Psychotherapy has come a long way, from the emergence of Psychoanalytic Therapy in the 1890s to modern EBT (Evidence-based treatments) like Behavioural and Cognitive Therapies. Undeniably, the most widely studied and researched form of therapy is CBT (Hofmann et al., 2012). CBT is considered a first-line form of psychotherapy for a range of psychological disorders and is adopted by many healthcare systems around the world, such as the NHS in the United Kingdom (NHS Choices, 2019). However, many mental health professionals would agree that there is no “one size fits all” model of therapy. Psychotherapists often adopt a “blended” form of therapy where they draw theories, techniques, and interventions from various modalities (Harvard Health Publishing, 2011).
Brief History of AAT
Aside from Behavioural and Cognitive Therapies, AAT (Animal-Assisted Therapy) has also seen a rise in popularity. AAT is not a newly found form of treatment as its tracks have been documented in 17th Century medical texts in England where patients suffering from psychological issues were encouraged to interact with animals, in hopes to improve their condition (Washington Post, 2017).
Sigmund Freud, the Father of psychoanalysis, is infamous for his controversial theories of the human mind and sexuality. However, what is not as well-known was his utilisation of his pet dog Chow Chow, named Jofi. In the later years of his practice, Freud often had Jofi present in sessions and allowed Jofi to roam free in the room (Stall, 2007). Freud noted that Jofi had a particularly calming effect on his patients, especially with children. He observed that Jofi’s presence had his patients become more open and forthright, which assisted him in his assessments (WSJ, 2010).
Despite this, AAT was only formally studied and researched by Boris Levinson in the 1960s. Levison, like Freud, allowed his pet dog to be present during sessions and noticed that it encouraged younger patients who were emotionally troubled to feel more comfortable (Alliance Of Therapy Dogs, 2018). Levison theorised that the presence of pets could ease the therapeutic process with emotionally troubled children (Levinson, 1984). However, more recent studies have shown that AAT can benefit the mental health of not just children, but also adults and the elderly (Alliance Of Therapy Dogs, 2018).
Morden Understanding and Perspective of AAT
Numerous studies have shown that owning pets can improve both our physical and mental health. (Urbanski & Lazenby 2012, Cherniack & Cherniack 2014, Matchock 2015). Odendaal (2000) and Hajar (2015) found that interacting with animals, or even merely patting them, reduced the levels of cortisol in our bodies. High levels of cortisol are associated with impaired cognitive ability, reduced sociability, and a cause of imbalances in synapse regulation; triggering stress (Bernstein, 2019). Pet ownership has also been associated with reducing one’s risk for heart diseases and a stronger immune system (Shmerling, 2018).
A study by Stony Brook University in 2017, found that canines were the first animal mankind had domesticated, the study further revealed that they were domesticated alongside us and even aided us during the evolutionary process (SBU, 2018). Dogs have been credited as our close companions due to their high trainability as well as being highly social animals. All of which makes them a sought-after research focus by medical researchers (Robinson, 2020).
As we look back at Freud’s and Levison’s findings, they observed that dogs could aid the therapeutic process, especially with children. However, this is not an injunction that AAT could only benefit children. Recent studies have shown that AAT can be an effective treatment for all ages and neurocognitive disorders like Dementia and a wide range of psychiatric disorders such as PTSD, MDD, and ASD. (Fung 2017, Altschuler 2017, Lundqvist et al. 2017). Pets have shown their ability to help us combat stress, feelings of anxiety, and depression (Wood et al., 2005). Having a pet has been shown to help owners even in their social life, facilitate the formation of relationships, and widening our social support network (Wood et al., 2015).
In 2016, a collaboration between The Human Animal Bond Research Institute (HABRI) and Cohen Research Group found that more than half of its survey respondents reported witnessing the physical health of their friends and/or family improving due to pet ownership and 74% of pet owners reported improvement in their mental health while 54% of pet owners revealed an improvement in their psychical health due to pet ownership. In the same survey, 93% of pet owners agreed that the healthcare system should provide AAT to war veterans diagnosed with PSTD, to aid them in their recovery process.
Animal interaction and its effects on us
To understand our physiological responses while interacting with animals, a study was conducted where pet owners were asked to either quietly read a book or pet their own dog, or pet an unfamiliar dog. The cortisol levels were measured before and after the experiment. The researchers found that cortisol levels, in the group of pet owners who were asked to pet their own dog or an unfamiliar dog, decreased significantly. However, there were no changes in cortisol levels of the group of pet owners asked to read a book quietly (Odendaal & Meintjes, 2003). Another study, conducted in an adult cardiology in-patient ward, patients were found to experience a significant decrease in their systolic pulmonary artery pressure during and after a 12-minute visit by a person accompanied with a dog as compared to a visit by a person without a dog (Cole et al., 2007).
