Discussion: Qualitative Research Process

The Open Journal of Occupational Therapy Volume 6 Issue 3 Summer 2018

Article 12

7-1-2018

How Service Dogs Enhance Veterans’ Occupational Performance in the Home: A Qualitative Perspective Terry K . Crowe University of New Mexico, [email protected]

Mylinh T. Nguyen HealthSouth Rehabilitation Hospital and, [email protected]

See next page for additional authors

Credentials Display Terry K. Crowe, Ph.D., OTR/L; Mylinh T. Nguyen, MOT, OTR/L; Brenda G. Tryon, MOT, OTR/L; Stephanie Barger, CPDT-KA, CBCC-KA, Victoria Sánchez, DrPH, MPH

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Recommended Citation Crowe, Terry K.; Nguyen, Mylinh T.; Tryon, Brenda G.; Barger, Stephanie; and Sanchez, Victoria (2018) "How Service Dogs Enhance Veterans’ Occupational Performance in the Home: A Qualitative Perspective," The Open Journal of Occupational Therapy: Vol. 6: Iss. 3, Article 12. Available at: https://doi.org/10.15453/2168-6408.1468

How Service Dogs Enhance Veterans’ Occupational Performance in the Home: A Qualitative Perspective

Abstract Background: This qualitative study explored the lives of veterans diagnosed with posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI) and how the partnerships with their service dogs supported improved occupational performance in their homes.

Method: Semi-structured individual interviews were conducted with six veterans with PTSD and/or TBI who graduated and received their service dogs from the Paws and Stripes Program in Albuquerque, NM. Home activities of daily living (self-care, household tasks, leisure activities, and family and friend relationships) guided the interview questions. The individual interviews were audio recorded, transcribed, and coded using qualitative data analysis software. Preliminary themes were independently developed by two graduate research assistants. Final themes and subthemes were generated by team consensus.

Results: The overarching theme was veteran and service dog partnerships improved occupational performance in the home. Four primary themes arose that supported the overarching theme: (a) providing physical safety and peace of mind; (b) supporting healthy behaviors; (c) my service dog, my hero; and (d) influencing family and friend relationships.

Discussion: Findings from this study support that veteran and service dog partnerships improved the veterans’ occupational performance in their homes. The service dogs assisted the veterans on physical and emotional levels and improved their healthy behaviors.

Comments Stephanie Barger reports that as the director of programs for Paws and Stripes, she has significant knowledge about the individuals studied in this program and did not take part in the collection or analysis of the data. The service dog vest is patent-pending.

Keywords veterans, service dogs, posttraumatic stress, traumatic brain injury, qualitative methods

Cover Page Footnote We offer a heartfelt thanks to Paws and Stripes for opening their doors to this research study and collaborating with us. We extend our sincere gratitude to all of the veterans and service dogs who participated in this study. We also thank the veteran who participated in the pilot study.

Complete Author List Terry K. Crowe, Mylinh T. Nguyen, Brenda G. Tryon, Stephanie Barger, and Victoria Sanchez

This applied research is available in The Open Journal of Occupational Therapy: https://scholarworks.wmich.edu/ojot/vol6/iss3/12

Since World War I, occupational therapists have played a crucial role in the rehabilitation and

reintegration of veterans with physical and psychological injuries that range from amputations to

posttraumatic stress disorder (Cogan, 2014). Approximately 61% of veterans who were deployed to Iraq

and Afghanistan sought health care from Veterans Affairs between the years 2002 to 2015 (U.S.

Department of Veterans Affairs, 2015). The Department of Veterans Affairs reported that many of the

returning service members experienced medical conditions that included posttraumatic stress disorder

(PTSD), traumatic brain injury (TBI), major depressive disorders (MDD), or musculoskeletal injuries.

Over 299,000 veterans who served in the Iraq and Afghanistan wars were diagnosed with PTSD

between the years 2002 to 2015 (U.S. Department of Veterans Affairs, 2017). PTSD is a psychiatric

disorder that can occur in individuals who have experienced or witnessed a traumatic event. Symptoms

include flashbacks; distressing dreams; avoidant tendencies of people, places, and objects or activities

that may elicit distressing memories; ongoing guilt, shame, and anger; feeling detached from others;

irritability; hypervigilance; and difficulty sleeping (American Psychiatric Association, 2013).

