Have you ever looked deep into the eyes of an animal and felt entirely known? Often, the connections weshare with nonhuman animals represent our safest and most reliable relationships, offering unique andprofound opportunities for healing in periods of hardship. This book focuses on research developments,
models, and practical applications of human-animal connection and animal-assisted intervention fordiverse populations who have experienced trauma. Physiological and psychological trauma are exploredacross three broad and interconnected domains: 1) child maltreatment and family violence; 2) acute andpost-traumatic stress stemming from military service, war, developmental trauma, and other sources; and3) times of crisis, such as the ever-increasing occurrence of natural disasters, community violence and terror,
injustice, and anticipated or actual grief and loss.
Contributing authors, who include international experts in the fields of trauma and human-animal
connection, explore how our relationships with animals can help build resiliency and foster healing totransform trauma. The inclusion of animals in a variety of formal and informal models of trauma recovery
and emerging practice is discussed in depth, with particular attention paid to canine- and equine-assisted
interventions and psychotherapy. Of central focus are the potential impacts to animals who provide
trauma-informed services, and how we can both respect their participation and implement best practices andethical standards to ensure their well-being. As animals play important roles all over the world, cross-culturaland often overlooked animal-assisted and animal welfare applications also are highlighted throughout the text.

TEDESCHI
and JENKINS

Edited by Philip Tedeschi and Molly Anne Jenkins
Foreword by Dr. Bruce D. Perry“Transforming Trauma is a book that many people have long been waiting for. The outstanding originaltransdisciplinary essays written by renowned scholars cover a wide array of topics, all of which focus on
nonhuman animals’ ability to help us learn the importance of forming and maintaining deep, meaningful,and reciprocal relationships with them and other human animals.”— Marc Bekoff, author of Canine Confidential: Why Dogs Do What They Do“Tedeschi and Jenkins have produced the go-to sourcebook on the role of animal-assisted interventions forchildren and adults coping with the debilitating effects of psychological trauma. With diverse and engaging
contributions from international experts in the field, Transforming Trauma fills an important gap in the AAI/
anthrozoology literature, and it does so with considerable insight and compassion, not only for the humanvictims of trauma, but also for the animals who help them on the road to recovery.”— James A. Serpell, Professor of Animal Welfare and Ethics, University of Pennsylvania
School of Veterinary Medicine“Tedeschi and Jenkins’ new book on trauma and AAI is more than a must-have addition to the field. Besides
being an extensive compendium of the state of the art and the science behind it, the volume includes serious and refreshing discussions about our responsibilities to the animals involved in AAI and how we canevaluate their welfare. Read this book if you are interested in healing trauma in humans, preventing it inanimals, and the science behind AAI. It’s a winner.”—Patricia McConnell, PhD & CAAB Emeritus, author of The Education of Will

New Directions in the Human - Animal BondPURDUE UNIVERSITY PRESS

West Lafayette, Indiana
www.press.purdue.edu

Ë|xHSLFPHy537959zv;:%:#:*:;
ISBN: 978-1-55753-795-9

USD $42.95

PURDUENEW DIRECTIONS IN THE HUMAN-ANIMAL BOND
Series editors: Alan M. Beck and Marguerite E. O’Haire, Purdue University
A dynamic relationship has always existed between people and animals.
Each influences the psychological and physiological state of the other. This
series of scholarly publications, in collaboration with Purdue University’s College
of Veterinary Medicine, expands our knowledge of the interrelationships between
people, animals, and their environment. Manuscripts are welcomed on all aspectsof human-animal interaction and welfare, including therapy applications, public
policy, and the application of humane ethics in managing our living resources.
Other titles in this series:
A Reason to Live: HIV and Animal Companions
Vicki Hutton
That Sheep May Safely Graze: Rebuilding Animal Health Carein War-Torn Afghanistan
David M. Sherman
Animal-Assisted Interventions in Health Care Settings: A Best Practices Manualfor Establishing New Programs
Sandra B. Barker, Rebcca A. Vokes, and Randolph T. Barker
Moose! The Reading Dog
Laura Bruneau and Beverly Timmons
Leaders of the Pack: Women and the Future of Veterinary Medicine
Julie Kumble and Donald F. Smih
Exploring the Gray Zone: Case Discussions of Ethical Dilemmas for the
Veterinary Technician
Andrea DeSantis Kerr, Robert “Pete” Bill, Jamie Schoenbeck Walsh,
and Christina V. Tran
Pet Politics: The Political and Legal Lives of Cats, Dogs, and Horses in Canada
and the United States
Susan Hunter and Richard A. Brisbin, Jr.
Free Market Dogs: The Human-Canine Bond in Post-Communist Poland
Michał Piotr Pręgowski and Justyna Włodarczyk
Teaming With Your Therapy Dog
Ann R. HowieCome, Let Me Guide You: A Life Shared With a Guide Dog
Susan Krieger
Animal Cruelty and Freedom of Speech: When Worlds Collide
Abigail Perdue and Randall Lockwood

Edited by Philip Tedeschi and Molly Anne Jenkins
Foreword by Dr. Bruce D. Perry

Purdue University Press, West Lafayette, Indiana

Copyright 2019 by Purdue University.
Printed in the United States of America.
Library of Congress Cataloging-in-Publication Data
Names: Tedeschi, Philip, 1961– editor. | Jenkins, Molly Anne, 1979– editor.
Title: Transforming trauma : resilience and healing through our connections
with animals / [edited by] Philip Tedeschi, Molly Anne Jenkins.
Other titles: New directions in the human-animal bond.
Description: West Lafayette, Indiana : Purdue University Press, [2019] |Series: New directions in the human-animal bond | Includes bibliographicalreferences and index.
Identifiers: LCCN 2019008633 | ISBN 9781557537959 (pbk. : alk. paper) |ISBN 9781612495200 (epub) | ISBN 9781557538505 (epub open accessknowledge unlatched) | ISBN 9781612495194 (epdf )Subjects: | MESH: Animal Assisted Therapy — methods | Trauma and Stressor
Related Disorders — therapy | Bonding, Human-Pet | Resilience, PsychologicalClassification: LCC RM931.A65 | NLM WM 450.5.A6 | DDC
615.8/5158 —​ dc23 LC record available at https://lccn.loc.gov/2019008633
An electronic version of this book is freely available, thanks to the support of libraries working with Knowledge Unlatched. KU is a collaborative initiative designed
to make high-quality books Open Access for the public good. The Open AccessISBN for this book is 978-1-55753-850-5.
Cover image: “Safe” by Elicia Edijanto, 2014, watercolor on paper. From the artist:“My art is my cathartic release, just like a journal or diary where I can share myfeelings. For me, nature is always the best remedy. River flowing, herd of horses
running, sun setting, moving grasses of the savanna, and so forth can always bring
tranquility and reassure my mind. The relationship between human and animals
and nature is very beautiful. I use children and animal as my subjects because
they’re honest and sincere. They both have inimitable compassion toward eachother. It’s so easy to catch the subtleties in their gestures and expressions because
they’re unpretentious. Back in the old days, we used to live in nature, side by sidewith all its elements—human, animals, plants, in harmony. We used to live inbalance and complement each other. This thought has such a calming effect onme, and when I put it in a painting, I feel a wonderful peace inside. I want people
to feel it too. I want to share this beautiful feeling.”

Dedications
Philip Tedeschi
Some of my most trusted and reliable friends are nonhuman animals.
Fortunately, in my own life, the human-animals who raised and loved me
were trustworthy as well. I want to express my deepest gratitude to myparents — John and Anne Tedeschi, both inspired intellectuals and scholars — whose commitment to issues of social justice, respect for others, andlearning is only surpassed by the love they have for their children. In thesafe harbor of our home, my sisters and I were encouraged to learn, to thinkfor our ourselves, and to seek adventure and exploration. Throughout mylife, these gifts have helped me connect with animals and the natural world,
as well as raise a family of my own. This book and its penetrating message
of wonder and hope is dedicated to the loves of my life: my wife, Rebecca
Albright, and my children, Gemma, Ruby, and Micah Tedeschi. You power
my world, and it has been my genuine honor to share this life with you.
My heartfelt gratitude goes out to my fantastic colleagues and theindomitable team at the Institute for Human-Animal Connection at theGraduate School of Social Work, University of Denver. You are many andyou know who you are. Namaste.
Molly Anne Jenkins
I owe a great debt of gratitude to my dear ones — both human and animal,
too many to count or mention here — who offered insight and surrounded
me with encouragement throughout the creation of this most excitingbook. Thank you, Phil, for always inspiring me to come into my own andto take the conversation in new, unexplored directions. To mom, my first
editor: thank you for your unwavering dedication to the causes that matter,for your support of me and my writing, for giving me Riley when I neededhim most. With all my love, I dedicate the pages that follow to my sweet
little family — Queenie, whose friendship swells my heart; Murray, whokeeps me ever on my toes; and my wondrous Nick, who believes in me
and says so, day in and day out.

Contents
Foreword
Bruce D. Perry, MD, PhD

xiIntroduction
Human Trauma and Animals: Research Developments,
Models, and Practice Methods for Trauma-Informed
Animal-Assisted Interventions
Philip Tedeschi, MSSW, LCSW; and Molly A. Jenkins, MSW, AASW

1

Chapter 1
The Impact of Human-Animal Interaction in Trauma Recovery
Marguerite E. O’Haire, PhD; Philip Tedeschi, MSSW, LCSW; Molly A. Jenkins, MSW, AASW;
Sally R. Braden, MSW, AASW; and Kerri E. Rodriguez, MS

15

Chapter 2
Advocacy and Rethinking Our Relationships With Animals:
Ethical Responsibilities and Competencies in Animal-Assisted
Interventions
Zenithson Ng, DVM, MS, DABVP (Canine and Feline)

55

Chapter 3
Clinical Objectives for Animal-Assisted Interventions: Physiologicaland Psychological Targets in Trauma-Informed PracticeAndrea M. Beetz, MA, PhD; and Ira Schöfmann-Crawford, MA
91
Chapter 4
Implications of Animal-Assisted Psychotherapy for the Treatmentof Developmental Trauma Through the Lens ofInterpersonal Neurobiology
Nancy Parish-Plass, MA; and Jessica Pfeiffer, LCSW, SSW
123
vii

viii

TRANSFORMING TRAUMA

Chapter 5
The Power of Play and Animals: Animal Assisted Play Therapy asan Integrative Practice Model for Mental Health TreatmentRisë VanFleet, PhD, RPT-S, CDBC
189
Chapter 6
Children and Animals: The Importance of Human-Other Animal
Relationships in Fostering Resilience in Children
Sarah M. Bexell, PhD; Susan Clayton, PhD; and Gene Myers, PhD217
Chapter 7
The Healing Power of Nature: The Impact of Interventions
in Farm Settings
Michael Kaufmann; Miyako Kinoshita, M.S.Ed.; and Susan Puckett Teumer, MA

241

Chapter 8
Horses in the Treatment of Trauma
Nina Ekholm Fry, MSSc., CCTP

265

Chapter 9
Why the Dog?
Ann R. Howie, MSW; Aubrey H. Fine, EdD; and Lindsay A. Rojas, LSW, MSW, AASW

299

Chapter 10
Animals in Action: Therapeutic Roles in Healing Military Trauma
Cheryl A. Krause-Parello, PhD, RN, FAAN; Allison E. Boyrer, MS, MA, BSN, RN;
and Eleni Padden, BA
327
Chapter 11
The Battle for Hearts and Minds: Warrior Canine Connection’s
Mission-Based Trauma Recovery Program
Rick A. Yount, LSW; Robert Koffman, MD; and Meg D. Olmert

355

Chapter 12
Animal-Assisted Crisis Response: Offering Opportunity for Human
Resiliency During and After Traumatic Incidents
Raquel Lackey, CGA, CMA, CGMA; and Gehrig Haberstock, MSW, AASW
373
Chapter 13
Loss, Grief, and Bereavement in the Context of
Human-Animal Relationships
Susan Cohen, DSW; and Adam Clark, LCSW, AASW

395

Contentsix

Chapter 14
The Global and Cross-Cultural Reach of Trauma-Informed
Animal-Assisted Interventions
Betty Jean Curran, LMSW, AASW; Molly A. Jenkins, MSW, AASW;
and Philip Tedeschi, MSSW, LCSW

423

Conclusions
Molly A. Jenkins, MSW, AASW; and Philip Tedeschi, MSSW, LCSW

463

Selective Index

475

Foreword
Trauma, resilience, healing, and connection—these words have permeatedthe young field of traumatology for the last thirty years. Indeed, hundredsof articles, book chapters, and books have these words in the titles; thousands of researchers and clinicians study and write about trauma, resilience,
connection, and healing. Yet the current book is so important because ofa unique and powerful lens applied to these issues—the human-animal
relationship. The capacity of human-animal interactions to play a central
role in the therapeutic approach to trauma is, at once, ancient and unappreciated. These authors are pioneers. They share their thoughts andexperiences in these chapters. This is a refreshing perspective in the current
climate where the “evidence-based” loop tends to inhibit creative exploration of promising clinical practices. Evidence of effectiveness is essential
for us to move our field forward; yet, without systematic exploration ofplausible practice and program elements, no progress will take place. And
what could be a more plausible and effective source of healing than thatprovided by centuries of convergent evidence, independently collectedfrom multiple cultures on different continents?
This capacity for strong, nurturing (and helping) relationships is an
essential element of therapeutics. In studies of the effectiveness of therapy,
one common (and most powerful) factor emerges: the capacity to forma helping relationship is the best predictor of outcomes independent ofclinical technique or therapeutic perspective. Reflect a moment on theintense emotional connections between humans and animals—you may
have one yourself. Our literature and arts celebrate these relationships—
Black Beauty, National Velvet, The Black Stallion, Old Yeller, One Hundred
and One Dalmatians—and remember Toto, Lassie, and so many more.

xi

xii

TRANSFORMING TRAUMA

It stands to reason then, that the human-animal connection could be
used for therapeutic purposes. The rationale and practice are outlined
throughout this book.
Another emerging, important factor in therapeutic work in trauma
is the importance of regulation as a key factor in effective engagement.
A dysregulated child (or adult) is difficult to connect with and impossible
to reason with. And, of course, a sensitized, overly reactive stress response isa major characteristic of most trauma-related syndromes. This sensitization
frequently interferes with the capacity to utilize any cognitive dominantinterventions (e.g., Trauma-Focused Cognitive Behavioral Therapy or TFCBT). The organization of the central nervous system (CNS) is such thatall sensory input (read as “all experience”—including therapeutic engagement) first is processed and, if appropriate, acted on by lower, more reactive
networks in the brainstem and diencephalon before limbic and cortical
networks have a chance to process or act. This means a clinician attempting
to engage a dysregulated individual with these lower neural networks on
hyperdrive will be fundamentally frustrated. The sequence of engagement
dictated by our neuroanatomy is to regulate first, then relate, and thenreason. Our capacity to get to the most important and most “human”
part of our brain depends upon a minimal level of regulation. Enter man’s
coevolutionary partners, the dog and horse.
In the codependent evolution of humankind and animals, dogs, specifically, were major regulators for humans. For possibly 32,000 years,
humans and dogs have depended upon each other. When a known dog
is present and projecting nonverbal, nurturing signals, part of the humanbrain knows “the camp is safe.” Dogs, with their superior capabilities inhearing and smell, expanded the sensory alarm radius for their human clan
dramatically. Deep in our brain we know that if the dog is relaxed andplayfully engaged, we are safe. The mere presence of a calm dog will calm
us down. In contrast, a shift in vigilance or an alarm bark tells us somethingis afoot. Similar shifts in a horse’s behavior can have comparable impact on
our regulatory state. The horse has been our coevolutionary partner for lesstime than dogs, probably 8,000 years or so, but this capacity to read andrespond to the subtle emotional cues of a human in ways that are regulating
and reassuring is equally strong. Certainly, this coregulatory capacity is amajor component of therapeutic work with animals.
A second and equally important regulating element of interacting with
our animal partners is the impact that repetitive, rhythmic somatosensory

Forewordxiii

activity has on our stress-response systems. Petting, grooming, riding, andwalking with our animals will provide a powerful regulating rhythmic
input that is known to calm a dysregulated individual.
The combination, then, of human-animal connectedness to regulate
and relationally engage (relate) provides a perfect matrix for the therapeutic process with an individual experiencing trauma. This is most helpful
if the trauma has been in the context of early life relationships resulting
in attachment problems; in these cases, the individual has developed human-specific relational evocative cues that can disrupt attempts to use
traditional therapies that are relationally mediated. The client will be escalated and dysregulated by attempts to “connect.” In these situations, theanimal-specific sensory cues that are present during the regulating and relationship-building processes are not “evocative” and disruptive. The client
can engage, learn, grow, and heal in context of the human-animal relationship, preparing them for healthier human connectedness in the future.
The authors of this book provide an exciting and promising exploration of the power of our connections to animals. These ancient andimportant connections may prove to be some of our most effective andflexible ways to engage and heal. Certainly, these insights will improve
our current limited capacity to meet the needs of the vast numbers ofmaltreated and traumatized children, youth, and adults.
Bruce D. Perry, M.D., Ph.D.
Senior Fellow, The ChildTrauma Academy, Houston, TX
Professor (Adjunct), Department of Psychiatry and Behavioral Sciences,
Feinberg School of Medicine, Northwestern University, Chicago, IL
Professor (Adjunct), School of Allied Health, College of Science, Healthand Engineering, La Trobe University, Melbourne, Victoria, Australia

INTRODUCTION

Human Trauma and Animals:
Research Developments, Models, andPractice Methods for Trauma-Informed
Animal-Assisted Interventions
Philip Tedeschi, MSSW, LCSW; and Molly A. Jenkins, MSW, AASW

Throughout the writing and editing of this book, Samara has been by ourside, providing levity and support through countless brainstorming sessions, discussions, and rewrites. Her head and body are generally pointed inour direction, even through the snores that characterize her deepest sleep.
With just a small squint of her resting eyes, we take comfort in knowing she is observing our various actions, behaviors, and moods — rarely
missing a thing or skipping a beat. Samara is a black Labrador retriever
who lives and works with Philip Tedeschi, and plays an integral role atthe University of Denver’s Graduate School of Social Work. Through ourcollective time together on this project, she has taught the two of us a greatdeal. Originally adopted from Colorado’s Prison Trained K9 Companion
Program (PTKCP), Samara now works with students in our graduate-levelanimal-assisted social work program, with several other clinical assignments
ranging from visiting with children who have experienced developmental
trauma to assisting adults with persistent mental illness and homelessness. As such, we have spent a lot of our time with her, and although weknow dogs as a species well, we are routinely amazed by her intuition andemotional attunement, as well as her personality, which seems to be fully
1

2

TRANSFORMING TRAUMASamara in her element: wide open spaces.

committed to our work of caring for people and educating students. It isdifficult not to be amazed by the patience and level of consistency she offers
to establish her side of a relationship. On most days, you can be sure you’ll
find her right in the thick of it.
ORIGINS
Every book concept has a birthplace. This particular book has two influential origins that captured our attention, and increased our alreadyardent interest in exploring how animals consistently play a profound andfacilitative role in human trauma recovery. However, the pages that follow
are not so much a story of our own journey to explore this topic as a significant window that we hope both frames and clarifies a paradigm in needof greater understanding. In the process of editing this volume, we haveencountered many important concepts, new findings, and influences, all ofthem shaped by intimate testimonials, accounts of actual implementationof programs and practices, and emerging and well-established research. We
are pleased to be able to present the meaningful and varied work of eachof the contributing authors in the forthcoming chapters.
One of the first catalysts for this book was a conference entitled,“Transforming Trauma: Research Developments and Methods for TraumaInformed Animal-Assisted Interventions,” held in 2015 at the Universityof Denver and organized by the Institute for Human-Animal Connection

Human Trauma and Animals3

as part of the “Animals on the Mind” Conference Series. The Institutefor Human-Animal Connection has existed at the University of Denver(housed in the Graduate School of Social Work) since 2007. This conference offered two days of focused presentations on contemporary research
to practice models to illuminate the discourse and new research directions
occurring in the field of human-animal interaction (HAI). Overall, thislearning event was an impactful step toward highlighting the emerging
evidence basis for animal-assisted intervention (AAI) in a variety of trauma
recovery domains, including developmental trauma, adult post-traumaticstress, and crisis response.
Equally important were the compelling accounts among conference
participants, many of them students, who frequently shared a resolute certainty regarding the power and transformative capacity of human-animal
connection. More often than not, these participant convictions stemmed
from personal experiences where animals and animal relationships served
as critical elements in their own recovery, in some cases literally saving theirlives. Over the last decade, many students enrolled in the animal-assistedsocial work program at the University of Denver (in which Tedeschi directs
and Jenkins graduated and serves as affiliated faculty) have shared that
their interest in incorporating animals into social work and therapeutic
settings emanated from personal experiences where an animal helped themcope and find the resilience to move forward from the impacts of childabuse, parental divorce, and grief related to other losses (among others).
It is difficult to argue with someone who has personal experience as his or
her proof of concept, much less many “someones.” These powerful personal testimonials of human-animal connection, as well as an intention toenrich the AAI field’s understanding and therapeutic application of them,
have offered important emphasis in shaping the focus and narratives ofthis book.
THE ETHICS OF HUMAN-ANIMAL CONNECTION
Above all, we hope the most powerful takeaway from this volume will
be a commitment toward an emerging new ethical mandate in AAI. It is
inevitable in the offering of a book such as this, where we have examinedwith some detail the complex situations in which we place animals, towonder if we should, in fact, be promoting these activities. For example, we might wonder what it is like to be a dog who is assigned to live

4

TRANSFORMING TRAUMA

with an angry, depressed, or potentially suicidal individual diagnosed with
post-traumatic stress disorder (PTSD), or who is asked to respond to theinconsolable grief of a community responding to the losses inflicted after
a school shooting. In compiling this text, we have been humbled by theremarkable capacity of animals to be at our sides, often through no choiceof their own, during these moments of adversity. Nevertheless, we are justas certain that sustained practice and research improvements are essential
to ensuring that our expectations of animals who take part in this work
are fair, reasonable, and informed.
In the chapters to come, you will likely find agreement among thecontributors that we must offer optimum support for animal well-beingin AAI, and that our current welfare standards — developed to support
visiting therapy dogs through the application of basic animal welfare standards, such as the Five Freedoms — will no longer suffice to fully meet our
obligation. The worst possible outcome of this amazing field of HAI would
be to succeed in our pursuit for evidence that animals do in fact improve
human health, but then systematically launch yet another problematic andexploitative mode of interacting with them on a large scale. The risk that
this could be an unintended outcome of progress developments within
the field is likely. We say this because human-centric agendas often fail tobuild in adequate, critical review from the perspective of how our actions
impact nonhuman animals. In the context of trauma response, it may beeven more likely that the consideration offered to the animals involved
might be overshadowed by the gravity of responding to the crisis or to
the intensity of need among human clients. As we move forward with theprocesses of defining the potential of HAI, developing and continuously
refining AAI protocols to support effective intervention, and documenting outcomes through improved scientific study, we must also seek — as a
stipulation — a rethinking of our relationships with other animals and our
ethical obligations as stewards of their comfort and well-being.
THERAPEUTIC EFFECTS OF HUMAN-ANIMAL INTERACTIONSAND EMERGING PRACTICES
Throughout this book, every effort was made to articulate and examine
the unique, therapeutic, and diverse ways that animals seem to help humans overcome trauma. The AAI field is growing in remarkable ways.
Importantly, the significance of the origins for this book’s development isHuman Trauma and Animals5largely based on the current prevalence of AAI practice, with thousands ofprograms, nationally and internationally, beginning to incorporate animals
for specific human health objectives and outcomes. This increase in interest may be due, at least in part, to the challenges encountered in finding
effective treatment for persons who have experienced trauma, includingthat which is associated with the complexity of decades of war; various
forms of child maltreatment; large-scale disaster, violence, and inhumanity;and mass victim events. This difficulty might be especially true in casesof treatment-resistant forms of trauma, as well as large numbers of people
needing services with urgency due to high rates and risk of suicide. For example, the Veteran’s Administration Health Care System (VAHCS) reportsthat 50% of clients with PTSD admitted to its evidence-based programs
quit within the first three sessions, with 66% of those who actually completed treatment still meeting the criteria for a PTSD diagnosis (National
Intrepid Center of Excellence, 2014).
Increasingly, research suggests that HAIs have a positive impact onhuman emotional health. A prominent conclusion is that HAI provides
overall emotional support, and correlates with reductions in depression,anxiety, and stress (McCardle, McCune, Griffin, & Maholmes, 2011).
Some researchers suggest that the reason for AAI’s success is rooted in
an animal’s ability to create relationship, offer affection, and provide aless-threatening opportunity to connect with the helper or intervention(Kruger & Serpell, 2006). There is general consensus in the field that AAI’s
quality of enhancing rapport-building between client and therapist is oneof the greatest strengths that animals offer in trauma-informed settings(Beetz, 2017). For instance, AAI can be employed to develop safety in thetherapeutic alliance and increase the retention of clients, both of which
serve as significant challenges in trauma treatment. Enhanced motivation
increases retention, which is the best predictor of positive results, increased
likelihood of bonding with treatment providers, actively participating intreatment, and endorsing treatment goals (Lefkowitz, Paharia, Prout,
Debiak, & Bleiberg, 2005).
Moreover, animals are often perceived as being more genuine than humans, given that they do not hold human biases (Chandler, 2005; Pichot& Coulter, 2007). In this way, clients often trust a therapy animal more
readily than they do humans, and this can serve as a precursor to developing
trust with a human therapist. The presence of an animal may also reducethe client’s overall anxiety about being in treatment, and offer additionaland regular opportunities to have a client reevaluate the trustworthiness6

TRANSFORMING TRAUMA

of his or her therapist. In addition, the therapeutic animal may provide
the client with a surrogate for therapeutic touch, allowing for the use ofphysical touch in an ethical and appropriate manner (Chandler, 2005).
ANIMALS’ ROLE IN GROWTH AND RESILIENCEIN TRAUMA RECOVERY
What happens when we are not able to trust people? Or when a life eventso completely shakes the foundation of our willingness to have humanrelationship that a traditional therapeutic “trusting relationship” is nolonger a viable approach to therapeutic intervention? These types of deep
trauma experiences have the potential to establish long-term patterns offunctioning that can interfere with an individual’s normal development
and healthy living. For example, childhood trauma can disrupt normative
emotional development, as well as negatively influence a child’s ability toexperience emotional security (Perry, 2008). Childhood trauma is associated with biological stress reactions that influence brain development andcan disrupt motor, emotional, behavioral, language, social, psychosexual,
moral, and cognitive skill development. In turn, challenges to behavioral
and emotional regulation contribute to disruption in attachment and likely
impact all relationships throughout the life span. These developmental
disruptions can leave a child at risk for developing internalizing disorders,such as separation anxiety disorder, dysthymia, major depressive disorder,and externalizing disorders (e.g., attention deficit hyperactivity disorder or
ADHD and oppositional defiant disorder) (van der Kolk, 2002). Notably,
they may also result in a diagnosis of PTSD.
Increased research and scholarship in this area appears regularly, anda significant level of interest seems directed at the potential that animals
offer for recovery and resilience in response to trauma. Research methods
have expanded to explore the underlying mechanisms at work, including
the changes that animals can have on our physiological and neurobiological
functioning (Beetz, 2017). Time and again, people also reflect that the presence of a trusted nonhuman animal allows them to experience the comfort
that comes only from feeling physically and emotionally safe; indeed, theimportance of feeling safe with animals in trauma recovery is highlighted
throughout the chapters of this book, and even influenced our choice ofcover art (“Safe,” by Elicia Edijanto) and design. Further, animal-assisted
treatment of complex trauma, and particularly as it manifests in PTSD, isHuman Trauma and Animals7

at the forefront of clinical research and public discourse, particularly given
the increasingly visible social challenges amongst post-9/11 veteran andactive service member communities.
Within this text, we have utilized in places the concepts of resilienceand post-traumatic growth. These concepts remain somewhat controversial,in part because they lack the full authority of significant evidentiary support. Briefly defined, post-traumatic growth (or PTG) suggests that trauma
for some persons, and under some circumstances, is beneficial (including
psychologically and physically), with recognition that trauma is not experienced uniformly and that not all individuals react to trauma experiences inthe same way. Resilience has been described as “the ability of an individual,family, group, community, or organization to recover from adversity andresume functioning even when suffering serious trouble, confusion, or
hardship” (Kirst-Ashman & Hull Jr., 2012, p. 22). Presumably, developing
or emphasizing a person’s resiliency following the adverse event(s) may
improve his or her well-being, and ease the challenges and symptoms ofthe trauma so that the person may achieve a higher level of functioning
and, thus, quality of life. That is to say, greater resiliency may lead to PTG.
Through experience, research, review, and discussion of material, we
have encountered the inclusion of animals (companion, therapy, service,and those living in nature) in the lives of individuals as offering opportunity for significantly improved functioning. As such, we postulate that
one reason why animals may be so helpful in trauma recovery is because of
their capacity to foster resiliency in those affected. Throughout this book,
we hope that readers will consider the following questions time and again:
1) What factors might impact the reframing of PTSD to PTG? and 2) Is
the presence of, or connection with, an animal a significant or particular
contributor to this transformative process?
RESEARCH AND IMPLEMENTATION SCIENCE
The primary purpose of research is to test theories through the disciplineof sustained and sound inquiry, thereby building authoritative scientificknowledge. Clear terminology, testable protocols, and robust objective measures that underpin strong methodological evaluation are all advantageous
research components. Like other AAI investigators before us, we will fallshort here in establishing absolute certainty and specificity in regard to particular models, and in providing unassailable endorsement of their scientific,

8TRANSFORMING TRAUMA

clinical, and practical applications. We will, however, begin to see appearing
from the underbrush of these chapters, concepts that hold consistency andstructure, have basis in existing practice and research, and offer promise as
emerging trauma-informed interventions that deserve our attention.
In virtually every article published in the existing HAI literature, theauthor bemoans the scarcity of supportive research and calls for more.
But more of what, exactly? From our perspective, the needs that continue
to hamper AAI and HAI research efforts, primarily, are related to a lackof monetary (and other resource), innovation, and implementation support. Recent trends in funding new research with rigorous standards, while
well-intentioned, may inadvertently have their own drawbacks, particularly
in terms of feasibility and practicality. Therefore, in addition to meeting
expectations for refined research with scientific gold standard, we may also
want to refocus on — and fund — more testable theories and methodologies in order to boost the certainty in these ideas and the impact of theseinterventions.
As alluded to above, there exists a significant research-to-practice gap
in the field of AAI, in that practical applications often fail to be manifested
in reproducible fidelity to the research models or protocols. The inclusionof animals in trauma-informed programs is diverse in both practice setting and client population. As the field moves forward to investigate thehealth-related potential of AAI, it is clear that the evidence base needed toensure that treatment models are effective and implemented with quality
has not kept pace with expansions in practice. Furthermore, individualorganizations involved in delivering AAI often have limited capacity for
program and staff development, quality implementation, and practice evaluation, all of which can affect the quality and efficacy (or lack thereof )of the wider field. Researchers are likewise hindered as a result of thisresearch-to-practice gap because they are often attempting to examine interventions that are loosely defined and/or inconsistently administered.
Thus, we contend that greater emphasis on “real-world” research, as wellas increased resources to bring these findings into implementation, arecritical to consider as the field continues its growth in the areas of trauma
treatment and recovery.
On the whole, two new goals of investigative research in trauma-​informed
AAI settings should be to establish a general, consensus-based literacy related to the underlying conceptual frameworks that can inform practitioner
training programs, and to examine specific methods under which thisHuman Trauma and Animals9knowledge might be utilized to achieve greater methodological fidelity
and approaches to evidence-based practice outcomes in AAI. As editors,
we attempted to ensure that each chapter offers clear, coherent, and factual
content. However, given that this emerging field of trauma-informed AAI
is still in an “information-gathering phase” of sorts, we did not attempt
to substantively change the terminology or central concepts presented byeach author or set of authors.
As such, we realize and have accepted that the discussion of certain
concepts — specifically related to the definitions, use, and application of
select terminology (e.g., the biophilia hypothesis) — will differ somewhat
due to the divergent approaches and professional backgrounds of our contributing authors. As editors, we might have approached this challenge
by forcing a shared definition and set of formal agreements on the useof these key terms. Instead, we were compelled to offer the flexibility foreach contributor to discuss these terms in his or her distinct and intentional manner (as long as accuracy was maintained). Although this may
require an expansive intellectual effort on the part of the reader, we haveconcluded it may, in time, serve to offer a more robust and comprehensive understanding of these core concepts at this early stage in the field’s
growth. Eventually, we believe that requiring a shared set of definitions
and terminology will likely be important and worth seeking agreement forthe purpose of accurate translation, as well as the enhancement of practiceand research protocols. At the same time, we support the need to create
sufficient space to explore the diversity of ideas and models, and to allow
for innovation and integration of new knowledge. We hope that the use ofterminology and concepts in this volume offers adequate attention to bothof these objectives, and that the diversity of thought strengthens, rather
than hinders, the ultimate potency of the text.
CONCLUSION
In the following chapters, we are honored to introduce you to our contributing authors whose insight and generosity of spirit in sharing theirideas we wish to acknowledge and celebrate. They represent a diverse andhighly qualified array of experts on the topics offered. In this volume, we
and our contributors will primarily focus on three categories of humantrauma experience: 1) child and family violence; 2) crisis response and10

TRANSFORMING TRAUMA

intervention; and 3) post-traumatic stress, particularly among military
service members and veterans. As discussed earlier, this compendium ofchapters and associated ideas were not written with the intention thatthey would necessarily coalesce with one another or be vetted for agreement between authors. It is, however, our hope that the organization ofchapters builds toward consilience of a more integrated knowledge onthese subjects.
Edward Wilson has stated that “the greatest enterprise of the mind
has always been and always will be the linkage of the sciences and the humanities” (Wilson, 1998, p. 9). He reflects openly on the limitations andfragmentation that often define our approach to education, scholarship,and research, and in turn, presents a stunted way in which we tend to gain
knowledge and understanding. In an effort to address these challenges,
Wilson imagines a process that reaches far beyond transdisciplinary integration. He indicates that the concept of consilience occurs when inductive
knowledge obtained from one core branch coincides with another, allowing
for the true testing of theory. According to Wilson (1998), “the strongest
appeal of consilience is in the prospect of intellectual adventure and, given
even modest success, the value of understanding the human condition witha higher degree of certainty” (p. 9).
Here, we feature contributions from a diverse set of professions anddisciplines. To name a few, we have academics involved in the social andbiological sciences; practitioners in education, psychotherapy, and humanand nonhuman medicine and public health; and clinicians serving thecontinuum of the human condition across the life span. This book’s contents include those proffered by scientists oriented toward analysis andmeasurement who might dispute the suggested best methods and tools, oreven the most important questions to ask, posed by therapists or teachers(and vice versa). This, again, is reflective of divergent methodologies anddiffering standards of illuminating fact-based knowledge and, thus, of reporting different colors and dimensions of the truth. Indeed, the present
contributors routinely use a lexicon and language indicative of their uniquelens and disciplines, placing differing weight on what is significant andwhat constitutes relevant knowledge. In linking together the chapters, wesought to gain greater consilience among the core branches of knowledge
that engineer our progress and certainty. As you read this book, movingfrom one chapter to the next, consider taking on the enterprise of linking knowledge, rather than ranking information hierarchically. Valuable

Human Trauma and Animals11

knowledge will come at you from differing perspectives, even from nonhuman perspectives if you listen carefully.
People have a way of placing themselves first. One of the more important lessons learned from the creation of this work is that humans
can often be lazy and careless about our relationships with one another,even when attempting to help. Spoken and increasingly written language
appear to be the only information and methods of communication wetend to offer our human counterparts in order to understand and to beunderstood. Animals, on the other hand, use everything except verbal
language in which to communicate and understand others and the world
around them. Even when trying to understand the contributions offeredby our nonhuman relationships, we often fail to appreciate the emotional,
cognitive, and communicative diversity of other animals. Greater attention
must be paid to how animals communicate their needs, preferences, andsupport, particularly in the context of AAI for trauma.
As we finish writing this introductory piece, Samara has not abandoned her post. She lays quietly close to the desk and, per usual, offers us
her ever-reliable patience and good nature. We have attempted in this bookto both encourage and retain the authentic voice of each contributor. In
the process, we hope we have captured hers as well.
REFERENCES
Beetz, A. M. (2017). Theories and possible processes of action in animal assisted
interventions Applied Developmental Science, 21(2), 139–149.
Chandler, C. K. (2005). Animal assisted therapy in counseling. New York, NY:
Routledge.
Kirst-Ashman, K. K., & Hull Jr., G. H. (2012). Understanding generalist practice(6th ed.). Boston, MA: Brooks/Cole Publishing.
Kruger, K. A., & Serpell, J. A. (2006). Animal-assisted interventions in mental
health: Definitions and theoretical foundations. In A. H. Fine (Ed.), Handbook
on animal-assisted therapy: Theoretical foundations and guidelines for practice (2nded., pp. 21–38). San Francisco, CA: Elsevier.
Lefkowitz, C., Paharia, I., Prout, M., Debiak, D., & Bleiberg, J. (2005).
Animal-​assisted prolonged exposure: A treatment for survivors of sexual assault
suffering posttraumatic stress disorder. Society & Animals: Journal of Human-​Animal Studies, 13(4), 275–295.

12

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McCardle, P., McCune, S., Griffin, J. A., & Maholmes, V. (Eds.). (2011). How
animals affect us: Examining the influence of human-animal interaction on childdevelopment and human health. Washington, DC: American Psychological
Association.
National Intrepid Center of Excellence (NICoE). (2014). Fact sheet. Retrieved
from http://www.nicoe.capmed.mil/Shared%20Documents/NICoE_Updated_One_Pager_3_4_2014.pdf
Perry, B. (2008). Child maltreatment: A neurodevelopmental perspective on therole of trauma and neglect in psychopathology. In T. Beauchaine & S. P. Hinshaw (Eds.), Child and adolescent psychopathology (pp. 93–129). Hoboken, NJ:
John Wiley & Sons.
Pichot, T., & Coulter, M. (2007). Animal-assisted brief therapy: A solution-focused
approach. New York, NY: The Haworth Press.
van der Kolk, B. A. (2002). The assessment and treatment of complex PTSD. In R.
Yehuda (Ed.), Treating trauma survivors with PTSD (pp. 127–156). Arlington,
VA: American Psychiatric Association Publishing.
Wilson, E. O. (Ed.). (1998). Consilience. New York, NY: Vintage Books, Random
House.

ABOUT THE AUTHORS
Philip Tedeschi is the executive director of the Institute for Human-Animal
Connection, and faculty at the University of Denver’s Graduate School ofSocial Work. Recognized for his expertise in clinical methods for animal-assisted interventions, he is the founder and supervisor of the University’s
Animal-Assisted Social Work and Animals and Human Health Professional
Development certificate programs. His teaching, research, and scholarship focus on the bioaffiliative connection between people and animals,
human-animal interactions, animal welfare, interpersonal violence andanimal cruelty, social ecological justice, One Health, and bioethics.
Molly Anne Jenkins is an affiliated faculty member and adjunct professor at theGraduate School of Social Work’s Institute for Human-Animal Connection
at the University of Denver. She previously served as research analyst andhuman-animal interaction specialist for American Humane Association,
where her research focused on the effects of animal-assisted intervention

Human Trauma and Animals13

for children with cancer and their parents, as well as therapy dogs. Her
background and primary interests center on human-animal relationships;
animal welfare, sentience, and behavior; veterinary medicine; social andecological justice; and One Health. She currently serves on the Boards ofYouth and Pet Survivors at Children’s Hospital Colorado and the American
Psychological Association’s HAI Section.

CHAPTER 1

The Impact of Human-Animal
Interaction in Trauma Recovery
Marguerite E. O’Haire, PhD; Philip Tedeschi, MSSW, LCSW; Molly A. Jenkins, MSW, AASW;
Sally R. Braden, MSW, AASW; and Kerri E. Rodriguez, MS

BACKGROUND
There is a documented call for adjunctive and integrative treatments toaddress the needs of individuals who have experienced trauma (Imel,
Laska, Jakupcak, & Simpson, 2013; Najavits, 2015). Concurrently, there
are new advances toward an evidence base for human-animal interaction(HAI), as well as efforts to develop and refine professional standards andcompetencies in the HAI field (O’Haire, Guérin, & Kirkham, 2015a).
Given powerful anecdotal and scientific accounts of the benefits of HAI,a growing number of practitioners have begun to incorporate animals into
their mental and physical health services.
The inclusion of animals in therapeutic applications is known asanimal-assisted intervention or AAI (Kruger & Serpell, 2010). AAI ranges
from informal activities with animals to provide enrichment (animal-assisted
activities or AAA); to individualized and structured sessions with animals,
targeted at meeting the client’s therapeutic goals (animal-assisted therapy
or AAT); to the incorporation of animals in educational settings to achieve
academic objectives (animal-assisted education or AAE). The premise of
AAI is that the animal’s presence is expected to provide a unique andtherapeutic benefit, above and beyond other complementary approaches
15

16

TRANSFORMING TRAUMA(Chandler, 2012). For people who have experienced trauma, these benefits
may include a source of nonjudgmental support, stress-reducing companionship, positive outlets for joy and laughter, a safe haven for physical touchand emotional vulnerability, and “bio-affiliative safety” (Chandler, 2012;
O’Haire, et al., 2015a; Taylor, Edwards, & Pooley, 2013; Yount, Ritchie,
Laurent, Chumley, & Olmert, 2013).
The concept of bio-affiliative safety offers promising explanations andknown processes for how we become vigilant of, and responsive to, various threat-related stimuli. Concurrently, these same systems allow us torecognize safe environments and relationships. Bio-affiliative safety is best
explained through the important contributions of Dr. Stephen Porges,
whose work has focused uniquely on how our neural system processes
threats. Specifically, when a threat exists, our preconscious neural capacities
are engaged to offer adaptive threat and defensive responses. According toPorges (2004),
Neural circuits provide physiological mechanisms that reflexively organize mobilization or immobilization behaviors before
we are consciously aware of what is happening. When, on theother hand, neuroception tells us that an environment is safe andthat the people [or animals] in this environment are trustworthy,
our mechanisms of defense are disenabled. We can then behave
in ways that encourage social engagement and positive attachment. (p. 24)
In Porges’ explorations of the polyvagal system and the concept of neuroception, we can begin to understand how the presence of a nonhumananimal interaction may offer critical information for accurate responses
to our immediate actual or perceived safety (or lack thereof ). For those
persons working to overcome trauma, the significance of an animal companion in providing a sound sense of safety and well-being (in times of
uncertainty and otherwise), an increased capacity for self-regulation, andthe impetus for functional reengagement with the social environment cannot be underestimated.
History

Though humans have experienced animal companionship for millennia,
our understanding of the benefits of these relationships has evolved considerably, especially over the last 50 years (Serpell, 2006). As we have begun toThe Impact of Human-Animal Interaction in Trauma Recovery17

comprehend the ways in which animals help humans thrive, their inclusion
in our therapeutic interventions has inherently followed. At times, these
beginnings have stemmed from fortuitous chance. This was certainly thecase for Smoky, a small Yorkshire terrier who is often heralded as the firsttherapy dog (Wynne, 1996). She was found by an American soldier during
World War II, and accompanied him and his comrades through numerous
missions. Through interacting with Smoky, the soldiers found respite andan impetus for positive emotion; the trauma and terror of their combat
seemed to somehow lessen through connecting with the mere four-pound
dog. Since the war, the story of Smoky has spread and is often credited withleading to a boom in the use of therapy and service dogs for individuals inrecovery from traumatic physical and psychological injuries.
By the 1970s, there were dedicated organizations and groups focusedon AAI. Today, thousands of therapy animal and handler teams interact
with trauma survivors during their healing processes. Recently, service
animals have also begun to be specially trained to assist those who haveexperienced trauma (Taylor et al., 2013; Yount et al., 2013). While historically service animals have solely been enlisted for physical assistance, theirapplication has broadened into the psychological realm to build upon thegrowing acknowledgment of the effects of animals on human well-being(Tedeschi, Fine, & Helgeson, 2010).
Overview of Trauma

A majority of people will experience trauma at some point in their lifetime(Breslau et al., 1998). Not all of these individuals will face ongoing struggles after a traumatic event, but many will. Trauma can take on numerous
forms and stems from a variety of different causes — many more than weare able to comprehensively cover in this single chapter alone. As such, ourfocus here is on the following three core categories of trauma: child andfamily violence, post-traumatic stress, and crisis response.
Child and Family ViolenceChild maltreatment and family violence are devastating and pervasive.
Though public awareness of these issues has grown over time, many cases
still go unreported (Gracia, 1995). Children are at particular risk of pooroutcomes due to the negative and traumatic impacts of witnessing and/or
experiencing family violence, abuse, and/or neglect on early developmental
trajectories (Anda et al., 2006; McCloskey & Walker, 2000). Importantly,
child maltreatment can establish developmental trauma impacts, such as

18

TRANSFORMING TRAUMA

an impaired capacity for trust and attachment. Seeking assistance can also
be frightening and even dangerous if a perpetrator suspects that a survivor
may leave. In these situations, the presence of an animal may serve several purposes.
In the home environment, pets often function as sources of perceived
unconditional positive regard and consistent support for members of thefamily (Walsh, 2009). In the fearful cycle of violence or neglect, a companion animal may provide a refuge, friendship, source of positive emotional
exchange, and safe outlet for warmth and affection. In some cases, whendomestic violence and child maltreatment are present, family pets are also
at risk of significant harm (known commonly as “the Link”) (Ascione &Arkow, 1999). For example, animals may be hurt by the abuser as a way
to threaten, control, or punish family members who love them. In suchsituations, people may place themselves in harm’s way by trying to protect
their animals from abuse and, although not always correlated, children
who are abused may even learn to hurt animals themselves (Arluke, Levin,Luke, & Ascione, 1999; Currie, 2006).
In the clinical environment, the presence of an animal may enhance
the tone of the room and the therapeutic relationship by providing a
positive impetus for connection and rapport between the client and theprofessional (Prothmann, Bienert, & Ettrich, 2006). Physical contact involved in stroking the animal may release tension and assist those withtrauma to achieve physiological self-regulation (Nagengast, Baun, Megel,& Leibowitz, 1997). Watching or playing with the animal may also lessen
the gravity of the situation (Hansen, Messinger, Baun, & Megel, 1999).
For children in particular, the animal may play a critical role in reducing
fear and distress during otherwise unpleasant and challenging interactions
with adults, such as reliving traumatic events for the purposes of reportingor testifying (Parish-Plass, 2008).
CASE STUDY
In 2015, two black Labradors, Dozer and Lupe, were officiallysworn in as the newest “staff members” to California District
Attorney Michael Ramos. Serving on a special victims’ canine
unit, Dozer and Lupe work inside courtrooms to support children and families as they provide testimony of physical and sexual
trauma. One of Ramos’ clients, a young boy sexually abused by

The Impact of Human-Animal Interaction in Trauma Recovery19

a relative, was understandably stressed over having to publicly
relive his trauma. When Lupe nudged the child’s leg, prompting
for a pet, the boy began rubbing Lupe’s ears, which allowed him
to relax and disclose his story with greater ease (McCleery, 2016).
The presence of such “courtroom facility dogs” is becoming increasingly common in cities across the United States.

Post-Traumatic Stress
A proportion of individuals who experience trauma, including children
who have experienced maltreatment, will go on to develop post-traumaticstress disorder (PTSD) (Breslau, 2009; Kilpatrick et al., 2013). The sourceof trauma can vary, from traumatic experiences during war, family violence, sexual assault, serious illness, and natural or manmade disasters.
PTSD is characterized by clinical symptoms of reexperiencing, such as
flashbacks or nightmares; avoidance, such as staying away from certain
places; memory loss; and hyperarousal, such as being on high alert or startling easily (American Psychiatric Association, 2013). It can develop at any
point throughout the life span, and is related to marked impairments ineveryday functioning at work and at home. Notably, experts in the field oftreating trauma among our military populations have increasingly begun
to use the term post-traumatic stress (PTS). PTS is now often differentiatedfrom PTSD in recognition that normal and adaptive responses to experiencing stressful or life-threatening events may trigger at least some of thesymptoms of a PTSD diagnosis in almost anyone who experiences them(Regel & Joseph, 2010). In an attempt to destigmatize the very naturalfight-or-flight response to a traumatic event, we feel it is most accurate
to use the term PTS interchangeably with PTSD where appropriate (e.g.,when not discussing diagnostic criteria). The inclusion of this nomenclature will hopefully lend support to the notion that symptoms such as
reexperiencing, avoidance, and hyperarousal in response to trauma can benormal, rather than pathological. Additionally, acknowledgment of these
normative responses may even help foster resilience in those who havebeen traumatized.
While there are many available treatments for PTS, it is a challenging condition to effectively treat. There is a strong evidence base for theeffectiveness of some treatments, such as eye movement desensitization
and reprocessing (EMDR) and exposure therapy, among others (Foa et20

TRANSFORMING TRAUMA

al., 1999; Rothbaum, Meadows, Resick, & Foy, 2000). Exposure therapy,
for example, involves both imagined and real-life exposure to reminders orcomponents of the traumatic event in a gradual progression that enables
the person to build up to facing, rather than avoiding, his or her fears (Foa,
Chrestman, & Gilboa-Schechtman, 2008). In the hierarchical series of
exposure events, the individual habituates to specific, anxiety-producing
stimuli or environments associated with the traumatic event (e.g., being
in a dark room or crowd). The progression is slow and follows the pace of
the individual. Although effective, this treatment is often perceived as unpleasant and aversive to many clients (Becker, Zayfert, & Anderson, 2004).
Nevertheless, it is important that people with PTS persist and engage inthese sorts of evidence-based treatments, because they can help to achieve
improved outcomes.
As a complement to existing practices, animals often provide unique,additional benefits to the alleviation of PTS symptoms. For example, thepresence of an animal often offers a source of safety and support (Marr etal., 2000; Yount et al., 2013). Animals can also reduce loneliness (Banks& Banks, 2002) and create connections among friends and family members through positive interactions (McNicholas & Collis, 2006; Wood etal., 2015), which may be especially important for individuals with PTS
who are often socially isolated. In a more formal capacity, animals can be
involved in AAIs or trained as service animals to assist with individualized
needs, and to address specific, daily challenges caused by PTS.
For example, a core role of many psychiatric service dogs is to promote a biofeedback function to reduce anxiety or arousal. Service dogs aretrained or naturally learn to sense when an individual is experiencing aheightened state of stress, which may lead to an anxiety or panic attack. In
many such cases, the animal alerts the individual by nudging and/or licking
them, and thus encourages the person to concentrate on the dog, take deep
breaths, and use mindfulness techniques to refocus on the present. The
service dog will continue to nudge the person until they take these actions.
The biofeedback notification, along with an anxiolytic interaction, can help
to decrease anxiety and instill calm among people in situations of stress.
Other trained tasks or AAIs can also be undertaken, based on the individual’s specific needs. However, it is important to note that the inclusionof animals in PTS services should not be perceived as a stand-alone or
replacement treatment. The current body of evidence suggests that social
support may be the single most important variable needed for trauma
recovery and, for some individuals, the support that animals provide canThe Impact of Human-Animal Interaction in Trauma Recovery21

enhance and expedite their treatment and healing processes (Flannery Jr,
1990; Guay, Billette, & Marchand, 2006).
CASE STUDY
Staff Sargent Brad Fasnacht was clearing mines on an Afghanistanroad in 2009 when he was injured by an IED blast, causing
a broken spine, two broken ankles, and a traumatic brain injury — consequently exacerbating his PTS. After learning how towalk again, Brad decided to get a service dog, named Sapper, tohelp alleviate his PTS symptoms. Brad was in a constant hypervigilant state, scanning streets and trees for snipers. With Sapper,
Brad’s anxiety improved and prevented what would have often
previously resulted in a panic attack. Because Brad lost some of
his hearing in the blast, Sapper would notify Brad of necessary
sounds, alarms, or even if someone was approaching him frombehind. Like many other individuals with PTS, Brad also hadnightmares, but he was able to wake from them when Sapper
licked his face (Thompson, 2012).

Crisis Response
The aforementioned forms of trauma represent ongoing and often lifelong
issues. We are devoting a separate chapter of this book to crisis response,
because of the unique and acute elements that define it. In the wake ofcrisis (e.g., natural disasters, acts of community violence and terror), communities are shaken. Normalcy seems a distant memory and panic, loss,
and numbness pervade. In these times, many people take great comfort in
the presence of a friendly animal, such as a therapy or companion animal(Chandler, 2005; Crawford, 2003). Given the myriad studies showing thatanimals, particularly dogs, can reduce and buffer physiological and endocrine stress responses (Beetz, Uvnäs-Moberg, Julius, & Kotrschal, 2012b),
it is no surprise that incorporating animals into crisis response has become
increasingly prevalent (Chandler, 2005).
Animal-assisted crisis response (AACR) or disaster stress relief (DSR)
is a specific type of AAI that incorporates a working team of a therapy dog
and a certified first responder. The first contact with an individual who has
undergone trauma can be fragile; incorporating a therapy dog into a crisis
response team can: 1) help build rapport by developing a bridge between

22

TRANSFORMING TRAUMA

the individual and a responder or mental health professional; 2) act as asafe and calming presence; 3) provide certain relief through interactionthat does not require effortful or verbal communication; and 4) encourage physical movement (Greenbaum, 2005). The animal can also act as atransitional “object” to encourage present-minded thoughts and provide
those in crisis with a reality-orienting focus (Greenbaum, 2005).
The first example of a major disaster response that incorporated animals was during the 1995 bombing of the Murrah Building in Oklahoma
City. Twenty therapy dog-handler teams were sent to provide comfort
during the initial trauma recovery of victims and their families. As first
responders are known to experience secondary trauma, compassion fatigue, and burnout (Alexander & Klein, 2009; Figley, 1995; Palm, Polusny,& Follette, 2004), the addition of therapy dogs into the crisis response
protocol was found to be as important to the responders and handlers
as to those actually being served in the community. During the terrorist
attacks of September 11, 2001, approximately 500 therapy animal-handler
teams from three surrounding states were deployed to provide relief fortraumatized individuals, displaced persons, police officers, firefighters, US
Army Reserve troops, and other professional and volunteer relief workers.
In recent years, national standards and protocols have been developed tofacilitate safe crisis response for both the dogs and people involved as practice continues to grow and gain national acceptance (National Standards
Committee for Animal-Assisted Crisis Response, 2010).
CASE STUDY
Just days after one of America’s deadliest massacre shootings andhate crimes at Pulse, an LGBT nightclub in Orlando, Florida,
K-9 Comfort Dogs and handlers were brought forth to help
console victims of the attack and their loved ones, as well asothers in need of support. Comfort dogs were present in hospitals, churches, and even attended memorial services in orderto help those in distress feel, even if just temporarily, a sense ofcalm and security during such tragedy. Many hospitalized victims
could not get out of bed, but were seen smiling, and in a few
cases, started talking again through their interaction with thedogs (Bromwich, 2016).

The Impact of Human-Animal Interaction in Trauma Recovery23

THEORY AND POTENTIAL MECHANISMS
Various theories and mechanisms have been proposed to explain theunique benefits of animals and animal relationships for people, including
those who have experienced trauma. The increasing popularity of AAI inclinical environments is, perhaps, rooted in the evolutionary benefits ofour bonds with animals, as well as the theory that humans have an innate
need to be in connection with other living beings, including animals andthe natural environment (Wilson, 1984; Fine, O’Callaghan, Chandler,
Schaffer, Pichot, & Gimeno, 2010; Melson & Fine, 2010). This instinctive pull toward nature (“biophilia”) and/or beneficial connection with it(“bio-affiliation”) are just two explanations for why so many people consider their relationships with animals to be amongst their most significant.
In the specific case of trauma-informed applications, some mechanisms arerooted in empirical evidence, while others remain anecdotal and challenging to define with a singular theory. The most commonly cited theories
and mechanisms in this area are explored below, categorized broadly bypsychological and physiological bases.
Psychology

The benefits of animals for trauma recovery are often framed by biopsychosocial theories that explore the relationships between social beings,
including social support, attachment, and cognitive perception. These theories generally relate to interactions between humans, but are reframed here
to highlight their relevance to HAI.
Social Support Theory
The social support theory proposes that animals provide both direct andindirect support to humans. In a direct way, animals act as sources of
nonjudgmental support, perceived unconditional positive regard, andcompanionship (Friedmann, Katcher, Lynch, & Thomas, 1980; Kruger,
Trachtenberg, & Serpell, 2004; Wood et al., 2015). Indirectly, animals
often serve as social lubricants or facilitators of interaction between humans(Gunter, 1999; McNicholas & Collis, 2006; O’Haire, McKenzie, Beck,& Slaughter, 2013).
Not only is a lack of social support one of the strongest predictors ofdeveloping PTS (Ozer, Best, Lipsey, & Weiss, 2003), but the presence ofsocially supportive connections often plays a critical role in the recovery

24

TRANSFORMING TRAUMA

from experiencing a traumatic event (Guay et al., 2006). In this context, apositive relationship with an animal provides a unique form of supportive
companionship that may be unavailable or unsolicited from human social interaction (Serpell, McCune, Gee, & Griffin, 2017). Moreover, theemotional support received from an animal may also act as a “buffer” toattenuate perceived or anticipated stress (Polheber & Matchock, 2013).
In the face of trauma, people can feel ostracized, stigmatized, and alone,with intrusive thoughts, flashbacks, and nightmares further isolating themfrom their communities and social networks. As a social facilitator, thetrusted presence of an animal may help foster social engagement for these
individuals, as well as their meaningful reconnection with society (Taylor
et al., 2013; Wood et al., 2015).
Attachment Theory
There are many different ways to define attachment. Here we refer toattachment as the social bond created between two individuals, whether
human or animal (Budge, Spicer, Jones, & George, 1998). It is most often
characterized as a relationship that provides feelings of safety as a securebase (Bowlby, 2005). For individuals who have experienced trauma, there
is a need for feelings of safety and security (Pearlman & Courtois, 2005),
and in many cases, animals can offer this form of attachment in uniqueways (Beck & Madresh, 2008; Kurdek, 2008). This is consistent withfindings that humans gain social and emotional support from animals
during stressful contexts (e.g., Beetz, Julius, Turner, & Kotrschal, 2012a;
McNicholas & Collis, 2006). Additionally, the attachment relationshipis often mutually beneficial, in which the animal may obtain emotional
and physical security from a trusted human’s care and presence (PratoPrevide, Custance, Spiezio, & Sabatini, 2003; Topál, Miklósi, Csányi, &Dóka, 1998).
There is some debate as to whether this form of attachment between
humans and animals is adaptive in the long term, or whether it is mosteffective as a transitional relationship, similar to the use of transitional objects with children (Winnicott, 1953). In this scenario, the animal provides
a source of comfort during the time of greatest need, which is slowly transitioned into security independent of the animal (Triebenbacher, 1998).
The timing and duration of the attachment or transitional relationshiplikely depend on the severity and source of the trauma, the availability ofThe Impact of Human-Animal Interaction in Trauma Recovery25

the animal (e.g., whether a service animal or visiting therapy animal), andthe needs of the individual.
Cognitive Perception
One of the least appreciated ways in which animals can benefit trauma
survivors is through their ability to change people’s perception. People
with animals are perceived as friendlier, happier, less threatening, and more
approachable (Eddy, Hart, & Boltz, 1988; Friedmann & Lockwood, 1991;
Lockwood, 1983; McNicholas & Collis, 2000; Wells, 2004); such perceptions may serve to further facilitate interactions and support between
people. Likewise, these perceptual differences also extend to environmental
settings; the simple presence of an animal changes the way we discern oursurroundings. Imagine the terrifying emotions that overwhelm individuals
following a hurricane disaster. If the arrival of a friendly therapy dog canchange the tone of the scene, this in and of itself is an important functionalrole of the animal. This perceptual change can also be useful in initial therapeutic encounters or in a wide range of clinical environments, including
treatment approaches and settings for PTS. The clinician’s office may beperceived as more welcoming and less threatening if an animal is present(Fine, 2010; Kruger, Serpell, & Fine, 2006; Wells & Perrine, 2001). It
has also been suggested that the clinician will appear more approachable,
which could in turn accelerate a therapeutic alliance necessary to achieve
positive change (Wesley, Minatrea, & Watson, 2009).
Psychophysiology

Beyond the psychological theories that endeavor to explain our relationships with animals, there are several complementary psychophysiologicalmechanisms suggested to underlie HAIs. Such mechanisms highlighted
here include arousal modulation and neuroendocrine changes.
Arousal Modulation
One of the core symptoms of PTS is hyperarousal, which includes aheightened state of alert (American Psychiatric Association, 2013). Often,
individuals with PTS feel that danger is around every corner, and they cannot relax or feel at ease. It has been posited that the presence of an animal
can reduce anxious arousal and encourage feelings of safety. For example,
research in nontraumatized populations has demonstrated that being with

26

TRANSFORMING TRAUMA

or stroking an animal can lead to reductions in physiological indicatorsof arousal, such as lowered heart rate, blood pressure, and skin conductance (Friedmann, Katcher, Thomas, Lynch, & Messent, 1983; Nagengast
et al., 1997; Odendaal & Meintjes, 2003; O’Haire, McKenzie, Beck,& Slaughter, 2015b; Vormbrock & Grossberg, 1988). Interacting withanimals also significantly reduces self-reported fear and anxiety (Barker,
Knisely, Schubert, Green, & Ameringer, 2015; Barker, Pandurangi, & Best,
2003; Lass-Hennemann, Peyk, Streb, Holz, & Michael, 2014). For individuals who experience intrusive flashbacks from trauma, anecdotal reportssuggest that animals can alleviate hyperarousal and distress by promoting
feelings of calmness and security (Taylor et al., 2013; Yount, Olmert, &Lee, 2012). Thus, the presence of an animal may act as an effective complementary strategy to modulate arousal in trauma populations to moreproductive levels for everyday functioning.
Neuroendocrine Changes
Neuroendocrine regulation plays a large role in current psychophysiological theories relevant to our connections with animals (Borgi & Cirulli,2016), with various hormones having been proposed to underlie changes
following HAI and AAI. One frequently researched biomarker relevant toarousal and stress is the hormone cortisol. Reductions in cortisol levels, aswell as neurotransmitters like epinephrine and norepinephrine, during andfollowing HAI demonstrate the stress-reducing capacity of animals (Beetz
et al., 2012a; Cole, Gawlinski, Steers, & Kotlerman, 2007; Handlin et al.,2011; Odendaal, 2000; Odendaal & Meintjes, 2003). Moreover, the dysregulation of cortisol levels has been shown to impact brain functioning,
specifically in the amygdala and hippocampus (which has implications
for emotional response, memory, learning, and decision making) (Shin,Rauch, & Pitman, 2006; Yehuda, 2002). Perhaps not surprisingly, dysregulated cortisol levels are common among those with a PTSD diagnosis (Shinet al., 2006). Therefore, interventions that either help reduce or regulate
cortisol — such as HAI — could likely be of multifaceted benefit for thosewith trauma histories.
Another primary target in current psychophysiological theory is thehormone oxytocin, which is often informally called “the love hormone”
due to its relevancy in mother-infant bonding, as well as other attachment
relationships (Beetz et al., 2012b; Galbally, Lewis, Ijzendoorn, & Permezel,
2011; Hurlemann & Scheele, 2016). Oxytocin also has far-reaching effects

The Impact of Human-Animal Interaction in Trauma Recovery27

on social interaction (i.e., increasing trust, empathy, generosity) and stress(i.e., inhibiting stress-related activity), while also acting as an anxiolytic(MacDonald & MacDonald, 2010). Thus, oxytocin may modulate such
PTS symptoms as hyperarousal, anxiety, and difficulty with interpersonal
relationships. In fact, recent studies have begun to examine the potential
therapeutic effects of intranasal oxytocin for individuals with PTS (e.g.,
Flanagan, Sippel, Wahlquist, Moran-Santa Maria, & Back, 2018). In HAI
research, oxytocin has been shown to increase in both humans and pet dogs
following short interactions, particularly those that involve gazing into
one another’s eyes (Handlin, Nilsson, Ejdebäck, Hydbring-Sandberg, &Uvnäs-Moberg, 2012; Miller et al., 2009; Nagasawa et al., 2015). These
human and canine changes in hormone regulation are thought to provide
physiological evidence for a long-held and (hopefully) mutually beneficial
bond between humans and other animals (Beetz et al., 2012b).
EMERGING PRACTICESAs appreciation of our bonds with animals has gained momentum, so
too has the field of HAI as a serious focus of academic and professional
pursuit. Graduate-level programs in social work, psychology, counseling,
public health, education, and veterinary medicine have increasingly begun to understand how important these relationships can be for bothhuman and animal health (Jenkins, Ruehrdanz, McCullough, Casillas, &Fluke, 2012). For example, the Center for the Human-Animal Bond at
Purdue University’s College of Veterinary Medicine is a recognized pioneer
in AAI education, as is the University of Denver’s Graduate School ofSocial Work’s (GSSW’s) Institute for Human-Animal Connection. In fact,
animal-assisted social work (or AASW), which is an empowerment-based
AAI approach applicable across multiple settings, disciplines, and populations, has expanded GSSW’s clinical- and practice-based education, andhas brought many social workers in-training to the university.
Organizations such as Pet Partners, Therapy Dogs International(TDI), Alliance of Therapy Dogs, and the Professional Association of
Therapeutic Horsemanship International (PATH Intl.) (to name a few)
have spearheaded the promotion of AAI practice, as well as the registration and/or certification of therapy animals and their handlers to provide
these services in a variety of settings. Likewise, many Assistance Dogs

28

TRANSFORMING TRAUMAInternational (ADI)-accredited organizations now specialize in the training
and placement of service dogs with people who have disabilities, including
PTSD. Worldwide, practitioners — ranging from mental health professionals to teachers to service dog trainers to community members andvolunteers — are implementing diverse AAI applications in their efforts to
help people recover from trauma.
Approaches to animal-assisted trauma recovery vary and are often tailored according to the following factors: 1) the client’s source of trauma
and/or diagnoses; 2) the client’s individual needs and treatment goals; 3)
the client’s age, gender, race, socioeconomic status, and other key demographics; 4) the practitioner’s discipline, training, theoretical framework(s),therapeutic methods, and resources; 5) the geographical location in which
treatment is taking place; 6) the species, individual characteristics, andcultural perceptions of the animal(s); and 7) whether or not the animal
is owned by the practitioner (i.e., a “therapy animal” who visits with aclient) or the client (i.e., a “service animal,” “emotional support animal,”or “companion animal”/pet who lives with a client).
Given these various factors, it is somewhat difficult to provide a complete and accurate summary of what comprises typical or even prevailing
AAI practice. Indeed, there is nothing typical about working with living
animals (who also have unique needs and idiosyncrasies) to improve thelives of people. Further, even in comparable clinical situations where thesefactors are more or less controlled, AAI protocol fidelity is anything but
commonplace. While a lack of pure practice fidelity is understandable, andin select cases necessary or even preferable, it can make determining “whatworks best” in AAI practice a significant challenge. This reality has, in part,
contributed to the complexity of conducting sound and meaningful AAI
studies across diverse populations (Trujillo, Tedeschi, & Williams, 2011).
Additionally, while it is true that rigorous experimental designs (e.g.,
randomized controlled trials or RCTs) are desirable for strong evidence of
AAI effectiveness, it also is important to note that many relational aspectsof HAIs are subtle or inherently qualitative and, thus, difficult to capturein quantitative methodologies alone. Some may dismiss the anecdotal andqualitative research that pervades the literature on HAI and AAI, but thesedata should not be rejected out of hand; just as quantitative data can inform issues of causation, generalizability, and mechanism, qualitative data
often provides rich, detailed accounts of actual day-to-day applications
and personal experiences. Of significance, embedded in these accounts weThe Impact of Human-Animal Interaction in Trauma Recovery29

might seek or uncover specific approaches to support previously undefinedneeds of trauma survivors and/or the well-being of animals.
Because research and study methodology in the area of trauma-informed
AAIs are just beginning to take shape and gain attention, we are hesitant tocharacterize and/or endorse any one practice model as being more effective
than another. In truth, the AAI practice approaches and protocols outlined
throughout this book, as well as others presently being implemented acrossthe globe, should really be considered “emerging practices” that have astrong foundation in what we now know to be effective in both trauma andgeneral AAI work. Concurrently, these existing and innovative practices
should not be dismissed simply because research has not yet fully supported
their use. Rather, this work should be encouraged and thoughtfully implemented to address the current needs of those with trauma and to informresearch, thereby strengthening future practice (i.e., a “practice-to-researchto-practice” model).
As such, we proffer that the following are necessary steps in AAI practice and research development: 1) improve the ethical standards for all
animals involved in AAI; 2) apply implementation science approaches
toward AAI practice fidelity, including understanding what factors increase
the effectiveness of these interventions and challenging the research to service delivery knowledge gap; 3) expand the confines of what is considered
fundable research in this field, through more progressive and inclusive
approaches, to spur scientific inquiry; and 4) foster intervention researchand the inclusion of AAI practice in established degree programs. We hopeto provide a resource for practitioners and the public-at-large on what isworking feasibly and effectively as we speak, as well as identify knowledge
gaps to optimize future study endeavors in the AAI field.
Practice With Therapy Animals

AAT and AAA are included under the umbrella term of AAI, and weredeveloped primarily to complement more traditional treatment and therapeutic services. While many types of animals can be therapy animals,
dogs — followed by horses — are by far the most common (Friedmann,
Son, and Tsai, 2010; Granger & Kogan, 2006; Nimer & Lundahl, 2007;
O’Haire et al., 2015a). As stated earlier, AAT is defined as a targeted intervention that incorporates a trained therapy animal to help clients or patients
meet specific treatment goals. AAT sessions typically include a therapist
or doctor, and the client is often matched with the same animal-handler

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TRANSFORMING TRAUMA

team over the course of treatment. In contrast, AAAs are less formal, andare often characterized by brief therapy animal visits in hospitals, schools,
libraries, and other settings. AAA visits, which tend to be more spontaneous than AAT sessions, seek mainly to provide people with comfort andenrichment. Of note, those in the HAI field often use these terms interchangeably or inconsistently when referring to their work, which, in turn,can cause confusion regarding practice intentions and specifics (Barker &Wolen, 2008; Palley, O’Rourke, & Niemi, 2010).
There is some debate among those in the field over how AAT sessions
should be defined and structured. For example, some believe that in order
for an intervention to be considered AAT, it must include: 1) the recipient;2) the interventionist; 3) the animal-handler (often a volunteer); and 4)
the therapy animal (Delta Society, 2008; Kruger & Serpell, 2010). Other
schools of thought assert that the interventionist can also serve as thehandler, and that this may even be the best option as the professional islikely knowledgeable about the particular recipient population and theirneeds. Conversely, others argue that having an interventionist serve as bothprofessional and handler may place the client and the animal at risk, since
the individual is unable to fully attend to either participant simultaneously(Jenkins et al., 2012).
At present, those who are interested in integrating therapy animals into
their practice or volunteer work need not obtain any formal credentials to
do so. That said, it is strongly recommended, and often required (depending upon the setting), that the individual not only seek AAI education,
but also train, register, and insure the individual’s therapy animal throughsuch organizations as Pet Partners, TDI, or PATH Intl. Each registeringbody has their own specific standards of practice, and many require thatthe handler and animal be reregistered on a regular basis. Examples ofsuch practice standards with dogs specifically include: the dog must be atleast one year of age and be in good physical health; the dog’s behavior
must be predictable in a variety of unfamiliar settings; the dog and handler must complete repeated training courses and pass evaluations; theanimal-handler team should visit for no more than two hours at a time, toallow for the dog to rest and express normal behaviors; and the dog should
actively seek interaction with people during visits (Pet Partners, 2017).
Further, central to the registration process is for the handler to develop
a keen understanding of the animal they are partnering with, including theanimal’s suitability for therapy work, their individual and species-specificThe Impact of Human-Animal Interaction in Trauma Recovery31

needs, and their typical and stress-related behaviors (VanFleet, Fine,
O’Callaghan, Mackintosh, & Gimeno, 2015). Equally important is to beknowledgeable about the population served, and how best to meet theirneeds while ensuring that the animal is safe and enjoying the therapeuticinteraction. Taken together, these proficiencies are necessary to support amutually beneficial experience for the people and therapy animals involved.
Practice With Service Animals

Service or assistance animals (most commonly dogs) differ from therapy
animals in that they live with the person they are serving, and are trained
to perform specific, quantifiable tasks to ease the challenges associatedwith that person’s physical and/or psychiatric disability (Sutton, 2015).
The 1990 Americans with Disabilities Act (ADA) stipulates legally covered disabilities among service dog owners, including visual and hearing
impairments, physical mobility issues, multiple sclerosis, diabetes, epilepsy, autism, and a PTSD diagnosis (American Humane, 2016; U.S.
Department of Justice, 2011). At the turn of the last century, it was estimated that approximately 10,000 dogs were service dogs. With time andincreased interest in how animals impact our well-being, the number ofservice dogs (and the individuals and organizations that provide them)
have also experienced steady growth (Sandler, 1996).
That said, there currently is a lack of universally recognized service
dog training, certification, and identification standards, and professional
trainers, organizations, and laypersons may all train service dogs. This
lack of evidence-based standardization often presents confusion regarding
practice and even the rights of those with service dogs, such as in theiraccess to housing, public places, and travel (American Humane, 2016).
At a minimum, service dogs should be individually trained in the essentialfunctions or tasks that a person could not otherwise perform due to his
or her disability. In addition, service dogs should be well behaved in thecommunity and with strangers (as specified by the Public Access Test),
and have a strong sense of loyalty to their handler (Psychiatric Service
Dog Partners, 2017). Yet, given the needs of those they serve, much moreis often required of these dogs. Several organizations and stakeholders are
currently responding to the growing need for qualified PTS service dogs bydeveloping and optimizing additional training and evaluation standards.
Recent research advancements indicate that service dogs may be able
to help veterans with PTS or traumatic brain injury (TBI) confront their

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symptoms by providing a sense of security and serving as a motivator to engage positively with people and the world around them (U.S. Department
of Veterans Affairs or VA, 2014). While some organizations specialize inproviding dogs to veterans (e.g., K9s For Warriors, Paws Assisting Veterans,
paws4people), others focus on having veterans train service dogs for fellow
veterans with disabilities (e.g., Warrior Canine Connection). Both K9s
For Warriors and Warrior Canine Connection are the subjects of ongoing
research, via the VA, the Center for the Human-Animal Bond at Purdue
University, and others, with initial efficacy data indicating positive outcomes for veterans (i.e., reduced PTSD symptomology, increased qualityof life, and positive social relationships) (Kloep, Hunter, & Kertz, 2017;
O’Haire et al., 2015a; Yarborough et al., 2017).
EVIDENCE-BASED RESEARCH
To validate the growing accounts of positive outcomes from HAI and AAI
practices, scientists have begun to conduct an increasing number of studies
to better understand if, how, and when animals can benefit humans. As
discussed previously, practice is vastly outpacing research with respect totrauma populations. However, there are a small group of studies that have
paved the way for this emerging and critical field of research.
A recent systematic review identified ten studies on AAI for trauma,of which four were unpublished theses (O’Haire et al., 2015a). Since thattime, we have identified a handful more, including a few unpublishedtheses, which have now been published in peer-reviewed scientific journals.
Though sparse, the studies have been notably positive. The majority of theresearch to date has focused on child victims of abuse, with little to noresearch on military veterans and/or those in need of crisis response (seefigure). Most study populations were children and adolescents, with some
focused on adults. The dearth of research on adults with military trauma isquickly changing, however, with many ongoing studies on the topic. The
most common animals in this review were dogs and horses, with somestudies including a broad range of farm animals that often also included
dogs and horses.
The characteristics of the intervention in research were wide-ranging,yet there were some patterns. Outside of service dogs, AAI interventions

The Impact of Human-Animal Interaction in Trauma Recovery33

Breakdown of key elements of current research on AAI for trauma.

with a therapy animal included a set number of sessions of time-limited
duration. Sessions typically occurred 1–2 times per week over the courseof 7–8 weeks. Roughly half of the sessions were conducted with groupsof clients, while the other half were one-on-one with an individual andinterventionist. Session duration was highly variable, ranging from 20 minutes to four hours. The interventionists had varying backgrounds, fromclinical psychologists to animal trainers to untrained volunteers. There wasno standardized procedure described for intervening, and/or training theanimal, handler, or team. Likewise, whether or not the animal and handler
were registered to provide AAI was not well-documented. Thus, across allstudies, the main unifying component was simply an animal’s presence.
This illustrates that the field of research, as well as practice, is emerging
and has not yet identified the most effective, or best, protocols to follow.
Though most studies were small and preliminary, several findings
emerged as areas that may be promising for further investigation. Thatsaid, they should be interpreted with caution, as the research in this area isin its infancy, requiring much larger and more rigorous designs to validate
initial outcomes. One of the most commonly reported outcomes concerned
depression, with seven studies reporting reduced depressive symptoms inparticipants from before to after AAI sessions. PTSD symptomology andanxiety were also key outcome measures. One notable study compared themental health and functioning of 153 children, ages 7–17 years, undergoinggroup treatment for childhood sexual abuse either with (treatment) or without (control) AAT with a therapy dog. Results indicated that children in the
AAT group exhibited lower anxiety, depression, anger, and PTSD symptoms than those receiving usual group treatment (Dietz, Davis, & Pennings,2012). Additional outcomes across fewer studies included increased positive

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TRANSFORMING TRAUMA

emotion, life satisfaction, and social engagement in conjunction with AAI.
Further positive outcomes were reported, yet the aforementioned areas
emerged across multiple studies, and thus, may be the most reasonable
areas to anticipate changes from AAI for trauma as a broad category.
ETHICAL FOUNDATIONS FOR THE HUMAN-ANIMAL BOND
AND ANIMAL-ASSISTED INTERVENTION
Equally important to supporting human well-being and trauma recovery
via AAI is the need to ensure that the animals who provide this importantwork — often when incorporated or deployed in traumatic working environments — are offered optimum support, care, protection from harm, andrespect in terms of their own individual needs and preferences. Throughout
this book, we intend to celebrate, clarify, and advocate for the roles ofanimals in our lives, while also honoring the principles of mutuality inhuman-animal relationships and ensuring that the emerging AAI field does
not ignore the responsibility to animal well-being. We also feel it is criticalto draw specific attention to the procedure, practices, and issues related
to animal well-being, as well as to the ethical responsibilities we have toanimals who are activated to the agenda of human health.
As Dr. Leo Bustad reflected on over 20 years ago in his timeless book,
Compassion: Our Last Great Hope, with sensitivity and responsibility guiding the development of new AAI practices, we must also seek specificity
related to ensuring that we are not establishing yet another homocentric or
exploitive approach to our relationships with nonhuman animals (Bustad,1990). Accordingly, those who involve animals in their work to help improve the lives of others have a strict, moral, and enduring responsibility
to the animal participants. The American Veterinary Medical Association(AVMA, 2017) has offered the following widely circulated definition of
the human-animal bond (HAB) — one that not only describes the featuresof our relationships with animals and the environment, but also highlights
the importance of mutuality:
A mutually beneficial and dynamic relationship between people
and animals that is influenced by behaviors that are essential tothe health and well-being of both [emphasis added by this chapter’s authors]. This includes, but is not limited to, emotional,

The Impact of Human-Animal Interaction in Trauma Recovery35

psychological, and physical interactions of people, [other] animals, and the environment. (para. 1)
Of note, the conceptualization and place that nonhuman animals holdin status and value may render oversimplified notions about the nature ofthese relationships. It is important to acknowledge that the HAB has existed in numerous forms, and that accounts of human-animal relationships
and AAI vary across cultures and countries. These connections include
many types of nonhuman animals who have historically served as richsources of social support, protection, and “objects” of bidirectional affection and attachment.
As noted previously, the most common species of animals selected
for use in AAIs are dogs and horses, although some organizations permit
the registration of other species. Likewise, many therapeutic farms maintain a variety of animals, such as pigs, miniature horses, goats, sheep,chickens, turkeys, birds, cows, reptiles, small animals (e.g., guinea pigs),
and even wildlife. In-the-wild interactions, such as swimming with dolphins or riding elephants, have increasingly gained in popularity despite alack of consensus regarding their efficacy, impact on animals, and ethicalimplications (Serpell, Coppinger, Fine, & Peralta, 2010; Zamir, 2006).
Zamir (2006) makes a strong argument against the use of any wildlife in
AAIs; indeed, Zamir attests that due to the domestication process andthe likelihood of severe species reduction or elimination among wildlife populations, only dogs and horses are suitable for inclusion in AAIs.
Despite potential for animal harm in animal-assisted work due to roughhandling, injuries, illness or stress, Zamir (2006) ultimately concludes
that both dogs and horses live healthier, longer, and more comfortable
lives symbiotically with humans, and that “a world in which practices like
AAT exist is an overall better world for these beings than one that does notinclude them” (p. 195). It should be noted, however, that many agencies
and organizations do not adopt this position and continue to utilize awide variety of both wild and domestic species for the anticipated benefit
to humans via these animal interactions. Although we are not endorsingthat only specific species participate in AAI, this lack of cohesion across the
HAI field, along with other factors, emphasizes the necessity to establish
and constantly refine ethical standards that address these discrepancies
and prioritize well-being as a condition for any animal’s inclusion in AAI
applications.

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Current Approaches to Advocacy and theSupport of Animal Well-Being
The development of an ethical framework for the conscientious inclusion ofanimals for therapeutic purpose has historically been contentious. Experts
in animal welfare, behavior, and ethics continue to debate issues surrounding consciousness, sentience, and the rights of animals (Bekoff, 2007). For
example, some contend that if society demands strictly scientific or quantifiable data prior to the enactment of policy or standards, we may continue
to struggle for some time with the requisite assessment and measurementof animals’ more subjective internal states, such as emotion, quality of life,and pain. Conversely, others argue that by accepting the “face value” ofhuman perception of animal well-being, the risk is unacceptably high thatcompeting motivators or factors (i.e., economics, personal gain, ignorance,
and/or consciously or unconsciously placing a higher priority on human[both client and handler] needs, rather than animal needs) may unduly
influence and compromise the integrity of one’s perspective (Tedeschi,
Bexell, & NeSmith, 2013). Therefore, as discussions regarding subjective
internal states remain important in furthering our understanding of nonhuman animals and their experiences, we may be unable to wait for suchdebates to be settled in the abstract while animals are being asked to work
now under a host of increasingly complex AAI conditions (many of them“high-stress” in nature). With that said, below are some current, important
contributions that attempt to provide a grounded, ethical framework whenworking and living with animals in the context of AAI.
IAHAIO Definitions and Guidelines
In 2014, the International Association of Human-Animal Interaction
Organizations (IAHAIO), one of the key professional organizations
advancing the HAI field, released a white paper entitled The IAHAIODefinitions for Animal Assisted Intervention and Animal Assisted Activity
and Guidelines for Wellness of Animals Involved (Jegatheesan et al., 2014).
This succinct report provides a clear discussion regarding ways to improveattention to both the physical and emotional health of the participating animal. For example, many animals are particularly sensitive to anger
and emotion. Interventions that place an animal at the center of a family
working through conflict, and/or encourage an individual to share theirtraumatic experiences with the animal present, may pose a stressful experience for participating animals.

The Impact of Human-Animal Interaction in Trauma Recovery37

Often, the enthusiasm surrounding the field’s potential can create arush to incorporate animals in therapeutic situations without careful concern for efficacy and safety, as well as ethical regard for the nonhumanparticipant(s). Yet, the integrity and welfare of our animal participants
need to be imminently addressed to ensure conscientious, responsible, andeffective AAI practice. The matter is all the more urgent as the incorporation of AAIs in therapeutic settings continues to expand and diversify. As
such, an immediate priority for AAI practice should be the development
and finesse of a dynamic code of ethics that parallels and evolves to match
actual AAI practices. At present, this IAHAIO report seeks to identify
the welfare needs of therapy animals, and serves as a valuable resource forprofessionals who include animals in their practices and services.
The Five Freedoms
The Five Freedoms, originally published in the Brambell Report in 1965,
are arguably the most frequently referenced framework for assuring animal welfare. Initially developed to address the welfare needs of farmanimals, they are also relevant in other HAI and AAI applications. The
Five Freedoms state that animals are entitled to: 1) freedom from thirst,
hunger, and malnutrition; 2) freedom from discomfort; 3) freedom from
pain, injury, and disease; 4) freedom from fear and distress; and 5) freedom
to express normative behavior (Brambell, 1965).
In the most recent and currently available edition of The Handbook
on Animal-Assisted Therapy (Fine, 2015), veterinarian Dr. Zenithson Ng
and his colleagues reflect on a useful expansion of the Five Freedoms into
three key areas (physical, affective, and nature), and provide several examples of the well-being issues facing animals in therapeutic settings (suchas sensitivity to anger and high emotion, as discussed above). In addition,
they make a point of identifying the animal-handler as critical to ensuring
attention to these details (Ng, Albright, Fine, & Peralta, 2015). Of note,
Dr. Ng also discusses the Five Freedoms in the context of AAI in chapter
2 of this volume.
The Therapy Animal’s Bill of Rights
In her recent book, Teaming with Your Therapy Dog (2015), longtime
animal-assisted social worker Ann Howie offers a unique juxtaposition
by suggesting a Therapy Animal Bill of Rights. Howie has written thisBill of Rights — with selected, key elements included below — from the38

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perspective of therapy dogs to exemplify the importance of their needs,
preferences, and experiences (Howie, Fine, and Rojas expand upon thesein chapter 9). Howie (2015) writes,
As a therapy dog, I have the right to a handler who:
• Provides gentle training to help me understand what I
am supposed to do• Is considerate of my perception of the world• Helps me adapt to the work environment• Guides clients, staff, and visitors to interact with me
appropriately• Takes action to reduce my stress• Provides a well-rounded life with nutritious food, medical care, physical and intellectual exercise, social time,and activities beyond work
• Respects my desire to retire from my work when I think
it is time (p. 125)
The Capabilities Approach
Nussbaum’s Capabilities Approach (2006), with its focus on dignity, respect, and justice, offers an ethical practice framework that is both extensive
and flexible enough to account for each AAI participant, as well as a wide
variety of treatment modalities. The ten capabilities that apply to bothhuman and animal participants in AAI include: 1) life; 2) bodily health;
3) bodily integrity; 4) senses, imagination, and thought; 5) emotions; 6)
practical reason; 7) affiliation; 8) other species; 9) play; and 10) control
over one’s environment.
In the context of human healing professions, the dignity of all participants involved must be considered. From this view, adopting a code of
ethics where the integrity and welfare of the animal participants is valued
at least as much, or even more highly, than the perceived benefit to humanrecipients should again be an imminent goal for organizations, educational
institutions, and individual practitioners. Arguably, only when an animal is properly cared for will there actually be a therapeutic transfer. The
Capabilities Approach provides a sound, practical, and ethical foundationof justice and respect for all beings involved in AAI (to be established at
the outset and continued throughout the therapeutic process), and offers

The Impact of Human-Animal Interaction in Trauma Recovery39

a common ground to move forward in a unified effort to improve the livesof both humans and animals. According to Nussbaum (2006),
Animals are entitled to a wide range of capabilities to function,
those that are most essential to a flourishing life, a life worthyof the dignity of each creature. Animals have entitlements based
upon justice. (p. 392)
Physiological measures have been both the traditional “gold standard”
and elusive “holy grail” in the inquiries regarding the welfare of therapy
and service animals, despite frequent calls for the addition of more holistic
approaches that assess the whole animal (Taylor & Mills, 2007; Yeates &Main, 2009). Vital to the discussion of ethics, welfare, and the quality oflife of animal participants in AAIs are centered concerns regarding working conditions (i.e., length and frequency of working time and breaks,
setting familiarity, temperature, water accessibility, amount of space, andtasks/weight loads); positive versus negative training methods; (chronic)
stress; calming signals, displacement, and/or stereotypic behaviors; communication; and social/activity needs (Ng et al., 2015). However, current
limitations should neither halt inquiry nor should an ethical AAI framework that is too rigid to allow for scientific growth or the developmentof more progressive models be adopted. Rather, enhancing awareness andunderstanding of these various issues, and their relationship to animal
welfare, are important components of continued research progress and
AAI practice advancement.
GAPS AND NEXT STEPS
It is an exciting and important time to be involved in research on AAI for
trauma because the evidence base has received so little attention to date.
Preliminary studies have begun to establish proof-of-concept by demonstrating positive outcomes from interacting with animals (O’Haire et al.,2015a). The next step in this direction is to convincingly demonstratethat the benefits of including an animal in trauma treatment are aboveand beyond what would be expected from the presence of another novel,appealing entity (i.e., a toy, game, or activity), which would presumably
be less costly or logistically complex to incorporate/implement if effective.

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It is also vital to evidence that the outcomes are not simply reported
because people want to see them happen. This is often called an “expectancy bias,” and occurs when people are invested in seeing change and thus
report that there is change (and often believe there is change) even when
there is not (Rosenthal & Rosnow, 1991). Common ways to address thisthreat to the validity of the research are to include reports from people
who are not invested in the outcomes (or do not even know the treatment
occurred) or to incorporate physiological measurements, which should be
inherently less biased. Thoughtful measurement and research design are
the keys to advancing the reputation and credibility of AAI for trauma.
Other critical areas to pursue are intervention development and quality
enhancement. All of the AAI programs for trauma that have been published in research studies have used different formats, programs, and timing(O’Haire et al., 2015a). Few have published a protocol or manual thatcan be replicated. Thus, even if research shows that one program works,
how can another program in another state or country expect the sameoutcomes? Without a manual, replicable protocol, or an evidence base forthe core components of the program, it is nearly impossible to expect thesame outcomes to occur and/or to systematically enhance the program’s
practices. Some practitioners are understandably hesitant to move toward
manualization due to the individualized nature of their practice (Addis,
Wade, & Hatgis, 1999). However, manualized modules could arguably
allow for flexibility if they were selected for independent use (i.e., where
an interventionist selects the specific modules that best suit the individual).
Likewise, recommendations could be customized for specific populations,and a set of standardized options could be provided to suit a variety of
species, settings, and practitioner preferences. The need for evidence-based
protocols should not be hindered by individual differences; rather, theseneeds should drive the creation and evaluation of tailored and adaptablecomponents and modules that can be scientifically evaluated and improved
over time (Connor-Smith & Weisz, 2003).
An additional important gap in the current research is evidence of thecomponents that are most important and effective to drive positive outcomes from AAI for trauma specifically. For example, we do not know if it
is more effective to have 1 session versus 10 versus 100. We do not know the“dose” required to see a treatment response or the most effective frequency(e.g., once weekly versus once monthly). These are important researchquestions to address following preliminary efficacy studies. Conducting a

The Impact of Human-Animal Interaction in Trauma Recovery41

components analysis of the intervention can assist practitioners in knowing which activities may be most effective with animals, which animals
to include, how important bonding with the same animal is versus theimportance of novelty, and the multitude of other choices interventionists
make when designing and implementing AAI “best practices” for trauma.
Instead of viewing one’s own AAI program as superior and complete, we
recommend a continued process of testing and collecting data, no matter
how small or technical the scale, to enhance and provide the best possible
services to individuals who are seeking assistance through HAI.
A final and immensely important gap in the current research is further study of the well-being of the animals involved. This goes beyond
a simple determination of whether or not the animals are safe and welloverall. It involves a component analysis to ensure that we understandwhich activities are best for both the human and the animal. We suspectthat the most optimal outcomes occur when both parties are engaged andbenefiting from the interaction. Without the animal, AAI does not exist.
Both quantitative and qualitative research should place more emphasis on
this essential partnership to maximize mutually beneficial outcomes andethical standards.
CONCLUSIONSThe emerging landscape of HAI for trauma deserves attention. It has anecdotally saved lives and created hope for others. From incorporating animals
into first response crisis teams to therapeutic interventions for those whohave faced the anguish of war and violence, AAI continues to permeate
into trauma treatment and recovery. However, the scientific foundation ofthese various practices is currently limited and, as such, federal (and other)
support for programming has been sparse. Research is being far outpacedby current AAI practice, and it is clear that additional scientific inquiry isneeded to quantify outcomes and create a solid evidence base.
While animals may not be appropriate for all individuals who haveexperienced trauma, it is essential to identify and validate those whomthey can help. Understanding bidirectional effects is also of paramountimportance, with welfare implications for both participating human andnonhuman animals. Existing and innovative AAI applications and inquiries should continue to address the urgent needs of those with trauma,

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ensure the well-being of animal participants, inform future research, andoptimize practice. We hope this chapter, as well as others in this volume,
will contribute to these efforts by shining a light on how trauma-informed
AAIs are currently understood and realized, as well as how they may bestrengthened as the field continues to advance.
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ABOUT THE AUTHORS
Marguerite (Maggie) O’Haire received her BA in psychology from Vassar
College and her PhD in psychology from The University of Queensland.
She is currently an associate professor of human-animal interaction in theCenter for the Human-Animal Bond in the College of Veterinary Medicine
at Purdue University. Dr. O’Haire’s research focuses on the biopsychosocial
impacts of interacting with animals for various populations, includingchildren with autism spectrum disorder and military veterans with PTSD.
Sally R. Braden received her BS in psychology from Wofford College inSpar­tanburg, South Carolina. She was then employed as a foster carecase manager for the Department of Social Services, and later moved to
Raleigh, North Carolina, where she was employed as the program director for the Elizabeth Edwards Foundation. In 2015, Braden received
her Master of Social Work and Animal-Assisted Social Work certificate

The Impact of Human-Animal Interaction in Trauma Recovery53

from the University of Denver. Braden currently works at Denver HealthHospital in Psychiatric Emergency Services, and her research interests include animal-assisted interventions in acute psychiatric settings.
Kerri E. Rodriguez is currently a PhD student of human-animal interaction in
the Center for the Human-Animal Bond at Purdue University’s College of
Veterinary Medicine, under Dr. Marguerite O’Haire. She received her BSfrom Duke University and her Master of Science from the University of
St. Andrews. Her research focuses on the psychosocial and physiologicaleffects of service dogs among individuals with physical disabilities andmilitary veterans with PTSD.

Biographical sketches for Philip Tedeschi and Molly A. Jenkins can be found on
p. 12 of this volume.

