Animal-Assisted Psychotherapy with Canine Co-Therapist ...



Animal-Assisted Psychotherapy with Canine Co-Therapist: Attachment Model for Families with Young ChildrenPamela PitlanishOakland UniversityAbstractAnimal-assisted therapy (AAT) literature cites many references to human infancy. Terms such as bonding have been borrowed from human infancy research regarding the formation and purpose of close parent-infant dyadic relationships. Children and animals have natural affective relationships, and numerous studies have shown that both children and adults develop attachments to companion animals. There is a body of evidence pointing to positive results of animal-assisted therapy (AAT) with children, however these are primarily for autism, health care, or in educational settings rather than in psychotherapy. Professional therapists employing AAT with the early childhood population are scarce. This paper proposes the development of an attachment model for animal-assisted psychotherapy with a canine co-therapist for families of young children, with the assumption that animals can serve as attachment figures for children and families in psychotherapy. Several key features and cautions for parent-infant work which includes the addition of a therapy dog are suggested. A quasi-experimental outcome evaluation could be feasible by comparing 2 groups of families, 1 which chooses to enroll in animal-assisted psychotherapy, and a control group of families which receive standard family therapy, but without a therapy animal. Results on attachment on attachment scores, parent-child relationships, use of therapy animal by parents for increased ability to read their child’s cues, and emotions, and to respond appropriately can be measured through standardized measures on attachment with parent-completed Devereux Early Childhood Assessment (DECA) scores, and by 20-question parent-completed questionnaire.Keywords: animal, canine, animal-assisted therapy, attachment, psychotherapy, young children, families, infant mental healthAnimal-Assisted Psychotherapy with Canine Co-Therapist: Attachment Model for Families with Young ChildrenBorn into a family which lived in the country on 40 acres, with a barn and many outbuildings, fields of corn everywhere, and pets of all species, writer considers herself very fortunate. Born into a family suffering the chaos of one alcoholic parent, one codependent parent, a mentally ill sibling, and persistent chaos and violence--not so fortunate. But this combination would prove to direct her life and career choices. Throughout childhood, the numerous family pets, including dogs, cats, fish, geese, and even raccoons, provided supportive relationships for this writer. Although she later developed a myriad of self-destructive methods for drowning out the pain of loneliness, trauma, fear, self-loathing and chronic anxiety, she realized her parents’ high expectations for her education. She finally succeeded—somehow—to earn a Bachelor of Fine Arts degree, then continue on many years later to pursue a Master of Social Work (MSW) degree. Social Work was likely embedded in her psyche and genes from birth, considering the family life she experienced. But it wasn’t just the field of Social Work that hooked her. During orientation, someone handed out brochures on the different certification programs one could specialize in while earning their MSW. She read on the cover of one, “Graduate Certificate in Infant Mental Health (IMH),” at the then Merrill-Palmer Institute. Having absolutely no idea what those words meant, she simultaneously had no ability to turn back from that point on. She began her graduate education with a 9-month-old and a 3 ?-year-old at home. Their success in childhood and in life, juxtaposed with her painful early experiences, has maintained a prominent position in her mind since prior to their births. Daniel Stern, in Diary of a Baby (2008), beautifully describes the purely sensory experience of an infant within the confines of a crib. He portrays the purity of human life, prior to the point at which unadulterated sensory experiences of the world and the essence of emotions become confined by words, definitions, and judgements: Joey is six weeks old…Joey is looking at the sunlight falling on his wall (“A Patch of Sunshine”). Then he looks at the bars of his crib and, through them, at the wall beyond (“Space Songs”). He becomes hungry and cries (“A Hunger Storm”) and, finally, is fed (“The Hunger Storm Passes”). Like shots in a movie, one moment may be continuous with the next, or fade into it, or cut abruptly against it, or be separated from it by a blank pause. It is not clear to Joey how he gets from one moment to the next or what, if anything, happens between them. (Is it so clear for us?) But all his senses are focused on each one, and he lives each intensely. Many are the prototypes of moments that will recur over and over throughout life. (p. 15). Writer’s earliest memory, being alone in a crib, crying--seemingly forever--with alternating light and dark vertical lines was triggered by reading about Joey during her beginning studies in IMH at Merrill-Palmer. Early childhood mental health, critical for later development, was a personal issue while becoming a professional mission. Writer’s twenty year long career in Community Mental Health (CMH) was spent primarily in the homes of at-risk families of infants and toddlers, using the model Selma Fraiberg developed in the 1970’s. This was a child-centered, psychodynamic, relationship-based model of parent-infant psychotherapy (Fraiberg, Adelson, & Shapiro, 1975). After the exceptional professional experiences received within the CMH system, she retired to part-time solo private practice where she now treats individuals and families from pregnancy through adult. She has trained her two dogs for certification with Therapy Dogs International (TDI) and uses them in her practice, particularly with children. The combination of writer’s early experiences in infancy, the supportive role of the many animals to which she developed attachments beginning in early childhood, and the professional Social Worker/Infant Mental Health Specialist she became in adulthood have fused into this plan for the development of a model for animal-assisted psychotherapy (AAP) using a canine co-therapist with an attachment-based treatment orientation for families and their young children. AAT literature cites many references to human infancy. For example, use of the term bond, as in human-animal bond, is referenced as being borrowed from parent-infant relational terminology (Beck, 1999). This is one of the reasons why this writer finds using animals in psychotherapy with families of infants and toddlers to be fitting. Parish-Plass (2013) cites a prominent early parent-infant author