Human-Animal Interaction Bulletin 2018, Vol. 6, No. 2, 83-102
Effects of a therapy dog program on the wellbeing of older veterans living in a long term care residence Colleen Anne Dell* 1, Darlene Chalmers 2, James Gillett 3, Megan Steeves 4 , Betty Rohr 5 , Barbara Fornssler 6, Alicia Husband4, Oluwatomisin Iwajomo 4, Chelsea Nickel 6 1 University of Saskatchewan, Department of Sociology & School of Public Health 2 University of Regina, Faculty of Social Work 3 McMaster University, Department of Health, Aging & Society 4 University of Saskatchewan, School of Public Health 5 University of Saskatchewan, Faculty of Medicine 6 University of Saskatchewan, Department of Sociology
Current health care practices do not adequately meet the health needs of older adult war veterans. Increasingly, animal assisted interventions (AAIs) are being identified as potentially beneficial for this population. To explore this, this study, informed by a One Health framework, measured the outcomes of the St. John Ambulance (SJA) Therapy Dog Program on the wellbeing of older adults at a Veterans Affairs Canada residence in Saskatchewan, Canada. Over a 13 week period, two groups of veterans, of 8 and 10 in number respectively, who were living at the residence were purposively selected to participate in weekly individual and group therapy dog visits. The type of visit varied according to the level of cognition of the veteran, with lower level individuals visiting in a group format. A modified instrumental case study design was applied incorporating both quantitative and qualitative approaches, including questionnaires, focus groups, case history, and observation. Quantitative measures were analyzed descriptively, and qualitative measures were analyzed thematically. The findings revealed a positive influence of therapy dogs on memory recollection and reminiscence among veterans; positive health impacts on veteran wellbeing as understood through the significance of the therapy dog team encounter; and, perceived meaningful support from the therapy dog handlers and love and support from the therapy dogs. The analysis is contextualized within the growing literature on AAIs and contributes important insights to adequately meeting the needs of older adult war veterans, and potentially for the increasing population of recent war veterans. Additionally, key policy, practice, and research recommendations are proposed, including further investigation of therapy dog visits.
* Corresponding author: [email protected] Acknowledgements: This research was supported by a grant from Veterans Affairs Canada, through St. John Ambulance Canada. We would like to acknowledge their financial contribution and guidance on the study. We would also like to acknowledge the large and dedicated team that contributed to the study: Cathy Anderson, Paula Bacon, Ashley Balysky, Jennifer Carr, Debbie Chorneyko, Cristi Flood, Wes Forese, Jennifer Gareau, Judith Hutton, Holly Keeler, Michelle Martin, Hanah Molloy, Stephanie Peachey, Colleen Pylypow, Andrea Serack and Jane Smith. And we would like to acknowledge the veterans with whom we had the privilege of visiting.
It takes a diverse and committed team to successfully undertake a research project of this type. Members of our team included: Cathy Anderson, Paula Bacon, Ashley Balysky, Darlene Chalmers, Jennifer Carr, Debbie Chorneyko, Colleen Anne Dell, Cristi Flood, Wes Froese, Barbara Fornssler, Jennifer Gareau, James Gillett, Judith Hutton, Alicia Husband, Oluwatomisin Iwajomo, Holly Keeler, Michelle Martin, Holly McKenzie, Hanah Molloy, Chelsea Nickel, Stephanie Peachey, Colleen Pylypow, Betty Rohr, Andrea Serack & Jane Smith. A special thank you to Harper Goodfellow for formatting the final article.
