ASSIGNMENT
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Sample_Final_Proposal1101.docx1
Running head: IMPROVED QUALITY OF LIFE
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IMPROVED QUALITY OF LIFE
Improved Quality of Life for Veterans with PTSD through Service Dogs
Improved Quality of Life for Veterans with PTSD through Service Dogs
Introduction
Post-traumatic stress disorder (PTSD) has become an increasingly serious mental health issue for veterans and non-veterans alike. PTSD is developed over time following a traumatic event such as a natural disaster, a sexual assault, or exposure to a combat zone (Schnurr et al., 2014). PTSD presents with symptoms such as anxiety, depression, constant hypervigilance, and re-living traumatic events. There is also an increased risk of suicidal tendencies among those who suffer with PTSD. Suicide among veterans with PTSD continues to be a significant problem (Krause-Parello, Sarni, & Padden, 2016). There are a limited number of therapies that are known to help veterans with PTSD. Three of those therapies are cognitive processing therapy (CPT), prolonged exposure (PE) therapy, and eye movement desensitization reprocessing (EMDR). Along with therapy a few different types of medication have been known to help relieve, or at least decrease the severity, of some PTSD symptoms. The main two types of medication used are selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors (Department of Veterans Affairs, 2018a). Comment by Carvajal,Lorelei A: Well done with APA format
Evidence and past research have shown that many veterans remain symptomatic even after receiving therapy, medication, or a combination of both. It has become increasingly clear that there needs to something else added to their treatments to help relieve PTSD symptoms on a more permanent basis. Many veterans are now turning to service dogs to help them through their flashbacks, anxiety attacks, and hypervigilance (Krause-Parello et al., 2016). A service dog, in this case, is one that has been specially trained to assist with issues related to PTSD, such as those mentioned above. (Schoenfield-Tacher, Hellyer, Cheung, & Kogan, 2017). In the last few years, more research has been focused on both the benefits and challenges of veterans having a service dog. While the research is still sparse, most of the current research shows a service dog will help improve the quality of life for veterans suffering from PTSD (Krause-Parello, et al., 2016). This current study looks at how a service dog will improve the quality of life for veterans with PTSD, help veterans through flashbacks, anxiety attacks, and hypervigilance, and decrease suicidal behaviors and thought.
Problem Statement
Between 2006 and 2016 over 6,000 veterans committed suicide each year. This averages out to about 20-22 veteran suicides a day. Many of those suicides were due to mental health issues or physical issues (Department of Veterans Affairs, 2018c). How many of those suicides were directly linked to PTSD is currently unknown; however, veterans suffering from PTSD are at a higher risk for suicide (Krause-Parello et al., 2016). The Department of Veterans affairs (2018) reports that 11-20% of veterans who served in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) are diagnosed with posttraumatic stress disorder per year. About 15% of veterans from the Gulf War (Desert Storm) are diagnosed with PTSD per year and about 30% of veterans from the Vietnam War are diagnosed with PTSD at some point in their lifetime (Department of Veterans Affairs, 2018b). Veterans suffering from PTSD are looking towards nontraditional treatments such as service dogs to help relieve their symptoms.
Hypothesis and Research Questions
Based on what is known about veterans with PTSD and their quality of life (Saunders et al., 2017), and that service dogs have been shown to improve quality of life for those with disabilities, including mental (Yarborough B., Stumbo, Yarborough M., & Owen-Smith, 2018), the hypothesis has been developed with intentional consideration of these things. combined with veterans’ traditional treatment, a service dog will improve their quality of life at a quicker rate than traditional treatment alone. It is the hope of this study to answer the following questions as well as prove the hypothesis: Comment by Carvajal,Lorelei A: Your intro is very well done and- detailed and organized.
1. Does a service dog improve quality of life when combined with therapy? Secondly,
2. Do veterans’ families and friends benefit from the veteran owning a service dog?
3. Are veterans who do not want or qualify for a service dog still able to improve their quality of life at the same rate as those with a service dog?
Literature Articles Review
Posttraumatic stress disorder (PTSD) has become a serious mental health issue for veterans, usually stemming from a traumatic event (Schnurr et al., 2014). According to Hahn, Tirabassi, Simons, R. and Simons, J. (2015), military members go through many stressful events on active duty. This can range from constant moving to deployments away from family and friends. Deployment comes with its own set of stressors from combat exposure to sexual assault (Hahn, Tirabassi, Simons & Simons, 2015). According to Hahn et al. (2015), combat exposure and sexual assault are “significant predictors of posttraumatic stress disorder” (p.8). Symptoms of PTSD are many, differing from veteran to veteran depending on their personality and the traumatic event(s) witnessed. There are, however, some common symptoms such as re-living traumatic events, hypervigilance, anxiety, depression, suicidal thoughts and behaviors, and poor social functioning (O’Hare & Rodriguez, 2018; Lessard et al., 2017).
