The Role of Animal-Assisted Interventions in Addressing Trauma-Informed Care, LA Stewart, L Bruneau, A Elliott

Tags: counseling, interventions, the counselor, crisis response, animal-assisted therapy, AACR, mental health, Therapy Dogs International, potential, therapy animal, client safety, professional counselors, experiential approaches, trauma recovery, animal welfare, animal stress, the professional counselor, animal advocacy, Interventions and techniques, Individual counseling, stress and trauma, animal exploitation, the therapeutic relationship, working relationship, multidisciplinary team, Graham, multicultural implications, relationship, human-animal interaction, North Atlantic Books, trauma theory, Anna Elliott Stewart, mental health services, Adams State University, trauma survivors, Idaho State University, AAT, college counseling, therapeutic relationship, Montana State University, Jennings, Laura Bruneau, National Standards Committee, Retrieved, Journal of Neuropsychiatry and Clinical Neuroscience, Journal of Psychosomatic Research, college counseling centers, Journal of Emergency Nursing, International Journal of Emergency Mental Health, Pet Partners
Content: Article 46 The Role of Animal-Assisted Interventions in Addressing Trauma-Informed Care Leslie A. Stewart, Laura Bruneau, and Anna Elliott Stewart, Leslie A., is an assistant professor of counseling at Idaho State University. In addition to facilitating therapeutic horsemanship as a former Professional Association for Therapeutic Horsemanship (PATH, Intl.) instructor, Leslie has incorporated animal-assisted therapy in mental health with a dog and a rabbit in college counseling and juvenile detention settings, as well as in clinical supervision. Leslie has experience designing and implementing AAT counseling programs in college counseling centers and has served as a professional consultant regarding AAT to private psychotherapy practices in her area. Bruneau, Laura, is an associate professor of counselor education at Adams State University. Her primary research area is creativity in counseling, which includes therapeutic reading and animal-assisted interventions. Laura has developed a canine-assisted reading program at an elementary school and a canine-assisted stress relief program on a university campus. She and her dog are a Pet Partners Team and a Reading Education Assistance Dog Team. Elliott, Anna, is an assistant professor of counseling at Montana State University. Her clinical and research interests are focused on trauma recovery, adolescents, and wilderness therapy. She identifies with using experiential approaches in counseling and has worked extensively with adolescents and families in the wilderness therapy setting. Abstract Animal-assisted interventions (AAI) is an interdisciplinary term to describe interventions that integrate various species of animals into the care and wellbeing of human beings. When implemented with the appropriate education and training, AAI offers several key benefits that are central to trauma-informed care, including: reducing treatment anxiety, facilitating development of strong therapeutic rapport, decreasing feelings of detachment, and offering a non-verbal avenue for expression and processing. In this manuscript, the authors propose two ways AAI can add to trauma-informed care: animal-assisted therapy in counseling (AAT-C) and animal-assisted crisis response (AACR). Authors will discuss relevant literature, provide examples of appropriate interventions and techniques, and offer resources for further information. Keywords: animal-assisted therapy, trauma-informed care, crisis response counseling
Ideas and Research You Can Use: VISTAS 2016 With more than half of adults in the United States having experienced at least one major traumatic event, crisis, or disaster (Briere & Scott, 2014), trauma survivors represent a majority of clients seeking mental health services (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005). As mental health providers have become increasingly responsive to the prevalence of trauma, efforts have been made to implement systemic changes to attend appropriately to the needs of survivors (Harris & Fallot, 2001; Jennings, 2004). In a 2004 report on developing trauma-informed behavioral Health Systems, a trauma-informed system is described as "one in which all components of a given service system have been reconsidered and evaluated in the light of a basic understanding of the role that violence plays in the lives of [those] . . . seeking mental health and addiction services" (Jennings, 2004, p. 20). Given this definition, the mental health system must be attuned to the needs of trauma survivors (Jennings, 2004). For this article, trauma-informed counseling is understood as therapeutic work with clients in which the counselor possesses the knowledge of how trauma impacts individuals, families, and larger systems. While the focus of the counseling may not be trauma specific, case conceptualization and interventions account for the impact of trauma. In particular, counselors must be cognizant of re-traumatizing