Examining Changes in Posttraumatic Stress Disorder Symptoms and Substance Use Among a Sample of Canadian Veterans Working with Service Dogs
Operational Stress Injury (OSI)
Defined by Veterans Affairs Canada (VAC) as any persistent psychological difficulty resulting from operational duties in the Canadian Forces (CF) or Royal Canadian Mounted Police (RCMP). This broad definition acknowledges the enduring impact of military or law enforcement service on mental health.
The Canadian Institute for Public Safety Research and Treatment defines OSI as any mental disorder or mental health condition resulting from operational stressors experienced in military or public safety professions. This definition emphasizes the direct link between occupational stressors and mental health outcomes.
OSI encompasses a range of conditions, including anxiety, depression, and posttraumatic stress disorder (PTSD), highlighting the diverse ways in which operational stress can manifest.
Posttraumatic Stress Disorder (PTSD)
Defined as a psychological response to intense traumatic events, especially life-threatening ones (American Psychological Association [APA], 2013; VAC, 2017). PTSD can develop after experiencing or witnessing events that involve actual or threatened death, serious injury, or sexual violence.
Growing health concern among Canadian veterans (Thompson et al., 2016), reflecting the increasing recognition and prevalence of PTSD within this population.
Approximately 15,000 Canadian war-service veterans and peacekeeping forces members have received a PTSD diagnosis (Rebeira et al., 2017), indicating the significant burden of PTSD among those who have served in the military.
Potentially psychologically traumatic events (PPTE) in a military context include direct combat and dangerous war zones (Carleton, et al., 2020). These events can lead to long-term psychological distress and impairment.
Veterans may develop mental disorders from PPTE exposures before or after service, compounding with service scenarios and increasing PTSD risk (Carleton, et al., 2020). This highlights the cumulative impact of traumatic experiences on mental health.
Four main PTSD symptom categories (DSM-5):
Intrusive thoughts:
Involuntarily re-experiencing traumatic events via involuntary memories, flashbacks, or distressing dreams (APA, 2020). These intrusive symptoms can be highly distressing and disruptive to daily life.
Avoiding reminders (avoidance/numbing):
Avoiding people, places, activities, objects, situations, or circumstances that resemble or are associated with the event and trigger distressing memories (APA, 2020). This avoidance behavior can lead to social isolation and functional impairment.
Avoiding discussing the traumatic event or associated feelings (APA, 2020). This emotional numbing can interfere with processing the trauma and seeking support.
Rumination about preventing the event or seeking revenge/justice (APA, 2013). These thought patterns can perpetuate feelings of anger, guilt, and hopelessness.
Negative thoughts and feelings (pessimism):
Distorted beliefs about oneself or others. These cognitive distortions can contribute to feelings of worthlessness, shame, and mistrust.
Loss of interest in normal activities. This anhedonia can significantly impact quality of life and contribute to depression.
Flat affect, characterized by a restricted range of emotional expression.
Feeling detached from loved ones, leading to difficulties in interpersonal relationships.
Ongoing fear, horror, anger, guilt, or shame (APA, 2020). These intense emotions can be overwhelming and difficult to manage.
Pessimism or difficulty imagining a future (APA, 2013), reflecting a sense of hopelessness and despair.
Arousal or reactive symptoms:
Anxiety, characterized by excessive worry and nervousness.
Increased arousal, leading to heightened vigilance and reactivity.
Hypervigilance, an exaggerated state of alertness and scanning for threats.
Exaggerated startle responses, demonstrating heightened sensitivity to sudden stimuli.
Reckless or self-destructive behavior, which can be a way of coping with intense emotional pain.
Irritability, characterized by increased frustration and impatience.
Angry outbursts, which can strain relationships and lead to social problems.
Difficulty concentrating, impacting cognitive functioning and daily tasks.
Sleep problems (APA, 2013), including insomnia, nightmares, and restless sleep.
Additional issues:
Relational problems, resulting from difficulties with intimacy, trust, and communication.
Social avoidance, leading to isolation and decreased social support.
Employment difficulties, due to challenges with concentration, emotional regulation, and interpersonal skills.
Physical health problems, as chronic stress can contribute to various health conditions.
Legal difficulties, potentially stemming from impulsive or aggressive behaviors.
Homelessness, reflecting the complex interplay of factors that can impact housing stability.
Depression, often co-occurring with PTSD and exacerbating symptoms.