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A wide body of knowledge suggests The veterans felt support and love from the that the human-animal bond and the therapy dogs and support from the handlers. relationships that stem from it positively impact human health (Anderson, Reid, & Older Adult Veteran Wellbeing Jennings, 1992; Allen, Shykoff, & Izzo, Older adult war veterans make up a 2001; Cutt, Knuiman, & Giles-Corti, 2008; sizable portion of the North American Friedmann & Thomas, 1995; Garrity & population, and consequently their health Stallones, 1998; Headey, 1999; Koivusilta & needs are an important consideration Ojanlatva, 2006; Levine et al., 2013; (Wilmoth & London, 2011). Both literature Pachana, Ford, Andrew, & Dobson, 2005; and practice show that current health care Parker et al., 2010; Parslow & Jorm, 2003a, responses to older veteran wellbeing are 2003b; Raina, Waltner-Toews, Bonnett, lacking with regard to their physical, Woodward, & Abernathy, 1999). Animal psychological, social, and spiritual needs. assisted interventions (AAIs) are understood The gerontology literature generally refers to as “[a]ny intervention that intentionally the wellbeing of older adults as successful includes or incorporates animals as part of a aging, in contrast to ‘usual’ aging (Rowe & therapeutic process or milieu” (Kruger & Kahn, 1987). Although there is no single Serpell, 2006, p. 23) and are frequently definition of successful aging, common applied to improve human health. Existing amongst understandings is that it is inclusive studies on AAIs primarily focus on the of the entire individual. It is generally therapeutic contribution of animals, such as premised on the understanding that physical, dogs in most cases (Nimer & Lundahl, 2007), behavior and social factors contribute to and in areas including pediatrics, mental wellbeing and more recently the addition of health, oncology, long-term care (Banks & spiritual factors (Crowther, Parker, Banks, 2005), and palliative care. The Achenbaum, Larimore, & Koenig, 2002; literature suggests that visiting dogs and their Mackenzie, Rajagopal, Meibohm, & handlers can offer a variety of human health Lavizzo-Mourney, 2000). benefits – ranging from stress relief (Bell, Older war veterans are in poorer 2013; Friedmann, Thomas, & Eddy, 2000; physical health than their non-veteran Handlin et al., 2011; Miller et al., 2009) counterparts. Veterans report difficultly through to companionship (DeMello, 2012; functioning, rate their health status as fair or Hart, 2010). This paper shares the key poor, and have worse physical and mental findings of a modified instrumental case health outcomes than their non-veteran peers study investigating how group and individual (Brooks, Laditka, & Laditka, 2008; O’Toole, St. John Ambulance (SJA) therapy dog visits Catts, Outram, Pierse, & Cockburn, 2009; influenced the wellbeing of older adult war Villa, Harada, Washington, & Damron- veterans in a Saskatchewan Veterans Affairs Rodriguez, 2003; Benyamini & Solomon, Canada (VAC) residence. Informed by a One 2005). The aging process itself is associated Health framework, the study found that with numerous negative life events, including visiting with a St John Ambulance (StJA) the loss of a spouse, the absence of a work therapy dog contributes positively to role, the shift from home to residential wellbeing. Therapy dogs in the program accommodation, and physical decline brought back fond memories for the veterans, (Busuttil, 2004). These life events may which provided opportunities for the veterans exacerbate the symptoms and psychological to reminisce with the therapy dog handlers. impact of combat for veterans, and lead to resurfaced stressors and in turn negatively
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE impact their physical health (Busuttil, 2004; adults’ lives. The social needs of aging apply Kaup, Ruskin, & Nyman, 1994). to veterans in general, and include resources One form of psychological impact of (e.g., social support, relationships, financial, combat prevalent among veterans is post illness), purposeful activities (e.g., traumatic stress disorder (PTSD), which is engagement, exercise) and mental health frequently attributed to older veterans’ (e.g., address depression, loneliness) increasing mental health needs. While (Chapman, 2009; Choi & McDougall, 2009; combat exposure has an indirect effect on Evans 2009; Alpass & Neville, 2003). health status, PTSD has been found to have a The status of older adult war significant direct impact (Schnurr & Spiro veterans’ spiritual needs is less certain. There III, 1999). Specifically, older adults with is a dearth of research in this area, with more PTSD, including war veterans, suffer from a present in the general adult aging literature variety of impairments, are less satisfied with (Hodge, Bonifas & Chou, 2010; Hodge & life, and receive sub-par treatment related to Horvath, 2011). Both the spiritual care and their unmet mental health needs (van Zelst, spiritual needs of older adult war veterans can de Beurs, Beekman, van Dyck, & Deeg, be different than non-veterans, due to 2006). Perhaps unsurprisingly, this cohort is veterans’ involvement in combat and also frequently dissatisfied with the associated traumas (Chang et al., 2012). healthcare they receive, especially as they Being part of the military can impact appear to be over-prescribed tranquillizers veterans’ spirituality. At times this impact and under-prescribed antidepressants (van can be positive, but in many cases it is related Zelst et al., 2006). Among veterans, PTSD to unresolved combat-associated feelings of may be coupled with other psychological guilt (Chang et al., 2012; Drescher & Foy, health needs, including depression and 1995). dementia. Depression has also been found to The needs of older adults in Veterans increase veterans’ risk of dying prematurely Affairs Canada (VAC) facilities are many, (Byers, Covinsky, Barnes, & Yaffe, 2012; ranging from social isolation to post- Meziab et al., 2014). And a greater traumatic stress disorder. All of these prevalence of dementia has been identified in conditions can exacerbate their