Exploratory Study of Animal Assisted Therapy Interventions Used by Mental Health Professionals EXPLORATORY STUDY OF ANIMAL ASSISTED THERAPY INTERVENTIONS USED BY MENTAL HEALTH PROFESSIONALS Dana M. O'Callaghan, M.A. Dissertation Prepared for the Degree of DOCTOR OF PHILOSOPHY UNIVERSITY OF NORTH TEXAS May 2008 APPROVED: Cynthia Chandler, Major Professor Sue Bratton, Committee Member Dennis Engels, Committee Member Aubrey Fine, Committee Member Dee Ray, Program Coordinator Janice Holden, Chair of the Department of Counseling and Higher Education M. Jean Keller, Dean of College of Education Sandra L. Terrell, Dean of the Robert B. Toulouse School of Graduate Studies O'Callaghan, Dana M. Exploratory Study of Animal Assisted Therapy Interventions Used by Mental Health Professionals. Doctor of Philosophy (Counseling), May 2008, 110 pp., 24 tables, 17 illustrations, 47 references The purpose of this study was to explore the various animal assisted interventions mental health professionals incorporate in the therapeutic treatment process, as well as the various therapeutic purposes intended with each technique. Participants were recruited from animal assisted therapy related databases. Participants included professionals who practiced in the mental health field. Thirty one participants qualified for the study. A survey was developed based on information found reviewing literature related to animal assisted therapy. Nineteen animal assisted therapy techniques and ten therapeutic intentions were identified from a review of the literature. Participants were asked to rate on a Likert scale how often they incorporated each technique in their treatment process. Additionally, participants were asked to identify which therapeutic purposes they intended with each technique. Results indicated participants incorporated a variety of animal assisted techniques for various therapeutic intentions. Results indicated seven animal assisted techniques were incorporated by more than 50% of the participants. Building rapport in the therapeutic relationship was the most common therapeutic intention reported with a variety of animal assisted techniques. Copyright 2008 by Dana M. O'Callaghan ii ACKNOWLEDGEMENTS Words do not seem to accurately reflect the gratitude and appreciation I feel for those who have supported me during this process. To my loving husband, Lyle, who has held my hand from day one on this journey. I thank you for your unconditional love and support as we travel this road together. To my O’Callaghan and Kabalican family, thank you for your love and encouragement, although many miles away. Thank you to my chair, Dr. Chandler, for your endless encouragement during this process, as well as giving me great opportunities to explore and contribute to the field of animal assisted therapy. Dr. Aubrey Fine, you have been an inspirational mentor in the field of AAT, I can not thank you enough for all that you have done for me. Also to my committee members, Dr. Sue Bratton and Dr. Dennis Engels, your warmth and support have encouraged me throughout my time here at UNT-thank you so much. To my friends here at UNT, thank you for welcoming Lyle and I into your lives and becoming my secondary family in Texas. iii TABLE OF CONTENTS Page ACKNOWLEDGEMENTS ............................................................................................... iii LIST OF TABLES ............................................................................................................vi LIST OF FIGURES........................................................................................................ viii Chapters 1. INTRODUCTION ....................................................................................... 1 Statement of the Problem ............................................................... 4 Review of Related Literature ........................................................... 4 Variations of Animal Assisted Therapy Programs and Related Studies..................................................................................... 12 AAT Related Literature and Therapeutic Implications ................... 17 Justification of Animal Assisted Technique Questions .................. 21 Purpose of the Study..................................................................... 27 2. METHODS AND PROCEDURES ............................................................ 28 Research Questions...................................................................... 28 Research Assumptions ................................................................. 28 Definition of Terms ........................................................................ 28 Method .......................................................................................... 29 Statistical Analysis ........................................................................ 34 3. RESULTS AND DISCUSSION ................................................................ 36 Results .......................................................................................... 36 Demographics Related to the Therapy Animal.............................. 39 Discussion..................................................................................... 71 Implications ................................................................................... 80 Strength of Study .......................................................................... 81 Limitations ..................................................................................... 81 Future Research ........................................................................... 84 Appendices iv A. CONSENT FORM AND MENTAL HEALTH PROFESSIONAL ANIMAL ASSISTED THERAPY TECHNIQUE SURVEY ....................................... 87 B. PARTICIPANTS INCORPORATING AAT BY VARIOUS TREATMENT MODAILITIES .......................................................................................... 98 C. FREQUENCY OF PARTICIPANT'S INCLUSION OF AAT TECHNIQUES ............................................................................................................... 103 REFERENCES............................................................................................................ 106 v LIST OF TABLES Page 1. Demographic Information ................................................................................... 37 2. Educational Information ...................................................................................... 38 3. Mental Health/Licensure Certification ................................................................. 39 4. Frequency of Participants in Talk Therapy ......................................................... 42 5. Frequency of Participants in Play Therapy ......................................................... 43 6. Frequency of Participants in Activity Therapy..................................................... 44 7. Frequency of Participants in Expressive Arts Therapy ....................................... 45 8. Technique 1........................................................................................................ 54 9. Technique 2........................................................................................................ 55 10. Technique 3........................................................................................................ 56 11. Technique 4........................................................................................................ 57 12. Technique 5........................................................................................................ 58 13. Technique 6........................................................................................................ 59 14. Technique 7........................................................................................................ 60 15. Technique 8........................................................................................................ 61 16. Technique 9........................................................................................................ 62 17. Technique 10...................................................................................................... 63 18. Technique 11...................................................................................................... 64 19. Technique 12...................................................................................................... 65 20. Technique 13...................................................................................................... 66 21. Technique 14...................................................................................................... 67 22. Technique 15...................................................................................................... 68 23. Technique 16...................................................................................................... 69 vi 24. Technique 17...................................................................................................... 70 vii viii LIST OF FIGURES Page 1. Technique 1 therapeutic intentions..................................................................... 54 2. Technique 2 therapeutic intentions..................................................................... 55 3. Technique 3 therapeutic intentions..................................................................... 56 4. Technique 4 therapeutic intentions..................................................................... 57 5. Technique 5 therapeutic intentions..................................................................... 58 6. Technique 6 therapeutic intentions..................................................................... 59 7. Technique 7 therapeutic intentions..................................................................... 60 8. Technique 8 therapeutic intentions..................................................................... 61 9. Technique 9 therapeutic intentions..................................................................... 62 10. Technique 10 therapeutic intentions................................................................... 63 11. Technique 11 therapeutic intentions................................................................... 64 12. Technique 12 therapeutic intentions................................................................... 65 13. Technique 13 therapeutic intentions................................................................... 66 14. Technique 14 therapeutic intentions................................................................... 67 15. Technique 15 therapeutic intentions................................................................... 68 16. Technique 16 therapeutic intentions................................................................... 69 17. Technique 17 therapeutic intentions................................................................... 70 1 CHAPTER 1 INTRODUCTION A recent report indicated that pet-related spending continues to grow. In 2007, it was estimated that Americans spent $40.8 billion dollars in pet-related expenditures. Currently, 63% of U.S. households own a pet (American Pet Products Manufacturers Association, 2007, 2008). Such numbers suggest that pets play an important role in people‟s lives. Animals no longer play the role of just family pet, in the field of animal assisted therapy; animals also have a distinct role in the helping professions. Historically, animals in the helping professions can be dated back to a century ago, when Florence Nightingale first noted throughout effects of animal companionship on long-term hospital patients (Nightingale, 1969). Even Sigmund Freud illustrated the unique relationship between people and animals (Beck and Katcher, 1996). In a letter, Freud wrote (p. 127): It really explains why one can love an animal like Topsy (or Jo-fi) with such an extraordinary intensity: affection without ambivalence, the simplicity of a life free from the almost unbearable conflicts of civilization, the beauty of an existence, complete in itself. And yet, despite all divergence in the organic development, that feeling of an intimate affinity of an undisputed solidarity. Often, when stroking Jo-fi, I have caught myself humming a melody which, unmusical as I am, I can‟t help recognizing as the aria from Don Giovanni: „A bond of friendship unites us both.‟ Although Freud appeared to be cognizant of the therapeutic influence of animals, he did not incorporate them professionally into his work. In the field of Animal Assisted Therapy (AAT), as a whole, Boris Levinson is noted as the first mental health professional to document the therapeutic relationship. In the 1960s, Levinson discovered this potentially therapeutic relationship between 2 animals and children accidentally while working with an uncommunicative patient who began speaking when she was introduced to Levinson‟s dog, Jingles (Mallon, 1997). From that point on, Levinson explored the relationship between his patients and animals. Although others often ridiculed and mocked him about his research, Levinson continued to contribute to the field of AAT for much of his career (Mallon). Since the 1960s, researchers have examined the role of animals in the therapeutic process; however, there is still much to learn about the various types of interventions that therapists often use in their practices, and their perceptions of the effectiveness for their clients. Since Levinson‟s time, animal assisted therapy continues to evolve and develop as a therapeutic intervention. Various organizations have developed to advance the field of animals in the helping professions. One of the largest, non-profit organizations dedicated to the promotion of human- animal health connections is Delta Society (2007). In 1990, they developed their Pet Partners Program, which registers therapy animals and their handlers. Presently, there are over 10,000 Pet Partners teams in all 50 states and four other countries (Delta Society). With the growth of animal assisted therapy, the need for education and research in the field is vital. Due to the infancy of the field, much variability exists in the literature. There is, thus, an increased need in the field to distinguish the types of animal assisted related programs and services. LaJoie (2003) proposed a classification system in order to better organize the literature in this field. Various terminology is used to describe the role of animals as a therapeutic tool. LaJoie presented a ranking system where pet ownership was the lowest end of the ranking and described “the simplest form of a 3 therapeutic relationship wherein there was less structure, less intensity and less focus on the relationship between the client and the animal” (p. 47). While the higher end of the ranking would describe Animal Assisted Therapy interventions. The goal of the proposed classification system was to create a clearer communication system for the field of animal assisted therapy. With such variability in terminology, there exists a lack of understanding and clarity in the field. Two types of terminology that commonly are used interchangeably are animal assisted therapy (AAT) and animal assisted activities (AAA). In an attempt to distinguish between the two, Delta Society offered the following definitions (pp. 10-11): Animal assisted therapy: AAT is a goal directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/human services professional with specialized expertise, and within the scope of practice of his/her profession. AAT is designed to promote improvement in human physical, social, emotional, and/or cognitive functioning [cognitive functioning refers to thinking and intellectual skills]. AAT is provided in a variety of settings and may be group or individual in nature. This process is documented and evaluated. Animal assisted activities: AAA provides opportunities for motivational, educational, recreational, and/or therapeutic benefits to enhance one‟s quality of life. AAA is delivered in a variety of environments by specially trained professionals, paraprofessionals, and/or volunteers, in association with animals that meet specific criteria. Many studies exploring the efficacy of animal assisted therapy fail to distinguish between the two forms of practice. As such, in the literature review that follows, I addressed relevant studies exploring both AAT and AAA. For the purpose of the study, I explored the practice of AAT in the mental health field. 4 Statement of the Problem The body of literature devoted to the incorporation of animals in the mental health setting is slowly increasing. While much of the literature takes the form of anecdotal stories and personal narratives, such accounts only reveal some of the AAT techniques that mental health professionals have utilized. Some research indicated possible benefits associated with AAT; however, it has not explained specific ways in which mental health professionals have integrated therapy animals into the therapeutic process. According to Fine (2005), AAT is most effective when paired with skillful mental health treatment. This further highlights the need for an in-depth look into how therapists incorporate animals into the scope of their practice. Fine also cautioned, “One should not look at AAT in isolation but rather observe how the animals support and augment the clinician‟s ability to work within his/her theoretical orientation (p. 168).” Thus, the goal of this study was to discover animal assisted techniques mental health professionals utilize within their treatment process. This study explored investigated interactions among and between a therapy animal, client, and mental health professional within the therapeutic process, and various therapeutic purposes involved in the inclusion of therapy animals within the therapeutic process. Review of Related Literature The following is an extensive review of relevant literature and research related to AAT. The review will discuss the following areas: (1) exploration of various animal assisted therapy studies and their therapeutic implications, (2) variations of animal assisted therapy programs and related studies, (3) related AAT literature and therapeutic implications, and (4) justification of animal assisted technique questions. 