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VA restarting study on service dogs and PTSD

March 24, 2015

A VA study is comparing service dogs and emotional support dogs to help Veterans with PTSD.
A VA study is comparing service dogs and emotional support dogs to help Veterans with PTSD. (Photo: ©iStock/ Foto-front)

A VA study is comparing service dogs and emotional support dogs to help Veterans with PTSD. (Photo: ©iStock/ Foto-front)

Reedy Hopkins says that before he underwent exposure therapy for PTSD, he would always feel on guard in public places.

"I quit going to crowded areas. I used to love to walk the National Mall, or go into the museums...I couldn't enjoy it, because I was constantly on guard, looking around, watching everybody's movement...I still have a hard time going into a restaurant and not sitting with my back to the wall."

Hopkins is a 28-year Air Force Veteran who served in Iraq. He is one dozens of Veterans who share their stories on the AboutFace website of VA's National Center for PTSD.

Can Veterans with posttraumatic stress disorder benefit from service dogs or emotional support dogs? That's the question VA researchers hope to answer in a three-year study that is getting underway in early 2015 and will wind down in 2018. The study aims to enroll 230 Veterans with PTSD, from three regions: Atlanta, Iowa City, and Portland, Ore.

Service dogs for PTSD and other mental health problems are a topic of keen interest, and the study was mandated by Congress in 2010. VA launched a pilot the next year, but the study was halted after two service dogs bit children in Veterans' homes. Further problems with the health and training of some of the dogs led to a second suspension of the study in 2012.

The setbacks were a learning experience for VA. The new version of the study, now underway, has far tighter standards for the dogs, and a more rigorous design. The new study is being overseen by VA's Cooperative Studies Program (CSP), which has decades of experience running large multisite clinical trials.

Safety is top priority

"Safety is our main concern," says Dr. Patricia Dorn, director of VA Rehabilitation Research and Development, which is partnering with CSP on the study. "As in all VA clinical trials, the safety and well-being of the Veteran comes first. In this study, we also extend that concern to the dogs. We want to make sure they are safe and well cared for."

Along with that, says Dorn, the revised study meets a high bar in terms of its ability to generate reliable scientific evidence.

"This study is rigorously designed," says Dorn. "The findings should give VA a solid basis for making decisions about the provision of service dogs for Veterans with PTSD."

As of now, VA provides service dogs only for Veterans with certain physical disabilities, such as vision or hearing loss, or the loss of a limb. The findings of the new PTSD study could potentially change that policy.

Beyond that, says Dorn, her team believes that "the study will make an important contribution to the literature on the use of service animals for those with mental health diagnoses."

First randomized, controlled trial of its type

To date, there is ample evidence on the benefits of service dogs for people with physical disabilities, but very little in the area of mental health.

"There is no randomized controlled trial whatsoever involving service dogs and mental health conditions," notes Dr. Michael Fallon, VA's chief veterinarian.

It might seem like a no-brainer that service dogs can help people with PTSD, depression, or other mental conditions. Who wouldn't benefit from having a four-legged friend at his side? The idea is hugely popular, admits Fallon. "The public, by and large, is in love with the concept of service dogs."

He acknowledges that anecdotal reports on the topic tend to be very positive. But he points out that in reality, things can go awry.

"We also have anecdotal reports that things can go poorly if you don't have the right dog. We know from our experience in the pilot study that a poorly trained dog can be detrimental to the Veteran. If the dog is behaving poorly in crowds, say, that can reduce the amount of time the Veteran wants to be out in public."

Going out in the community is one of the parameters the researchers will measure. Overall, the focus is on quality of life and limitations on daily activities. Secondary outcomes the researchers will look at include PTSD symptoms, depression, sleep, suicidal intent, use of health care, and job status.

Study comparing service and emotional support dogs

Unlike the pilot version, the new study will compare the benefits of two types of dogs. Half the Veterans in the study will be randomly assigned to receive a service dog. The others will get an emotional support dog.

The difference between service and emotional support dogs is mainly a matter of training, explains Fallon.

"An emotional support dog is a very well-behaved pet that provides comfort and companionship," he says. "They're not trained to do specific tasks that address the disability, whereas a service dog is.

The difference has legal ramifications. Service dogs are allowed in most public places—including VA hospitals and clinics—but emotional support dogs are not.

Comparing the two types of dogs adds scientific rigor to the study, says Dorn. If the service dogs do indeed improve outcomes, how much of that can be attributed to the general benefits of canine companionship, and how much to the specific trained tasks? If it's simply the love and support of a dog that account for Veterans' progress, then emotional support dogs should be just as effective, in theory.

Similarities, differences between the dogs

For purposes of the study, says Fallon, "we're requiring the same medical standards and the same advanced obedience training for both types of dogs."

There are other similarities: Regardless of the type of dog they receive, Veterans will have round-the-clock support.

"There are contacts [between the Veterans and study staff] at a minimum of every three months, but if there are concerns on anyone's part, whether that's a member of the study team, or the Veteran, or a family member, we will do home visits, clinic visits, telephone calls, or whatever else is required," says national study chair Dr. Gabrielle Saunders, of the Portland VA Medical Center.

