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BioMed Central
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Clinical Practice and Epidemiology
in Mental Health
Open Access
Research
Animal-assisted therapy with farm animals for persons with
psychiatric disorders: effects on self-efficacy, coping ability and
quality of life, a randomized controlled trial
Bente Berget*
1
, Øivind Ekeberg
2
and Bjarne O Braastad
1
Address:
1
Norwegian University of Life Sciences, Department of Animal and Aquacultural Sciences, P.O. Box 5003, NO-1432 Ås, Norway and
2
University of Oslo, Department of Behavioural Sciences in Medicine, P.O. Box 1111 Blindern, NO-0317, Oslo, Norway
Email: Bente Berget* - bente.berget@umb.no; Øivind Ekeberg - oivind.ekeberg@uus.no; Bjarne O Braastad - bjarne.braastad@umb.no
* Corresponding author
Abstract
Background: The benefits of Animal-Assisted Therapy (AAT) for humans with mental disorders
have been well-documented using cats and dogs, but there is a complete lack of controlled studies
using farm animals as therapeutic agents for psychiatric patients. The study was developed in the
context of Green care, a concept that involves the use of farm animals, plants, gardens, or the
landscape in recreational or work-related interventions for different target groups of clients in
cooperation with health authorities. The present study aimed at examining effects of a 12-week
intervention with farm animals on self-efficacy, coping ability and quality of life among adult
psychiatric patients with a variety of psychiatric diagnoses.
Methods: The study was a randomized controlled trial and follow-up. Ninety patients (59 women
and 31 men) with schizophrenia, affective disorders, anxiety, and personality disorders completed
questionnaires to assess self-efficacy (Generalized Self-Efficacy Scale; GSE), coping ability (Coping
Strategies Scale), and quality of life (Quality of Life Scale; QOLS-N) before, at the end of
intervention, and at six months follow-up. Two-thirds of the patients (N = 60) were given
interventions; the remaining served as controls.
Results: There was significant increase in self-efficacy in the treatment group but not in the control
group from before intervention (SB) to six months follow-up (SSMA), (SSMA-SB; F
1,55
= 4.20, p=
0.05) and from end of intervention (SA) to follow-up (SSMA-SA; F
1,55
= 5.6, p= 0.02). There was
significant increase in coping ability within the treatment group between before intervention and
follow-up (SSMA-SB = 2.7, t = 2.31, p = 0.03), whereas no changes in quality of life was found. There
were no significant changes in any of the variables during the intervention.
Conclusion: AAT with farm animals may have positive influences on self-efficacy and coping ability
among psychiatric patients with long lasting psychiatric symptoms.
Background
The utilization of agricultural farms as a basis for promot-
ing human mental and physical health in cooperation
with health authorities is growing in several countries in
Published: 11 April 2008
Clinical Practice and Epidemiology in Mental Health 2008, 4:9 doi:10.1186/1745-0179-4-
9
Received: 26 October 2007
Accepted: 11 April 2008
This article is available from: http://www.cpementalhealth.com/content/4/1/9
© 2008 Berget et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0
),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Clinical Practice and Epidemiology in Mental Health 2008, 4:9 http://www.cpementalhealth.com/content/4/1/9
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Europe and in the United States of America. In some
countries this is called Green care, a concept which is not
restricted to the use of animals, but also includes plants,
gardens, forests, and the landscape. Historically, Green
care farms were associated with hospitals, psychiatric
departments and other health institutions. Today, most
Green care projects involve community gardens, city
farms, allotment gardens and farms. Because many Green
care farms are rather small compared with traditional
farms, there is often a diversity of activities, with the pos-
sibility of meaningful work for different people and target
groups. Other positive experiences with Green care like
self-esteem, responsibility and sense of purpose are simi-
lar in the different countries [1]. During the last decade,
an increasing number of persons with mental disorders
work with farm animals as part of their therapy [2-5].