in Animal-Assisted Psychotherapy: Theory, Issues, and Practice when discussing the similarity between D. Winnicott’s terminology and the use of an animal as a transitional object. This paper will examine the potential for enlisting the assistance of a canine co-therapistwith families of young children, and will look at the following questions: Whereas animals are noted for alleviating children and adolescents’ reservations regarding attending therapy (Katcher & Wilkins, 1998), could the use of a therapy animal—dog, for instance—also be enticing to a family of infants and toddlers? Should a therapist insure that interventions with a therapy dog are pertinent to psychotherapy, and not simply employ animal-assisted interventions? But the more basic question might be, is there even a difference between AAP and AAT? Can AAP play an important role in family therapy which focuses on attachment relationships? How might one design specific interventions for a therapist and canine co-therapist in order to assist a family of young children with their therapeutic goals? Can a therapy dog assist parents in recognizing and responding to their child’s emotional needs? Might parents model the relationship between therapist and therapy dog for use with their child? Do attachment scores on a standardized test rise when AAP is provided to families with young children? Also, does the practice of tuning-in to a therapy dog’s body language and emotions assist parents in tuning-in to their child? This exploration has been diagrammed in a Logic Model (Figure 1) with some of these questions listed as outcomes. They will also be addressed in the section on evaluation, within a client survey for post-treatment. Needs AssessmentMental health challenges in early childhood are common, often overlooked, and underserved. According to the National Center for Children in Poverty, one in five children Nationwide from the ages of 0 to 18 has a diagnosable mental health condition CITATION Sta10 \l 1033 (Stagman & Cooper, 2010). In Michigan alone, 20% of children suffer from at least one mental, behavioral, social, or emotional condition CITATION KID15 \l 1033 (The Annie E. Casey Foundation). Genesee County, Michigan has a population of slightly over 30,000 children ages zero-to-five, with 1,000 of these being confirmed cases of child abuse or neglect CITATION KID15 \l 1033 (The Annie E. Casey Foundation). And yet —a primary referral source on the Internet--lists only 20 therapists serving Genesee County who advertise on their site, with just 10 treating the birth-to-five population, and only three of those using an attachment model.For little ones, social-emotional health is mental health. Social-emotional development is critical at the early ages, because success in school and in life depends on a child’s ability to relate well with others, to get their needs met in socially-appropriate ways, and to self-regulate CITATION Nat07 \l 1033 (National Scientific Council, Center on the Developing Child at Harvard University, 2007). Clinical treatment of young children is best conducted in as close to the child’s natural environment as possible, within the family unit that can be both the source and relief of negative experiences: “The emotional well-being of young children is directly tied to the functioning of their caregivers and the families in which they live…When children overcome these burdens [trauma, maltreatment, emotional abuse], they have typically been the beneficiaries of exceptional efforts on the part of supportive adults” (Center on the Developing Child, Harvard University). Addressing the issues within the child’s family is therefore essential, and is considered best practice in the field of child psychotherapy. The infant mental health model was established in the early 1970’s by Selma Fraiberg at the Child Development Project in Ann Arbor, Michigan (Fraiberg, 1987). This model uses what is termed kitchen table therapy, coined from the flexibility of professional boundaries during home-based sessions, within an attachment model that focuses on the parent-infant dyadic relationship and on the internal working models of both child and parent (Shapiro, 2009). In Reflections on the Work of Professor Selma Fraiberg: A Pioneer in the Field of Social Work and Infant Mental Health, Shapiro (2009) notes Fraiberg’s inclusion of parents in the treatment team, “Her therapeutic work with parents was aimed at developing a working alliance with them, and helping them provide a holding environment for their child that was empathic, stable, and attentive to developmental needs” (p. 48).In attachment theory, symbolic representations of the attachment object become internal working models—or templates—which the infant uses to understand themselves, others, and expectations for relationships. Ribaudo (2014) describes these as “patterns of interactions that, through repetition and over time, ‘tell’ the infant what to expect from caregivers and the environment.” One can see in Figure 2 how primary caregiver’s behavior influences the development of a child’s working model, and in turn, the attachment classification. Like other animals, humans are “biologically predisposed to seek out and sustain physical contact and emotional connection to selective figures with thom they become familiar and come to rely on for psychological and physical protection” (Sable, 2012). Can animals serve as attachment figures for children and families in psychotherapy? Many believe that this is not only possible, but have implemented animal-assisted psychotherapy programs around this premise. While a client’s positive change in psychotherapy can be attributed, in part, to new meanings of self and others which arise out of a healthy relationship with (human) therapist who is nurturing, responsive, and empathic (Lieberman, Silverman, & Pawl, 2005), it should not be surprising that a therapy dog, with their non-judgemental character, can assist a client—particularly a child—in developing new internal working models. Parish-Plass (2008) recognizes the uniqueness of AAT for inducing positive change with children suffering from insecure attachment, which includes the animal’s serving “as a safe haven, as a secure base and as an attachment figure” (p.14). Because of the similarities between young children and animals, particularly their innate ability for honesty and play, one of the newest modalities combining child therapy and AAT is animal assisted play therapy (AAPT), where “Play and playfulness are essential ingredients of the interactions and the relationship” (VanFleet R., 2008). In 2004, Kruger, Trachtenberg, & Serpell stressed the importance of documenting mental health interventions when animals are an additional part of the treatment, stating, “Animal-assisted interventions (AAIs) are currently poorly defined. The lack of a unifying set of practice guidelines or a shared terminology is hampering efforts to evaluate and gain acceptance for the field” (p. 2). Whether a clinician chooses to develop treatment interventions prior to sessions may be a matter of personal preference, more so than a sign of how closely the clinician is following a specific model. Many mental health therapists conduct sessions as Parish-Plass (2013) describes animal-assisted psychotherapists in Israel practicing: “the therapist flows with the client (psychodynamic, client/child centered, non-directive), as opposed to a directive approach in which the therapist prepares activities ahead of time” (p. xxi). In the Animal-Assisted Therapy Certificate Program at Oakland University, Rochester, Michigan, one of the first assignments is to create lesson plans for AAT interventions: “Whether you are using your pet to counsel, visit a nursing home, help a child practice reading, assist in physical therapy, etc. there will need to be a specific task or goal to accomplish and the lesson plan will make that possible” CITATION Joh13 \l 1033 (Johnson, 2013). Embarking upon this newer modality of psychotherapy called AAP, this writer has been challenged to figure out just how to engage clients with the canine co-therapist so that treatment goals are accomplished in as short a time as possible, maximum participation by co-therapist is facilitated, and that maximum benefits of AAP are realized. In traditional psychotherapy with no canine co-therapist, it is often useful when working with young children and families to have specific interventions outlined ahead of time that are designed to facilitate the family’s movement toward their particular treatment goals. Wilson and Barker (2003) noted the importance of matching proven human-animal interventions (HAI) with a specific client base: “Once HAI interventions have been standardized and evaluated with research supporting their effectiveness with specific popultations, practitioners will be able to select the most appropriate HAI intervention for their client popuation” (p. 23). It is for these reasons that the challenge of developing a model and eventual guide of specific AAP interventions for use with families of young children based on attachment theory is being undertaken. MethodologyWhile terminology in this field is often used incorrectly and/or interchangeably, it is important to define the terms to which this writer is referring for this particular practice and methodology. Pet Partners (formerly Delta Society) CITATION Pet15 \l 1033 (Pet Partners, n.d.) provides this definition of animal-assisted therapy on their website: AAT is a goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/human service professional with specialized expertise, and within the scope of practice of his/her profession. AAT is designed to promote improvement in human physical, social, emotional, and/or cognitive functioning [cognitive functioning refers to thinking and intellectual skills]. AAT is provided in a variety of settings and may be group or individual in nature. This process is documented and evaluated. (From Standards of Practice for Animal-Assisted Activities and Therapy)Parish-Plass (2013) defines animal-assisted psychotherapy as:…a form of psychotherapy which is conducted with the same rationales and goals as mainstream psychotherapy Therefore, we are first and foremost psychotherapists, and together with that AAP therapists, for the client may not always be inclined to take advantage of an animal’s presence in an active or obvious manner. The client—not the animal—is at the center and is the focus, the raison d’etre. We, not the animals, are the therapists, for only we are cognizant of the client’s psychological processes and issues that need to be worked through and how to do so, according to what is in the best interests of the client (p. xviii). The methods for conducting child and family sessions using a therapy dog at Centered Insight Healing, PLLC (CIH), are based on the practitioner’s professional training and certification as a Licensed Clinical Social Worker (LMSW), and endorsement through the Michigan Association for Infant Mental Health as an Infant Mental Health Specialist and Mentor, (IMH-E?[IV]). This specific early childhood training is founded on principles outlining healthy social-emotional development of young children. Therapist has a license to practice independently with 24 years of clinical experience, which includes four years in solo private practice.One of two therapy dogs owned and handled by the therapist and certified through TDI, is chosen for working with specific families if the parent/guardian elects to participate in AAP. The therapist currently has a 7-year-old spayed female Rottweiler named Izzy, and an 11-year-old neutered male Border Collie named Buddy. Both were rescued by the therapist/handler over five years ago, and have been certified through TDI for over two years. Both have participated in several psychotherapy sessions with children, adults, families, and groups. This practice is located in an adjacent community to Flint, Michigan, which has suffered severe financial and population decline subsequent to the withdrawal of auto manufacturing plants. Population has been halved from 200,000 at the height of manufacturing in the 1960’s, to 100,000 today. Fortunately, 94.7% of Michigan’s children have health insurance CITATION Mic13 \l 1033 (Michigan Department of Community Health, 2013). CIH receives referrals from several insurance networks within which contracts have been signed, “word-of-mouth,” and from internet advertising. The clinic offers a sliding-fee scale for clients paying privately with limited income. The practice is a suite on main floor within an office building, directly inside of rear entrance. A large grass area and parking lot are available outdoors for exercising and relieving dog. As seen in Figure 3, a sign has been placed on suite door notifying visitors of other suites that a dog is on the premises, thereby alerting those who may suffer allergies.The following principles guide the AAT psychotherapy with families of young children:Family/relationship-centered practice: The client is the family. Therefore, even though, for insurance and billing purposes there will be an identified patient (IP), the targeted unit of change is the family unit.In IMH work, the client is more specifically defined as the relationship between parent (usually mother) and young child, which is identified as best-practice CITATION Wea03 \l 1033 (Weatherston & Tableman, 2003), but for which there are no outlined AAT interventions.For purposes of this practice, “early childhood” refers to the ages of 0 to 5 CITATION SAM \l 1033 (SAMHSA, n.d.)Best-practice