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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Psychol Trauma. 2021 Feb 25;14(3):347–356. doi: 10.1037/tra0001021

Expectations versus Experiences of Veterans with Posttraumatic Stress Disorder (PTSD) Service Dogs: An Inductive Conventional Content Analysis

Leanne O Nieforth 1, Kerri E Rodriguez 2, Marguerite E O’Haire 1
PMCID: PMC8483598  NIHMSID: NIHMS1738422  PMID: 33630635

Abstract

Objective:

The objective of this study was twofold; to describe the benefits and drawbacks of a PTSD service dog from the perspective of Veterans with service dogs and to compare these reports to the expectations of Veterans who were on a waitlist for a PTSD service dog.

Method:

A total of 128 United States post-9/11 Veterans with PTSD were recruited from a nonprofit service dog provider (K9s For Warriors), including n=69 with a PTSD service dog and n=59 on the waitlist. Participant responses to open-ended survey questions were analyzed with a conventional content analysis and classified into 214 codes across six sub-themes creating three larger themes. A subset (20%) of the data was independently coded to establish inter-rater reliability (Cohen’s Kappa = .804). Frequency data was used to compare theme and subtheme prevalence between groups.

Results:

Veterans’ experiences and expectations were centered upon the effects the service dogs had on Veteran mental health, human-dog interaction, and the associated drawbacks. Although the majority of Veterans reported benefits from their service dogs, findings revealed veterans on the waitlist more frequently mentioned benefits than those with a service dog. Study findings suggest that the drawbacks expected from service dogs differ from the drawbacks experienced.

Conclusion:

Understanding expectations versus experiences provides critical information for mental health professionals that are informing veterans on individualized interventions for PTSD. This knowledge will enable professionals to temper expectations and educate veterans on specific benefits and drawbacks so that they have a more rounded view of PTSD service dogs.

Keywords: Posttraumatic Stress Disorder, Military Veterans, Service Dogs, Human-Animal Interaction, Health Expectations

It is estimated that up to 23% of post-9/11 Veterans have posttraumatic stress disorder (PTSD; Fulton et al., 2015). A wide variety of evidence-based, effective PTSD treatment options exist (e.g., cognitive processing therapy, exposure therapy, eye movement desensitization and reprocessing (EMDR), pharmacotherapy). However, although these treatments can provide clinical improvement for PTSD symptoms for some Veterans, up to two thirds of Veterans retain their PTSD diagnoses after participating in cognitive processing therapy or prolonged exposure therapy (Steenkamp et al., 2015). Additionally, some treatment options for PTSD have been demonstrated to have low enrollment rates and high dropout rates (e.g., Steenkamp et al., 2015). One study of 49,425 Veterans found that only 9.5% of Veterans with newly-diagnosed PTSD attended nine or more mental health sessions within the first year (Seal et al., 2010). Other studies found that only 38-45% of veterans who met criteria for mental health disorders indicated that they wanted to seek out empirically-based treatment (cognitive processing, exposure therapy and EMDR), with nonresponse rates as high as 50% (Hoge et al., 2006; Schottenbauer et al., 2008). Seeking treatment is often stigmatized as a sign of weakness in military culture (Fragedakis & Toriello, 2014); therefore, Veterans may often remain in denial of the effects of their traumatic experiences in an effort to avoid this negative stigma. Complementary interventions with limited stigma may be necessary to reach Veterans with PTSD, as reducing stigma may contribute to increased participation and completion rates for Veterans receiving PTSD treatment (Davis et al., 2014; Mittal et al., 2013).

One emerging complementary intervention for PTSD is a psychiatric service dog, specially trained to assist in mitigating a Veteran’s PTSD symptoms (e.g., Scotland-Coogan, 2019) while potentially carrying less stigma than a traditional intervention (Taylor, Edwards, & Pooley, 2013). Service dogs are different from emotional support or therapy dogs as they are trained to do specific tasks to mitigate a disability whereas an emotional support or therapy dog is not trained to do specific tasks (Hoy-Gerlach et al., 2019). Some service dog providers train the dogs and then pair them with Veterans, while other providers instruct the Veterans to train the dogs themselves as part of a therapuetic process (Vincent et al., 2019).

