John navigating Times Square with Lundy, November 2014 (courtesy of Marshall Peters, SDI).
John navigating Times Square with Lundy, November 2014 (courtesy of Marshall Peters, SDI).
14.1 History and Overview of the Therapeutic Service Dog Training Program Offered at Walter Reed National Military Medical Center
A pilot of the service dog training therapy program (SDTTP) model was launched in July 2008 at The Men’s and Women’s Trauma Recovery Program at the Veterans Administration (VA) Hospital in Menlo Park, CA. The SDTTP was conceived as a safe and effective complementary treatment to reduce the symptoms of posttraumatic stress disorder (PTSD). The perception of this program as an opportunity to reengage in a meaningful mission had a strong appeal to the powerful warrior ethos of this patient population. Over the next 2 years, this volunteer SDTTP proved to be highly popular and demonstrated a low dropout rate. In 2009, patient reports of reductions in their PTSD symptoms and clinical observations of the program’s success were presented at the Veterans Administration National Mental Health Conference and the annual meeting of International Society for Traumatic Stress Studies. Approximately 200 service members participated in the pilot SDTTP program, five service dogs were placed with veterans in need, and two warrior trainers (WT) have become accredited service dog trainers currently pursuing careers in this field.
In 2009, the SDTTP was integrated into the Walter Reed’s occupational therapy (OT) and recreational therapy (RT) programs. Clinicians at Walter Reed continued to observe reduction in patients’ PTSD symptoms and patients reported improved wellness and high satisfaction with the program. The SDTTP, which is staffed by professional service dog trainers with clinical experience, is now also offered as an adjunct therapy for PTSD at the National Intrepid Center of Excellence (NICoE), WRNMMC, Ft Belvoir Community Hospital, the VA hospital in Menlo Park, CA, and NeuroRestorative’s residential treatment program in Germantown, MD. Approximately 3000 active-duty service members and veterans have participated in the SDTTP since February 2009 [1].
The golden and labrador retrievers used in the program are bred for the health and temperament necessary for mobility service dogs. It takes approximately 2 years to mature and train a service dog. From day one, these purpose-bred dogs are gently handled and exposed to increasing social and sensory experiences bolstering their devotion and confidence in humans. Patients and their families participate in this fun and essential early socialization training. Around 3 months of age, the young dogs are ready to start the training program. Participants begin to teach the dogs basic commands and eventually work toward completing the list of 90 commands which each dog must be competent in to become qualified as skilled, certified, service dogs. The patients’ participation in the SDTTP depends on their needs as well as the length and flexibility of their treatment program. Some WTs may work with the dogs for 2 weeks, while others are in the program for a year or more. This means that over 50 WTs can experience the psychological, physiological, and behavioral therapeutic value of the program during the course of training one service dog.
14.2 Case History/Presentation (John)
ID: 40-year-old male, married, white, AD/USN/E7 Chief Navy SEAL
John joined the Navy in 1992 (21 years service)
Current Military Status: Active Duty
Family History: John was married to his current wife in 2005 and together, they have five children.
John completed 11 deployments including Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). He was exposed to multiple blasts during the deployments, including one in November 2010 when he sustained shrapnel wounds to his head. John began experiencing memory loss, loss of balance, and severe headaches. He did not seek medical attention until February 2012, after returning to the USA. John also experienced numerous significant emotional loss throughout his career, including but not limited to, losing 40+ friends who were killed in combat.
May 2011, John returned from deployment in Afghanistan to his home in Virginia Beach, VA. He had an extremely difficult time readjusting to normal family life. John continued experiencing constant headaches, loss of balance, increased irritability, speech difficulty, and episodes of memory loss. Combat-related dreams and daydreams, avoidance of social situations, hypervigilance, isolating himself from people, and increasing marital and family conflicts were a few of the challenges he was facing at that time.
14.2.1 Diagnosis and Treatment
May 2012, John was diagnosed and treated for traumatic brain injury (TBI) at NICoE located on the WRNMMC campus, where he received 6 weeks of intensive evidence-based and complementary, alternative medicine (CAM) treatments. His treatment continued over the next 15 months with therapies provided by both Portsmouth Naval Hospital Brain Trauma Outpatient Clinic and also the Richmond VA Inpatient Transitional Rehab Program. However, John’s symptoms continued to worsen.
September 2013, John was transferred to WRNMMC’s inpatient TBI ward (7E). Neurological examinations were normal and behavioral observations ruled out TBI as the cause of John symptoms. PTSD became the working diagnosis.
John began a 7-month comprehensive, intensive psychological and behavioral rehabilitation program consisting of: OT , RT, and speech-language pathology (SLP). John’s medications were evaluated and adjusted to increase efficacy and decrease pharmacological burden. At this time, John and his wife also started intensive marital counseling. The counseling resulted in a significant decrease in marital discord and subsequently correlated with improvement in some of John’s symptoms.
14.2.2 SDTTP Clinical Notes from Service Dog Trainer and Recreational Therapist
14.2.2.1 September 25, 2013: First Encounter with SDTTP
Shortly after his arrival on 7E, John was invited to participate in a volunteer SDTTP as part of OT/RT services. The intent was for this program to help improve his verbal fluency, increase independence in recreation/leisure participation, and increase community functioning. John liked the idea that these dogs would be partnered with veterans in need. He agreed to work with the therapist and the service dog instructor (SDI) even though he was skeptical that training the dogs would help his recovery. As part of his inpatient treatment he attended hour-long service dog training sessions 2–3 times per week for approximately 5 weeks.