5 Animal Assisted Therapy Studies and Therapeutic Implications Early history of animal assisted therapy. Well before Boris Levinson documented his work with his dog, Jingles, and his clients, other therapists had also incorporated animals into the therapeutic process. One of the earliest noted applications of AAT occurred in 1919; coincidentally, the Secretary of the Interior advocated the incorporation of dogs in the treatment of psychiatric patients (Burch, 1996). It was not until 24 years later, however, that AAT was documented again, this time, at the Pawling Army Air Force Convalescent Hospital in New York, among therapists working with recovering veterans (Hooker, Freeman, & Stewart, 2002). Then the use of animals in a mental health setting, again, was absent from the literature, until 1962, when Boris Levinson published his work The Dog as a “Co-therapist” (1997). Since the publication of this work, AAT has gradually been integrated into the mental health field. Levinson‟s (Mallon,1997) work focused on relationships among and between his child clients, the dog, and the therapist. He suggested that when a pet is incorporated into a therapeutic relationship, it is similar to a group situation, and that a new and different relationship is the basis for the treatment process. Levinson included his dog in different therapeutic interventions. He explained that incorporating the dog not only provided him with more opportunities as a therapist, but it also generated more comfortable opportunities for the child to identify, project, and empathize during his or her treatment. In Levinson‟s view, including an animal in the therapeutic process ultimately provided opportunities for limit setting, role playing, transference, and interpretation. 6 Animal Assisted Therapy Studies and Implications Researchers began examining aspects of AAT as an adjunct to that of the mental health field in the 1970s. An early survey, for example, investigated the use of animals in psychotherapeutic settings by members of the American Psychological Association (Rice, Brown, & Caldwell, 1973). Out of the 319 respondents, 39% were aware of the use of pets in psychotherapy and 16% had utilized animals in their own therapeutic work. A portion of the survey also investigated some of the specific uses of animals, in conjunction with psychotherapy. Rice et al. found that the most common use of animals within the psychotherapeutic setting was related to facilitating the development of social relationships, but therapists also used AAT as an adjunct in other interventions within the therapeutic setting. According to the researchers, “Respondents also cited using an animal as a source of comfort, especially during the early stages of therapy, as a reward in behavior modification framework, and even from a gestalt perspective exploring the meaning of touch, smell, and warmth” (p. 324). The survey did not ask how often the therapy animal or the various animal related techniques were incorporated in the therapeutic process. Further expansion of the information found by Rice et al.‟s research is needed, as well as a more in-depth exploration regarding the mental health practitioners‟ intentions for specific animal assisted techniques. One of the first controlled studies to explore the use of animals in a mental health environment was performed by Corson and Corson in 1975. They called it pet- facilitated psychotherapy; and described it as an adjunct to the therapy process, making it clear that it was not intended to replace psychotherapy (Corson & Corson, 1980). Their study sample consisted of patients who failed to respond favorably to other forms 7 of traditional therapy. The patients typically exhibited symptoms of withdrawal; they were uncommunicative, and some were even confined to their beds. Among the five patients they studied closely, the researchers found an increase in verbalization during the process of pet-facilitated psychotherapy, which consisted of nondirective interactions with the animals. Within the hospital, dogs were kept in kennels and introduced to patients as a part of the therapeutic study. Over time, patients began to interact more with the dogs, some asking to take them out on walks, while others came down regularly to visit or groom their dogs. Corson and Corson‟s study was ultimately one of the first to systematically examine the use of animals in therapeutic settings. In another significant study the physiological effects of human-animal interactions were investigated. Odendaal (2000) examined how the presence of a dog contributes to human well-being. In this study, the healthy humans and dogs interacted positively, while blood pressure and the following parameters: β-endorphin, oxytocin, prolactin, β- phenylethylamine, dopamine, and cortisol, were measured in an attempt to examine the effects on both the humans and dogs. The results showed a significant decrease in blood pressure and cortisol for the human participants, during five to 24 minutes of positive human-dog interactions. Results also indicated for both dogs and humans there was a significant increase in β-endorphin, oxytocin, prolactin, phenlyacetic acid (metabolite of β-phenlyethylamine) and dopamine. This study was one of the first studies conducted to show the positive physiological consequences of interacting with a dog, thus providing a rationale for using animals during the therapeutic process due to a more relaxed state of being. 8 In another study that explored the use of two styles of AAT interventions with adult college students suffering from depression (Folse, Minder, Aycock, & Santana, 1994), the participants were assigned to either a directive AAT group, in conjunction with group psychotherapy, or to a nondirective AAT group. There were 11 participants in the treatment group and 23 in the control group. The animals played a fairly similar role in both groups; however, the animals had different personalities, which, in turn, had different affects on the group members. One of the dogs was a two-year-old female Collie who was quiet and gentle, while the other dog was a seven-month-old female Collie puppy that was described as energetic, outgoing, and seeking attention. While the older dog interacted less with the participants, the participants reported that he provided a safe distraction during emotionally-laden moments. The other dog, in contrast, exhibited more puppy-like behavior, which precipitated most of the conversations and interactions in that group. Results did not indicate a difference among the directive versus the nondirective groups, and effect sizes were not calculated for either groups. AAT interventions are also taking place in mental health settings throughout the world. A study in Israel, for example, was conducted to assess the effects of AAT on long-stay geriatric schizophrenic patients over the course of one year (Barak, Savorai, Mavashev, & Beni, 2001). The effective outcome was measured as a change in the clients‟ Social-Adaptive Functioning Evaluation (SAFE) scores. These scores measure such dimensions as social interpersonal, instrumental, and life skills functioning, and are rated by observations and interactions with the subjects. The AAT sessions were conducted by three AAT counselors, but there was no distinction made as to whether 9 they were mental health counselors or AAT handlers. The interventions consisted of activities of daily living (ADL) modeling activities, which included petting, feeding, grooming, bathing, and teaching the animals to walk on a lead for greater mobility. A second goal in the treatment process was to increase mobility and socialization through walking the animals outside of the hospital grounds. At the end of the AAT sessions, the participants processed the activities and had time to say goodbye to their animal companions. Results on the SAFE scores showed that clients improved on the social functioning scale. Thus, Barak et al. (2001) suggested that human-animal interactions may facilitate social functioning. In another study, animal assisted therapy was found to be effective in reducing anxiety among hospitalized psychiatric patients (Barker & Dawson, 1998), the patients were categorized under four different diagnostic disorders: 49.2% with mood disorders, 25.6% with psychotic disorders, 16.6% with substance abuse disorders, and 8.6 with “other” disorders. Anxiety was measured by the State-Trait-Anxiety Inventory before and after the sessions. Two hundred and thirty patients participated in at least one AAT group session or one therapeutic recreation group session. Fifty patients completed pre and post measurements for both sessions. The AAT sessions consisted of a therapy dog and semi-structured interactions with the dog handler talking about the dog and encouraging the patients to carry out commands and basic obedience with the dog. The results indicated no significant difference between the patients who participated in either AAT or therapeutic recreation. The results did, however, indicate that for within group differences found for the therapeutic recreation group there was a significant decrease in anxiety for those diagnosed with mood disorders only, in comparison to the 10 AAT group which showed a significant decrease in anxiety for the patients diagnosed with mood disorders, psychotic disorders, and “other” disorders. Anxiety scores for patients diagnosed with psychotic disorders considerably reduced after animal assisted therapy compared to therapeutic recreation. Barker and Dawson suggested that “…animal assisted therapy may offer patients with psychotic disorders an interaction that involves fewer demands, compared with traditional therapies” (p. 800). The authors suggested that AAT appeared to have an effect on a wider range of diagnosis. Further considerations for this study include extending sessions beyond one single AAT session, although this arrangement was limited due to patients being discharged at various times. Barker and Dawson (1998) also suggested that no significance was found, possibly because of the small number of participants who completed all measurements. In contrast, another study explored the incorporation of a therapy animal in an attempt to reduce children‟s anticipatory anxiety entering therapy sessions, as measured by children‟s bio-behavioral measurements, as well as the Behavioral Assessment System for Children-Parent Rating Scale (BASC-PRS) (Athy, 2005). Athy‟s study combined animal assisted therapy with a play therapy session during one individual 30-minute play therapy session. The results of the two factor repeated measures analysis of variance indicated no significant differences between the two groups. In fact, the results actually indicated an increase in the children‟s anxiety in the first 30 minutes of play therapy with the presence of a therapy dog. Athy suggested that new and unknown factors, including the play therapist, the pet, armband monitor 11 measuring the bio-behavioral symptoms, and an unfamiliar environment, may have contributed to such results. A recent meta-analysis further explored AAT studies. Nimer and Lundahal (2007) sought to explore three such objectives: (1) to assess the average effect of AAT, (2) to investigate the stability of this average effect, and (3) to evaluate whether variability in the implementation of AAT and/or participants influenced outcomes. The inclusion criteria for studies included: a) reported on AAT and not AAA or pet ownership, b) included at least five participants in a treatment group, c) were written in English, and d) provided sufficient data to compute an effect size (p. 227). Their search resulted in 37 studies in peer-reviewed sources and 12 dissertations. Studies were divided into three broad categories, depending on presenting problems of AAT recipients: medical problems, mental health difficulties, or behavioral problems. Results indicated that positive, moderately strong findings were observed across the three above areas. The authors also found that due to the “complexity of interventions...and variability of AAT use” (p. 234) further analysis of the sub groupings is strongly suggested. Although this meta- analysis offered promising results in the field of AAT, such results may be premature. Authors continued to emphasize the importance of research in the field. AAT literature is still growing and evolving as a practice and area of research. Thus, there still exists a need for further controlled studies regarding its efficacy. 12 Variations of Animal Assisted Therapy Programs and Related Studies More recent variations in the field of animal assisted therapy include the inclusion of animal training programs for therapeutic purposes. Although most of these programs do not specifically incorporate a therapy animal into the treatment process, they do, however, integrate an animal as an essential part of the therapeutic treatment. Residential treatment settings. AAT has spread into different mental health settings. Residential treatment programs are organized and staffed to provide both general and specialized non-hospital-based interdisciplinary services 24 hours a day, seven days a week. Residential treatment services provide environments in which the persons reside and receive services from personnel who are trained in the delivery of services for persons with behavioral health disorders or related problems (Mental Health Dictionary, n.d.). A small number of treatment facilities across the nation have incorporated the human-animal bond. For example, Green Chimneys, in upstate New York, is a facility that serves adolescents who are experiencing difficulties and challenges. The unique characteristic of Green Chimneys is its location on more than 166 acres, with its own 75-acre farm. Not only are animals a fundamental factor in the treatment process, but the importance of nature is emphasized as well (Green Chimneys, 2007). Green Chimneys is both a residential treatment center for children with emotional, behavioral, and learning challenges, and a special education school. Interacting with nature and animals in a variety of programs is an integral part of the treatment process of Green Chimneys. Some of Green Chimneys‟ animal assisted programs include: East Coast Assistance Dogs, where dogs are trained as puppies by 13 resident teacher Dale Piccard, and by selected Green Chimneys‟ students. These dogs eventually are placed with individuals with both physical and/or motor difficulties (Green Chimneys, 2007). Another creative intervention is the Wildlife Rehabilitation Program, which takes in injured animals and educates Green Chimneys‟ students about the care and nurturing of the wounded animals. Colorado‟s Boys Ranch is yet another treatment facility that features the use of AAT. Its program serves adolescent boys who are facing behavioral and emotional challenges (Colorado Boys Ranch, 2005). The treatment teams consist of mental health professionals who use various treatment models, such as individual, group, and family therapy. Many of their programs involve animal related interventions, such as New Leash on Life. This particular program matches each boy with a dog from a local animal shelter. Over the course of ten weeks, the boys train, groom, and care for their dogs and eventually prepare the dogs to be adopted by their new families. The goal of these animal assisted programs is to increase the boys‟ learning of compassion, gentleness, responsibility, and respect for animals, other people, and themselves. A similar program was developed and studied at the Chris Adams Girls Center in Northern California. The Chris Adams Girls Center is a 20-bed residential facility that houses female juvenile offenders, ranging from 13 to 18-years-old (Cobaleda-Kegler, 2006). The residential facility incorporates an animal related program called Tender Loving Care (TLC), with a 12-week course. This program includes a group process, as well as journal writing and assignment and weekly topics, designed to facilitate therapeutic work with the animals, and training sessions for the residents to learn obedience training. The interventions feature specific themes that are addressed each 14 week. The following is a detailed description of the AAT program‟s weekly topics which structure the session. Week 1 Introductions, getting to know one another, respect, honesty, generosity Week 2 Daily care needs: emotional, physical, psychological: caring, kindness. Week 3 Understanding communication: straightforwardness. Week 4 Developing healthy relationships with people and animals: Compassion, trustworthiness, sincerity, integrity. Week 5 Boundaries in relationships: commitment, honesty, fairness, responsibility Week 6 Applying humane education in your daily life: goodwill, common good, moral obligations, citizenship, and altruism. Week 7 Stress management: focus, good judgment, self-control, obey the law. Week 8 Self-esteem, self-acceptance. Week 9 Transformations: helloes and goodbyes: forgiveness, perseverance, resilience. Week 10 Love and attachment: bonding, boundaries, mirroring. Week 11 Grief and loss: coping mechanisms, comfort, anger, resistance. Week 12 Closure and graduation. In addition to these outlined topics and activities with the animals, the group also meets for an hour of group therapy with the therapist to process issues raised by the individuals‟ work with the animals (Cobaleda-Kegler, 2006). Another relevant study on the variations of therapeutic programs with animals explored the effects of a therapeutic animal training approach with expelled youth in an alternative high school setting (Granger & Granger, 2004). Participants (n=31) were assigned to one of three treatment groups: control, individual AAT, or small group AAT. Participants were measured on standardized teacher and student behavior rating scales (BASC-The Behavior Assessment Scale for Children), as well as pre and post test 15 observations related to student indices of direction following, acceptance of staff feedback, and respectful and caring responses toward others, in addition to differences in classroom absences (Granger & Granger). The results did not indicate any significant differences between changes in attitudes toward school, aggressive behavior, interpersonal relations, and classroom absences. Yet, for both of the AAT treatment groups, a paired samples t-test indicated a difference between teacher ratings in the area of social skills. An effect size of d=.49 indicated a moderate effect for increased social skills of students with adult and peer interactions within this setting, thus possibly implying the effects of enhanced social skills. Qualitative interviews revealed students and staff supported the project and enjoyed their experiences. Granger and Granger suggested further exploration with increased participants may ultimately expand their findings. Equine Assisted Therapy Research Under the umbrella of animal assisted therapy, horses and their therapeutic effects have created a variation of animal assisted interventions called equine assisted therapy. The Equine and Assisted Growth and Learning Association (EAGALA, 2007), promotes equine assisted psychotherapy through research and education. The following studies highlight the effects of equine assisted therapy. A recent study explored the effectiveness of equine assisted group counseling with at risk children and adolescents. Trotter (2006) examined “at risk” youth and the effects of equine assisted group counseling, in comparison to a curriculum-based group counseling intervention. The study examined the externalizing, internalizing, maladaptive, and adaptive behaviors of 164 elementary and middle school students 16 considered at risk of academic failure. Participants participated in either a two hour, twelve week equine assisted group counseling program, or a one hour, twelve week curriculum-based group guidance treatment. Results were measured on two instruments: the Behavior Assessment System for Children-Self-Rating, Parent-Rating, and Teacher-Rating Scales (BASC), and the Animal Assisted Therapy Psychosocial Session Form (AAT-PSF) Results of an ANCOVA comparison of both groups using the BASC-Self, Parent, and Teacher Reports showed statistically significant improvement in seven behaviors, compared to the curriculum-based program. Results of the repeated measures ANOVA AAT-PSF, which measured the equine assisted therapy group only, showed statistically significant improvement on all three scale scores: 1) overall total behaviors; 2) increased positive behaviors; and 3) decreased negative behaviors (Trotter). A new variation in the incorporation of equine facilitated therapy is the incorporation of equine facilitated therapy with couples. A recent study by Russell- Martin (2006) compared equine facilitated couple‟s therapy to solution-focused couple‟s therapy, as measured by relational adjustment scores on the Dyadic Adjustment Scale (DAS). Participants included 40 couples, aged 21-45, who participated in a six-week treatment program, either in the equine facilitated therapy group (EFT), or in the solution-focused therapy (SFT) group. The DAS was administered at the first, third, and sixth session of treatment. The first two administrations of the DAS did not result in significant differences between the groups, but the third administration did result in significant differences, with the EFT group scoring higher on relational adjustment of the DAS. Russell-Martin suggested that EFT and SFT were both effective as treatment 17 approaches to couples relational adjustment, as measured by the DAS. This study also added to the quantitative support of EFT as an effective treatment approach, as seen in the results by the sixth session of treatment. AAT Related Literature and Therapeutic Implications The Delta Society (2007) offered ten potential therapeutic implications of animal assisted therapy. 