Animal-Assisted Psychotherapy: Theory, Issues, and Practice

PREFACE

When I was a child, our home was always full of animals roaming around. We had as many as three dogs at any given time (including Tammy, whom we had rescued from an abusive situation), parakeets (one who was best friends with my dog Mendel and would often ride around on his back, but was at war with my other dog, Anness), sparrows that I had saved and raised, a baby raccoon (who slept in bed with me—where else?), a baby alligator that my parents bought me in a Florida airport gift shop (what can I say … it was the early ’60s), and of course my horse, Baby Doll (who had been extremely abused), who was the love of my life and who had a profound effect on me for many years.

After moving from the United States to a kibbutz in Israel and leaving behind my doctoral studies in psychology, I worked in early childhood education and naturally brought to work any baby animal I happened to be raising at the time. I noticed the deep effect that these animals had on the atmosphere, and especially on the children with emotional difficulties. Although many tried to convince me to return to my studies in psychology, I had no intention to do so—until I heard of a new program starting in animal-assisted psychotherapy (AAP). This was a chance for me to connect my love for children with my love for animals and learn to do what I had unknowingly already started to dabble in—help children to discover themselves and to work through their emotional problems through their relationships with animals. It was there at the training program at Oranim College that I met Dikla Tzur, a clinical psychologist and lecturer who opened up for me the realm of AAP and the depth of opportunities it affords for understanding a child’s emotional world and helping the child work through emotional issues.

Since finishing my studies in AAP, I have become a specialist in the area of AAP with at-risk children. For 12 years I have worked in various institutions belonging to the Welfare Ministry, such as a residential care center for abused children, a daycare center for at-risk children, and an emergency shelter for children who have suffered extreme abuse and/or neglect. I serve as a member of the psychotherapy staff with duties equal to those of the clinical psychologist and the clinical social workers. Together with my dog, Mushu, and my cockatiel, palm dove, three lab rats, and two Siberian hamsters, I work in a play therapy setting using a psychodynamic (non-directive and client-centered) approach. My colleagues often comment about the great amount of content raised and worked through in the therapy process through the integration of the animals.

When I am asked what is my profession, the reaction to my answer is usually, So you take your dog to visit the elderly in nursing homes? A few years ago, when the national director of child protection services in Israel saw me in the emergency shelter in which I am part of the therapy staff, she said, How nice—the kids come, pat the animals, and feel better, right? My answer was, Not exactly. After a half-hour conversation, during which I explained my therapeutic goals, she invited me to give a lecture at the national convention for child protection services officers, and later met with the Ministry of Health to suggest providing AAP for minors who are victims of sexual abuse.

At the university in which I am now studying for a master’s degree in social work, I of course spread the word about AAP. Some academics are excited by the idea, but many are suspicious. I often receive the comment, It just doesn’t work that way. One expert in the field of attachment said to me, I can’t stand it when people misuse attachment theory and the idea of an attachment figure. They apparently did not read Bowlby’s reference regarding the role of animals in assisting people suffering from grief and loss, in which he states that children may attach to a pet dog after having lost or been rejected by their parents (Bowlby, 1980, p. 175.) Many AAP therapists apply for advanced degrees in therapy fields in order to do research in the field of AAP and the human-animal bond, but they find it nearly impossible to find advisors willing to supervise their research. But then there are those very few who immediately get it, and are willing to take a chance and support our research.

But first, back to basics: What is therapy? There is physical therapy, psychotherapy, chemotherapy, speech therapy, and more. Then there’s aromatherapy—buy a good-smelling shampoo and feel better. Many people say that jogging or dancing is great therapy. But what is animal-assisted therapy? Most people view AAT as an intervention involving an animal which affects a person’s emotional well-being (whether or not carried out by a trained therapist). Pat a dog and feel happy. Have a child with a behavior problem learn to train dogs and he will internalize the limits. I will be the first to say that these activities are very therapeutic, may be no less important in the life of a child than therapy, and I would not like to see the world without them. Does that make them therapy? The word therapy has no clear definition can be confusing. I prefer to talk about the difference between therapy and therapeutic. All of the above may be therapeutic, but is the human member of a Pet Partners team a therapist? What is the difference between therapeutic riding and EFP (equinefacilitated psychotherapy)? Who is an animal-assisted therapist? Is someone trained in therapeutic riding a therapist? Is a psychologist who has his dog in the therapy setting with him an animal-assisted psychotherapist?

The question What is animal-assisted therapy? is not simply an academic one, but also an ethical one. Those who claim to be a therapist and receive a child for therapy are holding the soul and psychological welfare of that child in their hands. In the best case scenario, a child with emotional problems who is sent to therapeutic riding (the training for which is minimal and does not include the study of psychotherapy) may not receive psychotherapy but may benefit in other ways, for instance from the human-animal bond and the one-on-one time with an adult. Of course, the problem is that the parents think they are doing everything necessary to provide their child with psychotherapy, yet this is not what the child receives.

In the worst case scenario, direct and actual damage may be done by a therapist without proper training when the emotional content that is raised is not dealt with properly. During my days as a student in the field, I attended a lecture by a dog specialist trained in a health field who claimed to be doing emotion-focused therapy with an elderly man who had lost his memory of his life before the age of 12, when he had suffered a terrible trauma. Through working with this specialist and her dog, this man was reminded of his own childhood dog and experienced a breakthrough: he was flooded with memories and broke down crying. Although we expected to hear how the therapy proceeded from this critical point, we were surprised that the specialist considered this breakthrough to be the goal of her therapy, and she considered her work to be done. My fellow students and I had studied enough to realize that this man was at a psychologically vulnerable point and was in need of a knowledgeable therapist who could help him work through the difficult memories and accompanying emotions that had been hidden for so long, probably for good reason. Yet without such a therapist, he was left exposed, broken, and alone. The involvement of animals in the therapy setting is a powerful tool and as such must be used by professionals who understand the implications.