Currently most veterans are treated with medication, therapy, or a combination of the two. Common medications are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). These are forms of antidepressants believed to help treat symptoms of PTSD (Department of Veterans Affairs, 2018a). The most common therapies used for PSTD are Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), Eye Movement Desensitization and Reprocessing (EMDR), and Present Centered Therapy (PCT) (ADAA, 2018). Current research has begun to show that even when combined, the current treatments for PTSD do not always result in a decrease of symptoms and improvement in quality of life (Krause-Parello et al., 2016). Yarborough, B., Stumbo, Yarborough, M., and Owen-Smith (2018), suggest using service dogs for veterans with PTSD (Yarborough et al., 2018). There is very little research done into the benefits of veterans using service dogs to help combat their PTSD symptoms; however, the research that has been done shows great promise. The purpose of this literature review is to outline the current treatment methods posttraumatic stress disorder, to provide definitions of service dogs, to show evidence of benefits to using service dogs for PTSD assistance, and prove that future research is needed to determine the effect of service dogs on veterans diagnosed with PTSD.
Current Treatment Methods
According to the Department of Veterans Affairs (2018) “trauma-focused psychotherapies are the most highly recommended treatment for PTSD.” Trauma-focused psychotherapies are treatments where the patient focuses on the traumatic event and its meaning. (Department of Veterans Affairs, 2018a). Forms of Cognitive Behavior Therapy (CBT) work best for trauma-focused psychotherapies, such as Cognitive Processing therapy, Prolonged Exposure therapy, and Eye Movement Desensitization and Reprocessing. Present Centered Therapy is not a CBT form of therapy but has been shown to help with veterans with PTSD (ADAA, 2018a). SSRIs and SNRIs can be effective treatments as well; however, the work better in combination with therapy (Department of Veterans Affairs, 2018a).
SSRIs and SNRIs
SSRIs and SNRIs are known to be the first line defense medications for effective treatments of anxiety disorders and depressive disorders (ADAA, 2018b). They work by blocking the reuptake of serotonin which helps regulate mood, anxiety, appetite, and sleep (Alexander, 2012). However, both SSRIs and SNRIs have the possible side effect of insomnia (ADAA, 2018b). This is not a good option for veterans with PTSD as one of the symptoms is sleep issues such as nightmares or insomnia (Crowe & Nguyen, 2018).
Posttraumatic Stress Disorder Therapies
CBT is the most effective treatment for PTSD because it is a trauma-focused treatment. Veterans with PTSD are made to focus on the traumatic event and its meaning (Department of Veterans Affairs, 2018a). CBT is a proactive form of therapy where the patient engages in therapy both in and outside of sessions (ADAA, 2018a). Veteran hospitals focus mainly on CPT, PE, and EMDR sessions to help those diagnosed with PTSD (Department of Veterans Affairs, 2018a). CPT helps PTSD suffers learn how to correct wrong beliefs about their traumatic event and create a new understanding to help lessen the negative effects of PTSD. PE help patients gradually handle trauma-related triggers. They are facing what was once avoided slowly to learn triggers are not dangerous (APA, 2019). Schnurr et al. (2014) found that CPT and PE were the most effective forms of treatment among veterans (Schnurr et al., 2014). A study by Resick et al. (2015) on active duty military personnel showed that group Present-Centered therapy for PTSD was another form of effective treatment both in the short-term and long-term (Resick et al., 2015). It is possible that if this form of therapy works with active duty military, it could work just as well for veterans with PTSD.
Definition of Service Dogs
According to O’Hare and Rodriguez (2018), even though evidenced-based therapies and medication are effective, the dropout and nonresponsive rates are about 50%. This could be one reason why veterans are seeking non-traditional help, such as service dogs (O’Hare & Rodriguez, 2018). According to the Americans with Disabilities Act (ADA), service “dogs are individually trained to do work or perform tasks for people with disabilities, including a physical, sensory, psychiatric, intellectual or other mental disability” (ADA, 2010). Service dogs have gone through specialty training to be able to perform tasks or do work to assist individuals with disabilities. Psychiatric service dogs are specifically trained to help those with mental health disabilities such as PTSD (Parenti, Foreman, Meade, & Wirth, 2013).
