Review An exploration of the potential bene®ts of pet-facilitated therapy SARAH J.SARAH J. BRODIEBRODIE R N , B N Staff Nurse, University Hospital of Wales, Cardiff, UK FRANCIS C.FRANCIS C. BILEYBILEY B N , M S c , P h D , R M N , R G N , P G C E , F E T C e r t Senior Lecturer in Nursing, University of Wales College of Medicine, Cardiff, UK Accepted for publication 18 May 1998 Summary · There is mounting evidence to suggest that those who keep pets are likely to bene®t from various improvements in health. · Despite founders of nursing such as Florence Nightingale advocating the importance of animals within the care environment, their integration into hospitals and other health care settings has been slow. · The literature on animal-induced health bene®ts is reviewed and the conclusion is drawn that the potential bene®ts of pet therapy are considerable. · It is suggested that nurses can assume an active role in advocating ward pet or pet-visiting schemes. Keywords: health bene®ts, pet-facilitated therapy, social support, stress. Introduction Domesticated animals have played a signi®cant role in the life of humans for thousands of years. At ®rst it was believed that the earliest record of an association between dogs and humans was 12 000 years old (Davis & Valla, 1978). Later discoveries have revealed that dogs may have been domesticated by native American Indians over 30 000 years ago (Canby, 1979). Pets can be found in over 60% of households (Marx et al., 1988) and most people will own a pet at some time during their lives (Gammonley, 1991). In the UK, we share our homes with 29.5 million pet ®sh, 7.23 million cats, 6.55 million dogs and 1.42 million rabbits (Pet Food Manufacturers' Association, 1996). Such a situation seems to reinforce the position that `close relationships link all living things in the environment, but the forces that connect people and animals are especially strong and enduring' (Bustad, 1980; p. 4). ANIMALS IN SOCIETYANIMALS IN SOCIETY In recent years, an interest in the signi®cance of what is now termed the `human±animal bond' (Yoxall & Yoxall, 1979) has developed. One explanation for this arousal is the `green revolution' (McCulloch, 1984), in which society is trying to re-establish links with nature, including plants and animals. Francis (1976) highlighted that, amongst 500 people in hospitals, gaols, nursing and residential homes, the most frequently missed `thing' was a pet animal (for Correspondence: F. C. Biley, School of Nursing Studies, UWCM, Cardiff CF4 4XN, UK (e-mail: biley@cf.ac.uk). Journal of Clinical Nursing 1999; 8: 329±337 Ó 1999 Blackwell Science Ltd 329 those who had previously owned pets). Voith (1985) identi®ed that 99% of owners consider their pet to be a family member. BONDING AND ATTACHMENTBONDING AND ATTACHMENT Many reasons have been cited for the development of reciprocal attachment between animals and humans (McCulloch, 1984). This attachment can be interpreted as a friendly, affectionate, companionable interaction between an animal and a human (Messent & Serpell, 1981) which has potential bene®ts. Weiss (1982) high- lighted that attachment is one of the social provisions that is vital for the maintenance of wellbeing. This can be obtained through a variety of relationships with individ- uals or animals (Sable, 1995), the attachment to the latter being mutual and reciprocal but less complicated than human±human interactions (Rynearson, 1978). A pet is usually chosen for its ability to initiate and respond to attachment, and pet animals are currently bred to stimulate these attraction and attachment responses in humans. Humans are predisposed to become attached to other humans, especially children, and if animals exhibit childlike behaviours and features this attachment is understandable (Voith, 1985). Pet-facilitated therapy Pet-facilitated therapy (PFT), or animal-assisted therapy, has been described as an applied science, using animals to solve human problems (Gammonley, 1991). It involves the introduction of an animal into an individual's or group's immediate surroundings, with therapeutic intent. Such a therapeutic intervention can be an interdisciplinary ini- tiative (Barba, 1995), with nurses playing a central facilitative role. HISTORY OF PET-FACILITATED THERAPYHISTORY OF PET-FACILITATED THERAPY Levison (1969) began to promote the health-inducing bene®ts of human±animal interaction in the 1960s, but there is earlier evidence of animals being used for therapeutic purposes. In the 9th century, family care involving animals was given to handicapped people in Gheel, Belgium (Bustad & Hines, 1984). The York Retreat, an asylum, replaced restraint with love, kindness, understanding, trust and animals during the 1790s (Jones, 1985). Animals were used in a home for epileptics in Germany in the 1800s (McCulloch, 1982) and in a World War II convalescent hospital (Netting et al., 1987). Currently, there are some health care establishments that have visiting animal programmes or residential animals and societies have been set up to promote interest in this area. It has been suggested that animals can make a hospital ward appear less antiseptic and more natural (Barba, 1995) and that they can help preserve an element of normality in an individual's life (Haggar, 1992). THE BENEFITS OF PET-FACILITATED THERAPYTHE BENEFITS OF PET-FACILITATED THERAPY In order to explore