guidelines for mental health services for young children indicate focusing on supporting the development of a consistent, nurturing relationship between child and primary caregiver, so that secure attachment is formed. This in turn supports optimal social-emotional development, which is seen as the foundation for mental health for young children CITATION ZER \l 1033 (ZERO TO THREE: National Center for Infants, Toddlers and Families).Young children are best served in the context of family and culture.Hypotheses about the process of AAP with families of young children: Human infants are both social and vulnerable creatures, as are animals, and the use of an animal in therapeutic work with families of infants/toddlers may be extremely facilitative of change.AAT offers a unique manner of facilitating goal-attainment by being able to connect with children through many developmental domains. Parish-Plass (2008) listed these as: “Enabling connection, Normalcy, Safety and friendliness of the therapy setting, Acceptance, Reality at a safe psychological distance, Self-esteem, The animal as an attachment figure, Allowing for the working through of attachment issues in the ‘here and now’ within the therapy setting, Development of more adaptive representations and strategies, Empathy, Need for control, Touch, Regression in the service of the ego,” and “Separation, loss and bereavement” (pp. 13-15).A therapy animal serves the purpose of attachment figure, meeting the requirements of proximity-seeking, safe haven, secure base, and separation distress CITATION Sil13 \l 1033 (Silcha-Mano, 2013). The mere presence of a pet in the office during psychotherapy with a family does not constitute AAP. The presence of a therapy dog enhances the therapeutic process in order to increase parent’s awareness and insight about themselves, and about their relationship with their child. In addition, dependent on the age of the young child and involvement in play with therapy animal, the child is able to utilize the dog as a transitional object, in order to create new meanings for and about themselves (Parish-Plass N., 2013). Therapist maintains self-awareness regarding any potential expectations about “desired” interactions between family and dog, and follows family’s lead, being their “dance partner” in the relational dance, entering into the family dynamics as they enact their truths. In the style of Minuchin & Fishman (1981): “Family members enact their dance in relation to the therapist [dog included], who is not only an observer, but also a musician and dancer himself” (p. 81).Awareness of the animal’s needs, physical, social, emotional, and of paramount importance, safety: “Companion animals are highly attuned to the family emotional climate and are very sensitive to highly charged affective states of members…” (Walsh, 2009). This can allow the family therapist a unique tool for assessing and treating families.Taking note of any suspicions of animal abuse when conducting family assessments, as the inter-relationship between domestic violence (DV) and animal cruelty is well documented. While domestic violence may enter into the themes of families seen for treatment, it is not the sole purpose of families seeking treatment at CIH. Nonetheless, safety of the therapy animal must be ensured at all times, with all clients, and especially with those screened as having histories of animal abuse.Preparing the office environment to maintain HIPAA (Health Information Portability and Accountability) privacy regulations when needing to take animal outdoors for relief. While some family members may choose to remain indoors (in inclement weather, for example) during dog walks, confidential records must remain under lock and key in therapists absence.Maintaining an expectation that outdoor walks with animal and family are not breaks from the therapeutic process, but a continuation in different environment: “The therapist must at all times stay aware of content brought up during the walk and keep the focus on the therapy process, despite the surrounding stimuli…” (Parish-Plass & Oren, 2013, p. 255)Supplies for dog are maintained in office, including training treats, comfortable bed, water bowl, toys, and cleaning supplies in the case of accidents. Also, hand sanitizer is to be made available to family members for after-session cleaning.Awareness of the safety of clients, particularly small children:Be extremely mindful of risks to infants/toddlers who may be hyperactive & frighten or cause anxiety/aggression in the animal, depending upon the temperamental characteristics of the animal used.Parent/Guardian is required to sign AAT Consent prior to treatment (Appendix A). This clarifies health, safety, training and certification of therapy animal, treating veterinarian’s contact information, with attention toward child/family’s safety, but limitations of liability of practice. Awareness of the relationship and interactions between therapist, animal, and client:This relationship can serve as a model for the parent-child relationship in the same way that IMH Specialist models parental conversation with the child(ren) during sessions, or speaks “for” the baby, in such instances where it’s critical that the parent be made aware of baby’s needs to which the parent is not attending. For example, where the therapist recognizes a child’s fear expression and need for closeness which may be missed by the parent, the IMH Specialist will be the child’s voice and express their fear and need for security in words, “Mommy, I’m scared of the big dog! I’ll feel safer if I can sit on your lap.” The relationship between therapist and animal, as viewed by the client, can serve as an example of safety, nurturance, acceptance, and love, by the therapist’s positive regard of the animal and attention to its care. Additionally, the client may see in the therapist the ability to provide positive regard for the animal in spite of its negative behaviors, and carry this positive regard to the client, if they make mistakes CITATION Sil13 \l 1033 (Silcha-Mano, 2013). Development of alternate stories for families: Zilcha-Mano (2013) writes that a therapy animal can “help facilitate processes by which change occurs through the development of a secure base for the client, which in turn helps facilitate the progress of exploring the client’s internal working models” (p. 126). This relies on the clinical expertise of the therapist to explore and process past relationships with the client, not solely on the presence of therapy dog in treatment room,In the case of a family where domestic violence is occurring, utilize the therapy animal to educate on, and reinforce the development of empathy via observation of the animal’s emotions, identification with these emotions, and the linking of emotions