Exploring best practices in animal- assisted therapy with children in the Western Cape JA Thompson 12024716 Dissertation submitted in partial fulfillment of the requirements for the degree Magister Artium in Psychology at the Potchefstroom Campus of the North-West University Supervisor: Dr L Wilson Co-supervisor: Mrs S Weideman April 2013 ii LETTER OF PERMISSION PERMISSION TO SUBMIT THIS DISSERTATION FOR EXAMINATION PURPOSES We, the supervisor and co-supervisor, hereby declare that the input and effort of Ms JA Thompson in writing this manuscript reflects research done by her on this topic. We hereby grant permission that she may submit this dissertation for examination in fulfilment of the requirements for the degree Magister Artium in Psychology. ................................................................ ...................................................... Dr L Wilson Mrs S Weideman Supervisor Co-supervisor iii Animals have an uncanny ability to pick up on your state of mind, especially if you are antagonistic or hostile. All it takes to make progress is an open-minded attitude, and with a bit of patience and persistence it eventually clicks into place. The best part is you will recognise it when it happens. Believe me anyone can do it and, as many people already know, it is so worthwhile. There are no deep secrets, no special abilities and definitely no psychic powers necessary. Lawrence Anthony in The Elephant Whisperer, 2010:196 In memory of: Oma, who taught me how to care for animals, and Carol Hilton-Barber, my dear friend, whose enthusiasm, love for life and passion for animal-assisted therapy, will always be remembered. iv DECLARATION I, Jennifer Anne Thompson, hereby declare that the dissertation entitled “Exploring best practices in animal-assisted therapy with children in the Western Cape” is my own work and that all the resources that were used or quoted have been included in the reference list. ………………………………………………….. Jennifer Anne Thompson April 2013 v ACKNOWLEDGEMENTS I would like to acknowledge the following people for their contribution towards the research: o My parents - thank you for all your love and support. o Nic - for your unending willingness to listen and help. o Anerene - thank you for helping me clarify and achieve my goals. o Michelle - thank you for taking an interest in animal-assisted therapy and for all the printing you did at the beginning of the study. o Sharon – thank you for trusting and teaching me. o All the people who believed I could complete this and helped me to believe the same - thank you for your support and prayers. o The professionals who took part in the research – thank you for your time and your valuable contribution to the study. o Lizane - thank you for being exactly what I needed you to be. vi ABSTRACT This dissertation serves as a report on the qualitative exploration of best practices in animal-assisted therapy (AAT) with children. The aim of the study was to explore and describe best practices in the field of AAT with children in the Western Cape. The research made use of the case study design, which offered the researcher the opportunity to interact with a small number of individuals and look for patterns in the research participants’ words and experiences. Four participants, who were trained mental health professionals and had offered AAT to children, were selected to participate in the research. A literature review of animal-assisted therapy and best practice provided a theoretical basis for the research. The history of AAT, the uses and benefits of AAT and the animals incorporated in AAT were explored. The term “best practice” and its application in mental health and AAT were also discussed. The verbatim transcriptions of the audiotaped data were analysed and interpreted using Interpretative Phenomenological Analysis (IPA) and an AAT conceptual framework (brought about by the literature review). Themes were developed from the empirical data and substantiated by the literature review. Five main themes emerged as a result of the analysis. The first theme, Training of the animal-assisted therapist, focused on both the mental health training and the AAT training of the therapist. The second theme, Training of animals incorporated in animal-assisted therapy, revealed the importance of training the animal to be included in AAT. The third theme, Different client populations in animal-assisted therapy, looked at which populations should be included, excluded or included and carefully managed during AAT. The fourth theme, Ethical considerations in animal-assisted therapy, revealed the importance of considering both the child’s and the animal’s welfare. The fifth theme, Regulation of animal-assisted therapy, gave a more in-depth description of the current regulation of AAT in the Western Cape and provided suggestions for the regulation of AAT. Based on the findings of the five themes, recommendations were made for best practice in AAT with children in the Western Cape. vii KEY TERMS Animal-assisted therapy Best practice Case study design Children Interpretative Phenomenological Analysis viii OPSOMMING Hierdie skripsie dien as ? verslag van ‘n kwalitatiewe ondersoek van beste praktyk in dier-gesteunde terapie met kinders. Die doel van die studie is om beste praktyk in die veld van dier-gesteunde terapie met kinders in die Wes- Kaap te eksploreer en beskryf. Die navorsing het ‘n gevallestudie ontwerp gebruik, wat die navoser ‘n geleentheid gebied het om met ‘n klein groepie individue te werk en die patrone in die deelnemers se woorde en ervarings te vind. Vier deelnemers, opgeleide geestegesondheid professionele persone wie dier-gesteunde terapie met kinders aangebied het, is geselekteer as deelnemers vir die studie. ‘n Ondersoek na dier-gesteunde terapie en “beste praktyk” het ‘n teoretiese basis vir die navorsing verskaf. Die geskiedenis van dier-gesteunde terapie, die gebruike en die voordele van dier-gesteunde terapie asook die diere wat gebruik word in dier-gesteunde terapie is geëksploreer. Die term beste praktyk en die gebruike daarvan in geestesgesondheid en dier-gesteunde terapie is ook bespreek. Die verbatim transkriberings van die onderhoude is ge-analiseer en geïnterpreteer deur middel van Interpretatiewe Fenomenologiese Analise (IPA) en ‘n dier-gesteunde terapie konsepsuele raamwerk. Temas is ontwikkel deur middel van die empiriese data wat ingesamel is en gestaaf is deur die literatuur ondersoek. Deur die data analise het vyf hoof temas na vore gekom. Die eerste tema, Opleiding van die dier-gesteunde terapeut, het op die geestegesondheid opleiding en die dier-gesteunde terapie opleiding van die terapeut gefokus. Die tweede tema, Opleiding van diere wat in dier- gesteunde terapie gebruik word, het die belangrikheid van die opleiding van hierdie diere ingesluit. Die derde tema, Verskillende kliënte groepe in dier- gesteunde terapie, het gefokus op watter groepe moet ingesluit of uitgesluit moet word in dier-gesteunde terapie asook watter kliënte met omsigtheid ingesluit kan word. Die vierde tema, Etiese oorwegings in dier-gesteunde terapie, het die belangrikheid om albei die kind en die dier se welsyn te ix oorweeg beklemtoon. Die vyfde tema, Regulasie van dier-gesteunde terapie, het ’n meer in-diepte beskrywing van die huidige regulasie van dier-gesteunde terapie in die Wes-Kaap voorsien asook voorstelle vir die regulasie van dier- gesteunde terapie. Gebasseer op die bevindings van die vyf temas, is aanbevelings vir beste praktyk in dier-gesteunde terapie met kinders in die Wes-Kaap gemaak. SLEUTELTERME Beste praktyk Dier-gesteunde terapie Gevallestudie ontwerp Interpretatiewe Fenomenologiese Analise Kinders x CERTIFICATE OF EDITING xi TABLE OF CONTENTS Page LETTER OF PERMISSION ii DECLARATION iv ACKNOWLEDGEMENTS v ABSTRACT vi OPSOMMING viii CERTIFICATE OF EDITING x LIST OF FIGURES xviii LIST OF TABLES xix LIST OF ADDENDA xx CHAPTER ONE 1. INTRODUCTION TO THE STUDY 1 1.1 Introduction and problem statement 1 1.2 Research question 3 1.3 Aim and objectives 3 1.4 Research methodology 4 1.4.1 Research approach 4 1.4.2 Research design 4 1.4.3 Sampling and sampling method 5 1.4.3.1 Method and criteria for selection of participants 5 1.4.4 Data collection 6 1.4.5 Data analysis 6 1.5 Trustworthiness 7 1.6 Ethical aspects 7 1.7 Definitions of terminology 9 1.7.1 Animal-assisted therapy 9 1.7.2 Best practice 9 1.7.3 Children 9 1.7.4 Western Cape 10 1.8 Structure of dissertation 10 1.9 Summary 10 xii CHAPTER TWO 2. ANIMAL-ASSISTED THERAPY 11 2.1 Introduction 11 2.2 Animal-assisted therapy 11 2.3 The history of animal-assisted therapy 13 2.4 Research in animal-assisted therapy 14 2.5 Types of animals included in animal-assisted therapy 16 2.5.1 Animal-assisted therapy with dogs 16 2.5.2 Animal-assisted therapy with horses 16 2.5.3 Animal-assisted therapy with other animals 16 2.6 The benefits of animal-assisted therapy 18 2.6.1 Physical benefits of AAT 18 2.6.2 Psycho-social benefits of AAT 19 2.6.3 Animal-assisted therapy aids the therapeutic process 19 2.6.3.1 AAT helps to build rapport and trust between therapist and client 19 2.6.3.2 AAT creates a safe and supportive environment in therapy 20 2.6.3.3 AAT can serve as a model for a healthy relationship 21 2.6.3.4 AAT provides the opportunity to master certain skills and improve self-esteem 21 2.7 Risks involved in animal-assisted therapy 22 2.7.1 Health risks 22 2.7.2 Physical safety risks 22 2.7.3 Emotional safety risks 23 2.7.4 Clients with contraindications for AAT 23 2.8 Animal-assisted therapy in different settings 23 2.8.1 AAT in institutional settings 24 2.8.2 AAT in private practice 25 2.8.2.1 AAT offers an opportunity for creative assessment 25 xiii 2.8.2.2 AAT provides the opportunity to role-play 26 2.8.2.3 AAT provides the opportunity to project onto another living being 26 2.8.2.4 AAT offers creative ways to assist the client to share feelings 26 2.9 Conclusion 26 CHAPTER THREE 3. BEST PRACTICE WITHIN ANIMAL-ASSISTED THERAPY 28 3.1 Introduction 28 3.2 Best practice 28 3.2.1 Criteria used to determine best practice in a professional field 29 3.2.1.1 Acceptance among practitioners 30 3.2.1.2 Legally solid 30 3.2.1.3 Best outcomes 30 3.2.1.4 Consistent outcomes 30 3.2.1.5 Best value for money 30 3.2.1.6 Best fit 30 3.2.1.7 Consistency with local and overseas standards 30 3.2.1.8 Adaptability 30 3.2.1.9 Stakeholder acceptability 30 3.3 Best practice in mental health 30 3.3.1 Professional code of conduct in mental health 31 3.4 Best practice in animal-assisted therapy 32 3.5 The future of best practice in animal-assisted therapy 36 3.6 Conclusion 37 xiv CHAPTER FOUR 4. CHILDREN IN THE WESTERN CAPE AND AVAILABLE SUPPORT SERVICES 38 4.1 Introduction 38 4.2 South Africa 38 4.3 The province of the Western Cape 39 4.4 Children in the Western Cape 40 4.4.1 Schooling 40 4.4.2 Living arrangements 41 4.4.3 Child abuse, domestic violence and divorce 41 4.4.4 Supportive services for children in the Western Cape 41 4.5 Conclusion 42 CHAPTER FIVE 5. RESEARCH METHODOLOGY 43 5.1 Introduction 43 5.2 Aim of the study and research question 43 5.3 Research approach 44 5.4 Research design 45 5.5 Sampling and sampling method 46 5.5.1 Method and criteria for selection of participants 46 5.5.2 Process of selection 47 5.6 Data collection 47 5.6.1 Method of data collection 48 5.6.2 Semi-structured one-on-one interviews 48 5.6.3 Reflective notes 50 5.6.4 Field notes 50 5.7 Data analysis 50 5.8 Trustworthiness 53 5.8.1 Credibility 53 5.8.2 Transferability 54 5.8.3 Dependability 54 5.8.4 Confirmability 54 xv 5.9 Ethical considerations 55 5.9.1 Informed consent 55 5.9.2 Action and competence of the researcher 55 5.9.3 Release or publication of findings 56 5.9.4 Confidentiality and violation of privacy 56 5.9.5 Harm to participants 56 5.9.6 Feedback to participants 57 5.9.7 Deception of participants 57 5.9.8 Ethics in analysing and reporting 57 5.10 Conclusion 58 CHAPTER SIX 6. EMPIRICAL DATA AND LITERATURE CONTROL 6.1 Introduction 59 6.2 Participants 59 6.3 Findings of the Interpretative Phenomenological Analysis (IPA) 61 6.3.1 Theme 1: Training of the animal-assisted therapist 62 6.3.1.1 Sub-theme 1.1: Training as a mental health professional 62 6.3.1.2 Sub-theme 1.2: Training to work with animals 62 6.3.2 Theme 2: Training of animals incorporated in animal-assisted therapy 64 6.3.2.1 Sub-theme 2.1: Training dogs for AAT 65 6.3.3 Theme 3: Animal-assisted therapy and different client populations 66 6.3.3.1 Sub-theme 3.1: Populations included in AAT 67 6.3.3.2 Sub-theme 3.2: Populations excluded from AAT 69 6.3.3.3 Sub-theme 3.3: Populations requiring specialised management during AAT 70 xvi 6.3.4 Theme 4: Ethical considerations in animal- assisted therapy 71 6.3.4.1 Sub-theme 4.1: Ethical considerations concerning the child 71 6.3.4.2 Sub-theme 4.2: Ethical considerations concerning the animal 73 6.3.5 Theme 5: Regulation of animal-assisted therapy 75 6.3.5.1 Sub-theme 5.1: Current regulation of AAT in the Western Cape 75 6.3.5.2 Sub-theme 5.2: Suggestions for regulation 76 6.4 Conclusion 77 CHAPTER SEVEN 7. EVALUATION OF THE RESEARCH, CONCLUSIONS AND RECOMMENDATIONS 78 7.1 Introduction 78 7.2 Evaluation of the research 78 7.2.1 Aim of the research 79 7.2.2 Objectives of the research 79 7.2.1.1 Objective one 79 7.2.1.2 Objective two 79 7.2.3 The research question 80 7.3 Conclusions from the literature review 80 7.4 Findings of the research study 83 7.5 Conclusions of the study 85 7.6 Possible contributions of the research 87 7.7 Possible limitations and strengths of the research 88 7.7.1 Possible limitations of the research 88 7.7.1.1 Gender of the participants 88 7.7.1.2 The sample size 89 7.7.1.3 Researcher bias 89 7.7.2 Possible strengths of the research 89 7.7.2.1 Consolidation of study findings 89 xvii 7.7.2.2 Rich and detailed descriptions 89 7.8 Recommendations 89 7.8.1 Recommendations for training in AAT 89 7.8.2 Recommendations for further research 90 7.8.3 Recommendations for ethical considerations in AAT with children 90 7.8.4 Recommendations for the regulation of AAT 90 7.8.5 Recommendations for best practice in AAT with children 91 7.9 Closing remarks 91 REFERENCE LIST 92 xviii LIST OF FIGURES Page Figure 3.1: The hierarchy of evidence (Fine, 2010:558) 36 Figure 6.1: Overview of themes and sub-themes 61 xix LIST OF TABLES Page Table 2.1: Comparison of animal-assisted activities and animal- assisted therapy (Pet Partners, 2012:1) 12 Table 6.1: Summary of participants’ details 60 xx LIST OF ADDENDA Page Addendum 1: Example of the semi-structured interview schedule 116 Addendum 2: Consent form 117 Addendum 3: Biographical questionnaire 121 Addendum 4: Principles in animal-assisted therapy programmes 122 Addendum 5: Criteria used in the Kauffman Best Practices Project 124 Addendum 6: First theme: Training the therapist 125 Addendum 7: Second theme: Training the animal 127 Addendum 8: Third theme: Different client populations and AAT 128 Addendum 9: Fourth theme: Ethical considerations in AAT 130 Addendum 10: Fifth theme: Regulation of AAT 131 1 CHAPTER ONE INTRODUCTION TO THE STUDY 1.1 INTRODUCTION AND PROBLEM STATEMENT Animal-assisted therapy (AAT) is a form of therapy defined as “a goal directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/human services professional with specialized expertise and within the scope of practice of his/her profession” (Pet Partners, 2013:1). During AAT in mental health treatment, both the professional and animal(s) work together as a team, intervening in specialised ways to further the accomplishment of therapeutic goals such as self-efficacy, attachment/relationship, empathy, self-regulation and problem resolution (VanFleet, 2008a:9; Fine, 2010:174). AAT is becoming “recognised as a treatment modality much like dance, music, art and poetry therapy” (Fine, 2000:115). As an adjunct to traditional forms of therapy, AAT can be applied across a wide range of psychotherapeutic, social and clinical contexts, such as when working with AIDS clients and individuals living with terminal illnesses (Fine, 2000:221); clients dealing with psychological issues of attachment and trust; relationship problems; anger, rage and aggression; loss and grief; depression; and boundary issues (VanFleet & Faa-Thompson, 2010:6). VanFleet (2008a) asserts that AAT improves self-image and confidence and also facilitates the development of empathy and caring for others (VanFleet, 2009). Literature suggests that animals can be considered beneficial adjuncts in the establishment of a therapeutic relationship between the client and the therapist (Melson, 2001; Odendaal, 2002; Sentoo, 2003; Trotter, 2012; VanFleet, 2010; Webb, 2002; Zugich, Klontz & Leinart, 2002). A number of people and organisations are currently offering AAT in South Africa (SA). Although these professionals are registered with a council that governs their professional work in general, there is currently no structure in place that governs animal-assisted interventions per se. Currently, no 2 influence can be exerted over persons offering this service independently, barring peer group advice and feedback. It seems that, due to the lack of regulation in the field, both mental health professionals and non-professionals are practising AAT in South Africa. It is therefore impossible to guarantee the standard or efficacy of practice. This could result in unethical conduct and cause potential harm to the clients or the animals involved in AAT. During the literature research, the researcher was unable to find research on the manner in which professionals in SA utilise AAT with children. This lack of knowledge could potentially affect the professional who might not be able to work effectively with the child or the child might not be able to experience a therapeutic modality that could possibly aid the attainment of their therapeutic goals. The researcher intends to explore and describe the best practices as experienced by professionals, either Registered Counsellors or Psychologists (registered with the Health Professions Council of South Africa) or social workers (registered with the South African Council for Social Workers) utilising animal-assisted therapy (AAT) with children aged five to eighteen years in the Western Cape, SA, with the intention of raising awareness and contributing to the dialogue of AAT within a therapeutic context in South Africa. For the purpose of this study, “best practice” can be defined as the method and techniques that have “consistently shown results superior to those achieved [by] other means” (Business Dictionary, 2011). VanFleet (2008a) is of the opinion that “although enthusiasm for AAT is widespread and empirical studies have shown its potential value, more research on its processes, outcomes and applications will strengthen its place in mental health treatment.” Rump (2008:18) supports this by stating that research is needed to contribute to the awareness of AAT in order to “foster understanding and acceptance of this therapeutic aid” in South Africa. The National Research Foundation (2011) listed the following research projects: “The use of animal- facilitated play therapy with the learner with autism” (Rinquest, 2005), “Therapeutic horse riding to enhance the awareness of the child with fetal alcohol syndrome” (De Villiers, 2005) and “Animal-assisted therapy (AAT) – 3 what is it?” (Hettema, 2006). Further investigation led to the discovery of the following research completed in South Africa: “Physically disabled adolescents’ experience of therapeutic riding. A phenomenological investigation” (Weideman, 2007), “Exploring the use of animal-assisted therapy in educational psychology” (Scholtz, 2010), “Animal-assisted therapy – magic or medicine? “ (Odendaal, 2000), “The effect of a companion dog on depression and anxiety levels in residents of a long term care facility” (Le Roux & Kemp, 2009), “The effects of an animal-assisted reading program on the reading skills of third grade learners in a Western Cape primary school “ (Le Roux, 2013) and “The influence of animal-assisted play therapy on the self-esteem of adolescents with special needs” (Sentoo, 2003). 1.2 RESEARCH QUESTION The research question defines the focus of the research problem (Mouton, 2001:53) and was formulated as follows: What are the best practices utilised for animal-assisted therapy with children in the Western Cape? 1.3 AIM AND OBJECTIVES Fouché and De Vos (2011:94) indicate that the purpose or the aim of a study refers to why something is done or why it exists. This study aimed to explore and describe best practice in the field of AAT with children in the Western Cape – to document, identify categories of meaning and generate hypotheses for further research (Marshall & Rossman, 2011:69). This study furthermore aimed to add to the current research in AAT in South Africa and contribute to dialogue with regard to best practice in AAT with children in the Western Cape. To achieve the above-mentioned aim, the following objectives were formulated: To explore and describe best practices as utilised by professionals offering animal-assisted therapy to children in the Western Cape. 4 To gather descriptions and formulate conclusions regarding the best practices for animal-assisted therapy as provided by professionals working in the context of the Western Cape. 1.4 RESEARCH METHODOLOGY The research methodology of a study refers to the research approach, research design, sampling method, data collection, data analysis and the ethical aspects pertaining to the study (Fouché & Delport, 2011:74). The following section will discuss the research methodology of the present study in more detail. 1.4.1 Research approach A qualitative approach was used in order to gain in-depth knowledge about the research topic and to solve the problem at hand (Fouché & Delport, 2011:64; Patton, 2002:227). Fouché and Delport (2011:65) state that “the qualitative research paradigm, in its broadest sense, refers to research as it elicits participant accounts of meaning, experience and perceptions”. The research focused on the professionals’ perceptions of best practice in animal- assisted therapy. Descriptive and exploratory research was utilised, as information in this new area of interest was limited (Fouché & De Vos, 2011:95) and in an attempt to gain new insight into the use of AAT with children in the Western Cape. 1.4.2 Research design The case study strategy, and more specifically the collective case study design, was the research design used in this research. The research design provided the plan outline of how the observations were made and how the project was carried out (Fouché, Delport & De Vos, 2011:143). The case study design provided the researcher with the opportunity for interaction with a small number of individuals, so as to look for patterns in the research participants’ words, actions and experiences (Fouché & Schurink, 2011:320). 5 1.4.3 Sampling and sampling method Sampling refers to experiencing a small part or portion in order to gain an understanding of a whole. In qualitative research, non-probability sampling is “used almost without exception” (Strydom & Delport, 2011:391) because it results in the accumulation of rich data. The method and criteria for selecting the participants that formed the sample in the current study will be discussed in the following section. 1.4.3.1 Method and criteria for selection of participants The term universe “refers to all potential [participants] who possess the attributes in which the researcher is interested” (Strydom, 2011:223). The population sets the boundary on the universe. In the research, the population was limited to professionals utilising AAT with children in the Western Cape. The sample, or a small portion of the total set of persons (Strydom, 2011:224) was selected from the population. Due to the qualitative, exploratory and descriptive nature of the study, and the limited number of potential research subjects, the researcher used non-probability snowball sampling. Snowball sampling provided information-rich cases that added to an in-depth understanding of the divergent cases (Patton, 2002:244). Participants referred the researcher to other individuals that met the criteria of the study, the researcher continued with snowball sampling until no new cases were found (Strydom, 2011:233). The inclusion criteria for the sample were the following: • Participants had to be trained and certified to offer mental health therapy, either Registered Counsellors or Psychologists (registered with the Health Professions Council of South Africa) or social workers (registered with the South African Council for Social Workers); • Participants had to have the experience of offering animal-assisted therapy to children residing in the province of the Western Cape, South Africa; • Participants needed to be able to converse comfortably in English as translation could result in vital information getting lost; 6 • Participants had to be willing and comfortable to discuss their experiences of providing AAT. 1.4.4 Data collection Semi-structured one-on-one interviews, as the main method for data collection, were used (Greeff, 2011:352). The semi-structured interviews provided the researcher the opportunity to interact with each participant individually and obtain a detailed account of their perceptions on best practices of AAT. Semi-structured interviews provided more flexibility and enabled the researcher to ask open-ended questions as well as probe for more information, when required (Greeff, 2011:351). During the semi-structured interviews the researcher used an interview schedule (Delport & Roestenburg, 2011:186). The interview schedule (Addendum 1) contained specific instructions, questions and transition phrases. The interview questions were organised around the area of interest. Field notes (Creswell, 2005:189) in the form of observational notes were made on each interview (Creswell, 2005:189; Patton, 2002:262). Interviewing with the divergent cases continued until data saturation, the point at which new interviews would no longer have produced new information, was reached (Yin, 2009:15). The participants also completed a biographical questionnaire (Addendum 3). 