the evidence that would support, or otherwise, the use of pet-facilitated therapy, a computer- ized and a manual search of the English language nursing, medical, social work, veterinary science and public health literature were performed. Using the key words pets, pet therapy, pet-facilitated therapy and companion animals, a wealth of published material in the form of position papers, case studies and various experimental designs was revealed, and formed the basis of a detailed and systematic review (Brodie, 1997). The perceived bene®ts of pet- facilitated therapy are presented here. To complement this paper, a review of the disadvantages of pet-facilitated therapy (in preparation) will appear later. Pets can be used to stimulate awareness and interaction, and provide pleasure (Kalfon, 1991). Fila (1991) describes a case study of an elderly man who was admitted to hospital for dis®guring surgery and became withdrawn and angry. Interactions with a visiting dog and guinea pig allowed him to `reconnect' with his prehospitalized life. From being depressed and angry, he became happy and relaxed. A detailed but small scale study by Francis et al. (1985) reported improved social interaction, psychosocial func- tion, life satisfaction, social competence and psychological well-being, and reduced depression, amongst a group of 40 adult home residents who had weekly visits from puppies. It is thought that pets can form a non-threatening reassuring, non-verbal and tactile comfort, that may help break a cycle of loneliness, hopelessness and social withdrawal (Michaels, 1982) and that interventions to change the environment in order to reduce isolation and loneliness are important (Kalfon, 1991). Katcher & Friedmann (1980) highlighted nine healthful components which pets can help develop. These included providing companionship and pleasurable activity, facili- tating exercise, play and laughter, being something to care for and a source of consistency, allowing feelings of security, being a comfort to touch and pleasurable to watch. The literature also suggests that pet animals perform other roles. For example, animals provide a link with reality which can enhance emotional stability (Frank, 1984), they can become the receptive partner in a relationship of mutual trust that promotes self-awareness (Heiman, 1965) and something with whom a non-judge- 330 S.J. Brodie and F.C. Biley Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 mental acceptance is possible (Levison, 1972). Frank (1984; p. 30) stated that an animal can be a `companion, friend, servant, admirer, con®dante, toy, team-mate, slave, scapegoat, mirror, trustee, or defender'. Other potential animal roles include: being an outlet for one's ancient primate grooming urges (Searles, 1960), improving the owner's sense of well-being (Rowan & Beck, 1994), facilitating humour (McMullough, 1981) and an excuse for idle play (Smith, 1983). Francis (1981; p. 369) summarized reported pet uses and bene®ts by stating that `domesticated animals offer us unconditional affection, constant companionship and an ever-present ear, almost too much to believe in a world of apparently increasing alienation, fragmentation and sterile technology'. Most of these reasons have been cited on many occasions since (Hibell, 1987; Gammonley, 1991; Rose- nkoetter, 1991), but perhaps two of the most important roles that animals can play are those of companion and something to care for (Mugford, 1980). PHYSICAL BENEFITSPHYSICAL BENEFITS In a carefully controlled study, Friedmann et al. (1980) tested the hypothesis that the absence of signi®cant companions may interfere with people's ability to maintain normal activity levels and healthy behaviours, which may in turn in¯uence the progress of illness. The effect of social isolation or support upon the survival of 96 patients who were hospitalized with a diagnosis of myocardial infarction or angina pectoris was examined. After one year, only 92 subjects could be traced, and of these 14 had died, giving an 84% survival rate. Among the 92 patients, three of the 53 patients (6%) who had one or more pets had died, and 11 of the 39 patients (28%) who did not have pets had died. The researchers concluded that dog ownership could be a measure of physical status affecting health, due to the exercise input that their care required, so another comparison was made between non-pet owners and people owning pets other than dogs. All of the 10 who owned pets other than dogs survived. They found that the relationship between pet ownership and survival does not depend upon the sex or physiological status of the patient, but that pet ownership was a signi®cant variable related to one year survival irrespective of myocardial infarction severity or type of pet. These ®ndings have been con®rmed in a later study (Reade, 1995). Anderson (1992) compared risk factors for cardiovas- cular disease amongst pet owners and non-pet owners. The blood pressure, plasma cholesterol and triglyceride values of 5741 pet owners and non pet owners who were being screened at a cardiovascular disease risk clinic were compared. Pet owners had signi®cantly lower systolic blood pressure and plasma triglycerides than non-pet owners. Male pet owners also had lower cholesterol levels despite having similar body mass index, smoking habits and socioeconomic status. Pet owners reported taking