International Association of
Assistance Dog Partners
Disaster is not what a trauma victim needs:
Risks and negative consequences of protection dogs for individuals with post traumatic stress disorder
Natalie Sachs-Ericsson, Ph.D.
Associate in Clinical Psychology Florida State University Department of Psychology
The following report is not an originally scientific work on my part but rather a compilation of various articles on post-traumatic stress disorder written by researchers in the field of post traumatic stress disorder (PTSD). The purpose of the following is to inform the reader on the history, symptoms, and etiology of PTSD. Secondly to describe why dogs selected and trained for protection work are inappropriate for public access as assistance dogs for individuals with PTSD.
I am a clinical psychologist on the faculty of Florida State University in the department of psychology. I have general training in treatment of different psychiatric disorders, and teach classes in abnormal psychology. However, post-traumatic stress is not my area of speciality. I am very interested in the area of dogs and their positive impact on the health and psychological functioning of humans and am doing research in this area. I also have experience in selecting and training dogs for individuals with disabilities. For the last five years I have run a small program, Shelter-to-Service, that selects dogs from the shelter, socializes them and sends them to professional assistance dog programs for advanced training.
Because I believe that dogs can considerably enhance the psychological and physical health of humans, it is only after serious thought that I have written this paper to describe the reasons why I believe the use of protection dogs for individuals with PTSD is a very bad idea.
Post traumatic stress disorder
The risk of exposure to trauma is part of the human condition but only recently have we come to acknowledge the long term and severe consequence of trauma to some individuals (Friedman, 2000). It has been reported that more than 60% of men and 51% of women experience at least 1 traumatic event in their lifetimes (Davidson, 2000). Post traumatic stress disorder is the term now used to refer to individuals who acquire a series of disturbing and distressing symptoms in response to a life-threatening trauma.
The history of the development of PTSD as a concept is described by Trimble (1985). In 1980, the American Psychiatric Association added PTSD to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme. The DSM-III diagnostic criteria for PTSD were revised in DSM-III-R (1987) and DSM-IV (1994). Diagnostic criteria for PTSD include a history of exposure to a "traumatic event" and symptoms from each of three symptom clusters: intrusive recollections, avoidance/numbing symptoms and hyperarousal symptoms. A fifth criterion concerns duration of symptoms. The Diagnostic Statistic Manual of the American Psychiatric Association's (DSM-IV) definition of post-traumatic stress disorders (PTSD) is presented in Table 1.
Table 1 DSM-IV Post traumatic stress disorder (DSM-IV)
A. The person has been exposed to a traumatic even in which both the following are present:
The person witnessed or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to physical integrity. The persons responses involve intense fear, helplessness, or horror.
B. The traumatic event is persistently re-experienced in one or more of the following ways:
Recurrent or intrusive recollections of the event, including images, thoughts, or perceptions. Recurrent distressing dreams of the event. Acting out feeling if the traumatic event were reoccurring includes a sense of reliving the experience, illusions, hallucinations, and disassociate flashbacks, (including those that occur on awakening or intoxicated). Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.
C. Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness, as indicated by the three or more of the following:
Efforts to avoid thoughts, feelings or conversations associated with the trauma. Efforts to avoid activities, places or people that arouse recollections of the trauma, Inability to recall aspects of the trauma Markedly diminished interest or participation in significant activities. Feelings of detachment or estrangement from others Sense of foreshortened future.
D. Persistent symptoms of increased arousal as indicated by 2 or more of the following:
Difficulty falling asleep Irritability or angry outbursts Difficulty concentrating Hypervigilance Exaggerated startle response
E. Duration of these symptoms for more than 1 month
F. The disturbance cause clinically significant distress important areas of functioning.
Epidemiology of PTSD
One important finding, is that PTSD is relatively common. Recent data from the national comorbidity survey indicates PTSD prevalence rates are 5% and 10% respectively among American men and women (Kessler et al., 1996). In the general population women have a higher incidence of PTSD after experiencing a trauma than do men. This may be due to the large proportion of women who experience a sexual or physical assault that may more likely to be related to subsequent symptoms of PTSD than other traumatic life events.
PTSD was originally conceptualized as a disorder that occurred in direct response to a potentially life threatening traumatic life event in an otherwise normal individual. However epidemiological research has shown that only a small proportion of individuals exposed to trauma actually develop PTSD (Breslau et al. 1998). Thus it became apparent that exposure to trauma alone was not sufficient in the development PTSD. Two areas of inquiry include the nature of the trauma and individual differences in pre-existing vulnerability markers.
As it would seem intuitively, researchers have found that the more severe the traumatic life event the more likely it is for PTSD to occur. In their review (Halligan & Yehuda, 2000) several factors that place the individual at increase risk for developing PTSD after exposure to a life threatening event were explored. These factors include; environmental risk factors, demographic risk factors, prior psychiatric disorders, dissociation, cognitive risk factors, biological risk factors and familial or genetic risk factors.
