For one veteran coping with PTSD and depression, his saving grace came in the form of a one-eyed dog who had been previously abused. This is his story, in his own words.


My name is Matthew Goschke; I’m born and raised in Rochester, New York. I’ve lived here my whole life besides my experiences with the military. I currently run security for the City of Rochester, loss prevention for The Home Depot and am pursuing my paramedic degree. After my military service I found integrating back into civilian life a lot more difficult then I had anticipated.

Light at the end of a “very dark” road

I was discharged from the Army honorably for PTSD and depression, which are results of my military time in service. It’s a terrible thing to have to deal with and the road I was on was a very dark one. I felt as if no one truly understood what I was going through. I started missing sleep, social life and work because of what was going on in my mind.

EliA good friend of mine recommended possibly getting a pet as a companion to help take my mind off things. I took her advice and went to my local shelter in Rochester. At this time not only was I dealing with my medical issues, I was going through a terrible divorce where I pretty much lost everything.

Since my adoption my life has done a complete 360. I couldn’t be happier. I was told by my grandmother “everything happens for a reason;” this is an exact example of that.

People are sometimes weirded out by the connection my dog and I have. I just know it’s the realest thing I’ve ever felt. Might not make sense because I can’t put a word on it, but bear with me here!

A dream fulfilled, then PTSD and depression

I joined the military in 2007 as a diver, but re-classed to what was my life long dream: to be a military police officer. I was honorably discharged from the Army for PTSD and depression due to events during my time of service. Since I can remember, the only thing I’ve ever wanted was to serve my country and be in the armed forces. I followed my dream.

Finding it hard to cope with my PTSD and depression, I had been to countless doctors and put on countless meds that I couldn’t even spell to save my life. Nothing seemed to work at all. After a friend of mine put the idea out there about a pet, I thought: it couldn’t hurt; I had tried it all.

I went to the Lollypop Farm shelter in Rochester. When I arrived it was the first time I had heard of the Pets for Patriots program and thought it would be great!

A one-eyed dog becomes a “symbol of hope”

Words cannot express how much my dog has changed my life. I shouldn’t say changed – I should say SAVED.

Matthew Eli tattooI saw no good end in sight until I met Tia, who I renamed Eli (she didnt seem to mind). She was in a bad spot just as I was: she was abused, starved, made to fight, had scars, lost her eye and even was electrocuted. She was a symbol hope for me.

This dog had been through all of these unthinkable events and was still as happy as could be. She is my motivation. My CURE. My life.

She is now my ESA (Emotional Support Animal). I’m off virtually all medications and Eli is actually prescribed to me by my doctor. She is my miracle.

She’s extremely funny; with only one eye she constantly runs into things and chases her tail (though only from one side). She’s gentle, protective, loyal, trustworthy and everything I wish I can be and display the rest of my life.


Matthew and Eli When asked what he would tell other veterans who might be thinking about adopting a last-chance pet through Pets for Patriots, Matthew says, “Simply to DO IT!”

In what ways has your pet been your personal miracle?


Oscar (therapy cat)

Oscar (born 2005) is a therapy cat living in the Steere House Nursing and Rehabilitation Center in Providence, Rhode Island, United States. He came to public attention in July 2007 when he was featured in an article by David Dosa, a geriatrician and assistant professor at Brown University, in the New England Journal of Medicine. According to Dosa, Oscar appears able to predict the impending death of terminally ill patients. Explanations for this ability include the lack of movement in such patients, or that the cat can smell ketones, the biochemicals released by dying cells.[1]

Oscar became the subject of a book by Dosa in 2010, Making Rounds With Oscar: The Extraordinary Gift of an Ordinary Cat.[2]


Oscar was adopted as a kitten from an animal shelter and grew up in the third-floor end-stage dementia unit at Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. The 41-bed unit treats people with Alzheimer’s, Parkinson’s disease and other illnesses, most of whom are in the end stage of life and are generally unaware of their surroundings.

Oscar was one of six cats adopted by Steere House, which bills itself as a “pet friendly” facility (a variety of pets visit and reside at the facility),[3] after the death of Steere House’s original therapy pet Henry (named for benefactor Henry J. Steere).

Death prediction

After about six months, the staff noticed that Oscar, just like the doctors and nurses, would make his own rounds. Oscar would sniff and observe patients, then curl up to sleep with certain ones. The patients he would sleep with often died within several hours of his arrival. One of the first cases involved a patient who had a blood clot in her leg that was ice cold at the time. Oscar wrapped his body around her leg and stayed until the woman died.[4] In another instance, the doctor had made a determination of impending death based on the patient’s condition, while Oscar simply walked away, causing the doctor to believe that Oscar’s streak (12 at the time) had ended. However, it would be later discovered that the doctor’s prognosis was simply 10 hours too early: Oscar later visited the patient, who died two hours later.[5]

Oscar’s accuracy (which stood at more than 25 consecutive reported instances when the NEJM article was written) led the staff to institute a new and unusual protocol: once he is discovered sleeping with a patient, staff will call family members to notify them of the patient’s (expected) impending death.[5]

Most of the time the patient’s family has no issue with Oscar being present at the time of death. On those occasions when he is removed from the room at the family’s request, he is known to pace back and forth in front of the door and meow in protest. When present, Oscar will stay by the patient until they die, then after death will quietly leave the room.

Oscar is described by Dr. David Dosa as “not a cat that’s friendly to [living] people.”[6] One example of this was described in his NEJM article. When an elderly woman with a walker passed him by during his rounds, Oscar “[let] out a gentle hiss, a rattlesnake-like warning that [said] ‘leave me alone.'”[5]

As of January 2010, Oscar had accurately predicted approximately 50 patients’ deaths.[2]

Possible explanations

Dr. Joan Teno, a professor of community health at Warren Alpert Medical School of Brown University in Providence who cares for Steere House residents and sees Oscar on a regular basis, said: “It’s not that the cat is consistently there first. But the cat always does manage to make an appearance, and it always seems to be in the last two hours.”[7]

Dr. Dosa (also affiliated with Alpert Medical School), who describes the phenomenon in an essay in the July 26 issue of the NEJM, says that “(Oscar) doesn’t make too many mistakes. He seems to understand when patients are about to die,” speculating that “the cat might be picking up on specific odors surrounding death.” Dr. Teno supports this view: “I think there are certain chemicals released when someone is dying, and he is smelling and sensing those.” [4]

Some animal behavior experts say the explanation about Oscar sensing a smell associated with dying is a plausible one. “I suspect he is smelling some chemical released just before dying,” says Margie Scherk, a veterinarian in Vancouver, British Columbia and president of the American Association of Feline Practitioners. “Cats can smell a lot of things we can’t,” she says. “And cats can certainly detect illness.” Dr. Jill Goldman, a certified applied animal behaviorist in Laguna Beach, California says that “Cats have a superb sense of smell,” adding that keeping a dying patient company may also be learned behavior. “There has been ample opportunity for him to make an association between ‘that’ smell [and death]”[4] (Oscar has spent nearly his entire life in the end-stage dementia unit of Steere House, where death is common and expected).

The sense of smell may, however, be just one explanation. Dr. Daniel Estep, a certified applied animal behaviorist in Littleton, Colorado suggests that “One of the things that happens with people who are dying is that they are not moving around much. Maybe the cat is picking up on the fact that the person on the bed is very quiet. It may not be smell or sounds, but just the lack of movement.”[4]

Dr. Thomas Graves, a feline expert from the University of Illinois, told the BBC: “Cats often can sense when their owners are sick or when another animal is sick. They can sense when the weather will change, they’re famous for being sensitive to premonitions of earthquakes.” [8]

Pitlik (2009) used Oscar as a metaphor for the infection by carbapenem-resistant Klebsiella pneumoniae. There is no definite evidence of the virulence of KPC, and this bacterial infection is not the cause for the patient’s death, but an indication of the poor prognosis.[9]

Scientific explanation

Skeptics have classed Oscar’s alleged abilities as pseudoscientific.[10][11] It has been noted that Dr. Dosa may have failed to follow Hyman’s categorical imperative, which states “Do not try to explain something until you are sure there is something to be explained”.[10] No experimental evidence has proven that Oscar has any psychic ability. The bulk of the evidence provided by Dosa, such as case studies where Oscar lay with dying patients, is heavily testimonial.

Oscar’s abilities were discovered by a supervising nurse who described herself as someone who wanted people to believe Oscar had powers and who subjectively searches for supporting evidence.[10][12] Dosa’s works appear to suffer from biased selection; his book about Oscar fails to mention any instances of Oscar being wrong, despite the fact that the same testimonial evidence that supports Oscar’s ability suggests that he has been wrong before. For example, there are stories of nurses bringing Oscar into the rooms of dying patients and forcing him onto their beds, despite Oscar’s protests.[10]

Dosa’s case also appears to benefit from some logical fallacies. It has been noted that much of the supporting testimonial evidence has been manipulated to create a reader-friendly story, while the opposing evidence is often ignored;[10] this suggests the logical fallacy of enumerating favourable circumstances.[13] He also uses the appeal to authority, stating that “experts” have discussed this and arrived at the conclusion that it was an ability of Oscar’s,[14] as well as post hoc ergo propter hoc: even if it were true that Oscar was in the beds with the patients before they died, there are third variables that could explain his behavior equally well.