According to the Defense and Veterans Brain Injury Center (2017), more than 300,000 U.S.

military personnel were diagnosed with TBI between the years 2000 to 2015. TBI is caused by a blow,

bump, or jolt to the head and is diagnosed by severity ranging from mild to severe (Centers for Disease

Control and Prevention, 2017). Symptoms of TBI vary and may include physical symptoms (e.g.,

headache, trouble sleeping, vision problems, noise and light sensitivity, and feeling dizzy), cognitive

symptoms (e.g., memory problems, difficulty staying focused, poor judgment, trouble putting thoughts

together), and/or emotional symptoms (e.g., depression, anger, outbursts, anxiety, and personality

changes) (Miles, Graham, & Teng, 2015; U.S. Department of Veterans Affairs, 2015; U.S. Department

of Veterans Affairs, 2017). PTSD frequently accompanies TBI (Gironda et al., 2009; Hoge et al., 2008;

Ruff, Riechers, Wang, Piero, & Ruff, 2012). The co-occurrence of PTSD and TBI can have overlapping

physical, cognitive, and psychological symptoms (Bryant, 2011; Miles, Graham, & Teng, 2015;

Speicher, Walter, & Chard, 2014; Spencer, Drag, Walker, & Bieliauskas, 2010). These cognitive,

psychological, and behavioral impairments can affect reintegration into civilian roles and participation

in occupations (Hwang, Peyton, Kim, Nakama-Sato, & Noble, 2014; Radomski & Brininger, 2014;

Speicher et al., 2014). These studies stated that concerns can include driving in the community;

resuming household, family, work, and leisure roles; self-management of stress and pain; and

establishing healthy routines.

Some veterans with a history of PTSD and/or TBI are partnering with service dogs to assist them

in occupations that have been impacted by their disability (Crowe, Sánchez, Howard, Western, &

Barger, 2017; Froling, 2009; Hemmerly-Brown, 2011; Miller, 2014). Occupations refer to daily life

activities in which people engage and which have purpose, meaning, and perceived use (American

Occupational Therapy Association, 2014). As defined by the Americans with Disabilities Act (ADA),

service animals include dogs that are individually trained to do work or perform tasks directly related to

a person’s disability (ADA National Network, 2017). Service dogs may perform tasks for veterans with

a history of PTSD and/or TBI, including performing safety room checks, reminding the veteran to take

prescription medication, responding to the onset of an anxiety attack, or alerting the veteran to take

breaks or avoid activities that can trigger flashbacks or stress-related symptoms (Froling, 2009). Alerts

are a form of communication the service dogs use to inform people about distressing changes,

impending triggers, or when to take a break. Triggers can vary and may include seeing or hearing

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something, or even a specific smell, that can set off a memory or flashback of a traumatic event (U.S.

Department of Veterans Affairs, 2015).

Service dogs are increasingly being paired with people with a variety of disabilities. These

partnerships have been shown to improve self-esteem and overall well-being and to increase social

interactions and independence (Allen & Blascovich, 1996; Crowe et al., 2014; Rintala, Matamoros, &

Seitz, 2008; Winkle, Crowe, & Hendrix, 2011). For example, women with mobility disabilities had

more social interactions in their community and performed functional tasks more efficiently and with

less effort when their service dogs were present (Crowe et al., 2014).

There is the potential for similar findings when veterans are paired with service dogs. In a

qualitative study, Crowe, Sánchez, Howard, Western, and Barger (2017) found that service dogs helped

veterans transition from isolation to being integrated into the community. The service dogs helped the

veterans to navigate daily life, facilitate social opportunities, and transform their sense of worth and

purpose. Anecdotal publications have described the physical benefits of service dogs, including the

ability to live more independently secondary to mobility assistance (e.g., retrieving dropped items);

psychological and emotional benefits, such as preventing panic attacks; and increasing social interaction

opportunities (Hemmerly-Brown, 2011; Miller, 2014; O’Brien, 2008). Yet more research is needed to

systematically explore the benefits of veteran and service dog partnerships.

This is the first study that explored how service dogs assist veterans’ occupational performance

in their homes. Occupational performance is defined as the engagement in a task or occupation resulting

from the dynamic interaction among the person, environment, and occupation (American Occupational

Therapy Association, 2014). Activities in the home (self-care, household tasks, leisure activities, and

interactions with family and friends) provided the overarching framework for this study.

The research questions were:

1. How do service dogs influence veterans’ emotional well-being in the home?

2. How do service dogs influence veterans’ physical well-being in the home?

3. What are the general benefits and challenges of service dogs for veterans when

interacting with family and friends in the home?

Method

Setting: Paws and Stripes

Paws and Stripes is a nonprofit organization providing service dog training, education, and

mental health support for veterans with PTSD and/or TBI (Paws and Stripes, 2015). Each veteran

carefully chooses his or her service dog from an animal shelter with guidance from the Paws and Stripes

professional trainers. Paws and Stripes has a team of trainers with various levels of experience in dog

training, adult education, and the medical field. The training team is overseen by the director of

programs and the head trainer, who hold nationally recognized certifications through the Certification

Council for Professional Dog Trainers (CPDT). Once a member of the training team meets the criteria

to qualify for certification through CPDT, they are encouraged to pursue certification.

