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What Do Therapists Think About Dogs?
Andrea Wheeler, M.A.
A Dissertation Submitted to the Faculty of
The Chicago School of Professional Psychology
In Partial Fulfillment of the Requirements
For the Degree of PsyD Clinical Psychology
K. Marinka Gadzichowski, PhD
Stephen Lally, PhD, ABPP
December 12, 2022
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Unpublished Work
2022 by Andrea Wheeler
All Rights Reserved
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What Do Therapists Think About Dogs?
A Dissertation Submitted to the Faculty of
The Chicago School of Professional Psychology
In Partial Fulfillment of the Requirements
For the Degree of Doctor of Psychology in Clinical Psychology
Andrea Wheeler
2022
Approved By:
K. Marinka Gadzichowski, Ph.D., Chairperson
Stephen Lally, Ph.D., ABPP, Chairperson
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Dedication
In loving memory of “my little soulmate”, Stymie, my companion of 14 years who
showed me a dog’s true ability to sense, and attend to human emotion and love unconditionally.
Also, in honor of my dog, Dorothea (Dotty), who acts as my own emotional support animal.
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Abstract
Dogs have been companions to humans for quite some time and, more recently, have gained
traction in clinical settings. The current study aimed to gain a better understanding of therapists’
opinions about bringing dogs into therapeutic sessions. It also sought to understand the frequency
with which therapists in the Washington, DC, Maryland, and Virginia tri-state area are asked to
provide letters of support for emotional support animals (ESA) and their opinions of ESAs. A
sample of 25 participants who were licensed mental health professionals in the tri-state area took
a brief survey. Although age, primary theoretical orientation, and degree type were all entered
into logistical regression, the only statistically significant factor was age. Exploratory findings
revealed mixed opinions of incorporating dogs into therapy sessions and ESAs. Limitations to
the study included a narrow sample size impacting generalizability, and future recommendations
include expanding recruitment procedures. The current study may serve as preliminary evidence
to build upon a large gap in the literature on the topics of therapist approval and assessment
procedures for animal-assisted therapy and ESAs.
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Table of Contents
List of Tables ................................................................................................................................ 10
Chapter 1: Nature of the Study ..................................................................................................... 11
Background ................................................................................................................................... 11
The Human-Animal Bond......................................................................................................... 12
Animals for Assistance and Companionship ............................................................................ 13
Emotional Support Animals ...................................................................................................... 14
Animal-Assisted Therapy ......................................................................................................... 16
Problem Statement ........................................................................................................................ 17
Purpose of the Study ..................................................................................................................... 18
Research Questions and Hypotheses ............................................................................................ 19
Quantitative Research Question ................................................................................................ 19
Quantitative and Qualitative Research Question ...................................................................... 19
Theoretical Framework ................................................................................................................. 20
Humanistic Psychology and Person-Centered Therapy ............................................................ 20
Psychodynamic ......................................................................................................................... 21
Cognitive-Behavioral ................................................................................................................ 25
Scope of the Study ........................................................................................................................ 26
Definitions of Key Terms ............................................................................................................. 26
Significance of the Study .............................................................................................................. 26
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Summary ....................................................................................................................................... 27
Chapter 2: Literature Review ........................................................................................................ 29
Additional Possible Theoretical Frameworks ............................................................................... 29
Experiential Approaches ........................................................................................................... 29
Social Psychology/Sociology.................................................................................................... 31
Biophilia Hypothesis................................................................................................................. 32
Family Systems ......................................................................................................................... 36
History of Assistance Animals...................................................................................................... 37
Archaic Period Through the 19th Century ................................................................................. 37
Late 20th Century and Beyond .................................................................................................. 38
Americans with Disabilities Act ............................................................................................... 42
Service Animals, Emotional Support Animals, and Therapy Dogs.............................................. 42
Service Animals ........................................................................................................................ 42
Emotional Support Animals ...................................................................................................... 44
Therapy Dogs ............................................................................................................................ 45
Animal-Assisted Interventions, Activities, and Therapy .............................................................. 46
Benefits of Spending Time with Animals ..................................................................................... 47
Physiological/Biological ........................................................................................................... 48
Psychological ............................................................................................................................ 52
The Importance of Awareness of Benefits (HABRI, 2016) ..................................................... 59
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Summary ....................................................................................................................................... 61
Chapter 3: Research Design and Method...................................................................................... 62
Research Questions and Hypotheses and Their Rationales .......................................................... 63
Quantitative ............................................................................................................................... 63
Quantitative and Qualitative ..................................................................................................... 64
Population and Sample ................................................................................................................. 65
Demographics ............................................................................................................................... 65
Procedures ..................................................................................................................................... 67
Instrumentation ............................................................................................................................. 68
Chapter 4: Findings ....................................................................................................................... 69
Setting ........................................................................................................................................... 69
Results ........................................................................................................................................... 69
Therapist Thoughts on Dog in Session ..................................................................................... 71
Therapist Views of Dog Impact on Client/Patient .................................................................... 71
Summary ....................................................................................................................................... 75
Chapter 5: Summary, Conclusions, and Recommendations ......................................................... 77
Interpretation of Findings ............................................................................................................. 77
Recommendations ......................................................................................................................... 79
Implications................................................................................................................................... 80
Limitations .................................................................................................................................... 81
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Conclusion .................................................................................................................................... 82
References ..................................................................................................................................... 83
Appendix: Survey Questions ...................................................................................................... 105
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List of Tables
Table 1: Racial and Ethnic Background Statistics ....................................................................... 66
Table 2: Degree Type Statistics .................................................................................................... 66
Table 3: Theoretical Orientation Statistics ................................................................................... 67
Table 4: Logistic Regression Analysis .......................................................................................... 70
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Chapter 1: Nature of the Study
The current study explores therapists’ perceptions and openness to the prescription of
emotional support animals (ESAs) and the use of animal-assisted therapy (AAT) in clinical
practice. This chapter will provide the background information pertinent to the study and its
importance. The study was prompted by the literature gap and general lack of understanding and
agreement around how licensed therapists perceive ESAs and AAT. Research questions are
indicated with accompanying hypotheses. A comprehensive theoretical framework aligned with
the topic is examined. The study scope is outlined and key terms are identified and defined. The
significance of the study is considered. The chapter closes with a summary of main points and
explains the organization of the remainder of the document.
Background
Canis Lupus Familiaris, also known as domestic dogs and referred to in this study as
dogs, have taken on many roles for human assistance throughout time, such as service dogs,
emotional support dogs, and therapy dogs (Ghose, 2013). Dogs and humans have had a bond for
at least 15,000 to 30,000 years when they split from grey wolves. Research also shows parallels
in evolution between humans and dogs, including digestion and metabolism genes and serotonin
processing. They have provided assistance to humans dating back all the way to upper
Paleolithic periods, with roles including companionship, hunting, and transportation (Ní
Leathlobhair et al., 2018).
According to National Geographic (Bates, 2018), the grave and remains of a man and a
woman were discovered in Oberkassel, Bonn, Germany in 1914. What made this discovery even
more remarkable were the remains of a dog, now referred to as the Bonn-Oberkassel (BO) dog.
The remains of the three beings indicate they were buried together approximately 14,000 years
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ago. The BO dog was suggested to be a domesticated pet, sick and being cared for by its human
caretakers (Janssens et al., 2018). Its illness was severe and would not have survived as long as it
did without the care of humans. This implies that humans formed emotional and caring bonds
with their dogs as early as the upper Paleolithic Era.
The Human-Animal Bond
The human-animal bond (HAB) is a therapeutically powerful connection defined as a
symbiotic relationship between human and animal that is regulated by behaviors crucial for both
parties’ wellbeing and health (Fine, 2011; Wright, 2001). It represents the mutually supportive
and trusting relationship of the human and animal (Eskite-Tant, 2016). Humans and animals
have been bonded since ancient times. The bond grew through domestication and continues to
flourish with acknowledging animals as sentient beings and recognizing all they offer to human
life (Fine, 2011). Pet ownership illustrates humans’ advantages of the HAB, including aiding in
psychological wellbeing (e.g., alleviation of psychological symptoms), recovery from physical
ailments, and social support (e.g., easing loneliness, encouraging social interaction; Blazina et
al., 2011).
Developmentally speaking, strong emotional connections with other beings are
established and strengthened throughout life (Pachana et al., 2011). Pets provide stable and
dependable bonded relationships to humans, especially children and adolescents, enduring the
many transitions associated with the stages of life. Pets often act as confidants for children and
adolescents in times of turmoil and peace. Children who grow up with pets form connections
with animals crucial to the HAB. Pets teach children empathy, responsibility, and how to love,
and provide social support. In adolescence, the focus shifts to maintaining the already established
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bond with one’s pet. By adulthood and into old age, the HAB(s) continue to blossom and pets
offer adults the same benefits as children and adolescents.
The HAB is seen as responsible for the health benefits experienced from spending time
with animals, providing explanation as to why AAT and ESAs are advantageous for a wide
variety of people (Brown, 2004). The HAB is complex, with no individual or combination of
theories able to fully explain it. Theories that account for some of the HAB come from
developmental psychology, attachment theory, learning theory, psychoanalytic theory, social
psychology, and biological and evolutionary studies.
Animals for Assistance and Companionship
The first documented use of dogs in a therapy setting in the United States was in 1919 at
St. Elizabeths Hospital in Washington, DC, where dogs provided companionship to patients
residing in psychiatric care (Urichuk & Anderson, 2003). The use of animals in a variety of
settings such as in schools, and hospitals, as well as in psychological, occupational, and physical
therapies has become progressively more popular.
Over time as dogs continued to take on roles of assistance and companionship to humans,
it became necessary to create titles or categories for the different types of aid they offer. These
categories are called service animals (SAs), emotional support animals (ESAs), and therapy
animals. SAs are dogs, or sometimes miniature horses, trained to carry out specific tasks for their
handlers with a disability (U.S. DOJ, 2020). ESAs can essentially be any animal, typically a pet,
that provides psychological relief to its handler but requires no training (Alt, 2018; Reisen,
2019). Therapy animals are very similar to ESAs in terms of their function. They differ in the
fact that therapy animals are trained to work with diverse populations and sometimes in groups
rather than providing relief to only their handler (Schoenfeld-Tacher et al., 2017). Therapy
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animals may be used for animal-assisted interventions (AAI), which include animal-assisted
activities (AAA) and animal-assisted therapies (AAT). AAIs are structured and goal-oriented
mediations with animals meant to provide therapeutic relief (Kruger & Serpell, 2010; Pet
Partners, n.d.-c).
Emotional Support Animals
Dogs have proven throughout time to be extremely useful human companions. This
companionship is helpful to humans in many ways, and specifically in this study for emotional
and psychological support and relief. Interacting with animals offers a wide array of health
benefits, further discussed in Chapter 2, including reductions in anxiety, loneliness, blood
pressure, physical pain, and even needed medications (Gawlinski & Steers, n.d.). The use of
ESAs has continually been on the rise in the 21st century. There are increasingly many different
websites that offer certifications. The problem is that these are certifications in name only, with
no official certification or registration process for ESAs. Instead, a person who would like to
register their animal as an ESA must receive a letter from a treating health professional
indicating the animal is a psychological necessity (Alt, 2018; Reisen, 2019; Younggren et al.,
2016).
A study conducted by the University of California at Davis indicated a 1,000% increase
between 2002 and 2012 in ESAs in the state (Matei, 2019). The National Service Animal
Registry is just one site that offers certifications for assistance animals. In 2011, they registered
2,400 ESAs; that number significantly increased in 2013, registering 11,000 ESAs (Marx, 2014).
In 2015, they registered at least 65,000 ESAs with a 200% increase in 2019 (Matei, 2019). The
website has a feature that shows users how many total ESAs have been registered on the day
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they visit the site. As of July 10, 2020, the number of ESAs reached 209,383 (National Service
Animal Registry, n.d.).
College campuses have also noticed a rise in ESA requests from students within the past
decade. Washington State University indicated receiving about two or three requests in 2011; as
of 2019, that number has increased to around 65 to 70 requests (Bauer-Wolf, 2019). Ohio State
University reported approximately 175 ESAs accompanying students in residence halls as of
2019. In order to ensure the legitimacy of the animals, they noted looking for details in a letter
from a student’s therapist that are typically lacking in template emails from certification
websites. Further, they inquire with the therapist of their history working with the student.
It is important for colleges not to overlook the necessity of ESAs for students. A number
of lawsuits against universities have been filed by students who sought to have their ESA live
with them on campus. One student from Grand Valley State University in 2013, two students
from University of Nebraska at Kearney in 2015, and one student from Kent State University in
2016 filed and won lawsuits against their schools for denying their requests to have their ESAs
on campus with them (Bauer-Wolf, 2019). Campuses have also adopted their own ways of
incorporating animals on campus. The University of South Carolina has a resident therapy dog
for their students and Stetson University is a pet-friendly campus regardless of whether or not a
pet is a SA or ESA.
ESAs used to be considered services animals by airlines and enjoyed the privilege of
flying with their owners by law per the U.S. Department of Transportation’s (DOT) Air Carriers
Access Act (ACAA; U.S. DOT, 2005) so long as the individual presented the airline with a letter
of necessity. Airlines for America (2019) indicated a 58.3% increase in the number of ESAs on
flights while there was only a 3.1% increase in passengers in 2017. In 2018, airlines saw a 14.3%
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increase in the number of ESAs on flights with a 4.7% increase in passengers; although the
increase in air traveling ESAs slowed, it still remained significantly higher than the growth seen
in passengers. However, as of December 2, 2020, the DOT announced their final rule on air
travel with service animals which indicated they no longer consider ESAs to be service animals,
therefore revoking their access to fly with their owners (U.S. DOT, 2020).
Animal-Assisted Therapy
Dr. Boris Levinson, a child psychologist, came across the therapeutic value of dogs by
happenstance when he left a socially withdrawn child in a room with his dog, Jingles. When he
returned to the room, the child was actively engaged in interacting and conversing with Jingles.
He then began to frequently include Jingles in sessions with clients (Fine, 2011). Dr. Levinson
was the first to formally research and introduce AAT to the American Psychological Association
(APA) in the 1960s, which was originally met with skepticism (Alliance of Therapy Dogs,
2018a; Fine, 2011; Whiteman, 2014). About a decade after the introduction to the APA, Dr.
