Volume 43 Number 3, May/June 2006 Pages 357 — 366
Animal-assisted therapy for persons with aphasia: A pilot study Beth L. Macauley, PhD, CCC-SLP, HPCS Department of Communicative Disorders, The University of Alabama, Tuscaloosa, AL Abstract — This study explored the effects and effectiveness of animal-assisted therapy (AAT) for persons with aphasia. Three men with aphasia from left-hemisphere strokes participated in this study. The men received one semester of traditional therapy followed by one semester of AAT. While both therapies were effective, in that each participant met his goals, no significant differences existed between test results following traditional speechlanguage therapy versus AAT. Results of a client-satisfaction questionnaire, however, indicated that each of the participants was more motivated, enjoyed the therapy sessions more, and felt that the atmosphere of the sessions was lighter and less stressed during AAT compared with traditional therapy. Key words: animal-assisted therapy, aphasia, brain injury, communication, increased motivation, rehabilitation, speech-language pathology, speech-language therapy, stroke, therapy animals, therapy efficacy. Abbreviations: AAT = animal-assisted therapy, AD = Alzhei-mer's disease, ADL = activities of daily living, MLU = mean length of utterance, SAFE = Social-Adaptive Functioning Evaluation, WAB = Western Aphasia Battery. Address all correspondence to Beth L. Macauley, PhD, CCC-SLP, HPCS; Mary K. Chapman Center for Communication Disorders, University of Tulsa, 600 South College, Tulsa, OK 74104; 918-631-2903; fax: 918631-3668. Email: beth-macauley@utulsa.edu DOI: 10.1682/JRRD.2005.01.0027
INTRODUCTION Animals have been used to improve the emotional and functional status of humans since the time of the ancient Greeks [1]. The use of animals ranges from companion animals that provide camaraderie and emotional support to assistance animals that provide direct physical-functional support to therapy animals that aid with the habilitation-rehabilitation in physical, occupational, speech-language, and recreation therapy. Therapy animals include turtles, chicks, rabbits, birds, cats, potbellied pigs, fish (aquariums), dogs, and horses. Each animal has specific skills, temperaments, and aptitudes that it brings to the therapy environment. For example, dogs are very friendly and facilitate communication and interaction, while horses offer a riding experience that facilitates the normalization of muscle tone. Within rehabilitation, animals are used more often in counseling, physical therapy, and occupational therapy than in speech-language therapy. Possible reasons for the lack of animal-assisted therapy (AAT) in speech-language therapy include lack of research (1) supporting its use, (2) describing the best ways to incorporate animals in the therapy sessions, (3) determining what types of clients or what types of speech-language disorders respond
to the use of animals, and (4) demonstrating the effectiveness of animal therapy compared with traditional speech-language therapy. This study examined the effects and effectiveness of AAT for persons with aphasia.
ANIMAL-ASSISTED THERAPY The first documented use of animals in therapy occurred in 1792 at the York Retreat in England, where farm animals were used to improve the attitude of mental patients. The founder of nursing, Florence Nightingale, documented the benefits of animals in therapy settings in 1860. She "observed that a small pet is often an excellent companion to the sick" [2]. In the 20th century, animals have been incorporated into numerous healthcare professions, including clinical psychology; nursing; counseling; and recreational, physical, occupational, and speech therapies [3]. AAT has also been conducted in many different environments, including schools, counseling agencies, hospitals, nursing homes, hospice care centers, long-term care centers, residential facilities for persons with severe physical and mental disabilities, juvenile detention centers, and prisons (http://www.deltasociety.org). The incorporation of animals into a mental health program in the United States began in 1919 at St. Elizabeths Hospital in Washington, DC [4]. The integration of AAT into clinical psychology was first credited to the child psychologist, Boris Levinson, who published a paper entitled "The dog as a `co-therapist'" in Mental Hygiene in 1962 and a book on incorporating animals into child psychology in 1969. Levinson discovered that when his dog Jingles was present during therapy or counseling sessions, significant progress was made when compared with sessions during which Jingles was not present. He went on to find that many children who were withdrawn and uncommunicative would interact positively with the dog [5-6]. Pet visitations are used in the acute-care setting to help establish rapport, facilitate communication, and increase patient responsiveness and social interaction [2]. Through the idea of pet visitation, AAT developed. The Delta Society, an organization formed to promote the bene-fits of the human-animal bond, formally defines AAT as
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. AAT is provided in a variety of settings and may be group or individual in nature. This process is documented and evaluated (http://www.deltasociety.org). The Delta Society describes the benefits of AAT to be in the areas of improved empathy, outward focus, nurturing, rapport, acceptance, entertainment, socialization, mental stimulation, physical contact, touch, and physiological benefits (http://www.deltasociety.org). More specifically, AAT in hospitals reduced stress among patients and provided both physiological and psychological benefits to the patients [7].