and experiences of both human and animal in the cycle of violence. This is particularly potent when there has been a family pet harmed by an abuser. The program at the YWCA of Greater Cincinnati, which utilizes an AAT model, has a two-fold purpose, which is to halt the cycles both of animal abuse and child abuse. “Participants unlearn negative behaviors and contribute to the prevention of future violence against animals or persons” CITATION YWC07 \l 1033 (Ventura & Booth, 2007).In addition to use of a therapy dog with the family-as-victim, it would be extremely useful to use a therapy dog with the perpetrator (in separate sessions, apart from the victims of domestic violence), in order to increase their ability to formulate empathy, as they might recall and process their own early experiences of either witnessing or committing acts of violence toward animals/humans. Facilitating the grieving process for families upon termination from treatment, or during, if the therapy animal should die prior to the realization of treatment goals. An animal allows and encourages parental figures to nurture children through both life and death, and the presence or absence of a therapy animal allows the parent to be, in Winnicott’s words, the “good-enough mother” CITATION Win53 \l 1033 (Winnicott, 1953), by attending to the emotions and needs of the child in providing a secure base and holding environment. So, too, does the therapist act as good-enough mother to the family when being required to prepare them for the therapy animal’s impending death, or critical illness.The documentation of methods, processes, outcomes for further study:The newness of the field of AAT/AAP, and particularly AAP with IMH, leaves the therapist the responsibility of insuring that either articles on the process and methodology get to publication in peer-reviewed journals, or at the very least, the work is documented with clear outcome data for further review and clarification of this model. It is important, therefore, to develop a set of questions for parent/guardians to complete post-treatment, surveying their experience with the process of AAP and attachment-based family psychotherapy. Only those families signing consents for participation in research will be included in any further studies for publication, though any family’s interventions and responses may be documented for later supervision and/or review.Client/family response to intervention used will also be recorded, separate from chart progress notes and process notes, for purpose of further supervision and/or review, and to maintain separation from chart in the unlikely event of a court subpoena.Details about specific interventions used, number, age of individual family members participating, particular specifics about dog involved, indoor/outdoor activity, etc., shall be documented.BudgetThe budget plan is being based on a part-time practice with one clinician. This practice was started in 2011 as a plan for retirement from full-time employment, with an initial goal for practice being ten clients per week. The clientele includes children, adults, and families, and therefore not all cases are those which would fit into the attachment-based family model outlined in this plan. Since startup of this practice, approximately 15 clients out of a total of 169 seen for services, or 11%, have at least one child under the age of 5. Not all of these 15, however, might be appropriate for the model outlined here. Over the past 12 months this practice had a total session count of 227. The number and ratio, involving families with a child under the age of 5, was 110, or 49% of the total treated.The costs identified in chart (Table 1) are based on the total expenses of operating the practice, and take into account some 51% of clients not included in the AAT model planned. Assuming 15 families and 20 sessions per year, and averaging $64.00 per session (insurance reimbursement rate for family session with client present), the annual revenue based on a cancellation rate of 20% would be $12,288. Using the 49% ratio of families with children under the age of 5, and operating expenses of $16,672, the annual cost of operation is $8,169. Not included in the list of expenses is the initial cost of adopting the dogs, the one-time startup costs of initial business card and brochure printing, setting up the corporation, office equipment, or the cost of existing furniture and office decor.Similar ProgramsIn spite of there being a number of outpatient therapists using AAT with individuals, children and families, this writer has not been able to find early childhood family therapists or IMH Specialists who are working with canine co-therapists using an attachment model, which makes finding research evidence for AAP with this population and model difficult. In addition, research articles generally do not include program cost or financial sustainability information. While funders would prefer to see this type of data to justify contributions, Centered Insight Healing, PLLC, as a for-profit private practice, is currently sustaining itself through client insurance claims, and private-pay clients. While the ultimate goal of this writer is the creation of a manual of specific AAP interventions for use with the early childhood population using attachment theory, a model for AAP with this population must first be outlined. Polheber & Matchock (2013) found that even short-term exposure to a non-familiar dog reduced cortisol, the stress hormone, in a laboratory setting, which speaks to the potential beneficial effects of therapist’s dog on families in an outpatient mental health office. This confirmed previous research (Allen, K. M., Blascovich, J., et al., 1991) on the beneficial effects of pet dogs mitigating stress for their owners. The authors found to be the most influential for the study of AAT or AAP with families of young children using an attachment model are Ris? VanFleet and Nancy Parish-Plass. VanFleet practices, teaches, conducts research, and publishes on AAPT (animal-assisted play therapy) and Filial Play Therapy with children. AAPT is used by VanFleet and others “as an adjunct to other therapeutic modalities such as play therapy, Filial Therapy, family therapy, parent education, and cognitive-behavioural therapy” (VanFleet, 2010). Her Playful Pooch training program for therapists integrates animal-assisted therapy and play therapy in a novel and appealing model for those treating children and families with the aid of dogs. Several goals have been identified for using AAPT with children and families, including self-efficacy, attachment and relationship enhancement, development of empathy, self-regulation, and problem-resolution (VanFleet, 2010). Nancy Parish-Plass also practices, researches, and publishes on AAT with families