Nurse Education Today 47 (2016) 43–50

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Nurse Education Today

journal homepage: www.elsevier.com/nedt

Military veterans and canine assistance for post-traumatic stress

disorder: A narrative review of the literature
Cheryl A. Krause-Parello ⁎, Sarah Sarni, Eleni Padden
C-P.A.W.W. (Canines Providing Assistance to Wounded Warriors), Health Research Initiative for Veterans, University of Colorado, College of Nursing, Anschutz Medical Campus, 13120 E. 19th
Avenue, Aurora, CO 80045, United States

a r t i c l e i n f o a b s t r a c t

Article history: Background: Veterans with post-traumatic stress disorder (PTSD) are a vulnerable population at high risk for
Received 25 October 2015 depression, isolation, and suicide. A substantial body of anecdotal evidence exists supporting the use of canines
Received in revised form 15 April 2016 as an effective adjunct treatment for this population. However, a comprehensive review of its use based on
Accepted 24 April 2016 scientific literature has thus far not been conducted.
Methods: A narrative literature review was conducted to examine the current state of the science on canine
Keywords:
assistance for veterans diagnosed with PTSD in order to synthesize current empirical knowledge on the subject.
PTSD
Veterans
Articles were retrieved among the small body of recent literature using computerized database searches. Inclu-
Canine assistance sion criteria included peer-reviewed journal publications published through October 1st, 2015. Only originally
Military published articles that examined the outcomes of canine assistance on veterans with PTSD were examined.
Service dogs Additionally, each included article was specific to veterans, dogs, and, PTSD in combination rather than article
Therapy dogs that discuss the concepts separately. Exclusion criteria included symposia and conference material, dissertations,
Post-traumatic stress disorder media articles, and no mention of canines as a treatment modality. 563 articles were retrieved; 6 met the criteria.
Literature review When evaluating data, information and themes were extracted into an Excel table; this table was employed in
the synthesis of information into manuscript form.
Results: The following themes were explored within the selected publications: What is Canine Assistance; Why
Use Canine Assistance for PTSD in Veterans; Concerns; and Future Directions. The literature endorsed canine
assistance for PTSD in veterans as a promising modality. Authors also raised concerns about lack of protocols,
cost and availability barriers, and animal welfare calling for additional, rigorous research to advance its use as
a treatment for veterans with PTSD.
Conclusions: PTSD continues to pose significant psychological, health, and welfare challenges to veterans and the
multi-disciplinary providers who treat them. Analysis of this literature should expand knowledge and outline
future directions for healthcare professions and improve health and wellness for veterans with PTSD through
the use of canine assistance.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Post-traumatic stress disorder (PTSD) is a potentially debilitating
psychiatric condition that overwhelmingly affects veterans. Considered
a signature wound of the Iraq and Afghanistan wars, PTSD is complicat-
ed and diverse in both its development and expression (Burke et al.,
2009; Troyanskaya et al., 2015). A variety of vulnerabilities categorized
as pre-trauma, peri-trauma, and post-trauma have been related to the
development of PTSD (Hoge et al., 2007). Veterans with a diagnosis of
PTSD characteristically present with experiences from each of these
categories. It has been hypothesized that the additive effect of various
vulnerability factors such as previous history of a mental disorder,
⁎ Corresponding author.
E-mail addresses: Cheryl.Krause-Parello@ucdenver.edu (C.A. Krause-Parello),
Sarah.Sarni@ucdenver.edu (S. Sarni), Eleni.Padden@ucdenver.edu (E. Padden).
perceived social support, and subsequent life stressors may propel
individuals towards the development of the disorder (Hoge et al.,
2007). Presenting symptoms of PTSD can include re-experiencing trau-
matic events, increased arousal and constant hypervigilance, as well as
avoidant, numbing, defensive, and self-medicating behaviors. Further-
more, PTSD is associated with increased risk for suicidal behavior,
especially among female, young, and rural veterans (Department of
Veterans Affairs [VA], 2012; Kemp, 2014); harrowing current estimates
point to the loss of approximately 22 veterans a day to suicide (Kemp
and Bossarte, 2013).
Healthcare professionals currently address PTSD via multiple treat-
ment modalities. Strategies include pharmacological interventions,
behavioral approaches, such as support groups and stress management
teaching, as well as therapeutic methods, including cognitive behavioral
therapy, eye-movement desensitization therapy, reprocessing therapy,
exposure therapy, and trauma-focused therapy (Corrigan and Cole,

http://dx.doi.org/10.1016/j.nedt.2016.04.020
0260-6917/© 2016 Elsevier Ltd. All rights reserved.
44 C.A. Krause-Parello et al. / Nurse Education Today 47 (2016) 43–50
2008; Taylor et al., 2015). Unfortunately, many individuals remain
symptomatic even after receiving these evidence-based treatments.