the client or exploiting vulnerabilities (Jennings, 2004). In summary, professional counselors must be equipped with the knowledge and skills necessary to provide effective trauma-informed care. The 2016 CACREP Standards (Council for Accreditation of Counseling and Related educational programs, 2016) reflect the importance of trauma-informed care in counselor education programs by requiring counseling faculty to train their master's students in crisis intervention and trauma-informed and community-based counseling strategies (Section 2.F.5.m.). While the quality of the relationship is a major factor in all counseling approaches, Courtois and Ford (2013) found that the quality of the counseling relationship is the most important component in successful trauma therapy. Briere and Scott (2014) further asserted that a positive therapeutic relationship decreases attrition rates and avoidance; increases disclosure, openness, and medication compliance; and encourages clients' capacity to tolerate painful thoughts and traumatic memories. In addition to a positive therapeutic relationship, Shallcross (2010) noted that the use of creative and experiential approaches, such as multisensory approaches, are particularly helpful in trauma-informed counseling. Given the importance of the therapeutic relationship and utilizing creative, diverse approaches, professional counselors may benefit by exploring treatment modalities that enhance these components in counseling. Further, authors in trauma-informed counseling have increasingly demonstrated the importance of integrating experiential and bodyfocused interventions into the trauma recovery process (Clark et al., 2014; Levine, 2010; Meyer et al., 2012; Ogden & Minton, 2000; van der Kolk, 2014). These interventions may include trauma-sensitive yoga (van der Kolk, 2014), somatization experiencing (Levine, 2010), sensorimotor psychotherapy (Ogden & Minton, 2000), and eye movement desensitization response (Shapiro, 1998). Van der Kolk, in particular, has extensively examined the neurobiology of trauma and articulated the importance of body-focused practices, as people have trouble thinking and speaking when reprocessing traumatic memories (van der Kolk, 2014). Therefore, the integration of body work in counseling helps clients in coming back into relationship 2
Ideas and Research You Can Use: VISTAS 2016 with their bodies so they can learn how to regulate their stress responses and make meaning of their experiences. In addition to recognizing the value of the therapeutic relationship in trauma-informed counseling, clinicians and researchers are also further advocating for the importance of incorporating interventions that encourage clients to come back into relationship with the self through the body (Levine, 2010; Ogden & Minton, 2000; van der Kolk, 2014). Animal-assisted interventions (AAI) exist within this realm of experiential or body-oriented trauma interventions, promoting connection with oneself and others. AAI is an umbrella term for multiple therapeutic and educational modalities such as animalassisted therapy and animal-assisted activities. All AAI modalities are goal oriented, designed to improve client functioning, and delivered by a practitioner with specialized expertise and training within his/her scope of practice (Animal-Assisted Interventions International, 2013). When implemented with the appropriate education and training, AAI offers several overarching benefits to the trauma-informed and crisis response process, including: (a) reducing treatment anxiety, (b) facilitating the development of a strong therapeutic rapport, (c) decreasing feelings of detachment from others, and (d) offering an expressive, non-verbal avenue for expression and processing (Chandler, 2012; Fine, 2010; Stewart, Chang, & Rice, 2013). In this manuscript, the authors will define two ways in which AAI can be used to address symptoms of trauma: animal-assisted therapy in counseling (AAT-C) and animalassisted crisis response (AACR). Authors will discuss empirically supported benefits associated with both approaches, provide examples of relevant techniques and interventions, describe appropriate ethical and multicultural considerations, and offer resources for further information. To help orient the reader, acronyms used throughout the manuscript are summarized below: Animal-assisted interventions (AAI): Goal-oriented interventions incorporating animals, which are designed to improve client functioning, and delivered by a practitioner with specialized expertise and training within his/her scope of practice. Animal-assisted therapy in counseling (AAT-C): The incorporation of specially trained and evaluated animals as therapeutic agents into the counseling process. Animal-assisted crisis response (AACR): Trained human-canine response teams that provide comfort, stress relief, and emotional support to those affected by crises and disasters. Animal-Assisted Therapy in Counseling When integrating AAI interventions in counseling, a professional counselor is implementing animal-assisted therapy in counseling (AAT-C). AAT-C, a subspecialty for mental health professionals, is defined as the incorporation of specially trained and evaluated animals as therapeutic agents into the counseling process; thus, professional counselors utilize the human-animal bond in goal-directed interventions as part of the treatment process (Chandler, 2012). For example, a professional counselor can integrate AAT-C interventions into a trauma-informed treatment plan. Multiple authors (Chandler, 2012; Fine, 2010; Reichert, 1998; Yorke, Adams, & Coady, 2008) have found that AAT- 3
