April – June 2012 

Perspectives 1 

MG David A. Rubenstein; COL Mustapha Debboun; Richard Burton 

The Early Years 5 

COL (Ret) Elspeth C. Ritchie; COL Robinette J. Amaker 

Policy Initiatives for the Use of Canines in Army Medicine 8 

LCDR Kathleen L. Watkins, USPHS 

Definitions of Animals Used in Healthcare Settings 12

LTC James T. Mills; MAJ Arthur F. Yeager 

Historical Perspectives of the Human-Animal Bond Within the Department of Defense 18

COL Perry R. Chumley

Dogs and Human Health/Mental Health: From the Pleasure of Their Company 21

To the Benefits of Their Assistance 

Jan Shubert, LCSW 

Research on Benefits of Canine-Assisted Therapy for Adults in Nonmilitary Settings 30

Janet S. Knisely, PhD; Sandra B. Barker, PhD; Randolph T. Barker, PhD 

The Effects of Animal-Assisted Therapy on Wounded Warriors in an 38

Occupational Therapy Life Skills Program 

CPT Christine E. Beck; MAJ Florie Gonzales, Jr; Carol Haertlein Sells; et al 

Training the Combat and Operational Stress Control Dog: 46

An Innovative Modality for Behavioral Health 

William Krol 

Occupational Therapists as Dog Handlers: The Collective Experience with 51

Animal-Assisted Therapy in Iraq

MAJ Lorie Fike; CPT Cecilia Najera; CPT David Dougherty 

Crossing the Berm: An Occupational Therapist’s Perspective on 55

Animal-Assisted Therapy in a Deployed Environment

CPT Brian T. Gregg 

Rehabilitative Canine Interactions at the Walter Reed National Military Medical Center 57

MAJ Arthur F. Yeager; CPT Jennifer Irwin 

Canines for Combat Veterans: The National Education for Assistance Dog Services 61

Kathy Foreman; Cynthia Crosson, MD 

Service Dog Training Program for Treatment of 63

Posttraumatic Stress in Service Members

Rick A. Yount, MS; Meg D. Olmert; Mary R. Lee, MD 

Reclaiming Identity Through Service to Dogs in Need 70

Ellen V. Alers, MA; Kevin M. Simpson 

Therapy Dogs and Stress Management Assistance During Disasters 74

Jan Shubert, LCSW 

canine-Assisted Therapy in Military Medicine 
LTG Patricia D. Horoho 

The Surgeon General 

Commander, US Army Medical Command 

MG David A. Rubenstein 

Commanding General 

US Army Medical Department Center & School 

April – June 2012 The Army Medical Department Center & School PB 8-12-4/5/6 

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Photo courtesy of COL (Ret) Elspeth Ritchie, MC, USA 
April – June 2012 1

Perspectives

COMMANDER’S INTRODUCTION

MG David A. Rubenstein

Humans have domesticated animals for assistance and 

companionship since before the beginning of recorded 

history. Beasts of burden permitted the development of 

civilization by breaking land for agriculture with plows, 

and carrying crops, products, and people in larger quantities and over longer distances than human backs and 

feet could ever achieve. The longest recognized domesticated animal, the canine, provided humans with assistance in hunting and security, as well as companionship, 

throughout history, and continues to serve in those and 

other capacities today.

Everyone is, of course, familiar with the “police dog,” a 

fi xture of law enforcement agencies for most of the last 

century. Police have also used dogs for tracking offenders and fi nding victims and lost individuals for many 

decades. Less well-known, but with a legacy of use that 

precedes that of law enforcement, is the military working dog, perhaps fi rst widely known to the public as the 

K-9 Corps starting in World War II. The modern military working dog is used in many capacities, and is now 

recognized as a very important component of military 

capability for the operational environment that challenges us today.

Historically speaking, only relatively recently have the 

benefi ts that canines offer to human health and well-being been recognized, formally examined, and applied. 

Service dogs assisting the blind have been common for 

several decades, and the use of dogs to assist those with 

other physical handicaps, for example, the deaf and those 

with ambulatory limitations, has expanded rapidly as organizations training and supplying such dogs have multiplied. The military healthcare system, as well as that 

of the Veterans Administration, have also used canines 

for such purposes as Wounded Warriors are reintegrated 

into the civilian world. However, the formal use of dogs 

by military medicine as part of therapy during recovery 

from both physical and psychological injuries is an even 

more recent application.

This issue of the AMEDD Journal focuses on that expanding role of dogs in the military healthcare system. 

COL Bobbi Amaker and COL (Ret) Cam Ritchie have 

assembled a collection of articles that explore the recognition and acceptance of the value of therapy dogs 

by both military and civilian healthcare professionals. 

The articles examine the various capacities in which 

dogs work among patients in medical facilities. There 

are also detailed discussions of the fairly recent initiative of deploying specially trained dogs overseas with 

combat and operational stress control teams to assist in 

their vitally important work in the mitigation of stress 

and anxiety among deployed personnel. Interestingly, as 

described in one article, this role of canine therapy has 

been applied repeatedly to disasters and tragic events in 

the United States, beginning with September 11, 2001, 

to address the confusion, stress, and anxiety of both victims and rescue/recovery workers in dealing with the 

feelings of futility, frustration, and loss.

Many readers who have pets or other involvement with 

animals in their lives will probably not be particularly 

surprised at the descriptions of human reactions to the 

presence of the dogs depicted in these articles. However, 

all readers should fi nd the extent of the situations and 

conditions to which dogs are successfully lending assistance to be intriguing, and perhaps a bit surprising. 

Although attempts to systematically quantify and scientifi cally evaluate the results of animal-assisted therapy 

have been and will continue to be made, for now the anecdotal evidence of its overwhelmingly positive impact 

is not only encouraging, but also substantial enough to 

support its continuation.

A FAREWELL NOTE

As I end my tour commanding the Army Medical 

Department Center and School, it is an honor to highlight 

my more than 2,700 teammates who live our mission 

every day: to envision, design, and train a premier 

military medical force for decisive action in support of 

our Nation. Best wishes to each of them, and to you, for 

every future success in ensuring the health of present 

and past warriors and their families.

On The Cover

Therapy dog Zeke during deployment with the 212th Medical Detachment COSC Team in Iraq (see page 49).
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

EDITORS’ PERSPECTIVE

COL (Ret) Elspeth Ritchie and COL Robinette Amaker 

set the stage for this issue of the AMEDD Journal with 

their overview of the beginnings of canine-assisted therapy within Army medicine. They chronicle the “who, 

where, and when” that marked the evolving understanding and acceptance of this nontraditional augmentation 

to existing therapies for both physical and psychological 

injuries.

As the use of service and therapy dogs gained momentum among civilian-sector medical practices and facilities, it began to gain the attention of a number of military 

healthcare practitioners, and consequently appeared in 

military medical facilities as some practitioners took the 

initiative to examine its value fi rsthand. Their observations were communicated to others, and interest in the 

use of service and therapy animals became more widespread at military locations. However, as with any “freelance” activity emerging at various points throughout a 

formal system, eventually the disparate approaches to 

the use of animals in military medical facilities reached 

a point from which they could not continue disorganized 

and unregulated. LCDR Kathleen Watkins describes 

how the Army took the initiative to establish policies 

and standards across Army medicine, and became the 

lead agency to formalize service and therapy animal 

use throughout all military medical activities, including 

deployed locations. Of note is the fact that the fi rst formal step in this effort occurred relatively recently, when 

representatives from nongovernment animal-assisted 

practices organizations met with representatives from 

all military services in December 2009. This summit 

was the fi rst step to establish the framework for development of policies and guidelines to govern use of animals 

in medical facilities throughout the Department of Defense. The rapidity with which the standards and guidelines have emerged, and the enthusiasm with which the 

initiatives have been received can only refl ect the recognition of the value of animal-assisted practices, from 

both therapeutic and cost-effect perspectives.

Regulating policies and protocols which standardize any 

practice or activity must be specifi c and unambiguous, 

which means, fi rst and foremost, that clear defi nitions 

must exist for all terminology and concepts. Obviously 

this applies to the use of animals in medical interventions in military facilities. LTC James Mills and MAJ 

Arthur Yeager present a well-written, thoroughly researched explanation of the categories and terminology 

that are now used to describe animal-assisted activities 

in medical settings, both civilian and military. Interestingly, a federal law, the Americans with Disabilities Act, 

led the way with incorporation of defi nitions of service 

animals. Some state statutes address therapy and activity animals, but such defi nitions are not consistent and 

applicable nationwide. Following the overview of the 

regulatory environment, the article clearly outlines the 

new Army-wide policy, just published in January 2012. 

This article should be read as a foundation for understanding the various categories and conditions that are 

involved in the use of service and therapy animals.

COL Perry Chumley’s article reveals that there have 

been occasions of US military use of animal-assisted 

therapy since World War I, but those were limited to 

specifi c locations and situations. However, the Army 

Veterinary Corps watched the civilian sector’s efforts, 

beginning in the 1960s, to investigate individual experiences related to animals involved in assisting human 

health conditions. Later, Army veterinarians became 

the DoD’s lead elements in exploring the human-animal 

bond to determine what benefi cial aspects may be useful within the Army medical system. Their interest and 

efforts provided a foundation within the Army on which 

the current service and therapy animal efforts, described 

in later articles, are based.

Jan Shubert has provided a clearly presented, extensively researched article that carefully examines the 

various aspects of animal-assistance developments, organizations, applications, and legislation in the United 

States. She presents a wealth of interesting and valuable 

information, and the extent of the research and writings 

represented by the numerous reference citations is indeed impressive. This article is an excellent overview of 

the current situation across US society as a whole with 

regard to attitudes, research, progress, and problem areas in efforts to use animal-assistance for the benefi t of 

impaired human beings.

Dr Janet Knisely, Dr Sandra Barker, and Dr Randolph 

Barker conducted an extensive, detailed literature review 

to examine the current research fi ndings and opinions as 

to the benefi ts of canine-assisted therapy in the civilian 

medical environment. Their investigation looked specifically at literature examining hospitalized adult patients 

with medical problems and psychiatric disorders, and 

residents of nursing homes and long-term care facilities. 

Their fi ndings are summarized across several categories 

of patient care, treatment regimens, clinical situations, 

and quality of life conditions. The article provides a 

fascinating and informative look at some of the considerable efforts attempting to quantify and measure the 

benefi ts of using animal-assistance in human medical 

therapies. Of interest is the authors’ conclusions that the 

results/outcomes of such animal use in military medical 

PERSPECTIVES
THE ARMY MEDICAL DEPARTMENT JOURNAL

April – June 2012 3

facilities has not been scientifi cally evaluated, a theme 

that appears in several of the articles in this issue.

Recognizing the dearth of such research with injured or 

ill subject members, CPT Christine Beck and her colleagues designed and conducted a study to investigate 

the effects of animal-assistance in an occupational therapy life skills program of the Warrior Transition Brigade 

at the (then) Brooke Army Medical Center. Their excellent and interesting article refl ects a careful, analytic approach to examine factors that are exceedingly diffi cult 

to quantify, and therefore reliably measure. The results 

indicate similarities with such research performed in the 

private sector. Although, as documented in the article, 

the research project had some limitations, the signifi -

cance of the study is refl ected in the statement, “...it is 

important to note that it is the fi rst research on the use 

of [animal-assisted therapy] in a garrison environment 

with wounded service members.” Their study is now the 

foundation upon which future research can build, hopefully sooner rather than later.

As illustrated by William Krol’s article, good ideas are 

very often the result of good observation and sound logic. 

Therapists noticed that a dog trained to assist in physical 

therapy for Wounded Warriors also became a source of 

emotional support for those with whom he had contact. 

Their response to the dog was the initiative for therapists and behavioral health caregivers to seek specially 

trained dogs for use in theater to assist the combat and 

operational stress control (COSC) teams in their efforts 

among deployed personnel. Mr Krol describes the chronology and events that followed, resulting in the deployment of support dogs to both Iraq and Afghanistan. His 

excellent article is an encouraging look at the dedication 

and cooperative spirit of the people and organizations, 

both civilian and government, who quickly came together to develop a program dedicated to the assistance and 

support of our deployed Warriors. Further, those dogs 

return and continue their work to benefi t Warriors requiring therapy, whether physical or behavioral, in military medical facilities or transition units.

The deployment of therapy dogs with COSC teams is described in two articles written from the perspective of 

those who employed them in theater, occupational therapists who had been trained as their handlers. In the fi rst 

article, MAJ Lorie Fike and her coauthors describe the 

learning curve; the considerations, concerns, diffi culties, 

and requirements (some anticipated, others not) that were 

encountered during the fi rst deployment of therapy dogs 

directly into the combat theater. The handlers, teams, and 

other units made it work, especially as the presence of the 

dogs became increasingly recognized and appreciated by 

deployed personnel. As with any fi rst evolution, lessonslearned are extremely important, and this article is a 

superb documentation of such lessons that will be invaluable to those who deploy with COSC dogs in the future.

CPT Brian Gregg’s article is a fi rst person account of his 

personal experiences as a therapy dog handler in Iraq. 

His focus is the reactions and emotional responses that 

his dog elicited among those with whom he interacted. 

CPT Gregg also describes the advantages the dog provided by dramatically reducing the stigma of attending 

stress and anxiety preventive education classes in small 

group settings directly in the area of operations. This 

engaging article is a brief snapshot into the deeply personal affect that a therapy animal can have among those 

in highly stressful environments, with an attendant improvement in their quality of life.

As interest in and acceptance of the use of animals in 

therapy assistance roles has grown, agencies and facilities have initiated various programs and activities involving animals to examine if value can be derived for 

their traditional practices, and, more importantly, their 

patients. As a result, a number of nonprofi t organizations 

have been established for the sole purpose of providing 

animals, primarily dogs, to medical facilities, agencies, 

and individuals for use in various programs and extended therapy applications. MAJ Arthur Yeager and CPT 

Jennifer Irwin have contributed an article describing the 

human-animal bond programs implemented initially at 

the Walter Reed Army Medical Center, and then carried 

over into the consolidated Walter Reed National Military Medical Center. The article details a number of organizations that provide dogs and work with the Center 

in various ways, either by supplying service and therapy 

dogs fully trained for specialty purposes, or getting the 

recovering Warriors involved with training the dogs 

themselves. That training can be for medical therapy and 

assistance purposes, or simply as companion animals. 

No matter the program’s structure or purpose, the benefi t 

to the injured or ill service member is tangible, whether 

in enhancing the effectiveness of their therapy, or simply 

increasing their confi dence and self-worth. The extent of 

the programs at this one military hospital will surprise 

and encourage you, as all indications are that Wounded 

Warriors undoubtedly benefi t from these efforts.

The next articles describe in detail three of the nonprofi t 

organizations that work with military medical activities, 

including Walter Reed, as discussed by MAJ Yeager and 

CPT Irwin in their article. First, Kathy Foreman and Dr 

Cynthia Crosson discuss the National Education for Assistance Dog Services, which provides fully trained service dogs to assist Warriors with physical disabilities, 
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

both during their therapy and rehabilitation, and then 

as they return to civilian life. These dogs are providing 

both emotional and physical support, and as such restore 

the Veteran’s dignity and self confi dence to move into 

the next phase of life.

The article from Rick Yount, Meg Olmert, and Dr Mary 

Lee tells the story of one of the early organizations to use 

animals in therapy for posttraumatic stress, other mental 

health problems, and traumatic brain injuries. The Warrior Canine Connection teaches service members suffering from those problems to train service dogs to provide 

assistance to physically handicapped Warriors. There 

is, of course, a signifi cant need (and demand) for such 

trained dogs, and the program, in existence since 2006, 

has shown how two different Warriors can benefi t from 

a single dog, as one trains it to assist the other. This is 

an inspiring undertaking, and the results are undeniable. 

Warrior Canine Connection now works with the National Intrepid Center for Excellence in Bethesda to expand 

and improve its positive impact on Warriors and Veterans suffering with mental stress and brain injuries.

Ellen Alers and Kevin Simpson describe another program that teaches Wounded Warriors to train animals as 

therapy. However, these dogs are trained for a different 

reason from those discussed in the previous paragraph. 

The Washington [DC] Humane Society works with the 

Walter Reed Warrior Transition Brigade to involve recovering service members in training their rescued or abandoned dogs to be acceptable for adoption. The program, 

called Dog Tags, is an extensive 24-week training syllabus presented in 3 linked levels, which earns certifi cation as a dog trainer upon completion. The program can 

be the foundation for entry into the career fi eld of animal 

services. The program has existed since 2008, and has 

been an unqualifi ed success, both for the Warriors and 

the dogs. This excellent article presents a tremendous, 

uplifting example of another “win-win” undertaking. 

The Warriors benefi t, the dogs benefi t, and the families 

that adopt a Warrior-trained pet are also benefi ciaries as 

their new family member is a well-rounded dog, already 

prepared for his or her new happy life.

Whenever we see footage of earthquake damaged structures, collapsed buildings, avalanches, mudslides, or 

the most tragic—bomb damaged structures, invariably 

we see rescue dog teams from all over the world desperately working to locate every possible survivor under the debris. We also see people frantically working 

to locate and rescue any survivors, and later, to recover 

the dead. What is not evident in those short video segments is the stress and anxiety that such work infl icts 

on those so engaged. Jan Shubert closes this issue of the 

AMEDD Journal with a very interesting article about 

the use of therapy dogs to comfort those workers and the 

families of both survivors and those who were killed. 

She describes an organization called Therapy Dogs International, which was established in 1976 to provide 

visitation dog teams to comfort hospitalized patients. 

The fi rst disaster for which they were called to assist 

was, sadly, the 1995 bombing of the Murrah Building 

in Oklahoma City. That and other successful interventions spawned the establishment of another organization in 1999 specifi cally to provide assistance to disaster 

scenes, which eventually included Ground Zero in New 

York in September 2001, and New Orleans in 2004. In 

many ways these dogs provide a very similar service as 

the Army’s COSC dogs discussed in other articles. They 

help mitigate feelings of stress, anxiety, helplessness, 

and frustration that can be overwhelming in such situations. Similar to the COSC dogs, they have been quietly assisting at many scenes of signifi cant tragedy and 

stress, not always noticed by many, but greatly appreciated by those who benefi t from that all too real (albeit 

diffi cult to explain) human-animal bond.

PERSPECTIVES

Articles published in the Army Medical Department Journal are indexed in MEDLINE, the 

National Library of Medicine’s (NLM’s) bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD 

Journal content will be identifi ed to researchers during searches for relevant information 

using any of several bibliographic search tools, including the NLM’s PubMed service.
April – June 2012 5

In 2012, it seems that service dogs and therapy dogs 

are everywhere. These include dogs for both civilians 

and service members with combat injuries. Traditional 

service dog organizations are now providing dogs to 

children with autism and Soldiers with posttraumatic 

stress disorder (PTSD). Service members are also training dogs, either to be adopted from shelters or become 

service dogs for other service members and Veterans.

The use of service dogs for physical disabilities is well 

established. Therapy dogs are increasingly used in disaster settings. Evolving trends include:

 The expanded use of dogs for wounded Soldiers and 

other service members and Veterans.

 The use of dogs in the overseas combat theater to 

assist with combat and operational stress control.

 Therapy dogs to assist with PTSD and other behavioral health issues.

The acceptance of canines in Army medicine and in the 

civilian world has virtually exploded. As with all innovations, there have been some lessons-learned. This 

article describes the early use of therapy dogs, both in 

the theater of war and at the Walter Reed Army Medical Center in Washington, DC. The evolution of current 

policy initiatives and formalization is detailed in the 

following article in this issue (see page 8).

Neither this article nor others in this dedicated issue of 

the AMEDD Journal discuss the use of other animals, 

such as horses for equine therapy or cats for companionship. Certainly there are valid and evolving therapeutic 

uses for those animals. However, due to the rapid expansion of interest, effort, and commitment of resources 

in the employment of dogs, as well as the unquestioned 

successes of such work, we elected to confi ne the articles in this issue to that species.

THE BEGINNINGS: THE FIRST USE OF THERAPY DOGS IN

COMBAT AND OPERATIONAL STRESS CONTROL UNITS

Combat and operational stress control (COSC) teams 

have been active in the US Army since 1992. They 

provide education and therapy in the theater of war, 

emphasizing prevention and seeking to prevent unnecessary evacuation. Easy accessibility to care and reduction of the stigma associated with behavioral/mental 

health care is a major goal.

In early 2007, the US Army Veterinary Command asked 

for a consultation from the Behavioral Health Division at 

the Offi ce of The Army Surgeon General (OTSG). The 

topic was approval of the deployment of 2 dogs with a 

combat and operational stress control unit.

Animal-assisted therapy began in the Army in December 

2007 when The Acting Surgeon General, MG Gale Pollock, approved the request of the 85th Medical Detachment (COSC) to send 2 dogs to Iraq. The commander of 

the detachment anticipated that the dogs would provide 

an element of stress relief unmatched by any human.

The use of dogs with COSC teams seemed like a great 

idea. Behavioral Health was all for it, initially. Yet there 

were a signifi cant number of details to be addressed. The 

most pertinent questions included whether the Army 

could accept a donation of a dog, how to keep the dog 

healthy in theater, and how to measure the effectiveness 

of the intervention. The underlying theme reappears in 

several of the articles in this issue: “seems like a great 

idea,” but the “devil is in the details.”

The donation part was relatively straightforward. Since 

the dogs were each valued at roughly $25,000, the ethics 

advisors had to determine that it did not show undue 

infl uence on OTSG by the donors. America’s VetDogs 

(Smithtown, NY) donated 2 black Labrador retrievers, 

SFC Boe and SFC Budge, to the Army. Two occupational 

therapy assistants traveled from Iraq to New York for 

dog handling training, and then returned to Iraq with 

their new charges.

Fortunately, the US military deploys Army veterinarians to ensure the public health and food safety of service members. They also care for other working dogs, 

such as those working with military police and explosive ordnance disposal. It was, therefore, relatively easy 

to ensure that the animals entered with a clean bill of 

health and remained healthy.

The Early Years

COL (Ret) Elspeth C. Ritchie, MC, USA

COL Robinette J. Amaker, SP, USA
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

Much more diffi cult was the issue of how to measure 

effectiveness. How would we, or The Surgeon General, 

know if the dogs were actually working? It was easy 

to measure contacts and good press articles, but very 

hard to measure PTSD symptoms averted, suicides prevented, or marriages saved. Such questions led to some 

of the research described in articles in this issue.

Another major question was the optimal length of stay 

for the dogs in theater. No policy had been developed 

before SFCs Budge and Boe deployed to cover how 

long they should be there, or what should happen to reintegrate them into a normal environment upon return. 

Those fi rst dogs ended up in Iraq for 2 deployments, a 

total of 24 months. The Veterinary Command and the 

Behavioral Health Division were reluctant to approve 

more dogs in theater until the details were resolved.

Upon return, the fi rst dogs, SFCs Boe and Budge, went 

to the Eisenhower Army Medical Center at Fort Gordon, 

GA, and worked at the Residential Treatment Facility. 

The clinicians who worked with SFC Boe soon noticed 

that she seemed to be traumatized by her experience, 

and consequently might not relate well to Soldiers. After 6 weeks of reconditioning at VetDogs in Smithtown, 

NY, SFC Boe was returned to Eisenhower without any 

diffi culties and is doing wonderful work with Soldiers 

with mild traumatic brain injuries. A plan was developed with VetDogs under which they would take the 

dogs to retrain and recondition them for 6 weeks upon 

return from deployment. Eventually, the continuing uncertainty about deployment policy resulted in a December 2009 summit of commands, agencies, specialists, 

and nongovernmental organizations with involvement 

or interest in such use of therapy dogs (details on page 

8 of this issue).

There were other important lessons learned from that 

fi rst deployment. Like most people, Soldiers want to 

feed the dogs treats and snacks, and they gained weight. 

Close attention had to be paid to their diet. The dogs had 

to be isolated from local feral animals. Other lessons 

emerged over the next few years. For example, well-intentioned individuals tried to bring in other dogs, often 

not as well-trained and/or without command approval. 

Those efforts were most always unsuccessful.

Consequently, it was very hard to persuade the command 

in Afghanistan to accept dogs. They were also worried 

about the potential for disease transmission, especially 

rabies, which is a serious problem there. Eventually, the 

command was persuaded, and in June 2010, 2 dogs were 

allowed into theater with the 212th Medical Detachment 

(COSC). As of this writing, both are still in Afghanistan.

THE FIRST USE OF DOGS AT THE WALTER REED

ARMY MEDICAL CENTER

Several occupational therapists at the Walter Reed Army 

Medical Center (WRAMC) brought their personal dogs 

to work with the Wounded Warriors. They were an instant success. Wounded Warriors who were very tired of 

all the human attention and had withdrawn responded 

very well to the touch of an animal.

Predictably, there were also issues that developed concerning policies related to the use of animals at WRAMC. 

Again, there were unanticipated wrinkles. For example, 

there was no good way to screen all animals entering 

WRAMC to ensure that they were well-trained service 

animals, rather than simply a “pet in a vest.” Another 

concern was about the potential transmission of disease, 

specifi cally methicillin resistant staphylococcus aureus. 

However, the Commander, WRAMC was sympathetic 

to the use of canines, so the Occupational Therapy Department developed policies for the use of animals. One 

result was an internal policy that service animals should 

not be issued until a service member was ready to move 

off post to other housing. That made sense, as someone 

would have to care for the dog if the service member 

was still undergoing surgeries or other therapies.

TRAINING ISSUES

A major internal debate was the level of training that 

service or therapy dogs should receive. The early service dogs received about 2 years of training, which made 

them very expensive, between $25,000 and $50,000 per 

animal. Some advocates claimed that dogs could be 

trained by their service member handlers, at much less 

expense. The Warrior Transition Brigade Service Dog 

Training Program, described later in this issue (see page 

58) used rigorous methods to teach service members 

how to train service dogs. Still, there are proponents 

of much less training. At present, there are no studies 

available to address this question.

BENEFIT OF DOGS IN DECREASING PTSD SYMPTOMS

Meanwhile, anecdotal examples of psychological benefi ts continue to be documented, and are discussed in 

other articles in this issue. In the authors’ visits to VetDogs and the National Education for Assistance Dog 

Services, we heard statements such as:

I used to take fi ve different medications for my 

PTSD. Now I take two.

I could not be in malls or other crowded places. 

Now, with my dog, I can tolerate them, knowing he 

will rescue me.

THE EARLY YEARS
April – June 2012 7

THE ARMY MEDICAL DEPARTMENT JOURNAL

When my husband returned from Iraq, he was a jerk. 

Since we got our dog, we have reunited as a family.

When I have a nightmare, he puts his muzzle into 

my face, and the nightmare stops.

We also heard a number of accounts about dogs who allegedly could abort seizures, ie, “my dog senses when a 

seizure is about to come on, and his touch stops it.”

NEXT STEPS

Personal accounts are compelling, but not usable as a 

basis for designing protocols or justifying the commitment of resources. There is a need for scientifi c data to 

more fully understand how the human-animal bond can 

continue to help our service members. Medical science 

professionals are moving to use evidence-based and evidence-informed research to develop practice guidelines, 

such as those in planning at the National Intrepid Center 

of Excellence in Bethesda, Maryland. This issue of the 

AMEDD Journal presents the beginnings of this body of 

knowledge.

ACKNOWLEDGEMENTS

There were many in the Army Medical Department who 

contributed to these efforts. Specifi cally, we would like 

to acknowledge LTG (Ret) Eric Schoomacher, MG (Ret) 

Gale Pollack, BG (Ret) Tim Adams, COL (Ret) Gary 

Vroegindewey, MAJ (Ret) Stacie Caswell, and Mr Herb 

Coley.

AUTHORS

COL (Ret) Ritchie is the Chief Clinical Offi cer, District 

of Columbia Department of Mental Health, Washington, 

DC.

COL Amaker is the Assistant Chief, Army Medical 

Specialist Corps and Occupational Therapy Consultant 

to The Army Surgeon General. She is also Director 

and Associate Professor in the Doctor of Science in 

Occupational Therapy program, US Army Medical 

Department Graduate School, Fort Sam Houston, Texas.

in memoriam

With heavy hearts, the Army 

Family said goodbye to our 

beloved SFC Budge, who lost his 

short battle with lymphoma on 

July 28, 2010. He was not only an 

incredible friend, but a remarkable 

comfort provider who touched the 

lives of many service members at 

his numerous duty stations. His 

service included 2 tours in Iraq, 

one each at Fort Hood and Fort 

Bragg, and his final assignment at 

Fort Gordon.

SFC BUDGE

10/02/04

07/28/10
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

There is documented evidence dating from as early as 

1940 citing the use of dogs to assist Wounded Warriors 

in therapeutic settings. Since that time, various efforts 

have emerged throughout the Army promoting the use 

of dogs to assist Warriors to attain higher levels of independence and self-reliance, allowing them to function 

more successfully in their communities and jobs. Most 

recent efforts include the use of service dogs and animal-assisted activities dogs in Warrior transition units, 

military medical treatment facilities, combat and operational stress control units and other settings.

As these service dog and animal-assisted activities efforts have emerged and expanded to support the Army’s 

9,661* Wounded Warriors and the rest of the Army 

community, so has the need for policies that defi ne and 

govern the appropriate use, accompaniment, and maintenance of dogs and related programs. While the Army 

is not governed by the Americans with Disabilities Act 

of 1990 (ADA) (42 USC ch 126), in the absence of an 

overarching Army animal-assisted activities policy, the 

ADA and Department of Defense Technical Bulletin TB 

MED 41

 have become references for development of local policies throughout the Army.

The ADA prohibits discrimination against people with 

disabilities in employment, transportation, public accommodation, communications, and governmental activities. Specifi c sections of the Act are dedicated to the 

protection of people with physical and/or mental disabilities from discrimination in receiving public services, to 

include accompaniment by a service dog. Given the current climate of war, these provisions may have considerable impact on support available to disabled Veterans, 

as well as service members returning from Iraq and Afghanistan with both physical and psychological wounds.

Under the ADA, businesses must allow people with disabilities to bring their service animals onto business 

premises in whatever areas customers are generally 

allowed. Although not bound by these guidelines, the 

Army Medical Command has made a signifi cant effort 

to develop policies and provisions that respect service 

members, Army personnel, and all other persons accompanied by a service animal on Army installations.

TB MED 41

 is the governing Department of Defense 

(DoD) regulation that establishes the processes necessary to maintain human-animal bond programs, animal 

visitation, animal-assisted activities, and animal-assisted 

therapy. This regulation promotes and supports humananimal bond programs by providing guidance on care, 

maintenance, and disease prevention of animals, including dogs. As of this writing, the US Army Veterinary 

Command, the DoD Executive Agent for Veterinary Services, is in the process of revising TB MED 4. The revision will include current defi nitions for animal-assisted 

activities, animal-assisted therapy, and service dogs.

HISTORY

In November 2009, the Army Veterinary Command 

(VETCOM) engaged the Behavioral Health Division of 

the Offi ce of The Surgeon General (OTSG) in discussion 

concerning the growing interest in animal-assisted activities, and the numerous initiatives throughout the Army 

that involved use of dogs. To help coordinate these initiatives, VETCOM and the Behavioral Health Division held 

an animal-assisted therapy summit December 15 to 17, 

2009 at Fort Myer, Virginia. The agenda included current 

efforts, research, metrics for program evaluation, and logistical and legal challenges. The forum brought together 

8 nongovernmental organizations for the fi rst half of the 

proceedings to discuss their programs. Other attendees 

included staff from the Warrior Care and Transition Offi ce; Army medical treatment facilities; the OTSG Rehabilitation and Reintegration Division, Walter Reed Army 

Medical Center; US Air Force; US Navy; and combat 

and operational stress control staff who work with and 

handle the animal-assisted activities dogs in theater.

Products from the summit included mission priorities, 

a research agenda, and the corporate way ahead. During the meeting, the group discussed the signifi cance of 

defi ning the different types of dogs and their appropriate use. The group defi ned and differentiated between 

animal-assisted activities, animal-assisted therapy, and 

service dogs. One of the outcomes of the meeting was 

the decision to develop an Army Medical Command 

Policy Initiatives for the Use of

 Canines in Army Medicine

LCDR Kathleen L. Watkins, HSO, USPHS

*Data current as of January 9, 2012. Source: US Army Warrior 

Transition Command Report.
April – June 2012 9

(MEDCOM) policy to provide standardized guidance 

on the use and maintenance of dogs at all medical treatment facilities. The Walter Reed Army Medical Center 

(WRAMC), which had signifi cant experience managing 

an animal-assisted activities program and was already 

working on a local policy to govern their thriving dog 

programs, was identifi ed as the lead to begin developing 

the MEDCOM dog policy.

On February 5, 2010, a follow-up meeting was held to review the progress since the summit. Participants included 

the OTSG Behavioral Health Division, WRAMC, Europe Regional Medical Command, the Veterans Administration, and a host of nongovernmental organizations 

and subject matter experts in animal-assisted activities, 

and research. Topics included (a) optimizing the use of 

dogs in the combat and operational stress control teams 

in Iraq; (b) moving forward with research opportunities 

at WRAMC and the Europe Regional Medical Command; (c) potential use of dogs in Warrior Transition 

Units; (d) development of a MEDCOM-wide policy and 

updating a number of animal policies, including DoD 

TB MED 4,1

 WRAMC facility policy, and the combat 

and operational stress control policy; (e) various models 

which may be helpful; (f) visiting animal-assisted activities program/facilities, and (g) the importance of clarifying the diverse use of dogs (service, animal-assisted 

therapy, and animal-assisted activities). Participants at 

the meeting also noted that Army Family Action Plan2

Issue #653 which recommended funding a program 

to provide service dogs to Wounded Warriors was assigned to the Warrior Transition Command for exploration and proliferation. On March 8, 2010, Issue #653 

was transferred from the Warrior Transition Command 

to the OTSG Behavioral Health Division for examination by senior offi cials within OTSG and MEDCOM.

In March 2010, the Behavioral Health Division visited 

America’s VetDogs—an organization in Long Island, 

New York, that trains and provides guide and service 

dogs to assist wounded service members and Veterans 

who have visual, physical, occupational, and/or emotional impairments—to gain further understanding of 

how dogs were being used to assist wounded service 

members and Veterans. The visit included an overview 

of the program, a tour of the facility, observation of service dog training, and interaction with Veterans who 

were currently enrolled in the program. A class of 11 

Soldiers, Marines, and Veterans were observed as they 

learned to train their service dogs to perform specifi c 

tasks to address their individual needs.

The VetDogs Chief Executive Offi cer provided information to assist the Behavioral Health Division with 

its expanded mission related to animal-assisted therapy 

and funding service dogs for Wounded Warriors. Topics included: (a) pros and cons of developing an army 

animal-assisted therapy/service dog program versus use 

of existing, accredited nongovernmental organization 

programs, (b) optimizing the use of dogs in the combat 

and operational stress control teams, (c) logistics related 

to sending dogs to Afghanistan with the 254th Medical 

Detachment from Germany, and (d) developing research 

strategies and metrics. America’s VetDogs offered a 

donation of 2 service dogs specifi cally trained for the 

tasks they will perform with the 254th Medical Detachment. The donation was later approved by The Surgeon 

General.

On April 12, 2010, the OTSG Behavioral Health and Rehabilitation and Reintegration Divisions visited the National Education for Assistance Dog Services (NEADS)/

Dogs for Deaf and Disabled Americans in Princeton, 

Massachusetts. NEADS, a nonprofi t organization that 

uses inmates to train their dogs, provides canine assistance dogs to combat Veterans and people with hearing 

and physical disabilities. The use of inmates, while cost 

effective, is also intended to provide a therapeutic support for the inmates.

The visit to NEADS included an overview of the program, a tour of the facility, observation of the training, 

demonstrations, and interaction with Veterans in the 

program diagnosed as having physical disabilities, posttraumatic stress disorder, and traumatic brain injury. 

The NEADS Chief Executive Offi cer and staff provided 

information on the impact of their program and expansion into animal-assisted therapy. Topics included: (a) 

NEADS expanded programs to help persons with disabilities, (b) metrics and NEADS Traumatic Alert Dog 

Program pilot study regarding the impact of placing service dogs with Veterans diagnosed with posttraumatic 

The class of Soldiers, Marines, and Veterans learning to 

work with service dogs at the America’s VetDogs facility in 

Long Island, New York (March 2010). Photo courtesy of the 

author.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

stress disorder, and (c) pros and cons of developing an 

Army animal-assisted therapy/service dog program versus use of existing accredited programs. Following the 

visit to NEADS, the OTSG Rehabilitation and Reintegration Division briefed the MEDCOM Chief of Staff 

on the therapeutic use of dogs in the Army, resulting in 

a request for a follow-up brief in May 2010.

