672506

research-article2016
CCP0010.1177/1359104516672506Clinical Child Psychology and PsychiatryShani

Article
Clinical Child Psychology
and Psychiatry
Animal-assisted dyadic therapy: 1­–13
© The Author(s) 2016
A therapy model promoting Reprints and permissions:
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development of the reflective DOI: 10.1177/1359104516672506
ccp.sagepub.com
function in the parent–child bond

Liat Shani
The Israeli Association of Animal-Assisted Psychotherapy (IAAAP), Israel

Abstract
Animal-assisted psychotherapy (AAP) inherently incorporates standpoints, interventions, and
ways of action promoting the development of the reflective function and mentalization, and thus
has special value for parent–child psychotherapy. Two central tools in AAP contribute to this
process. The first is the ethical stance of the therapist, who sees the animals as full partners in
the therapy situation, respecting them as subjects with needs, desires, and thoughts of their own.
The second tool combines nonverbal communication with animals together with the relating, in
the here and now, to the understanding and decoding of body language of everyone in the setting.
Nonverbal communication in AAP enables access to implicit communication patterns occurring
between parent and child. This article provides a survey of theoretical development and research
constituting a basis for the development of therapeutic approaches for the improvement of
parent–children dynamics, followed by a description of a dyadic therapy model of a mentalization-
based treatment originating from a psychoanalytic-relational orientation. Clinical examples are
provided to illustrate AAP processes in parent–child psychotherapy (consent was received for
examples that were not aggregated).

Keywords
Animal-assisted psychotherapy, dyadic therapy, mentalization, parent–child therapy, nonverbal
communication

Introduction to parent–child psychotherapy

Bowlby’s (1982) theory of attachment, together with the work of other theoreticians (such as
Mahler, 1968; Sullivan, 1953; Winnicott, 1965) dealing with the interpersonal context of child
development, highly influenced the understanding of the importance of the early parent–infant
relationship for personal and interpersonal development, as well as the understanding of develop-
mental difficulties in early childhood.

Corresponding author:
Liat Shani, Rechovot Hanahar 4/8, Ramat Gan 5252404, Israel.
Email: liatshany@013.net

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2 Clinical Child Psychology and Psychiatry 

Recent evidence has shown the reciprocal effects of the parent–child relationship occurring
from infancy, as well as the influence of the quality of the dyadic relationship on child development
(see Beebe & Lachmann, 2003; Glat & Bialik-Cohen, 2003). These studies show how the mother–
infant system is formed in the first few weeks of the infant’s life, each participant a component in
the system with his or her own ability to self-regulate. The development of the relationship and the
attachment pattern is determined by the mutual influences of both. That is, the mother–infant rela-
tionship is perceived as a system in which there is a shared organization characterized by rhythm,
movement, approaching, and distancing, as well as emotional regulation according to each one’s
state and needs.
Filmed observations of face-to-face interaction of infants and mothers show mutual cycles of
communication established in a coordinated fashion in the mother and infant (Beebe, 2003). There
are mother–infant pairs in which may be seen a mismatch in the dyad, and then one can see the
infant withdraw from the connection. Watching these encounters on film in slow motion, one can
discern the nonverbal signs of the “interactive dance” that are very subtle and may last only a split
second, yet are rich and varied.
Tronick (1998) suggests that the dyadic mother–infant system allows infants to expand their con-
sciousness beyond their cognitive abilities, which are not yet mature, and organize in a coherent
fashion the information that is absorbed from their external environment and from their internal
experience itself. Tronick named this phenomenon the dyadic state of consciousness. The mother’s
awareness and her ability to translate interactive states is a sort of scaffold or infrastructure upon
which and through which is built the infant’s consciousness. Furthermore, Tronick (1998) believes
that there exists an inherent striving toward these dyadic states of consciousness, as in “I interact
therefore I exist.”1 The quality and frequency of these dyadic states of consciousness influence to a
great degree the process of emotional and social development and the development of object
representations.
In addition, neurological research shows the influence of early attachment between mother and
infant on the infant’s brain development (Schore, 2002). Attachment problems and chronic stress
are likely to cause structural changes in the brain and can be expressed later in life through diffi-
culty in emotional regulation and coherent processing of emotional, social, and physical informa-
tion as well as in emotional disorders (Klorer, 2005).
Much research deals with how the parent–infant relationship has influenced and is influenced
by the development of intersubjective approaches to the understanding of personality. (Stern et al.,
1998). These developments in theory and academic study have led researchers, therapists, and
theoreticians to begin focusing on parent–infant relations in order to enlist the connection between
them for the healthy development of the infant (Sleed & Bland, 2007).

