A Dream Becomes Reality: Building an Animal-Assisted Treatment Program

Introduction

Volunteer visiting dog and miniature horse programs are growing in popularity in healthcare settings. These animal assisted support programs, although potentially therapeutic for patients, typically do not include trained and appropriately credentialed providers implementing clinical interventions (Fine, 2015; Johnson Binder, Parish-Plass, Kirby, Winkle, et al., 2024) and do not meet the criteria for being classified as standalone psychotherapeutic interventions. Animal Assisted Treatment (AATx) (formerly known as Animal Assisted Therapy, AAT) includes therapeutic interventions in which appropriately socialized/trained therapy animals and licensed/credentialed healthcare professionals partner with patients to achieve therapeutic goals (Fine, 2015; Johnson Binder et al., 2024). Clinical applications of AATx are novel and challenging to implement due to 1) taking place in highly regulated healthcare environments; and 2) the extensive training and supervision required for providers to implement AATx into clinical practice safely and ethically.

While studies exploring AATx services to adults with medical needs have demonstrated benefits [e.g., in treating substance use (e.g., Kern-Godal, Brenna, Arnevik, Ravndal (2016) and in dementia care (e.g., review in Chen, Wang, Zhang, et al 2022)], research on the efficacy of AATx with children, and in particular those with chronic illness, is limited (Klemetsen &  Lindstrøm, 2017; Katsinas, 2001). This may be in part due to the complexities of actively engaging animals with potentially medically fragile and immune compromised children. Cotoc and colleagues revealed consistent results supporting improvement in mood, self-esteem, and quality of sleep in their systematic review of the research incorporating AATx with pediatric oncology patients (Cotoc, An & Klonoff-Cohen, 2019). They also found that these patients reported reduced fear and anxiety related to medical procedures, and they observed benefits of AATx for caregivers (family members and healthcare workers). Lindström Nisson and colleagues found that children interacting with animals in medical settings reported increased feelings of wellbeing and joy and decreased pain perception during treatment (Lindström Nisson, Funkquist, Edner and Engvall, 2020). Parents reported high levels of motivation and comfort, greater enjoyment and improved child mood when a dog was involved in physical and occupational therapy for children rehabilitating from brain injuries (Narad, Kenestrick, Wade, et al., 2023). 

Animal Assisted Interventions and Treatment at our Institution

Visiting animals have been a part of the healthcare environment at Nemours Children’s Health in Jacksonville, Florida, for many years. Initially, this included volunteer dogs in the main lobby or clinic waiting rooms to greet families and provide a calming influence. In addition, volunteer miniature horses would visit and greet children in the main lobby, including a horse with a prosthetic foot whose owners shared his healthcare story. Anecdotally, we observed these encounters reducing stress and serving as a reward for reaching goals and wanted to find a way to incorporate these special moments therapeutically. 

Our team became particularly interested in expanding our therapy animal services after a continuing education presentation by a professor from the University of North Florida, one of our local partnering universities. Carlene Taylor, EdD, NCC, LMHC-QS is also a certified equine specialist in mental health and learning (ESMHL) and her presentation stimulated a great deal of excitement about integrating registered animals into therapy visits with mental health professionals. Upon learning more, several of our clinicians enrolled in a 3-semester graduate certificate program in Animal Assisted Therapy in Counseling in 2019. Unfortunately, much of this learning ended up happening virtually during the COVID-19 pandemic, but this forced pause gave us time to create policies and procedures, gather donations to support our program, engage with internal and external partners, and design and build an outdoor facility at our clinic, located in a busy metropolitan medical hub (see photo). During this initial phase of COVID-19, our team also created a series of educational and entertaining YouTube videos to remain connected to our patients and the community (e.g., Happy Therapy Animal Day – First Zoom Meeting of ADAPT Assisted Dog and Pony Therapy team & Friends; How to Social Distance with Your Pet – Nemours ADAPT; Learn How to Do Controlled Breathing With Your Pet – Nemours Adapt Team).

