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The Development and Validation of a Research Evaluation

Instrument to Assess the Effectiveness of Animal-Assisted Therapy

A Dissertation
Presented to the
Faculty of the
School of Health Administration
Kennedy-Western University

In Partial Fulfillment
Of the Requirements for the Degree of
Doctor of Philosophy in
Health Administration

by
Sarah Velde
Seattle, Washington

Acknowledgments
The author would like to thank the following people for their help,
expertise, direction, support and cooperation of this important research:
Dianne Bell & the Bellevue Delta Society, Rosalie Frankel, Christi Dudzik,
Francis Martin, Megan Wolf and her dog Zorro, Marilyn Lawrence, Ann
Howie, Heidi Ranger, Andrea Wall, Judith Lipton, Heather Toland,
Francine Won, Shirley Desmon, Laurie Hardman, Danielle Vega, Taryn
Hefler, Mark Garcia and Rene Pizzo.
The author would also like to thank the Kennedy-Western
University student advisory staff as well as the proposal and final paper
reviewers for reading and reviewing the proposal and final project.

Abstract of Dissertation
The Development and Validation of a Research Evaluation
Instrument to Assess the Effectiveness of AAT Programs

By
Sarah Velde
Kennedy-Western University
Problem
Formal animal-assisted therapy (AAT) programs currently have few
or no scientific tools widely available to help guide the course of AAT and
measure its overall effectiveness on patients; thus, AAT is in need of more
documentation and evaluation. The purpose of this study was to
thoughtfully construct a worthwhile, scientifically sound AAT effectiveness
evaluation tool for use by health professionals and volunteers who utilize
and deliver AAT.
Methods
A review of literature provides a comprehensive background on
how AAT evolved as an alternative clinical therapy and examines many
past AAT-related studies. As part of the planning and construction phase,
the new tool was first circulated among a group of reviewers in the AAT
profession for suggestions on improvement. The tool was then utilized in

daily practice by a group of AAT volunteer therapists and animal handlers


to evaluate its validity and reliability. Subsequent to implementation, key
informant interviews were held with the volunteers in order to solicit further
modifications and revisions to the tool. Brief follow-up surveys were also
distributed to the same group of volunteers to capture further logistics for
data analysis.
Findings
Data from this study suggest that AAT programs throughout the
western United States are providing a worthwhile and quality health and
rehabilitation service to sick and/or injured patients. Patients in this study
had positive attitudes toward AAT, which commonly resulted in enhanced
therapeutic effects regardless of age, gender or diagnosis. Throughout
implementation, therapists and animal handlers considered the newly
developed AAT evaluation instrument a useful guide in helping them
accomplish goal-oriented AAT deliverables. The utilization of this
particular tool in daily practice initially resulted in a wide array of proposed
improvements and modifications which were integrated into a final AAT
guidance and evaluation template to formulate a more prolific, universal
and scientifically sound evaluation instrument for therapists and handlers
to use in a much larger capacity. Further research may be warranted.

TABLE OF CONTENTS
CHAPTER 1
INTRODUCTION ........................................................................1
Statement of the Problem...........................................................6
Purpose of the Study ..................................................................6
Importance of the Study .............................................................7
Scope of the Study .....................................................................8
Rationale of the Study ................................................................9
Definition of Terms ...................................................................10
Overview of the Study ..............................................................13
CHAPTER 2
REVIEW OF RELATED LITERATURE.....................................16
Physiological Benefits, Stress Reduction and Relaxation.........21
Improving Quality of Life...........................................................31
Pets as Prescriptions................................................................56
A Closer Look at AAT and Pet Visitation Programs.. .64
Animal-Assisted Activities (AAA) ....................... .64
Animal-Assisted Therapy (AAT) ........................ .71
Risks and Problems Associated with AAT................................88
CHAPTER 3
METHODOLOGY .....................................................................97

Approach ................................................................................100
Data Gathering Methods ........................................................104
Database of Study ..................................................................108
Validity of Data .......................................................................109
Originality and Limitation of Data............................................112
Summary ................................................................................115
CHAPTER 4
DATA ANALYSIS ...................................................................116
Discussion of Initial AAT Tool Revisions ................................117
Implementation Results ..........................................................121
Key Informant Findings...........................................................126
Follow-up Survey Results.......................................................139
Discussion of Final AAT Tool Revisions .................................142
Delta Society Considerations ................................................144
CHAPTER 5
SUMMARY, RECOMMENDATIONS & CONCLUSIONS........146
BIBLIOGRAPHY ....................................................................................154
APPENDICES ........................................................................................175

LIST OF TABLES
Table
1. Panel of Reviewers ...........................................................................117

2. First Round Revisions to AAT Tool Draft ..........................................118

3. Volunteer User Group Demographics ...............................................121

4. Number of Visits per Volunteer .........................................................123

5. AAT Client/Patient Demographics.....................................................123

6. Results from Follow-up Survey .........................................................139

What is man without the beasts? If all the beasts were gone, man would
die from great loneliness of spirit.
- Chief Sealth (Seattle), Duwamish Tribe, 1850

Chapter 1
Introduction
In ancient and primitive times, animals and humans have relied on
each other for existence, survival and camaraderie. Throughout the
centuries, animals have gone from being owned simply for basic necessity
and product to being owned purely for ones fun and enjoyment. The role
of animals has changed, as it has evolved into many different expressions
such as physical, social, emotional or cognitive. A great deal of research
has been carried out relating to pet ownership, pet attachment and how it
facilitates healthy living, well being and enriches quality of life. In fact,
animals have come so far as to aid patients in formal therapeutic settings
such as hospitals, clinics and physical therapy and/or rehab unitshence,
coining the term animal-assisted therapy, or AAT. Determining the
effectiveness of AAT will be the focus of this research.
Today, nearly 60% percent of millions of households in the Western
world have some type of animal, of which the majority are cats and dogs
(Edney, 1995). Millions of pets reside in the homes of Americans; there
are more than 63 million cats, 55 million dogs, 25 million birds, 250 million
fish, and 125 million other assorted creatures that people own and care for
as pets (Hirschman, 1994). Three percent of American households have

a pet reptile of some sort (Wood, 2004). In 1993, the United States
Census Bureau reported that 75% of U.S. households had pets (U.S.
Bureau of the Census, 1993). In fact, U.S. families have more pets than
children. Dogs are more commonly seen in families with young children
(Albert & Bulcroft, 1988). Bulcroft (1990) found 87% of 1000 people
surveyed strongly felt their pet was a member of the family, therefore
concluding that most Americans feel pets are a natural and valued part of
family life (p. 14). Triebenbachers similar study involving grade school
students found that those surveyed felt the same away about pets as
family (1998). A similar and more recent study regarding pets as family
members by Cohen (2002) found that women were less lonely and had
fewer problems in general in living with a pet than men. They also
reported that an average of 16 hours per day with their pet indicated
stronger and higher bonding levels among the women studied. After
discussing the findings at length, Cohen summarized that . . . pets are
firmly inside the family circle (2002, p. 632).
Animal companions are important to all ages. Siegels (1995) study
among 877 teenagers found that half resided in families with pets of some
sort, in which over half of these teens surveyed indicated that their pets
were very significant and important. Interestingly, Johnson and Meadows

(2001) justify todays pet ownership rates, as in a recent article they wrote
as the majority of society has become more technologically dependent
and dispersed through greater mobility, extended family support may be
less available. This phenomenon may in part explain the statistic that
more than half of households include pets (Johnson and Meadows,
2002, p. 617). Bustad (1996) also shared this view, as he stated that:
The importance of animals to the well being of people is
becoming more and more evident. This is especially true as
we realize that at no time in history have so many members
of Western society been devoid of healthy interaction among
themselves and with the environment.

More and more

people are electing to live alone; many who are married


choose not to have children. Singles or couples who have
children are compartmentalized. Many fathers and mothers
work outside the home, usually in different locations and
sometimes on different schedulesthis deprivation of
nurturing

opportunities

and

compartmentalization

has

resulted in increased stress, depression, loneliness and


overall serious challenges to the health and well being of a
significant segment of our population. Companion animals

have refused compartmentalization and serve as nurturers


for many people; they also are objects of nurture, promoting
touching, playing and sharing with few time restraints (p. 3).
People keep pets for many reasons, one reason being simply for
companionship and the need to care for another living thing. Although
millions of people have kept animals as pets over the years, studies about
the actual therapeutic benefits of owning animal companions have just
become popular in the last 25 years. Due to this, researchers have begun
to design and conduct studies researching the wide range of effects of
animals on a persons self-worth, level of loneliness, anxiety, security,
heart rate, blood pressure, cholesterol level and other psychological and
physiological states.
The utilization of animals in improving or enhancing physical and
mental health status is not a new phenomenon. Willis (1997) explained
that medical literature from as far back as the 17th century includes
references to horseback riding as a relief for back problems and other
disorders. He also acknowledged that in the 18th century animals were
kept in an England facility for the mentally disturbed, and not much later
pets were used as morale boosters for disabled and disadvantaged
communities in Germany. Florence Nightingale wrote in 1859, a small

pet is often an excellent companion for the sick, for the long chronic cases
especially (as cited in an article by Willis, 1997, 78). When an animal is
present, people tend to share stories and readily engage in
communication about pets they used to have.
Day by day, both animal companions and animals used specifically
for therapeutic reasons have made endless positive contributions for
people of all ages and from all walks of life. Physically they have helped
facilitate rehabilitation and healing processes and have enabled us to
become more active and energeticthus reducing blood pressure and
cholesterol levels. Socially they have inspired and motivated us to more
readily communicate with others and reduce boredom. Emotionally they
have provided us the opportunity to become less lonely, depressed and
anxious. Cognitively they have aided us in exercising our thinking skills
and memory. The combination of these four goal-oriented domains
constitute animal-assisted therapy (AAT), a relatively new approach where
animals are incorporated as part of an alternative or adjunct therapy to the
more traditional approach. Because of perceived high patient satisfaction
and perceived patient-therapist-handler success rates, AAT is quickly
becoming more widely accepted and utilized in many health care
organizations across the country.

Problem Statement
Formal AAT programs in the United States currently have few or no
scientific tools in place to help guide the course of AAT and measure
effectiveness on patients. From the fields perspective, AAT is in need of
more documentation and evaluation. Clinical therapists, volunteers and
animal handlers on all levels who utilize and deliver AAT have expressed
a demand for a new, prolific evaluation instrument to use in conducting
AAT sessions.

Purpose of the Study


The primary objectives of this study were 1) to characterize the
features of western United States AAT programs and procedures, 2) to
thoughtfully plan and construct a valuable, scientifically-sound AAT
effectiveness evaluation tool for clinical therapists and their volunteer
animal handler counterparts who utilize and deliver AAT, and 3) to test the
new evaluation instrument in practice for reliability and validity. The study
goal is to essentially offer and promote the tool on a larger scale for wider
acceptance and utilization in settings where AAT is formally occurring
both for use in daily practice and to potentially meet third-party payment
requirements.

Importance of the Study


Hundreds of previously existing articles are essentially anecdotes
or testimonials about the introduction of pets into a facility by health care
workers and animal handlers. Little or no formal scientifically valid
evaluation instruments exist in measuring the effect of AAT for patients of
varying capacities, and there have been few scientific research studies
published regarding the effectiveness of AAT. This topic is significant in
that it provides a first look into the design, construction and development
of a practical AAT effectiveness tool, and will serve as a basis for future
related research to stem.
General AAT research is fairly new and AAT as an alternative form
of treatment while incorporating animals as a therapy tool is increasingly
gaining popularity in the United States. Several previous studies,
particularly the vast and early findings of AAT researchers Friedmann,
Katcher and Siegel, along with the 1980s AAT pioneering efforts of Shari
Bernard, provide important and rigorously collected data regarding AAT
therapeutic benefits. However, these studies have been limited by small
sample size and short duration; therefore, there continues to be a pressing
need to measure the effect AAT has on patients.

Information and data gathered from this initial exploratory research


will help clinical therapists, volunteer teams and animal handlers who
utilize and deliver AAT, AAT researchers and other allied health care
professionals involved with the human-animal bond as they look for ways
to increase life span, lower incidences of depression, refine cognitive
abilities and improve the quality of physical and mental health of their
patients.

Scope of the Study


The focus of this research was to successfully produce a useful
instrument to assess and evaluate the effectiveness of AAT on patients
who are undergoing this alternative form of therapy due to a chronic
condition, injury, illness or disability. The study population consisted of
therapists, volunteers and handlers who currently utilized and delivered
AAT in the western United States. Participating facilities had some type of
AAT program in order to be eligible and studied. Buy-in and support from
several therapists and animal handlers who provided AAT was obtained
early. Sources of data included verbal and written comments from
therapists and animal handlers providing AAT who utilized the newly
developed AAT effectiveness tool throughout each therapy session, as
well as follow-up questionnaire responses from the same group regarding

design, content, validity, reliability and further utilization of the new tool.
In-depth opinions, thoughts and perceptions from key therapist and animal
handler volunteers delivering AAT was sought regarding the use of the
AAT effectiveness evaluation tool. After implementation of the newly
developed instrument commenced, coded data regarding the new tool
was transposed to a study database and examined for reliability and
validity issues. This undertaking was not invasive in any way.

Rationale of the Study


As stated previously, very few or no formal scientific AAT
effectiveness evaluation tools are currently in existence for clinical
therapists and their animal handler counterparts who provide AAT in
measuring the effectiveness of the programs they deliver. As with any
new plan, program or procedure, professionals who deliver AAT need
specific direction and guidance when initiating such a regimen, and health
administrators of these facilities also need justification and validation to
support their decision in incorporating novel and alternative programs
such as AAT with patient care being first and foremost in mind.
Because formal AAT is still quite rare, there has been a lack of
abundant scientifically gathered and published effectiveness data.
Although various tools exist for physical, occupational and speech-

language therapy, little or no background information is widely available


on the actual design, developmental process or implementation of such a
tool to specifically measure AAT effectiveness in patients. That is why a
study of how this new instrument fit into the flow and schedule of such
programs in daily practice was an important first step in measuring the
effects of AAT in patients of varying capacities (i.e. inpatient, outpatient,
individual, group). Determining its ease of use, reliability and validity,
success or failure rate, and advantages or disadvantages of
implementation for all users involved provided a solid basis in which to
ascertain future findings from broader AAT effectiveness studies.

Definition of Terms

Animal-assisted activities (AAA): activities including animals which


provide opportunities for motivational, educational and recreational
benefits to enhance quality of life.

Animal-assisted therapy (AAT): a scheduled, goal-directed


intervention in which an animal is an integral part of the treatment
and healing process; promotes improvement in physical, emotional,
social and cognitive functioning.

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Animal companion: an animal who is considered a friend or part of


the family by a human; the term animal companion is commonly
used interchangeably with pet.

BMI: body mass index; a comparative number that measures the


correlation between body height and weight.

Cortisol: a hormone associated with stress.

Diastolic: the part of the heartbeat cycle during which blood


pressure is lowest or when the heart is relaxed.

Domestic: animals living near or about the habitations of humans.

Eden Alternative: the initiative founded by Dr. William Thomas to


ultimately see long-term care facilities as habitats for human beings
rather than institutions for the frail and elderly with the use of
companion animals and the opportunity to care for other living
things (Thomas, 1996).

Edenizing: a process developed to help eliminate the three


plagues of life in an institution: loneliness, helplessness and
boredom (Thomas 1996).

Electroconvulsive therapy: using electrical shock to cause a


seizure and release many chemicals, or neurotransmitters, in the
brain in order to deliver messages from one brain cell to another-causing the brain to work better.

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Geriatric: of or relating to aging.

Hypertensive: having abnormally high blood pressure.

Hypoglycemic: a diabetic complication resulting in abnormally low


blood glucose levels in which the body is unable to produce enough
insulin to metabolize glucose.

Immunosuppressed: lacking a fully effective immune system.

Pervasive Developmental Disorder (PDD): a neurobiological


disorder that affects a childs social, mental, linguistic, and physical
development.

Melanoma: skin cancer.

Pet Partners: a Delta Society program which allows volunteer pet


owners to provide services to people in hospitals, nursing homes,
rehabilitation centers, schools and other facilities while spending
quality time with their pets; it is the only national registry requiring
training and screening of animal/handler teams.

Prolactin: a hormone associated with feeling secure and nurtured.

Schizophrenia: a mental disorder causing a separation between


the thought process and emotions; may include confusing reality
with hallucinations and/or delusions and paranoia. Change in
personality with bizarre behavior may occur.

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Zoonotic / zoonoses: animal diseases naturally transmissible to


humans.

Overview of the Study


The overall purpose of this study among those who utilize and
deliver AAT was to determine if the current AAT programs in place were
fully benefiting patients who sought this alternative modality. This
undertaking was accomplished by thorough planning, development and
the validation of a new evaluation instrument. It is hoped that this
research will provide a basis in which to construct future related AAT
evaluation studies and to design additional scientific evaluation materials.
The primary audience of this paper should include those involved in
delivering formal AAT programs, such as physical/occupational therapists,
volunteer animal handlers, social workers, rehabilitation counselors,
hospital and nursing home administrators, front-line nurses, physicians
and patient advocacy groups as well as other allied health providers and
administrators considering the implementation of an AAT program into
their own facility. These groups of professionals already know through
research that AAT has been a rapidly growing phenomenon over the
years and has generally proved to be quite beneficial to patients in both a
mental and physical sense. This audience may also be aware of the

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successes and failures of AAT, and may simply desire more research in
order to support already existing evidence of how specifically trained
therapy animals impact patients.
A second audience would consist of lay people who have an avid
interest in this topic, such as veterinarians, allied health care researchers,
and patients and their families who are considering AAT as an alternative
treatment modality.
In the following pages, a thorough review of the literature provides
evidence and findings of past and present literature on the topics of pet
ownership and attachment and the therapeutic value of both animalassisted activities (AAA), and AAT. The benefits and risks of using
animals to facilitate and maintain physical and mental health of humans in
general will be reviewed and described in great length from a historical
context to present day situations. Literature about the quality of life and
various health outcomes for people of all ages and backgrounds who have
owned or have access to animal companions will also be described. A
vast array of clinical studies completed by AAT field experts and other
health professionals will be presented, compared and contrasted as well.
Subsequent to study implementation and data gathering, results
from the study will be presented, displayed and discussed in great detail,

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along with final conclusions and recommendations for further AAT-related


research.

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Chapter 2

Review of Related Literature


This review of the literature addresses past and present research
around the topic of pet ownership, the human-animal bond, AAT and how
it is being utilized in the present day. An in-depth look into the humananimal bond and pet ownership will be presented. Major steps and
challenges in planning and implementing AAT programs will be described
and therapeutic interactions among animals and patients and staff will be
accounted for. Clinical research has found that the benefits of owning
animals include increased longevity, improved diet and exercise habits
and improved memory in the elderlyjust to name a few. These findings
have been proven successful among the elderly, hospital patients,
institutionalized and disabled people, prison inmates and disturbed
children. Throughout the literature review that follows, several review
articles and published research studies from books, professional journals,
conferences/seminars documenting the positive and therapeutic health
benefits from AAT and pet ownership will be described, compared, and
contrasted. Information will be provided about animal-assisted activities
and AAT. Finally, a look at the risks associated with AAT is included.