Suicidal ideation (Whitworth et al., 2019; Yarborough et al., 2017), highlighting the critical need for intervention and support.
Strong association with suicide, depression, substance use, and homelessness risks (Stander et al., 2014; Wisco et al., 2014), emphasizing the importance of integrated treatment approaches.
Treating PTSD
Veterans rarely seek mental health services (Hoge et al., 2014), due to stigma, lack of awareness, and barriers to access.
Dropout rates for PTSD treatment are around 50% (Stern et al., 2013), reflecting the challenges of engaging and retaining veterans in care.
Reasons for dropout/poor participation:
Need for numerous/lengthy intervention sessions, which can be burdensome and time-consuming.
Desire to avoid appearing "weak", due to cultural norms and perceived stigma.
Avoidance/denial of trauma experiences, making it difficult to engage in treatment.
Poor veteran-clinician therapeutic relationships, highlighting the importance of empathy, trust, and cultural competence.
Desire to omit PTSD diagnosis/treatment from formal records (Schottenbauer et al., 2008; Fragedakis & Toriello, 2014), due to concerns about confidentiality and potential negative consequences.
Stigma related to mental health issues in the military creates barriers to help-seeking and delays treatment (Dell et al., 2017; Hoge et al., 2014). This stigma can be internalized and perpetuated by peers and leaders.
Veterans increasingly seek symptom relief via service dogs (LaFollette et al., 2019; Whitworth et al., 2019), reflecting a growing interest in alternative and complementary therapies.
Service Dogs (SDs)
Specifically trained to perform tasks for individuals with physical, sensory, neurological, developmental/cognitive impairments, or other daily challenges, including PTSD (LaFolette et al., 2019). SDs can be trained to assist with a wide range of disabilities and conditions.
Trained to assist with PTSD symptoms via specific behaviors/tasks tailored to individual needs (Whitworth et al., 2019). This individualized approach ensures that the SD's training is relevant and effective for the handler.
Benefits of SDs:
Mitigating physical challenges, such as mobility limitations and balance issues.
Decreasing depression symptoms, by providing companionship, increasing activity levels, and promoting a sense of purpose.
Improving quality of life, emotional health, and interpersonal relationships (Husband et al., 2020; O’Haire & Rodriguez, 2018; Vincent et al., 2017; Yarborough et al., 2017). SDs can provide a sense of security, reduce social isolation, and enhance overall well-being.
Improved well-being, reflecting a general sense of increased happiness and satisfaction.
Increased calm feelings, as the presence of an SD can have a soothing and grounding effect.
More positive affect, leading to increased feelings of joy, hope, and optimism.
Lowered hyperarousal, anxiety, and hypervigilance feelings while working with SDs (Knisley et al., 2012). SDs can help to reduce the physiological symptoms of anxiety and trauma.
PTSD and Substance Use
Veterans with PTSD have an increased risk of developing substance use problems (Banducci et al., 2016; Bowe & Rosenhack, 2015). This comorbidity is often driven by attempts to self-medicate and cope with PTSD symptoms.
Explained by high rates of prescribed medication use/misuse (e.g., opioids) and use of licit (e.g., alcohol) and illicit (e.g., cocaine) substances to cope with PTSD symptoms (Butler & Taylor, 2015; Harnish et al., 2016). Substance use can provide temporary relief but can ultimately worsen PTSD symptoms and lead to addiction.
Among Canadian veterans, over half of men and over a quarter of women with PTSD problematically use alcohol and drugs (VAC, 2017), highlighting the gender-specific patterns of substance use among veterans with PTSD.
Male veterans are more likely to have comorbid PTSD and substance use disorder compared to female veterans (Cribbs, 2017), indicating potential differences in vulnerability and risk factors.
Alcohol misuse and cigarette smoking are the most prevalent substance use problems among veterans (Hoggatt et al., 2017), contributing to a range of health problems and social consequences.
Alcohol is commonly accepted in Canadian military culture, complicating identification of problematic use (Gibson et al., accepted November 2020; Richer et al., 2016). This normalization can make it difficult for veterans to recognize and address their alcohol misuse.
Alcohol use increases the risk of interpersonal violence, poorer physical/mental health, and mortality (Bridevaux et al., 2004). These adverse outcomes highlight the serious consequences of alcohol misuse.
