Animal-Assisted Therapy for Inpatients: Tapping the Unique Healing Power of the Human–Animal Bond

339ALTERNATIVE AND COMPLEMENTARY THERAPIES DOI: 10.1089/act.2010.16603 • MARY ANN LIEBERT, INC. • VOL. 16 NO. 6DECEMBER 2010

A substantial body of research supports the health benefits of the unique relationship between humans and companion animals,1 and these findings are being increasingly applied in complementary animal-assisted therapy (AAT) programs in a variety of health care settings. This article defines related terms, briefly summarizes supporting research findings, and features profiles of several AAT and similar programs that are being incorporated into patient care.

Notes on Terminology

Although commonly referred to as pet therapy, animal-assisted therapy (AAT) is the preferred term recommended by the Delta Society, a national organization involved in the training and certification of such services (see Resources). The Delta Society also differentiates AAT from animal-assisted activities (AAA), which, together, are broadly considered to be animal-assisted interventions. AAT is defined as: “a goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/human service profes-sional with specialized expertise [regarding the clinical appli-cations of human–animal interactions]. . . .”2 Such applications are designed to promote improvement in a patient’s physical, cognitive, emotional, and/or social functioning.2 The following is an example of AAT:

A woman recovering from a stroke has limited standing and walking tolerance. A physical therapist utilizes the presence of a dog to motivate the client by placing the dog on a raised table and asking the client to stand while strok-ing or brushing the dog’s back and head. To increase the client’s ambulation skills, the therapist has the client walk the dog for short distances around the facility grounds.2

Although AAA may have motivational, educational, and/or recreational benefits that enhance a patient’s quality of life, AAA refer to more casual activities that involve pets visiting patients without specific individualized treatment goals, sched-

uled times and length of visits, and evaluation and documenta-tion of patient progress. Professionals completing training in AAT can become certified to provide such therapy, whereas professional, paraprofessionals, and volunteers trained in AAA can only be registered.3

Another noteworthy distinction is between service animals and therapy animals. Service animals, which are not usually therapy animals, are legally defined under the Americans with Disabilities Act (1990), as any animals who are trained to meet the disability needs of handlers.4

Criteria for Participation in AAT

According to the Delta Society, the ideal animal candi-date for AAT is healthy, prosocial, well-behaved, skilled in basic obedience, clean, well-groomed, and at least 1 year old. The health of animals in the Society’s Pet Partner® teams is screened by a veterinarian, and the aptitude and skills of each team is evaluated.5 As part of testing of dogs for suitability as therapy dogs, Therapy Dogs International (see Resources) evaluates dogs’ behavior around people with such equipment as wheelchairs and crutches.6 The American Veterinary Medi-cal Association also provides guidelines for AAA, AAT, and resident animal programs. Therapy animals are monitored for their health and well-being, and ability to meet facility safety and infection control policies.7

Research Findings

The practice of utilizing animals for therapeutic purposes dates back to at least the late eighteenth century, when dogs and other animals were introduced into mental institutions to help socialize patients.8 Recent studies support the psychoso-cial and physiologic benefits of AAT as an adjunct treatment for patients with psychiatric conditions.9 In a study of 30 in-patients diagnosed with schizophrenia, the patients were ran-domly assigned to either weekly AAT or a control group for 2 months. The treatment group had significant questionnaire-as-

Animal-Assisted Therapy for Inpatients

Sala Horowitz, PhD

Tapping the Unique Healing Power of the Human–Animal Bond

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ALTERNATIVE AND COMPLEMENTARY THERAPIES • DECEMBER 2010

MARY ANN LIEBERT, INC. • VOL. 16 NO. 6

sessed reduction of psychiatric symptoms, and improvements in self-esteem, self-determination, and social support.10

AAT has also gained widespread support in other health care settings, including hospital critical care units and hospic-es.11 In a content analysis of the themes of written testimonials of adult and pediatric patients in a Midwest regional hospi-tal, the most prevalent themes identified following an AAT session were the induction of relaxation (85%), reduction of pain (49%), positive change in attitude (29%), and induction of sleepiness (28%). Pediatric patients were significantly more likely to describe a feeling of relaxation and calm upon expo-sure to AAT, compared to adult patients.12 In another study of pediatric patients, ages 3–17, in an acute-care setting, an AAT-intervention group (n = 18) experienced a significant reduction in pain level, compared with a control group (n = 39).13