Although Animal-Assisted Therapy (AAT) for humans
with mental disorders has been well documented with
cats and dogs, there is a complete lack of controlled stud-
ies of farm animals as therapeutic agents for psychiatric
patients. Previous studies of AAT with companion ani-
mals have documented that human-animal interaction
may decrease stress levels [6-12], and is shown to improve
self-confidence, social competence and quality of life
[13,14]. As it is shown that different types of animals may
have different impact on people's health [15,16], it is
therefore worth investigating to what extent contact and
work with farm animals will contribute to self-efficacy,
coping ability and quality of life among psychiatric
patients.
In AAT with farm animals, we suggest that the combined
effect of both contact and work with the animals can affect
the patients positively; by providing a source of physical
contact with a living "other", and increased coping ability
and self-esteem through routines that include feeding,
milking, and caring for other living creatures. Green care
programs with farm animals can be important supple-
ments to a traditional psychiatric treatment in reaching
the goals of self-esteem and coping ability. An interven-
tion with farm animals will shift from care in an institu-
tional regime to increased social integration and
normalisation of care.
We have earlier reported increased intensity and exactness
of work by patients with psychiatric disorders in a 12-
week intervention with farm animals [17,18]. The
patients also showed significantly lower anxiety at the end
of the intervention and at follow-up six months after the
end of the intervention compared with baseline. No such
changes were found for the control group.
In the present paper based on the same sample we report
on effects on self-efficacy, coping ability and quality of life
of a 12-week intervention with farm animals for adult psy-
chiatric patients. The aims of the present study were as fol-
lows:
1) To examine whether animal-assisted therapy for psy-
chiatric patients was associated with higher self-efficacy,
coping ability and quality of life after treatment and at six
months follow-up.
2) To assess if there were different treatment responses in
the different diagnostic groups.
3) To investigate the relationship between changes in self-
efficacy, coping ability and quality of life and specific
questions related to the intervention.
For checklist of the randomized trial, see Additional file 1.
Methods
Sample
Therapists recruited the candidate patients, and informed
written consent was obtained. The Norwegian Data
Inspectorate and the Regional Committee for Medical
Research Ethics approved the project, and the study took
part between February 1, 2003 and January 1, 2006.
Ninety adult psychiatric patients with a variety of psychi-
atric diagnoses were requited, and there were 59 (65.6%)
women and 31 (34.4%) men [Additional file 2]. The
mean age (± SD) was 34.7 ± 10.7 (range 18–58) years. In
the patient group there were 14 inpatients (15.5 %) and
76 outpatients (84.5 %). Diagnoses were made by the
treating psychiatrists using the ICD 10 criteria [19], and
the main diagnoses were 34 (37.7 %) schizophrenia and
schizotypal disorders (F 20–29), 22 (24.4 %) affective dis-
orders (F 30–39), 10 (11.1 %) anxiety and stress-related
disorders (F 40–49), and 22 (24.4 %) disorders of adult
personality and behaviour (F 60–69). There was one
patient with eating disorders (F 50) in the treatment group
who dropped out, and one patient with behavioural dis-
orders due to psychoactive substance use (F11) in the con-
trol group who completed the project. This patient was
omitted when analysing for effects of diagnosis. For 15
randomly chosen patients, the diagnoses were checked for
consensus between treating and research psychiatrists
using the ICD 10 criteria [19] and all were found to
accord.
More than 50 % of the patients had been ill for more than
five years, and 72 % had been treated in psychiatric health
institutions for more than three years. As much as 83% of
the 90 included patients received daily medication,
mainly antipsychotics (53 %), antidepressants (50 %),
sedatives (35 %) and mood stabilizers (27 %). Exclusion
criteria were: (a) age less than 18 years, (b) acute psychotic
disorders, (c) mental retardation, (d) serious drug addic-
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tion, and (e) being in a job during the six last months
prior to start of intervention. No minimal levels of symp-
toms were required.
Randomization
The patients were randomized by computerized random
numbers by BOB to intervention with farm animals or to
a control group. There was two-thirds (60 patients) to AAT
and one-third (30 patients) to control. The reason for this
division was that we expected more drop-outs in the treat-
ment than in the control group due to experience in a
pilot project. Diagnoses and other demographic variables
were unknown during the randomization process. The
patients were well informed of the possibilities of getting
into either of the two groups, and no one withdrew after
the results of the randomization.
