Changing Behavior: Roles for Learning, Negotiated Settlements, and Individualized Treatment Plans

Chapter 3


Changing Behavior


Roles for Learning, Negotiated Settlements, and Individualized Treatment Plans



Overview



Thinking About Goals of Treatment


The goal of treatment for canine and feline behavioral concerns is a negotiated settlement. Everyone may not get what they want, but everyone can get what they need. This is true whether the behaviors of concern are normal behaviors that the clients dislike or will not tolerate or true behavioral pathologies that put the patient and others at risk. This negotiated settlement is obtained by identifying factors that can be changed through intervention, factors that can be avoided, and factors that require risk mitigation (Box 3-1).



Negotiated settlements can be created only in the context of honest discussion, the first step of which is to learn what the clients want as an outcome. Clients may not be able to have exactly what they want, but to negotiate a settlement that works for them successfully. Full disclosure of needs, concerns, fears, and annoyances/frustrations is essential. As clients discuss their concerns, fears, and distress, the “available space” for a negotiated outcome becomes apparent. With more information and a better understanding of the behavior and how it can be changed, this “available space” can only increase, and options that clients did not think were possible often become so.


The easiest way to learn what clients want is to ask them. Some clients do not have an appreciation of how much the dog or cat is suffering or how much risk may be present until they work through an extensive, exhaustive history questionnaire. The process of completing a history questionnaire informs the client’s opinion of what they want and what a negotiated settlement can look like. Further discussion during the consultation allows clients to understand where and how their pet is troubled as they begin to understand normal behaviors/responses and the extent to which their pet deviates from these. If clients appreciate the level of distress that their pets are experiencing and understand that such distress can be alleviated humanely, they are more willing to meet the pet’s needs and become less focused on their fears and their desire for a “cure.” We “cure” almost no conditions in this field, but—as with so many physical conditions—we can do a stellar job of controlling them, providing an excellent quality of life (QoL) for the pet and the client.


Good, standardized history questionnaires—when followed by an informed review to establish agreement on terminology and validity of assessment—do two things:



There are two sets of standardized history questionnaires included within this text and on the companion website: long questionnaires for cats and dogs with known behavioral concerns and short questionnaires for cats and dogs to use as routine screening tools at every appointment.


The concept of the outcome of a negotiated settlement helps clients to understand that although the cat or dog may never behave perfectly, improvement, happiness, safety, and less stress for everyone all are attainable outcomes. This concept also helps clients to understand that the processes of improving and negotiating relationships is lifelong and that they will continuously build on actions that have come before. As such, these settlements give clients permission to make temporary choices that may make their lives easier and increase their tolerance for handling the dog or cat. For example, boarding the dog during a family visit may be easier for the clients than having the dog present, especially if they worry (regardless of whether the worry is justified).


Negotiated settlements allow clients to understand that setbacks are likely, the route will not be linear, mistakes will be made, but improvement is still attainable, and recovery can be one of the ultimate goals. If everyone can focus on creating the best possible relationship with the pet, while meeting the dog’s or cat’s needs, treatment decisions can become much more clear and straightforward.



Keys to Successful Intervention and Treatment in a Negotiated Settlement


There are four required aspects of intervention to facilitate successful treatment as part of a negotiated settlement (Box 3-2).




1. Avoid the circumstances that provoke the behavior from the dog or cat or that are known to be a factor in the pet exhibiting the behavior.


2. Do not punish the dog or cat. Punishment merely tells the pet what not to do and will further raise levels of anxiety and reactivity.


3. Design and implement an appropriate behavior modification plan for that pet in that household using the techniques and strategies discussed later. Essential components of behavior modification include:



4. Praise and reward the dog or cat for any behaviors considered acceptable or good, even if they are normal behaviors and occur when the pet is not interacting with anyone. This is the most important part of treatment, and almost everyone ignores it.


5. Approaches involving clear signaling, positive rewards, and predictable human behavior have been shown experimentally to be superior for training dogs.



All of these strategies are explained and demonstrated in the accompanying video, Humane Behavioral Care for Dogs: Problem Prevention and Treatment.