Ghosts in the nursery: intergenerational transmission and reenactment of

traumatic relationships
In light of this theory and research, various models of parent–child therapeutic interventions have
been developed. The work of Selma Fraiberg and her colleagues is an important milestone in the
development of therapy approaches for therapy with parents and their children. In their classic
article, “Ghosts in the nursery” (Fraiberg, Adelson, & Shapiro, 1975), they identified a phenome-
non in which traumatic experiences from the parents’ past “invaded” their present connection with
their young children and disrupted the process of attachment between them and dramatically influ-
enced the developmental processes of the infants. The model presented by Fraiberg and her col-
leagues emphasized the repair of attachment between mothers and their children, together with

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Shani 3

support and containment of the mothers in their difficulties, allowing for the gradual working
through of their past traumatic experiences, while concurrently helping the parents understand the
developmental needs of their infant. Based on this model, Alicia Lieberman’s therapy model of
Child–Parent Psychotherapy (CPP) (Lieberman & Reyes, 2012; Lieberman, Van Horn, & Ghosh
Ippen, 2005) is intended for families that have experienced trauma due to family violence and for
mother–child dyads in which the child is from age 0 to 5.

Survey of additional existing models for parent–child therapy interventions

Additional models exist which deal with parent–child psychotherapy, such as Cramer’s (1995)
model of short-term intervention, a psychoanalytic therapy approach in which place is given to the
exposure of unconscious conflicts that the parents bring into their relationships with their infant.
Influenced by Cramer’s approach, Manzano, Palacio-Espasa, and Zilkha (1999) presented an
approach to short-term psychotherapy intervention with parents and their children or adolescents.
This approach, dealing with the exposure of the parents’ projections and fantasies that they named
narcissistic scenarios of parenthood concerning the child, grew out of the understanding that the
scenarios are unconsciously acted out by the parents and their child and are the basis of the symp-
toms the child presents.
The Parent–Infant Project (PIP), developed at the Anna Freud Center in London, describes work
with both parents and their infant, where the connection between them is the main focus of their
work. This model’s goal is to disrupt negative intergenerational patterns and encourage behaviors
which promote healthy parent–infant attachment (Baradon et al., 2005).
In an additional short-term intervention model (Beebe, 2003, 2006), the therapist observes the
films together with the parent and they analyze the reciprocal influences of the interaction through
relating to terms such as degree of arousal, gaze, regulation, vocalization, distress, and calm. This
approach allows parents to actually observe information concerning implicit relations, or their
unconscious communication pattern with their infant.2 Although implicit knowledge is not acces-
sible to the parent’s consciousness, it influences and creates the type of regulation and translation
between parent and child, expressed in relationships with others through body language and vari-
ous actions (Stern, 1985). Observation of films is accompanied by working through parents’ emo-
tions during their interaction and their representations of the infant in order to change the
representations to be more adaptive and the communications between the members of the dyad to
be more coordinated (Beebe, 2003).
These parent–child psychotherapy approaches are related to the improvement of parents’ ability
to mentalize their interactions with their children.

Mentalization and the reflective function in the parent–child relationship

Fonagy defined mentalization as a

preconscious imaginative mental activity, namely, perceiving and interpreting human behavior in terms of
intentional mental states (e.g., needs, desires, feelings, beliefs, goals, and reasons). It is imaginative
because we have to imagine what other people might be thinking or feeling. (Fonagy, Gergely, & Target,
2007, p. 288)

and we must imagine the possible reasons for their behavior. Mentalization helps us to observe
others’ behaviors and make them understandable and predictable.

