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AnimalAssistedTherapy USEAPPLICATIONBY CONDITION Editedby
ERICALTSCHULER DepartmentofPhysicalMedicineandRehabilitation, MetropolitanHospital,NewYork,NY,UnitedStates; DepartmentofRehabilitationMedicine,NewYork MedicalCollege,Valhalla,NY,UnitedStates
AcademicPressisanimprintofElsevier
125LondonWall,LondonEC2Y5AS,UnitedKingdom 525BStreet,Suite1650,SanDiego,CA92101,UnitedStates 50HampshireStreet,5thFloor,Cambridge,MA02139,UnitedStates TheBoulevard,LangfordLane,Kidlington,OxfordOX51GB,UnitedKingdom
Copyright © 2023ElsevierInc.Allrightsreserved.
Nopartofthispublicationmaybereproducedortransmittedinanyformorbyany means,electronicormechanical,includingphotocopying,recording,oranyinformation storageandretrievalsystem,withoutpermissioninwritingfromthepublisher.Details onhowtoseekpermission,furtherinformationaboutthePublisher’spermissions policiesandourarrangementswithorganizationssuchastheCopyrightClearance CenterandtheCopyrightLicensingAgency,canbefoundatourwebsite: www.elsevier. com/permissions.
Thisbookandtheindividualcontributionscontainedinitareprotectedunder copyrightbythePublisher(otherthanasmaybenotedherein).
Notices Knowledgeandbestpracticeinthis fieldareconstantlychanging.Asnewresearch andexperiencebroadenourunderstanding,changesinresearchmethods,professional practices,ormedicaltreatmentmaybecomenecessary.
Practitionersandresearchersmustalwaysrelyontheirownexperienceandknowledge inevaluatingandusinganyinformation,methods,compounds,orexperiments describedherein.Inusingsuchinformationormethodstheyshouldbemindfulof theirownsafetyandthesafetyofothers,includingpartiesforwhomtheyhavea professionalresponsibility.
Tothefullestextentofthelaw,neitherthePublishernortheauthors,contributors,or editors,assumeanyliabilityforanyinjuryand/ordamagetopersonsorpropertyasa matterofproductsliability,negligenceorotherwise,orfromanyuseoroperationof anymethods,products,instructions,orideascontainedinthematerialherein.
ISBN:978-0-323-98815-5
ForinformationonallAcademicPresspublicationsvisitour websiteat https://www.elsevier.com/books-and-journals
Publisher: StacyMasucci
AcquisitionsEditor: NikkiP.Levy
EditorialProjectManager: AnnaValutkevich
ProductionProjectManager: NiranjanBhaskaran
CoverDesigner: MarkRogers
TypesetbyTNQTechnologies
Dedication Wededicatethebooktoourheroesandheroines,theunseenheroesand heroineswho fightPTSDonadailybasisandtotheextraordinaryservice animalsthathelptheseheroesandheroinesstayhealthy.
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RomeoandJuliet (1597Quarto),ActI,Scene4
Andthendreamesheofcuttingforrainethroats, Ofbreachesambuscados,countermines, Ofhealthes fiuefadomedeepe,andthenanon Drumsinhiseare: atwhichhestartesandwakes, AndswearesaPraierortwoandsleepesagaine.