Post traumatic stress disorder is more likely to occur among individuals who have a pre-existing psychiatric or personality disorder. If an individual meets diagnostic criteria for PTSD, it is likely that he or she will meet DSM-IV criteria for one or more additional diagnoses (Kulka, et al., 1990; Davidson & Foa, 1993). Most often these co-morbid diagnoses include major affective disorders, dysthymia, alcohol or substance abuse disorders, anxiety disorders, or personality disorders. High rates of co-morbidity complicate treatment decisions concerning patients with PTSD since the clinician must decide whether to treat the co-morbid disorders concurrently or sequentially.
There is a variety of treatment approaches to lessen the severity of PTSD symptoms and decrease the impact of PTSD symptom on the individual's life. I will not attempt to review them here. However, clinicians are cautioned to be sensitive to the fact that common reactions to a traumatic event include lack of trust, and a frightening belief that the world is a very dangerous and threatening place (Janoff-Bullman, 1992). Interventions that decrease hyper-arousal, hyper-vigilance and decrease cognitions of over-estimations of fear and threat are likely to decrease the symptoms of PTSD. Generally, interventions for individuals with PTSD include cognitive-behavioral treatments, exposure, relaxation training, and increasing social support. However, for a most thorough and well written guide in the treatment of PTSD please refer to the Expert Consensus Guide Series: Treatment of PTSD (Foa, Davidson, Frances, 1999; Expert Consensus Guideline Series J Clin Psychiatry 1999;60 (suppl 16), see Table 2.
Table 2: Brief Descriptions of the Most Recommended Psychotherapy Techniques
(Obtained from Foa, Davidson, Frances, 1999)*
Anxiety management (stress inoculation training): teaching a set of skills that will help patients cope with stress:
Relaxation training: teaching patients to control fear and anxiety through the systematic relaxation of the major muscle groups.
Breathing retraining: teaching slow, abdominal breathing to help the patient relax and/or avoid hyperventilation with its unpleasant and often frightening physical sensations.
Positive thinking and self-talk: Teaching the person how to replace negative thoughts (e.g., "I'm going to lose control") with positive thoughts (e.g., "I did it before and I can do it again") when anticipating or confronting stressors.
Assertiveness training: teaching the person how to express wishes, opinions, and emotions appropriately and without alienating others.
Thought stopping: distraction techniques to overcome distressing thoughts by inwardly "shouting stop."
Cognitive therapy: helping to modify unrealistic assumptions, beliefs, and automatic thoughts that lead to disturbing emotions and impaired functioning. For example, trauma victims often have unrealistic guilt related to the trauma: a rape victim may blame herself for the rape; a war veteran may feel it was his fault that his best friend was killed. The goal of cognitive therapy is to teach patients to identify their own particular dysfunctional cognitions, weigh the evidence for and against them, and adopt more realistic thoughts that will generate more balanced emotions.
Exposure therapy: helping the person to confront specific situations, people, objects, memories, or emotions that have become associated with the stressor and now evoke an unrealistically intense fear. This can be done in two ways:Imaginal exposure: the repeated emotional recounting of the traumatic memories until they no longer evoke high levels of distress.
In vivo exposure: confrontation with situations that are now safe, but which the person avoids because they have become associated with the trauma and trigger strong fear (e.g., driving a car again after being involved in an accident; using elevators again after being assaulted in an elevator). Repeated exposures help the person realize that the feared situation is no longer dangerous and that the fear will dissipate if the person remains in the situation long enough rather than escaping it.
Play therapy: therapy for children employing games to allow the introduction of topics that cannot be effectively addressed more directly and to facilitate the exposure to, and the reprocessing of, the traumatic memories.
Psychoeducation: educating patients and their families about the symptoms of PTSD and the various treatments that are available for it. Reassurance is given that PTSD symptoms are normal and expectable shortly after a trauma and can be overcome with time and treatment. Also includes education about the symptoms and treatment of any comorbid disorders.
*the authors of this review also asked experts about eye movement desensitization reprocessing (EMDR), hypnotherapy, and psychodynamic psychotherapy, but they did not rate these techniques highly for the treatment of PTSD.
Cognitive-behavioral interventions (Foa, Steketee, & Olasov-Rothbaum, 1989). have been shown to efficacious in a variety of different psychiatric disorders including PTSD and are used to directly impact the individual's propensity to evaluate benign situations as threatening. Bryant (2000) reports that in the initial aftermath of the traumatic event some individuals experience an exaggerated fear of future threat (Warda & Bryant, 1998) and that this cognitive bias extends to a wide range of potential threats, including social, somatic, and external events (Smith & Bryant, in press). Cognitive Processing Therapy (Resick, 1994).) is specifically tailored for the symptoms that are observed most frequently in treatment of sexual assault victims and combines the work of a number of PTSD theorists. Attention to and treatment of the anger component of PTSD (Gerlock, 1996; Novaco, 1996) is also considered by some as an essential element in trauma recovery work. Anxiety reduction using relaxation training may also be useful in decreasing arousal and fear.