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4 Clinical Child Psychology and Psychiatry 

Mentalization develops in the interpersonal context. Fonagy described the reflective function as
the ability of the parent to reflect and hold in her mind both her and the child’s internal states simul-
taneously. The infant’s mind grows through the existence of the parent’s mind, or to paraphrase
Descartes, “someone else thinks about me and therefore I exist as a thinker” (Levy, 2012).
Additional studies have shown that parents’ reflective functioning plays a crucial role in the
child’s ability to develop efficient tools and flexibility to regulate oneself and to establish stable
and satisfying relationships (see Slade, 2007). Fonagy’s theoretical work and research, concerning
processes of mentalization and the importance of reflective functioning to establish secure attach-
ment, have had a profound influence on therapy interventions in parent–child relationship. As a
result, in the last 20 years, mentalization-based therapy approaches3 have been developed with the
goal of developing the parents’ reflective ability and motivating mentalization processes among
parents in general and in the context of children in particular (Fewell, 2013). The Haifa model of
dyadic therapy is one of these therapy processes.

The Haifa model for dyadic therapy

The Haifa model for dyadic therapy is an approach developed by Ben-Aaron, Harel, Kaplan, and
Patt (2001) from the University of Haifa and is used extensively throughout Israel. Based on the
theory of mentalization from a psychoanalytic-relational point of view as it relates to therapy for
childhood relationship disorders, this model integrates attachment theory with object relations
theory (Sharabany, 2013). Accordingly, the focus is on visible interpersonal interactions between
the parent and child and also on the internal representational world (Harel, Kaplan, Avimeir-Patt,
& Ben-Aaron, 2006).
One unique aspect of the model is the structure in which mother–child meetings alternate with
father–child meetings, together with regularly scheduled meetings of the therapist with the parents.
Attention is paid to the dynamics both within each of these three dyads and between them. A partic-
ipant-observer, the therapist “provides continuity to the therapeutic process and helps in the integra-
tion of the self-and-other representations of the participants” (Ben-Aaron et al., 2001, p. 28). Dyadic
therapy consists of the evaluation of various interactions and meanings of the relations between the
participants in therapy, how they work, are experienced, and communicated during the sessions. The
goal of dyadic therapy is to restore parents’ and children’s ability to regulate, organize, and represent
mental states within their relationship with each other (Harel, Kaplan, & Avimeir-Patt, 2013). This
is done by enlisting the parent–child relationship for the good of the continuation of growth and for
more appropriate working through content that arises (Glat & Bialik-Cohen, 2003). The therapist
contributes to the process by empathetically translating to the parents and children the influence of
the reciprocal interaction occurring within the dyad in order to lead to changes within it. Thus, one
of the therapist’s central roles is to regulate the joint actions. That is, the therapist helps parent and
child to contemplate together what has happened, pointing out the verbal and nonverbal communi-
cation existing between them and the way in which one influences the other through verbal media-
tion and development of the reflective ability within the relationship. The therapist contemplates the
communication patterns expressed in the meetings with the intention of identifying and bringing to
consciousness of the parent and child the implicit patterns existing between them.
Therapy interventions of this approach include building interest and attention to the mental state
of the other, focusing in such a way that the child perceives the parent’s mental state and the parent
perceives the child’s mental state. For instance, the therapist might say, “What do you think
Mommy is thinking?” “What do you think your child is thinking?” The therapist may present an
array of ways through which one may see the external reality and develop the ability of parent and
child to play and build a symbolic space between them, allowing an encounter with content and

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Shani 5

subject matter that occupy them both in the common play space, from the understanding of the
importance of play for emotional development (Winnicott, 1971) and for development of the
reflective function (Fonagy & Target, 1996; Harel et al., 2013).