In popular culture

  • In 2011, a feature film was announced as being in development, based on Dr. Dosa’s book.[15]
  • In Doctor Sleep, Stephen King‘s sequel to The Shining, grown-up Dan Torrance is aided at a hospice by a prescient cat who can sense when people are about to die. King stated in an interview that Oscar served as an inspiration to the story.[16]
  • Oscar was featured in an episode of Discovery Channel’s show Weird or What?
  • Season 5 episode 18 of House M.D. “Here Kitty”, involves a cat that had predicted numerous deaths by curling up next to dying victims’ bedsides.[17]

See also

Human–canine bond

Example of the human-canine bond

Human–canine bonding is the mutually beneficial and dynamic relationship between humans and dogs that is studied by psychologists, anthropologists, and ethologists.[1]

Dogs are domesticated descendants of wolves, and have a significant impact and role in human lives. In the United States, over 62% of people have a household pet and 37% of those pets are dogs.[2]

The related topic of anthropomorphism deals with the ideas people have about what animals know. Anthrozoology is a new field of study addressing human-animal interactions.


A Labrador Retriever with his owner on a jetski

The concept of the human-animal bond was articulated as early as the late 1930s, when Konrad Lorenz and his friend and colleague Nikolaas Tinbergen worked with geese in order to study the instinctive behaviors of animals, leading them to rediscover the principle of imprinting. The same concept was recognized in Boris Levinson‘s books Pet-Oriented Child Psychotherapy (1969) and Pets and Human Development (1979), which had an immense influence on the establishment of the field of study. Levinson is known for accidentally discovering the benefits of assisted-pet therapy. He found that withdrawn and uncommunicative children would interact positively whenever he brought his dog, Jingles, to their therapy sessions. His discovery was further reinforced by Sam and Elizabeth Corson at Ohio State University, who were among the first to research and evaluate pet-facilitated therapy.[3]

Only in the early 1980s was the term ‘human–animal bond’ officially invented by Leo K. Bustad, who delivered a summary lecture on the Human-Pet Relationship on October 28, 1983 at the International Symposium in Vienna. This symposium was held in honor of Konrad Lorenz, and during his lecture Bustad praised him for his work on the human–animal bond and encouraged others to build on Lorenz’s work on the subject.[4] Lorenz later adopted it in his research on imprinting in geese.[2]

Bustad and other pet therapy advocates formed the Delta Society, which was built on the earlier work of Levinson and Croson.[3] In the 1970s and 1980s, national and international conferences led to greater recognition of the human–animal bond. Since then, there has been widespread media coverage of animal-assisted activity and therapy programs and service dog training.[4]


A combat tracker dog handler with his dog

There are three major theories concerning the human–canine bond, known as the biophilia hypothesis, the social support theory, and the self-object theory.

According to the biophilia hypothesis, our relationships with non-human animals are driven by survival needs: assistance in acquiring food and safety. There is an instinctive bond between human beings and other living things, and this theory helps explain why ordinary people care for and sometimes risk their lives to save domestic and wild animals, and keep plants in and around their homes. The domestic animal demonstrates how humans love life and want to support and sustain life.

According to the social support theory, animals are a source of social support and companionship, which are necessary for well-being.[2][5] In other words, as humans we need others to survive. Support is seen for the social support theory in the influence of a pet on an empty-nester family. In this view the animal is part of our community, and is important for psychological well-being.

According to self psychology, an animal can be a “self object” that gives a sense of cohesion, support, or sustenance to a person’s sense of self. Self psychology explains why some animals are so crucial to a person’s sense of self and well-being.[6] In some cases, individuals have been known to feel stronger, more protected, and more powerful in the company of their companion animal. The animal itself creates a human’s personality.

Benefits of the Human–Canine Bond

Puppy with girls

According to the American Veterinary Medical Association, the human–canine bond is influenced by emotional, psychological, and physical interactions that are essential to the health and well-being of both people and dogs.

Animal-assisted therapy (AAT), service dogs, and animal-assisted activities demonstrate this human–canine bond and this interaction with an animal; in most cases a dog helps improve the quality of life.[7]

The AVMA officially recognizes that the human-animal bond exists, that it has existed for thousands of years, and that it has had a major impact on veterinary medicine.[8]

The human–canine bond also pertains to working dogs, such as modern police dogs and search and rescue dogs.

See also

Animal-assisted therapy

Animal-assisted therapy (AAT) is a type of therapy that involves animals as a form of treatment. The goal of AAT is to improve a patient’s social, emotional, or cognitive functioning. Advocates state that animals can be useful for educational and motivational effectiveness for participants.[1] A therapist who brings along a pet may be viewed as being less threatening, increasing the rapport between patient and therapist.[2] Animals used in therapy include domesticated pets, farm animals and marine mammals (such as dolphins). While the research literature presents the relationship between humans and companion animals as generally favorable, methodological concerns about the poor quality of the data have led to calls for improved experimental studies.[3]
Wilson’s (1984) biophilia hypothesis is based on the premise that our attachment to and interest in animals stems from the strong possibility that human survival was partly dependent on signals from animals in the environment indicating safety or threat. The biophilia hypothesis suggests that now, if we see animals at rest or in a peaceful state, this may signal to us safety, security and feelings of well-being which in turn may trigger a state where personal change and healing are possible [4]

Dogs are common in animal-assisted therapy.


Animal-assisted therapy sprouted from the idea and initial belief in the supernatural powers of animals and animal spirits. It first appeared in the groupings of early hunter gatherer societies. In modern times animals are seen as “agents of socialization” and as providers of “social support and relaxation.” [5] Though animal assisted therapy is believed to have began in these early human periods it is undocumented and based on speculation. The earliest reported use of AAT for the mentally ill took place in the late 18th century at the York Retreat in England, led by William Tuke.[6] Patients at this facility were allowed to wander the grounds which contained a population of small domestic animals. These were believed to be effective tools for socialization. In 1860, the Bethlem Hospital in England followed the same trend and added animals to the ward, greatly influencing the morale of the patients living there.[6]

Sigmund Freud kept many dogs and often had his chow Jofi present during his pioneering sessions of psychoanalysis. He noticed that the presence of the dog was helpful because the patient would find that their speech would not shock or disturb the dog and this reassured them and so encouraged them to relax and confide. This was most effective when the patient was a child or adolescent.[7] The theory behind AAT is what is known as Attachment theory.

Therapy involving animals was first used in therapy by Dr. Boris Levinson who accidentally discovered the use of pet therapy with children when he left his dog alone with a difficult child, and upon returning, found the child talking to the dog.[8] However, in other pieces of literature it states that it was founded as early as 1792 at the Quaker Society of Friends York Retreat in England.[9] Velde, Cipriani & Fisher also state “Florence Nightingale appreciated the benefits of pets in the treatment of individuals with illness. The US military promoted the use of dogs as a therapeutic intervention with psychiatric patients in 1919 at St Elizabeth’s Hospital in Washington, DC. Increased recognition of the value of human–pet bonding was noted by Dr. Boris Levinson in 1961”.[9]


Golden Retrievers are often trained as assistance dogs.

Animals can be used in a variety of settings such as prisons, nursing homes, mental institutions,[10] hospitals and in the home.[2] Assistance dogs can assist people with many different disabilities; they are capable of assisting certain life activities and help the individuals navigate outside of the home.[2]

Steps in animal-assisted therapy include three stages for physical and psychological health improvement.

Stage One:
Patient goes to session with therapist without animals present to assess therapy needs. The next session the animal is introduced to the client and interactions between the animal and client begin.

Stage Two:
Developing a bond between the animal and client by developing motor skills. Examples include feeding the animal treats or grooming. Then an introduction of verbal skills using verbal commands such as stay and sit. Therapists use animals as a form of motivation for the client. The client is asked to perform tasks like getting water and food for their animal to improve motor functions like walking. Positive social interactions with animals is translated and generalized to positive human interactions.

Stage Three:
Therapist monitors improvement with animal interaction and human interaction and judges positive social situation. Patients are then given power and independence with the freedom to make choices for the animal assisted therapy partner. After client can interact with humans as well as they can with animals treatment is complete.[11]

As with all other interventions, assessing whether a program is effective as far as its outcomes are concerned is easier when the goals are clear and are able to be specified. The literature review identified a range of goals for animal assisted therapy programs relevant to children and young people. They include enhanced capacity to form positive relationships with others i-relief in pet ownership.[12]

Marcus et al.[13] conducted a study using therapy dogs in an Outpatient Pain management clinic. Patients sat in either a waiting room, or a room with a therapy dog in it. Results demonstrated that there were significant improvements on pain, mood, and other distressful measures when patients or family members were placed in the therapy dog room. The study took place over a 2 month time period. They concluded that patients visited by these therapy dogs have a reduction in their pain rating and an improvement in their mood, with this in mind, there have been many nursing homes and hospitals that elicit the help of cats and dogs as a comfort for patients in their time of need. Patients in these scenarios report elevated mood and comfort when the animal is around. It is also thought that animals create a more positive environment for the hospital or clinic itself, with staff member also reporting elevated moods, as well as creating a more positive appearance of the clinician to the patient. Preliminary findings suggest that stress reduction in healthcare professionals may occur after as little as 5 minutes of interaction with a therapy dog.[14] Another example is Cole’s 2007[15] study on patients who were in critical care after experiencing heart failure. The patients were visited three different times over a period of three months by either a volunteer with a therapy dog, a volunteer by themselves, or the usual care that they had been receiving. The results showed a significant decrease in the cardiopulmonary pressure, neurohormone level, and anxiety level of those patients who received the twelve minute visit by the therapy dog. Cole cites many other resources such as Blascovich,[16] and Shykoff [17] where AAT has helped reduce blood pressure and stress among individuals, however these studies focus more on pet ownership as a method rather than AAT.