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In an article by Willis (1997), McCulloch defined AAT as the


introduction of an animal into the immediate surroundings of an individual
or a group as a medium of interaction with a therapeutic purpose (p. 78).
Early cave drawings have been reported to illustrate wolves as family
companions. It has been noted that as far back as the 9th century in
Belgium, care was provided to the disabled via animals; in fact, these
programs are still in place there today (Bustad & Hines, 1984). Some of
the first documented AAT occurred in the early 1790s at a Quaker York
Retreat asylum in England, where efforts for improvement and change led
to teaching self-control to psychiatric patients by having small animals
such as chickens and rabbits depend on them. From the late 1860s until
present, animals were used as part of a therapeutic measure in a German
epileptic treatment center. During WWII, the New York Army Air Corps
Convalescent Center incorporated farm animals in its patient recovery
programs. Later that decade, a childrens home opened in the same state
and incorporated animals as a form of positive reinforcement.
Aside from these very early instances, the next noted and recorded
use of animals used for therapeutic measures occurred when psychiatrist
Boris Levinson included them in his psychology practice in the 1960s and
early 1970s in order to help promote better interaction between client and
counselor. Levinson had actually discovered this by accidentas while

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his dog was present at one session a withdrawn and somewhat


uncommunicative child more readily and willingly opened upthus,
showing slight improvement in therapy while interacting with Levinsons
pet dog. Since then, professionals in psychological and psychiatric
counseling have been incorporating this idea with successful and
encouraging outcomes. As cited by Perelle and Granville, Levinson stated
that a pet can provide, in boundless measure, love and unqualified
approval. . . many elderly and lonely people have discovered that pets
satisfy vital emotional needs (1998, p.1). In fact, it was Levinson who
brought about todays commonly accepted concept of animal-assisted
therapy. Three decades later, Mason and Hagan (1998) supported and
confirmed the usefulness of animal-assisted psychotherapy for all ages
and mental health related diagnoses. Also building on Levinsons results,
Nagengast, Baun, Leibowitz, and Megel (1993) found lower levels of
anxiety and distress among children who were undergoing physical exams
with an animal present, and Wells (1998) reported less agony among
children who were undergoing invasive medical procedures while an
animal was present (cited by Barker, 2004). Along the lines of invasive
medical procedures Barker, Pandurangi and Best (2003) also found that
implementing a short AAT session immediately prior to undergoing
electroconvulsive therapy could be quite useful, as the anxiety and fear

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levels of those particular patients were decreased by 18% and 37%


respectively. Even progress in post-coma patients has been seen by eye
tracking and heart rate when an animal is present. Of mention, animals
have recently been used in courtrooms to help console and calm children
who are about to testify in court. Per these findings, one could safely
conclude that animal companions act as a necessary distraction in all
types of stressful environments.
Beginning in the 1970s, Katcher and Beck conducted several
studies on the human-animal bond and its benefits. In their early years of
research on this topic they found little impact from previous studies
primarily only slight therapeutic outcomes. Throughout recent decades
with much improved research design there has been a wide abundance of
studies on this topic. As cited by Monson (1995), Katcher and Beck later
found 2 reasons why pets help people physically and mentally: (a) pets
draw a persons attention outward and stop destructive rumination; and
(b) pets and their owners form a society unto themselves, which makes
that person more socially attractive to other people (p. 96). Beck and
Katchers (1983) more comprehensive list of benefits derived from
researching companion animal ownership in general is as follows:
1) Companionship, comfort and security;
2) Something to care for;

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3) Pleasurable activity;
4) Source of constancy; and
5) Opportunity for laugher and play.
Most veterinary educators and practitioners now focus on the
health benefits of companion animal ownership in their curriculums. The
scientific side of AAT and its benefits were first explored in minute detail
by the Delta Society in 1984 (Willis, 1997). The Delta Society is a national
organization that specifically studies and researches the effect of humananimal interactions. Today, in a more recent context, the fact that human
and animal interactions can result in physiological and psychological
benefits is increasingly being accepted, researched and discussed. The
late Leo Bustad, veterinarian and past director of the Delta Society, had
these important words of wisdom to share with the public:
A dog can be a wonderful cheerleader.

It can buoy our

spirits and help banish depressing thoughts. It can distract


us from our worries, make us feel more secure and motivate
us to exercise. Most importantly, pets are a great source of
fun and laughter, and many studies have shown that humor
is a powerful tool in reducing stress and promoting healing
(Barrett, 2004, p. 2).

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Physiological Benefits, Stress Reduction and Relaxation


Results from studies described below maintain that the humananimal bond can foster feelings of self-worth, help deter loneliness, reduce
anxiety, encourage contact with others, establish security, and promote
feelings of being needed. There are also many physical benefits, such as
reduced blood pressure and decreased heart and breathing rate. Simply
owning a dog has proved beneficial to ones physical health, as dogs
commonly provide ongoing opportunities for exercise and physical activity.
A 1991 study cited by Monson (1995) reported that people owning dogs
took more frequent and longer walks; hence, had fewer minor health
problems over a period of 10 months. This was also the case and proven
true in the London walk study of 1979 (Fitzgerald, 1986). A study by
Hawley and Cates (1998) has shown that physical benefits derived when
petting an animal include decreased blood pressure and breathing rate
and improved cardiovascular function in diverse age groups. The
following studies reaffirm these benefits, and have paved the way for AAT
programs to be implemented and accepted in a wide variety of settings.
Few contrasting studies on this topic exist, as a pet ownership study by
Endenburg and Knol (1994) revealed that of 871 Dutch respondents
surveyed, 43% thought their animal companions to be a nuisance due to
their behavior, various illnesses, shedding and clean-up after them.

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Goleman and Gurin (1995) reported on an earlier study by


Friedmann, Katcher, Lynch, and Thomas (1980) regarding patients with
heart disease who were recently released from a coronary care unit. The
researchers found higher survival rates 1 year later among pet owners. In
essence, this study proved that pet ownership among the described study
population predicted a stronger survival rate than having solely spousal or
family support.
At the time of the Friedmann et al study described above, there was
no scientific evidence on the association between human survival rates
and pet ownership. Thus, Friedmann et al (1980) next recruited 96
coronary care patients to participate in a 2-year pivotal study pertaining to
the effect of social support and survival. Interviews to collect social data
through a large social inventory were conducted for patients prior to
hospital discharge. As year 1 of the study commenced, all patients were
recontacted and Friedmann et al (1980) found that 78 (84%) patients were
still living. Of the 53 (58%) of the patients who were pet owners, only 3 of
them had died. Of the 39 patients who were not pet owners, 11 had
passed away. Ultimately, Friedmann et al. (1980) concluded in this study
that pet ownership may be a measure of the patients physical status (p.
308) and that death by heart attacks could be decreased by 3%. As a
follow-up, Friedmann and Thomas (1995) measured the social support

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among 369 pet owners with a history of acute myocardial infarction, or


heart attack. From this undertaking they found social support to be quite
high among pet owners and reported that pet ownership predicted higher
survival rates. Data from similar social support studies completed in more
recent times also confirm these results, as one in particular by researchers
Allen, Blascovich and Mendes (2002) studied 240 married couples where
half of the couples owned a pet. Through heart rate and blood pressure
readings while each performed somewhat acute stressful and unpleasant
tasks (i.e., rapid arithmetic subtraction and submerging a hand in ice water
for 2 minutes), either a pet or friend was present. The group where the
pet was present displayed lower heart rates and blood pressure readings,
as well as quicker and more accurate arithmetic. A similar study by Allen,
Shykoff and Izzo (1999) also confirmed the importance of social support
via pet ownership among 48 hypertensive stockbrokers.
In a study funded by the National Institutes of Health (NIH),
Friedmann et al (1980) reported that complex, varied and interesting daily
activity was found to be the strongest social predictor of longevity (p.310).
Friedmann was one of the first pioneering researchers to discover the
positive correlation between humans and their animal companions, and
many studies have thus followed since the 1980s. In contrast to these
particular findings, Helsing et al (1981) were unable to find in their studies

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a positive or beneficial association between mortality rates and pet


ownership in widows or others experiencing bereavement, nor did they
find a link between pet ownership and suicide rates.
In the early 1980s studies with the same concept both from Katcher
(1981) and Baun et al (1984) found lower blood pressures and/or muscle
tension and higher levels of relaxation among pet owners with dogs
present. Participants were observed and measured while interacting with
their own dog and a strangers dog; however, slightly greater benefits
were seen among their own dog. A follow up study to this research by
Schuelke et al (1991) confirmed increased relaxation among 31
hypertensive subjects with a dog present, but contrary to these findings,
results were found in a subsequent study a few years later by Gaydos and
Farnham (1988). Related research of mention with an interesting study
design was the dog adoption study by Allen (2001), where 60 borderline
hypertensive participants living alone adopted a dog for 1 year and at
study end had displayed overall lower blood pressures than the control
group who only did meditation. The authors justify this studys importance
because dogs acted as a replacement for drug therapy.
New and novel physiological neuro-endocrine research completed
around this topic in a recent trial actually found that not only did human
cortisol (stress) hormone levels decrease, but that dog cortisol levels

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decreased as well while being petted (Dale, 2004). The same was said
for the dogs prolactin levels. This proves that a human-animal
relationship is indeed beneficial to both parties involved. Even as far back
as 1929 readings of a dogs arterial blood pressure decreased as a result
of human touch, and later the dogs primary neurochemicals involved with
human interaction and bonding were increased (Cusack & Smith, 1984).
With all the excitement around the newly published results around
the therapeutic benefits of pet ownership and AAT, the NIH shortly
thereafter funded a comprehensive conference/workshop to increase
awareness, strengthen and promote more AAT research. Jennings (1997)
reaffirmed that the benefits from AAT and pet ownership parallel Healthy
People 2000s goals and objectives around promoting and increasing
physical activity and/or fitness and the prevention and treatment of mental
health disorders.
Goleman and Gurin (1995) reported on a study carried out by
Siegel (1990) finding that elderly pet owners visited their physicians fewer
times in a year than those who did not own pets. In a 1-year health
behavior study among elderly Medicare enrollees, Siegel (1990) contacted
enrollees every 60 days about their number of doctor visits. Of the 938
enrollees, about one-third (37%) were pet owners. Siegels (1990) results
showed that pet ownership among the enrollees was one of the major

25

predictors of clinic visits during the study period and that pet ownership
among the elderly may decrease the demand for health care services, as
well as may have helped people cope during stressful and difficult life
events they encountered during that year. Patients in this study generally
reported that they got great comfort from their pets during stressful times
(Goleman and Gurin, 1995, p. 338). In the study, almost 75% percent of
the enrollees had indicated they felt their pet provided feelings of security
and companionship. In this particular study, people felt dogs provided the
best support.
According to important research by Serpell (1991), a series of 4
questionnaires over a prospective 10-month study of 71 new adult pet
owners (47 adopted dogs and 24 adopted cats), survey results indicated
that subjects (especially dog owners) continuously reported fewer minor
health problems such as the common cold, influenza, and backaches;
respondents did not focus on their health problems. They also took more
walks, thus improving their physical status, and reported a long lasting,
improved general health status over the next several months. Positive
results of dog ownership on every level were more significant than those
of cat ownership, as the author speculates this was because of security
reasons leading to improved self-esteem and increased confidence.
Mason (1994) reported on a 1992 cross-sectional survey by Anderson

26

involving 5,741 Australians where pet owner respondents (14%) displayed


lower blood pressure, cholesterol and triglyceride levels than those who
did not own pets. The pet owners were also more physically active.
These findings suggested that the ownership of pets could lower the risk
of cardiovascular disease. However, Parlsow and Jorm (2003) found
contradicting evidence by replicating this study nearly 10 years later
whereas nearly 60% of the 2,551 Australian respondents were pet
ownersa much higher percentage than in Andersons study. The study
does not support the previous positive health findings because pet owners
altogether had higher body mass indexes (BMI), higher diastolic blood
pressures and were more likely to be cigarette smokers.
A year long longitudinal study of nearly 1000 adults aged 65 and
older conducted by Raina et al (1999) found that the pet-owning
respondents were younger, married (or living with someone) and more
physically active than the non pet-owning respondents. Smith, Seibert,
Jackson and Snell (1992) also found pet ownership to be more likely
among older married adults. Although there was no relationship among
pet ownership and psychological health, general activities of daily living
were improved. For example, seniors with arthritis were forced to get up
and become more mobile despite their pain because their pet needed
daily care and attention. Dembicki and Anderson (1996) found similar

27

results around physical activity in their research involving elderly dog


owners, as those with dogs tended to walk for a significantly longer period
of time than those with no dogs. As expected, the research also found
lower serum triglyceride levels in individuals who did more walking.
Another survey among 128 elderly metropolitan dog walkers revealed that
over half of the walkers/respondents described a very strong friendshiplike bond with their dog. Those surveyed also provided positive attitudes
around companionship, emotional bond, usefulness, loyalty and the
absence of negotiation (Peretti, 1990).
To build on and support a previous study by Anderson, Reid and
Jennings (1992), a social support and resting blood pressure study by
Allen, Gross and Izzo (1997) recorded the blood pressures of elderly
women living alone for 6 continuous months. Compared to a group of
elderly women owning petsnamely cats or dogsthe blood pressures
were quite lower in the pet-ownership group. The authors stated that the
notable finding here is that, although increases in blood pressure are a
normal part of aging, social support provided by people and/or pets can
moderate age-related increases (Allen, Gross and Izzo, 1997, p. 94). Out
of 144 elderly individuals in various living arrangements, Goldmeier (1986)
found that people owning pets had improved levels of morale and that
older women were prone to lower levels of loneliness. Along these lines,

28

a study done by Akiyama, Holtz and Britz (1987) showed that widows who
owned pets had less physical health ailments and less depression than
those who did not. In contrast, however, researchers Miller and Lago
(1989) earlier found that pet ownership in elderly women had no effect on
their physical health.
According to Barba (1995), stress reduction is one outcome of a
formal AAT program. Animals provide many distractions to keep the focus
off oneself, giving people something to focus on rather than the stress
they are enduring. Cole and Gawlinski (1995) studied this and later
witnessed the changes in stress levels in an intensive care unit, as patient
posture changed from stiff to relaxed, and facial expressions became
pleasant and content in the presence of animals.
Researchers Allen, Bascovick, Tomaka and Kelsey (1991)
measured the blood pressures and other physiological stress indicators of
45 women while each performed a set of stressful and challenging mental
tasks such as counting backwards from a high number in a timed and
quick manner. When these women subjects completed the tasks in the
presence of researchers and friends, their stress level was recorded as
high. However, when these same women had their pet dogs near them
while completing the daunting mental tasks they illustrated absolutely no
reaction to stress. As cited by both Friedmann et al (1983) and Cole and

29

Gawlinski (1995), Sebkova completed a similar stress level study in 1977


and found that women had experienced lower anxiety levels in a
somewhat stressful setting if their pet dog was present. A similar study
was also carried out on a smaller scale by Fleming (2003) where 23
college students completed timed quizzes and questionnaires in the
presence of a dog, no dog or an aquarium. Investigator observation
yielded that students exposed to the dog displayed less nervous behavior
(i.e., pencil tapping, leg shaking); they also appeared less physically
anxious and tense than the other test takers. Fleming (2003) concluded
that self-reported testing anxiety among the students studied and
observed was low and marginally significant.
Stress and anxiety are both linked to heart disease. Studies done
on dental patients have proven that they suffer less stress and anxiety
immediately before having oral surgery due to concentrating on a fish
aquarium at the dentists office (Mason, 1994). Watching the fish relaxed
the patient and suppressed their fears. Similarly, a later study proved that
hosting small animals such as gerbils, birds and fish in a waiting room at a
pediatricians office also aided in relaxing children (Monson, 1995). In
1985 Riddick found that the presence of a goldfish aquarium was
associated with higher relaxation and lower blood pressures among
elderly apartment residents. To further investigate the relaxation benefits

30

of fish aquariums, researchers Cole and Gawlinski (2000) later


investigated the physical and psychological outcomes for those awaiting
heart transplants in a Los Angeles hospital. It was designed in such that
10 study subjects aged 18 to 80 were given an aquarium containing
goldfish for their hospital room. During the first 2 weeks awaiting heart
transplantation, subjects were instructed to feed and name the goldfish.
Surprisingly, results from baseline to follow-up generally showed no
difference in anxiety, stress or relaxation levels. However, the aquariums
were subsequently used at length in the intensive care unit, where they
quickly became very popular.

Improving the Quality of Life


More and more, the use of animals to improve overall quality of life
and encourage those who have been isolated, unsociable and emotionally
distant is gaining popularity. Most of these programs were started in the
1970s. The Delta Society, who has been truly a pioneer in exploring the
human-animal relationship, has been in existence for over 25 years and
has approximately 1,500 members. The Delta Societys primary
objectives are to 1) promote research, 2) increase the interdisciplinary
approach and 3) measure the roles and functions of human-animal
interactions (Delta Society, 1996). One of the largest animal-affiliated

31

programs in the United States is the Delta Societys Pet Partners


Program, which includes more than 8,000 teams in the United States and
6 other countriesincluding Japan and Italy. They provide services
(including volunteer training and animal screening) to over 900,000 people
and/or patients a year in various types of housing and facilities through the
therapeutic use of dogs, rabbits, cats, guinea pigs, donkeys, llamas, and
birds (Swift, 1997).
Other organizations have also followed suit, as the CENSHARE
program at the University of Minnesota fully involves itself in investigating
the human-animal bond. Similarly, the University of Pennsylvanias
Veterinary School has also dedicated itself to the human-animal
relationship, as in the late 1970s they established a Center for the
Interaction of Animals and Society in order to further study the companion
animal effects on health.
Veterinarians as independent researchers have also climbed on the
bandwagon around the human-animal bond and AAT. For example, Dr.
Francois Martin, Associate Director of the Center for the Study of Animal
Well-Being and Head of People-Pet Partnership at Washington State
Universitys College of Veterinary Medicine, commented on the
emergence of the human-animal bond and what his veterinary programs
offer and employ to promote awareness and recognition. . . it is

32

necessary for our veterinary medicine students to first be aware of the


human-animal bond and to learn about this bond before they begin to
practice veterinary medicine. This is why we teach classes around this
topic during their first year of veterinary school (personal phone
conversation, October 29, 2004). He also proposed the future feasibility of
incorporating a notion such as this into local 4-H programs. Martins
division also operates a fully accredited 4-day per week horseback riding
program for people with disabilities, including 4 horses and 100
volunteers.
Animals have the capacity to improve the overall life quality in the
later years and also for diseases or disorders that have no cure. For
example, Alzheimers disease, which has no cure and is rapidly
approaching an epidemic-like status, has recently been a condition of
interest in implementing AAT. Common everyday skills such as
communication and recall have been found to be enhanced with the use of
AAT in this particular population. Studies by Baston et al (1995),
Churchill, Safaoui, McCabe and Baun (1999) and Richeson (2003) have
reported optimistic outcomes including decreased agitation and higher
levels of social contact and verbalization among Alzheimers patients while
having access to a visiting, or therapy, dog. Another study among
Alzheimers inpatients proved that this population was found to be less

33

anxious, moody and aggressive when devoted to an animal. The animals


had a relaxing and normalizing effect on the Alzheimers patients and their
memory capacity increased as a result of recalling the animals names,
breeds and colors (Cross, 1998). In support of this research, Fritz (1995)
also found in a similar study that 34 out of 64 Alzheimers patients
displayed less anxiety, mood changes and verbal aggression when
provided with a companion animal in home. A more recent study by
Edwards and Beck (2002) found the implementation of fish aquariums in
two different Alzheimers care centers to improve nutritional intake and
diet among 54 (87%) of 62 inpatients.
Pet ownership and the human-animal bond are important in the
later years. One of the populations who have greatly benefited from the
presence of animals and who have been most extensively studied has
been the elderly, especially those living alone. Statistics from the United
States Census Bureau (1995) conveyed that in 1993 there were 32% of
people aged 65 to 74 that lived alone and that 57% of people aged 85 or
older lived alone. In older adults at least 65 years of age, the rate of
depression runs about 15% (Tavormina, 1999). From depression other
physiological and psychological ailments can result, thus much research
has been done evaluating the effect pet ownership has on depression.
For the elderly population, Garrity, Stallones, Marx and Johnson (1989)