The animals incorporated in animal therapy must be used as a part of the professional's specialty. For example, a speech-language pathologist must use the animal in the context of speech-language therapy, not as a companion pet. The major factor for success with AAT is viewing the animal as a cotherapist rather than an object. This helps develop the relationship between the animal and the patient, creating a bond needed for optimal success [8]. The study of this unique and irreplaceable human-animal bond is at the heart of many different research centers across the United States, such as the Center to Study Human Animal Relationships and Environments at the University of Minnesota, Minneapolis, Minnesota; the Center for Human-Animal Interaction at Virginia Commonwealth University Medical Center, Richmond, Virginia; the Center for Human Animal Relationships at Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, Virginia; and the Center for the Interaction of Animals and Society within the School of Veterinary Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. Although AAT is used in various settings, very little empirical research has documented its effectiveness. Anecdotal reports of the benefits of AAT exist but have not been published in peerreviewed research journals. Following extensive literature review, we found no study to date that investigated the use of AAT for persons with stroke or aphasia. Despite the lack of research in AAT for persons with aphasia, numerous studies have been performed on the effects of AAT on other adult populations, such as residents of nursing homes [9-12]; patients in acute-care hospitals [1316]; patients in intensive care units [17]; and adults with spinal cord injury [18], dementia [19-20], depression [21], psychiatric disorders [21-23], and schizophrenia [24-26]. Of the six studies that targeted participants with psychiatric disorders (including schizophrenia), four are worthy of additional discussion. Barker and Dawson examined whether an AAT session reduced the anxiety levels of hospitalized psychiatric patients [22]. In the study, 230 patients participated in a single AAT session and a single traditional recreation therapy session. Before and after participating in the two types of sessions, subjects completed the State-Trait Anxiety Inventory, a self-report measure of anxiety. Barker and Dawson used a repeated-measures analysis to test differences in scores from before and after the two types of sessions. Statistically significant reductions in anxiety scores were found after the AAT session for patients with psychotic, mood, and other disorders and after the traditional therapeutic recreation session for patients with mood disorders. The authors concluded that AAT was associated with reduced anxiety levels for hospitalized patients with a variety of psychiatric diagnoses. Barak et al. evaluated the effects of AAT in a closed psychogeriatric ward over a 12-month period [24]. The participants were 10 elderly persons with schizophrenia and 10 matched control subjects. The AAT consisted of weekly 4-hour sessions that targeted mobility, interpersonal contact, communication, and activities of daily living (ADL) (including personal hygiene and independent selfcare) through the use of cats and dogs as "modeling companions." Raters blind to the participant's group assessed each person with the scale for Social-Adaptive Functioning Evaluation (SAFE) at
the beginning and end of the 12-month period. When the pre- and posttest scores were compared, the AAT group showed more significant improvements than the matched control subjects on both total SAFE score and social functions subscale. The authors concluded that AAT proved a successful tool for enhancing socialization, ADL, and general well-being. Kovacs et al. studied the effectiveness of AAT in the rehabilitation of schizophrenic patients in a residential social institution [25]. The participants received 9 months of weekly AAT sessions. At the completion of therapy, the participants demonstrated significant improvement in domestic and health activities as assessed by an independent rater using the Independent Living Skills Survey. The authors concluded that AAT was helpful in the rehabilitation of the persons with schizophrenia. A recent study by Nathans-Barel et al. documented significant improvement in anhedonia for a group of adults with schizophrenia following 10 weeks of AAT when compared with the control group who were treated without AAT [26]. The patients who had the AAT sessions also showed improved use of leisure time and a trend toward improved motivation. The authors concluded that AAT may contribute to the psychosocial rehabilitation and quality of life of persons with schizophrenia. Of the seven studies that examined AAT for elderly persons with dementia or depression or in nursing homes, four are worthy of additional discussion. Fick studied the effect of AAT on the frequency and types of social interactions among nursing home residents [10]. Point sampling was used to evaluate the behaviors of 36 male nursing home residents at a Department of Veterans Affairs medical center under two conditions: "dog present" and "dog absent." A significant difference in verbal interactions among residents occurred with the dog present. The author concluded that AAT is an effective treatment strategy for increasing socialization among residents in long-term care facilities. Because an increase in social interactions can improve the social climate of an institution, the therapeutic use of animals is a valuable adjunct for reaching treatment goals [11]. Banks and Banks studied the effects of AAT on loneliness for residents of long-term care facilities [11]. They randomized 45 residents into three groups (no AAT, AAT once/week, AAT three times/week; n = 15/group). The Demographic and Pet History Questionnaire and version 3 of the University of California at Los Angeles Loneliness Scale were administered before and after a 6week treatment period. Results indicated that AAT significantly reduced loneliness scores. However, the results of this study must be viewed with caution because each AAT session was conducted by a person and a dog, and the presence of another adult may have contributed to the decrease in loneliness. Edwards and Beck took a more unique approach and studied whether the presence of fish aquariums influenced the nutritional intake of individuals with Alzhei-mer's disease (AD) [20]. They studied 62 individuals with AD who lived in specialized units. Baseline nutritional data were obtained followed by a 2-week treatment period during which the aquariums were introduced. The treatment
data were collected daily for 2 weeks and then weekly for 6 weeks. The results indicated that the nutritional intake of the persons with AD increased significantly when the aquariums were introduced and continued to increase during the 6-week follow-up. Weight also increased significantly over the course of the study. The authors concluded that the presence of the fish aquariums improved the environment of the facilities, thereby improving residents' moods and increasing their desire to eat. The authors also reported that the participants required less nutritional supplementation following the introduction of the fish aquariums, which resulted in healthcare cost savings. Richeson studied the effects of AAT on the agitated behaviors and social interactions of older adults with dementia [12]. Fifteen nursing home residents with dementia participated in daily AAT for 3 weeks, and results indicated a statistically significant decrease in agitated behaviors and increase in social interaction pre- to posttest. In a unique study of the effects of AAT, Odendaal measured in both people (n = 18) and dogs (n = 18) six neurochemicals associated with decreased blood pressure before and after positive interaction between the two [27]. Statistically significant results (p < 0.05) indicated that the neurochemicals involved in decreasing blood pressure and increasing attention-seeking behavior increased in both species following the interaction. This study provides neurochemical evidence for the reduction of blood pressure and increase in outward focus following AAT. According to Chapey, persons with aphasia may experience anxiety, depression, frustration, panic, and other mood disorders [28]. Speech-language pathologists, while attempting to improve language function, may actually exacerbate these mood disorders by reminding the persons with aphasia of their speech difficulty. The sudden and severe inability to communicate may render the person unwilling to participate in therapy and cause withdrawal from family and friends. However, the application of AAT to this population targets outward focus, desire to communicate, improvement of mood, decrease in loneliness, and more enjoyable treatment. In addition, many researchers have found that animals exhibit unconditional acceptance through tail wags, facial expressions, purring, and barking, regardless of the person's language difficulties [13]. This helps the patient build confidence. Unfortunately, little research has evaluated the effectiveness of AAT in the clinical setting with a speech-language pathologist. A literature search, including an annotated bibliography of hippotherapy (the use of equine movement as a treatment strategy) research [29], revealed that six studies to date have examined the effectiveness of AAT within speech-language pathology. All the studies targeted children; four studies examined hippotherapy [30-32]1and two studies examined AAT with a dog [33].2 Therefore, the purpose of this research project was to first examine the effects of speech-language AAT for persons with aphasia and second to compare the effectiveness of speech-language AAT with traditional speech-language therapy for persons with aphasia. The following research questions were asked:
1. Is speech-language AAT effective for persons with aphasia? 2. If speech-language AAT is effective, is it less, more, or equally effective as traditional therapy? 3. Will persons with aphasia report differences in their motivation and attitude during traditional versus AAT? 1
Macauley BL. The effects of hippotherapy on respiration and motor speech in persons with cerebral palsy [unpublished master's thesis]. Gainesville (FL): University of Florida; 1989. 2 Macauley BL, Tanner AK, Laing SP. The effectiveness of animal-assisted therapy for preschoolers with language delay: A pilot study. Unpublished observations; 2002.
