Effectiveness of Animal Assisted Therapy after brain injury: A bridge to improved outcomes in CRT

Abstract

BACKGROUND: Animal Assisted Therapy (AAT) has been widely used as a complementary therapy in mental health treatment especially to remediate social skill deficits. The goal of AAT is to improve social, emotional, and cognitive functioning.

OBJECTIVE: The purpose of this article is to draw upon the literature on AAT and explore specific applications to cognitive rehabilitation therapy (CRT) and social skills training.

METHODS: This study provides a systematic review of most of the available literature on ATT and assesses that potential uses of ATT for brain injury rehabilitation.

RESULTS: Although the efficacy of AAT is not currently well documented by rigorous research, (Kazin, 2010) anecdotal evidence suggests that brain injury survivors may benefit from the combination of AAT and cognitive rehabilitation techniques.

CONCLUSIONS: Acquired Brain Injury (ABI) survivors with cognitive impairments can benefit from AAT as part of a comprehensive and holistic rehabilitation treatment plan.

Keywords

Animal Assisted Therapy cognitive rehabilitation acquired brain injury therapy service dog therapy dog

Introduction

Chandler (2012) has asked the question “why involve animals in therapy?” Neurorehabilitation therapists may well ask the same question. According to Shipman (2011), living with animals is a uniquely human trait. She maintains that a connection with animals has been important for at least 2.6 million years, since the onset of tool making. No other species lives in such a strong connection with animals as humans do. Humans nurture relationships with other species in a unique way. None of us are surprised that we cherish our pets, consider them family members, and according to recent research (Friedmann, et al., 1980) may even survive longer if we live with them.

According to Chandler (2005) AAT is a goal-directed therapy that uses animals as a motivating force to enhance a treatment session for the benefit of the client. Chandler (2010) notes that AAT is considered an adjunct to existing therapy. The therapist can incorporate the animal into whatever professional style of therapy they wish. AAT therapy can be directive or nondirective in its approach; for example, a dog can be actively involved with the client or merely present in the room. AAT sessions can be integrated into individual or group therapy and used with a wide range of age groups and disabilities. AAT is a practice modality and is not an independent profession. However, therapists using AAT must have the proper training and credentials for their profession e.g. psychologist, speech pathologist, occupational therapist, or cognitive rehabilitation therapist. The therapy dog, in addition to being trained and credentialed, must have a health certificate acceptable to the clinic or facility where AAT is offered. The therapist may need additional insurance coverage for the animal.

2 Definitions of therapy animals

There are a number of different definitions of the use of animals in therapy; for example, there are service dogs, emotional support animals, and therapy dogs. Service dogs, or other animals, directly assist the client to meet a specific need such as guide dogs for the blind, seizure alert dogs, and more recently to alert a client to low blood sugar events. For example, personal experience calls to mind a service dog that provided physical support to a quadriplegic man by opening doors, assisting in wheelchair transfer, pulling his wheelchair on steep inclines, carrying a backpack with books, and bringing his phone to him. The service dog was covered under the Americans With Disabilities Act (ADA) and was allowed to accompany the man, who was a student, to all of his classes, and lived with him in his dorm.

Dogs can also provide emotional support for persons with psychiatric disabilities, e.g. Anxiety Disorders, but may or may not be certified as therapy dogs. Emotional support dogs are not defined by the ADA as service dogs, as they are not trained in the same way. This difference can cause conflict and misunderstanding. A client may not be allowed to have an uncertified emotional support animal in housing that only allows service animals. The same is true for taking emotional support animals on public transportation. An emotional support dog is not covered under ADA.

A therapy dog assists the therapist as a partner in the rehabilitation process e.g. in occupational therapy, physical therapy, speech therapy, counseling and in cognitive rehabilitation. AAT uses the human- animal bond in goal directed interventions as an integral part of the treatment process. Certified therapy animals are the focus of this article.

The Delta Society and Therapy Dogs International are examples of organizations that provide certification for therapy dogs. A credentialed therapist works with a therapy dog, within the scope of their professional practice and licensure, sets therapeutic goals, guides the interaction between the client and the animal, measures progress toward meeting therapy goals, and evaluates the process. AAT may be billed to third-party payers just as in any other kind of reimbursable therapy (Gammonly et al., 1997). Veterans Moving Forward (Army News Service, 2011) began a program in 2011 to provide therapy dogs to veterans with physical and mental challenges, including traumatic brain injury, and post-traumatic stress disorder.