34

found that pet ownership and attachment were associated with lower
levels of depression. Animals used in therapy have ranged from domestic
cats and dogs to horses and dolphins. Arkow (1988) stated that animals
have provided many benefits to older adults, as they stimulate social
interaction. Animal companions do not judge; they simply give
unconditional affection to those who allow it, and are therefore treated like
members of the family.
Many studies have found that older adult pet owners who live alone
take better care of themselves. A survey by Cole (1998) among Modern
Maturity magazine subscribers found 95% of them owning a pet, with 89%
of respondents owning a pet solely for companionship. Suthers-McCabe
(2001) supports that finding stating companionship is the most frequently
cited benefit of older pet owners (p. 94). People also keep pets for
security reasons, and those having disabilities may need specially trained
animals to aid them in their activities of daily livingsuch as meal
preparation, walking, dressing and bathing. In general, the elderly
population has reported that pets have fulfilled their needs and have
helped them remain reality based; pets have improved, enhanced and in
some cases restored their self-concept and self-worth while bonding to
them. Whether in private homes, nursing homes or senior community

35

settings, studies have shown that in these types of environments animals


have been proven to be a positive factor.
Although institutional applied research tends to be more popular
around pet ownership and AAT, there are currently some novel
epidemiological efforts that are further investigating the link between pet
ownership/attachment and the elderly who live alone. Results from those
studies have yet to be analyzed, presented and published. Most of the
literature gathered for this project suggests the importance of future
longitudinal epidemiological research to study the human-animal bond and
pet ownership in general, and many authors emphasize the need for more
funding, resources and data to further investigate human-animal
interactions during AAT.
Efforts have been made promoting the older adult-animal bond. An
example of this as cited by Willis (1997) is a federal law making it illegal to
forbid pets in elderly subsidized housing. Further, ongoing community pet
visitation programs have been especially popular because even though
many elderly people may suffer from cancer or heart problems, they also
suffer from loneliness and feelings of isolation. Animals help ease these
feelings and improve the quality of life in many positive ways. This was
confirmed in a study by Muschel (1984), where 12 out of 15 cancer
patients alluded to feeling less fearful, depressed, isolated and lonely in

36

the presence of animals. Further, a questionnaire to 70 breast cancer


recovery patients in several support groups where over half owned pets
was conducted to investigate the role pets play in support and recovery.
Eighty-eight percent of the pet owners self reported less perceived
disfigurement through cancer. The study found that pet ownership was
linked to a better overall patient perceived control of breast cancer and
treatmentincluding doctor visits (McNicholas, Collis, Kent and Rogers,
2001). Of important note, the families and caregivers of those who have
cancer and other terminal illnesses also benefit from companion animals.
Johnson and Meadows (2002) conducted a social support study on
older Latinos and their pets, as no research had been previously cited on
that particular population and no public information had yet been made
available on that specific topic. In 24 Latino dog owners over age 50,
nearly all viewed their dogs as valuable companions or as an equal.
Thirteen participants also had a cat, 3 had a bird and 1 had a pet rodent.
Three-quarters of the population studied self reported to be in excellent
health, exercising 2 to 7 times per week. Authors Johnson and Meadows
declared that for these older Latinos, pets were as important as they have
been reported to be among Caucasians (2002, p. 617).
AAT has proved positive for another disease of interest of which
there is no cureAIDS. A study by Conti et al (1995) showed pets are

37

significant to the chronically ill, as a 4-month follow-up asked a series of


questions to AIDS patients about their animal companions. Of 408 AIDS
patients, 81% felt emotionally attached to their pets. Both Siegel et al
(1999) and Carmack (1991) also reported health benefits of pet ownership
among male AIDS patients such as decreased stress and levels of
depression, while Castelli, Hart and Zasloff (2001) reported on increased
comfort levels of cat ownership in particular.
Over 76 million people in the United States are currently
approaching retirement (Tavormina, 1999), and the current senior citizen
population continues to grow due to increased longevity and the baby
boom generation. Milikow and Kohn (1999) project that the 85 years and
older population in the United States will soon rise from 3 to 6 million due
to increases in life expectancy. As humans age, the number of long-term
care admissions increases. Some people have no choice but to reside in
nursing homes, of which there are now more than 17,000 nursing homes
across America. In the United States more than 1.5 million people are
currently residing in these nursing homes (Rimer, 1998). The significance
of these statistics is that it is imperative to enhance the quality of life in the
later years, and a popular avenue that has been explored at length in
long-term care facilities has been the ongoing implementation of AAT
and/or pet visitation.

38

Over the years, many studies have resulted in beneficial findings


around the senior population and AAT programs in health and daily care.
Out of 233 United States long term care facilities, 66% reported that AAT
had a beneficial effect on the residentsprimarily in the areas of self
esteem, social interaction, pain reduction, decreases in blood pressure,
increases in muscle strength and range of motion (Behling, 1990).
Intriguingly enough, general findings from Kaiser et al (2002) revealed that
3 out of 5 nursing home residents had no preference as to the type of
visitor they hadwhether it be a young happy person or a dog. Perelle
and Granville (1998) reported findings from Corson and Corson that
nursing home residents were less lonely and socially withdrawn after dogs
had been introduced to their environment. Just by being there, pets often
ease the transition of residents into long-term care facilities and patients
into health care institutions. Long-term care facility residents have shown
increased communication when animals have been introduced, and those
who have been isolated or withdrawn for long periods of time have been
found to respond to the animals (Allen, 1998).
Fick (1993) studied 36 male residents in a Veterans Administration
nursing home involved in situations when a dog was either present or
absent. This study found that the presence of the dog promoted
significant verbal interaction and socialization among the residents.

39

Similar findings around verbal interaction were also confirmed by


researchers Rogers, Hart and Boltz, (1993). Fick (1993) summarized this
study by noting:
These findings are consistent with existing literature, thus
providing further evidence of the value of AAT programs as
an effective medium for increasing socialization among
residents in long-term care facilities. Because an increase in
social interactions can improve the social climate of an
institution and occupational therapists frequently incorporate
group process into their treatment, the therapeutic use of
animals can become a valuable adjunct to reaching
treatment goals (Fick, 1993, p. 529).
Robb, Boyd and Pristash (1980) found similar results in a long-term
care population using puppies as a social catalyst, and Brickels previous
study using cats found that nursing home residents were more open to
therapy, were more sociable and enjoyed the feline visits (Perelle and
Granville, 1998). Later research by Velde (1999) among 3 long-term care
facilities in metropolitan Minnesota confirmed that residents were more
open and willing to undergo physical therapy with animals present and
discovered that residents who had been withdrawn for long periods of time
began reaching out and responding to the animals.

40

If not treated immediately and appropriately, loneliness is known for


having the potential to lead to other chronic health problems. The quicker
it is acknowledged and acted upon, the probability of future health
concerns is low. One way to combat and/or prevent loneliness is by
introducing animals. The therapeutic use of pet visitation and AAT in longterm care has also been justified by researchers Banks and Banks (2002),
as 30 residents participating in a 6-month AAT pilot period showed a
substantial decrease in loneliness over time. These same residents had
reported owning a pet of some type in the past.
Perelle and Granville (1998) evaluated a pet visitation program
among 53 nursing home residents. They studied the association between
behavioral change and gender of the residents over a 10-week period.
Eighteen males and 35 females participated. Student volunteers brought
animals into the nursing home to visit once a week for 2 hours at a time.
In the end, results from the 35 residents were analyzed, showing that
gender did in fact play a substantial part in the behaviors. Visiting animals
appeared to promote social behavioral change, and had a positive but
different effect on both males and females. Males displayed a faster and
greater rate of social improvement, while females showed slower but
steady rates. The authors explained this outcome by the fact that females
in general tend to already communicate with each other and staff more

41

than males. Further, Perelle and Granville hypothesized that individuals


may already be predisposed by their genetic makeup to positive
associations with animal companions (1998).
Today, many nursing homes have either resident animals or visiting
pets and support resident pet ownership because residents often reach
out and interact with the animals. In fact, all 50 states allow pets in
nursing homes. People can open up and be responsive when a dog is
present, noted Dr. Robert Anderson, an expert on the human-animal
bond (cited by Paine, 1996, p. 62). For those whose time has come to
reside in nursing homes, Baun, et al (1984) found that it was also effective
for residents to bring their own pets into the nursing home to live rather
than allowing different or unknown pets to visit or reside there as well.
Pets have provided seniors with responsibility, routine, exercise,
companionship and focus. Past research has found that seniors believe
keeping and owning a pet of their own was more important than moving to
a place of convenience that does not accept pets (The Healing, 1998).
Cole and Gawlinsky (1995) and Thomas (1996) reported on a study by
Mugford including 30 elderly people living in their own homes. In order to
evaluate subjects psychological well being and attitudes, a sub-group was
given birds to care for. Study results showed that the sub-group caring for
birds had formed close attachments to the birds while developing

42

improved self-esteem and a clearer self-concept of what kind of person


they were. The birds, essentially promoting social contact among the
participants, were the primary topic of conversation among the elderly
population studied.
Long-term care facilities often bear the stigmas of loneliness,
helplessness and boredom; rather, they should be seen as habitats for
human beings rather than institutions for the frail and elderly. Nursing
homes have also been compared to prisons and psychiatric institutions, as
residents eat, sleep, receive treatment and exercise in one location under
one roof. Breakfast, lunch and dinner are served at the same time each
day with limited menu items. Repetitive activities are scheduled
throughout the remainder of the day and eventually become mundane.
There is essentially a virtual lack of freedom and outside social
encounters. Fortunately, a wide array of positive, therapeutic
interventions have come into play in nursing home facilities in the United
States. These interventions have introduced plants, children and animals
into the lives of residents in order to help eliminate loneliness,
helplessness and boredom. Nearly 25 years ago, a group of human and
animal health specialists recognized the need to bring the animal and
human worlds together to form the first pet-affiliated program for geriatric
residents in institutional settings. One of the more recent initiatives in

43

long-term care has been the Eden Alternative. The Eden Alternative is
another way to promote happiness and well being within a nursing home.
Many nursing home administrators have been choosing to employ one or
more aspects of the Eden Alternative concept in their facilities.
Dr. William Thomas first illustrated the differences between care
and treatment in his book about the Eden Alternative. As medical director
of a New York nursing home, Thomas was the first physician and pioneer
to implement such a program. In nursing homes, many times care is
carried out as treatment; there is so much treatment, but too little care.
However, in Thomass book, taking care is defined as helping one to live
and grow. Thomas (1996) stated that if we are going to be serious about
taking care of nursing home residents rather than just treating their ills,
many things must change. . . we must face up to the three neglected
plagues: loneliness, helplessness and boredom (p. 23). Ultimately,
Thomas would like to see all nursing homes adopt this mission and be
overall better places to live.
In 1991, Thomas facilitated an approach to accomplish this vision.
It was called the Eden Alternative, and it was first accepted and funded by
the New York Department of Health. The Eden Alternative builds on the
current health care system, but has three different principles based on
biological diversity, social diversity, music and nature. Feeling that it was

44

Thomass obligation to fulfill the lives of the residents, he declared that the
primary goal of the Eden Alternative was to do away with the plagues of
nursing homesloneliness, helplessness and boredom. He
accomplished this by incorporating companion animals into long-term
community settings to live with the residents. Thomas hopes to succeed
where treatments and medications fail. In order to promote biological
diversity, Thomass long-term care facility initially adopted more than 100
birds. Each resident was allowed to have a bird in their room if they so
chose. A number of dogs, cats, rabbits and chickens were soon
introduced as well. The Eden Alternative also attempts to improve the
quality of life by involving plants, gardens and children.
A primary idea of the Eden Alternative is to educate the public to
see nursing homes as communities for human beings instead of
institutions for the frail and elderly. The Eden Alternative demonstrates
ten core principles which administrators and staff are encouraged to carry
out. According to Dr. Thomas, nursing homes employing this concept
should:
1. Understand that loneliness, helplessness and boredom account
for the bulk of suffering in a typical nursing home;

45

2. Commit itself to surrendering the institutional point of view and


adopts the human habitat model that makes pets, plants, and
children the pivots for daily life in the nursing home;
3. Provide easy access to companionship by promoting close and
continuing contact between the elements of the human habitat
and residents;
4. Provide opportunities to give as well as to receive care by
promoting resident participation in the daily round of activities
necessary to maintain the habitat;
5. Imbue daily life with variety and spontaneity by creating an
environment in which unexpected and unpredictable interactions
and happenings can take place;
6. De-emphasize the programmed-activities approach to life and
devotes those resources to the maintenance and growth of the
habitat;
7. De-emphasize the role of prescription drugs in the residents
daily life and commits these resources to the maintenance and
growth of the habitat;
8. De-emphasize top down bureaucratic authority in the home and
seeks instead to place the maximum possible decision-making

46

authority either with the residents or in the hands of those


closest to the residents;
9. Understand that changing is a process, not a program, and that
the habitat, once created, should be helped to grow and to
develop; and
10. Places the need to improve residents quality of life over and
above the inevitable objections to change; leadership is the life
blood of this process, and nothing can be substituted for it
(1996, p. 66).
On the contrary to those who feel that animals provide a daily,
orderly routine/ritual to long-term care facility residents, Thomas (1996)
feels that animals play a big role in the need for variety and spontaneity.
He states, the practice of leading life completely surrounded by artificial
enclosures and routines is a recent and unproven development (p. 29).
To promote the spontaneity component, animals create happenings which
in turn become stories to the residents, allowing for social interaction, thus
improving quality of life.
Thomas wrote that the Eden Alternative is a radically nonmedical
way of thinking about nursing homes. In practice, it substitutes a holistic
understanding of human needs and capacities for a medical model of care
driven by diagnosis and therapy (1996, p. 50). Taking this into

47

consideration, a study on the amount and costs of medications


administered to residents was completed over a period of 2 years in 1 test
and 1 control long-term care facility. In the test site implementing the
Eden Alternative, researchers found that medication costs were 38%
below that of the control site. This finding showed that the Eden
Alternative site spent less money on medications because they
administered less medication to residents. Since then, Thomas (1996)
reported that the site was able to cut medication usage from
$3.80/patient/day to $1.18/patient/day without putting the residents in any
harm. For one resident, just the daily routine of tending to the birds
proved more beneficial for her state of mind than her
psychotropic/tranquilizing medication did. Essentially, this novel concept
helped decrease costs while maintaining or improving the quality of life
among residents.
Thomas (1998) later conducted a 3-year study evaluating the
number of deaths among residents from an Eden site versus a control
site. He found that after 18 months of full implementation, the Eden site
had 15% fewer deaths than the control site. When the study approached
the 3-year mark, there were 25% fewer deaths. When coupling this with
the decrease in medications administered at the Eden site, one may
hypothesize that the residents there had many reasons to live.

48

Thomas has been on CNN, 48 Hours and USA Today both


describing and promoting the Eden Alternative vision and its many
benefits. In one of his educational videos, residents generally noted that
by living in an Eden community, the sound of birds makes them feel like
they are outside and felt that their lives were not organized around
treatments. Nursing home staff also mentioned that the Eden Alternative
promotes care for the whole humannot just the physiological part. It
was also noted that since the implementation of this concept has become
quite popular in numerous settings, that staff, volunteers and families have
become more involved.
Subsequent to Thomass research and wide-spread uprising and
implementation of this new concept, there have been numerous follow up
studies by geriatric health researchers. Coleman, Looney, OBrien and
Ziegler et al (2002), for instance, investigated the overall quality of life
after 1 year of Eden Alternative implementation at a long-term care facility.
They found that compared to a control site, there were fewer falls and
nutritional deficiencies at the Eden site. However, findings were not
apparent in areas such as cost savings, resident illness/infection rates and
cognition levels. Meanwhile, Barba, Tesh and Courts (2002) uphold that
future research efforts around the Eden Alternative should focus directly
on residents, staff and caregivers.

49

Although minimal, implementing an Eden project does pose some


risks, which include illness, injury, allergies, legal liability (i.e. tripping over
small animals) and regulatory sanctions. Animals carry illnesses; hence,
nursing homes strictly control the possible spread of disease. Thomas
(1996) reported that there have been no infections caused by the animals
at his facility and that all animals are put through rigorous behavioral tests
before being introduced into an Eden setting. This reduces the risk of
injury (i.e. biting, scratching) from the animals. Fortunately, it has been
found that as humans age, they experience less allergic reactions, as their
immune systems tend to repress the creation of an allergic reaction
(Thomas, 1996). The number of animals per square foot is much smaller
in nursing homes, and coupled with the air flow/filtering systems, the risk
of allergic reactions is very low. As for legalities and regulatory
compliance, inspectors and surveyors see the Eden Alternatives
therapeutic and positive impact on the residents, their families and the
quality of life. Thomas (1996) has urged nursing homes wishing to
implement the Eden Alternative to be proactive with inspectors and
surveyors and to ask them for advice and suggestions while keeping them
abreast of the undertaking. It should also be noted that most states allow
animals in long-term care facilities within limitations.

50

In implementing this conceptwhich usually takes 1 to 2 years


long-term facilities must have a certified Eden Associate on staff. To date,
over 400 people in the United States have underwent Eden-associate
training. Over the course of a 3-4 day training session, Dr. Thomas
teaches associates the 10 core Edenizing principles and specific
implementation guidelines. There are currently over 300 long-term care
facilities committed to fully practicing the Eden Alternative in the United
States. However, there are hundreds of other nursing homes who have
implemented just certain aspects of the idea. The Eden Alternative
continues to grow in popularity, as adult day care services, home health
care and assisted living situations have also shown avid interest in the
concept (Thomas, 1996).
Before introducing animals into a long term-care setting, it is
imperative they undergo a thorough veterinary exam and are licensed. A
preliminary survey of the preferred species of animals is administered to
residents; however, golden retrievers and greyhounds have been two
commonly recommended dogs. It is recommended that the facility obtain
a mixture of sizes and breeds of the animals for variety. The Eden
Alternative also strongly suggests that animals are first fostered, as it is a
vital component to the animals stress level, adaptation and transition into
the setting. In some cases, the facility will work with an animal

51

behaviorist. The following list was developed as a general guide in


considering and selecting the number of animals to place in nursing
homes:

One dog per every 20-40 residents; dogs should be


obedient, good mannered and reliable;

One cat per every 10-20 residents; cats should be healthy,


well-tempered and mature;

One to two birds per each resident; birds are generally safe,
cost-effective and long lived; and

Fish tanks should be placed where groups of residents


commonly gather (Barba, Tesh and Courts, 2002).