The farms and farmers
Among the 15 recruited farmers there were seven women
and eight men. Only two farmers had earlier experience
with psychiatric patients. The main productions were
dairy cows (N = 10 farms, mean 20 animals), specialised
meat production with cattle (N = 2, mean 22 animals),
sheep (N = 2, mean 30 animals), or horses (N = 1, mean
18 animals). All farmers had small animals like rabbits,
poultry, pigs, cats or dogs as a part of the milieu on the
farm.
Intervention
The treatment group received standard therapy (individ-
ual, group therapy or other kinds of therapy) and stable
medical treatment in addition to the intervention. The
control group got treatment as usual. No significant differ-
ences in standard therapy, medication, educational level
and outpatient/inpatient ratio at baseline were found
between the groups.
The patients visited a farm for three hours twice a week for
12 weeks to work with the farm animals. One or two
patients visited the farm at each time. The patients were
only working with the animals; they were not allowed to
do other kinds of farm work. The farmers were told that
the work should depend on the patient's coping ability
and interest, and that patients should have the opportu-
nity of physical contact with the animals. The farmers
were always close to the patients during the work with the
animals to ensure that there were no risks related to the
contact with the animals. The patients were also trained in
the working routines during the first week of the interven-
tion. An overview over the most frequent behaviours in
the interaction with the animals is given in Table 1.
Outcome measures
Three different inventories were used. These instruments
are all tested for their validity and reliability and are com-
monly used in psychiatric research and clinical practice.
The patients' scores were obtained before the intervention
(SB), in the end of the intervention (after: SA), and six
months after the end of the intervention (SSMA). Self-effi-
cacy was measured with the Generalized Self-Efficacy
Scale (GSE) assessing the strength of an individual's belief
in his/her ability to respond to novel or difficult situations
[20]. The scale comprises ten items, and the patient
responds to a 4-point scale from 1 'not at all true' to 4'
exactly true'. The score range is 10–40. Coping was meas-
ured using the Coping Strategies Scale of the Pressure
Management Indicator [21,22]. The scale comprises six
items measuring control coping and four items measuring
support coping and the patient responds to a 6-point scale
from 1 'never used by me' to 6 'very much used by me'.
The score range is 10–60. A Norwegian version of Quality
of Life Scale (QOLS-N) was used comprising 16 items and
reflecting relations to other humans, work, and leisure
[23]. The patient responds on a 7-point scale with 1 'very
content' to 7 'very discontent' with the score range of
16–112. High scores reflect high degree of self-efficacy,
coping and quality of life. Thirty of the patients complet-
ing the intervention answered a final questionnaire
Table 1: Different behaviours that were observed during the interactions with the animals
Behaviour Explanation
1. Physical contact with the animals Patting, brushing, washing, looking after=?, nursing, or saddling or riding horses.
2. Communication Verbalization, visual contact.
3. Moving the animals Behaviours that include moving animals between different places in the cowshed, and
between different pastures.
4. Feeding Feeding adult animals with concentrate or forage, or milk feeding the small animals.
5. Go/stand/run or sit down The participants moved around in the cowshed to bring tools and straw to clean the boxes,
or remained inactive.
6. Cleaning Cleaning the cowshed or washing buckets and bottles.
7. Milking All routines connected to the milking procedure.
8. Receiving instructions Receiving instructions from the farmer.
9. Various Behaviours that occur rarely, like filming the animals or taking pictures of the animals.
10. Threatening behaviour directed from the animals. Receiving threatening or aggressive behaviour or signals from the animals.
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related to their experience with the intervention. The fol-
lowing questions were used: "To what extent has the con-
tact and work with the animals affected your coping
ability in daily life; – your mood; – your self-esteem; –
your working ability; – made you more extrovert and talk-
ative?" and "To what extent has the physical contact with
the animals been important to you as part of the work?".