Recent quantitative and qualitative studies have concluded that service dogs may be a promising adjunct intervention for military Veterans with PTSD. In quantitative studies using versions of the PTSD Checklist (PCL), findings suggest lower PTSD sympotology among those with service dogs compared to those on the waitlist in both cross-sectional (O’Haire et al., 2018; Yarborough et al., 2017) and longitudinal (Vincent, Dumont et al., 2019) studies. Service dogs have also been associated with improvements in Veterans’ sleep quality, depression and anxiety, and overall quality of life (Rodriguez et al., 2018; Vincent, Dumont, et al., 2019). Supplementing the quantitative research on this topic, qualitative research supports these findings. One study held focus groups and semi-structured interviews with Veterans (N=9) with PTSD or TBI and found that service dogs helped Veterans move from isolation to reintegration, navigate daily life, facilitate social opportunities, and reclaim their life through an overarching theme of acting as a calming catalyst (Crowe et al., 2018). Another qualitative study which interviewed Veterans who utilized service dogs (N=21) suggested that PTSD service dogs positively influenced veteran physical and psychosocial functioning through providing social support and coping resources (Krause-Parello & Morales, 2018). Veterans also report that having a PTSD service dog reduces hypervigilance, improves sleep quality (N = 41, Yarborough et al., 2018) and helps them remain present in situations due to the dog’s ability to disrupt re-experiencing episodes (N = 7, McLaughlin & Hamilton, 2019). While informative, these initial qualitative studies focus on relatively small sample sizes and do not focus on the comparison of the expectations (waitlist) versus experiences of service dog partnership. This study aims to fill this gap.

While both qualitative and quantitative findings suggest meaningful effects of service dogs for PTSD symptoms, further research is necessary to define the therapeutic components of PTSD service dogs. Potential mechanisms for how the human-canine relationship may contribute to the development of positive regard and reassurance in stressful situations for Veterans include stress-buffering, social support theory, and attachment theory (Crowe et al., 2018; Rodriguez et al., 2018; Whitworth et al., 2019). Veterans with PTSD service dogs were found to have significantly altered cortisol profiles compared to a control group of Veterans on the waitlist, suggesting potential effects to the stress response system (Rodriguez et al., 2018). The therapeutic benefits of service dogs have also been examined through the lens of the perceived social support they offer the Veteran in terms of the reassurance they provide as well as the increasing sense of purpose they offer (Crowe et al., 2018). Attachment theory offers a unique theoretical perspective as a potential explanation for Veterans’ changes in social functioning after receiving a service dog (O’Haire et al., 2018) because the Veteran-service dog bond may decrease veterans’ insecure attachment and relational avoidance by forming a bridge to foster relationships with family members and friends (Whitworth et al., 2019). These theoretical explanations have primarily been associated with the positive benefits of service dogs; however, Veterans have also reported drawbacks and difficulties associated with PTSD service dogs. Having a PTSD service dog can lead to unwanted attention and intrusive questions for the veterans as well as challenges in terms of procurement of the dog and grieving the death of the dog (e.g. Krause-Parello & Morales, 2018).

As the prevalence of the service dog-Veteran partnership continues to increase, there remains a need within the literature for a focus on the differences between what Veterans expect of their service dogs versus what they actually experience with their service dog. Expectations and subsequent experiences have been demonstrated to influence the effectiveness of therapeutic interventions (Seligman et al., 2009). Studies on cognitive-behavioral interventions for PTSD found that when expectations and experiences match, there is a positive effect on attendance, client satisfaction, and overall quality and perceptions of therapeutic outcomes (Constantino et al., 2011; Price et al., 2015). In addition, having high expectations or being hopeful has been shown to ameliorate PTSD symptoms and offer enhancement of the beneficial outcomes related to an intervention (Gilman et al., 2012). On the other hand, discrepancies between expectations and experiences can have negative effects that can lead to poorer outcomes, including dropping out of treatment or returning the dog to the provider (Vincent, Auger, et al., 2019).

The objective of the current study was twofold: (1) to describe the benefits and drawbacks of having a PTSD service dog from the perspective of Veterans with service dogs and (2) to compare these reports to the expectations of Veterans who on the waitlist. Most studies thus far have focused on the positive aspects of Veteran’s experiences with service dogs. This study is unique in that it not only describes the benefits of PTSD service dogs, but also the drawbacks. The phenomenological approach captures Veterans’ first-hand experiences of the service dog intervention thus directly informing the feasibility and acceptability of the intervention. Understanding the Veteran’s expectations of their service dogs will not only further define therapeutic mechanisms but will also provide insight as to how to optimize service dogs as a complementary intervention for veterans with PTSD.

