Psychiatric Service Dogs for Adjunct Treatment of PTSD

Introduction

Stress has a profound physiological effect on the human body, interfering with the endocrine and immune systems. Stress decreases the ability to adjust and exist in our hyper-novel world. According to Rathus, many visits to the doctor “perhaps even most, can be traced to stress-related illness” (2017, 4.1). The burden of stress taxes not only our bodies, but also our medical and financial resources. Furthermore, self reported stress metrics are on the rise (Rathus, 2017, 4.1). Negative effects are often amplified in cases of Post Traumatic Stress Disorder (PTSD). 

Traumatic stress disorders are characterized by extended patterns of abnormal behavior following a traumatic event. Common abnormal behaviors include avoidance behavior, reexperiencing trauma, anxiety, depression, heightened arousal, and emotional numbing. A PTSD diagnosis requires maladaptive symptoms lasting longer than one month (Rathus, 2017, 4.3.2). This can onset at the time of the trauma or any time period thereafter. Many survivors of traumatic experiences report symptoms for years, even decades, after the fact (Rathus, 2017, 4.3.2). According to the U.S. Department of Veteran Affairs, 6% of the U.S. population will suffer from PTSD at some point in their lives (National Center for PTSD, 2022). Traumatic experiences vary greatly, with the three leading causes being motorvehicle accidents, sexual misconduct, and combat. (Rathus, 2017, 4.3.2) 

The link between combat and PTSD has been studied for decades. Many organizations such as K9’s for Warriors and This Able Veteran, have been created for treatment of veteran PTSD and depression. Even though PTSD is strongly linked to combat in the minds of the public, it is not the leading cause of traumatic stress disorders. “Traumas involving terrorist attacks and other violent acts, particularly rape and assault, witnessing atrocities, and being kidnapped, are more likely to lead to PTSD than many other forms of trauma” (Rathus, 2017, 4.3.2). With sexual assault affecting 1 in 6 American women and PTSD “about twice as likely” to develop in women (Rathus, 2017, 4.3.2) this is a compelling, and potentially underfunded treatment case. 

The cognitive behavioral lens is most commonly applied in cases of PTSD. A neutral stimulus such as a car, or neighborhood, becomes paired with an unconditioned negative stimulus such as an accident or assault. “Through operant conditioning a person may learn to avoid any contact with trauma-related stimuli. Avoidance behaviors are operant responses that are negatively reinforced by relief from anxiety. Unfortunately, by avoiding trauma related cues, a person also avoids opportunities to overcome the underlying fear” (Rathus, 2017, 4.3.3). The extinction of fear requires coming into repeated contact with the conditioned stimulus, sitting with anxiety, and observing the absence of negative outcomes. 

Veterans are guided through exposure therapy treatments, recounting combat experiences, or in some cases entering virtual reality reenactments with the guidance of a therapist. Similarly, rape victims undergo prolonged exposure, “repeatedly recounting the horrifying ordeal in the presence of a supportive therapist” (Rathus, 2017, 4.3.4). But sexual assault most often happens in places familiar to the victim with people known by the victim. Overcoming fear and resuming a normal lifestyle may be hindered by the patient’s daily proximity to the trauma. Many people suffer in silence, resigning themselves to remain in the safety of their homes, or the perceived safety of a relationship, when entering the world alone is too stressful to bear. Cognitive behavioral therapy methods for veterans have shown the most success when complemented by other forms of healthy coping: meditation, self-relaxation, stress management, and in more recent cases canine intervention, which shows great potential as an adjunct treatment for survivors of sexual assault. 

Discussion 

For centuries war veterans have struggled to reintegrate into the societies they work tirelessly to defend. Accounts from the Civil and Franco-Prussian wars of the nineteenth century mark the first records of psychological impacts of war. At the turn of the twentieth century, Wilson announced a generation of young men who had returned “Shell Shocked” with “hidden damage to the brain caused by the impact of big guns” (Friedman, 2022). As hydro and shock therapy were administered in an effort to ease symptoms, doctors became increasingly perplexed. Veterans came in with the same neuroces, panic, insomnia and irritability without ever having seen combat. A century later, this is still true of the majority of PTSD sufferers, even those who have served active military duty. According to the U.S Department of Veteran Affairs, about 4% of American men, and 10% of American women will be diagnosed with PTSD in their lifetime (Friendman, 2022). Although cultural pressure often leads men to under report unwanted sexual acts, the fact that women have more than double the chance of a traumatic stress diagnosis, as well as experiencing worse symptoms, is staggering. Many researches have sought to understand what aspects of sexual misconduct correlate to ongoing traumatic stress. 