1.4.5 Data analysis Interpretative Phenomenological Analysis (IPA) and an AAT conceptual framework (brought about by the literature review) guided the analysis and interpretation of the data. IPA is one of the newest qualitative approaches in data analysis and has become increasingly popular in areas such as health and counselling psychology (Clarke, 2010:58). IPA would provide a comprehensive examination of the therapists’ experiences of offering animal- assisted therapy and their views of best practice in the field of animal-assisted therapy. The data analysis aimed to reduce the large amount of raw information, filter the significant data from the trivial data, identify the 7 noteworthy patterns in the data and construct a framework that would convey the essence of what the data revealed (Schurink, Fouché & De Vos, 2011:397). 1.5 TRUSTWORTHINESS The four constructs, credibility, transferability, dependability and conformability, as suggested by Lincoln and Guba (1999:397) were used in the research. These constructs were used to ensure trustworthiness and assisted in determining the “truth value” and soundness of the research (Schurink, Fouché & De Vos, 2011:419). A more detailed explanation on the constructs will be provided in chapter five (see 5.8). 1.6 ETHICAL ASPECTS Informed consent (Babbie, 2010:66) was obtained from each participant who participated in the study (see Addendum 2). Participants received their own copy of the consent form. The information regarding the rights of participants, the aim of the research, the risks and benefits, was clearly explained to each participant prior to the participant agreeing to take part in the study. It was stipulated that each participant had the choice whether or not to participate in the research (Strydom, 2011:116). Strydom (2011:123) emphasises the importance of sufficient skills and competencies in research. The researcher had sufficient skills through her studies in psychology, education, play therapy and AAT to conduct the research and received adequate supervision throughout the process. Bless, Higson-Smith and Kagee (2006:145) state the importance of the researcher’s ethical behaviour during the research. The researcher’s behaviour and actions were guided by the research ethics and ethical clearance was obtained from the ethical committee of NWU prior to the commencement of the study. Participants in the current study were informed of the reason for the research interviews and the possible publication of the results. Recordings of the interviews and the transcribed data have been safely stored (Oliver, 2003:90) by the researcher at the North-West University’s Centre for Child, Youth and 8 Family Studies. The participants were informed that the study is being submitted as a dissertation to North-West University as part of an MA (Psychology) degree. Publication credit has been given to all the individuals who have contributed to the research. The researcher respected each participant’s right to privacy and confidentiality. Strydom (2011:119) states that data should be handled in a confidential manner and dealt with sensitively; the researcher endeavoured to do this. The participants’ names were masked in the data by assigning a letter of the alphabet to each participant in the report. This was done in order to ensure that anonymity and confidentiality of all participants was maintained and pseudonyms were given in the event that a client was named, as suggested by Strydom (2011:119). Refusal of the individuals to participate in the study would have been respected, however all those approached chose to take part in the study. During the course of the current study the researcher was sensitive to the interests of the participants, ensuring that the participants were guarded against any form of physical discomfort or emotional harm. Strydom (2011:115) indicates the importance of this during research. Time for debriefing was made available, should any of the participants have experienced emotional harm during the interviews. The participants in the current study were given access to the research findings and the opportunity to comment on the findings and feedback regarding the results of the research was made available to each participant, as suggested by Oliver (2003:148). The current study did not involve any deception and the researcher was committed to being honest with the participants at all times. To the researcher’s knowledge, there was no deception of participants during the study. 9 1.7 DEFINITIONS OF TERMINOLOGY The following terms have been used throughout the dissertation. In order to ensure a complete understanding of the research process and the research findings, the terminology will be defined. 1.7.1 Animal-assisted therapy Animal-assisted therapy (AAT) is a form of therapy defined as “a goal-directed intervention in which an animal that meets specific criteria, is an integral part of the treatment process. AAT is directed and/or delivered by a health/human services professional with specialized expertise, and within the scope of practice of his/her profession” (Pet Partners, 2013:1). AAT is becoming “recognised as a treatment modality much like dance, music, art and poetry therapy” (Fine, 2000:115). During AAT, the professional and the animal(s) work together as a team, intervening in specialised ways to further the accomplishment of therapeutic goals such as self-efficacy, attachment/relationship, empathy, self-regulation and problem resolution (VanFleet, 2008a:9). 1.7.2 Best practice The term “best practice” suggests the quality of an exercise. In “The Concise Oxford Dictionary”, “best” is defined as “of the most excellent or outstanding or desirable kind” and “in the best manner” (The Concise Oxford Dictionary, 1992:104). Practice is defined as a “habitual action or performance” and “a repeated exercise in an activity requiring the development of skill” (The Concise Oxford Dictionary, 1992:935). The researcher understands best practice to be the most exemplary way of performing a task. 1.7.3 Children In the research, the term “children” referred to human beings between the ages of 5 and 18 (school-going age) and below the legal age of majority in South Africa. 10 1.7.4 Western Cape The province of the Western Cape is one of the nine provinces in South Africa. The total land area of the province is 129,462 square kilometres and the province is located in the most south-western corner of South Africa, at the tip of the African continent (South Africa.info, 2013:1). 1.8 STRUCTURE OF DISSERTATION Chapter one will introduce the purpose of the research, give a brief overview of the research methodology and define the terminology used in the research. Chapter two will discuss the history, uses and benefits of animal-assisted therapy and the animals incorporated in AAT in more detail. Chapter three will present a summary from the literature available regarding best practices. Chapter four will describe the context of the Western Cape province and chapter five will explain the research methodology and design used in the research. In chapter six, the empirical data and literature control will be presented. The final chapter will reflect on the results of the research, conclusions will be drawn and recommendations will be made. 1.9 SUMMARY Chapter one introduced the research and presented the problem statement and research question. The methodology used in the research was discussed and new terminology was defined. In chapter two, the focus will shift to animal-assisted therapy and the current literature available regarding this rapidly expanding field. 11 CHAPTER TWO ANIMAL-ASSISTED THERAPY 2.1 INTRODUCTION Animal-assisted therapy (AAT) has gained worldwide recognition over the last twenty years. Although there is evidence that AAT has a long history (Hooker, Freeman & Stewart, 2002:17), the use of AAT began to gain true momentum in the early 1990s and is thus considered a relatively new field. It has grown in popularity and has gained wide acceptance and is evolving into mainstream psychology (Uyemura, 2011:2). The notion of animals helping people with physical or emotional impairments and the anecdotal reports about the benefits of including animals in therapy has fuelled the development of the field, with research on AAT following behind at a slower pace (Eggiman, 2006:1). The following literature chapter will focus on AAT, the history of AAT, research in AAT, the types of animals included in AAT, institutional settings in which AAT is made use of, the benefits of AAT and the risks involved. 2.2 ANIMAL-ASSISTED THERAPY Originally labelled “pet therapy” (Fine, 2010:136) the term “animal-assisted therapy” has now been accepted as an umbrella term for psychologically, physically and developmentally therapeutic activities that include animals. Pet Partners (formerly known as The Delta Society), an American non-profit organisation that assists people to incorporate therapy, service and companion animals into their lives, defines AAT as: A goal-directed intervention in which an animal that meets specific criteria is an integral part of the treatment process. AAT is directed and/or delivered by a health/human service professional with specialized expertise, and within the scope of practice of his/her profession. AAT is designed to promote improvement in 12 human physical, social, emotional, and/or cognitive functioning (Pet Partners, 2013a:1). A distinction is drawn between animal-assisted therapy and animal-assisted activities. The latter refers to the inclusion of animals in activities that may have therapeutic value as an unintentional benefit but do not directly involve trained therapists, nor are the activities goal-directed (Matuszek, 2010:188). Animal-assisted activities (AAA) are primarily based on visitations. Volunteers take their trained and certified animals to institutions such as schools, hospitals and retirement homes where interaction with children, patients and the elderly is facilitated. However, according to Fine (2010:86), AAA may also include therapeutic horse riding programmes, or live-in companion animals. The former, AAT, comprises outcome-based activities that are in line with a therapeutic goal and is presented by a trained, registered therapist. The following comparison in Table 2.1 illustrates the differences between AAA and AAT. AAA AAT Casual “meet and greet” activities that involve animals and volunteers visiting people. Significant part of treatment plan for people who desire or need therapeutic intervention for physical, social, emotional or cognitive challenges. No specific treatment goals planned. Goals are stated for each session. Same activity can be used with many people. Individual treatment for each patient. Detailed notes not required. Notes on patient’s progress taken at each session. The content of the visit is spontaneous. Visits are scheduled, usually at set intervals. Visit can be as long or short as desired. Length of visit is pre-determined to best suit needs of the patient. Table 2.1. Comparison of AAA and AAT (Pet Partners, 2012:1) 13 According to Chandler (2011:4), AAT can alter the dynamics of a traditional therapy session in a number of ways. Children may be more motivated to attend and participate in therapy because of a desire to spend time with the therapy pet. The child’s focus may be temporarily shifted away from pain because of the interaction with the therapy pet to the extent that they can work harder and longer in therapy and potentially gain more benefit in each session. Physical contact with the animal could offer the child healing nurturance and affection. Children may experience soothing comfort from petting or holding the therapy pet. The animal could give the child an experience of genuine acceptance. Children may be able to form a more trusting relationship with therapists who demonstrate by the way they interact with the therapy animal that they can be trusted. In many instances, based on the unique characteristics of the child’s conditions or needs, the child may be able to perform tasks and activities and reach goals that would not have been possible without the assistance of the animal. 2.3 THE HISTORY OF ANIMAL-ASSISTED THERAPY The first reported evidence of AAT was in Belgium in the ninth century (Matuszek, 2010:190) and there is evidence that animals were included in therapy in the 1790s at the York Retreat, an asylum in England (Hooker et al., 2002:18; Melson, 2001:107). Bethal, a home for people living with physical impairments in Germany, introduced animals into their programme when it was founded in 1867 (Odendaal, 2002:60). In 1962 Boris Levinson, a psychologist in New York, documented his experiences with his “co-therapist” Jingles (Matuszek, 2010:190) in the paper entitled “The dog as co-therapist”. Levinson suggested that animals broke down psychological barriers, facilitated communication and helped to build the relationship between him and the children with whom he was working. In the 1970s, Prof. Samuel Corson and Dr Elizabeth Corson completed groundbreaking research that focused on the success of animals assisting in therapy with psychiatric patients because other forms of therapy had been ineffective (Beck & Katcher, 1996:134; Urichuk & Anderson, 2003:23). However, it was in the 1980s that AAT began to gain momentum (Odendaal, 14 2002:62). The Delta Society (now Pet Partners), which aims to support research and establish standards for AAT, was founded in the United States in the early 1980s. The International Association of Human-Animal Interaction Organizations (IAHAIO) a “global umbrella organization” (IAHAIO, 2012:1) that aims to unify all the human-animal interaction associations worldwide, was founded in 1990. IAHAIO conferences are held every three years and include papers from many European, Australasian and American countries – Africa has yet to be represented. 2.4 RESEARCH IN ANIMAL-ASSISTED THERAPY Although there are many historical accounts of animals assisting humans in recovery, there is very little empirical research available for the period prior to 1980. In 1980, Friedmann, Katcher, Lynch and Thomas (1980:311) completed their now-famous research entitled “Animal companions and one- year survival of patients after discharge from a coronary unit”. The research suggested that pet owners had a greater chance of surviving coronary artery disease than non-owners. Research began to increase in the 1980s and a few books were written, such as Janet Ruckert’s The four-footed therapist - How your pet can help solve your problems (Odendaal, 2002:69). During the 1990s, a number of books were written on AAT such as Shari Bernard’s Animal-assisted therapy – A guide for health care professionals and volunteers (Odendaal, 2002:73) but much of the research was based on anecdotes and observations made by those involved in AAT and were not regarded as true scientific research. Research in AAT has become more specific over the last decade, with the focus on identifying what makes AAT effective. In 2002, a South African researcher, Dr Johannes Odendaal made use of scientific research methods to establish a physiological basis for the benefits of positive human-animal interaction. Odendaal (2002:137) discovered that there was a decrease in blood pressure and an increase in the levels of the hormone oxytocin in both the dogs and the humans after the human-animal interaction. Oxytocin is known to lower heart rate and stress hormones in humans and animals and is believed to make people more trusting and trustworthy (Olmert, 2009:xv). 15 The humans’ blood levels of oxytocin in Odendaal’s research almost doubled after positive human-animal interaction. AAT has been found to be effective with a number of populations such as the elderly (Dembicki & Anderson, 1996:30; Harris, Rinehart & Gerstman, 1993:27; Krause-Parello, 2012:201), children who have been abused (Parish- Plass, 2008:12; Reichert, 1998:177) and adolescents living with behavioural problems, including ADHD (Katcher & Wilkins, 1998:194) and conduct disorder (Lange, Cox, Bernert & Jenkins, 2006:18). AAT has also been found to be valuable for people living with Alzheimer’s disease (Hooker, Freeman & Stewart, 2002:20; Hardiman, 2010:14) and autism (Reynolds, 2009:14) as well as those who suffer from affective disorders, anxiety (Hoffman, Lee, Wertenauer, Ricken, Jansen, Gallinat, & Lang, 2009:147), aphasia, dementia (Wlliams & Jenkins, 2008:34), depression (Souter & Miller, 2007:178), personality disorders and schizophrenia (Hardiman, 2010:15; O’Haire, 2010:231). O’Haire (2010:231) suggests that we have yet to discover the true potential of AAT and that the possibilities of incorporating animals into interventions that improve human health appear to be endless. Much of the AAT research has begun to focus on establishing a framework for AAT. Geist (2011:243) made use of the Attachment Theory in an attempt to explain why AAT could be effective in improving the socio-emotional and behavioural functioning of students with emotional disturbances. Recent research by O’Callaghan and Chandler (2011:92) identified ten therapeutic intentions therapists have, such as enhancing trust and facilitating insight, and eighteen techniques therapists use in AAT in an effort to educate therapists on how to incorporate AAT into their practice. Examples of the techniques identified include reflecting on the client’s relationship with the animal and encouraging the client to tell the animal about stresses and concerns. Although a fair amount of research has been done in the field of AAT (Berget & Grepperud, 2011; Braun, Stangler, Narveson & Pettingell, 2009; Cournoyer & Uttley, 2007; Hoffman et al., 2009; Klontz, 2007; Tsai, Friedmann & Thomas, 2010) more is required in order to establish credibility for the field, 16 scientific proof is needed to explain why, how and to whom AAT is beneficial. Fine (2010:170) suggests that there needs to be a more appropriate bridge between clinical practice and best practice research. Such research is required in order to develop more rigid guidelines for therapists who are offering this form of therapy in their private practices (Turner, Wilson, Fine & Mio, 2010:569). Guidelines for the implementation of AAT in private practice should identify the conditions necessary to preserve the health and safety of the animals and clients (Mallon, Ross, Klee & Ross, 2010:143); these guidelines would be based on the principles that underlie AAT. A “principle” is defined by “The Concise Oxford Dictionary” (1992:948) as “a fundamental truth or law as the basis of reasoning or action”. Principles do not stipulate how you perform a task, they merely provide the reasoning behind the behaviour. An example of the principles of AAT in the North American context, adapted from Mallon, Ross, Klee and Ross (2010:143), is provided in Addendum 4. 2.5 TYPES OF ANIMALS INCLUDED IN ANIMAL-ASSISTED THERAPY AAT includes a variety of animals, both wild and domestic. The animals that have lived alongside humans for many years, namely dogs, cats and horses, appear to be the animals most commonly incorporated into AAT (Melson, 2001:105). 2.5.1 Animal-assisted therapy with dogs Centuries of work alongside their human companions have resulted in a strong interspecies bond, thus it is not surprising to find that dogs are the animals most commonly included in animal-assisted therapy (Urichuk & Anderson, 2003:30). A survey of American and Canadian humane societies indicated that 96% of the animals involved in AAT were either dogs or cats (Beck & Katcher, 1996:136). VanFleet (2008c:18) found that dogs are the most commonly chosen animal for animal-assisted play therapy due to their strong play drive, their willingness to engage in different activities and their trainability. 17 2.5.2 Animal-assisted therapy with horses Horses are herd animals and thus are known to be very social and sensitive creatures, exhibiting a heightened sense of awareness. VanFleet and Faa- Thompson (2010:12) are of the opinion that horses bring unique properties to the psychotherapy process. One of the greatest opportunities a horse can offer is its sheer size, power and presence, which can elicit a number of emotions in clients. The involvement of equines in animal-assisted play therapy and other mental health work has a strong sensory component – touch experiences that could not be appropriately offered by a human therapist are permissible (VanFleet, 2010:13). Horses provide many opportunities for metaphorical learning and elicit a range of emotions and behaviours in humans, which can be used as a catalyst for personal awareness and therapeutic growth (Klontz, 2007:257-267; VanFleet, 2010:13). 2.5.3 Animal-assisted therapy with other animals Cats are often included in AAT, especially with elderly persons who would benefit more from a creature that is smaller and calmer than a dog and can be easily held and handled. Small, domesticated animals such as rabbits, ferrets, guinea pigs and chinchillas (Melson, 2001:119) offer opportunities for children to take responsibility and practise nurturance; they can also offer physical comfort during difficult moments in therapy. Green Chimneys Children’s Services, a residential care facility for children with emotional and behavioural impairments in Brewster, New York State, offers AAA and AAT with rabbits, ferrets, goats and sheep, alpacas and donkeys (Melson, 2001:100). Dolphin-assisted therapy remains a controversial form of AAT and according to Melson (2001:116) presents an ethical dilemma. It is felt that the inclusion of dolphins or any wild animal such as snakes, spiders, birds of prey, foxes (Pira, Stefanini, Meers, Normando, Samuels & Odberg, 2010:49) and elephants in therapy, is unsafe for the client and exploitative of the animal (Melson, 2001:116). This point of view is debatable, as strict ethical guidelines that are implemented with respect for all parties involved can allow for 18 powerful inter-species contact. It is however paramount that the safety of all concerned receives priority and that very clear boundaries be put into practice to ensure this. 2.6 THE BENEFITS OF ANIMAL-ASSISTED THERAPY Hamama, Hamama-Raz, Gadan, Greenfield, Rubinstein and Ben-Ezra (2011:1976) suggest that the goals in AAT are to: • improve socialisation and communication; • reduce isolation, boredom and loneliness; • brighten affect and mood, lessen depression, • provide pleasure and affection; • address grieving and loss issues; • improve self-esteem, be presented with opportunities to succeed and feel important, and improve feelings of self-worth; • improve cooperation and problem-solving ability; • improve concentration and attention, and increase engagement; • improve expression of feelings; • reduce general anxiety; • improve an ability to trust; • learn appropriate touch. Research has shown that AAT results in physical, mental and socio-emotional benefits such as reduced blood pressure, reduced anxiety, increased focus and attention, greater self-control and increased trust and empathy (Hoffman, et al., 2009:145; O’Callaghan & Chandler, 2011:92). 2.6.1 Physical benefits of animal-assisted therapy AAT can lead to physical changes in the human body, these include a decrease in blood pressure and cortisol and an increase in dopamine and oxytocin levels (Odendaal, 2002:137). Research has shown that the health benefits of AAT also include lowered blood pressure and heart rate (Van Pelt, 2010:8). Odendaal (2002:137) concluded that positive human-animal interaction resulted in a decrease in blood pressure and cortisol and an increase in dopamine and oxytocin in both the dog and the human 19 participants that took part in the study. Many of the advocates for AAT feel that oxytocin is the scientific answer that explains some of the benefits of AAT and that the psycho-physiological, emotional and physical component to interacting with an animal is due to an increase in oxytocin levels (Hardiman, 2010:14; Shallcross, 2011:2). Oxytocin is recognised as one of the best, most powerful, magnificent, healthy social hormones we have and it has been shown to be the hormone most affected in a positive way through human- animal interaction (Shallcross, 2011:3). Uyemura (2011:3) states that animal- assisted therapy is here to stay simply because the oxytocin effect is undeniable. 