As we work our way through the COVID-19 pandemic, there are many shifts required as to how we live and work. Following shut-down periods when online methods of conducting therapy might be used, there are opening-up periods in which in-person sessions become more possible. At the time of this writing, and the foreseeable future, the virus is still present and capable of infecting people as much as before. Risks can be mitigated but not eliminated until the virus is rendered under control which occurs with the development of effective treatments and, ultimately, a vaccine.
Those who work with their animals face some additional challenges when conducting therapy. A prior blog, Teletherapy Sessions with Animals: Initial Considerations, discussed factors of importance when animals of the therapist or the client are involved in teletherapy sessions. As most states in the United States and elsewhere begin to open up gradually, in-person sessions become possible again. Even so, it will not be like it was before the pandemic hit, at least for now.
Information about the spread of COVID-19 has changed over time. It is likely to change again. Because it is a brand new virus that behaves differently from other viruses classed as coronaviruses, information has been scarce and seemingly inconsistent. This is normal given the speed with which scientists have tried to develop a clear understanding of this virus, and the fact that some aspects have not shown themselves at first. It’s confusing, but confusion is part of the early stages of a pandemic such as this. To make matters much worse, conspiracy theories and false claims about the virus abound. Some are created by people who simply don’t know the science, some are supplied by those seeking the spotlight with their radical but unsupported views, and some are created by bots (computers). There is much information to weigh in order to make good decisions for ourselves, our families, and our therapy work!
At the current time, most hospitals and nursing facilities are not permitting visitors, and this has implications for those who involve their animals in volunteer visitation and social support programs. In many cases, such AAI programs simply cannot remain active until these circumstances change. Even so, those who have actively visited medical patients or skilled nursing residents with their animals can still send letters or emails featuring photos or videos of their animals to people who are familiar with them.
The remainder of this blog post focuses on professionals involving animals in their work, although volunteer therapy dog teams might find some of the information useful as well.
It’s an Individual Decision
Determining when and how to conduct Animal Assisted Play Therapy® (AAPT) or other Animal Assisted Interventions (AAI) in-person is by necessity a very individual decision. Some of the factors that figure into such decisions follow:
- the current extent and spread of the virus in one’s area
- country, state, and local laws, regulations, or emergency orders that are in effect in one’s region (by government, Centers for Disease Control and Prevention, World Health Organization)
- the policies and procedures of one’s insurance companies
- the ability to ensure necessary social distancing measures, such as frequent hand washing, disinfecting the facility or venue, ability to maintain a 6-foot (2 meter) distance between people, the wearing of masks, and how one avoids possible coronavirus exposure or infection in oneself and one’s clients
- the presence of risk factors such as compromised immune systems of one’s clients or oneself
- the risk tolerance a therapist has; i.e., one’s comfort level with both teletherapy and with face-to-face sessions while the virus remains active
- the needs of clients and the extent to which they can be met using different treatment modalities
- the presence of a private outdoor area or larger indoor spaces in which to work
- the quality of air circulation in the facility
- the nature of clients’ goals, how the animals are involved, and the extent to which interventions can be conducted within social distancing guidelines
All therapists want to practice safely. They do not want to expose their clients to the virus nor do they want to expose themselves to infection. Because an estimated 32% of the spread of this virus is done by people who have no symptoms at all, this makes decision-making trickier. To make the best decisions, it is critical for practitioners to understand as much as possible about what is currently known about the spread of the virus and the implications of that for how they work with their clients in a face-to-face manner.
One of the most helpful articles to date is entitled The Risks – Know Them – Avoid Them (click the title to read it) by Dr. Erin Bromage, a comparative immunologist and professor of biology at the University of Massachusetts Dartmouth (www.erinbromage.com). The early statistics in this article have since increased, but he details in understandable terms the ways in which the virus spreads, and the risk factors for infection. He also outlines different venues and how they might influence the spread of the virus. Of particular importance are his discussions of (1) infectious dose (how much of the virus you take in), (2) distance (how close you are to the source of the virus), and (3) duration (how long you are exposed). He describes how indoor spaces with poor air circulation and/or many people are particularly risky. The length of exposure, even to smaller doses of the virus, plays a large role. As he summarizes, “The principle is viral exposure over an extended period of time.” The article provides a great deal of useful information for anyone trying to minimize risk in their personal lives or in their workplace.
In general, there is considerably less risk in outdoor spaces where the air is moving, such as a breeze or wind. Recent reporting suggests that most transmission occurs person-to-person rather than from surfaces, but surfaces cannot be ruled out entirely. Masks help prevent us from infecting others, and vice versa. Frequent hand washing and avoiding touching our faces are key factors as well.
Professional Associations Offer Suggestions
Professional associations are excellent sources of information about resuming in-person work, too. For example, the American Psychological Association (www.apa.org) has an article, COVID-19: When Is It OK to Resume In-Person Services? (click on title to access it). As one restarts in-person work, it is also important for the organization to rework the consent forms, including the new risk factors that will be present. These should be discussed with each client, and signatures obtained from the appropriate parties. APA offers an article on this, Sample Informed Consent Form for Resuming In-Person Services (click on title to read).