more exercise but they also ate more meat and take-away foods. It was concluded that pet ownership can reduce cardiovascular risk. However, despite the large sample size employed in this study, these results should be treated with caution. Factors such as pet owners being from a higher socio-economic group and experiencing lower cardiovascular risk (McMichael, 1985) may have produced the results that were obtained. Anderson (1992) addressed this issue by using participant groups from comparable socio-economic classes, measured by family income and levels of education. Pet owners in this study engaged in healthy and unhealthy lifestyles, yet investigations showed they still had lower blood pressure and plasma levels than non-pet owners. This mixed behaviour would seem to indicate that pet ownership can be a variable for predicting the risk of cardiovascular disease. In one randomized controlled trial, Katcher (1981) investigated the potential short-term physiological effects of animal interaction on humans. Pet owning subjects had statistically signi®cant decreased blood pressure when they interacted, talked and petted with their own dog when compared with a resting control group and with individ- uals who read aloud. The failure to identify inclusion criteria and other aspects of methodological procedures makes this study impossible to replicate exactly; however, the link between animal interactions and its effect on blood pressure has been investigated elsewhere. Baun et al. (1984) compared the physiologic effects of petting a known dog with whom a bond has been formed against the bene®ts of unbonded dog interaction and quiet reading. A sample of 24 read quietly, petted an unbonded dog and petted the bonded dog in a randomly assigned order. Blood pressure, heart and respiration rate were recorded every three minutes throughout the nine minute interac- tion. It was found that petting a bonded dog signi®cantly decreased systolic and diastolic blood pressure and the interaction was as effective as sitting reading. In a small scale study (n � 10), of questionable generalizability, Thoma (1984) measured skin temperature, muscle ten- sion, blood pressure and heart rate amongst those petting a bonded dog or an unbonded dog. There was a signi®cant increase in skin temperature and decrease in muscle tension for the group that petted a bonded dog, but there were no signi®cant differences in blood pressure and heart rate between petting bonded and unbonded dogs. These studies suggest that petting a dog may have relaxing Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 Potential bene®ts of pet-facilitated therapy 331 effects, as shown by decreases in blood pressure and increases in peripheral skin temperatures. Gaydos & Farnham (1988) replicated the Baun et al. (1984) study. However, their research did not support the original study's ®ndings: reading was found to be the intervention that induced greater levels of relaxation. Oettings (1985) studied the association between petting a companion dog, practising a relaxation technique and a combination of the two. No statistical differences were found between any of the treatments in changes in blood pressure, heart rate or peripheral skin temperature. GENERAL HEALTH BENEFITSGENERAL HEALTH BENEFITS In addition to these studies, others have investigated the bene®ts to general health. For example, Serpell (1991) examined changes in behaviour and health status amongst 71 adults who had acquired a new pet dog or cat and 26 non pet owners who acted as controls. Data were collected on health complaints, number and distance of any recreational walks taken and on general health. The groups did not differ signi®cantly with regard to demo- graphic variables; however, dog owners reported a highly signi®cant decrease in minor health problems, improved general health and an increase in the number of walks taken. Cat owners reported initial positive changes to general health but these changes disappeared after six months. The link between dog owners' increased recre- ational walks and improved health was explored but no statistically signi®cant associations were found. Siegel (1993) tested the hypothesis that pet owners would report fewer doctor contacts than non pet owners even during times of stress. The physician utilization behaviour of 938 Medicare enrolees was studied for a year. It was found that health status, income and pet ownership were major determinants of contact with the doctor, but pet owners made fewer visits to the doctor. Indications that pet ownership can in¯uence social and psychological processes rather than just physical health arise, and the study supports the reported importance of social support in buffering potentially negative consequences of life stresses (Cohen & Syme, 1985). A sample of 1232 households with a resident over 65 was studied using a cross-sectional rather than the preferable longitudinal design in order to investigate pet ownership and attachment as supportive factors in the health of older people (Garrity et al., 1989). No signi®cant differences were found in physical health between pet owners and non pet owners. Those who had feelings of strong attachment towards their pets were found to experience lower levels of depression, but this was not a uniform ®nding. Those with low human con®dante support reported lower depression levels when