In a randomized study of 76 patients hospitalized with heart failure, a 12-minute visit with a volunteer and therapy dog resulted in significantly improved hemodynamic measures (systolic pulmonary artery pressure and pulmonary capillary wedge pressure), and reduced neurohormone (epinephrine and norepinephrine) levels and state anxiety, compared with base-line measures of patients visited by a volunteer only or receiv-ing usual care.14

For elderly patients in long-term care facilities, animals pro-vide needed tactile contact and a dimension of identity for indi-viduals who have suffered losses of family, friends, professional affiliations, and functioning. The presence of an animal-facili-tated social interaction reduced agitation and aggression in pa-tients with dementia. Watching fish in an aquarium stimulated residents to eat more and gain weight.15 Residents in a long-term care facility reduced their as-needed analgesic medication use and pulse rate, and reported improved overall quality of life (QoL) as the result of contact with a therapy dog.16

Examples of Animal-Assisted Intervention Programs

The larger hospitals described below were ranked among the nation’s best hospitals in an online article entitled “U.S. News 2010 –11 Best Hospitals.” Edward Hospital & Health Services, the smaller community hospital, described below, re-ceived recognition as one of the nation’s top 100 hospitals for cardiovascular care in 2008, and has received other awards and forms of recognition.17

Cedars-Sinai Medical CenterLocated in Los Angeles, California, Cedars-Sinai Medical

Center is the largest nonprofit hospital in the western United States.18 Cedars-Sinai’s POOCH Program, which stands for Pets Offer Ongoing Care and Healing, was first developed in the hospital’s Rehabilitation Unit in 1992. In 1995, volunteer coor-dinator Barbara Cowen, LCSW, introduced the Delta Society–certified volunteer dog teams in the hospital’s HIV/AIDS unit.

Ms. Cowan said: “It is well-documented in the literature how unconditional love and affection can lessen a patient’s fear

and loneliness, which are feelings often associated with hospi-talization.” Nurses noticed that, after a POOCH visit, patients sometimes have slower heart rates and require less pain medi-cation. By 2000, the program was expanded to the hospital’s

medical and surgical cardiology units, and its pediatric unit. One team involved a canine cancer survivor who continued his visitations to patients after leaving the hospital.19

Recreation therapists utilize the dogs, matched to patient needs, as an active part of the healing process. For example, if a patient is working on balance or arm strength, the dog is incor-porated into the exercise. A game of fetch can become an exer-cise in balance, range of arm movement, and socialization.20

POOCH teams are now employed on a regular weekly or biweekly basis in nearly all of the hospital’s medical units including intensive care, pediatric intensive care, cancer, and high-risk obstetrics. Ms. Cowen says that the only downside to the program is that patients often request more time with the teams or ask for specific dogs to visit—requests that are not logistically possible to meet.

Mayo Clinic This first and largest integrated not-for-profit medical

group practice in the world is in the process of establishing a formal AAT program at its clinic in Rochester, Minnesota. In spring 2010, the Clinic published a children’s book (Jack the Helping Dog),21 whose main character is modeled after Dr. Jack, a miniature pinscher, who is the Clinic’s “paws-down favorite therapist.” Brent A. Bauer, MD, an internist in the department of complementary and integrative medi-cine says:

Why do we offer animal-assisted therapy to Mayo Clinic patients? Because it works! Of course, almost every pa-tient “feels” better after a visit by a dog like Jack. But scientific studies have shown that this type of therapy can reduce pain in children, improve outcomes in adults hospitalized with heart failure, and reduce medication use in elderly patients.22

In writing about the healing power of pets on his blog on stress-reduction, Edward T. Creagan, MD, an oncologist in the Mayo Clinic’s palliative-care program, notes: “As scien-tists have discovered, animals have healing powers. When you stroke a cat or pet a dog, you experience a surge of heal-ing hormones and chemicals that produce feelings of peace and serenity.”23

Nurses noticed that, after a POOCH visit, patients sometimes have slower heart rates and require

less pain medication.

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Edward Hospital & Health Services At Edward Hospital & Health Services, a community hos-

pital at Naperville, Illinois, in the Chicago area, about 100 teams of therapy dogs and their handlers have visited approxi-mately 100,000 patients with associated general therapeutic goals since 2002.24 Patty Kaplan, BSN, RN, the president of Paws 4 Therapy, Inc. (based in Illinois), was hired as the direc-tor to implement the facility’s first AAT program.

Professional dog trainers screen, select, and train the vol-unteer dog-handler teams. Applicants that pass temperament training must also pass training that incorporates desensitiza-tion of the dogs to hospital surroundings and teaches dog han-dlers about hospital policies and procedures, including safety and infection control.