Animal-assisted psychotherapy4
Animal-assisted psychotherapy (AAP) is based on the natural bond between humans and animals,
integrating animals into therapy processes in the therapy structure of therapist–client–animal.
Researchers and mental health professionals have seen the special advantages and beneficial influ-
ence of animals on sufferers of a variety of difficulties such as attention disorders (Katcher &
Wilkins, 1994), mental disorders, and psychiatric difficulties (Rossetti & King, 2010). It has been
found that therapeutic interactions with animals lead to reduction in anxiety and stress (Odendaal,
2000) and reduction in anhedonia in psychiatric populations (Nathans-Barel, Feldman, Berger,
Modai, & Silver, 2005). Contact with animals comforts, calms, and results in a general feeling of
psychological well-being (Odendaal, 2000).
Boris Levinson, a clinical psychologist, was the first to recognize AAP as an independent ther-
apy approach and he began to build a comprehensive knowledge base for the field (Levinson,
1969, 1972). Levinson claimed that an animal would be a natural object for attachment and more
appropriate for attachment than inanimate objects. He assumed that relationships with living beings
allow for a wider range of behaviors to surface in the course of reciprocal interaction. Also, an
animal is likely to serve as a secure base and safe haven5 (Zilcha-Mano, Mikulincer, & Shaver,
2012). Today, we are witnessing a growing knowledge base, developing from clinical practice and
research from the field of AAP that are anchored in theory and research (e.g. Bachi, Terkel, &
Teichman, 2012; Parish-Plass, 2008; Pirani & Shani, 2003; Urichuk & Anderson, 2003; Wesley,
Minatrea, & Watson, 2009), as well as extensive theoretical conceptualization (Kruger & Serpell,
2010; Parish-Plass, 2013a;) and connections to other psychotherapy approaches (Chandler, 2010;
Faa-Thompson & VanFleet, 2010; Ish-Lev & Amit, 2013; Lac, 2014; Maayan & Lakh, 2013) and
evidence-based therapy models suggesting attachment theory as a perspective for AAP (Bachi,
2013; Zilcha-Mano, Mikulincer, & Shaver, 2011).

Ethical stance and nonverbal communication as fundamental tools in AAP

I believe that the animals are full partners in the AAP therapy situation. This partnership is accom-
panied by unique ethical issues influencing the way we act toward all those present in the therapy
setting. In AAP, the therapist emphasizes the animal’s welfare. According to this stance, animals
are related to as separate beings with their own needs and desires that are not always aligned with
those of the client, and the therapist is responsible for their physical and mental welfare based on
knowledge about animals in general as well as on a personal acquaintance with the needs and
behavior of the animal being worked with. This stance influences the way the intervention will be
carried out in the therapy situation that includes a therapist, client, and animal and has an important
place in the establishment of relations based on trust with the client.6
The fact that animals do not talk yet do have nonverbal language leads us to the task of under-
standing, solving, and regulating of nonverbal communication between us and them. In order to
draw near to an animal, the client learns to be aware of the characteristics of the animal’s body
language, his needs, and unique personality. The therapist mediates these interactions in such a
way that advances the development of the client’s reflective ability, as will be shown later. The next
section will describe how these two tools—ethics and nonverbal communication—are the basis for
reflectivity being an inherent part of AAP.

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6 Clinical Child Psychology and Psychiatry 

Animal-assisted dyadic therapy

Reflectivity as an inherent part of AAP
The ethical stance of the AAP therapist emphasized above, together with the fact that animals
express themselves through their bodies, creates a situation in which in order to create a connection
with an animal, the therapist must think, imagine, and try to feel together with the client what the
animals may be feeling. In addition, the therapist must try to think, together with the client, how
their own behavior (both the therapist’s and the client’s) influences the animal. The presence of the
animals encourages reflective processes just by the fact that they are living beings and feel but do
not speak in human language. During the therapy process, the need arises to verbalize the animal’s
feelings, desires, and needs, and to raise hypotheses concerning possible reasons for their behavior,
while emphasizing their being subjects. This theme is present in the therapy setting both at the
verbal level and in the therapist’s ways of acting and relating. These principles will be demon-
strated with the help of a case study from animal-assisted dyadic therapy.

