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The Effect of Animal-Assisted Therapy on Changes in Mood, Stress, and Resilience and their
Relationship to Fatigue and Function in Wounded Active Duty Service Members
CPT Christine Beck
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Animal assisted therapy (AAT) has steadily gained popularity among healthcare workers
and facilities as well as in the general public in both the United States and in Europe over the last
decade. The United States Military has a long history of promoting AAT with wounded
Warriors (Bustad, 1980; Velde, Cipriani, & Fisher, 2005). Despite the numerous anecdotal
reports, documented research by professionally trained clinicians on the effectiveness of AAT
with this unique population is non-existent. The purpose of this study was to improve the
successful reintegration of warriors in transition (WTs) by evaluating the effects of an
occupational therapy intervention with and without AAT.
Literature Review
Animal Assisted Therapy
The Delta Society, a well-recognized leader and research sponsor for AAT, defines the
treatment as ³a goal-directed intervention 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 (Delta Society, 2010a). Boris Levinston is often referred to as the ³father of AAT´
because he is the first professionally trained clinician to document his observations of the use of
a dog during treatment sessions with patients(Hooker, Holbrook Freeman, & Stewart, 2002).
This work was the starting point for clinical research that started in the 1960s and has grown in
popularity ever since. Although he is considered the ³father,´ the history of AAT dates back to
1792 in England and 1867 in Germany (Bustad, 1980).
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literature is the lack of methodologically sound studies. The majority of studies are case report.
In order for AAT to become a respected and valid intervention, more methodologically
soundefficactiveness studies must be completed using experimentaldesigns (Arkow, 2004;
Gammonley et al., 2003). In addition to methodologically flawed studies, some of the most
commonly cited limitations of AAT include its cost, risk of injury (e.g., through bites) and the
possibility of it being ill-suited to particular client populations, such as those who dislike or fear
animals or those for whom cultural factors restrict their ability to have contact with animals
(Brodie et al., 2002).
In the 1970s, Dr. Levinston continued his work and was joined by many more clinicians
who believed in the therapeutic benefits of animals. Psychiatrist Dr. Michael McCulloch began
³prescribing´ pets as a therapeutic option for his patients to improve quality of life. Dr. Leo
Bustad, the dean of the College of Veterinary Medicine at Washington State University,
developed (AAT) programs at Pullman Memorial Hospital and Tacoma Lutheran Nursing
Home. Psychiatrist Dr. Dean Katcher and a team of researchers at the University of
Pennsylvania began studying the effects of animals on human health and wellbeing (Morrison,
2007).
In 1980, Mculloch, Bustad and Katcher joined together to form an organization known
today as the Delta Society (Morrison, 2007). The Delta Society has grown considerably over the
last 30 years and is considered one of the most respected and well-known organizations in the
area of AAT. They sponsor research, develop guidelines, and have developed the Pet Partners®
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The 1990s continued the upward trend of public interest and research on the topic of
AAT. In 1990, Dr. William Thomas developed an innovative therapeutic environment, called
the Eden Alternative, which sought to assimilate the natural world, including animals, into long-
term care (Hooker et al, 2002). After the September 11th attacks, therapy dog teams volunteered
counseling services through the American Red Cross to those who had lost loved ones or been
injured themselves (Teal, 2002).
Barker (2002) examined whether a session of AAT would decrease levels of anxiety with
patients diagnosed with anxiety disorders. The results showed that there were statistically
significant reductions in anxiety scores after AAT sessions with those with psychotic disorders,
and mood disorders. Berget, Ekeberg, and Braastad (2008) analyzed the effects on AAT with
farm animals on persons with psychiatric disorders such as schizophrenia, personality, and
anxiety disorders. They found that subjects demonstrated increased skills in interactions with
other humans after receiving AAT.
The preferred choice of mammal used in AAT is the canine. This is because canines are
very social, dependent, and trainable creatures (Velde, Cipriani, & Fisher, 2005; Arkow, 2004).
Dogs should be ³alert, bright, happy, and healthy, playful without being too rowdy« even-
tempered, good-natured, and willing to withstand travel and environmental stress´ (Arkow, p.
73).
AAT in the United States Military
The United States Military contributed to AAT¶srich history by promoting the therapeutic
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recovering from operational fatigue at the United States Army Air Corps Convalescent Hospital
in Pawling, New York. Patients worked with farm animals as part of their therapy(Bustad, p.