Pets may promote kindness in children.

Becoming AAT certified

In order to become Animal-Assisted Therapy certified, a pet owner must go through Pet Partners, formerly Delta Society,[18] a nonprofit organization that emphasizes the use of animals in therapy to help people live healthier and happier lifestyles.[19] There is a simple four step process that Pet Partners offers to become a registered Pet Partners Team. The first step is on online or in classroom course where the pet handler, or owner, is trained to guide the animal in therapy sessions. They are also trained on what signs to look for in the patients to make sure they are comfortable and at ease. The next step is a screening of the health of the animal for any diseases or issues that may inhibit the animal from being useful in therapy. The animal needs to be approved by a professional veterinarian before moving on to the next step. The third step includes a test that checks the skills and ability of the animal and handler to react in therapy sessions. The last step is the submission of the Registration Application. Once approved, the animal and their owner are certified to assist in therapy in hospitals, retirement homes, and other places.[20]

Benefiting children

Children also can receive positive benefits from Animal Assisted therapy in the class setting. Frieson[21] (2010) conducted a study with children and therapy dogs in a class room setting and found that the animals provide a social and emotional support system for the child, with assumptions that because the animal seems non-judgmental to the child, it is perceived as comforting, raises the child’s self-esteem and makes it easier for the child to express themselves.[22]

Therapists rely on techniques such as monitoring a child’s behavior with animal, their tone of voice, and indirect interviewing. These techniques are used, along with the child’s pet or other animal, in order to gain information.[8] Before pet therapy can be useful, the child and the animal must first develop a sense of comfort with each other, which is easier to achieve if the child’s own pet is used.[8] The applied technique that generates the most helpful information about the victim’s experience is telling the child that the animal wants to know how they are feeling or what happened. Applying pet therapy to victims of sexual assault can also reduce depression, anxiety, and other symptoms of post-traumatic stress disorder. Pet therapy promotes social interaction and is increasingly more accessible to those who already have pets. Victims of sexual assault are less likely to be anxious and are comforted by the presence of a companion that is offered through pet therapy.[23] While there are other ways in which victims of sexual assault can receive therapy, the application of pet therapy does have a certain degree of success in these situations. For example, pet therapy helps the counselor and victim develop a positive alliance and a great sense of rapport more quickly.[23] As mentioned before, the presence of a pet or other animal helps victims of sexual assault feel more comfortable in a therapy setting. The application of pet therapy in sexual assault cases has also contributed positively to victims outside of counseling sessions.[23] The positive feelings that pet therapy induces during therapy sessions with sexual assault victims will carry over with victims outside of therapy. The increased comfort that having a companion builds will also help victims remain more comfortable from day to day, which will lead to fast recovery.[8] Studies of the human-companion animal bond reveal many physiological and psychological benefits. “Petting a dog with which one is bonded to promotes relaxation, characterized by decreased blood pressure and increases in peripheral skin temperature”.[9] Other benefits include releasing stress, increasing morale, increased calmness, decrease preoperative anxiety, improve patient outlook, reduce the need for preoperative medication, reduce fear and anxiety in patients with a psychiatric condition. Velde, Cipriani & Fisher (2005) also stated “Motivation is increased with animal interaction. For example, persons who had refused therapy came to the therapy sessions when they knew animals were going to be present.[9] Interaction with animals changes the morale of long-term care residents. Occupational therapy participants continue doing therapeutic activities for a longer duration when animals are present, thereby potentially increasing the benefits of this therapy.[9]

Mental institutions, hospitals and nursing homes

A 1998 study looked at the use of AAT in reducing anxiety levels of institutionalized patients. They determined that anxiety levels were significantly reduced in patients with mood disorders and psychotic disorders after a session of AAT. In fact, for the patients with psychotic disorders, those who participated in AAT had twice the reduction in anxiety scores as those who participated in some other form of recreational activity. This suggests the low demands of human-animal interaction was effective for individuals with psychotic disorders as compared to traditional therapy.[24] A controlled study of 20 elderly schizophrenic patients found significant improvements through the use of cats and dogs as companions, indicating that this population may benefit from the companionship of an animal, especially if they do not have access to friends or family.[25][medical citation needed] Pets may also provide an opportunity for fun and relaxation.[2] Another example can be seen with the famous case of Oscar the cat and a Providence, Rhode Island nursing home. Patients and family member reported a sense of calming when the cat would enter their room. Although the cat was a sign that the patient was dying, family members were thankful for the comfort that the cat seemed to instill in their loved one. The cat would jump on the patients lap and stay with them until they passed. In [26] National Capital Therapy Dogs Inc., a non-profit, all-volunteer organization that provides animal-assisted therapy to many people in health facilities, shelters, schools and libraries, has more than fifty teams of pet/human therapist combinations that work with patients that have severe medical conditions. They are able to improve morale for people who are undergoing intense medical treatments, reducing depression and anxiety as well as chronic pain.

Nursing homes

Animal assisted therapy draws on the bond between animals and humans in order to help improve and maintain an individual’s function and is being used to assist in the process of enhancing the individual’s quality of life in nursing homes.[27] Psychologists and therapists notice increasing unfavorable behaviors of elderly people that are transferred to nursing homes. Once the patients become settled into their new environment, they lose their sense of self-efficacy and independence. Simple, everyday tasks are taken away from them and the patients become lethargic, depressed, and anti-social if they do not have regular visitors.[28]

Animal assisted therapy (AAT) is a type of therapy that incorporates animals in the treatment of a person; especially elderly people in nursing homes or long term care (LTC) facilities. The goal of using animals as a treatment option is to improve the person’s social, emotional, and cognitive functioning and reduce passivity. When elderly people are transferred to nursing homes or LTC facilities, they often become passive, agitated, withdrawn, depressed, and inactive because of the lack of regular visitors or the loss of loved ones.[29] Supporters of AAT say that animals can be helpful in motivating the patients to be active mentally and physically, keeping their minds sharp and bodies healthy.[30] Therapists or visitors who bring animals into their sessions at the nursing home are often viewed as less threatening, which increases the relationship between the therapist/visitor and patient.[31]

There are numerous techniques used in AAT, depending on the needs and condition of the patient. For elderly dementia patients, hands on interactions with the animal are the most important aspect. Animal assisted therapy provides these patients with opportunities to have close physical contact with the animals warm bodies, feeling heartbeats, caress soft skins and coats, notice breathing, and giving hugs. Animal assisted therapy counselors also plan activities for patients that need physical movement. These planned tasks include petting the animal, walking the animal, and grooming the animal. These experiences seem so common and simple, but elderly dementia patients do not typically have these interactions with people because their loved ones have passed or no one comes to visit them. Their mind needs to be stimulated in the ways it once was. Animals provide a sense of meaning and belonging to these patients and offer something to look forward to during their long days.[28]

The AAT program encourages expressions of emotions and cognitive stimulation through discussions and reminiscing of memories while the patient bonds with the animal. Many of the troubling symptoms in elderly dementia patients include decreased physical functioning, apathy, depression, loneliness, and disturbing behaviors and are all positively affected by AAT interventions. Animal assisted therapy is very useful in helping these negative behaviors decrease by focusing their attention on something positive (the animal) rather than their physical illness, motivating them to be physically active and encouraging communication skills for those with memory loss.[28] Numerous researchers found that communication with animals have a positive effect on older adults by increasing their social behavior and verbal interaction, while also decreasing tense behavior and loneliness.[32]


There are many types of AAT ranging from the use of dogs, to cats, even to small animals such as fish and hamsters. The most popular forms of AAT include Canine therapy, Dolphin therapy, and Equine therapy.