Benefits of Service Dogs
Different research studies and literature reviews have shown the benefits of combining service dogs with other treatments for veterans with PTSD. O’Hare and Rodriguez (2018) encourage the use of psychiatric service dogs in combination with usual care of PTSD. Their research showed that veterans with a psychiatric service dog had a better quality of life, less PTSD symptoms, and better social interactions (O’Hare & Rodriguez, 2018). Service dogs have also improved workplace success for veterans with PTSD (Thorne, Devlin, & Dingess, 2017). Through the research done, there have been some main themes: supporting healthy behaviors, providing safety and peace of mind, influencing family and friend relationships, and according to Crowe and Nguyen (2018), “my service dog, my hero” (p.8).
Supporting Healthy Behaviors
For veterans with PTSD, service dogs can promote heathy behaviors such as sleep, medication and pain management, and physical/emotional health awareness. Service dogs can be trained to wake their handler from nightmares or night terrors (Yarbrough et al, 2018). According to Yarborough et al. (2018), veterans with service dogs have reported relief from nightmares and improved quality and quantity of sleep. OEF/OIF veterans also reported a decrease in sleep disturbances which resulted in less missed days of work (Thorne et al., 2017). According to a study done by Crowe and Nguyen (2018), veterans with service dogs reported that just the presence of their dogs allowed them to fall asleep quicker or stay asleep longer (Crowe & Nguyen, 2018).
Many veterans take different medications; it can be difficult for those with PTSD to remember to take the medications at the correct time. There has been evidence showing that service dogs can help remind veterans with PTSD to take their medication correctly (Crowe & Nguyen, 2018). Veterans have also reported that their service dogs alert them when it is time to take a break before the pain gets too bad to tolerate (Crowe & Nguyen, 2018). Lessard et al. (2018) conducted a study that showed some veterans with service dogs were even able to decrease the amount of medication they were taking (Lessard et al., 2018).
Service dogs are also able to alert their handlers of physical and emotional health issues. One veteran explained that his service dog would stay by his side during times of physical or emotional pain (Crowe & Nguyen, 2018). The everyday care a service dog needs helps veterans remain active, which can also help with improving both physical and emotional health issues. Dogs require exercise and companionship, in turn it forces veterans with PTSD get out of the house more and give companionship (Lessard et al., 2018).
Providing Safety and Peace of Mind
Veterans with PTSD are hypervigilant, anxious, and always looking for threats around them. Service dogs can give veterans a sense of safety and peace of mind. Service dogs can redirect veterans’ attention away from triggers or calm them in the presence of a trigger (Thorne et al., 2017). Service dogs will help keep veterans with PTSD grounded in the present by nudging them or somehow gaining their attention during a flashback or triggered episode. Some veterans have stated that just the mere physical touch of their service dog can bring them back to the present; relieving them of the terrors of their flashbacks (Yarborough et al., 2018).
My Service Dog; My Hero
Veterans across almost every research study has concluded that without their service dog they would not be around or able to function properly. According to veterans in a study done by Crowe and Nguyen (2018), they would not be able to conduct the interview if it were not for their service dog sitting with them keeping them calm (Crowe & Nguyen, 2018). A common reaction from veterans about their service dogs is that they brought the veterans back to life (Yarborough et al., 2018).
Challenges of Service Dogs Comment by Carvajal,Lorelei A: Your lit review is incredibly well done and identified some of the important themes related to your topic.
As with all things that have benefits there are challenges to having a service dog. The overarching challenge is veterans not overestimating the benefits of a service dog. Service dogs do not replace traditional therapy and medication; they enhance traditional treatments. Some veterans also do not realize that the benefits are not immediate, in fact, sometimes it takes someone close to that person to point out the benefits (Yarborough et al., 2018). Another challenge is there is no standard for training, breed of dogs used, or follow-ups after training. This can put a strain on the veterans trying to gain access to a service dog (Lessard et al., 2018). Finally, all research reviewed had on major challenge in common, there is not enough empirical research done on the effects of service dogs on Veterans with PTSD.