compared to less attached elders with low con®dante support. No correlation was found amongst pet owners with high human support regardless of attachment to their pets. This indicates that pet factors may have only a protective physical health role under certain circumstances, for example when people have few human con®dantes. In con¯ict with these results, Akiyama et al. (1987) found that recently widowed pet owners experienced fewer physical and psychophysical symptoms of ill health than non pet owners and that depression levels were not related to the strength of pet attachment. SOCIAL BENEFITSSOCIAL BENEFITS Social support has an important in¯uence upon one's health. Lynch (1977) wrote that individuals who lack companions may be lacking an important antidote to stress, and this may affect their physical health. Social support promotes health through buffering adverse stress- ful life events and producing fewer stressful challenges (House, 1981; Broadhead et al., 1983; Cohen & Syme, 1985). It is signi®cant therefore, that pet animals are advocated as a source of companionship, similar to the strong attachment bonds that develop amongst close family and friends (Gerstman, 1987). Cox & Ford (1964), Kidd & Feldman (1981) and Lynch (1977) have all reported that married people suffer fewer age-speci®c deaths and diseases, and have fewer emotional dif®culties, than those who are single, widowed or divorced. The lack of close relationships and social support is a possible explanation for this. Goldmeier (1986) aimed to discover whether animals could ®ll the gap created by absent humans. One hundred and forty-four elderly participants, living alone, living with others, living alone with pets or living with others and pets, were assessed. The groups were demographically similar and results showed that pets did not make a difference to morale amongst those who lived with others but that they improved the morale of those living alone. Having a pet also improved loneliness dissatisfaction scores, but this study concludes that pet ownership must be seen in the context of the people who share the older person's life (Goldmeier, 1986). For example, pets are more signi®cant for those who have fewer companions, a suggestion that has been made elsewhere (Garrity et al., 1989). The correlation between decreased loneliness and pet ownership has also been recognized (Levison, 1978; Muschel, 1984; Cusak, 1988; Kidd & Kidd, 1994). This might be because pets facilitate interactions between Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 332 S.J. Brodie and F.C. Biley humans (Corson et al., 1975; Mugford & McComisky, 1975; Brickel & Brickel, 1980; Robb et al., 1980; Lund, 1984; Elliot & Milne, 1991). One longitudinal research study (Mugford & McComi- sky, 1975) explored the possible effects of pet ownership upon non-institutionalized pensioners. A 30-item ques- tionnaire, investigating attitudes towards self, others, the environment and physical and psychological health, was administered to a sample which was divided into ®ve groups. Groups one and two owned televisions, three and four did not, and ®ve had an equal number of television owners and non-owners. Members of groups one and three were given a budgerigar and two and four were given pot plants. The researchers found that the presence of a budgerigar produced positive changes in attitude regard- less of television ownership and the bird became a focal point in conversation, a social lubricant. Sam and Elizabeth Corson were animated by Levison's early reports on PFT (Levison, 1969) and investigated the feasibility of establishing pet-facilitated programmes. They worked with 50 withdrawn and uncommunicative patients and facilitated interaction between the subjects and selected animals. Three patients did not accept the animal but improvement was witnessed in the others. These included development of self-respect, indepen- dence and self con®dence as well as promotion of social interaction amongst patients, staff and a wider circle (Corson & Corson, 1980). Robb et al. (1980) aimed to explore the impact of inanimate and animate external stimuli on social behaviour of a chronically ill, predominantly aged population in long-term care. Observations of verbalization, smiling, looking, opening eyes and leaning forward were made during the presentation of a wine bottle, a plant, a puppy or when there was no stimulus introduced. The highest number of social behaviours per resident occurred when the puppy was present. During this time, hostility and repetitive statements ceased and the puppy proved to be a social catalyst, inducing more frequent verbalizations. Others have reported similar results (Fields, 1977; New- berry, 1985; Kalfon, 1991). Most studies of human/animal interactions have used older adults as their target population; however the utility of animals in other societal groups has also been explored. Guttman et al. (1985), Levison (1969) and Mugford (1980) all acknowledge the importance of animals in the lives and socialization of children. Levison (1969) argued that caring for a pet during childhood has numerous bene®ts, including the development of sensitivity towards the feelings and attitudes of others, increased tolerance, self-acceptance and self-control, as well as an introduction to the reality of life and death. The animal acts as socialiser, as well as a