Additionally, distinct challenges have been identified in administering
effective mental health care treatments to service members. Mental ill-
ness can carry a negative connotation in the military, with service mem-
bers under pressure to remain stoic. This may result in a hesitance to
seek treatment for fear of ostracism and loss of status, community,
and benefits (Taylor et al., 2015; McNally, 2012). The culture that exists
in many components of the military emphasizes strength—physical as
well as mental. As such, a persistent stigma against mental health issues,
and an unwillingness to be seen as weak may play a key role in discour-
aging veterans from seeking help with emotional problems (Greene-
Shortridge et al., 2007).
Additionally, the transition from active duty to veteran status is
difficult for many individuals as they move from the certainty of a
routine and sense of purpose to uncertainty and daily flux. Gaps in social
and behavioral health support during reintegration can lead to the
deterioration of mental health for new veterans (Defense Centers of
Excellence, 2010). Substance abuse, homelessness, and suicide continue
to remain significant problems for the veteran population struggling
with PTSD (Leeies et al., 2010; Carlson et al., 2013; Wisco et al., 2014;
Finley, 2014). There is a clear and pressing need for a variety of dynamic,
empirically validated approaches to aid service providers in addressing
the PTSD health crisis currently facing our military veterans. As such,
this narrative review will focus on critically examining a promising
new approach by exploring the impact that canine assistance has been
demonstrated to have upon this pressing issue in military mental health
and wellness.
Canine assistance is defined in this article as involving interactions
between veterans with PTSD and any type of canine (i.e. service dogs,
psychiatric service dogs, therapy dogs, and companion dogs), for the
purposes of alleviating PTSD symptoms and facilitating recovery. Taking
into consideration the largely compassionate and non-judgmental
demeanor of canines, these animals have the potential to be especially
well suited for the needs of a veteran with PTSD who may be experienc-
ing isolation during reintegration, as well as a persisting desire to
maintain appearances of psychological strength to their human com-
panions and service providers. The ability for dogs to serve as alert
mechanisms for their handlers may also ameliorate some of the difficul-
ties that individuals struggling with hypervigilance must frequently
manage (Lefkowitz et al., 2005; Holowka et al., 2012; Furst, 2015). It
has been established that there are a variety of complex social and
emotional benefits that may arise from human interactions with a
canine, such as a lessening of depressive and anxious symptoms
(Hoffmann et al., 2009; Le Roux and Kemp, 2009; Crossman et al.,
2015; Wright et al., 2015). As such, a thorough review of the existing
literature must be conducted in order to examine the current state of
scientific knowledge in regards to studies evaluating canine assistance
for veterans with PTSD. This is a necessary step to move the evolving
field of study forward in both a systematic and innovative fashion. We
will also identify current issues that must be addressed to improve
contemporary practice and optimize health outcomes for veterans,
ultimately aiming to make this information more comprehensively
accessible to our community at large.
Approximately 7.6% of Iraq and Afghanistan veterans reporting
combat exposure have received a diagnosis of PTSD (Smith et al.,
2008). Further, 25% of all veterans seeking health-care from the VA
are diagnosed with a psychological condition; up to 52% of these indi-
viduals are diagnosed with PTSD (Seal et al., 2007). PTSD and its devas-
tating sequelae, which include depression, violence, substance abuse,
homelessness, and suicidal ideation, take not only an immense toll on
both the service member's immediate circle, but on society as well
(Finley, 2014; Stander et al., 2014; Begic and Jokic-Begic, 2001; Leeies
et al., 2010; Carlson et al., 2013; Wisco et al., 2014). These statistics
make it obvious that the investigation of treatments for PTSD must be
made a national priority. As such, this review actively seeks to explore
the knowledge base regarding the ways in which canines may provide
support to our nation's veterans, in hopes that these jarringly desolate
statistics may, through evidence-based practice and the implementa-
tion of strategic canine assistance, no longer be representative of the
health and wellbeing of our honorable service member population.
2. Methods
2.1. Research Questions
The specific research questions (RQs) were to answer: RQ 1 What is
the definition of canine assistance; RQ 2 What are the benefits of canine
assistance in the veteran population; RQ 3 What are the concerns of
canine assistance in the veteran population; and RQ 4 What are the
future directions needed for research regarding the use of canines for
assistance and promotion of healing in a population of military veterans
with PTSD.
2.2. Literature Search
Computerized database searching was the primary measure used to
access relevant publications. Five electronic databases were used:
FindIt, Medline, CINAHL, PubMed, and PsychINFO.
Search words included all combinations of these key words PTSD,
veteran, canine; military, dog, and canine assistance.
The inclusion criteria for the search included the following:
1) Peer-reviewed journal publications.
2) All publications through October 1st, 2015.
3) Only originally published articles that examined the outcomes of
canine assistance on veterans with PTSD.
4) The article was specific to veterans, dogs, and, PTSD in combination
rather than article that discuss the concepts separately.