1. Emotional safety--the therapist may be viewed as more approachable if there is an animal present. The power structure has shifted and the environment is less threatening. 2. Relationships--clients who have difficulty developing a relationship with other human beings are able to relate to an animal. The animal can be a source of love and companionship and the client can direct feelings of love and concern for an animal when he or she may have difficulty with the expression of emotions in a human relationship. 3. Limit setting and consequences--animals respond quickly to stimulus provided by a client. Learning that there are limits to the behavior that an animal will accept can help the client generalize the concept of limits and consequences to the human environment. 4. Attachment--an animal can offer the opportunity for uncomplicated attachment. Learning the skills of attachment from the relationship with an animal will help in developing a relationship with other human beings. 18 5. Grief and loss--many people have experienced the loss of a beloved animal. Processing that loss can assist the client in working through issues of loss and abandonment. 6. Reality orientation--the presence of an animal may help to ground a client in the present. 7. Pleasure, affection and appropriate touch--the client chooses whether or not to touch or hug an animal. Since he or she makes the choice, the interaction is safe, non-threatening and pleasant. 8. Socialization--the presence of animals provides the opportunity for social interaction and interpersonal connection. 9. Play and laughter--a client can learn how to play through interactions with an animal. 10. Anxiety--the ability to focus on the animal rather than the internal feelings of anxiety can help the client to learn distraction skills in a non-threatening environment. Although previous research has explored the efficacy of some of these applications, strong support appears inconclusive. Nevertheless, literature from experts and those that practice in the field seem to support and elaborate on these findings. These days, seeing animals lingering in school hallways, or greeting children in the morning before class, is becoming a more common occurrence because school mental health professionals are recognizing the value of AAT. Trivedi and Perl (1995) recounted the way Sarah Jane, a therapy dog, helped their counseling sessions with students. Sarah Jane‟s role is to serve as a companion for children who participate in counseling sessions. Sarah Jane is simply a source of comfort and unconditional 19 acceptance for the children. Trivedi and Perl noted that a therapy animal does not need to be accompanied by specific interventions within the mental health session; rather, the animal‟s presence is sufficient enough to create an environment in which a child can make therapeutic gains. Consequently, the presence alone of a therapy animal facilitates a sense of comfort and safety within the therapeutic environment. A recent incorporation of therapy animals, in a specific treatment modality is in the field of play therapy. VanFleet (in press) offers the following definition for animal assisted play therapy (p. 31): Animal Assisted play therapy is the use of animals in the context of play therapy, in which appropriately trained therapists and animals engage with children and families primarily through systematic play interventions, with the goal of improving children‟s developmental and psychosocial health as well as the animal‟s well-being. Play and playfulness are essential ingredients of the interactions and the relationship. VanFleet describes how therapy animals can be included in both directive and nondirective approaches in the play room. In nondirective play therapy, the therapy animal becomes another “object” in the play room with which the child can choose to incorporate into their play. If the child chooses not to involve the therapy animal into his or her play, a play therapist may include the therapy animal as a part of the tracking responses often incorporated into play therapy. In contrast, therapists can also integrate a therapy animal with more directive interventions. VanFleet describes how structured activities can include training, storytelling, fantasy play, and games (p. 77). Reinforcement is an integral part of behavioral therapy. Wilson (2000), as one key example, stated that positive reinforcement increases the frequency of a behavior or response, followed by a positive event. Rewards may act as incentives for treatment progress, or for small behavioral changes. Mental health professionals who incorporate 20 animals into the therapeutic process may add spending time with an animal as an enticement for their clients. Psychologist Hennie Swanepoel, who works in South Africa, creatively integrates spending time with a gentle elephant as a reward when a client accomplishes a new goal (Kraft, n.d.). Some of the literature has also reported on the key ways that animals assist in developing rapport within a therapeutic relationship. Therapy animals can be a source of building rapport in the therapeutic relationship (Chandler, 2005; Fine, 2006). Mental health professionals may appear less threatening with an animal as a co-therapist by their side. Chandler suggested that a friendly, furry animal face is often all that it takes to help people who are frightened of other people to feel safer. Levinson also frequently addressed this process and implied that bringing in the animal at the beginning of therapy often helps ease the client‟s reservations or anxiety. Fine recounted his animals welcoming clients into his therapeutic setting, even stating that animals are influential in establishing the emotional energy within the room. Thus, not only can an animal help build rapport, but a friendly animal can make the therapeutic setting safe and inviting. Modeling can also take place within an animal assisted therapeutic setting. A mental health professional intentionally or unintentionally may model certain behaviors with the therapy animal. Fine (2005) noted that various therapeutic moments can revolve around role modeling with a therapy animal, and those discussions with adults on boundary setting, the need to be loved and admired, and appropriate ways of interacting are all relevant to one another. For example, Fine mentioned that 21 sometimes during a session, boundaries need to be placed on the animals, which, in turn, can evolve into a therapeutic conversation on limit setting. Fine (2005) also noted that when he incorporated modeling into his therapeutic sessions, discussions regarding limit setting sometimes would arise. Levinson, however, discussed limit setting as a specific, animal assisted intervention topic. Although setting limits often arises from a child‟s spontaneous behavior, Levinson found that limit setting was often an integral part of the therapeutic process. He shared his experiences, in which some of his clients expressed desires to hurt or kill his dog, and although he did not discourage children from expressing themselves, such moments facilitated discussions about setting limits and boundaries with his child clients. Justification of Animal Assisted Technique Questions Kruger and Serpell (2005) described animal assisted interventions as any intervention that intentionally includes or intentionally incorporates animals as a part of the therapeutic or ameliorative process or milieu. A review of the literature related to AAT within mental health settings indicates that animal assisted interventions may incorporate a variety of therapeutic techniques prompted by the mental health professional incorporating the therapy animal into the process. As such, Chandler (2005) described AAT as a therapeutic modality which can be integrated with various theoretical orientations and complement a range of techniques. For the purpose of this study, the researcher examined the specific therapeutic techniques that utilized the therapy animal as a part of the therapeutic process, regardless of theoretical orientation. What follows describes the various animal assisted techniques found in the literature, which served as a basis for the survey questions. 22 Relational techniques. Chandler (2005) highlighted various animal assisted therapy techniques and their therapeutic implication. One of the common uses she described as basic relational techniques. She suggested that “it can be very therapeutic to reflect, paraphrase, clarify, and summarize the behaviors and expressions of the therapy pet, the client, and the interactions between them” (p. 91). Chandler described some responses incorporating her therapy dog, Rusty, for example, “A moment ago you seemed a little anxious and your voice was fast and high-pitched. Now as you sit there stroking Rusty‟s fur, you seem quieter and more introspective.” Responses can relate to the client‟s nonverbal interactions with the animal, as well as the client‟s relationship with the animal. Statements such as these may contribute to clients‟ increased self- awareness or self-exploration during therapeutic sessions. Facilitating touch. Touch between a mental health professional and a client has had controversial and ambiguous results. Pattison (1979) suggested that clients who engaged in touch often experienced deeper exploration and evaluated their therapeutic experience more favorably. Animals may fulfill the client‟s need for physical touch or contact. Chandler (2005) addressed the animal‟s ability to act as an alternative for physical contact from the mental health professional. Unlike sand or inanimate objects, according to Chandler, live animals engage in affectionate behaviors that reinforce the therapeutic benefits of touch. As such, therapists who practice AAT have provided examples of the therapeutic benefits of this form of contact between animals and humans. For example, Brenda Dew (2000) shared her experiences with her therapy dog, Moses, whom she described as her co-therapist. She explained that Moses often allowed her clients to touch and pet him without overwhelming the clients. In a similar 23 fashion, Laurie Burton (2001), a school counselor, illustrated how her therapy dog, Blaze, provided a soft touch during an individual session with a young boy, explaining that the boy hugged and petted Blaze, as he conversed with her during their meetings. Walking therapy. Another animal assisted technique, which Fine (2005) described as providing an alternative to a traditional mental health setting, is what he called “walking therapy.” Over the course of his therapeutic work, his birds and dogs often accompany his clients on walks around his private practice neighborhood. During these walks, Fine often facilitates therapeutic discussions on the animals‟ spontaneous behaviors. Fine also noted that connecting with the outdoors and nature enhances the therapeutic discussions for some of his clients. The incorporation of “therapeutic walking” or “walking therapy” does not require a directive setting. Instead, it offers a nondirective and natural animal assisted intervention. Obedience training and tricks. Teaching obedience to an animal, most often times a dog, requires patience and determination on the part of the trainer. Fine (2005) shared his experiences with some of his clients and incorporated such training as a part of the therapeutic intervention. Fine reported that a part of the process is connecting how “the process of change in the animal has [a] similar objective to their own treatment goals.” Teaching an animal a trick or commands is a growing trend in many therapeutic programs involving animals. For example, Second Chance is a program that pairs at- risk offenders with shelter dogs to train the dogs on basic obedience and socialization. Such programs offer both the animals and the youth opportunities to practice empathy, 24 responsibility, and kindness. The concept of obedience training is incorporated in both therapeutic programs and individual treatment sessions. Chandler (2005) described her experience with clients engaging in trick training with her therapy dogs. Although at times a client may experience frustration when a therapy animal is not performing a certain trick, finally accomplishing these tasks may enhance feelings of self accomplishment and pride. History sharing. Chandler (2005) suggested incorporating animals when attempting to gather information about a client‟s family history, such as in a genogram. Genograms are schematic diagrams of a family‟s relationship system, used to trace recurring family patterns over the generations (Corsini & Wedding, 2000). Genograms can be used for various reasons and in various fashions as a part of a therapeutic intervention. Chandler proposed “When the therapy animal has a pedigree with some type of registry, such as American Kennel Club for dogs, sharing the animal‟s family ancestry is a fun way to introduce the client‟s own family tree exercise” (pp. 99-100). These techniques may lead to clients sharing of their own family history or social support. Creating metaphors. Mental health professions often use metaphors when communicating during the therapeutic process. Both Chandler (2005) and Fine (2006) addressed the utilization of metaphors related to therapy animals for the therapeutic process. Fine noted incorporating his therapy birds metaphorically within the therapeutic process. Chandler suggested that using animal-related metaphors in therapy is based on the idea that even though the imagery and metaphor briefly shift the 25 focus to the animal, clients tend to process the animal‟s experience or story through their own perspectives, which draws from their own life experiences. Story telling. In the literature, mental health practitioners have identified specific interventions from their experiences with incorporating animals into their work. For example, Reichert (1998) addressed the use of AAT with a population of sexually abused children. Reichert identified storytelling as an integral part of the therapeutic process in working with these children, and that animals also play a role in that process. Reichert also stated that although animals can play an important part of the treatment, AAT does not stand alone in treating sexually abused children; rather, it must be used in conjunction with other types of therapy. One such approach integrates indirect interviewing through the animal to help gather information from small children. For instance, Reichert described a social worker generating questions, such as, “Buster would like to know how old you are.” Reichert illustrated a further use of the animal relationship specifically to the purpose of disclosure. The social worker may encourage children to reveal their sexual abuse story to the animal in the session; they also may choose to whisper their story into the dog‟s ear. Reichert described a story related to a challenge that the animal encountered, which was followed by questions connected to the story. Many possible stories could be created to suit a child‟s specific experiences. Reichert claimed that by integrating the animal into the story, the social worker gives children an opportunity to identify with the animal and project their feelings onto the animal, thus facilitating disclosure and the expression of feelings. Role playing. Another technique that mental health professionals can incorporate within the therapeutic process is the use of role playing. Depending on 26 mental health professionals‟ orientation and approach, role playing may differ in its purpose and structure. Therapy animals can participate in scenarios in which children act out their imaginative role plays. Nebbe (1991) implied that role playing with an animal can lend insight into the child‟s personal struggles. Levinson (Mallon, 1997) referred to the technique of “behavioral rehearsal” as a possible animal assisted intervention. He suggested that the child and the mental health professional, along with the animal, can act out traumatic situations. Role plays tend to be a more directive intervention and, therefore, require more guidance from the mental health professional. Spontaneous interactions. Evidence of the physiological implications or effects and the social benefits of human-animal interactions in therapeutic settings in related literature also suggests that having an animal in a therapeutic setting may facilitate the therapeutic process in unintentional ways that may create new opportunities for clients‟ further exploration and awareness. Animals can display behaviors spontaneously, without being directed by the therapist. As such, animals can provide unprompted interactions that can result in beneficial therapeutic exchanges. Dew (2005), for example, depicted the following interaction that took place during a therapy session with her co-therapist, Moses (p. 200): As I began the session discussing why he was here, all the client would do was to grunt unintelligible English, which was becoming frustrating for me as well as for him. Suddenly, I caught a glimpse of my partner rising from his seat and walking over to the client. Moses sat directly in front of the client, gazed into his eyes with his soft brown eyes and placed his paw on the client‟s lap. I worried that the client might feel his space was being invaded, so I started to reprimand Moses for violating this person‟s territory. Much to my surprise, the client began to touch Moses and speak to Moses in excellent English. Once again, Moses had initiated an action that allowed me to join with the client. 