In his guidebook, Arkow (1998) listed 7 key benefits of


implementing animals into any facility:
1. Animals provide a more natural, home-like environment;
2. Residential dogs provide security and deter intruders;
3. Publicity and public relations about the facilitys unique
program are increased;
4. AAT programs are cost-effective and need minimal funding;
5. Interdisciplinary cooperation among involved professionals
to focus on one common is present;

52

6. An opportunity exists to involve and educate outside groups;


and
7. An opportunity exists to work with other health care facilities.
Once animals are introduced and a general pet-affiliated program is
fully established, a health care facility can market the fact that they are
unique in offering a different setting for their patientsa setting of caring,
compassionate and successful care for all involved. Its not just the
residents who benefit; pets also improve the well being of staff workers
and contribute to improved morale and lower attrition rates. Past studies
of animals in the workplace have found that they help promote a flexible
culture and friendly environment, help co-workers and customers relax
and make the work setting less stressful. In a study by Carmack and Fila
(1989), health care staff positively commented that they were able to
spend more time with patients and that the animals helped reduce their
own stress levels in a busy setting. Animals encourage increased
interaction and socialization between patients, staff, families and visitors.
Winkler, Fairnie, Gericevich and Long (1989) found this to be true among
nursing staff in a nursing home study. In a more comprehensive study by
Wells and Perrine (2001), 193 employees from 31 different companies
noted that they saw the presence of animals in the workplace benefiting
the company as a whole and reported that it was a good way to decrease

53

stress levels among employees. Incorporating animals into the work


culture can lead to happier employees and subsequently less turnover.
Although somewhat controversial, prisons are increasingly utilizing
animals in internal vocational training programs. Some inmates have
allowed and requested pets to aid them throughout rehabilitation and the
behavior modification process. The concept of inmates training dogs was
first proposed in 1980. After an 11-week training program at a pilot prison,
the prison psychiatrist reported that the inmates were overall more
cooperative with prison life and duties and also had more self-control
(Arkow, 1998). The concept of having pets in prisons rapidly spread, and
much additional research took place thereafter. In a study among female
prisoners, dogs were introduced for training purposes as part of the
womens rehabilitation process. Once trained, the dogs were provided to
elderly people and individuals with disabilities. The program outcome
showed a positive increase in the psychological and emotional well being
of the women prisoners (Anthrozoos, 1994). In recent years the idea of
using prison inmates to train dogs for people with disabilities has quickly
spread.
Fitzgerald (1986) reported on a study where animals were
introduced into a prison setting for the criminally insane. The program
was successful in increasing the morale and improving communication

54

among 375 inmates. Further, Fitzgerald (1986) also found that with the
introduction of animals into the prison, violence, suicide attempts and
destructive behavior decreased. AAT researchers Connor and Miller
(2000) announced that their future research efforts may focus on the
possibility of inmates training dogs for adoption from local humane
societies.
Although it is not essential for animals to have verbal
communication from their human owners, a University of Pennsylvania
study found that 98% of pet owners actually talked to their pets (Glass,
1996). Glass also reported that there has been research indicating that
most animals understand emotion and have compassion, as when
animals show compassion and seem to understand how you feel, you
have a tendency to communicate with them much more (1996, p. 15).
Glass elaborated subsequent to the study that animals have helped those
who continually repress their emotion, as dogs in particular have been
very helpful in motivating people to express themselves (1996). As stated
previously, this was recognized and documented during Levinsons
psychological sessions. In order to effectively communicate with their
pets, humans need to demonstrate ongoing respect, appreciation,
understanding and body language.

55

Pets as Prescriptions
For some time, physicians have been encouraging pet adoption
and recommending pets to people who are lonely or who have
experienced a great loss. The most common prescribing specialties are
oncology and cardiology, and the pets most often recommended are cats,
dogs, birds and fish. One physician cited by Cross (1998) stated that
anytime you can use a pet with a person who feels isolated, it helps make
a connection for them in the world (p. 60).
More often than not, physicians prescribe pets in order for patients
to have a quicker and better recovery. In fact, a local psychiatrist often
suggests pet adoption to her cancer patients who are experiencing
symptoms of depression as well as other patients having invisible
disabilities (J. Lipton, personal communication, April 29, 2005).
Physicians not only have prescribed pets for psychological reasons, but
for physical reasons as well. For example, walking a dog is great
exercise, petting or playing fetch with a pet helps strengthen injured
fingers and limbs, and simply playing with an animal improves motor
coordination.
In the Kal Kan Report (1986), almost half of all responding
physicians, psychiatrists and psychologists reported they had prescribed
or recommended pets to people between the ages of 50 and 65 who were

56

lonely, depressed or stressed. These respondents also prescribed pets


almost as frequently to people aged 66 to 80. Nearly 10 years ago, Folse,
Minder, Aycock and Santana (1994) found an association between contact
with animals and low depression levels among college students. In a
study involving 148 young single women living alone, Zasloff and Kidd
(1994) found those living with no pet were significantly lonelier than those
who did own a pet. Regarding psychological health, there have been only
a handful of studies over the years finding no significance or links among
pet ownership and enhanced psychological status.
Besides recovery, animals are increasingly proving themselves as
an aide in disease prevention and illness detection. Dogs, cats and even
various reptile species have been reported to caution upcoming seizure
onsets (Duncan, 1997). Dogs, commonly known for their sense of smell,
have recently been at the center of such research since the 1980s. In his
book of sensory modalities, Hughes (1999) reported, it is likely that dogs
can detect certain chemicals that may be associated with the onset of an
epileptic seizure (p. 9).
According to Cross (1998) retrained bomb and drug-sniffing dogs
have detected cancerous lesions on patients; a tiny percentage of these
dogs have been able to accurately and reliably forewarn. Researchers
are currently investigating what it is exactly that a dog actually recognizes

57

as cancerwhether it be a certain scent or simply the dogs natural


disposition and innate personality. Additionally, there have recently been
some reports on dogs alerting malignant melanoma and hypoglycemic
states in people with diabetes (Dalziel, Uthman, McGorray and Reep,
2003).
In some cases, dogs have been nearly 100% accurate in detecting
illness and oncoming seizures in epileptic patients. In fact, they can warn
anywhere from 15 to 45 minutes before onset of a seizure by picking up
on a persons change in body odor and electromagnetic fields, thus
allowing the victim to adequately prepare for an oncoming episode or seek
necessary medical assistance.
In an epilepsy study by Reep (1998), 3 out of 31 interviewees
reported their dogs predicted an oncoming seizure while 28% reported
their dogs maintained a close presence during seizure. Dogs in this study
tended to have close bonds with their owners and possessed quite
attentive temperaments. However, the study found their seizure-detecting
behavior to be erratic and spontaneous, and no certain type of breed
stood out as better than another. In a similar study, Kirton, Wirrell, Zhang
and Hamiwka, (2004) surveyed families with epileptic children. Out of
40% of families who owned dogs, 40% of the dogs responded to seizures
in some waywith 40% of them displaying alerting behavior prior to onset

58

of a childs seizure. The authors concluded that forewarning occurred


early and that there was a higher quality of life in families owning a dog
that illustrated seizure-specific behavior.
Support Dogs, a Britain charity that trains dogs for the disabled,
claims they have successfully trained over 20 dogs for seizure alert
purposes (Strong and Brown, 2000). Through prior training, each dog was
able to accurately, reliably and consistently forewarn of an oncoming
seizure in his or her owner from 10 to 45 minutes beforehand. This
training process took up to 6 months to complete and produced no
negative results (training can sometimes take up to 2 years). In a follow
up publication, Brown and Strong (2001) speculated it was subtle changes
in human behavior that alert the dog prior to any seizure onset. In yet
another follow up study, these same authors also went on to find a
decrease in the overall incidence of seizures, in which they hypothesized
that that simply owning a dog for seizure alert purposes in turn gives the
owners more independence, freedom and lessens the fear of their illness
(Strong and Brown, 2002).
In a preliminary seizure-alert dog study by Dalziel, Uthman,
McGorray and Reep (2003), 31% (9) of 29 epileptic dog-owning
respondents reported their dog helpful in responding to seizures. Three of
these dogs actually predicted the onset of the seizure in this population an

59

average of 3 minutes prior to the incident. As for cautionary behavior, the


dogs reacted as to whine, bark, pace or stare. In support of Reeps (1998)
previous findings, again no breed was better than the other. Other
interesting findings from this study were that dogs were more likely to alert
people who had complex partial seizures, migraines, dizziness, nausea
and faster breathing rates (Dalziel, Uthman, McGorray and Reep, 2003).
To date, most research on the topic of illness and seizure detection
has been anecdotal and testimonialsome believe an animals familiarity
and attachment to his or her owner aids in perceiving subtle changes prior
to a seizure. Very little research on this topic has actually been
completed. Further advances in medical research are possible with more
in-depth scientific and longitudinal research on this topic. Dalziel, Uthman,
McGorray and Reep (2003) reveal that sophisticated scientific research on
canine sense of smell and hearing has focused primarily on the
development of detection devices and that the results from these studies
are top secret and unavailable to the public and other researchers due to
proprietary issues and military funding.
Past evidence from animal behavioral experiments through
observation suggested that animals sense environmental events in a way
different from humans (Hughes, 1999). Regarding sensory modality,
Hughes (1999) states in his book:

60

Rather than ESP, perhaps we should call these internal


sensory systems our sixth sensea sense beyond the more
familiar modalities of vision, hearing, touch, taste and smell.
What are these new sensory modalities? Well, first of all,
they are not new. Their possessors have been relying on
them for millions of years. Its just that weve discovered
them only since the 1970s and 1980s. But newness aside,
they include such hi-tech systems as biological sonar
systems, sophisticated navigational systems and senses
based on electrical fields (p. 6).
The presence of animals in any given situation is a win-win
situation. Even dogs and/or other animals who are not especially trained
in seizure onset and alert procedures can help by simply being present
during and after the seizure by reorienting the victim and providing a
friendly and familiar face. Because seizure alert dogs are far and few
between, many dog training facilities are instead focusing on seizure
response dogs. Dogs trained in seizure response are able to help prevent
injury during seizures, bark to alert family members or neighbors, and to
activate alarm systems for calling medical assistance. Regarding seizure
detection, the Epilepsy Institute (2004) concludes the following:

61

1. Despite wide-spread publicity, relatively few people with


epilepsy report their pets having this ability;
2. Judging from the behavior of animals, more people with
epilepsy have reported seizure response than seizure alert; and
3.

Some accounts appear quite viable but warrant scientific


research to confirm seizure detection ability.

Horseback riding, or hippotherapy, has been used and prescribed as


a form of movement disorder therapy since the 1600s and focuses on
abilities rather than disabilities. The 1960s marked the first use of
hippotherapy in the United States. To date, there are over 500
hippotherapy centers in the nation with more than 26,000 riders (North
American, 1998). As a form of AAT, hippotherapy helps develop and
strengthen muscles surrounding the spine, as while riding, one is forced to
respond to the horses gait in a natural fashion. Obviously, an institutional
clinical setting is not necessary for this type of therapy. Through research,
physical benefits derived from hippotherapy are quite often improved and
enhanced hand-eye coordination, muscle strength, flexibility, posture and
balance. Those who ride have often experienced emotional and mental
rewards such as empowerment, self-esteem, patience and confidence.
Although hippotherapy helps relieve back problems, it is prescribed
primarily to those who are mentally and physically challenged and to those

62

with multiple sclerosis, cerebral palsy and/or spastic muscle disorders.


Monson (1995) reported that the motion and almost massage-like warmth
of the horses body helps to relax the tight muscles commonly found in
those who have multiple sclerosis. . . men and women who have always
been confined to beds or wheelchairs feel a sense of freedom as they ride
high above the ground (p. 99). To date, empirical evidence regarding
hippotherapy is limited and obscure; however, studies out of Europe are
rapidly becoming more available. Regarding spinal injury, dogs have also
been quite popular as through AAA and AAT they have promoted sensory
stimulation and perceptual improvements for those injurednot to
mention distracting one from his or her constant pain.
The use of llamas has shown to be beneficial in people who have
endured major trauma and stress, as this particular species has been
known to bond very quickly and easily to humans. In fact, research has
found that llamas help reduce stress levels. Studies have shown that the
use of llamas in prisons has been beneficial, while inmates who have
cared for them have demonstrated relatively low rates of violent behavior
during their first 3 weeks of prison life (Wickens, 1998).

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A Closer Look at AAT and Pet Visitation Programs


McCullouch (1985) outlined 4 different forms of human-animal
interactions. First, there is the actual full-time pet that resides in the same
home as the owner. Secondly, there is a visiting (or part-time) animal
companion available for scheduled visits per a facilitys pet visitation
program. Third, there are resident animals (or mascots) that live in group
homes or long-term care settings. Lastly, there is the specially trained
animal which is utilized to provide aid to those in need of physical,
emotional, cognitive or social therapy. The 2 most common types of
therapy programs the utilization of animals are pet visitation, or animalassisted activities (AAA), and AAT. The intricacies of these programs and
their recorded benefits are described in detail below. However, for
purposes of this project we will look more closely at AAT.
Animal-Assisted Activities. One way animals have been introduced
to long-term care facilities and hospitals is through animal-assisted activity
programs, also described as pet visitation or canine candy-striping. These
types of programs usually have multiple volunteers who bring the
patients, residents or their own animals in house to simply provide social
contact with hospital patients, nursing home residents and schools for the
disabled, encouraging hands-on interaction with the animals. Key
features of AAA as described by the Delta Society (2004) include 1) no

64

planned or specific treatment goals during visits, 2) volunteers and/or site


personnel do not take medical chart notes, and 3) content and length of
visits are spontaneous. The animals also provide forms of
communication, recreation and entertainment, as visiting pets provide a
break from a long, monotonous day and boost the spirits of those they
visit. Main objectives of a pet visitation or AAA program noted by Saylor
(1998) include:
1. To enhance social contact between patients and workers;
2. To decrease fear and/or anxiety induced by the hospital setting;
3. To provide recreational activities and decrease boredom; and
4. To revive patients spirits and lessen depression.
Over 600 United States hospitals are implementing some type of
AAA. A study by Hawley and Cates (1998) found that hospital patients
have benefited from their own family pets when brought in to visit. No
downsides or disadvantages to their pet visitation policies were reported.
Although beneficial to both nursing home residents and hospital
patients, Thomas (1996) feels that an AAA program at least 1 day per
week for 1 hour per day cannot provide the full benefits of an actual
resident pet. According to Thomas (1996), residents should have access
to and close, continuing contact with animals at any time and as much as
they wish, and goes on to say that the real value of the human-animal

65

bond comes from an enduring, caring relationship with a pet (1996, p.


38).
An Australian study recently studied the effect of a new pet
visitation program through the use of multiple surveys in one of its
hospitals and found that AAAalthough somewhat of a new concept in
Australiawas widely accepted among both staff and younger patients.
In fact, the allied health workers were more excited about the program
than non-clinical workers (Moody, King and ORourke, 2002). From this
study came a new tool developed by the researchers for use in evaluating
future AAA studies.
Saylor (1998), after successfully implementing a pet visitation (or
AAA) program at her Denver, Colorado medical facility, suggested some
general guidelines to follow when implementing a similar program:
1. Write a proposal specifically requesting permission to implement
the pet visitation program (outline risks and benefits);
2. Solicit support from staff;
3. State what type of animals will be used, discuss selection of
breed, how the animals will be used and who will participate in
visits;
4. Seek approval from infection control committee;
5. Describe screening criteria for all involved;

66

6. Determine infrastructure, program objectives and orientation,


policies and procedures, liability coverage and staff training;
7. Animal handlers must be responsible, qualified and committed
to scheduled visits; and
8. Animals must be clean and well-groomed with a good
temperament, and must be current with all vaccinations and
immunizations.
Typically, all AAA visits must be supervised. Dogs must be on a
leash at all times. Rabbits and cats are trained to stay in a basket carrier
so they can be passed among patients/residents. All visits should have a
reasonable time limit. Naturally, staff and patients should respect other
staff and patients who are allergic to or fearful of animals. Sizes and
breeds must first also be taken into consideration, as smaller dogs or
other animals may be considered less intimidating. Following are some
basic guidelines when preparing for AAA: 1) owner/handler must bathe
pet at least 24 hours before visit, 2) owner/handler must carry along pets
current record of vaccinations and immunizations, 3) pet must accompany
the handler on a leash or in a carrier at all times, and 4) pet can be asked
to leave at any time (Connor and Miller, 2000).
One example of an AA program is the Healing Paws AAA program
at Childrens Hospital and Regional Medical Center in Seattle,

67

Washington, which generally provides sick children a welcome distraction


and emotional comfort from the everyday hospital setting. The program
has been in existence for 6 years and uses dogs only. The dogs must be
at least 2 years of age and be Delta-trained and approved. There are 6
teams of handlers/volunteers who bring their dogs to the hospital on
rotating schedules. All hygiene and infection rules and regulations are
strictly followed, and dogs are forbidden to visit young patients who are
immunosuppressed, in isolation or undergoing transplants. Staff has been
very receptive thus far and the program has been especially successful in
the rehab and psych units (R. Frankel, personal communication, October
12, 2004). An outline of this program is available in Appendix A.
Saylor (1998), noted previously, states her Denver AAA program is
different than others because:
Patients are gathered in one designated area rather than
having pets go from room to room. The rationale is that a
central gathering gets patients out of their rooms and gives
them an opportunity to share their pet stories with other
patients and visitors. This allows for social interaction for
patients who are a long way from home and who may never
have any visitors (p. 36).

68

Giuliano, Bloniasz and Bell (1999) reported promising results from


a pet visitation program they implemented in their facilitys critical care
unit:
Implementing a pet visitation program for critically ill patients
affords healthcare providers the opportunity to offer a unique
and humanistic therapeutic intervention to appropriate
patients. Although it is a time-consuming endeavor, it has
been well received by those patients and families that have
participated in pet visits (p. 49).
Overall patient satisfaction was also found subsequent to AAA
implementation in a pediatric cardiology inpatient unit, as 30 young
patients reported feelings of normalization and relaxation supported by
lower heart and respiratory rates (Wu, Niedra, Pendergast and McCrindle,
2002).
AAA has also been used in school settings in more recent years, as
a Texas woman frequently brings her 2 dogs to an elementary school in
order to provide a form of stress relief and comfort to young students.
Research has shown that introducing animals to children early in life
produces positive outcomes later in lifesuch as responsibility, emotional
stability, sensitivity, empathy, tolerance, nurturance, self-control, selfesteem and coping with the life/death experience. For example, a

69

Seattle, Washington library program entitled Reading with Rover helps


instill confidence in youngsters as they read to a dog.
From pre-school to adolescence, animal companions act as
playmate, protector, listener and friend. In times of anxiety or sadness,
children have often turned to their animal companions for support. In
1985, Kidd and Kidds study found 90% of 3 to 13 year olds reporting
positive outcomes from pet ownership such as unconditional love,
acceptance, happiness and comfort. Nearly half of 285 early teens
reported interacting with their pet while upset (Covert, Whiren, Keith &
Nelson, 1985). Further, a study by Triebenbacher (1995) discovered that
owning and having contact with pets in early to late adolescence
predicated more involvement in school-based activities than students of
grade school age. Animals in the classroom also help motivate students
in learning about different breeds and care of the animal, tricks, training
and handling, and about the human-animal bond and responsibilities of
pet ownership.
Various handlers also brought their dogs on site to interact with
traumatized students after the 1998 Springfield, Oregon shootings and the
Columbine shootings of 1999. More schools are incorporating the use of
animals in their counseling office, as research has shown this decreases
student anxiety levels and promotes more participation during individual or

70

group counseling therapy (Chandler, 2001). Chandler summarized


incorporating animals into school counseling services can make for a
trusting bond between counselor and student, can help students focus on
the issue at hand and can also help them get in touch with their feelings
(2001). Studies have also shown that children who have pets in their
household are more likely to participate in extracurricular activities, sports
and hobbies.
Animal-Assisted Therapy. One step beyond pet visitation (AAA) is
animal-assisted therapy, where certain facilities such as but not limited to
rehabilitation, post-operative, acute care, hospice and social work
introduce 1 or more animals into a formal physical therapy treatment plan.
AAT is not a separate field of practice altogether; it is a goal-oriented
modality which is incorporated into a patients treatment plan. An
occupational therapist named Shari Bernard introduced the use of AAT
specifically for the physically disabled population in 1985. AAT programs
are usually managed and carried out by skilled, health care professionals
and animal handlers as part of a normal clinic schedule and notes are kept
in the patients medical record. Site volunteers play a major part in this,
too. Depending on the facility, credentials of the therapists and the
patients insurance, AAT may or may not be billable to a third party payer
or reimbursed the same way as any other clinical therapy. Interaction