After establishing a relationship with his or her service dog, each veteran commits to an intensive

weekly training program that can take up to 18 months. Veterans participate in groups with and without

their service dogs and in individual sessions with their service dogs and the professional trainers at the

Paws and Stripes facility. Once the service dog/veteran team demonstrates basic skills and

acceptable public manners, training sessions move to public locations for further task-oriented training.

The training focuses on teaching the dog skills that address each veteran’s unique challenges and

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needs. For example, dogs are taught to help the veterans by providing additional space in crowded

situations, monitoring the environment by checking blind corners or entryways, physically assisting the

veterans on stairs or in transitions from sitting to standing, physically picking up items, and alerting the

veterans to increased anxiety. Finally, weekly workshops without the service dogs provide a classroom

environment where the veterans learn the many theories, practices, and other elements important for

successful completion of the program. Figure 1 outlines the multiple required steps to meet graduation

competencies.

In addition to the dog training competencies, veterans enrolled in the Paws and Stripes program

and their service dogs must attend individual sessions with a mental health provider familiar with the

rigors of the program two times a month. The goal of the mental health component is to assist the

veterans in coping with the challenges that they face while enrolled in the program. This includes

assisting the veterans to develop skills to counter symptoms they experience as they move to more

difficult levels of the training. These skills include developing communication skills to address public

interest, addressing family issues that may arise from the changing dynamics in the home caused by the

introduction of a service dog, and exploring de-escalation techniques to assist in regulating their

symptoms. The focus of this component is to develop techniques that enhance the communication

between the veteran and his or her service dog by dealing with the symptoms and triggers that the

veteran faces each day, rather than unpacking why a symptom flares up or is triggered by something.

While it may be necessary to delve into the original traumatic event when the issue is affecting program

progress, it is not the focus of the mental health component of the program. However, the veterans are

encouraged to pursue such other treatment outside of the program.

Figure 1: Paws and Stripes Enrollment and Training Process.

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Participants

Participant recruitment began with the Paws and Stripes staff presenting information about the

research project and inviting Paws and Stripes graduates to participate in interviews to share their

personal experiences about their service dogs. Paws and Stripes staff then forwarded the names and

contact information of interested veterans to the principal investigator (first author). The first author

contacted perspective participants via phone and/or email to determine eligibility, to fully describe the

study, and to answer questions. Inclusion criteria required that the veterans (a) graduated from the Paws

and Stripes Program in 12 months, (b) owned a service dog trained by Paws and Stripes, (c) lived in

New Mexico, (d) could speak and understand English, (e) had a diagnosis of PTSD and/or TBI, (f) were

18 years of age or older, and (g) were willing to participate in the study. Six veterans—four men and

two women—between 27 to 55 years of age agreed to participate in the study (see Table 1).

Table 1

Veteran Demographics

Age

(years)

Gender Marital

Status

Military Branch

(% Disability)

Diagnosis Service Dog Training

(months)

51 Male Married Army (100) PTSD &

TBI

18

55 Female Single Army (90) PTSD 12

40 Male Married Army (100) PTSD &

TBI

11

27 Female Married Air Force (90) PTSD 10

54 Male Married Army/Marines

(100)

PTSD 9

33 Male Married Army (70) PTSD &

TBI

10

Data Collection

We used an exploratory qualitative research design to answer our research questions about the

veteran and service dog partnerships in the home. This study was approved by the University of New

Mexico Human Research Projects Office (UNM HRPO). All of the participants completed a

demographic survey form and signed an informed consent form before participating in the semi-

structured individual interviews.

The five-member research team created the interview guide for the individual interviews. The

interview guide focused on collecting data on home activities in the following areas: self-care,

household tasks, leisure activities, and interactions with family and friends. The first, second, and third

authors conducted a pilot interview with one veteran whose data was not included in this study. This

veteran’s feedback was used to refine the interview guide. The pilot data was later transcribed,

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independently coded by the second and third authors (graduate assistants), and cross-referenced to

establish reliability between both graduate research assistants prior to coding the six interviews.

The six individual interviews were scheduled and conducted by the first author either in the

veteran’s home or at the Paws and Stripes facility. Out of respect for the veterans, we allowed them to

choose the interview location. Some of the veterans were comfortable leaving their homes and preferred

the familiarity of the Paws and Stripes facility, while others were uncomfortable with people they did

not know coming to their homes. Paws and Stripes staff were not present at the interviews. Each

graduate assistant attended three interviews. The semi-structured individual interviews varied from 45

to 90 min. The veterans received a $25 gift card for their participation.

