Mental Health and Social Inclusion

Pets, animal-assisted therapy and social inclusion

Sue Holttum,
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 Research Watch

Pets, animal-assisted therapy and social inclusion

The long relationship between domesticated animals and humans

Humans have kept domestic animals for thousands of years. Pet animals, especially dogs,

can be part of the social life of a household. This has led some people to wonder whether pets bring

benefits for children’s development, including social development. Social development is crucial for

social inclusion. Without the ability to make positive relationships with others, children can develop
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mental health difficulties (Mikulincer and Shaver, 2012).

Also, in recent decades therapy that incorporates animals (animal-assisted therapy), has

grown in popularity (Serpell et al., 2017). Animal-assisted interventions include supporting children

stressed by a visit to the dentist or having an injection, visiting older people with dementia in

residential care homes to boost their mood, and helping children, young people or adults as part of

treatment for mental health difficulties (Lundqvist et al., 2017). However, Serpell et al. (2017)

suggest that many studies of animal-assisted therapy do not appear to be based on a clear theory of

how or why animals might be therapeutic. This is important because if therapists know how animals

help, they can make therapy more effective and they are more likely to measure the right things to

test how helpful it is.

Why might animals be helpful?

Serpell et al., (2017) discuss five possible theories of why animals can be therapeutic:

1. Helping people build social relationships with others

2. The attachment bond with an animal is directly supportive

3. Animals are cute so people bond with them as they would with an infant and this is

enjoyable

4. Animals are especially good at distracting us from distress

5. All of the above

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 Building relationships

Serpell et al. (2017) discuss research that suggests the mere presence of an animal increases

people’s interaction with people when they go out. They suggest (p. 224) an animal may be an “ice-

breaker” in that it is both like a person and not like a person. It is like a person in that we often want

to interact with it, but it can feel less threatening than a person if we are anxious.

Support from attachment with an animal

As Serpell et al. (2017) point out, both humans and some other animals (such as horses and
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wolves) are social animals in that they live in groups. Relationships within the group are supported

by attachment bonds. Given that humans and other social animals can form attachments, humans

and animals can form attachments with each other. Serpell et al. (2017) point to research showing

that people who are socially isolated tend to suffer more illness and earlier death than less isolated

people, possibly because they have no buffer for day-to-day stress. Our natural stress-response

helps us with short-term threats, but is harmful if prolonged (Juster et al., 2010). Serpell et al. (2017)

explain that when a mother and infant interact, and also adults in close relationships, a hormone

called oxytocin is released in their brains, and this in turn reduces the stress response, so we feel

calmer. Our brain’s reward system is also involved, so we feel good in the company of close friends.

Serpell et al. (2017) discuss research on humans who are petting or talking to their pet dogs. The

same oxytocin effect is seen in both dog and human.

Animals can be cute

Cuteness, suggest Serpell et al. (2017), may be a reason why some animals have an

especially calming effect. They tell us that humans react to cuteness in a baby, a carton animal, or a

dog. When we perceive these as cute, we often feel an urge to nurture and care for them. This can

be seen in the way people’s brains react (using brain scanners) when shown cute pictures. It might

explain why many people like dogs with big eyes and flat faces, say Serpell et al. (2017).

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 Serpell et al. (2017) describe a Japanese study (Nagasawa et al., 2015) with people who were

either dog owners or had hand-reared wolves. Human-animal pairs were filmed for 30 minutes, and

the researchers measured length of time owners talked to or petted the animal, length of time the

animal gazed at the human, and measured the human and animal’s oxytocin before and after

interaction. Wolves spent very little time looking at the human, but the longer the dogs gazed at

their owners, the more oxytocin was found to have risen in the human afterwards. Dogs who gazed

longer also had a greater increase in oxytocin. Nagasawa et al. (2015) suggested that as humans
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domesticated wolves over thousands of years, they selected animals that gazed more, just like a

human infant. This gaze makes both human and animal feel good, and helps them bond.

Animals are pleasantly distracting

Serpell et al. (2017) cite research showing that distraction can reduce distress, so they

wonder if animals just happen to be good distractors. They conclude that they are, but in a special

way. Not only do they divert attention from distress. They are themselves rewarding, as might be

gathered from the previous sections. Serpell et al. (2017) tell us there are specific brain cells in an

emotion-processing part of the brain that react to animals but not people or objects. Babies, they

tell us, also like looking at animals more than objects.

