The Chimo Project - Improving Mental Health Through Animal Assisted Therapy

Transcription

1 The Chimo Project - Improving Mental Health Through Animal Assisted Therapy Independent Evaluator s Final Report Dr. Bonnie M. Dobbs Associate Director Rehabilitation Research Centre University of Alberta T6G 2G4 This report was prepared for The Chimo Project and for Alberta Health and Wellness.

2 Acknowledgements This project would not have been possible without the vision and dedication of Dennis Anderson, The Chimo Project Director, the enthusiasm and expertise of Dr. Liana Urichuk, The Chimo Project Coordinator, and the capable abilities of Sylvia Imbeault, Sherryl Husereau, and Anne Nield, Administrative Assistants. Sincere appreciation is extended to members of the Professional Advisory Committee who gave so freely of their time and expertise. Thanks also are extended to the members of the collaborating organizations: Bosco Homes, Canadian Mental Health Association, the Edmonton SPCA, and the Pet Therapy Society of Northern Alberta. Sincere appreciation is given to Blair MacKinnon and co-workers from Alberta Health and Wellness (Health Innovation Fund), and Drs. Peggy and Dale Howard from Howard Research Associates for their guidance and encouragement throughout. A very special thank you is extended to the clients and therapists who participated in the study-their willingness to give of themselves and their time has allowed for the advancement of knowledge of Animal Assisted Therapy. Finally, sincere thanks to Shawn Drefs (BSc), Christine Vandenberghe (MEd), and Natalie Dautovich (BA), Research Assistants, for their assistance with this project. The Chimo Project Independent Evaluator s Final Report i

3 Contents Highlights Executive Summary viii xii Project Overview 1 Approach to Project Implementation 3 Approach to Evaluation 5 Project Description and Context 6 Preliminary Phase 7 Preliminary Phase Objectives 7 Evaluation Overview i. Literature Search, Database, and Review Initiative 7 ii. Recruitment Initiative 7 iii. Orientation Manual Initiative 8 Results i. Literature Search, Database, and Review Initiative 9 ii. Recruitment Initiative 9 iii. Orientation Manual Initiative 11 Phase One 13 Phase One Objectives 13 Evaluation Overview 13 Results 17 A. Private Practice Client Results i. Demographics 17 ii. Therapy Results (AAT vs. Control Clients) 21 iii. Summary of Results Private Practice Clients Therapists i. Demographics 42 ii. Therapy Results (AAT vs. Control Clients) 44 iii. Summary of Results Private Practice Therapists 56 B. Residential Care Client Results i. Demographics 58 ii. Therapy Results (AAT vs. Control Clients) 61 iii. Summary of Results Residential Care Clients 73 The Chimo Project Independent Evaluator s Final Report ii

4 2. Therapist Results i. Demographics 75 ii. Therapy Results (AAT vs. Control Therapists) 76 iii. Summary of Results Residential Care Therapists 87 C. Unanticipated Findings 88 Learning 91 Contributions to the Health System 93 Implications 95 Appendices 96 A. Overview of Evaluation Plan 97 B. Orientation Manual Questionnaire 103 C 1. Canadian Canine Good Citizen (CCGC) Test 106 C 2. Aptitude Test for Dogs in Mental Health Settings 107 D. Client Questionnaires (AAT vs. Control) 110 E. Means and Standard Deviations for Private Practice Clients 121 F. Therapist Questionnaires (AAT vs. Control) 123 G. Means and Standard Deviations for Private Practice Therapists 135 H. Means and Standard Deviations for Residential Care Clients 137 I. Means and Standard Deviations for Residential Care Therapists 139 The Chimo Project Independent Evaluator s Final Report iii

5 Tables Table 1. Recruitment Initiative Survey 10 Table 2. Results (Frequencies) of Ratings From Therapists on the Orientation Manual Entitled Improving Mental Health Through Animal Assisted Therapy 12 Table 3. Demographic Results for Private Practice Clients (AAT and Control) 19 Table 4. Private Practice: Goals developed for AAT and Control Clients for Sessions 1 and 4 (Number of Clients, Percentage) 32 Table 5. Demographic Results for Private Practice Therapists 43 Table 6. Private Practice: Therapist Data (Number and Percentage of Clients For Whom Goals Were Developed) for AAT and Control Clients for Sessions 1 and 4 50 Table 7. Demographic Results of Residential Care Clients (Averages and Standard Deviations) 59 Table 8. Residential Care: Goals Developed for AAT and Control Clients for Sessions 1 and 4 (Number of Clients, Percentage) 68 Table 9. Residential Care: Therapist Data (Number and Percentage of Clients For Whom Goals Were Developed) for AAT and Control Clients for Sessions 1 and 4 81 Appendices Table A1: Overview of Proposed Evaluation Plan for Preliminary Phase and Phase One Objectives 97 Table A2: Overview of Proposed Evaluation Plan for Impact of Animal Assisted Therapy Initiative 99 Table E1: Means and Standard Deviations for Private Practice Clients (Section B) 121 Table E2: Means and Standard Deviations for Private Practice Clients (Section E) 122 Table G1: Means and Standard Deviations for Private Practice Therapists (Section B) 135 Table G2: Means and Standard Deviations for Private Practice Therapists (Section E) 136 Table H1: Means and Standard Deviations for Residential Care Clients (Section B) 137 The Chimo Project Independent Evaluator s Final Report iv