27 Spontaneous interactions may provide therapeutic moments, but the occurrence of such moments are not directed or initiated by the therapist. In sum, given some of the interventions described throughout the literature reviewed herein, mental health professionals appear to utilize animal assisted therapy within their practices, coupled with other therapeutic techniques. Therefore, a closer look into these AAT interventions, and how they are incorporated into the therapeutic process itself, may further uncover how animal assisted therapy is practiced. Purpose of the Study The purpose of this study was to determine the various interventions that mental health professionals incorporate during their AAT relationships. This study attempted to clarify the different animal assisted techniques, as well as explored which techniques were incorporated more often than other interventions in therapeutic relationships. The outcome of this study may ultimately shed much light on how mental health professionals are incorporating therapy animals into therapeutic settings, and the results could also provide information on how animals are an adjunct to the therapeutic relationship. Although, mental health professionals have incorporated therapy within their practice for quite some time, the process of animal assisted therapy remains ambiguous. This study describes various ways mental health professionals integrated therapy animals into their practices. 28 CHAPTER 2 METHODS AND PROCEDURES Research Questions What types of animal assisted therapy interventions do mental health professionals incorporate into their practice and how often do they utilize these interventions? Further, for what therapeutic intentions (purposes) do they utilize specific animal assisted therapy interventions? Research Assumptions 1. Mental health professionals who practice AAT utilize a variety of AAT techniques. 2. Mental health professionals who practice AAT incorporate some AAT techniques more often than others. 3. Mental health professional incorporate AAT techniques for different therapeutic intentions. Definition of Terms Animal assisted therapy refers to a “goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/human service professional with specialized expertise, and within the scope of practice of his/her profession. AAT is designed to promote improvement in human physical, social, emotional, and/or cognitive functioning [cognitive functioning refers to thinking and intellectual skills]. AAT is provided in a variety of settings and may be group or individual in nature. This process is documented and evaluated” (Delta Society, 2007). 29 Animal assisted techniques refers to “any intervention that intentionally includes or incorporates animals as part of a therapeutic or ameliorative process or milieu (Kruger and Serpell, 2005, p. 25). Mental health professional refers to a licensed practitioner or licensed intern in the field of mental health. Center for Animal Assisted Therapy Mental Health Professional refers to a member of the University of North Texas, Center for Animal Assisted Therapy‟s database who has identified themselves as a mental health professional working with a registered therapy animal. Delta Society identified mental health professional refers to a member of Delta Society who has identified themselves as a mental health professional working with a registered therapy animal. Yahoo Animal Assisted Therapy Professional Online Group refers to an online group connected to Yahoo search engine, which members consist of professionals or paraprofessionals involved in animal assisted therapy. Method Participants Participants were recruited from three sources: Delta Society‟s database, The Center for Animal Assisted Therapy‟s identified mental health professionals, and Yahoo‟s Animal Assisted Therapy Online Professional group. Participants were selected by including those members identified as mental health professionals or mental health professional interns who are currently practicing animal assisted therapy or have practiced animal assisted therapy. Due to the specialized nature of these participants 30 purposive sampling was utilized. Nardi (2006) described purposive or judgmental sampling as a technique used in order to gather a sample for a unique purpose or when the researcher knows they have particular traits that are of interest to study. Members from Delta Society‟s database and The Center for Animal Assisted Therapy‟s database were first contacted regarding participation in the research and then I posted a message to the Yahoo Online AAT Professional group when discovering its existence online. Instrument Initial survey questions were developed to gather demographic information pertaining to the mental health professional and the therapy animal. Thomas (2004) suggests demographic information provide a profile of the respondents, thus the demographic questions included as many response categories as possible. According to Groves, Fowler, Couper, Lepkowski, Singer, and Tourangeau (2004) respondents are hesitant to provide answers that are not explicitly requested in the responses. Demographic survey questions included: gender, date of birth, racial/ethnic identification, professional discipline, licensure, environment where animal assisted therapy is practiced (such as school setting, private practice, community agency, etc.), primary population participant serves, theoretical orientation (if applicable), number of years as a mental health professional, and number of years incorporating an animal into their professional practice. Survey questions were designed in closed format. A closed format is known to produce standardized data and provide clarity for the respondents (Fink, 2003). Fink suggested guidelines for presenting uncluttered survey questions by instructing respondents how and where to mark the responses and emphasizing any special tasks or requirements in the question. Questions followed such guidelines in 31 order to promote clarity and accuracy of data collection. Due to the inclusion of a therapy animal in the therapeutic process, the demographic section of the survey also included questions related to the therapy animal in order to provide a thorough picture of the respondents and their animal assistants. These questions were also formatted with wording that makes sense for the intended respondents. These questions addressed information regarding the therapy animals, such as number of therapy animals utilized in practice, type of animal or animals utilized in practice, age, breed, sex, and certification of therapy animals. Further questions also related to ownership of the therapy animal, the process of introducing the therapy animal to clients, and amount of time therapy animal is included into therapy practice, and reasons why a therapy animal may not be included in session. These questions were designed in order to gather information regarding the different aspects of the therapy animal and the process of incorporating a therapy animal into practice. The above questions were inclusive and exhaustive in order to gather as much information from the respondents as needed to present a clear profile. The second portion of the survey instrument asked questions regarding the specific animal assisted therapy techniques mental health professionals utilize in the therapeutic process and the intended purpose of those techniques. Survey questions were formed from an in-depth review of literature on animal assisted therapy, specifically regarding techniques and the benefits of techniques. Nineteen AAT techniques were identified from the literature review. Regarding AAT techniques respondents were asked to rate on a Likert scale how often they utilized each of the techniques with their clients: 0=Never, 1=Seldom, 2=Often, 3=Always. In addition, ten 32 therapeutic intentions were identified to represent the purpose or reason the therapist utilized a certain technique. Respondents were asked to identify the therapeutic intentions they associated with each specific animal assisted technique. Respondents were also given the option to choose the category “other” therapeutic intention, and asked to describe any other therapeutic reason they may utilize a specific animal assisted technique. Open ended questions were also included toward the end of the survey to inquire about various activities and spontaneous moments that have occurred with the incorporation of a therapy animal in the therapeutic process. I consulted with a statistician regarding survey design. In addition to consulting with a statistician, I conducted an expert review with six specified mental health professionals who incorporate therapy animals into their practice and are knowledgeable about animal assisted therapy, in order to test the clarity of the survey questions and to receive feedback for improvement of the survey design, as suggested by Fink (2003). I incorporated the expert reviewers‟ comments and made appropriate modifications to the survey design and questions. Data Collection Participants were initially contacted to determine their willingness to participate and to determine whether they preferred an electronic or paper version of the survey. Surveys were delivered either through e-mail or postal mail depending upon the preference of the participant. Groves et. al (2004) noted the use of various modes of data collection allowed respondents to choose an option most suitable for them. From the Delta Society database of 56 mental health professionals, 32 were sent an electronic version of the survey while 24 members, who had mailing addresses only, 33 were sent a paper version. From the Center for Animal Assisted Therapy, 33 members were contact, 28 were sent an electronic version and five of these members requested paper surveys. Lastly, four members from the Yahoo Online AAT Professional group contacted me in order to request an electronic survey in response to an e-mail invitation to participate. A total of 93 surveys were distributed. Forty one professionals responded to the survey, yielding a 44% response rate. Of those that did respond, ten did not qualify for various reasons: one respondent did not have a license in mental health and the other respondents did not practice AAT in a professional mental health setting. Thus, a remainder of thirty one (n=31) participants qualified and were analyzed for the study. Although Borque and Fielder (2003) noted response rates for online surveys tend to be low, higher response rates were found in professional membership organizations due to members‟ higher motivation. Those who practice AAT tend to be interested in helping the field grow. For example, two respondents contacted me in order to clarify their qualifications and reported filling out the survey, even though they were unsure if they qualified but hoped that their information would be helpful. Surveys were available to fill out for a specified time of four weeks. After two weeks, a follow up email or postal letter were sent out to remind participants of the time frame to fill out the survey. Follow up reminders sent in the mail also included an extra copy of an informed consent letter and a copy of the survey. Follow up emails included a link to the survey. Several methods were used to further increase survey participation and response rate. First, the survey introduction was personalized. Second, the format of the survey was carefully constructed to be as quick and simple to complete as possible. Third, incentives were used to increase survey participation. Borque and Fielder (2003) 34 suggested that incentives not only encourage respondent participation, but some incentives can illustrate to participants “…their time is valuable and worth compensation” (p. 164). Participants in this study were offered a drawing for a $100.00 gift certificate to a popular pet store that offers local and internet shopping. Due to the nature of the study, the pet store gift certificate seemed appropriate for those working with animals. Statistical Analysis Data was inputted into a Statistical Package for the Social Sciences (SPSS) program. SPSS is an inclusive program most often used for analyzing research data in the social science field (Gall, Gall, and Borg, 2003). Due to the limited amount of research in the field of animal assisted therapy, particularly in relation to animal assisted techniques, this study‟s intent was an exploratory design. Exploratory research is performed in order to better understand what is happening on an underdeveloped topic for which there is a lack of information (Nardi, 2003; Heppner, Kivlighan, and Wampold, 2008). Due to the exploratory nature of the study, descriptive statistics, frequency tables, and percentages were used to analyze most of the data. Additionally, due to the low response rate, analysis exploring group differences could not be run. A Crohnbach alpha was utilized with non-demographic items to analyze internal consistency of the survey. There are various types of missing data and several ways to address missing data in research (Lynch, 2003). For these results, missing data was adjusted by substituting the overall mean. When a small amount of missing data exists, substituting the overall mean is a common strategy (Fink, 2003.). A majority of participants 35 completed the entire survey. I also noted in the results section when participants did not have a response. 36 CHAPTER 3 RESULTS AND DISCUSSION This chapter describes analysis of the data collected to address the stated assumptions and research questions: What types of animal assisted therapy interventions do mental health professionals who practice animal assisted therapy incorporate into their practice and how often do they utilize these interventions? Further, for what therapeutic intentions (purposes) do they utilize these specific animal assisted therapy interventions? Data were collected using both online survey method and paper based mail surveys. Data were coded and analyzed using SPSS 16.0 statistical data analysis program. Results Respondents were first asked to answer questions related to demographic information: date of birth, gender, ethnic identification, as well as information regarding their occupation and licensure information. Due to the study exploring the practice of mental health professionals, much information was gathered regarding their professional information. The 31 participants were comparably distributed by gender, 16 (51.6%) respondents identified as male and 14 (45.1%) female, one (3.2%) participant did not respond. Most participants were between the ages of 46 and 65. Two (6.0%) participants did not indicate date of birth. All respondents identified their ethnic group as Caucasian (see Table 1). 37 Table 1 Demographic Information Variable n Percentage Gender Male 16 51.6 Female 14 45.1 No Response 1 3.2 Age 26-35 3 9.6 36-45 3 9.6 46-55 11 35 56-65 11 35 66-75 1 3.2 No Response 2 6 Ethnic Identification Caucasian 31 100 Participants were asked about their academic degree in a mental health field. Of the 31 participants, all reported having a college degree, with the majority having a masters‟ degree (see table 2). Those who were not licensed/certified or licensed/certified interns were not included in the study. In regards to their mental health licensure/certification, most participants reported having a license as either a professional counselor or a clinical social worker. Some participants reported having multiple licenses, thus the number of licenses adds to a number greater than the number of participants (see table 3). 38 Table 2 Educational Information Highest Degree in Mental Health Field Frequency Percentage College Degree College 1 3.2 Masters Degree Doctorate Degree Masters‟ 22 8 70.9 25.8 Table 3 Mental Health Licensure/Certification Information Mental Health Licensure/Certification Frequency Percentage Marriage and Family Therapist Marriage and Family Ther Apistp 3 9.6 Professional Counselor 15 48.3 Clinical Social Worker Clinical/Counseling Psychologist 8 4 25.8 12.9 School Psychologist School Counselor 0 3 0 9.6 Chemical Dependency Counselor 2 6.4 Sex Offender Treatment Provider 1 3.2 (table continues) 39 Table 3 (continued). Mental Health Licensure/Certification Frequency Percentage Interns 2 6.4 Participants were asked to identify their mental health guiding theory for client conceptualization. Two (6.4%) participants indicated adlerian theory, eight (25.8%) indicated cognitive behavioral theory, one (3.2%) reported family systems, one (3.2%) reported humanistic, two (6.4%) indicated gestalt theory, fourteen (45.1%) reported conceptualizing clients from various theoretical orientations, and three (9.6%) indicated the other category. Participants were asked how many years they have practiced as a mental health professional. Responses ranged from one year to 30 years. Four (12.9%) indicated practicing in the mental health field from one to five years, five (16.1%) indicated six to ten years, six (19.3%) participants 11 to 15 years, nine (29.0%) reported 16 to 20 years, three (9.6%) indicated 21 to 25, and four (12.9%) reported 26 to 30 years. Demographics Related to the Therapy Animal The survey also contained questions related to participants‟ practice involving the therapy animal. Questions were designed to obtain a detailed picture of how a therapy animal is incorporated into their practice. 