Pets as Therapy: Effects on Social Interaction in Long-Stay Psychiatry by Cassie Gonce

MENTAL HEALTH

Pets as therapy: effects on social interaction in Jong-stay psychiatry Pauline L Hall, Zoey Malpus Abstract Many studies have suggested that health and social benefits may be derived from pet ownership or visitation and research has Included Investigation of the effects of pet visitation upon Interaction levels within severely mentally HI populations. The study featured In this article aimed to examine further this relationship while attempting to control for the effects of an extraneous variable (the human dog handler) using an A-B-C-A reversal design. The article concludes that the presence of a pet does, indeed, promote social interactions within a iong'Stay psychiatric population.

Pauline L Hall is Clinical Specialist, TTicrapy Centre, Moorsidc Unit, Trafford General Hospital, Manchester, and Zoey Malpus is Assistant Psychologist, Trafford Primary Care Psychological Therapy Services, Mental Health Services of Salford, Manchester Accepted for publication: October 2000

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nimals are used to help humans in many different ways ranging from working shire horses to guide dogs for the blind. Similarly, animals as pets can be of value to their owners in a variety of ways. There have been many studies which suggest that the effects of pet ownership can be beneficial to physical, social and psychological wellbeing. Research has found that stroking a pet can be relaxing and can result in a reduction in blood pressure (Katcher et al, 1983). The presence of pets can also promote social interaction in older people (Rogers et al, 1992) and reduce psychological responses to anxiety (Wilson, 1991). A large amount of research has also considered the benefits of pet-facilitated programmes whereby volunteers bring their own dogs to visit people in their own social environments. Such studies demonstrate a wide range of beneficial effects to those involved. For example. Gray (1988) described a case study where an older patient was successfully weaned off the long-term use of night sedative medication by stroking an animal before bedtime. It is also claimed that visiting pets can create feelings of domesticity in nursing home residents who are unable to live independently due to age or illness (Savishinsky, 1992). Many studies have specifically focused upon pet-facilitated interactions within psychiatric populations. Patients who are withdrawn and largely unresponsive to attempts

by staff to engage in interaction have been described as responding positively to a 'therapy dog' with smiles, hugs and talking (Voelker, 1995). However, such studies are criticized for providing only anecdotal findings {Beck and Katcher, 1984) and therefore experimental studies have been conducted in an attempt to offer greater scientific rigour. Walsh et al (1995) found that the presence of a 'pets as therapy' (PAT) dog had generalized palliative effects on patients with dementia in a secure psychiatric ward when compared with a matched control group. Effects included a decrease in the incidents of screaming and verbal abuse towards nursing staff combined with an increase in more social behaviours such as smiling and talking. More recently. Barker and Dawson (1998) utilized a pre- and post-treatment crossover design to investigate changes in anxiety ratings for the same psychiatric inpatients under two sets of conditions. The first condition, the treatment condition, entailed a single session of pet therapy, and the second condition, the comparison condition, consisted of a recreational group activity. Barker and Dawson found no statisrically significant differences in 'anxiety chatige' scores between the two conditions. A possible explanation for this finding may be that human interaction (present in both conditions) is responsible for facilitation of any changes and that the critical component of pet visitation may in fact be interaction with the handler not the pet. Thus, the positive results claimed by other studies (Voeiker, 1995; Walsh et al, 1995) may also be influenced by the confounding variable of the dog handler as many previous studies have also failed to take account of the factor of novelty. That is, positive effects observed during animal visitation may simply be due to the introduction of a novel and exciting stimuli and may dissipate when familiarity ensues.

