Animal-assisted dyadic therapy: A therapy model promoting development of the reflective function in the parent

Abstract

Animal-assisted psychotherapy (AAP) inherently incorporates standpoints, interventions, and ways of action promoting the development of the reflective function and mentalization, and thus has special value for parent–child psychotherapy. Two central tools in AAP contribute to this process. The first is the ethical stance of the therapist, who sees the animals as full partners in the therapy situation, respecting them as subjects with needs, desires, and thoughts of their own. The second tool combines nonverbal communication with animals together with the relating, in the here and now, to the understanding and decoding of body language of everyone in the setting. Nonverbal communication in AAP enables access to implicit communication patterns occurring between parent and child. This article provides a survey of theoretical development and research constituting a basis for the development of therapeutic approaches for the improvement of parent–children dynamics, followed by a description of a dyadic therapy model of a mentalization-based treatment originating from a psychoanalytic-relational orientation. Clinical examples are provided to illustrate AAP processes in parent–child psychotherapy (consent was received for examples that were not aggregated).

Keywords

Animal-assisted psychotherapy dyadic therapy mentalization parent–child therapy nonverbal communication

Introduction to parent–child psychotherapy

Bowlby’s (1982) theory of attachment, together with the work of other theoreticians (such as Mahler, 1968; Sullivan, 1953; Winnicott, 1965) dealing with the interpersonal context of child development, highly influenced the understanding of the importance of the early parent–infant relationship for personal and interpersonal development, as well as the understanding of developmental difficulties in early childhood.

Recent evidence has shown the reciprocal effects of the parent–child relationship occurring from infancy, as well as the influence of the quality of the dyadic relationship on child development (see Beebe & Lachmann, 2003; Glat & Bialik-Cohen, 2003). These studies show how the mother–infant system is formed in the first few weeks of the infant’s life, each participant a component in the system with his or her own ability to self-regulate. The development of the relationship and the attachment pattern is determined by the mutual influences of both. That is, the mother–infant relationship is perceived as a system in which there is a shared organization characterized by rhythm, movement, approaching, and distancing, as well as emotional regulation according to each one’s state and needs.

Filmed observations of face-to-face interaction of infants and mothers show mutual cycles of communication established in a coordinated fashion in the mother and infant (Beebe, 2003). There are mother–infant pairs in which may be seen a mismatch in the dyad, and then one can see the infant withdraw from the connection. Watching these encounters on film in slow motion, one can discern the nonverbal signs of the “interactive dance” that are very subtle and may last only a split second, yet are rich and varied.

Tronick (1998) suggests that the dyadic mother–infant system allows infants to expand their consciousness beyond their cognitive abilities, which are not yet mature, and organize in a coherent fashion the information that is absorbed from their external environment and from their internal experience itself. Tronick named this phenomenon the dyadic state of consciousness. The mother’s awareness and her ability to translate interactive states is a sort of scaffold or infrastructure upon which and through which is built the infant’s consciousness. Furthermore, Tronick (1998) believes that there exists an inherent striving toward these dyadic states of consciousness, as in “I interact therefore I exist.”¹ The quality and frequency of these dyadic states of consciousness influence to a great degree the process of emotional and social development and the development of object representations.

In addition, neurological research shows the influence of early attachment between mother and infant on the infant’s brain development (Schore, 2002). Attachment problems and chronic stress are likely to cause structural changes in the brain and can be expressed later in life through difficulty in emotional regulation and coherent processing of emotional, social, and physical information as well as in emotional disorders (Klorer, 2005).

Much research deals with how the parent–infant relationship has influenced and is influenced by the development of intersubjective approaches to the understanding of personality. (Stern et al., 1998). These developments in theory and academic study have led researchers, therapists, and theoreticians to begin focusing on parent–infant relations in order to enlist the connection between them for the healthy development of the infant (Sleed & Bland, 2007).

Ghosts in the nursery: intergenerational transmission and reenactment of traumatic relationships

In light of this theory and research, various models of parent–child therapeutic interventions have been developed. The work of Selma Fraiberg and her colleagues is an important milestone in the development of therapy approaches for therapy with parents and their children. In their classic article, “Ghosts in the nursery” (Fraiberg, Adelson, & Shapiro, 1975), they identified a phenomenon in which traumatic experiences from the parents’ past “invaded” their present connection with their young children and disrupted the process of attachment between them and dramatically influenced the developmental processes of the infants. The model presented by Fraiberg and her colleagues emphasized the repair of attachment between mothers and their children, together with support and containment of the mothers in their difficulties, allowing for the gradual working through of their past traumatic experiences, while concurrently helping the parents understand the developmental needs of their infant. Based on this model, Alicia Lieberman’s therapy model of Child–Parent Psychotherapy (CPP) (Lieberman & Reyes, 2012; Lieberman, Van Horn, & Ghosh Ippen, 2005) is intended for families that have experienced trauma due to family violence and for mother–child dyads in which the child is from age 0 to 5.

