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Abstract

Background. Animal-assisted therapy (AAT) interventions have been shown to assist in coping and improve patient responses to symptoms. Specifically, the presence of an animal has been found to lower anxiety and motivate participation in therapy. We aimed to explore the acceptability of and experience of AAT during individual breast cancer counseling sessions. Methods. Patients undertaking counseling with a therapy dog present were invited to participate in the study. Patients were individually interviewed and asked to reflect on their experiences of AAT. Data generation and analysis were concurrent. Transcripts were analyzed thematically using a process of constant comparison. Results. Our sample included 8 female participants, 39 to 61 years old, at an average of 3 years post–breast cancer diagnosis. The majority of patients reported a positive experience with AAT. Themes that emerged around their counseling experience included benefits in the process of initiating counseling and benefits for greater engagement and personal disclosure. Conclusions. Incorporating AAT into the delivery of counseling for breast cancer patients appears to be feasible and acceptable at a patient level. From a clinical perspective, AAT promoted increased communication with health professionals. This is of clinical importance as a means to improve participation and engagement in therapy—important elements in therapeutic outcomes. However, further evaluation of the impact of AAT on specific patient outcomes and psychological morbidity is required.

Keywords

breast cancer qualitative animal therapy psychological morbidity

Introduction

Breast cancer continues to be the most commonly diagnosed cancer in Canadian women older than 20 years and is the second leading cause of cancer deaths.¹ Furthermore, psychological distress is highly prevalent, and up to 57% of breast cancer patients experience depression and anxiety.^2-5 As a result, access to supportive intervention is a critical component of cancer care at any time patients are experiencing distress across the spectrum of diagnosis, treatment, and survivorship.

Complementary and alternative therapies, including pet therapy, have been identified by the National Institute of Health as a means for creating a healing environment.^6,7 Pet therapy interventions have been shown to assist coping and improve patient responses to symptoms.⁶ Previous research indicates that animal-assisted therapy (AAT) enhances physical, physiological, and psychological health.^6,8,9 Specifically, the presence of an animal has been found to lower anxiety and motivate participation in therapy.^10,11

Pet therapy or AAT is a group of interventions that involves the incorporation of trained animals in a health care setting to provide diversion, a sense of comfort, and feelings of familiarity.⁶ Various terms are often used interchangeably, and although all these types of programs include animal visitation, there are some important differences. First, AAT is a specific therapeutic activity incorporating the deliberate inclusion of an animal within scheduled sessions underpinned by defined treatment goals.¹² In contrast animal-assisted activities involve access to an animal in the absence of therapeutic goal setting for motivational, educational, and recreational purposes.⁸

It has been hypothesized that the presence of an animal can complement and enhance the counseling process^13,14 by facilitating trust between patient and therapist.¹² Several studies suggest that the presence of an animal facilitates the development of rapport and serves as an icebreaker for discussion between therapist and patient in various diagnosis settings, including mental health and pediatric care.^8,10,12 Furthermore, the presence of an animal can create a neutral environment for sharing, providing a means for diverting feelings of anxiety when patients are sharing difficult and personal information.¹⁰

There is growing interest in the benefits of AAT in various health settings, such as intensive care, pediatric,¹⁵ mental health,¹⁶ spinal cord injury,¹⁷ pain management,^18,19 and aged care.^20,21 However, reliable empirical evidence toward the benefit of including an animal in the therapy process remains inconclusive.²² Assessment of the potential benefit of pet therapy interventions for the treatment of distress has been difficult because of the small number of studies conducted and their methodological limitations. Although some research has been done in pediatric²³ and chemotherapy settings,²⁴ there remains uncertainty about the efficacy of AAT for people with cancer. Many studies report improved patient satisfaction and reduced problems in care^25,26; but they have not differentially explored psychological morbidity.⁶ To our knowledge, there is no research exploring AAT in women with breast cancer.⁶

As a result, there is a need for further research specific to AAT in a breast cancer setting to develop evidence-based practice and policy in a cancer population. We used qualitative techniques to explore research questions inductively in a natural context, so as to provide an opportunity for study participants to give detailed accounts of their experiences and present their own perspectives and interpretation of these experiences,²⁷ which cannot always be captured using quantitative methods.²⁸ The aim of this study was to explore breast cancer patients’ experience and acceptability of the presence of a therapy dog during counseling sessions post–cancer diagnosis.