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Listofcontributorsxv Acknowledgmentsxvii
SECTION1Introduction
1.Introductionandsynopsisofchapters3
EricAltschuler
References7
2.Historyofanimal-assistedtherapy(AAT)andtheoriesof mechanismofactionofAATforposttraumaticstressdisorder (PTSD)9
EricAltschuler References14
3.Incorporatinganimal-assistedtherapyintotreatmentfor posttraumaticstressdisorder17
CarinM.Lefkowitz Introduction17
Thebenefitsofanimal-assistedtherapyforsurvivorsoftrauma18
Thestateoftheresearch20
Abriefsummaryofevidence-basedpsychotherapiesforPTSD22
ModelsforincorporatingAATintoevidence-basedpsychotherapiesforPTSD23 Caseexamples27
PhilandFonzie:thedogthataidedexposuretherapy27 Conclusions30 References30
4.Posttraumaticstressdisorderinhistory,literature,andart33
EricAltschuler
References40
SECTION2ApplicationsofAAT 5.Theuseofservicedogsformilitaryveteranswith posttraumaticstressdisorder45
JamesWhitworth
Introduction45
DescriptionofservicedogsforveteranswithPTSD46
ServicedogtrainingprogramsforveteranswithPTSD47
Currentguidelinesforselectingandpairingservicedogsforveterans49
ReportedbenefitsofservicedogsforveteranswithPTSD50
Mentalhealthbenefits51
Improvementsinrelational/social/occupationalfunctioning54
Physical/medicalimpacts54
ImpactsofservicedogsonfamilymembersofveteranswithPTSD55
USDepartmentofVeteransAffairsstudyofservicedogsforveteranswithPTSD56
ChallengesinstudyingtheuseofservicedogsforveteranswithPTSD56
Theoreticalunderpinningsofservicedogprograms58
Conclusion59 References60
6.Equine-assistedtherapyforveteranswithPTSD65
DianeScotland-Coogan
Introduction65
Militarycultureandtreatment66
Posttraumaticstressdisorder66
Experientiallearning72
Ethicalpractices73
Equinetherapywithveterans73
Familyconsiderations74
Substanceabusedisorderandequinetherapy76
Whatdoesthismeanforveterans?76
Independenceandself-mastery77
Focus,concentration,andmemory77
Relationships78
Anxiety,depression,andanger78 References78
7.Avian-assistedtherapyforposttraumaticstressdisorder85 GregPara
Whyparrots?86
Mystory88
Hownewisaviantherapy?91
Establishinganaviantherapyprogram92
Creatinganavianenvironment93
References95
8.Animal-assistedtherapyforposttraumaticstressdisorder insexualtraumasurvivors97 SimoneSwartzentuberEmmons
Personalstory97
Benefitsofservicedogsforsurvivorsofsexualassaultdiagnosed withPTSD102
Howtoapproachasurvivorofsexualassaultandservicedogteamin amedicalsetting?107
ServiceDogStrongorganization111
Potentialdrawbackstohavingaservicedog115
Conclusion116
References117
9.Animal-assistedtherapyforpediatricpatients119 BethL.Macauley Dogs120 Horses129 Otheranimals135 Conclusion137 References137
10.Animal-assistedtherapyforcardiacconditions147 SamiV.Abate
Prevalenceofheartdiseaseandheartfailure147
Heartfailurepathophysiologyandmanagement147
Animal-assistedinterventionsandcardiacoutcomes148
Animal-assistedinterventionsandheartratemodulation149
Animal-assistedinterventionsandstressmitigation151
Animal-assistedinterventionsandphysicalactivity153
Exemplar:theapplicationofanimal-assistedinterventionsinheartfailure155
Animal-assistedinterventionsandcardiacoutcomesinuniquepopulations158
Lookingbackandforward:theheartofanimal-assistedinterventions159 References161
11.Animal-assistedtherapyingeriatricpatients165 DominicM.DeMarco,KalaChinnaswamyandGeorgeT.Grossberg References168
SECTION3Animaltrainers’ andpatientperspectives
12.Canine-assistedtherapyforposttraumaticstressdisorder inwarveterans:perspectiveofananimaltrainingorganization173 JessicaNelson
Mission,structure,andoverviewofPawsforHeroes173 PawsforHeroesveteranclients174 Applicationprocess176
Ineligibleveterans177
In-personinterviewmeeting177 Serviceanimalsversuscompanionanimals178 Thelegaldifferencebetweenaserviceanimalandacompanionanimal179 In-homeevaluation181
