MENTAL HEALTH

Pets as therapy: effects on socialinteraction in Jong-stay psychiatry

AbstractMany studies have suggested that health and social benefits maybe derived from pet ownership or visitation and research has IncludedInvestigation of the effects of pet visitation upon Interaction levelswithin severely mentally HI populations. The study featured In thisarticle aimed to examine further this relationship while attemptingto control for the effects of an extraneous variable (the human doghandler) using an A-B-C-A reversal design. The article concludes thatthe presence of a pet does, indeed, promote social interactions withina iong'Stay psychiatric population.

Animals are used to help humans inmany different ways ranging fromworking shire horses to guide dogs for

the blind. Similarly, animals as pets can be ofvalue to their owners in a variety of ways.

There have been many studies which sug-gest that the effects of pet ownership can bebeneficial to physical, social and psychologi-cal wellbeing. Research has found thatstroking a pet can be relaxing and can resultin a reduction in blood pressure (Katcher etal, 1983). The presence of pets can also pro-mote social interaction in older people(Rogers et al, 1992) and reduce psychologicalresponses to anxiety (Wilson, 1991).

A large amount of research has also con-sidered the benefits of pet-facilitated pro-grammes whereby volunteers bring theirown dogs to visit people in their own socialenvironments. Such studies demonstrate awide range of beneficial effects to thoseinvolved. For example. Gray (1988)described a case study where an older patientwas successfully weaned off the long-termuse of night sedative medication by strokingan animal before bedtime. It is also claimedthat visiting pets can create feelings ofdomesticity in nursing home residents whoare unable to live independently due to ageor illness (Savishinsky, 1992).

Many studies have specifically focusedupon pet-facilitated interactions within psy-chiatric populations. Patients who are with-drawn and largely unresponsive to attempts

Pauline L Hall is ClinicalSpecialist, TTicrapy Centre,Moorsidc Unit, TraffordGeneral Hospital,Manchester, and ZoeyMalpus is AssistantPsychologist, TraffordPrimary Care PsychologicalTherapy Services, MentalHealth Services of Salford,Manchester

Accepted for publication:October 2000

Pauline L Hall, Zoey Malpus

by staff to engage in interaction have beendescribed as responding positively to a 'ther-apy dog' with smiles, hugs and talking(Voelker, 1995).

However, such studies are criticized forproviding only anecdotal findings {Beck andKatcher, 1984) and therefore experimentalstudies have been conducted in an attempt tooffer greater scientific rigour. Walsh et al(1995) found that the presence of a 'pets astherapy' (PAT) dog had generalized palliativeeffects on patients with dementia in a securepsychiatric ward when compared with amatched control group. Effects included adecrease in the incidents of screaming andverbal abuse towards nursing staff combinedwith an increase in more social behaviourssuch as smiling and talking.

More recently. Barker and Dawson (1998)utilized a pre- and post-treatment crossoverdesign to investigate changes in anxiety rat-ings for the same psychiatric inpatients undertwo sets of conditions. The first condition,the treatment condition, entailed a single ses-sion of pet therapy, and the second condition,the comparison condition, consisted of arecreational group activity.

Barker and Dawson found no statisricallysignificant differences in 'anxiety chatige'scores between the two conditions. A possibleexplanation for this finding may be thathuman interaction (present in both condi-tions) is responsible for facilitation of anychanges and that the critical component ofpet visitation may in fact be interaction withthe handler not the pet.

Thus, the positive results claimed by otherstudies (Voeiker, 1995; Walsh et al, 1995)may also be influenced by the confoundingvariable of the dog handler as many previousstudies have also failed to take account of thefactor of novelty. That is, positive effectsobserved during animal visitation may simplybe due to the introduction of a novel andexciting stimuli and may dissipate whenfamiliarity ensues.

2220 BamsH JOURNAL OF NURSING, 2000, VOL 9, No 21

PETS AS THERAPY: EFFECTS ON SOCIAL INTERACTION IN LONG-STAY PSYCHIATRY

Haugie {1992) attempted to overcome thismethodological flaw in her study whichaimed to investigate the relationshiphetween the presence of a pet and socialbehaviour in long-stay environments. Usinga repeated measures design, Haugie conclud-ed that the presence of a pet animal promot-ed social interaction among older psychiatricpatients. However, this study was only con-ducted over a 4-week period, during whichtime three different conditions wereobserved (baseline, dog intervention andphotographic intervention). Thus, as thepresence of the dog amounted to less than 4weeks, it is arguable whether it can beclaimed that the novelty had dissipatedwithin this fairly short time period.