All of the above

All of these things that might make animals therapeutic can be brought together, suggest

Serpell et al. (2017, p. 226) in what they describe as a “biopsychosocial model”. The bio is things like

oxytocin, the psycho is personality, distress etc, and the social is social relationships, culture etc. If

there is a change in one of these three systems, suggest Serpell et al. (2017), it will change the

others. They suggest that the animal may reduce the stress people experience, which in turn reduces

the biological markers of stress and the potential harm that these can do if stress is prolonged. This

in turn may allow more positive social interactions, within or outside therapy. These changes, they

suggest, could be measured in research on animal-assisted therapy.

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 Might children and young people benefit from pets?

Purewal et al. (2017) examine whether studies have shown benefits from there being a pet

in the household. They wonder if pets might compensate if children’s parents are not able to provide

enough nurturance. They also wonder if pets might help children learn to speak, because animals

appear interested when children talk to their pet. Purewal et al. (2017) cite Melson’s (2003)

suggestion that children’s learning may be improved in the presence of a pet because they feel less

stressed, and reduced stress helps learning. Purewal et al. (2017) cite research showing that reading
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to a dog seems to help children learn to read.

What sort of research papers are there on children’s development and pets?

Purewal et al. (2017) found 22 studies, with the majority (19) covering emotional well-being.

Different papers also covered behaviour, thinking, learning, and social relationships. Most studies

were done at one point in time (cross-sectional), but two were longitudinal, that is, following people

for a period of time and looking at changes. Longer studies make it easier to suggest what might be

causing what, because causes usually come before effects. None of the studies were randomised

controlled trials, often viewed as the highest quality in terms of establishing cause-effect

relationships, but these would be difficult to do regarding families owning pets. They either do or do

not.

What did the studies tell us about pets in the home and children and young people?

Anxiety: Purewal et al. (2017) tell us that in one study of households with a dog compared to those

without, children were slightly less likely to have panic attacks, be afraid of being alone at home, or

be fearful of others. However, another study found no differences in anxiety.

Depression: In one American study homeless young people with a pet were less depressed than

those without. However, an Australian study of school-children found no difference in mood

between those with and without a pet. In one of the longitudinal studies, parents reported that their

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 children who were well attached to a dog had fewer crying spells 12 months later; but another study

found no difference in depression where there was a pet compared to not. Purewal et al. (2017)

suggest that the presence or absence of a pet may not be enough. It may be the relationship with

the pet that is important, which could explain the finding of no difference just on the basis of there

being a pet or no pet in the household.

Self-esteem: Young people’s self-esteem did not differ between pet-owning and non-owning

households in a study of children traumatised by war in Croatia, Purewal et al. (2017) tell us, but
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another study found a relationship between level of attachment to a pet and self-esteem. A

longitudinal study reported that children increased more in confidence over six months depending

on how attached they were to a pet – stronger attachment going with higher increase in confidence.

Two further studies showed conflicting findings. Two studies involving interviews with children

supported the idea that it is attachment that confers the benefit, rather than just presence or

absence of a pet: Children felt better about themselves in the presence of the pet than with people.

University students had higher self-esteem if they had their first pet below the age of six or over 10

years. A Kenyan study of goat ownership found higher self-esteem in orphaned children who were

given a goat, but Purewal et al. (2017) point out that they might regard the goat as property rather

than a pet.

Loneliness: The study of homeless young people found them to be less lonely if they owned a pet,

and they said the animals helped them cope. Young people at secondary school reported being less

lonely if they had a pet, and their strength of attachment to the pet was linked with the number of

people they felt were available to them for social support. In another study that found no difference

in loneliness between pet owning and non-owning young people, Purewal et al. (2017) suggest this

may have been because the young people were not very attached to the pet.

Behaviour: Parents reported better behaviour in their five-year-old child if the child was well

attached to the pet, but the same was not found for slightly older children. In a longitudinal study,
5
 an initial improvement in children’s behaviour was reported when the pet was acquired, but it only

last a month. Three out of four studies comparing pet-owning homes with non-pet homes reported

better behaviour in children in the pet-owning homes but one found no difference. In the study of

homeless young people, they said that looking after the dog made them more responsible and they

also looked after themselves better. Purewal et al. (2017) suggest that pet owning may increase self-

reliance.

Thinking: Children who were strongly attached to a pet were better at understanding others’
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viewpoint, important in social interaction, compared to those less well attached. The guidance of

parents seemed important, in that the children more attached to their pet had received more

parental guidance on caring for the pet. They were also better at problem-solving. In another study,

parents also thought their children were more self-reliant and could make decisions more

independently if they were well attached to a pet.

Learning: Two studies reported that children in pet-owning households had better knowledge of

biology than those in non-pet households. In one interview study, young children said that they liked

the attention their pets gave them, and Purewal et al. (2017) suggest this may support learning.