METHODS Participants The participants for the current study were three men with aphasia from left-hemisphere stroke who were enrolled in speech-language therapy at the Speech and Hearing Center at The University of Alabama, Tuscaloosa, Alabama. Criteria for inclusion included presence of nonfluent aphasia with Western Aphasia Battery (WAB) [34] auditory comprehension scores above 50/60, no allergies to dogs, an affinity to or liking for dogs, and evidence of frustration during speech tasks (e.g., facial expression, refusal to speak, tone of voice). Participant 1 was a 63-year-old man with mild nonfluent aphasia who was 4 years poststroke. His speech was slow and effortful and contained short phrases consisting of content words with good intonation and a mean length of utterance (MLU) of 3.7. His treatment goals included expanding phrases, increasing MLU, improving articulation, and word finding. Participant 2 was a 59-year-old man with moderate nonfluent aphasia who was 7 years poststroke. His speech was also slow and effortful and contained short phrases consisting of nouns with poor intonation and an MLU of 3.1. His treatment goals included verb naming, expanding phrases, and increasing MLU. Participant 3 was a 67-year-old man with severe nonfluent aphasia who was also 7 years poststroke. His speech was very slow and effortful and contained single word responses with an MLU of 1.1. His treatment goals included producing noun-verb phrases, increasing the content of speech by increasing MLU, and decreasing frustration and effort. All participants were living at home with a spouse or caregiver throughout the study.
Design This study implemented a baseline-treatment design with pre-, mid-, and posttesting. To measure the effectiveness of AAT and traditional therapy, we administered both formal and informal measures. The formal measurement consisted of the WAB [34], and the informal measure consisted of a client-satisfaction questionnaire. The questionnaire was designed to measure each participant's motivation and attitude toward the therapy sessions and was derived from a client-satisfaction questionnaire used in a previous study [31]. The questionnaire can be found in Appendix 1 . The WAB was administered at the beginning of the first semester of therapy (Time 1), between the two semesters (Time 2), and at the conclusion of the second semester of therapy (Time 3). The questionnaire was administered at Times 2 and 3 only. This study was approved by The University of Alabama Institutional Review Board (03-JCH-005), and signed consent forms were obtained from each participant.
Therapy All participants attended one semester of traditional therapy and one semester of AAT. All sessions were individual in nature, 30 minutes in length, and held weekly for 12 weeks. Both the traditional and AAT interventions contained similar activities and targeted similar goals. During the AAT sessions, the participating animal was an 8-year-old neutered male Newfoundland that was a certified Pet Partner® from the Delta Society. A Pet Partner® is an animal that has completed the certification procedures and passed the required behavioral and temperament evaluations from a certified Delta Society Evaluator. Qualifications for a Pet Partner® animal are similar to the Canine Good Citizen criteria from the American Kennel Club and include the obedience commands sit, stay, come, lie down, heel, speak on command, and not jumping on people. Pet Partners® additionally requires that the animals pass temperament standards such as being tolerant of wheelchairs, canes, loud noises (yelling, whistles, and bells), and people who walk with clumsy movements or speak loudly and unintelligibly. The animal must not be skittish, nervous, or afraid when challenged by these environments. The animal must also receive regular grooming and veterinary checks, be current with vaccinations, and be on a flea/tick prevention program. Both the traditional and AAT sessions were conducted by a graduate student clinician in the Department of Communicative Disorders at the University of Alabama under the supervision of a certified speech-language pathologist who was present in the room. The AAT sessions added a Newfoundland that was certified as a Pet Partner® along with the supervising speech-language pathologist. All therapy and assessment sessions were conducted at the Speech and Hearing Center at The University of Alabama. Examples of therapy activities across traditional and AAT sessions can be found in Appendix 2 .
RESULTS Research Question 1 To determine whether speech-language AAT is effective for persons with aphasia, we compared results of the WAB from Times 2 and 3 and evaluated questionnaire responses from Time 3. While the WAB scores did not change significantly, the questionnaire indicated that all participants believed that they progressed more during the AAT sessions (Table 1). In addition, all participants met or exceeded their therapy goals during the AAT semester, indicating that AAT was effective.
Table 1. Western Aphasia Battery Aphasia Quotient scores for each participant before therapy (Time 1), after traditional therapy and before animal-assisted therapy (AAT) (Time 2), and after AAT (Time 3).
Time 1 2
Participant 1 84.4 81.1
Participant 2 75.5 75.1
Participant 3 63.2 64.8
3
83.7
76.2
66.3
The scores from the questionnaire revealed that each participant reported improvement in speechlanguage abilities after AAT. When analyzing the questionnaire, we considered responses in the range of 1 to 3 as negative (i.e., regression of skills), responses in the range of 4 to 7 as no improvement (i.e., maintenance of previously learned skills), and responses in the range of 8 to 10 as positive improvement (i.e., active learning and retention of new skills). If a participant circled two numbers, the average of the numbers was used in the calculations (i.e., if a participant circled 8 and 9, then an 8.5 was used). As can be seen in Table 2, the average scores fell in the 5 to 9 range for Time 2, with an overall mean of 7.5, and in the 7 to 10 range for Time 3, with an overall mean of 8.3, indicating that the participants believed that AAT helped them improve their ability to communicate.
