Animal-assisted therapy: A group therapy treatment manual for children exposed to trauma
TABLE OF CONTENTS Page ACKNOWLEDGEMENTS iii I. INTRODUCTION 1 II. REVIEW OF LITERATURE 4 History of Human-Animal Relationships 4 History of Animals as Therapeutic Agents 6 Animal-Assisted Therapy: Theoretical Frameworks and Therapeutic Implications 14 Biophilia Hypothesis 15 Psychodynamic Theory 16 Attachment Theory 18 Self Psychology 19 Cognitive and Social Cognitive Theories 22 Learning Theory 23 Social Mediation 24 Role Theory 25 Ecological Systems 26 Animal-Assisted Therapy: Research and Interventions 27 Socialization Catalysts 27 Adults and the elderly 27 Children and adolescents 35 Arousal and Anxiety Reduction 37 Adults and the elderly 37 Children and adolescents 44 Cognitive, Emotional, and Behavioral Modification 47 Adults and the elderly 47 Children and adolescents 53 Utilizing Animal-Assisted Interventions 57 General psychotherapeutic benefits 58 Psychotherapeutic goals and techniques 61 Animal-Assisted Therapy and Trauma 66 Child and Adolescent Trauma 66 Description 66 Incident rates 67 Physiological Effects of Trauma 68 Physiology of the stress response 68 Detrimental effects of stress 69 Traumatic stress and children 71 Psychological Effects of Trauma 74 Affective trauma symptoms 75 IV
Behavioral trauma symptoms 77 Cognitive trauma symptoms 81 Trauma Interventions and Efficacy Studies 82 Cognitive-behavioral interventions 83 Eye Movement Desensitization and Reprocessing 90 Individual psychotherapy 92 Psychopharmacological interventions 92 Research limitations 95 Animal-Assisted Therapy as a Trauma Intervention 97 Adults 97 Children and adolescents 98 Legitimacy of Human-Animal Research 101 III. DEVELOPMENT OF AN ANIMAL-ASSISTED GROUP THERAPY TREATMENT MANUAL 103 Program Rationale 103 Outpatient Group Therapy 103 Group Member Selection 105 Group Facilitators 107 Therapeutic Animals 108 Program Structure 110 Focus and Rationale 110 Key Points 110 Goals and Objectives 111 Materials and Preparation I l l Instructions for Activities and Interventions 112 Positive statements 112 Session Evaluation 113 Safety Protocol 114 Session Rationale 115 Session 1: Introductions 115 Session 2: Understanding Our Feelings 121 Session 3: Coping with Our Feelings 130 Session 4: Building Trust and Support 145 Session 5: My True Self 155 Session 6: Take Good Care 166 Session 7: Looking Ahead 180 Session 8: Graduation and Goodbye 192 IV. DISCUSSION 201 Summary and Conclusions 201 Limitations 203 Areas for Future Research 205 v
REFERENCES 208 APPENDICES APPENDIX A: ANIMAL-ASSISTED THERAPY: A GROUP THERAPY TREATMENT MANUAL FOR CHILDREN EXPOSED TO TRAUMA 220 Table of Contents 221 I. Treatment Manual 223 Introduction 223 Program Rationale 226 Outpatient Group Therapy 226 Group Member Selection 227 Group Facilitators...: 228 Therapeutic Animals 229 Program Structure 231 Focus and Rationale 232 Key Points 232 Goals and Objectives 232 Materials and Preparation 232 Instructions for Activities and Interventions 233 Positive Statements 233 Session Evaluation 234 Safety Protocol 235 Session Rationale 236 Session 1: Introductions 236 Session 2: Understanding Our Feelings 240 Session 3: Coping with Our Feelings 246 Session 4: Building Trust and Support 255 Session 5: My True Self. 261 Session 6: Take Good Care 268 Session 7: Looking Ahead 277 Session 8: Graduation and Goodbye 284 Future Research Considerations 289 II. Group Therapy Protocol 291 Session 1: Introductions 292 Session 2: Understanding Our Feelings 296 Session 3: Coping with Our Feelings 301 Session 4: Building Trust and Support 310 Session 5: My True Self 316 Session 6: Take Good Care 324 Session 7: Looking Ahead 334 Session 8: Graduation and Goodbye 343 vi
III. Appendices 350 List of Appendices 351 Appendix Al: Parent/Guardian Permission Form 352 Appendix A2: Child/Ward Participation Form 353 Appendix A3: Group Member Eligibility Pre-Screening Form 354 Appendix A4: Group Rules Contract (Handout # 1) 355 Appendix A5: Introducing... (Handout #2) 356 Appendix A6: Learning about Feelings: True or False? (Handout # 3)... 357 Appendix A7: Feelings Checklist (Handout # 4) 358 Appendix A8: Knowing When to Cope: A Search for More Clues (Handout # 5) 359 Appendix A9: Got Skills? (Handout # 6) 360 Appendix A10: Circles of Trust and Support (Handout # 7) 361 Appendix Al l: Job Title Cards 362 Appendix A12: Discovering My True Self (Handout # 8) 363 Appendix A13: Hip, Hip Hooray! (Handout #9) 364 Appendix A14: My Rights (Handout # 10) 365 Appendix A15: Healthy Habits (Handouts # 11a, b, c) 366 Appendix A16: Future Goals (Handout # 12) 369 Appendix A17: Therapy Book Cover (Handout # 13) 370 Appendix A18: My Therapy Animal Friends (Handout # 14) 371 Appendix A19: Certification of Graduation (Handout # 15) 372 Appendix A20: Session Evaluation Forms 373 Appendix A21: Safety Protocol 381 Appendix A22: Sample Demographics Questionnaire 382 Appendix A23: Sample Assessment and Outcome Measures 383 References 385 vii
