Everybody loves Fido! The Ethics of Including Animals in Mental Health Work

Written by Tara Moser and Jodi Smith

Peer reviewed

Summary: Animals have been used as adjuncts in therapy since the time of Freud, and there are more and more programs that use animals to help patients communicate and heal. Animal Assisted Play Therapy is a combination of play therapy and animal assisted therapy, where play with animals is used to help children. Including an animal in your work, especially in work with children, brings a unique set of responsibilities to the animals as well as your clients. This article discusses the guiding principles of Animal Assisted Play Therapy, and the ethics involved in working with animals in this way.

Therapy dogs are popular all over the world, but the term is not regulated and is often misunderstood and misrepresented. Who doesn’t enjoy having their companion animals around for love and comfort? There are many benefits in many settings for the inclusion of animals. Research continues to affirm the validity of physiological, social, cognitive, and psychological benefits of interacting with animals in a variety of settings other than the animal’s home.^1,2 There is a growing trend of mental health professionals extending the love they share with their companion animals to their clients by including animals in their practice. Although well meaning, it is often done haphazardly and without fully understanding all that it entails. The decision to involve sentient beings in play therapy practice is not one that should be taken lightly.

There is a growing body of research demonstrating the importance and value of play, not just in childhood, but throughout the lifespan. Play is viewed as a basic, and primal, human activity. The United Nations Convention on the Rights of the Child recognized play as a universal right.³ Play is a mechanism for reducing stress and enhancing overall well-being in people of all ages. Jaak Panksepp, a renowned neuroscientist, suggested that play is not only essential for healthy development, but critical in managing stress and distress.⁴ Play is non-threatening and universal, seen across cultures and in all animal species. It is a basic need that is known as a natural stress reducer, and it often takes precedence over other activities. However, it can only occur when the players feel safe. Play can be non-verbal, allowing for interactions between individuals who speak different languages, who are pre-verbal or unable to speak, or who simply do not want to engage in talk. Play, and the language of play, helps create emotional safety.⁵ Play benefits all the players (and often the observers), human and animal alike in direct and indirect interactions.

Play therapy is a therapeutic modality wherein play is utilized as a primary mechanism for communication, understanding, and healing in counseling or psychotherapy.

Trained play therapists purposefully incorporate play into their work, within a variety of theoretical approaches, to address specific presenting problems. The range of theoretical orientations and approaches that fall under the umbrella of play therapy as a modality is vast. Most major models of psychotherapy now have a play therapy approach based on that theory. Additionally, there are many play-therapy-specific approaches that exist independent of but grounded in and/or integrating several theories (i.e., filial play therapy, neurosequential play therapy, Theraplay, AutPlay, and many more).

Play therapy is more than a set of interventions or techniques; it is a way of being with clients in a therapeutic setting. It is not dependent on toys (though toys are often incorporated) but does rely on relationships and a playful way of being. Schaefer and Drewes (2013) identify 20 specific therapeutic powers of play. These serve as the foundation of play therapy and help explain how and why play therapy works. These “core agents of change” serve to “facilitate communication, foster emotional wellness, enhance social relationships and increase personal strengths.”⁶ Play therapists see that challenging situations are often best dealt with in playful, non-threatening ways, as long as it is done purposefully, thoughtfully, and with respect. Although often viewed as an effective approach for working with children, since play is their natural way of learning, communicating, and approaching the world, play therapy is also utilized with teenagers and adults. It is important to note that play therapy is much more than playing in therapy and requires specific and extensive training. The Association for Play Therapy is an excellent resource for those wishing to learn more about play therapy and its applications.

Animal Assisted Play Therapy™(AAPT) was conceptualized and created to provide a foundation for professionals wishing to bring animals into their mental health practice. AAPT was developed by Risë VanFleet, PhD, RPT-S, CDBC, CAEBI, and Tracie Faa-Thompson, MA, AASW, PGdipNDPT, CAEBI, starting 30 years ago, but has been rapidly growing as a mental health discipline for the past 15 years. It merges multiple fields including animal assisted therapy, play therapy, ethology, and animal behavior. AAPT has been defined as: “the integrated involvement of animals in the context of play therapy, in which appropriately-trained therapists and animals engage with clients primarily through systematic playful interventions, with the goal of improving the client’s developmental, and psychosocial health, while simultaneously ensuring the animal’s well-being and voluntary engagement. Play and playfulness are essential ingredients of the interactions and the relationship.”⁵

Although originally conceptualized for mental health professionals (master’s level or higher, with a license to practice independently), AAPT has expanded and is appropriate for a wide array of people wishing to incorporate animals into other fields as well. This includes, but is not limited to, other allied health fields, such as occupational therapy and physical therapy, recreational therapists, speech therapists, educators, and even dog trainers.