118-119, 1980). More recently, AAT dogs have been deployed with U. S. Army occupational
therapists as part of Combat Stress Control (CSC) units in Iraq and Afghanistan. The mission of
the CSC unit is to prevent and behavioral health issues while in theatre.
Occupaitonal Therapy at the WTB
Occupational therapy practitioners are members of an interdisciplinary team that work
with Soldiers assigned to the WTBs across the Army. They work with the Soldiers on stress
management, addressing goals, communication skills, conflict resolution, and other life skills
that will foster a successful transition either back to active duty or with their return to civilian life
(Erikson,Seacrest, & Gray, 2008). At the WTB on Fort Sam Houston, TX, the occupational
therapy department conducts training in the Warrior in Transition Advancement Program
(WiNTAP). This is a mandatory program for all Soldiers who are assigned to the WTB. It
includes psychoeducational groups that focus on goal setting, stress management, sleep hygiene
and communication. The occupational therapists also identify needs that the Soldiers have and
aid them in obtaining the resources to meet those needs.
For the many Soldiers assigned to the WTB, the transition goes beyond preparing to
transition back to their units or civilian life. They may still be in the ³transition/readjustment´
time frame from being deployed to a combat zone. Hoge (2010) says that this
³transition/readjustment´ time frame is ill-defined and full of hazards. He estimates that this
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hundreds, if not thousands, of miles away from their families, their organic units, from everyone
who normally could be there to help with this ³transition/readjustment´ back from combat.
For Soldiers at the WTB who are there for reasons other than a combat related injury, the
stress from ³transition/adjustment´ back from combat can be substituted by feelings of guilt that
they are receiving treatment alongside those who were wounded in the combat zone. One
Soldier in the study said that being at the WTB adds stress on a daily basis because he feels
³unworthy´ because he is there because of a cardiac condition.
Research Design
This study was quasi-experimental, using a pre-test post-test control group, without
randomization, (2 X 3 mixed model, repeated measures ANOVA) with two group levels
(standard of care and standard of care plus AAT).
Participants
Warriors in Transition (WTs) who were referred for the WInTAP program were screened
by the occupational therapy staff at the WTB. Upon meeting the inclusion and exclusion criteria,
the WT was provided a flyer regarding the study. Inclusion criteria was that the participants be a
United States service member assigned or attached to the Brooke Army medical Center Warrior
Transition Battalion (WTB) and be at least 18 years of age. Participants were excluded from the
if they were: (1) unable to understand verbal and written English, (2) pregnant, (3) known allergy
to dogs, (4) open wounds, (5) previous or concurrent participation in the Cognitive Behavioral
Education Strategies (CBESt) program, (6) Concurrent participation in the Army Center for
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daily interaction with their own dog. A total of 24 Soldiers currently on active duty in the Army
participated in this study. See Table 1 for demographic information.
Procedure
After approval by the Institutional Review Board at Brooke Army Medical Center at Fort
Sam Houston, TX, eligible participants were screened by the occupational therapy staff of the
Warrior Transition Battalion.Potential participants were then referred to the research team. This
was followed by a phone call from the research team to schedule a face to face meeting for
further explanation of the study purpose and procedures. The Soldiers who agreed to participate
were provided with baseline assessments. Control group participants were recruited from the
WInTAP group sessions. The group was given a 2-3 minute introduction to the study and those
who were interested stayed after the class to fill out the baseline assessments. Investigators also
obtained a written informed consent, signed authorization to use protected health information
(PHI) for research purposes that meets HIPAA requirements from all participants in both groups.
At baseline, post-intervention, and at the one month follow-up, the following assessment
tools were administered: the Functional Status Questionnaire (FSQ), the Profile of Mood States
(POMS), the Occupational Self-Assessment (OSA), Perceived Stress Scale (PSS) and the
Connor Davidson ResilienceScale (CD-RISC). Participants were offered the choice of self-
administration or administration by the PI/AI if a disability was present that prevented them from
being able to complete the forms themselves. Assessments were conducted in a private area and
participants were encouraged to ask if they required explanation.
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Rubenstein, & Fink, 1986). It is divided into five main sections: physical function of the
activities of daily living, psychological function, role function, social function, and a variety of
performance measures. The ADL subscale consists of questions about activities such as
dressing, bathing, transfers, and mobility. The IADL subscale covers activities such as shopping,
using public transportation, and maintaining a household. The social activity subscale is related
to social interaction such as the one's ability to visit with family and friends. The FSQ has been
shown to exhibit construct and convergent validity by comparison to health status measures such
as reported bed disability days and restricted activity days (Brach VanSwearingen, FitzGerald,
Storti, &Kriska, 2004; Reuben, Valle, Hays &Siu, 1995). This measure takes approximately 5
minutes to complete.