In 2015 the University of Illinois Chicago conducted a cluster analysis on types of sexual assaults and their relation to PTSD symptoms. This research built on 2009 studies at Brown University, where assault cases were clustered into categories of physical force, alcohol intake, and verbal coercion. The 2015 study took into account additional variables such as perceived life threat and perpetrator identity. The main question in both studies was similar: Were the consequences of assaults of physical force similar to those of incapacitation, and how might these factors relate to the development of PTSD. 

A key finding of the study was the “inverse relationship between the level of violence employed by the perpetrator and victim alcohol consumption” (Peter-Hagene, 2015, pg 1). Presumably this is because there is less need for violence if the victim is influenced by alcohol. But does the absence of violence mean an absence of stress related symptoms? These non-violent accounts make up the majority of misconduct. According to the National Sexual Violence Resource Center in 2019, 1 in 4 college age women report an unwanted sexual experience. Broadening the scope shows that 1 in 5 women of the general population have experienced attempted or completed rape, and 24.8% of men experienced some form of sexual violence in their lifetime (National Sexual Violence Resource Center, 2022). The epidemic of sexual assault makes the understanding and treatment of related PTSD a question of the utmost importance for maintaining a healthy society. 

The aforementioned study predicted that negative peritraumatic responses would be highest for violent assaults, high for alcohol-related assaults, and lower in less severe assaults. As hypothesized, “victims of forceful, violent attacks develop the highest levels of PTSD, perhaps because victims’ subjective feelings of distress or perceived life threat during the assault increase PTSD symptoms,” (Peter-Hagene, 2015, p. 2). Two waves of longitudinal data were used, collected one year apart with a control placed on the variability of PTSD at the first data entry (Peter-Hagene, 2015, p. 3). The 877 participants were varied and ethnically diverse. One third of participants were still in school, but the average income of all participants was relatively low. 

A modified version of the Sexual Experience Survey was offered to participants for assessment. Violence was measured on an objective scale from 1 to 6 and PTSD symptoms were assessed with the Post Traumatic Stress Diagnostics Scale. Further accounts were made for the stigmitazation and cultural climate of sexual assault by offering questainaires to understand levels of self-blame, reactions to disclosure, and coping strategies. As expected, assault characteristics are not independent of each other and certain patterns emerged. Employing Ward's clustering method on assault characteristics, three distinct categories emerged: violent, alcohol related, and coercive. The violent cluster correlated directly to more physical force, but showed a much smaller difference than expected in perceived threat to life with the alcohol cluster reporting 35% of victims who thought that their lives were in danger (Peter-Hagene, 2015, p. 4). Incapacitation like violence produces a traumatic fear response.

In addition to perceived life threat, the alcohol group experienced more self blame and equal symptoms of trauma at the second time marker as the violence group, even though they showed much lower symptoms at time marker one. The second interesting factor was the social support reaction. Alcohol related assaults received the lowest levels of positive support and showed higher levels of self blame than any other group. High violence and alcohol related groups showed similarly high levels of maladaptive coping. Contrary to expectations “high-violence and alcohol-related assault types were related to increased PTSD via the same mediators: characterological self blame and negative social reactions” (Peter-Hagene, 2015, p. 6). The study suggests that victims of violent crime are most likely to seek treatment, while crimes that occur through incapacitation lead to maladaptive coping, prolonging the PTSD symptoms. Further research should be done on longitudinal coping mechanisms and success. But this study suggests that PTSD is a likely outcome, even in cases without violence, especially in cases where social support is negative. If many of the test subjects did not report due to shame, there is potential that much more of the population is in need of PTSD treatment than expected. There are great therapeutic gains to be had by extending the current veteran programs to the general public, particularly methods like canine therapy which offer immediate relief and feelings of positive social support. 