Dolphin therapy

Dolphin assisted therapy refers to the practice of swimming with dolphins. Proponents claim for such encounters “extraordinary results of the therapy and breakthroughs in outcomes”,[33] however this form of therapy has been strongly criticised as having no long term benefit,[34] and being based on flawed observations.[35] Psychologists have cautioned that dolphin assisted therapy is not effective for any known condition and presents considerable risks to both human patients and the captive dolphins.[36]

Equine therapy

Hippotherapy can be used as a treatment for people with physical or mental challenges.
Main article: Hippotherapy

A distinction exists between hippotherapy and therapeutic horseback riding. The American Hippotherapy Association defines hippotherapy as a physical, occupational, and speech-language therapy treatment strategy that utilizes equine movement as part of an integrated intervention program to achieve functional outcomes, while the Professional Association of Therapeutic Horsemanship International (PATHI) defines therapeutic riding as a riding lesson specially adapted for people with special needs.[37] According to Marty Becker, hippotherapy programs are active “in twenty-four countries and the horse’s functions have expanded to therapeutic riding for people with physical, psychological, cognitive, social, and behavioral problems”.[38] Hippotherapy has also been approved by the American Speech and Hearing Association as a treatment method for individuals with speech disorders.[37] In addition, equine assisted psychotherapy (EAP) uses horses for work with persons who have mental health issues. EAP often does not involve riding.[39][40] Additional information pertaining to equine assisted therapy can be seen with Laira Gold’s open clinical study of EAT [41]


Although animal assisted therapy has been considered a new way to deal with depression, anxiety, Autism, and childhood aliments such as Attention deficit hyperactivity disorder, there has been criticism as to the effectiveness of the process. According to Lilienfeld and Arkowitz animal-assisted therapy is better considered a temporary fix. They point to the lack of longitudinal data or research to see if there is evidence for long term improvement in patients undergoing the therapy. They then suggest that this further supports the idea that AAT is more of an affective method of therapy rather than a behavioral treatment. They also state the dangers of these therapy programs in particular the Dolphin assisted therapy. Dolphin assisted therapy has not been shown to have significant results when dealing with a child’s behavior. Instead Lilienfeld suggest that again animal assisted therapy might be a short term reinforcer, not a long term one. They also suggest that studies dealing with children should look into more balanced measures, such as having one group of children in the Dolphin group and the other in a setting where they still receive positive reinforcement. It is also suggested that DAT is harmful to the dolphins themselves; by taking dolphins out of their natural environment and putting them in captivity for therapy can be hazardous to their well being.[42] There are not many quantitative studies about the impact of swimming with dolphins have on social behavior.[43] Of the few studies, data has seemed limited or mixed in results. The first research on the effects of Dolphin-Assisted Therapy as a treatment was a case study by Betsy Smith in 1987. The dolphins were used to motivate a child with autism to communicate.[43] Smith concluded that the use of Dolphin-Assisted Therapy has shown promising results on increasing attention spans and improved interaction and play behavior in the children. Other studies after concerning Dolphin Assisted Therapy yielded about the same results but failed to take into account other situational factors, what is also known as a confound, one or more effective ingredient in a study [44] that may have an impact on results in the study. Heimlich discussed in her study of AAT’s effect on severely disabled children that without evidence that this type of therapy works outside a laboratory setting, assumptions can not be made that it is an effective form of therapy.[45][undue weight? ] In addition, O’Haire noted that while most studies had reported positive results for autism, these studies were limited by “many methodological weaknesses,” concluding that further research is needed.[46]

Another limitation of pet therapy also centers on the application during scenarios that involve adults who have been sexually assaulted. While pets do tend to cause more comfort to victims, pet therapy may not be the catalyst that provides positive success in therapy sessions. As mentioned above, adults tend not to focus as much on having an animal companion, and therefore, pet therapy cannot be attributed as the reason for success in those types of therapy sessions.[8] Pet therapy does not raise any ethical concerns as far as advancing nonscientific agendas. On the other hand, there are some ethical concerns that arise when applying pet therapy to younger victims of sexual assault. For example, if a child is introduced to an animal that is not their pet, the application of pet therapy can cause some concerns. First of all, some children may not be comfortable with animals or may be frightened, so there would be ethical concerns with using pet therapy, which could be avoided by asking permission to use animals in therapy. Second, a special bond is created between animal and child during pet therapy. Therefore, if the animal in question does not belong to the child, there may be some negative side effects when the child discontinues therapy. The child will have become attached to the animal, which does raise some ethical issues as far as subjecting a child to the disappointment and possible relapse that can occur after therapy discontinues.[8]

See also

Play therapy

From Wikipedia, the free encyclopedia

Play therapy is generally employed with children aged 3 through 11 and provides a way for them to express their experiences and feelings through a natural, self-guided, self-healing process. As children’s experiences and knowledge are often communicated through play, it becomes an important vehicle for them to know and accept themselves and others.


Play therapy is a form of counseling or psychotherapy that uses play to communicate with and help people, especially children, to prevent or resolve psychosocial challenges. This is thought to help them towards better social integration, growth and development.

Play therapy can also be used as a tool of diagnosis. A play therapist observes a client playing with toys (play-houses, pets, dolls, etc.) to determine the cause of the disturbed behavior. The objects and patterns of play, as well as the willingness to interact with the therapist, can be used to understand the underlying rationale for behavior both inside and outside the session..

According to the psychodynamic view, people (especially children) will engage in play behavior in order to work through their interior obfuscations and anxieties. In this way, play therapy can be used as a self-help mechanism, as long as children are allowed time for “free play” or “unstructured play.” Normal play is an essential component of healthy child development.

One approach to treatment is for play therapists to use a type of desensitization or relearning therapy to change disturbing behavior, either systematically or in less formal social settings. These processes are normally used with children, but are also applied with other pre-verbal, non-verbal, or verbally-impaired persons, such as slow-learners, or brain-injured or drug-affected persons.


Play has been recognized as important since the time of Plato (429-347 B.C.) who reportedly observed, “you can discover more about a person in an hour of play than in a year of conversation.” In the eighteenth century Rousseau (1712-1778), in his book ‘Emile’ wrote about the importance of observing play as a vehicle to learn about and understand children. Friedrich Fröbel, in his book The Education of Man (1903), emphasized the importance of symbolism in play. He observed, “play is the highest development in childhood, for it alone is the free expression of what is in the child’s soul…. children’s play is not mere sport. It is full of meaning and import.” (Fröbel, 1903, p. 22) The first documented case, describing the therapeutic use of play, was in 1909 when Sigmund Freud published his work with “Little Hans.” Little Hans was a five-year-old child who was suffering from a simple phobia. Freud saw him once briefly and recommended that his father take note of Hans’ play to provide insights that might assist the child. The case of “Little Hans” was the first case in which a child’s difficulty was related to emotional factors.

Hermine Hug-Hellmuth (1921) formalized the play therapy process by providing children with play materials to express themselves and emphasize the use of the play to analyze the child. In 1919, Melanie Klein (1955) began to implement the technique of using play as a means of analyzing children under the age of six. She believed that child’s play was essentially the same as free association used with adults, and that as such, it was provide access to the child’s unconscious. Anna Freud (1946, 1965) utilized play as a means to facilitate positive attachment to the therapist and gain access to the child’s inner life.

In the 1930s David Levy (1938) developed a technique he called release therapy. His technique emphasized a structured approach. A child, who had experienced a specific stressful situation, would be allowed to engage in free play. Subsequently, the therapist would introduce play materials related to the stress-evoking situation allowing the child to reenact the traumatic event and release the associated emotions.

In 1955, Gove Hambidge expanded on Levy’s work emphasizing a “Structured Play Therapy” model, which was more direct in introducing situations. The format of the approach was to establish rapport, recreate the stress-evoking situation, play out the situation and then free play to recover.

Jesse Taft (1933) and Frederick Allen (1934) developed an approach they entitled relationship therapy. The primary emphasis is placed on the emotional relationship between the therapist and the child. The focus is placed on the child’s freedom and strength to choose.

Carl Rogers (1942) expanded the work of the relationship therapist and developed non-directive therapy, later called client-centered therapy (Rogers, 1951). Virginia Axline (1950) expanded on her mentor’s concepts. In her article entitled ‘Entering the child’s world via play experiences’ Axline summarized her concept of play therapy stating, “A play experience is therapeutic because it provides a secure relationship between the child and the adult, so that the child has the freedom and room to state himself in his own terms, exactly as he is at that moment in his own way and in his own time” (Progressive Education, 27, p. 68).

In 1953 Clark Moustakas wrote his first book Children in Play Therapy. In 1956 he compiled Publication of The Self, the result of the dialogues between Abraham Maslow, Carl Rogers, Clark Moustakas and others, forging the Humanistic Psychology movement.

Filial therapy, developed by Bernard and Louise Guerney, was a new innovation in play therapy during the 1960s. The filial approach emphasizes a structured training program for parents in which they learn how to employ child-centered play sessions in the home. In the 1960s, with the advent of school counselors, school-based play therapy began a major shift from the private sector. Counselor-educators such as Alexander (1964); Landreth (1969, 1972); Muro (1968); Myrick and Holdin (1971); Nelson (1966); and Waterland (1970) began to contribute significantly, especially in terms of using play therapy as both an educational and preventive tool in dealing with children’s issues.

1973 Clark Moustakas continues his journey into play therapy and publishes his novel “The child’s discovery of himself”. Clark Moustakas’ work as being concerned with the kind of relationship needed to make therapy a growth experience. His stages start with the child’s feelings being generally negative and as they are expressed, they become less intense, the end results tend to be the emergence of more positive feelings and more balanced relationships. Today, his daughter Kerry Moustakas continues his legacy as an author and president of The Michigan School of Professional Psychology. 2004 Clark and Kerry Moustakas publish Loneliness, Creativity and Love: Awakening Meanings in Life.

Growth of organizations

In 1982, the Association for Play Therapy (APT) was established marking not only the desire to promote the advancement of play therapy, but to acknowledge the extensive growth of play therapy. Currently, the APT has almost 5,000 members in twenty-six countries (2006). Play therapy training is provided, according to a survey conducted by the Center for Play Therapy at the University of North Texas (2000), by 102 universities and colleges throughout the United States. The APT provides certification in play therapy and play therapy supervision for clinicians. They also offer a list of play therapists by local and training opportunities.