The patients answered on a 5-point scale from 1 'much
worse/very little' to 5 'much better/very much', with point
3 'no change'.
Statistics
Analysis of variance (ANOVA) was performed by standard
least square means with three difference scores (interven-
tion period: SA-SB; intervention + post-intervention:
SSMA-SB, and post-intervention: SSMA-SA) as the
dependent variables, patient group (treatment: T/control:
C) and diagnosis as the independent variables, and the
interaction between patient group and diagnosis.
Matched-paired t-tests were performed to examine differ-
ences in means between time points for each group (T or
C). Spearman correlation analyses were used to measure
correlations between self-efficacy and coping, and to
relate the difference in the patient's scores in the interven-
tion period (SA-SB) to their answers on the experience of
the intervention (treatment group only). Chi-square tests
analysed for differences between completers and drop-
outs. The level of significance was set at p < 0.05. All anal-
yses were conducted with SAS [24].
Results
There were 41 completers (68 %) in the treatment group
and 28 (93 %) in the control group. The scores of the
completers on self-efficacy (GSE), coping strategy (Cop-
ing Strategies Scale), and quality of life (QOLS-N) at dif-
ferent times are presented in Table 2.
There were no significant baseline differences between the
groups in any of the inventories.
For the GSE scores, the ANOVA analysis revealed no effect
of treatment during intervention (SA-SB) compared with
the control group (Table 2). However, the difference in
scores between six months after intervention and before
(SSMA-SB) was significantly higher in the treatment than
in the control group, reflecting a larger increase in self-effi-
cacy for the treatment group. A similar effect was found in
the post-treatment period (SSMA-SA). Within the treat-
ment group there was no significant increase in self-effi-
cacy during the intervention. At six months follow-up the
GSE scores were significantly higher than the baseline
(SSMA-SB = 2.6, t = 3.68, p = 0.001) and higher than at the
end of intervention (SSMA-SA = 2.2, t = 4.38, p = 0.0001).
For the control group there were no significant differences
between any of the time points.
For the F30-group the ANOVA analysis of GSE scores
showed significance during the intervention (T
F30(SA-SB)
(24.8–22.6) = 2.2, C
F30(SA-SB)
(25.4–27.3) = -1.9, F = 5.01,
p = 0.03), and from before to six months after (T
F30(SSMA-
SB)
(28.3–22.6) = 5.7, C
F30(SSMA-SB)
(27.3–27.3) = 0.0, F =
6.36, p = 0.01), reflecting an increased self-efficacy for the
affective patients in the treatment group. Within this
patient group, GSE showed nearly significant increase in
the intervention period for the treatment group (SA-SB =
24.8–22.6 = 2.2, t = 2.09, p = 0.066), and significant
increases between before and six months after (SSMA-SB
= 28.3–22.6 = 5.7, t = 3.56, p = 0.006) and during the
post-treatment period (SSMA-SA = 28.3–24.8 = 3.5, t =
2.54, p = 0.03). For the control group no such change was
found. There was no significant change in scores for any
of the other diagnoses.
Table 2: Scores in Self-efficacy (GSE), Quality of Life Scale (QOLS-N) and Coping Strategies Scale before the intervention, at the end
of the intervention, and six months after the end of the intervention for the treatment (N = 41) and control (N = 28) groups (mean ±
SD).
1
Variables Score before
(SB)
Score after
(SA)
D.F F
(SA-SB)
P Score six months
after end of
intervention
(SSMA)
D.F F
(SSMA-SB)
PD.F. F
(SSMA-SA)
P
Self-efficacy (GSE)
Treatment group 23.1 ± 5.12 23.5 ± 6.56 1,60 0.02 n.s. 25.7 ± 5.93 1,55 4.20 0.05 1,55 5.6 0.02
Control group 25.6 ± 6.40 25.3 ± 6.62 25.4 ± 5.92
Quality of Life
Scale (QOLS-N)
Treatment group 64.3 ± 14.93 64.3 ± 17.09 1,60 0.49 n.s. 66.7 ± 16.86 1,57 0.38 n.s 1,57 0.38 n.s
Control group 63.2 ± 14.06 64.4 ± 13.52 66.0 ± 15.25
Coping Strategies
Scale
Treatment group 31.6 ± 8.51 32.8 ± 8.67 1,60 0.01 n.s. 34.3 ± 8.10 1,57 0.79 n.s. 1,57 0.39 n.s
Control group 32.2 ± 7.38 31.4 ± 8.69 31.6 ± 8.02
1
Analysis of variance (ANOVA) is used to test the differences in means between registration times and groups.