The very little hamster who couldn’t talk

Two parents and their daughter, Miriam (3.5 years old) who suffers from developmentally delayed language
acquisition, were referred for dyadic therapy after Miriam began to show symptoms that proved to be
cause for concern. Miriam was described as characterized by sadness, passivity and incessant crying. A
kindergarten teacher described her as emotionally withdrawn and unhappy. After the intake with the
parents, it came to light that the mother had previously been in dyadic therapy with her daughter due to
her own emotional problems. A young couple, both parents had a complex background of neglect in their
childhood. The main problem that was presented, both from reports from the kindergarten and daycare
staffs and from the parents themselves, was the father’s tendency to get angry at Miriam and reject her
because of her developmental difficulties. Therefore, it was decided that the dyadic therapy would focus
on the father-daughter dyad and the mother would participate in parent counseling. The father showed
motivation for therapy and despite an initial difficulty showing up for weekly sessions, he began to attend
the sessions consistently.

In the joint father-daughter meetings, the difficult relationship between them quickly became apparent.
Miriam seemed heart-wrenchingly emotionally withdrawn, yet it seemed that the father had difficulty
seeing this and put great pressure on her to speak. For instance, he asked her to draw and name the colors.
The therapist intervened in an attempt to regulate the tension between them. She pointed out to him
Miriam’s body language, which relayed a great deal of tension and defensive withdrawal into herself
because of the pressure. Yet the father found it difficult to regulate his behavior in the sessions, causing
Miriam to withdraw from every attempt by the father to interact with her. In parent counseling, it became
evident that the highly charged nature of the interaction was partially due to his past experiences as a
child with developmental difficulties. The father was reenacting painful patterns of rejection and lack of
acceptance through his relationship with his daughter.

At the time, Miriam showed interest in a hamster in the therapy room. She spent much time observing him
and showing interest in him, at first passively. Later she started to actively look for a connection with him,
trying to draw close and touch him. After a few sessions, Miriam said “hamster” (in the initial stage of
therapy, Miriam had not yet talked). Surprised at the influence of the hamster on his daughter’s vitality,
even the father started to show interest in a connection with the hamster. Through the mediation of the
therapist, the father and daughter formed a partnership in the care of the hamster, together giving him
food and water, cleaning the cage and preparing toys for him. In this process, the therapist mediated the
interactions while encouraging the father and daughter to observe the body language of the hamster and
pay attention to when he was interested in drawing closer, when it seemed that he want to distance himself,

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Shani 7

what type of touch he liked, how he felt when Miriam held him, how he felt when they entered suddenly into
his living space. This father-daughter partnership, created in the context of the relationship with the
hamster, in turn created a connection and closeness between them and generated a mentalization process
in both father and daughter. In a joint session illustrating this point, Miriam observed the hamster and how
he did not leave his enclosure. Connected to the hamster and waiting for a chance to interact with him,
Miriam was disappointed.7 The therapist reflected Miriam’s disappointment and encouraged the father
and daughter to think why, in their opinion, the hamster did not come out today. Miriam explained to her
father, “Maybe he is scared of us” and the father answered her, “Why do you think he is scared?” Miriam
answered “Because he is little, very little, and he doesn’t know how to talk well . . .” The father reacted
empathetically and in a containing way, saying, “You are right. He really is so little . . . so let’s not take
him out of his enclosure today. Let’s help him, give him food together. He needs our help.” At that moment
there was a deep sense of connection between the two. In this session and in many sessions after, the father
began to understand in a deeper way the difficulties in his relationship with his daughter and the reasons
for her distance from him.