In an effort to gain further insight into the impact of 

dogs on Wounded Warriors, during April 2010 representatives from the OTSG and VETCOM also toured 

the Army’s most robust animal-assisted therapy program located at the Walter Reed Army Medical Center. 

Also present were representatives from the MEDCOM, 

DoD, nongovernmental organizations, and congressional staffers from Senator Barbara Boxer’s offi ce, the 

US House of Representatives Committee on Veterans’ 

Affairs, the Minority Staff of the House Veterans Affairs Committee, and the Subcommittee on Health of 

the House Committee on Veterans’ Affairs. The group 

observed the Specialized Therapy K-9 program; the 

Warrior Transition Brigade occupational therapy work 

and education program “Paws for Purple Hearts” Service Dog Training Program; and the Warrior Transition 

Brigade occupational therapy work and education program, the Washington, DC Humane Society Warrior in 

Transition Behavior and Grooming Training Program. 

Wounded Warriors diagnosed with posttraumatic stress 

disorder demonstrated methods for training service 

dogs, which is part of their therapy. Wounded Warriors 

also gave testimony regarding the positive impact of the 

program on their lives. The day ended with a research 

meeting at which the topics of discussion included: (a) 

establishing qualifi cation criteria and identifying the 

number of Wounded Warriors who may benefi t from 

having a service dog, (b) research and data collection, 

(c) identifi cation of funding sources, and (d) scheduling 

a follow-up teleconference at the end of May for further 

discussion regarding research.

Following the OTSG/VETCOM tour of the Walter Reed 

Army Medical Center in May 2010, there was discussion initiated by WRAMC on whether or not to move 

forward with development of an Army-wide MEDCOM 

dog policy, or direct efforts towards the revision of DoD 

TB MED 4,

1

 lead by VETCOM. It was determined that 

while both efforts were signifi cant to the advancement of 

animal-assisted activities, a comprehensive MEDCOM 

policy was needed to provide standardization for use 

of dogs at Army medical treatment facilities. Policies 

existed at the local level but were not applicable to all 

medical treatment facilities, therefore creating inconsistencies between the medical treatment facilities on the 

maintenance, care, and use of dogs, and causing lack of 

differentiation between pets, animal-assisted activities, 

animal-assisted therapy, and service dogs. The task of 

writing the MEDCOM dog policy was transferred from 

WRAMC to the Offi ce of The Surgeon General, with 

the author as action offi cer.

On November 9, 2010, the OTSG Behavioral Health Division published the fi rst MEDCOM-wide policy on use 

of canines in Army medicine. OTSG/MEDCOM Policy 

Memorandum 10-0773

 provides guidance on the authorized use, ownership, and accompaniment by service 

dogs at military medical treatment facilities and Warrior Transition Units.

To further explore the possible benefi ts of dogs for 

Wounded Warriors, on December 3, 2010, the Behavioral Health Division held a teleconference with WRAMC 

subject matter experts on animal-assisted activities. The 

teleconference focused on current uses of dogs with 

Wounded Warriors and surveying to determine how 

many Wounded Warriors may benefi t from having a dog. 

The teleconference resulted in a recommendation to use 

components of the Functional Independence Measure 

and Functional Assessment Measure (tools which are 

currently used at WRAMC) to assist with determining 

cognitive and physical disabilities of Wounded Warriors 

and the appropriateness of referral to a nongovernmental organization that donates service dogs to service 

members and Veterans.

On April 11, 2011, the OTSG Rehabilitation and Reintegration Division published OTSG/MEDCOM Policy 

Memorandum 11-030.4

 The policy recognizes that dogs 

have long assisted healthcare professionals in various 

rehabilitative treatments, including combat and operational stress control. Policy Memo 11-030 establishes 

the role of animal-assisted therapy and animal-assisted 

activities dogs in combat and operational stress control 

units, operational employment with combat and operational stress control units, and animal-assisted therapy 

and animal-assisted activities dog programs throughout 

the battle space. The policy also identifi es Army occupational therapists as the primary handlers of these 

dogs in the Army, with behavioral health professionals 

as alternates.

The Behavioral Health Division consulted with the Rehabilitation and Reintegration Division on use of the 

Functional Independence Measure and Functional Assessment Measure as instruments for determining the 

number of Wounded Warriors that may need or benefi t from having a service dog. Noting the Functional 

POLICY INITIATIVES FOR THE USE OF CANINES IN ARMY MEDICINE
April – June 2012 11

THE ARMY MEDICAL DEPARTMENT JOURNAL

Independence Measure and Functional Assessment 

Measure scales are not widely used by Army occupational therapists, OTSG Rehabilitation and Reintegration recommended a general survey as an alternative 

measure. Other options presented during this meeting 

included obtaining data for the past 3 years from the 

Army programs that support animal-assisted activities, the Veterans Administration funded dog program, 

and nongovernmental organizations that match service 

members and Veterans with service dogs. As a result, in 

May 2011 the author developed a survey to determine 

the trend of service dog matching and placements with 

Wounded Warriors and service members over the past 

3 years. Survey participants included the Veterans Administration, Army regional medical commands, and 

America’s VetDogs and NEADS, the 2 nongovernmental organizations who primarily provide service dogs to 

Soldiers and Veterans.

In December 2010, the Clinical Services Division, Offi ce 

of the MEDCOM Assistant Chief of Staff for Health Policy and Services, convened a meeting with the Army animal-assisted activities stakeholders to review the Army’s 

efforts and policies related to dogs. During the meeting, 

the Clinical Services Division was identifi ed as the lead 

division for all MEDCOM animal-assisted activities efforts. There was also discussion regarding the need for 

an Army-wide animal policy to provide guidance for not 

only dogs, but for use of all animals in Army healthcare 

settings. Following the meeting, the Clinical Services 

Division examined the Army’s animal-assisted activities 

efforts and trends, and reviewed the OTSG Behavioral 

Health Division survey on Wounded Warriors who may 

benefi t from having a service dog. In October 2011, the 

Clinical Services Division began staffi ng a draft policy on the use of animals in the healthcare setting. The 

draft policy provides guidance on use of service animals, 

animal-assisted therapy and animal-assisted activities 

to include canines, equines, and other species. When 

published, this policy will apply to all Army medical 

treatment facilities using animals in the healthcare setting, Wounded Warriors, and benefi ciaries treated within 

medical treatment facilities, regardless of component or 

duty status. Publication is expected in the near future.

Recognizing the growing interest in the use of dogs to 

assist service members, the Deputy Assistant Secretary 

of Defense for Wounded Warrior Care and Transition 

Policy (DASD WWCTP) held a DoD service dog policy 

development meeting off-site in March 2011. The meeting was held to discuss development of a comprehensive 

DoD service dog policy that will provide clear guidance 

to all of the military services, commanders, healthcare 

providers, and service members who work with, qualify 

for and/or will benefi t from the use of service dogs on 

DoD installations. Leaders and subject matter experts, 

including the Behavioral Health Division, convened at 

this meeting to discuss development of the DoD service 

dog policy that will assign responsibilities and provide 

instructions for the use of service dogs by service members within the DoD. The DoD service dog policy will 

also establish policy for the authorized use of animalassisted activities and animal-assisted therapy on DoD 

installations. A draft policy was developed at the conclusion of the meeting. Since that time, the DASD WWCTP 

has continued to refi ne the document. A publication date 

has not been determined.

REFERENCES

1. Department of Defense Technical Bulletin TB 

MED 4: DoD Human-Animal Bond Principles and 

Guidelines. Washington, DC: US Dept of the Army; 

June 16, 2003. Available at: http://armypubs.army.

mil/med/dr_pubs/dr_a/pdf/tbmed4.pdf. Accessed 

January 10, 2012.

2. Army Family Action Plan page. US Army OneSource 

Web site. Available at: https://www.myarmyone

source.com/FamilyProgramsandServices/Fam

ilyPrograms/ArmyFamilyActionPlan/Default.aspx. 

Accessed January 10, 2011.

3. Offi ce of The Surgeon General. Memorandum: 

MEDCOM Policy on Use of Canines and Other 

Service Animals in Army Medicine. Fort Sam 

Houston, TX: US Army Medical Command; November 9, 2010. OTSG/MEDCOM Policy Memo 

10-077.

4. Offi ce of The Surgeon General. Memorandum: 

MEDCOM Policy on Animal-assisted Therapy 

(AAT)/Animal-assisted Activity (AAA) Dog Utilization in Combat and Operational Stress Control 

(COSC). Fort Sam Houston, TX: US Army Medical Command; April 2011. OTSG/MEDCOM Policy Memo 11-030.

AUTHOR

LCDR Watkins is Chief, Administrative Branch, Behavioral Health Division, Offi ce of The Army Surgeon General, Alexandria, Virginia.
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

With the exception of maggot debridement and medicinal 

leech therapy, active and passive medical interventions 

using a live animal are defi ned by the human-animal 

bond. Encounters center on the dynamic and interactive 

relationship between humans and animals to provide 

psychological or physical benefi t.1,2 This bond is the core 

of several therapeutic approaches using various species. 

The most common are assistance or service animals; 

therapy and activity animals; and emotional support, 

companion, or social animals. The effi cacy of the humananimal bond as a healthcare tool greatly depends on how 

the animal’s roles are used by a group or an individual. 

Unlike medical equipment, defi ning specifi c functions 

of a living tool is essential to the maintenance and common logistical factors that affect the health and welfare 

of the animal. From a legal perspective, defi nitions are 

necessary for establishing eligibility, benefi ts, and even 

liability when considering whether the standard of care 

is met. As the military medical community increases its 

use of animals, specifi cally canines, clarifi cation of utility is needed to develop policy and ensure good practice.

ASSISTANCE OR SERVICE ANIMALS

Throughout much of the world, assistance animals are 

categorized into guide dogs, hearing dogs, or service 

dogs.3,4 However, in the United States, the synonymous 

term “service animal” is often used and may mean any 

type of assistance animal.4

 In 2010, the Americans with 

Disabilities Act (ADA) (42 USC §12101-12213 and 47 

USC §§225, 611) was revised with regard to the defi nition and use of service animals. For purposes of US law, 

the ADA [as amended] defi nes a service animal as:

any dog that is individually trained to do work or perform 

tasks for the benefi t of an individual with a disability, 

including a physical, sensory, psychiatric, intellectual, or 

other mental disability.5(p56250)

Further, it stipulates that

Individuals with disabilities shall be permitted to be 

accompanied by their service animals in all areas of a 

public entity’s facilities where members of the public, 

participants in services, programs or activities, or 

invitees, as relevant, are allowed to go.5(p56251)

The ADA defi nition of disability is a “physical or mental 

impairment that substantially limits one or more major 

life activities of such individual.” 6

 To be considered a 

service animal, a direct link must exist between the animal’s work or tasks and the handler’s disability. However, 

the animal’s work must be a trained behavior and not a 

response that is natural to the animal. The current ADA 

defi nition does not consider violent protection (whether 

trained or untrained), crime deterrence due to an animal’s presence, emotional support, well-being, comfort, 

or companionship as acceptable work or tasks for the 

defi nition of a service animal. Although animals such 

as primates, equines, avians, felines, porcines, and even 

bovines have all been trained to help humans perform 

daily tasks, 28 CFR §35.104 (as amended in 2010) limits 

the defi nition of a service animal to canines only and 

does not include any other species of animals, regardless 

of whether those other species are wild or domesticated, 

trained or untrained.5(p56250) A trained miniature horse as 

an alternative to an assistance dog is the one exception 

to permitting the use of a noncanine species in the role 

Definitions of Animals Used

 in Healthcare Settings

LTC James T. Mills, III, SP, USA

MAJ Arthur F. Yeager, SP, USA

Raliegh, a facility animal and trained service dog, providing balance 

assistance and ambulation propulsion (in the role as a service dog) 

at the Military Advanced Training Center, Walter Reed Army Medical 

Center. Photo courtesy of the authors.
April – June 2012 13

of a service animal in a public space.5(p56251) However, a 

miniature horse is not defi ned as a service animal by 28 

CFR §36.104 and its use is subject to certain limitations, 

as outlined in 28 CFR §35.136.5(p56250),7

The ADA delineates further conditions and rules regarding service animals.5(p56251) A service animal must 

be house broken, under the control of the handler at all 

times, harnessed or leashed at all times (unless that restraint would interfere with the performance of the animal’s work), and is not subject to size, weight, or breed 

limitations.5(p56271) A public entity cannot inquire about 

the nature of an individual’s disability, but, to determine 

whether an animal qualifi es as an assistance animal, an 

entity may ask the handler whether the animal is required 

because of a disability and what work or task the animal 

performs for the disabled person. The public entity cannot ask for proof of documentation that the animal is a 

qualifi ed or trained assistance animal or require payment 

of a surcharge for access to a public space or facility, even 

if that entity requires payment for pet access.5(p56251)

Canines are the most common species of assistance 

animals, working well as guide dogs, hearing dogs, or 

service dogs. Guide dogs assist the visually impaired 

(blind or low vision) with navigation such as avoiding 

obstacles, stopping at curbs and steps, and negotiating 

traffi c.8

 Hearing dogs are trained to alert those with 

hearing impairment (deaf or hard of hearing) to the 

presence of people or household and community sounds 

by making physical contact and, if appropriate, leading their handlers to the source of the sound.9

 Service 

dogs are trained to perform a wide variety of common 

and customized tasks for individuals with impairments 

other than auditory or vision dysfunction.10 Assistance 

with physical, cognitive, or psychiatric disabilities can 

promote functional independence and increased quality of life. Specially trained service dogs can perform 

a variety of tasks including, but not limited to, providing balance and counterbalance; alerting the handler to 

pending medical disorders such as seizures or hypoglycemia or assisting during episodes of those disorders; 

assisting to pull a wheel chair; retrieving a variety of 

large or small items; alerting to the presence of an allergen; turning lights on and off or pushing elevator and 

automatic door buttons; assisting with functional transfers; providing nonviolent protection or rescue work.10

Specifi c skills that address a particular disability may 

be included in their title, such as “balance dog” or “psychiatric service dog.” The latter may assist individuals 

with psychiatric and neurological disabilities by preventing or interrupting impulsive or destructive behaviors, or mitigating behavioral health disabilities in other 

ways.5(p56250) All of the above examples of assistance dog 

tasks are consistent with the ADA defi nition of a service 

animal.5(p56250)

THERAPY AND ACTIVITY ANIMALS

While federal law does not defi ne therapy and activity 

animals, some states do have laws defi ning such animals.11 Regardless of a therapy or activity animal’s legal 

defi nition, they are not service animals and do not have 

public access privileges afforded to service animals. 

The main distinction between therapy or activity animals and service animals is that the former, through the 

use of the human-animal bond, provide services to other 

people (with or without disabilities) under the direction 

of their handlers, whereas, the latter are trained to do 

work or tasks solely for their dedicated handler with 

a disability.11 They are expected to work reliably and 

safely with others, often with many distractions. Recognizing that the therapeutic effects of the human-animal 

bond are not exclusive to people with disabilities,1,12,13

several professional and animal advocacy organizations 

have defi ned the various types of nonassistance/service 

animals. One such organization, Delta Society, has defi ned both animal-assisted therapy (AAT) and animalassisted activities (AAA) animals.14

Animal-assisted therapy is part of a goal-directed, individualized healthcare treatment plan for individuals 

with physical, social, emotional, or cognitive dysfunction, where the AAT intervention is documented in 

the patient’s health record. Animal-assisted therapy is 

Hero, a trained service dog, providing comfort and emotional support (in the role of animal-assisted activities) at the Occupational 

Therapy Clinic, Walter Reed Army Medical Center. Photo courtesy 

of the authors.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

Classifi cation of types of animals used in various healthcare settings and situations.

Guide 

Dog

Hearing 

Dog

Service 

Dog

Service 

Miniature 

Horse

AAT Animal AAA 

Animal

Emotional 

Animal

Support 

Resident/

Animal

Facility 

Companion 

Animal Therapy 

Social/

Dog

Recreational 

Animal 

Mascot

Legally defi ned Yes5 Yes5 Yes5 Yes5 states In some11 states In some11 states In some25 No5 No11 No11 No No

Federal legal defi nition as an assistance/service animal Yes5 Yes5 Yes5 No5,7 No5 No5 No5 No5 No5 No No No

spacesaccess to public facilities and Federal legal protections for 

Yes5 Yes5 Yes5 conditions With certain5 No24 No24 No5 No5 No5 No No No

access to housingFederal legal protections for Yes5,25 Yes5,25 Yes5,25 conditions With certain5,25 No25 No25 Maybe20,21,25 No No No No No

for a dedicated handlerPerforms trained tasks/work Yes5 Yes5 Yes5 Yes5 No11 No11 No21 No No No No Noactivitiesplanned or spontaneous Used as part of a facility’s 

No No No No Planned14 Both14 No Maybe17 No Both Both Both

treatment planUsed as part of a healthcare No No No No Yes14 No14 No Maybe17 No No No NoUsed to achieve specifi c healthcare treatment goals N/A N/A N/A N/A Yes14 No14 N/A Maybe17 N/A N/A N/A N/A

group sessionsUsed with individualized or N/A N/A N/A N/A Individual14 Both14 N/A Maybe17 N/A N/A N/A N/Arequired.Medical documentation N/A N/A N/A N/A Yes14 No14 N/A Maybe17 N/A N/A N/A N/Apredetermined.Visit schedule and length is N/A N/A N/A N/A Yes14 No14 N/A Maybe17 N/A N/A N/A N/Ahandler.healthcare professional or any Visit conducted/supervised by a 

N/A N/A N/A N/A Healthcare professional14 Any handler14 N/A Maybe17 N/A N/A N/A N/A

Can be a pet No No No No Maybe11 Maybe11 Maybe11 Maybe17 Yes11 Yes11 Yes YesUsed to provide comfort No No No No No11 Maybe11 Yes21 Maybe Maybe Maybe Maybe Maybe

Used for recreation No No No No No No No No No No Yes22 NoUsed for esprit de corps No No No No No No No No No No No Yes22

AAA indiates animal-assisted activities.AAT indicates animal-assisted therapy.

DEFINITIONS OF ANIMALS USED IN HEALTHCARE SETTINGS
April – June 2012 15

THE ARMY MEDICAL DEPARTMENT JOURNAL

conducted on scheduled visits, of a regular interval and 

directed or delivered by a professional within the practice scope of a health/human service provider. Animalassisted therapy animals may or may not have previous 

formal assistance/service dog training. Examples of 

AAT may be a patient with balance dysfunction using 

a trained dog wearing a rigid-handled harness to assist 

with gait training, or the use of trained dogs in military combat stress control units for behavioral health 

interventions.

Comparatively, AAA are untailored “meet and greet” activities without specifi c treatment goals. Animal-assisted 

activities can be conducted in group settings with many 

people, and no documentation is necessary. Unlike a 

therapy program, the AAA visits and activities can be 

spontaneous, of any length or frequency, and conducted 

by any handler. Examples of AAA might include a volunteer handler with dog visiting a hospital pediatric oncology ward to raise the spirits of children, or a dog training 

organization bringing their animals to an outpatient facility to positively interact with Wounded Warriors.

Animals used in AAT and AAA are often dogs, but also 

frequently include equines, such as hippotherapy programs, which use horses as part of an integrated rehabilitation treatment program supervised by a healthcare 

therapist.15,16 Resident or facility animals can be AAT or 

AAA animals and are similar in that each works with 

a volunteer or professional whose training falls under 

the auspices of a formal program. The work of a facility 

animal can include visitations or professional therapy in 

one or more locations. A very common example of facility animals is the simple presence of fi sh in a doctor’s offi ce. However, dogs are common as well and can provide 

a more intimate and effective human-animal bond experience. Resident animals can live or work in a facility 

full time. They are often owned by the organization or a 

facility staff member and can be handled and cared for 

by the staff, volunteers, or residents. After appropriate 

training and screening, resident animals may formally 

participate in a facility’s planned or spontaneous activities and therapies with patients or residents.17 Resident 

animals may also function in the role of emotional support, companion, social, or mascot animals.

EMOTIONAL SUPPORT, COMPANION, SOCIAL, 

AND MASCOT ANIMALS

Although the medical evidence for the health benefi ts 

of the human-animal bond is not defi nitive,18 evidence 

suggests that pets can promote health and wellbeing in 

disabled and able persons alike.12,19 Skills that are inherent to a canine do not necessarily assist an individual 

in completing a task, but instead can provide emotional 

support to an individual. Emotional support animals 

provide comfort to persons with psychiatric disability 

but do not perform trained tasks to assist the individuals. 

Because the comfort offered by the mere presence of an 

animal is not a trained skill, emotional support animals 

are not covered under US laws that apply specifi cally 

to service animals, unlike a psychiatric service animal 

that provides specifi c trained work or a task to help mitigate a handler’s psychiatric disability. However, some 

persons with psychiatric disability served by emotional 

support animals may be afforded certain housing rights 

as a “reasonable accommodation” under Section 504 of 

the Rehabilitation Act of 1973 (29 USC §701) and the 

Federal Fair Housing Amendments Act of 1988 (FHAA) 

(42 USC §3601-3619).20,21 Emotional support canines are 

sometimes referred to by other terms such as “social 

dog,” “companion dog,” or “therapy dog.” Social, emotional support, companion, or therapy animals may be 

untrained or animals that were once considered for formal assistance/service dog training but, due to health, 

disposition, trainability, or other factors, did not complete the training.11 Such dogs are often made available 

as pets for people with certain disabilities. Nonetheless, 

emotional support animals are not legally considered 

pets due to their qualifi cations under Section 504 and 

FHAA, but a companion animal is synonymous with 

a pet. The meanings of a social/companion animal are 

nearly self-explanatory. Conversely, the varied meanings of what is therapeutic in regards to a therapy animal, 

are not as clear or concrete. Furthermore, the variety of 

perspectives with regard to therapeutic effi cacy range 

from the individual(s) experiencing and facilitating the 

human-animal bond, up to and including the federal 

government that infl uences accommodation, public access, and healthcare.

Raliegh, a facility animal, providing counterbalance during a physical therapy sesson (in the role of animal-assisted therapy) at the 

Military Advanced Training Center, Walter Reed Army Medical Center. Photo courtesy of the authors.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

OFFICE OF THE ARMY SURGEON GENERAL/ARMY MEDICAL

COMMAND POLICY

A recently issued policy memorandum22 from the Offi ce 

of The Surgeon General/Army Medical Command provides defi nitions for various types of animals for purposes of establishing policy guidance and procedures 

for the use of animals in Army healthcare. It is the intent 

of this policy that, although the Army is not generally 

bound by the ADA, Army Medical Command facilities 

“will abide by [ADA] provisions to as great a degree as 

is practicable and when such adherence does not hamper 

readiness.” 22 As such, the policy similarly defi nes animals as above with a few differences to note. The policy 

defi nes service animals as dogs only. Additionally, the 

policy defi nes “service-dogs-in-training” as dogs undergoing training as part of Wounded Warrior therapeutic 

internship opportunities in which wounded Soldiers 

train service dogs for fellow service members. Some 

state regulations grant public facility/space access to 

trainers while they instruct clients with disabilities and/

or the service-dogs-in-training.23 “Recreational animals” 

are defi ned as “animals not owned by an individual and 

used solely for recreational purposes,” 22 for example, 

horses ridden at a dude (tourist) ranch. The terms “companion,” “emotional support animals,” and “pets” are 

synonymous and defi ned as “any animal owned by individual Soldiers or benefi ciaries not meeting the defi nition of a service animal.” 22 Military working dogs are 

government-procured and owned dogs used for military 

working purposes, such as explosive detection, security, 

or search and rescue. Finally, the policy defi nes mascots 

as animals adopted by nondeployed Army units for purposes of esprit de corps.

22

According to the governing triservice regulation,24 to 

qualify as a mascot, the animal must be on orders signed 

by an offi cer of 0-5 grade or higher. Such mascots are 

owned by the Department of Defense and, thus, are eligible for veterinary medical/surgical care and support 

services.25 However, animal mascot or pet adoption is 

subject to the policies and limitations of animal adoptions which are imposed by theater commands in respective areas of responsibility, such as the prohibition 

of animal adoption in the deployed environment per US 

Central Command Area of Responsibility General Order Number 1B (GO-1B), dated March 13, 2006.*

The overwhelming novelty of experiencing animals in a 

therapeutic setting relies on the familiarity that American culture has with canines and family pets. More specifi cally, military patients respond well to the animal 

interaction and with less concern whether a service dog 

has public access; whether an emotional support dog’s 

effi cacy can be proven; or whether a therapy dog fosters 

rehabilitative care. For many, a dog’s all-accepting disposition and wide range of intangible health promoting 

factors is a welcome oasis in a setting where anxiety, 

pain, or decreased function are often prevalent. Some 

of the defi ning characteristics of the different types of 

animals involved in healthcare are presented in the Table. Understanding the legal, professional, and common 

defi nitions of these types of animals will help providers deliver the best care and develop appropriate policy 

to maximize the tangible and intangible benefi ts of the 

human-animal bond.

REFERENCES

1. History and mission page. Center for the HumanAnimal Bond, Purdue University School of 

Veterinary Medicine website. http://www.vet.

purdue.edu/chab/. Accessed November 7, 2011.

2. Wellness guidelines for animals in animal-assisted 

activity, animal-assisted therapy and resident 

animal programs [2011]. American Veterinary 

Medical Association website. http://www.avma.

org/issues/policy/animal_assisted_activity.asp. 

Updated April 2011. Accessed November 7, 2011.

3. About assistance dogs. Assistance Dogs International 

Inc website. http://www.assistancedogsinternational.

org/aboutAssistanceDogs.php. Accessed November 

7, 2011.

4. Frequently asked questions page [What Are Service 

Animals?]. Service Dog Central website. http://www.

servicedogcentral.org/content/faq. Accessed November 7, 2011.

5. 75 Federal Register Vol 75(178) (2010) (codifi ed 

at 28 CFR §36). http://www.ada.gov/regs2010/title

III_2010/titleIII_2010_fr.pdf. Accessed January 13, 

2012.

6. 28 CFR §35.104 (1991). Available at: http://www.

dol.gov/oasam/regs/cfr/28cfr/Part35/35104.htm. 

Accessed November 7, 2011.

7. Fact sheet: highlights of the fi nal rule to amend the 

Department of Justice’s regulation implementing 

Title II of the ADA (2011). Department of Justice 

website. http://www.ada.gov/regs2010/factsheets/

title2_factsheet.html. Accessed November 7, 2011.

8. About guide dogs page. Assistance Dogs International, Inc website. http://www.assistancedogsinter

national.org/guide.php. Accessed November 7, 2011.

9. About hearing dogs page. Assistance Dogs International, Inc website. http://www.assistancedogs

international.org/hearing.php. Accessed November 

7, 2011. *Internal, limited distribution military document, not generally 

accessible by the public.

DEFINITIONS OF ANIMALS USED IN HEALTHCARE SETTINGS
April – June 2012 17

THE ARMY MEDICAL DEPARTMENT JOURNAL

10. About service dogs page. Assistance Dogs International, Inc website. http://www.assistancedogsinternational.org/

service.php. Accessed November 7, 2011.

11. Service animal basics page. Delta Society website. http://www.deltasociety.org/Page.aspx?pid=303. Accessed 

November 7, 2011.

12. Horowitz S. The human-animal bond: health implications across the lifespan. Alternative Compl Ther.

2008;14(5):251-256.

13. Issues: human-animal bond. American Veterinary Medical Association website. http://www.avma.org/issues/

human_animal_bond/default.asp. Accessed November 7, 2011.

14. Animal-assisted activities/therapy 101. Delta Society website. http://www.deltasociety.org/Page.aspx?pid=317. 

Accessed November 7, 2011.

15. Debuse D, Chandler C, Gibb C. An exploration of German and British physiotherapists views on the effects of hippotherapy and their measurement. Physiother Theor Pract. 2005;21(4):219-242.

16. Hippotherapy as a treatment strategy. American Hippotherapy Association website. http://www.americanhip

potherapyassociation.org/hippotherapy/hippotherapy-as-a-treatment-strategy/. Accessed November 7, 2011.

17. Guidelines for animal assisted activity, animal-assisted therapy and resident animal programs [2011]. American 

Veterinary Medical Association web-site. http://www.avma.org/issues/policy/animal_assisted_guidelines.asp. 

Accessed November 7, 2011.

18. Chur-Hansen A, Stern C, Winefi eld H. Gaps in the evidence about companion animals and human health: some 

suggestions for progress. Int J Evid Based Healthc. 2010;8(3):140-146.

19. Carson L. The animal/human bond: a prescription for good health. J Health Educ. 2006;37(6):361-365.

20. Brewer K. Housing discrimination and companion animals [2005]. Animal Legal & Historical Center website. 

http://www.animallaw.info/articles/ovuspetsandhousinglaws.htm. Published 2005. Accessed November 7, 2011.

21. Psychiatric service and emotional support animals [publication #5483.01, 2011]. Disability Rights California 

website. www.disabilityrightsca.org/pubs/548301.pdf. Accessed November 7, 2011.

22. Offi ce of The Surgeon General. Memorandum: Overarching Guidance on the Use of Animals in the Healthcare 

Setting (Service Animals, Animal Assisted Therapies, and Animal Assisted Activities). Fort Sam Houston, TX: 

US Army Medical Command; January 30, 2012. Policy Memorandum 12-005.

23. Assistance Dogs International’s Guide to Assistance Dog Laws. Santa Rosa, CA: Assistance Dogs International; 

2006:143.

24. Army Regulation 40-905, SECNAVINST 6401.1B, AFI 48-131: Veterinary Health Services. Washington, DC: US 

Departments of the Army, Navy, and Air Force; August 29, 2006. Available at: http://www.apd.army.mil/pdffi les/

r40_905.pdf. Accessed January 13, 2012.

25. Huss RJ. Why context matters: defi ning service animals under federal law. Pepperdine Law Review. 2010;37:1163-

1216. Available at: http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1548674.

AUTHORS

LTC Mills is the Physical Therapy Staff Offi cer, Rehabilitation and Reintegration Division, Offi ce of the Army Surgeon 

General, Alexandria, Virginia.

MAJ Yeager is Chief, Occupational Therapy, Reynolds Army Community Hospital, Fort Sill, Oklahoma.

Raliegh is a facility animal at the Military Advanced Training Center, Walter 

Reed National Military Medical Center. 

Photo courtesy of the authors.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

ANIMALS AND THE MILITARY

Ever since mankind went to war, animals have played 

signifi cant roles. Such roles have been either in offi cial 

capacities such as cavalry horses, sentry dogs, carrier 

pigeons, and unit mascots, or unoffi cially as a Soldier’s 

battle companion. Prior to a battle, the Roman army 

performed a ritual that involved offering food to sacred 

chickens: if the chickens ate the food, it was an omen 

that the gods would join them; if the chickens refused to 

eat, defeat was imminent.1

During World War II, highly trained carrier pigeons 

provided a means of communication. Today, most utilitarian uses of animals in the military are not well known, 

except for the military working dogs that are trained 

to attack the enemy and detect explosives or narcotics. 

However, our military inventory of animals expands to 

US Navy dolphins, Special Operations horses, Marine 

Corps mules, and even peacocks that act as security 

alarms at key government installations. 

Lieutenant Colonel George A. Custer of Battle of the 

Little Big Horn infamy, was known to have his dogs 

around him during campaigns. He affectionately mentions being surrounded by his dogs in several letters to 

his wife, such as the one written on June 12, 1876:

Tuck regularly comes when I am writing, and lays her 

head on the desk, rooting up my hand with her long nose 

until I consent to stop and notice her. She and Swift, 

Lady, and Kaiser sleep in my tent.2

During World War II, General Eisenhower once remarked that his Scottish terrier mascots were especially 

appreciated, “because they are the only ‘people’ I can 

turn to without the conversation returning to the subject 

of war.” 3

Animal mascots have long been associated with unit esprit de corps. Interservice rivalries have boasted the Air 

Force Falcon versus the Army Mule or the Navy Goat 

versus the Marine Corps Bulldog. Animal mascots have 

been placed on offi cial unit orders and even given rank 

by the adoring units that proudly parade them around the 

military posts. Stories abound of animal mascots being 

integral parts of combat units, offering pride, stress relief, and a sense of humility during challenging periods.

Pets are bona fi de members of the military family, even 

perhaps assisting with military family transfers or service member deployments as the pet is seen as a stabilizing factor for children of military families.4

 It has also 

been shown that for a married couple without children, 

the attachment level to the pet can be very high, implicating a “surrogate” child relationship with animals 

(P.R.C., unpublished data, 1992).

ANIMALS AND MILITARY HEALTHCARE

In the healthcare fi eld, there exists an increasing popularity of the bond that is enjoyed between humans and animals. Multiple healthcare professions have recognized 

potential health benefi ts of the interactions that humans 

experience with animals. For example, it is well documented that the act of stroking a pet can signifi cantly 

lower a person’s blood pressure. The presence of dogs 

has been associated with reductions in blood pressure, 

mean arterial pressure, heart rate, and distress. Friedmann et al demonstrated a decreased mortality rate in 

pet owners one year after discharge from a coronary 

care unit.5

 These examples illustrate the beginning of 

many potential treatment benefi ts offered by companion 

animals in a clinical treatment setting.

Animals have found such a place in assisting the human 

healthcare professionals, the practice now known as 

animal-assisted therapy. In fact, there is an early history of animal-assisted therapy in US military treatment 

facilities. The US military promoted the use of dogs as 

a therapeutic intervention with psychiatric patients in 

1919 at St Elizabeth’s Hospital in Washington, DC.6

 Another early documented human-animal bond program 

involved the Department of Defense (DoD) at Pawling 

Army Air Force Convalescent Center, Pawling, NY, in 

the 1940s.7

 The Center’s farm animals were integrated 

into the treatment milieu for emotionally traumatized 

veterans and provided a purposeful interaction during 

their convalescence.

Following World War II, Dr Boris Levinson, a psychologist, used his own dog as a co-therapist during counseling sessions and published his fi ndings in the 1960s. 

Interest in this fi eld grew rapidly with the formation of 

the Delta Society in 1981, along with international membership and infl uence, leading to recognized benefi ts of 

Historical Perspectives of the Human-Animal

 Bond Within the Department of Defense

COL Perry R. Chumley, VC, USA
April – June 2012 19

human-animal bond interactions being accepted by the 

healthcare professions. 

In 1983, LTC Thomas Catanzaro, US Army Veterinary 

Corps, wrote of the interdependent relationships of 

animals, humans, and the health professions, and also 

described many considerations for establishing an animal-assisted therapy program in his An Administrator’s 

Guide for Animal Facilitated Therapy Programs in Federal Healthcare Facilities.

8

In 1985, the US Army Veterinary Corps, the DoD Executive Agent for Veterinary Services, took the lead in 

developing a better understanding of human-animal 

relationships and actively pursued ways for this knowledge to contribute to the military community. To that 

end, a Veterinary Corps offi cer, MAJ Lynn Anderson, 

was designated as the Human-Animal Bond Advisor to 

The Surgeon General of the Army in 1986. 

The Veterinary Corps established a 2-year Masters of 

Public Health program with an emphasis in the humananimal bond and community health specialties at the 

University of Tennessee in Knoxville. Upon graduating from this program in 1992, the author became the 

Veterinary Corps’ subject matter expert and established 

and directed the US Army Service Dog Training Center 

(SDTC) at Fort Knox, Kentucky from 1995 to 2004. 

The SDTC was a pilot program initiated to assist physically disabled Veterans and/or exceptional family members. The SDTC trained select stray dogs to become the 

indispensible helpers for physically disabled Veterans or 

family members. The SDTC staff consisted of 2 civil 

service animal trainers who trained not only the animals, 

but also select inmates from the Law Enforcement Command’s local prison. By assisting with training the dogs, 

the inmates received a rehabilitative experience as they 

transformed the unwanted stray dogs into invaluable 

helpers for those in need. The STDC program graduated 

its fi rst trained human recipient and animal teams on 

Veterans Day, 1997. Throughout its 7-year history, the 

SDTC successfully graduated over 60 human-animal 

teams represented by all of the DoD Services. Unfortunately, this program closed in October 2004 due to funding constraints within the Army Medical Department. 

Various animal-assisted activity programs, including 

animal visitation, operate at a number of Army medical centers (AMC), most notably at Tripler AMC (Honolulu) and Brooke AMC (Fort Sam Houston, TX), as well 

as the Munson Army Health Center, Fort Leavenworth, 

KS, and the Walter Reed National Military Medical 

Center (Bethesda, MD). Such programs are supported 

by the local Army medical commands and operate with 

a core of Red Cross volunteers. The main purpose of 

these programs involves bringing smiles to the patients, 

family members, and hospital staff. In doing so, patients 

focus on the animals which may help alleviate their fear, 

anxiety, or pain. Often, the hospital staff reports an increase in interaction with the patients associated with 

animal visitation programs. An example of continued 

animal-assisted activity program success is the recognition of the Tripler AMC program, which has existed 

for over 20 years, by the Annual Hawaii State Chapter Heroes Award. Also, before it was deactivated, the 

Army Veterinary Command recognized the values of 

such involvement with a competition each year for the 

best human-animal bond program among its subordinate branches. Another type of approach is represented 

by a unique human-animal bond program at Fort Myer, 

VA, the Equine-Assisted Program, which uses the caisson horses to help improve balance for certain traumatic 

brain injury patients.