2.6.2 Psycho-social benefits of animal-assisted therapy The mental benefits of AAT include reduced anxiety, grief and isolation (Krause-Parello, 2012:195). Hoffman, Lee, Wertenauer, Ricken, Jansen, Gallinat and Lang (2009:147) found that thirty minutes with a therapy dog significantly decreased anxiety in the acutely depressed patients who partook in the study. Yamauchi and Pipkin (2008:113) state that children in Arkansas Children’s Hospital who participated in AAT required less pain medication than the children in the control group, who did not receive AAT. Braun, Stangler, Narveson and Pettingell (2009:105) reported that children who took part in AAT prior to painful medical procedures, displayed decreased levels of distress, children with post-traumatic stress disorder appeared calmer as a result of AAT and children with pervasive developmental disorders exhibited increased attention and positive behaviours. 2.6.3 Animal-assisted therapy aids the therapeutic process. The socio-emotional benefits of AAT include greater self-control, increased trust, empathy and teamwork and improved problem-solving skills. 2.6.3.1 AAT helps to build rapport and trust between therapist and client O’Callaghan (2008:73) found that some of the therapeutic purposes for integrating AAT were to build rapport in the therapeutic relationship, whilst enhancing the child’s social skills, enhancing trust within the environment, and 20 facilitating the feeling of safety in the therapeutic environment. The psychotherapist Boris Levinson (Melson, 2001:109) is quoted as having said, “eventually, some of the affection elicited by the dog spilled over onto me and I was consciously included in the play.” Children who no longer trust people often find it easier to trust an animal and then have the opportunity to generalise this trust as a whole, including the mental health professional whom the animal trusts (Kirby, 2010:62), thus a therapist who is assisted by an animal is regarded as less “dangerous” (Beck & Katcher, 1996:128). O’Callaghan and Chandler (2011:100) found that, in their sample, enhancing therapeutic rapport was a prominent intention when therapists chose to include AAT in therapy sessions. Using AAT to build rapport and establish trust with clients appears to be the primary intention of therapists working with resistant clients. Therapists are seeing the dramatically positive effects of working with a therapy animal with dysfunctional or resistant clients, in comparison to work done without a therapy animal (Chandler, 2011:4). 2.6.3.2 AAT creates a safe and supportive environment in therapy Successful therapy can only occur when children feel safe in their environment (Urichuk & Anderson, 2003:39). O’Callaghan found in her research that participants reported how the therapy animals’ presence within the therapeutic environment can create a sense of safety and a feeling of warmth and acceptance for clients (O’Callaghan, 2008:74). In a study on abused Japanese children and their experiences with animals, Yamazaki (2010:63) found that maltreated children are more likely to engage with animals and to rely on them for support more often than non-maltreated children. This finding was consistent with other studies (Eggiman, 2006:1; Parish-Plass, 2008:7; Schultz, Remick-Barlow & Robbins, 2007:265) that emphasised the acceptance and sense of self-esteem that animals can provide for abused children. A study of eighty children (aged seven to sixteen years) at Green Chimneys Children’s Services in New York State in 1994 found that the children were inclined to relate to the farm animals as one would to a confidential and nonjudgmental therapist (Parshall, 2003:48). The children reported an increased feeling of well-being and that they received 21 comfort from hugging the animals (Melson, 2001:104; Parshall, 2003:49). Geist (2011:254) considered the Attachment Theory to explain the benefits of AAT and concluded that, within the safety of the therapeutic environment, children can begin to experience a healthier expression of attachment with the therapy dog and ultimately the therapist. 2.6.3.3 AAT can serve as a model for a healthy relationship Animals provide opportunities and benefits that traditional therapy often does not (Kirby 2010; VanFleet, 2008b). The use of animals within a therapeutic context provides advantageous conditions: offering immediate feedback of the child’s behaviour from a third party (the animal); an opportunity to project onto an animate object that is not the mental health professional; and the experience of unconditional acceptance and love and a “pure” relationship with another being (Kirby, 2010). An animal can offer the opportunity for uncomplicated attachment and learning the skills of attachment from the relationship with an animal can serve as the building blocks for developing a relationship with other human beings (Pet Partners, 2013a). A mental health professional may also intentionally or unintentionally model certain behaviours with the therapy animal, in order to facilitate the client’s growth (O’Callaghan, 2008:20). 2.6.3.4 AAT provides the opportunity to master certain skills and improve self-esteem Working alongside a therapy animal often enhances the child’s confidence and belief in their abilities, providing them with a sense of control and ego- mastery. Whilst building the bond with the animal, the child experiences empathy and a sense of control, which ultimately will contribute to the child's self-esteem (Hamama et al, 2011:1976). Sentoo (2003) found that animal- assisted play therapy enhances self-esteem and VanFleet (2008a) asserts that AAT improves self-image and confidence as well as facilitating the development of empathy and caring for others (Cournoyer & Uttley, 2007:120; VanFleet, 2009). Turner, Stetina, Burger, Lederman Maman, Handlos and Kryspin-Exner (2009:93) discovered that animal-assisted competence training (a form of AAT) with children between the ages of five and seven can 22 positively influence children’s use of emotion regulation strategies and their ability to recognise emotions. Weideman (2007:iii) discovered that adolescents living with physical disabilities achieved personal growth, a sense of accomplishment, an improvement in confidence levels and thus improved self-esteem through their participation in therapeutic horse riding. 2.7 RISKS INVOLVED IN ANIMAL-ASSISTED THERAPY Fine (2010:185) cautions that, in the event that therapists do not have adequate training on how to incorporate AAT in their private practice, therapists may inappropriately apply AAT and receive poor results. Not only will therapists receive poor results, they may, in fact, cause harm. There are a number of risks that need to be considered and minimised in order for AAT to be effective. 2.7.1 Health risks The increase in AAT usage has highlighted the possible risk of diseases, known as zoonotic diseases (Hooker et al., 2002:21) being transmitted from the animal to the patient, especially in the health care setting (Fine, 2010:142). The foremost suggestion to prevent zoonosis is to develop and follow strict guidelines and protocol when working with therapy animals (Fine, 2010:143). It is interesting to note that Yamauchi and Pipkin (2008:113) found that not a single infection or adverse reaction had occurred over the six year period that four thousand children worked with therapy dogs in a children’s hospital in Arkansas. Researchers tend to agree that AAT is a therapeutic modality in which the benefits greatly outweigh the risks (Braun et al., 2009:108; Hooker et al., 2002:21). 2.7.2 Physical safety risks It is paramount that the physical safety of clients and animals be considered during an AAT session. Animals need to be trained and tested to ensure that they do not pose a threat to the safety of the client and clients need to be educated as to how to approach and interact with the therapy animal. The interaction between the client and the animal should be under the constant supervision of the therapist (American Veterinary Medical Association, 23 2011:2). A therapist, who does not have training to work with a particular animal, will include an animal handler as part of the therapeutic team. The handler’s role is to prepare the animal for the therapy sessions, to train, assess and groom the animal and see to its veterinary care (Fredrickson- MacNamara & Butler, 2010:127). 2.7.3 Emotional safety risks It is integral that best practice is followed in order to ensure the emotional safety of clients who receive AAT. For example, clients may perceive that an animal has rejected them, usually because of unrealistic expectations of the animal's behaviour toward them, and this can intensify low self-esteem (American Veterinary Medical Association, 2011:1). Therapists need to be aware of the emotional safety risks and take appropriate action, should the need arise. 2.7.4 Clients with contraindications for AAT There are times when AAT will not be beneficial, when the interaction between the client and the animal would be potentially harmful. According to The University of Texas Medical Branch Institutional Handbook of Operating Procedures (2000:2) clients who have allergies, a fear of animals, open sores or a weakened immune system would fall into this category and should not be permitted to interact with a therapy animal. Clients who are actively dangerous to themselves or other people, are medically unstable, delirious, dissociative, psychotic or extremely confused or are abusing a substance should also be precluded from an AAT session (PATH International, 2012) 2.8 ANIMAL-ASSISTED THERAPY IN DIFFERENT SETTINGS AAT, like other forms of therapy, aims to reach the child in order to gain a better understanding of his or her experiences, promote emotional expression and insight, which will result in change and ultimately improve the child’s quality of life (Parish-Plass, 2008:13). AAT has been found to be particularly effective with children, possibly as a result of children’s interest in animals as well as the common characteristics that children and animals share: their dependence on adults, their honest feedback and propensity to live in the 24 moment, their non-verbal and concrete method of communication and their ability to play naturally (VanFleet, 2010:6). 2.8.1 Animal-assisted therapy in institutional settings AAT has been found to be effective with adults in a number of institutional settings, such as prisons, retirement homes and hospices (Beck & Katcher, 1996:153; Matuszek, 2010:193; Van Pelt, 2010:8). In a survey conducted on nursing homes, retirement villages and institutions for the elderly or impaired in Brisbane, Australia, in 1991, it was found that 69% of the institutions had resident pets and 12% had made use of animal-assisted therapy programmes (Odendaal, 2002:75). Twenty-three (79%) of the twenty-nine Belgian detention facilities interviewed by Meers, Stefanini, D’Hanens, Normando, Samuels, Kalmar, & Odberg (2010:50) stated that they offer either AAA or AAT as part of their rehabilitation programmes. The institutions that formed part of the study either work with shelter animals (17%) or have residential animals (83%). A study in Australia in 1994 found that the female prison inmates demonstrated a decrease in depression and an increase in their self-esteem after working with therapy dogs for six months (Parshall, 2003:50). In Belgium, Pira et al. (2010:49) found that 85% of the 284 institutions (146 homes for the elderly, 18 centres for palliative care, 30 clinics, 65 institutions for people living with challenges and 72 centres for youth at risk) interviewed used some sort of animal-assisted intervention, either AAA or AAT. Copper Canyon Academy is a boarding school for girls aged 13–17 who require a structured therapeutic environment (Aspen Education, 2013). The school offers residents canine-assisted and equine-assisted therapy programmes and reports that participating in the programmes offers the students a “tremendous healing experience” (Aspen Education, 2013). Anderson and Olsen (2006:36) found that the presence of a dog in a classroom for children with severe emotional disorders contributed to an increase in the students’ emotional stability and led to a de-escalation of episodes of emotional crisis. 25 Research indicates that AAT decreases physiological arousal in hospitalised children thus it is useful in helping them cope better in a hospital setting (Tsai, Friedmann & Thomas, 2010:245). Arising from current research, it has now been suggested that AAT should be made available to children and adolescents with disabilities, spinal cord injury patients, and orthopeadic clients (Hooker et al., 2002:21). 2.8.2 Animal-assisted therapy in private practice AAT in private practice is most beneficial when it serves to support and augment the therapist’s work within his or her approach (Fine, 2010:171). Therapists incorporating AAT in their private practice generally rely on the therapy animal’s presence in the therapy room to decrease the initial reservations a client may have about therapy and to help build rapport with the client (Fine, 2010:174). Therapists working with children report the benefits of including animals in their private practice (Reichert, 1998:178; Rothe, Vega, Torres, Soler & Pazos, 2005:373; VanFleet, 2008c:19) highlighting that an animal provides an opportunity for the child to feel more at ease when establishing a relationship with the therapist and when sharing confidential information. In their research, O’Callaghan and Chandler (2011:90) found that mental health professionals who integrate AAT into their practice make use of at least eighteen techniques, for example, reflecting on a client’s relationship with the animal or encouraging the client to tell the animal about the concerns the client may have, and also at least ten intentions in their therapy. Apart from building rapport in the therapeutic relationship, the therapists’ intentions when choosing AAT included: facilitating insight, encouraging the sharing of feelings, enhancing the client’s social and relationship skills and an opportunity to model specific behaviours (O’Callaghan & Chandler, 2011:94). 2.8.2.1 AAT offers an opportunity for creative assessment Prothmann, Albrecht, Dietrich, Hornfeck, Stieber and Ettrich (2005:43) found that analysing the child–dog interaction can afford a valuable contribution to 26 the therapist’s psycho-diagnosis of a child or adolescent. How the child interacts with the animal can provide the therapist with valuable information about the child’s functioning and behaviour. 2.8.2.2 AAT provides the opportunity to role-play Children who have been traumatised often experience blockages when it comes to their emotions, thus they experience playing and imagining to be very difficult (Oaklander, 2006:24). Interaction with a therapy animal can help a child learn how to play again (Pet Partners, 2013a). Therapists encourage role-playing with the therapy animal with the intention of facilitating the child’s insight into the situation in which the child finds himself or herself (O’Callaghan, 2008:75). 2.8.2.3 AAT provides the opportunity to project onto another living being One of the greatest benefits of AAT is that a child, who is unable to own his or her feelings, can project the feelings onto the therapy animal. Reichert (1998:177) found that nine to thirteen year old girls in a support group for sexual abuse would project their feelings onto the therapy dog present at group sessions before they were ready to discuss their feelings openly. 2.8.2.4 AAT offers creative ways to assist the client to share feelings When it is difficult for a child to get in touch with or express their feelings, an animal can often help. Techniques to facilitate emotional expression can either be very subtle, or very direct. An example of a direct technique is to ask the child a question from the therapy animal’s perspective (Chandler, 2011:186). Children have been known to be more comfortable talking to animals about their feelings rather than talking to adults. Lange et al. (2006:27) found that adolescents working in an anger-management group with a therapy dog reported that the dog helped them to calm down and discuss events and experiences that made them angry. 2.9 CONCLUSION AAT is effective with a wide range of clients, particularly adolescents and children. The relationship between the therapist and the child, the relationship 27 between the therapist and the animal and the relationship between the child and the animal (Parish-Plass, 2008:12) provide AAT with the potential to transform traditional therapy with children. However, in order for AAT to be effective and successful, it is paramount that the welfare of the three key role players the therapist, the client and the animal, be considered. 28 CHAPTER THREE BEST PRACTICE WITHIN ANIMAL-ASSISTED THERAPY 3.1 INTRODUCTION Chapter two discussed the history of AAT, the benefits of AAT and the types of animals incorporated in AAT. Chapter three will explore definitions for the term “best practice”, examples of the criteria used to establish best practice, best practice in mental health, best practice in AAT and the chapter will conclude with the future of best practice in AAT. 3.2 BEST PRACTICE The term “best practice” suggests the quality of an exercise. “The Concise Oxford Dictionary” (1992:104, 935) provides the following definitions: • Best (adjective) - “of the most excellent or outstanding or desirable kind” and “in the best manner” • Practice (noun) - ”habitual action or performance” and “a repeated exercise in an activity requiring the development of skill” Thus, the best practice of an activity suggests quality performance or activity of a high standard that requires the development of skill. The State Education Resource Centre of Connecticut State (2012) is of the opinion that the term “best practice” has been used to describe what works in a particular situation or environment and that when data supports the success of a practice, it is referred to as a “research-based practice” or “scientifically based practice” (SERC, 2012:1). On occasion, best practice will be the result of success. Most often, however, the mistakes and failures in practice lead to a better way of accomplishing something (Quality Planning, 2012:1). In order to achieve the best practice in a field, one needs to identify and learn from the mistakes that have been made to ensure that the mistakes will not be repeated; the result is that the quality of the practice is improved (Quality Planning, 2012:1). 29 Best practice is not something that is based on an individual’s opinion. It should be decided as a result of general acceptance among practitioners, using a commonly agreed-upon set of factors to evaluate the usefulness and quality of the practice (Quality Planning, 2012:1). While best practice often refers to a way of doing something that has already been tried and tested many times, it may also refer to an improvement in practice that is recognised by peers as a more effective method or approach, fitting the circumstances of a situation (Quality Planning, 2012:2). Determining what forms best practice, therefore, needs to be drawn from a collective view, not just an individual’s experience, although most of the time professional opinions struggle to reach a consensus. There is always room for improvements in the way things are done in any organisation or profession and progress is usually best made by learning from others who have already faced the same problems (Quality Planning, 2012:2). The agreed-upon options of improvement are referred to as "best practice". "Practice" refers to an activity that is repeated elsewhere by others in the same profession and “best" refers to the best way of doing something, taking into account the particular circumstances and needs of the practitioners, (Quality Planning, 2012:2). It must be remembered that best practice is dynamic in nature – what is considered to be best practice today may be regarded as out-of-date in the future. Advances in practice, changes in technology and changes in law or governance structures, values, knowledge or other influences will outdate methods or make them less relevant, useful and/or appropriate. Thus, that which is considered best practice in a particular field needs to be reviewed frequently. 3.2.1 Criteria used to determine best practice in a professional field In order to achieve best practice, professionals need to understand how the practices were judged as the most preferred way of achieving the goals in a profession. To ensure the quality of the practice, certain criteria stipulate what can indeed be termed as best practice within professions. The following criteria for best practice have been adapted by the researcher from the website entitled Quality Planning (2012). The criteria aim to establish whether 30 or not a particular practice should be regarded as best practice. It should be noted that any particular practice may not meet all the criteria, but should display a number of the attributes that suggest best practice. 3.2.1.1 Acceptance amoung practitioners Several practitioners of appropriate competence must verify that the practice is indeed best practice. 3.2.1.2 Legally solid The practice must be validated by legal processes (for example, tested in court and must be beyond further challenge) and/or accepted by legal practitioners as legally sound and appropriate. 3.2.1.3 Best outcomes The practice is regarded as having produced better outcomes than would be achieved by alternative methods. 3.2.1.4 Consistent outcomes The practice has been demonstrated to produce the same results on a number of occasions. 3.2.1.5 Best value for money The practice is regarded as cost-effective, affordable, and makes use of available resources. 3.2.1.6 Best fit The practice best meets the needs of the particular circumstances. 3.2.1.7 Consistency with local and overseas standards The practice uses or is consistent with local and international standards or codes of practice. 3.2.1.8 Adaptability The practice can be used or replicated elsewhere effectively under the same or similar circumstances to produce the same outcomes. 3.2.1.9 Stakeholder acceptability Primary stakeholders generally accept the practice. 3.3 BEST PRACTICE IN MENTAL HEALTH Clinical protocols enable healthcare providers to offer appropriate diagnostic treatment and services to patients and quality training to clinical staff 31 (Heymann, 1994:14). An example is The Kauffman Best Practices Project To Help Children Heal From Child Abuse (Hensler, Wilson & Sadler, 2004) that provides a protocol for selecting the most acceptable treatment from a group of interventions intended to treat victims of child abuse. To be selected as "best practice", the protocol as well as the treatment “had to have a sound theoretical base, general acceptance in clinical practice, and [substantial ] anecdotal or clinical literature” (Hensler, Wilson & Sadler, 2004:7). The treatment also “required absence of evidence of harm, at least one randomised controlled study, descriptive publications, a reasonable amount of the [required] training and the possibility of being used in [ordinary] settings “ (Hensler, Wilson & Sadler, 2004:7). Addendum 5 details the exact criteria used in the Kauffman Best Practices Project as reported by Hensler, Wilson and Sadler (2004:6). The example of the Kauffman Best Practices Project illustrates the importance of research with regard to interventions in the mental health field. Evidence- based practice (EBP) is a recent “buzz-word” in healthcare professions (Earle- Foley, 2011:38). In mental health, EBP refers to high-quality mental health practice that is based on sound scientific research. EBP “requires practitioners to follow psychological approaches and techniques that are based on the best available research” (American Psychological Association, 2005:1). “Accordingly, a therapy is considered efficacious and specific if there is evidence from at least two settings that it is better than a pill or psychological placebo or another bona fide treatment” (Hollon & Ponniah, 2010:892). If there is “evidence from two or more settings that the therapy is superior to no [other] treatment, it is considered [merely] efficacious and if there is support from one or more studies from just a single setting, the therapy is considered possibly efficacious until it is replicated” (Hollon & Ponniah, 2010:892). 3.3.1 Professional code of conduct in mental health The Health Profession Council of South Africa (HPCSA) adheres to the South African Health Profession Act 56 of 1974 (South Africa, 2006:51) as the basis for the HPCSA’s Ethical Code for Professional Conduct. In chapter one, 32 under the heading Professional Competencies, it is stipulated that a psychologist who is “developing competency in a [psychological] service or technique that is new to him or her or new to the [psychology] profession will engage in ongoing consultation with other psychologists or relevant professions and shall search for and obtain appropriate education and training in the new area” (HPCSA, 2013:4). Furthermore, psychologists are obligated to “inform their clients of the innovative nature and of any known risks associated with the specific psychological services or techniques, allowing the client to exercise his or her freedom of choice” prior to receiving the specified services or techniques (HPCSA, 2013:4). 