The interviews were audio recorded with a recording device (Olympus Digital Voice Recording

VN-6000, Olympus Corp., Shinjuku, Tokyo, Japan). Each graduate assistant transcribed verbatim the

interviews they attended. The other research assistant then listened to the audio recordings and read the

transcriptions completed by the other graduate assistant to ensure accuracy and, if needed, to correct the

transcripts.

Data Analysis

The graduate assistants worked with the fifth author, a senior qualitative researcher, to create the

analytic and coding framework. Descriptive coding and thematic analysis began with question-level

coding to create a codebook with categories that led to further development of themes. For example, a

coding category was safety in the home. Quotes that described how the service dog assisted in

preventing falls and providing safe mobility (balance assistance, picking up items) were categorized

under safety in the home. Refinements were made to the codebook as the graduate research assistants

read and coded the pilot transcript prior to coding the six interviews. We omitted identifying

characteristics to protect the identity of the veterans and their service dogs. The veterans were assigned

a number between 1 and 6, and their service dogs were identified as service dog. The graduate assistants

used QDA Miner 4 Lite qualitative data analysis software to code each transcript (Provalis Research,

2014).

To enhance study rigor and validity, the graduate assistants used a primary/secondary coding

approach where each served as the primary coder for the three interviews they transcribed and as

secondary coder for the interviews transcribed by the graduate assistant. They identified preliminary

themes separately and then compared themes to assess coding consistency and agreement. Coding

differences were discussed until the two graduate research assistants reached a consensus. The full

research team then met to discuss themes and subthemes. Final theme consensus was reached and the

team discussed selected quotes to define the themes and subthemes.

Results

The veterans reported that their service dogs helped to improve their occupational performance

in their homes. Four themes and six subthemes emerged from the data that illustrated these changes: (a)

providing physical safety and peace of mind; (b) supporting healthy behaviors (sleep, medication and

pain management, physical health awareness, and emotional awareness); (c) my service dog, my hero;

and (d) influencing family and friend relationships (benefits, challenges). These themes came together

to support the overarching theme: Veteran and service dog partnerships improved occupational

performance in the home (see Figure 2).

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Figure 2. Four primary themes supporting the overarching theme.

Theme 1: Providing Physical Safety and Peace of Mind

Physical safety. Because of war-related injuries, some of the veterans reported having mobility

issues that impacted home safety. Three of the six veterans reported that their service dogs assisted with

safe mobility and fall prevention in the home. For example, Veteran 5 expressed, “If I’m going up a

stairway, he’ll help me get up the stairway by kinda leaning on me while I’m walking.” Veteran 1

experienced “dizzy spells” and could avoid falls with assistance from his service dog. He stated, “I

don’t have to bend over to pick up anything, she picks up everything for me, my shoes, my cane, my

keys.” Some of the veterans reported that their service dogs physically assisted them to get up after a

fall. Veteran 3 shared:

He follows me around in case I fall because I do have falling spells every now and then.

Say I’m mopping the floor in the hallway, he’ll lay at the far end of the room and he’ll

just sit there until I get back to him and then he’ll move and get into the living room until

I mop back to him. And if I do fall, then he comes over and I’ll stay laying down and

even though I feel OK, he won’t let me up or help me up until he knows that I’m OK.

Peace of mind. Four of the six veterans reported feeling safer in their homes after owning a

service dog. This renewed sense of security enabled the veterans to focus on completing meaningful

occupations at home and achieving healthy behaviors instead of focusing on security for their families

and themselves. Veteran 1 shared his sense of greater ease.

People can knock on my door without me grabbing my gun at the door now, because I

know when it’s necessary by her [service dog] tone. When I first got back, somebody

would knock on the door . . . and [I] would [be] jumping and running for my gun.

Feeling relaxed in their home was also commonly reported, as shared by Veteran 2: “I couldn’t

relax without him. I feel if anything is coming, [service dog] will let me know.” Many of the

veterans stated that having a service dog was parallel to having a fellow soldier “watch his or her

back” during service in the military. Veteran 5 expressed: “OK . . . when you’re out there in a

combat situation, you feel that with your fellow brothers, with your fellow marines, and you

know they got your back. I know my [service dog’s] got my back.”

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Theme 2: Supporting Healthy Behaviors

The veterans reported achieving or reengaging in healthy behaviors (sleep, medication and pain

management, physical health awareness, and emotional awareness) with the assistance of their service

dogs.

Sleep. The majority of the veterans reported that they had trouble falling asleep, staying asleep,

or experienced night terrors or nightmares due to a history of PTSD and/or TBI. Five of the six veterans

reported that the presence of the service dog assisted them in falling asleep or staying asleep. Veteran 6

shared:

So, there have been times where I have woken up in the middle of the night and [service

dog] wasn’t physically right next to me because he was on the ground. So, I call . . . he’ll

come up and comfort me.