Perceived Stress Scale (PSS). The PSS"measures the degree to which situations in one's
life are appraised as stressful" (Cohen, Kamarck, &Mermelstein, 1983, p. 385). The PSS was
used to assess the perception of stress among the participants. This scale consists of fourteen
questions that ask about participants¶ feelings related to general stress within the past
month.Participants responded to the questions using a 5-point Likert scale with answers ranging
from0 (never) to 4 (very often). After the PSS was completed, a total stress score was calculated
forthe individual students with reverse coding of seven items in the scale. The PSS has been
foundto be reliable (.85) in college and community samples (Cohen et al., 1983). This measure
takes approximately 2 minutes to complete.
Profile of Mood States (POMS). The POMS as used to measure the mood state of the
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Vigor-Activity,Fatigue-Inertia, and Confusion-Bewilderment. A high total score indicates mood
disturbance and high subscale scores for tension, anger, fatigue, depression, and confusion
indicate disturbance in each respective domain. The subscale score for vigor is subtracted from
the total because of the positive nature of that domain.
Internal consistency has been reported for all items as above 0.90 with test-retest
reliability ranging between 0.65 for Vigor and 0.74 forDepression (McNair, Lorr, &Droppleman,
1971). The POMS has been used with a wide variety of health states to assess mood state
(Curran, Andrykowski, &Studts, 1995). This measure takes approximately 9 minutes to
complete.
Connor-Davidson Resilience Scale (CD-RISC). The CD-RISC is made up of 25 items
and assesses resilience and is rated based on the participant¶s feelings during thepast month.
Scales are scored by summing the total of each item. All items carry a 5-point range of
responses, from 0 = ³not true all the time´ to 4 = ³true nearly all the t ime´. The total score can
range from 0 to 100, and higher scores indicate greater resiliency. The CD-RISC claims to
(Connor & Davidson, 2003).
Internal consistency ( coefficient) was .89 (Connor and Davidson, 2003). Item
correlations ranged from .30 to .70 (Connor and Davidson). Test-retest reliability, assessed in 24
individuals, was .87 (Connor and Davidson). CD-RISC scores were positively correlated with
Kobasa hardiness (n = 30, r = .83, p <.001), and it was also negatively correlated with the
perceived stress scale (n= 24, r = -0.76, p <.001). Campbell-Sills and Stein (2007) also
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psychometric properties and allows for efficientmeasurement of resilience´ (p. 1019). This
measure takes approximately 5 minutes to complete.
The Occupational Self Assessment (OSA). The OSA (Baron, Kielhofner, Iyenger,
Goldhammer, &Wolinski, 2001) is an assessment tool and outcome measure is based on the
Model of Human Occupation. It is a client centered measure that uses self-report from asked the
participants to rate their functioning as well as the impact of the environment on their
functioning. It is a series of statements to which the client indicates how well they do the activity
4-point Likert-type scale (1=lot of problem to 4=extremely well) and its importance to them
(1=not so important to 4=most important. The competence scale was used in this study.
Rasch analysis determined that there were no items misfits on the competence scale
which reveals good construct validity (Kielhofner& Forsyth, 2001). It was also found to be
useful in a consistent manner by 90% of the participants with a wide range of disabilities on a
more recentRasch analysis (Kielhofner, Forsyth, Kramer, Iyenger, 2009). This measure takes
approximately 7 minutes to complete.
Fatigue Scale. The Fatigue Scale is an 11 point numeric measure where 0= no fatigue
and 10 = worst fatigue imaginable. A linear numeric scale is considered to be an acceptable
method for measuring a unidimensional characteristic (Portney& Watkins, 2007). This measure
takes less than 1 minute to complete.
Intervention
Both the experimental group and the control group received ³treatment as usual´ which
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minute semi-structured interaction with a pet team. The majority of the pet teams in this study
are Pet Partners®.
The experimental group also received AAT for 30 minutes after each Life Skills class
session. Theyworked 1:1 with the dog and dog handler. The intervention consisted of the
handler instructing the participant how to administer a simple command such as sit, stay, lay
down, roll over, or fetch. After the participant was successful with administeringfive commands
with the dog, the remainder of the 30 minutes was spent engaging in activities of the participants
choice. Activities included going for a walk on the grounds of the Warrior Family Support
Center, sitting quietly and petting the dog, brushing the dog, and teaching the dog new tricks.