6 Table H2: Means and Standard Deviations for Residential Care Clients (Section E) 138 Table I1: Means and Standard Deviations for Residential Care Therapists (Section B) 139 Table I2: Means and Standard Deviations for Residential Care Therapists (Section E) 140 Figures Figure 1. An overview of the study: sources of recruitment, categories of participants, and type of participant within each category 14 Figure 2. Private Practice: Median number of sessions attended over the course of the study by AAT and Control clients. 20 Figure 3. Private Practice: Mean depression scores at Times 1 (baseline) and 2 for AAT and Control clients 21 Figure 4. Private Practice: Average depression scores for AAT clients as a function of pet ownership at Time 1 (baseline) and Time 2 22 Figure 5. Private Practice: Mean anxiety scores at Time 1 (baseline) and Time 2 for AAT and Control clients 23 Figure 6. Private Practice: Anxiety scores at Time 1 (baseline) and Time 2 for AAT clients as a function of pet ownership 24 Figure 7. Private Practice: AAT client ratings for Therapy in General for Sessions 1 and 4 27 Figure 8. Private Practice: Control client ratings for Therapy in General for Sessions 1 and 4 28 Figure 9. Private Practice: Mean difference scores (Session 4 Session 1) for Therapy in General for AAT and Control clients 29 Figure 10: Private Practice: Session 1 average ratings on Therapy in General for AAT clients who owned pets versus those who did not own pets 30 Figure 11. Private Practice: Session 4 average ratings on Therapy in General for AATclients who owned pets versus those who did not own pets 31 Figure 12. Private Practice: AAT and Control clients ratings for Sessions 1 and 4 on whether therapy helped them in their home, school, and work performance 34 The Chimo Project Independent Evaluator s Final Report v

7 Figure 13. Private Practice: Mean ratings for AAT clients for Sessions 1 and 4 on whether therapy helped them at home 35 Figure 14. Private Practice: AAT client ratings on the use of animals in therapy for Sessions 1 and 4 37 Figure 15. Private Practice: Average ratings for AAT clients for Session 1 as a function of pet ownership 38 Figure 16. Private Practice: Average ratings for AAT clients for Session 4 as a function of pet ownership 39 Figure 17. Private Practice: AAT therapists ratings for Therapy in General for Sessions 1 and 4 46 Figure 18. Private Practice: Control therapists ratings for Therapy in General for Sessions 1 and 4 47 Figure 19. Private Practice: Mean difference scores (Session 4-Session 1) for Therapy in General for AAT and Control therapists 48 Figure 20. Private Practice: AAT and Control therapists ratings for Sessions 1 and 4 on whether therapy helped clients in their home, school, and work performance 52 Figure 21. Private Practice: AAT therapists ratings on specific information about the animal (positive items) 54 Figure 22. Private Practice: AAT therapists ratings on specific information about the animal (negative items) 55 Figure 23. Residential Care: Mean number of sessions attended over the course of the study by AAT and Control clients 60 Figure 24. Residential Care: Mean depression T scores at Times 1, 2, and 3 for AAT and Control clients 61 Figure 25. Residential Care: Anxiety T scores at Times 1, 2, and 3 for AAT and Control clients 62 Figure 26. Residential Care: AAT client ratings for Therapy in General for Sessions 1 and 4 65 Figure 27. Residential Care: Control client ratings for Therapy in General for Sessions 1 and 4 66 Figure 28. Residential Care: Mean difference scores (Session 4-1) for AAT and Control clients. 67 The Chimo Project Independent Evaluator s Final Report vi

8 Figure 29. Residential Care: AAT and Control clients ratings for Sessions 1 and 4 on whether therapy helped them at home and school, and in Residential Care 70 Figure 30. Residential Care: AAT client ratings on the use of animals in therapy for Sessions 1 and 4 72 Figure 31. Residential Care: Therapist s ratings for AAT clients for Therapy in General for Sessions 1 and 4 78 Figure 32. Residential Care: Therapist s ratings for Control clients for Therapy in General for Sessions 1 and 4 79 Figure 33. Residential Care: Mean difference scores (Session 4 Session 1) for Therapy in General for AAT and Control clients as per therapist ratings 80 Figure 34. Residential Care: Therapists ratings for AAT and Control clients for Sessions 1 and 4 on whether therapy helped clients in their performance at home, school, and in Residential Care 83 Figure 35. Residential Care Therapists ratings on for specific information about the animal (positive items) 85 Figure 36. Residential Care: Therapists ratings for specific information about the Animal (negative items) 86 Figure 37. Private Practice: Time 1 depression scores as a function of pet ownership 88 Figure 38. Private Practice: Time 4 depression scores as a function of pet ownership 89 Figure 39. Private Practice: Time 1 anxiety scores as a function of pet ownership 90 Figure 40. Private Practice: Time 4 anxiety scores as a function of pet ownership 90 The Chimo Project Independent Evaluator s Final Report vii