Army military veterinarians of the Public Health Command perform the behavioral temperament evaluations 

and health examinations for the animals involved with 

the animal-assisted therapy and animal-assisted activity 

programs throughout the contiguous United States, Hawaii, and Germany. This involvement helps to ensure that 

the appropriate animals are employed to assist patients, 

clinicians, and families during the healing processes. 

As an adjunct to more traditional treatment modalities, the Walter Reed National Military Medical Center 

(WRNMMC) is currently involved with several humananimal bond programs that allow rehabilitating Soldiers 

to skillfully train potential mobility service dogs for 

Veterans with mobility impairments. This program is 

in collaboration with the therapeutic service dog training program operated by Warrior Canine Connection, a 

nonprofi t organization located near WRNMMC. At the 

Eisenhower Army Medical Center, Fort Gordon, GA, 

certain Soldiers who are recovering from posttraumatic 

stress disorder are recommended by behavioral healthcare providers to work with dogs to facilitate their goaloriented therapeutic regimens.

In the military operational environment, pairs of certifi ed therapy dogs have been specially trained and deployed to Iraq and Afghanistan with several combat 

and operational stress control units. The 212th Medical 

Detachment and the 254th Medical Detachment both 

employed therapy dogs for approved studies related to 

how the animals’ involvement may affect certain attitudes such as mood state, job satisfaction, stress levels, 

and resilience levels. To date, results of that study are 
20 http://www.cs.amedd.army.mil/amedd_journal.aspx

pending. The dogs are viewed as a means of breaking 

down the perceived barriers and facilitating social interaction between Soldiers and occupational health medical professionals.

Interest in the human-animal bond fi eld expanded enough 

that an Animal-Assisted Therapy Summit was organized 

in December 2009 by the Behavioral Health Division, 

Offi ce of The Army Surgeon General. The 3-day meeting at Fort Myer was initiated to help describe and defi ne 

existing animal-assisted activity and animal-assisted 

therapy programs and terminologies, as well as uses of 

animals in combat stress control units, Warrior transition 

units, and several military treatment facility programs. A 

consensus was developed to enhance standards, polices, 

objectives, and research metrics for various existing and 

potential programs.

THE FUTURE OF THE HUMAN-ANIMAL BOND AND

HEALTHCARE

Although it is widely held that there are both physical and psychological health benefi ts of pet ownership, 

there have been few well-controlled studies. However, 

the more subtle benefi ts that may be objectively measured via lower drug dosages or blood cortisol levels, 

and may be investigated as possible adjuncts to conventional therapies in pain management. Recently, Olmert9

summarized fi ndings that show blood oxytocin levels 

rising in both animals and people as they interact with 

each other. Oxytocin is thought to be associated with 

pair bonding and a reduction in fear or anxiety.

Another area of investigation with possible far-reaching 

implications is the human-animal bond effect as a broad 

alternative to conventional direct pain relief. Using a 

multidisciplinary approach, the human-animal bond 

programs associated with animal-assisted therapy may 

offer a signifi cant role for select patients to minimize 

pain. For example, the activity of caring for animals, 

both small and large, assists people with arthritis by 

providing activities that requires them go outside and 

walk a dog or feed a horse. Select patients who possess 

the inherent “nurturing” attribute may have a more apparent pain tolerance while in the company of animals. 

This nurturing attribute of animals may be the key difference that separates the effect that animals may render 

to patients versus an inanimate or animate “distracter” 

that may temporarily alleviate pain.

There is a defi nite role for companion animals in the 

treatment of our military personnel in multiple treatment venues. Involving the animals as an adjunct to 

traditional treatment modalities has been shown to have 

positive psychological and physical benefi ts for some patients during the healing process. Although much of the 

evidence that supports the use of animals is anecdotal, 

the empirical data is increasing with promising results.

For clinical staff interested in learning more about 

animal-assisted therapy programs, the Department of 

Defense Technical Bulletin TB MED 43

 is an excellent 

initial source for information and guidance.

REFERENCES

1. Roth JP. Roman Warfare. New York, NY:Cambridge 

University Press; 2009:61.

2. Custer EB. Boots and Saddles. Norman, OK: University of Oklahoma Press; 1961:272.

3. Department of Defense Technical Bulletin TB 

MED 4: DoD Human-Animal Bond Principles and 

Guidelines. Washington, DC: US Dept of the Army; 

June 16, 2003:2-2. Available at: http://armypubs.

army.mil/med/dr_ pubs/dr_a/pdf/tbmed4.pdf. 

Accessed January 10, 2012.

4. Anderson LJ. The pet in the military family at transfer time: it is no small matter. In: Sussman MD, ed. 

Pets and the Family. New York, NY: The Haworth 

Press; 1985:205-222.

5. Friedmann E, Katcher AH, Lynch JJ, Thomas SA. 

Animal companions and one year survival of patients after discharge from a coronary care unit. 

Public Health Rep. 1980;95(4):307-312.

6. Velde BP, Cipriani J, Fisher G. Resident and therapist views of animal-assisted therapy: implications 

for occupational therapy practice. Aust Occup Ther 

J. 2005;52:43-50.

7. Bekoff M. Animal assistance to humans: animalassisted interventions. In: Bekoff M, ed. Encyclopedia of Human-Animal Relationships. Vol 1. 

Westport, CT: Greenwood Press; 2007:1-2. 

8. Catanzaro TE. An Administrator’s Guide for 

Animal Facilitated Therapy Programs in Federal 

Health Care Facilities. Fort Sam Houston, TX: 

US Army-Baylor University Graduate Program 

in Health Care Administration; 1983. Available 

at: http://www.dtic.mil/cgi-bin/GetTRDoc?Loca

tion=U2&doc=GetTRDoc.pdf&AD=ADA222034. 

Accessed January 18, 2012.

9. Olmert MD. Made for Each Other: The Biology 

of the Human-Animal Bond. Cambridge, MA: Da 

Capo Press; 2009.

AUTHOR

COL Chumley is Chief, Human-Animal Bond Programs, 

DoD Veterinary Service Activity, Offi ce of The Army 

Surgeon General, Falls Church, Virginia.

HISTORICAL PERSPECTIVES OF THE HUMAN-ANIMAL BOND WITHIN THE DEPARTMENT OF DEFENSE
April – June 2012 21

FROM PETS TO ASSISTANTS

Although we tend to identify the 20th century as the 

time when dogs and animals in general were fi rst used 

to provide assistance to people with a variety of physical and mental diagnoses, this actually is not the case. 

The fi rst documented example of the therapeutic use of 

animals occurred in 9th century Gheel, Belgium, where 

animals were part of the “therapie naturelle” provided 

for the handicapped by members of the community.1(p7),2

The fi rst use of animals specifi cally for the treatment 

of the mentally ill occurred in late 18th century York, 

England.3,4 After the death of a Quaker in the inhumane 

conditions in what was then the York Asylum, a wealthy 

Quaker merchant, William Tuke, raised money to open 

the York Retreat in 1796 to care for the insane. Tuke’s 

methods were quite different from the coercive and punitive approaches in use at that time. Patients wore their 

own clothing and had the opportunity to work at crafts, 

read books, write, and wander the grounds, which contained a variety of small animals. The combination of the 

example set by the York Retreat, the continued efforts of 

the Tuke family to improve the treatment of the mentally 

ill, and a scathing report on conditions in British mental 

hospitals during the 1830s initiated gradual improvements in the overall treatment of the mentally ill.4

The fi rst documented therapeutic use of animals in the 

United States took place during World War II at an 

Army Air Corps convalescent hospital in Pawling, New 

York. According to Bustad and Hines,1(p19) the hospital 

functioned more as a rest home than a medical facility 

for patients suffering from “operational fatigue,” which 

is probably called posttraumatic stress disorder today. 

The facility provided both an academic program and the 

physical activity of working at the facility’s farm. 

DEFINING SOME TERMS

Although the history of human-animal relationships 

is fi lled with tales of how animals, dogs in particular, 

benefi ted humans, most of those examples were relatively informal, possibly even coincidental. The dogs did 

not receive any specifi c training, and there were no formal programs. In the 20th century, however, formal programs were developed to train dogs to provide a variety 

of services to humans.

Basically, there are 2 categories of dogs that provide 

assistance to people with disabilities: service dogs and 

therapy dogs. Although the phrase “assistance dog” is 

used frequently, and there is an organization called “Assistance Dogs International,” the term assistance dog has 

no meaning in law. A recent amendment to the Americans with Disabilities Act (ADA) (42 USC §12101-12213 

and 47 USC §225, 611), which became effective March 

15, 2011, defi nes a service animal as:

any dog that is individually trained to do work or perform 

tasks for the benefi t of an individual with a disability, 

including a physical, sensory, psychiatric, intellectual, or 

other mental disability....The work or tasks performed by 

a service animal must be directly related to the handler’s 

disability.5

Whether or not therapy dogs are covered under the 

amended ADA depends on the disability of their handlers, how they are trained, and how they are used, as 

specifi ed in the defi nition presented above. It should be 

noted that the ADA clearly includes psychiatric assistance as a category for service dogs.

Ensminger defi nes a therapy dog and its work as:

...a dog that, with a handler, visits individuals or 

groups to provide some relief from an institution, such 

as a hospital, or condition, such as cerebral palsy or 

Alzheimer’s. Therapy dogs may be used one-on-one as 

part of a treatment program for an individual, which is 

often called animal assisted therapy (abbreviated AAT), 

but mostly therapy dogs in the United States today visit 

facilities to help or at least cheer up the populations of 

those facilities.6(pxii)

Dogs and Human Health/Mental Health:

 From the Pleasure of Their Company

 To the Benefits of Their Assistance

Jan Shubert, LCSW

The views expressed in this article are those of the author and do not reflect the views of the US Environmental Protection 

Agency, the US Army, or the US Army Medical Department.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

Clearly, under the new ADA defi nition of service dogs, 

dogs used according to Ensminger’s defi nition do not 

qualify as service dogs.

SERVICE DOGS

Service dogs, as defi ned in the amended ADA, assist individuals with a variety of physical disabilities, including 

vision impairments, hearing impairments, mobility disorders, and seizure disorders. As important as these services are to their recipients, the most important service 

by far is the companionship that the dogs provide, particularly to individuals who may have been experiencing 

considerable isolation because of their disabilities.

Service Dogs for the Visually Impaired

According to Ensminger,6

 the fi rst use of service dogs 

for the visually impaired dates to post-World War I Germany where dogs were trained to guide soldiers blinded during the war. In 1927, Dorothy Harris Eustis, an 

American living in Switzerland and breeding and training German shepherd dogs, learned of the German program and wrote an article that appeared in the November 

5, 1927 edition of The Saturday Evening Post.

7

 Her article eventually led to the founding of the fi rst American 

organization for the training of guide dogs for the blind, 

The Seeing Eye, in 1929.8

 Since then, a number of other 

organizations have been established for the training of 

guide dogs for the blind, including Guide Dogs for the 

Blind and Leader Dogs for the Blind. According to Ensminger,6

 there were approximately 9,000 guide dogs in 

the United States as of 1999, most of whom had been 

trained by the 3 organizations mentioned above.

Service Dogs for the Hearing Impaired

The fi rst organization to train dogs to assist people who 

had hearing impairments was established as a result of 

one woman’s efforts to replace a dog that had died. In 

1973, Elva Janke contacted the Twin Cities Action News 

television program asking for assistance in training a 

dog to alert her to sounds that she could not hear.9

 A 

trainer was found through the intervention of the director of the Minnesota Humane Society. Three years later, 

the American Humane Association in Denver, Colorado, 

established a national training center. In 1979, a separate 

organization, Hearing Dog, Inc, was established. The 

name was changed to International Hearing Dog, Inc 

after the organization placed a dog in Canada. Since its 

founding, the organization has trained and placed more 

than 1,100 hearing dogs, all of whom come from shelters. 

The dogs are trained to alert their handlers to a variety 

of sounds, including alarm clocks, telephones, doorbells, 

crying babies, sirens, and smoke alarms.10 According 

to Ensminger,6

 there were approximately 4,000 hearing 

dogs in the United States as of 2001. Now, as with dogs 

for visually impaired individuals, there are numerous 

organizations training and placing hearing dogs.

Service Dogs for the Mobility Impaired

Today, the efforts of service dogs are not limited to 

serving as eyes and ears for individuals with visual or 

hearing impairments, they also serve as arms and legs.10

Service dogs for those with mobility impairments can 

perform a number of tasks for their handlers, including 

retrieving or fetching specifi c items or dropped items, 

opening doors, turning lights on or off, and carrying 

backpacks. The larger breeds can also serve as braces to 

help stabilize ambulatory handlers, assist them in getting out of chairs, and even pulling wheelchairs.

Service Dogs for Those Suffering from Seizures

There have been reports that some dogs can sense 

physiological changes in their owners when a seizure 

is approaching and alert the owner ahead of time.6

 This 

warning allows the owner to move to a safe place and 

prepare and/or take preventive medication. Such reports 

are primarily anecdotal in nature. In 1999, however, a 

British organization, Support Dogs, was reported to have 

trained 6 dogs to detect and indicate coming seizures, 

providing a warning ranging from 10 to 45 minutes before the seizure.11 The study also indicated a reduction 

of seizure activity. More recently (2004), the University 

of Florida School of Veterinary Medicine conducted a 

study of 29 individuals who had epilepsy and also owned 

dogs. Nine dogs reportedly responded to their owners’ 

seizures, and three of these were also reported to have 

alerted their owners before the seizure.12 Nevertheless, 

there is skepticism in the scientifi c community that dogs 

can actually be trained to sense coming seizures.

THERAPY DOGS

As described earlier, there were informal efforts to include animals in the treatment of the mentally ill in the 

18th and 19th centuries. In the 20th century, these efforts became more intentional. The therapist truly considered to be the true father of animal-assisted therapy, 

however, is Boris Levinson. He acknowledged that his 

discovery of the effectiveness of a dog in building rapport with a child client was purely accidental.13 The child 

and his mother arrived early for their appointment, before Levinson had time to confi ne his dog, Jingles. Until 

that time, Levinson had been unable to establish a relationship with the child, but Jingles quickly facilitated 

the establishment of a therapeutic relationship between 

Levinson and the child. Levinson went on to include 

dogs in many of his therapeutic sessions and to write and 

speak about the success of this new form of intervention. 

His initial efforts to present the results of his animalassisted therapeutic efforts at professional conferences 

DOGS AND HUMAN HEALTH/MENTAL HEALTH:

FROM THE PLEASURE OF THEIR COMPANY TO THE BENEFITS OF THEIR ASSISTANCE
April – June 2012 23

THE ARMY MEDICAL DEPARTMENT JOURNAL

were met with more than a little ridicule. Despite the 

skepticism with which Levinson’s colleagues greeted 

his presentations, a survey he conducted with clinicians 

in the New York State Psychological Association indicated that more than one-third of the respondents had 

themselves used animals in their practices.14 Levinson 

persisted in his efforts to interest mental health professionals in the benefi ts of including animals in their 

therapeutic activities, publishing Pet-oriented Child 

Psychotherapy15 in 1969 and Pets and Human Development13 in 1973, as well as numerous journal articles. A 

principal reason for Levinson’s persistence regarding 

the importance of human-animal relationships was his 

belief that humans had become totally alienated from 

each other and from nature.13

Another breakthrough occurred around the same time 

that Levinson was promoting the benefi ts of animal-assisted therapy. Samuel and Elizabeth Corson pioneered 

in the use of dogs, fi rst in a psychiatric facility associated with Ohio State University and then with a nursing 

home population in the early 1970s.1,6(p104),14,16,17 Corson 

et al16 indicated that the introduction of the dogs into the 

treatment of patients previously unresponsive to a variety of different interventions increased social interactions among the patients and also improved patient/staff 

relationships. Subsequently, several studies were conducted between the late 1970s and the mid 1990s that 

not only verifi ed the Corsons’ results, but also made the 

mind-body connection, demonstrating the relationship 

between the stress relief provided by pets and improved 

cardiovascular health.14

Around the same time, 2 important organizations were 

established.6

 Therapy Dogs International was founded 

in 1976 by Elaine Smith,18 an American nurse who had 

worked in England and observed how patients responded to visits by the hospital chaplain who was accompanied by his dog. In 1977, the Delta Foundation was 

founded in Portland, Oregon, by several medical and 

veterinary professionals who were interested in the effects of human-animal relationships. The organization 

became the Delta Society in 1981, and also focuses on 

training, certifying, and registering therapy and service 

dogs in addition to its continued interest in research into 

human-animal interactions.19

ANIMAL-ASSISTED ACTIVITIES AND

ANIMAL-ASSISTED THERAPY

Over the years, numerous different terms have been 

used to describe the act of using animals to assist people. 

To simplify matters, the Delta Society divided the types 

of activities into 2 categories: animal-assisted activities 

(AAA) and animal-assisted therapy (AAT). In AAA, 

specially trained professionals, paraprofessionals, or 

volunteers provide opportunities for motivational, educational, recreational, and/or therapeutic benefi ts to enhance the quality of life in a variety of settings without 

setting specifi c goals. AAT is an intervention, delivered 

by a health/human service professional with specialized 

expertise, in which an animal that meets specifi c criteria is an integral part of the treatment process. Key 

features include specifi ed goals and objectives for each 

individual and measured practice.20

The term “therapy dog” has been applied to dogs who 

provide both AAA and AAT interventions with individuals or groups. Therapy dogs can be trained to assist in a medical crisis (eg, fetching medication, dialing 

911), with treatment (eg, alerting someone with intense 

startle refl exes to the approach of another person), with 

emotional reactivity (eg, physical contact to help ground 

someone with an extreme fear reaction), and with security (verifying safe situations, turning lights on for 

those suffering from posttraumatic stress disorder).21

Under specifi c circumstances, therapy dogs providing 

this type of assistance to individuals with mental disabilities also can be considered service dogs under the 

ADA. Ensminger6

 points out that dogs also can empower 

individuals with panic disorder or agoraphobia to venture out into the world, and can help ground and orient 

someone with a dissociative disorder. There also are anecdotal reports that service dogs can be of assistance to 

children who have autism.

Animals also can be incorporated into therapeutic 

approaches that focus on an Eriksonian life stage 

approach.22,23 Fine suggests that AAI/AAT can be incorporated into therapeutic approaches to individuals as they move through Erikson’s 8 stages of human 

development.

THEORETICAL BASES FOR AAT AND AAA

Kidd and Kidd24 acknowledged the lack of an all-encompassing theory for the human-companion animal bond 

and examined the potential applicability of animal/animal, human/human, and human/object relations model 

theories for the development of a theory explaining the 

human-animal bond. After examining various theories 

in each model group, they concluded:

The best that can be said is that sometimes, under 

some circumstances, and in some ways, human/animal 

relationships are analogous to animal/animal, or to 

human/human, or to human/object relationships.24(p143)

They called for research to establish a database that 

could be used to develop theories relating to the human/

animal bond. 
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

Kruger and Serpell20 also discussed the lack of a unifying theoretical framework for human-animal relationships or animal-assisted interventions. They divided the 

various theories that have been proposed into 2 categories: those that are based on the intrinsic characteristics of the animals that contribute to therapy, and those 

that focus on the animals as tools that can foster client 

change. In the fi rst category, they cite the “biophilia hypothesis,”* learning theory, and social mediation theories, attachment theory, object relations theory, social 

provisions theory, and nondirective or Rogerian theory.

In the second category, that of the animal as a tool to foster or facilitate client change, we fi nd cognitive and social cognitive theory and role theory. Animals are seen 

as useful in changing such behavior because, unlike 

many people, their feedback is both quick and honest. 

In addition, working with animals can lead to increased 

feelings of self-effi cacy and accomplishment, which, in 

turn, lead to more positive self-regard. In role theory, 

as opposed to role playing, a person actually takes on 

the new role and its responsibilities (eg, dog training 

in a juvenile detention center). Success in the new role 

is believed to lead to an improved self-image and selfconfi dence.

In discussing attachment, Bowlby stated:

To say of a child that he is attached to, or has an 

attachment to, someone means that he is strongly 

disposed to seek proximity to and contact with a 

specifi c fi gure and to do so in certain situations, 

notably when he is frightened, tired, or ill....The 

theory of attachment advanced is an attempt to 

explain both attachment behavior, with its episodic 

appearance and disappearance, and also the enduring 

attachments that children and older individuals 

make to particular fi gures.25(pp371-372)

Following Bowlby then, the relationship that many children and adult pet owners have with their pets can be 

said to be a form of attachment behavior, particularly 

when the animal serves as a confi dant and provides solace during times of stress. According to Crawford et al,26

the aspects of attachment theory that are equally applicable to both human-human attachment and human-animal attachment include “emotional bond, goodness of 

fi t, secure base, seeking proximity, and representational 

models.” To Siegel,27 a relationship with a companion 

animal represents one of many potential social bonds. 

Among the aspects that contribute to the benefi ts of the 

human-companion animal relationship are the nonjudgmental characteristics of the animal’s regard for its owner, the childlike qualities of the animal (ie, neoteny), and 

the touching that is involved in the relationship (ie, it is 

akin to Rogerian therapy with the benefi t of touch).

Parish-Plass,28 in particular, provides an example of the 

application of attachment theory through the means of 

AAT in an innovative program for abused and neglected 

children in Israel. She describes how the use of AAT 

can allow abused and neglected children to form stable 

relationships with animals (ie, attachments) with the assistance of a therapist, thereby helping them to develop 

healthier ways of relating to others and, hopefully, reduce the likelihood of them becoming abusive and neglectful parents themselves.

On a lighter note, Beck and Madresh29 compare attachments to romantic partners and attachments to pets, 

concluding that “pet owners experience more security 

in relationships with their pets than with their romantic 

partners.”29(p52) Interestingly, this conclusion is at least 

partially confi rmed by an Associated Press poll in 2010 

that asked pet owners whom they would choose if one 

had to go: their signifi cant other or their pet. The poll 

found that 14% of those interviewed (n=1,501, nationwide) would choose their pet!30

EFFECTS OF HUMAN-DOG RELATIONSHIPS ON HUMANS

Discussions of the benefi ts of pet ownership, AAA, and 

AAT are frequently met with skepticism largely because 

of the relative paucity of scientifi c documentation (ie, 

randomized controlled trials) and the heavy reliance on 

anecdotal accounts. Over the last 25 years, a number of 

reviews of the state of research in the animal-assisted 

intervention fi eld have been conducted. In 1984, Beck 

and Katcher31 reviewed claims of therapeutic benefi ts of 

pets and also examined the research approaches to test 

that hypothesis. They found primarily descriptive studies that presented but did not test hypotheses and lacked 

demonstrations of the benefi ts of treatment or a cause 

and effect relationship.

In 2008, Barker and Wolen32 conducted a review of research of the effects of both pet ownership and animalassisted activities (including animal-assisted therapy) 

conducted since 1980 to see if anything had changed 

since the 1984 Beck and Katcher review.31 They reviewed 129 studies, most of which were still descriptive 

in nature, although they did note that signifi cantly more 

experimental studies have been conducted, some of 

which they praised for the methodology utilized. They 

concluded that:

DOGS AND HUMAN HEALTH/MENTAL HEALTH:

FROM THE PLEASURE OF THEIR COMPANY TO THE BENEFITS OF THEIR ASSISTANCE

*A hypothesis put forward by Edward Wilson, PhD, that humans evolved as creatures deeply enmeshed with the intricacies of nature, and that we still have this affi nity with nature 

ingrained in our genotype. Information available at: http://

wilderdom.com/evolution/BiophiliaHypothesis.html.
April – June 2012 25

THE ARMY MEDICAL DEPARTMENT JOURNAL

a few pockets of evidence do exist and appear to be 

growing. Pets appear to buffer the impact of stress on 

some owners, and may be associated with other health 

attributes such as increased physical activity...32(p492)

A number of studies have examined the effects of human-dog relationships on physical health. Friedmann 

and colleagues,33 Siegel,34 and Anderson et al35 found 

pet ownership (particularly dogs) benefi ts to include enhanced survival rates in individuals with cardiovascular 

disease, reduced need for physician visits, and reduced 

systolic blood pressure and plasma triglycerides. Allen 

and associates36 found reduced physiological activity 

during the performance of stressful tasks when individuals were in the presence of their pet dogs. Odendaal37

documented physiological responses when humans had 

positive interactions with dogs: β-endorphin, oxytocin, 

prolactin, β-phenylethylamine, and dopamine increased 

signifi cantly among both humans and dogs; cortisol decreased signifi cantly in humans, but not in dogs.

On the other hand, Grossberg et al38 found increased 

blood pressures and heart rates when individuals were 

performing stressful tasks in the presence of their pet 

dogs. Garrity and colleagues39 not only found no evidence of physical health benefi ts for elderly pet owners, 

but they actually found negative effects in the form of 

reduced human network support.

Regarding emotional well-being, Mugford and M’Comisky40 conducted one of the earliest studies of the benefi ts of companion animals for the elderly, in this case 

budgerigars (ie, parakeets), and found increased social 

interaction as a result of having the birds. Barker and 

Dawson,41 Brickel,42 and Goldmeier43 found that contact 

with a therapy dog or personal pet reduced depression 

and anxiety for those living in an institution or living 

alone.

Like the studies of physical effects of interactions with 

dogs, studies of psychological effects also were not 

uniformly positive. Ory and Goldberg,44,45 Miller and 

Lago,46 and Zasloff and Kidd47 found no differences in 

perceived happiness, psychological well-being, or loneliness between participants who owned pets and those 

who did not.

EFFECTS OF HUMAN-DOG RELATIONSHIPS ON THE DOGS

Numerous studies have been conducted on how dogs 

can be used to help humans and on the effectiveness of 

that help. Relatively few studies, however, have been 

conducted on the effects on dogs of providing such assistance. In 2000, Serpell et al48(pp417-426) identifi ed 7 potential animal welfare problem areas:

 Failure to provide for animal’s behavioral needs

 Breeding or selection of animal-assistance animals

 Failure to consider animal developmental events 

and processes

 Use of inappropriate or inhumane training 

methods

 Having unrealistic expectations of the animals

 Using inappropriate equipment and facilities for 

the animals

 Inadequately trained end users

Serpell, Coppinger, and Fine also point out what they 

refer to as an ethical “tension between interests”48(p415)

in the use of dogs to assist humans. That can become an 

outright confl ict of interest if the dogs experience pain, 

fear, or an inability to satisfy their own needs.

The different uses of dogs to provide assistance to humans all have their own potentials for turning the “tension between interests” into confl icts of interests. For 

example, service dogs tend to be on duty 7 days a week, 

24 hours a day, resulting in the possibility of inadequate 

“down” time, as well as potential issues from wearing a 

harness for long periods of time and the potential for injuries from pulling a wheelchair. Resident therapy dogs 

in nursing homes and other residential facilities can also 

be expected to be on duty for long periods of time and 

potentially subjected to inappropriate handling/touching, as well as over-feeding and inadequate exercise. 

Visiting therapy dogs are taken in motor vehicles to visit 

nursing homes, schools, hospitals, and other facilities, 

often in crates. The transportation itself can be stressful 

for some animals, who also may be subjected to inappropriate handling as well as emotional stress transmitted from distressed humans, such as those in hospitals. 

Therapy dogs in private practices, even when working 

with loving and loved owner/therapists, can experience 

stress if suffi cient provisions are not made for them to 

retreat to a place where they will be undisturbed for periods of time. They also can be exposed to emotional 

stress transmitted by distressed clients. Preventing confl icts of interest between dogs and their roles in assisting 

humans requires effort at a number of levels.

A good starting point is the source of the animals. In 

many cases, service dogs are bred by the organization 

that is training and placing the dog, or they come from 

shelters, depending on the type of service to be provided. Some dogs also are purchased or donated. Service dogs for the visually impaired are often bred by the 
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

organization. Concerns have been raised about the early 

life of these dogs49,50 as they may spend their fi rst year 

moving from a kennel in which they were born, to a 

temporary family for socialization, back into the kennel for extensive training, and then placement with a 

(hopefully) permanent human partner. Serpell and colleagues49 believe that these environmental changes can 

have adverse psychological effects on the dogs and may 

contribute to the high failure rate in service dog training. 

At the same time, however, Fallani et al51 examined the 

bond formed by a service dog with its blind owner and 

compared this bond with that formed between pet dogs 

and their owners. Some of the pet dogs actually showed 

higher anxiety than did the other dogs. In their study, 

guide dogs were able to form deep attachments to their 

blind owners in spite of their previous relationships with 

puppy walkers and trainers.

There are also concerns about the breeding practices 

within some organizations because of the inbreeding 

tendencies that may result in the desired fairly uniform 

appearance and behavior, but also result in a variety of 

genetic disorders. Another ethical question relates to the 

dogs bred to be service dogs who do not make it to training because of early diagnosis of genetic problems, or 

those who do not make it through training because of 

temperament or personality issues. In the case of the latter, at least one of the breeding/training/placement organizations adopts these animals out. Whether this is the 

case with all of the organizations that breed their own 

dogs is unknown. In the case of the former, the severity of the genetic problem may affect what happens to 

the puppy. But, the ethical question remains regarding 

breeding practices that result in signifi cant numbers of 

dogs with genetic defects.

Shelters are another source of service (particularly 

hearing dogs) and therapy dogs. On the one hand, this 

is a signifi cant benefi t for dogs that otherwise might be 

euthanized. On the other hand, the frequent paucity of 

information about the backgrounds of shelter animals 

does raise the question of how to identify animals appropriate for service or therapy roles.48

All of these points raise a number of ethical issues relating to the use of animals, particularly dogs, to provide service and other forms of therapeutic assistance 

to humans.

WHERE DOES THE FIELD GO FROM HERE:

SUMMARY, CONCLUSIONS AND SUGGESTIONS

We clearly use dogs to meet a large variety of human 

needs, both physical and emotional, frequently not only 

neglecting the effects on them, but not even recognizing 

them. For example, as Butler so eloquently states:

Nothing else dogs do compares to the kinds of intrinsically 

stressful social interaction that takes place when they 

visit clinical, educational, or posttrauma situations. No 

other canine-related event, no sport nor competition 

requires a dog to enter the intimate zones of unfamiliar 

humans and remain there for several minutes of petting 

and hugging.52(p31)

Butler also points out that the act of hugging, one so accepted in many parts of human society, is one that not 

only is foreign to a dog’s nature, but is also an act that 

dogs can perceive as one of dominance and experience 

as stressful. Yet hugging is encouraged in countless service dog and AAA/AAT interactions with dogs.

So, what direction should the fi eld take in the future? 

First, given that service dog and AAT/AAA activities 

are not likely to end, more must be done to safeguard 

the physical and mental health of the dogs. How can animals be protected from potential exploitation and harm? 

A good starting point would be subscribing to and guaranteeing the “5 freedoms,” which are accepted as determinants of animal welfare49(pp482-483): freedom from 

thirst, hunger, and malnutrition; freedom from discomfort; freedom from pain, injury, and disease; freedom 

from fear and distress; and freedom to express normal 

behavior, including socialization with its own species.

The next step is for trainers and handlers to be able to 

recognize the signs of stress in their puppies and dogs. 

There are numerous training courses, websites, and 

training manuals that can provide this information. Further, more needs to be done to screen shelter and privately owned animals to ensure that the dogs being trained 

for various service dog and AAA/AAT activities truly 

have the appropriate temperaments for this work. Last, 

more needs to be done in the area of initial and followup training by the service dog placement organizations 

to ensure that the dog recipients have a clearer understanding of how their dog communicates with them (ie, 

dog body language) and that their expectations of their 

dog are appropriate. Bustad and Hines1

 included a role 

for veterinarians in helping to ensure the well-being of 

service and AAT/AAA dogs.

It also is clear that the future of the service dog and the 

AAT/AAA fi eld needs to include a strong focus on research, not only research into the benefi ts of the association for humans, but research into the effects of this 

association on dogs. Beck and Katcher53 make a number 

of suggestions for future research, including combining 

DOGS AND HUMAN HEALTH/MENTAL HEALTH:

FROM THE PLEASURE OF THEIR COMPANY TO THE BENEFITS OF THEIR ASSISTANCE
April – June 2012 27

THE ARMY MEDICAL DEPARTMENT JOURNAL

the biophilia hypothesis with social support theory to 

broaden the scope of human-animal relationship research 

to incorporate the larger natural environment. This approach connects back to Levinson’s13 belief that humans 

had become too divorced from contact with the natural world. They also recommend further research into 

the physiological effects on humans of associating with 

dogs and into the physiological effects of the relationship on the dogs. Additionally, as Garrity et al,39 Ory and 

Goldberg,44,45 Miller and Lago,46 and Zasloff and Kidd47

found, AAT/AAA does not always have positive results. 

It is important to identify populations for whom the relationship might not be helpful to avoid causing harm to 

those individuals and also to avoid subjecting dogs to 

potentially negative and even harmful situations.

Regardless of which research methodology is used, as 

Beck and Katcher53 have emphasized, it must be interdisciplinary in nature, involving not only mental health and 

medical professionals, but also sociologists, ethnologists, 

animal behaviorists and trainers, and likely numerous 

other professional communities. Our awareness of the 

extensiveness of the human relationship with dogs may 

have been awakened with the fi nding of the site of the joint 

burial of an ancient human and a puppy approximately 

12,000 years ago,54 but we may only have scratched the 

surface of the real meaning of the relationship.

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old people. In: Anderson RS, ed. Pet Animals & Society. London: Bailliere Tindall; 1975:54-65.

41. Barker SB, Dawson KS. The effects of animalassisted therapy on anxiety ratings of hospitalized 

psychiatric patients. Psychiatr Serv. 1998;49(6):797-

801.

42. Brickel CM. Depression in the nursing home: a 

pilot study using pet-facilitated psychotherapy. In: 

Anderson RK, ed. The Pet Connection: Its Infl uence on Our Health and Quality of Life–Proceedings of the Minnesota-California Conferences on 

the Human-Animal Bond. Minneapolis: Center to 

Study Human-Animal Relationships and Environments, University of Minnesota; 1983:407-415.

43. Goldmeier J. Pets or people: another research note. 

Gerontology. 1986;26(2):203-206.

44. Ory MC, Goldberg EL. Pet possession and life satisfaction in elderly women. In: Katcher AH, Beck 

AM, eds. New Perspectives on Our Lives with 

Companion Animals. Philadelphia: University of 

Pennsylvania Press; 1983:303-317.

45. Ory MG, Goldberg EL. An epidemiological study 

of pet ownership in the community. In Anderson 

RK, Hart BL, Hart LA, eds. The Pet Connection: 

Its Infl uence on Our Health and Quality of Life–

Proceedings of the Minnesota-California Conferences on the Human-Animal Bond. Minneapolis: 

Center to Study Human-Animal Relationships and 

Environments, University of Minnesota; 1983:320-

330.

46. Miller M, Lago D. The well-being of older women: 

The importance of pet and human relations. Anthrozoös. 1990;3(4):245-250.

47. Zasloff RL, Kidd AH. Loneliness and pet ownership 

among single women. Psychol Rep. 1994;75:747-752.

DOGS AND HUMAN HEALTH/MENTAL HEALTH:

FROM THE PLEASURE OF THEIR COMPANY TO THE BENEFITS OF THEIR ASSISTANCE
April – June 2012 29

THE ARMY MEDICAL DEPARTMENT JOURNAL

48. Serpel J, Coppinger R, Fine AH. The welfare of assistance animals: An ethical comment. In: Fine AH, 

ed. Handbook on Animal-Assisted Therapy: Theoretical Foundations and Guidelines for Practice. 1st 

ed. San Diego, CA: Academic Press; 2000:415-431.

49. Serpell JA, Coppinger R, Fine AH, Peralta JM. 

Welfare considerations in therapy and assistance 

animals. In: Fine AH, ed. Handbook on AnimalAssisted Therapy: Theoretical Foundations and 

Guidelines for Practice. 3rd ed. Amsterdam, Neth: 

Elsevier/Academic Press; 2010:481-503.

50. Coppinger R, Coppinger L. Dogs: A New Understanding of Canine Origin, Behavior, and Evolution. 

Chicago, IL: University of Chicago Press; 2001.

51. Fallani G, Previde EP, Valsecchi P. Do disrupted 

early attachments affect the relationship between 

guide dogs and blind owners?. Appl Anim Behavr 

Sci. 2006;100:241-257.