CHAPTER 2

Advocacy and Rethinking Our
Relationships With Animals:
Ethical Responsibilities and Competencies
in Animal-Assisted Interventions
Zenithson Ng, DVM, MS, DABVP (Canine and Feline)

INTRODUCTION
We ask a lot of our animal companions. In reality, we don’t even ask, butrather expect them to enter unfamiliar environments, to be approachedand touched by strangers, to follow commands, and to act appealing or“cute,” all for our own and other people’s personal gain. While the human recipient benefits from interacting with the animal, and the handler
benefits from seeing the animal bring joy to others, we have to ask if theanimal is benefiting from their participation in animal-assisted interventions (AAIs), is unaffected by them, or is possibly even subjected to undue
negative consequences as a result. If given free will, would an animal naturally remain in an interaction designed to comfort an individual or would
it choose to flee from the situation at hand? With the limited amount ofdefinitive evidence that animals truly have a significantly positive impact on humans, or that non-living animal substitutes, such as lifelike
canine robots, may bring about similar positive impact and that there
are potential risks of these activities to animal welfare, one may question
the ethical use of animals for these interventions. As such, it is essential
55

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that the field of AAI keep animal welfare at the forefront of practice andresearch pursuits.
Animal welfare can be appropriately described as the “animal’s attempt
to cope with its environment at a physiological, behavioral, and medical
level” (Broom, 1996, p. 24). Welfare is often graded on a scale from very
good to very poor (Haverbeke, Diederich, Depiereux, & Giffroy, 2008).
However, grading welfare in animals can be notoriously problematic andcomplex because it is usually based on an observer’s subjective evaluation of the animal’s well-being (Hetts, Clark, Arnold, & Mateo, 1992;
Hiby, Rooney, & Bradshaw, 2006). When utilizing animals for purposesof providing a service for humans in the form of AAI, there is an ethicalobligation for these animals to achieve “very good” welfare status. Good
welfare and well-being can be characterized as a state in which an animal
is free from distress most or all of the time, is in good physical health,exhibits a substantial range of species-typical behaviors, and is able to deal
effectively with various environmental stimuli (Hetts et al., 1992; Novak& Drewsen, 1989).
Most animal welfare experts believe that animals are sentient beings,
although it is difficult for research to definitively confirm this. A sentient
being implies that the individual has the ability to experience emotional
effects of pleasure and suffering. Research in cognitive ethology, psychology,
and neuroscience is increasingly recognizing the complexity of animal emotions and consciousness (Bekoff, 2007; Panskepp, 2005; others). There iscompelling evidence that some animals likely feel a full range of emotions,
including fear, joy, happiness, shame, resentment, jealousy, rage, anger, love,pleasure, compassion, respect, relief, disgust, sadness, despair, and grief(Bekoff, 2000, 2007). For example, elephants have long been noted toexpress a high emotional intelligence similar to human beings (Bradshaw,
2004). Because of elephants’ intricate bonds with one another, mother elephants have been observed mourning over a dead offspring for days after
death, often touching and caressing the corpse, seemingly trying to bring thedeceased back to life. Additionally, after the death of an elephant, the herd
may grieve the corpse for years after death; when the skull of a deceased elephant was brought back to the herd in a zoo, the elephants gathered aroundand performed a ritual of touch and caressing (Moss, 1992). These deliberate behaviors demonstrate that animals form close attachments to otherliving beings and cope with the trauma of loss. In the case of domesticatedanimals, pet owners will often report behaviors that indicate depression orsadness in a pet after the death of a cohabitating animal companion.

Advocacy and Rethinking Our Relationships With Animals57

Likewise, post-traumatic stress disorder (PTSD) has been recognizedin animals that have experienced an event that is unpredictable and outof their control (Foa, Zinbarg, & Rothbaum, 1992). In military working dogs, for instance, canine PTSD is characterized by a collection of
behavioral signs including hyperresponsivity and hypervigilance to environmental events; behaviors aimed at escaping or avoiding previously
positive or neutral environments; changes in social interaction with their
human handler; and failure to perform previously mastered critical tasks(Stampfl, 2012). This suggests that animals not only experience emotion,
but can also suffer harmful consequences, including trauma, from suchemotions and experiences.
One underlying reason for this is that adverse events are commonly
ingrained in animals’ memories, and recurrence of similar events evokes
a variety of stress behaviors, physiologic changes, and likely emotional
consequences. Based on a previous experience, animals quickly learn tofear specific conditions such as types of people, locations, and smells. The
classic situation that is often associated with a traumatic experience for an
animal is a visit to the veterinary hospital. As soon as an animal arrives atthe vet, it recognizes what has occurred in the past, which often involves
sensing the fear and anxiety of other animals, loud noises (i.e., dogs barking
and cats yowling), forced restraint, and treatments involving injections,oral medication, and rectal exams. These feelings of discomfort may be
exacerbated by the fact that the animal is often ill and requiring veterinary
care in the first place. The fear, elevated blood pressure, retreat, and stressbehaviors exhibited by these animals at the veterinary hospital are often
characterized as “white coat” syndrome. These negative experiences shape
the animal’s behavioral and physiological stress response, and can be considered to be a form of trauma. A recognition of the negative experience
for animals has resulted in the strong movement for veterinary clinics topractice low-stress or fear-free methods to elicit positive emotions in bothanimals and owners.
Similarly, the nature of working with people who have experienced various forms of trauma through AAI may be more intense and strenuous and,thus, may have certain stress implications for the therapy animal as compared to work with other populations. Individuals who have experienced
trauma may be particularly emotional, unpredictable, and erratic in their
behaviors and emotions. If a patient with an unstable temperament wereto vocalize loudly or inflict physical harm on an animal in an outwardly
violent manner, the animal will likely be fearful of the circumstances that

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led to the negative experience. These seemingly subtle circumstances may
include the particular individual or identifying characteristics of that individual (i.e., gender, hair color, voice intonation, clothing color or pattern),
the location of the event, or the inherent smells permeating throughout
the experience. Any or all of these factors may result in trauma, where theanimal would avoid/retreat from the stimulus or exhibit signs of stressand anxiety.
Treatment for animals with anxiety disorders often involves counterconditioning, in which the fearful stimulus is paired with a positive reward,
with the ultimate goal being to change the animal’s emotional responseto that stimulus. For example, in a therapy dog that has become fearfulof men because a man had hit the dog during an AAI session, counterconditioning would involve exposing the dog to a male giving treats andtoys. For anxiety disorders not amenable to behavioral modification, orthat impair the animal’s ability to express normal behavior, the inciting
stimulus should be avoided altogether or pharmaceutical intervention may
be required. However, if AAI is traumatic enough to require that an animal
take anti-anxiety medications to continue work, it is in the best interestof the animal to discontinue any future AAI involvement. Moreover, consultation with trainers or veterinary behaviorists would likely be necessary.
In addition to experiencing a variety of emotions themselves, animals
are able to recognize different emotional states in other species as well.
Most work investigating the human-dog relationship shows that dogs are
uniquely suited to identify, and be sensitive to, the emotional cues fromtheir owners (Duranton & Gaunet, 2015). Dogs are able to discriminate
happy from sad human faces and respond differently to that specific emotion (Albuquerque et al., 2016; Muller, Schmitt, Barber, & Huber, 2015;
Nagasawa, Murai, Mogi, & Kikusui, 2011). Moreover, specific areas ofthe dog brain are responsive to human voice and cues, demonstrating thatthey are able to recognize and process different human emotions (Andics,
Gacsi, Farago, Kis, & Miklosi, 2014). Specifically, canine brain imaging
reveals that dogs perceive specific words differently from the intonation of
those words, similar to the way in which humans do (Andics et al., 2016).
This remarkable finding demonstrates animals’ innate ability to recognize
and respond to other species.
While animals may be able to recognize different emotions in otherspecies, we have to ask ourselves if they truly possess empathy. Empathy
is a shared state phenomenon to feel what another living being is feeling

Advocacy and Rethinking Our Relationships With Animals59(Preston & de Waal, 2002). It is postulated that many creatures demonstrate and possess empathic abilities (Kuczaj, Tranel, Trone, & Hill, 2001).
In humans, chemosensory anxiety signals can activate brain areas necessary to process emotional stimuli and recruit empathy-related resources(Prehn-Kristensen et al., 2009). If empathy is indeed present in nonhuman animals, it is likely that similar neuronal mechanisms exist in these
species as well.
For example, the interspecies relationship between dog and humansuggests that dogs have the ability to empathize with people (Silva & deSousa, 2011). The most compelling evidence that animals are empathic
creatures is the synchronization of hormones between human and dog.
One study investigated the change in hormones in agility dogs and theirhandlers and found that testosterone levels in handlers were correlated
with, and predicted change in, cortisol levels in their dogs (Jones & Josephs,
2006). Additionally, another study found that the change in cortisol levels
in handlers simultaneously mirrored the change in cortisol levels in agility
dogs in competition (Buttner, Thompson, Strasser, & Santo, 2015). Thesestudies suggest a hormonal synchronization across species interacting with
one another.
Aforementioned, in AAI, an animal may be exposed to, and affectedby, a wide range of human personalities and mood states, especially intimes of despair, loss, and trauma. Indeed, human therapists are known tosuffer adverse effects on mental health and well-being in response to thistype of work (Linley & Joseph, 2007; Pearlman & Mac Ian, 1995). The
fundamental difference is that therapists go into this work out of theirown volition; animals do not. If animals truly are empathic, it is possiblethat they too could suffer negative consequences from internalizing andharboring these emotions. Crying, an expression of emotion commonly
observed in therapy sessions, may negatively impact therapy dogs. Froma physiological perspective, researchers have found that cortisol levels indogs increased after listening to a human crying (Yong, Ruffman, & Yong,2014). Likewise, from a behavioral perspective, dogs have also demonstrated a submissive approach toward a human crying compared to when
they were humming or talking (Custance & Mayer, 2012). Interestingly,
one paper reported that shortly after completing a study where a trained
therapy dog engaged in regular contact with college students reminiscing
about negative or traumatic events, it developed unforeseen behavior problems and was permanently retired from work (Hunt & Chizkov, 2014).

60

TRANSFORMING TRAUMAThis may suggest that AAI with people in distressed states can negatively
impact the animal.
We have an ethical obligation to ensure that these adverse effects areprevented. We often select certain animals, especially dogs, for AAI because
they are so sensitive and reactive to human cues (Udell & Wynne, 2008;
Vitztum & Urbanik, 2016), and have a high drive to please people (Udell,Dorey, & Wynne, 2010). It has even been suggested that animals possess
some degree of altruism (de Waal, 2008), making them ideal candidates forassisting in interventions seeking to improve human health and well-being.
However, we must be careful that we do not take advantage of the gentle
and compliant nature of these animals and put them into a state of learned
helplessness (Peterson, 1993). This is the condition of powerlessness inwhich the animal has learned it is unable to escape or avoid aversive stimuli, giving it no option other than to forfeit itself to the situation. Since
AAI animals are so obedient with a high desire to please, what can be perceived as a tolerant and quiet dog in the presence of an emotional human
could actually be a dog suffering from learned helplessness. It is our duty
to ensure that appropriate, evidence-based protocols are implemented toprevent these conditions.
The field of AAI currently is lacking in formal universal guidelines on
the ethics of human-animal relationships (Antonites & Odendaal, 2004).
It is presumed that most human-animal interaction (HAI) organizations
emphasize that animal welfare be protected and enhanced wherever possible (Preziosi, 1997; Santori, 2011). However, specific guidelines are
difficult to establish because research has not yet identified the precise
criteria necessary to guarantee welfare. The International Association of
Human-Animal Interaction Organizations (IAHAIO) (Jegatheesan et al.,2014) describes general guidelines to safeguard animal welfare in AAI,
while select studies have measured and are continuing to measure theeffects of AAI for therapy animals, but more work is necessary.
This chapter will address the ethical, practical, and research considerations and solutions for the welfare of the AAI animal. Animals should
not merely be made tools for human advantage, but rather be recognizedas partners and sentient beings that benefit us in so many ways. There are
four key factors that deserve special consideration to ensure animal welfare in AAI: the handler, the animal, the recipient, and the environment.
Additionally, it is necessary to provide practice guidelines for tasks to complete before, during, and after an intervention, especially one where humantrauma is of focus. The importance of animal well-being in ensuring andAdvocacy and Rethinking Our Relationships With Animals61

guiding safe, humane, effective, and sound therapeutic interventions will
be discussed.
ETHICAL CONSIDERATIONS IN AAI
When considering animal welfare in the context of AAI, a conceptual,ethical framework to apply are the Five Freedoms of animal welfare, first
proposed by the Farm Animal Welfare Council (FAWC) (Brambell, 1965).
These Five Freedoms include:
•
•
•
•
•

Freedom from thirst, hunger, and malnutrition
Freedom from discomfort
Freedom from pain, injury, and disease
Freedom from fear and distress
Freedom to express most normal behavior

To ensure “good” welfare status, the animal must meet each of the conditions of the Five Freedoms. Violation of any of these freedoms can resultin a poor welfare state via the incitement of stress.
While many would consider it unusual for a therapy animal to notmeet each of the Five Freedoms, there are certain aspects of AAI that may
challenge these freedoms. Concerning freedom from thirst, hunger, and malnutrition, an AAI animal (e.g., a therapy dog) is unlikely to suffer fromthese detriments due to the care provided by the owner/handler. However,these basic necessities may be affected when the animal is actively engaged
in an AAI session. For example, it has been reported that handlers who areworried about dogs urinating in the facility during a session may withhold
access to water, which can result in thirst and consequent dehydration(Hatch, 2007). Similarly, handlers may deny food to the animal for fearof accidental defecation in the facility, resulting in hunger. With freedom
from discomfort, the actual animal-assisted activity (AAA)/animal-assisted
therapy (AAT) facility may present certain risks that lead to discomfort.
These facilities, particularly hospital environments, often subject animals
to crowds of people, loud sounds, adverse smells, and unpredictable circumstances (King, Watters, & Mungre, 2011).
The freedom from pain, injury, and disease component is a relatively
straightforward concept to guarantee for all animals. To ensure this freedom, steps should be taken to minimize the risk of disease or injury to62

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participating animals. In addition, a plan should be in place to seek immediate medical assistance on the rare occasion that an animal becomes
ill or is hurt while participating in AAI. Injury to the animal can occur
due to being improperly handled by the human recipient of AAA or AAT,
but these occurrences are infrequently reported (Hatch, 2007). Notably,
however, handlers may refrain from reporting adverse events in these situations to avoid upsetting or embarrassing the visited client, especially if
the individual has special needs and the animal does not appear to havesuffered severe injury.
Freedom from fear and distress may be more of an abstract concept toensure in therapy and service animals. This freedom is met if the animal
is free of mental suffering. Mental suffering is a difficult parameter toobjectively assess, but all attempts should be made to decrease fear andstress in AAI animals. Although there are limited studies to report how
well dogs tolerate this type of work, stress may be quite prevalent in
AAA and AAT (Glenk, Stetina, Kepplinger, & Baran, 2011; King et al.,2011). The presence of a human being has the potential to cause stress inanimals (Jones & Josephs, 2006), and social interactions are reported tobe among the most potent stressors an animal may endure (McEwen &Wingfield, 2003).
Finally, the freedom to express most normal behavior may be the greatest
challenge to meet in AAI. This freedom requires that the animal be provided with sufficient space, proper facilities, and company of the animal’s
own kind. However, this freedom is difficult to apply in AAI because
AAA/AAT environments are unlike any that the animal would naturally
encounter. These animals did not choose to be trained for, or to engage in,
AAI — the owners decided this fate for them. Even if an animal achieves
AAA or AAT certification and registration, it does not necessarily meanthat the animal has the desire to voluntarily participate in these activities.
Because the handler is in control of the animal at all times, the animal istypically unable to vacate or escape these conditions if the need or desire
arises (Serpell, Coppinger, Fine, & Peralta, 2010). AAI is unlike any otheranimal activity in that it requires an animal to endure intimate, unsolicitedaffections from a human stranger for extended durations of time (Butler,
2004). Animals in these contrived circumstances must remain steady andcope with the interaction of unfamiliar people and strange settings without
being able to choose whether to stay or leave (Piva, Liverani, Accorsi, Sarli,& Gandini, 2008), which prevents expressing normal behavior.

Advocacy and Rethinking Our Relationships With Animals63

HANDLER SELECTION: CALM, KNOWLEDGEABLE,
AND PROACTIVE
The handler is the ultimate gatekeeper of animal welfare. An appropriate
handler should be one who is motivated to help the human recipient, as
well as safeguard the needs of the animal. The animal relies on the handler
for guidance and leadership; without an appropriate leader, the interaction
may not be safe or effective. Whether handlers are human health specialists or volunteers, they should be trained appropriately and be expected
to comply with a certain standard of practice. It should be noted that an
exuberant volunteer may disregard the animal’s needs in order to meethis or her own agendas in ensuring patient satisfaction. At the most basic
level, the handler should prioritize the animal’s welfare above the recipient’s
emotional or health needs, even if that means leaving the visit prematurely
or not holding it at all.
The ideal handler should be calm and controlled in his or her interactions. This would be a particularly desired quality for handlers working withpatients and clients who have experienced trauma, as stability is essential
to conveying a safe and trustworthy presence. Likewise, since handler andcanine hormone synchronization exists, the handler may strongly influence
the dog’s performance and experience in any given interaction. Anxiety in
an AAI handler can be sensed by, and reflected in, the dog (Hatch, 2007),
so it is important that the handler maintain a natural level of calmness. It
has also been shown that increasing stress levels in the owner decrease theaccuracy of performance in working dogs (Sumegi, Olah, & Topal, 2014).
Therefore, evaluation of personality characteristics and response to stressful
situations, such as test-taking, may be helpful in selecting calm handlers.
The key to ensuring knowledgeable handlers is providing an appropriate level of training in animal behavior and health. It has been reported
that most handlers are not properly educated in ethology (Fejsáková et al.,2009). Specifically, they should be knowledgeable about the species-specificbehaviors that may indicate compromise to animal welfare, as humans areoften poor at truly assessing animal welfare (Mariti et al., 2012). Thereexists the potential for the handler to harm the animal in AAI, as he or she
may misread or fail to read stress signals and respond to them appropriately(Hatch, 2007). Being able to recognize the behavioral signs of stress is thefirst essential lesson for the handler; being proficient in responding to thesesignals is the second.

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Dogs look to humans for guidance to react to certain circumstances(Call, Brauer, Kaminski, & Tomasello, 2003), demonstrating that theseanimals rely on the handler to provide the appropriate cues for them. In
one study, researchers found that undue stress was placed on working
dogs performing tasks because handlers frequently did not instruct thedogs properly, which put them at risk of injury and performance failure(Coppinger, Coppinger, & Skillings, 1998). Handlers should be trainedon the importance of taking an active, rather than passive, role in guiding
the animal through the interaction.
In addition, the handler should have excellent knowledge of, andrelationship with, that particular animal, recognizing the animal’s individual baseline behaviors when it is not in a stressful circumstance, suchas the home setting. He or she should also recognize the behaviors exhibited when the animal is under circumstances that it finds stressful.
Since stress-associated behaviors vary between individuals, recognizing thatparticular animal’s behaviors in contrasting situations can be helpful inassessing the animal’s comfort level in the AAI setting, and in anticipating
the circumstances or triggers that may pose a risk to the animal.
Deciding whether a patient is safe to visit is also an important andoften challenging task, and it is the handler’s responsibility to assess thesafety and stability of the potential recipient. Prior to engaging a visit, thehandler may inquire with other staff members about cautions regarding
specific individuals. Additionally, the handler is responsible for providing
structure and guidelines for safe interaction with the animal prior to theintervention. This may include how to approach the animal, where it prefers to be touched, and the most appropriate volume and tone of voice.
In one study, handlers were instructed to permit the visitation only if
the breathing pattern between the dog and patient were matched (Braun,
Stangler, Narveson, & Pettingell, 2009). Certain human recipients may
be unpredictable, and if a patient has a temper or tendency for violence,
visitation should be carefully considered and/or avoided. If aggression is
encountered, the handler should remove the animal from the situation in a
rapid and safe manner. The handler should possess the skills to respectfully
inform the client that a visit or future interactions may not be appropriate
under these circumstances. Furthermore, because the welfare of these animals is paramount, it is imperative that strong supervision for the safetyof the animal and all individuals involved be provided for such situations.

Advocacy and Rethinking Our Relationships With Animals65

On the opposite extreme, individuals who have experienced trauma
may be withdrawn and disengaged due to a lack of trust in others, which
may actually be an indication to integrate AAI in counseling. These recipients may show disinterest in engaging in HAI, and while this may appear
to be unharmful to the animal, there is a possibility that motivated animals (e.g., dogs with high drive) may be frustrated by such circumstances
because they exhibit engaging behaviors in exchange for positive humancontact. As such, it may be important for handlers and mental healthprofessionals to carefully consider the best animal-human matches for the
AAI (e.g., pairing recipients who are slow to engage with animals who havemore passive personalities).
Animal health education is another essential component to ensuringthat handlers are animal-welfare conscious. First, handlers should recognize signs of illness or sickness in the animal. They should seek veterinary
attention and not work with the animal if it is feeling unwell. In one study,
it was reported that 76% of dogs with urinary tract infections and 86%
of dogs with diarrhea were still taken on AAI visits (Lefebvre, Reid-Smith,
Waltner-Toews, & Weese, 2009). These handlers may not have been aware(or lacked formal understanding) that continued work could worsen these
conditions or that the animal could be carrying transmissible infectious
diseases. In another study of 90 AAI handlers, 40% could not name at least
one disease transmittable from animal to human (Lefebvre et al., 2006).
Overall, these data demonstrate that handlers should receive basic training
on the tenets of infection control and zoonotic diseases, especially when
visiting hospital settings or immunocompromised patients. Likewise, thehandler should have basic knowledge of first aid care for the animal in theevent an accident occurs onsite. This should include management of simple
wounds and toxins, as well as foreign body ingestion.
To assess the level of understanding from this training, the handler
should be tested and retested periodically. A written examination in
addition to performance in a role-playing simulation helps to ensure aminimum competency for handlers. The role-playing simulation is particularly important, not only to assess the animal’s behavior, but also thehandler’s response to the animal and specific situations. One study validating an evaluation showed that dogs demonstrated a high rate of stresssignals, and the authors postulated that handlers were unwilling or unable
to advocate for the animal’s welfare needs (Mongillo et al., 2015). A testing66

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requirement exemplifies a high standard of practice and permits the organization to observe how a handler deals with stress, both of which influence
animal health and welfare.
A handler who passes rigorous testing should be equipped with afoundation of knowledge and skills that supports the safety and welfareof the animal. This level of education should be appropriate to the capacity at which the handler is working, whether he or she be a volunteer,paraprofessional, or professional. For example, Pet Partners offers a tiered
model of handler competencies that defines minimal core, intermediate,
and professional knowledge, as well as skills and attitudes required ofthat specific animal-handler team (Stewart, n.d.). While every handler,
regardless of role, should have core knowledge that relates directly toanimal welfare (such as recognizing triggers to stress for his or her animaland preventing the spread of infectious disease), volunteers are not expected to have a deep understanding of a patient’s diagnosis or to design
theory-based interventions, which would be required of a professional.
Catering a specific level of training based on the particular AAI work thatthe handler will do demonstrates an advanced initiative that ensures thesafety, well-being, and welfare of both the animal and the recipient. It
is reasonable to assume that a higher level of education and training fora handler results in better outcomes for AAI recipients. Future researchshould address how the handler’s competency directly correlates withthe welfare of the animal, as well as clinical outcomes for the patient.
Regardless, entry-level AAI training and follow-up with continuing education for handlers are essential components to safeguard the interestsof all parties involved.
ANIMAL SELECTION: HEALTHY, PREDICTABLE,RELIABLE, AND CONTROLLABLE
Selecting the appropriate AAI animal is essential in safeguarding animal
welfare. We want an animal to not just tolerate the intervention, but to enjoy the experience and benefit from it. The animal that is physically healthy,
predictable, reliable, and controllable will be the best suited for AAI.
It is imperative that veterinarians be involved in the approval process (Mongillo et al., 2015). Prior to advanced screening or evaluation,

Advocacy and Rethinking Our Relationships With Animals67

a veterinarian should deem the animal physically healthy and behaviorally sound to participate in AAI. With regard to physical health, animals
with chronic disease may be considered for approval for AAI work. While
well-managed diseases that would not be impacted by AAI may be permitted for approval, animals with conditions that could worsen or grow more
painful from AAI activities should not be considered. For example, diseases
affected by touching, walking, increased activity, travel, or unpredictable
events such as cardiac, respiratory, neurological, or severe orthopedic disease pose an animal health risk. In addition, animals receiving medications
that may be toxic to humans should be precluded.
Many organizations have also prohibited any animals receiving raw
food diets from participating in AAI, as they are more likely to spread infectious disease (Lefebvre, Reid-Smith, Boerlin, & Weese, 2008). Because
there has been a lack of scientific evidence proving the long-term effects ofraw food diets, it has been a controversial topic that requires education andconsideration for the health and welfare of human participants.
The veterinarian should ensure absence of zoonotic disease by confirming the animal is up-to-date on a preventive health protocol tailoredto the animal’s specific health risks. An appropriate preventive health plan
includes routine vaccination, protection against endoparasites and ectoparasites, and verification of a negative fecal examination (as indicated by
the absence of common parasites such as roundworms, hookworms, whipworms, and others) performed by centrifugation. It is important to notethat a negative fecal examination indicates absence of potentially harmfulparasites at that current moment, and does not guarantee the animal has
not been infected thereafter.
Regarding vaccines, the rabies vaccination must always be given inaccordance to local laws (National Association of State Public Health etal., 2016), and a legal rabies tag must be visualized on the animal at all
times. It is at the veterinarian’s discretion to dictate whether or not coreand noncore vaccines are given in accordance with local disease states, asother vaccine-preventable diseases are less likely to pose a risk to humans.
In addition, flea, tick, heartworm, and intestinal parasite prevention should
be given regularly, typically on a monthly basis depending on the particular
product. The method of administration may be a factor in choosing a preventive for the AAI animal. Oral preventives may be preferred over topicalpreventives, as topicals can leave a temporary residue and odor that may

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TRANSFORMING TRAUMA

be off-putting to humans who are petting them. The veterinarian’s pivotal
role is to ensure that the animal is healthy enough to work and does notpose a health risk to others.
Once the animal has received medical clearance from the veterinarian,
the animal can be behaviorally evaluated. While an appropriate therapydog (for example) may be any age, sex, or breed, certain demographics
may render an animal more successful in AAI than others. In regard toage, it is important that animals less than one year not participate. These
animals are less likely to be calm and mature enough to handle the strict
requirements of AAI. Since calmness is a desirable trait in AAI, age is
an important consideration; it was recently found that the most calm
dogs were older (greater than seven years of age) (Kubinyi, Turcsan, &Miklosi, 2009). With regard to dog breed, while breeds such as Golden
and Labrador retrievers may be overrepresented as therapy and service
animals because of their high affiliative index, any breed of dog may beappropriate for AAI. However, a high level of trainability is highly desiredin potential candidates.
One factor that significantly impacts canine trainability is the number of professional training courses (e.g., obedience, agility) that the dog
has experienced, with the most trainable dogs having completed three ormore (Kubinyi et al., 2009). The quality of training may also impact thewelfare of the animal, as there is potential for inhumane training protocols
to be performed (Serpell et al., 2010). It has been shown that positive reinforcement training without punishment is more favorable than negative
reinforcement training, as it results in decreased frequency of unwanted
behaviors (Blackwell, Twells, Seawright, & Casey, 2008). Additionally,equipment for the AAI dog should consist of a nonretractable lead andcollar or head halter. Choke chains or prong collars should be prohibited,as a dog that requires this aggressive method of control is not likely to bean appropriate candidate for AAI.
Prior to in-house full behavior evaluation, a behavioral screening tool
may be utilized to screen for inappropriate AAI candidates. The Canine
Behavioral Assessment and Research Questionnaire (C-BARQ) may beable to predict aggressive behavior tendencies (Hsu & Serpell, 2003), so
further evaluation of an animal that scores with aggressive inclinations on
the C-BARQ may not be necessary. In addition, approving an animal witha bite history may likely be controversial. It may be assumed that a dog that

Advocacy and Rethinking Our Relationships With Animals69

has bitten another human being or animal will not be appropriate for HAI
work. However, the circumstances of a single, isolated bite incident may
be explored if the animal otherwise passes a rigorous behavioral evaluation.
While basic obedience and following commands on cue are desirable
characteristics in an AAI animal, the in-house behavior evaluation should
focus primarily on the temperament of the animal and its reactivity tostressors. The animal should be placed in role-play scenarios representativeof a typical AAI encounter. In general, the animal should “enjoy” and seekinteraction with strangers without showing signs of stress, fear, aggression,
shyness, or avoidance (Mongillo et al., 2015). The animal should be accepting of rough or awkward handling, loud noises, being approached and/or
crowded by strangers, and exposure to medical equipment. For animals
working in trauma-informed AAIs specifically, it may be important torole-play by exposing the animal to people performing unstable or erratic
behaviors such as flailing arms and/or kicking, in addition to extreme
verbal emotions such as yelling and/or excessive crying. Exposure to bothindividuals and crowds may also be useful in determining the suitability of
the animal’s participation in group therapy sessions or other interventionsof similar intensity.
In addition, the frequency of behavioral indicators of stress should beclosely evaluated. This is often overlooked in AAI evaluations. A recent
study reported a high rate of stress signals (about 2.5 stress signals/minute) in a dog during the evaluation, suggesting that the evaluation process
may itself be a stressful circumstance (Mongillo et al., 2015). Ultimately,
this was not a factor in deciding whether the dog was suitable for AAI,
but the frequency, duration, and type of animal stress signals should bestrongly considered in AAI evaluations. A suitable animal may certainly
demonstrate these behaviors in response to stressors, but the animal should
be resilient and return to its normal state in a reasonable amount of time.
In dogs, behavioral signs of stress (often referred to as calming signals, appeasement behaviors, or displacement behaviors) include increased
restlessness, snout licking, paw lifting, yawning, body shaking, nosing, circling, increased locomotor activity, and lowering of body posture (Beerda,
Schilder, van Hooff, & de Vries, 1997; Beerda, Schilder, van Hooff, deVries, & Mol, 1998; Beerda, Schilder, van Hooff, de Vries, & Mol, 2000;
Schwizgebel, 1982). In horses, behavioral signs of stress include repetitive
head movements, flightiness, restlessness, sweating, kicking, vocalizing,

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TRANSFORMING TRAUMA

pinned back ears, tail swishing, and pawing (Fureix, Jego, Sankey, &Hausberger, 2009; Kaiser, Heleski, Siegford, & Smith, 2006; McBride,
Hemmings, & Robinson, 2004). Cats are often subtler in demonstrating
fear and anxiety by being more withdrawn and frozen. Outward indications of stress in cats include retreating, avoiding eye contact, low body
posture while ambulating, vocalizing, hissing, pinning ears back, and tailswishing (Landsberg, Hunthausen, & Ackerman, 2012; Levine, 2008). It
is important to note that demonstration of stress behaviors in all species
varies greatly among individuals; rather than relying on a single behavioral
indicator of stress, it is more important to note the frequency and durationof potential stress behaviors in the context of the situation, and compare
these behavioral outcomes to the animal’s normal baseline behavior in arelaxed setting.
Although the essential characteristics of being controllable, reliable,and predictable help to identify a good candidate, these qualities do notnecessarily indicate that the animal “enjoys” human interaction. While enjoyment is difficult to objectively capture, the presence of attention-seeking
behavior may suggest enjoyment. Unsolicited behaviors, such as approaching, sniffing, licking, nudging, and body contact with a stranger, indicate
the animal actively solicits attention, which is a desirable characteristic
to have in an AAI animal (Custance & Mayer, 2012). In addition, sustained eye contact may indicate the animal enjoys human interaction. Dogs
with higher levels of oxytocin are able to maintain gaze with their owners
and subsequently increase their levels of oxytocin (Nagasawa et al., 2015).
Staring directly at a stranger with soft eyes in a relaxed manner is a highly
desired behavioral skill/trait that indicates animal welfare is not threatened.
Once an animal has been deemed suitable for AAI, the animal’s healthand behavior should be constantly monitored, both inside and outsideof work. After being tested in the role-play, the animal should be further
evaluated in its actual working environment, as an animal deemed appropriate for one type of intervention may not necessarily be appropriate
for a different application, human recipient, or setting. Generally, physical examination should be repeated annually, and behavioral surveillanceshould be repeated every 2–4 years. However, these specifications should be
adhered to on a case-by-case basis. If health or behavior changes are notedsooner, it is the handler’s responsibility to ensure the animal is reevaluated.
For example, a dog that was stepped on by a human may exhibit panting

Advocacy and Rethinking Our Relationships With Animals71

and retreating behaviors that were not observed prior to the evaluation. The
animal should be medically evaluated by a veterinarian and behaviorally
evaluated by the overseeing organization to determine the cause. If thechange in behavior is situational and not observed in the animal routinely,
it may warrant an evaluator to observe the specific situation so he or she canaccurately assess and address the condition. It is critical that the handler be
educated and observant of these subtle signs of behavior change, as formal
evaluations only provide a single snapshot of the animal’s demeanor atthat particular moment and may not be representative of overall welfare.
The assessment of temperament and reactivity to stress in identifying
healthy animals that are predictable, reliable, and controllable apply toall species. However, it should be noted that specific characteristics andevaluation tools of species desirable for AAI other than dogs have yet to
be validated. Cats, for example, are required to be nonaggressive, social,calm, and not stressed. They should tolerate being passed from person toperson without struggle, and purring may be a desired behavior in AAI.
Because cats are more flighty and thrive in predictable and consistent environments, they are typically less tolerant than dogs in being transported
or adapting to new settings and people, but they can certainly be trained
and conditioned if their temperaments allow.
Importantly, during any AAI, the safety of the client must be alignedwith the safety of the animal, and methods to reduce risk of harm cannot
be underemphasized. It is understood that an animal should not induce
physical harm through bites or scratches toward a human, which is mostly
preventable by selecting the appropriate animal that is nonaggressive andcontrollable. However, inadvertent scratches, play bites, or falls over animals can be injuries that the AAI participant may sustain even with themost well-mannered therapy animals. For example, scratches may occur if a
dog unexpectedly jumps or paws at a person or if a cat moves on or off thelap of a person. Trimming and filing of nails on a regular basis is importantto prevent such incidents. An open animal mouth that comes into contact
with the recipient’s skin, possibly from play or mouthing behavior, may
result in pain and excessive bruising even if it does not break the skin. Any
mouthing behavior should be stopped and corrected immediately by thehandler. People should also be aware of where the animal is located at all
times to avoid any trips or falls, as musculoskeletal injuries can be severe,
especially in geriatric adults (Stevens, Teh, & Haileyesus, 2010; Willmott,

72

TRANSFORMING TRAUMAGreenheld, & Goddard, 2012). In addition, through appropriate medical
and behavioral screening of animals, hand washing, and practicing safe interactions as discussed previously, the risk of zoonotic disease transmission
from animal to human participant can be minimized.
Finally, it is critical that any adverse event be immediately reported tothe appropriate administrative staff, whether it be the facility, the certifying AAI organization, or insurance provider. To date, there are no known
scientific reports of the frequency of adverse events occurring in AAI, butthese incidents are likely underreported. People are reluctant to describe
any negative event associated with an AAI because they may perceive theevent to be mild, believe that it was just an accident, or want to avoid
negative repercussions for the animal, handler, or organization. However,
it is very important that all details be recorded so the proper authorities
can address the situation and apply any measures necessary to ensure thesafety of all future participants. Nevertheless, the best method of avoiding
adverse event reports is to prevent them from the beginning to ensure thesafety of all parties involved.
RECIPIENT SELECTION:ACCEPTING AND APPROACHABLE
Just as we select for animals that are predictable, reliable, and controllable,
we should select for AAI recipients with similar qualities. However, this is
not always possible as many AAI interactions are spontaneous, and it is difficult to ensure that a stranger, especially one who is emotionally distraught
from trauma, would possess any of these qualities. To best be prepared, theanimal-handler team should anticipate that the client will be emotional
and unpredictable. The ideal recipient of AAI is willing and accepting of
the animal interaction and relates to the animal in a gentle, nonthreatening
manner. A successful AAI is one in which mutuality is present, and where
the human benefits from contact with a nonstressed animal.
There are people for whom AAI is inappropriate, as it may pose a risk
to human well-being and/or animal welfare. The recipient should be informed of exactly what to expect during the visit, and be asked permission
to visit before introducing the animal. People with active contagious infection should not be visited. A protocol should be in place to alert animal

Advocacy and Rethinking Our Relationships With Animals73

handlers of a potential infectious disease and to prohibit visitation. If apatient has open sores or wounds, visitation should be discontinued. Not
only can animals acquire infection, but they can also pass infection on toothers. In addition, caution should be used when working with immunocompromised individuals to prevent transmission of zoonotic disease fromanimal to human. Appropriate medical screening of the animal, as well as
deliberate hand washing before and after interacting with the animal, canmitigate the spread of infectious disease.
Overall, the animal should not be forced upon an individual who
is unaccepting of a visit. Fear of, and allergies to, animals are common
reasons for a patient to decline an animal visit; in some cases, a fear ofanimals may be directly linked with the history of trauma. In addition, thehuman individual may not be in an appropriate emotional state to receivea visitor, whether it be human or nonhuman. An individual suffering fromtrauma may exhibit high anxiety, cry uncontrollably, and/or speak loudly,
all of which may result in a fear or stress response in the animal. However,notably, while crying may increase cortisol (Yong et al., 2014) and induce
submissive behavior in dogs (Custance & Mayer, 2012), it was recently
found that a stressed person had no significant effect on cortisol or behavior
in AAI horses (Merkies et al., 2014).
In trauma-specific cases, the AAI animal may also not necessarily
know how to respond to an individual with unpredictable behaviors andemotions. Consequently, the animal may engage in avoidant behaviors
or exhibit signs of stress when exposed to this individual. In addition,
people with anxiety disorders due to trauma are often hypervigilant andhave difficulty concentrating. Such physiological and behavioral indicators
can be unsettling to animals, which may result in higher anxiety or evenmirroring the recipient’s behavior. For example, a person who constantly
needs to use his or her hands may stroke an animal too quickly with excessive pressure, which could then cause stress and restlessness in the animal.
Fundamentally, animals may not understand the intention of a behavior;
they only see and experience the outcome.
The age of the recipient may also play a role in affecting animal welfare,since children and their frequent erratic behaviors invoke higher levels ofstress in animals as compared to adults (Marinelli, Normando, Siliprandi,
Salvadoretti, & Mongillo, 2009). One case study reported that an AAI dog
exhibited behavioral signs of stress and suffered from Cushing’s disease, an74

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endocrine disorder characterized by high levels of cortisol, after persistentengagement with children with disabilities (Heimlich, 2001). It has also
been shown that service dogs for autistic children form stronger bonds
with the parental figures than with the children (Burrows & Adams, 2008),
indicating that dogs may be more comfortable with adults than with children. While many AAI handlers anecdotally state that their dogs “love”
children, it is advised that handlers take a more proactive role in educating
children how to safely interact with animals.
Just as an animal should not be forced upon a human, a human should
not force himself or herself upon an animal. Some exuberant individuals
may have the tendency to thrust themselves upon an animal or engage inforceful petting, hugging, grabbing, pulling, squeezing, or pinching. These
individuals should be instructed how to safely interact with the animal,
ideally allowing the animal to approach the human first. Techniques that
may lessen the perception of threat to an animal include moving slowly,
speaking softly, and avoiding direct eye contact. In addition, positioning
oneself to be at the same level as the animal by crouching can be helpful. Guiding where the animal does and does not like to be touched, as
well as demonstrating the amount of pressure to apply during petting,are helpful techniques in ensuring the animal’s comfort and trust level.
The handler can also be effective in teaching the recipient what behaviors
indicate discomfort or stress, and to modify or discontinue the interaction if these signs occur. The recipient should recognize that an animal
interaction should not be taken for granted, but rather earned when the
animal learns it can trust him or her. This will lead to safer interactions
for all participants.
ENVIRONMENT SELECTION:
COMFORTABLE AND CONTROLLED
Even with the right handler, animal, and recipient, AAI may be unsuccessful if it does not take place in an appropriate environment. Onceclearance for animal admission is granted by the facility, many factors
should be considered when selecting the right environment conducive tothe health and welfare of the animal in AAI. The setting should ideallybe quiet and absent of sudden loud noises, as they may be distracting

Advocacy and Rethinking Our Relationships With Animals75

to animals, especially those with noise phobias. To ameliorate the stresswith unpredictable commotion, background noise such as classical music
may facilitate a more calming environment (Kogan, Schoenfeld-Tacher, &Simon, 2012). Similarly, the environment should be free of distractions.
The presence of other people, dogs, and/or human food may be distracting
and arousing to the AAI animal. If possible, the animal should be kept
separated from other animals to ensure appropriate engagement with thehumans involved. Although selection of the ideal AAI setting is preferred,
this may not always be possible to guarantee when working with traumatized populations in shelters, hospitals, or disaster/crisis environments,
settings that can be more unpredictable or stress-inducing to the animal.
Therefore, it is imperative that proper handler and animal selection be
performed in these cases.
The ambient temperature should be set at room temperature, typicallywhere both handler and client are comfortable. However, pocket pets,
birds, and reptiles often require warmer temperatures. If this is not possible, a heat source such as a warm pack or heating lamp should be available
to the animal at all times. Likewise, it is important that the environment
have secure footing for the animal. Most hospitals and institutional facilities have slick floors. While these are easier to sanitize, carpets or rubber
flooring are preferred surfaces for animals to walk.
Throughout the interaction, the environment should remain as clean
as possible. However, dogs have a keen sense of smell, and overwhelming scents of perfumes, cleansers, or deodorizers may be distracting andoff-putting to animals. In addition, animals may have contact allergies or
eye sensitivities to these aromatic compounds, so products should be usedjudiciously.
Importantly, the AAI location should have an area designated for the
animal for rest and respite. This serves as a safe zone where the animal cantake a “time-out” break and have access to water. If a space is not dedicatedto freedom from human interaction, the handler should take regular breaks
in a quiet area away from other activities. Therapy dogs should also haveeasy access to an outdoor area for urination and defecation.
The novelty of an environment appears to be an important factor to
the welfare of the animal as well. Although cortisol levels were not different in AAI dogs between the home and AAI setting in a recent study, they
were significantly higher in a novel setting (Ng et al., 2014). In addition,

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researchers recently proposed that the novelty of the setting was a significant factor in the high frequency of stress behavioral signals observed in
AAI dogs (Mongillo et al., 2015). An unfamiliar location may be stressful
to an animal, and the more acclimated the animal is with the environment, the more comfortable it will be. Therefore, it may be reasonable tointroduce the animal to the AAI environment for the first time without
human interaction.
There is some evidence that species-specific pheromones infused into
the environment by manual spray or plug-in diffusers can reduce stress andfear in dogs and cats in certain environments (e.g., Feliway spray or diffusers for cats) (Kronen et al., 2006; Tod, Brander, & Waran, 2005). This may
be a noninvasive method to make the AAI environment more comfortable
for the animal, especially when other factors cannot be controlled.
AAI may also take place outdoors, especially when working withhorses, engaging in farm settings and/or nature-based applications, orvisiting individuals in disaster locations (customarily with therapy dogs).
Extreme weather conditions, especially heat, should preclude visitation.
In outdoor environments, fresh water should be available at all times,
and shelter in a shaded area should be provided to avoid dehydrationand heat exhaustion. The most common ailments found in dogs working
in disaster areas are minor cuts and scrapes from debris, such as broken
glass, nails, or other sharp objects (Slensky, Drobatz, Downend, & Otto,
2004). Footwear on dogs may help in preventing some issues, but, again,
it is important that handlers are knowledgeable of basic first aid in thesesituations.
Another concern in outdoor environments is exposure to air debris,
toxins, and allergens. For example, search and rescue dogs deployed for
9/11 showed higher liver values, suggesting that they were exposed to highlevels of toxins or antigens (Otto, Downend, Serpell, Ziemer, & Saunders,
2004). However, these abnormalities were clinically insignificant, as there
was no evidence of increased incidence of liver disease, cancer, respiratory
problems, or behavioral conditions in these dogs compared to nonworking
dogs five years later (Otto et al., 2010). While no long-term effects have
yet to be reported in dogs working in disaster settings, handlers should becognizant of the particular risks involved.
Additionally, outdoor environments where wildlife or unvaccinatedanimals reside put AAI animals at risk of contracting a host of infectious

Advocacy and Rethinking Our Relationships With Animals77

diseases. Animals can easily acquire parasites such as fleas, ticks, and intestinal worms, which can be prevented with regular administration ofchemoprophylaxis. In addition, bacteria and viruses may be prevalent as
well, so ensuring the animal is current on vaccines recommended by theveterinarian is essential in ensuring animal health.
BEFORE THE VISIT
Once the key factors of choosing the right handler, animal, recipient, andenvironment have been decided, securing animal welfare depends on how
the AAI is conducted before, during, and after the session. To prepare theanimal before the visit, it should be confirmed that the animal has had
no medical or behavioral problems in the last 72 hours. As long as it ishealthy and willing to go to work, it should be groomed to be clean andfree of odors. While bathing regularly ensures a clean coat, bathing too
frequently may strip the coat of its natural oils, predisposing it to dryness
or other skin issues. Nails should be trimmed and filed down to reducerisk of injury from scratching. Teeth should also be brushed, if possible,
to minimize halitosis and dental disease.
At a minimum, dogs and cats should wear a collar with identifying
information. Pocket pets, birds, or reptiles should be confined to, andtransported in, an appropriately sized container before, during, and after
the session. If apparel, such as a scarf indicating it is an AAI animal, isworn for the visit, it should be nonobtrusive and placed on the animal
immediately before entering the facility and removed immediately after.
While many perceive that dressing animals in clothing or costumes makes
them look cute, this practice should be avoided, especially in animals that
do not typically wear them. Wearing clothes is not natural for the animal,
prevents tactile interaction between the person and the animal, and may
be uncomfortable or constricting.
Transportation to the AAI location may pose an issue to animals thatare anxious during travel. Some animals may be anxious during travel
if the only times they leave the home are for visits to the vet, which, as
discussed earlier, may be an adverse experience. Counterconditioning by
taking trips to positive locations and rewarding them may help mitigate
this particular stress. In addition, some animals may demonstrate travel

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sickness, an issue that warrants management advice from the veterinarian.
The animal should be given the opportunity to relieve itself upon arrivaland prior to entering the AAI facility.
DURING THE VISIT
During the visit, it is the handler’s obligation to advocate for the animal inregard to the duration, frequency, and intensity of the AAI. The handler
should be mindful of the animal, environment, and people visited, andable to recognize when a situation may not be safe or comfortable. The
handler should be vigilant in looking for an increase in stress-associatedbehaviors, and actively remedy distressing situations by modifying or concluding the visit.
The animal should be safely directed through the visit with attentive
guidance, rather than tight restraint. For example, a dog should be held
on a loose lead so it has some freedom to approach or remove itself froma stranger. If the interaction is in a confined environment, an appropriate
AAI dog may not necessarily be required to be on-leash, as cortisol levels
have been shown to be higher on-leash than off-leash (Glenk et al., 2013).
A small pocket pet, bird, or reptile can be gently handled as long as its
container is within reach.
The duration of the visit is an important factor in the welfare of theanimal. Traditionally, most organizations recognize that visits should be
limited to a maximum of one hour (Lefebvre et al., 2008). While recent
research findings show that cortisol levels in dogs did not change significantly over the course of a one-hour AAI session to indicate increased levelsof stress (Ng et al., 2014), the strict one-hour guideline is controversial
and warrants further investigation. For example, some animals are readily
accepting of a full hour of work, some may be unaffected by numerous
hours, and others may fatigue after a 20-minute interaction.
One important variable in AAI that likely impacts animal fatigue
is the intensity of the session. One study demonstrated that AAI dogs
that worked shorter sessions (one hour) had higher cortisol levels thandogs that worked longer sessions (more than six hours) (Haubenhofer& Kirchengast, 2006). The likely explanation for this is that the shorter
sessions were more intense while longer sessions were more relaxed andAdvocacy and Rethinking Our Relationships With Animals79

included frequent breaks. Therefore, the intensity and quality of the interaction likely matter more than the finite amount of time spent working.
For example, a dog may be able to tolerate a longer visit with one or two
immobile geriatric patients than with five to ten active children. This is an
important consideration regarding AAI with trauma, as sessions may be ofa higher intensity, and discussion of sensitive topics may foment extreme
emotions and actions in these clients. As a result, these sessions may be
more stimulating or stress-inducing to the animal, which requires more
frequent breaks and active monitoring for behavioral signs of stress.
No matter the session intensity, breaks for the animal are essential(King et al., 2011), and should serve as an opportunity for the animal to be
free of human contact, to play or express normal behavior, to relieve itself,
and to drink water. As previously mentioned, some handlers have expressed
concern about providing water for the animal for fear of the animal having an accident in the facility (Hatch, 2007). Healthy, well-trained dogs
should not have an accident if they are given the opportunity to go to thebathroom outside before and/or during the visit. In addition, restricting
water during work can lead to dehydration and contribute negatively tothe animal’s welfare. While no specific guideline for timing of breaks has
been validated, it should be given at least one during a session, especiallywhen behavioral indicators of stress are observed.
Hand washing and/or sanitizing is essential to the health of the animal and to all individuals who come into contact with that animal. In
fact, it is the most critical practice that can be implemented to combat
the transmission of zoonotic disease. This is important in all visits, butparticularly critical in hospital settings where contagious diseases such as
methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile (C. diff) are highly prevalent and can be easily transmitted. Although
AAI dogs in hospitals were colonized with such diseases in one study,
they were not found to be clinically infected or ill (Lefebvre et al., 2009).
However, the potential for infection in the animal or transmission to otherindividuals still exists. Since practices such as shaking paws, getting up on
beds, licking faces, and taking treats were risk factors for colonization of
MRSA and C diff, these activities should be avoided or kept to a minimum
whenever possible. Furthermore, excessive treats predispose the animal toobesity and can be distracting, so use of treats during AAI sessions should
be limited, if not prohibited.

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TRANSFORMING TRAUMAAFTER THE VISIT
After the session, the animal should be thoroughly rewarded to positively
reinforce the event and ensure a positive experience. Whether it is enthusiastic praise, play/exercise, toys, or treats, it should be a high-value reward
to that particular animal.
Monitoring forms should also be completed by the handler to record
the details of the AAI session. Accurate record keeping permits the AAI
organization or facility to monitor the progress of the visits and address any
minor issues that may have occurred. This information may include how
many people were visited, the duration of the session, session activities, andany adverse effects. A list of stress-associated behaviors may be provided
as a reference for individuals to report what was observed during the visit.
To prevent infectious disease, hand washing at the completion of thesession is essential. Since paw contact with contaminated surfaces is the
typical source of colonization, it may be reasonable for the handler to wipe
the paws with an antiseptic wipe as well. Bathing the animal after an AAI
session is likely unnecessary, unless contact with an infectious individual
is confirmed.
RECURRING VISITS AND RETIREMENT
The handler must be vigilant about monitoring for abnormal animal behaviors or symptoms in and out of work, paying close attention to theanimal’s response toward returning to the facility or to interactions with aparticular recipient. If there is hesitation to visit demonstrated by freezingor an increase in stress signals or behavior before, during, or after the visit,
further investigation is warranted. Any notable changes in behavior should
be assessed by an animal behaviorist or animal health expert associated with
the AAI organization. Of course, any abnormal health problems exhibitedby the animal should allow for him or her to be temporarily relieved ofduties and seen by a veterinarian. The return to work after illness should
be at the discretion of the veterinarian.
Every being that has a job should be granted the reward of retirement.
The decision to retire an animal from AAI work depends on a variety offactors. While the handler is the ultimate decision maker in this regard, heor she must be the voice and advocate for the animal. Two studies of AAI

Advocacy and Rethinking Our Relationships With Animals81

have reported that participating dogs passed away before the completion of
the studies (Braun et al., 2009; King et al., 2011), although specific details
about their fatalities were undisclosed. While their deaths are unlikely
to be related to AAI work, it brings up the ethical question of why theseanimals were not relieved of their duties prior to death. Some may argue
that animals still enjoy working until their final days, but this remains animportant issue in the life span of an AAI animal.
With the physical changes associated with aging, the veterinarian
should evaluate the animal on at least an annual basis. While senior animals can be affected by any chronic disease and/or cancer, one of the mostcommon and important clinical signs to watch for is pain. Discomfort
from osteoarthritis, exacerbated by obesity, is prevalent in older dogs,
and recent research has revealed that musculoskeletal issues are the mostcommon reason for guide dogs to retire early (Caron-Lormier, England,
Green, & Asher, 2016). Maintaining a healthy weight through diet andexercise is crucial, and joint supplementation may be helpful in slowing
the process. The handler must be cautious of activities that place physicalstress on the animal’s body during AAI, such as getting into and out ofcars for transport.
CONCLUSIONSOur current knowledge of the way in which AAI impacts the welfare ofparticipating animals is limited, with few studies rigorously evaluating theshort- and long-term effects. Since AAIs are so variable and dependent on
the individuals and circumstance, controlled prospective trials are scarce.
Likewise, research in this area has, to date, demonstrated mixed results
regarding the stress-related welfare concerns of working therapy dogs (i.e.,
see Glenk et al., 2013; Haubenhofer & Kirchengast, 2006, 2007; Kinget al., 2011; Marinelli et al., 2009; McCullough et al., 2018; Ng et al.,2014). The study of animal emotion, stress, and welfare is generally challenging, as these concepts cannot be measured directly, but rather throughbehavior and physiology (Mendl, Burman, Parker, & Paul, 2009). Even
with advances in measuring parameters such as cortisol, proper interpretation of this physiologic indicator is difficult, as an increase or decrease
does not necessarily correlate with a positive or negative emotion (Edgar,
Nicol, Clark, & Paul, 2012). Therefore, multiple physiological parameters

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should be interpreted in conjunction with behavioral signs. Future studies
should incorporate advanced imaging and cardiovascular effects to obtain acomprehensive look at the animal. In addition, as evident throughout thischapter and others in this volume, the field of HAI is heavily canine focused,
and research on all species used for this work will be valuable to the fieldin making future evidence-based and species-specific recommendations.
Although this discussion has focused on recognizing the potential
negative consequences and risks of HAI (and especially AAT/AAA) on
animals, we must acknowledge that there are likely beneficial effects forthese animals as well. When we have done everything in our power tosafeguard animal welfare, a positive AAI can be mutually beneficial forboth the human and the animal. In selecting the right handler, animal,
recipient, and environment, and following appropriate protocols, we will
ensure the success of these interactions.
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ABOUT THE AUTHOR
Zenithson Ng is a clinical assistant professor of veterinary medicine at the
University of Tennessee. He earned his veterinary degree from Cornell
University and completed an American Board of Veterinary Practitioners(ABVP) Canine/Feline residency, combined with a master’s degree inhuman-animal bond studies, at Virginia Tech. His research and teaching interests span all aspects of the human-animal bond, including theeffect of human-animal interaction on both humans and animals, theveterinary-client relationship, and stress reduction in veterinary andanimal-assisted intervention settings.

CHAPTER 3

Clinical Objectives for Animal-Assisted
Interventions: Physiological andPsychological Targets in TraumaInformed PracticeAndrea M. Beetz, MA, PhD; and Ira Schöfmann-Crawford, MA

In their lifetimes, many humans will experience traumatic events. Somewill cope successfully with such trauma and, within a certain amountof time, show resilience, and not suffer further negative effects. Others,in contrast, may develop post-traumatic reactions such as post-traumaticstress disorder (PTSD), which is frequently accompanied by other clinically
relevant symptoms such as depression, anxiety, substance abuse, or sleeping
disorders. Animal-assisted intervention (AAI), especially for PTSD, has
become more popular as a form of treatment. In the United States, particularly organizations for war veterans have worked with dogs and horses toimprove veterans’ quality of life and reduce symptoms of PTSD. Researchon this practice, as well as on AAI for other traumata — such as sexual abusein childhood and natural disasters — remains scarce.
In the following chapter, an introduction to traumatization and PTSD
and their neurobiological correlates will be given. Current forms of standard interventions will be described before the basis of AAI for trauma (i.e.,the scientifically documented effects of human-animal interaction [HAI]and the theoretical frameworks employed to explain the positive effects

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of animals on humans) is introduced. Then, briefly, the different possible
AAIs around trauma and their effects will be discussed, followed by thepresentation of current empirical evidence.
TRAUMA, PTSD, AND RELATED DISORDERS
Experiencing a traumatic event can lead to several reactions, including
acute stress reactions as well as the development of PTSD and comorbid
disorders. One of the first difficulties when dealing with trauma-related
reactions involves determining whether a reaction to a stressor is an abnormal, and therefore diagnosable, reaction or a common adaptive and normal
stress reaction. Today, the following reactions to traumatic experiences
are usually distinguished in accordance with the DSM-5 (the following
information on trauma, PTSD, neurobiology, genetics/epigenetics, andtherapy for PTSD is based on the edited book by Schnyder and Cloitre,
2015, which gives an up-to-date overview of the topic).
Acute Stress Disorder (ASD)/Acute Stress Reaction (ASR)

Acute stress disorder (ASD) can be considered a pre-stage of PTSD, anddescribes an acute stress reaction during the time directly after trauma
exposure. As in the diagnosis of PTSD, a traumatic event must have been
experienced and accompanied by feelings of fear, helplessness or horror,and symptoms of dissociation, reexperiencing, avoidance, and increased
arousal. The nature of the trauma may vary widely, from physical or sexual
abuse and torture to exposure to natural disasters, large-scale acts of violence, and accidents. However, for a diagnosis of ASD or PTSD, the event
had to be an exposure to death, threatened death of others or oneself, or aviolation of one’s physical integrity.
Post-Traumatic Stress Disorder (PTSD)

According to the DSM-5, besides the exposure to death or threatened
death, four other criteria need to be met for a PTSD diagnosis: reexperiencing of the event, avoidance of situations that could trigger the memory,
negative alterations in cognition/mood, and hyperarousal. Particularly thecluster of negative alterations accommodates feelings of guilt and thoughtsof self-blame that many with PTSD report, as well as negative expectations
about the world and the future.

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The estimation of the lifetime prevalence of PTSD strongly varies between countries and regions. The lifetime prevalence for American adults
is estimated between 7–12% (DiGangi, Guffanti, McLaughlin, & Koenen,
2013; Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). Living in aregion with higher exposure to traumatic events (crisis regions, refugee
camps, etc.) increases the occurrence of PTSD (e.g., 58% after combat exposure; Kessler et al., 1995, 2005). According to the National Comorbidity
Survey (NCS; Kessler et al., 1995), most US-American adults are confronted with leastwise one traumatic event. Professions with an increased
risk of experiencing traumatic events, such as rescue workers, also experience a higher prevalence of PTSD (Fullerton, Ursano, & Wang, 2004).
After one year, a 13% higher prevalence to develop PTSD occurred inworkers with disaster operation experience. Confirmed by several studies,such numbers indicate a cumulative influence of traumatic events, otherwise known as the building block effect (Schauer et al., 2003). This effectsuggests that anybody can develop PTSD; it is merely a matter of how
many traumatic events a person experiences. Neuner and colleagues (2004)
found in one sample of over 3,300 refugees living in the West Nile region,a positive correlation between traumatic load and PTSD prevalence, as
well as symptom severity.
THE PSYCHOLOGY OF PTSD
While several theoretical frameworks exist and are considered importantin the development of PTSD, only some of those, which can be connected
to AAI, will be discussed here.
Fear Conditioning Theories

Many theories about PTSD emphasize the way the trauma is processed
according to the functioning of memory. Regarding the main symptoms,
such as intrusive memories (e.g., flashbacks that seem so vivid that theperson feels like the traumatic event is happening again) or impaired
concentration, the idea of PTSD as a memory disorder seems plausible.
One of the most considered theories when it comes to anxiety disorders is
Mowrer’s two-factor theory (1960). According to Mowrer, previous neutral
stimuli present at the time of the traumatic event become a determining
factor in the development of PTSD; this is what is also known as classical

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conditioning. For example, a soldier’s camouflage uniform (conditioned
stimulus) becomes fear-associated with a particular traumatic event, suchas the explosion of an improvised explosive device (IED) on patrol (unconditioned stimulus). When the person is confronted with the conditioned
stimulus (i.e., the camouflage uniform), it evokes the memories of the
explosion and linked emotions, such as fear. By avoiding the conditioned
stimuli, and everything that reminds the person of the traumatic event,
PTSD symptoms decrease on a short-term basis (operant conditioning),
but over the long-term it maintains the disorder (Keane, Zimering, &Caddell, 1985).
Foa, Steketee, and Rothbaum (1989) and Foa and Rothbaum (1998)
emphasized that traumatic events violate the basic beliefs of safety. Thisemotional processing theory assumes that the activation of one memory(e.g., a sudden bang) would automatically generate the fear that was related to this event, including the physiological (sweating, heart beating),
emotional (fear), and behavioral (fight, flight, freeze) response. The fear
network can be easily activated by a large number of environmental cuesand has a low threshold.
Therapeutic interventions based on this theory would focus on theextinction of the conditioned response, by unlinking the conditioned
stimulus from the unconditioned response by exposure, while trying tomaintain a calm state (e.g., by using relaxation techniques, safety imagination, and/or AAI).
Cognitive Theory of PTSD

Threat appraisal is an essential factor in developing PTSD (Ehlers & Clark,
2000). In some cases, traumatic events may leave a person feeling like aconstant and continuous threat exists. Ehlers and Clark (2000) describe
pathological ways of coping and responding to such traumatic events.
Negative appraisals about 1) the probability with which the life-threatening
events will occur (overestimation, meaning that the world is a bad anddangerous place); 2) the capability of acting (self-efficacy) vs. being helpless(being helplessly exposed to threats); and 3) the self (bad things only happen to bad people, thoughts about being guilty) are most common. Ehlers
and Clark (2000) suggest that the memory of the trauma is incompletely
elaborated in matters of the context of time and place.
They also distinguish between two different memory functions,data-​driven processing and conceptual processing. Data-driven processing

Clinical Objectives for Animal-Assisted Interventions95

focuses on the memory of sensory information and leads to perceptual
priming, whereas conceptual processing focuses on embedding the information in the appropriate context (autobiographical knowledge). Many
PTSD patients report feelings of continuous threat because they overestimate the probability of the occurrence of negative events. This can lead tooverly cautious and seemingly paranoid behavior; for example, only leaving
the house with weapons or making their homes into highly secure fortifications. Because of impaired autobiographical memory processes (highly
associative and perceptual priming), PTSD patients often remember the
worst moments of the trauma, but fail to complement the traumatic influences and impressions with knowledge they currently possess (e.g., “I
survived and will see my family again”). This leads to continually experiencing the threat of the traumatic event instead of labeling it as a feelingof a past event.
NEUROLOGICAL THEORIES OF PTSD
The fear network model (Elbert & Schauer, 2002) explains how a higher
number of traumatic stressful events sum up and intensify fearful memories. Elbert and Schauer (2002) assume traumatic memories are arrangedin networks. Sensory, perceptual, and affective information, as well as
cognitions and the physiological response, are stored in a highly interconnected manner within these networks. When exposed to traumatic stress,
the body reacts with an alarm response with body and mind becoming
extremely aroused and/or energized, with the purpose of survival. Thishighly adaptive process includes fight or flight, and if neither is possible,
a freeze reaction (tonic immobility). Metcalfe and Jacobs (1996) refer tothe sensory, emotional, cognitive, and physiological responses in the network as “hot memories.” “Cold memories,” on the other hand, indicate
context information (spatial and chronological) and are stored separately(as opposed to the interconnections between the hot memory elements).
Within this model, it is evident that both the perceptional processes,
as well as parts of the hot memory system, occur in the same area of thebrain (e.g., amygdala, insula), whereas processes related to cold memories require hippocampus activity and medial temporal lobe structures(Brewin, Dalgleish, & Joseph, 1996; Brewin, Gregory, Lipton, & Burgess,2010). With normal or nontraumatic/nonstressful experiences, both hot

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and cold information are usually well combined and stored in the autobiographical memory. With traumatic experiences, this memory process
is disturbed. First, the rush of the stress hormone cortisol (released withtraumatic experiences and the resultant emotional state of alarm) affects
the hippocampus and therefore could explain the deficiency in declarative memory (Elzinga & Bremner, 2002). Second, according to the fear
network model, this network can grow, and single elements can graduallyintertwine. Every single hot memory node (e.g., emotions such as fear or
guilt; physical reactions such as trepidation; perceptions such as seeing
blood; smells in the environment; or cognitions) can be concurrently partof different traumatic events. Different traumatic events can lead to thesame reactions and share the same hot memory elements, and the fear
network can contain elements of more than one traumatic event. Thus,
the more traumatic events the person experiences, the wider the fear network grows. The activation of one node within this growing network can
activate the whole fear network itself and, with it, strengthen the interconnections of the network.
As mentioned above, the declarative memory processes are disturbed
during traumatic events and needed autobiographical representations of
the event cannot take place. The lack of an autobiographical representationof the traumatic event explains the occurrence of intrusive symptoms,
such as flashbacks (i.e., the ignition of one element of the network canlead to the activation of the whole structure with a feeling of actual circumstances in the “here and now”). In contrast, having a well-integrated
autobiographical memory causes the feeling — after the hot memory has
been triggered — to be accepted as having occurred in the past (Kolassa &Elbert, 2007; Wilker & Kolassa, 2013).
GENETIC AND EPIGENETIC FACTORS OF PTSD
The main factor in developing PTSD involves the exposure to a traumatic
event. However, current research focuses on genetic risk factors and theinteraction with traumatic load (Cornelis, Nugent, Amstadter, & Koenen,
2010; Wilker & Kolassa, 2013). Since the focus of this chapter is on theadvantages of AAI for trauma, only genetic and epigenetic factors having a potential influence on the development of PTSD (i.e., the genes

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responsible for the neurotransmitters serotonin and dopamine) will bebriefly discussed.
Serotonin inhibits the amygdala, thereby affecting emotional learning and memory (Meneses & Liy-Salmeron, 2012; Ressler & Nemeroff,
2000) and, in particular, fear conditioning (Greenberg et al., 1999; Heilset al., 1996; Lonsdorf et al., 2009; Munafò, Brown, & Hariri, 2008).
Additionally, dopamine has a large influence on the formation of fear
memories (Guarraci, Frohardt, Falls, & Kapp, 2000) and certain special
genetic types that affect enzyme activity, thus indirectly leading to higher
extracellular dopamine levels (Lachman et al., 1996) and impaired learning regarding fear extinction (Lonsdorf et al., 2009). Further research
has investigated genes associated with the glucocorticoid system and thecortisol-binding affinity and PTSD (see Bachmann et al., 2005; Binder,
2009; Hauer et al., 2011). While much of this research has been conductedin animal experiments, first studies in humans confirm genetic and epigenetic influences on the development of PTSD (Metha et al., 2013).
STRUCTURAL AND FUNCTIONAL BRAIN ALTERATIONSIN CONNECTION TO PTSD
For the sake of understanding, structural and functional brain alterations related to trauma and PTSD must briefly be discussed. Three brain
structures — the medial prefrontal cortex, the amygdala, and hippocampus — may be particularly influenced and modified by PTSD. Because of
its connection with the amygdala and the functioning of the hippocampus(which is responsible for explicit learning and memory [Rauch, Shin, &Phelps, 2006]), the medial prefrontal cortex plays an important role in
influencing the stress response. Alterations in volume of the hippocampus
have been found in persons with trauma (Smith, 2005; Woon, Sood, &Hedges, 2010) or PTSD (Karl et al., 2006; Kitayama, Vaccarino, Kutner,
Weiss, & Bremner, 2005), which could explain impaired autobiographicalmemory processes. Also, an increased amygdala reaction in PTSD patientswas found when exposed to aggravation stimuli (Brohawn, Offringa, Pfaff,
Hughes, & Shin, 2010; Hayes, Hayes, & Mikedis, 2012). This is associatedwith decreased activity in the medial prefrontal cortex after exposure to
aversive cues (Hayes et al., 2012).

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TRANSFORMING TRAUMASTANDARD PSYCHOTHERAPEUTIC INTERVENTIONS FOR PTSD
Prevention of PTSD

As mentioned above, experiencing traumatic events is likely to happen
during a person’s lifetime and most survivors, being highly resilient,
will adjust without needing psychotherapeutic intervention. However,in order to help prevent the development of PTSD, debriefings such as
Critical Incident Stress Debriefing (CISD) were developed for people
having experienced stressful events. CISD (Everly & Mitchell, 1999) involves a standardized, single debriefing session that can last up to 3–4
hours. Research, however, reveals no differences between debriefing receivers and non-receivers (Bisson, Brayne, Ochberg, & Everly, 2007).
Recommendations (Foa, Keane, Friedman, & Cohen, 2009) against theuse of debriefing interventions now exist since the self-healing processes
within the natural adaption skills after trauma would be disturbed. Today,
psychological first aid (PFA) (Brymer et al., 2006), which focuses on fundamental strategies to provide safety and emotional support or information,
as well as access to social support systems, is the preferred preventative
PTSD method.
The following evidenced interventions are regularly employed today.
Prolonged Exposure Therapy (PE)The underlying model of PE is the emotional processing theory (EPT; Foa& Kozak, 1985, 1986). The basic idea of EPT is that emotions, especiallyfear, are organized in the memory as cognitive networks. These networks
include different kinds of information about the feared stimuli, the fear
response, and the meaning associated with that stimuli and that response.
This is a natural and highly adaptive fear response, which should help people avoid danger in the future. To change the malfunctioning fear structure
in PTSD patients, Foa and Kozak (1985) suggest first activating the fear
network and then replacing the unrealistic (fearful) information with realistic information. Main therapeutic techniques include imaginal exposure(reprocessing the traumatic experience) and in vivo exposure using trigger
stimuli that the patient usually avoids.
The activation of negative emotions happens in a safe, therapeutic
surrounding, and corrective learning happens by gaining a new perspective
about what happened. Also, the repeated confrontation with the feared
memory leads to the realization that the trauma remains in the past.

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Revisiting the traumatic event may be stressful, but the patient does not
fall apart because of it.
Cognitive Processing Therapy (CPT)CPT for PTSD is based on the assumption of an assimilation of the traumatic event into already existing core beliefs (about the self, the others, andthe world) in a way that tries to make it consistent with existing personal
beliefs. CPT is divided into 12 different therapy sessions across five phases.
Phase one is about the differential diagnosis, phase two is about psychoeducation about PTSD, and phase three consists of the reprocessing of thetraumatic event. In phase four, the previous filtered beliefs and emotions
regarding the trauma are challenged and, if needed, changed. Phase five
involves the patient transitioning back to a functional life.
Eye Movement Desensitization andReprocessing (EMDR Therapy)

On the basis of the Adaptive Information Processing (AIP) model, EMDR
is an integrative therapy approach. Extremely stressful experiences canoverwhelm the information processing system. Usually the system tries
to integrate new experiences by linking them to already existing memory
networks. The system processes aversive experiences in a mitigating way
by linking them with the networks containing adequate information, suchas: “I have survived” or “I have successfully handled these things before.”
Traumatic experiences fail to be integrated into the existing memory networks and, therefore, the needed adaptive associations cannot develop.
These unprocessed (stressful) memories are accompanied by emotions,
physical sensations, and thoughts that occurred at the time of the stressful event. The source of dysfunctional beliefs and core values, such as: “I
am helpless and worthless,” are manifestations of unprocessed experiencesfrom the past. EMDR is a standardized eight-phase treatment (Shapiro,
2001). The patient is asked to follow the therapist’s hand movement fromside to side with their eyes (bilateral stimulation, also possible with acoustic or sensational stimulation) while thinking about the traumatic event.
During the process, associations, feelings, thoughts, and beliefs arise andare processed by the trauma survivor. Schnyder and Cloite (2015) note,“The goal is to stimulate the inherent information processing system of thebrain and, with as little clinical intrusion as possible, allow it spontaneously
to make the appropriate connections” (p. 210).

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Narrative Exposure Therapy (NET)Based on the fear network model (Elbert & Schauer, 2002; Metcalfe& Jacobs, 1996), it is assumed that traumatic memories are stored in a
“trauma network.” Emotional, sensory, physiological, and cognitive representations of the traumatic experience are identified as hot memory and areunconnected with the information about the context in the cold memory
system. The confrontation with environmental or even internal cues (e.g.,
noises, startle responses, cognitions) gives the impulse to activate the wholefear/trauma network, which leads to intrusive symptoms. Subsequently,
PTSD patients suffer from an easily ignitable hot memory system, withsevere difficulties in combining the appropriate cold memory (chronological, autobiographical, contextual) information (Schauer, Neuner, & Elbert,2011). The reconnection of hot and cold memory is the main purpose ofNET, and should result from constructing a chronological narrative or
lifeline (Catani et al., 2009; Crombach & Elbert, 2015; Elbert, Hermenau,
Hecker, Weierstall, & Schauer, 2012; Hermenau et al., 2012; Ruf et al.,2010; Schaal, Elbert, & Neuner, 2009; Schauer et al., 2004).
Following PTSD diagnosis and psychoeducation about the symptoms
and how to handle them, the patient is asked to describe his or her lifeline.
A long rope on the floor symbolizes the patient’s life span, and the patient
places objects that symbolize major events (rocks for negative events, flowers for positive events, and sticks for events about aggression) along therope. In the next session, the narration beginning at the very first momentof life starts. Step by step the patient constructs a chronological narrationof his or her life with a clear focus on traumatic events. The therapist asks
in detail about emotional responses, thoughts, and sensations, and thenlinks the memories to episodic facts (time, place), always ensuring that thetrauma survivor never disconnects from the “here and now” while talking.
At the end of therapy, the patient receives the complete narration of hisor her life.

HUMAN-ANIMAL INTERACTIONS (HAI) —EFFECTS RELEVANT FOR TRAUMA AND PTSD
Several effects of HAI, which could be relevant for interventions for trauma
and PTSD, have been documented by controlled research — be it as effectsof companion animal ownership, interaction with animals in experiments
or other settings, or as a result of AAI (primarily with dogs) (Beetz, Julius,

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Turner, & Kotrschal, 2012a). It should be kept in mind that since researchattempts to mimic and control optimal conditions, only the largely positive effects of HAI are demonstrated. In contrast, real-life HAIs might
not always be positive, and thus probably will not have the same desired
effects as research HAIs.
Social Effects

The company of friendly looking animals elicits positive social attention
from others (Eddy, Hart, & Boltz, 1988; Hart, Hart & Bergin, 1987), andthus, people walking dogs often know more people in their neighborhood(Wood et al., 2015). Several studies have documented that the presence ofanimals increases verbal and nonverbal social interaction, which has beentermed the “social catalyst effect” of animals. Furthermore, people in thecompany of animals receive more trust from others (Gueguen & Ciccotti,2008), which could be important for psychotherapy, particularly whenestablishing a good therapeutic relationship with the client (Schneider &Harley, 2006).
Psychological Effects

The presence of dogs seems to promote concentration and motivation(Gee, Church, & Altobelli, 2010; Gee, Crist, & Carr, 2010; Hediger &Turner, 2014; Wohlfarth, Mutschler, Beetz, Kreuser, & Korsten-Reck,
2013; Wohlfarth, Mutschler, Beetz, & Schleider, 2014); reduce depression(Souter & Miller, 2007) and anxiety; and help establish a sense of calmness,particularly before and during stress-eliciting situations (such as psychotherapeutic or medical treatments) (Barker, Pandurangi, & Best, 2003;
Barker, Rasmussen, & Best, 2003; Lang, Jansen, Wertenauer, Gallinat,& Rapp, 2010). Less established, but nevertheless documented by some
HAI research, is the reduction of pain perception, aggression, and thepromotion of empathy.
Neurobiological/Physiological Effects

As documented in numerous studies, interactions with animals canbuffer human stress systems. Endocrinology indices as indicators of the
hypothalamic-pituitary-adrenal system (HPA-axis), as well as cardiovascular parameters of the autonomic nervous system (ANS), are positively
affected during HAI. Particularly in stressful situations, physical contact with a friendly dog buffers human cortisol levels (Beetz et al., 2011;
Odendaal, 2000; Viau et al., 2010) and dampens the cardiovascular system

102

TRANSFORMING TRAUMA(Friedmann, Katcher, Thomas, Lynch, & Messent, 1983; Motooka, Koike,
Yokoyama, & Kennedy, 2006) by lowering blood pressure and heart rate.
Furthermore, contact with dogs, in particular familiar dogs, increases
the level of the hormone oxytocin and the neurotransmitter dopamine(Odendaal, 2000; Odendaal & Meintjes, 2003). Also, positive effects on
the general health of companion animal owners have been observed. Theseowners have fewer heart and sleeping problems, better fitness, fewer doctor
visits, and have a higher survival rate after myocardial infarction (Headey,
1999; Headey & Grabka, 2007; Headey, Na, & Zheng, 2008).
THEORIES EXPLAINING THE EFFECTS OF HAI
Why animals can have the effects described above, frequently measured
against the contact or standard treatments involving humans only, cannot
be explained by a single all-inclusive theory. However, the following mechanisms and theoretical approaches might help explain what makes HAI
different, and also possibly effective, for the treatment of trauma and PTSD
(for a more detailed report, see Beetz, in press; Julius, Beetz, Kotrschal,
Turner, & Uvnäs-Moberg, 2013).
Biophilia

Biophilia (Wilson, 1984) describes human affinity to nature in general,
including animals, which developed during evolutionary history andcontributed to the survival of humans (e.g., animals indicating danger or
predators representing a threat), thus improving their fitness (Serpell, 1986;
Wilson, 1984). This supposed interest is supported by the fact that children, already a few months old, show more interest in animals than objects(DeLoache, Pickard, & LoBue, 2011). Furthermore, the biophilia-effect(Julius et al., 2013) describes the linked phenomenon that on a subconscious level, humans seem to perceive calm and resting animals (specificallythose non-dangerous to humans — a resting lion or black widow spider
should not have this effect) in their immediate surroundings as a signal ofa safe environment, and experience feelings of security or safety themselves,
which is accompanied by psychological and physiological relaxation.
This concept could be further applied in trauma-informed AAI, especially in regard to animal welfare considerations. For example, if a horsedemonstrates calm and relaxed behavior during the intervention, one
could reasonably assume that he or she is not experiencing stress, at leastClinical Objectives for Animal-Assisted Interventions103

not significantly. This is encouraging and important information for thetherapist or handler to have as they monitor and support the animal’swell-being throughout the session. Moreover, evidence that the horse feels
comfortable in the therapeutic setting (via the absence of extreme alarm,
arousal, or agitation) may likely convey to the client that the environment
and therapist are safe and trustworthy. Interacting and connecting with arelaxed horse during therapy may generate feelings of calm or stillness inthe client as well, which could be particularly beneficial for those copingwith the aftermath of traumatic events. In other words, ensuring animal
welfare during AAI (which is often a complex and subjective process prone
to human error) is not only essential for supporting the participating animal, but also the integrity of the intervention.
Experiential vs. Verbal Symbolic System

An advantage of animals is their nonverbal way of communication andinteraction. In processing information and related forms of motivating
arousal, the experiential system and verbal-symbolic system (Schultheiss,2001) can be distinguished (implicit-experiential functioning and explicitcognitive functioning, respectively [Epstein, 1994]). The experiential system
directly processes sensory input from the real world, like sounds, pictures,and smells. This input is usually closely linked to emotions and employs
implicit memory or representations. In contrast, the verbal-symbolic system uses words and symbols to process information (Schultheiss, 2001)
and is associated with analytic-rational thinking and declarative memory(Epstein, 1994). Professional settings, such as psychotherapy, mainly employ verbal communication about consciously represented experiences.
However, when dealing with emotions, such as in the treatment of traumatization and PTSD, HAI, which emotionalizes while providing a focus
of attention and a feeling of security (see biophilia above), may set an ideal
stage for successful intervention. HAI promotes an advantageous balance
between the verbal communication with the therapist, while addressing
implicit-experiential processes and motivating clients.
Motivation

Similar to the information processing theories, in motivation theory intrinsic and extrinsic motivation (McClelland, 1985), or implicit and explicit
motive systems (Schultheiss, Strasser, Rösch, Kordik, & Graham, 2012),
are usually distinguished. While explicit motivation energizes behaviors
depending on rewards or avoidance of punishment, implicit motivation

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promotes enjoying executing a task for itself and acting for one’s own satisfaction. Implicit motives are triggered by natural incentives [(i.e., mostly
nonverbal stimuli [Stanton, Hall, & Schultheiss, 2010]) on an unconscious
level, and are closely connected with affect and behavior (McClelland,
Koestner, & Weinberger, 1989). Accordingly, goals are pursued in an affectively charged, “hot” mode (Schultheiss, Jones, Davis, & Kley, 2008),
while goals linked to explicit motivation are followed in a “cold” or neutral
mode. Animals seem to mainly activate implicit motives (Wohlfarth et al.,2013), and thus promote intrinsic motivation, which is mainly aroused via
the experiential system. All the sensory input that animals provide makes
it more likely to activate intrinsic motivation via the experiential system.
With traumatized patients, especially those with chronic PTSD, low motivation to participate in therapy might pose a problem. Via AAI, however,intrinsic motivation to participate in the intervention might be more easily
achieved, and thus could be utilized to work specifically on the trauma, inparticular the integration of the more accessible emotions and cognitions.
Activation of the Oxytocin System

A neurobiological mechanism, which might be key in explaining manyof the positive physiological, but also psychological, effects of animals
on humans, is the activation of the oxytocin system, mainly via touch(Beetz, Uvnäs-Moberg, Julius, & Kotrschal, 2012b; Julius et al., 2013).
Comprehensive research in animals and humans has documented thatthe activation of the oxytocin system, meaning the release of the hormone oxytocin, includes many of the same effects of HAI, such as thepromotion of communication, social interaction, trust, calmness, and agood mood, as well as a reduction of anxiety, stress-related parameters,
and pain perception. Oxytocin, a neurotransmitter and hormone, is released via stimulations like breastfeeding, massage, stroking, or in general,pleasant physical contact and touch (Beetz et al., 2012b; Carter & Porges,
2016; Insel, 2010; Uvnäs-Moberg, 2003). In several studies, oxytocin levels
rose after a person petted a friendly dog, and the effect further increased
when petting the person’s own dog (Handlin et al., 2011; Odendaal, 2000;
Odendaal & Meintjes, 2003).
This mechanism also explains why animal-assisted settings can promote the above-mentioned effects and set a good stage for successful
trauma-therapy, perhaps better than in a human-only setting. Patients in
AAI should develop more trust toward their therapist early in therapy, beClinical Objectives for Animal-Assisted Interventions105

in a better mood, be more motivated, be ready to communicate, and be
more relaxed. This is particularly important for patients with PTSD who
mistrust others and are anxious and stressed in many social situations.
While touch has no place in usual psychotherapy (and therefore the oxytocin system cannot be activated this way in these situations), touch is animmanent part of interacting with animals (Jegatheesan et al., 2015). In
addition to the traumatization, some patients may also have an insecureor disorganized attachment, which is associated with an impaired ability
to profit from social support and oxytocin-activation via touch from otherhumans (Julius et al., 2013).
Social Support and Caregiving

Touch can also be a form of social support, most often found in combination with emotional support (Ditzen et al., 2007). This combinedform of social support is the most effective in buffering stress responses(Demakis & McAdams, 1994; Ditzen et al., 2007). Even though therapists
provide different forms of social support, the aspect of touch is omitted
and with it a very effective way of reducing stress, which often prevails intrauma-therapy where patients are asked to confront their trauma.
A further advantage of animal-assisted therapy (AAT) is the chance toprovide caregiving to another living being. Caregiving behavior (George &Solomon, 2008; Solomon & George, 1999), which stems from the behavioral system developed to care for offspring (including holding, touching,
and feeding), is accompanied by oxytocin release (Uvnäs-Moberg, 2003)
and the positive effects thereof. However, in a therapeutic context, it would
be inappropriate for a patient to show caregiving behavior toward his or her
therapist, in particular any involving physical contact. Animals, in contrast,
are typically willing recipients of caregiving (feeding, brushing, stroking).
Thus, in their role as a provider of social support via their presence and as
recipients of care by the patient, animals can effectively activate the oxytocin system. Importantly, providing care and affection for an animal shares
many of the same positive effects as receiving social support (Dunbar,
2010; Julius et al., 2013).
Distraction and Mindfulness

Probably based on biophilia, as well as the fact that animals in our surroundings catch our attention, distraction might also be a mechanism to
explain some positive effects of HAI. Distraction effects might be most106

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prominent in the reduction of pain, anxiety, and negative mood (Beetz &Bales, 2016). Distraction effects have been found with music (Kleiber &Adamek, 2012), cartoons (Lee et al., 2012), clowns (Vagnoli, Caprilli, &Messeri, 2010), and engaging in video games (Nilsson, Enskar, Hallqvist,& Kokinsky, 2012; Patel et al., 2006). Additionally, the level of engagement with such distracting objects or experiences likely correlates withthe buffering of stress and negative emotions. Animals could be highly
engaging, and thus provide an optimal distraction for patients from such
symptoms as hopelessness or despair.
At the same time, interacting with animals provides effortless training
in mindfulness. Recently, mindfulness-based therapeutic approaches havebecome quite popular. When interacting with animals, humans need toconcentrate on what happens in the present and AAI, in comparison toother mindfulness trainings, provides a relatively easy way to achieve this.
Patients with PTSD, who suffer from intrusions of traumatic content andflashbacks, can certainly profit from mindfulness-based approaches. Theirproblems with concentration (due to sleeping issues, anxiety, and being
in a group setting), however, make more traditional mindfulness trainings
difficult. In contrast, simply interacting with animals, even if just goingfor a walk, grooming, or playing with an animal, is a very different but
effective form of mindfulness training.
ANIMALS PROMOTE OPTIMAL PRECONDITIONSFOR THERAPY
Optimal learning experiences, in education and likely in therapy, needsettings that promote attention, concentration, positive mood, motivation,
and a relaxed and calm state. Animals can help to establish such a positive
setting. In addition, even though they cannot take the role of the therapist,suitable animals in AAI can provide some aspects needed for successful
therapy, described as core conditions of client-centered psychotherapy by
C. Rogers (1951).
For example, animals usually present certain traits such as congruence,or genuineness, which allow clients to experience the therapist as they reallyare. Additionally, animals typically provide unconditional (or perceived
unconditional) positive regard— they do not care about human norms andClinical Objectives for Animal-Assisted Interventions107

simply react to how the client acts toward or around them. In AAI, friendly
animals interested in contact with humans and tolerant to some unusual
behaviors are employed. Animals can also provide empathy since they often
accurately perceive human emotions and states of clients (Albuquerque etal., 2016; Reid, 2009). PTSD patients, like most humans, might not show
their weaknesses, fears, or tension openly. Animals, in contrast, usually
pick up on a patient’s current state and act empathically, yet accordingly(e.g., by also showing consoling behavior or apprehension toward subtle
aggression, or by getting anxious with anxious patients).
Furthermore, since a prominent symptom of trauma is a lack of trust
toward others, the effects of promoting trust toward the therapist using afriendly animal is particularly important for patients having experienced
a trauma. Animals, therefore, could support the formation of a trusting
therapeutic alliance (Tedeschi, Sisa, Olmert, Parish-Plass, & Yount, 2015),
yet another key variable for successful therapy (Barber, Connolly, CritsChristoph, Gladis, & Siqueland, 2000; Shirk, Karver, & Brown, 2011).
Given that PTSD patients are generally hypervigilant with alerted
stress systems, which causes impairment of the information integrationfrom the fear network and autobiographical memory, therapy remains
a highly supported option. As mentioned above among the effects of
HAI, some, even if rather scarce, evidence exists that animal interaction
can increase serotonin levels in humans. If higher serotonin levels could
be promoted within an AAI, this would be very useful for patients withtrauma/PTSD, since the regulation of serotonin may be changed in these
individuals. However, increased serotonin also inhibits the activity of theamygdala, which promotes an optimal physiological activation allowing
for better integration of emotions and facts (of “hot” and “cold” memories,
see above).
As mentioned above, integrating animals can support very different
forms of trauma therapy, since it mainly affects the therapeutic setting. In
particular, when working with memories and emotions, AAI can be usefulsince animals emotionalize patients and help to regulate the activation of
the patient, calming them down or motivating them as needed. This optimal activation, in turn, is the precondition for optimal executive functions(Diamond & Lee, 2011; Miyake et al., 2000) including working memoryand self-reflection, which are only optimal in the absence of stress indicators (e.g., high cortisol levels, high sympathetic activity).

108

TRANSFORMING TRAUMAEXAMPLES OF AAI FOR TRAUMA
Prevention: Psychological First Aid (PFA) With Dogs

When humans, in particular large groups, experience a traumatic eventor critical incident, PFA attempts to prevent the development of a post-​
traumatic adjustment or stress disorder (Kaul & Welzant, 2005; Watson,
Brymer, & Bonanno, 2011). Animals can be integrated in this prevention.
In one example, the introduction of a specially trained dog after the homicide of a university student lifted the mood of the students attending thecrisis intervention and provided comfort to the students. Another exampleof trained dogs providing support and calm in the context of crisis intervention is described for children who have lost someone and are grieving(both examples cited in Eaton-Stull, 2015). Also, in Manhattan after 9/11,
dogs worked at Ground Zero with disaster relief to provide the people who
worked and volunteered there with social support, as well as a chance tofind distraction and connection to life during their breaks.
Interventions for Trauma and PTSD

While there may be many practice projects working with AAI for persons with trauma and/or PTSD, only a few studies have investigated theireffectiveness. One field in which AAI is popular is the therapeutic workwith those who have experienced abuse. Mainly equine-assisted interventions (Kemp, Signal, Botros, Taylor, & Prentice, 2013) or interventions
with dogs (Dietz, Davis, & Pennings, 2012; Hamama et al., 2011) can befound, with only a few involving other species. Group sessions, as well as
individual treatment conducted by psychotherapists and/or social workers,
have been investigated. Effects (see O’Haire, Guerin, & Kirkham, 2015)
include a reduction of depressive symptoms and PTSD symptoms (to include anxiety and dissociation) and the promotion of attachment security.
Another important field of AAI for PTSD is the work with war veterans. Here, both AAI with dogs and horses can be found (e.g., Döhrer,
Schöfmann, & Beetz, 2014; Ernst, Schöfmann, & Beetz, 2016), withresearch documenting a decrease in PTSD symptoms and depression, as
well as an increase in happiness, resilience, sleep, satisfaction, and social
support (Nevins, Finch, Hickling, & Barnett, 2013).
While the work with survivors of abuse or military veterans usuallyconsists of therapy, another form of AAI for traumatized persons is the support of traumatized witnesses via dogs during interrogation in court, by theClinical Objectives for Animal-Assisted Interventions109

police, or during clinical interviews. The calming and fear-reducing effectof dogs not only helps the person psychologically, but given that memory
retrieval is optimal in the absence of stress, these effects also promote a
more detailed and accurate account of events, which is important for the
precision of legal proceedings.
PTSD Service Dogs

An additional form of animal support involves service dogs that permanently live with the person with trauma-related problems or PTSD. Sucha long-term relationship provides the possibility of establishing a secureattachment. Companion animals indeed can develop into attachment figures for humans of all ages who seek social support from them when understress (McConnell, Brown, Shoda, Stayton & Martin, 2011; McNicholas& Collis, 2006; Rost & Hartmann, 1994). PTSD service dogs are mostly
found among military veterans and seem to improve their mental health,likely via the above-described effects and underlying mechanisms of
HAIs. Additionally, service dogs (or assistance dogs) also support veteranswith physical impairments due to injuries (amputations, blindness, etc.).
Anecdotal reports of one program, which also includes the veterans in the
training of service dogs, include improvements in patience, impulse control, emotion regulation, sleep, depression, sense of purpose, and further
symptoms and problems related to PTSD (Yount, Olmert, & Lee, 2012).
CONCLUSIONS
Overall, theoretical considerations based on existing knowledge about
trauma, PTSD, and the effects of HAI, as well as first experiences withanimals in the treatment and prevention of PTSD, support the justification of AAI for trauma. More controlled and peer-reviewed studies totest these assumed effects, however, are needed. O’Haire, Guerin, andKirkham (2015) reviewed the existing research (published in English) andfound that, indeed, AAI (with dogs and horses specifically) for trauma and
PTSD due to abuse and war trauma do have significant effects on PTSD
symptoms and related problems. Since, at the moment, there are only few
studies, AAI should be recommended as a complementary therapy andnot the primary treatment for trauma and PTSD (see Ernst et al., 2016).
Patients with trauma and PTSD need to undergo specific trauma therapy

110

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in order to integrate the emotional and physiological responses with theexplicit memories of the relevant event(s).

ACKNOWLEDGMENT
We would like to thank Christiana Crawford for her input on a first draftof this chapter.

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ABOUT THE AUTHORS
Andrea M. Beetz holds an MA in psychology and a PhD in psychology
and special education, and works as lecturer and researcher at the IUBH
University of Applied Sciences, Deptartment of Health Care (Distance
Learning), Bad Honnef, Germany, and the Department for Special
Education at the University of Rostock, Germany. The focus of her work is
on attachment theory, the human-animal relationship, and animal-assisted
interventions, especially in (special) education. She serves on the board of
the International Association of Human-Animal Interaction Organizations(IAHAIO) and as president of the International Society for Animal Assisted
Therapy (ISAAT).

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Ira Schöfmann-Crawford received a master’s in clinical and health psychology
from the University of Konstanz, Germany, in 2010, and is a licensed
cognitive-behavioral psychotherapist (Academy of Psychotherapy, Cologne,
Germany, 2018). She holds the rank of captain in the German Air Forceand works as a clinical psychologist at the Bundeswehr Central Hospitalin Koblenz, Germany.