Methodology
Research has shown that posttraumatic stress disorder (PTSD) is one of the leading causes of poor quality of life among veterans (Saunders et al., 2017). In recent years, service dogs have gained popularity to bring about a better quality of life for veterans with PTSD. This is accomplished by reducing their hypervigilance, giving them better sleep quality, and keeping the veteran in the present (Yarborough et al., 2018). This study aims to shine more light on the topic and to help veterans receive service dogs to be able to improve their quality of life. The purpose of this methodology section is to display the methods and techniques used to prove quality of life improvement among veterans with PTSD.
Participants
PTSD is prevalent among people from all walks of life and all ages; however, this study will focus on veterans diagnosed with PSTD. Participants will be recruited from three different Veterans Affairs clinics: State College VA, Pennsylvania Clinic, Charlottesville VA Clinic, Georgia, and Perry VA Clinic, Virginia. They will also be recruited from waitlists of nonprofit organizations supplying veterans with service dogs. This study will use a sample size of 104 veterans, 52 from the VA clinics and 52 from various service dog waitlists. There will also be a matching number of males and females in each group. It is the hope of the researchers that by having 104 participates in the study they can increase its reliability and reduce error. (Myers & Hansen, 2012). The sample size will also better reflect the veteran population allowing the researchers to generalize the results to all veterans.
Materials and Instruments
In this research proposal, there will be several questionnaires, materials, and extra personnel used. The World Health Organization Disability Assessment Scale II (WHODAS II) will be used to assess the functioning of six different activities during the last 30 days (WHO-DAS II, 2001). To measure physical and mental components of each participate the Veterans Rand 12 Item Health Survey (VR-12) will be used (Selim et al., 2009). To assess the 20 DSM-V symptoms of PTSD the study will use a self-report measure known as the PTSD checklist (PCL-5). Participants will answer questions about how symptoms have bothered them in the last 30 days (Weathers, Litz, Herman. Huska, & Keane, 1993). The study also wants to track how the service dog is helping with veterans’ quality of sleep so the Pittsburg Sleep Quality Index (PSQI) will be utilized (Buysse, Reynolds, Monk, Berman, & Kupfer, 1998). The Patient Health Questionnaire (PHQ-9) will be used to assess the severity of depression and anxiety associated with PTSD (Kroenke, Spitzer, & William, 1989). The final questionnaire that will be utilized during this study is the Dimensions of Anger Reactions (DAR), to assess each participants anger directed at others level (Forbes, Hawthorne, Elliott, McHugh, Biddle, Creamer, & Novaco, 2004).
Along with the above-mentioned questionnaires and surveys, the participants will also be directed to keep a daily medication log to track if the use of medications increase or decrease throughout the study. The log will also be used to see what medications each patient is taking and at what doses. While the need to take the medication may not decrease, the dosage may decrease. Another log used will be a daily/weekly journal of each participants’ moods, outbursts, flashbacks, sleep quality, and daily struggles or successes. The study is looking to track how a veteran’s quality of life changes after receiving a service dog and a daily/weekly journal will help do that. Veterans will not be the only people participating in the study; it is unreasonable to think that the veterans’ families and friends will not be impacted during this study as well. The study will ask the veterans’ family and friends to keep a weekly/monthly journal of their observations of the changes in quality of life for the veteran as well. This will allow the researchers to gain knowledge and a different perspective to consider outside of just the veteran’s opinions.
Service dogs are the main instruments and tools for this study. They play a key role in this study as its main purpose is to find the benefits of service dogs for veterans with PTSD. The service dogs will be given to veterans on the top of waiting lists for nonprofit organizations who help pair veterans with service dogs. For the control group and the experimental group alike, their therapist will be interviewed as well, if the veterans sign a waiver allowing the researchers to interview their therapist. It is believed that the therapist will give more insight and data as to how veterans’ quality of life is changing with or without a service dog.
Procedure
The procedure for this study was based on a current study being conducted by Saunders et al. (2017). In conducting the procedure, all participants will go through a four-phase screening process. The first phase is done telephonically with an approved script to ask about their PTSD symptoms, are they currently being seen at a VA clinic, who lives in theie household, and other family pets in the house. The second phase is a medical review of those willing to participate. In between phase two and three volunteers will start to be filtered out by the inclusion/exclusion criteria. At this point the study will require a letter of recommendation from their therapist to continue in the study. Phase three will be an in-person screening at a local VA test site, at which point the volunteers will present both the recommendation and HIPPA release forms for the duration of the study. If all criteria are met at this point, an in-home interview will be conducted with the remaining participants to ensure a safe environment for the researchers and a dog. During the in-home interview, if they pass the interview, participants will fill out the following questionnaires: WHODAS II, PCL-5, PSQI, VR-12, PHQ-9, DAR, and medication log. All the above will be done on pen and paper by the participant (Saunders, 2017).