Search parameters were highly inclusive because of the small total
body of research on the subject. All relevant articles meeting the identi-
fied criteria were included. A total of 563 articles were retrieved (see
Fig. 1). An initial review of the abstracts was conducted to remove
articles that were clearly unrelated to canine assistance for veterans
with PTSD, qualitative studies, or the level of detail was insufficient to
evaluate the study's quality. Exclusion criteria included symposia and
conference material, dissertations, theses, media articles, and no men-
tion of canines used as a treatment modality. After the exclusion of
article only six published articles met inclusion criteria (see Table 1).
Although a large number of articles were retrieved there is a small
body of research pertaining to specifically canines, veterans, and PTSD.
2.3. Literature Screening and Synthesis of Themes
A narrative literature review was conducted to gather, assess,
critique, and synthesize information on the current state of the science
on canine assistance for veterans with PTSD. Retrieved articles were
screened independently by two designated authors. Articles were
assessed via relevance of title and abstract content to our inclusion
criteria and search terms. If an article's abstract was not substantial
enough to deem it includable or excludable, the entirety of the article
was evaluated the designated authors in order to make a finalized
decision regarding inclusivity. Theme identification was performed by
the designated authors. Designated authors independently identified
prominent themes in the included literature approved for review. All
disagreements concerning article inclusivity and identification of recur-
ring and relevant themes were resolved via discussion and subsequent
consensus.
 C.A. Krause-Parello et al. / Nurse Education Today 47 (2016) 43–50
Fig. 1. Literature search strategy.
2.4. Data Synthesis
When synthesizing the data, the articles were reviewed and overall
quality evaluated. Data from the articles was outlined; evaluation
included the assessment of similarities and differences between publi-
cations as well as theme recognition. Themes were developed based
on a synthesis of the content from all six included articles. Themes
were then reviewed and cross-referenced/verified by an independent
rater. The following themes were explored by authors of the selected
publications: What is Canine Assistance; Why Use Canine Assistance
for PTSD in Veterans; Concerns; Future Directions. This information
was next extracted into an Excel table; relevant information and themes
from each article were entered into the table. This table was then
employed in the synthesis of the information into manuscript form.
3. Results
3.1. Research Question #1
3.1.1. What is the Definition of Canine Assistance?
Four primary types of canine assistance were identified.
45
In the 6 manuscripts canine assistance was defined as engaging in
beneficial interactions with service dogs (n = 1 paper); therapy dogs
(n = 1 paper); emotional support dogs (n = 1 paper); and companion
dogs (n = 1 paper).
3.1.1.1. Service Dogs. Service dogs (SDs) are considered working dogs.
These dogs are exhaustively trained to respond precisely to specific dis-
abilities of their owners, and are typically allowed entry into public facil-
ities under the protection of the Americans with Disabilities Act (ADA)
(Taylor et al., 2015). Service dogs are commonly known to assist indi-
viduals with physical disabilities, such as paralysis, blindness, diabetes,
and seizures. Psychiatric service dogs attend to individuals with diagno-
ses such as schizophrenia, bipolar disorder, obsessive–compulsive dis-
order, panic and anxiety disorders, as well as PTSD. Psychiatric service
dogs are trained to respond specifically to the psychiatric symptoms of
their owners. For veterans with PTSD, these canines may diffuse panic
and aggression via physical contact, ameliorate the deleterious sleep
quality effects of nightmares, and assist in procuring help for veterans
in emergent distress (Yount et al., 2013; Taylor et al., 2015). Such service
dogs are sometimes trained by the owner with qualified assistance
(Taylor et al., 2015). For example, veterans may participate in training
their own service dog or service dogs for other disabled veterans. This
46 C.A. Krause-Parello et al. / Nurse Education Today 47 (2016) 43–50

Table 1
Summary of the literaure review.

Study Year Purpose Methods

Finley 2014 Explore how public institutions may direct and organize PTSD Literature review; specific methods not defined in
treatment for veterans, in the context of current data and publication.
CAM options.
Laas-Henneman, Peyk, 2014 Determine if therapy canines have anxiety and 80 female participants exposed to induced traumatic stress
Streb, and Michael stress-reducing effects during induced traumatic stress. through film clip. 4 groups: dog, toy dog, friendly person,
alone. Physiological stress and subjective stress and anxiety
measures collected at timed intervals.
Stern et al. 2013 Determine the effects of companion canines on veterans with 30 veterans with PTSD, aged 34–67, treated at outpatient VA
PTSD. clinics. Participants completed questionnaires assessing
mental/physical health and relationship with a companion
dog.
Taylor, Edwards, and Pooley 2015 Examine post-war canine ownership experiences of Iraq and Triangulated, three-phase qualitative content analysis of data.
Afghanistan veterans, especially in reintegration into civilian Qualitative data relates veterans who served in
society, using journalistic accounts, advocacy publications, Iraq/Afghanistan, were diagnosed with PTSD post-service, and
and social media commentary. utilized a canine to alleviate symptoms.
Wynn 2015 Evaluate CAMa interventions used in treatment for PTSD. Literature review; specific methods not defined in
publication.