Furthermore, to date there are no existingstudies which have examined the presence ofthe dog handier as a possible confoundingvariable. It is often the case that clients whohave stayed in psychiatric institutions formany years display extremely limited levels ofsocial interaction.

Thus, the present study aims to control theinfluence of both novelty and also the effectsof the human dog handler in order to exam-ine the relationship between the presence of aPAT dog and levels of social interaction with-in a long-stay psychiatric population.

The null hypotheses under investigationare:1. That pet visitation will have no effect on

the number of observed social interactionsin long-stay psychiatric clients beyondthose which can be accounted for by thepresence of a human visitor (i.e. a handlerwithout a dog)

2. That there will be no effects on socialinteraction (i.e. talking, smiling, laughing)due to the presence of a PAT dog beyondthose which may be reasonably accountedfor by novelty factor.

METHOD

SubjectsA nursing home for clients with severe andenduring psychiatric illness was utilized inthis study as the multidisciplinary teamhad previously identified PAT dog visitationas a desired need. As such, the studyinvolved a convenience sample as the clientgroup were specifically selected. There wasa total of 10 residents and consent was

obtained from the rL-sponsiblc medical offi-cer iis written, informed consent was unob-tainable from the residents themselves dueto the severity of their illness. Nevertheless,attempts were made to obtain voluntaryconsent from the clients.

A poster informing the residents of theforthcoming dog visitation, the nature of thestudy and the client's rights was displayed incommunal areas before commencement of theresearch. The poster was written using simplewords in large colourful lettering with a pic-ture of a black dog to catch the resident'sinterest and aid comprehension. Additionally,staff were asked to explain the poster to theclients at any appropriate opportunity.

Implied consent was facilitated by restric-tion of the dog's presence to one room. Theresidents were free to enter or leave theroom as they wished and had access to alter-native rooms at all times if they did not wishto remain beside the dog. Ultimately, therewere ethical implications in the difficulty ofascertaining consent. It was agreed by themultidisciplinary team that the dog couldvisit, as the potential benefits were deemedto outweigh the risks (e.g. aggressivenessfrom the dog or a fearful or allergic reactionfrom a client).

The dog (Phoenix) was trained to a highstandard of obedience, i.e. Phoenix possesseda Kennel Club Good Citizens Award.Approval and the relevant insurance toundertake PAT visitations was obtained fol-lowing temperament testing. The handlersupervised the dog at all times and used aleash for control.

All staff, the handler and the observer wereaware of the importance of noting any nega-tive reactions in the client group. Appropriateaction would have been taken to resolve anysituations which may have been detrimentalto a resident's wellbeing; if necessary, thiswould have included the immediate removalof the dog. Such considerations were pro-posed to the local ethics committee andapproval was granted to undertake the study.

Consistent data were obtained for fiveclients. All subjects were male, aged over 65and had experienced institutionalized care forover 40 years. As such, the subjects in thisstudy displayed institutionalized behavioursuch as a reluctance to initiate interaction, alack of conversational ability', motor retarda-tion and little expressed interest in their

All staff,the handler

and the observerwere awareof the importanceof noting anynegative reactionsin the client group.Appropriate actionwould have beentaken to resolve anysituations whichmay have beendetrimental to aresident's wellbeing;if necessary thiswould haveincluded theimmediateremoval ofthe dog.

BRmSH JOUKNAL OF NURSINC, 2000, VOL 9, NO 21 2221

MKNTAL H FAITH

bindings indicatea small increase

in the number ofobserved socialresponses withintroduction of thedog handler.However, during theperiod of dog visits,this increase wasmarkedlygreater...verbalinteractions initiallypeaked withintroduction of thedog...This maysuggest that thefactor of noveltyis...an importantconsideration...

Table 1 . Collective mean scores for each condition

Socialbehavkxir

Baselinecondition A(weeks 1,2)

Handlercondition B(weeks 3,4)

Treatmentcondition C(weeks 5-lB)

PoBt-treatmentcondition A(weeks 19, 20)

Verbal

Non-verbal

0.08

0.51

0.54

0.53

1.10

1.41

0.70

0.36

ronment incorporating fellow residents, staffand television.

DesistA quasi-experimental repeated measures designwas employed incorporating A-B-C-A reversal(Campbell and Stanley, 1966). Baseline (con-trol) observations were taken for two sessionsat weekly intervals. These baseline observationsrequired that there was no dog or dog handlerpresent and that only the observer was presentto conduct ratings (condition A). As the observ-er was already familiar to the clients, minimalinterference was assumed.