health older adults with PSTD (Qureshi et al., 2010; challenges and negatively impact overall Meziab et al., 2014; Yaffe et al., 2010). If left wellbeing. Identifying effective responses to untreated, this comorbidity has been found to veteran needs in older age is a health priority, reduce affected veterans’ quality of life and especially when considering the addition of life satisfaction, while simultaneously high numbers of recent war veterans and their exacerbating existing symptoms and related health concerns. To address these neglected mental health needs (Ikin, gaps, some medical professions, such as Creamer, Sim, & McKenzie, 2010). nursing, are increasingly identifying AAIs as The social needs of older adult a means to supplement veterans’ health care veterans are most often considered as a result (Conrad, Armstrong, Young, Lacy, & of a study’s unexpected findings. For Billings, 2016). instance, Bernsten and colleagues’ (2001) large scale randomized study underscored the SJA Therapy Dog Program as an Animal importance of older age veterans’ Assisted Activity psychosocial wellness, but initially the Over the past three decades, research research set out to measure how a community highlighting the importance of the human- pharmacy program could improve older animal bond and the health and social
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE benefits of companion animals has expanded specific medical condition or person” (Huss, and diversified across populations and 2012, p. 444). The overall intent is to enhance contexts (Toohey, McCormack, Doyle- the recipients’ quality of life through the Baker, Adams, & Rock, 2013). For instance, provision of motivational, educational, numerous studies have focussed on the and/or recreational benefits (Pet Partners, benefits for specific age groups, such as older n.d.). adults living in long-term care facilities The goal of the SJA Therapy Dog (Banks & Banks, 2005) and with conditions Program is to offer support and love to the like dementia (Walsh, 2009; Motomura, individuals with whom the dogs and handlers Yagi, Ohyama, 2004). The contribution of visit (St. John Ambulance, 2015). The SJA animals to veterans’ health is documented in Therapy Dog Program began in 1992 in a variety of ways, including service animals, Ontario, Canada, and has since been animal assisted activities, animal assisted implemented in all Canadian provinces and therapy, resident animals, and emotional territories. The program was initiated in support animals (Carper, Bartone, & Petty, Saskatchewan in 2007, and has grown to 2016). Canine assisted interventions are well- include over 175 therapy dog teams. These suited for the veteran population in part therapy dog teams have undergone screening, because of the unique history of dogs in orientation, evaluation, placement, and have military service. Dogs have served during established a regular visitation schedule that war for therapy, companionship, combat, and qualify them as members of the SJA Therapy rescue. Service dogs are also increasingly Dog Program. This process helps to ensure being used to manage mental health problems the welfare of the therapy dog, its handler, like anxiety and trauma experienced among and visiting clientele which is of central recent veterans returning from service importance to the SJA Therapy Dog (Gillett & Weldrick, 2014). Program. Animal assisted activities (AAAs) are a distinct type of animal assisted intervention, Effects of a Therapy Dog Program on the and include programming like the SJA Wellbeing of Older Veterans Living in a Therapy Dog Program. While resonating Long Term Care Residence with some of the core values of AAIs, there This study is the first of its kind to are key criteria unique to AAAs. In AAAs examine the SJA Therapy Dog Program with specifically trained professionals, older adult war veterans. The research paraprofessionals, and volunteers visit in a question addressed is: What are the health variety of contexts with animals that meet impacts of group and individual SJA therapy specified criteria (Pet Partners, n.d.), dog visits with older adults in a recognizing that the vast majority in practice Saskatchewan Veteran Affairs Canada are moderately trained volunteers. While an residence? Specifically stated, what is the AAA is not therapy per se, it can be significance of the encounter for the resident therapeutic. This distinction is made because with the SJA Therapy Dog Program, in AAAs there are no treatment goals like accounting for its goals of offering love and there are in Animal Assisted Therapy, support? The University of Saskatchewan detailed notes are not taken, and visit content Human and Animal Research Ethics Boards, is spontaneous (Delta Society, n.d., cited in the Saskatchewan Health Region, and the Kruger & Serpell, 2006, p. 23). An AAA is VAC residence approved this study, to ensure typically “informal, takes places in a variety the health and safety of both human and of environments, and is not targeted at any animal participants.
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This study draws on a One Health Modified Instrumental Case Study Framework, which accounts for the interface A modified, instrumental case study between humans, animals, and environment design was applied for several reasons. and recognizes their inter-connection Foremost, it allows for the in-depth (Centers for Disease Control and Prevention, exploration of topics, and secondly, it 2013, n.p.). The zooeyia focus of this contextualizes data through the use of framework specifically acknowledges the multiple sources. The case study design is benefits of animals to human health considered to be modified because the (Hodgson & Darling, 2011). Chalmers and collected data is not as in-depth as Dell (2015) have applied the framework to unmodified case study designs, but is still AAIs, explaining that the animal is the health rich nonetheless. The case study in this intervention. Humans are accounted for in at instance is instrumental because it is intended least two ways: the client and the human to understand a particular issue of interest, handler interaction with the