Staff Perspective: My Therapist Has a Wet Nose – The State of Research on Animal-Assisted Therapy for Military Clients
If you’re reading this, you’re probably one of those tree-hugging vegans who wants to bring their dog to work every day. Me too. Full disclosure: I wrote this blog mostly so I could watch cat videos on company time. But perhaps you have more noble aspirations, such as understanding the current state of research on animal-assisted therapy for military clients. A quick Internet search suggests you’re not alone. Clinicians, researchers, and patients alike are writing about the role that animals could play in Service members’ recovery from trauma, depression, and even TBI. Veterans and Service members are increasingly requesting service dogs as part of their treatment. Anecdotally, most of us would confirm that a sweet, well-behaved animal brightens our moods. But do clinicians have enough high-quality data to justify adding puppies and horses to the payroll?
Major Butch, a therapy dog with the 219th Medical Detachment (Combat Operational Stress Control), concludes her tour in Afghanistan at Bagram Air Field, Feb. 1. (DoD photo by Maj. Charles Patterson, Task Force MED-A Public Affairs/Released)
The answer to that question is complicated for several reasons, starting with the many different ways that human-animal interaction is utilized to address human illness. Let’s first define some key terms:
Emotional support/companion animals: Provide emotional support for patients with psychiatric conditions. The patient selects and owns the animal. These animals are not typically trained in specific condition-related tasks. Rather, the simple presence of the pet provides comfort to the patient.
Service dogs: Defined under the Americans with Disabilities Act as dogs that are trained to perform psychiatric, physical, sensory, or intellectual condition-specific tasks. (Some examples: interrupting patient’s self-directed violence or reminding the patient to take medication.) A specific dog is chosen based on the patient’s particular needs, and the patient is the dog’s owner. Federal law requires that service dogs be permitted to accompany their owners in public settings. Miniature horses have recently received similar protections in some locations.
Therapy animals: These animals receive obedience-training and accompany a handler to provide emotional support to patients in settings such as hospitals, retirement homes, or therapy clinics. The handler typically owns the animal.
Animal-assisted activities (AAA): Casual or unstructured activities where therapy animals are present to offer emotional support or entertainment. There are no specific goals for these encounters. Examples include having an aquarium in a waiting room or therapy dogs visiting nursing homes.
Animal-assisted therapy (AAT): Structured, planned intervention in which a therapy animal or service dog is present and an integral part of the treatment. Specific patient goals are set for each encounter.
Decades of research demonstrate that positive interactions with animals are good for humans, leading to improved mood, reduced cortisol levels, increased oxytocin levels, reduced blood pressure and heart rate, decreased anxiety, and increased positive social interactions. Many case studies and experiments also suggest that the presence of a therapy animal facilitates the therapy alliance. The US Army has deployed specially-trained therapy dogs to support soldiers in Iraq and Afghanistan since 2007. Theoretically, the benefits of AAT for our warriors should be a no-brainer.
At least two groups are researching this as I write. The Warrior Canine Connection (WCC), in collaboration with our friends at the Uniformed Services University of the Health Sciences (USUHS), is one of them. The WCC has a unique program in which Service members diagnosed with PTSD and/or TBI train service dogs who will ultimately be placed with Veterans with physical disabilities. The Service members have anecdotally reported reduced anxiety, improved social relationships, decreased need for medication, and a renewed sense of purpose as a result of the program. The WCC is striving to empirically validate these findings through physiological and psychometric assessments, including genetic biomarkers. Researchers at Purdue University are also using a controlled research design to study the effects that service dogs have on PTSD symptoms in combat Veterans.
I can also offer much anecdotal evidence. I’ve treated many patients with PTSD who explicitly named their pets as part of their treatment team, several who only trusted me as a therapist after their service dogs “approved” of me, and two who only engaged in evidence-based psychotherapy (EBP) when their service dogs were integrated into the treatment. I’ve seen the most sullen and withdrawn patients transform into smiling, socializing friends when a service dog entered the waiting room.
Given my interest in EBPs, I have been eagerly awaiting research to demonstrate that AAT could be as effective as our EBPs, or could augment our EBPs. Since so much research has focused on AAT’s effects on stress and anxiety, I have been especially curious about AAT for PTSD. This evidence has been slower to mount, however. To date, no one has compared AAT to established EBPs such as Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT). So while AAT may help warriors to heal, we don’t have data to suggest that it can be as helpful as our EBPs. Frankly, well-designed research is expensive and funding has not been easy to obtain for this type of research.