The baseline observations were consistentwhich then allowed the dog owner to attend.Observations were undertaken with thedog owner present (condition B) for a further2 weeks. The dog was then introduced for areasonably lengthy period of 14 weeks (con-dition C). Finally, to increase confidence inthe effects being directional to the imposedconditions, the dog and handler wereremoved (i.e. to return to condition A).

ProcedureAll observations were made in the same roomeach week. Each client was observed for a1-minute period for an optimum of five peri-ods in each session allowing calculation of anindividual mean response.

Observations were made for two clearlydefined categories: social verbal and socialnon-verbal behaviour. Social verbal behaviourincluded talking and laughing; social non-ver-bal behaviour included smiling, eye contactand stroking the dog. Behaviour could bedirected towards the dog, the handler, staff orother clients. Visits were made once-weeklyand lasted approximately 90 minutes.

Specific information about observationsmade and copies of the rating scales may beobtained from the authors. Only one observ-er rated the subjects throughout, although shewas not blind to the study aims.

RESULTS

The results showed a notable increase in thecollective mean of both verbal and non-verbalsocial behaviours during the period of dogvisitation. The average number of verbal (i.e.talking, laughing) and non-verbal (i.e. smil-ing, making eye contact) social behavioursdisplayed per minute at different time periodsthroughout the study is displayed in Table 1.

The mean observed social verbal behav-iours ranged from 0 per minute in week twoup to 1.56 per minute in week 18. The non-verbal behaviours ranged from 0.32 perminute in week one to 2.90 in week 15.

The above results are more clearly illustrat-ed by means of a visual time analysis {Figure1). Findings indicate a small increase in thenumber of observed social responses withintroduction of the dog handler. However,during the period of dog visits, this increasewas markedly greater.

Verbal social interactionIt can be observed from Figure 1 that verbalinteractions initially peaked with introductionof the dog (week 5). This may suggest that thefactor of novelt>- is indeed an imponant con-sideration as this was followed by a decreasebefore the verbal responses settled in a fairlyconsistent pattern after week 9. Therefore, theresults indicate a decline during the penultimatevisitation of the dog {week 17) with the great-est peak overall observed in the fmal visit (week18). This may be explained by the breaking ofthe news in week 17 that the projea wasapproaching termination. Anecdotally, thepeak of week 18 can be construed as clientssaying goodbye to the dog.

Non-verbal social interactionThe pattern of expressed non-verbal responsesis much slower in achieving a prominentincline. The clients did not demonstrate anincrease in non-verbal social behaviours until

2222 BumsH JOUR.MAI. OF NURSING, 2000 , V O L 9, N o 21

PETS AS THERAPY: EFFECTS ON SOCIAL INTERACTION IN LONG-STAY PSYCHIATRY

around week 10 which may be indicative of ini-tial feelings of caution. This again suggests thepossibility' of shorter studies producing mis-leading results as the non-verbal behavioursonly increased dramatically after week 13 whenthe clients appeared familiar and confidentwith the dog. The results support the idea thatthis increase was indeed due to the presence ofthe dog as a sharp decrease is observed whenthe dog is not present (week 19).

CASE STUDY

As this study comprised only a small numberof subjects more detailed responses to the pres-ence of the dog can be obtained by consideringan individual case study. An example of anindividual response to the presence of the PATdog is presented below (see also Table 2).

Case study of verbal social interactionThe representations of a single case study givean illustration of the effect of the PAT dog onan individual client (Figure 2). The baselineobservations (0) offer support for the notionthat such clients display very little interactionwithin their normal environment. The interac-tion increased a little when the dog handlermet with the client (maximum 1). However,the effect of the dog handler was superseded bythe introduction of the dog. The behavioursincreased to 2.4 before settling for a fewweeks. This was followed by a second increasewhich peaked with the final visit (4.6).

Case study of non-verbal social interactionThe results from this client yield a similar pat-tern for non-verbal responses {Figure S).Again, the baseline was 0 and there was asmall increase upon introduction of the doghandler (1). Like the collective mean data (seeFigure i ) , the non-verbal behaviour decreasesuntil week 8 and the client appeared to over-come any apprehensions of the dog at thistime. The non-verbal behaviours thenincrease to a level far greater than those when

only the handler was present (maximum 4.6).Finally, there is again clear indication that theeffects were due to the presence of the PATdog as observed behaviours returned to zerowhen the dog is withdrawn.

Equally important is the richness of thenonverbal interactions attributed to the pres-ence of the dog. For example, initial non-ver-bal responses from the client above com-prised eye contact and head nodding. As hisconfidence with the dog increased, heengaged in a game of throwing her biscuits tocatch and walked with her for short distancesin the garden.