Congruent with the hospital’s goal to make a hospitalization stay as stress-free as possible, volunteer dog-handler teams vis-it patients, at their request upon admission, in most units of the

hospital. Visits usually last about 5 or 10 minutes and help pa-tients to feel less anxiety, pain, and loneliness. Reducing these feelings may result in increased mobility, social interaction and communication, and lowered blood pressure. For example, the dog teams—at least one of which is available 365 days a year—have increased patient participation in group therapy in the hospital’s mental-health facility. The program has increased patient satisfaction scores 20%–40%.25 Ms. Kaplan believes that all such visits are therapeutic in nature, whether they are formally structured or documented or not.

Pam Davis, the president/chief executive officer of Ed-ward stated: “To a person, our staff, patients and visitors have enjoyed the addition of the animals to our campus. They have made a difference in morale for staff and patients alike. . . .”26 Likewise, a study of the attitudes of nursing staff members (RNs, patient care technicians, and other clinicians; N = 347) toward AAT at Edward showed that nearly all were familiar with the program and had a posi-tive attitude toward it.27 The dog handlers also benefit from their participation, according to Ms. Kaplan and a coauthor writing on a Paws 4 Therapy website.27

In a case-controlled study of patient use of pain medication following total joint replacement therapy, patients who elected to receive an AAT visit tailored specifically to their needs (n = 87) were found to require significantly less pain medication than pa-tients who declined a visit by an AAT team (n = 87). The greatest difference was seen in the first 2 postoperative days.28

This AAT program has been cited as a “best practice” by the Joint Commission on Accreditation of Healthcare Organiza-tions and served as a model for its stringent infection control

standards for a recent revision of Illinois Department of Public Health regulations.17

Oregon Health & Science University Doernbecher Children’s Hospital

Doernbecher Children’s Hospital, in Portland, Oregon, has been ranked among the best pediatric oncology hospitals in the nation. The AAT program at Doernbecher is provided through the hospital’s Child Life Program, with a mission to help pediat-ric patients and their families cope with hospital stays. Accord-ing to Cindy Barshay, MA, CCLS [Certified Child Life Spe-cialist], the facility has been offering this service since the late 1980s. Physicians who are initially negative or skeptical about the program often become enthusiastic supporters when they witness how the program has brought a degree of normalcy into the lives of children who often must undergo difficult therapies.

From observations of patients and their families with an AAT team consisting of volunteer AAT coordinator Carol Markt and her Delta Society–certified cat Joey, it was clear how they all interacted with the animal and showed a positive effect on their moods. The cat’s presence helped elicit patients’ comments about their own pet(s) at home. Ms. Markt pointed out that such visits frequently help shift the focus from the illness experience, and break down barriers between staff members and patients.

From their mutual interactions with the pet, patients see the more personal sides of their doctors and other clinical staff members. When asked whether she considers her visitations as mainly pet visits or as part of a patient’s treatment, Ms. Markt responded that there is a fine line between pet visits and AAT. For example, during a visit with her cat, she has seen patients become visibly calmer or more responsive. Patients, parents, and other caregivers have commented about the joy, support, and pain relief these visits have provided. Nurses have remarked on the stress relief that these pet therapists provide.

New York–Presbyterian Hospital/Columbia University Medical Center

New York–Presbyterian Hospital, affiliated with Colum-bia University and Cornell University, both in New York City, is the largest hospital in the city. Therapy dogs play an

Visits usually last about 5 or 10 minutes and help patients to feel less

anxiety, pain, and loneliness.

Edward Hospital & Health Services therapy dog team with patient and moth-er; courtesy of Patty Kaplan, BSN, RN. Photo courtesy of Edward Hospital.

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important role in the hospital’s inpatient rehabilitation unit. In partnership with the hospital’s volunteer department, the Delta Society, and the Good Dog Foundation (see Re-sources), the therapeutic recreation department, managed by Mary Beth Pozuto, CTRS, MA, OTR/L, provides teams of trained dogs to visit patients as part of therapeutic inter-ventions.29

AAA/AAT in Hospice Care

Animal-assisted interventions are increasingly also being offered in hospices. According to Minaxi Patel, MSW, who works with the CarePals Pet Therapy Program at Optimal Hospice Care facilities throughout California (based in Bakersfield, California), such interventions are ideal for a hospice because they are consistent with the goal of provid-ing comfort at the end of life.