client. The that is, how participation in the SJA Therapy environment is also accounted for in two Dog Program contributes to the wellbeing of ways. First, the natural environment, where veterans (Stake, 2000). Specifically, this the human-animal interaction occurs, study collects and analyzes data with the goal provides a potential space for human of understanding lived experiences within the wellbeing by specifically attending to the framework of the SJA Therapy Dog Program dissociative split between nature and the goals, as well as in relation to the empirical human spirit (Wilson, 1984; Kellert & evidence located within the AAI, companion Wilson, 1993; Kahn, 1997). Second, the animal, and general human health literature. social environment is acknowledged, which The One Health framework helps to make reflects humans’ need for the support of their sense of the data. kin and extended families, communities, and society at-large for their health and Data Collection wellbeing. It also includes the program, and Data were gathered from multiple and all other people directly involved in the diverse sources. Case histories outlining intervention (Chalmers & Dell, 2015). basic demographic details, veterans’ Applying a One Health Framework to relationships with dogs, and staffs’ this study, the natural environment is not perceptions of the veterans’ wellbeing were measured, but is recognized in part by the developed. An 18-item questionnaire was Eden Alternative® Philosophy of Care of the completed by veterans following the visits participating Saskatchewan Veterans Affairs detailing their experiences with the two Canada (VAC) residence. This particular objectives of the SJA Therapy Dog Program. philosophy is premised on 10 principles A 9-item questionnaire was completed by a compatible with the One Health framework research observer, handler, and/or staff (Eden Alternative, 2015), as it supports cats, following each visit for the same reason and fish, birds and bearded dragons to live at the based on their observations. Finally, two 90 Saskatchewan residence, and for companion minute focus groups with staff at the mid and dogs to regularly attend with staff, adults in end points of the study were held. Primarily the day program and/or general visitors. The qualitative methods were chosen because One Health framework corroborates an they are especially relevant to research inclusive definition of wellbeing that attends questions concerned with subjective to the physical, psychological, social and experiences, meanings, and processes (Berg, spiritual aspects of health. 1998; Boyatzis, 1998; Kirby, Greaves, &
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Reid, 2006). They also allow for examining veterans. The type of visit varied according data within an established One Health to the level of cognition of the veteran, with theoretical framework. The qualitative lower level individuals visiting in a group inquiry is guided by phenomenology’s focus format. The one-on-one visiting requirement on the subjective experience, recognizing the for veterans was that they be: (1) interested in importance of documenting veterans’ visiting, and (2) able to answer questions on viewpoints (Denzin & Lincoln, 2008; Patton, how the visit made them feel. The group 2002; Speziale & Carpenter, 2007), while at visiting requirement was that the veteran be the same time recognizing that the interested in visiting. perspectives of others lend to the creation of Individual visits with the SJA individual’s stories such that they can therapy dog and handler, and attended by a collaboratively unfold (Creswell, 2007). The research observer and sometimes staff goal is to “describe the meaning of the lived member, lasted on average 15 minutes, and experience of the phenomena” (Starks & group visits were 25 minutes. The individual Trinidad, 2007, p. 1373). visits happened in a common residence room, Quantitative methods are drawn on to and staff or a researcher brought the veteran succinctly document findings in areas that to this space. During the visit the veteran were identified in the literature, including would typically sit on the couch or a chair, anxiety, calmness, emotional control, health, and depending on their comfort level and the loneliness and confidence (Taylor, Edwards size of the dog, the therapy dog would either & Pooley, 2015; Mossello et al., 2011; Furst, be on the floor at their feet or beside them on 2015; Wells, 2009; Hodgson et al., 2015). the couch. Most often, the handler and Quantitative data was analyzed using IBM veteran would visit and the veteran would pet SPSS version 23. Descriptive analysis was the dog, but sometimes only limited human conducted to provide the means of the Likert interaction took place, depending on the scale data that focused on the outcomes of the veteran’s lead. In some cases, if the veteran Therapy Dog program. A paired samples t- was not mobile to pet the dog that day, the test was undertaken to determine whether handler would have the dog do a trick so the there was a significant difference between the veteran could watch or toss a ball for the dog means of how veterans felt before to how to fetch close by. The group visit took place they felt after their visit with the therapy dog in a specific veteran house. Staff gathered the (p < .05). To examine change over time, an interested veterans in the common area ANOVA was conducted to compare means outside the kitchen to visit. The visit of outcomes between the first and last visit (p commonly included the veterans sitting in a < .05). circle with the handler taking the dog around Data were collected over a 13-week to visit each of the participants, so they could period starting on September 1st, 2015 pet and interact with the therapy dog as well through to November 30th, 2015. Eight as the handler, although the majority of veteran residents were purposively selected attention focussed on the dog. Group and to participate in weekly individual therapy individual visiting data are presented dog visits (2 veterans fell ill after a month of together, unless there is a marked difference, visiting and 6 continued), and 10 veteran and then it is noted. residents were selected to participate in A total of 13 therapy dogs, and 7 weekly group therapy dog visits. The handlers, attended the visits (therapy dogs veterans participating in individual visits did were mainly consistent with individual visits so once a week, as did the group visiting and varied with group visits). All of the