CHAPTER I INTRODUCTION Humans and animals have an extensive interaction history that spans across time and around the globe. As the human-animal relationship developed, a companionship evolved which resulted in an enduring inter-species bond. Humans and companion animals are capable of providing each other with a source of unconditional love, acceptance, and loyalty that is often absent among human relationships. Since companion animals play such a significant role in the lives of humans, it is worthwhile to consider how companion animals may be integrated into the human healing process. Over the past 30 years, human-animal interaction research has slowly progressed across a variety of disciplines such as anthropology, psychology, nursing, sociology, and education (Podberscek, Paul, & Serpell, 2000). During the 1960s, child psychologist Boris M. Levinson (1969) discovered that a severely withdrawn boy could therapeutically benefit from interactions with a dog. Since then, Levinson's writings have encouraged researchers and clinicians to investigate the benefits of animal-assisted therapy (AAT). Previous animal-assisted therapy research reveals that therapeutic animals can improve socialization, reduce anxiety and arousal, and assist with cognitive and behavioral modification for adults, the elderly, children, and adolescents. Approaches include both individual and group therapy models across settings such as nursing homes, inpatient/rehabilitation units, private practices, prisons, pediatrician offices, and children's hospitals. Studies have demonstrated improvements for individuals suffering from an array of psychological disorders and associated symptoms (Bizub, Joy, & Davidson, 2003; Harbolt & Ward, 2001; Martin & Farnum, 2002). 1
2 More recently, clinicians are implementing animal-assisted interventions in working with traumatized individuals, including children and adolescents. Since child trauma often involves gross violations of trust, respect, and security, clinicians are challenged to provide clients with a safe therapeutic environment that can foster both consistency and compassion. In the appropriate setting, including therapeutic animals could serve as one significantly contributing component to the therapeutic process. AAT research has been conducted across a diverse range of populations and treatment settings; however, very limited research focuses on implementing animal- assisted interventions in treating children with a history of psychological trauma (Eggiman, 2006; Reichert, 1998; Wooley, 2004). One significant underlying factor is a lack of animal-assisted manualized treatments. Consequently, clinicians interested in implementing animal-assisted interventions carry a burden of treatment planning which may be based more on trial and error versus validated support. More importantly, without standardized interventions, it is difficult to implement, assess, and disseminate empirically-based findings to the larger community. Animal-assisted interventions, although found valuable to some, will continue to exist as an untapped, underdeveloped resource for a majority of researchers and practitioners. In an effort to facilitate further empirical study, this dissertation focuses on the development of an animal-assisted group therapy treatment manual designed for children ages eight to 12 with a history of trauma. The eight session group treatment manual is intended for use at an outpatient facility and includes a registered therapeutic dog, turtle, and two group facilitator clinicians. The animal-assisted interventions are grounded in empirically-validated trauma treatment research and reflect a variety of child-animal
3 bonding theories reviewed by the researcher. Two group facilitators will serve as both clinician and registered therapeutic animal handler. Activities and interventions include hands-on interactions with the therapeutic animals along with worksheets and handouts. Group facilitators assess each child's treatment progress via session-specific evaluation forms completed post-session. This dissertation consists of four chapters: (I) Introduction, (II) Review of Literature, (III) Development of an Animal-Assisted Group Therapy Treatment Manual, and (IV) Discussion. Chapter II discusses various topics related to animal-assisted therapy and child trauma research. The researcher reviews the history of human-animal