Do We Have to Wait until the Dog or Cat Has a Problem to Create a Set of Rules for Negotiated Settlements?


No! In fact, if everyone in the veterinary practice begins to model their puppy/kitten, new dog/cat, and wellness visits in the manner suggested in Chapter 1, everything that was just discussed can be implemented as a plan to prevent a problem or intervene early in problem development. This is called anticipatory guidance. Anticipatory guidance is used a lot in some human medical specialties, such as pediatrics, but it is underused in veterinary medicine. For a discussion of using this approach with children and dogs, see the “Protocol for Introducing a New Baby and a Pet” and the “Protocol for Handling and Surviving Aggressive Events.”


Any method that can be used to treat a behavioral problem will work as well or better to prevent one. All of the protocols for treating specific behavioral concerns can be used to prevent full-blown problems and as early interventions. If veterinary staff use interventional protocols and behavior modification plans in this manner, we will save lives, have more fun, have more profitable businesses, and have better relationships with our clients and patients.



Prognoses and Predictors of Outcomes


Treatment of infectious or neoplastic conditions is largely dependent on the disease process and available interventions. The social and physical environment and daily behaviors of the family members of the ill dog or cat matter little for such treatment outcomes compared with the medications and other interventions used to treat the condition. This situation is completely reversed for behavioral conditions.



Because of this, prognosis is not well linked to diagnosis in veterinary behavioral medicine. Five main factors are generally thought to contribute to the success of treatment:



Of these factors, client compliance may be the most critical. This finding should not be interpreted to “blame” the clients for the pet’s problems. With the exception of abusive or neglectful situations, most canine or feline behavioral problems are not created by people. It is true that people make mistakes, that they do not understand other species, and that it is possible to make any situation worse by inappropriate interventions. However, no study has been successful in showing that pets’ problem behaviors/pathologies are attributable to similar problems in their people (Clark & Boyer, 1993; Jagoe and Serpell, 1996; Parthasarathay and Crowell-Davis, 2006; Voith et al., 1992). Interestingly, studies have shown that people who read their pets’ signals best, best meet their pets’ needs, and find their pets charming and brilliant (Bradshaw and Nott, 1992; Rooney et al., 2001), suggesting a strong and profitable role for the veterinary profession in education of clients.


Boxes 3-3 through 3-6 outline good and poor prognosticators for behavioral conditions. Prognosis is best understood if client-driven and patient-driven factors are considered separately. A review of these lists suggests that the rate-limiting step for how well dogs and cats can become is the domain of their humans.



Box 3-3   Client-Driven Factors Associated with Poor Outcomes




• Clients who cannot or will not comply with instructions meant to minimize risk, stress, and distress


• Clients who have a lack of understanding or acceptance of the dog’s or cat’s needs


• Clients who want or need to blame the dog or cat


• Clients who have an idealized world view of how their cat or dog “should” act and look


• Clients who are caught in a cycle of anger and fighting within the family that always seems to revolve around the dog and the dog’s behavior


• Clients with lots of other stressors in their life: dogs and cats with behavioral concerns can be, but don’t have to be, strains on marriages and family relationships


• Clients who have ill-behaved or unsupervised or unsupervisable young children


• Clients who live in very reactive, unpredictable households and environments


• Clients who do not like the cat or dog


• Clients who “need” a “quick fix”


• Clients who have and wish to adhere to a rigid timetable for improvement


• Clients with overly busy households, especially if they contain young children


• Clients who believe that children should be able to do anything they want with pets


• Clients with any perception or belief that the dog or cat is unpredictable and so inherently dangerous


• Clients with a continuing belief that the dog or cat is “unpredictable,” even after a consultation with a specialist


• Clients who fear the patient


• Clients who are angry with the patient


• Clients who need to control all aspects of the patient’s behavior


• Clients with dissention within the household over how treatment should be enacted, especially if one household member wants the pet dead or out of the house


• Clients who feel embarrassed or that a behavioral problem reflects poorly on them


• Clients who are unable or unwilling to avoid provocative situations


• Clients who are feeling especially financially compromised


• Clients who have used remote shock to “control” real or perceived aggressive behaviors


• Clients who experience adverse changes in financial or housing circumstances


• Clients who have seriously considered putting down the dog or cat and entertain this thought in most or all discussions involving the pet






Are There Any Generalized Instructions That Can Be Quickly Given to Clients When They Express a Concern About Pet Behaviors?