Exposure is a treatment used in many of the anxiety disorders that has also proven to be efficacious. There are different therapeutic approaches to exposure based therapies, however, treatment of PTSD with exposure is difficult for the individual because he or she must relive some very painful experiences.
One of the most important factors for an individual with PTSD is social support. Social support is one of the most important factors in buffering individuals from distress and protecting individuals from relapse from an array of psychiatric disorders (Joiner, 1997). Unfortunately the very nature of some psychiatric disorders cause an increased risk in interpersonal dysfunction leading to conflict, stress and lack of social support (Hokanson, & Rubert, 1991). Some aspects of the symptoms of PTSD often impact the patient's social support system in a negative manner leading to an increase in interpersonal conflict and a decrease in social support.
Thus it must be understood that individuals with PTSD are not easily "cured" through psychotherapy and the therapy itself it stressful. It is no wonder that individuals would try to find creative alternatives for the victims of trauma in order for them to experience their environment as a safer place. Some individuals who undoubtedly have good intentions have proposed the use of protection dogs for individuals with PTSD. However, I believe that public access for protection dogs for victims of crime or trauma is a very inappropriate solution to a real problem. Intuitively it may be appealing for an individual who experiences the world as a threatening place to have a protection trained dog by their side. However, I believe that a protection dog would ultimately have a negative impact on the individual who have PTSD because of the dog's very real potential for attacking an innocent human or another dog.
How do dogs impact PTSD symptoms:
There is a reason why dogs are referred to as man's best friend. They offer a constant source of non-judgmental social support. While there are no empirical studies of the impact of dogs on individuals with PTSD, research on the impact of dogs on the reduction of stress and anxiety in human do suggests that dogs may indeed lower arousal (Sebkova, 1977; Wilson, 1991) and increase feelings of safety (Serpell, 1991).
Why not protection dogs:
All dogs have the potential to bite and cause physical harm or even death to humans. Those of us involved in the assistance dog movement carefully select assistance dogs for training that have no aggression. The most reputable assistance dog programs will excuse any dogs from their program that display aggression to humans or to other animals even under very stressful circumstances in which aggression would seem understandable. It takes a program with a clear set of ethical principles to dismiss a dog for one aggressive incident after literally 20 to 30 thousand dollars worth of training. However, this ethical act is performed routinely in the better assistance dog programs across the US.
Individuals with disabilities accompanied with an assistance dog go everywhere with their dog and into all sorts of stimulating environments. A dog with the potential for aggression will most likely ultimately show it. The consequences can be disastrous. However, it takes a lot of experience to evaluate a dog's potential for aggression.
In contrast to assistance dogs, protection dogs are chosen for their high arousal, high prey drive and aggression potential (Slabbert and Odendaal, 2000). What happens if an individual with PTSD acquires a trained protection dog, a dog that has been selected for its innately high arousal and strong prey drive? The individual with PTSD has high arousal levels and has the propensity to perceive threat where none exists. This is part of the troubling and painful experience of PTSD. A dog is a pack animal and follows his leader. When one member of the pack becomes aroused so do the rest of the members of the pack. Thus the dog reads and processes threat in the environment, in part, through the experience of the owner. The anxiety, fear and hypervigilance of the individual with PTSD will be communicated to the dog. A protection dog is likely to respond to arousal and fear in its owner by potentiating the likelihood for an aggressive response, even when there is no real threat.
What we are talking about is a dog that has been trained by deliberately stimulating his prey drive to elicit aggressive behavior for guard or protection purposes. Some call it "attack training,"others refer to it as "protection training." Such a dog is likely to do what it was selected and trained to do when he feels or perceives threat. The experience of threat is innate in all creatures. However, individuals with PTSD have a pervasive heightened arousal and exaggerated perception of threat. They also have problems with anger control and are more likely than others to become engaged in interpersonal conflicts. How will these emotions impact the protection dog? I believe it will increase the likelihood of aggression towards innocent people or other dogs.
The use of protection dogs by individuals with PTSD places the general population at risk for harm. Secondly, the individual with PTSD may be placed in an emotionally devastating situation if their dog were to attack and harm an innocent individual or another dog. Because of the protection dog's potential for aggressive behavior, an individual that has a protection dog must be hypervigilant of the dog's behavior and constantly be on guard to insure that the dog does not react with aggression in a situation where it is not warranted. In this respect, an individuals with PTSD accompanied by a protection dog in a public setting is likely to experience an enhancement of their hyper-vigilance because the individual must be concerned that the dog will not inappropriately act out aggressively.