relationships and the history of animals as therapeutic agents. Next, the researcher discusses animal-assisted therapy within the context of nine theoretical frameworks and relevant therapeutic implications. This follows with a review of animal-assisted therapy research studies and examples of how to utilize various animal-assisted therapeutic interventions. Subsequently, the researcher discusses the physiological and psychological effects of child and adolescent trauma. Then the researcher reviews current trauma treatment research, including animal-assisted interventions. The chapter concludes with a discussion regarding the need for a manualized treatment which incorporates animal- assisted interventions. Chapter III describes the treatment manual with a focus on six critical components: Program Rationale, Program Structure, Session Evaluation, Safety Protocol, and Session Rationale. Chapter IV begins with the project's summary, conclusions, and limitations. A discussion follows regarding areas for future research which includes research design considerations and examples of trauma assessment and evaluation measures. Appendix A contains the treatment manual in its entirety.
CHAPTER II REVIEW OF LITERATURE History of Human-Animal Relationships Animals have played a very significant role in the lives of humans for thousands of years. In our ancestor's lives, animals functioned as hunters, guardians, companions, and within various religious roles (Enders-Slegers, 2000). Human's earliest art expressions portrayed the importance of animals across cave paintings, ancient pictures, and statues (Enders-Slegers). Not surprisingly, our present-day affinity with animals may result from an ancestral trait inherited when humans communed closer to nature (Serpell, 2000). Humans living within hunter and gatherer societies possessed attitudes and beliefs about animals that reflected esteem and respect. Animals were considered as fully rational and intelligent beings that were not inferior to humans (Serpell, 2000). Game animals were treated with respect and consideration in order to earn goodwill. Hunters believed that, if an animal was unwilling to be hunted, no amount of skill would accomplish a killing. Similar to beliefs about humans, animals were thought to have spirits or souls that survive after death. As such, if an animal was hunted disrespectfully, a belief existed that the animal's spirit may seek restitution on the hunter or his family, for example, by inflicting injury, illness, madness, or death (Serpell). As civilization progressed, humans began to transition from hunters and gatherers to farmers and herdsmen. Serpell (2000) commented that this switch from hunting to farming is associated with changes occurring between the human-animal relationship. Due to a need for survival, hunters were required to understand and identify animals in 4
order to enhance their hunting abilities (Serpell). Hunters did not socially interact with animals; the animal was independent and allowed itself to be killed via its own free will (Serpell, 1996). Differing from the hunters, farmers and herdsmen did not perceive domesticated animals as free agents; instead, the animals were dependent on humans for survival (Serpell, 2000). Farmers and herdsmen lived with their domesticated animals in somewhat of a social group, which suggests the establishment of human-animal bonds. As a result, the moral dilemma of killing the domesticated farm animal was more intense for the farmer, such that killing the animal was an intense betrayal of trust (Serpell, 1996). In order to cope with this moral dilemma, humans began to separate and view themselves as superior to animals (Serpell, 1996). Therefore, the transition from hunting to farming represented a fundamental modification in human mental and moral organization, such that human-animal relationships shifted from egalitarianism to a hierarchical dualist schema (Serpell). It is unknown when humans began the practice of domesticating animals; however, evidence suggests that the dog was domesticated approximately 30,000 years ago and the cat was domesticated approximately 9,000 years ago (Catanzaro, 2003). As early as 12,000 BP (Before Present), there was indication of a special human-animal bond when a human in Israel was found buried with a puppy (Clutton-Brock, as cited in Enders-Slegers, 2000). It is suspected that domestication may have initiated when humans, no longer needing to constantly hunt wild animals for food humans, left the wilderness (Levinson, 1997). Interestingly, Zeuner (as cited in Levinson) stated that the adoption of pets seemed to coincide with the beginning of permanent human settlements.