Misuse of opioids is correlated with adverse outcomes including inpatient/emergency room admissions, opioid-related accidents/overdoses, and violence-related injuries (Seal et al., 2012; Bohnert et al., 2014; Seal et al., 2012). The opioid crisis has had a significant impact on veterans, with many experiencing addiction and overdose.
Cannabis is another commonly used substance among veterans (Bonn-Miller et al., 2012). The use of cannabis for medicinal and recreational purposes has increased in recent years.
Cannabis use among one sample of veterans increased just over 50% from 2002 to 2009 (Wagner et al., 2007), reflecting a growing trend in cannabis use among this population.
The impact of SDs on veterans’ comorbid PTSD and substance use has not been studied to date, highlighting the need for further research in this area.
Current Project
Designed to examine if AUDEAMUS, Inc. SDs assist veterans with managing PTSD symptoms and addressing problematic substance use. This project aims to determine the effectiveness of SDs as a therapeutic intervention for veterans with PTSD and substance use issues.
Examined the complementary role of SDs (O’Haire & Rodriguez, 2018) and potential contribution to PTSD symptom and substance use changes for the veterans (Mayne, 2008). The research seeks to understand how SDs can enhance traditional treatment approaches and improve outcomes for veterans.
Addressed criticisms of SD research:
Lack of long-term follow-up studies, which limits the ability to assess the sustained impact of SD interventions.
Limited data collection, making it difficult to draw firm conclusions about the effectiveness of SDs.
Lack of quantitative measurement, relying primarily on qualitative data and subjective reports.
Observation in unnatural settings (Herzog, 2014; Marino, 2012), which may not accurately reflect real-world experiences.
AUDEAMUS, Inc. is a national holistic SD training program for Canadian military veterans who suffer from OSIs, including PTSD. This program provides veterans with the opportunity to train their own SDs and develop a strong bond with their animal.
AUDEAMUS, Inc. Training Model
Stage 1: Assessing an applicant’s needs (mental and physical) and capabilities with respect to caring for and training a SD, examining compatibility between applicant and dog, and completing a behavioral assessment of the dog to ensure suitability for SD training. This initial assessment ensures that the veteran and dog are a good match and that the dog has the temperament and skills necessary for SD training.
Stages 2 and 3: Trainers assist handler/SD teams with learning basic obedience skills using positive reinforcement (e.g., sit, stay, down, leave it, heal, touch), engaging/connecting as a team (i.e., forming a bond), preparing for public access, and understanding the importance of emotional regulation and recovery for safety and security in all situations. These stages focus on building a strong foundation of obedience and teamwork.
Stages 4 and 5: Training for public access requirements, and SDs are taught more specific skills to meet their handler’s needs (e.g., detection, response, alertness, mobility, hypervigilance, anxiety, interruptions). These stages involve advanced training in real-world settings and the development of specialized skills to address individual PTSD symptoms.
Stage 6: Teams must build on skills taught in previous stages and demonstrate skills required for full public access. This final stage ensures that the SD team is prepared to navigate public spaces safely and effectively.
Handler/SD teams can obtain certifications following each stage, providing recognition of their progress and achievements.
Each team determines their training schedule and timeline, allowing for flexibility and individualized pacing.
Each veteran has a unique experience with training, fluctuating between accomplishments and challenges. This acknowledges the complex and often unpredictable nature of the training process.
Methods
Participants:
Five males with a mean age of 43 years (range 36–51 years). This small sample size reflects the challenges of recruiting veterans for research studies.
Two self-identified as Métis, two as Caucasian/white, and one as First Nations, highlighting the diversity of the veteran population in Canada.
All had at least some college- or university-level education, indicating a relatively high level of education among the participants.
Four grew up with pets, some with dogs (n = 3), suggesting a potential pre-existing affinity for animals.
Two did not have any household pets at the beginning of the project, indicating that prior pet ownership was not a requirement for participation.
Three were matched with dogs through AUDEAMUS, Inc., while two trained a family dog, demonstrating a variety of approaches to SD acquisition.
One veteran replaced their SD around the 6-month time point, highlighting the potential challenges of finding the right SD match.
Another requested a female dog around the same time point and was matched with one by AUDEAMUS, Inc., reflecting the importance of individual preferences and needs.
Participating veterans reported 4.5 to 34 years of service with the Canadian Military or Navy, indicating a wide range of military experience.
Four were on medical leave or retired at the beginning of data collection, and one retired at the 9-month time point, suggesting that the participants were experiencing significant health challenges.