CHAPTER 4

Implications of Animal-Assisted
Psychotherapy for the Treatment ofDevelopmental Trauma Through theLens of Interpersonal Neurobiology
Nancy Parish-Plass, MA; and Jessica Pfeiffer, LCSW, SSW

There has been a growing interest in the contributions of animal-assisted
psychotherapy (AAP) to the psychological healing process for children
who suffer from developmental trauma — that is, children who have experienced abuse (physical, emotional, sexual) or severe neglect (Bachi, Terkel,& Teichman, 2012; Balluerka, Muela, Amiano, & Caldentey, 2014; Dietz,
Davis, & Pennings, 2012; Muela, Balluerka, Amiano, Caldentey, & Aliri,
2017; Parish-Plass, 2008; Trotter, Chandler, Goodwin-Bond, & Casey,
2008; Eliana Gil in Sori & Schnur, 2015; Tedeschi, Sisa, Olmert, ParishPlass, & Yount, 2015; VanFleet & Faa-Thompson, 2014). This interest has
been extended to an attempt to understand how the integration of animals
into the process of psychotherapy may have positive impacts on neurological processes that will further facilitate healing from the neurological effectsof trauma (Bona & Courtnage, 2014; Perry, 2013; Trotter & Baggerly,
2019; Yorke, 2010). This chapter explores the therapy process throughthe lens of the principles of psychodynamic theory and psychotherapy,
especially play therapy, and then through the lens of interpersonal neurobiology of developmental trauma and therapy for those having experienced

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such trauma. It will be shown how these two lenses are interlinked and mutually reinforcing. This discussion will be developed in the context of AAP
as a form of therapy that integrates the psychological with the neurological,
uniquely advancing both processes for survivors of developmental trauma.
DEVELOPMENTAL TRAUMA — NOT JUST A TYPE OF PTSD
Trauma expert Judith Herman (1992) found in the literature concerning
adults with a history of trauma that there are many clinical manifestationsof prolonged exposure to repeated trauma that do not fit neatly into the
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria of
post-traumatic stress disorder (PTSD). These effects included symptomology 1) appearing to be more complex, diffused, and tenacious; 2) involving
characteristic personality changes, including deformations of relatedness
and identity; and 3) involving further harm, inflicted both by self andothers. The symptomology was characterized by a multiplicity of symptoms, somatization, dissociation, and affective changes. She referred tothis phenomenon as complex PTSD (cPTSD) or complex disorder of extreme
stress (DESNOS). Van der Kolk (2005) expanded the definition of complex
trauma to refer to “the experience of multiple, chronic and prolonged,
developmentally adverse traumatic events, most often of an interpersonal
nature [e.g., sexual or physical abuse, war, community violence] and early-​
life onset” (p. 402), and coined the term developmental trauma disorder.
He emphasized that exposure to such trauma usually commenced in earlychildhood within the child’s caregiving system and included neglect (physical, emotional, and educational) and abuse.
UNDERSTANDING THE PSYCHOLOGICAL EFFECTS OF
DEVELOPMENTAL TRAUMA IN THE CHILD
In her groundbreaking book, Trauma and Recovery, Herman (1997) statedthat disconnection from others is a core experience of psychological trauma.
This statement is in line with perhaps the most extensive theoretical, as wellas empirical, study of children with developmental trauma, initiated byJohn Bowlby. Bowlby studied the behavior of institutionalized infants andtoddlers, and later of mother-child dyads. In the institutions, he noticedImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma125

that, despite having been provided with warm clothes and proper food,these children failed to thrive physically, developmentally, cognitively, andemotionally. He concluded that this phenomenon grew out of the loss oforiginal caretakers (parents) and the lack of emotional availability for thechildren, as well as insensitivity toward the emotional needs of the children
on the part of the caretakers in the institution.
These observations led Bowlby (1969, 1973, 1980) to develop his theory of attachment, which, in turn, led to decades of intensive psychologicaland neurobiological research on the effects of various types of caretaker-­child relationships on a child’s development in all realms (psychological,
behavioral, cognitive, neurological, and physical). Bowlby’s theory of attachment is now the basis for understanding not only child development(both in healthy upbringing and in the face of developmental trauma),
but also for the healing of developmental trauma — both psychologicallyand neurologically.
Bowlby proposed that for healthy psychological development, a childneeds a primary caretaker who serves as a secure base from which she may
feel safe enough to explore the environment, and as a safe haven to which
the child may return in the case that she feels threatened. Caretakers ofchildren suffering from developmental trauma served as neither. Not surprisingly, Bowlby (1988) devoted two chapters in his book, A Secure Base,to a discussion on the subject of violence in the family as an example ofinsensitive and inconsistent parenting, from the point of view of attachment theory and insecure or disorganized behavior patterns. From this
discussion, it is clear that these patterns are a result of relational trauma.
From the research on the subject of the relationship between relational trauma (whether coming from abuse, neglect, divorce or separation,other traumatic family events, insensitive and/or inconsistent parenting,unresolved loss, or parental depression) and insecure or disorganized attachment, a picture has arisen of the pervasive psychological, emotional,
and behavioral effects of relational trauma. In a review of the consequencesof maltreatment, exposure to family violence and loss, Cook and colleagues(2005) found impairment in seven domains:• Attachment (e.g., problems with boundaries, distrust and suspiciousness, social isolation, interpersonal difficulties, difficulty
attuning to other people’s emotional states, difficulty with perspective taking)126

TRANSFORMING TRAUMA• Biology (e.g., sensorimotor development, somatization, in­creased medical problems)• Affect regulation (e.g., difficulty with emotional self-regulation,difficulty labeling and expressing feelings, problems knowing
and describing internal states, difficulty communicating wishes
and needs)• Dissociation (e.g., distinct alterations in states of consciousness,amnesia, impaired memory for state-based events)• Behavioral control (e.g., poor modulation of impulses, aggression toward self and others, pathological self-soothing
behaviors, difficulty understanding and complying with rules,
reenactment of trauma in behavior or play)• Cognition (e.g., difficulties in attention regulation and executive functioning, problems with processing novel information,
problems focusing on and completing tasks, difficulty planningand anticipating, problems with orientation in time and space)• Self-concept (e.g., lack of continuous, predictable sense of self,
low self-esteem, shame and guilt)
Many children who have suffered from abuse and/or neglect during
the preverbal stage of development may exhibit difficulty in symbolization (Thompson, 1999). Cicchetti (1990) outlined a number of deficits
found in maltreated children, two of which were (a) deficits in children’s
emotional language, and (b) deficits in children’s ability to decode facial
expression of emotions in others.
Crittenden (2006) proposed that maltreated children might be warierof failure, knowing that they may not receive support in the case of misjudgment, and therefore be in danger. These children will be less likely
to dare to attempt new strategies, leading to rigidity and preventing reflective integration as well as the development of alternative and moreelaborate dispositional representations (DRs), developmental pathways thatare the outcomes of the interaction between neurological maturation andexperience. Such a child will be likely to stay with immature and often
inappropriate strategies and behavioral responses in any given situation.
Van der Kolk (2005) notes that the effects of chronic maltreatment
and trauma are further complicated when the source of the distress isthe caregiver. These children are not likely to experience the external

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environment as a possible source of relief in distressing situations, andtherefore will have trouble relying on others for help. This observation isreminiscent of the insecure anxious avoidant pattern of attachment definedby Ainsworth (1985).
NEUROLOGICAL EFFECTS OF TRAUMA:
UNDERSTANDING THEIR PSYCHOLOGICAL IMPLICATIONSNeuroscience research has a long and impressive history reaching back toancient Egypt. From these ancient times and through the Middle Ages, it
was clear that the brain was the source of mental illness. Already in the 19th
century, neuron research was being conducted (Finger, 1994). In the 20th
century, universities instituted the study of what they called psychobiology,
which was later changed to neurobiology.
In recent times, the study of trauma has gained much ground interms of psychological theory and research (as covered earlier in thischapter through the work of John Bowlby, Judith Herman, and Besselvan der Kolk), as well as in theory and research in what has come to be
known as interpersonal neurobiology (as covered later in this chapter
through the work of Louis Cozolino, Daniel Siegel, Stephen Porges, andBruce Perry).
It is fascinating and even exciting to see how the study of interpersonal neurobiology reinforces these psychological theories, some of whichwere constructed through observation long before the current neurologicalstudy of trauma and others concurrently. In this section, we present theneurological underpinnings of the emotional, psychological, cognitive, andbehavioral implications of trauma mentioned in the previous section.
Among theorists and researchers in the area of interpersonal neurobiology and trauma, it is now well-accepted that prolonged stress in general,and especially developmental trauma, causes major damage to the neurological system and leads to a lack of integration between parts of thesystem. In an extensive review of the neurological effects of maltreatment(Teicher et al., 2003), it can be seen that maltreatment ceases the development of, or injures, three integrative areas of the brain: 1) the corpus
callosum (that links the left and right hemispheres); 2) the hippocampus(that links implicit memories to each other to form explicit memory); and128

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3) the prefrontal cortex (that links the cortex, the limbic area, and the brain
stem, controlling the body and the social world). As a result, information
flow will be disrupted.
Furthermore, maltreated children are more likely to suffer from problems with cortisol regulation, causing difficulties in social functioning(characterized by withdrawn or disruptive behavior) (Alink, Ciccetti, Kim& Rogosch, 2012). According to Prendiville (2016):
The resulting lack of smooth integration contributes to difficulties
in regulation and a compromised stress response system. When an
individual is in a state of alarm, the frontal cortex (the thinking
brain) and the limbic system (the emotional brain) shut down.
Only the lower brain areas are activated, and the individual will
struggle with establishing a feeling of safety, processing incoming information, successfully engaging with others, recognizing
emotional states, self-regulating [and] organizing their thinking. (p. 52)
Cozolino (2017) discusses the importance of the default mode network (DMN), a coherent neural network of various regions of the brain,
which continues to function even when we are in a resting state, until anovel situation or possible threat arises. The DMN allows us to “synthesize a sensory experience of the body and internal world that allows us tohave a conscious experience of ourselves in imaginal space within the flowof time” (p. 158), as well as to focus on our relationships. In disorders
characterized by anxiety, such as PTSD and developmental trauma, “Thesustained hyperarousal and vigilance . . . is a core factor . . . [that] disrupts
the ability to activate the DMN, exiling victims from their internal worlds,
a coherent sense of self, and the ability to connect with others” (p. 163).
Providing further evidence of the damaging effects of trauma on neurological development and the DMN, Daniels and colleagues (2011) foundthat DMN connectivity observed in women with severe chronic PTSD
due to prolonged maltreatment during childhood closely paralleled thatobserved in a study of children aged seven to nine years (Fair et al., 2008).
Bluhm and colleagues (2009) found less precuneus connectivity (PCC)with the right amygdala (the emotional center of the brain) in subjects
suffering from PTSD, negatively affecting the activity of the DMN.

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De Bellis and Zisk (2014) suggest that childhood trauma causes dysregulation of executive or control circuits, negatively affecting networks
responsible for one’s ability to think and regulate sense of self, motivation,and behavior. De Bellis and Zisk (2014) conclude that, “the data to datestrongly suggest that childhood trauma is associated with adverse brain
development in multiple brain regions that negatively impact emotionaland behavioral regulation, motivation, and cognitive function” (p. 205).
Suo and colleagues (2016) found in their study of pediatric PTSD
that damage due to trauma of one area of the brain will dramatically affectconnections with linked areas, and that trauma has adverse effects on brain
maturation, as well as causing abnormalities in the intrinsic connectivity
network. These phenomena, they pose, lead to decreased efficiency in thelocal and global network due to damage of linked regions of the brain.
According to Siegel (2012), this breakdown of connectivity, or linkage,
between areas of the brain prevents communication between these parts,
causing impaired integration, leading to dysregulation and anxiety. The
neural system is, thus, at risk to fall into a state of either chaos or rigidity.
Perry (2009) examines the consequences of child maltreatment on
the neural connectivity from a neurodevelopmental lens. Crucial sets ofneural networks originating in the lower, more primitive brain areas having
developed in utero, project into every other part of the developing brain.
That is, the organization of the higher areas depends upon the input from thelower areas of the brain. Perry (2009) writes, “If the patterns or incoming
neural activity [from the lower areas] in these monoamine systems is regulated, synchronous, patterned, and of ‘normal’ intensity, the higher areas
will organize in healthier ways; if the patterns are extreme, dysregulated,
and asynchronous, the higher areas will organize to reflect these abnormal
patterns” (p. 242). Each of these areas, or functional domains, mediates adistinct function: brainstem — sensory integration; diencephalon — regulation; limbic — relational; and cortex — cognitive.
The Neurobiological Effects of Developmental
Trauma on Social Engagement

According to the polyvagal theory (Porges, 2011), during times of threat,
our very neurons perceive and evaluate this threat (neuroception) without
any cognitive awareness, directing the individual toward defensive strategies.
Our higher-level neural systems (present in mammals) lead us to seek social

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engagement (the myelinated vagus parasympathetic circuit) for safety andlowering of anxiety. Should this strategy fail or not be available, neuroception leads us to devolve into a more primitive, sympathetic circuit leading
to either fight (aggressive behavior) or flight (avoidant behavior). If thisfails, the most primitive unmyelinated vagus circuit takes over, leading tofreeze (immobilization, shutdown), when there is less blood flow to thebrain, and dissociation may occur.
In connection with this dissociation, the breakdown in the functioningof the higher-level neural systems due to fear leads to cognitive impairment,
thus compromising one’s reactions, emotional responses, and thought(Prendiville, 2016). Rauch and colleagues (1996) found that a decrease in
the transformation of subjective experience into speech occurs during the
provocation of traumatic memories. That is, the traumatized person may
be at a loss of words to describe, even to himself, his traumatic experiences.
This research may explain what van der Kolk (1998) describes as a lossof explicit memories of certain events related to traumatic experiences.
However, the implicit memories still may remain, in the form of emotional and behavioral reactions to a stimulus with associated perceptions
without an accompanying explanation for these reactions and perceptions(van der Kolk, 1998). The presence of these reactions and perceptions arelikely to be anxiety-producing and stressful without an understanding of
their source or context.
According to Perry (2008), a prolonged stress response disrupts theneural system mediating this above response, possibly leading to a persistently activated state characterized by dysregulation and lack of ability
to self-soothe. One example of such prolonged stress is that of inconsistent,
abusive, or neglectful caregiving in early childhood, when the brain is most
rapidly developing and organizing. Such experiences alter normal development of neural systems involving relationships, together with the stressresponse and disorganization of neural systems mediating social-emotional
functioning (Ludy-Dobson & Perry, 2010).
There has been a great amount of research focusing on the neuropeptide oxytocin and its role in much of our social behavior and emotional
well-being in the presence of others. Porges (2011) suggests that oxytocin supports emotional and autonomic processes, allowing for what
he describes as immobility without fear (to be differentiated from immobilization or freeze due to helplessness). According to Carter (2017),
immobility without fear is an important biobehavioral enabler providingImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma131

opportunities to express attachment, a sort of “neural choice” to stay in
one place. In the face of challenge, oxytocin and activation of its receptors signal psychological safety, permitting positive social behaviors andpassive coping.
Among other findings, oxytocin has been found to be responsible forsocial affiliation and support (Carter, 1998; Heinrichs, von Dawans, &Domes, 2009; Theodoridou, Rowe, Penton-Voak, & Rogers, 2009), attachment security (Buchheim et al., 2009), trust (Kosfeld, Heinrichs, Zak,
Fischbacher, & Fehr, 2005), sharing emotions (Lane et al., 2012), reduction of fear response (Huber, Veinante, & Stoop, 2005; Meyer-Lindenberg,2008), and management of stress and anxiety (Heinrichs, Baumgartner,
Kirschbaum, & Ehlert, 2003; Neumann, 2002).
However, maltreated subjects have been shown to be characterized
by lower levels of oxytocin (Heim, Newport, Mletzko, Miller, Young, &Nemeroff, 2006) and oxytocin reactivity (Wismer Fries, Zigler, Kurian,Jacoris, & Pollak, 2005) than in controls. In a review article covering
the literature concerning the connection between oxytocin, experience ofmaltreatment, and their effects on trust, sense of safety, fear response, anxiety, and social interaction, Olff, Langeland, Witteveen, and Denys (2010)
suggest that, “Early stress and abuse experiences (particularly childhood
emotional abuse and neglect and early parental separation) seem to disrupt
the normal development of the oxytocin system in children, a mechanism
critical to the regulation of emotional behaviors increasing the risk of developing PTSD. This may lead to long-term disruptions in the ability to
be calmed and comforted by social bonding interactions” (p. 526).
Social connectedness and healthy relationships may serve as a buffer,or protective factor, from the neurobiological effects of child maltreatment, as well as a source of healing from maltreatment (Ludy-Dobson &Perry, 2010; Perry, 2009). Perry (2009) states that resilience and the ability
to cope with trauma are related to healthy relationships. Indeed, Zimrin(1986) found that one factor predicting higher functioning among adults
who were maltreated as children was either the presence of an empathetic
adult at the time of the maltreatment, or alternately, long-term psychotherapy (that is, the long-term presence of an empathetic figure after themaltreatment).
These implications of social connectedness reinforce the importance of therole of social engagement as a protective strategy proposed in the polyvagal theory. Porges and Carter (2011) state that “systems that support sociality, because132

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they are intertwined with restorative physiological states, also may be protective
against the costly or destructive effects of chronic fear or stress” (p. 58). Thatis, social support and connectedness protect from the neurological damage
usually occurring due to maltreatment, thus preventing developmental trauma.
GOALS AND PROCESS OF PSYCHOTHERAPY FOR TRAUMATaking into account the psychological and neurological origins and implications of developmental trauma, the literature recommends three majoremphases for the therapy process for survivors of developmental trauma.
The first emphasis involves psychotherapy based on a healing relationshipbuilt on support, understanding, acceptance, and trust, and which provides
a sense of safety and presents a healthier model of relationships.
Herman (1997) states that, “recovery [from trauma] can take place
only within the context of relationships” (p. 133). Similarly, Banks (2006)
sees the destruction of relationships as the largest obstacle to healing fromthe effects of trauma. She feels that models of therapy striving for objectivity and neutrality, and attempting to help the client to overcome
dependency, may in fact retraumatize the client with a history of childhood
abuse. Banks recommends relational therapy with the goal of the development of a mutual, growth-fostering relationship.
Pearlman and Courtois (2005) expand on the relevance of relational
therapy for complex trauma, noting the need to treat attachment disturbances and dissociative processes in the context of the therapeutic
relationship. Pearlman and Courtois explain that an attachment-relational
approach also emphasizes the formation of the therapeutic alliance1, theestablishment and maintenance of the framework of treatment and its
boundaries, and the addressing of relational and behavioral reenactmentsof past attachments and trauma. Cloitre, Stovall-Mclough, Miranda, andChemtob (2004) concluded from the results of their research that “thetherapeutic relationship may be an especially ‘active’ ingredient in the remediation of childhood abuse-related PTSD” (p. 414).
Likewise, Ludy-Dobson and Perry (2010) refer to the “biological giftof the healing power of relationships” (p. 39). Siegel (2010) states that
attunement with another allows for resonance with the inner world of theother, leading to a feeling of “feeling felt,” resulting in the feeling of security
found in close relationships. This relational attunement and resonance canImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma133

be explained by a process called brain-to-brain coupling (Hasson, Ghazanfar,
Galantucci, Garrod, & Keysers, 2012) in which signals are transmitted tothe environment by one neural system and perceived by another neuralsystem and synergy may be achieved.
The second emphasis involves recognition of the trauma itself, processing it, and forming a meaningful narrative. Both Herman (1997) andvan der Kolk (2005) stress that, in order to heal, victims of trauma must
remember, proclaim, mourn, and process their traumatic experiences.
According to van der Kolk (2005), therapy must emphasize the recovery
and integration of traumatic memories with their associated effects, as wellas the necessity for validation of the patient’s traumatic experiences. The
validation of the trauma is a precondition for restoration of an integrated
self-identity and the capacity for appropriate relationships with others.
Here, it is important to activate implicit memory (expressed in physical sensations, emotions, perceptions, and behaviors), which should beprocessed into explicit form in order to enable the trauma to be recognized
and consequently be worked through, leading to a narrative that adds
meaning and sense to the trauma.
The third emphasis, on the neurological level, is on the regrowth ofneural connective tissue, or linkage, between regions of the brain, resulting in integration within the neural system (Siegel, 2012). According toSiegel (2012), the individual will then be able to achieve 1) emotionaland behavioral self-regulation; 2) understanding of self, with the ability to
express oneself and one’s needs to others; and 3) participation in healthy
relationships. These achievements will lead to lower anxiety and to higher
and more satisfying functioning.
An interaction exists between these three emphases, each mutually
reinforcing and facilitating each other, leading to the psychological andneurological healing of the effects of relational trauma. According to Geller
and Porges (2014), “The capacity of the brain to develop new neural connections leading to calmer and healthier emotional states is facilitated whena safe therapeutic environment is promoted through the cultivation andexpression of therapists’ presence” (p. 188). One can see that the emphasis
on interpersonal neurobiological principles will facilitate the healing relationship as well as the work dealing more directly with the trauma itself.
Furthermore, participation in a healthy relationship in therapy, together
with recognizing the trauma and the related narrative, as well as finding thewords to express the sensations (that is, turning implicit knowledge into

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explicit knowledge), will in turn further the regrowth of neural connective
tissue and neural integration.
Originating from his neurodevelopmental approach to interpersonal
neurobiology and trauma, Perry (2009) created a therapy approach called
Neurosequential Model of Therapeutics (NMT). In the first stage of NMT,
deficits and the related systems and areas of the brain are first identified.
The second stage involves targeting patterned, repetitive activation in theneural systems that mediate the dysfunction in the sequence that is identical to the normal sequential process of development. In other words,
therapy should commence with deficits associated with the lowest areaof the brain, sequentially moving up the brain to the next deficit as improvements are seen. For instance, self-regulation, anxiety, and impulsivity
should be targeted before emotional problems, and then only afterward
should cognitive problems be addressed. Perry emphasizes that a key component of the NMT model is the relational environment of the child inthat it serves as the major mediator of therapeutic experiences.
PLAYING THE TRAUMA: PSYCHODYNAMIC RELATIONAL
THERAPY WITH CHILDREN SUFFERINGFROM DEVELOPMENTAL TRAUMAChild psychotherapists have long known that the best way to peek into
the inner world of the child is to be present for, or join in on, the child’s
play (Axline, 1969; Freud, 1946; Klein, 1932; Landreth, 2012; Winnicott,1971). Play is a form of self-exploration and expression of experiences,emotions, and thoughts that children may have difficulty, or have a fearof, verbalizing to others (Landreth, 2012) or even to themselves.
Potential Space and Its Importance in Play Therapy

An element critical to play is the concept of potential space. According toWinnicott (1971), the potential space is the intermediate area of experiencing, or transitional space between one’s outer reality and inner world,allowing for play that brings together elements of both worlds in such a
way that helps the client work through conflictual and anxiety-producing
issues. Potential space exists only in a setting that feels safe to the client,
allowing for the reenactment and reexperiencing of feelings, thoughts,
and experiences without fear of actual danger, as well as offering a safeImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma135

environment for emotional expression, observation, and contemplationof thoughts, emotions, and dynamics, and for the freedom to consider
options and possible solutions.
Thirty years after Winnicott coined the term potential space, Raichle
and colleagues (2001) coined the term default mode of brain function, occurring when a person is not involved with goal-directed activities. As
described earlier, only when the neurological network involved in the default mode (or DMN) is at rest, and there is no sense of threat, can one
experience an imaginal space in the flow of time. This process may serveas the neurological explanation of Winnicott’s concept of potential space.
Play occurring within the context of a facilitating and generative relationship with a psychotherapist permits the development of a sense of
security within the therapy setting (Levy, 2011).
The Interpersonal Neurobiological Implications of Play Therapy
for the Healing of Developmental Trauma

In the last century, Vygotsky (1976) posited that make-believe or sociodramatic play leads to self-regulation. Authors of literature review chapters(Gioia & Tobin, 2010; Whitebread, Coltman, Jameson, & Lander, 2009)
discuss research that reinforces this observation, in terms of both behavioral
and emotional self-regulation and especially when a supportive adult (suchas a therapist) participates in this type of play together with the child.
The literature concerning trauma psychotherapy for children often
refers to the play therapy approach (Gaskill & Perry, 2014; Gil, 2017; Gil& Terr, 2013; Goodyear-Brown, 2010). This is not surprising since a greatamount of significance is attributed to the role of play in interpersonal
neurobiology (Gaskill & Perry, 2014; Porges, 2015b; Siegel & Bryson,2012), especially in the context of self-regulation.
Porges (2015b) states that play serves as a neural exercise of using thesocial engagement system to efficiently downregulate our fight/flight behaviors, requiring practice to become effective. The improvement of neural
regulation of our social engagement system leads to resilience in dealing
with disruptions in our lives. According to Porges (2001), “It may be possible that creating states of calmness and exercising the neural regulation ofbrainstem structures may potentiate positive social behavior by stimulatingand exercising the neural regulation of the social engagement system” (p.
142). In this way, play enables the neural systems of maltreated children
to become familiar with, and capable of, the regulation of their defensive

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systems, going back and forth between fight/flight and social engagement,
and experiencing types of social engagement and recognizing its presence.
Siegel and Bryson (2012) note that reactivity, originating in the lower,
more primitive brain, makes one feel shut down, upset, and defensive. The
receptive state activates the social engagement system, related to the upperareas of the brain, and gives one a feeling of being safe and seen. Siegel
and Bryson then posit that playfulness, in the presence of a supportive andinvolved adult, turns reactivity to receptivity.
Explaining play therapy in a way that combines psychological andneurobiological principles, Levy (2011) states that, “Affect regulation,
self-awareness, and self-complexity is developed by the process of containing, regulating, and repairing the treatment relationship, the engenderingof experimentation, and promoting the experience of self-states throughplay” (p. 53). Levy further explains that experiencing various self-statesin the play therapy relationship is related to the promotion of greater
complexity in the child’s self-organization. These self-states become moreelaborated, more flexibly experienced, and better integrated within thechild’s personality.
Siegel (2015) states that play cultivates integration, both relationallyand neurologically. That is, integration actually links fibers between brain
areas, allowing for neural communication and therefore creating balance.
Play helps clients to start imagining, to search for meaning and narrative. Integration and finding meaning together increase neural regulation,
lower anxiety, and provide a feeling of safety. Yet there are factors resulting
from the experience of chronic maltreatment by an adult that are likely
to prevent these processes from occurring. These are discussed in the following section.
BARRIERS TO PSYCHOTHERAPY IN CHILDRENWITH DEVELOPMENTAL TRAUMA
Poor Therapeutic Alliance

Many researchers and theorists point to the nature of the connection
between attachment style and the therapeutic alliance, specifically thatavoidant style of attachment (both dismissing and fearful) was related
to poor therapeutic alliance (Eames & Roth, 2000; Kivlighan, Patton,& Foote, 1998; Mallinckrodt, Gantt, & Coble, 1995; Mallinckrodt,Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma137

McCreary, & Robertson, 1995; Mikulincer & Shaver, 2010; Parish &Eagle, 2003; Robbins, 1995; Satterfield & Lyndon, 1998). Research suggests that the client may project onto the therapist feelings, perceptions,
expectations, and sensitivities from previously established working models formed by past relationships and experiences with abusive attachment
figures, negatively affecting the establishment and development of thetherapeutic alliance (Gelso & Carter, 1994; Green, 2006; Satterfield &Lyndon, 1998; Mallinckrodt, 1991).
In his research on the impact on neurobiological systems of childmaltreatment as a social experience, Cicchetti (2002) found an interaction between cognitive, social, emotional, and biological systems to be alikely contributor to maltreated children’s construction of their world asmarked by fear and hypersensitivity to future maltreatment. Lack of trustin the intentions of others (Briere, 1988; Herman, Russell, & Trocki, 1986;
Putnam, 2003; Somer & Szwarcberg, 2001; van der Kolk, 2005), as well asa lack of understanding of social cues and intentions of others (Cicchetti,1990), is a common consequence of interpersonal trauma. Therapy, thevery situation that is meant to heal, is often perceived as emotionallythreatening. This phenomenon is likely to have a negative effect on theestablishment of the therapeutic alliance.
Therefore, social engagement, which is meant to reduce anxiety andheal the brain from the effects of interpersonal trauma, instead is inhibited,
activating the client’s more primitive, sympathetic circuit of fight or flight.
That is, the client is likely to be avoidant of a relationship with the therapist. Indeed, Lopez, Melendez, Sauer, Berger, and Wyssmann (1998) founda relationship between insecure attachment and dropout rate from therapy.
Many other studies have found a high rate of attrition among maltreatedchildren suffering from PTSD (Murphy et al., 2014). Chemtob, Novaco,
Hamada, and Gross (1997) found that PTSD-related anger symptoms
caused ruptures in the therapeutic relationship.
In order to uncover the root of trauma responses in children and successfully guide healing, the therapist must overcome resistance and defenses
presented by the children toward the therapy process. The therapy setting
must be perceived as safe, which will not occur if the therapist present isfelt to be dangerous.
To remedy this situation, Zoicas, Slattery, and Neumann (2014) suggest that since the oxytocin system is associated with social fear, restoringbalance to the oxytocin system may alleviate some of the symptoms. Olff

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and colleagues (2010) suggest that oxytocin may enhance a sense of safety
and perception of the therapeutic relationship as a place providing support. They suggest administering oxytocin prior to therapy sessions withsufferers of PTSD in order to increase the building of the therapy allianceand enhance therapy outcome. A review by Striepens, Kendrick, Maier,and Hurlemann (2011) of studies employing the use of internasal oxytocin for its therapeutic potential notes the plethora of prosocial effects,
including the domains of trust, generosity, socially reinforced learning,and emotional empathy.
This research seems to point to the benefit of the use of exogenous
oxytocin, which would lead to immobilization without fear, allowing theclient to stay in the therapy setting with the therapist, and letting the therapeutic alliance occur. However, Carter (2017) points out that conditions
such as chronic use of exogenous oxytocin, or its use in exceptionally highdoses, may downregulate the oxytocin’s own receptors.
Collapse of Potential Space

Whether the medium for therapy is that of play (in the case of children) or
direct discussion (in the case of adults), the existence of potential space isa critical element in the process of psychotherapy. However, contact with
one’s inner world of emotions and content related to the trauma is likely
to raise the trauma survivor’s anxiety, leading to reexperiencing the danger
associated with the trauma, the collapse of the potential space, and escapefrom this emotionally dangerous content into the real world. When thisoccurs, the client often becomes emotionally unavailable for therapy.
In neurobiological terms, contact with a threatening inner world may
cause the polyvagal system to inhibit the limbic (emotional and relational)
and cortex (cognitive) areas of the neural system, leading to flight (fromcontact with the threatening content) or even dissociation.
Anxiety found in children suffering from developmental trauma may
also originate from the lack of integration in the neurological system, as
explained earlier in this chapter. Lack of words, deficits in ability to decodefacial emotional expression, and lack of explicit memories make it difficult
to ascribe meaning to experiences and prevent the formation of a coherent
narrative. Fearing the emotional chaos in their inner world, these children
will prefer the certainty of reality, resulting in the collapse of the potential
space that is essential for self-expression through play.

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma139

Cozolino (2017) explains that the DMN is chronically inhibited after
severe trauma in early childhood, significantly impairing one’s ability todevelop a coherent sense of self, affect regulation, introspection, and empathy for others. As a result, a child with developmental trauma may neverachieve the ability to withdraw into an inner world for comfort. With noaccess to their inner world, play therapy is not an option. As a first step,
the therapist must employ a treatment context involving the amygdala.
Deficit in Ability to Symbolize

Many children who suffered from maltreatment during the preverbal
stage of development may exhibit difficulty in symbolization (Thompson,1999). According to Siegel (2012), relationship histories may impair thedevelopment of the mentalizing reflective function as a result of impairment of the integrative function of essential associative neural pathways,
specifically a blockage of the corpus callosal fibers interconnecting the twohemispheres, and of interconnections within the right hemisphere itself.
Siegel (2012) writes, “This impairment can be pervasive and can lead to achild’s generalized inability to mentalize, as revealed in impaired symbolicplay” (p. 261), making the use of potential space difficult if not impossible.
Shame and the Presentation of False Self to Others

In research that focuses on trauma in general and abuse in particular,
shame is a prevalent and significant factor resulting in the delay of disclosure of the abuse by the victim (Hershkowitz, Horowitz, & Lamb, 2005;
Lev-Wiesel, Eisikovits, First, Gottfried, & Mehlhausen, 2016). Studies
have shown that maltreated children suffer from low self-esteem (Pearce& Pezzot-Pearce, 1997) and see themselves as devalued and incompetent(Bretherton & Munholland, 1999). Furthermore, according to Feiring and
Taska (2005), “Persistent shame may explain failure to process the abuse
and the maintenance of posttraumatic stress disorder symptoms” (p. 337).
The explanation behind this finding may lay in the unbearable shame
the abuse survivor feels as a result of the abuse, and the need to hide thatshame from others and also from oneself. This process leads the client topresent a false self 2 in an attempt to hide the source of the shame, and tohide from the resulting emotional pain, resulting in the lack of authentic
emotional expression and self-disclosure of thoughts and events. Instead,the client tries to appease the therapist and to present a more positive self

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to the therapist. As in the discussion above concerning the collapse of thepotential space, the client will be less able to make use of the therapeutic
relationship for healing, and she may even withdraw from it (Safran &Muran, 1996).
Loss of Touch With Self

A well-known consequence of trauma, especially in the case of sexual abuse,is the experience of emotional and sensory numbness. Dissociation may
occur when either fight or flight fails to protect or is not an option. Yetanother reaction to the trauma may involve the trauma survivor becoming
emotionally overwhelmed and trying to hide the emotions or even the factof the abuse from themselves or from others. In many cases, there will be amemory deficit concerning the trauma. Memory deficits may be explainedby a disruption of neurological functioning caused by chemical responses
to the trauma (U.S. Department of Health and Human Services, 2014).
Whether the reaction is numbness, dissociation, feeling of being
emotionally overwhelmed, or lack of memory, the client will have a very
difficult time in therapy recognizing and processing the trauma, and creating a coherent narrative surrounding it.
If the sensory issues related to the trauma (originating from the brainstem) are not recognized and processed, then the higher parts of the neuralsystem will become poorly regulated and dysfunctional — emotionally,
behaviorally, relationally, and cognitively. The client will be unable tocognitively make sense of the trauma she suffered and to work through it.
This will likely lead to the client formulating an alternative and false explanation for the implicit memories (expressed in emotional and behavioral
reactions), thereby preventing their translation to explicit memories andthe process of healing.
Lack of Regulation

Though extreme dysregulation can be a symptom for a child who has
experienced trauma and for a child who has experienced neglect, at theneurobiological level the roots of this symptom differ in the impact they
have on the developing brain. Trauma, in simplistic terms, is the over-­activation of the stress response system for extended periods of time, which
in turn causes that system to change. Neglect is the opposite. Neglect isthe absence of activation for the neurons in critical and sensitive periods
during development. For both, the fact that the brain is a use-dependentImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma141

organ and develops in a sequential fashion is at the center for each formof maltreatment (Perry, 2008).
According to Perry Pollard, Blakely, Baker, and Vigilante (1995), theacute adaptive states, during and following traumatic events, can become
maladaptive traits if they persist long enough. Perry (2009) writes:
When a child is threatened and the stress response is activated in
an extremely prolonged or repetitive fashion, the neural networks
involved in this adaptive response will undergo a ‘use dependent’
alteration. The very molecular characteristics of individual neurons, synaptic distributions, dendritic trees, and a host of othermicrostructural and microchemical aspects of these importantneural networks will change. And the end effect is an alterationin the baseline activity and reactivity of the stress response systems
in the traumatized individual. (p. 244)
Likewise, Perry (2002) states, “The earlier and more pervasive theneglect is, the more devastating the development problems for the child.
Indeed, a chaotic, inattentive and ignorant caregiver can produce pervasive developmental delay” (p. 89). Due to the sequential development of
key areas of the brain, neurotransmitters that run from the lowest part ofthe brain (the brainstem) to the highest part of the brain (the cortex) are
affected in their ability to have healthy communication with one another.
Child Welfare Information Gateway (2001) notes:
If a child does not receive kindness as an infant, he may not know
how to show kindness as an adult. If a child’s cries for attention are
ignored as a toddler, he may not know how to interact positively
with others later. These capacities may not fully develop because
the required neuronal pathways were not activated enough to formthe ‘memories’ needed for future learning. (p. 10)Children with developmental trauma have had little if any practice inusing the social engagement system to downregulate, for the environment
was more often than not dangerous or uncertain, and neuroception kept
them in neurophysiological states supporting mobilization and shutdown(Porges, 2015b). In other words, their baseline state is that of hyperarousal
or dissociation.

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TRANSFORMING TRAUMAEngaging children in play therapy who are either hyperaroused or
dissociative can be very challenging, and it may even be outside the child’s
capability to participate in play therapy. Motor hyperactivity, behavioral
impulsivity, hypervigilance, avoidance, emotional volatility, and inability to maintain attention are just a few of the symptoms children who
have experienced developmental trauma display. They may misinterpret
prosocial behavior of other children as threatening, preventing reciprocal
inhibition of fight/flight behaviors and/or reacting with either aggression
or avoidance. These behaviors make sustainability in play with children
suffering from developmental trauma extremely difficult.
Van der Kolk (2014) describes the effects of what happens when achild’s (or adult’s) baseline state becomes a heightened state of alarm or
fear: “When that system breaks down, we become like conditioned animals: the moment we detect danger we automatically go into fight or
flight mode” (p. 62). Play with a highly dysregulated child is very hard,due to their difficulty controlling their emotions and impulses. Van der
Kolk (2014) continues, “They may startle in response to any loud sound,
become enraged by small frustrations, or freeze when somebody touches
them” (p. 63).
ANIMAL-ASSISTED PSYCHOTHERAPY
Although Freud was accompanied in therapy sessions by his dog Jofi
(Grinker, 2013), animal-assisted psychotherapy (AAP) was only brought
to the attention of the clinical community 40 years later by psychologist
Boris Levinson, at a conference of the American Psychological Association(Levinson, 1962) and later through articles and books (e.g., Levinson,
1965, 1984; Levinson & Mallon, 1997). Levinson’s insights into themechanisms of AAP, through his work with maltreated children and accompanied by his dog Jingles, are still relevant today (Fine, 2017) andserve as a useful and credible base for current and ongoing clinical work,
theoretical development, and research.
AAP is a clinical field based on accepted principles and goals of psychotherapy, and may be applied in the context of various theoreticalframeworks and clinical approaches. AAP may be carried out in relation
to attachment theory (Bachi, 2013; Balluerka et al., 2014; Zilcha-Mano,
Mikulincer, & Shaver, 2011), intersubjectivity (Parish-Plass & Oren,Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma1432013), Jung (Maayan, 2013), psychodynamic therapy (Parish-Plass, 2008,2013a), gestalt (Kirby, 2010; Lac, 2016), cognitive therapy (GonzalezRamirez, Ortiz, & Landero-Hernandez, 2013), play therapy (Parish-Plass,2008, 2013b; VanFleet & Faa-Thompson, 2017), group therapy (Harel,2013), parent-child (dyadic) therapy (Shani, 2017), and eye movement desensitization and reprocessing (EMDR) (Jenkins, 2013). Chandler (2017)
systematically covers a number of psychotherapy approaches integrating
animals into their setting.
The integration of animals into the therapy setting, by a therapist
who understands the opportunities provided by the human–animal bond,may expand these principles to further advance the therapy process. The
presence of animals in the psychotherapy setting may serve as a rich andmultifaceted medium for the expression of the client’s inner world (Oren& Parish-Plass, 2013). The fact that an animal is alive, breathes, walks,
plays, is spontaneous, makes sounds, has smell, eats, has babies, gets sick,and even dies catalyzes the therapy process in many ways. For instance, theanimal’s genuineness and aliveness brings up many issues and emotions
from the client’s life, which makes the animal a more likely object for projection and transference than a doll or other inanimate object.
Fairbairn (1944) claimed that the basis for all psychopathological conditions could be found in disturbances in early childhood relationships.
Similarly, Bowlby (1969) posited that all humans base their social interactions on internal working models formed in interactions with their parents.
The client’s ensuing relational style is carried into other relationships, aswell as into the therapy situation. These models may be worked on within
therapy. For this reason, psychotherapy is based on the exploration of theclient’s emotional issues through the utilization of the relationship in thetherapy setting. In AAP, the presence of a number of potential relationships
existing simultaneously allows for reenactment, within the therapy setting,of many other relational experiences. Thus, the inclusion of animals in thetherapeutic setting expands this principle by providing opportunities in thehere-and-now for processing past relational issues, identifying and working
on underlying relational patterns and internal models, and offering adaptive alternatives (Parish-Plass & Oren, 2013).
Because the AAP setting may serve as a microcosm of one’s social world
due to the number of potential relationships that may occur (client-therapist,
therapist-animal(s), client-animals(s), and even animal-animal), individual AAP has certain elements and advantages of group therapy (Ish-Lev

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TRANSFORMING TRAUMA& Amit, 2013). As in group therapy, there are a number of participants(client, therapist, animals) in the setting, allowing for various dynamics
to occur between them, and each participant may at any given time be an
active participant or an observer. Yet in the case of AAP, the client is the
only focus of the therapy process.
Chandler (2017) refers to various categories of significant human-animal
relational moments (SHARMs) that occur during human-animal interaction: greeting (the therapist’s facilitating the greeting between client andanimal, commenting on the animal’s body language and possible meaningor value of this body language), acknowledgment (the therapist acknowledging the animal’s communication of something of value to the client,
the therapist, or about the animal himself ), speculation (the therapist wondering aloud about the animal’s thoughts or feelings, which might provide
insight or awareness to the client; asking the client to speculate, providing a
medium through which the client may project the client’s internal experience), interpretation (offering an interpretation of the animal’s behavior or
asking a client to interpret an animal’s behavior to imply what the animal
is experiencing or may be communicating), assurance (a client experiencing
assurance or self-assurance due to the animal’s behavior around the client
or due to a client’s observation of the animal’s behavior), and checking in(a therapist’s pointing out that the animal is checking in to make sure theclient or therapist is okay; the therapist or client checking in with the animal to see if the animal is okay). These SHARMs provide opportunities
for effective processing of those moments by a client and a therapist. The
human-animal relational processing of a SHARM gives personal meaning
and relevance to the relational moment.
These opportunities are especially salient for work with maltreatedchildren, whose source of trauma was an injurious relationship.
AAP: ADVANCING THE PRINCIPLES OF PSYCHOTHERAPYAND INTERPERSONAL NEUROBIOLOGYIN THE HEALING OF TRAUMA
Similar to Herman’s stance on trauma and recovery, Perry (2009) stresses
the healing power of relationships in children suffering from trauma,
stemming from research in the area of the interpersonal neurobiology oftrauma and healing of trauma. Yet, as shown earlier in this chapter, manyImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma145

maltreated children are suspicious of relationships with adults and are
avoidant of them, either dropping out of therapy, being unable to participate in the psychotherapy process, or refusing to attend therapy atall. Psychotherapy with such children is often characterized by a poor
therapeutic alliance, the collapsing of potential space, a deficit in ability
to symbolize, and/or shame and presentation of false self. Porges (2015b)
writes, “The vulnerability of the Social Engagement System to environmental cues of danger and life threat is profound. Even with the removalof danger cues, the Social Engagement System may remain dormant unless
it is appropriately stimulated with safety cues” (p. 120).
We will now suggest ways in which the integration of animals into
the process of psychotherapy might provide solutions for these issues andtherefore advance the process. The case examples provided are drawn from
Pfeiffer’s experience as a therapist at a facility school for children, ages 5–13
years old, who have experienced severe maltreatment.
Animals as Facilitators of the Therapeutic Alliance

Taking into account the research mentioned earlier, many maltreated children will find the therapy situation to be very threatening, and they will be
unlikely to trust the therapist or her positive intentions toward them. Thesefeelings make the establishment of the therapeutic alliance very difficult if
not impossible. Yet recent research presents evidence that the therapeutic
alliance with maltreated children can be established earlier and stronger in
AAP in a play therapy setting than in non-AAP play therapy (Parish-Plass,2018). This finding may explain the results found by Dietz and colleagues(2012) and Signal and colleagues (2017) that the addition of dogs to thetherapy plan for maltreated children leads to higher rates of treatmentcompletion. This research reinforces past studies that have shown that thatthe presence of an animal may serve as a facilitator of social interaction(Corson, Corson, Gwynne, & Arnold, 1977; McNicholas & Collis, 2000;
Messent, 1983).
As mentioned above, the client may sometimes be an observer of therelationship between the therapist and the animals. It is our experience thatthrough the therapist’s genuine interactions with the animals, the client
judges the therapist as to what type of person she is, if she can be trusted,
and if she is respectful, protective, and caring. In addition, the client may
notice the animals’ behavior toward the therapist, such as looking for her
attention and protection, trusting her, expecting to be fed by her, and146

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appearing happy to see her. Due to children’s tendency to identify withanimals (as smaller and more helpless than adults),3 their perception thatthe animals can trust the therapist may lead the child to feel that he canalso trust the therapist and feel safe with her.4
Lockwood (1983) found that a situation portrayed in a picture that
included an animal was perceived in a more positive light than that in an
identical picture but without an animal. Similarly, a person shown in a
picture accompanied by an animal was perceived with more positive regard
than a person shown in an identical picture but not accompanied by ananimal. One may infer from this research that the presence of an animalin therapy is likely to make the therapy setting less threatening, and thetherapist will be perceived more positively.
There may be a number of possible explanations for these findings.
Studies have found that an animal may serve both as a secure base (fromwhich to explore) and as a safe haven (to which one may return in case ofperceiving threat), both in general (Zilcha-Mano, Mikulincer, & Shaver,2012) and specifically in the therapy setting (Zilcha-Mano, 2019). Thus,an animal’s presence is likely to lead the client to perceive the therapy setting as safe and secure. Once the therapy environment is considered safe,that is that there is a neuroception of safety, the client may have accessto neural circuits that enable one to socially engage and benefit from thephysiological states associated with social support (Porges, 2003, 2006).
The way is now paved for the establishment of the therapeutic alliance.
Geller and Porges (2014) emphasize the importance of a mutual relational presence that promotes relational depth, safety, and therapeuticchange. For the relational presence to develop, there must be a felt, communicated, and received presence within and between therapist and client.
As has been shown, many maltreated children resist therapy and refuse orseem to be incapable of creating a therapeutic alliance. They are unlikely
to experience the therapist’s presence.
Claire Winnicott (1968) discussed the importance of the “third
thing,” a common interest that draws the focus from the threatening
therapist-client relationship and places it instead on something outsideof the therapy dyad. The animals in the therapy setting may provide that
common ground, both therapist and client taking care of the animals
together, observing and discussing their behavior, and playing with them.
Through the common caring and playfulness that occurs, and the multiple
relationships developing in a nonthreatening way, the client may feel anImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma147

atmosphere of relationships in the room to be less threatening and evennatural and authentic. Presence by all in the setting may be communicatedand felt by each other and for each other more strongly, contributing to
the development of a relational presence between the therapist and client.
Both theory and research in the area of interpersonal neurobiology
contributes much to the understanding of how animals may contributeto the establishment of the therapeutic alliance with clients suffering fromdevelopmental trauma. The biophilia hypothesis (Kellert & Wilson, 1993;
Wilson, 1984) posits that humans have an innate need for deep and intimate association with animals, as well as an inclination to affiliate with life
in order to achieve meaning and fulfillment. Support was found for thishypothesis in a study by Mormann and colleagues (2011). Using an fMRI
brain scan, they found a preferential response for pictures of animals (asopposed to people or landmarks) in the neurons of the right amygdala, thearea of the brain performing a primary role in the processing of emotional
reactions. In turn, findings from recent research support the hypothesisthat the amygdala is associated with social interactions (Bickart, Wright,
Dautoff, Dickerson, & Barrett, 2011), and that oxytocin may regulatesocial behavior and prosocial tendencies partly through amygdala neuromodulation (Chang et al., 2015).
In light of this research, and research suggesting that interactions
with animals cause the release of oxytocin in humans (Nagasawa, Kikusui,
Onaka, & Ohta, 2009; Odendaal, 2000), there could be a relationshipbetween the amygdala’s preferential response for animals and the oxytocin
released due to seeing the animals. Research would be needed to understand whether the relationship is causative (and in which direction) or
correlational. Considering the connections within the neural system illustrated in Figure 2 in Porges (2001), it would seem that seeing the animal,
recorded in the amygdala, is what reaches the hypothalamus and causes
the release of oxytocin (if indeed, seeing animals results in the releaseof oxytocin). This would explain the “anti-stress” effect caused by being
with animals, as seen both in research on state anxiety, lowering of bloodpressure, and lowering of cortisol. Perhaps the presence of the animal, ina supportive and safe atmosphere, subdues the limbic activation (Porges,
2003), dampening the stress response system of the hypothalamic pituitary adrenal (HPA) axis (cortisol) and fight/flight mechanism (Porges,
2015a), thus allowing for immobilization without fear and social engagement behaviors. Carter and Porges (2016) further explain that humans

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may feel a sense of emotional safety with animals in that affection with ananimal may be less complex to experience and return than with humans.
We suggest that the response to animals (due to the amygdala’s reaction to them, and/or due to the release of oxytocin during interaction
with them or even by just seeing them) increases the likelihood of social
interaction, social behavior, and prosocial tendency, thus facilitating theestablishment or strengthening of the therapeutic alliance.5 In effect, thepresence of animals in the AAP setting would provide a natural alternative
to the administering of possibly dangerous exogenous oxytocin in orderto return balance to the oxytocin system of the maltreated client, with all
the positive emotional effects and implications for the therapy process thatwould ensue.
Carter (2017) asserts that, “Developmental exposure to social experiences and to peptides, including oxytocin and vasopressin, also can‘retune’ the nervous system, altering thresholds for sociality, emotion
regulation and aggression” (p. 499). Here, Carter points to the positiveeffect of the combination of social experiences and neuropeptides on
the nervous system. Interaction with animals provides both in a way
unique to AAP.6
According to Geller and Porges (2014), the detection of safety promotes receptivity toward others. We physiologically calm down and our
defenses are inhibited and downregulated. Geller and Porges (2014) go on
to say, “Defensive strategies are then replaced with gestures associated withfeeling safe and with this state of safety there is a perceptional bias toward
the positive. Appropriately executed prosocial spontaneous interactions
reduce psychological and physical distance” (p. 183).
The feeling of safety brought about through the presence of and interaction with the animals, is therefore likely to facilitate the therapeutic
alliance with the therapist, as well as promote receptivity to the therapy
process. That is, in light of the above research, one may conclude that thepresence of animals allows for social engagement for the purpose of preventing or healing the deleterious psychological and neurobiological effectsof trauma. This helps us to understand why the avoidantly attached client
will often cooperate with AAP therapists when they have not done so withother psychotherapists.
Not only will the therapeutic alliance be difficult to establish withmaltreated children, but also ruptures in the alliance are more likely tooccur (Chemtob et al., 1997). AAP provides unique opportunities forImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma149

the resolution of alliance ruptures (Zilcha-Mano, 2017). For instance,
as discussed by Zilcha-Mano (2017), an animal serving as a safe havenmay allow the client to stay in therapy during the resolution process.
The secure base provided by the animal may help clients explore theirinternal working models reflected in alliance ruptures with their therapists, leading to the repairing of the alliance with the therapist, as wellas to the ability to form healthier relationships. A rupture in the client’s
relationship with the animal in therapy may be a psychologically safer
way for the client to work through maladaptive relational patterns, withthe help of the therapist.
CASE EXAMPLE
Surrounded by adults she had never met on her first day of schoolwith us, Haley, age eight years old, was highly overwhelmed. Her
anxieties were extremely high, and she did what she tended to dowhen she felt that out of control. She undressed and curled up
in a ball, screaming and crying for her mom. New environments
and new adults were so threatening to Haley that she moved immediately into a terror state. The adults were trying everything
to let her know she was safe, but their actions and words were
not enough. After a bit of time with no success, a staff member
asked if perhaps my therapy dog, Charlie, could come out andwalk by to see how she would respond. Charlie initially walked ata far distance from her, but close enough for her to see. Though
there was not a major shift in behavior, the staff did notice that
she began paying attention to the dog near her. Charlie slowly
came closer and eventually, with permission from Haley, was able
to sit by her. I asked if Charlie could walk her to my office withthe staff member so she could get dressed and perhaps spendsome time getting to know Charlie, to which Haley agreed. This
became our first therapy session. Through her frequent reference
to me as Charlie’s mom, I felt Haley could trust me because shewitnessed Charlie trusting me as her mother. Through her timewith us, Charlie played a significant role in Haley’s trauma treatment. Charlie was present in all our play sessions, and supported
transitions in Haley’s day when needed. Charlie was able to bea safe haven and secure base, which allowed Haley to stay in150

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therapy. Prior to Haley joining us, she had been in four different
schools and had at least five different therapists. I truly believe
the presence of Charlie is why Haley was able to engage withme in therapy.

Expansion of Potential Space7

There are a number of ways in which the integration of animals in aplay therapy setting might expand the potential space of children with
developmental trauma. A necessary condition for the expansion of theclient’s potential space is the lowering of anxiety. Studies have foundthat the presence of animals reduces anxiety, as evidenced by lower cortisol levels (Barker, Knisely, McCain, & Best, 2005; Beetz et al., 2011;
Odendaal, 2000;), lower state anxiety (Shiloh, Sorek, & Terkel, 2003),
and lower blood pressure (Friedmann, Katcher, Thomas, & Lynch, 1983;
Zilcha, Mikulincer, & Shaver, 2012). Based on the literature covered
earlier in this chapter, this lowering of anxiety may be achieved throughthe presence of animals, observing them, or interacting with them in thefollowing ways:
1. The animal may serve as a safe haven should anxiety-producing
content become too difficult.
2. Social engagement with the animal has a calming effect on thechild.
3. The animal may mediate the interactions between the childand the therapist, or serve as a bridge between the child andthe therapist, leading to social engagement between themand eventually to the therapeutic alliance, which in turn lowers anxiety and contributes to the perception of the therapy
setting as a safe place.
4. Interacting with the animals, as well as with the therapist,causes the growth of neurological fibers between areas of thebrain, creating smoother communication between those areas
and balance in the system. The client is better able to findmeaning in his actions and emotions, which also leads to thelowering of anxiety and feeling safe (Siegel, 2010).

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma151

Once the client feels calmer and safer, she is better able to be open to
the ways in which the animals more directly influence the potential space.
1. Serving as a secure base, the animal facilitates the client’s exploration of her inner world.
2. Maltreated children are frightened and anxious by the chaos
and dangerous content residing in their inner world. Imagination may lead to frightening places and images. They often
prefer to stay as close as possible to a world that is predictable
and concrete. Animals provide the opportunity for some forunbeknownst forays into the world of play, through interactions with animals who they perceive as concrete and real. Animals have much in common with humans, sharing many of thesame characteristics, emotions, behavior, and health aspects.
Yet they are not humans, thus, play with them occurs at a safe
psychological distance from threatening content, making themsafe objects for projection of the client’s inner conflicts and confusion, feelings, thoughts, and experiences. The projection onto
animals, that is observing their states, actions, and reactions
and reflecting and judging them from her (the client’s) own
context but from the outside, can indeed be considered play forthe sake of working through her issues. This AAP play situation
can be considered to be mindsight,8 leading to neural integration (D. Siegel, personal communication, October 4, 2016).
3. A virtual laboratory for relationships, AAP provides opportunities and stimulation for reenacting and working through many
types of past and present relationships, within the context ofmultiple relationships in the here-and-now. Through the therapeutic alliance, the client will be able to receive support in
the face of difficult content that arises. The therapist mediates
between the child and animal, and between the child and her
inner fears, allowing for the working through of the content.
Together with the therapist, the client observes them and wonders about them, arrives at insights through this mediation, andtries new options and new strategies within these relationships.
4. Reenactment may sometimes come too close to reexperiencing,thus retraumatizing the client. The interaction with the animals

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brings integration, allowing the memories to “move on” so they
are sensed as in the past as opposed to in the present. The client
may now reenact without refeeling.
5. Integrating animals into the psychotherapy setting allows
implicit representations, whether emotions, bodily sensations,perceptions or behaviors, to become activated. When the representations are implicit only, the child does not have a sense ofremembering. These emotions, bodily sensations, perceptions,and behaviors may be projected onto the animal. In the wordsof Daniel Siegel, in AAP,
The implicit representations are being activated into consciousness, and the social child has enough trust that [thetherapist has] created with [the] animal in the therapeutic
setting to allow the dance of the implicit representations
to enter into the interaction with the pet, with the animal. . . . This is the way mental models and priming
also participate in implicit activations and then withinconsciousness. . . . In this way, clients] can work throughtheir unresolved issues. . . . What is happening then is
the hippocampus [underdeveloped due to trauma] ofthat child is watching the play with the animal and theresolution of . . . why a loving figure would be abusive
and working it through in some play where the childgoes from helplessness to being empowered, for example.
[This] is a push towards integration completely, and aworking through [of ] these negative states of anger andsadness and fear. . . . Those are decreased states of integration, and the liberation of this working through within
the play is actually a movement towards higher states ofintegration and that’s where you get positive emotional
states of joy, literally, and empowerment, of ‘broaden andbuild’ is what Barbara Frederickson would call it. [AAP
offers an] opportunity to let the developmental trauma,with its blocked memory and narrative integration, be
opened up. So, in the setting of therapy, integration canbe created, neuroplasticity can allow changes to occur.
Literally, memory retrieval becomes a memory modifier,as deeper and longer states of integration are created.9

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma153

Furthermore, this process allows for the translation of implicit knowledge into explicit knowledge, leading to newfound understanding of theorigin of sensations and emotions.10
6. Mitchell and Aron (Ogden, 1999) state that therapists must“mine their [patient’s] potentially rich yield of access points
into the patient’s inner world” (p. 461). The implications ofdevelopmental trauma (anxiety, loss of memory, the threatening nature of contact with traumatic memory of experiencesand emotions) often prevent that access to the client’s innerworld. Due to posits of the biophilia hypothesis, backed up
by research that shows that animals may serve as direct accessin the inner emotional area of the brain, the right amygdala(Mormann et al., 2011), it can be supposed that clients may be
more naturally disposed to be in contact with their inner worldin the presence of an animal.
Cozolino (2017) explains that the right amygdala (in conjunction
with the right cortex) is involved with the internal emotional experiencesof self and other. Furthermore, the right amygdala is likely to be involved
with emotional pain, such as shame and loneliness. The right amygdalais also a component of neural circuits related to attachment. Thus, when
the right amygdala is activated by the sight of an animal (Mormonn et al.,2011), we can connect with and work on our emotional pain that is associated with attachment issues. This activation of the right amygdala assists
us in accessing both positive and negative implicit memories associatedwith attachment issues that need to be addressed in therapy (L. Cozolino,
personal communication, June 15, 2017).
CASE EXAMPLE
Developing safe and healthy relationships with children who
have experienced complex trauma can be extremely difficult.
Anna challenged me on this point as a therapist from the beginning. Though I worked hard to create a safe therapeutic space forher to engage in play, she was resistant and would not do anything more than engage in the same board game over and over.
She even refused to have sessions in the play therapy room, andwould only want to meet in my office. Due to her trauma history

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and explosive anger, I integrated Charlie slowly into our sessions.
Initially, Charlie just being present was the focus. I didn’t draw
attention to it, and I let Charlie and Anna ebb and flow in theirinteractions. Anna might reach out and pet Charlie while playing
the board game. Charlie might walk over to Anna at different
times during our session, or she might just lay close by, watching.
Or Charlie might come over to me and gently lay her head on mylap while I was focusing on the board game. After several sessionsof these interactions, I slowly began to move our sessions to theplay room. We would bring the board game with us and keepthat consistent, but there was a shift in Anna’s reaction to being
in the room with Charlie. Anna would spontaneously get up
and walk around the room with Charlie to explore the different
toys together. Eventually, though the board game was still present, Anna would move right into play. Her play was extremely
violent, and she would attack me with toy swords and guns theentire time. With Charlie being present, she was able to receive
support and slowly begin to share her trauma history throughplay. She could attack me, but afterward Charlie was there, anonthreatening, nonjudging, living being who would sit next toher and just be present. With the support of Charlie, her play
was also able to change. In the beginning, her play was raw anger
without much of a story. But that story slowly changed, and she
began taking the role of protector and protecting Charlie fromthe “bad people.” Though it took a long time, she was able toarticulate that she wished she had someone to protect her like she
was protecting Charlie. Anna kept a psychological distance fromplay because she was afraid of what my reactions might be if shetruly shared her anger. Charlie was able to increase the safety ofour therapeutic space and provide a relationship in which Anna
was able to reenact and work through past relationships without
fear of repercussion.

Deficit in Ability to Symbolize

Due to the inability of some maltreated children to symbolize, a doll isjust a doll — a piece of plastic and cloth. It cannot represent a crying or
frightened or happy child. A toy gun is only a piece of plastic with noImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma155

symbolic meaning. Mentalization and symbolic play will not and cannot
take place. Research in the area of mirror neurons helps us understand how
clients may unknowingly project themselves onto an animal, allowing forsymbolization and the mentalizing to take place for those who otherwise
are not able to do so.
The mirror neuron system involves numerous parts of the brain, coding biological motion and integrating sensory information, allowing foractions by one person to become messages understood by another without
any cognitive mediation (Acharya & Shukla, 2012). Findings by Iacoboni,
Molnar-Szakacs, Gallese, Buccino, & Mazziotta (2005) suggest that mirror neurons hold an active part in understanding the intentions behindobserved actions in others. Keysers and Gazzola (2014) suggest this process occurs when the neural substrates of our own actions are vicariously
activated while witnessing the actions of others, causing one’s mirror neuron system to project oneself onto others with an egocentric bias. Basedon the research concerning mirror neurons, Pally (2017) asserts that weunderstand others based on what we believe we would do in the same
situation, and that this process is related to the process of mentalization,or the reflective function.
For those unable to symbolize, it is impossible for them to see a doll as
if alive, moving, or having intentions. The mirror neuron system will not be
activated, and the client will not project onto the doll. Yet, like a human,an animal moves, breathes, eats, has facial expressions and other body language, approaches clients or hides from them. Animals certainly do haveintentions. The movement and behavior of the animal may stimulate themirror neurons to activity, likely causing the client to unconsciously calculate what she would do in a similar situation, and then ascribe intentions
to the animal based on her own personal experience, emotions, needs,
thoughts, and sensations.
It is the egocentric bias of the mirror neuron system that may be
the basis of conclusions drawn by Pally (2010) that, “Since people use
their own intentions to understand the intentions of others, there isoften room for misunderstanding” (p. 399). In AAP, as well as otherforms of psychodynamic psychotherapy, it is exactly the misunderstanding mentioned by Pally that we as therapists take advantage of. Thismisunderstanding is the client’s projection that will advance the therapy
process. We must remember that the AAP setting is not a lesson in animal
behavior, nor a lesson in body language or social skills. Rather, we allow
and even encourage clients to project their own needs, emotions, feelings,

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and thoughts onto the animal, and to interpret the animal’s behavior
according to those needs.11
The opportunity provided by the animals for the client to symbolize
has both psychotherapeutic and neurobiological advantages. The opportunity to symbolize (albeit unknowingly) allows for the client to create his
potential space to work through his issues of trauma. The use of animals
to symbolize leads to neurological processes creating neural linkage, leading to integration and contributing to balance, reduction of anxiety, andincreased positive functioning.
Justification for assuming parallel processes of mirror neuron activation, and projection of intentions onto humans as well as onto animals, canbe found in research by Spunt, Ellsworth, and Adolphs (2017). Employing
fMRI scans, they found that attributions of emotion to both humans
and to nonhuman animals draw on the same neural mechanism. The
researchers conclude that this mechanism is spontaneously activated byparticipants while observing nonhuman animal facial expressions, evenin the absence of explicit verbal cues, which might have caused them toattribute emotion. Furthermore, in a study in which participants watchedshort video clips of geometric figures interacting with each other, Scheele
and colleagues (2015) found that oxytocin concentrations were associatedwith anthropomorphic tendencies. Higher levels of oxytocin were related
to the tendency to attribute social meaning to nonsocial agents and actions.
As mentioned earlier, evidence points to a rise in oxytocin in humans whenin the presence of animals.
CASE EXAMPLE
I had been trying to engage Brandon in EMDR for a few weeks
with no luck. We were stuck in trying to develop a safe or special
place as an internal resource. The concept of a safe or special place
was to foreign for him; he had never experienced such a place andshowed limited ability to use his imagination to create one forhimself. In the play therapy setting, Brandon was not even able
to relate to the idea of creating a safe place for one of the dolls.
One day in session, I decided to ask Brandon if he thought thatCharlie ever felt the need for a safe place. That session Brandon
built an intricate fort around Charlie in which nothing bad could
happen to her. There was no talking that session, and I decided

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to not use bilateral stimulation that week. The following week,
we did the same thing. Brandon worked for an hour straightto build a safe place surrounding Charlie. Slowly over the next
several weeks, without noticing, Brandon began to build the fortaround himself as well. I was eventually able to introduce alternating bilateral stimulation, and Brandon was able to articulate
why the space was so safe for Charlie and him. What was initially
too dangerous to think about could now be addressed throughthe integration of Charlie in play. Brandon was able to initiallykeep his own defenses up, yet still work though his trauma by
assuming what might be needed to keep a dog safe.

From Shame and Presentation of False Self to Self-Acceptanceand Expression of True Self

“I’m a cute kid. I can be really nice. But sometimes I can be just like yourcockatiel and attack other kids. I can’t stop myself. I don’t know what ishappening to me, and it’s so embarrassing!” Children with developmental
trauma have often been shamed and humiliated — by others or by themselves — for their behavior, for being a victim, for their family’s behavior,
or even just for being who they are. In order to take advantage of the therapy process, these children must shed their false selves and be willing toaccept and share their feelings about their true selves. This may be a near
impossible task for children who feel shame.
According to Porges (2017c), when in a “mammal to mammal” social
engagement state, the traumatized client carries within her internal voicesthat are kind and compassionate, rather than self-condemning. She will feel
more self-respect and will be less judgmental toward herself. We feel that
AAP facilitates the process in which social engagement leads the child tobe less judgmental and more compassionate toward herself, in turn leading
to the expression of true self in the therapy process.
In AAP, the client witnesses the relationship between the therapist andthe animals, as well as the therapist’s attitude toward the animals. Whilethe child might try to hide parts of her true self from the therapist out ofshame, the animals unapologetically express their true selves. The hamstermight bite, the cockatiel might try to steal treats from a closed box, and thedog might be ugly. The therapist shows love and acceptance for them all,

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caring for them according to their needs, while openly talking about thefull range of the animal’s characteristics. Through the client’s identification
with the animals, and the atmosphere of open discussion in the session inwhich all subjects are acceptable, she is likely to feel accepted for all herparts. She may then be more willing to discuss them and exhibit them,and will feel less of a need to appease the therapist. Her true self is more
likely to show itself, the therapeutic alliance will be strengthened, and thenemotional content arising from the true self may be worked through in amore meaningful way.
CASE EXAMPLE
Homelessness, domestic violence, and methamphetamine abuse
where just a few of the major experiences James had even before
taking a breath in this world. It impacted not only his cognitive
functioning, but his sense of self and how he presented to others.
Within our therapy sessions, James worked hard for perfection
and would not take a lot of chances in case a mistake might bemade. His engagement was superficial and initially it was hard
to make any therapeutic progress. My relationship with Charlie
was the basis for how James began to open up to me. Throughout
our sessions, he would see Charlie make “mistakes”: spill waterout of her bowl, run after a squirrel, bark at geese, and jump up
on James to give him kisses, all things some might say a “good”
therapy dog would not do.12 However, those actions played apowerful role in building trust with James because he witnessed
firsthand how I continued to accept and love Charlie, while recognizing her for all her different parts. James also noticed how I
managed those actions with kind and gentle redirections. Charlie
could just be herself without fear. James’ internal messages began
to shift, and he began to take chances in his play. He would show
more affect and his body language was not as closed off.

Back in Touch With Oneself With the Help of AAP

As has been alluded to in many different ways in this chapter, the way backto oneself, from dissociation, from being more concerned with survival, isthrough social connection. However, when the child interprets danger even

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when it is not there, she will not be able to reach the social engagementmode, which would have paved the way for feeling, remembering, andsharing so as not to be alone in her anxiety. For her, adults are dangerous,and she is not open to the possibility that this adult, her therapist, would
be any different. The presence of animals in therapy supplies the feeling ofsafety, as mentioned earlier, which helps traumatized clients to return andbe in touch with themselves in many ways.
According to the polyvagal theory, mammals are able to cue to othermammals about safety, a necessary condition of social engagement, leading to social interactions that support health, growth, and restoration.
Porges (2013) posits that these healing interactions between mammals may
even be cross-species. If the client notices the animals in the room feelingsafe, and interacting safely with the therapist, then she is likely to receive
these cues and be open to social engagement, both with the animals andeventually with the therapist (as explained in the section concerning thetherapeutic alliance).
This neuroception of safety provided by the presence of an animal will
help the client to be less wary of danger from the environment, and free
her to be aware of herself and her feelings (physically and emotionally),
within the context of the other mammals (animals and therapist) in theroom. She might be open to touch, patting the animals and letting themcuddle with her. She might become interested in the parakeet’s chirping,or in the smell of the hamsters. This sensory stimulation will help growthand integration in the brainstem.
If sensing enough danger, neuroceptive features of the polyvagal system may send a person to a shut-down condition involving reduced bloodflow to the brain (Porges, 2011), resulting in dissociation. However, in
their study of subjects with depressive disorder (who usually exhibit lowered activity in their prefrontal cortex [PFC]), Aoki and colleagues (2012)
found that subjects interacting with a dog showed increased blood flow tothe brain, as well as increased activity in the dorsolateral region of the left
hemisphere of their PFC. That is, interaction with a dog may be grounding
and may keep one in touch with oneself in such a way that would prevent
dissociation.
There are times in therapy that, although the therapeutic alliance has
been created and the potential space has been expanded, the danger sensation returns due to threatening content that has surfaced during thesession. In this case, it is our experience that the animal may serve as a safe
haven during this uncertain point. Such a client will often retreat to the dog

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in the session, quietly cuddle with him for a period of time, rest, and later
be able to return and work on the real feelings that had finally surfaced.
Here, neuroception has identified for the client where her safe place is, thus
allowing her to retreat from the emotionally dangerous situation yet also
use social engagement instead of flight, dissociation, or loss of sense of self.
Finally, due to the animal serving as a natural and unconscious accessinto the emotional neural center, the right amygdala, the animal’s relationship with the client might serve as an anchor to the client’s emotional
world. As a result, through therapy, implicit representations may be transformed to explicit memories, leading to more self-understanding, thenresulting in a deeper acquaintance with one’s real self.
CASE EXAMPLE
One does not need to use much imagination to think of whata child must have lived through in their early years to have attempted suicide before age seven. This was Sam, a child who
would suddenly slip into dissociative symptoms in our sessions.
When he was dissociating, he would begin pulling out his nails
and would not be responsive to human communication. Our
play sessions were client-led and often during the reenactment of
his trauma history through play, he would begin to dissociate. It
was always difficult to see, but I learned fairly quickly that what
grounded him into reality the fastest was Charlie. She would simply walk over to him while he began to try to pull his nails out
and lick his cheek. Slowly, Sam would become grounded and able
to pet Charlie and even lay his head on her for a while. Charlie’s
physical presence played into grounding him, but the sensory
opportunities she also provided helped as well. The sensation of
being licked on the cheek, the repetition of petting her soft fur,and the up and down motion of Charlie’s slow breathing all helped
Sam maintain the present in our sessions.
Charlie and I worked with Sam for a year and a half, and thedecrease in Sam’s tendency to dissociate when triggered in our
sessions was remarkable. Charlie was able to consistently interact
with Sam in our session each time he would begin to dissociate.
Over time, her presence and their bond directly impacted hisbrain’s coping skill of shutting down. In addition, the consistency

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma161of those sensory outlets in the sessions resulted in a decrease in
his tendency to dissociate. After so many times of Charlie initiating the grounding, Sam was eventually able to begin initiating
it for himself.

Attaining the Ability to Self-Regulate

One of the complications of developmental trauma that seems most pervasive, affecting the child in therapy but even more so at home and in school,
is dysregulation and the child’s lack of ability to self-regulate. Throughout
the literature mentioned earlier, multiple areas of regulation are referred to:affective (emotional) regulation, behavioral regulation, neural regulation,
attention regulation, dysregulation of executive or control circuits, andregulation of sense of self. Furthermore, the baseline for dysregulation ishigher as a result of the trauma, therefore, the traumatized child is in apersistently activated and dysregulated state.
According to Porges (2013), social engagement leading to emotional
regulation takes place in mammal-to-mammal, including human-animal,interactions. He posits that human-animal interactions function to exercise
neural pathways in such a way that people then develop more resilientneural circuits that regulate behavior. Social engagement with people leads
to physiological outcomes, such as lower heart rate and higher oxytocinlevel, which are similar to those mentioned earlier for social engagementby humans with animals and are likely to have an effect on regulation. Thissimilarity reinforces Porges’ inclusion of human-animal interactions as a
type of social engagement according to the polyvagal theory.
For clients who find the relationship with the therapist threatening, as
well as for those who need play interactions with animals to expand theirpotential space, the animals provide an alternative, more authentic, andspontaneous opportunity for the type of social engagement that allows forthe neural exercise to occur, leading to self-regulation. In AAP, there aremany opportunities for clients to practice using their fight/flight systems,
as well as diffusing them with social engagement. The therapist is there
supportively mediating — between the client and the animals, as well as
between the client and her own emotions, thoughts, and sensations.
Another path to the achievement of regulation through AAP can befound in the concept of the development of a personal narrative, which

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may take place in play with the help of the animals. When the child has no
narrative or coherent story, there is no logic to the experiences in his life.
There will be no integration of these experiences, and the neurological system will be dysregulated. Meaning and logic of a coherent narrative leads
to integration between the right and left hemispheres, between the lower
and upper parts of the brain, and between implicit and explicit knowledge
and memory, thus calming the system and increasing the client’s ability
to mentalize.
In AAP, clients project onto the animals and reenact their past andpresent experiences and traumas through their interactions with them,developing and observing their own narrative from a safe psychologicaldistance. The AAP therapist is present to witness, reflect, and help theclient to establish and work through their narrative. The client will feel felt
by the therapist, also increasing self-regulation.
CASE EXAMPLE
To say Matt moved a mile a minute would be an understatement.
Matt was essentially the poster child for traumatized kids who
have extreme hyperarousal symptoms. He was very hypervigilant(his eyes were open wide, and he was constantly scanning theenvironment for threat), could not focus on a task for longer
than three minutes, and his body was always in motion. Trying
to engage Matt in play therapy felt almost impossible at times,
and I learned very early into our play sessions that staying in theoffice was not going to be an option. Using interests I knew Matt
had, I purchased the superhero masks I knew he loved. Upon
entering my office and seeing the masks, his eyes lit up and hestated he “wanted to be a superhero” and wanted Charlie to be
his sidekick. He got all dressed up and then proceeded to dress
Charlie up in a cape as well. Though it was only for a quick fiveminutes, he was able to sit and talk with Charlie and me about
his expectations and, while walking her, about other important
things to remember to keep her safe. Matt then took over walking
Charlie and walked for 45 minutes around the building. Having
to focus on keeping Charlie safe elicited a new capacity for slowing himself down internally. While I could have been his sidekick
if Charlie had not participated in the play session, the reality

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma163

is Charlie provided a stronger reward connection for Matt at abiological level. As a canine, Charlie was more eager to play, andher genuineness was very apparent. Her tail was wagging, and shewould pull gently (yes she pulls the leash sometimes) because she
was excited about walking with him. In turn, the reward neurons
being released in Matt due to playing with Charlie began to help
regulate him. Charlie also provided an opportunity for a bottom
to top form of regulation (versus a top-down approach), which
was very helpful in regulating Matt. She kept the environment
safe, which focused on Matt’s brainstem. Matt was engaged in alarge motor activity that focused on his diencephalon, and theplay was relational which, focused on his limbic system. All ofthese were crucial to help Matt become more regulated.
NEUROLOGICAL EFFECTS OF ALTRUISTIC, CARING, AND
COMPASSIONATE BEHAVIOR BY THE THERAPIST AND THE
CLIENT ON THE AAP PROCESS AND HEALING FOR THE CLIENT
In his book, The Neuroscience of Psychotherapy, Cozolino (2017) contributes
greatly to the understanding of psychotherapy in the context of interpersonal neurobiology of trauma. His discussions hold many implications
for the field of AAP with those suffering from developmental trauma. A
discussion of these implications13 provides an opportunity to present an
integration of many points covered thus far into one coherent model.
There is one phenomenon of AAP that has thus far not been discussed
in the context of interpersonal neurobiology, yet is present in every session and has important implications for psychotherapy with those having
experienced developmental trauma. In the discussion of the therapeutic
alliance, the effects on the client of watching the therapist’s empathetic
approach to the animals, and caring behavior of the therapist toward theanimals, were noted. Cozolino adds more components to our understanding of this mechanism of AAP.
Inherent in AAP therapists is their love of animals in general, andespecially for their own animals and those animals with whom they work
closely. We often include our clients in the care of the animals, whether it
be giving them food and water, cleaning cages, administering medical care,or even taking the client with us on a trip to the vet with a sick or injured

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animal. Many maltreated clients who live in residential care or in foster
homes often work through their experiences of having lived in neglectful
conditions at home, or having felt that their needs in their current living
situations are not being met, by trying to make better homes for the animals in the therapy setting (i.e., building new cages, making them more
fun, safe, comfortable, etc.).
It is this love and caring not only by the therapist, but also by the clientthat may have healing effects on the traumatized brain. Cozolino (2017)
emphasizes the importance of guided altruism in the psychotherapy setting, leading to a cascade of positive effects enhancing success in therapy byactivating certain neurobiological and psychological processes, including
decreased stress, deeper therapy relationship, increased neural plasticity,
increase in self-awareness, self-reflective capacity, perspective-taking, openness to feedback, deeper internalization of the therapeutic experience,increased self-esteem, self-agency, personal responsibility, and empathy.
Here, it is possible that mirror neurons are involved, becoming activated when the client sees the therapist relating empathetically and caring
for the animal. Thus, the client feels altruistic through observing the therapist, and through activation of the orbital and medial prefrontal cortex(ompfc) circuitry. The ompfc is considered to be the apex of the attachment
circuitry.
Cozolino (2017) writes, “The activation of ompfc circuitry throughaltruistic behavior will likely stimulate bonding and attachment in situations when the altruist feels safe. This may explain why taking care of animals
often serves as a valuable bridge with people for those with social anxiety or
post-traumatic stress disorder. This could be a step toward connection thatmight allow clients to experiment with more risky relationships with people.
The circuits connecting the ompfc and the amygdala are a central neuraltarget for change in psychotherapy” (p. 268, italics added by this chapter’sauthors). Here, Cozolino not only provides an explanation of the underlying neurological process involved in the animal serving as a facilitator of thetherapeutic alliance in AAP with clients fearing the therapeutic relationshipdue to developmental trauma, but also points to this relationship as anactivator of neural circuits that are essential for change in psychotherapy.
Another consequence of the stimulation by altruistic behavior of
the ompfc is that “the ompfc is able to regulate the amygdala and othersubcortical structures allowing proximity to caretakers and loved ones tomodulate our anxiety and fears” (Cozolino, 2017, p. 268).

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma165

From this discussion, one may come to the conclusion that the presence of animals affects the amygdala from two directions: 1) the animals
activate the amygdala in the first place (bringing up internal emotions concerning traumatic interactions with others, content that needs to be worked
through); and 2) watching the therapist interacting compassionately withthe animals permits the client to allow himself to become close to thetherapist, modulating the anxiety and fears associated with that emotional
content that otherwise would be too threatening and anxiety-producing torecognize and work through. It is the interaction of these two directions
that advances the therapy process.14
Cozolino (2017) further suggests that since altruistic behaviors activate neural regions associated with bonding and secure attachment,client-­therapist collaboration is enhanced, creating brain and mind statesallowing for neural growth and learning. Psychological mindfulness inherent in the therapeutic relationship expands self and other awarenessthrough the growth of the use of language15 and self-reflection. Finally,
the client’s experience of self may be changed from helpless (a strong factor in trauma) to helpful, from victim to actor. These assertions reinforce
and provide neurological bases for some of the roles mentioned in Orenand Parish-Plass (2013) and Parish-Plass and Oren (2013) of animals in
AAP, as well as in this chapter, such as animals’ roles in decreasing anxiety,facilitating the therapeutic alliance, facilitating play and flexibility throughneural plasticity, and increasing the ability of mentalization.
Porges (2017a) suggests an additional therapeutic mechanism involved
with showing compassion to others. Allowing and respecting another’s
right to “own” their experiences of pain and loss enables us to allow andrespect our own pain and loss, without experiencing shame. If a childsuffering from developmental trauma feels compassionate and acts on thatcompassion in her caring behavior toward the animal, she may also becomecompassionate toward herself, accepting and respecting her own loss andemotional pain. This process will enable her to own these feelings and experiences, talk about them with the therapist with whom she participatesin the compassionate behavior toward the animals, and work them throughwithin the safe environment provided by AAP. For compassion to develop,
Porges emphasizes the need for a “neural platform” enabling one to feelsafe when confronted with the pain and suffering of others. In AAP, thissense of safety is provided by the unique qualities of the therapeutic alliancefound in AAP, as well as the psychological and physiological consequences

166

TRANSFORMING TRAUMAof the presence of the animals in the therapy setting that lead to lowering
anxiety and a sense of safety, as mentioned earlier in this chapter. This
neural platform in AAP may also allow one to feel safe when confronted
with one’s own pain and suffering (allowing for self-compassion), andmay have been found in research by Klimecki, Leiberg, Ricard, & Singer(2014), which showed that compassion training leads to neural plasticity
and activation in a nonoverlapping brain network, which they conclude
leads to resilience.
Another positive implication of compassionate behavior may be extrapolated from 2010 research by Feldman and her colleagues on the effectsof fathers’ active participation in childrearing. Whereas a mother’s caretaking behavior toward her newborn infant is initiated by the release ofoxytocin as a result of the birth process, the father has no such physiological impetus leading to caretaking behavior toward the infant. Feldman,
Gordon, Schneiderman, Weisman, & Zagoory-Sharon (2010) found a
bio-behavioral feedback loop in which a father’s touch and contact with his
infant increases his levels of oxytocin, which in turn results in more touchand contact within the attachment relationship. In light of this research,
it may be assumed that the same bio-behavioral feedback loop exists in
AAP when the client participates in compassionate care of an animal. The
rise in oxytocin resulting from this compassionate care of animals is thenlikely to lead to the positive implications of oxytocin mentioned earlier
for the therapy process, such as trust in the therapist, the ability to stay inthe otherwise anxiety-producing therapy situation, sharing of emotions,
regulation, and more.
Reinforcing the implications of compassionate behavior toward animals for the healing from trauma, Zimrin (1986) found in her study ofchildhood maltreatment survivors that two predictors of successful functioning later in life were: 1) the presence of an empathetic adult, either
at the time of the trauma or later in long-term psychotherapy, and 2) if,
as a child, the subject was responsible for taking care of a sibling or a pet.
CONCLUSIONS
Although the two areas, psychotherapy and interpersonal neurobiology,
grew from different theoretical backgrounds and different research bases,
they have reached many of the same conclusions, perhaps most notablyImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma167

in their emphasis on the need for social connection for both preventionof and healing from trauma. Many times, professionals in fields that may
parallel each other are competitive, invested in proving how their field
is unique and contributes more than others to the understanding of theissues. Certainly this is true today, for instance, in the ongoing struggle
between cognitive behavioral therapy (CBT) and psychodynamic clinicalpsychology. Through mutual respect, openness, curiosity, a desire to learn
from each other, and a genuine interest in helping survivors of trauma,
today’s neurobiology researchers and mental health clinicians have cometogether. They are finding commonality in such a way that encourages
growth, integrating the two fields in such a way that raises both to higher
levels of functioning. Similar to the concept posited by Dan Siegel (2012),
the fields of neuroscience and psychotherapy are creating linkages while
respecting differences, leading to growth and health.
One way we see the similarity between the two fields is through theiremphases on similar concepts. While Bowlby discussed terms such as attachment, security vs. insecurity, anxious and avoidant, Porges and Siegel
both discuss social engagement, safety, dysregulation, and flight. A child canuse social engagement to diffuse the tendency toward fight/flight in a threatening situation. Bowlby refers to attachment figures as a safe haven in thetime of threat. Herman posits that trauma heals only in the context of relationships. Porges and Siegel discuss the importance of relationships as they
buffer the child with developmental trauma from the effects of trauma, andlead to neural integration and regulation in healing from trauma. Winnicott
discusses the potential space as a way for the child to be in touch with her
inner world and play it out within a safe relationship. Cozolino refers to thedefault mode network, which, when the client feels no threat, allows him
to be in touch with his inner world and imaginal space in a flow of time.
A history of developmental trauma raises many barriers to therapy
with these clients. The integration of animals into the psychotherapy setting circumvents some of these barriers and lowers others. In an attempt
to help the clinician understand the mechanisms of AAP in working withclients with developmental trauma, we have described six barriers and delineated possible solutions provided by AAP to each one of them. However,the separation between them is artificial, made for the sake of clearer explanation, and they are all interconnected and even mutually influencing
each other. In addition, any given solution often relies on a number ofother solutions.

168

TRANSFORMING TRAUMAFor instance, the creation of a narrative is dependent on the existenceof potential space, for which the client must feel safe in the setting, andwhich is partially dependent upon the establishment of the therapeutic
alliance. Once the client feels safe, she will be more likely to set aside thefalse presentation of her true self and allow for the expansion of potential
space, as well as feel in touch with her inner self, where she can discoverher own story through play. At this point, through integration, she will
self-regulate.
However, the client with developmental trauma may have the inclination to refuse therapy, not take advantage of the therapy, or drop outof therapy, due to a sense of danger she feels when in a room alone with atherapist. How might animals facilitate the therapy process?
• An animal in the therapy may be a target for social engagement,
helping to diffuse the flight impulse.
• The client will feel more secure to explore herself throughthis social engagement with the animal as a secure base, andwill retreat to the animal as a safe haven when she feels too
overwhelmed.
• The therapy setting itself will feel more authentic with theanimal acting naturally in the room, and both the therapist
and client interacting with the animal in a genuine and spontaneous way.
• The client notices the care given to the animals by the therapist,and that the animals look to the therapist for fun but also forcompassion, help, and safety. The animal will thus facilitate
the establishment of the therapeutic alliance with the therapist,
making the therapy setting feel even safer.
• The client may find it very difficult to play due to the anxiety-­producing content of her inner world. Interaction with theanimals will have physiological, neurological, and psychologicaleffects on the client, lowering the child’s anxiety level.
• The activation of the right amygdala through being with theanimals serves as an access point to the client’s inner emotional
experiences, especially as related to relationships with others.
• Altruistic behavior of the therapist, together with the client,stimulates a feeling of safety and bonding between the two,
allowing the therapeutic relationship to modulate the client’sImplications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma169

•

•

•

•

•

anxieties and fears, facilitating the ability of the client to face
and work through difficult emotional content.
The client may have difficulty symbolizing due to the early
age of her trauma. The animals may serve as targets for her
projections, through the activation of mirror neurons and her
identification with the animals, allowing for play with the animals from a safe psychological distance.
The potential space is expanded by the calming effect of theanimal on the client, as well as by the default mode network
activated in an environment perceived by the client as safe dueto the relationships of the therapist with the animals. Due tothe acceptance of the client by the animal and the therapist,
the client will feel that she can present her real self that she had
previously kept hidden due to shame.
The client will now feel safe enough to be more in touch withherself, hidden inside even from herself. The animal’s characteristics will stimulate the client’s sensory system through smell,sound, touch, and movement. She will begin to find words forher experiences and her emotions, and will start to develop anarrative. The therapist will be present for the client, empathetically reflecting the content and helping the client make senseof the story that is developing.
Through 1) social engagement with the therapist and also withthe animal, 2) the expansion of the potential space and ability
to play and find words for self-expression, 3) implicit representations that can be transformed into explicit memories and beworked through, and 4) the discovery of a coherent narrative,
the client will achieve integration and self-regulation.
The sight of, and a relationship with, an animal activate neuralcircuits (with the right amygdala as a component) related toattachment. The activation and development of this circuitry
can possibly be used in subsequent relationships with others(L. Cozolino, personal communication, June 15, 2017). This
process will allow social behavior learned in the therapy setting
to be exported to the client’s relationships outside of therapy.

Although the field of AAP is now becoming recognized by interpersonal neurobiologists and acknowledged as beneficial for those having

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experienced developmental trauma, only one neurobiologist, Bruce Perryof the ChildTrauma Academy, is known to actually employ AAP in his
work. Perry’s Neurosequential Model of Therapeutics (NMT) takes into
account the key systems and areas in the brain affected by adverse developmental experiences. In his centers for maltreated children, Perry (2013)
identifies therapeutic goals in four functional domains that are meant toreach these areas of the brain and have a reparative effect on them.
Perry suggests that AAP may help reach three of these domains (sensory integration, self-regulation, and relational), leading to the integrationof the related areas of the brain, which is essential in the healing of thechild suffering from trauma (Siegel, 2003). 1) Animals aid the sensory
integration domain by helping the client get in touch with her true self
through sensory stimulation (movement, smell, sight, sound, and touch).
2) Animals aid the self-regulation domain by helping the client present hertrue self through acting it out in play due to an expanded potential space,and learning to interact with the animals in an attuned and appropriate
way. 3) Animals aid the relational domain by creating an atmosphere ofparticipation in different relationships (between child and animals, between the therapist and animals, between the child and the therapist, andeven between animals). The child learns to trust the therapist throughobserving the positive, caring, and respectful relationship between thetherapist and the animals.
Porges (2017b) emphasizes the biological imperative for humans toachieve safety through coregulation of physiological state, enabled by relationships and interaction with other appropriate mammals. He queries as
to how we can get the nervous system to spontaneously engage in a healthy
way. In this context, Porges predicts that, “Trauma treatment may move toworking with dogs, horses, and other mammals” (Porges, 2017b, p. 196).
We claim that the future is already here.
Animal-assisted psychotherapy is a growing field worldwide; however,there are many misunderstandings surrounding the profession (Parish-Plass,2017). It is important to expand the understanding of the mechanisms
involved in this type of psychotherapy through theory-building, research,and clinical reporting. This chapter lends support to the view that AAP
adds a unique contribution as a relational therapy for children who haveexperienced developmental trauma, especially for those children who are
avoidantly attached and resist the establishment of the therapeutic alliance.

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma171

ACKNOWLEDGMENTS
We would like to warmly thank Daniel Siegel, Stephen Porges, Louis
Cozolino, and Sue Carter for their generous and supportive comments on
the ideas presented in this chapter.
NOTES
1. Considered to be the key to successful therapy, the therapeutic alliance is madeup by the mutual agreement by the therapist and client concerning the goalsof the therapy, the methods used to reach these goals, and therapist-clientbond (Bordin, 1979). In children, this bond is the main, if not only, elementof the therapeutic alliance (Fjermestad et al., 2012). For the therapeutic alliance to be established, the client must feel that the therapist is empathetic,
supportive, trustworthy, authentic, and genuinely interested in the good of
the client, and everything that the therapist does is toward that end. It could
also be said that the therapist will serve as a safe haven and a secure base forthe client.
2. Winnicott (1965) referred to the authentic and spontaneous real self vs. the false
self, developed as a defense mechanism against impingement, as a painful
and intrusive experience of the real self, leading to disconnectedness and afeeling of inner emptiness.
3. Bellak (Bellak & Abrams, 1996) developed the widely used projective Children’sApperception Test (similar to the adult Thematic Apperception Test — TAT)
based on the tendency of children to identify with animals.
4. Examples of identification with animals in therapy facilitating the therapeutic
alliance may be seen in Parish-Plass, 2008.
5. This assertion is dependent upon the degree to which the animals are perceived
to be “safe” by the client.
6. This explanation throughout this chapter of the effects of oxytocin would beincomplete without a description of the interaction between oxytocin andvasopressin, and their receptors, both components of an integrated neuralsystem regulating social behavior. The interactions of the two neuropeptides
supply a more complete explanation of the importance of social behavior in the regulation of anxiety and responses to threats. At optimal levels,
both oxytocin and vasopressin may contribute to the dampening of social

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anxiety, which would permit the approach to unfamiliar others. Furthermore,both oxytocin and vasopressin systems are also affected by early life experiences, in turn affecting their regulation of social behavior across the life span.
According to Sue Carter (personal communication, August 31, 2017), “These
complex interactions are only now becoming apparent, but may in time help
to predict when animal-assisted therapies will be most helpful.” For further
discussion, see Carter (2017).
7. For further discussion on the effects of animals on the potential space, see ParishPlass, 2013b.
8. Mindsight is a term used by Daniel Siegel referring to insight into one’s own
mind and into the mind of others. It is a way of focusing on and being awareof the nature of one’s inner world (Siegel, 2009, 2010).
9. This quote is taken from an online Q&A session (October 4, 2016), as part of an
online course with Dr. Dan Siegel on the subject of the interpersonal neurobiology of trauma and healing of trauma. The quote is part of Siegel’s answer
to Parish-Plass’s question: “I am an AAP therapist working in an emergency
shelter for at-risk children. Many of these children are characterized by a highlevel of anxiety and are unable to play, for contact with their inner world is
far too threatening. I often see the children projecting their emotions, theirstories, onto the animals and working through their issues in this way. Can
this be considered to be play (in the therapeutic sense), leading to integration? Any insights of yours will be helpful.”
10. For further discussion on the subject of the mentalization and translation of
implicit knowledge into explicit knowledge through AAP, see Shani, 2017.
11. While we are interested in the client fulfilling his own needs for the therapy
process through the animals present in the setting, it is essential and ethically critical that the animal’s needs are always kept in mind, and that they
will always be protected. The AAP therapist must be constantly aware of thedifference between projective play with the animal that is harmless and thatwhich has the potential to cause any harm or unnecessary stress to the animal,and prevent that from occurring.
12. We prefer an untrained dog with a temperament appropriate for taking part intherapy, rather than a well-trained dog. We are more interested in dogs withauthentic behavior, rather than obedient behavior.
13. This discussion is based on a series of personal communications with Cozolino,
whose enthusiasm and willingness to help us arrive to a greater understandingof the material and its implications for AAP is highly appreciated.

Implications of Animal-Assisted Psychotherapy for the Treatment of Developmental Trauma173

14. It is important to realize that all of these processes involve not only the amygdala and the ompfc, but also the autonomic and polyvagal nervous systems
as well (L. Cozolino, personal communication, June 15, 2017).
15. It was mentioned earlier that developmental trauma leads to a deficit in emotional language and a fear of verbalizing.