Yount, Ritchie, St. Laurent, Chumley, 2013 Demonstrate the effects of service dog training as an Literature review; 2 case studies
and Olmert intervention for veterans with PTSD and mild TBIb.
a
CAM: complementary alternative medicine.
b
Traumatic brain injury.

training in itself has been anecdotally described as helpful to veterans in
managing their emotions, attention, and social interaction (Yount et al.,
2013).
3.1.1.2. Therapy Dogs. Therapy dogs (TDs) are obedience trained and
possess agreeable dispositions for contact with people within medical
facilities and other settings, such as nursing homes and detention
centers. Oftentimes, the individuals that they interact with may be unfa-
miliar to them. This highlights the importance of ensuring that a trained
therapy dog will have a welcoming and largely calm temperament so
that they are capable of accommodating contact with unfamiliar
persons while also serving as a source of comfort. Therapy dogs do not
have the same access to public facilities as service dogs, as they are
typically utilized in different settings. They do not possess the same pro-
tections as service dogs under the ADA. These animals interact with
many people under the control of a handler, rather than attend strictly
to the needs of their individual owner. Therapy dogs enhance therapeu-
tic activities and well-being through interaction, typically in clinical
facilities, and may be utilized during animal assisted interventions
(AAI). AAI can be defined as a strategy that incorporates animal interac-
tion as a therapeutic tool to reduce stress and promote healing among
diverse populations. Specifically, therapy dogs may accompany patients
at psychotherapy appointments, provide simple physical comforts via
body contact, and allow patients to engage in interactions that may
aid in motor skill improvement such as brushing or grooming (Taylor
et al., 2015). Therapy dogs may help individuals with PTSD who are
having issues with social interaction and isolating themselves from
others (Wynn, 2015). Therapy dogs have been shown to reduce stress
and anxiety responses during traumatic stressors (Laas-Henneman
et al., 2014). Moreover, findings from recent literature have proposed
therapy dogs as an adjunctive treatment for PTSD (Laas-Henneman
et al., 2014).
3.1.1.3. Emotional Support Dogs. Emotional support dogs (ESDs) are dogs
that provide companionship and support, specifically for individuals
with psychiatric impairments or disabilities (Taylor et al., 2015). They
are intended to promote psychological wellbeing for the individual
who utilizes them. These dogs do not undergo particular training to
provide aid to an individual; instead, the natural, untrained behaviors
of the dog are what helps to mitigate an individual's disability (Taylor
et al., 2015). Unlike service dogs, they do not perform specific, trained
tasks that are necessary to ameliorate an individual's psychiatric
disability. A designated emotional support dog can be an individual's
companion dog, but to be specifically considered an emotional support
dog they must provide companionship and support categorized as
specifically helpful towards lessening the discomfort associated with
an individual's psychiatric impairment or disability. Although they
may be recommended and at times prescribed by mental health profes-
sionals, they do not generally have access to public places and not
possess the same protections as service dogs under the ADA. ESDs do
not typically possess the same practical working skills that service and
therapy dogs use to assist persons with disabilities.
3.1.1.4. Companion Dogs. Companion dogs (CDs) are defined as
specifically being non-service animals (Stern et al., 2013); i.e. they have
not been trained exhaustively to respond precisely to specific disabilities
of their owners in any capacity and the primary purpose they serve is
that of a pet. Additionally, companion dogs are not specifically trained
to any degree to provide support for an individual suffering from a
psychiatric disability. Companion dogs are not allowed entry into public
facilities. SDs, TDs, and ESDs serve more specialized, health-oriented pur-
poses for the individual who utilizes them than would a companion dog
(Taylor et al., 2015). Interactions and social relationships with
companion dogs or “pets” may still assist humans by naturally facilitating
a wide variety of associated health benefits (Stern et al., 2013).
3.2. Research Question #2
3.2.1. What are the Benefits of Canine Assistance in the Veteran Population?
Potential effects of canine assistance may be both social and
physiological.
3.2.1.1. Social Benefits. Authors generally viewed canine assistance as
providing companionship and social connection, which is often absent
in the lives of veterans struggling with PTSD. Dogs were cited as supply-
ing a source of emotional attachment and mutual caregiving, as well as
social interactions and networks for individuals who are at high risk for
social isolation, depression, and potential suicidal ideation (Taylor et al.,
2015; Laas-Henneman et al., 2014). Additionally, dogs may provide
assistance with basic functions, a means of support and coping during
exposure to stressors and subsequent reactions, and assurance of safety
and vigilance (Laas-Henneman et al., 2014; Finley, 2014).