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Haugie {1992) attempted to overcome this methodological flaw in her study which aimed to investigate the relationship hetween the presence of a pet and social behaviour in long-stay environments. Using a repeated measures design, Haugie concluded that the presence of a pet animal promoted social interaction among older psychiatric patients. However, this study was only conducted over a 4-week period, during which time three different conditions were observed (baseline, dog intervention and photographic intervention). Thus, as the presence of the dog amounted to less than 4 weeks, it is arguable whether it can be claimed that the novelty had dissipated within this fairly short time period. Furthermore, to date there are no existing studies which have examined the presence of the dog handier as a possible confounding variable. It is often the case that clients who have stayed in psychiatric institutions for many years display extremely limited levels of social interaction. Thus, the present study aims to control the influence of both novelty and also the effects of the human dog handler in order to examine the relationship between the presence of a PAT dog and levels of social interaction within a long-stay psychiatric population. The null hypotheses under investigation are: 1. That pet visitation will have no effect on the number of observed social interactions in long-stay psychiatric clients beyond those which can be accounted for by the presence of a human visitor (i.e. a handler without a dog) 2. That there will be no effects on social interaction (i.e. talking, smiling, laughing) due to the presence of a PAT dog beyond those which may be reasonably accounted for by novelty factor. METHOD Subjects A nursing home for clients with severe and enduring psychiatric illness was utilized in this study as the multidisciplinary team had previously identified PAT dog visitation as a desired need. As such, the study involved a convenience sample as the client group were specifically selected. There was a total of 10 residents and consent was

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obtained from the rL-sponsiblc medical officer iis written, informed consent was unobtainable from the residents themselves due to the severity of their illness. Nevertheless, attempts were made to obtain voluntary consent from the clients. A poster informing the residents of the forthcoming dog visitation, the nature of the study and the client's rights was displayed in communal areas before commencement of the research. The poster was written using simple words in large colourful lettering with a picture of a black dog to catch the resident's interest and aid comprehension. Additionally, staff were asked to explain the poster to the clients at any appropriate opportunity. Implied consent was facilitated by restriction of the dog's presence to one room. The residents were free to enter or leave the room as they wished and had access to alternative rooms at all times if they did not wish to remain beside the dog. Ultimately, there were ethical implications in the difficulty of ascertaining consent. It was agreed by the multidisciplinary team that the dog could visit, as the potential benefits were deemed to outweigh the risks (e.g. aggressiveness from the dog or a fearful or allergic reaction from a client).

All staff, the handler and the observer were aware of the importance of noting any negative reactions in the client group. Appropriate action would have been taken to resolve any situations which may have been detrimental to a resident's wellbeing; if necessary this would have included the immediate removal of the dog.

The dog (Phoenix) was trained to a high standard of obedience, i.e. Phoenix possessed a Kennel Club Good Citizens Award. Approval and the relevant insurance to undertake PAT visitations was obtained following temperament testing. The handler supervised the dog at all times and used a leash for control. All staff, the handler and the observer were aware of the importance of noting any negative reactions in the client group. Appropriate action would have been taken to resolve any situations which may have been detrimental to a resident's wellbeing; if necessary, this would have included the immediate removal of the dog. Such considerations were proposed to the local ethics committee and approval was granted to undertake the study. Consistent data were obtained for five clients. All subjects were male, aged over 65 and had experienced institutionalized care for over 40 years. As such, the subjects in this study displayed institutionalized behaviour such as a reluctance to initiate interaction, a lack of conversational ability', motor retardation and little expressed interest in their

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MKNTAL H FAITH

bindings indicate a small increase in the number of observed social responses with introduction of the dog handler. However, during the period of dog visits, this increase was markedly greater...verbal interactions initially peaked with introduction of the dog...This may suggest that the factor of novelty is...an important consideration...

Table 1 . Collective mean scores for each condition

(weeks 1,2)

Handler condition B (weeks 3,4)

Treatment condition C (weeks 5-lB)

PoBt-treatment condition A (weeks 19, 20)

Verbal

0.08

0.54

1.10

0.70

Non-verbal

0.51

0.53

1.41

0.36

Social behavkxir

Baseline condition A

ronment incorporating fellow residents, staff and television.