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE handlers were middle to older age females confidence), the data analysis was and had been with the SJA Therapy Dog undertaken with a focus on health impacts in Program for an average of 2 years. They these areas. Data collected via the Likert were chosen by the program coordinator to scale was analyzed descriptively and open- participate because of their experience level ended questions were analyzed qualitatively. and positive history with the SJA Therapy All data was examined across cases as well as Dog Program. The dogs’ average age was 7, within the context of a specific case. with the youngest being 4 and oldest 11 years Given the study’s qualitative design, of age. They ranged in breed from a small 10 which “aims to reflect the complexity of the pound Toy Poodle mix to a 60 pound Lab. phenomena studied, and present the The average age of the veteran underlying structures which ‘make sense’ of participating in individual visits was 92 years that complexity” (Green & Thorogood, 2009, and had lived at the residence for an average p. 197), our pragmatic approach to the of 9.75 months. Of the 8 veterans, 5 were qualitative data employed thematic analysis. involved in active combat during World War This inductive approach is consistent II; and 2 veterans were considered to have philosophically and methodologically with frail to moderate mental health, with the interpretive studies (Creswell, 2013). remaining 6 having stable mental health. Thematic analysis seeks to identify recurrent Comparatively, a total of 10 veterans patterns in textual data. Data analysis participated in the group therapy dog visits. involves searching for themes by analyzing The average age of the veterans was 91.8, and words and segments of text. The themes are the average time living at the residence was then compared across several other themes 9.4 months. Three of the veterans served and clustered based on similarity in meaning actively during World War II, 2 did not, and (Saldana, 2010). As such, each data set is it is unknown for the remaining veterans. At essentially taken apart and re-contextualized the conclusion of the study period, a total of into high level themes that offer an account 8 male veterans completed 62 questionnaires of the story that serves to explain what is (62 individual visits, 0 group visits), 8 staff occurring in the data (Thorne, 2000). completed 14 questionnaires (12 individual visits, 2 group visits), 9 handlers Findings (representing 12 dogs) completed 76 Quantitative Data questionnaires (66 individual visits, 10 group The quantitative data indicated visits), and 8 observers completed 83 positive health impacts for both group and questionnaires (70 individual visits, 13 group individual SJA therapy dog visits with older visits). adults in a Saskatchewan Veteran Affairs Given the broad interpretive and Canada residence. After spending time with specifically phenomenological design of the the therapy dog, the majority of the veteran study, the data analysis offers insight into the responses indicated agreement with feeling significance of the therapy dog team less lonely (83%), calmer (79%), less encounters. As well, given that this study is stressed (78%), and less anxious (73%). To a framed within both the SJA Therapy Dog lesser extent, two-thirds of the veteran Program’s goals (i.e., love and support) and responses (65%) indicated agreement about the empirical evidence located within the being more in control of their emotions/in the companion animal, AAI and general human moment, and about half indicated feeling health literature (i.e., anxiety, calm, control healthier (53%) and more confident (43%). of emotions/present, stress, healthy, lonely, The quantitative data also relayed that
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE the significance of the encounter for the recommend the therapy dog program to other resident was positive, including attaining the veterans, 58% of the responses were “Yes”, program’s goals of offering love and support. 1% were “No”, 8% were “Unsure”, and the On average, the veterans rated their feelings remaining 33% did not respond. Veterans as happier after spending time with the that responded negatively reasoned that the therapy dog (3.3 to 4.5), and this was value of the visit for veterans with dementia statistically significant (p <.001). In response was unknown. Ratings from veterans, to whether the veterans were glad they met handlers, observers, and staff on three with the therapy dog, 89% responded “Yes”, questionnaire items related to love and 3% were “Unsure”, and the remaining 8% did support demonstrate that the veterans not respond. The veterans shared feeling received support from the handler foremost, loved, feeling supported, the dogs provided followed very closely by receiving love and companionship and it felt good to be around. support from the therapy dog (see Table 1). In response to whether they would
Table 1. Ratings.
Questionnaire Item Veterans* Handlers Observers Staff
Felt loved/comforted by the dog Item Mode 4 3 3 3 Item Average 4.1 2.5 2.8 2.8 Number of Responses 35 75 79 12 Percentage of Positively Rated 83 60 82 75 Responses (%)**
Felt supported by the dog Item Mode 4 3 3 2 Item Average 4.1 2.7 2.8 2.4 Number of Responses 35 75 77 12 Percentage of Positively Rated 80 72 84 42 Responses (%)**
Felt support by the dog handler Item Mode 5 3 3 3 Item Average 4.3 2.7 3.0 2.8 Number of Responses 34 71 78 12 Percentage of Positively Rated 85 75 99 75 Responses (%)**
*Veterans rated items on a 5-point Likert scale. Handlers, observers, and staff rated items on a 3-point Likert scale. ** Positive responses were defined as ratings of 4 or 5 on a 5-point Likert scale or as ratings of 3 on a 3-point Likert scale.
