∗University of Denver Graduate School of Social Work
†California State Polytechnic University
Heaven goes by favor; if it went by merit, you would stay out and your dog would go in.
Emerging human/animal interaction therapies and applications call for re-definition in the field of assistance animals and a re-examination of previous conceptualization of use, terminology, training guidelines and formal designations. Specifically, this chapter explores the participation of specialized assistance, service and support animals in their application to social, emotional and psychiatric issues. Of major concern to the authors of this chapter are the new demands on service animals, especially as applied to patients with serious mental health concerns. The benefits for the people who are psychiatric service animal recipients are more obvious. They include:
Increased social interaction
Reduced feelings of avoidance and stigmatization
More empowering conversations focused on their abilities and their dog’s abilities rather than disabilities
Feelings of improvement in general health
Emotional and psychological support from their dog resulting from sharing their emotions, concerns, and engaging in contact with the dog when upset or sad (Lane et al., 1998).
Box 20.1 Case study
A 74-year-old widower contacted the Psychiatric Service Dog Society (PSDS) explaining that his panic disorder with agoraphobia had rendered him reclusive to his home for most of the last 15 years. He said that he used to have friends, but they eventually stopped calling, because of his refusal to leave his home for friendly outings. He was too afraid to go out because he did not want to risk having a panic attack in public. So he turned down the friendly invitations, which eventually tapered off. He stayed home with his four-year-old German shepherd dog named “Maggie.”
He explained that many years ago he used to be a puppy raiser for a guide dog training school. He had trained his German shepherd dog to a high standard of obedience both on- and off-leash. After some discussion, he decided that he would like to train his dog to be a psychiatric service dog.
Several months after completing his training, he called very excited to share some news. He said, “I decided to take Maggie with me to a restaurant for a cup of coffee. The people at the restaurant were so pleasant and they welcomed Maggie, that I decided to order a sandwich with my coffee!” He went on to explain that he hadn’t been in a restaurant for 15 years! “Training Maggie to be my psychiatric service dog has allowed me to do the things that I used to do before I became so disabled by panic disorder. I can’t thank you enough for giving me back my life through Maggie.”
20.2 Labels, definitions and controversy
Throughout this chapter definitions will clarify new terminology in the emerging field of psychiatric assistance animals. Attempts will be made to provide distinction for the applications between service, emotional support and therapy animals. There are three types of assistance applications as identified by organizations such as Assistance Dog International. They include: (1) guide dogs for the blind and individuals with seeing impairments, (2) hearing dogs for the deaf and individuals with hearing impairments and (3) service dogs specially trained for persons with other recognized disabilities (www.assistancedogsinternational.org/aboutAssistanceDogs.php)
Assistance Dog International (ADI) defines Service Dogs as follows: “Service Dogs assist people with disabilities other than vision or hearing impairment. With special training these dogs can help mitigate many different types of disabilities. They can be trained to work with people who use power or manual wheelchairs, have balance issues, have various types of autism, need seizure alert or response, need to be alerted to other medical issues like low blood sugar, or have psychiatric disabilities. These specially trained dogs can help by retrieving objects that are out of their person’s reach, by pulling wheelchairs, opening and closing doors, turning light switches off and on, barking to indicate that help is needed, finding another person and leading the person to the handler, assisting ambulatory persons to walk by providing balance and counterbalance, providing deep pressure, and many other individual tasks as needed by a person with a disability” (ADI, 2009).
Confusion continues to exist on formal definitions for service animals and there are frequent reports of misuse of classifications and labeling by those who wish to achieve public access with an animal who is strictly assigned as a companion animal or pet. The Americans with Disabilities Act (ADA) (P.L. 101–336) is the most far reaching and comprehensive civil rights legislation adopted to address the discrimination against persons with disabilities. Public and private entities as well as federal, state and local entities offering public accommodations, services and transportations are required to comply with the law. Because there is no single universally defined certification or proof required for public access with a service animal, inaccurate use of the label adds to the confusion and increased likelihood of conflicts. In an attempt to establish best practices, ADI provides a “model law” (www.assistancedogsinternational.org/modellaw.php) to assist in the definition of accepted standards that are consistent with ADA guidelines (1990). The ADA indicates a service animal must be individually trained to “do work” or “perform tasks” of benefit to a disabled individual in order to be legally established from companion animal to service animal status. The ADA defines a “disability” as a “mental or physical condition, which substantially limits a major life activity.”