40 Participants were asked how many years they have incorporated a therapy animal into their mental health practice. Participants‟ responses ranged from one to 20 years. Nineteen participants (61.2%) reported one to five years, five (16.1%) indicated six to ten years, five (16.1%) reported 11-15 years, and two reported 16-20 years. Participants indicated the various therapy animals they have incorporated into therapy. Of the 31 respondents, 21 (67.7%) reported working with dogs, two (6.4%) indicated working with cats, two (6.4%) reported working with horses, and six (19.3%) reported working with multiple animal species such as both dogs and horses, or dogs and cats. Of the six participants who indicated working with multiple species, one (3.2%) participant indicated working with a guinea pig, and one (3.2%) respondent reported working with a mini donkey. The most common dog breed reported was golden retriever. Most of the animals were registered as therapy animals through Delta Society, Therapy Dogs International, or the American Kennel Club‟s Canine Good Citizen certification. Participants were asked to describe setting in which they primarily practiced AAT. Fourteen (45.1%) participants reported private practice as the primary place they practice AAT, four (12.9%) indicated a community agency, three (9.6%) reported a middle school, two (6.4%) responded practicing on a college campus, three (9.6%) indicated a hospital, three (9.6%) reported an elementary school setting, one (3.2%) indicated a residential treatment center, and one (3.2%) described more than one location as their primary setting where they practiced AAT(see appendix). Some of the other locations indicated as places where participants practiced AAT were an adoptive 41 agency, outpatient child guidance clinic, outpatient psychiatric program, a barn, nursing home, and a preschool. Participants were asked what percentage of time they practiced AAT in various treatment modalities. Responses were grouped according to a) percentage of time AAT was incorporated, b) therapeutic modality practiced, c) treatment format (individual or group), and d) population served (children, adolescents, adults, and elderly). The following results are not mutually exclusive. Participants incorporated AAT most frequently into talk therapy, play therapy, activity therapy, and expressive arts therapy. Of the 31 participants, 28 (90.3%) reported practicing talk therapy, 18 (58%) reported practicing play therapy, six indicated practicing (19.3%) activity therapy, six (19.3%) reported practicing expressive arts therapy, five (16.1%) reported practicing sand tray therapy, four (12.9%) indicated practicing adventure therapy, three (.09%) practiced biofeedback therapy, one (3.2%) reported practicing music therapy, and one (3.2%) also reported practicing drama therapy. Tables four through seven present the frequency of AAT therapy practice for the four most common treatment modalities reported; table data include format (individual or group), population (children, adults, or elderly), and percentage of time AAT is incorporated. For a complete list of tables by each treatment modality see Appendix B. 42 Table 4 Frequency of Participants Incorporating AAT in Talk Therapy 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 5 4 1 7 Group 2 3 0 3 Adolescent Individual 11 3 1 3 Group 2 2 1 3 Adult Individual 7 3 1 10 Group 5 1 0 4 Elderly Individual 2 0 3 1 Group 1 0 1 0 43 Table 5 Frequency of Participants Incorporating AAT in Play Therapy 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 4 3 3 4 Group 0 3 1 1 Adolescent Individual 3 1 1 4 Group 1 0 1 1 Adult Individual 0 1 0 0 Group 0 0 0 0 Elderly Individual 0 0 0 0 Group 0 0 0 0 44 Table 6 Frequency of Participants Incorporating AAT in Activity Therapy 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 3 1 2 2 Group 1 1 0 1 Adolescent Individual 1 1 1 3 Group 0 1 0 1 Adult Individual 1 1 0 1 Group 0 0 0 0 Elderly Individual 0 0 0 0 Group 0 0 0 0 45 Table 7 Frequency of Participants Incorporating AAT in Expressive Arts Therapy 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 1 1 0 1 Group 0 0 0 0 Adolescent Individual 0 1 0 0 Group 0 0 0 1 Adult Individual 0 0 0 0 Group 0 0 0 0 Elderly Individual 0 0 0 0 Group 0 0 0 0 Respondents were asked how often they practice AAT. Participants reported the following: five (16.1 %) reported once a week, six (19.3%) reported twice a week, three (9.6%) indicated three times a week, five (16.1%) reported four times a week, six (19.3%) reported five times a week, four (12.9%) indicated three times a month, and two (6.4%) reported that it varies how often they practice animal assisted therapy professionally. Participants were asked whether or not the therapy animal is present with every client; eight (25.8%) reported the therapy animal is present with every client, 22 (70.9%) 46 indicated that the therapy animal is not present with every client; one (3.2%) participant did not answer. Participants reported some of the reasons for not including the therapy animal with every client. Animal allergies and appropriateness of client for AAT were commonly reported as reasons why a therapy animal was not included. Some participants reported that clients had a fear of animals, history of abuse of animals, clients with impulsivity, or phobias related to animals may not be appropriate for animal assisted therapy. Some participants also indicated that some of their clients have no interest in working with a therapy animal. Some also noted that depending on their work schedule some days are not conducive for the animal‟s welfare, such as long hours. When asked if the therapy animal is introduced to the client in the first session respondents answered the following, 20 (64.5%) reported yes, the therapy animal(s) is introduced to the client(s) in the first session; ten (32.2%) indicated that they did not introduce the therapy animal in the first session, one (3.2%) participant did not respond. Those who did not include the therapy animal in the first session indicated some of the reasons as to why they did not include the therapy animal in the first session; such as evaluating for the clients‟ appropriateness of working with a therapy animal; for example if they have a fear of animals. One participant indicated having a book that they created about their therapy animal and has the child read the book and discuss what their session would look like if the therapy animal was included. Some participants indicated wanting to assess clients and situation in order to evaluate the animal‟s welfare as well. Participants tended to think about the welfare and comfort level of both the client and therapy animal. 47 Participants also indicated whether a therapy animal was typically present the entire amount of time during the session. Of the 31 participants, 28 (90.3%) indicated that the therapy animal was present during the entire session, three (9.6%) reported that the therapy animal was not present during the entire session. One participant explained that they could not make a therapy cat stay during the entire session, if the cat decided it wanted to leave. Participants were also asked whether they were the primary caregivers of the therapy animal, 29 (93.5%) indicated they were the primary caregiver, two (6.4%) reported they were not the primary caregiver. One participant indicated they were primary caregiver of one therapy animal, but not of another therapy animal that was incorporated into their practice. Assumption 1 Mental health professionals incorporate therapy animals in conjunction with a variety of therapeutic techniques. A list of therapeutic techniques involving the therapy animal were listed and reviewed by a panel of experts. These techniques were compiled based on the literature described in chapter one. Participants were asked to rate how often they incorporated these animal assisted techniques in their mental health treatment process. Participants rated their use of the specific techniques on a Likert scale with 0=Never, 1=Seldom, 2=Often, and 3=Always. It was assumed that mental health professionals utilized a variety of techniques, which incorporated the therapy animal, into the therapeutic process. One item, “Spending time with therapy animal is a reward for progress in therapeutic treatment,” was not analyzed due to its lack of clarity and 48 inclusion of a therapeutic intention within the question. For a table of results see Appendix C for the 18 techniques that were analyzed. One of the participants did not answer these ratings. Technique 1. Therapist reflects or comments on client‟s relationship with therapy animal. All participants reported incorporating this technique. Nineteen (61.3%) reported often reflecting or commenting on client‟s relationship with the therapy animal, nine (29%) indicated always. Two (6.4%) participants reported seldom practicing this technique. Technique 2. Therapist encourages client to interact with therapy animal by touching or petting therapy animal. All participants reported incorporating this technique with their clients, similarly to technique one. Most participants reported practicing this technique often (n=19, 61.3%), six (19.4%) participants reported seldom, and five (16.1%) reported always. Technique 3. Therapist encourages client to play with therapy animal during session. Results for this technique indicated that most participants reported often (n=14, 45.2%) and eleven (35.5%) reported seldom. Three (9.7%) participants reported never, and one (3.2%) reported always. Technique 4. Therapist encourages client to tell therapy animal about client‟s distress or concerns. Most participants reported seldom (n=16, 51.6%) or never (n=7, 22.6%) encouraging the client to tell therapy animal about their distress or concerns. Five (16.1%) reported often, and 2 (6.5%) reported always. 49 Technique 5. Therapist and client engage with therapy animal outside of traditional therapeutic environment; i.e. taking therapy animal for walk. Results indicated this technique was less likely to be practiced among participants. Ten (32.3%) reported never, seven (22.6%) indicated seldom, 11 (35.5%) reported often, and two (6.5%) indicated always. Technique 6. Therapist interacts with therapy animal such as having animal perform tricks. Results suggested that participants were rather split on whether they interacted with the therapy animal such as having the animal perform tricks. Ten (32.3%) participants reported never, six (19.4%) indicated seldom, 12 (38.7%) reported often, and one (3.2%) indicated always. Technique 7. Therapist encourages client to perform tricks with therapy animal. Most participants indicated either never (n= 11, 35.5%) or seldom, 6 (19.4%) encouraging the client to perform tricks with therapy animal. Six (19.4%) participants indicated often, and four (12.9%) reported always. Technique 8. Therapist encourages client to perform commands with therapy animal. Most respondents indicated incorporating this technique to some degree. Six (19.4%) respondents indicated never, eight (25.8%) indicated seldom, 11(35.5%) reported often, and 4 (12.9%) indicated always. Technique 9. Therapist comments or reflects on spontaneous client animal interactions. All participants indicated commenting or reflecting on spontaneous client animal interactions. Results showed participants often (n=16, 51.6%) or always (n=11, 35.5%) incorporated this technique. Three (9.7%) participants, on the other hand, reported seldom. 50 Technique 10. Information about therapy animal‟s family history (breed, species, and so forth) is shared with client. Results for this technique indicated that most respondents reported often (n= 13, 41.9%) or always (n=6, 19.4%) sharing information about therapy animal‟s family history. In contrast, three (9.6%) participants responded never and eight (25.8%) indicated seldom. Technique 11. History related to therapy animal is shared with client. Results indicated participants had a variety of responses for this technique. Seven (22.6%) participants indicated always incorporating this technique, whereas 11 (35.5%) reported often. Conversely, eight indicated seldom (25.8%) and three (9.6%) reported never. Technique 12. Animal stories and metaphors with animal themes are shared with client by therapist. Many of the participants reported sharing animal stories and metaphors with animal themes. Fourteen (45.2%) respondents reported often incorporating this technique, and three (9.7%) indicated always. Nine (29.0%) indicated seldom, and four (12.9%) reported never practicing this technique. Technique 13. Therapist encourages the client to make up stories involving the therapy animal. A majority of clients reported never or less likely incorporating this technique. Fifteen (48.4%) indicated never encouraging the client to make up stories involving the therapy animal. Eleven (35.5%) responded seldom, and four (12.9%) responded often. 51 Technique 14. Therapist utilizes the client-therapy animal relationship, such as: “If this dog were your best friend, what would he know about you that no one else would know?” AND/OR “Tell Rusty (therapy dog) how you feel and I will just listen.” Results indicated participants were rather split regarding practicing this technique. Eleven (35.5%) reported often incorporating this technique. Eight (25.8%) indicated seldom, and ten (32.3%) reported never. Technique 15. Therapist encourages client to recreate/reenact experience where therapy animal plays a specific role. A majority of participants indicated never (n=19, 61.3%) encouraging a client to recreate/reenact experience where therapy animal plays a specific role. Six (19.4%) respondents indicated seldom integrating this technique, and five (16.1%) indicated often. Technique 16. Therapy animal is present without any directive interventions. Over half of the respondents reported that the therapy animal is present without any directive interventions. Nineteen (61.3%) indicated this occurs often, and four (12.9%) indicated always. In contrast, one (3.2%) reported never and six (19.4%) indicated seldom. Technique 17. Therapist creates specific/structured activities with therapy animal. Results indicated participants were closely split regarding this technique. Eleven (35.5%) respondents reported often and three (9.7%) indicated always. Whereas seven (22.6%) respondents indicated seldom, and eight (25.8%) reported never creating specific/structured activities with therapy animal. Technique 18. Therapy animal engages with client in spontaneous moments that facilitate therapeutic discussion. 52 All participants indicated the therapy animal engages with client in spontaneous moments that facilitate therapeutic discussions to some degree. A majority of respondents reported this exchange happens often (n=21, 67.7%). Four (12.9%) indicated seldom and another five (16.1%) reported always. Assumption 2 Mental health professionals incorporate some animal assisted therapy techniques more often than others. Of the 18 therapeutic techniques, results indicated certain techniques to be more commonly integrated as reported by a majority of the participants. The following techniques were identified as often or always utilized by a majority over 50% of the participants. 1. Therapist reflects or comments on client‟s relationship with therapy animal. 2. Therapist encourages client to interact with therapy animal by touching or petting therapy animal. 3. Information about therapy animal‟s family history (breed, species, and so forth) is shared with client. 4. History related to therapy animal is shared with client. 5. Animal stories and metaphors with animal themes are shared with client by therapist. 6. Therapy animal is present without any directive interventions. 7. Therapy animal engages in spontaneous moments that facilitate therapeutic discussion. 53 Results indicated one technique was reported by a majority of participants as never practiced in therapy, that is they never encouraged the client to recreate/reenact experience where therapy animal plays a specific role. Assumption 3 Mental health professional incorporate specific animal assisted interventions for certain therapeutic intentions. In addition to rating the frequency of use for the 18 different animal assisted techniques, participants were asked to identify the types of therapeutic intentions, or purposes, for which an animal assisted technique was applied. Seventeen, of the 18 techniques were listed, due to technique 18 relating to spontaneous moments. Ten therapeutic intentions were identified from the literature review. The following tables and graphs present the frequency of participants‟ responses indicating therapeutic intentions for each animal assisted technique that was used. A majority of participants indicated that for technique one, “reflecting or commenting on the client‟s relationship with the therapy animal” served several different therapeutic intentions or purposes. The most common intention was to “build rapport in the therapeutic relationship.” The second most common intention was to “enhance relationship skills.” 54 Technique 1: Therapist reflects or comments on client’s relationship with therapy animal. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 6 83.9 b. facilitating insight 7 54.8 c. enhancing client‟s social skills 8 58.1 d. enhancing relationship skills 24 77.4 e. enhancing self confidence 23 74.2 f. modeling specific behaviors 16 51.6 g. encouraging sharing of feelings 17 54.8 h. behavioral reward 8 25.8 i. enhancing trust within therapeutic environment 18 58.1 j. facilitating feelings of being safe in therapeutic environment 17 54.8 k. Other 1 3.2 Figure 1. Technique 1 therapeutic intentions. The most common therapeutic intention reported for Technique 2, “the therapist encourages the client to interact with the therapy animal by touching or petting the therapy animal,” was “building rapport in the therapeutic relationship.” The second most 0 5 10 15 20 25 30 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 55 common intentions were both “enhancing relationship skills” and “enhancing trust within therapeutic environment. Technique 2: Therapist encourages client to interact with therapy animal by touching or petting therapy animal. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 22 71 b. facilitating insight 9 29 c. enhancing client‟s social skills 17 54.8 d. enhancing relationship skills 15 48.4 e. enhancing self confidence 15 48.4 f. modeling specific behaviors 14 45.2 g. encouraging sharing of feelings 11 35.4 h. behavioral reward 7 22.6 i. enhancing trust within therapeutic environment 17 54.8 j. facilitating feelings of being safe in therapeutic environment 16 51.6 k. other 2 9.7 Figure 2. Technique 2 therapeutic intentions. 0 5 10 15 20 25 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 56 Results for Technique 3, “encourage client to play with therapy animal,” indicated participants reported two therapeutic intentions as the most common, “enhancing client social skills” and “enhancing client relationship skills.” Technique 3: Therapist encourages client to play with therapy animal during session. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 13 41.9 b. facilitating insight 8 25.8 c. enhancing client‟s social skills 17 54.8 d. enhancing relationship skills 17 54.8 e. enhancing self confidence 14 45.2 f. modeling specific behaviors 10 32.3 g. encouraging sharing of feelings 11 35.5 h. behavioral reward 7 22.6 i. enhancing trust within therapeutic environment 12 38.7 j. facilitating feelings of being safe in therapeutic environment 14 45.2 k. other 2 6.5 Figure 3. Technique 3 therapeutic intentions. 0 2 4 6 8 10 12 14 16 18 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 57 Results for Technique 4, “Therapist encourages client to tell therapy animal about client‟s distress or concerns,” indicated participants most commonly reported “enhancing trust within therapeutic environment”. The second most common intention reported was “encouraging sharing of feelings.” Technique 4. Therapist encourages client to tell therapy animal about client’s distress or concerns. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 8 25.8 b. facilitating insight 11 35.5 c. enhancing client‟s social skills 3 9.7 d. enhancing relationship skills 5 16.1 e. enhancing self confidence 4 12.9 f. modeling specific behaviors 2 6.5 g. encouraging sharing of feelings 15 48.4 h. behavioral reward 0 0 i. enhancing trust within therapeutic environment 16 51.6 j. facilitating feelings of being safe in therapeutic environment 14 45.2 k. other 1 3.2 Figure 4. Technique 4 therapeutic intentions. 0 2 4 6 8 10 12 14 16 18 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 58 Results for Technique 5, “engaging with therapy animal outside of traditional therapeutic environment”, were evenly distributed among most intentions. Three intentions were equally reported by participants as the most common: “building rapport in therapeutic relationship,” “enhancing self confidence,” and as a “behavioral reward.” Technique 5. Therapist and client engage with therapy animal outside of traditional therapeutic environment; i.e. such as taking therapy animal for walk. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 12 38.7 b. facilitating insight 7 22.6 c. enhancing client‟s social skills 11 35.5 d. enhancing relationship skills 7 22.6 e. enhancing self confidence 12 38.7 f. modeling specific behaviors 10 32.3 g. encouraging sharing of feelings 10 32.3 h. behavioral reward 12 38.7 i. enhancing trust within therapeutic environment 9 29.0 j. facilitating feelings of being safe in therapeutic environment 6 19.4 k. other 2 6.5 Figure 5. Technique 5 therapeutic intentions. 0 2 4 6 8 10 12 14 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 59 Technique 6, “therapist interacting with therapy animal such as having animal perform tricks,” was most commonly intended to “build rapport in the therapeutic relationship.” The second most common intention reported was to “enhance trust within therapeutic environment.” Technique 6. Therapist interacts with therapy animal such as having animal perform tricks. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 13 41.9 b. facilitating insight 6 19.4 c. enhancing client‟s social skills 2 6.5 d. enhancing relationship skills 5 16.1 e. enhancing self confidence 3 9.7 f. modeling specific behaviors 11 35.5 g. encouraging sharing of feelings 1 3.2 h. behavioral reward 6 9.4 i. enhancing trust within therapeutic environment 12 38.7 j. facilitating feelings of being safe in therapeutic environment 8 25.8 k. other 2 6.5 Figure 6. Technique 6 therapeutic intentions. 0 2 4 6 8 10 12 14 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 60 Results for Technique 7, “therapist encourages client to perform tricks with therapy animal,” indicated the most common therapeutic intention for this technique was to “enhance self confidence”. The second most common intention reported was to “enhance relationship skills.” Technique 7. Therapist encourages client to perform tricks with therapy animal. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 9 29.0 b. facilitating insight 6 19.4 c. enhancing client‟s social skills 10 32.3 d. enhancing relationship skills 11 35.5 e. enhancing self confidence 16 51.6 f. modeling specific behaviors 8 25.8 g. encouraging sharing of feelings 3 9.7 h. behavioral reward 9 29 i. enhancing trust within therapeutic environment 8 25.8 j. facilitating feelings of being safe in therapeutic environment 6 19.4 k. other 2 6.5 Figure 7. Technique 7 therapeutic intentions. 0 2 4 6 8 10 12 14 16 18 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 61 A majority of clients indicated Technique 8, “encouraging client to perform commands with therapy animal”, served the purpose of “enhancing self confidence”. The second most frequently reported purpose was to “enhance client‟s social skills”. Technique 8. Therapist encourages client to perform commands with therapy animal. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 10 32.3 b. facilitating insight 7 22.6 c. enhancing client‟s social skills 16 51.6 d. enhancing relationship skills 9 29 e. enhancing self confidence 22 71 f. modeling specific behaviors 15 48.4 g. encouraging sharing of feelings 5 16.1 h. behavioral reward 6 19.4 i. enhancing trust within therapeutic environment 9 29 j. facilitating feelings of being safe in therapeutic environment 8 25.8 k. other 4 12.9 Figure 8. Technique 8 therapeutic intentions. 0 5 10 15 20 25 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 62 A majority of the participants reported for Technique 9, “commenting or reflecting on spontaneous client animal interactions”, two most frequent therapeutic purposes, “facilitating insight” and “enhancing client‟s social skills.” Technique 9. Therapist comments or reflects on spontaneous client animal interactions. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 15 48.4 b. facilitating insight 20 64.5 c. enhancing client‟s social skills 19 61.3 d. enhancing relationship skills 18 58.1 e. enhancing self confidence 16 51.6 f. modeling specific behaviors 10 32.3 g. encouraging sharing of feelings 11 35.5 h. behavioral reward 0 0 i. enhancing trust within therapeutic environment 9 29.9 j. facilitating feelings of being safe in therapeutic environment 8 25.8 k. other 1 3.2 Figure 9. Technique 9 therapeutic intentions. Many of the participants reported for Technique 10, that when “information about therapy animal‟s family history is shared with client”, the most common purpose was to 0 5 10 15 20 25 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 63 “build rapport in therapeutic relationship”. The second most commonly reported therapeutic intent was “enhancing trust within therapeutic environment.” Technique 10. Information about therapy animal’s family history (breed, species, and so forth) is shared with client. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 26 83.9 b. facilitating insight 7 22.6 c. enhancing client‟s social skills 6 19.4 d. enhancing relationship skills 7 22.6 e. enhancing self confidence 4 12.9 f. modeling specific behaviors 4 12.9 g. encouraging sharing of feelings 10 32.3 h. behavioral reward 1 3.2 i. enhancing trust within therapeutic environment 17 54.8 j. facilitating feelings of being safe in therapeutic environment 11 35.5 k. other 4 12.9 Figure 10. Technique 10 therapeutic intentions. Similarly to Technique 11, when “history related to the therapy animal is shared with client”, the most common purpose was to “build rapport in therapeutic relationship”. 0 5 10 15 20 25 30 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 64 The second most common intent reported was “enhancing trust within therapeutic environment.” Technique 11. History related to therapy animal is shared with client. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 24 77.4 b. facilitating insight 13 41.9 c. enhancing client‟s social skills 8 25.8 d. enhancing relationship skills 9 29 e. enhancing self confidence 5 16.1 f. modeling specific behaviors 3 9.7 g. encouraging sharing of feelings 11 35.5 h. behavioral reward 0 0 i. enhancing trust within therapeutic environment 14 45.2 j. facilitating feelings of being safe in therapeutic environment 11 35.5 k. other 4 12.9 Figure 11. Technique 11 therapeutic intentions. Results indicated for Technique 12, when “animal stories and metaphors with animal themes are shared with client”, the most frequent intention was to “facilitate 0 5 10 15 20 25 30 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 65 insight”. The second most common attention reported was to “build rapport in therapeutic relationship.” Technique 12. Animal stories and metaphors with animal themes are shared with client by therapist. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 14 45.2 b. facilitating insight 21 67.7 c. enhancing client‟s social skills 7 22.6 d. enhancing relationship skills 7 22.6 e. enhancing self confidence 6 19.4 f. modeling specific behaviors 9 29 g. encouraging sharing of feelings 11 35.5 h. behavioral reward 0 0 i. enhancing trust within therapeutic environment 8 25.8 j. facilitating feelings of being safe in therapeutic environment 6 19.4 k. other 2 6.5 Figure 12. Technique 12 therapeutic intentions. Results indicated when “encouraging the client to make up stories involving the therapy animal,” the most common intent was to “encourage sharing of feelings”. 0 5 10 15 20 25 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 66 Participants reported “facilitating insight” and “enhancing client‟s social skills” as the second most common intention. Technique 13. Therapist encourages the client to make up stories involving the therapy animal. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 6 19.4 b. facilitating insight 10 32.3 c. enhancing client‟s social skills 10 32.3 d. enhancing relationship skills 5 16.1 e. enhancing self confidence 9 29 f. modeling specific behaviors 3 9.7 g. encouraging sharing of feelings 11 35.5 h. behavioral reward 0 0 i. enhancing trust within therapeutic environment 6 19.4 j. facilitating feelings of being safe in therapeutic environment 5 16.1 k. other 1 3.2 Figure 13. Technique 13 therapeutic intentions. The most common intention related to Technique 14, “therapist utilizes client- therapy animal relationship,” was to “encourage sharing of feelings”. The second common intention reported was to “facilitate insight.” 0 2 4 6 8 10 12 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 67 Technique 14. Therapist utilizes the client-therapy animal relationship, such as: “If this dog were your best friend, what would he know about you that no one else would know?” AND/OR “Tell Rusty (therapy dog) how you feel and I will just listen.” Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 10 32.3 b. facilitating insight 14 45.2 c. enhancing client‟s social skills 9 29 d. enhancing relationship skills 9 29 e. enhancing self confidence 9 29 f. modeling specific behaviors 2 6.5 g. encouraging sharing of feelings 16 51.6 h. behavioral reward 0 0 i. enhancing trust within therapeutic environment 12 38.7 j. facilitating feelings of being safe in therapeutic environment 10 32.3 k. other 2 6.5 Figure 14. Technique 14 therapeutic intentions. Participants indicated Technique 15, “encouraging client to recreate/reenact experience with therapy animal”, as the least practiced technique. Additionally, the few who did practice this technique indicated its common purpose was to “facilitate insight”. Participants reported the second common intent was to “encourage sharing of feelings.” 0 2 4 6 8 10 12 14 16 18 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 68 Technique 15. Therapist encourages client to recreate/reenact experience where therapy animal plays a specific role. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 2 6.5 b. facilitating insight 9 29 c. enhancing client‟s social skills 5 16.1 d. enhancing relationship skills 5 16.1 e. enhancing self confidence 2 6.5 f. modeling specific behaviors 3 9.7 g. encouraging sharing of feelings 8 25.8 h. behavioral reward 0 0 i. enhancing trust within therapeutic environment 4 12.9 j. facilitating feelings of being safe in therapeutic environment 3 9.7 k. other 1 3.2 Figure 15. Technique 15 therapeutic intentions. Results indicated the most common purpose for Technique 16, “therapy animal is present without any directive interventions”, was to “facilitate feelings of being safe in therapeutic environment”, and the second most was to “enhance trust within therapeutic environment”. 0 1 2 3 4 5 6 7 8 9 10 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 69 Technique 16. Therapy animal is present without any directive interventions. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 14 45.2 b. facilitating insight 4 12.9 c. enhancing client‟s social skills 6 19.4 d. enhancing relationship skills 7 22.6 e. enhancing self confidence 7 22.6 f. modeling specific behaviors 2 6.5 g. encouraging sharing of feelings 9 29 h. behavioral reward 1 3.2 i. enhancing trust within therapeutic environment 16 51.6 j. facilitating feelings of being safe in therapeutic environment 21 67.7 k. other 3 9.7 Figure 16. Technique 16 therapeutic intentions. A majority of participants indicated, for Technique 17, “therapist creates activities with therapy animal,” the most common purpose was to “enhance client‟s social skills”. The second most common intent was both to “enhance self confidence” and to “model specific behaviors. 0 5 10 15 20 25 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 70 Technique 17. Therapist creates specific/structured activities with therapy animal. Therapeutic Intentions Frequency Percentage a. building rapport in therapeutic relationship 6 19.4 b. facilitating insight 13 41.9 c. enhancing client‟s social skills 17 54.8 d. enhancing relationship skills 14 45.2 e. enhancing self confidence 15 48.4 f. modeling specific behaviors 15 48.4 g. encouraging sharing of feelings 10 32.3 h. behavioral reward 3 9.7 i. enhancing trust within therapeutic environment 7 22.6 j. facilitating feelings of being safe in therapeutic environment 6 19.4 k. other 1 3.2 Figure 17. Technique 17 therapeutic intentions. Nineteen various animal assisted therapy techniques were identified based on information in the literature, adding to the content validity of the instrument. One technique was thrown out due to its unclear wording, thus eighteen techniques were analyzed. The list was also reviewed, examined, and approved by a panel of experts in the field implying face validity. In order to examine internal consistency reliability on the 0 2 4 6 8 10 12 14 16 18 a b c d e f g h i j k N u m b e r o f P a rt ic ip a n ts Therapeutic Intentions 71 Likert scale scores, Crohnbach alpha was computed. An alpha of .86 was calculated for the entire sample (n=31). Alpha coefficient values range from 0 to 1 and are calculated to illustrate the reliability of factors from scales or questionnaires (Santos, 1999). In order to determine internal consistency for the therapeutic intentions, which were rated on a different scale, a Crohnbach alpha was also calculated indicating an alpha of .95. Thus, internal consistency for both parts of the survey appear to be high. Discussion In the course of the past forty years, the incorporation of therapy animals in the mental health field has increasingly gained much attention. Therapy animals within the field of mental health have, sometimes, been referred to as “co-therapists,” suggesting their integral part within the treatment process itself. Results of this study indicated that therapy animals are incorporated in the therapeutic process in a variety of ways. Results also suggested that participating mental health professionals integrated various animal assisted therapy techniques with specific therapeutic purposes. Mental health professionals, located through three animal assisted therapy- related databases, were surveyed regarding their integration of a therapy animal into the therapeutic process. Participants were licensed mental health professionals or mental health interns and represented the following disciplines: psychology, counseling, social work, marriage and family therapy, school counseling, and hypnotherapy. Assumption 1. Assumption one addressed the incorporation of therapy animals with a variety of techniques which were identified through a comprehensive literature review. Results from frequency ratings indicated that professionals incorporated a variety of animal assisted techniques. As stated in some of the literature (Mallon, 1992; 72 Chandler, 2005; Fine, 2006), animal assisted therapy (AAT) is considered an adjunct to therapy and can complement the different ways a professional works in therapy. For this group of professionals, when a therapy animal is integrated in the treatment process, participants often integrate a variety of techniques, which also includes the therapy animal. Assumption 2. Assumption two results indicated that some animal assisted techniques were integrated more often than others. Results indicated seven animal assisted techniques were often or always utilized by a majority of the participants. In addition to frequently utilized techniques, results also revealed techniques that were less frequently incorporated into the therapeutic process. The most common animal assisted therapy technique incorporated by these participants was “reflecting or commenting on a client‟s relationship with a therapy animal.” Results also indicated that this technique also served a variety of therapeutic purposes; most participants reported this technique was intended to build rapport in the therapeutic relationship. Such results may suggest that incorporating a therapy animal can engage a client further in the therapeutic relationship. Chandler (2005) noted, for example, how a client‟s relationship with a therapy animal can enhance the therapeutic relationship with the human therapist; and possibly, during the earlier stages of counseling, they may form bonds with the animal that are stronger than that of the typical therapist-client relationship. These results also illustrate how professionals recognize and actively call attention to the connection that takes place between a client and a therapy animal. 73 Another technique which many participants reported practicing often was “encouraging the client to interact with the therapy animal by touching or petting the animal.” Some of the therapeutic purposes for integrating this technique were to build rapport in the therapeutic relationship, enhancing the client‟s social skills, enhancing trust within the environment, and facilitating feeling safe in the therapeutic environment. Therapy animals also provide clients with a unique opportunity for physical touch during a therapy session. Mental health professionals typically do not engage in physical contact with their clients, therefore, therapy animals are able to provide that connection. The ability of clients to have a source of physical contact through interaction with the therapy animal was further noted by some of the authors in the AAT literature (Pattison, 1979; Dew, 2000; Chandler, 2005). This source of physical connection is yet another distinctive characteristic of animal assisted therapy. Two particular animal assisted techniques related to information about the history of the therapy animal. As such, a majority of the participants reported that these two techniques were also commonly integrated into the therapeutic process. One technique involved information related to the therapy animal‟s family history, such as the breed of the animal, or the history of the species of the animal. The other technique involved the history related to the specific therapy animal. For both of these techniques, the most common therapeutic purpose was to build rapport within the therapeutic relationship. Thus, for these participants, integrating the unique aspects of the therapy animal and its past was a means of connecting with clients. One participant, for example, described how sharing the story of rescuing the therapy animal from a shelter often related to child clients who were adopted. 