Qualitative Data Highpoints of the therapy dog team visits Through thematic analysis, insight For all veterans, reasons for visiting was gathered on the significance of the with the therapy dog centered on the visit therapy dog team encounter between the being enjoyable, a source of happiness, and a therapy dog team and veteran, including positive encounter. Veterans also reported highpoints of the therapy dog team visits, that it gave them something to do. They veteran change over time; visiting mentioned appreciating the opportunity to challenges; and welfare of the therapy dog. see a dog and ‘just be’ with it, and make
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE linkages to distant, fond memories. Handlers, emotional expression and communication, observers, and staff shared similar sentiments and the therapy dog visits attending to this. about the visits being an opportunity for The veterans overwhelmingly felt engagement and a source of happiness for the support from the therapy dogs and veterans. The visits also provided an interpreted it similar to the love the dogs opportunity for reminiscence about fond offered: the feelings gained from ‘just being’ memories, largely about when they had a pet, with the dog, the development of a bond or and this was especially true for veterans friendship with the dog through mutual visiting one-on-one. Staff also emphasized affection, and specific identification of the role of the therapy dog visits in addressing feeling comfort as a form of support. Feelings veterans’ loneliness and boredom. of support were linked more strongly though During the visits veterans to the positivity of the encounter (i.e. emphasized seeing, connecting, and being laughter, smiling). Observers and handlers entertained by the therapy dog, and visiting shared similar views to the veterans, but also with the handler as their favourite parts. emphasized physical interactions and the Observers and handlers described the one-on- recollection of fond memories, and this was one visits as being happy, enjoyable, reported across both visiting formats. comforting, relaxing, and in the moment, Handlers noted greater recognizable while group visits were described as happy improvement among veterans in the group and enjoyable, but were limited in terms of visits (i.e. talking, physical interaction with being calming and/or relaxing. Staff the dog), and this was likely due to the low emphasized the positivity of the visits, engagement at baseline. Staff reported the regardless of the format. veterans felt special with the focused Examining what feeling loved by the attention, and many generally wanted more therapy dog meant to the veterans, they time with the therapy dog. highlighted the overt affection they received Veterans and observers also reported from the dog (e.g., physical closeness), the handler as a source of support. Observers including ‘just being’ with it, and the emphasized the conversation and positive development of a bond with the dog that interaction between the veterans and contributed to feelings of joy and safety. handlers, and suggested that the handler Observer and handler data supported this offers support through their role in the interpretation of love for veterans visiting veteran reminiscing and interacting with the individually. In the group format, observer therapy dog. However, handlers only data paid limited attention to the veterans interpreted themselves as supportive when physically interacting with the dog and/or directly engaged in conversation with the receiving affection. Instead, observers placed veterans, and were more likely to attribute emphasis on veterans enjoying being around support to the therapy dog. The staff a dog. However, handler data highlighted confirmed the supportive role of the handlers. physical interaction in the group format, and Analysis of the specific cases also emphasized embodied expressions: confirmed that each of the participating increased smiling, nodding, and talking. Staff veterans enjoyed dogs in general, with the specifically shared that the veterans appeared majority saying they ‘love’ dogs, regardless to bond with the dog over time, and following of living with companion animals prior to visits veterans spoke positively and their residence. Prior to the start to the SJA recollected fond memories. One staff noted Therapy Dog Program, all 8 veterans the general difficulty veterans experience in engaged with the animals living at and
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE visiting the residence. This means that this indication of change over time, noting study may be showing its level of positive elevated mood (happier, more relaxed and impact due in part to the participating client present, warmer) and increased interaction, population. The cases also offered insight with these types of observations most notable into the development of the bond between the for the one-on-one visits. The staff, from their veteran and the therapy dog. While the unique vantage point of working daily with veterans initially attended the sessions the veterans, noted foremost that the veterans largely because it gave them something to do, talked about the dogs as time went on, over time a connection, companionship and recalling points of their visits. They also relationship with the therapy dog formed. shared that there was an increase in This was variously important for the different anticipation and excitement for the visits – it veterans; the bond was related for some to the was something to look forward to, and dogs being associated with fond memories, brought about happiness afterward among the for others the feeling of closeness and veterans who visited. affection (physical and emotional) that the Challenges therapy dog offered, and for others still, the Data was specifically examined for general sense of happiness experienced discussion about veterans’ experiences during the visit. Insight was also gained from during the war, as this presumably may not the case studies on the role of the handler in be a positive experience. There was very little contributing to the veterans connecting with talk about the war before, during, or after the the therapy dogs. The therapy dog was visits, except by one veteran. The visits perceived as being the link to the veterans’ infrequently brought up challenging fond memories, and the handler provided the emotions for the veterans, and these emotions human counterpart with whom to reminisce. were related to death and/or