3.4 BEST PRACTICE IN ANIMAL-ASSISTED THERAPY The emphasis in AAT has shifted from the welfare of the client to the welfare of all the parties involved: the client, the therapist and the animal. In a field that has the potential for an immense amount of abuse (Evans & Gray, 2011:3) the many possible risks need to be identified. In order to make sure this is done effectively, therapists need to be well-informed, trained and monitored to ensure that they are providing the best and most effective AAT (Lefebvre, Golab, Christensen, Castrodale, Aureden, Bialachowski, Gumley, Robinson, Peregrine, Benoit, Card, Van Horne & Weese, 2008:82). Lange et al. (2006:28) suggest that it is wise for interested professionals to learn more about AAT by reading books and journals and attending seminars, workshops and conferences on AAT topics to increase the benefits and decrease the potential risks of AAT. Educated therapists will be able to determine which animal characteristics will best suit their needs, thus the therapist will choose an animal that will be a good addition to his or her practice (Urichuk & Anderson, 2003:137). Fine (2010:185) warns that, without adequate training, a therapist is likely to incorporate animals in therapy inappropriately and thus achieve poor results. The following questions serve to ensure quality practice when incorporating AAT (Fine, 2010:171) • What benefits can AAT provide for this client? 33 • What benefits will animals provide in the clinical intervention? • Will the animal’s involvement act as a social lubricant to promote a safer environment or can it be more intensely integrated into the clinical efforts? • How can the AAT approach be incorporated within the planned intervention? • How will the therapist need to adapt his or her approach in order to incorporate AAT? It is integral that the therapist ensures that the interaction between client and animal remains therapeutic, with the focus on achieving therapeutic goals and that AAT be integrated into the client’s treatment plan (Mallon, Ross, Klee & Ross, 2010:143). During animal-assisted therapy with children, two therapeutic goals are enhanced: the need to develop trust and feel loved while at the same time developing a feeling of competence (Fine, 2010:180). The animal’s presence assists the child to learn to trust the therapist whilst also providing an opportunity for the child to take responsibility (Parish-Plass, 2008:13). Research conducted by O’Callaghan (2008:67) on therapists utilising AAT revealed that 29% of the therapists made use of AAT with the intention of enhancing self-confidence and 39% made use of AAT to enhance trust within the therapeutic environment. The therapist usually presents opportunities for children to develop competence through structured activities with the animal such as training, games and storytelling (VanFleet, 2008a:77). Guidelines need to be established with regard to the practice of AAT. These should include (but not be limited to) aspects such as: the types of clients to involve with animals, the types of animals that are the best to incorporate in therapy, choosing the best individual animal after considering the animal’s temperament and training, and how to handle clients with allergies (Hooker et al., 2002:21). Once it has been decided that AAT will be beneficial for the client, there are a number of factors to consider. Parshall (2003:53) suggests that cultural, ethical and legal considerations be taken into account when planning the 34 treatment, in order to ensure best practice for AAT in the mental health setting. Considerations such as careful planning to ensure that the therapy animal will assist in realising the therapy goals, investigating the client’s history of pet ownership and attitude towards animals, ensuring that interaction with the therapy animal is beneficial for both the client and the animal, using AAT as a supplement to other therapeutic approaches rather than in isolation, and working with animals that have been certified to be involved in AAT, will result in best practice in the field of AAT. Best practice in AAT includes the appropriate behaviour of the animal involved in therapy. A therapy animal needs to be assessed to ensure that it is suitable for the task of inclusion during therapy sessions (Lefebvre et al., 2008:80). Problem behaviours that could cause harm or illicit responses that are not conducive to therapeutic goals such as jumping up, nipping, biting or mouthing, inappropriate urinating, excessive vocalising and inappropriate eating need to be addressed (Urichuk & Anderson, 2003:133). Animals need to be continuously assessed to ensure that their behaviour remains acceptable in a variety of situations. The following practical guidelines serve to ensure therapy of high standard: • Therapy animals need to be calm and gentle and enjoy being around people; • Therapy dogs must have an excellent temperament; • The therapist needs to prepare the animal for unusual sights, sounds and smells; • The therapy animal must be obedient and follow instructions; • The therapy animal must be able to regain self-control once play or excitement has ended; • The animal must be able to sit quietly for extended periods of time; • The animal must be able to navigate through crowded environments; • The animal must be comfortable with strangers; • The therapy dog must walk comfortably in a heel position and must follow the commands of “sit”, “down”, “come” and “stay”; 35 • The therapy animal must practise self-control; • The therapy dog must ignore other animals including animals that show aggression (Fine 2010:185). Unfortunately, until now, little research has been done on the welfare of the animals involved in AAT and there is no systematic assessment of the potential threats to the welfare of the animals (Endenburg & van Lith, 2011:212). Animal welfare problems could range from various forms of animal neglect, animal abuse and human aggression towards the animals, to stress signals that go unnoticed, and animals running away and hiding from clients during sessions. In their study on animal-assisted interventions in Belgium, Pira et al. (2010:49) found that one quarter of the respondents reported occasional negative effects on the animals involved. Similarly, in a study on prisons and rehabilitation centres, Pira et al. (2010:50) found that six of the facilities (25% of the sample) reported occasional negative effects in an anecdotal way. These included: management problems, negligence with feeding procedures, breeding without permission of the guards, bite accidents involving rabbits and dogs, the animals exhibiting stress signals, hiding and running away from prisoners. Wolff and Frishman (2005:131) believe that any participant of AAT should be carefully screened to ensure a positive interaction; the participant should not have a negative attitude towards animals and should be in a suitable medical condition in order to prevent any harm during the interaction. Even when the basic needs of the animals, such as food, fresh water and safety have been addressed, it is important for therapists to consider the strain of therapeutic interventions on the animals. Braun et al. (2009:108) believe that animals appear to ‘‘take on’’ the pain of the client and suggest limiting the number of intense sessions to no more than three per week, whilst providing massages and other calming measures to the animal after intense sessions. Urichuk and Anderson (2003:160) list twenty-two stress signals in dogs and suggest that therapists learn how to recognise the signals in order to take the necessary action and prevent injury. 36 3.5 THE FUTURE OF BEST PRACTICE IN ANIMAL-ASSISTED THERAPY AAT aims to augment the therapist’s ability and skill to work within his or her theoretical orientation (Fine, 2010:171) and many therapists acknowledge the added benefit of an animal’s presence within the therapeutic context (Anderson & Olsen, 2006; Berget & Grepperud, 2011; Braun et al., 2009; Chandler, 2012; VanFleet & Faa-Thompson, 2010). Given the increasing emphasis on evidence-based practice, it is imperative that professionals differentiate between the practices developed for volunteers visiting facilities with their pets and the practices necessary for the incorporation of animals in mental health treatment (Moga & McNamara, 2012). Research in AAT is often anecdotal (Eggiman, 2006:1) and lacks quantitative, controlled observations (Fine, 2010:547). In order for AAT to take its place as “evidence-based”, research must advance in the hierarchy of evidence (Fine, 2010:558), as illustrated in Figure 3.1. Systematic review of randomised controlled trials Randomised controlled trials Non-randomised trials and observational studies Anecdotes, case studies, surveys, qualitative research Figure 3.1. The hierarchy of evidence (Fine, 2010:558). As the field of AAT continues to expand, the need for education and research is vital (O’Callaghan, 2008:2). In order to distinguish what the field of AAT could aspire to, some of the criteria of the Kauffman Best Practices Project (Hensler, Wilson & Sadler, 2004:6) could be used in the application of AAT with children. AAT should have a sound theoretical basis in generally 37 accepted psychological principles, indicating that it would be effective in treating children. The treatment should be generally accepted in clinical practice as appropriate for use with children. A substantial clinical-anecdotal literature should exist, indicating the treatment’s value for children, their parents, and/or their families from a variety of cultural and ethnic backgrounds. There should be no clinical or empirical evidence, or theoretical basis, indicating that AAT constitutes a substantial risk of harm to those receiving it, compared to its likely benefits. 3.6 CONCLUSION Best practice, defined as quality performance or activity of a high standard, is expected in every professional field and especially in the healthcare professions. The best practice in a field is not based on one individual’s opinion but rather a number of experienced professionals who verify that the activity is indeed regarded as best practice. The Kauffman Best Practices Project provides an example of research that identified a protocol to establish the best practice intervention for a specific population of children. The field of AAT is growing rapidly, and rapidly gaining recognition as a treatment method that can be applied to an array of client issues in a number of practice settings. In order to continue gaining popularity and recognition and to strengthen its position in the scientific world, AAT needs to become known as an evidence-based practice, a high-quality mental health practice that is based on sound scientific research. 38 CHAPTER FOUR CHILDREN IN THE WESTERN CAPE AND AVAILABLE SUPPORT SERVICES 4.1 INTRODUCTION Chapter three presented the literature review on best practice, including the suggested criteria for best practice, and concluded with best practice in AAT. Chapter four will focus on the South African province of the Western Cape and children who reside in the Western Cape. 4.2 SOUTH AFRICA The Republic of South Africa, the most southern country on the African continent, has a population of 51,7 million (Statistics South Africa, 2012b:2). The country boasts eleven official languages, most of which are indigenous to South Africa, and four recognised population groups: Asian/Indian, Black, Coloured and White. South Africa is divided into nine provinces: Gauteng, KwaZulu-Natal, North West, Free State, Mpumalanga, Limpopo, Northern Cape, Eastern Cape and the Western Cape. South Africa is a developing nation that continues to bear the scars of a previous political system of inequality (Hamilton, 2003:65). For example, the 1996 census indicated that 47,4% of the households in South Africa had electricity in order to cook food, however, the 2011 census reported that this figure had increased to 73,9% (Statistics South Africa, 2012a:36). Furthermore 29,8% of the South African population is unemployed (Statistics South Africa, 2012a:70) and 77,6% of the population lives in formal housing (Statistics South Africa, 2012b:9). The Human Development Report is commissioned and published annually by the United Nations in an attempt to raise awareness about human development worldwide (United Nations, 2013:1). In 2011, South Africa was ranked 123 out of 187 countries. While this ranking is quite low in international terms, South Africa’s Human Development Index of 0.62 was well above the regional average of 0.46 for Sub-Saharan Africa (Australian Government, 2012:1). It is estimated that 1,4 million people have migrated to 39 South Africa from other African countries in the last 15 years (Statistics South Africa, 2012c:5). South Africa is, furthermore, the country with the highest number of people who are HIV positive, 5 600 000 South Africans are living with the virus (Central Intelligence Agency, 2013:1; Statistics South Africa, 2012c:5). UNAIDS estimates that 270 000 South Africans die of AIDS every year and that there are 2 100 000 children who have been orphaned as a result of AIDS (UNAIDS, 2012:1). 4.3 THE PROVINCE OF THE WESTERN CAPE The Western Cape is the most southern province of South Africa, at the very tip of the African continent. The province of the Western Cape covers an area of 129 370 km2 and has a population of 5,2 million people (Statistics South Africa, 2012a:44), approximately 10,4% of the South African population. Cape Town, the capital of the Western Cape province, has seen a rapid population growth since 1997 as a result of rural-urban migration and cross- border migration, both legal and illegal (Herrick, 2012:1050). Afrikaans, isiXhosa and English are the main languages in the region. In 2011, 21,6% of the people in the Western Cape between the ages of 15 and 64 were unemployed (Statistics South Africa, 2012a:42). The average household income in 2011 was R143 000 per annum (Statistics South Africa, 2012a:43). Substance abuse is a major concern in the Western Cape; 43,6% of the drug- related crimes that occurred in South Africa in 2012 occurred in the Western Cape (Crime Stats SA, 2012:10). KwaZulu-Natal had the second highest incidence of drug-related crime, however, at 21,3% it is half that of the Western Cape. Alcohol remains the most frequently abused substance in the Western Cape (Harker, Kader, Myers, Fakier, Parry, Flisher, Peltzer, Ramlagan & Davids, 2008:7) resulting in one of the highest Foetal Alcohol Spectrum Disorder rates in the world (Harker et al., 2008:9). The Western Cape has one of largest regions for the production of wine and brandy in South Africa. The high rate of Foetal Alcohol Syndrome has been attributed 40 to the historic agricultural system in which alcohol supplemented the low wages that staff in the wine industry received. Methamphetamine abuse, or “tik” as it is locally called, is a major challenge in the Western Cape (Western Cape Government, 2010:7). 98% of the addicts who seek help in South Africa come from the Western Cape and the highest level of use is found in children under 19 years of age (Western Cape Government, 2010:7). The drug is considered one of the most dangerous drugs available, as the users are regarded as being prone to violence (Western Cape Government, 2010:6). 4.4 CHILDREN IN THE WESTERN CAPE According to the 2011 census, there are approximately 1463804 children under the age of 14 years in the province of the Western Cape (Statistics South Africa, 2012a:45). The South African Social Security Agency (Kibel, Lake, Pendlebury & Smith, 2010:107) recorded that there were 557784 children receiving Child Support Grants from the government in the Western Cape in 2009. The Child Support Grant is a social assistance programme available to South African children whose parents do not have the financial means to care for them (SASSA, 2012: 1); the grant per child is currently R280,00 per month 4.4.1 Schooling The 2011 census revealed that 2,7% of the people under the age of twenty years in the Western Cape had no formal education. This is the lowest proportion of people with no formal education in any of the provinces in South Africa (Statistics South Africa, 2012a:21). It is interesting to note, however, that only 28,6% of the population of the Western Cape had completed Grade 12 (Statistics South Africa, 2012a:21). One in three homes in the province had a computer in working order (Statistics South Africa, 2012a:30) and 43,7% of the households had access to the Internet (Statistics South Africa, 2012a:35) 41 4.4.2 Living arrangements In the 2011 census, 80,4% of the households in the Western Cape were regarded as a “formal dwelling” (Statistics South Africa, 2012a:25) while just over 300 000 people lived in informal or traditional dwellings (Statistics South Africa, 2012a:66). Hall and Wright (2011:3) found that 23% of the children in South Africa live with both their biological parents, 41% live with only their mothers and 23% do not live with either of their biological parents. 4.4.3 Child abuse, domestic violence and divorce The 2011 South African Police Service briefing on domestic violence and crimes against children younger than 18 years suggested that crimes against children in the Western Cape increased by 29,2% during the years 2009 and 2010 (SAPS, 2011:10). The increase was the highest of all the provinces in South Africa. 31014 cases of domestic violence were reported to the South African Police Services in the Western Cape during the same period (SAPS, 2011:9). According to the 2011 census, 18571 children were involved in the divorces that took place in South Africa in that year (Statistics South Africa, 2012d:40). 4.4.4 Supportive services for children in the Western Cape The literature review revealed a number of non-profit organisations in the Western Cape that aimed to assist children in need. The Western Cape Street Children’s Forum (2013:1) has identified twenty-four organisations that focus on offering counselling, outreach and residential facilities to children. Manenberg Early Intervention Project, New Life Projects, Beth Uriel Shelter and Youth Outreach are a few of the organisations that form part of the network (Western Cape Street Children’s Forum, 2013:1). The South African Association of Marital and Family Therapy offers family services and parent education in the province (Western Cape Government, 2013:184). The Music Therapy Community Clinic provides therapeutic services to underprivileged and previously disadvantaged children in the Western Cape (Music Therapy Community Clinic, 2013:1) and the Child Trauma Clinic offers play therapy to children dealing with trauma (Child 42 Trauma Clinic, 2013:1). Wezokuhle Day Care and Kinderfonds 2000 offer child services to assist children in need (Western Cape Government, 2013: 99) and the Mitchells Plain Crisis Line provides support services for child victims of violence and abuse (Western Cape Government, 2013:70). The researcher identified two organisations in the Western Cape that offer therapeutic horse riding to children with disabilities, both Amado Animal Assisted Therapy Riding Centre (AMADO, 2013:1) and South African Riding for the Disabled Association (SARDA, 2012:1) are able to assist children from low-income communities. Unfortunately the demand is more than the organisations can handle, for example, AMADO has a waiting list for two hundred children (Sharpe, 2013:58). The Western Cape also has an animal- assisted activity organisation entitled Pets As Therapy that offers to visit schools with trained dogs (Western Cape Government, 2013:234). Two organisations in the Western Cape, Reflectionz and Montrose Equine Youth Development Programme, offer equine-assisted psychotherapy to children facing emotional difficulties. In the last three years, 198 youth have completed the Montrose Equine Youth Development Progamme. The participants came from the following places of safety and community-based programmes: Metro Evangelical Services, Beth Uriel House of Light, Mamelani projects, Elkana Children’s Home, Ikamva Labantu, Homestead Child and Youth Centre, The Adonis Musati Project, No Limits Programme for Street Children, Margaret’s House, ACVV Malmesbury, Straatlig, Durbanville Children’s Home, Baphumelele Fountain of Hope and Naudeshof Farm Youth. 4.5 CONCLUSION Chapter four focused on the province of the Western Cape, South Africa, and the children who reside in the area in which the research was conducted. The schooling, living arrangements and the social problems that many of these children experienced were also highlighted. The chapter concluded with the social services for children that are available in the Western Cape, as well as including organisations that offered animal-assisted activities and animal- assisted therapy. Chapter five will give an in-depth account of the research methodology used in the study. 43 CHAPTER 5 RESEARCH METHODOLOGY AND DESIGN 5.1 INTRODUCTION The study focused on exploring and describing best practices in animal- assisted therapy with children in the Western Cape and therefore chapter four gave a discussion on children in the Western Cape. The purpose of this chapter is to elaborate on the research design and methodology as outlined in chapter one. The chapter will therefore focus on the aim of the study, the research approach and research design that were chosen and the data collection methods that were used. The chapter will conclude with the data analysis method and the application of credibility, transferability, dependability, confirmability and the ethical considerations during this study. 5.2 AIM OF STUDY AND RESEARCH QUESTION The purpose or aim of a study refers to why one does something or why something exists (Fouché & De Vos, 2011:94). This study aimed to explore and describe best practice in the field of AAT with children in the Western Cape – to document, identify categories of meaning and generate hypotheses for further research (Marshall & Rossman, 2011:69) as a need for research in the field of AAT had been identified (see 2.4). The basic research was motivated by the researcher’s curiosity and interest in AAT in the Western Cape. By utilising a descriptive method of study, an in-depth description of the experiences of the participants who took part in this study could be emphasised. The study aimed to add to the research in AAT in South Africa and contribute to dialogue with regard to best practice in AAT with children in the Western Cape, it was felt that the in-depth description of the experiences of mental health professionals offering AAT would achieve this aim. The research question that was formulated to achieve the aim of the study was: What are the best practices utilised for animal-assisted therapy with children in the Western Cape? 44 To achieve the above-mentioned aim, the following objectives were formulated: To explore and describe best practices as utilised by professionals offering animal-assisted therapy to children in the Western Cape. To gather descriptions and formulate conclusions regarding the best practices for animal-assisted therapy as provided by professionals working in the context of the Western Cape. 5.3 RESEARCH APPROACH The exploratory nature of the study necessitated a qualitative descriptive approach within which research participants could explore their worldviews in relation to the purpose of the study. The descriptive approach enabled the researcher to explore the participants’ worldviews in relation to the study and, as a result, adequately document the participants’ opinions regarding best practices in AAT with children. A qualitative approach provided a more sensitive and meaningful account of human experience (Bless, Higson-Smith & Kagee, 2006:44). The qualitative research approach, in its most general sense, refers to research that draws out participant accounts of meaning, experience and perceptions (Fouché & Delport, 2011:65). The researcher was offered the opportunity to develop an understanding of the research participants and what it meant to the participants to find themselves in a particular situation (Biggerstaff & Thompson, 2008:177) specifically, offering animal-assisted therapy to children. Creswell (1998:75) explains that the qualitative approach is based on the following five assumptions: The ontological assumption, defined as how reality is viewed, suggested that the research participants’ reality was subjective and was constructed by the participants involved in the study. In other words, the research focused on understanding the meaning the of participants’ beliefs regarding best practice in AAT with children. The epistemological assumption recommended that the researcher attempt to lessen the distance between herself and the research 45 participants. The researcher aimed to achieve this by communicating with the participants through emails prior to the interviews. The researcher also requested that the interviews be conducted in a setting chosen by the participants, preferably a setting in which the participants felt comfortable. The axiological assumption acknowledged that research is value laden, thus the researcher reported her values and biases and the effect they had on the data. Throughout the research process, the researcher was cognisant of her prior experience with and studies in AAT and, as a result, how her values and biases regarding AAT could negatively impact the accuracy of the research. The rhetorical assumption stipulated that the researcher use personal and literary language in the research that is based on the study’s “Definitions of terminology” (see 1.7). The most appropriate language to be used in reporting the results of this research included terminology such as “animal-assisted therapy”, “animal-assisted activities”, “equine- assisted psychotherapy” and “best practice”. The methodological assumption resulted from the four assumptions above and was concerned with how the knowledge was gained. The methodological question is: which research techniques will best serve the researcher in looking for what can be known? The methodological assumption required that the researcher had to work inductively when analysing the data, developing categories from the data rather than specifying the categories before the data was collected. It was imperative that the researcher allowed the data to reveal the categories, in order for the research to be deemed credible. Descriptive and exploratory research was utilised, as information in this new area of interest was limited (Fouché & De Vos, 2011:95) and provided the opportunity to gain new insight into the use of AAT with children in South Africa. 