Levinson surveyed psychologists and found that 16% used pets in therapy sessions, suggesting
therapists were beginning to embrace AAT (Whiteman, 2014). He was also a key player in the
establishment of the term HAB (Fine & Beck, 2015). A statistical analysis of complementary and
alternative therapies offered by hospice care providers in 2007 indicated 58.6% offered pet
therapy (Bercovitz et al., 2011). Lombardi (2018) of National Geographic indicated at least
50,000 therapy dogs across the United States.
An increase in the usage of AAT over time is not as clear as the spike seen in ESAs, but
interest appears to be growing. Purdue University reported a significant increase in scientific
studies of AAT for autism from 1989 to 2015 (Guérin, n.d.). From 2000 to around 2014, the
number of results in Google Scholar searches of the term “animal-assisted” has increased from
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approximately 150 to 1,050, respectively. The frequency percentage of the term “human-animal
bond” published in books rose from virtually zero to approximately 1,750 around 2000 (Rowan,
2015).
Despite the upward trend since Dr. Levinson introduced AAT, many experts consider it
to be underused across healthcare domains. This is believed to be due to the fact that most
existing and developing research is qualitative. The nature of healthcare fields typically require
quantified evidence of the benefits offered by a treatment (Alliance of Therapy Dogs, 2018b;
Whiteman, 2014). Further, the use of ESAs has significantly risen in the current century. With an
underuse of AAT in clinical practice but a rise in those with ESAs, it is necessary to assess the
perceptions and opinions practicing licensed mental health professionals (MHPs) have regarding
the topics.
Problem Statement
Experts in AAT believe it has been underused across healthcare settings despite the
potential benefits the treatment offers. Within mental health settings, the benefits of AAT have
the potential to enhance treatment outcomes. Concurrently, there has been a rise in the
prescription and use of ESAs. This discrepancy needs to be investigated to determine what, if
any, factors may be deterring practicing therapists from including dogs into their treatment
interventions with patients.
I, the researcher, have passionately loved and cared for dogs since childhood. The love
continued to grow and blossomed over time, and I started to realize how in tune my pet dog was
to my emotions. I also began to notice how he would change his behavior to mirror mine when
experiencing positive emotions or to provide me with comfort and warmth when experiencing
negative emotions.
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The Millennial generation currently make up the largest group of pet owners in the nation
and 67% regard their pets as family members (Lintz, 2018). The people I spend the most time
with, family and friends, often speak of how their own dogs and other dogs cheer them up. This
piqued my interest into how my love for dogs may extend beyond myself and that people who
like dogs may experience some therapeutic benefit from a dog being in a therapy session. I knew
my love, care, and understanding of dogs was too important to leave out of my studies and future
professional life. I became inquisitive as to how I could incorporate dogs into my career as a
psychologist. Reflecting on my experiences with my dog and friends’ and family members’
similar experiences, I questioned why the consistent use of dogs within therapeutic settings was
rarely a treatment option.
Literature suggests dogs enhance the lives of humans and positively impact their
emotions and well-being, this area will be thoroughly explored in Chapter 2. Having this
information may not be enough for a practitioner to incorporate it into their therapeutic
interventions. There may be reason to believe extraneous factors are hindering licensed MHPs
from integrating AAT into their standard of practice.
Purpose of the Study
Regarding AAT, the current study sought to examine individual differences regarding
therapists’ willingness to use AAT in practice. It also aimed to explore the beliefs of AAT from
currently practicing licensed therapists. In terms of ESAs, the study intended to determine
therapists’ opinions of their usefulness and what methods they have put in place for assessing
and documenting them. For the purpose of this study, the term “ESAs” specifically refers to dogs
as we exclusively investigated therapists’ perceptions of them.
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Findings gathered descriptive and exploratory data on currently practicing licensed
MHPs’ views of AAT and ESAs. These findings may offer useful information related to the rise
in ESAs and the underuse of AAT in professional settings. Data may also reveal apprehensions
from mental health providers when employing AAT and allow for the opportunity of continued
education on the topic. Further, results could be used as preliminary evidence to the acceptability
of usage of AAT and ESAs and aid to bridge the discrepancy between the popularity of the two.
Participants were practicing licensed MHPs in the tri-state area of the District of
Columbia (DC), Maryland (MD), and Virginia (VA). Data was collected via internet-based
survey and was distributed to practicing clinicians recruited through social media platforms. The
study was a mixed-method, non-experimental, descriptive design that was observational in
nature.
Research Questions and Hypotheses
Quantitative Research Question
RQ1: Do the type of degree a therapist holds, their age, and their primary theoretical
orientation predict whether or not they have ever brought a dog into the therapeutic session?
H01: Degree type, age, and primary theoretical orientation do not predict the likelihood
that a therapist has brought a dog into the therapeutic session.
H11: Degree type, age, and primary theoretical orientation significantly predict the
likelihood that a therapist has brought a dog into the therapeutic session.
Quantitative and Qualitative Research Question
RQ2: Additional exploration was conducted to better understand what therapists thought
about the effects of bringing a dog into the therapeutic session on the client as well as on
themselves.
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RQ3: To better understand how therapists perceive ESAs, they were asked their opinions
on ESAs, whether they had been asked to provide a letter in support on a patient having an ESA,
and whether patients could benefit from ESAs and under which conditions.
Theoretical Framework
There was and continues to be an evident spike in ESAs since the beginning of the
current century (Marx, 2014; Matei, 2019). AAT is still considered underused but appears to be
gaining popularity over time. To gain a better understanding of why this may be, the study
addresses therapists’ individual differences pertaining to their opinions and perceptions of AAT
and ESAs. Being around animals has an abundant amount of benefits emotionally and physically
which may be attributed to the HAB and human-animal interactions (HAI), to be discussed in
Chapter 2.
Several theories may help conceptualize the phenomenon of a sharp increase in ESAs and
a gradual rise in use of AAT. Further, the selected theories may provide more clarity related to
the variables of a clinician’s training that would make them open to incorporating dogs into
therapy. These theoretical frameworks include humanistic psychology and person-centered
therapy, psychodynamic, cognitive-behavioral, and family systems.
Humanistic Psychology and Person-Centered Therapy
Humanistic psychology is a theory grounded in uncovering what it means to be naturally
human and understanding the unique human experience. The relationship humans have with their
pets is often humanistic in a sense (Fine & Beck, 2015). Owners take on humanlike attitudes
toward their pets and externalize their feelings onto them. Moreover, many owners see their pets
as a replacement for other people. Having a pet allows for more consistency throughout the
human’s daily life and may result in greater sense of security. Some forms of equine AAT
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involve activities which actively engage the client in being self-aware via their self-experiences,
which aligns with aspects of humanistic psychology (Latella & Abrams, 2015).
Carl Rogers’s person-centered therapy approach within humanistic psychology places a
heavy emphasis on self-concept and self-experiences within actual lived experiences (Cooper et
al., 2013). The therapeutic alliance is extremely important and is cultivated by therapists through
several key skills: empathy, unconditional positive regard (UPR), and congruence (genuineness).
These same skills are used to create a safe environment for the client to grow into healthy
functioning and self-awareness. The therapeutic alliance and potential for client growth may be
enhanced by AAI, as the client develops relationships with both the therapist and the animal.
Clients frequently perceive therapists as more trustworthy and empathetic if practicing with AAI;
this can potentially strengthen and accelerate rapport development (Bruneau & Johnson, 2016).
Animals are also seen as empathetic and genuine and provide clients with UPR. The animal may
help the client feel safer in therapy, making them comfortable to disclose more. Increased
disclosure potentially augments insight and self-awareness, promoting self-acceptance and
growth.
Psychodynamic
Object Relations Theory
Object relations theorists place prominence on understanding the dominant love objects
in a child’s world, emphasizing themes of safety, agency, separation, and individuation
(McWilliams, 2011; Parish-Plass & Oren, 2013). The theory is concerned with social
interactions, how one seeks out the “object” (typically a person or living being) is related to their
development of self, how one internalizes the object relationship, and the internalized
representations of the self, the object, or the self-object relationship.
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In therapy, the therapist-client relationship can be seen as a self-object relationship. The
client works to change internal representations by re-externalizing through interacting with the
therapist. In terms of AAT, the therapist, client, and animal make up the therapy triangle (ParishPlass & Oren, 2013). The animal, as a living being, provides the client with another “object” in
the room and allows more chances for the client to re-externalize objects, or their self, in their
representational world. An animal in the therapy room can offer the client wish fulfillment of
relationships they have longed for; it could also function as a transitional object, as the client is
independent of the animal but can still feel closely connected to it. Having an animal as a third
being, or object, in the therapy room gives the therapist and client the opportunity to connect on
the basis of their shared experience of the presence of the animal, or external object.
Projection
Projection can be related to object relations theory. In psychodynamic theory, it is one of
the primary defensive processes in which one mistakes and denies their own internal experiences
as coming from external forces, or objects (McWilliams, 2011). Oftentimes, projection is the
manifestation of unexpressed social disturbances. Sigmund Freud noticed animals would often
be present in children’s dreams (Melson & Fine, 2015). He suggested the animal figures were
projections of authoritative adults in the child’s life who are too threatening to overtly emerge in
their dream world. Carl Jung emphasized animal figures portrayed aspects of the self and were
symbols of humans’ instinctive nature. Freud’s and Jung’s assertions imply animals provide a
source of projection for both internalized self and object representations, of which AAT can be
particularly useful.
Although inanimate objects can be used as targets of projection, the act of projecting onto
a living being tends to be more intense and genuine (David, 2013). Clients may have an easier
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time expressing feelings that are unconscious and/or unwanted due to projecting onto the animal
acting as an external object rather than speaking about themselves. Further, the animal may
remind the client of themselves and provide some relief; if the client deems some of their own
characteristics as undesirable but sees those traits mirrored in the animal, it can reduce stress and
allow the client to feel more positively about themselves. For example, a client being treated for
social anxiety and shyness may find comfort in their therapist’s therapy dog who is calm and
quiet in nature. It is difficult to discern between genders in some animals which allows for the
client to project any gender onto them. Other animal characteristics that can trigger projections
are size, color, and features unique to specific animals.
Attachment Theory
Although attachment theory is not necessarily specific to psychodynamic; for the purpose
of this study it will be considered as falling within the psychodynamic category. Attachment
theory is a psychological theory of humans’ need to protect others and be protected by others
(Fine & Beck, 2015). Its foundation is that a principal need of human infants is to create a
meaningful bond with an adult caregiver, which is the attachment object (Laschinger, 2012;
Melson & Fine, 2015). Attachment is initially developed by the infant-mother relationship and
falls into classifications of avoidant, secure, ambivalent, or disorganized (Van Ijzendoorn &
Sagi, 1999; Liotti, 2012).
Infants who develop secure attachments have been provided with a sense of safety,
security, and protection, especially in situations perceived as dangerous, by their attachment
object which is likely a human caregiver (Melson & Fine, 2015). Pets can also serve as
attachment objects for children, providing them with calmness and a sense of security and
reassurance. Children with secure attachments are more likely to be resilient, adjust to their
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environment, and cope with stress throughout their lives; the attachments children have with
their pets is possibly associated with the same positive outcomes. Pets can help children develop
healthy coping skills by giving them the consistent acceptance and nurturing needed to promote
such skills. Children often seek out their pets for emotional support and comfort during stressful
situations (e.g., parents arguing, challenging transitions) or when in a state of distress. This also
may alleviate behavioral issues, as looking to their pets in trying times provides children with an
outlet to regulate their responses to external stressors.
Adults have also reported their pets as attachment objects, always being there for them in
times of need and looking to them for emotional support when distressed (Meehan et al., 2017).
Attachment theory indicates intimate relationships directly impact emotional well-being. Pets
provide their owners with unconditional love which makes them important attachment objects
for their human’s general mental health (Hart & Yamamoto, 2015). At times, owners may look
to their dogs instead of family and friends as an attachment object in the event of emotional
turmoil.
Attachment behaviors are indicated as those characterized by one seeking out and
maintaining closeness to another distinct individual who they deem more capable of coping in
the world (Fine & Beck, 2015). The relationship humans have with their pets mirrors that of
parent and child. Pets rely on their humans very similarly to the way children do with their
parents; protection from danger, regularly taking care of them, and being their voice due to lack
of language abilities. Numerous pet owners speak to their pets with baby talk and play with them
as they would with a child. The extreme attachment to pets is oftentimes seen in the event of
natural disasters, when humans withhold from evacuation without their pets.
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Cognitive-Behavioral
Cognitively, cognitive-behavioral therapy (CBT) was built from the theory of the
cognitive model which suggests psychological issues result from negative thoughts and cognitive
distortions that impair one’s perception of situations; these faulty perceptions directly affect
mood and behavior (Beck, 2011). Behaviorally, CBT explains the development and maintenance
of psychological symptoms through classical and operant conditioning, postulating humans are
the creator of their environment as well as the product of it (Bruneau & Johnson, 2016). CBT is a
dynamic, problem-focused treatment modality with structured sessions (Wenzel et al., 2016). It
is reliant on specific goals, set collaboratively by the client and therapist, to work toward in and
out of the session to engender efficient results. Specific goals are to be observable and
measurable in order to regularly track progress.
Since AAIs are goal-oriented, they fit in nicely with CBT. Particularly, AAT is used in
healthcare fields to augment typical treatment modalities and involves specific goals, structured
sessions, and tracking progress (Ernst, 2014; Eskite-Tant, 2016; Pet Partners, n.d.-c). Animal
interactions can be gratifying, making AAIs activate the reward system to enhance motivation
for treatment (Bruneau & Johnson, 2016; Parish-Plass, 2008). Teaching an animal a new trick
takes time, patience, and many repetitions, making it a great common exercise in AAIs. As the
animal learns its new trick, the client is simultaneously learning and strengthening skills of
planning, frustration tolerance, and goal setting. Training the animal also increases the client’s
sense of self-efficacy. The presence of an animal promotes one to have more positive perceptions
of situations; this implies AAIs can aid in ameliorating cognitive distortions which negatively
impact mood and behavior.