In 1985, the work of two key Canadians in the field of child psychology and play therapy, Mark Barnes and Cynthia Taylor, resulted in the establishment of Certification Standards through the non-profit Canadian child psychotherapy and play therapy association. A fledgling group of practising Canadian child psychotherapists and play therapists worked on developing an organization to meet professional needs. It gradually expanded and eventually a Board of Directors was formed; objects and by-laws were designed, revised, re-revised and finally approved by the Government of Canada. The Canadian association was eventually recognized as a non-profit organization in 1986.

During 1995/1996, a whole new horizon opened up for the profession of play therapy as a result of the Canadian Play Therapy Institute’s pioneering efforts on an International basis. Play Therapy International was founded from the Canadian Play Therapy Institute and there now existed a mutually supportive recognition between Play Therapy International/The International Board of Examiners of Certified Play Therapists, The Canadian Play Therapy Institute, as well as a number of other professional bodies throughout the world.

In the UK, The United Kingdom Society for Play and Creative Arts Therapies Limited (known in short as PTUK) was originally set up in October 2000 as Play Therapy UK with the encouragement of Play Therapy International. Meanwhile the British Association of Play Therapists was distinguished from its American counterpart in 1996 and was granted charity status within the UK in 2006 by the UK Charities Commission.

By 2010 Play Therapy International has partnered sister organisations in Ireland, Canada, Australasia, France, Spain, Wales, Malaysia, Romania, Russia, United Kingdom, Slovenia, Germany, New Zealand, Hong Kong, Korea and Ethiopia.


An individual engaging in sandplay therapy.
Equipment used for sandplay therapy.

Play therapy can be divided into two basic types: nondirective and directive. Nondirective play therapy is a non-intrusive method in which children are encouraged to work toward their own solutions to problems through play. It is typically classified as a psychodynamic therapy. In contrast, directive play therapy is a method that includes more structure and guidance by the therapist as children work through emotional and behavioral difficulties through play. It often contains a behavioral component and the process includes more prompting by the therapist. Directive play therapy is more likely to be classified as a type of cognitive behavioral therapy.[1] Both types of play therapy have received at least some empirical support.[2] On average, play therapy treatment groups when compared to control groups improve by .8 standard deviations.[2]

Nondirective play therapy

Nondirective play therapy, also called client-centered and unstructured play therapy, is guided by the notion that if given the chance to speak and play freely under optimal therapeutic conditions, troubled children and young people will be able to resolve their own problems and work toward their own solutions. In other words, nondirective play therapy is regarded as non-intrusive.[3] The hallmark of nondirective play therapy is that it has few boundary conditions and thus can be used at any age.[4] This therapy originates from Carl Rogers‘s non-directive psychotherapy and in his characterization of the optimal therapeutic conditions. Virginia Axline adapted Carl Rogers’s theories to child therapy in 1946 and is widely considered the founder of this therapy.[5] Different techniques have since been established that fall under the realm of nondirective play therapy, including traditional sandplay therapy, family therapy, and play therapy with the use of toys. Each of these forms is covered briefly below.

Play therapy using a tray of sand and miniature figures is attributed to Margaret Lowenfeld, who established her “World Technique” in 1929. Dora Kalff combined Lowenfeld’s World Technique with Jung’s idea of the collective unconscious and received Lowenfeld’s permission to name her version of the work “sandplay” (Kalff, 1980).[full citation needed]

As in traditional nondirective play therapy, research has shown that allowing an individual to freely play with the sand and accompanying objects in the contained space of the sandtray (22.5″ x 28.5″) can facilitate a healing process as the unconscious expresses itself in the sand and influences the sand player. When a client creates in the sandtray, little instruction is provided and the therapist offers little or no talk during the process. This protocol emphasizes the importance of holding what Kalff (1980) referred to as the “free and protected space” to allow the unconscious to express itself in symbolic, non-verbal play. Upon completion of a tray, the client may or may not choose to talk about his or her creation, and the therapist, without the use of directives and without touching the sandtray, may offer supportive response that does not include interpretation. The rationale is that the therapist trusts and respects the process by allowing the images in the tray to exert their influence without interference.[citation needed]

Sand tray therapy can be used during family therapy. The limitations presented by the boundaries of the sandtray can serve as physical and symbolic limitations to families in which boundary distinctions are an issue. Also when a family works together on a sandtray, the therapist may make several observations, such as unhealthy alliances, who works with who, which objects are selected to be incorporated into the sandtray, and who chooses which objects. A therapist may assess these choices and intervene in an effort to guide the formation of healthier relationships.[6]

Using toys in nondirective play therapy with children is another common method therapists employ, a method which was derived from the creative toys used in Freud‘s theoretical orientations.[7] The idea behind this method is that children will be better able to express their feelings toward themselves and their environment through play with toys than through verbalization of their feelings. Through these actions, then, children may be able to experience catharsis, gain more or better insight into their consciousness, thoughts, and emotions, and test their own reality.[8] Popular toys used during therapy are animals, dolls, hand puppets, crayons, and cars. Therapists have deemed toys such as these more likely to encourage dramatic play or creative associations, both of which are important in expression.[7]


Play therapy has been considered to be an established and popular mode of therapy for children for over sixty years.[9] Critics of play therapy have questioned the effectiveness of the technique for use with children and have suggested using other interventions with greater empirical support such as cognitive behavioral therapy.[1] They also argue that therapists focus more on the institution of play rather than the empirical literature when conducting therapy [10] Classically, Lebo argued against the efficacy of play therapy in 1953, and Phillips reiterated his argument again in 1985. Both claimed that play therapy lacks in several areas of hard research. Many studies included small sample sizes, which limits the generalizeability, and many studies also only compared the effects of play therapy to a control group. Without a comparison to other therapies, it is difficult to determine if play therapy really is the most effective treatment.[11][12] Recent play therapy researchers have worked to conduct more experimental studies with larger sample sizes, specific definitions and measures of treatment, and more direct comparisons.[10]

Research is lacking on the overall effectiveness of using toys in nondirective play therapy. Dell Lebo found that out of a sample of over 4,000 children, those who played with recommended toys vs. non-recommended or no toys during nondirective play therapy were not more likely to verbally express themselves to the therapist. Examples of recommended toys would be dolls or crayons, while example of non-recommended toys would be marbles or a checker game.[7] There is also ongoing controversy in choosing toys for use in nondirective play therapy, with choices being largely made through intuition rather than through research.[8] However, other research shows that following specific criteria when choosing toys in nondirective play therapy can make treatment more efficacious. Criteria for a desirable treatment toy include a toy that facilitates contact with the child, encourages catharsis, and lead to play that can be easily interpreted by a therapist.[8]

Several meta analyses have shown promising results toward the efficacy of nondirective play therapy. Meta analysis by authors LeBlanc and Ritchie, 2001, found an effect size of 0.66 for nondirective play therapy.[3] This finding is comparable to the effect size of 0.71 found for psychotherapy used with children,[13] indicating that both nondirective play and non-play therapies are almost equally effective in treating children with emotional difficulties. Meta analysis by authors Ray, Bratton, Rhine and Jones, 2001, found an even larger effect size for nondirective play therapy, with children performing at 0.93 standard deviations better than non-treatment groups.[1] These results are stronger than previous meta-analytic results, which reported effect sizes of 0.71,[13] 0.71,[14] and 0.66.[3] Meta analysis by authors Bratton, Ray, Rhine, and Jones, 2005, also found a large effect size of 0.92 for children being treated with nondirective play therapy.[2] Results from all meta-analyses indicate that nondirective play therapy has been shown to be just as effective as psychotherapy used with children and even generates higher effect sizes in some studies.[1][2]

There are several predictors that may also influence the effectiveness of play therapy with children. Number of sessions is a significant predictor in post-test outcomes, with more sessions being indicative of higher effect sizes.[1] Although positive effects can be seen with the average 16 sessions,[5] there is a peak effect when a child can complete 35-40 sessions.[3] An exception to this finding is children undergoing play therapy in critical-incident settings, such as hospitals and domestic violence shelters. Results from studies that looked at these children indicated a large positive effect size after only 7 sessions, which provides the implication that children in crisis may respond more readily to treatment [2] Parental involvement is also a significant predictor of positive play therapy results. This involvement generally entails participation in each session with the therapist and the child.[15] Parental involvement in play therapy sessions has also been shown to diminish stress in the parent-child relationship when kids are exhibiting both internal and external behavior problems.[16] Despite these predictors which have been shown to increase effect sizes, play therapy has been shown to be equally effective across age, gender, and individual vs. group settings.[1][2]

Directive play therapy

Directive play therapy is guided by the notion that using directives to guide the child through play will cause a faster change than is generated by nondirective play therapy. The therapist plays a much bigger role in directive play therapy. Therapists may use several techniques to engage the child, such as engaging in play with the child themselves or suggesting new topics instead of letting the child direct the conversation himself.[17] Stories read by directive therapists are more likely to have an underlying purpose, and therapists are more likely to create interpretations of stories that children tell. In directive therapy games are generally chosen for the child, and children are given themes and character profiles when engaging in doll or puppet activities.[18] This therapy still leaves room for free expression by the child, but it is more structured than nondirective play therapy. There are also different established techniques that are used in directive play therapy, including directed sandtray therapy and cognitive behavioral play therapy.[17]