74 Results indicated that even though the therapy animal was consciously incorporated by mental health professionals in a variety of directive and structured ways, a therapy animal was also a part of the therapy process without any directive interventions. In other words, the animal‟s presence, alone, intended to provide therapeutic benefits. Participants indicated that the most common therapeutic purposes for incorporating a therapy animal without any directive interventions was to enhance trust in the environment and to facilitate feeling safe in the therapeutic environment. As indicated by the previous literature reviewed (Trivedi & Perl, 1995; Beck & Katcher, 1996; Chandler, 2005; Fine, 2006) ;), the therapy animals‟ existence within the therapeutic environment can ultimately create a sense of safety, warmth, and acceptance for clients. For a majority of the participants, the company of a therapy animal had therapeutic value specifically related to the therapeutic environment. Results also indicated that spontaneous moments were common occurrences when incorporating a therapy animal in practice, and when they did occur, the participants often commented or reflected on these spontaneous happenings. A therapist may not always be able to predict or direct some of the behaviors that a therapy animal engages in during a session, but the participants in this study suggested that some of these unintentional events can lead to therapeutic discussions. One particular participant reported the “decision-making” behavior of the therapy cat; when the cat chose to leave a session, the therapist “could not make it stay”. This finding seems to support some of the literature which implied that some of the therapeutic value of AAT is the unplanned, which often reflects the natural character of the therapy animal. 75 Participants also reported sharing animal stories or metaphors with animal themes were also a common practice, with over half reporting often or always integrating this technique. Findings in the literature (Reichert, 1998; Chandler 2005; Fine; 2006) suggested that including either the therapy animal or animal themes included in stories or metaphors can serve to facilitate a variety of therapeutic purposes. For these participants, “facilitating insight” was the most common intent when incorporating this technique. Thus, when a therapy animal is present in the therapeutic process, these participants naturally include them in such therapeutic dialogues. Although the participants indicated incorporating a variety of techniques, a couple of techniques were least commonly integrated among these participants. When asked if therapists encouraged a client to recreate/reenact an experience where a therapy animal played a specific role, the majority indicated either seldom or never. Such results imply that for these participants, this technique was not commonly incorporated with their clients. Due to differences in mental health professionals‟ therapeutic approaches, this technique may not fit within their therapeutic framework. Perhaps, some clients may spontaneously engage in role playing with a therapy animal, however, most of these participants were less likely to direct this technique. Previous literature reviewed also described role playing, specifically with children and a therapy animal, as a way to gain insight and facilitate imaginative relationships (Nebbe, 1991; Mallon, 1997). Those participants that reported encouraging a client to role play with the therapy animal also indicated that the most common intent was to facilitate a client‟s insights. 76 Assumption 3. One of the most frequent therapeutic purposes that the participants reported for a variety of techniques was to build rapport within the therapeutic relationship. For a majority of these participants, building rapport was related to the following: therapist reflecting or commenting on the client‟s relationship with a therapy animal, the therapist encouraging the client to interact with a therapy animal by touching or petting the therapy animal, sharing information about the therapy animal‟s family history (breed, species, and so forth) with the client, as well as sharing history related to the therapy animal with the client. Chandler (2005) further emphasized the importance of building rapport in therapy for successful counseling. Results for these participants implied that incorporating a therapy animal can be a means to facilitate building rapport within the therapeutic relationship. Results also indicated, for these participants, building rapport can be approached in different ways. Results for these participants ultimately suggested that the integration of a therapy animal in various ways provides more opportunities with which to build rapport with their clients, thus enhancing the therapeutic relationship itself. Consistently, the least frequent therapeutic intention was the purpose of a behavioral reward. Participants did not incorporate a majority of animal assisted techniques for the intent of a behavioral principal. Instead, participants appeared to incorporate the therapy animal as an extension of the treatment, in contrast to a condition of improvement. In other words, spending time with the therapy animal was a natural inclusion to the therapy process. This finding seems consistent with the findings in the literature reviewed which supported the integration of a therapy animal as a part 77 of the therapeutic process, compared to its conditional method. Only one literary work cited incorporating a therapy animal as a behavioral reward (Kraft, n. d.). Other Findings A majority of participants reported that therapy animals were not incorporated with every client. Those participants described some of the various reasons for not including a therapy animal, such as allergies, appropriateness of client, or client‟s preference of not working with a therapy animal. Such responses highlight the unique responsibility animal assisted therapists have of assessing the welfare of both the therapy animal and the client. Some clients noted the preference of not having a therapy animal present during the first session in order to better assess the client‟s appropriateness in working with a therapy animal. Chandler (2005), in particular, noted the importance of screening a client before the start of AAT in order to protect both the client and the therapy animal. She also included a client screening form as a tool to incorporate in practice. Participants also discussed some of the reasons clients may not be appropriate to work with a therapy animal, such as fear of animals, history of animal cruelty, and possible aggression level of client. Allergies were the most common reason a therapy animal was not included with clients. Thus, animal assisted therapists have a responsibility to take into account the health and welfare of clients, therapy animals, and others who may come into contact with a therapy animal in their practices. An additional factor in caring for the welfare of the therapy animal is the amount of time that the therapy animal is included in their practices. Some participants in this group indicated not including the therapy animal with every client due to the incompatible working hours which could fatigue a therapy animal. For instance, some 78 participants owned more than one therapy animal and rotated the days in which certain therapy animals came to work. Another participant reported bringing a therapy animal only on certain days. Thus, variations in the practice of animal assisted therapy may represent different facets, such as the therapy animal‟s health and well-being. Participants were also asked open-ended questions related to their animal assisted therapy practices. Even though these responses were not analyzed and coded, some of the responses warranted attention in order to illustrate the participants‟ perceptions of AAT and that of their practices. Participants were asked to describe some the traits that made the therapy animal therapeutically valuable. Participants often referred to the therapy animal as calm. One participant, in particular, highlighted the opportunity for tactile touch that the therapy animal provided in their practice: My therapy dog offers a physical comfort to clients that I, as a responsible therapist, cannot provide. She is able to provide tactile sensory stimulus to clients who are otherwise internally preoccupied (i.e., schizophrenic clients). She also serves as a „protector‟ of the client's information, as she „keeps secrets, and is a guardian breed (it works as a nice metaphor). Another participant described the work that her therapy animal can do just by being present: “Facilitate patient reducing defenses…one session with an animal can equal 10 sessions without an animal, especially with resistant patients”. Other respondents described the way in which a therapy animal can greet their clients at the door and welcome them into the therapeutic environment. Another participant described her therapy dog‟s valuable teaching lesson: Sometimes, all that Pongo brings to a session is calm and presense [sic]. The value of just his loyal and dependable presense is enough. He is drawn to grief---not in an overtly demonstrative way, but in a very subtle and gentle way. He may sit at their feet or lay on the sofa so that they can reach over and rub his head and shoulders while they talk. Sometimes, the rhythm of his sleeping breathing takes fear, anxiety, or 79 agitation from the room. He teaches everyone who walks in the value of being present. He will teach the kiddos and adults alike how everyone and every dog is different and we all show love and affection in different ways. It helps everyone to remember that everyone brings something different to the table and it is what we do with that that makes the difference. He teaches almost everyone in the most subtle way imaginable---that they are lovable. Participants were also asked to describe their relationship with the therapy animal which may contribute to the therapeutic value of AAT. One participant described the way in which relating stories of her therapy animal served as a way to share with a young client: I can often use her issues/struggles as object lessons for clients. In the case of an adolescent client who was a school phobic, I related to her that my dog was also a school phobic and had a hard time making friends with other dogs. This intervention served as a way to both earn the girl's trust and to illustrate that she was not alone in her anxiety about school. Since we've started working with her, she has not missed a single day of school! Another individual commented on her specific relationship with her therapy animal: My client learns about how I relate to my animal and gets some insight into who I am and how I move through the world. They get a feel of how I can draw strong and compassionate boundaries and still honor the relationship that I share with my dog (a good life lesson); our relationship shows how respectful and loving relationships work and how important trust is in all relationships. It allows the client to see my human nature and helps to create a comfortable, safe, and relaxed environment. Participants were also asked to describe some of the specific/structured activities that they incorporated into therapy sessions with animals. One respondent described such an activity that was practiced with a child client: Therapy dog is the teacher today. It is his job to teach you several lessons with his behavior only. He will not instruct you or tell you what to do. You can ask him questions, you can groom him, or take him on a walk if you like, but remember that all the while he is teaching you 3 things today, and you have to be mindful to get those lessons so we can talk about them at the end of the session. 80 Another respondent illustrated yet another activity: Almost all of my youth are working on teaching Marley a trick or a sequence of tricks - after the youth has picked the trick or sequence of tricks, each session is structured around that trick and the therapeutic goal - I like to have some sort of structure for each day, but also allow sessions to be fluid in some cases. Results further indicated that spontaneous moments occurred often in therapy, which also facilitated the therapeutic discussions. Respondents were asked to describe any of those spontaneous moments. Some of their responses are illustrated as follows: “Adolescent blew up in family session and dog retreated to crate in fear-patient was able to see how her behaviors affect others and her relationships.” Finally, another participant stated, “Cat began purring as client petted him. Child admitted, tearfully, that being with Data was the best thing at school.” Implications The field of animal assisted therapy continues to evolve in its research and education. Much can be learned from those that practice in the field. The mental health professionals who participated in this study revealed some of the specific ways in which a therapy animal is integrated into the therapy process as well as for specific therapeutic purposes thus, lending to the notion that therapy animals play a distinct role in the therapeutic process when integrated into treatment. From the mental health professionals‟ perspectives, a therapy animal can enhance the therapeutic process. The field of animal assisted therapy has evolved in a variety of fields, even beyond the mental health field. Results from this study also revealed that AAT is incorporated in a variety of settings, and in creative ways. Participants in this study primarily practiced AAT in a private practice setting, but many other working environments were noted, such as schools, community agencies, hospitals, and barns. 81 Practitioners wanting to incorporate AAT into their practices may meet with some resistance, however. One participant reported how it took some time for the agency to allow AAT as an appropriate modality. Perhaps, the results from this study may educate how AAT is incorporated into the therapeutic process. Thus, this would support professionals in the field who want to incorporate AAT into their practices. Strength of the Study This study was one of the first examinations of mental health professionals‟ incorporation of specific animal assisted techniques within the therapeutic process, as well as uncovering the various therapeutic intentions related to each technique. Results revealed a variety of methods in which participants facilitated interactions between the therapist, client, and therapy animal. For these participants, the common theme that emerged from the results was the intent to build rapport in the therapeutic relationship. This intention was reported as the most common therapeutic purpose with a variety of techniques. For these participants a therapy animals‟ presence in the therapeutic process offered a way to enhance the therapeutic relationship. The relationship between the client and therapy animal was also often reflected on by most of the participants, as indicated by frequency scores for technique one. Fine (2006) described a therapy animal as being an “extension to a therapist” (p. 173). The therapy animal can provide opportunities to further build rapport. This idea seemed evident for these participants. Limitations One of the primary limitations of this study was the lack of resources for the target population. Although three resources were utilized in order to gather potential 82 participants, finding appropriate participants was a challenge. Delta Society‟s database identified only 56 mental health professionals, yet a number of those who responded did not qualify for the study because they did not practice AAT as a mental health professional, which suggested that Delta Society‟s database contained some misinformation. The Center for Animal Assisted Therapy at the University of North Texas is still in the process of creating an area database of professionals in the field and was only able to identify 33 mental health professionals who utilized AAT in the surrounding community. The last resource, the Yahoo AAT professional group, although they had over 200 members with varied professions, such as occupational therapists, nurses, and teachers, only four members volunteered to participate in the survey. Other attempts were made to contact more AAT mental health professionals, such as contacting other agencies which registered therapy animals, but they did not have databases which identified their members‟ professions. The lack of organized databases and resources which identify animal assisted therapists also reflects the infancy of the field itself. A second limitation occurred due to the mixed methods of providing the questionnaire through an online distribution and a paper survey. The online survey contained a slightly different format for the second part of the survey in regard to therapeutic intentions. Participants who completed the online survey were able to select as many therapeutic intentions as they wanted; on the other hand, the paper survey had only five spaces provided for the therapeutic intentions. Participants who completed the paper survey may have wanted to choose more but may have perceived the five spaces as their limit. This difference may have impacted the amount of 83 therapeutic intentions, slightly. Many participants who completed the paper survey, wrote additional responses in the space below, and were not limited by the five designated spaces. A further limitation related to the survey method involved the inability to gather more information from the participants. Because the survey instrument had more direct questions, the participants‟ responses varied and could not be clarified. As such, perhaps, an interview would provide more detail about their practices of AAT. Nardi (2006) suggested that face-to-face or telephone interviews may help with clarifying information from respondents, as well as “unanticipated” answers may uncover new findings. Because the field of AAT contains variability in the way that it is practiced, an open-ended interview may further reveal the diverse methods of how AAT is performed. Although the goal of this study was to uncover the behavior practices of mental health professionals who incorporated AAT, this design presented another limitation. One of the aspects of the design, which may have presented a limitation, was the use of vague quantifiers with the Likert scale. A critical component of the survey design inquires about the frequency of the incorporation of specific animal assisted interventions. Groves, Fowler, Couper, Lepkowski,Singer, and Tourangeau (2004) referred to these items as frequency behavior questions. Such questions may reflect inaccurate estimates, especially when matched with vague quantifiers. Vague quantifiers refer to response scales which incorporate terms, such