Methods

Study Design

This was a qualitative study undertaken with breast cancer patients participating in a counseling program with a trained counselor (oncology clinical social worker) working with a therapy animal (5-year-old, female hypoallergenic Standard Poodle cross Labrador Retriever, called Tallulah). For the purposes of this study, AAT was defined as any type of regular interaction with a therapy dog with the intention of creating positive behavioral and emotional changes during counseling. Approval for this project was obtained from the Conjoint Health Research Ethics Board of the Faculty of Medicine, University of Calgary.

Using a pragmatic paradigm,^29,30 a naturalistic approach incorporating in-depth semistructured interviews was used as a means of addressing our research question. This approach was chosen to explore the range, depth, and complexity of cancer patients’ experiences with AAT and the contextual influences on these experiences.²⁷ Data collection and analysis were undertaken concurrently using an inductive thematic approach.³¹ Inductive thematic analysis requires involvement and interpretation by the researcher, using set procedures, to identify both explicit and implicit ideas within the data that allows theorizing about constructs and the generation of themes.^31,32

Recruitment

This study was conducted within the Psychosocial Resources Department, Tom Baker Cancer Centre, Calgary, CA. Patients were eligible for inclusion in the project if they had a diagnosis of breast cancer, were community dwelling, and had participated in a minimum of 3 counseling sessions involving the therapy dog between January and June 2014. Exclusion criteria were severe cognitive or language impairment. Consent to participate in this qualitative study was not a requirement for attending routine counseling. All invited participants (n = 8) were provided with detailed information and invited to participate in this qualitative study. A total of 8 cancer patients gave informed consent to participate in a qualitative interview, forming the sample for this study.

Intervention

A therapy dog, Tallulah, was present in the majority of counseling sessions undertaken with participants in this study. Tallulah has 3.5 years of experience and is certified through the Pet Access League Society, an organization that screens potential therapy animals for their suitability to provide AAT. Prior to participation, Tallulah was examined by a veterinarian and met the University of Calgary sanitary protocol. When patients were referred to the participating counselor at theUniversity of Calgary, they were informed that a dog was present during sessions with the treating counselor involved in this study. Patients who preferred not to spend time with animals were allocated to an alternative counselor, or Tallulah left the room. The goal of Tallulah’s presence was to facilitate participant engagement in therapy and the development of a therapeutic alliance.

Data Generation

The primary author contacted participants to invite consent to participate in an individual semistructured interview, conducted over the phone, at a time convenient to them. Interview duration ranged between 20 and 60 minutes. In-depth interviews were conducted by the first author using an interview schedule.^18,20 However, the participant was free to express views and experiences in her own words and diverge from the interview guide.³³ Interviews began by asking participants to share their “story” of cancer and experience of counseling as a means to develop rapport; subsequent questions explored participant experiences of counseling involving a therapy dog. The iterative process of cumulative and concurrent data generation and analysis, incorporating a process of constant comparison, allowed emergent themes to inform continuing data collection³¹—for example, the experience of increased confidence in sharing.