9 Highlights The Chimo Project was a 27 month project, representing the collaboration of the Canadian Mental Health Association, the Pet Therapy Society of Northern Alberta, the Edmonton SPCA, and Bosco Homes. Funding was provided by Alberta Health and Wellness (Health Innovation Fund). The primary goal of the project was to assess the effectiveness of Animal Assisted Therapy (AAT) in the Private Practice and Residential Care settings in clients with mental health disorders (depression and anxiety related disorders). AAT is a goal directed intervention in which an animal that meets specific criteria is an integral part of the treatment process (The Delta Society, ). Clients and mental health therapists participated in the study. There were 26 clients (15 received AAT, 11 received traditional forms of therapy) and eight therapists from the Private Practice setting. Ten youths (seven received AAT and three received traditional forms of therapy) and one therapist participated from the Residential Care setting. A non-randomized, experimental-control repeated measures design was employed. Clients were followed for approximately three months, with data obtained from clients and therapists at each therapy session. Quantitative data were collected from clients and therapists for the following areas: 1) information related to Therapy in General (mood, coming to therapy, etc.), 2) individual therapy goals, 3) effects of therapy on school, work, home, and Residential Care performance, and 4) specific information related to AAT (completed by AAT clients and therapists for AAT clients only). Much of the literature directed at assessing the value of animal involvement in therapy consists of qualitative case studies, anecdotal reports, or publications by private organizations. While descriptive or observational studies contribute to our knowledge of clinical phenomena, they are not designed to quantify effect or define causal relationships. Experimental studies overcome those shortcomings. There has been a handful of experimental studies assessing the effects of AAT in the therapeutic setting. However, the majority of those studies suffer from methodological limitations such as small sample size, lack of a control group, instrumentation, study length, etc. Although some of the methodological limitations from previous studies have been addressed with the current study (e.g., use of a control group, study length, instrumentation), a number of methodological limitations remain. Small sample size, particularly in the Residential Care setting, and non-randomization are the primary limitations. Therefore, the results presented must be interpreted with caution. Further research, using a randomized design and a larger sample size, is needed to support or refute the current findings. 1 The Delta Society. (2000). Animal assisted therapy. Retrieved June, 2000 from The Chimo Project Independent Evaluator s Final Report viii

10 Key Findings: A. From the Private Practice Setting Client data: In general, change scores (Session 4 vs. Session 1) between the two groups (AAT vs. Control) on Therapy in General (attitudes toward therapy sessions, interaction with therapist, willingness to disclose during therapy, and effects of therapy) were similar. Although the differences between the two groups were not significant, there was a tendency for Control clients to score higher on almost all measures. Further research, with larger samples, is needed to clarify the present findings. AAT appears to be particularly suited for clients in the Private Practice setting with depression and/or anxiety disorders who own pets. Clients who do not own pets may not do as well with AAT as those who do own pets, particularly in the beginning stages of therapy. Therapist data: In general, therapists ratings for clients receiving traditional forms of therapy (Control clients) were more positive than ratings for clients receiving AAT. Specifically, therapists with clients receiving traditional forms of therapy thought that the clients attitudes toward therapy (e.g., looking forward to coming to therapy) and focusing during therapy improved more across sessions compared to therapists with clients receiving AAT. The differences in ratings between AAT therapists and therapists providing traditional forms of therapy do not appear to be related to pet ownership of the clients. AAT therapists and therapists using traditional forms of therapy indicated that the clients performed better at home as a result of therapy. B. From the Residential Care Setting Client data: Due to the small sample size (n = 10: 7 AAT clients and 3 Control clients), statistical analyses were not conducted. Thus, the results are descriptive only. In general, AAT appears to be an effective adjunct to therapy for youths in a Residential Care setting who have been diagnosed with depression and/or anxiety disorders. Compared to clients receiving traditional forms of therapy, clients receiving AAT were more positive in their attitudes toward coming to therapy, in their ratings on interactions with the therapist, and in their willingness to disclose during therapy. There was, however, no change in their ratings of hopefulness, for improvements in mood, or feelings of anxiousness between Sessions 1 and 4. AAT clients thought that therapy helped them to perform at home and at school, and in Residential Care to a greater extent than clients receiving traditional forms of therapy. The Chimo Project Independent Evaluator s Final Report ix

11 Ratings toward the use of animals in therapy were very positive for clients receiving AAT. Overwhelmingly, clients felt that the animal accepted them for who they were. At the beginning of therapy, clients in the Residential Care setting indicated that they had trouble concentrating with the animal in the room. However, over time, this decreased substantially such that by Session 4, clients indicated that they did not have trouble concentrating with the animal in the room. Therapist data: Over time (e.g., between Session 1 and 4), the trend was for greater differences for AAT clients compared to Control clients for Therapy in General. That is, according to the therapist, AAT controls showed a greater improvement on ratings related to comfort level and ability to focus during therapy, willingness to come to therapy, willingness to talk about feelings, etc. compared to clients receiving traditional forms of therapy. In terms of performance, the therapist thought that therapy helped both AAT and Control clients perform better at home and at school, and in Residential Care. The ratings increased between sessions for both sets of clients. However, the therapist thought that therapy helped AAT clients performance more so than clients receiving traditional forms of therapy. The therapist s ratings for use of the animal in therapy were, overall, positive. That is, the animal was deemed to be beneficial in establishing rapport more quickly. Having the animal present seemed to make clients more willing to come to therapy as well. The therapist indicated that initially (Session 1), clients paid more attention to the animal than to the therapist, that clients were more distracted by the animal, and that clients were unable to focus on clinically relevant issues. However, the pattern was such that by Session 4, the therapist thought that clients paid less attention to the animal, were less distracted, and were more focused. The therapist indicated that there were no aggressive behaviors directed at the animal for either Session 1 or 4. C. Unanticipated Findings An unanticipated finding was that pet ownership appears to moderate the effects of mental illness. A comparison of clients depression scores at the beginning of the study indicated that AAT clients who owned pets had lower depression scores than AAT clients who did not own pets. The same pattern was found for Control clients. In general, after approximately three to four months of therapy, depression scores were reduced for both AAT and Control clients irrespective of pet ownership. However, the same pattern of lower depression scores for pet ownership clients remained. The Chimo Project Independent Evaluator s Final Report x

