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April 2017

Out of the Box & In the Pasture by Angela Fournier, Jennifer Laitala & Elizabeth Letson

Angela Fournier
From left to right: Angela Fournier, PhD, professor in the Department of Psychology at Bemidji State University; Elizabeth Letson, MS, owner of Eagle Vista Ranch & Wellness Center; and Jennifer Laitala, BA, author, photographer, and equine specialist.

“This is just like my life,” the client[i] said, as she pulled on the lead rope in an attempt to get the horse to move with her through the obstacle course. The tall brown horse didn’t move. A few minutes later, she let go of the lead rope and stood quietly in front of the horse.  “I’m stuck. I can’t get this horse to move. He doesn’t want to go,” she said as she looked toward the facilitation team.

The facilitators (a mental health professional and an equine specialist) stood in the outdoor arena during the client’s equine-assisted psychotherapy (EAP) session and held the space while she worked on her activity.  At that moment, though, the client quietly stood next to the horse and looked toward the two facilitators like she was waiting for an answer to an unasked question.  After a long pause, the mental health professional asked, “What’s happening?”  The client responded by gesturing toward the horse and saying, “This is my courage.”

The client was a woman who came to the facility on a weekly basis to work through a traumatic event that had left her feeling anxious and depressed. A few months earlier, she had heard about a therapy practice that involved horses. She loved animals, but had never spent time around horses. In fact, she mentioned that the large animals scared her a little bit. Nonetheless, she was curious and wanted to give EAP a try.

The client spent a few of her first sessions outside in the pasture watching the horses from a distance. Anger. Fear. Triggers. All were present those days. A few of her goals were to be able to write or journal about the trauma, to work through triggers, and move forward with her life.  As the sessions progressed, she spent more time out in the pasture, grooming the horses and writing in her journal. One day she shared her story with a horse, the tallest and biggest horse in the herd.

“This horse represents my courage, because I feel stuck and I can’t seem to get started,” she said in response to the facilitator’s question. The client stood next to the horse she named Courage. She held the lead rope in one hand and a crumpled piece of paper in the other.  The client’s goal for the current session was to work on letting go.  She had journaled about some past events in her life that she felt were preventing her from working through her recent trauma. She had torn that particular page from the journal, and was ready to “put it in the past.”

ANGELA FIG 1When asked what it might look like to heal from her trauma, she built an obstacle course with three barrels, a small wooden bridge, orange cones, and at the end of the course was an orange bucket (see Figure 1). She labeled the barrels trust, fear, and family; the bridge was healing; and the bucket was the past.  Her task was to bring a horse along with her as she navigated through the obstacles and drop her journal entry into the past.

Figure 2For several minutes, the client stood in silence. Behind her was a representation of her life and the past bucket. In front of her was Courage, tall and still. While the two stood “stuck” at the beginning of the course, a small brown horse and a small white horse walked through the course and in the direction of the past. They stopped at the fears barrel. Courage began moving through the course, stopping at the same barrel. Seeing all three horses at the barrel, the client began to cry. She explained that the two small horses were like her worries, always there, sneaking in, nagging at her, feeding her fears and holding her back. Specifically, she worried about being good enough – good enough at work and at home, good enough for her family and her friends. She looked at the small horses – her Worries – and noticed Courage had begun nudging at them.  She started to smile and pointed out that Courage was larger than both Worries combined (see Figure 2); Courage could push the Worries away if he wanted to.

 The client approached Courage, unclipped the lead rope, took off his halter, and dropped it on the ground.  After a moment, Courage moved toward the Worries. The client stood with the crumpled paper in her hand as Courage nipped at the Worries, which moved quickly, and shuffled out of the course completely. Courage continued through the course to the past. He stuck his head into the past and tipped it on its side.