Stern et al. (2013) surveyed veterans with PTSD being treated at VA
outpatient clinics with questionnaires assessing mental and physical
health and relationships with a companion animals. Study results
demonstrated that participants who lived with companion dogs
 C.A. Krause-Parello et al. / Nurse Education Today 47 (2016) 43–50
reported less loneliness, depression, isolation, worries regarding per-
sonal and family safety, and increased calmness. This encouraging find-
ing ultimately suggests that living with a companion dog may
contribute to lessening various psychological hardships characteristic
of PTSD (Stern et al., 2013). Taylor et al. (2015) conducted an analysis
of media and social media accounts in order to determine what veterans
with PTSD using canine assistance experience, in their own words.
Veterans described service dogs that ground them in the midst of
triggering episodes and overwhelming symptoms via physical contact
and comforting actions, an increased sense of security and less
hypervigilance, and increased success in attempts to re-engage in
society. The author proposed that service dogs are effective because
they meet specific needs of safety, belonging, and mutual caregiving
(Taylor et al., 2015).
Per Laas-Henneman et al. (2014), the majority of studies which have
demonstrated that canines aid in coping employ designs in which
participants are exposed to natural, mild stressors, such as cognition
challenges and performance stress, rather than trauma, and thus may
not be applicable to veterans with PTSD. Responding to the lack of
data involving canine assistance and traumatic stress, healthy female
participants were exposed to a validated film-trauma paradigm, in the
presence of either a friendly stranger, a canine, a toy dog, or alone.
Participants in the canine group showed decreased subjective anxiety
(p b 0.01) and negative affect (p b 0.05) after the film compared to
participants in the alone group, demonstrating that canines may assist
in coping with trauma. No significant differences were found between
the canine group and friendly person group with the alpha level set at
p b 0.05; both groups showed equal benefits in terms of subjective anx-
iety and negative affect. These results are of note, as social interaction
and support are considered integral to PTSD treatment and recovery.
Veterans with PTSD who are at risk for isolating behaviors may feel
capable of establishing relationships with canines, potentially resulting
in reduction of anxiety and negative affect, similar to the effect of social
support. Additionally, skeptics of canine assistance as a therapeutic
modality question whether or not potential benefits are generated
based on the relationship developed over time between a dog and its
owner, rather than the interaction itself. Participants in this investiga-
tion were exposed to the film-trauma paradigm with a canine they
had never seen prior to the exposure and significant results were still
observed; therefore, the author surmised that canine interaction may
be beneficial to veterans with PTSD as an adjunct treatment even if
the veteran is not the owner and if the human-canine relationship is
not necessarily established in the context of consistent every-day life
activities.
3.2.1.2. Physiological Benefits. The various physiological benefits that
canine assistance may potentially have upon veterans were discussed
at length in articles that met the inclusion criteria for this review.
Yount et al. (2013) postulated that veterans reported relief when
interacting with a canine partner due to an increase in endogenous
oxytocin that animal-interaction provides. Citing a study demonstrating
that a dose of oxytocin administered to veterans with PTSD resulted in a
decreased physiologic response to incited traumatic memories, the
authors noted that there is currently no FDA approved, pharmacological
oxytocin treatment available for PTSD. The authors also briefly exam-
ined how canine interaction had been shown to significantly increase
endogenous levels of oxytocin in humans (however, these were studies
done with civilians). The authors further discussed the mediating
importance of oxytocin to brain systems such as the HPA-axis, the
amygdala, and the medial prefrontal cortex—systems which are all,
Young and colleagues pointed out, critically interlinked with PTSD
neurobiology and symptomology. By logical extension, then, canine
interaction may have the potential to increase levels of oxytocin in
veterans, much as it has been shown to do in other cohorts. Taking
into consideration that exogenous administration of oxytocin in a veter-
an sample has already been shown to ameliorate some PTSD symptoms,
47
significantly increasing levels of oxytocin naturally via interaction with
a canine may well be a viable and largely noninvasive treatment modal-
ity to consider for veterans with PTSD.
Wynn (2015) stated that complementary alternative medicine
(CAM) interventions, such as canine assistance, provide additional
treatment options to patients and clinicians, and that canine assistance
in particular has been shown to aid individuals with a variety of psycho-
logical disorders at various ages, both subjectively and physiologically
via stress biomarkers. In particular, Wynn highlighted that decreases
in blood pressure (a physiological indicator of stress) have been docu-
mented after interactions with pets such as dogs in a civilian cohort,
asserting that this is of great interest for future studies examining
specific stress-decreasing effects that dogs may have upon veterans
with PTSD. Finally, Taylor et al. (2015) delve into a theoretical discus-
sion of canine interaction contributing to the amelioration of the
human freeze and hypervigilance response. The authors explained
that the freezing/hypervigilance response increases the release of
norepinephrine, and may ultimately contribute to states of fear and con-
stant watchfulness in veterans with PTSD. This increased state of fear
may contribute to a naturally heightened desire to flee (as per our
fight-or-flight response mediated by the body's sympathetic nervous
system), which is oftentimes in direct contradiction to a veteran's deep-
ly ingrained desire to “stand and fight”. This can be an additional source
of serious emotional distress which can be intensified when, instead of a
flight response, a veteran has a fight response, such as verbal or physical
aggression. Findings from their study indicated that veterans perceived
dogs as having the ability to “nudge” them out of a state of fear and/or
aggression, and support a transition back to a more tranquil state.