71

during an AAT session is usually one-on-one between the patient and the
trained animalmost commonly a dog. Connor and Miller (2000) state
that work, sport and herd dogs should strongly be considered for AAT as
they have been found to stand out among the rest of the breeds in relation
to therapy work. The reason dogs are primarily used in AAT is because
their behavior is the most predictable and the easiest to test. . .
temperament and training of the individual dog are the two most important
factors in a great therapy dog (Connor and Miller, 2000, p. 23).
Key features of AAT as described by the Delta Society (2004)
include 1) objectives and goals are specific for each individual, and 2)
patient progress and development are evaluated. McCulloch (1983) also
recommends having a plan in place to coordinate AAT with other
treatment modalities, to prepare a cost-benefit analysis and to maintain
realistic expectations throughout the program. Animals used in AAT can
be any size or breed, however, it is essential that they like to be around
people, be well trained/well mannered and have a stable temperament
and disposition.
Therapeutic benefits these animals are capable of providing via
therapy can include petting, feeding, attaching a collar, brushing and
walking to improve range of motion and motor coordination. Giving
obedience commands can help improve speech skills. Opportunities to

72

recall details and describe past pets can help enhance cognitive, memory
and social skills, as well as can comparing 2 totally different pets. AAT is
a goal-oriented intervention program. Primary goals of AAT include:
Physical
-improve fine motor, ambulatory and wheelchair skills
-improve vital signs, standing balance and equilibrium
-auditory stimulation
Mental
-increase verbal interactions, attention skills, memory recall
and self-esteem
-develop recreational skills
-reduce loneliness and/or anxiety
Educational
-increase vocabulary
-improve memory and understanding of sizes, colors, etc.
Motivational
-improve involvement in social interactions/activities
-increase exercise
-develop trust (Delta Society, 2004).
As stated previously, AAT programs are utilized in a wide variety of
settings. For example, critical care units incorporate AAT specifically for

73

enhancing communication skills among patients, relieving stress in the


unit or rebuilding or improving cognitive skills and range of motion
exercises. Rehabilitation departments commonly use AAT for re-teaching
and relearning activities of daily livingsuch as muscle control, balance
and coordination. For hospice and psychotherapy patients, AAT lends
itself to less stressful situations and unconditional love and approval.
Other benefits from overall AAT interaction include empathy, outward
focus, nurturing, rapport, acceptance, entertainment and socialization
(Delta Society, 2004).
Schulte (2002) provided the following theories on how AAT works:
1) animals are comforting and remind patients of home, 2) animals
contribute to a natural environment, 3) animals are non-threatening, nonjudgmental and forever accepting, 4) animals provide the opportunity for
exercise, play and laughter and 5) animals provide a link to reality.
Specifically for mental health treatment, some activities within AAT are for
the patient to teach the animal a new trick, to learn about the care, breed
and feeding of the animal, to recall and repeat information about the
animal to others, to learn how to gently handle the animal and walk it on
its leash, to give the animal affection, to observe and interpret the
animals behavior, to practice assertiveness/confidence training and to
follow a set of instructions in an activity with the animal.

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AAT programs are increasingly gaining legitimacy, popularity and


acceptance in hospitals, long-term care facilities and rehabilitation centers
most commonly among trauma survivors, the elderly and children with
disabilities. In fact, Jorgensen (1997) states the following about the
introduction of animals into therapy. . . the potential to use animals as a
therapeutic intervention exists on many levels and the concept of animal
assisted therapy should be considered. From pediatrics to geriatrics,
acute-care facilities to community health, and from prevention to healing,
the human-animal bond can be integrated in a holistic approach to care
(p. 249).
AAT is offered on either a group or individual basis for those
needing therapy and should be evaluated in order to determine its
efficacy, which is the purpose of this project. As cited by Allen, (1998),
Pat Gonser, founder and director of Pets and People, stated that any
activity that an occupational or physical therapist prescribes, we can
duplicate with an animal (p. 34). On the contrary, few others claim that
pet interactions and activities cannot replace traditional treatment
modalities and that AAT should only be used in the event that all other
treatments fail; utilizing animals in this way is simply adjunct or alternative
to the already existing programs.

75

Because of such positive feedback and results from past AAT


studies showing the relationship between humans and animals, over
2,000 AAT programs have been established in United States hospitals
and nursing homes over the past 25 years. According to Voelker (1995)
the most common AAT programs are aimed at rehabilitation and
psychotherapy. There has even been some research in the past 20 years
involving marine animals in dolphin-assisted therapy in order to determine
if they can heal by ultrasound or if it has an effect on human biological
tissue (Brensing, Linke and Todt, 2003). For example, a 1989 study
among autistic children resulted in improved language skills and attention
span while in the presence of dolphins (Nathanson and de Faria, 1993).
However, further research is needed to determine if dolphin-assisted
therapy is more beneficial than traditional AAT. In any case, Barba (1995)
stated that an implementation of any AAT-related program is very costeffective.
Children with chronic medical conditions visit the doctor and are
likely to be hospitalized 4 times more than healthy children (Newacheck &
Halfon, 1998). For this population it is important to enhance and maintain
the quality of life by utilizing AAT. The use of fish aquariums and AAT
among young children with attention deficit hyperactive disorder (ADHD)
has been proven worthwhile, as youngsters are more cooperative and

76

focused in classroom learning (Katcher and Wilkins, 1994). According to


a study by Martin and Farnum (2002), children aged 3 to 13 with pervasive
developmental disorders (PPD) can also benefit from AAT. Ten young
participants underwent a series of tri-weekly AAT sessions for nearly 4
months which usually resulted in increased talking, laughter, focus,
liveliness and energy level. This study is a start, but indeed shows
promise for young patients with PPD. Research around the
implementation of an AAT program in a Quebec pediatric oncology unit in
1999 has recently reported on the quality of this program, where patient
well-being, adaptation to the hospital environment and signs of alleviated
psychological distress in patients, parents and staff have become
apparent (Gagnon et al, 2004). The overall effectiveness of this particular
program involving children with solid tumors is currently being researched
as part of phase two.
Cole and Gawlinski (1995) evaluated patients in an intensive care
unit over a period of 6 months incorporating AAT where volunteers made
over 120 visits. Survey results indicated that patients had lower levels of
loneliness and higher levels of calmness and happiness. Patients also
indicated they would definitely recommend AAT to friends and family, if
needed. In fact, a later cardiac care unit survey reported half of its

77

patients would rather choose a hospital allowing some form of pet


visitation than one that did not (Khan and Farrag, 2000).
Institutionalized psychiatric inpatients have been the topic of much
research, more recently including AAT-specific studies. For example, an 8
month pre and post-treatment crossover design study including 230
middle-aged inpatients with various psychiatric disorders underwent either
an AAT session with a dog or a general recreational group therapy
session. Inpatients with multiple psychiatric problems who participated in
weekly AAT sessions reported much less anxiety and minimal mood
swings compared with the control group, in which the authors conveyed to
be quite statistically significant (Barker and Dawson, 1998). Similarly,
levels of socialization, communication, engagement and affect/mood
showed overall improvement in a psychiatric unit setting over a 3 and onehalf year period for over 2,000 patient contacts (Howie, 1994).
Barak, Savorai, Mavashev and Beni (2001) later conducted a casecontrol study among 20 geriatric schizophrenic inpatients where AAT was
implemented in order to affect social contact and verbalization, mobility
and activities of daily living among patients. Over a period of 1 year, AAT
via dogs and cats occurred once per week in 4 hour intervalseach
motivating the patients in the brushing, feeding, walking and bathing of the
animals. Subsequent to data analyses, findings of this study showed

78

substantial social contact among this study population and improved


activities of daily living. A few years later via a 9-month period of pre and
post-testing, Kovacs, Kis, Rozsa and Rozsa (2004) found significant
results regarding the rehabilitation of middle-aged schizophrenic patients
in a social setting. Nathans-Barel et al reported similar findings such as
improved rehabilitation, motivation and quality of life in a more recent
study involving chronic schizophrenic patients (2005). Moreover, a similar
pre and post-treatment AAT intervention among 58 elderly psychiatric
inpatients of varying disabilities had occurred some years previous
resulting in somewhat improvedyet nonsignificantbehavioral
tendencies (Zisselman, Rovner, Shmuely and Ferrie, 1996).
Per further research, an AAT program at the University of Texas
has been currently studying whether or not including therapy dogs upon
patient discharge would be beneficial in motivating the patient to
remember what functional techniques to use in everyday living. Connor
and Miller (2000) have suggested that pain medication, ventilator weaning,
functional improvement, length of hospital stay and body image are priority
topics of much needed research around AAT.
Not everyone feels the same way about animals, as staff must be
aware of the fact that there are going to be patients and staffdue to
various backgrounds, cultures and valueswho do not want to be around

79

animals, who are fearful of animals, or who do not enjoy animals. In


response to this fact, institutions have set ground rules to protect the rights
of those who do not want contact with animals. This works both ways as
well, as one must not force a therapy animal into performing or repeating
any activities they clearly dislike. Good animal handlers are able to
quickly recognize signs of stress in their animal and take action to
minimize or eliminate it.
AAT provides the opportunity for patients to bond emotionally with
animals, which in turn speeds up their recovery process. While AAT takes
place, Kaufmann formally states the animal is not an object or tool to be
used, but an active partner in a relationship (1997, p. 7). This was very
apparent in observing some formal AAT sessions at a local childrens
physical therapy clinic near Seattle, Washington. Both sessions were
hourly and held back-to-back; the first with a new 10-year old patient using
a walker and the next with a returning 7-year old patient who was born
premature and was told that he would never walk. Both patients had been
undergoing AAT for several years. AAT sessions at this clinic are typically
held twice per month. Within these sessions there are several 10-minute
activities that the patient can choose from, such as:

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1. Play catch/fetch: patient asks handler if he/she is ready (patient


must use handlers name and make eye contact) and throws ball
for dog to fetch.
2. Dog-a-pult (similar to catapult): patient asks handler if he/she is
ready (patient must use handlers name and make eye contact) and
places ball in catapult device for dog to activate and catch. Patient
speaks command for dog to go.
3. Dog jumps through hoop: patient chooses toy for dog to
retrieve and brings it to animal handler. Patient holds hoop for dog
to jump through to retrieve toy and speaks command to jump.
After dog jumps through hoop, patient must place hoop on floor and
jump in and out of hoop.
4. Soccer/kickball fetch: patient must retrieve soccer ball from toy
bin and ask handler if he/she is ready (must have eye contact and
use handlers name). Patient kicks soccer ball for dog to fetch,
while alternating foot from left to right every other kick.
5. Hide food from dog: patient must tell handler to cover dogs
eyes. Patient walks around playground to hide doggy treat(s) and
commands dog to go find it when finished.

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6. Feed dog water: patient retrieves dog dish, opens water bottle
and pours water into dish. Patient then uses sign language
commanding dog to drink.
Each activity incorporates the patients cognitive, physical,
emotional and social abilities. At the beginning of each activity the
therapist explains the rules. Returning patients will be asked if they
remember the rules from their previous visit and to recite them.
Throughout the activities the therapist and handler continually ask the
patient thought-provoking questions relating to the activity at hand such as
How many more throws should we do?, How many kicks have we
done?, Whose turn is it? or How many balls has the dog caught?
Positive reinforcement is continuously used throughout the session and
clearly patients concentrate on their abilities rather than limitations (L.
Adams and M. Wolf, personal communication and observation, December
16, 2004).
Another handler and dog visit 5 different facilities a week and see
up to 20 patients a day. Over half the time, the visits are goal-oriented
sessions in the rehab and/or psych units. Of note, an experienced handler
will be able to easily recognize when his or her dog is getting tired or
stressed out from the visits, as they exhibit shallow panting or become
fidgety. If this is the case, a break is in order for both dog and handler (C.

82

Dudzik, personal communication, November 1, 2004). It is to everyones


benefit to maintain the dogs regular schedule before performing AAT.
AAT can be used for any age group at any time during a hospital
stay. Although AAT differs from facility to facility depending on its patient
needs, Ouhl (2004) listed some general guidelines to follow when
considering the implementation of an AAT program:
1. Learn about the organizations insurance liability coverage
concerning animals;
2. Search for already existing policies and procedures around
incorporating animals into a health care setting;
3. Have the animal evaluated by a certified therapy animal advisor;
4. Check with facilitys insurer and/or attorney about incorporating
animals into a health care setting;
5. Consult experiences of other health care facilities in the area
that already have AAT programs in place; and
6. Obtain appropriate AAT training and/or implementation
resources.
It is imperative that all facilities implementing and maintaining an
AAT program have a policies and procedures manual which outlines the
appropriate and necessary criteria of how to properly conduct an AAT
visit. Liability insurance of the animal is usually an organizational

83

requirement more often than not. Certification and/or registration of the


animals is required, as proper training and certification ensures more
consistent and predictable behavior. Typically, animals undergoing
consideration and training for AAT should be at least 1 year old, followed
by an obedience program. Connor and Miller (2000) note that:
Temperament begins at birth. Well-socialized animals are
more comfortable in strange places, are easier to train, and
adapt better to changes in their environment. Potential AAT
animals should be exposed to every busy situation possible.
They should be walked around schools, shopping centers,
and pet storesanywhere with lots of activity and people.
Therapy work is stressful for an animal, so socialization is
key to help expose a potential therapy animal to all possible
stimuli (p. 24).
Not only is it important to have a well-adjusted and obedient
therapy animal, but it is equally important that the handler be an excellent
candidate in doing this type of work in addition to bonding with the animal
him or herself. Animal handlers are critical to the success of every AAT
programs. Both animal and handler make up and eventually qualify as a
team, who in turn gets evaluated on their working relationship in regard to
carrying out AAT-specific work. Although qualifying criteria varies from

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program to program, the team must generally undergo a probation period


and perform a set number of AAT sessions in order to become official.
Likewise, the team must typically complete a set number of AAT sessions
per year and undergo recertification every 2 years or so in order to stay
current.
There are over 180 organizations in the United States in some
shape or form dedicated to AAT. Therapy Dogs International (TDI) is the
largest organization providing services to the ill and disabled. In the
United States, Canada and the Bahamas, TDI has over 9,000 dogs in their
dog therapy programs (Swift, 1997). In the United Kingdom, where there
are nearly 15 million dogs and cats altogether, over 4,000 are therapy
dogs and cats actively working in hospitals (Khan and Farrag, 2000).
Additionally, a London-based Pets as Therapy charity program has 9,000
pet owners who share their pet with hospice and hospital patients.
Another London-based non-profit agency called the Hope Project has
been providing pets and veterinary care to its homeless population for the
past 14 years. Likewise, the Doney Clinic in Seattle, Washington has also
been providing veterinary services to the homeless and their pets since
1989.
A Boston, Massachusetts organization called Helping Hounds, Ltd.
has been serving seniors in long-term care facilities, people with brain

85

injuries and Alzheimers disease, the chronically ill and the mentally
challenged. The organizations goal is to improve the quality of life for
people with those disorders and/or diseases. Willis (1997) stated that the
New England Assistance Dog Service rehabilitation program has a similar
concept with an 88% success rate, primarily serving people with severe
disabilities.
Two popular dog visitation programs in Minnesota include Bark
Avenue on Parade and Pals on Paws. Volunteers from these
organizations provide friendly dog interactions to those who are elderly, ill
and disabled. They also bring the dogs to long-term care facilities,
hospitals and senior community settings in order to promote cheerfulness
and optimism among staff, visitors and patients. A similar program called
POOCH (Pets Offer Ongoing Care and Healing) has been quite popular at
Cedars-Sinai for a number of years. Paws Across Texas provides
companion dogs and volunteer handlers especially for AAT purposes.
Also of mention are the Skeeter Foundation and the Chenny Troupe, 2
important organizations that encourage and fund AAT research.
Although pet food companies have financed research studies in the
past, current funding to study the health benefits of animals has been
quite minimal, as research grants have usually been only in the ballpark of
$10,000 or less (Monson, 1995) and the NIH has been known to turn

86

down proposals initiated by panels of blue ribbon experts. As cited by


Monson, (1995), Beck sadly stated that most investigators are not
interested in studying the human-animal bond and its benefits (p. 99).
One would wonder why this is, as Dossey (cited by Cross) stated that . .
.evidence favoring the health value of pets is so compelling that if petfacilitated therapy were a pill, we would not be able to manufacture it fast
enough. . . it should be available in every hospital, clinic and nursing home
in the land (1998, p. 60). Although it has been thought that the
psychological benefits are difficult to measure and quantify, due to its
miraculous results and improvements, the demand and awareness for
AAT continues to grow and the need to attract funding continues.
Research and information associating animals with physical
benefits is still unfinished, as many studies have shown that outcomes are
not directly related to any common pattern. Skeptics claim that it is
unclear if it is truly pets or the human volunteers and staff who are
contributing to the successes and improvements. However, more and
more literature suggests the utilization of animals has been useful and a
success. The number of those who do not enjoy companion animals
remains quite low, and the benefits exceedingly outweigh the risks.

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Risks and Problems Associated with AAT


As stated previously, the benefits of AAT significantly outweigh the
risks. In fact, Hart, Trees and Duerden (1996) found very few signs of
zoonoses related to AAT. However, when implementing and evaluating
an AAT program, one must nevertheless closely investigate the potential
risks, such as the threat of zoonotic diseases, hazards and infection,
unexpected animal bites and allergic reactions to fur, feathers and animal
dander. Possible transfer modes include experiencing direct contact (i.e.
bites, scratches), droplet contact, vector-borne contact (i.e. through
mosquitoes, fleas, tickets), and via airborne (Guay, 2001). According to
Haas (1987), Ettinger and Feldman (1993) the populations most at risk for
potentially contracting zoonoses include the elderly, those who are
immunosuppressed (i.e. undergoing treatment for HIV/AIDS,
chemotherapy or organ transplants) and the very young. Wong (1998)
devised the following list of the 11 most susceptible conditions:
1. Alcoholism / liver cirrhosis;
2. Cancer;
3. Chronic renal failure;
4. Congenital immunodeficiencies;
5. Diabetes;
6. HIV / AIDS;

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7. Immunosuppressive treatments for autoimmune diseases,


cancer and transplant recipients;
8. Long-term hemodialysis;
9. Malnutrition;
10. Pregnancy; and
11. Splenectomy.
For these populations, transmission rates can be controlled and
reduced by the number of infected animals on site, the route and
efficiency of transmission, patient characteristics, patient-animal
interaction and by preventive measures (Schantz, 1990). Cancer patients
generally must have a neutrophil count greater than 1,000 mcl in order to
be near animals (Connor & Miller, 2000). Further, patients who are senile,
developmentally disabled or who have traumatic brain injury may
unknowingly and unintentionally provoke animals. Each institution should
follow its own policies regarding the risk of AAT around vulnerable or
immunosuppressed patients.
For people with HIV / AIDS, experts claim that adult dogs or cats
are a better choice rather than younger puppies or kittenswho are still in
the playful stage and may exhibit play-biting or accidental scratching
(Downing, 1993). Sullivan (2000) lists precautionary steps for individuals
with HIV / AIDS to consider while being around animals:

89

1. Avoid reptiles;
2. Be around older, calmer dogs and cats;
3. Stay away from cats with FIV (feline immune deficiency virus);
4. Wash hands after petting or playing with animals;
5. Be informed about flea control; and
6. Ensure therapy animals are indoor animals.
As previously noted, the most common animals associated with
and trained for AAT are dogs, but because cats and birds are also used in
some instances and are gaining more popularity, zoonotic risks associated
with those species will be looked at as well. Haas (1997), Schantz (1990),
Ettinger and Feldman (1993), Hart, Trees and Duerden (1996) and Angulo
et al (1994) reported the most common zoonoses associated with dogs
are:

Fleas;

Bacteria from animal bites such as Staphylococcus aureus,


Pseudomonas and streptobacillius;

Foodborne bacterial diseases such as salmonella and


campylobacter;

Heart worm;

Hook worm;

Round worm; and

90

Tapeworm.