A 2017 study exposed their participants to a “traumatic-film” which depicted a fictional enactment of physical and sexual abuse. To assess the psychological effects. participants were given time to complete Positive and Negative Affect Schedule (PNAS) which measures their changes in mood before and after the film, and the State-Trait Anxiety Inventory (STAI), which is a self-reported questionnaire which measures the respondent’s level of anxiety. In addition, the participants’ blood pressure, cortisol levels, and Electrocardiogram (ECG) were also taken multiple times; before the screening of the “traumatic film”, during the film, after the film, and during the CAT which lasted around 15 minutes. A separate group of participants were exposed to the same film and tests but however was instructed to have a 15-minute self-relaxation period instead of CAT intervention. The results showed that the group with CAT intervention had a significant decrease in their reported stress and anxiety levels as compared to the group without CAT intervention. However, this study did not find that CAT aided in decreasing the physiological responses to stress, such as lowering blood pressure or heart rate. The researchers theorised that because the participants were allowed to interact with the dog, and thereby inducing physiological responses (increased blood pressure and heart rate) due to increased bodily movements. Nevertheless, it reaffirmed previous studies that showed AAT intervention aided in combating feelings of anxiety and stress (Lass-Hennemann et al., 2018).
AAT for the treatment of Psychiatric Disorders
AAT as a treatment for PTSD
The International Association of Human-Animal Interaction Organizations (IAHAIO) distinguishes AAT from Animal Assisted Activities (AAA). A key difference being that AAT requires the presence of a licensed psychotherapist trained in AAT which is not a requirement in AAA as they are subjected to different sets of requirements such as a certified guide-dog trainer for the visually-impaired. IAHAIO describes Animal Assisted Interventions as “goal oriented and structured intervention(s) that intentionally includes or incorporates animals in health, education, and human services for the purpose of therapeutic gains in humans. It involves people with knowledge of the people and animals involved.” (IAHAIO, 2014).
Research in the use of AAT, specifically CAT (Canine-Assisted Therapy) for the treatment of PTSD has provided some promising results. Post-Traumatic Stress Disorder (PTSD), is a condition that arises from a traumatic experience or a “shocking, scary, or dangerous event” (NIMH, 2019). Individuals with PTSD often experience physiological responses to danger such as increased blood pressure and heart rate, and the triggering of their innate ‘fight or flight’ responses even when there is no imminent danger present. This can lead to feelings of anxiety, fear, and depressed moods and can result in the individual’s constant avoidance of any events that could trigger the traumatic memory. In chronic cases, symptoms would start to affect one’s social life and inhibit proper daily functioning (R. Gilman & Logan, 2015). PTSD can affect anyone but has been observed to be prominent in military war veterans.
As AAT was only formally researched and studied in the 1960s, many of such studies remain in the primary phase. However, in a study involving service dogs and military veterans diagnosed with PTSD, the result showed a decrease in PTSD symptoms such as depressive moods. It also increased sociability among the studied group. However, the study concluded that CAT as a stand-alone treatment was insufficient to effectively improve symptoms of PTSD but can be a meaningful addition to treatment plans as CAT had “confer[ed] clinically meaningful improvements in PTSD symptomology” (O’Haire & Rodriguez, 2018).
In a media release by the United States Department of Veteran Affairs, CAT can be an additional form of intervention for individuals with PTSD. However, they stated that CAT should not be relied on as the sole treatment or intervention for individuals with PTSD as it cannot replace EBT like Present-Centred Therapy and CBT which address the root cause of PTSD. CAT interventions can ease the therapeutic process by providing companionship and can “help bring out feelings of love” as well as combating feels of anxiety, low moods, and fear. On the other hand, service dogs (guide dogs/disability dogs) can also act as emotional support dogs but may however require additional training (USDVA, 2014). In a pilot study with veterans diagnosed with PTSD, 29 veterans received AAT, which included weekly 3 hours interaction with the canines for a month. These interactions included grooming, playing, relaxing, and walking. These 29 veterans received AAT on top of their standardised treatment at the military hospital. The control group of veterans included 31 soldiers who received standardised treatment at the military hospital without AAT. When the study was concluded, researchers found that veterans who received both AAT and standardised treatment reported the increased ability to experience joy. They also noted that over the course of the AAT, the relationship between the veterans and the dog handlers improved significantly. This was something the researchers considered important as “patients with PTSD [who] usually have difficulties trusting others, especially new people” (Beetz et al., 2019). This was noted in the context that AAT was only delivered 4 times by the dog handlers over the course of the month.