Another study found children who were strongly bonded with their pet had higher verbal

intelligence scores than children with no pet in the household.

Social development: One study found that parents reported their young children to have better

social skills if they were well bonded with their pet. Another study found children who were well

bonded to their pet spent less time with other people. However, as Purewal et al. (2017) point out, it

is not simply time with others that may be beneficial. It depends on the quality of those

relationships. Two studies reported no difference in social relating depending on presence or

absence of a pet.

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 We still do not really know if pet ownership helps children’s development

As Purewal et al. (2017) tell us, these studies were not high quality. Many simply compared

children in homes with and without a pet, and did not look at the quality of attachment to the pet.

There can also be other differences between households with and without a pet. For example

greater income might be associated with pet-ownership, and wealth can bring various benefits.

Purewal et al. (2017) suggest that the research supports certain possible ways in which pet

ownership might benefit children. These are in line with the suggestions of Serpell et al. (2017) and
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are as follows:

1. Emotional

2. Self-esteem and social

3. Thinking skills and academic

Emotional benefits: When children interact with their pet, it reduces stress and physiological

arousal. Forming a relationship with a pet may help children with their social skills and thereby help

them to form better relationships with people. They may also meet more people when out with a

dog. The bond with a dog also may enable youngsters to feel good about themselves because of the

pet’s attention and lack of judgment. However, the degree to which a child is able to become

attached to a pet may depend on their attachment to a parent figure, and how nurturing that person

is able to be, suggest Purewal et al. (2017).

Self-esteem and social benefits: Purewal et al. (2017) suggest that the increase in self-esteem

increases children’s social network and support, and these in turn improve self-esteem further.

Loneliness is decreased directly due to the pet’s companionship, and also through the improved

social network. Social skills are improved because there is more social interaction with people.

Thinking skills and learning: Interaction with a pet with a close bond tends to reduce stress, and this

in turn enables clearer thinking and better decision-making, which improves behaviour, suggest

Purewal et al. (2017). Clearer thinking also helps learning, alongside improved social support.
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 What next in research on children and pets?

Many of these proposed mechanisms are similar to those suggested by Serpell et al. (2017).

However, we still lack clear evidence that these are the mechanisms operating in relation to pets.

Purewal et al. (2017) suggest a need for more studies that follow children over time in households

with and without a pet. Also, other things might explain the benefits seen, that is, other differences

between households with and without pets. Purewal et al. (2017) suggest these can more

confidently be ruled out with larger studies with more diverse households with and without pets.
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Dogs in therapy, activities and support

Lundqvist et al. (2017) focus on dogs in their review of 18 studies because dogs, they state,

are the animal most often found in therapy or support. As well as dog-assisted therapy, there are

dog-assisted activities, which can be therapeutic but are not designed to improve health as such,

whereas dog-assisted therapy usually is, say Lundqvist et al. (2017). Dog-assisted therapy usually

involves a professional therapist, whereas dog-assisted activities may be done with volunteers with

brief training. Having said that, Lundqvist et al. (2017) suggest that the difference between activities

and therapy with dogs is not always clear. Lundqvist et al. (2017) also look at dog-assisted support,

which is used where people are having a stressful health procedure. Lundqvist et al. (2017) focus on

studies with at least 20 participants, with measured outcomes, and where they could compare what

happened in an intervention with a dog compared to without.

Was dog-assisted activity helpful for people with dementia?

Lundqvist et al. (2017) found seven studies with people in care homes with dementia, where

dogs were brought for activity between 10 and 90 minutes depending on the study, and with

numbers of sessions from 12 to 72. Six out of the seven studies had at least one positive outcome.

Depression was reduced in two studies when dog visits were compared with either usual care or

another activity. In one study, people’s rate of decline in mental functioning was less after eight

months, compared to the group without dog visits. Depression was no better when 10-minute dog

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 visits were compared with playing with a robot or toy animal. Lundqvist et al. (2017) thought that on

balance, dog visits are likely to be helpful to older people in care for dementia.

Is dog-assisted therapy helpful for mental health conditions?

Lundqvist et al. (2017) found four studies of dog-assisted therapy for mental health. All were

randomised trials. Three were with children or adolescents for 12 weeks, and one was with adults

for 24 weeks. Two of the studies with young people were for acute mental health conditions, and

were compared with usual treatment. The young people had better overall functioning, attended
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school more, and felt that their symptoms had reduced. A third study investigated cognitive

behaviour therapy (CBT) for attention-deficit hyperactivity disorder (ADHD). When CBT was with a

dog, ADHD improved more compared to without a dog. The study of adult inpatients with a

diagnosis of schizophrenia reported that after 24 weeks of dog-assisted therapy compared to usual

care, those who had dog-assisted therapy showed increased motivation, and levels of the stress

hormone cortisol were lower.