In the same article, however, authors Brodie, Biley and Shewring


(2001) were quick to indicate the overwhelmingly unlikeliness of dogs
posing the threat of potential zoonoses to staff and patients involved in
AAT due to very weak transmission rates. Good hygiene measures such
as thorough hand washing and required immunizations and vaccinations
of animals will allow safe AAT programs. In facilities where dogs are
allowed on patients beds, a sheet or padding of is commonly used as a
barrier in order to reduce the risk of any zoonotic transmission.
Although cats are not used as much as dogs for AAT, Haas (1997),
Schantz (1990), Ettinger and Feldman (1993), Hart et al (1996) and
Angulo et al (1994) reported the most common zoonoses hazards
associated with cats, which include:

Bacteria (cat scratch disease);

Protozoa Toxoplasmosis (Toxoplasma gondii);

Fungi; and

Ring worm.

Again, authors Brodie, Biley and Shewring (2001) point out that
good hygiene such as frequent hand washing, regular litter box changes
and feline diet control will result in weak transmission rates. In facilities

91

where cats are allowed on patients beds, a disposable cloth or sheet


serves as a barrier in order to reduce the risk of zoonotic transmission.
Regarding birds, the most common zoonotic diseases summarized
by Haas (1997), Schantz (1990), Ettinger and Feldman (1993), Hart,
Trees and Duerden (1996) and Angulo et al (1994) are:

Bacteria (Clamydia);

Salmonellosis; and

Influenza virus.

Generally, common hygiene measures taken to weaken the


zoonotic transmission between bird and human and should include
implementing strict hygiene policies, acquiring the bird(s) from a respected
and reputable source and frequent cage cleaning.
A note about fish and aquariumsthe spread of zoonotic disease is
well prevented due to the fact the fish are in a controlled and confined
environment. However, care must be taken and gloves should be worn
while cleaning the aquarium tank.
With the typical anxiety around rabies, the literature points out that
the risk of acquiring such a disease in a health care setting is very
minimal, as there are mandatory regulations requiring rabies vaccinations
for dogs in all states (Guay, 2001). Animals employed in AAT should be

92

kept indoors and closely supervised at all times in order to prevent bites
by a wild animal that may have the rabies virus.
The American Academy of Allergy, Asthma and Immunology (1995)
reports that 15% of the population is allergic to dogs and cats; however,
young children exposed to animals from birth to age 1 have lower
incidences of asthma and allergies later in life. In North America, 6% of
people seen by clinical allergy specialists have allergic reactions (i.e.
rashes, etc.) strictly from animals (Elliot, Tolle, Goldberg and Miller, 1985).
This is a relatively low percentage. Of course, precautions such as careful
and preliminary research regarding animal selection (cats cause the
majority of allergic reactions), obtaining a comprehensive patient
screening/history and frequent bathing and grooming of the animals can
all contribute to safe and successful AAT in a controlled and supervised
setting.
Just in the past 15 years, much more research has been dedicated
to the risks of zoonotic diseases among the sick and elderly. However, to
date little information has been published regarding the figures or statistics
reported on the number of bites from animals enlisted in AAT programs.
In the meantime, health care administrators and staff have simply noted
the most troublesome breeds. Actually, Guay (2001) reported that
spaying and neutering can decrease bite rates by two-thirds. Further on

93

this topic, Khan and Farrag (2000) reported that a California hospital had
zero zoonotic infections from 3,281 dog visits to 1,690 patients over a 5year period. Similarly, they also reported that a childrens hospital had no
increase in the rate of zoonotic infections or incidents over a 2-year
period.
From 1991 to 1993, no unusual incidents such as injury, accidents
or illness occurred from AAA and AAT at Saint Peter Hospital in
Washington, and only 2 minor injuries occurred in the third year of
implementation (Howie, 1994). Likewise, accounts from 50 state agencies
and 284 Minnesota long-term care facilities have shown that both visiting
and residing pets were safe for patients and residents in these facilities,
and that no serious incidents or allergic reactions were apparent for 1
yearexcept for 2 minor injuries (National Center for Biotechnology
Information, 2004). Currently, a University of Texas study is exploring this
topic further.
Authorities caution against obtaining an exotic pet for therapeutic
and casual purposes, as they are known to possess unpredictable and
aggressive behavior and are not meant to be kept as pets in captivity.
Exotic species could also quite possibly bring unknown diseases into the
United States. This has not stopped a London hospital, however, from

94

periodically bringing in such animals such as lion and tiger cubs, snakes
and various other reptiles to its patients.
Administering and maintaining rigid animal infection control policies
and guidelines and appointing appropriate committees to accurately report
incidents and/or injuries will help contribute to safe and successful AAT
program. An example of such policies from both Harborview Medical
Center and Childrens Hospital in Seattle Washington are included in
Appendix B. Once standards are in place, ongoing evaluation,
improvements and revisions should occur. AAT policies should not be
confused with service dog or assistance animal policies.
In addition to zoonotic concerns, the Delta Society warns that the
use of AAT may not be appropriate among groups of people having the
potential for jealousy, possessiveness or competition among the
animal(s). Furthermore, patients who are quick to demonstrate unrealistic
expectations related to their recovery may not be the best candidates for
AAT.
The review of literature has touched on the historical use of animal
companions and the demographics and characteristics of pet ownership
and pet attachment. It has also described in great deal the physical,
psychological, social and cognitive benefits derived from AAT. From
pediatrics to geriatrics, and throughout several different diseases and

95

disorders, readers have learned that AAT can indeed be a therapeutic


form of health care if implemented successfully. As with any new
program, organizational policies and procedures should be enforced in
order to lessen the risks associated with implementation.

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Chapter 3

Methodology
This study aimed to gather valuable information regarding the
effectiveness of AAT through the extensive planning, development and
validation of a new evaluation instrument. This initial research was
primarily of exploratory nature, as this initial undertaking intended to be a
starting point in which to conduct further AAT effectiveness evaluation
studies. The overall goal of this study was to produce a prolific, scientific
and functional AAT effectiveness tool for therapists and their animal
handler counterparts (sometimes called Pet Partner teams) who deliver
AAT programs. The hope is that this instrument, in final form, will be
useful in conducting and measuring the effects of AAT on patients, and
will be utilized on a much larger scale in the near futureperhaps to
someday satisfy third-party payment provisions. The primary study
objectives consisted of 1) characterizing the features of AAT programs
and procedures in the western United States, 2) thoughtfully planning and
constructing a valuable and scientifically-sound AAT effectiveness
evaluation instrument for therapist-handler teams delivering AAT, and 3)
testing the new tool in live daily practice in order to account for reliability
and validity issues.

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Prior to using the new instrument in the field, 11


consultants/evaluators in the AAT, human-animal bond and therapeutic
fields first dedicated their time and expertise in reviewing and judging the
draft AAT effectiveness tools content, clarity and validity, and provided
valuable advice regarding form quality and improvement in order to
enhance the flow and ease of use among those who would be delivering
AAT treatments and procedures. The Delta Society, an important
organization that studies human-animal interactions, was an active and
helpful resource throughout the preparation of this research and provided
direction and consultation throughout the remainder of the study. The tool
was kept to 1 page (double-sided) in length as not to have been
burdensome or laborious to participating therapists and handlers already
having busy travel and clinic schedules.
The initial research around proficiently developing a useful AAT tool
and accounting for its validity was a starting point and exploratory process.
Subsequently, utilizing the new tool tested the effectiveness of AAT by
estimating the adequacy and usefulness in the volunteer user group. At
this juncture, a study to design, implement and validate the new
instrument was the most useful and effective choice of design due to the
short duration of the project, the study goal, objectives and the given
population.

98

All research involves measurement and observation. Piloting new


evaluation instruments and forms are an initial and essential aspect of
sound research. In fact, van Teijlingen and Hundley (2001) justify this by
stating:
. . . Researchers have an ethical obligation to make the best
use of their research experience by reporting issues arising
from all parts of a study, including the pilot phase. Welldesigned and well-conducted pilot studies can inform us
about the best research process and occasionally about
likely

outcomes.

Therefore

investigators

should

be

encouraged to report their pilot studies, and in particular to


report in more detail the actual improvements made to the
study design and the research process.
For purposes of this student dissertation project, a multi-state
undertaking such as this was most appropriate due to the rigid university
timelines and lack of funding, additional staff and resources.
Van Teijlingen and Hundley (2001) also give the following reasons
that are applicable to projects such as this:

To develop and test adequacy of research instruments;

Assess the feasibility of a larger related study;

Establish effectiveness of the sampling frame and technique

99

Identify logistical problems

Estimate variability in outcomes to help determining sample


size;

Collect preliminary data;

Determine resources needed for a future study;

Assess proposed data analysis techniques to uncover potential


problems;

Convince potential funders that a future study would be worth


funding; and

Convince stakeholders that a future study is worth supporting.

The above justifications all contributed to carrying out a successful


study. Progressing through initial processes of evaluation tool
development while gathering meaningful data along the way on a topic
such as this will assist in designing more scientific and quantitative studies
in the future. Furthermore, it will help estimate future resources needed
for designing similar materials and for conducting larger prospective
studies.

Approach
In order to gauge interest, the Delta Society helped locate
appropriate AAT volunteer teams, therapists, and animal handlers from

100

the states of Washington, Oregon, California and Arizona. These initial


talks and meetings collectively resulted in buy-in, enthusiasm and support.
The call for volunteers (see Appendix I) was very well received throughout
the western states and 8 professionals agreed to lend their time and
expertise in testing the form in daily practice. Two were from Washington,
1 was from Oregon, 4 were from California and 1 was from Arizona (see
Appendix J for map). Some of the therapists and handlers offered to
approach and encourage their staff and colleagues to participate as well.
The ongoing and overwhelming interest, willingness, enthusiasm
and motivation among the volunteer therapists and handlers who currently
provide AAT to participate in this project were key in producing a
successful study. In addition, the Delta Society offered superior
consultative service, direction, educational resources and collaborative
efforts throughout the project, as they have long recognized the imminent
need of AAT evaluation and were eagerly anticipating the results of this
study.
In order to gather a historical perspective on AAT tool development,
relevant background information on a former AAT evaluation instrument
previously developed and modified by a group of researchers from Florida
Gulf Coast University (FGCU) was sought. Obtaining a historical
perspective from this group about their instruments overall developmental

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process, revisions and current utilization was most helpful in determining a


basis for this particular undertaking. For this project, FGCUs primary
instrument developer/researcher kindly consulted on the construction of
this studys new instrumentproviding necessary insight along the way.
Using FGCUs AAT instrument as a reference, along with various
Delta Society guidance documents, multiple pieces of relevant literature
and existing examples of AAT-related forms and questionnaires, the
investigator of this study drafted a new condensed AAT evaluation tool
version appropriate for a larger and more diverse patient population
undergoing AAT. A first draft (see Appendix F) of the new AAT
effectiveness evaluation tool was initially circulated among the
consultant/evaluators, as well as among the Delta Society, local therapists
and the researchers from FGCU for suggestions, modifications and
revisions before formal implementation occurred.
During a 6-week trial period, the volunteers who were utilizing and
delivering AAT implemented and tested the new AAT effectiveness
instrument in their daily practice. During that time, they completed the
new tool for each patient who was referred to and/or who utilized the
facilitys AAT program. Casting a broad net such as this enabled AAT
form users to capture a substantial amount of useful data on a widespread
patient population of varying abilities and conditions.

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Before implementation began, a 6-week supply of AAT


effectiveness evaluation instruments complete with instructions, a
log/tracking form and self-addressed stamped envelopes was provided to
the volunteers delivering AAT. The tools specific aim was to gather
important and relevant information in thoroughly measuring the physical,
social, emotional, speech and cognitive abilities of patients undergoing
AAT. In accompaniment to this form, the investigator included on a face
sheet the instructions for use, background information about the new tool
and study, and contact information in the event that there was a question
or problem during the trial period. As clinical and rehab facilities are
usually fast-paced and extremely busy settings, packets were prepared
and compiled as to create very minimal extra work and to not be
burdensome for the form users. Bimonthly reminders were made during
this time.
Tokens of appreciation such as thank you cards and PETCO gift
certificates were provided to therapists and handlers who utilized the new
AAT effectiveness evaluation tool. Information was held in strict
confidence during the data collection phase. Upon study completion,
results were grouped and reported in the form of aggregate summaries.
Further, a discussion was held with the Delta Society regarding the
feasibility of the new AAT tools future use on a larger scale.

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Data Gathering Methods


As stated previously, a group of expert consultant/evaluators
submitted comments, suggestions and revisions regarding content validity
from initial form distribution and review. All information was collected and
compiled after the reviewing process. After taking all comments into
consideration from the reviewers, the investigator modified the form
accordingly (see Appendix G) and prepared it for implementation among
the participating therapist and handler volunteers throughout Washington,
Oregon, California and Arizona.
After each AAT session, the volunteer users transcribed and
recorded appropriate data onto the new AAT tool. Patient/client names
were not revealed or recorded, as all forms were anonymous. However,
appropriate demographic data was obtained. Patients who had repeat
visits within the 6-week time frame were accounted for and coded
appropriately (see Appendix H). Upon retrieval, data was coded and
entered into a secure, password-protected Access database for end-ofstudy examination.
Once the 6-week pilot run commenced, the investigator conducted
in-depth personal interviews with the volunteer therapists and handlers
who were involved with implementing the tool in practice. Interviewing
these professionals helped gather meaningful and qualitative information

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in the informants own words in order to gain a description of how they


perceived the implementation of the AAT tool based on their own personal
experience. This group was also asked in an objective manner about any
general health benefits and/or improvements among patients that they had
witnessed in using the new tool, about the tools ease of use, their likes
and dislikes of the tool and any other useful comments related to the new
form. The investigator invited thought-provoking discussion from each
individual about overall implementation, form quality and content,
advantages and disadvantages of using the tool, methods to improve the
form and data collection in general (i.e. paper vs. electronic), and solicited
comments about using it as a standard guide on a larger scale for AAT
purposes (see Appendix D for research questions).
Methods in data collection depended on the users availability,
location and preference; interviews were held at the convenience of the
key AAT personnel involved in implementation with the option of
completing the interviews via phone, email or face-to-face. Field notes
(see Appendix K for template) were used in compiling the interviews, and
thoughts and words were written as descriptive summaries in order to
compare and contrast differing thoughts and opinions about the tools
overall validity.

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In addition to the personal interviews a brief, follow-up


questionnaire (see Appendix E) was sent to each professional who utilized
the tool in practicewith the option of completing it via email or regular
mail. The questionnaire was 1 page in length and contained many shortanswer and check-box responses in order to accommodate busy work
schedules and to facilitate timely completion. Self-addressed, stamped
return envelopes were provided. The questionnaire was voluntary and
questions were optional. The survey took under 5 minutes to complete.
Results from the short questionnaire were entered into a secure,
password-protected Access database for end-of-study examination and
reporting. In order to assess the new tools validity and reliability,
questions included but were not limited to perceived patient health
benefits, ease of form completion, extra time involved, form benefits, form
quality and content, user likes and dislikes, helpfulness to patient chart,
thoughts on future use on a larger scale and suggestions for text and
formatting improvements.
A post-implementation meeting with the Delta Society was held in
order to discuss the results of this research, including further AAT tool
modifications and improvements in order to best suit their future needs as
far as offering this as part of future training efforts or adding it to their
research library and website.

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Research questions for participating therapists, volunteers and


handlers delivering AAT around this studys goals and objectives included
open-ended questions such as:

How is AAT effectiveness currently being assessed/evaluated in


your daily practice?

Was the new tool useful in conducting therapy sessions?

Did using the tool make your job easier?

Was it easy to use? Burdensome?

Was the tool effective in meeting patient goals?

Did the tool appropriately address the 4 functional domains:


cognitive, social, physical and emotional?

Did the new tool help contribute to overall patient improvement?

What were the positive and negative experiences associated with


piloting the new tool? Advantages and disadvantages? Likes and
dislikes?

Was the tool too short? Too lengthy?

Do you think the tool would satisfy third party payment requests?

Did the tool measure what it was intended to measure?

Would you use this tool again? Would you recommend it to other
AAT professionals?

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How can the tool be modified, revised and improved? Should any
questions be discarded?

Database of the Study


All data were anonymous and not linked to any identified
participant. Over the course of this study the investigator held information
in strict confidence. If results of this research are published or presented,
information will be reported in aggregate form.
After the initial planning, drafting and circulation of the new
instrument among the consultant experts, comments and suggestions
regarding overall instrument improvements were compiled and grouped,
and are thoroughly discussed in Chapter 4. The tool in its revised and
testing format is available in Appendix G, reflecting modifications and
improvements submitted by the evaluators/reviewers. Descriptive tables
and text reflecting qualitative and meaningful information resulting from
key informant interviews and discussions about overall implementation of
the new tool in daily practice is organized, assembled, reported and
discussed in Chapter 4 as well.
Upon retrieval of the piloted and completed AAT evaluation
instruments, form data were coded and entered into a secure, passwordprotected Access database for end-of-study examination, illustration and

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discussion. One unique study ID number was generated per form


completed/received and a tracking log (Appendix H) was provided in the
case of any repeat visits (if applicable). Quantitative data resulting from
the piloted AAT evaluation tool was analyzed in an Access database to
later present in the form of queries, percentages, report tables and/or
descriptive statistics in Chapter 4. Qualitative data resulting from the tool
itself is arranged, discussed and reported in Chapter 4 as well.
Information from the brief follow-up questionnaires was transferred
into a secure, password-protected Access database for examination,
illustration and discussion. Quantitative data resulting from these
questionnaires was analyzed in an Access database by running queries to
tabulate the results. Brief table displays are presented in Chapter 4.
Qualitative data captured from the questionnaire is compiled, discussed
and reported as well.

Validity of Data
One of the most important steps in planning and developing a new
instrument was to determine it validity, or to ensure it measured what it
was intended to measure. The level of validity was affected by the
instrument itself, the questions that were asked, the behavior(s) assessed
and the qualifications of the users who tested the instrument; these factors

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were carefully controlled for throughout this research by ensuring that the
right questions were asked in the most appropriate and accurate way
possible.
In order to have a valid form it needs to provide dependable and
consistent results, or be reliable. Reliability constitutes validity, thus
producing a reliable tool during this research is of utmost importance. The
level of reliability was affected by the instruments length, objectivity and
knowledge and confidence of its users. These factors were controlled for
throughout this research as well, as a form that yields inconsistent results
would be unable to report accurate data about what is actually being
measured.
In order to accurately and successfully account for validity and
reliability issues, the investigator followed Benson and Clarks (1982)
systematic steps/phases in instrumentation development: 1) planning, 2)
construction, 3) evaluation, and 4) validation. A professional consultation
with an experienced psychometrician would have been quite costly and
time consuming, so relying on past and current psychometric literature
served as an adequate reference for purposes of this particular research.
Benson and Clark (1982) state that the most important phase in
instrument development and validation is planning, as this is where the
content and behavior to be assessed and user group are to be specified.