What can be concluded from the above literature is that AAT is an effective form of intervention for PTSD but cannot be relied upon as the sole or chief treatment method. It is an indisputably positive supplement for EBT. AAT can act as an additional pillar of emotional support for individuals undergoing EBT as the therapeutic process is not always easy. After all, AAT has clearly shown its capacity to provide some relief from emotional disturbances. Therefore, while AAT cannot replace EBT as a treatment for individuals suffering from PTSD, it can act as a fidus Achates for EBT.
AAT interventions for ASD
AAT has also been suggested as an additional intervention on top of EBT for individuals diagnosed with Autism Spectrum Disorder (ASD). Although individuals with ASD can experience different symptoms, depending on the severity, individuals with ASD often face difficulties in communicating with and socialising with others. They may also often prefer to be solitary and present difficulties in understanding the emotions of people around them (IMH, 2012).
Turner (2011) stated that AAT, especially CAT involving trained therapy dogs were a desirable addition to EBT for individuals with ASD. The author stated that canines were animals that were highly social and expressive through their body language. Turner (2011) articulated that a trained therapy dog could facilitate the therapeutic process, acting as both a partner of the counsellor and a partner of the client. Dogs have been found to mirror the emotions of their owners just as displaying similar levels of stress and anxiety (Dogs Mirror Stress Levels of Owners, Researchers Find, 2019). This can be something counsellors can capitalise on and utilise therapy dogs as an “emotional bridge” (Turner, 2011) to the inner world of the client. With this, counsellors can help clients establish trusting and meaningful relationships through the therapy dogs which then can be translated into relationships outside the session room (Katcher, 2000). It was found that children who interacted “[with] real animals showed better social skills and more sharing, cooperation, and volunteering. They also had fewer behavioral problems” (NIH, 2018).
Martin and Farnum (2002) conducted a study where they placed either a ball, or a stuffed toy, or a therapy dog in a session room with a child diagnosed with ASD and their therapist. They observed that children in rooms with the therapy dogs showed more signs of interaction, communication, and attention, they were found to be more engaged and less distracted. Children in the sessions with the therapy dogs were also found to have been more proactive and compliant with conversations with the therapist, suggesting that the presence of a therapy dog may help “increase meaningful, focused discussions” (Martin & Farnum, 2002). Serpell (2006) stated that AAT can be a tool to help people socialise as the therapy animal would naturally become a bridging topic of conversation. This is especially important in patients with ASD as such experiences could impart crucial socialisation skills to them.
AAT interventions for MDD
Major Depressive Disorder (MDD) is one of the most common psychiatric disorder in the world, including Singapore. The Singapore Mental Health Study 2016 (SMHS 2016) found that 1 in 7 of the population experienced depressive symptoms at a point in their life and 1 in 16 people had been formally diagnosed with Depression.
Barker et al. (2003) found that AAT interventions helped reduce feelings of anxiety by 18% and lowered fear by 37%. This study was conducted on patients diagnosed with MDD. Patients were provided with AAT interventions prior to their ECT procedure. This study, although, did not find that AAT could directly relief patients of their symptoms of MDD, it showed that AAT interventions played a “useful role in psychiatric and medical therapies in which the therapeutic procedure is inherently fear-inducing or has a negative societal perception” (Barker et al., 2003).
In a 2008 study, 12 in-patients with acute MDD were asked to complete a pre-AAT and post-AAT STAI questionnaire. When the results were examined, the researchers found a significant reduction in STAI scores after the introduction of AAT interventions (specifically CAT). This reduction in STAI scores meant that the levels of stress and anxiety in the studied MDD patients decreased. This study suggested that AAT interventions presented an optimistic outlook for further scientific research into how AAT interventions could benefit patients with MDD (Hoffmann et al., 2009).
MDD is a result of “complex interaction of social, psychological and biological factors” (WHO, 2020). Individuals with depression commonly face issues such as overwhelming stress, loneliness, and a sense of hopelessness (Alpass & Neville, 2003). Animals are “a source of comfort and support” and they are “sometimes brought into hospitals or nursing homes to help reduce patients’ stress and anxiety” (NIH, 2018). Therapy dogs are “very present” and can sense when a person is struggling with their issues. The ability of animals to bring comfort to people has been suggested to be a result of their “unconditional acceptance, making them a calm comfort” (NIH, 2018) for people interacting with them.
AAT interventions for Dementia
According to Lai et al. (2019), who ran a study on patients with Dementia, AAT interventions could “slightly reduce depressive symptoms”. Similarly, a 2013 research study found that AAT interventions significantly reduced symptoms of agitation, anger, and depression in patients with Dementia. Based on the results, the researchers suggested that AAT interventions could “delay progression of neuropsychiatric symptoms in demented nursing home residents” (Majić et al., 2013) and was a promising intervention to Demented patients who displayed agitation or depressive symptoms. However, more research is needed in order to establish the long-term impacts of AAT interventions with patients with Dementia.
