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 one’s 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 units—hence,

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

2

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). Triebenbacher’s 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. Siegel’s (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

3

(2001) justify today’s 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 schedules…this 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

4

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 person’s 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

5

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 energetic—thus 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.

6

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 field’s 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.

7

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.

8

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

9

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-

10

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.

11

• 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.

12

• 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 child’s 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.

13

• 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

14

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 animal-

assisted 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,

15

along with final conclusions and recommendations for further AAT-related

research.

16

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 human-

animal 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 elderly—just 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.

17

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 children’s 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 accident—as while

18

his dog was present at one session a withdrawn and somewhat

uncommunicative child more readily and willingly opened up—thus,

showing slight improvement in therapy while interacting with Levinson’s

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 today’s 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 Levinson’s 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

19

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 person’s 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

Katcher’s (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;

20

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 human-

animal 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).

21

Physiological Benefits, Stress Reduction and Relaxation

Results from studies described below maintain that the human-

animal 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 one’s 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.

22

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 patient’s 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

23

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

24

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 stranger’s 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 study’s 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

25

decreased as well while being petted (Dale, 2004). The same was said

for the dog’s 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 dog’s arterial blood pressure decreased as a result

of human touch, and later the dog’s 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 2000’s 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. Siegel’s (1990) results

showed that pet ownership among the enrollees was one of the major

26

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

27

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

owners—a much higher percentage than in Anderson’s 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

28

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 friendship-

like 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 pets—namely cats or dogs—the 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,

29

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

30

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 dentist’s 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

pediatrician’s 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

31

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 Society’s 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

32

programs in the United States is the Delta Society’s Pet Partners®

Program, which includes more than 8,000 teams in the United States and

6 other countries—including 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 Pennsylvania’s

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

University’s 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

33

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. Martin’s

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, Alzheimer’s 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 Alzheimer’s patients while

having access to a visiting, or therapy, dog. Another study among

Alzheimer’s inpatients proved that this population was found to be less

34

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

had a relaxing and normalizing effect on the Alzheimer’s patients and their

memory capacity increased as a result of recalling the animal’s names,

breeds and colors (Cross, 1998). In support of this research, Fritz (1995)

also found in a similar study that 34 out of 64 Alzheimer’s 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 Alzheimer’s 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)

35

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 living—such 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

36

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

37

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

treatment—including 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 cure—AIDS. A study by Conti et al (1995) showed pets are

38

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.

39

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 residents—primarily 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 had—whether 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 Veteran’s 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.

40

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 Brickel’s 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.

41

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 long-

term 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

42

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

43

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

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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 Thomas’s 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

45

Thomas’s 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 homes—loneliness, 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, Thomas’s 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;

46

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

47

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

48

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.

49

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 human—not 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 Thomas’s research and wide-spread uprising and

implementation of this new concept, there have been numerous follow up

studies by geriatric health researchers. Coleman, Looney, O’Brien 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.

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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 Alternative’s

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.

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In implementing this concept—which 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 animal’s stress level, adaptation and transition into

the setting. In some cases, the facility will work with an animal

52

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 facility’s 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;

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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 patients—a setting of caring,

compassionate and successful care for all involved. It’s 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

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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

women’s 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

55

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 Levinson’s

psychological sessions. In order to effectively communicate with their

pets, humans need to demonstrate ongoing respect, appreciation,

understanding and body language.

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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

57

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

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as cancer—whether it be a certain scent or simply the dog’s 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 person’s 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 way—with 40% of them displaying alerting behavior prior to onset

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of a child’s 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

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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 Reep’s (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 testimonial—some believe an animal’s 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:

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Rather than ESP, perhaps we should call these internal

sensory systems our sixth sense—a 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. It’s just that we’ve 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:

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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 horse’s 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

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

Monson (1995) reported that the “motion and almost massage-like warmth

of the horse’s 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 injured—not 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 facility’s 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 animal-

assisted 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

patient’s, resident’s 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

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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

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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 AAA—although somewhat of a new concept in

Australia—was 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 O’Rourke, 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;

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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 pet’s

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 Children’s Hospital and Regional Medical Center in Seattle,

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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).

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

a pet visitation program they implemented in their facility’s 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 life—such as responsibility, emotional

stability, sensitivity, empathy, tolerance, nurturance, self-control, self-

esteem and coping with the life/death experience. For example, a

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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 Kidd’s 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

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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 patient’s 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 patient’s medical record. Site volunteers play a major part in this,

too. Depending on the facility, credentials of the therapists and the

patient’s insurance, AAT may or may not be billable to a third party payer

or reimbursed the same way as any other clinical therapy. Interaction

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during an AAT session is usually one-on-one between the patient and the

trained animal—most 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

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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

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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 living—such 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, non-

judgmental 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

it’s leash, to give the animal affection, to observe and interpret the

animal’s 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.

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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 cost-

effective.

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

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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

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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 one-

half year period for over 2,000 patient contacts (Howie, 1994).