constant source of security and companionship which enhances emotional development. Another group who experience increased interaction levels when there are animals present are people with disabilities. Hart (1987), Mader et al. (1989) and Zee (1983) all reported that visually impaired people with guide dogs experience more conversations and interactions than those using another type of mobility aid, such as a cane. The animal appears to dissolve any barriers which normally inhibit interaction. This is a continuation of Lockwood's (1983) work exploring whether the presence of an animal altered the perception of another person. His study involved asking students to describe the mood depicted in a series of drawings of individuals and groups in various interactions and some of the pictures included animals. It was found that the pictures containing animals were perceived more positively and the people in the interaction were described as friendlier, more relaxed and less threatening. It can be concluded that animals promote positive images which in turn facilitate interactions. Animals have also been known to ease family pressure and act as a buffer during con¯ict (Gerstman, 1987) and to enhance social environments (Brickel & Brickel, 1980). PSYCHOLOGICAL IMPROVEMENTS INDUCEDPSYCHOLOGICAL IMPROVEMENTS INDUCED BY ANIMALSBY ANIMALS Many studies have explored the psychological impact of animals. For example, subsequent to the work of Fried- mann et al. (1980), Katcher (1981) found that subjects who were sitting and resting or greeting their own pet dog had lower blood pressure readings (implying a greater state of relaxation) than those who were reading aloud to another person or were talking to a researcher. In a further study of the relaxation effects of pet animals, Katcher et al. (1983) explored the effects of animals which could not be touched upon blood pressure and relaxation, as stroking itself had been reported the decrease blood pressure (Montagu, 1978). Fifteen hypertensives and 20 normotensives were asked to watch a blank wall for 20 min whilst baseline blood pressure was established. Their concentration was then shifted to an aquarium ®lled with brightly coloured ®sh. Signi®cant decreases in blood pressure were found in both groups. Reading aloud after watching the tank elicited an increase in blood pressure, but not a return to the initial levels. This study would seem to indicate that the ®sh were having a protective buffering effect against future stressors. Cole & Gawlinski (1995) explored the value of aquar- iums in promoting relaxation, measuring the stress level of Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 Potential bene®ts of pet-facilitated therapy 333 patients awaiting heart transplants. A tank containing four brightly coloured ®sh was placed in each patient's room. Patient stress levels, blood pressure and heart rate were measured. The results of this study, which was incom- pletely reported (even basic information such as sample size and statistical results were not given), seemed to indicate that the ®sh became a positive visual stimulus which instilled a sense of control, and provided distraction from the hospital and a vehicle for relaxation. Bolin (1987), Fila (1991), Francis et al. (1985), Garrity et al. (1989), McMulloch (1981), Salmon & Salmon (1981) and Siegel (1990) have highlighted signi®cant inverse relationships between pet ownership and depression, while others have reported improved self-esteem (Mugford & McComisky, 1975; Dela®eld, 1976; Robb & Stegman, 1983) and a decrease in irritable behaviour (Zisselman, 1996). Fila (1991) exposed a patient who felt hopeless and had become depressed and withdrawn to a guinea pig and witnessed laughter, talking and a more relaxed state. Although the majority of the literature available on the effects of pets shows positive results, several studies have found no relationship between health improvement and pet ownership. Lago et al. (1983) could ®nd no link between pet ownership and improved morale and Lawton et al. (1984) were unable to establish a relationship between pet ownership and improved psychological health. Cameron & Matterson (1972), Friedmann et al. (1984) and Robb & Stegman (1983) concluded that there was no association between pet ownership and improved psychological health. Friedmann et al. (1984) compared psychological status among 309 pet-owning and non pet- owning students. They were assessed for anxiety, depres- sion, type A behaviour, androgyny, sensation-seeking, mood, resting blood pressure and health status, and were categorized into current, former or never being a pet owner. This study produced no signi®cant evidence indicating that there might be psychological and physio- logical differences between the groups. Robb & Stegman (1983) investigated the possible association between com- panion animals and enhanced coping abilities. Measures of morale, locus of control, social interaction, mental status, psychological symptoms, disease, medication and physical functional abilities were taken from a largely male sample of 56, and the notion of health related bene®ts from pet ownership was rejected as a result of the ®ndings. SPECIAL GROUP BENEFITSSPECIAL GROUP BENEFITS Along with these physical, social, and psychological bene®ts amongst the general population, animals have been reported to have positive effects