I believe that only those fields which are conducted by someone properly trained, including extensive academic coursework with a strong theoretical and practical base, together with field hours and clinical supervision, can ethically be considered a therapy field. Practitioners should be aware of what services they are and are not able to provide. Part of the ethical participation in any profession is the knowledge of the limits of that profession.

A number of therapy professionals, such as occupational therapists, physical therapists, and speech therapists, use animals as aids to reach the therapeutic goals specific to their profession. Yet the general public uses the term AAT to refer mainly to the emotional effects of an animal on a human. This view is a type of theft of the term and is disrespectful to the other animal-assisted professions. In professional journals and the lay media, confusion abounds. One hears terms such as AAI (animal-assisted interventions), AAT (animal-assisted therapy), AAA (animal-assisted activities), and AAE (animal-assisted education). On the surface, the differences sound clear. So then why do I see articles about AAT used in libraries as a tool to teach children to read? Is teaching therapy? Are teachers therapists? Those in the field of AAT are looking for legitimacy for the field through academic research, but there is no generally agreed-upon definition of AAT, making it almost impossible to make any sense of the research. It is not clear exactly what is being studied or what the definitions of the variables are, and this confusion makes it impossible to compare research studies and make any general conclusions about the efficacy of the field.

Here in Israel, where I studied animal-assisted psychotherapy (AAP), we have grappled with these questions and issues for over 15 years. The direction taken was to sidestep the issues of What is therapy? and Who is a therapist? and instead to concentrate on the definition and development of a narrower field, that of AAP. A number of serious academic training programs sprang up as the dialogue continued (currently there are five certificate programs in colleges around the country, in which college graduates study). Graduates of these programs who are now clinicians in the field, together with the founders of and lecturers in the academic programs, have been actively participating in a dynamic dialogue to define the boundaries of the field, as well as in the expansion of the development of a theoretical base for what we all do in our clinical practice. Through our experience in the field, we have developed definitions and rationales that guide us in our work with our clients. Our guiding principle is that AAP is a form of psychotherapy which is conducted with the same rationales and goals as mainstream psychotherapy. Therefore, we are first and foremost psychotherapists, and together with that AAP therapists, for the client may not always be inclined to take advantage of an animal’s presence in an active or obvious manner. The client—not the animal—is at the center and is the focus, the raison d’etre. We, not the animals, are the therapists, for only we are cognizant of the client’s psychological processes and issues that need to be worked through and how to do so, according to what is in the best interest of the client. As our partners, the animals unknowingly assist us toward our goal. In our therapy, we focus on underlying psychological processes and not on symptoms, skills training, or psychoeducation. Our goal is not to raise a client’s self-esteem, rather to concentrate on discovering the reason for the low self-esteem (perhaps the client had been consistently humiliated by parents, or sexually abused) and work through the related issues. An AAP therapist has the status of an independent therapist (such as a clinical psychologist, clinical social worker, or art therapist). AAP is not an adjunct to another therapy.

Through this dynamic and intensive process of development and definition of the field of AAP in Israel, we have found that we have developed directions and rationales in both definitions and in practice different from those found in other parts of the world. Five years ago I published an article in a well-known academic journal (Parish-Plass, 2008) about my work with at-risk children, with the express purpose of sharing with the international clinical community the Israeli approach to AAP. I received many positive reactions, with both clinicians and academicians commenting upon the innovative and advanced nature of our approach to AAP. Many commented on the logic and helpfulness of our definitions and the theoretical background we use to guide ourselves. Since I felt that this article touched upon only the tip of the iceberg, these reactions encouraged me to gather the ideas of those who I consider to be the top thinkers in the field of AAP in Israel in order to present a more comprehensive view of the field the way it is taught and practiced here. The process of doing the background research and writing of this book has been an adventure, and has led us to a wonderfully fruitful dialogue and to discoveries that I and the other contributors did not know that we had in ourselves.

While in the initial stages of putting together this book, I was particularly pleased to receive a phone call one day from two AAP therapists who wanted my feedback on an article they had decided to write based upon one small paragraph, one aha! experience in therapy that was as yet a tiny seedling in my brain, that I had included in my article. That idea had fueled their imagination and opened up possibilities in their therapy sessions with the children they work with, and they wanted to develop the ideas that were sprouting. I suggested that it would be a wonderful idea as a chapter for this book and would show the development of an idea as it could lead to the growth of the profession. In their chapter, Roni Amit and Hadas Ish-Lev took the idea and ran with it, giving it an exciting depth which will no doubt contribute to the development of the theoretical understanding of a mechanism behind the field of AAP.

My main goal in editing this book is to develop the theoretical base of AAP. In turn, as happened with Roni and Hadas, I hope the dialogue that will come out of the ideas presented in this book will stimulate research in order to help us more fully understand the mechanisms involved in what we in our practice see every day. And most of all, I hope that the ideas raised and the research that comes out of this book will open up new possibilities for helping our clients—children and adults alike—in the psychotherapy process. I hope readers will find this dialogue concerning the AAP therapy triangle as thought provoking and exciting as I do!

REFERENCES

Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss: Sadness and depression. New York: Basic Books.

Levinson, B. M., & Mallon, G. P. (1997). Pet-oriented child psychotherapy (2nd ed.). Springfield, IL: Charles C. Thomas.

