Animal-Assisted Psychotherapy
390 pages
English

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Animal-Assisted Psychotherapy

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390 pages
English

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The integration of animals into the therapy setting by psychotherapists has been a growing trend. Psychological problems treated include emotional and behavioral problems, attachment issues, trauma, and developmental disorders. An influential 1970s survey suggests that over 20 percent of therapists in the psychotherapy division of the American Psychological Association incorporated animals into their treatment in some fashion. Anecdotal evidence suggests that the number is much higher today. Since Yeshiva University psychologist Boris Levinson popularized the involvement of animals in psychotherapy in the 1960s, Israel has come to be perhaps the most advanced country in the world in the area of animal-assisted psychotherapy (AAP). This is true especially in the areas of academic training programs, theory-building, and clinical practice. Great effort has been put into understanding the mechanisms behind AAP, as well as into developing ethical guidelines that take into account the therapist's responsibility toward both client and animal. This book exposes the world to the theory and practice of AAP as conceived and used in Israel. It emphasizes evidence-based and clinically sound applications with psychotherapeutic goals, as differentiated from other animal-assisted interventions, such as AAE (animal-assisted education) and AAA (animal-assisted activities), which may have education or skills-oriented goals. Not just anyone with a dog can call him-or herself an animal-assisted therapist. This volume demonstrates not only the promise of animal-assisted psychotherapeutic approaches, but also some of the challenges the field still needs to overcome to gain widespread legitimacy.

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Date de parution 15 juillet 2013
Nombre de lectures 0
EAN13 9781612492742
Langue English

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ANIMAL-ASSISTED PSYCHOTHERAPY
Theory, Issues, and Practice
“A great deal has happened since I first heard of animal-assisted therapy and activities. This volume supports the statement that one does not call himself or herself a therapist unless trained and licensed. The programs bringing people into contact with animals are varied and structured. The book offers different approaches for children and adults. Value is accomplished through anecdotes which provide actual happenings for the reader, along with a strong theoretical description of the applied approach. One gains a clear idea of the therapist’s approach and of the participation of animals to strengthen the result. What a great book!”
— Samuel B. Ross, Jr., PhD, Founder of Green Chimneys

“This comprehensive book stands as the state-of-the-art guide to animal-assisted psychotherapy. Mental health professionals practicing AAP will repeatedly turn to this well-organized work for guidance and will find solid bridges between theoretical reasoning, empirical research, and psychotherapeutic practice. The volume is grounded in cutting-edge research, and Parish-Plass has brought together the leading experts in the field.”
— Mario Mikulincer, PhD, Professor and Dean, School of Psychology, Interdisciplinary Center (IDC), Herzliya

“Nancy Parish-Plass has edited a volume that will be of strong interest to those providing animal-assisted psychotherapy. The book brings together chapters from numerous authors on critical topics. As a psychologist who has integrated animals in therapy for many years, I believe that this is a valuable resource to clinicians and researchers in the field.”
— Aubrey H. Fine, EdD, Professor, California Polytechnic State University
“As the field of animal-assisted psychotherapy grows in popularity and use, it is essential that the work is grounded in theory, research, and the highest quality standards of ethical practice. This book provides a superb resource for clinicians using this promising modality. Editor Nancy Parish-Plass has woven the excellent contributions into a volume that provides a model of AAP practice, clear discussion of the complex issues inherent in AAP, and the unique ethical standards for the protection of both human clients and the animals involved. Program descriptions and case illustrations throughout the book enrich its message. All clinicians using or wishing to use AAP will benefit greatly from reading this wonderful addition to the relatively scant professional literature on AAP.”
— Risë VanFleet, PhD, Founder and President, Playful Pooch Program and Family Enhancement & Play Therapy Center; Past President and Board Chair, Association for Play Therapy