Many of the veterans also reported that when experiencing night terrors, their service dogs would

interrupt the cycle by alerting them to wake up. Veteran 5 stated:

There’s been times that I’d be laying, I’d be half asleep, he puts his head right there on the

edge of the bed, so I know, he’s there if I’m having a nightmare or something, he’ll kind of wake

me up.”

Veteran 2 explained how her service dog would alert her:

When I have night terrors, [service dog] wakes me up. He touches me with his nose on a

sensitive part of my arm and I wake up. Well, I didn’t know why I was waking up. And

I was still married, and I asked my husband, “What is going on?” And we didn’t sleep in

the same room because of my night terrors. And he goes, “Well, I heard you, and you

were screaming, and so [service dog] woke you up.

Medication and pain management. Remembering to take medications was often a challenge to

the veterans. Each veteran was on different medications ranging from supplements to prescribed

medications. Five of the six veterans were alerted by their service dogs to take their daily medications

and/or supplements at the right time. Veteran 4 reported, “He’ll just go over where my medications are

at a specific place on the counter, and he’ll go over there and just wait. So, I’m like, ‘Oh yeah, I need to

go take them [medications]’.” Pain management was another concept that arose for four of the veterans.

When a veteran experienced pain at a level that might impact functional participation in occupations, his

or her service dog would detect the pain and alert the veteran to take a break, step away, rest, or take

pain medication. The service dog’s alerts varied from ignoring commands to tactile alerts. Veteran 2

expressed:

If I just keep pushing, you know soldiering on, and adapting and overcoming, and I don’t

take my medication, [service dog] will refuse to get vested [service dog wears vest when

working], and if he does, he will refuse to get into the car. Then I take my medication.

Now if I forget, he reminds me to take my medication because he senses my mood and

work [quality] deteriorates if I don’t take my medication.

Physical health awareness. Some of the veterans reported that their service dogs perceived the

state of their physical health. Veteran 3 reported that his service dog provided tactile alerts, “If my back

or legs are hurting real bad, he will actually lay on my back just so I can’t get out of bed.” The service

dogs also assisted in early detection of pain symptoms. As in the case of Veteran 5, his service dog

prevented the escalation of his migraines:

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I’ve learned, just with pain, they’ll tell you, “What’s your worst pain [level], [on a scale

of 1 to] 10?” With the migraines, I could be a three or four and they’re manageable. My

[service dog] will alert me at a [pain level] two or three. He will come up and start

stepping into me.

Veteran 1 shared:

When I had a heart attack, I was standing [and] just went into total pain. She jumped on

top of me and I thought, “What the . . . ?” She never jumps on me but she threw me on

the chair. She doesn’t jump on me, that’s not what she’s trained to do, but she jumped on

me, she threw me in the chair. I started sweating like a pig. She started licking my face,

nudging me, and licking me, that’s when I said, “Something's wrong”. I called 911 and

the next thing you know I was on a helicopter to [the hospital].

Emotional awareness. The service dogs not only detected physical health issues, they

also supported the veterans’ awareness of their emotions. The veterans with a history of PTSD

and/or TBI reported that they commonly experienced stressful emotions, such as anxiety or

feeling disconnected to their emotions. A few of the veterans reported that their service dogs

increased their awareness of their emotions through alerting them to pay attention to incidents

that trigger negative emotional responses. The veterans were often able to recognize triggers in

response to the service dogs’ alerts and take proactive steps to self-regulate. Veteran 6 expressed

how he enjoyed playing war video games; however, these video games also increased his anxiety

levels. When his service dog detected his high anxiety levels, his service dog would alert him to

take a break. Veteran 6 stated, “Basically, I had to teach [service dog] by listening to him

[becoming aware of the dog’s alerts]. You know, by putting the controller down and just

relaxing for a little bit.” Veteran 6’s service dog would transition from subtle alerts (e.g.,

nudging his leg) to more obvious alerts (e.g., barking) if he did not take a break during the initial

alerts. In other cases, the service dog provided deep pressure or tactile input by leaning against

the veteran, providing a calming effect and deescalating emotions of high anxiety before they

transformed into a panic attack. Veteran 5 shared, “That physical contact kind of eases me, it

gives me a sense of ease.” His service dog provided him with a sense of calm through tactile

input. Veteran 4 reported a similar experience:

He [service dog] will come to me when he knows I’m stressed. Just kind of lean on me.

The other two [family dogs], I feel like we don’t have that connection so they may have

not ever done that or I don’t know but he [service dog] definitely calms me down a lot.

Theme 3: My Service Dog, My Hero

The veterans experienced a special bond with their service dogs that exceeded their expectations.

“[Service dog] is my arms and my legs and my heart,” stated Veteran 2. The veterans spoke not only of

the support they received from their service dogs but also about the camaraderie that developed between

the two. Veteran 1 stated, “I couldn’t sit here and talk to you right now if it wasn’t for [service dog]

sitting next to me, reminding me that I am bigger than I think I am. You know, I’m bigger than I feel.”