Survey of additional existing models for parent–child therapy interventions

Additional models exist which deal with parent–child psychotherapy, such as Cramer’s (1995) model of short-term intervention, a psychoanalytic therapy approach in which place is given to the exposure of unconscious conflicts that the parents bring into their relationships with their infant. Influenced by Cramer’s approach, Manzano, Palacio-Espasa, and Zilkha (1999) presented an approach to short-term psychotherapy intervention with parents and their children or adolescents. This approach, dealing with the exposure of the parents’ projections and fantasies that they named narcissistic scenarios of parenthood concerning the child, grew out of the understanding that the scenarios are unconsciously acted out by the parents and their child and are the basis of the symptoms the child presents.

The Parent–Infant Project (PIP), developed at the Anna Freud Center in London, describes work with both parents and their infant, where the connection between them is the main focus of their work. This model’s goal is to disrupt negative intergenerational patterns and encourage behaviors which promote healthy parent–infant attachment (Baradon et al., 2005).

In an additional short-term intervention model (Beebe, 2003, 2006), the therapist observes the films together with the parent and they analyze the reciprocal influences of the interaction through relating to terms such as degree of arousal, gaze, regulation, vocalization, distress, and calm. This approach allows parents to actually observe information concerning implicit relations, or their unconscious communication pattern with their infant.² Although implicit knowledge is not accessible to the parent’s consciousness, it influences and creates the type of regulation and translation between parent and child, expressed in relationships with others through body language and various actions (Stern, 1985). Observation of films is accompanied by working through parents’ emotions during their interaction and their representations of the infant in order to change the representations to be more adaptive and the communications between the members of the dyad to be more coordinated (Beebe, 2003).

These parent–child psychotherapy approaches are related to the improvement of parents’ ability to mentalize their interactions with their children.

Mentalization and the reflective function in the parent–child relationship

Fonagy defined mentalization as a

preconscious imaginative mental activity, namely, perceiving and interpreting human behavior in terms of intentional mental states (e.g., needs, desires, feelings, beliefs, goals, and reasons). It is imaginative because we have to imagine what other people might be thinking or feeling. (Fonagy, Gergely, & Target, 2007, p. 288)

and we must imagine the possible reasons for their behavior. Mentalization helps us to observe others’ behaviors and make them understandable and predictable.

Mentalization develops in the interpersonal context. Fonagy described the reflective function as the ability of the parent to reflect and hold in her mind both her and the child’s internal states simultaneously. The infant’s mind grows through the existence of the parent’s mind, or to paraphrase Descartes, “someone else thinks about me and therefore I exist as a thinker” (Levy, 2012).

Additional studies have shown that parents’ reflective functioning plays a crucial role in the child’s ability to develop efficient tools and flexibility to regulate oneself and to establish stable and satisfying relationships (see Slade, 2007). Fonagy’s theoretical work and research, concerning processes of mentalization and the importance of reflective functioning to establish secure attachment, have had a profound influence on therapy interventions in parent–child relationship. As a result, in the last 20 years, mentalization-based therapy approaches³ have been developed with the goal of developing the parents’ reflective ability and motivating mentalization processes among parents in general and in the context of children in particular (Fewell, 2013). The Haifa model of dyadic therapy is one of these therapy processes.

The Haifa model for dyadic therapy

The Haifa model for dyadic therapy is an approach developed by Ben-Aaron, Harel, Kaplan, and Patt (2001) from the University of Haifa and is used extensively throughout Israel. Based on the theory of mentalization from a psychoanalytic-relational point of view as it relates to therapy for childhood relationship disorders, this model integrates attachment theory with object relations theory (Sharabany, 2013). Accordingly, the focus is on visible interpersonal interactions between the parent and child and also on the internal representational world (Harel, Kaplan, Avimeir-Patt, & Ben-Aaron, 2006).

One unique aspect of the model is the structure in which mother–child meetings alternate with father–child meetings, together with regularly scheduled meetings of the therapist with the parents. Attention is paid to the dynamics both within each of these three dyads and between them. A participant-observer, the therapist “provides continuity to the therapeutic process and helps in the integration of the self-and-other representations of the participants” (Ben-Aaron et al., 2001, p. 28). Dyadic therapy consists of the evaluation of various interactions and meanings of the relations between the participants in therapy, how they work, are experienced, and communicated during the sessions. The goal of dyadic therapy is to restore parents’ and children’s ability to regulate, organize, and represent mental states within their relationship with each other (Harel, Kaplan, & Avimeir-Patt, 2013). This is done by enlisting the parent–child relationship for the good of the continuation of growth and for more appropriate working through content that arises (Glat & Bialik-Cohen, 2003). The therapist contributes to the process by empathetically translating to the parents and children the influence of the reciprocal interaction occurring within the dyad in order to lead to changes within it. Thus, one of the therapist’s central roles is to regulate the joint actions. That is, the therapist helps parent and child to contemplate together what has happened, pointing out the verbal and nonverbal communication existing between them and the way in which one influences the other through verbal mediation and development of the reflective ability within the relationship. The therapist contemplates the communication patterns expressed in the meetings with the intention of identifying and bringing to consciousness of the parent and child the implicit patterns existing between them.