In 2021 Congress recognized the weight of PTSD and signed the Puppies Assisting Wounded Servicemembers (PAWS) Act, which funded five years of federal grant money for private entities that provision service dogs to eligible veterans. The act was a response to high rates of veteran suicide and substance abuse. It passed because “rigorous scientific research provides persuasive weight to the growing anecdotal evidence that service dogs ameliorate the symptoms associated with post-traumatic stress disorder, and in particular, help prevent veteran suicide” (Congress, 2021). 

A 2017 study examined effects of novel training programs where veterans trained their own service canines and the results were remarkable. Participants completed a battery of self-report questionnaires administered online. They were then enrolled in an intensive 21 day onsite training program through This Able Veteran, a nonprofit organization. The dogs for this study had been previously trained for eight to twelve months, tailoring tasks such as guarding in public, waking from nightmares, and applying pressure during panic episodes, to the needs of the veterans. 

Ideally the dog allows graded exposure to feared activities instead of becoming an avoidant coping mechanism. Some psychologists worry that the dog may become a crutch, acting as a buffer between the veteran and facing the anxiety head on. This is why canine therapy is recommended as adjunct therapy with other traditional methods such as prolonged exposure. The intensive program included “a psychoeducational format coupled with supportive group interactions, daily journaling, and didactics on a number of helpful life skills” (Kloep, 2017, p. 4). Dog training works well in groups which further allows for social bonding and support amongst patients in such programs. 

Many studied veterans, like sexual assault victims, begin to avoid the outside world. Severe anxiety disrupts daily functioning through “sleeplessness, disengagement from relationships with others, reckless behavior, and avoidance of public places” (Kloep, 2017, p. 1). Beyond the acts they are trained to perform, “psychiatric service dogs facilitate reengagement in everyday life. This is particularly beneficial with PTSD where avoidance is often a primary coping strategy. If properly trained for socialization, psychiatric service dogs may also facilitate social interaction, further increasing opportunities for contact with others” (Kloep, 2017, p. 2). Given that “enhanced social support is associated with improved outcomes” (Kloep, 2017, p. 2) this is a particularly important benefit. 

Canine training workshops included multiple exposure-based trips to stores, restaurants and movie theaters. “Veterans were taught to manage their dogs in stressful environments and how to allow their dogs to assist them to experience the present moment and effectively manage feelings of anxiety, fear, and panic attacks” (Kloep, 2017, p. 4). The results of this three week trial were amazing indicating that “100% of the current sample achieved clinically significant change in PTSD symptoms at 6-month follow-up. Results also indicated that 91.7% (n 11) achieved reliable change for PTSD symptoms and depression” (Kloep, 2017, p. 6). It is important to emphasize that these results do not suggest and support the utility of psychiatric service dogs as a standalone treatment. The researchers recommend that further research be done to “formally integrate this type of training program to more established treatments (such as PE) as an adjunctive treatment” (Kloep, 2017, p. 8). It is suspected that some immediate gains are made from canine training and animal bonds alone, and that the act of training a service dog may increase attendance of prolonged exposure therapy. Right now of the 49,425 veterans estimated to have PTSD, “only 9.5% attended nine or more psychotherapy sessions, in a VA setting” (Kloep, 2017, p. 2). 

The dogs used for this study were large breeds with a service lineage. This is a major bottleneck for extending further programs. Most programs have been set up around the military and require expensive service animals from formal service lineage with an estimated cost of $25,000 (Congress, 2021). This problem has potential to be solved by another major domestic problem, unhomed shelter dogs. An Italian study tested the use of a three part algorithm to filter shelter dogs for service training viability and managed to achieve no false positives and only a few false negatives (Lucidi, 2005). This research combined with the findings from novel canine treatment programs leave hope for widespread symbiotic relationships between dog and human. 

Reflection 

For many women, it is unclear the moment when we cease to feel safe in our own bodies. It might be somewhere after mothers warn us not to run in the park and before a partner’s coworker reaches under our top coat to pull us onto his lap. It is between hearing strangers murmur “how ‘bout a piece of one of those” and seeing a familiar face in the morning, knowing in the blur of alcohol they did not receive consent. Who’s to say if the fear appeared in a single moment, or if instead it crept up like a red honda behind a girl on a morning run, windows down, shouting words that make her heart race and her feet move faster. I never considered these events together until my collective past began to inhibit my ability to live daily life. 