Associations that serve other professions or operate in other countries might well offer their own versions of articles such as these. Readers are urged to check with those resources as well.
What’s the Deal with Animals?
The information about animals has been confusing at times. While a handful of animals have tested positive for COVID-19, most of them showed no or very mild symptoms. There is some question about the details of some of the reports as well. While some organizations have suggested elaborate cleansing protocols for therapy animals, we need to consider what that would be like for the animals. Of course, if the animals work just 1-2 hours per day, perhaps 2 or 3 days per week, it might be less cumbersome, but the animals’ experiences of all this must be considered of great importance.
Once again, getting as many facts as possible is important. It is a good idea to check with reliable sources periodically for any changes. The current belief among veterinary scientists is that there has been no evidence to suggest that pets pass the virus to humans. Surface transmission in general is considered a secondary pathway for transmission, and pet hair or fur is fibrous and porous, so even less likely to transmit the virus. On the other hand, collars, leashes, and halters could serve as a means of surface transmission, so regular cleaning of those items would be prudent. It does not seem necessary to subject animals to extensive cleansing beyond their usual good hygiene, and asking clients to wash their hands when the interactions start and finish. The American Veterinary Medical Association offers the article, Animals and COVID-19 (click on the title), and is a good resource to check back with from time to time.
An Approach to Planning for In-Person AAPT/AAI Sessions During the Pandemic
Many of the considerations for restarting in-person sessions apply whether or not an animal is involved. The other resources mentioned here and those from other professional organizations will undoubtedly have more details about reopening a general practice, and so the remaining focus of this blog is to suggest a way of planning as well as a handful of general tips that pertain primarily to the involvement of animals in one’s work.
To try to think through all the aspects of a restart with the COVID-19 threat still among us, it is useful to visualize what a client goes through from arrival on our premises through departure. Doing this visualization several times is likely to reveal details that didn’t arise the first time one does it. This will raise questions to be answered, such as “How will they arrive on the property or in the building?” “Who will be permitted building access?” “Where will I keep my animals?” Will there be human-to-human contact if I use my waiting room, or can I avoid that by scheduling?” “What happens during therapy that in the past required close contact?” “If applicable, how will payment be accomplished?”
Think about areas that are enclosed and likely to present higher risk, such as the bathroom. How and how often will disinfection be assured? What toys–for humans or animals–get handled and how will they be properly cleaned? If brushes are used to groom horses at the end of a session, how will they be disinfected?
During sessions, will more than one person be interacting and touching the animals at the same time? Can this be avoided if clients are not from the same family, as in a group session? Can hand sanitizer be located in strategic areas to permit sequential handling?
This process of thinking through everything, coupled with solid information about COVID-19 transmission is likely to lead to safer procedures that minimize risk. Remember to think space (viral dose), distance (6-10 feet), and duration when considering these facets of the entire process.
A Few Tips from Animal Assisted Play Therapy® Work
The following tips are drawn from AAPT work, and represent some adaptations of methods described in two books by VanFleet & Faa-Thompson: Animal Assisted Play Therapy (2017) and Manual of Animal Assisted Play Therapy® Techniques (2019).
There have been reports of some children feeling fearful of masks. They are not familiar with them or they have developed some negative associations with them. They might be comfortable with their own family members wearing them, but fearful of strangers who do. In advance of meeting the therapist, it is a good idea for them to understand that everyone will be wearing masks much/all of the time. The therapist can even email a photo of themselves in a fun mask.
The International Institute for Animal Assisted Play Therapy® (IIAAPT) has developed a project using an app that “gives voice” to animals who talk about pandemic-related topics in a light-hearted manner. It’s called Animals Speak! (within our blog posts at iiaapt.org). Issue 10 features Beagle mix Josie Patches talking about her worries about masks. This and the other issues can be shared with children. Issue 10 can be found here. Furthermore, therapists can create some fun interactions involving masks that will help demystify them. There are a number of animal masks available that cover nose and mouth (and one could wear another mask beneath them if the fabric is thin). These can be used playfully to help clients feel safe with masks where the mouth and nose are covered. These are also very useful for other animal-themed interventions or activities later in therapy, too.
Train Clients in Fun Ways
Whatever your expectations of clients’ behavior, you can offer some brief, but playful, training, first without the animal present and later with the animal. This is how we usually teach clients to meet and greet animals safely and is detailed in the Animal Assisted Play Therapy® book noted above. If you expect the child to wait in one spot and allow the animal to approach them, then you can practice that with a stuffed animal, but in this case, you won’t take the stuffed toy animal all the way to the client so you can maintain social distance. Teaching a client to keep a loose leash can easily be done with a stuffed toy dog with a leash on the harness, and the therapist can provide some teaching and guidance from a distance as the client tries it out with the toy. The key is to keep clients doing things so they can develop the necessary skills. Therapists can still demonstrate with the dog, and then allow the client to have a similar interaction.