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ABOUT THE AUTHORS
Nancy Parish-Plass, MA social work, has completed studies in animal-assisted
psychotherapy and advanced psychotherapy. Her positions include: seniorstaff member at the AHAVA Emergency Shelter for At-Risk Children, AAP
clinical supervisor, editorial board member of HABRI Central, member of
the IAHAIO International Task Force for the Development of Guidelines
for Animal-Assisted Interventions and Animal Welfare, and chairpersonof the IAAAP — Israeli Association of Animal-Assisted Psychotherapy. Her
research focuses on the therapeutic alliance and self-disclosure in AAP withmaltreated children.
Jessica Pfeiffer is a licensed clinical social worker, licensed school social
worker, and a ChildTrauma Academy Education Fellow. She is the ownerof Intricate Roots Educational Consulting Services supporting educational
systems in implementing a trauma-informed lens and providing therapeutic services to children, adolescents, and families. Pfeiffer is also a faculty
member at the Institute for Human-Animal Connection in the Graduate
School of Social Work at the University of Denver. Currently, she is working toward her doctorate in clinical psychology in the School of Psychology
at the University of Colorado Denver.

CHAPTER 5

The Power of Play and Animals:
Animal Assisted Play Therapy asan Integrative Practice Model for
Mental Health TreatmentRisë VanFleet, PhD, RPT-S, CDBCBACKGROUND
Literary great Mark Twain once said, “Against the assault of laughter,nothing can stand.” Child development theorist Erik Erikson said, “Theplaying adult steps sideward into another reality; the playing child advances
forward to new stages of mastery.” Physicist Albert Einstein said, “Playis the highest form of research.” What did they all know that we might
be missing?
Play is a much-overlooked resource in therapeutic work with people of
all ages. It creates bonds, reduces stress, fosters an atmosphere of emotionalsafety, provides fresh perspective, allows one to practice new behaviors,
encourages flexibility and creativity, and offers the opportunity to gain
mastery. Gradually over the past 70 years, the use of play, laughter, andhumor to help people overcome social, emotional, and behavioral difficulties has become more broadly accepted. Research has also shown its value
in the formal therapeutic process (Bratton, Ray, Rhine, & Jones, 2005).
Arguably, the benefits of animal-assisted interventions (AAIs) can be magnified when conducted more playfully (VanFleet & Faa-Thompson, 2012,
189

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2015a, 2017). This chapter discusses the integration of animal-assisted
therapy (AAT) with play therapy. Brief descriptions of play (including
animal play), play therapy, and Animal Assisted Play Therapy™ (AAPT)
are followed by details of the principles and procedures involved in AAPT,
as well as considerations and case examples that highlight its application
with children who have experienced complex trauma and attachment
disruptions.
HISTORY AND TERMINOLOGYPlay offers certain benefits to the players. It usually is fun and filled withjoy, providing a release from stress. It facilitates the development of physical, cognitive, social, and adaptive capacities and skills, and permits thenonverbal (and sometimes verbal or vocalized) expression of emotions,motivations, interests, and desires. Play also helps creates bonds in social
animals, both human and nonhuman. Conversely, scholars note that theabsence of play in a child’s life may be linked with antisocial behavior(Brown, 2009). The American Academy of Pediatrics (Ginsburg, 2007)
states, “Play allows children to use their creativity while developing their
imagination, dexterity, and physical, cognitive, and emotional strength,”while adding, “play is important in healthy brain development” (p. 183).
These benefits apply to children and adults.
Play also serves many purposes for nonhuman animals (henceforthreferred to as animals), both in the wild and in captivity. To date, the mostcomplete definition of animal play is one proffered by Gordon Burghardt(2005). He has detailed a five-point definition to distinguish play fromother similar patterns of animal behavior. In brief, his definition is as follows: “Play is repeated, incompletely functional behavior differing from
more serious versions structurally, contextually, or ontogenetically, andinitiated voluntarily when the animal is in a relaxed or low-stress setting”(Burghardt, 2005, p. 82). Play does not serve any immediate function, andit arises from within the animal in a spontaneous, voluntary, and enjoyablemanner. It differs qualitatively from survival behaviors; play fighting isdifferent from actual fighting in identifiable ways, even though they mightlook the same initially. There is much repetition in animal play, but there
are at least some differences in the repetitions. Play takes precedence overother activities when it occurs, but it occurs only when animals feel safe.

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Although the benefits of play are clear, its value in both human andanimal life has long been overlooked. Perhaps it was seen as frivolous, oras something humans and animals engaged in only when more “serious” or“worthwhile” pursuits were completed. It was only when cognitive ethologists (e.g., Bekoff, 2018; Bekoff & Byers, 1998), as well as psychologists
and neuroscientists (e.g., Burghardt, 2005; Panksepp, 2005, 2012), documented the pervasiveness of play in the animal world and the pathways
for play in the brain, that the topic gained considerable traction. In themeantime, social scientists noted the value of play for children, adults, andwhole societies, but continued to struggle with a clear definition (Brown,
2009; Chudakoff, 2007; Sutton-Smith, 1997).
Sutton-Smith (1997) has identified seven different forms of rhetoric
to describe play, including: 1) as an adaptation that assists learning anddevelopment; 2) as a form of strategy or skill that establishes hierarchy; 3)
as an optimistic mechanism that offsets pessimistic views; 4) as a means
to transform the ordinary through pretense and exaggeration; 5) as an
expression of one’s identity; 6) as a way to establish social and community
bonds; and 7) as fun, which contrasts with work. Over the last 20 years, therecognition of play as a subject of serious study has grown, with publishedbooks, articles, and research becoming increasingly prevalent (Brown,
2009; Burghardt, 2005; Käufer, 2013; Maestripieri, 2012; Panksepp,2012; Pellegrini & Smith, 2005; Pellis & Pellis, 2009). Periodicals such as
the American Journal of Play, the British Journal of Play Therapy, and theInternational Journal of Play Therapy have provided additional outlets forresearch about play and its application in therapeutic work.
Play therapy has been defined as a “broad field that uses children’snatural inclination to play as a means of creating an emotionally safe
therapeutic environment that encourages communication, relationship-​building, expression, and problem resolution for the child” (VanFleet,
2004b, p. 5; VanFleet, Sywulak, & Sniscak, 2010, p. 11). There are many
forms of play therapy that represent the major personality theories, suchas psychodynamic play therapy, cognitive-behavioral play therapy, andchild-centered play therapy (humanistic). Play therapy has increasingly
been extended successfully to adults, adding the elements of playfulness
and humor with other forms of intervention. Play and humor are important coping mechanisms that can be incorporated into therapy for a wide
range of challenges. In addition, because play tends to increase motivation,
it is a useful tool in other forms of intervention that may be onerous in

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nature, such as physical, occupational, and speech/language therapy, as
well as diverse forms of education for people of every age (VanFleet, 2008;
VanFleet & Faa-Thompson, 2017).
Moreover, play interventions have even been applied with animals suffering from fear or stress disorders, such as with puppy mill, unsocialized,
and feral dogs. For example, VanFleet (2014b) created the conditions ofsafety for extremely fearful dogs to engage in natural play with other dogs
specially selected to serve as social facilitators. These canine play interactions occur at the pace and full choice of the fearful dog, and are followed
by invitations and opportunities for human-dog play as the fearful dog
shows interest. Notably, this approach has resulted in the observation ofincreased social behaviors and reduced fear among unsocialized, anxious,or feral dogs.
AAPT harnesses the power of play, as well as the many benefits ofincluding animals in human mental health, allied health, and educational
therapies and interventions (i.e., AAI) (Chandler, 2017; Fine, 2015; ParishPlass, 2013). Animals working in professional settings, including hospitals,
nursing facilities for older adults, and schools (among others), can facilitate
the achievement of client goals in many areas of therapeutic need, and are
valuable for social support and connection. AAPT is defined as:
The integrated involvement of animals in the context of play therapy,
in which appropriately trained therapists and animals engage with clientsprimarily through systematic playful interventions, with the goal of improving clients’ psychosocial health, while simultaneously ensuring theanimal’s well-being and voluntary engagement. Play and playfulness are
essential ingredients of the interactions and the relationships (VanFleet,
2004a; VanFleet & Faa-Thompson, 2015c, 2017, p. 17).
While the author of this contribution first engaged in AAPT-type
activities over 35 years ago, and others are likely to have incorporated
playfulness into their AAI work, the systematic and formal developmentof the AAPT field began in 2004 (VanFleet, 2008). Two years later, a professional collaboration between Risë VanFleet and Tracie Faa-Thompson,
both mental health professionals and credentialed play therapists withsimilar approaches to working with animals (including equine-assisted interventions, in Faa-Thompson’s case), began. This collaboration has since
resulted in further articulation of the use of play in AAI, including in-depth
training programs and a comprehensive, competence-based certification

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for mental health, allied health, and education professionals (International
Institute for Animal Assisted Play Therapy® or IIAAPT, 2017).
ANIMAL ASSISTED PLAY THERAPY (AAPT) — AN OVERVIEW
AAPT differs from other forms of animal-assisted therapy (AAT) in its
systematic incorporation of, and focus on, play and playfulness. The appropriate use of a lighter tone in therapy creates greater emotional safety
for human clients by lifting intensity and offering acceptance, while also
increasing the likelihood that the animals involved will genuinely enjoy theprocess. AAPT is beneficial for psychotherapy and family therapy clients
across the life span. The playful environment reduces stress and builds
connections, not only with the animals involved, but also between client
and therapist (VanFleet & Faa-Thompson, 2017). AAPT heavily emphasizes relationships between therapists and animals, clients and animals, andtherapists and clients. Clients then learn to extend what they learn about
relationships in therapy to other relationships in their lives.
Importantly, AAPT also emphasizes the welfare of animals involvedin this work. It is essential that animals be treated with respect throughout
the process. At no time is an animal expected to “tolerate” the behaviors
of humans. A substantial knowledge of the animal species being incorporated, including body language and behavior, as well as of the individual
animal, is required of the practitioner. While animals are evaluated fortheir suitability for AAPT work, including being well-behaved and undercontrol during play sessions, the burden of risk management is placed
upon the therapists. For example, therapists must be able to accuratelyinterpret their animal’s body language and intervene at the first signs ofstress or fatigue. This provides the animals with greater freedom to moveand participate voluntarily without the use of leashes and other equipmentthat can dampen their behavior and choices. The therapist and animal aretrained to such a degree that dogs work off-leash and horses work at liberty,
in which they are free to go where they choose.
A training process created and tested specifically for AAPT is used tofurther prepare therapists and their animals for this more intensive andenduring work. Through online courses and hands-on training workshops,
therapists learn to read their animals’ behavioral cues fluently, improve

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their abilities to anticipate situations that might be stressful for their animals, and ensure that the animals can always move away from situations
that they find uncomfortable. There is a strong emphasis on building positive and strong therapist-animal partnerships that are then shared withclients in a variety of playful ways while simultaneously ensuring animal
well-being. Therapists also learn to split their attention skillfully between
clients and their animals to ensure a valuable experience for all.
Principles

VanFleet and Faa-Thompson (2010, 2017) have outlined the following
principles underlying AAPT:
•
•
•
•
•

Mutual respect for clients and animals;
Physical and emotional safety for both the human and animal;
Enjoyment by all;Acceptance of clients and animals for who they are;Use of positive, nonaversive training and equipment for
the animals;• Healthy, mutually beneficial relationships;• Process-orientation with measurable results, grounded intheory; and• The importance of developing an empirical base.
In AAPT, the animals’ needs and preferences are considered on par withthose of the humans, and practitioners learn how to balance and respect
both, including leveraging natural animal behaviors to help achieve therapeutic outcomes. For example, when animals in AAPT are selected forsociability and curiosity, and the therapist-animal relationship helps theanimal see most humans as desirable companions, animals are able to maketheir own choices to approach or move away from clients. When they move
away, clients might feel rejected or disappointed. Usually, clients’ reactions
reflect feelings they might experience in family or peer relationships, suchas abandonment fears or feeling isolated. The therapist then helps clients
work through their reactions in real time, using the therapeutic skills attheir disposal. It is often during these spontaneous moments, where theanimals are free to behave authentically and unexpectedly, that the mostvaluable therapy occurs.

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Likewise, the natural behaviors of animals create rich opportunities forhuman learning and behavioral change. For instance, the AAPT therapist
might call the child’s attention to the animal’s body language and behavior
during play (i.e., the display of behavioral indicators of stress). Gradually,
the child then learns to adjust his or her own behavior to accommodate
and respect the needs of the animal. In other words, the therapy is not somuch about getting the animals to do what the clients want all the time,
but helping clients with their reactions to what naturally happens in sessions, even when the animals don’t “play along” exactly as the clients would
wish or expect. AAPT practitioners continuously help children develop
two-way, mutually respectful relationships with the animal, whether they
are engaging in obstacle course exercises or sitting quietly together while
the child gives advice about a “problem” the dog is having (for example).
Such lessons are anticipated to transfer to the client’s social relationships
outside of therapy, and the therapist facilitates this when it does not occur
naturally. Additional examples of how AAPT principles play out in the actual work are described in greater detail later in this chapter and elsewhere(see VanFleet, 2014c, VanFleet & Faa-Thompson, 2017).
Primary Goals

The primary goal areas of AAPT include the development of self-​
efficacy, healthy attachment and relationship, empathy, self-regulation, andproblem-resolution for a wide range of specific difficulties (VanFleet &Faa-Thompson, 2010, 2017). The approach is flexible and can be adapted
to many different ways of working with clients. Often, multiple goal areas
can be addressed with the same interventions. When applied by allied
health and/or mental health professionals or educators, AAPT goals candiffer according to the specific objectives of their profession, as well as
their therapy and teaching methodology. In the mental health field, AAPT
has been used to address such clinical targets as anxiety, attention deficits, autism spectrum disorder, chronic medical illness, delinquency andtruancy, attachment problems, family tensions, depression, selective mutism, oppositional and conduct problems, obsessive compulsive disorder,
grief, and trauma (VanFleet, 2008; VanFleet & Colţea, 2012; VanFleet& Faa-Thompson, 2014, 2015b, 2017). Furthermore, AAPT has often
been applied to help clients who experience fears of dogs or horses. These
fears might come from prior traumatic experiences with animals, or from

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overly cautious caretakers who demonstrate or “model” their own fears ofanimals with their children.
Trauma-Specific Applications

AAPT is particularly well-suited for working with children who have experienced trauma, but is also effective with adolescents, adults, and families.
This chapter focuses on AAPT’s application with maltreated and traumatized children with concomitant attachment difficulties. When children
have experienced abuse, neglect, domestic violence, exposure to substanceabuse, and attachment disruptions, they often develop mistrust of people,
along with serious emotional, social, and behavioral problems (Gil, 2006;
James, 1994; Terr, 1990; VanFleet, 2015; VanFleet & Sniscak, 2003b).
Effective treatment must include the facilitation of healthy attachment experiences, while providing avenues for overcoming the sequelae of trauma.
This can be particularly challenging because children are typically hurt
most by adults and, therefore, have difficulty trusting them, including
therapists.
AAPT offers an alternative to traditional forms of therapy by addressing these trust-related issues in two primary ways. First, using the languageof play creates emotional safety. Children are not required to “talk” directly
about their problems, which is often frightening and can run the risk ofretraumatization. Instead, play therapy gives them opportunities to express
themselves and to be understood, as well as symbolically work through andmaster their intense and often confused feelings. Second, the involvementof animals allows for trust and early experiences of healthy attachment relationships within the therapeutic process itself (VanFleet & Faa-Thompson,2017). In the author’s experience, directly with clients and in supervisionof other AAPT practitioners, the connection between client and animal
occurs quickly and, not long after, rapport with the therapist is facilitatedby the presence of the animal. A consistent clinical finding is that traumatized children’s ability to work on their problems in a non-defensive andopen manner is considerably enhanced when animals are present in AAPT
(as compared to play therapy without animals). Animals’ social lubricant
or catalyst effects (McNicholas & Collis, 2000, 2006) are significant whenworking with children with trauma and attachment problems, thereby
helping them connect with human support systems more readily (VanFleet& Faa-Thompson, 2017).

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THEORY AND POTENTIAL MECHANISMS
Psychology

Developmental research clearly shows the importance of animals for children (Jalongo, 2018; Melson, 2001; Melson & Fine, 2015). For many
years, play therapists have noted the importance of animal figures, puppets,
and toys in the therapeutic playroom. Children frequently select animal
objects and roles in child-centered play therapy (VanFleet et al., 2010),
and therapists typically include animal representations as part of their playrooms and sessions.
Adults also express interest in animals. In the author’s shared family
practice, a significant number of adult clients explain that the involvement of animals in therapy was the main reason this practice was chosenover others. Some theorists have suggested that people have a strong needto seek connection to nature (e.g., biophilia hypothesis; Wilson, 1984).
Others (Louv, 2012; Olmert, 2009) believe that the connection to animals
offers a route to connect with the environment at a time when people
are disconnected from it and each other by busy schedules, disappearing
opportunities to experience nature, and increasing involvement with electronic devices and online social experiences.
Clients of all ages who participate in AAPT can have attachment or
relationship challenges. Change occurs in the context of relationships, andsometimes it is easier to develop a relationship with a nonhuman animal
than a human one. It is important for therapists to remember that theirrelationships with their own animals serve as models and metaphors fortheir clients (VanFleet & Faa-Thompson, 2017), and that a key skill is torecognize the various relationship dynamics that occur during sessions sothey can make the most of relational moments (Chandler, 2017).
The actual practice of AAPT spans a variety of psychological theories.
Likewise, there are forms of play therapy that are derived from nearly
all psychotherapeutic theories, including psychodynamic, humanistic,
cognitive-behavioral, and family systems. The manner in which play isincorporated differs according to the theory being used. The same is trueof AAPT. For example, AAPT can be conducted from a humanistic perspective in a nondirective manner in which the therapist creates safety andacceptance while the client decides the activities, expressions, and interactions. It can also be conducted from a cognitive-behavioral perspective

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in which the therapist suggests activities or interactions that are likely tomeet a specific goal for that session. In nondirective AAPT, a child mightdress up as a police officer and announce that the dog is a police dog. The
child may want the dog to accompany her around the room to look for“bad guys.” If the dog does not do this, the therapist can help, at the sametime reflecting the play through the dog, as exemplified by: “Wow! Thosebad guys are hiding around here somewhere. Rover, Mary wants you to
help! Come here and look behind this chair! Now Mary wants you to sniff
around those blocks. Good work, Rover!”Such play themes of threat (i.e., the presence of “bad guys”) andmastery (i.e., finding the “bad guys”) are commonly used by children in
nondirective AAPT, while the therapist conveys safety and support throughthe use of empathic responding and the animal participates.
Directive AAPT can take many forms. One intervention — with thegoals of improving family communication and cohesion— asks a family
to set up an obstacle course and then work together to get the dog to go
through it, all without touching the dog and using no more than 10 treats.
Another might be tasking a client to teach the dog a new trick, with thehelp of the therapist, for the purposes of enhancing the client’s self-efficacy.
There is great latitude in AAPT for therapists who operate from different theoretical bases. Perhaps the most relevant theories that guide AAPTinterventions are life-span development (where humans are viewed as continuously developing from birth to death) and attachment/relationship/
systems approaches, which emphasize the importance of caring and mutual
relationships (VanFleet & Faa-Thompson, 2017).
As noted earlier, AAPT offers a very useful component in multimodal
therapy that is typically needed for children who have experienced complex trauma and attachment disruptions. Through play, it provides theemotional and interpersonal safety that is needed for therapy to work well.
The involvement of animals opens the door to communication, as well as
to therapeutic processing (VanFleet & Faa-Thompson, 2017). As clients
interact with the animals, they relax and begin to lower their defenses. One
teen client told the author, “When I first came here, I was very suspicious.
I didn’t want to talk with a stranger about my problems. But I quickly
began to trust you more because you were sharing Kirrie with me, plus
you made it fun. You didn’t put a lot of demands on me and you seemedto accept me for me.”The Power of Play and Animals199

In many ways, when animal involvement is skillfully facilitated by thetherapist, it offers a secure base from which the child can explore. That
exploration can go in many directions: exploration of the traumatic experiences and attached emotions of identity, of relationships, of hopes andwishes, and of the road ahead. The playful, active nature of AAPT stretches
beyond traditional talk therapies, allowing children to form actual andgenuine relationships with the animals and with the therapist, as they use
the range of interventions to heal and make progress.
Physiology

Traumatized children often display emotional and behavioral dysregulation. Without the grounding of consistent relationships, they can end
up in a downward spiral in which their misunderstood and externalized
behaviors lead to even greater misunderstanding and possibly isolation(James, 1994). Play therapy offers them a means of expressing the feelings
associated with trauma, as well as a way to master those feelings in developmentally appropriate ways. This, in turn, allows children to try out new,more adaptive behaviors in a safe and secure environment.
Neuroscience has provided considerable knowledge about trauma’s
effects in recent years, and it is well-established that expressive therapies,
including play, are appropriate for treatment based upon the imprint of
trauma in the brain (Perry & Szalavitz, 2010; van der Kolk, 2014). Whenthe attachment system for the child has been compromised or damaged,
there is a need for healthier “templates” of relationship. The importanceof consistent, caring relationships for helping children overcome trauma
and attachment problems has also been established (Garbarino, Kostelny,& Dubrow, 1991; Garbarino, Dubrow, Kostelny, & Pardo, 1992; Siegel,2012; VanFleet & Sniscak, 2003a). The child needs a framework to realize
that, in securely attached relationships, adults are focused on meeting theirneeds rather than ignoring, subjugating, or hurting them. In the case of
AAPT, the animal may also serve as a reliable source of support and connection for children, which could further aid their ability to trust, and seek
relationships with, others.
In addition, playful interactions with animals may result in the release of opioids in the body, as well as oxytocin (Olmert, 2009; Panksepp,2012). Both can help provide a greater sense of safety and well-being as
children begin to work through very difficult experiences and feelings.

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Seeking and play, two of the emotional systems mapped through the brain
by Panksepp (2012), are likely important in AAPT applications as well.
Both of these neurological systems are thought to help counteract negative
emotional experiences, and help people explore inwardly and outwardly
in their relationships.
Interacting playfully with animals while the therapist facilitates also
allows children to have genuine experiences with another living being. It
allows them to touch, explore, teach, and respond to the animal. Touch,in particular, is important to social animals — both human and nonhuman. While touching between therapist and child is limited in therapy,
there are many more opportunities to explore appropriate touch with ananimal. Children can learn through direct experience how and where an
animal likes to be touched. For example, in AAPT, the “three-second rule”
is often used. With this, the child pets or scratches the animal for threeseconds and then stops. The therapist and child watch for the animal’s
reaction. If the animal remains in place or looks at the child or nudges thechild’s hand, it is usually an indication that the animal would like moreof that touch. If the animal shows stress signals (e.g., chewing or licking,turning his or her head or body away), it suggests that the animal is notinterested in being touched further in that way. In AAPT, therapists help
children use this rule to learn about the interests of the animal, and to show
concern for the animal’s feelings, reactions, and boundaries. Clinical andanecdotal evidence suggests that touching, and being touched by, animals
may provide children with sensory stimulation; comfort, relaxation, andthe relief of physiological stress; unique opportunities to engage in gentle
and/or consensual physical contact, which may likely be uncommon forchildren who have been maltreated; and help in forming and maintaining
respectful social relationships.
CURRENT AAPT RESEARCH
It is difficult to conduct good research until there are practitioners who
fully understand the method and how to apply it in competent and consistent ways. With emerging fields, this takes time. Today, there is preliminary
research on AAPT, as well as consistent clinical findings, but only recently
have therapists been certified in the practice.

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Play therapy and Filial Therapy (where parents learn to conduct special nondirective play sessions with their own children; see Guerney &Ryan, 2013 and VanFleet, 2014a) provide the foundations of AAPT, andare empirically supported and/or evidence-based approaches in both theUnited States and the United Kingdom (Bratton et al., 2005; VanFleet,
Ryan, & Smith, 2005). Research on the impact of these two approaches
has grown considerably over the past 20 years, although more researchon play-based interventions is needed, especially in regard to the various
forms and clinical outcomes of AAPT that integrate both of these models.
A first step in an emerging field is to see if the professional training is useful. Hansing (2014) studied 67 mental health professionals who
had attended at least the Level 1, 48-hour workshop in AAPT (24 hoursof which are hands-on), and found that the development of counselor
self-efficacy was significantly higher for professionals who had participatedin both the online and hands-on training when compared to those who
had taken only the online courses. Additionally, Thompson (2009) conducted a preliminary study of AAPT using subjects as their own controls
with animals present or absent from child-centered play therapy sessions;she found fewer play disruptions and overt signs of anxiety when the dogs
were present.
VanFleet (2008) also completed a preliminary study of AAPT from thepoint of view of 21 child clients. In this assessment, children were asked
to select an unlimited number of miniature toy figurines for their sandtray
from a wall display of over 1,000 options (including animal and people
items, as well as non-animal objects such as vehicles, houses, trees, anddishes). Researchers directed the children to base their choice of miniatureon what they perceived to be the best parts of therapy. In all cases (i.e.,
100% of the time), those children who had been previously involved with
AAPT with dogs included at least one miniature of a dog in their sandtray.
In contrast, children who had not received AAPT, but could play with all
playroom items (animal and non-animal) in their therapy, included a dog
figurine only 20% of the time. These findings suggest that the experienceof connecting with dogs during AAPT is a meaningful aspect of therapy
for children, and likely more so than playing with toy dogs alone. At present, this study is expanding with more therapists, a larger child sample,
an analysis of horse miniatures for those in equine AAPT, and an external
assessment of sandtray photos.

202

TRANSFORMING TRAUMAIn related research, Faa-Thompson (2014) recently asked children in
her AAPT trauma groups (designed to help children with their feelings,
problematic behaviors, social relationships, and emotional regulation) todevelop their own assessment of their AAPT experience, and to complete
it at the end of their program. Each child provided five questions that they
considered important to include in an AAPT program evaluation andanswered them. Question examples included: “What were the best things
you did?”, “Which animals liked you the best?”, and “What was it likedoing [AAPT] with other kids you didn’t always like before the program?”
The current assessment survey, which has been informed by the children
who participated in this process, has since been used effectively with otherclients. Additionally, the feedback from children on these evaluations has
been overwhelmingly positive, particularly in regard to their perceptionsof AAPT participation as valuable.
Additionally, Wenocur (2018) studied the impact of AAPT whenused with children in a homeless shelter. She used grounded constructivist
theory to perform an integrated analysis of projective drawings, accompanying narratives, parent interviews, and the treatment records of 11
children, aged 6 to 11 years, who participated in AAPT sessions at the
shelter. The study illustrated children’s lived and wished-for experiences ofattachment relationships. It also showed that tasks associated with taking
care of the dogs were important to the children, and that parents identified the dogs’ involvement as a component of the program’s success fortheir children.
CASE STUDY: JAKE AND KIRRIE
Identifying information about clients has been changed to protect confidentiality.
Kirrie (a play therapy dog) eagerly greeted 12-year-old Jake when
he arrived for his fifth AAPT session. Her tail wagged so strongly
that her hips swung back and forth. Jake smiled broadly and said,“She’s got her wiggle on again. That’s how I know she’s happy
to see me!” He proceeded to pet her under the chin and said hewanted to play hide-and-seek with her. I reflected, “You’re looking
forward to more hide-and-seek with her!” and then assisted him
as he set up the “game” they had played together for the first timein the prior session.

The Power of Play and Animals203

Jake proceeded to hide in various locations in the large playroom while I kept Kirrie’s attention. When he was well-hidden, I
gave Kirrie the cue, “Go find Jake!” She then moved around theroom, sniffing and looking until she found him. I did not tell her
where to go, but merely described aloud what was happening so
Jake would know what she was doing: “She’s over by the window,
sniffing all around the stuffed animals. Now she’s checking out
under the table. Here she comes your way.” Kirrie approached thechair in which Jake was hiding. It was an egg-shaped chair with a
movable shade that pulled down in front to conceal him. Kirrie
approached, pushed the shade up with her nose, and licked his
arm as Jake got out laughing. I reflected his delight, “You reallylike it when she looks for you and finds you!” Jake (who rarely
spoke unless he was in a session with Kirrie) replied, “Yep! She isreally looking for me — not just pretending!” I empathically responded with, “It feels so good that she really, truly wants to findyou. You can tell she cares for you and wants to find you when
you’re missing!” Jake hid several times during that session, and werepeated the process.
At the time, Jake was in foster care with a long history of
extreme physical abuse from his mother’s boyfriends. He had also
been molested while in a prior foster placement. An adoption had
fallen through because of the adoptive parents’ inability to control
his behavior. Another adoptive family was being considered, andthis time the agency was willing to pay for therapy to address Jake’s
social, emotional, and behavioral difficulties associated with histrauma and attachment disruptions. He had already shown improvement with play therapy and family therapy with his foster
mother. The work with Kirrie had been added to assist with his
mistrust of people, attachment problems, self-esteem, and occasional attempts to be unkind to animals.
Jake’s AAPT sessions involved a number of interventions
that were designed to support him and his treatment goals. He
helped teach Kirrie several new tricks using positive reward-based
methods (clicker training), with the aim of improving his senseof competence and confidence. When I prompted him to check
how Kirrie was reacting to his various behaviors, he learned aboutbasic body language in dogs. He also learned how to create a kind

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and caring relationship with the dog, and to respect her boundaries and preferences. Emphasis on how the dog was feeling andresponding helped him see her as the emotional, cognitive beingthat she was. As Jake developed skills and confidence, we heldfamily sessions where he could show his foster mother what hehad accomplished and learned with Kirrie. Before I tried specificinterventions to help him transfer his ability to be kind to thedogs in his foster family, he generalized what he had learned on
his own and began treating the family dog with the same regard
as he did Kirrie.
Jake’s sessions typically involved a period of nondirective
AAPT, where he was able to select what and how to play, followedby more structured, or directive, AAPT held in a different room
or in a private outdoor area. During the directive AAPT segments,
I suggested more specific playful interactions (e.g., teaching her
new tricks, scratching her favorite spots, giving her “advice” forproblems that resembled his, playing games that involved taking
turns or watching her reactions to new toys) that helped Jakebuild relationship, consider Kirrie’s feelings, teach and help her
with tasks, and provide nurturance to her. I also included some
impulse-control activities where Jake and Kirrie did an energetic
and exciting activity, followed by a calmer period where Jake’s“job” was to help Kirrie settle down. Jake was always motivatedto work in AAPT with Kirrie, and his foster mother, adoption
worker, and teacher all noted differences in his behavior after justthree sessions. The secure relationships Jake had with both the dog
and therapist provided the context in which he could work on
overcoming his trauma, developing coping strategies, and feelingmore at ease in the world and with himself.
According to his foster mother, after 10 sessions with Kirrie,
Jake showed improved self-regulation in daily life. His inappropriate and/or intrusive behavior with the family dog had disappeared
entirely. She also reported that he seemed more at ease withhimself. While the play therapy and family therapy had helped significantly, it seemed that his work with Kirrie opened new doors
for him. He became better able to express himself and cope withlife’s challenges in more constructive ways. The process continued
as he met and was eventually adopted by a second family.

The Power of Play and Animals205

In general, the different applications and therapeutic activities of AAPT allowed Jake to express his feelings in an accepting
environment and to master them through something he genuinely enjoyed — play. AAPT also provided him with coping skills
and increased confidence to handle the often considerable stresses
in his life. Finally, it helped him learn about emotions in himself
and others, and how to build mutually respectful relationships.
AAPT allowed Jake to experience being cared for as well as caring
for the dog, facilitated by the therapist. These are core features ofhealthy attachment and development (Bifulco & Thomas, 2013;
Bowlby, 1988), and AAPT provided Jake a playful and safe environment in which to explore, perhaps for the first time, thesevery significant aspects of his life.

BEST PRACTICES
Protocols

AAPT is a form of play and family therapy. Its practice depends on thegoals developed in tandem with families, so the specific methods selectedin any given case are driven by that individual assessment. The methods
used are also determined by the animal’s personality, abilities, and preferences (which can vary from day to day). The Animal Appropriateness Scale(VanFleet & Faa-Thompson, 2017) is used to select animals, and positive
reinforcement- and relationship-based methods of training are utilized.
A “goodness of fit” model is also applied, whereby therapists consider
their animals’ characteristics, including energy level, curiosity, engagement,
playfulness, sociability, and preferred activities. These are then matchedwith the type of AAPT being employed. For example, Grazie, the horse,
had a relatively short attention span, so she was included in sessions thatwere shorter in duration. Magnum, however, was an extremely sociable
and curious horse, always trotting to greet people when they approached
the gate to his field. As such, he was included in more active interventions
that integrated those features.
AAPT therapists watch carefully for any signs of stress in the animals,
and they proactively ensure the comfort and safety of their therapy partners. Children are not permitted to intrude in the animals’ space; if and206

TRANSFORMING TRAUMA

when this happens, the situation is used to help the child think about the
animal’s needs and behave accordingly. If that is not possible, then the therapist can set limits. For more detailed information about AAPT standardsof practice, please see VanFleet and Faa-Thompson (2017).
As mentioned previously, even carefully selected and well-trained animals do not always do as they are asked in therapy sessions, and unplanned
animal behaviors are often expected. Horses might choose to graze rather
than interact. Dogs might refuse to jump over an obstacle, or may backaway when confronted with a new prop or toy. These situations are often
of great therapeutic value and can provide important healing potential
for clients. For example, the animal does not behave as the child wishes,
and the child reacts with disappointment or anger. The AAPT therapist
then processes that reaction with the child. There are various methods ofprocessing, ranging from empathic listening to brief, guided questioning
to explore the reasons behind the animal’s reaction or to suggest that theclient try again, using a different approach. In most cases, verbal discussions about the child’s feelings or behaviors are not used or are kept short.
The unique value in AAPT is in the doing, the experiencing.
Different forms of AAPT have their own methods, as is true of traditional play therapy. Nondirective AAPT follows the same standards
and practices as child-centered play therapy, where activities are mostly
led by the child. Cognitive-behavioral AAPT is conducted similarly tocognitive-behavioral play therapy, in that it incorporates more directive approaches designed to adjust perceptions and behaviors. There are different
levels of structure in different interventions, and it is part of the therapy
to consider what approaches are likely to work best to meet individual
client goals while still suiting the animals and considering their well-being(VanFleet, Fine, O’Callaghan, Mackintosh, & Gimeno, 2015).
ANIMAL WELFARE
There are numerous considerations in AAPT, just as there are in all AAI, in
the area of animal welfare. These include the fundamental care and healthof the animals, but also reach far beyond their physical well-being. For
example, AAPT practitioners must carefully evaluate whether a particularanimal is well-suited or wants to be involved, and if he or she truly enjoys
working with client populations. A keen understanding of the client andThe Power of Play and Animals207

therapist behaviors, as well as environmental factors, that create either stressor comfort in the individual animal is essential. Likewise, practitioners
must be able to recognize signs of animal stress, fatigue, and injury/illness,and respond in a manner that benefits or safeguards their animal before,
during, and after the interaction takes place.
Likewise, AAPT practitioners must consider what benefit the animals
are likely to get from their participation. Therapists must carefully consider
what a reasonable workload is for each animal, and how that is influenced
by their age, health, and development. Furthermore, AAPT practitioners
must ensure that all activities and interactions respect the dignity andchoices of the animals. It is important for animal welfare, but also for the
integrity of therapeutic interventions and the well-being of clients, that animals are never depersonalized or devalued in the pursuit of helping people.
Finally, AAPT practitioners need to develop self-awareness to ensurethat they are always modeling respectful interactions with the animals fortheir clients, both in therapy and in their home lives. This is accomplishedby developing fluency in the body language and communications of thespecies with whom practitioners work, as well as actively attending to
the specific behaviors and reactions of the therapy animal on an ongoingbasis. In essence, the therapist learns to respond in an empathic manner
to subtle changes in body language that suggest that human behaviors are
too intrusive or threatening to the animal, and to adjust until the animal
signals that the stress has been eliminated. This starts with practitioners’
awareness of the impact of their own behavior with the animal, and extends
into therapy sessions with clients.
This skill is taught and reinforced during AAPT training programs.
For example, it is quite common for people, often without thinking, touse leash pops (i.e., quick yanks) or to steer dogs around on a tight leash.
In AAPT training, therapists learn that these are ineffective ways to workwith dogs, and instructors provide feedback in the moment to help improve the trainee’s handling techniques and self-awareness. In such cases,
incorporating off-leash alternatives with the dog to build relationship andconnection helps offset these often natural human tendencies to push andpull dogs, and/or pop their leashes. If a dog wanders off, the therapist finds
playful and dog-friendly ways of regaining the dog’s attention, and provides
clearer communication about his/her expectations.
These are just some of the animal welfare considerations that arisein this work. While most professionals readily agree that it is important

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to treat animals humanely in a general way, there is less agreement whenit comes to details of practice. What are the implications of collars vs.
harnesses for the well-being of dogs? Is control-oriented equipment, suchas prong collars for dogs or knotted rope halters for horses, acceptable orshould they be prohibited? Exactly how does one create a securely attachedrelationship with animals of different species? Are natural behaviors of animals permitted (such as grazing or sniffing), or is it better to prevent thesefrom occurring? As the reader can see, once this discussion gains greater
specificity, there is more room for disagreement, yet these are discussions
that are critical to have. Details on this topic are explored fully in VanFleet
and Faa-Thompson (2017).
All of the AAPT training programs and materials emphasize that animal welfare is equally as important as client considerations. The principlesof AAPT are clear that animals should not merely be tolerating their involvement, but that they should enjoy it and show that in their behavior.
Throughout the process, animals are given choices; they are never forced
to participate. It is important from a welfare point of view, but also for theauthenticity of the therapy, that the animals’ participation in the interactions is voluntary. For example, handler training emphasizes that animals
are always provided with an “escape route” or opportunity to rest. Whenropes or leashes are used, therapists ensure that they are kept loose andthat animals are never pulled. Overall, handlers must frequently advocate
for their animals’ needs and preferences whenever necessary (VanFleet &Faa-Thompson, 2017).
PROFESSIONAL CERTIFICATIONS
Professionals wishing to use AAPT must receive practice-specific training.
They need working knowledge of, and hands-on skill development in,psychotherapy and play therapy, as well as animal behavior, welfare, andethics. This requires not only training, but also supervision of actual workin the field. The International Institute for Animal Assisted Play Therapy®
(IIAAPT, 2013) offers a stringent certification process based on demonstrated competencies (see “IIAAPT Requirements and Competencies”).
There are different levels of certification, but all must demonstrate thecore competencies. In addition to postgraduate degrees and credentials,
professionals must complete several online courses and over 100 hours of

The Power of Play and Animals209

in-person, hands-on training with dogs and horses that help develop thesecompetencies. The supervision requirement involves discussion of casesand videos of the professional’s work in AAPT with a supervisor who iscertified by their primary profession and in AAPT specifically.
IIAAPT Requirements and Competencies

•
•
•
•
•
•
•
•
•
•
•
•

•
•
•

Education, credentialing, and competence in psychotherapy andplay therapy relevant to the client groups served
Adherence to ethical standards of mental health practice (or the
profession in which licensed)
Work within one’s scope of practice
Adherence to AAPT guiding principles and humane guidelines
Ability to select, conduct, and process therapeutic interventionsin the service of client goals
Ability to use humor and playfulness appropriately to facilitate
therapeutic processes
Knowledge of appropriate selection and socialization of animals
Ability to develop and maintain securely attached, collaborative,
humane relationships with therapy animals at all times
Ability to carry out positive, nonaversive training and preparationof animals
Adherence to the goodness-of-fit model for including animals in
different forms of AAPT
Ability to proactively ensure the well-being and comfort of clientsand therapy animals
Dedication to preserving the dignity of all humans and animals involved, and to avoiding any form of depersonalization of
the animals
Knowledge of two species’ body language, and competence inreading and responding to these communications in real time
Ability to focus on the well-being of clients and the animal partners simultaneously
Ability to formulate treatment plans that conform to the highest
standards of professional practice, while ensuring the welfare andhumane treatment of animals

The certification program is conducted in a collaborative manner, which provides individualized feedback and assistance throughout.

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Certification is also available for supervisors, instructors, and canine andequine support professionals.
GAPS AND NEXT STEPS
Research

There is a need for more qualitative and quantitative research on AAPT’s
effectiveness for people who have experienced trauma. To date, researchfindings have been anecdotal and/or largely quantified clinical outcomes,
along with a small number of qualitative or mixed methods studies, withtime being invested to ensure consistent training and competencies oftherapists using the method. Encouragingly, a pool of highly trained andresearch-oriented AAPT therapists and animals is growing, and more studies in the field are now possible. As discussed earlier, preliminary researchhas been promising, and clinical results have been exciting. The IIAAPT
has provided data-collection assistance to researchers engaged in several
studies on AAI and AAPT, with initial results expected in 2019–2020. The
IIAAPT welcomes inquiries about these and future studies, as the program
values collaboration with universities, students, and other programs.
Practice

Perhaps the biggest gap resides with the many therapists who do not realize that they should obtain training before involving animals in theirprofessional work. This is not only problematic in AAPT, but in AAI ingeneral. When therapists understand that training is needed, they often
underestimate to what degree, and they are satisfied taking only an online
course or instruction geared toward volunteer visitation programs. AAI
programs that offer social support and enrichment are extremely useful,but it is important to acknowledge that the work in professional practice
is much more involved and complex. Specialized preparation is needed forthe animals and the therapists, especially in terms of building their own
relationships and in planning and facilitating effective AAPT with clients.
When a therapist says, “The more I learn, the more I realize I have to learn,”
it indicates that he or she is aware of the true enormity of knowledge andhands-on skills needed to do this work.
For therapists who have met the required competencies in certification, there are needs for ongoing continuing education, as well as support

The Power of Play and Animals211

for those involving other species beyond the most common (i.e., dogs,
horses, cats, rats, and rabbits). The general principles of AAPT are the sameacross all species, but whenever a new species is involved, the practitioner
must learn a substantial amount of information about that species andthe particular animal they are now partnering with. New online courses
are currently being developed to support many aspects of AAPT work,and 2019–2020 will see the addition of special educational opportunities
beyond the core courses to help therapists develop the mutual, playful,and securely attached relationships with their animals that are needed forpractice. AAPT therapists have been extremely creative to date, and future
publications and conferences will feature their ideas and input.
CONCLUSIONS
Involving appropriately prepared animals in play therapy sessions withtraumatized children combines the strengths of both approaches — AAI
and play — and has the potential to greatly facilitate therapeutic outcomes. Clinical results using this emerging field demonstrate enhanced
trust-building in therapy, as well as the ability to meet therapeutic goals
in unique and creative ways. These therapeutic goals include the development of: competence and confidence; feeling cared for while learning
about mutually respectful relationships; genuine empathy and concern
for others; self-regulation; and solutions to a wide range of other traumaspecific challenges. The use of play-based approaches benefits traumatizedclients as they safely “play out” and master the intense feelings related totheir traumatic experiences (e.g., child maltreatment) and consequentattachment disruptions. At the same time, the playfulness of AAPT creates a welcoming, enjoyable environment for the animals, whose needs
are considered equal to those of any human in the equation. Overall, therelationship and welfare emphases of AAPT make it a useful way to workwith clients of all ages who struggle with trauma reactions and otherdifficulties.
AAPT has been evolving with considerable consumer input, as well asa strong sense of clinical quality and animal welfare. An in-depth training
program and rigorous certification based on demonstrated competencies
have been implemented for mental health and allied health professionals
and educators. The AAPT field is now ready for evidence-based research212

TRANSFORMING TRAUMA

to measure its effectiveness, with the hope that collaborative relationships
can be formed to enable this next step forward.
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Application of animal-assisted interventions in professional settings: An overview of alternatives. In A. H. Fine (Ed.), Handbook on animal-assisted therapy:Foundations and guidelines for animal-assisted interventions (4th ed., pp.157–
177). London, UK: Elsevier.
VanFleet, R., Ryan, S. D., & Smith, S. K. (2005). A critical review of Filial Therapy interventions. In L. Reddy & C. E. Schaefer (Eds.), Empirically-based playinterventions for children (pp. 241–264). Washington, DC: American Psychological Association.
VanFleet, R., & Sniscak, C. C. (2003a). Filial Therapy for attachment-disrupted
and disordered children. In R. VanFleet & L. Guerney (Eds.), Casebook of Filial
Therapy (pp. 279–308). Boiling Springs, PA: Play Therapy Press.
VanFleet, R., & Sniscak, C. C. (2003b). Filial Therapy for children exposed totraumatic events. In R. VanFleet & L. Guerney (Eds.), Casebook of filial therapy(pp. 113–137). Boiling Springs, PA: Play Therapy Press.
VanFleet, R., Sywulak, A. E., & Sniscak, C. C. (2010). Child-centered play therapy.
New York, NY: The Guilford Press.
Wenocur, K. P. (2018). It’s the journey: The developmental and attachment implications of Animal Assisted Play Therapy for children in emergency housing (Doctorate

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in Social Work (DSW) dissertation). Retrieved from https://repository.upenn.edu/edissertations_sp2/117
Wilson, E. O. (1984). Biophilia. Cambridge, MA: Harvard University Press.

ABOUT THE AUTHOR
Risë VanFleet, PhD, RPT-S, CDBC, is a licensed psychologist specializing inchildren and families, a registered play therapist-supervisor, and a certified
dog behavior consultant with 46 years of experience from Boiling Springs,
Pennsylvania. Well-known internationally for her extensive writing andteaching in play therapy, Filial Therapy, and AAPT, she is the cofounder,
with Tracie Faa-Thompson, of the International Institute for Animal
Assisted Play Therapy® (www.iiaapt.org). Their coauthored book, Animal
Assisted Play Therapy, was awarded the Maxwell Award from the Dog
Writers Association of America for the best book on the human-animalbond in 2018.

CHAPTER 6

Children and Animals: The Importanceof Human-Other Animal Relationships
in Fostering Resilience in Children
Sarah M. Bexell, PhD; Susan Clayton, PhD; and Gene Myers, PhD

BACKGROUND
HistoryThis chapter offers a slightly different lens than that of most other chaptersin this volume. Instead of a clinical lens, we present foundational insights
into human child-other animal relationships, ways bonds between children and other animals develop naturally, ways they can be fostered bypractitioners, and, importantly, why human child-other animal bonds areimportant both for typically developing children, as well as for children
who have experienced traumatic events. We extend the analysis of humanchild-other animal bonds to include the importance of the natural environment for the full appreciation of biotic and abiotic factors in the worldof all children, which support human health and well-being. Additionally,
we touch upon the modern appreciation of the One Health nexus, whichreminds humanity that human, other animal, and natural environment
health must be simultaneously protected and maintained in order for sustained health to be obtained. Practical and tested protocols to allow forthese bonds are shared.

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Bonds between humans and individuals of other species have been
important throughout human evolution. Humans, as relatively weak in
physical form compared to other species, have always studied other species
to protect ourselves, learn about the environment around us, and masterhow to kill for sustenance through the development of cunning and tools,
for example. Over millennia, humans have also sought companionshipwith other species, and these friendships, or bonds, have enriched human lives so significantly as to warrant worry about human psychologicalwell-being if suddenly we find ourselves alone through the destructionof others. Here, we would like to get away from asking questions such as
why other animals are important in the lives and development of children.
This line of inquiry often perpetuates the status quo of humanocentrism.
We do not exist in an exclusively human world, and children seem to see
this more clearly than most adults. As developing children study the world
around them, each facet is important to attend to and understand, to findout what is safe, what is dangerous, and what provides the most comfort,
stimulation or sustenance, for example. While all objects of a child’s attention will find their way into the repertoire and understanding of theworld of the child, perhaps the most concentrated subjects of interest areliving and animate beings (including other humans) who can be perceived
as possessing self-determination.
In observations of and interactions with other beings, there is a developing sense of “we are in this together” and a camaraderie that often
is forgotten, in terms of relations with other animals, throughout theprocess of aging and within modern individual human development. If
there is universal acceptance that relationships with other humans are
essential to healthy development, why have we for so long thought of
human-other animal relationships as different, and in many cases, nonessential? Practitioners of animal-assisted interventions (or interactions)(AAIs) capitalize on these innate understandings, without necessarily fullyrecognizing them or having the scientifically accepted terminology to describe what many of us feel. It is common to hear about the “magic” ofencounters with other animals in therapeutic settings, and there is a senseof urgency to research and define these magical powers, down to the invisible chemicals that are produced in the human body that confer the
comfort many humans feel in the company of other animals, especiallydomesticated companion animals. In our anthropocentric drive to make

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the lives of humans better, at all costs, perhaps we are blinded by ourquest, and beautifully orchestrated evolutionarily beneficial relationships
are blurred or, worse yet, distorted and destroyed.
We all inhabit the same planet, and it would be beneficial for adulthumans to also accept that we truly are all in this together. Biodiversity
on Earth is in steady and drastic decline. One solid indicator shows losses
of vertebrate (animals with backbones, not including humans within thisexample) populations averaging 58% over the 40 years up to 2012 (World
Wildlife Fund, 2016), making the worry of finding ourselves alone all too
real. How will this impact normal child development? If we can create
mutually beneficial relationships with all of life on Earth, likely morehealing than just from traumatic events would ensue, and just maybe
many of those traumatic events could be avoided in the first place. Froman evolutionary perspective, all life has value, none above another. As
humans have placed themselves above all others, the consequences haveincluded mass extinction, epidemic social ills, dangerous transformationsof Earth (our life source), and a growing sense that in the grand scheme, we
as individuals no longer matter. There are too many of us, our societies are
rapidly becoming less democratic, and our individual voices are obscured
or even completely unheard. There perhaps can be nothing so damaging
to a person as to realize they might not matter, from which psychologicaland social pathologies emerge that create trauma for both victims andperpetrators.
In step with the modern tendency to overlook the importance of otherlife forms (other than those abused for human sustenance) in the healthof the developing child, recognition of the importance of other animals
in the lives of children in scholarly works has been scarce, while their
inclusion in folklore, children’s stories, and in their actual lives has beenrich. Provocative exceptions to the lack of inclusion of children’s relationships with other animals in scholarly works include Myers’ (1998/2007)
The Significance of Children and Animals: Social Development and Our
Connections to Other Species; Melson’s (2001) Why the Wild Things Are;
and Ascione’s (2005) Children and Animals: Exploring the Roots of Kindness
and Cruelty, among others, that will provide support here. An explanation
for the sparse attention to the issue could be that it may seem too obvious:
everyone knows or naturally assumes that children’s knowledge of, andrelationships with, other animals are paramount in their development and220

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understanding of the world around them, for example through keeping or
viewing animals (Myers, 2007). However, could the reasons also be more
problematic, as alluded to above?
Today’s children are raised in environments where the presence of
wildlife is increasingly rare; being raised on a farm is uncommon; andlife in housing often includes restrictions on companion animals, resulting in the lack of positive interactions to understand and connect withother species. However, the presence of companion animals in the livesof some children is growing exponentially, as covered in several chaptersof this volume. But mixed messages about animals are often conveyed
to children with little to no explanation or reconciliation (e.g., animal
as companion, food, family member, marketing tool, object of entertainment, victim of domestic violence, victim of neglect, someone to bepurchased, someone who was bred to be beneficial to humans), resulting
in contradictory framings and confusion. The lack of attention to theimportance of animals in the lives of children could also be a psychological protective measure. Many adults may not want to acknowledge thesixth mass extinction (Ceballos et al., 2015), or the modern-day abuses(e.g., factory farms, laboratories, circuses, rodeos, zoos, pollution, andmass habitat destruction such as land and water conversions) that we are
all complicit in because our modern economies make it difficult to avoid
our own participation.
Yet another reason could be that, both physically and emotionally, ourmodern urbanized communities have allowed us to forget animals’ importance. While the technology that surrounds us is touted as simplifying or
making our lives more convenient, it in fact consumes or backgrounds
our every waking moment, distancing us ever further from other animals,
including other humans. Additionally, adults who choose to have children(or did not have a choice) are under great pressure to make enough money
to support the children they brought into the world, creating distancing
from animals as well as their own children as they work long hours tomake ends meet. Acknowledging the need for other animals in healthy
child and human development could bring about another imperative toprotect and preserve those with whom we share Earth. In order for interactions with other animals to be therapeutic, and especially to help achild recover from a traumatic event, the child must first be in a trusting
relationship with the other animal. This chapter will focus on why andChildren and Animals221

how these important relationships are formed in the context of wider social
forces as outlined above.
THEORY AND POTENTIAL MECHANISMS
Psychology

Why are other animals psychologically important in the lives of children?
There are many reasons, including development of self in relation to others (Shepard, 1996); having someone safe to care about and to take careof which increases responsibility, empathy, compassion, self-efficacy, andskill mastery (Wiens, Kyngas & Polkki, 2016); as social support (Brown,2004); in learning how to be an ally for someone else; in developing an
understanding of the world around them; in making sense of Earth andin finding their place in the world (Wilson, 1984); and the sheer humanneed for reliable relationships even when all is right in our personal lives(Blazina, Boyraz & Shen-Miller, 2011). Here we explore the psychologicalmechanisms of biophilia, empathy, prosocial moral development, continuity of care, and the need for nature, each of which provide support for
the understanding of human child-other animal bonds.
Biophilia. An overarching psychological phenomenon underpinning theimportance of other animals in child development is biophilia (Wilson,
1984). Biophilia is the term coined by sociobiologist Edward O. Wilson(1984) to describe what he believes is the innate human affinity for thenatural world. Evolutionarily and biologically, humans are connected tonature and are hardwired to be attracted to nature (for safety as well as
serenity). Wilson describes how a human tendency to focus on life andlifelike processes is a biologically based need, and integral to development
as individuals and as a species (Kellert, 1993; Wilson, 1984). Today, mostchildren globally have very few positive experiences in nature and withanimals (Louv, 2005; Melson, 2001; Myers, 2012). In the absence ofsuch experiences, children may feel personally ill-equipped to function
in natural settings, perceiving nature as hostile and dangerous (Bixler &Floyd, 1997). Children need this exposure to sustain their interest, trust,and ultimately, concern for the well-being of other animals, as well as thenatural world (Louv, 2005; Myers, 2007). Later, we will present examples

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of how practitioners can provide these experiences for children, as well as
why they should.
Empathy. Young children naturally and willingly empathize with other humans (Eisenberg, Fabes & Spinrad, 2006; Quann & Wien, 2006) as wellas other animals, and feel compelled to help animals in distress (Melson,
2001; Myers, 2007; Thompson & Gullone, 2003). This provides children
with a strong sense of purpose. Experiences with animals for whom they
can help provide care will deepen their ability to empathize with others,
both of their own species and individuals of other species (Bexell, 2006).
Child development specialists previously thought that children outgrew
their affinity for, and connections to, animals. However, we worry thatsomething else is happening, specifically, that by children’s development
of distancing mechanisms after exposure to socially normalized abuses orstatements that diminish the lives of other animals, their empathy withanimals weakens and allows them to treat animals and the environment
with lack of true understanding, compassion, and respect. Normative experiences and programmatic planning should aim to reclaim and nurture
those innate empathic feelings with animals in the hopes that children
will understand their world, be kind to humans and other animals, maintain self-respect and self-love, and in the future understand and act topreserve the natural environment for the animals they have grown to love
and admire.
Empathy and prosocial moral development. Theories of empathy and moral development have focused on either the behavioral, cognitive, or emotional
dimensions of prosocial moral development (Hoffman, 2000). Hoffman(2000) combines the three dimensions and provides a framework of prosocial moral development in children. He states that the starting point forthe development of morals is empathy — one feels what is appropriate foranother’s situation, rather than one’s own. Hoffman (2000) believes that
moral development is rooted in empathy, and that our highest morals arefounded on empathic feelings we experience, often vicariously, with others
who make us want to act with kindness toward them. While most of his
research (see Hoffman, 2000, for a review) has focused on the developmentof moral behavior toward humans, we hypothesize that the same theories
can be applied to children’s relationships with other animals.

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Specifically, Hoffman (1979) states that what he calls empathic distress,
or awareness of another’s distress, is a prosocial motivator. This is evidenced
in his findings (Hoffman, 1979) that empathic distress not only correlates
positively with people’s helping behavior, but in many cases precedes andcontributes to helping behavior. For example, when a child sees anotherchild who is distressed because he cannot find his mother, she instinctually
feels what the distressed child is experiencing and asks her own mother tohelp him. Once the other mother is found, the previously distressed childfeels better and so does the helpful child, which reinforces the helpful
behavior via the opportunity to have good feelings. Therefore, like othermotives, empathic distress diminishes in intensity when one helps, but continues at a high level when one does not help (Hoffman, 2000). The sameprocess occurs in healthy humans when one sees a distressed or injured
member of another species and provides appropriate and needed help.
Some people think of animals as not sentient and therefore impossible
to empathize with, and this has enabled extreme cases of animal abuse
and insensitivity (Ratloff, 2005; Song, 2004). In contrast, within AAIs,
practitioners often explain to children the type of care that the individual
therapeutic animal needs. This explanation allows children to recognize
the power differential between humans and the other animal, and to seethat they are also in the position of holding the power to help provide
for the other animal’s needs for both physical and mental health. With
this knowledge and understanding, children often participate in the careof the animal such as walking, feeding, brushing, and even consoling. A
relationship built on trust and care forms, and both child and animal canbegin to predict the needs of the other.
For example, on the side of a child who has experienced a traumatic
event and is with a therapist to work through their concerns, a therapy
animal will sense that the child may need their love and the comfort they
provide. On the side of the animal, the child will learn the other animal’s
patterns of expressing their needs, such as going for a walk, seeking wateror respite, or needing the child to be calm to help them both feel safe. This
process of attunement between child and animal is reassuring to both, andfor the child, the relationship may be one in which he or she feels the safest,
as well as a valued contributor to someone who needs his or her love andunderstanding. For many children who have experienced maltreatment,these features of safety, reliability/trust, genuine communication, and224

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feeling like a valued member of the relationship may be extremely rare, if
not completely unique. They may have never felt this way in their othersignificant relationships (i.e., with their parents), making their new relationship with an individual of another species paramount in their healing
and founding of their own self-worth and self-efficacy.
Human-other animal bond. Young children are able to identify other animals
as social others (Myers, 2007). In identifying with animals on a social level,
relationships form due to consistency of behavior and expectations that
confer comfort and a caring bond. To connect with another animal, likewith our own species, it is believed that children need to first understandand appreciate them (Sobel, 1996). Intervention programs can be designed
to foster the human-animal bond in participants, as well as provide concrete ways to care for animals. Knowledge about other species (including
their biology, habitats, emotions, cognition, abilities, traumas, and plights)
both in the wild and under human care can be presented in appropriate
contexts to develop realistic concern and connection. However, the focus
should be on love and compassion for animals, and how to demonstratecare for them (Bexell, 2006). Later, we provide specific examples of protocols and programming that provide these experiences for children.
Another way to foster the human-other animal bond involves giving
particular biographic information about animals and using names andpersonal pronouns even with those who are typically less “personalized”
or considered to be unsafe (e.g., reptiles, insects), so children can see themas individuals and not just as a member of a species (Myers, 2007). Just as
we know the dangers of stereotypes humans utilize to marginalize otherhumans, we tend toward the same generalizations in our thoughts of otheranimals (e.g., rats are dirty, bats are scary, the only use for a cow is as food,chickens are stupid). However, anyone who has had the chance to really
get to know a cow, a rat, a bat, or a chicken finds it difficult to treat any
member of those species according to today’s socially normalized notions.
Interventions can highlight traits that are similar between children andother animals, while emphasizing special and exceptional traits of animals
and the abilities of providing care that children possess. This strategy iscommonly used in humane education (Bexell, 2006; Raphael, 1999; Weil,
2004). People often are more interested in, and in turn protective of, animals whom they can perceive as intelligent, strong, fast, cute, industrious,

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creative, kind, and/or protective of their children (for example) (Hoage,1989). All living beings have special qualities that help them survive andcreate balance in their native ecosystem, so interventions can make thosequalities apparent and inspiring to children. In this process, children cantake a reprieve from their own history and pain and focus love and support
toward others who need them. This is empowering for young children andgives them a sense of purpose to heal and to continue to be able to help
others. When a child cares about another human or animal, that child also
tends to care about that other’s environment. It is hoped that by providing
opportunities to form bonds with animals, children may begin a lifetimeof care toward animals as well as the environment.
Multiple points of contact. Another supporting intervention modality is what
we call multiple points of contact between children and other animals (Bexell,
2006; Bexell, Jarrett & Xu, 2013). The provision of multiple points ofcontact with the same animal builds trust through multiple planned orchance interactions between a person and another animal. According toMyers (2007) and Shepard (1996), children must develop trust of new
animals they meet, and the animals must be allowed time to trust them.
Children acquire this trust after observing how an animal reacts in different
situations, just as the animal is doing with them. With multiple interactions building upon the other, both the child and the other animal cansee consistency of behavior (involving intentions and personality of eachother) and may be better able to predict each other’s behavior in futureinteractions (Bexell, 2006; Myers, 2007). Providing multiple repeated experiences that allow a child and another animal to become familiar others,
to become acquaintances or even friends, corresponds with how humans
develop relationships with new people. Established human-other animal
connections provide the experience of attunement: two beings responding to the core self of each other (Irvine, 2004; Lasher, 1998). Because
relationships in the lives of maltreated children or those exposed to family
violence are often not reliable, consistent, predictable, or stable, which
can further reinforce hyperarousal for these children, the experience ofconsistently supportive relationships with animals can be of great benefit.
In sum, relationships, including with animal companions, can provide asafe, responsive setting for inner growth (Lasher, 1998), and for healing inboth children and other animals who have experienced trauma.

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Cross-cultural continuity of concern. A hypothesis we feel has strong merit andpromise for fostering bonds between children and other animals is that across-cultural continuity of concern for animals, and empathy with animals, may exist in children (Hoffman, 2000; Myers, 2007; Turiel, 1983).
The literature documents young children across cultural lines expressing
empathic feelings toward the suffering or discomfort of other people(Turiel, 1983). A study among Chinese and American preschool children
strongly suggests that such empathy for other animals also exists (Bexell,
Jarrett, Yang, & Tan, 2005). However, as children develop cognitively, theyrealize there are inconsistencies in what adults say and do to animals andthe environment, causing discontinuity or lessening in children’s concern(Myers, 2007). While some practitioners of AAIs may worry that children of some cultures may have trouble understanding and bonding withanimals, we posit that every culture includes their own familial environments that vary greatly in their ability to hinder or enhance bonds withother animals.
In one study, six-year-old children of farm owners and farmworkers
did not express concern for animals when the interests of the animals
conflicted with interests of farming (Severson & Kahn, 2010). However,
Severson and Kahn (2010) showed that when conflicts with humans
were removed in a hypothetical dilemma, six-year-olds articulated empathy toward, and biocentric moral inclusion of, animals. Thus, family
practices and beliefs may encourage attitudes ranging from distrust anddisgust to respect and adoration of all species. This is likely confusing forchildren — that adults treat other animals (and other humans) differently
depending upon situations these others find themselves in. However, Kahn
(1997) found that children from multiple cultures express concern for andwillingness to protect nature and other animals, with no contingencies
on benefits to them, but for full consideration of the intrinsic value ofnature and other animals. With a strong practitioner who has foremostin her/his mind and heart the well-being of the child and other animal, it
is predicted that a therapeutic milieu can be fostered between almost any
young child and animals.
Children’s need for nature. It has been well-documented that for children, timein nature is important both physically and psychologically (e.g., Burriss &Boyd, 2005; Hart, 1997; Louv, 2005; Moore, 1997; Nabhan & Trimble,1994). Adult recollections of special places and preferred play areas testify

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to the importance of nature in childhood (Chawla, 1994, 1999); many
adults identify the most significant place in their childhood with the outdoors (Sebba, 1991). Natural areas have been found to satisfy some criticaldevelopmental needs of young children, and many scientists fear that without exposure to nature and outdoor play, development could be hindered(Burriss & Boyd, 2005; Louv, 2005). Increasingly, children have fewer
opportunities to play outdoors, especially in natural or even semi-naturalareas (Louv, 2005; Nabhan & Trimble, 1994). Many children never develop a personal bond with the natural world, and may grow up believing
they are separate from, rather than a part of, nature (Louv, 2005). Children
today also may never develop an awareness of the interrelationships thatexist among all living things, and may never give thought to the fact that
all their food, air, and water comes from nature (Miles, 1986/87; Partridge,
1984; Wilson, 1993, 1994). Realities such as these are dangerous because
human health depends on the health of the natural environment, and inchildren’s purposeful and conscientious awareness of this relationship.
Early years are significant in a child’s development of his/her value
system (Bredekamp & Copple, 1997; Kals, Schumacher, & Montada,1999). Children are surrounded by materialistic cultural values that leadto overconsumption. Automobiles and technology keep them isolated andindoors. A plethora of disposable convenience items and public media
convey that new is always better (De Graaf, Waan, & Naylor, 2001; Louv,
2005; Prévot-Julliard, Julliard, & Clayton, 2014; Schor, 1998). To help
counter these influences, the ability of living beings to hold children’sinterest should be used to: help them understand the living environment,
including themselves and other animals; respect the appearance andwell-being of the world; and take responsibility for its care (Katcher &Wilkins, 1993). Children are likely to be receptive to such attempts; after
all, many prefer natural areas to play in (Chawla, 1999; Korpela, 2002).
A number of studies have demonstrated the positive impact of green
spaces on children’s social and emotional well-being (Kuo & Faber Taylor,2004; Wells & Evans, 2003; Wells & Rollings, 2012). The opportunity
for children to develop an environmental identity — an underlying senseof self as interdependent with and connected to the natural world — isalso likely to promote their attention to environmental issues (Clayton,2012). A strong environmental identity is linked to early experiences with
the natural world (Prévot, Clayton, & Mathevet, 2016). Among adults, it
is associated not only with pro-environmental concern and behavior and228

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support for animal rights (Clayton, 2008), but also with personal well-­being (Olivos & Clayton, 2016).
BEST PRACTICES
Service Providers

Perhaps some of the best organizations providing the types of programmingreferred to throughout this chapter are local nature centers and sanctuaries in the case of rescued wild or farm animals, and humane societies in
the case of domesticated companion animals. For example, the Zoology
Foundation at Crooked Willow Farm in Larkspur, Colorado (zoology
foundation.org/our-animal-sanctuary), in partnership with the Institutefor Human-Animal Connection at the University of Denver (www.du.edu/humananimalconnection), provides a camp experience to typically developing children ages 8–12 years with the primary goal of fostering thehuman-animal bond (see procedures below) to improve animal and nature
protection.
An important facet of the experience is that the individual animals havebeen rescued from human actions (e.g., hoarding, neglect, abandonment)
and are now thriving under human love, proper care, and respect. The
camp curriculum is based on one that was designed to work cross-culturally
and originally implemented for children in China (Bexell, 2006; Bexell,
Jarrett, Xu & Feng, 2009; Bexell et al., 2013) (see below for further description). The camp experience actively constructs the human-animal bond
via multiple points of contact. It builds a continuum of care throughout
the week of camp by first introducing the children and other animals ina way to foster relationships, then teaching how to provide care for eachindividual animal, then introducing experts (e.g., animal behaviorists, veterinarians, wildlife rehabilitators, conservation biologists) who become rolemodels to the children, and finally learning what the animals need fromhumans in order to live well, and with as much self-determination as issafe for each individual.
Protocols

The protocol that was used at the Zoology Foundation at Crooked
Willow Farm was originally created as a human-other animal bond intervention with children in China, and capitalizes on the above-mentioned
multiple-points-of-contact and continuum of care (Bexell, 2006; Bexell &Children and Animals229

Feng, 2013; Bexell et al., 2013). The original program in China consistedof a five-day, overnight camp experience developed for typically developing children, ages 8–12 years, and took them along the continuum of care
(Bexell, 2006; Bexell et al., 2013). Students first intimately met small animals (e.g., rabbits, guinea pigs, hamsters, parakeets, and tortoises), whom
the students were encouraged to recognize as individuals with distinctive
personalities and feelings similar to their own. This was followed by lessintimate exposure to more fully wild species (including giant pandas, redpandas, zebras, golden monkeys, giraffes, and lemurs).
Children were then given responsibilities for the care of the small animals and were allowed to bond with individual animals and think about
their emotional states. Our hope was that these intimate experiences would
not only instill caring feelings about individual animals, but also extend toa deepening feeling about the environment on which all animals depend,thus encouraging awareness that destroying an animal’s environment isakin to directly harming individuals within a child’s realm of care. Our
hypothesis was that children would be able to make these intimate connections and thereby choose to change their own personal behaviors that
harm the environment and wild animals. Near the end of camp, we asked
children how activities that harm the environment might impact the animals they came to know, and we encouraged them to talk with their friends
and family about their newly found respect for animals and worries about
how their homes are treated.
The camp was designed to encourage the human–other animal bondin participants, as well as provide concrete ways to care for animals andnature. Knowledge about animals, both in the wild and in captivity, waspresented in appropriate contexts to elicit emotional feelings from children
in a safe environment wherein expressions of love and compassion for animals were not only acceptable, but preferred, behavior. Our curriculum
highlighted those traits that are similar between humans and other animals, but also revealed specialized characteristics of animals to help pique
students’ interest in, and acceptance of, the unique natural history of ourdiverse world (Hoage, 1989).
This protocol could be adapted and added to AAIs with any individual or population that either has not had much positive interaction withother animals or in nature, or to enrich the lives of clients who currently
do have relationships with other animals. For example, in AAI applications, practitioners typically work to first establish rapport between theirclients and therapy animals; this protocol could provide direction in

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encouraging greater intimacy, trust, and mutual respect in these child-​
animal relationships.
It is important to note that the program in China used all the describedmechanisms with children who had not experienced a known traumatic
event. In other words, the program was not designed to address specificneeds in regard to trauma or symptoms. But very similar practices, when
done with rescued animals for children with trauma, could also work powerfully for therapeutic ends, as well as conservation and humane ones.
Ensuring that individual animals utilized in therapeutic interventions arerescued and not purchased is critically important. The act of purchasing another being is a violation of their rights and sets the tone that other animals
are not our equals and can be bought and sold, acquired and abandoned,
nurtured or neglected, bred only to serve human interests. Children who
have suffered from traumatic events could be retraumatized if they learn of
the unethical treatment of animals they have come to love. Additionally,
the life history of each individual rescued animal is important, just as thetraumatic events that happened to traumatized children are, but also thejourney to regaining trust in others, allowing yourself to be loved, andfinding the sense of security that opens doors to happiness and well-being,
can be shared between children and these individual animals.
Professional Certifications

There are at least three important certification options to date. Two arewith the Institute for Human-Animal Connection at the University ofDenver, which provides professional development certification in “Raising
Compassionate Kids: Humane Education and Interventions for Early
Learners,” as well as in “Animals in Human Health.” Additionally, theInstitute for Humane Education offers workshops, certifications, and fullgraduate degree programs in humane education.
Relevant professional competencies in these areas include: 1) possession of a firm understanding of the interlinking of human, other animal,and environmental health (the One Health nexus); 2) deep empathy with,and passion for, working for the well-being of humans, other animals,
and the natural world simultaneously; 3) learning how to foster the best
qualities in young children, for their health and well-being and for that of
the natural world; and 4) learning to create and implement high-quality
animal-assisted and humane education programs and interventions guided

Children and Animals231

by experienced and trained professionals who can offer ethical and skillsbased certifications.
ANIMAL WELFARE
Challenges

The greatest challenge to animal welfare is in preparing adults to teachthe correct information, and most importantly, to model the appropriate
behavior toward any species, wild or domesticated, in interventions designed to facilitate the child-animal bond. Without training and correctknowledge of animals’ species-specific and individual needs, in combination (usually) with empathy and compassion for other animals, adults caninadvertently teach fear, disgust, anxiety, or improper care or treatment,
instead of respect, proper care, and love (Bexell & Feng, 2013).
Recommendations
How to Foster Relationships Between Children
and Other Animals

Rachel Carson (1956) believed that for children to keep alive an inborn
sense of wonder, they each need the companionship of at least one adult who
can share it and rediscover with them the joy, excitement, and mystery of
the natural world. A goal in intervention design to foster the human-​animalbond is to prepare role models for children, models who exemplify new
patterns of caring about and for animals, as well as protecting the environment in a way that encourages children to take responsibility for animal
well-being. The ability to nurture other animals appears to be a universal of
human nature; however, appropriate nurturing does not necessarily appear
without role models acceptable to the local community, as well as adequate
opportunities to engage in such behavior (Irwin, 2003). People who are
passionate and knowledgeable about animals and who model care, concern,and admiration for them are needed to implement these interventions.
The first step in providing proper care and respect of animals is an understanding of both who and what they are, knowledge best gained throughthe study of the natural history of the species a practitioner plans to workwith, and a study of their individual behavior and personality.

232

TRANSFORMING TRAUMAChildren should also study animal behavior, both through direct experience and anecdotally through experts. The awareness of an animal’s
behavior can give children insight into the animal’s mind and feelings.
Moreover, children can realize for themselves that animals have thoughts,
intelligence, feelings, and behaviors similar to their own. As they recognize these similarities, their interest in, and appreciation of, the individual
animal usually increases (Bexell, 2006). With the growth of solid scientific evidence showing qualities of animal minds and behavior akin tohuman animal minds and behavior (e.g., Bekoff, 2006; Darwin, 1998;
de Waal, 2016; Fossey, 2000; Goodall, 2000; Griffin, 2001; Masson &McCarthy, 1996; McConnell, 2003; Mitchell, Thompson, & Miles, 1996;
Moss, 2000; Poole, 1998, Shanor & Kanwal, 2011), practitioners can now
confidently use the scientific literature to describe human similarities withother animals. Likewise, practitioners can use the findings from animal
behavior research to engender human respect, care, and nurturance of ouranimal kin. The study of cognitive ethology, how animals use their minds
to adapt and survive, is a young and positive area of science (Bekoff, 2006;de Waal, 2016). Understanding the minds of other animals opens children’seyes and hearts to create meaningful relationships with them.
In past training of program implementers in China, the first author
and colleagues found that instructors were highly influenced by exposure
to compassionate and knowledgeable trainers. New instructors readilychanged their own attitudes and behavior toward animals (Bexell, Yu,
Feng, Yang, & Xu, 2004), and were inspired to model for their participants care and interest in animals as sentient beings. This modeling ofrespect and admiration for animals is critical to success in fostering healthy
human-other animal bonds.
The importance of modeling is based on social learning theory(Bandura, 1977). Bandura states that most learning occurs on a vicarious
basis by observing other people’s behavior and the consequences that behavior has for them. The capacity to learn by observation enables humans(and other animals) to acquire large, integrated patterns of behavior without having to form them by trial and error (Bandura, 1977). According toBandura (1977), behavior change usually begins when someone receives
extrinsic incentives for a particular behavior, but to become incorporated into a person’s repertoire, intrinsic incentives are usually necessary.
Reinforcement, perhaps in the form of approval by a respected model, acts

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as an extrinsic prerequisite for the development of intrinsic reinforcement,
formed by the development of relationships between children and otheranimals in a program or intervention. A good deal of intrinsic reinforcement comes in the form of emotional feedback (Bandura, 1977). If that
feedback is pleasant, in the case of emotionally satisfying relationships
with animals, it should serve to reinforce and maintain the performance of
caring behavior toward animals, thus fostering relationships that enhance
resilience in both partners.
Role models can show that behaviors have consequences, and we want
to exemplify the positive consequences that derive from compassionate careof other animals. This point applies not only on the level of immediate
face-to-face intervention, but also (and simultaneously) on a societal level.
Today, human societies globally have normalized extreme levels of abuse ofother animals and of other humans. Models whose behaviors differ fromthese expected, predicted behaviors may be more influential than models
that exhibit stereotyped conventional behaviors (Harris & Evans, 1973).
In essence, everyone can widen their impact by modeling compassionate
relationships.
CONCLUSION
The best way forward for AAI research and practice would be to movefrom questioning the importance of children’s bonds with other animals
to finding or developing and testing best evidence-based practices for allowing these bonds to occur naturally. We are still at the early stages ofunderstanding questions like, what types of relationships with animals aretherapeutic as well as humane? Are companion animals in the home thebest model? Can relationships fostered through classroom-based curricula
be as effective, or even more so? Are there certain species that are more
appropriate, and is this different for healthy children as compared to those
who have experienced trauma? Is there a critical period for these experiences? What are the best ways for adults and institutions to encourage
mutually beneficial bonds between children and other animals?
Greater facilitation of healthy relationships between children, other animals, and the natural world would bring about systemic change in humanhealth, animal protection, and preservation of Earth and her processes. The

234

TRANSFORMING TRAUMAOne Health nexus asks us to examine our responsibilities toward human
life, other life, and environmental health, and is changing our conceptionsof resilience and what it will take to get us to a more pragmatic, as well as
humane, human presence on Earth. Children rarely find difficulty in recognizing the worth of other animals, but rely on capable humane models
to demonstrate how the animals should be treated to maintain respect andcompassion. The growing body of AAI practitioners is one of the strongest
groups demonstrating our need for sharing our lives with other species.
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ABOUT THE AUTHORS
Sarah Bexell, PhD, is a clinical associate professor at the Graduate Schoolof Social Work and director of Humane Education for the Institute for
Human-Animal Connection, both at the University of Denver. She teaches
sustainable development, humane education, and animal studies. She isfaculty with the Institute for Humane Education-Valparaiso University andsenior advisor at China’s Chengdu Research Base of Giant Panda Breeding.
Susan Clayton, PhD, is the Whitmore-Williams Professor of Psychology at
the College of Wooster in Ohio. A social psychologist by training, herresearch focuses on the importance of the human relationship with natureand how it can be utilized to promote environmental concern. She has
written extensively about the implications of climate change for humanwell-being.
Olin Eugene (Gene) Myers, Jr., PhD, is a professor of environmental studies atHuxley College of the Environment, Western Washington University. His
work deals with four interrelated areas: the psychological foundations ofchildren’s relation to animals; the ontogenetic development of environmental care and responsibility; the integration of psychology into conservationand sustainability practice; and teaching environmental ethics for preparation of future eco-social justice educators.

CHAPTER 7

The Healing Power of Nature:
The Impact of Interventions
in Farm Settings
Michael Kaufmann; Miyako Kinoshita, M.S.Ed.; and Susan Puckett Teumer, MA

INTRODUCTION
A group of adults with Down syndrome participate in vocational animalcare at a dairy farm with cattle; a child on the autism spectrum, accompanied by a therapist, observes a pair of Bactrian camels in a pasture; andwar veterans with post-traumatic stress disorder (PTSD) participate in a
guided self-reflection surrounded by a herd of horses. In each example, itis the farm setting and contact with animals and nature that is intended toserve as a catalyst for positive change in humans. At present, the potentialof activities like these — those that enlist diverse farm environments forthe purposes of learning and teaching, as well as facilitating health andwell-being in a wide range of populations — is gradually being confirmed(Haubenhofer & Strunz, 2013).
The intent of this chapter is to provide an overview of how two specificfarm settings contribute to the treatment and education of children withtrauma histories, via reviewing the experiences of the former Our Farm
Program and highlighting the example of present-day Green Chimneys
School. Of note, we as authors do not intend this chapter to clinically guidethe therapist treating trauma patients; rather, we will present program
241

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potential through the lens of administrative structure, program implementation, and outcome observation, with a dual focus on intervention
activities and the evident impacts of animals and farm environments in apractical human services context.
BACKGROUND AND SIGNIFICANCE
Children with trauma histories frequently display academic failure, emotional dysregulation, behavioral maladjustment, and social skill deficits.
Many of the elements inherent in farm- and nature-based therapeutic
programming have been demonstrated to address such needs. In his 2005
book, Last Child in the Woods, Richard Louv expressed concerns about
the lack of access that present-day children in most industrialized countries have to the natural world, coining the term nature-deficit disorder.
According to Louv (2005), studies suggest that exposure to nature may
reduce the symptoms of attention deficit hyperactivity disorder (ADHD),
and can improve cognitive abilities and resistance to negative stresses anddepression in children. Farms offer a variety of interaction opportunities
in nature that frequently present domesticated animals, maintain horticulture, and contain natural habitat for native wildlife.
In 2013, the American Academy of Pediatrics issued a policy statement
to support structured and unstructured recess/play as an essential, planned
respite from rigorous cognitive tasks to enhance subsequent academic
attentiveness and cognitive school performance (American Academy of
Pediatrics, 2013). Animals and nature in farm settings provide an enrichedenvironment for such recess and play activities for children who struggle
with traditional classroom environments. For example, Gee, Fine, andSchuck (2015) discuss a number of research studies that suggest that thepresence of nature and animals reduces disruptive behaviors and increases
prosocial skills among students in both typical and special needs classrooms, from preschool through eighth grade.
In The Walking Larder: Patterns of Domestication, Pastoralism, andPredation, Clutton-Brock made a case that nature and our symbiotic,
life-sustaining relationship with the natural world, particularly as related
to domesticated animals, have filled our myths and theology, and havehelped shape societies and culture (Clutton-Brock & World Archaeological
Congress, 1989). Likewise, Rollin refers to the loss in modern times of a

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mystical connection to animals and nature (a relationship captured in ancient cave paintings), and how industrialization and urbanization threaten
the intimate connection to animals in our consciousness (Fine, 2006).
In the latter part of the last century, an understanding evolved of amore purposeful therapeutic interaction with farm animal species in human services. According to Hildegard George (1988), “all farm animals
are social by nature; this means that man can enter into a social relationship with these animals by taming them at certain critical stages within
the animal’s development” (p. 408). Describing her work as a therapist
with adolescents, George (1988) concluded, “The practicalities of using
animals — pets as well as farm animals — are as limitless as the creativity ofthe therapist” (p. 408).
More recently, Haubenhofer and Strunz (2013) offered comprehensive, evidence-based writings on the value of farm settings for children.
Diverse authors explain how traditional animal-assisted therapy (AAT) andactivity (AAA) concepts with companion animals (e.g., dogs) can be replicated with farm animal species, but also touch on the broader and moreunique impacts of nature-based settings that farms provide (Haubenhofer& Strunz, 2013). While there are a great many practice models that might
be used to incorporate these strategies in farm- and nature-based programming for children who have experienced trauma, we offer two select models
for the reader’s consideration.
THE OUR FARM MODEL
The competency-based model of animal-assisted interventions (AAIs) provided at Our Farm in central Texas from 2001–2006 offered an example ofa farm program that was demonstrated to be highly successful in addressing
the needs of children who had experienced early trauma. Public school
students and staff from their schools participated in half-day programmingeach week at the farm, providing direct care for a variety of large andsmall animals. It is believed the improved self-efficacy of the students, as
described below, provided the basis for a number of affective, cognitive,
and academic improvements that were observed.
The brainchild of Dr. Aaron H. Katcher and a project of the nonprofit
Animal Therapy Association, Our Farm served as a demonstration site
for schools looking to effectively implement experiential learning with

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animals and nature into their curricula. The program’s conceptual foundation was based on work done previously in the Devereux Foundation’sCompanionable Zoo, and documented in The Centaur’s Lessons: Therapeutic
Education Through Care of Animals and Nature Study (Katcher & Wilkins,
2000). The model used at Our Farm was unique, however, in that it established certain competencies — knowledge and skills to complete tasks
successfully — and utilized these as the framework of the programming.
Staff at partnering schools selected students receiving special education services or deemed “at risk” of school failure to participate in thiscompetency-based farm program. Students ranged from kindergarten
through high school, with approximately 75% of them male. Over 90%of the participants were from special education classes, most carrying multiple diagnoses. Disabilities commonly seen included autism spectrum
disorders, learning disabilities, ADHD, and severe emotional disability.
Other students not otherwise served in special education were selected
due to a lack of academic motivation, behavioral concerns, poor social
skill development, and/or low self-esteem. While there was no attempt
to look statistically at the number of participating students who had experienced trauma — and indeed such data would have been very difficult
to collect — patterns of behavior and anecdotal data collected over time
indicated trauma was likely quite prevalent among participants. In fact,
one could argue that the very nature of having such a disability, especiallyin a neurotypical school environment where bullying might be a factor,
could in and of itself be traumatic.
While program participants attended sessions at the farm in groups,
generally 6 to 12 students at a time, each individual student selecteda particular animal with whom to work. With support from the farmteacher and school staff (special educator, paraprofessional, counselor, oreven principal — it varied from school to school), the student learned toappropriately handle, feed, and care for that animal, working week after
week until he or she had achieved mastery of the skills and information
deemed necessary to provide for the animal’s needs.
Sessions always began and ended with group time, allowing for reminders of expectations, notices of changes at the farm, recognition ofindividual student accomplishments, and special activities related to thefarm’s seasonal work. However, work time was individual, and within
one session students might engage in a variety of animal care activities,
such as washing a rabbit cage, as well as feeding, holding, and brushing

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the rabbit; scooping the donkey’s pen, providing fresh water and hay, andleading him around the yard; tidying a rat’s enclosure, teaching the rat a
new trick, and sitting to read a book with her; making a salad for the large
desert tortoise, giving him exercise time beyond his typical pen, reviewing facts about that reptile’s natural habitat, and discussing how we may
accommodate for his needs within the current environment; setting up
an obstacle course and leading an alpaca through it, while rewarding theanimal’s accomplishments with healthy treats the student had prepared;
and collecting eggs, cleaning the coop, and providing fresh food and water
to the chickens.
Animal care was guided by skill cards, giving basic information about
each animal, including food, water, exercise, grooming, and natural environment. For very young or nonverbal students, picture skill cards weredeveloped, giving the student a sequence of pictures to show the care of
the animal. Once a student had mastered the competencies set for thatparticular animal, he or she was issued a license (modeled after the state’s
driver’s license and including a picture of the student and animal together).
The student was then free to “independently” handle and care for the animal, and even teach other students about the animal and its care. Equallyimportant, once licensed, the student picked another animal of a different
species and began to learn to care for it as well.
Although the students were focused on mastery of the establishedcompetencies — or at least the tangible rewards that accompanied thatmastery — school and farm staff were simultaneously addressing specificgoals established for each student. The range of these goals was as broad aseach group was diverse, and included language development, motor skills,
concept development, self-regulation, and social skills. So, while a student
might be intent on earning a license with the pot-bellied pig, the school
counselor working with that student might help guide interactions withthe pig in a way that helped the student establish healthy boundaries, askill that might later be discussed in terms of fostering and maintaining
interpersonal and social relationships.
Growth toward mastery of competencies truly progressed at individual
rates. Some students needed significant repetitions, and might license with
only one or two animals during the course of a school year. Others needing
more challenge could license with a different animal almost once a month.
Students often engaged in added research about the animals, reading fromthe library provided at the farm or from other resources available at school.

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Two students (from different schools), who were basically “nonwriters,”
each self-initiated research projects. One student wrote a successful proposal to add a snake to the program, while the other created two different,
leveled versions of skill cards for the farm’s bourbon red turkeys. This task
was particularly useful, as skill cards had not yet been developed for thecare of these animals. Among other skills, this particular student’s work
provided new and helpful directives to follow when handling the bourbon red turkeys (i.e., “Turkeys generally don’t like to be handled, but if
you move slowly and quietly, the toms may let you touch their feathers”)(Our Farm, 2005). Often, the work required students to collaborate, allowing real-life opportunities for communication, turn-taking, sharing,
perspective-​taking/​empathy, and problem solving. Progress toward individual goals was noted each session by both school and farm staff, and goals
were adjusted as needed.
One integral component of the program was the celebration of success.
Students were recognized within the group for reaching milestones, both
“licensing” with a given animal as well as simply reaching personal bests,
such as being able to halter an animal for the first time or even push thewheelbarrow independently. School staff began to identify each student’s
individual interests and competencies, often for the first time. In turn, thestudents also viewed themselves differently. This became evident in groupsessions as conversations became more animated with students sharing
stories of their successes, in individual work time when “I can’t” was replaced by “Watch me,” and in notes from school staff indicating students
had proudly relayed their new knowledge and accomplishments to others.
Our data showed that positive changes were noted very quickly at school,
and anecdotal reports indicated these improvements were noted both atschool and at home.
Utilizing the Achenbach Teacher Report Form (Achenbach, 1991)
and the Behavior Assessment System for Children Teacher Rating Scales(BASC TRS; Reynolds & Kamphaus, 1998), there was an immediate andstatistically significant decrease in all problematic behaviors at the farm as
opposed to the school. These improved behaviors included those associated with externalizing problems, internalizing problems, hyperactivity,
aggression, conduct, anxiety, depression, attention and learning problems,
atypical behaviors, and withdrawal. Notably, quantitative measures did not
substantiate additional improvement over time at the farm or a definite
transfer of skills from the farm to school, although qualitative measures(including teacher reports) did indicate both occurred.

The Healing Power of Nature247

One possible explanation for the changes documented in the Our
Farm program (and one that is quite relevant in working with individuals
who have experienced trauma) can be found in the construct of self-​
efficacy. Albert Bandura, a leading researcher in this field, defines perceived
self-efficacy as “people’s beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affecttheir lives” (Bandura, 1994, p. 71). In their review article, Benight andBandura (2004) integrated findings from the existing literature regarding
the role of self-efficacy in coping with trauma. In their concluding remarks,
they state:
The results yield consistent support for perceived coping self-­
efficacy as a focal mediator of posttraumatic recovery. People who
believe they can surmount their traumatization take a hand in
mending their lives rather than have their lives dictated by theadverse circumstances. The consistency of findings across diverse
types of traumatizations speaks to the generality of the enablingand protective function of beliefs of personal efficacy to manage
the impact of calamitous events. (p. 1144)
Bandura asserts there are four main factors influencing the developmentof self-efficacy, and each of these can be found in the competency-basedmodel. The first of these factors is mastery experiences, which were present
in the “license” system at Our Farm. High standards were set for licensing
with each animal, and school and farm staff provided scaffolding to support
students in achieving these goals. The next factor — vicarious experiences ofpeers successfully completing difficult tasks — was also an integral part of thismodel as groups celebrated participants’ accomplishments. Through peer
and adult coaching, participating students experienced the third factor,
social persuasion, by coming to believe they could indeed persevere andreach their lofty goals. Bandura’s fourth and final factor — perceptions ofstrengths and vulnerabilities inferred from somatic and emotional states — isaddressed in the positive mood of students and school staff at the farm. As
Relf and Lohr (2003) discuss in their review, people’s positive responses
to nature have been documented for decades, and they were certainly
apparent at Our Farm.
Additionally, according to Bandura (1994), cognition, motivation,
and affect are all influenced by one’s perceived self-efficacy. One participantof Our Farm, George, had a severe learning disability that greatly impacted

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his sense of self-worth. Presumably due to frustration over his inability toachieve the high level of academic success he expected of himself (and as
experienced by many of his peers), he had become quite aggressive toward
other students, and therefore was placed in a self-contained classroom
for students with severe emotional and behavioral disabilities. Ten years
old when he first came to Our Farm, George thrived in the program andactively participated for each of the farm’s five years of operation. In aninterview two months after he had started at the farm, George’s adoptive
mother remarked, “He told me the other day that he’s learned to likehimself because he’s found something he’s good at.”Overall, the hundreds of students who received services at Our Farmover the course of five years showed a significant decrease in problematic
symptoms often seen in individuals with a history of trauma. It is believedthat the competency-based model of AAI employed at Our Farm, which
included high levels of both adult support and farm-school communication, allowed the participating students to increase their self-efficacy, thus
reducing symptomatic behavior typically associated with trauma — bothat the farm and in other settings.
THE GREEN CHIMNEYS PROGRAM MODEL
Founded in 1947, Green Chimneys is accredited by New York State as a
special education school, offering treatment services incorporating environmental and recreational programs, as well as AAIs and nature-based
programming for students in its residential and therapeutic day treatment
programs. Located on a rural campus, a farm and wildlife center andgarden of considerable size are part of this residential treatment center forchildren. Currently, there are over 200 farm animals, permanently injured
wildlife, horses, and a small number of shelter therapy dogs-in-training at
the farm. Through strong academics, as well as recreational and clinicalinterventions (i.e., an enriched academic curriculum meeting New YorkState standards, an experiential learning environment, onsite clinical services and therapeutic support, and a focus on individual needs), children
explore and discover strengths in a structured, nature-based setting. The
primary goals of the program are to improve student self-esteem, compassion, coping, and social skills.
Green Chimneys has a long history as a leader and innovator in education and therapeutic treatment for children with special needs and, asThe Healing Power of Nature249

such, the organizational philosophy supports a safe and healing environment. We at Green Chimneys integrate psychoeducational approaches in
response to best practice models that identify trauma as a central aspect ofhuman experience. Trauma-informed care has become an accepted standard in human services: “Every outpatient and inpatient mental healthsetting, child protection service, parenting program, domestic violence
shelter, school, and homeless shelter today must contend with the issue ofa past history of exposure to trauma in their clients” (Bloom, n.d., para. 1).
Green Chimneys therapeutic treatment and management practices alignwith a trauma-informed approach of creating and maintaining an optimal
environment for safety and recovery. Established universal values and ashared language help create an environment in which everyone feels safe,
respected, and included. It is how we teach skills, set program activity
priorities, and make decisions that ultimately impact those we serve.
The population at Green Chimneys currently consists of emotionallyfragile boys and girls (ages 6–18 years, with a male to female student ratio of 9:1), who are coping with a variety of challenges related to anxiety
disorders, ADHD, autism spectrum disorders and pervasive developmental disorder, bipolar disorder, impulse control disorder, mood disorder,
post-traumatic stress disorder, and reactive attachment disorder. Utilizing
the treatment team model, each child has a group of professionals who
work together to provide consistent and diverse treatments during his or
her stay at Green Chimneys. The average length of stay is 20–24 months.
Each child in the residential treatment center is assigned an individual
psychiatrist who becomes a vital member of that child’s treatment team.
The primary function of the psychiatrist is to monitor and regulate thechild’s psychotropic medications, and to educate staff and families regarding his or her types of medications, target symptoms, and any possible side
effects. The goal of youth mental health treatment at Green Chimneys is tostabilize a child’s mood and behavior, thus enabling him or her to benefit
from academic instruction, as well as develop self-regulation and effective
coping skills.
Upon admission, each child is also assigned a therapist, who may be
a licensed clinical social worker, mental health counselor, psychologist, or
graduate- or PhD-level intern specializing in mental health. Therapists
meet with each child for weekly individual psychotherapy sessions and also
work with direct care staff in weekly living unit group sessions. Specialized
small groups in areas such as trauma support, international adoptees, andchildren who are freed for adoption may also be offered.