Methods

The University Human Research Protection Program Institutional Review Board (IRB Protocol # 1504015973) approved this study. Institutional Animal Care and Use Committee (IACUC) approval was waived because no interactions occurred between researchers and dogs.

Participants

Participants were recruited and approved for a service dog through K9s For Warriors, a national nonprofit organization providing service dogs free of cost to military Veterans and service members with PTSD. Inclusion criteria for approval by the K9s For Warriors program included: a community diagnosis of PTSD, traumatic brain injury (TBI), or military sexual trauma (MST) from a physical or mental health provider, United States post-9/11 military service with either honorable discharge or current honorable service, free of substance misuse, no more than two pet dogs in the home, and no conviction of crime against animals. To be included in the study, Veterans also had to meet the diagnostic cutoff for PTSD on the PTSD Checklist (PCL; Weathers et al., 1993).

A total of N=144 Veterans participated in the online survey portion of the larger study. Veterans were excluded from the final sample (n=16) if they did not completely fill out the qualitative portion of the survey (n=14) or if they had duplicate surveys in the database (n=2). The final sample of 128 Veterans (Appendix A) included n=69 previously placed with a PTSD service dog and n=59 on the waitlist to receive a service dog. Participants were mostly male (103 males and 25 females) with an average age of 37.9 years old (range 22-60 years, SD=8.38).

Participants both on the waitlist and with a service dog had unrestricted access to their usual care. At the time of their participation in the study, participants on the waitlist had been waiting for a service dog an average of 7.5 months since their applications had been approved by K9s For Warriors (range of 2.1-18.7 months, SD=4.3). Participants with a service dog had received their PTSD service dog an average of 51.5 months prior to participating in the study (range of 3-121.7 months, SD: 33.3). To receive their service dogs, Veterans attended a 3-week training program on site at K9s For Warriors in Ponte Vedra, FL. During this program, Veterans learned how to care for and interact with their new service dog alongside 6-10 other veterans for a minimum of 120 hours of hands-on training. Service dogs were primarily Labrador Retriever-mixed breeds sourced from local shelters. Service dogs received a minimum of 60 hours of training with K9s For Warriors dog trainers prior to the 3-week program with the Veterans.

Procedures

Participants were recruited by the research team with an invitation in the mail and a follow-up phone call invitation. After voluntary informed consent, study participation included an online survey and two-days of saliva collection. Veterans were compensated $20 for reviewing materials, $20 for completion of the survey, and $20 for completion of saliva sampling. Previously published papers have presented the quantitative (O’Haire et al., 2018) and physiological (Rodriguez et al., 2018) outcomes of this study.

Measures

This study represents the qualitative survey data collected from open-ended questions asked in an online survey. The use of qualitative responses independent of standardized surveys was pursued to capture participants’ individual experiences and expectations in their own words. The first question asked was, “What is (or what do you expect will be) the most helpful aspect of having a service dog?” The second question asked, “What has (or what do you expect will be) the service dog been trained to do that helps the most?” and the third question asked, “What are (or what do you expect will be) the drawbacks of having a service dog?” The final question asked, “Is there anything else you would like to share to advance the science and understanding of service dogs?”

Analysis

An inductive conventional content analysis was employed to analyze the differences between Veterans’ expectations and experiences of PTSD service dogs (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). All coding and analyses were conducted with NVIVO 12 qualitative data analysis software (QSR International, Melbourne, Australia, 2015). Three phases occurred in the analysis process Preparation, Organizing and Reporting (Elo & Kyngäs, 2008). During the first phase, Preparation, the research team determined that the unit of analysis would be the written responses from each individual rather than individual questions. The research team also immersed themselves into the data through recurrent readings in order to become very familiar with the data as a whole. During the next phase, Organizing, themes were determined directly from the data through a process of open coding. The process entailed continued readings of the entire dataset and assignment of codes based on single phrases within responses. When a response contained multiple phrases, two codes were assigned (e.g., “[my service dog] will help me by reducing my anxiety when out in public and by helping me to sleep better” would receive the codes Getting Out, Anxiety and Night). Phrases that were obscure were coded as Uncodable, phrases that were repeated within the same response were coded as Redundant, and phrases that were unclear were coded as Ambiguous. Twenty percent of the total responses were randomly selected and coded independently by two members of the research team in multiple rounds to reach inter-coder reliability (Cohen’s kappa = 0.804). After inter-coder relatability was established, one individual went on to code the dataset in its entirety based upon the categories within the codebook that had been created. Once the dataset was coded in its entirety, a total of 214 codes were organized into 45 categories. These categories emerged from multiple discussions between the research team members as we worked to group similar and disimilar codes together into higher order headings (Burnard, 1991). The categories were then grouped into six subthemes created by comparing data and sorting based on comparison, which were then compiled into three themes: (1) Mental Health, (2) Human-Dog Interaction, and (3) Drawbacks (Dey, 1993). In the final phase of the process, Reporting, the frequency of each category within veteran responses was analyzed to quantify veterans’ expectations versus experiences. Appendix B presents the percentage of veterans with a service dog (Service Dog) versus the percentage of veterans on the waitlist (Waitlist) that expressed each category within their responses.