Parish-Plass, N. (2008). Animal-assisted therapy with children suffering from insecure attachment due to abuse and neglect: A method to lower the risk of intergenerational transmission of abuse? Clinical Child Psychology and Psychiatry, 13(1), 7–30. http://dx.doi.org/10.1177/1359104507086338

INTRODUCTION

GOALS

Animal-assisted psychotherapy (AAP) is a burgeoning field of psychotherapy which has received much attention in Israel over the past few years. As practiced here, it is based upon the belief that emotional difficulties and pathologies likely originate from problematic relationships in the past, and therefore the client must use relationships in the here and now in order to change. Virtually all psychotherapy approaches rely at least to some extent on the relationship between the client and the therapist. One brilliant aspect of integrating animals into the therapy setting is that the setting becomes a laboratory for relationships. Expanding on the use of these relationships within therapy are the approaches used by most AAP therapists in our professional community, which are based mainly upon relationships, reenactment of past relationships within the therapy setting, and reflection on relationships past and present.

Whatever the exact theoretical preference of the therapist, most AAP therapists in Israel ascribe to an approach in which the therapist flows with the client (psychodynamic, client/child centered, non-directive), as opposed to a directive approach in which the therapist prepares activities ahead of time. In addition, most therapists—whether with or without animals—use the play therapy setting with children. Thus, most AAP therapists allow the children to play freely, seeing this play as a form of communication of emotions and expression of how the children experience life and relationships. Children will use play behavior, toys and games, the animals, and the therapist, separately or in combination, in order to facilitate this expression. The therapist must understand both the distress of children and how to observe their behavior in order to know how to react in a way that advances them in the therapy process. One goal of this book is to present various theoretical explanations so that readers may understand the mechanisms behind how integrating animals into the therapy process facilitates the process. Only through a coherent presentation of these ideas may a dialogue be used to develop them and to reach further understanding of how to use the mechanisms for the good of the client.

STRUCTURE

This book is split into three sections—theory, issues, and practice—with reference materials included as appendices. The first and third sections are both a combination of theory and practice. This is unavoidable because AAP is a theory-based clinical profession. AAP, by our definition, is not a technique, and it cannot be learned in a workshop. The practice cannot in any way be separated from the theory. Only by understanding what the theory is based on and why, will the therapist know how to use a therapy medium in order to advance the client in the therapy process. This book is not a manual or a cookbook. AAP is a theory-based approach, a way of thinking in the therapy setting which allows therapists to help clients to find themselves, find their strengths from within themselves. The first section (chapters 1 through 8) focuses on mechanisms and the theory behind them, which explains various aspects of AAP. Most of these chapters include examples from therapy sessions to illustrate the mechanisms and guiding principles of AAP. The third section (chapters 14 through 17) focuses more on the practice, elaborating on techniques used in psychotherapy with various populations.

The second section (chapters 9 through 13) concentrates on AAP as a developing profession, on the therapist as a professional, and on issues and dilemmas surrounding the practice of AAP.

TARGET AUDIENCES

In my attempt to spread the word about our approach to AAP here in Israel, I hope this book will reach a number of audiences.

First and foremost, I would like to reach AAP therapists in Israel and abroad. For those who are familiar with our approach and use it, I hope to help arrive at a verbal expression for the processes they find occurring in therapy with their clients. If I can provide them with words and a common language for what they are already doing, then they will be more aware of their work and able to enter into a more fertile dialogue (with themselves, other therapists, and their clients) about their work. The chapters will broaden their knowledge base, challenge what they thought were their limits, open up new dimensions of how to help their clients, and create dialogue with other therapists to advance the field

Second, I hope that this book will serve as a textbook for students of AAP studying in academic institutions. With students in mind, there is an emphasis on definitions of psychological and psychotherapeutic processes and theories as the context to which the influence of the animals (and all they entail and bring with them) is added. Together, they form the field of AAP. This is the format through which my fellow students and I studied in class with Dikla Tzur—lecturer, clinical psychologist, AAP therapist, and supervisor. For instance, we would receive a lecture on the subject of grief and loss in terms of both psychological theory and psychotherapeutic principles. We would then talk about the subject of grief and loss in the context of animals and the human-animal bond. Finally we would explore options of integrating animals into the therapy process with grief and loss, hearing examples from her clinical experience. Through her classes we all discovered the world of psychotherapy no less than the world of AAP, and the combination contributed to our integrated knowledge, as well as to our developing professional identities. I hope that these chapters will help students grow as psychotherapists from within the profession of AAP and in its context.

Third, I hope that psychotherapists from other fields will be exposed to our work and encouraged to enrich their therapy toolbox by entering into more serious study of AAP. Such an exchange of ideas between therapists from the fields of AAP and art therapyled to the development of a course well attended by AAP therapists from around the country (and to a fascinating chapter of this book). Because psychotherapists may come from various theoretical backgrounds, the structure of the chapters—forming a theoretical base from which the discussion of the practice of AAP grows—will put everyone on the same page.

And finally, I hope that this book will reach the world of academia, serving as a stimulus for further theory building, academic discourse, and especially research. If the field of AAP is to reach the level of respectability it deserves in the world of psychotherapy and academic study, its mechanisms must be researched and its efficacy studied. My hope is that this process will lead to the establishment of a master’s degree program in AAP.

The language of this book is decidedly based upon academic and clinical principles. This book is not meant for lay people who volunteer with their dogs, dog trainers, or animal handlers. Although I would be pleased for anyone to read this book and gain perspective on AAP, I hope that no one other than academically trained clinicians will try to make use of the information in their work. The field of AAP is a form of psychotherapy in every sense of the word and therefore demands the same level of training, clinical supervision, responsibility for the psychological welfare of the client, and ethical considerations as other psychotherapy professions.