Use Stakes and Long Lines
To avoid close contact when handing off a leash, the use of a stake in the ground (outdoors) with a 15-20 foot line can work very well. The line is attached to the dog’s harness. The dog needs to be responsive to being called, and both therapist and client can have some treats. The therapist completes a demonstration, or their turn in a game of some sort. Then the dog is released (it’s helpful to have a release cue), and the client calls the dog to them, offering a treat when the dog arrives. Then the client has their interaction or turn. The dog needs to be prepared in advance to know how far the leash goes, and the therapist must be sure that they and the client never ask the dog to come to the end of it so as to prevent injury.
Mark the Distances
For clients of any age, but especially children, it’s a good idea to use some sort of physical markers to delineate appropriate distances for the environment being used. Outdoors, small cones can show where different clients are to stand to wait their turn in a relay, for example. Indoors, cones can be used as well, or masking tape on the floor as is often done to block scenes in theater productions. To make it more playful, hula hoops or pool noodles can be used to show clients where to stand. If you have lots of 6-foot leashes, they can be used creatively to mark off the minimum distances.
Teach the Animals to Respond to Cues at a Distance
With a well-trained and socialized therapy dog, it can be quite easy to teach him/her to respond to cues from a distance. Key cues for behaviors useful in therapy are taught and then proofed (generalized). The therapist can give cues to the animal without being close to where the animal might be located with the client.
Work Off Leash or At Liberty
In AAPT, we prefer to work with animals when they are fully free to come and go. This means that the use of leashes for dogs or ropes for horses are the exception rather than the rule. When animals, therapists, and clients are used to working in this manner, it becomes very easy to spread out the humans and give the animals freedom to respond to the clients or to do their own thing, as they see fit. It is still important to ensure that the animals have an “exit route” at all times.
Much Is About Structuring
Structuring typically refers to the things one does to set up the environment in advance so clients succeed. When animals are involved in therapy, this structuring should also set the animals up for success. This process requires thinking ahead with every activity to incorporate social distancing principles. It’s not really that hard to do with a little bit of forethought. For example, having hand sanitizer in outdoor venues can reduce the need for trips to the bathroom.
Build Relationship and Keep It Playful
Play therapists know the power of play to create safety and permit the working through of various emotions and problems. Many children might be stressed with the sudden changes in their lives and the continual need for adjustment. If their parents are anxious, it is likely that children will be, too. Of course, it is quite normal under pandemic circumstances for adults to be worried or stressed. Therapy depends on comfortable relationships to work well. When therapists ensure that their relationships are genuine, empathic, playful, and nonjudgmental, the clients can relax into whatever is planned. Animals can assist with this process when they enjoy being with clients.
Stay Outdoors When Possible
The risk of infections drops considerably when activities take place outdoors. For therapists who have a private outdoor area of sufficient size, holding sessions there can reduce risk. At the same time, it is important that client confidentiality is maintained. Any outdoor area should be out of sight of potential onlookers.
Develop Your Competencies
It is critical when involving animals in our professional work that we ensure that we have the proper training, supervision, and experience to do this work with clients’ and animals’ needs in mind. It is risky to simply take our nice family dog to work, as the dog might not be cut out for therapy work. Multi-modal training is essential so that the best possible model and metaphor is created for clients. The Animal Assisted Play Therapy® book contains considerable detail about the competencies needed to do this work well, and this will be the subject of a future blog as well. Furthermore, even though provisions can be made for clients to share or interact with family companion animals during teletherapy (children should be under parental supervision as discussed in our blog mentioned above), this is a decidedly bad idea for in-person therapy. There are huge liability issues that attend, and most therapists do not have the high-level skills to work with unfamiliar animals.
Remember to Use Split Attention and Proactive Attention Skills
Our AAPT training competencies include split attention and proactive attention (see the Animal Assisted Play Therapy® book for details). Both of these are always important, but particularly critical during in-person sessions during the pandemic. We must use our peripheral vision and awareness to ensure that clients follow social distancing throughout the sessions. We must also look ahead to things that can interfere with the social distancing of clients and step in to restructure or intervene in those situations. These two skills are exceptionally important for safety in any therapy session, but we must now add our observation and awareness to the new behaviors we are asking of our clients.
As you might realize, making these types of transitions, first to teletherapy and then back to in-person sessions with social distancing added, can be challenging. These are just a handful of the considerations needed. Even so, it is hoped that the approaches and resources listed here will be helpful. There is always more to learn, but life is far from static. We can provide a good model for our clients of all ages about how to adapt to change, even when it is unexpected and unwanted. The pandemic raises many therapeutic issues that are present in “normal” daily life, and creative therapists can look for the opportunities to help their clients cope with changes and become creative in their own adaptations.
The International Institute for Animal Assisted Play Therapy® offers online and live training courses for those interested in the many aspects of involving animals in a voluntary and reciprocal way in their mental health, allied health, and education services. www.iiaapt.org.
Article and photos © 2020, International Institute for Animal Assisted Play Therapy®, www.iiaapt.org. All rights reserved.