upon smaller, more selective groups such as those with sexual problems (Pichel & Hart, 1989), those who are considered infertile (Blenner, 1991), prisoners (Arkow, 1984; Lee, 1976), the abused (Ascione, 1992), people suffering terminal illness (Muschel, 1984) and individuals classi®ed as mentally handicapped (Davis, 1986). Animals can have a positive impact on violent children (Katcher, 1994) and upon school truancy rates (The Delta Society, 1995). Conclusion It is apparent that there are frequent methodological dif®culties in the study of pet-facilitated therapy, often caused by the complexity of the subject area, but studies are also confounded by aspects of poor design, such as small sample size and failure to randomise. Some con¯icting results have been produced, but in general research studies and other published material would seem to tentatively indicate that human/pet animal interaction can have positive effects on human health. Improvements in phys- ical health, reduced risk of cardiac problems, lowered blood pressure and general overall health have been seen. In addition, animals seem to improve social interactions and promote social happiness and harmony for the general population as well as for certain groups such as children and those with a disability. Decreased loneliness, improved morale and increased social interaction appear to result from interaction with animals. Psychological improve- ments have been noted amongst those interacting with animals and the conclusion can be drawn that the mere presence of animals can instigate higher levels of relaxation amongst their human companions. A positive correlation between decreased depression and socialization with com- panion animals has been yet to be proven and studies also exist that dismiss the link between pet ownership and improved psychological health. In general it may be justi®ed to accept that those people who interact with pet animals may bene®t from improved physical, psychological and social health experiences and animals can also provide speci®c bene®ts for special groups in society. Therefore, it is probably important that nurses and other health care professionals are aware of the role that companion animals can play in promoting optimal holistic health. References Brodie S.A. (1997) Pet Therapy and Human±Animal Interactions: A Critical Review of the Literature. BN (Hons) Dissertation, University of Wales College of Medicine, Cardiff. Akiyama H., Holtz J.M. & Britz W.E. (1987) Pet ownership and health status during bereavement. Omega 17, 187±193. Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 334 S.J. Brodie and F.C. Biley Anderson W.P. (1992) Pet ownership and risk factors for cardiovascular disease. Medical Journal of Australia 157(5), 298±301. Arkow P. (1984) Pet Therapy: A Study of the Use of Companion Animals in Selected Therapies, 3rd edn. Humane Society, Colorado. Ascione F.R. (1992) Children who are cruel to animals; a review of research and implications for developmental psychopathology. Anthrozoos 6, 226±247. Barba B. (1995) A critical review of research on the human/ companion animal relationship 1988±93. Anthrozoos 8(1), 9±15. Baun M., Bergstrom N., Langston N. & Thoma L. (1984) Physiological effects of human/companion animal bonding. Nursing Research 33(3), 126±129. Blenner J.L. (1991) The therapeutic functions of companion animals in infertility. Holistic Nursing Practice 5(2), 6±10. Bolin S.E. (1987) The effects of companion animals during conjugal bereavement. Anthrozoos 1, 26±35. Brickel C.M. & Brickel G.K. (1980) A review of the roles of animals in psychotherapy and the elderly. International Journal of Ageing and Human Development 12(2), 119±128. Broadhead W.E., Kaplan B.H. & James S.A. (1983) The epidemi- ological evidence for a relationship between social support and health. American Journal of Epidemiology 117, 521±537. Bustad K.L. (1980) Animals, Ageing and the Aged. University of Minnesota Press, Minneapolis. Bustad L.K. & Hines L. (1984) Historical perspectives of the human±animal bond. In: The Pet Connection: Its In¯uence on our Health and Quality of Life (Anderson R.K., Hart B.L. & Hart L.A., eds). University of Minnesota Press, Minneapolis. Cameron P. & Matterson M. (1972) Psychological correlates of pet ownership. Psychological Reports 30, 286. Canby T.Y. (1979) The search for the ®rst Americans. National Geographic 156(3), 330±363. Cohen S. & Syme S.L. (eds) (1985) Social Support and Health. New York Academic Press, New York. Cole K. & Gawlinski A. (1995) Animal assisted therapy in the intensive care unit. Research Utilisation 30(3), 529±536. Corson S.A. & Corson E.O. (1980) Pet animals as non-verbal communication mediators in psychotherapy in institutional settings. In: Ethology and Non-Verbal Communication in Mental Health: An Interdisciplinary Bio-Psychosocial Exploration (Corson S.A. & Corson E.O., eds). Pergammon Press, Oxford. Corson S.A., Corson E.O., Gwwynne P.H. & Arnold E.H. (1975) Pet facilitated psychotherapy in a hospital setting. In: Current Psychiatric Therapies (Maserman J.H., ed). Grune and Stratton, New York. Cox P.R. & Ford J.R. (1964) The mortality of widows shortly after widowhood. The Lancet 1, 163±164. Cusak O. (1988) Pets and Mental Health. Hawthorn Press, New York. Davis L. (1986) Down on the farm. Nursing Times 82(48), 40. Davis M. & Valla F.R. (1978) Evidence for