dying. Change over time The elderly health status of the Comparing the first to the last visit, veterans was identified at times as impeding the data demonstrated that overall veterans on the therapy dog teams’ level of felt statistically better after visits; average engagement. Additionally, observers and means on the items for the first visit ranged handlers highlighted the emotional challenge from 3.5 to 4.0 (out of 4.0) while average of some visits for the veterans and handlers means for the final visit were consistently (e.g., discussions of dying on the part of the 4.0. Most notable was feeling less lonely and veteran), as well as structural challenges calmer over time. Looking at the qualitative related to the visit scheduling. Due to data, there is likewise some indication of potential feelings of loss at the conclusion of positive change over time by observers, the program, staff shared their belief that live- handlers, and staff. Observers identified that in pets may be more beneficial than visiting change was more notable for veterans in the dogs, while at the same time recognizing a group visits, compared to handlers, who live-in dog may not be practical. shared that change was more notable for Animal welfare veterans visiting individually. Some Due to the importance of animal observers shared that interest in and a welfare in the SJA Therapy Dog Program, connection/bond to the therapy dog increased observers, staff and handlers observed the as the number of visits progressed, including dogs’ behaviour throughout the visits. The increased physical interaction with the dog most common observation was the dogs’ (not for the group visits/already interacting). active interactions with the veterans, and The handlers similarly presented some their desire to be near them. The dogs
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE displayed good manners, affection, curiosity life satisfaction, and quality of life, while and excitement. In some instances, minor others have shown little evidence of signs of stress were noted in a dog when a improvement of any kind (Hyams & Scogin, visit began, which led to the dog being 2015). Further research among diverse temporarily distracted. The main source of populations and with diverse prompts (such stress was identified as the smell of nearby as therapy dogs) is needed. food. Staff shared that the therapy dogs were The health impacts of the therapy dog well-behaved and engaged affectionately visits with the veterans centered on with the veterans. reductions in loneliness, and lessened feelings of stress and anxiety and for some Discussion veterans positively affecting calmness. Overall, the findings revealed a Although the literature is limited, it suggests positive influence of therapy dogs on older war veterans suffer from physical, memory recollection and reminiscence psychological, social and spiritual health among veterans; positive health impacts on issues at a greater extent than non-veterans veteran wellbeing as understood through the (Brooks et al., 2008; Kazis et al., 1998). significance of the therapy dog team Further, it is known, for example, that mental encounter; and, perceived meaningful and physical health are interrelated; the support from the therapy dog handlers and reduction of acute stress can improve love and support from the therapy dogs by the immune system function (Dhabhar, 2014). veterans. Each is discussed in turn. Studies examining the role of AAIs in First, the findings from this study long-term care facilities have found that the suggest that visiting with a therapy dog inclusion of animals can decrease loneliness brought back fond memories for older adult (Banks & Banks, 2002; Fick, 1993). war veterans, and provided an opportunity to Additionally, AAIs have been linked to reminisce. Attention to the role of decreased depression, anxiety, and other reminiscence is growing in the older adult agitated behaviours in long- term care literature, especially as concerns regarding residents, especially among those living with dementia and Alzheimer’s disease increase depression, feelings of loneliness, and (Kaminsky (Ed.), 1984; Ros et al., 2016). dementia, while also improving cognitive This is because reminiscence has the functioning (Banks & Banks, 2002; Fick, potential to enhance psychological wellbeing 1993; Le Roux & Kemp, 2009; Moretti et al., among older adults (Bohlmeijer, Roemer, 2011; Sellers, 2005). Reductions in Cuijpers, & Smit, 2007), and this may be loneliness, stress, and anxiety may be, in part, especially important for the veteran due to AAIs role in increasing social population. The veteran population can interactions in long-term care residences experience more traumatic memories as they (Fick, 1993; Sellers, 2005; Taylor, Maser, approach the end of life (Rintamaki, Weaver, Yee, & Gonzalez, 1993) and the animal’s role Elbaum, Klama, & Miskevics, 2009), and as a buffer from stress- or anxiety-generating may vividly remember life threatening stimuli (Arkow, 2011; Hart, 2010; Kruger & memories more accurately than other Serpell, 2010). The animal may offer memories (Walton, 2010; Langer, 2011). reprieve from a situation, permitting one to However, studies have not conclusively cope with a perceived sense of comfort, determined the effectiveness of positive happiness, and joy (Walsh, 2009). reminiscence, though some have indicated To understand the health impacts of increases in socialization, self-esteem, mood, the visiting therapy dogs, the significance of
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE the encounter for the veterans highlighted the Research, policy and practice happiness that visits with the therapy dogs implications arose from the study findings brought them, and the positivity of the specific to animals, humans and the encounters and connection and bond with the environment. First, further research is needed dog. These findings are reflected in the on the value of AAIs for older adult veterans, literature which shares that animals can and specifically visits with dogs for those in trigger happy memories, improve mood, and long term care residences. Of particular bring about a sense of happiness, joy, and interest is the impact of veterans having a wellbeing (Arkow, 2011). This triggering companion animal, specifically a dog, prior may be related to the influence of beneficial to residing at the residence, and the linkage hormones and neurochemicals that shift of this to reminiscence during the therapy dog participants’ feelings