Data Analysis
Prior to the analyses, assumptions of normality and linearity were evaluated and data
from the experimental group was screened for outliers. Measures of central tendency were used
to describe the data. Independent samples t -test and chi-square analyses were performed to
examine demographic differences between the two groups.
Using the Friedman¶s ANOVA test for µmood,¶ µresilience,¶ and µstress¶, the group of
within subject scores was compared to each other at baseline, post-intervention, and follow-up
using a 0.05 significance level. The Friedman¶s was used to analyze these sets of data because
the assumption of normality could not be verifiedand the sample size for each group was small
(Elliott & Woodward, 2007). Assumption of sphericity was checked using Mauchly¶s test. Due
to the lack of significant overall test results, follow-up pairwise comparisons were not
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All data were entered into SPSS v. 16 and were validated for accuracy by a second
research team member.
Demographics
Results showed that the experimental and control groups did not differ significantly in
chronological age, rank, number of deployments, sex or primary diagnosis (See Table 1).
Changes in Mood, Resilience, and Stress ± Experimental Group
The Friedman¶s test was run to compare score rankings on the PSS and CDRISC. The
PSS resulted in a chi-square value of 2.33 and a p-value of .311 indicating that there was no
statistically significant difference in rankings. The CDRSC resulted in a chi-square value of
2.263 and a p-value of .323, which also indicates a lack of statistical significance. The data
shown in Table 2 compares the µmood¶, µresilience¶, and µstress¶ scores at baseline, post-
intervention, and at follow-up for the experimental group.The POMS resulted in a chi-square
value of XXX and a p-alue of XXX
Relationship Between Mood and areas of Function and Fatigue ± Experimental Group
At baseline, Spearman¶s rho identified that the strongest significant relationship between
these variables was a correlation between µmood¶ scores on the POMS and psychological
µfunction¶ scores on the FSQ (rho = .-917, p =.01). Correlations between µmood¶ on the POMS
and µfunction¶ on the Competence scale on the OSA (rho =.-760, p =.01). Nonparametric
correlations also identified moderate to good positive correlations between µmood¶ on the POMS
and µfatigue¶ on the Fatigue Scale (rho = .596, p =.05) and µmood¶ on the POMS and the quality
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.-882, p =.01). It also identified moderate negative correlation between µmood¶ scores on the
POMS and psychological µfunction¶ scores on the FSQ (rho =.-657, p =.05).
At follow-up, the only association that was found to be significant was between the
µmood¶ scores on the POMS and µfunction¶ on the Competence scale of the OSA (rho= .772,
p=.05).
Relationship Between Resilience and areas of Function and Fatigue ± Experimental Group
Spearman¶s rho found significant correlations between µresilience¶ scores on the CD-
RISCand µfunction¶ on the Competence scale of the OSA at baseline (rho= .735, p =.01), at post-
intervention (rho=.961, p=.01), and at follow-up assessments (rho=.845, p=.01). The only other
significant correlation between µresilience¶ was a correlation found between µresilience¶ on the
CD-RISC and psychological µfunction¶ scores on the FSQ (rho=.755, p=.01) at the post-
intervention assessment.
Relationship Between Stress and areas of Function and Fatigue ± Experimental Group
At baseline, Spearman¶s rho found a moderate to good positive correlation between
µstress¶ on the PSS and the level of µfatigue¶ on the Fatigue Assessment (rho=.624, p=.01). A
correlation was also found between µstress¶ and the quality of interaction area of µfunction¶ of the
FSQ (rho=.691, p<.05). At baseline and at post intervention, correlations were found between
µstress¶ on the PSS and µfunction¶ on the Competence scale of the OSA (rho= -.717, p =.01;
rho=-.619, p=.05) and psychological µfunction¶ on the FSQ (rho= .833, p=.01; rho=849, p=.01).
Correlations between the µmood¶ variable and the variables of µfunction¶ and µfatigue¶
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scores on the POMS and µfunction¶ on the Competence scale of the OSA as well as between
µresilience¶ scores on the CD-RISC and µfunction¶ on the Competence scale of the OSA.
Discussion
Analysis of the data suggests that as mood improved, so did the participants
psychological µfunction¶ such as less feelings of depression and anxiety, suggesting that the
better mood the participant was in, the better perceived ability to sustain a pattern of
occupational behavior which is productive and satisfying.
