The Effects of Animal-Assisted Therapy on Anxiety Ratings of Hospitalized Psychiatric Patients
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The Effects of Animal-Assisted
Therapy on Anxiety Ratings of
Hospitalized Psychiatric Patients
Sandra B. Barker, Ph.D.
Kathryn S. Dawson, Ph.D.
Objective: Animal-assisted therapy involves interaction between pa- Stress and anxiety are considered
tients and a trained animal, along with its human owner or handler, contributory factors to cardiovascular
with the aim of facilitating patients’ progress toward therapeutic goals. disease. Investigators have hypothe-
This study examined whether a session of animal-assisted therapy re- sized that companion animals may
duced the anxiety levels of hospitalized psychiatric patients and serve to lower levels of stress and anx-
whether any differences in reductions in anxiety were associated with iety (4,7,8). Several authors have re-
patients’ diagnoses. Methods: Study subjects were 230 patients referred ported lower blood pressure readings
for therapeutic recreation sessions. A pre- and posttreatment crossover among adults and children when a
study design was used to compare the effects of a single animal-assist- previously unknown companion ani-
ed therapy session with those of a single regularly scheduled thera- mal is present during various stressful
peutic recreation session. Before and after participating in the two activities (5,9–14).
types of sessions, subjects completed the state scale of the State-Trait Animals have been associated with
Anxiety Inventory, a self-report measure of anxiety currently felt. A positive effects on patients in a variety
mixed-models repeated-measures analysis was used to test differences of health care settings (15). When an-
in scores from before and after the two types of sessions. Results: Sta- imals were first introduced to these
tistically significant reductions in anxiety scores were found after the settings, they were generally brought
animal-assisted therapy session for patients with psychotic disorders, for visits that were incidental to the
mood disorders, and other disorders, and after the therapeutic recre- treatment program. Currently, ani-
ation session for patients with mood disorders. No statistically signifi- mals are purposely included in treat-
cant differences in reduction of anxiety were found between the two ment through various interventions
types of sessions. Conclusions: Animal-assisted therapy was associated broadly known as animal-assisted
with reduced state anxiety levels for hospitalized patients with a vari- therapy.
ety of psychiatric diagnoses, while a routine therapeutic recreation ses- Animal-assisted therapy involves
sion was associated with reduced levels only for patients with mood dis- the use of trained animals in facilitat-
orders. (Psychiatric Services 49:797–801, 1998) ing patients’ progress toward thera-
peutic goals (16). Interventions vary
widely, from long-term arrangements
W
ithin the last decade, stud- cardiovascular benefit was document- in which patients adopt pets to short-
ies supporting the health ed in an Australian study involving term interactions between patients
benefits of companion ani- 5,741 participants (6). The authors and a trained animal in structured ac-
mals have emerged (1–4). Cardiovas- found that pet owners had significant- tivities.
cular effects are often the focus, due ly lower blood pressure and triglyc- Although animals have typically
partly to findings from a 1980 study eride levels compared with non-pet- been well received on psychiatric ser-
that reported longer survival rates fol- owners, and the differences could not vices, much of the data attesting to
lowing myocardial infarction for pet be explained by differences in ciga- their benefits has been anecdotal
owners compared with people with rette smoking, diet, body mass index, (17–19). Several decades ago, Searles
no pets (5). More recent evidence of or socioeconomic profile. (20) and Levinson (21) addressed the
therapeutic benefit of a companion
dog for patients with schizophrenia,
Dr. Barker is associate professor of psychiatry, internal medicine, and anesthesiology contending that the caring, human-
and Dr. Dawson is affiliate assistant professor of biostatistics at the Medical College of canine relationship helped ground
Virginia, Virginia Commonwealth University, P.O. Box 980710, Richmond, Virginia the patient in reality. Chronic mental-
23298. Dr. Barker’s e-mail address is sbbarker@hsc.vcu.edu. ly ill residents in supportive care
PSYCHIATRIC SERVICES ♦ June 1998 Vol. 49 No. 6 797homes who were visited by puppies pared for the same patients under sessions was shared by three recre-
had decreased depression after the two conditions: a single animal-assist- ational therapists.
visits, compared with a matched con- ed therapy group session and a single The study used the state scale of
trol group (22). therapeutic recreation group session the State-Trait Anxiety Inventory to
More recently, Arnold (23) de- that served as a comparison condi- measure patients’ levels of anxiety be-
scribed the use of therapy dogs with tion. The setting for this study was the fore and after the animal-assisted
patients with dissociative disorders. inpatient psychiatry service of an ur- therapy session and the therapeutic
Benefits included the dog’s calming in- ban academic medical center. The recreation session (30). The State-
fluence, ability to alert the therapist service treats adult patients with a full Trait Anxiety Inventory is a brief,
early to clients’ distress, and facilita- range of acute psychiatric disorders. easy-to-administer self-report mea-
tion of communication and interac- The average length of stay is seven to sure that is widely used in research
tion. Others have proposed that an an- eight days. and clinical practice.