Directed sandtray therapy is more commonly used with trauma victims and involves the “talk” therapy to a much greater extent. Because trauma is often debilitating, directed sandplay therapy works to create change in the present, without the lengthy healing process often required in traditional sandplay therapy.[19] This is why the role of the therapist is important in this approach. Therapists may ask clients questions about their sandtray, suggest them to change the sandtray, ask them to elaborate on why they chose particular objects to put in the tray, and on rare occasions, change the sandtray themselves. Use of directives by the therapist is very common. While traditional sandplay therapy is thought to work best in helping clients access troubling memories, directed sandtray therapy is used to help people manage their memories and the impact it has had on their lives.[19]

Roger Phillips, in the early 1980s, was one of the first to suggest that combining aspects of cognitive behavioral therapy with play interventions would be a good theory to investigate.[11] Cognitive behavioral play therapy was then developed to be used with very young children between two and six years of age. It incorporates aspects of Beck’s cognitive therapy with play therapy because children may not have the developed cognitive abilities necessary for participation in straight cognitive therapy.[20] In this therapy, specific toys such as dolls and stuffed animals may be used to model particular cognitive strategies, such as effective coping mechanisms and problem-solving skills. Little emphasis is placed on the children’s verbalizations in these interactions but rather on their actions and their play.[18] Creating stories with the dolls and stuffed animals is a common method used by cognitive behavioral play therapists in order to change children’s maladaptive thinking.


The efficacy of directive play therapy has been less established than that of nondirective play therapy, yet the numbers still indicate that this mode of play therapy is also effective. In 2001 meta analysis by authors Ray, Bratton, Rhine, and Jones, direct play therapy was found to have an effect size of .73 compared to the .93 effect size that nondirective play therapy was found to have.[1] Similarly in 2005 meta analysis by authors Bratton, Ray, Rhine, and Jones, directive therapy had an effect size of 0.71, while nondirective play therapy had an effect size of 0.92.[2] Although the effect sizes of directive therapy are statistically significantly lower than those of nondirective play therapy, they are still comparable to the effect sizes for psychotherapy used with children, demonstrated by Casey,[13] Weisz,[14] and LeBlanc.[3] A potential reason for the difference in the effect size may be due to the amount of studies that have been done on nondirective vs. directive play therapy. Approximately 73 studies in each meta analysis examined nondirective play therapy, while there were only 12 studies that looked at directive play therapy. Once more research is done on directive play therapy, there is potential that effect sizes between nondirective and directive play therapy will be more comparable.[1][2]

Parent/child play therapy

Several approaches to play therapy have been developed for parents to use in the home with their own children.[21]

Training in nondirective play for parents has been shown to significantly reduce mental health problems in at-risk preschool children.[22] One of the first parent/child play therapy approaches developed was Filial Therapy (in the 1960s – see History section above), in which parents are trained to facilitate nondirective play therapy sessions with their own children. Filial therapy has been shown to help children work through trauma and also resolve behavior problems.[23]

Another approach to play therapy that involves parents is Theraplay, which was developed in the 1970s. At first, trained therapists worked with children, but Theraplay later evolved into an approach in which parents are trained to play with their children in specific ways at home. Theraplay is based on the idea that parents can improve their children’s behavior and also help them overcome emotional problems by engaging their children in forms of play that replicate the playful, attuned, and empathic interactions of a parent with an infant. Studies have shown that Theraply is effective in changing children’s behavior, especially for children suffering from attachment disorders.[24]

In the 1980s, Stanley Greenspan developed Floortime, a comprehensive, play-based approach for parents and therapists to use with autistic children.[25] There is evidence for the success of this program with children suffering from autistic spectrum disorders.[26][27]

Lawrence Cohen has created an approach called Playful Parenting, in which he encourages parents to play with their children to help resolve emotional and behavioral issues. Parents are encouraged to connect playfully with their children through silliness, laughter, and roughhousing.[28]

In 2006, Garry Landreth and Sue Bratton devleoped a highly researched and structured way of teaching parents to engage in therapeutic play with their children. It is based on a supervised entry level training in child centered play therapy. They named it Child Parent Relationship Therapy.[29] These 10 sessions focus on parenting issues in a group environment and utilizes video and audio recordings to help the parents receive feedback on their 30 minute ‘special play times’ with their children.

More recently, Aletha Solter has developed a comprehensive approach for parents called Attachment Play, which describes evidence-based forms of play therapy, including nondirective play, more directive symbolic play, contingency play, and several laughter-producing activities. Parents are encouraged to use these playful activities to strengthen their connection with their children, resolve discipline issues, and also help the children work through traumatic experiences such as hospitalization or parental divorce.[30]

See also

External links

Writing therapy

Writing therapy is a form of expressive therapy that uses the act of writing and processing the written word as therapy. Writing therapy posits that writing one’s feelings gradually eases feelings of emotional trauma.[1] Writing therapeutically can take place individually or in a group and it can be administered in person with a therapist or remotely through mailing or the Internet.

The field of writing therapy includes many practitioners in a variety of settings. The therapy is usually administered by a therapist or counselor. Several interventions exist online. Writing group leaders also work in hospitals with patients dealing with mental and physical illnesses. In university departments they aid student self-awareness and self-development. When administered at a distance, it is useful for those who prefer to remain personally anonymous and are not ready to disclose their most private thoughts and anxieties in a face-to-face situation.

As with most forms of therapy, writing therapy is adapted and used to work with a wide range of psychoneurotic illnesses, including bereavement, desertion and abuse. Many of these interventions take the form of classes where clients write on specific themes chosen by their therapist or counsellor. Assignments may include writing unsent letters to selected individuals, alive or dead, followed by imagined replies from the recipient or parts of the patient’s body, or a dialogue with the recovering alcoholic’s bottle of alcohol.

Research into the therapeutic action of writing

The expressive writing paradigm

Expressive Writing is a form of writing therapy developed primarily by James W. Pennebaker in the late 1980’s. The seminal expressive writing study[2] instructed participants in the experimental group to write about a ‘past trauma’, expressing their very deepest thoughts and feelings surrounding it. In contrast, control participants were asked to write as objectively and factually as possible about neutral topics (e.g. a particular room or their plans for the day), without revealing their emotions or opinions. For both groups, the timescale was 15 minutes of continuous writing repeated over four consecutive days. It was also instructed that should a participant run out of things to write, they should go back to the beginning and repeat themselves, perhaps writing a little differently.

Typical writing instructions include:

For the next 4 days, I would like you to write your very deepest thoughts and feelings about the most traumatic experience of your entire life or an extremely important emotional issue that has affected you and your life. In your writing, I’d like you to really let go and explore your deepest emotions and thoughts. You might tie your topic to your relationships with others, including parents, lovers, friends or relatives; to your past, your present or your future; or to who you have been, who you would like to be or who you are now. You may write about the same general issues or experiences on all days of writing or about different topics each day. All of your writing will be completely confidential.

Don’t worry about spelling, grammar or sentence structure. The only rule is that once you begin writing, you continue until the time is up.

Several measurements were made before and after, but the most striking finding was that relative to the control group, the experimental group made significantly fewer visits to a physician in the following months. Although many report being upset by the writing experience, they also find it valuable and meaningful.[3]

These results have hatched a whole host of further studies, numbering over 200.[4] One of these went on to strongly suggest that expressive writing has the potential to actually provide a ‘boost’ to the immune system, perhaps explaining the reduction in physician visits.[5] This was shown by measuring lymphocyte response to the foreign mitogens Phytohaemagglutinin (PHA) and Concanavalin A (ConA) just prior to and 6 weeks after writing. The significantly increased lymphocyte response led to speculation that expressive writing enhances immunocompetence.

Reception and criticism of Pennebaker’s theories

Pennebaker’s experiments, begun over twenty years ago, have been widely replicated and validated. Following on from Pennebaker’s original work, there has been a renewed interest in the therapeutic value of abreaction. This was first discussed by Josef Breuer and Freud in Studies on Hysteria but not much explored since.[citation needed] At the heart of Pennebaker’s theory is the idea that actively inhibiting thoughts and feelings about traumatic events requires effort, serves as a cumulative stressor on the body, and is associated with increased physiological activity, obsessive thinking or ruminating about the event, and longer-term disease.[6] However, as Baikie and Wilhelm note, the theory has intuitive appeal but mixed empirical support:

Studies have shown that expressive writing results in significant improvements in various biochemical markers of physical and immune functioning (Pennebaker et al, 1988; Esterling et al, 1994; Petrie et al, 1995; Booth et al, 1997). This suggests that written disclosure may reduce the physiological stress on the body caused by inhibition, although it does not necessarily mean that disinhibition is the causal mechanism underlying these biological effects. On the other hand, participants writing about previously undisclosed traumas showed no differences in health outcomes from those writing about previously disclosed traumas (Greenberg & Stone, 1992) and participants writing about imaginary traumas that they had not actually experienced, and therefore could not have inhibited, also demonstrated significant improvements in physical health (Greenberg et al, 1996). Therefore, although inhibition may play a part, the observed benefits of writing are not entirely due to reductions in inhibition.