20.3 The history of assistance animals
The earliest use of modern assistance animals emerged from the use of canines as messengers during World War I and their capacity to work effectively under difficult combat circumstances. These dogs’ heroic efforts quickly established their effectiveness and capacity to find wounded soldiers, as an article from The Literary Digest written in 1917 stated:
These army, or Red-Cross, or sanitary dogs, as the Germans call them, are first trained to distinguish between the uniform of their country and that of enemies. Then the dog must learn the importance of a wounded man as being his principal business in life. News of the wounded must also be brought to his master. He must not bark, because the enemy always shoots. There are various ways in which the dog tells his master of his discovery. One method is, if no wounded have been discovered, to trot back and lie down, whereas if he has found a wounded man he urges the master to follow.
These skills soon resulted in the further use of dogs to assist veterans in a number of ways, most notably those whom had lost their eyesight.
On November 5, 1927, Dorothy Harrison Eustis introduced America to the concept of using dogs as guides for the blind in a historic article in The Saturday Evening Post. By 1929, she had founded The Seeing Eye, which became the first group in the USA to breed, raise, and train guide dogs.
Over the decades, the consistency and trustworthiness of assistance animals resulted in their use for many additional human support purposes. By the middle of the twentieth century, service dogs were accepted as an important and effective alternative to support citizens with disabilities. Over the past century, the roles of service animals have been expanded to extensive support for an ever-widening list of disabilities. Canine Companions for Independence (CCI), founded in 1975 in Santa Rosa, California, pioneered the concept of the specialized service dog, a highly trained canine used to assist people who have disabilities through performing specific tasks to support already existing human services. Service dogs may be trained for people with many different types of disabilities and can perform many tasks that a person with a disability may not be able to accomplish independently. Some of the tasks might include picking up dropped articles, pulling wheelchairs, assisting walkers, turning lights on and off, opening and closing doors, carrying school books, alerting their owners and pulling their owners out of bed. CCI uses specially trained golden retrievers, Labrador retrievers, and crosses of these two breeds. As of 2009, CCI had established over 3,000 graduate teams (CCI History, 2008).
In 1977, Roy Kabat, who began as a trainer for animal actors in movies and television, founded Dogs for the Deaf, an organization which believed that dogs from shelters and humane society dogs could be trained to help the deaf. They now train over 100 dogs a year, including service dogs for persons with autism. As was discussed in an earlier chapter by Grandin et al., they frequently provide dogs that are trained to work with children with autism by acting as an anchor to prevent the child from bolting into dangerous situations. These dogs often have a calming effect on the child and possibly improve the child’s ability to communicate and establish relational attachment.
20.4 Therapeutic benefits of contact with animals: the possible psycho-social benefits of service animals
Studies show that simply interacting with animals, and interacting with dogs in particular, has a strongly ameliorative effect on people with a range of psychiatric disorders, increasing evidence that despite differing designations, all assistance dogs convey psychosocial benefits. Animal-assisted therapy (AAT) reduces anxiety (Barker and Dawson, 1998), improves social contact (Villatra-Gil et al., 2009), can decrease use of psychotropic medication (Geisler, 2004), and improve overall quality of life for the patient. In these studies, the extent of the therapeutic relationship has been limited to an interaction between the patient and the animal such as clients voluntarily stroking (Geisler, 2004; Kovacs et al., 2004) or talking to the animal or talking about the animal to a handler (Barker and Dawson, 1998; Geisler, 2004). When the animal is asked to perform a task, it is often a basic obedience command such as “sit” or “down” or a “trick” such as “shake hands” (Barker and Dawson, 1998). Namely this requires dogs to be housebroken, have mastered basic and frequently advanced obedience training, and not to have undesirable behaviors such as nuisance barking, aggressive behavior, or inappropriate sniffing, licking, or other forms of intrusion into a client’s personal space (Froling, 2003). Since animals do have such strong, positive effects on people with psychiatric and psychological disorders, and the standard of conduct for animals working in a therapeutic capacity by necessity must be strict, there is a legitimate need for new, expanded definitions and guidelines for what defines and differentiates a service animal and what comprises “work” or a service “task,” especially as it relates to psychiatric disabilities.