PawsforHeroes’ dogevaluationandplacementprocess181 Assessmentprocess181 Veterinarianwellnessexam187 Fosterprocess188
Providingprofessionaldogtraining188 Presentingthedogtotheveteran188
Providingadditionaltrainingtotheveteranandtheiremotionalsupportdog189 “After-care” financialsupport189 References190
13.Animalwelfare191 ChalotteGlintborg Introduction191 Mentalillnessandanimal-assistedinterventions192 Trainingmethodsandlinkbetweenanimalabuseandviolencetowardhumans195
14.Canine-assistedtherapyforposttraumaticstressdisorder:awar veteran’sperspective215 PawsforHeroesClient-ArmyVeteran
SECTION4Conclusion
15.Conclusionandfuturestudiesandapplicationsof animal-assistedtherapy221 EricAltschuler
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Listofcontributors SamiV.Abate
InspiraHealth,AVPClinicalResearchandNursingExcellence,Vineland,NJ,United States
EricAltschuler
DepartmentofPhysicalMedicineandRehabilitation,MetropolitanHospital,NewYork, NY,UnitedStates;DepartmentofRehabilitationMedicine,NewYorkMedicalCollege, Valhalla,NY,UnitedStates
KalaChinnaswamy
SaintLouisUniversitySchoolofMedicine,DepartmentofPsychiatryandBehavioral Neuroscience,SaintLouis,MO,UnitedStates
DominicM.DeMarco
SaintLouisUniversitySchoolofMedicine,DepartmentofPsychiatryandBehavioral Neuroscience,SaintLouis,MO,UnitedStates
SimoneSwartzentuberEmmons
ServiceDogStrong,Portland,ME,UnitedStates
ChalotteGlintborg
AalborgUniversity,DepartmentofCommunicationandPsychology,Aalborg,Denmark
GeorgeT.Grossberg
SaintLouisUniversitySchoolofMedicine,DivisionofGeriatricPsychiatry,Department ofPsychiatryandBehavioralNeuroscience,SaintLouis,MO,UnitedStates
CarinM.Lefkowitz
PrivatePractice,Philadelphia,PA,UnitedStates
BethL.Macauley
DepartmentofCommunicationSciencesandDisorders,GrandValleyStateUniversity, GrandRapids,MI,UnitedStates
JessicaNelson
PawsforHeroes,Houston,TX,UnitedStates
GregPara
SarasotaParrotConservatory,Myakka,FL,UnitedStates
PawsforHeroesClient-ArmyVeteran Houston,TX,UnitedStates
DianeScotland-Coogan SchoolofEducationandSocialServices,SaintLeoUniversity,SaintLeo,FL,United States
JamesWhitworth UniversityofCentralFlorida,Orlando,FL,UnitedStates
Acknowledgments ThankstoAnnaValutkevichfromElsevierforsuggestingwritinga comprehensivevolumeonanimal-assistedtherapyandtoKyleGraveland therestoftheeditorialandproductionteamsfromElsevierforhelping bringAnna’sideatofruition.Theoldsayingisthatthesecrettobeingseen asagoodbookeditoristohavegoodchapterauthors.Iamfortunateto havechapterauthorswhomakemelooklikeagreateditor.Iespecially appreciatethatallofthechapterauthorsarenotonlyscholarsintheir respective fieldsanddisciplines,butalsofront-linepractitionersofthesame. IthankSheilaBrodyandDr.HillelSwillerforhelpfuldiscussions.
EricLAltschuler,MD,PhD
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SECTION1 Introduction Thispageintentionallyleftblank
CHAPTER1 Introductionandsynopsisof chapters EricAltschuler1, 2
1DepartmentofPhysicalMedicineandRehabilitation,MetropolitanHospital,NewYork,NY,United States; 2DepartmentofRehabilitationMedicine,NewYorkMedicalCollege,Valhalla,NY,United States
Posttraumaticstressdisorder(PTSD,see Table1.1 fordiagnosticcriteriafor PTSD)canfollowwartrauma,sexualabuse,orothertraumas(Bissonetal., 2015; Shalevetal.,2017).PTSDsymptomscanalsobeexperiencedby caregiversofindividualswithPTSD(Clawsonetal.,2013),andeven militarycommanderscanexperiencewithPTSDresponsesregarding traumaexperiencedbytheirsubordinates(Altschuler,2016).Medications andcounselingareoftennoteffectiveintreatingPTSD(Shalevetal.,2017; Raskindetal.,2018),sonewtreatmentsareneeded.Someyearsago,I suggested(Altschuler,1999)thatanimal-assistedtherapy(AAT)mightbe beneficialforPTSD.Sincethen,useofAATforPTSDhasgrown dramaticallyandisnowusedworldwide.