This example allows us to contemplate the process of the development of the reflective function in
the dyad and its influence of this developing ability on the father–daughter connection. The father
had reenacted with his daughter “ghosts” from his traumatic past, making it difficult for him to see
his daughter’s needs during the session. The partnership in the context of the hamster and the con-
nection with him created an intermediate area of experiencing (Winnicott, 1971), the focus of
shared playing and activity that developed into a representation, in both Miriam and her father, of
“small and helpless.” In this process, through the therapist’s mediation, the father and daughter
observed, thought, imagined, and tried throughout the meetings to decipher the hamster’s body
language in order to come close to him in a beneficial way. It is likely that for both father and
daughter, this process significantly contributed to the development of the reflective stance, relating
to the behavior in terms of internal states. The child considered her behavior (withdrawal, avoid-
ance from connection) to be generated by emotion (fear, suspicion). The father succeeded in dis-
covering empathy “for the hamster in need of help,” representing his daughter, and exhibited
considerate and appropriately sensitive behavior (“Let’s help him”).8 From this stance, the father
was able to experience his daughter, for the first time, in an exciting session that included true
understanding.
In the parental counseling session, while working through the situation in this session, the father
shared with the therapist familiar experiences of anger and rejection by his parents toward him. He
could connect with feelings of shame and incompetence that the anger and rejection awakened in
him. From this, he could painfully contemplate his daughter Miriam’s experience “as a little ham-
ster who cannot talk.” In his eyes, this metaphor turned Miriam’s behavior to logical, allowing him
to feel empathy for her difficulties. He seemed to begin differentiating between his representations
and his daughter’s representations, while showing expressions of attention and interest toward his
“real daughter” whom he was beginning to discover while in therapy. Later, there was significant
influence of the change in the father–daughter relationship on Miriam’s development and emo-
tional state. She began to talk more fluently during the therapy process, despite the many family
difficulties (in the parents’ relationship and also individual personal difficulties in both parents).
Miriam began to exhibit initiative, exploratory behavior, enjoyment in play, and satisfactory func-
tioning in the kindergarten.
The development of the reflective stance is related to attention, understanding, and deciphering
body language, as well as to the connection to one’s own and other’s internal states. Identification,
understanding, and development of awareness of sensations and bodily experiences are important
bases for self-regulation and reciprocal regulation. In the next section is a discussion of the ways
that these processes are enhanced through animal-assisted dyadic therapy.

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Body language and nonverbal communication with animals as a therapy tool

As mentioned above, animals have a presence of a primitive nature. They do not speak, they smell,
they make sounds, and may have soft fur or a hard shell. They have a warm tongue that licks, have
their own rhythm, and move in space. An animal’s physical presence in the AAP therapy session
creates a therapy situation in which touch, regulation, texture, and movement are part of the client-
animal interactions. As a way to communicate with animals, the client starts to become aware of
his own body language, of what the body language relays to others and ways that self-regulation
helps him to create a beneficial relationship with the animal.
The animal’s presence lays the foundation for focusing on primary physical issues, such as
touch, understanding, and deciphering of body language. Touching an animal allows also for a live
encounter with physical boundaries, which is likely to contribute to the establishment of a feeling
of bodily cohesion as part of a strategy for self-regulation.9 The therapist relates to the body lan-
guage of both client and animal as a way to stimulate awareness of (1) the bodily experience of the
client, (2) internal states that influence his body language, and (3) the way in which it is expressed
in interaction with the animal.

“Rosa’s Language”

Ayal, 8 years old, participated in animal-assisted dyadic therapy together with his two parents. Ayal found
it difficult to regulate his behavior at home and at school and often displayed wild and impulsive behavior.
In the meetings with the mother, there was often unbearable tension between the two as the mother brought
up more and more issues in the session. Ayal was no longer able to process, either angrily retreating from
the interaction or acting out his rage.

Present in the session was Rosa, a mixed-breed Labrador-type dog. Ayal and Rosa had a close connection
and they had between them a physical rhythm of petting, calming, and play, which calmed them both. The
mother also wanted very much to get close to Rosa, but Rosa recoiled from her. When this happened, the
therapist reacted, “Pay attention to Rosa’s body language. Why do you think Rosa moved away? What
might help create a connection between the two of you?” Ayal explained to his mother: “She doesn’t want
to, because you came too close and you look into her eyes too much . . . She feels pressured . . . She needs
you to be farther away and to let her come to you.” The mother listened to Ayal and changed the way she
approached Rosa. Rosa started to look for the mother’s presence, and the mother was excited by Ayal’s
ability to understand the dog. “You understand her language . . . I’m happy that you explained it to me.”
In the following sessions, a different rhythm developed between the mother and son, a rhythm that had
space and attention to the way each one present in the session signaled, through body language, states of
tension, excitement, need for closeness or distance. The “language” that Ayal had explained to his mother
became a meaningful theme which was processed in parental counseling, helping the two to establish a
more appropriate connection between them.