Facility dogs are assigned duty to work at the side of a professional caregiver, health-care practitioner or physical or occupational therapist to engage veterans in activities.

3 Efficacy of AAT: A systematic review of the literature

Table 1 summarizes several studies of ATT within the last two decades. Although this is not an extensive literature base, the general theme that emerges from the available data suggest that ATT is an effective and relatively inexpensive adjunct therapy that has been shown to reduce anxiety, increase client motivation, provide emotional support and companionship and increase client safety. Although few of these studies concerned ABI participants, those that have generally show the same effects that are achieved with other client populations.

Nimer and Lundahl (2007) reviewed 250 studies, 49 of which were submitted to meta-analytic procedures. Overall, AAT was associated with moderate effect sizes in improving outcomes in four areas: Autism-spectrum symptoms, medical difficulties, behavioral problems, and emotional well-being. Contrary to expectations, characteristics of participants and studies did not produce differential outcomes. The data suggest that use of dogs in AAT is consistently associated with moderately high effect sizes.

Chitic, Rusu, Szamoskozi (2012) performed a meta-analysis which documented large effect sizes for ATT interventions on communication and social skills. This study indicated that the type of animal used, the AAT certification of the animal, the manner of the administration of the AAT intervention, the type of measurement, the number of subjects, the number of sessions, and the duration of the sessions moderated the effects of AAT

Winegardner, J. Ashworth, J. Jennings (2012) presented a paper at the International Special Interest Group in Neuropsychological Rehabilitation of the World Federation for NeuroRehabilitation (WFNR) that explored the benefits of a therapy dog as part of a multi-disciplinary brain injury rehabilitation team at the Oliver Zangwell Centre in England. A qualitative survey of client and staff perspectives explored the benefits of a therapy dog. The authors concluded that “ most clients and their families enjoyed having a therapy dog in the centre, supporting the value of therapy animals in rehabilitation.”

Chandler et al. (2010) matched AAT with counseling interventions and suggested that AAT is “ effective in increasing positive social behaviors and decreasing behavior problems” (Fick, 1993). Other published studies support the notion of ATT’s benefits for enhancing self-esteem and decreasing depression and anxiety (Hergovich, Monsi, Semmler, and Zieglmayer, 2002; Trotter et al., 2008).

Odindaal (2000) reported that gently stroking and talking to pet dogs doubled levels of oxytocin, increased beta-endorphins and dopamine production, and decreased blood pressure and cortisol levels. Contact with therapy dogs induced an immediate, physiologically calming state of relaxation by attracting and holding attention and providing people a form of stress reducing social support.

Fine (2006) reported animal interventions have enhanced psychophysiological health and healing. Holcomb and Meacham (1989) reported that AAT increased client motivation to participate in therapy, as well as having the added benefit of increasing the client’s sense of calm and safety. Kinsley, Barker and Barker (2012) reported a significant reduction in anxiety using AAT in recreation therapy when animals were involved, compared to when animals were not involved in the same recreation activity. A study with children (Friedman et al., 1983) reported reductions in levels of blood pressure, stress, and anxiety were lower when the therapist was accompanied by an animal. Holcomb and Weber (1997) also reported decreased depression and increased socialization occurred in elderly people interacting with visiting therapy animals.

4 AAT and cognitive rehabilitation

The studies outlined above suggest several benefits of AAT that are specific to clients with ABI. First, clients may be more motivated to attend and participate due to the presence of a therapy animal. Second, clients focus may be temporarily shifted away from their cognitive problems because of the interaction with the therapy animal. It could be argued that they may then be able to work harder and longer in therapy, and potentially gain more benefit per session. Third, Clients may receive healing nurturance and affection through physical contact with the therapy animal. Learning is enhanced when an individual is in a calm and receptive attitudinal state (Parente and Herrmann, 2010. p. 287). Fourth, clients may experience genuine acceptance by a therapy animal that they are not experiencing in their everyday social environment. Often clients are socially isolated secondary to their injury. AAT may help them to feel safe enough emotionally to connect to other people again. Fifth, clients may be able to more easily form a working alliance with their therapists who demonstrate they can be trusted by the therapy animal. Sixth, ATT may be especially effective with resistive clients (Chandler, 2012). Finally, clients with cognitive and social problems may be able to perform activities and achieve goals that would not otherwise be possible without the presence of a therapy animal.