imal can serve as a clinical bridge in The animal-assisted therapy session The state scale, which measures
psychotherapy, providing an entree to consisted of approximately 30 min- the level of anxiety felt at the present
more sensitive issues (16,24,25). utes of group interaction with a ther- time, has been found to be sensitive
On an inpatient psychiatric unit, apy dog and the dog’s owner. During to changes in transitory anxiety expe-
animal-assisted therapy was found to the semistructured session, which rienced by patients in mental health
attract the greatest number of pa- was held once a week, the owner treatment. The inventory consists of
tients among those who selected talked generally about the dog and 20 items related to feelings of appre-
groups to attend voluntarily and was hension, nervousness, tension, and
found to be the most effective in at- worry. For each item, subjects circle
tracting isolated patients (26). Other one of four numbers corresponding
researchers found that a group meet- to ratings of not at all, somewhat,
ing for psychiatric inpatients held in The moderately so, or very much so. In-
a room where caged finches were lo- struments are scored by calculating
cated had higher attendance and animal-assisted the total of the weighted item re-
higher levels of patient participation, sponses. Scores can range from 20 to
and was associated with more im- therapy session consisted 80, with greater scores reflecting
provement in scores on the Brief higher levels of anxiety.
Psychiatric Rating Scale, compared of about 30 minutes of The internal consistency for the
with a matched group held in a room state scale of the State-Trait Anxiety
without birds (27). Anecdotally, psy- group interaction with Inventory is high; median alpha coef-
chiatric patients who are withdrawn ficient is .93 (30). The construct valid-
and nonresponsive have been de- a therapy dog and ity is supported by studies showing
scribed as responding positively to a that state scale scores are higher un-
therapy dog with smiles, hugs, and the dog’s der stressful conditions.
talking (16). For elderly patients
with dementia, lower heart rates and owner. Procedures
noise levels were associated with the A total of 313 adult psychiatric pa-
presence of a therapy dog (28), and tients consecutively referred for ther-
patients with Alzheimer’s disease sig- apeutic recreation over an eight-
nificantly increased socialization be- month period in 1996 were eligible
haviors when a therapy dog was encouraged discussion about pa- for the study. Patients are referred for
nearby (29). tients’ pets as the dog moved freely therapeutic recreation as soon as they
Based on the evidence in the litera- about the room interacting with pa- are stable enough to participate in
ture associating companion animals tients or carrying out basic obedience group activities, generally within 24
with anxiety reduction and with posi- commands. to 72 hours of admission.
tive responses from clinical popula- The comparison condition was a When patients were initially re-
tions, this study investigated the ef- therapeutic recreation group session ferred for therapeutic recreation,
fect of an animal-assisted therapy held on the unit on the day following they were asked to sign a consent
group session on the anxiety levels of the animal-assisted therapy session. form to participate in a group session
psychiatric inpatients. Also of re- Therapeutic recreation sessions were involving a therapy dog. Patients were
search interest was whether any anxi- held daily on the unit. They varied in not eligible to participate if they had
olytic effect found varied by diagnos- content, including education about any known canine allergies, were
tic group. how to spend leisure time, presenta- fearful of dogs, or did not sign a con-
tions to increase awareness of leisure sent form. Study subjects attended
Methods resources in the community, and mu- both an animal-assisted therapy
A pre- and posttreatment crossover sic and art activities. Coordination of group session and a therapeutic
design was used for this study. both the animal-assisted therapy ses- recreation group session. The two
Changes in anxiety ratings were com- sions and the therapeutic recreation types of sessions were held once a
798 PSYCHIATRIC SERVICES ♦ June 1998 Vol. 49 No. 6Table 1
Mean pretreatment, posttreatment, and change scores on the State-Trait Anxiety Inventory for hospitalized psychiatric pa-
tients with various diagnoses who participated in an animal-assisted therapy session or therapeutic recreation
Animal-assisted therapy (N=93) Therapeutic recreation (N=137)
Diagnosis and measure N Mean SD F1 p< N Mean SD F1 p<
Mood disorders
Pretreatment 53 47.58 12.73 83 47.58 12.73
Posttreatment 45 42.35 12.74 80 43.68 10.78
Change 44 4.05 9.08 6.71 .01 80 4.08 9.08 16.8 .001
Psychotic disorders
Pretreatment 34 48.47 15.26 45 46.31 12.55
Posttreatment 26 42.65 12.53 39 43.41 14.56
Change 26 5.77 13.72 7.62 .006 39 2.08 9.06 1.90 ns
Substance use disorders
Pretreatment 16 48.93 13.17 15 45.33 11.30
Posttreatment 13 44.07 14.00 14 43.28 8.19
Change 12 5.17 10.00 2.66 ns 13 .69 7.79 .09 ns
Other disorders
Pretreatment 11 52.81 11.68 5 50.40 19.56
Posttreatment 11 45.54 13.74 5 50.20 18.74
Change 11 7.27 9.67 5.06 .026 5 .20 6.87 .003 ns
1 df=1, 194
week on consecutive days at the same The dogs and owners met hospital measure for the session. Fifty patients
time on each day. policy for participating in animal-as- completed a pre- and a posttreatment
The three recreational therapists sisted therapy, including documenta- measure for both types of sessions.