46 5.4 RESEARCH DESIGN The research design used, or the plan outlining how the observations were made and how the researcher carried out the project (Fouché, Delport & De Vos, 2011:143), was the collective case study design. The purpose of a case study design is to provide an in-depth and full description of the phenomena (Fouché & Schurink, 2011:322). The case study design provided the researcher with the opportunity for interaction with a small number of individuals, so as to look for patterns in the research participants’ words, actions and experiences (Fouché & Schurink, 2011:320). Creswell (1998:63) suggests that typically in the collective case study design, a researcher chooses no more than four cases and warns that a study focused on a number of cases often lacks the depth that a single case offers. Smith and Osborn (2007:57) suggest that students using interpretative phenomenological analysis for the first time should consider three cases an extremely useful sample size. The current study made use of four cases. 5.5 SAMPLING AND SAMPLING METHOD The sampling method, or the method used to select research participants, will be discussed in the following section. 5.5.1 Method and criteria for selection of participants The researcher began by establishing a rationale for the purposive sampling strategy used to select participants (Creswell, 1998:64) and stipulated specific criteria for the participants in the study. The population of professionals utilising AAT with children in the Western Cape set the boundary on the universe. The sample, or a small portion of the total set of persons (Strydom, 2011:224) was selected from the population. Purposive sampling was chosen due to the very specialised population of the study; the participants had to be qualified mental health therapists who offered AAT. Participants referred the researcher to other individuals that met the criteria of the study. This is known as snowball sampling. The researcher continued with snowball sampling until no new cases were found (Strydom, 2011:233). The criteria included the following: 47 • Participants had to be trained and certified to offer mental health therapy (for example social workers, HPCSA registered counsellors or psychologists); • Participants had to have the experience of offering animal-assisted therapy to children in the Western Cape; • Participants needed to be able to converse comfortably in English as translation could result in vital information getting lost; • Participants had to be willing and comfortable to discuss their experiences of providing AAT. The following two factors hindered the selection of participants (Weideman, 2007:127) • There are no mandatory governing bodies for AAT practitioners in South Africa. • The demand for this type of therapeutic intervention greatly outweighs the supply of qualified practitioners. 5.5.2 Process of selection Internet searches, as well as information taken from the Equine-Assisted Growth And Learning Association (EAGALA) online Contacts list, resulted in contact information for potential participants. Participants who met the criteria (see 5.5.1) were identified, emailed or contacted telephonically and invited to participate in the study. The criteria as stipulated above for the selection of participants resulted in a very small sample. 5.6 DATA COLLECTION The researcher began collecting data by identifying individuals who could participate in the research. Mental health therapists and counsellors working with children and providing AAT in the Western Cape, who met the criteria, were discovered using the internet and by word of mouth. The researcher contacted the individuals telephonically or by email and personally requested that each individual be a part of the study. The data was collected, information was recorded, any field issues (for example, interviewing and 48 observing issues) were dealt with and the data was securely stored. The study made use of semi-structured one-on-one interviews as a data collection method and ensured that the data collected was securely stored by making use of good quality audio-visual tapes, which were later duplicated onto DVDs for effective storage. 5.6.1 Method of data collection There are a number of data collection methods used in qualitative research in the social sciences. These include written questionnaires, unstructured or semi-structured one-on-one or telephonic interviews, focus groups and online surveys (Fouché, Delport & De Vos, 2011:156). One-on-one interviews can take the form of extended and formalised conversations (Greeff, 2011:348), known as unstructured interviews, which aim to explore the research topic, or semi-structured interviews, which are guided by a set of pre-determined questions (Greeff, 2011:352). It was felt that semi-structured one-on-one interviews would serve to gather the most useful information for the current study as the interviews would provide the researcher with the opportunity to interact with each participant individually and gain a detailed account of the participant’s perceptions about offering AAT to children in the Western Cape. Semi-structured interviews provided more flexibility and enabled the researcher to ask open-ended questions as well as probe for more information, when required (Greeff, 2011:351). 5.6.2 Semi-structured one-on-one interviews Semi-structured one-to-one interviews suggest that the research participants are the experts in the topic that is being researched (Greeff, 2011:352). The semi-structured interviews enabled the researcher to engage in dialogue with each participant, to follow the participant’s interests and concerns and to probe when interesting or important topics arose during the interview (Smith & Osborn, 2007:58). Semi-structured interviews served to facilitate rapport- building between the researcher and the participant, allowing flexibility to cover topics fully and generally producing richer data (Smith, 2008:59). 49 An interview schedule was used during the interviews. An interview schedule usually contains specific instructions, pre-determined questions and transition phrases for the interviewer to use (Greeff, 2011:352). The interview schedule was motivated by the research question that the researcher aimed to answer in the research and by the available literature on AAT. An expert in the field of AAT was consulted and provided feedback on the interview schedule. It must be noted that the interview schedule served as a guide and did not dictate the process of the interview (Smith, 2008:58). The interview schedule used in the current study was inspired by the literature study and the researcher’s experience with AAT. See addendum 1 for the interview schedule used in the study. The questions focused on the participants’ general experience of best practices in providing AAT, for example:  What do you believe are the challenges of animal-assisted therapy with children?  Which populations do you feel benefit the most from animal- assisted therapy? Some of the questions were about AAT in South Africa, for example:  What do you believe are the advantages of animal-assisted therapy in South Africa?  How do you see the future of animal-assisted therapy in South Africa? And finally, the questions focused on the participants’ views of best practice in AAT, for example:  What would you like to see as the minimum standards for animal- assisted therapy in South Africa?  What are the ethical considerations for animal-assisted therapy? 50  What do you regard as best practice in animal-assisted therapy? Participants were interviewed in a setting of their own choice, as people usually feel most comfortable in a setting they are familiar with (Smith & Osborn, 2007:63) resulting in more effective data collection. The settings included the therapists’ rooms and a public coffee shop. 5.6.3 Reflective notes Reflective notes were used to record the researcher’s reflections or deliberations on the research process. The notes that the researcher made described the researcher’s personal experience of the research process (Thorne, Kirkham & MacDonald-Emes, 1997:175). Reflective notes were used in order to minimise the researcher’s bias (Thorne, Kirkham & MacDonald-Emes, 1997:175). The researcher has a long history of observing AAT, thus it was important to identify and reflect on any of the researcher’s beliefs regarding AAT that may have hindered the research. 5.6.4 Field notes Detailed descriptions of experiences, thoughts and prejudices (Greeff, 2011:359) were written by the researcher soon after leaving the field in which the data was collected. These are known as field notes and are regarded as an additional data collection technique in case studies (Fouché & Schurink, 2011:316). Strydom (2011:335) suggests two practical guidelines for making field notes, which were also applied in this study: record exactly what is seen and heard and then expand field notes beyond the immediate observations. In the current stuffy, the field notes provided the researcher with additional data and the opportunity to process the semi-structured interviews shortly after they had been completed. 5.7 DATA ANALYSIS Data analysis in qualitative research involves reducing a large amount of raw information, filtering significant data from trivial data, identifying the noteworthy patterns and constructing a framework that will convey the 51 essence of what the data revealed (Schurink, Fouché & De Vos, 2011:397). Once the interviews were transcribed, the interview transcripts were analysed case by case through systematic, qualitative analysis (Smith, Flowers & Larkin, 2009:4). Interpretative Phenomenological Analysis (IPA) and an AAT conceptual framework (prompted by the literature review) guided the data analysis and interpretation in the current study. Interpretative Phenomenological Analysis (IPA) was chosen as the approach for data analysis in this study . IPA is one of the newest qualitative approaches in data analysis and has become an increasingly popular approach in areas such as health and counselling psychology (Clarke, 2010:58). The key theoretical perspectives of IPA are phenomenology, idiography and interpretation (or hermeneutics, the theory of interpretation) (Smith, Flowers & Larkin, 2009:6). Phenomenology is a philosophical approach to the study of experience (Smith, Flowers & Larkin, 2009:11) and refers to the researcher’s desire to get as close as possible to the personal experiences of the research participants (Smith, Flowers & Larkin, 2009:37). Idiography is concerned with the particular and, as a consequence, analysis of the data must be thorough and systematic (Smith, Flowers & Larkin, 2009:29). In an effort to focus on the particular, the research made use of a small, purposefully selected and carefully situated sample (Smith, Flowers & Larkin, 2009:29). IPA was developed to allow rigorous exploration of each participant’s subjective experience and, in particular, social cognitions (Biggerstaff & Thompson, 2008:177). Thus it was felt that IPA would provide a comprehensive examination of the therapists’ experiences of offering animal assisted therapy and their views of best practice in the field of animal-assisted therapy. Analysis always involves interpretation and successful interpretation is based on reading from within the terms of the text (Smith, Flowers & Larkin, 2009:36). In IPA, the researcher has an active role in the two-stage process of interpretation: each participant in the study is trying to make sense of his or her own world and the researcher is trying to make sense of the participants trying to make sense (Smith & Osborn, 2007:53). Unfortunately, a 52 shortcoming of exploratory studies is that they seldom provide satisfactory answers to research questions, although they can hint at the answers and can suggest research methods that could provide more definitive answers. IPA is a cyclical process that moves the researcher through various stages. These were applied in this study in the following way (Biggerstaff & Thompson, 2008:176): Stage 1: The researcher encountered the text in the transcripts for the first time by reading through the text several times to familiarise herself with the data. Stage 2: The researcher began to identify preliminary themes in the text. Stage 3: The researcher grouped the themes that had been identified into clusters of themes. Stage 4: The researcher drew up a table of the five main themes. Within each stage of IPA, the following steps were used during the data analysis and interpretation: Step one - Organise and prepare the data for analysis. During the first stage of analysis, the first step for the researcher was to transcribe each of the DVDs of the interviews. The researcher then read through the transcripts a number of times and made notes regarding interesting and significant responses in the left hand margin of each transcript (Smith & Osborn, 2007:67). The researcher commented on language use, amplifications, similarities and contradictions. Memoranda were written about each transcribed interview, allowing the researcher to read through the data several times in order to get a sense of the data in its entirety and become familiar with it, before reducing the data (Schurink, Fouché & De Vos, 2011:409). 53 Step two - Reducing the data The data was reduced through the process of coding the data. Relevant data in the transcripts was identified and labeled (Schurink, Fouché & De Vos, 2011:411). The researcher then moved into the second stage of IPA and began categorising the data by organising the data into a small, manageable set of themes that would be used in the final report (Schurink, Fouché & De Vos, 2011:410). The themes identified information that mattered to the participant as well as conveyed meaning for the participant. The researcher made use of the right hand margin in order to document the emerging theme titles (Smith & Osborn, 2007:68). The themes that emerged were then transferred to a separate sheet of paper, analysed for connections and clustered into potential superordinate themes (Smith & Osborn, 2007:74), part of stage three in the analysis process. Step three - Visualising, representing and displaying the data In the third step and the final stage of the research analysis, the researcher drew up a table of superordinate themes. Identifiers, in the form of numbers, were added to indicate where in the transcript each theme could be found (Smith & Osborn, 2007:72). Finally, a narrative account and representations of the data, as presented in Chapter six, were compiled using thematic categories from the data analysis as subheadings and supported with verbatim extracts from the participants (Smith, Flowers & Larkin, 2009:4). This included forming a larger meaning about the phenomenon based on the participants’ personal views and comparisons with past research that had been presented in the literature review. 5.8 TRUSTWORTHINESS Lincoln and Guba (cited in Schurink, Fouché & De Vos, 2011:419) have suggested four constructs: credibility, transferability, dependability, and conformability, which were used to ensure the trustworthiness, and assisted in determining the “truth value” and soundness, of the current study (Schurink, Fouché & De Vos, 2011:419). 54 5.8.1 Credibility The credibility or authenticity of the research refers to the assurance that the research participants’ views and the researcher’s reconstruction and demonstration of those views correspond (Schurink, Fouché & De Vos, 2011:420). In order to increase the credibility of the study, the researcher used various strategies (Schurink, Fouché & De Vos, 2011:420). The researcher aimed to provide an in-depth description highlighting the complexities of the factors in the study. Another strategy, triangulation of different sources of data (Schurink, Fouché & De Vos, 2011:420), also aimed to ensure the credibility of the research. The research participants were asked to scrutinise the data once it had been transcribed, in order to ensure the authenticity of the research. 5.8.2 Transferability The transferability or generalisation of the research is the extent to which the research findings could be transferred to another setting or situation (Schurink, Fouché & De Vos, 2011:420). It is noted that the research took place in the Western Cape and thus the findings are limited to the Western Cape. Making use of multiple sources of data serves to strengthen the research’s transferability, thus data triangulation (Schurink, Fouché & De Vos, 2011:420) served to enhance the transferability of the research. The different sources that were used included semi-structured interviews, field notes, observation and reflective notes. 5.8.3 Dependability The dependability of research focuses on the logical, traceable and documented (Schurink, Fouché & De Vos, 2011:420) process of the research, in order to ensure that the research is a true depiction of the reality. The process of the research was well documented and is traceable; the researcher has stored all the relevant documentation pertaining to the research at North-West University’s Centre for Child, Youth and Family Studies. It is the researcher’s opinion that the aim to focus on the participants’ experiences and perceptions of best practice in AAT was best achieved through semi-structured interviews (Greeff, 2011:351). In order to 55 gain an accurate account of best practices in AAT with children in the Western Cape, the process of the research, including the interviews, can be traced using DVDs, computer files and hard copies of the interview transcripts. 5.8.4 Confirmability The confirmability of the research, or whether another researcher could confirm the findings of the present study, serves to eliminate researcher bias and promote the accuracy of the research. In this study, an audit trail (Schurink, Fouché & De Vos, 2011:421) was conducted by using methods such as recorded audiotapes, summaries, and themes that were developed as well as personal notes. The process of the research has been explained in detail, enabling other researchers to replicate and confirm the findings of the research. 5.9 ETHICAL CONSIDERATIONS 5.9.1 Informed consent Participants have the right to know the details of a study, for example, what the research is about, the risks and benefits of taking part in the research and their right to leave the study at any point during the research (Strydom, 2011:117). The information regarding the rights of participants, the aim of the research, the risks and benefits, was clearly explained to each participant prior to the participant agreeing to take part of the study. Informed consent was obtained (Babbie, 2010:66) from each participant in the form of his or her signature on a document that stated that he or she understood the details of the study and gave his or her permission to be included in the study (see Addendum 2). Each participant received a copy of the document for his or her own records (Bless, Higson-Smith & Kagee, 2006:142). It was stipulated that each participant had the choice whether or not to participate in the research. All the research participants spoke English and had the ability to read and write, thus the researcher is confident that the participants fully understood the consent form. With the permission of the participants’ informed consent, the data was video-recorded and then transcribed to be kept as evidence. 56 5.9.2 Action and competence of the researcher The competence of the researcher refers to the researcher’s professional training by an accredited institution to be proficient enough to perform quality research (Bless, Higson-Smith & Kagee, 2006:141). It is the ethical responsibility of the researcher to have sufficient skill and competency to conduct the research (Strydom, 2011:123). The researcher’s studies in psychology, education, play therapy and AAT equipped her with the necessary skills for the research and supervision was received throughout the research process. The researcher’s behaviour and actions were guided by the research ethics that were stipulated in the study’s research proposal and approved by an ethical committee prior to the commencement of the study (Bless, Higson-Smith & Kagee, 2006:145). 5.9.3 Release or publication of findings Research findings are often published in order to share the findings with the scientific community (Bless, Higson-Smith & Kagee, 2006:146), however the identity of the participants in the study needs to be protected. Participants in the current study were informed of the reason for the research interviews and the possible publication of results (Oliver, 2003:65) and letters of the alphabet were assigned to the participants to ensure anonymity. The researcher ensured that the data was interpreted correctly and that the report was written accurately. The recordings of the interviews and the transcribed data has been safely stored by the researcher (Oliver, 2003:90) at the North West University’s Centre for Child, Youth and Family Studies. The participants were informed that the study is being submitted as a dissertation to North- West University as part of an MA (Psychology) degree. Publication credit has been given to all the individuals who have contributed to the research. 5.9.4 Confidentiality and violation of privacy The South African constitution stipulates that every South African has the right to privacy (South African Government, 2013:2). It is every individual’s right to decide when and where his or her thoughts, attitudes and beliefs will be revealed (Strydom, 2011:119). The researcher was entrusted with personal information in the form of the data that was collected, thus it was integral that 57 the information was treated with care and that the researcher respected each participant’s right to privacy and confidentiality. In the current study, data was handled in a confidential manner and dealt with sensitively (Strydom, 2011:119). The participants’ names were masked in the data (Creswell, 1998:134) by assigning a letter of the alphabet to each participant in the report. This was done in order to ensure that anonymity and confidentiality of all participants was maintained (Strydom, 2011:119). Refusal of the participants to participate in the study would have been respected, however all the participants chose to take part in the study. 5.9.5 Harm to participants The most basic ethical consideration in research is to ensure that participants in the study are not harmed as a result of participating in the study (Bless, Higson-Smith & Kagee, 2006:141). During the course of the current study the researcher was sensitive to the interests of the participants, ensuring that the participants were guarded against any form of physical discomfort or emotional harm (Strydom, 2011:115). Should one of the participants have experienced emotional harm during the interviews, a time for debriefing would have been made available. It is felt that the research process in the current study did not produce unpleasant effects on the participants. 5.9.6 Feedback to participants Not only do research participants have the right to be informed about the results of a study in which they made a contribution (Bless, Higson-Smith & Kagee, 2006:141) but feedback regarding the results of a study is valuable to the participants as they have a vested interest in the development of their field. The participants in the current study were given access to the research findings, and the opportunity to comment on the findings and feedback regarding the results of the research was made available to each participant (Oliver, 2003:148). This served to educate the participants and also ensured that the research was a true reflection of the participants’ experiences. 58 5.9.7 Deception of participants Deception of participants during research usually takes the form of the researcher hiding the true nature of the study in order to prevent the participants changing their natural behaviour, which would alter the research results (Bless, Higson-Smith & Kagee, 2006:144; Creswell, 1998:132). More generally, any untruth could be classed as deception. The current study did not involve any deception and the researcher was committed to being honest with the participants at all times. To the researcher’s knowledge, there was no deception of participants during the study. 