12 The anxiety scores for AAT and Control clients were examined for the relationship between pet ownership and level of anxiety at entry to the study and after approximately three to four months. Essentially, the same pattern of results was obtained for the anxiety scores as for the depressions scores. The Chimo Project Independent Evaluator s Final Report xi

13 Executive Summary This report reflects the results from The Chimo Project, a 27 month project funded by Alberta Health and Wellness. There were two phases to the project: a Preliminary Phase and Phase One. Goals for the Preliminary Phase included compilation of the extant literature on Animal Assisted Therapy (AAT), recruitment and orientation of qualified mental health professionals into the study, development of an Orientation Manual to be used by therapists on an ongoing basis, and the development of criteria and screening procedures for the selection of clients and animals for participation in the study. For Phase One, the goals were as follows: to develop AAT risk management policies and procedures for both human and animal welfare, to screen potential animals for participation in AAT, and to assess the impact of AAT on the mental health outcomes of clients participating in the project. A review of the literature entitled Animal Assisted Therapy: A Review of the Literature (Gardiner & Dobbs, ) was completed at the beginning of the project. That report is available on request. Eight therapists were recruited into and received orientation to the project over the course of the study. An orientation manual entitled Improving Mental Health Through Animal Assisted Therapy (Urichuk & Anderson, ), was developed and is designed for mental health professionals interested in learning how animals can act as adjuncts to the therapeutic process for individuals with mental health concerns. The manual also is available on request. Finally, during the preliminary phase, enrollment criteria and procedures for screening were developed for clients and animals participating in the study. In Phase One, risk management policies and procedures were developed for therapists, clients, and animals to reduce or alleviate risks associated with the use of AAT. The policies and procedures were approved by the Health Research Ethics Board-Panel B at the University of Alberta. To assess the efficacy of AAT, clients who had been diagnosed with depression and/or anxiety disorders were recruited from the Private Practice and Residential Care settings. The study sample consisted of Experimental clients (clients receiving AAT) and Control clients (clients receiving traditional forms of therapy). At the completion of the project, there were 15 AAT and 11 Control clients from the Private Practice setting, and seven AAT and three Control clients from the Residential Care setting. A total of eight therapists also participated in the project-seven of the therapists were from the Private Practice setting and one was from the Residential Care setting. A non-randomized, experimental-control repeated measures design was employed. Data were collected from clients and therapists using self-administered questionnaires. Questionnaires included the Beck Depression Inventory (or the Beck Depression Inventory-Youth) for clients with depression, the Beck Anxiety Inventory for clients with anxiety disorders (or the Beck Anxiety Inventory-Youth), and questionnaires developed for the study (e.g., information related to therapy in general, attainment of therapy goals, effects of therapy on school, work, home, and Residential Care performance, and specific information related to AAT). Clients and therapists completed the questionnaires at the end of each therapy session. 2 Gardiner, A., & Dobbs, B. (2001). Animal assisted therapy: A review of the experimental literature. Unpublished manuscript. 3 Urichuk, L. & Anderson, D. (2003). Improving mental health through animal assisted therapy. Edmonton. The Chimo Project Independent Evaluator s Final Report xii