Ideas and Research You Can Use: VISTAS 2016 C uniquely impacts the therapeutic relationship, particularly helping the professional counselor build positive alliances more quickly and with greater perceived genuineness, warmth, and empathy. In many cases, the relationship between the client and therapy animal facilitates rapport building between the client and the counselor (Chandler, 2012). Additionally, the relationship between the counselor and therapy animal may potentially enhance the trust building process, as the client witnesses the animal's trust in the counselor as well as the counselor's vigilant and empathetic care for the animal (Stewart et al., 2013). When AAT-C practitioners effectively and visibly advocate for the welfare of the therapy animal, this positively impacts the counselor-client relationship (Stewart et al., 2013). Considering the quality of the counseling alliance as a critical component in trauma-informed counseling, the inclusion of AAT-C may be a valuable treatment modality when working with trauma survivors. Reichert (1998) further asserted that the therapy animal's warm, nonjudgmental nature might facilitate client disclosure during counseling sessions. George (1988) observed that the need for language in therapy decreases when a therapy animal is introduced in counseling, as clients might find it easier to express themselves through physical interaction with the animal. Yorke et al. (2008) noted the development of a relationship with a therapy animal may offer the unique opportunity for acceptance, nurturance, intimacy, safe touch, and physical affection. The findings of these authors (George, 1988; Reichert, 1998; Yorke et al., 2008) are relevant to key components in trauma-informed care such as relationship building and opportunity for experiential and body-focused interventions. Thus, incorporating AAT-C interventions in traumainformed counseling may have the potential to help professional counselors address some of the unique challenges associated with this therapy. Clinical Applications As described by Stewart et al. (2013), the working relationship between the counselor and the therapy animal serves as a powerful intervention that may enhance the therapeutic relationship in ways that would not be possible without the inclusion of the animal. This impact on the relationship is in itself a primary intervention with AAT-C. It is important to note that AAT-C interventions described in this manuscript are only effective when utilized within the context of this highly developed counselor-therapy animal working relationship. Much like the therapeutic relationship between counselor and client, this counselor-therapy animal relationship is characterized by mutual trust, respect, and advocacy (Stewart et al., 2013). Interventions and techniques in AAT-C can vary greatly depending on a multitude of contextual factors such as individual client needs and preferences, provider theoretical orientation or approach to counseling, and individual therapy animal personality and preferences. However, in-the-moment processing is used by all AAT-C providers to process the client-animal interaction, including successes, challenges, and the clientanimal relationship. A skilled AAT-C provider can translate these experiences into therapeutically meaningful metaphors, skills, or insights relevant to the individual client's treatment plan. Most AAT-C techniques, including those applied in trauma-informed counseling, may be conceptualized as either specific/directive techniques or as processoriented/non-directive techniques. The examples described below were developed by the 4
Ideas and Research You Can Use: VISTAS 2016 first author's clinical experience as well as input from colleagues and is not intended to be an exhaustive list of interventions and techniques. Specific/directive techniques. Positive obedience training or new trick training may help counselors address concerns such as communications skills, frustration tolerance, assertiveness, etc. In these interventions, counselors provide psychoeducation and coaching relevant to positive, relationship-based animal training techniques. As the client works with the therapy animal to perform certain obedience tasks or learn new tricks, the counselor serves as a consultant. Counselors process challenges and successes as they arise, and perspective-taking/empathy is encouraged throughout the process. Socialization walks are another technique that can be utilized to help clients who are struggling to interact with others in spontaneous social situations