CDC Seeks Data on How Vets with PTSD Are Helped by Dogs; Therapy Dog Organizations Could Provide Valuable Input but May Not Be Participating

The Centers for Disease Control has begun distributing two surveys, one to veterans and one to �assistance dog providers,� in an attempt to gather data on how dogs may be helping veterans find jobs and reintegrate into society.  The survey for veterans to complete is getting a negligible response rate, so the CDC is now asking the Office of Management and Budget to approve an incentive for veterans who at least attempt to complete the form.  The incentive would be a $50 prepaid VISA card. 

An Assistance Dog Providers Survey is getting a sufficient response in the CDC�s opinion, but it must be questioned whether all the organizations that could provide valuable input are aware of this survey�s existence.  �Assistance dog,� as defined by the CDC, includes therapy dogs, yet at least one of the largest national therapy dog organizations I contacted (not the one to which I belong) was unaware the survey was being conducted.  Neither the current release in the Federal Register, nor a preliminary release on September 9, discussed in a prior blog, defined assistance dog and the definition would only become apparent to organizations from project documents that have to be requested from the CDC.  Although the response rate from service dog training organizations might be adequate, the use of service dogs by veterans is only part of spectrum of canine relationships that the CDC is attempting to gather data about. 

The issues with the two surveys are most easily discussed separately.  

Veterans Survey

The survey for veterans asks about their experience with pet ownership and how various experiences with animals have helped them physically and emotionally, and whether such experiences have been helpful in getting them reintegrated into society.  To date, only 66 veterans have completed the survey, barely 1% of the 6,000 responses the CDC has been hoping to get. 

One reason for the poor response rate is indicated in the request sent to the Office of Management and Budget.  In describing changes that are being made to a flyer that will be distributed through various veterans� and other organizations, the CDC says that it has added a statement to the flyer �indicating that the survey is not affiliated with the Veterans Administration (VA), as some veterans may have negative feelings about the VA that would discourage their participation in the survey.� The CDC is certainly correct in this supposition as the VA has actively inhibited many veterans from obtaining and using service animals, as discussed here before. 

Another issue for some veterans may be the nature of the questions asked.  The CDC states:

�This survey will ask potentially sensitive questions, such as the race/ethnicity of the respondent and the respondent�s diagnosis. This demographic information is necessary to analyze any consistent patterns among veterans� race/ethnicity and psychological diagnosis, as well as with level of attachment to pets and the need for assistance animals for specific populations of veterans. This information will be used to inform assistance dog training organizations of the needs of veterans obtaining assistance dogs. It will also be a step toward understanding the idiosyncratic needs of veterans based on various psychological diagn[oses].�

The time to complete the survey is estimated by the CDC to be up to an hour, which may also discourage some. 

In order to overcome these and perhaps other unknown reasons for the poor response rate to date, the CDC is now seeking approval from the Office of Management and Budget to offer a $50 VISA gift card for veterans �completing all or portions of the survey.� 

Assistance Dog Providers Survey

The second survey the CDC is distributing is for assistance dog providers, about which the CDC appears confident it will get enough responses.  This survey �will be sent by email to approximately 1,000 service dog providers,� from which the CDC hopes to get 300 responses.  As of October 17, the CDC reports that 91 organizations had completed this survey.  Three hundred might seem like an optimistic number if one thinks only of organizations that train service dogs for veterans, but the agency defines assistance dogs rather broadly as a term including�

�service dogs, service animals, therapy dogs, visitation dogs, recreation support dogs, social therapy dogs, guide dogs, hearing dogs, seeing eye dogs, eye dogs, sight dogs, mobility dogs, mobility assistance dogs, balance dogs, disability dogs, hearing dogs, hearing ear dogs, signal dogs, psychiatric service dogs, PTSD dogs, anxiety dogs, emotional support dogs, skilled companion dogs, home help-mate dogs, companion dogs, court dogs, medic alert dogs, seizure alert dogs, seizure response dogs, diabetic alert dogs, autism dogs, detection dogs, facility dogs, facilitated service dogs, 3rd party dogs, READ dogs, high schooled assistance dogs, emergency response dogs, search & rescue dogs, career dogs, and police dogs.� 

This includes a great many types of trained and professional dogs.  Despite this all-encompassing approach, the current version of the survey instrument being sent to assistance dog organizations defines only four types of assistance dogs, as follows (in the wording and emphasis of the survey itself):

