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Perspectives: commander's introduction.

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 fixture of law enforcement agencies for most of the last century. Police have also used dogs for tracking offenders and finding 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 first 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 benefits 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 find 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 scientifically 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.

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 firsthand. 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 first 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 first 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 reflect 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 specific and unambiguous, which means, first and foremost, that clear definitions 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 definitions of service animals. Some state statutes address therapy and activity animals, but such definitions 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 specific 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 beneficial 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 benefit 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 findings and opinions as to the benefits 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 findings 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 benefits 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 facilities has not been scientifically 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 reflects a careful, analytic approach to examine factors that are exceedingly difficult 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 significance of the study is reflected in the statement, " is important to note that it is the first 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 benefit 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 first article, MAJ Lorie Fike and her coauthors describe the learning curve; the considerations, concerns, difficulties, and requirements (some anticipated, others not) that were encountered during the first 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 first evolution, lessons-learned 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 first 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 nonprofit 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 benefit to the injured or ill service member is tangible, whether in enhancing the effectiveness of their therapy, or simply increasing their confidence 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 benefit from these efforts.

The next articles describe in detail three of the nonprofit 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, 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 confidence 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 significant need (and demand) for such trained dogs, and the program, in existence since 2006, has shown how two different Warriors can benefit 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 certification as a dog trainer upon completion. The program can be the foundation for entry into the career field of animal services. The program has existed since 2008, and has been an unqualified success, both for the Warriors and the dogs. This excellent article presents a tremendous, uplifting example of another "win-win" undertaking. The Warriors benefit, the dogs benefit, and the families that adopt a Warrior-trained pet are also beneficiaries 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 inflicts 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 first 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 specifically 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 significant tragedy and stress, not always noticed by many, but greatly appreciated by those who benefit from that all too real (albeit difficult to explain) human-animal bond.

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.

MG David A. Rubenstein
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Author:Rubenstein, David A.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Apr 1, 2012
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