due to anxiety or other concerns. After addressing potential confidentiality issues, the counselor and client together take the dog for a walk in a nearby area/situation that has been assessed as safe and appropriate (e.g., local park or coffee stand). Clients can benefit from the increased social ease associated with including animals in social situations while learning to manage fear and anxiety in public social situations. Other potentially useful techniques that may be helpful for trauma survivors are animal-assisted meditation and animal-assisted grounding techniques. In these techniques, clients learn to ground themselves through touching the therapy animal and engaging in meditative experiences based on sensory experiences with the animal (e.g., petting the animal, brushing the animal, or sitting closely beside the animal). These sensory experiences would be inappropriate or difficult to include in the counseling process without the inclusion of a therapy animal. Before initiating this technique, counselors need to clarify appropriate touch with the therapy animal (e.g., knowing animal's preferred touch areas, prohibiting coercive or restraining touch, etc.). Process-oriented/non-directive techniques. Non-directive AAT-C interventions rely on a counselor's ability to respond to and process spontaneous interactions between a therapy animal and client. An example of a non-directive AAT-C technique includes the counselor taking the role as process observer to the client-animal interaction. When in this role, the counselor observes the client-animal interaction, offers reflections, and asks open-ended questions about the interaction, the animal's responses, and the client's interpretation of the animal's responses. For example, a therapy dog might be napping during a client's arrival. In this instance, the counselor would observe the client's response to the animal's behavior and process that interpretation. Based on individual client needs and the counselor's approach, the counselor may opt to offer ideas or information about the animal's response (e.g., informing the client that dogs require more sleep than people and must nap during the day) or he/she may opt to allow the animal's behavior to remain ambiguous to allow for further processing (e.g., reflecting the client's feelings about the dog choosing to nap rather than interact). Another non-directive AAT-C intervention involves the animal taking the role as an informant for the counselor. When a provider is appropriately trained in speciesspecific behavior and familiar with the individual therapy animal, the counselor may be able to interpret the animal's responses towards a client to gain important information. Interpretation will vary depending on species of animal and individual animal personality. An example of this is the first author's (now retired) therapy dog's responsiveness to changes in client arousal. This particular animal consistently noticed 5
Ideas and Research You Can Use: VISTAS 2016 even subtle changes in client arousal and would respond with curiosity and concern. The dog's response allowed the client to develop enhanced self-awareness and emotional regulation and aided the counselor in assessing the client's arousal state. This particular intervention may be especially applicable to trauma-informed counseling during client reprocessing work and grounding exercises. Animal-Assisted Crisis Response Animal-assisted crisis response (AACR) provides comfort, stress relief, and emotional support to those affected by crises and disasters through trained human-canine response teams (Graham, 2009; National Standards Committee for AACR, 2010). Like AAT-C, AACR is a specific modality that falls under the umbrella of AAI. AACR is a distinct modality with significant promise for the crisis response field, as AACR teams effectively provide Psychological First Aid (Eaton-Stull & Flynn, 2015) through acting as an intermediate between survivors and practitioners (Bua, 2013). Further, AACR may be potentially more effective than non-animal-assisted crisis response in providing comfort, decreasing anxiety, and facilitating a sharing of emotions when working with those in crisis (Chandler, 2012). In recent years, counselors have been called upon to provide their expertise in a variety of crisis situations, including naturally occurring disasters, human-made disasters, and technologically based disasters (Uhernik, 2008). In these instances, counselors provide a briefer form of counseling, helping the survivor feel safe (Chandler, 2008) and decreasing physiological arousal (Orner, Kent, Pfefferbaum, Raphael, & Watson, 2006). In this role, the counselor listens, offers emotional support, and encourages contact and communication (Orner et al., 2006). Overall, the goals of crisis response counseling are to empower the person, building upon individual strengths and self-sufficiency, to help the person cope with these life-changing events. This section highlights how counselors can work in tandem with AACR teams, making use of the benefits already described with AAT-C. However, a