This reciprocal and symbiotic relationship also generalized to engaging in social participation in the

home. Veteran 3 shared, “I’ve had to learn with him because I couldn’t have done this. I wouldn’t even

[have] been talking to you a year ago, or a year and a half ago.” This common sentiment from all of the

veterans highlighted the unique partnership between the veteran and his or her service dog and

characterized the changes the service dog brought to each veteran’s life.

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Theme 4: Influencing Family and Friend Relationships

Benefits. Residual impacts from being involved in the wars in Iraq and Afghanistan affected not

only the veterans but also their families. Having a history of trauma, PTSD, and TBI may cause some

veterans to create emotional barriers with their family and friends. Veteran 4 reported, “Since I’ve had

[service dog], I’ve learned so much throughout the program. I really feel like it has made me a more

calm, understanding mom, and I feel like I’ve been closer to my husband.” During the interviews, some

of the veterans reported a distant relationship from some family members after their military service and

prior to owning their service dogs. Veteran 1 shared, “I could never tolerate the grandkids, I mean, they

were just intolerable. I just had no patience for them. It just wasn’t a good thing for a grandfather.”

Integration of the service dog helped Veteran 1 build a relationship with his grandchildren. He stated:

When I got [service dog], she started going with me everywhere, doing everything with

me. My grandkids wanted to be involved with [me and the dog] . . . but yeah, [service

dog] has taught me to be more patient.

Some of the veterans reported that the skills they gained from building the partnership with their service

dogs were transferable to interacting or reconnecting with their family. In other circumstances, the

service dog provided a physical barrier between the veteran and a family member to facilitate a more

comfortable interaction. Veteran 6 shared:

When we went to the funeral, it had probably been a year since I’d seen my dad. My dad

comes up to me, gives me a hug and we start talking. Almost immediately [service dog]

got in between my dad and [me] . . . he definitely was picking up because I was

uncomfortable being around him.

The ability to maintain and establish friendships can also be affected by a history of PTSD and/or

TBI. Through involvement with Paws and Stripes, Veteran 3 expressed how the program helped

him develop a friendship with another veteran through shared dog training experiences.

I’ll be honest, since getting back from Iraq, I would say, I had one friend and that was the

person I married after my first wife left me and until I started this program and graduated,

and now [another veteran] comes up to my house on weekends. He’s the first true friend

that I’ve had in 11 years.

Veteran 3 also shared how a new friendship helped him by further explaining: “It’s pushing my

friend, so we’re helping each other through some things and it’s neat.” Veteran 4 also shared

how she established friendships with other veterans in the program:

I do have another friend that is in the program right now. She has a service dog and

she’ll sometimes come over. And we’ll just leave [service dog] and her service dog in

here the house, so they can play.

In some cases, part of the caregiver role, which often fell on other family members, was partially

alleviated by the service dog. The service dog retrieved items for the veteran or relieved the

caregiver from always having to stay with the veteran in the home. For example, Veteran 1

shared:

If [my wife] is not here, she has to go to the store [or] has to do something . . . she doesn’t

worry about me because [service dog] will lay right next to me and will not move until

[my wife] gets back . . . once [my wife] gets back, [service dog] will get out of bed . . .

but if there’s nobody here, she won’t leave my side.

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Challenges. Although the veterans reported that the service dogs helped improve the quality of

family relationships and friendships, challenges were also identified when integrating the service dog

into the family. Some of the challenges reported by the veterans included family members or friends

who were not accepting of their service dogs, a loss of family relationships or friendships, and/or a strain

to a long-standing relationship or friendship due to the addition of the service dog. Two of the veterans

experienced a change in the interactions they had with family and friends. Veteran 3 expressed, “It was

very difficult for my wife because that was her job to watch my back for 10 years and so it was very

difficult for a while.” Some family members did not understand PTSD and the important role the

service dog played for the veteran. Veteran 5 shared:

Well you know family, most, I don’t want to say most, the majority of my family say

they understand. They look at him as a pet rather than as a service dog, especially my

brother and my mom, because they tend to say, “Well, there’s nothing wrong with you.”

They can’t understand what PTSD is.

The additional and constant presence of the service dogs changed the family dynamics in more than half

of the veterans’ homes. As Veteran 2 recalled about friends she made in church: “I was going to that big

church, we had which is called ‘community group’, it is where you had a group of people who met every

week, same group, and they became your family, I mean really a family.” These gatherings often took

place at Veteran 2’s home, but stopped shortly after she received her service dog. Veteran 2 explained,

“Everyone else has pets but they don’t want me to bring my [service] dog.” This resulted in a loss of

close friendships with people she also considered family.