The µfatigue¶ correlation indicates that the higher the mood dysfunction, the more
fatigued the participant was. The unexpected correlation between µmood¶ and social interaction
µfunction¶ may suggest that they are reaching out when they are in need of help to family
members, peers, professionals, or cadre or possibly due to the nature of being a Soldier in the
WTB, they are required to interact with these people on a daily basis as part of their recovery and
do not have the option to isolate themselves.As the correlations between resilience and areas of
function and fatigue demonstrate a good to excellent relationship at all three assessments, it is
safe to assume that the more resilient the participant scored, the higher their level of occupational
performance, regardless of the other variables.
The correlations between µstress¶ and areas of µfunction¶ and µfatigue¶ indicate that as
their levels of stress moved up or down, so did their level of occupational performance and
psychological function at baseline and post-intervention.
The Soldiers in the WTB report that they are ³constantly´ asked to fill out surveys that
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the Soldiers in the study. They are mandated by their chain of command that they fill them out
and some admitted to not reading the questions and just circling numbers because they had to.
Annoyance was expressed by at least 3 of the participants of having to fill out 29 minutes worth
of surveys as part of the study. Also worth noting is that atthe follow-up, 3 participants
verbalized having ³bad weeks´ when the team member simply said ³hi, how are you doing´ as a
greeting, which may have influenced their scores.
Limitations
The small number of participants (n=24) was lower than what was needed to detect
significant differences between the groups. This study also relied solely on self-reported
ratingscales which raise the issue of the participants accurately and honestly reporting their
levels of mood, resilience, and stress. Another limitation may be that the measures were given
too long after the interventions actually took place. Had they been given immediately after, a
statistically significant improvement may have been. If there were improvements,they may
haveimmediate and not strong enough to overcome the other day to day stressors in the
participants life between the intervention and the time the post-intervention and follow-up
assessments were given.
Recommendations for future studies
y Although experimental research designs seem to have the most merit and are
considered the gold standard for scientific research (Portney& Watkins, 2007),
qualitative research methods may be more appropriate to assess and gather
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y Assess immediate effects of receiving the AAT and benefits of providing ³in the
moment´ relief of their stress by engaging in the occupation of interacting with a
dog.
Conclusion
The use of AAT with the military population is in need of continued study. The
incidental qualitative input that was provided by the participants during and immediately after
the interventions lead the investigators to believe that, although not statistically significant
changes were seen in this study, there were ³in the moment´ benefits to the participants engaging
in the AAT sessions.
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Table 1 Demographic Data
AAT GR O
UPn=12
CONTR
OL GR
OUPn=12
Age in years (Avg / SD) 37.08 / 11.79 35.5 / 9.19
Male 10 7
Female 2 5
Military Status
AD 8 7
RC 4 5Grade
Officer 2 3
Enlisted 10 9
Months in service
(Avg/ SD)124.08 / 107.05 118.5 / 80.849
Number of Deployments
1 6 52 6 4
>2 0 3
Aggregate Months Deployed
(Avg / SD)16.42 / 7.513 16.71 / 8.703
Previous Dog Ownership
Yes 9 10 No 3 2
Negative Experience with
Dog
Yes 1 2 No 11 10
Current Dog OwnershipYes 1 3
No 11 8
Primary Medical Condition
Behavioral Health 3 0Orthopedic 5 8
Other 4 4
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Table 2 Repeated-Measures Analysis of Variance
Mean Std. Deviation Ranks
PSS* x2(3)=2.333;Sig.=.311
Baseline 15.00 7.443 1.68
Post-Intervention 15.55 8.847 2.0
Follow-Up 20.27 3.259 2.32
CD-RISC*
x2(3)=2.263; Sig.=.323
Baseline 73.30 14.795 1.65
Post-Intervention 77.70 15.748 2.3
Follow-Up 77.50 14.909 2.0
POMS*
x2(3)=XXX; Sig.=.XXX
Baseline 52.45 8.937 1
Post-Intervention 52.27 9.067 2
Follow-Up 52.27 9.981 3
*df = 2
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Table 3.1 Baseline Correlations
*Correlation is significant at the 0.01 level (2-tailed); **Correlation is significant at the 0.05 level (2-tailed)
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Table 3.2 Post-Intervention Correlations
*Correlation is significant at the 0.01 level (2-tailed); **Correlation is significant at the 0.05 level (2-tailed)
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Table 3.3 Follow-Up correlations
*Correlation is significant at the 0.01 level (2-tailed); **Correlation is significant at the 0.05 level (2-tailed)
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