52. Butler K. Therapy Dogs Today: Their Gifts, Our 

Obligation. Norman, OK: Funpuddle Publishing 

Associates; 2004.

53. Beck AM, Katcher AH. Future directions in 

human-animal bond research. Am Behav Sci. 

2003;47(1):79-93.

54. Davis SJM, Valla FR. Evidence for domestication 

of the dog 12,000 years ago in the Natufi an of Israel. Nature. 1978;276:608-610.

AUTHOR

Ms Shubert leads a Critical Incident Stress Management 

Team in the Offi ce of Emergency Management of the US 

Environmental Protection Agency. She is also involved in 

a clinical practice in Ashburn, Virginia, and is a doctoral 

student at Fielding Graduate University.

The lifesize statue of a proud service dog greets all who visit the facilities 

of America’s VetDogs in Smithtown, New York (see article on page 8).

Photo courtesy of LCDR Kathleen L. Watkins, USPHS.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

There is a growing body of literature that has examined 

the physiological and psychosocial impact of pet ownership, animal-assisted activities (AAA), and animal-assisted therapy (AAT) employed in a variety of settings 

and with various patient populations such as those with 

cardiovascular disease, cancer, stroke, dementia, and 

psychiatric disorders. Additionally, new interest is seen 

within the workplace. In general, there is evidence demonstrating improvement in anxiety, fear, depression, and 

loneliness with associated physiological changes following animal-assisted therapy which has important implications for use of such therapy with military personnel 

suffering from combat stress, posttraumatic stress disorder, and other disorders similar to those listed above. 

Although there are several AAT programs employed 

by the military, there have been no published empirical 

investigations of these programs. The purpose of this 

paper is to present an overview of research conducted 

in nonmilitary settings including hospitals, psychiatric 

facilities, nursing homes/assisted living centers, and the 

workplace.

BENEFITS OF AAT FOR HOSPITALIZED PATIENTS WITH

MEDICAL DISORDERS

The benefi ts of AAT for patients hospitalized with 

heart failure was investigated by Cole1

 who compared 

a 12-minute AAT visit with a 12-minute volunteer only 

visit and treatment as usual. Seventy-six patients were 

randomly assigned to one of the 3 groups and physiological and self-report measures of anxiety were measured. 

Change from baseline indicated a signifi cant decrease in 

systolic pulmonary artery pressure and pulmonary capillary wedge pressure both during (8 minutes) and after 

(16 minutes) the AAT visit compared with the other 2 

study groups. Compared to the volunteer only group, 

signifi cant decreases in epinephrine and norepinephrine 

levels were measured both during and after AAT. There 

was also a signifi cantly greater decrease in reported 

anxiety for the AAT group compared with those who 

received the 12-minute volunteer visit as measured by 

Spielberger’s State-Trait Anxiety Inventory.*

A study conducted with a similar sample of patients with 

a primary diagnosis of heart failure employed a hybridized intervention combining AAT and an early ambulation program, thus deemed canine-assisted ambulation 

(CAA).2

 Sixty-nine hospitalized cardiac patients, physician-ordered and approved for ambulation, were prompted to ambulate by a restorative aide. If the patients 

refused, they were approached a second time with the 

proposal of ambulating while accompanied by a therapy 

dog. To prevent bias from study effects, consent to have 

the individual’s data be included was obtained after the 

ambulatory activity or after the patient’s second refusal. 

Distance ambulated (in steps) was calculated by pedometer, and patient satisfaction with CAA was measured by 

a Likert scale survey composed of 5 items. As compared 

to a stratifi ed historical sample of which 28% of patients 

refused ambulation, only 7.2% of the study sample refused ambulation completely. Moreover, 18.9% of the 

experimental group patients reversed their initial refusal 

to ambulate when given the opportunity to participate in 

CAA. Those that engaged in CAA walked almost twice 

(96% more) as many steps as the ambulating patients 

Research on Benefits of Canine-Assisted

 Therapy for Adults in Nonmilitary Settings

Janet S. Knisely, PhD

Sandra B. Barker, PhD

Randolph T. Barker, PhD

ABSTRACT

Research has examined the physiological and psychosocial impact of animal-assisted activities (AAA) and 

animal-assisted therapy (AAT). The current review article summarizes the benefi ts of AAA and AAT for 

hospitalized patients with medical disorders, psychiatric patients, and residents of nursing homes and longterm care facilities. The literature regarding inclusion of animals in business and organizational settings is 

also reviewed. Although there is clear evidence of improved physical and psychological health from AAA and 

AAT in the civilian population, there is a dearth of published fi ndings of the evaluation of such benefi ts for 

military personnel.

*A commonly used measure of trait and state anxiety. Description 

and Information available at: http://www.apa.org/pi/about/publi

cations/caregivers/practice-settings/assessment/tools/traitstate.aspx.
April – June 2012 31

in the historical group. Self-report data indicated that 

the participating patients were satisfi ed with CAA experience. For other patient populations, such as postoperative, stroke, and neurologically impaired outpatients 

among whom ambulation is encouraged, this study suggests CAA may be motivational and an effective adjunct 

to existing ambulation and patient care routines. Furthermore, as early ambulation has been associated with 

decreased length of stay and thus reduced patient care 

costs among cardiac patients, the use of CAA may additionally improve similar outcomes.

Another study evaluated a one-hour AAA session with 

oncology patients while they were receiving chemotherapy in a day hospital.3

 Self-report measures of anxiety, 

depression, somatic symptoms, and aggression were 

collected as well as heart rate, arterial oxygen saturation, and blood pressure. The AAA session was divided 

into three 20-minute segments involving patients watching the dog exercise with the handler, playing with the 

dog, and feeding or holding the dog. Unlike the controls, 

patients in the AAA group demonstrated a signifi cant 

decrease in depression and increase in arterial oxygen 

saturation. Signifi cant reductions in anxiety, aggression, 

and blood pressure were also reported however no group 

differences were noted. Johnson,4

 investigating mood and 

self-perceived physical and emotional health, compared 

AAA visits to volunteer visits and reading group visits 

that were all 15 minutes in duration, 3 times a week for 4 

weeks immediately prior to radiation treatment. Changes 

in mood assessed before the fi rst and after the last session were compared within and between groups. No signifi cant differences were found for any of the subscales 

of the Profi le of Mood States or physical and emotional 

health ratings, however, trends of decreased anxiety and 

improved emotional health were reported. The lack of 

signifi cant changes and between group differences may 

be due in part to the small sample size (n=10 for each 

group), disease progression, or time of assessment. An 

exit survey revealed that some patients in all groups rated the intervention as helpful and the majority indicated 

they would recommend it to another patient.

BENEFITS OF AAT FOR PSYCHIATRIC SYMPTOMS AND

SETTINGS

While a comprehensive literature search yielded no published research on the effects of AAT in military psychiatric settings, fi ndings from civilian studies provide 

support for investigating this complementary approach 

with military populations and suggest benefi ts that may 

extend to military personnel experiencing psychiatric 

symptoms. This section will focus on research investigating the effect of AAT on adult civilians receiving 

psychiatric care and adults under stressful conditions.

A number of studies report benefi ts of AAT in inpatient 

psychiatric settings. At Virginia Commonwealth University’s Center for Human-Animal Interaction (CHAI), 

researchers completed a series of studies exploring the 

effect of AAT on dysphoria in hospitalized psychiatry 

patients. In their initial study of 231 acute psychiatric 

patients participating in a single session of traditional 

recreational therapy (RT) and RT incorporating a therapy dog, the investigators found a signifi cant reduction in 

anxiety following both conditions.5

 However, reduced 

anxiety in the traditional TR condition was only found 

for patients with mood disorders compared with anxiety 

reductions in the AAT group that were found for those 

with mood disorders, psychotic disorders, and cognitive and other disorders. Only the patients with primary 

substance abuse disorders showed no signifi cant change 

in anxiety, under either condition, perhaps due to their 

acute stage of physiological withdrawal.

The CHAI researchers also conducted 2 studies investigating the effect of AAT on patient dysphoria prior to 

undergoing electroconvulsive therapy (ECT). In the fi rst 

study, 42 patients were placed in rooms with and without a fi sh tank prior to ECT and were assessed pre- and 

postcondition on measures of fear, anxiety, depression, 

frustration, blood pressure, and heart rate.6

 No signifi -

cant differences were found for either condition on any 

of the variables, although a trend toward reduced anxiety was noted. A follow-up study was conducted with 

35 ECT patients, comparing a single 15-minute session of AAT involving a therapy dog with 15 minutes 

of reading/looking through magazines on anxiety, fear, 

and depression.7

 A signifi cant 37% reduction in fear and 

(nonsignifi cant) 18% reduction in anxiety were found in 

the AAT condition. Although no signifi cant differences 

were found for anxiety or depression, the majority of patients reported on a postintervention interview that they 

believed AAT reduced their anxiety and depression.

Other researchers investigated the effect of 4 weeks of 

AAT on 69 hospitalized psychiatric patients and reported increased social behaviors and responsiveness to surroundings in the AAT group compared with a control 

group.8

 Similarly, increased interactions associated with 

4 weeks of AAT, compared with photographic sessions, 

were reported for a sample of 37 elderly psychiatric patients.9

 Addressing the appeal of AAT for hospitalized 

psychiatric patients, another study found that including AAT in occupational therapy groups signifi cantly 

improved group attendance and attracted isolated individuals to the group regardless of diagnosis.10

Focusing specifi cally on patients diagnosed with schizophrenia, researchers in Spain conducted a study of 21 
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

schizophrenic patients assigned to a treatment group 

with or without AAT.11 While the AAT group showed 

signifi cant improvements in social contact and positive 

and negative symptoms after 25 sessions, there were no 

signifi cant differences between the groups. However, 

the study was limited by the small sample size and a 

14% dropout rate. An Israeli study of AAT with 20 elderly schizophrenia patients residing in long-term care 

facilities also reported benefi ts after 12 months of weekly AAT.12 Those in the AAT group had signifi cantly 

improved social functioning compared with the control 

group.

Other studies have focused on the effect of AAT on depression. A recent meta-analysis reviewed these studies 

to determine the effectiveness of AAT in reducing depressive symptoms.13 Focusing on studies that included 

randomization, a control or comparison condition, and 

self-report measure of depression, the authors reported a 

signifi cant, medium effect size based on 5 studies meeting their inclusion criteria, concluding that AAT is associated with fewer depressive symptoms.

While most of the AAT interventions in studies with psychiatric populations involve companion animals, typically dogs, Berget and colleagues14 explored the effect of 

a 12-week intervention with farm animals on self-effi -

cacy, coping ability, and quality of life on 90 Norwegian 

patients with a variety of psychiatric diagnoses. Results 

indicated signifi cant improvements in self-effi cacy and 

coping ability, but not quality of life 6 months following 

the intervention for those in the treatment group compared with the control group.

As part of a major longitudinal study (the Study of Transition and Recovery Strategies) conducted in Oregon 

and Washington on individuals’ recovery from mental 

illness,15 perceptions of the roles pets played in recovery 

from serious mental illness were qualitatively analyzed. 

Interviews with 177 pet owning individuals revealed 

perceptions that pets assisted in individuals’ recovery by 

“(a) providing empathy and therapy; (b) providing connections that can assist in redeveloping social avenues; 

(c) serving as ‘family’ in the absence of or in addition to 

human family members; and (d) supporting self-effi cacy 

and strengthening a sense of empowerment.”14(p430)

The above studies provide evidence of benefi ts of AAT 

with clinical samples of civilian adults with psychiatric symptoms or disorders which may extend to active 

military and veterans with similar symptoms and disorders. The accumulating civilian literature serves to emphasize the dearth of research conducted with military 

samples. Similarly, the civilian research supporting the 

role of pets and AAT as buffering the impact of stressful 

events has particular relevance for the military population, and yet no studies have been published with military samples.

A series of studies conducted by Allen and colleagues 

provide evidence of the positive effect of pets on cardiovascular reactivity in response to stressful conditions. 

Studying 45 female dog owners completing a mental 

stress task with their dog, close friend, or alone showed 

little or no cardiovascular stress reactivity during the 

task with the dog present, but signifi cantly increased activity with the close friend present.16 In a related study 

of 240 pet-owning and non-pet-owning married couples, 

pet (dog or cat) owners had lower resting heart rate (HR) 

and systolic and diastolic blood pressure (SBP and DBP); 

showed less HR, SBP, and DBP reactivity during psychological and physiological stress tasks; and showed 

faster return to baseline than non-pet owners.17 For pet 

owners, lowest physiological reactivity and the quickest return to baseline occurred when the pet was present, compared with when a spouse or friend was present. 

Adding further support to the stress-buffering effects of 

pets, Allen and colleagues18 randomly assigned hypertensive stock brokers starting angiotensin-converting 

enzyme (ACE) inhibitor therapy to acquire a pet or to a 

6-month wait list control condition. Pet owners showed 

higher performance on a mental task and lower physiological reactivity (HR, BP, and renin activity) than those 

in the control condition. The ACE inhibitor therapy signifi cantly reduced only resting BP.

Also looking at the buffering effect of pet presence on 

physiological response to stress, other researchers found 

pet presence was associated with lower blood pressure 

during a stressful task for older hypertensive adults,19

and reduced HR and mean arterial pressure in a sample 

of normotensive adults who completed mental stressors.20 An Australian study found no effect of dog presence on cardiovascular responses to stress, but reported 

a cardiac autonomic profi le most favorable for dog owners when a dog was present and for non-dog owners 

when a dog is absent.21 A more recent exploratory study 

assessed autonomic, endocrine, and neurophysiologic 

stress indicators in a small group of healthy adult dog 

owners interacting with their own or an unfamiliar therapy dog following a mental stress task and reported consistent patterns of relaxation shown in cortisol, HR, BP, 

brain wave activity, and self-reported anxiety and stress 

responses.22,23 Adding further physiological evidence of 

the relaxation effect of AAT, Barker and colleagues24 reported reduced salivary and serum cortisol in healthcare 

professionals, in the absence of a stress task, following 

as little as 5 minutes of AAT.

RESEARCH ON BENEFITS OF CANINE-ASSISTED THERAPY FOR ADULTS IN NONMILITARY SETTINGS
April – June 2012 33

THE ARMY MEDICAL DEPARTMENT JOURNAL

BENEFITS OF AAT FOR RESIDENTS OF NURSING HOMES/

LONG-TERM CARE FACILITIES

There are a number of empirical studies that have been 

conducted with residents of long-term care facilities. 

Research suggests that the use of AAA or AAT with 

this population may reduce depression25-27 and increase 

social interaction.27-32 For example, Fick28 evaluated social interaction in 36 residents in a nursing home care 

unit at a Veterans Administration medical center. Dogs 

were present for 15 minutes at the beginning or end of 

four 30-minute group therapy sessions. Behaviors were 

assessed 15 times during 10 minutes with and without 

the dog per session. Both verbal and nonverbal person 

interactions doubled when the dog was present compared to observations recorded when the dog was not 

present. Similar fi ndings were reported for 15 nursing 

home residents randomly assigned to treatment as usual, 

pet-facilitated psychotherapy, or no treatment.27 Following 4 weeks of two 45- to 90-minute sessions per week, 

social interactions in the pet therapy condition were 

twice that of the no pet group, and signifi cant reductions in depression were reported for the treatment as 

usual and pet therapy group. Another study measured 

changes in mood in residents of nursing homes with a 

visiting dog, with a resident dog, and without a dog.26

The Profi le of Mood States questionnaire was administered prior to the dog being introduced to the facility 

and again at fi ve 3-month intervals. Signifi cant mood 

changes were reported by residents with a dog living 

at the facility including decreased tension, confusion, 

depression, and fatigue. A decrease in fatigue was also 

reported by residents of the facility with a visiting dog. 

The control group exhibited signifi cant decreases in depression, and increases in vigor were reported by residents in all 3 groups.

Additional studies have focused on loneliness in the 

elderly. Banks and Banks33 evaluated loneliness in 45 

long-term care facility residents randomly assigned to 

three 30-minute AAT sessions per week, one 30-minute 

AAT session per week, or no AAT. Sessions were conducted for 6 weeks and the UCLA Loneliness Scale was 

administered before the fi rst and last session. Signifi cant 

reductions in loneliness scores were observed for both 

the one and 3 sessions per week AAT groups compared 

to control, however, there was no difference between 

the 2 AAT groups. A follow-up study34 was designed 

to compare the relative contribution of socialization and 

human-animal bond as the means by which AAT reduces loneliness. Eighteen residents received individual 

AAT sessions (human-animal bond) and 19 residents received group AAT sessions (human-human bond) with 

2 to 4 participants. Although a decrease in loneliness 

for both groups was measured after 6 weeks of weekly 

30-minute sessions, only those residents receiving individual AAT sessions reported a statistically signifi cant 

reduction. The investigators suggest the lack of facilitation of human-human socialization in this study might 

be due to subject/setting characteristics such as hearing 

loss, incompatible backgrounds, or established familiarity between residents.

Several studies have investigated possible benefi ts of pet 

presence and AAT for those with Alzheimer’s disease 

and dementia, specifi cally (see Filan and LlewellynJones35 for a review). Using an observation checklist, 

one study36 reported an increase in the number of total 

social behaviors in 12 Alzheimer’s patients when pets 

were present in an institutionalized setting, and another37

found less verbal aggression and anxiety in a sample of 

64 Alzheimer’s patients living at home and exposed to 

companion animals compared to those not exposed. No 

signifi cant differences were found in cognitive decline 

or frequency of reported psychiatric, mood, or psychomotor disorders. However, secondary analyses found 

those more attached to their pets had signifi cantly fewer 

mood disorders. An Australian study with 14 dementia patients in a psychiatric unit reported no differences 

in daily functioning and blood pressure, but decreased 

heart rate and ward noise was found during AAT over 

a 12-week period.38 While another study with institutionalized patients with Alzheimer’s disease reported 

increased socialization behaviors, no signifi cant differences were found on physiological stress indicators.39 A 

more recent Japanese study40 involved semistructured 

interviews with 8 elderly women with varying stages 

of dementia who participated in AAT twice a month for 

2 years. Themes pertaining to the women’s AAT experience included the ability to develop interest in self, 

others, and the environment resulting from the calming 

effect of AAT and the opportunity to interact with the 

volunteer component of the AAT team.

The accumulating evidence supporting the effectiveness 

of AAT in mediating the physiological stress response, 

reducing anxiety and depressive symptoms, and increasing social behaviors in civilian populations underscores 

the need for testing these effects with military populations. AAT is practiced globally and is typically provided by community volunteers who have trained their 

dogs, or other pets, and have met the requirements for 

therapy dog certifi cation by an external credentialing 

organization. Thousands of civilians, both clinical and 

nonclinical populations of adults and children, participate in AAT each year. Extending the benefi t of AAT to 

military personnel represents a low-cost, therapeutic intervention with powerful potential and virtually no side 

effects. While the incorporation of AAT into treatment 
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

programs for active duty and veterans with anxiety and 

depressive disorders may appear most obvious, the potential of AAT to mediate stress associated with physical disabilities and acute and chronic illnesses remains 

largely untested and worthy of evaluation.

ANIMALS AND THEIR INCLUSION IN BUSINESS AND

ORGANIZATIONAL SETTINGS

As has been demonstrated, there is an emerging interest 

in including animals in hospitals, nursing homes, and 

other healthcare facilities,24,41 but few empirical studies 

have looked at the effect in the business setting. Companies such as Google, AOL, Autodesk, Proctor and 

Gamble’s Pet Care division IAMs, and others either allow animals in the workplace or in a nearby dog care 

facility. Griffi n42 reports anecdotal evidence that organizational support of this kind creates positive benefi ts 

such as lower worker turnover rates and more productive and satisfi ed employees. Findings from a 2003-2004 

survey by The American Pet Products Manufacturers 

Association,43 a not-for-profi t trade organization serving 

the interests of pet product manufacturers, also support 

the inclusion of pets in the business setting. Seventythree percent of those surveyed believe having pets in 

the workplace create a more productive environment; 

27% believe they reduce absenteeism; 100% say they 

relax employees; 73% believe pets increase creativity of 

employees; and 96% believe pets create a more positive 

environment than not having them present.

Using an author-developed questionnaire, Wells and 

Perrine44 surveyed employee perceptions in several 

small companies permitting pets. Eighty-four percent of 

employees who brought pets to work in these companies 

responded and all were business owners or managers. 

The greatest perceived benefi t was a lowering of stress, 

with some suggesting improved health and organizational satisfaction.

In 2004, the American Psychological Association began 

presenting awards for healthy workplace settings. The 

companies were drawn from many types of industries 

representing new work-life benefi t programs, such as 

those directly benefi ting employees, supporting families, and encouraging healthy practices. One Vermont 

electronics company permitting pets in the workplace 

was found to be appropriate for this yearly recognition. “The company tries to build a close-knit team that 

is motivated to be productive...Every time we hire an 

employee, it’s like bringing in a new family member” 

indicated Don Mayer, owner of the company.45

Product advertising and the entertainment industry have 

also used animals to portray characteristics deemed 

important to the company or product.23,46-49 Classic images of well known US and global icons, including Lassie, Rin Tin Tin, Benji, Garfi eld, Felix the Cat, Mighty 

Mouse, Bugs Bunny, and Mickey and Minnie Mouse, 

signify strength, love, connection, and identity.50 These 

images have been used primarily for entertainment 

purposes but they have also been used to brand their 

products.51,52 Examples of animals used as brands are 

the gecko lizard for the US insurance company GEICO, 

the yellow tail kangaroo for the Australian vineyard 

Yellow Tail, the greyhound for Greyhound Bus in the 

United States and Canada, and the winged griffi n for 

Perugina European Chocolate.53 Permitting pets in the 

workplace takes such branding one step further, perhaps 

in an attempt to solidify the positive attributes associated by their brands and exemplify organizational culture values.

The increased acceptance of pets in the workplace may 

be explained in part by the research of Holbrook and 

colleagues.54 They found the human-animal relationship 

to be more than pet as an object of ownership. These researchers found that consumers’ relationships with animal companions are not necessarily a means to an end. 

This market research also found that buying pet products and services suggests that pets are now perceived 

as sacred rather than as possessions. 

Two other studies using student samples looked at animals in a simulated workplace setting. The fi rst study 

by Perrine55 surveyed undergraduate students using 

a questionnaire and picture slides of offi ces with and 

without dogs and cats. While no signifi cant differences 

existed between dogs and cats, there were some interesting fi ndings. Students perceived that the presence of 

the animal in the offi ce enhanced an occupants’ mood 

and social interaction. They also perceived the offi ce to 

be less professional, less busy, less clean and safe. The 

second study was an experiment conducted by researchers at Central Michigan University. In looking at work 

team collaboration, they found that those teams that had 

a dog present rated teammates higher in trust, cohesion, 

and intimacy.56

A recently completed preliminary study conducted in the 

workplace setting investigated the effect of employees’ 

dogs’ presence at work on stress and organizational perceptions.22 Comparisons were made between employees 

who bring their dogs to work, employees who do not 

bring their dogs to work, and employees without pets 

on physiological and perceived stress, perceptions of job 

satisfaction, organizational affective commitment, and 

perceived organizational support. Among the key fi ndings was that the 3 combined groups scored signifi cantly 

RESEARCH ON BENEFITS OF CANINE-ASSISTED THERAPY FOR ADULTS IN NONMILITARY SETTINGS
April – June 2012 35

THE ARMY MEDICAL DEPARTMENT JOURNAL

higher on multiple job satisfaction subscales than the reference norm group for these scales. No signifi cant differences were found between the groups on physiological 

stress (measured by early morning cortisol levels) or 

perceived organizational support. Although perceived 

stress was similar at baseline, stress was lower for the 

group with their dogs present and increased for owners 

without their dogs present and the non-pet owner groups 

over the course of the day. Interestingly, the group who 

do not bring their dogs to work had signifi cantly higher 

stress levels at the end of the day than the group with 

their dogs present. A signifi cant difference was found 

in the stress patterns for the group who bring their dogs 

to work on days their dogs were present compared with 

days their dogs were absent. On days without their dogs, 

owners’ stress increased throughout the day, mirroring 

the pattern of the group who do not bring their dogs to 

work. 

Given research momentum from a variety of disciplines 

as identifi ed in the previous section, Barker’s53 conceptual research called for more interdisciplinary focus on 

this important and pioneering focus. His article integrated the research of psychology, social psychology, medicine, veterinary medicine, business, communication, 

management, and marketing, calling for future research 

in areas including:

 Communication among and between employees 

and between employees and managers when companion animals are present in the workplace...

 Companion animals as a form of social support that does or does not buffer stress in the 

workplace...

 Companion animals in the workplace as a means 

to increase or decrease their employee owners’ 

health and quality of work life...

 The welfare of the animal in the workplace...

Other settings are also identifi ed as an important next 

step in this research area. 53(pp309-312)

While no published studies have investigated the impact 

of pet presence in military settings, the research presented in this section suggests a number of implications, 

including dogs in theater, that warrant future investigation and comparisons. Many organizations in the business and healthcare areas have developed policies for 

allowing animals to accompany their owners to work. 

Perhaps the military could investigate the possibility of 

this kind of activity as a beginning point. It would also 

be possible to investigate similar variables identifi ed 

above. The stress, communication, health, and well being of the Soldier and the animal are prime opportunities for future study.

SUMMARY

There is substantial evidence of improved health and 

well-being of individuals in various health care and business settings through animal-assisted intervention. The 

research reviewed above demonstrates both physiological responses (stress-buffering effect) and psychosocial 

improvements as a result of human-animal interaction. 

The evaluation of such outcomes needs to be expanded 

to military personnel. There are a number of venues in 

which animals are employed in the military (several of 

which the authors will describe in subsequent articles), 

the benefi ts of which are largely unknown.

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Behav Psychother. 1992;20(4):367-372.
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

10. Holcomb R, Meacham M. Effectiveness of an animal-assisted therapy program in an inpatient psychiatric unit. Anthrozoös. 1989;2:259-264.

11. Villalta-Gil V, Roca M, Gonzalez N, et al. Dogassisted therapy in the treatment of chronic schizophrenia inpatients. Anthrozoös. 2009;22(2):149-159.

12. Barak Y, Savorai BA, Mavasbev BA, Beni A. 

Animal-assisted therapy for elderly schizophrenic 

patients: a one-year controlled trial. Am J Geriatr 

Psychiatry. 2001;9(4):439-442.

13. Souter MA, MIller MD. Do animal-assisted activities effectively treat depression? A meta-analysis. 

Anthrozoös. 2007;20(2):167-180.

14. Berget B, Ekeberg Ã, Braastad BO. Animal-assisted therapy with farm animals for persons with psychiatric disorders: effects on self-effi cacy, coping 

ability and quality of life, a randomized controlled 

trial. Clin Prac Epidemiol Ment Health. 2008;4:9.

15. Wisdom JP, Saedi GA, Green CA. Another breed of 

service animals: STARS study fi ndings about pet 

ownership and recovery from serious mental illness. Am J Orthopsychiatry. 2009;79(3):430-436.

16. Allen KM, Blascovich J, Tomaka J, Kelsey RM. 

Presence of human friends and pet dogs as moderators of autonomic responses to stress in women. J 

Pers Soc Psychol. 1991;61(4):582-589.

17. Allen K, Blascovich J, Mendes WB. Cardiovascular reactivity and the presence of pets, friends, and 

spouses: the truth about cats and dogs. Psychosom 

Med. 2002;64(5):727-739.

18. Allen K, Shykoff BE, Izzo JL, Jr. Pet ownership, 

but not ace inhibitor therapy, blunts home blood 

pressure responses to mental stress. Hypertension. 

2001;38(4):815-820.

19. Friedmann E, Thomas SA, Cook LK, Tsai C, Picot 

SJ. A friendly dog as potential moderator of cardiovascular response to speech in older hypertensives. 

Anthrozoös. 2007;20(1):51-63.

20. DeMello LR. The effect of the presence of a companion-animal on physiological changes following the termination of cognitive stressors. Psychol 

Health. 1999;14(5):859-868.

21. Kingwell B, Lomdahl A, Anderson W. Presence 

of a pet dog and human cardiovascular responses 

to mild mental stress. Clin Auton Res. 2001;11:313-

317.

22. Barker RT, Knisely JS, Barker SB, Cobb RK, Schubert CM. Preliminary investigation of employee’s 

dog presence on stress and organizational perceptions. Int J Workplace Health Manag. In press.

23. Roth M. The effects of cultural and socioeconomics on the performance of global brand image strategies. J Market Res. 1995;32(2):163-176.

24. Barker SB, Knisely JS, McCain NL, Best AM. Measuring stress and immune response in healthcare 

professionals following interaction with a therapy 

dog: a pilot study. Psychol Rep. 2005;96:713-729.

25. Stasi MF, Amati D, Costa C, et al. Pet-therapy: a 

trial for institutionalized frail elderly patients. Arch 

Gerontol Geriatr. 2004;38(suppl 9):407-412.

26. Crowley Robinson P, Fenwick DC, Blackshaw JK. 

A long-term study of elderly people in nursing 

homes with visiting and resident dogs. Appl Anim 

Behav Sci. 1996;47(1-2):137-148.

27. Brickel CM. Depression in the nursing home: a pilot study using pet-facilitated therapy. In: Anderson RK, Hart BL, Hart LA, eds. The Pet Connection. Minneapolis, MN: University of Minnesota, 

Center to Study Human-Animal Relationships and 

Environments; 1984:407-415.

28. Fick KM. The infl uence of an animal on social interactions of nursing home residents in a group setting. Am J Occup Ther. 1993;47(6):529-534.

29. Bernstein PL, Friedmann E, Malaspina A. Animalassisted therapy enhances resident social interaction and initiation in long-term care facilities. Anthrozoös. 2000;13(4):213-224.

30. Richeson NE. Effects of animal-assisted therapy on 

agitated behaviors and social interactions of older 

adults with dementia: an evidence-based therapeutic recreation intervention. Am J Recreation Ther. 

2003;2(4):9-16.

31. Sellers DM. The evaluation of an animal assisted 

therapy intervention for elders with dementia in 

long-term care. Act Adapt Aging. 2005;30(1):61-77.

32. Perelle IB, Granville DA. Assessment of the effectiveness of a pet facilitated therapy program in a 

nursing home setting. Soc Anim. 1993;1(1):91-100.

33. Banks MR, Banks WA. The effects of animalassisted therapy. J Gerontol A Biol Sci Med Sci. 

2002;57A(7):M428-M432.

34. Banks MR, Banks WA. The effects of group and 

individual animal-assisted therapy on loneliness in 

residents of long-term care facilities. Anthrozoös. 

2005;18(4):396-408.

35. Filan SL, Llewellyn-Jones RH. Animal-assisted 

therapy for dementia: a review of the literature. Int 

Psychogeriatr. 2006;18(4):597-611.

36. Kongable LG, Buckwalter KC, Stolley JM. The effects of pet therapy on the social behavior of institutionalized Alzheimer’s clients. Arch Psychiatr 

Nurs. 1989;3(4):191-198.

37. Fritz CL, Farver TB, Kass PH, Hart LA. Association with companion animals and the expression of 

noncognitive symptoms in Alzheimer’s patients. J 

Ner Ment Dis. 1995;183(7):459-463.

RESEARCH ON BENEFITS OF CANINE-ASSISTED THERAPY FOR ADULTS IN NONMILITARY SETTINGS
April – June 2012 37

THE ARMY MEDICAL DEPARTMENT JOURNAL

38. Walsh PG, Mertin PG, Verlander DF, Pollard CF. 

The effects of a “pets as therapy” dog on persons 

with dementia in a psychiatric ward. Aust Occup 

Ther J. 1995;42(4):161-166.

39. Batson K, McCabe B, Baun MM, Wilson C. The 

effect of a therapy dog on socialization and physiological indicators of stress in persons diagnosed 

with Alzheimer’s disease. In: Wilson CC, Turner 

DC, eds. Companion Animals in Human Health. 

Thousand Oaks, CA: Sage Publications, Inc; 

1998:203-215.

40. Kawamura N, Niiyama M, Niiyama H. Animal-assisted activity: experiences of institutionalized Japanese older adults. J Psychosoc Nurs Ment Health 

Serv. 2009;47(1):41-47.

41. Wilson CC, Turner DC, eds. Companion Animals 

in Human Health. Thousand Oaks, CA: Sage Publications, Inc; 1998.

42. Griffi n D. You, the cubicle, and Fido: a number of 

local pet-friendly workplaces point to the benefi ts 

in productivity and morale, but not everyone supports the practice. Baltimore Sun. May 5, 2003. 

Available at: http://www.baltimoresun.com/balpets050503,0,6052680.story. Accessed January 25, 

2012.

43. American Pet Products Manufacturers Association 

(APPMA). 2003-2004 APPMA National Pet Owners Survey. Greenwich, CT: American Pet Products 

Manufacturers Association, Inc; 2004.

44. Wells M, Perrine R. Critters in the cube farm: perceived psychological and organizational effects 

of pets in the workplace. J Occup Health Psychol. 

2001;6(1):81-87.

45. Carlson L. Employees reap awards and rewards for 

psychologically healthy workplace. Employee Benefi t News. April 19, 2004.

46. Cheney G. Rhetoric in an Organizational Society: 

Managing Multiple Identities. Columbia, SC: University of South Carolina Press; 1990.

47. Elliot R, Wattanasuwan K. Brands as symbolic resources for the construction of identity. Int J Advertising. 1998;17(2):131-145.

48. Schultz P. The morally accountable corporation: a 

postmodern approach to organizational responsibility. J Bus Comm. 1996;33(2):165-183.

49. Upshaw L. Building Brand Identity. New York, NY: 

John Wiley & Sons, Inc.; 1995.

50. Big Dogs, Little Dogs. The A&E Television Networks. 1998.

51. Stutts N, Barker R. The use of narrative paradigm 

theory in audience value confl ict identifi cation. 

Manag Comm Q. 1999;13(1):209-244.

52. Argenti P, Forman J. The Power of Corporate Communication: Crafting the Voice and Image of Your 

Business. New York, NY: McGraw-Hill Publishing 

Co.; 2002.

53. Barker R. On the edge or not? opportunities for 

interdisciplinary scholars in business communication to focus on the individual and organizational 

benefi ts of companion animals in the workplace. J 

Bus Comm. 2005;42(3):299-315.

54. Holbrook M, Stephens D, Day S, Holbrook S, 

Strazar G. A collective stereographic photo essay on key aspects of animal companionship: the 

truth about cats and dogs. Acad Market Sci Rev. 

2001;2001(1). Available at: http://www.amsreview.

org/articles/holbrook01-2001.pdf. Accessed August 25, 2010.

55. Perrine R, Wells M. Labradors to Persians: perceptions of pets in the workplace. Anthrozoös. 

2006;19(1):65-78.

56. Crowe A. Dogs improve offi ce productivity. AOL 

Jobs Web site. August 24, 2010. Available at: http://

jobs.aol.com/articles/2010/08/24/dogs-improve-offi ce-productivity/. Accessed August 25, 2010.

AUTHORS

Dr Knisely is an Associate Professor, Department 

of Psyhchiatry, Virginia Commonwealth University, 

Richmond, Virginia.

Dr Sandra Barker is a Professor and the Bill Balaban 

Chair in Human-Animal Interaction, Department 

of Psyhchiatry, Virginia Commonwealth University, 

Richmond, Virginia.

Dr Randolph Barker is a Professor, Department of 

Management, Virginia Commonwealth University, 

Richmond, Virginia.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

Since 2007, the US Army has managed the care of several thousand service members (SMs) with injuries and 

diseases through the US Army Wounded Warrior Program.1

 A major component of the Wounded Warrior program are the Warrior Transition Units (WTUs) located 

throughout the country. There are currently 29 Army 

installations with WTUs whose members have polytraumatic injuries with combined diagnoses including 

traumatic brain injury, posttraumatic stress, depression, 

burns, and limb amputations. Because of the complexity of these diagnoses, SMs may remain on active duty 

within the WTU for many months, up to 2 years, pending resolution of medical and other issues. It is the duty 

of SMs to heal, followed by either return to active duty 

or transition to veteran status. While at a WTU, SMs 

receive many services including Occupational Therapy 

(OT) Life Skills programs.

According to the Offi ce of The Surgeon General, occupational therapists primarily provide services to wounded Warriors in transition (WTs) during the rehabilitation 

phase of the comprehensive transition plan with overlap 

in the earlier phases of assessment and goal setting.2

 According to this plan, the role of the occupational therapist and certifi ed occupational therapy assistant is to:

assess all WTs and provide functional interventions 

as needed to improve WTs’ physical, cognitive, 

psychological/behavioral, and vocational capacity to 

perform daily self-care, work and leisure activities. 

