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The Effect of Animal-Assisted Therapy on Changes in Mood, Stress, and Resilience and their

Relationship to Fatigue and Function in Wounded Active Duty Service Members

CPT Christine Beck



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Animal assisted therapy (AAT) has steadily gained popularity among healthcare workers

and facilities as well as in the general public in both the United States and in Europe over the last

decade. The United States Military has a long history of promoting AAT with wounded

Warriors (Bustad, 1980; Velde, Cipriani, & Fisher, 2005). Despite the numerous anecdotal

reports, documented research by professionally trained clinicians on the effectiveness of AAT

with this unique population is non-existent. The purpose of this study was to improve the

successful reintegration of warriors in transition (WTs) by evaluating the effects of an

occupational therapy intervention with and without AAT.

Literature Review

Animal Assisted Therapy

The Delta Society, a well-recognized leader and research sponsor for AAT, defines the

treatment as ³a goal-directed intervention directed and/or delivered by a health/human service

professional with specialized expertise, and within the scope of practice of his/her profession.

AAT is designed to promote improvement in human physical, social, emotional, and/or cognitive

functioning (Delta Society, 2010a). Boris Levinston is often referred to as the ³father of AAT´

because he is the first professionally trained clinician to document his observations of the use of

a dog during treatment sessions with patients(Hooker, Holbrook Freeman, & Stewart, 2002).

This work was the starting point for clinical research that started in the 1960s and has grown in

popularity ever since. Although he is considered the ³father,´ the history of AAT dates back to

1792 in England and 1867 in Germany (Bustad, 1980).



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literature is the lack of methodologically sound studies. The majority of studies are case report.

In order for AAT to become a respected and valid intervention, more methodologically

soundefficactiveness studies must be completed using experimentaldesigns (Arkow, 2004;

Gammonley et al., 2003). In addition to methodologically flawed studies, some of the most

commonly cited limitations of AAT include its cost, risk of injury (e.g., through bites) and the

possibility of it being ill-suited to particular client populations, such as those who dislike or fear

animals or those for whom cultural factors restrict their ability to have contact with animals

(Brodie et al., 2002).

In the 1970s, Dr. Levinston continued his work and was joined by many more clinicians

who believed in the therapeutic benefits of animals. Psychiatrist Dr. Michael McCulloch began

³prescribing´ pets as a therapeutic option for his patients to improve quality of life. Dr. Leo

Bustad, the dean of the College of Veterinary Medicine at Washington State University,

developed (AAT) programs at Pullman Memorial Hospital and Tacoma Lutheran Nursing

Home. Psychiatrist Dr. Dean Katcher and a team of researchers at the University of

Pennsylvania began studying the effects of animals on human health and wellbeing (Morrison,

2007).

In 1980, Mculloch, Bustad and Katcher joined together to form an organization known

today as the Delta Society (Morrison, 2007). The Delta Society has grown considerably over the

last 30 years and is considered one of the most respected and well-known organizations in the

area of AAT. They sponsor research, develop guidelines, and have developed the Pet Partners®



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The 1990s continued the upward trend of public interest and research on the topic of

AAT. In 1990, Dr. William Thomas developed an innovative therapeutic environment, called

the Eden Alternative, which sought to assimilate the natural world, including animals, into long-

term care (Hooker et al, 2002). After the September 11th attacks, therapy dog teams volunteered

counseling services through the American Red Cross to those who had lost loved ones or been

injured themselves (Teal, 2002).

Barker (2002) examined whether a session of AAT would decrease levels of anxiety with

patients diagnosed with anxiety disorders. The results showed that there were statistically

significant reductions in anxiety scores after AAT sessions with those with psychotic disorders,

and mood disorders. Berget, Ekeberg, and Braastad (2008) analyzed the effects on AAT with

farm animals on persons with psychiatric disorders such as schizophrenia, personality, and

anxiety disorders. They found that subjects demonstrated increased skills in interactions with

other humans after receiving AAT.

The preferred choice of mammal used in AAT is the canine. This is because canines are

very social, dependent, and trainable creatures (Velde, Cipriani, & Fisher, 2005; Arkow, 2004).

Dogs should be ³alert, bright, happy, and healthy, playful without being too rowdy« even-

tempered, good-natured, and willing to withstand travel and environmental stress´ (Arkow, p.

73).

AAT in the United States Military

The United States Military contributed to AAT¶srich history by promoting the therapeutic



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recovering from operational fatigue at the United States Army Air Corps Convalescent Hospital

in Pawling, New York. Patients worked with farm animals as part of their therapy(Bustad, p.