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Scope of the Study
The scope of this study is to evaluate the views licensed practicing therapists in the tristate area have on both ESAs and AAT. The study seeks to determine whether or not participants
are currently assessing their patients for necessity of an ESA. Further, the study explores
participants opinions of incorporating AAT in their own therapy sessions with patients.
Definitions of Key Terms
Animal-assisted interventions (AAI). Any sort of goal-oriented and structured mediation
purposefully integrating animals to create an environment that offers therapeutic benefits
(Kruger & Serpell, 2010; Pet Partners, n.d.-c).
Animal-assisted therapy (AAT). A type of animal-assisted intervention employed by
professionals in fields of health and human services to enhance typical treatment methods and
involve specific goals (Ernst, 2014; Eskite-Tant, 2016; Pet Partners, n.d.-c).
Emotional support animal (ESA). Companion animals providing emotional benefits, such
as symptom relief, from individuals suffering from a psychological disorder (Reisen, 2019).
Therapy dog. Dogs trained to offer support and comfort to a wide variety of people in
various clinical settings (Reisen, 2019).
Significance of the Study
Although not a new therapeutic intervention, AAT is believed to remain underused in
clinical contexts. Results will benefit therapists by providing the beginning of an understanding
as to what opinions therapists have about the use of AAT and ESAs. Results will offer
information regarding differences in willingness to use AAT among therapists. Findings of this
study may provide MHPs with novel information and increase their confidence levels when
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considering the use of AAT with a patient. Further, findings provided additional data on
therapists’ assessment and documentation when prescribing patients with an ESA.
MHPs nationwide can use the findings to ease apprehensions toward the use of AAT.
Further, the results may prove useful in providing MHPs an idea of what to be assessing for and
documenting when a patient comes to them requesting a letter for an ESA. The general public
may also benefit from the study findings by gaining knowledge about the different ways dogs
can be used in therapy and therapists’ perceptions on ESAs.
This study yielded results of the way current MHPs perceive AAT and ESAs. Psychology
is an evolving field, continuously searching for methods to best treat patients. Findings of the
study will potentially open doors for additional empirical studies to expand on the topic by
looking directly at patients’ reactions (e.g., change in emotion, openness to share, level of
comfortability) to having a dog in their therapy session. Further, future studies can use these
preliminary findings to introduce standardized methods of implementation of AAT and assessing
and documenting ESAs.
Summary
The current study aims to evaluate therapists’ view of ESAs and the incorporation of
AAT into clinical practice. Dogs have assisted humans in many ways throughout history. They
are commonly used in AAIs and their companionship offers both mental and physical health
benefits. An evident and continually increasing spike in ESA usage has been seen in the current
century. AAT has undergone a smaller, more gradual increase in usage since the mid-20th
century. Despite the upward trend, is still deemed underused by experts. For this reason, it is
necessary to assess clinicians’ opinions and perceptions of the two.
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The study’s purpose is to investigate the individual differences of therapists that make
them more open to AAT and ESAs. Findings may potentially be used to further explore the
discrepancy between AAT and ESA usage. Research questions pertain to therapist openness and
perception of effects to AAT and opinions on ESAs. Accompanying hypotheses are exploratory
or relate to individual differences. The theoretical framework outlines psychodynamic,
humanistic psychology, and cognitive-behavioral. Key terms indicated are AAI, AAT, ESA, and
therapy dog. Results will offer a preliminary understanding of therapists’ opinions on AAT and
ESAs.
Chapter 2 covers literature relevant to the topic as well as how it was retrieved.
Summarized literature includes topics of the history of assistance animals; differentiating
between SAs, ESAs, and therapy dogs; classifying AAIs, AAAs, and AAT; the evidence-base of
AAT; benefits of AAT and having pets; and the HAB. In Chapter 3, the research questions and
hypotheses are restated with rationale behind each. The research design and anticipated research
methodology is discussed. Such methodology includes information regarding population and
sample, procedures, validity threats, instrumentation, data processing, assumptions, limitations,
and ethical assurances. The findings of the study are reported in Chapter 4 and interpretations of
results are discussed in Chapter 5, along with limitations and future directions for research.
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Chapter 2: Literature Review
The literature involving the use of dogs in a clinical context is limited and varied. It is
important to assess the current literature for already established benefits of ESAs or the use of
dogs in session despite the lack of studies assessing therapists’ perceptions of such. Further, it is
necessary to discern between terms within the study as some may be incorrectly used
synonymously with others. In this chapter, topics to be discussed include: additional possible
theoretical frameworks, the history of assistance animals; differentiating and specifying types of
assistance animals; differentiating and specifying AAIs; and the benefits spending time with
animals.
Additional Possible Theoretical Frameworks
I have chosen to constrain the study through the particular theoretical frameworks of
humanistic psychology, psychodynamic, and CBT, but it is important to acknowledge that
additional potential frameworks exist. Although the findings are not considered through the
lenses of these frameworks, the information was deemed pertinent to include in the literature
review. Such theories include existential approaches of existential therapy and gestalt therapy,
social psychology/sociology’s social support theory and affection exchange theory, the biophilia
hypothesis related to cultural development and cognitive evolution, human development, and
socialization, and family systems.
Experiential Approaches
Existential Therapy
Existential therapy concentrates on the essential characteristics that make up the human
existence (Bruneau & Johnson, 2016). Therapists accompany the client on their journey by
focusing on the present experience, allowing for them to improve their self-awareness to develop
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authenticity, and aiming to build interpersonal relationships. Animals are always living in the
present moment and interact spontaneously. Additionally, animals, just like clients, have unique
stories of their journey and relationships. In AAI, spontaneous interactions between animal and
client incite exploration of the issues in the present. Further, clients hearing stories about the
animal encourages them to explore their own journey and relationships.
Gestalt Therapy
Like humanistic psychology and existential therapy, Gestalt therapy is concerned with
self-awareness (Bruneau & Johnson, 2016). Awareness is improved by placing focus on the
direct surroundings of the present moment cultivating healthy boundaries with others. AAI is a
present-based treatment modality and clients can evaluate the animal’s behavior and recognize
related emotions as well as seeing the animal mirror their own behaviors. Exploration of
relational boundaries can be facilitated through AAI. When clients interact with the animal, they
give the therapist in the moment data regarding their interpersonal style for which the therapist
can provide remedial feedback. Animals also improve nonverbal communication and body
awareness. Gestalt therapy additionally confronts the detrimental, unresolved feelings, or
“unfinished business,” clients bear from various impactful experiences. AAI may assist the client
in working through unfinished business. With the animal, the client can express contradictory
elements of the burdensome experience(s) and begin to process and integrate those elements.
Further, clients may feel more comfortable disclosing the material of their unfinished business to
the animal rather than their therapist.
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Social Psychology/Sociology
Social Support Theory
The social support theory argues those with higher levels of perceived social support are
better able to cope and experience less stress (Skeath et al., 2015). Social support is vital for
mental health and healthy functioning and is often sought out between humans to cope with
trying times (Fine & Beck, 2015). Since pets can be seen as a replacement for humans, they can
offer social support to their owners. People may find it easier to bond with and might become
more attached to animals than other humans due to the animal’s nonjudgmental nature. Owners
with dogs also have an increased chance for social interaction. Socially speaking, pets have the
ability to provide their owners with comfort and positive outlets to communicate with other
humans.
Regarding HAI and AAIs, the social support theory suggests not only do animals provide
humans with comfort, but they also assist in social interactions between humans (Skeath et al.,
2015). Animals are said to make their human counterparts more approachable to other humans
and also provide a topic of conversation for social interaction. Reductions in isolation and
loneliness are connected to increases in social interaction, which an animal may provide to
humans.
Affection Exchange Theory
The affection exchange theory is the concept of giving and receiving affectionate
communication to another being, typically between humans, but also between humans and
animals (Skeath et al., 2015). Affection is defined as “an internal psychological state of positive,
often intimate regard for another” and takes on the forms of “verbal (e.g.., saying I love you),
direct nonverbal (e.g., giving someone a hug), and indirect nonverbal (e.g., helping someone
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with a task”; Skeath et al., 2015, p. 266) communication. Both the giver and receiver of
affectionate communication in significant relationships can experience mental health and
physical benefits. However, affectionate communication between humans may not always be
welcomed or reciprocated. It can also be misconstrued, such as being seen as a proposition or a
form of manipulation. These risks are mitigated with AAIs and particularly with therapy dogs.
Therapy dogs are screened for having a predisposition toward being affectionate (Skeath
et al., 2015). Such dogs engage in behaviors such as seeking affection from and lovingly
responding to humans. This offers humans a source of affection that is consistent, whereas
affection between humans may waver. Animals do not have the same capability as humans of
manipulation which means their affectionate communication is authentic, making therapy dogs
trustworthy beings for humans to rely on. Because of these factors, the risks of lack of
reciprocation and potential manipulation are lowered. Further, physically touching a dog, such as
petting, can reduce tension and increase sense of security in the therapeutic setting for clients.
Biophilia Hypothesis
The biophilia hypothesis (BH) argues that humans depend on nature for more than just
sustaining their livelihood, but also their longing for satisfaction and meaning (Kellert, 2013).
The BH states that humans have an inherent drive to connect and relate to other living beings; it
is suggested this drive strengthened with the rise of time spent by humans in unnatural settings
(Fine & Beck, 2015). This is demonstrated by humans having associated visualizations of
landscapes and animals naturally engaging in their habitats with feelings of tranquility (Katcher
& Wilkins, 2013).
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Cultural Development and Cognitive Evolution
Shepard (2013) provides insight on how the BH has developed via human evolution,
including the evolution of cognition which is a foundational aspect of biophilia. This cannot be
fully understood without the discussion of the nature/culture correlation, which nods at the idea
that humans look to animals, diverse beings, to act as reflections of themselves. Throughout
history, nature has acted as a language to guide human beings. Humans have observed and
interpreted the interactions and distinctions between wild animal species. Mutually beneficial
relationships between species as well as predator and prey relationships provided humans with a
model of which to develop their own societies, determining which subgroups to include or
exclude. The development of culture is a result of inclusion and exclusion from a society.
Humans existed throughout regions; naturally, differences occur between groups in various
areas. The disparities likely resulted in groups isolating themselves from others. The isolation
brought on the development of culture with the emergence of differences such as distinctive
languages and segregation of races. Characteristics unique to a culture united its members and
gave them a sense of identity and belonging. Further, animals were, and still are, often used by
humans to symbolize qualities of a society, suggesting group relationships are rationalized
through parallels made between humans and animals. For example, the bald eagle has been used
as the emblem of the United States since the late 1700s, following the Declaration of
Independence, because it represents freedom, independence, and strength (American Bald Eagle
Information, n.d.; Radford, 2010).
Some prehistoric art aligns with the nature/culture correlation (Shepard, 2013). Such art
portrayed parallels between humans and animals and alludes to the possibility that those parallels
are a basis of the evolution of human consciousness. As the humans evolved over eras, their art
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reflected advancements in symbolically referencing animals to enhance communication in an age
where they were both hunting and being hunted. Implying that humans methodically attempted
to cumulatively internalize crucial images over time, this suggests conscious evolution. Using
this imagery of animals illustrates brain development and self-consciousness surfacing; it
depicted humans closely examining animals to continue differentiating themselves from animals
and making distinctions between animals.
The development of primitive societies molded the human species. The theory of the
function animals served in this development goes beyond mere admiration for them. It is a
breadth of historical accounts and systems recognizing animals contributed to the human race
both affiliation and a means to meet basic physiological needs. Humans appreciated animals as
sentient beings, but the circle of life dictates that one must die for the other to live. In this way, a
connection between the relationship of love and death exists. In this way, there is a connection
between humans’ love for animals as well as the necessity to use them as a food source. This
idea of the BH is indicative of the effects of animals on the evolving human self-conscious,
strengthening the innateness of the human need to deeply connect with nature (Shepard, 2013).
Human Development
Animals are more involved with human development than often realized, as outlined by
Shepard (2013). From infancy and throughout childhood, humans play games and hear or read
stories about animals. When engaging in games or play, children imitate and identify with
animals, potentially strengthening a child’s innate connectedness with them. Many babies’ and
children’s stories involve personified animals working through typical childhood worries. These
anecdotes frequently have happy endings and oftentimes hint at the child’s innate resolutions to
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overcome their worries. Moreover, when animals are personified in such tales, they grant
children the possibility to deeply correlate the animals to themselves.
In adulthood, humans can use visualization to call forth the animals which embody their
unique personality features and pieces of their experience, also called inner animals (Shepard,
2013). This is used as a form of therapy, as one reflects on an experience and engages in
imaginary conversation with inner animals who come from various bodily areas. The inner
animals bring to light their fears and needs often hidden in the unconscious. These imaginary
conversations one has with their inner animals is indicative of humans’ foundational approach of
using animal representations to symbolize their inner life. Through inner animals, the self is
validated as being alive from within. Further, inner animals assist in creating congruence
between one’s inner and outer worlds, which is crucial to the person’s cognitive development.
Developing the inner self is related to physical wild animals in terms of maturation and
relations between species (Shepard, 2013). A true biophilia is the result of maturity and the
growth of a healthy identity. Visualizations of animals as parts of the self who act as guides to
bring together humans’ inner and outer worlds to a state of congruence are representative of how
one’s own being came to exist via the outer world. The theory indicates that the human species is
an animal species and has evolved from different animals since the beginning of time, therefore
humans have the responsibility of recognizing that those different animals continue to live within
them. Traces of the different animals’ DNA are present in humans even to this day, ratifying the
affinity to animals proposed in the BH.
Socialization
Katcher and Wilkins (2013) explore the role the BH plays in human evolution based on
the social relationships between humans and animals. The authors outline evidence that animals
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have an ability to elicit speech from humans and humans have a tendency to view animals as
family. One of the earliest uses of language was to relay messages to others regarding food
sources or danger experienced while away from the group. They hypothesize this use of
language is explained by: “the use of social intelligence to make inferences about animal
behavior as if animals were purposefully signaling the way humans do (anthropomorphic
inference),” and “the ascription of kinship to certain animals” (p. 185). The former suggests the
entirety of the environment becomes a social climate and the latter proposes a reduction of
human isolation by incorporating animals into socialization patterns which assist in human health
maintenance.