5 AAT and the CRT model

Parente and Herrmann (2010) present a systematic approach to retraining cognition that includes a problems and solutions treatment planner. The treatment planner is a self-report survey instrument of common cognitive problems reported by the client. Solutions are then offered to solve the problems. The treatment planner was actually created by ABI survivors in a CRT group who listed common problems they experienced in their personal life, employment situation and relationships (Parente & Stapleton, 1999). The authors added problems and solutions to the treatment planner over a 23 year period (Parente & Stapleton, 1999). The items were then organized into major areas that may represent more than one cognitive domain. The areas of most frequently acknowledged problems in the treatment planner are: 1. Executive function, 2. Social Skills, 3. Mood Regulation, 4. Learning, 5. Memory, and 6. Attention. An outline of these activities that have been merged with Chandler’s ATT techniques is presented in Table 2. An “X” in any cell of the box indicates that the technique would likely improve cognitive functioning in that particular cognitivedomain.

The author asserts that merging these six areas with specific AAT techniques would accelerate, enhance, or otherwise complement the process of CRT. The assessment of the client’s cognitive problems begins with those significant problems the client acknowledges; the checklist is simply a structured mechanism for isolating those problems. Once administered, the therapist can then modify the solutions that derive from the client’s responses to begin treatment. Although it will not be possible to integrate all of the solutions into the ATT context, many can be adapted. For example, the client and therapist can discuss mood regulation with and without the therapy dog or create a mnemonic for emotional control (e.g., Dial down the anxiety, Organize your thoughts, Go to your calm place). Social interaction is increased when the client uses the dog as a means of meeting other pet owners. Attention and planning improve when the therapist and client create new activities that involve the therapy animal.

One of the most frequently reported and emotionally devastating deficits is the social isolation and loneliness of the survivors of acquired brain injury. The use of AAT can provide an unconditional, nonjudgmental relationship within the therapy environment. It is a powerful force to rebuild social connection, lost self-esteem and social confidence. AAT can be a motivating force to practice social skills. A dog, or other therapy animal makes no judgment as to the person’s physical ability, their changed social or employment status, their inability to articulate and express affection, or to miss social cues. The therapy animal is very forgiving of social faux pas and lives largely in the moment. The mere presence of a therapy animal has been linked to lower blood pressure and a calmer mood. The author hypothesizes that a therapy animal is a calming presence throughout the CRT session whether it is directly involved in the skills being taught or not.

Fine (2006) has written extensively about the positive effects of the presence of animal as it affects the perception of the therapist as a non-threatening and trustworthy person. He maintains that in order to have a good therapeutic alliance trust is necessary.

The presence of a therapy animal can be a social catalyst and provide a reason for social conversation that is more comfortable for the client. Often persons with TBI have difficulty initiating conversations, or initiate in an inappropriate social way, that further isolates them from meeting new people or re-establishing communication within an existing relationship. Many survivors have difficulty understanding social cues, especially subtle non-verbal cues, which cause problems in relationships and may in the worst case scenario result in social isolation. For example, if the client can be asked to walk the therapy dog through the rehabilitation center or group living situation. He/she can chat to people about the dog, thereby relieving the initial tension of what to talk about and providing an appropriate focus. If the client is able to have a well-trained companion animal outside of CRT sessions, the therapist can work with the client to visit dog parks or merely take a walk in a safe neighborhood, and initiate conversations.

A therapy animal is totally a non-verbal being. A dog, or horse is highly attuned to non-verbal cues from humans and provides cues to the trained observer. A therapy animal’s “emotional” reaction is immediate and fairly clear. AAT if used skillfully provides opportunities for the client to learn “to read” behavior in a non-threatening way, with little fear of rejection. For example, if a client becomes irritated or agitated, and the therapy dog moves away, it is a teachable moment to discuss why that happened. The use of insight and hindsight questions can be used effectively in this scenario; “What did I do that made this happen?“or”What could I have done differently?”