“[This book] puts together scholarship on many perspectives of how animals fit into the therapeutic milieu. It provides the theoretical bases for use of animals in psychotherapy practice and provides guidance and evidence for practitioners. It is very readable, and great clinical vignettes are used to illustrate the authors’ points. It will be of interest for psychotherapists but also in clinical psychology, social work, and advanced practice nursing.”
— Erika Friedmann, PhD, Professor, School of Nursing, University of Maryland
New Directions in the Human-Animal Bond
Alan M. Beck, Series Editor
ANIMAL-ASSISTED PSYCHOTHERAPY
Theory, Issues, and Practice
Edited by NANCY PARISH-PLASS
PURDUE UNIVERSITY PRESS, WEST LAFAYETTE, INDIANA
Copyright 2013 by Purdue University. All rights reserved.
Printed in the United States of America.
Library of Congress Cataloging-in-Publication Data
Parish-Plass, Nancy, 1955–
Animal-assisted psychotherapy : theory, issues, and practice / Nancy Parish-Plass.
     pages cm.—(New directions in the human-animal bond)
ISBN 978-1-55753-651-8 (pbk.)—ISBN 978-1-61249-273-5 (epdf)—ISBN 978-1-61249-274-2 (epub) 1. Animals—Therapeutic use. 2. Pets—Therapeutic use. 3. Human-animal relationships. I. Title.
RM931.A65P37 2013
615.8′5158—dc23
2013011023
Cover design by Mary Jane Gavenda based on original art by Ronit Kahn
Notice to Readers
This publication is sold with the understanding that the publisher is not engaged in rendering medical or psychological services. The authors, editor, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book. Application of the information in a particular situation remains the professional responsibility of the practitioner.
DEDICATION
I would like to dedicate this book to those who have contributed most to my professional development as an animal-assisted psychotherapist: Boris Levinson, my clients, and my animals.
This book would not be complete without emphasizing my great debt to Boris Levinson, the father of animal-assisted psychotherapy (AAP), as we practice it here in Israel. In his book, Pet-Oriented Child Psychotherapy , Levinson presents his vision and insight in amazing detail, and his book is still a bible for me till today. I find there references to principles and issues that are being discussed at length and in research still today and, I have no doubt, that will be so for many years. I refer to it time and again and often rediscover principles, stated in concise and clear ways, that help and inspire me in my writing and clinical work. In the latest edition of Levinson’s book (1997), Gerald Mallon added further insight into the animal-assisted psychologist and man that Levinson was which helps us all feel that we would love to have sat with him and shared experiences. I hope we would have made him proud.
Of course, I never could have arrived at where I am today without my clients, who share the journey with me, helping to open my eyes and discover even more dimensions in the amazing processes that occur in therapy with the animals.
And last but so much not least, to Mushu, Mali, Pinuki, Puffy, Marshmallow, Ketchup, and Chips, and to those who will always be with me and in the hearts of so many children—Foxy Lady, Brownie, Tuka Matuka, Nana, Kuku, Boker, Boujie Boujie, and the rest. You all are great in the way that you just let those projections come right at you and still keep on scampering, sleeping, barking, cooing, hiding, peeking, flying, kissing, climbing, and cuddling so enthusiastically!
CONTENTS
ACKNOWLEDGMENTS
PREFACE
INTRODUCTION
THEORY
CHAPTER 1
The Integration of Animals Into the Therapy Process and Its Implications as a Unique Medium in Psychotherapy
Dror Oren and Nancy Parish-Plass
CHAPTER 2
The Animal as a Relational Medium: An Object Relations Approach to the Therapy Triangle in Animal-Assisted Psychotherapy
Nancy Parish-Plass and Dror Oren
CHAPTER 3
Projection and Projective Object in Child Animal-Assisted Psychotherapy
Rachel Ben David
CHAPTER 4
The Contribution of Animal-Assisted Psychotherapy to the Potential Space in Play Therapy
Nancy Parish-Plass
CHAPTER 5
Animal-Assisted Psychotherapy From an Attachment Perspective
Sigal Zilcha-Mano
CHAPTER 6
Elements of Group Psychotherapy Found in Individual Animal-Assisted Psychotherapy
Hadas Ish-Lev and Roni Amit
CHAPTER 7
The Therapy Zoo as a Mirror to the Psyche
Efrat Maayan
CHAPTER 8
Equine-Facilitated Psychotherapy: Practice, Theory, and Empirical Knowledge
Keren Bachi
ISSUES
CHAPTER 9
Dilemmas, Questions, and Issues Concerning the Integration of Animals Into the Psychotherapy Setting
Nancy Parish-Plass and Dror Oren
CHAPTER 10
The Unique Ethical Stance of Animal-Assisted Psychotherapy
Rachel Ben David
CHAPTER 11
Why Israel? A Unique Direction in the Development of the Definition and Practice of Animal-Assisted Psychotherapy
Nancy Parish-Plass and Sari Bar-On
CHAPTER 12
Life Cycle Analysis of the Equine-Facilitated Psychotherapy Field
Keren Bachi
CHAPTER 13
Is Animal-Assisted Psychotherapy a Profession? The Consolidation of the Professional Identity of the Animal-Assisted Psychotherapist in Israel
Sari Bar-On, Anna Shapiro, and Anat Gendelman
PRACTICE
CHAPTER 14
The Relationship Between the Animalistic and the Artistic: A Therapeutic Model Integrating Animal-Assisted Psychotherapy With Art Therapy
Efrat Maayan and Elana Lakh
CHAPTER 15
“What Does the Turtle Have Inside Its House?” Animal-Assisted Psychotherapy With Foster Children
Shira Hellmann
CHAPTER 16
“Take Me Under Your Wing”—Love in Animal-Assisted Psychotherapy: A Clinical Perspective on the Unique Therapeutic Bond Between Animals and Humans
Sarit Lev-Bendov and Inbar Barel
CHAPTER 17
Animal-Assisted Group Psychotherapy for Children
Orit Harel
• • •
CONCLUSION
APPENDIX A
The Child and the Animal and the Potential Space Between: A Comparison of Animal-Assisted Education and Animal-Assisted Psychotherapy
APPENDIX B
Roles of Animals in Animal-Assisted Psychotherapy
APPENDIX C
Code of Ethics: The Israeli Association of Animal-Assisted Psychotherapy
APPENDIX D
The 18th Session of the Israeli Knesset
APPENDIX E
Representative Certificate Program in Animal-Assisted Psychotherapy
CONTRIBUTORS
INDEX
ACKNOWLEDGMENTS
First I would like to thank Dikla Tzur for inspiring me to write this book. I would also like to say to my children, Joshua, Ayal, Talya, Nitsan, and Safra (my daughter by choice), that I appreciate your patience and your smiles every time I said, “After the book …,” and I hope now to be able to spend more time with you, and especially with my little granddaughter, Abigail, and my grandson by choice, Orian. I would like to give a special thanks for the unwavering support of my colleagues at the emergency shelter, who also became used to hearing “After the book …,” and of my friends, especially Dawn Weiner-Kaplow and family, Francine Haliva, Lilach Horowitz, Rivka Klein (and I wish that her mother, Tseisha Neidt, could have been here to share this with me), my brother, Mike Parish, my sister, Suzanne Plass, Moris Ohayon (who always said, “You can do anything,” when I wasn’t so sure), and Yossi “Library” Mizrachy, who supported me and put up with me with a smile during the last “push.” Ronit Kahn—I think of you each time I look at the wonderfully warm and expressive illustration you created for the cover of this book. Thank you to Thomas Ogden, Lois Carey, and Rise VanFleet for reading chapters and providing such encouraging feedback. And finally, to copy editor Kelley Kimm, for your unending patience, perceptiveness, understanding, and cheerful sense of humor, to publisher Charles Watkinson, for your warmth and support, and to Alan Beck—who is simply a mentch !
PREFACE
When I was a child, our home was always full of animals roaming around. We had as many as three dogs at any given time (including Tammy, whom we had rescued from an abusive situation), parakeets (one who was best friends with my dog Mendel and would often ride around on his back, but was at war with my other dog, Anness), sparrows that I had saved and raised, a baby raccoon (who slept in bed with me—where else?), a baby alligator that my parents bought me in a Florida airport gift shop (what can I say … it was the early ’60s), and of course my horse, Baby Doll (who had been extremely abused), who was the love of my life and who had a profound effect on me for many years.
After moving from the United States to a kibbutz in Israel and leaving behind my doctoral studies in psychology, I worked in early childhood education and naturally brought to work any baby animal I happened to be raising at the time. I noticed the deep effect that these animals had on the atmosphere, and especially on the children with emotional difficulties. Although many tried to convince me to return to my studies in psychology, I had no intention to do so—until I heard of a new program starting in animal-assisted psychotherapy (AAP). This was a chance for me to connect my love for children with my love for animals and learn to do what I had unknowingly already started to dabble in—help children to discover themselves and to work through their emotional problems through their relationships with animals. It was there at the training program at Oranim College that I met Dikla Tzur, a clinical psychologist and lecturer who opened up for me the realm of AAP and the depth of opportunities it affords for understanding a child’s emotional world and helping the child work through emotional issues.
Since finishing my studies in AAP, I have become a specialist in the area of AAP with at-risk children. For 12 years I have worked in various institutions belonging to the Welfare Ministry, such as a residential care center for abused children, a daycare center for at-risk children, and an emergency shelter for children who have suffered extreme abuse and/or neglect. I serve as a member of the psychotherapy staff with duties equal to those of the clinical psychologist and the clinical social workers. Together with my dog, Mushu, and my cockatiel, palm dove, three lab rats, and two Siberian hamsters, I work in a play therapy setting using a psychodynamic (non-directive and client-centered) approach. My colleagues often comment about the great amount of content raised and worked through in the therapy process through the integration of the animals.
When I am asked what is my profession, the reaction to my answer is usually, “So you take your dog to visit the elderly in nursing homes?” A few years ago, when the national director of child protection services in Israel saw me in the emergency shelter in which I am part of the therapy staff, she said, “How nice—the kids come, pat the animals, and feel better, right?” My answer was, “Not exactly.” After a half-hour conversation, during which I explained my therapeutic goals, she invited me to give a lecture at the national convention for child protection services officers, and later met with the Ministry of Health to suggest providing AAP for minors who are victims of sexual abuse.
At the university in which I am now studying for a master’s degree in social work, I of course spread the word about AAP. Some academics are excited by the idea, but many are suspicious. I often receive the comment, “It just doesn’t work that way.” One expert in the field of attachment said to me, “I can’t stand it when people misuse attachment theory and the idea of an attachment figure.” They apparently did not read Bowlby’s reference regarding the role of animals in assisting people suffering from grief and loss, in which he states that children may attach to a pet dog after having lost or been rejected by their parents (Bowlby, 1980, p. 175.) Many AAP therapists apply for advanced degrees in therapy fields in order to do research in the field of AAP and the human-animal bond, but they find it nearly impossible to find advisors willing to supervise their research. But then there are those very few who immediately get it, and are willing to take a chance and support our research.
But first, back to basics: What is therapy? There is physical therapy, psychotherapy, chemotherapy, speech therapy, and more. Then there’s aromatherapy—buy a good-smelling shampoo and feel better. Many people say that jogging or dancing is great therapy. But what is animal-assisted therapy? Most people view AAT as an intervention involving an animal which affects a person’s emotional well-being (whether or not carried out by a trained therapist). “Pat a dog and feel happy.” “Have a child with a behavior problem learn to train dogs and he will internalize the limits.” I will be the first to say that these activities are very therapeutic, may be no less important in the life of a child than therapy, and I would not like to see the world without them. Does that make them therapy? The word therapy has no clear definition can be confusing. I prefer to talk about the difference between therapy and therapeutic . All of the above may be therapeutic, but is the human member of a Pet Partners team a therapist? What is the difference between therapeutic riding and EFP (equinefacilitated psychotherapy)? Who is an animal-assisted therapist? Is someone trained in therapeutic riding a therapist? Is a psychologist who has his dog in the therapy setting with him an animal-assisted psychotherapist?
The question What is animal-assisted therapy? is not simply an academic one, but also an ethical one. Those who claim to be a therapist and receive a child for therapy are holding the soul and psychological welfare of that child in their hands. In the best case scenario, a child with emotional problems who is sent to therapeutic riding (the training for which is minimal and does not include the study of psychotherapy) may not receive psychotherapy but may benefit in other ways, for instance from the human-animal bond and the one-on-one time with an adult. Of course, the problem is that the parents think they are doing everything necessary to provide their child with psychotherapy, yet this is not what the child receives.
In the worst case scenario, direct and actual damage may be done by a therapist without proper training when the emotional content that is raised is not dealt with properly. During my days as a student in the field, I attended a lecture by a dog specialist trained in a health field who claimed to be doing emotion-focused therapy with an elderly man who had lost his memory of his life before the age of 12, when he had suffered a terrible trauma. Through working with this specialist and her dog, this man was reminded of his own childhood dog and experienced a breakthrough: he was flooded with memories and broke down crying. Although we expected to hear how the therapy proceeded from this critical point, we were surprised that the specialist considered this breakthrough to be the goal of her therapy, and she considered her work to be done. My fellow students and I had studied enough to realize that this man was at a psychologically vulnerable point and was in need of a knowledgeable therapist who could help him work through the difficult memories and accompanying emotions that had been hidden for so long, probably for good reason. Yet without such a therapist, he was left exposed, broken, and alone. The involvement of animals in the therapy setting is a powerful tool and as such must be used by professionals who understand the implications.
I believe that only those fields which are conducted by someone properly trained, including extensive academic coursework with a strong theoretical and practical base, together with field hours and clinical supervision, can ethically be considered a therapy field. Practitioners should be aware of what services they are and are not able to provide. Part of the ethical participation in any profession is the knowledge of the limits of that profession.
A number of therapy professionals, such as occupational therapists, physical therapists, and speech therapists, use animals as aids to reach the therapeutic goals specific to their profession. Yet the general public uses the term AAT to refer mainly to the emotional effects of an animal on a human. This view is a type of theft of the term and is disrespectful to the other animal-assisted professions. In professional journals and the lay media, confusion abounds. One hears terms such as AAI (animal-assisted interventions), AAT (animal-assisted therapy), AAA (animal-assisted activities), and AAE (animal-assisted education). On the surface, the differences sound clear. So then why do I see articles about AAT used in libraries as a tool to teach children to read? Is teaching therapy? Are teachers therapists? Those in the field of AAT are looking for legitimacy for the field through academic research, but there is no generally agreed-upon definition of AAT, making it almost impossible to make any sense of the research. It is not clear exactly what is being studied or what the definitions of the variables are, and this confusion makes it impossible to compare research studies and make any general conclusions about the efficacy of the field.
Here in Israel, where I studied animal-assisted psychotherapy (AAP), we have grappled with these questions and issues for over 15 years. The direction taken was to sidestep the issues of “What is therapy?” and “Who is a therapist?” and instead to concentrate on the definition and development of a narrower field, that of AAP. A number of serious academic training programs sprang up as the dialogue continued (currently there are five certificate programs in colleges around the country, in which college graduates study). Graduates of these programs who are now clinicians in the field, together with the founders of and lecturers in the academic programs, have been actively participating in a dynamic dialogue to define the boundaries of the field, as well as in the expansion of the development of a theoretical base for what we all do in our clinical practice. Through our experience in the field, we have developed definitions and rationales that guide us in our work with our clients. Our guiding principle is that AAP is a form of psychotherapy which is conducted with the same rationales and goals as mainstream psychotherapy. Therefore, we are first and foremost psychotherapists, and together with that AAP therapists, for the client may not always be inclined to take advantage of an animal’s presence in an active or obvious manner. The client—not the animal—is at the center and is the focus, the raison d’etre. We, not the animals, are the therapists, for only we are cognizant of the client’s psychological processes and issues that need to be worked through and how to do so, according to what is in the best interest of the client. As our partners, the animals unknowingly assist us toward our goal. In our therapy, we focus on underlying psychological processes and not on symptoms, skills training, or psychoeducation. Our goal is not to raise a client’s self-esteem, rather to concentrate on discovering the reason for the low self-esteem (perhaps the client had been consistently humiliated by parents, or sexually abused) and work through the related issues. An AAP therapist has the status of an independent therapist (such as a clinical psychologist, clinical social worker, or art therapist). AAP is not an adjunct to another therapy.
Through this dynamic and intensive process of development and definition of the field of AAP in Israel, we have found that we have developed directions and rationales in both definitions and in practice different from those found in other parts of the world. Five years ago I published an article in a well-known academic journal (Parish-Plass, 2008) about my work with at-risk children, with the express purpose of sharing with the international clinical community the Israeli approach to AAP. I received many positive reactions, with both clinicians and academicians commenting upon the innovative and advanced nature of our approach to AAP. Many commented on the logic and helpfulness of our definitions and the theoretical background we use to guide ourselves. Since I felt that this article touched upon only the tip of the iceberg, these reactions encouraged me to gather the ideas of those who I consider to be the top thinkers in the field of AAP in Israel in order to present a more comprehensive view of the field the way it is taught and practiced here. The process of doing the background research and writing of this book has been an adventure, and has led us to a wonderfully fruitful dialogue and to discoveries that I and the other contributors did not know that we had in ourselves.
While in the initial stages of putting together this book, I was particularly pleased to receive a phone call one day from two AAP therapists who wanted my feedback on an article they had decided to write based upon one small paragraph, one aha! experience in therapy that was as yet a tiny seedling in my brain, that I had included in my article. That idea had fueled their imagination and opened up possibilities in their therapy sessions with the children they work with, and they wanted to develop the ideas that were sprouting. I suggested that it would be a wonderful idea as a chapter for this book and would show the development of an idea as it could lead to the growth of the profession. In their chapter, Roni Amit and Hadas Ish-Lev took the idea and ran with it, giving it an exciting depth which will no doubt contribute to the development of the theoretical understanding of a mechanism behind the field of AAP.
My main goal in editing this book is to develop the theoretical base of AAP. In turn, as happened with Roni and Hadas, I hope the dialogue that will come out of the ideas presented in this book will stimulate research in order to help us more fully understand the mechanisms involved in what we in our practice see every day. And most of all, I hope that the ideas raised and the research that comes out of this book will open up new possibilities for helping our clients—children and adults alike—in the psychotherapy process. I hope readers will find this dialogue concerning the AAP therapy triangle as thought provoking and exciting as I do!
REFERENCES
Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression . New York: Basic Books.
Levinson, B. M., & Mallon, G. P. (1997). Pet-oriented child psychotherapy (2nd ed.). Springfield, IL: Charles C. Thomas.
Parish-Plass, N. (2008). Animal-assisted therapy with children suffering from insecure attachment due to abuse and neglect: A method to lower the risk of intergenerational transmission of abuse? Clinical Child Psychology and Psychiatry, 13 (1), 7–30. http://dx.doi.org/10.1177/1359104507086338
INTRODUCTION
GOALS
Animal-assisted psychotherapy (AAP) is a burgeoning field of psychotherapy which has received much attention in Israel over the past few years. As practiced here, it is based upon the belief that emotional difficulties and pathologies likely originate from problematic relationships in the past, and therefore the client must use relationships in the here and now in order to change. Virtually all psychotherapy approaches rely at least to some extent on the relationship between the client and the therapist. One brilliant aspect of integrating animals into the therapy setting is that the setting becomes a laboratory for relationships. Expanding on the use of these relationships within therapy are the approaches used by most AAP therapists in our professional community, which are based mainly upon relationships, reenactment of past relationships within the therapy setting, and reflection on relationships past and present.
Whatever the exact theoretical preference of the therapist, most AAP therapists in Israel ascribe to an approach in which the therapist flows with the client (psychodynamic, client/child centered, non-directive), as opposed to a directive approach in which the therapist prepares activities ahead of time. In addition, most therapists—whether with or without animals—use the play therapy setting with children. Thus, most AAP therapists allow the children to play freely, seeing this play as a form of communication of emotions and expression of how the children experience life and relationships. Children will use play behavior, toys and games, the animals, and the therapist, separately or in combination, in order to facilitate this expression. The therapist must understand both the distress of children and how to observe their behavior in order to know how to react in a way that advances them in the therapy process. One goal of this book is to present various theoretical explanations so that readers may understand the mechanisms behind how integrating animals into the therapy process facilitates the process. Only through a coherent presentation of these ideas may a dialogue be used to develop them and to reach further understanding of how to use the mechanisms for the good of the client.
STRUCTURE
This book is split into three sections—theory, issues, and practice—with reference materials included as appendices. The first and third sections are both a combination of theory and practice. This is unavoidable because AAP is a theory-based clinical profession. AAP, by our definition, is not a technique, and it cannot be learned in a workshop. The practice cannot in any way be separated from the theory. Only by understanding what the theory is based on and why, will the therapist know how to use a therapy medium in order to advance the client in the therapy process. This book is not a manual or a cookbook. AAP is a theory-based approach, a way of thinking in the therapy setting which allows therapists to help clients to find themselves, find their strengths from within themselves. The first section ( chapters 1 through 8 ) focuses on mechanisms and the theory behind them, which explains various aspects of AAP. Most of these chapters include examples from therapy sessions to illustrate the mechanisms and guiding principles of AAP. The third section ( chapters 14 through 17 ) focuses more on the practice, elaborating on techniques used in psychotherapy with various populations.
The second section ( chapters 9 through 13 ) concentrates on AAP as a developing profession, on the therapist as a professional, and on issues and dilemmas surrounding the practice of AAP.
TARGET AUDIENCES
In my attempt to spread the word about our approach to AAP here in Israel, I hope this book will reach a number of audiences.
First and foremost, I would like to reach AAP therapists in Israel and abroad. For those who are familiar with our approach and use it, I hope to help arrive at a verbal expression for the processes they find occurring in therapy with their clients. If I can provide them with words and a common language for what they are already doing, then they will be more aware of their work and able to enter into a more fertile dialogue (with themselves, other therapists, and their clients) about their work. The chapters will broaden their knowledge base, challenge what they thought were their limits, open up new dimensions of how to help their clients, and create dialogue with other therapists to advance the field
Second, I hope that this book will serve as a textbook for students of AAP studying in academic institutions. With students in mind, there is an emphasis on definitions of psychological and psychotherapeutic processes and theories as the context to which the influence of the animals (and all they entail and bring with them) is added. Together, they form the field of AAP. This is the format through which my fellow students and I studied in class with Dikla Tzur—lecturer, clinical psychologist, AAP therapist, and supervisor. For instance, we would receive a lecture on the subject of grief and loss in terms of both psychological theory and psychotherapeutic principles. We would then talk about the subject of grief and loss in the context of animals and the human-animal bond. Finally we would explore options of integrating animals into the therapy process with grief and loss, hearing examples from her clinical experience. Through her classes we all discovered the world of psychotherapy no less than the world of AAP, and the combination contributed to our integrated knowledge, as well as to our developing professional identities. I hope that these chapters will help students grow as psychotherapists from within the profession of AAP and in its context.
Third, I hope that psychotherapists from other fields will be exposed to our work and encouraged to enrich their therapy toolbox by entering into more serious study of AAP. Such an exchange of ideas between therapists from the fields of AAP and art therapyled to the development of a course well attended by AAP therapists from around the country (and to a fascinating chapter of this book). Because psychotherapists may come from various theoretical backgrounds, the structure of the chapters—forming a theoretical base from which the discussion of the practice of AAP grows—will put everyone on the same page.
And finally, I hope that this book will reach the world of academia, serving as a stimulus for further theory building, academic discourse, and especially research. If the field of AAP is to reach the level of respectability it deserves in the world of psychotherapy and academic study, its mechanisms must be researched and its efficacy studied. My hope is that this process will lead to the establishment of a master’s degree program in AAP.
The language of this book is decidedly based upon academic and clinical principles. This book is not meant for lay people who volunteer with their dogs, dog trainers, or animal handlers. Although I would be pleased for anyone to read this book and gain perspective on AAP, I hope that no one other than academically trained clinicians will try to make use of the information in their work. The field of AAP is a form of psychotherapy in every sense of the word and therefore demands the same level of training, clinical supervision, responsibility for the psychological welfare of the client, and ethical considerations as other psychotherapy professions.
THE HUMAN-ANIMAL BOND, AAP, AND THIS BOOK
This book is meant to be a textbook delineating theory, mechanisms, definitions, and other seemingly dry subjects. All this stands in juxtaposition to the warm, emotional, playful, fuzzy, spontaneous, loving (and sometimes angry, threatening, or sad) aspects of the human-animal bond and on which AAP is based. On the one hand, I made the conscious decision not to include a chapter about the human-animal bond, for that is not the point of this book. Those interested can find a number of excellent books on that subject. The reader must keep in mind at all times that it is not the purpose of AAP to further the human-animal bond, provide the client an opportunity for a warm relationship, or teach the client to be more empathetic toward animals. In AAP, the human-animal bond is a tool used to facilitate the therapy process with the client suffering from emotional problems.
On the other hand, while reading the various chapters, the reader will notice references made to this amazing bond and how it is used to facilitate the therapy process. AAP does not “use” animals, but rather considers them as partners in relationships. It is the relationship potential in the setting which has such a strong influence on the therapy process. This process begins with the authentic relationship of the therapist with the animal. (At the college in which I studied AAP, the admissions committee does not accept prospective students who do not consider a relationship with animals as an integral part of their emotional life.) This process continues on to the way that the client sees the relationship between the therapist and the animals in the setting. The client takes notice: Is the therapist kind, warm, and caring toward the animals? Is the therapist protective of the animals? The process then expands to the client’s relationship with the animal, and finally to the projections of the client onto the animal of other objects relations in the client’s inner world. Not only do chapters discuss these relationships in terms of advancing the therapy process of the client, but readers will also find mention of the importance of the bond between the therapist and the animal as a source of support for the therapist. It often happens, for instance, after a particularly emotional meeting with a client, that I pick up my dog, Mushu, and give her a long, warm hug. I find it stabilizing (the reader will also find material in this book pertaining to the physiological effects by the presence of the animal on the human) and calming. I also find that I have someone with me who bore witness, who shared the experience with me. Anthropomorphizing? Maybe, or maybe not. Is Mushu harmed by this? I see no evidence of this whatsoever, for I see that she loves coming with me to therapy and shows no signs of avoidance. She trusts that I will always be there to protect her from stress or harm. This is one of the interactional aspects of the bond that gives AAP its strength and effectiveness. The reader will find examples and explanations of this bond and how it works in therapy throughout this book.
A WORD ABOUT ETHICS IN AAP
I would like to point the reader’s attention to the subject of ethics as it is dealt with throughout the book. Ethics is a critical part of the discussion of any therapy field, but it is doubly relevant in AAP, for the therapist must be equally attentive toward the rights, safety, and emotional and physical welfare of both client and animal. In addition to Chapter 10 , which specifically covers ethical considerations specific to AAP, the reader will find that most of the authors touch upon the subject of ethics in one way or another. No direction was given to the chapter authors to include the subject of ethics in their writing; however, it was natural for them to do so. The worry about the animal alongside of the worry about the client is part of who we are and is probably what makes us effective as AAP therapists.
I invite the reader to peruse Appendix C , which contains the Ethics Code of the IAAAP (the Israeli Association of Animal-Assisted Psychotherapy). Notice that it covers ethical considerations concerning both client and animal. We see it as a work in progress. It may seem that the IAAAP ethics code does not speak enough to the needs of the animal; however, the IAAAP sees the Israeli laws against cruelty to animals as binding on all members.
ONE MOMENT BEFORE
This book contains throughout many examples taken from therapy sessions that illustrate the theories and principles discussed. All identifying client information has been changed.
There may be some readers who will find the term human as distinguished from animal to be derogatory toward animals, as if this separation implies that humans are above animals. Many people of this opinion refer to human animals and nonhuman animals. I find that not only cumbersome but also placing humans in the center among all animals. In my family, it was clear that animals had a special place in the scheme of things and we were often more considerate of animals than of people, for we realized that they could not stand up for themselves in the way that people do. For me, the term animal is a positive one I often associate with warmth and even at times admiration. Therefore, while it is clear that humans are a type of animal, the term animal will be used as a general term referring to nonhuman animals in general. Finally, some authors found it difficult to decide which term they felt comfortable with to describe the person coming to them for therapy. This truly felt like a dilemma for most of us. Patient gives the feeling that the person is sick, while client sounds cold and impersonal. It is difficult to use either word when describing a child. Yet when talking about general principles, the author may use the word client or patient to refer to either an adult or a child. We all would have preferred to use the Hebrew word metupal , meaning a person who is being given care.
THEORY
1
THE INTEGRATION OF ANIMALS INTO THE THERAPY PROCESS AND ITS IMPLICATIONS AS A UNIQUE MEDIUM IN PSYCHOTHERAPY
Dror Oren and Nancy Parish-Plass
The most visible creatures I know of are those artists whose medium is life. The ones who express the inexpressible … without brush, hammer, clay, or guitar. They neither paint nor sculpt—their medium is being. Whatever their presence touches has increased life. They see and don’t have to draw. They are artists of being alive .
—Anonymous
INTRODUCTION
At this time in the development of animal-assisted psychotherapy (AAP), which is still in its infancy in terms of the state of research and theory development, it is necessary to find a way to understand the mechanisms behind the processes that occur in AAP. Appendix B contains a list of the various roles animals fulfill in psychotherapy, according to various psychological theories, which sheds light on this subject. In this chapter we come from a different direction, describing a unifying model that delineates the implications for the psychotherapy process of the presence of an animal, in all that this presence entails, as a medium through which the process of psychotherapy takes place. This is a model borrowed from the world of philosophy, scientific literature, and cultural literature, specifically pertaining to art. In psychoanalytic writing, the concept medium is borrowed from the world of communication (McLuhan, 1964) and from the world of art criticism.
It is important to remember that almost anything can be used as a medium in the therapy setting in order to express feelings: dreams, inanimate objects in the room, play, and even the therapist him- or herself. Any of these mediums may serve as a mediator, an object of projection, as a way to express one’s inner world. Of course, some of these mediums may be chosen by the therapist. Therefore, it is the responsibility of the therapist to deepen his or her understanding of the potential and the limitations of the medium chosen. This chapter discusses animals and all that they bring with them into the psychotherapy process as the medium in AAP.
From our experience, compared to the mediums of other psychotherapies, the presence of animals in the therapy setting adds a richer and more multifaceted medium, characterized by a width and depth that deserves inspection. This conceptualization of the presence of the animal as a medium, as a source of enrichment for the therapy process, was borne out of our discussions of Ishai, Oren, and Ishai’s article, “Medium for Expression and Medium for Healing: On Medium in Therapy” (in press). These rich discussions eventually led to this chapter.
This chapter starts with a general discussion of the term medium in the context of psychotherapy, including its definition and an explanation of the use of a medium, in terms of the therapist, the client, and what exists and develops between them. The use of a medium in psychotherapy, together with its intricacies, implications, and advantages, is also discussed. Next, the chapter focuses on the concept of the presence of an animal (or animals) in the psychotherapy setting as a medium, with all that this entails. The various unique qualities of the animals and their surrounding environments, their effect on therapist and the client, and what they may contribute to the therapy process, are discussed. (In Chapter 2 the implications of the relational qualities of the involvement of animals as a medium are expanded upon. Chapter 9 examines the various dilemmas and issues that need to be addressed when the involvement of animals is used as a medium in psychotherapy.)
THE USE OF A MEDIUM IN THERAPY
Definitions of the word medium are many and varied. According to Merriam-Webster (Medium, n.d.), some of the definitions more relevant to our discussion are (1) a means of effecting or conveying something, such as a substance regarded as the means of transmission of a force or effect, or a surrounding or enveloping substance; (2) a mode of artistic expression or communication, or material or technical means of artistic expression; and (3) a condition or environment in which something may function or flourish, or a nutrient system for the artificial cultivation of cells or organism.
As can be seen, some of these definitions grew out of art and the philosophy of art and its derivations, while others grew out of a biological model. The intent of the model presented in the article “Medium for Expression, Medium for Curing” (Ishai, Oren, & Ishai, in press) is that the medium answers the following definition: “The medium is that through which messages are transferred from the therapist to the client and from the client to the therapist, as well from each to themselves. A medium may be general or unique, consistent or variable, facilitating or restricting, simple or multi-faceted.” According to Ishai, Oren, and Ishai (in press), a medium is a unique means of communication in therapy, a mediating factor through which one’s inner world may be expressed. Different types of mediums influence the experience of therapy in different ways, and mediums may be used in a number of ways. While often it serves as the channel for the communication of messages, it sometimes turns into the content itself (in the case of talking as a medium, talking about how one talks). At other times the medium may stay in the background, part of the general atmosphere, present in case the therapist or client chooses to make use of it. “The client has the feeling of having the right to choose the medium through which he asks to transmit his expressions, and within which he is interested in having contact with his therapist” (Ishai, Oren, & Ishai, in press).
Similar to D. Winnicott, we distinguish between the therapist-client relationship and the communication that exists between the therapist and the client. Communication is based upon the behavioral expression of an idea, a desire, an attitude, or an emotion. A relationship is the specific emotional entity that exists within the context of interpersonal interactions, whereas communication is the mode through which the relationship is created, expressed, and exists. In order to better understand the dynamics of communication, it is essential to explain its elements.
Communication involves different actions, the central ones being expression, transmission, comprehension/listening, deciphering, pausing (experiencing), giving of meaning, reaction, and expression of that reaction. These actions usually occur in this order, simultaneously existing in parallel as a type of echoing which enriches the communication process. There exists between them overlapping and changes in the order of occurrence (e.g., first reacting, and only afterward giving meaning). Various mediums specialize in one or more of these actions. The most efficient medium performs all of these actions. Most of the time, it is acceptable to relate to language, including speech, writing, and reading, as the most efficient mediums. However, different theoretical and clinical approaches might recognize the need for additional, nonverbal mediums in order to reach certain therapeutic goals. These mediums may be used as alternatives or in conjunction with the verbal medium. It is important to remember that everything can serve as a medium. The therapist may suggest various mediums found in the room (e.g., the chair, game, or sand), which are then talked about (“Here one can talk about everything,” or “I see that you always choose to sit in the rocking chair instead of on the couch”) and expressed by asking direct questions (“The dream sounds very interesting. Tell me about it.” Or, “Winning the game seems very important to you. How do you feel when you lose?”), as well as by indirect reference and hints. Not only may objects be mediums, but also a client is likely to use relating to objects in the clinic, to the therapist, to the headlines in the news, or money, as mediums through which the client can express him- or herself.
Certain mediums are common to most psychotherapists, such as emotional expression and use of the world of emotions in general, the attempt to give meaning, a search for patterns, and use of empathy and understanding. In addition, most therapy is based upon an overall theory that people experience the world according to the way in which they perceive it and then conduct themselves accordingly. Therefore, the goal of therapists’ work is to give clients a perception that they have a higher degree of control over their life than they had before, or were aware of. Furthermore, mediums develop within therapy which are charac teristic of each therapist, client, and approach. When therapists have a unique medium to which they ascribe importance, such as play, art and artistic expression, musical instruments, or an animal and his environs, they will introduce it into the therapy setting. It may happen that a certain client will be referred to a therapist specializing in a certain medium, out of an assumption that that the client will relate to this medium and use it for self-expression. Clearly, the client comes with his or her own mediums, such as physical attributes, perception of the role of luck, personal theories of the way others relate to him or her, and so forth. The therapist may be a medium for the client, due to voice qualities, physical appearance, manner, personality (serious or with a sense of humor), and such. Of course, the therapist may also become the medium through the client’s projections. With some adult clients, and more often with child clients, projection may express itself in concrete touch, which may force the therapist to take his or her body out of the range of possibilities.
In medium-sensitive therapy, it is important to identify the difference between the therapist’s medium and the client’s medium. In addition, it is assumed here that a necessary requirement for the therapy process is, among other things, the creation of the connection, a third unique medium common to both client and therapist which serves as a bridge between their mediums. It is important to understand the differences between various mediums which are generated by distinct theories and types of clinical interventions. This raises many questions, for instance those regarding hierarchy, such as which mode of language is preferable—verbal, pre-verbal, or body; which medium is appropriate; which has more power, or larger influence, on the process of therapy and its results—theory or practice; and whether therapist-client communication should be explicit or implicit. Other questions arise and touch upon experiences of interpersonal and intersubjective partnership, such as, Is it possible to relate to the therapy experience as uniform and homogeneous—that is, involving the use of only one medium? Perhaps the increase in the number of mediums present in each communicative process testifies to the heterogeneous nature of the experience and explains the difficulty of obtaining the internal and continuous sense of development and freedom? And together with this, does the effort to communicate in a therapeutic manner obligate us to create uniformity, unity, and even merging or symbiosis?
According to our conceptual approach, three principle generators create the cure for mental health problems, the change that therapists aspire to achieve in the therapy process: theory, technique, and medium. Theory is the collection of explanations which serve us in our search for understanding. Technique (or intervention) is the practical plane within which the therapist functions in order to create the change. Examples of this would be questioning, body language, reflecting, and interpretation. A medium is the unique mode through which a specific client expresses him- or herself in any given situation. The medium is present in between theory and technique and is neither of them. Our view is that the medium is equal to therapy and technique in the therapy experience. In psychotherapy, the mediums of the client come in contact with those of the therapist. With the development of the therapy process which is medium sensitive, at the center can often be found the creation of a bridging factor, a third medium. This additional medium, discussed later in this chapter, has a unique place in the communication between the client and the therapist within therapeutic space.
From this discussion, it becomes clear that alongside the influences of theory and technique, the medium is a powerful generator of occurrences and situations and thus significantly influences the therapy process. It is important to understand the extent to which the medium determines the nature, progress, and results of the therapy. Therapists must be aware of, and well acquainted with, the medium employed, as well as the medium which was chosen by the client, to discover and understand the nature of the medium common to both therapist and client, to use it, to decipher its messages, and to become acquainted with its potential for dominating the therapy. Therapists must take responsibility for the medium they choose, as well as the client’s medium and any ensuing medium that develops from within the therapy relationship. That is, care must be taken by therapists not to let the medium take over the therapy, nor to become the focus of the therapy instead of the clients, their issues, and their progress in therapy. Therapists must ensure that any medium be allowed to change and evolve according to developments within the therapy process. And finally, therapists must be open to additional mediums throughout the therapy—that is, let their chosen medium live “in peace” with other mediums that might also help the therapy process.
In therapy that is medium sensitive, the therapist must become acquainted with the various appearances, uses, and levels of the medium. For instance, in the case of speech as medium, not only must the therapist be aware of talking and language, but also of the elements of language, as well as a variety of representations and the way in which they are created. This demands sensitivity and attention to the material and physical properties of the medium, to its effect on the senses, and to its design and technology (activating and operating). In this example, the technology is language structure, syntax, semantics, and experience of language. Sometimes it is the musical quality of the voice, its harmony and disharmony, and sometimes it is the activity of quietness, of being quiet, of listening. This medium, which operates from within the therapy, may be joined by other language-related mediums from without: text messages, communication by telephone, e-mail, writing, and so forth.
Opportunities Afforded by the Medium—a Window to That Which Cannot Be Expressed
There are many barriers to communication in therapy, as in any social situation. Clients may or may not agree to talk about or express various content or emotions, or even be able to do so. The source of these barriers may be cognitive or emotional in nature. Clients may not be able to express to others, or to themselves, due to anxiety level, fear of the emotional reaction of others (e.g., anger, disappointment, sadness, humiliation), out of loyalty (fear of hurting a loved one), and so forth. In addition, within the therapeutic discourse, the therapist might discover the “treason” of talking: Inexact words and thoughts that are incomplete may be impossible for some to express, and accompanied by tense behavior and body language incongruent with verbal expression. Thus is established a barrier to connection, because despite the fact that the medium of talking is supposed to bear the content and pass it on to the psychotherapist, in this case communication through the use of the medium of talking is blocked or distorted.
Here one can see that it is essential that the therapist distinguish between interactions/relational patterns (in this case, talking) and communication (in this case, body language and tone of speech), and understand the relationship or correspondence between the two. The medium of body language served as a threshold into the client’s inner world, allowing expression—consciously or unconsciously, to self or to the therapist—of that which lay behind the barrier. The body language belied the client’s verbal language, presenting an alternative channel of communication. The fact that the client was unintentionally passing on messages to the therapist through nonverbal means, despite his or her not wanting or the inability to do so verbally, illustrates that one medium may be more dominant (expressing truer content) than another. It is essential that therapists recognize and are well acquainted with the qualities and potential for expression of the mediums they choose to employ, as well as of those of mediums which exist in every therapy setting, and even of the unique relationships and interactions between mediums for each client.
As was mentioned earlier, a medium may be a condition or environment in which something may function or flourish, or a nutrient system for the artificial cultivation of cells or an organism. In other words, the presence of the medium serves as a given as a field of communication, about which may be spoken or unspoken, known or unknown, sort of like the air we breathe, or like speech that we take for granted and use without thinking about it. It is present, whether we use it or not, at any given time, enveloping us whether we are aware of it or not. It is exactly this seemingly simple, naïve nature of a medium which allows clients to use it unself-consciously, without feeling defensive, thus feeling that they are not letting their defenses down. They continue to feel safe, while unaware that they are expressing that which is within.
It is essential to identify and distinguish between that which has been till now left outside of expression and communication, yet is deserved of discovery and needs to be expressed, stated, and worked through, and that which is psychologically dangerous to the client and will (should?) not be said and exposed under any circumstance. Such content may be threatening, and talking about it may force the client to deal with issues that the client has neither the maturity nor the psychological nor emotional capacity to comprehend or to cope with. The therapist must take great care to employ the medium in a way that will enable psychological development without harming the client.
In both cases, the medium has a critical role. Even content which would be dangerous to the mental health of the client were it to be expressed openly (both to the therapist and to the client) needs to finds a way out, even if only in the form of “I have a secret that can never be told, a thought that can never be acknowledged” that is expressed in unsolvable code. In both cases, content of the client’s inner world needs to be expressed in order to relieve inner pressure, a certain loneliness, or a feeling of being cut off and not seen, even if only at a subconscious level.
In the former case, a medium may facilitate the initial expression of content that otherwise could find no way to be expressed. This expression of the client’s inner world, through the use of the medium, leads to reenactment of past situations, which then leads to opportunity for the content to be worked through, unknowingly by the client and hopefully knowingly by the therapist. At first, the therapist may reflect or discuss the content in the context of the medium, thus respecting the client’s defenses. This amounts to going behind the defenses without trying to lower them to work with the content. Only later, according to the discretion of the therapist and when the client is feeling safe enough, will the therapist start making the very slow and careful move from reflection to interpretation, leading to an eventual “discovery” and open discussion of the content.
In the case of psychologically dangerous content with which clients are not yet ready to cope, the medium may allow for expression in such a vague and ambiguous way that clients continue to feel safe, despite the expression. Here, it is important for the therapist to leave the expression in its raw form, to not confront clients with the possible meanings of their use of the medium. Here, the role of the therapist is to be with clients so they will not be alone with the content being expressed. In this way, the therapist, in his or her use of the medium, allows for contact with that content that clients may subconsciously be dealing with, at the level that they are able to tolerate and bear.
We will finish with an example provided by Marion Milner, a pioneer in her attempt to develop the idea of medium in therapy. In her paper, “The Role of Illusion in Symbol Formation” (1952, in Milner, 1987), she presents the case of Simon, a child who experienced the events of a World War and had problems functioning at school. In therapy, Simon chose to play with fire. He pretended that there was a war between two villages, burned the plastic dolls, and created material which he “cooked.” Milner tried to interpret to Simon the war games and fire in terms of aggression, separation, and oedipal conflict. However, during the clinical process, she felt an impasse and decided to examine possible barriers to the therapy that might have been the result of her theoretical approach. This process enabled her to become free of the theory which had influenced her work with Simon, through heightened awareness of the independent presence of the medium, and to build a new theory:
The greatest progress in his analysis came when I … was able to deal with the negative counter-transference. At first, without really being aware of it, I had taken for granted the view of infantile omnipotence which is described by Fenichel…. But when I began to suspect that Fenichel was wrong here … then the whole character of the analysis changed. (Milner, 1987, p. 104)
She arrived at the awareness of the importance of the choice of mediums and their design, which do not express omnipotence but rather prove the existence of basic creativity, which had been blocked. Through personal observation and listening to the creative processes in which she herself was involved, as well as through observation of how her client expressed himself in his own unique ways, she formulated the concept of medium. She added that the cure came from the use of the most appropriate medium—that which enables the minimizing of the gap between the inner and the outer realities (Milner, 1987). In this way, the client develops faith in the reality created by his self, as the child’s basic belief that when he opens his eyes and sees the world around him, he was the one who created it. “He feels it is the lovely (or horrible) stuff he made,” (p. 100) and as with material, the world may be designed and changed, for good and for bad, and that one may express messages through the material he has chosen and that he can let the medium that he has created for himself positively influence his relationships. Milner went as far as to identify herself as a medium: “I was his lovely stuff” (p. 103).
The Third
Earlier we referred to the creation of a third unique medium common to both client and therapist, which serves as a bridge between their mediums. The literature of psychotherapy contains many references to this idea. We mention here two references that stand out: the third thing by Clare Winnicott (1968) and the analytic third by Ogden (1999).
Clare Winnicott (1968) was interested in finding a solution to a common barrier found in psychotherapy—the lack of willingness or ability of the client to communicate with the therapist. In medium-sensitive therapy, therapists may not understand the client’s use of the medium when it is pathological or not communicative enough. Winnicott mentioned the importance of establishing between the client and therapist a neutral area in which communication is indirect. “We participate in shared experiences, about which both we and the children feel something about something else, a third thing, which unites us, but which at the same time keeps us safely apart, because it does not involve direct exchange between us” (p. 70).
This third thing, in the context of this chapter, is a medium in psychotherapy which enables the therapist and client to feel that they have something in common. In referring to this third thing, McMahon (1992) explains that it “may be an outing or journey, a pet, a hobby or … simply play” (p. 58). This third thing is outside of the therapist-client relationship and can be looked at and observed by both, because it does not belong to, or come from inside of, either. The act of observing and experiencing together this seemingly objective medium facilitates the development of sharing each other’s opinions and feelings. This sharing is, in effect, communication. In other words, the third thing forms a sort of bridge between them across which messages may flow, thus facilitating communication.
There are many instances in which the therapist-client relationship is threatening and anxiety producing for the client (as in the case of therapy with at-risk children). It is possible that the presence of a third thing takes away the focus from this relationship, placing it instead on the medium. This would reduce the anxiety-producing intensity of the therapist-client relationship. In addition, the sharing mentioned is likely to strengthen the emotional bond between the therapist and client, thus encouraging a natural development of the therapeutic alliance, the relationship without which therapy cannot occur. Another form of third relevant to the idea of medium is that of the analytic third, proposed by Thomas Ogden (1999), which refers to a third subjectivity unconsciously cocreated by the therapist and client, “which seems to take a life of its own in the interpersonal field between them” (p. 487).
Interim Summary
Thus far, the term medium has been used to illustrate that through which self-expression may occur, that through which one’s inner world is expressed and communicated to another by a variety of behaviors. In the context of psychotherapy, the medium provides an opportunity for feelings and actions to be experienced and situations to be reenacted. The medium has been discussed in terms of its implications for both the client and the therapist. Furthermore, the importance of the therapist’s taking responsibility for being well acquainted with the medium and his or her relationship with it, and for knowing how to use the medium to facilitate client self-expression, reenactment, and working through the issues that come up within the therapy, have been emphasized. Thus, the therapy process is enriched and flourishes through the availability of the medium for the use by the client and the therapist. Finally, the role of the medium has been discussed as something that provides a common experience or common field of communication for the client and therapist.
THE ANIMAL AS A MEDIUM IN AAP
Whereas the chapter till now has delved into the general concept of medium in psychotherapy, focusing attention on its definitions, facets, and roles, the rest of this chapter discusses how an animal may serve as a unique type of medium. The animal as a medium in psychotherapy will be discussed within the context of the general concept of medium as described earlier, while the many facets that are unique to the animal as medium will also be discussed. Among these unique facets, we will discuss (in this chapter and in chapters 2 and 9 ) the multidimensional phenomenon of the intricate triangle—therapist-client animal—that exists in AAP, the meaning of the animal for the therapist, professional concerns pertaining to the animal as a medium, and dilemmas that arise when the medium is a living being.
According to Ishai et al. (in press), a medium has many and varied uses and implications: as material, platform for, and means for communication, a fertile ground for its development, a generator of content, a motivator or stimulation for change, containing messages or themes and values, and as a personal and interpersonal experience. The presence of an animal in therapy offers all these advantages. More so, we claim that an animal, with all that his presence entails, is rich and meaningful, because it is a multidimensional and multifaceted medium. Throughout this chapter, any general reference to the animal as a medium will heretofore refer also to all that his presence entails: his physical or metaphorical presence, his setting (whether isolated or with other animals, in a cage or free-roaming, in a play-therapy room or a petting zoo, or in a natural habitat such as a forest), his effect on the human senses (e.g., his sounds, smell, movement, visual presentation), his accessories (e.g., cage, leash, food), his behavior, and more.
The presence of animals, along with its implications, creates a large variety of simultaneous emotional, authentic, and spontaneous expressions, which bypass barriers to communication, facilitating and expediting its development into a curative medium. In turn, the animal as a medium catalyzes the development of the curative processes in psychotherapy.
This medium is on a basic level a “nutrient system,” fertile ground, climate, or condition, from which the therapy process may grow and progress. One explanation of this may be found in the concept biophilia , proposed by Edward O. Wilson (1984) in his book by that name. In a book later published by Stephan Kellert together with Wilson (1993), they write:
[The] human tendency to relate with life and natural process might be the expression of a biological need, one that is integral to the human species’ developmental process and essential in physical and mental growth…. The biophilia hypothesis proclaims a human dependence on nature that extends far beyond the simple issues of material and physical sustenance to encompass as well the human craving for aesthetic, intellectual, cognitive, and even spiritual meaning and satisfaction…. [There is a] human need , fired in the crucible of evolutionary development, for deep and intimate association with the natural environment, particularly its living biotica…. [One assertion of the hypothesis is] that the human inclination to affiliate with life and lifelike process is … likely to increase the possibility for achieving individual meaning and personal fulfillment. (pp. 20–21)
Although as of yet there has been little research carried out to test the biophilia hypothesis, a recent study has found a neurological basis for this concept. Mormann et al. (2011) studied the amygdala, the area of the brain which has been shown in research to perform a primary role in the processing of emotional reactions. The researchers found a preferential response for pictures of animals (as opposed to pictures of people or landmarks) in the right amygdala. This finding of categorical selectivity was independent of chemically related emotion or arousal, and the researchers concluded that this finding “may reflect the importance that animals held throughout our evolutionary past” (p. 1247). An implication of this finding is that our very brains are wired to receive the animals as a medium, which touches us in a very deep and basic way.
In their introduction to Ogden’s chapter, Mitchell and Aron (Ogden, 1999) stated that therapists must “mine their [patient’s] potentially rich yield of access points into the patient’s inner world” (p. 461). Mormann et al.’s (2011) research points to animals as being a natural access point to the depths of our emotional being. In conjunction with this, the existence in the therapy setting of the animal, by his very nature, is a rich and multidimensional stimulus of associations, memories, sensations, emotions, content, and more, all of which have their roots in the inner world of the client. The client’s thoughts, emotions, sensations, interactions, and behaviors which are stimulated by the presence of the animal are all access points that provide the AAP therapist with opportunities to view and vicariously experience the inner world of the client. In addition, the animal acts, reacts, and initiates, of his own free will. This facet of the AAP setting generates situations and occurrences that affect the client, awakening even more associations, memories, sensations, emotions, content, reactions, and so forth, all of which also have their roots in the inner world of the client. As a result, for many clients, the presence of animals opens up the floodgates to material that previously had not been emotionally or psychologically accessible to them.
There are two implications for therapy that result from all that is generated within the client as a result of the presence of the animal, as described above. First, on a consciousness and awareness level, depending upon the ability of the client to self-reflect, all of these associations, emotions, and so forth may be used as material for therapy processes that will lead to insight and change. Second, for clients who are threatened by the material suddenly intruding into their consciousness and unable to accept it, animals may serve as an object of the clients’ projection of their own emotions and thoughts, or as an object of transference, or redirection of feelings toward another person that is related to the content. In other words, clients who are not able to self-reflect may identify with an animal, project their inner world and emotions onto the animal, and reflect the animal. Thus, through their reflections of the animal they are actually self-reflecting in a nonthreatening way. This second implication provides rich material for reenactment of that threatening content in the here and now, with the support and mediation of the therapist. Further discussion of this issue may be found in Chapter 4 .
In short, the animal serves as a mode of client self-expression on many different levels and in many different ways. In the context of the theory proposed by Ishai, Oren, and Ishai (in press), the animal as a medium serves as a unique means of communication in therapy.
An Animal as a Medium for Communication or Expression of the Client’s Inner World—to Self and to the Therapist
It is crucial for the process of healing through psychotherapy that clients come into contact with their inner world and its content, and then express that content to themselves and to the therapist. As was mentioned earlier, a medium is also a means of communication, or a channel for communication of emotion or content that needs to be expressed between the client and therapist. With the help of the animals in the therapy setting, this communication may take many forms and serve many purposes. A client may have a difficult time communicating experiences or emotions and discussing them with the therapist, and it is easier to talk about them through the animal’s behavior. One child may set up a situation in which the animals “role-play” (according to the behavior that the child knows the animal will exhibit as it fits into the content that child needs to express) and the child is the director, assigning roles and setting up situations. This might represent the child’s communicating a problematic experience to the therapist so the child will not be alone with it. A client with a behavior problem, or one who is chronically shy or anxious, may want to observe the animals together with the therapist and ask questions about the differences in behavior and underlying emotions and experiences of, say, the hyperactive rat, the hiding hamster, or the sleeping dog. This shows the therapist what some of the client’s underlying issues are and is an invitation to the therapist to enter into a dialogue about the animal’s behavior (along with the causes and implications), while allowing the client’s defenses to stay intact. In turn, this provides the therapist with an opportunity to also comment and reflect, to add possible interpretations, and to ask questions, as if about the animal’s emotions, intentions, behavior, past experiences, and so forth.
CLINICAL VIGNETTE—RINA