Table 2. Mean participant responses on client-satisfaction questionnaire after traditional therapy and before animal-assisted therapy (AAT) (Time 2), after AAT (Time 3), and the difference between them. Scale of 1 to 10: 1 = strongly disagree, 10 = strongly agree. Difference Question Time 2 Time 3 |Time 2 - Time 3| 1. Clinician/supervisors were prompt in meeting therapy or diagnostic 8.5 9.0 0.5 appointments. 2. The therapy environment was healthy and appealing. 7.0 8.0 1.0 3. The clinician was courteous and concerned in his/her clinical 9.0 9.0 0.0 activities. 4. There were noticeable improvements in my ability to communicate 6.0 7.0 1.0 following the semester of therapy. 5. Communication with the clinician was open and questions were 8.5 9.0 0.5 readily answered. 6. I was motivated to attend the therapy sessions. 7.5 8.5 1.0 7. My clinician was interested in me as an individual and considered my 9.0 9.5 0.5 special needs. 8. The therapy activities were beneficial. 7.5 8.5 1.0 9. My instructions were clear and understandable. 9.5 9.5 0.0 10. The clinician helped me relate the therapy activities to everyday life. 7.0 8.5 1.5 11. Therapy tasks were appropriately chosen and well organized. 8.0 8.5 0.5 * 12. I enjoyed my therapy sessions. 7.0 10.0 3.0 13. My clinician was well prepared. 8.5 9.0 0.5 â&#x20AC; 14. I talked about my therapy with family and/or friends. 3.5 8.2 4.7 15. My clinician was alert and competent in executing the therapy 6.8 7.4 0.6 activities. * 16. The therapy activities were fun and interesting. 5.5 9.5 4.0 17. Sufficient equipment and materials were available for each session. 8.0 8.0 0.0 18. I would choose to return for another semester. 8.2 10.0 1.8 19. The clinician provided helpful emotional support and counseling as 7.5 7.5 0.0 needed. * 20. I would refer others for services. 7.0 9.5 2.5 * 21. Overall satisfaction rating. 7.5 9.5 2.0
Mean Overall *
Difference of 2 â&#x20AC; Difference > 4 points = noteworthy.
7.5 to
4
points
8.8 =
1.3 important.
Research Question 2 To determine whether AAT is less effective, more effective, or equally effective as traditional clinicbased therapy, we compared the WAB scores from Time 1 to Time 2 and from Time 2 to Time 3. Results indicated little difference on the WAB for each subject across the three measurements (Table 1). However, all participants met or exceeded their therapy goals during both semesters. With the questionnaire, the differences in each question across Time 2 (posttraditional therapy) and Time 3 (post-AAT) were compared. A difference of less than 2 points was considered negligible, a difference between 2 and 4 points was considered important, and a difference greater than 4 points was considered noteworthy. Please note that the same clinicians conducted both the traditional and AAT sessions. As seen in Table 2, the differences in the participants' responses from Time 2 to Time 3 ranged from 0 to 4.7, with an overall mean difference of 1.3. Within the questionnaire, the responses from questions concerning the clinician (questions 1, 3, 5, 7, 9, 10, 11, 13, 15, 17, and 19) should have remained relatively equal, while the responses for questions concerning the therapy (questions 2, 4, 6, 8, 12, 14, 16, 18, 20, and 21) should have differed. We found this to be true because the mean difference from Time 2 to Time 3 for the clinician questions was 0.5, while the mean difference from Time 2 to Time 3 for the therapy questions was 2.2. This difference was considered important and indicated that according to the participants, AAT was more enjoyable than traditional therapy.
Research Question 3 To determine whether the participants were more motivated to attend therapy during AAT than during traditional therapy, we examined the mean from questions 6, 12, 14, and 16 from Times 2 and 3. As can be seen in Table 2, for these four questions, the participants' mean score was 5.88, with a range of 3.5 to 7.5 for traditional therapy, and the participants' mean score was 9.05, with a range of 8.5 to 10 for AAT. All participants reported that they were more motivated to attend the therapy sessions when they knew the dog would be present.
DISCUSSION Previous research in AAT has examined its efficacy in adult populations, but no studies have examined the benefits of AAT for persons with stroke and aphasia. Results of these previous studies suggest that using animals as an integral part of therapy sessions was effective and motivating. Increased motivation has also been shown in AAT studies with children with language disorders.3 The animal used in the majority of these studies was a dog. The purpose of the present study was to investigate the effectiveness of using AAT with adults with aphasia and to determine if AAT was more effective, equally effective, or less effective than traditional speech-language therapy. Results
indicated that AAT is effective as a treatment strategy for persons with aphasia and is at least as effective as traditional therapy. Although no differences were noted in formal testing across all conditions, all the participants improved and met their treatment goals each semester. The participants also reported that they enjoyed the AAT sessions more than the traditional sessions and looked forward to their therapy sessions when the dog would be present with greater anticipation. The participants also demonstrated more emotion during the AAT sessions as they initiated communication about their own pets or loss of pets.
3
Macauley BL, Tanner AK, Laing SP. The effectiveness of animal-assisted therapy for preschoolers with language delay: A pilot study. Unpublished observations; 2002.