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For the Quality of Life Scale (QOLS-N) there was no sig-
nificant difference in scores between or within the total
treatment or control groups for any periods. However, the
ANOVA analysis showed significant difference in the F30-
group between follow-up and before intervention
(T
F30(SSMA-SB)
(71.9–58.5) = 13.4, C
F30(SSMA-SB)
(64.6–67.4)
= -2.8, F = 6.30, p = 0.01), reflecting an increase in QOLS-
N for the affective patients in the treatment group.
For the Coping Strategies Scale the ANOVA analysis
revealed no treatment effect for any of the periods (Table
2). However, there was significant positive change in
scores for the treatment group between before and six
months after (SSMA-SB = 2.7, t = 2.31, p = 0.03). For the
control group there were no significant differences
between any of the registration times. There were no sig-
nificant changes in scores in any of the different diag-
noses.
Patients with the largest increase in self-efficacy during the
intervention also showed the largest increase in coping (r
s
= 0.45, p = 0.0029). A similar effect was also found
between baseline and six months after (SSMA-SB, r
s
=
0.57, p = 0.0002), and in the post-treatment period
(SSMA-SA, r
s
= 0.64, p < 0.0001). There were no such cor-
relations for the controls in any of the registration periods.
There were also significant correlations between the differ-
ence in GSE scores during the intervention (SA-SB) and
the patients' answers related to the intervention (treat-
ment group only). Patients with the largest increase in
GSE reported the largest increase in coping ability in daily
life (r
s
= 0.40, p = 0.03). Similarly, the patients with the
largest increase in coping strategy reported the largest
improvement in mood (r
s
= 0.42, p = 0.02), and they
favoured to a larger extent physical contact with the ani-
mals (r
s
= 0.40, p = 0.03).
The dropouts in the treatment and control group left the
project after a range of 1–6 weeks, and there were 31(75.6
%) women and 10 (24.4 %) men among the completers
in the treatment group, and 17 (60.7 %) women and 11
(39.3 %) men in the control group. The main reasons for
dropping out of the intervention was little interest in the
animal species on the farm (26.7 % answering 'very much
the reason'), that the work was boring (20 % answering
'very much'), and private reasons (26.7 % answering 'very
much'). Comparison between completers and the drop-
outs showed significant differences between the groups in
institutional connection, manifested as higher drop-out
among the hospitalised patients (χ
2
= 13.01 p = 0.006).
There was also a higher degree of patients using sleeping
medicine among the dropouts (χ
2
= 3.77 p = 0.05). There
were no other differences in medication.
Discussion
During the six months follow-up period self-efficacy was
significantly better in the treatment group, but not in the
control group. According to Bandura, self-efficacy refers to
the expectation that one can effectively cope with and
master situations through one's own personal efforts
[25,26]. The finding that self-efficacy was higher during
the six months follow-up period in the treatment but not
in the control group, could be attributed to several expla-
nations. One is that the patients may have learned new
tasks during the intervention, and afterwards felt more
self-confident. Another potential explanation is effects of
the ordinary psychiatric treatment being improved by the
AAT intervention, i.e. the AAT serving as a catalyst for pos-
itive development in the patient. A third explanation is
that the contact with the animals may have produced a
pleasurably experienced social interaction that made the
patients less afraid of new situations, and that the effects
first appeared during the follow-up period. A similar pat-
tern was also found for coping strategy within the treat-
ment group in the period between before the intervention
and six months follow-up. A study of Ventura et al. [27]
concluded that psychotic patients who had greater feel-
ings of self-efficacy and problem-focused coping strate-
gies, appeared to be more likely to cope with day-to-day
stressors. Our study also showed that the patients in the
treatment group with the largest increase in self-efficacy
during both the intervention and the follow-up period,
showed the largest increase in coping strategy in the same
periods, whereas such effects were not found for the con-
trols. Similarly the patients with the largest increase in
GSE scores also reported the largest increase in coping
ability in daily life when relating the questions to the
intervention experience. Likewise, the patients with the
largest increase in coping also reported favouring physical
contact with the animals. Although there was no signifi-
cance during intervention, these findings indicate that
AAT with farm animals offer a combined effect of both
contact and work with the animals that have positive
influences on the development of self-efficacy and coping
ability.