DISCUSSION

Following the introduction of the PAT dogthere was a notable increase in the amount ofverbal and non-verbal interaction displayedby the clients. This increase was greater thanthat observed when only the dog handler waspresent. The positive effects obtained in thisstudy support previous research (Haugie,1992; Voelker, 1995) which concludes thatthe presence of a pet promotes social interac-tion among psychiatric patients. However,this study extended the credibility of thisnotion by control of the novelty factor.

Figure 1. tVlean verbai and

non-verbal scores for each

condition.

Observed interaction

rved

bob

sm

ber

1IO 1

VerbalNan-verbal

Week

Table 2 . Mean of observed interaction from an individual case

Week

Verbal

Non-verbal

1

0

0

2

0

0

3

0

1

4

1

1

5

1

0

.7

.6

6

2

0

.4

.2

7

1

0

8

1

1

.4

.2

9

1

0 .6

10

0.8

2

11

1.4

1.2

12

3

1.2

13

2

3.4

14

1.4

2.4

15

1.6

1.4

16

1.4

2.8

17

2

3.8

18

4.6

1

19

0.2

0

20

0

0

BwnsH JOURNAL OF NURSING, 2000, VOL 9, No 21 2223

MENTAL HEALTH

InJct'd, results prtivcd th;U initial responsesdo iiDi indicate wh.it will hnppL-ii when clientsbi'Ciinic l.imili.ir with the pet.

This reasonably lengthy study suggests thatthe increased social bcliaviour shown in thisclient group were sustained at levels greaterthan biiseline when the factors of novelty andthe presence ofa dog handler were taken intoconsideration. The dat.i therefore supportreifction of the null hypotheses.

The findings of this study highlight theeffectiveness of the presence of a dog inincreasing expressed positive hehaviourswithin this severely impoverished clientgroup. The generalizability of the currentfindings are limited hy the small sample sizebut they nevertheless provide a useful indica-tion of the patterns of favourable verbal andnon-verbal behaviours following the intro-duction of a PAT dog.

The findings may also be prone to bias asthe rater was aware of the study aims. For

3

oD

<D

TDO

O

_O0

Num

ber

ol

5 - 1

4 -

3 -

2 -

1 -

0 -A

1

B /

1

3

Subject X - verbal

thA /

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 '

5 7 9 11 13 15 17 19

Week

Figure 2. Example of an Individual verbal response to the presence of the PAT dog.

3

9oo

- Q

-Doto

JS0

"o

iE3

Z

5

4 -

3 -

2 -

1 -

0 -A• 1 '

1

Subject X - non-verbal

• /\^\ / \\ / \

1 \ 1 \1 \ 1 \/ \ / \

B I V \/—«k /- S. /~~* V

/ V / • ^ / \1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 '

3 5 7 9 11 13 15 17 19

Week

Figure 3. Example of an Individual non-verbal response to the presence of the PAT dog.

example, the observer may have interpretedambiguous or neutral client responses as'social interaction', thus giving exaggeratedrecordings of observed positive responses.Attempts were made to minimi/.e this by con-sistent use of clearly defined observational(e.g. classifying non-verbal social behaviouras smiling, making eye contact with the han-dler or the staff, strtjking or feeding the dogand offering out cigarettes).

A further independent variable which mayhave influenced interaction levels is that ofthe staffs' reaction to the dog. The presentstudy did not allow any standardized mea-surement of this factor due to the complexi-ties of the Hawthorne effect (Roethlisbergerand Dickson, 1939) which highlights how aperson's behaviour can change due to theawareness that he/she is being observed.Thus, as the observation of the clients natu-r.illy included staff/client interaction, it is pos-sibie that the staffs' awareness of this mayhave motivated an increased frequency ofinteraction. It is uncertain if the behaviour ofthe clients changed directly as a result ofbeing observed; however, their understandingof the concept of 'observation' was question-able due to the severity of their illness.

It is important to note, however, thatanecdotal observations suggest that the staffused the dog as a facilitator of client interac-tion, both with and without its presence. Forexample, during dog visitations, staff wouldmake warm comments to the clients such asremarking how the dog was pleased to seethe resident or explaining to the client thatthe dog had come to visit. In between visits,staff would inform the clients of the plansfor the next visit as well as asking questionssuch as whether the client enjoyed the visitsfrom the dog.