14 The key findings are presented below. The findings from clients and therapists in the Private Practice setting are presented first, followed by client and therapist findings from the Residential Care setting. Private Practice Setting: Client Data: There were no significant differences between AAT and Control clients in terms of age, gender, marital status, physical health, or depression or anxiety scores upon entry to the study. There were, however, significant differences between the two groups for pet ownership, with 64% of AAT clients owning pets compared to 90% for Control clients. The groups were similar in terms of availability of support (e.g., people to count on), as well as number of sessions attended during the study period. Both groups attended five sessions on average. Depression and anxiety scores were examined for change over time. The median time period for assessing change was three months, with a range of one to eight months. Depression scores decreased for both AAT and Control clients over time. The decrease was statistically significant for the Control clients but not significant for the AAT clients. Thus, there was a significant improvement in level of depression for Control clients over the course of therapy sessions but not for AAT clients. Anxiety scores also were examined for change over time. Similar to the depression score results, there was a modest decrease in the AAT clients anxiety scores over time but this difference was not significant. There was a significant decrease in anxiety scores for the Control clients however. In the Private Practice setting, there were substantially more Control clients who owned pets than clients receiving AAT. The data were examined to determine if pet ownership had an effect on response to therapy. For clients receiving AAT, the baseline ratings on Therapy in General (e.g., look forward to coming to therapy, improved mood, etc.) were higher for clients owning pets than for those not owning pets. Interestingly, the differences in ratings between clients owning pets versus those not owning pets for Therapy in General were reduced at Session 4. Thus, it appears that clients receiving AAT who own pets may, at the beginning of therapy, be more receptive to having the animal present than are those who do not own pets but that difference is minimized quite quickly over the course of a few therapy sessions. Ratings on use of animals in therapy also were higher for both Sessions 1 and 4 for AAT clients who owned pets versus those who did not. To examine the effectiveness of AAT compared to traditional forms of therapy, change scores (Session 4 - Session 1) were calculated for each of the groups on Therapy in General (attitudes toward therapy sessions, interaction with therapist, willingness to disclose, and effects of therapy). Although the trend was for more positive difference ratings for the Control group, that difference was not statistically significant. The findings suggest that AAT is a useful adjunct to therapy in the Private Practice setting. However, caution in interpreting the results is warranted given the small sample size. In addition to ratings on Therapy in General, clients also provided ratings on the extent to which therapy helped them at home, school, and work. The trend was for AAT client ratings to decrease or stay the same across sessions, and to increase (i.e., help to a greater extent) for the Control clients. The Chimo Project Independent Evaluator s Final Report xiii

15 Finally, clients were asked to provide ratings on statements specific to the use of animals in therapy. Areas of interest included attitudes toward coming to therapy, comfort level with the animal, ability to focus during therapy, willingness to disclose/discuss feelings, and feeling accepted by the animal. The ratings were generally positive for all items, with little in the way of change between Sessions 1 and 4. The majority of clients did not have trouble concentrating with the animal in the room. Therapist Data: As noted earlier, seven therapists from the Private Practice setting participated in the study. The therapists provided ratings on statements similar to those rated by the clients (e.g., for Therapy in General, effects of therapy on home, school, and work performance, use of animals in therapy). In general, the therapists ratings for clients receiving traditional forms of therapy were more positive than for clients receiving AAT overall. Specifically, therapists with clients receiving traditional forms of therapy thought that the clients attitudes toward therapy (e.g., looking forward to coming to therapy), and focusing during therapy improved more across sessions compared to therapists with clients receiving AAT. In addition, the differences in ratings between AAT therapists and therapists providing traditional forms of therapy do not appear to be related to pet ownership of the clients. Residential Care Setting: Client Data: Due to the small sample size, (n = 10: 7 AAT clients and 3 Control clients), statistical analyses were not conducted on Residential Care clients or therapists data. Thus, the results presented in this report are descriptive only. In general, AAT appears to be an effective form of therapy for youth in a Residential Care setting who have been diagnosed with depression and/or anxiety disorders. Compared to clients receiving traditional forms of therapy, clients receiving AAT were more positive in their attitudes toward coming to therapy, and in their ratings on interactions with the therapist and willingness to disclose during therapy. There was, however, no change in their ratings of hopefulness, for improvements in mood, or feelings of anxiousness between the two sessions. AAT clients thought that therapy helped them to perform at home and at school, and in Residential Care to a greater extent than clients receiving traditional forms of therapy. Ratings toward the use of animals in therapy were very positive for clients receiving AAT. Overwhelmingly, the clients felt that the animal accepted them for who they were. At the beginning of therapy, clients in the Residential Care setting indicated that they had trouble concentrating with the animal in the room. However, over time, this decreased substantially such that by Session 4, none of the clients indicated that he/she had trouble concentrating with the animal in the room. The Chimo Project Independent Evaluator s Final Report xiv

16 Therapist data: Over time (e.g., between Sessions 1 and 4), the trend was for greater differences for AAT clients compared to Control clients. That is, according to the therapist, AAT controls showed a greater improvement on ratings related to therapy (comfort level, ability to focus, willingness to come to therapy, willingness to talk about feelings, etc.) compared to clients receiving traditional forms of therapy. In terms of performance, the therapist thought that therapy helped clients to perform better at home and at school, and in Residential Care. The ratings increased between sessions and the therapist thought that therapy helped AAT clients performance more so than clients receiving traditional forms of therapy. The therapist s ratings for use of the animal in therapy were, overall, positive. That is, the animal was deemed to be beneficial in establishing rapport more quickly. Having the animal present seemed to make the client more willing to come to therapy, etc. The therapist indicated that initially (Session 1), the client paid more attention to the animal than the therapist, was more distracted by the animal, and was unable to focus on clinically relevant issues. However, the pattern was such that by Session 4, the therapist thought that the client paid less attention to the animal, was less distracted, and was more focused. The therapist indicated that there were no aggressive behaviors directed at the animal for either Session 1 or 4. Comparison between Private Practice and Residential Care (Therapists Ratings) It is interesting to note the difference in the pattern of ratings from the therapist in Residential Care versus therapists in Private Practice. In general, the ratings for the Residential Care setting are more positive than for Private Practice. In comparison to the Private Practice setting, the ratings on attention to the animal, distractibility, and focusing are higher in the Residential Care setting than in Private Practice. This may be the result of the age of the client. In the Residential Care setting, the average age of the clients receiving AAT was 15 years. In the Private Practice setting, the average age was 40 years. The Chimo Project Independent Evaluator s Final Report xv