providing services to the inpatient tion of the dog’s current vaccinations, Failure to complete all four measures
psychiatry unit volunteered to assist controllability, and temperament. was primarily due to time conflicts
with the study. Because the thera- The volunteers were advised of the with medical treatments and patient
pists were not blind to the treatment animal-assisted therapy group session discharges.
condition, steps were taken to mini- and given direction on how to lead
mize bias by training the therapists the therapy group. Patient characteristics
in standard data collection proce- The mean±SD age of the 313 pa-
dures. At the beginning and end of Analysis tients referred for therapeutic recre-
each animal-assisted therapy group Instruments were scored twice for ac- ation was 37±12 years, and their
session and the comparison thera- curacy by one of the authors using the mean length of stay was 10.98±8.88
peutic recreation group session the scoring keys for the State-Trait Anxi- days. A total of 174 patients were
following day, the recreational thera- ety Inventory. A mixed-models re- women, and 139 were men. The ma-
pist administered the State-Trait peated-measures analysis was used to jority were black (169 subjects, or 54
Anxiety Inventory. The therapists compare pre- and posttreatment dif- percent) and single (195 subjects, or
read the instrument verbatim to any ferences in anxiety scores between 63 percent). They had completed an
patient who had difficulties reading. and within the animal-assisted thera- average of 11.3±2.6 years of educa-
For the animal-assisted therapy py condition and the therapeutic tion.
group, the pretreatment instrument recreation condition by diagnostic For analysis, patients were catego-
was completed before the dog en- category. rized by primary discharge diagnosis.
tered the room. The diagnoses were collapsed into
Two female owners of therapy dogs Results four categories: mood disorders, in-
volunteered to provide the animal-as- Because this study was conducted in a cluding all depressive, bipolar, and
sisted therapy sessions. The first vol- clinical setting, pre- and posttreat- other mood disorders, for 154 pa-
unteer provided the therapy for the ment measures on all subjects under tients (49.2 percent); psychotic disor-
initial four months of the study; then both conditions were difficult to ob- ders, including schizophrenia, schizo-
she became ill and could not contin- tain. Six patients refused to partici- affective disorder, and other psychot-
ue. The second volunteer agreed to pate because of canine allergies or ic disorders, for 80 patients (25.6 per-
continue the study following the same fear of dogs. Of the 313 patients who cent); substance use disorders, for 52
format used by the first volunteer. were eligible for the study, 73 percent patients (16.6 percent); and all other
Her participation required reversing (N=230) participated in at least one disorders, including anxiety, cogni-
the days that the animal-assisted ther- animal-assisted therapy group session tive, personality, and somatization
apy session and the therapeutic recre- or one recreation group session and disorders, for 27 patients (8.6 per-
ation session were offered. completed a pre- and a posttreatment cent).
PSYCHIATRIC SERVICES ♦ June 1998 Vol. 49 No. 6 799Comparison of therapy groups peutic recreation. However, this lack animal-assisted therapy or therapeu- Table 1 shows the mean scores of the of difference could be due to the tic recreation. This lack of difference 230 study participants on the State- small number of patients (N=50) who may be due to the small sample size Trait Anxiety Inventory before and af- completed all four study measures. A or due to a relationship between state ter attending an animal-assisted ther- power analysis of the magnitude of anxiety and physiological withdrawal apy group session and a therapeutic differences between the change that is less amenable to change within recreation group session as well as the scores for animal-assisted therapy and one session of animal-assisted therapy mean change scores. Change scores therapeutic recreation indicated that or therapeutic recreation. were calculated using data from pa- larger samples would be needed to The reduction in anxiety scores for tients with measures at both pre- and achieve an 80 percent power level at patients with psychotic disorders was posttreatment time points. The F test an alpha of .05: a sample of 300 pa- twice as great after animal-assisted and p values show the significance of tients with psychotic disorders, 125 therapy as after therapeutic recre- the change across time. No statistical- patients with substance use disorders, ation. This finding suggests that ani- ly significant differences in anxiety and 61 patients with other disorders. mal-assisted therapy may offer pa- change scores were found between For patients with mood disorders, the tients with psychotic disorders an in- animal-assisted therapy and thera- difference in anxiety change scores teraction that involves fewer de- peutic recreation. Although no signif- was too small for any reasonably sized mands compared with traditional icant between-group differences therapies. As Arnold (23) contends, were found, within-group differences perhaps the therapy dog provides were statistically significant for both some sense of safety and comfort not animal-assisted therapy and thera- found in more traditional inpatient peutic recreation (F=6.71, df= 1, 194, The therapies. Alternatively, the dog may p=.01, and F=16.81, df=1, 194, provide a nonthreatening diversion p
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