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While drafting and subsequently implementing this new tool, it


successfully measured the receptivity in and of itself among participating
and practicing therapists, volunteers and handlers. In the construction
phase, Benson and Clark (1982) first suggest a vast review of the existing
literature to ensure that a valid instrument does not already exist, followed
by the development of several open-ended questions and objectives
around the behavior to be assessed. In the case of this study, there were
little or no current appropriate and validated AAT evaluation instruments in
wide practice. As indicated previously, the purpose of this particular
undertaking was to develop such a tool. Following the construction phase
the form was piloted, thus gathering valuable critiques regarding form
length, time, content and clarity. Qualitative evaluations, interviews and
debriefing sessions among reviewers were both necessary and essential
steps in instrument development, as data collected from the trial helped
estimate instrument reliability and validity.
The following pilot study procedures outlined by Peat, Mellis,
Williams and Xuan (2002) were employed and followed in order to
improve the validity of this exploratory research and used in the planning,
development and validation of the AAT instrument:

Administer the instrument in a similar way as it would be in a


larger study;

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Interview reviewers for feedback to identify tool ambiguities


and difficult questions;

Record the time taken to complete the instrument;

Discard unnecessary, difficult or ambiguous questions;

Assess whether questions give an adequate range of


responses; and

Reword, revise or rescale questions that were not answered


as expected.

On average, participating volunteer therapists and handlers held


AAT sessions anywhere from once a month to twice a week.

Originality & Limitations of Data


Very few formal or valid AAT-specific effectiveness evaluation tools
are in existence for use for therapists and handlers. Therefore, only
minimal scientific data have been previously collected to determine the
therapeutic value of AAT for patients of differing capabilities. Clinical
therapists and animal handlers in facilities implementing formal AAT
procedures and treatments wish to collect AAT-specific effectiveness data
for making scientific attempts to measure the effects of their present AAT
efforts. Such information is needed to identify the outcomes of these
sessions, and many interested parties await these important research

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results. Original data collected from this initial exploratory research can
therefore serve as a starting point in which to build future related studies
and construct more comprehensive future AAT effectiveness evaluation
materials.
Research such as this does have limitations; instituting 1 test run to
estimate and evaluate reliability and validity issues does not fully
guarantee that the new AAT instrument tool will be a success. Along with
patience, validation requires continuous and focused efforts. Benson and
Clark state validation is a continual process, one in which an end point is
rarely achieved, but is only successively approximated (1982, p. 799).
Developing a scientifically sound instrument such as this for use by AAT
professionals was time consuming and will more than likely become a
work in progressrequiring multiple research efforts by many. Although
results from this implementation could allude to similar response rates in a
larger scale study, it cannot be fully assumed because there has been no
previous extensive statistical groundwork in this situation, and pilot study
numbers are usually smaller. Further, future roadblocks may not come
into full view until a larger, widespread and more comprehensive
undertaking is in the midst of being conducted.
Because the time allotted to complete this final paper was relatively
brief due to university requirements, data were unable to be collected in a

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longitudinal manner. As noted previously, the use and expertise of a


psychometrician required funding and extra time, so it was not considered
during this project. Further, obtaining support, cooperation and the
necessary approvals from several individuals involved in this research
took extra time. Thus, a 6-week period of data collection was indeed a
study limitation. However, all data were original and intriguing, as no
information has been previously collected in these particular settings and
for this particular purpose. Due to the timeliness of this research project
and the imminent need for formal AAT effectiveness evaluation, many
interested parties have eagerly awaited the findings.
To the investigators knowledge, an undertaking such as this has
never been executed in this particular manner. This is not a replicated
study; it is essentially of exploratory nature and an initial effort to collect
preliminary data, to build future longitudinal AAT related research upon
and to act as an educational resource for those wishing to evaluate and
improve their AAT practices. Upon the completion of this initial research,
further efforts should be made in determining the feasibility of using such
an instrument/tool on a larger scale.

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Summary of Chapter 3
This research was conducted in order to evaluate the effect of AAT
by designing and testing a newly developed AAT evaluation instrument.
Additionally, efforts were made to gather the attitudes, thoughts and
perceptions of therapists and handlers about utilizing the new instrument
in practice. Methods included analyzing anonymous data from the new
tool in both qualitative and quantitative fashions, holding personal
interviews and debriefing sessions with key therapists and handlers
following implementation, and administering a brief follow-up
questionnaire to this group of AAT tool users in order to account for
reliability and validity issues. The hope is that this new tool can be easily
modified and implemented on a larger scale in order to fit the needs of a
more universal audience consisting of AAT professionals and
organizations wishing to begin and evaluate their own AAT practices.

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Chapter 4

Data Analysis
As discussed previously, designing, testing and validating a new
instrument was the most useful and effective choice of design due to the
short duration of the project, the study goal, objectives and the given
population. Following an initial round of revisions by the form reviewers,
AAT experts such as therapists, social workers and Pet Partner volunteer
animal handler teams tested the effectiveness of AAT by estimating the
adequacy and usefulness of the new tool while in daily practice. They
then had the chance to convey their opinions and suggestions for
improvement via key informant interviews and a brief follow-up survey.
Upon retrieval of all study data, multiple queries were run and
common themes were extracted in order to accurately and successfully
account for validity and reliability. Each persons response to both the
interview and short survey were analyzed for common remarks, patterns
and themes, and also to identify and expose ambiguities and/or
unnecessary data fields in order to revise and rescale the new AAT
instrument.

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Discussion of Initial AAT Tool Revisions


The AAT tool in draft form (Appendix F) was initially circulated for
feedback among a select group of 11 expert reviewers and consultants
(illustrated in Table 1 below) from the physical therapy, occupational
therapy, social work and AAT fields to review and evaluate the content,
clarity, validity and format of the draft tool prior to its utilization among a
larger volunteer group in daily practice. Members of this panel were
chosen because each has vast and unique experience in their chosen
field and possessed expert knowledge about AAT and/or research design.

Table 1
Panel of Reviewers

Role
AAT Trainer/Consultant

Geographic Location
Washington

AAT Instructor/Evaluator

Washington

Washington

Delta Society AAT &


Pet Partners Program Coordinator
Counselor/AAT Instructor

Washington

Clinical Researcher

Washington

Registered Nurse

New Jersey

Art & Play Therapist

Washington

Physical Therapist

Washington

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Table 1 continued. . .
9
10

Delta Society
Pet Partner Volunteer
Occupational Therapist

Florida
Oregon

11

AAT Program Director

Oregon

Members on this panel responded by providing constructive and


valuable input regarding the forms overall quality and relayed the
necessary improvements that should be made in order to enhance the
flow and ease of use among those utilizing AAT. The proposed
modifications and revisions gathered from this round of review are outlined
in Table 2 below:

Table 2
First Round Revisions to AAT Tool Draft
Revision
Suggestion / Modification
#
1
Move Age, Female/Male & Dx up one line under Client/
Patient ID#
2

Add check one behind Observations Prior to AAT

Delete the word ultimately

Add more instruction in completing the 4 domains

Include action words in describing skills and abilities

Clarify form instructions at top

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Table 2 continued. . .
7

Add a rating scale to describe quality of skill/ability

Add a third column for Recommendation using check boxes for


type of follow up necessary

Delete the areas for Progress Notes and Recommendations


for Follow-Up

10

Improve overall grammar, font and formatting

11

Change the word communal to group

12

List therapist and handler names separately

13

Replace words visit and encounter with the word session

14

Move Type of animal to the Therapist section

15

Add a section for therapist to list and describe patient goals

16

Include a space to capture Length of session

17

Each category should be evaluated for one specific goal; list


separate yet related goals for each domain

18

Add check boxes throughout form for N/A

19

In the Observations section, add the word appeared

20

Insert sitting and standing to balance

21

Insert upper and lower to extremities

In addition to the first round of revisions, additional remarks from


this group of reviewers included:

The form is easy to understand and would be easy to use.

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This form can be utilized for a wider age group of clients.

The form seems great!

Items on this form appear very specific and easy to record.

The form is very specific; knowledge of overall treatment


goals and progress towards these goals seems to be a
necessity.

The form looks great--it will be a great tool and easy to use.

The form seems like it would be pretty reliable between


variable evaluators.

It may be helpful to have a similar form for the animals


involved in the work, as it could ask many of the same
questions.

The evaluation tool is a bit bulky regarding skills and


abilities.

The tool should be simplified in order for me to use it.

Each and every suggestion was thoughtfully considered and the


proposed modifications were carefully incorporated into the form. This was
a challenging and creative process as the form was to remain at a
condensed 1 page double-sided in length as promised. The modified AAT
tool in its revised, test run implementation format can be found in
Appendix G.

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Implementation Results
The form was tested in the volunteer user group of therapists and
animal handlers for a period of 6 weeks during the months of June and
July 2005. The attempt was to collect as many completed AAT forms for
various analyses on forms data and to gather comments about usage and
validity. AAT therapist and handler volunteers from Washington, Oregon
California and Arizona utilized the revised tool in daily practice in their AAT
sessions. Including both experienced therapists and Pet Partner
volunteers maximized the variations and spectrum of data captured in this
study (see Table 3 below for details).

Table 3
Volunteer User Group Demographics

Role/Specialty
1

Geographic
# Yrs AAT
Location
Gender Experience

Therapy
Animal

Delta Society Pet


Partner VolunteerHandler

California

mini-horse

Delta Society Pet


Partner VolunteerHandler

California

mini-horse

Clinical Psychologist

California

10

dog

California
Oregon

F
F

10
14

dog
dog

4 Licensed Social Worker

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Table 3 continued. . .
5

Delta Society Pet


Partner VolunteerHandler

Recreational Therapist

Delta Society Pet


Partner InstructorHandler
Delta Society Pet
Partner VolunteerHandler

Washington

12

dog

Washington

dog

Arizona

N/A

dog

Friendly reminders and messages were sent to each volunteer


throughout implementation to maintain momentum and help facilitate
timely completion. At the end of the 6-week implementation period 57
completed AAT evaluation forms were returned to the investigator, 30
(53%) from therapists and 27 (47%) from Pet Partner handlers.
Therapists in Washington completed the most sessions in this time period.
Due to the short duration of the study, there was not an opportunity
to capture a mass amount of longitudinal data on any repeat client/patient
visits that occurred. However, it was found that 14 patients did undergo a
second visit within the timeframeusually still requiring further follow-up.
Washington therapists completed the most repeat visits. Table 4 below
illustrates a detailed look at the number of forms completed for each
volunteer.

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Table 4
Number of AAT Visits per Volunteer
Volunteer

# of AAT Visits

# of Repeat Visits

18

24

Meaningful data from these forms were carefully entered into a


confidential Access database and queried and analyzed for significant
trends and patterns. Demographics regarding patients and clients who
underwent AAT during this time period are displayed below in Table 5.

Table 5
AAT Client/Patient Demographics
Age range

7 to 88 years

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Table 5 continued. . .
Gender

31 (55%) Females, 26 (45%) Males

Session type

54 Individual, 3 Group

Length of session
range

2 to 60 minutes

Number of repeat
sessions

14 (25%)

Range of primary
diagnoses

Acute renal failure, ADHD, TBI, cancer, stroke,


dementia, depression, bone fractures, heart
bypass surgery, localized pain, weakness,
aneurysm, multiple sclerosis, cerebral palsy,
amputation, viral encephalitis, quadriplegic

Range of goals

General ambulation; improve strength,


coordination and balance; facilitate verbalization,
speech and socialization; comfort and
relaxation; relieve stress; decrease anxiety;
emotional uplift; improve concentration and
attention span; organize thoughts and
vocabulary; promote eye contact and focus; pain
management; improve mobility and endurance;
problem-solve; improve self-esteem and
communication; encourage walking.

# Physical skills
observed

40 (72%); avg. quality rated average to good


indicating a need for improvement

# Cognitive skills
observed

36 (63%); avg. quality rated average to good


indicating a need for improvement

# Social / Emotional
skills observed

46 (81%); avg. quality rated good to very


good indicating a need for
improvement
29 (51%); avg. quality rated good to very
good indicating a need for
improvement
34 (60%)

# Speech / Language
skills observed
Played with animal

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Groomed and/or fed


animal

21 (37%)

Took animal for walk

13 (23%)

Client/patient eager
and accepting of
animal and AAT

44 (78%)

Client/patient hesitant 11 (20%)


and needed prompting
Client/patient refused

1 (1%)

These data confirm that goal-oriented AAT sessions primarily occur


in a 1-on-1 setting between the therapist and client/patient rather than as a
group setting, as group settings are more commonly seen with animalassisted activities (AAA), which was described in the literature review.
However, group AAT sessions can occur, but are rare. The 3 group
sessions that occurred in this study were in California and led by both
therapists and handlers primarily using a mini-horse. Naturally, these
sessions were a bit longer. As mentioned previously, repeat sessions in
this study accounted for only a quarter (25%) of the total sessions; thus,
were uncommon and sporadic.
In over three quarters of all cases, clients/patients appeared eager
and accepting of the animal, AAT session and actually played with the
animal as part of the goal-oriented therapy. In 13 instances the animal

125

was even taken for a walk. From all received forms there was only 1
refusal to AAT. Subsequent to analyses, physical ability and
social/emotional skills were most highly observed during the sessions,
with volunteers reporting an average performance quality rating of
average to good and good to very good, respectively. Per volunteer
group reporting, all domains (physical, social/emotional, cognitive,
speech/language) consistently averaged a need for improvement and
further follow up. The most common diagnosis seen in therapy sessions
during this time was stroke, a cardiovascular disease where blood vessels
leading to the brain become clotted or are blocked.
In summary, these data portray that nearly anyone despite of age,
gender or clinical diagnosis can participate in, enjoy and benefit from goaloriented AAT sessions of various lengths.

Key Informant Findings


Following implementation, key informant interviews were held with
members of the volunteer group at their convenience to discuss in depth
their overall experience and to answer a set of research questions
(Appendix D). Interviews were held either in-person, over the telephone
or via email to accommodate busy schedules. A great deal of constructive
and qualitative information regarding AAT tool content, structure, ease of

126

use and validity and reliability was captured and recorded. Comments
from research questions asked of form users are summarized below.

1. Discuss your facilitys AAT program and how the effectiveness of


AAT is currently being assessed / evaluated.

Clients are seen up to 60 minutes per sessionusually


weekly, bimonthly or monthlywith volunteer teams and
therapists moving from room to room or designated therapy
areas for 1-on-1 contact.

The animal is incorporated into goal-oriented speech,


cognitive, social or physical therapy.

Volunteers or animal handlers check in with the nurses


station or a therapist, who in turn distributes orders for AAT.

The program director invites us to make initial and return


visits. The animal is groomed and petted during each
session while we encourage patients/clients to speak.

AAT volunteers sometimes do not have access to


client/patient age and diagnosis, but session notes and
observations are given to the therapist to transfer to the
medical chart.

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Volunteer handlers complete forms by writing observational


summaries of each client.

Therapists can vary considerably in how much they use an


animal as part of therapy. In any case, they keep data for
each client to meet job requirements and to monitor patient
progress.

Clinic staff members document or report observations of


functional skills from sessions and relay them to the
therapist.

Many of the visits positively affect the families of


clients/patients on an emotional level.

2. Was the tool a useful guide and/or an effective mechanism in


conducting therapy sessions? Did it make your job easier? Was it
easy to use or was it burdensome?

It was effective in providing good feedback on focus areas.

It helped focus the user on what is to be accomplished in


each session.

The tool was helpful and easy to use.

Therapy goals are set outside of AAT sessions; goals listed


on the tool were not always the goals of the clients worked
with.

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The tool provided good ideas and was a useful reference


guide as to what could be addressed during the sessions.

It was a useful guide and provided an effective way of


directing the overall visit per the 4 domains.

The Cognitive, Social/Emotional and Speech/Language


sections were more burdensome with too much information.

When therapists already document patient progress in the


medical chart, this tool was extra work.

As a volunteer making shorter visits traveling from room-toroom it was time consuming and burdensome.

The tool is more applicable to employed hospital therapists


and clinical staff than to AAT volunteer handlers.

3. Do you believe the new tool was effective in helping meet patient
goals/needs? Did it properly address the functional domains
(cognitive, physical, social, emotional) in determining patient goals?

It met the functional domains during visits.

An assessment form does not necessarily meet patient goals


itselftherapy works toward meeting goals.

The tool was mostly effective in meeting social and


emotional goals.

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Cognitive and physical skills were more difficult to gauge, as


some patients were discharged by the time the next AAT
visit was scheduled.

4. Did the tool help contribute to overall patient improvement?

It reminded form users of the focus areas.

A form itself does not necessarily contribute to patient


improvement.

Patient improvement is attributed more to the patients and


therapists hard work.

The tool could track improvements if the results could be


graphed.

5. What were the positive and negative experiences associated with


using the new tool? Advantages and disadvantages? Likes and
dislikes?

It was easy to use.

The tool was helpful in evaluating the benefits of AAT.

The tool gave direction to the overall visit, but found the
recommendation for follow-up choice to be too narrow.

If no follow-up needed is consistently chosen, therein lies


concern that patients/clients may retreat to original behavior.

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It was unclear how to treat the goal achieved section, as


this is something that can be worked on continually; the
client can always continue to improve.

The rate quality and recommendations for follow-up


sections were confusing, as some patients were only seen
once and did not have a chance for further follow-up.

Therapists have their own goals but some of those goals


were not listed on this form.

The Social/Emotional section was quite useful and most


readily seen.

The tool could track changes if used by therapists who saw


patients on a more frequent basis.

Completing the tool was time consuming.

Unlike hospital therapists, AAT volunteers/handlers do not


know enough about the patients medical history to track
whether or not therapy goals are being met.

6. Comment on the length of the tool: Too long? Too short?

The length was just right.

The length was too long.

The length was too short; it needs more options available.

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For clients/patients who have short attention spans--the


paperwork took longer than the visits.

This is a good length for hospital therapists.

7. Do you think the tool has potential to satisfy third party payment
requests?

Yes, there is adequate data to show the validity of AAT.

Perhaps if it was more specific.

Yes, it could track patient progress or lack thereof.

Insurance companies hope for early discharge; the hospital


could determine the patients need for continued therapy or
discharge.

8. In your opinion, did the tool measure what it was intended to


measure?

Yes.

It was unable to measure repeat visits, as some patients


were only in a specific care unit for 1 week.

9. Would you use this tool again in practice? Would you recommend
it to other therapists and/or handlers?

Yes, as a reference guide.

It could be recommended for use by hospital therapists, but


not to volunteers or handlers.

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10. How can this tool be improved? Describe any modifications and
revisions.

Allow for more distinction within the 4 domains.

Rule out ambiguity and the ability to score client/patient


other than just yes or no.

Remove the goal achieved and recommendations for


follow-up columns in all domains.

Lessen the amount of information on the form.

Rate quality should be more functionally specific.

Include space to describe baseline performance in the 4


domains.

Address more neurological injuries and illnesses (i.e.


relearning to eat, talk, think).

Devote a section specifically for reading skills.

The goal achieved sections did not apply for sporadic


visits; clients having frequent visits may prove the tool more
useful.

Remove no follow-up needed, so patients/clients do not


retreat back to old behaviors due to no follow-up or
motivation.

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Add a space for Session number behind each ID # in order


to see progression, regression or status of repeat visits.

Add more space between sections to account for variation.

Include name of animal on form.

Limit the number of skills and abilities listed under each


domain.

Lengthen the current form.