These are important findings for speech-language pathologists who are interested in new and innovative techniques to use with persons with chronic aphasia. This study provides the first empirical evidence that incorporating animals into treatment sessions for speech-language intervention will not sacrifice progress and, in fact, may even facilitate progress toward selected treatment goals. AAT offers the speech-language pathologist an exciting adjunct to traditional therapy by bringing additional creativity and variety to the therapy setting. With animals incorporated into speech-language therapy, the client will be more motivated to attend therapy, more willing to pay attention, and more likely to participate in the therapy activities. In addition, the dog provides a unique way to decrease the effortfulness that is a hallmark of nonfluent aphasia. That is, the participants spoke with more effort when responding to the clinician than when asked to direct their responses toward the dog, even though in most cases, they were saying the same word or phrase, such as "I am hungry," "Go to Cypress Inn to eat," and "It is raining outside." Clinicians who were not affiliated with the study were asked to observe a session and subjectively decide if the participant spoke with more or less effort when speaking to the clinician than when speaking to the dog. All the observers believed that the participant spoke with more effort toward the clinician and less effort toward the dog. In addition, one observer reported that she believed the participant had improved prosody when speaking to the dog as compared with speaking to the clinician. These findings are consistent with prior studies that reported decreased anxiety and stress when subjects were speaking to an animal versus a person. The change in orientation of turning and speaking to the dog appeared to change the environment of the therapy session. That is, the tension in the air seemed to decrease perceptibly and lightness increased. This environmental change was reported by the participant, the participant's spouse or caregiver who observed the session, and the clinician. An unexpected benefit of AAT included a trend toward an increased number of spontaneous communicative initiations produced during the sessions. That is, the participants initiated speech more often during the AAT sessions than during the traditional sessions. Most of these initiations were speech directed toward the dog. It makes sense that if a task is perceived as easier and less
stressful (e.g., more enjoyable), then a person will initiate that task more often. The current investigation included only three persons with chronic nonfluent aphasia. Perhaps a larger study that included more participants, especially those within the first 6 months after brain injury, would reveal statistically significant differences. We should also mention that separating the specific effect of the dog from the nonspecific effects on outcome variables is difficult. That is, the dog was brought into the sessions during the second semester of therapy when the client was already familiar with the clinician. Interaction effects may have also existed between the two treatments (traditional and AAT) since AAT followed traditional therapy for all three participants. Not surprisingly, the participants in the current study were more likely to direct their communicative initiations toward the dog than the speech-language pathologist. This is an important finding because it documents that the presence of the dog motivates the people to communicate and may even help provide them with something to talk about. Why must our clients with aphasia be motivated to communicate? When clients are hesitant or embarrassed about their speech difficulties, improving their speech is difficult. Talking is a voluntary activity. A clinician cannot use therapeutic techniques designed to expand, extend, and/or model appropriate form, function, or use of language if the client will not provide the language stimulus. The results from the current investigation suggest that the dog may act as a unique catalyst to motivate the client to talk and provide an atmosphere of unconditional acceptance for the disordered speech that is produced.
CONCLUSIONS Avenues for future research include determining the effectiveness of AAT for persons with different types of communicative disorders and different types of brain injury. One example of this is to incorporate appropriate and certified animals into speech-language therapy sessions for people with traumatic brain injury or fluent aphasia following stroke. Is AAT equally effective for group treatment as for individual treatment? Does the type of animal incorporated into the therapy session matter? Some clients may be fearful of dogs but respond warmly to cats. Does the presence of a fish aquarium in the treatment room improve the outcome of therapy? The future research arena for AAT is exciting in its numerous possibilities. We hope that this study will encourage other speech-language pathologists to incorporate Pet Partner速 animals into therapy and stimulate further research studies on the effectiveness of AAT in speech-language therapy.
ACKNOWLEDGMENTS Dr. Macauley is now with the Mary K. Chapman Center for Communication Disorders, University of Tulsa, Tulsa, Oklahoma. This material was unfunded at the time of manuscript publication.
The author has declared that no competing interests exist.
