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Do Service Dogs Help Treat PTSD? V.A. Still Doesn’t Know

Jasper Craven | NY Times

On a sunny October day in 2017, Lara Trump, the president’s daughter-in-law, held a meeting in the West Wing to promote an initiative that would pair shelter dogs needing homes with veterans wanting to act on the increasingly widespread notion that well-trained dogs can improve the lives of people suffering from post-traumatic stress disorder and other mental-health conditions.

Sitting at a long wooden table in the Roosevelt Room, Trump lobbied the leaders of the Department of Veterans Affairs and the Humane Society of the United States. She also showed her support for the Puppies Assisting Wounded Servicemembers (PAWS) Act, a piece of bipartisan legislation first introduced in 2016 that would establish a grant program pairing veterans with psychiatric service dogs, which are rigorously trained to help their owners cope with stress, anxiety or fear.

The meeting was an impressive show of political force that featured top White House officials, lawmakers, two cabinet secretaries and at least one service dog. Less than two months later, the V.A. formed a partnership with the Humane Society. But by May 2019, almost a year and a half later, their joint program had provided dogs to only 19 veterans. And despite Trump’s efforts — by that time she had held a half dozen meetings with lawmakers and other government officials to build support for legislation — the PAWS Act never went to a vote. It faced stiff resistance from V.A. officials who said the bill could “result in unintended and negative consequences” for veterans entrusting their well-being to “this unsubstantiated treatment regime.”

While the V.A. covers the veterinary care and the equipment costs of service dogs for veterans with certain physical disabilities, like blindness or vision impairment, department leaders have long contended that there isn’t enough clinical evidence to prove their benefits for treating mental-health issues. “I would say there are a lot of heartwarming stories that service dogs help, but scientific basis for that claim is lacking,” Dr. Michael Fallon, the V.A.’s chief veterinarian, said during an interview with National Public Radio in 2017. “The V.A. is based on evidence-based medicine. We want people to use therapy that has proven value.”

The V.A. is currently conducting research into the effectiveness of service dogs, but the process has been slow. Research started in 2011 was supposed to wrap up in 2015 but has repeatedly been stalled by problems with the study’s design and execution. In May, the V.A. said the findings of the study, which has cost $16 million to date, would be released to the public in 2020.

Meanwhile, some lawmakers are growing impatient with what they perceive as a lack of initiative at a time when there is a growing mental-health crisis in America’s veterans community. In June, Representative John Rutherford, a Florida Republican, reintroduced the PAWS Act, to establish a $10 million grant program through the V.A., which would give qualified nonprofit organizations up to $25,000 for each veteran they pair with a service dog. The stipend would cover the canine’s training, and the training of the recipient with his or her service dog. The bill is sponsored by both Democrats and Republicans, pitting lawmakers against the V.A., which is refusing to endorse any new stopgap service-dog program before its internal research is completed.

Stuck in the middle are the veterans themselves. Among those receiving disability benefits from the V.A., more than one in five suffers from PTSD. Veterans who have responded poorly to conventional treatments have had to improvise, sometimes by paying thousands of dollars up front to acquire service dogs, then covering the significant costs of feeding and caring for them. To make matters worse, veterans seeking service dogs without any support from the V.A. are forced to wade into a largely unregulated industry: Some end up with a dog that provides few benefits because it isn’t properly trained. Veterans advocates say access to a psychiatric service dog without the associated financial burden can’t come soon enough.

In January 2009, Al Franken, fresh off his winning campaign for a Senate seat, met Luis Montalván, a medically retired Army captain who had served two tours as an intelligence officer in Iraq, and his golden retriever named Tuesday. Montalván had returned home with a shattered leg, spinal damage, a brain injury and PTSD symptoms that included vivid nightmares, flashbacks, panic attacks and a fear of public spaces. The only therapy that eased Montalván’s symptoms was Tuesday, whom he received from a group called Educated Canines Assisting With Disabilities. Tuesday sensed if Montalván’s breathing sharpened or he began to perspire, and then intervened with a nuzzle. If Tuesday noticed Montalván thrashing while asleep in bed, he would wake the former soldier from his nightmare with a series of sloppy face-licks. Tuesday was even trained to direct the Army veteran from his bed to his pill bottles each morning.