In addition to the awareness of body states and efficient strategies for self-regulation that are part
of AAP, the mutual therapist–client–animal communication enables bringing implicit knowledge
to the surface (Stern et al., 1998). This is a nonverbal knowledge pattern that is not accessible to
consciousness, holding within it unconscious knowledge about “how to be with someone else”
(Stern, 1985). Accordingly, this knowledge pattern is important in dyadic therapy, allowing acces-
sibility to unconscious patterns existing in the parent–child relationship, that the acquaintance with
them may advance the process of awareness and change.

“Who is leading me?” in a walk together with Duvi the dog

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Shani 9

In one of the father-daughter dyadic sessions, Miriam got over her earlier suspicions and initiated a
relationship with the dog Duvi. Miriam patted her and expressed a desire to take her for a walk outside. The
therapist suggested to the father that they take a walk together and he agreed to the suggestion. During the
walk, the father seemed distant and indifferent to something new in his daughter’s behavior (creation of a
relationship with Duvi, whom she had been wary of at the beginning of therapy, and the initiative to go for
a walk with her). This pattern of difficulty paying attention and recognizing new processes shown by the
child characterized their relationship. Miriam walked limply, holding yet not holding the leash. As a result,
Duvi lead the walk to directions that she chose but were not necessarily appropriate (e.g. in the direction of
garbage bins). The therapist turned the father’s and daughter’s attention to Duvi’s body language. “Since
you don’t show her where you would like her to go, she wanders in different directions and it is not clear to
her how to conduct herself during the walk. It is as if she is saying, ‘Who is leading me here? Where should
I go?’” The therapist’s words caused the father to notice the fact that Miriam was doing something new and
different. He was surprised by this and reinforced her by saying, “Miriam, you are holding Duvi! Come and
let’s show her together where to go.” The father started to direct the walk together with Miriam and
especially to pay attention to her. From session to session, one could see a change in the way Miriam walked
with Duvi. From a limp and unsure hold, she started to lead Duvi more and more confidently and solidly,
feeling proud under the watch of her father observing and reinforcing her.

In this example, one can see how the implicit father–daughter relationship pattern is expressed in
the walk together with the dog and how the mutual translation exists between them. The father has
difficulty noticing this because of his personal difficulties and depressed retreating into his own
internal world. The father’s passivity and distancing from his daughter’s actions, together with his
difficulty in acknowledging and accepting them, is expressed in the daughter’s behavior. She trans-
lates his lack of reaction to lack of permission. She is not sure of the course of action that needs to
be taken and exhibits insecure and passive behavior. It is also expressed in the dog’s body language
in that she reacts to the limp hold of the leash by walking in a confused and random way in different
directions. In this way, the dog brings to the surface the unconscious dynamics that exist between
the two. The therapist’s relating to the confusion and insecurity exhibited by the dog in this situa-
tion allows the father to pay attention to what is happening and to react now in a different way to
his daughter’s initiative.

Summary and conclusion

AAP is characterized by unique mechanisms that significantly contribute to the dyadic therapy
approach. Many therapy models dealing with parent–child interventions state the development of
the ability to mentalize as a main goal. The central focus of this article is the reflective stance that
is inherent in AAP, which in turn influences the development of the reflective function, which then
stimulates mentalization processes.
The developing reflective ability within the framework of AAP is based on the ethical stance
described here. Animals are seen as independent beings, having needs and desires of their own that
are not always compatible with ours or that of the client. This stance serves as the foundation of
AAP theory and technique. In this AAP therapy process, we deal with the understanding and deci-
phering of nonverbal communication as part of an attempt to create a relationship with the animal.
This built-in engagement with nonverbal bodily elements allows the development of awareness of
bodily feelings, self-regulation, and mutual regulation, together with observation of implicit action
patterns existing between the parent and child. The intent is to create more adaptive patterns in the
dyad. Animals wander about in the setting, drawing closer or moving away, playing, creating rela-
tionships. They are similar to us yet different. Their presence in the therapy setting creates a living

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10 Clinical Child Psychology and Psychiatry 

channel for communication between parent and child, enabling the advancement and stimulation
of central elements in the approach of dyadic therapy.
The perceptions and conceptualizations presented in this article, concerning the contributions of
AAP to the development of the reflective function and mentalization, are based on the author’s
clinical experience and academic study. Although theory-building is critical for the understanding
of the processes described above, there is a clear need for research to validate the claims made.