Occupational therapy services include professional 

interventions to promote WT goal setting, life skills 

development, advanced educational classes, consultation 

and coordinator for work rehabilitation, community and 

work reintegration activities.2(p1)

It is the goal of the OT Life Skills program to support 

the reintegration of WTs, either within the Army or in 

their return to civilian life. Interventions by occupational therapists in WTUs have primarily focused on life 

skills and work reintegration programs. The programs 

typically facilitate development of abilities in daily 

organization and time management; personal health 

including sleep, medication management, healthy eating and avoiding addictions; stress management and 

relaxation techniques; leisure exploration and development; communication and relationships; confl ict resolution skills; money management; career exploration and 

planning; educational, prevocational and work readiness training; and vocational reintegration. Intervention 

strategies include psychoeducational programs, activity 

and task analysis, compensatory cognitive retraining, 

The Effects of Animal-Assisted Therapy on

 Wounded Warriors in an Occupational

 Therapy Life Skills Program

CPT Christine E. Beck, SP, USA

MAJ Florie Gonzales, Jr, SP, USA

Carol Haertlein Sells, PhD, OTR

MAJ Cynthia Jones, SP, USA

CPT Theresa Reer, SP, USA

MAJ Steven Wasilewski, SP, USA

CPT Yao Yao Zhu, SP, USA

ABSTRACT

Animal-assisted therapy (AAT) has gained much attention in civilian and military health care. Evidence supports 

its benefi ts with varied populations with diseases and disabilities, but no research has been done with injured or 

ill service members. This pretest, posttest nonrandomized control group study evaluated the effects of AAT on 

Warriors in transition (N=24) attending an Occupational Therapy Life Skills program with the long-term goal 

of improving their successful reintegration. Although signifi cant differences were not found between the groups 

on most measures, anecdotal reports by participants and observers indicate that participants eagerly anticipated 

being with the therapy dogs, expressed pleasure and satisfaction with the experience, and regretted seeing it end. 

There were signifi cant correlations between mood, stress, resilience, fatigue, and function at various measurement points. This is the fi rst study to formally assess the benefi ts of AAT with wounded service members in 

garrison. Suggestions for future research are provided.
April – June 2012 39

biofeedback, adaptive skills training, rehearsal, routine 

and habit development, personal coaching, environmental modifi cations, and confl ict resolution.3

Historically, life skills programs have been used in the 

treatment of acutely and chronically ill psychiatric patients in both civilian and military settings.4-8 In 1974, 

Army occupational therapists established a Life Skills 

Development Program for psychiatric inpatients at the 

Eisenhower Army Medical Center, Fort Gordon, GA. 

This program was later considered an “evolving treatment approach” in occupational therapy.5(p35) Research 

on life skills programs has yielded positive effects for 

participants. One study examined the effects of a life 

skills program with homeless individuals residing in 

shelters or supportive housing.4

 This unique population 

presents with “diverse life skill needs related to living 

independently”4(p190) and often displays occupational 

performance defi cits related to fi nances, housing, personal care, as well as diffi culties associated with satisfying their basic needs and health concerns. The life 

skills program was uniquely designed to meet the needs 

of 3 distinctively different groups: (1) homeless youth 

without families or employment skills, (2) female victims of domestic violence in need of fi nance management, and (3) individuals with mental illness in need 

of food and nutrition knowledge and skills. Of the 73 

attendees, 32 completed the program with a resultant 

20 (62%) exhibiting increased mastery scores following completion of the program of signifi cant difference 

between pre- and posttest scores. In a case study of a 

homeless youth, life skills such as communication skills, 

decision making, money management, study skills, as 

well as aspects of work and relationships, were provided 

by occupational therapists.8

 Upon completion of the life 

skills program, the individual was able to successfully 

implement specifi c skills in the real world. In another 

study, researchers measured the impact of a 12-week 

life skills program, the Bridge Program, for adults with 

psychiatric disabilities.9

 The researchers noted that 

many individuals with psychiatric disabilities whose 

symptoms were successfully managed with medications 

still lacked the requisite knowledge, skills, and confi -

dence to pursue and gain access to college and technical 

education programs. On a postintervention survey, 86% 

of participants indicated that the Bridge Program facilitated improvement in academic skills and preparation 

for future educational pursuits; 12 of the 18 participants 

enrolled in higher education courses.9 Finally, a series 

of 3 life skill program modules were provided to recipients of mental health services at the Royal Brisbane and 

Women’s Hospital (Australia).10 Modules included education on nutrition, healthy eating, and the evaluation 

of food labels; identifi cation of health risk factors; and 

strategies by which to increase one’s participation in social, intellectual, creative, and physical activities. Initial 

feedback indicated that 34 of 35 participants found the 

program useful, interesting and educational.10

The strategies implemented in these programs focus on 

skill development, adaptation or compensation; the success of these efforts often depends upon the psychological and emotional well-being of the individual service 

member. Warriors in Transition experience multiple 

stressors as they receive medical care and process information critical to their future plans. The interaction 

between humans and animals, primarily dogs, has been 

demonstrated to promote relaxation, calm, and optimism 

in critical care medical settings, and reduce anxiety and 

fear in psychiatric patients.11 The Delta Society, a recognized leader and research sponsor for animal-assisted 

therapy (AAT), defi nes the treatment as “a goal-directed 

intervention directed and/or delivered by a health/human service professional with specialized expertise, and 

within the scope of practice of his/her profession. AAT 

is designed to promote improvement in human physical, social, emotional, and/or cognitive functioning.”12(p1)

The primary ways in which AAT occurs are: (a) as companions to individuals living independently, (b) in residential institutions for companionship and stimulation, 

and (c) as visitors in nonresidential settings for stimulation of interaction and interest.11 The preferred choice of 

mammal used in AAT is the canine because dogs are 

very social, dependent, and trainable creatures.13 They 

should be “alert, bright, happy, healthy, and playful 

without being too rowdy... even-tempered, good-natured, and willing to withstand travel and environmental stress.”13(p73)

Historically, the US military has promoted the therapeutic use of animals with wounded Soldiers. In the years 

that followed World War I, dogs were used with psychiatric patients at St Elizabeth’s Hospital in Washington, 

DC.11 More recently, AAT dogs have deployed with US 

Army occupational therapists for prevention and restoration programs as part of combat and operational stress 

control (COSC) units in Iraq and Afghanistan.

The mission of the COSC unit is to prevent and treat behavioral health issues while in theater. Numerous studies have reported the benefi ts of AAT for people with 

a wide range of physical and psychological stress and 

diseases.14-18 Despite the documented use of AAT across 

populations and settings, much of it is descriptive and 

exploratory with few well-designed systematic studies 

which measure program effectiveness, and there have 

been no such studies with injured or ill service members 

in garrison. The purpose of this study was to determine 
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

if WTs who participated in AAT with dogs while attending Life Skills programs had improved mood states, 

decreased stress levels, increased resilience, lowered 

levels of fatigue, and improved daily function for reintegration and transition to the next stage of their life, as 

compared to WTs who did not interact with dogs. The 

long range goal of this research is to contribute to a base 

of evidence for use of AAT within the military. Specifi cally, this study attempted to answer the following 

research questions:

 Are there differences over a period of 8 weeks in 

mood state, stress levels, resilience, fatigue, and 

daily function between groups following participation in the standard of care (OT Life Skills programs) with and without ATT? 

 Is mood, stress, and resilience related to the level of 

fatigue and daily function of WTs?

METHOD

This study employed a quasi-experimental design with 

a pretest, posttest, nonrandomized control group (23) 

mixed model, repeated measures ANOVA). Participants 

were assigned to one of two group levels, the OT Life 

Skills program (control) and Life Skills program plus 

AAT (experimental). They completed outcome measures 

at 3 time periods: baseline, postintervention (4 weeks 

after baseline) and follow-up (8 weeks after baseline). 

The study was approved by the Brooke Army Medical 

Center Institutional Review Board for the Protection of 

Human Subjects.

RECRUITMENT

Participants were recruited with fl yers and by invitation 

of WTU staff. Exclusion criteria included pregnancy, 

dog allergies, open wounds, previous or concurrent participation in the Cognitive Behavioral Education Strategies program, concurrent participation in the Army 

Center for Enhanced Performance (ACEP) program, 

concurrent participation in an equine therapy program, 

and daily interaction with their own dog. Inclusion criteria was status as a US service member assigned or attached to the WTU, at least 18 years of age, and able to 

read and speak English.

MEASURES

The measurement tools were a demographic information form and standardized assessment measures for 

mood, stress, resilience, fatigue, and function.

Profi le of Mood States (POMS). The POMS consists of 65 

descriptors which measure 6 dimensions of mood:

1. Tension-anxiety

2. Depression-dejection

3. Anger-hostility

4. Vigor-activity

5. Fatigue-inertia

6. Confusion-bewilderment 19

Items are measured on a 5-point scale where 0=not at all 

and 4=very often. Internal consistency has been reported for all items as ≥0.90; test-retest reliability ranges 

from 0.65 for the vigor scale to 0.74 for the depression 

scale.19 The POMS has been used with a wide range of 

health conditions to assess mood state.20

Perceived Stress Scale (PSS). The PSS is a widely used 

instrument to measure one’s perception of stress.21 It 

consists of 10 items measured on a 5-point Likert scale 

with responses from 0=never to 4=very often. The 

questions ask about one’s feelings related to general 

stress within the past month. Internal consistency has 

been established with Cronbach’s alpha=0.84-0.86; testretest reliability ranges from 0.55-0.85.21 Concurrent 

and predictive validity have been established to global 

life-event scales as a predictor of stress.21

Connor-Davidson Resilience Scale (CD-RISC). The 25 

items of the CD-RISC address self-rated dimensions 

of the construct of resilience.22 Items are scored on a 

5-point Likert scale where 0=“not true all the time” and 

4=“true nearly all the time.” The total scores range from 

0-100 where higher scores indicate greater resiliency.22

Internal consistency (α coeffi cient) was found to be 

0.89.22 Item correlations ranged from 0.30 to 0.70 and 

test-retest reliability yielded an intraclass correlation coeffi cient of 0.87.22

Fatigue Scale. The Fatigue Scale is an 11-point numeric measure where 0=no fatigue and 10=worst fatigue 

THE EFFECTS OF ANIMAL-ASSISTED THERAPY ON WOUNDED WARRIORS IN AN OCCUPATIONAL THERAPY LIFE SKILLS PROGRAM

Wounded Warrior interacting with a therapy dog. Photo 

courtesy of the authors.
April – June 2012 41

THE ARMY MEDICAL DEPARTMENT JOURNAL

imaginable. A linear numeric scale is considered to be 

an acceptable method for measuring a unidimensional 

characteristic.23

Functional Status Questionnaire (FSQ). The FSQ is a 

comprehensive self-report of the patient’s physical, psychological, social, and role functions.24 There are 28 

items found in 6 subscales:

1. Basic activities of daily living (ADL)

2. Instrumental ADL

3. Psychological function

4. Work performance

5. Social activity

6. Quality of interaction

The scales have demonstrated good reliability with established construct validity.24

The Occupational Self Assessment (OSA). The OSA consists of 21self-report items to measure perceived level of 

competence and values about participation in everyday 

activities (occupational performance).25 Clients rate how 

well they do activities such as “concentrating on my 

tasks” and “managing my fi nances” on a 4-point Likerttype scale where 1=lot of problems to 4=extremely well, 

and the importance of the activity to them where 1=not 

so important to 4=most important. Rasch analysis has 

demonstrated good construct validity of the competence 

scale26 and consistency by 90% of participants with a 

wide range of disabilities.27

INTERVENTIONS

All participants attended Occupational Therapy Life 

Skills classes on stress management, communication/ 

anger management, and healthy living for a minimum 

of 3 and up to 6 classes. The experimental group also 

received AAT for 30-minute sessions immediately after 

each Life Skills class, each session was on a 1:1 basis 

with a pet therapy team (ie, a dog and its handler). The 

AAT intervention was as follows: the handler instructed 

the participant in using basic dog obedience commands 

such as sit, stay, lie down, sit up, shake and fetch. After the participant was successful with administering 

5 commands to the dog, the remainder of the 30 minutes was spent engaging in activities of the participant’s 

choice, such as going for a walk on the facility grounds, 

sitting quietly and petting the dog, brushing the dog, 

and teaching the dog new tricks. All AAT sessions 

were supervised by research staff. Fidelity checks were 

conducted on the AAT intervention and OT Life Skills 

class to ensure consistency in delivery of interventions 

throughout the study.

DATA ANALYSIS

All data analysis was performed using SPSS* version 

16.0. Descriptive statistics were used to examine the data. 

Assumptions of normality and linearity were evaluated 

and data was screened for outliers. Independent samples 

t-test and chi-square analyses were performed to examine the demographic differences between the control 

and experimental group. Repeated measures ANOVA 

was used to identify differences among baseline, post, 

and follow-up scores of the POMS and OSA. Friedman’s 

repeated-measures ANOVA was done to determine differences on the PSS, CD-RISC, FSQ subscales and Fatigue scale at the 3 measurement points. Assumption 

of sphericity was checked using Mauchly’s test. In the 

presence of a signifi cant overall test, pairwise comparisons were performed with the Wilcoxon-signed ranks 

test, with the P values adjusted using the Bonferroni 

correction to maintain an overall 0.05 comparison rate. 

Spearman’s rank correlation coeffi cient was used to examine the relationship of stress, mood, and resilience to 

fatigue and function at baseline, post-intervention, and 

follow-up.

RESULTS

Participants

Based on the inclusion criteria, 27 service members volunteered, received and signed the informed consent document, and were assigned to one of the 2 groups. Three 

participants were not able to complete the study and 

dropped out after baseline measurement; their data were 

not included in the fi nal analysis. A total of 24 subjects 

participated in the study. Demographic information is 

presented in the Table.

Between Groups

There were no differences over a period of 8 weeks in 

mood state, stress levels, resilience, fatigue, and most 

measures of daily function following participation 

in OT Life Skills classes with and without ATT. Signifi cant differences were found for 3 subscales of the 

FSQ (where a higher score indicates improvement); 

psychological function (PF), work performance (WP), 

and quality of interaction (QI). Friedman’s test for 

comparison of the FSQ-PF resulted in χ2(2)=7.9 with 

P< .05. Psychological function was highest at baseline 

and lowest at the follow-up measurement period. Multiple comparisons indicate that there were no signifi cant 

differences from baseline to post-intervention measurement or post-intervention to follow-up. Friedman’s test 

for comparison of the FSQ-WP resulted in χ2(2)=18.86 

and P< .000. Work performance was lowest at baseline 

*Statistical Package for the Social Sciences, SPSS Inc, 

Chicago, IL
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

and highest at the follow-up measurement period with 

multiple comparisons indicating signifi cant differences 

between those two time points. Finally, for the FSQQI, Friedman’s test resulted in χ2(2)=23.48 and P< .001. 

Quality of interaction was lowest at baseline and highest at the follow-up measurement period with multiple 

comparisons indicating signifi cant differences among 

all measurement periods.

Relationships

Correlational analysis found signifi cant relationships as 

follows: between stress and fatigue (baseline, r=0.624), 

stress and occupational performance (OSA) (baseline, 

r= -0.717; postintervention, r= -0.619) and FSQ-PF 

(postintervention, r= -0.849), stress and FSQ-QI 

(postintervention, r=0.691); between mood and fatigue 

(baseline, r=0.596), mood and occupational performance 

(OSA) (baseline, r= -0.760; postintervention, r= -0.882, 

follow-up, r= -0.772), mood and FSQ-PF (baseline, r= 

-0.917; postintervention, r= -0.657), mood and FSQ-QI 

(baseline, r=0.717); between resilience and occupational 

performance (OSA) (baseline, r=0.734; postintervention, 

r=0.961; follow-up, r=0.845), resilience and FSQ-PF 

(postintervention, r=0.755).

COMMENT

This is the fi rst study to examine the use of AAT in conjunction with OT Life Skills programs as an intervention 

for wounded service members in a garrison environment. 

Despite the primarily nonsignifi cant results, there is anecdotal evidence that supports the value of the intervention with service members. During the study, several 

participants reported feeling more calm and at ease after 

working with the dogs. In addition, “the dogs” were often a topic of conversation among participants and other 

service members, staff, and family members who observed the pet therapy teams. Several Soldiers informed 

the Warrior Family Support Center Director that they enjoyed the dog sessions, looked forward to seeing the dogs 

again and regretted the conclusion of the study. The Director also expressed regret when the study ended as this 

was the only source of AAT for Soldiers at this facility.

The signifi cance differences in scores on 3 subscales of 

the FSQ are of some interest. Psychological function (PF) 

scores decreased (got worse) whereas work performance 

Demographics of participants in the study.

OT Life Skills

with AAT (n=12)

OT Life Skills

(n=12)

Age in years – Average (SD) 37.08 (11.79) 35.5 (9.19)

Gender

Male 10 7

Female 2 5

Active Duty 8 7

Reserve Component 4 5

Offi cer 2 3

Enlisted 10 9

Months in service [average] (SD) 124.08 (107.05) 118.5 (80.849)

Number of deployments

1 6 5

2 6 4

More than 2 0 3

Months deployed [average] (SD) 16.42 (7.513) 16.71 (8.703)

Previous dog ownership

Yes 9 10

No 3 2

Negative experience with dog

Yes 1 2

No 11 10

Current dog ownership

Yes 1 3

No 11 8

Primary medical condition

Orthopedic 5 8

Behavioral Health 3 0

Other 4 4

THE EFFECTS OF ANIMAL-ASSISTED THERAPY ON WOUNDED WARRIORS IN AN OCCUPATIONAL THERAPY LIFE SKILLS PROGRAM

Wounded Warrior walking with a therapy dog, accompanied by a certifi ed handler. Photo courtesy of the authors.
April – June 2012 43

THE ARMY MEDICAL DEPARTMENT JOURNAL

(WP) and quality of interaction (QI) increased. Although 

it is diffi cult to interpret this result with any confi dence 

given the small sample size, it may suggest that over 

time (ie, the 8-week duration of this study), the barracks 

environment and circumstances surrounding medical 

procedures and appointments may contribute to feelings of 

being “downhearted and blue,” “down in the dumps,” and 

“nervous” (PF items). By contrast, Soldiers in the WTU 

are encouraged to enroll in work-readiness programs 

and attend education programs that may contribute to an 

improvement in WP scores. They may be more confi dent 

about their work performance over time despite feeling 

down and more nervous. Improved QI scores may be 

related to the decrease seen in PF scores; as wounded 

service members struggle with the emotional issues 

associated with recovery from illness and injuries, they 

have more individual and group interventions with WTU 

staff and behavioral health providers. Thus the number 

of interactions increases and the Soldier consequently 

feels less “isolated” and “irritable,” and more likely to 

get along “well with other people” (QI items).

The signifi cant relationships between stress and fatigue, 

occupational performance, and psychological function 

suggest that as levels of stress increased, occupational 

and psychological function decreased. This may be explained by the demands placed upon wounded service 

members in a WTU. They report that they are constantly asked to complete satisfaction and climate surveys 

which are intended for program improvement. However, 

this constant bombardment of Likert-type surveys is 

considered “annoying” and “pointless” to some of the 

participants in the study. Since they are mandated by 

their chain of command to fi ll out the climate surveys, 

some admitted to not reading the questions and just circling numbers. At least 3 participants expressed annoyance with having to fi ll out 29 minutes worth of surveys 

as part of this study. Also worth noting is that at the 

follow-up measurement period, 3 participants in the experimental group verbalized having “a bad week” which 

may have infl uenced their scores. The explanation for 

increased stress and increased quality of interaction offered earlier may apply here as well.

Regarding the relationships between mood and other 

characteristics, it was noted that as mood improved, 

fatigue decreased and occupational performance and 

psychological function increased. This suggests that 

the better one’s mood, the less feelings of being “downhearted and blue” with an improved perception of one’s 

ability to sustain a pattern of occupational performance 

(ie, “concentrating on my tasks” and “managing my fi -

nances” which are OSA items) that is productive and satisfying. The unexpected relationship between decreased 

mood and improved quality of interaction may be explained as noted earlier.

The relationships between resilience and occupational 

performance and psychological function suggest that 

as one is more resilient, he or she is also more able to 

manage daily life and feel more “calm” and “happy” (PF 

items). Interestingly, resilience and improved psychological function had a strong correlation at the postintervention period and were not signifi cant at follow-up. 

This fi nding suggests that the impact of AAT might 

help strengthen these short-term relationships and that 

time may dissipate all benefi ts gained from AAT. It is 

possible that AAT primarily brings about reminiscence 

and comfort due to the immediate socialization that one 

experiences when interacting with pets. Recollection of 

memories related to past personal experiences with pets 

may provide a transient state of emotional well-being. 

It has been found that pets are a source of conversation 

and a means for reducing irritability and decreasing 

withdrawn behavior.28

LIMITATIONS

As noted earlier, the small sample size was a limitation 

in this study. A power analysis was done to determine 

the required sample size for 80% power. To fi nd the 

minimum clinical difference between groups, 50 participants were needed; 25 in each group. Thus, our study 

sample was too small to detect signifi cant differences. 

The lack of randomization was another limitation in this 

study. Participants who favored dogs were more likely to 

volunteer for the AAT group, whereas individuals who 

were not partial to dogs may have volunteered for the 

control group. However, according to the demographics of both groups, there were no signifi cant differences 

in previous and current dog ownership and history of 

negative dog experiences.

In spite of screening and training of pet therapy teams, 

differences were noted by study staff in the AAT sessions where some pet handlers were more interactive 

than others. This variability may have been overcome 

by the irregular assignment of different pet therapy 

teams to participants at each session; that is, no effort 

was made to consistently have a participant with the 

same pet therapy team. Thus, differences in pet teams 

and the handlers may not have been a factor.

In addition, treatment sessions (both AAT and OT Life 

Skills classes) varied in number, with a range of 3 to 6 

classes. This variability in treatment could contribute 

to the lack of benefi t associated with the interventions. 

Based upon earlier suggestions that AAT may have more 

short-term benefi ts, the length of time from intervention 
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

to postintervention and follow-up measurement (4 and 8 

weeks, respectively) suggests that any benefi ts from the 

interventions may have dissipated by the time of assessment. This study also exclusively used self-report measures which may not have captured immediate benefi ts 

of the intervention and were reported by some participants as burdensome to complete.

CONCLUSION

Recognition and management of service members’ behavioral health symptoms have become a priority in the 

Army.29,30 It is now recognized as critical to the quality of life of wounded service members which must be 

addressed at the WTU. Other research clearly supports 

the use of AAT and life skills training when provided 

separately.9,10,14,16,17 Although this study clearly comes 

with limitations and the results should be interpreted 

with caution, it is important to note that it is the fi rst 

research on the use of AAT in a garrison environment 

with wounded service members. Future research that 

considers limitations noted here, especially sample size, 

randomization, duration of time from intervention to assessment, participant burden in assessment, and control 

over variability of treatment sessions should be considered. Examination of the cause-effect relationships 

among the variables of stress, mood, resilience, fatigue, 

and function would be of great benefi t. A mixed method 

approach that gathered qualitative data could further 

identify and examine anecdotally reported benefi ts of 

using AAT with the military population.

ACKNOWLEDGEMENTS

The authors thank the Soldiers who participated, the pet 

therapy teams, the Occupational Therapy staff at the 

San Antonio Military Medical Center Warrior Transition Unit, and CPT Cecilia Najera, Offi cer-in-Charge, 

Occupational Therapy Service, San Antonio Military 

Medical Center.

REFERENCES

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2009;174:566-571.

2. OTSG/MEDCOM Comprehensive Transition Plan 

Policy 09-011. Washington, DC: Offi ce of The 

Surgeon General, US Dept of the Army; March 10, 

2009.

3. Erickson M, Secrest D, Gray A. Army occupational therapy in the Warrior Transition Unit. Occup Ther Pract [serial online]. 2008;13(13):10-14. 

Available at: http://www.aota.org/Pubs/OTP/2008/

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4. Helfrich C, Aviles A, Badiani C, Walens D, Sabol 

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207. Available at: http://informahealthcare.com/

doi/pdf/10.1080/J003v20n03_12.

5. Thomes LJ, Bajema SL. The life skills development 

program: a history, overview and update. In: Ellsworth PD, Gibson D, eds. Psychiatric Occupational 

Therapy in the Army. New York, NY: The Haworth 

Press;1983:35-48.

6. Mairs H, Bradshaw T. Life skills training in schizophrenia. Br J Occup Ther. 2004;67(5):217-224.

7. Porter J, Capra S, Watson G. An individualized foodskills programme: development, implementation and 

evaluation. Aust Occup Ther J [serial online]. June 

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8. Aviles AM, Helfrich CA. Homeless youth: causes, 

consequences and the role of occupational therapy. 

Occup Ther Health Care. 2006;20(3-4):99-114. Available at: http://informahealthcare.com/doi/pdf/10.1080/

J003v20n03_07.

9. Gutman SA, Schindler VP, Furphy KA, et al. The 

effectiveness of a supported education program 

for adults with psychiatric disabilities: the Bridge 

Program. Occup Ther Ment Health. 2007;23(1):21-

38. Available at: http://www.tandfonline.com/doi/

pdf/10.1300/J004v23n01_02.

10. O’Sullivan J, Gilbert J, Ward W. Addressing the health 

and lifestyle issues of people with a mental illness: 

the healthy living programme. Australas Psychiatry. 

2006;14(2):150-155. Available at: http://informahealthcare.com/doi/pdf/10.1080/j.1440-1665.2006.02275.x.

11. Velde B, Cipriani J, Fisher G. Resident and therapist 

views of animal-assisted therapy: implications for 

occupational therapy practice. Austral Occ Ther 

J. 2005;52(1):43-50. Available at: http://onlinelibrary.

wiley.com/doi/10.1111/j.1440-1630.2004.00442.x/pdf.

12. What are animal-assisted activities/therapy? Delta Society Web site. Available at: http://www.deltasociety.org

/Document.Doc?id=10. Accessed December 21, 2011.

THE EFFECTS OF ANIMAL-ASSISTED THERAPY ON WOUNDED WARRIORS IN AN OCCUPATIONAL THERAPY LIFE SKILLS PROGRAM
April – June 2012 45

THE ARMY MEDICAL DEPARTMENT JOURNAL

13. Arkow P. Animal-assisted Therapy and Activities: A 

Study, Resource Guide and Bibliography for the Use 

of Companion Animals in Selected Therapies. 10th ed. 

Stratford, NJ: self-published; 2011. Available at: http://

www.animaltherapy.net/Publications.html.

14. Barker SB, Dawson KS. The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients. Psychiatr Serv. 1998;49(6):797-801.

15. Berget B, Ekeberg O, Braastad BO. Attitudes to animal-assisted therapy with farm animals among health 

staff and farmers. J Psychiatr Ment Health Nurs. 

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wiley.com/doi/10.1111/j.1365-2850.2008.01268.x/pdf. 

Accessed November 15, 2010.

16. Souter MA, Miller MD. Do animal-assisted activities effectively treat depression? A meta-analysis. 

Anthrozoos. 2007;20:167-80.

17. Friedmann E, Son H. The human-companion 

animal bond: how humans benefi t. Vet Clin Small 

Anim. 2009;39:293-326.

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19. McNair DM, Lorr M, Droppleman LF. Manual for 

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20. Curran S, Andrykowski M, Studts J. Short form of 

the profi le of mood states (POMS-SF): psychometric information. Psychol Assess. 1995;7(1):80-83.

21. Cohen S, Kamarck T, Mermelstein R. A global 

measure of perceived stress. J Health Soc Behav. 

December 1983;24(4):385-396.

22. Connor KM, Davidson RT. Development of a new 

resilience scale: the Connor-Davidson resilience 

scale (CD-RISC). Depress Anxiety. 2003;18(2):76-

82. Available at: http://onlinelibrary.wiley.com/

doi/10.1002/da.10113/pdf. Accessed October 15, 

2010.

23. Portney LG, Watkins MP. Foundations of Clinical 

Research: Applications to Practice. 3rd ed. Upper 

Saddle River, NJ: Pearson/Prentice Hall; 2009.

24. Jette AM, Davies AR, Cleary PD, Calkins DR, 

Rubenstein LV, Fink A, et al. The functional status 

questionnaire: reliability and validity when used 

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Gen Intern Med. 1986;1(6):427]. J Gen Intern Med. 

1986;1(3):143-149.

25. Baron K, Kielhofner G, Iyenger A, Goldhammer 

V, Wolenski J. The Occupational Self Assessment 

(OSA). Ver 2.1. Chicago, IL: University of Illinois 

at Chicago; 2003.

26. Kielhofner G, Forsyth K. Measurement properties 

of a client self-report for treatment planning and 

documenting therapy outcomes. Scand J Occup 

Ther. 2001;8:131-139.

27. Kielhofner G, Forsyth K, Kramer J, Iyenger A. 

Developing the occupational self assessment: the 

use of Rasch analysis to assure internal validity, sensitivity and reliability. Br J Occup Ther. 

2009;72(3):94-104.

28. Zisselman MH, Rovner BW, Shmuely Y, Ferrie P. 

A pet therapy intervention with geriatric psychiatry. 

Int Psychogeriatr. 1995;7(4):535-545.

29. Nauert R. Canine therapy for military PTSD. Psychology Central News. July 9, 2010:A1, A4. Available at: http://psychcentral.com/news/2010/07/09/

canine-therapy-for-military-ptsd/15444.html.

30. Lorge EM. Dogs help wounded warriors heal at 

Walter Reed. US Army Web site; 2008. Available 

at: http://www.army.mil/article/10451/Dogs_help_

wounded_warriors_heal_at_Walter_Reed/. Accessed December 21, 2011.

AUTHORS

CPT Beck is Offi cer-in-Charge of the 528th Combat and 

Operational Stress Control Fitness Team and the Warfi ghter Restoration Center, Bagram Airfi eld, Afghanistan.

When this article was written, MAJ Gonzales was Chief, 

Occupational Therapy Branch, Medical Education and 

Training Campus, Joint Base San Antonio, Texas.

Dr Haertlein Sells is Professor, Chair and Graduate Program Coordinator, Department of Occupational Science 

and Technology, College of Health Sciences, University 

of Wisconsin-Milwaukee, Milwaukee, Wisconsin.

MAJ Jones is Chief, Musculoskeletal Medicine, Schofi eld 

Barracks Health Clinic, Schofi eld Barracks, Hawaii.

CPT Reer is Offi cer-in-Charge, Inpatient Occupational 

Therapy Services, Department of Surgery and Rehabilitation, William Beaumont Army Medical Center, El 

Paso, Texas.

CPT Zhu is Assistant Chief, Department of Occupational Therapy, Tripler Army Medical Center, Honolulu, 

Hawaii.

MAJ Wasilewski is currently deployed overseas.
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

For many thousands of years, dogs and humans have 

been companions. Although there is debate about when 

wolves became domesticated,1

 based on osteoarcheologic and genetic research, examples of this domestication 

have been traced to the Upper Paleolithic era (approximately 40,000 to 10,000 years ago).2

Regardless of when and how this partnership developed, 

canines have performed vital jobs for man throughout the ages. Historically, war dogs have been used by 

armies, including Egyptian, Greek, Persian, and Roman.3

 As fi ghting dogs, they were trained to attack the 

enemy or, when used defensively, to protect caravans or 

forts. In more recent times, dogs have been used as couriers to carry messages in battle or pull carts of wounded 

Soldiers.4

Dogs were used in an unoffi cial capacity during the 

Revolutionary War. The fi rst recorded use of dogs by 

the US Army was during the second Seminole War 

(1835–1842),3(p138) but it was not until World War II that 

this relationship was formalized. Patriotic dog owners formed “Dogs for Defense,” a civilian group that 

reached out, with the aid of the American Kennel Association, to other dog owners across the country to donate 

quality canines to the US Army Quartermaster Corps.5

In 1942, the Secretary of War approved the creation of 

the fi rst K-9 corps.5,6 Since then, dogs have served with 

their handlers in confl icts around the world in a variety of roles, including sentries, scouts, messengers, and 

mine detectors.

A NEW ROLE FOR MILITARY DOGS

America’s VetDogs began as a project of the Guide Dog 

Foundation for the Blind, a not-for-profi t agency, which 

has trained guide dogs for blinded Veterans since the 

end of World War II. VetDogs was created to provide an 

overall assistance dog program to enhance and increase 

the services the organization offered to disabled Veterans of all eras. Beginning in 2003 with a presentation 

at the National Disabled Veterans Winter Sports Clinic, 

America’s VetDogs has built a solid reputation of providing guide and service dogs to disabled Veterans.

VetDogs was invited to train a balance dog to work at the 

Walter Reed Army Medical Center with vestibular patients as they adjusted to their new prostheses. However, 

it was realized that wounded Soldiers were also using the 

golden retriever (named George) for emotional support 

during their rehabilitation. Indeed, after George’s original handler was reassigned, the dog became a “good will” 

ambassador-at-large for recovering service members.

Based on observations of how these men and women responded to George’s presence, a new role was envisioned 

for therapy dogs as an innovative “tool” that combat and 

operational stress control (COSC) teams could use in 

theater to help break down the stigma attached to mental 

health care. They would allow members of the COSC 

team to reach out and help Soldiers who might be experiencing combat stress or home-front issues during their 

deployments as part of Operation Iraqi Freedom (OIF) 

Training the Combat and Operational Stress

 Control Dog: An Innovative Modality for

 Behavioral Health

William Krol

ABSTRACT

Combat and operational stress control (COSC) dogs represent a new category of military working dog. America’s VetDogs, a nongovernmental, not-for-profi t organization, trains and provides therapy dogs to work with 

the US Army’s combat and operational stress control teams deployed to Afghanistan or Iraq. By taking the 

therapy/service dog concept to the next level, these dogs have become an important modality in the Army’s 

initiative to safeguard Soldiers’ behavioral health while deployed, allowing COSC unit members to break 

down stigmas that are still present when dealing with behavioral health issues. The training process begins by 

choosing a pool of dogs, exposing them to different sensory experiences over several months, and training the 

primary and secondary handlers who will be responsible for the dogs while deployed in theater. After their 

deployment ends, the dogs are retrained by America’s VetDogs to further serve in military or Veterans Administration medical centers as physical, occupational, or behavioral therapy dogs.
April – June 2012 47

or Operation Enduring Freedom (OEF). America’s VetDogs was approached to train dogs to serve in this pioneering capacity. VetDogs and Army personnel worked 

together for a year to refi ne the aspects of the program, 

including training and dog handling responsibilities. In 

December 2007, SFC Boe and SFC Budge, two black 

Labrador retrievers (Figure 1), assumed a historic role: 

the fi rst-ever combat and operational stress control dogs 

to be deployed in theater as specially trained skilled 

therapy dogs.

America’s VetDogs worked in collaboration with the 

Army Public Affairs Offi ce in New York, NY, to generate media coverage of the handover ceremony as 

America’s VetDogs donated the dogs to the Army. Local 

New York and national media covered the story before 

the dogs’ deployment, and updates appeared on CNN, 

Fox News Channel, and National Public Radio. Stories 

appeared in newspapers, websites, and blogs, including 

press releases generated by the different units that were 

visited by the COSC dogs.

TRAINING THE COSC DOG

To ensure that America’s VetDogs provides only the 

highest quality, fully trained dogs to the Army, training 

and acclimating a COSC dog team and preparing it for 

deployment (including the training of handlers) is a 4- 

to 6-month process. The search for a COSC dog begins 

with a review of the medical records of available dogs 

currently residing in the Guide Dog Foundation kennels (America’s VetDogs obtains its dogs from its parent, 

the Guide Dog Foundation for the Blind) and includes 

Labrador retrievers, golden retrievers, and Labrador/

golden retriever crosses. Trainers evaluate dogs that 

come only from the Foundation’s stock because of the 

detailed medical histories kept for each dog. All dogs 

chosen for the COSC training program must have clean 

bills of health because the availability of veterinarians 

and the conditions the dogs may face once deployed 

are not predictable. The dogs are reviewed for temperament, health issues, and adaptability. Trainers look for a 

“sound” dog, one that is confi dent and comfortable with 

new experiences. It must not react adversely to unpleasant experiences nor have residual effects when it does 

encounter such conditions. A pool of approximately 20 

dogs will eventually be narrowed down to 12 dogs, and 

then 6 dogs.

After a certain number of dogs have been identifi ed as 

potential COSC dogs, a trainer works with a local volunteer fi re department to expose them to different types of 

vehicles and equipment, sights, sounds, and smells. During a typical visit, fi refi ghters will sound the horns and 

fl ash the lights so the trainer can evaluate the dog’s reaction. If it bolts or otherwise shows that it is afraid, the 

dog will not be used for the COSC program. However, 

minor anxiety exhibited by the dog can be overcome.