of young children, and includes attachment theory in her practice model. Parish-Plass specifies the multi-faceted relational philosophy of animal-assisted play pherapy (AAPT) with children being “based on emotional connection and relationship—between therapist and child, between therapist and animal, between child and animal, between animal and animal” (Parish-Plass, 2008, p. 12). This is not unlike IMH work, in which the IMH Specialist is required to be keenly aware of the multiple dyadic relationships in the room at any given time: Between therapist and mother, therapist and infant, mother and infant, therapist and mother-as-infant, and therapist and therapist-as-infant. Many professional journal articles on the topic of AAT and early childhood primarily focus on children in educational settings, and/or children diagnosed with autism. In fact, doing a literature search using psychINFO with key words mental health, early childhood, and animal assisted therapy resulted in only two peer-reviewed journal articles, one on AAT for early intervention with conduct-disordered children, the other on therapeutic horseback-riding for children with autism. Conducting a search of therapists advertising or listed in some way online, finds 2,223 Michigan-based therapists using to market their practice. Using the site’s advanced search to limit the results to only those therapists stating a specific focus on the 0-5 age group with an attachment-based treatment orientation resulted in a total of five. While animal-assisted therapy is not an option in the site’s advanced search feature, one can open each profile and discover that only two Michigan therapists, one of whom is writer, offer AAT with the 0-5 age group using an attachment-based treatment orientation. The American Association of Psychology’s therapist directory lists 13 Michigan professional psychologists, however, none identify AAT in their full profiles. is another large online therapist directory, which lists 41 Michigan therapists identifying “children” as a population category they serve, and who provide family therapy. This site offers no ability to fine-tune the advanced search for attachment-based treatment orientation or for early childhood as a popultaion category. It is unknown, therefore, whether the single resulting therapist advertising on who listed “Equine and Animal Assisted Psychotherapies” as one of their approaches to therapy works with the 0-5 population using an attachment model. These results indicate that there is, indeed, a market for AAP with the early-childhood population in Michigan, if not Nationwide.Table 2 lists some of the few programs found doing an Internet search for “animal assisted therapy programs,” and/or “animal assisted therapy practitioners.” The purpose of this search was to find a number of programs, then to limit those to ones which focused on writer’s areas of concern: family therapy, young (ages 0-5) children, attachment model, and AAT with specifically, canines. From this table, one can see that three of the six programs meet all of the criteria designed for use in the Centered Insight Healing, PLLC program, with two (highlighted) of the three funded in the same manner, by private pay clients and insurance. These are the Beech St. Program, which is a program of Ris? Van Fleet’s, and Cori Noordyk, LLMSW, who is in private practice in Michigan. What is not known by this information is which, if any, of the programs utilize a program evaluation or research component, and therefore, no program effectiveness is known. This is a component that should be put in place, if the goal of one’s work is not only to provide quality services to families, and to enhance the field of AAT, but also to expand knowledge of the efficacy of such programs. Where The Beech Street Program, Ris? Van Fleet, and Nancy Parish-Plass have succeeded, in addition to their practice of AAP/AAPT with children, is in writing, publishing, and training of others interested in or practicing AAT. Van Fleet’s Playful Pooch trainings are generally sold-out well in advance of her conferences, which are held all over the United States, and are sought-after by AAT/AAPT professionals. The Beech Street Program is an affiliate of the Family Ehancement & Play Therapy Center, Inc., which produces the professional and parent training programs on animal-assisted play therapy, filial play therapy, and research, supervision, and consultation for professionals. There is also an International Collaborative on Play Therapy, which is promoted partly through group pages. The Beech Street Program’s CITATION Abo09 \l 1033 (Van Fleet, 2009) website states, “Our goal is to ensure that our services are the highest quality possible, and this is accomplished by research, clinical supervision/consultation, & training programs.” This is a unique and creative way to promote animal-assisted therapy practice, as well as to enhance the field of AAT/AAPT. Unlike Van Fleet’s marketable approach, CIH is focusing on only direct treatment of children and families with AAT and the resultant outcome measures in order to maintain a part-time solo private practice, and to increase awareness of AAP through an eventual guide of interventions.EvaluationA quasi-experimental outcome evaluation could be feasible by comparing two groups of families, one which chooses to enroll in animal-assisted psychotherapy, and a control group of families which receives standard family therapy, but without a therapy animal. The control group families would receive the same psychotherapy services from clinician as the AAP group, just with no therapy dog interventions. In the case where the therapy dog may be in the office for other families on specific days, it could be kept in a separate room so that it would not influence on the treatment or outcomes. The difficulty with this design might be insufficient number of control group families, simply due to the low client base and part-time structure of CIH. In order to measure outcomes as occurring in the Logic Model (Figure 1), two separate measures will be utilized: The first, a standardized, norm-referenced assessment, and a parent-completed survey. The standardized measures developed by the Devereux Foundation for early childhood have been validated and reliabilty-tested as measures of protective factors in young children, ages 0-5. Devereux defines attachment as “a measure of a mutual, strong, and long-lasting relationship between a child and significant adult(s)” (LeBuffe & Naglieri, 1999, p. 26). Two separate measures which measure attachment based on child’s developmental age are needed for the 0-5 age range. The Devereux Early Childhood Assessment, Infant/Toddler (DECA-I/T) assesses attachment and initiative from 1-month to 18-months, and adds the self-regulation scale