3.3. Research Question #3
3.3.1. What are the Concerns With Canine Assistance?
Lack of standards regarding best practices, cost and availability
barriers, and animal welfare were identified as primary concerns.
3.3.1.1. Best Practices. Three primary concerns were identified: a lack of
consensus regarding best practices (Wynn, 2015) cost and availability
barriers (Stern et al., 2013), and animal welfare (Taylor et al., 2015). A
chief concern expressed in the literature is that there is a deficiency of
agreement and standardization on a variety of details regarding canine
assistance and PTSD in veterans. It has yet to be determined to what
degree canines are affective at ameliorating symptoms, including in
comparison to other CAM interventions. Finley noted that while there
is palpable support and interest in academic, military, and medical
communities, a question exists as to whether or not canine assistance
actually prevents the recovering veteran from truly conquering trigger-
ing environments and situations, as compared to other treatment alter-
natives (Finley, 2014). Finley raised the issue of canine assistance in fact
possibly impeding a veteran from cultivating their own self-derived
sense of control over stressful situations (Finley, 2014). If canine assis-
tance is in fact an effective treatment modality, what mechanisms en-
able this success? Per Taylor et al. (2015), there is lack of agreement
as to whether or not it is the specific services, protections, and physio-
logic effects that interaction with canines can provide, or if the emotion-
al attachment that an owner develops with the dog is the essential
factor of effectiveness.
Specifics about the best practices of canine assistance for veterans
with PTSD also remain undefined, including what type of dog, level of
training, and protocol for interaction would be most helpful. As CAM
for PTSD in veterans is a relatively young field, much of the evidence
available thus far is anecdotally based. Studies that pursue canine
assistance and its benefits often involve its effects on individuals
exposed to mild, natural stressors, rather than traumatic events (Laas-
Henneman et al., 2014). Currently, clinicians may not include canine
assistance in treatment due to unfamiliarity with resources, lack of
scientifically based clarify regarding the degree to which the dog itself
48 C.A. Krause-Parello et al. / Nurse Education Today 47 (2016) 43–50
aids in the recovery process, lack of standardized protocols, and the vast
number of CAM modalities that are available (Wynn, 2015).
3.3.1.2. Cost and Availability Barriers. Multiple authors discussed
concerns related to the availability and cost of training service dogs.
Although service dogs were only one of the four types of canines exam-
ined in this review, it is critical to consider both their potential costs as
well as their potential benefits. Estimates predict that 8–12% of service
members who have served in Iraq and Afghanistan have returned
with a psychological condition and that 30–35% of these individuals
would meet criteria for PTSD (Taylor et al., 2015). With sophisticated
training for service dogs costing upwards of $20,000, is it realistic to
consider service dogs as a viable adjunct treatment? If so, are the
rewards worth the costs? To decrease costs, Stern et al. (2013) call for
investigation into adoption programs, wherein shelter dogs are rescued
and trained by veterans being guided by the instruction of professional
trainers. This approach could also have the potential to reduce wait
times for service canines, which can be up to two years, during which
the veteran waiting for the dog must continue to cope with the effects
of their PTSD. Yount et al. (2013) discussed that this veteran-training
model is already being implemented by the Warrior Canine Connection
service dog-training program, in which veterans work towards training
service dogs for themselves as well as for other veterans. While the
Warrior Canine Connection dogs are bred specifically for the purpose
of becoming service dogs (taking into account breed, temperament,
etc.). It is suggested by the authors of this review that perhaps a future
collaboration and extension of the program involving shelter dogs with
appropriate temperaments could be explored in order to help in lessen-
ing costs associated with costs that veterans must cover when obtaining
a service dog in particular. It is also vital to note that there is a large and
growing number of volunteer training organizations around the United
States as well as abroad. These organizations may also serve as supports
and potential partners to veterans as they work towards minimizing
costs and optimizing health outcomes throughout the training process.
3.3.1.3. Animal Welfare. Wynn (2015) expressed concern for the welfare
of the animal itself. Canines providing assistance to veterans with PTSD
typically remain in the custody of the veteran. Wynn highlighted con-
cerns that these animals may not have enough access to rest, recovery,
downtime, and routine to remain psychologically healthy themselves.
While it has not been empirically established that the symptoms of
human PTSD are indeed safe for animals to healthfully cope with long
term, it has also not been determined that animals necessarily experi-
ence negative health effects by living with individuals who suffer from
PTSD. Considering the large number of veterans who may potentially
benefit from canine assistance, and the high capacity for individual
differences when it comes to respecting animal welfare, we recommend
that the issue not be viewed in binary. Wynn pointed out the need for
further empirical evidence as the source of the cited concerns and called
for additional, rigorous study as critical to the advancement of canine
assistance as an adjunct treatment for PTSD in veterans.
