Animal-Assisted Green Care Farming for Patients With Mental and Physical Disorders: A Narrative Review

Abstract

Green care is an umbrella term that includes numerous therapeutic interventions that immerse the patient into nature and natural environments. Animal-assisted therapy (AAT) with farm animals is a component of green care that may benefit patients with mental health disorders. While the majority of research exploring farm AATs originated in Europe, interest in this therapeutic intervention is emerging in the United States. While there are green care farms utilizing animal therapies in the United States, these therapeutic interventions have not been reported in the scientific literature. Further exploration of this topic in the United States may benefit various patient populations and contribute to overall better health care. A literature review found that farm AATs may be beneficial for patients with mental health disorders, but did not identify any studies addressing AAT with farm animals in the context of physical health disorders. This may be a desirable direction for future research.

Keywords

mental health nursing green care animal-assisted therapy animal-assisted therapy with farm animals nature-based therapy nature-assisted therapy

Implications for Knowledge Translation

Green care-based interventions, including care farming, therapeutic horticulture, wilderness therapy, ecotherapy, facilitated green exercise, and animal-assisted therapy (AAT), may promote health in patients with a variety of mental and physical disorders; multiple studies suggest that AAT with farm animals is beneficial for patients in traditional health-care or rehabilitation settings.

The majority of research exploring farm AATs is from Europe; interest in this therapeutic intervention is emerging in the United States but, except for hippotherapy, the literature does not reflect research.

Participants regarded their experiences with AAT as an opportunity to immerse themselves in “ordinary life; for a person suffering from clinical depression, a return to ordinary life may signify a path to recovery.”

Green care is described as the immersion of a patient into nature and the natural environment, exposing them to a therapeutic setting that may help recovery and healing (Berget et al., 2010). Since prehistoric times humans have associated themselves with nature, as part of a social-ecological system (Liu et al., 2007). Kellert and Wilson's Biophilia hypothesis (1993) suggested that the connection between humans and other life forms may be related to the inherent desire of humans to connect with nature.

Green care-based interventions may promote health in patients who suffer from a variety of mental and physical disorders (Berget et al., 2010). Green care may include care farming, therapeutic horticulture, wilderness therapy, ecotherapy, and facilitated green exercise (Berget et al., 2010). In addition to these interventions, animal-assisted therapy (AAT) with farm animals (AATF) is considered a significant component of green care (Bokkers, 2006). Multiple studies suggested that AAT is beneficial for patients in traditional health-care or rehabilitation settings (Haubenhofer et al., 2010; Pedersen, Ihlebæk, & Kirkevold, 2012; Scholl et al., 2008).

Even pet companionship may have benefits for the patients. In an early animal therapy-related study, 28% of patients who did not own a dog or a cat died within 1 year after a myocardial infarction, while only 5.7% of pet owners did not survive to the 1-year mark (Friedmann et al., 1980). The use of AAT in pediatric patients was associated with improvement in well-being in the inpatient setting (Lindström Nilsson et al., 2020). Overall, AAT may have benefits for patients who suffer from both mental and physical health-related illnesses (Beetz et al., 2012).

At the end of the 20th century, green care farming to promote health and well-being became a widely accepted therapeutic intervention in a number of European countries. The United Kingdom had 170 green care farms in 2011 (Leck et al., 2014) while the Netherlands had 591 farms in 2005 (Hassink et al., 2007; Leck et al., 2014). While sporadic online sources about green care farming in the United States are available, it was not possible to retrieve data regarding the exact number of green care farms in the United States through either database or internet-based searches. The dearth of sources about green care farming in the United States may imply that green care farming is not as widespread as in European countries.

While the dearth of reports of most green care activities is a reality in the United States, hippotherapy (therapy using horses) is visible and available in most of the regions of the country where climate and terrain allow equine-related recreational activities, and is one of the most developed and researched domains of green care. The American Hippotherapy Association (AHA) was established in 1992 and has developed standards and curricula for hippotherapy (2021). Currently, 304 hippotherapists are listed on the AHA website, and they provide services in most states in the United States.

Review Question

A literature review was conducted to answer the question, Is farm animal-assisted green care beneficial for patients who suffer from mental or physical disorders?

Design and Literature Search

We conducted a narrative review of existing scientific literature on green care therapies involving farm animals. The topic of AATF is not well researched and there is no large body of literature that examines this arena of therapeutic interventions with animals. Because of that the authors elected to proceed with a narrative review format rather than a systematic review. The search was conducted in three electronic databases: PubMed, Cumulative Index to Nursing & Allied Health (CINAHL), and PsycINFO. The following free text search terms were utilized: “green care,” “farm animal-assisted,” “nature-based therapy,” “nature-assisted therapy,” and “working in nature.” Because green care is not a common therapeutic intervention, all articles were reviewed regardless of publication date. The search included original studies from scientific literature, English language publications, and studies that discussed use of farm animals in therapeutic interventions.