Figure 1. SFC Boe and SFC Budge were the fi rst-ever combat and operational stress control dogs. They served in Iraq 

from 2007 to 2009. Photo courtesy of Lou Buonomo.

Figure 2. A VetDogs trainer works with a candidate combat and operational stress control dog to board and exit 

a helicopter at the Intrepid Sea, Air, and Space Museum 

in New York, NY. Photo courtesy of the author.
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

The dogs are loaded and unloaded onto different vehicles so they are comfortable with a variety of equipment. 

There is also a mechanic’s “pit” that was previously used 

to make repairs on trucks. The VetDogs trainer leads the 

dog into the pit because it simulates a dark cave with 

many different smells, including burn smells. If the dog 

balks, the trainer gently encourages the dog without 

forcing it; the dog must be able to trust its handler. 

The dogs are also acclimated to the sounds of gunfi re 

and helicopters. VetDogs works cooperatively with the 

aviation division of a local police department and the Air 

National Guard for access to working helicopters and 

other military aircraft. Trainers have also worked at the 

Intrepid Sea, Air, and Space Museum (New York, NY), 

teaching the dogs to jump in and out of the helicopters 

(Figure 2) on display on the Intrepid’s fl ight deck. Until 

they are deployed, the dogs’ helicopter training is static.

Thanks to the relationship between VetDogs and a local 

fi ring range, the dogs are exposed to the sounds of gunfi re, from automatic weapons to pistols (Figure 3). The 

trainers want to ensure that the dogs maintain a calm attitude and demeanor when exposed to these sounds. The 

dogs are also conditioned to wear special goggles, vests 

or backpacks, and ear muffs.

Additional sensory exposures include different types of 

surfaces (sand, stone, gravel, etc) and busy streets and 

highways so the dogs are comfortable around moving 

trucks and other loud noises.

VetDogs trainers also work on obedience training, basic 

commands, and controllability. They will use a motivational object (MO) or “drive toy” to enhance a dog’s 

obedience skills. An MO can be used as a distraction if 

the dog is in a stressful experience—the dog focuses on 

the toy, not the situation, thereby alleviating its stress. 

Obedience is vital because eventually the dog will be in 

situations with equipment to which it has not previously 

been exposed.

The most important function of a COSC dog is its adaptability to different environments, noises, and crowds 

so that the dog enhances the work of the COSC team, 

without being a distraction. The dog must have excellent house manners and behave impeccably in a myriad 

of situations.

Dogs must not scavenge for food, so trainers work on 

teaching the dog to ignore “food distractions.” For example, a handful of kibble is tossed on the fl oor, and the 

dog maneuvers around it without stopping to eat.

During its mission, the dog may be called upon to have 

enough energy to engage in morning physical training 

exercises, while later in the afternoon it may be required 

to lie quietly in a clinical setting, where Soldiers can 

interact with it. The dogs can provide emotional comfort 

through physical interactions such as playing fetch or 

simple petting.

The dog must also adapt to a number of different handlers depending on the current mission or future deployments. The presence of the dogs allows their COSC team 

handlers to concentrate on their duties.

INTEGRATED TRAINING

The fi rst COSC team training took place in December 

2007 on the campus of America’s VetDogs in Smithtown, NY. Two occupational therapy assistants from the 

85th Medical Detachment were temporarily assigned to 

Smithtown for 5 days to learn basic handling techniques 

for SFC Boe and SFC Budge. 

When the 85th Medical Detachment returned to the 

United States, the dogs were assigned to the 528th Medical Detachment. Prior to their deployment, handlers 

from this unit also trained at VetDogs headquarters with 

“demo” dogs to familiarize themselves with obedience 

training and handling techniques.

TRAINING THE COMBAT AND OPERATIONAL STRESS CONTROL DOG:

AN INNOVATIVE MODALITY FOR BEHAVIORAL HEALTH

Figure 3. A VetDogs trainer and Army handler with a combat 

and operational stress control dog at the fi ring range. Note 

the dog is wearing its special ear muffs. Photo courtesy of 

the author.
April – June 2012 49

THE ARMY MEDICAL DEPARTMENT JOURNAL

Because the VetDogs campus does not offer the unique 

training facilities an Army base provides, VetDogs trainers currently travel to a unit’s home base to train the dogs’ 

primary and secondary handlers. The VetDogs trainer 

spends half of the fi rst day working with the whole unit. 

Team members who are not the dogs’ handlers will have 

the opportunity to understand the roles the canines will 

play as members of the COSC team. The trainer will 

also discuss proper handling techniques. 

After the initial session, the trainers focus on the primary and secondary dog handlers. The primary handler 

is an occupational therapy assistant with an interest in 

the mission, and there are 8 to 14 potential handlers for 

every 2 dogs in theater.

At the request of the Army, VetDogs trainers traveled 

to Landstuhl, Germany, to train 2 COSC dogs that 

would be deployed with the 254th Medical Detachment 

to Afghanistan. These were the fi rst COSC dogs to be 

deployed as part of OEF. VetDogs trainers have also 

trained personnel of the 212th Medical Detachment at 

Fort Campbell, KY, and the 98th Medical Detachment at 

Joint Base Fort Lewis-McChord, WA.

IN THEATER

When deployed, the dogs accompany their handlers 

wherever they go. The dogs serve as an icebreaker and 

communications link between troops and care providers, 

and, whether in a one-on-one or group setting, members 

of COSC teams have reported that service members 

would talk to them for longer periods of time than if 

they were alone.

As part of its commitment to the Army, America’s VetDogs trainers are constantly in touch with COSC dog 

handlers throughout their deployment so they remain 

confi dent that VetDogs will resolve any issues that might 

arise with the dogs.

As of this writing, a total of 8 dogs have served as part of 

OIF, OEF, and Operation New Dawn. The dogs have interacted with thousands of service members, both in theater and in new assignments once they return home. SFC 

Budge and SFC Boe served 2 consecutive tours of duty, 

fi rst with the 85th Medical Detachment and then with the 

528th Medical Detachment. SFC Zeke and SFC Albert 

were attached to the 212th Medical Detachment, and then 

the 85th Medical Detachment. SFC Butch and SFC Zack 

served with the 98th Medical Detachment in Iraq, and 

SFC Apollo and SFC Timmy were assigned to the 254th 

Medical Detachment in Afghanistan. Apollo and Timmy were reassigned to the 528th when the 254th rotated 

home. For both the 85th and 528th Medical Detachments, 

the assignments represented the second time the units 

had requested COSC dogs to be members of the combat stress control team. Zeke is currently with the 113th 

Medical Detachment, stationed in Afghanistan.

NEW DUTY ASSIGNMENTS

When Boe and Budge returned to the United States in 

2009, they had not been reassigned. However, a civilian 

physical therapist at Eisenhower Army Medical Center 

(EAMC) on Fort Gordon, GA, had requested a dog to 

work with her patients. The dogs were available and residing at America’s VetDogs, so the next phase in the 

careers of the COSC dogs had begun.

It is now standard procedure for America’s VetDogs 

to meet a COSC unit upon its return and transport the 

dogs back to the VetDogs campus in Smithtown. There, 

VetDogs trainers reevaluate the COSC dogs for behavior 

and temperament. When they perform a “temperament 

test,” the trainers compare a dog’s behavior from before 

deployment to its behavior after deployment. Dogs are 

retrained to correct behaviors that might have been acceptable in theater but would not be in a hospital or other 

medical setting.

Once the Army Medical Command has determined a 

dog’s next mission, the dog may be trained to perform 

specifi c tasks. Such tasks include providing balance and 

stability with the use of a special balance harness or 

by “bracing,” opening doors, picking up dropped items, 

pressing buttons, turning on light switches, creating a 

safe “personal space zone” or leading someone to a door 

to go outside. Depending on the task, task training involves constant repetition of the task and positive reinforcement when the dog performs it successfully. Each 

step forward builds on the success of previous steps.

Trainers from America’s VetDogs reevaluated and retrained Boe and Budge to serve at EAMC, along with a 

third dog trained especially for the medical center. Just 

one example of their effectiveness and value: a Soldier 

recovering at EAMC was encouraged by her occupational therapist to interact with Budge. She began to realize 

that the dog was not only helping with her vestibular 

problems, he was helping to improve her mental state. 

With the dog by her side, she felt comfortable going out 

by herself, and later trained with her own service dog 

from America’s VetDogs. She credits her service dog 

with giving her the freedom to reclaim her life. Further, 

when her tire blew out during a wheelchair basketball 

game and she reacted to the noise, her service dog came 

running to her side as it had been trained to do. This so 

impressed a fellow Veteran in the stands that he applied 

for his own service dog in April 2011.
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

AMERICA’S VETDOGS–THE VETERAN’S K-9 CORPS

In addition to COSC dogs, America’s VetDogs also provides individual assistance dogs and training for disabled Veterans of all eras. To date, over 200 disabled 

Veterans have received assistance dogs to help them 

with daily life activities. These dogs range from guide 

dogs for Veterans who are blind or visually impaired 

to service dogs that provide balance and stability for 

amputees or those with traumatic brain injuries, seizure 

alert response dogs for those with seizure disorders, and 

dogs to alert diabetics when they have low blood sugar.

Of those service members who were still on active duty 

when they trained with their service dogs, 20% have 

chosen to remain active.

VetDogs also trains facility and physical and occupational therapy dogs that are placed at various military 

and Veterans Administration (VA) medical centers. In 

addition to the Walter Reed National Military Medical Center and the Eisenhower Army Medical Center, 

VetDogs has placed dogs at VA facilities in Northport, 

NY, Dublin, GA, and Lake City, FL. Recently, Boe was 

transferred to Fort Benning, GA.

In June 2009, America’s VetDogs received the Secretary 

of the Army’s Public Service Award, which recognizes 

“exceptional service that makes a substantial contribution to the accomplishment of the Army’s missions.”

The timeline of the development of the COSC dog program, beginning in 2006, is shown in the inset.

REFERENCES

1. Burying man’s best friend. interview with Darcy 

Morey. Archaeology [serial online]. November 

8, 2006. www.archaeology.org/online/interviews/

morey.html. Accessed November 22, 2011. 

2. Pionnier-Capitan M, Bemilli C, Bodu P, et al. New 

evidence for Upper Palaeolithic small domestic dogs in south-western Europe. J Archaeol Sci. 

2011;38(9):2123-2140.

3. Karunanithy D. Dogs of War: Canine Use in Warfare from Ancient Egypt to the 19th Century. London, UK: Yarak Publishing. 2008.

4. Dogs of war in European confl ict. New York Times. 

February 21, 1915. http://query.nytimes.com/gst/abs

tract.html?res=F20A13FF395B17738DDDA80A94

DA405B858DF1D3. Accessed November 22, 2011.

5. Waller AM. Dogs and National Defense: Study 

on the history of War Dog training and utilization 

during and after World War II. Fort Lee, VA: Offi ce of the Quartermaster General, US Dept of the 

Army; 1958. http://www.qmmuseum.lee.army.mil/

dogs_and_national_defense.htm. Accessed November 22, 2011.

6. Quartermaster War Dog Program. US Army 

Quartermaster Foundation website. http://www.qm

found.com/K-9.htm. Accessed November 28, 2011.

AUTHOR AND ACKNOWLEDGEMENT

Mr Krol is the communications manager for America’s 

VetDogs–the Veteran’s K-9 Corps. The author thanks 

Valerie Cramer, a service dog instructor for America’s 

VetDogs, who provided background and details on the 

training of COSC dogs.

2006

A new role for therapy dogs in theater is envisioned after it is observed 

how wounded service members interact with George, a therapy dog at 

Walter Reed Army Medical Center.

2007

Occupational therapy assistants with the 85th Medical Detachment 

are temporarily assigned to VetDogs headquarters to train with SFC 

Boe and SFC Budge, who are deployed to Iraq in December.

2008

Members of the 528th Medical Detachment travel to VetDogs headquarters to learn dog-handling techniques before they deploy to Iraq 

and assume responsibilities for Boe and Budge.

2009

SFC Zeke and SFC Albert are trained to replace Boe and Budge. VetDogs instructors travel to Fort Campbell, KY, to facilitate training with 

members of the 212th Medical Detachment.

Boe and Budge return and spend several months at VetDogs headquarters while they are reevaluated and retrained for service at Eisenhower Army Medical Center. MSG Maverick is trained and will join 

them for the traumatic brain injury clinic, and inpatient and outpatient 

behavioral health.

America’s VetDogs receives the Secretary of the Army’s Public Service 

Award.

2010

SFC Apollo and SFC Timmy are trained in Landstuhl, Germany, to accompany the 254th Medical Detachment to Afghanistan. They are 

stationed at Bagram Airfi eld.

SFC Budge is diagnosed with lymphoma, one of the most common 

cancers in dogs, and passes away. He touched the lives of many Soldiers, Veterans, and their families and is remembered during a memorial service at Fort Gordon.

2011

Zeke and Albert return home and are reevaluated and retrained for 

their next duty assignment. Albert joins Maverick at Eisenhower. Zeke 

redeploys with the 113th Medical Detachment, and is currently in Afghanistan. 

SFC Boe is reassigned to Fort Benning, Ga.

SFC Butch and SFC Zack are trained at Joint Base Fort Lewis-McChord 

with the 98th Medical Detachment for deployment to Iraq as part of 

Operation New Dawn. After a 9-month deployment, the unit rotates 

home. Butch and Zack are currently in residence with America’s VetDogs for evaluation and retraining.

TRAINING THE COMBAT AND OPERATIONAL STRESS CONTROL DOG:

AN INNOVATIVE MODALITY FOR BEHAVIORAL HEALTH
April – June 2012 51

In December 2007, a new program to include therapy 

dogs in combat and operational stress control units was 

initiated by Army occupational therapists. The intent of 

the program was to complement the job of the therapists by using a highly skilled dog to achieve therapeutic 

goals. The dogs, SFC Boe and SFC Budge, were a donation from America’s VetDogs, a subsidiary of Guide 

Dogs of America. Therapy dogs are trained to provide 

individuals a pleasurable interaction via animal-assisted 

activities (AAA) or animal-assisted therapy (AAT). According to the Delta Society*:

Animal-assisted activities provide opportunities 

for motivational, educational, recreational, and/

or therapeutic benefi ts to enhance quality of life. 

Animal-assisted activities are delivered in a variety 

of environments by specially trained professionals, 

paraprofessionals, and/or volunteers, in association 

with animals that meet specifi c criteria.2

Animal-assisted therapy is a goal-directed intervention in which an animal that meets specifi c criteria 

is an integral part of the treatment process. AAT is 

directed and/or delivered by a health/human service provider working within the scope of practice 

of his/her profession. Animal-assisted therapy is 

designed to promote improvement in human physical, social, emotional, and/or cognitive functioning. AAT is provided in a variety of settings and 

may be group or individual in nature. This process 

is documented and evaluated.3

As of this writing, 6 dogs have deployed to Iraq and Afghanistan, offering Soldiers a small reminder of home. 

For the Army occupational therapists who led the way 

in this endeavor as primary handlers, the path has been 

rocky but ultimately rewarding.

PREDEPLOYMENT TRAINING

Predeployment training was vital for the dog handlers, 

because none of the handlers were previously trained 

in nor had they utilized AAT in their profession. The 

3 handlers’ previous experience with dogs ranged from 

no experience to owning a dog as a family pet. In February 2010, the 85th Medical Detachment Combat and 

Operational Stress Control (COSC) hosted 5 days of 

predeployment training at Fort Hood, Texas. Two trainers and 4 dogs from VetDogs of America traveled to 

Fort Hood to train over 15 unit personnel. The 4 dogs 

were assigned to individuals that would most likely be 

the primary and secondary dog handlers once in theater. 

At the end of each day’s training, the dogs went home 

with their assigned handler. The overnight stays helped 

ensure the handlers understood the responsibilities 

of taking care of a dog full-time. The formal training 

consisted of an overview of AAT, history of VetDogs 

of America, instruction on commands, obedience training, ways to utilize the dogs in theater, and general care 

of the dog. An Army veterinarian provided instruction 

on heat casualties, general medical care, and required 

check-ups for the dogs. Next, the trainees were afforded 

the opportunity to take their new training to the streets. 

They took the dogs to the post exchange, hospital mental 

health clinics, the range, and the motor pool. These sites 

exposed the therapy dogs and the handlers to a variety 

Occupational Therapists as Dog Handlers:

 The Collective Experience with

 Animal-Assisted Therapy in Iraq

MAJ Lorie Fike, SP, USA

CPT Cecilia Najera, SP, USA

CPT David Dougherty, SP, USA

ABSTRACT

The fi rst pair of US Army animal-assisted therapy (AAT) dogs deployed to Iraq in December 2007 with the 

85th Medical Detachment Combat and Operational Stress Control unit. As of this writing, 6 dogs have deployed 

to Iraq and Afghanistan, offering Soldiers a small reminder of home. Army occupational therapists led the way 

in this endeavor as primary handlers; the path has been rocky but ultimately rewarding. This article depicts how 

occupational therapists used AAT and animal-assisted activities to help Soldiers cope with the stressors of living in a deployed environment. Challenges and lessons-learned, including anecdotal examples, are discussed.

*The Delta Society is a national nonprofi t organization which focuses on training, certifying, and registering therapy and service 

dogs, and conducts research into human-animal interactions.1
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

of military environments. The outings allowed the handlers to practice their new skills in a safe and controlled 

environment. They received constructive feedback from 

the trainers about what was good as well as what should 

be changed. Caring for a canine, especially while deployed, is a massive responsibility, and the predeployment training was a valuable and essential component 

of the success of the program.

TRANSFER OF CARE

Some dogs deployed and redeployed with the same unit, 

yet other dogs remained in theater and had to be transferred to new handlers. In March 2010, SFC Zeke and 

SFC Albert were transferred from the 212th Medical 

Detachment (COSC) to the 85th Medical Detachment 

(COSC). During the transfer process, the redeploying 

therapist educated the incoming therapist regarding the 

dog’s daily schedule and his likes/dislikes. They also 

informed the new handlers about how and where to obtain additional food, supporting veterinarians, upcoming medical needs, and units they supported. Some units 

were accustomed to seeing the dogs on a weekly basis 

and others had set appointments to see the dogs. The 

outgoing handlers also transferred information regarding a research project that involved the dogs. The dogs’ 

belongings such as kennels, beds, food, treats, and work 

vests were also transferred. The most diffi cult part was 

after the transfer was completed and the previous handler was still on the forward operating base. SFC Zeke 

was confused, and he did not know from whom to accept commands. For a short time, SFC Zeke tested his 

boundaries. He was like a child with a substitute teacher, 

and he wanted to see what he could get away with. After 

about one week, he acclimated to his new handler and 

the two of them were able to do some great things across 

the base.

ACCLIMATION

The therapy dogs not only have to acclimate to new handlers, but they must also acclimate to new environments 

and new people on a daily basis. Each AAT dog has a different personality and each acclimated to new situations 

and new people differently. At times, SFC Zeke would 

get more timid in unfamiliar situations while SFC Albert 

would get overly excited. Overall, the dogs were friendly, 

well-mannered, and thrived on interaction. They slept 

well, ate well, and were very kind to the individuals who 

cared for them, as well as to the individuals who interacted with them. The dogs seemed to inherently know when 

they were at work versus when they could relax. When 

their work vests were put on their demeanor changed. 

They were more attuned to commands, obedience, and 

performing tricks. The dogs were not afraid of the 

environment or the individuals who interacted with them. 

In fact, there is only one incident when SFC Zeke became 

afraid. He walked near a very loud generator, stopped, 

and would not proceed. His handler did not make a big 

deal of the situation. She simply took a different route and 

the problem was solved. For the most part, the AAT dogs 

adapted well to new people and new situations.

DOG CARE

Some handlers were dog owners at home and were familiar with taking care of a dog. A deployed environment 

proved to be much different. There were no fenced back 

yards where one could let the dogs out to run and play. 

In the summer, the temperature is consistently 120°F 

in Iraq and the rainy season brings endless amounts of 

mud. Unlike military working dogs that stay in a caged 

kennel when they are not working, the animal assisted 

therapy dogs shared living quarters with the primary 

dog handler. The primary handlers had a vested interest in keeping the dogs clean, which also required extra time and effort. The handlers were not able to go 

to the local grocery store and buy dog food, but they 

had to plan months in advance in order to secure food. 

The signifi cant responsibility was exhausting and overwhelming at times because being a primary handler was 

not a primary duty, but an additional duty. The handlers 

were still responsible for performing duties as offi cerin-charge, educators, mental health offi cers, and occupational therapists. Their duty day was not over when 

the clinic closed, because they still had to walk the dogs, 

feed them, and take them to visit Soldiers on the forward 

operating base (FOB). They were responsible for maintaining a healthy weight for the dogs which proved to 

be one of the most diffi cult and stressful parts of caring 

for them. The assigned dogs were Labrador retrievers, a 

breed which has a nature to be scavengers. The handlers 

had to be careful when taking them on walks and interacting with individuals on the FOB. Many people really 

wanted the dogs to like them, and they knew that with 

food comes affection. Many individuals would go to 

great lengths to sneak treats to the dogs despite numerous requests to not feed them. The handlers’ dedication 

to their role sometimes prompted feelings of fear that 

they might not be up to the responsibilities in the care 

of their canine charges. At times, one handler seriously 

worried that her dog may get injured while she cared for 

him, and that would disappoint the Soldiers that really 

needed him. Properly caring for a dog requires much 

effort. All of the handlers faced some challenges while 

caring an animal-assisted therapy dog, but after being 

responsible for and interacting with such a valuable animal, they gained a new appreciation for dogs and have 

themselves become better pet owners.

OCCUPATIONAL THERAPISTS AS DOG HANDLERS:

THE COLLECTIVE EXPERIENCE WITH ANIMAL-ASSISTED THERAPY IN IRAQ
April – June 2012 53

THE ARMY MEDICAL DEPARTMENT JOURNAL

UTILIZATION OF THERAPY DOGS

Combat and operational stress control (COSC) in the 

Army focuses on actions taken by military leadership 

and programs geared to prevent, identify, and manage adverse combat and operational stress reactions 

(COSR).4 Occupational therapists who deploy as part of 

a COSC unit may be assigned to either a restoration or 

prevention program. 

Restoration programs are designed to teach military 

members basic coping skills to aid with completion of 

a successful deployment. The programs vary due to the 

location needs and the environment, but typically run 

for 3 to 7 days and include group classes and individual 

therapy sessions. By the time an individual is referred or 

volunteers to enroll in a restoration program, he or she 

has exhibited or is beginning to experience COSR. 

In contrast, prevention programs are led by mobile 

teams who visit service members in their area of operations. The goal of the prevention team is to educate the 

population on the services provided by the COSC unit 

and to provide basic education on managing COSR. It is 

important for the prevention team to build a strong relationship with the leadership and the units so that they 

feel comfortable seeking services from the COSC, particularly when traumatic events occur.

The therapy dogs were initially used as part of the 

prevention team to assist the therapists with making 

contacts and describing their services. Mental health 

personnel are encouraged to make contacts with command teams, which might range from company commanders to brigade commanders and fi rst sergeants to 

command sergeant majors. This can be both frustrating 

and intimidating, however, the ambience became more 

inviting when the therapy dog was present. The dog’s 

presence helped the therapist seem more approachable 

and assisted with the fl ow of conversation. Senior offi cers and enlisted personnel took more time to listen to 

the mental health staff and fi nd out what services were 

available for their Soldiers. The mental health team also 

walked through motor pools and aircraft hangars, and 

throughout the FOB’s work and living spaces to make 

contact with service members and to try to gauge the 

stress and morale levels. If the therapy dog was present, service members appeared more likely to share their 

concerns, fears, and goals, and to let down their guard 

for a short time. Soldiers who were angry and stressed 

suddenly smiled. Many people shared stories about their 

own dog and showed pictures of their animals. As service members became more comfortable with the COSC 

team, therapy dogs began to play another role in restoration programs. They were incorporated into group 

classes to assist with self-esteem, anger management, or 

communication skills. If requested by the service member and the schedule permitted, therapy dogs were also 

used for individual therapy sessions to assist with anxiety reduction. The therapy dogs allowed the COSC units 

to market their services in a unique way, because they 

were able to post fl yers and write stories about the therapy dogs. The primary handlers noticed an increase in 

requests for unit visits and commands scheduled more 

commander briefs after the stories were published. They 

successfully opened doors for the COSC and ultimately 

the prevention mission was much easier and more effective with therapy dogs as members of the team.

TRAVELING WITH THERAPY DOGS

Traveling is often necessary in order for the COSC prevention team to reach service members in remote areas. 

During one therapist’s deployment to Iraq, she traveled 

as far south as Baghdad and as far north as Mosul. The 

preferred mode of travel was fl ight, whether via helicopter or USAF transport airplane. Deployment fl ights 

are unpredictable, moreover, the frequent sandstorms in 

Iraq resulted in COSC team personnel being stranded 

in other installations for several days or even weeks at a 

time. Having a therapy dog further complicated the situation for various reasons. First, space is limited and the 

handler is often responsible for carrying his or her own 

bags and equipment. Combat gear is already heavy, and 

add to that the responsibility for a dog and its equipment, 

and ensuring the dog is calm during travel. The whole 

evolution can become quite stressful. When preparing 

for travel, every attempt was made to travel as lightly 

as possible. With the risk of being stranded on another 

location with fewer resources, it was diffi cult to ascertain exactly how much dog food to take; too little would 

be dangerous for the dog, too much would be heavy and 

burdensome. Another concern was fi nding lodging if 

stranded. Space was limited, especially when accompanied by a dog. For example, if the only sleeping space 

available was a communal tent, the therapy dog could 

not be left unattended. The dog would have to go everywhere with the handler, to include the bathroom and 

dining facilities. To complicate matters further, many 

dining facilities did not give the dog admission and the 

handler would have to ask others to bring food. Limited 

air conditioning in temperatures that exceeded 110°F 

were also a risk factor for the dog, and the handler had 

to ensure the dog was properly hydrated and cooled.

SEPARATION OF DOGS AND HANDLERS

Midway through the deployment, the 85th Medical Detachment Combat Stress Control became part of the 

drawdown of forces in Iraq, and the unit was required 

to reallocate its resources and expand its mission. The 
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

detachment commander had to evaluate her assets and 

determine who must relocate and assume responsibilities 

of new clinics. SFC Albert was chosen to relocate to a 

large FOB for which the unit would assume responsibility, but his primary handler was tasked to move to a different location. SFC Zeke was known to all across the 

FOB. The AAT program had tremendous support and 

made so many positive contacts at that location that the 

detachment commander decided to leave SFC Zeke in 

place. Being one of the senior offi cers in the unit, SFC 

Zeke’s handler was tasked to open a new clinic and therefore had to relinquish her duties as primary dog handler. 

She again had to face the responsibility to transfer care of 

SFC Zeke, however, this time it was she who would leave. 

Fortunately, the transfer of care was minimal, because 

she transferred him to his secondary handler who was already familiar with SFC Zeke’s schedule, routine, habits, 

and idiosyncrasies. The transition was rather seamless, 

unfortunately, the separation was more diffi cult, particularly for the handler. She missed the ability to pet him and 

snuggle with him when she had a bad day. His new primary handler wrote her to tell her that SFC Zeke stopped 

at her old door and waited for her to come back. Her heart 

ached but she felt proud that she had the opportunity to 

work with him and she was proud that he remembered 

her. The previous handlers of Zeke and Albert were able 

to interact with the other AAT dog in theater, but it was 

not the same. It was hard for them not to compare the 

dogs and they never felt the same connection.

THE AFFECT OF A THERAPY DOG ON A DEPLOYED

COMMUNITY

The discussion so far has focused on how therapy dogs 

assisted the occupational therapy handlers in performing their deployed mission. However, the strongest proof 

of the success of this program is evident in the deployed 

community bonds the dogs help form. Many of the therapy dogs participated in community activities such as 

running in local 5km races, attending church, and attending unit events such as promotion and reenlistment 

ceremonies. Community members often made sure to 

invite the therapy dogs as morale boosters and for motivation. For example, many Soldiers reported the desire 

to want to “outrun the therapy dog” in the 5km races. A 

perfect example of the community support was a birthday party planned for SFC Boe in October 2009. The local Morale, Welfare, and Recreation center was reserved 

for the event. Several Soldiers donated a “Clifford the 

Big Red Dog” piñata, the local dining facility created an 

amazing birthday cake with a chocolate replica of SFC 

Boe, and the local Army band volunteered their Dixie 

Band to play at the party. More than 100 community 

members attended the event and participated in many 

of the activities that included sumo wrestling, piñata 

breaking, cake-eating, and dancing. Activities such as 

these break up the monotony of the deployed environment and offer simple pleasures normally experienced 

back home that help create the sense of a community.

CONCLUSION

For the past 5 years, combat stress control units have 

been using animal-assisted therapy dogs in theater. This 

article describes the experiences of 3 Army occupational therapists as primary dog handlers while deployed, a 

period that was fi lled with both challenges and rewards. 

Ultimately, it was an experience of a lifetime for the 

occupational therapists who were the primary dog handlers, as well as for the service members and civilians 

who had a therapy dog in their deployed environments. 

One of the most diffi cult coping aspects of deployment 

to a war zone is the fact that service members are away 

from family and loved ones during diffi cult and highly 

stressful times. The presence of a therapy dog in this 

situation offers our service members the ability to express and receive affection in an appropriate manner. 

On almost a daily basis, a visitor to these therapy dogs 

would state “I just needed a hug from the therapy dog,” 

or would exclaim “That is just what I needed!” upon 

receiving a sloppy kiss from the dog. The therapeutic 

activity of playing fetch or petting a therapy dog offers 

service members a simple pleasure from home that can 

make one more day of deployment bearable. Sometimes, 

the small gesture of unconditional love from a dog can 

literally make all the difference in the world.

REFERENCES

1. Welcome to Delta Society page. Delta Society Web 

site. Available at: http://www.deltasociety.org/Page.

aspx?pid=659. Accessed January 26, 2012.

2. Animal-Assisted Activities (AAA) page. Delta Society Web site. Available at: http://www.deltasociety.

org/Page.aspx?pid=319. Accessed January 26, 2012.

3. Animal-Assisted Therapy (AAT) page. Delta Society Web site. http://www.deltasociety.org/Page.

aspx?pid=320. Accessed January 26, 2012.

4. Field Manual 4-02.51. Combat and Operational 

Stress Control. Washington, DC: US Dept of the 

Army: July 6, 2006.

AUTHORS

MAJ Fike is Chief, Occupational Therapy Services, Carl 

R. Darnall Army Medical Center, Fort Hood, Texas.

CPT Najera is Offi cer-in-Charge, Inpatient Occupational 

Therapy Service, San Antonio Military Medical Center.

CPT Dougherty is Chief, Occupational Therapy Services, 

Bayne Jones Army Community Hospital, Fort Polk, 

Louisiana.

OCCUPATIONAL THERAPISTS AS DOG HANDLERS:

THE COLLECTIVE EXPERIENCE WITH ANIMAL-ASSISTED THERAPY IN IRAQ
April – June 2012 55

As an Army occupational therapist assigned to the 

212th Combat and Operational Stress Control (COSC) 

Detachment, I was given the opportunity of a lifetime 

providing service to my fellow Warriors, the Soldiers, 

Marines, Sailors, and Airmen, along with Department 

of Defense employees of the United States. My role was 

to manage a CSC clinic that provided behavioral healthcare in Iraq and to conduct fi tness and prevention operations for which I had been trained. In addition to the 

doctrinal education and concepts that I formally learned 

through the Army’s Combat and Operational Stress 

Control Course (COSC), I received a new tasking—one 

in which I would be assigned a 4-legged, furry battle 

buddy named Sergeant First Class Albert.

Albert is a tan Labrador retriever that was donated to 

my detachment by an organization named America’s 

VetDogs to assist our efforts in treating clients who had 

experienced combat and operational stress reactions 

(COSR) during their tour of duty. In August of 2009 he 

was “boots on the ground,” prepared to save a life one 

paw at a time. This mission was my initial fi rst-hand 

experience in using animal-assisted therapy (AAT) as a 

therapeutic medium for behavioral healthcare. Albert’s 

ability to engage clients as they entered the COSC clinic, attend a one-on-one appointment with a provider, or 

even visit the Soldier at their duty location proved to be 

benefi cial in enhancing the mood of our clients and their 

contemporaries.

He was able to ease tension of many of our clients in 

order to assist in their willingness to seek out the COSC 

unit for care and to openly discuss the issues that had 

troubled them. His presence aided in normalizing the 

context of a deployed setting for many clients that had 

not seen their loved ones for many months. The avid 

dog lover naturally enjoyed his services, but many other 

clients who previously did not have affection toward canines would open up to his charismatic nature and engage in leisure activities with him. Many of our clients 

would play fetch, pet him, and even go through his series of commands in order to develop assertiveness.

Albert’s training allowed him to be used within our fi tness program to teach multiple life skills classes such 

as effective communication, anger and stress management, and assertiveness training. He assisted our clients 

by building their confi dence in how they projected their 

voice and tone, delivering clear and concise directions, 

and by implementing contextually appropriate use of 

body language and gestures when communicating. In 

addition to developing communication skills, many of 

the service members were able to use his services as 

a healthy coping mechanism for dealing with stressful 

life events. He was more than any mascot could be in 

enhancing esprit de corps, he was a friend in a rough 

and unforgiving environment that helped many clients 

see the value in their mission abroad and enabled them 

to relate with other service members within a psychoeducational group setting.

The ability to travel with Albert to each unit within our 

contingency operations base provided opportunities to 

engage our clients from a preventive standpoint. The 

COSC unit performs prevention operations as a community-based approach to service our clients who may 

not have had an opportunity to engage a provider within 

the walls of the clinic. Under this premise, I was able to 

teach classes in a small group setting, within their respective area of operations while using Albert as a way 

to provide continuous opportunities for preventive education. He simultaneously operated as another outlet for 

the Soldiers to vent and cope with their stressful predicaments in a positively focused manner. As we would visit 

a unit, news would travel to adjacently oriented units 

that would also request our services. This only further 

assisted our detachment in trying to reach all of the potentially at-risk COSR casualties. Furthermore, we had 

a buy-in from the command groups that we supported 

to assist in fi ghting the negative stigma associated with 

seeking behavioral healthcare.

The benefi ts of Albert’s services could best be defi ned by 

the number of smiling faces that routinely greeted him. 

As the popularity of his presence resonated throughout 

Crossing the Berm: An Occupational

 Therapist’s Perspective on Animal-Assisted

 Therapy In a Deployed Environment

CPT Brian T. Gregg, SP, USA
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

the base, Albert would add units to his weekly visits and 

would be frequented by new clients within the clinic. 

There were few locations where he was not allowed, and 

his efforts were even lauded by the 3rd Infantry Division Commander as demonstrated by his recognition as 

the Military Working Dog of the Month. 

Hindsight is always 20/20. With the experience of using 

a canine for animal-assisted therapy, I can honestly say 

that the wait for Albert to arrive in theater was well worth 

it. A lot of training had to be planned, coordinated, resourced, and implemented for all of the personnel within 

the detachment who were designated as animal handlers. 

It ultimately proved benefi cial in maintaining Albert’s 

skill set and to maintain continuity among the handlers. 

As a lesson-learned, Albert was received very well by the 

population treated and was useful for the life skills classes that I instructed with him. His effort has added to the 

foundation of AAT in a deployed setting and will hopefully guide a doctrinal change in how the Army utilizes, 

trains, and deploys canines for behavioral healthcare.

The procurement of canines while in garrison would be 

the most effective means of establishing AAT capability 

prior to a deployment. Canines are pack animals and require time to adjust to their handler, thereby identifying 

their role and responsibility within the pack. Albert adjusted well to his changing environment, however, this 

was greatly infl uenced by his personality. Maximizing 

the amount of time spent between Albert and the detachment boded well for his transition. I strongly advocate 

that a COSC unit requisition the assignment of a canine 

as soon as they are tasked with an AAT mission.

I highly recommend the use of animal-assisted therapy 

as a treatment modality for combat and operational stress 

control detachments, with emphasis placed on a concerted effort to establish a standard procurement process that 

integrates the canines into a detachment’s deployment 

cycle. As soon as a unit enters their “reset window,” it 

would be benefi cial to have the canine available to begin 

training, rapport building, and integration within COSC 

operations. My experience with AAT was challenging 

and rewarding, all in the same light. More importantly, I 

learned that these furry friends have a benefi t that transcends the relationship of a typical pet owner, indeed, 

rather, is should be likened to that of a comrade in arms, 

focused on conserving the fi ghting strength. I thank my 

superiors who tasked me for the opportunity represented 

by this wonderful assignment, and America’s VetDogs 

for providing such an effi ciently trained canine.