Related to socialization, Katcher and Wilkins (2013) suggest examining response patterns
of patients with various pathologies to AAIs to further explore the innateness of the BH. The
authors cite the rising rate of animals in residential facilities for the elderly and animal visitation
programs for inmates. They noted the results of a study preceding the increase of AAIs indicated
patients who were depressed and asocial responded positively to interacting with an animal.
Many studies followed on the effects animal contact had on socially withdrawn patients;
consistent findings revealed the patients would, “focus their attention on the animals”; “interact
with the animals, holding, stroking, and hugging them”; “smile and laugh”; and “talk to the
animals and volunteers” (p. 178). Moreover, children with autism receiving AAT with dogs
exhibited significant increases in favorable social behavior and decreases in autistic behaviors.
Family Systems
Theories of family systems suggest a person is a part of a larger system and even
seemingly trivial changes within the system will alter it (Bruneau & Johnson, 2016). Therapy
involves developing and improving communication and interaction patterns between family
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members. Pets play a significant role within the family system and, as previously indicated, are
often regarded as family members. Having an animal present in the therapy room stimulates
conversation about them which can reveal information pertaining to the client’s family dynamic
and structure as well as means in which the family functions. Animals are in tune with human
emotion and mood, possessing the ability to modulate the emotional atmosphere. Because of this,
their presence in the therapy room can expedite therapeutic processes. For example, if family
members begin to yell at each other during the session, the animal may try to hide or seek out the
family member who it senses needs the most comfort.
History of Assistance Animals
Archaic Period Through the 19th Century
The use of animals for therapeutic purposes has an extensive history, dating back to
before the common era and progressing over time. Ancient Greeks used horses “to lift the spirits
of the severely ill” around 600 BC (Alliance of Therapy Dogs, 2018a; Eskite-Tant, 2016).
According to the Alliance of Therapy Dogs (2018a), in medieval Belgium, “humans and animals
were rehabilitated together,” (Animal-Assisted Used in Medieval Belgium section) offering
reciprocal companionship. Physicians in the 1600s used horses to aid their patients’ physical and
mental health (Alliance of Therapy Dogs, 2018a). Specifically, medical doctors used horseback
riding in the 17th century because it was beneficial for a type of arthritis as well as emotional and
neurological issues (Eskite-Tant, 2016).
As eras and centuries progress, animals continue to show evidence of therapeutic healing
abilities. In 1792, the Society of Friends hosted a retreat in York, England, and used animals to
aid in treating those with mental illness (Milligan, n.d.). In 1860, Florence Nightingale suggested
the addition of small companion animals for healing processes, specifically in chronically ill
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patients, after observing a reduction in stress and anxiety levels in psychiatric patients when
interacting with small pets (Alliance of Therapy Dogs, 2018a; Eskite-Tant, 2016). Eskite-Tant
(2016) reported a psychiatric hospital, Bethel, in Bielefeld, Germany, began incorporating
animals “into a community for those with disabilities” (Historical Perspectives section, para. 2)
in 1867.
Late 20th Century and Beyond
Horses’ abilities to aid in the physical healing of humans were researched in the late
1800s (Eskite-Tant, 2016). Early evidence of such healing potential come from Olympic
equestrian, Lis Hartel, from Denmark who became paralyzed from polio in 1944. After
rehabilitating herself for three years with her horse, she successfully regained use of most of her
muscles and earned the silver medal for women’s dressage at the 1952 Olympic Games in
Helsinki (Olympics, 2017).
In 1919, St. Elizabeths Hospital in Washington, DC, first introduced human-animal
interaction in the United States when they used dogs for companionship with soldiers residing in
psychiatric care (Eskite-Tant, 2016; Urichuk & Anderson, 2003). During World War II,
American Red Cross launched a new program at the Convalescent Hospital at Pawling Air Force
Base in New York. This program used animal therapy for wounded soldiers, opening an
extensive rehabilitation program where they looked after dogs and farm animals. Veterans
reported working with the animals shifted their focus away from war and associated traumas
(Eskite-Tant, 2016; Milligan, n.d.; Tarsia, n.d.).
Sigmund Freud practiced therapy with his dog in the 1930s, believing it could “tell the
truest character in a human,” (Alliance of Therapy Dogs, 2018a, Animal-Assisted Used in
Medieval Belgium section) as the dog would stay by patients free of stress and tension and stay
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on the opposite side of the room from patients who were not. He noticed that the dog’s presence
made his patients feel more comfortable and had an easier time taking more away from therapy
(Milligan, n.d.). Dr. Boris Levinson, a child psychologist, published the original version of his
book “Pet-Oriented Child Psychotherapy” in 1969, launching the AAT movement with his
findings that pets contributed to a secure environment for both child and adult patients. With the
release of his book, he became the first proficient clinician to provide formal introduction and
documentation for how pets can accelerate rapport between the patient and therapist. This
expedited therapeutic alliance in turn raises the probability of the patient to be motivated for
treatment (Levinson & Mallon, 1997).
Innovative Organizations
Therapy Dogs International. The late 1900s brought the introduction of a few
organizations related to therapy dogs and the HAB. First, the volunteer organization Therapy
Dogs International (TDI) was founded in 1976 (Milligan, n.d.). TDI was created to provide dogs
with testing, certifications, insurance, and registration to become volunteer therapy dogs (TDI,
n.d.-a). The organization has three aims: bring together and grow the number of accessible
therapy dogs, give these dogs the acknowledgement and appreciation they deserve, and to
provide facilities with education regarding the advantages and significance of visits with therapy
dogs.
The Delta Foundation. Shortly after, the Delta Foundation was founded in 1977 in
Portland, Oregon, to research the HAB (Milligan, n.d.). It was founded by a group of
veterinarians and doctors who all observed in their own practices their human clients’ mood and
health were being positively impacted by pets. This group included Leo K. Bustad, DVM, PhD,
who is recognized as coining the term “human-animal bond.” They speculated that their
40
observations were just scratching the surface of the effects that animals have on humans and
dedicated themselves to ensuring research would be carried out to provide more in-depth
investigations.
They changed their name to The Delta Society in 1981 to reflect the rapid influx of
professionals interested in this line of research (Pet Partners, n.d.-b). Early research findings
provide evidence that spending time with and interacting with animals contributed to reductions
in blood pressure, stress and anxiety, and an increased endorphin release in the brain. In order to
expand on their research base, The Delta Society began to develop initiatives, one of which
being the Pet Partners program. This program offered standardized training to both volunteers
and health-care professionals in AAT and related activities. In 2012, they changed their name
entirely to Pet Partners to accurately communicate their mission. Their mission is “to improve
human health and well-being through the HAB,” indicating a belief that this bond is mutually
beneficial between animal and human and benefits physical, social, and emotional aspects of
one’s life (Pet Partners, n.d.-d, Pet Partners’ mission section).
International Association for Human-Animal Interaction Organization. The
International Association for Human-Animal Interaction Organization (IAHAIO) was
established in 1990 to unite people and organizations in order to promote the recognition of the
HAB (Milligan, n.d.). This global association connects organizations that participate in research,
practice, or education of activities involving human-animal interaction. IAHAIO (2020) indicates
a mission “to provide international leadership in advancing the field of human-animal
interaction,” (Mission section) by means of research, education, and collaboration with others
across domains.
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National Service Dogs. National Service Dogs (NSD) was founded in Canada in 1996
initially as a program to breed and train dogs to assist children with autism (Tarsia, n.d.). NSD
(n.d.-a) reports a mission “to empower people to achieve their full potential with strategically
trained and certified service dogs, catalysts for restorative change” (About NSD section). Since
its establishment, NSD has created three additional programs to its original autism program:
certified service dogs for post-traumatic stress disorder (PTSD), canine assisted intervention
(CAI), and companion dog services.
Families participating in the autism program can reportedly expect benefits to include
restraint in behavioral outbursts, enhanced levels of safety, and promoting appropriate social
interactions (NSD, n.d.-c). Their program for veterans and first responders suffering from PTSD
encourages its participants to reengage in society, reduces symptoms of hypervigilance and
anxiety, and offers them gentle redirection if experiencing symptoms of depersonalization or
derealization (NSD, n.d.-d).
Regarding CAI, NSD trains and matches their dogs with professionals for therapy (NSD,
n.d.-b). The use of CAI dogs in therapy provide many benefits within the realms of improved
psychological, physical, social, and emotional functioning. Further, a research study of CAI dogs
indicated evidence of increased levels of patient openness, encourage prosocial reactions, and
provide a buffer for patients when topics become uncomfortable in therapy. Finally, the
companion dog program places dogs into families of children with disabilities (NSD, n.d.-e). The
program is based on the acknowledgement of the unique bond between pets and their families as
well as the therapeutic benefits of having a pet.
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Americans with Disabilities Act
In 1990, Americans with Disabilities Act (ADA) was passed into law by Congress, which
delineated the legal rights, including service animals, of individuals with disabilities (ADA,
1990; Tarsia, n.d.). Service animals were broadly defined as any dog or other animal trained to
carry out tasks providing assistance to a person with a disability (Mid-Atlantic ADA Center,
n.d.). The U.S. Department of Justice (DOJ) revised their enforcement of the ADA in 2010 to
specify that the main qualifying animal for a service animal is a dog (U.S. DOJ, 2020). The
revision provides further specifications for service animals.
Service Animals, Emotional Support Animals, and Therapy Dogs
SAs, ESAs, and therapy dogs all provide a benefit of some sort to humans. The general
public oftentimes uses these terms synonymously. However, each takes on a specific set of
responsibilities and is granted different rights and permissions. Differentiation between the three
terms is necessary as research has suggested a widespread misconception throughout the nation’s
public regarding descriptions and rights for each type of animal (Schoenfeld-Tacher et al., 2017).
Service Animals
In 2010, the U.S. DOJ revised their enforcement of the ADA to reflect specifications on
what animals were able to qualify as SAs. SAs are defined as “dogs that are individually trained
to do work or perform tasks for people with disabilities” (U.S. DOJ, p. 1, 2020) and there are no
restrictions on breeds of dogs. Miniature horses may also qualify under certain requirements, but
the majority of SAs are in fact dogs. According to the ADA (U.S. DOJ, 2015), the trained task(s)
should be specific actions that have a direct correlation to assisting the person’s disability.
Handlers are given the right to train the dog on their own and professional training is not
required. Psychiatric service animals (PSAs) are a subgroup within the realm of ADA
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requirements where the dogs’ trained task(s) is sensing the beginning stages of a psychiatric
episode and reducing the impact on their handlers (Younggren et al., 2016). However, the ADA
(U.S. DOJ, 2015) does not recognize ESAs, therapy dogs, or comfort or companion animals as
service animals.
SAs are granted the most access to the public of the three groups of animals. The ADA
indicates handlers and SAs are to be permitted in all areas of an organization accessible by the
public unless it poses a threat to health or safety; for example, a SA should not be present in an
operating room or may be denied access to a building if evidencing aggressive behavior (U.S.
DOJ, 2020, 2015). Regarding travel, modes of public and private transportation are required by
law to accommodate SAs and their handlers (Brennan, 2014). Further, the U.S. DOT’s ACAA
(U.S. DOT, 2005) requires airlines to allow individuals with a disability to fly with their SA.
Related to housing, the Fair Housing Act (FHA) of the U.S. Department of Housing and Urban
Development (DOHUD; U.S. DOHUD, 2013) requires overseers of a property to allow a person
to have a service, emotional support, or other assistance animal whether or not there is a pet
policy in place.
The ADA does not require licensure or certification for SAs; various websites offer the
purchase of certifications but do not bear any of the rights under the act (U.S. DOJ, 2020, 2015).
So long as a dog meets the definition provided by the ADA, it can be a SA. What is required of
SAs is that they remain under the control of their handler and generally should be under some
sort of restraint, such as a harness or leash, unless it hinders their ability to help their handler or
their handler’s disability makes it unable to use them. Further, SAs must abide by the same local
requirements of pet dogs in terms of vaccination, registration, and licensing.
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Emotional Support Animals
The ADA (U.S. DOJ, 2020) is very clear that animals who serve a single purpose of
providing emotional support are not classified as SAs. Instead, these animals are referred to as
ESAs and are considered companion animals that provide emotional benefits or aid to those who
suffer from a psychiatric disability. The American Kennel Club (AKC) describes that ESAs can
provide symptom relief from anxiety, fear, depression, and loneliness (Reisen, 2019). Typically,
ESAs are dogs or cats, but individuals can opt for other animals (U.S. DOHUD, 2013).
ESAs are much more limited than SAs in terms of public access; in fact, the only shared
access between the two is the FHA. That is, ESAs are required permission to housing properties.
Caveats include individualized assessments for housing (DOHUD, 2013). Given that ESAs are
not restricted to domesticated animals, DOHUD (2013) indicates individualized assessments to
take place in order to ensure the safety of other residents.
According to Alt (2018), there is currently no required training, registration, or
certification for ESAs. Rather, ESAs are prescribed by treating health professionals who deem
the stability of an animal a necessity for a patient with a diagnosed psychological disability
(Reisen, 2019; Younggren et al., 2016). Given ESAs have more rights and public access than
pets, it can be seen as slightly problematic that there are no regulations in place for assessing a
patient’s need for one and the suitability of the animal. Younggren et al. (2020) acknowledged
the significance of this issue and proposed an assessment model for MHPs. The model consists
of four guidelines and places a heavy emphasis on the key legal term “disability.” It highlights
the importance of MHPs ability to apply laws pertaining to ESAs, a thorough evaluation of the
patient’s psychological need and possibility of malingering, a comprehensive investigation of the
animal, and a careful observation of the interaction between patient and animal.
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Therapy Dogs
Therapy dogs and ESAs are similar in that they both provide support and comfort to
humans (AKC, n.d-a; Karetnick, 2019). The difference is that therapy dogs are trained to work
with a wide range of people in various environments while ESAs are trained to help an
individual. The AKC indicates that therapy dogs are typically part of non-profit organizations
and volunteer with their handlers in clinical settings to offer love and affection to those they
serve. As such, they must be trained to be comfortable with variety and change in terms of
environment and interacting with people. Further, the non-profit they are affiliated with should
provide licensing and insurance. Therapy dogs should be relaxed, enjoy being with people, and
remain unreactive to startling sounds or movements that can be expected in the environments
they serve. Although therapy dogs are denied the levels of public access granted to SAs and
ESAs, the nature of their work allows them into hospitals, nursing homes, mental health
facilities, and schools.