Data Analysis

Each interview was recorded with participant consent and transcribed verbatim, with identifying data removed. The inductive analysis process included the 3 types of constant comparative method.^31,34 This involved the following: (1) identifying units of meaning using a process of reading the transcripts line by line; (2) grouping units into categories, whereby each category was labeled and given a 4-letter code to assist with retrieval between the data (eg, the experience of comfort was labeled COMF), irrespective of the research question; and (3) examining relationships between codes in the context of the research question to form themes. Data analysis was conducted by 2 authors (JW, MH) with in-depth discussion and input from all authors. Consistency of findings was upheld through discussion of interpretations between researchers to confirm codes and categories. Any differences in researcher perspective were resolved by negotiation and, if necessary, regrouped and recoded until consensus was reached. New codes were then fed back into the analysis to cross-check codes and themes and develop an overall interpretation of the data. The work in 1985 by Lincoln and Guba³⁵ guided the analysis process to ensure rigor, through the strategies of credibility, transferability, reliability, and conformability.

Rigor in this qualitative study was upheld through the strategies of immersion in data, reflexive analysis, memo writing, peer debriefing, and consensus coding between team members and discussion with a broader team.^35,36

Results

Participant demographics are outlined in Table 1. A total of 8 female breast cancer survivors participated in this qualitative study (age range = 39-61 years). The majority were 3 years post–cancer diagnosis.

Table 1.

Participant Demographics.

Participant Number	Gender	Age	Living Situation	Employment Status	Country of Birth	Year of Diagnosis
1	F	44	Husband	Disability Pension	Canada	2013
2	F	58	Husband	Part-time	Canada	2011
3	F	58	Alone	Disability Pension	Czechoslovakia	2013
4	F	52	Husband and children	Part-time	Canada	2009
5	F	57	Children	Disability Pension	Canada	2013
6	F	61	Husband	Disability Pension	Canada	2010
7	F	39	Husband and children	Leave of Absence	Canada	2011

Overall, 2 key themes emerged that inform increased understanding of the experiences of patients with AAT: (1) greater positive anticipation of counseling and (2) benefits of AAT.

Greater Positive Anticipation of Counseling

All participants reported that a central reason for attending counseling was to gain assistance dealing with difficult emotions surrounding their cancer experience, such as depression, anger, and adjustment issues. Participants also reported subsequent difficulties with life stressors such as work and family demands.

“And then when I started having problems again, just trouble dealing with emotional stuff and all these kinds of issues coming up.” (Participant 7, age 37 years)

All participants reported benefits from knowing that Tallulah would be present in their counseling sessions. In fact, all participants identified themselves as dog lovers, which promoted attendance to counseling.

“Yeah, I’m a real animal lover . . . I was quite excited about it [attending counseling].” (Participant 4, age 52 years)

There was consensus among participants that Tallulah’s presence was valued, creating a sense of anticipation and preparation toward counseling. First, the presence of Tallulah provided a sense of familiarity based on the participant’s previous experience with animals.

“I’m a dog person also . . . I guess it felt to me like [being with] my own dog, you know.” (Participant 6, age 61 years)

Several participants identified previously highly valued relationships with a deceased pet—in most cases a dog. Indeed, anticipation of counseling with Tallulah elicited feelings of joy and comfort reminiscent of experiences with their own animals.

“I lost my dog three years ago, so it was really, really, really healing for me.” (Participant 4, age 52 years)

All participants indicated that attending counseling was a difficult and confronting experience. However, the majority of participants expressed they felt more relaxed and looked forward to counseling knowing that Tallulah would be present.

“I looked forward to her [Tallulah] very much . . . It makes you more relaxed and all that.” (Participant 3, age 58 years)

Central to participants’ breast cancer experience was the need to attend many, varied appointments for assessment and treatment. Attending cancer-related appointments was essential but was often accompanied by anxiety and stress. In contrast, participants reported that attending counseling sessions with Tallulah was made more enjoyable amid their schedule of other difficult appointments or life stressors. Tallulah reportedly eased feelings of stress toward attending yet another appointment.

“You know, a lot of times you go for different things, different appointments and you don’t really look forward for them, but not like this [seeing Tallulah].” (Participant 4, age 52 years)

In fact attending counseling with Tallulah was linked to feelings of enjoyment associated with feelings of visiting an old friend, and subsequently, participants felt comfortable and relaxed.