AUTHOR

CPT Gregg is Chief, Occupational Therapy, William 

Beaumont Army Medical Center, Fort Bliss, Texas.

CROSSING THE BERM: AN OCCUPATIONAL THERAPIST’S PERSPECTIVE ON

ANIMAL-ASSISTED THERAPY IN A DEPLOYED ENVIRONMENT

Military working dogs have been deployed with US combat forces since the beginning of operations 

in Iraq and Afghanistan. Here, Grek and his Army handler wait at a safe house before an assault 

against insurgents in Iraq during 2007. US Air Force photo by SSgt Stacy Pearsall.
April – June 2012 57

Due to rapid advances in the medical fi eld, effective holistic forms of patient care are often precluded from best 

practice consideration. Without evidence-based data on 

these nontraditional interventions, resources are likely 

to focus more on costly equipment, complicated surgeries, and increasingly heavy use of medication. Successful programs such as animal-assisted therapy remain 

unknown to the medical community at large and, consequently, underutilized, despite their demonstrated effi cacy in the rehabilitative milieu. This paper highlights 

canine programs currently used by the US Army that 

use trained animals and handlers to achieve specifi c 

physical, cognitive, and psychosocial goals.

Animals are a signifi cant part of American culture and 

share a symbiotic relationship throughout the history of 

humans worldwide. In November 2005, the American 

Heart Association released the results of a study showing that 12-minute visits with therapy dogs improved 

heart and lung function, reduced blood pressure, diminished harmful hormones, and decreased anxiety in heart 

patients.1

 Despite limited therapeutic evidence in both 

the civilian and military sectors, it is reasonable to surmise that the benefi ts of animal involvement in rehabilitative settings can be extremely helpful for patient and 

provider alike. 

The Walter Reed National Military Medical Center 

(WRNMMC) is one such facility that is an emerging 

leader in implementing various human-animal bond 

programs. As the military’s fi rst combined service medical center facility, WRNMMC currently provides support to over 500 Wounded Warriors and their Family 

members living in on- or off-campus facilities. Enhancing healthcare needs throughout their rehabilitation was 

the impetus for implementation of the following humananimal bond programs.

SERVICE DOG PROGRAM

The Service Dog Program works with civilian organizations accredited under Assistance Dogs International 

(ADI) (Santa Rosa, California). Currently, recipients 

of these dogs are limited to Wounded Warriors with 

physical disabilities. However, research is underway 

into extending eligibility to include Wounded Warriors 

diagnosed with posttraumatic stress disorder through 

studies, guidance, and education. Participation in the 

Service Dog Program starts with a physician, therapist, or the Warrior Transition Brigade. Eligible service 

members are educated on the available ADI accredited 

nonprofi t organizations (NPO) that have a 501(c) tax exemption. The WRNMMC has verbal agreements with 

participating NPOs that have excellent reputations and 

strong follow-up records of their clients. Wounded Warriors cannot accept service dogs from an NPO until they 

reach outpatient status or are living off-campus. This 

requirement stems from policies aimed at protecting 

patients’ health and welfare as well as their respective 

service dog. Once a patient selects an organization, he 

or she fi lls out a referral application and submits it to the 

selected agency. The chosen agency makes a qualifi cation determination and contacts the patient to coordinate 

matching with a service dog that will meet their needs.

CANINES FOR COMBAT VETERANS

Canines for Combat Veterans (CCV) was founded to 

specifi cally address the unique assistance needs of combat Veterans and is one of several leading NPOs that 

provide service dogs to Wounded Warriors. Under the 

auspices of the National Education for Assistance Dog 

Services (NEADS, also known as Dogs for Deaf and 

Disabled Americans), CCV donates service dogs to 

Wounded Warriors from all foreign wars, past and present. Additionally, they provide a 2-week training course 

for the Veteran and a primary care assistant. This program includes lodging, meals, and round trip transportation to their Princeton, Massachusetts training facility. 

Customized training of the dog is completed based on 

the user’s needs prior to receipt of the dog. NEADS provides ongoing monthly follow-ups with the Veteran to 

ensure that the dog is meeting the Veteran’s needs.*

Prior to its recent consolidation with the Navy National 

Medical Center, the Walter Reed Army Medical Center 

(hereinafter called Walter Reed) was the only medical 

treatment facility to use a fully trained service dog for 

both demonstration purposes and patient interactions 

as a therapy dog. In accordance with donation limitations and CCV guidelines, the adopted dog belonged to 

a combat Veteran who was also a rehab therapist. The 

Rehabilitative Canine Interactions at the

 Walter Reed National Military Medical Center

MAJ Arthur F. Yeager, SP, USA

CPT Jennifer Irwin, SP, USA

*See related article on page 61.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

handler need not possess a debilitating injury if the service dog is used to provide patient education in a clinical 

setting. In this case, the therapist was solely responsible 

for the health and welfare of the dog as well as gaining 

supervisory guidance in the application and frequency 

of canine use in the clinic. 

In addition to standard service dog commands, the therapist and CCV dog demonstrate the following tasks that 

can be performed by most service dogs: press buttons to 

open ADA doors,* manually open and close other doors, 

retrieve prosthetics and assistive devices, turn lights on 

and off, open refrigerator to retrieve an object and close 

refrigerator door, assist with fl oor to stand transfers, fi nd 

up to 8 separately identifi ed objects selected by the patient, and retrieve items like keys and even coins.

This program not only benefi ts many patients and their 

respective primary care assistants, it is a valuable tool for 

the multidisciplinary education of all providers. Likewise, 

the staff member who adopts the dog gains valuable insight to the training and skill maintenance requirements 

their patients will encounter. Ultimately, it assists the patient and provider in making a more accurate assessment 

of whether such a resource is appropriate and benefi cial.

PETS2VETS

The objective of Pets2Vets (Arlington, Virginia) is to alleviate the psychological suffering of our nation’s Warriors while reducing the number of sheltered animals in 

the United States.2

 Those benefi ciaries without physical 

disabilities who are not eligible for a service dog may 

qualify for participation in Pets2Vets. Typically, these 

dogs do not have the training or capacity to provide 

physical assistance. Instead, these “pets” are trained 

to promote a wide range of psychosocial benefi ts wellknown to man that are considered therapeutic, albeit 

much more diffi cult to validate with tangible evidence. 

To qualify for participation in Pets2Vets at WRNMMC, 

active duty members or their family must participate in 

shelter visits, attend pet training and care classes, and 

must reside off-campus. Much like the Service Dog Program discussed earlier, a provider or the Warrior transition unit recommends the patient who then submits 

an application to Pets2Vets. In turn, Pets2Vets makes 

a qualifi cation determination and follows up with the 

patient for participation in their program.

SPECIALIZED THERAPY K-9 PROGRAM

The Specialized Therapy K-9 Program uses trained 

service dogs for specifi c therapeutic applications in 

WRNMMC’s Military Advanced Training Center 

(MATC). The MATC’s multidisciplinary team provides 

Wounded Warriors with care from initial surgery to reintegration with their units, or transition to Veterans Administration care.

The program allows certifi ed therapy dogs to work within an approved clinical setting while under the supervision of a medical provider who is also the personal 

owner of the dog. Participating dogs are certifi ed by an 

approved service dog or therapy dog agency, and up-todate medical records must be maintained within the section where they are working. Periodic assessments and 

continuing education of the dog are documented by the 

owner and or participating agency to ensure that proper 

safety and training precautions are current.

As of this writing, there are 2 dogs that work regularly 

in the MATC. Their schedule and scope of practice is 

determined by the department chief, the owner/handler, and the providers that use the dogs in their therapy. 

Wounded Warriors receiving care at the MATC may 

participate in rehabilitation that incorporates some if not 

all of the following tasks: general dog handling skills; 

fallen/seated position to standing; retrieval of objects; 

gait and balance training with a harness; strength and 

balance training with tug of war; cognitive training and 

coordination with physical movement through sequential movement patterns, tasks, and/or verbal commands; 

chest wall expansion through voice commands (H. 

Naranjo, oral communication, October 27, 2010). These 

adjunct forms of rehabilitation add graded environmental complexity to purposeful activities that can improve 

social and therapeutic engagement via interaction with 

the dogs. Further, these novel interventions can foster 

psychological well-being, calmness, and ultimately motivate a patient to improve their quality of life by applying for their own service dog.

WARRIOR TRANSITION BRIGADE OCCUPATIONAL THERAPY

WORK AND EDUCATION PROGRAM

There are a variety of therapeutic dog interactions offered by the WRNMMC Warrior Transition Brigade’s 

Occupational Therapy Work and Education Program. 

The following differ slightly by the tasks being performed as well as the amount of involvement by the 

Wounded Warriors.

Warrior Transition Brigade Service Dog Training 

Program

This evolving initiative was initially a collaboration of 

the Bergin University of Canine Studies (Santa Rosa, 

California), the Department of Veterans Affairs, and the 

REHABILITATIVE CANINE INTERACTIONS AT THE WALTER REED NATIONAL MILITARY MEDICAL CENTER

*Meets criteria and specifi cations of the Americans with Disability Act (ADA), 42 USC §12101-12213 and 47 USC §§225, 611.
April – June 2012 59

THE ARMY MEDICAL DEPARTMENT JOURNAL

Walter Reed Army Medical Center Warrior Transition 

Brigade (WTB).3

 Now, a variety of NPOs are partnered 

with WRNMMC to create a therapeutic learning opportunity for Warriors in transition and other service 

members diagnosed with posttraumatic stress disorder 

or traumatic brain injury. Instructors address some of 

the symptoms associated with these injuries by coaching service members in the training of future service 

dogs for other Veterans. Eligible service members are 

referred to the program by the WRNMMC WTB Occupational Therapy Department. Program participants 

develop a connection with the dogs they are training and 

experience their unconditional love, affection, and support that can provide signifi cant stress relief during the 

service members’ community reintegration.*

Research indicates that dedicated interaction with canines promotes sociability and cushions the negative 

physiological effects of anxiety.1

 Training sessions are 2 

hours long up to 4 days per week and include dog-learning theory, grooming, and hands-on supervised training, 

both on- and off-campus. These sessions provide a sense 

of accomplishment for the Wounded Warriors and can 

improve cognitive, emotional, and social competence. 

Ultimately, the fully trained dogs are then partnered 

with Veterans with combat-related physical disabilities. 

Assisting in this partnership exemplifi es the portion of 

the Soldier’s Creed that declares “I will never leave a 

fallen comrade,” while challenging Wounded Warriors 

to practice the emotional and cognitive skills that enhance the trainers’ overall recovery. The impact of the 

Warrior Service Dog Training Program on Veterans and 

service members reaches well beyond its participants. 

The presence of this program on military installations 

brings the trainers and their dogs into friendly contact 

with dozens of other service members every day. Such 

interactions can provide periods of reduced stress for all 

parties as well as an opportunity for the participants to 

share their positive experiences with fellow Veterans 

and service members. 

While under training, the dogs are housed at night and 

on weekends by volunteer “puppy parents” comprised 

primarily of WRNMMC staff and cadre. Dogs trained 

in the program are loaned to the WTB by NPOs and 

are carefully screened for temperament, health, and genetic abnormalities. Training is based strictly on positive reinforcement and consists of 90 different service 

dog commands to mitigate various functional obstacles 

of the future recipient of the dog. It can take up to 2 

years for service dogs to complete training. Once a 

dog graduates from the program, it is returned to the 

NPO for placement with a Veteran. As of this writing, 

3 Warrior-trained service dogs have been placed with 

Veterans, and 2 more have graduated and are awaiting 

placement. Although the trained service dog is provided 

at no charge to the recipient, the health and welfare of 

the dog becomes the Veteran’s responsibility. The average service dog works for up to 8 years, after which the 

dog may remain in the home with the Veteran or a family member and a successor service dog will be provided 

at no cost by an affi liated NPO.

Washington Humane Society “Dog Tags” Behavior 

and Grooming Training Program

The only congressionally-chartered animal welfare 

agency in the United States, the Washington Humane 

Society (WHS) has been the leading voice for animals 

in the District of Columbia since 1870.4

 The WHS operates the only shelter in the nation’s capital that does not 

decline animals and is open 24 hours a day.

Wounded Warriors who volunteer for Dog Tags attend 

animal training and behavior classes twice a week in 

a vocational environment comprised of both classroom 

lecture and hands-on training. Classes are conducted at 

the Washington Humane Society’s Behavior & Learning 

Center. The 3-tiered program is certifi cate based and targets individuals who either plan on a career in veterinary 

work or simply interested in the recreational, hobbyist 

level of learning while spending time with animals.5

The fi rst tier of training consists of a basic knowledge 

and understanding of how canines learn. The second 

tier focuses on socialization techniques and canine developmental stages. The last tier addresses relationships 

and canine behavior. All tiers build upon each other and 

all involve grooming exercises throughout the training 

cycle. This program exposes Wounded Warriors to the 

therapeutic effects of canine interaction, and allows participants to contribute to their temporary community, 

while potentially gaining experience for future jobs in 

animal-related fi elds.†

Animal-assisted Therapy

Clinical staff members of the Warrior Transition Brigade 

at WRNMMC are authorized to bring their personal pets 

several times a week, provided the dog is certifi ed as a 

therapy dog by Therapy Dogs International (Flanders, 

New Jersey). According to a recently issued policy memorandum from the Offi ce of The Surgeon General/Army 

Medical Command,6

 animal-assisted therapy is defi ned 

as the use of a certifi ed animal to facilitate patient recovery from physical, mental, or social illness, using the 

*See related article on page 63. †See related article on page 70.
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

pet as a “co-therapist” to achieve a specifi c therapy goal. 

Therapy dogs are used by the occupational therapists 

during patient encounters or visits (when appropriate) to 

provide support to Warriors in transition (WTs). Their 

presence in the clinic provides opportunities for patients 

and staff alike to relieve stress and anxiety through animal contact. Therapy dogs attend the Warrior Transition 

Brigade weekly formations, providing opportunities for 

a larger number of WTs to benefi t. Additionally, WTs 

separated from their own personal pets due to deployment and or injuries are afforded temporary companionship while actively convalescing at WRNMMC.

American Red Cross Pet Visitation

The Red Cross Pet Visitation program consists of supervised hospital visits twice a month by Red Cross 

volunteers and their personal pet dogs which have been 

certifi ed by the American Kennel Club Canine Good 

Citizen program. Unlike many of the other programs, 

these dogs are permitted to visit different inpatient 

wards in addition to typical interaction with patients 

passing through the hallways. Pet visitation provides 

measurable effects on health, including noticeable improvements in both mental and physical well-being to 

those who are hospitalized.

CONCLUSION

What the former Walter Reed Army Medical Center and 

now WRNMMC has spearheaded in the way of animalassisted therapy has paved the way for other medical 

treatment facilities within the military health care system to follow. The tremendous and far-reaching impact 

animal-assisted therapy has had on current and prior 

Wounded Warriors is diffi cult to measure and therefore hard to quantify. Indeed, it is especially diffi cult 

for those who have not experienced close interaction 

with animals, particularly dogs, to truly appreciate the 

therapeutic power of that interaction. The willingness 

of those fi rst at Walter Reed and now WRNMMC to explore nontraditional approaches and try animal therapy 

has impacted injured Warriors in positive ways that are 

still largely unmeasured. Unfortunately, these successes 

may remain largely unrecognized unless and until more 

such programs are instituted throughout the military 

medical system.

REFERENCES

1. Cole KM, Gawlinski A, Steers N, Kotlerman J. 

Animal-assisted therapy in patients hospitalized with 

heart failure. Am J Crit Care. 2007;16(6):575-585. 

Available at: http://ajcc.aacnjournals.org/content/16

/6/575.full.

2. Pets 2 Vets (2010). P2V: About Us. Available at: 

www.p2v.org. Accessed December 2, 2010.

3. Bergin University of Canine Studies (2009). Paws 

for Purple Hearts. Available at: http://www.berginu.

org/academics/PPH.html. Accessed November 29, 

2010.

4. National Museum for Crime and Punishment (2008). 

Crimes Against Animals. Available at: http://www.

crimemuseum.org/Crimes_Against_Animals. Accessed November 29, 2010.

5. Washington Humane Society (2010). Dog Tags: 

Partners in Healing. Available at: http://support.wash

humane.org/site/PageServer?pagename=pro

grams_dogtags. Accessed November 29, 2010 

6. Offi ce of The Surgeon General. Memorandum: 

Overarching Guidance on the Use of Animals in 

the Healthcare Setting (Service Animals, Animal 

Assisted Therapies, and Animal Assisted Activities). Fort Sam Houston, TX: US Army Medical 

Command; January 30, 2012. Policy Memorandum 12-005.

AUTHORS

MAJ Yeager is Chief, Occupational Therapy, Reynolds 

Army Community Hospital, Fort Sill, Oklahoma.

CPT Irwin is Healthcare Administrator, Healthcare 

Operations and Strategic Planning, Walter Reed National 

Military Medical Center, Bethesda, Maryland.

REHABILITATIVE CANINE INTERACTIONS AT THE WALTER REED NATIONAL MILITARY MEDICAL CENTER
April – June 2012 61

National Education for Assistance Dog Services 

(NEADS)/Dogs for Deaf and Disabled Americans* has a 

long history of meeting the needs of the disabled. Established in 1976 as an agency to train and place dogs with 

the hearing impaired, NEADS evolved into one of the 

major canine assistance agencies catering to the needs 

of individuals with a variety of physical disabilities.

Training our dogs is at the heart of our work. Puppies 

enter our program at 8 to 10 weeks of age, living and 

learning in our Laura J. Niles Early Learning Center 

(Princeton, MA) for 8 weeks. We take full advantage 

of early learning capacity with a specialized curriculum 

that provides an enriched environment of stimulating experiences, vigorous socialization, and service dog “prep” 

work, as well as lots of playtime with their housemates. 

The program builds a solid, socialized, and eager-tolearn foundation, and readies puppies for the next stage 

of training; placement in our Prison PUP Program or in 

foster homes. At this point, puppies must spend up to a 

year “growing up” and learning the basics before receiving their advanced task-work training on the NEADS 

campus as service dogs.

Our Prison PUP Program†

 has operated in minimum/

medium security correctional facilities across New 

England for the past 12 years. Our program utilizes 2 

inmates, a primary and a back up, to raise each puppy. 

Inmates raise and train puppies right in their rooms, 

taking responsibility for crate training, house breaking, 

care, and grooming. A NEADS trainer visits each prison program once a week to conduct a 2-hour class for 

the inmates in the program. Here, the inmates learn how 

to teach their puppy basic obedience and service dog 

tasks. In addition, they learn how to groom and properly 

care for their puppy, basic fi rst aid, and canine health. 

The trainer assesses each puppy weekly, making training recommendations and assigning homework for the 

handler for the upcoming week.

The dogs trained by inmates are some of our best-trained 

dogs. Inmates have little else to do and training our dogs 

provides them with a task that not only helps them pass 

the time but allows them to use their prison time to give 

something back. The dogs also help the inmates, providing a calming presence and unconditional love.

After completing the Prison PUP Program, the dogs return to our campus for fi nal task training and proofi ng 

in order to be matched with a client.

Based upon a well-recognized reputation of training service dogs, NEADS was the fi rst program to be invited 

to the Walter Reed Army Medical Center to discuss the 

possibility of training dogs for Veterans who had sustained combat injuries. From these discussions, the Canines for Combat Veterans program was born.

In May of 2006, we worked with the Walter Reed staff 

to determine how we could best meet the needs of these 

Veterans, many of whom were dependent upon manual 

wheelchairs or were learning to use prostheses. As we 

talked with Veterans themselves, one of the most requested tasks for a potential service dog was to aid the 

Veteran who, often in public, fell and required assistance 

to get up. Veterans admitted to embarrassment and feelings of helplessness when they felt dependent upon others to help them. On the other hand, having well-trained 

dogs that could partner with them in this task would 

give these Veterans an increased sense of self-mastery.

In addition to assistance after falling, Veterans felt the 

need for support when using their prosthetics. With this 

in mind, we developed a specially fi tted harness that 

allowed the Veterans to use the dog to aid them while 

walking. Interestingly, of the Veterans who were provided with dogs trained to a harness in those early years 

of the program (2006 and 2007), most, if not all have, 

recovered to the point in their rehabilitation that they no 

longer need the harness on the dog to help with balance.

Perhaps the most popular overall task performed by service dogs for Veterans is retrieval. A service dog can 

pick up an article as small as a coin or credit card and 

as large as a cane or crutch. Since the Veteran is often 

unable to reach to the fl oor for a dropped object because 

Canines for Combat Veterans: The National

 Education for Assistance Dog Services

Kathy Foreman

Cynthia Crosson, MD

*http://www.neads.org

†http:///www.neads.org/page.aspx?pid=383
62 http://www.cs.amedd.army.mil/amedd_journal.aspx

CANINES FOR COMBAT VETERANS: THE NATIONAL EDUCATION FOR ASSISTANCE DOG SERVICES

such action might put him or her at risk for a fall, having 

a dog that will retrieve is a valuable asset.

An interesting response from Veterans applying for service dogs was the request to give the dog to a fellow Veteran whom they perceived needed a dog’s help more than 

the applicant. We did not often get this request from the 

private sector. Veterans seemed to be concerned: “What 

if I do not use the dog on a daily basis? Perhaps I don’t 

need one as badly as the next guy.” 

Our response was that the dog became a form of insurance and empowerment. An example we often used was 

that an applicant may not drop his keys every day, but 

when the keys are dropped and perhaps falls into an inaccessible place, the dog can quickly retrieve, hold, and 

give the keys back. Because of the dog’s ability to perform this task, the Veteran will not be forced to wait 

until someone came along to pick up the keys. The Veteran could maintain (or in some cases, regain) his or her 

independence and protect his or her feelings of worth.

A particular strength of the NEADS program is that 

we take great care in matching dogs with their human 

partners. Applicants complete a detailed application and 

participate in several in-depth interviews, the purpose of 

which is to get to know the applicant and fi nd the right 

dog match to meet his or her needs. These individual 

interviews became especially important as we sought 

to address the individual requirements of the Veterans 

who applied to our program. 

As we continued to place dogs with Veterans who had 

been physically injured in combat, we recognized that 

many of them were also suffering from posttraumatic 

stress (PTS). Our observations and other anecdotal evidence indicated that a natural byproduct of having a service dog was often the alleviation of symptoms of PTS. 

This led us to wonder if we could develop a program to 

help Veterans, who may or may not have a physical impairment, to cope with their posttraumatic stress.

In July 2009, NEADS undertook a 2-year study to more 

defi nitively evaluate whether specially selected and 

trained service dogs could lessen the symptoms of PTS 

in Veterans. This study, the Trauma Alert Dog program, 

was designed to assess the experiences of 10 to 15 Veteran-dog teams and to determine how the dog was assisting the Veteran with his trauma symptoms. Veterans 

who applied were telling us that they feared going into 

public places and had to sit with their backs to walls 

in order to feel safe. They found that they had diffi culty with sleep and complained of frequent nightmares. 

Could a dog really help them with these issues?

For the PTS pilot study, we placed trained service dogs, 

with 15 combat Veterans (in groups of 3 or 4) diagnosed 

with PTS, who had served in Iraq or Afghanistan. The 

Veterans in the study were all from the New England 

area. It was our hope that the dog would provide a bridge 

for these Veterans that would help them to reintegrate 

into their environments with less anxiety. Veterans who 

also needed the tasks of a service dog as well as PTS 

support were given dogs that had dual functions. Following placement, the Veterans were closely followed 

for the fi rst year and their progress evaluated. 

To date we feel that this study has been quite successful. 

The results are being tabulated and we will publish our 

results in the near future.

Whether placing dogs with Veterans to aid them with 

their physical disabilities or with those who can benefi t 

from the support of a dog to help them cope with their 

combat-related PTS, we, at NEADS, are strongly committed to meeting the needs of our Veteran clients.

AUTHORS

Ms Foreman is Director, Client Relations for NEADS/

Dogs for Deaf and Disabled Americans.

Dr Crosson is a psychiatric consultant for NEADS/Dogs 

for Deaf and Disabled Americans.
April – June 2012 63

BACKGROUND

In 1996, Rick Yount, a social worker who specialized 

in working with children in the foster care system, was 

directed by the court to transport an 11-year-old boy 

from his biological mother to an emergency foster home. 

Yount took his new golden retriever pup, Gabe, along for 

the ride and found that this young dog had a knack for 

soothing a child, even during the most traumatic times. 

Yount subsequently had Gabe certifi ed as a therapy dog, 

and Gabe began accompanying him to work every day.

In 2001, Gabe inspired Yount to create the awardwinning Golden Rule Assistance Dog (GRAD) program. 

The Morgantown [West Virginia] Alternative Learning 

Center hired Yount to offer his GRAD program to atrisk teens unable to participate in the public school 

system. Training service dogs helped the teens develop 

social and emotional skills. Two of the GRAD-trained 

assistance dogs were partnered with disabled Veterans.

In 2008, Yount created a similar program to help troops 

returning from combat zones cope with the trauma of 

war. The Warrior-trained service dog program he established at a large Veterans Administration residential treatment center for posttraumatic stress disorder 

(PTSD), was conceived as a safe, effective, nonpharmaceutical intervention to help treat the symptoms of 

PTSD and traumatic brain injury. The program was also 

designed to offer service members suffering from PTSD 

the opportunity to reengage in a critical military support 

mission while receiving treatment for their psychological wounds. The purpose-bred program dogs, trained 

by service members with PTSD, become highly skilled 

assistance dogs capable of offering Veterans with disabilities the social support and mobility assistance they 

need to enhance the quality of their lives. The Warrior 

Ethos has inspired even the most traumatized service 

members to participate in and benefi t from the program. 

Approximately 200 service members have participated 

in the pilot for this service dog training program at the 

Veterans Administration (VA) treatment facility. Five 

Warrior-trained service dogs have been placed with Veterans. Two service members have become accredited 

service dog-trainers and are pursuing careers in this 

fi eld.

In 2009, Yount and the VA team presented anecdotal 

program observations at the Veterans Administration National Mental Health Conference and the annual meeting of the International Society for Traumatic 

Stress Studies. Based on the promising effects, Yount 

was asked to establish the program at a prominent Department of Defense medical center. Over 50 Soldiers 

have participated in the formal internship program or 

Service Dog Training Program for

 Treatment of Posttraumatic Stress

 in Service Members

Rick A. Yount, MS

Meg D. Olmert

Mary R. Lee, MD

ABSTRACT

In July 2008, social worker and certifi ed service dog trainer Rick Yount created the fi rst Warrior dog-training 

program designed to be a safe, effective, nonpharmaceutical intervention to treat the symptoms of posttraumatic stress disorder (PTSD) and traumatic brain injury in Veterans and service members undergoing treatment at a large Veterans Administration residential treatment facility. In 2009, Yount was asked to establish the 

program at a prominent Department of Defense medical center. In October 2010, Yount was invited to create a 

service dog training program to support the research and treatment mission at the new National Intrepid Center 

of Excellence (NICoE), in Bethesda, Maryland. This program, now being offered through the nonprofi t foundation Warrior Canine Connection, continues to produce anecdotal evidence that training service dogs reduces 

the PTSD symptoms of Warrior-trainers and that the presence of the dogs enhances the sense of wellness in 

the NICoE staff and the families of our Wounded Warriors. Under the research leadership of the NICoE, the 

Warrior Canine Connection research team plans to systematically investigate the physiological, psychological, 

and behavioral benefi ts of this program.
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

the patient service dog training program since February 

2009.

In October 2010, Yount was invited to design a service 

dog training program at the new National Intrepid Center of Excellence (NICoE), located on the campus of 

the Walter Reed National Military Medical Center in 

Bethesda, Maryland. The NICoE is a medical facility 

dedicated to the research, diagnosis, and treatment of 

military personnel suffering from traumatic brain injury 

and psychological health issues. Through this program, 

now being offered through the nonprofi t foundation 

Warrior Canine Connection (WCC), approximately 85 

Wounded Warriors have had direct involvement with the 

service dogs in training at the NICoE.

The idea of incorporating a volunteer service dog training program specifi cally designed to remediate the core 

symptoms of PTSD builds on a well-described body 

of research into the use of therapy dogs with patients 

who have psychiatric disorders.1,2 Studies have shown 

that under stressful conditions, the presence of a dog is 

effective at reducing stress responses in healthy adults, 

adults with hypertension, and in children with attachment disorders.3,4

The WCC service dog training program provides Wounded Warriors with PTSD the opportunity to engage in 

highly focused, safe, positive social contact with dogs 

that are specifi cally bred for the temperament that best 

responds to and solicits therapeutic social engagement. 

Anecdotal information from this program supports previous fi ndings that suggest that training service dogs reduces the symptoms of PTSD in the Warrior trainers.

MILITARY NEED FOR SERVICE DOGS

In 2009, Seal et al5 found that approximately 40% of 

Iraq and Afghanistan Veterans treated at American 

health centers during the previous 6 years were diagnosed with PTSD, depression, or other mental health issues. Their study also found that a lack of social support 

(separated, divorced, widowed, etc) may pose a serious 

risk for new postdeployment mental health problems 

and underscores the need for social support services for 

returning Veterans who are unmarried and/or without 

social support. Sixty percent of PTSD patients still meet 

the criteria for PTSD after being treated with empirically supported interventions.6-7 Therefore, it is imperative to explore adjunctive treatments for PTSD that may 

improve outcomes.

There is also substantial interest in service dogs among 

Veterans with spinal cord injuries. In 2007, Brashear and 

Rintala reported that 30% of Veterans with spinal cord 

injuries indicated at least some interest in obtaining a 

service dog, and 42% desired information concerning 

service dogs.8

 This urgent need of Veterans for welltrained service dogs has been recognized by Congress 

with passage of several laws authorizing the Department 

of Veterans Affairs to provide service dogs to disabled 

Veterans. Further, the Army Family Action Planning 

Committee named “funding of service dogs for Wounded Warriors” as their number 2 priority for 2010.9

COST EFFECTIVENESS

The WCC program breeds its own high-quality, purpose-bred service dogs. Warrior Canine Connection 

staff or trained “puppy-parents” take responsibility for 

the welfare and behavior of the dogs at all times when 

the dogs are on military or Veterans Administration 

property. This circumvents the logistical diffi culties of 

owning and keeping service dogs on military or Veterans Administration property. It also affords active-duty 

service members and Veterans who cannot or do not 

own dogs the opportunity to experience the high quality 

connection with a dog that can provide powerful relief 

of PTSD symptoms. The program is also highly costeffective, providing dog-assisted therapeutic relief to the 

largest number of PTSD patients with a limited number 

of service dogs. The Warrior-trainers experience relief 

from their PTSD symptoms while creating highly valuable service dogs that can be provided free of charge 

to Veterans with disabilities. The net result is a highly 

symbiotic, effective method of meeting several critical 

needs of Wounded Warriors and their caregivers.

WORKING DOGS /WORKING TRAINERS

The WCC training philosophy is based on positive 

methods of shaping behaviors that are most effective at 

forming strong social bonds. Mastering the skills and 

patience required to train a service dog helps the WCC 

trainers to regain control of their emotions, focus their 

attention, and improve their social competence and 

overall sense of wellbeing. Two participants in the original Veterans Administration pilot program have gone on 

to pursue accreditation as professional dog trainers, and 

it is anticipated that many more will be inspired to become professionally involved in creating the thousands 

of service dogs that will be needed by our Wounded 

Warriors.

DOGS HEALING THE WORKPLACE

The impact of the WCC program has been observed 

to reach well beyond its participants. Health practitioners, staff, and patients being treated throughout the 

Department of Defense medical center report feeling 

happier just having such beautiful, loving, well behaved 

dogs with which to interact throughout the day. These 

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April – June 2012 65

THE ARMY MEDICAL DEPARTMENT JOURNAL

frequent and fun encounters also offer Warrior-trainers 

the therapeutic opportunity to share their positive experiences with fellow Veterans and service members.

DOGS HEALING THE HOME

The methodology used in training service dogs to assist individuals with mobility impairments has striking 

similarities to the best practices of effective parenting. 

The goal of creating a respectful and responsible service 

dog requires the employment of sound behavioral shaping techniques based on positive and humane methods. 

Using the service dog training to draw attention to these 

parallels provides a means to teach critical parenting 

tools in a nonthreatening manner.

CLINICAL OBSERVATIONS AND PARTICIPANT TESTIMONIALS

As reported by Yount and his VA colleagues at the 2009 

Veterans Administration National Mental Health Conference10 and the Annual Conference for the International Society for Traumatic Stress Studies, anecdotal 

reports collected from clinicians and program instructors indicate that Veterans and service members who engage in the training of service dogs exhibit the following 

improvements:

 Increase in patience, impulse control, emotional 

regulation

 Improved ability to display affect, decrease in emotional numbness

 Improved sleep

 Decreased depression, increase in positive sense of 

purpose

 Decrease in startle responses

 Decrease in pain medications

 Increased sense of belongingness/acceptance

 Increase in assertiveness skills

 Improved parenting skills and family dynamics

 Fewer war stories and more in the moment 

thinking

 Lowered stress levels, increased sense of calm

The ability of these dogs to help Warrior-trainers become 

less reliant on powerful pain and antipsychotic medications takes on particular signifi cance in light of the 2010 

Department of Defense report, Health Promotion, Risk 

Reduction, and Suicide Prevention,11 which found that 

suicides and accidental drug overdoses are on the rise, 

particularly in the Army and Marine Corps. According 

to the report, one third of Army suicides involve prescription drugs, and 14% of Army personnel are taking 

prescribed opiate painkillers. Many service members 

also take more than one kind of medication, including 

those that are known to increase suicidal thinking in 

patients.

The following voluntary interviews* were given to 

WCC staff by service members participating in the 

WCC program:

It’s been great working with the dogs. They are 

helping me with my depression, anxiety, and sleep. 

With a WCC dog at my side, my stress measurements 

returned to normal for the fi rst time.

The dogs have a drive to work and take care of 

people. They do so because they care, not because 

they have to. It’s great knowing that I am helping 

to train a service dog for a service member who 

has physical disabilities.

The dog I am training bonded quickly with my 

daughter and me. I was given the opportunity to 

take the dog I bonded with overnight while my 

4-year-old daughter was visiting. She was able to 

see a different side of me. Instead of being a strict 

father, she and the dog were getting praised for 

doing something right rather than being punished 

for something they did wrong. It brought to light 

*All persons involved in these accounts gave consent for publication.

Photo courtesy of the authors. The Authors
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

a different parenting technique that she responded 

to better. The dog allowed us to connect in a very 

positive way. Working with the dog has taught 

me patience, which also carries over to being a 

parent.

It is hard for me to put into words how very 

important working with these dogs has been to 

me. After my initial injury, I was told that I would 

not be able to lead and train Soldiers in the way I 

had always hoped I would be able to do. Working 

with the WCC dogs gave me a purpose again and 

a way to continue to give back to Soldiers, which 

has been really good for me. Training these dogs 

helps me rebuild my confi dence level and to feel 

I am functioning as an effective member of the 

Army and of society.

Going out into crowded public places has been very 

hard for me. However, to train a service dog, your 

have to lead them confi dently through places like 

grocery stores and on underground trains. I fi nd 

that while teaching the young dogs how to navigate 

these places, I am much more comfortable as well. 

I am even learning how to enjoy interaction with 

strangers who approach me to talk about the dog. 

Being allowed to sleep with a dog that I am training 

has been really helpful. I had been only managing to 

sleep a couple of hours a night before being cleared 

to have a WCC dog spend the night with me. That 

night I slept almost 6 hours and had no nightmares. 

Sleeping with the dogs has consistently improved 

my sleep time and I have fewer nightmares. One 

dog even licked me awake from one. I awake so 

much more refreshed. My wife has noticed the 

improvement as well.

WHY DOGS WORK: THE NEUROBIOLOGY OF THE

HUMAN-ANIMAL BOND AND ITS RELATIONSHIP TO

POSTTRAUMATIC STRESS

The use of psychiatric service dogs in various settings 

with patients who have psychiatric disorders is welldescribed.1,2 It is important to note that most combat 

traumatic injury is caused by humans, therefore humans 

may be potent triggers of PTSD symptoms and events. A 

dog, on the other hand, can be perceived as trustworthy 

and create a sense of security.

The results of animal and human experiments show that, 

under stressful conditions, the existence of a partner to 

which the subject shows attachment and bonding can 

produce a “stress buffering effect.”12 For example, interaction with animals reduces symptoms of depression13

and stress responses as measured by cardiac reactivity 

and serum cortisol.14

Research also shows that positive social interactions 

with dogs may offer a safe, effective, and relatively 

inexpensive way to increase endogenous levels of the 

neurochemical oxytocin and other important antistress 

agents in humans.