Overarching Theme: Veteran and Service Dog Partnerships Improved Occupational Performance

in the Home

In general, the veterans reported that before they received their service dogs their health issues

often prevented them from fully engaging in meaningful occupations. Many of the veterans reported

how having a history of PTSD and/or TBI symptoms caused them to experience issues ranging from

decreased sleep to increased pain, which ultimately affected their participation in valued occupations.

However, with the assistance of their service dogs, the veterans reengaged in many occupations in their

homes. For example, Veteran 3 reported:

If I had forgotten to take a shower in the morning, [service dog] will not let me out of

my bathroom because that is something that relaxes me for the day and so he doesn’t

like me starting the day . . .. [My service dog] stands at the door . . . if the door is kinda a

little open he’ll push it closed and lay down right in front of it. Then it doesn’t take me

long to figure out, “Ok, I need to take a shower”.

Veteran 3’s service dog helped him do his self-care tasks so he could successfully engage in other

occupations throughout the day. The veterans shared how the responsibilities of caring for their service

dogs often intermingled with their own daily routines, therefore promoting them to engage in

meaningful occupations. Veteran 5 reported:

I get up and I take my vitamins and I get ready to feed [service dog]. I feed him, we go

through the routine . . . I usually have a cup of coffee or something, watch the news a

little bit, get ready, whatever I have to get done, I usually do things at home or I go out if

I have to go out, I plan my day out. I get [service dog] dressed, I get myself dressed, I

take a shower, [service dog] is there with me as I am getting dressed.

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Veteran 5 continued to describe how his service dog provided increased motivation, thus enabling him

to engage in physically active occupations even when he felt unmotivated. Veteran 5 reported:

Some days I don’t feel like doing anything, [service dog] kinda gives me motivation.

He’ll get me up . . . and sit there like, “come on let’s go do something”. He will want to

go outside, just to go. I play toss, he likes to run, so I’ll go out there and toss the ball

with him. We play . . . he kinda gets me motivated. He helps me not to sit there and

waste the day.

Veteran 2 shared a similar experience: “He gets me motivated, to get up and get outside.” In some

cases, the service dog physically assisted the veteran with specific tasks needed to complete an

occupation. Veteran 4 expressed how her service dog assisted in her occupation as a mother.

For example, if I drop a diaper, I’ll be like pick it up (snaps with fingers), I’ll just snap

and [service dog] will pick it up and bring it to me, a clean diaper of course, you know if

we’re changing a diaper . . . . If I dropped the spoon and [service dog] picked it up and

brings it to me. Um what else . . . [service dog will] shut like the dishwasher or the

cabinets or doors so that’s always helpful.

Veteran 2 shared, “It’s a great household thing. He shows me where my keys are when I’ve lost them.

When I lose them, and I lose them quite frequently, so I ask [service dog] to find them.” The veteran

and service dog partnership also improved occupational performance in the home by improving many of

the veterans’ abilities to engage in occupations shared with family members or friends. Veteran 1

experienced how his service dog brought his family closer by just spending time together, thus providing

a common connection between the veteran and his family members. “I have been able to have

incredible times with my family since I’ve had him [service dog]. My family, doing the family things,

family time, I guess you could say. There was none before. I couldn’t be around family; I couldn’t be

around anybody.” These experiences of family bonding increased the veterans’ relaxation, joy, and

performance in leisure activities with family and friends. Family leisure activities also strengthened the

family bond when the service dog was not working, as described by Veteran 4: “We, as a family, we’ll

play with all three dogs, we play tug-of-war, we play fetch, so that’s just a stress reliever for me and it’s,

you know, giving them exercise. We are also together as a family.”

Overall, the veteran and service dog partnership helped improved each veteran’s ability to

engage in meaningful occupations in his or her home by addressing issues that may have hindered

occupational performance.

Discussion

This study, which focused on veterans’ occupational performance in the home, will add to the

limited research addressing veteran and service dog partnerships. The themes and subthemes that

emerged from this study supported the overarching theme: Veteran and service dog partnerships

improved occupational performance in the home. By providing physical safety and peace of mind;

supporting healthy behaviors, such as better sleep and medication management; and facilitating

improved family and friend relationships, the service dogs promoted occupations that provided

opportunities to improve the veterans’ home environments.