One big difference between the study being conducted by Saunders et al. and this one is the use of veterans without service dogs. To be able to gain a baseline for both veterans with service dogs and without, an observation period will be conducted while the experimental group waits for a dog to become available. During this time, hopefully no more than three months, the participants are to continue their regular treatment, therapy and or medication. They will also be filling out their daily/weekly journals and conducting telephonic interviews with the study team. Upon completion of the observation period, journals will be collected, and each participant will be given a new journal to complete their daily/weekly entries. For the first two months in-home interviews will be conducted on a weekly, then bi-weekly basis. At these in-home interviews, participants will again complete the above-mentioned questionnaires. After the first two months, the in-home interviews change to a monthly interview for two months. At all these interviews, the study team is checking on how the pairing of dog and veteran is fairing (only for the experimental group), reviewing the journal entries for changes in quality of life, mood, and physical health. After the first 4 months of the study interviews will be conducted telephonically every other month. During month 12, participants will attend an appointment at their local VA clinic, where they will complete the questionnaires again and turn in their journals and medication logs. At each interview point during the study, friends and family are requested to complete an interview as well. This is to get data from others as to the changes they are noticing that the veteran may not. Starting at month 5 the study team will also be conducting interviews with the participants’ therapist to gain another perspective.
For the follow up phase of this study, all participants will participate in another home visit, at which point an interview will be conducted with the family and friends as well. This will be done at 3, 6, and 9 months after the initial study was completed. There will be three more iterations of VA visits to complete the questionnaires. These iterations will be completed at 6, 12, and 18 months after the completion of the study. The follow up phase is being conducted to help understand and learn of the long-term effects a service dog can have on a veteran’s quality of life.
Design
Using a longitudinal, quasi-experimental design will help answer important research questions in this study. Three main questions arise which are, does a service dog improve quality of life when combined with therapy? Secondly, do veterans’ families and friends benefit from the veteran owning a service dog? Finally, are veterans who do not want or qualify for a service dog still able to improve their quality of life at the same rate as those with a service dog? This research proposal would use a basic longitudinal design which can examine quality of life differences between those with service dogs and those without. This type of experiment is also used when it is beneficial to observe changes over a longer time period (Myers & Hansen, 2012). This is the best design to answer the research questions because it allows researchers to examine the effects of service dogs at different points in time and measure the improvements or challenges felt and seen by veterans suffering from PTSD. After evaluating current research, it has been seen that not all veterans with PTSD want or qualify for a service dog. There has been no study done to compare the improvements in quality of life between veterans who want or have a service dog and those who do not. Using a quasi-experimental design will allow the research to compare the two groups without having to randomize the groups (Myers & Hansen, 2012). Veterans can spend up to two years on the waitlist for a service dog; it would be unethical to randomly assign veterans to the experimental or control group ignoring those who have been on the waitlists. A quasi-experimental design allows the researchers to choose veterans from the top of the waitlist for the experimental group. It also allows for participants who do not want or qualify for a service dog for the control group to be chosen from VA clinics.