“Yeah, it was just like, . . . going to see an old friend with her dog. Yeah, it was more like being at home.” (Participant 4, age 52 years)

“There was more ease when she was there and, you know.” (Participant 3, age 58 years)

Furthermore, participants indicated that the presence of Tallulah helped them prepare for their counseling session. Being able to talk to and pet Tallulah created a sense of ease and calm before the session commenced.

“Because I can pet her and all this and, you know, you just, just, I don’t know, I just feel kind of a destocking and all this, you know.” (Participant 6, age 61 years)

Benefits of Pet Therapy

All participants reported benefit with attending counseling to deal with difficult life issues during or post–cancer treatment. In addition, all participants said that their experience of counseling was enhanced by the presence of a therapy dog. Participants with previous experience of counseling indicated that their experience of counseling with Tallulah made them feel less isolated and alone.

“I guess it was different from what I had done in the past and just to have another warm body though was, was comforting.” (Participant 1, age 44 years)

Participants described the challenges of initiating counseling and feelings of being hesitant or daunted about sharing difficult emotions associated with their cancer experience. However, the presence of Tallulah was identified as being an icebreaker and a means of connecting with or starting difficult conversations with the counselor.

“Because it [was] kind of like an icebreaker . . . when you have a pet there. Yeah, it’s like you have a common thread.” (Participant 4, age 52 years)

“Tallulah is very, very calm. She was appeasing. So right from the get go, at the beginning of the session I would have her with me and then once in the session I felt better, then I could let her go. (Participant 2, age 58 years)

At the commencement of each session, participants reported that they would pat and greet Tallulah and, in some cases, bring her treats. This process promoted feelings of being relaxed and confident, following which conversation was perceived to flow more readily.

“It makes me feel happy. It makes me feel more calm. . . . When Tallulah is there and even in general when she [counselor] gets me talking about dogs that I’m way more relaxed, I’m way more confident, I’m a lot more animated.” (Participant 7, age 39 years)

Engagement in counseling following a breast cancer diagnosis required expression of difficult emotions. This was closely linked to feelings of grief attributed to experience of life changes and distress as participants dealt with their mortality and loss of valued life roles, such as work and leisure. Indeed, many participants indicated being emotional during their sessions.

“The sessions here are very emotional, very, very emotional always—especially when I was still going through the treatment.” (Participant 2, age 58 years)

Central to participants’ experience was the feeling that Tallulah’s responses provided acknowledgment and validation toward any expressions of grief and distress. In all interviews, participants identified that Tallulah intuitively perceived their feelings of sadness and grief (expressed by tone of voice or crying) and that she would come close to them and sit in near proximity, providing comfort.

“I think that was a good thing . . . she [Tallulah] would just kind of come and, you know, be available. In a sense dogs just sense that a person is upset, you know . . . I thought she [Tallulah] was, you know, she was pretty sensitive.” (Participant 6, age 61 years)

“When I started getting a little bit anxious, Tallulah just came over and sat down.” (Participant 7, age 39 years)

Closely linked with feelings of greater acknowledgment of distress was that Tallulah promoted feelings of unconditional acceptance and not being judged for their feelings.

“I think, just, you know, just, they’re just very comforting I think, dogs are very not judgmental” (Participant 6, age 61 years)

“To be not be judged . . . because you were sharing quite difficult things that you found helpful to have that acknowledgement. (Participant 2, age 58 years)

However, when participants were not in distress, it was noted that Tallulah would return to her bed. All participants reported that Tallulah was never a distraction or intrusion and valued her discreet behavior.

“And then if you were calm she would lie down and if you were upset she will just come over and just sometimes just sit beside you.” (Participant 5, age 57 years)

“Some dogs can be attention seeking and just always kind of nudging you, whiny, then, you know, very attention seeking . . . but not Tallulah” (Participant 1, age 44 years)

During their counseling session, many participants valued the opportunity to receive affection from and give affection to Tallulah while sharing deeply.