118-119, 1980). More recently, AAT dogs have been deployed with U. S. Army occupational

therapists as part of Combat Stress Control (CSC) units in Iraq and Afghanistan. The mission of

the CSC unit is to prevent and behavioral health issues while in theatre.

Occupaitonal Therapy at the WTB

Occupational therapy practitioners are members of an interdisciplinary team that work

with Soldiers assigned to the WTBs across the Army. They work with the Soldiers on stress

management, addressing goals, communication skills, conflict resolution, and other life skills

that will foster a successful transition either back to active duty or with their return to civilian life

(Erikson,Seacrest, & Gray, 2008). At the WTB on Fort Sam Houston, TX, the occupational

therapy department conducts training in the Warrior in Transition Advancement Program

(WiNTAP). This is a mandatory program for all Soldiers who are assigned to the WTB. It

includes psychoeducational groups that focus on goal setting, stress management, sleep hygiene

and communication. The occupational therapists also identify needs that the Soldiers have and

aid them in obtaining the resources to meet those needs.

For the many Soldiers assigned to the WTB, the transition goes beyond preparing to

transition back to their units or civilian life. They may still be in the ³transition/readjustment´

time frame from being deployed to a combat zone. Hoge (2010) says that this

³transition/readjustment´ time frame is ill-defined and full of hazards. He estimates that this



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hundreds, if not thousands, of miles away from their families, their organic units, from everyone

who normally could be there to help with this ³transition/readjustment´ back from combat.

For Soldiers at the WTB who are there for reasons other than a combat related injury, the

stress from ³transition/adjustment´ back from combat can be substituted by feelings of guilt that

they are receiving treatment alongside those who were wounded in the combat zone. One

Soldier in the study said that being at the WTB adds stress on a daily basis because he feels

³unworthy´ because he is there because of a cardiac condition.

Research Design

This study was quasi-experimental, using a pre-test post-test control group, without

randomization, (2 X 3 mixed model, repeated measures ANOVA) with two group levels

(standard of care and standard of care plus AAT).

Participants

Warriors in Transition (WTs) who were referred for the WInTAP program were screened

by the occupational therapy staff at the WTB. Upon meeting the inclusion and exclusion criteria,

the WT was provided a flyer regarding the study. Inclusion criteria was that the participants be a

United States service member assigned or attached to the Brooke Army medical Center Warrior

Transition Battalion (WTB) and be at least 18 years of age. Participants were excluded from the

if they were: (1) unable to understand verbal and written English, (2) pregnant, (3) known allergy

to dogs, (4) open wounds, (5) previous or concurrent participation in the Cognitive Behavioral

Education Strategies (CBESt) program, (6) Concurrent participation in the Army Center for



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daily interaction with their own dog. A total of 24 Soldiers currently on active duty in the Army

participated in this study. See Table 1 for demographic information.

Procedure

After approval by the Institutional Review Board at Brooke Army Medical Center at Fort

Sam Houston, TX, eligible participants were screened by the occupational therapy staff of the

Warrior Transition Battalion.Potential participants were then referred to the research team. This

was followed by a phone call from the research team to schedule a face to face meeting for

further explanation of the study purpose and procedures. The Soldiers who agreed to participate

were provided with baseline assessments. Control group participants were recruited from the

WInTAP group sessions. The group was given a 2-3 minute introduction to the study and those

who were interested stayed after the class to fill out the baseline assessments. Investigators also

obtained a written informed consent, signed authorization to use protected health information

(PHI) for research purposes that meets HIPAA requirements from all participants in both groups.

At baseline, post-intervention, and at the one month follow-up, the following assessment

tools were administered: the Functional Status Questionnaire (FSQ), the Profile of Mood States

(POMS), the Occupational Self-Assessment (OSA), Perceived Stress Scale (PSS) and the

Connor Davidson ResilienceScale (CD-RISC). Participants were offered the choice of self-

administration or administration by the PI/AI if a disability was present that prevented them from

being able to complete the forms themselves. Assessments were conducted in a private area and

participants were encouraged to ask if they required explanation.