Rina, 10 years old and a daughter of recently divorced parents, was brought to the emergency shelter because of neglectful parenting and violent behavior on her part. Her mother worked three jobs and was not emotionally or otherwise available for her children. Rina often did not show up for school and was left alone for many hours. Sometimes her mother even told her to stay home to babysit her younger sister or to clean the house. When at school, she was violent toward other children and exhibited many other behavioral problems. At home she often had tantrums and broke objects in anger, and she once threatened to stab her older sister with a pair of scissors. Rina was diagnosed as showing early signs of conduct disorder . She reported that her mother once threw her out of the house.
In therapy sessions, a deep and heavy sadness flooded the atmosphere. Rina talked of her many pets, most of whom had died tragically. She had saved a kitten from the street and was afraid that her mother was about to “throw her back there.” When she saw that the lab rats in the session tried to get to the hamsters, she said that it would be better for the hamsters to die and go to heaven, for there the rats would not be able to get to them.
Rina talked of missing her father very much, and now feeling alone, but could not elaborate. She also talked proudly of her independence, describing how she has been taking busses alone since age 7. At home, she enjoyed never being told what to do.
Rina loved playing with the hamster family in therapy sessions. She often put them into the two-story, four-room dollhouse. She watched fascinated as the hamster parents and babies moved from room to room. Sometimes, she blocked a door between two rooms, leaving the parents in one room and the babies in another. Throughout the time we watched this scene together, Rina explained to me (Nancy) what was happening, often reflecting to me the hamsters’ feelings. As they climbed over each other or ran in different directions, she would tell me of their fighting, of their need for space, or alternately of their loneliness. In one session, the female hamster jumped out of the dollhouse, again and again, from the room she had been in with the male hamster. Rina always returned her to the male hamster. She reflected that the female was miserable with her boyfriend and that she had run away in order to look for love somewhere else. In another session, the mother hamster repeatedly jumped out of the dollhouse because she was trying to commit suicide.
Two sessions were particularly heart wrenching. In the first, the mother hamster ran around the house “hysterically.” Rina explained that she did so “because she couldn’t deal with the situation at home.” Rina took the part of the hysterical mother, screaming, and even simulated a panic attack complete with hyperventilation. The mother hamster leapt from the house and “went to hide far away from the family” under the toy shelves. In the next session, Rina left the father in the cage and put only the mother and the babies in the dollhouse. The mother hamster again left the house. Rina took the role of one of the babies and started crying with great intensity, “Mommy, Mommy, where are you?” Rina looked extremely distressed. This appeared to portray a different situation than the last one, for the father was no longer there. After what seemed to be a long period (at least to me) of this highly distressed behavior playacted by Rina, the mother hamster come out from under the toy shelves. Rina brought the mother hamster back to the dollhouse. Playing the mother, Rina said in a tone of indifference, “What’s the problem? I just went off to work. Now I’m back.” Rina then explained that the baby hamster felt better now because she knew that the mother was okay.
There was a large gap between the show of independence that Rina voiced to me and the panicked feeling of abandonment and fear that she seemed to feel after her mother’s disappearance. It seems that the show of independence was a defense against experiencing the feelings of helplessness and utter fear, about which she dared not speak. Through her expression of her associations which arose from the actions of the hamsters and the situation they created, and her experience of this situation as a reenactment of her past experiences with her family, Rina was able to express her innermost anxieties without destroying the defenses she had built to hold herself together. Once the content came up and was expressed, she began to compare herself to the animals in the therapy—feeling scared and angry. After each of these sessions, Rina started talking about her loneliness, about her mother’s not being there when she needed her, about her mother’s expectations that she take care of her little sister “even at night, so Mommy can sleep,” about her violent behavior at school and her strong feelings of guilt for hurting others.
The therapist who treated Rina before her arrival at the emergency shelter had reported that Rina lacked focus, was always pushing limits, tried to cause a reenactment of rejection, used defenses of distancing and acting out, and used silence as a weapon. In AAP, Rina was able to involve the animals in the therapy process in such a way as to create for herself, with my help, enough potential space to playact her extremely distressing life situation. She stayed focused on various parts of her distress (not only the abandonment and fear discussed here, but also other distressing issues related to her family reality) in the safe potential space created in the AAP play therapy situation and was able to express those parts. Having expressed her emotional experience to me through her reflection of the animals’ emotional experience, Rina was able to discuss her feelings more directly with me and work on them openly. Perhaps due to having found an appropriate medium of self-expression, Rina was able to let go of her other defenses (e.g., pushing limits, using silence as a weapon) and use the process of psychotherapy more efficiently.

Yet another child will express his or her inner world by acting it out through interactions with the animals, and it is for the therapist to reflect and explore together with the child the meaning and implications of the child’s behavior, to understand the source of the reenactment and work it through, often through continuing interactions with the animals. This continuing series of reciprocal behaviors between the child and the animals, and discussion between the child and therapist, is in effect an ongoing dialogue, or communication, between them. This is a positive type of acting out that serves as a communication, with the animals serving as the medium of the communication, leading to insight and change.
CLINICAL VIGNETTE—SIMON

Simon, 8 years old, was a serial cat abuser and killer before he arrived at the emergency shelter, yet he also loved animals. He had been reenacting his experience with his mother, who had cruelly physically abused him, although she loved him so much that she reported herself to the welfare office because she was frightened of the harm she was doing to him. In the early stages of therapy, Simon loved the rats and they returned his affection. At a later stage he began to attempt to hurt them, and succeeded in startling them. I (Nancy) was in a state of constant readiness to protect the rats from physical harm and emotional stress. Simon’s behavior in these sessions paralleled his behavior in the living quarters of the shelter, where he often cuddled with the resident dog and derived much comfort from her, yet all of the childcare workers and other children were on guard to protect her from Simon. Once a childcare worker asked him, “You love Nella so much. Why do you hurt her?” He answered with a question: “What’s the connection?” During a conversation about his history of cat abuse and his need to startle the rats, Simon explained to me that he knew very well what fear felt like, but he loved to see what it looked like from the outside.
Eventually Simon became distressed because the rats he loved so much were no longer willing to come to or be held by him, yet they still came to me for attention. When Simon asked why this was, I explained to him that the rats no longer wanted to suffer the stress of being near him, that they had the right not to be frightened, and that they came to me because they felt safe and comfortable with me. After Simon had been home for a weekend visit, he came to a session and proudly announced that his mother had tried to hit him, but he had run away. He told me that never before had it occurred to him that he could run away. This he had learned from watching the rats and from my reflections and interpretation of the rats’ emotions and behavior. The empathy I showed the rats, and the protection I provided them from Simon, while still accepting him, allowed Simon to have empathy for himself as a victim of his mother’s abuse and to realize that he should be protected. Simon stated that he no longer needed to see what fear looked like and wondered if the rats would ever love him again. We discussed how he could make the rats feel comfortable with him once more. His overt aggressive behavior toward the rats disappeared, and the rats slowly began to trust him again. This experience led to ensuing conversations about his relationship with his mother, and later to what type of relationship he would like to have with his own children one day.