“Yeah, exactly it’s the physical contact. So when you’re patting Tallulah and talking—the feelings actually go to Tallulah, not to [counselor]. Tallulah can endure all the feelings, she doesn’t care, right?” (Participant 2, age 58 years)

As a result, interaction between participants and Tallulah was perceived to lighten the intensity of engagement in counseling, often making sessions calmer and fun.

“It is just very heart-warming and very calming and very relaxing . . . how the animal can calm you down and you know what I mean? (Participant 4, age 52 years)

“But it’s always . . . it’s always more . . . it’s like it makes it more fun. It makes it less, it makes it less serious, it’s like it makes it feel lighter.” (Participant 7, age 39 years)

Another predominant expression among participants was the benefit of the presence of Tallulah in being a catalyst to sharing. Participants reported that they felt more open and free to share.

“I was more open to the [counselor] than I have been with other people [counselors] in the past.” (Participant 5, age 57 years)

“It was just really nice and I was just free to be myself.” (Participant 4, age 52 years)

Specifically, participants identified that Tallulah provided a calming presence when they were finding it difficult to find words to express their emotions. Tallulah’s presence helped them relax and provided a calming distraction while taking the time to frame their thoughts.

“It [AAT] was awesome because you know you get, sometimes you get kind of stuck or nervous or anxious or wound up. I found it really relaxing to just have a dog there . . . and I often don’t like saying things unless I have phrased it properly. So I find that if when Tallulah is there, I just sort of say things.” (Participant 7, age 39 years)

In fact, all participants reported that their session flowed more readily as a result of talking to Tallulah in contrast to a therapist alone. Many participants expressed the need to take a break or a “moment to get your breath” (Participant 1, age 44 years) during their counseling session. The presence of Tallulah reportedly provided an opportunity for distraction and to temporarily divert attention from the session without feeling awkward.

“Yeah, sort of takes off the pressure of having to come up with something to say and continue the conversation like. I guess I just needed a break from talking; that was nice to focus my attention on something else. . . . You know, I can pet her [Tallulah] for a few minutes and not have to talk about anything at that time and yeah.” (Participant 1, age 44 years)

Overall, all participants indicated that they would recommend AAT except for people who were scared of animals.

“I think it was a positive experience overall, it wasn’t, I wouldn’t see any problem with it at all, you know, unless somebody did not like dogs, but then I think that would be, oh, you know, out of fear or something, you know, but other than that I think it would be very positive.” (Participant 6, age 61 years)

Discussion

This study identified the experiences of breast cancer patients’ participation in individual counseling sessions involving a therapy dog. Inductive thematic analysis identified 2 key themes: (1) greater positive anticipation of counseling and (2) benefits of AAT. The results provide valuable insight into how breast cancer patients experienced AAT and inform clinicians on how to provide relevant services.

The findings indicated that AAT was considered nonburdensome and was a positive and beneficial experience for participants. Interestingly, all participants indicated they were dog lovers, which created feelings of anticipation toward attending future counseling appointments. Indeed, all participants indicated that the experience of breast cancer involved the need to attend numerous cancer-related appointments, which were perceived as being confrontational and stressful. In contrast, participants’ experience of counseling combined with AAT was considered exciting and promoted feelings of ease and comfort. Findings from this study highlight the benefits of the availability of a therapy dog during counseling for breast cancer in people with an expressed interest in animals, particularly dogs.