17 Project Overview A review of the AAT literature (Gardiner & Dobbs, 2001) indicates a distinct lack of reliable experimental studies examining the effectiveness of AAT with clients in therapy. In general, research to date is comprised of qualitative case studies or anecdotal accounts. The call for scientific research on AAT was first made in the late 1960 s (Levinson, ), a call which has been repeatedly echoed (Banks & Banks, ; Beck & Katcher, ; Fawcett & Guollone, ). Despite these calls, there has been little in the way of experimental exploration of the efficacy of AAT. That which is available (Barker & Dawson, ; Beck, Seraydarian, & Hunter, ; Draper, Gerber & Laying, ; Kelly, ) has provided little in the way of support for the use of animals in therapy. Small sample sizes, along with other methodological limitations account, in part, for the disappointing findings. Despite the lack of strong empirical evidence, there is widespread belief in the use of AAT. Needed, therefore, is welldesigned research examining the use of AAT with individuals with mental health disorders. The current project was designed to meet that need. The Chimo Project was a unique and innovative project, representing initially the collaboration of the Canadian Mental Health Association, the Pet Therapy Society of Northern Alberta, and the Edmonton SPCA. Bosco Homes became an important collaborator following the initiation of the project. The project received funding through the Health Innovation Fund (Alberta Health and Wellness). The initial funding period was for 18 months. An additional 10 months of funding was granted from the Health Innovation Fund. This funding was critical to the success of the project as it enabled the project team to recruit more clients and therapists into the study. The resulting increase in sample size has added to the validity of the study. Amount of funding for the project totaled $331, The primary goal of The Chimo Project was to enhance and improve the well being of selected consumers of mental health services through animal-assisted therapy (AAT). Individuals diagnosed with either two mental health disorders (depression and anxiety) were included in the project. Individuals were recruited from two settings: Private Practice and a Residential Group Home. The study sample consisted of Experimental clients (clients receiving AAT) and Control clients (clients receiving traditional forms of therapy). At the completion of the project, there were 15 AAT and 11 Control clients from the Private Practice setting, and seven AAT and three Control clients from the 4 Levinson, B. (1969). Pet Oriented Child Psychotherapy. Springfield, Illinois: Charles C. Thomas. 5 Banks, M.R., & Banks, W.A. (2002). The effects of animal-assisted therapy on loneliness in an elderly population in long-term care facilities. Journals of Gerontology Series A-Biological Sciences & Medical Sciences, 57A, 7, MB428-M Beck, A.M., & Katcher, A.H. (1984). A new look at pet-facilitated therapy. JAVMA, 184(4), Fawcett, N.R., & Gullone, E. (2001). Behavior Change, 18(2), Barker, S.B. & Dawson, K.S. (1998). The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatric Services, 49(6), Beck, A.M., Seraydarian, L., & Hunter, G.F. (1986). Use of animals in the rehabilitation of psychiatric inpatients. Psychological Reports, Draper, R.J., Gerber, G.J., & Layng, E.M. (1990). Defining the role of pet animals in psychotherapy. Psychiatry Journal of the University of Ottawa, 15(3), Kelly, T.A. (2002). Pet facilitated therapy in an outpatient setting. Dissertation Abstracts International: Section B: the Sciences and Engineering, Vol 62(9-B), April 2002, 4222, US: University Microfilm International. The Chimo Project Independent Evaluator s Final Report 1

18 Residential Care setting. A total of eight therapists participated in the study-seven from the Private Practice setting and one from the Residential Care setting. The Chimo Project Independent Evaluator s Final Report 2

19 Approach to Project Implementation The Chimo Project represents a unique collaboration among the Project Director (Dennis Anderson), the Project Coordinator (Dr. Liana Urichuk), Chimo Staff (Sylvia Imbeault, Sherryl Husereau, Anne Nield-Administrative Assistants), The Chimo Project Professional Advisory Committee (Dennis Anderson, Paul Arnold-Schutta, Dr. Bonnie Dobbs, Dr. Beverley Edwards-Sawatsky, Ms. Patricia Gay, Nancy Kiss, George Lucki, Stephanie McDonald, Darlene McDonnell, Dr. Earl Mansfield, Dr. Steve Marsden, Wanda Polzin, Peter Pagano, Dr. Liana Urichuk), the Edmonton SPCA, the Pet Therapy Society of Alberta, and the Independent Evaluator (Dr. Bonnie Dobbs). Members of the Professional Advisory Team met regularly during the life of the project. The initial stages of the project were devoted to developing data collection tools (client and therapist questionnaires), developing recruitment criteria (clients, therapists, and animals), applying for ethics approval (Health Research Ethics Board-Panel B, University of Alberta), and recruitment of therapists. A non-randomized experimental-control repeated measures design was used in both the Private Practice and Residential Care settings. Although random assignment of subjects to intervention/control groups is the ideal research design, inclusionary/exclusionary criteria restrictions, size of the therapist recruiting population (Private Practice setting), size of client population (institutional setting), and time and cost limitations of the study (27 months) made random assignment of subjects unfeasible. A number of techniques were used to recruit therapists into the study. Use of existing networks-therapists in Alberta were identified and contacted by the Project Coordinator regarding participation in the study. Recruitment notices were sent out to mental health therapists using distributed by the Psychologists' Association of Alberta. Posters were posted at Veterinary Clinics in the Edmonton region. Recruitment aids were posted at Breeding Clubs. Form letters were forwarded to trainers, veterinarians, and psychiatrists. The primary source of data collection from therapists and clients was through the use of self-administered questionnaires. Data collection instruments included the Beck Depression Inventory (or the Beck Depression Inventory-Youth) for clients with depression, the Beck Anxiety Inventory for clients with anxiety disorders (Beck Anxiety Inventory-Youth), and questionnaires developed for the study. There is a paucity of empirical investigation into the efficacy of AAT. Thus, instruments assessing its efficacy are unavailable. As a result, questionnaires were developed for the study. Although these questionnaires do not have established psychometric properties, the questionnaires were designed to quantify information available from case studies and anecdotal reports. The Chimo Project Independent Evaluator s Final Report 3