In 2003, Odendaal and Meintjes15 fi rst showed that human-dog affi liative behavior (quiet play with the dog 

involving talking, stroking, and petting the dog with 

the human subject’s attention focused completely on the 

dog) produced a signifi cant change in neurohormones 

related to stress reduction: increases in beta endorphin, 

oxytocin (OXT), prolactin, dopamine, and decreases in 

cortisol. The most impressive increase was in plasma 

levels of OXT (doubling in both dog and human after 

an interaction session). Subsequent to that study, Nagasawa16 showed that focused eye contact between humans 

and dogs increased OXT levels in the human (urine level). Miller17 found that serum oxytocin levels increased 

more for women when interacting with their dogs than 

when reading nonfi ction material. Most recently, Handlin et al18 found a signifi cant increase in serum oxytocin 

in both dog and owner after 15 minutes of friendly interaction, along with a decrease in the heart rate of their 

owners. The authors concluded that this antistress effect 

indicates that sensory interaction with dogs can trigger 

a concurrent increase of oxytocin in the human brain. 

Neumann19 agrees:

It is very likely that such interactions activate intracerebral 

OXT pathways contributing to the positive mental and 

physical health effects of dog ownership.

The hypotheses gained support when Strathearn et al20

found that elevations of peripheral oxytocin are, indeed, 

correlated with increased activity in the oxytocin-related hypothalamic-pituitary regions and the reward centers of the human brain.

The neuropeptide oxytocin has been shown to modulate 

symptoms important in the psychopathology of PTSD, 

such as anxiety including fear response and hyperarousal, interpersonal diffi culties/social isolation, physical 

pain, and sleep disturbances. According to Marazziti 

and Dell’Osso, it is well established that OXT acts on the 

hypothalmic-pituitay-adrenal axis.21 Oxytocin neurons 

also modulate the locus coeruleus, the central amygdale, 

and other arousal centers of the central nervous system 

to attenuate stress-induced neuroendocrine activity.22

Oxytocin receptor-expressing neural circuits in the central amygdale connect to the medial prefrontal cortex 

SERVICE DOG TRAINING PROGRAM FOR THE TREATMENT OF POSTTRAUMATIC STRESS IN SERVICE MEMBERS
April – June 2012 67

THE ARMY MEDICAL DEPARTMENT JOURNAL

to suppress neurons that produce the freezing reaction 

to fear while promoting risk assessment and exploratory 

response to frightening stimulus.23 Oxytocin has also 

been shown to reduce levels of endotoxin-induced levels 

of cytokines, adrenocorticotrophic hormone (ACTH), 

and cortisol.24 All of these brain systems and neurochemical responses have been shown to be functionally 

important in PTSD.25,26

Glucocorticoids and their upstream regulators, OXT, 

corticotrophin-releasing hormone, arginine vasopressin, and ACTH, have also been shown to be altered in 

PTSD.27,28 There is evidence that in PTSD there is defi cient glucocorticoid signaling, whether from cortisol 

defi ciency or from changes in the glucocorticoid receptor. As such, this has also been associated with defi cient 

inhibition of immune response, resulting in increases of 

plasma and colony stimulating factor cytokines such as 

IL-6, IL-1 and TNF alpha.29-31 Posttraumatic stress in 

combat veterans has been shown to be associated with 

an increased prevalence of diseases of infl ammatory 

etiology, such as athersosclerosis, arthritis, etc.32 Oxytocin has also been shown to be a powerful antioxidant 

with antiinfl ammatory functions that quicken healing of 

wounds, interperitoneal sepsis, and renal ischemia in rodents and humans.33,34

With respect to anxiety and arousal, in animal studies, OXT has been shown to potentiate the anxiolytic 

effect of diazepam through its action on the amygdale 

and inhibits the norepinepherine system’s arousal of 

the sympathetic nervous system, while increasing parasympathetic tone.21 Also, OXT imbalances have been 

linked to anxiety in patients with major depression35 and 

autism.36

In rats, oxytocin and corticotrophin-releasing factor neurons co-localized in the paraventricular nucleus and bed 

nucleus of the stria terminalis strongly suggest that they 

provide a crucial feedback loop between these 2 systems 

that could signifi cantly impact affective and social behaviors, particularly during times of stress.37 Streipens 

and colleagues38 have compiled a comprehensive review 

of the research showing that intranasal oxytocin application enhances a “plethora of prosocial effects” including: 

a reduction in interpersonal confl ict and negative communication; promotion of trust in strangers; increased 

gaze to the eye region of faces; improvement in the correct identifi cation of the internal emotional state of another; enhancement of the processing of positive social 

information compared to negative information; reversal 

in the effect of aversive conditioning of social stimuli; 

enhancement of the buffering effect of social support 

on stress responsiveness; and reduced stress response in 

people with a history of early trauma.

War veterans with PTSD given one dose of OXT demonstrated decreased physiologic response to provoked 

combat memories.39 Oxytocin has also been shown to 

modulate pain in humans40,41 and has been shown to impact sleep patterns in animal studies,42 two signifi cant 

corollary symptoms of PTSD.

Oxytocin levels are naturally increased by loving gaze, 

gentle touch, warmth, and close social relationships. Olff 

et al43 suggest that the “optimalization of social support” 

might naturally boost oxytocin and aid in the treatment 

of PTSD symptoms. WCC’s dogs are bred to do just that. 

They welcome nurturing touch and provide that profound sense of social support that appears to make them 

potent, natural oxytocin agonists and valuable therapeutic partners in the treatment of combat PTSD.

THE NEED FOR EMPIRICAL STUDY OF THE WARRIOR CANINE

CONNECTION INTERVENTION

Based on the scientifi c literature and the clinical and anecdotal observations of the program to date, we hypothesize that the focused, positive interactions involved 

in training a service dog are linked to an increase in 

oxytocin, and reduction in biomarkers of stress and infl ammation. Studies designed to investigate the causes 

and effects of the WCC program may provide valuable 

evidence that has been lacking in the study of animalassisted therapy.44,45 We hope that the WCC service 

dog training study will advance not only our scientifi c 

understanding of the healing powers of animals in our 

lives, but provide the rigorous science that the Department of Defense and the Department of Veterans Affairs need to support animal-assisted therapy programs 

and the placement of service dogs with service members 

and Veterans with psychiatric and physical disabilities.

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AUTHORS

Mr Yount is Executive Director, Warrior Canine 

Connection, Inc, Brookeville, Maryland.

Ms Olmert is Research Director, Warrior Canine 

Connection, Inc, Brookeville, Maryland.

Dr Lee is a Psychiatrist with the Intermural Research 

Program of the National Institute on Drug Abuse, 

Baltimore, Maryland. 
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

dog tag n. 1. A metal identification disk attached to 

a dog’s collar. 2. A military identification tag worn 

on a chain around one’s neck.

Source: Webster’s II New Riverside University Dictionary

To many wounded service members, the trauma of war 

has altered their sense of identity. Often it is the change 

in one’s ability to cope in life because of mental and 

cognitive diffi culties, or altered body image from burns 

or the loss of limb(s). Whatever the reasons, something 

is lost—often the confi dence in one’s capacity to serve 

and be productive given the new circumstances. It is 

recognition of this desire of Wounded Warriors to serve 

combined with the needs of shelter dogs that inspired the 

staff at the Washington Humane Society’s (WHS) Behavior and Learning Center to develop Dog Tags, open 

(free of charge) to all ranks of enlisted service members 

recuperating at the Walter Reed National Military Medical Center (WRNMMC).

Dog Tags is a natural extension of the WHS’s vision: 

to create ways for animals and people in need to help 

one another. It is one in a series of ongoing programs 

that actively encourage the human/animal connection, 

yet Dog Tags is unique in that it is tailored to a specifi c 

adult population, one that brings special understanding 

to help WHS’s more challenging dogs. These Warrior/

dog partners are superbly situated to emerge stronger 

and better able to cope because of shared experiences. 

The Washington Humane Society is the only openaccess animal shelter in the District of Columbia. No 

animal in need is turned away, and every effort is made 

to place all adoptable animals in homes. Although the 

commitment to adoption is solid, not all dogs appear to 

be good candidates for placement in a family. Nevertheless, WHS takes the view that these dogs can learn, 

grow, and improve their behavior and their chance for 

adoption. But, given the volume of dogs that enter the 

shelter each year (2,000 to 2,500), evaluating them and 

implementing individual behavioral rehabilitation plans 

are daunting. This is where Dog Tags meets such needs, 

serving a vital function.

WARRIOR/DOG PARTNERS

All Dog Tag program participants face challenges. The 

recovering Soldiers at WRNMMC are dealing with the 

stress and pain of compromised agility and coordination. They are, to differing degrees, dependent on others 

for help; resulting in self-doubt about their identity as independent, self-reliant service members. Likewise, the 

dogs often come from traumatic situations and may be 

physically injured or emotionally scarred, demonstrating resource guarding by aggressively defending food, 

space, toys, etc. Other dogs are surrendered because of 

typical puppy or adolescent characteristics. They chew 

(furniture, carpets, clothes, and shoes), are “mouthy” 

(use their mouths to interact with people or other dogs, 

lacking bite inhibition), test boundaries (jump up, refuse 

to move, stand and bark), get into “mischief” (raid the 

trash, steal dirty clothes, chase the cat), or pee on the 

carpet.

In some shelter programs, due to lack of resources or 

expertise, behaviors such as mouthing and resource 

guarding can label a dog “unadoptable,” which means 

Reclaiming Identity Through

 Service to Dogs in Need

Ellen V. Alers, MA

Kevin M. Simpson

ABSTRACT

Dog Tags is an animal-assisted therapy offered by the Washington Humane Society (WHS) in partnership 

with the Walter Reed National Military Medical Center (WRNMMC). The program is open to all ranks of 

enlisted service members using WRNMMC services. Dog Tags is a 3-tiered certifi cate program allowing Soldiers, recovering at WRNMMC, to learn and apply progressively complex and challenging elements of canine 

positive reinforcement training to dogs awaiting adoption at the WHS. Although each tier is a self-contained 

and complete curriculum, subsequent tiers build on the skills and knowledge acquired in the previous one(s). 

Dog Tags Warrior/trainers work with fully-screened (health and temperament) shelter dogs to provide these 

dogs with mental stimulation, environmental enrichment, and socialization that are vital to their successful 

adoption and integration into new homes. The Soldiers also benefi t because they develop new skills, build 

positive bonds with the dogs, and continue to serve their community.
April – June 2012 71

either rejection from a program and/or euthanasia. Yet, 

no matter the circumstances that bring these Warriors 

and dogs to WRNMMC and the WHS respectively, they 

are treated as individuals, their problems evaluated, and 

steps taken to help them reach a positive outcome; be it 

a return to the force, reintegration into civilian life, or a 

loving permanent home. Dog Tags is there to help these 

Warrior/dog teams create a new beginning.

For Soldiers, life at WRNMMC can be routine, boring, and/or full of surgeries and medical appointments. 

Finding an activity outside of the ordinary can be very 

helpful in making their stay more productive and enjoyable. It is similar for the dogs in the shelter environment, 

where often it is noisy and lacking in positive stimulation, which may be play and one-on-one time with 

people and friendly dogs. Both parties have temporarily 

lost their autonomy; having to live by the routines and 

requirements of others, making daily life frustrating, 

perhaps a little depressing. Dog Tags works to alleviate 

these stresses by creating a positive mentally and physically demanding environment where independence and 

self-determination is restored, bonds are established, 

and progress achieved.

METHOD AND STRUCTURE

Dog Tags is a 3-tiered certifi cate program designed to 

teach wounded Soldiers foundational skills in positive, 

reward-based animal training and care—skills essential 

to entry into the fi eld of animal services. Each 8-week 

module is complete, self-contained, and earns certifi cation upon completion. Although it is not required that 

students complete all 3 modules, when linked together, 

those modules become increasingly diffi cult and demand greater individual responsibility and creativity. 

Dog Tags is constructed such that students, from hobbyists to those wanting to launch a new career, can be 

accommodated and trained based on their goals and 

commitment.

Level I (fi rst tier): 8 weeks, 1.5 hours twice a week at the 

WHS Behavior and Learning Center. The subject matter 

covers:

 Philosophies of training and learning theory.

 Historical trends in canine training techniques from 

harsh dominance to total positive methods.

 Conditioning: classical–stimulus elicits an involuntary response, eg smelling a food you dislike and 

feeling nauseated; operant–voluntary response to 

stimulus, eg, the dog offers to sit because it has 

earned him a treat.

 Observation of canine body language; eg, what is 

communicated when a dog’s tail is high and stiff, 

hackles are raised, or belly is exposed.

 Foundational obedience skills: sit, down, wait, stay, 

come when called, etc.

 Introduction to canine parlor tricks: shake, roll over, 

crawl on your belly, etc.

 Agility obstacles: jumps over a hurdle or through a 

hoop, over an A-frame, through a tunnel, etc.

 Training equipment: leashes, harnesses, neck collars, head collars, and treat/bait bags.

 Motivational tools: food, touch, voice, play, etc.

Students work with fully-screened shelter dogs, training them in basic obedience and good manners, such 

as calm interactions with dogs and humans, to develop 

the quiet polite behavior necessary for typical home 

and neighborhood environments. All of the exercises 

help build confi dence in both the dogs and the Warrior/

trainers. All instruction with the dogs is given using humane, motivational techniques (food treats and praise 

as rewards while ignoring and/or redirecting unwanted 

behaviors). There are also readings, lectures, and written exams throughout the module to mark progress and 

identify areas for concentration and improvement.

Level II (second tier): 16 weeks (completion of Level I 

plus an additional 8 weeks), 1.5 hours twice a week at 

the WHS Behavior and Learning Center. Subject matter 

covers:

 Understanding and resolving common canine behavioral problems: chewing, house soiling, jumping up.

 Studying the art of assisting group classes: working 

on their observational and communication skills 

by helping outside student handlers with timing rewards, manipulating a leash, and treats. 

 Offering individualized guidance; preparing enrichment activities for the kennel population awaiting adoption – stuffi ng Kong toys (KONG Company, 

Golden, Colorado) with tasty food items to alleviate 

boredom while dogs are in their kennels, etc.

As in Level I, there are readings, lectures and written exams throughout the module to mark progress and identify areas for concentration and improvement.
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

Level III (third tier): 24 weeks (completion of Levels I 

and II plus an additional 8 weeks), 1.5 hours twice a 

week at the WHS Behavior and Learning Center:

 In-depth instruction in canine relationships and 

pack dynamics.

 Learn to hold and conduct group obedience classes 

and private consultations with the general public.

 Advanced training in obedience and service dog 

exercises. The Soldiers use their more advanced 

knowledge of animal behavior to develop creative 

approaches to correct more complex behavioral 

problems.

They also perfect their listening, communication and 

interpersonal skills as they interact with the public and 

dogs outside the program while conducting private consultations and group obedience classes.

BENEFITS AND OBSERVATIONS

Although each Soldier is awarded a certifi cate documenting his or her service and successful mastery of 

the skills and knowledge upon completion of a training 

module, there are numerous positive physical and mental/emotional benefi ts derived from the experience.

Initially many Soldiers come to Dog Tags to break the 

monotony of life at WRNMMC, but over time they fi nd 

the physical and mental demands of handling an untrained dog exquisitely challenging and uniquely therapeutic on several fronts:

 Physical. The subtle or, depending on the dog, not 

so subtle demands on balance and fi ne motor control to manipulate prosthetic legs and arms/hands.

 Mental. Teaching a dog basic manners improves 

observational skills and timing. Capturing minute advances and rewarding them quickly builds 

confi dence and trust. Complex problem solving: 

breaking down elaborate tricks (eg, gathering toys 

and putting them in a box) into tiny steps and building on these to accomplish the fi nal task. Perseverance: keep the goal in mind, and be willing to make 

tiny steps to get there.

 Emotional. Patience: learning what motivates a dog 

(touch, food, high happy voice, quiet gentle coaxing) and using this to advance as a team. Coping 

with frustration when physical and verbal force are 

not in the training tool kit—fi nding a way to end 

on a good note is a very valuable skill. Confi dence: 

seeing the results of hard work and communication 

coming together and achieving the goal. Most important; knowing when to stop a training session 

and play or just spend quiet time together.

The dogs benefi t in similar ways. Dogs chosen for the 

Dog Tags program are fully screened (health and temperament) prior to selection for Dog Tags, but may have 

behavioral or physical problems that make them less 

likely to move out of the shelter and into a home quickly.

Nevertheless, the screening process indicates their potential to reach a positive outcome through consistent, 

kind training with the Soldiers.

A case in point is Smitty, a beagle/pug mix that came 

into the shelter severely emaciated and neglected by his 

owner. Smitty’s circumstances and resulting condition 

left him with extreme timidity toward people and food 

guarding issues. Nevertheless, his temperament evaluation identifi ed his potential and, as it turned out, he was 

a perfect canine candidate for Dog Tags. 

Smitty’s rehabilitation began with Soldier/trainers in 

Level I. They worked with him on foundation obedience 

skills to build his confi dence and trust with humans. Simultaneously, advanced Soldier/trainers, under WHS 

staff supervision, devised and executed a behavior modifi cation plan to overcome his resource guarding. For 

example, trickling kibble into his dish so he associated 

humans as a source for food; interspersing his kibble 

with obedience training and high value treats, such as 

hot dogs, to help Smitty realize he could work with humans, have fun, and get fed. In the end, this intense and 

holistic approach to training earned Smitty an American Kennel Club Canine Good Citizen certifi cate, often 

the fi rst step for dogs in training for therapy work, and a 

successful adoption.

The Soldier/trainers not only witnessed Smitty’s progress, but were vital to his recovery and eventual adoption. Dog Tags Soldier/trainers were able to provide 

RECLAIMING IDENTITY THROUGH SERVICE TO DOGS IN NEED
April – June 2012 73

THE ARMY MEDICAL DEPARTMENT JOURNAL

the intense training and attention Smitty deserved, and 

he surpassed all expectations. Everyone’s confi dence 

soared because their training and skills were truly tested and proved to be solid and valuable.

OUTCOMES AND CONCLUSIONS

Since 2008, Dog Tags has trained over 40 Soldiers and 

helped approximately 75 dogs into new homes. As of 

this writing, at least 2 Soldiers are in the process of establishing a dog training business, and many others have 

returned to school furthering their education to become 

veterinary technicians or enter some other aspect of the 

animal services industry.

Additionally, Soldiers have reported other benefi ts that 

extend beyond the scope of what Dog Tags was designed to provide. The WHS and its staff have become 

a home away from home and an extended family, where 

Soldiers can visit and help. Volunteering at the shelter 

has helped Soldiers reestablish work routines and solid 

work habits, helping them to become more outgoing and 

social than before entering the program, in turn lowering stress and increasing happiness.

Dog Tags has honored service, built confi dence, revealed 

new talents, provided new job opportunities, and much 

more. The Warrior/trainers rediscovered, reinvented, 

and reclaimed their identity as strong and capable individuals whose talents and skills continue to save lives 

and make a huge difference for the dogs and families 

they serve.

ACKNOWLEDGEMENT

Photos courtesy of the Washington Humane Society.

AUTHORS

Ms Alers, an archivist at the Smithsonian Institution, is a 

volunteer at the Washington Humane Society.

When this article was written, Mr Simpson was Director, 

Animal Behavior and Training at the Washington 

Humane Society.
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

HISTORICAL OVERVIEW

The therapeutic use of animals can be traced back to 

the times of the ancient Egyptians, Greeks, and Romans. 

These practices were abandoned for centuries, however, 

as a result of changing religious and cultural mores. The 

resumption of the use of animals for therapeutic purposes can be attributed to the efforts of a Quaker merchant in 18th century York, England.1,2 William Tuke, 

acting on his dismay over the death of a Quaker in the 

York Asylum, raised funds to open the York Retreat in 

1796 to care for the insane. Unlike in other facilities for 

the mentally ill of that time, patients at the York Retreat 

were treated with respect, allowed to pursue a variety 

of activities and freely wander the grounds, which were 

inhabited by a variety of small animals. Tuke’s efforts, 

combined with a very negative report on conditions in 

British mental hospitals,2

 gradually led to improvements 

in the treatment of the mentally ill, including at the notorious Bethlehem Hospital (commonly known as Bedlam), where it had been the accepted practice to charge 

admission to the public to view the inmates.3

In the 19th century, animals also were incorporated into 

the treatment of individuals with other disorders, including epilepsy, at Bethel, a residential facility in Germany 

established for young people suffering from epilepsy. 

Originally established as a working farm, Bethel still 

exists today and provides assistance to individuals 

dealing with a broad range of disabilities.1

 During the 

Crimean War, Florence Nightingale kept cats both for 

rodent control and companionship, and was known to 

have had numerous cats throughout her lifetime as well 

as recommend their companionship for the chronically 

ill.2

 In the United States, the fi rst documented therapeutic use of animals occurred during World War II at a 

Pawling, New York, convalescent hospital for injured 

members of the Army Air Corps. Apparently the hospital was used primarily as a rest home for patients suffering from “operational fatigue,”4

 which today would be 

called posttraumatic stress disorder.

DEVELOPMENT OF THERAPY DOGS: A BRIEF OVERVIEW

In a sense, the use of dogs as therapeutic adjuncts developed accidentally. Although Sigmund Freud was known 

to have been accompanied by his chow dog during his 

analysis sessions with patients toward the end of his life, 

he may not have initially included his dog in the sessions 

with any specifi c goal in mind other than the comfort it 

provided to him. After a while, however, he apparently 

noticed that the presence of the dog seemed to provide 

his patients with feelings of security and acceptance, 

and facilitated their analyses.5

The second accidental use of a dog as a therapeutic adjunct tool occurred when Boris Levinson unintentionally exposed a child client to his dog, Jingles.6

 The mother 

and child had arrived early for their appointment, before 

Levinson had had time to confi ne his dog. Levinson 

had been having diffi culty establishing rapport with the 

child, but Jingles paved the way by playing with the child, 

thus facilitating the child’s acceptance of Levinson himself. That positive experience led to Levinson’s frequent 

inclusion of Jingles in his therapy sessions. Although 

Levinson’s efforts to promote the use of dogs in therapy 

were not well received publicly within his profession, a 

survey he conducted among clinicians in the New York 

State Psychological Association indicated that more 

than one-third of the respondents had used animals in 

their practices.7

 Gradually, Levinson’s efforts stimulated research into the mental and physical health effects of 

including dogs and other animals in therapeutic interactions and also into the effects of keeping pets.8-10

In the 1970s, 2 organizations were established that also 

contributed greatly to the use of dogs as therapeutic adjuncts. In 1976, Elaine Smith founded Therapy Dogs 

International (TDI). While working as an American 

nurse in England, she had observed the way patients responded to the dog that accompanied the hospital chaplain on his visits. Upon her return to the United States, 

she established TDI in New Jersey and developed a program to train dogs to visit institutions.11 Therapy Dogs 

International also certifi es dogs and maintains a registry 

of certifi ed dogs and handlers. The following year the 

Delta Foundation was established in Portland, Oregon, 

by a number of medical and veterinary professionals 

who were interested in the effects of human-animal relationships. That organization became the Delta Society 

Therapy Dogs and Stress Management

 Assistance During Disasters

Jan Shubert, LCSW

The views expressed in this article are those of the author and do not reflect the views of the US Environmental Protection 

Agency, the US Army, or the US Army Medical Department.
April – June 2012 75

in 1981. The Delta Society also trains, certifi es, and 

registers service and therapy dogs (ie, Delta Society Pet 

Partner teams) and also continues its interest in research 

into human-animal interactions.12

To bring some clarity to this emerging fi eld, the Delta 

Society divided animal-associated interactions into 2 

categories: animal-assisted activities and animal-assisted therapy, under the following defi nitions:

Animal-Assisted Activity (AAA) provides opportunities for motivational, educational, recreational, 

and/or therapeutic benefi ts to enhance the quality 

of life. AAAs are delivered in a variety of environments by specially trained professionals, paraprofessionals, and/or volunteers in association 

with animals that meet specifi c criteria. Key 

features include absence of specifi c treatment 

goals; volunteers and treatment providers are not 

required to take detailed notes; visit content is 

spontaneous.

Animal-Assisted Therapy (AAT) is a goal-directed intervention in which an animal that meets 

specifi c criteria is an integral part of the treatment 

process. AAT is directed and/or delivered by a 

health/human service professional with specialized expertise and within the scope of practice of 

his/her profession. Key features include specifi ed 

goals and objectives for each individual and measured practice.13

THERAPY DOGS AND CRISIS RESPONSE

The fi rst example of a major disaster response by teams 

of therapy dogs and handlers was the bombing of the 

Murrah Building in Oklahoma City in 1995. At the request of the Federal Emergency Management Agency, 

TDI sent 20 teams to provide comfort to the responders, 

victims, and their families. In 1998, the work of therapy 

dogs took another step forward as a result of the response of 2 Delta Society Pet Partners teams to a shooting at Thurston High School in Springfi eld, Oregon. The 

teams were deployed by the National Organization for 

Victim Assistance. Twenty-fi ve people were injured and 

4 were killed in that incident. In their work at the school, 

the 2 Delta teams were able to reach students who had 

not been receptive to mental health professionals. Cindy 

Ehlers and her keeshond, Bear, made up one of the teams. 

While the Thurston High School response was quite 

small in comparison to the Oklahoma City incident, it 

was signifi cantly larger in terms of its long-term effect, 

because it created a champion for the fi eld that was to 

become known as animal-assisted crisis response.

Ehlers continued her training with Delta, becoming an 

evaluator and then an instructor. In 1999, convinced by 

her Thurston High School experience that dogs could 

contribute greatly to comforting and supporting shocked 

and grieving people, she founded HOPE Pets and developed the fi rst special crisis response training for pet 

partner teams. The organization offered its fi rst formal 

animal-assisted crisis response (AACR) training in July 

2000,14 focusing primarily on exposing and training 

the dogs to deal with situations they might experience 

traveling to and working at a disaster. A second training, modifi ed to include more information on emotional 

trauma for the human partners, was held in June 2001.

AACR at Ground Zero

In September 2001, Ehlers, her second keeshond, Tikva, and 3 other HOPE AACR teams were contacted by 

the American Red Cross and asked to travel to New 

York City in the aftermath of the terrorist attacks on 

September 11. Ehlers’ experiences and those of one of 

the other Oregon Pet Partners teams, Josiah Whitaker 

and his German shepherd, Hoss, were described in the 

book, Therapy Pets: The Animal-Human Healing Partnership.

15 Both teams spent 2 weeks working 12-hour 

days walking the perimeter of Ground Zero to provide 

support to the fi refi ghters and others searching for bodies, visiting the Family Assistance Center where family 

members awaited word of their loved ones and also applied for assistance, and riding the ferry boats that took 

grieving families to view the Ground Zero site. 

Ehlers and Whitaker were frequently paired with 2 mental health professionals from Ohio, James Rogers and 

Karen Soyka. In a brief article they wrote a few years 

after the event, Rogers and Soyka referred to their work 

with the HOPE teams as “another gift – or experience of 

grace,”16(p28) refl ecting on how the presence of the dogs 

had allowed them to connect with the recovery workers 

in ways that would have been very diffi cult if they had 

been alone.

In a discussion of appropriate uses of AACR at a disaster, Greenbaum17 identifi ed a number of ways in which 

the animals were helpful. They served as a therapeutic bridge and helped to establish rapport with a mental 

health professional. This was certainly the experience of 

Rogers and Soyka.16 Greenbaum17 also noted that the animals served as symbols of qualities that individuals had 

or wished they had (ie, afraid, helpless, brave, strong) 

or they were used to communicate thoughts and feelings indirectly (ie, speaking for the dog: “she’s afraid”). 

She pointed out that the animals helped to normalize the 

situation for the responders by reminding them of their 
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

lives outside of the situation. In addition, petting the animals is known to exert a calming effect7,18 by facilitating 

the body’s production of oxytocin, a hormone known to 

produce a calming effect.19,20 These effects were noticeable to the human members of the teams. Last, the animals served as protective shields for the families riding 

the ferry boats to view Ground Zero and enabled them 

to begin to fi nd the strength to deal with their losses. 

Frequently, the animal-handler teams responding to the 

terrorist attacks were paired with mental health professionals with results similar to those described by Rogers and Soyka.16 They served a variety of populations, 

ranging from the fi rst responders actually engaged in 

recovery operations, to American Red Cross, Federal 

Emergency Management Agency, and Salvation Army 

workers, as well as families of victims.

Approximately 500 animal-handler teams* provided assistance in New York, New Jersey, and Virginia in response to the terrorist attacks on September 11, 2001.17

Numerous breeds of dogs were used in this response, 

including golden retrievers, Labrador retrievers, greyhounds, collies, cocker spaniels, standard poodles, Shetland sheep dogs, Samoyeds, Portuguese water dogs, 

Dalmatians, and a variety of hounds and mixed breeds.22 

Even a few cats were used. The teams came from a variety of organizations and geographic locations. Most of 

the teams had training in AAA/AAT, but, except for the 

initial trainings organized by Ehlers in Oregon, no formal crisis response training programs existed at the time. 

This pointed to the need to distinguish between AACR 

and AAT/AAA. How does AACR differ from AAA/

AAT? According to Teal, animal-assisted crisis response

is the utilization of trained evaluated animals and 

handlers in crisis and traumatic recovery sites and 

centers to assist with the psychological needs and 

physiological stress factors of those persons present. The Visiting Animal is utilized as a transitional 

object to provide those in crisis and traumatic situations with a reality orienting relationship providing 

for solace, deep comfort and reduction of physiological stress signs. The utilization of animals in 

trauma and crisis response may provide critical 

grounding experiences for the beginnings of future 

psychological recovery and healing from aforementioned event.23(p2)

Providing assistance in the aftermath of this event presented a major learning experience for the animal-handler 

teams.22 They learned that both animal and handler 

could be exposed to unaccustomed sights and smells, as 

well as potentially hazardous substances. They learned 

that handlers needed to know crisis intervention techniques. Their dogs needed to be able to tolerate frequent 

handling and bathing, as well as the wearing of booties 

to protect their sensitive feet. For those dogs assisting on 

the ferry boat rides, they had to be able and willing to 

board the boat as well as tolerate the ride and the lack of 

any down time during the trips.

Perhaps the most important lesson learned was that neither the dogs nor the handlers could tolerate the 12-hour 

days under the horrifi c circumstances without detrimental effects. It is likely that many of the handlers, and 

most likely the dogs, suffered from secondary traumatic 

stress from their exposure to the severe emotional pain 

of the responders and the families of the victims. In addition, although respiratory protection was available for 

the handlers (most, however, chose not to use it for a 

variety of reasons), there was not then nor is there today 

any respiratory protection for dogs. They were likely exposed to a variety of hazardous substances, including 

particulate matter, asbestos, metals, dioxin-like material, 

and volatile organic compounds.24 Although there was no 

formal monitoring program for the therapy dogs, there 

was one for the search and rescue dogs in which many of 

the therapy dogs participated. Among the dogs known to 

suffer from respiratory diffi culties is Ehlers’ dog, Tikva 

(C. Ehlers, oral communication, February 2009).

In addition to the lessons learned cited above, Greenbaum17 pointed out that it is important to recognize 

circumstances and locations for which AACR is not appropriate and also to be aware of allergy, phobia, and 

cultural issues (eg, individuals from some cultures do 

not react positively to dogs). When considering criteria 

for both human and canine members of an AACR team, 

Greenbaum17 called for education in critical incident 

stress management for the human team member, and 

discussed a number of criteria for the canine team members. These include good health and currency of immunizations, freedom from phobias, high comfort levels with 

diverse populations and dogs as well as other species, 

acclimation to crowding, good food refusal skills, good 

basic obedience skills, a calm demeanor, transportation 

training, confi nement training, ability to urinate/defecate on command and on different surfaces, and training for various types of stimuli (eg, sirens, construction 

equipment noises). In addition, human members of the 

teams must be able to assess and deal with the stress levels of their canine partners by knowing when to remove 

them from the fi eld.

*It should be noted that 96 search and rescue teams also 

were deployed to New York, New Jersey, and Virginia sites. 

Although their mission was very different from that of the 

AACR teams, there were many instances where these dogs 

provided the same type of comfort to the responders.21

THERAPY DOGS AND STRESS MANAGEMENT ASSISTANCE DURING DISASTERS
April – June 2012 77

THE ARMY MEDICAL DEPARTMENT JOURNAL

Greenbaum17 noted that there were 2 days of memorial 

events held in Liberty State Park in New Jersey and at 

Ground Zero, September 10 and 11, 2002, on the fi rst 

anniversary of the 2011 terrorist attacks. Four AACR organizations, Bright and Beautiful Therapy Dogs; Dogs 

in Service, Inc; St. Hubert’s; and a chapter of Therapy 

Dogs International (S. D. Greenbaum, oral communication, April 2011), collaborated to ensure that enough 

AACR teams would be available. According to Greenbaum,17 this was the fi rst time 4 AACR organizations 

collaborated under a single incident command system. 

She considered this to be a constructive model for the 

future of AACR.

DEVELOPING AACR TRAINING

After Ehlers returned to Oregon from New York, she 

changed the name of HOPE Pets to Hope Animal-Assisted Crisis Response to refl ect the fact that the dogs 

were much more than pets. She also incorporated the 

organization. She then set about developing a 4-day 

AACR training program that focused on both the canine and the human components of the team. Training 

topics included animal/handler safety, animal fi rst aid, 

important canine equipment for deployments, and animal behavior basics. Background information on disaster mental health and stress management also was part 

of the training. The last 2 days of the training focused 

on travel/transportation training and disaster simulations. The teams rode on buses, went to an airport, used 

public restrooms, and boarded an airplane. They then 

participated in a disaster exercise in which a local fi re 

department played a role. At the end of the 4 days, trainee teams were evaluated for their readiness to continue 

training with the organization.

Ehlers went on to train numerous teams for Hope AACR 

and responded to Hurricane Katrina in 2004. Then she 

left Hope AACR and founded another organization initially called AACR (now known as National AACR). The 

2 organizations have trained approximately 200 AACR 

teams nationwide and present the most consistent and 

uniform training available in the fi eld. What began with 

the response of 2 therapy dog teams to a high school 

shooting has resulted in national recognition of the special talent that dogs have to alleviate stress in civilian life 

as well as in the military.* Between them, the 2 organizations have responded to the September 2001 terrorist 

attacks, along with the 10th anniversary memorial; Hurricanes Katrina, Rita, and Ike; California wildfi res; Virginia Tech and Northern Illinois University shootings; 

and countless local incidents. The AACR response to 

the Northern Illinois University shootings was featured 

in the “Making a Difference Today” segment of the NBC 

Today Show on July 14, 2008 (available at: http://today.

msnbc.msn.com/id/21134540/vp/25673508#25673508).

Recently, in recognition of the incredible growth of the 

fi eld and the number of different organizations now offering AACR training and certifi cation, the 2 founding 

organizations collaborated on the development of Animal-Assisted Crisis Response National Standards. The 

purpose of the standards is to move toward uniform training and oversight to aid in mutual deployments, as well 

as to ensure the well-being of the canine members of the 

AACR teams.25 First, the standards call for training by 

instructors who are both actively involved in AACR and 

familiar with the incident command system. Then, the 

standards then go on to identify requirements for training, evaluation, experience, certifi cation, standards of 

conduct, and AACR organizations. According to former 

National AACR President Ehlers, “These standards are 

the fi rst of their kind....They give emergency response 

agencies the tools they need to call on the right AACR 

teams.”26 HOPE AACR President Amy Ridout added, 

“When emergency response agencies call on AACR 

teams that follow the national standards, they will know 

that they are getting teams that are not only committed 

to helping people, but also are experienced in crisis response.”26 Equally important, the development of these 

national standards is an indication that the organizations 

are truly paying attention to the lessons learned after the 

response to the September 2001 terrorist attacks.

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25. National Standards Committee for Animal-Assisted 

Crisis Response. Animal-Assisted Crisis Response 

National Standards. March 7, 2010. Available at: 

http://www.hopeaacr.org/AACR%20National%20

Standards%207%20Mar%202010.pdf. Accessed 

February 13, 2011.

26. Animal-assisted crisis response national standards 

released [press release]. Washington, DC: HOPE 

Animal-Assisted Crisis Response; March 30, 2010. 

Available at: http://www.hopeaacr.org/hope_news.

htm. Accessed January 25, 2012.

AUTHOR

Ms Shubert leads a Critical Incident Stress Management 

Team in the Offi ce of Emergency Management of the US 

Environmental Protection Agency. She is also involved in 

a clinical practice in Ashburn, Virginia, and is a doctoral 

student at Fielding Graduate University.

THERAPY DOGS AND STRESS MANAGEMENT ASSISTANCE DURING DISASTERS
 April – June 2012 79

THE ARMY MEDICAL DEPARTMENT JOURNAL
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

THE BORDEN INSTITUTE
SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL

The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international 

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