Fig 3

The client walked toward the past, moving steadily through trust, fear, and family.  As she approached the past, she paused for a moment.  She set the past upright, dropped the crumpled paper in, and walked away. When processing with the facilitation team, she noted that each time she had visited the ranch previously, she had focused on getting closer to Courage. She hadn’t even noticed the Worries in the pasture, even though they had always been there, following her around. She realized the Worries had been with her even before the trauma and were impeding her path to healing. She set a goal to spend time with the Worries in her next session, hoping to better understand them and get them under control. As she was talking, she looked at her course and noticed that from a certain angle, everything was lined up behind the family barrel, and she couldn’t even see the past (Figure 3). She smiled.

Thinking Outside the Box in Psychotherapy

This is an example of EAP, following the model of the equine-assisted growth and learning association (eagala). A mental health specialist and an equine specialist partner with horses to help clients find their own solutions. Engaging with horses in ground-based activities results in metaphors; the horses, props, and surroundings become symbols in the client’s story (eagala, 2015; Thomas & Lytle, 2016). Rather than talking explicitly about internal factors (e.g., thoughts, feelings), the client engages authentically with the external environment and internal factors become evident. EAP is an out-of-the-box way to inform and engage the therapeutic process. Clients can become aware of influencing factors (e.g., the Worries) and enact change (e.g., reframe the Worries as much smaller than Courage). This treatment can be a powerful modality for the therapeutic process. The client in this story could be undergoing cognitive-behavioral therapy, with adjunctive eagala sessions aimed at identifying and working through maladaptive thought and behavior patterns. In this way, the client participates in an empirically-supported treatment (i.e., cognitive-behavioral therapy) supplemented with an animal-assisted component. EAP is an out-of-the-box way to inform and engage the therapeutic process.

Developing the Evidence Base

The evidence base for EAP is still developing. Reviews of the literature indicate equine-related treatments can result in positive outcomes (e.g., Selby & Smith-Osborne, 2013). Meta-analyses on animal-assisted therapies in general reveal moderate effect sizes, suggesting therapy incorporating animals has beneficial effects (Nimer & Lundahl, 2007).  However, the research has a variety of limitations that must be addressed through more rigorous means (Anestis, Anestis, Zawilinski, Hopkins, & Lilienfeld, 2014).

While research has been conducted using experimental methods to test a specific EAP treatment with a specific patient population (e.g., Nurenberg et al., 2014), the literature is largely based on descriptions of applied research; investigators gather data on an EAP program happening in the real world (e.g., Kaiser, Spence, Lavergne, & Vanden Bosch, 2004; Trotter, Chandler, Goodwin-Bond, & Casey, 2008). Such real-world experiences offer limited opportunities for experimental manipulation and control. In fact, a recent meta-analysis found that most studies on EAP had no control group (i.e., Anestis et al., 2014). Furthermore, most studies to date have examined the outcomes of the treatment (e.g., did symptoms improve? did behavior change?). Concerns about developing the evidence base also call for theory development; we need to understand the therapeutic process itself. This requires looking more broadly, at human-animal interaction (HAI) in general, rather than focusing solely on the outcomes of anima-assisted therapies. Therefore, we are calling for researchers to get creative and think outside the box when studying animal-assisted therapies.

Figure 4Shift toward basic research. We are studying the short-term effects of brief, unstructured interactions on healthy undergraduate psychology students. Yes, laboratory research with healthy adults is quite different than animal-assisted therapy with a real client and thus has certain limitations to external validity. But in return, we can control for some of the threats to internal validity that hinder research in our field. Once the basic phenomena are understood, we can test them in more generalizable situations. Figure 4 shows researchers observing and recording volunteer participants while interacting with a dog in the laboratory. The laboratory has worked well to study HAI with smaller companion animals; we’ve worked with dogs, cats, rabbits, rats, and even a hedgehog named Whimsy.

Pasture as laboratory. For larger animals, the confines of a traditional laboratory are FIgure 5inappropriate. So we’ve partnered with Eagle Vista Ranch & Wellness Center, a local private practice incorporating EAP. On days when there are no clients booked, we turn the pasture into a laboratory, studying the basic phenomena of HAI with horses. Figure 5 shows student participants in a pilot study being observed by a researcher. Using the pasture as a laboratory to study healthy student participants in their interactions with horses allows us to control for some of the myriad of variables that differ between an office session and an eagala session. Beyond interaction with horses, this therapy includes an outdoor setting, experiential approach, two facilitators, and novelty, each of which can contribute to any differences found between eagala sessions and traditional psychotherapy.