domestication of the dog 12,000 years ago in the nation of Israel. Nature 26, 608±610. Dela®eld G. (1976) Self perception and the effects of mobility training. Unpublished PhD Thesis, University of Nottingham, Nottingham. Elliott V. & Milne D. (1991) Patient's best friend. Nursing Times 87(6), 34±35. Fields S.Y. (1977) Pet±person social interaction in institutional settings, an ethnomethodological analysis. Unpublished PhD Thesis, Ohio State University, Ohio. Fila D. (1991) The signi®cance of companion animals to a geriatric vascular patent: a case study. Holistic Nursing Practice 5(2), 11±15. Francis G.M. (1976) Loneliness: measuring the abstract. Interna- tional Journal of Nursing Studies 13, 153±160. Francis G.M. (1981) The therapeutic use of pets. Nursing Outlook, 29, 369±370. Francis G.M., Turner J. & Johnson S. (1985) Domestic animal visitation as therapy with adult home residents. International Journal of Nursing Studies 22(3), 201±206. Frank S. (1984) The touch of love. Journal of Gerontological Nursing 10(2), 39±35. Friedmann E., Katcher A.H., Lynch J.L. & Thomas S. (1980) Animal companions and one year survival of patients after discharge from a coronary care unit. Public Health Reports 95(4), 307±312. Friedmann E., Katcher A., Eaton M. & Berger B. (1984) Pet ownership and psychological states. In: The Pet Connection, its In¯uence on our Health and Quality of Life (Anderson R., ed). University of Minnesota Press, Minneapolis. Gammonley J. (1991) Pet projects. Journal of Gerontological Nursing 17(1), 12±15. Garrity T.F., Stallones L., Marx M.B. & Johnson D. (1989) Pet ownership and attachment as supportive factors in the health of the elderly. Anthrozoos 3(1), 35±43. Gaydos L.S. & Farnham R. (1988) Human-animal relationships within the context of Roger's principle of integrality. Advanced Nursing Science 10(4), 72±80. Gerstman B.B. (1987) Pet ownership and human well-being. Compendium Small Animal 9(21), 132±137. Goldmeier J. (1986) Pets or people: another research note. The Gerontologist 26(2), 203±206. Guttman G., Predovic M. & Zemanek M. (1985) The in¯uence of pet ownership on non verbal communication and social compe- tence in children. Proceedings of an International Symposium on the Human±Pet Relationship. IEMT Weyringgasse, Vienna. Haggar V. (1992) Good companions. Nursing Times 88(44), 54±55. Hart A. (1987) Socializing effects of service dogs for people with disabilities. Anthrozoos 1(1), 41±44. Heiman M. (1965) Psychoanalytic observations on the relationship of pet and man. Veterinary Medicine: Small Animal Clinician 2, 713±718. Hibell G. (1987) Pet therapy on a hospital ward. Geriatric Nursing and Home Care 7, 8±11. House J.S. (1981) Work, Stress and Social Support. Addison-Wesley, Menlo Park. Jones B. (1985) The psychology of the human/companion animal bond. An Annotated Bibliography. University of Pennsylvania Press, Philadelphia. Kalfon E. (1991) Pets make a difference in long term care. The Journal of Gerontological Nursing Association 15(4), 3±5. Katcher A.H. (1981) Interactions between people and their pets; form and function. In: Interrelations Between People and Pets (Fogle B., ed). Charles C Thomas, Spring®eld. Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 Potential bene®ts of pet-facilitated therapy 335 Katcher A. (1994) Personal communication. In: The health bene®ts of human±animal interaction (Rowan A.N. & Beck A.M., eds.) Anthrozoos, 7(2), 84±88. Katcher A.H. & Friedmann E. (1980) Potential health value of pet ownership. Compendium of Continuing Education Practice Vet 2(2), 117±121. Katcher A., Friedmann E., Beck A. & Lynch J. (1983) Looking, talking, and blood pressure. The physiological consequences of interaction with the living environment. In: New Perspectives on Our Lives with Companion Animals (Katcher A. & Beck A., eds). University of Pennsylvania Press, Philadelphia. Kidd A.H. & Kidd R.M. (1994) Bene®ts and liabilities of pets for the homeless. Psychological Reports 74, 715±722. Kidd A.M. & Feldman B.M. (1981) Pet ownership and self perception of older people. Psychological Reports 48, 867±875. Lago D., Knight B. & Connell C. (1983) Relationships with companion animals among the rural elderly. In: New Perspectives on Our Lives with Companion Animals (Katcher A. & Beck A., eds). University of Pennsylvania Press, Philadelphia. Lawton M., Moss M. & Moles E. (1984) Pet ownership; a research note. The Gerontologist 24(2), 208±210. Lee R. (1976) The Pet Dog: Interactive Correlates of a Man-Animal Relationship. Unpublished Report, Dept of Psychiatry, University of Hull, Hull. Levison B.M. (1969) Pet-Orientated Child Psychotherapy. Charles C. Thomas, Spring®eld. Levison B.M. (1972) The dog as a co-therapist. Mental Hygiene 47(1), 59±65. Levison B.M. (1978) Pets and personality development. Psychology Reports 42, 1031±1038. Lockwood R. (1983) The in¯uence of animals on social perception. In: New Perspectives on our Lives with Companion Animals (Katcher A. & Beck A., eds). University of Pennsylvania Press, Philadelphia. Lund A.A. (1984) Can pets help the bereaved? Journal of Gerontological Nursing 8, 8±12. Lynch J.J. (1977) The Broken Heart: Medical Consequences of Loneliness. Basic Books, New York. Mader B., Hart L.A. & Bergin B. (1989) Social acknowledgements for children with disabilities, effects of service dogs. Child Development 60, 1529±1534. Marx M.B., Stallones