Depending on where a handler wants to take their therapy dog, they may or may not need
a registration (Alt, 2017). The AKC does not offer a certification of their own, but they have
endorsed an extensive list of organizations internationally, although mostly in the United States.
Instead, they offer a therapy dog title program (AKC, n.d.-a). To accomplish this, handlers must
complete an application, obtain a certification through an endorsed organization, complete the
required number of visits, then register the dog to the association (AKC, n.d.-d). The AKC also
indicates that many organizations require their Canine Good Citizen Test as a measure of
temperament and public behavior (AKC, n.d.-b).
Although it appears there are no universal qualifications for therapy dogs, Petco (n.d.)
offers handlers an idea of what to expect from a typical therapy dog certification test. This
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includes listening skills, comfort with strangers and tolerance of unfamiliar noises or smells,
restraining from jumping and calmness when being petted, and good leash skills. Further, they
report that in order to maintain the certification, dogs must stay up to date on vaccinations, get a
yearly fecal test with negative results, and always stay well-groomed and clean. The Alliance of
Therapy Dogs (2017a) and TDI (n.d.-b) outline similar requirements and processes, such as
being at least a year old, undergoing an evaluation for handling skills, and observed visits with
patients at facilities.
Animal-Assisted Interventions, Activities, and Therapy
AAIs are classified as any sort of goal-oriented and structured mediation purposefully
integrating animals to create an environment that offers therapeutic benefits (Kruger & Serpell,
2010; Pet Partners, n.d.-c). AAI is the broader umbrella term encompassing AAAs and AAT, and
Pet Partners (n.d.-c) indicates that these interventions involve an animal paired with either a
volunteer or professional. Given this definition, it appears that therapy dogs are best matched for
AAIs. AAAs and AAT may seem similar, but each offers different types of interventions and it is
important to distinguish between the two.
AAAs take on the form of more casual visits to institutions such as hospitals, nursing
homes, schools, and hospice centers (Pet Partners, n.d.-a). Although activities are goal-directed,
there are no specific treatment goals, no protocol, and no requirement for volunteers or
professionals to take notes (Eskite-Tant, 2016). Goals of the activities are broad and meant to
boost the quality of life of those participating by offering “opportunities for motivational,
educational, and/or recreational benefits” (Pet Partners, n.d.-c, Animal-Assisted Activities
[AAA] section) through the HAB. During AAAs, a participant is introduced to the animal under
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the assumption that, while the animal is present, it offers temporary therapeutic gains (Friedmann
et al., 2010).
AAT is a more specific type of AAI typically used by professionals in the fields of health
and human services, such as medical doctors and/or nurses, occupational, physical, and/or speech
therapists, and MHPs (Pet Partners, n.d.-c). AAT is used to augment typical treatment modalities
and involves specific goal setting from the clinician (Ernst, 2014; Eskite-Tant, 2016). As such,
interventions are planned with structure and require documentation by the clinician to track
progress. Goals of AAT include enhancing emotional, social, cognitive, or physical functioning
in the client.
Benefits of Spending Time with Animals
Interacting with animals is associated with psychosocial and physiological effects and
benefits (Beetz et al., 2012). This relationship is likely due to an activated oxytocinergic system,
suggesting it is the underlying factor of the positive effects seen from the HAB and HAIs.
Oxytocin is a hormone released when receiving sensory stimuli from a being of close
relationship. It is an influencing factor in many psychological, behavioral, and physiological
functions, including social interaction, stress, anxiety, pain, and health and restoration.
In terms of social interaction, oxytocin is a stimulator, leading to increases in social
skills; facial recognition; eye contact; trust; generosity; and learning by conditioning; with
decreases in aggression and depression (Beetz et al., 2012). Further, it nurtures pair bonding
between beings. It provides anti-stress effects by reducing stress hormone levels, especially as a
reaction to social stressors, blood pressure, and heart rate. Oxytocin acts as an anxiolytic,
especially in the face of a social threat, and as an anti-inflammatory, increasing pain thresholds.
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It also enhances functioning of the endocrine system, controlled by the parasympathetic nervous
system, which is associated with boosted restoration, growth, and digestive function.
The social interactions, physical or not, between humans and dogs is reasonably linked to
spikes in oxytocin (Beetz et al., 2012). Petting or talking to dogs leads to significant increases in
plasma oxytocin, beta endorphins, and dopamine with decreases in cortisol and heart rate. When
interacting with one’s own pet dog, oxytocin levels double, indicating oxytocin secretion is
correlated with closely bonded relationships. Even gazing at one’s pet dog is associated with
elevated oxytocin levels. HAIs supply humans with a multitude of psychological and
physiological/biological benefits very closely related to those seen in oxytocin, such as improved
motivation, physical and psychological well-being, mood, and self-esteem (Fine & Beck, 2015;
Morrison, 2007).
Physiological/Biological
Stress Relief and Heart Health
Interacting and spending time with companion animals, especially dogs, is correlated
with anti-stress and heart health (Beetz et al., 2012). When faced with stress, the body’s
sympathetic nervous system (SNS), or fight or flight system, is triggered to prepare it for action.
The SNS incites the endocrine system to release epinephrine, norepinephrine, and cortisol,
hormones that activate the stress response. Epinephrine and norepinephrine increase heart and
respiratory rates and cortisol frees stored energy to be available to the body. HAI minimizes the
intensity of stress responses by positively influencing the endocrine system to reduce the levels
of stress hormones in the body (Breedlove & Watson, 2018). These stress reductions put less
strain on the heart, suggesting animals have a positive impact on heart health.
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Significant decreases were seen in adults’ cortisol levels during interactions with pet
dogs, unfamiliar dogs, and therapy dogs (Barker et al., 2005; Odendaal, 2000; Odendaal &
Meintjes, 2003). Likewise, insecurely attached children experienced significant reductions in
cortisol levels when receiving support from a dog compared to a human during a stressful social
situation. Further, stress responses were lower in the children who pet the dog more (Beetz et al.,
2011). Hospitalized heart failure patients had reduced levels of epinephrine and norepinephrine
after therapy dog visits. They also had drops in blood pressure, likely associated with the
decreases in the two stress hormones (Cole et al., 2007).
Evidence has indicated blood pressure and heart rate were reduced when petting a dog
(Grossberg & Alf, 1983; Vormbrock & Grossberg, 1988). Undergraduate students had
significantly reduced blood pressure and heart rate when petting a dog compared to verbal and
visual interactions with it as well as talking amongst each other or reading. Heart rate reductions
were also found in hospitalized children engaging in AAT (Kaminski et al., 2002). Relatedly, pet
owners had significantly lower pulse and blood pressure levels before engaging in a cognitive
task and a test measuring vascular changes (Allen et al., 2002). Increases in vascular reactivity
were lower during the task and test, and vascular recovery was faster among pet owners.
Pet owners may be better equipped for stressful situations than non-owners. A group of
hypertensive pet owners in high-stress professions performed mentally stressful tasks while on
antihypertensive medication alone and again on the medication while in the presence of a pet
(Allen et al., 2001). It was found that antihypertensive medications lowered only resting blood
pressure whereas pets reduced stress responses of increased blood pressure and heartrate.
Further, pet owners performed better on the tasks. Patients with borderline hypertension
experienced significant drops in blood pressure within 5 months of adopting a shelter dog
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(Robinson & Segal, 2019). Moreover, in a population of elderly participants, pet owners
contacted their doctors fewer times than non-owners in response to stressful life events,
suggesting the ameliorating effects of their pets’ support (Siegel, 1990).
Since pets have been linked to decreased stress and blood pressure, they may help reduce
the risk of heart disease. Qureshi et al. (2009) found that cat owners were at lower risk for
developing and/or dying from cardiovascular diseases. Friedmann et al. (1980) found the
likelihood of survival after one year of patients who had suffered a heart attack was significantly
higher for pet owners. An explanation of this finding to is related to social support; the lack of a
significant companion can lead to social isolation and depression which is associated with higher
prevalence of degenerative diseases, including heart disease. Chronic heart failure patients have
better outcomes and shorter hospital stays if partaking in early ambulation; however, many
patients refuse which may be problematic for them (Abate et al., 2011). Combining AAT with
ambulation therapy, that is, walking with a therapy dog, led to less refusal rates and further
distances walked by patients. Additionally, pet ownership has been linked to lower levels of
triglycerides and cholesterol (Robinson & Segal, 2019).
Pain Perception and Management
Research suggests animals can be helpful for pain management. An elderly population
with chronic joint pain participated in kinesiotherapy with adjunctive AAT (Rodrigo-Claverol et
al., 2019). Results indicated decreased pain perception and pain induced insomnia. Additionally,
including supplemental AAT improved participants’ intervention motivation and satisfaction.
After joint replacement surgery, adults who used pet therapy needed 50% less pain medication
(Loyola University Health System, 2009). Further, nursing home residents saw reductions in the
amount of care needed to manage their pain after AAT (Darrah, 1996).
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Immunity
The immune system is inhibited when cortisol is released into the body (Breedlove &
Watson, 2018). There are a variety of stressors faced in daily life whether or not one has a
psychological disorder. Consequently, the stress response is often triggered and releasing
cortisol, wearing down the immune system and weakening the body’s ability to protect against
diseases. Animal interactions lead to reductions in cortisol levels, as previously discussed,
demonstrating the role of HAI in strengthening the immune system.
There is also evidence that petting a dog significantly increases immunoglobulin A
levels, an antibody fundamental in the prevention of a multitude of diseases and illnesses
(Charnetski et al., 2004). High immunoglobulin A levels are associated with diminished
likelihood of sickness, including reduced vulnerability to upper respiratory infection.
Allergic reactions are the immune system’s response to allergen encounters (Immune
Deficiency Foundation, 2013). Allergies to dogs and cats are common. Lifetime exposure to
dogs and cats can reduce sensitivities to their allergens (Wegienka et al., 2011). The presence of
a pet dog or cat in the first year of life decreased the risk of allergy sensitivity, cutting the risk by
up to half for developing pet allergies.
General Health
Headey conducted several studies assessing health benefits of pet ownership. His study of
dog and cat pet owners in Australia revealed they are in better health than non-pet owners
(Headey, 1999). They made less visits to the doctor and had significantly lower uses of
medication for sleep or heart problems. Dog owners were also found to engage in mild exercise
1.6 times more than non-owners. Findings led to estimated national health expenditure savings
between $988 million and $1.813 billion as a result of having pets. In Australia and Germany,
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pet owners made the least amount of doctor visits, making them the healthiest population of both
nations (Headey & Grabka, 2007).
Similar results were found in young and middle-aged adult female dog owners in China
compared to their non-dog owning counterparts (Headey et al., 2008). They reported higher selfreported fitness and health, better sleep, and exercising more. Participants also indicated less
visits to the doctor and less sick days from work, suggesting in addition to health benefits, dogs
provide financial benefits to their owners as well.
Human beings operate on the biological clock and circadian rhythm mechanisms to
navigate daily life (National Institute of General Medical Sciences, n.d.; Northwestern Medicine,
n.d.). Maintaining a daily routine that regulates these mechanisms is associated with improved
health, including better sleep, reduced stress, better fitness, and more effective time usage.
Animals also operate on such mechanisms (Robinson & Segal, 2019). Pets rely on their owners
to care for them. Dogs in particular need consistent schedules of feeding and exercise to keep
them steady and peaceful. In this way, pets assist in creating a daily routine for their owners
which contributes to mental and physical health.
Psychological
Animal interactions are linked to many mental health benefits. A review of AAIs for
trauma and related symptoms consisted mainly of horses and dogs produced positive results,
with reductions seen in anxiety, depression, and PTSD symptoms (O’Haire et al., 2015). AAT
has been found to have positive impacts on internalizing and externalizing psychological
diagnoses and related symptomatology; psychological distress; the therapeutic process;
psychological well-being; mindfulness; autonomy; ego strength; sense of identity; emotional
expression; motivation; sense of meaning; anxiety; stress; affect; energy levels; happiness; and
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perceived social support (Barker et al., 2017; Jones et al., 2019; Klontz et al., 2007; Machová et
al., 2019; Shearer et al., 2016; Trotter et al., 2008; Ward-Griffin et al., 2018).
Pets are powerful support sources for those who suffer from mental health issues. The
nonjudgmental nature of pets allows their owners a place to open up about topics otherwise
uncomfortable to talk about with other humans (Brooks et al., 2018). Moreover, the
unconditional love they offer provides their owners with a nurturing environment to grow into
self-acceptance and congruence. The positive environment created by pets contributes to
growing self-efficacy, existential meaning, positivity, self-worth, and identity.
Aiken (2011), the librarian of Yale Law School’s Lillian Goldman Law Library,
recognized adjustment issues students face in law school that lead to heightened levels of stress.
He was privy to the evidence and benefits of therapy dogs as he owned one, Monty. Aiken
implemented one of the first university therapy dog programs in the world at the library in 2011
where students could interact with now-retired therapy dog Monty. Aiken’s program soon
inspired universities worldwide to enact campus therapy dog programs (Xu, 2015).
Learning
The presence of an animal in the classroom or students engaging in AAIs leads to
improvements in school performance (Alliance of Therapy Dogs, 2017b). Dogs have been
associated with stimulating cognitive skills, such as memory and problem-solving abilities,
facilitating interactions of students and teachers, supporting self-esteem development, and easing
anxiety. These factors are crucial to advance education, highlighting the advantages of
incorporating dogs into school settings.
Having a dog present in the classroom led to raised school attendance and paying more
attention to the teacher (Beetz et al., 2012). Marked improvements were noted by high-risk
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students and children with autism partaking in AAT related to hyperactivity, inattention,
distractibility, staying on task, and focusing (Bass et al., 2009; Trotter et al., 2008). Preschoolers’
performance on memory, match-to-sample, and imitation tasks in the presence of a dog incited
less instructional prompts, less irrelevant choices or errors, and better instructional adherence,
respectively (Beetz et al., 2012).