• A service dog performs specialized skills directly related to the handler's disability. Service dogs meet the standards for public access as protected by the Americans with Disabilities Act (ADA).
• A professional therapy dog is handled, utilized, or supervised by a health or human services professional in a therapeutic setting. Although they may have specialized skills, they are not service dogs or visitation dogs.
• A visitation therapy dog provides support, comfort, and companionship to individuals in settings such as hospitals and nursing homes. They are not service dogs nor professional therapy dogs, and do not have public access rights.
• A support dog provides emotional or physical support or assistance related to the handler's disability, usually only in the handler's home (they may have very limited public access rights). They are not service dogs, professional therapy dogs, or visitation therapy dogs.

For each of these four categories, organizations are asked how many and what percentage of dogs that enter the program end up performing the desired function and how many dogs are put in service annually.  For professional therapy dogs, the questionnaire asks �with which health and human services professionals have your professional therapy dogs been placed?� Respondents may choose from occupational therapists, physical therapists, psychologists, physicians or psychiatrists, counselors, nurses, social works, and other (please specify). 

The survey questionnaire seems to be based on a model that is most appropriate for a service dog training program, not for a certifying organization where dogs are trained by other individuals or groups and pass a qualifying test administered by the organization.  Visitation therapy dog respondents are not asked about what sorts of facilities the therapy dog teams are working in.  Since such information is gathered to varying degrees by the certifying organizations, the CDC may be missing an opportunity to learn more about where veterans are being offered animal-assisted activities and therapies. 

Value of Survey Information

The CDC�s primary aim in conducting the surveys is to gather information about how bringing dogs into the therapies and lives of veterans may help them find jobs and happiness.  It is apparently not the only reason, however, as the October 23 release states that it is �part of a larger project that will identify priorities and new opportunities for research, as well as address policy implications associated with public access rights afforded to service dogs by the Americans with Disabilities Act.�  Whether the CDC has an understanding with the Department of Justice to share results, or whether the DOJ has asked the CDC for input regarding possible changes to its access rules, is not clear.  The reference may not be specific to service dog access issues in any case.  It is curious that in defining a support dog, the CDC says that �they may have very limited public access rights.�  This could refer to travel and housing contexts, but the CDC could also be thinking that changes might be made to rules regarding transportation modes under control of the Department of Justice, e.g., taxis.   

Another possible area of change with regard to animal access might be hinted at in another type of function specifically defined by the CDC, the professional therapy dog.  The CDC says these dogs are neither service dogs nor visitation dogs, but does not mention whether they have access beyond that of pets.  This is the only specifically defined assistance dog type where access is not referred to in the CDC�s definition.  In Service and Therapy Dogs in American Society (p. 110), I mention one instance where a dog that might belong in this category had limited access under a state statute, but I know from personal communication with one researcher that there are those in those working in treatment facilities who believe that dogs involved in animal-assisted therapies should have access rights similar to service dogs.  For instance, in New York City, handlers of therapy dogs are often limited in the facilities they can visit by the lack of access to subways and buses.

The CDC expects the results of the Assistance Dog Providers Survey to help with research projects being conducted at West Virginia University and has asked that Dr. Joseph Scotti of the WVU Psychology Department to be named a collaborating investigator.  The submission to OMB also refers to Lindsay Parenti, of the same department, one of whose papers on the categorization of assistance animals I cited in a prior blog.

Conclusion

The CDC appears to be distancing itself from the VA�s policy of granting a single service dog umbrella organization a monopoly on who can provide service dogs for veterans.  The agency also recognizes that a comprehensive study of the benefits of dogs for veterans involves looking across a number of types of interactions veterans are having with dogs, from service dog pairings to companion animals to occasional interactions with therapy dogs. 

As I have noted previously, gradients of interaction and qualification must be taken into account before a determination can be made as to where public resources are best placed and before legal restrictions can be designed equitably.  Transferring authority to a private organization without understanding the complexities of how veterans can be given the best opportunities to be aided in what they face is irresponsible, yet amazingly enough the Army has followed the blind lead of the VA in this regard, and has kept a ban on dogs for PTSD.