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Sessions are individualized to each child using a number of different
therapeutic modalities including, but not limited to, dialectical behavior
therapy, cognitive behavior therapy, AAT, and play therapy. All therapists practice within a family systems and trauma-informed framework.
Psychoeducation groups on social skills and other topics are frequently held.
An enriched treatment milieu that brings people together with animals
and plants in a mutually beneficial relationship forms the foundation of theGreen Chimneys approach. Nature-based programs at Green Chimneys
support the school and residences, as well as clinical approaches and theoverall therapeutic process. The entire team of farm and clinical staff is partof the treatment process, and the nature-based activities provided each day
are a cornerstone of each child’s experience.
Animal interactions are divided into the following categories and all
rely on structure and supervision:• Farm-Based Education Classes: Credentialed special educationteachers with a background in animal-assisted and/or horticulture education host scheduled classes in the various farm areas.
Classroom teachers have the opportunity to integrate experiential learning on the farm and outside in their curriculum.
• Learn and Earn Farm Jobs: Non-therapist staff members —including animal caretakers, residential staff, and interns —workwith individual children through a therapeutic AAA program.
Understanding the difference between these animal activities
and goal-directed therapy conducted by a licensed practitioner,
these staff are trained to implement and facilitate for the children such meaningful activities as cleaning stalls, taking a calf
for a walk, preparing animal food, or harvesting ripe tomatoes
from the garden. All the activities are designed to support theoverall social, emotional, behavioral, and academic treatment
plan goals for individual students.
• Therapy Sessions: Formal AAT sessions are conducted by licensed mental health professionals at the farm for specific,
goal-directed treatment involving animals. Occupational therapists and speech and language pathologists also utilize thefarm setting, and incorporate interaction with animals in theirtreatment approaches.

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Conceptual Philosophy of Nature-Based Programs
The Green Chimneys program brings people and animals together witha variety of philosophies, theories, and potential mechanisms at work.
While these provide theoretical frameworks to the whole, it is critical tounderstand that the Green Chimneys approach relies on a complex amalgamation of organically blended approaches, as described below:• Milieu Therapy: Milieu therapy refers to the organization of theentire social system (such as in a hospital or therapeutic community) as a therapeutic instrument, a planned environment
exerting an independent force, and a total environment thatcan be structured to meet treatment goals (Soth, 1997). Milieu
therapy can be conceptualized as a treatment procedure that
attempts to make the total environment, including all personnel and patients of the therapeutic community, conducive to
psychological improvement. In milieu therapy, the staff conveys
to the patients/clients/students the expectation that they can
and will behave more normally and responsibly.
• Green Care: Green care is an inclusive term for many complex
interventions, such as care farming, AAT, therapeutic horticulture, and others. What links this diverse set of interventions
is their use of nature and the natural environment as a framework in which to create these approaches (Sempkin, Hines, &Wilcox, 2010).
• Eco-Psychology: Eco-psychology is a concept situated at the intersection of a number of fields of inquiry, including environmental philosophy, psychology, and ecology, but is not limited
by any disciplinary boundaries. At its core, eco-psychology suggests that there is a synergistic relation between planetary andpersonal well-being — that the needs of the one are relevant toneeds of the other (Schroll, 2017).
• Biophilia: Coined by E.O. Wilson, biophilia describes the deepneed people have to experience natural habitats and species.
The term suggests that there is an instinctive bond between
human beings and other living things. Wilson (1984) proposesthat the strong and meaningful affiliations humans have withnature are rooted in biology.

252

TRANSFORMING TRAUMA• Animal-Assisted Interventions (AAI): AAIs are goal-oriented andstructured interventions that intentionally incorporate animals
in health, education, and human service for the purpose oftherapeutic gains and improved human health and wellness.
AAT, animal-assisted education (AAE), and AAA are all formsof AAIs. Across these interventions, the animal may be part ofa volunteer therapy animal team working under the directionof a professional, an animal who belongs to and works with theprofessional himself or herself, or a service animal who lives
with his or her handler full-time (Pet Partners, 2017).
• Humane Education: Humane education is the process of teaching and promoting humane attitudes toward people, animals,
and the environment. Key elements of humane education include providing accurate information; fostering the three Cs:
curiosity, creativity, and critical thinking; instilling the three
Rs: reverence, respect, and responsibility; and offering positive
choices and tools for problem solving (Institute for Humane
Education, 2017).
Interactions With Animals and Plants in a Farm SettingChildren are encouraged by their treatment team to apply the lessons
learned in the Green Chimneys Farm environment to everyday life. At family case conferences, it is often evident that life skills practiced in the barns,gardens, and on the farm are applied to interactions in other environments
by students. They appear to learn patience while training a calf. Watching abee pollinate a sunflower inspires academic curiosity. The process of livingwith animals becomes the basis of conversations with adults and peers, aswell as self-reflection. The progression of growing vegetables from seed toharvest requires patience and persistence, as the rewards for garden care
do not come instantly and may take months to actualize. Following theharvest, the children prepare the vegetables and herbs they have grown inculinary classes, and share the meals with others. Sharing the rewards oftheir patient and dedicated work with others who enjoy the food heightens
the impact. The garden experience also offers opportunities for social cooperation and delayed gratification, and enhances the children’s self-esteem.
These and other farm experiences can also awaken enthusiasm and support educational and therapeutic goals, as well as foster skill development.

The Healing Power of Nature253

Interest has been found to play an energizing role in cognitive functioning,with research indicating that interest has a strong effect on learner motivation and in predicting future intention (Alexander, Jetton, & Kulikowich,1995). The fact that children identify the farm as “enjoyable” implies thatthey are interested and may be motivated to learn in that environment.
In order to understand the specific benefits offered at the farm forchildren with trauma histories (i.e., psychiatric hospitalizations, loss, academic failure, and in select cases, abuse and neglect), it may be helpful to
break down intention and outcomes into separate goal areas, and outline
how these may be met through interactions at the farm.
Academic Goals
Nature-based programs integrate skills such as reading, writing, mathematics, social studies, and history into “real-life,” seemingly nonacademic
situations. By connecting these academic subjects to something concreteand practical in daily life, the concepts students are learning become tangible and meaningful. For example, division on a math sheet in a classroom
environment is a stress inducer and a child may shut down without trying.
Dividing baby carrots into equal amounts to feed to the bunnies, on theother hand, is a much more motivating task, and children are willing to try
it without necessarily realizing that they are engaging in an academic goal.
Process Goals
Nature- and animal-based activities help teach children who struggle withmultistep instructions or who lack problem-solving skills. Measuring
animal feed, distinguishing names of plants, or grading the size of eggs
requires effort and results in incremental task mastery over time without
being consciously focused on an outcome. As in all learning, the tasks
can be broken down into small steps, but the child’s motivation and theexperiential aspect of the farm activities are a powerful support.
Character Goals
In Positive Youth Development Theory, Richard Lerner defines character as
respect for societal and cultural norms, possession of standards for correct
behaviors, a sense of right and wrong (morality), and integrity (Lerner,2011). Upon entering Green Chimneys, children have an opportunity tobuild respectful relationships with animals. Adults and peers model caring

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treatment of animals, enforce high standards of animal welfare, and define
rules of what is right or wrong to do with various species. Children learn torespect these cultural rules. For example, no one is ever to chase a peacock
walking around campus, and animals are not to be fed treats by hand (inorder to reduce begging and biting). These rules of relating to animals
become the norm, are reinforced by the campus community, and integrate
into broader milieu expectations required to effectively and successfully
function in the academic and residential community. Moreover, whenchildren have a chance to nurture an orphaned animal, care for an animal
who requires geriatric care, or nurse an animal recovering from illness, they
relate to those animals and become particularly and emotionally involvedin the experience by accepting the responsible role of caregiver.
Conceptual Thinking
Students apply academic concepts learned in the classroom to work in thegarden and with animals through measuring garden beds, experimenting
with the effect of light on plant growth, calculating feed amounts, andweighing the animals. Complex conceptual relationships that eventually
are taken for granted must first be comprehended. Various scientific andbiological concepts must be understood for a child to grasp the correlation
between how a daily increase in feed or calories, over time, results in theweight gain of a thin animal. Additional opportunities for concept application and self-reflection include recognizing how animals who have been
injured or rescued from abuse situations require similar care and nurturing
as people who have experienced their own trauma or injury (e.g., themselves or others they know).
Motor Coordination
Students hone fine motor coordination as they carefully spread seeds acrossa flat of soil, work with pressed flowers, and handle and groom animals.
Proper tool usage in a stall while cleaning the barn strengthens fine andgross motor skills, and provides a productive release for energetic students
who have trouble sitting still. Occupational therapists at Green Chimneys
have counted more than 25 different padlocks, dead bolts, latches, andhandles that children must master in the process of working with the animals and in the garden, offering fine and gross motor skill development,
opportunity for sequencing, and mastery in navigating the complex barn
environment.

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Sensory Integration
Children with special needs often have different sensory integration challenges, but a common experience is to be overwhelmed. Some may not beable to tolerate the smell of a dog, while others have auditory oversensitivity to dog barking (Fine, Grandin, O’Haire, Carlisle, & Bowers, 2015).
These same reactions can be observed in the barn with pigs, chickens,and other farm animals. The experience can also vary depending on thetime of day. When the child enters the livestock barn in the morning, thenoise, movement of hungry animals, and smells of the dirty stalls from thenight before are much greater than at midday when all the stalls have beencleaned and the animals are resting and digesting their food. Depending on
the moment, situation, and/or student, the barn can be either a soothing
and enjoyable environment or an overwhelming sensory experience. Thatsaid, it has been observed that children at the farm increasingly toleratesensory input as they get used to the animals, farm machinery, and various
stimuli in the setting.
In addition, showing a child how a new horse gets acclimated to thefarm — and how the animal, too, goes through a process of learning to copewith new noises, new smells, and new sights — often allows the student toobserve the desensitizing process in action. It is possible that seeing how
the horse acclimates, and how this may not always be easy for that animal,
could help normalize the difficulties and anxious responses that children
have when confronted with new environments and overwhelming sensory
experiences. This could help children feel less abnormal or alone in their
feelings and more connected to the horse, while also providing them withcapacity skills and hope to better cope during future transitions.
Emotional Regulation
Work with farm animals in natural settings stimulates the senses (similar
to work with companion animals), provides a quiet refuge for contemplation and internal renewal, and may enhance feelings of self-worth. Ina review of mechanisms of effectiveness, Morrison (2007) suggests that,while frequently based on self-reports, children as a patient population
appear to benefit from AAIs in the areas of self-esteem, decreased stress,
and improved morale.
Emotional dysregulation is one of the most common causes of crisis
for children at Green Chimneys. A goal of treatment at Green Chimneys
is to deepen awareness among the children and families regarding the

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TRANSFORMING TRAUMA

impact of trauma and its triggers, and to build a greater understanding of
how different kinds of trauma impact emotions and behavior. The organizational structure and treatment framework of the program, at the farmand in all areas, encourages recognition of trauma and aims to educate
and support clients in an open-ended and sincere process. Therapists often
utilize the farm environment to explore self-regulation with children, topractice coping skills, to explore emotions, and to examine responses tovarious life situations.
While Green Chimneys utilizes the Cornell Based Therapeutic Crisis
Intervention (TCI) model (Cornell University, 2017), which includes
physical restraints as part of the intervention strategy in cases where achild endangers himself or others, we are increasingly aware of how any
restraint may be dangerous to all participants and could reenact trauma.
According to Sandra Bloom (2010), “One of the most important challenges to the therapeutic environment is the successful management of
traumatic reenactment” (p. 4). Because of this understanding, one of ourmeasurements of success is in the reduction and elimination of restraints
during any period of time in the program, and we track these incidents
throughout the day and week. This informal measurement tool validated
positive behaviors, mood, and the absence of restraints at the farm while
we reviewed critical incidents. Of note, the percentage of restraints in thefarm setting is extremely low compared to the school, residential units, andother areas of the campus. Although it is impossible to know the specificcause of these data, they hint at a higher degree of emotional regulation in
the nature-based environments due to farm staff, the animals, nature itself,
or a combination of all three factors.
Turning Compassion Into Action
The interaction with individual animals who have special needs can encourage compassionate responses from children. By caring for an orphaned,
ill, injured, weakened, or aging animal, children can express sympathy
and are often compelled to assist with that animal’s care voluntarily. In
some cases, children who have experienced past trauma (e.g., psychiatrichospitalization, the loss of a family member, being given up for adoption)
relate to a specific animal who reflects similar experience. Therapists often
utilize these points of connection to help children cope and work throughtheir own trauma. For example, a group of children with adoption histories

The Healing Power of Nature257

bottle fed and helped raise orphaned lambs as part of their weekly adoptee
support group. Guided by social workers, they processed their own experience as orphans, while also providing nurturance to young animals who
had lost their families through separation.
CASE STUDY: THERAPY SESSIONS WITH A
STUDENT AND TWO BACTRIAN CAMELSStudent: Jack, male, 11th grade day student
Admission to Green Chimneys program: During 6th grade
Presenting problems: Lack of self-confidence; anxiety; task avoidance;
poor peer interactions; failure in multiple school placements due
to explosive behaviors
Therapeutic services: Had his own psychiatrist and psychotherapist
outside of school; during school, he received counseling twice aweek with a school social worker

Jack, his therapist, and the farm staff and animals were all looking
for a challenge that would motivate him and build his confidence.
Typically, Jack would shut down and disengage whenever he faceda challenge. As he was easily overwhelmed — he often put his head
down on a desk, refused to participate in schoolwork, or walked
out of the classroom to avoid tasks. Originally, the plan to help
Jack included a variety of species; however, when introduced to thecamels, Phoenix and Sage, in the second session, the therapist noticed that Jack was fascinated by these large animals who were notvery familiar to him. With Phoenix and Sage, he was more talkative and visibly more engaged, maintaining conversation and eye
contact with both his therapist and the animal specialist (both ofwhom supervised each session). During sessions, the therapist andanimal specialist would reflect back to Jack key experiences withthe camels, such as how he helped Phoenix and Sage to learn newthings and how he effectively demonstrated self-soothing skills
during periods when the camels were tied. It was anticipated thatthe camels would motivate Jack and help him gain self-confidence,
relationship and leadership skills, patience, and flexibility.

258

TRANSFORMING TRAUMAIn a 12-month period, Jack built a deeper relationship withthe camels, particularly Sage. Much time was spent on animalcare activities, including grooming and bathing, feeding, walking
on a lead, and clicker/target training for various behaviors. At theconclusion of each session, successes, setbacks, and impressions
were discussed and processed.
Gradually, Jack became more engaged and came up with ideas
for things to do with the camels during each session. He was encouraged, and his opinions and confidence grew along with hiscompetence in understanding the camels’ behaviors and emotions,as well as how to properly handle them. After a few sessions,Jack was transitioned into a leadership role by inviting preschool
students to meet the camels, with Jack as the guide and the safekeeper for the younger kids. Jack rose to this leadership challenge
and was successful. The therapist reflected these experiences backto Jack, tying them to his treatment goals including self-regulation
and awareness.
Over time, sessions with the camels offered Jack opportunities to conquer his fears, and gain a sense of empowerment in asafe and enjoyable environment. Repeated exposure resulted inincreases in emotional regulation, distress tolerance skills, andmastery over anxiety. At the beginning of the school year, Jackrefused to take his psychological or academic testing as he felt
intense pressure and struggled with performance anxiety. After
working closely with Sage, who also frequently exhibits emotional and anxious behavior in new situations, Jack exploredvarious coping and self-regulation skills for both the camel andhimself. In early spring of that year, Jack expressed that he wasready to take the psychological testing and complete it. As an
extra support, we offered Jack a picture of Sage and a small toy
camel to keep with him. When the time came for him to takethe New York State regions exams, he asked for the toy camel
as a tool to refocus and regulate his emotions when he became
overwhelmed, thereby actively advocating for his own needs
for the first time. We are happy to report that Jack successfully
passed his exam.

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CASE STUDY: FARM ACTIVITY SESSIONS AS AN ADJUNCT SUPPORTTO COPING WITH TRANSITIONS AND SELF-REGULATION
Student: Peter, male, 7th grade, resident at Green Chimneys
Admission to Green Chimneys program: During 6th grade
Presenting problems: Academic level of grade 2 with an IQ of 65;
difficulty keeping up socially and academically in the classroom
and residential unit; multiple behavioral crises a day; struggles
with transitions, changes in routine, and peer interactions
Therapeutic services: Participated in individual, group, medication,and family therapy; targeted AAAs supplemented his therapy

Multiple farm activity sessions were scheduled as a support forPeter to coincide with his most challenging and anxiety-producing
times of the day. One session was set for late morning when it wasclose to transitioning from the classroom to lunch. The other wasscheduled just before or after the time when he transitioned fromthe dormitory to school. These transition times were particularly
hard for Peter, as he tended to be triggered by noise and movements, and felt out of control as a result. His farm activities were
1:1 with specially trained farm staff focusing on general animalcare in the wildlife center with birds of prey.
Peter required significant amounts of staff attention in order to be successful and to maintain his composure. Sharing theattention of adults with peers was very difficult for him. Peter
enjoyed physical activities, was an experiential learner, and found
the farm offered him opportunities to get outside away from theoverwhelming classroom environment. Since the animal care
activities were individualized for him, he was generally helpful,productive, and motivated to cooperate with his assigned staff. It
also was suggested that Peter benefited from grounding activities
in which he did some heavy lifting to calm his body. Caring for thehawks, eagles, and owls allowed incorporation of activities such as
pushing heavy wheelbarrows with food. Staff carefully chose theactivity that would both physically and emotionally benefit Peter.
By strategically offering him time at the wildlife center withthe birds as an adjunct activity, we were able to support his overall

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therapy goals, resulting in a reduction of frequent behavioral crises
caused by anxiety over transitions. The treatment team also createda calmer and quieter environment for his transitions, allowing
him to do so after other students were settled, and when staff had
more time to tend to his needs. With these interventions, Peter
gradually became more stabilized within the overall program.
This kind of individualized and adjunct support at the farmis often applied for students with additional, various behavioral
challenges, including attention and focus, completing a task/
sequencing, distractibility, emotional stabilization, frustration
tolerance, hyperactivity, impulsivity, and organizational skills
and/or prioritization.

CONCLUSION
We have provided an overview of how farm settings — specifically the former Our Farm program in Texas and the existing Green Chimneys School
in New York State — can aid in the treatment and education of children
with trauma histories. Anecdotal and empirical evidence was presented toconstruct a defensible framework for farm-based program settings, suggesting positive impacts on cognition, motivation, and affect, as well as social,academic, and psychological progress for children with trauma histories
when integrated into a more broad-based treatment approach. It would
be premature to conclude that there is a sufficient evidence base in thisarea, as best practices are only slowly emerging regarding when and how
to utilize farm settings in education and therapy for special populations.
However, the potential of this work to support children in special education and treatment settings is promising. To further the evidence basein this area, Green Chimneys partnered with the University of Denver’s
Institute for Human-Animal Connection in 2016 to thoroughly explore the influence of Green Care models on measures of Positive Youth
Development (Lerner, 2011) for students ranging in age from 6 to 18
years. The research team will focus this multiyear study through the useof a Positive Youth Development lens to see if this unique Green Careincorporative framework allows youth with behavioral, developmental,
and/or environmental challenges to meet treatment goals and develop their

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individual strengths. As Bustad (1990) notes, “We must immerse students
in living things. The growing interest in nourishing and caring for plants
and animals must be encouraged, especially in our children, for we needto preserve and care for the life of the entire planet” (p. 124).
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disorder. Chapel Hill, NC: Algonquin Books of Chapel Hill.
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ABOUT THE AUTHORS
Michael Kaufmann is the farm and wildlife director at Green Chimneys andthe director of the Sam and Myra Ross Institute, dedicated to researchon human connection to animals and the natural world. He served theAmerican Society for the Prevention of Cruelty to Animals (ASPCA) andthe American Humane Association (AHA) as a key program director inanimal-assisted activities/therapy, humane education, and animal welfare. Kaufmann has contributed to defining publications in the field of
human-animal interaction, and serves on numerous national boards andcommittees. He lectures internationally, with a special focus on animal
welfare and the practical/administrative animal management issues withdiverse species involved in human-animal interaction programs.
Miyako Kinoshita is a farm education program manager at Green Chimneys.
She holds a master’s degree in education, and is a certified advanced-level
therapeutic riding instructor with the Professional Association of
Therapeutic Horsemanship International (PATH Intl.). Kinoshita specializes in prevention, early detection, and intervention of emotional andbehavioral crisis in AAA settings, and has presented many workshops andlectures throughout the United States and Japan. She was a past committee
member for the Equine Facilitated Mental Health Association (EFMHA),
and served on the board for PATH. Having led Green Chimneys’ equine
programs for many years, she now focuses her work on the extensive intern training programs (including supervision of the international internprogram), as well as the integration of farm programming with the educational, clinical, and residential programs.

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Susan Puckett Teumer has been a public school educator for 30 years, andserves as adjunct faculty at the Institute for Human-Animal Connection
at the University of Denver. She was the lead teacher for Animal Therapy
Association’s Our Farm program in Taylor, Texas, where she developed andinstituted competency-based programming in animal-assisted education.
With a Master of Arts in education, Teumer has taught students of all levels
and of varying learning needs. She served as a volunteer, trainer, evaluator,and national board member for the Delta Society’s Pet Partner program,and has worked as program coordinator, volunteer, instructor, and executive committee member for Human-Animal Bond in Colorado. Teumer
has also spoken at numerous education forums, including lecturing internationally on AAI, and has contributed to a textbook on the subject.

CHAPTER 8

Horses in the Treatment of Trauma
Nina Ekholm Fry, MSSc., CCTP

INTRODUCTION
Advances in the field of neuroscience over the past 30 years have led to amore comprehensive view of the effects of trauma on the brain, mind, andbody (van der Kolk, 2014; Siegel, 2012). Traumatic events and associateddebilitating symptoms such as intrusive memories and thoughts, heightened arousal, dissociative states, and somatic issues all impact the ability
to enjoy life and connect with others, leading to a life of distress if notaddressed. Fortunately, awareness of trauma as an etiological factor in mental illness and addiction has led to more effective treatments that directly
address trauma, and also the emergence of so-called trauma-informedcare. This is a framework that encourages the recognition of symptoms of
trauma, regardless of setting; realizes their prevalence in client populations,staff, and others; and seeks to integrate awareness of trauma in policy andpractices (SAMHSA, 2015).
In addition to better understanding the nature of trauma, finding
ways to help individuals seek treatment, to remain in treatment, and forpractitioners to optimize treatment is crucial (Najavits, 2015; Sayer et al.,2009). The inclusion of horses in the treatment of trauma has the potential
to address each of these three areas. However, more research is needed tosupport the emergence of equine interactions as an enhancement of trauma

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approaches, whether as part of treatment that directly addresses trauma orin strengthening functioning and coping skills more generally.
In this chapter, I discuss the inclusion of horses in the treatment of
trauma through their benefit to central tasks in trauma recovery, organized
in a tri-phasic framework (Herman, 1992).
DEFINITIONS
Equine-assisted therapy (EAT), also referred to as equine-assisted mental health (EAMH) when focusing on psychological treatment, is how
mental health professionals appropriately credentialed to legally practice
psychotherapy or counseling in their state or country include equine interactions and the equine environment to enhance their clinical treatment
and assessment, within their scope of practice. It is not a standalone therapy. The mental health professional has received education, training, andsupervision in equine-assisted mental health in order to practice ethicallyand effectively. Equine-assisted therapy will be used interchangeably withequine-assisted mental health, and, when used in this context, refers to psychotherapy, as opposed to other therapies (such as physical or occupational
therapy). Terms such as therapeutic riding — which in the United Statescommonly refers to a recreational activity that is not provided by mental
health professionals and cannot, as such, be referred to as therapy — will bedefined at the time of mention (the American Hippotherapy Association
recommends use of the term adaptive riding to avoid misunderstanding[2018]). Finally, equine refers to horse, mule, or donkey, and will be usedinterchangeably with horse.
BACKGROUND
History of Horses in Human Health

Since the domestication of horses approximately 6,000 years ago (Outram
et al., 2009; Vilà et al., 2001), the versatility of equus caballus is thought tohave contributed to the development of human civilization in many meaningful ways, most notably in transportation, trade, warfare, and agriculture(Johns, 2006). The ability to travel more efficiently with the help of horses
made new communications and trade possible, which some scholars believe

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contributed to the development of modern languages (Anthony, 2007).
Horses are still being used in farming, ranch work, and logging around theworld, although to a much lesser extent (Brandt & Eklund, 2007; Pickeral,2005). Horsemeat and other horse-related products, such as the urine ofpregnant mares used in pharmaceutical compounds for human hormone
replacement therapy, are produced around the world, although horses are
not regarded as production animals. Increasing numbers of horses are partof sport and leisure, and most recently in physical and psychological therapy for humans (Edenburg, 1999). In the United States, miniature horses
are permitted for use as service animals under the law (Americans with
Disabilities Act, 2010).
In addition to their prominent role in art and mythology, the impactof the horse on human health has been discussed in medical literature as
early as by the ancient Greeks (Bain, 1965). Accounts from the second century CE up to the late 1900s focused primarily on the effects of horseback
riding on the human physique (see Ekholm Fry, 2013, for an overview).
When discussing the history of horses as part of trauma treatment, or evenpsychiatric treatment as such, it is important to consider the history anddevelopment of mental health treatment itself (Porter, 2002). The faintbeginnings of today’s mental health treatment with horses can, perhaps, be
traced to the 1800s, when institutions such as York Retreat in England emphasized “moral” and mental treatment over, but also alongside, the abusive
confinement practices and crude medical procedures of the time, and whenmodel asylums were designed to function like working farms in country
settings with horses and other animals. Similar advances were made inFrance and other European countries, with early study of trauma taking
place through doctors Charcot and Janet at the Hôpital du Salpêtrière in
the late 1800s (van der Kolk, 2003). In Finland, Lappvikens Sjukhus in
Helsinki, built in 1841, was modeled on the idea that the environment isimportant for treating mental illness, and patients at the hospital did haveaccess to horses in stables and pastures, as they were used in farming andfor transportation (K. Wahlbeck, personal communication).
The notion of psychological trauma came into focus through accounts of “shell shock” during World War I (see van der Kolk, 2014, foran overview). Some propose that horses were used in the rehabilitation ofwounded soldiers during World War I; however, a reliable source for thisis difficult to find. Since the study of trauma, and the understanding of it
as an etiological factor in mental disorders, was not a focus until the late

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1970s (van der Kolk, 2003), there are no accounts of including horses inthe treatment of trauma until much later. By the 1990s, there was someindication of the emergence of horses as part of psychological treatmentin the United States and Europe, but it is truly in the past 20 years thatequine-assisted therapy has developed more formally.
Inclusion of Horses in Mental Health Treatment

Interacting with horses, both on the ground and on their backs, often
inspires sayings such as “the horse is my therapist” (Davis, Maurstad, &Dean, 2014, p. 299). However, addressing trauma, either directly throughthe traumatic memory or through strengthening other aspects of functioning, relies on the presence of a skilled and appropriately credentialed
therapy professional, just like in other treatment areas. Providing mental
health services together with a horse without education, training, and supervision in doing so and, importantly, without specific training in the
population or diagnosis (or client challenge), is not ethical practice andmay cause scope of practice violations.
Equine-assisted mental health can be understood as having simultaneously experiential, somatic (mind-body focused), and relational elements.
While there are benefits to including animals in treatment that are present
regardless of species, discussed in Fine (2015) and in this book, there aresome aspects unique to horses that are highlighted as follows.
Setting. Equine-assisted therapy takes place in a nontraditional environment that can seem a better alternative to some clients than meeting thetherapist in a small, enclosed office space. The option of being outdoors
in nature or indoors (in spaces such as the indoor arena or barn office), or
both, during the session allows for some flexibility depending on client
preference and the weather. The setting in which equine-assisted therapy
takes place is often a natural one, bringing with it additional benefits discussed elsewhere (cf. Louv, 2008; Thompson-Coon et al., 2011). Humaninteractions with horses for leisure and work tend to have positive meanings in different cultural and religious settings (Frewin & Gardiner, 2005;
Pickeral, 2008), and so participating in equine-assisted therapy can fostera connection to a larger equestrian culture for the client.
Touch and movement. As proposed by Schulz (1999), rhythm, touch, and skincontact, naturally present in equine-assisted therapy, are essential elements

Horses in the Treatment of Trauma269

of human development. The horse not only presents an opportunity for
touch that might not be feasible in typical therapy, but they also provide
large surfaces for body interaction, and even the ability to physically carrythe client. Brooks (2006) notes how the horse can provide a client withthe experience of being held in an environment that is perceived as safe.
Brooks also comments on how the client’s use of touch with an animal
can be part of diagnostic assessment. The perception of a safe relationship,
together with non-noxious sensory stimulation, can stimulate the release ofoxytocin, a hormone involved in stress-reduction, calm states, and a feelingof connectedness (Uvnäs-Moberg, Handlin, Petersson, 2014). In addition
to general physical benefits, movement can help with attention, relaxation,
and a sense of connection in the therapy session. Brushing, leading, andriding are common ways to move together with horses.
Relational influence. The biophilia hypothesis, proposed by Wilson (1984),
theorizes that humans have an innate tendency to focus on life and lifelike
processes. It does not suggest that humans have a natural affection foranimals but that attention to, and knowledge of, environmental cues has
been an important part of human evolution (Kruger & Serpell, 2010). In
other words, events in nature may be associated with a sense of safety ora sense of danger for humans. The biophilia hypothesis is used to support
the notion that low-intensity interaction with a relaxed horse can havea calming, de-arousing effect, and it is likely that other factors, such as
rhythmic touch, are also part of reducing arousal and facilitating a statechange (a shift from one state of mind to another) in the client. A major
feature of equine-assisted mental health is the opportunity for the client
to form a relationship with an other-than-human being (Esbjorn, 2006;
Hayden, 2005). Direct behavioral feedback, as well as the invitation to
engage in body-based communication, give the client new insights into
their own relational behavior. The horse can also function as an ally to theclient and be perceived as a source of nonjudgmental support. Wanting
to see the horse and to practice new behaviors that facilitate a relationshipwith the horse (such as self-regulation) can be a source of motivation formany clients.
Practice. Equine-assisted mental health is experiential in nature and often
involves the opportunity to practice behaviors. The use of metaphor isoften employed to help create an isomorphic bridge between what is

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happening with the client and the horse to other contexts in the client’s
life. Helping to make the intangible, such as the client’s feelings andthoughts, tangible through physical and visual representation in the session, can create new avenues for self-insight. This includes the valuable
opportunity to experience and practice new behaviors in a less-threateningsocial setting. At the same time, equine interactions do come with a levelof risk, and the client can practice taking emotional risks together withthe therapist.
Joint venture. The therapeutic alliance has been determined as a consistent factor related to therapeutic outcome (Ardito & Rabellino, 2011;
Lambert & Barley, 2001), so it makes sense to focus on ways to evaluate
and strengthen this relationship. Clients consciously or unconsciously assess the therapist and the therapy situation for clues related to safety andneed for self-protection; hearing how the therapist talks about the horseand seeing how he or she interacts with the horse can create a basis of trust
for the client: “This is also how I will be treated in this relationship.” The
opportunity for the therapist and client to actively do things together inequine-assisted therapy, rather than simply talk about the client’s issues,
may be a strengthening factor for the therapeutic alliance. As a result, theclient may feel more buy-in from the therapist for the client’s therapeutic
journey, a sense of “joint venture.”

The aspects described above are made possible by the nature of the horse
as a social prey mammal, which has implications for their brain structure, relational behavior, and learning, specifically associative learning.
Compared with horses, humans have an enlarged prefrontal cortex, andwhile other areas of the brain are similar in mammals, humans possess
reasoning skills and self-insight as a result of this difference, which horses
do not (McGreevy, 2012; Siegel, 2012). As a prey animal, horses pay
close attention to self- and energy-preservation, and as a social animal, tointeractions with others. Their sociosensual awareness, a concept first introduced by anthropologist E. Richard Sorenson (1978) and which is sharedwith humans, means that they benefit from orienting and responding to
the states of others.
These and other aspects of how horses and their environment specifically help enhance trauma treatment are discussed in the next section.

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THEORY AND POTENTIAL MECHANISMS
Tri-Phasic Model as a Framework for Trauma Recovery Tasks

The presentation of how horses can enhance the treatment of trauma in thissection is based on current understanding of trauma from advances in neuroscience, promoted by practitioners and researchers such as van der Kolk
(2014), Siegel (2012), Ogden (Ogden, Minton, & Pain, 2006), Lanius(Frewen & Lanius, 2015), Porges (2011), Gilbert (2010), Perry (2009), andLevine (2010). I utilize the tri-phasic approach to trauma treatment, first
proposed by Herman (1992), as a framework within which integrative tasks
related to trauma recovery such as memory processing, reducing hyper- or
hypoarousal, working with the body, developing core mind skills, creating
meaning making and new narratives, achieving response flexibility, and(re) experiencing connection through relationships can be organized. The
three phases can be characterized as: Phase I — Stabilization and Moving
Toward a Sense of Safety; Phase II — Integration of Traumatic Memories andEvents; and Phase III — Reconnection. There is no set or “right” way to address trauma in each complex client situation as the impact of trauma on
an individual, as well as the length of treatment, depends on a number of
lived experiences. These include attachment history; existence of previous,
untreated traumatic experiences; the developmental timing of the trauma;characteristics of the trauma; and other supportive or destabilizing factors.
There are a number of approaches employed in the treatment of trauma(Foa, Keane, & Friedman, 2010), and a distinction should be made between treatment models that directly address the traumatic memory, suchas eye-movement desensitization and reprocessing (EMDR), prolonged
exposure (PE), and cognitive processing therapy (CPT), and those that
address coping skills and supportive factors (see Imel, Laska, Jakcupcak, &Simpson, 2013, for a discussion on issues in conducting meta-analyses oftrauma treatment for this reason). In the tri-phasic model presented here,
the third phase (with the central task of reconnection) and the first phase(where central tasks relate to stabilizing and managing the mind) could
be thought of as supportive on their own, but it is important to note thatmastery of tasks in phase I is a prerequisite for the second phase (where
integration of traumatic memories and creation of coherent narratives arecentral tasks). Treatment tasks for each of the four diagnostic clusters related to behavioral symptoms for post-traumatic stress disorder (PTSD) in272

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the DSM-5 — intrusion (reexperiencing); avoidance; negative alterations
in cognitions and mood; and arousal (disturbances in arousal and reactivity such as hyper- or hypoarousal) (American Psychiatric Association,2013) — can also easily be found within the three phases of the trauma
treatment framework.
I agree with van der Kolk (2014) that eventually addressing thetraumatic memory is central to reducing trauma symptomology. The neurobiology and neuroanatomy related to the process of integrating traumatic
memories is discussed at length by Siegel (2012), but can, in short, bedescribed as follows: traumatic memories have certain features that separate them from non-traumatic, or typical, memories. Traumatic memories
lack a “time stamp,” causing a person to have the experience again in thepresent, as opposed to simply thinking back to the past when it happened.
Ogden and colleagues (2006) call this “the here-and-now experience of thetraumatic past” (p. 167). Traumatic memories are fragmented and disorganized, with images, smells, and sounds experienced without sequence.
The reason why this occurs is the lack of involvement of parts of the brain
responsible for time and perspective, as well as creation of a coherent story
line, at the time of the overwhelming experience(s). Helping the mind
process the event with all necessary parts active is facilitated by reducing
arousal, the excess of which created the lack of integration in the firstplace, and means that flashbacks and the reliving of the trauma will ceaseto happen. The ability to maintain calm while accessing the sensations andemotions that have caused such pain in order for the memory integration
to happen is practiced as part of tasks in phases I and III and specificallyapplied in phase II.
Risk of Re-Traumatization in EAMH

Therapists who are working with a population with identified trauma but
not directly with trauma treatment, and who include horses in treatment
and whose session content may fall within phases I and III, need to makesure that their approach is, at a minimum, trauma-informed. The risk ofre-traumatization has to be taken into consideration in session planning.
Rothschild (2000) addresses three situations where the traumatic event
can be accidentally triggered in therapy: 1) in state-dependent recall, 2)in postural-dependent recall, and 3) during exercises that involve accelerated heart rate. State-dependent recall occurs when the current state
replicates the internal state produced in conjunction with the traumatic

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event. Each client’s trauma is different, but caution should be taken if facilitating equine-assisted interactions with a high level of mental discomfort(involving a lot of unknowns or little instruction) or where there is need toperform under time pressure (such as in group games). Postural-dependent
recall is similar, but specifically relates to the body being in a position
associated with the traumatic event. Sitting astride a moving horse might
trigger traumatic memories of sexual activities due to movement in thehips, for instance. Therapists placing clients in sensory positions on theback of the horse, such as in a prone position facing the tail, need to keep
in mind that immobilization without fear (Porges, 2003) can be difficult toachieve in that position for some clients with trauma. Finally, Rothschild(2000) notes that an accelerated heart rate is part of hyperarousal in PTSD.
Activities that might involve running or moving quickly and that are notentirely within an individual’s control (such as part of a game or group exercise), might, through state-dependent recall, act as a trigger (Kozlowska,
Walker, McLean, & Carrive, 2015). For the same reason, dramatic evocation of emotion common in certain psycho-spiritual approaches to EAMH
should also be done with caution with a trauma population. In addition,
activities that intentionally evoke a flight response in horses have welfare
implications and are discussed in the section on equine welfare.
Finally, the nontraditional setting and inclusion of a horse may leadto clients disclosing about their traumas more quickly, either by choiceor through gaining access to previously unknown experiences. It is thetherapist’s responsibility to help the client pace their processing so thattreatment does not become re-traumatizing (Rothschild, 2000).
How Horses Can Enhance Trauma Treatment

Each phase in the framework is explained with general intention and tasks,
adapted from Herman (1992), along with the horse’s role in optimizing
the achievement of these tasks.
Phase I: Stabilization and Moving Toward a Sense of Safety
The feeling that the world, other people, relationships, and own thoughts
and body are dangerous hinders a trusting connection with self and others. Re-experiencing traumatic events through fragmented flashbacks andexperiencing disturbances in arousal leads to attempts to disconnect fromthese extreme emotions through withdrawal from relationships, fromoneself, and from one’s body. Use of drugs and substances, and excessive

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engagement in behaviors, also function as self-management strategies (vander Kolk, 2004). Lanius, Bluhm, and Frewen (2011) found that clientsdiagnosed with complex PTSD have deficits in brain functioning related
to emotion regulation, social emotional processing, and self-awareness,among others.
Tasks in Phase I

Tasks in phase I relate to helping clients find safety in their bodies andrelationships through exploring ways to manage their mind and emotions.
Identifying sources of strength and understanding the function of traumatic symptoms are also in focus.
Establishing a therapeutic relationship and a roadmap for treatment. Since trauma
affects the ability to build and maintain relationships, especially wheretraumatic events are related to other people, experiencing safety in thetherapeutic relationship can be difficult for clients. Through the presence ofthe horse, clients can assess how others in relationship with the therapist are
talked about and treated (see also studies of how animals affect the social
perceptions of others, such as Lockwood, 1983, and Rossbach & Wilson,
1992). This likely contributes to the client feeling more comfortable in
the early therapeutic relationship (Tedeschi, Sisa, Olmert, Parish-Plass,& Yount, 2015). When client and therapist jointly focus on the horse,
through brushing or observing, initial conversations can feel less threatening. This nonconfrontational spatial relationship (unlike sitting and facing
one another in a traditional therapy office) can facilitate the sense of safety
for the client.
Psychoeducation. Helping clients understand what is happening in theirminds and bodies as a result of what are initially adaptive responses totrauma can reduce shame and confusion (Ogden et al., 2006), and starts
the process of meaning making (Siegel, 2012). Further normalization andunderstanding of behaviors come through observation of similar behaviors
and biological functions in the horse. Relaying curiosity from the client
about the horse’s behavior to their own can be very effective in encouraging self-awareness and reflection. In addition, it might be easier for clientsto initially talk about themselves through the safer focus on the horse(s).
Body access and awareness. Regardless of approach, the central role of the
body in the treatment of trauma has been much recognized (cf. Levine,

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2010; Rothschild, 2000, 1999; van der Kolk, 2014). The intense physicalreactions coming from the body as a response to heightened emotional
states can lead to numbing or disconnecting responses for self-protection.
This creates temporary relief but has a side effect: it is hard to “feel alive”
without accessing a major part of oneself. Some clients put themselves into
dangerous situations in order to “feel,” while others narrow their lives to an
extreme due to the painful impact of constantly scanning for danger (vander Kolk, 2014). Vertical integration, a term proposed by Siegel (2012) for
the integration of the mind and body, and the way the mind, body, andbrain work in concert, is central to consider in the treatment of trauma.
Interacting with one’s body applies directly to interacting with horses.
The horse creates a setting where the need for body access and awarenessmakes sense, and this can motivate clients to engage in something thatmight cause initial discomfort. Increased understanding of the role of the
body in communication, as well as access to it through practicing with thehorse, helps supply the client with tools that help regulate body sensations.
The ability to calm the body, through affecting the functioning of theautonomic nervous system, is a necessary component of emotion regulation and traumatic memory integration (Baranowsky & Gentry, 2015;
Siegel, 2012).
Developing mind skills. In order to start achieving a sense of safety within, it
is important that clients start recognizing signs of internal escalation andde-escalation, where models such as the Window of Tolerance (Ogden etal., 2006) come into good use. Related to this is finding ways to reduce
extreme emotional states without maladaptive avoidance strategies. Mindskills, such as focusing skills, self-observation, and self-support, help clientsto “apply the brakes” (Rothschild, 1999), and create a way to both feeland observe, as opposed to being completely taken over by a feeling. The
ability to self-observe and other metacognitive strategies are cut off wheninternal arousal reaches a certain point. Decreasing arousal is directly related to the ability to engage in self-observation (Siegel, 2012). Horses canenhance the practice of mind skills and emotion management in a numberof ways. For instance, horses provide a compelling reason to focus on thepresent, and clients can use this both as an anchor in thought pendulation
activities and as a way to practice tolerating a calm state (see Ekholm Fry,
2016, for a more detailed discussion). Engaging with horses in activities
that require focus, such as leading the horse through an obstacle course, notonly creates an opportunity for the client to consciously notice what focus

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feels like, but can also motivate them to practice when the setting makes
it functional. Activities done together with the horse might create more
buy-in from the client than a guided visualization or other less tangible
strategies would on their own. State shifts happen naturally in interaction with another living being, and the therapist can help identify those
happening between the client and the horse without needing to address
them within the therapeutic relationship. The latter is likely less tolerated
by the client until later in treatment. An additional benefit of practicing
mind skills together with the horse is the opportunity for bonding. If theclient perceives that the relationship between themselves and the horse istrusting and safe, the elements of touch and rhythmic movement that are
not possible between the therapist and client can help facilitate a releaseof oxytocin (Uvnäs-Moberg et al., 2014).
Putting words to feelings and distress. Clients with PTSD often have difficulties
identifying and labeling their emotions (Lanius et al., 2011). An early neuroimaging study by Rauch and colleagues (1996) showed decreased activity
in Broca’s area (a part of the brain with functions linked to speech andlanguage) in participants with PTSD during exposure to a traumatic narrative. This suggests that it might be difficult for traumatized individuals
to verbalize what they are feeling when becoming emotionally distressed.
Putting words to experiences can help bring organization to sensations,facilitating the creation of a coherent narrative (Siegel, 2012). In addition
to previously mentioned approaches to facilitating sharing by the client,such as allowing the client to project their own feelings onto the horse or
describing their own emotional state through the identity of the horse, thedynamic nature of equine interaction brings up different emotions that canbe identified and explored by the client in the moment. In addition, it isimportant for clients to start noticing that there is, in fact, some variationin the intensity of their distress, especially since distress without exploration can seem constant. The subjective units of distress (SUDs) scale, firstdeveloped by Wolpe and Lazarus (1966), is a helpful tool in achieving this.
Through practice of identifying level of comfort or level of distress associated with lower-arousal tasks in the therapeutic setting (such as picking up
a horse’s feet or walking around the back of a horse), clients can practicewithout overwhelming emotional content hindering skill building. Positive
experiences with the horse can facilitate the recognition of other sourcesof strength in the client’s life.

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Understanding orienting and appraisal — reducing disturbances in arousal. After a
traumatic event, orienting and appraisal systems often become altered,leading to a narrowing of perception and an appraisal process sensitized
to perception of threat. The constant scanning for an inner sense of threat,also referred to as neuroception (Porges, 2011), and outer cues of threat anddanger cause abnormal levels of arousal. Disturbances in arousal, whichis part of the DSM-5 diagnostic criteria for PTSD (American Psychiatric
Association, 2013), has negative effects on mood and cognition (see Ogden
et al., 2006, for an excellent overview to orienting responses). Observing
how the client evaluates threat, what factors go into the appraisal, and how
able the client is to rework the appraisal process are helpful assessment tools
for trauma therapists (Ogden et al., 2006). Interaction with horses can help
the client to start making voluntary choices about what to orient toward,
to allow for new information to enter into the appraisal process. Being able
to reflect on the orienting/appraisal process as it happens enables the client
to start making strategic choices about how to respond. As mentioned in
the previous task, there are interactions around horses that clients might
have apprehension about, such as picking up the feet, which is necessary for
their care, and walking around the back of the horse. Simply approaching alarge animal can also feel daunting, especially if the client has no previous
experience or poor past experiences with horses. This flexible environment
provides an excellent experiential opportunity for the therapist and client
to explore and make sense of the client’s orienting responses.
An example of this that happens frequently in my practice is walking
around the back of the horse, which naturally happens when interactingwith horses. Walking around a horse that is fully comfortable with humaninteraction and trained for a number of tasks on the ground is best doneby walking closely to the rump. Horses have a wide field of vision and anarrow blind spot near the rear, which can be accessed by the horse slightly
moving their head (McGreevy, 2012). The trainability of horses and theirenergy-preserving nature means that they have no reason to kick back or
step on the client. The exceptions to this would be if the horse startled, or
displayed a response to pain or conflict.
Each of my clients receives brief instruction and demonstration withanother human, if available, on how to pass behind a horse at the beginning of a session. Even when equipped with information they know iscoming from a professional, and with horses that are trained, most clientsmight feel some apprehension when walking around the horse but are

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willing to try. But for some, the amount of hyperarousal and disruption
to a typical orienting process as a result of their past traumatic experiences
might not allow them to distinguish this situation from those in their past.
Unless the client’s arousal is much too high, the client now has a tangible
opportunity in the therapy session to practice what to orient toward, toallow for new information to enter into the appraisal process, and to reflect
on the orienting/appraisal process as it happens.
If the client asks that I go with them around the horse when they are
not yet able to attempt this action with only verbal support from me, I
position myself at the horse’s side, facing their tail, and ask the client tostand behind me. Being positioned behind me, as opposed to in front, isa less threatening position for the client. I slowly walk to the tail of thehorse, with the client following, and when I am standing by their back legs
(this position seems the most risky to the client) I pause, and together withthe client we appraise the situation so that we can make strategic decisions
based on what is happening in that moment. I ask the client to notice theirown internal state. I describe mine to the client. Then we assess what thehorse’s state might be, based on level of tension or relaxation in its body,
how the horse holds its neck, where the ears are pointed, and whether there
are any elements in the environment that might contribute to the horse
moving, such as other horses approaching. Throughout this dual attention
exercise together with the horse, I demonstrate a calm body state and mightalso encourage the client to slow down their breath. By paying attention
to cues in the environment that are happening right now, and allowing
some past experience to enter the decision-making process, clients can now
start the process of reworking these acquired schemas. The knowledge that
overwhelming experiences of the past have created some unhelpful biases
in their thinking and feeling can be liberating for the client. The morecautious nature of horses, compared to dogs, for instance, can also help
clients relate to their own experience of hyperarousal and hypervigilance.
As noted by Briere and Scott (2006), hope is not typically described asa therapeutic goal, but should be seen as a crucial therapeutic action.
Hopelessness arises from the perception that negative things will remain
constant, which, for those affected by traumatic experiences might be unbearable. New internal and external experiences made possible from thetasks in phase I facilitate the idea that change is possible (van der Kolk,
2004), and help prepare clients for the tasks in phase II. The task of phase

Horses in the Treatment of Trauma279

I should not be seen as “complete” when moving to the next phase, but aspart of the ongoing therapy process.
Phase II: Integration of Traumatic Memories and Events
The integration of traumatic memories involves lessening their emotional
intensity so that they can function as typical memories and not be relived
or fragmented. This integrative process also includes making sense of what
has happened through a narrative that can become part of the client’s
larger life story. The process can also involve mourning losses, such as nothaving a typical childhood, or living with injuries sustained in the courseof the traumatic events (Herman, 1992). This is the phase of treatment
least tolerated by clients (Najavits, 2015), so preparation and timing must
be appropriate. Interactions with a preferred horse can help motivate theclient to remain in treatment during the height of therapeutic intensity.
Tasks in Phase II
Integrating traumatic memories. The ability to maintain a calm body in response to experiencing fragments of traumatic memory will help the mind
organize and store these experiences so that they can later be retrieved, as
opposed to painfully and intrusively relived. In an early text, Wolpe (1958)
proposed that by having people relax while they were in situations thatprovoked fear, subsequent exposures to the situations would become lessdistressing. The ability of the client to engage in dual awareness, keeping
part of their focus on the present and part on the traumatic images andsensations is also necessary (Ogden et al., 2006). The horse can support
this process in a number of ways: as a reminder and facilitator of a calm
state, as a support for a distressing process, and as an appealing anchor to
the present.

Constructing and integrating a narrative. Creating coherent narratives withdescriptions of sensations associated with the trauma and sequence of
events assists in memory integration and meaning making for the client(Rothschild, 2000). The narrative can then be integrated into the client’s
life story and is available for examination and reexamination. The therapist
is responsible for helping the client pace the narrative process. Rothschild(2000) suggests stages to constructing the trauma narrative, and Briereand Scott (2006) recommend starting and ending each session with low
therapeutic intensity. Interaction with the horse can function as a physical

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break for the client who is becoming too activated. In order to reinforce aconnection to the present, the client can also create a visual representationof the trauma narrative in the arena together with the horse and therapist.
By creating a physical representation of intangible experiences of the mind,
dual attention and self-observation can be made easier. Incorporating
movement and the connection to the horse can help clients tolerate thenarration of fragmented details related to the trauma. Starting and ending
with low therapeutic intensity can be easily achieved through interactions
with the horse such as grooming, feeding, or leading the horse back totheir pasture.
Phase III: Reconnection
When the acute effects of traumatic experiences are gradually fading, thereis space and opportunity for the client to reconnect with themselves andothers in their lives. Within this phase lies endless opportunity to pursue
self-exploration, further integration and meaning making of the increasingly coherent trauma-related narrative, and creating connection throughhealthy relationships and meaningful activities that make life enjoyable.
Including the horse facilitates experiential engagement in this process witha relational partner to the client.
Tasks in Phase III
Connecting with self. Tasks in Phase I initially helped the client to establish abasic sense of safety and management of their emotions. In Phase III, thesetasks can be revisited through a new sense of agency. Exploring patterns of
thinking and behaving in relation to overall goals in the client’s life may
also involve treatment for addictions and substance abuse that might arise
as ways to cope with the trauma. The client is now faced with the task ofestablishing trust in themselves and compassion toward who they were
before, during, and after the trauma. Herman (1992) calls this “reconcilingwith oneself.” Equine-assisted therapy used as an enhancer in the treatment
session provides an experiential, somatic, and relational space for the client
to explore these and other tasks, and can easily be incorporated with otherapproaches such as art therapy. One of my clients said after a session in thisphase: “I remember that there are all these different parts to me.”Connecting with others. Our neurobiology is designed to promote and reward social behavior, and our brain is reliant on others for development

Horses in the Treatment of Trauma281

and survival (Siegel, 2012). So, without others, we cannot fully function.
The symptoms of traumatic experiences not only hinder the ability to feelpresent and fully alive, but also largely prevent a feeling of connection withothers (van der Kolk, 2014). The experience of an attuned relationshipand the experience of repair after rupture, both part of secure attachment(Siegel, 2012), can be carefully fostered between therapist, client, and horse.
Relational skills such as setting and maintaining boundaries, perspective
taking, empathy, and communicating one’s own needs can be practiced
experientially through including equine interactions in treatment.
Connecting with community. Shapiro and Maxfield (2003) note, “Let me makeit fruitful, let me be useful, let me help others” (p. 214). Taking part incommunity activities and being of service to others can be part of post-­
traumatic growth (Calhoun & Tedeschi, 2014). The connection to horses
and the culture surrounding horses established through equine-assisted
therapy as a treatment enhancer can provide a place for the client to engage in their larger community. Volunteering in programs that provide
opportunity for individuals with physical disabilities to be around horses
and learn to ride, or spending more time with horses by helping at barns
or horse rescues can be satisfying avenues to be of service.

CONSIDERATIONS FOR EQUINE WELFARE
IN TRAUMA TREATMENT
When including an animal in human therapy services, therapists have a
responsibility to attend to the welfare of the animal. The nature of this
responsibility can be seen from a number of perspectives, from that of
One Health (Gibbs, 2014), meaning the understanding that the health ofhumans, the health of other animals, and the health of the environment
are interconnected and interdependent; to ethical and moral reasons; toreasons related to therapeutic outcomes; and to risk management, all ofwhich are interlinked.
How horses are managed and handled affects their levels of stress andpain, which in turn affect their behaviors. Horses that are fearful or aggressive pose a larger risk to humans (Popescu & Diugan, 2013). Since
the treatment of horses and their overall demeanor in the therapy session
affects the client’s perception of safety, a connection between the welfare

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and treatment of the horse and therapeutic outcomes in equine-assisted
therapy can be proposed (Ekholm Fry, 2014).
Challenges

Therapist knowledge, skills, and attitudes have the biggest impacts on
the welfare of horses that are included in human trauma treatment. For
instance, attitudes such as: “horses are called to heal trauma” or “my horse
loves doing trauma work” fail to take into consideration actual mental abilities of horses, such as the lack of reasoning and self-reflection (McGreevy,2012), and may cause the therapist to overlook signs of stress or discomfort
in the horse. The belief that “the horse can take care of themselves” andallowing for so-called natural consequences in the session if a client acts
inappropriately with the horse, also may cause stress due to inconsistenthandling and lack of predictability and controllability for the horse (Weiss,1971). Interactions between the client and the horse must be very closely
monitored so as to not elicit high levels of stress in the horse, and thetherapist should ensure that interactions do not run counter to a healthy
relationship between the client and the horse. Activities that might elicit
flight in the horse should be avoided altogether (McGreevy & McLean,
2010) as it does not make sense to work in a trauma treatment setting
without a trauma-informed relationship with the horse.
Inadequate, inappropriate, or nonexistent work role preparation accounts for confusion and unwanted behaviors in horses, together withinappropriate management practices such as confinement, restricted access to hay or grass, and lack of access to other horses (McGreevy, 2012).
Mental health practitioners who are not trained in equine behavior may
not be able to recognize subtle cues that horses communicate when distressed, or might not know how to create a therapeutic environment that
includes consideration for the horse. They might, in turn, not intervene
soon enough or in a therapeutic way when interactions with the client are
creating high levels of stress in the horse.
The effect on the horse from a human who exhibits symptoms of trauma
are thought to be stressful, but based on inconsistent results from studies
measuring the effects of a tense or anxious human on a horse, there is noclear evidence for this (Hama, Yogo, & Matsuyama, 1996; Keeling, Jonare,& Lanneborn, 2009; Merkies et al., 2014). For instance, Merkies and colleagues (2014) found that the horses in their study reacted more calmly toa human whose heart rate was elevated due to anxiety than to one whoseHorses in the Treatment of Trauma283

heart rate was elevated due to physical exercise. Hama and colleagues (1996)
found an elevation in equine heart rate initially when being stroked by study
participants who had negative attitudes toward companion animals, butthat heart rate then decreased. Keeling et al. (2009) found corresponding
elevations in equine heart rate during a leading and riding task as a resultof anticipatory stress in the human created for the purpose of the study. In
addition, Gehrke, Baldwin, and Schiltz (2011) found no difference in heart
rate variability (HRV) during a 24-hour period between horses engaging
in unspecified equine-assisted therapy and thoroughbreds used for racing.
A study by Yorke and colleagues (2013) hypothesized that cortisol
levels would correlate between children diagnosed with PTSD and theirassigned therapeutic riding horse during a 12-day program period. Results
were inconclusive and it is unclear whether the design of the study appropriately accounted for the variables involved. Only two studies to date havespecifically measured responses of horses to individuals diagnosed with
PTSD (Malinowski et al., 2018; Merkies, McKechnie, & Zakrajsek 2018).
Malinowski and colleagues (2018) found that stress levels, demonstrated
by equine plasma cortisol concentrations and heart rate variability in the
study, did not change in horses involved in sessions with veterans who had
been diagnosed with PTSD. The horses did not demonstrate increased levels of wellbeing after these interactions per analysis of plasma oxytocin via
oxytocin immunoassays, either. It may be of relevance that the horses in the
study were conditioned and experienced as adaptive riding horses, working
in 8–10 lessons per week in addition to being ridden by volunteers 2–4
times per week. Merkies and colleagues (2018) found that behavioral andphysiological responses of horses to humans, measured by equine heart rateand salivary cortisol, were more pronounced based on human experience
with horses than whether the human was diagnosed with PTSD. It is likelythat horses, similar to humans, have different thresholds of tolerance fortension and other states in others due to a variety of factors.
Recommendations

In the competencies for therapists using animal-assisted therapy in counseling, promoted by the American Counseling Association (Stewart, Chang,Parker, & Grubbs, 2016), the section on animal knowledge includes understanding species-specific behaviors and needs, animal training techniques,and paying attention to signals of stress. In addition, therapists working
with horses in trauma treatment should know:

284

TRANSFORMING TRAUMA• How to establish an equine work role and prepare a horse forwork in your therapy setting, using training based on learningtheory (Doner & Ekholm Fry, 2015).
• How to select horses for the specific therapy work you do (thatis, the work role you expect the horse to fill). This includes bothassessing overall temperament and understanding the learned
behaviors that help the horse avoid experiencing confusion orconstant conflict in the therapy setting.
• How to assess, or simply understand, how and what horses
communicate about their emotional and physical health (andcontinuously respond to this communication in a trauma-­
informed manner, as you would with humans).
• How to employ strategies that enhance welfare in horses andmaintain a realistic appreciation of their cognitive capacities toavoid misinterpretation of behavior.
• How to recognize signs of mental and behavioral wellness inhorses, not just welfare issues (see Waran & Randle, 2017, fora discussion).
• How to manage the horse’s living environment so that species-​
specific needs in feeding and housing arrangements are met.
• How to recognize signs of pain and discomfort (especially related to the horse’s limbs and back, and to the muscling needed
to carry humans) that might warrant discontinuation of work.
• How to train and handle horses using practices that are basedon learning theory, and which do not involve inescapable pressure, flight, or flooding. Therapists who include riding in theirtreatment should know how to develop and strengthen coremuscles in horses.
• How to employ post-session strategies based on cognitive, emotional, and physical needs of horses.
Simply loving or owning horses is not enough to competently include
them in therapy. Similarly, a focus on the term “relationship” does notprevent abusive training practices or misinformation about horses from occurring. The desire to maintain a relationship with the horse can, however,function as a motivator to take in information about handling, training,and management practices that will be in the best interest of the horse, but
might not immediately fit human convenience or thinking.

Horses in the Treatment of Trauma285

There is a need to move beyond basic frameworks such as the Five
Freedoms (Farm Animal Welfare Council, n.d.), developed for settings
where animals are farmed, and to rethink our relationships with animals. In
trauma treatment, it is important to be sensitive to features of equine interactions that perpetuate the power differences between humans and horses
in a way that might introduce a sense of exploitation into the therapeutic
environment. Just as therapists are aware of the power dynamic between
themselves and their clients, this awareness must also be extended to relationships with horses in the session and beyond. Is it acceptable to refer
to horses part of equine-assisted therapy as “partners,” but simultaneously
deny them basic needs in their living situation (for example, keeping horses
separate in small spaces, sometimes isolated from each other; denying themconstant access to fiber; and making them endure periods of fasting)? Is
it acceptable for well-intended trainers to subject horses to training andhandling that causes them pain and confusion, such as flooding, which
has been abandoned in human trauma and phobia treatment practice?
More discussion is needed around these issues; otherwise animal-assisted
interventions, and specifically horses as part of therapy, simply represent
additional avenues for humans to exploit animals.
GAPS AND NEXT STEPS
ResearchThrough examining results from a systematic literature review on
animal-assisted interventions for trauma (O’Haire, Guérin, & Kirkham,2015), and conducting extensive database searches, 25 journal articles
with a primary focus on trauma and equine-assisted therapy published in
English were identified. The articles varied greatly in content and methodological rigor; despite this, most of them are commonly cited. In addition,
six doctoral dissertations on equine-assisted therapy and trauma were identified (Abrams, 2013; Beck, 2014; Gomez, 2016; Held, 2006; Mattson,
2015; McCullough, 2011).
Of the 25 articles, some included qualitative studies (Meinersmann,
Bradberry, & Roberts, 2008; Schroeder, Stroud, Sherwood, & Udell,2017; Thelle, 2010; Yorke, Adams, & Coady, 2008), and some describedequine-assisted trauma-focused programs (Ferruolo, 2016; Froeschle, 2009;
Mykhaylov, Serdiuk, Vodka, Aliieva, & Vashkite, 2016; Newton-Cromwell,

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TRANSFORMING TRAUMA

McSpadden, & Johnson, 2015; Porter-Wenzlaff, 2007). One study, where
cortisol levels were measured, used the term equine-assisted therapy in its
title (Yorke et al., 2013), but it appears a therapist was not involved indelivering the intervention. Based on this, the program might be better
categorized as adaptive riding (therapeutic riding), see “Definitions,” instead of therapy. Results from this study were inconclusive.
Fifteen articles presented quantitative research. One study (Schultz,
Remick-Barlow, & Robbins, 2007), which has often been cited, consistedof a convenience sample of all children referred to a therapist over thecourse of 18 months, with diagnoses that included PTSD. Children’s
Global Assessment of Functioning (GAF) scores were assigned by thetreatment team pre- and posttreatment. Children who had a history ofphysical abuse and neglect had a statistically significant greater percentage
improvement in GAF scores after treatment than those who did not havea history of abuse and neglect. All children showed an improvement after
receiving equine-assisted treatment based on assigned GAF scores. The
remaining studies used evidence of trauma symptomology or identified
childhood sexual abuse (CSA) as inclusion criteria for participants.
Two studies (Johnson et al., 2018; Lanning, Wilson, Woelk, &Beaujean, 2018) specifically discussed the use of adaptive riding (therapeutic riding) to reduce PTSD symptoms. Both studies emphasized that thisnon-therapy riding approach should be seen as a complement to trauma
treatment.
Sample sizes ranged from 1 to 68, from a single case study (Nevins,
Finch, Hickling, & Barnett, 2013) and collection of cases (Naste et al.,2017), to couples (Romaniuk, Evans, & Kidd, 2018) and group treatment (Earles, Vernon, & Yetz, 2015; Johnson et al., 2018; Kemp, Signal,
Botros, Taylor, & Prentice, 2014; Lanning et al., 2018; McCullough, RisleyCurtiss, & Rorke, 2015; Mueller & McCullough, 2017; Shambo, Seely,& Vonderfecht, 2010; Signal, Taylor, Botros, Prentice, & Lazarus, 2013;
Whittlesey-Jermone, 2014). Four studies involved children and adolescents(Naste et al., 2017; Kemp et al., 2014; McCullough et al., 2015; Mueller& McCullough, 2017), the rest had adult participants (Burton, Qeadan,& Burge, 2019; Earles et al., 2015; Johnson et al., 2018; Lanning et al.,2018; Malinowski et al., 2018; Nevins et al., 2013; Romaniuk et al., 2018;
Shambo et al., 2010), and in one study the same program was delivered to
all three age groups (Signal et al., 2013). Four studies had a control group(Burton et al., 2019; Johnson et al., 2018; Lanning et al., 2018; Mueller

Horses in the Treatment of Trauma287& McCullough, 2017). In two of the studies with controls (Johnson et al.,2018; Lanning et al., 2018), clinically meaningful improvements in PTSD
symptoms were found using the same measure (PCL-Military) in both studies, but no significant effect for other measures in either study was found. In a
study by Burton and colleagues (2019), the PCL-Military was also used andgarnered statistically significant improvements in PTSD symptoms, but nostatistically significant difference was found when compared with the control
group (wherein participants received treatment-as-usual for PTSD). The
equine-assisted therapy provided in this study was not specifically designed
to enhance existing trauma treatment approaches. In the study by Mueller
and McCullough (2017), increased effectiveness of equine-assisted therapy
treatment over office-based therapy (used as a control) was not found.
A study without a control group found significant reduction in PTSD
symptoms (Malinowski et al., 2018). It is, however, unclear, how the intervention should be characterized, since it was described as a 5-day program
called “Equine-Assisted Activities and Therapies,” where incompatible
language and terms were used (an intervention cannot simultaneously beboth therapy and not).
Most studies had little to no description of session content or indication of a protocol, and in some cases only typical horsemanship activities
were mentioned. Studies by Kemp et al. (2014) and Signal et al. (2013) had
overlapping participants and design and appeared to use a set protocol for
all, which was described by Kemp and colleagues as based on experiential
learning with the help of horses and delivered by mental health professionals. Four articles included more detailed information on enhancing clinicaltheory through equine interactions to meet the needs of the population
studied (Naste et al., 2017; Schroeder & Stroud, 2015; Schroeder et al.,2017; Shambo et al., 2010). Naste and colleagues (2017) also emphasizedthat existing EAMH treatments for trauma are limited with respect to theirintegration of existing evidence-based frameworks (which I address in thischapter). The distinction between treatment models that directly address
traumatic memories and those focusing on supportive skills, as discussed
in the earlier section on the “Tri-Phasic Model as a Framework for Trauma
Recovery Tasks,” is also evident when reviewing the current equine-assisted
therapy studies. None of the approaches in these studies seem to engage
the traumatic memory directly.
Along with more typical issues in methodology, such as lack of randomization and control, small sample size and quasi-experimental design

288

TRANSFORMING TRAUMA(see O’Haire et al., 2015, for a discussion), additional challenges related
to investigating the effectiveness of trauma treatment that includes horses
are: 1) lack of replicable treatment protocols, 2) lack of integration withevidence-based treatment approaches, and 3) large differences in the background and training of therapists providing equine-assisted mental healthservices. It is likely that the latter significantly contributes to the lack ofcomparable research in this area.
As mentioned above, the American Counseling Association recently
published competencies for practitioners who include animal-assisted therapy in their counseling practice (Stewart et al., 2016). This document
constitutes an important step toward establishing a specific scope of practice for therapists providing animal-assisted interventions in the UnitedStates. The development of species-specific competencies seems a natural
next step, and each country must work to establish similar documents andexpectations for their practitioners through their own governing bodies.
Increasing competence among practitioners will certainly help inform research protocols.
An example of comprehensive, academic training in equine-assisted
therapy is the Equine-Assisted Mental Health Practitioner Certificate
program at the University of Denver’s Institute for Human-Animal
Connection, which the author coordinates. This is a professional programfor master’s- and doctoral-level therapists who want to include equineinteractions as a way to enhance treatment in their practice. The program
meets the American Counseling Association’s competency requirements foranimal-assisted therapy and can function as a model for other programs.
More agreement is needed, specifically in equine-assisted therapy, around
length of training and basic competencies to further both research andpractice. The equine-assisted EMDR approach EquiLateral, developed by
Sarah Jenkins in the United States, shows promise in terms of producing a
replicable protocol for examining the effects of horses in the treatment of
trauma, as it follows an existing evidence-based and manualized treatment.
Scientific investigation of whether there are specific parts of trauma
treatment that are, in fact, enhanced by equine-assisted therapy is necessary, since the inclusion of horses in therapy is more expensive thanservices taking place in a typical office. Services involving horses can also
be more difficult to access with regards to transportation, and they doinclude an element of inherent risk. Research findings can help guide thedevelopment of more training opportunities for therapists who want toHorses in the Treatment of Trauma289

include horses in trauma treatment, after meeting basic competencies foranimal-assisted therapy.
Practice

Therapists who include horses in their practice need education, training,and supervision in working with trauma before intentionally working withand addressing traumatic experiences in their clients. It is important tonote that the horse themself is not the provider of the treatment; rather,
it is the skill of the therapist that allows for the horse to be intentionally
included in order to assist the client in meeting their goals.
It is necessary to disclose whether the treatment provided is meant
to directly address the processing of the traumatic memory or strengthen
other supportive skills, or both, when describing equine-assisted mental health to clients and other practitioners. When clients want horseinteractions outside of formal treatment, adaptive riding (also known
as therapeutic riding), which in the United States is an activity focusedon riding and horsemanship skills taught by specifically trained riding
instructors, is an option. Some adaptive riding centers offer groups specifically for veterans, for instance. There are also other recreational activities,
such as trail riding and horse training clinics that therapists could recommend to their clients. However, quality does vary, especially in terms of
the welfare of the horses involved, which can lead to counterproductive
experiences.
Continued efforts to organize and professionalize related to practicewith horses in treatment, including promoting collaboration and agreement on competencies, will strengthen current use and understanding ofequine-assisted therapy and the inclusion of horses in the treatment of
trauma. Honest recognition of, and willingness to discuss, issues related
to the practice area, such as those detailed in the equine welfare section,is also necessary.
CONCLUSIONS
The inclusion of horses in the treatment of trauma as a way to enhancecurrent clinical approaches, discussed in this chapter, could motivate clients to seek treatment and remain in treatment, both of which are central
issues in trauma treatment overall (Najavits, 2015; Sayer et al., 2009).

290

TRANSFORMING TRAUMAThe experiential, somatic, and relational nature of equine-assisted
mental health meets the need for clients to have experiences in trauma
treatment that are not solely based on talking, but that experientially address the despair and psychophysical burden of living with trauma (van derKolk, 2004). Concerns among practitioners using PE and CPT regarding
dropout rates and client tolerance for treatment (Najavits, 2015) could be
mitigated by motivating and supportive aspects that equine interactions
and the equine environment bring to treatment.
Variation in therapist competencies, skill, and training in equine-assisted
mental health in general, and in trauma practice in particular, reflects a
non-unified area with disagreements regarding competency. This is one ofthe potential barriers to investigating treatment of trauma that includes
equine interactions, and likely accounts for gaps in the study of its effectiveness. Equally important to consider is the impact of the horse’s healthand needs on the therapeutic environment and on the quality of the therapy session. To gain more recognition for equine interactions as a way toenhance current treatment options for trauma, practitioners, organizations,and grant makers need to work together in establishing competencies,
practice guidelines, and opportunities for research.
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ABOUT THE AUTHOR
Nina Ekholm Fry, MSSc., CCTP, is the director of Equine Programs at Universityof Denver’s Institute for Human-Animal Connection, and adjunct professor
in the Graduate School of Professional Psychology and the Graduate School ofSocial Work. She has a background as a mental health practitioner providing
clinical services; as a competitive rider and equine behavior consultant; and as
an academic professional engaged in national and international organizations
for therapeutic equine interactions. She has a particular interest in ethics andsocial justice perspectives within the human-animal connection.

CHAPTER 9

Why the Dog?
Ann R. Howie, MSW; Aubrey H. Fine, EdD; and Lindsay A. Rojas, LSW, MSW, AASW

Companion and working canines have become integral to many people’s
21st-century lives. Arguably, the process of domestication has helped dogs
become wonderful companion, therapy, and service animals (Ensminger,2010). Dogs have been found to be a viable support for individuals sufferingfrom trauma by serving as a buffer from physical and emotional challenges,
and helping them indirectly manage stress (Carter & Porges, 2016). This
chapter intends to focus on the importance of our relationships with dogs
and to explain some of the benefits that dogs provide to people in general, as
well as to those who face trauma. Important canine welfare considerations
and strategies in animal-assisted intervention (AAI) are also discussed.
FIRST THINGS FIRST
It is important to first clarify terminology, as several terms related toworking dogs are currently used and easily confused by the public andprofessionals alike:
Service Animals: The Americans with Disabilities Act (ADA) (1990) defines
service animals as animals “individually trained to do work or performtasks for the benefit of a person with a disability” (para. 3). These disabilities may be physical or psychiatric (i.e., post-traumatic stress disorder or
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TRANSFORMING TRAUMAPTSD, anxiety, depression, and others). Through the ADA, service dogs arelegally entitled to be in public places with their partner (the person with adisability) as long as they are well-controlled (including housetrained) anddo not cause a fundamental alteration in the business. After an amendment
to the ADA effective in 2011, only dogs and miniature horses are now legally recognized as service animals. The ADA uses the term service animal,
rather than assistance animal, even though many organizations use thoseterms interchangeably. Some people incorrectly refer to police “K9s” (andother working dogs) as “service dogs.” While it is true that these working
dogs provide an important service, they are not considered service dogs
under the ADA.
Therapy Animals: The United States has no legal definition of a therapy animal. As a result, therapy animals (including dogs) are legally consideredpets. Therapy animals are generally domesticated species who have been
trained and screened for appropriateness to a) visit facilities with theirhandler to brighten people’s days, or b) work with therapists to help clients
meet specific therapy goals. Handlers must obtain permission to go into
public places with their therapy animals.
Emotional Support Animals: Emotional support animals (ESAs) provide comfort or emotional support to their person. The person is considered tohave a disability, but the animal is not held to ADA standards for service
animals. Rather, ESAs are considered pets or companions and are not covered by the ADA. Many people, including human health care professionals,
incorrectly call ESAs “therapy animals.”

Notably, ESAs may be recognized by landlords under the Fair Housing Act.
The U.S. Department of Housing and Urban Development (2013) considers ESAs to be “assistance animals,” which can cause confusion amongpeople who consider “service animal” and “assistance animal” to mean thesame thing. ESAs may be many species and do not require specific training
other than general good behavior and housetraining. ESAs are allowed in
housing where pets are not permitted unless the animal poses a threat tothe health or safety of others through its conduct. The landlord may require
documentation of need for the ESA.
ESAs of only domesticated species may be recognized by airlines under the Air Carrier Access Act. Airlines may require people who wish to
fly with an ESA to notify the airline in advance of the flight and provide

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documentation of their need for an ESA by a mental health professional.
The Air Carrier Access Act allows airlines to require highly specific documentation related to both the person and the animal.
This chapter specifically focuses on dogs working as therapy animals
as part of a client’s treatment plan, and also includes select references tocanine pet companions. Given the potential for confusion regarding terminology, the authors have made every effort to clarify the roles of dogs
discussed in this chapter.
A JOURNEY TOGETHERAs Anatole France noted, “Until one has loved an animal, a part of one’s
soul remains unawakened.” Human affinity for canine interaction has remained significant over time. Excavation of ancient burial grounds reveals
that dogs were sometimes buried next to people, occasionally with collars
or other mementos, indicating that those dogs were held in high esteem(Archaeology Magazine, 2016). Egyptian Pharaoh Ramses the Great built
a tomb for his dog, Pahates, with the inscription, “Bed Companion to the
Pharaoh.” Likewise, Queen Victoria of England died in bed next to Turi,
her Pomeranian (Coren, 2014). This inclination for humans to share theirbeds or private spaces with dogs still holds true today. In fact, a 2015 HarrisInteractive Poll reported that 71% of dog owners allow their dogs to sleepon their beds, suggesting a high degree of affection and regard between
people and their pet dogs.
This same Harris Interactive Poll also reported that 95% of pet owners
consider their companion animals to be members of their family, with 96%
of dog owners identifying their dogs as family members (Harris Interactive
Poll, 2015). The strength of these close kinships was brought to light in
2005, following Hurricane Katrina, when many faced with leaving theiranimals behind or staying in unsafe conditions chose to endanger themselves by remaining with their animal companions. Such accounts led to thepassage of the Pets Evacuation and Transportation Standards (PETS) Act in2006, which directed the Federal Emergency Management Administration(FEMA) to develop emergency preparedness plans that took into accountthe needs of people with pets and service animals (Hodges, 2011). Indeed,
positive differences in how people with animals were treated in shelters
were evident during the 2017 Hurricanes Harvey and Irma, as comparedto Katrina.

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Yet still there remains room for improvement. Arguably, recognizing
animals as members of the family (for instance) could be a promising stepfor employers to better support their workforce. People often need leavefrom work to care for a sick family member or bereavement leave after adeath in the family, yet few employers designate companion animals asfamily members. Consequently, when a dog is in need of medical care orpasses away, pet owners may not be allotted the time to address the concern or to grieve their loss in ways that correspond with the depth of thatconnection. This may be particularly pertinent for those who are socially
isolated and consider their relationship with their pet(s) as primary.
There currently is a plethora of research supporting the impact of interacting with canines on human-health-related variables, such as lowering
rates of cardiovascular disease (Levine et al., 2013) and cholesterol (Serpell,1991). These particular health outcomes may have much to do with increased activity through walking and play among people who live with dogs
(Cutt, Giles-Corti, Knuiman, & Burke, 2007). Indeed, many people — including this chapter’s authors — freely admit that they will get up whenfeeling ill to exercise their companion dogs when they would rather stay inbed. Select research has also demonstrated the positive well-being effects
of touching an animal (Olmert, 2013), as well as laughing and feeling joy
by way of their behavior and personality. Importantly, study findings continually acknowledge the impacts of laughter on people’s emotion-related
behavior, in that it both decreases stress and improves immune functioning(Bennett, Zeller, Rosenberg, & McCann, 2003).
As much as we like being around dogs, it is doubtful that our strong
relationships with them would persist if dogs did not respond positively
to our attention (Call, Bräuer, Kaminski, & Tomasello, 2003). Caninesobtain information, often accurately, from human facial cues and can use
audiological and visual information to identify emotions in both caninesand humans (Albuquerque et al., 2016). Furthermore, Nagasawa andcolleagues (2015) recently found that mutual gaze, a behavior most commonly signifying attachment between mother and child, is also observedin human-pet dog relationships.
Furthermore, research is now demonstrating more precisely that dogs
are capable of understanding human words. An imaging study demonstrated that dogs’ brains respond to actual words, not just the tone inwhich they are said or communicated (Andics et al., 2016). In this study,
brain scans on dogs utilizing functional magnetic resonance imaging(fMRI) found that dogs processed purposeful words (i.e., the phrase “wellWhy the Dog?303

done” in Hungarian) in the left hemisphere of the brain, similar to theway humans process language (Andics et al., 2016). Miklósi and Kubinyi(2016) recently reported that selective forces during domestication may
have supported the emergence of the canine brain structure underlying
this capability. Remarkably, it is now believed that some dogs are able torecognize more than 1,000 human words.
UMWELT
Von Uexkull (1934/1957) conceptualized the term umwelt as the “phenomenal world or the self-world of the animal” (p. 319). The ways in whichdogs perceive and relate to the world that surrounds them has been described as their umwelt (von Uexkull, 1934/1957). Humans who are awareof and respect a dog’s umwelt appreciate that he or she responds to, andlearns from, environmental elements that humans do not perceive as well,such as auditory and olfactory stimuli. Moreover, understanding how a dog
perceives the world, through considering his or her umwelt, is critical forhumans to strengthen their interactions and relationships with dogs. For
example, although canine vision is in lower resolution than human vision,
dogs’ abilities to smell and to hear are profoundly better than our own.
In regard to human-animal interaction (HAI) and AAI, canine umwelt
can be consulted to further substantiate empirical evidence in the field. For
example, from a research perspective, Horowitz and Hecht (2014) argue
that canine umwelt be considered in a study’s design and methodology.
Ways in which this may be realized are discussed later in this chapter.
THEORETICAL BACKGROUND AND POTENTIAL MECHANISMS
There are three primary, respected theories that help explain the strong
and transformative qualities of the human-canine bond: biophilia, social
support, and attachment. Here, we discuss them individually, first highlighting the theory of biophilia. Of note, the order in which these theories
are presented does not reflect our opinion of which theory more strongly
explains the bond, but rather that each of the orientations helps provide a
different way of viewing the relationship between humans and dogs. The
figure shown illustrates the relationship between these three theories as a
metaphoric three-legged stool.

304

TRANSFORMING TRAUMAThe analogy of the three-legged stool can be used to describe the relationship between the three human-animalbond theories and the Storge concept of familial love. (Fine & Mackintosh, 2016; reprinted with permission.)

Biophilia Hypothesis

The biophilia hypothesis argues that humans possess an inherent desire
to connect with nature and other life-forms (Kellert & Wilson, 1995).
Fine (2014) and Fine and Weaver (2018) suggest that biophilia connects
humans to the external world. Additionally, interacting with animals in thehome (or in a clinical setting) may replicate the feeling of being in nature,
which, in turn, enriches well-being (Fine, 2014).
Seemingly, humans will subconsciously feel safer and less threatenedin social settings when in the presence of a safe animal, supposedly becauseof that animal’s connection to nature. For those who have experienced
trauma, especially in the case of individuals with PTSD, social disengagement and avoidance of certain stimuli are common (Hopper, Frewen, Van
der Kolk, & Lanius, 2007; Williamson, Porges, Lamb, & Porges. 2014).
According to the biophilia effect, the physical presence or existence of aclose bond with a canine can provide a sense of safety that may allow these
individuals to engage in situations (social, outside of the home) that they
typically would avoid otherwise (Kellert & Wilson, 1995).
Attachment Theory

Attachment theory argues that humans are genetically predisposed to form
attachments with others, especially parent to child (Ainsworth & Bowlby,
1991; Goldberg, Grusec, & Jenkins, 1999). In the context of HAI, Payne,Why the Dog?305

Bennett and McGreevy (2015) argue that the human-canine relationshipis mutually beneficial, with humans providing access to basic needs (suchas food, water, and shelter) and both species providing a source of emotional fulfillment for each other. Payne and colleagues (2015) and Payne,
DeAraugo, Bennett, and McGreevy (2016) highlight that bonding behaviors, such as petting a dog, can enhance the attachment between the humanand his/her dog. Additionally, dogs often exhibit behaviors characteristicof attachment relationships, such as proximity seeking where a dog “seeksout” the attachment figure as a way to manage stress (Payne et al., 2015).
In regard to individuals experiencing trauma from failed attachments, dogs
can present a new or unique opportunity to form a successful and reliableattachment bond (Zilcha-Mano, Mikulincer, & Shaver, 2011).
As noted earlier, mutual gazing can often be found in relationships
between humans and their pet dogs. This “looking into one another’seyes” causes oxytocin release in both humans and canines (an “interspecies
oxytocin-mediated positive loop”), which produces social rewarding effects
and may be indicative of strong attachment with underlying coevolutionary components (Nagasawa et al., 2015, p. 333). Likewise, Fine (2014)
identifies research proposing that oxytocin released by mutual gaze may
also affect dopamine (a neurotransmitter with functions related to pleasure
and reward), which results in both the dog and the person wanting to bewith each other on a frequent and regular basis.
In their study of potential stress relief effects of connecting with dogs,
Miller and colleagues (2009) measured levels of serum oxytocin in men andwomen after interacting with pet dogs with whom they had reported emotional attachments, as well as after a period of reading nonfiction material
without the dog present. Data were collected after the participants returned
home from work in order to evaluate potential stress effects of both conditions. Findings showed that oxytocin levels increased significantly morewhen women interacted with their dog as compared to when they were in
the reading condition. Interestingly, these effects were not noted in maleparticipants. These findings suggest that the release of oxytocin during
human-canine interaction may decrease stress and anxiety, and that theseeffects could be dependent on human sex/gender. One may also infer fromthis study’s findings that individuals with close canine attachments may
experience greater physiological benefits and stress reduction than those
without canine attachments or where the connection with their dog is306

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not as deep. However, this presumption, as well as the role of gender inhuman-canine bonding and interactions, should be fully investigated andvalidated by future research.
Social Support Theory

In the context of the human-animal bond, this theory proposes that social
support can be found in interactions between humans and nonhumananimals. Social supports buffer against loneliness, anxiety, depression, andrelated illnesses (Ozbay et al., 2007). In humans, social support enriches
quality of life by improving physical and mental well-being (McNicholas& Collis, 2006). Some pet owners have reported believing that their companion animals offer social support that is greater than, or equal to, thatfound in human-to-human relationships (Beck & Madresh, 2008).
Animals who provide social support can help people manage stressand handle difficult life transitions that accompany traumatic experiences(Maharaj, Kazanjian, & Haney, 2016). In regard to PTSD, several studies
have found that symptoms such as anger and social withdrawal may resultin the erosion of social support from people (Clapp & Beck, 2009). Whenconsidering these effects, it is important not to underestimate or trivialize
research indicating the role of canines as reliably nonjudgmental, comforting, or affectionate; one could argue that the social support provided
by pet dogs is indispensable to people who may be isolating themselvesfrom others (Fine, 2015). Likewise, canine social support may be especiallyvaluable for people with PTSD, as their symptoms of anger, flashbacks, or
social withdrawal, for example, may alienate the humans who might havepreviously served as support networks.
A 2013 study conducted with veterans by Stern and colleagues reported that service and emotional support canines, referred to as canine
companions in this study, acted as supportive confidants for individuals
with PTSD, thus providing an opportunity to discuss difficult issues without fear of interruption, criticism, or judgment. Moreover, the veteransin this study reported that their dogs acted as social supports by reducing
their fear and improving their level of comfort in social situations (Sternet al., 2013).
In a related case example, Kyle, a man in his mid-twenties returningfrom serving a combat tour in Afghanistan, was discharged after a gunshot
wound with a Purple Heart military decoration. When he attempted toWhy the Dog?307

reenter nonmilitary life, he found it difficult to stay grounded and to reintegrate himself into his previous, preservice lifestyle. His friends did notknow how to help him. Often startled by loud noises and uncomfortable innovel situations, he would retreat emotionally and psychologically, finding
solace in his newly adopted mixed-breed Labrador, Scarlet. Kyle had heardof ESAs and had dogs and pets throughout his life. Consequently, he feltthat having an ESA dog as part of his new life as a veteran would not only
provide needed companionship, but could also be beneficial in terms ofhis health and well-being.
Kyle’s initial beliefs about the value of getting a dog came to fruition,
both anecdotally and practically. As examples, he definitely viewed Scarlet
as an important and positive dimension in his life, and was able to recognize how she supported him. The two became inseparable; whereverKyle went, Scarlet would be right next to him. Kyle relished having her
company, and it was apparent that he was more at ease when Scarlet wasnear. When he slept, Scarlet rested next to him. When he became restless
and anxious, Scarlet immediately came closer to him, often by lying on
his legs and applying necessary pressure with her weight. With the supportof Scarlet by his side, Kyle felt calmer and better able to cope throughrelaxation and reassurance.
Similarly, children living in abusive or neglectful households may alsofind the presence of a pet animal to be socially supportive. According
to McDonald and colleagues (2015), children experience close bonds
with companion animals and rely on pets as a way of managing stress.
McDonald et al. (2015) note that pets may serve as security — providing
attachment figures, offering comfort, consistency, and support to children
who are coping with adverse environments. Furthermore, the animal’spresence in such situations could also act as a buffer against the negative
impacts that domestic and intimate-partner violence have on the child.
Given this supportive relationship, it is particularly traumatic for suchchildren to observe incidences of their pet being abused or mistreated(McDonald et al., 2015).
In addition, therapy dogs serve not only as a source of social support for children with trauma histories, but also as a motivator to share
their experiences. According to the American Society for the Preventionof Cruelty to Animals (ASPCA), simply the nearby presence of a therapy
animal seems to provide comfort and enhances healing and recovery for308

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children who have experienced maltreatment (Phillips, 2014). In manystates, the legal system has taken note of the social support a dog provides
by allowing children to testify while accompanied by a court facility dog(Holder, 2013). These dogs commonly provide a calming presence during
this painful and distressing experience (Dellinger, 2008).
As the following case account exemplifies, the supportive roles of dogs
in the lives and treatment of children who have experienced maltreatment
are both ample and multifaceted. Susan had visited many therapists over
the years, but seemed resistant to accept support. She had built up numerous defense mechanisms, such as avoidance, repression, and anger. Susan’sfather had sexually assaulted her when she was quite young, and he had
minimal contact with her following his release from prison.
Over time, Susan’s relationship with her mother worsened; she felt
betrayed by her mother for not protecting her and resented her greatly.
Home life was dysfunctional, and Susan had a hard time getting along withher younger siblings. At home, her main source of comfort was her young
pet dog, with whom she spent time walking and playing. Although she hadseen several therapists, Susan did not open up to them. However, whenintroduced to AAI, the therapy dog’s presence in her sessions provided
Susan with social support that helped ease her tension. Both immediately
and over time, Susan’s facial expressions reflected her comfort with being
supported by the therapy dog. The dog seemed to ameliorate her anxiety,promoted safety and security, and boosted her confidence to open up
emotionally.
It is worth noting here that clinicians must be mindful of not only
how a therapy dog is incorporated into a treatment plan, but also of theclient’s response to the animal. Clinicians can structure interventions thatprovide an opportunity for the client to respond to the therapy dog inways that reflect how the client responds to the world in general. Suchinteractions then become grist for the therapeutic process. The clinician
must also ensure that the client does not “hide” behind the animal to avoid
focusing on difficult subject areas that need attention. When integrated
effectively in therapy sessions, a therapy dog can be supportive, which may
promote engagement and rapport. For example, Susan was able to open up
and reveal some of her significant emotional conflicts and traumas whenin the presence of the therapy dog. In particular, the dog helped her feel
more comfortable, and made coming to therapy more appealing for her.

Why the Dog?309

This simple snapshot of Susan is highly reflective of children who
have been abused. Therapy dogs change the therapeutic milieu, enhance
rapport between therapists and clients, and provide support when needed.
Additionally, they may act not only as emotional confidants, but also as
friends and playmates. Over the past 20 years, an increasing number ofmental health clinicians have incorporated therapy dogs in individual andgroup therapy. For example, there are numerous programs throughout thecountry that use AAI (including dog-training programs) to treat youth withtroubled pasts, including maltreatment or involvement in the juvenile justice system (e.g., the Pairing Achievement With Service [PAWS] Programin Brownwood, Texas [Ward, 2013]). In some cases, youth are asked tohelp train shelter dogs to improve the dogs’ adoptability. Clinicians who
have used this approach now realize that, although children believe the primary purpose of the intervention is teaching the dogs, they ultimately learn
more about themselves and how they can become loving and responsible
caregivers through these mutually beneficial and supportive relationships(Ward, 2013).
EVIDENCE-BASED RESEARCH ON HUMAN-CANINEINTERACTIONS AND TRAUMA
Research on HAI with dogs in the context of trauma is emerging. Owen,
Finton, Gibbons, and DeLeon (2016) conducted interviews with veteranswith PTSD who had participated in therapeutic treatment plans involving
canines, and found the veterans experienced greater reductions in psychological distress and improved overall functioning as compared to those who
did not receive AAI. Likewise, Hamama and colleagues (2011) assessed
the impact of a canine-assisted intervention with adolescent girls witha history of abuse. The AAI group demonstrated a reduction in several
PTSD symptoms in comparison to the non-AAI group. Dietz, Davis, andPennings (2012) also found that children with a history of sexual abuse
who interacted with therapy dogs in group therapy had greater decreases intrauma symptoms (i.e., anger, anxiety, and depression) than did similarly
situated children who did not interact with dogs during therapy.
In animal-assisted prolonged exposure (Lefkowitz, Prout, Bleiberg,
Pahiria, & Debiak, 2005), AAI is paired with prolonged exposure (PE)310

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treatment, which involves a client reliving or revisiting his or her individual
trauma incident(s). By including therapy dogs in the client’s exposure to
his or her trauma-related stimuli, clinicians seek to “reduce [the client’s]
anxiety, lower physiological arousal, enhance the therapeutic alliance, andpromote social lubrication” (Lefkowitz et al., 2005, p. 275). Further, in
their study with sexual assault survivors, Lefkowitz and colleagues (2005)
sought to reduce attrition from traditional PE treatment by incorporating
therapy dogs into sessions. Therapy dog involvement in treatment appeared
to reduce trauma symptoms, making sessions more tolerable.
An additional noteworthy application of canines in trauma recovery is
the field of animal-assisted crisis response (AACR). Following emergencies
such as natural and community disasters (i.e., fires, floods, hurricanes,
shootings, and accidents), therapy dogs are deployed with their handlers
as a team to provide comfort for individuals and communities (Hall etal., 2004). These AAI approaches, which are still in their infancy and, todate, lack a substantial evidence base, are discussed in greater depth laterin this book.
The health benefits that humans receive from our relationships withdogs are now more scientifically accepted than ever before. However,whether or not dogs likewise benefit from these interactions remains, atthis stage, relatively uncertain. Not surprisingly, current research comes
predominantly from a human-centered (anthropocentric) perspective
rather than a canine-centered one. For example, whereas anthropocentric research focuses on (human-preferred) vision or verbal language,
canine-centered research might measure a dog’s use of scent or behavior(Horowitz & Hecht, 2014).
Allowing for dogs’ umwelt in AAI is an area of focus for future investigation. However, research that examines canine umwelt can be challenging
due to the individual nature of each dog and his or her behaviors andsubjective perceptions. As such, it is essential for both clinicians and handlers to not only know general canine displacement behaviors (i.e., thosein response to a stressor), but also to be familiar with how their individual
dog typically expresses himself or herself. Counting displacement behaviors in a research study is invaluable, yet if a particular canine expresses
himself in a way that is not included on a predetermined checklist, thenthe results may be skewed away from umwelt. This example demonstrates
how critically important it is to consider each therapy dog as an individualWhy the Dog?311

rather than as a member of any category (like “therapy dog”), just as we
do for our human clients.
NEUROBIOLOGICAL MECHANISMS ATTRIBUTEDTO HUMAN-ANIMAL INTERACTION
The exact mechanisms underlying HAI are only beginning to be the focus
of serious study. Notably, one mechanism of increasing interest is that ofsocial neuroscience, with several human brain structures being implicated.
Mormann and colleagues (2011) found that, in humans, the right sideof the amygdala (involved in emotions and memory) reacted differently
to pictures of animals than it did to pictures of people, suggesting that
this specific side of this brain region evolved to allow humans to process
information relating exclusively to animals. Furthermore, Sugawara andcolleagues (2012) reported decreased activity in the putamen, thalamus,
the fusiform gyrus, and the left middle frontal gyrus, regions of the brain
typically associated with stress, when people interacted with their pet dogs.
Beetz and Bales (2016) suggest that similar neurobiological mechanisms that drive interactions between humans are implicated in interactions
between pet dogs and owners. Key players in the biological functions ofinteractions between humans and canines are the hormones oxytocin andvasopressin; the steroid hormone cortisol, which serves as a biomarker for
stress in most mammals; and the neurotransmitter dopamine (Odendaal& Meintjes, 2003; Olmert, 2013).
Odendaal and Meintjes (2003) were among the first to recognize theinfluence of the human-animal bond on physiological stress. Following
positive interactions between humans and canines, oxytocin nearly doubled in both species and cortisol concentrations decreased significantly inhumans (Odendaal & Meintjes, 2003). As discussed previously, oxytocin
is involved with positive social and nurturing behaviors and produces a
calming effect (Beetz & Bales, 2016). Specifically, the nerves in the hypothalamus that generate oxytocin join with the vagal nerve. Activation of theparasympathetic nervous system is what ultimately stops the productionof stress hormones, such as cortisol, and lowers both blood pressure andheart rate (Beetz & Bales, 2016). Furthermore, oxytocin may increase anindividual’s tolerance for pain and help wounds heal more quickly (Fine,

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2014; Olmert, 2013). Given that the majority of research in this area has
focused on oxytocin effects of human-pet dog relationships (Handlin etal., 2011; Nagasawa et al., 2015; Odendaal & Meintjes, 2003), further
exploration into how oxytocin is released in the context of AAI with lessfamiliar dogs would be useful. For example, such studies may provide potential explanation for why our connections with canines often serve as aresource for helping individuals tolerate emotional and physical pain, andheal faster than they would on their own.
SUGGESTED BEST PRACTICES
Suggested best practices in the field of AAI include therapist and volunteer
handler training, as well as experience with the client population (i.e.,diagnosis and treatment) and the specific animal species with whom they
are partnering. In order to practice ethically with a therapy animal, thetherapist and handler require additional education and supervision specificto working with animals. Necessary training includes observation and interpretation of animal behavior, humane training methods and husbandry,
respectful relationship building, animal selection, and animal health considerations (Delta Society, 1999; Fine, 2015; Howie, 2015).
Thoughtful therapists’ and handlers’ experiences show that therapy
dogs can absorb client projections and imbalances. Recent research supports these observations, calling them emotional contagion (Huber, Barber,
Faragó, Muller, & Huber, 2017). One of the benefits of working with atherapy animal is to help clients, including those struggling with trauma,learn how to regulate their emotions and act toward a therapy animal andtoward people responsibly and respectfully when emotional. It is crucial
that therapists and handlers remember that the therapeutic environment
exposes therapy dogs to clients’ emotions, which may be unpredictable.
Moreover, unlike humans, therapy dogs often do not have the ability toleave the interaction at will when feeling overwhelmed or uncomfortable.
Accordingly, ethical practitioners must ensure that therapy animals
are not used as shock absorbers for clients’ emotions. It is unfortunately
easy for a well-meaning therapist or handler to expose a therapy dog toexcessive emotion simply by seeing client after client day after day. Thisrisk is exacerbated by the benevolent desire to help people, which can leadto prioritizing the client’s needs over the animal’s, even unintentionally.