Earlier in this chapter, the actions of communication (i.e., expression, transmission, comprehension/listening, deciphering, pausing/experiencing, giving meaning, reaction, and expression of that reaction) were delineated, and it was stated that any given medium will specialize in one or more of these actions. Moreover, it was stated that the most efficient medium is one which performs all of these actions. In AAP, an animal is a rich medium for communication. For example, a dog may express excitement at seeing the client and transmit that excitement with an open mouth, by seeking eye contact with the client, and by wagging his tail and barking. The client listens and looks at the dog, deciphers the behavior by noticing the open mouth, eye contact, wagging tail, and bark, and pauses, experiencing the transmission through the memory of similar past experiences of how her mother looked at her with a smile and called to her, and she understands that the dog is looking for her attention. This client will feel happy about the dog’s invitation for interaction and will hug the dog. On the other hand, another client, after the dog’s same expression and transmission, will listen and look and decipher the behavior by noticing the open mouth and teeth, the eye contact, and the bark, will pause and experience this transmission through the memory of similar past experiences of how his mother stared into his eyes threateningly while yelling at him—a precursor to her hitting him—and will think that the dog is about to attack him. His emotional reaction will be one of fear and feeling threatened, and he will express this reaction by either running away or trying to hit the dog.
Both sequences of behavior, containing all the possible actions of communication, are stimulated through the animal as a medium for communication. Within the therapy setting, this communication has two levels: it is a concrete communication between client and dog taking place in the here and now, and it is also a communication to the therapist of the client’s inner world in terms of how the client perceives the approach of objects in his or her social sphere and how the client reacts to that approach—in other words, his or her internal working models. The very transference of the role of welcomer or attacker to the dog also communicates to the therapist which content has a significant place in a client’s inner world.
It is interesting to note that the animal here serves as a medium on many levels simultaneously: he is a sensorial medium (sight and sound), a social medium (creating a social situation which brings up associations and content from relational objects), as well as a medium for communication of emotions and content from his inner world. The variety of mediums as channels of communication, in combination with the number of actions of communication making the animal an efficient medium for communication, serves two purposes, both important for the therapy process. First, the strength of such a multidimensional medium acts as a catalyst for the process of therapy. Second, such a rich medium or channel for communication of the client’s content and emotional state, to the therapist and in the presence of the therapist in the here and now, is likely to strengthen the therapist-client relationship. In the here and now, the therapist is an ever-present observer of, and sometimes partner to, the client’s experiencing within the interaction with the animal, making way for reflection, clarification, and discussion of what happened in that interaction.
The Situation, Created by the Presence of an Animal, as a Medium
Many elements of the situation surrounding an animal in therapy will have implications in the therapy: the setting of the animal, type and gender of animal, number of animals and number of types of animals, whether the animal is free-roaming or in a cage, and whether or not the animal is in his natural setting. (In addition, the animal brings with him many accessories: food, water, leash, brush, cage, hamster wheel, wood shavings, and so forth.) Even without any behavior exhibited by the animal himself, these elements will have an effect on the therapy process in one way or another. They may have their own uses and objective meanings, yet clients will perceive them through the lens of their own inner world and will use them according to their emotional and psychological needs.
AAP is characterized by flexibility in the type of therapy setting. The AAP therapist may use any of various settings, each setting having its own meanings, implications, opportunities, advantages, and disadvantages. The setting may be a petting zoo in which there is a large variety of animals living in a comparably natural environment. For instance, ducks may swim in a pond, rabbits may be able to enter into underground burrows, and parakeets may live in flocks. The relationship of the animal to his setting brings up issues, as do the elements within the setting (e.g., body of water, plants, an abandoned egg on the path, stepping on animal “droppings,” holes for hiding or getting stuck in). The animals may be taken care of by the therapist, or by a zookeeper who may or may not be known to the client. There may be little personal relationship between the animals and the therapist, and the animals might not have names. The setting may be a forest, where the client may see a lizard catching a fly or be stung by a bee, and which may bring up issues concerning “the law of the jungle.” The setting may be, in the tradition of Boris Levinson (Levinson & Mallon, 1997), a walk into the neighborhood of the clinic with the dog. There the client observes and behaves while the therapist reflects. For example, a client who was removed from his home due to severe neglect saw every dog and cat he encountered during the walk as abandoned, frightened, and starving, and for the first time was able to connect with his inner feelings of abandonment. The setting may be a play therapy clinic, filled with toys and art supplies, to which the therapist brings animals in traveling cages. Here, the likelihood is greater that there exists a relationship between the therapist and the animals, who may even be perceived as part of the therapist’s family, or at least as a certain extension of the therapist.
If there is only one animal, there will be a simple triangle made up of client, therapist, and animal. (See Chapter 2 for a wider discussion of this triangle.) The possibilities are more limited when there is only one animal, or no interaction is allowed between the animals. There is no variety, no possibility for relationships between animals, and no possibility for multiple and simultaneous transferences of relational objects. If there are a number of animals, the number of potential relationships and projections grows. When there are more animals present, different types of animals have different meanings and representations for the client. For example, without ever leaving the cage (and therefore not able to partake in any actual dangerous behavior), a lab rat may represent danger due to the attached stigma. On the other hand, a hamster may represent softness and vulnerability, merely because he is small, furry, and curled up. For a maltreated child, a family of hamsters may bring up associations of an at-risk family, for violent fights often break out between the adults, the father is often removed after a birth to prevent him from eating his young, and the (now single) mother quite roughly drags the young hamsters around the cage with her teeth.
Animals may be free-roaming or caged. A client may be threatened by a free-roaming animal, or may see this as an opportunity for open and mutual initiations of interactions. One shy client may gain from the initiative of a free-roaming animal looking for connection, while another may feel safer, or more in control, with the animal in a cage. The cage itself often has various meanings that may be used during therapy by the client. It may represent a home, a playground, a punishment, protection from outside danger, a dangerous trap, jail, a limit to freedom, or a place to run away from or to. The shavings in a cage may be perceived as a soft mattress, as clean, or as dirty. The animal’s food may be given or withheld. A dog’s leash may be perceived as a concrete connection while on a walk, or a method of control.
The very presence of animals influences each client, behaviorally and emotionally, in a different way. According to the content of the inner world, the client may become more active or quieter, and may change his or her emotional state or muscle tone. Whereas a client may walk into a play therapy setting and ignore the presence of the toys, it is rare that a client walks into a setting with animals and does not relate to the fact of their presence, much like what would happen should the client walk into a room with another person in it. By the very fact of the animals’ aliveness, there is an interpersonal/interactional potential exuded in the setting, with all that this implies.
The atmosphere of the setting at the commencement of therapy is often artificial and tense. The room is unfamiliar and the therapist is a stranger. The circumstances are often uncomfortable, for the client is coming to therapy because of a problem, or even because he or she is thought of as problematic. The client may immediately feel that the therapist is evaluating and judging him or her, and the first interactions are often stilted and nervous. The presence of the animals in the therapy setting tends to ameliorate this situation by making it more authentic and less threatening, less sterile, which allows for more natural conversation. The presence of the animal in the room adds a sense of normalcy and encourages more natural and spontaneous behavior and communication. Research has shown that the presence of an animal contributes to a positive perception of a situation, one characterized by friendliness and safety (Lockwood, 1983). Later in this chapter we will refer to the therapy triangle that exists in the AAP setting. One of the implications of this triangle is the establishment of an atmosphere of safety and trust through the therapist’s interactions with the animals, in which the therapist proves to be a safe haven and secure base for them.
Physiological effects have also been found to be associated with human-animal interactions. Studies have shown that interactions with animals result in lower blood pressure and heart rate (Friedmann, Katcher, Thomas, Lynch, & Messent, 1983), changes in hormonal levels (higher oxytocin levels and lower cortisol levels) leading to a lowering of stress and anxiety, a general sense of pleasure (Odendaal, 2000), and an increased ability to feel pleasure (Nathans-Barel, Feldman, Berger, Modai, & Silver, 2005). The client may, consciously or not, recognize the calming effect of the animal and even use it.
The implications of the effects of the presence of the animals and the atmosphere thus created are likely to lead to an increase in the client’s emotional availability for the therapy process to occur and also in his or her ability to deal with anxiety-producing content. For instance, we have heard statements from clients such as, “I feel better when the animal is in the room.” An 8-year-old at-risk boy, overwhelmed by difficult content, spoke of Nancy’s dog Mushu’s softness and warmth, transferred through role-play the role of “good mother” to the dog in therapy, and cuddled with her. He then worked on the subject of good versus bad mother. A 13-year-old youth with a macho personality and criminal leanings made a very difficult emotional breakthrough and was showing signs of extreme anxiety. He walked over to Mushu, curled up with her in a fetal position, lay there for 20 minutes, and at the end of the session smiled and asked if he could stay another hour. Both of these clients consciously used the animal to calm themselves in order to stay within the therapy process, much as in the use of biofeedback.
These last few points explain an interesting phenomenon found in AAP which might indicate an important mechanism behind the AAP process. As just explained, the research shows the calming effect of the presence of animals (Friedmann et al., 1983; Nathans-Barel et al., 2005; Odendaal, 2000). Previously mentioned research points to other neurological explanations, suggesting that animals provide an access point into one’s inner world (Mormann et al., 2011). Finally, research was mentioned showing that animals act as social facilitators (Corson, Arnold, Gwynne, & Corson, 1977; Lockwood, 1983), thereby making the social situation of therapy more natural and the therapist more approachable for the client. All these factors point to the animal as a medium creating a situation in which the client will be more emotionally available to take advantage of the other characteristics of this same medium, so that the client may more likely be able to take advantage of the therapy process. In other words, there is a two-tiered effect in which the medium creates the conditions which enable it to be taken advantage of by the client (and by the therapist who has the training, knowledge, and ability to do so).
Animal as Sensorial Medium
The medium, as defined by Ishai, Oren, and Ishai (in press), is derived from the creative discipline and notes the qualities of the material, color, shape, message/theme, and image. The presence of animals adds to the medium also movement, sound, smell, and behaviors that enrich the therapeutic experience and facilitate as well as expedite the creation of reenactment, working through, insight, and change in the client.
An animal is a medium that by its very nature contains within it elements of movement, sound, smell, color, shape, texture, warmth, and physical tactile sensation, all of which automatically stimulate a person’s basic senses. This stimulation occurs with contact with the animal at any level. These senses are rooted in our very existence from the time even before birth and are more basic than any of our cognitive and emotional processes, and often bypass them. This is especially true when for any reason these processes decrease or shut down.
All of us suffer to some extent from a decrease in cognitive or emotional functioning, whether as a result of physically or emotionally painful experiences, trauma, memories, or relationships. This decrease is a defense which allows us to function in our lives on a daily basis. The defense becomes problematic when it interferes with our functioning, relationships, and realization of our goals. This may happen when we have defenses which are too rigid for a situation, when the pain or anxiety is too much to bear and we are forced to raise our defenses much higher than is advantageous for functioning, or if our defenses that are meant to protect us fall apart. All of these situations lead to unhealthy or even paralyzed cognitive and/or emotional functioning. A person suffering in this way may come to psychotherapy looking for help, but may struggle to enlist cognitive and/or emotional strength, and therefore have great difficulty touching that which is inside. This may be expressed as denial, chaos, confusion, helplessness, or the inability to articulate, or through emotional shutdown. Therapists may have little choice other than to stand aside, reflecting to the client what they observe.
An AAP setting is full of stimuli which, through their basic nature and automatic effect on the most primitive areas of the brain, bypass the problematic cognitive and emotional functioning (or barriers), giving clients something to grasp that may be nonthreatening and seemingly unrelated to the pain and anxiety which affect functioning. This may allow clients to start reconnecting with themselves, while still keeping a connection with the environment, through the stimulus to their senses emanating from the animal, in addition to the animal himself as an entity. Clients are also accustomed to the presence or use of these sensations in their relations with the human environment, these awakening memories or sensations familiar to them from their relational objects with others in their life, as well as from past experiences. An animal may look, sound, or behave like someone in a client’s life, or even like the client him- or herself. In addition, at a later stage, a client may become comfortable using these stimulated senses as a basis for discussion, associating, remembering, reenacting, for working through and analyzing, for insight and change.
Senses, as primitive as they are in origin, are also associated with emotions, memories, and experiences. Here we will mention some of the various ways in which animals, through sensual stimulation, may influence clients, who will react in any number of ways depending on their perception of the stimulation and according to the content of their inner world. This influence may in turn stimulate the ability of clients to access their inner world, leading to self-expression and an increased ability to communicate with the therapist and to interact socially in a more adaptive manner. Animals in the therapy setting make for a very efficient medium in that they stimulate multiple senses simultaneously. It is the prerogative of clients, according to their needs, to choose (consciously or unconsciously) the sense or senses through which to relate.
Sound
Animals create sound, which serves as a language through which they communicate and express sensations and emotions, and may also serve as an initiation for interaction with others (client, therapist, or other animals) in the setting. The client encounters a set of tones familiar to the therapist but that may or may not be familiar to the client. These tones are specific to the type of animal, the individual animal, and the animal’s mood at the time. Also, the animal’s voice may have varying characteristics. It may be loud, soft, shrill, sudden, or continuous. It may be experienced by the client as pleasant, funny, frightening, soothing, or confusing. The sound may be initiated by the animal or may be a reaction to someone or something in the setting. The client may interpret the sound as emotional expression, communication, a threat, a reaction, an invitation, or initiation. The client may choose to ignore the sound, comment on it to the therapist, or react to the animal who emanates it.
Smell
The animal may have a smell that his body emanates, a smell that begins or gets stronger when in contact with him. The smell may cause a sensation and a reaction of disgust, for instance. In addition, animals may also expel bodily fluids, such as saliva, urine, or feces. The animal’s body waste adds an element of smell.
CLINICAL VIGNETTE—AMOS

Amos was 9 years old when he came to therapy due to behavioral problems both at school and at home. He also suffered from encopresis, which he had never been able to recognize. Often, Amos came to a session with a strong smell of dried feces emanating from him, yet he always denied “smelling something in the room.” Amos became especially fond of constructing violent war scenarios with the toy soldiers and guns in the room. At first his affect was flat, or he would deny the violence in his play, but he eventually learned to express emotion appropriate to the storyline in the war scenes. However, he still was not able to express negative emotions about anything in his real relational world. He also became particularly fond of playing with the rats, making mazes for them to run through, cuddling with them, and playing games with them. Knowing that they like to hide in dark places, he put them inside a drawer. However, I (Nancy) heard them scratching, trying to get out, so we opened the drawer. Although their feces is usually dry and lacking in smell, we found that they had had bowel movements that were soft and noxiously smelly. I explained that this happens when they feel stressed or anxious about something, as they probably felt being shut in the drawer with no way to get out. Amos answered, “I sometimes have anxious kaki, too.” He then explained that recently he was supposed to appear in a school play, but that he was very anxious and frightened about it and did not want to participate. However, the adults forced him to appear in the play, and while standing on stage, he had “anxious kaki, just like with the rats.” After that, Amos was able to talk freely about the encopresis, telling me when it had happened and how he felt about it. Later he talked about how his eating habits changed according to his emotions. As he became freer to discuss his emotions, he began to confide in me his anger and fears concerning others in his life.

Movement
Water drips, a ball bounces, and paint spills. All of these actions are initiated by the client. Toys and art supplies are inanimate objects.
As a living organism, the animal has free will and initiates movement, choosing at any given moment to sleep, to react, to draw closer or to move away, to run quickly or walk slowly or to stay in place, to bare his teeth or to lick. He may move in familiar ways, expected by the client, or he may exhibit type, speed, and character of movement that is not familiar or expected. One client may laugh at the unexpected movement, while another may be startled. Each type of animal has a different type of movement, which each client may relate to in a different way depending on his or her inner world and emotional needs. A reptile will move very differently than a hamster. In the case of birds, the client will be confronted with flight. Many clients are very alarmed when a bird flies around in a room, and they show a great deal of fear of the wings. Others watch in wonder, wishing that they too could fly. There are clients who try to startle the bird into flight, some out of a desire to control, some out of aggression, and some out of a lack of understanding that the bird may be distressed. One dog may be calm and sleep most of the time, while another is lively and constantly running and jumping. Each client will react differently to the animal’s pace. One child may identify with the high energy of the lively dog, while another may be distracted or frightened. One child may feel contained by contact with a calm dog, while another may be frustrated by the dog’s slow pace.
The animal as a medium characterized by self-initiated movement is indeed unique. The animal has his own desire, or will, and he can choose to draw close or move away, to be passive or active, to move away from or toward. He may or may not agree to be controlled by the client, may or may not react, and may or may not initiate. There is a question of expectations within situations and interactions with another living being.
Touch
Human beings have an innate need for touch, which is basic to the human social experience. Touch may be calming, create trust, reduce anxiety, prevent feelings of isolation, and create conditions for emotional availability and openness. It also may represent threat, sexuality, control, or intrusiveness. As in any significant relationship, clients may seek out touch from the therapist; however, touch between clients and therapists is a complex issue and raises dilemmas. The therapist’s goal is to create a basic sense of security for clients, and touch may help when it is straightforward, simple, free of ulterior motives, for the good of the client, and in the control of the client. However, touch may also have a myriad of meanings for clients, depending on their past experiences (e.g., whether touch was forced on them or denied to them), and also whether the touch originates from transference issues (e.g., the therapist may represent a parental figure, an aggressor, or a sexual object). Clients may also incorrectly interpret touch from the therapist according to their psychological needs in terms of the content of their inner world and their past experiences.
The presence of animals in the therapy setting presents a unique way of answering this basic need for creating a sense of security through physical touch with another living emotional being. Boris Levinson, the father of modern-day AAP, wrote in his groundbreaking book, Pet-Oriented Child Psychotherapy :
Disturbed children have a strong need for physical contact but are afraid of human contacts because they have been hurt so much and so often by people. Since the hurt is not associated with the dog, this conflict resolves itself…. A dog apparently poses less of a threat because he can satisfy the child’s need for physical contact without the painfully embroiling emotional entanglements that the child already knows accompany emotional involvement with humans. (Levinson & Mallon, 1997, p. 59)
The therapist will monitor the touch, while reflecting the interactions and situation surrounding that touch. When touch with an animal is positively motivated, and the animal may request to touch or be touched, the client will usually not feel forced to touch, and does not worry that the animal may feel rejected. The client is less likely to be mechanical when touching animal, or false, in order to fulfill others’ expectations. On the other hand, the touching of the animal may be an expression of the content being worked on in therapy. The touch may represent motherly touch, romantic touch, being hit, being controlled, or being raped. (See further discussion of these issues in Chapter 9 .) In this case, it is the therapist’s responsibility to help the client work through the issues brought up by these types of touch.
Another touch-related issue is the actual sensation of touch. Animals may or may not have fur. Their fur may be prickly or soft. The client may feel the hard smoothness of nails and teeth, the dog’s cold, wet nose, or his warm breath. The animal may be dirty or clean. Touching him may leave fur or dirt on the client. All these sensations will bring up associations and representations from the past and present for the client to work on in therapy. An advantage of the sense of touch is that when memories of past experiences cannot be mentalized, they can be felt, because touch is much more basic, coming from a more primitive place.
Sight
The animal has visual qualities that will be perceived by the client. The animal is characterized by color and by shape. In the eyes of the client, the animal may be pretty, pleasing, or ugly, disgusting, calming or frightening.
CLINICAL VIGNETTE—RUTH

Ruth was 3½ years old when she came to therapy in the daycare center run by the welfare office, yet she still only talked in two-word sentences. At first extremely anxious and on the verge of crying, she slowly began to feel more comfortable within the therapy setting, and after 3 months was already speaking in full sentences and expressing herself. Her fear of her father was evident both in her stories and in direct conversation. When her father came to take her home, she often tried to refuse to go with him, crying in protest. In therapy, she openly talked of both emotional and physical abuse by her father toward both her mother and her. Although during the first stages of therapy she was very fond of the dog, Mushu, over time she became afraid of her. Once, Mushu barked, wanting Ruth to feed her some cornflakes (food which serves as a treat for both animals and children). Paying no attention to Mushu’s wagging tail or smile, Ruth yelled at her in a very angry voice, “You have tiger’s eyes just like Daddy’s and black hair just like Daddy’s. I hate it when you yell at me and hit me. You are not my friend!” In every session for the next year, Mushu represented her father. She punished “her father” for his violence by tying Mushu (with a collar and leash) to a table in the corner of the room. As Mushu would bark, looking for attention or food or her bone, Ruth would refuse to give her what she wanted. “You don’t deserve to get anything, after what you have done to us.” At a later stage, she started to intermittently allow Mushu to have some food, but still while tied up. Ruth needed to feel safe and in control at all times. After a year, her father was arrested and imprisoned for a year for his violent behavior toward Ruth’s mother. With her father truly distanced from her, Ruth was now able to deal with her ambivalence toward her father and express it through Mushu. One day she took Mali (the cockatiel), whom she often identified as “the daughter,” and put her on Mushu’s back. As she contemplated their being together, she said, “Daddy is not my friend, but I still love him.”