as seldom, often, and/or frequent (Groves et al.). Such expressions are interpreted differently for each individual. Wanke (2002) suggested that in order to help respondents understand the intent of the question the researcher should provide an anchor, so as to relate the 84 question itself. Due to the variations in the ways in which mental health professionals conduct therapy, utilizing specific anchors was difficult. Nardi (2006) also addressed one of the disadvantages of a survey design is the discrepancy among what respondents report they do, and what they actually do. Because this design asked the participants to recall and report on what they actually did, caution should be taken on the accuracy of the results. Future Research One of the biggest struggles limiting this study was locating potential participants, yet there is a need to learn more from those who practice animal assisted therapy. Future studies may address this dilemma by surveying members of the major mental health associations, such as the American Psychological Association, American Counseling Association, American School Counselor Association, National Association of Social Workers, and the American Association for Marriage and Family Therapy, in order to locate those who practice with a therapy animal. Creating a database of professionals who practice animal assisted therapy may also offer more opportunities for research and education on the behaviors of mental health professionals in the field. In order to expand on or further explore the ways that therapy animals act as “co- therapists” or adjuncts in the therapeutic process, future studies may incorporate direct observations or videotaped recordings of animal assisted therapy sessions. Nardi (2006), in particular, highlighted the benefits of qualitative observations and field methods, noting that behavior could more accurately be observed in context, as well as that of nonverbal behaviors. This would further explore the nonverbal interactions 85 between clients and therapy animals, as well as some of those spontaneous moments that the mental health professionals in this study reported frequently occurring. This study explored the behaviors of mental health professionals who incorporate AAT into treatment. Some of their responses indicated some of their perceptions regarding the value of AAT, as seen in some of their open-ended comments. Perhaps, an additional study which would increase knowledge regarding the practice of AAT within the mental health field would focus on clients‟ perceptions and attitudes regarding working with a therapy animal. Analysis could look at any discrepancies between the practitioners‟ beliefs about AAT and the clients‟ reactions to AAT. Results from this sample indicated that certain animal assisted techniques corresponded with certain therapeutic purposes. In order to expand on these implications, further research may measure if certain techniques actually resulted in their intended therapeutic purpose. Due to some of the inconclusive results from the previous studies reviewed regarding the effectiveness of animal assisted therapy, future research may compare some of these specific techniques with the incorporation of a therapy animal, and without the presence of a therapy animal. Although many questions still exist in the field of animal assisted therapy, more studies are revealing the important ways that a therapy animal is incorporated into the healing process in the mental health arena. This study shed light on some of the key ways mental health professionals integrated a therapy animal within the therapeutic process. It also revealed, for these practitioners, the purposes for incorporating specific animal assisted techniques in one‟s therapy sessions. Ultimately, while the animal 86 assisted therapy field continues to develop, an ongoing, more in-depth understanding of its practice will also uncover its potential critical influence in the field of mental health. 87 APPENDIX A CONSENT FORM AND MENTAL HEALTH PROFESSION ANIMAL ASSISTED THERAPY TECHNIQUE SURVEY 88 My name is Dana O‟Callaghan and I am conducting a research study about animal assisted therapy interventions incorporated by mental health professionals. You have been one of the animal assisted therapists selected to participate in this study. If you agree to take part in this study, you will be asked to complete a questionnaire about your integration of animal assisted interventions within your therapeutic practice. It will take approximately 15-20 minutes to complete. Participation in this study may benefit the field of animal assisted therapy and the mental health field by providing information on the practices of animal assisted interventions. Your responses may help us learn about how therapy animals are integrated into the therapeutic process. Participation in this study is completely voluntary. You have the right to skip any question you choose not to answer. There are no foreseeable risks involved in this study. All research records will be kept confidential by the principal investigator. No individual responses will be disclosed to anyone because all data will be reported on a group basis. If you have any questions about this study please contact Dana O‟Callaghan at or my faculty advisor, Dr. Cynthia Chandler, Department of Counseling and Higher Education, University of North Texas, 940-565-2914. When you complete the questionnaire, you will also be asked if you would like to be included in a drawing for a $100.00 Petsmart gift card. One name will be randomly selected. The winner of the drawing will be mailed within two weeks of the survey deadline. This research project has been reviewed and approved by the UNT Institutional Review Board. Please contact the UNT IRB at 940-565-3940 with any questions regarding your rights as a research subject. Your signature below indicates that you have read or have had read to you all of the above and that you confirm all of the following:  You understand the possible benefits and the potential risks and/or discomforts of the study.  You understand that you do not have to take part in this study, and your refusal to participate or your decision to withdraw will involve no penalty or loss of rights or benefits. The study personnel may choose to stop your participation at any time.  You understand why the study is being conducted and how it will be performed.  You understand your rights as a research participant and you voluntarily consent to participate in this study.  You may keep the additional enclosed copy of this form for your records. _______________________________ Printed Name of Participant 89 ________________________________ __________ Signature of Participant Date ________________________________ __________ Signature of Principal Investigator or Designee Date 90 1. What is your date of birth? ______Month______Day______Year 2. What is your gender? ______ Male ______ Female 3. What is your ethnicity? ______ Caucasian ______ African American ______ Hispanic ______ Asian ______ Native American ______ Bi-racial ______ Multi-racial ______ Other 4. What is your highest degree in the mental health field? ______ Some College Education ______ College Degree ______ Master‟s Degree ______ Doctorate Degree 5. What is your occupation? ___________________________________________________________ 6. What is your professional mental health license or certification? ______ Licensed Marriage and Family Therapist ______ Licensed/Certified Professional Counselor ______ Licensed Clinical Social Worker ______ Licensed Clinical or Counseling Psychologist ______ Licensed School Psychologist ______ Licensed/Certified School Counselor ______ Other (Please describe)____________________ 91 7. What is your primary mental health guiding theory for client conceptualization? ______ Adlerian ______ Jungian ______ Person Centered/Child Centered (Rogerian) ______ Reality Therapy ______ Rational Emotive Behavior Therapy ______ Cognitive/Behavioral Therapy ______ Family Systems ______ Existential ______ Humanistic ______ Gestalt ______ Developmental ______ Transpersonal ______ Feminist ______ Eclectic ______ None ______ Other (Please describe)_____________________ 8. How many years have you practiced as a mental health professional?____ 9. Are you the primary caregiver for the therapy animal? ______Yes ______No 92 10. Please list the therapy animals you have or have had that assisted you in your mental health work? Species/Breed Name(s)/Age(s) Number of years practiced as therapy animal? Certified (Yes/No) List Types of Certification (Delta, TDI, etc.) ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ 11. In what setting(s) do/did you utilize animal assisted therapy? Please rate from most to least (1=most) the primary setting where you most often practice AAT. ______ Private practice ______ Hospital ______ Elementary school campus ______ Middle school campus ______ Senior high school campus ______ Community agency ______ Residential treatment setting ______ College campus ______ Detention center ______ Prison ______ Crisis/Disaster setting (please describe)____________________ ______ Other (please describe)____________________ 12. How many years have you incorporated AAT into your mental health practice? ____ 93 13. Is the therapy animal(s) present with every client you see? ______ Yes ______ No If no, please indicate some of the reasons why therapy animal is not included?______________________________________________________________ ______________________________________________________________________ 14. For the following chart please place a checkmark to the left of each therapeutic modality you practice. Then, for each treatment modality you practice, indicate the percentage of time you incorporate animal assisted therapy in either individual (I) or group (G) format. CHILDREN ADOLESCENT ADULT ELDERLY I G I G I G I G Modality % % % % % % % % Talk Therapy Play Therapy Music Therapy Biofeedback Therapy Sandtray Therapy Expressive Arts Therapy Drama Therapy Activity Therapy Adventure Therapy 94 15. How often do you typically practice AAT as a professional? ____Once a week ______Once a month ____Twice a week ______Twice a month ____Three times a week ______Three times a month ____Four times a week ______Varies ____Five times a week 16. Is the therapy animal(s) introduced to the client(s) in the first session? ______ Yes ______ No If no, when and how is the therapy animal incorporated into the therapy process? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 17. If the therapy animal(s) is present in a session, is it typically present during the entire session? ______ Yes ______ No ______ If no, what percentage of the time is the therapy animal typically present in the session? 18. Please tell me some of the traits the therapy animal(s) has that makes the therapy animal(s) therapeutically valuable. ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 19. Please describe aspects of your relationship with the therapy animal that contributes to the therapeutic value of AAT. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 95 Scale: Never = 0, Seldom = 1, Often = 2, Always = 3 Using the scale provided above, please rate how often you, the therapist, utilize with clients each of the animal assisted therapy interactions listed below. Please indicate in space on the left of the numbered item. Then, for the following list of therapeutic intentions below please indicate, for each animal assisted intervention you utilize, the therapeutic intention you relate to each intervention. Therapeutic Intentions A. Building rapport in the therapeutic relationship G. Facilitating insight B. Enhancing client‟s social skills H. As a behavioral reward C. Enhancing relationship skills I. Enhancing trust within D. Enhancing self confidence therapeutic environment E. Modeling specific behaviors J. Facilitating feeling of being F. Encouraging sharing of feelings safe in therapeutic environment K. Other ____ 1. Therapist reflects or comments on client‟s relationship with therapy animal. Intention ____ ____ ____ ____ ____ ____2. Therapist encourages client to interact with therapy animal by touching or petting therapy animal. Intntion ____ ____ ____ ____ ____ ____3. Therapist encourages client to play with therapy animal during session. Intention ____ ____ ____ ____ ____ ____4. Therapist encourages client to tell therapy animal about client‟s distress or concerns. Intention ____ ____ ____ ____ ____ ____5. Therapist and client engage with therapy animal outside of traditional therapeutic environment; i.e. such as taking therapy animal for walk. Intention ____ ____ ____ ____ ____ ____6. Therapist interacts with therapy animal such by having animal perform tricks. 96 Intention ____ ____ ____ ____ ____ ____7. Therapist encourages client to perform tricks with therapy animal. Intention ____ ____ ____ ____ ____ ____8. Therapist encourages client to perform commands with therapy animal. Intention ____ ____ ____ ____ ____ ____9. Therapist comments or reflects on spontaneous client animal interactions. Intention ____ ____ ____ ____ ____ ____10. Information about therapy animal‟s family history (breed, species, and so forth) is shared with client. Intention ____ ____ ____ ____ ____ ____ 11. History related to therapy animal is shared with client. Intention ____ ____ ____ ____ ____ ____12. Animal stories and metaphors with animal themes are shared with client by therapist. Intention ____ ____ ____ ____ ____ ____13. Therapist encourages the client to make up stories involving the therapy animal. Intention ____ ____ ____ ____ ____ ____14. Therapist utilizes the client-therapy animal relationship, such as: “If this dog were your best friend, what would he know about you that no one else would know?” AND/OR “Tell Rusty (therapy dog) how you feel and I will just listen.” Intention ____ ____ ____ ____ ____ ____15. Therapist encourages client to recreate/reenact experience where therapy animal plays a specific role. Intention ____ ____ ____ ____ ____ 97 ____16. Spending time with therapy animal is a reward for progress in therapeutic treatment. Intention ____ ____ ____ ____ ____ ____17. Therapy animal is present without any directive interventions. Intention ____ ____ ____ ____ ____ ____18. Therapist creates specific/structured activities with therapy animal. Intention ____ ____ ____ ____ ____ Please describe Please describe one activity and one therapeutic purpose________________________________________________________ ______________________________________________________________ ______________________________________________________________ _____19.Therapy animal engages with client in spontaneous moments that facilitate therapeutic discussion. Please describe moments.________________________________________ ______________________________________________________________ ______________________________________________________________ APPENDIX B PARTICIPANTS INCORPORATING AAT BY VARIOUS TREATMENT MODAILITIES 98 99 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 1 0 0 0 Group 0 0 0 0 Adolescent Individual 0 0 0 0 Group 0 0 0 0 Adult Individual 0 0 0 1 Group 0 0 0 1 Elderly Individual 0 0 0 1 Group 0 0 0 0 Frequency of Participants Including AAT in SandTray Therapy 100 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 2 1 0 0 Group 0 0 0 0 Adolescent Individual 1 2 0 0 Group 0 0 0 0 Adult Individual 0 0 0 0 Group 0 0 0 0 Elderly Individual 0 0 0 0 Group 0 0 0 0 Frequency of Participants Including AAT in Drama Therapy 101 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 1 0 0 0 Group 1 0 0 0 Adolescent Individual 1 0 0 0 Group 1 0 0 0 Adult Individual 0 0 0 0 Group 0 0 0 0 Elderly Individual 0 0 0 0 Group 0 0 0 0 Frequency of Participants Including AAT in Adventure Therapy 102 1%-25% 26%-50% 51%-75% 76%-100% Children Individual 2 0 2 0 Group 0 0 1 0 Adolescent Individual 1 0 0 1 Group 0 0 0 1 Adult Individual 1 0 0 0 Group 0 0 0 0 Elderly Individual 0 0 0 0 Group 0 0 0 0 103 APPENDIX C FREQUENCY OF PARTICIPANTS INCLUSION OF AAT TECHNIQUES 104 Technique Never Seldom Often Always 1. Therapist reflects or comments on client‟s relationship with therapy animal. 0 2 19 9 2. Therapist encourages client to interact with therapy animal by touching or petting therapy animal 0 6 19 5 3. Therapist encourages client to play with therapy animal during session 3 11 14 1 4. Therapist encourages client to tell therapy animal about client‟s distress or concerns. 7 16 5 2 5. Therapist and client engage with therapy animal outside of traditional therapeutic environment; i.e. such as taking therapy animal for walk. 10 7 11 2 6. Therapist interacts with therapy animal such as having animal perform tricks. 10 6 12 1 7. Therapist encourages client to perform tricks with therapy animal. 11 6 6 4 8. Therapist encourages client to perform commands with therapy animal. 6 8 11 4 9. Therapist comments or reflects on spontaneous client animal interactions. 0 3 16 11 10. Information about therapy animal‟s family history (breed, species, and so forth) is shared with client. 3 8 13 6 11. History related to therapy animal is shared with client. 3 8 11 7 12. Animal stories and metaphors with animal themes are shared with client by therapist. 4 9 14 3 105 13. Therapist encourages the client to make up stories involving the therapy animal. 15 11 4 0 14. Therapist utilizes the client-therapy animal relationship, such as: “If this dog were your best friend, what would he know about you that no one else would know?” AND/OR “Tell Rusty (therapy dog) how you feel and I will just listen.” 10 8 11 0 15. Therapist encourages client to recreate/ re-enact experience where therapy animal plays a specific role. 19 6 5 0 16. Therapy animal is present without any directive interventions. 1 6 19 4 17. Therapist creates specific/structured activities with therapy animal. 8 7 11 3 18. 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Belmont, CA: Brooks/Cole. http://mentalhealth.samhsa.gov/resources/dictionary.aspx ACKNOWLEDGEMENTS LIST OF TABLES LIST OF FIGURES 1. INTRODUCTION Statement of the Problem Review of Related Literature Animal Assisted Therapy Studies and Therapeutic Implications Animal Assisted Therapy Studies and Implications Variations of Animal Assisted Therapy Programs and Related Studies Equine Assisted Therapy Research AAT Related Literature and Therapeutic Implications Justification of Animal Assisted Technique Questions Purpose of the Study 2. METHODS AND PROCEDURES Research Questions Research Assumptions Definition of Terms Method Participants Instrument Data Collection Statistical Analysis 3. RESULTS AND DISCUSSION Results Demographics Related to the Therapy Animal Assumption 1 Assumption 2 Assumption 3 Discussion Other Findings Implications Strength of the Study Limitations Future Research Appendices A: CONSENT FORM AND MENTAL HEALTH PROFESSION ANIMAL ASSISTED THERAPY TECHNIQUE SURVEY B: PARTICIPANTS INCORPORATING AAT BY VARIOUS TREATMENT MODAILITIES C: FREQUENCY OF PARTICIPANTS INCLUSION OF AAT TECHNIQUES REFERENCES