HAI as a continuous variable. In both Figures 4 and 5, the researchers are recording human and animal behavior using the Human-Animal Interaction Scale (HAIS) (Fournier, Berry, Letson, & Chanen, 2016; Fournier, Letson, & Berry, 2017), which is connected to a second limitation of HAI research to date – the field is limited by HAI being studied as a categorical variable. Clients or patients who receive animal-assisted therapy are compared with those who do not (e.g., Klontz, Bivens, Leinart, & Klontz, 2007). But perhaps there can be varying quantities of HAI and those varying quantities could have differential effects. The HAIS is an instrument designed to measure the amount of interaction that occurs in a given time period. We have used it to determine whether there are particular kinds of interactions that are associated with outcomes (e.g. do participants who pet an animal leave in a better mood than participants who just watch an animal?). We have also tested whether an overall amount of interaction is associated with outcomes (e.g., do participants who experience a greater quantity of interaction with the horses leave in a better mood than those who experience less interaction?). We can distinguish between human behavior toward the animal (e.g., the human petted, groomed, and fed the animal) and animal behavior toward the human (e.g., the animal sniffed and licked the human), as well as whether one is more closely associated with outcome variables than the other (e.g., which has a greater effect on human mood – what the human does during the interaction or what the animal does?).

Conclusion

There are many questions to be answered about HAI and its effects. The field will benefit from researchers studying this construct from multiple perspectives. This may mean measuring it as a continuous rather than categorical variable. Our certainty about HAI’s effects will rely in part on our ability to move beyond correlational or quasi-experimental design and use rigorous experimental methods. The field needs explanatory theory, which requires investigations of the process, not just outcomes. Understanding the interaction between two or more complex organisms is challenging and developing the evidence base is a tall order. We need to be both creative and curious when studying HAI.  It’s critical that we understand, with certainty, if and how interacting with a horse named Courage impacts human health and well-being.

References

Anestis, M. D., Anestis, J. C., Zawilinski, L. L., Hopkins, T. A., & Lilienfeld, S. O. (2014). Equine-related treatments for mental disorders lack empirical support: A systematic review of empirical investigations. Journal of Clinical Psychology, 70 (12), 1115-1132.

Equine Assisted Growth and Learning Association (2015). Fundamentals of the EAGALA model: Practice untraining manual (8th ed.). Santaquin, UT: EAGALA.

Fournier, A. K., Berry, T. D., Letson, E., & Chanen, R. (2016). The human-animal interaction scale: Development and evaluation. Anthrozoös, 29 (3), 455-457.

Fournier, A. K., Letson, E., & Berry, T. D. (2017). HAIS: Human-Animal Interaction Scale and manual. Bemidji, MN: Angela Fournier.Nimer, J., & Lundahl, B. (2007). Animal-assisted therapy: A meta-analysis. Anthrozoös20(3), 225-238.

Kaiser, L., Spence, L. J., Lavergne, A. G., & Bosch, K. L. V. (2004). Can a week of therapeutic riding make a difference?—A pilot study. Anthrozoös17(1), 63-72.

Klontz, B. T., Bivens, A., Leinart, D., & Klontz, T. (2007). The effectiveness of equine-assisted experiential therapy: Results of an open clinical trial. Society & Animals15(3), 257-267.

Nuremberg, J. R., Schleifer, S. J., Shaffer, T. M., Yekllin, M., Desai, P. J., Amin, R., Bouchard, A., & Montalvo, C. (2014). Animal-assisted therapy with chronic psychiatric inpatients: Equine-assisted psychotherapy and aggressive behavior. Psychiatric Services in Advance, October 1, 1-7.