and mood, and are visit. Second, there is a need to recognize the released when petting an animal (Odendaal & importance of the environment in which Lehmann, 2000). For some, it has been AAIs occur, and differences that may result reported that interacting with dogs can from community culture, behaviours and parallel the social support experienced in relationships, socio-economic status and human-human relationships (Fine & Beck, health, different pet populations, and regimes 2010). Other researchers, such as Muschel of care (Herzog, 2011; Siegel, 2011; Wells & (1985), contend that dogs offer a connection Rodi, 2000). And third, considerations need to the natural world; perspectives such as to be made for animal welfare on the same biophilia propose that humans may level as human health in AAIs, including experience a change in mood while in the disease transmission as well as physical and presence of animals and nature (Myers & mental health. Saunders, 2002). Limitations The veterans, observers, handlers, There are three key limitations to this and staff felt the veterans received support study. First, veterans’ health, including from the handler, followed very closely by physical and cognitive limitations, receiving love and support from the therapy intermittently challenged the data collection dog. Experiences of love and support from process. In some instances, observers helped the therapy dogs are likely a result of the the veterans complete their questionnaire, dogs’ innate ability to offer and receive and so assumptions may have been made. In nurturance (Chandler, 2017; Levinson, 1984; the most extreme cases, as shared, 2 of the Melson & Fine, 2010), which manifests into veterans were unable to complete the study nonjudgmental warmth, companionship, and after the one-month mark due to their health bonding that enables humans to love and trust status. (Arkow, 2011). The significant role of the A second limitation of the study handler as part of the therapy dog team has relates to the positive results, which could be only recently been identified (Adams et al., due, in part, to a number of confounding 2015), and adds insight into the literature factors, including self-selection of reflecting on the role animals can play in participating veterans’ with strong life assisting humans’ communication across a histories of relationships with companion variety of contexts (Gee, 2011; Grandin, Fine animals, including possibly during their & Bowers, 2010; Hodgson & Darling, 2011; service. However, such a factor may be a Roux, Swartz, & Swart, 2014; Solomon, necessary requirement for a specialized 2010; Wesley, Minatrea, & Watson, 2009). intervention involving therapy dogs, and in this case, resulted in a homogenous study
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EFFECTS THERAPY DOG PROGRAM OLDER VETERANS LONG TERM CARE RESIDENCE sample made up of elderly, Caucasian males. English and French, and an accompanying The study would be strengthened by the resource sheet is available in both languages addition of a comparison group. at no charge by visiting: Lastly, it is important to note that http://www.colleendell.ca/videos/. The given the specific philosophy and working research and practice literature on the role of environment of the Veterans Affairs Canada reminiscence of older adults and wellbeing is residence, the findings of this study cannot be evolving, and so ideally this product will reliably generalized to the wider older adult offer a contribution (Haslam et al., 2014). veteran population outside of this specific Conclusion site. However, implications from this study to Increasingly, AAIs are being other environments can be made with this identified as a means to supplement the understanding in mind. Moving forward, the health care received by older adult war limitations present in this study and their veterans. This study applied a One Health broader implications must be considered. framework to better understand how group Knowledge Translation and and individual St. John Ambulance (SJA) Dissemination therapy dog visits impact the wellbeing of The veterans, handlers, therapy dogs, older adults in a Saskatchewan Veterans residence staff, observers, and researchers Affairs Canada (VAC) residence. The held a final celebration to bring the research findings revealed a positive influence of project to a close. At this 90 minute therapy dogs on memory recollection and celebration, cake was served and certificates reminiscence among veterans; positive health of completion and pictures of the visiting impacts on veteran wellbeing as understood therapy dogs were distributed to all veteran through the significance of the therapy dog participants. Video was taken at the event and team encounter; and, perceived meaningful was used to create a music video. A song was support from the therapy dog handlers and created by Wes Froese, a recreation love and support from the therapy dogs. The coordinator and musician at the residence results have important implications for who works with the veterans, to share the meeting the health needs of older adult war overarching findings of the study. The song veterans and potentially the increasing was developed by Wes after he witnessed the population of recent war veterans. Due to the experiences of the veterans in the SJA importance of effectively meeting these Therapy Dog Program and sat in on the final populations’ needs, further investigation of staff focus group. The music video is therapy dog visits is warranted. available with and without subtitles in Responses to Mental Stress. Hypertension, 38, 815–820. References Alpass, F. M., & Neville, S. (2003). Loneliness, Adams, C., Arratoon, C., Boucher, J., Cartier, G., health and depression in older Chalmers, D., Dell, C.A.,…Wuttunee, males. Aging & Mental Health, 7(3), M. (2015). The helping horse: How 212-216. Retrieved from Equine Assisted Learning contributes to http://web.a.ebscohost.com.cyber.usask. the wellbeing of First Nations youth in ca/ehost/pdfviewer/pdfviewer?vid=30& treatment for volatile substance misuse. sid=02529e8a-cb0a-493f-9544- Human Animal Interaction Bulletin, 1(1), 4f2807782a6a%40sessionmgr4008 52–75. Anderson, W.P., Reid, C.M., & Jennings, G.L. Allen, K., Shykoff, B. E., & Izzo, J. L. Jr. (2001). (1992). Pet Ownership and Risk Factors Pet Ownership, but not ACE Inhibitor for Cardiovascular Disease. Medical Therapy, Blunts Home Blood Pressure Journal of Australia, 157, 298-301.
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