for toddlers, aged 18-months to 3 years. The DECA Preschool Program assesses attachment, self-control (vs. self-regulation, as in the DECA-I/T), and initiative for the 2- to 5-year age group. A Total Protective Factors score is also provided for each developmental age, conceptualized as a combination of attachment and initiatie scores for the 1-month to 18-month age group, and a combination of attachment, self-control, and initiative for the preschool ages, 2-5. Devereux recommends, however, administering the DECA-I/T for toddlers up to 36 months. The DECA assessment measures will be provided to representative parents or guardians of each family receiving treatment, whether in control or AAP group. Parents complete the questionnaires, and therapist scores results and collects data on pre- and post-test to compare results and identify changes in children’s social-emotional development as a result of services CITATION Fle14 \l 1033 (Fleming & LeBuff, 2014). CIH will not be computing statistical scores or significance, but will rather collect data for the purposes of identifying whether AAP treatment resulted in greater positive social-emotional—specifically on attachment scale--scores (5-7 T-Score points = medium change, >8 T-Score points = large change).The second outcome measure will be a parent-completed 20-question evaluation at completion of services. CIH will have the representative parent or guardian for each family complete an Evaluation Questionnaire (Appendix A), which asks clients to rate 19 questions about their perception of parent-child relationship and services received with AAP on a five-point Likert Scale from “strongly agree” to “strongly disagree,” and one open-ended question for other comments. Questions were specifically designed to examine parental judgement of improvement in parent-child relationship, modelling of animal-human relationship for parent-child relationship, ability of parent to assist child with managing difficult emotions, or self-regulation, and change in parental confidence. Therapist will collect and analyze results of these parent-reported values for positive or negative views of AAP.For evaluation, the DECA scores can still be used as an outcome measure for both the AAP-treatment group and the control group as a measure of attachment strength, but the parent-completed questionnaire would not be pertinent to the control group. ConclusionThere is a need and market for AAP practitioners working with the early-childhood population. The attachment model fits well with AAP, as there are numerous referenced works citing similar attachment terminology and processes for the human-animal bond, as occur within human parent-infant pairs. A methodology for outlining AAP with a canine co-therapist has been suggested. An evaluation of model effects on parent-child attachment using standardized and non-standardized tools is described. A control group of families receiving family therapy with no canine co-therapist can be included for more precise conclusions. Future goals should include publication of AAP interventions for use with families of young children, using a canine co-therapist.ReferencesAllen, K. M., Blascovich, J., & al, e. (1991). Presence of human friends and pet dogs as moderators of autonomic responses to stress in women. Journal of Personality and Social Psychology, 61(4), 582. Retrieved from Beck, A. M. (1999). Companion animals and their companions: Sharing a strategy for survival. Bulletin of Science, Technology & Society, 4, 281-85.Board of Regents of the University of Wisconsin System. (2008). Developing a logic model: Teaching and training guide.Bretherton, I., & Munholland, K.A. (1999). Internal working models revisited. In J. Cassidy & P.R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 89– 111). New York: Guilford PressFleming, J. L., & LeBuff, P. A. (2014). Measuring Outcomes with the DECA. Retrieved June 12, 2015, from Center for Resilient Children: , S., Adelson, E., & Shapiro, V. (1975, Summer). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant-mother relationships. Journal of American Academy of Child Psychiatry, 14(3), 387-421.Harrell, A., Burt, M., Hatry, H., Rossman, S., Roth, J., & Sabol, W. (n.d.). Evaluation strategies for human service programs: A guide for policymakers and providers. Washington, D.C.: The Urban Institute. Retrieved June 17, 2015, from , A. (2013, October). Creating lesson plans with intentionality. p. 2. [PowerPoint Slides]. Retrieved from , K. A., Trachtenberg, S. W., & Serpell, J. A. (2004). Can Animals Help Humans Heal? Animal-Assisted Interventions in Adolescent Mental Health. Center for the Interaction of Animals and Society. University of Pennsylvania School of Veterinary Medicine.LeBuffe, P. A., & Naglieri, J. A. (1999). Devereux early childhood assessment: technical manual. Lewisville, N.C.: Kaplan Early Learning Co.LeBuffe, P. A., & Naglieri, J. A. (2003). The Devereux Early Childhood Assessment Clinical Form (DECA-C). Lewisville, NC: Devereux Foundation.Michigan Department of Community Health. (2013). The uninsured in Michigan: A profile. National Scientific Council, Center on the Developing Child at Harvard University. (2007, January). The science of early childhood development: Closing the gap between what we know and what we do. Retrieved from Parish-Plass, N. (2008). Animal-assisted therapy with children suffering from insecure attachment due to abuse and neglect: A method to lower the risk of intergenterational transmission of abuse? Clinical Child Psychology and Psychiatry, 13(1), 7-30.Parish-Plass, N. (2013). The contribution of animal-assisted psychotherapy to the potential space in play therapy. In N. Parish-Plass (Ed.), Animal-Assisted Psychotherapy: Theory, Issues, and Practice (pp. 79-109). West Lafayette, IN: Purdue University Press.Parish-Plass, N., & Oren, D. (2013). Dilemmas, questions, and issues concerning the integration of animals into the psychotherapy setting. In N. Parish-Plass (Ed.), Animal-Assisted Psychotherapy: Theory, Issues, and Practice (pp. 245-60). West Lafayette, IN: Purdue University Press.Pet Partners. (n.d.). Animal-Assisted Therapy (AAT). Retrieved June 25, 2015, from , J., & Matchock, R. (2013). The presence of a dog attenuates cortisol and heart rate in the Trier Social Stress Test compared to human friends. J Behav Med Journal of Behavioral Medicine, 860-867.SAMHSA. (n.d.). Intervention Summary - Child-Parent Psychotherapy (CPP). Retrieved from Shapiro, V. (2009). Reflections on the work of professor Selma Fraiberg. Clinical Social Work Journal, 37(1), 45-55. doi:, S. (2013). Animal-assisted psychotherapy from an attachment perspective. In N. Parish-Plass (Ed.), Animal-Assisted Psychotherapy: Theory, Issues, and Practice (pp. 111-43). West Lafayeet, IN: Purdue University Press.Stagman, S., & Cooper, J. L. (2010, April). Children's mental health: What every policymaker should know. (J. Knitzer, & J. H. Lefkowitz, Eds.) Retrieved from National Center for Children in Poverty, Columbia University Mailman School of Public Health: Annie E. Casey Foundation. (n.d.). KIDS COUNT Data Center. Retrieved May 26, 2015, from Fleet, R. (2009). Beech Street Program About Us. Retrieved June 25, 2015, from , C., & Booth, C. O. (2007). 