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Rubenstein, & Fink, 1986). It is divided into five main sections: physical function of the

activities of daily living, psychological function, role function, social function, and a variety of

performance measures. The ADL subscale consists of questions about activities such as

dressing, bathing, transfers, and mobility. The IADL subscale covers activities such as shopping,

using public transportation, and maintaining a household. The social activity subscale is related

to social interaction such as the one's ability to visit with family and friends. The FSQ has been

shown to exhibit construct and convergent validity by comparison to health status measures such

as reported bed disability days and restricted activity days (Brach VanSwearingen, FitzGerald,

Storti, &Kriska, 2004; Reuben, Valle, Hays &Siu, 1995). This measure takes approximately 5

minutes to complete.

Perceived Stress Scale (PSS). The PSS"measures the degree to which situations in one's

life are appraised as stressful" (Cohen, Kamarck, &Mermelstein, 1983, p. 385). The PSS was

used to assess the perception of stress among the participants. This scale consists of fourteen

questions that ask about participants¶ feelings related to general stress within the past

month.Participants responded to the questions using a 5-point Likert scale with answers ranging

from0 (never) to 4 (very often). After the PSS was completed, a total stress score was calculated

forthe individual students with reverse coding of seven items in the scale. The PSS has been

foundto be reliable (.85) in college and community samples (Cohen et al., 1983). This measure

takes approximately 2 minutes to complete.

Profile of Mood States (POMS). The POMS as used to measure the mood state of the



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Vigor-Activity,Fatigue-Inertia, and Confusion-Bewilderment. A high total score indicates mood

disturbance and high subscale scores for tension, anger, fatigue, depression, and confusion

indicate disturbance in each respective domain. The subscale score for vigor is subtracted from

the total because of the positive nature of that domain.

Internal consistency has been reported for all items as above 0.90 with test-retest

reliability ranging between 0.65 for Vigor and 0.74 forDepression (McNair, Lorr, &Droppleman,

1971). The POMS has been used with a wide variety of health states to assess mood state

(Curran, Andrykowski, &Studts, 1995). This measure takes approximately 9 minutes to

complete.

Connor-Davidson Resilience Scale (CD-RISC). The CD-RISC is made up of 25 items

and assesses resilience and is rated based on the participant¶s feelings during thepast month.

Scales are scored by summing the total of each item. All items carry a 5-point range of

responses, from 0 = ³not true all the time´ to 4 = ³true nearly all the t ime´. The total score can

range from 0 to 100, and higher scores indicate greater resiliency. The CD-RISC claims to

(Connor & Davidson, 2003).

Internal consistency ( coefficient) was .89 (Connor and Davidson, 2003). Item

correlations ranged from .30 to .70 (Connor and Davidson). Test-retest reliability, assessed in 24

individuals, was .87 (Connor and Davidson). CD-RISC scores were positively correlated with

Kobasa hardiness (n = 30, r = .83, p <.001), and it was also negatively correlated with the

perceived stress scale (n= 24, r = -0.76, p <.001). Campbell-Sills and Stein (2007) also



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psychometric properties and allows for efficientmeasurement of resilience´ (p. 1019). This

measure takes approximately 5 minutes to complete.

The Occupational Self Assessment (OSA). The OSA (Baron, Kielhofner, Iyenger,

Goldhammer, &Wolinski, 2001) is an assessment tool and outcome measure is based on the

Model of Human Occupation. It is a client centered measure that uses self-report from asked the

participants to rate their functioning as well as the impact of the environment on their

functioning. It is a series of statements to which the client indicates how well they do the activity

4-point Likert-type scale (1=lot of problem to 4=extremely well) and its importance to them

(1=not so important to 4=most important. The competence scale was used in this study.

Rasch analysis determined that there were no items misfits on the competence scale

which reveals good construct validity (Kielhofner& Forsyth, 2001). It was also found to be

useful in a consistent manner by 90% of the participants with a wide range of disabilities on a

more recentRasch analysis (Kielhofner, Forsyth, Kramer, Iyenger, 2009). This measure takes

approximately 7 minutes to complete.

Fatigue Scale. The Fatigue Scale is an 11 point numeric measure where 0= no fatigue

and 10 = worst fatigue imaginable. A linear numeric scale is considered to be an acceptable

method for measuring a unidimensional characteristic (Portney& Watkins, 2007). This measure

takes less than 1 minute to complete.

Intervention

Both the experimental group and the control group received ³treatment as usual´ which



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minute semi-structured interaction with a pet team. The majority of the pet teams in this study

are Pet Partners®.