Unlike many humans, a dog will be more forgiving and willing to re-connect fairly soon. For example, the client is invited to notice how a calm voice, and behavior affects the dog in a positive way. A complaint from the wife of one of the author’s clients was “he just doesn’t get it, he/she should have known I was upset”. The AAT experience can be a transitional means to better understand humans’ reactions to the client’s behaviors that are never directly communicated by family or friends. Geist (2011) addresses this “transitional attachment” in depth by providing a conceptual framework for animal assisted therapy based on psychological attachment theory.

There are a myriad of ideas that can be incorporated by creative therapists to engage in successful AAT strategies for new learning. The author recommends Grover‘s (2010) excellent book, 101 Creative Ideas for Animal Assisted Therapy. A clear practical guide that assists in matching the AAT intervention to the client, the animal and the client’s treatment goals

Clearly, these activities require creativity and thought. The purpose of Table 2 is to provide a structured framework that a therapist can use to guide the ATT process. The actual therapy plan will obviously differ for each client.

6 Efficacy challenges and the research agenda

Measures of the effectiveness of AAT, and even, a consistent definition of the term are still blurry. There still is no systematic and replicated body of quantitative evidence to support outcomes and no well-designed studies of AAT and CRT. Animal assisted therapy is viewed by many as a vague realm of complementary interventions. Nevertheless, the idea of animal/human connections as a healing force is a powerful one. The challenge is to explain these benefits empirically so they can be systematically applied in the context of therapy.

Kazdin (2010) provides an excellent review of research questions and strategies for establishing the evidence base of AAT. What are therapists trying to accomplish with AAT? What value would it add to CRT? What are the special strengths of adding AAT to CRT and for whom and under what conditions is AAT likely to create positive outcomes? However, given the health implications of delivering and funding interventions, scientific evidence is critical. Because CRT has not been universally accepted as an effective intervention, adding AAT to it will likely quake the ground without research. How might we begin to design and study the efficacy of AAT as a CRT support?

The most fundamental question is whether treatment is effective and surpasses changes over time that might otherwise occur without treatment. A well designed randomized controlled study would add significantly to the research on AAT within the therapeutic context is possible. For example, Kazdin suggests that a research question may ask, what facet of the animal’s presence in the session contributes to therapeutic progress? Is the presence of the animal, or the interactions of the client with the animal that leads to positive change? Single case experimental designs might be helpful for evaluating effectiveness of AAT. Qualitative research models might also be used to evaluate the lived experiences of the client with AAT and the themes that emerge that change their lives, elaborating the subjective experience of the therapist/client/animal interaction.

Conflict of interest

The author has no conflict of interest to report.

References

American Veterinary Medical Association (2012). U. S. Pet ownership statistics, http://www.neuliferehab.com/animals-therapy-helps-recovery-tbi-clients/

Barker

, & Dawson

(1998). The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatric Services, 49, 797–801.

Chitic

, Rusu

A. S.

, & Szamoskozi

(2012). The Effects of Animal Assisted Therapy on Communication and Social Skills: A Meta-Analysis. Transylvanian Journal of Psychology, 13(1), 1–17. Publisher: Presa Universitara Clujeana.

Chandler

C. K.

, Portrie-Bethke

, Minton

C. A.

, Fernando

D. M.

, & O’Callaghan

(2010). Matching Animal Assisted Therapy Techniques and Intentions with Counseling Guiding Theories. Journal of Mental Health Counseling, 32(4), 354–374.

Chandler

C. K.

(2005). Animal assisted therapy in counselingNew York: Routledge.

Conference Program Abstracts of the 9th Annual Conference of the Special Interest Group in Neuropsychological Rehabilitation of the World Federation for Neurorehabilitation (WFNR) (2012), Brain Impairment, 13(1), 132–195.

Fick

(1993). The influence of an animal on social interactions of nursing home residents in a group setting. The American Journal of Occupational Therapy, 47, 529–534.

Fine

A. H.

(2006). Incorporating Animal Assisted therapy into Psychotherapy: Guidelines and suggestions for Therapists. In Fine

A. H.

(ed) Handbook on Animal Assisted Therapy: Theoretical Foundations and guidelines for practiceSan Diego: Academic Press.

Friedmann

, Katcher

A. H.

, Lynch

J. J.

, & Thomas

S. A.

(1980). Animal Companions and one year survival of patients after discharge from a coronary care unit. Public Health Reports, 95, 307–312.

