments have proved to be unsuccessful in alleviating symptoms (Lefkowitz et al., 2005). The emotional and physical benefits of AAT that have been demonstrated with patients with mental illness such as anxiety, depression, and schizophrenia (Becker, 2002; Sockalingam et al., 2008), might also prove to be helpful for veterans in need of help for mental health issues. The stigma of mental illness has been identified as a major deterrent to seeking treatment in the military (Campbell, 2008).

A major benefit of AAT is that animals do not see or care about stereotypes. Unlike people who might make judgments based on stereotypes, animals react only to the feelings of the individual (Pointon, 2005) without being impacted by inaccurate social standards of behavior.  Becker (2002) reported that animals can assist one in truly feeling emotions. Often, emotions can entail extreme sadness or fear. To allow such feelings would be awful because to feel those things would mean that control over them would be lost and thus the pain would be unbearable. In these situations, animals can serve as an example of how to experience feelings, rather than suppressing them, in order to release them (Becker).

Just as the elderly might experience loneliness and isolation (Banks & Banks, 2002; Kawamura et al., 2007), so might veterans who feel as if no one is able to relate to their situations (Perlman et al., 2010). Animals can provide long-term relief from stress and social support by making the person feel loved and cared for without obligations or judgments (Lefkowitz et al., 2005). For veterans struggling with stereotypes and stigma (Campbell, 2008), animals might prove to be a non-judgmental companion in therapy.

Veterans may also be unwilling or unable to talk about their experiences (Greenberg et al., 2003) and possibly not had the opportunity to develop healthy coping mechanisms, such as is the case with children and individuals with developmental disabilities. Lefkowitz et al. (2005) concluded that one reason why AAT is effective is because clients do not need to possess social skills in order to communicate with an animal. Additionally, AAT has been shown to positively affect those with limited speech due to either choice or lack of ability (Macauley, 2006). This same principle could help veterans when communicating with others, thus hopefully aiding in the healing process by strengthening communication skills.

An additional benefit of AAT may be for veterans with physical disabilities following combat. For individuals with such disabilities, riding horses is often encouraged in order to promote better physical healing and recovery (Becker, 2002). For veterans with physical disabilities, limitations are well recognized by people but not by animals (Lefkowitz et al., 2005), thus allowing healing without judgment based on physical abilities or lack thereof.

Conclusion

Utilizing AAT and education within the framework of the social learning theory could offer another avenue of treatment for a deserving population in need of help for mental illness. The number of veterans requiring treatment continues to expand (Tanielian & Jaycox, 2008) and with ongoing combat situations, it seems likely that these numbers will continue to grow. Even with the extensive amount of information concerning the proposed interventions for veterans, it cannot be assumed that these theoretical and treatment proposals will work for all veterans and several limitations exist for both the social learning theory and AAT.

Limitations

To begin with, regarding the social learning theory-based proposal involving education and training, much more research is needed concerning the effectiveness of this approach with veterans. Even though the theory has been shown to work well with children and students (Bigler & Liben, 1992; Dereli, 2009; Demirbas & Yagbasan, 2006), there has been little support for using this approach with veterans. Additionally, this approach may be difficult and time consuming for practitioners and clients, due to the fact that changing long-standing attitudes and beliefs will not occur overnight and will require work from all parties involved (Hardin & Greer, 2009).

Even though AAT can play a positive role within treatment, the treatment may be inappropriate for some individuals because of a fear of animals or medical conditions, such as allergies (Minatrea & Wesley, 2008). For the safety of the individual as well as the animal, AAT might prove to do more harm than good in such situations (Lefkowitz et al., 2005). Additionally, although it has been beneficial for many clients, it is not a miracle treatment and may not be the most appropriate option for all clients (Fischman, 2005). However, counselors might find other populations besides veterans in which AAT might prove necessary to increase both verbal and non-verbal communications within the counseling relationship (Minatrea & Wesley, 2008).

Ultimately, practitioners must recognize and affirm the individuality of clients, thus realizing that no one treatment method is always superior to another, therefore proceeding with treatments that are most appropriate for an individual.

Implications for practitioners

It is evident that effective treatment is necessary for veterans with symptoms of mental illness. Regardless of what therapeutic approach or techniques are used in treating veterans, Shaw and Hector (2010) proposed five strategies for successful and empathetic treatment. First, it would be useful to learn what the veteran’s job was in the military. This may help to give the practitioner a better picture of the client’s military-related experiences. Second, clinicians are encouraged to explore the meaning of the veteran’s experiences, both before, during, and after deployments. A third suggestion is to involve family members and significant others within treatment in order to support all parties involved with the situation. Fourth, it is imperative to redefine roles and daily schedules, being that while on deployments, military members’ schedules are often set and specific to the day.

Finally, it is suggested that practitioners determine the dangerousness of the veteran’s experiences while assessing possible mental health problems. In order for a veteran to experience healing and relief, one has to first get to treatment. This must involve addressing stereotypes and stigma. In order to provide effective treatment, it is imperative that mental illness be understood for what it is – genuine illnesses with painful symptoms that can be treated. The possible effects of untreated mental illness, such as violence, homelessness, and relationship problems, have to be recognized as personal, familial, and social issues. In order to change the problem, one must first help the person.

Treatment must come from both military and civilian practitioners. Stigma, stereotypes, and inaccessible resources cannot continue to be reasons for not receiving help for mental illness. The false expectations and stereotypes that keep many veterans silent have to be addressed in order to open the door for more veterans in need of help. Additionally, help does not need to only come from clinicians but also from animals. The lack of judgment that animals offer can aid healing for isolated and traumatized veterans. In conclusion, it is hoped that with better treatment, education, and research, veterans will receive the help that is very much needed and deserved.

Pets Loyal 2 Vets was created for this reason and we will work hard to support Minnesota veterans diagnosed and treated for PTSD, TBI and military assault traumas.

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