Therapy interventions of this approach include building interest and attention to the mental state of the other, focusing in such a way that the child perceives the parent’s mental state and the parent perceives the child’s mental state. For instance, the therapist might say, “What do you think Mommy is thinking?” “What do you think your child is thinking?” The therapist may present an array of ways through which one may see the external reality and develop the ability of parent and child to play and build a symbolic space between them, allowing an encounter with content and subject matter that occupy them both in the common play space, from the understanding of the importance of play for emotional development (Winnicott, 1971) and for development of the reflective function (Fonagy & Target, 1996; Harel et al., 2013).

Animal-assisted psychotherapy⁴

Animal-assisted psychotherapy (AAP) is based on the natural bond between humans and animals, integrating animals into therapy processes in the therapy structure of therapist–client–animal. Researchers and mental health professionals have seen the special advantages and beneficial influence of animals on sufferers of a variety of difficulties such as attention disorders (Katcher & Wilkins, 1994), mental disorders, and psychiatric difficulties (Rossetti & King, 2010). It has been found that therapeutic interactions with animals lead to reduction in anxiety and stress (Odendaal, 2000) and reduction in anhedonia in psychiatric populations (Nathans-Barel, Feldman, Berger, Modai, & Silver, 2005). Contact with animals comforts, calms, and results in a general feeling of psychological well-being (Odendaal, 2000).

Boris Levinson, a clinical psychologist, was the first to recognize AAP as an independent therapy approach and he began to build a comprehensive knowledge base for the field (Levinson, 1969, 1972). Levinson claimed that an animal would be a natural object for attachment and more appropriate for attachment than inanimate objects. He assumed that relationships with living beings allow for a wider range of behaviors to surface in the course of reciprocal interaction. Also, an animal is likely to serve as a secure base and safe haven⁵ (Zilcha-Mano, Mikulincer, & Shaver, 2012). Today, we are witnessing a growing knowledge base, developing from clinical practice and research from the field of AAP that are anchored in theory and research (e.g. Bachi, Terkel, & Teichman, 2012; Parish-Plass, 2008; Pirani & Shani, 2003; Urichuk & Anderson, 2003; Wesley, Minatrea, & Watson, 2009), as well as extensive theoretical conceptualization (Kruger & Serpell, 2010; Parish-Plass, 2013a;) and connections to other psychotherapy approaches (Chandler, 2010; Faa-Thompson & VanFleet, 2010; Ish-Lev & Amit, 2013; Lac, 2014; Maayan & Lakh, 2013) and evidence-based therapy models suggesting attachment theory as a perspective for AAP (Bachi, 2013; Zilcha-Mano, Mikulincer, & Shaver, 2011).

Ethical stance and nonverbal communication as fundamental tools in AAP

I believe that the animals are full partners in the AAP therapy situation. This partnership is accompanied by unique ethical issues influencing the way we act toward all those present in the therapy setting. In AAP, the therapist emphasizes the animal’s welfare. According to this stance, animals are related to as separate beings with their own needs and desires that are not always aligned with those of the client, and the therapist is responsible for their physical and mental welfare based on knowledge about animals in general as well as on a personal acquaintance with the needs and behavior of the animal being worked with. This stance influences the way the intervention will be carried out in the therapy situation that includes a therapist, client, and animal and has an important place in the establishment of relations based on trust with the client.⁶

The fact that animals do not talk yet do have nonverbal language leads us to the task of understanding, solving, and regulating of nonverbal communication between us and them. In order to draw near to an animal, the client learns to be aware of the characteristics of the animal’s body language, his needs, and unique personality. The therapist mediates these interactions in such a way that advances the development of the client’s reflective ability, as will be shown later. The next section will describe how these two tools—ethics and nonverbal communication—are the basis for reflectivity being an inherent part of AAP.

Animal-assisted dyadic therapy

Reflectivity as an inherent part of AAP

The ethical stance of the AAP therapist emphasized above, together with the fact that animals express themselves through their bodies, creates a situation in which in order to create a connection with an animal, the therapist must think, imagine, and try to feel together with the client what the animals may be feeling. In addition, the therapist must try to think, together with the client, how their own behavior (both the therapist’s and the client’s) influences the animal. The presence of the animals encourages reflective processes just by the fact that they are living beings and feel but do not speak in human language. During the therapy process, the need arises to verbalize the animal’s feelings, desires, and needs, and to raise hypotheses concerning possible reasons for their behavior, while emphasizing their being subjects. This theme is present in the therapy setting both at the verbal level and in the therapist’s ways of acting and relating. These principles will be demonstrated with the help of a case study from animal-assisted dyadic therapy.