John: I felt like, sure I’ll play with your dog for a little bit, but what I really need to be doing is working on brain games or getting help for my speech and math issues.
SDI: In our first session, John’s presentation was one of quiet and reserve. Speech and sequencing was a noticeable issue. A verbal greeting that would normally take seconds was challenging and proved to be a point of frustration.
RT: John was attentive and demonstrated bright affect as evidenced by smiling and laughing intermittently when directly interacting with the service dog. He responded appropriately to constructive feedback from the SDI and agreed to continue participation in the program.
14.2.2.2 Weeks 2 and 3 of the SDTTP
SDI: John seemed to be somewhat disinterested in our appointments initially, but would dutifully attend them anyway. Within the first few sessions working with Lundy (9 month-old male Golden Retriever) there was a noticeable and distinct bond forming between the two of them. Although John was having trouble initially remembering commands or even our names, his affect was noticeably more positive and he appeared more resilient to the challenges of remembering/verbalizing commands.
John: On the third visit I couldn’t remember Lundy’s name, even though, just days before, I had said it a hundred times. I couldn’t remember the commands or say them because of my speech issues. I thought it was a waste. On the fourth session, it suddenly dawned on me that the dog training demanded the same brain skills as the computer games—except in real life/time. This training was helping me, I was helping Lundy become a service dog, and we were both working toward helping a Veteran in need. That’s when I started to take program seriously.
SDI: At first we were conducting training sessions on the ward. As our sessions progressed and John formed an even closer bond with Lundy, we ventured to the first floor of the hospital—a crowded, noisy environment that would begin to challenge his arousal and avoidance issues. Lundy is routinely mistaken for a hospital therapy dog and was often abruptly approached and engaged by random people. These situations allowed John to practice and become more comfortable with healthy confrontation and setting boundaries with people.
John: As part of OT, I’d have to navigate the Metro or go shopping. These were stressful experiences, but I could manage to do them without talking to any strangers. Going out in public with Lundy meant that many people would approach and I would have to talk to them. I could talk to Lundy and I could talk to guys I knew, but memorizing, ‘I’m sorry Ma’am he’s a service dog in training,’ and articulating that to a stranger made me very apprehensive. The first couple of outings were pretty stressful. I just focused on Lundy and said, okay, let’s get through this. But Lundy was excited to be around me and just having him at my side gave me a sense of confidence and pride. My speech really improved as I worked with Lundy and I found it was getting easier to talk to strangers. That was a real confidence builder for me.
RT: John demonstrated active listening and learned training skills with verbal feedback requiring minimal demonstrations by the SDI. The dogs are rewarded with verbal praise, treats, and petting. He successfully ambulated through crowded hallways with a dog using verbal cues and adjusting his pace for proper training technique. John was initially distracted with passers-by, however his attention increased until he was able to focus on the task independently. John engaged in a conversational task while sitting in a public eating area with minimal difficulties noted. 10 Oct 2013.
14.2.2.3 18 October 2013: Week 4 of SDTTP: Public Training Outing (Bethesda Lunch with Metro)
SDI: Because John’s attention was focused greatly on Lundy and the success of his training, we were able to successfully introduce increasingly stimulating environments for John and Lundy. Four weeks into the training program he agreed to an outing that involved taking the underground Metro train from WRNMMC to downtown Bethesda. Upon arrival at the metro station John was noticeably agitated at the task of riding the 230-foot escalator, down the dark tunnel, to the train. He gathered himself and was ready to step towards the downward escalator: Lundy however, was not. Lundy, being a puppy, had not yet been exposed to escalators and he stopped in his tracks. Since John’s “white-knuckle, grit-your-teeth and bear it” coping strategy was not going to work for Lundy, in this situation, John was now confronted with slowing down and encouraging Lundy onto the escalator. As he focused on helping Lundy to feel more comfortable with the new experience, John effectively convinced himself to become comfortable with it as well.
John: My stuttering and stammering made me very self-conscious in public and I had very low confidence. I knew that I had to display confidence so that Lundy would feel confident. I tried to just focus on Lundy and move directly to the task, but Lundy stopped short when he saw the moving steps. With the SDI’s help I slowed down the process by walking back and forth so that Lundy could get used to the idea of this strange machine. I had to keep praising him and encouraging him. Finally, we were able to get on the escalator and both Lundy and I became more and more confident as we rode it up and down.
RT: Overall, John maintained exceptional emotional regulation when training the service dog while in the community. He required minimal cueing to offer verbal commands to the dog when appropriate.
14.2.2.4 21 October 2013: Week 5 of SDTTP. Public Training Outing – Walter Reed Navy Exchange (NEX)
RT: John attended a therapeutic SDTTP session with RT and SDI on an outing to the NEX. He demonstrated appropriate affect and required intermittent cueing to praise the dog when necessary. John ambulated throughout the session with independence. John demonstrated good emotional regulation skills when teaching simple commands to “stay” and “heel” when near dog food aisles. John was noted to require distant supervision as he and Lundy approached the escalator. John was also required to practice providing verbal commands when in the electronics area due to the increased distractions such as visual and auditory stimulation. He was noted to demonstrate fluid speech in 95 % of session and independently participated in conversational tasks.
Related posts:
Prolonged Exposure for Combat Veterans with PTSD
Adding a Face and the Story to the Data: Acupuncture for PTSD in the Military
Trauma and Pain: Linking Emotional and Physical Symptoms
The Multifactorial Approach to PTSD in the Active Duty Military Population
Treatment of Conversion Disorder with PTSD
A Community Building Approach to PTSD Using the Arts in a Military Hospital Setting
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