AAPT goes significantly beyond other known animal-assisted therapies that have animals present in treatment. AAPT training focuses on specific qualities and competencies for both the animal and the therapist, recognizing that incorporating an animal into the therapeutic process requires additional skills that can be quite complex.⁵ Play and playfulness as a connector of communication are a priority for all who train in AAPT, not just those who are play therapists. Play is essential to our relationship with animals!

The therapist’s theoretical framework, along with the animal’s abilities, enjoyment, and engagement, can result in AAPT sessions that are therapist-led, client-led, or animal-led. The continuum of client-initiated to directive tasks can vary depending on the needs of the client as well as ensuring the animal’s needs are met. The therapist delicately balances attention to client and animal needs to maintain a therapeutic process and humane involvement. This could result in a session appearing similar to a dog training session; however, the client may be working on their impulse control while engaging a dog in some clicker training. It could also look like a client role-playing through dress-up clothes, toy guns, or obstacles in the room, and encouraging the dog and therapists to fulfill assigned roles in their process. In both, play has a different structure, the therapeutic goals are clear to the clinician, and the animal is playing and learning with people they trust and finds joy in the reward of engagement with.

History

Animals have been included in mental health fields dating back to the days of Freud and Levinson. Jofi was the name of the dog that Sigmund Freud included in his psychotherapy work.⁷ Boris Levinson, who is often referred to as the founder of animal assisted therapy (AAT), wrote about his dog Jingles as an “accidental” inspiration for pet therapy.⁸ History shows many examples of animals passively included, often without preparation, and with most of the attention being on how the client benefitted, without consideration for the animal’s choice or well-being. These historical beginnings often noted emotion elicited by clients/patients; however, there was not clarity regarding the clinical purpose of these inclusions. The benefit was seen but not yet developed.

There are several terms and acronyms that are familiar and often referenced when one is including animals in mental health settings. Animal assisted interventions (AAI), animal assisted activities (AAA), and animal assisted therapy (AAT) are the most commonly used, and often misused. These terms are often used interchangeably. AAI is an umbrella term for goal-oriented activities or interventions that purposely incorporate animals. AAT is the incorporation of animals into purposeful, planned activities, guided by a human service provider; this is most often seen in private practice, in organizations, or with a volunteer team. AAA is often less formal, less structured and does not necessarily have a human service provider involved (petpartners.org). AAPT has included them all in the foundations of its development with the inclusion of directive and non-directive approaches to treatment goals.

As animal-assisted therapy continues to be a growing field of study for mental health professionals across the world, this inclusion of animals is quite diverse and expansive in its scope. Therapy teams are included in various settings, such as hospitals, nursing homes, and schools, as well as in medical and mental health clinics, to name a few. Often these programs are known for their AAI and AAT services, including everything from traditional visitation programs, reading programs, and crisis response, to involvement in behavioral analysis, occupational therapy, physical therapy, speech therapy, and direct mental health services. Some of these named volunteer programs that may be familiar are Pet Partners, Therapy Dogs International, and HOPE AACR. The handlers in these programs, if they are clinicians, are covered under the named program’s liability as volunteers and are not operating under their clinical license. The training and support offered in these programs can vary, and should not be seen as a substitute for those who are pursuing the inclusion of animals therapeutically in their own clinical practice; rather they are a stepping stone to development for their mental health practice to include animals independently of additional programs and without extra handlers. When providers are independently licensed and including animals in practice, they are not volunteering, they are including their animals in their actual practice with their own clients. The volunteer organizations have clear guidelines that state that while you can be a trained clinical professional as a volunteer with them, they do not cover you with their liability unless you are attending one of their events and not representing yourself, your own clinical practice, or anything not associated with the volunteer organization.

AAI, AAI, and AAPT share many commonalities in their foundations and applications as well as in their benefits. Most importantly, all occur within the context of relationships, and those relationships (human to human and human to animal), in and of themselves, are the most powerful component of the interaction. Dogs can serve as a bridge to connect and act as a “social lubricant.”^9-11 In addition to anecdotal reports of the benefits of incorporating animals into therapeutic settings, the physical and emotional benefits of animal interactions have been scientifically proven.¹² Studies have shown that the presence of a dog can result in overall lower distress levels.¹³ Touch and eye contact with canines has been shown to lower blood pressure, decrease cortisol, and increase oxytocin.^14-16 Curry et al. (2015) found that individuals had an increased trust in strangers following an interaction with a dog and showed less anxiety and fewer depressive symptoms if they had a dog present, than those who did not, when writing about a traumatic event.¹⁷ The literature supporting the benefits of the human animal bond is rapidly growing.