Compared to their no treatment counterparts, public school third graders in an animalassisted reading program saw a 12% improvement in reading fluency (4 Paws Learning and
Wellness Center, n.d.). Homeschooled youth improved reading fluency by 30%. Further,
students experienced emotional gains. Before the program, many expressed self-consciousness
around reading; after, they made statements exuding self-confidence. Parents and teachers also
indicated observing more self-confidence in the students (AKC n.d.-c; Jones, 2010).
Behavior
Interacting with animals is associated with improvements in problem behaviors. Elderly
dementia patients receiving AAT had significant reductions in agitation directly after the
intervention (Richeson, 2003). When using AAT in mental health practices, a decrease in
disruptive behaviors was seen in sessions (Jones et al., 2019). High-risk students engaging in
AAT led to parent reports of significant reductions in internalizing (e.g., behaviors related to
anxiety and/or depression), and externalizing (e.g., disruptive behaviors) problem behaviors with
improvements in adaptive skills. Further, there were notable reductions seen in aggression and
conduct problems (Trotter et al., 2008). Young, elementary school students also exhibited a
decrease in aggressive behaviors with a dog present in the classroom (Hergovich et al., 2002).
AAT increased sensory seeking behaviors and decreased sedentary behaviors, and significantly
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improved self-regulation and motor skills in children with autism (Bass et al., 2009; Gabriels et
al., 2012).
Socialization and Depression
Socialization can be enhanced through animal presence and interaction. Isolation
oftentimes leads to depression, making social interaction important for the prevention and
alleviation of such symptoms (Hediger et al., 2019). Hosey et al. (2018) indicated intensive care
units can be dehumanizing experiences for patients. The authors propose the use of AAIs with
dogs in ICUs to assist in creating a more humanized environment for patients. In a downward
arrow fashion, AAI holds the potential to reduce suffering, in turn increasing social engagement
which consequently leads to reductions in physiologic changes that would necessitate medical
interventions.
With youth, dogs were also found to be effective influences on the development of
empathy, increasing ability to differentiate themselves from others (Hergovich et al., 2002).
Further, the presence of a dog was associated with improved social integration between children.
Children admitted into psychiatric care were more emotionally balanced after therapy dog
sessions (Prothmann et al., 2006). Moreover, hospitalized children engaged in AAT resulted in
more positive affect and enhanced mood (Kaminski et al., 2002).
Relatedly, visits from animals in long-term care facilities, such as hospitals, nursing
homes, and retirement communities, reduce feelings of loneliness in older adults and the elderly,
individually through more intense animal interaction and in groups by promoting social
interaction with other people (Beetz et al., 2012). Patients in long-term care units of hospitals are
at risk of hospitalization syndrome which leads to isolation and depressive symptoms (Machová
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et al., 2019). Brief therapy dog sessions with these patients revealed increases in mood as well as
socialization between patients, staff, and family members,.
Nursing home residents with dementia have benefited from AAIs. Significant increases in
social interaction have been found throughout the interventions (Richeson, 2003). Moreover,
family members of patients and nursing staff have expressed marked changes in alertness and
responsiveness of the patients during the interventions. Similarly, research has revealed AAIs
promoted social interaction, both verbal and nonverbal, and had beneficial impacts on pleasure
with the residents (Wesenberg et al., 2018). Institutionalized elders interacting with birds
reported improved quality of life and decreased depression (Beetz et al., 2012).
A retirement community welcomed a new part-time resident in 2011, Ginger the therapy
dog (Erikson Living, 2011). Her handler reported Ginger provides great companionship and
having bettered as a person from taking care of her. Further, Ginger’s handler indicated she has
aided in bonding with neighbors and strangers, as she sparks conversation. After her handler
observed the positive impact Ginger provided them with, they thought to share the benefits with
others. Consequently, Ginger joined the retirement community to assist residents with forming
friendships with one another and to lift their spirits.
Patients who suffer from brain injury often experience consequential difficulties related
to social competence, including reductions in communication skills, emotional expression,
appropriate responses to emotional stimuli, and empathy (Hediger et al., 2019). Brain injury
patients participated in either conventional neurorehabilitation therapy sessions alone or with
adjunct AAT. In the AAT group, significant increases were noted in social behavior, including
verbal and nonverbal communication and displaying positive emotions. Further, patients with
AAT were more motivated for and satisfied with treatment.
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In terms of mental health practice, pairing AAT with mindfulness training was found to
be favorable by participants in a study conducted by Schramm et al. (2015). Participants reported
stable improvements in depressive symptomatology with a significant decrease in rumination.
Significant increases in mindfulness skills were also found, including improved attentiveness,
perception and evaluation of situations, and ability to face difficulties. Moreover, canine-assisted
psychotherapy led to increased socialization seen in therapy sessions (Jones et al., 2019).
Children receiving inpatient psychiatric care were more socially extroverted in therapy sessions
with a dog present (Prothmann et al., 2006); furthermore, inpatient adults with schizophrenia
participating in AAT were more socially interactive with others and responsive to their
environment (Marr et al., 2000).
When combining play therapy with AAT, the presence of a dog has a significant impact
on a child’s response to the session. Specifically, children showed increases in mood, affect,
openness, and the ability to engage in thematic play (Thompson, 2009). Moreover, rapport was
more easily established and there was a decrease in aggressive behaviors and disruption of play.
AAT also significantly reduced depressive symptoms in child sexual abuse (CSA) survivors
(Dietz et al., 2012; Kemp et al., 2014). Children with autism significantly improved expressive
communication, including increased social interaction and language usage, and had greater social
motivation when engaging in AAT (Bass et al., 2009; Gabriels et al., 2012; Sams et al., 2006).
Anxiety and Trauma
Anxiety is typically linked to stress; therefore, the stress relief benefits of animals
previously discussed are likely related to and contribute to findings related to anxiety reduction.
Animals bring about a sense of calmness in the face of stress, lessening the anxiety felt in the
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situation (Shiloh et al., 2003). For example, when presented with a fear inducing stimuli,
participants stroking a live animal had reduced anxiety levels than those who did not.
Long-term care facility residents and hospitalized patients exhibited decreased anxiety
from dog interactions. In a nursing home, elderly residents indicated less confusion and tension
with more calmness as a result of their resident therapy dog (Crowley-Robinson et al., 1996).
Elder dementia patients had decreases in restlessness from canine-assisted therapy (Beetz et al.,
2012). Patients hospitalized with heart failure had anxiety reductions when being visited by a
therapy dog (Cole et al., 2007).
Animal interactions reduce anxiety of those being treated for psychological disorders.
Before receiving electroconvulsive therapy, psychiatric patients who underwent AAT shortly
beforehand indicated significant decreases in fear and anxiety; less anxiety before
electroconvulsive therapy was also indicated by an aquarium in a waiting room (Barker et al.,
2003a, 2003b). Psychiatric inpatients’ anxiety was reduced at the end of and after AAT sessions
(Barker & Dawson, 1998); further, psychiatric patients who participated in an AAI program had
reduced anxiety 6 months after the intervention (Berget et al., 2011). Decreases in anxiety after
clinical interviews conducted with dogs were noted by patients with schizophrenia (Lang et al.,
2010). For children with autism, animals give sensory input to the child which can provide them
with relaxation and calmness (Gabriels et al., 2012).
Those who suffer from trauma can experience residual effects of anxiety. As such,
trauma victims and survivors can greatly benefit from HAI and AAT. Youth survivors of CSA
undergoing counseling with adjunctive AAT evidenced significant reductions in symptoms of
anxiety and trauma, including unwanted behaviors associated with the trauma (Dietz et al., 2012;
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Kemp et al., 2014). Caregivers of children with trauma favored trauma-focused CBT (TF-CBT)
with adjunct AAT over TF-CBT alone or with medications (Dravsnik et al., 2018).
Hunt and Chizkov (2014) investigated the effects of a therapy dog on processing
variables pertinent to CBT on young adults reliving traumatic experiences. A commonly used
technique in exposure therapy for trauma is writing out the traumatic event in great detail. The
presence of a dog during writing significantly reduced anxiety and had no effect on emotional
processing. Findings suggest typical PTSD interventions may benefit from adjunctive AAT, as it
increases tolerability while not impacting effectiveness.
Pets may be advantageous for those who suffer from PTSD. Human relationships are
complex in nature; pets do not cross boundaries and do not provoke conflict, things that might
trigger trauma reactions (Brooks et al., 2018). PTSD patients indicated their pets came to their
side and attempted to improve their mood when experiencing trauma symptoms. Further, they
reported their pets caused them an increase in calmness, a decrease in worry, and a sense of
security.
The Importance of Awareness of Benefits (HABRI, 2016)
The Human Animal Bond Research Institute (HABRI) evaluated pet owners’ awareness
of the health benefits offered by interacting with animals in 2016. Survey results offered
evidence of the human health benefits, including personal experience and significance of
familiarity for pet care (HABRI, 2016). Critical statistics are also provided linked to views of
veterinarians, doctors, and society. Of respondents, 74% reported observed improvements in
their own mental health with 75% also indicating mental health improvements seen in pet
owning family and friends. Improvements in personal physical health were seen in 54% of
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respondents and 55% additionally reporting physical health improvements for friends and family
who own pets.
The survey revealed learning more scientific knowledge of the HAB and health benefits
of pet ownership increased pet owners’ probability of actively improving their pet’s health
(HABRI, 2016). When presented with scientific knowledge: 92% of respondents were more
likely to keep up with maintenance of their pet’s health; 89% were more likely to regularly visit
the veterinarian; 88% were more likely to improve their pet’s nutrition; 62% were less likely to
skip veterinarian visits; and 51% were more likely to buy health insurance for their pets.
Becoming educated on scientific research of human health benefits also improves animal
welfare: 89% of respondents were more likely to better care for their pets; 75% were more likely
to microchip pets; 74% were less likely to surrender their pet; 77% believed the HAB is mutually
beneficial; and 80% who knew about the health benefits spent the majority of their time with
their pets. The scientifically backed health benefits of pets encourage pet ownership: 87% of
respondents were more likely to suggest getting a pet to family or friends; 81% were more likely
to get another pet in the future after their current pet passes away; 49% were more likely to get
another pet in addition to their current one; and 57% with more than one pet currently were more
likely to get another.
Respondents indicated veterinarians as reliable sources to obtain scientific data regarding
the human health benefits of pets and, in doing so, can build the relationship with the pet owner
(HABRI, 2016). Survey findings revealed: 97% of respondents positively view their
veterinarian; and 66% would have better opinions of, and 61% would more likely visit, their
veterinarian if HAB health benefits were discussed. Expanding communication of the HAB can
also benefit doctors: 88% of respondents believe medical professionals should endorse pets for
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healthy living; and 65% would have more positive opinions of, and 59% would more likely see,
a doctor if they talked through HAB health benefits.
Finally, respondents believe society should take advantage of the body of scientific
research that exists outlining how pets improve human health, and that society ought to be more
pet friendly (HABRI, 2016). In terms of society: 93% of respondents believe veterans with
PTSD should be supplied with SAs by the government; 69% believe the government should
assist in making pet ownership more affordable; 84% believe pet owners should receive
discounts should from health and life insurance companies; 87% would more likely make
purchases from pet-friendly businesses; and 58% believe employers should take into
consideration letting pets accompany employees to work.
Summary
This chapter covered literature and data relevant to the current study’s topic and purpose
of investigating therapists’ views of ESAs and AAT. A detailed history of assistance animals
was reviewed dating from the Archaic period to the near present. The terms for assistance
animals, SA, ESA, and therapy dog, were defined, and the differences from one another were
described as were AAIs, including AAT and AAAs. Specifying these terms is important as they
may be used incorrectly. The myriad of health benefits humans experience from the HAB and
spending time with animals was uncovered, pointing to the oxytocinergic system to explain the
positive effects. Information pertaining to the use of dogs within mental health practices was
variable and limited. This indicates a gap in the literature related to MHPs’ willingness to
prescribe ESAs or incorporate AAT into typical practice, and the therapeutic value of AAT
within the clinical context.
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Chapter 3: Research Design and Method
Based on the literature review, there are a number of indications of the benefits of the
presence of dogs and some suggestion that different theoretical orientations are in support of
that. Coming from that, the current study was done looking specifically at the use of animals, to
what degree different factors support that, as well as looking at the notion of ESA use and
evaluation.
The current study examined individual differences regarding therapists’ willingness to
use AAT in practice. It also explored the beliefs that practicing licensed therapists hold regarding
the use of AAT. In terms of ESAs, the study intended to determine therapists’ opinions of their
usefulness and what methods they have put in place for assessing and documenting them. The
study was descriptive and exploratory, taking inventory on current licensed therapists views of
AAT and ESAs. Findings regarding acceptability and usage of AAT and ESAs may potentially
lay the groundwork for future research of the topics.
This chapter covers research methodology. Research questions and hypotheses are
reintroduced while providing rationale for each. Such research questions are quantitative or both
quantitative and qualitative in nature, thus offering various rationale behind hypotheses. The
selected research design is non-experimental and descriptive, being observational in nature.
The desired sample for the study was 120 participants who were practicing licensed
therapists in the tri-state area of Washington, DC, Maryland, and Virginia. There were 25 actual
participants recruited. Participants were recruited via Facebook groups to complete a survey that
took approximately 10 to 15 minutes and were entered into a raffle for a gift card upon
completing the survey. Participants were told they could email the researcher to receive results
upon study completion. Participants’ demographics are delineated.
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The survey incorporates questions aimed at assessing individual differences between
participants regarding opinions and perceptions of the use of dogs in therapy and ESAs. The
survey was accessible to those with the web-link to the site Google Forms. Data was
subsequently downloaded from the site and uploaded into Statistical Product and Service
Solutions (SPSS) for data analysis.
Prior to beginning recruitment, permission to recruit participants from the Institutional
Review Board was obtained. Before partaking in the study, participants were prompted to read
and sign an informed consent form. Participants remained anonymous, and the option to see their
IP addresses were not used in Google Forms, thus rendering complete anonymity.
Research Questions and Hypotheses and Their Rationales
Research questions have been crafted to shed more light on therapists’ perceptions of
AAT and ESAs. There has been significant growth in the realm of ESAs while AAT has been
deemed undervalued by experts (Morrison, 2007). Many people love and cherish their pets as
family members and report a positive impact on well-being and emotions. As a mixed-method
study, research questions are either quantitative, qualitative, or both in nature. Hypotheses and
rationale are listed below for each.