Inthisbook,expertsintheirrespective fields,allofwhomarealso practitioners, firstdiscussandthenreviewthetheoreticalbasisandincorporationofAATinthetreatmentofPTSD.Thebookincludesachapter onPTSDinhistory,literature,andart,whichisfollowedbychapters outliningtheevidencefortheuseofcanineandequine-assistedtherapyfor PTSDandachapterontheuseofavian-assistedtherapyforindividualswith PTSD.SubsequentchaptersaddresstheuseandimplementationofAAT forPTSDinsexualtraumasurvivors,anduseofAATinpediatric,geriatric, andheartfailurepatients.Finally,theprocessofsettingupanorganization toprovideemotionalsupportcaninesiscoveredalongwithareviewofthe importantissueofanimalwelfare.Thebookconcludeswiththepowerful narrativeofawarveteran’sbenefitfromAATandareturninlightofthisto asoliloquyfromShakespeare’sHenryIV,Part1.
Followingthisintroductionandsynopsis,in Chapter2,Ireviewthe historyofAATanditsusetotreatPTSDanddiscusssometheoriesonthe mechanismofAATinPTSD.
Table1.1 Diagnosticcriteriaforposttraumaticstressdisorder.
Note:Thefollowingcriteriaapplytoadults,adolescents,andchildrenolder thansixyears.Forchildrensixyearsandyounger,seecorrespondingcriteria below.
A. Exposuretoactualorthreateneddeath,seriousinjury,orsexualviolence inone(ormore)ofthefollowingways:
1. Directlyexperiencingthetraumaticevent(s).
2. Witnessing,inperson,theevent(s)asitoccurredtoothers.
3. Learningthatthetraumaticevent(s)occurredtoaclosefamily memberorclosefriend.Incasesofactualorthreateneddeathofa familymemberorfriend,theevent(s)musthavebeenviolentor accidental.
4. Experiencingrepeatedorextremeexposuretoaversivedetailsofthe traumaticevent(s)(e.g., firstresponderscollectinghumanremains; policeoffi cersrepeatedlyexposedtodetailsofchildabuse).
Note: CriterionA4doesnotapplytoexposurethroughelectronicmedia, television,movies,orpictures,unlessthisexposureisworkrelated.
B. Presenceofone(ormore)ofthefollowingintrusionsymptomsassociated withthetraumaticevent(s),beginningafterthetraumaticevent(s) occurred:
1. Recurrent,involuntary,andintrusivedistressingmemoriesofthe traumaticevent(s).
Note: Inchildrenolderthansixyears,repetitiveplaymayoccurinwhich themesoraspectsofthetraumaticevent(s)areexpressed.
2. Recurrentdistressingdreamsinwhichthecontentand/oraffectofthe dreamarerelatedtothetraumaticevent(s).
Note: Inchildren,theremaybefrighteningdreamswithoutrecognizable content.
3. Dissociativereactions(e.g., flashbacks)inwhichtheindividualfeelsor actsasifthetraumaticevent(s)wererecurring.(Suchreactionsmay occuronacontinuum,withthemostextremeexpressionbeinga completelossofawarenessofpresentsurroundings).
Note: Inchildren,trauma-specificreenactmentmayoccurinplay.
4. Intenseorprolongedpsychologicaldistressatexposuretointernalor externalcuesthatsymbolizeorresembleanaspectofthetraumatic event(s).
5. Markedphysiologicalreactionstointernalorexternalcuesthat symbolizeorresembleanaspectofthetraumaticevent(s).
C. Persistentavoidanceofstimuliassociatedwiththetraumaticevent(s), beginningafterthetraumaticevent(s)occurred,asevidencedbyoneor bothofthefollowing:
1. Avoidanceoforeffortstoavoiddistressingmemories,thoughts,or feelingsaboutorcloselyassociatedwiththetraumaticevent(s).
(Continued)
Table1.1 Diagnosticcriteriaforposttraumaticstressdisorder. cont'd
2. Avoidanceoforeffortstoavoidexternalreminders(people,places, conversations,activities,objects,andsituations)thatarousedistressing memories,thoughts,orfeelingsaboutorcloselyassociatedwiththe traumaticevent(s).