Limitations
A quasi-experimental design is similar to an experimental design; however, it is missing one important thing that makes it a true experiment. For this study the one thing that is missing is random assignment to either the control group or experimental group (Myers & Hansen). It would be unethical to ignore those on the service dog waiting lists for the sake of random selection. This ethical consideration is the reason for the quasi-experiment; however, that may make it a little more difficult to correlate the results with the whole veteran population. Due to the length of this study a longitudinal design was used; however, the risk here is a high level of dropouts as veterans feel fatigue effects of the study. Fatigue effects are when participants get bored or worn out with the study (Myers & Hansen, 2006). It is possible that those who want a service dog are symptomatically different than those who do not seek one. There is a possibility that those who participate in this study and get a service dog, may have lesser or greater symptoms than those who only seek therapy and/or medication treatments (Stumbo & Yarborough, 2019). Because of this I have added an observation period to gain a baseline measurement of all participants. High participant expectations for the service dogs is the final limitation. Those seeking a service dog may have exaggerated their symptoms to get higher on the waiting list or onto the waiting list at all. Veterans may also believe that a service dog is the answer to all their symptoms; however, research has shown service dogs work best when combined with normal treatment. Veterans may experience worsen symptoms at the beginning, while getting used to having a service dog (Stumbo & Yarborough, 2019). This experience may cause participants with a service dog drop out of the study
Ethical Considerations
According to the Merriam-Webster dictionary, ethics is defined as “the discipline dealing with what is good and bad and with moral duty and obligation” (Merriam-Webster, 2019). It is also defined as “a set of moral principles: a theory or system of moral values” (Merriam-Webster, 2019). The American Psychological Association (APA) has come up with their own set of ethics that all psychologist must adhere to. They are written to cover a wide range of possible situations that could lead to unethical practices. The Code of Ethics were established to protect clients, participants of a research study, and students from inhumane treatment. This code requires researchers to gain informed consents, allows participants to drop out at any time during the experiment, and requires a debriefing at the end of the experiment (APA, 2017). The Code of Ethics also protects clients, participants, and students from harassment of any kind, discrimination, and undue harm. This document also states that there must be no conflict of interest or relationships outside of a professional manner. If there is a conflict of interest the psychologist must report it right away and remove him or herself from the situation (APA, 2017). The proposed research study, benefits of service dogs for veterans with PTSD, is not without some ethical considerations.
Researcher Bias and Veterans Wait Listed
First thing would be my personal connection with veterans as I am a veteran myself. For this ethical dilemma I would have to propose the study, but ensure the selection process, conduction of the study, and the analytics were done with those who have no connection to veterans. Also, there is the ethical question of who gets to participate in the study. It would be unethical to recruit veterans who are not on the waiting lists for a service dog to participate in the experimental group. Recruitment of veterans would have to come from multiple locations such as different service dog waiting lists and from VA clinics. Those on the waiting list would get the service dog and those from the VA clinics would not.
Humane Treatment of Dogs
According to the American Psychological Association (APA) code of ethics (2019), any animal used in a research study is to be treated as humanely as possible. Those involved in the study must also take into consideration the animals’ comfort and health while conducting their study. All housing and caring of the animals used in research need to be within federal, state, and local laws as well (APA, 2017). For the purposes of this study an allowance and animal insurance will be given to the participants given a service dog. They will also be required to take them to at least two veterinarian visits to ensure the health of their dog.
Do no Harm
The APA code of ethics also ensures the humane treatment of all human participants. The code of ethics explains that human participants should not be put in harm’s way, this means physically and mentally. Researchers are not to put human participants at risk just for the objective of proving their hypothesis (APA, 2017). For that reason, all participants will be instructed to continue their regular therapy and medications for as long as doctors require. Finally, with adding an animal to a household, there are acquired expenses. We do not want to put the participants in a financial bind by participating in this study. Each participant will receive compensation for their travels and time away from work, if they work, for participating in the study on top of the animal allowance.
IRB Process
To ensure that human rights and dignity are being protected during research studies, there was an Institutional Review Board (IRB) created. All research proposals must be approved by an IRB before the research begins. Every institution that will receive federal funding for research must have an IRB. The IRB will categorize each proposal that comes to them for the purpose of review. Research that poses more than a minimal threat to human participants’ safety will get a full review. This process is to ensure the researchers are following the Code of Ethics set forth by the APA. It is also to ensure that other laws and regulations are being followed (Lewandowski, G. Ciarocco, N., & Strohmetz, D. B., 2015). This research proposal will have to go through a full review due to the possibility of worsening symptoms for a short period of time when veterans receive their service dog.
Conclusion Comment by Carvajal,Lorelei A: Your proposal is exceptional. It is clear that you took time to review, revise, and continue to improve upon your topic- your research questions align with your methodology. The entire proposal is seamless.
Through research and development, the proposed study would provide documented information that directly correlate with service connected PTSD patients and the service dogs who improve their way of life versus those without service dogs. Past research has shown different limitations to be taken into consideration. One of the most important aspects that must be considered in each section of methodology is the physical, mental, and emotional health of the participants. By remembering and taking into consideration that each participant suffers from PTSD, it is easier to stay within the ethical standards put forth by the American Psychological Association. It is required that during the experiment, all participants are protected from harm, this includes mental and emotional harm (APA, 2017). Updates and changes have been added to the methodology section in consideration of such things. Comment by Carvajal,Lorelei A: indent
References Comment by Lorelei Carvajal: Very well done on this assignment! You really took the time to review the literature and identify important themes. I would just revise the beginning paragraph and you will be good on this section.
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