THE HUMAN-ANIMAL BOND, AAP, AND THIS BOOK

This book is meant to be a textbook delineating theory, mechanisms, definitions, and other seemingly dry subjects. All this stands in juxtaposition to the warm, emotional, playful, fuzzy, spontaneous, loving (and sometimes angry, threatening, or sad) aspects of the human-animal bond and on which AAP is based. On the one hand, I made the conscious decision not to include a chapter about the human-animal bond, for that is not the point of this book. Those interested can find a number of excellent books on that subject. The reader must keep in mind at all times that it is not the purpose of AAP to further the human-animal bond, provide the client an opportunity for a warm relationship, or teach the client to be more empathetic toward animals. In AAP, the human-animal bond is a tool used to facilitate the therapy process with the client suffering from emotional problems.

On the other hand, while reading the various chapters, the reader will notice references made to this amazing bond and how it is used to facilitate the therapy process. AAP does not use animals, but rather considers them as partners in relationships. It is the relationship potential in the setting which has such a strong influence on the therapy process. This process begins with the authentic relationship of the therapist with the animal. (At the college in which I studied AAP, the admissions committee does not accept prospective students who do not consider a relationship with animals as an integral part of their emotional life.) This process continues on to the way that the client sees the relationship between the therapist and the animals in the setting. The client takes notice: Is the therapist kind, warm, and caring toward the animals? Is the therapist protective of the animals? The process then expands to the client’s relationship with the animal, and finally to the projections of the client onto the animal of other objects relations in the client’s inner world. Not only do chapters discuss these relationships in terms of advancing the therapy process of the client, but readers will also find mention of the importance of the bond between the therapist and the animal as a source of support for the therapist. It often happens, for instance, after a particularly emotional meeting with a client, that I pick up my dog, Mushu, and give her a long, warm hug. I find it stabilizing (the reader will also find material in this book pertaining to the physiological effects by the presence of the animal on the human) and calming. I also find that I have someone with me who bore witness, who shared the experience with me. Anthropomorphizing? Maybe, or maybe not. Is Mushu harmed by this? I see no evidence of this whatsoever, for I see that she loves coming with me to therapy and shows no signs of avoidance. She trusts that I will always be there to protect her from stress or harm. This is one of the interactional aspects of the bond that gives AAP its strength and effectiveness. The reader will find examples and explanations of this bond and how it works in therapy throughout this book.

A WORD ABOUT ETHICS IN AAP

I would like to point the reader’s attention to the subject of ethics as it is dealt with throughout the book. Ethics is a critical part of the discussion of any therapy field, but it is doubly relevant in AAP, for the therapist must be equally attentive toward the rights, safety, and emotional and physical welfare of both client and animal. In addition to Chapter 10, which specifically covers ethical considerations specific to AAP, the reader will find that most of the authors touch upon the subject of ethics in one way or another. No direction was given to the chapter authors to include the subject of ethics in their writing; however, it was natural for them to do so. The worry about the animal alongside of the worry about the client is part of who we are and is probably what makes us effective as AAP therapists.

I invite the reader to peruse Appendix C, which contains the Ethics Code of the IAAAP (the Israeli Association of Animal-Assisted Psychotherapy). Notice that it covers ethical considerations concerning both client and animal. We see it as a work in progress. It may seem that the IAAAP ethics code does not speak enough to the needs of the animal; however, the IAAAP sees the Israeli laws against cruelty to animals as binding on all members.

ONE MOMENT BEFORE

This book contains throughout many examples taken from therapy sessions that illustrate the theories and principles discussed. All identifying client information has been changed.

There may be some readers who will find the term human as distinguished from animal to be derogatory toward animals, as if this separation implies that humans are above animals. Many people of this opinion refer to human animals and nonhuman animals. I find that not only cumbersome but also placing humans in the center among all animals. In my family, it was clear that animals had a special place in the scheme of things and we were often more considerate of animals than of people, for we realized that they could not stand up for themselves in the way that people do. For me, the term animal is a positive one I often associate with warmth and even at times admiration. Therefore, while it is clear that humans are a type of animal, the term animal will be used as a general term referring to nonhuman animals in general. Finally, some authors found it difficult to decide which term they felt comfortable with to describe the person coming to them for therapy. This truly felt like a dilemma for most of us. Patient gives the feeling that the person is sick, while client sounds cold and impersonal. It is difficult to use either word when describing a child. Yet when talking about general principles, the author may use the word client or patient to refer to either an adult or a child. We all would have preferred to use the Hebrew word metupal, meaning a person who is being given care.

THEORY

1

THE INTEGRATION OF ANIMALS INTO THE THERAPY PROCESS AND ITS IMPLICATIONS AS A UNIQUE MEDIUM IN PSYCHOTHERAPY

Dror Oren and Nancy Parish-Plass

The most visible creatures I know of are those artists whose medium is life. The ones who express the inexpressible … without brush, hammer, clay, or guitar. They neither paint nor sculpt—their medium is being. Whatever their presence touches has increased life. They see and don’t have to draw. They are artists of being alive.

—Anonymous

INTRODUCTION

At this time in the development of animal-assisted psychotherapy (AAP), which is still in its infancy in terms of the state of research and theory development, it is necessary to find a way to understand the mechanisms behind the processes that occur in AAP. Appendix B contains a list of the various roles animals fulfill in psychotherapy, according to various psychological theories, which sheds light on this subject. In this chapter we come from a different direction, describing a unifying model that delineates the implications for the psychotherapy process of the presence of an animal, in all that this presence entails, as a medium through which the process of psychotherapy takes place. This is a model borrowed from the world of philosophy, scientific literature, and cultural literature, specifically pertaining to art. In psychoanalytic writing, the concept medium is borrowed from the world of communication (McLuhan, 1964) and from the world of art criticism.