Results

Theme #1: Mental Health

Almost all Veterans with service dogs (97%) and on the waitlist (100%) reported how service dogs did, or were expected to, benefit their overall mental health. Responses were captured with 26 categories that were collapsed into the overall theme of Mental Health with 4 subthemes: Daily Life (5 categories), Cognition (5 categories), Emotion Management (10 categories), and Interpersonal Skills (6 categories).

Subtheme: Daily Life.

The most commonly cited aspects of mental health were related to improvements in daily life and changes in general routines and activities. Among Veterans with service dogs, a majority (59%) described the effect of their service dogs on getting out and the emotions connected to being in public places. One Veteran shared, “[my service dog] has allowed me to go to crowded public places to support my children’s activities that I previously would not have gone to.” There were also frequent mentions of improvements related to quality of life (41%) and returning to normalcy (30%). Veterans with service dogs shared responses such as “[I am] able to get back into society and do normal things such as shopping during the day and driving” and “[my service dog] has definitely improved my life in so many ways and has given me a better outlook overall.” One fourth (26%) of Veterans with a service dog described benefits related to nights, such as the dog providing comfort, “at night, when I am my most restless, I have [my service dog] for company.” Other references to nights included the service dog’s effects on reducing nightmares or improving sleep (“he sleeps with me and wakes me up from nightmares”). Veterans with service dogs also mentioned medication-related benefits (23%), including a reduction of their medications and the ability of their service dogs to remind them to take daily medications. When comparing expectations from Veterans on the waitlist to experiences of Veterans with a service dog regarding mental health benefits, minimal differences were observed.

Subtheme: Emotion Management.

Among Veterans with service dogs, the most commonly reported benefit to emotion management was related to anxiety (29%). One Veteran shared that the most helpful thing about her service dog was to “be able to walk through life knowing that if I were to have an anxiety attack it wouldn’t be the end of the world, I would have my battle buddy [service dog] to get through it.” Veterans also mentioned how their service dogs brought them peace (23%), such as “an incredible sense of peace and overall happiness.” Benefits regarding PTSD symptoms were also frequently mentioned among veterans with service dogs (20%). According to one Veteran, her service dog helped her to “find ways to manage PTSD symptoms so that she could be a part of society again.” Veterans also mentioned that their service dogs helped them manage their emotions (17%), anger (16%) and depression (14%). “[My service dog] can sense my emotions and help support me,” explained one Veteran. Veterans also shared that their service dogs helped them with safety (10%), hypervigilance (10%) and stress (4%). One Veteran shared, “my irritability, anger, hypervigilance, paranoia and mood have all improved.” Some Veterans also shared that their service dogs helped them to have better self-understanding (3%).

Veterans on the waitlist were more likely to describe emotion management compared to those with a service dog. The largest difference was in the category anxiety (34% difference). Additionally, more Veterans on the waitlist described their future service dogs benefiting stress (18% difference), emotion (17% difference), depression (15% difference) and safety (10%) than described by veterans with a service dog. Other categories had minimal differences between waitlist expectation and Veteran experience (range 1-5%).

Subtheme: Interpersonal Skills.

Among Veterans with a service dog, the most common category within the Interpersonal Skills subtheme was relationships (44%), or the service dog’s ability to help with the interactions they had with their families and friends. One Veteran shared, “[my service dog] has allowed me to become the father and husband I am supposed to be. I could not be more grateful.” Veterans’ responses also often mentioned reintegration (14%) with regards to getting involved in their community with the help of their service dog. One Veteran shared, “I went from a suicidal mess to President of my college’s honor society, published writer, student senator and my family life is better than it has ever been.” In addition, Veterans referenced their service dog’s impact on loneliness (10%) and independence (10%). One Veteran shared, “I can go out in public…talk to strangers…I feel less lonely.” Responses from Veterans with service dogs also related to crowds (6%) or feeling more comfortable in crowded places.