Thomas, L., & Lytle, M. (2016). Transforming therapy through horses: Case stories teaching the EAGALA model in action. Santaquin, UT: Equine Assisted Growth and Learning Association.

Trotter, K. S., Chandler, C. K., Goodwin-Bond, D., & Casey, J. (2008). A comparative study of the efficacy of group equine assisted counseling with at-risk children and adolescents. Journal of Creativity in Mental Health3 (3), 254-284.

Selby, A., & Smith-Osborne, A. (2013). A systematic review of complimentary and adjunct therapies and interventions involving equines. Health Psychology, 32 (4), 418-432.

Could we be creating stress for therapy dogs? Amy Johnson

Picture1

I’m going to go out on a limb here and say that, as animal lovers, the thought of an animal being mistreated would make any of us angry. But, what if we were mistreating our animals inadvertently? How would we know?

How do we know, for example, when we bring our therapy dogs to our client sessions that we are not causing them undue stress? When bringing dogs (or any animal) into the therapeutic milieu, considering the dogs’ welfare has to be a top priority. When we look at the treatment triad of client, therapist, and animal, equal weight on each corner of the triangle is critical.

Animal assisted therapy is different from art therapy, music therapy or play therapy in that crayons and drums are not living, sentient beings. A sandbox can sit in a room all day with kids scratching figures on it without it ever once needing a drink of water. The dogs we bring need much more. There will be days when they do not feel good, days they do not want to go to work and clients they are not comfortable being around. Paying attention to what our dogs are telling us ensures that the animal assisted intervention (AAI) sessions are not only successful, but that we are not neglecting our dogs for the sake of our clients.

Our dogs/animals did not ‘sign up’ to be a part of the therapeutic process. Dogs are not “humans with fur,” as many like to describe them. They are dogs who do dog things. They sleep…a lot. They like to play. Chew on toys.

BENTLEY A
Bentley on his way to the office

I do not have a therapy dog; I have a Bentley. He is a rescue pug/poodle mix with an under bite and does not always communicate very effectively; who loves (and that is an understatement) to ride in the car and go to the office with me. How do I know? Being a dog trainer (CPDT-KA) helps me read his body language, but the basics are pretty simple; and in the simplest of terms, it is based loosely on the Pleasure Principle. We seek pleasure, avoid pain. Dogs….animals…do the same.

Does my dog willingly do something or do I have to ‘encourage’ him? When I bring Bentley to the office, he willingly runs to the garage door, dances next to the car, hops right in, trots to the door of the building and speeds ahead of me down the hall to the office. He knows the door and stops at it, looking back at me, tongue lolling out, and panting (ok, maybe because he is a bit ‘chunky’). Once we are ‘at work,’ he greets guests at the door and lays at their feet (or on the square of light coming in from the window on the floor) during sessions.

But, he is not a therapy dog, nor will he ever be. He can be cranky and has poor communication skills. He hates to be pet on top of the head, which he will tell you with a low growl, but he will move in for more when his chin is scratched or chest rubbed (research supports that most dogs experience less stress with a chest scratch than any other part of the body). Reach for his belly and if he feels comfortable, he will roll over, but not for everyone; and everyone who comes in knows this and they respect his boundaries.

For many of my clients, he offers quite a few benefits. Research also supports the efficacy of AAI with populations such as children who often feel fewer anxiety symptoms while interacting with [registered therapy] dogs, which allows them to increase engagement with adults (Friesen, 2010; Prothmann, et al, 2006). Bentley shows many of my young clients, who do not always know what their body language looks like to outsiders, how to objectively see their own behaviors. Because it seems like he might not like everyone, when he does “go in for the scratch,” the young clients express that they feel special and privileged that Bentley trusts and likes them. My clients learn how to meet Bentley where he is, at which point we can talk about doing the same with people.