Per current AAT programs and procedures at sites where therapists


and handlers frequently conduct AAT, participating volunteers indicated
they on average conduct AAT at least once per week with clients and
patients who are both scheduled for and who separately request AAT
during a prolonged hospital stay. They also see clients on an outpatient
basis for specific rehab goals as well. During sessions, the therapy animal
is incorporated into all 4 domains (physical, emotional, cognitive, speech)
when at all possible. All volunteers generally complete some form of
documentationwhether it is progress notes or dictation by the therapist
or simply longhand notes and observations witnessed by the handler or
other clinical staff involved. Per the literature, this is typically how AAT is
accomplished throughout the therapeutic field. Since past literature and
this current group of volunteers did not already use a standardized or

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universal AAT guide, form or template, this study indeed confirms the
need of this undertaking in order to successfully and carefully construct
one common AAT evaluation guide that would be available for AAT
professionals nationwide.
As depicted in the summaries above, both therapists and handlers
felt the new AAT tool provided focus to their sessions and was a useful
guide and an effective mechanism in conducting therapy sessions. Some
volunteers even felt it made their job easier and assisted them on focusing
on what they should exactly evaluate. While some handlers felt that the
tool was easy to use, a few remarked it was lengthy and burdensome
because they primarily conducted short sessions to assess only 1 or 2 of
the functional domains at a time. Handlers executing these short sessions
specifically requested that the cognitive, social/emotional and
speech/language domains be narrowed down in listing the skills and
abilities. On the other hand however, therapists conducting longer
sessions assessing all domains remarked that the domains did not include
a wide enough spectrum of skills to be evaluated, as they at times have
their own patient goals in mind.
All users generally believed that the new toolcoupled along with
the consistent efforts of patients and therapistswas effective in helping
meet patient goals/needs and that it reliably addressed the 4 functional

135

domains in determining these goals; thus contributing to patient


improvement overall. The majority of users concurred that improvements
listed and accounted for on the tool could be readily tracked by graphing
(i.e. weekly, monthly, etc). This was an exciting idea that was widely
accepted by the users.
Some therapists and handlers participating in the test run reported
that skills and abilities within the social/emotional domain were the most
highly visible and observed, thus being easiest to evaluate. Still, others
noted that abilities in the physical and cognitive domains were the most
difficult to witness because volunteers felt they needed more time to see
goals accomplished through repeat visits (i.e., the patient would be
discharged from the hospital before certain AAT follow-up activities could
be conducted).
Varying opinions regarding the tools length ranged from too short
to too long. Volunteersespecially handlerswho conducted the shorter
sessions felt the tool was too much additional paperwork for their brief
encounters and was somewhat burdensome, but that it was of suitable
length for in-house hospital therapists who formally spend more time on all
domains. Those who considered the form too short requested more
space under each domain along with room for additional skill and ability
options to evaluate.

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The users reached a consensus that the tool captured enough AAT
evaluation information in order to be valid and reliable to satisfy third party
payment requests. Because insurance companies want early discharges,
the hospital could then use the completed assessment tool to determine
and predict discharge. Another consensus among all produced the feeling
that the tool measured what it was initially intended to measure and was
reliable and valid in serving its purpose. There was a flutter of concern,
however, about how to accurately measure long-term goals in the
absence of repeat sessions, but that is out of anyones control if the
client/patient is discharged early.
The popular notion from volunteers in the user group was that they
would definitely use this tool again in daily practice as a reference guide to
help conduct their AAT sessions. Many voiced that it would be helpful in
providing additional focus and direction. In terms of future use, volunteers
interviewed stated they would recommend it to therapists and AAT
providers. Handlers in the test group commented that often times they are
not provided with the most recent and/or comprehensive patient medical
histories. Thus, those conducting shorter sessions therefore would rather
utilize and complete a similar but more general form which allows space
for notes and observations they could later deliver to the therapist or place
in the patients medical chart.

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Having the tool available to help conduct AAT was commonly


regarded as a positive experience throughout the test run while the idea of
additional paperwork aspect often caused some apprehension and was
seen as negative and a disadvantage. In general, the volunteers liked it
because it was easy to use and helped facilitate the session, but disliked
certain aspects of the tool such as perceived ambiguities and certain
sections. Both therapists and handlers from the test run indicated they
were thankful they had the tool as a reference guide to refer to during AAT
but more handlers were unsure how to exactly rate the quality of certain
skills and abilities (i.e. they felt they did not possess the level of expertise
as a hospital-based therapist or counselor to clinically rate a physical skill).
Many users from implementation remarked that the form could be
greatly improved for a wider audience by simply adding more space for
variations and distinctions seen during AAT. The most commonly
proposed modification that nearly everyone agreed upon was to omit the
column and choices for no follow-up needed. A few of the proposed
revisions actually were contradictive to one anothersuch as requesting
the tool be overall shortened with less skills/abilities versus lengthening
the tool to create space for baseline performance and additional skills for
other specific illnesses.

138

All summaries, anecdotes and remarks from this group of test run
volunteers were very sensible, meaningful and worthwhile. In order to
construct the most valid, reliable and scientifically-sound evaluation tool
while satisfying the revision requests of all parties involved, all proposed
revisions were carefully considered and subsequently applied to the final
AAT evaluation tool template (Appendix L). This process is explained
later in this chapter.

Follow Up Survey Results


A short, voluntary follow-up survey was also sent via mail and email
to each volunteer who participated in the test run in order to collect
additional logistical quantitative information so the Delta Society can
prepare it for future use and implement further modifications if necessary.
Compiled results are illustrated in Table 6 below and are subsequently
discussed.

Table 6
Results from Follow-Up Survey

139

Question
Range of AAT experience
Average time to complete AAT tool

Response
1 to 14 years
11 minutes

Average ease of use (on a rating scale of 1 5 where


1=difficult and 5=easy)

3
Yes

No

Tool helped evaluate effectiveness of AAT on patients

80%

20%

Tool was a useful guide in conducting AAT sessions

80%

20%

Considered tool helpful to patients medical chart

100%

0%

Would use tool again

67%

33%

Would recommend tool to others

50%

50%

Would rather complete tool electronically or download it from


website

50%

50%

Think form has potential to satisfy third party payment


requirements

75%

25%

The average years of AAT experience in the user group ranged


from 1 to 14 years, with an average of 7 years. The time to actually
complete the AAT evaluation tool ranged from 10 to 15 minutes, with an
average of 11 minutes. Similar to interview reporting, the majority of users
responding from the survey considered the tool a useful guide throughout
the session. Follow-up surveys indicated that nearly all users completed
the form after the AAT session rather than during actual therapy.

140

The tools ease of use on a rating scale of 1 to 5 (with 1 being most


difficult and 5 being very easy) ranged from 2 to 4, with an average rating
of 3. As stated previously, most volunteers felt the tool helped evaluate
the effectiveness of AAT on their patients/clients and that the tool was a
useful guide in conducting AAT sessions. All volunteers considered the
tool helpful to the patient chart and 67% of them indicated they would use
it again. Interestingly, results from the follow-up survey show that the user
group was divided on the topic of recommending the tool to other AAT
professionals, while previous inquiring around this topic during the
interviews suggested otherwise.
Since much work of this day and age is primarily done over the
Internet, email and other electronic avenues, it seemed pertinent to inquire
about the feasibility of accessing it electronically. Again the volunteer
group was divided in their response to downloading the evaluation tool
from a webpage or completing it electronically. Lastly, the majority of
volunteers thought the form had potential to someday satisfy third party
payment requirements, which supports earlier results from the key
informant interviews.
The main suggestions for improvement from the follow-up survey
were to 1) add more space throughout the tool for additional AAT notes
and, 2) make it become more user/reader-friendly. The key concern from

141

this group was that the tool may add additional paperwork to already busy
therapists and handlers who keep tight clinic and travel schedules.
Generally, therapists felt the current tool should remain as is
pending some minor revisions for actual therapists and allied health care
staff. The handlers, on the other hand, felt they did not have the level of
expertise, training and resources that licensed therapists do in order to
make clinical decisions and rate abilities. This sub-group indicated they
would be more comfortable recording general notes and observations on a
shorter, less detailed assessment form. Per these viewpoints, the ongoing
and emergent theme was that a new, condensed version of the AAT
evaluation form should be developed and made available specifically for
AAT animal handlers (or Pet Partner volunteers) to record observations
and notes, while the current version is more universally appropriate for
hospital-based therapists and counselors.

Discussion of Final AAT Tool Revisions


In designing the AAT tool into a final, user-friendly template, the
suggestions and modifications from the volunteer test group were carefully
incorporated in hopes of constructing a scientifically sound AAT evaluation
instrument to be used on a wider scale. Like the initial changes applied to
the test run version, this was also a challenging and creative process

142

while remaining objective for the study, yet mindful as not to create extra
paperwork for AAT professionals. The hope is for the revised and final
AAT tool evaluation template to be utilized as a guide for sites, therapists
and handlers to modify for their own specific work and needs. It allows for
manipulation of data fields. It can be shortened or lengthened. Sections
can be added or eliminated according to each individual, department or
site need.
In order to satisfy multiple revision requests, the tool was first
lengthened to allow each domain (physical, cognitive, social/emotional,
speech/language) to have its own page. This allowed for more space to
record baseline performance, notes and observations for each skill and
ability, and to also add skills related to diseases, disorders, illnesses and
injuries that are not listed. A few of the skills and abilities relating to group
participation and unconsciousness were deleted, as they were rarely
checked or observed during the test run. The majority of users in the
implementation group steadfastly commented that there is always need for
follow-up and that the no follow-up needed option should not be listed,
thus those sections were omitted and space to instead record a date for
next appointment or interim assignment was provided in its place. An
AAT session number was appropriately added to accompany the repeat
visit field since future users on a long-term basis would most likely have

143

increased opportunities for repeat client/patient visits. A space to record


the animals name was added as well. Lastly, due to the fact that nearly
every user in the test run felt the tool was a useful reference guide for
AAT, the investigator felt it appropriate to change the title to Tool for
Guiding and Evaluating Animal-Assisted Therapy. The final AAT
evaluation instrument template is located in Appendix L.

Delta Society Considerations


Upon compilation of the results, key study findings and the draft-tofinal versions of the AAT evaluation tool were shared with the Delta
Society. Details from the planning, constructing, evaluation and validation
processes were described and each version of the tool was discussed
while elaborating on reasoning for the proposed modifications. This
organization was enthusiastic about the study results and from their
standpoint, felt the study goal had been met.
The Delta Society felt that the AAT tool is a valuable instrument in
that it can be utilized either as is or as a template that can be modified by
facilities for the population they serve. In discussing the results of this
research, this organization felt they should continue to remain focused on
offering the new tool specifically to health care professionals formally
conducting AAT. They will present and promote the tool to clinical sites

144

and therapists through 1) featuring it in the Fall 2005 quarterly publication


called Interactions, a magazine that describes how and why animal
companions improve quality of life, 2) emailing a copy of the tool to their
Pet Partner affiliates and other AAT health care professionals, and 3)
posting it on their website (www.deltasociety.org), which is accessed
nationally and internationally by millions of peopleincluding therapists,
counselors, social workers, human-animal bond experts, AAT
researchers, Pet Partners volunteers, instructors and evaluators, animal
trainers and handlers, sites implementing their first AAT program, clinics
and hospitals, rehabilitation centers, residential and long-term care
facilities, students and a vast array of other health care providers.
In summary, the planning, construction, evaluation and validation
stages of this study were all executed, accounted for and appropriately
examined from beginning to end using all existing data available. This
undertaking, through field-testing in 4 western states, was successfully
accomplished to benefit the field of AAT and those who help individuals
with illnesses or injuries in regaining mobility, motivation and happiness.
A study summary and conclusions, as well as recommendations for further
research, can be found in Chapter 5.

145

Chapter 5

Summary, Conclusions and Recommendations


Research around the effects of AAT has been recently trending
higher. The overall goal of this study was to produce a new, functional
AAT effectiveness tool for therapists and animal handler teams who
provide AAT to sick and injured patients.
Through vast research efforts, this study found that AAT programs
and procedures throughout the western United States confirmed and
supported what the literature described they should be, and that clinical
professionals and volunteers involved with AAT are providing a unique
and special service to those with illnesses and injuries. People who
administer AAT are usually 1) a hospital/facility-based licensed therapist
or psychologist and, 2) a Delta Society affiliated volunteer animal handler,
trainer or instructor who coordinates schedules with hospital therapists
and travels from site to site. Data collected from anonymous clientele and
patients who underwent AAT during the test period suggest that people of
any age, sex or condition can benefit from AAT. In fact, the majority of
individuals receiving AAT were eager, accepting and quite responsive to
this unique form of therapy, which ultimately suggests that AAT is a valid

146

and reliable modality in and of itself and therefore deserves to be


evaluated, studied and researched in more depth in years to come.
Per the literature review, initial talks with the Delta Society and
interviews with key informants who participated in the study, it was
confirmed as cited in the literature that very few formal and validated AATspecific effectiveness evaluation tools existed for therapists and handlers
to use throughout their practice. In the past, very little scientific data has
been collected to actually measure the effects of AAT. Through this
particular research, it was found that participating sites were indeed
documenting and tracking observations, but not via any one universal
scientific AAT instrument or document. In response to the demands of
individuals in the AAT field, the investigatorwith assistance from the
Delta Society, reviewers/evaluators from the AAT field and a group of
therapists and handlers representing the states of Washington, Oregon
California and Arizonacarefully planned and constructed a
comprehensive scientifically-sound AAT effectiveness evaluation
instrument for therapists and animal handler teams delivering AAT. The
tool was overhauled twice during the studyonce prior to implementation
and again afterwards.
Subsequent to initial modifications proposed by AAT expert
evaluators, the AAT tool was utilized in daily practice among a volunteer

147

group of both therapists and handlers to gather information around its


ease of use, content, reliability and validity. This group provided valuable
input as to how to appropriately modify the tool for future and more formal
use universally. Key themes extracted from this study concluded that:
1. The AAT tool provided focus and direction to therapy sessions.
2. The AAT tool was a useful guide in conducting therapy
sessions.
3. The AAT tool was scientifically valid and reliable way to
evaluate AAT.
4. The AAT tool has potential to satisfy third party payment
requests.
5. The AAT tool can assist in tracking progress when there is
opportunity for repeat visits and follow-up.
The key concerns extracted from this study concluded that:
1. The AAT tool could potentially add extra paperwork to therapists
and handlers.
2. Handlers do not always have ready access to patient medical
histories.
3. Handlers may not possess the expertise to clinically rate
performance quality.

148

The key conclusions from tool revision requests were that:


1. There is always room for improvement and follow-up.
2. The AAT tool should allow for variation within the domains.
3. The AAT tool should be shortened into a condensed version
especially for handlers to record general notes and
observations.
4. The AAT tool should be user-friendly.
In summary, in order to satisfy multiple requests and integrate all
improvements, the AAT tool in final form (Appendix L) was adjusted into a
user-friendly guidance and evaluation document template which allows
future therapists, handlers and facilities to modify it to their specific needs.
It will be available via the Delta Society, headquartered in Bellevue,
Washington, through future AAT trainings, email notifications and
organizational publications. They will also post it on their website
(www.deltasociety.org) for immediate download for their 1500 members
and affiliates to utilize during AAT and for health care professionals
throughout the AAT field who wish to begin a program at their facility. The
information gained from this research study will allow this organization a
basis in which to design and initiate further related studies that emphasize
integrating AAT into more health care systems.

149

The implications of this research to the discipline were overall


positive, thus producing new and valuable data surrounding the
effectiveness of AAT and the planning, development and validation
processes involved. Current AAT practices, per se, need not be
redefined, but can instead be improved and refined with the addition of an
in-depth researched, field-tested guidance and evaluation instrument.
Although multiple and sometimes contradictory modifications were
proposed throughout the study, fairness and objectivity prevailed resulting
in the development of a valid and prolific AAT guidance and evaluation
tool to better assist those who help others overcome illness and injury.
Much further research is still needed on this topic, as validation is
an ongoing process requiring a great deal of professional efforts. In fact,
many scientific instruments are initially created, reviewed, revised only to
plateau as a work in progress. Information from this study can be readily
applied to future AAT studies. Data extensively gathered throughout the
planning, construction, evaluation and validation phases can serve as a
basis in which to spring further AAT effectiveness evaluation research.
Having data available through these initial research activities should both
help and improve the design of more scientific and quantitative studies in
the future. Further, information from this undertaking will help estimate

150

future resources needed for designing similar tools and for conducting
larger AAT studies.
Regarding further research, the next logical step would be to repeat
the study using the newly created AAT guidance and evaluation tool in a
wider scope. This should be accomplished by expanding the geographical
area to include the entire United States; hence, a larger sample size of
therapists and handler teams and AAT tools from which to extract data.
The AAT tool, study background and design, forms and instructions and
follow-up surveys should be displayed electronically and available for
immediate Internet download via the Delta Societys website. Because
the current study was not lengthy enough to collect longitudinal data from
repeat visits, the follow-up trial should be extended by at least 3 months in
order to collect and analyze this information. Further, the current study
due to educational timeline and deadline requirementswas conducted
during the summer months, which are usually considered slow and many
people are on vacation; therefore, a future study and data collection
should occur during the fall, winter or spring in order to produce more
data. Lastly, if finances allow, it would be beneficial to hire an
experienced psychometrician to scrutinize and edit the final AAT
evaluation instrument. Clearly preparation for this subsequent follow-up
research would involve extra time, resources and finances, but more

151

aggressive analyses could be run between therapists, handlers, facilities,


states and domains. Also the follow-up study could have more scientific
rigor if baseline to follow-up and pre and post-test data were collected.
Depending on time and financial resources, additional
recommendations and next steps for future related research should
include but not be limited to:
1. Utilize the new AAT evaluation tool in a study specifically
designed to determine its feasibility in actual health insurance
and third party administrator payment situations. If the results
prove successful, policies, legislation and payment methods
around AAT delivery could be instituted.
2. Further investigate each domain separately (physical versus
cognitive versus social versus speech).
3. In future prospective studies, investigate causal associations
and links between AAT and clinical effects on human health (i.e.
which demographic benefits the most/least from AAT, what
frequency/length of session is most effective, what species of
animals are most therapeutic, etc).
4. Plan, construct, evaluate and validate a similar, user-friendly
tool specifically for AAT group therapy. The tool should include
a space to record the number of clients/patients per group,

152

number of males vs. females, range of diagnoses, type of


interactions and a place to record overall observations and
reactions throughout the group session.

As stated previously, AAT over the past 25 years has evolved as a


relatively new phenomenon and the scientific research in evaluating its
effects has only just recently begun. Possibilities for new and exciting
studies and further scientific research to advance the knowledge around
this topic are endless. It is hoped that the groundwork achieved from this
study coupled with the valuable knowledge derived will serve as a basis in
which future AAT evaluation studies to stem.

153

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Appendices

Appendix A: Animal Assisted Activities - Child Life Policy ...........................


.................................................................. .pdf doc. in .zip file
Appendix B: Animals in the Hospital - Childrens Hospital & Harborview
Medical Center Infection Control Policies and Procedures .....
................................................................. .pdf doc. in .zip file
Appendix C: AAT Effectiveness Evaluation Tool Instructions ......................
.......................................................184 (word doc. in .zip file)
Appendix D: Key Informant Interview Questions .........................................
.......................................................185 (word doc. in .zip file)
Appendix E: Follow-Up Questionnaire................186 (word doc. in .zip file)
Appendix F: First Draft of AAT Tool.....................187 (word doc. in .zip file)
Appendix G: Revised AAT Tool ..........................189 (word doc. in .zip file)
Appendix H: ID Code/Tracking Log .....................191 (word doc. in .zip file)
Appendix I: Volunteer Ads .............................................. .pdf doc. in .zip file
Appendix J: Map of Participating AAT Locations ....194 (ppt doc. in .zip file)
Appendix K: Research Questions Field Notes Template..............................
.......................................................195 (word doc. in .zip file)
Appendix L: Final AAT Tool Template .................197 (word doc. in .zip file)

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