My story is not an uncommon one, living through harassment and assault. Learning to scan crowds for eyes that linger too long. Plotting mental maps of well lit neighborhood homes should I need to sprint back to them for help. Grocery stores are exposed, crowds unsafe, nature a place where screams go unheard. My choices became dictated by a deep fear of men and what they could do to me. 

After a weekend trip of seventy-two hours, in which I slept a total of eight, my therapist asked if I had ever considered a canine companion. Since attending college my mind had not been the same. It was there that I learned my physical vulnerability and mental stamina. It was there that I had my first bout of acute gastritis and locked myself in the bathroom until frequent bouts of hyperventilation passed. After college I receded further into my fears, developing symptoms which I now understand to be trauma related anxiety and depression. 

Even in the wake of the “Me Too” movement, stigmatization and victim blaming increase the likelihood of maladaptive coping strategies after experiencing sexual assault, particularly in cases where alcohol was consumed. In recent years, studies on sexual traumas have found a compelling inverse correlation between social support and development of PTSD symptoms. This makes empathy and non-judgement of the utmost importance when supporting victims. Factors such as religious shame and close relation with the perpetrator can increase the complexity of victim emotions. Women who find open and supportive social circles are much more likely to have resilient outcomes. 

From my research and personal experience cognitive behavioral therapy with emphasis on prolonged exposure to conditioned stimulus seems the best approach to treatment. But there are many factors which lead me to believe that canine therapy is the best entry point. Training dogs teaches behaviorism to humans. Through conditioning a dog to accomplish tasks and achieve mental calm, the trainer may turn inward, seeking understanding of his or her own conditioning. This provides language to discuss the operant conditioning of PTSD. It also provides immediate support, life purpose, and grounding in the present moment. Canines live beautifully in the present. 

In April I found myself three hundred feet up on a bluff, gazing down at turquoise waves lapping the sand, overcome with joy. I had done something I never thought I would be able to do. After three years of cognitive behavioral therapy, and a year of daily training with my canine companion, I went for my first trail run alone. In the first year of having a dog I was able to leave an unhealthy relationship, live on my own for the first time, and travel the country in my scratched up Subaru. I know how small life can become when it is bound by a terrified mind. Traumatic stress disorders currently infringe upon the liberties of many Americans. I am hopeful for a future where the shared language of dogs and humans is widely understood and widespread therapeutic partnerships exist amongst shelters, trainers, and psychologists. 

References 

Friedman, Matthew J. (2022). History of PTSD in Veterans: Civil War to DSM-5. https://www.ptsd.va.gov/understand/what/history_ptsd.asp#:~:text=In%201980%2C%20AP A%20added%20PTSD,sexual%20trauma%20victims%2C%20and%20others. 

Kloep, Hunter, R. H., & Kertz, S. J. (2017). Examining the Effects of a Novel Training Program and Use of Psychiatric Service Dogs for Military-Related PTSD and Associated Symptoms. American Journal of Orthopsychiatry, 87(4), 425–433. https://doi.org/10.1037/ort0000254 

Lucidi, Bernabò, N., Panunzi, M., Villa, P. D., & Mattioli, M. (2005). Ethotest: A new model to identify (shelter) dogs’ skills as service animals or adoptable pets. Applied Animal Behaviour Science, 95(1-2), 103–122. https://doi.org/10.1016/j.applanim.2005.04.006 

National Sexual Violence Resource Center. (2022, June 24). Statistics. https://www.nsvrc.org/statistics 

Peter-Hagene, & Ullman, S. E. (2015). Sexual Assault-Characteristics Effects on PTSD and Psychosocial Mediators: A Cluster-Analysis Approach to Sexual Assault Types. Psychological Trauma, 7(2), 162–170. https://doi.org/10.1037/a0037304 

Rep Rutherford, John H. (2021). H.R. 1022. Congress, https://www.congress.gov/bill/117th-congress/house-bill/1022/text