Much of the research done has been focused on household pets such as dogs. However, there are other animals capable of sensing human emotions and mirroring it, providing us an insight into our emotional state of mind. A study conducted in Sweden found that horses could detect feelings of anxiety of their riders, which followed by its’ heartbeat increasing at the same pace as their handlers. Humans may present a façade of calmness but are struggling within, horses may even avoid interaction and communication with us (The Arbor Behavioral Healthcare, 2019). With this, Equine-Assisted therapy (EAT), psychotherapy involving the interaction with a horse, and a trained EAT therapist emerged as a branch of AAT. In a study conducted across a duration of 4-weeks, horse riding was shown to be able to reduce anxiety and help improve low moods of the participants by building-up their self-confidence, as well as increasing the attention span of individuals with ADHD (So et al., 2017).
Guinea pigs are growing in popularity among pet owners because they are, after all, our furry little friends. In recent times, guinea pigs have become a popular choice when it comes to AAT. In 2015, a study conducted on 128 children, these students were from 15 different schools. Prior to the study, both teachers of the experimental and control group were asked to complete a Pre – Social Skills Rating System (SSRS) which was to help the teachers “quantify children’s social functioning” (O’Haire et al., 2013) as well as behavioural and commitment issues. In the experimental group, 2 guinea pigs in the classroom setting, the students could interact and play with the guinea pigs under the supervision of the teacher. The control group was not provided the guinea pigs. The researcher examined the post-SSRS report by both teachers of the experimental and control group. For the experimental group, the post-SSRS report found that was a surge in improved social skills and the reduction of problematic behaviours while the post-SSRS report for the control group showed little to no changes (O’Haire et al., 2013).
AAT in Singapore
AAT services are available in Singapore, although it is not as widely used in psychiatric settings. Therapy Dogs Singapore (TDS) was set up in 2004 as a non-profit welfare organisation by a group of volunteers. TDS was established to “[share] unconditional love and affection of their canine companions with society’s disadvantaged through Pet Assisted Therapy (PAT), which aims to meet physical, as well as socio-emotional needs.” (TDS, 2004). TDS often conduct informal visits to homes, special need schools and selected hospitals which involves “Animal Assisted Therapy (AAT) programmes, partner[ing] closely with physiotherapy and occupational therapy goals” (TDS, 2004). AAT is a relatively new and unfamiliar form of psychotherapy model in Singapore and has only garnered interest in recent years.
Another pioneering centre of AAT, specialising in CAT, is Pawsibility Singapore which offers counselling and psychological assessments with the help of therapy dogs (Pawsibility, 2013). Founder Maureen Huang expressed that her journey as a certified AAT specialist in Singapore was a tumultuous one as “We had only a handful of clients in our first year. And it was … demoralising when we faced a lot of rejection.” (Ng, 2019).
It was only after intense engagement of counsellors and teachers that AAT began to spark the interests and awareness of the masses, and particularly in the settings of schools and cooperates. She cited an experience she had during a session with teenagers, when she initially entered the room; the majority of the youths did not respond or react. However, when she entered the session room again with Hope, her therapy dog, many of the teenagers came forward to interact with Hope and engaged in conversations with her regarding how sessions would work and her experience with Hope. With this, she managed to meaningfully bridge a connection with the group of teenagers and had a discussion with them (Ng, 2019).
Numerous programmes involving AAT has also begun to emerge in recent years, SOSD (Save Our Street Dogs), a dog shelter has collaborated with Pawsibility and pushed forward a programme called ‘Healing Paws’ in 2014. Healing Paws is a programme that recognises the ability of dogs to provide companionship and a sense of unconditional love and acceptance. It is centred around AAA (Animal Assisted Activities), to help people in need such as residents in elderly homes and hospices by providing recreation, motivation, and companionship. These visits are free of charge and involve informal activities such as strolling with the dogs, playing with them, or simply structured like “meet and greet” sessions (Healing Paws, 2014).
Although AAT in Singapore today constitute only a small part of our understanding treatments for psychological stress, programmes initiated by volunteers and non-profit organisations have shown that AAT has the potential to grow and evolve into a more mainstream service. The initiatives put forth by individuals are a step in the right direction and will point us in the direction of a more diverse range of psychological treatments. Such experimental initiatives are much needed in a country like Singapore where our approach to mental health remains relatively preliminary. However, I believe that as we progress forward as a nation to a more holistic view of our health, physical and mental, positive advancements will be made as we have seen from greater initiatives like Beyond The Label which aims to remove the stigma on mental health.
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Contributor: Julian Anschel Lai Jang Ein
Julian is currently pursuing the Bachelor of Arts (Honours) Guidance and Counselling with Northumbria University. He is also a student member of APACS, actively contributing psychological articles.