brief introduction to AACR is necessary. AACR has been in effect since 1995 when the Federal Emergency Management Agency (FEMA) called out teams to the Oklahoma City Bombing (Greenbaum, 2006; Shubert, 2012). At present, AACR has been active in a variety of crisis sites, including the World Trade Center attack (2001), Hurricane Katrina (2005), the Virginia Tech massacre (2007), the Northern Illinois University shooting (2008), and most recently, the Sandy Hook Elementary shootings (2012). AACR teams may also provide support after the death of students or first-responders (Hope Animal-Assisted Crisis Response, 2015). There are over 200 certified AACR teams (National Standards Committee for AACR, 2010). National standards were created in 2010, ensuring the highest degree of professionalism and setting standards of conduct. An AACR team completes over 25 hours of training, including crisis intervention, incident command, animal behavior, and human and canine stress management. Experiential training further prepares these teams for the difficulty of crisis work. Teams must pass an evaluation and engage in active, professional activity to maintain their credential. In contrast to other types of AAI, dogs are the most common species in AACR as they are predictable, trainable, and can work long hours (Chandler, 2012). Handlers must 6
Ideas and Research You Can Use: VISTAS 2016 carefully evaluate dogs for AACR; for example, the dog needs to be calm in the most chaotic of situations. A calm and friendly temperament is more important than a particular breed. Dogs must be in good health and have basic obedience skills. Also, dogs must be trained for transportation, crowding, and to be calm even with strange sights, sounds, and smells. Most AACR handlers are volunteers rather than licensed professionals in the mental health field (Graham, 2009). Volunteering as an AACR team requires great commitment. For example, crisis call outs can come with little warning and last for several days, travel to and from sites may be difficult, and teams are likely to experience people expressing intense emotions. Further, crisis scenes are chaotic and unpredictable, and the personal costs of volunteering can be high (Hope AACR, 2015). As part of a multidisciplinary team, AACR is integrated into the crisis response community; AACR is more than having a dog present at a crisis scene (Greenbaum, 2006). After collaborating with the counselor, the handler can initiate goals for interacting with clients. AACR teams must be monitored and supervised during the crisis response and have a main point of contact, e.g. university counseling center, etc. Therapy dog teams may be registered with other agencies, such as Pet Partners or Therapy Dogs International. However, these teams typically do not have formal training in crisis response, and Hope AACR and National AACR represent the most comprehensive training in crisis response (Shubert, 2012). Clinical Applications Like AAT-C, dogs are intentionally incorporated into the crisis response process and serve as a grounding mechanism with AACR. This grounding is particularly important for trauma survivors, as the dog provides a sense of normalcy and an opportunity for appropriate touch (Chandler, 2012). Because of the positive physiological effects of being with a dog (Friedmann, Katcher, Lynch, Thomas, & Messent, 1983; Odendaal, 2000), an AACR team may help to reduce acute trauma symptoms, such as shock, confusion, withdrawal, and elevated blood pressure (Chandler, 2012). In working in tandem with an AACR team, counselors make use of AACR as a tool to establish rapport, build therapeutic bridges, normalize reactions, and act as a calming agent during a crisis (Greenbaum, 2006). An AACR team is especially useful in establishing rapport with clients who have not been responsive to other methods. Trauma survivors may isolate themselves and exhibit withdrawn behavior; reaching out and petting a dog can be a first step in working through isolation. Chandler (2008) noted a consistent pattern of spontaneous interaction when engaged in animal-assisted crisis response counseling in contrast to non-animal crisis response counseling. Clients may ask questions like, "What is your dog's name?" or "Why are you here?" (Graham, 2009). Often, clients will talk about their animals, allowing for sharing and developing of rapport (Graham, 2009). Further, AACR dogs can identify clients who need help, alerting the crisis response counselor to these vulnerable clients (Greenbaum, 2006). Similar to AAT-C, working alongside an AACR team may make the counselor seem more approachable, increasing the chance that the client is willing to receive help. Trusting a dog may feel easier and less complicated for a person who is experiencing a crisis. In essence, AACR teams build bridges with clients, facilitating communication and 7