At this point you might be thinking, “If therapy animals are good, and EBPs are good, just combine both!” I’ve done this myself and I can tell you that it has worked. When applied responsibly and it adheres to the theoretical underpinnings of EBPs, AAT could supplement gains made in psychotherapy. For example, for my patient who agreed to participate in PE only if his service dog could accompany him to sessions, we agreed ahead of time on a plan to phase out the dog’s attendance, just as we would with a human “coach.” That said, since we don’t have empirical data about combining AAT with EBPs, we must proceed as we do with any other modification: cautiously. (Read my colleague, Dr. Timothy Rogers’, blog on modifying EBPs here.)
It is very easy, despite our best intentions, to undermine therapy by including service dogs. A much-anticipated study in the VA is raising eyebrows for that reason. Veterans in this study are all receiving treatment for PTSD. In the experimental condition, veterans will receive specially-trained service dogs, while veterans in the control condition will receive emotional support dogs. The service dogs will be trained to perform tasks such as sweeping the veteran’s house before he enters or creating a barrier between the veteran and other people in public settings. Of course, most EBPs for PTSD have in common techniques for helping patients to challenge their negative assumptions and interpretations, and to approach anxiety-provoking situations instead of avoid them. At best, the described service dog interventions would prevent patients from fully immersing themselves in challenging situations and developing a sense of personal mastery. At worst, they could reinforce all of the behaviors that we know maintain PTSD.
No one wants AAT to become an empirically supported practice more than me...it’s the only way that I’ll convince CDP to buy me a miniature horse! But until we have research suggesting otherwise, our first-line recommendations for treatment should continue to be EBPs. If patients have service or companion animals, therapists need to thoughtfully and openly discuss how to best incorporate them so that the tenets of treatment are not violated. This second point remains true even if EBPs or trauma-focused therapies are not appropriate for a particular patient. It’s always important to discuss with your patient how they are utilizing their service dog or companion animal to meet their particular treatment goals, rather than working against them.
Have you had experience with AAT or AAA? Please share your experiences in the discussion below.
Dr. Carin Lefkowitz is a clinical psychologist and Cognitive Behavioral Therapy trainer at the Center for Deployment Psychology.
If you’re reading this, you’re probably one of those tree-hugging vegans who wants to bring their dog to work every day. Me too. Full disclosure: I wrote this blog mostly so I could watch cat videos on company time. But perhaps you have more noble aspirations, such as understanding the current state of research on animal-assisted therapy for military clients. A quick Internet search suggests you’re not alone. Clinicians, researchers, and patients alike are writing about the role that animals could play in Service members’ recovery from trauma, depression, and even TBI. Veterans and Service members are increasingly requesting service dogs as part of their treatment. Anecdotally, most of us would confirm that a sweet, well-behaved animal brightens our moods. But do clinicians have enough high-quality data to justify adding puppies and horses to the payroll?
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| Major Butch, a therapy dog with the 219th Medical Detachment (Combat Operational Stress Control), concludes her tour in Afghanistan at Bagram Air Field, Feb. 1. (DoD photo by Maj. Charles Patterson, Task Force MED-A Public Affairs/Released) |
The answer to that question is complicated for several reasons, starting with the many different ways that human-animal interaction is utilized to address human illness. Let’s first define some key terms:
Emotional support/companion animals: Provide emotional support for patients with psychiatric conditions. The patient selects and owns the animal. These animals are not typically trained in specific condition-related tasks. Rather, the simple presence of the pet provides comfort to the patient.
Service dogs: Defined under the Americans with Disabilities Act as dogs that are trained to perform psychiatric, physical, sensory, or intellectual condition-specific tasks. (Some examples: interrupting patient’s self-directed violence or reminding the patient to take medication.) A specific dog is chosen based on the patient’s particular needs, and the patient is the dog’s owner. Federal law requires that service dogs be permitted to accompany their owners in public settings. Miniature horses have recently received similar protections in some locations.
Therapy animals: These animals receive obedience-training and accompany a handler to provide emotional support to patients in settings such as hospitals, retirement homes, or therapy clinics. The handler typically owns the animal.
Animal-assisted activities (AAA): Casual or unstructured activities where therapy animals are present to offer emotional support or entertainment. There are no specific goals for these encounters. Examples include having an aquarium in a waiting room or therapy dogs visiting nursing homes.