It is interesting to note that it is obvious to the client that the animals also have senses. They feel a stroking hand, see a threatening movement, smell the food held by the client, hear a shout. Therefore, the stimulation is mutual—animals stimulate the client’s senses while the client stimulates the animal’s senses (intentionally or not). They relate to each other in a very basic way, on a primitive level, in the here and now. It is as if there is an interaction between two sets of senses, initiating with and reacting to each other through the medium of behavior. This is the basis for actual interaction, for the building of a relationship in which the client and animal get to know each other and learn what to expect from each other. This phenomenon leads to the animal’s being a social medium (a subject elaborated on in Chapter 2 ). (For further discussion of an animal as a sensorial medium, see Chapter 14 .)
Aliveness of the Animal as a Medium
Special note should be made of the aliveness of the animal as a medium. Animals are not inanimate objects, nor are they symbolic representations of a living creature, as are the dolls and plastic animals in play therapy. The inanimate medium may break or wear out. An animal lives, breathes, moves, reacts, gets hurt, becomes sick, and dies. This brings in a range of new possibilities. This life is not that of the client nor that of the therapist nor that of a significant other, yet it still is a life. It is this quality of aliveness in the animal which allows for actual relationships to occur in the therapy setting, and facilitates the transference of objects onto the animals and in turn allows for the client, in the here and now, to interact with these transferred objects in order to work through the related content which is so painful.
The fact that the animals are alive means that they will also die. Many clients are troubled by issues of separation, loss, and grief. In a setting which contains animals, especially small ones such as hamsters, rats, and insects (e.g., the Vietnamese stick insect), death is inevitable. Because of the actual relationship with the animal, replacing a dead animal is not like replacing other mediums. One may buy more blue paint, or an identical toy dog. For Fido, there is no identical replacement—the loss is final. The client may witness the process of the animal’s illness and death with the support, accompaniment, and mediation of a containing therapist who also feels affected by the loss, yet is able to deal with the loss in an open and healthy way and still be there for the client.
CLINICAL VIGNETTE—SARA

Sara, 10 years old, was brought to therapy by her parents due to her inability to express any emotions concerning the death of her two grandparents, who had died within 10 months of each other, or even to talk about them. Her parents were especially worried because Sara had been very close to her grandparents, who took her to and from school each day, gave her lunch, and stayed with her till her parents came home from work much later. Sara seemed like a generally well-adjusted child, and although she came happily to therapy, playing with the animals and dolls and going for walks with me (Nancy) and my dog, Mushu, no meaningful or worrying content came up. Despite her parents’ experience that Sara refused to talk of her grandparents, she talked openly with me about them. She remembered them picking her up from school, her grandfather’s games with her, and the special fruit salad her grandmother would make for her on weekend mornings. However, she made no mention of their sicknesses or deaths.
In time, Boker, the white rat, became sick with a fatal lung disease. Her deterioration was slow but noticeable. Although Sara did not completely follow the stages of grief—denial, anger, bargaining, depression, and acceptance—as delineated by Kübler-Ross and Kessler (2005), she dealt with Boker’s illness and impending death in a way that was reminiscent of them. At first she ignored the signs, even as I pointed them out to her. As the symptoms became more obvious and more debilitating to Boker, Sara began to bargain. She tried to convince me to get a second—and third, fourth, and fifth—medical opinion. She then checked the Internet for a possible cure for Boker’s illness. All along, I expressed my (authentic) frustration at not being able to do anything to help Boker get better, my (authentic) hurt at seeing Boker hurting, and my (authentic) sadness at Boker’s impending death. As she came to accept the situation, Sara began to tell me of her grandmother as she became sick. When Boker’s appetite started disappearing, Sara said, “Near the end, my grandmother didn’t want to eat, either.” At one session I told Sara that the next session would be the last time Boker would come, for the trip seemed to be getting hard for her. The next week, Sara brought a small and furry windup mouse as a present for Boker, so that when she stayed home without the other two rats, she would not be alone. Three weeks later, I told Sara that Boker had indeed died. I was able to show my own sadness and at the same time be supportive of Sara in her sadness.
Throughout therapy with Sara, I met with her parents each month for parental counseling. The father, whose parents were those who had died, brought up much of the family history, including many of the hardships his parents had suffered. His very close relationship with them was evident, as was his grief. The mother was also very close with her husband’s parents and related to them as parental figures. When it seemed like the need for therapy had come to an end, the father said, “Sara enjoys coming to you and the animals so much, why don’t we just let her keep coming.” Sara was in full agreement. It became obvious to me that the issue was a family one and not just Sara’s. The father was having a problem separating, from the therapy and from his parents. He did not want to accept the finality of the termination of therapy (in which there was much discussion of his and Sara’s relationship with his parents) or of his parents’ deaths. Now that this issue had come out into the open, it could be dealt with. The parents admitted that they had found it difficult to bring up memories of the father’s parents in front of Sara, or even between themselves. Often, a child may be the identified patient, or the member of the family who is openly expressing the family pathology. It soon became clear, in discussions with Sara and later with her parents, that Sara had been exhibiting parentified behavior. She felt the need to protect her parents from their pain of talking about the grandparents, who were no longer there. Once the parents realized this, they began to consciously talk with Sara about their memories of her with her grandparents, and they started to look at pictures of all of them together. As a result, Sara brought to therapy a photo album of the family which included many pictures of her grandparents. The parents reported that Sara had started to bring up memories at home and share them with her parents. It was clear to everyone that the time for the termination of therapy had come when the father’s grandmother died and Sara freely shared her feelings with her parents.

An additional advantage of the aliveness of the animal within the therapy setting is that it offers an interpersonal experience within the therapeutic experience that, compared to that with the therapist, is more natural and “clean,” providing an authentic social situation. The animal has no ulterior motive as has the therapist. The animal is not suspect, manipulative, or evaluative. The animal writes no reports and makes no recommendations. The animal acts of his own free will and not under the direction of the therapist. The therapist has no control over whether the animal will or will not recognize or like the client, or will be frightened of the client. This situation leads to more spontaneous and authentic reactions and behavior on the part of the client, in turn facilitating the flow of authentic expression. More extensive discussions of the animal as a live medium may be found in Chapter 2 and Chapter 9 .
The Animal as a Medium for the Therapist
Till now, the emphasis has been on the animal as a medium for the client. However, many AAP therapists believe that the animal serves as a medium also for the therapist. There are many times in the therapy process in which the therapist senses an impasse and feels helpless. The presence of the animal in the therapy setting provides the therapist with additional tools and opportunities for breakthrough that otherwise might not occur. As mentioned earlier, working in the here and now allows for implementation of insight and practice of newly learned and adaptive behaviors. In addition, the reality at a safe distance, or the reflection and interpretation by the therapist of the interactions between the client and the animal (and mediation between them) in the here and now, will likely be less threatening and more acceptable to the client than the therapist’s reflecting and interpreting direct interactions between him- or herself and the client. Many such examples may be found throughout this book.
AAP and Psychotherapy Techniques
The involvement of animals as a medium in the psychotherapy process lends itself to various well-known techniques in psychotherapy, which may then be taken advantage of by the AAP therapist in order to advance the therapy process.
The analytic third . Ogden (1999) refers to the use by the therapist of the analytic third, a third subjectivity unconsciously cocreated by the therapist and client, “which seems to take a life of its own in the interpersonal field between them” (p. 487). The goal of the psychotherapist us to utilize the analytic third “as a vehicle for the understanding of the conscious and unconscious experience of the analysand” (p. 483). The involvement of animals in psychotherapy expands the possibilities that may be afforded by the analytic third. (For further discussion of the analytic third as a basis for the theoretical explanation of the mechanism behind that which occurs within the AAP therapy triangle [therapist-client-animal], and its use in AAP, see Chapter 2 .)
Groups . There are many ways in which the involvement of animals in therapy turns the therapist-client dyad into a group. The therapist may discover the elements of group therapy in AAP individual therapy and use them to advance the therapy process for the good of the client. (For an elaboration of this concept, see Chapter 6 .)
Animals may also be integrated into group therapy. As a result of the unique effects that animals have on humans, such as enhancing trust, reducing tension, and providing opportunities for altruistic giving, meaningful discussions, and practicing social skills, animals may enhance the achievement of various treatment goals relevant to the practice of group psychotherapy. (For further discussion of how the incorporation of animals into group therapy may enhance the efficacy of the group treatment process, see Chapter 17 .)
Play therapy . Due to maturational issues related to a child’s cognitive and emotional abilities to self-express, children are less likely to discuss their emotions, experiences, and problems and are more likely to play them. Anna Freud stated that playing with toys may serve to express fantasies and facilitate the emergence of unconscious material (Sandler, Kennedy, & Tyson, 1980). For this reason, in the context of child therapy, Axline (1969) and Landreth (2002), two well-known authors in the field of play therapy, have stated that play is the most appropriate language of children, and Piaget (1962) stated that play is the means through which children assimilate the world and give meaning to their experiences in order to transform them into part of themselves. Play therapy has been the preferred therapy technique for working with children with emotional problems from the time of Freud until today (Schaefer, 2011).
Play and fantasy occur in the potential space , an intermediate area which bridges the child’s inner emotional world and the child’s external reality and contains parts of both (D. Winnicott, 1971). According to Winnicott, the safer and more secure this space is from harmful intrusion of the external reality, the larger the potential space and the more the child may be creative in his or her play and use it for self-expression and working through issues. The presence of animals (and all that it entails) provides a tool for the expansion of the potential space as a result of the fact that animals are reminiscent of the human experience (alive, emotive, and interactive) but at a safe distance (not actually human). They stimulate associations that may then encourage the child to interactively play with them in “as if” reenactments, in a way not possible with inanimate dolls and toys, in a safe setting mediated by the animal-assisted play therapist. (For further discussion of the incorporation of animals into play therapy, see Chapter 4 , Parish-Plass [2008], and VanFleet and Faa-Thompson [2010].)
Projection . Projection, a type of transference, occurs when people perceive their own traits in others, even inaccurately believing that they themselves do not possess these traits. This projection may defend persons who find a trait to be threatening and want to avoid recognizing it in themselves (Baumeister, Dale, & Sommer, 1998).
Melson and Fine (2010) claim that “animals slip under the radar of human defense mechanisms” (p. 227), their presence opening a window into underlying issues. This may be explained by the fact that animals are similar in many ways to humans, yet not the same, and thus they may represent reality but at a safe, nonthreatening distance. In addition, they may be more easily manipulated than humans. All this makes them easy targets for projection. In Chapter 3 of this book, Ben David states that many of the interactions with and reactions to an animal may be the result of the client’s use of the animal as the object of projection and transference.
Projection of self onto animals by children may be explained by the fact that children tend to identify with animals, because both are small and the underdog in relation to adults (Bellak, 1975). In his discussion of the rationale behind his use of animals in the Children’s Apperception Test (CAT), Bellak states:
Animals play a prominent role in children’s phobias and as identification figures in children’s dreams…. It could be assumed that the animals would offer some manifest disguise: aggressive and other negative sentiments could more easily be ascribed to a lion than to a human father figure, and the child’s own unacceptable wishes could be more easily ascribed to the less transparent identification figure, as compared to human children. (p. 179)
The tendency of children to use animals as an object of projection may be employed as a tool by the AAP therapist. The therapist may decide to initiate a projection by introducing an animal or a story about an animal’s history or behavior (which may be true or false, as described in Chapter 3 ) that is relevant to the client in some way. This initiated projection may encourage the client’s projection onto the animal and discussion about content that might thus come to light from within the client’s inner world through this projection.
Animals as assessment tools . Another way to use projection onto animals is as an assessment tool. Much information may be collected about clients (e.g., their self-perception, dreams, feelings of what they lack, and so forth) by asking them questions such as which animal would they like or not like to be, which animal is similar to them, or if they were a dog, which type would they be. As a consequence of his experience that children identify with animals, Bellak (1975) created the CAT, which is the child correlate to the adult projective personality test, the Thematic Apperception Test (TAT). This test is meant to evaluate personality traits, attitudes, and psychodynamic processes. Also, questioning clients about their pet history may supply a great deal of information about family dynamics and their experience within their family. Children and pets often share the same fate. Which pets and how many did the client have? How long did they live, and under what conditions? How were the pets related to? How were they cared for? What place did the animals have in the family? Much has been written concerning the fact that animals are often considered as family members, take on roles in the family, and even reflect and are drawn into a family’s pathology (such as triangulation and domestic violence). The following vignette illustrates the similar fate shared by children and animals.
CLINICAL VIGNETTE—SAUL

Saul and his family were sent to therapy by the welfare agency due to severe parental neglect at home. When I (Nancy) asked if he had any pets, he said, “I used to have a bird just like Mali [the cockatiel in the therapy session]. I loved her so much. But she died. I told my mother for two weeks that the bird didn’t have any more food, but my mother didn’t have time to go buy more food.

For further discussion of these issues, see Ascione and Arkow (1999), Walsh (2009), Cain (1983, 1985), Melson and Fine (2010), and Bowen (1978).
AAP as a Way to Overcome Client Resistance
Resistance is a type of defense mechanism well known in psychotherapy, and it has been argued that therapy may not take place without recognizing and dealing with it. There has been much written, from the time of Freud and until today, about the analysis of resistance and how to get past it to arrive at a greater depth of awareness and insight, as well as how to use resistance to gain a greater understanding of the client and his or her processes. According to Sandler, Dare, and Holder (1971), “the form and context of the resistance has come to be seen as a useful source of information to the therapist” (p. 82). Because dealing with resistance is so basic to the therapy process, the therapist should understand the techniques that facilitate getting past it.
It is important to emphasize that defense mechanisms play a very important role in protecting people from debilitating anxiety (thereby allowing them to continue to function), and even physical danger, and therefore may be adaptive in various situations. Defense mechanisms become problematic when they are employed in situations in which awareness is needed. This maladaptive use of defense mechanisms interferes with emotional, cognitive, and behavioral maturation and functioning. Resistance in therapy may take many forms, but it always has the same goal—that of protecting the client from psychological pain.
The therapist must get past this resistance in order to bring clients to a state of self-awareness in order to achieve insight and change. Foulkes (1975) states that, in dealing with resistance, the therapist should always be as concrete and to the point as possible. However, this may have an adverse effect, either making clients even more defensive or leaving them emotionally exposed without the support of ego defenses that serve to protect them from debilitating anxiety.
Another more commonly used technique is to recognize a client’s current need for ego defenses and leave them intact, while circumventing or bypassing them (Sandler, Dare, & Holder, 1971). This technique (introduced by Freud) involves repetition, or the client’s acting out, as opposed to remembering, that which has been forgotten or repressed. Without the client’s awareness, situations and relationships from the past are reproduced and repeated in the here and now in therapy, not as memories but rather as actions. The greater the resistance, the more the client will act out as opposed to remember. The task of the therapist is to bring the acting out into the mental sphere, allowing discussion and therapeutic intervention to take place. In other words, this process permits the necessary working through of the client’s resistance, or repeatedly exploring together the same themes from different angles and in different contexts (Sandler & Sandler, 1997).
There may be times when the client refuses, or it is not appropriate, to discuss issues which need to be dealt with in a direct way, but the client may be willing to discuss an issue in the context of another person (or animal). As mentioned earlier, sometimes the therapist may intervene using an initiated projection, in which the therapist tells the client about part of the personal history of the animal, or invents such a history about the animal, that is reminiscent of the client’s emotional issues, but without drawing the parallel. The client and therapist may then discuss, out of caring, worry, and empathy toward the animal (or anger or disappointment, if more appropriate to the therapy process and goals), the “animal’s issues.” This is one indirect way to get around the client’s resistance without awakening that resistance. The discussion may stay in the realm of indirect discussion of the client’s issues, with no direct reference to the client, or it may lead into a more direct discussion.
According to Sandler, Dare, and Holder (1971), one type of resistance is repression resistance , which is a defense against the awareness of painful or dangerous impulses, feelings, and memories and is an ever-present (though fluctuating) force that acts in opposition to the aims of treatment. This type of resistance protects the individual from consuming awareness of distressing and painful mental content. The closer the repressed material comes to consciousness, the greater the resistance. It is the therapist’s task to facilitate, through his or her interpretations, the emergence of such content into consciousness in a form which can be tolerated by the patient.
CLINICAL VIGNETTE—RACHEL

Taken out of her home due to severe emotional and physical neglect, Rachel, aged 9, resided in an emergency shelter for at-risk children. She and her brother had been found searching through dumpsters for food. The social worker, who met with Rachel and her mother during her mother’s weekly visits, reported that during the visits, Rachel stood in the corner or sat near the social worker, silent with eyes downcast. The mother paid no attention to her, did not ask how she was, played with her only when forced into a three-way game together with the social worker, and never hugged her or touched her in any way. Yet in the residential area of the shelter, as well as in therapy sessions, Rachel was perceived as a talkative and happy child. Her high-level cognitive and survival skills were protecting her, yet did not allow her to be in touch with the pain she felt inside. Any attempt by me (Nancy) to connect her to any emotional pain was rejected as she responded, “I’m great!”
One day, in the middle of a session, Rachel looked at my dog, Mushu, who was sleeping under the table, and said, “Look at poor Mushu. She looks so sad!” Agreeing with her, I said, “Wow—you’re right. I hadn’t noticed. Why do you think she is so sad?” Rachel asked me for how long I had had Mushu. When I answered that Mushu had been with me for 8 years, Rachel said, “That means that Mushu hasn’t had a hug from her mother for 8 years. Of course she’s so sad. I understand these things. My mother hugs me all the time, so I know how important a mother’s hug is. Poor Mushu!” Together, we patted Mushu and tried to console her, explaining to her that we understood her sadness and pain.
Rachel’s projection onto Mushu of her own sadness was a way of sharing it with me without having to lower her own defenses and admit to me and to herself the great pain she was feeling, for she was as yet not able to do so. At a later stage in therapy, Rachel played with plastic animals, often putting pairs of mother-child animals together. The mothers were often highly critical or denigrating toward their children, or they just ignored them. The children were always desperate for their mothers’ attention. She then put all the children into the dollhouse, together with a figurine of a woman. This was the social worker. Later in the development of the story, which lasted for several sessions, the mothers came to visit their children. Whenever the mothers were not nice, the social worker intervened. Eventually, the social worker taught the mothers how to hug their children, and a more positive relationship started to grow between them.
Rachel was not able to directly encounter the emotional pain associated with the fact that her mother did not show any emotional warmth or interest in her and thus was resistant to discussing this pain and working through it. Here we see how Mushu’s act of sleeping was genuinely perceived by Rachel as sadness and even depression, according to her need to project her own emotional state onto someone outside of her, enabling her to encounter that sadness at a safe distance. Under the guise of Mushu’s sadness, occurring in the here and now, Rachel was able to share with me her sadness about her mother’s neglectful behavior toward her and to feel my empathy for her plight. She could now feel seen and understood, and that her plight was deserving of empathy. Through Mushu’s very aliveness and Rachel’s use of the animal atmosphere and tools in the room, and my ability to recognize Rachel’s use of an animal for emotional self-expression and use that to advance the therapy process, Rachel was able to work through her experiences at home as opposed to those in the shelter and work on her internal working models of adult-child relationships.