There was no effect on quality of life at any of the registra-
tion periods for the total patient group. This is in contrast
to earlier controlled studies with pets [28,29]. We found
however, as for GSE, increased quality of life among per-
sons with affective disorders. These findings indicate that
patients in this diagnostic category profit most on the
treatment. This is in accordance with the study of Antoni-
oli and Revely [30] who found significant reduction in
depression during AAT with dolphins compared with the
control group.
It is a question whether the length of the intervention in
our study was too short, or the frequency of farm visits too
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low to get significant differences between the groups dur-
ing the intervention. The delayed effect in GSE and Cop-
ing Strategy Scale could indicate this, but this very effect
also indicated that the intervention with farm animals did
have some effects additional to the usual treatments.
Even if the results on self-efficacy and coping are rather
moderate, they are positive based on the limited sample
size and the rather unspecific intervention. According to
Wilson and Barker [31], questions must be raised whether
the characteristics of the animals, the farmer, the settings
and the interaction among these variables may influence
the assessed outcomes. In addition, most of the patients
(72 %) had been treated in psychiatric health institutions
for more than three years, which makes it unlikely to
achieve a rapid and great improvement. We found a sig-
nificantly higher drop-out rate among the hospitalised
patients compared with the outpatients. This indicates
that some inpatients were in an unstable phase. In future
studies these might have to be excluded to minimize the
drop-out rate.
The strengths of this study are that it is the first rand-
omized controlled follow-up design with farm animals,
and that the logistics have contributed to increased coop-
eration between health institutions, therapists and farm-
ers, and made Green care more accepted among the health
professions in Norway. Further strengths were that the
health outcome measures were based on validated stand-
ardized instruments, the completeness of the assessments,
and the relatively moderate drop-out rate. Limitations
were the moderate number of patients in the different
diagnostic categories, and the inherent inability to blind
the active treatment.
Conclusion
The results of this study suggest that AAT with farm ani-
mals may be a useful addition to traditional psychiatric
treatment, particularly for patients with affective disor-
ders. Self-efficacy was higher at follow-up compared with
baseline and at the end of the intervention in the treat-
ment group but not in the control group. The patients
with the highest increase in self-efficacy during interven-
tion reported the largest increase in coping ability. Further
controlled studies are needed for confirmation and to
more accurately define the treatment parameters and the
psychiatric population with the greatest potential of ben-
efiting from an intervention with farm animals.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
BB has undertaken the conception and design of the
study, the data collection and analysis. She has also
drafted the manuscript. ØE and BB have contributed to
the design of the study and to the drafting and revision of
the manuscript. All authors read and approved the final
version.
Additional material
Acknowledgements
The authors are grateful for the participation by patients, farmers and med-
ical staff. Statistical assistance from Ingeborg Pedersen is highly appreciated.
The project was funded by a grant from the Research Council of Norway,
grant no. 152747/I10.
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Additional file 1
CONSORT Statement 2001 – Checklist. Checklist describing where in
the article important aspects of the randomized controlled trial are found.
Click here for file
[http://www.biomedcentral.com/content/supplementary/1745-
0179-4-9-S1.doc]
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The Consort E-Flowchart Aug. 2005. Flowchart of the research design.
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Clinical Practice and Epidemiology in Mental Health 2008, 4:9 http://www.cpementalhealth.com/content/4/1/9
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