Acknowledgements
This article is based on an article published by the author in Hebrew: Shani Kassif, L. (2014). Tipul diyadi
hne’ezar b’ba’alei chaim: Model tipuli hamikadem et hahitkadmut hafunktsia hareflectivit b’kesher hore-
yeled (Animal-assisted dyadic therapy: A therapy model promoting development of the reflective function in
the parent-child bond). Chai’ot V’Chevra (Animals and Society: The Israeli Journal for the Connection
Between People and Animals), 50, 17–28.

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

Notes
1. Tronick showed in his research the dramatic influence on infants when denied these dyadic states of
consciousness due to a parent who is depressed or suffers from other disorders. Even in this difficult situ-
ation, the infant will strive for dyadic states; however, the result is likely to be destructive for the infant
(Weinberg & Tronick, 1998).
2. Stern et al. (1998) described two parallel sets of knowledge, or of different relational representations. One is
explicit, declarative knowledge, or symbolic representations accessible to our consciousness and represented
through language. These representations may be interpreted in an analytic situation. However implicit, pro-
cedural knowing is knowledge registered in us at a preverbal level and is expressed in our behavior and in
the way we conduct ourselves, but is not accessible to our consciousness. This knowledge is internalized
and exhibited through our interactions, communication, the mutual regulation, and translation existing in the
parent–infant dyad. Rhythm, movement, desired distance from others, enthusiasm or indifference toward
new behavior, desired or undesired behaviors are all registered in the infant in the first year of life, a prever-
bal stage, as unconscious behavioral patterns. Stern et al. felt that a major proportion of the process of change
that commenced during therapy was generated by change in the implicit relational knowing.
3. Mentalization-Based Treatment (MBT) has been in use not only in the context of parents and their chil-
dren but also with other populations.
4. Animal-assisted psychotherapy (AAP) is meant by the author to follow the guidelines set by the IAAAP—
The Israeli Association of Animal-Assisted Psychotherapy—which integrates the type of knowledge and
training demanded in Israel for practice in this field.
5. According to Attachment Theory, securely attached children use an attachment figure as a secure base
from which they may explore, and as a safe haven to which they may return in times of distress or regres-
sion (Ainsworth, 1991).
6. For a more extensive discussion of the ethical stance in AAP and ethical issues accompanying AAP
therapists, see Ben David (2013) and Parish-Plass and Oren (2013).
7. As part of the ethical stance of the AAP therapist that was mentioned earlier, the therapist respects the
desire of the hamster to stay in his enclosure and not to interact if he does not want to do so.
8. Fonagy and Target (1996) emphasized the importance of play for the development of the reflective func-
tion. AAP allows for the creation of a unique intermediate space which promotes both individual and
cooperative play (Pirani & Shani, 2003). For further discussion of the expansion of this space through
AAP as it promotes symbolic play, see Parish-Plass (2013b).
9. In this context, Ogden describes the autistic-contiguous position as the most primitive dimension in
the human experience, mainly consisting of experiences of touch, together with sensory experiences of

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Shani 11

sound, movement, and rhythm. These experiences, especially experiences of touching on skin, create
over time the experience of delineation and bodily cohesion (Ogden, 1992). I assume that it is possible to
understand much of the interactions in AAP in terms of defenses and anxieties that are characteristic of
the autistic-contiguous position, especially the need to establish a sense of bodily cohesion through touch
and “to be one piece.” This subject deserves to be expanded, but not in the framework of this article.

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Author biography
Liat Shani (BA educational counseling and artcertificate in animal-assisted psychotherapy, MA in expressive
and creative therapy) has worked as an AAP therapist with at-risk populations in various settings and is a
pioneer in the field of Animal-Assisted Dyadic Therapy. She has developed a unique model of animal-assisted
group therapy for survivors of drug abuse. Liat has been a lecturer in and director of the Levinsky College
certificate program in AAP, and is currently in the board of the IAAAP – The Israeli Association of AAP, is
a senior clinical supervisor, and has a private practice.

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