Desist A quasi-experimental repeated measures design was employed incorporating A-B-C-A reversal (Campbell and Stanley, 1966). Baseline (control) observations were taken for two sessions at weekly intervals. These baseline observations required that there was no dog or dog handler present and that only the observer was present to conduct ratings (condition A). As the observer was already familiar to the clients, minimal interference was assumed. The baseline observations were consistent which then allowed the dog owner to attend. Observations were undertaken with the dog owner present (condition B) for a further 2 weeks. The dog was then introduced for a reasonably lengthy period of 14 weeks (condition C). Finally, to increase confidence in the effects being directional to the imposed conditions, the dog and handler were removed (i.e. to return to condition A). Procedure All observations were made in the same room each week. Each client was observed for a 1-minute period for an optimum of five periods in each session allowing calculation of an individual mean response. Observations were made for two clearly defined categories: social verbal and social non-verbal behaviour. Social verbal behaviour included talking and laughing; social non-verbal behaviour included smiling, eye contact and stroking the dog. Behaviour could be directed towards the dog, the handler, staff or other clients. Visits were made once-weekly and lasted approximately 90 minutes. Specific information about observations made and copies of the rating scales may be obtained from the authors. Only one observer rated the subjects throughout, although she was not blind to the study aims.

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RESULTS

The results showed a notable increase in the collective mean of both verbal and non-verbal social behaviours during the period of dog visitation. The average number of verbal (i.e. talking, laughing) and non-verbal (i.e. smiling, making eye contact) social behaviours displayed per minute at different time periods throughout the study is displayed in Table 1. The mean observed social verbal behaviours ranged from 0 per minute in week two up to 1.56 per minute in week 18. The nonverbal behaviours ranged from 0.32 per minute in week one to 2.90 in week 15. The above results are more clearly illustrated by means of a visual time analysis {Figure 1). Findings indicate a small increase in the number of observed social responses with introduction of the dog handler. However, during the period of dog visits, this increase was markedly greater. Verbal social interaction It can be observed from Figure 1 that verbal interactions initially peaked with introduction of the dog (week 5). This may suggest that the factor of novelt>- is indeed an imponant consideration as this was followed by a decrease before the verbal responses settled in a fairly consistent pattern after week 9. Therefore, the results indicate a decline during the penultimate visitation of the dog {week 17) with the greatest peak overall observed in the fmal visit (week 18). This may be explained by the breaking of the news in week 17 that the projea was approaching termination. Anecdotally, the peak of week 18 can be construed as clients saying goodbye to the dog. Non-verbal social interaction The pattern of expressed non-verbal responses is much slower in achieving a prominent incline. The clients did not demonstrate an increase in non-verbal social behaviours until

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only the handler was present (maximum 4.6). Finally, there is again clear indication that the effects were due to the presence of the PAT dog as observed behaviours returned to zero when the dog is withdrawn. Equally important is the richness of the nonverbal interactions attributed to the presence of the dog. For example, initial non-verbal responses from the client above comprised eye contact and head nodding. As his confidence with the dog increased, he engaged in a game of throwing her biscuits to catch and walked with her for short distances in the garden.

around week 10 which may be indicative of initial feelings of caution. This again suggests the possibility' of shorter studies producing misleading results as the non-verbal behaviours only increased dramatically after week 13 when the clients appeared familiar and confident with the dog. The results support the idea that this increase was indeed due to the presence of the dog as a sharp decrease is observed when the dog is not present (week 19). CASE STUDY As this study comprised only a small number of subjects more detailed responses to the presence of the dog can be obtained by considering an individual case study. An example of an individual response to the presence of the PAT dog is presented below (see also Table 2).

DISCUSSION

Following the introduction of the PAT dog there was a notable increase in the amount of verbal and non-verbal interaction displayed by the clients. This increase was greater than that observed when only the dog handler was present. The positive effects obtained in this study support previous research (Haugie, 1992; Voelker, 1995) which concludes that the presence of a pet promotes social interaction among psychiatric patients. However, this study extended the credibility of this notion by control of the novelty factor.