Scientific results cannot be handicapped by expectations and still be scientific, but research on the benefits of dogs is generally tending towards a positive assessment of their ability to make many people with both physical and psychological disabilities more comfortable, and ultimately more successful.  Cures from animal interactions are rare and should not be a sole criterion for success.  The CDC is to be commended for looking at the complexities of the issue and trying to obtain input by those most in need of the psychological and physical benefits of human-animal interactions. The agency has also taken steps to get in contact with, and obtain information from, a broad range of stakeholders working with dogs and veterans.  By making some changes to the Assistance Dog Providers Survey, even more useful data could be obtained. 

West Virginia University has a website with both surveys posted. WVU specifically notes that providers and trainers of therapy dogs are being sought to complete the assistance dog survey.  Copies of documents may also be obtained from Leroy A. Richardson of the CDC, 1600 Clifton Road, MS�D74, Atlanta, GA 30333 or send an email to omb@cdc.gov.  Mr. Richardson can be reached directly at 404-639-7570.

Appendix: Email I sent to officials of the CDC and NIOSH:

Dear ....

I believe the Assistance Dog Providers Survey will provide important information to the Centers for Disease Control and Prevention regarding the effects that various types of interactions with animals, particularly dogs, are having on veterans and their ability to return to productive positions in society. I have not had the opportunity to review the Survey of Veterans and will not comment here on that other than to say that I believe the decision to add language to the flyer emphasizing that the survey was not created by the Department of Veterans Affairs is appropriate. 

As to the survey of Assistance Dog Providers, I will make several observations. First, in the interest of full disclosure, I am a member of a national therapy dog organization and have been visiting various facilities for six years with my therapy dog, which under your survey would be defined as a visitation therapy dog. Other than in my capacity as a member of a therapy dog organization, I do not represent that organization or any other organization, business, or individual involved in therapy dog work. Further, because I have written a book and maintain a blog on various professional dog issues, any direct representation of any of the organizations involved in service or therapy dog work could conflict with the objectivity of my reporting and I do not anticipate that I would have any such organizations as clients. 

I believe that obtaining information from training organizations will be helpful in assisting the CDC and other federal agencies to develop appropriate policies and in allocating resources for research projects and government-funded programs that will help veterans return to work.  I would argue, however, that there are organizations that could provide important information that may be overlooked or which may decline to participate because of the title of the survey and because of the focus of its questions.

As to the title of the survey, many people associated with the training  and certification of skilled dogs will assume that an �assistance dog� is either (1) a service dog, (2) a category of trained dogs that includes both service and emotional support dogs, (3) a dog that qualifies for living with an individual who has disabilities in a building, condominium, or community with a no-pets policy, or (4) a dog trained by a member of Assistance Dogs International, a national organization.  There are undoubtedly other meanings that could be found for �assistance dog� than these.  Anyone assuming that your use of the term fits in such a category will likely not be aware of your broad definition (0920-0985 REV Section A) which defines assistance dogs as including �service dogs, service animals, therapy dogs, visitation dogs, recreation support dogs, social therapy dogs, guide dogs, hearing dogs, seeing eye dogs, eye dogs, sight dogs, mobility dogs, mobility assistance dogs, balance dogs, disability dogs, hearing dogs, hearing ear dogs, signal dogs, psychiatric service dogs, PTSD dogs, anxiety dogs, emotional support dogs, skilled companion dogs, home help-mate dogs, companion dogs, court dogs, medic alert dogs, seizure alert dogs, seizure response dogs, diabetic alert dogs, autism dogs, detection dogs, facility dogs, facilitated service dogs, 3rd party dogs, READ dogs, high schooled assistance dogs, emergency response dogs, search & rescue dogs, career dogs, and police dogs.�  It is to be noted that this definition appears in a document that I obtained only by direct contact with the CDC and is not contained in either of the recent releases published in the Federal Register (September 9 and October 23).  Even if many of the types of specialized dogs listed in this definition will not be particularly relevant to veterans in their efforts to return to work, some types of dogs (e.g., therapy dogs) are regularly encountered by many veterans in residence, medical, and rehabilitation settings and organizations with information on those dogs may be helpful in providing the CDC with data and contacts.