Montalván said that Tuesday, and not much else, brought him peace of mind. The problem, he pointed out to Franken, was that there wasn’t a streamlined process for veterans to receive psychiatric service dogs. The V.A. didn’t recognize psychiatric service dogs as an evidence-based therapy for PTSD. There were nonprofits around the country specializing in training service dogs for veterans, but no clear standards for what type and level of training a dog should receive. The animals were also extremely expensive. Moved by Montalván’s story, Franken introduced as his first Senate bill a call for the V.A. to do a three-year pilot study into the benefits and feasibility of using service dogs to treat PTSD and other injuries and disabilities. The bill received bipartisan support and was incorporated into the 2010 defense budget.

The legislation appeared to be a victory for service-dog advocates, but the study almost immediately encountered problems. The V.A. initially partnered with vendors whose poorly trained animals introduced unexpected complications. The V.A. did not supervise the vendors’ screening for health problems or aggressive behavior. As a result, roughly 25 percent of the dogs developed hip dysplasia, two dogs bit children, one dog died of an undiagnosed disorder and one with a spinal tumor was euthanized. In addition, contractors had discouraged participants from reporting problems with their dogs to the V.A., which tainted the findings early on in the study. Because of these issues, the agency suspended its trial twice in 2012, just months after it began.

“We relied upon the organizations themselves, all of which professed to be very experienced and to be able to produce high-quality dogs, and unfortunately that did not turn out to be true,” Fallon told lawmakers in a 2016 congressional hearing. “We were not familiar enough with the service-dog community when we embarked on the pilot study. There’s no question that we’ve made mistakes.”

The V.A. fired the dubious contractors, hired its own trainers and redesigned the study, which paused its research for two years. “The complexity and scope of this study are far beyond any others ever attempted” related to the use of psychiatric service dogs, said James Hutton, the deputy assistant secretary for the V.A.’s Office of Public and Intergovernmental Affairs. “V.A. had to design its own procedures, which is a very time-consuming process.”

Around the same time that Franken was pushing for change and the V.A.’s study was getting off to its shaky start, the suicide rate among veterans ages 18 to 34 jumped, pushing the V.A. to relax eligibility requirements for PTSD diagnoses. The number of PTSD disability claims nearly tripled between 2008 and 2017. Today, more than 1.7 million veterans receive mental-health care through the V.A. The department currently endorses two types of cognitive behavioral therapy to treat PTSD — prolonged exposure and cognitive processing — as well as eye movement desensitization and reprocessing (E.M.D.R.). The V.A. also prescribes antidepressant medications, like Zoloft, Prozac and Paxil. But while some veterans who use these treatments see their symptoms subside, others experience few discernible improvements. A 2016 review of available evidence on the V.A.’s psychotherapeutic remedies noted that prolonged exposure therapy was not effective for 40 percent of veterans with PTSD. Medications show about the same success rate and sometimes cause debilitating side effects.

In early 2017, the V.A. secretary at the time, David Shulkin, started the Center for Compassionate Care Innovation to explore emerging therapies that might improve physical and mental health for veterans. Shulkin sidestepped V.A. red tape and found money in the budget to pair up to 100 veterans with service dogs. “I was told: ‘We can’t do that. We have research going on,’” Shulkin said. “My response was, ‘What about the veterans who are suffering today?’” Shulkin, the only holdover from the Obama administration in Trump’s cabinet, was forced out of the V.A. in March 2018.

In Washington, some lawmakers are losing patience. Representative Jim McGovern, a Massachusetts Democrat, said he has been pushing V.A. officials for years on this issue, to little effect. “What I usually hear is, ‘We are looking into it,’” McGovern said. “I’ve never gotten the sense it’s been the priority it needs to be. I haven’t checked in this year with V.A. folks, because I’ve just kind of given up on them.”