Another type of resistance discussed by Sandler, Dare, and Holder (1971) is transference resistance. This powerful obstacle to treatment, entailing thoughts and feelings involving the person of the therapist, may arise as a consequence of the client’s tendency to reexperience repressed earlier important attitudes, feelings, and experiences instead of recalling them. These will tend to arise anew in the here and now of the therapy situation. This resistance expresses and reflects the struggle against infantile impulses which have emerged in direct or modified form, in relation to the person of the therapist. The therapy situation has reanimated, in the form of current distortion of reality, material which had been repressed or had been dealt with in some other way. Transference resistances may disappear and be replaced by transference attachments which reinforce the therapeutic alliance. The therapeutic alliance is the relationship between therapist and client that is based upon trust, a feeling of collaboration, and containing behavior by the therapist, and without which change is less likely to occur (Bordin, 1979; Kanzer, 1981). Indeed, a moderate but robust relationship has been found between the therapeutic alliance and outcome in therapy (Fluckiger, Del Re, Wampold, Symonds, & Horvath, 2012; Shirk, Karver, & Brown, 2011) across a broad range of therapy orientations and modalities (Shirk & Karver, 2003).
However, it is likely that transference resistance will be especially strong in at-risk children. On the basis of their experience with the adults in their lives, these children have good reason not to trust other adults. Indeed, research has found that children who have suffered abuse and ensuing trauma are characterized by feelings of distrust in others (Eltz, Shirk, & Sarlin, 1995; Herman, Russell, & Trocki, 1986; Somer & Szwarcberg, 2001; Van der Kolk, 2005). Thus, they are likely to transfer their lack of trust of the adults in their lives to the therapist. Yet without the therapeutic alliance, there is little chance for the process of psychotherapy to occur. Consequently, discovering a way to facilitate the establishment of the therapeutic alliance is even more critical for these children.
CLINICAL VIGNETTE—NOAM

Noam, a fourth grade pupil in the school in which I (Nancy) worked, was referred to therapy due to his withdrawn demeanor and his social status (neither rejected nor accepted but rather isolated) among his peers. He did not share his feelings with those around him, including the teacher who had tried to draw him out emotionally. Noam had recently completed a year and a half of therapy, with no change. In a meeting with his mother (his father refused to come), the mother did not seem to be concerned about his state.
When he came to the first session, Noam was very suspicious and even belligerent. He announced (while smiling) that he knew this was therapy and that he had refused to talk to his psychologist for a year and a half (which I had already known from the school psychologist, who also said that he would be a “hard nut to crack”) and had no intention of talking to me. When I told Noam he did not have to talk in the sessions, he looked confused and asked what he was supposed to do and why was he there. I responded that there were lots of games, art materials, and of course the animals. Sensing that Noam was very intelligent and cognitively oriented, I explained that someone at the school felt that he seemed to be not very happy and wanted him to feel better, and that research shows that being with animals makes us feel better. He thought for a minute, and then said that he has lots of animals at home. Throughout the meeting, while connecting with my animals, he told me about his pets—a dog and some birds.
In the next couple of meetings, while playing with my animals (he was not interested in the games or art supplies), Noam confided in me about his sadness concerning his animals and asked my advice. He told me that his dog was very old and getting sick, and how he is sad because his father makes the dog stay outside, even at night, for the dog disgusts the father. His hurt was great. Another meeting was spent talking about his birds. He had told me in the previous meeting that eggs had hatched and how exciting it was to see the babies. This time, again very sad, he told me that he woke up one morning and found all the babies dead. “The day before, they were all chirping and happy, making lots of noise. Why would they all of a sudden die like that?” Knowing about the research linking animal abuse, child abuse, and domestic violence (Ascione & Arkow, 1999), I became suspicious of possible abuse in the home. In a discussion of his father’s reaction to the family dog’s illness, Noam shared that he was reminded of his father’s behavior toward Noam’s 2½-year-old brother. When the mother was not home, and the little brother cried about something, the father couldn’t stand it and shut the brother outside, even at night. In their discussion of what has come to be referred to as The Link , Ascione and Arkow (1999) state that in the family, children and animals share the same fate. This was certainly true in Noam’s family. Not long after, Noam expanded the discussion to include his own experiences with his father, which included both physical abuse (hitting) and emotional abuse (yelling, threatening, and severe humiliation). In meetings with the mother (the father did not agree to come), she did not seem to be concerned about his state. She first belittled the idea of any abusive behavior in the home, but in later meetings she admitted to Noam’s being hit (“it’s not so bad”) and to her being a victim of ongoing rape by her husband.
The welfare office was notified and appropriate steps were taken, including a court injunction to keep the father away from the family. Therapy continued for 2 years, and Noam continued to use the animals, as well as direct discussion, to work through his difficult content.
At the time of termination of therapy (his parents had separated, and his mother was moving with the children to a different county), we reviewed the various stages of the therapy process. I reminded Noam of his statement that he had no intention of talking to me, and then I said, “And from that moment, you never stopped talking! What happened?” He broke into laughter, saying that he remembered that well. Then he became serious and said, “I saw that the animals trusted you, so I thought I could, too.” Since Noam, I have heard similar statements from other at-risk clients, such as, “I saw how you cared for the animals and I thought you would take care of me in the same way,” and “I never trust any adult, unless I see that they treat animals well and with respect.”
Noam exhibited strong transference resistance at the beginning of therapy. He learned in his family that he could not trust adults to treat him fairly or to protect him, so it was clear to him that a therapist could not be trusted as well. However, through observing my interactions with the animals and identifying with them, Noam eventually felt comfortable enough to create a connection with me. He came to feel safe within the AAP setting, which probably also had a calming effect on his anxieties, allowing him to work on his difficult family issues.
An additional principle at work in Noam’s case is that of Clare Winnicott’s (1968) third thing, as described earlier in this chapter. He was not able or willing to talk of himself with me yet he was very motivated to talk with her about a subject outside of both of them that we obviously had in common—animals—even to the point of asking my advice. Through this third thing, I was able to gain Noam’s trust, thus facilitating the establishment of the therapeutic alliance.

The Animal as Emotional Support for the Therapist
It is interesting to note the effect of the animal on the therapist. After a meaningful relationship has been formed between the client and therapist, the client may come close to revealing to the therapist a difficult secret, such as abuse. The therapist may feel the client’s unspoken emotional turbulence and sense the existence of the secret, and the emotions increasing as the secret is about to be revealed. The therapist may become anxious (either as a result of projective identification or due to her own fears of hearing about what might have happened to the client she cares for) and unwittingly communicate this anxiety to the client. The client needs the therapist to be steady and strong, able to contain the client’s anxiety and experiences. If the client feels that his emotions and secrets will topple the therapist, he is likely to back off to protect the therapist so as not to lose her. In AAP, the animal may in effect serve, if unwittingly, as a type of social support for the therapist during emotionally difficult sessions, thus enabling the therapist to be more emotionally available for the client. As was mentioned earlier, interaction with an animal results in the release of oxytocin in the human, leading to the lowering of anxiety. This phenomenon works not only on the client, but also on the therapist. In addition, the AAP therapist feels a relationship with the animals in the setting, and therefore is likely to not feel alone in coping with emotionally difficult content and client behavior within the therapy session. Indeed, Pistorius, Feinauer, Harper, Stahmann, and Miller (2008) found that pets were among the vitally important support systems mentioned by therapists in their work with abused children. Two factors, the hormonal effects and the feeling of not being alone, are likely to help the therapist to stay focused on the client (and not on her own emotional state) and emotionally available for the client, thus communicating to the client that she is capable of being there for the client at that critical moment in which the secret is revealed.
Choice of Animal and Setting
The therapist has several choices to make when deciding to integrate animals as a medium into the therapy process. One set of choices pertains to which animals to integrate and how many. Sometimes these choices are limited by reality. For instance, one therapist may choose to work with his or her own dog and may not have access to other animals. Another therapist, also limited to bringing his or her own animals to therapy, may live in a rented apartment where dogs are not allowed, yet may keep hamsters. As described throughout this book, besides the mechanism of projection onto the animal by the client, a major mechanism behind AAP concerns the way the client relates to the relationship between the therapist and the animal in the setting, and the type of animal may be less critical to the therapy process than the fact that a relationship exists between the therapist and animal. Many AAP therapists work, as did Boris Levinson, with only one animal.
Some therapists are able and prefer to integrate a number of animals into the therapy process, thus allowing for interactions between the animals and affording more opportunities for the client to express his or her inner world and social experiences, both past and present. In addition, this provides more opportunities for the client to choose an animal who may stimulate certain associations that will encourage projection and transference. (For more discussion of these opportunities, see Chapter 2 and Chapter 6 .) That is, having more than one animal in therapy makes for a richer medium. This idea is similar and parallel to the rationale behind the presence of a large variety of toys and games in a play therapy setting (Klein, in Segal, 1980). For instance, a therapist may decide that in an AAP setting, it is preferable to have any of the following: four to six animals, both males and females, a variety of classes of animals (e.g., mammals, birds, insects, lizards), some of the animals as individuals (e.g., one dog) and some of the animals as pairs or families (e.g., a pair of birds or a family of hamsters), at least one animal that may be experienced as frightening or aggressive in terms of common stigma (e.g., a lab rat).
Along with determining the importance of having a variety of certain toys in play therapy, Klein (in Segal, 1980) emphasized the extreme importance of the toys’ being a permanent part of the therapy setting. Children must know what to expect upon entering the room and be able to hold in their mind, from meeting to meeting, what they have done and even what they plan to do. It is generally accepted in the world of psychotherapy that the setting must be constant and dependable. We cannot emphasize strongly enough that this is certainly true also of the AAP setting. AAP is not a zoology class in which the client is merely exposed to or taught about different animals each week. Rather, the client should be able to develop a relationship with the animal(s) over time. It is exactly this growing and developing relationship, based upon object relations, which is so important in therapy. This is even truer for clients with attachment issues. On the backdrop of this permanence and stability of the AAP setting, any changes in the animals—inherent in the reality brought to the therapy process by the fact that the animals are alive—will take on a greater meaning and influence on that process. This is particularly true with animal birth, sickness, and death.
Here we would like to address an issue that is often discussed in the world of AAI (animal-assisted interventions): Is it recommended or even possible to match a client of a certain population or with certain characteristics to a certain type of animal? For instance, is there any theoretical or practical basis for integrating into therapy only a furry animal for at-risk children, or only reptiles for clients suffering from autism? In the experience of many senior AAP therapists, this idea has not proved useful or relevant. Indeed, almost no professional training programs in Israel prescribe this approach.
As is true for any medium, above and beyond any concrete meaning that an animal may have, an animal is a sponge for absorbing any projection or object transference that serves the need of the client. It is our experience that any given type of animal will not consistently have a specified therapeutic effect on a particular type of client. Rather it depends upon the client’s inner world and needs to project or transfer, as well as the interaction between the personality of the particular, individual animal and the inner world of the client. A snake may represent danger for one client and renewal (due to the shedding of the skin) for another. A bird may represent freedom for one client, danger for another (some are frightened by a bird’s beating wings or sudden movements), or fragility for another.
In my (Nancy’s) experience with at-risk children in residential settings, clients’ choices of animals to work through their issues in therapy are wide ranging and depend on the content of their inner world. For instance, two brothers, with almost identical life experiences and identical psychiatric and psychological evaluations, chose different animals and worked through different issues through the therapy process. One brother’s processes (through his own choice) first centered on birds, then a turtle, and finally hamsters. He worked through his relationship with his father as well as concentrated on the subject of home. The other brother’s processes started with an orphaned calf, then an abandoned egg, and later a goat and her kid, together with a dog throughout the process. This brother worked through his feelings of anger and abandonment due to his mother’s disappearance from his life. Both brothers’ psychological development within the therapy process was advanced by their choice of animals.
Another choice enabled by AAP is that of the type of setting. Each setting has its own meanings, implications, advantages, and disadvantages.
Therapy zoo . Here there will be a large variety and number of animals, allowing more choice. Also, of all the possible settings, a therapy zoo most closely approximates a natural environment (perhaps containing a small pond for ducks, dirt paths, and grass). Here the client will be more likely to encounter content concerning the life cycle: birth, sickness, family issues, sexuality, and death. However, there may be a more impersonal feeling, depending on the size of zoo, on the type of relationship (personal or not) the therapist has with the animals, whether or not the therapist is the animals’ caretaker, and whether or not the animals have names. Depending upon the degree of the therapist’s relationship with the animals, the client may be less likely to use the therapist-animal relationship as a target for projection and there may be less use of the AAP therapy triangle. (For further discussion of this issue, see Chapter 2 .) In addition, in many zoos visitors may be allowed entrance during the therapy session, minimizing or destroying the intimate and private nature of the therapy session. As in any therapy setting, it is important to structure the therapy zoo as a container, with clear limits that will contain the client, and to protect the client from unwanted noise in the therapy process. (For more discussion of psychotherapy in a therapy zoo, see Chapter 7 and Chapter 14 .)
Nature room at school . This is similar to a therapy zoo in many ways; however, it lacks part of the natural setting afforded by a zoo.
Therapy room with the therapist’s animals (a single animal or a variety) . Because the animals belong to the therapist, there is a greater likelihood that the client will transfer the role of parent onto therapist. The presence of more animals means more potential objects for transference and projection. The animals are more likely to be attached to and open to people, looking for interaction with them. In the play therapy setting, there are opportunities for combining animals with toys (e.g., the family of hamsters running around the dollhouse), providing an additional access point to the client’s inner world. (For more discussion of psychotherapy in a therapy room in a traditional clinic, see Chapter 4 .)
Stable . A stable as a whole, with the addition of the riding ring and perhaps surrounding fields and trails, is a rich therapy setting. The therapy may or may not include riding the horse. Other possibilities include cleaning the horse and/or the stall. A disadvantage of most stables is their public nature, which interferes with the private, intimate aspect of the therapy session. (For more discussion of psychotherapy in a stable, see Chapter 8 and Chapter 12 .)
As did Levinson (Levinson & Mallon, 1997), many AAP therapists in a clinic setting take the dog for a walk with the client as part of the session, further expanding the limits of the setting, and therefore the possibilities for the advancement of the psychotherapy process.
CLINICAL VIGNETTE—JOHNNY

Residing at the emergency shelter due to having experienced severe emotional neglect and abuse, Johnny, aged 10, was introverted, typically exhibiting a false self and parentified behavior toward both the animals and me (Nancy). The sessions consisted, time after time, of his writing letters to each of the animals and to me about how wonderful and talented we all were. There seemed to be no sign of his inner world and he exhibited a gaping emptiness. After 3 months of therapy, Johnny decided that he wanted to take Mushu, my dog, for a walk. The walk was pleasant, but there was no increase in the content he brought up. The next time, Johnny asked if we could take all the animals out for the walk. We were quite a sight, walking the nearby streets with Mushu on a leash and us carrying three cages with the bird, hamsters, and rats. Now that the most important (to Johnny) part of the therapy setting was taken out of the emergency shelter, Johnny started talking about his sadness, his fears, and his anxieties. “Now I can talk—at the shelter, the walls have ears. I can tell you anything, but not when we are in the shelter.” (This was despite that fact that he knew that I share the content of his meetings with the staff.) Every dog and cat in the street was experienced by Johnny as abandoned. One elderly and shoddily dressed woman, whom we saw setting out a yoghurt container for a timid street cat, was seen by Johnny as a battered wife. “She understands the pain of the cat, who has probably been abused and then abandoned,” explained Johnny.

Regardless of the setting and the number and type of animals chosen, stability within the setting is essential. This is true also in terms of the animals themselves. It is important to remember that AAP is not a zoology lesson and not an extracurricular activity meant to interest and excite the client. The client will, during the therapy process, create an ever-developing and evolving relationship with the animal(s) upon which the therapy process rests. As in any relationship, there are stages, and different content will be brought up by each stage. This relationship will be the basis for reenactments of other relationships in the client’s relational world, enabling the client to work through issues. If an animal is sometimes present and sometimes not, then he may not be relied upon for the development of the client’s story. If animals are constantly being switched, then relationships cannot be developed. If animals are always appearing and disappearing, then the sickness and death of an animal, or the birth of a new one into a family, is less meaningful and relevant.
PROFESSIONALIZATION
It is crucial to understand that the involvement of animals in psychotherapy is not only a tool but also an approach. In other words, just in the way that having paint and brushes in the therapy setting does not make a play therapist an art therapist, and using role-play in play therapy does not make a clinical psychologist a drama therapist, having a dog in a psychotherapy setting does not make the psychotherapist an AAP therapist. Rather, it is essential for the therapist to be aware of the characteristics of the medium, the opportunities it affords, and the implications, all in the context of the therapy process. The therapist must become acquainted with the medium he or she offers, not only at the level of technique (e.g., how one color spreads as opposed to another, or how one animal reacts toward a sudden movement compared to another), but rather at the level of the essence and meaning that is hidden within that medium.
AAP therapists must be skilled in the profession in order to be aware of the implications of the presence of their medium—animals in therapy—in order to know how to enlist the assistance of an animal, the advantages and disadvantages of the animal’s presence, the dilemmas of the profession, and issues unique to the field. AAP therapists must be aware of the implications of and opportunities afforded by the various settings (e.g., zoo, play therapy room, and so forth). Due to the fact that animals are living beings, and that therapists are inherently encouraging the use of animals as a target for clients’ projection of objects from their inner world, therapists who choose to work in AAP should deepen their theoretical knowledge in object relations theories and in intersubjective approaches to psychotherapy.
Therapists must understand their relationship with their medium so that the medium is just that, and does not become the focus of the therapy, nor too dominant. Ongoing supervision is needed to prevent this from happening.
As well as understanding all of the issues concerning the use of an animal as a medium, AAP therapists must study the ways of making use of the medium according to psychotherapeutic principles. It must be perfectly clear that AAP therapists are first and foremost psychotherapists, and secondarily AAP therapists. Clients are the focus, not the animals. Therapists must be capable of following clients and taking into account their needs, even if clients choose not to relate to the animals in any overt way. For this reason, we stress the importance of professional training in the field of psychotherapy for AAP therapists.
There is, however, a reason for the student of AAP to study psychotherapy in an AAP training program. The course of study should include the study of psychotherapy, the study of animals, and that which is between them. Such study encourages the development of the student’s professional identity as an AAP therapist. Students in such a program find that this identity is something one grows into through study, experience, and association with other AAP therapists. The medium is studied in the context of psychotherapy, while psychotherapy is studied within the context of the medium. In this way, the connection between the two is understood at a deeper level and then internalized.
Finally, we would like to emphasize that in AAP, the authentic reactions and behaviors of the animals aid the therapist, who can enlist them for the purpose of therapeutic work. Animals are always spontaneous and authentic and can be direct and basic in their reactions, while the therapist must be calculated, careful, and empathetic in his or her reactions. The role of the therapist is to mediate, to collect and direct both the animals’ reactions and those of the client and to enlist what is occurring spontaneously and authentically between them for the purpose of helping the client to arrive at insight. Working in tandem in this way, there is an illusion of co-therapy between the animal and the therapist enlisting his help. However, it is important to make it clear that the animal is not aware of the psychotherapy process and is in no way behaving or reacting for the purpose of healing the client. For this reason, the animal cannot be considered a therapist, or even a co-therapist. A therapist must always be aware of psychotherapy methods, alternatives, and goals, none of which an animal is capable of taking into account. As was mentioned earlier, the medium—here, the animal—serves as a generator of situations, a stimulus for associations, fertile ground for reenactment, and a target for projections and transferences. It is the sole responsibility of the therapist to know how to use all of these to advance the therapy process for the good of the client.
For further discussions of the professionalization of the field of AAP and of the training for the AAP therapist, see Chapter 11 and Chapter 13 .
CONCLUSION
AAP has a special place in the world of psychotherapy in that not only does it involve a medium to help the client reach his or her inner world, express it, and work through the issues that caused emotional pain and distress, but it is a medium that is particularly rich and even unique among the mediums found in many psychotherapy settings, thus expanding the number of possibilities in therapy. This richness presents more opportunities for self-expression, communication, reenactment, working through, insight, and change than other mediums, and in ways not found with other mediums.

• Other mediums stimulate the client’s senses, emotions, and memories. Any relationship with the medium is totally in the mind of the client. However, due to the aliveness and dynamic nature of an animal, who may affect the client passively, actively, and interactively, the client may actually have an interpersonal relationship with the medium (the animal) that is concrete and real.
• The animal is a multisensorial medium, enabling more points of access into the client’s inner world than other mediums.
• The presence of the animal(s) creates the potential for an atmosphere of relationships in the therapy setting through the social microcosm in the room, providing opportunities for working on attachment issues in the here and now.
• In light of the biophilia hypothesis and related research that the human brain is wired to receive animals as a stimulus, animals serve as a neurologically based point of access into the client’s psyche.
• The AAP setting, including the presence of animals, naturally includes many related accessories (e.g., cage, food, brush, leash, and so forth) that will not be present in other settings. These accessories add richness to the medium, stimulating many more associations.
• AAP may take place in a number of different settings, including a zoo, traditional clinic, or a stable, or even on a walk with a dog or a trail ride into a forest with a horse.
• AAP’s therapy triangle expands the analytic third, providing more opportunities than the traditional therapist-client relationship upon which psychotherapy is based.
• In AAP, the medium, as a stimulus for the process of psychotherapy, itself facilitates the conditions for the client to use that stimulus. This process is due to the calming effects of hormonal changes in the client as a result of the presence of the animal, as well as the influence of the authentic atmosphere provided by the presence of the animal in the setting.
• The medium is actually alive, behaving, and reacting in a way that is similar to humans but not the same, allowing for projection and object transference at a safe distance. Unlike in traditional play therapy using dolls, in AAP the client may truly believe these transferences and more easily use them for the therapy process. “Look at how the animal feels and behaves. It’s the animal, not me.” This process enables the use of a medium as a mode for self-expression without the client’s perceiving that his or her defenses have been lowered.
In this chapter we have attempted to explore many of the characteristics and mechanisms of the medium in order to better understand the possibilities afforded by animals, their presence, and all that they bring with them to the therapy setting that improves the psychological well-being of the client. The animal was discussed as a medium also for the therapist, helping the therapist to lower client resistance and even providing emotional support for the therapist. Finally, the need was discussed for the professionalization of the field in order to provide full understanding of how to combine principles of psychotherapy with the understanding of the nature of the medium of animals, and how to use this medium for the benefit of the client. We have no doubt that since the field is still in its infancy, future study will discover this medium to be even richer in possibilities than we present in this chapter.
As was mentioned earlier, the animal and his presence may be a powerful generator of content which may be very anxiety producing for client, content that may even be dangerous to the client’s psychological health and well-being if not dealt with by a professional who understands the implications of the experiencing of this content and the intricacies of its expression. Barriers (such as defense mechanisms) to experiencing dangerous content are in place to protect the client, and should be bypassed or removed only by a therapist who has the ability to handle the consequences for the good of the client. Too many well-intentioned but untrained individuals with their pets take on these tasks, to the detriment of the client. The need for the professionalization of AAP is critical for the psychological well-being and safety of the client.
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2
THE ANIMAL AS A RELATIONAL MEDIUM: AN OBJECT RELATIONS APPROACH TO THE THERAPY TRIANGLE IN ANIMAL-ASSISTED PSYCHOTHERAPY
Nancy Parish-Plass and Dror Oren
INTRODUCTION
As mentioned in Chapter 1 , the animal’s presence, characteristics, and behavior stimulate the client’s sensory system, causing emotional and cognitive reactions such as associations, thoughts, and interpretations, which eventually lead to verbal and behavioral reactions. These reactions are likely to be influenced by the client’s internal models of interpersonal interaction based upon the history of interaction with significant others in the client’s interpersonal world. This process is reminiscent of Bowlby’s (1969) theory of internal working models, which states that the nature of people’s interactions with others in the present is based upon their inner representations, or internal working models, of interpersonal interaction, originating in their early experiences with their parents and other significant figures. The animal also brings into the situation his own (species-specific as well as individual) personality traits, and also his internal models, attachment patterns, and past experiences of interpersonal interactions with humans. Just as the client has free will (in terms of choice of activity, choice to draw near or keep his or her distance, and so forth), so does the animal. The client may initiate interaction with animals by calling the cat, picking up the hamster, threatening the cockatiel, or teasing the dog with food. The cat may react by running toward the client, the hamster by biting, the cockatiel by flying away, or the dog by barking. The animal will also initiate interaction: a dog may look into client’s eyes, or bring a toy to invite the client to play, a bird may fly to the client, or a cat may rub against the client for a pat. The client may react by yelling at the dog, throwing the toy for a game of fetch, brushing the bird away, or cuddling with the cat. There are tail wags and smiling, cowering, begging for attention, ignoring, rejecting, and feeding—all within the context of social interaction, the initiating with and reacting to a living other.
At first, the client who is meeting the animal does not know the nature of this medium, but becomes acquainted through observation, through trial and error—daring to approach, interact, and create a connection, perhaps characterized by closeness, or control, avoidance, or rejection. The client must learn the animal’s language, which will lead to a kind of dance of communication between the two. There will be situations which will call for mediation by the therapist, such as, “Don’t approach the bird too quickly or else he is likely to become startled and bite.” As interactions take place and a connection is established, both sides start to know what to expect of each other, and these interactions become a relationship, and may even be considered a social relationship. As in any relationship, both sides invite, expect, become insulted, bond, seek out, become angry, and look for consolation. Judgments and assumptions are made, resulting in further reactions. From session to session, the relationship grows and gains a history. All these situations, behaviors, thoughts, and emotions occur in the here and now, yet are reminiscent of other social relationships from the past.
The similarity between the animal’s behavior and the client’s behavior, which in reality usually come from different sources, may often lead to anthropomorphizing the animal, or assigning human traits and intentions. This similarity further encourages the development of the potential space, the intermediate place where inner world and external reality meet and imaginative and creative play may develop (D. Winnicott, 1971), opening up a grand opportunity for the therapy process.
CLINICAL VIGNETTE—HANNAH