Ideas and Research You Can Use: VISTAS 2016 serving as a medium for connection (Graham, 2009). The counselor can help to initiate this contact (e.g., "I think Fido needs a hug right now."). The animal may provide a sense of commonality, uniting "strangers in a strange environment" (Chandler, 2012, p. 274). Through these first social interactions, the counselor begins to collect information, assess current needs and concerns, and develop a connection with the person in crisis. AACR teams meet the clients in the here and now and ground them in the present, bringing the person back to feeling comfortable. Petting, feeding, and playing with a dog is an aspect of normal life, thus providing a sense of stability for the client. AACR dogs offer an opportunity for appropriate touch, and clients can experience the role of a nurturer through these self-initiated interactions with the dog (Graham, 2009). Further, dogs can also act as symbols or transference objects and give the client a way to talk about their feelings during a crisis. For example, a client might say, "He's afraid of all the noise," rather than speaking for oneself. Or, a client may describe the dog as "brave" or "strong," attributing qualities to the dog the person wished he or she had (Shubert, 2012). A counselor can help the client start talking about the traumatic event (e.g., "What do you think Fido needs to know about what happened here?"). AACR teams give counselors an additional means to help those impacted by a crisis or trauma (Greenbaum, 2006). For instance, Chandler (2012) provides examples of how an AACR dog can help teach relaxation exercises, an important component of crisis response counseling. In one example, clients are taught deep breathing exercises and then are asked to place their hands on the dog while breathing, being mindful of the dog's breathing and warm fur. Clients could also be directed to relax the dog by attempting to make the dog as still and calm as possible through petting, or to humor the dog by getting the dog to respond in a positive manner through making funny faces (Chandler, 2012). First-responders and mental health professionals can also benefit from AACR (Chandler, 2008; Graham, 2009). Bua (2013) asserted that AACR dogs increase selfefficacy for AACR handlers and crisis professionals who work alongside AACR teams. She further posited that an AACR dog provides an emotional and psychological buffer for professionals, functioning as a self-care tool. A handler describes this after September 11, 2001: The dogs gave me a reason to get up, and when I did, they found my pain and held it for me. I shed my first tears on Wusel's [AACR dog] furry neck. And after I did, I felt the weight in my chest start to lift. The dogs sat with my grief so I could sit with my clients'. The dogs validated my pain and in turn, I validated my clients'. Without the work Wusel did for me, I couldn't have done the work for my clients. (Sypniewski, 2011, para. 13) Overall, AACR teams provide a useful service to those in crises and disasters, providing a sense of comfort to those who have potentially lost so much. As one parent from Sandy Hook described, "you guys [the dogs] are the only thing that is constant" (Betker, 2013). Professional counselors and clients can benefit from integrating AACR into the crisis response milieu, but counselors must understand the roles of AACR teams to maximize the benefit to clients. Anecdotal stories from AACR teams (Chandler, 2008; Graham, 2009; Gramlich, 2013; Shane, 2011) provide a rich perspective for those who wish to learn more about AACR. However, as AACR is a new, specialized field, more research is needed beyond case descriptions. 8
Ideas and Research You Can Use: VISTAS 2016 Ethical and Multicultural Considerations This section will review ethical and multicultural considerations of AAT-C and AACR, including competence and integrated ethics, animal advocacy, client welfare, multicultural considerations, best practices, and legal considerations. Competence and Integrated Ethics The ethical practice of AAI carries certain considerations. The therapy animal must be specially trained, and a formal evaluation by a nationally recognized therapy animal registration organization of the animal's suitability to work in a therapeutic setting is strongly recommended. Examples of organizations that provide such evaluations are Pet Partners, Inc., Therapy Dogs Inc., and Therapy Dogs International (Stewart, Chang, & Jaynes, 2013). Providers of AAI must demonstrate skill in clinical applications of human-animal interactions (Pet Partners, Inc., 2015) before incorporating a therapy animal into clinical work, and several researchers have revealed that AAI providers are specific and intentional in their selection and application of AAI techniques (Chandler, 2012; Stewart et al., 2013). Practicing AAI requires providers to have pertinent skills and to take precautions to proactively address the potential risks involved. In addition to being competent in general counseling, the provider must have both AAI related hard and soft skills. Hard skills are those shared by animal professionals across disciplines (e.g., veterinarians, animal trainers, stable managers, etc.) and are relevant to species-specific animal expertise. Hard skills include a clear understanding of positive methods of