Some major veterans service organizations, including the Veterans of Foreign Wars and the American Legion, have supported the PAWS Act and faulted the department as being unnecessarily resistant toward alternative treatments, including psychiatric service dogs. “It’s frustrating that the V.A. study is taking so long,” said Carlos Fuentes, the legislative director at Veterans of Foreign Wars. “While the V.A.’s evidence-based therapies are great, they don’t work for everyone. We have members who have been helped tremendously by service dogs.”

In May, the V.A. said that the last participants would finally complete the study in June and that the agency would deliver its final reports next year. One report, due out next spring, will address whether service dogs and emotional-support dogs measurably reduce the symptoms of PTSD and improve quality of life. The second report, which won’t be available until the end of next year, will address whether the use of these dogs resulted in reduced health care costs, although Hutton said that “cost does not drive such discussions” at the V.A. After reviewing the reports, it will be up to the department’s leaders to decide whether to make changes to its service-dog policy.

The outcome could have significant ramifications for the veteran population. “I’ve had multiple veterans come up to me and tell me that they would have probably committed suicide but for being paired with a service dog,” said Ron DeSantis, formerly a congressional representative from Florida and now the state’s governor. “It’s not often people look you in the eye and tell you that they probably would have done that.”

In 2011, when the V.A.’s study first began, there was no clinical research available on how service dogs could help veterans manage their PTSD. But in the years since, a growing body of research has emerged. The data is of varying quality. Most studies have pulled from small samples, and some were carried out in partnership with private service-animal organizations. In 2014, the preliminary results of a study from Kaiser Permanente involving 75 veterans paired with service dogs showed that the therapy had positive effects on the study participants, including reduced symptoms from PTSD and depression, along with improved interpersonal relationships and a lower likelihood of substance abuse. A 2016 review of available literature about the treatment found that most studies “endorsed canine assistance for PTSD in veterans as a promising modality” but called for more research.

The most recent studies have also produced promising findings. A 2018 Purdue University study of 73 veterans found that participants with service dogs produced significantly higher levels of cortisol, a hormone involved in processing stress. They also experienced a 12-point drop, on average, on the V.A.’s standardized PTSD symptom checklist, said Dr. Maggie O’Haire, the study’s lead author. Kerri Rodriguez, one of O’Haire’s co-authors on the study, said, “While not a cure for PTSD, we found service dogs are an effective complementary treatment that have significant effects on multiple areas of life.” Purdue is now engaged in a three-year clinical trial, funded by the National Institutes of Health, to monitor the long-term effects of service-dog therapy on veterans.

Veterans who have received service dogs through their own means often attest to these benefits. Cole Lyle, a Marine Corps veteran who helped write the original PAWS Act and has tirelessly lobbied on Capitol Hill on this issue, offered harrowing testimony in 2016, shortly after Fallon’s remarks, about the mental-health crisis afflicting his community. Just a week earlier, Lyle said, he had intervened when a Marine with whom he once deployed became suicidal. Days before that, another Marine, this one a friend of a friend, killed himself. Lyle had considered suicide himself at one point, after coming home from Afghanistan in 2011, haunted by memories from his work on the night shift in the trauma center at Camp Bastion in Helmand Province. As Lyle told his story, his German shepherd named Kaya lay calmly at his feet. Kaya came from an accredited organization and had cost Lyle and his family about $10,000. “I believe that allowing veterans to fight PTS without all options available to them is tantamount to sending our military to fight an enemy without a secondary weapon in their arsenal,” Lyle said. “A dog can give you a sense of purpose that a pill will just not ever do.”

It’s unclear whether the V.A. will meet the latest delivery date for its research as promised. If the final reports are released to the public in 2020, it will have been more than 10 years since Franken first conceived of the legislation after meeting Luis Montalván and his dog, Tuesday. Montalván will never see the outcome of the work he inspired. On Dec. 3, 2016, he died by suicide in a Texas hotel room, after undergoing a leg amputation that year. Tuesday wasn’t with him at the time.

Topics
Legislation
Mental Health
Service Animals
VA