D. Negativealterationsincognitionsandmoodthatareassociatedwiththe traumaticevent(s),beginningorworseningafterthetraumaticevent(s) occurred,asevidencedbytwo(ormore)ofthefollowing:
1. Inabilitytorememberanimportantaspectofthetraumaticevent(s) (typicallyduetodissociativeamnesiaandnottootherfactorssuchas headinjury,alcohol,ordrugs).
2. Persistentandexaggeratednegativebeliefsorexpectationsabout oneself,others,ortheworld(e.g., “Iambad,”“Noonecanbe trusted,”“Theworldiscompletelydangerous,”“Mywholenervous systemispermanentlyruined”).
3. Persistent,distortedcognitionsaboutthecauseorconsequencesofthe traumaticevent(s)thatleadtheindividualtoblamehimself/herselfor others.
4. Persistentnegativeemotionalstate(e.g.,fear,horror,anger,guilt,or shame).
5. Markedlydiminishedinterestorparticipationinsigni ficantactivities.
6. Feelingsofdetachmentorestrangementfromothers.
7. Persistentinabilitytoexperiencepositiveemotions(e.g.,inabilityto experiencehappiness,satisfaction,orlovingfeelings).
E. Markedalterationsinarousalandreactivityassociatedwiththetraumatic event(s),beginningorworseningafterthetraumaticevent(s)occurred,as evidencedbytwo(ormore)ofthefollowing:
1. Irritablebehaviorandangryoutbursts(withlittleornoprovocation) typicallyexpressedasverbalorphysicalaggressiontowardpeopleor objects.
2. Recklessorself-destructivebehavior.
3. Hypervigilance.
4. Exaggeratedstartleresponse.
5. Problemswithconcentration.
6. Sleepdisturbance(e.g.,difficultyfallingorstayingasleeporrestless sleep).
F. Durationofthedisturbance(CriteriaB,C,D,andE)ismorethanone month.
G. Thedisturbancecausesclinicallysignifi cantdistressorimpairmentinsocial, occupational,orotherimportantareasoffunctioning.
H. Thedisturbanceisnotattributabletothephysiologicaleffectsofa substance(e.g.,medication,alcohol)oranothermedicalcondition.
ReprintedwithpermissionfromtheDiagnosticandStatisticalManualofMentalDisorders,Fifth Edition, © 2013.AmericanPsychiatricAssociation.
In Chapter3,clinicalpsychologistCarinLefkowitzexplainshowto incorporateAATintoclinicalpractice.She firstdiscussesthetheoryand practicalaspectsofincorporatingAATinclinicalpractice,thengivescase studyexamples.
In Chapter4,IdiscussPTSDinhistory,literature,andart.Written recordsshowthatPTSDhasafflictedourspeciesthroughoutitshistory. PTSDisalsofeaturedinworksofgreatliteratureandart.Notsurprisingly, Shakespearehasaremarkablycomplete asifhegotacopyoftheDSM centuriesinadvance andwonderfuldescriptionofPTSDinacombat veteran(HotspurinHenryIV,Part1).Interestingly,almostallofthese earlyandartisticdescriptionsofPTSDareinwarveterans.
In Chapter5 James,Whitworth,Ph.D.AssociateProfessoratthe UniversityofCentralFlorida,alicensedclinicalsocialworker,andaUnited StatesAirForceretiredLt.Colonel,discussestheevidencesupportingthe useofservicedogsformilitaryveteransdealingwithPTSD.In Chapter6, DianeScotland-Coogan,AssistantProfessorandclinicalsocialworkeratSt. LeoUniversity,describesthebasis,use,andevidenceforequine-assisted therapyforveteranswithPTSD.
In Chapter7,GregPara,awarveteranandfounderofSarasotaParrot Conservatory,describeshisworkusingavian-assistedtherapytohelpindividualswithPTSD.
In Chapter8,SimoneEmmonsbravelytellsthestoryoftherapeshe sufferedwhileservingintheUnitedStatesArmyduringtheWaronTerror andhersubsequentPTSD.Sherelateshowshefoundedtheorganization ServiceDogsStronginMainetoprovideservicedogsforsexualassault survivorswithPTSD.Ms.Emmonsdescribestheapproachandchallenges intreatingasexualassaultsurvivorwithPTSD.Ms.Emmonsemploysand advocatesthetechniqueofhavingthePTSDsurvivorparticipateintraining theirservicedog.TrialsofthisapproacharewarrantedforAATforPTSD insexualassaultsurvivorsandpossiblypatientswithPTSDduetoother causes.Ms.Emmonsalsohighlightstheprocessandchallengesofsettingup anorganizationwiththemissionofprovidingserviceanimalstoindividuals withPTSDwhoexperiencedsexualassaultandtraumaandalsohow commontheseresponsesareinthispopulation.