Individuals with disabilities have fought a courageous battle to gain their civil rights to equal employment, equal access, and be treated with the same dignity and respect granted to all human beings. The assistance dog movement has worked hard to produce the image of an assistance dog as a safe and obedient dog. What will the public's reaction to individuals with physical disabilities accompanied by an assistance dog become if protection dogs are allowed public access? People will come to fear individuals with trained assistance dogs including individuals with guide dogs to assist the blind, hearing dogs to assist individuals who are deaf or hard of hearing, and service dogs for individuals with mobility related impairments. The use of protection dogs will undermine the public's confidence in all assistance dogs, and further the isolation of individuals with disabilities.
Even though a person has been a victim of a devastating crime I do not think this justifies the endangerment of the general population by sanctioning the use of trained protection dogs for use in public settings. This is not because I do not have the utmost respect for the pain and difficulties of individuals that have any type of psychiatric disorder. Nor do I believe that people with physical disabilities that use trained assistance dogs are more important in some way than individuals with psychiatric disorders. Individuals with psychiatric disorders are often stigmatized, misunderstood, and treated as a second class citizen by the community and by the health system. Their health care is often under funded.
I have the deepest concern and empathy for those individuals who are the victims of trauma and who have developed and struggle with PTSD. My empathy comes from training as a psychologist and my work with individuals who have experienced such trauma. My empathy also comes from my personal life experiences. As a college student I was the victim of a violent crime. This event occurred in addition to other psychological difficulties I was already experiencing at that time. I have experienced many of the symptoms of PTSD. I can not walk down an isolated street at night without significant fear and distress. I have been particularly terrified at times when alone in my house at night. The acquisition of my first dog changed all this considerably. However, there have been times in response to my fear that my dog has over reacted. One time I panicked when I saw a jogger behind me one night when I was out walking my dog. My panic grew as the jogger came closer. My dog usually calm and happy to see strangers of any kind lunged to the end of the leash, growled, and bared his teeth at what turned out be a neighbor. My dog sensed my fear and acted accordingly. If I didn't have strong hold of the leash the consequences could have been quite negative.
In revealing my own story I hope to impress on anyone that may think that those of us who are against the use of protection dogs for victims of crime are insensitive to their situation. In contrast I encourage those with such problems that feel they have the capacity to bond with a dog and have the ability to care for a dog to obtain a well behaved dog, with a solid temperament that has no aggression. I believe such a dog will significantly enhance the person's psychological, social, and health functioning.
I hope others with experience in training protection dogs will attest to the dangerousness of protection dogs in public settings. There are unscrupulous individuals in all walks of life and this includes dog trainers. Many states do not require certification for the training and selling of protection dogs. Therefore anyone can claim that he or he is an expert trainer of protection dogs. Because people want to make money, there may be trainers who will claim that their protection dogs are 100% safe in a family or public setting. Some will claim that by limiting the agitation phase of protection training so that the dog is only lunging, barking and growling and not yet schooled in bite work, this means the handler and the public have nothing to worry about. However, trainers of protection dogs who have considerable experience, are licensed for protection work, and have incomes that are not solely based on protection dogs should be consulted regarding their opinion of the use of any protection trained dog among the general public. I believe most will tell you that dogs trained to respond with any level of aggression on command should not be given public access with anyone but highly trained law enforcement personnel.
Potential aggression must be carefully evaluated in assistance dogs because they are constantly exposed to situations that would provoke aggression even in the average dog. Incidents in which assistance dogs are accidentally hurt, have a door closed on the dog's foot, or in which a curious child runs up and hugs the dog from behind are things that happen routinely in training assistance dogs in public settings.
What type of response would a protection dog show if little Johnny runs up to hug the dog? The dog can not discriminate between a benign and possibly intrusive child and an actual threat. If the child continues to rush the dog, a trained protection dog is far more likely to react with a bite than to retreat from this perceived threat. Little Johnny is at grave risk of being mauled.
Many children are frightened by dogs and when they encounter assistance dogs or dogs in training it is not uncommon for the child to scream, flail their arms and to run. This type of behavior is also extremely provocative to a dog with a high prey drive, especially a dog trained for protection work.
In short there are many circumstances in a public setting that are very provocative to dogs. This is why we must be diligent and dismiss any dog from an assistance dog program that shows aggression. I believe protection dogs trained for personal defense that have public access are likely to show aggression leading to significant harm of individuals when there is no real threat to their owner.
I encourage all those involved with the assistance dog community, individuals who have experienced severe trauma, and friends and family of victims of trauma to recognize that the use of protection dogs for individuals with PTSD or other anxiety disorders is a formulation for disaster. Disaster is not what a trauma victim needs.
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