3.4. Research Question #4
3.4.1. What are the Future Directions Needed for Research Regarding the
Use of Canines for Assistance and Promotion of Healing in a Population of
Military Veterans With PTSD?
Large scale, controlled quantitative investigations on health benefits
to veterans, research which focuses on best practice protocols, as well as
feasibility studies should be done in coming years to progressively and
thoroughly move this research field forward.
3.4.1.1. Future Directions. The literature widely concludes that further
empirical data is needed in order to advance the use and support of
canine assistance for veterans with PTSD. For canine assistance to be
utilized by providers and made an available, reimbursed modality,
thorough and rigorous study is essential. Taylor et al. (2015) suggested
that a large-scale, quantitative investigation involving private, direct
participation with veterans is needed. Wynn (2015) suggested that
the advancement of knowledge relating to CAM modalities such as
canine assistance require “control groups, validated instruments, stan-
dardization of procedures, and appropriate follow-up to measure
sustainment of effect.” In addition to recommendations for methodolo-
gy and rigor, authors suggested that future directions focus on best
practices for canine assistance, cost and benefit to the healthcare
system, and the feasibility of widespread implementation.
The reviewed articles have demonstrated that canine assistance may
aid veterans with PTSD to manage symptoms via numerous mecha-
nisms of effect. By and large, however, it is widely acknowledged that
more studies examining the physiological and psychological effects
that canines have upon veterans must be done to expand and solidify
this field of study. Taking into consideration the various points that
the authors of these articles have made regarding the different human
psychological dynamics and physiological systems that canines have
the capacity to measurably impact, it is clear there are multiple ways
in which this interaction must be further investigated— particularly
with respect to PTSD. It is currently the responsibility of the scientific
community to exhaustively examine these mechanisms to work
towards a more comprehensive knowledge of effective health care in-
terventions for our veteran population.
4. Discussion
Considered cumulatively, this existing research suggested that
canine assistance is an encouraging and non-invasive method for poten-
tially reducing detrimental psychological and physiological symptom-
atology associated with PTSD in veterans. Interacting with canines was
evidenced to support social interactions for isolated individuals, lessen
suicidal ideation as well as depressive symptoms, and reduce stress
and anxiety during analog trauma—all of which are relevant factors to
consider when analyzing interventions which may prove to be specifi-
cally effective for treating PTSD (Taylor et al., 2015; Laas-Henneman
et al., 2014). Additionally, reductions in loneliness, depression, isolation,
worries regarding personal and family safety, and an increase in calm-
ness as a result of living with a canine were demonstrated in a sample
of veterans with PTSD (Stern et al., 2013). Yount and colleagues outlined
the role that oxytocin plays in social and physical wellbeing, the poten-
tial oxytocin-mediating effects that service canines in particular may
have upon veterans, and the relationship between oxytocin and PTSD,
ultimately suggesting that service canines may have effects upon partic-
ular neural systems evidenced to have functional ties to PTSD symptom-
atology (Yount et al., 2013). Wynn analyzed the psychological and
physiological impacts that CAM interventions like canine assistance
may have upon individuals, such as lowered anxiety and depression
symptomatology, and a decrease in blood pressure (Wynn, 2015). He
also stressed the need to consider animal assisted therapies as powerful
supplements to current PTSD treatments. Taylor et al. (2015) further ex-
amined the potential connection between the neuroendocrine freeze/
fight/flight response and canine assistance, positing that assistance
canines may have the potential to ameliorate some of the effects of
this response in the context of hypervigilance associated with PTSD in
a veteran cohort.
The findings of this narrative literature review are critical to delin-
eating the varying ways in which canines may be of vital aid to veterans,
and how fully incorporate canine assistance into current private and
federal systems that support veteran health and wellness within the
United States and beyond. A fundamental understanding of the differing
categories of assistance canines referred to throughout literature on
canine assistance is crucial to designing research and implementing
practical interventions that will give rise to replicable and inventive
studies. Drawing from the various sources reviewed, this paper sought
to organize assistance canines into respective groups. Our article
 C.A. Krause-Parello et al. / Nurse Education Today 47 (2016) 43–50
outlined four main categories of assistance canines—service dogs,
therapy dogs, emotional support dogs, and companion dogs.
While companion dogs may at times be conversationally referred to
as “pets”, Taylor and colleagues noted that the blanket term of “pet”
used by media reporters was possibly damaging to the public's view
of the specialized roles of various assistance canines, and may blur the
lines that differentiate between service dogs, therapy dogs, emotional
support dogs, and companion dogs (Taylor et al., 2015). We support
the assertion that the use of the word “pet” to describe assistance
canines has the potential to contribute to the homogenization of assis-
tance canines. This homogenization may not seem critical in shorthand
conversation; however, delineating the distinct roles of assistance
canines will prove instrumental in shaping the particulars of future re-
search, legislation, and public policy. Vital differences in the unique
niches that these various types of dogs fill are not always obvious to
the layman observer, and this makes it all the more important for the
scientific community to make effortful progress in solidifying our ver-
nacular to establish clear-cut and distinct terminologies regarding
these animals. Future literature on the subject should make every
attempt to group assistance canines into specific and consistent func-
tional categories in order to contribute to a more standardized body of
literature on the subject.