While developing our AATx program, we conducted an initial implementation study, including surveying staff and developing educational materials. This was a valuable way to identify concerns about expanding our animal programs from visiting (animal assisted support) to integrated AATx (Schilling, Kahhan, Pfeffer Whitlock, et al., manuscript in preparation). Primary concerns expressed by our associates centered around hygiene, animals disrupting patient care, and whether AATx would utilize financial resources earmarked for other services. We developed a video for all associates to view which provided education about our plans to address identified concerns, increasing acceptance of the program considerably. Taken together, these strategies allowed us to produce a comprehensive AATx program, the Assisted Dog and Pony Therapy (ADAPT) program at Nemours Children’s Health, Jacksonville. Public facing information about the ADAPT program may be found on our website or through Nemours YouTube videos: Assisted Dog and Pony Therapy (ADAPT) program – Nemours Children’s Health System.

Equine Therapy Services

The equine arm of our ADAPT program initially partnered AATx certified psychology providers with volunteers and their mini horses and was immediately popular with patients and staff alike. Our team utilizes the diamond model (Brooks, 2005), which includes a therapist, patient, mini horse, and certified equine specialist in the paddock. We developed an 8-session, structured treatment plan that was implemented initially with Oncology and Endocrinology patients with comorbid mental health diagnoses. Significant interest was expressed by other psychologists and medical staff members, leading to our development of an alternate plan to allow AATx components to be integrated as an adjunctive part of an outpatient therapy session or medical visit (20 minutes per activity). Six goals were identified for these activities: 1) Psychoeducation about emotions, 2) Illness related anxiety & coping, 3) Communication of feelings, 4) Anxiety & stress management, 5) Building confidence/empowerment, 6) Rewarding activity. Brief therapeutic interventions targeting each goal were designed and manualized (Hodges, Taylor, Binder and Schilling, manuscript in preparation) to be applied by licensed providers after engaging in continuing education in AATx. Example activities include: 1) Mindfulness with a mini horse, 2) Matching breath/steps/energy, 3) Relaxation station scavenger hunt (searching the paddock for relaxation activities and completing them with the horse), and 4) Lead the herd through obstacles (an obstacle course in which the horse is led over/around obstacles while the patient describes the obstacles they have faced and overcome as part of their medical or psychological treatment). Our next step is collecting data to measure the effectiveness and acceptability of these interventions. 

For the canine arm of our ADAPT program, providers who completed the Animal Assisted Therapy in Counseling certificate program worked with their personal dogs to seek registration as animal therapy teams. This was completed through the local arm of a national registration body (Pet Partners). Information about the training requirements for this certification can be found here: Therapy Dog Certification: How To Get Therapy Dog Certification. Additional evaluation specific to the clinic site was completed by Nemours volunteer services to make sure the canine partners could safely and confidently participate in a children’s healthcare setting. Other processes included staff training, clinic signage, and contingency planning (e.g., purchasing portable crates and supplies, designating areas for breaks, establishing cleaning protocols). Templates and scripting were created to assist in identifying appropriate patients, completing animal therapy consents, and scheduling.

While equine therapy procedures were structured (i.e., an 8-session treatment plan), canine therapy procedures allowed for more fluid inclusion of therapy dog partners into evidence-based treatment approaches (e.g., CBT, ACT) already being utilized. For example, when teaching diaphragmatic breathing to a patient, they could practice this by blowing bubbles for the therapy dog or matching their breathing to the therapy dog at rest. When reviewing fight or flight and the mind/body connection, an analogy could be made between what anxiety or stress feels like in the human body and reflecting on dog behaviors (e.g., withdrawal, shaking). The therapy dog may also be engaged in the therapeutic setting in ways that improve mood symptoms in the moment. For example, one patient created the plan to “hold hands [hand and paw]” with a therapy dog when starting a new insulin pump to assist with their procedural anxiety.  Another patient with leukemia said he was too anxious to share his first-grade project face to face with the clinician, but happily presented it to the attentive therapy dog, including showing pictures of himself in the hospital and describing his fears when initially diagnosed.

Future Directions

We hope that this information will encourage those who recognize the importance of ABPP certification to consider unique ways to build their practices. While the AATx program at Nemours through ADAPT is still growing, we suggest the following actionable steps for tho

se considering starting an animal treatment program:

• Enlist the full support of administration (start with the animal lovers!).
• Assess the concerns of those who will have even indirect contact with the animals (e.g., medical staff, security, housekeeping).
• Consider whether you are likely to have community support (e.g., donations, volunteers).
• Consult with a clinician experienced in AATx.
• Review requirements and options for training and registration (e.g., PATH, Pet Partners).
• Consider options for engagement with staff and prepare for interest from medical providers who will want to incorporate animals.