For example, Ms. Patel cites the positive effects of AAA/AAT with a patient with end-stage Parkinson’s disease, who derived comfort, pain relief, and improved range of motion from pet-ting a dog. In an article about AAT in hospice care, Maureen Horgan, LicSW, ACSW, who works with her therapy dog at

Providence Hospice in Seattle, Washington, was quoted as say-ing that: “[the] animals help provide socialization and support-ive listening for the patients, and in some cases, assistance with symptom management.”30

Conclusions

As research and experience indicate, the complementary mo-dality of animal-assisted activities and therapy is being more widely integrated into mainstream health care settings including inpatient rehabilitation units, critical care, children’s hospitals, and hospices. Organizations such as The Delta Society have advanced the training, certification, and promotion of this therapy. n

References

1. Horowitz, S. The human–animal bond: Health implications across the lifespan. Altern Complement Ther 2008;14:251–256.2. Delta Society. Animal-Assisted Therapy Overview. Online document at: www.deltasociety.org/Page.aspx?pid=267 Accessed September 25, 2010.3. Delta Society. Animal-Assisted Activities/Therapy 101. Online document at: www.deltasociety.org/Page.aspx?pid=317 Accessed September 14, 2010.

Organizations

The Delta Society 875 124th Avenue NE, Suite 101 Bellevue, WA 98005 Phone: (425) 679-5500 Fax: (425) 679-5539 E-mail: [email protected] Website: www.deltasociety.org

This non-profit organization is dedicated to improving human health through therapy and service animals. Through its Pet Part-ners® program, the Delta Society trains volunteers and their pets (dogs mainly) for registration and certification in animal-assisted activities and animal-assisted therapy throughout the United States and other countries.

The Good Dog Foundation 607 Sixth Street Brooklyn, NY 11215 Phone: (718) 788-2988 Fax: (718) 788-3269 E-mail: [email protected] Website: www.thegooddogfoundation.org

The Good Dog Foundation educates the public and service providers about the benefits of animal-assisted therapy, and trains and certifies volunteers and their dogs to serve in Good Dog Teams in health care and other facilities.

Therapy Dogs International (TDI) 88 Bartley Road Flanders, NJ 07836 Phone: (973) 252-9800 Fax: (973) 252-7171 E-mail: [email protected] Website: www.tdi-dog.org

Founded in 1976, TDI is a nonprofit volunteer organization dedicated to regulating, testing, and registering therapy dogs

and their volunteer handlers for the purpose of visiting hospitals, nursing homes, and other facilities where therapy dogs may be needed. This group operates in all 50 states and also have some teams in Canada.

Hospitals

Cedars-Sinai Medical Center 8700 Beverly Boulevard Los Angeles, CA 90048 Phone: (310) 423-3277 Website: www.cedars-sinai.edu

Edward Hospital & Health Services 801 S. Washington Street Naperville, IL 60540 Phone: (630) 527-3000 Website: www.edward.org

Mayo Clinic 200 First Street S.W. Rochester, MN 55905 Phone: (507) 284-2511 Fax: (507) 284-0161 Website: www.mayoclinic.org

New York Presbyterian Hospital/Columbia University Medical Center 622 West 168th Street New York, NY 10032 Phone: (212) 305-2500 Website: www.nypsystem.org

Oregon Health & Science University Doernbecher Children’s Hospital 3181 S.W. Sam Jackson Park Road Portland, OR 97239 Phone: (503) 418-5380 Website: www.ohsu.edu/xd/health/services/doernbecher