T.F., Garrity J.R. & Johnson T.P. (1988) Demographics of pet ownership among U.S. adults 21±64 years of age. Anthrozoos 2(1), 33±37. McCulloch W.F. (1984) An overview of the human-animal bond: present and future. In: New Perspectives on Our Lives with Companion Animals (Katcher A. & Beck A., eds). University of Pennsylvania Press, Philadelphia. McCulloch A.J. (1982) Animal facilitated therapy: overview and future direction. California Veterinarian 8(36), 13±24. McMichael A.J. (1985) Social class and mortality in Australian males. Community Health Studies 9, 220±230. McMullough M.J. (1981) Animal facilitated therapy: overview and future direction. California Veterinarian 36, 13±24. Messent P. & Serpell J. (1981) A historical and biological view of the pet-owner bond. In: Interrelations Between People and Pets (Fogle B., ed). Charles C. Thomas, Spring®eld. Michaels E. (1982) Pets and the elderly: a therapeutic friendship. Canadian Medical Association Journal 127, 70±71. Montagu A. (1978) Touching. Harper and Row, New York. Mugford R.A. (1980) The social signi®cance of pet ownership. In: Ethology and Non-Verbal Communication in Mental Health: An Interdisciplinary Bio-Psychosocial Exploration (Corson S.A & Corson E.O., eds). Pergammon Press, Oxford. Mugford R. & McComisky J. (1975) Some recent work on the psychotherapeutic value of cage birds with old people. In: The Pet Connection: Its In¯uence on our Health and Quality of Life (Anderson R.K., Hart B.L. & Hart L.A., eds). University of Minnesota Press, Minneapolis. Muschel J. (1984) Pet therapy with people with terminal cancer patients. Social Casework, The Journal of Contemporary Social Work 10, 451±457. Netting F.E. Wilson C.C. & New J.C. (1987) The human-animal bond: implications for practice. Social Work 32(1), 60±64. Newberry S.R. (1985) The Kingsmead cats: pet therapy evaluated. British Journal of Gerontological Nursing 5, 7. Oettings K.S. (1985) Petting a companion dog and autogenic relaxation. Unpublished PhD Thesis, University of Nebraska Medical Centre, Nebraska. Pet Food Manufacturers' Association (1996) PFMA Pro®le 1996. PFMA, London. Pichel C.H. & Hart L.A. (1989) Desensitization of sexual anxiety; relaxation, play, and touch experiences with a pet. Anthrozoos 2(1), 58±61. Reade L.S. (1995) Pet ownership, social support and one year survival among post myocardial patients in the Cardiac Arrythmia Suppression Trial (CAST). The SCAS Journal 3(3), 20±24. Robb S., Boyd M. & Pristash C. (1980) A wine bottle, plant and puppy: catalyst for social behaviour. Journal of Gerontological Nursing 6(12), 721±728. Robb S.S. & Stegman C.E. (1983) Companion animals and the elderly people: a challenge for evaluation of social support. Gerontologist 23, 277±282. Rosenkoetter M. (1991) Health promotion: the in¯uence of pets on life patterns in the home. Holistic Nursing Practice 5(2), 42±51. Rowan A.N. & Beck A.M. (1994) Editorial: The health bene®ts of human±animal interactions. Anthrozoos 7(2), 85±89. Rynearson E.K. (1978) Humans and pets and attachment. British Journal of Psychiatry 133, 550±555. Sable P. (1995) Pets, attachment, and well-being across the life cycle. Social Work 40(3), 334±341. Salmon I.M. & Salmon P.W. (1981) A dog in residence: a companion animal study undertaken at the Cauli®eld Geriatric Hospital. Anthrozoos 7, 34±35. Searles H.F. (1960) The Non-Human Environment. International Universities Press, New York. Serpell J. (1991) Bene®cial effects of pet ownership on some aspects of human health and behaviour change. Journal of the Royal Society of Medicine 84, 717±720. Siegel J.M. (1990) Stressful life events and the use of physician services among the elderly: the moderating role of pet ownership. Journal of Personality and Social Psychology 58(6), 1081±1086. Siegel J.M. (1993) Companion animals: in sickness and in health. Journal of Social Issues 9(1), 157±167. Smith S. (1983) Interactions between pet dogs and family members: an ethological study. In: New Perspectives on Our Lives with Companion Animals (Katcher A. & Beck A., eds). University of Pennsylvania Press, Philadelphia. Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 336 S.J. Brodie and F.C. Biley The Delta Society (1995) Who Needs Pets? The Answer Could Be You. The Delta Society, New York. Thoma L.M. (1984) Physiological Effects in the Hypertensive Individual of Petting Bonded Versus Unbonded Dogs. Unpublished PhD Thesis, University of Nebraska Medical Centre, Nebraska. Voith V. (1985) Attachment of people to companion animals. Vet Clinics of North America: Small Animal Practice 15, 289±295. Weiss R.S. (1982) Relationship of social support and psychological well-being. In: The Modern Practice of Community Mental Health (Schulking R., ed). Jossey-Bass, San Francisco. Yoxall A. & Yoxall D. (1979) Proceedings of the Meeting of a Group for the Study of Human-Companion Animal Bond, March 23±25 University of Dundee, Scotland. Zee A. (1983) Guide dogs and their owners: assistance and friendship. In: New Perspectives on Our Lives with Companion Animals (Katcher A. & Beck A., eds). University of Pennsylvania Press, Philadelphia. Zisselman M.N. (1996) A pet therapy intervention with geriatric psychiatry inpatients. The American Journal of Occupational Therapy 5(1), 47±51. Ó 1999 Blackwell Science Ltd, Journal of Clinical Nursing, 8, 329±337 Potential bene®ts of pet-facilitated therapy 337