5.9.8 Ethics in analysing and reporting Part of the process of reporting the results of a study is to include the study’s technical shortcomings, failures, limitations in the study, negative findings and methodological constraints (Bless, Higson-Smith & Kagee, 2006:145). That said, many researchers adapt their data to provide a predetermined, preferable result. The results of the current study are, to the researcher’s knowledge, a true reflection of the data. 5.10 CONCLUSION In chapter five, the purpose of the study, the research approach, research design and research procedures that were utilised in the study were explained. Further, the data collection and data analysis procedures, the ethical guidelines, as well as the quality criteria of the research were discussed. In chapter six the results of the data analysis and data interpretation procedures will be presented. 59 CHAPTER SIX EMPIRICAL DATA AND LITERATURE CONTROL 6.1 INTRODUCTION Chapter five gave a detailed description of the research methodology used in this study. The chapter looked at the qualitative approach that was used, the collective case study design, the purposive sampling method, the data collection and the analysis of the data. The chapter concluded with the ethical considerations that were adhered to during the research. Chapter six presents a discussion of the findings of the research, the results of the interpretative phenomenological analysis as well as the empirical data obtained from the semi-structured interviews. The literature control will serve to contextualise and generalise the analysis and interpretation of the data (Delport, Fouché & Schurink, 2011:303). 6.2 PARTICIPANTS The following section will provide more information about each participant’s background and profession. In order to protect the identities of the participants and maintain confidentiality, each participant received a letter of the alphabet in lieu of her name. Table 6.1 offers a summary of the details of each participant. Participant AA had a Master’s degree in Counselling Psychology and worked in private practice. She offered equine-assisted therapy and had experience working with adults, children, teenagers, youth at risk and women who had been abused. She had been incorporating AAT into her private practice for four and a half years. Participant BB had a Doctorate in Child Psychology and offered AAT with the assistance of her dog. She made use of an eclectic mental health theory, 60 incorporating play therapy, cognitive behaviour therapy (CBT) and a narrative model, when necessary. She primarily worked with children, adolescents and their parents and she had been offering AAT to her clients for nine years. Participant CC held an Honours degree in Clinical Social Work and was completing a Master’s degree in Clinical Social Work. She had offered equine-assisted therapy to her clients for three years and had experience working with adults, children and teenagers. She made use of a psychodynamic approach. Participant DD had a Master’s degree in Counselling Psychology and offered AAT with the assistance of her dog in her private practice. She made use of narrative therapy and transactional analysis. She had worked with clients from any population that sought her assistance and she had been offering AAT for 9 years. Participant AA Participant BB Participant CC Participant DD Gender Female Female Female Female Age 44 50 30 59 Highest degree obtained Masters (Counselling Psychology) Doctorate (Child Psychology) Honours (Clinical Social Work) Masters (Psychology) Funding Private practice Private practice Private practice Private practice Primary mental health theory used Systemic eclectic Eclectic: client centred play therapy, CBT (for anxiety), a narrative model with adolescents Psychodynamic approach using a holistic intervention of theoretical influences. Narrative therapy and transactional analysis Number of years offering AAT 4,5 years 9 years 3 years 9 years Animals incorporated in AAT Horses Dog Horses Dog Table 6.1: Summary of participants’ details 61 6.3 FINDINGS OF THE INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS (IPA) Five main themes relating to the best practices in AAT with children were identified during the interpretative phenomenological analysis. Figure 6.2 is a diagrammatic depiction of the themes and sub-themes that will be discussed in this chapter. Figure 6.1 Overview of themes and sub-themes Exploring best practices in animal-assisted therapy with children in the Western Cape • Sub-theme 1.1: Training as a mental health professional • Sub-theme 1.2: Training to work with animals THEME 1: Training of the animal-assisted therapist • Sub-theme 2.1: Training dogs for AAT • Sub-theme 2.2: Utilising the natural behaviour of horses THEME 2: Training of animals incorporated in animal-assisted therapy • Sub-theme 4.1: Ethical considerations concerning the child • Sub-theme 4.2: Ethical considerations concerning the animal THEME 4: Ethical considerations in animal- assisted therapy • Sub-theme 3.1: Populations included in AAT • Sub-theme 3.2: Populations excluded from AAT • Sub-theme 3.3: Populations requiring specialised management during AAT • THEME 3: Animal-assisted therapy with different client populations • Sub-theme 5.1: Current regulation of AAT in the Western Cape • Sub-theme 5.2: Suggestions for regulation THEME 5: Regulation of animal-assisted therapy 62 6.3.1 Theme 1: Training of the animal-assisted therapist During the research, it became apparent that the therapist’s training in a mental health profession as well as training in animal-assisted therapy is of paramount importance when offering animal-assisted therapy to children. Addendum 6 is a visual summary of the references in the data that related to training for the animal-assisted therapist. 6.3.1.1 Sub-theme 1.1: Training as a mental health professional The majority of the participants stressed the importance of mental health training for therapists in order to achieve best practice in animal-assisted therapy with children. This is supported by the following comments: • “A well-trained psychologist needs to be in the arena, knowing what they are doing” (Participant AA). • “So the mental health is very important, purely because of the powerfulness of the work” (Participant CC). The participants’ comments echo AAT literature, which states that in order to ensure best practice, therapists offering AAT need to be trained mental health professionals (O’Callaghan & Chandler, 2011:98; Pet Partners, 2013:1; Urichuk & Anderson, 2003:23). 6.3.1.2 Sub-theme 1.2: Training to work with animals The majority of the participants felt that therapists should receive specialised AAT training in order to incorporate animals into therapy effectively and to ensure the needs of the child and the animal are met. • “I just feel very strongly about people being trained for this space” (Participant AA). • “Best practice would be that ideally you could be trained in it in some way” (Participant BB). • “That’s one of my biggest things is that, just encouraging people to make sure that they are properly trained” (Participant CC). 63 The literature on AAT also advocates the importance for mental health professionals to be professionally trained to involve animals in their work (Turner et al., 2010:552). Fine (2010:185) asserts that professionals must have training on the techniques of AAT and that therapists need to be made aware of best practice procedures that will ensure quality, as well as safety, for all parties. He cautions that, in the event that therapists do not have adequate training on how to incorporate AAT in their private practice, therapists may inappropriately apply AAT and receive poor results (Fine, 2010:185). The majority of the participants felt that, in order to achieve best practice, training had to be accredited. • “A stringent modular approach that is accredited as well” (Participant AA). • “Accreditation – I mean, this workshop that I went on now, for this weekend, you can get 16 CPD points for that” (Participant AA). Two of the participants mentioned that best practice in AAT with children should entail ongoing training for the therapist and that they themselves are constantly being trained to work with the animals that form part of the therapy they offer. Both of the participants incorporate horses into their therapy. • “My training is ongoing” (Participant AA). • “I have to do continuous training through them” (Participant CC). Literature supports the idea of continuous training for the therapist. The European Society for Animal Assisted Therapy state in their Guidelines of quality assurance in animal-assisted therapy that therapists trained in animal- assisted therapy should continue with supplementary further education in order to gain certification (ESAAT, 2012:1). In contrast with the therapists working with horses, the participants who incorporated dogs in their therapy reported that currently there is no formal training specialising in AAT in the Western Cape. The result is that the participants who include dogs in their therapy have trained themselves in order to incorporate animal-assisted therapy into their practice. 64 • “There hasn’t been a formal training in my field” (Participant BB). • “I have myself done no courses in it. I trained myself” (Participant DD). This is concurrent with the researcher’s findings. To the researcher’s knowledge, there is no formal training for animal-assisted therapy for mental health professionals in the Western Cape. The University of Pretoria in Gauteng offers a short course entitled “Human-animal Interaction” that is aimed at professionals. The course covers topics such as ethics, AAT in practice and the link between animal abuse and violence towards humans. The Ethology Academy, also based in Pretoria, offers a distance-learning course in animal-assisted activities that is based on the research of the late Dr Johannes Odendaal (see 2.4 of chapter 2). It is the researcher’s opinion that the course could provide a good introduction to the field of AAT. Another distance-learning AAA course is offered by PATus, an organisation offering “pet assisted therapy”, and the South African Dog Training College. Pet Partners (based in Washington, US) offers an online Therapy Animal Handler course, however the course is primarily aimed at preparing volunteers for their AAA visitation programme (Pet Partners, 2013b:1). Professional Development Resources, an accredited provider of continuing education to psychologists, social workers and counsellors based in Florida, US, offers an online continuing education course in AAT (Professional Development Resources, 2013:1). In its document entitled “Quality Control in the Practice of Animal-Assisted Interventions”, the International Society for Animal-assisted Therapy (ISAAT) stipulates that a therapist should complete a continuing education programme in AAT from an approved institution (International Society for Animal-Assisted Therapy, 2013a:1). 6.3.2 Theme 2: Training of animals incorporated in animal-assisted therapy The empirical data highlighted the importance of training the animal incorporated in AAT with children. Addendum 7 is a visual summary of the references in the data that related to training the animal for inclusion in AAT. 65 6.3.2.1 Sub-theme 2.1: Training dogs for AAT The participants who incorporated dogs into their therapy stated that best practice in AAT with children would only be achieved if the dogs were trained to assist the therapist. • “She’s received lots of other training, ‘cause they have to be very well trained to work in a medical practice” (Participant DD). • “Minimum standards, I would say that the dog has to have full training, there must be a first certificate, there must be a senior certificate or a diploma, with a registered dog club” (Participant DD). The European Society for Animal-Assisted Therapy stipulates that dogs involved in AAT have to be trained (ESAAT, 2013b:5). Fine, O’Callaghan, Chandler, Schaffer, Pichot and Gimeno (2010:206) feel that dogs incorporated into canine-assisted play therapy need to be well trained, especially if they are involved in non-directive play therapy. The participants who worked with dogs reported that their dogs had received obedience training. One of the dogs had done the Canine Good Citizens test. The Canine Good Citizens test is an assessment in obedience training that was developed and certified by the American Kennel Club (American Kennel Club, 2013:1) • “I was with her for a year with the Kennel Union … and then we also did the Canine Good Citizens” (Participant BB). • “Through the training, through doing certificates and diplomas” (Participant DD). The data revealed two additional benefits of an animal that is obedience trained prior to being incorporated in animal-assisted therapy. During therapy, children gain confidence from working with a well-trained dog and this can be used to develop a child’s self-confidence (O’Callaghan & Chandler, 2011:94). • “It’s very empowering for a child to have a well-trained dog around them” (Participant DD). The other benefit is that the training certifications the dogs received can also assist with regard to liability, should the need arise. 66 • “Proper trained animals in a practice would actually have certificates and diplomas that will actually, can stand for them in court” (Participant DD). In the State of Rhode Island, a therapy dog must by law have a current certificate of good health issued by a veterinarian, and must meet “temperament criteria” consisting of a certificate of good temperament for the animal and training criteria relating to the AAT the dog is involved in (Huss, 2010:28). The researcher did not find any South African law or legal instructions regarding dogs in therapy. 6.3.2.2 Sub-theme 2.2: Utilising the natural behaviour of horses None of the participants mentioned the need to train horses for AAT. However half of the participants indicated that the horse acts as a mirror for the child and their deep inner experience. • “The horse mirrors everything that is going on in the person and its actually a lot of times we’re asked if the horses are trained to do this, but its just natural – they are prey animals and so they naturally do that, they instinctively do that” (Participant AA) • “We’ve had several kids that have been very unruly, behaviour not socially adequate, verbally, emotionally disruptive, aggressive and the horses reflect it, mimic it and the kids learn from it” (Participant CC) Frewin and Gardner (2005:5) emphasize that the benefit of AAT involving horses is that the horses respond to the immediacy of your intent and behaviour and Rothe, et al. (2005:375) state that the horse acts as a mirror for the child and his or her deep inner experience. 6.3.3 Theme 3: Animal-assisted therapy and different client populations The AAT literature confirmed that AAT can be used in the treatment of various populations but that certain client populations are better suited for AAT than others; however, there is little research on animal-assisted therapy for 67 targeted populations (O’Haire, 2010:230). In order to achieve best practice in AAT with children, it is important to ascertain which populations are best suited to AAT, which require exclusion from this form of therapy and which client populations need to be carefully managed during AAT. 6.3.3.1 Sub-theme 3.1: Populations included in AAT The participants suggested a number of populations that they felt should be included in AAT. The majority agreed that adults, adolescents and children all benefit from animal-assisted therapy. • “I mean, with adults, they would sit, adults and adolescents, sit on the floor with my dog, ‘cause its healing for them” (Participant DD). • “I’ve seen benefits in all areas, you know with adults, with children” (Participant AA). • “I work with adults, adolescents and children” (Participant DD). • “I thought she would be good with, for the children but actually it works very, very excellently with the adults” (Participant DD). The literature review on AAT confirms what the empirical data revealed; AAT is regarded to be effective for adults, adolescents and children (Fine, 2010:183; Trotter, Chandler, Goodwin-Bond & Casey, 2008:270). The majority of the participants also agreed that socio-economic status does not play a role in whether or not a child will benefit from AAT, in fact the empirical data revealed that one of the advantages of animal-assisted therapy is that it can be valuable to both disadvantaged and affluent populations. • “It doesn’t matter which population you take, even if you take underprivileged kids from a township through to kids who come from middle class or upper society” (Participant CC). • “I believe it’s one type of therapeutic technique that does not discriminate and can be used across populations. That’s what’s so nice about working with an animal, they don’t understand race, creed, 68 intellect or anything like that, they just relate to you, as you are” (Participant AA). The participants who incorporate horses in their therapy agreed that clients who struggled with substance abuse would benefit immensely from AAT. They hasten to add that clients who struggle with substance abuse should not be part of AAT if they are currently using drugs, as they will risk the safety of all involved. • “I do believe that it works very, very well with the addictions, because of the manipulative behaviour that the addicts use. The horses just have a very honest way of telling them what’s what and it’s up to the addict to change their mind or make the change” (Participant CC). • “I wouldn’t want to work with people who are under the influence of drugs or alcohol, basically because their senses and emotions are deadened” (Participant AA). The literature on AAT asserts that, although there is a lack of empirical evidence to support AAT benefiting the substance abuse population, several rehabilitation programmes in the United States provide such therapeutic services (Wesley, 2006:53). Cody, Steiker and Szymandera (2011:199) suggest that the field of animal-assisted therapy with equines is so broad in terms of the populations that it serves that the research has been sporadic and has not built on the research that had been done previously. The majority of the participants indicated that elderly people would benefit greatly from AAT. • “I think there is immense space for it to move into, I think with the elderly” (Participant BB). Hart (2010:64) states that AAT sessions with an elderly person can reduce loneliness significantly and Baun and Johnson (2010:286) suggest that animals are therapeutic for elderly people who are living in an institution. The majority of the participants have experience offering AAT to youth at risk and one participant had worked with children who had foetal alcohol syndrome. 69 There is literature that supports the inclusion of both of these populations (De Villiers, 2005: 60; Trotter et al., 2008:255). 6.3.3.2 Sub-theme 3.2: Populations excluded from AAT The data revealed a lack of consensus on which populations should be excluded from AAT as each participant suggested a different population. Extreme fear of or phobias regarding animals were enough reason for one participant to feel a client should be excluded, however another participant felt that such a client could benefit from AAT and should be included in AAT but would require careful management. One of the participants mentioned that children had been referred to her specifically to work on their phobia of dogs. • “I have had people where the reason for referral is dog phobias and obviously she (referring to the therapy dog) is part of the process” (Participant BB). It was felt that severely physically or intellectually impaired children, people who do not like animals, people who are very sensitive to touch and smell and very young children would not benefit from AAT. • “With regards to equine-assisted therapy, your severely mentally challenged populations. Purely because the process we work on is through metaphors and reflecting and they cognitively can’t conceptualise” (Participant CC). • “I also think people that maybe on a sensory level are very very sensitive for smell and for touch, are not going to enjoy it because an animal is touch. So that’s going to spin them out, if their sensory integration for touch is not okay, and for smell” (Participant DD). There is very little literature on which populations should be excluded from AAT. Grandin, Fine and Bowers (2010:251) state that, although AAT may be beneficial for some children and adults with autism spectrum disorders, for others it will not be effective due to the client’s sensory oversensitivity (be it smell, touch or sound). Davis (2011:39) states that a client who believes that animals have no place being inside may not be able to relax and benefit from 70 AAT in indoor settings. Other authors (Filan & Llewellyn-Jones, 2006:607) - suggest that aggressive clients present a danger to the animal and the therapist, and should generally be excluded from AAT. Urbanski and Lazenby (2012:279) suggest that a thorough history of the child’s allergies, past animal experiences and immune status be conducted prior to making a decision regarding the inclusion in AAT. 6.3.3.3 Sub-theme 3.3: Populations requiring specialised management during AAT As previously mentioned, the majority of the participants felt that children who suffer from phobias towards animals should be carefully managed during AAT, but that it did not necessitate exclusion of this population from AAT. The empirical data revealed that people dealing with psychosis, people who fear or are anxious about animals, children who have been attacked by an animal and children who are not comfortable with animals due to cultural reasons should all be included in AAT. However, the therapy will require careful management and the therapist may initially have to work on desensitising the child. • “I think anxieties definitely, of course you can still work with them but you really have to be a lot more careful and definitely very skilled in that area, in order to not trigger anything further” (Participant AA). • “Another challenge can maybe be, if the child is fearful of an animal or of a doggie, to actually desensitise a child” (Participant DD). The literature on AAT suggests that cultural differences remain poorly understood, little is known about how cultural background and beliefs interact with the therapeutic outcomes using AAT, and that research is needed to make AAT culturally relevant and sensitive (Melson & Fine, 2010:241). Children who have been attacked by a dog may experience extreme fear and anxiety (Boat, 2010:275) a large amount of therapy and time may be needed before the fear and anxiety diminishes (Boat, 2010:276). Barker and Dawson (1998: 800) found the reduction in anxiety for patients with psychotic disorders was twice as great after animal-assisted therapy as after therapeutic 71 recreational intervention; however, the authors do not mention whether or not the participants required specialised management. 6.3.4 Theme 4: Ethical considerations in animal-assisted therapy The ethical considerations in AAT tend to be a little more complex than in traditional talking therapy, as the therapist is not only concerned about treating the child ethically. The therapist needs to ensure that the animal is also treated ethically, in order for the therapy to be deemed best practice. Many of the ethical considerations concerning the child also pertain to the animal, for example, the safety of both the child and the animal was regarded by the participants to be very important. 6.3.4.1 Sub-theme 4.1: Ethical considerations concerning the child The majority of the participants felt the safety of the child was the key ethical consideration in order to achieve best practice in AAT with children. • “Definitely safety working around horses and just allowing the children to have an understanding about what it is” (Participant CC). • “One needs to obviously consider their (the clients’) safety, so with (the dog) I’m very aware of parasites and her health and that kind of thing. One also has to be aware of how (the child) interacts with her, because she’s a very calm, well-trained dog but obviously if someone hurts her she would be aggressive, so (the therapist) has to watch” (Participant BB). The literature on AAT concurs that safety is the foremost concern for the therapist (Rothe et al., 2005:381). Turner, et al. (2010:555) point out that an empirical research base is currently being undertaken in the United States in order, among other things, to establish whether and under what conditions the incorporation of animals in therapy is safe and effective. Whilst discussing the need to have an equine facilitator to assist the therapist in therapy sessions that incorporate horses, one participant had the following to say: 72 • “Had I not had my co-facilitator there, having had their training, a session could have been very different and it’s not ethically responsible to the clients that are coming to see you (to not have an equine facilitator), as well as your safety aspects for both horse and client” (Participant CC). The literature on AAT also advocates the involvement of an equine professional, when working with horses in therapy (Trotter et al., 2008:261; Cody et al., 2011:199) in order to ensure the safety of all the parties involved. Protecting the child’s best interests was deemed an important ethical consideration in AAT with children. Melson and Fine (2010:240) state that responsible clinicians, who are aiming for best practice in the field of AAT with children, will give equal priority to the welfare of participating animals and children, and that guidelines for best practices in AAT with children would include choosing an animal that meets the child’s needs (Melson & Fine, 2010:241). Honesty and respect are critical in any therapeutic relationship (Van Servellen, 1997:93). The data revealed the importance of being honest and respectful and, as a result, explaining AAT to the child before the child begins therapy was considered very important. • “Ethical is that you need to be honest and you need to explain everything about the dog that forms part of the therapy before the individual enters the office” (Participant DD). • “You need to show respect to the patient, to the client and to your dog” (Participant DD). The literature on AAT concurs that proper integration of the animal in a safe therapeutic partnership is based on mutual respect (Serpell et al., 2010:482). Being mindful of the powerful nature of AAT and being able to contain the child when dealing with the unresolved issues that may surface was another ethical consideration raised by the participants. 