The experimental group also received AAT for 30 minutes after each Life Skills class

session. Theyworked 1:1 with the dog and dog handler. The intervention consisted of the

handler instructing the participant how to administer a simple command such as sit, stay, lay

down, roll over, or fetch. After the participant was successful with administeringfive commands

with the dog, the remainder of the 30 minutes was spent engaging in activities of the participants

choice. Activities included going for a walk on the grounds of the Warrior Family Support

Center, sitting quietly and petting the dog, brushing the dog, and teaching the dog new tricks.

Data Analysis

Prior to the analyses, assumptions of normality and linearity were evaluated and data

from the experimental group was screened for outliers. Measures of central tendency were used

to describe the data. Independent samples t -test and chi-square analyses were performed to

examine demographic differences between the two groups.

Using the Friedman¶s ANOVA test for µmood,¶ µresilience,¶ and µstress¶, the group of

within subject scores was compared to each other at baseline, post-intervention, and follow-up

using a 0.05 significance level. The Friedman¶s was used to analyze these sets of data because

the assumption of normality could not be verifiedand the sample size for each group was small

(Elliott & Woodward, 2007). Assumption of sphericity was checked using Mauchly¶s test. Due

to the lack of significant overall test results, follow-up pairwise comparisons were not



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All data were entered into SPSS v. 16 and were validated for accuracy by a second

research team member.

Demographics

Results showed that the experimental and control groups did not differ significantly in

chronological age, rank, number of deployments, sex or primary diagnosis (See Table 1).

Changes in Mood, Resilience, and Stress ± Experimental Group

The Friedman¶s test was run to compare score rankings on the PSS and CDRISC. The

PSS resulted in a chi-square value of 2.33 and a p-value of .311 indicating that there was no

statistically significant difference in rankings. The CDRSC resulted in a chi-square value of

2.263 and a p-value of .323, which also indicates a lack of statistical significance. The data

shown in Table 2 compares the µmood¶, µresilience¶, and µstress¶ scores at baseline, post-

intervention, and at follow-up for the experimental group.The POMS resulted in a chi-square

value of XXX and a p-alue of XXX

Relationship Between Mood and areas of Function and Fatigue ± Experimental Group

At baseline, Spearman¶s rho identified that the strongest significant relationship between

these variables was a correlation between µmood¶ scores on the POMS and psychological

µfunction¶ scores on the FSQ (rho = .-917, p =.01). Correlations between µmood¶ on the POMS

and µfunction¶ on the Competence scale on the OSA (rho =.-760, p =.01). Nonparametric

correlations also identified moderate to good positive correlations between µmood¶ on the POMS

and µfatigue¶ on the Fatigue Scale (rho = .596, p =.05) and µmood¶ on the POMS and the quality



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.-882, p =.01). It also identified moderate negative correlation between µmood¶ scores on the

POMS and psychological µfunction¶ scores on the FSQ (rho =.-657, p =.05).

At follow-up, the only association that was found to be significant was between the

µmood¶ scores on the POMS and µfunction¶ on the Competence scale of the OSA (rho= .772,

p=.05).

Relationship Between Resilience and areas of Function and Fatigue ± Experimental Group

Spearman¶s rho found significant correlations between µresilience¶ scores on the CD-

RISCand µfunction¶ on the Competence scale of the OSA at baseline (rho= .735, p =.01), at post-

intervention (rho=.961, p=.01), and at follow-up assessments (rho=.845, p=.01). The only other

significant correlation between µresilience¶ was a correlation found between µresilience¶ on the

CD-RISC and psychological µfunction¶ scores on the FSQ (rho=.755, p=.01) at the post-

intervention assessment.

Relationship Between Stress and areas of Function and Fatigue ± Experimental Group

At baseline, Spearman¶s rho found a moderate to good positive correlation between

µstress¶ on the PSS and the level of µfatigue¶ on the Fatigue Assessment (rho=.624, p=.01). A

correlation was also found between µstress¶ and the quality of interaction area of µfunction¶ of the

FSQ (rho=.691, p<.05). At baseline and at post intervention, correlations were found between

µstress¶ on the PSS and µfunction¶ on the Competence scale of the OSA (rho= -.717, p =.01;

rho=-.619, p=.05) and psychological µfunction¶ on the FSQ (rho= .833, p=.01; rho=849, p=.01).

Correlations between the µmood¶ variable and the variables of µfunction¶ and µfatigue¶



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scores on the POMS and µfunction¶ on the Competence scale of the OSA as well as between

µresilience¶ scores on the CD-RISC and µfunction¶ on the Competence scale of the OSA.