Veterans with a history of PTSD and/or TBI may experience health issues that can serve as

barriers when trying to engage in occupations or return to previously held occupational roles. The most

commonly affected occupational performance barriers reported by the veterans in our study, which

incorporated service dogs, were the areas of self-care, household tasks, physical and emotional health,

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and relationships with family and friends. These areas of occupational performance overlapped with

findings from the Plach and Sells (2013) and Speicher, Walter, and Chard (2014) studies, which

explored the occupational performance of the veteran population without service dogs. In these two

studies, the Canadian Occupational Performance Measure-COPM (Law et al., 2014) was administered to

identify the occupational performance barriers that veterans experienced when returning to their civilian

lives after military service. These studies also identified occupational performance barriers, including

self-care (sleep, physical health, mental health), productivity (household management), and leisure and

social participation (relationships, emotional regulation, and emotional de-sensitivity). Radomski,

Davidson, Voydetich, and Erickson (2009) found that veterans with a history of TBI had occupational

performance difficulties in the areas of life skills and routines, household tasks, family relationships,

leisure activities, and work tasks. The veterans in our study reported disrupted occupational

performance in their homes in similar areas prior to receiving their service dogs.

The veterans with a history of PTSD and/or TBI in our study used service dogs to assist them in

their daily lives. The experiences and perspectives shared by the veterans with service dogs highlighted

how these partnerships improved occupational performance in their homes. These study findings are

consistent with existing anecdotal reports regarding veteran and service dog partnerships (Hemmerly-

Brown, 2011; Miller, 2014; O’Brien, 2008). Anecdotal reports also described benefits, such as mobility

assistance (e.g., retrieving dropped items); the ability to live more independently; increased social

interactions; and psychological and emotional benefits, such as preventing panic attacks, deescalating

distressing emotions, and alerting to triggers.

Congruent with the outcomes from other studies focusing on people with disabilities and service

dogs (Crowe et al., 2014; Rintala, Matamoros, & Seitz, 2008; Winkle et al., 2011), the veterans in this

study reported experiencing an increase in their overall well-being and in their independence in

performing some occupations. Another similarity is that the veterans in our study reported an increase

in the frequency of social opportunities, as well as in their personal skill development and independence.

Overall, this study indicates that there is potential for other veterans with a history of PTSD and/or TBI

to benefit from a veteran and service dog partnership.

Limitations

This study provides a better understanding of veteran and service dog partnerships and lays the

initial groundwork to guide future studies. Given that perspectives are limited to the veterans who

choose to participate in this study and were willing to share their experiences, the findings may not

generalize to all veterans who have a history of PTSD and/or TBI or to nonveteran populations. The

diversity of the veterans’ learned skills and training methods used by Paws and Stripes may not be the

same across service dog organizations, which may deploy different training approaches. Therefore, this

study cannot be generalized to all service dog organizations.

Implications for Future Research

This is the first study that focused on occupational performance in the home for veterans with

service dogs. In future studies, the severity of symptoms associated with PTSD and/or TBI should be

taken into consideration. We noted that each veteran’s needs varied; therefore, the level of assistance

and acquired skills of each service dog varied as well. Future quantitative studies with larger samples

and pre and post studies focusing on veterans’ occupational performance and quality of life before and

after receiving a service dog would be beneficial. Comparison studies between the effects of veteran

and service dog partnerships and veteran and companion dog partnerships would be another avenue to

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explore. In addition, studies focused on other occupational therapy areas, such as community

reintegration, would benefit the research on veteran and service dog partnerships. Finally, exploration

of the role of occupational therapy in facilitating occupational performance for nonveteran populations

who partner with service dogs remains fertile ground for additional exploration.

Implications for Practice

Occupational therapists will continue to play an influential role in the rehabilitation and

reintegration of veterans returning from military service. Occupational therapists interested in providing

services to veterans who have expressed an interest in owning a service dog should become familiar

with reputable service dog organizations in their geographic area. Occupational therapists can help

facilitate veterans in their quest to obtain service dogs or provide an appropriate referral. With their

competencies in the physical, cognitive, and mental health areas, occupational therapists can perform

assessments with veterans to identify areas of occupational performance difficulties. Once occupational

performance needs are identified, occupational therapists can be a vital part of the collaboration between

the veteran, the service dog organization, and the professional dog trainers. This collaboration can

facilitate better placement of service dogs that match the veterans’ strengths and occupational

performance needs and enable targeted preparation for dog handling and the education of other team

members about disability issues. Occupational therapists can bring a unique and holistic perspective to

this new collaboration, ultimately enhancing the veteran and service dog partnership.

Terry K. Crowe, Ph.D., OTR/L, professor and founding director, occupational therapy graduate

program, University of New Mexico, Albuquerque, NM

Mylinh T. Nguyen, MOT, OTR/L, occupational therapist, HealthSouth Rehabilitation Hospital and

University of New Mexico Hospital, Albuquerque, NM

Brenda G. Tryon, MOT, OTR/L, OnPointe Health, Albuquerque, NM

Stephanie Barger, CPDT-KA, CBCC-KA, director of programs, Paws and Stripes, Albuquerque, NM

Victoria Sánchez, DrPH, MPH, associate professor, College of Population Health, University of New

Mexico

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