20 Challenges The initial recruitment of therapists was more difficult than originally anticipated due to the need for therapy animals that had passed the Canadian Canine Good Citizen (CCGC) Test. Due to recruitment difficulties, a change was made to the protocol that allowed for the use of animals that passed the Aptitude Test for Dogs in Mental Health Settings. This change, which was approved by the Health Research Ethics Board- Panel B, facilitated recruitment of therapists. A second challenge was the recruitment of clients, particularly Control clients. Enrollment of Control clients was low in the early stages of the study, due in part to restricting recruitment of controls from therapists with AAT clients. In August of 2002, recruitment procedures were changed such that controls were recruited from therapists that did not have Experimental clients enrolled in the study. This change increased the number of Control clients participating in the study. To facilitate recruitment of clients (both AAT and Control), the protocol was expanded to include clients with other mental health disorders (e.g., Post Traumatic Stress Disorder, providing that they had a secondary diagnosis of depression or anxiety). Approval was received from the Health Research Ethics Board-Panel B at the University of Alberta for the expansion of the protocol. This expanded the size of the recruitment population and increased the generalizability of the study. A third challenge related to data collection. Although the Project Coordinator worked diligently with therapists, a number of questionnaires were returned with data missing. The non-return of questionnaires from clients was particularly problematic (some therapists provided the clients with the questionnaires, and allowed them to complete the questionnaires at home. However, more often than not, the questionnaires were not returned to the therapist). Although therapists were counseled regarding a change in this practice (e.g., to have clients complete the questionnaires in the clinical setting), this did not translate into alterations in practice from some therapists. The Chimo Project Independent Evaluator s Final Report 4

21 Approach to Evaluation The Independent Evaluator (Dr. Bonnie Dobbs) worked closely with The Chimo Project team in all phases of the project. Dobbs, in collaboration with Urichuk and Anderson, designed the client and therapist questionnaires, and selected instruments for the study (e.g., Beck Depression Inventory, Beck Anxiety Inventory). Urichuk was responsible for the recruitment of therapists and for data collection (sending out and collecting questionnaires). Dobbs assumed responsibility for data entry, cleaning of data, data analysis and synthesis, and preparation of the final report (results and final Independent Evaluation report). Client and therapists questionnaires were designed to answer questions relevant to the evaluation questions. The Chimo Project Independent Evaluator s Final Report 5

22 Project Description and Context Project Overview The project consisted of two phases: Preliminary Phase A review of the literature related to human-animal bonding and the use of companion animals in therapeutic settings. The recruitment and orientation of qualified mental health professionals to the project. Phase One The introduction of AAT into the treatment plans of individuals participating in the project. Organization of the Report The report is organized by project phases. Thus, information related to the Preliminary Phase is first presented, followed by Phase One information. For the Preliminary Phase, the project objectives are presented, followed by the evaluation objectives. A description of the procedures for recruitment and orientation of qualified mental health professionals also is presented. For Phase One, the project objectives and evaluation objectives are presented. A description of sample characteristics is presented (e.g., age, gender, marital status, ratings of physical health, pet ownership, degree of informal support), followed by the results of AAT for the Private Practice group and the Residential Care group. For each of the practice settings, the demographic results are first presented, followed by the results specific to therapy outcomes and use of animals in a therapeutic setting. The Chimo Project Independent Evaluator s Final Report 6

23 Preliminary Phase As noted above, the Preliminary Phase consisted of a review of the literature related to human-animal bonding and the use of companion animals in therapeutic settings. Qualified health professionals were recruited and received orientation to the project during this phase of the project as well. Preliminary Phase Objectives The objectives for the Preliminary Phase were to: develop a database of literature related to human-animal bonding and the use of companion animals in therapeutic settings, recruit qualified mental health professionals to participate in the project, orientate recruited mental health professionals in the use of AAT, prepare an Orientation Manual on The Use of Companion Animals in Therapeutic Settings for use by other mental health professionals, and develop criteria and screening procedures for the selection of companion animals to be used in Phase One of the project. Evaluation Overview An overview of The Chimo Project Evaluation Plan is provided in Appendix A. The Preliminary Phase consisted of three initiatives: i) a Literature Search, Database Development, and Review Initiative, ii) a Recruitment Initiative, and iii) an Orientation Manual Initiative. The evaluation activities related to each of the initiatives are outlined below. i. Literature Search, Database Development, and Review Initiative-a search of the extant literature related to human-animal bonding and the use of companion animals in therapeutic settings, the development of a literature database, and a review of the literature. The Literature Search, Database Development, and Review Initiative was not evaluated per se. Rather, the Independent Evaluator conducted a comprehensive literature search and wrote an integrative review of the literature based on studies of the benefits of AAT for persons with depression and/or anxiety disorders (Gardiner & Dobbs, 2001). ii. Recruitment Initiative-evaluation of criteria used to recruit qualified mental health professionals to the project. The goal of the Recruitment Initiative Survey was to determine the congruency between the recruitment criteria for mental health practitioners for The Chimo Project and the qualifications of the mental health practitioners selected for the project. Congruency was determined by an assessment of the fit between the recruitment criteria and the résumés of the mental health practitioners participating in the project. The Chimo Project Independent Evaluator s Final Report 7