Discussion

Analysis of the data suggests that as mood improved, so did the participants

psychological µfunction¶ such as less feelings of depression and anxiety, suggesting that the

better mood the participant was in, the better perceived ability to sustain a pattern of

occupational behavior which is productive and satisfying.

The µfatigue¶ correlation indicates that the higher the mood dysfunction, the more

fatigued the participant was. The unexpected correlation between µmood¶ and social interaction

µfunction¶ may suggest that they are reaching out when they are in need of help to family

members, peers, professionals, or cadre or possibly due to the nature of being a Soldier in the

WTB, they are required to interact with these people on a daily basis as part of their recovery and

do not have the option to isolate themselves.As the correlations between resilience and areas of

function and fatigue demonstrate a good to excellent relationship at all three assessments, it is

safe to assume that the more resilient the participant scored, the higher their level of occupational

performance, regardless of the other variables.

The correlations between µstress¶ and areas of µfunction¶ and µfatigue¶ indicate that as

their levels of stress moved up or down, so did their level of occupational performance and

psychological function at baseline and post-intervention.

The Soldiers in the WTB report that they are ³constantly´ asked to fill out surveys that



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the Soldiers in the study. They are mandated by their chain of command that they fill them out

and some admitted to not reading the questions and just circling numbers because they had to.

Annoyance was expressed by at least 3 of the participants of having to fill out 29 minutes worth

of surveys as part of the study. Also worth noting is that atthe follow-up, 3 participants

verbalized having ³bad weeks´ when the team member simply said ³hi, how are you doing´ as a

greeting, which may have influenced their scores.

Limitations

The small number of participants (n=24) was lower than what was needed to detect

significant differences between the groups. This study also relied solely on self-reported

ratingscales which raise the issue of the participants accurately and honestly reporting their

levels of mood, resilience, and stress. Another limitation may be that the measures were given

too long after the interventions actually took place. Had they been given immediately after, a

statistically significant improvement may have been. If there were improvements,they may

haveimmediate and not strong enough to overcome the other day to day stressors in the

participants life between the intervention and the time the post-intervention and follow-up

assessments were given.

Recommendations for future studies

y Although experimental research designs seem to have the most merit and are

considered the gold standard for scientific research (Portney& Watkins, 2007),

qualitative research methods may be more appropriate to assess and gather



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y Assess immediate effects of receiving the AAT and benefits of providing ³in the

moment´ relief of their stress by engaging in the occupation of interacting with a

dog.

Conclusion

The use of AAT with the military population is in need of continued study. The

incidental qualitative input that was provided by the participants during and immediately after

the interventions lead the investigators to believe that, although not statistically significant

changes were seen in this study, there were ³in the moment´ benefits to the participants engaging

in the AAT sessions.



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Table 1 Demographic Data

AAT GR O

UPn=12

CONTR

OL GR

OUPn=12

Age in years (Avg / SD) 37.08 / 11.79 35.5 / 9.19

Male 10 7

Female 2 5

Military Status

AD 8 7

RC 4 5Grade

Officer 2 3

Enlisted 10 9

Months in service

(Avg/ SD)124.08 / 107.05 118.5 / 80.849

Number of Deployments

1 6 52 6 4

>2 0 3

Aggregate Months Deployed

(Avg / SD)16.42 / 7.513 16.71 / 8.703

Previous Dog Ownership

Yes 9 10 No 3 2

Negative Experience with

Dog

Yes 1 2 No 11 10

Current Dog OwnershipYes 1 3

No 11 8

Primary Medical Condition

Behavioral Health 3 0Orthopedic 5 8

Other 4 4



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Table 2 Repeated-Measures Analysis of Variance

Mean Std. Deviation Ranks

PSS* x2(3)=2.333;Sig.=.311

Baseline 15.00 7.443 1.68

Post-Intervention 15.55 8.847 2.0

Follow-Up 20.27 3.259 2.32

CD-RISC*

x2(3)=2.263; Sig.=.323

Baseline 73.30 14.795 1.65

Post-Intervention 77.70 15.748 2.3

Follow-Up 77.50 14.909 2.0

POMS*

x2(3)=XXX; Sig.=.XXX

Baseline 52.45 8.937 1

Post-Intervention 52.27 9.067 2

Follow-Up 52.27 9.981 3

*df = 2



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Table 3.1 Baseline Correlations

*Correlation is significant at the 0.01 level (2-tailed); **Correlation is significant at the 0.05 level (2-tailed)



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Table 3.2 Post-Intervention Correlations




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Table 3.3 Follow-Up correlations




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