When comparing responses between groups, Veterans on the waitlist more often described future benefits regarding interpersonal relationships compared to those with a service dog in all categories except for reintegration. The biggest differences were in crowds (13% difference) and loneliness (12% difference). Other categories had minimal differences, suggesting that expectations and experiences were similar (range: 4-7%).

Subtheme: Cognition.

In terms of Cognition, or thought processes, Veterans with service dogs most often referenced coping skills (20%). One Veteran shared that a goal that he had achieved with his service dog was to get “a better grasp on symptoms with a strong set of coping skills.” Responses from Veterans with service dogs also mentioned increases in concentration (14%), confidence (8%) and attitude (8%). There were minimal differences observed between the service dog and waitlist group across all categories (range: 1-4%).

Theme #2: Human-Dog Interaction

Nearly all Veterans with service dogs (97%) and on the waitlist (95%) referenced the human-dog interaction. Responses were captured with 9 categories divided into 2 subthemes: Trained Tasks (7 codes) and Dog as a Positive Companion (2 codes).

Subtheme: Trained Tasks.

To be considered a service dog by the ADA (Americans with Disabilities Act, 2010) PTSD service dogs must be trained to do specific tasks to mitigate a disability. Veterans’ responses most commonly contained the trained tasks of alert (41%, nudging or licking to alert to Veteran distress or anxiety), cover (32%, standing behind Veteran and alerting to approaching people) and block (26%, standing behind the veteran to create personal space). One Veteran with a service dog shared, “[my service dog] alerts on anxiety. If I am anxious she won’t leave me alone, it’s all about giving me a paw or a hug.” Veterans also mentioned the categories re-focus (16%), brace (14%, to help with balance or mobility) and daily activities (9%) which included providing a daily routine for the Veteran and retrieving objects for the Veteran. One Veteran shared that the most helpful task her service dog does is “blocks people from getting too close and forces me to focus on her when I have rage episodes.”

Veterans with service dogs mentioned task-related benefits more often than the waitlist. The biggest differences were for block (11% difference) and cover (10% difference). There were also moderate differences in mentions of brace (6% difference) and in help with daily activities (5% difference). The other tasks had minimal differences (range: 1-2%).

Subtheme: Dog as a Positive Companion.

Responses about the dog as a positive companion included benefits from the dog’s companionship or presence. Responses most commonly referenced positivity (81%). One veteran shared, “my service dog helps me feel at ease and happy despite symptoms of PTSD that might arise.” Veterans also mentioned companionship (39%). Another veteran shared, “[my service dog gives] constant companionship, I know he is always by my side. We are always together.” Compared to the waitlist, Veterans with service dogs more often mentioned dog positivity (15% difference), and less often mentioned dog as a companion (22% difference).

Theme #3: Drawbacks

Both Veterans with service dogs (75%) and on the waitlist (68%) mentioned drawbacks associated with PTSD service dogs, captured across 10 categories. Among Veterans with service dogs, the most commonly cited drawback was increased public attention (43%). One Veteran shared, “I get too much attention from people and too many personal questions.” Others included public perception (25%), access (17%), and travel (17%). One Veteran shared, “People at times can be misinformed about service dogs and I do not always feel like being an educator. I just want to get through shopping or a meal without looks or questions.” Lower frequency responses included maintenance (13%, overall dog care and time spent), adjusting (12%), and stigma (6%).

When comparing Veterans with service dogs to those on the waitlist, there was substantial variability. Half of the drawbacks (5 categories) were described more often by those with service dogs (range: 3-23% difference), while the other half (5 categories) were described more often by those on the waitlist (range: 3-10% difference). Key areas that were higher among those with service dogs included attention (23% higher), perception (15% higher), travel (12% higher), and access (9% higher). Areas that were lower among those with service dogs included costs (10% lower), maintenance (9% lower), and stigma (8% lower).

Discussion

This study aimed to describe the benefits and drawbacks of having a PTSD service dog from the perspective of Veterans with service dogs, and to compare those reports to the expectations of Veterans on the waitlist. Three overarching themes emerged, including: (1) Mental Health, (2) Human-Dog Interaction, (3) Drawbacks.