The ethical principle adopted in thisstudy, that the benefits would outweigh therisks, was endorsed. Numerous favourableeffects were apparent in the presence of thedog, whereas negative reactions wereabsent. However, following termination ofthe dog, visits it was reported by staff thatsome of the residents appeared to miss thedog. Although the offer of recommencementof visits remained an option, the staffproposed instead to adopt a permanent petfor the home.

Despite the limitations inherent in thisstudy, the introduction of a pet visitation pro-

2224 BRmsH JOURNAL OF NURSING, 2000, VoL 9, No 21

PETS AS THERAPY: EFFECTS ON SOCIAL INTERACTION IN LONG STAY PSYCHIATRY

gramme appeared to promote social interac-tion in individuals with chronic mental ill-tiess. It was noted that the initial presence ofthe dog resulted in little change in social inter-action. However, after approximately six vis-its, the residents became more familiar andconfident with the dog. A notable increase inpositive responses was especially evident fornon-verbal behaviours (e.g. smiling, touch-ing). There appeared to be a similar, althoughless marked, trend for verbal behaviours (e.g.talking, laughing). As the trend was far lessapparent with only the handler present, thefindings of this study support the notion thatit is indeed the pet, not the human handler,which promotes social interaction.

CONCLUSION

Replicating this current study but making itmulticentred and using a larger sample sizewould be useful. The utilization of a matchedcontrol group who is visited by the handlerwithout the dog for the same time period asthe comparison group receive visits from thehandler and the dog, would also be informa-tive. When compared to the findings fromthe present study, which indicate that effectson social behaviour are far greater from thepresence of a handler and dog than they arefrom the handler alone, this could offergreater validity.

It would also be interesting to lengtben thetime period even further to test whether theincreased levels of positive behaviour are sus-

tained. Perhaps one of the most appropriateways to conduct this would be to study thelong-term effects in a similar residential envi-ronment of a pet living with the clients.

At present, however, this study adds sup-port to the body of evidence which concludesthat pet visitation yields beneficial effectswithin a severely mentally ill population.BIH

Barker SB. Dawson KS {1998) The effects of ani-mal-assisted therapy on anxiety ratings of hospi-talized psychiatric patients. Psychiatr Serv 49{6):797-801

Beck A, Katcher A (1984) A new look at pet-facili-tated therapy, J Am Vet Med Assoc 184: 414-21

Campbell DT, Stanley JC (1966) Experimental andQuasi-experimental Designs for Research. Rand-McNally, Chicago

Cray KB (1988) A man's best friend. Nurs Times84(54): 4 0 ^

Haugic E (1992) An evaluation of companion petswith elderly psychiatric patients. BehavPsychotherap 20: 367-72

Katcher AH, Friedmann E, Beck AM (1983)Talking, looking and blood pressure: physiologi-cal consequences of interaction with the livingenvironment. In: Katcher AH, Beck AM, eds.New Perspectives on Our Lives with CompanionAnimals. University of Pennsylvania Press,Philadelphia: 351-9

Rcpcfs J, Hart LA, Boltz RP [ 1992) The role of pet(Jogs in the casual conversations of elderlyaduks. J Soc Psychol 133:265-77

Roethlisberger FJ, Dickson WJ {1939)Management atid the Worker. HarvardUniversit)' Press. Cambridge

Savishinsk) JS (1992) Intimacy, domesticit)' and pettherapy with the elderly: expectation and experi-ence among nursing home volunteers. Soc SetMed 34: 1325-34

Walsh PG, Mertin PC. Verlander DF, Pollard CF(1995) The effects of a pet as therapy dog on per-sons with dementia in a psychiatric ward. AiistOcc Therap J 42: 161-6

Wilson CC (1991) The pet as an anxiolytic inter-vention. / Nerv Ment Dis 179: 482-9

Voelker R (1995) Puppy love can be therapeutictoo. JAMA 174: 1897-9

KEY POINTS

The positive effects observed in this study support previous research which concludesthat the presence of a pet can promote social interaction among psychiatric clients.

The factor of novelty should be taken into consideration when observing the effects ofintroducing a pet to a client group.

The findings of this study support the idea that it is the pet and not the human han-dler which acts as the catalyst to social interaction.

It would be useful to study the long-term effects of having a pet living permanentlywith psychiatric clients in a residential environment.

It was nolc'dV that the initialpresence of the dogresulted in littlechange in socialinteraction.However, afterapproximately sixvisits, the residentsbecame morefamiliar andconfident with thedog. A notableincrease in positiveresponses wasespecially evident fornon-verbalbehaviours{e.g. smiling,touching).

Ki-nuH JOURNAL OF NumiNC, 2000, VOL 9, No 21 222S