Other theories related to writing therapy

An additional line of enquiry, which has particular bearing on the difference between talking and writing, derives from Robert Ornstein‘s studies into the bicameral structure of the brain.[7] While noting that what follows should be considered “wildly hypothetical”, L’Abate, quoting Ornstein, postulates that:

One could argue (…) that talk and writing differ in relative cerebral dominance. (…) if language is more related to the right hemisphere, then writing may be more related to the left hemisphere. If this is the case, then writing might use or even stimulate parts of the brain that are not stimulated by talking.[8]

Julie Gray, founder of Stories Without Borders notes that “People who have experienced trauma in their lives, whether or not they consider themselves writers, can benefit from creating narratives out of their stories. It is helpful to write it down, in other words, in safety and in non-judgment. Trauma can be quite isolating. Those who have suffered need to understand how they feel and also to try to communicate that to others.”[9]

The role of the distance therapies

With the accessibility provided by the Internet, the reach of the writing therapies has increased considerably, as clients and therapists can work together from anywhere in the world, provided they can write the same language. They simply “enter” into a private “chat room” and engage in an ongoing text dialogue in “real time”. Participants can also receive therapy sessions via e-text and/or voice with video, and complete online questionnaires, handouts, workout sheets and similar exercises.[10]

This requires the services of a counsellor or therapist, albeit sitting at a computer. Given the huge disjunction between the amount of mental illness compared with the paucity of skilled resources, new ways have been sought to provide therapy other than drugs. In the more advanced societies pressure for cost-effective treatments, supported by evidence-based results, has come from both insurance companies and government agencies. Hence the decline in long term intensive psychoanalysis and the rise of much briefer forms, such as cognitive therapy.

Writing therapy via the Internet

Currently the most widely used mode of Internet writing therapy is via e-mail (see analytic psychotherapist Nathan Field’s paper The Therapeutic Action of Writing in Self-Disclosure and Self-Expression[11]). It is asynchronous; i.e. messages are passed between therapist and client within an agreed time frame (for instance, one week), but at any time within that week. Where both parties remain anonymous the client benefits from the “disinhibition” effect; that is to say, feels freer to disclose memories, thoughts and feelings that they might withhold in a face-to-face situation. Both client and therapist have time for reflecting on the past and recapturing forgotten memories, time for privately processing their reactions and giving thought to their own responses. With e-therapy, space is eliminated and time expanded. Overall it considerably reduces the amount of therapeutic input, as well as the speed and pressure that therapists habitually have to work under.

Ironically, the anonymity and invisibility provides a therapeutic environment that comes much closer than classical analysis to Freud‘s ideal of the “analytic blank screen”. Sitting behind the patient on the couch still leaves room for a multitude of clues to the analyst’s individuality; e-therapy provides almost none. Whether distance and reciprocal anonymity reduces or increases the level of transference has yet to be investigated.


The oldest and most widely practiced form of self-help through writing is that of keeping a personal journal or diary—as distinct from a diary or calendar of daily appointments—in which the writer records their most meaningful thoughts and feelings. One individual benefit is that the act of writing puts a powerful brake on the torment of endlessly repeating troubled thoughts to which everyone is prone. Moreover, as Kathleen Adams notes, through the act of journal writing, the writer is also able to “literally [read] his or her own mind” and thus “to perceive experiences more clearly and thus feels a relief of tension”.[12] As one person describes it: “Quite what happens when near-obsessive ruminations, which frequently take place in the small hours of the night, are committed to paper is difficult to describe. It does feel as if the trap door of a mental treadmill has been opened to allow persecutory thoughts to escape. Though the accompanying feelings may persist for a time, the thoughts begin to integrate or dissipate or reach some constructive resolution.”[citation needed]


Pulitzer Prize for Poetry finalist Bruce Weigl, a veteran of the Vietnam War, has discussed the therapeutic benefits of writing, especially when combined with other forms of therapy, for people coming to terms with traumatic experiences such as war. According to Weigl, “What it helps you do is externalize things, give a shape to it. And that’s what Denise Levertov kept telling me is that, Look, you control it now. It doesn’t control you anymore. You own it now.” [13]

See also

External links

  • SelfAuthoring Suite A set of four web-based expressive writing exercises designed to help people clarify their past, improve their present, and plan their futures. The future authoring program has dramatically improved the academic performance of struggling university students.
  • Structured Journal Template based web application for structured journaling focused on achieving specific goals.

Adventure therapy

From Wikipedia, the free encyclopedia

Adventure therapy, as a distinct and separate form of psychotherapy, has become prominent since the 1960s. Influences from a variety of learning and psychological theories have contributed to the complex theoretical combination within adventure therapy. The underlying philosophy largely refers to experiential education. Existing research in adventure therapy reports positive outcomes in effectively improving self-concept and self-esteem, help seeking behavior, increased mutual aid, pro-social behavior, trust behavior and more. Even with research reporting positive outcomes it appears that there are many disagreements about the underlying process that creates these positive outcomes.[1][2][3]


Many different terms have been used to identify the diverse methods of treatment in the wilderness environment. Ewert, McCormick, & Voight, (2001) distinguished between adventure therapy, wilderness therapy, and outdoor experiential therapy. According to them, adventure therapy uses outdoor activities involving risk and physical and emotional challenge. Wilderness therapy usually refers to the use of primitive methods in wilderness contexts requiring adaptation or the ability to cope. Outdoor experiential therapy is outdoor treatment to promote “rehabilitation, growth, development, and enhancement of an individual’s physical, social and psychological well-being through the application of structured activities involving direct experience” (Ewert et al., 2001, p. 109). The latter may be part of a residential treatment program. More recently, adventure therapy has evolved to include the use of adventure activities supported by traditional therapy. Often adventure therapy is conducted in a group or family context, though increasingly adventure therapy is being used with individuals.[3][4] Adventure therapy approaches psychological treatment through experience and action within cooperative games, Trust activities, Problem Solving Initiatives, High adventure, outdoor pursuits, and wilderness expeditions. Some believe that in adventure therapy there must be a real or perceived psychological and or physical risk generating a level of challenge or perceived risk. Challenge can be viewed as significant in eliciting desired behavioral changes. Positive behavior changes, which are synonymous with psychological healing, can occur through a variety of processes. For example, through the use of vicarious experience, verbal persuasion, and overwhelming mastery experiences, participants’ efficacy in the adventure activity may be increased (Bandura, 1997). These increases may then be generalized to treatment outcomes within and across life domains (Bandura, 1997; Weitlauf, Cervone, Smith, & Wright, 2001; Cervone, 2005). Five factors can be used to promote generalization of efficacy across domains: overwhelming mastery experiences, identification of similar sub-skills, co-development of sub-skills, cognitive restructuring of efficacy beliefs and generalizing sub-skills (Bandura, 1997, pp 50–54). Debriefing or processing provides a context for implementing therapeutic techniques related to the desired outcomes. It typically involves a discussion where facilitators lead a discussion to help participants internalize the experience and relate it to therapeutic goals.

Adventure therapy encompasses varying techniques and environments to elicit change. These include cooperative games, problem solving initiatives, trust building activities,high adventure (rock climbing/rappelling, ropes courses, peak ascents); and wilderness expeditions (backpacking, canoeing, dog sledding, sailing, etc.).[2][5] Wilderness therapy, adventure based therapy, and long term residential camping are the most common forms of adventure therapy.[2]


The use of adventure as a part of healing process can be traced back in history to many cultures including Native American, Jewish and Christian traditions.[3] Tent therapy, emerged in the early 1900s. This therapy brought certain psychiatric patients out of hospital buildings and into tents on the hospital’s lawn. Many patients showed improvement during this treatment that prompted a series of studies, which failed to present enough evidence to support efficacy. Literature on this therapy lasted approximately 20 years and then dropped off completely.[1]

In the late 1930s this approach reappeared mainly as camping programs designed for troubled youth. This era influenced the present day use and extent of adventure therapy programs with adolescents. The format for these programs utilized observation, diagnosis and psychotherapy. One of the first of these programs was Salesmanship Club Camp based in Dallas, Texas and founded by Campbell Loughmiller in 1946. His philosophy of adventure in therapy included the theory that the “…perception of danger and immediate natural consequences for [a] lack of cooperation on the part of [participants]…[after confronting danger] built self-esteem, [while] suffering natural consequences taught the real need for cooperation.”[6] These ideas informed some adventure therapy programs

This period also saw the creation of Outward Bound (OB) in the 1940s by Kurt Hahn.[3][4][7][8][9][10] Outward Bound was a direct response to Lawrence Holt, part owner of the Blue Funnel Shipping Company, who was looking for a training program for young sailors who seemed to have lost the tenacity and fortitude needed to survive the rigors of war and shipwreck, unlike older sailors who, because of their formative experiences on sailing ships, were more likely to survive.[11] In this way Outward Bound was engaging in a form of adventure therapy – intervening in the lack of tenacity through the use of challenging adventure training.