PTSD Service Dogs for Mental Health

The most commonly referenced mental health benefits experienced by veterans with a service dog were the ability to get out into society (59%), increased quality of life (41%), improved relationships (38%), the ability to return to normal life (30%) and decreased anxiety (29%). This is in agreement with previous quantitative and qualitative studies that have described the benefits of PTSD service dogs for military Veterans. Specifically, cross-sectional studies from this same population have observed that compared to the waitlist, Veterans with PTSD service dogs report less anxiety, an increased ability to get out into the community, and increased quality of life (O’Haire et al., 2018; Rodriguez et al., 2018). Qualitative studies have described how PTSD service dogs can lead to decreased anxiety, the ability to get back to normal life, and improvements with interpersonal relationships (Crowe et al., 2018; Scotland-Coogan, 2019).

Veterans on the waitlist expected future benefits to their mental health more often than experienced by veterans with service dogs. Specifically, Veterans on the waitlist described 22 out of 26 mental health-related categories more often than Veterans with a service dog. This suggests that mental health benefits were at the forefront of Veteran’s anticipations for their future service dogs. Some previous literature that has demonstrated that being hopeful and having high expectations can reduce PTSD symptomology as well as have a positive effect on client satisfaction and therapeutic outcomes (Gilman et al., 2012; Noble et al., 2001). However, other studies have demonstrated that discrepancies between expectations and experiences are associated with negative effects on treatment outcomes (Noble et al., 2001; Vincent et al., 2019). Given the discrepancy of expectations and experiences regarding service dog influence on mental health in this data, future research should consider how to balance hopefulness with realistic expectations for maximal outcomes.

Human-Dog Interaction

The role of the human-animal bond in the service dog-Veteran partnership was clearly represented in both responses for Veterans on the waitlist as well as Veterans with a service dog. Nearly all Veterans with service dogs (97%) referenced human-dog interaction in their responses, suggesting that the perceived value of service dogs extends beyond the task-oriented components of the relationship. Specifically, Veterans in this study described how their service dogs brought positivity into their lives (81%) as well as the companionship (39%). Similarly, previous studies have found that Veterans report high levels of interpersonal closeness with their service dogs (LaFollette et al., 2019) and suggest that service dogs can offer valuable emotional and social support (Crowe et al., 2018; Krause-Parello & Morales, 2018).

Responses from Veterans on the waitlist did not contain descriptions of positivity to the degree mentioned by Veterans with service dogs. This suggests that Veterans on the waitlist potentially underestimate the power of the human-animal relationship that they will experience. It also suggests that the benefits of service dogs may go beyond simple companionship and offer additional insight to the interaction between Veteran and service dog. The positivity associated with the partnership could nurture optimism for the Veteran, and previous literature suggests that optimism may be a protective factor for PTSD (Rauch et al. 2013).

In addition to insight into the Veteran service dog partnership, this study offers new insight into the use of PTSD service dogs’ trained tasks. The variety of tasks mentioned throughout responses indicates the individuality of each service dog-Veteran pair in terms of which tasks Veterans find to be the most useful based on their unique PTSD symptoms (Rodriguez et al., 2020). Veterans with service dogs more frequently mentioned trained tasks than Veterans on the waitlist. This may indicate that those on the waitlist have less fine-tuned knowledge of the terminology and specific tasks they will learn with their future service dogs. A previous study showed that differing expectations and inability to maintain training of the service dog led to veterans dropping out of service dog interventions (Vincent, Auger, et al., 2019). Establishing clarity of service dog tasks to Veterans on the waitlist may mitigate the discrepancies between expectations and experiences that could potentially lead to negative outcomes from the intervention.

Drawbacks

When asked what the drawbacks of a service dog were, Veterans with service dogs most frequently mentioned issues with unwanted attention (43%), access to public places (17%) and travel (17%). These drawbacks have also been reported in previous qualitative literature (Krause-Parello & Morales, 2018; Vincent, Auger, et al., 2019; Yarborough et al., 2018). It is possible that Veterans assume that the public is more informed about appropriate behavior around service dogs than holds true. Many people are inherently drawn to animals and want to interact with them (Wilson, 1984), such that actively ignoring an animal and withholding interaction is challenging. Limitations to public knowledge of service dogs may also be in part caused by widespread confusion of service dogs, therapy dogs, and emotional support animals (Rauch et al., 2013). PTSD service dogs are trained to do specific tasks that mitigate symptoms of a Veteran’s PTSD, whereas emotional support animals are not trained to do specific tasks and are not legally allowed public access (Hoy-Gerlach et al., 2019). Multiple participants mentioned having issues while in public with their service dogs because they were accused of having a “fake service dog” or because people demanded identification or certification that they had a “real service dog.” In fact, research has found that those with an invisible disability (like PTSD) experience doubts about the legitimacy of their service dogs more than those with visible disabilities (Mills, 2017). Multiple states have instituted laws that attempt to decrease the number of fraudulent service dogs (Wisch, 2019), but this issue remains ongoing. The public’s misunderstanding regarding the legitimacy of service dogs may exacerbate situations for veterans who may already be uncomfortable in public spaces (Yarborough et al., 2018).