The very little hamster who couldn’t talk

Two parents and their daughter, Miriam (3.5 years old) who suffers from developmentally delayed language acquisition, were referred for dyadic therapy after Miriam began to show symptoms that proved to be cause for concern. Miriam was described as characterized by sadness, passivity and incessant crying. A kindergarten teacher described her as emotionally withdrawn and unhappy. After the intake with the parents, it came to light that the mother had previously been in dyadic therapy with her daughter due to her own emotional problems. A young couple, both parents had a complex background of neglect in their childhood. The main problem that was presented, both from reports from the kindergarten and daycare staffs and from the parents themselves, was the father’s tendency to get angry at Miriam and reject her because of her developmental difficulties. Therefore, it was decided that the dyadic therapy would focus on the father-daughter dyad and the mother would participate in parent counseling. The father showed motivation for therapy and despite an initial difficulty showing up for weekly sessions, he began to attend the sessions consistently.

In the joint father-daughter meetings, the difficult relationship between them quickly became apparent. Miriam seemed heart-wrenchingly emotionally withdrawn, yet it seemed that the father had difficulty seeing this and put great pressure on her to speak. For instance, he asked her to draw and name the colors. The therapist intervened in an attempt to regulate the tension between them. She pointed out to him Miriam’s body language, which relayed a great deal of tension and defensive withdrawal into herself because of the pressure. Yet the father found it difficult to regulate his behavior in the sessions, causing Miriam to withdraw from every attempt by the father to interact with her. In parent counseling, it became evident that the highly charged nature of the interaction was partially due to his past experiences as a child with developmental difficulties. The father was reenacting painful patterns of rejection and lack of acceptance through his relationship with his daughter.

At the time, Miriam showed interest in a hamster in the therapy room. She spent much time observing him and showing interest in him, at first passively. Later she started to actively look for a connection with him, trying to draw close and touch him. After a few sessions, Miriam said “hamster” (in the initial stage of therapy, Miriam had not yet talked). Surprised at the influence of the hamster on his daughter’s vitality, even the father started to show interest in a connection with the hamster. Through the mediation of the therapist, the father and daughter formed a partnership in the care of the hamster, together giving him food and water, cleaning the cage and preparing toys for him. In this process, the therapist mediated the interactions while encouraging the father and daughter to observe the body language of the hamster and pay attention to when he was interested in drawing closer, when it seemed that he want to distance himself, what type of touch he liked, how he felt when Miriam held him, how he felt when they entered suddenly into his living space. This father-daughter partnership, created in the context of the relationship with the hamster, in turn created a connection and closeness between them and generated a mentalization process in both father and daughter. In a joint session illustrating this point, Miriam observed the hamster and how he did not leave his enclosure. Connected to the hamster and waiting for a chance to interact with him, Miriam was disappointed.⁷ The therapist reflected Miriam’s disappointment and encouraged the father and daughter to think why, in their opinion, the hamster did not come out today. Miriam explained to her father, “Maybe he is scared of us” and the father answered her, “Why do you think he is scared?” Miriam answered “Because he is little, very little, and he doesn’t know how to talk well . . .” The father reacted empathetically and in a containing way, saying, “You are right. He really is so little . . . so let’s not take him out of his enclosure today. Let’s help him, give him food together. He needs our help.” At that moment there was a deep sense of connection between the two. In this session and in many sessions after, the father began to understand in a deeper way the difficulties in his relationship with his daughter and the reasons for her distance from him.

This example allows us to contemplate the process of the development of the reflective function in the dyad and its influence of this developing ability on the father–daughter connection. The father had reenacted with his daughter “ghosts” from his traumatic past, making it difficult for him to see his daughter’s needs during the session. The partnership in the context of the hamster and the connection with him created an intermediate area of experiencing (Winnicott, 1971), the focus of shared playing and activity that developed into a representation, in both Miriam and her father, of “small and helpless.” In this process, through the therapist’s mediation, the father and daughter observed, thought, imagined, and tried throughout the meetings to decipher the hamster’s body language in order to come close to him in a beneficial way. It is likely that for both father and daughter, this process significantly contributed to the development of the reflective stance, relating to the behavior in terms of internal states. The child considered her behavior (withdrawal, avoidance from connection) to be generated by emotion (fear, suspicion). The father succeeded in discovering empathy “for the hamster in need of help,” representing his daughter, and exhibited considerate and appropriately sensitive behavior (“Let’s help him”).⁸ From this stance, the father was able to experience his daughter, for the first time, in an exciting session that included true understanding.

In the parental counseling session, while working through the situation in this session, the father shared with the therapist familiar experiences of anger and rejection by his parents toward him. He could connect with feelings of shame and incompetence that the anger and rejection awakened in him. From this, he could painfully contemplate his daughter Miriam’s experience “as a little hamster who cannot talk.” In his eyes, this metaphor turned Miriam’s behavior to logical, allowing him to feel empathy for her difficulties. He seemed to begin differentiating between his representations and his daughter’s representations, while showing expressions of attention and interest toward his “real daughter” whom he was beginning to discover while in therapy. Later, there was significant influence of the change in the father–daughter relationship on Miriam’s development and emotional state. She began to talk more fluently during the therapy process, despite the many family difficulties (in the parents’ relationship and also individual personal difficulties in both parents). Miriam began to exhibit initiative, exploratory behavior, enjoyment in play, and satisfactory functioning in the kindergarten.