Dr. Kelly Skelton, a psychiatrist who is overseeing the study at the Atlanta VA, adds, "We have study staff available 24/7 to respond to any concerns." Her site is home to VA's national dog training support office. Fallon, also based in Atlanta, says one Veteran in the study has already called the hotline to learn how he can keep his dog from getting into the garbage can in the kitchen.

That's largely where the similarities end between the two types of dogs.

Veterans receiving emotional support dogs will have the animal delivered to their home. "They will work with the local VA dog trainer to learn how to look after the dog," says Saunders. Those receiving a service dog will travel to one of three vendors working with the study and spend up to two weeks on-site for training with their animal. One site is in California, another in Alabama, and a third in North Carolina.

PTSD-specific commands for service dogs

There's another difference, and it's central to the study: The service dogs will be trained to respond to five specific commands chosen especially for the PTSD population.

"Block" and "Behind" tell the dog to stand in front of or behind the Veteran, creating a secure space. "Lights" has the dog flick on a light switch, usually with its nose. "Sweep" means the dog will enter a building or room ahead of the Veteran and bark if anyone is present. Finally, "Bring" is similar to "fetch."

Researchers believe such tasks may help address core PTSD symptoms such as hyper-vigilance. The PTSD brain generates fear and alertness even when there's no objective evidence of danger. One Veteran featured on AboutFace, who had been an "IED hunter" with a combat engineering unit in Iraq, tells how he assumed a "combat position" on his deck one evening when a car rode past his house a few times. It turned out to be his daughter's friends, searching for the address.

"The commands are really ways to mitigate against that hyper-vigilance," says Skelton. "So 'sweep' is going in to a location and looking to make sure there are no intruders, so the Veteran can enter that location and feel safe, particularly in their own home. Watch their back, block from in front—these are ways to reduce that exaggerated threat response, so they can go out in the environment, engage with family, jobs, hopefully come to psychotherapy appointments. That's what we're trying to get at."

Study participants will also get therapy

Importantly, one requirement for Veterans in the study is that they be in some form of mental health treatment for their PTSD. The dogs, says Skelton, may be a way to help therapy kick in and achieve its aims.

"We hope that eventually some of the specific [service dog] tasks won't be required quite as much. What we usually do in terms of PTSD treatment is exposure-based therapy, where we essentially extinguish the false fear response, so that over time, they won't be as hyper-vigilant. They won't need the sweeping, the checking, the blocking, someone watching their back all the time."

The theory, she says, is that the dogs "can serve as a bridge to get them past that initial fear. That way, they can get out more and engage in therapy so they can eventually free themselves of that excessive fear response."

Regardless of the outcomes that Veterans in the study experience, they will all have the option to keep their dog after the study ends.

Says Skelton, "We anticipate the vast majority will choose to do so."

And while the men and women in the study may or may not see dramatic improvements in their own quality of life, they will be helping to provide answers that are likely to help generations of Veterans going forward.

"We are excited to be conducting the study," says Dorn. "We, like the Veterans, want to learn if either type of dog is a positive addition to treating PTSD."

After Army career, dog trainer has key role in VA study

During his 20-year Army career, Sgt. 1st Class Derrick Tillman had the opportunity to use his dog-handling skills to help protect the president, secretary of state, and other government VIPs.

Now, he says, his mission is no less important.

Army Veteran Derrick Tillman, VA's national dog trainer, is responsible for evaluating and approving each dog before it gets matched with a study participant.
Army Veteran Derrick Tillman, VA's national dog trainer, is responsible for evaluating and approving each dog before it gets matched with a study participant. (Photo by Adam Hernandez)

Army Veteran Derrick Tillman, VA's national dog trainer, is responsible for evaluating and approving each dog before it gets matched with a study participant. (Photo by Adam Hernandez)

Tillman is an integral part of VA's study on service dogs and PTSD. A program manager and VA's national dog trainer, he visits the three vendors participating in the study to evaluate and approve each dog, whether service dog or emotional support dog.

In addition to core standards of behavior and obedience for all the dogs—including American Kennel Club "Canine Good Citizen" standards—service dogs bound for the study have to perform the specific PTSD commands.

"The foundation of all dog training is obedience," says Tillman, who retired from the Army in 2008 and has also worked as a civilian dog trainer. "That plays a huge part in what we require of the dogs in this study. They need to be very obedient and well-behaved."

Then there's temperament. Tillman says there's no set formula for getting to know a dog. Some require more time than others.

"It depends on the dog," he says. "They are all different. Bonding is important. We call it rapport-building. I don't go in with any pre-conceived notions. Some dogs will be willing to work for you sooner than others."

While all the dogs have to meet the same high standards, there will be some differences in "personality." For example, some may be a bit more "active" than others, says Tillman. That's where the vendor helps match dogs to Veterans.

"If the Veteran is randomly selected to receive a service dog, he or she travels to the vendor, and the vendor take several dogs and finds out which one will work best for that Veteran. It's based on an interview process prior to the pairing."

Tillman, based in Atlanta, also helps troubleshoot questions that come up from Veterans who have already received a dog. He collaborates with local VA dog trainers in that role.

All in all, Tillman says he is excited to be part of the trial, which he believes is an important step forward for Veterans with PTSD.

"It gives me a great sense of pride," he says. "In the military, we served the country as a whole. In this study, I get to serve those who have served. That in itself makes you feel good."

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