It is important to remember that almost anything can be used as a medium in the therapy setting in order to express feelings: dreams, inanimate objects in the room, play, and even the therapist him- or herself. Any of these mediums may serve as a mediator, an object of projection, as a way to express one’s inner world. Of course, some of these mediums may be chosen by the therapist. Therefore, it is the responsibility of the therapist to deepen his or her understanding of the potential and the limitations of the medium chosen. This chapter discusses animals and all that they bring with them into the psychotherapy process as the medium in AAP.

From our experience, compared to the mediums of other psychotherapies, the presence of animals in the therapy setting adds a richer and more multifaceted medium, characterized by a width and depth that deserves inspection. This conceptualization of the presence of the animal as a medium, as a source of enrichment for the therapy process, was borne out of our discussions of Ishai, Oren, and Ishai’s article, Medium for Expression and Medium for Healing: On Medium in Therapy (in press). These rich discussions eventually led to this chapter.

This chapter starts with a general discussion of the term medium in the context of psychotherapy, including its definition and an explanation of the use of a medium, in terms of the therapist, the client, and what exists and develops between them. The use of a medium in psychotherapy, together with its intricacies, implications, and advantages, is also discussed. Next, the chapter focuses on the concept of the presence of an animal (or animals) in the psychotherapy setting as a medium, with all that this entails. The various unique qualities of the animals and their surrounding environments, their effect on therapist and the client, and what they may contribute to the therapy process, are discussed. (In Chapter 2 the implications of the relational qualities of the involvement of animals as a medium are expanded upon. Chapter 9 examines the various dilemmas and issues that need to be addressed when the involvement of animals is used as a medium in psychotherapy.)

THE USE OF A MEDIUM IN THERAPY

Definitions of the word medium are many and varied. According to Merriam-Webster (Medium, n.d.), some of the definitions more relevant to our discussion are (1) a means of effecting or conveying something, such as a substance regarded as the means of transmission of a force or effect, or a surrounding or enveloping substance; (2) a mode of artistic expression or communication, or material or technical means of artistic expression; and (3) a condition or environment in which something may function or flourish, or a nutrient system for the artificial cultivation of cells or organism.

As can be seen, some of these definitions grew out of art and the philosophy of art and its derivations, while others grew out of a biological model. The intent of the model presented in the article Medium for Expression, Medium for Curing (Ishai, Oren, & Ishai, in press) is that the medium answers the following definition: The medium is that through which messages are transferred from the therapist to the client and from the client to the therapist, as well from each to themselves. A medium may be general or unique, consistent or variable, facilitating or restricting, simple or multi-faceted. According to Ishai, Oren, and Ishai (in press), a medium is a unique means of communication in therapy, a mediating factor through which one’s inner world may be expressed. Different types of mediums influence the experience of therapy in different ways, and mediums may be used in a number of ways. While often it serves as the channel for the communication of messages, it sometimes turns into the content itself (in the case of talking as a medium, talking about how one talks). At other times the medium may stay in the background, part of the general atmosphere, present in case the therapist or client chooses to make use of it. "The client has the feeling of having the right to choose the medium through which he asks to transmit his expressions, and within which he is interested in having contact with his therapist" (Ishai, Oren, & Ishai, in press).

Similar to D. Winnicott, we distinguish between the therapist-client relationship and the communication that exists between the therapist and the client. Communication is based upon the behavioral expression of an idea, a desire, an attitude, or an emotion. A relationship is the specific emotional entity that exists within the context of interpersonal interactions, whereas communication is the mode through which the relationship is created, expressed, and exists. In order to better understand the dynamics of communication, it is essential to explain its elements.

Communication involves different actions, the central ones being expression, transmission, comprehension/listening, deciphering, pausing (experiencing), giving of meaning, reaction, and expression of that reaction. These actions usually occur in this order, simultaneously existing in parallel as a type of echoing which enriches the communication process. There exists between them overlapping and changes in the order of occurrence (e.g., first reacting, and only afterward giving meaning). Various mediums specialize in one or more of these actions. The most efficient medium performs all of these actions. Most of the time, it is acceptable to relate to language, including speech, writing, and reading, as the most efficient mediums. However, different theoretical and clinical approaches might recognize the need for additional, nonverbal mediums in order to reach certain therapeutic goals. These mediums may be used as alternatives or in conjunction with the verbal medium. It is important to remember that everything can serve as a medium. The therapist may suggest various mediums found in the room (e.g., the chair, game, or sand), which are then talked about (Here one can talk about everything, or I see that you always choose to sit in the rocking chair instead of on the couch) and expressed by asking direct questions (The dream sounds very interesting. Tell me about it. Or, Winning the game seems very important to you. How do you feel when you lose?), as well as by indirect reference and hints. Not only may objects be mediums, but also a client is likely to use relating to objects in the clinic, to the therapist, to the headlines in the news, or money, as mediums through which the client can express him- or herself.