The development of the reflective stance is related to attention, understanding, and deciphering body language, as well as to the connection to one’s own and other’s internal states. Identification, understanding, and development of awareness of sensations and bodily experiences are important bases for self-regulation and reciprocal regulation. In the next section is a discussion of the ways that these processes are enhanced through animal-assisted dyadic therapy.

Body language and nonverbal communication with animals as a therapy tool

As mentioned above, animals have a presence of a primitive nature. They do not speak, they smell, they make sounds, and may have soft fur or a hard shell. They have a warm tongue that licks, have their own rhythm, and move in space. An animal’s physical presence in the AAP therapy session creates a therapy situation in which touch, regulation, texture, and movement are part of the client-animal interactions. As a way to communicate with animals, the client starts to become aware of his own body language, of what the body language relays to others and ways that self-regulation helps him to create a beneficial relationship with the animal.

The animal’s presence lays the foundation for focusing on primary physical issues, such as touch, understanding, and deciphering of body language. Touching an animal allows also for a live encounter with physical boundaries, which is likely to contribute to the establishment of a feeling of bodily cohesion as part of a strategy for self-regulation.⁹ The therapist relates to the body language of both client and animal as a way to stimulate awareness of (1) the bodily experience of the client, (2) internal states that influence his body language, and (3) the way in which it is expressed in interaction with the animal.

“Rosa’s Language”

Ayal, 8 years old, participated in animal-assisted dyadic therapy together with his two parents. Ayal found it difficult to regulate his behavior at home and at school and often displayed wild and impulsive behavior. In the meetings with the mother, there was often unbearable tension between the two as the mother brought up more and more issues in the session. Ayal was no longer able to process, either angrily retreating from the interaction or acting out his rage.

Present in the session was Rosa, a mixed-breed Labrador-type dog. Ayal and Rosa had a close connection and they had between them a physical rhythm of petting, calming, and play, which calmed them both. The mother also wanted very much to get close to Rosa, but Rosa recoiled from her. When this happened, the therapist reacted, “Pay attention to Rosa’s body language. Why do you think Rosa moved away? What might help create a connection between the two of you?” Ayal explained to his mother: “She doesn’t want to, because you came too close and you look into her eyes too much . . . She feels pressured . . . She needs you to be farther away and to let her come to you.” The mother listened to Ayal and changed the way she approached Rosa. Rosa started to look for the mother’s presence, and the mother was excited by Ayal’s ability to understand the dog. “You understand her language . . . I’m happy that you explained it to me.” In the following sessions, a different rhythm developed between the mother and son, a rhythm that had space and attention to the way each one present in the session signaled, through body language, states of tension, excitement, need for closeness or distance. The “language” that Ayal had explained to his mother became a meaningful theme which was processed in parental counseling, helping the two to establish a more appropriate connection between them.

In addition to the awareness of body states and efficient strategies for self-regulation that are part of AAP, the mutual therapist–client–animal communication enables bringing implicit knowledge to the surface (Stern et al., 1998). This is a nonverbal knowledge pattern that is not accessible to consciousness, holding within it unconscious knowledge about “how to be with someone else” (Stern, 1985). Accordingly, this knowledge pattern is important in dyadic therapy, allowing accessibility to unconscious patterns existing in the parent–child relationship, that the acquaintance with them may advance the process of awareness and change.

“Who is leading me?” in a walk together with Duvi the dog

In one of the father-daughter dyadic sessions, Miriam got over her earlier suspicions and initiated a relationship with the dog Duvi. Miriam patted her and expressed a desire to take her for a walk outside. The therapist suggested to the father that they take a walk together and he agreed to the suggestion. During the walk, the father seemed distant and indifferent to something new in his daughter’s behavior (creation of a relationship with Duvi, whom she had been wary of at the beginning of therapy, and the initiative to go for a walk with her). This pattern of difficulty paying attention and recognizing new processes shown by the child characterized their relationship. Miriam walked limply, holding yet not holding the leash. As a result, Duvi lead the walk to directions that she chose but were not necessarily appropriate (e.g. in the direction of garbage bins). The therapist turned the father’s and daughter’s attention to Duvi’s body language. “Since you don’t show her where you would like her to go, she wanders in different directions and it is not clear to her how to conduct herself during the walk. It is as if she is saying, ‘Who is leading me here? Where should I go?’” The therapist’s words caused the father to notice the fact that Miriam was doing something new and different. He was surprised by this and reinforced her by saying, “Miriam, you are holding Duvi! Come and let’s show her together where to go.” The father started to direct the walk together with Miriam and especially to pay attention to her. From session to session, one could see a change in the way Miriam walked with Duvi. From a limp and unsure hold, she started to lead Duvi more and more confidently and solidly, feeling proud under the watch of her father observing and reinforcing her.