Case study of verbal social interaction The representations of a single case study give an illustration of the effect of the PAT dog on an individual client (Figure 2). The baseline observations (0) offer support for the notion that such clients display very little interaction within their normal environment. The interaction increased a little when the dog handler met with the client (maximum 1). However, the effect of the dog handler was superseded by the introduction of the dog. The behaviours increased to 2.4 before settling for a few weeks. This was followed by a second increase which peaked with the final visit (4.6).

Figure 1. tVlean verbai and non-verbal scores for each condition.

Observed interaction

mber

Case study of non-verbal social interaction The results from this client yield a similar pattern for non-verbal responses {Figure S). Again, the baseline was 0 and there was a small increase upon introduction of the dog handler (1). Like the collective mean data (see Figure i), the non-verbal behaviour decreases until week 8 and the client appeared to overcome any apprehensions of the dog at this time. The non-verbal behaviours then increase to a level far greater than those when

obs rved b

Verbal Nan-verbal

Week

Table 2 . Mean of observed interaction from an individual case

Week

Verbal

Non-verbal 0

1 .7 2 .4 1

1 .4

0.8

1.4

1.6

1.4

4.6

0.2

0 .6 0 .2 0

1 .2

0 .6

1.2

3.4

2.4

1.4

2.8

3.8

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MENTAL HEALTH

InJct'd, results prtivcd th;U initial responses do iiDi indicate wh.it will hnppL-ii when clients bi'Ciinic l.imili.ir with the pet. This reasonably lengthy study suggests that the increased social bcliaviour shown in this client group were sustained at levels greater than biiseline when the factors of novelty and the presence ofa dog handler were taken into consideration. The dat.i therefore support reifction of the null hypotheses. The findings of this study highlight the effectiveness of the presence of a dog in increasing expressed positive hehaviours within this severely impoverished client group. The generalizability of the current findings are limited hy the small sample size but they nevertheless provide a useful indication of the patterns of favourable verbal and non-verbal behaviours following the introduction of a PAT dog. The findings may also be prone to bias as the rater was aware of the study aims. For

Subject X - verbal

5-1

o D

TD O

O _O

Number ol

Week Figure 2. Example of an Individual verbal response to the presence of the PAT dog. Subject X - non-verbal

5 3

9 o

4 -

• ^\ \

-Q

-D

too JS

/ /

1 \

0 "o

1 -

• 1 ' 1

/ 1

\ \

/~~*

\V \

• ^ / 1

\ 1 \ /

/—«k /-

/\ \

Week Figure 3. Example of an Individual non-verbal response to the presence of the PAT dog.

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example, the observer may have interpreted ambiguous or neutral client responses as 'social interaction', thus giving exaggerated recordings of observed positive responses. Attempts were made to minimi/.e this by consistent use of clearly defined observational (e.g. classifying non-verbal social behaviour as smiling, making eye contact with the handler or the staff, strtjking or feeding the dog and offering out cigarettes). A further independent variable which may have influenced interaction levels is that of the staffs' reaction to the dog. The present study did not allow any standardized measurement of this factor due to the complexities of the Hawthorne effect (Roethlisberger and Dickson, 1939) which highlights how a person's behaviour can change due to the awareness that he/she is being observed. Thus, as the observation of the clients natur.illy included staff/client interaction, it is possibie that the staffs' awareness of this may have motivated an increased frequency of interaction. It is uncertain if the behaviour of the clients changed directly as a result of being observed; however, their understanding of the concept of 'observation' was questionable due to the severity of their illness. It is important to note, however, that anecdotal observations suggest that the staff used the dog as a facilitator of client interaction, both with and without its presence. For example, during dog visitations, staff would make warm comments to the clients such as remarking how the dog was pleased to see the resident or explaining to the client that the dog had come to visit. In between visits, staff would inform the clients of the plans for the next visit as well as asking questions such as whether the client enjoyed the visits from the dog. The ethical principle adopted in this study, that the benefits would outweigh the risks, was endorsed. Numerous favourable effects were apparent in the presence of the dog, whereas negative reactions were absent. However, following termination of the dog, visits it was reported by staff that some of the residents appeared to miss the dog. Although the offer of recommencement of visits remained an option, the staff proposed instead to adopt a permanent pet for the home. Despite the limitations inherent in this study, the introduction of a pet visitation pro-