REFERENCES 1. Riede D. The relationship between man and horse with reference to medicine throughout the ages. People, Anim, Environ. 1987;5(2):26-28. 2. Jorgenson J. Therapeutic use of companion animals in health care. Image J Nurs Sch. 1997;29(3):249-54. [PMID: 9378480] 3. Gammonley J, Howie AR, Kirwin S, Zapf SA, Frye J, Freeman G, Stuart-Russell R. Animal-assisted therapy: Therapeutic interventions. Bellevue (WA): Delta Society; 1997. 4. Burch MR. Volunteering with your pet: How to get involved in animal-assisted therapy. New York (NY): Howell Books; 1996. 5. Levinson BM. The dog as a "co-therapist." Ment Hyg. 1962;46:59-65. [PMID: 14464675] 6. Levinson BM. Pet-oriented child psychotherapy. Springfield (IL): Thomas Publisher; 1969. 7. Carmack BJ, Fila D. Animal-assisted therapy: A nursing intervention. Nurs Manage. 1989;20(5):96,98,100-101. [PMID: 2726087] 8. Kaufmann M. Creature comforts: Animal-assisted activities in education and therapy. Reaching Today's Youth. 1997;1(2):27-31. 9. Gammonley J, Yates J. Pet projects: Animal assisted therapy in nursing homes. J Gerontol Nurs. 1991;17(1):12-15. [PMID: 1899683] 10. Fick K. The influence of an animal on social interactions of nursing home residents in a group setting. Am J Occup Ther. 1993:47(6):529-34. [PMID: 8506934] 11. Banks MR, Banks WA. The effects of animal-assisted therapy on loneliness in an elderly population in long-term care facilities. J Gerontol A Biol Sci Med Sci. 2002;57(7): M428-32. [PMID: 12084804] 12. Richeson N. Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia. Am J Alzheimers Dis Other Demen. 2003;18(6):353-58. [PMID: 14682084] 13. Barba BE. The positive influence of animals: Animal-assisted therapy in acute care. Clin Nurse Spec. 1995;9(4): 199-202. [PMID: 7634227] 14. Cole KM, Gawlinski A. Animal-assisted therapy: The human-animal bond. AACN Clin Issues. 2000;11(1):139-49. [PMID: 11040560] 15. Connor K, Miller J. Help from our animal friends. Nurs Manage. 2000;31(7):42-46. [PMID: 15127507] 16. Miller J, Ingram L. Perioperative nursing and animal-assisted therapy. AORN J. 2000;72(3):477-83. [PMID: 11004963] 17. Cole KM, Gawlinski A. Animal-assisted therapy in the intensive care unit. A staff nurse's dream comes true. Nurs Clin North Am. 1995;30(3):529-37. [PMID: 7567577] 18. Counsell CM, Abram J, Gilbert M. Animal assisted therapy and the individual with spinal cord injury. SCI Nurs. 1997;14(2):52-55. [PMID: 9295752] 19. Kanamori M, Suzuki M, Yamamoto K, Kanda M, Matsui Y, Kojima E, Fukawa H, Sugita T, Oshiro H. A day care program and evaluation of animal-assisted therapy (AAT) for the elderly with senile dementia. Am J Alzheimers Dis Other Dement. 2000;16(4):234-39. [PMID: 11501346] 20. Edwards NE, Beck AM. Animal-assisted therapy and nutrition in Alzheimer's disease. West J Nurs Res. 2000;24(6): 697-712. [PMID: 12365769] 21. Gress K. Animals helping people. People helping animals. Interview by Shirley A. Smoyak. J Psychosoc Nurs Ment Health Serv. 2003;41(8):18-25. [PMID: 13677008] 22. Barker SB, Dawson KS. The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatr Serv. 1998;49(6):797-801. [PMID: 9634160] 23. Barker SB, Pandurangi AK, Best A. Effects of animal-assisted therapy on patients' anxiety, fear, and depression before ECT. J ECT. 2000;19(1):38-44. [PMID: 12621276] 24. Barak Y, Savorai O, Mavashev S, Beni A. Animal-assisted therapy for elderly schizophrenic patients: A one-year controlled trial. Am J Geriatr Psychiatry. 2001;9(4):439-42. [PMID: 11739071] 25. Kovacs Z, Kis R, Rozsa S, Rozsa L. Animal-assisted therapy for middle-aged schizophrenic patients living in a social institution. A pilot study. Clin Rehabil. 2004;18(5): 483-86. [PMID: 15293482] 26. Nathans-Barel I, Feldman P, Berger B, Modai I, Silver H. Animal-assisted therapy ameliorates anhedonia in schizophrenia patients. A controlled pilot study. Psychother Psychosom. 2005;74(1):31-35. [PMID: 15627854]
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Odendaal JS. Animal-assisted therapy-Magic or medicine? J Psychosom Res. 2000;49(4):275-80. [PMID: 11119784] 28. Chapey R. Language intervention strategies in aphasia and related neurogenic communication disorders. 4th ed. Baltimore (MD): Lippincott, Williams & Wilkins; 2001. 29. Macauley BL. Hippotherapy: An annotated bibliography for research and education. Woodside (CA): American Hippotherapy Association; 2004. 30. Dismuke RP. Rehabilitative horseback riding for children with language disorders. In: Anderson R, Hart BL, Hart LA, editors. The pet connection. Minneapolis (MN): Hawthorne Press; 1984. p. 154-80. 31. Macauley BL, Gutierrez K. The effectiveness of hippotherapy for children with language-learning disabilities. Commun Disord Q. 2004;25(4):205-17. 32. Macauley BL, Drewry C. Hippotherapy facilitates use of an augmentative communication device: A case study. Sci Educ J Ther Riding. 2004;1-8. 33. Adams DL. Animal-assisted enhancement of speech therapy: A case study. Anthrozoos. 1997;10(1):53-56. 34. Kertesz A. Western Aphasia Battery. NewYork (NY): Psychological Corp; 1982.
Submitted for publication January 26, 2005. Accepted in revised form November 3, 2005.
Last Reviewed or Updated Friday, September 29, 2006 2:45 PM
Psychiatr Serv 49:797-801, June 1998 Š 1998 American Psychiatric Association
Article
The Effects of Animal-Assisted Therapy on Anxiety Ratings of Hospitalized Psychiatric Patients Sandra B. Barker, Ph.D. and Kathryn S. Dawson, Ph.D.
Abstract OBJECTIVE: Animal-assisted therapy involves interaction between patients and a trained animal, along with its human owner or handler, with the aim of facilitating patients' progress toward therapeutic goals. This study examined whether a session of animal-assisted therapy reduced the anxiety levels of hospitalized psychiatric
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patients and whether any differences in reductions in anxiety were associated with patients' diagnoses. METHODS: Study subjects were 230 patients referred for therapeutic recreation sessions. A preand posttreatment crossover study design was used to compare the effects of a single animalassisted therapy session with those of a single regularly scheduled therapeutic recreation session. Before and after participating in the two types of sessions, subjects completed the state scale of the State-Trait Anxiety Inventory, a self-report measure of anxiety currently felt. A mixedmodels repeated-measures analysis was used to test differences in scores from before and after the two types of sessions. RESULTS: Statistically significant reductions in anxiety scores were found after the animal-assisted therapy session for patients with psychotic disorders, mood disorders, and other disorders, and after the therapeutic recreation session for patients with mood disorders. No statistically significant differences in reduction of anxiety were found between the two types of sessions. CONCLUSIONS: Animal-assisted therapy was associated with reduced state anxiety levels for hospitalized patients with a variety of psychiatric diagnoses, while a routine therapeutic recreation session was associated with reduced levels only for patients with mood disorders.