In this example, one can see how the implicit father–daughter relationship pattern is expressed in the walk together with the dog and how the mutual translation exists between them. The father has difficulty noticing this because of his personal difficulties and depressed retreating into his own internal world. The father’s passivity and distancing from his daughter’s actions, together with his difficulty in acknowledging and accepting them, is expressed in the daughter’s behavior. She translates his lack of reaction to lack of permission. She is not sure of the course of action that needs to be taken and exhibits insecure and passive behavior. It is also expressed in the dog’s body language in that she reacts to the limp hold of the leash by walking in a confused and random way in different directions. In this way, the dog brings to the surface the unconscious dynamics that exist between the two. The therapist’s relating to the confusion and insecurity exhibited by the dog in this situation allows the father to pay attention to what is happening and to react now in a different way to his daughter’s initiative.

Summary and conclusion

AAP is characterized by unique mechanisms that significantly contribute to the dyadic therapy approach. Many therapy models dealing with parent–child interventions state the development of the ability to mentalize as a main goal. The central focus of this article is the reflective stance that is inherent in AAP, which in turn influences the development of the reflective function, which then stimulates mentalization processes.

The developing reflective ability within the framework of AAP is based on the ethical stance described here. Animals are seen as independent beings, having needs and desires of their own that are not always compatible with ours or that of the client. This stance serves as the foundation of AAP theory and technique. In this AAP therapy process, we deal with the understanding and deciphering of nonverbal communication as part of an attempt to create a relationship with the animal. This built-in engagement with nonverbal bodily elements allows the development of awareness of bodily feelings, self-regulation, and mutual regulation, together with observation of implicit action patterns existing between the parent and child. The intent is to create more adaptive patterns in the dyad. Animals wander about in the setting, drawing closer or moving away, playing, creating relationships. They are similar to us yet different. Their presence in the therapy setting creates a living channel for communication between parent and child, enabling the advancement and stimulation of central elements in the approach of dyadic therapy.

The perceptions and conceptualizations presented in this article, concerning the contributions of AAP to the development of the reflective function and mentalization, are based on the author’s clinical experience and academic study. Although theory-building is critical for the understanding of the processes described above, there is a clear need for research to validate the claims made.

Footnotes

Acknowledgements

This article is based on an article published by the author in Hebrew: Shani Kassif, L. (2014). Tipul diyadi hne’ezar b’ba’alei chaim: Model tipuli hamikadem et hahitkadmut hafunktsia hareflectivit b’kesher hore-yeled (Animal-assisted dyadic therapy: A therapy model promoting development of the reflective function in the parent-child bond). Chai’ot V’Chevra (Animals and Society: The Israeli Journal for the Connection Between People and Animals), 50, 17–28.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author biography

Liat Shani (BA educational counseling and artcertificate in animal-assisted psychotherapy, MA in expressive and creative therapy) has worked as an AAP therapist with at-risk populations in various settings and is a pioneer in the field of Animal-Assisted Dyadic Therapy. She has developed a unique model of animal-assisted group therapy for survivors of drug abuse. Liat has been a lecturer in and director of the Levinsky College certificate program in AAP, and is currently in the board of the IAAAP – The Israeli Association of AAP, is a senior clinical supervisor, and has a private practice.

References

Ainsworth

M. D. S.

(1991). Attachment and other affectional bonds across the life cycle. In Parkes

C.M.

Stevenson-Hinde

Marris

(Eds.), Attachment across the life cycle (pp. 33–51). New York, NY: Routledge.

Bachi

(2013). Application of attachment theory to equine-facilitated psychotherapy. Journal of Contemporary Psychotherapy, 43, 187–196.

Bachi

Terkel

Teichman

(2012). Equine-facilitated psychotherapy for at-risk adolescents: The influence on self-image, self-control and trust. Clinical Child Psychology and Psychiatry, 17, 298–312.

Baradon

Broughton

Gibbs

James

Joyce

Woodhead

(2005). The practice of psychoanalytic parent-infant psychotherapy: Claiming the baby. London, England: Routledge.

Beebe

(2003). Brief mother-infant treatment: Psychoanalytically informed video feedback. Infant Mental Health Journal, 24, 24–52.

Beebe

(2006). Co-constructing mother-infant distress in face-to-face interactions: Contributions from microanalysis. Infant Observation, 9, 151–164.

Beebe

Lachmann

(2003). The relational turn in psychoanalysis: A dyadic systems view from infant research. Contemporary Psychoanalysis, 39, 379–409.

Ben-Aaron

Harel

Kaplan

Patt

(2001). Mother-child and father-child psychotherapy: A manual for the treatment of relational disturbances in childhood. London, England: Whurr.

Ben David

. (2013). The unique ethical stance of animal-assisted psychotherapy. In Parish-Plass

(Ed.), Animal-assisted psychotherapy: Theory, issues, and practice (pp. 47–64). Lafayette, IN: Purdue.

10.

Bowlby

(1982). Attachment and loss: Attachment, Vol. 1. New York, NY: Basic Books (Original work published 1969).

11.

Chandler

C. K.

(2010). Matching animal-assisted therapy techniques and intentions with counseling guiding theories. Journal of Mental Health Counseling, 32, 354–374.

12.

Cramer

(1995). Short-term dynamic psychotherapy for infants and their parents. Child and Adolescent Psychiatric Clinics of North America, 4, 649–660.

13.