Barak, Savorai, Mavashev and Beni (2001) later conducted a case-

control 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 intervals—each

motivating the patients in the brushing, feeding, walking and bathing of the

animals. Subsequent to data analyses, findings of this study showed

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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 improved—yet nonsignificant—behavioral

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 staff—due to

various backgrounds, cultures and values—who do not want to be around

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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 children’s

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 handler’s 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 handler’s 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 handler’s 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 dog’s

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 patient’s 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.

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Dudzik, personal communication, November 1, 2004). It is to everyone’s

benefit to maintain the dog’s 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 organization’s 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 facility’s 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

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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 stores—anywhere 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

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injuries and Alzheimer’s disease, the chronically ill and the mentally

challenged. The organization’s 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

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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 pet-

facilitated 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 kittens—who 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:

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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

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• 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 patient’s 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

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where cats are allowed on patient’s 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 aquariums—the 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

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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

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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 5-

year period. Similarly, they also reported that a children’s 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

year—except 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

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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 Children’s 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

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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 future—perhaps 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 tool’s 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.

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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. Well-

designed 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

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• 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

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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 instrument’s 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, FGCU’s primary

instrument developer/researcher kindly consulted on the construction of

this study’s new instrument—providing necessary insight along the way.

Using FGCU’s 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

facility’s 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 tool’s 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 tool’s 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-of-

study 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 informant’s 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 tool’s 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 user’s 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 tool’s

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 practice—with the option of completing it via email or regular

mail. The questionnaire was 1 page in length and contained many short-

answer 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 tool’s 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 study’s 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, password-

protected 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 instrument’s 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 Clark’s (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 progress—requiring 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 investigator’s 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 person’s 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 Geographic Location 1

AAT Trainer/Consultant

Washington

2

AAT Instructor/Evaluator

Washington

3

Delta Society AAT & Pet Partners Program Coordinator

Washington

4

Counselor/AAT Instructor

Washington

5

Clinical Researcher

Washington

6

Registered Nurse

New Jersey

7

Art & Play Therapist

Washington

8 Physical Therapist Washington

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9

Delta Society Pet Partner Volunteer

Florida

10

Occupational Therapist

Oregon

11

AAT Program Director

Oregon

Members on this panel responded by providing constructive and

valuable input regarding the form’s 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”

3 Delete the word “ultimately”

4 Add more instruction in completing the 4 domains

5 Include action words in describing skills and abilities

6 Clarify form instructions at top

Table 1 continued. . .

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7 Add a rating scale to describe quality of skill/ability

8 Add a third column for “Recommendation” using check boxes for type of follow up necessary

9 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.”

Table 2 continued. . .

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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

Geographic Location Gender

# Yrs AAT Experience

Therapy Animal

1

Delta Society Pet Partner Volunteer-

Handler California F 1 mini-horse

2

Delta Society Pet Partner Volunteer-

Handler California F 1 mini-horse

3

Clinical Psychologist California F 10 dog

4

Licensed Social Worker California F 10 dog Oregon F 14 dog

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5 Delta Society Pet Partner Volunteer-

Handler

6

Recreational Therapist Washington F 12 dog

7

Delta Society Pet Partner Instructor-

Handler Washington F 8 dog 8 Delta Society Pet

Partner Volunteer-Handler Arizona M 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 timeframe—usually 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.

Table 3 continued. . .

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Table 4

Number of AAT Visits per Volunteer

Volunteer # of AAT Visits

# of Repeat Visits

1

1 0

2

1 0

3

3 1

4

3 1

5

18 3

6

24 6

7

5 3

8 2 0

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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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

# Speech / Language skills observed

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

Played with animal

34 (60%)

Table 5 continued. . .

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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 and needed prompting

11 (20%)

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 animal-

assisted 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

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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 goal-

oriented 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

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use and validity and reliability was captured and recorded. Comments

from research questions asked of form users are summarized below.

1. Discuss your facility’s AAT program and how the effectiveness of

AAT is currently being assessed / evaluated.

• Clients are seen up to 60 minutes per session—usually

weekly, bimonthly or monthly—with 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 nurse’s

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-to-

room 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

itself—therapy 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 patient’s 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 patient’s 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

documentation—whether 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 tool—coupled along with

the consistent efforts of patients and therapists—was effective in helping

meet patient goals/needs and that it reliably addressed the 4 functional

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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 tool’s length ranged from too short

to too long. Volunteers—especially handlers—who 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 anyone’s 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 patient’s 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 another—such 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.

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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

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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.

Question

Response

Range of AAT experience

1 to 14 years

Average time to complete AAT tool

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 patient’s 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%

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The tool’s 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

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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

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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 it’s 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

144

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

the animal’s 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-to-

final 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

145

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 people—including 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.

146

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

147

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 AAT-

specific 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 investigator—with 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 Arizona—carefully 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 study—once 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

148

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.

149

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.

150

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

151

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 Society’s 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 requirements—was 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

152

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,

153

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.

154

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Appendices

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

.................................................................. .pdf doc. in .zip file

Appendix B: Animals in the Hospital - Children’s 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)