Ethics

As the popularity of including animals in various work settings increases, more attention should turn to the professional ethics involved for handlers. Ethics apply to all professionals and in professional work settings, especially in the fields of mental health. Each core discipline (i.e., social work, psychology, mental health, marriage and family, etc.) has its own code of ethics with similar foundational values. With the increase in animals being included in practice, more attention is needed to focus on the ethics for those who wish to include animals. This should include clinicians ensuring they have a solid knowledge and skill set in their core clinical discipline, theoretical foundations (in both their primary discipline and animal behavior), and for AAPT, they need play therapy training. Formal training in AAPT can build on these foundations with a focus on the human-animal bond, relationships, animal communication signals, and animal welfare. Many find that including ethology and dog training courses in their therapeutic continuing education builds on their skill set and enhances their abilities in AAPT.

One of the most important ethical considerations when including animals in therapy is handler competence. Just as all therapists who have and use toys in their practice are not necessarily play therapists, all those who include animals into their practice are not necessarily animal-assisted therapists. We must recognize that when we incorporate animals into therapy sessions, it is more complex than bringing our companion animal to work to hang out for the day. Therapists often believe they are equipped and have enough knowledge of therapy, and that adding an animal isn’t much different than adding a new technique they learned. Clinicians have to be aware that there may be things that they don’t know and need to explore. Adding animals to practice without appropriate training can be dangerous for all involved, and practicing any specialized therapeutic modality (e.g., EMDR, sandtray, etc.) without specific training and competency would be considered unethical by most state licensing boards and professional organizations. Lack of specific training could increase your professional liability and ability to obtain appropriate insurance. Additionally, it could increase the possibility of injury to the animals involved, as well as the clients working with them.

According to Dean (2010) the “first obligation is becoming familiar with professional and scientific knowledge. Second is acquiring professional skills.”¹⁸ This comes from the American Psychological Association code of ethics, which states that not following these obligations would constitute a violation of the ethical code,¹⁹ which could subject the clinician to sanctions and/or disciplinary action in their practice discipline. The Association for Play Therapy (2020) also implores play therapists to practice within the scope of their competence and professional experience.²⁰ Furthermore, “play therapists practice a new specialty after appropriate education, training, and supervised experience” has been obtained and simultaneously ensuring “the competence of their work while developing skills in the new specialty.”

Guiding principles

There are guiding principles in AAPT that provide fluidity throughout the training and integrative process of adding animals to play therapy. They are: respect, safety, enjoyment and choices, acceptance, training, relationship, empowerment, process, and foundations.⁵ These principles provide the foundation for the areas of competency needed for professionals to include – not use – animals as part of treatment. Just as one cannot become a play therapist without first being grounded in a mental health discipline, the same holds true for practicing AAPT. VanFleet and Faa-Thompson (2017)⁵ discuss competencies and professional ethics in AAPT fully.

Each of these guiding principles are webbed together to solidify the foundation of AAPT work. First and foremost, respect for the animal(s) is essential. What might respect look like? It begins with identifying that training (for the human) is important and comes before and during the incorporation of animals. This affects husbandry and training with the animal. Ethology, a strong understanding of animal behavior, and animal communication signals all tie into creating the relationship and thus respect. Respect should be seen as a practice and not just an ideal to have with our animals. Respect shows the handler, animal, and all they encounter that the animal is more than a tool to be utilized as needed, and that consideration for the animal’s feelings, wants, and needs are at the forefront. In sessions with the animal, agency is an essential component of respectful practice. Animals in AAPT should always have an option to engage as well as to disengage. Practitioners are encouraged to have at least one “safe zone” where the animal can retreat when tired or disturbed by an action. AAPT animals should be enjoying their involvement, not just tolerating what is happening. Enjoyment is assessed regularly and is based on understanding of animal communication, in general, as well as knowing the animal you are working with and removing them from situations they are not enjoying, even if the client wants them involved.

The AAT field, as well as the animal training world, has evolved significantly in the past decade. The general consensus in these fields, and in AAPT, is that all training should only include positive reinforcement methods.^21,22 This is considered best practice for social learning and also serves as a model for our clients and their families. The training process should build and maintain a relationship between the animal and the therapist, which is the foundation of AAPT work. Maintaining such competencies is an ongoing process that includes seeking continuing education and training throughout the life of the human-animal relationship.