Faa-Thompson

VanFleet

(2010). The case for using animal-assisted play therapy. British Journal of Play Therapy, 6, 4–18.

14.

Fewell

C. H.

(2013). Mentalization-based treatment: A valuable framework for helping maltreating parents. Journal of Social Work Practice in the Addictions, 13, 123–126.

15.

Fonagy

Gergely

Target

(2007). The parent-infant dyad and the construction of the subjective self. Journal of Child Psychology and Psychiatry, 48, 288–328.

16.

Fonagy

Target

(1996). Playing with reality: I. Theory of mind and the normal development of psychic reality. International Journal of Psychoanalysis, 77, 217–233.

17.

Fraiberg

Adelson

Shapiro

(1975). Ghosts in the nursery: A psychoanalytic approach to the problem of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14, 387–421.

18.

Glat

Bialik-Cohen

(2003). Ksharim, heksherim v’hitkashruyot: tipul v’ha’aracha dyadi’im [Connections, contexts and attachments: Dyadic therapy and evaluation]. Retrieved from hebpsy.net/articles.asp?id=117 (Psychologia Ivrit).

19.

Harel

Kaplan

Avimeir-Patt

(2013). Hafunctsia hareflectivit k’gorem mecholel shinui b’tipil em-yeled v’av-yeled [The reflective function as a generating factor for change in mother-child and father-child therapy]. In Kaplan

Harel

Avimeir-Patt

(Eds.), Hatipul hadayadi: Mifgash bein hama’aseh hatipuli v’hate’oria [Dyadic therapy: The encounter between the act of therapy and theory] (pp. 122–167). Haifa, Israel: Department of Psychology, University Haifa Press.

20.

Harel

Kaplan

Avimeir-Patt

Ben-Aaron

(2006). The child’s active role in mother-child, father-child psychotherapy: A psychodynamic approach to the treatment of relational disturbances. Psychology and Psychotherapy: Theory, Research and Practice, 79, 23–36.

21.

Ish-Lev

Amit

(2013). Elements of group psychotherapy found in individual animal-assisted psychotherapy. In Parish-Plass

(Ed.), Animal-assisted psychotherapy: Theory, issues, and practice (pp. 145–169). Lafayette, IN: Purdue.

22.

Katcher

Wilkins

G. G.

(1994). Helping children with attention deficit hyperactive and conduct disorders through animal assisted therapy and education. Interactions, 12, 5–90.

23.

Klorer

P. G.

(2005). Expressive therapy with severely maltreated children: Neuroscience contribution. Art Therapy: Journal of the American Art Therapy Association, 22, 213–220.

24.

Kruger

Serpell

(2010). Handbook on animal-assisted therapy: Theoretical Foundations and guidelines for practice (ed Fine

, pp. 33–48). San Diego, CA: Academic Press.

25.

Lac

(2014). Horsing around: Gestalt equine psychotherapy as humanistic play therapy. Journal of Humanistic Psychology. Advance online publication. doi: 10.1177/0022167814562424

26.

Levinson

B. M.

(1969). Pet-oriented child psychotherapy. Springfield, IL: Charles C. Thomas Publisher.

27.

Levinson

B. M.

(1972). Pets and human development. Springfield, IL: Thomas Publisher.

28.

Levy

(2012). Efshar lachshov: Skira kenes al mentalizatsia [One can think: A survey of the convention on the subject of mentalization]. Retrieved from www.hebpsy.net/articles.asp?id=2740 (Psychologia Ivrit).

29.

Lieberman

A. F.

Reyes

(2012). Child-parent psychotherapy and traumatic exposure to violence. Zero to Three, 32, 20–25.

30.

Lieberman

A. F.

Van Horn

Ghosh Ippen

(2005). Toward evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1241–1248.

31.

Maayan

Lakh

(2013). The relationship between the animalistic and the artistic: A therapeutic model integrating animal-assisted psychotherapy with art therapy. In Parish-Plass

(Ed.), Animal-assisted psychotherapy: Theory, issues, and practice (pp. 349–384). Lafayette, IN: Purdue.

32.

Mahler

M. S.

(1968). On symbiosis and the vicissitudes of individuation. New York, NY: International Universities Press.

33.

Manzano

Palacio Espacio

Zilkha

(1999). The narcissistic scenarios of parenthood. The International Journal of Psychoanalysis, 80, 465–476.

34.

Nathans-Barel

Feldman

Berger

Modai

Silver

(2005). Animal-Assisted-Therapy ameliorates anhedonia in schizophrenia patients: A controlled pilot study. Psychotherapy and Psychosomatics, 74, 31–35.

35.

Odendaal

J. S. J.

(2000). Animal-Assisted-Therapy—Magic or medicine? Journal of Psychosomatic Research, 49, 275–280.

36.

Ogden

T. H.

(1992). The autistic-contiguous position. In Ogden

T. H.

(Ed.), The primitive edge of experience (pp. 47–82). Northvale, NJ: Jason Aronson.

37.

Parish-Plass

(2008). Animal-assisted therapy with children suffering from insecure attachment due to abuse and neglect: A method to lower the risk of intergenerational transmission of abuse? Clinical Child Psychology and Psychiatry, 13, 7–30.