73 • “I think a mindfulness that this is not some sort of “mickey mouse” intervention, this is very, very powerful. And so that anybody who is going to do this intervention needs to be trained in a way that is able to contain and able to work in that space, but containing so that people don’t get left out there raw and exposed and vulnerable and then react to that” (Participant AA). • “It’s treated exactly the same as if the client was coming for a therapeutic session in a private practice, confidentiality and obviously safety with the client as well, debriefing and containment” (Participant CC). Fine et al. (2010:198) believe that an exciting new season begins as soon as a therapist learns about the power of incorporating an animal into psychotherapy. Kruger and Serpell (2010:35) emphasise that AAT is defined as an intervention that must be delivered or overseen by health/human service professionals practising within the scope of their profession. This illustrates the importance of a well-trained mental health professional (see 6.3.1.1) providing AAT to children. 6.3.4.2 Sub-theme 4.2: Ethical considerations concerning the animal The empirical data revealed the importance of considering the dog’s best interests. • “Protecting (the dog’s) best interests and protecting the child’s best interests … You’ve got to look at both best interests” (Participant BB). • “Some people don’t like animals, and that’s okay. And you as therapist that has a dog mustn’t be offended by that, or anything. It’s still what’s best for your client” (Participant DD). It is the ethical responsibility of the therapist to ensure the safety of the animal that is involved in AAT with children. Most of the participants mentioned special precautions that need to be taken when considering the animal’s safety. 74 • “Space, space for the dog – is there a safe space for the dog?” (Participant DD) • “I had one little (child) who was quite aggressive with (the dog), so then I had to move her out of the therapy space with him because I didn’t feel she was safe” (Participant BB). Best practice in AAT with children thus entails that the safety and well-being of these animals are safeguarded at all times (Serpell et al., 2010:482). Therapy animals should never be placed in any situation where there is the possibility that they could be at risk, either physically or emotionally (Serpell et al., 2010:482) and safeguards should be in place to ensure that the animal is safe, in the event that a child has a behavioural meltdown (Grandin et al., 2010:260). The therapist also needs to protect the animal’s best interests, needs and health, at the same time seeing to the needs and best interests of the child, as stated by the following participants: • “Ethics would be that you need to be aware of the animal’s needs as well as the human’s needs in the environment, and to be respectful of both, that would be the basics of the ethics, the best interests of both must be protected” (Participant BB). • “(The dog) is not just another toy in the playroom, she’s also an animal, with needs of her own” (Participant BB). The literature on AAT agrees that understanding animals’ social and behavioral needs is part of the ethical obligation of therapists (Evans & Gray, 2012:602; Serpell et al., 2010:482). The data revealed that the therapist has to consider the animal’s health, especially as the therapy animal ages. • “I am becoming aware of, and its going to be a new challenge for me, (the dog) is now eight years old, until now she’s had boundless energy. I am starting to notice that she gets tired, so I am going to have to start … [pause]. I need to be aware of that, I can’t expect her to maybe have as much face time with children. I maybe need to sometimes 75 give her breaks now, whereas before she never needed that. I am just aware of her changing needs and that’s a change for me” (Participant BB). Serpell et al. (2010:484) discuss the challenges that occur when therapy animals begin to age. They suggest that the therapy animal’s schedule for therapeutic involvement should be reduced, even if the adjustment disrupts the therapy practice. 6.3.5 Theme 5: Regulation of animal-assisted therapy Regulation of AAT would be the first step towards ensuring best practice in AAT with children. A regulating or governing body will ensure that its members attain official recognition as animal-assisted therapists (ESAAT, 2013a:1) will advance knowledge about research on the positive effects of AAT (Pet Partners, 2013b:1) and “will ensure the quality control of public and private institutions which offer continuing education/training in animal-assisted therapy” (ISAAT, 2013b:1). 6.3.5.1 Sub-theme 5.1: Current regulation of AAT in the Western Cape The empirical data revealed concerns regarding the quality of training in AAT. A concern that could be dealt with through mandatory membership with a governing body is unqualified “therapists” offering AAT. • “I would definitely like to see a lot more enforcement on qualifications and enforcing of training and ethical responsibility. I really feel that there are … its exciting to know how many people are open and wanting to do this work but it’s also very dangerous, the amount of people that are not properly qualified and just wanting to start this work because they know something about horses and have some form of psychology background but it’s not mental health based” (Participant CC). The participants who were Psychologists were registered with the Health Professions Council of South Africa (HPCSA) and the participant who was a 76 Clinical Social Worker was registered with the South African Council for Social Service Professions (SACSSP). The participants who were Psychologists were thus compelled to abide by the ethical rules and regulations of their council that are based on the South African Health Professions Act 56 of 1974 (South Africa, 2006:51). However, the ethical rules and regulations concern the therapists’ interaction and behaviour towards the client but not necessarily towards the animal. 6.3.5.2 Sub-theme 5.2: Suggestions for regulation When the participants were asked what they regarded as best practice in AAT with children, the participants expressed a need for a governing body in the Western Cape that would regulate and certify therapists using AAT as well as provide guidelines and protect the therapists, clients and animals involved. • “A governing body, a board that makes people everywhere accountable, that you cannot practise … that you need a practice number and if you don’t have a practice number, you need to stop (practising)” (Participant AA). • “Everyone is certified under a body and that there is an ethical board that they are responsible to” (Participant CC). • “Guidelines that protected the animals in their environment and protected you as therapist and protected who you are working with” (Participant BB). It was felt that recognition by the HPCSA would assist with the regulation of AAT in the Western Cape, possibly resulting in the development of a regulatory body specialising in AAT. • “Equine therapy needs to be recognised as a therapeutic intervention with the HPCSA” (Participant AA). In order to advance AAT into a recognised evidence-based intervention, quality evidence-based research is needed to prove how effective it is (Turner et al., 2010:567). 77 6.4 CONCLUSION The interpretative phenomenological analysis of the interviews, field notes and biographical questionnaires revealed five main themes with regard to best practice in AAT with children. These themes form the basis of the recommendations that will be discussed in chapter seven. The recommendations aim to assist mental health professionals who are already offering or would like to offer AAT to children in the Western Cape by contributing to dialogue and extending the knowledge of best practice in AAT. 78 CHAPTER SEVEN EVALUATION OF THE RESEARCH, CONCLUSIONS AND RECOMMENDATIONS 7.1 INTRODUCTION Chapter six provided the results of the data analysis and the empirical data collected from the research was compared to available literature on AAT. Chapter seven will focus on an evaluation of the research process, conclusions drawn from the study, and the limitations and contributions of the research. This chapter will conclude with recommendations that are based on the findings of the research. 7.2 EVALUATION OF THE RESEARCH The research aimed to explore and describe the best practices of professionals such as Registered Counsellors or Psychologists (registered with the Health Professions Council of South Africa) or Social Workers (registered with the South African Council for Social Service Professions) that offer animal-assisted therapy (AAT) to children in the Western Cape, with the intention of raising awareness and contributing to the dialogue of AAT within a therapeutic context in South Africa. A qualitative approach was employed in order to gain in-depth knowledge about the topic. The collective case study design enabled the researcher to interact with a small number of research participants. The sample consisted of four trained mental health professionals who had experience providing AAT to children and were willing to discuss their experiences of AAT. Semi-structured one-on-one interviews, field notes and biographical questionnaires were the methods of data collection. Interpretative Phenomenological Analysis (IPA) and an AAT conceptual framework guided the analysis and interpretation of the data. 79 7.2.1 Aim of the research The aim of the research was to explore and describe best practice in the field of AAT with children in the Western Cape. The study aimed to add to research regarding AAT in South Africa and contribute to dialogue with regard to best practice in AAT with children in the Western Cape. 7.2.2 Objectives of the research The researcher is of the opinion that the aim of the research was accomplished through the following objectives: 7.2.2.1 Objective one • To explore and describe best practices of professionals offering animal-assisted therapy to children in the Western Cape. Objective one was achieved through the use of a qualitative descriptive approach and a collective case study design. Participants who met the criteria as stipulated in 5.5.1 of chapter five were identified through purposive sampling. Semi-structured interviews were conducted with four participants. Three cases are regarded to be a very useful sample size for the first time a researcher uses interpretative phenomenological analysis. Four cases were advantageous as it offered the researcher an opportunity to obtain rich data regarding AAT with children in the Western Cape. Field notes and a biographical questionnaire were used as additional methods to collect data. All of the participants were English speaking. Although the criteria specified that the participants could be male or female, the participants were all female. 7.2.2.2 Objective two • To gather descriptions and formulate conclusions regarding the best practices for animal-assisted therapy as provided by professionals working in the South African context. The information collected was analysed and interpreted using interpretative phenomenological analysis (IPA) and an AAT conceptual framework based on 80 the review of AAT literature. Five main themes and eleven sub-themes relating to the best practices in AAT with children were identified during the interpretative phenomenological analysis. The themes and sub-themes were then compared to the available literature on AAT. Conclusions were drawn from the analysis and interpretation of the data and recommendations regarding best practice in AAT with children were made. 7.2.3 The research question The research aimed to answer the following research question: What are the best practices utilised for animal-assisted therapy with children in the Western Cape? The researcher chose to use a qualitative descriptive approach in an attempt to explore the views of the participants in this study, to describe and understand the phenomena (Fouché & Delport, 2011:65) regarding best practice in AAT with children. A qualitative descriptive approach enabled the researcher to gain an understanding of the participants’ perceptions and experiences of AAT with children. Semi-structured interviews, biographical questionnaires and field notes were the data collection methods that were used in the research. The multiple methods of collecting data aimed to ensure the credibility, transferability, dependability and confirmability of the research. The rich data that resulted from the various data collection methods was analysed using interpretative phenomenological analysis and resulted in five main themes relating to best practice in AAT with children. The researcher is of the opinion that the research question was answered by the research findings. 7.3 CONCLUSIONS FROM THE LITERATURE REVIEW The literature review led to the following conclusions: • The literature review on animal-assisted therapy The term animal-assisted therapy refers to psychologically, physically and developmentally therapeutic activities that include an animal 81 working alongside a therapist. The animal forms part of the goal- directed intervention (Pet Partners, 2013a:1) chosen for the client by the therapist. Animal-assisted therapy (AAT) differs from animal- assisted activities (AAA) in that AAT is goal-directed and includes the involvement of a therapist, whilst AAA includes animals in activities that may have therapeutic value but are not necessarily goal-directed and do not require the direction or supervision of a therapist. A variety of wild and domesticated animals such as alpacas, goats, donkeys, rabbits and dolphins have been incorporated into AAT, however the literature suggests that dogs, cats and horses (Beck & Katcher, 1996:136; VanFleet 2008c:18) are the animals most commonly included in AAT. Although there is evidence that AAT has a long history, AAT began to gain true momentum in the early 1990s and is thus considered a relatively new field. AAT has grown in popularity, has gained wide acceptance and is evolving into mainstream psychology (Uyemura, 2011:2). Research indicates that populations such as the elderly (Krause-Parello, 2012:201), children who have been abused (Parish- Plass, 2008:12), adolescents with behavioural impairments (Katcher & Wilkins, 1998:194), people suffering from personality disorders (Hardiman, 2010:15; O’Haire, 2010:231) or depression (Souter & Miller, 2007:178) can all benefit from AAT. AAT has also been found to be effective with people living with Alzheimer’s disease (Hooker, Freeman & Stewart, 2002:20) and dementia (Williams & Jenkins, 2008:34). Research has shown that the physical benefits of AAT include decreased blood pressure and increased levels of oxytocin (Odendaal, 2002:137) and the mental benefits include decreased depression and anxiety. Within the therapeutic context, AAT aids the creation of a safe and supportive environment and serves to build rapport and trust between the therapist and the client (O’Callaghan, 2008:73). Literature suggests that an animal within the therapeutic context can serve as a 82 model for a healthy relationship and that AAT provides clients with the opportunity to master certain skills, thus improving their self-esteem. Although a fair amount of research has been done in the field of AAT, more is required in order to establish credibility for the field. Literature suggests that research is required in order to develop more rigid guidelines for therapists who are offering this form of therapy in their private practices (Turner, Wilson, Fine & Mio, 2010:569). Such guidelines should identify the conditions necessary to preserve the health and safety of the clients and the animals involved in AAT. • The literature review on best practice The term “best practice” suggests the quality of an exercise, in other words, how well a task is performed. The literature concerning best practice suggests that determining what forms best practice needs to be drawn from a collective view, not just one individual’s experience (Quality Planning, 2012:2). Research can support the success of a practice and thus assist in determining what constitutes best practice in a specific profession. The literature indicates that best practice is dynamic in nature – what is considered to be best practice today may be “superseded in the future by advances in practice or technology, changes in law or authority structures and expectations, values, knowledge or other influences that outdate methods or make them less relevant, useful or appropriate” (Quality Planning, 2012:2). Therefore, what is considered best practice in a particular field needs to be reviewed frequently. Certain criteria stipulate what can indeed be described as best practice within a profession. The practice must be accepted among practitioners, validated by legal processes and regarded as achieving the best outcome consistently, in order to be labelled best practice. The practice must also offer the “best value for money, meet the needs of particular circumstances, be adaptable, be consistent with local and 83 international standards and be accepted by primary stakeholders” (Quality Planning, 2012:3). • The literature review on children in the Western Cape The Western Cape is the most southern province of South Africa, at the tip of the African continent. The province of the Western Cape covers an area of 129 370 km2 and has a population of 5,2 million people (Statistics South Africa, 2012a:44), approximately 10,4% of the South African population. According to literature there are approximately 1 463 804 children, aged 0–14 years, in the province of the Western Cape. The government provides Child Support Grants to just over a third of the children in the province. Statistics indicate that 97,3% of the people under the age of twenty years in the Western Cape have received formal education. Literature states that substance abuse is a major concern in the Western Cape and that alcohol remains the most frequently abused substance, resulting in one of the highest Foetal Alcohol Spectrum Disorder rates in the world (Harker et al.,2008:9). Methamphetamine abuse is also a major problem in the Western Cape; it is the cause of many of the social ills in the province. 7.4 FINDINGS OF THE RESEARCH STUDY The five themes that were identified from the empirical data were verified and supported by literature. The following section is a summary of the findings of the study. The research participants emphasised the importance of the therapist’s training in both mental health and AAT, in order to achieve best practice in AAT. It was felt that AAT is a powerful form of therapy and thus requires a well-trained mental health professional who has received specialised AAT training in order to incorporate animals into therapy effectively and to ensure 84 that the needs of the child and the animal are met. It was felt that AAT training must be accredited and that training should be continuous. The empirical data revealed that currently there is no formal training specialising in AAT in the Western Cape, thus the participants who include dogs in their therapy have trained themselves in order to incorporate animal-assisted therapy into their practice. The data revealed the importance of including an animal in AAT that is trained to be in the therapeutic space. The participants that were interviewed incorporated dogs and horses into their therapy. Those who incorporated dogs into their therapy reported that their dogs had received obedience training prior to being involved in AAT. The dog of one of participants had completed the Canine Good Citizen Test. The empirical data did not reveal the need to train horses specifically for AAT. This may be due to the manner in which horses are incorporated into AAT as their role is to reflect the child’s behaviour or to act as a mirror for the child and his or her deep inner experience. The empirical data obtained indicated that, while certain populations would benefit from AAT, other populations would not benefit, and yet other populations would require careful management during AAT. The empirical data suggested adults, adolescents, children and elderly people from all socio-economic populations should be included in AAT. There was a lack of consensus amongst the participants regarding which populations should be excluded from AAT; some participants felt that a child with a phobia towards the animal incorporated in therapy should be excluded, while other participants felt the child could be carefully managed in AAT. It was also revealed from the empirical data that children who do not like animals, are severely physically or intellectually impaired or are oversensitive to sensory stimuli, would not benefit from AAT. It was felt that very anxious children, children living with phobias, dealing with psychosis or who are not comfortable with animals due to cultural reasons, require careful management during AAT. The majority of the participants felt the safety of the child was the key ethical consideration. However, the participants added that both the child’s best interests and the animal’s best interests need to be catered for, in order to 85 achieve best practice in AAT with children. The participants felt an important ethical consideration is that AAT has to be delivered by a trained mental health professional who is able to contain the child’s emotions during the therapy sessions. The empirical data suggested that protecting the child’s best interests was deemed an important ethical consideration in AAT with children. The participants emphasised the importance of being honest and respectful and, as a result, explaining AAT to the child before the child begins therapy was considered very important. It was felt that it is the therapist’s responsibility to ensure that the safety and best interests of the animal are taken care of. The therapist also needs to consider the animal’s health, and even more so as the therapy animal ages. The empirical data revealed concerns about the quality of the AAT training available in the Western Cape and concerns about individuals, without mental health certification, who offer AAT. The participants expressed a need for an AAT governing body in the Western Cape. The empirical data suggested that recognition by the Health Professions Council of South Africa would assist with the regulation of AAT in the Western Cape, possibly resulting in the development of a regulatory body specialising in AAT. 7.5 CONCLUSIONS OF THE STUDY The study aimed to discover the best practices of mental health professionals that offer AAT to children in the Western Cape. The research revealed that best practice in AAT with children requires a trained and certified mental health professional. The professional needs to be well trained in AAT and assisted in therapy by a well-trained animal. The literature on AAT also highlights the importance for mental health professionals to be professionally trained to involve animals in their work and supports the idea of continuous training for the animal-assisted therapist. The study suggested that the therapist that endeavours to attain best practice in AAT considers the best interests of both the child and the animal and has the training and the skills required to contain the child within the therapeutic space. The literature on AAT confirms that best practice in AAT with children entails that the safety 86 and well-being of both the child and the animal are to be safeguarded at all times. The study brought to light that certain populations are well suited to, and will benefit from, AAT while in other populations AAT may be counterproductive. In order to achieve best practice with children, therapists offering AAT need to have an understanding of which populations are likely to benefit from AAT, which populations should be excluded and which should be carefully managed during AAT. The study revealed that responsible therapists, who are aiming for best practice in the field of AAT with children, will give equal priority to the welfare of the animals and the welfare of the children involved in AAT. Guidelines for best practices in AAT with children should include the importance of the safety of the child and the animal and the necessary steps required in order to ensure safety of all the parties involved. The empirical data revealed that there is a need for the regulation of AAT, specifically with regard to mental health certification and AAT training, if best practice in AAT with children is to be achieved. The literature on AAT supported the need for the regulation of AAT, in order to achieve best practice in AAT with children. Literature on AAT advises that a regulating or governing body will ensure that its members attain official recognition as animal-assisted therapists (ESAAT, 2013a:1), will advance knowledge about research on the positive effects of AAT (Pet Partners, 2013b:1) and will ensure the quality control of public and private institutions which offer continuing education/training in animal-assisted therapy (ISAAT, 2013a:1). Regulation of the field would also provide guidelines for therapists who offer, or intend to offer, AAT to children and would protect the therapists, children and animals involved in this form of therapy. 