6 One theory suggests that, as humans began to lose contact with nature and modernize their environments, they became motivated to strengthen their connection with nature through the adoption of pets (Levinson). History of Animals as Therapeutic Agents Incorporating companion animals into a therapeutic environment is not a novel approach. During the 9th century in Gheel, Belgium, animals were introduced to benefit people with disabilities (Burch, Bustad, Duncan, Fredrickson, & Tebay, 1995; Pettit- Crossman, 1997). Gheel residents extended family care to disabled individuals (a practice that still continues) and, although not its primary priority, incorporated animals such as dogs, cows, and birds as therapeutic agents (Pettit-Crossman). In 1699, John Locke recognized the value of how relationships with animals could facilitate improved socialization. He advocated giving children "dogs, squirrels, birds or any such things to look after, as a means of encouraging them to develop tender feelings and a sense of responsibility for others" (Locke, as cited in Serpell, 2006, p. 12). In 1792, a progressive Quaker named William Tuke, who was disturbed by the treatment of hospitalized psychiatric patients, founded the York Retreat in Yorkshire, England (Burch et al., 1995; Serpell, 2006). It implemented enlightening treatment methods, such as permitting patients to wear their own clothing, encouraging them to engage in handicrafts, to write, and to read books (Serpell). The York Retreat also encouraged residents to wander around the courtyards and gardens, which had various small domestic animals such as rabbits, sea-gulls, hawks, and poultry (Serpell). The patients became engaged with caring for the animals and, according to recorded descriptions, the residents' relationships with the animals appeared to facilitate social and
7 benevolent emotions (Serpell). As such, the York Retreat is frequently cited among research literature as the first recorded setting that implemented animals as therapeutic agents (Burch et al.; Jorgenson, 1997; Serpell). Throughout the 19th century, introducing animals within mental health facilities continued to become increasingly popular both in England and elsewhere (Serpell, 2006). In the 1830's, appalling conditions at Bethlem Hospital motivated the British Charity commissioners to stock mental asylums with farm and domesticated animals to facilitate a more pleasing atmosphere (Serpell). Florence Nightingale's (1969) work within the nursing setting also contributed to recognizing the beneficial effects of animal companionship, noting the following: A small pet is often an excellent companion for the sick, for long chronic cases especially. A pet bird in a cage is sometimes the only pleasure of an invalid confined for years to the same room. If he can feed and clean the animal himself, he ought always to be encouraged to do so. (p. 103) In 1867, Bethel, a home for people with epilepsy that incorporated animals within the treatment setting, was founded in Bielefeld, Germany (Burch et al., 1995). By 1977, the program consisted of approximately 5000 residents and over 5000 staff members. Since its beginning, birds, cats, dogs, horses, and other farm animals were included in many residences and work sites. Currently, it still exists as an extensive center for the care and healing of disabled individuals (Burch et al.). In 1919, the United States began to incorporate animals within a therapeutic setting. Secretary of the Interior Franklin K. Lane wrote to Dr. W. A. White, the Superintendent of St. Elizabeth's Hospital in Washington, D.C. and suggested that dogs
8 be introduced for psychiatric patients to play with and as a source of entertainment (Burch et al., 1995). Secretary Lane was motivated to contact Dr. White after observing the positive effects of dog companionship on World War I veterans experiencing mental illness. Although Dr. White agreed to implement animals within the hospital setting, there is no recorded evidence to confirm that it occurred; however, animal visits are known to be currently and routinely conducted at St. Elizabeth's Hospital (Burch et al.). The first extensive use of animals within U.S. hospital settings occurred in the 1940s at an Army Air Corps Convalescent Hospital in Pawling, New York (Jorgenson, 1997). The veterans, who were recovering from injuries and/or the effects of operational fatigue, required a program which would keep their minds active while obtaining rest (Burch et al., 1995). The program encouraged patients to work at the hospital farm with hogs, cattle, horses, and poultry, in addition to interacting with snakes, frogs, and turtles. Although