Studies exploring other domains of green care (such as horticulture, wilderness therapy, nature-based rehabilitation, care farming, and hippotherapy) were excluded. One reason for excluding hippotherapy from our search, in addition to its already strong presence in the literature, was the fact that horses have lost the status of traditional working farm animals. For many centuries horses were considered working farm animals, an integral part of land cultivation, transportation, and agricultural trade; this changed in the mid-twentieth century, when horses were rapidly replaced by machinery. Currently, horses are used mostly for recreational activities and sporting events (Vial & Evans, 2015).

Data Analysis and Extraction

The initial search yielded 61 articles. Following the application of the above inclusion and exclusion criteria, nine articles remained. 52 articles were excluded because they were focused on AAT in general, horticulture as therapy, hippotherapy, and wilderness-based therapies.

Three of the selected studies were qualitative exploratory studies, two were randomized controlled studies, one was a pretest–posttest quasi-experimental study, two were mixed-methods studies, and one was a descriptive correlational study. Eight studies were conducted in Western Europe and two in the United States. All studies discussed the benefits of AATF for patients with a primary diagnosis related to mental disorders. There were no studies focusing on AATF for patients who suffer from physical disorders. Studies are summarized in Table 1 (see Supplemental File 1).

Data Synthesis

AAT With Farm Animals for Patients With Mental Disorders

Berget et al. (2007) conducted a pretest/posttest quasi-experimental study describing the activities of 90 participants at one of 15 farms (10 with dairy cows and 5 with dairy cows, meat cattle, sheep, or horses) for 3 hours twice a week for 12 weeks. Patients presented with mental health disorders including schizophrenia; substance abuse; and personality, somatoform, affective, and behavioral disorders. The intervention consisted of feeding, milking, moving, and cleaning farm animals. Sixty participants were randomly assigned to an experimental group and 30 to a control group. Both groups received traditional therapies; participants in the experimental group also worked with animals, and were videotaped interacting with the animals at weeks 1 and 12. Recordings of 35 members of the experimental group who completed both video sessions were scored for proximity to the animal, and intensity and exactness of the work, compared to the performance of an average stockperson. Those 35 participants had statistically significant increases in intensity (0.26 ± 0.05, p < .0001) and exactness (0.31 ± 0.06, p < .0001) from weeks 1 to 12. The authors did not report findings for the control group.

In 2011, Berget and colleagues (2011) conducted a secondary analysis of data from their prior work (2007), evaluating the effect of AATF on depression and anxiety, measured by the Beck Depression Inventory (BDI) and Spielberger State Anxiety Inventory (STAI) at weeks 1, 12, and 24. Differences in means between time points in experimental and control groups were examined via matched-paired t-tests. Anxiety scores did not differ significantly in either those in the experimental group or the control group from weeks 1 to 12. However, those in the experimental group demonstrated a significant reduction in anxiety scores at week 24 (p = .004) as compared with baseline (p = .002). There were no significant differences in depression scores between weeks 1 and 12 in the experimental group, and no significant differences in depression scores between the two groups.

Pedersen, Martinsen et al. (2012) conducted a randomized control study of the effects of AATF with 29 persons suffering from clinical depression as measured by the BDI. In addition to usual care, randomly assigned experimental participants (n = 16) worked with dairy cows twice a week for 1.5–3 h for 12 weeks, grooming, feeding, and milking the cows and caring for calves. Participants in the control group received usual care only. Both groups completed the BDI at the beginning of the intervention, at 4 and 8 weeks, at the end of the 12-week intervention period, and 3 months post-intervention. The experimental group demonstrated statistically significant decreases in mean BDI scores (p = .003) as well as statistically significant increases in mean General Self-Efficacy (GSE) scores (p = .045) between the beginning and the end of the intervention.

A phenomenological study addressed the benefits of farm AATs for persons with clinical depression, suggesting that working with farm animals may improve coping skills in this group (Pedersen, Ihlebæk, & Kirkevold, 2012). The sample consisted of eight participants with clinical depression (confirmed via Mini-International Neuropsychiatric Interview and/or the BDI) who cared for dairy cows on six dairy farms twice a week for 12 weeks. Participants were involved in grooming, feeding, and milking the cows, and caring for the calves; the authors did not mention the amount of time spent with animals at each visit. An individual thematic structured interview lasting between 16 and 51 min was conducted with each participant. Malterud's (2001) systematic text condensation method was used for interview analysis, in which extracted subthemes are abstracted into new main concept themes, thus giving deeper insight into the topic. Four themes emerged: “Ordinary life,” “Being sick,” “Flexibility,” and “Coping.” The “Ordinary life” theme is especially notable: participants regarded their experiences with AATF as an opportunity to immerse themselves in the “Ordinary life” domain, something they do not experience often because of their health status. Participants also mentioned that engagement in AATF was a distraction from the notion of “Being sick.”

Interacting with animals may also contribute to the creation of a safe environment. Children in one study valued the experience with farm animals because the animals will not be sharing children's conversations with others (Mallon, 1994). It was mentioned in several studies that interaction with animals may improve social skills. Animals may serve as a “social lubricant” and facilitate interaction between humans (Hunt et al., 1992).