Before clinicians begin to include animals in their work, competence must be established via educating oneself about the species being included. Most domesticated and farm species make great partners in therapy work. This includes but is not limited to dogs, cats, horses, goats, and hamsters. Studying the behavior of your chosen species in order to better understand natural animal behavior and communication is an essential part of training in AAPT. If we do not understand how our animals communicate, we cannot ensure their safety and welfare and may misread or misunderstand what they are telling us. Although animal communication is a core component included in training when one is working towards their AAPT certification, continued education is encouraged and required, as the field continues to evolve.

Relationship is the foundation of AAPT work; this includes the client and therapist’s relationship, the client’s relationship with the animal, and the therapist’s relationship with their animal. It is important to always remember that all of our interactions with our therapy animals are opportunities to model a healthy and respectful relationship. The therapist’s connection to and respect for their animal will be obvious in the therapy room. There is a delicate balance in the inclusion of animals to clinical practice as the animal is never seen as the sole therapist; the animals assist, not replace the therapist.

Safety, enjoyment, and choices

Animal welfare is an essential component of including animals in therapy, especially AAPT; it is woven throughout all aspects of the work. Conceptualizing how animals will be involved in our work, appropriately including them, and not compelling them into compliance is a large part of the welfare focus of including animals. It is important for animals to have the five freedoms that are internationally defined and accepted: freedom from hunger and thirst; freedom from discomfort; freedom from pain, injury or disease; freedom to express normal behavior; and freedom from fear and distress.²³ Upon these conditions being met, freedom of choice to be part of the work may be offered to the animal. Animals should never be forced into compromising situations or asked to tolerate things outside of their comfort zone. The humans working with them should know their stress cues, calming cues, and how to provide a safe place for them as well as an exit for avoiding an uncomfortable situation.

In looking more deeply at the ethics of AAPT, play therapists must consider if the animals want to be there and if they are enjoying all aspects of the interactions.⁵ Whether a dog, cat, goat, horse, or even hamster, their inclusion in the session should be as part of the treatment goal and not only for convenience or because the therapist misses their animal companion while at work. Ensuring that the animals’ well-being is considered at all times is vital. This goes beyond making sure they are rested, fed, and not mishandled by clients. It means ensuring that they are enjoying the work. Many animals, especially dogs, will tolerate quite a bit, if it means they get to be closer to their owner and are making them happy. Tolerance is not enough; to ethically include animals in therapy, the animals must want to be there and enjoy their interactions with clients. As is true when working with animals in any setting, socialization and exposure to that setting and the “tools” they may encounter is essential. Just as ensuring an animal is comfortable around assistive equipment if they will be working in a medical setting, exposure and training around the sights, sounds, and smells one might encounter in a play therapy setting (for example, puppets, dollhouses, musical instruments, sand, and paint, to name a few) is important. When introducing new items to the working space, it is always recommended that the animal encounter and interact with those items first without a client present, to determine their reaction

Activities that depersonalize and objectify the animal can be dangerous, and we should also be cautious with anthropomorphism. While anthropomorphism is attributing human characteristics, feelings, or behaviors to an animal, depersonalizing is removing the freedoms and identifying the animal as a tool rather than a living being. Activities that can contribute to this are discouraged, and all activities should be carefully considered from this viewpoint prior to implementation. Projection (attributing one’s thoughts and feelings to another) is a common occurrence for clients in AAPT, but this is generally client-led, rather than therapist-led.⁵

Conclusion

The field of animal-assisted therapies is rapidly expanding, as is our knowledge and understanding of animals in general. When contemplating adding an animal to your mental health practice there is much to consider. In doing so, are you first looking at the ethical process of including an animal? Do you have the appropriate training through the International Institute for Animal Assisted Play Therapy? Is your animal suited for this work? What parts of your work are they suited for? Who is benefiting (you, your client, the animal)? Can you ensure your animal’s welfare, while attending to your client’s needs and maintaining your professional obligations? Continuing education for clinicians to determine how to safely and humanely include animals in play therapy practice is an ethical obligation.

References

Tara Moser, MSW, LCSW, RPT-S, CAAPT-I, owns a group practice in southwest Florida specializing in play therapy and AAPT for ages 2 through the lifespan. She is the founder of a nonprofit agency that includes kids and rescue dogs and is the current president of Florida Association for Play Therapy. She and her dogs are certified by the AAPT International Certification Board. tara@deltafamilycounseling.com

Jodi Smith, MSW, LCSW, RPT-S, CAAPT-I, has been working with children, teens, and their families in various capacities for over 25 years, specializing in play therapy and AAPT. Of Jodi’s two play therapy dogs, one is registered with Pet Partners and Certified with HOPE Animal Assisted Crisis Response. She and her dogs are certified by the AAPT International Certification Board. jodi@playispowerful.com