In the 1960s OB came to the United States through the OB school in Colorado[3][12] Outward Bound programs in Colorado and other schools quickly began to use Outward bound as an adjunctive experience work with adjudicated youth and adults (one of the first programs in 1964 offered recently released prisoners a job at Coors Brewery if they completed a 23-day course). In the late 70’s Colorado Outward Bound developed the Mental Health Project. Courses were offered to adults dealing with substance abuse, mental illness, being a survivor of sexual assault and other issues. In 1980 Stephen Bacon wrote the seminal text in Adventure Therapy The Conscious Use of Metaphor in Outward Bound which linked the work of Milton Erickson and Carl Jung to the process of Outward Bound.

Project Adventure, adopted the OB philosophy in a school environment and brought the ropes course developed at the Colorado Outward Bound School into use at schools. Project Adventure staff including Karl Rohnke are credited with developing many of the cooperative games, problem solving initiatives, trust activities, low elements, and high elements. PA first emerged in Hamilton-Wenham High School in Massachusetts in 1972 with a principal named Jerry Pieh, son of Robert Pieh founder of the Minnesota OB School. Jerry Peih wanted to bring the concepts behind the Outward Bound schools, developing self-esteem and self-confidence through mentally and physically straining and stressful situations, to classrooms.[3][4][7][8][9][10][13][14][15] PA programs were often used at part of the health curriculum in PE programs.

Eventually Paul Radcliffe, a PA trained facilitator and school psychologist, Mary Smithy a PA staff member along with a social worker from Addison Gilbert Hospital, started a 2-hour weekly outpatient group. Eventually this model was incorporated into school psychological services and was called the Learning Activities Group.[15] This later grew into Adventure-Based Counseling (ABC), a Project Adventure term that reflects the therapeutic use of adventure activities.[13]


Adventure therapy theory draws from a mixture of learning and psychological theories. The learning theories include contributions from Albert Bandura, John Dewey, Kurt Hahn, and Kurt Lewin. These theorists also have been credited with contributing to the main theories comprising experiential education. Experiential education is a theoretical component of adventure therapy.[8][16][17] The ideas and thinking of Alfred Adler, Albert Ellis, Milton Erickson, William Glasser, Carl Jung, Abraham Maslow, Jean Piaget, Carl Rogers, B.F. Skinner, Fritz Perls, and Viktor Frankl all appear to have contributed to the thinking in adventure therapy. Adventure therapy is a cognitive-behavioral-affective approach which utilizes a humanistic existential base to strategically enact change through direct experience through challenge.[2][5][15][18][19][20][21][22][23]

This theory, though, has been questioned extensively. These questions cover many issues. With all the importance that is placed upon adventure therapy as a therapeutic intervention, the research is restricted to cooperation and trust, and even less research examines therapeutic techniques with adventure therapy and outcomes on pathology.[8] The adventure therapy research field is having difficulty answering the basic questions of how, what, when, where and who. Further research on the standards, requirements, education, and training for individuals conducting adventure therapy is required.[8] The research is based upon the examination of self-concept and social adjustments.[4] In a meta-analysis study to statistically integrate all the available empirical research on adventure therapy, 99 studies were found covering a 25-year span.[24] Out of the 99 studies located, only 43 studies fit the criteria for analysis. Many of the studies excluded were dissertations and the authors stated that dissertation studies did not accurately represent the field of adventure programming. The 43 studies used varied in design, methods, and treatment goals. They report that the limited amount of studies for their meta-analysis is proof of the limitations in the research in adventure programming.

The major theme of these questions about adventure therapy is effectiveness. A group has emerged arguing that before any other question in adventure therapy can be answered the question what are the properties that influence the effectiveness of adventure therapy must be answered. This group argues that theory driven research instead of outcome driven research will answer this question. Outcome driven research means that outcomes are the source of explanations for AT theoretical structure.[25] Outcome driven research has generated many conflicting findings that confuse theoretical structure and explanations of effectiveness.[25][26] The outcomes in adventure therapy research are linked to existing psychological theories of change to explain, modify, or validate AT theory. The theories of change have upwards of 400 forms of therapy and related practices that have emerged from a conglomeration of psychological theories.[26] When outcomes are tied to existing psychological theories within the 400 forms of therapy it is impossible to understand the underlying influences of AT.

With all the research to date and the numerous reports of positive outcomes, there is still little understanding of the underlying processes influencing these positive outcomes.[25] This has caused extensive discussion concerning why adventure therapy appears effective in treating a multitude of DSM related mental disorders in children, adolescents, and adults.[2][8][27] Several researchers have attempted to explain the underlying process to adventure therapy.[2][4][8][14][16][17][19][27][28][29][30]

Adventure therapy is described as non-traditional therapy allowing for the pre-therapeutic adolescent to experience their mental health issues,[27] with several theoretical aspects: 1) it is a physical augmentation to traditional therapy for the purpose of a shared history with the participants and the therapist, 2) there is a sense of natural and logical consequences in the activities, 3) environment should be structured into the activities, 4) a participant perceives risk, stress, and anxiety so that they can problem solve and generate their own sense of community for feedback and behavior modeling, 5) participants will transfer their present attitudes and behaviors into the activities, 6) works with a small group of participants, and 7) requires a facilitator that models appropriate behaviors and guides the group towards adaptive self-regulation that is based upon appropriate behaviors.[27]

Adventure therapy has normalizing effects on deficits in delinquent adolescent’s developmental process,[14] as a process of moving into formal operational thinking which is achieved through the experiential learning theories.[14][29] A therapist holds the skills to make the adventure experience a therapy.[14] The theoretical basis of adventure therapy describes the participant as a learning being who achieves their greatest learning outside the classroom, through challenge and perceived risk, promoting social skills through experiencing a group challenge mixed with affect, cognition, psychomotor activity and formal operational thinking generated through metaphor.[8][16][17] Experiential learning becomes adventure therapy when the activities are planned and implemented as vehicles for patients to address individual treatment goals.[30] Adventure experiences molded into a more therapeutic group model ran by the therapist can have a more significant effect than the one day intervention run by counselors.[30] It is important to have the clinician as an integral part of the adventure therapy process so that there can be a strong transference of the adventure experience to other aspects of the therapeutic process.[4]

Baldwin, Persing, and Magnuson, though, report that many of these explanations are “…folk pedagogies…” that lack thorough empirical evidence.[31] Adventure therapy research has focused on outcomes without exploring theoretical structure.[32] The focus of AT research needs to concentrate on testing and validating theoretical structure.[32] Adventure therapy’s theoretical structure must be studied and documented.[25] After a theoretical structure is validated then a discussion on outcomes can occur.[32]


Although questions remain regarding the efficacy of adventure therapy, some research suggests adventure therapy is an effective modality for treatment.[33] A meta-analytic review of 197 studies of adventure therapy participant outcomes (2,908 effect sizes, 206 unique samples) found that the short-term effect size for adventure therapy was moderate (Hedges’ g = .47) and larger than for alternative (.14) and no treatment (.08) comparison groups. [34] There was little change during the lead-up (.09) and follow-up periods (.03) for adventure therapy, indicating long-term maintenance of the short-term gains.

A study of the effects of adventure therapy on 266 high risk youth in rural areas reported lasting improvement in behavior over a six-month period.[35] Another study on adventure therapy effectiveness reports that adventure therapy is effective because specifically designed activities can bring about specific outcomes.[36]

Adventure therapy is further viewed as effective because of the apparent positive effects in treating developmental issues with juvenile offenders and adolescent offenders with drug abuse and addiction issues.[29] The effectiveness of adventure therapy with offenders with drug abuse and addiction issues in mental health treatment is related to the characteristics present in addicted offenders. They “…(1) need more structure, [and] (2) they work better with an informal, tactilekinesthetic design….”[37] Adventure therapy as treatment is equally effective for adjudicated youth and other adolescent populations.[24][29] 62% of adolescents who participated in an adventure therapy group are at an advantage for coping with adolescent issues than adolescents that did not.[24] There is a 12% improvement in self-concept for adolescents who participate in adventure therapy.[24] Adolescents are approximately 30% better off in their ability to cope with mental health issues than those that do not participate in a psychotherapeutic treatment making the implication that adventure therapy effectiveness is comparable to the effectiveness of psychotherapeutic treatment.[24][38]

The concepts contributing to adventure therapy effectiveness are: increases in self-esteem, self-concept, self efficacy, self perceptions, problem solving, locus of control, behavioral and cognitive development, decreases in depression, decrease in conduct disordered behaviors, overall positive behavioral changes, improved attitude, and that adventure therapy generates a sense of individual reward. Further aspects that contribute to adventure therapy’s effectiveness are that it: increases group cohesion, aids in diagnosing conduct disorders in adolescents, improves psychosocial related difficulties, is effective in treating drug addicted and juvenile youth, treats sensation seeking behaviors, improves clinical functioning, facilitates connecting participants with their therapist and treatment issues, and increases interpersonal relatedness.[3][4][8][9][10][13][16][28][28][39][40][41][42][43][44]

When comparing the reduction in recidivism rates with traditional programs and programs with adventure therapy, programs using adventure therapy have lower recidivism.[1] There is an increases in interpersonal relatedness, which has been described as the most important factor for improving mental health issues.[4][8]

External links