2006-2007: 139th Annual Report. YWCA of Greater Cincinnati.Weatherston, D., & Tableman, B. (2003). Infant Mental Health Services: Supporting Competencies/Reducing Risk (2nd Edition 2003) |. Southgate, MI: Michigan Association for Infant Mental Health.Wesley, M. C. (n.d.). The logic model in mental health program development. Lindsey Wilson College.Wilson, C., & Barker, S. (2003). Challenges in designing human-animal interaction research. The American Behavioral Scientist, 47(1), 16-28.Winnicott, D. W. (1953). Transitional objects and transitional phenomena: A study of the first not-me posession. International Journal of Psycho-Analysis, 34, 89-97.ZERO TO THREE: National Center for Infants, Toddlers and Families. (n.d.). Retrieved from BIBLIOGRAPHY \l 1033 TablesTable 1BudgetPrivate Practice CostsDescriptionPay $30.00monthly$ 360.00 BooksMiscellaneous$12.00monthly$ 150.00 Corp. filingMI LARA$50.00annual $ 50.00 Domain nameGandi$15.00annual $ 15.00 EMRTherapyNotes$65.00monthly $ 780.00 Malpractice NASW Assur. Trust$170.00annual $ 170.00 Oakland UAAT Cert Program$350.00per session (x5)$ 1,750.00 Office 365Microsoft$99.00annual $ 99.00 Office RentLinden Valley Assoc.$455.00monthly$ 5,460.00 Office SuppliesStaples, Sam's Club$prn$ 1,000.00 PhoneT-Mobile$103.00monthly$ 1,236.00 MI-AIMHMI-AIMH$190.00annual $ 40.00 ACSWNASW$220.00annual $ 220.00 Liability The Hartford$500.00annual $ 500.00 LicenseMI LARA$65.00every 3 yrs $ 21.70 Tax filingH&R Block$122.00annual $ 122.00 WebsiteMoonfruit$108annual $ 108.00Subtotal: $12,081.70Dog(s)DescriptionPay ToAmountFrequencyAnnualFoodMagoo's$1,000.00annual$ 1,000.00 GroomingGroomingdale's$115.00quarterly$ 460.00 CertificationTherapy Dogs Int'l$70.00initial$ 70.00 TDITherapy Dogs Int'l$40.00annual$ 40.00 Toys, ExtrasMisc.$10.00monthly$ 120.00 VeterinaryPierson Pet Hosp.$2,900.00annual$ 2,900.00 Subtotal:$ 4,590.00One-time, or Non-recurring feesDescriptionPay ToAmountFrequencyAnnualAdvertisingVaries$726.00Initial invest.$ 726.00DECA Kaplan$410.00Once$ 410.00Office Equip.T-Mobile$29.00Monthly $ 303.00 Set up LLCAccountant$500.00One-time $ 500.00 Subtotal: $ 1939.00Grand Total:$18,610.70Table 2Program ComparisonKey program Features Family therapy0-5Attachment modelCanineFundingNotesProgramName AAT Programs of Colorado1 Donations Non-profitAlso trains professionalsBanbury Cross2 Private pay Grants DonationsEquineBeech St. Program3 Private pay InsuranceAlso trains professionalsCori Noordyk, LLMSW4 Private pay InsuranceHuman-Animal Solutions5 Private pay InsuranceMI Community Mental Health, IMH Model MedicaidNote. 1Animal Assisted Therapy Programs of Colorado. Retrieved from . 2Banbury Cross Therapeutic Equestrian Center. Retrieved from . 2Family Enhancement and Play Therapy Center: Beech Street Program. Retrieved from . 4Cori Noordyk Therapy, LLC. Retrieved from . 5Human-Animal Solutions. Retrieved from . 25882606195060Board of Regents of the University of Wisconsin System. (2008). Developing a logic model: Teaching and training guide.Harrell, A., Burt, M., Hatry, H., Rossman, S., Roth, J., & Sabol, W. (n.d.). Evaluation strategies for human service programs: A guide for policymakers and providers. Washington, D.C.: The Urban Institute. Retrieved June 17, 2015, from , M. C. (n.d.). The logic model in mental health program development. Lindsey Wilson College.00Board of Regents of the University of Wisconsin System. (2008). Developing a logic model: Teaching and training guide.Harrell, A., Burt, M., Hatry, H., Rossman, S., Roth, J., & Sabol, W. (n.d.). Evaluation strategies for human service programs: A guide for policymakers and providers. Washington, D.C.: The Urban Institute. Retrieved June 17, 2015, from , M. C. (n.d.). The logic model in mental health program development. Lindsey Wilson College.-335533208245Figure 1Logic Model400000Figure 1Logic Model3556000216Figures00FiguresFigure 2Attachment Styles & Working Models021971000(Bretherton, & Munholland, 1999)Figure 3“Dog on Premises” Signcenter1882140005101206-528255Mildly disagreeNeither agree nor disagreeStrongly disagreeMildly agreeStrongly agreeMildly disagreeNeither agree nor disagreeStrongly disagreeMildly agreeStrongly agreeAppendix AEvaluation QuestionsConsider each of the following statements as you now complete treatment. Your answers will help toimprove the services provided at Centered Insight Healing, PLLC. Please answer honestly, using a5-point scale, on the degree to which you agree with each statement. A response of “1” equals“disagree completely,” and “5” equals “agree completely.” A response of 3 equals “neitheragree nor disagree.” The first statement is a sample. The response circled is a 2, meaning23454109172575]THANK YOU!+00]THANK YOU!+the person “mildly disagrees.” Sample Question:I had a terrible time trying to find the office the first time here.1-58420-330200023451The availability of a therapy dog was a positive influence on my decision to bring my child and family to this practice for therapy.123452We would have come here for services even if animal-assisted therapy wasn’t offered.123453Therapy has not been helpful.123454My child looks forward to coming here for therapy because of the dog.123455The relationship between humans and therapy animal served as a model for my relationship with my child.123456My child communicates with me better since we’ve been coming to therapy.123457The availability of a therapy dog helped my family to feel comfortable working on difficult issues.123458My child likely feels they were able to trust the therapy dog.123459Animal-assisted therapy helped us make the changes we hoped for.1234510I understand my child better now.1234511I’m able to read my child’s emotions better.1234512The relationship between my child and I has improved.1234513My confidence as a parent has increased.1234514I am more able to provide consistent, nurturing parenting now.1234515My child talks about the therapy dog to others outside of therapy.1234516I am better able to help my child manage difficult emotions now.1234517The therapy animal showed unconditional acceptance to my child.1234518Our family believes that teaching children about humane education is important for developing empathy.1234519I would recommend animal-assisted therapy to other families with young children.1234520Other comments?Appendix B ................
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