Do dogs help with the stress and pain of medical procedures?

There were six studies of dog-assisted support for medical procedures, four of which showed

positive effects. Children undergoing a medical examination or an injection with a dog present

compared to no dog appeared less stressed according to an observation scale. Those having an

injection also had their levels of cortisol measured and it was significantly lower with the dog

present. One of the studies involving physical examination also measured children’s blood pressure,

heart rate and distressed behaviour and found all improved. However, there was no effect in a study

of children having dental procedures.

One study looked at pain in adults after an operation on a joint, involving a 15-minute dog

visit before physiotherapy over three days. The control group was the same except without a dog.

People reported significantly less pain when the dog visited. However, another study, involving a

visit from a dog for people having radiation therapy found no difference in general mood, self-

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 perceived health and thoughts about their life, compared to a visit from a human or reading

magazines, and this was over four weeks with 12 sessions. However, the measures were more

general rather than specific to the treatment, and general measures may not capture how people

experience the treatment procedure. Finally, a study of older people at home considered to be

experiencing stress, had everyone receiving a 60-minute visit without and with a dog. Its authors

reported lower blood pressure and heart rate with than without the dog. Lundqvist et al. (2017)

suggest that on balance, dog-assisted support is likely to be beneficial in terms of reducing stress.
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Where next for dog-assisted interventions?

Lundqvist et al. (2017) suggest that although all studies had a control condition to compare

dog visits with, overall quality was not high. Many had small numbers, and randomisation did not

always work, for example due to allergies. Some studies may not have used the best measures. So

Lundqvist et al. (2017) suggest that more and better research needs to be done. However, there

were some similar outcomes across different studies, such as lower observed distress in children,

and blood pressure and heart rate reductions in different studies. Probably more studies should

measure the stress hormone cortisol. If there is longer-term reduction in this after dog-assisted

activity or therapy that lasts several weeks, this could be of great health benefit.

Only two studies measured social functioning or participation; one on children with ADHD

and one on children with a mental health diagnosis. The children with ADHD had improvements in

social competence and skills, and those with a mental health diagnosis attended school more. Social

participation may be more relevant to people with mental health diagnoses or undergoing longer

medical treatments than for one-off medical procedures, where the main concern is the stress of the

procedure. Given the indication of improved social relationships, self-reliance and social skills in

young people with pets (Purewal et al., 2017), and the theories put forward by both Purewal et al.

(2017) and Serpell et al. (2017), studies of pet-assisted interventions in mental and physical health

could specifically include measures of social inclusion.

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 Conclusions

Given the long history of human-animal relationships and the capacity for social animals like

dogs, horses and humans to form attachments, it is not surprising that humans and pet animals can

form close bonds with each other. There are several ways in which, furthermore, attachment with a

pet animal might benefit children growing up in a household that has a pet, including helping them

to build relationships with people, providing comfort, and distraction from distress. Being less

stressed is also helpful for learning. Some of these ideas about why animals may be helpful have
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found some support from studies – both of children who have pets, and in dog-assisted

interventions. The stress-reduction effects may be the best-documented, with not just subjective

reports, but also biological markers of stress such as blood pressure and cortisol showing changes.

A note of caution, however: As Lundqvist et al. (2017) point out, some adults and children

have a fear of dogs, or allergies. Perhaps the important thing is to have a range of therapies

available. Probably also, people’s thoughts and feelings about particular animals before therapy

should be investigated. Perhaps previous experience of living with a pet and having had a close bond

with it might lead to a more favourable response to animal-assisted therapy with the same type of

animal than if the person has no experience of pet ownership. This needs more research, however,

since some animals’ cuteness may have the power to calm people who never had a pet.

Furthermore, research studies should examine to a greater degree the suggested social benefits of

both pet ownership and animal-assisted interventions, and specifically, social inclusion.

References

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10.1016/j.neubiorev.2009.10.002.

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dog-assisted interventions in health care: a systematic review”, BMC Complementary and Alternative

Medicine, Vol. 17, No. 358. DOI:10.1186/s12906-017-1844-7

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Biographical details:

Sue works four days per week as a senior lecturer at the Salomons Centre for Applied Psychology,
Canterbury Christ Church University, and one day per week as the research officer for the British
Association of Art Therapists. Sue is also chair of ResearchNet, a network of service user researchers.
Sue has experience of receiving mental health services and draws on this experience in her work.

12