Introduction Within the last decade, studies supporting the health benefits of companion animals have emerged (1,2,3,4). Cardiovascular effects are often the focus, due partly to findings from a 1980 study that reported longer survival rates following myocardial infarction for pet owners compared with people with no pets (5). More recent
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evidence of cardiovascular benefit was documented in an Australian study involving 5,741 participants (6). The authors found that pet owners had significantly lower blood pressure and triglyceride levels compared with non-pet-owners, and the differences could not be explained by differences in cigarette smoking, diet, body mass index, or socioeconomic profile. Stress and anxiety are considered contributory factors to cardiovascular disease. Investigators have hypothesized that companion animals may serve to lower levels of stress and anxiety (4,7,8). Several authors have reported lower blood pressure readings among adults and children when a previously unknown companion animal is present during various stressful activities (5,9,10,11,12,13,14). Animals have been associated with positive effects on patients in a variety of health care settings (15). When animals were first introduced to these settings, they were generally brought for visits that were incidental to the treatment program. Currently, animals are purposely included in treatment through various interventions broadly known as animal-assisted therapy. Animal-assisted therapy involves the use of trained animals in facilitating patients' progress toward therapeutic goals (16). Interventions vary widely, from long-term arrangements in which patients adopt pets to short-term interactions between patients and a trained animal in structured activities. Although animals have typically been well received on psychiatric services, much of the data attesting to their benefits has been anecdotal (17,18,19). Several decades ago, Searles (20) and Levinson (21) addressed the therapeutic benefit of a companion dog for patients with schizophrenia, contending that the caring, human-canine relationship helped ground the patient in reality. Chronic mentally ill residents in supportive care homes who were visited by puppies had decreased depression after the visits, compared with a matched control group (22). More recently, Arnold (23) described the use of therapy dogs with patients with dissociative disorders. Benefits included the dog's calming influence, ability to alert the therapist early to
clients' distress, and facilitation of communication and interaction. Others have proposed that an animal can serve as a clinical bridge in psychotherapy, providing an entree to more sensitive issues (16,24,25). On an inpatient psychiatric unit, animal-assisted therapy was found to attract the greatest number of patients among those who selected groups to attend voluntarily and was found to be the most effective in attracting isolated patients (26). Other researchers found that a group meeting for psychiatric inpatients held in a room where caged finches were located had higher attendance and higher levels of patient participation, and was associated with more improvement in scores on the Brief Psychiatric Rating Scale, compared with a matched group held in a room without birds (27). Anecdotally, psychiatric patients who are withdrawn and nonresponsive have been described as responding positively to a therapy dog with smiles, hugs, and talking (16). For elderly patients with dementia, lower heart rates and noise levels were associated with the presence of a therapy dog (28), and patients with Alzheimer's disease significantly increased socialization behaviors when a therapy dog was nearby (29). Based on the evidence in the literature associating companion animals with anxiety reduction and with positive responses from clinical populations, this study investigated the effect of an animal-assisted therapy group session on the anxiety levels of psychiatric inpatients. Also of research interest was whether any anxiolytic effect found varied by diagnostic group.
Methods A pre- and posttreatment crossover design was used for this study. Changes in anxiety ratings were compared for the same patients under two conditions: a single animalassisted therapy group session and a single therapeutic recreation group session that served as a comparison condition. The setting for this study was the inpatient
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psychiatry service of an urban academic medical center. The service treats adult patients with a full range of acute psychiatric disorders. The average length of stay is seven to eight days. The animal-assisted therapy session consisted of approximately 30 minutes of group interaction with a therapy dog and the dog's owner. During the semistructured session, which was held once a week, the owner talked generally about the dog and encouraged discussion
about patients' pets as the dog moved freely about the room interacting with patients or carrying out basic obedience commands. The comparison condition was a therapeutic recreation group session held on the unit on the day following the animal-assisted therapy session. Therapeutic recreation sessions were held daily on the unit. They varied in content, including education about how to spend leisure time, presentations to increase awareness of leisure resources in the community, and music and art activities. Coordination of both the animal-assisted therapy sessions and the therapeutic recreation sessions was shared by three recreational therapists. The study used the state scale of the State-Trait Anxiety Inventory to measure patients' levels of anxiety before and after the animal-assisted therapy session and the therapeutic recreation session (30). The State-Trait Anxiety Inventory is a brief, easy-to-administer self-report measure that is widely used in research and clinical practice. The state scale, which measures the level of anxiety felt at the present time, has been found to be sensitive to changes in transitory anxiety experienced by patients in mental health treatment. The inventory consists of 20 items related to feelings of apprehension, nervousness, tension, and worry. For each item, subjects circle one of four numbers corresponding to ratings of not at all, somewhat, moderately so, or very much so. Instruments are scored by calculating the total of the weighted item responses. Scores can range from 20 to 80, with greater scores reflecting higher levels of anxiety. The internal consistency for the state scale of the State-Trait Anxiety Inventory is high; median alpha coefficient is .93 (30). The construct validity is supported by studies showing that state scale scores are higher under stressful conditions.
Procedures A total of 313 adult psychiatric patients consecutively referred for therapeutic recreation over an eight-month period in 1996 were eligible for the study. Patients are referred for therapeutic recreation as soon as they are stable enough to participate in group activities, generally within 24 to 72 hours of admission. When patients were initially referred for therapeutic recreation, they were asked to sign a consent form to participate in a group session involving a therapy dog. Patients were not eligible to participate if they had any known canine allergies, were fearful of dogs, or did not sign a consent form. Study subjects attended both an animal-assisted therapy group session and a therapeutic recreation group session. The two types of sessions were held once a week on consecutive days at the same time on each day.
The three recreational therapists providing services to the inpatient psychiatry unit volunteered to assist with the study. Because the therapists were not blind to the treatment condition, steps were taken to minimize bias by training the therapists in standard data collection procedures. At the beginning and end of each animal-assisted therapy group session and the comparison therapeutic recreation group session the following day, the recreational therapist administered the State-Trait Anxiety Inventory. The therapists read the instrument verbatim to any patient who had difficulties reading. For the animal-assisted therapy group, the pretreatment instrument was completed before the dog entered the room. Two female owners of therapy dogs volunteered to provide the animal-assisted therapy sessions. The first volunteer provided the therapy for the initial four months of the study; then she became ill and could not continue. The second volunteer agreed to continue the study following the same format used by the first volunteer. Her participation required reversing the days that the animal-assisted therapy session and the therapeutic recreation session were offered. The dogs and owners met hospital policy for participating in animal-assisted therapy, including documentation of the dog's current vaccinations, controllability, and temperament. The volunteers were advised of the animal-assisted therapy group session and given direction on how to lead the therapy group.
Analysis Instruments were scored twice for accuracy by one of the authors using the scoring keys for the State-Trait Anxiety Inventory. A mixed-models repeated-measures analysis was used to compare pre- and posttreatment differences in anxiety scores between and within the animal-assisted therapy condition and the therapeutic recreation condition by diagnostic category.
Results Because this study was conducted in a clinical setting, pre- and posttreatment measures on all subjects under both conditions were difficult to obtain. Six patients refused to participate because of canine allergies or fear of dogs. Of the 313 patients who were eligible for the study, 73 percent (N=230) participated in at least one animal-assisted therapy group session or one recreation group session and completed a pre- and a posttreatment
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measure for the session. Fifty patients completed a pre- and a posttreatment measure for both types of sessions. Failure to complete all four measures was primarily due to time conflicts with medical treatments and patient discharges.