Quantitative
The first question addressed in the study is: does the type of degree a therapist holds,
their age, and their primary theoretical orientation predict whether or not they have ever brought
a dog into the therapeutic session.
I believed the results would differ based on the type of degree the MHP holds. A report
from the APA (Hamp et al., 2016) revealed doctoral-level psychologists perceived themselves as
having the greatest degree of influence over various other healthcare professionals. The report
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also indicated 89% of doctoral-level psychologists feel they have a complete mastery of the
profession with another 10% feeling they are proficient. Higher degree types (i.e., doctorates)
typically require more field experience to earn the degree and, therefore, those who hold them
may feel more comfortable incorporating novel ideas into treatment.
It is reasonable to believe results will differ based on age due to different generational
factors and societal beliefs (Fleschner, 2008; Twenge, 2017). The training MHPs receive now is
different than the generation before them, and the generation before them, and so on. Each
generation of trained MHPs receives different information regarding what is appropriate at that
time in the field. There have been subtle nuances throughout the years of training which may
account for the expected hypothesized differences.
It is reasonable to believe results will differ based on therapists’ individual theoretical
orientations. This has less to do with the actual therapist and more to do with the chosen
orientation in which they choose to practice. Some orientations appear to be more rigid than
others. For example, cognitive-behavioral therapy (CBT) is typically short-term treatment with
definitive goals and structured sessions. Contrarily, psychodynamic therapy is typically longterm treatment with more general theoretically based goals and unstructured sessions, relying on
free association from patients to lead (Pilecki et al., 2015). There are many theories of
psychotherapy and variations between them. I aimed to discover which theories are more open to
having a dog in the therapy session.
Quantitative and Qualitative
The second question of the study address the following: the therapists’ perceived effects
the dog would have on themselves in the session and the therapists’ perceived effects the dog
would have on patients in the session. This question is exploratory in nature with purpose to
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examine therapists’ anticipated effects on both themselves and their patients when engaging in a
therapy session with a dog. I believe, and the literature corroborates as seen in Chapter 2, dogs
impact humans in many ways including feeling comfort and expressing emotions.
The third question of the study addresses therapists’ perceptions and opinions of ESAs,
whether they have been asked by a patient to write a letter for an ESA, and if patients could
benefit from ESAs and under what conditions. This question seeks to examine and explore the
opinions of therapists about the role of an ESA and current assessment and documentation
processes. I believe if more therapists deem ESAs as an appropriate and beneficial adjunct to
therapy, they can become more normalized and gain traction as a trusted and respectable aspect
of psychological treatment.
Population and Sample
Practicing licensed therapists in the tri-state area of Washington, DC, Maryland, and
Virginia were recruited for this study via four different Facebook groups, “Therapists ‘R’ Us
Virginia,” run by Angela Callahan, “Mental Health Professionals Network,” run by Lauren
Mersey, “Mental Health Professionals Group,” run by Rachel Needle, and “Mental Health
Professionals of Northern Virginia,” run by Kelly Lynn. Participants were excluded if they were
afraid of or allergic to dogs, if they were unlicensed, and if they practiced outside of the tri-state
area. The survey was open for six weeks.
Demographics
A total of 27 participants began taking the survey, two failed to meet inclusion criteria
and were dropped from the final analysis; one was not a practicing MHP in the tri-state area of
DC, VA, and MD, and one was not licensed in DC, VA, or MD. The final analysis was
performed using the remaining 25 participants. Of the 25 participants included in study, 24 were
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female (88.9%) and 1 was male (3.7%). The mean age of the sample was 41.16 with a standard
deviation of 10.76. Racial and ethnic background statistics are shown in Table 1.
Table 1
Racial and Ethnic Background Statistics
White/Caucasian
Black
Hispanic
Multiracial
Frequency
Percentage
20
2
2
1
74
7.4
7.4
3.7
Participants were asked what their degree type was; the majority of participants held a
Master’s degree in Mental Health Counseling, a Master’s degree in Social Work, or a Doctorate
of Psychology (PsyD). The complete breakdown of those degrees can be found in Table 2.
Table 2
Degree Type Statistics
Master’s in Mental Health
Counseling
Master’s in Social Work
PsyD
PhD in Clinical Psychology
Master’s in Forensic
Psychology
MS and EdS in Mental
Health Counseling
Master’s in Marriage and
Family Therapy
Master’s in Rehabilitation
Counseling
MS and MAC
Master’s in Art Therapy and
Counseling
PhD in Counseling
Psychology
Frequency
Percentage
6
22.2
5
4
2
2
18.5
14.8
7.4
7.4
1
3.7
1
3.7
1
3.7
1
1
3.7
3.7
1
3.7
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Of the 25 participants, 11 indicated that CBT was their primary theoretical orientation
(40.7%), five indicated family systems was their primary orientation (18.5%), and the remainder
of the participants were spread across different theoretical orientations and a breakdown of those
can be found in Table 3.
Table 3
Theoretical Orientation Statistics
CBT
Family Systems
Existential/Humanistic
EMDR/AIP
Psychodynamic
Motivational/Somatic
Experiencing
Frequency
Percentage
11
5
3
3
2
1
40.7
18.5
11.1
11.1
7.4
3.7
Procedures
Recruitment was internet-based through social media groups that had granted access to
post on their pages. Flyers were posted in four Facebook groups specifically for MHPs.
Approved groups are previously indicated. The recruitment flyer indicated to potential
participants that the current study aims to gain a better understanding within the community of
psychology of how using dogs in therapy is viewed and under what conditions.
The recruitment flyer and post directed participants to a web-link to complete a self-made
survey (see Appendix) through the online platform Google Forms. The initial questions
addressed exclusion criteria and determined if a participant was viable for the study. The rest of
the survey focused on the aim of the study, with questions regarding therapists’ opinions and
perceptions of therapy dogs in a clinical context and ESAs related to their gender, cultural/ethnic
background, degree type, experience level, and theoretical orientation. The survey was estimated
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to take 10 to 15 minutes to complete. Participants were entered into a raffle to be one of four
winners to receive a $25 Amazon gift card.
Participants were provided with an email address so they may contact me should they
want to see the results of the study.
Instrumentation
Data was collected through a self-made survey assessing demographics, levels of
experience and education, preferred theoretical orientation, and perception of ESAs and using
therapy dogs in clinical practice. The survey was accessible to participants via web-link and was
used to gather information relevant to the study. The instrument was created strictly to collect
survey data. The reliability and validity of the survey was never established, and I am not
claiming or implying it as a valid and reliable instrument. The survey included a few open-ended
questions that could later be used to test reliability after looking at a thematic analysis. The
survey was approved by the Institutional Review Board of The Chicago School of Professional
Psychology and it began with informed consent for participants to review before entering.
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Chapter 4: Findings
The current study explores therapists’ perceptions and openness to the prescription of
ESAs and the use of AAT in clinical practice. This chapter will outline the findings of the study.
The study setting will be identified. A breakdown of participants’ demographics is explained.
Results are discussed regarding therapist view of the impact a dog would have on the
patient/client and on themselves, therapist opinions of ESAs, and therapist assessment of ESAs.
The chapter closes with a summary of main points and explains the organization of the
remainder of the document.
Setting
The survey was delivered using Google Forms. Participants had the option to take the
survey when they deemed convenient, and in the location of their choice.
Results
In order to examine the association between type of degree and bringing a dog into the
therapy session, a Fisher’s exact test was conducted. There was not a statistically significant
association between type of degree and bringing a dog into the therapy session, p=.156. Overall,
eight of the 25 participants had brought a dog into the session. There was no correlation with
those who had brought dogs into session versus those who had not in terms of their views of
incorporating a dog into the therapeutic session.
Of the seven participants who hold doctoral degrees, four (57%) had brought dogs into
the session at some point, while three had not. Out of the 18 participants who held Master’s
degrees, four (22%) had brought dogs into the session at some point while 14 had not.
In order to explore the relationship of type of degree, and age with willingness to bring a
dog into the therapy session, a logistic regression was performed using age, degree type, and
70
theoretical orientation as predictors. This logistic regression model was statistically significant,
χ2(2, N=25)=8.862, p=.012. Although the overall model was statistically significant, only age
was a significant predictor of whether or not therapists had brought a dog into the therapeutic
session at any point. As age increased therapists were more likely to have brought a dog into the
therapeutic session (see Table 4). The average age of the entire sample was 41.16 years old and
the average age of participants who had brought a dog into session at any point was 49.38 years
old.
Of the 11 participants who identified CBT as their primary orientation, three had brought
dogs into the therapy session at some point and eight had not. All three participants who
identified their primary orientation as existential-humanistic had brought dogs into the therapy
session at some point. The participants who identified psychodynamic as their primary
orientation were split with one who had brought a dog into the therapy session and one who had
not. Of the five participants who identified their primary orientation as family systems, one had
brought a dog into the therapy session while four had not. Finally, of the four participants who
identified “other” as their primary orientation, none had brought a dog into the therapy session. It
is possible that with a larger sample primary orientation may have been a significant predictor of
whether a therapist had brought a dog into the therapy session at some point.
Table 4
Logistic Regression Analysis
Independent Variable
Age
Degree Type
Model χ2 = 8.862
Nagelkerke R2 = .418
N = 25
b
.124
1.32
se
.058
1.12
Wald
4.53
1.32
df
1
1
p
.033
.25
.012
Odds
1.132
3.74
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Therapist Thoughts on Dog in Session
Participants were asked about their thoughts on having a dog in the therapeutic session.
Of 25 therapists surveyed, 14 (56%) indicated positive thoughts on having a dog in session. For
example, one participant stated, “I think it’s a great idea … I’ve witnessed/believe it can help
reduce barriers to talking about things, [and] expressing emotions.” Another reported, “it makes
my clients feel more comfortable and relaxed. I enjoy their company.” In this sample, six (24%)
indicated mixed thoughts on having a dog in session. For example, one participant stated,
“sometimes helpful for support. Sometimes just a gimmick …” and another reported, “… during
telehealth sessions, clients have had dogs in the room with them. It’s common for clients [to]
remove the dog from the room because it’s a distraction … though many will allow them to be in
the room passively or pet them while talking.” Of the participants, three (12%) indicated neutral
thoughts on having a dog in the session. For example, one participant stated, “I am open to it if
needed,” and another reported, “ok with well-behaved dog.” Of the therapists surveyed, two
(8%) failed to understand the question.
Therapist Views of Dog Impact on Client/Patient
Participants were asked about their views of the impact on the client/patient of having a
dog in the therapeutic session. Of 25 therapists surveyed, 13 (52%) indicated having a dog in
session would have a positive impact on the client/patient. For example, one participant stated,
“likely helpful with some,” and another reported, “I think it would be positive and could cause
them to open up faster and feel less guarded.” In this sample, 13 (52%) indicated it would have a
calming/comforting impact on the client/patient. For example, one participant stated, “calming,
ability to get physical comfort you can’t get from therapist,” and another reported, “for those
who are accepting, the dog’s presence could be calming. It could be especially useful for kids, as
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they may feel more comfortable talking to the dog instead of the therapist. Could be helpful in
grounding as something to touch.” Of the participants, five (20%) indicated a dog in session
would have a negative/distracting impact on the client/patient. For example, one participant
stated, “… for those that don’t like dogs it’s a problem.” Of the therapists surveyed, one (4%)
indicated it would have a neutral impact on the client/patient. For example, the participant stated,
“… no issue.” In this sample, one (4%) participant failed to understand the question. Of note,
some participants reported two or more responses and each of their answers were incorporated
into the respective categories. For example, some therapists indicated both a neutral/positive and
a negative/distracting impact on the client/patient, with one stating, “supportive and distracting,”
and another reporting, “I would imagine mixed reactions … perceptions and actual experiences
can be that a dog is a distraction in session … it could cause the client to open up more, feel
more relaxed, and have a way to ground in session.”
Therapist Views of Dog Impact on Themselves
Participants were asked about their views regarding the impact having a dog in the
therapeutic session would be on themselves as the therapist. Of 25 therapists surveyed, nine
(36%) participants indicated a dog in session would have a calming/comforting impact on
themselves as the therapist. For example, one participant stated, “… I think it could feel calming
and helpful for me,” and another reported, “I think it would help me feel more centered.” In this
sample, eight (32%) indicated having a dog in session would have a positive impact on
themselves as the therapist. For example, two participants stated, “positive impact,” and one
reported, “I would LOVE it.” Of the participants, seven (28%) indicated it would have a
negative/distracting impact on them. For example, one participant stated, “… it would likely be
distracting at times,” then described an instance when a client brought their dog into a session,
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and they ended up having to chase it down the hallway. Another participant reported, “I’m not a
fan of dogs, so if I were meeting clients in person I wouldn’t like it…” Of the therapists
surveyed, three (12%) indicated having a dog in session would have a neutral impact on the
client/patient. For example, one participant stated, “neutral …” In this sample, three (12%)
participants failed to understand the question. Of note, some participants reported two or more
responses and each of their answers were incorporated into the respective categories. For
example, some therapists indicated a calming/comforting, neutral, and/or positive impact on
themselves as the therapist, with one stating, “it would most likely either be calming or have no
measurable impact on my therapy engagement,” and another reporting, “neutral or positive,
sometimes my dog sits in the room while I have video sessions and his presence is comforting.”
Another therapist indicated both a negative/distracting and a neutral impact for themselves,
stating, “distracting at first but otherwise no issues.”
Therapist Opinions of ESAs
Participants were asked about their opinions of ESAs. Of 25 therapists surveyed, 12
(48%) reported having positive opinions of ESAs. For example, one participant stated, “I think
they are needed and helpful,” with several other participants making similar comments, and
another participant reported, “they can be beneficial with the right situation,” with several other
participants echoing such sentiments. In this sample, five (20%) participants reported having
mixed opinions of ESAs. For example, one participant stated, “divided; I believe ESAs … do
help the client, but I also see many people wanting an ESA letter simply to circumvent things
like pet deposits,” and another participant reported, “I think they are useful at times but
potentially over-utilized as a strategy.” Of the therapists surveyed, five (20%) participants’
opinions were related to wanting more standardization/regulation of ESAs. For example, one
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participant stated, “there should be stronger regulations and requirements for what is considered
an ESA and who can have one,” and another participant reported, “the industry needs to be
regulated at the very least.” In this sample, three (12%) participants reported negative opinions of
ESAs. For example, one participant stated, “it’s too easy to take too far. I wouldn’t want people
bringing random pets like snakes and similar to my office,” and another participant reported,
“strongly negative … every pet is technically an ESA … if not properly trained and have access
to restricted areas, they put service dogs and their owners at very high risk.” Although theoretical
orientation was not a significant predictor of prior or current use of dogs in session, it may be
important to note that all three of the three participants who practice out of an existentialhumanistic approach had positive opinions of ESAs.