animal training and handling, competency in identifying and interpreting the animal's communication signals, and ability to provide high-quality animal care (Chandler, 2012; Stewart et al., 2013; VanFleet, 2008). Soft skills are those that are specific to mental health professionals and are relevant to the intentional application of AAI as a therapeutic intervention within the mental health discipline. Soft skills include the ability to integrate AAI into existing counseling practices and the ability to facilitate human-animal interaction in ways that are not only safe but also therapeutically meaningful (Stewart et al., 2013). AAI is considered a specialty area within professional counseling, and, as such, specialized knowledge, skills, and attitudes are required to practice AAI ethically and effectively (Stewart et al., 2013). The issue of provider competence needs to be addressed before implementing AAI interventions with any client population. In addition to gaining formal registration with a nationally recognized therapy animal registration organization, competent providers of AAI must gain specialized training and supervised experience. Competent providers of AAI recognize that AAI involves much more than the presence of the therapy animal and are skillful and intentional when applying AAI interventions. Competent providers of AAI demonstrate integrated ethics (Stewart, 2014). Thus, competent providers of AAI are aware of AAI-specific ethical, legal, and multicultural considerations and incorporate these into their respective professional ethical codes. Since the ACA Code of Ethics currently lacks specific codes relevant to the practice of AAI, it is the provider's responsibility to identify and address all potential ethical considerations. Although the specifics of such integrated ethics may vary depending on treatment setting, client population, and individual animals involved, certain core 9
Ideas and Research You Can Use: VISTAS 2016 considerations apply to all providers of AAI. These core considerations include animal advocacy, client welfare, multicultural considerations, and best practice considerations. Animal Advocacy Providers of AAI understand that effective animal advocacy is essential to the ethical practice of AAI and prioritize their responsibility to animals involved in AAI (Stewart, 2014). Such providers understand that the welfare of the animal(s) involved in AAI is (are) the provider's responsibility. Further, AAI providers understand that animal welfare/advocacy directly impacts client safety and are aware of the potential for intentional or unintentional animal exploitation. To actively address the ethical implication of animal advocacy in AAI, providers prevent and respond to animal stress, fatigue, and burnout. Providers must be able to identify and respond to the animal's signals and body language as well as provide for the animal's needs, both on site and in general (e.g., access to fresh water, bathroom breaks, a quiet corner for retreat, regular and appropriate veterinary care and nutrition). Proactively planning stress-relief and stress-prevention strategies for the animal(s) involved, as well as immediately addressing unexpected animal stress, are essential to animal advocacy in AAI. Further, a provider's ability to recognize and accurately identify the animal's body language allows the provider to continually assess a therapy animal's suitability, strengths, and limitations. Providers take steps to minimize potential harm to the animal during training and preparation exercises by using positive, non-coercive training methods. With AACR, there is some debate in the field of AAI as to whether the dog handler can also be the counselor. In crisis response situations, the counselor and AACR handler should not serve in both capacities simultaneously as the handler's primary responsibility is to the animal (e.g., engaging the animal in the interaction, paying attention to the animal's needs and stress levels). In turn, the counselor's responsibility is to the client, establishing goals for interaction and requesting specific actions from the AACR team once the basic needs of the survivors are met. Client Welfare AAI providers have the ability to maximize the potential for safe interactions between clients and animals (Stewart, 2014). Providers are aware of the potential benefits and risks of including AAI and take active steps to minimize potential harm. AAI providers must recognize that AAI is not appropriate for every client or presenting concern and develop a method for screening clients who may/may not be appropriate for AAI interventions. When screening clients for AAI, providers consider allergies, animal phobias, history of abuse towards animals, and history of animal-related trauma. Providers recognize the direct impact of animal welfare on client safety, thus setting clear limits about client/patient conduct and behaviors towards the animal and emphasizing the animal's right to choose to interact or not interact with the client at any time. Multicultural Considerations AAI providers understand diversity, social and cultural factors relevant to AAI, and multicultural implications of AAI (Greenbaum, 2006; Stewart, 2014). Such providers are aware that human-animal interaction may hold different meanings across a variety of cultures and respect the attitudes of others, particularly those concerned with the animal's 10