24 iii. Orientation Manual Initiative-evaluation of the Orientation Manual titled The Use of Companion Animals in Therapeutic Settings that was developed for the project. An important component of the project was the development of an Orientation Manual for AAT. The manual Improving Mental Health Through Animal Assisted Therapy (Urichuk & Anderson, 2003), was designed to provide mental health professionals and others with currently known information on how animals can act as adjuncts to the therapeutic process for individuals with mental health concerns (p. xiv). The manual consists of five chapters. The first chapter provides an introduction to AAT, and consists of an overview of The Chimo Project, the history of AAT, anecdotal and case studies of AAT, experimental studies of AAT, and current use of AAT along with relevant references. In Chapter 2, the authors outline approaches to incorporating animals into mental health therapy interventions. Included are goals and strategies of AAT, the roles animals can play in therapy (e.g., assessment tools, projective tools, tools for storytelling, role modeling tools, and teaching tools), and alternative ways to utilize the human-animal bond. In Chapter 3, guidance is given for implementing AAT programs. Topics covered include standards for animal selection, guidelines for training and orientation, issues related to liability, and selected AAT training courses and/or degree programs. Chapter 4 is dedicated to issues related to monitoring and evaluation of AAT programs. Topics addressed include performance indicators, outcome measures, efficacy, testimonials as outcome measures, and safety and ethical issues. The final chapter deals with experimental research studies on AAT including studies on visitation within the home and institutional settings. Appendices include the Canadian Canine Good Citizen (CCGC) Test, the Aptitude Test for Dogs in Mental Health Settings, Therapist and Client Evaluation Questionnaires (developed specifically for The Chimo Project by Dobbs, Urichuk, & Anderson, 2001), and a summary of the goals and strategies for AAT in mental health settings. The manual is a valuable resource for any mental health therapist interested in implementing AAT in the clinical setting. The evaluation objective for the Orientation Manual was to provide an independent evaluation of the manual Improving Mental Health Through Animal Assisted Therapy (Urichuk & Anderson, 2003). A questionnaire was developed and sent to mental health professionals involved in the project and mental health professionals not involved in the project 12. The questionnaire is provided in Appendix B. 12 As per the evaluation plan, data also were to be collected from experts in training mental health professionals and those with expertise in AAT (e.g., Counseling and Clinical MHP educators). However, the manual was released in June, Thus, time constraints precluded the data collection from this category of experts. The Chimo Project Independent Evaluator s Final Report 8

25 Results i. Literature Search, Database Development, and Review Initiative As noted above, a comprehensive review of the literature related to humananimal bonding and the use of companion animals in therapeutic settings was conducted by the Independent Evaluator. Databases searched included PsychINFO, Medline, and Current Contents. Further articles were obtained from the reference lists of retrieved articles. A review of that literature, entitled Animal Assisted Therapy: A Review of the Experimental Literature (Gardiner & Dobbs, 2001) is available on request. ii. Recruitment Initiative The evaluation results of the Recruitment Initiative Survey are presented in Table 1. As can be seen, in general, the therapists met the 10 inclusionary criteria and the one exclusionary criterion (one therapist - J.M. - counseled Control clients only. As a result, criteria related to AAT were not applicable). The Chimo Project Independent Evaluator s Final Report 9

26 Table 1 Recruitment Initiative Survey Criteria Therapists TW BH DS WP PT JD JM BR Inclusionary Criteria 1. Licensed in profession. 2. Documentation of current and valid credentials and/or licensure available. 3. Practice within the scope of their profession. 4. Demonstrated commitment and willingness to participate in project. 5. a. Attended a seminar on animal and risk management practices. b. Demonstrate knowledge of animal and risk management procedures. 6. Goals set for AAT on an individual basis (for The Chimo Project clients). 7. Practice includes clientele meeting the inclusionary criteria for clients (DSM-IV criteria for depression/anxiety). 8. a. Willingness to complete study questionnaires at regular intervals. b. Willingness to be interviewed at completion of project. 9. Demonstrated animal handling skills as per CCGC criteria. N/A 10. An animal meeting the CCGC and/or Aptitude Test criteria. x N/A Exclusionary Criteria 1. History of allergies to animals. N/A 2. Dislike of animals. N/A = Met criteria N/A = Not Applicable The Chimo Project Independent Evaluator s Final Report 10