In Chapter9,BethMacauley,Ph.D.,CCC-SLP,HPCS,Associate ProfessorintheDepartmentofCommunicationSciencesandDisordersat GrandRapidsStateUniversity,discussestheuseofAATwithpediatric patients.In Chapter10,SamiAbate,Ph.D.,MSHS,MSN,RN,CCRN, DirectorofResearchandNursingQualityatInspiraHealth,discussestheuse
ofAATforpatientswithheartfailure.In Chapter11,psychiatristGeorge GrossbergandcolleaguesdiscusstheuseofAATingeriatricpatients.
In Chapter12,JessicaNelson,JD,PresidentandExecutiveDirectorof PawsforHeroes,explainstheirprocessforselectingandtrainingemotional servicecanines,andforpairingthesedogswithserviceveterans.
In Chapter13,CharlotteGlintborg,Ph.D.anAssociateProfessorinthe CenterforDevelopmentalandAppliedPsychologicalScienceatAalborg UniversityinDenmark,coverscrucialandimportantethicalissuesandissues regardingthewelfareofanimalsparticipatinginATT. Chapters7and8 on equine-assistedandavian-assistedtherapiesandalso Chapter10 onAATfor pediatricpatientseachhavesectionsonanimalwelfareandtheethical treatmentofanimals.
Inthepenultimatechapter(Chapter14),aUnitedStatesArmywar veterantellsthepowerfulstoryofhiscontinuedrecoveryfromPTSDdue tohiscompaniondog thedogalsohavingbeenrescued.
Inthe finalchapter(Chapter15),wereturntoKate’ssoliloquyabout herhusband,warveteranHotspur’sPTSDfromShakespeare’sHenryIV, Part1.Thischapterusesexamplesfromourwarveteran’sexperienceto highlighthowAATcanhelpamelioratethesignsandsymptomsofPTSD thatShakespearesoprescientlyandbrilliantlydescribed.
References Altschuler,E.L.(1999).Pet-facilitatedtherapyforposttraumaticstressdisorder. Annalsof ClinicalPsychiatry,11(1),29 30. https://doi.org/10.1023/A:1022808131941
Altschuler,E.(2016).PTSDinducedbythetraumaofsubordinates:TheRobertGates syndrome. OccupationalMedicine,66(3),182. https://doi.org/10.1093/occmed/kqv201 Bisson,J.I.,Cosgrove,S.,Lewis,C.,&Roberts,N.P.(2015).Post-traumaticstressdisorder. BMJ(Online),351. https://doi.org/10.1136/bmj.h6161
Clawson,A.H.,Jurbergs,N.,Lindwall,J.,&Phipps,S.(2013).Concordanceofparent proxyreportandchildself-reportofposttraumaticstressinchildrenwithcancerand healthychildren:Influenceofparentalposttraumaticstress. Psycho-Oncology,22(11), 2593 2600. https://doi.org/10.1002/pon.3321
Raskind,M.A.,Peskind,E.R.,Chow,B.,Harris,C.,Davis-Karim,A.,Holmes,H.A., Hart,K.L.,McFall,M.,Mellman,T.A.,Reist,C.,Romesser,J.,Rosenheck,R., Shih,M.C.,Stein,M.B.,Swift,R.,Gleason,T.,Lu,Y.,&Huang,G.D.(2018).Trial ofprazosinforpost-traumaticstressdisorderinmilitaryveterans. NewEnglandJournalof Medicine,378(6),507 517. https://doi.org/10.1056/NEJMoa1507598
Shalev,A.,Liberzon,I.,&Marmar,C.(2017).Post-traumaticstressdisorder. NewEngland JournalofMedicine,376(25),2459 2469. https://doi.org/10.1056/NEJMra1612499