When comparing expected versus experienced drawbacks, Veterans on the waitlist expected both the costs and maintenance of the service dog to be more of a drawback than experienced by Veterans with service dogs. In this study, service dogs were provided free of charge, so costs refer to care of the dog after pairing (e.g., veterinary care). Previous literature on assistance dogs also reports drawbacks related to costs and maintenance (e.g., training practice, scheduling veterinary appointments; Krause-Parello & Morales, 2018; Lessard et al., 2018; Rodriguez et al., 2019). In a study of service dogs for individuals with disabilities, researchers found that caregivers report spending more than 6 hours a week and more than $1,000 a year caring for and maintaining a service dog (Davis et al., 2004). However, many Veterans in this study mentioned that although their service dogs did cost a significant amount of money and required ongoing maintenance, it was “worth it” based on what they received in return from the interaction. With the bonds built between veterans and service dogs, costs were viewed as a necessary sacrifice rather than a significant burden.

Educating Veterans on potential drawbacks of service dogs prior to placement may present a more well-rounded representation of the service dog experience. In therapy settings, understanding the process of the intervention prior to participation has been associated with more positive perceptions of the therapeutic relationship and quality of the intervention (Lambert & Lambert, 1984). Thus, educating Veterans about the process and potential drawbacks they may experience in having a service dog could be important for its perceived success. In addition, it may be valuable to encourage Veterans who already have service dogs to share their own experiences and expectations. In fact, previous reintegration interventions for military Veterans with PTSD have benefited from this peer support approach (Brown et al., 2016; Greden et al., 2010). Future studies should consider analyzing a peer support approach to minimize discrepancies between expectations and experiences of service dogs for Veterans with PTSD.

Limitations & Future Directions

There are several limitations to this study. The cross-sectional nature gives insight into only one particular time point of the service dog-Veteran partnership. At the time of surveying, some of the participants had recently acquired their service dogs while others had been paired with their dogs for many years. In addition, this study recruited participants from a single service dog organization. It is unclear how the organization itself influenced how the Veterans framed their expectations and experiences. Therefore, results may not be generalizable to experiences with self-trained PTSD service dogs nor other service dog organizations with different protocols and processes (Vincent, et al., 2019). There also may be a selection bias present such that Veterans with service dogs who were motivated to participate voluntarily may have experienced more positive outcomes than those who declined to participate. Finally, data was collected via an open-ended survey. This method allowed for Veterans to express their expectations and experiences in their own words but was limited in that there was no ability to assess the severity of statements or to ask follow-up questions. Better richness and depth of the data would be available if questions were asked in an interview setting rather than as open-ended response questions on an online survey. Future studies should consider comparing experiences between new partnerships and older partnerships and should examine expectations and experiences over multiple training options and organizations.

Conclusion

The purpose of this study was to describe the benefits and drawbacks of having a PTSD service dog from the perspective of Veterans with service dogs and to compare these reports to the expectations of Veterans who were on a waitlist for a PTSD service dog. Qualitative analysis of Veterans’ responses revealed three themes: Mental Health, Human-Dog Interaction, and Drawbacks of service dogs. The most commonly reported benefits from Veterans with service dogs were the service dog’s ability to help Veterans get out into the community as well as the positivity that the service dog brought into Veterans’ lives. The most commonly mentioned drawback from Veterans with service dogs was the increased attention they received in public due to the presence of the service dog. Though Veterans with service dogs reported a variety of benefits, Veterans on the waitlist expected service dogs to help with mental health symptoms more often than Veterans with service dogs experienced. Additionally, Veterans shared that they used different service dog tasks than expected by Veterans on the waitlist. Understanding the differences between expectations and experiences may inform Veterans considering applying for a service dog, mental health professionals who advise clients on appropriate interventions, and service dog provider organizations that partner and train Veteran service dog pairs. This understanding may help to set realistic and evidence-based expectations for the service dog-Veteran partnership.