10.

Gammonley

, Howie

A. R.

, Kirwin

, Zapf

S. A.

, Frye

, Freeman

, & Stuart-Russell

(1997). Animal-assisted therapy: Therapeutic interventions. Renton, WA: Delta Society.

11.

Grover

(2010). 101 Creative Ideas for Animal Assisted Therapy: Interventions for AAT Teams and Working Professionals. Motivational Press. www.MotivationalPress.com

12.

Gallant

P. W.

(1997). Animal interaction compliments health care. Newsmagazine of the Canadian Association of Rehabilitation Professionals (BC Society), 18(1), 20–21.

13.

Hertel

(1994). Depressive deficits in memory impairment following traumatic brain injury. Neurorehabilitation, 4, 143–150.

14.

Holcomb

, & Meacham

(1988). Effectiveness of an Animal-Assisted Therapy Program in an Inpatient Psychiatric Unit. Anthrozoos A Multidisciplinary Journal of The Interactions of People & Animals2(4), 259–264.

15.

Hergovich

, Monshi

, Semmler

, & Zieglmayer

(2002). The effects of the presence of a dog in the classroom. Anthrozoos, 15, 37–50.

16.

Kazin (2010). Methodological Standards and Strategies for Establishing the Evidence Base of Assisted Therapies in Handbook on Animal-Assisted TherapyThird Edition, Fine

, (Ed). Elsevier. Academic Press, London.

17.

Knisley

J. S.

, Barker

S. B.

, & Barker

R. T.

(2012). Research on Benefits of Canine Assisted Therapy for Adults in Non-military Settings, www.cs.amedd_army.mil/amedd_journal.aspx (April – June, 2012).

18.

Lange

, Cox

, Bemert

, & Jenkins

(2006/2007). Is counseling going to the dogs? An Exploratory study related to the inclusion of an animal in group counseling with adolescents. Journal of Creativity in Mental Health, 2, 17–31.

19.

Nimer

, & Lundahl

(2007). Animal Assisted Therapy: A Meta-analysis. Anthrozoos, 20(3), 225–238.

20.

NeuLife Residential Post- Acute Centers http://www.neuliferehab.com/animals-therapy-helps-recovery-tbi-clients/ Retrieved 6/15/2015.

21.

Odendaal

S. J.

(2000). Animal assisted therapy: Magic or medicine?. Journal of Psychosomatic Research, 49(4), 275–280.

22.

Parente’

, & Herrmann

(2010). Retraining Cognition Techniques and Applications. (3rd ed.) Austin Tx. PRO-ED.

23.

Prigatano

G. P.

, & Klonoff

P. S.

(1988). Psychotherapy and neuropsychological assessment after brain injury. Journal of Head Trauma Rehabilitation, 3, 45–56.

24.

Parente’

, & Stapleton

(1993). An empowerment model of memory retraining. Applied Cognitive, Psychology, 1, 585–602.

25.

Parente’

, & Stapleton

(1999). Development of a cognitive strategies group for vocational training after traumatic brain injury. Neurorehabilitation, 13, 13–20.

26.

Sauffer

, Smith

, & MacDonald

Personal Communication. 8/20/2015

27.

Serad

(2010). Aspects Of Using Animal-Assisted Interventions In A Coaching Model. Scholarly Commons. upenn.edu/od_theses_msod/30.

28.

Shipman

(2011). The Animal Connection. New YorkW.W. Norton.

29.

Siegel

J. M.

(1980). Stressful life events use of physician services among the elderly: The moderating role of pet ownershi. Journal of Personality and Social psychology, 58, 1081–1086.

30.

Sohlberg

M. M.

, & Mateer

C. A.

(1986). Attention Process Training. Puyallup, WA: Association For Neuropsychological Research and Development .

31.

Sohlberg

M. M.

, & Mateer

C. A.

(1988). Effectiveness of an attention training program. Journal of Clinical and Experimental Psychology, 9, 117–130.

32.

Trotter

, Chandler

C. K.

, Goodwin-Bond

, & Casey

(2008). A comparative study of the efficacy of group equine assisted counseling with at-risk children and adolescents. Journal of Creativity and Mental Health, 3, 254–283.