A study conducted in the United States focused on experiences of patients with autism spectrum disorders while interacting with farm animals (Barnhart et al., 2020). Overall, the interaction with the animals helped to improve socialization skills and self-esteem of the patients. On the other hand, the inclusion of numerous species of animals in this study makes it difficult to understand which species contributed to the improvement in socialization and self-esteem. The study may lack fidelity to generalize the findings to the farm animal-assisted care arena.

This review included the only study addressing effects of AATF for persons with disabilities dwelling in a residential facility (Scholl et al., 2008). In this mixed-methods study, 10 disabled deaf persons with unspecified mental health diagnoses provided daily care for goats for 3 months with the help of a local farmer. After 3 months, the goats were relocated to a nearby farm for the winter, and participants visited them once a week for 1 hour for an additional 3 months, engaging in petting, brushing, playing, and feeding. Interactions with goats were videotaped at 11 time points over the 3-month period. For comparison, participants were also videotaped at their leisure time (without goats) on the same days. Researchers established 26 behavioral parameters for quantitative analysis including attentiveness, withdrawal, tactile contact, disengagement, and expression of joy, among others. Four parameters changed over the 11 timepoints: Attentiveness, expressions of joy, and tactile contact increased significantly, while disengagement decreased significantly: attentiveness (leisure: χ² = 36.23 p < .001; goats: χ² = 22.02 p = .009), expression of joy (leisure: χ² = 26.53 p = .002; goats: χ² = 46.44 p < .001), disengagement (leisure: χ² = 36.54 p < .001; goats: χ² = 26.62 p = .002), and tactile contact (leisure: χ² = 7.53 p ≤ .05; goats: χ² = 26.88 p = .001). Common themes relevant to the participants’ experiences with goats were extracted from qualitative observations and staff reports, including “increase in expression of joy,” “increase in initiative,” and “overcoming fear.”

Attitudes Toward Animal-Assisted Care Farming

Farmers play an integral role in providing green care therapies in general, and animal-assisted care farming in particular. Hassink (2005) explored attitudes of 20 Dutch farmers toward animal-assisted care farming. Instead of further industrializing farm activities and endangering animal welfare, these farmers elected to engage patients with mental health disorders through a process recognized in The Netherlands as sheltered farming. Data were collected in 2-hour semi-structured interviews, supplemented with field observations; the interview findings were validated by independent focus groups of farmers who had experience in AATF. The authors reported that farmers recognized the importance of creating human-animal bonds while providing these therapies.

Berget et al. (2008) explored 60 health professionals’ (mostly psychiatric nurses) and 15 dairy farmers’ knowledge of green care therapies, experience with AATF, and attitudes toward AATF. While all the farmers and most (n = 51) of the health professionals were knowledgeable about green care therapies, very few (n = 6) had direct experience of AATF. Nevertheless, both groups recognized the benefits of AATF.

Discussion

As a group, the studies included in this review suggest that farm AATs may offer significant benefits for patients with a variety of mental health disorders. The benefits observed include an overall decrease in depressive symptoms and improvement in self-efficacy. In addition, farm AATs may bring a sense of “normalcy” to patients who suffer from depression and/or anxiety. Pedersen, Ihlebæk, & Kirkevold (2012) mentioned the emergence of the “ordinary life” theme; some people associate “ordinary life” with routine and boredom, but for a person suffering from clinical depression, a return to ordinary life may signify a path to recovery. Contact with animals may improve social interaction and communication skills in people with autism (Ávila-Álvarez et al., 2020; Hernández-Espeso et al., 2021). Animals may serve as a “social lubricant” to facilitate interaction between humans (Hunt et al., 1992).

Conclusion

These studies show that AATF is a valuable intervention that may contribute to improvement in initiative, attentiveness, and self-efficacy. At the same time, AATF may decrease severity of anxiety and depression symptoms. Several qualitative studies reflected overall positive experiences related to AATF for patients with mental disorders. The reviewed studies also demonstrated variability of results depending on severity of initial symptoms. Future investigations should focus on increasing sample sizes, consistency of time spent in animal interactions, and robust description of qualitative data collection and analysis methods.

While there are multiple settings in the United States that utilize AATF, the research in this area is still in its infancy. Whereas this literature review suggests that farm AATs may be beneficial for patients with mental disorder, this search did not reveal any studies addressing AATF in the context of physical disorders. This may be another desirable direction for future research.

Implications for Further Research

While an internet search may reveal the presence of green care farms utilizing AATs, the results of these offerings have not been reported in the scientific literature. This may signify a need for further exploration of this topic. Research focusing on AATF may benefit different patient populations and contribute to overall better health care.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Alex Sargsyan, DNP, ANP-BC, CNE, (he/him) is an Assistant Professor in the College of Nursing at East Tennessee State University in Johnson City, Tennessee.

Lora H Beebe, PhD, PMHNP-BC, FAAN, (she/her), is a Professor in the College of Nursing at the University of Tennessee in Knoxville, Tennessee.

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