Certain mediums are common to most psychotherapists, such as emotional expression and use of the world of emotions in general, the attempt to give meaning, a search for patterns, and use of empathy and understanding. In addition, most therapy is based upon an overall theory that people experience the world according to the way in which they perceive it and then conduct themselves accordingly. Therefore, the goal of therapists’ work is to give clients a perception that they have a higher degree of control over their life than they had before, or were aware of. Furthermore, mediums develop within therapy which are charac teristic of each therapist, client, and approach. When therapists have a unique medium to which they ascribe importance, such as play, art and artistic expression, musical instruments, or an animal and his environs, they will introduce it into the therapy setting. It may happen that a certain client will be referred to a therapist specializing in a certain medium, out of an assumption that that the client will relate to this medium and use it for self-expression. Clearly, the client comes with his or her own mediums, such as physical attributes, perception of the role of luck, personal theories of the way others relate to him or her, and so forth. The therapist may be a medium for the client, due to voice qualities, physical appearance, manner, personality (serious or with a sense of humor), and such. Of course, the therapist may also become the medium through the client’s projections. With some adult clients, and more often with child clients, projection may express itself in concrete touch, which may force the therapist to take his or her body out of the range of possibilities.

In medium-sensitive therapy, it is important to identify the difference between the therapist’s medium and the client’s medium. In addition, it is assumed here that a necessary requirement for the therapy process is, among other things, the creation of the connection, a third unique medium common to both client and therapist which serves as a bridge between their mediums. It is important to understand the differences between various mediums which are generated by distinct theories and types of clinical interventions. This raises many questions, for instance those regarding hierarchy, such as which mode of language is preferable—verbal, pre-verbal, or body; which medium is appropriate; which has more power, or larger influence, on the process of therapy and its results—theory or practice; and whether therapist-client communication should be explicit or implicit. Other questions arise and touch upon experiences of interpersonal and intersubjective partnership, such as, Is it possible to relate to the therapy experience as uniform and homogeneous—that is, involving the use of only one medium? Perhaps the increase in the number of mediums present in each communicative process testifies to the heterogeneous nature of the experience and explains the difficulty of obtaining the internal and continuous sense of development and freedom? And together with this, does the effort to communicate in a therapeutic manner obligate us to create uniformity, unity, and even merging or symbiosis?

According to our conceptual approach, three principle generators create the cure for mental health problems, the change that therapists aspire to achieve in the therapy process: theory, technique, and medium. Theory is the collection of explanations which serve us in our search for understanding. Technique (or intervention) is the practical plane within which the therapist functions in order to create the change. Examples of this would be questioning, body language, reflecting, and interpretation. A medium is the unique mode through which a specific client expresses him- or herself in any given situation. The medium is present in between theory and technique and is neither of them. Our view is that the medium is equal to therapy and technique in the therapy experience. In psychotherapy, the mediums of the client come in contact with those of the therapist. With the development of the therapy process which is medium sensitive, at the center can often be found the creation of a bridging factor, a third medium. This additional medium, discussed later in this chapter, has a unique place in the communication between the client and the therapist within therapeutic space.

From this discussion, it becomes clear that alongside the influences of theory and technique, the medium is a powerful generator of occurrences and situations and thus significantly influences the therapy process. It is important to understand the extent to which the medium determines the nature, progress, and results of the therapy. Therapists must be aware of, and well acquainted with, the medium employed, as well as the medium which was chosen by the client, to discover and understand the nature of the medium common to both therapist and client, to use it, to decipher its messages, and to become acquainted with its potential for dominating the therapy. Therapists must take responsibility for the medium they choose, as well as the client’s medium and any ensuing medium that develops from within the therapy relationship. That is, care must be taken by therapists not to let the medium take over the therapy, nor to become the focus of the therapy instead of the clients, their issues, and their progress in therapy. Therapists must ensure that any medium be allowed to change and evolve according to developments within the therapy process. And finally, therapists must be open to additional mediums throughout the therapy—that is, let their chosen medium live in peace with other mediums that might also help the therapy process.

In therapy that is medium sensitive, the therapist must become acquainted with the various appearances, uses, and levels of the medium. For instance, in the case of speech as medium, not only must the therapist be aware of talking and language, but also of the elements of language, as well as a variety of representations and the way in which they are created. This demands sensitivity and attention to the material and physical properties of the medium, to its effect on the senses, and to its design and technology (activating and operating). In this example, the technology is language structure, syntax, semantics, and experience of language. Sometimes it is the musical quality of the voice, its harmony and disharmony, and sometimes it is the activity of quietness, of being quiet, of listening. This medium, which operates from within the therapy, may be joined by other language-related mediums from without: text messages, communication by telephone, e-mail, writing, and so forth.

Opportunities Afforded by the Medium—a Window to That Which Cannot Be Expressed

There are many barriers to communication in therapy, as in any social situation. Clients may or may not agree to talk about or express various content or emotions, or even be able to do so. The source of these barriers may be cognitive or emotional in nature. Clients may not be able to express to others, or to themselves, due to anxiety level, fear of the emotional reaction of others (e.g., anger, disappointment, sadness, humiliation), out of loyalty (fear of hurting a loved one), and so forth. In addition, within the therapeutic discourse, the therapist might discover the treason of talking: Inexact words and thoughts that are incomplete may be impossible for some to express, and accompanied by tense behavior and body language incongruent with verbal expression. Thus is established a barrier to connection, because despite the fact that the medium of talking is supposed to bear the content and pass it on to the psychotherapist, in this case communication through the use of the medium of talking is blocked or distorted.

Here one can see that it is essential that the therapist distinguish between interactions/relational patterns (in this case, talking) and communication (in this case, body language and tone of speech), and understand the relationship or correspondence between the two. The medium of body language served as a threshold into the client’s inner world, allowing expression—consciously or unconsciously, to self or to the therapist—of that which lay behind the barrier. The body language belied the client’s verbal language, presenting an alternative channel of communication. The fact that the client was unintentionally passing on messages to the therapist through nonverbal means, despite his or her not wanting or the inability to do so verbally, illustrates that one medium may be more dominant (expressing truer content) than another. It is essential that therapists recognize and are well acquainted with the qualities and potential for expression of the mediums they choose to employ, as well as of those of mediums which exist in every therapy setting, and even of the unique relationships and interactions between mediums for each client.