Hannah, aged 10, was taken out of the home due to parental neglect (emotional and physical), together with her self-endangering acting-out behavior. There were reports of violent interactions between her and her siblings. One day, Hannah opened the cage of the three lab rats that were much loved by her and through whom she often expressed herself. As the rats ran to me (Nancy) for attention, Hannah said, “Look how they are beating each other up trying to get a pat from you. They are so jealous of each other. But you have to give special attention to Brownie, because she is old and dying. The others will just have to live with it that you hug her more, since she needs it more. They’ll understand it after she dies, and then they’ll get more attention from you.” After we discussed her observations and interpretations, she volunteered, “That happens with me and my siblings all the time. I love my brother and he loves me. But when my parents are around, we always beat up on each other, because we are angry when the other gets a hug from our mother, because she never has enough time to be with us. We have to fight for it, but then the hugs end up by going to our little sister, because she’s a baby and needs it more. What can you do….” Here, Hannah perceived the rats, due to their behavior of running to greet me (“mother”), as desperate for my attention and fighting over me. This was enough to remind her of her own family situation and allowed her to talk about it. In this example, Hannah is using the rats’ behavior as a medium to express her emotions, as well as her perception of reality. In other words, she used her interpretation of their behavior to express herself. Hannah was able to describe her home situation and her accompanying emotions, together with her own interpretation of her mother’s behavior, along with the necessity to always have to understand the needs of her baby sister. I was eventually able to slowly move Hannah’s focus from justification for her mother’s general neglectful behavior to discussion about how she felt about never really getting enough care from her mother, how she felt living in a residential care situation, and her behavior in different situations.

At this point, there is a potential space created in which the client sees content that is in common between humans and animals. Through the animals, situations familiar to the client may present themselves which directly relate to basic human experiences, which the client may relate to or identify with: health versus sickness, birth, family issues and relationships, nurturing versus neglect, aggressor versus victim, basic impulses such as aggression and sexuality, emotional expression, and life versus death. In the case of Hannah with the lab rat siblings, she was able to observe and contemplate what represented to her an emotionally painful situation she experiences in her family but had not been able to talk about. She was then able to explain to me, in detail, exactly how the rats felt, thus putting words to her emotional experience within her family, perhaps for the first time.
AAP AND OBJECT RELATIONS
Theoretical Background
According to Bowlby (1969), secure attachment depends upon the development of appropriate internal working models, or mental representations, of the parent-child relationship. The first component of these internal working models is characterized by information, one’s expectations, and one’s affects concerning other individuals’ behavior in a relationship, while the second component is characterized by one’s representations of oneself and one’s role in relationship with those other individuals. These internal working models affect how one perceives, remembers, interprets, and reacts to experiences in similar relationships.
Clients base their current relationships on their past experiences, which may have been positive, conflictual, or problematic. Past problematic relationships may create problematic relationships in the present: past dysfunctional interactions and relationships (albeit adaptive within that given situation) lead to dysfunctional perceptions of interactions and interpersonal relationships in the present, which lead to dysfunctional interpersonal behavior, resulting in continuing dysfunctional interactions and relationships. Indeed, Fairbairn (1944) claimed that “it is to disturbances in the object-relationships of the developing ego that we must look for the ultimate origin of all psychopathological conditions” (p. 70). Hope for change may be found in the correction of internal working models which are maladaptive for present and more normative situations through insight and the chance to experience a corrective relationship. Therapy is a laboratory for gaining insight and for working on relationships, sometimes through the therapist-client relationship. Therapy is based upon interpersonal connection—that is, the therapist-client connection—without which successful therapy cannot take place. Theories of object relations help us understand the clients in view of how they see themselves and their relationships with others. Clients reenact their past relationships not only in their present life, but also in the therapy situation. This provides the therapist with material to work on together with the client in order to foster an opportunity for emotional expression, insight, and corrective experiences, which together will lead to change. A goal of psychotherapy, according to D. Winnicott (1965), is for the client to find his or her true self, as well as to provide missing environmental and relational experiences within the therapy situation (Mitchell & Black, 1995).
Object relations theorists split off from the Freudian view that a person’s psychological processes are internal and are dependent on instincts and drives. Various theorists broke from this view and recognized the human need for interpersonal connection in order to attain satisfaction. Fairbairn (1941) saw the libido as primarily object seeking as opposed to necessarily pleasure seeking. These theorists explored the nature of this object seeking and how it related to the development of the self.
Jacobson (1964) was interested in internal representations (each representation a collection of images from perceptions of experiences) of self and object (some of which are perceived as good and others as bad), the perceived dialogue between these representations, and their roles in the development of a healthy or unhealthy personality. Jacobson recognized that change takes place due to the resonance that occurs in each of the representations after interactions between them. For instance, should a mother not respond adequately to her son, he will feel frustrated. The son’s object representation will be characterized by disappointment, and will lead to devaluation of the object (representation of the mother, and perhaps the self as well) and then to aggression. Should the mother gratify the son’s needs, the object representation (the mother) will be a pleasurable one, the object will be valued, and the self will desire to possess and be merged with the object.
Kernberg (1980) made additions to Jacobson’s theory in a number of ways. Besides recognizing the existence of self and object images and representation, he talked of corresponding drive derivatives, or dispositions, to specific affective states. Together they serve as components of the internalization process that allows for their integration into the organization of the ego in its connection and functioning with the self, objects, and interpersonal interactions.
Sandler deepens the theory of object relations and our understanding of self and object representations in his concept of the representational world. The representational world consists of both the person’s images and representations of self and objects, with the self at the center, and the construction of the representational world is a product of ego functions. “The representational world provides the material for the ego’s perceptual structuring of sensory impulses for imagination and fantasy, for direct and modified action, for language, symbols, and for trial action in thought” (Sandler & Rosenblatt, 1962, p. 136).
As do other theorists, Sandler emphasizes the importance of the interactions between self and object representations. He widens the concept, however, to include fantasy interactions. These fantasy intrapsychic interactions are motivated by a need for wish fulfillment, or actualization. The basis of these fantasy interactions may be instinctual wishes, wishes to maintain well-being, needs for affirmation, safety, feelings of being in control, security, self-esteem, or the desire to defend oneself from unpleasant feelings. Other motivational tendencies may include a wish to maintain a relationship with a good primary object relationship and make a bad one disappear. All of these fantasy interactions comprise self-representations, object representations, and representations of their interactions.
Ogden (1983) notes that the interaction between various representations (self and object) are both unconscious and intrapersonal, and are “in dynamic interplay with current interpersonal experience” (p. 227). (Bowlby’s concept of internal working models also touches on this issue. Maladaptive internal working models foster problematic interactions, further reinforcing those models.)
Ogden (1983) further states that
it is the thesis of the present paper that the “internalization” of an object relationship necessarily involves a splitting of the ego into parts that when repressed constitute internal objects which stand in a particular unconscious relationship to one another. This internal relationship is shaped by the nature of the original object relationship, but does not by any means bear a one-to-one correspondence with it, and is in addition potentially modifiable by subsequent experience. The internal object relationship may be later re-externalized by means of projection and projective identification in an interpersonal setting thus generating the transference and countertransference phenomena of analysis and all other interpersonal interactions. (p. 227)
Adding Animals Into the Equation
Ogden (1983), together with (1) Bowlby’s (1969) theory of attachment and internal working models; (2) Winnicott’s (1953) theory of (not) good-enough mothering; (3) Fairbairn’s (1941) approach that object seeking is central to one’s basic needs; (4) Jacobson’s (1964) concept of resonance and subsequent change within a representation due to interaction with another representation; and (5) Sandler and Sandler’s (1998) theory of fantasized interactions between self and object representations, set the stage for an object relations view of therapy in general, and animal-assisted psychotherapy (AAP) specifically.
According to Jacobson (1964), the therapist-client relationship represents a self-object relationship, leading to interactions between the self-representation and object representation with resulting self-object relationship representation. With intervention by the therapist, leading to insight, repetition, and working through, the ensuing resonance within both self and object due to the interaction and resultant change in all representations will lead to change in the client. In addition, as Ogden (1992) suggests, the object relationship, once internalized, is re-externalized and projected, transferred onto the therapist, allowing the client to work on the object relationship representation through his or her interactions with the therapist.
In the case of AAP, the presence of additional objects in the room allows more opportunities for re-externalization of various objects in the client’s representational world. This might result in a reenactment of more complex social situations familiar to the client and enable the client to work through and gain insight into his or her role in such situations. This might happen to a certain extent in a traditional play therapy setting, but the presence of an animal (or animals) adds a dimension of reality to the situation that cannot be duplicated by the presence of an inanimate object. The addition of an animal in a therapy setting may allow for re-externalization of parts of the self-representation that the client feels the need to work on. In this case, the animal would serve as a bridge between the client and his or her own feelings and experiences, allowing the client to say, “I don’t feel jealous—it’s the dog that feels jealous,” or “I think you are great, but the dog is really angry at you.” The client could then work on his or her feelings from the outside by observation and/or interaction, even taking the part of another object in a switching of roles.
For instance, a client and therapist may play a game with a ball. The dog in the room may become excited and run to the therapist when he is holding the ball. The client may feel jealous that the dog went to the therapist to play. The client may then threaten the dog, who may run away, or perhaps run for protection to the therapist, who reacts by protecting the animal and setting limits with the client. The animal might exhibit fear, the therapist might exhibit concern for the threatened animal, and the client might feel even more jealousy. Resonance might result in the animal’s avoiding the client, the therapist’s feeling anger at the client, and the client’s feeling rejected by both. This might be a reenactment by the client of a situation in which she feels rejected by a parent who favors a sibling over her.
In this situation, the client may feel as if the therapist is the parent and the dog a sibling. In the here and now reality in the therapy room, the dog as a third factor may behaviorally mediate between the client and her own emotions. The projection onto these mediums is a type of expression which then may be focused upon as a therapy intervention. As a doll or cards may encourage projection, this situation allows for the projection onto the dog, the therapist, and even the relationship between them to become an opportunity for raising relevant issues. However, projection onto a living object is a more complex projection, a more active and authentic expression of conflict, relationships, and attachment, that may be worked on even without interpretation. For instance, the therapist may reflect by saying, “It seems that the dog is jealous of you, that we are having fun playing with each other.” The client may then react by saying, “Yup—I will yell at him and chase him away because he is jealous,” perhaps actually expressing what was done to her when she was jealous of a sibling getting attention from a parent. The therapist might then say, “He probably feels bad, alone, jealous of the attention I’m giving to you.” This represents a unique type of focus on the client’s feelings, enabled by the active presence of a live medium representing the externalized feelings of the client within the here and now, in turn enabling the therapist to verbally mediate in an indirect and thus nonthreatening way between the client and her own feelings.
The presence of more than one animal in therapy enables the re-externalization of relational systems of objects from the client’s inner relational world. For instance, taking into account that a lab rat is likely to try to attack a hamster (if given the chance), the presence of a rat and a hamster in the therapy setting may bring up content relating to the child’s experience as a victim of abuse. The child may choose to identify with the aggressor (“Let’s see what happens if we let the rat really chase after the hamster”) or the victim (“We have to put locks onto the door of the rat’s cage and build a shelter around the hamster’s cage. We have to make sure that the hamster feels really safe.”). A family of hamsters may represent for the client a loving mother nursing her babies, or parents fighting while the children stand by helplessly.
Another possibility afforded by the presence of an animal is that of wish fulfillment. In this way, the client may experience desired relationships, to practice them, to play them. It is much easier to manipulate animals than it is to manipulate people. For instance, a child who would like to have a younger sibling to take care of, and also to control, can take an animal and do just that.
Finally, an animal may serve as a living, more tangible transitional object, allowing the client to be independent of the object, while maintaining a feeling of close connection. In the emergency shelter, a group of three girls switched the names of the therapist and the dog at the beginning and end of every session, calling the dog Nancy and the therapist Mushu. They then hugged and cuddled with the dog, making statements such as, “It’s so much fun to hug you, Nancy. We miss you when you are not here. Nancy, we wish we could cuddle with you all the time like this.”
AAP provides many opportunities to change clients’ internal working models, both their perceptions of others’ actions and intentions (through the therapist’s mirroring and mediation of their interactions with the animals) and their emotional and behavioral reactions to the actions of others (through modeling, mirroring, and chances to practice with the animals in a supportive environment).
THE THERAPY TRIANGLE IN AAP AS A SOCIAL SITUATION THAT ENHANCES THE OBJECT RELATIONS–BASED THERAPY PROCESS
AAP is characterized by a triangle comprising the therapist, the client, and the animal, resulting in relationships offering a myriad of possibilities for the therapy process. In the case of one animal, there are three possible dyadic relationships in the setting: therapist-client, client-animal, and therapist-animal. There may be situations in which the therapist and client are interacting and the animal is on the side. Here, they may be observing the animal together and discussing many issues surrounding the animal, or they may not be relating to the animal at all. A different situation might be that the client and animal are interacting, and the therapist is on the side. Finally, the therapist and animal might interact and the client may decide to stay on the side. In addition, all three may interact together. From here, the client may take this to a number of places. The one on the side may be observing the other two, trying to understand, or judging, evaluating, learning, or even ignoring. The client, depending on his or her own inner world, may perceive these and more possibilities for any of the relationships. The client may feel that the nonparticipant is ignoring or being ignored, running away, rejecting or being rejected, resting, shy, snobby, or giving the participant an opportunity to interact alone with the animal. The client may decide to observe the interactions between the therapist and the animal to understand how to interact with the animal, to judge the therapist to see how he or she will treat the animal, or to see whether the animal is nice or threatening to the therapist. The client may prefer to interact alone with an animal in order to try out different behaviors, or to feel special in the eyes of the animal, or to show the therapist that the animal prefers the client over the therapist. The client may prefer for all three to interact together to create a feeling of togetherness, or because of a desire to be with an animal yet fearing to be alone with him. All are possible within role-play, depending on the situation the client is trying to set up.
Some settings include more than one animal, which results in further opportunities for the therapy process, as well as greater complexity, all of which the therapist must be aware. Depending on the makeup of the group of animals, the number of possible pairs for interactions and relationships rises exponentially, for not only are there possible interactions between the therapist and client with each one of the animals, but also interactions between the animals. There are the actual relationships and then there are the perceived (by the client) relationships, and the client’s perceptions of the relationships between the animals may change over time or according to the stage of the therapy process and the needs of the client to transfer or project. In any case, this situation provides an opportunity for the client and the therapist to observe and contemplate the interaction between the animals together, allowing for the emotional expression by the client and reflection and mediation by the therapist.
The therapist-client-animal triangle has elements of a group, leading to situations and reenactments which may only happen within a group. For instance, in the AAP setting there is the group (whether a group of animals or the group of therapist-client-animal), there is the collection of individuals within the group, and there is the unique role fulfilled by each member within the group (the one who is most loved, most protected, thought of as most important, weakest, or most envied, and there is the one who is in competition with others for social connections). It sometimes happens, for instance, that an animal may choose to sit next to the client, perhaps eliciting reactions such as, “He picked me over you because he likes me better,” or “He is on my side, not yours.” The therapist may then use this situation to encourage the client to enter into role-play and express disappointment, insult, feelings of rejection, and so forth. (For further discussion of the group elements found in AAP, see Chapter 6 .)
It is interesting to note the implications of the fact that the animal is brought by the therapist and maintains a relationship with the therapist. Whether he is one of a group of animals brought by the therapist, or certainly if he is the one animal chosen to work together with the therapist, for the therapist it is important as an immediate fact that the two have a close, meaningful relationship, with communication and connection. The relationship between the therapist and his or her animal is part of the setting and of the medium of the therapy. The client enters therapy in which there is a therapist and there is a relationship which is a given. There is one, the client, while there are two, the therapist and the animal. The client is invited to join this pair and to make it into a triangle. From here, two axes may develop: (1) the client will observe the relationship, relate to it, or react to it, and (2) the client will most likely search for his or her relative place (e.g., joining, rejecting, denying, competing) within the relationship, causing the pair to become a triangle.
First, the client enters a situation in which, for instance, there is a therapist and the therapist’s dog, and the client may feel that he has the place of younger brother in this family. He is likely to react affectionately to the animal, maybe as a means of placating, connecting with, or being liked and accepted by the therapist. (It is common for a client to express the wish that he could be a dog and then go home with the therapist.) On the other hand, the client may react with anger, disappointment, or jealousy, and may feel competitive with the animal, or with the therapist: Who does the therapist prefer—the client or the animal? Who does the dog prefer?
An animal may be seen by the client as an extension of the therapist (I. Barel, personal communication, October 2008), and the client may displace his or her feelings for the therapist onto the animal. The client may hug the animal instead of the therapist or try to hurt the animal in order to get revenge on the therapist. The client may say to the animal what is actually meant to be expressed to the therapist. This situation provides space for direct and indirect (and therefore less threatening) expression of feelings between the client and therapist.
In short, the AAP therapy triangle itself is an unprecedented medium for the expression of the client’s inner world, made up of the client’s relational objects and experiences. Because the animals are unaware of the transference and projective roles attributed to them and therefore do not reject them, but rather react to them through the client’s interactions with them, they unwittingly allow for those transferences and projection to occur, enabling endless possibilities for enactments according to the psychological needs of the client. The triangle is a virtual laboratory for therapy based upon object relations theory, which states that the human relationship is a primary motivational force in life (Fairbairn, 1941). Of course the therapist (for the human is the therapist and not the animal) is present to reflect and interpret, to aid the client in the working through of the issues raised within the reenactment, to help the client gain insight and change.
Connected to D. Winnicott’s theory of play is the concept of transference, one of the most commonly discussed phenomena in therapy from the time of Freud until today. Some say that without transference, which is the displacement of conflictual wishes from an earlier relationship to the relationship with the therapist, is an important and perhaps essential part of psychotherapy. Similar to the potential space, transference is a place where illusion, the concept which bridges fantasy and reality, and truth mingle. Transference illusion is the manifestation of the similarity of the subjective experience aroused by an event in the past and in the present. This brings the client in touch with the reality of his or her feelings, makes the client feel more real, and puts more emotion at his or her disposal (Klauber, 1987). As a consequence, the therapist-client relationship provides yet another opportunity and venue for repeating and working through resistance concerning issues from the past. Transference in therapy turns the passive into active (Sandler & Freud, 1985). In play, “displacement transfers conflicts so as to allow the search for and discovery of solutions for them; thus, it is not part of the original primary experience. It transfers affect and content while it shifts the conflict to symbolic objects” (Neubauer, 1994, pp. 108–109). As a consequence, the AAP therapy triangle, therapist-client-animal, provides a number of opportunities and venues for repeating and working through resistance concerning issues, situations, and objects from outside the therapy setting, from the past or from the present.
Another advantage of this therapy triangle is that the interactions are happening in the here and now within the therapy setting, and therefore are accompanied by the therapist. As a professional observer, the therapist will help the client gain insight into what was occurring in those interactions. Rarely are we in interactions with others with our therapist there to see the real interaction as opposed to just hearing about it, so reflections, interpretations, and insights are based only on the client’s perceptions of what happened and on what the client chooses to bring to the therapist. (This is also an opportunity for the advancement of the therapy process, but with other goals, and is material for a different book.) Once the insight is arrived at, the client has many opportunities to institute behavioral change (leading to the reinforcement of the internalization of that change) according to that insight. Through trial and error and re-correction, with the aid of the therapist, the client may practice new behaviors and get immediate feedback directly from the animals and with the mediation and support of the therapist. In other therapies, the client may practice change within the therapist-client relationship, but the behaviors will not be “clean,” natural, or authentic. Outside of the therapy setting, it is hard for the client to institute change in relationships, for the other will not always be understanding and allow the client to practice change and new behaviors. In general, animals will be more forgiving (although they certainly do not unconditionally accept a client) and allow for change. The client experiences the difference in the relationship, within the therapy setting, and can be helped by the therapist to identify the cause and effect of the changes. All this will reinforce change and the understanding of that change, facilitating the internalization of the new behavior and creating the possibility for the exporting of that change outside of therapy.
The here and now of the AAP triangle also provides opportunities similar to those of group therapy. For instance, in group therapy, the therapist observes the interactions of the group members and reflects on them, leading to working out, insight, and change—as was just described in terms of the triangle in the AAP setting. In addition, in group therapy, the therapist is both observer and participant (Yalom & Leszcz, 2005), which also characterizes the AAP therapist within the triangle. Compared to most approaches to group therapy, the AAP group is unique in that only one of the members of the group is the client, who is therefore the focus of the therapy. (For more on this subject, see the Chapter 6 .)
Attachment and the AAP Therapy Triangle
One may understand the opportunities for the therapy process of the AAP therapy triangle through the prism of attachment theory (Bowlby, 1969). Many people come to therapy because of emotional difficulties resulting from problematic relationships in the past that affect their functioning and sense of well-being in the present. As mentioned earlier, similarly to Fairburn, Bowlby posited that all humans base their social interactions on internal working models formed through their interactions with their parents as children. If the family environment is not a safe one, both physically and emotionally, and the parents do not protect them (or if the parents are the source of the danger), children form a model of adult-child behavior in which, for instance, they cannot trust or depend on the adults, must defend and take care of themselves, or are responsible for creating the conditions under which the adults will take care of them, leading to the the development of parentified behavior. (For further discussion of the parentified child, refer to Chapter 4 .) These models carry on into the child’s relationships with others (and continue to do so as the child matures into adulthood), having many implications for the client’s functioning within the therapy setting, process, and relationship. That is, clients with insecure attachment will carry this style into the therapy situation. Many of these clients will carry their distrust of adults into therapy and distrust the therapist, and the parentified client will also act parentified toward the therapist.
In a literature review concerning children and youth who were institutionalized after having suffered abuse and severe neglect in their families, Mikulincer and Shaver (2007) note evidence of the positive behavioral and emotional effects on these children of an emphasis on a positive attachment approach by childcare workers and therapists within the institution. In addition, they note evidence of improvement in attachment representations. It may be inferred from this that providing an atmosphere in the institution that exudes positive attachment interactions, behavior, communication, and relationships has a beneficial effect on the child in all of these spheres.
It demands merely a small leap to hypothesize that providing such an atmosphere in the therapy room would have a beneficial effect on the client in such a way that would facilitate the therapeutic alliance and the client’s ability to enter into the process of psychotherapy. In the AAP setting, the client is exposed to an atmosphere of positive parenting behavior on the part of the therapist toward the animal. Although every therapist tries to show the client positive regard and caring, containing behavior, many at-risk children do not trust this behavior and do not find it to be natural or authentic. However, seeing the therapist show this behavior toward the animals, together with the animals’ reactions of trust toward the therapist and expecting positive behavior and protection from the therapist, may be seen as proof of the authenticity of the therapist’s good intentions and trustworthiness. One client who was highly resistant to therapy before coming to me (Nancy) told me, “I never trust any adult. But if I see how he acts with animals, and he is okay with them, then I know I can trust him.” A client who refused to cooperate with a psychologist before coming to me said, “I saw that the animals trust you, so I knew that I could trust you, too.” A young girl, who earlier had insisted on leaving the door of the therapy room open for fear of being alone with me, said, “I saw that you were nice to the animals and treated them well, so I realized that you would be that way with me, too.” All three of these children, two of whom had been deemed untreatable, took full advantage of the process of psychotherapy for the time they were with me in therapy. (See Chapter 1 for a more extensive discussion of the therapeutic alliance.)
When beginning therapy with an at-risk child, or discovering during the therapy process that a child is at risk, changing the child’s internal working models of adult-child interactions becomes a major goal. The therapist shows the child that alternate, more positive models of these interactions exist. The therapist’s hope is that this will allow the child, in the present and in the future, to recognize others with whom he or she will be able to create positive and adaptive relationships. We believe that AAP is an effective and efficient way of reaching this goal. There are number of ways in which this may happen. First, within the atmosphere of positive attachment style, internal working models may be altered by the child’s witnessing the therapist’s relationship with the animal and their interactions. The child will see that there is a way to relate other than that which the child had experienced in the home environment. Second, this might then allow the child to accept caring, attentive, and containing behavior from the therapist. This is important not only for clients who may be distrustful toward the therapist, but also for parentified clients who will not allow the therapist to take care of them, but rather seek positive regard from the therapist by trying to take care of the therapist’s needs. At this point, the client will be more likely to share his or her inner world with the therapist and participate in the psychotherapy process. Third, AAP allows for clients to practice new attitudes and behaviors related to these more positive working models in their interactions with the animals. (Further discussion of AAP from the perspective of attachment theory can be seen in Chapter 5 , as well as in Zilcha-Mano, Mikulincer, and Shaver [2011].)
Intersubjectivity and the AAP Therapy Triangle
Another theoretical construct relevant to the idea of a relational medium, one which grew out of and was influenced by object relations theory, is that of the analytic third , proposed by Thomas Ogden (1999). In an afterword to his original article, Ogden wrote that the analytic third refers to a third subjectivity, unconsciously cocreated by the therapist and client, “which seems to take a life of its own in the interpersonal field between them” (p. 487). He goes on to state:
[The] intersubjective analytic third as an ever-changing unconscious third subject (more verb than noun) … powerfully contributes to the structure of the analytic relationship. The analyst’s and patient’s experience in and of the analytic third spans the full range of human emotion and its attendant thoughts, fantasies, bodily sensations, and so on. The task of the analyst is to create conditions in which the unconscious intersubjective analytic third (which is always multilayered and multifaceted and continually on the move) might be experienced, attached to words and eventually spoken about this with the analysand. (p. 488)
It is important to make clear that the analytic third is not the third thing referred to by Clare Winnicott (1968), something outside of the therapist and the client on which they can focus, enabling the therapist and client to feel that they have something in common. (For further discussion of the concept of the third thing and how it contributes to the therapy process, see Chapter 1 .) Rather it is that shared subjectivity dwelling within the interpersonal field between therapist and client. The analyst’s experience within this interpersonal field, the analytic third, is “utilized as a vehicle for the understanding of the conscious and unconscious experience of the analysand” (Ogden, 1999, p. 483). However, within the context of his discussion of the analytic third, Ogden writes of the client’s internal object world and forms of relatedness to external objects, and later mentions that “the influence of the analytic third might come to life in the form of acting-in or acting-out on the part of the analyst or the analysand or both” (p. 488). Finally, Ogden writes that “this experience of playful symbol- and metaphor-making allows one to create symbols that give shapes and emotional substance (sensate “embodiments”) to the self-as-object (“me”) which serve as mirrors in which the self-as-object (“I”) recognizes/creates itself.” (p. 490).
Perhaps the presence of a third thing—or medium—as that external object generates the shared experience of the therapist and the client as they relate to that external object, which in turn stimulates both the therapist’s and the client’s individual subjectivities to open up and send out feelers to each other and connect into a shared subjectivity, the analytic third, in the form of shared observations, emotions, thoughts, sensations, fantasies, and behaviors. Indeed, this shared experiencing of the medium which forms the analytic third is the playful symbol- and metaphor-making mentioned above. Ogden (1999) makes it clear that each person experiences the analytic third in the context of his or her own personality system, own experience and ways of experiencing and integrating sensations, own history, and so forth. One may extend this approach by suggesting that for this reason, the choice and use of a medium in therapy reflects and results from the client’s personal experience. This opens the way to a discussion of the countertransference experience of the therapist, and the therapist’s awareness and consequent use of that countertransference as his or her responsibility to “[explore] … the analysand’s unconscious internal world and forms of relatedness to external objects” (p. 487).
An animal in the psychotherapy setting may serve as a rich stimulus for the development of what Ogden (1999) refers to as the analytic third . As mentioned throughout this book, the animal serves as a concrete and real, live, interactive stimulus, in the here and now, for work in the psychotherapy process. Both the client and the therapist bring into the session their own subjectivities concerning the animal, or sets of perceptions, sensations, associations, emotions, and thoughts about animals on many levels: in general, about the type of animal (e.g., a rat, with all the stigmas surrounding it), and about the individual animal in the room (e.g., Foxy, the lab rat who is cuddly and loves hiding the food given to her by the client and coming back for more). In addition, both the therapist and client hold within themselves subjectivities as to their experiences, relationship, and interactions with the animal. As in the initial discussion earlier in this chapter of the therapist-client-animal therapy triangle that exists in AAP and is so basic to the mechanism of AAP, the client and therapist observe each other’s interactions with the animal and evaluate and judge each other on the basis of on those interactions. In a natural and unconscious way, relationships are formed, develop, and change from interaction to interaction—with the animals and with each other. Within the natural and authentic atmosphere of the AAP setting, the client and therapist will often talk to each other about what one and the other see and do with the animal. They discuss their perceptions, sensations, associations, emotions, and thoughts about animals in general and about the animal before them, as well as about how the other sees and interacts with the animal. In the context of Ogden’s description of the process created by the analytic third, that which is between the therapist and client, stimulated by the animal, is experienced, given words, and spoken about with the therapist. This experience is widened in the case of a setting with more than one animal in which the animals interact with each other and the client and therapist observe together those interactions.
Ogden (1999) mentions that the task of the therapist is to establish the conditions for the creation and development of the unconscious intersubjective analytic third, and this is accomplished by the therapist’s bringing animals into the therapy setting. The AAP therapist then facilitates the intersubjectivity dwelling within the interpersonal field between therapist and client, encouraging the client to project and transfer his internal object world onto the animal(s) and onto her (and that which is between them), as well as allowing herself to be in touch with her own subjective experience (countertransference) of the client in his interactions with and perceptions of the animal(s) and their relationship with her.
CLINICAL VIGNETTE—DAVID