He coaxes my teen clients to sessions even when they do not want to be there. We can talk about how past people have treated Bentley and why he acts the way he does today, just like many of them. I am sure none of this surprises you. You have probably seen the same. But what we always have to do in this process, is maintain our dogs’ well-being. A client who does not have good impulse control or one who stims (self- stimulatory behaviors) wildly, might make contact with Bentley in a way he does not like or makes him uncomfortable, so I let him have his quiet time away from the session.

I do this because within the animal human partnership, it is my ethical responsibility to ensure the safety and well-being of my dog. This means balancing not only the values of our profession and operating within our scopes of practice, but having a solid understanding of my dog’s needs. We have to be able to objectively review every interaction with welfare in mind (Horowitz & Bekoff, 2007). If a client is upset and really wants to hug a dog, but the dog is moving away from the client or hiding behind the therapist’s legs, the dog is sending a clear signal that he is not comfortable with the interaction. Conversely, if the dog is offering distance increasing signals (anything from tongue flicks to head turns), respecting the dog means honoring his wishes. Forcing our dogs to interact or accept a hug anyway suggests that his well-being is less important, and worse, could put him in a position where he might bite. We are the only advocates our dogs have.  And why would we want to mistreat our best friends? Instead, we can use the opportunity to discuss with the client why our dog might be uncomfortable. It demonstrates to the client that we do indeed care about everyone’s welfare.

Most practitioners depend on the principles of the human animal bond (HAB) when bringing AAIs into practice. The HAB, as defined by the American Veterinary Medical Association, is “a mutually beneficial and dynamic relationship between people and other animals that is influenced by behaviors that are essential to the health and well-being of both” (AVMA, 1998 as cited in NG, et al 2014). The key is mutually beneficial relationship, which means the animal must benefit from the interaction as much as the humans.

O’Callaghan (2008) posited that most practitioners who practice professional therapy use AAIs with the intention of augmenting the therapeutic relationship by building rapport, increasing trust and facilitating feelings of safety. If our dog is uncomfortable or stressed, what message is that sending to our clients?

I have often heard…or seen…well-intentioned people who adopt traumatized dogs and turn them into therapy dogs because of the similarities between clients who have experienced trauma and the dogs. For some, this can work very well; however, if the dog has been traumatized and fears people, or likes to remain at home, that should be honored. Dragging him to an office where there is a lot of activity, kids reaching out to pet him or other overstimulating environments can further traumatize the dog. This is the case with a practitioner I encountered who adopted such a dog and as the dog sits in her office with an open door and a baby gate, the dozens of people who pop by each day cause the dog to tremble, bow his head down, pull his ears back, and drool excessively. It does not take a dog trainer to know that this dog is afraid. This was her way of ‘socializing’ him, by flooding him with stimuli. Obviously, this is not acceptable treatment.

A study conducted by Ng, et al (2014) showed that an hour long visit with college students in a dorm setting did not cause an increase in stress-related behaviors in registered therapy dogs. However, King, et al (2011) found that salivary cortisol levels in registered therapy dogs were higher than baseline after a 60-minute visit in a hospital setting, meaning those dogs experienced increased stress. While the reason for these differences is not yet fully understood, it is likely that the hospital environment was less predictable during the activity compared to college dormitories. Not being able to predict what might happen next is often unsettling and anxiety-provoking for humans, and most likely in dogs as well (NG, et al , 2014). Social interactions can be some of the strongest stressors for dogs (McEwen and Wingfield, 2003; NG, et al, 2014). What this means is that therapy dogs show more stress responses when interacting with strangers in unfamiliar settings, when forced into positions, and when experiencing inappropriate or harsh training methods (Glenk, 2014). Added stressors are being hugged by strangers, especially in an unfamiliar setting. Additional studies show that dogs who have been practicing therapy dogs, are over two years old, who have been visiting the same place and interacting with the same people do not show increases in their cortisol levels during interactions (Ng, et al, 2014).

But beyond the studies, it is simple really. When you love and respect your friend, you do not want to mistreat them. And taking that a step further, you want to ensure that he is content, or even happy. Being aware, and objective, will keep our dogs happy….and allow everyone to benefit from AAI.

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