Patient characteristics The mean±SD age of the 313 patients referred for therapeutic recreation was 37±12 years, and their mean length of stay was 10.98±8.88 days. A total of 174 patients were women, and 139 were men. The majority were black (169 subjects, or 54 percent) and single (195 subjects, or 63 percent). They had completed an average of 11.3±2.6 years of education. For analysis, patients were categorized by primary discharge diagnosis. The diagnoses were collapsed into four categories: mood disorders, including all depressive, bipolar, and other mood disorders, for 154 patients (49.2 percent); psychotic disorders, including schizophrenia, schizoaffective disorder, and other psychotic disorders, for 80 patients (25.6 percent); substance use disorders, for 52 patients (16.6 percent); and all other disorders, including anxiety, cognitive, personality, and somatization disorders, for 27 patients (8.6 percent).
Comparison of therapy groups Table 1 shows the mean scores of the 230 study participants on the State-Trait Anxiety Inventory before and after attending an animal-assisted therapy group session and a therapeutic recreation group session as well as the mean change scores. Change scores were calculated using data from patients with measures at both pre- and posttreatment time points. The F test and p values show the significance of the change across time. No statistically significant differences in anxiety change scores were found between animal-assisted therapy and therapeutic recreation. Although no significant between-group differences were found, within-group differences were statistically significant for both animal-assisted therapy and therapeutic recreation (F=6.71, df= 1, 194, p=.01, and F=16.81, df=1, 194, p<.001, respectively). Among patients who participated in therapeutic recreation, only patients with mood disorders had a significant mean decrease in anxiety. Among patients who participated in animal-assisted therapy, patients with mood disorders, psychotic disorders, and other disorders had a significant mean decrease in anxiety. This finding suggests that animal-assisted therapy reduces anxiety for a wider range of patients than the comparison condition of therapeutic recreation.
Discussion and conclusions
Spielberger (30) provided normative State-Trait Anxiety Inventory scores for neuropsychiatric patients based on data from male veterans. Compared with the normative patients with depressive reaction, the patients with mood disorders in the study reported here had somewhat lower mean pretreatment scores (47.58± 12.73, compared with
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54.43±13.02). The pretreatment scores of the patients with psychotic disorders in this study were slightly higher than the scores for the normative patients with schizophrenia (48.47±15.26, compared with 45.70±13.44). In this study, no significant difference was found between the anxiety change scores after patients participated in animal-assisted therapy and after patients participated in therapeutic recreation. However, this lack of difference could be due to the small number of patients (N=50) who completed all four study measures. A power analysis of the magnitude of differences between the change scores for animal-assisted therapy and therapeutic recreation indicated that larger samples would be needed to achieve an 80 percent power level at an alpha of .05: a sample of 300 patients with psychotic disorders, 125 patients with substance use disorders, and 61 patients with other disorders. For patients with mood disorders, the difference in anxiety change scores was too small for any reasonably sized study to detect a significant difference. For within-group differences, a significant reduction in anxiety after therapeutic recreation was found only for patients with mood disorders, whereas a significant reduction after animal-assisted therapy was found for patients with mood disorders, psychotic disorders, and other disorders. The size of these reductions was similar to differences reported by Wilson (13) for college students whose anxiety scores were measured under varying levels of stress. No significant reduction was found in anxiety scores for patients with substance use disorders after either animal-assisted therapy or therapeutic recreation. This lack of difference may be due to the small sample size or due to a relationship between state anxiety and physiological withdrawal that is less amenable to change within one session of animal-assisted therapy or therapeutic recreation. The reduction in anxiety scores for patients with psychotic disorders was twice as great after animal-assisted therapy as after therapeutic recreation. This finding suggests that animalassisted therapy may offer patients with psychotic disorders an interaction that involves fewer demands compared with traditional therapies. As Arnold (23) contends, perhaps the therapy dog provides some sense of safety and comfort not found in more traditional inpatient therapies. Alternatively, the dog may provide a nonthreatening diversion from anxiety-producing situations
(31). Or perhaps it is the physical touching of the dog that reduces patients' anxiety, as has been reported for other populations (12). In this study setting, animal-assisted therapy was offered only one day each week. It would be interesting to study the effect of more frequent exposure to determine if the reduced anxiety is partly due to novelty or if increased exposure results in further anxiety reductions. Although some patients in the study remained hospitalized long enough to participate in more than one animalassisted therapy session, there were not enough such patients to permit investigation of the effect of repeated exposure. Therefore, data from their initial animal-assisted therapy and therapeutic recreation sessions were used for analyses. It is not possible to determine how much the dog or the owner contributed independently to the reductions in anxiety found in this study. Although the study's purpose was to examine the effect of animal-assisted therapy, further examination of the effect of its components is needed. Because many owners of therapy dogs volunteer their time to come to psychiatric units, animal-assisted therapy appears to be a cost-effective intervention. However, volunteers may not participate consistently. In this study, a second therapy dog and owner, a potential confounding variable, were introduced after the first owner became ill. Use of nonvolunteers could strengthen future studies by providing more consistent treatment conditions. Finally, although the results provide evidence of the immediate effect on state anxiety of a single session of animal-assisted therapy, further study is needed to determine if patients' overall level of anxiety is affected. Further studies of the effect of animal-assisted therapy on psychiatry services are needed to replicate the findings from this study and to advance our understanding of the therapeutic benefits of the human-animal interaction.
Acknowledgments The authors thank Al Best, Ph.D., for his assistance with statistical analysis and Pat Conley, Helen Brown, and Claudette McDaniel for their assistance with data collection.
Footnotes Dr. Barker is associate professor of psychiatry, internal medicine, and anesthesiology and Dr. Dawson is affiliate assistant professor of biostatistics at the Medical College of Virginia, Virginia Commonwealth University, P.O. Box 980710, Richmond, Virginia 23298. Dr. Barker's e-mail address is sbbarker@hsc.vcu.edu.
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