During the 2 years he had already been in therapy with me (Nancy), David did not once bring up the abusive and rejecting nature of his parents’ behavior toward him, nor did it come up as content in role-play. For 5 months, David kept a cell phone with him at all times, hoping that his mother might decide to call him, but she never did. In one session, we were brushing my dog, Mushu. He was using a soft brush and I was using a metal comb. At one point, the comb became caught in a knot in her fur and as I pulled too hard, she gave out a yelp. David quietly stood up, walked over to the play weapons, pulled out a plastic gun, pointed it at me, and “shot me dead.” He then put a set of play handcuffs on my hands and put me in jail. All this was punishment for my having “abused my daughter.” David was a witness to my failure to be empathetic toward Mushu. He identified with Mushu as the child who was harmed by an uncaring parent, played the person who expressed anger at the parent(which Mushu had not done and he had not been able to do with his own parents), and came to Mushu’s defense against me (which he felt that no one had ever done for him). This was the beginning of many sessions in which he role-played (directing me and sometimes the animals to play parts together with him) several situations of parents abusing and abandoning their children. Sometimes David cast me into the role of someone who was trying to save him from his abusers, but (at his direction) I never succeeded in saving him. Invariably, I found myself feeling uncomfortable and guilty. As a therapist whose goal was to help him, I suddenly found myself in the role of abuser, or at least of someone who was helpless to save him and thus forever disappointing him. It is clear that he was reenacting his experiences, dashed hopes, helplessness, and aloneness. At a later stage he was able to discuss directly his sadness, disappointment, and eventually anger at his parents’ behavior toward him.

Ogden (1999) also refers to the client’s internal object world and forms of relatedness to external objects and the need for these to come to life in therapy. In AAP, this is accomplished on a concrete level in the here and now. Here it is useful to remember that an animal represents reality, but at a safe distance, therefore making it easy to be anthropomorphized and used as an object of projections of self and transference of objects from the client’s inner relational world. This phenomenon allows for the creation of the analytic third. Whether through AAP in the play therapy situation, or within direct discussion between the therapist and client about the interpersonal field within the AAP therapy triangle, this intersubjective reality of the analytic third comes to life and is expressed through acting in or acting out (by the client, the therapist, and literally the animal for all are influenced by each other), as was mentioned in the last section. In AAP, the animal serves as the playful symbol and metaphor referred to by Ogden, allowing the client to give shape and emotional substance to the self-as-object as well as to recognize and recreate it.
In short, the presence of animals in therapy, together with a psychotherapist well versed in the possibilities and choices afforded by this, allows for the creation of an ever-changing intersubjective reality that exists in the interpersonal field between the client and therapist, the analytic third, which facilitates and enriches the process of psychotherapy. It is important to emphasize that the projections and transferences that occur during therapy, together with the therapist’s countertransference which occurs in parallel, are a type of communication which is concealed at an unconscious level. For the therapist who is aware of the existence of this process and is well versed in its use, it provides a crucial access point into the client’s inner world, allowing for the commencement of the investigation of the client’s underlying issues. The therapist can then slowly raise the level of communication from an unconscious level to a conscious one, leading to insight.
It cannot be emphasized enough that in order to be aware of the issues and processes inherent in the AAP therapy triangle and to know how to use this triangle for the purpose of the therapy process, an AAP therapist must acquire extensive knowledge in psychotherapy theories and processes, together with acquiring knowledge and training in therapy, both theoretical and practical, in the area of AAP. The AAP therapy triangle is based upon three vertices—therapist, client, and animal—and if one of them is not present, AAP will not occur. The AAP therapist should enable contact between the animal and the client, to have a deep understanding of the importance of the contact and the events that awaken due to them, to create a verbal connection between the events and themes that the client raises, to work through with the client the events between him or her and the animal in a general way, and to be aware of opportunities that are afforded by this contact between the client and the animal. All this will enable the establishment of the analytic third in AAP, which is the essence of the area within the therapist-client-animal triangle formed in AAP.
CONCLUSION
This chapter, originally a section of Chapter 1 , eventually became a chapter in its own right because of the great degree of influence that animals have on clients and their psychological processes in the therapy setting, due to their social characteristics and potential as a medium for issues concerning object relations, relative to the influence of the other characteristics of animals as a medium. It is the animal’s very existence as a living, social being that has a will of his own—who may create or initiate actual interpersonal interactions in the here and now of a therapy situation, in a most basic way reminiscent of a human’s very existence as a living, social being, similar yet different enough so as not to be threatening—that allows the client to empathize with, get angry at, want comfort from, and project onto him. In the AAP setting, the animal is a sensorial medium, interactive with the client, which turns the client’s relationship with the medium into an interpersonal relationship—concrete and real. As discussed, humans, like many animals, have a powerful drive for object seeking and will naturally seek interactions in their daily lives. This is true also in the therapy room.
This “similar yet different” behavior of the animals makes them safe objects for this object seeking. In other words, the AAP setting is a rich world of potential interactions and connections, there for the taking according to the needs of the client. As has been suggested, the basis for most people’s psychological problems in the present is a past made up of problematic interactions with relational objects. Therefore, AAP provides a laboratory full of potential relationships that may be worked on, in the here and now, as an integral part of the process of psychotherapy. In addition, it is notable that unlike those in the usual therapist-client relationship, interactions in these relationships are spontaneous, authentic, sometimes unpredictable, and sometimes characterized by a clash of expectations and personal theories. Clients may feel a familiar lack of control, reminding them of other situations and relationships. These interactions in turn stimulate authentic emotions and reactions which may be a part of clients’ usual patterns which have caused them pain and distress in their relational world. In such a way, authentic content may arise and be made available to be worked through.
Of course, therapists must maintain an active presence at all times. As psychotherapists, we must always be aware of when and how to intervene (or not), and when and how to reflect to our clients their emotions, behavior, and content, to mediate between clients and their own processes, and so forth. As AAP therapists, we should always be aware of the dynamics between the clients and the animals, mediate between them, reflect in terms of both the clients and the animals, as well as intervene to advance the therapy process in a way which takes advantage of the influence of the animals on the situation, and of course to intervene to help or limit the clients or animals when needed.
Perhaps the most important contribution of this chapter is the presentation of a theoretical basis for the therapy triangle that is such a major component of the process of AAP and therefore a significant influence on the psychotherapy process. Clare Winnicott (1968) discussed the importance of a third thing in the therapy setting, which is a nonthreatening focus for the otherwise resistant client together with the therapist. As has been understood for many years by even the very earliest AAP therapists (Corson, Arnold, Gwynne, & Corson, 1977; Levinson & Mallon, 1997), the animal joins the therapist and the client in the setting in such a way that a stalled therapy process may be advanced. Beck and Katcher (1983) wrote, “A triangle was formed in which the two significant people, doctor and patient, could feel good in each other’s presence through their involvement with a third being. Later the therapist and child could establish a direct relationship” (p. 93). This may be considered a sort of social facilitation observed in other situations with dogs (McNicholas & Collis, 2000; Messent, 1983). This use of the triangle is especially important at the beginning of the therapy process in that it seems to facilitate the establishment of the therapy alliance.
However, another use of the AAP therapy triangle has a deeper implication for the advancement of the psychotherapy process and perhaps explains one of the most significant mechanisms underlying the AAP process. Presented in this chapter is the use of Ogden’s (1999) concept of the intersubjective analytic third as it adds to our understanding of what occurs within the AAP therapist-client-animal triangle. In short, each of the vertices of the AAP therapy triangle brings into the therapy setting its own subjectivities concerning the others, and in the session they evaluate and interact with each other accordingly. The role of the therapist is to create the conditions for this process, be aware of what happens in it, and use it to advance the therapy processes of reenactment, finding words for the experience, working through, insight, and change. Although the creation of the analytic third and the use of it for therapy are meant to be part of any psychotherapy setting, the presence of animals provides certain advantages. First, the animals provide a more authentic atmosphere and a third entity, allowing for more natural conversation to take place at a safe distance while the client and therapist discuss the third—the animal—onto which they both may be projecting their intersubjective realities. In addition, the presence of the animal(s) expands the area and the experience.
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Corson, S. A., Arnold, L. E., Gwynne, P. H., & Corson, E. O. (1977). Pet dogs as nonverbal communication links in hospital psychiatry. Comprehensive Psychiatry, 18 (1), 61–72. http://dx.doi.org/10.1016/S0010-440X(77)80008-4
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McNicholas, J., & Collis, G. M. (2000). Dogs as catalysts for social interactions: Robustness of the effect. British Journal of Psychology, 91 (1), 61–70. http://dx.doi.org/10.1348/000712600161673
Messent, P. (1983). Social facilitation of contact with other people by pet dogs. In A. H. Katcher & A. M. Beck (Eds.), New perspectives on our lives with companion animals (pp. 37–46). Philadelphia, PA: University of Pennsylvania Press.
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Ogden, T. H. (1999). The analytic third: working with intersubjective clinical facts. In S. A. Mitchell & A. Aron (Eds.), Relational psychoanalysis: The emergence of a tradition (pp. 459–92). Hillsdale, NJ: Analytic Press.
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Winnicott, D. (1965). The maturational processes and the facilitating environment: Studies in the theory of emotional development . London: Hogarth Press.
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Zilcha-Mano, S., Mikulincer, M., & Shaver, P. R. (2011). Pet in the therapy room: An attachment perspective on animal-assisted therapy. Attachment & Human Development, 13 (6), 541–61. http://dx.doi.org/10.1080/14616734.2011.608987
3
PROJECTION AND PROJECTIVE OBJECT IN CHILD ANIMAL-ASSISTED PSYCHOTHERAPY
Rachel Ben David
INTRODUCTION
The advantages of pet-oriented child psychotherapy are usually attributed to animals as facilitators of relationships, as a source of connection, relaxation, comfort, and empowerment (Levinson & Mallon, 1997). These attributions are true in most therapeutic processes, which include the triangular therapist-client-animal relationship. The literature on human-pet bonds indicates that they often meet the four prerequisites for an attachment bond: proximity seeking, safe haven, secure base, and separation distress (Ainsworth, 1991; Hazan & Zeifman, 1994). Nevertheless, the animal’s central role as object 1 of projection is often neglected even within the most supportive literature of animal-assisted psychotherapy (AAP). The main goal of this chapter is to return the spotlight to a common phenomenon which usually takes place during free-flowing (Nairne, 2009) play with animals during therapeutic sessions.
Among verbal children (especially through the latency period) who attend these sessions, one may notice their spontaneous interpretations of the present animal’s feelings and thoughts. The therapist might be surprised to find out from his or her clients that the same dog lying in the corner of the room is bored in one session, deserted in the next session, and depressed in another. The same dog, wagging his tail and taking a few steps toward the child in order to make a friendly contact, might inadvertently frighten the child because of the child’s insecure attachment pattern (Bowlby, 1980; Zilcha-Mano, Mikulincer, & Shaver, 2011), the child’s negative reference predisposition (Dodge, 1985), or a transference of the child’s negatively introverted figures. It is very common during an AAP session for a child with emotional difficulties to place a smaller animal such as a guinea pig or hamster in unpleasant or dangerous situations, which might cause an ethical dilemma for the therapist.
The presence of another living entity besides the therapist and the client in the potential space (Winnicott, 1971), like a dog, a cat, a rabbit, a hamster, or any other four-legged partner, 2 creates new opportunities for object relations.

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