Animal-assisted therapy (AAT): Structured, planned intervention in which a therapy animal or service dog is present and an integral part of the treatment. Specific patient goals are set for each encounter.
Decades of research demonstrate that positive interactions with animals are good for humans, leading to improved mood, reduced cortisol levels, increased oxytocin levels, reduced blood pressure and heart rate, decreased anxiety, and increased positive social interactions. Many case studies and experiments also suggest that the presence of a therapy animal facilitates the therapy alliance. The US Army has deployed specially-trained therapy dogs to support soldiers in Iraq and Afghanistan since 2007. Theoretically, the benefits of AAT for our warriors should be a no-brainer.
At least two groups are researching this as I write. The Warrior Canine Connection (WCC), in collaboration with our friends at the Uniformed Services University of the Health Sciences (USUHS), is one of them. The WCC has a unique program in which Service members diagnosed with PTSD and/or TBI train service dogs who will ultimately be placed with Veterans with physical disabilities. The Service members have anecdotally reported reduced anxiety, improved social relationships, decreased need for medication, and a renewed sense of purpose as a result of the program. The WCC is striving to empirically validate these findings through physiological and psychometric assessments, including genetic biomarkers. Researchers at Purdue University are also using a controlled research design to study the effects that service dogs have on PTSD symptoms in combat Veterans.
I can also offer much anecdotal evidence. I’ve treated many patients with PTSD who explicitly named their pets as part of their treatment team, several who only trusted me as a therapist after their service dogs “approved” of me, and two who only engaged in evidence-based psychotherapy (EBP) when their service dogs were integrated into the treatment. I’ve seen the most sullen and withdrawn patients transform into smiling, socializing friends when a service dog entered the waiting room.
Given my interest in EBPs, I have been eagerly awaiting research to demonstrate that AAT could be as effective as our EBPs, or could augment our EBPs. Since so much research has focused on AAT’s effects on stress and anxiety, I have been especially curious about AAT for PTSD. This evidence has been slower to mount, however. To date, no one has compared AAT to established EBPs such as Prolonged Exposure (PE) or Cognitive Processing Therapy (CPT). So while AAT may help warriors to heal, we don’t have data to suggest that it can be as helpful as our EBPs. Frankly, well-designed research is expensive and funding has not been easy to obtain for this type of research.
At this point you might be thinking, “If therapy animals are good, and EBPs are good, just combine both!” I’ve done this myself and I can tell you that it has worked. When applied responsibly and it adheres to the theoretical underpinnings of EBPs, AAT could supplement gains made in psychotherapy. For example, for my patient who agreed to participate in PE only if his service dog could accompany him to sessions, we agreed ahead of time on a plan to phase out the dog’s attendance, just as we would with a human “coach.” That said, since we don’t have empirical data about combining AAT with EBPs, we must proceed as we do with any other modification: cautiously. (Read my colleague, Dr. Timothy Rogers’, blog on modifying EBPs here.)
It is very easy, despite our best intentions, to undermine therapy by including service dogs. A much-anticipated study in the VA is raising eyebrows for that reason. Veterans in this study are all receiving treatment for PTSD. In the experimental condition, veterans will receive specially-trained service dogs, while veterans in the control condition will receive emotional support dogs. The service dogs will be trained to perform tasks such as sweeping the veteran’s house before he enters or creating a barrier between the veteran and other people in public settings. Of course, most EBPs for PTSD have in common techniques for helping patients to challenge their negative assumptions and interpretations, and to approach anxiety-provoking situations instead of avoid them. At best, the described service dog interventions would prevent patients from fully immersing themselves in challenging situations and developing a sense of personal mastery. At worst, they could reinforce all of the behaviors that we know maintain PTSD.
No one wants AAT to become an empirically supported practice more than me...it’s the only way that I’ll convince CDP to buy me a miniature horse! But until we have research suggesting otherwise, our first-line recommendations for treatment should continue to be EBPs. If patients have service or companion animals, therapists need to thoughtfully and openly discuss how to best incorporate them so that the tenets of treatment are not violated. This second point remains true even if EBPs or trauma-focused therapies are not appropriate for a particular patient. It’s always important to discuss with your patient how they are utilizing their service dog or companion animal to meet their particular treatment goals, rather than working against them.
Have you had experience with AAT or AAA? Please share your experiences in the discussion below.
Dr. Carin Lefkowitz is a clinical psychologist and Cognitive Behavioral Therapy trainer at the Center for Deployment Psychology.