38.

Parish-Plass

(Ed). (2013a). Animal-assisted psychotherapy: Theory, issues, and practice. Lafayette IN: Purdue.

39.

Parish-Plass

(2013b). The contribution of animal-assisted psychotherapy to the potential space in play therapy. In Parish-Plass

(Ed.), Animal-assisted psychotherapy: Theory, issues, and practice (pp. 79–109). Lafayette IN. Purdue:

40.

Parish-Plass

Oren

(2013). The animal as a relational medium: An object relations approach to the therapy triangle in animal-assisted psychotherapy. In Parish-Plass

(Ed.), Animal-assisted psychotherapy: Theory, issues, and practice (pp. 47–64). Lafayette IN: Purdue.

41.

Pirani

Shani

(2003). Hatipul b’ezrat ba’alei chayim: Klee tipuli chadshani b’“merchav hapotentsiali” shel mechurim l’samim [Animal-assisted psychotherapy: An innovative therapy tool for the “potential space” of drug addicts.]. Mikbatz—Ktav Et Yisraeli L’tipul Kvutsati [Collection: Mikbatz: Israeli Journal for Group Therapy], 8, 9–24.

42.

Rossetti

King

(2010). Use of animal-assisted therapy with psychiatric patients: A literature review. Journal of Psychosocial Nursing, 48, 44–48.

43.

Schore

(2002). Dysregulation of the right brain: A fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 36, 9–30.

44.

Sharabany

(2013). Hatipul hadyadi em-yeled av-yeled: B’machshava shniya [Mother-child father-child dyadic therapy: On second thought]. In Kaplan

Harel

Avimeir-Patt

(Eds.), Hatipul hadayadi: Mifgash bein hama’aseh hatipuli v’hate’oria [Dyadic therapy: The encounter between the act of therapy and theory] (pp. 416–431). Haifa, Israel: Department of Psychology, University Haifa Press.

45.

Slade

(2007). Reflective parenting programs: Theory and development. Psychoanalytic Inquiry, 26, 640–657.

46.

Sleed

Bland

(2007). Parent-infant psychotherapy and research. In Kennedy

Midgley

(Eds.), Process and outcome research in child, adolescent and parent-infant psychotherapy: A thematic review (pp. 104–136). London, England: North Central London Strategic Health Authority.

47.

Stern

D. N.

(1985). The interpersonal world of the infant. New York, NY: Basic Books.

48.

Stern

D. N.

Sander

L. W.

Nahum

J. P.

Harrison

A. M.

Lyons-Ruth

Morgan

A. C.

. . . Tronick

E. Z.

(1998). Non interpretive mechanisms in psychoanalytic therapy: The “something more” than interpretation. International Journal of Psychoanalysis, 79, 903–921.

49.

Sullivan

H. S.

(1953). The interpersonal theory of psychiatry. New York, NY: Norton.

50.

Tronick

(1998). Dyadically expanded states of consciousness and the process of therapeutic change. Infant Mental Health Journal, 19, 290–299.

51.

Urichuk

L. J.

Anderson

(2003). Improving mental health through animal-assisted-therapy. Edmonton, Alberta, Canada: The Chimo Project.

52.

Weinberg

Tronick

E. Z.

(1998).The impact of maternal psychiatric illness on infant development. Journal of Clinical Psychiatry, 59, 53–61.

53.

Wesley

Minatrea

Watson

(2009). Animal-assisted therapy in the treatment of substance dependence. Anthrozoos, 22, 137–148.

54.

Winnicott

D. W.

(1965). The maturational processes and the facilitating environment: Studies in the theory of emotional development. London, England: Hogarth Press.

55.

Winnicott

D. W.

(1971). Playing: A theoretical statement. In Winnicott

D. W.

(Ed.), Playing and reality (pp. 38–52). London, England: Tavistock.

56.

Zilcha-Mano

Mikulincer

Shaver

P. R.

(2011). Pet in the therapy room: An attachment perspective on Animal-Assisted-Therapy. Attachment and Human Development, 13, 541–561.

57.

Zilcha-Mano

Mikulincer

Shaver

P. R.

(2012). Pets as safe havens and secure bases: The moderating role of pet attachment orientations. Journal of Research in Personality, 46, 271–280.

Animal-assisted dyadic therapy: A therapy model promoting development of the reflective function in the parent–child bond

Abstract

Keywords

Introduction to parent–child psychotherapy

Ghosts in the nursery: intergenerational transmission and reenactment of traumatic relationships

Survey of additional existing models for parent–child therapy interventions

Mentalization and the reflective function in the parent–child relationship

The Haifa model for dyadic therapy

Animal-assisted psychotherapy 4

Ethical stance and nonverbal communication as fundamental tools in AAP

Animal-assisted dyadic therapy

Reflectivity as an inherent part of AAP

Body language and nonverbal communication with animals as a therapy tool

Summary and conclusion

Footnotes

Acknowledgements

Funding

Notes

Author biography

References

Animal-assisted psychotherapy⁴