Each veteran had a different injury/PTSD source and development date, highlighting the variability of experiences among veterans with OSI.
Potentially traumatic events included abduction, witnessing a friend's death, sexual assault, and combat injury, reflecting the diverse range of traumas experienced by veterans.
PPTE exposures and PTSD development occurred on average 21 years ago (range = 11 to 35 years), indicating the long-term impact of trauma on mental health.
All self-identified as having a history of problematic substance use, highlighting the comorbidity of PTSD and substance use among veterans.
None were in active, serious addiction at the time of research participation, suggesting that the participants were in a relatively stable phase of recovery.
Each veteran reported diverse challenging life circumstances throughout the research, indicating the complex interplay of factors that can impact mental health.
Each underwent a variety of physical and mental health treatments over the year, reflecting the comprehensive approach to care that is often required for veterans with PTSD.
It is common for veterans to approach a SD organization when traditional treatment options are not aiding them in adequately managing their PTSD symptoms, suggesting that SDs are often seen as a last resort or complementary treatment option.
Procedure:
Exploratory (Stebbins, 2001), patient-oriented (Mallidou et al., 2018; Strategy for Patient-Oriented Research, 2019), within-subjects (Charness et al., 2012), longitudinal (Ployhart & Vandenberg, 2010), time series (Salkind, 2010) mixed-methods research design was employed. This comprehensive design allowed for in-depth exploration of the veterans' experiences over time.
Human and animal Research Ethics Boards at the University of Saskatchewan approved this research, ensuring the ethical treatment of both human and animal participants.
Recruitment involved AUDEAMUS, Inc. examining their waitlist of veterans diagnosed with PTSD and having self-identified concerns regarding problematic substance use. This targeted recruitment strategy ensured that the participants met the study criteria.
One veteran dropped out in the third month of data collection, highlighting the challenges of maintaining participant engagement in longitudinal studies.
Research participation inclusion criteria:
Formal PTSD diagnosis, ensuring that all participants met the diagnostic criteria for PTSD.
Struggle with PTSD enough to have requested participation in AUDEAMUS, Inc., indicating a high level of motivation and need for support.
Problematic use of at least one substance (primarily opioids), reflecting the focus on comorbid PTSD and substance use.
Mental health professional agreement to participation, ensuring that participation was deemed safe and appropriate for the individual.
Suitable family pet to train or be matched with a dog through AUDEAMUS, Inc., providing options for both veterans who already had a dog and those who needed to be matched with one.
Veterans were informed about the study in-person, then read and signed consent forms, ensuring informed consent and voluntary participation.
Data collection took place at six time points from May 2018 to May 2019: baseline, and 1, 3, 6, 9, and 12 months. This longitudinal data collection allowed for tracking changes in PTSD symptoms and substance use over time.
Veterans convened on average for 3 days in Saskatchewan with the research team to complete data collection and training with AUDEAMUS, Inc.. This in-person component facilitated data collection and provided opportunities for training and support.
Outside meeting times, veterans continued AUDEAMUS, Inc. training remotely with SD trainers, ensuring ongoing support and guidance.
PTSD symptoms were measured with the PTSD Checklist (PCL-5), a standardized self-report measure.
Substance use was measured with the Drug Use Screening Inventory (DUSI-R) Substance Use (SU) subscale, a standardized measure of substance use behaviors and consequences.
Semi-structured interviews were conducted at each time point, providing rich qualitative data on the veterans' experiences.
The use of quantitative measures and in-depth interviews allowed for data triangulation (Heale & Forbes, 2013), increasing the validity and reliability of the findings.
Measures:
PCL-5:
A 20-item self-report measure for assessing DSM-5 symptoms of PTSD (APA, 2013; Weathers et al., 2013). The PCL-5 is a widely used and well-validated measure of PTSD symptoms.
Veterans rated symptoms over the past month using a 5-point Likert-type scale ranging from 0 "not at all" to 4 "extremely". This scale allows for quantifying the severity of PTSD symptoms.
Meeting minimum clinical criteria for each PTSD cluster and a total score of >32 is indicative of a positive screen for PTSD (Carleton et al., 2020; Weathers et al., 2013). This cut-off score provides a standardized way to identify individuals who are likely to have PTSD.
A 5- to 10-point change represents reliable change, and a 10- to 20-point change represents clinically significant change (Weathers et al., 2013). These thresholds provide a framework for interpreting changes in PCL-5 scores over time.