Resources

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4. Delta Society. Pet Partners Program FAQs. Online document at: www.del tasociety.org/Page.aspx?pid=267 Accessed September 14, 2010.5. Delta Society. How to Become a Registered Pet Partners Team. Online docu-ment at: www.deltasociety.org/Page.aspx?pid=261 Accessed September 25, 2010.6. Therapy Dogs International. About TDI. Online document at: www.tdi -dog.org/About/aspx Accessed September 17, 2010.7. AVMA. Guidelines for Animal Assisted Activities, Animal-Assisted Ther-apy and Resident Animal Programs. Online document at: www.avma.org/is sues/policy/animal_assisted_guidelines.asp Accessed September 13, 2010.8. Serpell JA. Animal-assisted interventions in historical perspective. In: Fine, AH, ed. Handbook on Animal-Assisted Therapy: Theoretical Foun-dations and Guidelines for Practice. San Diego, CA: Academic Press, 2006:3 –20.9. Rossetti J, King C. Use of animal-assisted therapy with psychiatric patients. J Psychosoc Nurs Ment Health Serv 2010;48:44–48.10. Chu CI, Liu CY, Sun CT, Lin J. The effect of animal-assisted activity on inpatients with schizophrenia. J Psychosoc Nurs Ment Health Serv 2009;47: 42–48.11. DeCourcey M, Russell AC, Keister KJ. Animal-assisted therapy: Evalu-ation and implementation of a complementary therapy to improve the psy-chological and physiological health of critically ill patients. Dimens Crit Care Nurs 2010;29:211–214.12. Stoffel JM, Braun CA. Animal-Assisted Therapy: Analysis of Patient Tes-timonials. 2006 Online document at: http://juns.nursingarizona.edu/articles/Fall2006/stoffel.html Accessed September 22, 2010. 13. Braun C, Stangler T, Narveson J, Pettingell S. Animal-assisted therapy as a pain relief intervention for children. Complement Ther Clin Pract;15: 105–109. 14. Cole KM, Gawlinski A, Steers N, Kotlerman J. Animal-assisted therapy in patients hospitalized with heart failure. Am J Crit Care 2007;16:575–685.15. Filan SL, Llewellyn-Jones RH. Animal-assisted therapy for dementia: A review of the literature. Int Psychogeriatr 2006;18:597–611.16. Lust E, Ryan-Haddad A, Coover K, Snell J. Measuring clinical outcomes of animal-assisted therapy: Impact on resident medication usage. Consult Pharm 2007;22:580–585.17. U.S. News 2010 –11 Best Hospitals. Online document at: http://health.usnews.com/best-hospitals/rankings Accessed November 10, 2010. 18. Cedars-Sinai. About Cedars-Sinai. Online document at: www.cedars-sinai.edu/About-Us/ Accessed September 19, 2010.

19. Cedars-Sinai Medical Center. Newswise: Canine Cancer Survivor Volun-teers in Pet Visitation Program. Online document at: www.newswise.com/ar ticles/canine-cancer-survivor-volunteers-in-pet-visitation-program?=articles/ Accessed September 17, 2010.20. Science Blog (Cedars-Sinai Medical Center). Pet Therapy Programs Help Patients in Rehab, Physical Therapy and More. Online document at: www.sci enceblog.com/community/older/1998/A/199800911.html Accessed Septem-ber 17, 2010.21. Dacy M. Jack the Helping Dog. Rochester, NY: Mayo Clinic, 2010.22. Mayo Clinic. Mayo Clinic Releases First Children’s Book Based on Ther-apy Dog. Online document at: www.mayoclinic.org/news2010-rst/5771.html Accessed September 19, 2010.23. Creagan ET. Pet Therapy: How Animals Help Us Heal. (In Stress Blog). Online document at: www.mayoclinic.com/health/pet-therapy/MY01375 Accessed September 19, 2010.24. Edward Hospital. Animal-Assisted Therapy. Online document at: www.edward.org/body.cfm?id=1110&oTopId=110 Accessed September 14, 2010.25. Paws 4 Therapy, Inc. Paws 4 Therapy: Animal Assisted Therapy in Acute Care. Online document at: www.paws4therapy.com/aboutpaws4therapyinc.html Accessed September 19, 2010.26. Paws 4 Therapy, Inc. What Patients and Hospital Administrators Are Say-ing. Online document at: www.paws4therapy.com/testimonialslinks.html Ac-cessed September 19, 2010.27. Ludwig-Beymer, Kaplan P. Attitudes of Nursing Staff Toward Animal-Assisted Therapy. Online document at: www.paws4therapy.com/Images/AATAttitudeSummary.pdf Accessed September 19, 2010.28. Kaplan P, Ludwig-Beymer P. The Impact of Animal Assisted Therapy (AAT) on the Use of Pain Medication After a Surgical Procedure in an Acute Care Hospital. Online document at: www.paws4therapy.com/Images/AAT-pain-study.pdf Accessed September 19, 2010.29. New York Presbyterian Hospital, Rehabilitation Medicine: Pet Therapy. Online document at: www.cedars-sinai.edu/About-US/html Accessed Sep-tember 13, 2010.30. Van Pelt J. Animal-Assisted Therapy in Hospice care. Social Work Today 2010;10:8. Online document at: www.socialworktoday.com/archive/01261p8.shtml Accessed September 14, 2010.

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Animal-Assisted Therapy for Inpatients: Tapping the Unique Healing Power of the Human–Animal Bond