Ideas and Research You Can Use: VISTAS 2016 presence. Providers consider the multicultural implications of including AAI with clients on an individual basis. Best Practice Considerations Best practices in AAI include AAI-specific documentation and an awareness of legal issues that could impact the provider, the animal, and the client/patient (Stewart, 2014). Although the specifics of such documentation will vary based on professional setting, most providers of AAI should include certain examples of AAI-specific documentation. When implementing AAT-C, including a specific informed consent document is essential before engaging a client in AAT-C interventions and providers should be sure to include the AAT-C interventions in all clinical documentation. Legal Considerations Providers need to know local, state, and national laws relevant to human-animal interaction. Additionally, providers must inform their professional Liability Insurance carrier about including AAI into clinical practice. In addition to informed consent documents, many providers choose to include a hold harmless waiver, which in some instances may limit the AAI provider's liability. When possible, providers should include their agency/institution's legal team when developing AAI policies, procedures, and documentation. Future Directions and Resources This manuscript serves as a conceptual and informative resource for counselors and counselor educators interested in integrating AAI with trauma-informed counseling and crisis response. With appropriate training and expertise, a professional counselor may incorporate AAI interventions to treat trauma-related symptoms such as anxiety, isolation, and feelings of danger and vulnerability while simultaneously addressing the critical aspect of the therapeutic relationship and including body-focused and experiential interventions. The authors hope to inform counselors of a potentially valuable approach to providing trauma-informed care and to raise awareness about the highly specialized nature of AAI. As the topic of AAI remains underrepresented in counseling literature, more empirical literature is needed in the area of AAT-C and AACR in trauma-informed counseling. For more information about AAT-C, interested readers may refer to the American Counseling Association's resources, which include a practice brief on animal-assisted therapy (http://www.counseling.org/knowledge-center/practice-briefs) and the AnimalAssisted Therapy in Mental Health Interest Network (https://www.counseling.org/acacommunity/aca-groups/interest-networks#Animal). For further information on AAI, readers may refer to Pet Partners, Inc. (http://www.petpartners.org), Therapy Dogs International (http://www.tdi-dog.org), or the Center for Human-Animal Interventions (http://wwwp.oakland.edu/nursing/continuing-education/animalassistedtherapy). To locate an appropriately qualified AACR team, readers may contact the National Crisis Response Canine Teams (http://www.crisisresponsecanines.org/contact.html) and Hope Animal-Assisted Crisis Response (http://hopeaacr.org/). 11
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Ideas and Research You Can Use: VISTAS 2016 Stewart, L. A. (2014). Competencies in animal-assisted therapy in counseling: A qualitative investigation of the knowledge, skills, and attitudes required of competent animal-assisted therapy practitioners (Unpublished doctoral dissertation). Georgia State University, Atlanta, GA. Stewart, L., Chang, C., Jaynes, A. (2013, May). Creature comforts. Counseling Today. Retrieved from http://ct.counseling.org/2013/05/creature-comforts/ Stewart, L., Chang, C., & Rice, R. (2013). Emergent theory and model of practice in animal-assisted therapy in counseling. Journal of Creativity in Mental Health, 8(4), 329­348. Sypniewski, S. (2011). How the therapy dogs saved us: Behind the scenes healing from 9/11. Retrieved from http://www.tdi-dog.org/OurPrograms.aspx?Page=DSRD+ (Disaster+Stress+Relief+Dogs) Uhernik, J. A. (2008). The counselor and the Disaster response team: An emerging role. In Vistas online. Retrieved from http://counselingoutfitters.com/vistas/vistas08/ Uhernik_Article_30.pdf van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York, NY: Viking Penguin. Yorke, J., Adams, C., & Coady, N. (2008). Therapeutic value of equine-human bonding in recovery from trauma. Anthrozoos, 21(1), 17-30. VanFleet, R. (2008). Play therapy with kids & canines: Benefits for children's developmental and psychosocial health. Sarasota, FL: Professional Resource Press. Note: This paper is part of the annual VISTAS project sponsored by the American Counseling Association. Find more information on the project at: http://www.counseling.org/knowledge-center/vistas 14

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