DUSI-R:
Measures 10 domains (e.g., psychiatric disorder, work adjustment, peer relations) to identify potential consequences of alcohol and drug use. The DUSI-R provides a comprehensive assessment of the impact of substance use on various life domains.
Only the DUSI-R SU subscale was examined for the analyses, focusing specifically on substance use behaviors and consequences.
Substance use is measured with 16 items related to desire for/dependence on alcohol/drugs, context of alcohol/drug use, behavior while under the influence, and outcomes resulting from use. These items provide a detailed picture of the individual's substance use patterns.
The response scale is dichotomous (“yes/no”), simplifying the scoring and interpretation of the measure.
The PCL-5 and DUSI-R SU were analyzed by a researcher outside of the project using descriptive statistics and reliable change index (RCI; Jacobson & Turax, 1991), ensuring objectivity and rigor in the data analysis.
RCI (Jacobson and Truax, 1991):
Describes RCI as a statistic for determining whether a change in an individual/group’s score is statistically significant based on a scale’s test-retest reliability (e.g., Cohen’s D). RCI provides a way to determine whether observed changes in scores are likely to be due to real changes or simply measurement error.
signifies the likelihood that a change in test scores is the result of “true” or “reliable change” or “results from chance” (Hensel et al., 2007). This helps researchers to distinguish between meaningful changes and random fluctuations in scores.
In cases where sample sizes are small (i.e., ANOVA is not appropriate), population-based information is unavailable, and concerns about practice effects on scores through repeated testing are not present the use of RCI is the most appropriate statistic to employ (Atkins et al., 2005; Maassen, 2004). RCI is particularly useful in studies with small sample sizes, where traditional statistical methods may not be appropriate.
Interviews:
Transcribed by a neutral transcriber outside of the research team and then independently analyzed using Saldaña’s (2013) content analysis coding guide by two researchers outside of the project for reliability. This ensures objectivity and reduces the potential for researcher bias.
The guide was selected due to the preliminary and non-theory-development driven nature of this study (Saldaña, 2013). This approach allowed for a flexible and exploratory analysis of the interview data.
Results
PTSD Symptom Changes:
Individual scores and group means for the PCL-5 are reported in Table 1. This provides a summary of the quantitative data on PTSD symptoms.
At baseline, four veterans met the PCL-5 criteria for a positive screen of PTSD; at the 1-year time point, three veterans screened positive for PTSD. This indicates a slight decrease in the number of veterans meeting the criteria for PTSD.
Individual and groups means fluctuated over time, with clinically significant increases and decreases. This highlights the dynamic nature of PTSD symptoms and the importance of longitudinal data collection.
Sample mean scores for the PCL-5 decreased by 12.1 from baseline to 1-year, suggesting a reliable and clinically significant change overall (Weathers et al., 2013). This suggests that the SD intervention may have had a positive impact on PTSD symptoms.
Comparing group mean scores on the PCL-5 for Time 1 to Time 6, the RCI value was –1.89 (Table 1), which did not meet the –1.96+ cutoff to signify a statistically significant difference between the scores (Jacobson & Truax, 1991). This indicates that the observed changes in PCL-5 scores were not statistically significant, despite being clinically significant.
Interview Responses Regarding PTSD:
Veterans reported variation in their experience of PTSD and expression of symptoms. This highlights the heterogeneity of PTSD and the importance of individualized treatment approaches.
Some individuals reported experiencing symptoms from all four PTSD categories, while others only expressed symptoms from three of the four categories. This further underscores the variability in PTSD symptom presentation.
Intrusive thoughts:
Veterans commonly reported having nightmares, bad dreams, or “intrusive memories.” These intrusive symptoms can be highly distressing and disruptive to daily life.
Avoidance/numbing-related symptoms:
Self-isolation, low/restricted socialization, avoidance of public spaces, trust issues with others, and obsessive-compulsive tendencies. These avoidance behaviors can lead to social isolation and functional impairment.
Negative or numbing thoughts/feelings-related symptoms:
Suicidality, struggles with negative affect, and hopelessness. These symptoms reflect the profound emotional distress associated with PTSD.
Arousal/reactive-related symptoms:
Hypervigilance, anxiety, struggles with self-regulation, explosive anger, difficulties with focusing, aggressiveness, sleep problems, and hyperactive fight or light response. These symptoms reflect the heightened state of arousal and reactivity that is characteristic of PTSD.