Why the Dog?313

Clients experiencing trauma require a safe place to discharge emotion, andthe therapist’s office is one of those safe places. Importantly, the therapeutic
setting also needs to be safe for the therapy dog. Making the office a safe
place begins by considering the individual dog’s umwelt. Such strategies
may include choosing which client(s) the dog will work with, designinginterventions to accommodate the dog’s strengths, having a client-free zone
to which the dog can freely retreat, having a less-than-daily work schedule,
and working shifts of limited length so as not to fatigue or overwork thedog (King, Watters, & Mungre, 2011).
The therapist is also responsible for helping the therapy dog discharge the emotional energy that accumulates during therapy sessions.
This discharge must be done in a way that the dog as an individual finds
useful (again, respecting his/her umwelt), and not solely according to thetherapist or handler. The dog will have an important opinion on how
to effectively help with this release. Therapists and handlers who havedeveloped a relationship of emotional intimacy with their dog know how
to read their canine partner’s subtle behavioral communications much
like they do with a human friend or partner. For example, depending oncontext, a slight head turn, a quick lick of the lips, a delicate ear flick, aseemingly happy grin, a lowered tail or head, relaxed eyes, forward ears,
and particular foot positions all can indicate how the dog may be feelingat that very moment. Just as every human may not enjoy a five-mile run
after his or her workday, neither does every dog after AAI. Rather, s/he
may prefer quiet rest, aerobic or intellectual exercise, play, eating a favorite
food, or any number of activities specific to that particular dog. Using a
medical metaphor, AAI practitioners in Japan refer to this process as “recovery” (Yamazaki, personal communication, April 10, 2016); similar to
the importance of recovery after a medical procedure, recovery after AAI is
indispensable for the therapy dog (and for any working dog after a periodof service or exertion).
Obtaining a therapy dog’s consent to participate in AAI is also essential, and must be considered a continual and ongoing process, notsomething that merely happens with a formal evaluation every two years.
Clothier (2014) teaches that there are six Elemental Questions when asking
for a therapy dog’s consent before and during each AAI session. To ask thesequestions, the therapist or handler must become centered and prepared tolisten by watching. To understand the dog’s answers, the practitioner must
be fluent in general canine behavior, as well as the particular behaviors of314

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his or her therapy dog. Those who do not know how to ask these questions
or how to interpret a dog’s answers to them lack crucial training and/or
experience.
• Hello? When asked as a question, this means “Do you want tointeract with me?” “Do you want to interact with other people
today?” A dog who turns his head away (or acts in any way thatcreates distance) is answering, “No.”• Who are you? When we start a conversation with people, we
often first ask who they are. We need to know who our therapy
dogs are, too — not just when we first meet, but throughout our
relationship with them. When we have an emotionally intimate
relationship with our dogs, we know from their behavior what
they like, dislike, and/or merely tolerate. In other words, weknow who they are. This knowledge affects what we ask themto do. People who have a respectful relationship with theirdogs ask them to do only work that is congruent with theiressential nature.
• How is this for you? This question is completely about the therapy dog (not about the handler or the client). It is a question
to be asked continuously throughout the session. Once again,
a happy or contented dog expresses his emotional state throughbehavior. The therapist or handler must observe the dog’s behavior and adjust his or her therapeutic technique according
to the dog’s comfort with the interaction.
• May I? Here the therapist or handler is asking permission to
do things with the therapy dog, such as pet him, be near him,
and/or put equipment on him. A dog who creates distance
between himself and the therapist, handler, or client is doing
so to communicate his preference to be away from, rather thanimmersed in, an interaction.
• Can you? This question is about the dog’s ability: physical, intellectual, and emotional. Fido may be physically able to movenearer to a client, and he may be willing, but he may not understand the handler’s cue. Or perhaps he understands the cue,but emotionally he does not want to get close to that particular person. It is incumbent upon therapists and handlers to
respect all aspects of a dog’s ability. Respecting a dog’s ability

Why the Dog?315(and opinion) is the opposite of pushing a dog into a desired
position next to a client, even with gentle effort.
• Can we? This question invites a mutual decision about what
to do rather than the therapist or handler making a unilateraldecision. Just like the “how is this for you?” question, it isessential to continuously ask this throughout the interaction.
A dog who was enthusiastic at the beginning of a session may
not remain so through the end. Again, ethical practitioners
demonstrate their respect for the dog’s opinion by changing
therapeutic technique, or making arrangements for the dog to
go to a client-free zone, or both.
CANINE WELFARE
In addition to the practices and competencies discussed in the previous
section, therapists and handlers must advocate for and protect their therapy
dogs by helping to manage the client’s expectations of and interactions
with them. Again, individuals struggling with PTSD may have difficulties
sustaining close relationships with humans and nonhumans, and may exhibit erratic or highly emotional behaviors that impact their sense of trustand social problem solving. It is easy to see how these behaviors may be asource of stress for therapy dogs, ESAs, and service dogs who work or areotherwise connected with people who have experienced trauma. As such,it is incumbent upon the therapist and handler to foster an environmentof mutual respect for the needs of both parties. Just as the client is allowed
to express his or her personality and behaviors in individual ways, thetherapy dog must be given ample opportunities to communicate his or
her needs, and to have those needs respected during therapy sessions. Fine,
Albright, Nu, and Peralta (2013), as well as Serpell, McCune, Gee, andGriffin (2017), report that as the field of AAI becomes more establishedand accepted, attention must be given to safeguard not only the well-beingof the humans who are being served, but also the therapy animals involved.
Fine and Mackintosh (2016) argue that those involved with AAI must takea moral and ethical stand to deliver a treatment that ensures the welfare
of all parties involved.
Notably, Haubenhofer and Kirchengast (2006, 2007) have reported
that more than 50% of handlers volunteering with their therapy dog

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thought that AAI sessions were possibly or could be stressing or straining
for their dog. Furthermore, their research revealed that those therapy dogs
had increased levels of salivary cortisol concentrations on working days ascompared to nonworking days, and that the level of cortisol increased withmore sessions per week without respite and relaxation. Further, Glenk andcolleagues (2013) indicate that a potential way to decrease therapy dog
stress (i.e., cortisol) is to give the dog more choice about approach andavoidance movements during sessions (which coincides with Clothier’s
Elemental Questions [2014], as described above). These are essential factors to take into account when working with therapy dogs. Cliniciansmust be considerate of a dog’s work schedule, as well as experience during
sessions, so that he or she will not be placed into unduly stressful situations.
Overall, therapists and handlers must act as their animals’ advocate, as
highlighted in the Pet Partners acronym YAYABA: You Are Your Animal’s
Best Advocate (Pet Partners, 2017).
Fine and colleagues (2013) point out that, even though selected fortheir behavioral traits and consistency, therapy dogs will likely show someof the following behaviors recognized by canine behavior experts as signsof stress: panting, pacing, startle responses, pupillary dilation, trembling,whining, excessive licking, yawning, and/or hiding. If these or other behaviors are noted, practitioners must ask themselves what factors may becontributing to the dog’s stress, including client behavior, environmental
stimuli, therapist/handler behavior (including unrealistic expectations orinattention to canine needs), insufficient training for the dog, or possibly
a dog who is unsuited for the work. No matter how earnest or well-­intentioned, a poor fit between job and dog, whether from the structureof the job or the temperament of the dog, is nonetheless stressful and may
even go so far as to create illness (Heimlich, 2001).
King and colleagues (2011) found that therapy dogs under two yearsof age showed more behavioral signs of stress than therapy dogs who wereolder and had more experience. Their research also reported significant
elevations in canine salivary cortisol levels in 21 dogs from baseline toafter one hour of AAI in a hospital environment (King et al., 2011). Thesefindings suggest that dogs in working roles need outlets for good behavioral health, and that canine age or AAI experience may play a large rolein their levels of stress. In essence, handlers must regularly consider their
particular dog’s sensitivity and responses to environmental stimuli (i.e.,their umwelt), as well as their needs, and provide longer quiet time-out
periods for calm and respite.

Why the Dog?317

Peralta, Fine, Goldman, and Melco (2017) recently initiated a study
evaluating the impact on therapy dogs participating in a program withchildren with attention deficit hyperactivity disorder (ADHD). The dogs
involved in the study demonstrated only a mild behavioral response and no
significant findings in cortisol or heart rate changes while in the program.
Likewise, findings from a recent study by McCullough et al. (2018) indicated no significant differences in salivary cortisol levels between baseline
and AAI sessions among 26 therapy dogs visiting pediatric oncology patients and their families. These results seem to indicate that, with proper
supervision and well-trained therapy staff and handlers, canine stress canbe minimal and/or reduced in a therapy setting.
It should be noted that the settings for therapy dog work vary widely.
A private office is quite different from a busy hospital, with a spectrum of
options in between. As has been described in this chapter, many factors
are involved when considering the stress placed on the therapy dog, andsetting, supervision, and training are just three of them.
The authors believe that it is impossible to completely avoid stressfor a therapy dog, yet it is entirely possible to avoid therapy dog distress.
Avoiding distress requires that the therapist take several steps. “Therapist
Strategies for Canine Welfare” (below) is a summary of the steps presented in this section. Additionally, “The Therapy Animal’s Bill of Rights”(following) highlights important considerations and responsibilities for
AAI handlers.
THERAPIST STRATEGIES FOR CANINE WELFARE
1. Become educated about, and have experience observing andinterpreting, canine behavior.
2. Choose with intention which client(s) the therapy dog will workwith based on the dog’s strengths, abilities, and temperament.
3. Develop skill in dividing attention between the client and thetherapy dog during sessions.
4. Develop handling skills that support the individual dog rather
than increase stress.
5. Allow the dog to have client-free zones and as much freedomof movement as possible within the setting.
6. Formulate a plan to assure the therapy dog’s welfare within asession and after a session, including building recovery time
into the therapy dog’s schedule.

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7. Be willing to implement that plan should the dog’s welfare or
well-​being become threatened or compromised.
8. Ask the dog to work a less-than-daily work schedule, with
time-limited working shifts, and give the dog vacations fromwork.
THE THERAPY ANIMAL’S BILL OF RIGHTS
As a therapy animal, I have the right to a handler who:
• Obtains my consent to participate in the work
• Provides gentle training to help me understand what I’m supposed to do• Is considerate of my perception of the world• Helps me adapt to the work environment• Guides the client, staff, and visitors to interact with me
appropriately• Focuses on me as much as the client, staff, and visitors• Pays attention to my nonverbal cues
• Takes action to reduce my stress• Supports me during interactions with the client• Protects me from overwork• Gives me ways to relax after sessions• Provides a well-rounded life with nutritious food, physical andintellectual exercise, social time, and activities beyond work
• Respects my desire to retire from work when I think it is time
(Howie, 2015; reprinted with permission from Purdue University Press.)

CONCLUSION
Our understanding of the human-canine bond and how it relates to healing
following traumatic experiences continues to expand. Research demonstrates that people have strong and exceptional connections with dogs,
although the reasons why these relationships provide certain therapeuticadvantages are not altogether certain. In this chapter, we have discussed
how the socially supportive attachments we have long shared with dogs
are often beneficial for our emotional and physical health. Studies haveWhy the Dog?319

begun to demonstrate the various therapeutic effects of this bond in thecontext of trauma, such as in the case of individuals experiencing PTSD
and abuse (O’Haire, Guerin, & Kirkham, 2015). The exact psychologicaland neurological mechanisms responsible for these changes represent areas
for continued research attention. Equally important is further research
to identify the well-being effects of AAI work for therapy dogs. Goingforward, it may be of interest and benefit to specifically examine canine
personalities and temperaments, and how they may best fit with meetingthe needs of specific traumas through AAI.
Best practices emphasize the need for AAI practitioners to have a foundation of knowledge and continuing education about the species withwhom they work, and the populations they are serving. Several colleges anduniversities now offer single courses or certificate programs, which begin
to address this need, including the University of Denver’s Graduate Schoolof Social Work and the University of Tennessee at Knoxville’s Veterinary
Social Work program. Canine-specific education is also easily available
through webinars and seminars provided by canine professional organizations, such as Animal Behavior Associates, iSpeakDog, E-Training for
Dogs, Raising Canine, Pet Professional Guild, and more. Many of these
are available for the general public, as well as for canine professionals.
At the time of this writing, the American Psychological Association’s
Section on Human-Animal Interaction (Section 13 of Division 17) isdeveloping competencies for psychologists providing AAI. Likewise, theAmerican Counseling Association has accepted Stewart, Chang, Parker,
and Grubbs’ (2016) list of competencies for AAI practitioners providing mental health services. And, in 2014, the International Associationfor Human-Animal Interactions Organizations (IAHAIO) published awhite paper addressing definitions and procedures to assure animal welfare in AAI (individual countries have also published similar documents)(Jegatheesan et al., 2014). Such informational resources are currently available for public use.
AAI practitioners need to continue to seek increased awareness ofeffective, evidence-based applications for trauma recovery as they become
available and more established, as well as properly assure the well-beingof therapy dogs who take part in human mental health treatment. Suchknowledge is not only important ethically, but is key to ensuring that bothclient and therapy dog well-being are integral to AAI practice and researchwithout waver or hesitation.

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ABOUT THE AUTHORSAnn R. Howie, MSW, is an adjunct professor with the University of Denver
and is director of their Canine-Assisted Intervention Specialist Program.
She has worked professionally with both animals and humans since 1987,
and has pioneered competency-based team evaluations for AAI. Howie has

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providing physical fitness training for canines.
Aubrey H. Fine, EdD, is a professor of education at California State
Polytechnic University and a licensed psychologist. Fine is the author ofseveral books, including Our Faithful Companions, Give a Dog Your Heart,
The Handbook on Animal-Assisted Therapy, and Afternoons with Puppy.
His research pertains to the human-animal bond (HAB), animal-assisted
interventions (AAIs) and children, and social skills training with children
with ADHD.
Lindsay A. Rojas, LSW, MSW, AASW, is a licensed social worker in the stateof Colorado. She currently works in community mental health and private practice with her therapy dog, Dante, specializing in animal-assisted
therapy. She earned her undergraduate degree in psychology and Latino
studies from the University of Notre Dame in 2014. In 2017, she graduated with her master of social work degree and animal-assisted social work
certification from the University of Denver.

CHAPTER 10

Animals in Action: Therapeutic Rolesin Healing Military Trauma
Cheryl A. Krause-Parello, PhD, RN, FAAN; Allison E. Boyrer, MS, MA, BSN, RN;
and Eleni Padden, BA

Throughout history, dogs have consistently and fondly been regarded as“man’s best friend.” This relationship takes on an increasingly meaningfulrole in the context of wartime, when humans and dogs often depend upon
one another for survival. Vitally, bonding with dogs has been shown to beinvaluable to many military members and veterans as they work to copewith the trauma of combat and other hardships, both from anecdotal accounts and through recent scientific investigations evaluating the effectsof the human-animal interaction (HAI).
In exploring the myriad ways that animals, and specifically dogs, impact military and veteran health, we first provide an overview of the historyof military working dogs, thus establishing the reliable alliance that often
exists between these animals and active duty service members. The continuous loyalty and sense of safety that a military working dog provides
often resembles a service dog’s consistent, integrative support of veteranswith service-connected conditions as they return home and transition backto civilian life.
The reciprocal relationship of trust and mutual respect between dogs
and service members has been well established over decades of high-stakes
interaction in military settings and during wars and conflicts, which wewill consider in-depth in the following first sections. Concurrently, we lay
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the groundwork for further discussion later in this chapter regarding theutility and healing impact of dogs and other animals in ameliorating thephysical, physiological, and psychological symptoms of trauma within the
military and veteran population.
HISTORY OF MILITARY WORKING DOGS IN THE UNITED STATES
Military working dogs have saved countless lives in war and conflicts since
they first began serving with their military comrades (Mott, 2003). These
dogs not only serve side by side with their human military partner, butmany also provide a sense of comfort and safety on the battlefield’s frontlines (Reporter’s Notebook & Russo, 2011). Military working dogs haveheld and continue to play both official (e.g., alerting) and unofficial (e.g.,
providing solace) roles in the military, and have been used by the UnitedStates military since World War I. Along with their volunteer handlers,
these dogs are trained in teams as scouts, trackers, sentry dogs, mine/booby-​trap/tunnel dogs, and in the water for the detection of hostile forces(US War Dogs, n.d.).
Scouts serve as the “eyes and ears” for the military unit. Scouts typicallymonitor environments for threats, such as booby trap trip wires, ambushes,
hidden stashes of weapons or food, and enemy snipers. Trackers are used
when military units want to reestablish contact visually or olfactorily in order to locate missing personnel who may be wounded or dead, or to locate
the enemy. Sentry dogs are trained to walk the perimeter of base camps
for enemy combatants, predominantly during nighttime hours. The sentry
dog’s mission is to detect, detain, and destroy. The mine/booby-trap/tunnel
dog’s role is to detect land mines, booby-traps, trip wires, and undergroundhideaways and tunnels. These dogs also search villages for enemy supplies,
such as weapons and ammunition. Over several decades, military working
dogs have gained notoriety for their service in World War I, World War II,
Korea, Vietnam, the Persian Gulf, Bosnia, Kosovo, and Afghanistan and
Iraq. The history and achievements of several of these honorable dogs arehighlighted in the sections that follow.
World War I and Stubby

The most decorated military working dog who served in WWI was named
Stubby. In 1917, while training for combat at Yale University, Private
Robert Conroy came across a wandering Boston bull terrier puppy with

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a brindle coat (Bausum, 2014). Due to the dog’s short tail, he dubbed
him Stubby. Stubby became the official mascot of the 102nd Infantry
Regiment, assigned to the 26th Yankee Division. Stubby learned how tosalute, and, importantly, it was noted by many that he boosted the troop’s
morale (Russell, 2017). When the infantry received orders to set sail forFrance, Private Conroy snuck Stubby on the ship (since dogs were forbidden on base camp and missions),
and brought him up onto thedeck once they were far off landso that Stubby would not have todisembark.
Due to his acute sense of
smell — a dog’s sense of smell
is roughly 40 times greaterthan that of a human (Tyson,2012) — Stubby would promptly
alert the troops when gas waslaunched in the trenches.
Additionally, his precision hearing
allowed him to notify the troopsof danger and impending raids
by barking and running aroundthe base camp to signal his fellow
The American army dog Sergeant Stubby (ca. 1916–
brothers in arms. Stubby was the1926). (Photo from the U.S. National Archives.)
first military dog to ever be given
rank, and then promoted to sergeant, in the US Army based on his contributions to an operation that successfully captured an enemy spy. Stubby
served for 18 months overall. By the end of the war, he had served in 17
battles on the Western Front, receiving many metals of heroism and bravery throughout his service.
World War II and Chips

The most decorated (unofficially) military working dog who served in
WWII was named Chips. During WWII, there was a call for private citizens to donate their family dogs for military duty (Zimmerman, 2014).
Chips’ family answered the call and donated him for military service. In
1942, Chips, a German shepherd-collie-Siberian husky mix, was shippedout to the War Dog Training Center in Front Royal, Virginia, for training
as a sentry dog. Chips served with the 3rd Infantry Division overseas in

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Chips, the most decorated dog of World War II, November 19, 1943. (Photo from the U.S.
National Archives.)

Europe. During his time in the military, he specifically served as a tankguard dog. Chips would alert his military counterparts of impending ambushes. Based on Chips’ valor, he received many distinguished militaryawards and honors including the Silver Star for valor and a Purple Heart(Estrada, n.d.). However, these awards were ultimately taken away basedon the perception that a dog receiving military awards and honors wasdemeaning to the soldiers who received the same recognitions. In 1945,
Chips was discharged from the military and sent home to his family, wholater gave the dog to his military handler upon discharge. Subsequently,
in 1980, Disney made a movie entitled Chips, the War Dog based on his
colorful life.
Operation Neptune Spear and Cairo

In 2011, Cairo, a Belgian Malinois, became instrumental in Operation
Neptune Spear, which was responsible for the raid on Osama bin Laden’s
compound in Abbottabad, Pakistan (Schmidle, 2011). Cairo was trained
to sniff out bombs, attack enemy combatants, slide down ropes, and repel
and jump from 5,000 feet, amongst other tasks. Cairo was consistently
equipped with a Kevlar vest, a harness for repelling, a drainage system forwaterborne assaults, and a night vision camera. During this mission, Cairo

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assisted the US Navy Seals by scaling the compound and looking for hidden rooms and doors. He also alerted the Seals if anyone tried to escape,and warned them of approaching Pakistani security forces (Dozier, 2011).
There are many more military working dogs who have served and currently serve our country with great pride and loyalty who, out of necessity,
are not highlighted here. Moreover, dogs have also played a significant rolein the military not only in their combat roles, but also in their ability to
improve troop morale during times of uncertainty (Foliente, 2009). In
fact, military working dogs and other classifications of dogs often continue to serve our military even after they are discharged, including via
work as service dogs, emotional support dogs, and companion animals.
Considered cumulatively, the noble history of military working dogs, theirintegral place in military culture, and their critical importance to the very
livelihood of so many members of our nation’s armed forces underscore thefundamental capacity of dogs to aid in the healing of trauma for military
service members and veterans.
Dogs, War, and Wellness

During WWI, foreign Red Cross societies employed dogs who greatly
aided the Allied Forces (Browe, 2014). Dogs were present to help findwounded soldiers and bring them first aid supplies within their saddle
bags. This was important in that the dogs could reach soldiers, while navigating through dangerous territory, without alerting the enemy. The dogs
were trained to bring something back of the injured soldier to alert the
Red Cross staff of a soldier down, and to provide messenger and delivery
services, carry ammunition, and scout out weapon factories.
Following WWII, the American Red Cross began the use of therapy
dogs in the Army Air Forces Convalescent Center in Pawling, New York.
Seven hundred acres of farmland were acquired by the US government
in the 1940s, and were turned into a working farm (including dairy operations) with many farm animals. This marked one of the first times
animal-assisted therapies were employed to assist returning soldiers in theirrecovery from the visible and invisible wounds of war.
Military Wounds of War

Mental health disorders are the leading cause of disability in the UnitedStates and Canada, accounting for 25% of all years of life lost to disability
and premature mortality (World Health Organization, 2004). Harrowingly,

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suicide is a leading cause of death in the United States. A recent 2018
Centers for Disease Control (CDC) report posited that suicide is responsible for the deaths of a staggering 45,000 Americans each year (Stone etal., 2018). In many states, these data represent an average 30% increase insuicide rates over the past two decades, with the rates among veterans being
some of the highest in a subpopulation (Department of Veterans Affairs,
2016b). Military members have significant reintegration needs, including
physical, physiological, and psychological. Musculoskeletal injuries andpain, infectious diseases, noise and vibration exposure, and mental healthissues are just some of the ailments our veterans must cope with whenreturning from service.
Injuries from recent operations, such as Operation Enduring Freedomin Afghanistan and Operation Iraqi Freedom in Iraq, are profound, with anestimated 19% to 42% of veterans being diagnosed with a mental healthcondition (Hoge, Auchterlonie, Milliken, 2006). The long conflicts, whichhave required many troops to deploy multiple times and operate underan almost constant threat of attack, have exacted a far more widespread
emotional toll than previously recognized by most government studies
and independent assessments (Chandrasekaren, 2014). As such, it is ofsignificant importance to research a range of viable non-pharmacologicalmental health interventions, such as animal-assisted interventions (AAI)
and animal-assisted therapy (AAT). Specifically, it is critical that the scientific community work toward establishing evidence-based treatment
mechanisms with the potential to be implemented in a highly personalizedmanner to our nation’s veterans.
Invisible Wounds of War: Post-Traumatic Stress
Disorder and Traumatic Brain Injury

Veterans have often experienced inhumane events that one would not necessarily see in the everyday world. Post-traumatic stress disorder (PTSD) isa trauma and stress-related condition that can occur after a traumatic event
such as war, assault, or disaster (American Psychiatric Association, 2013).
Events such as mass suicides, mortar attacks, combat exposure, physicalabuse, terrorist attacks, sexual or physical assault, and other heinous acts
against humanity are just a handful of the atrocities that may be witnessedor experienced by military members at war. Notably, many noncombat
veterans may similarly experience extreme and traumatizing events, sexualor physical trauma, and moral injury. Whether the injury sustained is from

Animals in Action333

shrapnel, a roadside bomb or witnessing carnage, the pain and suffering ofservicewomen and men is real and, for many, chronic (Weinmeyer, 2015).
Such actions seen in combat are difficult to “erase” from memory, andmay result in hypervigilance and agitated states during a service member’s
return to civilian life. Military members and veterans may also experience
detachment and estrangement from others, difficulty with concentration,and sleep/wake cycle disturbances. During a PTSD event, the veteran may
believe that his or her life is in danger, and may feel he/she has minimal
to no control over the situation, thus causing heightened anxiety. If thisbelief does not subside, psychological and/or physiological changes may
disrupt the person’s life, making it exceedingly difficult or even impossible
to continue activities of daily living. The nature of PTSD (e.g., avoiding
situations and stimuli that may trigger symptoms) means many individuals
in need of help will eschew discussing their struggles (Furst, 2016).
Alongside PTSD, traumatic brain injury (TBI) has been coined an“invisible wound of war,” frequently giving rise to emotional and cognitive
problems. TBI is an acute brain event where symptoms may occur immediately, or present days or weeks following an injury or traumatic experience.
Classified as either mild or severe, TBI has also been found to coexist withchronic pain conditions, depression, PTSD, and sleep problems (Lee etal., 2017). At times, the person is not even aware they have had a brain
injury, such as one sustained from shock wave blasts or falls. Regardlessof the type of TBI diagnosed, the consequences to a person’s life, family,social circle, community, and occupation can be devastating.
Often, service members suffering from TBI concurrently suffer from
PTSD, thus complicating treatment regimens and compounding such
TBI-related symptoms as cognitive impairments and memory dysfunction. Although psychotherapy and pharmacotherapy are known as thecurrent best practices for the treatment of PTSD, a significant proportionof individuals with PTSD do not seem to respond to these treatments(Vincent et al., 2017). This underscores the pressing necessity for identifying and developing non-pharmacological interventions — such as
AAI involving therapy and service animals — to aid in lessening PTSD
symptoms. Potential effects of canine assistance may be both social andphysiological (Krause-Parello, Sarni, & Padden, 2016). Several militaryand veteran-specific interventions in hospital and deployed settings reportbenefits from therapeutic human-canine interactions, including increased
assertiveness, improved stress management, improved communications

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and parenting interactions, expanded affect and emotional regulation, andimproved morale for participants and health care workers/staff (Owen,
Finton, Gibbons, DeLeon, 2016).
Military Sexual Trauma

Severe or threatening forms of sexual harassment and sexual assault sustained during military service are referred to within the Veterans HealthAdministration as military sexual trauma (MST) (Kimerling, Gima, Smith,Street, & Frayne, 2007). Since 2002, the VA has implemented universal
screening for MST using a standard clinical reminder within the electronic
medical record. Veterans who screen positive for MST are more likely tohave a history of suicide attempts documented in their VA medical record(Kimerling et al., 2007).
Despite the expanding roles for women within the military (Street,
Vogt, & Dutra, 2009), MST affects far more women than men; approximately 41% of women and 4% of men reported experiencing MST duringa recent study surveying 60,000 veterans (Barth et al., 2016). Veterans withsexual trauma are likely to experience detachment and estrangement fromothers, sleep disturbances, and problems with concentration (Graham etal., 2016). For women who enter the military with significant previous
trauma histories and are exposed to additional traumatic events (such as
MST) during the course of military service, risk for cumulative trauma
exposure, significant occupational stress, and related mental and physicalhealth problems is high (Zinzow, Grubaugh, Monnier, Suffoletta-Mairle& Frueh, 2007). Worse yet, if the ability to cope is lost, one may also lose
his/her independence and be unable to maintain personal and professional
relationships or forge new ones. The feelings of safety induced by a canine
companion may help a survivor of MST challenge those fears, leading to areevaluation of the world as relatively safe and of himself or herself as strong
and competent (Lefkowitz, Paharia, Prout, Debiak & Bleiberg, 2005).
IMPACTS OF HUMAN-CANINE INTERACTIONSAs Bern Williams notes,“There’s no psychiatrist in the world like a puppy licking
your face.” The physiological and psychological effects that animals haveon humans have been documented consistently throughout history, andthe utilization of canines to comfort service members in military hospitalsettings, such as the Army Air Forces Convalescent Center in Pawling, isAnimals in Action335

a compelling early demonstration of how animals have a profound andhistorically noted impact on the health of active duty military and veterans. Findings in recent years have developed robustly. Here, we intend to
add to this discussion by taking a specific look at the biology of PTSD,
as well as the impact that animals, and, in particular, canines, have on thephysical and psychological health of traumatized military service members
and veterans.
Current treatment methods for PTSD are lacking. While treatments
such as cognitive behavioral therapy (CBT) (Harvey, Bryant, & Tarrier,2003), prolonged exposure (PE) therapy (Rauch et al., 2009; Tuerk et al.,2011), and pharmacotherapy (Ipser & Stein, 2012) have been evidenced
as efficacious for some patients, it remains a hard reality of the contemporary clinical field that these methods do not work for all individuals
with PTSD. Moreover, there exist a variety of shortfalls with prevailing
treatment methodologies, and nonresponse to treatment is common(Haagen, Smid, Knipscheer, & Kleber, 2015; Richardson et al., 2014;
Schottenbauer, Glass, Arnkoff, Tendick, & Gray, 2008; Shalev, Bonne, &Eth, 1996; Watts et al., 2013). Further investigation and investment inalternative ways to ameliorate this condition and improve quality of life
for patients is of extreme and pressing importance to researchers, healthcare professionals, patients, and caregivers alike.
Canine Welfare and Well-Being

Before fully delving into an examination of canine impacts on humanhealth, there is a need to recognize and reflect upon the ways in which
the reverse interaction may function. That is to say, are there benefits orconsequences (recognized in the literature) that canines receive or sufferfrom by interacting with humans? In particular, does a robust body of data
currently exist to suggest that there may be negative health impacts on canines as a result of their roles as key players in AAT/AAI, and, in particular,
as psychiatric service dogs? If so, how does this alter the ways in which
health professionals should responsibly manage AAT/AAI, specifically thecare for the canines involved?
It seems that the jury, for the most part, is still out. Interestingly, a
2006 study on the physiological stress levels in shelter dogs found thathuman contact — defined as “taking the dog into an outdoor enclosure,playing with the dog, grooming, petting and reviewing basic obediencecommands” — had a beneficial impact on stress and reduced salivary cortisol levels in these canines significantly (Coppola, Grandin, & Enns, 2006,

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p. 537). Although this study was conducted with shelter dogs, the actualtasks (e.g., exercising, grooming, petting, and obedience) carried out are
not dissimilar from many daily interactions that a service dog owner or ahealth care professional handling a therapy dog for AAI/AAT might perform; thus, these tasks may not be overly taxing to working dogs, at leastfrom a stress perspective. In regard to the growing body of AAI-specificresearch in this area, the results are generally mixed; some investigators
have found indicators of behavioral and/or physiological stress among therapy dogs after participating in AAI sessions with a variety of populations(Haubenhofer & Kirchengast, 2007; King, Watters, & Mungre, 2011),
while the evidence of such in other studies is minimal or absent (Glenk etal., 2013; McCullough et al., 2018).
Likewise, a lack of specific evidence exists with regard to stress-related
impacts for service dogs paired with people diagnosed with PTSD. It is suggested that this be an area for future research. Interestingly, some evidence
does exist with regard to the well-being of service dogs who work withchildren with autism. In fact, two 2008 studies examined this question,and the challenges that families faced when integrating service dogs into
their lives. Potential canine stressors were identified, and included suchfactors as minimal access to rest and recovery time after working, lack ofpredictability in daily routines, insufficient time for recreational activities,
and bonding with the parent instead of the child originally (Burrows,
Adams, & Millman, 2008). It could reasonably be assumed that someof the above stressors could also exist within the context of PTSD. Of
note, the same research group also determined in a congruent qualitative
study that although there were challenges with service dog integration intoa home and working environment — such as public access issues, added
work/training for the family, and financing of dog care — ultimately families “overwhelmingly” felt that these challenges were worth it given thebenefits provided to their children (Burrows & Adams, 2008, p. 559).
Anecdotal evidence and common sense tell us that dogs need time
to relax and partake in “vest-off” activities — or, as patients with service
dogs sometimes put it, to have time to “just be a dog.” For example,
military working dogs, in particular, have been shown to benefit fromenrichment, including exercise coupled with human contact (Lefebvre,
Giffroy, & Diederich, 2009). The proper amount of “vest-off” time has
yet to be quantified empirically, and is likely highly variable depending on
individual factors such as the particular tasks the dog is required to do, theAnimals in Action337

dog’s daily working environment, the age of the dog, the stage of trainingthat the dog is in, and so forth. However, the takeaway here is that psychiatric service dogs and therapy dogs involved in AAI/AAT should not be
expected to be working 100% of the time. Rather, they require care andcompassion in order to do their jobs correctly and accurately. Specifically,dogs need designated time for rest and play; opportunities to engage innatural and relaxed species-specific behaviors and activities; affectionate
attention; physical exercise; a consistent and nutrient-rich diet; proper
medical care; and routine check-ups. Additionally, psychiatric service dogs
may likely need reinforcement and upkeep in training for their specifictasks. If mobility-related equipment or any other equipment worn by thedog is utilized, it should ideally be properly fitted by professionals who
specialize in the ergonomics of service dog equipment, and be kept ingood working condition as well as updated as per the growth of the dog.
Improper fitting of equipment is not only a potential health concern for thedog, but it can also impede the proper execution of service-related tasks.
Physiological and Psychological Effectsof AAIs on Human HealthBearing in mind these considerations of canine well-being, let us proceed
in examining the potential impacts that dogs may have on human health,and, particularly, the amelioration of trauma in vulnerable populations.
A growing body of research suggests that interactions with dogs have asignificant effect on the human body’s stress response mechanisms, andmay contribute markedly to various domains of psychological well-being.
Considering the nature of PTSD and its classification in the DSM-5 as a
trauma and stress-related disorder, the capacity for dogs to influence physical and psychological stress in humans may have a particularly profound
impact on this condition.
Encouragingly, various contemporary reviews of efficacy have cited
AAT/AAI as a putative mechanism to improve mental and physical healthin numerous populations, including children with histories of sexual abuse,college-aged students experiencing stress, older adults, patients living withchronic or terminal illnesses, and individuals who have experienced additional challenges and/or other forms of trauma (Kamioka et al., 2014;
Krause-Parello & Friedmann, 2014; Nimer & Lundahl, 2007; O’Haire,
Guérin, & Kirkham, 2015; Krause-Parello, Sarni, & Padden, 2016). Such
research has documented significant improvements in areas including,338

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but not limited to, reducing loneliness (Banks & Banks, 2002; KrauseParello & Gulick, 2013); decreasing anxiety in hospitalized psychiatricpatients (Barker & Dawson, 1998); improving cardiovascular wellness inolder adults (Krause-Parello & Kolassa, 2016); and reducing depression(Friedmann, Thomas, & Son, 2011; Krause-Parello, 2012; Souter & Miller,2007) and stress (Allen, Shykoff, & Izzo, 2001; Barker, Knisely, McCain,Schubert, & Pandurangi, 2010). In a recent study, service dogs were foundto improve veteran physical and psychological health and aid in positive
reintegration into civilian life (Krause-Parello & Morales, 2018).
Based on the growing body of evidence suggesting that AAT/AAI
is a dynamic, empirically sound method by which to improve humanhealth and well-being, an upwelling of recent interest has developed withregard to the investigation of how these interventions may be applied
toward facilitating patient recovery from trauma and PTSD, particularly
within the military and veteran population. A hallmark of PTSD biology
is the documented alteration of cortisol (Lehrner, Daskalakis, & Yehuda,
2016; Yehuda, 2002), a hormone tied to stress perception and reactivity. Notably, cortisol levels impact the functionality of the hippocampus
and the amygdala, two brain regions that play a central role in how weexperience emotions and process memory (Lehrner et al., 2016; Myers,
McKlveen, & Herman, 2012; Rauch, Shin, & Phelps, 2006; Shin et al.,
2004; Shin, Rauch, & Pitman, 2006; Starcevic et al., 2014).
Difficulty with cortisol regulation is thought to be a significant factor
in both the neuropathology of PTSD, as well as the stress-related symptoms that are characteristic of this condition. Recent investigations andreviews have suggested that dysregulated levels of cortisol found in patientswith PTSD may play an important role in the neurodegeneration of the
hippocampus (Bremner & Bremner, 2016; Daskalakis, McGill, Lehrner, &Yehuda, 2016; Lehrner et al., 2016), which has historically been found tobe significantly smaller in individuals with PTSD (Woon, Sood, & Hedges,2010). This is not altogether surprising, given that people with PTSD often
display difficulty controlling emotional responses (e.g., extreme irritability
or sadness) and with memory functioning (e.g., reexperiencing the traumatic event through flashbacks).
An additional key hormone to consider in the context of trauma is
oxytocin. Oxytocin is a neuropeptide historically implicated in social interaction and bonding. In recent years, the capacity of administering oxytocin
to diminish the fear response has been evaluated as a way to potentiallyAnimals in Action339

aid in lessening trauma symptoms (Frijling et al., 2016; Olff, Langeland,
Witteveen, & Denys, 2010). In a groundbreaking 2016 study, Koch andcolleagues (2016a) found that intranasal administration of oxytocin dampened amygdala reactivity (i.e., fear response) toward all emotional faces inmale and female patients with PTSD, suggesting a therapeutic potentialof oxytocin for this population. Strikingly, a study by the same researchers
found that the administration of intranasal oxytocin normalized functional
connectivity in the amygdalae of patients with PTSD, and resulted in decreased subjective anxiety and nervousness in these individuals (Koch etal., 2016b). These research findings strengthen the case that oxytocin may
potentially have clinical applications for patients coping with fear response
dysregulation in conditions such as PTSD.
Importantly, contemporary research indicates that interactions withcanines may naturally impact levels of both cortisol and oxytocin in humans. A recent study found short-term interactions with dogs to havea quick, significant effect on decreasing levels of cortisol in humans 15
and 30 minutes after they began an interaction with a dog (Handlin etal., 2011). Furthermore, the presence of a dog attenuated cortisol levels
among undergraduate students in the Trier Social Stress Test (Polheber &Matchock, 2014), while participation in a dog-visitation program consistently lowered the salivary cortisol levels of inmates in a Japanese prison(Koda et al., 2016). Reductions in cortisol levels after interactions with atherapy dog have also been recently cited in populations of college students(Krause-Parello, Tychowski, Gonzalez, & Boyd, 2012).
In a recent study, the effects of a facility dog on hospitalized veteransseen by a palliative care psychologist were examined. Participants received
a visit from a VA facility dog, a clinical psychologist, and the dog’s handler (experimental condition), or an unstructured visit with the clinicalpsychologist alone (control condition). The veteran’s heart rate (HR) andsalivary cortisol were measured before, just after, and 30 minutes after boththe experimental and control conditions. A significant decrease in cortisol
was found when comparing the before time period to the 30 minutes after
time period for both the experimental (p = 0.007) and control condition(p = 0.036). A significant decrease in HR was also found when comparing the before time period to the 30 minutes after time period for boththe experimental (p = 0.0046) and control (p = 0.0119) condition. Whileboth conditions saw physiological indicators of stress reduction, results do
support that a VA facility dog, matched with a palliative care psychologist,

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had a significant, positive impact on salivary cortisol levels and HR in
hospitalized veterans on the palliative care service (Krause-Parello, Levy,
Holman, & Kolassa, 2016).
In addition, close bonds between people and their pet dogs may befurther facilitated by an increase in oxytocin. In fact, research shows thathuman-canine interactions, including those involving mutual gaze, havebeen linked to increased oxytocin in both species (Handlin, Nilsson,
Ejdebäck, Hydbring-Sandberg, & Uvnäs-Moberg, 2012; Nagasawa et al.,2015). Taken together, existing evidence delineating the oxytocin-​eliciting
and cortisol-altering effects of human-canine interactions provides a solid
foundation upon which to develop viable mechanistic explanations regarding the effects that these relationships may have within the context of
PTSD neuropathology and symptomology. Biologically, stress-reducing
aspects of interacting with dogs may have the therapeutic effect of disallowing environmental triggers to have catastrophic impacts on the stressresponse, thereby exerting protection over the neuroendocrine system, andconsistently serving to facilitate reregulation to typical levels of stress response. The less the system is retriggered and forced to react to negative
inputs, perhaps the more likely it is that the system will be able to minimize
dysregulation. Accordingly, human-canine interaction — and, in particular, interaction with highly trained psychiatric service dogs (discussednext) — may decrease the likelihood that triggered episodes or intrusive
memories of traumatic stress will recur, and may function to curtail theemotional impact that these triggers have on individuals. In turn, theseeffects may serve to protect from extreme episodes of stress compensation
and, in theory, promote reregulation and “healing” of the chronically dysregulated system.
Psychiatric service dogs, in particular, have the ability to quite literally be constantly present in the lives of individuals coping with PTSD.
From a therapeutic standpoint, this differentiates AAIs with service dogs
from approaches such as animal-assisted group therapy, CBT, PE, andother clinician-led therapies that require an assigned timeline in which toaccomplish goals. Service dogs represent a sustained mechanism of support for individuals with PTSD, with the capacity to extend far beyonda clinician’s office and, indeed, into every realm of an individual’s life. Bydefault, this sustained contact allows for an individual to consistently experience not only the psychological benefits of bonding and interacting withthe dog, but also the nuanced physiological effects that this interactionAnimals in Action341

facilitates (e.g., alterations of endogenous cortisol and oxytocin levels) andthe stress-regulating benefits that result from the interplay of such physiological processes.
This “all-the-time” therapeutic effect may only truly be achieved
otherwise by pharmacological interventions. Current pharmacologicalapproaches are limited, and various systematic reviews of pharmacological usefulness in PTSD treatment have concluded a stark lack of efficacy(Haagen et al., 2015; Watts et al., 2013). Thus, interaction with psychiatricservice dogs represents a highly consistent and ecologically valid modality
by which to deliver therapeutic effects to individuals with PTSD in a functional, real-world setting, and should be considered seriously as a powerfuladjunctive treatment mechanism by service providers.
CASE STUDYLYNDON AND ICE: FOUR-LEGGED LOVEThe following is an excerpt from a piece written by marine veteran, Lyndon
Villone, who has worked for the past several years to establish Heel the
Heroes, a charitable 501(c)(3) organization with the mission of providing
innovative programs and services uniting specially trained dogs and horses
with holistic therapies to aid in the recovering, reclaiming, and refiningof veterans’ lifestyles, and ultimately facilitating the empowerment andenrichment of veteran lives. From January 2011–November 2012, Villone
was stricken with grief over the loss of six people he considered to be family/brothers in arms, including the loss of his Marine mentor to overdose
medications. None of these deaths were from combat activities per se;
all of them happened stateside. From January of 2013 until present day,
Villone has been working to improve his lifestyle, along with the mental
and physical health needed to once again obtain a satisfactory quality oflife. When five-week-old Siberian husky “Ice” came into his life from abad breeding situation six days after the loss of Villone’s best friend, there
was no way to predict the lifeline Ice would ultimately become for Villone.
“Ice, come!” As the paws of a 60-pound Siberian husky glide
through the air springing from the ground with excitement inyour direction, it’s easy to admire the physical nature of a striking“wolf like” canine. Further beneath the skin, though, is a living,breathing, intelligent canine that is visibly happy in his efforts

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to obey your one simple
cue to return. These are
personal experiences I’ve
enjoyed while being fortunate enough to get toknow this animal. This canine has such an enhanced
personality, and definitive
things that he likes anddislikes. He gets happy, hegets sad, and he gets sick.
He needs proper nutrition, health maintenance,and love. Most every parent I’ve spoken with said
having kids changed theirlives. Caring for this amazLyndon and Ice: “The love from a dog is unconditional;
ing creature has required our love to them should be the same. With a bond thatme to get better as a per- strong, there will always be a positive influence taking
son, and has changed my place.” Corporal (CPL) Lyndon R. Villone; Fallujah, Iraq,
from March–October 2006, again from October 2007–
life forever.
A gigantic reason I’ve May 2008; United States Marine Corps; Parris Island,Camp LeJeune; Amphibious Assault Vehicle crewman
been able to understand(AAV) MOS = 1833.
my service dog Ice so wellis because we bonded through socializing him appropriately withpeople, sights, sounds, things, and other well-behaved dogs. I
studied proper introduction techniques for letting my dog meetother dogs for the first time as required of service dogs. It is only
fair to our dogs that we know what we are asking from them. They
operate differently than we do, but still have feelings. Ice does
more than brace for my vertigo spells, and apply pressure points
after nightmares and anxiety attacks. It’s mentally healing getting
to know another living animal’s personality in such a wholesome
and humbling presence. He’s changed me as a person.
It’s been my experience that I can take a peek into a person’s
character and personality by the way they care for their dog. We
live in a world where lack of trust is evident. You will always beable to trust a dog; they share blind faith and trust in you.

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IMPLICATIONS FOR PRACTICE AND POLICY:A CALL TO ACTION
There is sufficient preliminary research regarding the psychological andphysiological benefits of HAI, and its potential and specific usefulness in
impacting PTSD symptomology, to warrant the funding of large-scale controlled and longitudinal studies in order to further evaluate these effects. It
is the critical responsibility of private and governmental funding agencies
to recognize the potential for clinical impact in this field of research, and tocommit significant future funding to support researchers and projects with
the intent of understanding how precisely the stress systems of our bodies
react to animals, and how these interactions may be utilized therapeutically to aid both military and civilian populations struggling profoundlywith trauma.
Veterans diagnosed with PTSD often utilize the assistance of dogs tocope with their fundamental human needs for safety, affiliation, and succorance (Taylor, Edwards, & Pooley, 2013). However, veterans with PTSD
and TBI who acquire a service dog are not reimbursed, as service dogs are
not considered a medical expense (Krause-Parello et al., 2016). The VA currently has a clinician review process to evaluate each veteran and determine
if he or she qualifies for a service dog. Veterans who are approved for a service dog are currently referred to Assistance Dogs International-accredited
agencies. There is no charge for the dog or the associated training. The
VA provides veterinary care and equipment through VA Prosthetics andSensory Aids, yet does not pay for boarding, grooming, food, or otherroutine expenses that come with owning a dog. According to the VA, protecting someone, giving emotional support, or being a companion does not
qualify the dog as being “of service.” Therefore, a service dog is not a reimbursable expense, which is a significant health care disparity (Department
of Veterans Affairs, 2016a).
The Puppies Assisting Wounded Service members (P.A.W.S.) Act of
2017, H.R. 2327, is currently under review in the House of Representatives
to direct the Secretary of Veterans Affairs to make grants available to eligible organizations to provide service dogs to veterans with severe PTSD
and for other purposes. To be eligible for a service dog under the pilot
program, a veteran needs to be enrolled in the patient enrollment systemof the Department of Veterans Affairs under section 1705 of Title 38 of
the United States Code. Additional eligibility criteria include: 1) the veteran has to have completed an established evidence-based treatment for344

TRANSFORMING TRAUMAPTSD by a qualified health care provider (checklist PCL-5); 2) the healthcare provider or VA team needs to have determined that the veteran may
potentially benefit from a service dog; and 3) the veteran must agree tocomplete training successfully with the service dog by an eligible organization. The veteran must also see the health care provider or VA clinicalteam at least once every six months to determine if he/she continues tobenefit from a service dog.
Joining Forces is an initiative from the White House, former First
Lady Michelle Obama, and Dr. Jill Biden to help raise awareness of theneeds of veterans. Joining Forces has collaborated with various nursing
organizations to raise awareness of health issues with returning veterans,
specifically PTSD and TBI. Their goal is for every nurse to recognize signs
and symptoms of these conditions, and to support veterans in obtaining
quality referrals for treatment (Halderman, 2013).
Canines Providing Assistance to Wounded Warriors (C-P.A.W.W.) isa Health Research Initiative for Veterans in the Christine E. Lynn College
of Nursing at Florida Atlantic University. The C-P.A.W.W. initiative wasestablished in 2013 to advance the health and well-being of members of thearmed forces. The mission of C-P.A.W.W. is to comprehensively advanceinterdisciplinary research, education, and practice protocols for wounded
warriors and veterans through the development of evidence-based andrestorative interventions; to support military-related health initiatives bybuilding community partnerships; to investigate therapeutic interventions — particularly those involving canine assistance — that positively
influence health outcomes; and to emphasize system planning, innovative
public policy making, and thorough protocols of care development for
the armed forces. One of C-P.A.W.W.’s goals is to continue to conduct
research on the efficacy of service dogs by examining both biological andpsychological correlates in order to provide the empirical evidence needed
to support change in public policy regarding the reimbursement of service
dogs for our military veterans (Krause-Parello, 2015). More information
about this program can be found at www.nursing.fau.edu/c-paww.
Over time, dogs have played (and will continue to play) an importantrole in the lives of military service members and veterans. Initiatives likethe P.A.W.S. Act (P.A.W.S. Act, 2017), Joining Forces, and C-P.A.W.W.,
as well as the growing number of dedicated grassroots service dog training
organizations, are instrumental for promoting public education and awareness; providing supportive evidence regarding the benefits of service dogs forAnimals in Action345

military members and veterans recovering from invisible wounds of war; andultimately aiding veterans and other populations in obtaining service dogs
at little or no cost. Creative, effective, and highly personalized interventions
are urgently needed to help facilitate readjustment and post-deployment
mental health and well-being in military and veteran populations. AAIs are
an important step in the right direction to help change the lives of veterans — such as Corporal Lyndon R. Villone, with Ice by his side.
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ABOUT THE AUTHORS
Cheryl A. Krause-Parello, PhD, RN, FAAN is a professor at Florida Atlantic
University in the Christine E. Lynn College of Nursing (CELCON), anda faculty fellow in the Institute for Healthy Aging and Lifespan Studies(I-HeAL). Krause-Parello completed her PhD in nursing research at Rutgers
University, where she developed a program of human-animal interaction
research. She has also developed, and is the director of, a university-​based
health research initiative for veterans (C-P.A.W.W.; www.nursing.fau.edu/c-paww). The long-term goal of her program of research is to implement effective interventions to modulate the long-term effects of PTSD on
returning active duty military and veterans, and to identify additional populations where this intervention will be effective. One of Krause-Parello’s
prospective goals is to provide the evidence to support changes in public
policy so that service dogs will be covered as a reimbursable medical expense for those recovering from invisible service connected conditions.
Allison E. Boyrer, MS, MA, BSN, RN is a faculty member at the Universityof Colorado, College of Nursing at the Anschutz Medical Campus. She
is a graduate of Syracuse University (BSN); the University of SouthAnimals in Action353

Florida (MA in physical education); and the University of Colorado (MSin nursing: veteran and military health care). She is currently pursuing
her doctoral degree in education (EdD) for executive leadership at the
University of Colorado School of Education and Human Development.
Boyrer serves as the coordinator of Strategic Partnerships for the College
of Nursing, connecting community to practice.
Eleni Padden, BA, is a graduate of Johns Hopkins University in Baltimore,
Maryland. After obtaining her bachelor’s degree in 2015, Padden served
as a research assistant for the Canines Providing Assistance for Wounded
Warriors (C.P.A.W.W.) nonprofit research initiative, under the supervisionof Dr. Cheryl Krause-Parello at the Anschutz Medical Campus. She iscurrently working toward becoming a clinical social worker and publichealth scientist, and hopes to serve the veteran population over the courseof her career via therapy and innovative policy making.

CHAPTER 11

The Battle for Hearts and Minds:
Warrior Canine Connection’s MissionBased Trauma Recovery Program
Rick A. Yount, LSW; Robert Koffman, MD; and Meg D. Olmert

Fourteen years of war in Afghanistan and Iraq have taken a devastating
toll on a large percentage of the 2.7 million service members who carriedout these military missions. Post-traumatic stress disorder (PTSD) andtraumatic brain injury (TBI) are the signature wounds of these wars, andamong the most difficult to treat. Despite the billions of dollars being
spent on medical care for veterans, hundreds of thousands continue tosuffer the debilitating effects of these “invisible wounds.” Warrior Canine
Connection’s (WCC’s) Mission Based Trauma Recovery (MBTR) programis an innovative animal-assisted therapy initiative now offered within major
military and VA medical centers. This chapter will present MBTR’s clinically based methodology, scientific rationale, and one case study that will
demonstrate the program’s therapeutic impact and success.
SMBACKGROUND AND SIGNIFICANCEThe United States deployed 2.7 million service members in military
operations in Afghanistan and Iraq between 2001 and 2011. A 2015
Congressional Research Service Report estimates that since the start of
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combat operations, 177,461 service members were diagnosed with PTSD,
and an additional 327,299 suffered TBI (Fischer, 2015). A 2012 reportto Congress found that 26% of returning veterans who sought medical
treatment through the Veteran’s Health Administration (VHA) were diagnosed with PTSD. This report cautioned that these numbers do not reflect
the true physical and mental toll of combat trauma, since almost 50% ofveterans do not seek medical care through the VHA (Congressional Budget
Office, 2012). Nor do these statistics factor in the disruption to militaryfamilies when spouses/partners and relatives need to alter their lives andemployment schedules to care for loved ones (Bilmes, 2013).
Despite the $23.6 billion dollars spent on veteran health care between 2001 and 2013 (Fischer, 2013), many veterans continue to sufferfrom PTSD and TBI. Recent US Army studies reveal that less than 50%
of soldiers with a PTSD diagnosis receive treatment and, of those whodo, 20–40% drop out before completion (Levin, 2012). According to
Major Gary Wynn, a PTSD research psychiatrist at the Uniformed Services
University of Health Sciences in Bethesda, Maryland, veterans’ treatment
resistance and dropout rates result mainly from a lack of trust in healthcare providers and the stigma of a PTSD diagnosis. Major Wynn sees these
disturbing statistics as a mandate to better match therapies with patient
preference, and to “disguise” mental health care as primary care or thorough alternative interventions (Levin, 2012).
THE TROJAN DOG EFFECT
In 2008, licensed social worker and professional service dog trainer Rick
Yount set out to do exactly that. Yount recognized that mobility service
dog training could provide unique experiential opportunities to learn, or
relearn, emotional and behavioral skills impaired by combat trauma. He
also knew that thousands of veterans were waiting years to be partneredwith skilled service dogs that are trained to provide the mobility and/or emotional support that can change their lives. Under the legitimate
guise of a mission to train a service dog for another wounded warrior,
Yount created a service dog training program that inspired even the mosttreatment-​resistant patients to pick up a leash and discover the therapeutic benefits embedded in training great dogs for the purpose of helping afellow wounded veteran.

The Battle for Hearts and Minds357

A Warrior Trainer (MS) works with service dog-in-training, Ron. (Photo by Bonnie Grower/WCC. Used
with permission from WCC.)

Yount was invited to launch this innovative mission-based trauma program at the Men’s and Women’s Trauma Recovery Program at the Veterans
Hospital in Menlo Park, California. Over the next two years, this volunteer
program — operating as part of Recreation Therapy Services— proved to behighly popular, as indicated by participant and caregiver feedback and its
very low dropout rate. Approximately 200 service members participatedin the initial pilot program, five service dogs were placed with veterans,
and two program volunteers went on to become accredited, professional
service dog trainers.
In 2009, Yount and the Menlo Park VA team were asked to present anecdotal observations of the pilot program’s success at the Veterans
Administration National Mental Health Conference, and at the annual
meeting of the International Society for Traumatic Stress Studies. The
following are the clinical observations they presented that support the program’s ability to reduce a wide range of combat PTSD symptoms (Yount,
Olmert, & Lee, 2012):• Increased patience, impulse control, and emotional regulation• Improved ability to display affect and decreased emotional
numbness

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•
•
•
•
•
•
•
•
•

Improved sleep
Decreased depression and increased positive sense of purpose
Decreased startle responses
Decreased pain perception
Increased sense of belonging/acceptance
Increased assertive communication skills
Improved parenting skills and family dynamics
Fewer war stories and more in-the-moment thinking
Lower stress levels, and an increased sense of calm

In 2009, Yount was invited to establish this program model at the
Warrior Transition Brigade at Walter Reed Hospital, in Washington, DC.
In 2011, he established the nonprofit Warrior Canine Connection, Inc.,
to support, expand, and constantly improve the quality of WCC’s unique
MBTR model. WCC’s MBTR program is staffed by professional service
dog trainers and purpose-bred dogs. Currently, MBTR is a highly valued
complementary intervention supporting goal achievement in traditional
PTSD and TBI treatment modalities, such as cognitive and behavioral
health; substance abuse treatment; and occupational, recreational, andfamily therapies at the National Intrepid Center of Excellence (NICoE)
in Bethesda, Maryland; the Menlo Park, Virginia Hospital; and the Marcus
Institute for Brain Health in Denver, Colorado.
WCC is also reaching out to help the many thousands of veteranswhose struggles have resulted in serious legal trouble, and has become ahighly effective component of Veterans Treatment Court (VTC) programs
across the country. VTC programs provide treatment and rehabilitative restitution programs as alternatives to incarceration for veterans with combat
trauma. WCC’s model was first piloted in the Albuquerque, New Mexico,
VTC program in 2015 by WCC’s partners, Assistance Dogs of the West.
Additionally, WCC launched MBTR programming in three California
VTC programs (San Francisco, Santa Clara, and San Mateo) in 2016, andwas invited to bring MBTR to the Baltimore City, Maryland and Asheville,
North Carolinal, VTC programs in 2018. VTC judges, parole officers,
and court officials have embraced the WCC MBTR model as a powerfuland popular mission that enhances the veterans’ sense of well-being andpurpose on their road to recovery, restitution, and a meaningful, productive life.

The Battle for Hearts and Minds359

MBTR: IT’S A FAMILY AFFAIR
According to the VA’s National Center for PTSD, the emotional toll on
military families struggling with PTSD has been shown to be severe andpervasive (Price & Stephens, 2017). The negative effects of PTSD on
family relations create a debilitating feedback effect that exacerbates theveteran’s PTSD symptoms, and further erodes family stability. The results
can include compromised parenting, family violence, divorce and sexual
problems, aggression, and caregiver burden (Price & Stephens, 2017). Thisknock-on effect reverberating through military families suffering fromPTSD extends the tragic cost of war into generations to come. As such,
MBTR considers supporting military families as a “no-fail mission.”
Service members go through intense experiential training to become
warfighters, including tasks to become acutely reactive to threat, as well as
able to suppress emotions that would inhibit their performance in battle.
This military training often creates challenges when highly vigilant, emotionally numb warfighters return home to their families.
WCC’s warrior trainers are taught service dog training skills thatare based on the values and best practices of family-focused social work.
Bonding with and shaping the behavior of young dogs offer unlimited

MS walking with Birdie, his daughter, and RY’s daughter. (Photo by Bonnie Grower/WCC.
Used with permission from WCC.)

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experiential training opportunities for wounded warriors to practice patience, empathy, and consistency. Service members are also coached to use
positive expressions of emotion and praise to enhance their dog’s training
performance. Expressing — even feeling — positive emotions can be very
challenging for our volunteer trainers. However, through the training process, they see how their emotional efforts immediately capture their dog’s
attention and improve their ability to perform a command. Both partners
are rewarded with a sense of accomplishment and joy. Many program
participants have reported that regaining their ability to express positive
emotions with the dogs has improved their sense of well-being and has
had a significant impact on their family dynamics (Tedeschi, Sisa, Olmert,
Parish-Plass, & Yount, 2015).
ENSURING HEALTHY AND HAPPY SERVICE DOG/VETERAN BONDS
Given the large number of service members who will potentially work witha WCC dog over the two-year training cycle, it is critically important tochoose the right dogs for this work, and to prepare them for the various
tasks they will perform. WCC has a very well developed breeding programthat breeds Golden and Labrador retrievers, with a focus on canine healthand temperament. WCC puppies receive a tremendous amount of earlysocialization from a multitude of devoted volunteers, thereby instilling in
the pups a sense of trust and love for humans. Careful breeding selectionand early socialization set the dogs up for success, as well as ensure thatthey will thrive from the attention that they receive from their multiple
warrior trainers.
In addition to the nature/nurture considerations described above,
WCC dogs benefit from our close partnership with the staff of OlneySandy Spring Veterinary Hospital (an accredited member of the American
Animal Hospital Association), who provide expert medical care and consultation throughout the life cycle of the dogs. Furthermore, WCC dogs arealso examined annually by board certified ophthalmologists and cardiologists. Preplacement veterinary exams that include the veteran partner who
will receive the dog (whenever possible) help establish the important relationship between the veterinarian and veteran recipient. Likewise, WCC’s
Dog Program specialists provide ongoing support to the veteran/dog team,and maintain communication with them throughout the life of the dog.

The Battle for Hearts and Minds361

Ensuring a successful match between the dog and veteran recipientis another critical consideration. WCC carefully assesses both task needs
and individual personalities prior to placement. Instead of “E-Harmony,”
WCC uses “D-Harmony” to ensure that veteran and dog profiles are amatch. Expert screening of veteran recipients by qualified mental healthprofessionals is also essential in determining how the partnership dynamic
can enhance the well-being of both the veteran and the dog.
Over the last decade, WCC has been able to reach out across thecountry to an increasing number of warriors in-need. Over 5,000 service
members, veterans, and their families have volunteered to be part of this vital healing mission, with the overwhelming majority reporting an increased
sense of well-being and purpose from participation in the program. This
growing “canine corp” of warrior-trainers has also helped WCC partner(at no cost) 62 Assistance Dogs with veterans in need of mobility, psychosocial, and/or family support.
CASE STUDY OF MBTR
The following is a case study of a former WCC Warrior Trainer (henceforthreferred to as “MS”) whose experience illustrates the ways in which thisinnovative service dog training program can reduce a wide range of psychosocial and behavioral effects of combat-related PTSD. The case study
includes (in italics) the volunteer testimony of MS and excerpts from“Training a Dog to Train Me,” a paper MS wrote for a college psychology
class he completed while in treatment at Walter Reed. In addition, we
present case notes from the two authors who participated in his treatment
for PTSD. Rick Yount (“RY”) was MS’s clinical service dog trainer, andCaptain Robert Koffman, MD (“RK”) was senior consultant for integrative
medicine and behavioral health at NICoE during the patient’s course oftreatment (Koffman, now retired, serves as WCC’s chief medical advisor).
RK: MS, a 25-year-old marine sergeant, served eight years of active
military duty, including three combat deployments to Iraq and
Afghanistan, during which he engaged in numerous firefights andendured the loss of several fellow marines. He was also exposed
to multiple blast events, the most significant in 2010 when an
IED detonated, destroying his vehicle and causing loss of consciousness for approximately three to five minutes. Following his

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third and most traumatic deployment, he experienced persistent
hypervigilance, marked arousal, reexperiencing phenomena (i.e.,nightly nightmares), and profound emotional blunting. While atthe military treatment facility at his home base, he was diagnosed
with PTSD, mild TBI with chronic headache, and insomnia. The
service member began standard PTSD treatment, including pharmacotherapy with selective serotonergic uptake inhibitors (SSRIs)
and cognitive behavioral therapy.
In July 2011, MS was referred to NICoE’s intensive four-weektreatment plan due to worsening symptoms of PTSD and TBI,
including persistent and intractable headaches, near syncope (orthe temporary loss of consciousness due to low blood pressurethat worsens with exertion) and, perhaps most troubling, irritability, anger, marked hyperarousal, and startle. Insomnia was alsochronic and unmanageable. Chronic pain exacerbated all neuropsychiatric conditions. During treatment at NICoE, MS lived in
Fischer House apartments on the Walter Reed base.
MS’s psychological testing at NICoE revealed short-term
memory and processing speed deficits, most likely associated withhis TBI. While at NICoE, MS was offered group, individual, andsupportive psychotherapy. He was also given the opportunity toengage in various integrative modalities including expressive arts
therapy (i.e., mask-making and journaling), yoga, meditation,acupuncture, biofeedback (i.e., autogenic training and breathing
exercises), and WCC’s Mission-Based Trauma Recovery Program.
MS: When I first arrived at NICoE in 2011, I hadn’t slept decent
in months. I would go days on end with no sleep, before finallycrashing and getting a couple hours of broken sleep. Pills didn’t
help, and none of the other sleep hygiene stuff was working. It
affected everything I did. I didn’t have any energy, was always ina bad mood. I was always in pain and irritated and had very little
patience, which was likely exacerbated by the sleep deficiencies,
and I was generally just frustrated with life.
About a week into my treatment, I told a nurse I liked dogs
better than people, and she suggested I check out the Warrior
Canine Connection program. I agreed and met with Rick Yount

The Battle for Hearts and Minds363

and several of the dogs in the program. We discussed his program,and how the dogs needed training so they could be placed withveterans coming back with physical impairments. I have always
loved dogs — so just getting to spend time with them, it seemed
like a no-brainer for me.
RY: On MS’s first visit to our WCC office, I gave him an overview
of what he would need to do to help train a service dog for a fellow
veteran, including practicing patience and learning to praise thedog with positive affect. When I referred to the praise voice assimilar to “Richard Simmons,” MS hesitated a bit, but agreed toparticipate, knowing that he would be able to have a positive impact on another veteran’s life by training a service dog for him/her.
MS: One of my favorite memories of the program was the day I was
introduced to [WCC dogs] Olive and Birdie. Both were about ayear old, but with vastly different personalities. Olive was a sweetheart and had lots of energy, while Birdie was a little different thanthe dogs I knew when I was growing up. He was a bit more mellow
and laid back, but had a mind of his own sometimes, which I figured would require a lot more patience and motivation — things
I didn’t think I still had at the time. Rick let me work with bothdogs in the beginning on basic tasks like sit and down. After a few
days, Rick had asked which dog I preferred working with, and I
instantly responded Olive. Rick seemed to think otherwise, andproceeded to tell me I would be working with Birdie primarily.
He was a wise man.
RY: MS seemed to take pride in the service dog training skills he
was acquiring. He was learning how to include effective communication, patience, and to express positive affect to reinforce thedogs’ behaviors. The WCC dogs that MS helped to train gavehonest and immediate feedback that let him know what worked
and didn’t work. We coached MS to build his relationships withthe dogs, and to try to sound as genuinely happy as possible (evenwhen he wasn’t), because the dogs would respond better to thislevel of encouragement. Not only did this positive effort improve

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MS’s attitude, but he clearly saw how quickly it improved his dog
training skills as well.
MS: After a week or so working with the dogs, and mostly Birdie,
I looked forward to coming in each day, and made it a point to
get to the office in between my appointments to see the dogs andwork with Birdie. We had developed a bond and he was as eager
to work with me as I was with him. It is a tedious process sometimes, breaking larger tasks into smaller ones, and it didn’t always
click for him right away, which challenged a lot of the issues I
was struggling with. But, while frustrating at times, watching him
succeed in performing tasks was exciting.
RK: Heart rate variability (HRV) — the heart’s ability to effectively
respond to, and recover from, stress — is essential to healthy heart
function. Dysregulation of HRV is a common condition in thosewith PTSD and TBI (Edmondson & Cohen, 2013). MS’s HRV
patterns were consistently irregular. Two measures were taken tocompare MS’s HRV profile after breathing relaxation techniques
and while accompanied by a WCC dog. Only the presence ofthe WCC dog produced significant improvement of MS’s HRV
functioning.
MS: Recently a nurse monitored my HRV measures while I had
one of the WCC dogs on my lap. My heart rate was in the green
zone — the healthy zone — for the first time.
RK: MS’s case was one of the most challenging we had seen at
NICoE. While at NICoE, MS experienced an acute worsening of
his depression, accompanied by periods of suicidal ideation. MS’s
aggravated headaches and lack of sleep likely contributed to his
increased sense of hopelessness and subsequent despair. He wastransferred to a general medical ward for a full dihydoergotamine(DHE) protocol for intractable headaches, and to try different
medications to control his PTSD symptoms. Even the DHE protocol was not very successful. Due to his symptom severity andneed for additional treatment, his four-week stay at NICoE was

The Battle for Hearts and Minds365

doubled. Up until MS’s arrival, no patient had remained in ourcare for that long.
MS: After a few more weeks, Birdie started coming with me to myappointments. Just having him in the room with me made me alot less anxious.
RY: MS would come to our office and sleep with the dogs on theirbeds. At Menlo Park, I had seen how patients with severe insomnia
were able to get a good night’s sleep with a program dog at theirside. In anticipation of MS’s ultimate discharge, realizing thatusual care for PTSD and TBI was not entirely effective in MS’scase, I discussed the idea of documenting the benefit of sleepingwith a WCC dog that MS initially reported at NICoE. MS’s sleep
doctor agreed. Through actigraphy, the sleep doctor confirmed
MS’s severe insomnia markedly improved with Birdie by his side.
Subsequently, we were able to get permission from the Fischer
House manager for Birdie to sleep with MS on an ongoing basis.
RK: Actigraphy measures taken on two nights with sleep medication showed that, despite medication, MS had frequent movement
during the sleep periods. The next night, MS took sleep medication but also slept with Birdie. Actigraph readings showed that,with Birdie, MS had a more consolidated sleep period, less activity,and improved sleep efficiency.
MS: With Birdie at my side — sleep! Almost every night! It was
magnificent! And it progressed my treatment tenfold. I was slowly
becoming more like Birdie — the mellow, more laid back dog.
Birdie had taught me patience, and gave me motivation to get up
each morning. He had almost single-handedly corrected many of
my sleep problems.
RK: MS was legally separated from his wife following his stayat NICoE. He maintained shared custody of his four-year-old
daughter throughout his treatment while residing both on baseand at an off-base apartment.

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RY: MS was often accompanied by his four-year-old daughter. MS
was in an impossible position of caring for a four-year-old while intreatment and only getting two hours of sleep on a good night. His
daughter would sit solemnly in a chair in our office and appeared
to be shut down as a result of her father’s parenting style, whichat this point was authoritative and lacking patience. I decided totry having MS take Birdie overnight while his daughter was visiting. The sleepovers with Birdie turned out to have a profound
impact, not just on MS’s sleep, but also on his relationship withhis daughter and other family members.
MS: I was also given the opportunity to take the dog I bonded withovernight while my four-year-old daughter was visiting. She could
see a different side of me. Instead of being a strict father, she andthe dog were getting praised for doing something right, rather
than being punished for something they did wrong. It brought tolight a different parenting technique that she responded to better.
The dog allowed us to connect in a very positive way. Working
with the dog has taught me patience, which also carries over tobeing a parent. I credit the judge’s favorable decisions in the custody case of my daughter to the parenting skills I mastered whileworking with Birdie.
RK: MS’s symptom reduction improvement followed his involvement with WCC’s Birdie. As reported and demonstrated by
actigraphy, the service member enjoyed restorative sleep for the
first time since his redeployment years earlier. Moreover, improvements in his mood, sleep, and concentration, as well as increased
energy, indicated that he was experiencing a decrease in his depression. MS also reported a decrease in pain. MS was discharged after
completing the extended NICoE treatment course in significantly
better condition. After, MS began the process of applying fora medical retirement from the military. He remained on medical hold for the next 12 months and continued to be treated at
Walter Reed.
RY: MS’s involvement in the WCC program increased over themonths as he prepared to transition out of the military. This led

The Battle for Hearts and Minds367

to his decision to request permission from his commanding officer
to work full-time as an intern with WCC. MS’s internship was
supported by the Marine Corps’ Wounded Warrior Regiment.
MS: The dogs have a drive to work and take care of people. They doso because they care, not because they have to. It’s great knowingthat I am helping to train a service dog for a service member who
has physical disabilities.
RY: MS’s personal and medical progress was paralleled by his success as a service dog trainer. Not only did he become an advanced
service dog trainer, but he helped teach other WCC participants
on how to train the dogs. MS volunteered to participate in dozens
of MBTR public presentations and speaking engagements to senior military and civilian community leaders to share the benefits
he felt he gained from the program. MS was also able to attend
and complete a college psychology class. The class paper he wrote,“Training a Dog to Train Me,” was an account of how the WCC
program was helping him regain control of his life, and teaching
him how to be the father his daughter needed. As MS’s training
skills improved and the relationship with Birdie deepened, he wasgiven permission to become Birdie’s foster parent and keep the dog
with him in his room during the 14 months MS was on medical
hold at Walter Reed.
MS: Birdie reduced a lot of the abrasive personality I had accrued
over the past year, and allowed me to be able to be out in public
without being overwhelmed.
RY: After nearly two years of MS’s increasing involvement with
WCC, the time came to decide which veteran would receive Birdie
as a service dog partner. This can be an emotional time for the
trainers who have developed strong, healing bonds with the dogs.
It is our experience that the pride of being part of the mission to
train a dog for another warrior in need proves greater than any
sense of personal loss of that particular relationship. In the few
cases where patients felt significant sadness, clinicians found thoseemotions provided therapeutic insight into deeper loss the patient

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had experienced in combat, but had not yet processed. This isespecially significant in treating veterans who are struggling withsurvivor’s guilt. MS, on the other hand, had made his peace with
passing Birdie’s leash on to another deserving veteran. But MS’s
pending retirement and therapeutic recovery presented anotheroption. The undeniable synchrony of social style, assertiveness,and responsiveness that had developed between him and Birdie
made the choice clear: MS and Birdie were a perfect match.
MS: About the time Birdie was finishing his training, I was leaving Walter Reed. He was going to be heading on to bigger andbetter things, and I was moving forward as well. The bulk of mytreatment was done, and I was moving back home to be with mydaughter and start the next chapter in my life. To my surprise, I
got a phone call from WCC shortly before I left, informing methat Birdie was going to be placed with me as my service dog. I
couldn’t believe it!
RY: With Birdie at his side, MS returned home and to civilian life.
Since then, he has introduced this program to his local Veteran’s
Administration Medical Center. MS continues to work with
WCC, doing public outreach and sharing his experiences with
Birdie and the WCC program to offer hope for other veterans
who are struggling with the invisible wounds of war. MS maintains primary custody of his daughter and has established a very
healthy relationship with her, along with a stable relationship withhis current girlfriend and her younger son.
MS: My family has also noticed a difference in the way I interact
with them as a result of what I learned and experienced while
training my service dog. I am patient with my children when
they are around, I haven’t yelled at them in several months, andthey aren’t afraid of me when I’m around. I think that is a direct
result of working with my dog. I remain so grateful to everyone
at WCC for such a great gift! And I will forever be grateful tothe big black behemoth lying next to me as I write this. Birdie
has changed me back to the person I once was, and maybe
even better. While I will likely always struggle with some of myThe Battle for Hearts and Minds369

deficiencies, he hasn’t skipped a beat in being there right besideme helping me through them and to overcome them.

GIVING THE DOG ITS SCIENTIFIC DUEGiven the dire need for compelling, safe, and effective treatment for PTSD,
as well as the long wait and high cost for skilled service dogs, the WCC
model offers a clinically sound, cost-effective, and non-pharmaceutical
way to help meet these critical military goals. The therapeutic success of
WCC’s MBTR program has garnered unprecedented military, veteran,and Congressional support.
In 2014, WCC’s research partners at the Uniformed Services University
of Health Science (USU) Consortium for Health and Military Performance
were awarded funding by the U.S. Army Medical Research and MaterielCommand to conduct a randomized (wait-list) controlled trial to investigate the psychological, physiological, and neurobiological effects of six
hours of MBTR participation on 20 Walter Reed patients with PTSD.
The effects of MBTR on the HRV performance of this pilot’s subjects wererecently presented at the 2018 Walter Reed Research Forum Analysis, andthe data suggested that HRV was significantly improved within 10 minutes
and at the end of the 60-minute MBTR session (Bonner et al., 2018).
HRV (as described in the case study above) is a well-established measureof autonomic nervous system function and reflects one’s ability to respondto and recover from stressful experiences.
This significant finding offers objective evidence that participation in
MBTR can produce acute improvement in the autonomic nervous systemof patients with PTSD. This change in physiologic status may contributeto our other preliminary findings that MBTR participants also experienced
a significant reduction in pain and perceived stress and reported improvement in cognitive, emotional, and social functioning. The findings fromthis study are expected to be published later in 2019.
WCC is also the focus of a larger, biopsychosocial prospective study,
conducted by researchers at the Walter Reed National Military Medical
Center (WRNMMC), the NICoE, USU, and the University of Maryland.
This research examines the biopsychosocial effects of 6–12 hours of MBTR
on 220 PTSD patients from Department of Defense (DoD) treatment

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centers in the Greater Capital Region. Follow-up measures will be taken
three months after completion of the MBTR research sessions. This study
will also investigate MBTR’s effect on sleep behavior, social interactions,and family dynamics. Results are scheduled for 2020.
It is our hope that these rigorous research protocols will further establish the scientific and therapeutic integrity of our Mission-Based Trauma
Recovery model, as well as provide clinical and scientific guidelines forthe appropriate training of the new class of service dogs for psychologicalsupport of veterans with PTSD.
REFERENCES
Beetz, A., Uvnäs-Moberg, K., Julius, H. & Kotrschal, K. (2012). Psychosocial andpsychophysiological effects of human-animal interactions: The possible role ofoxytocin. Frontiers in Psychology/Psychology for Clinical Settings, 3(234). https://doi.org/10.3389/fpsyg.2012.00234
Bilmes, L. J. (2013, March). The financial legacy of Iraq and Afghanistan: How
wartime spending decisions will constrain future national security budgets.
Harvard Kennedy School of Government: Faculty Research Working Paper Series.
Retrieved from http://web.hks.harvard.edu/publications
Bonner, J., Abraham, P., Kazman, J., Silverman, M., Hagin, J., & Deuster, P.
(2018). Service dog training program effects on heart rate variability. Poster
presentation at the Walter Reed National Military Medical Center Research
Forum, Bethesda, MD.
Congressional Budget Office. (2012, February). The Veterans Health Administration’s treatment of PTSD and traumatic brain injury among recent combat
veterans (CBO publication No. 4097, pp. 10). Washington, DC: U.S. Government Printing Office. Retrieved from https://www.cbo.gov/sites/default/files/cbofiles/attachments/02-09-PTSD.pdf
Edmondson, D., & Cohen, B. E. (2013). Posttraumatic stress disorder and cardiovascular disease. Progress in Cardiovascular Diseases, 55(6), 548–56. https://doi.org/10.1016/j.pcad.2013.03.004
Fischer, H. (2013, February 5). U.S. Military casualty statistics: Operation New
Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom (Congressional Research Service Report for Congress). Retrieved from https://journalistsresource.org/wp-content/uploads/2013/02/RS22452.pdf

The Battle for Hearts and Minds371

Fischer, H. (2015, August 7). A guide to U.S. military casualty statistics: Operation
Freedom’s Sentinel, Operation Inherent Resolve, Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom (Congressional ResearchService Report for Congress). Retrieved from https://fas.org/sgp/crs/natsec/RS22452.pdf
Levin, A., (2012, July 20). Army psychiatrist makes case for collaborative care.
Psychaitric News, 47(14). Retrieved from http://psychnews.psychiatryonline.org/doi/10.1176/pn.47.14.psychnews_47_14_10-a
Price, J. L., & Stevens, S. P. (2017). Partners of veterans with PTSD: Researchfindings. National Center for PTSD, U.S. Department of Veterans Affairs. Retrieved from https://www.ptsd.va.gov/professional/treat/specific/vet_partners_research.asp
Quintana, D. S., Kemp, A. H., Alvares, G. A., & Guastella, A. J. (2013). A role
for autonomic cardiac control in the effects of oxytocin on social behavior
and psychiatric illness. Frontiers in Neuroscience, 7, 48. https://doi.org/10.3389/fnins.2013.00048
Tedeschi, P., Sisa, M. L., Olmert, M. D., Parish-Plass, N., & Yount, R. (2015).
Treating human trauma with the help of animals: Trauma informed intervention for child maltreatment and adult post-traumatic stress. In A. H. Fine
(Ed.), The handbook on animal-assisted therapy: Foundations and guidelines foranimal-assisted interventions (4th ed., pp. 305–319). New York, NY: Academic
Press.
Yount, R. A., Olmert, M. D., & Lee, M. R. (2012). Service dog training program for treatment of posttraumatic stress in service members. Army Medical
Department Journal, 63–69.

ABOUT THE AUTHORS
Rick A. Yount, LSW, is the founder and CEO of Warrior Canine Connection,
Inc. He synthesized decades of social work experience and service dog
training expertise to create a unique animal-assisted intervention to help
service members with post-traumatic stress disorder. He has lectured
and published on the therapeutic observations and potential of WCC’s
Mission-Based Trauma Recovery program.

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Retired Navy Captain Robert Koffman, MD, was the director for psychological health to the Navy Surgeon General and Chief of Clinical Operations
at NICoE, as well as the recipient of the US Special Operations Command
Patriot Award for significant, enduring support to wounded warriors andtheir families. As chief medical advisor for WCC, he provides critical support for our service dog partnering process and research protocols.
Meg Daley Olmert is a world-renowned expert on the human-animal bondand its therapeutic effects. Author of Made for Each Other: The Biology of
the Human-Animal Bond, Daley Olmert serves as director of Research for
Warrior Canine Connection, Inc., and is scientific advisor to The Comfort
Dog Project in Uganda.

CHAPTER 12

Animal-Assisted Crisis Response:
Offering Opportunity for Human Resiliency
During and After Traumatic Incidents
Raquel Lackey, CPA, CMA, CGMA; and Gehrig Haberstock, MSW, AASWINTRODUCTIONOn March 22, 2014, at 10:37 a.m., the normally peaceful community ofOso, Washington, was hit by a monumental mudslide that engulfed 49
homes and other buildings, killing 43 people and devastating the community. With urgency, over 600 personnel, including first responders andvolunteers from across the country, arrived on the scene. Exhausted andmissing their families, search and rescue (SAR) workers from Sacramento,
California, took a short break during their complex mission. Sitting withelbows resting on his knees, eyes cast downward, and feeling weary, oneof the workers did a double take when he saw Pickles, an animal-assisted
crisis response (AACR) black Labrador retriever.
Accepting the worker’s repeated glances as an invitation, the AACR
team approached the resting SAR worker. Once near the worker, Pickles
leaned on and nestled next to him. For a brief moment amidst the anguish, the SAR worker’s tense shoulders relaxed as he delighted in thepresence of his new friend. After talking for several minutes, the worker
embraced Pickles and finished his final few hours on the job, remarking
how Pickles had given him the needed energy to finish his deployment.
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Pickles provided this SAR worker with comfort by establishing rapport,
offering a calm and helpful distraction, and building a therapeutic bridge
through being fully present (something that is difficult for even the mostexperienced human professionals and rescue workers to do), thereby acting
as the catalyst to propel the worker through his final hours of searchingfor survivors in the mud.
The practice of incorporating dogs into crisis response first emergedin 1995, when the Federal Emergency Management Agency (FEMA) requested them on-scene to provide comfort following the Murrah Building
bombings in Oklahoma City, Oklahoma (Shubert, 2012). A few years later,
the National Organization for Victim Assistance summoned AACR teams
to the 1998 Thurston High School shooting in Oregon. While on scene,counselors who were unsuccessful using traditional techniques watchedin amazement as the human-canine teams broke down the walls of isolation among previously withdrawn students (HOPE AACR, 2017). Soon
after returning from her Oregon call-out with her canine partner, Bear,
Cindy Ehlers founded Hope Pets in 1999, which in 2001 became Hope
Animal-Assisted Crisis Response (HOPE). Ehlers’ newly formed nonprofit
organization, the first of its kind in the United States, was a foundational
step in formalizing what is commonly known today as animal-assisted
crisis response or AACR, particularly in setting the precedent for specialized training and a concentrated focus on the welfare and well-being ofparticipating canines (HOPE AACR, 2017).
AACR volunteers were also present following one of the most tragicdays in US history, and one that none of us living at the time will soon
forget — September 11, 2001. Teams consisting of human handlers andcanine partners were present at Ground Zero following the terrorist attacks (Shubert, 2012), and were called in by the American Red Cross to
support the efforts of counselors and chaplains as they provided care andcomfort to individuals and families awaiting updates about their loved
ones at Manhattan’s Pier 94 Family Assistance Center. The response to
September 11 prompted Ehlers to develop a comprehensive, multiday
training program to better prepare human-canine teams for the various
hardships often encountered during deployments, including precarious
environments, human fragility, and emotional and physical exhaustion.
Shortly thereafter, National Animal Assisted Crisis Response (presently
known as NATIONAL Crisis Response Canines) was founded in 2003.

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NATIONAL offers similar services as HOPE, and collaborated in thedevelopment of the 2010 AACR national standards.
WHAT IS ANIMAL-ASSISTED CRISIS RESPONSE (AACR)?
As defined by this chapter’s authors, AACR is the utilization of certified
canine-and-handler teams assisting in crisis interventions to support thepsychological and physiological needs of individuals affected by, and responding to, crises and disasters in complex, unpredictable environments.
These interventions, which provide needed respite during periods ofunimaginable turmoil, are becoming all the more important due to thegrowing number of annual Stafford Act Disaster Declarations (since 1953)
within the United States; when averaging 2000 to 2009 data, the original
figure of 19 annual declarations has increased to 56 per year (Lindsay &McCarthy, 2015). Likewise, on a global scale, there has been a documented
increase in weather-related events, particularly flooding and storm-related
events. Between 2005 and 2014, an average of 335 weather-related events
per year occurred, representing a 14% increase from the previous decade(UNISDR, 2015). Looking toward the future, we must recognize thatclimate-related disasters are on the rise, and be diligent in understanding
the interconnectedness of growing population exposure and vulnerability, and the ongoing expansion of climate-related hazards (Thomas &Lopez, 2015).
Given that natural disasters are known to lead to an increase in theprevalence of mental illness, these growing trends have problematic implications (Canino, Bravo, Rubio-Stipec, & Woodbury, 1990; Madakasira &O’Brien, 1987). Specifically, weather-related disaster incidents, as well as
those associated with community violence and acts of terrorism, are placing
emergency responders and those personally impacted by these events at
an elevated risk of experiencing trauma. Through human-animal interactions (HAIs), AACR provides comfort and encouragement for individuals
affected by crisis and disasters, including those who have lost all of theirpersonal possessions; first responders working through tiresome days anddangerous conditions; workers coordinating a response in an emergency
operation center (EOC); and volunteers making a difference in the lives
of affected individuals.

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TRANSFORMING TRAUMAEVIDENCE SUPPORTING ANIMAL-ASSISTED CRISIS RESPONSE
Due to the somewhat indescribable nature of the human-animal bond,which archaeological evidence suggests has existed for thousands of years,
it is understandable how AACR could look and even feel like magic to theuntrained eye (Wenzl, 2017). One example of this perceived “magic” isindicated in a 2013 doctoral dissertation by Filomena Bua. In her interviews with AACR handlers and crisis counselors who had worked on the
ground with AACR teams in Australia, Bua (2013) reported that her study
participants “believed that AACR dogs have an innate ability to find thepeople in crisis who appear to need the most support” (p. 94). While suchabilities and sensitivities to human emotion may indeed be present in dogs,
especially those who work in close connection with people, there is a needto acknowledge the significant training, skills, and qualifications necessary
to perform and implement AACR work safely and effectively. Currently,
substantial evidence exists to warrant the continuation of these services,while simultaneously demanding further and more rigorous exploration
to fully validate AACR protocols.
Whether or not someone develops a mental illness (i.e., post-traumaticstress disorder or PTSD; depression and anxiety; prolonged and traumatic
grief; secondary grief reactions; suicide or suicidal ideation; substanceabuse or dependency; and/or stress-related health problems) following a
traumatic disaster or crisis is contingent on numerous personal and environmental factors (Bonanno, Brewin, Kaniasty, & La Greca, 2010). While
many variations of these influences exist, Bonanno and colleagues (2010)provide a comprehensive overview of factors that may impact an individual’s resiliency across the entire crisis event (i.e., pre-disaster, disaster, andthe aftermath of disaster):• The pre-disaster context considers the following factors: the individual’s age, gender, and race/ethnicity; preparation and priorexposure; social support; economic resources; and personality.
• The disaster event factors primarily relate to proximal exposure,referring to the “events and consequences that occur during theapproximate period of the disaster itself ” (p. 20).
• Factors related to the aftermath of the disaster are mainly related to distal exposure, including economic resources lost;
displacement and relocation; and media coverage.

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Of all factors mentioned, AACR is best able to directly impact a person’s level and quality of social support (specifically received support oractual support provided), which hopefully has a positive influence on perceived support (or the personal, subjective experience of feeling supported)and a subsequent reduction in distress (Bonanno et al., 2010). As Bua(2013) proffers, humans and canines are social complements, enabling
the fulfillment of each other’s needs for connection and social adaptability,
leading to successful and supportive attachments. Given that the aforementioned concepts stem largely from attachment theory, it must be notedthat there are also other commonly accepted AAI theoretical perspectives
possibly at play, namely the biophilia hypothesis and the notion of animals
as being mediums, or bridges, in the therapeutic relationship (Scott, 2015).
Coupled with enriching an individual’s social support system and resources (even if only temporarily), AACR teams offer psychological andphysiological benefits to promote short-term resiliency, while acting as agrounding mechanism to root the client back to reality. When individuals
experience traumatic events, they are susceptible to both immediate anddelayed emotional reactions. AACR aims to empower individuals to be
mindful of their immediate reactions, such as numbness and detachment;
disorientation; elevated heart rate, respiration, and blood pressure; racing
thoughts; and distortion of time and space, in order to limit the development of delayed reactions (Center for Substance Abuse Treatment, 2014).
When faced with crises, humans have a tendency to close down and isolate,a phenomenon that AACR dogs and handlers are able to help individuals
overcome through the establishment of rapport and creating a sense ofsafety and support. The presence of a dog can also promote security, comfort, and stabilization, thus regrounding an individual who has experienced
a crisis in the present (Chandler, 2012) and facilitating resiliency.
Arguably, dogs may have a grounding and supportive impact because
their presence prompts neurochemical releases, such as oxytocin, in our circulatory system and brain (Bua, 2013; Olff, 2012). Often referred to as thelove or social bonding hormone, oxytocin is commonly released due to sensory stimulation, such as “breastfeeding, labor, sex, but also touch, warmth,and stroking” (Beetz, Uvnäs-Moberg, Julius, & Kortrschal, 2012, p. 11).
There is also recent evidence that mutual gazing between dogs and theirowners increases oxytocin levels for both the human and canine (Nagasawa
et al., 2015). As summarized by Beetz and colleagues in their 2012 literature review, oxytocin has been shown to influence how connected we378

TRANSFORMING TRAUMA

are with others; increase trust and social skills; decrease depression, bloodpressure, heart rate, and glucocorticoid levels; induce calmness; and potentially even increase pain thresholds (Handlin et al., 2011; Heinrichs,
Baumgartner, Kirschbaum, & Ehlert, 2003; Kaminski, Pellino, & Wish,
2002; Petersson, Eklund, & Uvnäs-Moberg, 2005; Rimmele, Hediger,
Heinrichs, & Klaver, 2009).
However, oxytocin is not the only neurochemical active in the bodyduring interactions with animals. Whether in a crisis situation or not, stress
reductions as measured by decreased salivary cortisol and blood pressure
have been observed in those interacting with an animal (Friedmann & Son,2009). Furthermore, increases in beta-endorphins, prolactin, and dopamine can occur in both humans and canines during positive human-animal
interactions (Odendaal & Meintjes, 2003). Lastly, and potentially significant in grounding individuals, the presence of a canine engages all fiveof our senses, facilitating a powerful bond and contact (i.e., touch and/or
physical affection) not customarily present or always appropriate amongst
strangers, such as first responders or mental health providers.
Looking specifically at the potential long-term benefits of AACR as
observed anecdotally, the comforting presence of a canine partner may facilitate trust that allows the client to begin to process his or her experience
and/or loss, as well as identify coping strategies that will help the person
move toward a “new normal.” For example, AACR teams may play animportant role in confidential briefings for individuals who have recently
lost family members in an event, and/or who are awaiting news of theirRex, an AACR canine, joins a family at a reunification site following a school shooting.
Photograph by Elizabeth Lyon, NATIONAL Crisis Response Canines.