As was mentioned earlier, a medium may be a condition or environment in which something may function or flourish, or a nutrient system for the artificial cultivation of cells or an organism. In other words, the presence of the medium serves as a given as a field of communication, about which may be spoken or unspoken, known or unknown, sort of like the air we breathe, or like speech that we take for granted and use without thinking about it. It is present, whether we use it or not, at any given time, enveloping us whether we are aware of it or not. It is exactly this seemingly simple, naïve nature of a medium which allows clients to use it unself-consciously, without feeling defensive, thus feeling that they are not letting their defenses down. They continue to feel safe, while unaware that they are expressing that which is within.

It is essential to identify and distinguish between that which has been till now left outside of expression and communication, yet is deserved of discovery and needs to be expressed, stated, and worked through, and that which is psychologically dangerous to the client and will (should?) not be said and exposed under any circumstance. Such content may be threatening, and talking about it may force the client to deal with issues that the client has neither the maturity nor the psychological nor emotional capacity to comprehend or to cope with. The therapist must take great care to employ the medium in a way that will enable psychological development without harming the client.

In both cases, the medium has a critical role. Even content which would be dangerous to the mental health of the client were it to be expressed openly (both to the therapist and to the client) needs to finds a way out, even if only in the form of I have a secret that can never be told, a thought that can never be acknowledged that is expressed in unsolvable code. In both cases, content of the client’s inner world needs to be expressed in order to relieve inner pressure, a certain loneliness, or a feeling of being cut off and not seen, even if only at a subconscious level.

In the former case, a medium may facilitate the initial expression of content that otherwise could find no way to be expressed. This expression of the client’s inner world, through the use of the medium, leads to reenactment of past situations, which then leads to opportunity for the content to be worked through, unknowingly by the client and hopefully knowingly by the therapist. At first, the therapist may reflect or discuss the content in the context of the medium, thus respecting the client’s defenses. This amounts to going behind the defenses without trying to lower them to work with the content. Only later, according to the discretion of the therapist and when the client is feeling safe enough, will the therapist start making the very slow and careful move from reflection to interpretation, leading to an eventual discovery and open discussion of the content.

In the case of psychologically dangerous content with which clients are not yet ready to cope, the medium may allow for expression in such a vague and ambiguous way that clients continue to feel safe, despite the expression. Here, it is important for the therapist to leave the expression in its raw form, to not confront clients with the possible meanings of their use of the medium. Here, the role of the therapist is to be with clients so they will not be alone with the content being expressed. In this way, the therapist, in his or her use of the medium, allows for contact with that content that clients may subconsciously be dealing with, at the level that they are able to tolerate and bear.

We will finish with an example provided by Marion Milner, a pioneer in her attempt to develop the idea of medium in therapy. In her paper, The Role of Illusion in Symbol Formation (1952, in Milner, 1987), she presents the case of Simon, a child who experienced the events of a World War and had problems functioning at school. In therapy, Simon chose to play with fire. He pretended that there was a war between two villages, burned the plastic dolls, and created material which he cooked. Milner tried to interpret to Simon the war games and fire in terms of aggression, separation, and oedipal conflict. However, during the clinical process, she felt an impasse and decided to examine possible barriers to the therapy that might have been the result of her theoretical approach. This process enabled her to become free of the theory which had influenced her work with Simon, through heightened awareness of the independent presence of the medium, and to build a new theory:

The greatest progress in his analysis came when I … was able to deal with the negative counter-transference. At first, without really being aware of it, I had taken for granted the view of infantile omnipotence which is described by Fenichel…. But when I began to suspect that Fenichel was wrong here … then the whole character of the analysis changed. (Milner, 1987, p. 104)

She arrived at the awareness of the importance of the choice of mediums and their design, which do not express omnipotence but rather prove the existence of basic creativity, which had been blocked. Through personal observation and listening to the creative processes in which she herself was involved, as well as through observation of how her client expressed himself in his own unique ways, she formulated the concept of medium. She added that the cure came from the use of the most appropriate medium—that which enables the minimizing of the gap between the inner and the outer realities (Milner, 1987). In this way, the client develops faith in the reality created by his self, as the child’s basic belief that when he opens his eyes and sees the world around him, he was the one who created it. He feels it is the lovely (or horrible) stuff he made, (p. 100) and as with material, the world may be designed and changed, for good and for bad, and that one may express messages through the material he has chosen and that he can let the medium that he has created for himself positively influence his relationships. Milner went as far as to identify herself as a medium: I was his lovely stuff (p. 103).

The Third

Earlier we referred to the creation of a third unique medium common to both client and therapist, which serves as a bridge between their mediums. The literature of psychotherapy contains many references to this idea. We mention here two references that stand out: the third thing by Clare Winnicott (1968) and the analytic third by Ogden (1999).

Clare Winnicott (1968) was interested in finding a solution to a common barrier found in psychotherapy—the lack of willingness or ability of the client to communicate with the therapist. In medium-sensitive therapy, therapists may not understand the client’s use of the medium when it is pathological or not communicative enough. Winnicott mentioned the importance of establishing between the client and therapist a neutral area in which communication is indirect. We participate in shared experiences, about which both we and the children feel something about something else, a third thing, which unites us, but which at the same time keeps us safely apart, because it does not involve direct exchange between us (p. 70).