7.6 POSSIBLE CONTRIBUTIONS OF THE RESEARCH Research on best practice in AAT is needed in order to bridge the gap between clinical practice and best practice research (see 2.4). The current 87 study aimed to add to the research in AAT in South Africa and contribute to dialogue with regard to best practice in AAT with children in the Western Cape. It is the researcher’s hope that increased dialogue regarding best practice in AAT, as a result of the research, will give rise to an increase in AAT with children that is of a high standard. The study endeavoured to extend the knowledge of best practice in AAT, providing conclusions that would assist mental health professionals who offer, or are planning to offer, AAT to achieve best practice in AAT with children. Evidence-based practice refers to high-quality mental health practice that is based on sound scientific research (see 3.3). Evidence-based practice requires practitioners to follow psychological approaches and techniques that are based on the best available research. The study provides evidence- based research on what constitutes best practice in AAT with children. By applying the principles of the Kauffman Best Practice Project (see 3.3) to AAT with children in the Western Cape, the following suggestions can be made: • AAT should have “at least one randomised, controlled treatment- outcome study indicating its efficacy with children and/or their families “ (Hensler et al., 2004:7) in the Western Cape. If multiple treatment- outcome studies have been conducted, the overall weight of evidence would support the efficacy of AAT with children in the Western Cape. • A book, manual, or other literature, that specifies the elements of the treatment protocol of AAT with children and describes how to conduct it, should be made available to clinical professionals (Hensler et al., 2004:7). 88 • AAT should be “delivered in common service delivery settings” serving “children and their families with a reasonable degree of treatment fidelity” (Hensler et al., 2004:7). • Only mental health professionals who have “received a reasonable level of training and supervision in its use” (Hensler et al., 2004:7) should deliver AAT to children in the Western Cape. By connecting the findings of the research with recommendations and subsequent suggestions for action, the research offers solutions to the problem statement that was stipulated in chapter one (see 1.1). The research has highlighted the need for the regulation of AAT in the Western Cape and the need for continuing education and training for mental health professionals offering AAT to children. It is hoped that the research will lead to these two needs being fulfilled in the near future. 7.7 POSSIBLE LIMITATIONS AND STRENGTHS OF THE RESEARCH The following section will detail the limitations and the strengths of the research. It is hoped that the acknowledgement of the strengths and limitations in the current study will aid future research. 7.7.1 Possible limitations of the research The following limitations of the research are acknowledged: 7.7.1.1 Gender of the participants The research participants were all female as all participants who were willing to participate in the research were female. No male mental health professionals offer AAT in the Western Cape. The researcher recognises that the results of the research may have differed if the sample had comprised both genders. 7.7.1.2 The sample size Due to the limited number of therapists offering AAT to children in the Western Cape and the very specific criteria with regard to inclusion in the 89 study, the sample consisted of only four participants, thus findings from the research cannot be generalised as further expansion could result in findings that differ from the present study. 7.7.1.3 Researcher bias The researcher had been interested in AAT for seventeen years prior to the research and therefore had preconceived ideas and opinions regarding best practice in AAT with children. The researcher acknowledged and discussed any personal bias that may have affected the research (Hunt, 2009:1289), in the hope that this would lessen the influence of the researcher’s preconceptions during the analysis and interpretation of the data. 7.7.2 Possible strengths of the research The following strengths of the research are acknowledged: 7.7.2.1 Consolidation of study findings The findings of the study could be confirmed by existing theory on the subject of animal-assisted therapy, which confirmed the findings of the study. 7.7.2.2 Rich and detailed descriptions The choice of semi-structured interviews served to build rapport between the researcher and the participants and generally contributed to the rich and detailed descriptions given by the participants. 7.8 RECOMMENDATIONS Based on the available literature regarding AAT with children and the research findings, the researcher proposes the following recommendations: 7.8.1 Recommendations for training in AAT The data revealed that there is a need for training that specialises in AAT in the Western Cape. Therapists trained in the techniques of AAT and educated in best practice procedures would be more likely to attain best practice in AAT with children. 90 7.8.2 Recommendations for further research AAT with children requires evidence-based research that documents actual intervention in order to gain recognition in the mental health profession (Turner et al., 2010:570). The field of AAT is growing faster than the evidence of its effectiveness is being produced. As previously mentioned, research in AAT has been sporadic and did not build on the previous research that had been done (Cody et al., 2011:199). The mental health profession will only begin to recognise AAT with children once well-planned and well-executed research becomes available. It was the researcher’s intention to add to the understanding of AAT in South Africa. Although the research focused on the Western Cape, it is felt that the research has contributed to the understanding of AAT in South Africa. In order to generalise the findings of the current study, it is recommended that similar research be done with a much larger sample of mental health professionals who offer AAT to children, thus further research is required on best practice in AAT with children in South Africa. 7.8.3 Recommendations for ethical considerations in AAT with children The research revealed that there are numerous ethical considerations with regard to both children and animals in AAT. The researcher feels that ethical rules and regulations regarding AAT with children need to be compiled. 7.8.4 Recommendations for the regulation of AAT The data revealed that there is a need for a regulatory body in the Western Cape that is dedicated to assisting and regulating mental health professionals who practise AAT. Worldwide, AAT has grown substantially over the last two decades and seems set to continue to do so in the future. Until such time as a mandatory regulatory body is set in place, clients will have to rely on the morals and personal ethics of the therapists who offer AAT and trust that the therapists are responsible and believe in the value of achieving best practice in the therapy they offer. 91 7.8.5 Recommendations for best practice in AAT with children Fine (2010:566) states that the debate on what really constitutes best practice in therapy continues to elude many professions, including the field of psychology. What constitutes best practice in AAT is even more difficult to define. However, in order to provide therapy to children that is of a high standard and in order to protect all the parties involved in AAT, it is integral that therapists work towards attaining what they believe to be best practice in the field of AAT with children. Creating an awareness and educating mental health professionals and the public about best practice is the first step towards attaining the goal of best practice in AAT with children in the Western Cape. 7.9 CLOSING REMARKS The findings of the study suggest that the number of therapists offering AAT to children in the Western Cape is likely to increase in the future. The research facilitated the process of attaining a description and an understanding of how therapists who currently offer AAT to children view best practice in the field of AAT with children. It is the researcher’s dream that the knowledge that has been gained in this study will not be forgotten but rather will lead to more discussion on best practice in AAT with children, more research on best practice in AAT with children and ultimately will result in a high standard of practice in the field of AAT with children in the Western Cape. 92 REFERENCE LIST Acts see South Africa. AMADO. 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What do you feel are the special precautions that need to be considered in animal-assisted therapy with children?  What would you like to see as the minimum standards for animal- assisted therapy in South Africa?  How do you see the future of animal-assisted therapy in South Africa?  What are the ethical considerations for animal-assisted therapy?  What do you regard as best practice in animal-assisted therapy? 117 ADDENDUM 2 Consent form PARTICIPANT’S CONSENT TO PARTICIPATE IN RESEARCH Title of the research: “An exploratory study of best practices in animal- assisted therapy with children in the Western Cape.” You are asked to participate in a research study conducted by Jennifer Anne Thompson from the Institute for Child, Youth and Family Studies at North- West University. The results of this study will be in fulfilment of an MA in Psychology. You have been selected as a possible participant in this study because of your knowledge and experience of animal-assisted therapy (AAT). You were selected in order to help the researcher gain a better understanding of best practices in AAT in the Western Cape. 1. PURPOSE OF THE STUDY The research goal is to understand the best practices when using AAT with children. Your input will help to contribute to a broader and more realistic understanding of AAT in South Africa. 2. PROCEDURES If you volunteer to participate in this study, you will be asked to participate in a face-to-face interview that will help the researcher gain a better understanding of your AAT work with children. The interview will take place during an agreed upon time and will last approximately one hour. It will be on a one-on- one basis, occur at your place of work, be audiotaped with your permission and transcribed (written out). All data (information obtained from the interview) will be stored in a safe place and will only be available to the researcher. During the interviews you will be asked to tell the story of your experience of children and AAT. Feedback, if you would like it, will be provided to you before the final report is published. 118 3. POTENTIAL RISKS AND DISCOMFORTS The study will be using semi-structured interviews to explore your experience of AAT with children. This may cause you to feel some discomfort when sharing information, but it will remain your choice what you do and do not want to tell the interviewer. If you feel uncomfortable during the interview because of emotional pain, the interview will be stopped and you will be given the opportunity to get the support and help you need to deal with this pain. You do not have to answer all of the questions and you may choose to stop participating in the research at any time. The researcher will be available to address any queries, issues or concerns and provide you with necessary support in the form of recommendations, information or referrals. 4. POTENTIAL BENEFITS TO SUBJECTS AND/OR TO SOCIETY There are no immediate direct benefits expected from this research. However, the interview may help others to better understand your form of therapy and provide the opportunity for dialogue and it will give you an opportunity to be heard. It is felt that research in AAT will result in more acceptance of this form of therapy. 5. PAYMENT FOR PARTICIPATION You will not be paid for your participation in this study, nor will you have to pay anything to participate in the research. 6. CONFIDENTIALITY Any information that is obtained in connection with this study and that can be identified with you will remain confidential and will only be revealed with your permission or as required by law. To keep your identity secret, pseudo (fake) names will be used for each participant. All data will be labelled with pseudo codes and stored in a locked filing cabinet or on the researcher’s PC that is protected by a password only known by the researcher. The interview with the researcher will be videotaped with your permission, for reference purposes and will be destroyed once the research is complete. The participants have the right to review/edit the tapes. The researcher’s 119 supervisor and North-West University will be able to view the information obtained from the study, however no names of the research participants will be revealed/made known. The final research report, using pseudo names, will be published at North-West University. 7. PARTICIPATION AND WITHDRAWAL You can choose whether to be in this study or not. If you do choose to be in this study, you may withdraw at any time without any consequences. You also do not have to answer questions that you do not want to answer, and still remain in the study. If at any stage you feel uncomfortable or change your mind about participating in the research, you may drop out of the study. The researcher may remove you from this research if circumstances arise which warrant doing so. 8. IDENTIFICATION OF INVESTIGATORS If you have any questions or concerns about the research, please feel free to contact Jennifer Thompson by telephone (0713629908) or email (doreyjenn@gmail.com) or her study leader, Lizane Wilson (23376147@nwu.ac.za). 9. RIGHTS OF RESEARCH SUBJECTS You can choose to stop participating at any stage of the research without penalty. You are not breaking any legal claims, rights or remedies because of your participation in this research study. SIGNATURE OF RESEARCH SUBJECT The information above was described to [me/the subject/the participant] by _________________________ [name of relevant person] in English and [I am/the subject is/the participant is] in command of this language or it was satisfactorily translated to [me/him/her]. [I/the participant/the subject] was 120 given the opportunity to ask questions and these questions were answered to [my/his/her] satisfaction. I hereby consent voluntarily to participate in this study / I hereby consent that the subject/participant may participate in this study. I have been given a copy of this form. ________________________________________ Name of Subject/Participant ________________________________________ ______________ Signature of Subject/Participant Date SIGNATURE OF INVESTIGATOR I declare that I explained the information given in this document to _____________________ [name of the participant]. [He/she] was encouraged and given ample time to ask me any questions. This conversation was conducted in English. ________________________________________ ______________ Signature of Investigator Date 121 ADDENDUM 3 Biographical questionnaire 1. Name:………………………………………………………………………….. 2. Date of birth: ………………………………….. 3. Gender: ………………………………….. 4. Highest degree in the mental health field? ………………………………... 5. Private practice, NGO or state funded? ......………………………….. 6. Do you work with individuals or groups? ……………………………... 7. Which populations do you work with? ……………………………... ………………………………………………………………………………… 8. Which is the primary mental health theory that you use? ………………….……………………………………………………………… 9. How many years have you incorporated AAT into your mental health practice? …………………………………… Thank you for your participation in the study; the time you gave and your involvement are greatly appreciated. 122 ADDENDUM 4 Principles in animal-assisted therapy programmes 1. All animals are to be carefully selected and are subject to behavioural assessment to determine their aptitude for working with people. 2. Staff will be surveyed to determine allergies, fears or dislike of animals and prior relationships with animals. 3. Clients will be surveyed to determine allergies, fears or dislike of animals and prior relationships with animals. 4. The rights of individuals who do not wish to partake in AAT will be considered and an off-limits area for animals will be maintained for this purpose. 5. Therapists should integrate the child’s interactions with animals into their comprehensive treatment plan, with specific and relevant goals. 6. Sessions that involve AAT must be documented in progress notes. 7. A client with a history of animal abuse shall be closely monitored. 8. The temperaments of animals working with clients will be closely monitored. Therapy animals will be permitted to rest every hour and a half and will not work longer than five hours per day. 9. The therapist will process AAT to assist the client in exploring new and possibly previously unexplored issues. 10. The therapist should encourage the client to occasionally work in settings other than the therapist’s office. 11. The therapist should utilise AAT as an opportunity to explore areas that can be regarded as a dress rehearsal for life, for example birth and death. 12. The therapist should utilise AAT as an opportunity to master developmental tasks. 13. The therapist should utilise AAT as an opportunity to promote the child’s feelings of self-worth. 14. The therapist should utilise AAT as an opportunity to promote responsibility and independence in the child. 15. The therapist should utilise AAT to teach the child the need to sacrifice or undergo inconvenience for the sake of a loved one. 123 16. The therapist should utilise AAT to promote companionship, warmth and love. 17. The therapist should utilise AAT as an opportunity to promote and nurture appropriate emotional responses from the child. 18. AAT needs to be integrated into the larger therapeutic milieu and to fit with the other adjunctive therapies the child is receiving as per their individualised treatment plan. Adapted from Mallon, Ross, Klee and Ross, 2010:143. 124 ADDENDUM 5 Criteria used in the Kauffman Best Practices Project When investigating the best treatment protocol for abused children, the Kauffman Best Practices Project used the following criteria (Hensler et al., 2004:6) • Treatment had to have a sound theoretical basis in generally accepted psychological principles indicating that it would be effective in treating at least some problems known to be outcomes of child abuse. • The treatment is generally accepted in clinical practice as appropriate for use with abused children, their parents, and/or their families. • A substantial clinical-anecdotal literature exists indicating the treatment’s value with abused children, their parents, and/or their families from a variety of cultural and ethnic backgrounds. • There is no clinical or empirical evidence, or theoretical basis indicating that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits. • The treatment has at least one randomised, controlled treatment- outcome study indicating its efficacy with abused children and/or their families. • If multiple treatment-outcome studies have been conducted, the overall weight of evidence supports the efficacy of the treatment. • The treatment has a book, manual, or other writings available to clinical professionals that specifies the components of the treatment protocol and describes how to conduct it. • The treatment can be delivered in common service delivery settings serving abused children and their families with a reasonable degree of treatment fidelity. • The treatment can be delivered by typical mental health professionals who have received a reasonable level of training and supervision in its use. 125 ADDENDUM 6 First theme A visual summary of the references in the data that related to training the therapist. THEME 1: TRAINING THE THERAPIST 1.1 Training as a mental health professional AA BB CC DD Psychology Masters 1.1 3.1 3.2 3.8 Clinical social work Honours, studying Masters 3.3 3.5 3.7 Trained to move out of situation or change it 1.47 Importance of mental health training 13.1 13.5 13.7 3.9 13.18 13.34 13.35 1.2 Training to work with an animal AA BB CC DD Workshops 1.3 Ongoing 1.2 1.35 1.37 1.38 Equine-Assisted Psychotherapy Institute of South Africa training 1.4 1.32 Accredited training 1.8 13.14 13.50 13.56 No formal AAT training 1.14 1.15 1.31 1.57 AAT training course in Pretoria 1.17 1.61 Self-trained 1.16 1.58 1.67 1.74 1.76 Gaining confidence to work with dog 1.26 1.27 Training useful 1.28 126 Training creates a sensitivity to animal’s needs 1.29 Equine-Assisted Growth and Learning Association training 1.33 1.36 Qualification with horses 1.40 1.43 Need for training in universities 13.9 10.13 13.83 Importance of training 13.13 13.30 13.31 13.35 13.48 13.49 Training should be based on research 13.32 127 ADDENDUM 7 Second theme A visual summary of the references in the data that related to training the animal. THEME 2: TRAINING THE ANIMAL 2.1 Training dogs for AAT AA BB CC DD Training 1.19 1.49 One year Kennel Union/dog school/dog club training 1.20 1.53 1.54 1.71 13.81 Canine Good Citizen 1.21 Exposed to noises 1.22 Unexpected things 1.23 1.25 Trained in the practice 1.48 Have to be well trained to be in a practice 1.50 1.73 13.67 13.77 13.78 13.79 13.80 Certificates/diplomas 1.52 13.63 13.82 Trained not to attack 1.51 1.55 Trained to meet child in specific way 1.56 Training is important 1.70 A trained dog empowers child 1.75 128 ADDENDUM 8 Third theme A visual summary of the references in the data that related to different client populations and AAT. THEME 3: DIFFERENT CLIENT POPULATIONS AND AAT 3.1 Populations included in AAT AA BB CC DD Adults 12.1 12.32 12.35 12.40 12.41 12.42 Children and teenagers 12.2 12.33 12.34 12.42 Disadvantaged communities 12.3 12.26 Affluent communities 12.4 12.27 12.28 Drug users who are not currently taking 12.5 12.23 12.24 Referral for dog phobias 12.6 All populations 12.7 12.9 12.17 12.20 12.25 Parents of children in therapy 12.8 Elderly 12.15 12.16 12.38 Girls who have been abused 12.21 Youth at risk 12.24 Populations with Fetal Alcohol Syndrome 12.22 People with emotional difficulties 12.36 People with physical impairments 12.37 Cognitive impairments 12.39 3.2 Populations excluded from AAT AA BB CC DD Under influence (drug/alcohol) 12.6 Afraid of animal and AAT not reason for referral 12.7 129 Extreme fear and do not want to work on fear of animal 12.8 12.40 Children who are too young 12.18 12.19 Severely physically disabled 12.30 Severe intellectual challenges 12.31 Children with phobias 12.39 Average fear 12.41 People that don’t like animals 12.42 People very sensitive to smell and touch (sensory integration) 12.43 12.44 3.3 Populations requiring specialised management during AAT AA BB CC DD Psychosis 12.7 Phobias 12.8 12.10 12.36 Cultural reasons 12.10 12.11 Fear 12.13 12.37 People who worry about hygiene issues. 12.12 Children that have been attacked 12.38 130 ADDENDUM 9 Fourth theme A visual summary of the references in the data that related to ethical considerations in AAT. THEME 4: ETHICAL CONSIDERATIONS OF AAT 4.1 Ethical considerations concerning the child AA BB CC DD Safety 15.3 8.22 15.22 Protecting the child’s best interests 15.13 15.14 15.16 Respect 15.15 15.29 Confidentiality 15.23 Debriefing 15.24 Able to contain 15.5 15.25 Mindful about impact of AAT 15.4 15.5 Honesty 15.27 Explain everything about the animal 4.2 Ethical considerations concerning the animal AA BB CC DD Safety 15.3 8.23 15.10 15.12 15.16 Respect 15.29 15.30 Protecting the animal’s best interests and needs 8.21 15.8 15.9 15.13 15.19 Consider animal’s health 15.11 15.18 ADDENDUM 10 Fifth theme 131 A visual summary of the references in the data that related to the regulation of AAT. THEME 5: REGULATION OF AAT 5.1 Current regulation of AAT in the Western Cape. AA BB CC DD Inadequate training 7.7 7.8 5.2 Suggestions for regulation. AA BB CC DD General board for accountability 10.1 HPCSA on board 10.7 13.6 A governing body 13.2 More guidance 10.14 Ethical guidelines 10.16 Lot more enforcement on qualifications, training, ethical responsibility 10.22 10.23 10.24 Everyone is certified under a body 10.25 10.26 Ethical board that they are responsible to 13.51