Animal-Assisted Crisis Response379

loved one’s fate or safe return. Below is a case study that illustrates theapplication of AACR in such situations.
CASE STUDY
Less than 24 hours after a shooting, and prior to families receiving confirmation of the deceased, an AACR team entered anemotionally charged room where individuals anxiously awaited
information about their loved ones. Engaging with individuals
in the room was met with varying degrees of success. As each
person responds differently to trauma and grief, some people embraced Areya, an AACR husky working with her human handler,
while others nonverbally refused contact. While navigating theroom, the handler recognized one woman’s interest in engaging
with Areya. The woman, who self-identified as a cat person, wasgiven brief respite while digging her fingers into Areya’s soft fur,petting her head, and gazing into her eyes, all while talking withthe handler about matters unrelated to the present traumatic
experience. After receiving confirmation that her loved one waskilled in the shooting, Areya and her handler gradually and respectfully reengaged the grieving woman as she began processing
her untimely loss. During such extreme grief reactions, our human instincts tell us to say comforting words or offer soothing
touches. However, following the lessons of AACR trainings andthe quiet example of Areya, the handler sat on the floor with thewoman and provided appropriate support by being silent, yet
fully present (J. Jackson, personal communication, September
30, 2016).

Unlike traditional therapy, the brief and urgent nature of crisis intervention requires rapport to be established nearly instantaneously for ameaningful dialogue to commence. This is where the presence of a canine
can be immensely beneficial. According to Graham (2009), the “dog serves
as an entrée to the establishment of a relationship and a venue for theaffected individuals to talk” (p. 76). Cynthia Chandler echoes Graham
when recalling her experiences of engaging with clients in Red Cross shelters during the aftermath of Hurricane Katrina. After her first two days of380

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deployment, Chandler and other Red Cross disaster mental health volunteers shared a mutual frustration of not being able to effectively connect
and converse with evacuees (Chandler, 2012). However, things changedon the third day when Chandler’s two dogs were allowed to accompany
her into the shelter. As she walked the aisles of the shelter, clients’ faces
and affect turned from shocked and grief-stricken to smiles and laughs,
sparking conversations between volunteers and clients (Chandler, 2012).
Simply put, Chandler’s dogs were able to remove “the barriers that had
been impeding the sharing process by evacuees” (Chandler, 2012, p. 274).
Similarly, Reverend Michael Rogers, a mental health professional withover 35 years of field experience, has remarked that it takes a recipient approximately one quarter of the time to open up and share with him whenan AACR team is present. Rogers (2014) summarized his response workwhen coupled with AACR teams by stating:
These highly trained dogs are a treasure. Not only are more people reached through their presence, the potential quality of eachhuman interaction is enhanced. Sharing a crisis response dog experience together is like sharing a meal. Defenses are lowered. Careis enhanced through open hearts. (para. 4)
Establishing safety and trust through rapport is the basis upon which
one can empower healing and change within traumatized individuals. An
acceleration in this foundational step, a concept Rogers (2014) calls rapid
rapport, is made possible when working with a canine partner. As reportedby the experience of some AACR responders, the presence of a speciallytrained and well-groomed dog allows the client to see the handler as atrustworthy individual, as the canine provides a visual representation of
the handler’s ability to care for another living being. Similarly, in Schneider
and Harley’s (2006) study on client perceptions of psychotherapists, findings showed that, when accompanied by a dog, psychotherapists were
responded to more positively, with clients indicating a greater willingness
to disclose private information. Empirical and anecdotal findings such asthese may be related to the ability of animals, particularly dogs, to serve
as catalysts or facilitators in creating “affiliation[s] and relations in social
interactions” (Guéguen & Ciccotti, 2008, p. 339; McNicholas & Collis,
2000, 2006).
Furthermore, select research has demonstrated that interaction withanimals may have salient calming effects for people through the reductionAnimal-Assisted Crisis Response381

of stress and anxiety, two symptoms almost always present in traumatizedindividuals. When utilizing a visiting canine animal-assisted intervention(AAI) with psychiatric patients receiving electroconvulsive therapy, Barker,
Pandurangi, and Best (2003) determined that interacting with a therapy
dog significantly reduced treatment-related anxiety and fear. In fact, someof the major physiological effects a dog can bring to a therapeutic relationship are reductions in heart rate and blood pressure, both of which are
typically elevated in stress-prone conditions, as well as in unfamiliar or uncomfortable social situations (Beetz et al., 2012; Bua, 2013). In their 2012
literature review, Beetz and colleagues discuss additional research findings
regarding the stress-related benefits of AAIs, including those interventions
that are brief in nature:• Reductions in stress after a five-minute interaction with a therapy dog among health care professionals (Barker, Knisely, McCain, & Best, 2005).
• Reduced state-anxiety after petting both hard-shelled animals(e.g., a turtle) and soft animals (e.g., a rabbit); notably thesestate-anxiety effects were not observed in participants after theypetted toy turtles and rabbits (Shiloh, Sorek, & Terkel, 2003).
• Improvements in cardiopulmonary pressures, neurohormone
levels, and anxiety in adult patients hospitalized with heart failure after a 12-minute visit with a therapy dog (Cole, Gawlinski,
Steers, & Kotlerman, 2007).
In many cases, AACR interventions occur with little to no verbal communication between the handler and human recipient. However, all AACR
handlers are trained in psychological first aid (PFA) to further enhancethe overall AACR experience and impact. The Minnesota Department of
Health (2016) defines PFA as, “[A]n evidence-informed approach that isbuilt on the concept of human resilience. PFA aims to reduce stress symptoms and assist in a healthy recovery following a traumatic event, natural
disaster, public health emergency, or even a personal crisis” (para. 1).
PFA employs “five elements of psychological response” — 1) senseof safety, 2) calming, 3) a sense of self and community efficacy, 4) connectedness, and 5) hope — that are crucial to address when responding toclients impacted by a disaster (McIntyre & Goff, 2012, p. 724). Whenan AACR team engages with an individual utilizing PFA (which emphasizes the importance of active listening and keen observation), they are

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During a free medical clinic in Seattle, Washington, this gentleman arrived for dental work.
After waiting for hours, his anxiety soared and he felt unable to receive treatment. Upon
request from clinic organizers, Sierra and her handler (a HOPE AACR team) accompanied him
while the dental procedure was performed. He was able to receive his needed treatment bykeeping his hand on Sierra throughout the entire procedure. Photograph by Auston James,
courtesy of Seattle King County Clinic (SKCC).

able to offer the benefits of a personalized intervention enriched by thepresence of the dog to empower the development of individual resiliency.
For example (and mirroring Chandler’s [2012] experience), one of thischapter’s authors was able to stabilize a distraught shelter resident into thepresent moment using PFA techniques with her AACR canine partner,
thereby aiding in the reunification of this individual with her family after
a period of separation.
NATIONAL STANDARDS AND BEST PRACTICESIn 2010, the founding AACR organizations of HOPE and NATIONAL
collaborated to create the Animal-Assisted Crisis Response National Standards(National Standards Committee for Animal-Assisted Crisis Response,2010). These standards provide guidance on handler and dog training,
evaluation, experience, certification, standards of conduct, and AACR organizations. Of note, AACR teams need to integrate seamlessly with thebroader response to minimize confusion. To do so, it is recommended
that handlers take and successfully pass four foundational FEMA courses:

Animal-Assisted Crisis Response383

FEMA IS-100.c, IS-200.b, IS-700.b, and IS-800.c. These courses, each ofwhich is currently available online, provide responders with an operationalframework of the Incident Command System (ICS), a component of the
National Incident Management System (NIMS) utilized in the UnitedStates that defines command, control, and coordination to facilitate effective response efforts (FEMA, 2008).
It must be noted here that AACR is not considered therapy or treatment, but rather a specialist intervention and support service for people
in crisis (Bua, 2013; Robinson, 2004). Currently (and as taught in certification workshops), PFA is the preferred minimum crisis intervention skill
used by AACR handlers, especially by those without a mental health background (Brymer et al., 2006). With continuing education required by the
AACR National Standards, trainings that this chapter’s authors have seen
as beneficial in enhancing handler skills include Critical Incident Stress
Management (CISM) and Applied Suicide Intervention Skills Training(ASIST). Building upon skills possessed by many already, PFA training
equips AACR responders with the ability to foster resiliency in those impacted by trauma, as well as support their own self-care and psychologicalwell-being during and after deployments (Minnesota Department of
Health, 2016).
As with any helping professional working with traumatized anddistressed individuals, AACR team members may be susceptible to experiencing trauma vicariously, which can lead to compassion fatigue and/or
burnout (Boscarino, Figley, & Adams, 2004). To reduce or address thispotential issue, confidential debriefings conducted by a trained CISM peerwith the oversight of a mental health professional are becoming a regularoccurrence for AACR teams following a deployment. While the symptoms of vicarious trauma are abundant and individualized, some affirmed
by AACR responders include difficulty falling or staying asleep, fluctuations in eating or alcohol consumption, and intrusive dreams (AmericanCounseling Association, 2011).
Accordingly, an AACR responder, or even a disaster response counselor,must be able to process and tolerate high levels of compounded stress, possess strong organizational and assertiveness skills, and excel at collaboratingwith countless other response stakeholders, all while being able to makedecisions independently (Chandler, 2012). Although AACR handlers havea responsibility to serve those in trauma and themselves, their primary role
is to ensure and advocate for the physical and psychological well-being of384

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their canine partner (National Standards Committee for Animal-Assisted
Crisis Response, 2010). Due to human reliance on verbal communication
and/or their attention to event specifics and the needs of AACR recipients,
handlers should be careful not to overlook their dogs’ behavioral indicatorsof stress and fatigue during a deployment. Knowing this, handlers needto develop an advanced understanding of their canine partner’s behavioral
and personality traits prior to being deployed. Correspondingly, having astrong relationship with their dog further enables handlers to advocate forhis or her needs both during and after highly stressful work.
While certain signs of canine stress — such as body shaking, panting,
lip licking, increased locomotion, and restlessness, to name a few — arewell-documented (Glenk, 2017), it is important to note that dogs participating in AACR might display additional manifestations. Throughdiscussions with AACR responders, some specific signs of stress, fatigue,
or being overworked among AACR dogs include refusing to wear theirworking vests when given the option, turning their heads to avoid engaging
with visitors, or lying down and facing away from activity. Handlers must
remember that advocating for their canine partner is a complex endeavorthat encompasses more than simply watching for stress signals during interactions. Indeed, careful planning and preparedness on the part of thehandler needs to occur. Factors to consider beforehand include the modeof transportation to, and during, deployments, as well as weather condition
variations between home- and deployment-life.
Moreover, the handler’s role as canine advocate becomes increasingly
important during extended deployments, as stress is typically cumulative.
Not only is the team entering into a chaotic environment, but the canines
may be continuously exposed to potentially stressful stimuli, including
unfamiliar surroundings, new sights and smells, and the high intensity ofneed presented by individuals seeking their comfort (National Standards
Committee for Animal-Assisted Crisis Response, 2010). It cannot be overstated that dogs, even more so than humans, respond differently to stressors
and manage their stress in unique ways.
Prior to becoming an AACR team, the handler and dog must be a certified therapy team with at least one year of experience (National Standards
Committee for Animal-Assisted Crisis Response, 2010). After gaining
this experience, the team can begin the process of determining whether
or not they would make a favorable AACR team. Experience has shownAnimal-Assisted Crisis Response385

that proper canine selection not
only strengthens the potential
for positive human outcomes,
but also is crucial for the dog toenjoy his or her job (Jegatheesan
et al., 2014). In complementing
earlier research conducted byOdendaal and Meintjes (2003),
Marcus (2013) concludes thattherapy dogs included in AAIs experience these visits as work. The
Oscar (left) and Pickles (right) pausing to take a break study’s inference that these activfrom their AACR work during the Highway 530 mudslide
ities require work and intentional
response in Oso, Washington. Photograph by Raquel
effort on the part of AAI animals
Lackey, HOPE Animal-Assisted Crisis Response.
is logical when one considers thattherapy dogs must calmly, willingly, and obediently accept petting andother forms of physical contact from strangers, rather than taking part inplay or other enjoyable activities (Marcus, 2013). With this in mind, andunderstanding that work and stress can have both positive and negative
aspects, some ethicists suggest that when balanced appropriately, the benefits received by dogs through human-animal connection support theircontinued participation in AAIs, such as AACR (Zamir, 2006). Given theunpredictability and high intensity of disaster deployments and settings,
one could reasonably contend that the sense of work (and therefore stress)
felt by AACR teams is comparatively greater than that experienced byhandlers and therapy dogs who participate in more traditional AAIs (e.g.,
in a therapist’s private office).
Likewise, the importance of a strong, reciprocal relationship between
handler and dog is elevated within AACR work, and teams must be able
to enter chaotic, unknown situations with a mutual trust to ensure eachother’s safety and well-being. As indicated by AACR responders, it is easy
to sometimes overlook the fact that enjoying human contact and taking
pleasure in being petted by a wide variety of people is also taxing, even for
carefully selected and trained AACR canine partners.
Even though difficult to quantify, canine partners on deployment
should also be prepared for, aware of, and be able to respond to environmental hazards that could place the team in danger (National Standards

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Committee for Animal-Assisted Crisis Response, 2010). The following
account about one author’s experience depicts how a strong connection
between handlers and their canine partners may have mutually beneficial
implications in AACR work.
CASE STUDY
Within 24 hours of the Highway 530 mudslide, an AACR teamwas deployed to provide comfort, care, and temporary respite
to those staffing the emergency operation center (EOC). Being
conscious to not overwork her canine partners, the handler
alternated workdays between her two AACR dogs. However,as she served as the sole handler for both dogs, the emotional
work slowly began to take its toll on her. Ten days and countlesshours into the deployment, her canine partner communicatedbehaviorally a request to not work for the remainder of the day,displayed by a slowing of the gait and taking a long pause before
entering the main EOC room. This happened to be the same
day that the handler began fighting a cough and cold. Withina few days, and while supporting teams remotely, the handler’scondition worsened, initiating a trip to urgent care and antibiotic
treatment. This account is indicative of how the close connections between AACR handlers and dogs can manifest, including
through potential mirroring of experience/symptoms, as well as
being in tune with each other’s subtle changes in affect, mood,and behavior.

In regard to canine selection, Chandler (2012) explains how and why
only certain dogs are suitable for AACR work. Chandler (201) writes, “A
therapy dog should not be brought to a crisis and disaster scene unlessthey have a high tolerance for stress, chaos, and noise; a consistent andreliable response to commands; and a highly sociable attitude towards all
people” (p. 287), all of which will be tested and verified during certification to ensure the prospective canine partners are qualified AACR dogs.
AACR canines, partnering with their advocate handlers, must be able tomanage the unpredictable environments surrounding traumatic events, as
exemplified in the following selected scenarios:Animal-Assisted Crisis Response387• AACR canines need to be adaptable in a variety of environments. For example, when taking part in a school presentation on depression and suicide prevention following a school
shooting, an AACR dog will likely be confronted with a gymnasium full of large crowds and loud noises. However, that
dog may also participate in quieter, yet still potentially stressful
and emotionally charged interactions, such as being present
during student group sessions focused on suicide and self-harmprevention.
• AACR canines often accompany their handler when in thepresence of media personnel after a disaster has occurred.
These situations often involve urgent questioning about thetraumatic event and the nature of AACR work from large andeager groups of people, as well as the stress of public speaking(for the handler, which could impact his/her dog), cameras,
and hot lights.
CONCLUSIONS AND NEXT STEPSGiven the increased frequency of traumatic events, both natural and “manmade,” the need and demand for AACR is growing. Concurrently, there
is increasing interest and publicity surrounding AACR, as well as an increasing number of organizations attempting to provide these services. At
present, AACR work is mostly carried out by volunteers. As experienced
daily by one of the authors, volunteers are often equally as capable ofperforming this specialized work as their paid staff counterparts. Whether
their volunteerism is driven by professional experience or personal passion, trained and qualified volunteers are indispensable in crisis response,
including, but not limited to, firefighting, search and rescue, and AACR.
With increased attention to the field comes greater need to attend to
the following: 1) to uphold (and revise as necessary) the existing national
standards to keep professionals, volunteers, canines, and clients safe; and2) to conduct more focused and rigorous research evaluating the human,canine, and community health outcomes associated with AACR interventions. As with other crisis response services, interventions like AACR and
PFA are difficult to study. Some of these challenges include the inability
to gather baseline data, the complexities of ethically or practically studying

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individuals in a state of crisis, and the relatively short nature of the AACR
intervention (Lyon, & Sullivan, 2007; Pekevski, 2013). Further challenges
of conducting ethical research in AACR include creating control groups,
ensuring participant consent, and establishing adequate sample sizes andrandomization of participants (Dieltjens, Moonens, Van Praet, De Buck,& Vandekerckhove, 2014; Pekevski, 2013; Stern & Chur-Hansen, 2013).
However, these challenges of scientific inquiry must be met in order toaccurately determine both the benefits and risks of working with animals
under these most demanding and strenuous of conditions. For example,
there is urgent need to understand, and then properly set, the expectations
that can be reasonably and ethically asked of an AACR canine partner,
particularly in regard to how long they can humanely work (i.e., length of
workday, deployment, and overall AACR career).
Additional studies specifically measuring the impacts and outcomes of
AACR would also help to solidify trauma-informed interventions, while
simultaneously validating their utility. In order to make strides toward thisend, we propose that researchers first focus on one particular area in needof investigation: the inclusion of AACR canines in CISM methodologies(i.e., those that center on immediate and concrete issues). For example,
studies examining how AACR dogs may impact the stress-related outcomes
and trauma symptoms of those who have experienced disaster or crisis (ascompared to the use of CISM without the inclusion of an AAI) would beof great benefit to this emerging area of study and practice. Ultimately,
there is an intrinsic responsibility to ensure that responders, both humanand canine, are properly supported and equipped to meet the needs of theindividuals with whom they interact, with research being an importantcomponent of establishing reliability and validity of AACR effectiveness.
As detailed above, responding to emergencies is not for all people ordogs, and those individuals who are interested should seek both knowledge
and experience before first volunteering with their therapy dog for deployment. One of the best ways to gain exposure in this area is by volunteeringwith the American Red Cross or for another disaster relief organization.
Volunteering in this area offers a valuable opportunity to gain experience
in responding to emergencies, interacting with clients who have recently
experienced a traumatic incident, and being ready to respond promptly after receiving an urgent call to action. These hands-on experiences will help
determine whether or not someone has the skillset to appropriately manage
both the short- and long-term effects of stress associated with AACR work.

Animal-Assisted Crisis Response389

In summary, while further research is certainly needed, there currently
exists evidence and scientific validity to support the incorporation of therapy dogs into crisis response efforts to benefit individuals and communities
who have experienced trauma. We propose that adherence to the following
four key principles will be important in further improving these emerging
practices and their comprehensive outcomes. First of all, handlers mustnever self-deploy when disaster strikes; rather, responders should always follow ICS structure to avoid additional chaos or causing harm to themselvesor their canine partner. Secondly, much like finding the “right” canine tobecome a successful service dog is a challenging endeavor, so too is thecase with working AACR dogs. Acknowledging that it takes a very special
dog and human handler to excel in this service, the relationship between
the canine and human must be built on unquestionable trust and respect.
The third principle pertains to the importance of educating the general
population on the Animal-Assisted Crisis Response National Standards sothat the health and safety of all involved — including those responding to,
and impacted by, the traumatic events; the AACR handlers; and especiallythe canines — are fully supported. Finally, and perhaps most importantly,
the welfare of the canine partner before, during, and after each deployment
is paramount. Our canine partners must have a particularly strong advocate to ensure that their well-being is safeguarded while working in theunpredictable midst of chaos and devastation, and that they emotionally,
mentally, and physically enjoy their participation in serving traumatized
populations during each and every AACR deployment.
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ABOUT THE AUTHORS
Raquel Lackey is a certified public accountant with over 25 years of experience in both public and private accounting. She is currently the presidentof Washington State Volunteer Organizations Active in Disaster, and serveson the boards of HOPE Animal-Assisted Crisis Response and Readingwith Rover. Along with her two dogs, Pickles and Bungee, Lackey has
volunteered in the area of crisis response since 2010, often serving morethan 400 hours annually. Lackey is a certified field traumatologist and394

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compassion fatigue educator with Green Cross Academy of Traumatology,
and has recently become a certified instructor with the International
Critical Incident Stress Foundation.
Gehrig Haberstock, MSW, graduated from Harding University and the
University of Denver with degrees in social work. Currently, he serves as
disaster program manager in Wyoming for the American Red Cross, witha particular interest in chaos management. In this role, he also provides
facilitative volunteer leadership in disaster relief and response. Haberstock
is an avid cyclist, passionate outdoorsman, and loves investing in his community and the people in it.

CHAPTER 13

Loss, Grief, and Bereavement in theContext of Human-Animal Relationships
Susan Cohen, DSW; and Adam Clark, LCSW, AASWINTRODUCTION
Our relationships with animals can be a cause of trauma or a buffer against
it. As this chapter will show, most human-animal interaction (HAI) research has explored the benefits of interacting with animals, especially in
our homes and in therapeutic settings. Less scholarly work has focusedon the effects for people when pets, therapy and service animals, wildlife,
livestock, or captive animals are lost or, more specifically, pass away.
This chapter discusses trauma in the context of grief, while exploring
the role of other animals in supporting humans through periods of loss.
In particular, we consider the special challenges of losing an animal companion, including the social devaluation and stigma of pet loss, as well as
the meaningful place of animals in the lives of vulnerable people and what
the loss of those relationships brings. Further, we discuss how animals can
support those in bereavement, as well as how the loss of a beloved animal
can be in and of itself traumatic, especially if disparaged or minimized.
Additionally, we consider recently publicized traumatic losses of certain
wild and captive animals, and how their deaths galvanized thousands ofpeople who never knew them, becoming a vehicle for grieving, as well as
political and often racial commentary. Finally, through clinical insight andcase examples from our experiences as counselors in both veterinary and
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academic settings, we discuss potential ways to frame these experiences so
as to not only protect those involved from enduring further trauma, but
to also make loss an opportunity for growth.
TRAUMA IN THE CONTEXT OF LOSSAs discussed at length throughout this book, traumatic events are often so
far outside previous or typical experience that one is often forced to revise
his or her worldview in response. Some such events seem obvious (i.e.,shootings, assault, watching your house burn to the ground). And yet,people react differently to similar misfortune. What is devastating to one
can be inspiring and motivating to another.
Generally speaking, a traumatic event is one that overwhelms the person’s perceived resources to cope with it. It is the kind of experience that
can alter our memory functioning, and cause us to be hypervigilant ofpotential indicators of peril or misery. In small doses, attention to suchwarning signals can be protective. However, when they turn chronic oroverwhelming, they become unmanageable and detrimental to a person’s
overall quality of life. For example, the traumatized individual may findthat ordinary, everyday events or stimuli — such as a helicopter flying overhead, a comment heard on television, or a song playing on the radio — cantrigger the traumatic memory in full force, disrupting normal activity, as
well as mood (McCann & Pearlman, 2015).
The distinctly emotional, and often traumatic, pain that comes withlosing someone we love (whether human or animal) is a universal experience, although grieving itself is highly subjective (Clements, DeRanieri,
Vigil, & Benasutti, 2004; Saavedra Perez et al., 2015; Shear, 2015; Simon,2013); an individual will process loss according to his or her own lens,
including personal histories, supportive networks, characteristics of thelost relationship, and preferred or customary ways of coping (both positive
and negative). The experience of grieving also typically varies depending
on cultural upbringing, race/ethnicity, gender, economic resources, andreligious or spiritual background.
Further, the manner in which we lose or say goodbye to someone (ornot, in some cases) is also important. Some people will lose a loved one who
gradually grows old and passes peacefully, while others will experience theshock of an unexpected or sudden loss, such as the suicide, homicide, or
unexpected accident or illness of a friend or family member (Clements etLoss, Grief, and Bereavement in the Context of Human-Animal Relationships397

al., 2004). Other significant losses, such as through divorce or separation,
the end of friendship, the regretful relinquishment of companion animals to
shelters, or pets running away from home, may also be profoundly traumaticfor individuals, both human and animal alike. Taken together, these myriad
factors often influence opinions regarding how long the grieving process
should last. Generally, strong emotional response within the first year ofloss is typical, although some research indicates that a two-year timeframe
is still considered to be a very “normal” grieving process (Simon, 2013).
However long the process lasts may not be as important as the integration of experience, which is highly individualized and expressive of
the grieving individual (Corr & Corr, 2012). Most grief counselors andclinicians, in an effort to respect differences in how people experience andmanage grief, hesitate to assign specific timeframes to such duration, butthey do consider the level of negative impact that a grief experience is having on the patient’s or client’s life. Indeed, the full weight of experiencing
loss is often substantial, and impacts a person in all aspects of living: mentally, spiritually, physically, socially, and financially (Corr & Corr, 2012).
Grief changes the way we have been living life, regardless of whether theloss is of relationship, of job, of plans and dreams for the future, or of loved
ones through death or other permanent separation. After loss, we are now
faced with the absence of someone or something we expected would bepresent in our lives for a long time, possibly forever. Consequently, ourperspectives and the stories we tell ourselves will (need to) shift, often inrather abrupt, unpredictable, and complex ways.
Moreover, significant grief and loss will nearly always adjust (or shatter,even if temporarily) a person’s sense of self and reality, as the loved one oractivity is no longer present in day-to-day life. Assumptions and routines
may be altered or halted, which, depending on the circumstance and typeof loss, can cause the bereaved to question one’s purpose in life and evenone’s very existence (Shear, 2015). People may also grapple with the reality
and uncertainty of their own mortality, whether it happens today or years
in the future, when working through their feelings of loss.
COMPLICATED GRIEF
When grief turns from a natural, although difficult, response to a more
complex experience leading to long-term challenges or adverse health effects, a person may be suffering from what is known as complicated grief.

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A traumatic loss can lead to expressions of complicated grief, which primarily include intrusive or uncontrollable thoughts about the deceased orindividual who is no longer present (Saavedra Perez et al., 2015; Shear,
2015; Simon, 2013; Supiano & Luptak, 2013). In other words, a personwith complicated grief tends to ruminate on the loss, and his or her pain
associated with it. These thoughts and memories may take on a repetitiveor cyclical pattern and can significantly lessen the bereaved person’s quality of life, causing increased suffering or negative consequences to occur(Clements et al., 2004; Shear, 2015; Simon, 2013). For example, grieving
may be so intense as to cause someone to stay home and miss multiple daysof work due to feeling overwhelmed and unable to function. As a result,the person might experience the additional losses of their job, financial
security, relationships with valued colleagues, and sense of professional
purpose or identity.
One of the primary theoretical perspectives underlying complicatedgrief is that of Bowlby’s Theory of Attachment (Bowlby, 1969/1982).
Within his work, Bowlby summarizes that it is the level of perceived attachment between individuals that dictates the strength of that particularbond (Bowlby, 1969/1982). Hence, it may be suggested that with stronger bonds or attachments comes greater risk of complicated grieving when
the bond is broken or lost (Bowlby, 1969/1982; Brown & Symons, 2016).
As suggested below, the levels of perceived attachment between humans and their pets may arguably be greater than that between humans incertain cases, thus highlighting the potential for complicated grief when abeloved animal is lost (Brown & Symons, 2016). Those who are socially
isolated or who have come to depend on their pets for comfort and companionship may find themselves doubly bereaved when the loss of theiranimal companion compounds other emotional pains.
The following case study exemplifies how a complicated grief responseto animal loss can manifest, especially in cases where the bereaved individual was isolated socially, and relied heavily on her pet for support andrelationship.
CASE STUDY
Cindy is a 32-year-old working professional who finds community
in regularly attending religious services, as well as bringing herdog, Sage, to the dog park every day after work. Cindy spends
many hours at the office, and is fortunate enough to be able toLoss, Grief, and Bereavement in the Context of Human-Animal Relationships399

bring Sage to work with her. In fact, Sage goes almost everywherethat Cindy does and serves as an important and constant companion in her life. Although she gets out for religious services, Cindy
is busy, and her social circle is fairly small.
One day, Cindy has an important meeting at the office andis unable to bring Sage with her. When she returns home, she
is shocked and dismayed to find Sage lying on the floor, notbreathing. Cindy rushes to the veterinarian, but Sage’s life unfortunately cannot be saved. Immediately, Cindy is distraught with
all-​encompassing grief, unable to grasp that her best friend and primary companion is suddenly gone. She blames herself for leaving
Sage on that day, and feels desperately alone as she continuously
contemplates what she could and “should” have done differently.
Eventually, months pass and Cindy hardly leaves her home,much less her bed. Social isolation, changed routines, and longedfor and painful memories of Sage have collectively decreased her
quality of life and engagement in the world. She has used up hertime off from work and is late on deadlines, while the caliberof her work and work ethic suffers immensely. Soon, Cindy’s
employer fires her due to her diminished work performance.
This only makes her feel worse and more isolated, as she refuses
visitors over the shame of her grief and losing her job. As a result,
Cindy starts to fall behind on her bills (including rent), and herhealth suffers due to inconsistent and unhealthy eating patterns.

Depending on an individual’s grief reaction, it can be very normal tostay in bed for days, if not weeks, during the acute phase of grief or periodof time directly after a loss event (Diminich & Bonanno, 2014). However,in the case study above, Cindy’s prolonged duration of grieving over Sage’s
passing led to increasing complications. Notably, a grief reaction can be frequently compounded with other previous experiences of loss, and whether
or not the individual has adequately processed these. It is reasonable, then,to assume that Cindy may have been struggling from compounded loss,
with potential factors such as a recent divorce, loss of a parent, or failure
to be promoted at work, underlying her relatively intense response.
When working with clients who are experiencing complicated grief,
it is important to first ensure that their basic needs of living are being
met. As such, checking on eating and sleeping habits, safety, shelter, and400

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hygiene can be important. In the beginning, small tasks can feel like major
accomplishments.
THE SIGNIFICANCE OF ANIMALS, ANIMAL BONDING
WHEN GRIEVING, AND ANIMAL LOSS
Increasingly, studies and polling have indicated that humans believe theirpets serve integral and meaningful roles as members of the family, including as surrogate children (Cohen, 2002; Field, Orsini, Gavish, & Packman,
2009; Harris Poll, 2015; Parker, 2016). Likewise, research shows that pets
often improve the functioning and quality of our lives, including overallemotional well-being, physical health and activity, and social connections
with others (Fine, 2015; Suthers-McCabe, 2001). Indeed, many turn totheir pets as sources of secure and reliable connection, often giving them
human-like characteristics (see “surrogate children” above) in order to fulfill this need (Field et al., 2009).
Trends such as these suggest an increasing attachment (Bowlby,
1969/1982) expression among humans for our pets and other animals. Pet
owners often expend significant time, money, and other resources to keep
their animal companions happy and comfortable (Cain, 1985; Josephson,2015). Likewise, many people form strong attachments to animals that do
not live with them. In a study of how clients at a large, urban veterinaryteaching hospital view their social network, both men and women often
included their friends’ pets as part of their support system (Cohen, 1998).
As we discuss later in this chapter, these attachments may even extend towildlife, as well as livestock and captive animals.
Importantly, such connections with companion, emotional support,
therapy and service animals, as well as those we merely observe in natureor through media, can provide unique healing to those suffering with theeffects of loss. For example, in cases of human loss, our pets can offer us
a comforting presence and strong impetus to begin moving through thestages of grief. As pet owners, we typically structure our day by the needs
and routines of our animal companions. We wake, feed, walk, touch, playwith, talk to, and express affection for our pets, all of which can be incredibly comforting and uplifting. What is more, providing care for ouranimal companions grounds us in what is still good and important in life.
In essence, animals may force us to take the first necessary steps towardhealing and recovery.

Loss, Grief, and Bereavement in the Context of Human-Animal Relationships401

However, when a beloved animal passes away or is lost, it is the absence of these very characteristics that often pains us the most. The traumaof losing a pet is profoundly life-changing for many, especially given thelength and depth of most human-pet relationships. Increasing evidence
has shown that the death of a companion animal can be just as severe andprolonged as the death of a human counterpart or loved one (Clements,
Benasutti, & Carmone, 2003). Particular challenges can arise when an
animal passes away due to his or her role as innocent and dependent in
the relationship/family, as well as the person’s role as primary guardian
responsible for the animal’s survival and well-being (Podrazik, Shackford,
Becker, & Heckert, 2000). Feeling responsible for the loss or losing one’s
purpose of caregiving likely complicates the bereavement response of agrieving individual (Lagoni, Butler, & Hetts, 1994), especially if the animal
was ill or injured and required the owner to administer at-home medical
treatment prior to death.
Likewise, the loss of an animal companion can disrupt our daily schedules and routines, our social and family lives, our degree of loneliness, andeven our sense of meaning regarding getting up in the morning or leaving
the house (as observed in the case study with Cindy and Sage) (Lagoni
et al., 1994). Importantly, a potential risk for retraumatization and complicated grieving exists when the pain that comes from losing an animal
is discounted, ridiculed, or disregarded by others. Feeling uncertainty or
guilt regarding the unique decision to euthanize a pet can also heighten any
trauma associated with the overall loss (Adams, Bonnett, & Meek, 2000).
THE IMPACTS OF COMPANION ANIMAL LOSS FOR
SELECT VULNERABLE POPULATIONSEldersOlder adults in American society and throughout the world often suffer
unique social disadvantages. They may live without human companions,
physical touch, or structure in their daily lives. Children move away, partners and friends die, and chronic illness, pain, and disability make goingout difficult. Financial constraints can also limit social activity. As a result,older people frequently become isolated from their broader community(Valtorta & Hanratty, 2012).
Pets and animal relationships can help fill many of these social needs.
For example, pets curl up with you on the couch, and are excited to see402

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you when you return home or rise in the morning. Moreover, elders wholive alone can talk to, and be affectionate with, their companion animal.
Research indicates that interacting with animals helps alleviate lonelinessand supports mental health in older adults (Banks & Banks, 2002; Fick,
1993), with one study finding that adults over 60 years of age who had
a pet were 36% less likely to report feeling lonely than non-pet owners(Stanley, Conwell, Bowen, & Van Orden, 2013).
To date, research has also indicated the positive health impacts ofpets for elders, including reduced agitation and other symptoms associated with dementia (Bernabei et al., 2013; Johnson & Meadows, 2002).
Dogs, in particular, may provide the impetus for mobility and routine,
and their need for exercise and nourishment presents older adults witha purposeful, healthy outlet. In fact, studies show that people who walktheir dogs get more exercise and even walk faster (Curl, Bibbo, & Johnson,2017). Likewise, one long-term study found a relationship between current
or previous pet ownership and improved cardiovascular disease survival
among older adults (Chowdhury, Nelson, Jennings, Wing, & Reid, 2017),
while another noted increased eating and better nutrition in those with
Alzheimer’s disease when in the presence of aquarium fish (Edwards &Beck, 2002).
After losing a pet (primarily via moves to assisted living environmentsor through the pet’s death), older adults of a certain age, health status, orability level may feel it is inappropriate to adopt another. Indeed, while
walking is beneficial for both people and dogs, some research indicates that
dog walking among older adults is not very common (Thorpe et al., 2006).
Since elders cannot predict the future, and may not know of anyone who
could care for the pet after they become ill or pass away, adopting again
may be daunting. For many older adults, this can mean that when a pet
dies, it is the end of their pet keeping life and the myriad benefits that comewith animal companionship. While some older people may feel relieved
to shed the responsibility of pet keeping, for others, the consequences oflosing that affectionate focus may be severe.
Children

Pet loss may also have a significant effect on children, as relationships withanimals are often monumental for their healthy development (Melson,
2001). In one of the author’s clinical experience, the death of a pet is oftena child’s first exposure to losing someone close to them. While US society

Loss, Grief, and Bereavement in the Context of Human-Animal Relationships403

is generally more open about death than it used to be, many parents may
still be reluctant to openly discuss the impending or actual loss of a family
pet with their children due to discomfort or uncertainty of what to say. For
example, parents may conceal the pet’s death until the child returns homefrom camp, or downplay the circumstances of the pet’s death to make iteasier for the child to understand and cope with the loss.
Additionally, parents may remain stoic for the perceived benefit of
their children, which could inadvertently leave the children feeling alone
in their grief, and that the life and loss of their pet is not important. In
such cases, children may also wonder how people would react if something
tragic happened to them, and could be concerned because they seem to
be more emotionally distraught about the loss than other members of thefamily (Fudin & Cohen, 1988). Overall, such research and clinical findings
demonstrate the importance of having forthright, age-appropriate discussions with children about animal loss in order to assist them through thenecessary grieving process.
Traumatized Individuals

People with existing trauma histories may also have a particularly difficult time coping with the loss of a pet. Trauma has long-lasting effects,
which animals can help relieve. For example, veterans often rely on service
dogs for guidance and protection, both at home and in public settings(Brulliard, 2018). Other individuals who have experienced trauma simply
appreciate the comfort of safe touch, undemanding companionship, andthe opportunity to socialize with ease that comes from being in the presence of trusted animals. The loss of such important social support not only
causes grief, but may also trigger setback for people already coping withthe present threat or aftermath of trauma.
Of note, animals can also be the cause of trauma. An individual may
have been hurt by an animal or witnessed one being harmed or injured.
In fact, accounts of people reporting symptoms of post-traumatic stress(PTS) after seeing and hearing their animals in pain have been documented(Watters, Ruff, & Jamora, 2013). In addition, forced separations frompets — whether through the trauma of natural disasters or family violence,for example — only intensify the devastation of losing that animal relationship. It is hard to accept that any one of us — young or old — may face
unexpected changes in living arrangements (including homelessness) that
require the relinquishment of a pet.

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Attachment to pets can be so strong that people are often reluctant
to leave their animals behind when natural disaster strikes, even if staying
with them greatly endangers their own safety (Hunt, Al-Awadi, & Johnson,2008). Likewise, adolescents living on the street are more likely to engage
in treatment if provisions are made for their pets (Rew, 2000). And people
faced with the threat or actual harm to pets by an abuser (i.e., in selectcases of domestic violence and child maltreatment) often choose to stayin personally abusive situations rather than abandon their pet by fleeing
to a nearby shelter that does not allow animals. Encouragingly, the Urban
Resource Institute in New York City recently made national news for opening three shelters that include pet-friendly apartments for individuals andfamilies escaping abuse at home (Newman, 2016). Special attention andaccommodations must be paid to those with preexisting psychologicalinjury who face further traumatization through the loss of a pet or otheranimal to whom they are attached.
CULTURAL STIGMA OF GRIEVING THE LOSS OF ANIMALSThe loss of pets continues to be devalued as compared to human death, despite ample evidence demonstrating the often important role that animals
play in our lives. Further, there exists a relative lack of research concerning
specific impacts of losing a pet, which is unexpected given the growing
recognition of close human-animal relationships as central to many people’s health and well-being. While mental health professionals and scholars
have been working in the HAI field for over 50 years, research pertaining
to the effects of animal loss among veterinarians, social workers, and otherrelevant practitioners also remains limited.
Some faced with the loss of a beloved animal have recently fared better
through increasingly supportive resources and networks. Today, there are
now sympathy cards specifically designed for pet loss, online supportive
chat groups, and opportunities to connect with others who are grieving
via social media. Recently one man made a post through Facebook, asking
for fellow dog lovers/owners to join him at the beach for his dog’s last visit
before euthanasia. As a result, hundreds of people and their dogs — manyof them strangers — showed up, offering their support through signs andwarm embraces. A video recording shows the man expressing his gratitude
for those who came to the beach, as well as for the many more who wrote
to him from around the world (ABC News, 2016). Furthermore, selectLoss, Grief, and Bereavement in the Context of Human-Animal Relationships405

veterinary settings offer mental health care services to clients in an effort tohelp those coping with animal illness and injury, natural and unexpected
death, and the unique decisions and emotions concerning pet euthanasia.
Yet, even with these promising developments, people who have losttheir pets too often feel pressure, even subtly, to justify the depth of theirpain and grief, or even of the connection once shared with the animal
itself. This process of advocating for something dear that will never return, all while receiving support that lacks in comparison to reactions tohuman loss, can be incredibly heartbreaking. Additionally, depending on
the animal’s species, those who are grieving may experience a response thatreflects a further hierarchy of loss, such as, “I could understand being so
upset if it were a dog, but a bird?” Others may also find their wish to beburied alongside their pet’s remains halted by legal restrictions, although
New York State has just recently allowed pet ashes to be buried in humancaskets (Maslin, 2016). According to the Green Burial Society (Green,2017), a handful of states have introduced bills to allow for joint burial,
but most of those few are either currently pending or have failed to pass.
In the United States today, many do not experience death or the normalization of the death process on a regular basis. Thus, clients may havean underlying uncertainty or dread when faced with an impending death,regardless of whether this death is of a human or companion animal. Whena death occurs, many cultures and communities have a prescribed wayof memorializing a grief experience and beginning the steps to process
through a loss. When faced with the loss of a companion animal, somepeople face no cultural norm for pet memorialization. In some cases, they
may feel guilt or shame for even considering it to be a devastation ortrauma on par with the loss of human life (Turner, 2003).
The presence of guilt may also be strong when difficult euthanasia decisions need to be made; indeed, this may be the only or first situation where
an individual is called upon to make such a permanent and heartbreaking
choice about ending the life of someone he or she loves. There appears to
be a lack of scientific evidence regarding the impact of euthanasia decisions
on the bereavement process (Podrazik et al., 2000). It has been historicallypresented that having to process through a euthanasia decision and procedure may cause significant emotional distress, including depression, guilt,
and anxiety (Adams et al., 2000; Podrazik et al., 2000).
Although research is limited in this area, it is the authors’ experience that guilt plays a strong role in the grief experienced by pet owners.
Anecdotally, there are often questions and personal turmoil regarding406

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making the right choice or whether it is the appropriate time to move
forward with euthanasia. Understandably, many want to hold on to theircompanion animal for as long as possible. After their animal has passed,
some may believe that they killed their pet or, conversely, that they waited
too long to act, both of which can cause people to internalize the pain andblame themselves. However, a common and helpful reframe may be toview euthanasia as a truly humane gift that we can provide to our beloved
animal companions, one that reduces their pain and suffering withoutcausing or prolonging distress.
Given these unique factors, it may be even more important for thosegrieving the chronic illness, death (both actual and anticipated), and loss ofa companion animal to receive appropriate support through their communities or via professional intervention. With specific and proper training,mental health and other helping professionals — such as social workers,
therapists, and counselors — can guide those experiencing pain and griefthrough critical decision making (i.e., regarding the medical treatment andeuthanasia of a companion animal); memorialization, burial, and cremation; normalization of the loss experience; and reflective listening focusing
on life review (or the thoughts and memories of the pet throughout their
lifetime), including other ways to conceptualize the loss and its meaning
for them. The bereavement or trauma experienced by the loss of a companion animal is profound and impactful, and should always be considered assuch by any helping professional or practice.
THE LOSS OF A WORKING ANIMAL
The involvement and potential benefits of animals in healing applications for humans in distress is well documented. Pets, as well as service
and therapy animals, increasingly assist people with disabilities, comfort
those traumatized by personal and large-scale disaster, and provide cheer
when times are too hard to bear (Brown & Katcher, 1997; Yorke, 2008).
Recently, increasing evidence has shown that animals present a form of perceived unconditional love and authentic support to the homes and facilities
in which they live and work (Bryan et al., 2014; Clements et al., 2003;
Suthers-McCabe, 2001), including a nonjudgmental presence that can be
crucial for helping professionals foster rapport and therapeutic benefit forclients through animal assisted intervention (AAI). Notably, the loss of anLoss, Grief, and Bereavement in the Context of Human-Animal Relationships407

AAI service or therapy animal can greatly affect not only his or her handler,
but also all those whom the animal is trained to help.
Service Animals

Service animals (either dogs or miniature horses) are trained to assist someone with a disability (either physical or psychiatric) by performing specifictasks that the person would not otherwise be able to do alone, such as
opening doors, retrieving medication, and alerting to the onset of a panic
attack. One service animal can impact many lives and even help foster
relationships between people. For example, people with service animals
have reported that more people speak to them, and engage in more topics
of conversation, when they are with their service animal (Eddy, Hart, &Boltz, 1988; Mader, Hart, & Bergin, 1989). According to handler Bob
Vogel, when he is with his service dog, Schatzie, conversations with others
are improved: “Trite comments like ‘no speeding’ and ‘you are such an
inspiration’ are replaced by compliments about your beautiful dog and its
stellar obedience” (Vogel, 2014, para. 1). Vogel adds that Schatzie wakes
his (able-bodied) daughter from bad dreams, and often joins the two ofthem in mobility events. Overall, it is important to note that, while service
animals help their handlers execute critical tasks, they are not mere “tools”;
in addition to helping the person with a disability navigate through theworld, service animals also provide comfort and, as described above, attract
friendly company (Mader et al., 1989).
Losing a relationship with a loyal and affectionate companion who
provides constant support — both vital and emotional — can devastate.
Large breed service dogs who are able to pull a wheelchair or navigate
through city sidewalks typically need to retire by age ten, after a working
life of seven to eight years (Finke, 2010). Service dog retirement often
leads to painful separation or a change in the previous human-animal
relationship (Fischler, 2014).
Additionally, once a service dog retires and becomes a pet without
legal recognition, it may become subject to housing rules that forbid pets,
potentially leading to a need to rehome the dog. Even if dogs can stayin the family, they may be confused about the change in their role andrelationship with their person (e.g., being left behind at walk time could
be puzzling or potentially stressful) (Fischler, 2014). A group of experienced service dog handlers recently described what led them to retireservice animals with whom they felt close, and how hard the process was

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to accept (Fischler, 2014). Becky Barnes Davidson, partnered with her
Golden retriever, Rowan, explains, “People who don’t work with a guide
don’t understand the depth of emotions we share with them. A pet dog
isn’t going to retire. When you say goodbye to a pet it’s one thing, but a
guide who has been with you 24 hours a day and has traveled everywherewith you is a lot different” (Fischler, 2014, para. 51).
Whether a retired service dog stays with the handler as a pet or moves
to a new home, eventually there will be a permanent separation when the
animal passes. Vogel described his painful discovery that Schatzie had incurable cancer with perhaps hours to live, by saying: “Surgery was out — I
wouldn’t put her through that kind of trauma. I was at the point that every
dog person dreads” (Vogel, 2014, para. 6 ). Notably, Vogel chose euthanasia
to prevent or limit any further discomfort or distress for Schatzie. However,
judging from his self-described sobbing for hours after losing her, thatchoice was a heartbreaking one for him to have to make.
Therapy Animals

Working as an AAI practitioner to help enrich the lives of others can be
an incredibly rewarding experience. Many individuals have an underlying passion for both humans and animals when they enter AAI practice.
Few clinicians, however, have considered the powerful impact of losing
their therapeutic animal partner, and continuing their practice alone, after
bonding and working closely together as a team with clients. In the casestudy, we describe such an experience, told from the perspective of one ofthis chapter’s authors.
CASE STUDY
It was just another day of work at my local equine organization,and the morning was sunny and crisp. Per usual, I was checking
the herd before partnering with a selected horse, Wilma, to help
guide a family therapy session with clients. Wilma was a beautiful
choice for this family due to her rock solid nature, comfortingpresence, and patience. She was a “go-to” for many challenging
families, as well as children with attachment concerns and complex diagnoses. In particular, Wilma did not typically present withdiscomfort when heavy human emotion or raised voices characterized a session. This family struggled with two children who

Loss, Grief, and Bereavement in the Context of Human-Animal Relationships409

expressed difficulty concentrating and were easily distracted. The
parents had large levels of tension between them and often became
frustrated when trying to engage with each other or their children.
To my dismay, when I went to find Wilma that morning, she
was lying down in the field, not moving. She had passed at somepoint overnight. Unfortunately, the cause and circumstances ofher death were unknown, but raised concern as she was not an
extremely old horse. I was consumed with my own grief over theloss of Wilma, as I had been growing as a clinician with her forover four years, and we had come to trust each other. She was
my friend. After the initial shock, I realized that in 20 minutes
the family was about to arrive, expecting to work with her. How
then, would this situation be handled?

In what follows we describe several clinical considerations for properly
managing situations such as those described in the above case study. Thatis, how AAI practitioners may be gentle with themselves and their own
feelings of grief, while properly supporting their clients in coping withthe loss of a therapy animal through careful preparation and necessary
precautions:
1. At the start of therapy with clients, begin therapeutic rapport
building with a discussion of endings. Even if the clinician is
not talking about death, per se, there may be times when an
animal may not be available to participate in a session. For
example, the animal may be sick, injured, or simply not in themood to participate that day (i.e., showing signs of anxiety,fatigue, annoyance, withdrawal); whatever the reason may be,
the animal’s preferences should be respected. In preparation ofsuch situations, AAI clinicians should create therapeutic interventions that do not include the animal, such as biofeedback ormood/feeling inventories that use animals as examples.
2. Have a plan implemented should a medical emergency happen with the therapy animal partner. Whether AAI involves acanine, horse, or smaller animal, being ready in an urgent or
stressful situation is extremely important. One’s rational mind
can become overwhelmed during shock or crisis, making an

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existing, documented plan to address the animal’s well-being
and client concern essential. For example, have veterinariancontact information available at all times, and write down the“steps” to take for assessment of the animal’s condition.
3. Have conversations ahead of time with clients to let them knowwhat the steps may be in case of an animal medical emergency
during session or, less urgently, if the AAI animal partner cannot
attend session that day. Having these conversations with clientsin a manner that supports a healthy processing experience forthem can help integrate their work into practice by modelingit yourself. Important components of these client discussions
will be to promote creation or engagement of healthy coping
skills. Reflecting on past losses may also be useful in helping
clients prepare for future medical emergencies involving either
their human or animal loved ones.
4. Take time to consider what memorialization and euthanasia
options might look like when the time comes. Although it
may be extremely difficult to think about the loss of a beloved
companion and therapeutic partner, this process is very important. Being ready with one’s own assessment of animal suffering
and what memorialization to pursue can reduce the amountof anxiety (and plausibly panic) during a crisis or emergency.
5. Carefully consider the level of disclosure with clients in theevent that a therapy animal becomes ill, is injured, or dies outside of their presence. This will, of course, vary depending upon
the client’s particular situation. Such questions as, “How will
you hold your own heart throughout the grieving process, andhold the heart of your client in a clinically appropriate way?”
may be particularly pertinent for practitioners. If the therapy
animal is also the clinician’s family pet, this may be even more
important to consider, as personal grief and impact will be
pervasive. Additionally, when clinicians integrate their own
companion animal into their clinical identity and professionalself, their clients will likely grieve the impact of this loss. Clients
may mourn in unhealthy ways due to their coping mechanisms
and diagnostic influence — the very reasons they came to therapy in the first place.

Loss, Grief, and Bereavement in the Context of Human-Animal Relationships411

6. Have a “back-up” plan. Should something happen to the animal, know how clients might be contacted and informed. Additionally, be prepared to engage with the client on your own,
without the assistance of a therapy animal.
7. Evaluate whether or not to cancel sessions due to personal
distress or the need to support other companion animals andfamily members. A clinician who forces himself or herself toengage in work while facing his or her own intense grief may be
doing a disservice to themselves and their clients. Thus, taking
time for self-care is not only essential for the therapist, but may
model the importance of doing so for the client(s). Furthermore, other animals who shared their lives with the deceased
or ill therapy animal may likely be experiencing their own senseof loss and grief, so it would be inappropriate to ask them to“stand-in” or engage in therapeutic work with a client. Only if
the clinician feels they are able do so safely and professionallyshould sessions continue.
MOURNING FOR WILDLIFE, LIVESTOCK, AND CAPTIVE ANIMALS
While the loss of pets or working animals touches the lives of those who
knew and loved them well, the publicized mistreatment or killing of lesser
known animals in the wild, in captivity, or on factory farms (e.g., throughhunting, poaching, slaughter, etc.) often cut just as deep, and cause a number of reactions from hundreds, if not millions, of people. In this section,
we discuss these various reactions in the cases of Cecil (a wild lion) andHarambe (a captive gorilla), and the complexity of grieving the loss ofthese particular animals.
On July 1, 2015, a “trophy” hunter shot (with an arrow) and killed alion, who normally lived in a protected sanctuary, on private land. Cecil
was a well-known lion to researchers and the public alike. Once the hunter’s name was released, reporters, animal lovers, activists, and the courts
pursued him with outrage, thereby forcing the closure of his dental practice. Cecil became a worldwide concern, with over 695,000 social media
hits and approximately 94,000 hits in the editorial media between July 1
and September 30, 2015 (Macdonald, Jacobsen, Burnham, Johnson, &412

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Loverage, 2016). The loss of Cecil was felt on a profound level for people
all across the globe.
Much like Cecil, another tragic shooting in 2016 demonstrated thatthe death of an animal, even one previously unfamiliar, can be traumatizing for those who witnessed it, those who read about it, and those who
were affected by the conversation and symbols that came of it. Harambe,
a 17-year-old endangered lowland gorilla, was the pride of the Cincinnati
Zoo. On May 28, a 3-year-old boy climbed a fence and fell into themoat surrounding the gorilla exhibit. Much to the concern of onlookers, Harambe proceeded to drag the child around the enclosure. People
had varying opinions regarding Harambe’s behavior, and the motivation
behind it. Despite their great affection for the gorilla and his potential
valuable role in replenishing the species, the zookeepers felt the need to end
Harambe’s life in order to protect the child. Since Harambe’s interaction
with the child took place in front of dozens of zoo patrons, video surfaced
early. Within hours, the public had turned on both the zoo and the child’s
parents as responsible for the tragedy. In an outpouring of rage and grief,social media commenters accused the parents of failing to adequately supervise their child (McPhate, 2016a).
Harambe’s death deeply distressed both eyewitnesses and people who
learned of it later. Onlookers worried about what might happen with theboy, but they also felt sorrow for the gorilla. Brittany Nicely, a mother who
happened to be present with her family, posted online, “Witnessing thissituation and hearing them shoot him has been one of the most horrific
things I have ever been a part of ” (Shammas, 2016, para. 6).
The staff of both the zoo where Harambe was raised as a young gorilla,
and the one where he lived and died, needed support. One zookeeper
remarked, “We’re the ones who took the loss on this . . . it doesn’t affectanyone as much as it does the people here at the zoo” (McPhate, 2016b,
para. 32). The director of Harambe’s original zoo, Jerry Stones, who hadraised Harambe nearly all of his life, was perhaps the most grief-stricken(Bult, 2016): “An old man can cry, too . . . Harambe was my heart. It’s likelosing a member of the family” (para. 5).
In addition, the large-scale grieving response to the deaths of Harambeand Cecil also triggered other forms of heartache and anger, particularly inregard to race and racial tensions. For example, for some in the Black Lives
Matter movement and other social justice communities, the outpouringof grief and media coverage for Cecil and Harambe felt disproportionately

Loss, Grief, and Bereavement in the Context of Human-Animal Relationships413

large (and thus disrespectful and hurtful) in comparison to the concern
over the many recent and tragic killings of black men, women, and youth
by police officers. A tweet from Roxane Gay, a renowned Haitian American
writer, professor, and commentator, exemplified much of these sorts offeelings: “I’m personally going to start wearing a lion costume when I leave
my house so if I get shot, people will care” (Adams, 2015).
At the same time, much of the news and social media backlash against
those grieving Harambe and Cecil criticized or disparaged the legitimacyof these emotional reactions, thereby echoing common stigmas associatedwith animal loss (i.e., “People are dying. PEOPLE”; “It’s a gorilla, get overit”) (Blatchford, 2016; Young, 2015). Not surprisingly, political commentators on both sides of the aisle used these particular animal deaths for theirown purposes, and much painful and, in some cases, racist debate ensued.
Some in the media proposed that people may be more vocal about thedeath of an animal than that of a black person because doing so is relatively
apolitical. According to Joshua Adams (2015), a writer with the Huffington
Post, “There’s a huge risk in saying #BlackLivesMatter, on social media or
elsewhere. There’s zero risk in mourning a lion. Even if we don’t agree with
one or the other or both, let’s stop acting like we don’t know exactly why
we talk about certain issues and not others” (para. 10).
While Adams’ point is well taken, many would argue that expressing
pain about the loss of an animal, particularly our own as previously discussed here, is not always safe (at least emotionally) or met with respect
and understanding either. This heated debate, while certainly useful inmany respects, undoubtedly reinforced or triggered further grieving on
both “sides” of the argument.
FOSTERING RESILIENCE AFTER ANIMAL LOSSAs the authors have discussed, preparing for the loss of a pet, service,or therapy animal — or even livestock, wild (like Cecil), or captive (likeHarambe) animals — can help clients and practitioners recover and copewith the grieving process. Practitioners may receive questions and inquiries from anxious pet owners about quality of life decisions, euthanasia
choices, and what to do should the “time” come. Clinicians, even those
without a pet loss or AAI specialty, should be familiar with the impact ofcompanion animal loss and its unique influence on the bereavement and414

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quality of life for clients. As stated within this chapter, normalization of
a commonly stigmatized experience of loss is extremely important, as is
having resources available regarding grief, support, emergency preparedness, and memorialization.
Additionally, clinicians should be familiar with signs of complicatedgrief and complex bereavement, and be able to recognize when referrals
to trauma specialists are warranted. In addition to reviewing the clinicalconsiderations offered in this chapter, practitioners should tailor specificsolutions according to the client population they are serving. Elders, forexample, who can no longer have a personal pet may benefit from caring
for the animal companions of neighbors. Likewise, they may participate
in animal-assisted activities or receive visits from family pets. While someelders may be relieved to have less responsibility after the last pet dies,others may be reminded of their own mortality. Clinicians should be open
to all possibilities, and be prepared to respond. Practitioners can also help
older adults with their grief by reminiscing and finding meaning in theiranimal relationships.
Likewise, children need honest communication about animal loss delivered in age-appropriate language. Parents and clinicians need to explain
what death is, why euthanasia may be the best and most humane choice,and what will happen to their beloved animal’s remains. When appropriate,children should be offered a chance to say goodbye or perhaps be present
for the pet’s last moments. The animal should also be actively remembered,
not forgotten or disregarded just because he or she has passed. Pictures ofthe pet or their treasured objects and toys should also not be disposed of if
they are important to the child (Tousley, 2017). In addition, since deathin some form will inevitably enter every child’s life, adults should be prepared for discussions about death with books, videos, and other resources
designed for children of different ages (Fudin & Cohen, 1988).
The loss of a service animal often means more than the loss of a meaningful relationship. In addition to officially trained service dogs, many
people live with animals who provide help or feel therapeutic. Withoutthem, the person may be unable to cope with anxiety, or easily navigate
and engage with the social world. When such an animal dies, the bereaved
person often cannot wait for his or her grief to subside. Helping professionals should give mourners an opportunity to describe their relationshipand loss, while simultaneously helping them locate and bond with a new

Loss, Grief, and Bereavement in the Context of Human-Animal Relationships415

animal (either service or companion) when the time is opportune (Cohen,2015). Likewise, losing a therapy animal can be devastating for the handler
and client. Taking time to grieve is important for AAI handlers and therapists in order to best support and serve their clientele through this loss, aswell as other life challenges.
The loss of an animal can also present opportunities for growth.
Researchers have begun to examine resilience in the face of stress, including the death of a loved one. There is growing evidence that mostpeople survive potentially traumatic events without developing significant,long-lasting mental health disorders. In one study of women who had been
physically assaulted, two factors predicted resilience: 1) the feeling that one
is in control of life’s circumstances and 2) social support networks (Rusch,
Shvil, Szanton, Neria, & Gill, 2015). As such, in the case of trauma related
to animal loss, mental health professionals might direct the bereaved toservices such as pet loss support groups. These could provide a safe place
to explore how much influence the grieving person had over his or her
animal companion’s medical situation. These services can also help clientsacknowledge control, while recognizing that all living things will die, nomatter how much they are loved. In a group setting, whether formal or adhoc, the grieving person can also receive the social support that researchshows can help.
The authors have been asked about whether or not the presence of atherapy or comfort animal, or someone’s personal pet, in pet loss groupmeetings is helpful. To some degree, this is a matter of clinical judgment,
based on where the participants in the group are at in terms of grieving
and recovery. Funeral homes have begun to include a friendly dog in theoffice or even during the ceremony (Lu, 2015), because mourners may
find it soothing. However, in a pet loss situation, seeing someone else’s
pet companion may only intensify one’s own lack or loss of relationship,
so involving animals in these applications should be done so cautiously.
Resilience and growth after the loss of a significant human-animal
relationship will be a fruitful area for further research. One of the mostrecent studies to explore this focus specifically is a paper by Packman, Field,
Carmack, and Ronen (2011). After losing a beloved pet, some study participants reported an improved ability to relate to others and feel empathy
for their problems; an enhanced sense of personal strength; and a greaterappreciation of life (Packman et al., 2011).

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TRANSFORMING TRAUMADISCUSSION
Everyone’s life includes a certain amount of pain and suffering. For many,
animals not only improve everyday existence, but also serve as a comfort
during the worst that life has to offer. In addition to the pleasures of touch,companionship, and humor that pets provide, some animals serve a formal
therapeutic function. They allow people with disabilities to function moreeasily, while restoring physical and mental well-being to people recoveringfrom illness, injury, and emotional pain.
In cases where life’s events overwhelm a person’s resources, trauma may
occur. Animals can either be at the root of that trauma or part of the healing process. One treasured animal may die, retire from service or therapy
work, or run away, causing immense pain. Another may come into one’s
life and transform it for good. The loss of such a buffer to hardship anddifficulty uncovers old wounds and creates new ones. Therapists, counselors, and other helping professionals should be prepared to work with those
whose interactions with animals form an important function in getting
through the challenges of day-to-day life. Such institutions as the Collegeof Social Work at the University of Tennessee in Knoxville, the Graduate
School of Social Work at the University of Denver in Colorado, and theArgus Institute in Fort Collins, Colorado, all provide important academic
professional training resources in this area for interested practitioners.
As this chapter demonstrates, our relationships with animals havealso changed over time. Some animals have lived peacefully with us forthousands of years, while others have been subjected to maltreatment andviolence. In recent times, some animals have moved from working partners
to pets to members of the family. This affection for companion animals
has perhaps changed how we view the natural world. The earth finds itself
under stress from climate change. Current communication technology andsocial media allow us to learn about remote events and happenings fromafar in ways we never could before. The death of a lion in Africa and theshooting of a gorilla in another city become worldwide knowledge, thecause of grief and pain, the focus of heated political rhetoric, and spurs
to action. As a result, more people seem passionately interested both inindividual animals and in the larger issues of animal keeping and species
preservation.
The HAI field continues to be rich with opportunities for learning.
In particular, scholars need to further explore the specifics of grief andLoss, Grief, and Bereavement in the Context of Human-Animal Relationships417

mourning after various types of animal loss. Potential questions for future
discussion include the following: What effects do different animal relationships have on the nature, duration, and recovery from grief? Under
what circumstances does the death of a loved one (either human or animal) become a trauma? How can the pain of animal loss be more broadly
accepted as legitimate and life changing for those in mourning? How cananimals best help humans recover from the trauma associated with loss?
Which animals (i.e., species) are best suited for this type of work, why,
and how can we best protect their welfare needs in the process? Can our
affection for individual animals inspire a wider concern for other living
things? The authors hope that the many social workers, counselors, andother practitioners working in the field of HAI can continue to partnerwith researchers to explore these and other questions, thereby validating
the impact of these powerful relationships, as well as the tremendous griefthat comes from losing them.
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ABOUT THE AUTHORS
Susan Cohen, DSW, has helped people make critical decisions about thehealth care of their pets for over 35 years. She currently serves as vicechairperson of SWAHAB (Social Workers Advancing the Human-AnimalBond), and facilitates support groups for veterinarians (VIN Foundation
Vets4Vets) and animal welfare groups. Cohen also currently lectures widely
to veterinary colleges and conferences, colleges of social work, veterinary
technician programs, and human health groups on communication, petloss and bereavement, human-animal interaction, client relations, andcompassion fatigue.
Adam Clark, LCSW, AASW, is a published writer, educator, and adjunct professor at the University of Denver’s Graduate School of Social Work. Clark
focuses his work on the psychology underlying the human-animal bond,specializing in endings and transitions. He is passionate about reducing
the cultural stigma associated with pet loss, supporting pet owners, andeducating veterinary professionals.

CHAPTER 14

The Global and Cross-Cultural Reachof Trauma-Informed AnimalAssisted Interventions
Betty Jean Curran, LMSW, AASW; Molly A. Jenkins, MSW, AASW;
and Philip Tedeschi, MSSW, LCSWINTRODUCTION
In this book’s preceding chapters, animal-assisted interventions (AAIs) aremainly presented from a Western-centered framework, focusing primarilyon the psychotherapeutic processes that take place between a therapy or service animal and an individual diagnosed with symptoms of post-​traumaticstress (PTS). However, without acknowledging cultural difference, understandings or even impacts of human-animal interactions (HAIs) in thecontext of international trauma recovery risk being undermined by thefalse universality of a Eurocentric framework. For instance, the etiology
and defining symptoms of trauma, the construct of the individual psyche, and characteristics of the human-animal bond may be understooddifferently through the discursive formations — historically situated andcontextualized systems of meaning—of non-Western cultures (Hall, 1997).
While it is important to note that the field of animal-assisted therapy(AAT) originated in, and assumes most of its philosophical tenets from,
Western mental health traditions, HAI programs and practices are locatedacross all continents. The International Association of Human-Animal
423

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TRANSFORMING TRAUMAInteraction Organizations (IAHAIO) has over 90 organizations registeredin their database, which represents just a small fraction of HAI programs
taking place throughout the world (IAHAIO, 2017). Many of these programs and practitioners undoubtedly navigate complex cultural contexts
in a variety of nuanced ways. To be sure, a number of underrepresented
programs may veer away from what is traditionally considered the norm bymental health communities in Western countries, specifically with regard
to trauma and the role of the human-animal bond in therapeutic processes.
Often, these programs are obscured due to a lack of financial resources,
knowledge, and/or local champions of AAIs. Yet, it is important for practitioners and researchers to recognize how these dynamic cultural contexts
may inform a variety of international HAI programs (including those thatare well-established), as they provide insight into effective, place-basedsocial work practices and broaden normative conceptions of AAIs throughpromoting cultural inclusivity.
Today, the biomedical approach is the dominant model used by mental
health practitioners and researchers of trauma (Breslau, 2004; Flouri, 2005;
Suarez, 2016; Zur, 1996). Emphasizing biological and behavioral correlates
in trauma response, this model characterizes post-traumatic stress disorder (PTSD) as a neurophysiological reaction that results from “exposure
to actual or threatened death, serious injury, or sexual violence” (either
directly or indirectly, such as via witnessing or learning that a traumatic
event or threat has occurred) (American Psychiatric Association, 2013,
p. 271). The assumed universality of trauma response from the lens of
the biomedical model allows the mental health community to build an
evidence base around a defined set of criteria, which are centered on neurophysiological processes that seem to transcend culture. Humanitarianand international aid workers, governments, and nongovernmental organizations utilize this model because it is seemingly generalizable acrosscultures, “legitimizes suffering” in the political arena, and often justifies
the allocation of international aid (Breslau, 2004, p. 115). The biomedical
model is thus a powerful discourse that is anchored by the “full authorityof science” (Breslau, 2004, p. 114).
However, it is imperative to note that trauma response is also mediated by a number of historically rooted discursive practices, and that“[c]ore physiological responses to trauma are usually translated into a diverse array of expressions depending on the socio-cultural context of theexperience” (Suarez, 2016, p. 144). Thus, while cross-culturally, a similar

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set of biological processes take place in response to actual or perceived
threat (Zambrano-Erazo et al., 2017), phenomenological responses totrauma are shaped by a number of cultural variables, such as ontologicalconceptions of self (Zur, 1996), understandings of destiny or fate (Zur,
1996), and conceptions of memory (Breslau, 2004), to name a few. For
instance, Kohrt and Hruschka (2010) note that, in the wake of the Maoist
civil war, Nepali and ethnic Nepali-Bhutanese trauma survivors blamed
traumatic events on the karma of past incarnations. The sins of past incarnations — both of self and family members — manifest in experiences of
personal loss and suffering. Because karma is associated with the shame of
personal and familial sins, some people choose not to seek help for their
psychological symptoms (Kohrt & Hruschka, 2010). In this way, cultural
narratives and cosmologies are woven into the ontologies of trauma (deJong & Reis, 2010), shaping expressions of, and responses to, psychologicalsuffering. As such, trauma response cannot be reduced to merely its neurophysiological processes; it must be understood within the relational context
of culture and the production of meaning within specific sign systems.
Research in cultural anthropology provides useful insight intocross-cultural accounts of trauma. In particular, studies centered on “idioms of distress,” or expressions of suffering that are culture-bound andcontextually specific, highlight the way in which all trauma response manifests through “embodied symbolic language . . . that derives its legitimacy
from its shared metaphors, meaning and understanding in a group” (deJong & Reis, 2010, p. 302; Nichter, 2010). Researching culturally specificaccounts of trauma response challenges the universality of the biomedical
model insofar as it points to the formative nature of discourse. While studies of trauma in cross-cultural contexts reference the multifaceted natureof trauma response, many scholars note that certain idioms of distresshighly overlap with symptoms of PTSD (Chhim, 2013; Hinton, Pich,
Marques, Nickerson, & Pollack, 2010; Kohrt & Hruschka, 2010). In a
sample of Cambodian refugees, Hinton and colleagues (2010) found thatthe cultural syndrome referred to as “khyâl attack,” or the “dysregulation ofwind flow,” which causes psychosomatic problems for its victims, overlaps
with reported symptoms of trauma, panic attacks, and panic disorders(p. 273). Hinton and colleagues (2010) note that it is important to understand the formative nature of khyâl attacks, because they are “a key
part of the reticulum that unites trauma event[s], social experience, andsomatic experience” (p. 273). Discursive practices and customs thus shape426

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the framework through which external, traumatic events are assimilated
into individual and community narratives.
Just as the experience of, and response to, trauma is mediated by cultural contexts, a person’s perceptions of animals and, consequently, HAIs
are often shaped by his or her distinct cultural histories, cosmologies,
values, and customary practices. This means that any HAI program, nomatter the location or clients served, will need to navigate these cultural
factors, which are often embedded in a person’s or community’s religious
beliefs and teachings (Jegatheesan, 2015). According to Serpell (2004),
attitudes toward animals are generally based on two primary “motivational determinants”: 1) affect for animals, manifested via love, sympathy,
and identification; and 2) perceived utility of animals to benefit humans
and their interests (p. 145). Moreover, these determinants may be further
modified by specific attributes of the particular animal or animals (e.g.,
intelligence, appearance, usefulness), characteristics of the individual person (e.g., personality, gender, age), and a variety of cultural factors (e.g.,history, folklore, and religion/expressions of faith) (Serpell, 2004). Singularor noteworthy incidents involving particular animals, such as pit bull bitesor rat infestations that lead to human illness, may, for example, also translate to broad community fear or aversion to dogs and rodents in general.
Religion, in particular, appears to play a foremost role in molding
cultural traditions and belief systems, including a culture’s view of theimportance of animals, their welfare, and people’s relationships with them.
The reasons underlying the cultural influence of religion in regard to animals are many, and far too extensive to be wholly covered here. Thatsaid, these influences are likely due, in part, to the deep-rooted role ofreligion in “[establishing] codes of morality that influence what is acceptable as thought, [behavior], and action” (Jegatheesan, 2015, p. 37). Whilemost religions acknowledge the intrinsic value of animal life, certain religions — namely Judaism, Islam, and Christianity — attest to the conceptsof human superiority or dominion over nonhuman animals (Szűcs, Geers,
Jezierski, Sossidou, & Broom, 2012; World Animal Net, 2017). This is instark contrast to Hinduism, for example, which believes that animals andhumans have souls in equal measure (World Animal Net, 2017). Throughthe passage of time, such beliefs (both animal-positive and -negative) are
powerful narratives that become ingrained in cultural traditions and everyday practices. As such, these cultural factors have strong implications for a
person’s estimation of, and affection for, animals, as well as his or her ability

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions427

to conceptualize animals in roles that do not conform to these beliefs (i.e.,
as supportive therapy animals aiding in human recovery and treatment).
To date, AAIs have been traditionally centered on a particular conception of animals as companions or even family members. While over
$40 billion are spent annually in pet-industry goods and services in the
United States, pet keeping is characterized differently across the world(Gray & Young, 2011). It is important to note that divergent notions ofanimals and their corresponding “place” in homes and communities are notnecessarily indicative of the strength or quality of bonds that people sharewith them. However, these dynamics do provide insight into the cultural
factors that shape HAIs. For instance, Gray and Young (2011) examinedhuman-pet dynamics across 60 cultures. Their results show that dogs were
only considered pets in 22 of the societies, while cats were considered petsin 11 societies. With regard to their function, dogs were primarily used
for hunting and defense, and most often lived and roamed outdoors (Gray& Young, 2011). This study contextualizes various pet keeping dynamics,
and decenters the common Western notion that companion animals wholive inside, and thus presumably in close connection with humans, are thenorm. Of course, this form of pet keeping is commonplace in the UnitedStates, which informs how most AAI programs are designed. However,
HAI programs in both national and international contexts must take into
account varying cultural views and roles of animals, while at the sametime working against certain perspectives, biases, and practices within that
culture that place animals at risk of harm.
OVERVIEW AND PURPOSE OF THIS CHAPTER
In this chapter, we highlight international HAI programs that are engaged
in important work with individuals and communities that, to a large extent, have experienced trauma. Over the course of one year (2016–2017),
we interviewed four programs from Uganda, Romania, Hong Kong, andCosta Rica in order to both elevate and explore in-depth an array of interventions that are implemented in diverse cultural contexts. Programs
were chosen to participate in this effort based upon the quality of theirwork, as well as their wide geographical representation on four continents;
if time and space had allowed, we would have asked additional programs
to take part. All interviews were conducted in English, and took place

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with organizational leaders over the telephone or via video conferencing
for approximately one hour. Each interview was audio-recorded (with interviewee permission) for the purposes of accurate transcription; in selectcases, the interviewees also provided the authors with written answers to
the questions we posed (see the following section).
While these programs present unique and culturally relevant frameworks for HAIs, these interventions are not intended to be representativeof all programs taking place in their respective countries. Indeed, there isgreat variety and creativity in international HAI programs, and these interviews give only a snapshot representation of four exceptional interventions.
Likewise, it may be important to note that these programs, while having
certain Western AAI influences, were all implemented within their own
cultural contexts, with primary direction and/or partnership from local
experts and community members.
In what follows, we describe each program and organize the interviews
according to seven important themes that arose across the board: 1) driving
factors for choosing HAIs as a point of intervention; 2) prominent cultural
views toward mental health and trauma, specifically; 3) cultural stereotypes
and views of animals; 4) challenges of running an HAI program; 5) welfare
considerations for participating animals; 6) outcomes at the individualand community levels; and 7) advice for people who wish to start an AAI
program in a non-Western culture where these practices may be rare orunderappreciated. These themes reflect, in large part, the questions we
asked each interviewee; however, they also represent important connector
points that emerged more organically from the conversations themselves.
For this reason, we attempt to remain as faithful to the original content of
the interviews as possible.
INTERVIEW QUESTIONSBelow are questions that we posed to the program representatives during
the interview process. Of note, not all questions were asked or discussedwith each interviewee, as to allow for natural, engaged, and nondirective
conversation.
1. Briefly describe your program.
2. What influenced your decision to work in this field?

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions429

3. How did your program get started?
4. How do you describe your program to others in your professional community, to stakeholders, and to potential clients?
5. How widely accepted is your work with animals?
6. How are animals viewed in your country?
7. How would you describe pet keeping practices in your country?
8. In your program, what standards or efforts are made to protect
the animals or respond to their well-being needs (if any)?
9. How is trauma viewed in your country?
10. Are there ways in which you have seen program participants (orstaff) infuse these practices with their own cultural practices,values, and belief systems?
11. What are your recommendations for people interested in starting their own AAI practice in locations where this work is either
not common or not widely supported?
THE PROGRAMS AND INTERVIEWEESThe Comfort Dog Project, Uganda
Sarah Schmidt, Program Coordinator

Based in the Gulu District of northern Uganda, The Comfort Dog
Project centers on psychosocial rehabilitation for survivors of war trauma
through the facilitation of human-dog companionship. As part of thelarger animal welfare organization, The Big Fix Uganda, this program
pairs participants, including former Lord’s Resistance Army (LRA) abductees, Uganda People’s Defense Force (UPDF) veterans, and otherwar-affected community members, with dogs who have been donatedby community members or rescued as strays (The Comfort Dog Project,2017). Each participant vows to be a lifelong guardian of his or her designated dog, ultimately learning to provide nutritious food and ample
shelter, training, and companionship to the dog. The human-canine bond
becomes the therapeutic means through which participants heal frompsychological and social symptoms of PTS that resulted from the devastating violence and displacement of the civil war between the LRA andthe Ugandan government. In our interview, Sarah Schmidt, the program
coordinator, described the most common type of trauma encounteredby their clients:

430

TRANSFORMING TRAUMAAll the people we work with intensively have either themselves
been forced to kill another person or have witnessed the killingof family members. And there are so many other atrocities. Thereis one woman in our program who was abducted and given to arebel leader as a wife. So, she was basically raped for ten years.
There were not just murders, but torture followed by murder.
And, several people of the program were, themselves, tortured inunspeakable ways.
Schmidt also described how traumas related to twenty years of displacement from the war impacted whole communities:
As part of the effort to control the rebel forces, the Ugandan military basically herded up all the people into IDPs, or internallydisplaced persons camps. The conditions in those camps were justhorrible. There were widespread disease and death and insufficient
infrastructure and people would stay in line all day long to get ajerrican of water. The atrocities that were faced by people for overtwenty years were really unimaginable.
The traumas experienced during the civil war left a lasting impact on
the communities in northern Uganda. Accordingly, “it has been estimatedby mental health professionals that 7 in 10 people . . . have been traumatically affected by the war” (The Comfort Dog Project, 2017). Schmidt
noted that the legacy of trauma is reflected in the rising suicide rate innorthern communities (personal communication, September 14, 2016).
An integrative approach to psychosocial healing, The Comfort Dog
Project is comprised of six phases: community sensitization and participant recruitment; client assessments; counseling and the development of
dog-guardian bonds; dog-guardian bonding activities; final assessments
and community integration; and service as mentors and program ambassadors (The Comfort Dog Project, 2017). These phases of the program target
important facets of the healing process by facilitating the human-animalbond while promoting social integration and, ultimately, animal welfare
advocacy and community education. Insofar as entire families are typicallyliving with the guardian and their dog, many people are peripherally “included in the counseling and the project, but the guardian, him or herself,
is the primary focus of [the] work” (Schmidt, personal communication,

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions431

CDP participants walking their comfort dogs in Uganda. (Used with permission from the CDP.)

September 14, 2016). In this way, the program not only targets the psychosocial health of its participants, but also impacts attitudes toward bothmental health and dog welfare in local communities.
Dogs for People, Romania
Victor Chitic, Staff Psychologist and Research Coordinator

Located in Bucharest, Romania, Dogs for People is a project of the larger
animal welfare organization, Four Paws (Vier Pfoten), and aims to trainstray dogs for therapeutic interventions with youth with special needs andolder populations. Started in 2004, this program seeks to foster healing relationships between individuals with special needs and stray-turned-​therapy
dogs through animal-assisted activities (AAAs) that promote mutually
beneficial human-animal bonds. Twice a week, dogs visit with children
under the guidance of a psychologist. During this time, “the children perform non-failure activities with the dog,” which can lead to increases inself-esteem and improvements in communication skills and concentration
abilities (Dogs for People, 2017). AAAs are also incorporated into communities that serve older adults, such as retirement homes, in order to engage
individuals who are experiencing the physical and psychological challengesof aging. According to Victor Chitic, staff psychologist and research coordinator at Dogs for People, the goals of this program are twofold: topromote the value of stray dogs by training them to be therapy dogs. As
stray dogs in Romania face many welfare challenges, this program provides

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A child and psychologist work together in the presence of a stray-turned-therapy
dog in Romania. (Used with permission from Dogs for People.)a step toward reframing the attitudes regarding animals and, consequently,
their living conditions.
Dogs for People collaborates with multiple institutions in order toreach their target and clinical populations. In our interview with Chitic, he
noted the various types of traumas experienced by Dogs for People clients:
In elders, traumatic experience can range from domestic abuse,abandonment by family or loss of family members. In children,
we often work with children that are orphans, so abandonmentis a recurrent issue, sometimes even peer abuse in state-operated
facilities. Other times we work with children from families who
are more protected. Children with disabilities perceive trauma ina different way. Things that are usually normal for children canbe traumatic for them and things that are traumatic for normalchildren can pass unnoticed for children with mental disabilities.
Animals Asia, Hong Kong
Karina O’Carroll, Animal Welfare Education Manager

Based in Hong Kong, Animals Asia Foundation is a large animal welfareorganization that focuses on three key issues: ending bear bile farming,
cat and dog welfare, and captive animal welfare (Animals Asia, 2017).

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions433

Dr. Dog and Professor Paws are two important volunteer-based programs
developed by Animals Asia to promote the human-animal bond and animal welfare, in general. Dr. Dog launched in 1991 as an AAA programthat brings certified therapy dogs to clients in “hospitals, disabled [centers]
and homes for the elderly” for regular visits (O’Carroll, personal communication, July 25, 2017). The Dr. Dog program is located across Hong
Kong and China, and volunteer handlers and their therapy dogs engage
with different populations, including older, underprivileged, youth, andspecial needs communities to foster understanding and improve wellbeing (Dr. Dog, 2017). The primary aim of Dr. Dog is to facilitate positive
human-animal interactions that translate into forms of social support forvulnerable populations.
Professor Paws, a school-based animal welfare education program, wasstarted in 2004. The program is comprised of educational sessions where anumber of animal welfare topics are discussed with the intention of raisingawareness; humane pet keeping is a major focus of this educational program. Accordingly, therapy dogs visit schools in Hong Kong and China
where students have the opportunity to overcome their fear of dogs, learn
safe and responsible handling practices, and engage in other lessons that
promote compassion for all animals (Professor Paws, 2017). According to
Karina O’Carroll, animal welfare education manager for Animals Asia,
many people in Hong Kong and China “have never even seen a dog” because they live in remote areas where “pet ownership is low,” or they livein certain Hong Kong housing where tenants “are forbidden to have pets”(O’Carroll, personal communication, July 25, 2017). In this way, Professor
Paws focuses on introducing young people to dogs in positive and educational encounters and settings that ultimately promote compassionate
interactions in the future.
Both Professor Paws and Dr. Dog seek to transform attitudes toward
dogs and other animals through the facilitation of positive HAIs. Impacting
attitudes through these interactions contributes to changing the culture ofcruelty toward all animals in Hong Kong and China. While Animals Asia
works to change policies that are inhumane, Dr. Dog and Professor Paws
are important programs that engage the public on an experiential level,ultimately bringing these welfare issues to the fore in a number of direct(educating students about the issues) and indirect (facilitating positive
HAIs in supportive settings) ways.

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Dr. Dog handlers and their therapy dogs. (Used with permission from Animals Asia.)

Centro de Intervenciones Asistidas con Animales(Centro IAA), Costa Rica
María José Rodríguez, Psychologist

Located in Heredia, Costa Rica, Centro de Intervenciones Asistidas con
Animales provides AAA, animal-assisted education (AAE), and AAT services to both individuals and groups. Therapy dogs are integrated mostly
into traditional one-on-one and group psychotherapy sessions, thereby
enhancing the therapeutic relationship between the therapist and clientand contributing to a calming atmosphere (Centro IAA, 2017). Centro
IAA also provides spaces for tutoring schoolchildren with a therapy dog
present, which can contribute to lowered stress and better concentrationin academics (Centro IAA, 2017). An additional AAE program of Centro
IAA is a monthly preschool class on values and developing emotional intelligence, including interactions with a therapy dog. Furthermore, Centro
IAA also partners with a number of private and public institutions, likeschools, colleges, senior living centers, and special education schools, toengage large groups of people in AAAs.
María José Rodríguez, psychologist and AAI specialist at Centro IAA,
leads a number of group activities and individual psychotherapy sessions
where she works with individuals who have experienced trauma:
In my private practice, I work mainly with children dealing withgrief for their parent’s divorce, [and] persons with emotional crises. I also work with hospitalized children with diverse physicalThe Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions435

María José Rodríguez and her therapy dog, Afra. (Used with permission from
M. J. Rodríguez.)

and emotional traumas. We do different projects in . . . facilities
throughout the year. Some of those [projects include] a 10-session
project in a mental health institution for women with autism, anda workshop for children in temporal shelters.
Overall, Centro IAA integrates therapy dogs as part of their team inorder to capitalize on the benefits of this nontraditional and unique modality. With four psychologists and a number of volunteers and therapy
dogs, Centro IAA is able to reach across the three domains of AAI: AAA,
AAT, and AAE.
INTERVIEWS
Below we provide select content and context from our discussions with eachof the four programs, according to the aforementioned interview themes.
Theme 1: Driving Factors for Choosing
HAIs as a Point of Intervention

By asking each program interviewee why he or she chose to center interventions on HAIs (and/or animal welfare), we sought to understand what
specific factors compelled them to enter this field. While a variety of animals have been used in HAIs, all four programs specifically integrate dogs
into their interventions. For The Comfort Dog Project (CDP), Animals
Asia (AA) and Dogs for People (DFP), animal welfare was described as a

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TRANSFORMING TRAUMA

driving force for implementing dog-centered HAIs. This motivation makes
sense, as these programs originally sprang from larger welfare organizations.
Interestingly, however, these programs focused on different dimensions of
welfare when describing their purpose for incorporating dogs.
Karina O’Carroll noted that, while some related organizations in
China and Hong Kong utilize other animals in HAIs, Animals Asia specifically integrates dogs in their Dr. Dog and Professor Paws programs
because it may be the most ethical choice.
K. O’Carroll, AA, Hong Kong: We have 25 years of experience withdogs . . . and their behavior is something we know well and canappropriately assess pre- and during visits. . . . We have concernsthat other species of animals may not be as adaptive as dogs can be,
but also that the visit situations, such as transport and handling,
could be traumatic to other species . . . the welfare of the animals
is something we hold paramount; it is one of the main reasons
why we work with dogs and their owners.

According to Victor Chitic, Dogs for People works primarily to redefine the role of stray dogs in Romanian culture.
V. Chitic, DFP, Romania: We are using former stray dogs saved fromvarious life-threatening or difficult conditions, thoroughly selected and trained to become therapy dogs, in order to change
the Romanian public’s mentality about stray dogs. So, although
the beneficiaries are people, on the long-term animals also benefit
from this project.

Sarah Schmidt described how The Comfort Dog Project saw a unique
opportunity in northern Uganda where the human-dog bond was already arelatively strong cultural attribute, distinguishing these communities fromothers in Uganda.
S. Schmidt, CDP, Uganda: Dogs were selected because — though in
general in Uganda, dogs have terrible lives — we saw that in thenorth with the Acholi people, there were people who had reallystrong bonds with their animals. I talked with people in the villages who told me stories about living with their dogs in IDP
camps, and the fact that it was very difficult to keep your dogs

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions437

in the camps. But, you know, they considered them part of thefamily, so they endured the hardship. . . . I have also repeatedly
seen people who will carry their dogs on their backs for literally
miles just to have their wound treated or will wait all day long fora rabies vaccination.
Additionally, the healing potential of the human-animal bond wasexperienced firsthand by the community psychologist, Francis OkelloOloya, an integral figure in the development and implementation of CDP
in Uganda.
S. Schmidt, CDP, Uganda: The use of dogs in our program really cameabout because of Francis [who] is a war trauma survivor. He wasblinded as a child by a bomb blast and lost his sight. [In highschool], he really faced a lot of challenges, because the sleeping
quarters were quite a distance from the latrine, and being a blind
person . . . he had to find some way in the middle of the night tonavigate himself from the sleeping quarters to the latrine. There
were two dogs who lived next to the school who started to makea habit of watching out for Francis. When he would come out of
his sleeping quarters at night, the dogs would come running overto him, letting him know they were there, and actually lead him
to the latrine. And this happened every night for the years that he
was in Gulu High School. Francis told me that having those dogs
there to help him gave him such comfort and confidence that hecould navigate the world.

The unwavering support, as well as the emotional and physical security, that Oloya received from these dogs contributed to his social andpsychological well-being, ultimately inspiring him to formally incorporate
dogs into the psychosocial rehabilitation of Northern Uganda’s trauma
survivors.
All programs expressed some level of rigor with regard to requirements
for dog selection and implementation. Centro IAA, AA, and DFP all utilize
a basic obedience and temperament test. For some, these tests are borrowed
from established AAI organizations.
M. J. Rodríguez, Centro IAA, Costa Rica: My dog, Afra, was an offspringof an assistance dog from Spain. Since her birth, she was selected

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and trained to be a therapy dog; she is the one whom I work withdaily. Currently, I own an eight-month-[old] Golden retriever thatis training to become a therapy dog, too. For the other dogs thatare volunteers, we apply a selection test based on the Pet Partners
Program from the USA, and every six months we do a reevaluation . . . meeting . . . [that includes] role-plays and work[shops]
for good handler-dog work.
V. Chitic, DFP, Romania: When we started the program in 2004, there
was no other AAT program in Romania, so we had absolutely noidea what we were doing. We just knew that we wanted to do it
for the children and for the animals. At the time, there were nobooks available (at least not in Romania), and not many Internet
resources either. We searched for a long time for the perfect recipe — the perfect selection test. After a while, we realized we werechasing our own shadow. There was no perfect test. So, we madeour own test by combining criteria from the American Kennel
Club’s “Good Citizenship” test and the Delta Society (at the time)
tests. The result was a new generation of dogs that had never displayed any aggressiveness toward humans.

In Uganda, the selection of dogs for the CDP was described as a collaborative effort with community members who seek better homes for theirdogs and know that this program can provide their animals with needed
resources, such as food, hygiene, and veterinary health care.
S. Schmidt, CDP, Uganda: The [participating] dogs come from homes
where there just isn’t enough food or resources to take care ofthem. [Because] there was no veterinary care in northern Uganda
for more than 20 years, the population of dogs grew very large.
When people have a litter of puppies, some kill them. But, mostpeople just let the dogs hang around. . . . As you can imagine,then, if a man can’t feed his own children, the dog isn’t going tosee food very often. So, when you see dogs in the villages, they
are usually very thin; they are full of worms and . . . parasites. It
is not always a reflection that the people don’t care about them.
It is just that they don’t have the resources. They don’t have themoney. They don’t have food to be able to care for the dogs better.

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions439

So, whenever we indicate on the radio that we are looking for dogs
for The Comfort Project, we usually have many, many people
come forward who really care about their dogs [and] want to see
a better life for their dogs. . . . We actually select the dogs who
seem to have the calmest, friendliest personalities. And then webring them back to the Big Fix and they undergo what we call“health rehabilitation.” . . . We spay and neuter them, vaccinate
them fully, deworm them, treat them for fleas and ticks, and try to
get them in good condition, and start working with them to bettersocialize them and then the dogs will be ready for placement.
While the CDP does not utilize a specific test in dog selection, theirprocess takes into account the needs of the community and the welfare of
the animals, providing them with essential resources. In this way, the dogs,
the community members, and the program participants all contribute to,and benefit from, the CDP’s model, which enhances broader public healthopportunities and outcomes.
Theme 2: Prominent Cultural Views Toward
Mental Health and Trauma

All programs described cultural stigmas toward mental health, and expressed the need for expanding public education and awareness of trauma’s
psychosocial effects. Accordingly, interviewees noted that many people donot seek counseling for a number of reasons related to both cultural stigma
and lack of opportunity.
K. O’Carroll, AA, Hong Kong: [In Hong Kong], people can still be quite“stoic” about traumatic events, brushing things under the carpet
or just expecting individuals to “get over it.”V. Chitic, DFP, Romania: Unfortunately, [the stigma toward mental
health in Romania] has a lot to do with gender roles. Traditionally,
men are taught that they have to withstand anything in order tobe “real men.” Until roughly ten years ago, military service was
mandatory. Going to the army was considered a lot like a rite ofpassage for boys to become men. In fairness, men were oftentimes
subjected to abuse and then taught to inflict the same onto newcomers. Apparently, that made them “real men.” Women, on the440

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other hand, are sometimes taught the same thing, as long as it suits
men. My view is that, for the most part, Romania is still a very
patriarchal, traditional, religious, misogynistic society. It is truethat things are starting to change, especially in the urban society
with more access to education and information, but this change
has come excruciatingly slow.
Chitic also noted that the stigmas regarding mental health prevent
individuals from seeking help.
V. Chitic, DFP, Romania: In general, seeing a psychotherapist is stillseen as a weakness. So, no, most men do not seek help. . . . The
social pressure of mental vulnerability, as well as admitting evenfor one’s self any kind of psychological vulnerability, is synonym
to utter failure.

According to Rodríguez, both access to, and attitudes toward, mental
health care in Costa Rica are split down the lines of socioeconomic status,
thereby potentially creating marked disparities in recovery and treatment.
M. J. Rodríguez, Centro IAA, Costa Rica: Parents of a high or middle-highclass usually seek professional help for their children when they
suffered from some traumatic experience. What I have been able
to observe in my professional experience is that there is no cultureof commitment [to the therapeutic process]. People expect me,
as . . . the therapist, to perform magic . . . in 3 or 4 sessions, everything [to be] addressed and all issues . . . healed. [For low-income
families], usually the [stress] of poverty and violence impede themfrom visualizing the importance of . . . professional care to growand overcome [mental health difficulties].

In countries like Uganda, however, mental health care is nearly impossible to attain:
S. Schmidt, CDP, Uganda: The mental health resources in Uganda arepractically nonexistent. The entire country has one national mental health institution, which is the hospital, and that . . . is about
275 kilometers from Gulu. So, if you have a mental illness inThe Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions441

northern Uganda, you have to get yourself into Gulu town, which
for some people is more than two hours transport by vehicle. And
people walk there. They don’t get to ride in vehicles. And even
if you get to Gulu . . . hospital, [it] is the [only] facility for overtwo million people. They have just a handful of mental healthprofessionals. So, you can see that even getting to the hospital isa challenge, and even if you get there, seeing someone would bea challenge. And, if you get there, getting the kind of treatmentthat you need is nearly impossible.
Because mental health care is scarce in the communities of northern
Uganda, many people have not been exposed to the “medicalized” discourse of PTSD and, therefore, have not connected their psychologicalsuffering to past traumatic events from within this framework.
S. Schmidt, CDP, Uganda: What’s very interesting to me is that while
symptoms of post-traumatic stress disorder were widespread in
the region, Francis told me that a lot of people didn’t understandthose things they were experiencing, like hypervigilance, nightmares . . . outbursts of anger, outbursts of sadness . . . they didn’tknow that those things were actually caused by what they had
experienced in the war. No one had ever explained what post-​
traumatic stress disorder is, or that it has certain symptoms. So,
people would just try to live with these symptoms and not evenunderstand why they were having them.