Various authors of the reviewed articles have discussed canine
assistance as an adjunct treatment for PTSD in veterans, rather than a
primary treatment (Yount et al., 2013; Wynn, 2015). The Department
of Defense and VA currently recognize trauma focused exposure
therapy, cognitive restructuring therapy, and stress inoculation therapy
as the primary options for treatment within their protocols for manage-
ment of PTSD (The Management of Post-Traumatic Stress Working
Group, VA, Department of Defense, 2010). Pharmacologically, the FDA
has approved only paroxetine and sertraline as medications appropriate
for use in the treatment of PTSD (Wynn, 2015). The selected literature in
this review suggested that canine assistance should not necessarily be
considered a cure for PTSD, but rather a complementary treatment to
primary therapies, especially for veterans who are not responding as
well as anticipated. Authors cited in this review raised concerns about
lack of protocols, cost and availability barriers, and animal welfare, call-
ing for additional, rigorous research to advance the use of assistance
canines as a treatment for veterans with PTSD.
As service members may avoid traditional therapeutic modalities for
psychiatric disorders due to fear of potential stigmatization, canine
assistance may prove beneficial by providing a continuous, stable,
healing modality outside of the clinical environment (Taylor et al.,
2015). The literature deemed the potential effects of canine assistance
to be both psychosocial and physiological. Taken together these articles
endorse canine assistance for PTSD in veterans as a promising modality.
Notably, Wynn categorized interventions involving canines to be
“complementary” as opposed to “alternative”—an important distinction
to make for researchers, service providers, patients, and the community
at large (Wynn, 2015). This line of thinking should be strongly support-
ed. Canine assistance not be considered to be solely an “alternative” or a
last resort to current methods of treatment. Rather, canine assistance
should be considered seriously as a supportive, adjunctive component
of PTSD treatment. Canine assistance should be treated as an indispens-
able tool with the potential capacity to enhance mental and physical
wellbeing and the ability to innovatively contribute to the thorough,
robust, highly individualized healing of our nation's veterans.
4.1. Limitations
There are methodological limitations related to the trustworthiness
of the results. The search revealed a limited number of published,
peer-reviewed articles on canine assistance for military veterans with
PTSD. In addition this review did not include gray literature, conference
abstracts, and qualitative studies which may be considered a limitation.
There is also the possibility based on the search terms used in this
49
review (e.g. PTSD, veteran, canine, military, dog, and canine assistance)
that other published articles may have used more precise terms and
therefore were not detected within the literature search. This possibility
must be acknowledged as a limitation. Although the inclusion criteria
for this review did not specify that the articles must be in the English
language, we did not search for articles written in languages other
than English.
5. Conclusions
The World Health Organization (2004) described mental health as “a
state of well-being in which the individual realizes his or her own
abilities, can cope with the normal stresses of life, can work productively
and fruitfully, and is able to make a contribution to his or her communi-
ty.” A logical extension of this idea is that positive mental health is the
underpinning of effective reintegration, readjustment, and well-being
for veterans. The consequences of PTSD in military veterans continue
to be a serious problem in the United States; each day an estimated 22
veterans die by suicide (Kemp and Bossarte, 2013). Countless more
veterans and their families struggle with the aftermath of their sacrifice
and service, engaged in an ongoing battle against PTSD. The burgeoning
literature and anecdotal experiences endorse canine assistance as a
promising, adjunct treatment modality for individuals receiving tradi-
tional therapies with less than ideal success. However, at this time, the
VA does not provide reimbursement for service dogs, therapy dogs, or
emotional support dogs for veterans with PTSD This is due in part to
the lack of research needed to better understand the mechanisms of
effect and impact of canines as a disability service for these individuals.
Further commitment from researchers and clinicians is needed in
order to develop the science required to advance the implementation
of canine assistance for veterans with PTSD. Focused psychological
and physiological research utilizing control groups and highly standard-
ized measures will be essential in methodically expanding this field of
inquiry. Collaboration between researchers, clinicians, patients, grass-
roots canine training organizations, dedicated veteran support initia-
tives, as well as animal shelters and rescues will be essential to the
evolution of knowledge regarding the myriad impacts that interacting
with canines may have upon veterans suffering from PTSD. Future stud-
ies should also prioritize focusing upon main points of concern currently
facing providers and researchers with respect to the utilization of canine
assistance for veterans, like optimizing best practices, minimizing
barriers such as the availability and cost of canine assistance, and ensur-
ing that all animal welfare needs are comprehensively met.
Acknowledgement
The authors greatly appreciate the editing assistance of Suzanne
Lareau, MS, RN.
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