Clinical Impact Statement:

This study illuminates the experiences of Veterans with PTSD service dogs and compares these experiences to expectations of Veterans who are on the waitlist for a service dog. Discrepancies between expectations and experiences may inform mental health practitioners as they determine if a PTSD service dog is an appropriate intervention for clients with PTSD.

Data Transparency Statement.

The data reported in this manuscript were collected as part of a larger data collection. Findings from the larger data collection have been reported in separate manuscripts. MS 1 (published) focused on quantitative survey data, while MS 2 (published) focused on biomarker data. MS 3 (the current manuscript) focuses on qualitative survey data which has not been analyzed previously.

Acknowledgments:

This publication was made possible with support from Grant Numbers, KL2TR001106, and UL1TR001108 (A. Shekhar, PI) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award. This publication was also supported by Grant D15HA-031 from the Human-Animal Bond Research Institute (HABRI) and Bayer Animal Health. Thank you to K9s For Warriors for their continued partnership. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or other funders.

Appendix A

Demographic characteristics

Service Dog
(n = 69)		 Waitlist
(n = 59)		 t or χ2 p
Age, M (SD) 38 (8.6) 38 (8.2) −0.36 0.72
Branch, n (%) 0.79 0.85
 Air Force 9 (13%) 6 (10%)
 Army 44 (64%) 39 (66%)
 Marines 7 (10%) 8 (14%)
 Navy 9 (13%) 6 (10%)
Education, n (%) 1.79 0.77
 Some High School 6 (8.7%) 3 (5.1%)
 High School/GED 42 (61%) 32 (54%)
 Some College 13 (19%) 15 (25%)
 2-year Degree 7 (10%) 8 (14%)
 4-year Degree 1 (1.4%) 1 (1.7%)
Employed, n (%) 16 (23%) 21 (36%) 1.82 0.18
Marital Status, n (%) 6.96 0.07
 Divorced 11 (16%) 13 (23%)
 Married 54 (78%) 34 (60%)
 Separated 0 (0%) 2 (3.5%)
 Single 4 (5.8%) 8 (14%)
 Unknown 0 (0%) 2 (3.5%)
Sex, n (%) 0.78 0.38
 Female 11 (16%) 14 (24%)
 Male 58 (84%) 45 (76%)
TBI 0.63
 No TBI 55 (80%) 44 (75%)
 TBI 14 (20%) 15 (25%)
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Statistical Tests performed: t-test and chi-squared test of independence

Appendix B

Percentage of veterans on the waitlist or with a service dog that reported each category within their responses.

Main Theme: Subtheme Categories Service Dog
(n = 69)		 Waitlist
(n = 59)
Mental Health: Daily Life Medication 23% 25%
Nights 26% 25%
Normalcy 30% 39%
Quality of Life 41% 37%
Getting Out 59% 63%
Mental Health: Emotion Management Self-Understanding 3% 5%
Stress 4% 22%
Hypervigilance 10% 5%
Safety 10% 20%
Depression 14% 29%
Anger 16% 17%
Emotions 17% 34%
PTSD Symptoms 20% 25%
Peace 23% 25%
Anxiety 29% 63%
Mental Health: Interpersonal Skills Caregiver Burden 0% 7%
Crowds 6% 19%
Independence 10% 15%
Loneliness 10% 22%
Reintegration 14% 10%
Relationships 38% 44%
Mental Health: Cognition Flashbacks 0% 2%
Attitude 6% 8%
Confidence 7% 8%
Concentration 12% 14%
Coping Skills 14% 20%
Human Dog Interaction: Trained Tasks Medication Retrieval 1% 0%
Daily Activities 9% 14%
Brace 14% 8%
Re-Focus 16% 15%
Block 26% 15%
Cover 32% 22%
Alerts 41% 39%
Human Dog Interaction: Dog as a Positive Companion Dog as a Companion 39% 61%
Dog Positivity 81% 66%
Drawbacks Dog Loss 1% 5%
Dog Non-Obedience 3% 0%
Costs 4% 14%
Stigma 6% 14%
Adjusting 12% 15%
Maintenance 13% 22%
Travel 17% 5%
Access 17% 8%
Perceptions 25% 10%
Attention 43% 20%
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Footnotes

We have no known conflict of interest to disclose.

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