Schmidt continued to explain how the organization provides initialand continuous community psycho-education to both inform the local
people about trauma and its symptoms, as well as recruit those who may
be interested in participating in the CDP.
S. Schmidt, CDP, Uganda: Francis held a number of meetings in thevillages, and he encouraged people to come who had sufferedduring the war. He had large turnouts of people, and he basicallysat down and explained to them that people who go throughwartime experiences may now have these symptoms. He would
talk about what these symptoms are: the nightmares, the flashbacks, the hypervigilance, the outbursts of anger, the withdrawal

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TRANSFORMING TRAUMA

from society. And, people were recognizing, “Yes, I have that!”
Now they were being provided with an explanation for why they
were suffering with those things. Then, in the course of holding
these village counseling sessions, Francis begins to introduce theconcept of The Comfort Dog Project.
Still, Schmidt noted that there continues to be stigma associated withmental health and symptoms resulting from traumatic experiences.
S. Schmidt, CDP, Uganda: I think that [trauma is] generally viewed
as being a weakness, something that is shameful. The people I’ve
known in Uganda have a real resilience, which has always impressed me. Life here is extremely difficult. It takes most of the
day to cook a meal, because it is so involved — carrying the water,
going to pick the things . . . life is very, very difficult. So, there
is sort of this attitude that there is no time to have any personal
problems. You’ve got to take care of your work; you get food toyour family that day, and that’s enough to worry about. . . . People
are just expected to go on with their lives.

Notably, most of these programs counter the cultural stigmas associated with mental health and trauma through facilitating interventions
that ultimately educate individuals and communities about the needs ofanimals, as well as the therapeutic power of animals and the human-animalbond. As such, attention to mental health concerns likely becomes morenormalized in the process.
Theme 3: Cultural Stereotypes and Views of Animals

Those involved in all four programs spoke extensively about the various views
and stereotypes of animals and animal roles in their respective countries
and how these views impacted their AAI practices. A common theme thatemerged was the perception of animals—particularly dogs or certain types ofdogs (i.e., strays)—as unclean, diseased, and thus, menacing or undesirable.
S. Schmidt, CDP, Uganda: Oftentimes, when people see dogs just running loose, they think that the dog is rabid. So, we’d [see] a desire[amongst some] to want to just kill that dog that is running loose.

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions443

V. Chitic, DFP, Romania: I guess the most common cultural variable isthe prejudice regarding dogs. They bite, they are dirty, they spreaddisease . . . it is mainly about fear, and I believe this fear comesfrom lack of proper education regarding dogs.

In Uganda, fear was also based on the traditional role of dogs as thefamily protector, as well as their participation in wartime operations. As
such, prior to the program’s implementation, dogs in Uganda were often
perceived as aggressive, which initially hindered the acceptability of their
inclusion in services designed to help people.
S. Schmidt, CDP, Uganda: There are a lot of people who really fear
dogs within northern Uganda, especially those who served in therebel army, because dogs were fierce protectors of their homes andfamilies. So, the rebel soldiers routinely came across very viscousdogs . . . and many of them were attacked by those dogs. Many[dogs] lost their lives during the war because of their protective
instincts. Nowadays, still, many people keep dogs for protection.
Those dogs are not socialized; they’re just there to be aggressive
and to scare off intruders. . . . So, the idea of having a dog as abest friend really seemed crazy to those people. And then the ideathat a dog could actually help you with your problems . . . thatreally seemed [strange].

Views such as these were challenging when the concept of AAI was
initially introduced. However, many of the interviewees believed thesestereotypes had lessened over time, and were, in many cases, impacted by
the projects’ activities.
M. J. Rodríguez, Centro IAA, Costa Rica: One barrier has been the perception that dogs are dirty and can transmit diseases, even if thisis not the case, since we comply with a protocol for cleaning andprevention of zoonosis . . . [however], something that supports
this type of therapy is that dogs now are considered part of thefamilies; this change has come about in the last few decades. This
makes parents more comfortable with using dogs as a therapeutic
tool in supporting their children’s therapy program.

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S. Schmidt, CDP, Uganda: So, when we started our project, a lot of
our initial guardians were ridiculed for, you know, walking with adog on a leash, going to a dog training class, you know, wearing
a shirt saying you were part of a dog project — they were ridiculed for that. And, they really had to undergo some hardshipjust to be part of the project. But now, over time,
people have started noticing that Comfort Dogs arevery clean, healthy-looking
dogs . . . that has createda desire for other people
to have dogs like those
Comfort Dogs — thosedogs who look so nice,and are so well-behaved
and obedient, and will sit
down and come, and will
do all these things when
asked. . . . People are really
starting to see that dogs dohave a nice purpose; that A CDP participant and his dog. (Used with permission
they are protective, but that from the CDP.)
they are also friendly.
K. O’Carroll, AA, Hong Kong: Culturally, I would say in both [HongKong and broader China], there is definitely — in the last ten
years, I would say — a growing interest and increase in animal
welfare issues and knowledge. And, people are paying more
attention to what is happening with animals, and realizing,
obviously, that animals are sentient, and they do deserve ourrespect and care, [including] how we treat them in all different
industries as well.

These evolving attitudes have promising implications for animal
welfare, animal involvement in mental health treatment, and enhanced
relationships between community members and animals.

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions445

In addition, individual and community attitudes toward animals help
shape pet keeping practices. Interviewees noted that these practices weredirectly tied to shifting cultural attitudes regarding animal sentience, andconsequently, increased awareness of animal welfare issues.
K. O’Carroll, AA, Hong Kong: We’ve got a bit of an overpopulation of[companion] animals issue in Hong Kong at the moment. So,
we’re always promoting adopting over buying. . . . Obviously,
China’s a much bigger place than Hong Kong, so they have morerural communities. . . . They’ve got a rapid increase currently in
pet ownership and companionship. So, awareness of animal welfare issues is rising. But, I think for China, unfortunately, thelegislation in regard to animal welfare policy is still . . . lacking,but we hope that soon there will be change in that area. In Hong
Kong, we actually have good . . . animal legislation for animal careand welfare and animal cruelty, but sometimes there are issues
with enforcement of those laws.

While O’Carroll noted that the increase in pet keeping has raised
awareness around animal sentience and welfare considerations, Chitic
claimed that, in Romania, awareness of animal sentience does not always
translate to humane practices.
V. Chitic, DFP, Romania: Pet owners certainly share [the] view [thatdogs are sentient], but sometimes there are . . . logical inconsistencies like: “I love dogs, I have a pet dog, but I hate stray dogs, I
think they should all be killed.”

Indeed, pet keeping trends in Romania bring new welfare concerns to
the fore, particularly around ethical care practices.
V. Chitic, DFP, Romania: I would say [pets are] very common, at least inan urban environment. Although, it is just my opinion, since there
is no official statistic on pet ownership [in Romania] . . . mostpeople have cats or dogs. Parrots or other caged birds, or sweet
water tropical fish are also common and [were common] during
the Communist regime. The new pets that came in the latest years446

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with the proliferation of pet stores and especially [the] online pet
trade — which is largely not regulated and raises major welfare
concerns — are reptiles, amphibians, and rodents. It seems there
is a rising demand for ferrets recently.
Noting his concerns about pet keeping and animal welfare issues,
Chitic continued to speculate on the factors driving irresponsible practices
in pet keeping, including often inappropriate attitudes regarding animals
and their particular attributes.
V. Chitic, DFP, Romania: [I’ve] found that people rarely go through[the] process of informing themselves before getting a pet, or, if
they do, they tend to disregard the information related to specificpotential problematic behavior in favor of — most often — how
the animal looks. Regarding pet keeping in Romania, there isalso a history of successive ‘fashion’ trends, as I mentioned about
the ferrets earlier. At some point during the Communist regime,
for example, Airedale terriers were in high demand and wereconsidered something of a social status. Only rich and [influential] people could afford to get and raise one. It might be worth
mentioning here the fact that that period — [the] mid- to late1980s — was marked by food shortages, especially meat. Airedales
are big dogs that require a lot of food, hence their exclusive nature
among Romanians at the time. Now, you can hardly see a few suchdogs in the parks or streets of Bucharest.

Problematic trends in pet keeping, and animal welfare in general, arecertainly not endemic to Romania, as all four programs point to notable
shortcomings with regard to welfare practices in their respective countries.
By seeking to challenge harmful cultural stereotypes of animals, these programs are forging spaces for creative alternatives in multiple domains ofanimal and public health.
Theme 4: Challenges of Running an HAI Program

Throughout these discussions, interviewees identified two key challenges ofrunning an HAI program in their respective countries: cultural stereotypesof animals and the lack of information and resources pertaining to AAIs.

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions447

S. Schmidt, CDP, Uganda: The general stereotype about dogs [has]been our most challenging [issue]. One of our loveliest first-year
Comfort Dogs was actually murdered because of those beliefs.
It was just a tragedy. The young client who had this dog was
so devoted . . . loved her so much. They were doing just so welltogether. And, because of either jealousy or bad feelings toward
dogs in general, the dog was just brutally attacked by someone
in the village.
V. Chitic, DFP, Romania: Most challenges stemmed from the way
people regarded dogs in general and stray dogs in particular. In
2004, when we started, there were a lot more prejudices against
dogs than there are now. The program was well received by the
public and the press because it was a novelty and exploited thegood image of anybody doing anything for free for children withdisabilities. From this point of view, the program has always been
beyond critiques.

While cultural attitudes and prejudices regarding animals are a major
challenge to these programs, lack of resources and information also presentsbarriers. Chitic noted how limited AAI information and resources required
him to prepare for the challenges posed by skeptics largely on his own.
V. Chitic, DFP, Romania: One of the challenges we faced in the beginning was the scarcity of information regarding this field.
Fortunately, [that is] not the case anymore. That forced us to becreative, [to] develop selection procedures for dogs and targetedinterventions with the dogs . . . another challenge was the reluctance of institutions to collaborate with us. The main concerns
were dog biting, zoonosis, and lack of efficiency. I managed toconvince them by always being prepared with an answer, up-todate proof of health checks of the dogs, scientific papers of thebenefits of interaction with dogs, and explaining in detail ourselection process for dogs.

Likewise, Rodríguez explains how she navigated the lack of AAI resources, information, and professional partnerships in Costa Rica.

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TRANSFORMING TRAUMA

M. J. Rodríguez, Centro IAA, Costa Rica: The main difficulty in Costa
Rica is the lack of formal education in AAI. There were no universities or educational centers to provide a formal training in thisfield. So, I had to search for a foreign university to get the proper
certification [the Institute for Human-Animal Connection at the
University of Denver]. When I came to Costa Rica with my certificate, I tried to join an organization who were working on AAI
here, but they didn’t want people with a different preparation, so
I started from my own.
Theme 5: Welfare Considerations

Interviewees described specific steps taken to prevent welfare issues among
participating animals from emerging. For example, the CDP has an extensive process through which they screen participants, and ensure the homeenvironment will be safe and welcoming for a Comfort Dog.
S. Schmidt, CDP, Uganda: Francis spends time counseling each person
before they are even considered for the program. So, he knows the
person, whether they are stable, whether they are going to be able
to provide a good home for the dog, whether the families can besupportive of the idea. . . . We have them interact with our dogs,
so we can witness for ourselves: Are they afraid of dogs? . . . Then
we go to the house and Francis talks to all the family members
and makes sure everybody is on board with the idea.
We talk to the local leader [as well]. In Uganda, the local
leaders . . . are very important. The LC1 [Local Council Leader]knows everybody in the village intimately. So, we talk to theLC1s. We make sure the house is a safe environment for the dog.
And, then, if a person passes all that criteria, they attend an animal care class and they have to complete that successfully. Ifthey complete that class successfully, then they’re paired with amentor who is a graduate of our program. . . . That mentor isactually paid a small compensation to follow up regularly with
the new guardian and their dog, to visit the home, and makesure things are going well. Also, we have a humane officer whogoes regularly to visit the new guardians after the dogs have beenplaced. And, then, the guardians attend a weekly training classThe Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions449

where they come with the dogs. . . . So, we observe them with
their dogs. We have one of our vet doctors who is always present
at the weekly training, so . . . we are making sure that any illness or injuries are being addressed regularly as it comes about.
The dogs will continue to receive free veterinary care for life fromthe Big Fix as well. . . . The only problem we have is that a lot of
our dogs are overweight. People actually overfeed them, so weare having to monitor the food a little bit. It’s ‘funny’ becausesome of our clients are so, so thin, but some of our dogs are so, so
fat, because that’s a way of showing your love. You feed the onethat you love.
Schmidt also described an important cultural practice that anchors theguardian’s life commitment to the Comfort Dog within the community.
S. Schmidt, CDP, Uganda: We also have a very, very serious guardian commitment that the guardian has to sign before the dog isplaced. And the signing of that guardian commitment occurs in
the presence of the LC1. So, that guardian commitment is signed
not only with all the comforts of having people present, but also
the LC1 is present. So, it adds a very serious thing, culturally.
That guardian commitment provides that person with a lifelongcommitment to their dogs, that they will always carry out for the
dog with certain criteria, and [that] there are consequences if that’s
not carried out.

Indeed, for the CDP, working closely with the cultural traditions andstructures of local communities ensures that welfare practices will be internalized and codified within local networks of meaning.
Theme 6: Outcomes at the Individual and Community Level

Interviewees described various outcomes and/or mechanisms ofchange — both for the people and for the animals — associated with their
HAI program. The stories and anecdotes they shared point to impacts
across individual and community scales. For instance, Schmidt explained
how involvement with caretaking practices reframes the guardians’ basic understanding of the human-dog bond, which ultimately filters out
into the community through outreach projects. These observations are in

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line with research (Wood, Giles-Corti, Bulsara, & Borsche, 2007, p. 43)
demonstrating that companion animals have a “ripple effect”; that is, pets
have meaningful benefits not only for their owners, but also for the broader
communities in which they live.
S. Schmidt, CDP, Uganda: We actually teach dog grooming and washing. And, when we first started doing this people thought we wereabsolutely insane, because nobody ever washed a dog or thoughtof doing that. The problem is that most of the dogs living in thevillage or in the bush are very dirty, smelly, most have mange,
and they are all covered with fleas and ticks. . . . [After grooming and bathing], we found that not only did [people] want totouch their dogs, but they didn’t want to put their dogs on the
ground again when they were clean. There were people who actually would carry their dogs home. They were so delighted that
their dogs were clean, and they began touching and petting theirdogs and interacting more with their dogs. So, we really felt likethat was helping us to accomplish one of our main goals, which
was to promote good human-animal bond. So, now we have our
CDP people going out and teaching grooming and washing. And,
now, we’re running into, you know, teaching basic obedience aspart of their [grooming] time and having people interacting in agood way with their dogs. Before . . . dogs were guard dogs; they
were used for hunting, and that was it. They were not touched or
handled or invited into the house or treated as friends. And now,
we’ve seen it changing, . . . because of [this] education.

Dog grooming, according to Schmidt, becomes a means throughwhich the human-animal bond is strengthened, contributing to the therapeutic process in the guardian’s psychosocial rehabilitation. One author/
interviewer asked Schmidt about the significance of the human-animalbond for other areas of the guardians’ lives.
Author/Interviewer: Do you, as a program, believe that the emphasis — almost metaphorical emphasis — on animal well-being thentranslates to the client’s human application of that to themselvesor their families?

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions451

CDP participants train and work with their comfort dogs. (Used with permission from the CDP.)

S. Schmidt, CDP, Uganda: Yes, our observation is that . . . all of ourguardians love their dogs so much. They think of them as children. They refer to them as my son or my daughter. There is reallystrong affection. We have had people who come to us and say,“My dog is sick. You have to come see him right away!” And we’ll
go visit the dog and find that actually . . . the dog is not really inthat bad of condition. The dog might have a cough or a cut orsomething. . . . [But], we find that the person is actually very sick,but that is not their concern at all. The guardian’s concern is thedog. So, even when they aren’t able to acknowledge their own issue
because they’re recognizing something in the dog, they’re able to
make an improvement.
Let me tell you a great story to illustrate that: One of ourclients suffered terrible atrocities — lost his wife and two children
in the war, right in front of him. He was suffering from terrible
depression and flashbacks. To try to cope . . . he [became addictedto] alcohol. We brought him to The Comfort Dog Project, and he
immediately formed a strong bond with his dog. . . . [Soon] hebecame very, very ill, [and] he couldn’t get out of his house or get
any help. His dog went and got help for him. He ended up being
in the hospital for a month. He believes the dog saved his life. So,

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he’s very strongly bonded with this dog. Last time I saw him, I wastold he was no longer drinking alcohol, which had been his major
problem. One of his major things was avoidance of his symptoms
through his use of alcohol. He stopped drinking alcohol. And I
said, ‘What? How did that come about?’ . . . He said that his dog
didn’t like the smell of alcohol, so he had to stop drinking it.
This story reveals the power of a therapeutic human-animal bond,and the unique, yet indirect, way individuals can heal through the often
uncomplicated relational dynamics shared with their animal companion.
What is more, this particular connection was likely strengthened throughthis individual’s enhanced perceptions of his dog (and thus the dog’s worth
and utility) — from serving as a helpful companion to a literal savior. In
this way, the importance of the bond with his dog superseded his dependence on alcohol. It is unknown whether this healthy change in behavior
and self-care stemmed from his desire to be a good guardian for his dog,from concern for his dog’s welfare if he continued drinking, and/or via
the replacement of alcohol with a far more effective source of solace andcomfort — canine companionship. However, what is evident and remarkable is the level of trust and commitment that both he and his dog had foreach other, and how these elements strengthened the potential for recovery
through mutuality. As Schmidt noted, “If we magnify the value of the lifeof these dogs, if we reject the notion that their lives are disposable, andwe value them, then . . . the guardians also feel valued in their own life”(personal communication, September 14, 2016).
Many stories shared by the interviewees referred to individual, therapeutic breakthroughs that resulted from HAIs.
M. J. Rodríguez, Centro IAA, Costa Rica: Recently, in a hospital there wasa little girl [who] was about eight years old who was bitten by theirhouse dog; her head had numerous stitches. When we [arrived]with the dogs, she was playing in the games room. When she saw
us, she became alarmed and suspicious. We didn’t approach heror seek to contact her; instead, we started by interacting with theother kids. About 15 minutes later, she came with her mother andasked for a brush to pet the dog and the magic began! Silently,
she reached out for the dog’s ears and the dog carefully allowed
her to caress [its] ears. Over the course of 30 minutes, she was

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions453

giving the dog a prize for being so good and obedient. She andher mother learned about dog body language, and began healing
the fear from being [bitten].
Another anecdote is that of a boy who was in my office because of the divorce of his parents. He started to cry because he
did not understand why his dad would not come back to thehouse. At that moment, Afra looked at him and licked the tearthat ran down his cheek. He, with a slight smile, [embraced] herand [said], “Afra, you understand me. You know that I miss my
dad very much.”
V. Chitic, DFP, Romania: I would say that the most spectacular casewas this 12-year-old girl that had been sexually abused by her
stepfather. At the time, she was being brought daily by her motherto this daycare center owned by an NGO. She never talked about
what happened to her to anybody and she was very withdrawn.
After a few sessions of working with one of our dogs, she developed a fantastic relationship with the dog, and she started talking
with the dog and sharing things about herself. She started sharing
details about her abuse to the dog.

Throughout these accounts, the nonthreatening interactions with therapy dogs seemed to invite individuals to safely process important aspectsof their trauma experiences — a breakthrough that could be attributed tothe therapeutic nature of the human-animal bond.
Furthermore, O’Carroll noted that animal welfare outcomes empowered community members in Hong Kong and China through exposureand humane education.
K. O’Carroll, AA, Hong Kong: Our main aim was to originally promoteanimal welfare through people welfare. It was giving people a positive experience with animals to change their . . . beliefs and theway they think about animals. But, as more people were coming
to understand that dogs have feelings . . . they were then changing their attitudes toward those animals and standing up to crueltrades, for example, in dog and cat meat eating . . . and the riseof adoptions, and not buying animals from pet shops. They’re
not commodities, they’re not toys. . . . There was more animal

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TRANSFORMING TRAUMAChildren participate in a Professor Paws activity. (Used with permission from Animals Asia.)

welfare focus initially, but over the years, people can see the positive change in people as well.
Indeed, the promotion and implementation of humane practices is
intimately connected to human public health and well-being. All of these
programs demonstrate that positive HAIs can facilitate healing, reframe
attitudes about animals and animal connections, and promote humane andconscientious behaviors — outcomes that are intrinsically interconnected.
Theme 7: Advice for Practitioners

When asked to reflect on the challenges their organizations faced when implementing their HAI programs, interviewees offered important advice on
creating programs that are both well-informed and culturally competent.
S. Schmidt, CDP, Uganda: You need the advice of an expert. . . . The
other recommendation I would have is that actual on the groundwork must be [closely] involved with a local person who is
intimately familiar with the local culture, because as an outsider,we can never fully create those cultural idiosyncrasies that are so

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions455

important to being effective. . . . Another really important thingis education. The Comfort Dog Project didn’t start until early
2015, The Big Fix had already been working for three years doing
education in the schools and in the villages about the Five Animal
Freedoms . . . about the sentience of animals. If we hadn’t had thatwork already done, it would have been very challenging to comein and just start the program. But, people in the Gulu district
had already been exposed to these ideas for several years. So, thatwas important.
K. O’Carroll, AA, Hong Kong: I think, on the ground, the volunteers that
we have for Dr. Dog and Professor Paws, most of them are local
community members, so they have their networks of friends andtheir networks of people that we can go and visit, too. It definitely
helps to have a sort of local knowledge and an understanding of
culture as well. In Hong Kong, we don’t really have a cat and dog
eating issue here, because it is illegal. But it is . . . still happening
in China and obviously other parts of Asia as well. So, trying to
do education work on those topics, and having your volunteer
staff [be] aware of the cultural sensitivity, and . . . to still be able
to do the education work while understanding all that is definitely
critical. . . . Having local staff and local knowledge . . . really does
make a difference when you’re trying to tailor your education or
tailor your impact — or what you’re trying to get across to the
local community.
V. Chitic, DFP, Romania: Be aware of any cultural factors and prejudicesagainst animals in general, and dogs in particular. Get to know
other people involved in HAI locally — view them as colleagues
and partners, not as competitors . . . there’s room for everyone.

The advice provided by the interviewees highlights the necessary collaborations with local people, organizations, and institutions for effective
HAI programs that are culturally inclusive and responsible. Cultural competence, as an ongoing process, allows for a program that is well integrated
with local systems and values, and is therefore empowering for the community members who are involved.

456

TRANSFORMING TRAUMADISCUSSION
In this chapter, we highlighted four international HAI programs that are
integrated in different cultural contexts, and are seeking to improve theconditions and welfare of animals, as well as the mental health care and/or
trauma recovery of people in their countries and local communities. The
Comfort Dog Project in Uganda, Dogs for People Program in Romania,
Animals Asia Foundation in Hong Kong, and Centro IAA in Costa Rica
offer insights that underscore the unique ways that HAI programs are implemented in cultures traditionally unfamiliar with this modality. Culturalcontexts, viewpoints, and traditions clearly shape conceptions of mental
health, trauma, animals, and human-animal interactions, broadly. As thesefour programs — and others doing similar work — navigate these contexts
in ethical and nuanced ways, they also contribute exponentially to the fieldby making it more culturally inclusive, relevant, and informed.
While these programs undoubtedly experience challenges in implementing therapeutic and welfare interventions in countries with certain
stereotypes about animals, specifically dogs, they have found creative ways
to develop their HAI interventions to ultimately benefit the individuals, theanimals, and the communities as a whole. These HAI programs have thus
forged important paths into complicated cultural situations and, throughinviting collaboration with local knowledge sources, have developed new
and effective organizational and practice models. These models thereby
provide the field of AAI with important, and in some cases even novel,
information on the therapeutic application of the human-animal bond,and should be widely recognized, invested in, and studied accordingly.
In addition, the interviews included in this chapter have raised anumber of important questions that may inform the broader field of AAI
research and practice. For instance, most interviewees described how they
push against negative cultural stereotypes of animals, which ultimately
mediates the implementation of AAIs. Once positive AAIs are facilitated,
powerful therapeutic outcomes may take place, such as increased client/participant self-efficacy and support during therapy, reduction of trauma
symptoms, and attitudinal shifts with regard to humane practices, animal welfare, and trauma recovery. In other words, the bond enables theoutcomes. One must ask, then: Is there a transcultural understanding of
the human-animal bond as a phenomenon? Do these programs tap into anatural affiliation by facilitating these positive encounters? By examining

The Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions457

HAIs in international contexts, we gain insight into these importantquestions via the human-animal bond from a variety of perspectives, notmerely our own.
Another important question pertains to the mechanisms of change
associated with the human-animal bond, particularly in different culturalcontexts. The Western-centered approach to psychotherapy is focusedon the individual — the psyche — and often AAT is directed with thisframework in mind. However, some international programs — such as
The Comfort Dog Project, discussed here — do not approach psychosocial
rehabilitation from trauma in this way. Rather, they facilitate powerful bonds between the guardians and the comfort dogs, and allow thetherapeutic outcomes (for individual people and animals, as well as thecommunity) to unfold in the process. Thus, an important question about
the mechanisms of change involved in these processes is raised: How do
indirect aspects of AAIs contribute to therapeutic outcomes, both on theindividual and community level? Are there parallel psychological processes
that take place when an individual grooms, feeds, trains, nurtures, visits
with, or simply observes a companion animal that help them process
traumas? Do indirect AAIs, based on the relational (and often nonverbal)
aspects of the human-animal bond, create a dynamic and flexible spacefor cultural difference that traditional, Western models of psychotherapy
do not? And, does the indirect, nonthreatening nature of these AAIs normalize mental health and illness in communities where it has traditionallybeen stigmatized? Clearly, we are just beginning to scratch the surface inunderstanding the implications of HAI programs and applications — bothinternational, as well as more well-known Westernized practices — for thefield of AAI.
Insofar as the AAI field is influenced by Euro-American mental healthtraditions, implementing HAI programs cross-culturally or in locations
where AAI is not yet broadly supported requires important ethical andpractical considerations. Jegatheesan (2015) recommends three primary
components for “a culturally responsive framework for AAI” when working
with diverse clients, although these can certainly apply to program implementation as well: 1) cultural self-awareness, with an emphasis on one’s
own cultural biases, assumptions, prejudices, and privileges; 2) knowledgeof clients gained through “dialogue-based” interactions; and 3) skill development, so that services are provided in a culturally respectful, inclusive,and effective manner.

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Across the board, the four participating interviewees highlighted
specific considerations, or competencies, for implementing a successful
HAI program in a non-Western culture. Cultural competence and animal
welfare were the most highly noted considerations. Cultural competence
includes continuous collaborative dialogues with local cultures to learn
about customs, attitudes toward animals, and histories. The Comfort Dog
Project, for example, demonstrates the importance of infusing local traditions and knowledge into one’s organization. Understanding the role of thelocal leaders (LC1s) in the communities allowed the program to develop an
appropriate contract for the guardians that ensures a lifelong commitment
to their comfort dog. This contract is weighted by the cultural significanceof having the LC1 witness its signing; the guardian thus feels empoweredby the weight of this commitment and the expectations of revered leaders,as he or she is supported by the community in maintaining his or her
own integrity. This program ritual also helps to ensure that the tenets ofthe program are aligned with the local values and belief systems, which
ultimately contributes to the program’s success.
The other major consideration for a successful HAI program is thepromotion of animal welfare. Ensuring humane practices is intrinsicallytied to positive therapeutic outcomes for people; if animal well-being iscompromised, so too are any potential benefits of the interaction. Indeed,a number of these programs noted beneficial outcomes across individual,
animal, and community levels. These transformations are undoubtedly
due to the integrative nature of these programs in that they pair animal
welfare with human welfare in an expanded model that ultimately promotes public health.
The programs interviewed in this chapter also model the important interconnections between human and animal health and well-being that arehighlighted by the One Health model (One Health Initiative, 2017). Thismodel, originating with the interdisciplinary study of zoonosis, asserts that“human health (including mental health via the human-animal bond phenomenon), animal health, and ecosystem health are inextricably linked,”
and calls for collaborations across disciplines to ensure health and well-being for all species (One Health Initiative, 2017, para. 1). Programs that are
informed by the One Health framework may thus avoid the asymmetrical
power relations that often result from the imposition of missionary-likeagendas in international contexts. Indeed, within the One Health framework, one species/one cultural framework/one ideology cannot be elevatedThe Global and Cross-Cultural Reach of Trauma-Informed Animal-Assisted Interventions459

above the rest, because health outcomes (including mental health) arecontingent upon the well-being of the ecosystem as a whole. It is no surprise, then, that many of these featured programs, which were initiallyanimal welfare-focused, have developed human welfare and mental healthagendas. Integrating animal welfare with human health agendas via theframework of One Health allows HAI programs to facilitate trailblazing
interventions that are ultimately humane and culturally inclusive. The
four programs outlined in this chapter provide a glimpse of the uniqueways that such interventions can be implemented across the globe withprofound outcomes.
ACKNOWLEDGMENTS
We would like to thank our four interviewees (Victor Chitic, Karina
O’Carroll, María José Rodríguez, and Sarah Schmidt and their respective
organizations) for their time and interest in participating in this chapter,and for sharing with us the very good work they do each and every day. We
also extend our sincere gratitude to their clients and animal participants.
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ABOUT THE AUTHORS
Betty Jean Curran, LMSW, AASW, is the director of Student Services at
EPEC’s The Grooming Project in Kansas City, Missouri, a 501c3 nonprofit
that trains parents living in poverty to become successful dog groomers.
Earning her Master of Social Work from the University of Denver, Curran
had the opportunity to work closely with the Institute for Human-Animal
Connection on a number of research projects. It was here that she became
passionate about understanding and utilizing the powerful and therapeuticpotential of the human-animal bond in a variety of contexts.

Biographical sketches for Molly A. Jenkins and Philip Tedeschi can be found on
p. 12 of this volume.

Conclusions
Molly A. Jenkins, MSW, AASW; and Philip Tedeschi, MSSW, LCSWWith this book, we and the contributing chapter authors sought to shedlight on the ever-evolving fields of animal-assisted intervention (AAI)
practice and research, particularly in regard to the inclusion of animals invarious modes of human trauma treatment and recovery. This domain iscurrently experiencing swift attention and growth, expanding in ways that
we are likely not even aware of. This is both exciting and a bit daunting,and as editors of the first book to highlight these specific applications, wehave felt a great responsibility to facilitate the provision of material that is
as practically useful as it is intriguing.
However, we feel it is important to acknowledge that this volume is notintended to be a comprehensive review of trauma-informed AAI practice
but, rather, a presentation of some of the key theoretical models, methodologies, research findings, and scientific pursuits that exist today, as well as
how each of these adds to the knowledge base and lays the foundation forfurther understanding. To be sure, an updated edition will likely be neededin the near future to account for the breadth of promising and complex
work currently underway in this area. Just as the types and impacts oftrauma are incredibly vast, so too are our relationships with animals andthe potential avenues for healing through human-animal connection. It
is, in fact, the depth of this very connection — in all of its resonant, genuine, and indescribable forms — that makes the AAI field so exciting, andso promising for those facing the hardships of trauma, in the first place.
Across the preceding chapters, a certain commonality regarding AAI
applications and their effects became apparent. Whether through pairing
463

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service dogs with military veterans facing post-traumatic stress (PTS); helping children take responsibility for the care and/or training of camels andother animals in nature-based settings; offering therapy dog visitation for
those in crisis in the wake of disaster; or incorporating play with animals
in a therapeutic context with children who have been maltreated, it was
clear that connecting with animals provided an overwhelming, and largely
unique, sense of security for people with trauma. Relationships characterized by both physical and emotional safety, as well as trust nourishedby reliable support, are often exactly what traumatized individuals andcommunities need the most.
Research and anecdotal accounts widely attest to the comfort and acceptance people experience when in the presence of animals; with animals,
we are free from the anxiety of self-doubt or second-guessing the unknown,and can feel assured in the tender stability of the bond we have collectively forged. In the trauma-informed practices covered in this volume,the benefits of animal-assisted safety and/or bio-affiliative safety manifested
in a number of ways, including (but not limited to) directly or indirectly
creating comfort and even joy with the therapist and throughout the therapeutic process; serving as a grounding force and secure base of which tofocus or return to when discussing or (re-) experiencing traumatic events;
providing opportunities and impetus for calm during periods of distress,
emotional dysregulation, or hyperarousal; offering a sense of physical security; and facilitating greater ease when (re-) engaging with others andthe social and natural world.
Moreover, several authors discussed how animals can enhance people’s
feelings of self-efficacy, -worth, and -purpose, all of which may have been
stifled by trauma and loss. Often, this took the form of mastery throughlearning about the behavior, preferences, and sensitivities of a particularspecies and its habitat; teaching or training an animal to perform certain
tasks; practicing empathic and relational skills with animals for use in othersocial contexts; and actively attending to the needs of animals by ensuring
they were healthy, clean, well-fed, and treated with kindness. As several
chapter authors discussed, the importance of being cared for by someone
we trust, while also providing care and compassion for that someone withneither shame nor trepidation, cannot be overstated.
Throughout each of these activities and achievements, the element ofconnection with the animal was always a steady fixture. In this sense, one
could argue that, through healthy and humane attachment to animals, weConclusions465

may be more apt to question our assumptions about them, and empathizewith them through recognition of their unique strengths and capabilities,
as well as the common experiences we share. In turn, advocacy for animal
welfare on a broad scale could likely advance by way of AAI participation
and, as Bexell, Clayton and Myers highlight in their chapter, throughobserving “care, concern, and admiration for [animals]” as modeled bytherapists, handlers, and other AAI interventionists.
Potential evidence of such developments was discernible across various
chapters in this book, including in our interviews with four international
AAI programs. For example, through dog bathing in Uganda, project participants (the majority of them war trauma survivors) were able to carefor, and bond with, their individual comfort dogs, all while transforming
common cultural and community perceptions of dogs as dirty and unsafe.
Interestingly, most of the international programs featured in this bookfirst stemmed from animal welfare initiatives, which then later led to theincorporation of a human mental health focus. Thus, these interventions,
whether primarily human- or animal-centered, have ample potential forbidirectional and mutual benefits, granted that the welfare of animals be
given equal footing. These features can assist in the healing and progressof individuals and communities alike, and could even help encourage therespectful treatment of a wide variety of animals who, they themselves, may
be burdened with the aftermath of trauma or cruelty.
Despite these positive accounts, study findings, and a general common
faith in the effectiveness of AAI, the field still struggles considerably withcredibility. Indeed, there has not yet been a strong integration of AAI concepts into modern psychology, medicine, or academics, although this is mostcertainly changing. Many cite the limited number of rigorously designed
HAI studies — with their methodological challenges, historically anecdotalslant, and somewhat ambiguous or tenuously supportive results — as primary underlying reasons for this. Others speak to the difficulty of accurately
and logistically studying the impact of animals for people in need. We do
not disagree with either assessment. The challenges of conducting soundand replicable research in this field are many, including restricted animal
access to select clinical settings due to safety and health concerns, an overall lack of validated HAI instrumentation, researcher expectancy biases,
potential human handler effects, and the complicated nature of stipulating
specific intervention protocols that encompass the various needs and proclivities of multiple living beings at once, to name just a few.

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Nevertheless, ensuring high-quality research studies that are both exact
and adaptable enough to have meaning outside of the “laboratory” are essential for this field to gain serious recognition and broader, more relevant
implementation. To date, this has been a difficult goal to achieve, partly
because of the relatively sparse (in terms of both the number of opportunities and the amount of available awards) and stringent nature of researchfunding in this area. To be competitive, many grant applicants are called
upon to incorporate a fairly consistent research design methodology into
their proposals, including the use of a control cohort or third comparisongroup to account for any novelty effects of AAIs; randomization; a large
sample size, including multiple study sites; validated instrumentation and/or physiological measures; quantitative vs. qualitative data; treatment protocol fidelity; and longitudinal designs.
While we do not wish to undermine the importance or value ofthese research elements, and believe they do have a central role to playin this arena, we worry that an absolute expectation of their inclusion
may be quite costly on the whole, as well as prohibitive for a number ofprospective researchers. This may not only prevent the contribution ofpotentially valuable research findings, but could serve to exclude these
individuals from gaining a seat at the table. As such, the good work of underrepresented and often underresourced programs is at risk of remaining
in these positions, or worse, being further marginalized and disparaged
as comparatively subpar because they lack the ability to evaluate theirpractices in ways deemed acceptable. We hope that, going forward, acommitment to high research standards and integrity can be augmented
by an expanded view of what is considered worthy of our time, attention,and monetary support.
In truth, all approaches to research have their unique up- and downsides. For example, some have argued that the very specific conditions
or factors present in rigorous studies that report positive HAI findings
often lack practicality in “real-world” settings and scenarios. As Beetz and
Schöfmann indicate in chapter 3, research in which optimal conditions
are intentionally applied and controlled may not be representative of actual human-animal interactions and, thus, may not have the observed
positive effect once practice implementation efforts are made. In otherwords, what is the advantage of studying the effectiveness of a certain intervention if that intervention is not actually able, or struggles significantly,
to have the desired effect? “Practice-to-research-to-practice” models andConclusions467

implementation science approaches, in which feasible and diverse practices
are assessed through an array of quality research methods with the aim ofthen optimizing further practice, may be particularly fruitful ways forward.
As evident throughout this book, AAI practices to support those impacted
by trauma has, to date, far outpaced research demonstrating their effects.
We believe there may be reasons for this, as well as ways to expand andenrich opportunities in this area for the betterment of those in need, as
well as the field’s standing and reach.
In addition to the aforementioned research factors, we contend thatthe slowly emerging estimation of AAIs as credible may have much to
do with how we collectively view the worth and capabilities of animals
themselves. Nonhuman animals, as a whole, are still not universally heldin high regard, even in societies and communities where some are adored
as companions and kin. This complexity of what we believe about animals, and how those beliefs impact our connections with them, is exploredin great depth by Hal Herzog in his 2010 book, Some We Love, SomeWe Hate, Some We Eat: Why It’s so Hard to Think Straight About Animals.
Arguably, inconsistent attitudes about various animal species — which areoften heavily influenced by historical, cultural, religious, economic, andpersonal factors — also shape our behaviors toward them, and our stanceon their general attributes and merit. According to Herzog (2010), “Onereason behavioral scientists have shied away from studying human-animal
interactions is that for many of them the topic seems trivial” (pp. 16–17).
We agree with Herzog that perspectives such as these are mistaken, andeven arrogant in their homocentrism and disregard of the often vital significance of animals in our lives. After all, not only is the utilization oftherapy and service animals growing and diversifying, but pet ownership
across the world is also on the rise. These relationships make up much of
how people spend their time, and thus have significant implications forhuman physical, social, behavioral, and emotional health.
Encouragingly, there has recently been growing acknowledgment andeven celebration of animals as sentient, emotive, and cognitively complex(Bekoff, 2007; Grandin & Johnson, 2009; Masson & McCarthy, 1994;
others). While still controversial in some circles, the notions that animals
can experience such feelings as grief, guilt, pride, shame, and jubilation, orthat their memory and problem-solving skills serve as key components totheir survival, are now well-documented. And yet, despite this progress, animals are still largely viewed through a hierarchal lens of “other”; other, or468

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rather less than, in their needs and preferences, in their privileges, in theirlegal standing, and in their aptitudes. Until respect for animals and theircapabilities are elevated, people will continue to take issue with human-​animal connection as truly transformative, and the AAI field will lack
serious appreciation. Nussbaum’s Capabilities Approach (2006), originallyconceived as an ethical framework for democracies to use when conceptualizing and securing individual human dignity, has strong applications
for nonhuman animals as well (as discussed in chapter 1). For example,
animals, like humans, are equally entitled to the following justice-based
capabilities: 1) life; 2) bodily health; 3) bodily integrity; 4) senses, imagination, and thought; 5) emotions; 6) practical reason; 7) affiliation; 8)other species; 9) play; and 10) control over one’s environment. In thecontext of AAI, these shared human and animal capabilities are notably
pertinent for practitioners when considering how to support the welfare
of all participants.
While the “otherness” of animals may hinder the level of credence
that AAI practice and research have thus far received, we posit that thisactually is what makes our relationships with animals so profound andhealing, and that their unique qualities should be upheld as we seek both
greater professional credibility for the field and justice for them. Indeed,animals are not exactly like us and, although anthropomorphism has
played a valuable and undervalued role in helping people see an empathic
commonality with other species, excessive anthropomorphism may ultimately do animals a disservice. According to renowned ethologist Marc
Bekoff (2013), “we should replace the notion of human exceptionalismwith species exceptionalism or individual exceptionalism, moves that will
force us to appreciate other animals for who they are, not who or what
we want them to be.”The perception of animal as “other” may also have fitting clinicalapplications when working with traumatized populations, individuals
who — through isolation, shame, guilt, and social bias or misunderstanding — may spend much of their physical and emotional lives at the margin.
These points of shared connection, of bonding through similar experienceor adversity, have the potential of strengthening the therapeutic processes
and outcomes of AAI. Throughout this volume, this concept of comparable
otherness as clinically useful was demonstrated in a number of ways and settings. As just one example, Sarah Schmidt from The Comfort Dog Project
shared the following anecdote with us during her interview:

Conclusions469[During the war], . . . the rebel soldiers were forced to carry out
horrible atrocities, including killing their own family members.
So, for these people to come back, even though the villages don’t
directly ostracize them, they feel ostracized based on their life
experience. They feel like people hate them. They feel like they’vebeen rejected, that they’re not looked upon the same as otherpeople. . . . I think that some of them have found special [connection] with the dogs, because historically, they know that dogs
are looked upon in the same way. So, I have felt like there’s a little
extra kinship in those cases.
Moreover, certain strands of human-animal connections are simply
not always present in similar bonds shared between humans, including
perceived nonjudgmental support and acceptance; reliable companionship;
quiet solace through nonverbal communication; sincere and unbridled
affection; hormonal (e.g., oxytocin) synchronization; and emotional safety
through mutual caregiving and trust. Alongside these benefits are also
subtleties that are much more nebulous and subjective. Those who haveever had a friendship with an animal can surely attest to the “magic” ofthe human-animal bond. It is this way of being with animals that is at theheart of AAI work, and likely contributes to the efficacy of these interventions to foster resiliency and growth in people with trauma histories. As
such, well-intentioned efforts to “professionalize” the AAI field — whether
through regimented practice standards or research protocols — should not
overlook or interfere with the natural nuances of these connections, forthey are what truly underlie positive and therapeutic change.
For example, in chapter 4 of this volume, Parish-Plass and Pfeiffer
provide a case study account of a therapy dog licking the face of a childreceiving animal-assisted play therapy after a previous suicide attempt.
The spontaneous behavior of licking, which current therapy dog practicestandards generally discourage in an attempt to limit the spread of zoonoses, served an unforeseen clinical purpose by grounding the child in thepresent through sensory touch experience and preventing him from dissociating. It is worth noting that such an experience in therapy would not
be possible or appropriate without the presence of an animal, as physicalcontact between therapists and clients is nearly always prohibited. Had
the therapist stopped or discouraged the dog from licking the client, thesebenefits would not have been realized. Worse yet, this could have confused

470

TRANSFORMING TRAUMA

the child, damaged his authentic interaction with the dog, and, perhaps
most importantly, even harmed his self-image and esteem by reinforcing
core beliefs of being unlovable in any relationship. Accordingly, it may betime for the field to think critically about the ongoing use of current AAI
guidelines by objectively weighing their potential advantages and risks(i.e., are the benefits of preventing the unlikely transmission of zoonosis
through dog licking fundamentally worth the potential risk of a young
client not feeling cared for in therapy?). Likewise, animal-assisted research
protocols that specify the sequence or length of session activities be just so
make good sense on paper, but could inadvertently impede or cut shortsomething just as, or even more, meaningful from happening. In essence,
while the caliber and precision of AAI programming and scientific inquiries
are crucial and we advocate for them wholeheartedly, they should also notcome at the expense of the individualized authenticity of the connection.
Currently, many HAI researchers are grappling with how to reconcile
these two worthy objectives; that is, how best to establish a sound evidencebase regarding the impacts of the indistinct, but consistent, phenomenathat characterize our relationships with animals. But, how do you reliably
measure something that most people have trouble describing, if not naming? And, if these subtleties cannot be measured, what does that meanin terms of demonstrating the effectiveness of AAI? Do the effects of ourinteractions with animals, however modest, need to be quantified in order
to be “real”? Undoubtedly, there may be more than one “way of knowing”
how and why these relationships impact us. As the AAI field continues togrow (particularly in the realm of trauma recovery), addressing questions
like these will become all the more pressing. It is up to us, as HAI practitioners and researchers, to seek ways to further understand just how the
intricacies of our bonds with animals can promote recovery and consolation when everything else in our lives feels fragile and threadbare. To quote
Victor Chitic from Dogs for People in Romania:
Ever since I saw that [AAI] works, I’ve been preoccupied in understanding how and why it does. To this day I feel like we’re justscratching the surface, but this desire to understand more about
these mechanisms is what’s keeping me going. It’s a puzzle, and I
like solving puzzles.

Conclusions471

One area where the impact of connection may be particularly apparent
is not in interactions with unknown or relatively unfamiliar animals (i.e.,therapy animals), but with the ones with whom we share our homes andprivate lives. Despite the prevalence of domesticated animals in the UnitedStates (for example), there are only 10,000 or so established AAI programs.
Thus, one could reasonably argue that much of the way we relate to, andbenefit from, animals is through pet ownership, companionship, and interaction through nature. What would happen, then, if we no longer had theability to see thriving animals in our environment, or be in close connection with them? How would this type of “relational poverty” impact ourwell-being? As Cohen and Clark discuss at length in chapter 13, the lossof various animals (both familiar and unfamiliar, but especially pets) candevastate a person with grief and sorrow, thus exemplifying the profoundimportance of the human-animal bond. As such, the relationships people
share with their companion animals could arguably offer the greatest potential in terms of healing, as well as bond-specific research opportunities.
As humans exist within several, interconnected social environments, manyfactors — including pet ownership — play an important contributing rolein our health and wellness.
Accordingly, it may be advantageous to evaluate the effects of pet
ownership as a formal therapeutic intervention — an HAI deemed appropriate and advised by a therapist or other mental health professional — forpeople who have experienced trauma. We are presently seeing a versionof this with trained psychiatric service dogs who, after a typically long,
costly, and demanding waiting period, live with those they serve (e.g.,veterans diagnosed with PTSD) and provide trauma-specific purposes.
However, would certain benefits remain if the relationship between human and animal was more “casual,” or if the only therapeutic goal wasthe connection itself? And, what possible impacts would such a process
have on the countless number of animals currently in need of adoptive
homes? Could enhanced partnerships between the mental health, shelter,and veterinary communities be established? Further, would such research
drive a revisiting or reframing of current ADA requirements in ways that
more fully support human-service dog attachments that are adaptive andproductive in the long-term? We believe these may be valuable research
avenues to pursue in the future.

472

TRANSFORMING TRAUMA

We would also like to see greater interest in how AAI and HAI may
impact people living with additional forms of trauma, such as those originating from sexual assault, domestic violence, divorce, chronic pain anddisease, eating disorders, bullying or discrimination, extreme poverty andhomelessness, incarceration, and displacement or migration due to conflict and environmental change. These additional research foci may not
only expand notions of what qualifies as trauma, but could also clarify thevarying roles and specific capacities of animals in human trauma response
and recovery. In the case of displaced populations, for example, their migration may pose a unique cultural challenge in this area due to issues ofpotential unfamiliarity with typical AAI and companion animals in their
new country. In future editions, we are also committed to including morein-depth discussions of the traumas experienced by, and inflicted upon,
nonhuman animals by such inhumane practices as poaching, “trophy” andother forms of hunting, and factory farming. The relentless nature of theseatrocities for animals, and animals’ often complex and emotionally painful
responses to them (Masson & McCarthy, 1994, and others), warrant oursteadfast attention and advocacy.
Likewise, as noted extensively throughout this volume, the vast majority of current AAI practice and research concerns the use of just two
primary species — canine and equine. As the two focused chapters onthese animals (dogs: chapter 9, Howie, Fine, and Rojas; horses: chapter 8,
Ekholm Fry) demonstrate, certain traits of these particular animals makethem aptly suited for AAI participation. However, let us take this opportunity to call out the dog and horse in the room: studies with diverse animal
species, whether they be dogs, cats, goats, horses, or swallows in nature, aresalient to increasing our understanding of the subtle and unique hallmarksof human-animal connection, as well as the appreciation of the inherent
worth of nonhuman animal life and our environmental surroundings.
Finally, throughout this book (and particularly in Ng’s chapter), we
made a point of calling attention to our abiding moral obligation to theanimals whose participation in this work we seek and beseech. It bears repeating that animals who serve our interests and needs through AAI do not
do so as a matter of choice; rather, their involvement is contingent on theactions and motivations of their human handlers. As such, we owe themour gratitude, our respect, and our commitment to their own personalized
sense of well-being. Readers of certain portions of this book may walk away

Conclusions473

questioning whether or not placing animals in these circumstances, particularly ones in which trauma is at the center, is altogether appropriate. We
welcome such quandaries as we believe they are critical in setting the stage
for understanding both concrete welfare risks, as well as strategies to ensure
the ethical inclusion of animals in AAI. In addition to the discussion andrecommendations offered by Ng in chapter 2, we hope that, with proper attention to advocacy, greater appreciation of species-specific considerations,and concentrated knowledge of the therapy or service animal’s individual
needs and behaviors through close handler-animal partnership, the benefitsof AAI will indeed outweigh the risks. As mentioned above, one of the chief
benefits of AAI may, in fact, be a greater commitment to animal welfare
and altruism. However, in order for this to become a confirmed reality,interventionists must not waver in their support of animal well-being as afocused priority. The AAI field would provide a great benefit if it were todevelop more in-depth, species-specific resources regarding animal welfare,and make them intentionally and readily accessible to AAI practitioners
and those in training.
In sum, we feel both fortunate and excited to have played a part in editing, and writing portions of, this volume on trauma-informed AAIs. The
field is expanding in such ways and at such speeds that are indicative of justhow promising our connections with animals can be for traumatized populations. Relationships with animals often have inherent qualities of caring,
love, mutuality, trust and safety, all of which can serve as key components
in an individual’s trauma recovery. As discussed above, further and morediverse research that integrates innovative practices, methods, and inquiries
are necessary to validate how, and under what circumstances, animals can
assist in trauma treatment. Indeed, we believe that if further evidence can
support the efficacy of AAI, the field could lend a powerful voice to therich importance of other animal lives, thereby reframing our connections
with them and socially shifting how we think, treat, and behave toward avariety of species and the world we share. At the same time, we are compelled to acknowledge the existence of unintended, adverse consequencesthat may likely accompany favorable AAI research findings. For example,
if we succeed in demonstrating the fundamental effectiveness of AAI, weworry that the field could broadly serve as yet another way to exploit
animals for the purpose of serving human priorities. It is therefore upon
us — as practitioners, researchers, and members of communities — to be
steadfast in our commitment to ensuring that AAIs and HAIs be conceived

474

TRANSFORMING TRAUMA

of ethically, and conducted in mutually beneficial ways that celebrate thetransformative nature of human-animal connection.
REFERENCES
Bekoff, M. (2007). The emotional lives of animals: A leading scientist explores animal joy, sorrow, and empathy — and why they matter. Novato, CA: New World
Library.
Bekoff, M. (2013, December 13). Human-animal relationships: Where we are andwhere we’re going. Huffington Post. Retrieved from http://www.huffingtonpost.com/marc-bekoff/humananimal-relationships_b_4439038.html
Grandin, T., & Johnson, C. (2009). Animals make us human: Creating the best life
for animals. New York, NY: Houghton Mifflin Harcourt.
Herzog, H. (2010). Some we love, some we hate, some we eat: Why it’s so hard to
think straight about animals. New York, NY: HarperCollins.
Masson, J., & McCarthy, S. (1994). When elephants weep: The emotional lives ofanimals. London, UK: Jonathan Cape.
Nussbaum, M. C. (2006). Frontiers of justice: Disability, nationality, species membership. Cambridge, MA: Belknap Press of Harvard University Press.

ABOUT THE AUTHORS
Biographical sketches for Molly A. Jenkins and Philip Tedeschi can be found on
p. 12 of this volume.

Selective Index
AAI. See Animal-assisted
intervention (AAI)
AAP. See Animal-assisted
psychotherapy (AAP)
AAPT. See Animal assisted playtherapy (AAPT)
Academic goals of nature-based
programs, 253
Achenbach Teacher Report Form, 246
Acute stress disorder (ASD), 92
Acute stress reaction (ASR), 92
Adams, Joshua, 413
Adaptive Information Processing(AIP) model, 99
Adaptive riding, 266, 283, 286, 289
Advocacy. See Animal welfare; Ethicsof animal-assisted intervention(AAI); Well-being, animal
Affect regulation in developmental
trauma, 126, 136, 139
Air Carrier Access Act (ACAA),
300–301
Alliance of Therapy Dogs, 27
American Counseling Association,
283, 288, 319

American Psychological Association(Division 17, HAI Section 13),
13, 319
American Red Cross, 331, 374,
379–380, 388
American Society for the Preventionof Cruelty to Animals (ASPCA),
307
Americans with Disabilities Act(ADA), 31, 299–300
American Veterinary Medical
Association (AVMA), 34
Amygdalacortisol levels and, 26, 338
emotional reactions in, 139,
153, 160, 311
hot memory system and, 95
ompfc circuitry and, 164presence of animals, effects on,
164–165, 168, 169
PTSD and, 128, 339
serotonin inhibition of, 97, 107
social interactions and,
147–148
Animal Appropriateness Scale, 205

475

476

TRANSFORMING TRAUMA

Animal-assisted crisis response(AACR), 21–22, 76, 310
conclusions and next steps for,387–389
defined, 375
evidence supporting, 376–382
introduction to, 373–375
national standards and bestpractices in, 382–387, 389
Pulse nightclub shooting, 22
Animal-Assisted Crisis Response
National Standards, 382, 389
Animal-assisted intervention (AAI),
3, 55–61, 303. See also Animalassisted therapy (AAT); Dogs;
Equine-assisted therapy (EAT)
activities during visit, 78–79
as an adjunctive/complementaryintervention, 15, 341
after the visit, 80
animal selection for, 66–72
conclusions on, 41–42, 81–82,
109–110, 166–170, 211–
212, 289–290, 463–473
defined, 15–16
emerging practices in, 4–6,
27–32
environment selection for, 74–77
ethical foundations of, 3–4,
34–35
ethical framework/standards for,3–4, 29, 34–35, 61–62,
230–231, 266, 268, 281,
312, 315, 387–388, 436,
445, 456–457, 468
evidence-based research on,
5, 9, 32–34, 40, 60, 82,
201, 233, 243, 287–288,

309–311, 319, 332,
343–344
in farm settings. See Farm
settings
gaps and next steps for, 39–41
global and cross-cultural reachof. See Global and crosscultural AAI
handlers in, 63–66
infection control during, 79, 80
paired with prolonged exposure
treatment, 309–310
physiological and psychology
effects of, on humanhealth, 337–342
play therapy. See Animal
assisted play therapy(AAPT); Animal-assisted
psychotherapy (AAP)
preparation for visit, 77–78
psychotherapy. See Animalassisted psychotherapy(AAP)
recipient selection for, 72–74
recurring visits and animal
retirement from, 80–81
research and implementation
science in, 7–9, 29, 467
theory and potential
mechanisms in, 6, 16,
23–27, 102–106, 142,
167, 170, 470
training of animals for, 68
for trauma. See Trauma recovery
Animal assisted play therapy(AAPT). See also Animal-assisted
therapy (AAT); Play therapy
animal welfare in, 206–208

Selective Index477

background on, 189–190
best practices in, 205–206
conclusions on, 211–212
current research in, 200–205
gaps and next steps for, 210–211
history and terminology of,
190–193
overview of, 193–194
physiology of, 199–200
primary goals in, 195–196
principles of, 194–195
professional certifications in,
208–210psychology of, 197–199
theory and potential
mechanisms in, 197–200
trauma-specific applications of,196
Animal-assisted psychotherapy(AAP), 123–124. See also
Animal-assisted therapy (AAT);
Play therapy
advancing the principlesof psychotherapy andinterpersonal neurobiology
in healing of trauma,
144–145
animals as facilitators oftherapeutic alliance and,
145–150
barriers to, in children with
developmental trauma,136–142
conclusions on, 166–170
deficit in ability to symbolize
in, 139, 154–157
developmental trauma and,
124–127

dissociation addressed by, 126,
140, 158–161
effects of therapist behavior in,
163–166
goals and processes of, 132–
134, 142–144
neurological effects of trauma
and, 127–132
potential space in, 134–135,
138–139, 150–154
psychodynamic relational therapy
with children suffering fromdevelopmental trauma,134–136
for PTSD, 98–100
self-regulation and, 140–142,
161–163
shame and presentation offalse self and, 139–140,
157–158
Animal-assisted social work, 1, 3
emerging practices in, 27
Animal-assisted therapy (AAT),
29–31. See also Animal-assisted
intervention (AAI); Animals,
therapy; Dogs; Equine-assisted
therapy (EAT)
as an opportunity for caregiving,
105, 254, 309, 46
effects of, on human health,
4–5, 60, 217, 230, 233–
234, 252, 266–268, 302,
335, 337–342, 458
Animals. See also Animals, service;
Animals, therapy; Dogs; Equineassisted therapy (EAT)
behaviors of, affiliative, stressrelated, 16, 31, 68, 81, 464

478

TRANSFORMING TRAUMA

Animals (continued)
companionship with, 16,
23–24, 218, 231, 307,
398, 402, 403, 416, 429,
445, 452, 469, 471
deaths of, 56, 80–81, 302, 395,
401–417
definition of service animal, 28,
31, 267, 299–300
emotions of, 56–57, 58–59,
107, 302, 408
empathy in, 59, 107
handler selection for, 63–66
history of human relationships
with, 16–17, 59, 218,
266–268
in international AAI programs.
See Global and crosscultural AAI
non-verbal communication
with, 101, 103–104, 318,
457, 469
as “other,” 467–468
pain of loss of. See Loss, grief,and bereavement foranimals
perceived as more genuine thanhumans, 5–6, 106
play in, 190–191
promoting optimal
preconditions for therapy,
106–107
PTSD and trauma in, 57–58
selection of (for AAI), 66–72
as sentient beings, 56
as social lubricants/catalysts/
facilitators, 23, 196, 241,
374, 380

well-being of, 34–35, 36–39,
206–208, 231–233,
281–285. See also Animal
welfare; Ethics of animalassisted intervention (AAI);
Well-being, animal
zoonotic disease, 65, 67, 72–73,
79
Animals Asia, Hong Kong, 432–434
interviews on, 435–459
Animals, service, 17, 20, 31–32, 63,
68, 299–300, 407–408. See alsoDogs
definition of, 17, 31, 62,
299–300
loss of, 407–408
PTSD, 31, 32, 109, 299, 315,
333, 336, 340–341, 343,
357, 369, 471
reimbursement for, 343–344
retirement of, 407
training of, 109
Animals, therapy. See also Dogs;
Equine-assisted therapy (EAT)
attachment to, 24–25
bill of rights of, 37–38, 318
definition of, 29, 300, 408, 471
loss of, 408
retirement of, 368, 430role of, in growth and resiliencein trauma recovery, 6–7
theory and potential
mechanisms in the
inclusion of, 23, 197–201,
221–228, 271–281
Animal welfare, 4, 34–39, 55, 56,
61, 63, 65, 102, 206–208, 231–
233, 319, 431, 458, 459, 473.

Selective Index479

See also Ethics of animal-assisted
intervention (AAI); Well-being,
animalCapabilities Approach, 38–39,
468
dogs, 207, 208, 315–318, 326
in equine-assisted therapy(EAT), 281–285
ethical standards in AAI, needfor, 29, 35, 41, 209
Five Freedoms of, 4, 37, 61–62,
285
IAHAIO Definitions andGuidelines, 36–37
individual needs of animals, 28,
34, 231, 473
military trauma interventions
and, 335–337
species-specific needs ofanimals, 30–31, 63, 76,
231, 283, 288, 337, 473
Therapy Animal’s Bill of Rights,
The, 37–38, 317–318
Anthropomorphism, 468
Anxiety, 138
Anxiolytic medication, treatment,
20, 27
Applied Suicide Intervention Skills
Training (ASIST), 383
Argus Institute, 416
Arousal modulation, 25–26
Assistance animals, 31, 300. See also
Animals, service
Assistance Dogs International(ADI), 27–28
Attachment figures, 109, 137, 167,
305, 307

Attachment problems, 125
relational therapy for, 132
Attachment, secure vs. insecure,
109, 137, 165, 281
Attachment theory, 24–25, 120,
125, 304–306, 377
complicated grief and, 398
dogs and, 24–25, 304–306
Attention Deficit Hyperactivity
Disorder (ADHD), 6, 195, 242,
317
Autism Spectrum Disorder, 31, 195,
241, 244, 249, 336, 435
Autonomic nervous system (ANS),
101–102
Bandura, Albert, 232, 247
Behavioral screening of animals, 68–69
Behavior Assessment System forChildren Teacher Rating Scales(BASCTRS), 246
Bekoff, Marc, 468
Bereavement. See Loss, grief, andbereavement for animals
Biden, Jill, 344
Big Fix Uganda, 429, 439, 449, 455
Bill of Rights, Therapy Animal’s,
37–38, 318
Bio-affiliation, 23
Bio-affiliative safety, 16, 464
Biodiversity, 219
Biofeedback function of service
dogs, 20
Biophilia, 23, 102–103, 147, 221–
222, 251, 304
Blood pressure, animal effects on,
57, 102, 147, 150, 377–378, 381

480

TRANSFORMING TRAUMA

Bloom, Sandra, 256
Body access and awareness inequine-assisted therapy (EAT),
274–275
Bowlby, J., 124, 125, 127, 143,
167, 398
Brain alterations in connection to
PTSD, 97
Brain-to-brain coupling, 133
Brambell Report, 37
Bua, Filomena, 376–377
Building block effect, 93
Burghardt, Gordon, 190
Bustad, Leo, 34
Cairo (dog), 330–331
Calming signals, animal (canine andequine), 39, 69
Canine Behavioral Assessment
and Research Questionnaire(C-BARQ), 68–69
Canine companions, 28, 55, 56,
306, 334, 452
Canines Providing Assistanceto Wounded Warriors(C-P.A.W.W.), 344
Capabilities Approach, 38–39, 468
Captive animals, 95, 400
grief over the loss of, 411–413
Cardiovascular effects of HAI, 82
Caregiving, 105, 124, 130, 401, 469
Carson, Rachel, 231
Case studies
animal-assisted crisis response(AACR), 379, 386
animal assisted play therapy(AAPT), 202–205

animal-assisted psychotherapy(AAP), 149–150, 153–154,
156–157, 158, 160–161,
162–163
animals in courtrooms, 18–19
complicated grief, 398–399
farm settings, 257–260
loss, grief, and bereavement,
408–409
military trauma, 21, 341–342,
361–369
Cecil (lion), 411–413
Center for the Human-Animal
Bond, 27, 32Centers for Disease Control (CDC),
332
Centro de Intervenciones Asistidas
con Animales (Centro IAA),
Costa Rica, 434–435
interviews on, 435–459
Character development, 253–254
Child and family violence, 17–19
developmental trauma and,
123–173
therapy dogs and, 123–173,
307–309
Child-animal relationships. See also
Human-animal bond (HAB);
Human-animal interaction(HAI); Humane education
animal welfare in, 231–233
background on, 217–221
best practices for, 228–231
conclusions on, 233–234
theory and potential
mechanisms in, 221–228

Selective Index481

Childrendevelopmental trauma and, 17,123, 124–127
loss of animals and grief in,
402–403
need for nature and, 226–228
Child Trauma Academy, xiii, 170
Chips (dog), 329–330
Chitic, Victor, 431, 470
interview of, 435–459
Chronic disease in dogs, 81
Classical conditioning, 93–94
Client-centered psychotherapy, 106
Climate change, 239, 416
Clostridium difficile, 79
Clothier’s Elemental Questions, 316
Cognitive behavioral therapy(CBT), 167, 335, 340, 362
Cognitive perception, 25
Cognitive processing therapy(CPT), 99, 271
Cognitive theory of PTSD, 94–95
Cold memories, 95, 100, 107
Comfort Dog Project, The, Uganda,
429–431, 468–469
interviews about, 435–459
Community violence, 21, 124, 375
Compassion fatigue, 22, 383
Complex disorder of extreme stress(DESNOS), 124Complex PTSD, 124Complicated grief, 397–400
Conceptual thinking skills, 254
Continuum of care, 228–229
Cortisol, 26, 59, 73–74, 75, 78, 82,
96, 97, 101, 107, 147, 150, 283,
286, 311, 316–317, 338–341
Courtroom facility dogs, 18–19

Cozolino, Louis, 127, 128, 139,
153, 163–165
Crisis response, 21–22, 373–387
Critical Incident Stress Debriefing(CISD), 98
Critical Incident Stress Management(CISM), 383
Cross-cultural continuity ofconcern, 226
Davidson, Becky Barnes, 408
De-arousal, importance of, 25–26,
269, 275
Default mode network (DMN),
128, 135, 139
Deficit in ability to symbolize, 139,
154–157
Department of Defense, 369
Deploymentof first responders, 22, 373, 378
of military service members, 10,331, 335, 344
Developmental trauma, 123–173.
See also Trauma
affect regulation in, 126, 136, 139
barriers to psychotherapy withchildren with, 136–142
behavioral control in, 126
biology of, 126
cognition in, 126dissociation in, 126, 140,
158–161neurobiological effects of,on social engagement,
129–132
psychodynamic relational
therapy with children
suffering from, 134–136

482

TRANSFORMING TRAUMA

Developmental trauma (continued)
self-concept in, 126
understanding the psychologicaleffects of, in children,
124–127
Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), 124,
272, 277
Dialectical Behavior Therapy(DBT), 250
Disability
developmental, 6, 124–125,244
emotional, 244, 405
learning, 244, 247
physical, 148, 281, 367
Disaster stress relief (DSR), 21–22
Discursive practices, formations,424–426
Dispositional representations (DRs),
126
Distraction and mindfulness with
HAI, 105–106
Dogs. See also Animals; Animals,
service; Animals, therapy
ability to read human faces andunderstand emotion by, 58
in animal assisted play therapy(AAPT), 189–211
appropriate breeds for therapy,
68
attachment theory and, 24–25,
125, 304–306
behavioral signs of stress in, 65,69
biophilia hypothesis and, 304
capacity to understand humanwords, 302–303

chronic disease in, 81
common ailments in working
dogs, 76
concentration and motivation
promoted by presence of, 101
conclusions on the therapeutic
inclusion of, 318–319
cortisol levels in, 59
cultural stereotypes of, 428,
446, 456
domestication of, 35, 242, 299,
303
empathy in, 59
evidence-based research on
trauma and humaninteractions with, 32–34,
211–212, 309–311
in international AAI programs.
See Global and crosscultural AAI
military working dogs, 57,
328–334
neurobiological mechanisms
attributed to humananimal interaction (HAI)
and, 100–102, 123–173,
311–312oxytocin and dopamine levels
increased in presence of,27, 70, 102, 104–105,
130–131, 156, 166, 283,
311, 377–378
perception of specific words
by, 58psychological first aid with, 108
PTSD service dogs, 4–11, 109,
332–345, 355–361. See
also Animals, service

Selective Index483

reliance on handler, 64
search and rescue dogs. See
Animal-assisted crisis
response (AACR)
sensitivity and reactivity tohuman cues in, 60
as strays, in AAIs, 429, 442
suggested best practices with,
312–315
theoretical background andpotential mechanisms of
the human-canine bond,
303–309
therapeutic roles of, 299–301
training of, 31, 309, 329, 344,
356, 359, 361
viewed as family members,
301–302welfare considerations of, 102,
207, 299, 315–318, 428
Dogs for People, Romania, 431, 470
interviews on, 435–459
Domestic violence, 18, 158, 196,
220, 249, 472
Dopamine, 97, 102, 305, 311, 378
Dr. Dog, program of Animals Asia,
433–434, 436, 455
Dysregulation, emotional andbehavioral, 26, 129, 130, 140–
142, 161, 167, 199, 242, 255,
339, 340, 364, 425, 464
EAMH. See Equine-assisted mental
health (EAMH)
EAT. See Equine-assisted therapy(EAT)
Eco-psychology, 251
Ehlers, Cindy, 374

Einstein, Albert, 189
Elders, loss of companion animals
for, 401–402
Emergency preparedness, 301, 414
Emerging AAI practice (vs. best AAI
practice), 34, 463
Emotional processing theory (EPT),94, 98–99
Emotional regulation, 6, 161, 202,
255–256, 258, 334
Emotional support animals (ESAs),
300–301
Empathy, 59, 107, 222
prosocial moral development
and, 222–224
Environment selection for AAI,
74–77
Epinephrine, 26
Equine-assisted mental health(EAMH), 266, 267–268
risk of re-traumatization in,
272–273
Equine-assisted therapy (EAT)/
Equine-assisted intervention,
108, 192, 205–206, 266, 285–
289. See also Animals
background on, 266–270
conclusions on, 289–290
considerations for equine
welfare in, 281–285
environment, benefits of, 268
gaps and next steps in, 285–289
hippotherapy, 266
history of horses in humanhealth and, 266–268
how horses enhance trauma
treatment in, 267,
272–274

484

TRANSFORMING TRAUMA

Equine-assisted therapy (continued)
introduction to the inclusionof, in treatment of trauma,265–266
recommendations for, 283–285
theory and potential
mechanisms in, 271–281
tri-phasic model as framework
for, 271–272, 287
phase I, 273–279
phase II, 279–280
phase III, 280–281
Erikson, Erik, 189
Ethics of animal-assisted
intervention (AAI), 3–4, 29,
34–35, 61–62, 230–231, 266,
268, 281, 312, 315, 387–388,
436, 445, 456–457, 468. See
also Animal welfare; Well-being,
animalanimal selection and, 66–72
Capabilities Approach, 38–39,
468
environment selection and,
74–77
exploitation of animals,potential for, 285
Five Freedoms of, 4, 37, 61–62,
285
frameworks/standards for, 8,
36, 38, 39, 61–62
handler selection and, 63–66
IAHAIO Definitions andGuidelines, 36–37
introduction to, 3–4, 29, 55–61
recipient selection and, 72–74
Therapy Animal’s Bill of Rights,
The, 37–38

Ethology, cognitive, 56, 232
Euthanasia, 405–406, 408, 410,
413, 414
Evidence-based research, 32–34,
211, 212, 309–311
on animal-assisted crisis
response (AACR), 376–382
on human-canine interactions
and trauma, 309–311
Evolution, co-evolution with dogs,
102, 305
Expectancy bias, 40, 465
Experiential vs. verbal symbolic
system, 103
Explicit knowledge, 153
Explicit memory, 127–128
Explicit motivation, 103–104
Exposure therapies, 19–20
narrative, 100
prolonged (PE), 98–99, 271,
309–310, 335
Eye movement desensitization andreprocessing (EMDR), 19, 99,
143, 156, 271, 288
Facility dogs, 19, 308, 339–340
Fair Housing Act, 300
False self, presentation of (intherapy), 139–140, 157–158
Family members, pets as, 301–302,
427
Family violence, 17–19
companion and therapy dogs
and, 307–309
developmental trauma and,
125–126
Farm Animal Welfare Council(FAWC), 61

Selective Index485

Farm settings
background and significance ofplay in, 242–243
conclusions on, 260–261
Green Chimneys program, 241,
248–260
introduction to, 241–242
Our Farm program, 241,
243–248
Fasnacht, Brad, 21
Fear conditioning theories, 93–94
Fear network model, 95–96
Federal Emergency Management
Administration (FEMA), 301, 374
Fight or flight response, in responseto stress, 19
Filial therapy, 201
Five Freedoms, 4, 37, 61–62, 285
France, Anatole, 301
Functional Magnetic ResonanceImaging (fMRI), 147, 156, 302
Gay, Roxane, 413
Genetic and epigenetic factors of
PTSD, 96–97
George, Hildegard, 243
Global and cross-cultural AAI
Animals Asia, Hong Kong,
432–434
Centro de Intervenciones
Asistidas con Animales(Centro IAA), Costa Rica,
434–435
Comfort Dog Project, The,
Uganda, 429–431
conclusions and discussion of,
456–459
Dogs for People, Romania, 431

interviews on, 435–459
introduction to, 423–427
Glucocorticoid System, 97
Graduate School of Social Work,
University of Denver, 1, 3, 27,
319, 416
Green Burial Society, 405
Green care, 251, 260–261
Green Chimneys Farm, 241–261
conceptual philosophy ofnature-based programs at,
251–252
interactions with animals andplants at, 252–260
Grief. See Loss, grief, andbereavement for animals andhumansGuide dog, 81
Habitat destruction, 220
Hand hygiene, 79, 80
Handler (AAI)
role of, 75, 78, 80, 312
selection for AAI, 63–66
Harambe (gorilla), 412–413
Heart rate variability (HRV), animal
effects on, 283, 364“Here and now,” present thinking,96, 100, 143, 272
Herman, Judith, 124, 132, 133,
271, 273, 280
Hippocampus, 26, 95–97, 127, 338
Homocentrism, 467
Hope Animal-Assisted Crisis
Response (HOPE), 374, 375,
382, 385
Hormone synchronization between
humans and dogs, 59, 63

486

TRANSFORMING TRAUMA

Horses. See Animals, therapy;
Equine-assisted mental health(EAMH); Equine-assisted
therapy (EAT)
Horticultural therapy, 251
Hot memories, 95, 96, 100
Human-animal bond (HAB),
34–35, 224–225. See also Childanimal relationships
Human-animal interaction (HAI),3, 15, 60, 303, 327, 395. See alsoChild-animal relationships
activation of oxytocin systemby, 104–105, 131, 378
conclusions on, 463–473
distraction and mindfulness
with, 105–106
emerging practices in, 27–32
ethical foundations for, 3–4,
34–35
evidence-based research on,
32–34
international reach of. See
Global and cross-cultural
AAI
loss, grief, and bereavement
and. See Loss, grief, andbereavement
military trauma and, 334–342
relevant effects of, for trauma and
PTSD, 57–58, 100–102
research and implementation
science in, 7–9
in trauma recovery. See Trauma
recovery
Human-canine interactions.
See Dogs; Human-animal
interactions (HAI)

Humane education, 224, 230,
252. See also Child-animal
relationships
Hurricane(s)Harvey, 301
Irma, 301
Katrina, 301, 379
Hypothalamic-pituitary-adrenal
system (HPA-axis), 101–102, 147
Idioms of distress, 425
Immobility without fear, 130
Implementation science, 7–9, 29, 467
Implicit knowledge, 153
Implicit memory, 103, 133
Implicit motivation, 103–104
Improvised Explosive Device (IED),
21, 94
Infection control, 79, 80
Institute for Human-Animal
Connection, 2–3, 27, 228, 230,
288
International Association of
Human-Animal Interaction
Organizations (IAHAIO),
36–37, 60, 319, 423–424
IAHAIO Definitions for Animal
Assisted Intervention andAnimal Assisted Activity andGuidelines for Wellness ofAnimals Involved, The, 36–37
International Institute for Animal
Assisted Play Therapy (IIAAPT),
208–210
Interpersonal neurobiology, 123–170
Intrusive memory, 93, 265, 340“Invisible wounds of war,” 331,
332–334

Selective Index487

Joint venture, 270
K9s for Warriors, 32
Katcher, Aaron H., 243–244
Koffman, Robert, 361–369
Last Child in the Woods, 242
Learned helplessness, in animals, 60
Learning theory, 232, 284
Lerner, Richard, 253
Levinson, Boris, 142
Link, the, 18
Loss, grief, and bereavement foranimals
in children, 402–403
complicated grief in, 397–400
conclusions and discussion of,
416–417
cultural stigma of, 404–406
in elders, 401–402
fostering resilience after, 413–415
introduction to, 395–396
mourning for wildlife, livestock,and captive animals and,
411–413significance of animals, animalbonding in, 400–401, 467
trauma in context of, 396–397
in traumatized individuals,
403–404
for working animals, 406–411
Louv, Richard, 242
Maltreatment, child, 5, 17–19,
123–173
developmental trauma resulting
from, 17–19
effects of, 124–127

therapy dogs and, 307–309.
See also Child-animal
relationships
Manualization, of AAI protocol, 40
Mastery, 189, 198, 221, 244, 245,
253, 258, 271, 464
Medial prefrontal cortex, 97, 164
Methicillin-resistant Staphylococcus
aureus (MRSA), 79
Milieu therapy, 251
Military sexual trauma (MST), 334
Military trauma, 327–328. See also
Warrior Canine Connection(WCC)
history of military working dogs
in the U.S. and, 328–334
impacts of human-canine
interactions on, 334–342
implications for practice andpolicy for, 343–345
post-traumatic stress disorder(PTSD), 31–32, 306–307,
332–334, 338–342
sexual harassment and assault, 334
use of service animals for,31–32, 299, 306–307, 407
Military working dogs, 57, 327–334
Mindfulness, 105–106
Mindsight, 151, 172
Mind skills, in equine-assisted
interventions for trauma, 275–276
Miniature horses, as service animals,
35, 267, 300, 407
Mission Based Trauma Recovery(MBTR). See Warrior Canine
Connection (WCC)
Modeling, compassionate care ofanimals, 232–233

488

TRANSFORMING TRAUMA

Motivation theory, 103–104
Motor coordination, 254
Movement (equine), effects of, 99,
155, 170, 273
Multi-cultural viewsof animals/dogs, 427
of trauma/mental health, 439
Multiple points of contact, 225
Mutual gaze, attachment between
humans and dogs, 302, 305, 340
Mutuality (mutually beneficial), of
AAIs, 34, 72, 473
Mutual relational presence, 146
Narrative exposure therapy (NET),
100
National Animal Assisted Crisis
Response, 374–375
National Comorbidity Survey, 93
Natural disasters, 21, 91, 92, 375,
403
Nature-based
education, 76
programming, 248, 250, 251–
252, 253
settings, 243, 248, 464
therapy, 242
Need for nature, 226–228
Neglect, 140–141
animal neglect, 18, 164,
child neglect, 17, 123, 126,
140, 220
Neural connective tissue regrowth,133
Neural integration, 134, 151, 167
Neurobiological effects
of animal assisted play therapy(AAPT), 199–200

of animal-assisted
psychotherapy (AAP),
123–171of human-animal interaction,
101–102, 311–312,
334–342of play therapy, 135–136
Neuroception, 16
Neurological theories of PTSD,
95–96
Neuroscience of Psychotherapy, The, 163
Neurosequential Model of
Therapeutics (NMT), 134, 170
Norepinephrine, 26
Obama, Michelle, 344
O’Carroll, Karina, 432–433
interview of, 435–459
Oklahoma City Bombing, 22, 374
One Health initiative, 217, 234,
458–459
Orbital prefrontal cortex, 164
Our Farm model, 241, 243–248
Outdoor settings for AAI, 75,
76–77, 227, 268, 335, 427
Oxytocin, 26–27, 102, 147, 156,
338–339
activation of, by HAI, 104–105
animal assisted play therapy(AAPT) and, 199
attachment and, 269, 305
dogs and, 312, 377–378
fear and, 137–138
intranasal use of, 27, 339
mutual gaze between humans
and dogs and, 302, 305,340
social engagement and, 131

Selective Index489

Pain
perception of, 101, 104, 358
response to, 71, 81, 277, 284,
311, 362, 378
Parenting skills, service dog effects
for, 358, 366
Perception, cognitive, 25
Perry, Bruce, xi, 170, 271
on interpersonal neurobiology
and animal-assisted
psychotherapy, 127, 129,
130–132, 134, 141, 144
Pervasive developmental disorder,
141, 249
Pet ownership, rates of, 433, 445, 467
Pet Partners, 27, 30
Pets Evacuation and Transportation
Standards (PETS), 301
PFA. See Psychological first aid(PFA)
Pharmacotherapy, 333, 335, 362
Pheromones, for stress-relief inanimals, 76
Physiology of/physiological effects forhumans or animals, 39–40, 466
of animal-assisted interventions
and their effects on humanhealth, 6, 16, 18, 25–27,
56–57, 81, 101–102,
337–342of animal assisted play therapy(AAPT), 199–200
Play therapy. See also Animal assisted
play therapy (AAPT); Animalassisted psychotherapy (AAP)
with children who arehyperaroused or
dissociative, 142

interpersonal neurobiologicalimplications of, 135–136
potential space in, 134–135,
138–139
Polyvagal system and theory, 16,
129, 138, 159
Porges, Stephen, 16, 127, 130, 133,
135, 146, 148, 167, 271
on anti-stress effect of being
with animals, 147
on biological imperative forhumans to achieve safety,
170
on compassion, 165
on healing interactions between
mammals, 157, 159
on social engagement, 145,
157, 161
Positive Youth Development Theory,
253–254
Post military deployment, 345, 336,
383, 389
re-integration in thecommunity, 332
Post-traumatic growth, 7, 281
Post-traumatic stress (PTS), 19–21
arousal modulation and, 25–26
cognitive perception in, 25
in loss of animals, 403
service animals for, 20, 31–32,
407
social support theory and, 23–24
Post-traumatic stress disorder(PTSD), 4, 6–7, 91–92
in animals, 57
cognitive theory of, 94–95
definition of, 4, 19, 57, 92
dogs and, 306–307

490

TRANSFORMING TRAUMA

Post-traumatic stress disorder(PTSD) (continued)
equine-assisted therapy (EAT)
and, 276–277, 283, 287
fear conditioning theories of,
93–94
genetic and epigenetic factorsof, 96–97
lifetime prevalence of, 93
neurological theories of, 95–96
prevention of, 98
psychology of, 93–95, 361
as reaction to trauma events/
experiences, 92–93
standard psychotherapeuticinterventions for, 19–21,
98–100structural and functional brain
alterations in connection
to, 97
theories explaining effects of
HAI on, 102–106
in veterans. See Military
trauma; Warrior Canine
Connection (WCC)
Post-traumatic stress disorder(PTSD), symptoms and effects of,aggression, anger, 100, 107
avoidance, 19, 92, 304
desensitization, 19, 99
detachment, 333
disorientation, 377
flashbacks, 19, 93, 106, 338
hyperarousal, 19, 92, 128, 273,
362
hypervigilance, 57, 333, 362
insomnia, 362, 365
memory loss, 19

nightmares, 19, 362
numbness, 357
re-experiencing, 273
social withdrawal, 306
Potential space (in therapy),
134–135
collapse of, 138–139
expansion of, 150–154
Preconditions for therapy, animals’enhancement of, 106–107
Predictability, in AAIof animal behavior, 385
of settings, 385
Process goals, nature-based
programs, 253
Professional Association of Therapeutic
Horsemanship International(PATH Intl.), 27, 30, 263
Professional certificationsin animal assisted play therapy(AAPT), 208–210
in human-animal-environment
interactions, humane
education, 230–231
Professor Paws, program of Animals
Asia, 433, 436, 454, 455
Prolonged exposure therapy (PE),
98–99, 271, 309–310, 335
Prosocial moral development,
222–224
Psychiatric service dog, PTSD
service dog. See Animals, service;
Military trauma; Warrior Canine
Connection (WCC)
Psychoeducation, 99, 100, 249,
250, 274
Psychological first aid (PFA), 98,
108, 381–382

Selective Index491

Psychologyof animal assisted play therapy(AAPT), 197–199
and biopsychosocial theories of
AAI, 23–25
of child-animal relationships,
221–228
eco-, 251of post-traumatic stress disorder(PTSD), 93–95, 361
Psychophysiology, underlying HAI,
25–27
Psychotherapy. See Animal-assisted
psychotherapy (AAP); standard
psychotherapeutic interventions
for PTSD
PTS. See Post-traumatic stress (PTS)
PTSD. See Post-traumatic stressdisorder (PTSD)
Public Access Test, 31
Pulse nightclub shooting, 22
Puppies Assisting Wounded Service
members (P.A.W.S.) Act of 2017,343–344
Quality of life, animal and HAIeffects on, 7, 32, 36, 39, 91, 306,
335, 396, 398–399, 413–414
Ramos, Michael, 18–19
Randomized controlled trials(RCTs), 28, 81, 369
Rapid rapport, 380
Reactive attachment disorder, 249
Recipient selection for AAI, 72–74
Record keeping for AAI, 80
Recurring visits, AAI, 80–81
Re-grounding, importance of, 377

Regulation, lack of, 140–142, 161–
163. See also Dysregulation
Reinforcement, extrinsic andintrinsic, 232–233
Relational influence of horses, 269
Relational poverty, 471
Relational presence in therapy, 147
Relational therapy, 132with children suffering fromdevelopmental trauma,134–136
Religion, effects on cultural views ofanimals, 426–427
Research in AAI
challenges and issues of, 388,
465
expectancy bias and, 40, 465
evidence-base and, 5, 9, 20,
32–34, 40, 60, 82, 211–212,
287–288, 309–311, 332
funding of, 8, 343, 369, 466
implementation science and,
7–9
practice-to-research-to-practice
approach to, 29, 466–467
protocol fidelity and, 28, 466
qualitative design and, 28, 41,
210, 285, 336, 466
quantitative design and, 41,
210, 466
replicable protocol and, 40,
288, 465
research-to-practice approach
to, 8, 466–467
rigorous design and, 33
validity of, 40, 388–389
Resilience, 6–7, 19, 91, 108,
233–234

492

TRANSFORMING TRAUMA

Resilience (continued)
after animal loss, 413–415
animal-assisted crisis response(AACR) and. See Animalassisted crisis response(AACR)
in children. See Child andfamily violence; Children
neural plasticity and, 166
post-traumatic growth and, 7,281
social engagement and, 131, 135
Retirement of animals from AAI, 80–81
Re-traumatization, risk of, 272–273
Risk management, in AAI, 193, 281
Rodríguez, María José, 434–435
interview of, 435–459
Rogers, Michael, 380
Safe haven, 16, 125, 146, 149–150,
159, 167–168
Safety, in human-animal relationships,
269–270, 300, 327–328, 334,
377, 380, 385, 389
Schmidt, Sarah, 429–431, 468–469
interview of, 435–459
Secondary trauma, 22
Secure base, 24, 125, 146, 149–151,
168, 199, 464
Self
expression of true, 157–158
loss of touch with, 140
shame and presentation of false(self ), 139–140, 157–158
Self-acceptance, 157–158
Self-efficacy, 94, 198, 201, 221,
224, 243, 247–248, 456, 464
Self-organization, 136

Self-regulation, 16, 18, 126, 169–
170, 195, 204, 211, 245, 249,
256, 258
attainment of, 161–163
case study on coping withtransitions and, 259–260
developmental trauma and lackof, 140–142
as a goal of psychotherapy,
133–135
relational influence and, 269
Self-soothing, 126, 257
Sensory integration, 129, 170, 255
Sentry dogs, 328–330
September 11, 2001 (9/11), 7, 22,76, 108, 374
Serotonin, 97, 107Service animals. See Animals, service
Service members, military, 10, 327,
331, 337, 334–335, 355, 356
Sexual harassment and assault in the
military, 334
Shame and presentation of false
self to others, 139–140, 145,
157–158“Shell shock,” 267–268
Siegel, Daniel, 271
on interpersonal neurobiology
and animal-assisted
psychotherapy, 127, 129,
133, 136, 139, 152, 167
on vertical integration, 275
Significant human-animal relational
moments (SHARMs), 144
Skin conductance, AAI effects on,
26
Smoky (dog), 17
Social effects of HAI, 101, 138, 439

Selective Index493

Social engagement
animal-assisted psychotherapy(AAP) for, 148, 158–161
inhibition of, 137
neurobiological effects ofdevelopmental trauma on,
129–132
play therapy and, 135–136
Social learning theory, 232
Social skills, 155, 242, 245, 248,
250, 378
Social support theory, 20, 23–24,
35, 98, 105, 108, 146, 210, 306,
307, 377, 403, 415, 433
dogs and, 306–309, 377, 403,
415, 433
Somatization, 124, 126
Sorenson, E. Richard, 270
Special education, 211, 244, 248,
250, 260, 434
Stafford Act Disaster Declarations, 375
State-dependent recall, 272–273
Stress reduction, animal effects on,
269, 305, 339–340, 378
Stubby (dog), 328–329
Subjective units of distress (SUDs)
scale, 276
Substance use, 91, 196, 280, 358,
376–377
Suicide, 5, 160, 332, 334, 376–377,
383, 396, 430, 469
Symbolization, difficulty in, 126,
139, 145, 154–157, 169
TBI. See Traumatic brain injury (TBI)
Teaming with Your Therapy Dog,
37–38
Tedeschi, Philip, 1, 3

Therapeutic alliance, 5, 25, 107,
136–138, 151, 158–159, 168,
170, 310
animals as facilitators of the,145–150
defining, 171n1
in equine-assisted therapy(EAT), 270, 274
poor, 136–138
therapist behavior and effects
on, 163–165
Therapeutic Crisis Intervention(TCI) model, 256
Therapeutic riding, 266, 283, 286,
289
Therapeutic touch, 6, 200, 268–269
Therapy animals. See Animals,
therapy
Therapy Dogs International (TDI),
27, 30“Third thing,” 146
Three-second rule, 200
Transitional “object,” animals as, 24
Trauma. See also Developmental
traumaanimal assisted play therapy(AAPT) for, 196. See
also Animal assisted playtherapy (AAPT)
animal-assisted psychotherapy(AAP) for. See Animalassisted psychotherapy(AAP)
child and family violence, 9,
17–19, 125, 220, 225,
249, 359, 403, 404
crisis response and, 3, 17,
21–22, 32, 310, 373–389

494

TRANSFORMING TRAUMA

Trauma (continued)
disorders as reactions to, 58,
92–93, 128, 192, 249,
415, 425
examples of AAI for, 108–109
loss, grief, and bereavement.
See Loss, grief, andbereavement for animals
military. See Military
trauma; Warrior Canine
Connection (WCC)
neurological effects of, 127–132
overview of, 17–22
post-traumatic stress (PTS),
19–21, 25, 27, 31, 403,
423, 429, 464
relevant effects of HAI for, 3,4, 5, 8, 15, 23, 27, 35, 61,
65, 100–102, 109, 303,
311, 343, 416
Trauma and Recovery, 124
Trauma network, 100
Trauma recovery
animal-assisted psychotherapy
for. See Animal-assisted
psychotherapy (AAP)
animal well-being and, 34–35,
36–39
background on inclusion ofanimals in, 15–16
conclusions on AAIs in, 41–42
current approaches to advocacy
and the support of animal
well-being in, 4, 34,
36–39, 60, 194, 458, 473
dogs in, 6, 28, 309–311, 356–
358, 360. See also Animals,
therapy; Dogs

emerging practices in, 27–32
evidence-based research on,
32–34
gaps and next steps for AAI in,
39–41, 210, 285
history of animalcompanionship and, 16–17
horses in. See Animals, therapy;
Equine-assisted mental
health (EAMH); Equineassisted therapy (EAT)
role of animals in growth andresilience in, 3, 6–7, 19,131, 135
theory and potential
mechanisms in, 23–27
tri-phasic model as framework
for, 271–272
Trauma response, 4, 137, 424–425,
472
Traumatic brain injury (TBI), 31–32
in veterans, 332–334
Treatment resistance in PTSD, 137,
356
Trojan dog effect, 356–358
True self, expression of, 157–158
Trust, 5–6, 16, 18, 24, 101, 270,
452, 464, 469
addressed by AAPT, 196, 198, 199
in animals, 74, 327, 342
animal-assisted therapy
promoting, 145–146, 170
child maltreatment and, 137,
145–146, 170, 223–225
in crisis situations, 380, 389
handlers and, 63
lack of, in trauma survivors, 65,
104, 107

Selective Index495

oxytocin system and, 104–105,
131, 378
psychotherapy and, 132
in self, 280
in veterans, 327, 356, 360
Two-factor theory, 93–94
Umwelt, 303
Unconditional love/non-judgmental
support/positive regard fromanimals, 23, 106–107, 146,
406–407
University of Denver, 1, 2–3, 27,
228, 230, 288, 319
University of Tennessee at Knoxville,
319, 416
Vaccines, 67–68
Verbal-symbolic system, 103
Vertical integration, 275
Veterans, PTSD in, 31–32. See also
Military trauma
Veteran’s Administration HealthCare System (VAHCS), 5
Veterinarians
in approval process for AAI,
66–67
effects of animal loss on, 404
Veterinary social work, 319
Villone, Lyndon, 341–342, 345
Vogel, Bob, 407
Volunteers, AAI, 22, 28, 30, 252
after disasters, 108, 373–375, 380
horse programs and, 283, 312
military dogs and, 328
Recreation Therapy Services,357
training of, 63, 66

untrained, 33
visitation programs, 210
Warrior Canine Connection(WCC) program, 360–
361, 367
Walter Reed National Military
Medical Center, 358, 361–362,
366–370
Warrior Canine Connection(WCC), 32, 355. See also
Animals, service; Military trauma
background and significance of,355–356
ensuring healthy service dog/
veteran bonds, 360–369
Mission Based Trauma
Recovery (MBTR) as afamily intervention for,359–360
research on protocols of, 369–370
trojan dog effect and, 356–358
Well-being, animal, 4, 66. See also
Animal welfare; Ethics of animalassisted intervention (AAI)
in animal assisted play therapy(AAPT), 206–208
in child-animal relationships,
221, 231–233
current approaches to advocacy
and support of, 36–39
defined, 56
dogs, 315–318, 336–337, 374,
383–384
in equine-assisted therapy(EAT), 281–285
handlers and, 103
military trauma and, 335–337

496

TRANSFORMING TRAUMA

Well-being, animal (continued)
One Health model and, 458
play therapy and, 192, 206
prioritizing of, 34–35, 473“White coat” syndrome, 57
Wildlife
Green Chimneys program and,
248, 259
grief over the loss of, 395,
411–413
rarity of childhood interaction
with, 219–220

risk of infection from, 76–77
selection of, for use in AAI, 35
Wilson, Edward O., 10, 221, 251,
269
Window of Tolerance, 275
Winnicott, D. W., 134–135, 146
Yount, Rick, 361–369
Zoology Foundation at Crooked
Willow Farm, 228–229
Zoonotic disease, 65, 67, 72–73, 79