This third thing, in the context of this chapter, is a medium in psychotherapy which enables the therapist and client to feel that they have something in common. In referring to this third thing, McMahon (1992) explains that it may be an outing or journey, a pet, a hobby or … simply play (p. 58). This third thing is outside of the therapist-client relationship and can be looked at and observed by both, because it does not belong to, or come from inside of, either. The act of observing and experiencing together this seemingly objective medium facilitates the development of sharing each other’s opinions and feelings. This sharing is, in effect, communication. In other words, the third thing forms a sort of bridge between them across which messages may flow, thus facilitating communication.

There are many instances in which the therapist-client relationship is threatening and anxiety producing for the client (as in the case of therapy with at-risk children). It is possible that the presence of a third thing takes away the focus from this relationship, placing it instead on the medium. This would reduce the anxiety-producing intensity of the therapist-client relationship. In addition, the sharing mentioned is likely to strengthen the emotional bond between the therapist and client, thus encouraging a natural development of the therapeutic alliance, the relationship without which therapy cannot occur. Another form of third relevant to the idea of medium is that of the analytic third, proposed by Thomas Ogden (1999), which refers to a third subjectivity unconsciously cocreated by the therapist and client, which seems to take a life of its own in the interpersonal field between them (p. 487).

Interim Summary

Thus far, the term medium has been used to illustrate that through which self-expression may occur, that through which one’s inner world is expressed and communicated to another by a variety of behaviors. In the context of psychotherapy, the medium provides an opportunity for feelings and actions to be experienced and situations to be reenacted. The medium has been discussed in terms of its implications for both the client and the therapist. Furthermore, the importance of the therapist’s taking responsibility for being well acquainted with the medium and his or her relationship with it, and for knowing how to use the medium to facilitate client self-expression, reenactment, and working through the issues that come up within the therapy, have been emphasized. Thus, the therapy process is enriched and flourishes through the availability of the medium for the use by the client and the therapist. Finally, the role of the medium has been discussed as something that provides a common experience or common field of communication for the client and therapist.

THE ANIMAL AS A MEDIUM IN AAP

Whereas the chapter till now has delved into the general concept of medium in psychotherapy, focusing attention on its definitions, facets, and roles, the rest of this chapter discusses how an animal may serve as a unique type of medium. The animal as a medium in psychotherapy will be discussed within the context of the general concept of medium as described earlier, while the many facets that are unique to the animal as medium will also be discussed. Among these unique facets, we will discuss (in this chapter and in chapters 2 and 9) the multidimensional phenomenon of the intricate triangle—therapist-client animal—that exists in AAP, the meaning of the animal for the therapist, professional concerns pertaining to the animal as a medium, and dilemmas that arise when the medium is a living being.

According to Ishai et al. (in press), a medium has many and varied uses and implications: as material, platform for, and means for communication, a fertile ground for its development, a generator of content, a motivator or stimulation for change, containing messages or themes and values, and as a personal and interpersonal experience. The presence of an animal in therapy offers all these advantages. More so, we claim that an animal, with all that his presence entails, is rich and meaningful, because it is a multidimensional and multifaceted medium. Throughout this chapter, any general reference to the animal as a medium will heretofore refer also to all that his presence entails: his physical or metaphorical presence, his setting (whether isolated or with other animals, in a cage or free-roaming, in a play-therapy room or a petting zoo, or in a natural habitat such as a forest), his effect on the human senses (e.g., his sounds, smell, movement, visual presentation), his accessories (e.g., cage, leash, food), his behavior, and more.

The presence of animals, along with its implications, creates a large variety of simultaneous emotional, authentic, and spontaneous expressions, which bypass barriers to communication, facilitating and expediting its development into a curative medium. In turn, the animal as a medium catalyzes the development of the curative processes in psychotherapy.

This medium is on a basic level a nutrient system, fertile ground, climate, or condition, from which the therapy process may grow and progress. One explanation of this may be found in the concept biophilia, proposed by Edward O. Wilson (1984) in his book by that name. In a book later published by Stephan Kellert together with Wilson (1993), they write:

[The] human tendency to relate with life and natural process might be the expression of a biological need, one that is integral to the human species’ developmental process and essential in physical and mental growth…. The biophilia hypothesis proclaims a human dependence on nature that extends far beyond the simple issues of material and physical sustenance to encompass as well the human craving for aesthetic, intellectual, cognitive, and even spiritual meaning and satisfaction…. [There is a] human need, fired in the crucible of evolutionary development, for deep and intimate association with the natural environment, particularly its living biotica…. [One assertion of the hypothesis is] that the human inclination to affiliate with life and lifelike process is … likely to increase the possibility for achieving individual meaning and personal fulfillment. (pp. 20–21)

Although as of yet there has been little research carried out to test the biophilia hypothesis, a recent study has found a neurological basis for this concept. Mormann et al. (2011) studied the amygdala, the area of the brain which has been shown in research to perform a primary role in the processing of emotional reactions. The researchers found a preferential response for pictures of animals (as opposed to pictures of people or landmarks) in the right amygdala. This finding of categorical selectivity was independent of chemically related emotion or arousal, and the researchers concluded that this finding may reflect the importance that animals held throughout our evolutionary past (p. 1247). An implication of this finding is that our very brains are wired to receive the animals as a medium, which touches us in a very deep and basic way.

In their introduction to Ogden’s chapter, Mitchell and Aron (Ogden, 1999) stated that therapists must mine their [patient’s] potentially rich yield of access points into the patient’s inner world (p. 461). Mormann et al.’s (2011) research points to animals as being a natural access point to the depths of our emotional being. In conjunction with this, the existence in the therapy setting of the animal,