Our findings also highlighted that the presence of a therapy dog created a scenario where participants looked forward to attending to counseling instead of fearing it. This is an important finding because high levels of psychological distress can lead to greater attrition,³⁷ in which case patients miss out on the well-documented benefits of counseling.^38,39

Our results suggest that AAT served as an icebreaker and catalyst for sharing, thus facilitating an enhanced therapeutic alliance, which has been identified in psychotherapy research as the key common factor linked to positive outcomes.⁴⁰ Indeed, feelings of difficulty in sharing emotions were notably alleviated through AAT because participants reported feelings of empowerment and increased confidence, simultaneously reducing the burden that many participants felt regarding the need to express themselves accurately and precisely. Furthermore, being able to pet a dog during counseling provided a sense of familiarity combined with feelings of greater comfort and calmness. This is consistent with previous research, which indicates that holding or touching an animal may act as a physical comfort and be soothing, instilling a sense of safety.¹⁰

Participants in this study identified that the presence of a therapy dog promoted feelings of unconditional acceptance and created a neutral environment where they felt less judgment toward the extent of emotions experienced as a result of breast cancer. Indeed, the explicit acknowledgment and validation of feelings of distress by a therapy dog enabled participants to feel more valued and generated feelings of comfort. This echoes previous research regarding the value of a therapy animal’s warm, nurturing, and nonjudgmental interaction in helping a patient feel more safe and, therefore, more comfortable to trust and disclose information during counseling sessions.^10,12,41 In this sense, the presence of the therapy dog modeled the ideal “unconditional positive regard,” which has been highlighted as a key characteristic of effective therapists.⁴²

Finally, this study identified that the presence of a therapy animal provided a medium for distraction and diversion for participants when struggling to voice difficult emotions. The ability to pet and talk to the therapy animal in these instances provided a sense of reprieve and enabled participants to take breaks from sharing in order to process information and collect their thoughts. Furthermore, the therapy animal compensated for silences in conversation and feelings of obligation to share information. This is consistent with research in different therapy groups, where the presence of a therapy animal has been identified as being a transitional object for patients, thus providing a means for conveying feelings through the animal as opposed to talking directly with the counselor.^12,41 Chandler¹² suggested that therapy animals can help patients focus on an issue as they interact with the animal and that sharing feelings with or about the animal enables an enhanced sharing process with the treating therapist.

Overall, findings from our study highlight the benefit of the use of AAT in counseling post–breast cancer diagnosis as a platform to increase participation and expression of emotions. These preliminary results highlight that AAT in breast cancer patients can ameliorate feelings of distress and promote feelings of peace and calm. As a result, AAT in breast cancer populations has the potential to reduce loneliness and agitation and facilitate interaction with a counselor. Benefits of access to AAT included factors such as novelty, safety, joy, excitement, and feelings of ease during the experience of counseling, which can be intimidating for many breast cancer patients. From a clinical perspective, AAT promoted increased communication with health professionals. Results from this study suggest that AAT has potential for great benefit because clinicians have increased opportunities to improve adherence to therapy sessions and more deeply explore patient emotions in a safe and comforting environment.

Study Strengths and Limitations

The use of a qualitative methodology was sensitive in identifying the factors that play a role in the use of AAT in counseling postcancer. This qualitative study sampled as many willing participants as possible, and all consenting participants were interviewed. Thematic saturation, a key component of qualitative research, was achieved with 5 participants (however, all consenting participants were interviewed) and promotes the transferability of our results. A limitation was that participants were only interviewed once, which limited the ability to capture changes over time. Furthermore, we did not interview patients who chose not to engage in therapy with the dog present, which preventions exploration of any differing attitudes and feelings toward AAT.

Conclusion

This study revealed that the experience of AAT during counseling for breast cancer is feasible and acceptable at a patient level, providing preliminary support for benefit in terms of increased disclosure of information and engagement with therapy. Cancer patients experienced increased calm and feelings of anticipation toward participation in counseling, alleviating feelings of anxiety and distress. From a clinical perspective, AAT promoted increased communication with health professionals, and consideration of the routine provision of AAT is recommended. Insights gained from this study will inform future studies that seek to confirm the efficacy of AAT in the breast cancer population. Evaluation of impact on patient outcomes and quality of life is required.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Animal-Assisted Therapy and Counseling Support for Women With Breast Cancer