Therapist Assessment of ESAs
Participants were asked about how they assess whether a client/patient could benefit from
an ESA. Of 25 therapists, 10 (40%) indicated they refer out/do not assess because it is out of
their scope of practice. For example, one participant stated, “since I’ve learned some about this, I
don’t write these letters since it’s out of my scope.” In this sample, six (24%) participants
indicated they use some variation of clinical judgment. For example, one participant stated, “with
support from [a] psychiatrist and if it was requested by the patient,” and another participant
reported, “they had all been clients of mine for over six months.” Of the participants, five (20%)
indicated if it is clinically indicated/treatment related. For example, one participant stated, “will
it help and can we use it as part of our treatment plan,” and another reported, “determination
based on case conceptualization of [the] therapy client.” Of the therapists surveyed, three (12%)
indicated they take their client’s word for it. For example, one participant stated, “their statement
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of symptoms…” In this sample, one participant (4%) indicated they do not currently assess for
ESAs but stated they “will probably in the future.”
Participants were asked if they had written an ESA letter for a client/patient and for what
accommodations. Of 25 therapists, 13 (52%) indicated they had written an ESA letter for a
client/patient. Of the participants, 13 (52%) indicated they had written letters for
accommodations for living arrangements and one (4%) for work. One participant (4%) reported
they had not yet written a letter, but likely would in the future for accommodations of living
arrangements, work, and transportation.
Participants were asked if they thought ESAs were particularly useful for certain
disorders. Of 25 therapists, 22 (88%) indicated ESAs would be useful for anxiety disorders. In
this sample, 21 (84%) participants indicated ESAs would be useful for trauma and stressorrelated disorders. Of the participants, 19 (76%) indicated ESAs would be useful for depressive
disorders. Of the therapists surveyed, four (16%) indicated ESAs would be useful for cluster B
personality disorders. In this sample, two (8%) participants indicated ESAs would not be useful
for any particular disorders.
Summary
This chapter covered the study’s findings and results. Study setting and participants’
demographics were reviewed. The majority of participants indicated a dog in the therapy session
would have a neutral/positive or calming/comforting impact on the patient/client and on
themselves. The majority of participants reported having positive opinions of ESAs; however,
the majority of participants indicated they do not assess ESAs. Findings aim to bridge the gap in
the literature related to MHPs’ willingness to prescribe ESAs or incorporate AAT into typical
76
practice, and the therapeutic value of AAT within the clinical context. The results of the study
will be discussed and conclusions will be drawn in the following chapter.
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Chapter 5: Summary, Conclusions, and Recommendations
This chapter will cover discussion and interpretations of results and findings of the current
study. Recommendations for future studies, the significance of the current study’s findings, and
limitations of the current study are also included in this chapter. The chapter ends with a conclusion
of the study. A desired sample size of 120 participants was determined by a power analysis using
the software G*Power and using a medium effect size to determine sample size. Unfortunately,
recruitment fell short of this number and there were only 25 participants in the sample. This limits
some of the conclusions that can be drawn and limited the strength of statistical analyses; however,
despite these limitations, there are still some interesting findings.
Interpretation of Findings
Although earlier discussed that the degree the use of dogs within therapy are not
supported by different theoretical orientations, I had hoped the data would show those which
orientations had used dogs in session; however, in the end, none of the analyses showed a clear
indication of that. Part of this problem has to do with the extremely small sample size. For
example, it is notable that all three participants who practice out of an existential-humanistic
orientation had brought a dog into session at some point and were favorable to use, there were
only three therapists representing this theoretical orientation, so it is difficult to come to any solid
conclusions. It would be interesting to see if this finding is unique to the sample or if it would
remain consistent with a larger sample size. Because results were not supported related to
theoretical orientation and use of a dog in session, by nature of the volume of the data, nothing
can be definitively stated.
Results indicated as age increased therapists were more likely to have brought a dog into
the therapeutic session at some point. As previously indicated, the average age of the sample was
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41.16 years old and the average age of participants who had brought a dog into session at any
point was 49.38 years old. This finding could suggest that older therapists typically have greater
experience levels than younger therapists, possibly making them more comfortable as a therapist
and not as concerned with incorporating “outside of the box,” per se, methods into therapeutic
practice. This finding might also suggest a generational change where people are now trying to
be more proper in their role as a therapist. Incorporation of a dog in session is not “by the book,”
per se, which may be seen as less proper in the newer generations of therapists. On that same
token, newer generations of therapists may not be as comfortable in their role as a therapist yet
and may not want to make mistakes.
Relatedly, although degree type was not a significant predictor of whether a therapist had
brought a dog into the therapy session at some point, it seems notable that 57% of participants
who held doctoral degrees had brought dogs into the session while only 22% of participants who
held Master’s degrees had done so. This finding may also have to do with greater comfortability
in the role of the therapist with greater experience levels, as doctoral degrees inherently have
more experience and training in the field.
There was no correlation with any demographic factors with therapist views of the impact
a dog in session would have on the client/patient and on themselves as the therapist, opinions of
ESAs, and procedures for ESA assessment. This may be due to the small sample size. With a
larger sample, such correlations could potentially be seen.
Although there was also no correlation with any demographic factors and opinions of
ESAs, it may be notable to report all three of the three participants who practice out of an
existential-humanistic approach had positive opinions of ESAs. This theoretical lens may
partially explain this. The humanistic approach of empathy, unconditional positive regard, and
79
congruence (genuineness) may assist in creating a space of safety and security, as the client has a
nonjudgmental companion that is in tune with their emotions, provides unconditional love, and is
inherently genuine in nature. These facets of humanistic psychology allow the client to
experience an atmosphere of warmth, safety, and security with another being that can provide
them with mutual attachment, empathy, and love. It is notable to acknowledge that many
participants reported feeling conflicted about ESAs or reported concerns related to the
standardization/regulation of ESAs. Further, in terms of ESA assessment, there was also no
correlation with any demographic factors, but the data suggests much variability in such
procedures. Despite conflicted views and desire for more standardization/regulation of ESAs and
variability in assessment procedures, approximately half of the sample had written ESA letters
for clients at some point in time. All participants who had written letters indicated they had done
so for client accommodations for living arrangements; as previously indicated, the FHA requires
all housing properties allow ESAs regardless of pet policies. These findings would suggest the
need for more training and education around ESAs. They also illustrate the necessity of
standardization and regulation for evaluating whether an ESA is clinically useful for a client to
ensure the strategy is not taken advantage of, as one participant reported such concerns.
Recommendations
The first step to continue building upon this body of literature would be trying to conduct
the study with a larger sample size. The current sample recruited participants from only four
different Facebook groups and it might be possible to get a larger and more representative study
if participants were recruited via other means, such as licensing boards or APA members.
Since much of the study results consisted of qualitative data, the next logical step would
be fine tuning of therapist views. This could be done by developing some sort of questionnaire or
80
measure to assess therapists’ opinions of having a dog in the session (e.g., items measuring
distraction, etc.). Further, a more in-depth interview process would be another first step forward,
such as administering such a measure or questionnaire in addition to an in-person interview. An
in-person interview would allow for more information to be gathered particularly from those
who had used dogs in session. More rich data could be gathered regarding how it has worked,
how it has been incorporated into therapy, how often the dog is there, how clients reacted, and
where the therapist saw it as being helpful or unhelpful/challenging.
With these steps taken, a randomized control trial looking into each of the study facets
could become more achievable. At some point, there needs to be an understanding of whether the
presence of a dog in session is actually beneficial to clients above not having one in the session.
It may be beneficial only for particular populations and not for others, but that information is
unknown right now, illustrating the need for more literature to be added to this body of research.
Implications
This study has started the foundation for another researcher to go back and create a
measure to assess how therapists view having dogs in session. Further, an in-depth in-person
interview can be developed to provide the study with more concentrated qualitative data.
Additionally, in this small and limited sample, a disconnect in the field was captured about how
we assess for ESAs. There is not an agreed upon rubric, it is not highly manualized, and they are
not like service dogs. If there is this much ambiguity of how we assess ESAs, an argument can
be made that moving toward a more standardized way of performing these assessments is
necessary. Since there is a vacuum in the literature, MHPs are left to make assessment decisions
up to their own discretion. Further, the desire for ESAs is also not going to go away, rather it
81
may continue growing, as such trends were previously reported in Chapter 2. Therefore,
assessment for ESAs needs more standardization and regulation.
Limitations
This study was an early foray into better understanding what therapists in the greater
Washington, DC metro area thought about bringing dogs into the therapeutic session and
understanding which variables may be predictive of bringing a dog into the therapy session. Due
to the exploratory nature of the study, there are some notable limitations. The sample size was
small, and geographically limited. Additionally, participants were limited to people who were
not afraid of dogs nor were they allergic to dogs. Finally, the overwhelming majority of
participants were women which also limits generalizability.
The small sample size limited the statistical conclusions as well. It is possible that a
larger sample may have shown differences in whether a therapist brings a dog into the session
based not only on age, but on degree type, and theoretical orientation.
The survey questions were exploratory in nature and many of the open-ended questions
yielded answers that varied tremendously. Some questions were not well understood by
participants, for example participants often answered how having a dog in the session would
affect them as though the question was about how having a dog in the session would affect the
patient.
Despite these limitations, the current study adds to the understanding of what therapists
think about bringing dogs into the session, and gives more information about how therapists
assess requests for ESA letters from their patients. Of particular value are the narrative responses
that the participants reported indicating which conditions they believe ESAs to be helpful for,
82
how they assess whether or not to provide an ESA letter, and their thoughts about bringing dogs
into the therapy session.
Conclusion
Results of therapists’ opinions and perceptions of incorporation of a dog in therapy
sessions and of ESAs was discussed. Age was the only significant predictor of having
incorporated a dog into session. Although other factors were not significant Existentialhumanistic approaches may be more associated with therapists’ positive views of ESAs but in
the current study it was explained by all three theories. There was significant variability in ESA
assessment described by participants in this study, which highlights the necessity of
standardization and regulation of evaluating whether an ESA is clinically useful for a client.
In conclusion, additional research needs to be conducted to determine how to put together
agreed upon universal guidelines for ESAs. Additionally, results of this study offer preliminary
evidence of therapists’ views of AAT incorporation and may aid in an increase in frequency of
use of the intervention and further normalize it as an appropriate treatment approach for a wide
variety of clients. Moving forward, future studies would likely benefit from more contained
surveys and a lack of geographical limitations. Ultimately, a randomized control trial will likely
be the best method to obtain the results this study preliminarily hoped for. Based on study
results, incorporation of animals into treatment appears to be viewed as feasible, which allows us
to look at the topic optimistically for the future.
83
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Appendix: Survey Questions
Exclusion criteria questions:
1. Are you afraid of dogs?
a. Yes
b. No
2. Are you allergic to dogs so much that you cannot be around them?
a. Yes
b. No
3. Are you a practicing mental health professional in the tri-state area of DC, VA, and MD?
a. Yes
b. No
4. Are you licensed in any of the following areas?
a. DC
b. MD
c. VA
d. All of the above
e. None of the above
Included participants questions:
1. What is your gender?
a. Female
b. Male
c. Transgender
d. Other (please specify)
i. *Space to specify*
2. What is your age?
a. *Write in age*
3. Describe your cultural/ethnic background.
a. *Free response*
4. What type of degree do you have?
a. PsyD
b. PhD in Clinical Psychology
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c. PhD in Counseling Psychology
d. Master’s in Social Work
e. Other (please specify)
i. *Space to specify*
5. When did you graduate with your terminal degree?
a. *Write in date*
6. What age were you when you graduated with your terminal degree?
a. *Write in age*
7. When did you get licensed?
a. *Write in date*
8. What is your primary theoretical orientation?
a. CBT
b. Psychodynamic
c. Family Systems
d. Existential-Humanistic
e. Other (please explain)
i. *space to explain*
9. How long have you been practicing as a licensed mental health professional?
a. *Write in years*
10. Do you have your own practice, or do you work for someone else?
a. Own practice
b. Someone else
11. Have you ever brought a dog into a therapy session?
a. Yes
b. No
12. Do you currently bring a dog into therapy sessions?
a. Yes
b. No
13. What do you think about having a dog in a therapy session?
a. *Free response*
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14. How do you think patients would react to having a dog in a therapy session?
a. *Free response*
15. What impact do you think the presence of a dog in a therapy session would have on you?
a. *Free response*
16. What impact do you think the presence of a dog in a therapy session would have on the
patient?
a. *Free response*
17. Would you want to have a dog in your therapy sessions with patients? Why or why not?
a. Yes
b. No
c. *Space to explain*
18. What benefits, if any, would there be having a dog in the therapy session?
a. *Free response*
19. What concerns or problems, if any, would there be having a therapy dog in the therapy
session?
a. *Free response*
20. What is your opinion on Emotional Support Animals (ESAs)?
a. *Free response*
21. How many letters, if any, have you written for a patient explaining why they need an
ESA for their living arrangement (e.g., apartment), work, transportation, etc.? (An
estimation is fine)
a. *Free response*
22. For what accommodations did the ESA cover? (Check all that apply)
a. Living arrangements
b. Work
c. Transportation
d. Other (please specify)
i. *Space to specify*
23. How do you assess whether or not someone needs an ESA?
a. *Free response*
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24. Have you ever declined to write a letter for a patient who asked for one, and if so, why?
a. Yes
i. *Space to explain*
b. No
25. Do you think ESAs are particularly useful for certain types of disorders?
a. Anxiety disorders
b. Depressive disorders
c. Trauma and stressor related disorders
d. Cluster B personality disorders
e. Other (please specify)
i. *Space to specify*