Over the 12 months, veterans described ways their SDs assisted in managing their PTSD. This qualitative data provides valuable insights into the mechanisms of action of SD interventions.
For intrusive thoughts/feelings symptoms, veterans reported their SDs waking them during nightmares.
Some veterans appreciated this and slept better, while others found being woken led to overall fractured and unrestful sleep. This highlights the individual variability in response to SD interventions.
Unwelcomed interruptions tended to be more of an issue with puppies compared to older, longer-trained dogs. This suggests that training and experience may play a role in the effectiveness of SD interventions.
None of the veterans reported ways in which their SDs supported them with managing intrusive negative memories. This suggests that SDs may be more effective at addressing some PTSD symptoms than others.
With avoidance-related symptoms, the SDs reportedly increased some of the veterans’ physical activity levels by getting them outside, helped them reconnect with activities/hobbies they once enjoyed, gave them the capacity to leave their homes and engage in public settings, and helped them be more mindful and present-focused. This highlights the positive impact of SDs on social engagement and activity levels.
Two veterans noted that while their SDs were briefly injured they ended up isolating themselves at home. This underscores the importance of the SD-veteran bond and the potential negative consequences of disruption.
Despite initial struggles with their SDs (e.g., dog’s anxiety, veteran concerns with having a male dog), they each reported feeling increasingly connected and bonded to their dogs over time. This highlights the importance of patience, perseverance, and finding the right SD match.
One veteran disclosed that the relationship with their SD was enough on its own and they did not need to connect with anyone else (i.e., other humans). This raises questions about the potential for SDs to substitute for human connection and the need for balanced social support.
Some of the veterans discussed the benefits of having a routine and sense of caring/responsibility with a SD, as well as the unconditional acceptance and bond they felt from the SD. This highlights the therapeutic benefits of the SD-veteran relationship.
Further, some of the veterans noted that they felt a connection and sense of belonging to the AUDEAMUS, Inc. group. This underscores the importance of social support and group-based interventions.
There were some examples of how the veterans perceived their SDs to support them with their negative or numbing thoughts/feelings.
At baseline, the veterans expressed feeling hopeful that their SD would be able to aid them in addressing their PTSD symptoms.
This level of hope decreased for some of the veterans part way through the project, particularly for the two individuals who relinquished their first SD and started working with a new one. This highlights the importance of managing expectations and providing support during the SD training process.
Hope also decreased for the veterans during times they struggled with physical ailments (e.g., chronic health conditions) or troubles at home (e.g., moving to a new home, conflict with children). This demonstrates the complex interplay of factors that can impact mental health and treatment outcomes.
However, levels of hope began to increase again for each veteran towards the end of data collection. This suggests that the SD intervention may have had a delayed positive impact on hope and optimism.
Each veteran reported times that their SD reacted to them (i.e., jumped up, interrupted) during both excited and depressed emotional states. This highlights the SD's ability to detect and respond to a range of emotional states.
Veterans reported ways in which their SDs aided in addressing arousal/reactive symptoms.
When the veterans felt anxious, angry, agitated, stressed, or triggered their SD reportedly nudged, barked at, or jumped up on them, which helped them refocus, manage their emotions, or get back to the present time. This demonstrates the SD's ability to provide real-time emotional support.
The SDs’ interventions and perceived support reportedly increased the confidence of the veterans to complete tasks on their own again, including driving.
Two of the veterans disclosed that the SDs helped them manage their road rage because they could either regulate by petting the dog or focus on the fact that they care about and want to protect their dog. This highlights the SD's ability to promote emotional regulation and prosocial behavior.
Beyond intervening when the veterans felt a negative emotion, they reported that the SDs helped them stay mindful, grounded, kept their minds preoccupied, and focused on something other than themselves. This demonstrates the SD's ability to promote mindfulness and attentional control.
However, there were occasions when SDs themselves were frustrating for the veterans and elicited feelings of stress, anger, depression, and led to them being triggered and less able to concentrate.
Each veteran reported at some point being frustrated with having to train their SD and maintain a regular training schedule (as required with the AUDEAMUS, Inc. model). This highlights the challenges of SD ownership and the need for ongoing support and training.
Negative public interactions with SDs sometimes resulted in the veterans feeling anxious, stressed, and embarrassed. This underscores the importance of public education and awareness about SDs.
The SDs sometimes solicited attention undesired by the veterans from people who wanted to interact and were curious about the dog