20.5 Psychiatric service animals
The most common applications in mental health situations for service animals are the major DSM-IVTR Axis I disorders that include: mood and anxiety disorders, including post-traumatic stress disorder, panic reactions, agoraphobia, and acute trauma reactivity. Psychiatric service animals are also widely used to mitigate the negative impact of mood disorders, most specifically severe depression. That said, there is widely recognized endorsement for the use of these specially trained service dogs to support persons with psychiatric disabilities. However, there appears to be in the professional circles a disagreement about the appropriateness of the term “psychiatric service dog.” It seems that persons living with chronic mental health disabilities generally favor the term “psychiatric service dog” but persons who do not live with such disabilities appear to be uncomfortable with the term proffering that it unfairly labels or identifies the owner as a person with a psychiatric disability. This might be easily addressed by simply vesting the animal with a designation as a service animal without need for diagnostic labeling or further definition.
As greater specificity has been required to support public access and the application to psychiatric conditions, practitioners have established legitimacy by defining the “work” or “tasks” of psychiatric service dogs for identified psychiatric conditions as a function of the handler’s diagnoses. A service dog, even when solely interacting with patients or helping an individual to cope with the effects of a debilitating psychiatric disorder, is performing an identifiable set of tasks providing assistance, despite the fact that these tasks may appear different from those forms of assistance traditionally associated with a service dog assisting for persons with physical disabilities.
Joan Froling focuses on the performance of “tasks” and outlines four areas where service dogs might be trained in specific tasks for individuals with psychiatric conditions:
Assistance in a medical crisis
Assistance coping with emotional overload
Security enhancement tasks.
Examples offered for each of these areas include: A dog might be trained to retrieve a bag holding medication upon command, or even backpacking medication or medical supplies on an ongoing basis. In order to provide support, a dog may be trained to bring a telephone or even dial 911 or a suicide hotline on a specialized k-9 rescue phone. In order to support a person with treatment, a dog can be trained to alert someone to take medication at a certain time of day or alert someone to provide assistance or be alerted to signals, sounds or doorbells. For those persons with extreme startle reflexes, being alerted to the presence of someone approaching can be helpful in managing these anxiety reactions. Froling also describes tasks that could assist consumers with emotional overload. For example, a dog that is trained to provide significant tactile contact in order to assist in “reality affirmation” can greatly improve a sense of control and grounding. This has been reported as highly effective in managing fear reactions, loss of orientation, nightmares and terrors. In some situations an animal’s trained insistent interaction with their owner can be used as a legitimized reason for an individual to leave stressful or threatening situations. Security and safety remain one of the more challenging psychiatric issues for service providers, as for example, in the case of combat veterans struggling with the disabling experience of hypervigilance. Froling suggests that a service dog can be trained to assist in identification of safe situations, turning on lights, checking the environment and leading the patient to a safe place or choosing an exit strategy. Patrons utilizing psychiatric service dogs also widely report feeling improved confidence in dealing with public outings (Joan Froling, Service Dog Tasks for Psychiatric Disabilities, July 30, 2009 www.iaadp.org/psd_tasks.html).
Esnayra (2009) emphasizes the importance of “work” relative to psychiatric service dogs; whereas persons with physical disabilities are supported by service animals in a physical manner, those that have mental health disabilities are supported either mentally or cognitively. It is evident that the work of psychiatric service dogs will look somewhat different to the work of service dogs for persons with physical disabilities. Unfortunately, many of the tasks performed for people with psychiatric disabilities fall under the heading of “coping skills” and, as such, are not permissible as a service that mitigates a disability (Froling, 2003). In many ways, the lack of understanding related to the experience of coping with a chronic mental heath condition, sometimes referred to as the “invisible disability,” is found in these restrictive criteria of the ADA guidelines as they relate to service animals.