The Assistance Dog Providers Survey as presently drafted defines four specific types of assistance dogs: service dogs, professional therapy dogs, visitation therapy dogs, and support dogs, and asks specific questions for providers of each of these types of dogs.  The questions seem to me to assume a model whereby an organization completing the form would be involved in the training of the dogs that may in time be deemed qualified to engage in a specific function.  While this may be true in many instances, there are also therapy dog certifying or registration organizations that qualify dogs trained by individuals and other training organizations by administering a test or tests the passing of which result in a handler and his or her dog receiving a certificate or registration document.  To my knowledge this is the primary method of operation of the major national therapy dog organizations. A question such as the following does not fit well within this model:  �Approximately what percentage of your dogs eventually become visitation therapy dogs?�  The dogs do not in any sense belong to the certifying organization or to the administrators of the tests.  Thus, they are not �your dogs.�  Nevertheless, if a dog passes the test or tests, the organization will keep records concerning the handler and the dog and will provide insurance for a handler operating within the organization�s guidelines.  The organization is also likely to know where the dog is making visitations as handlers are generally asked to submit reports on a regular basis or may receive referrals from the organization�s administrators. Such organizations are increasingly automated in their data collection and can likely provide information that could be useful to the CDC.  Thus, even if the organization finds out that its members are involved in work covered by the survey�s areas of inquiry, officials of the organization may not feel that the survey instrument can be appropriately filled out in its current form or may be deterred by the number of qualifications that would have to be inserted before many of the questions could be answered at all.  I would suggest that a relatively few changes could make the instrument more accessible in this regard.

Since you indicate that survey results �will lead to recommendations and guidance � pertaining to animal-assisted interventions �� (79 Fed. Reg. 63403), the inclusion of information from therapy dog organizations will be important in gathering data on animal-assisted activities and animal-assisted therapies involving veterans.  Since the database may well provide information that can be useful in further research efforts, therapy dog organizations could be useful in gathering data by answering questions such as the following:

1. What percentage of your members visit facilities, such as hospitals, residence facilities, outpatient facilities, etc. where the word �Veteran� appears in the name of the facility?
2. In the last year, how many of your members reported visiting facilities with �Veteran� in the name of the facility?
3. What is the number of separate facilities with the word �Veteran� that were visited?
4. What was the total time of your members� visits to such facilities in the last year?  
5. Are members of your organization required to take additional training in order to participate in animal-assisted therapies or other therapeutic interventions under the control of a medical or psychology professional?  

In addition to providing information from their own databases, therapy dog organizations might be willing to survey their members with additional questions that could either be collated by the organization or provided in some form that the CDC could itself work with.  Thus, members of the organization could be asked such questions as:

1. How many facilities do you visit where U.S. veterans are in residence or regularly receive treatment?
2. What types of facilities do you visit where you and your dog visit veterans: Hospitals? Nursing homes? Outpatient treatment centers? Etc. Etc.
3. How long on average do you and your dog stay with a veteran during a visit to a facility?
4. Do you and your dog participate in any structured therapeutic activities involving treatment of veterans?
5. If you participate in any structured therapeutic activities involving veterans, is the activity under the direction of a psychiatrist or psychologist? A physical therapist?  An occupational therapist? Etc.

The granularity of the inquiries could provide a great deal of information nationally on the animal-assisted therapies and activities that might involve therapy dogs. Obviously, privacy issues would come into play here that will have to be considered in designing questions or providing cautions to participating members. 

It is also to be noted that many therapy dog handlers are in contact with veterans who do not have pets but have a history of pet ownership and could be an ideal source for disseminating information about the Veterans Survey. In visiting the hospital which is currently the primary focus of my therapy dog visitations, I meet veterans who wish to tell me about dogs they have owned when they lived independently. Finally, many therapy dog organizations and therapy dog handlers are regular users of various social media and could help spread the word to veterans about the importance of the survey you are distributing for them.    

I have been in contact with one national therapy dog organization (not, incidentally, the one to which I belong) and found that the head of the organization was unaware of your survey despite having many thousands of members, many of whom visit facilities where veterans can be found.  Such visitations may, to use your terminology, involve either professional therapy dogs or visitation therapy dogs. I believe that not designing the survey to assure the participation of such organizations amounts to a missed opportunity for the CDC.  Also, it means that a significant part of the spectrum of potential interactions between veterans and animals is likely to be missed and not adequately described from the current survey you are using to gather data on assistance dog providers.  

John Ensminger, Esq.