the program was considered successful, insufficient funding resulted in its demise (Burch et al.). In the late 1960s and 1970s, interest in the benefits of therapeutic animal interventions resurfaced with the writings of Boris M. Levinson, who was an influential child psychotherapist and psychology professor at Yeshiva University in New York City. Levinson, who is known as the founder of pet-facilitated therapy, was the first professionally trained clinician to formally introduce and document how companion animals could accelerate a client's recovery. In his book Pet-Oriented Child Psychotherapy, Levinson (1969) described the benefits that his dog, Jingles, provided within the child and adolescent therapeutic setting. Levinson's work began one morning when a severely disturbed, withdrawn nine year-old male client arrived early for a
9 diagnostic appointment (Levinson, 1997). Jingles, who was never permitted in Levinson's office when clients were expected, ran up to the client and began to lick him. Surprisingly, the child showed no fright and instead cuddled up to the dog and began to pet him. During subsequent sessions, the client played with the dog, seemingly unaware of Levinson's presence. Eventually, some of the client's affection for the dog transferred onto Levinson, who was included in the play. Slowly, a sound rapport was established between Levinson and his client, which made it possible to address his emotional difficulties. Thus, the accidental meeting between the child and dog served as a key component in the client's eventual rehabilitation (Burch et al., 1995). Levinson's (1969) work continued to demonstrate that many withdrawn, uncommunicative children could positively interact with a dog. Levinson's remarkable findings contributed to the process of legitimizing the utility of animals within a therapeutic setting. During the 1960's, equine assisted physical therapy (known as hippotherapy or physical therapy with horses) began as a formal treatment modality (Chandler, 2005). Currently in the United States, it appears to be the leader of all animal-related therapies and demonstrates an increased legitimization in the field, as evidenced by its reimbursement from most health insurance companies (Chandler). In 1969, the North American Riding for the Handicapped Association (NARHA) was established; by 2003, it had over 700 affiliated centers across the U.S. and Canada (Kaufman, as cited in Chandler). In 1999, the Equine Assisted Growth and Learning Association (EAGALA) was established to address the need for resources, education, and professionalism in the field of Equine Assisted Psychotherapy (Equine Assisted Growth and Learning Association, 2007).
10 In the 1970s, psychiatrists Sam and Elizabeth Corson at the Ohio State University Psychiatric Hospital expanded on Levinson's work (Hooker, Freeman, & Stewart, 2002). The Corsons were the first to integrate animals and collect research data within the hospital setting (Hooker et al., 2002). Corson and Corson (as cited in Levinson, 1997) conducted one of the earliest pet-facilitated psychotherapy studies using a colony of 20 dogs at Upham Hall Psychiatric Hospital. Encouraging results were found for 28-30 patients who had failed to respond to more traditional treatments such as electro-shock therapy and psychotropic medications (Corson & Corson, as cited in Levinson; Corson, Corson, Gwynne, & Arnold, as cited in Levinson). In 1975, the Corsons expanded their research by introducing therapeutic animals to nursing homes, in which they noted significant physical, psychological, and social improvements (Hooker et al.). In the 1970s, Green Chimneys Children's Services, a New York residential treatment center, was established for children with various developmental disabilities and severe emotional and behavioral difficulties (Green Chimneys, 2005). Green Chimneys was one of the early pioneers in the use of therapeutic animals for at-risk youth; it is now a nationally renowned center which integrates both animal and nature therapies (Ascione, Barnard, Brooks, & Sell-Smith, 2006). Located on 160 acres, it is considered to have one of the strongest and most diverse therapy programs in the world (Ascione et al., 2006). It includes specific farm, animal, plant, and wild-life assisted activities, along with programs such as outdoor education, job training, and sports activities (Ascione et al.). Children entering Green Chimneys frequently have histories of severe trauma and serious psychological disturbances such as mood and anxiety disorders and psychosis. Regardless of the reason for referral, the children typically quickly integrate into the