Esnayra defines the “work” of psychiatric service dogs as “…assistance that engages the handler’s cognitive behavioral skills (i.e. dog alerts to the onset of hypomania when handler has Bipolar Disorder); or, assistance that leverages the dog’s natural response to its immediate environment for the purpose of reality-testing (i.e. hallucination discernment when handler has Schizophrenia); or assistance that prompts the handler to engage mind/body regulatory approaches (i.e. controlled deep breathing exercises with the dog when handler has Panic Disorder).” Many persons in the service dog world who are unfamiliar with subtleties of mental health and psychiatric applications frequently refer to these diverse forms of work as “emotional support.” This is an unfortunate erroneous attribution that oversimplifies the complex, non-verbal, therapeutic interactions between handler and dog that serve to stabilize and restore a mentally ill handler’s ability to function.
The United States Department of Justice, which oversees the enforcement of the Americans with Disabilities Act, states in a Notice of Proposed Rulemaking published in the Federal Register in June 2008, had been petitioned and encouraged to define that “performing tasks” should form the basis of the service animal definition, that “do work” should be eliminated from the definition, and that “physical” should be added to describe tasks. Tasks by their nature are physical, so the Department does not believe that such a change is warranted. In contrast, the phrase “do work” is slightly broader than “perform tasks,” and adds meaning to the definition. For example, a psychiatric service dog can help some individuals with dissociative identity disorder to remain grounded in time or place. As one service dog user stated, in some cases “critical forms of assistance can’t be construed as physical tasks,” noting that the manifestations of “brain-based disabilities,” such as psychiatric disorders and autism, are as varied as their physical counterparts. One commenter stated that the current definition works for everyone (i.e. those with physical and mental disabilities) and urged the Department to keep it. The Department has evaluated this issue and believes that the crux of the current definition (individual training to do work or perform tasks) is inclusive of the varied services provided by working animals on behalf of individuals with all types of disabilities and proposes that “this portion of the [service animal] definition remain the same” (www.ada.gov/NPRM2008/titleiii.htm. Accessed Feb. 9, 2010)
The Psychiatric Service Dog Society (PSDS) has collected over 12 years of documentation from a wide range of mental health consumers who were reclusive to their homes, sometimes for years, due to panic disorder with agoraphobia but who are now able to leave their homes accompanied by their PSD. There are numerous examples from veterans who report how important their PSD is to them. An example from one specific war veteran with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD), explained that he was not able to sleep at night because when he heard a noise, he believed it was an insurgent or an IED. With the support of his PSD, he was finally able to sleep at night, because he learned to trust that his dog would alert him to the presence of other people outside his apartment. Some veterans utilize their PSD in order to manage hypervigilance, a hallmark symptom of PTSD. They have learned how to read their dog’s body language in order to ascertain whether or not there is a threat in their immediate environment.
Sexual assault-induced PTSD is another area in which dogs seem to be the primary tool in a study focused on adult women. The clinician utilized both working dogs and pets in the intervention focusing on a number of different activities. Exposure was a major component of two key ways in which the therapists utilized dogs masterfully (Lefkowitz et al., 2005, pp. 287–289). The first was an exercise in which the client talked through a rape and re-imagined the incident vividly. A therapy dog was utilized as a buffer, listener, and focal point during this exercise. The second was a homework assignment designed to have the client revisit the site of the rape or other triggering environment with a dog with which they felt comfortable (Lefkowitz et al., 2005, pp. 287–289). The ability of the client to select his or her own animal in the second exercise seems highly logical to support a feeling of empowerment.
The detailed treatment plan developed by Lefkowitz et al. seems to be very aware of animal selection in their formulation. The authors state evidence that people are often anxious around new dogs and acknowledge the fact that clients might be more comfortable with a dog they have known longer or feel protected by in this intense exercise. It appears obvious that the authors made a conscious effort to incorporate empirically supported practices in working with the human/animal dynamic. Offering the client a choice in the second assignment shows a conscious effort to be flexible in a situation where the client might need to be more self-directed in order to achieve an outcome that truly impacts their progress favorably. The subtle changes found in a sense of empowerment, self-confidence and social support, although subtle, are often significant factors in positive outcomes in management of that mental heath issue.