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gramme appeared to promote social interaction in individuals with chronic mental illtiess. It was noted that the initial presence of the dog resulted in little change in social interaction. However, after approximately six visits, the residents became more familiar and confident with the dog. A notable increase in positive responses was especially evident for non-verbal behaviours (e.g. smiling, touching). There appeared to be a similar, although less marked, trend for verbal behaviours (e.g. talking, laughing). As the trend was far less apparent with only the handler present, the findings of this study support the notion that it is indeed the pet, not the human handler, which promotes social interaction. CONCLUSION Replicating this current study but making it multicentred and using a larger sample size would be useful. The utilization of a matched control group who is visited by the handler without the dog for the same time period as the comparison group receive visits from the handler and the dog, would also be informative. When compared to the findings from the present study, which indicate that effects on social behaviour are far greater from the presence of a handler and dog than they are from the handler alone, this could offer greater validity. It would also be interesting to lengtben the time period even further to test whether the increased levels of positive behaviour are sus-

tained. Perhaps one of the most appropriate ways to conduct this would be to study the long-term effects in a similar residential environment of a pet living with the clients. At present, however, this study adds support to the body of evidence which concludes that pet visitation yields beneficial effects within a severely mentally ill population.BIH Barker SB. Dawson KS {1998) The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatr Serv 49{6): 797-801 Beck A, Katcher A (1984) A new look at pet-facilitated therapy, J Am Vet Med Assoc 184: 414-21 Campbell DT, Stanley JC (1966) Experimental and Quasi-experimental Designs for Research. RandMcNally, Chicago Cray KB (1988) A man's best friend. Nurs Times 84(54): 4 0 ^ Haugic E (1992) An evaluation of companion pets with elderly psychiatric patients. Behav Psychotherap 20: 367-72 Katcher AH, Friedmann E, Beck AM (1983) Talking, looking and blood pressure: physiological consequences of interaction with the living environment. In: Katcher AH, Beck AM, eds. New Perspectives on Our Lives with Companion Animals. University of Pennsylvania Press, Philadelphia: 351-9 Rcpcfs J, Hart LA, Boltz RP [ 1992) The role of pet (Jogs in the casual conversations of elderly aduks. J Soc Psychol 133:265-77 Roethlisberger FJ, Dickson WJ {1939) Management atid the Worker. Harvard Universit)' Press. Cambridge Savishinsk) JS (1992) Intimacy, domesticit)' and pet therapy with the elderly: expectation and experience among nursing home volunteers. Soc Set Med 34: 1325-34 Walsh PG, Mertin PC. Verlander DF, Pollard CF (1995) The effects of a pet as therapy dog on persons with dementia in a psychiatric ward. Aiist Occ Therap J 42: 161-6 Wilson CC (1991) The pet as an anxiolytic intervention. / Nerv Ment Dis 179: 482-9 Voelker R (1995) Puppy love can be therapeutic too. JAMA 174: 1897-9

It was nolc'd V that the initial presence of the dog resulted in little change in social interaction. However, after approximately six visits, the residents became more familiar and confident with the dog. A notable increase in positive responses was especially evident for non-verbal behaviours {e.g. smiling, touching).

KEY POINTS The positive effects observed in this study support previous research which concludes that the presence of a pet can promote social interaction among psychiatric clients. The factor of novelty should be taken into consideration when observing the effects of introducing a pet to a client group. The findings of this study support the idea that it is the pet and not the human handler which acts as the catalyst to social interaction. It would be useful to study the long-term effects of having a pet living permanently with psychiatric clients in a residential environment.

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