Yes. If clients engage in the following behaviors, their pets either will never exhibit behavioral concerns or will start to improve. Depending on the problem, the type of improvement that the clients desire will require more specific and detailed help, but these are three no-fail steps (Box 3-7) that will help in any problem and that will form the basis of all the treatment interventions discussed in this chapter.




These three no-fail steps succeed because they encourage clients to meet the pet’s needs, and they provide information about the pets with respect to what the clients want, not what they don’t want. All of us work for information about which of our behaviors are acceptable or exceptional. Nowhere is this more true than for troubled cats and dogs, whose most valuable currency is accurate information.



Understanding Behavioral Interventions



What Can We Change or Manipulate?


In any situation involving problematic behaviors, there are three groups of environments that we can potentially manipulate and modify:



These environments are not independent. The extent to which psychotropic/behavioral medication may be warranted depends on the severity of the condition (how abnormal or problematic the neurochemical and behavioral responses are) and the ability to manipulate physical and social environments. Newer behavioral medications allow faster and more effective manipulation of the endogenous neurochemical environment, which helps to shape more appropriate neurochemical and behavioral responses to stimuli in the physical and social environments.



Roles for Arousal and Environmental Manipulation



Arousal


At the core of virtually all behavioral conditions, especially conditions related to anxiety, is the arousal level of the patient. Heightened arousal, beyond a certain adaptive level:



Non-adaptive arousal usually manifests as fear, which can have as a component defensive aggression, or anxiety, which can have as a component offensive aggression. Fear and anxiety are closely related but may not be identical at the neurophysiological level.


One should remember that when one diagnoses a problem related to fear or anxiety, one is doing so at the level of the phenotypic or functional diagnosis. Although much treatment and subsequent assessment focuses on changing the non-specific signs apparent at the phenotypic level, if psychotropic medication is used, we are intervening at the molecular and neurophysiological levels (which we then hope will help change the phenotypic level). New evidence about epigenetic effects suggests that effects at the molecular and neurophysiological levels may be governing the signs expressed by which we recognize the condition and the manner in which neurophysiological and molecular effects act (Krishnan and Nestler, 2008; Lubin et al., 2008; McGowan et al., 2009).


Anxiety is broadly defined as the apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria (in humans) and/or somatic symptoms of tension (vigilance and scanning, autonomic hyperactivity, increased motor activity and tension) (Overall, 1997, 2005a, 2005b). The focus of the anxiety can be internal or external. For an anxiety or fear to be pathological, it must be exhibited out-of-context or in a degree or form that would be sufficient to accomplish an ostensible goal (Ohl et al., 2008; Overall, 1997, 2000, 2005a, 2005b). The focus on context for the response and degree and form of behaviors informs all of our definitions of canine and feline behavior problems as discussed here.


We are quite good about recognizing situational anxiety in dogs where the stimulus is external (e.g., someone leaves the house, the client is out of sight), but we are not good at recognizing anxiety that is internally generated or found to be distressing by the dog (e.g., as in panic disorder, canine post-traumatic stress disorder, or generalized anxiety disorder (GAD); see Chapter 7 for a discussion of these conditions). Given what we now know about canine cognition, we must believe that true endogenous canine anxiety, such as that exhibited by dogs with GAD, occurs and can be recognized on the basis of the behaviors exhibited, across the contexts in which the behavior appears. The conditions specified in the general definition of anxiety should help us frame our criteria for diagnoses of pathological conditions involving anxiety and their assessments.


Accordingly, we should use as gauges of anxiety both behavioral and neurophysiological signs of anxiety. Behavioral signs of anxiety can include:



Neurophysiological signs of anxiety can include (Beerda et al., 1997, 1998, 2000):



• tachycardic or bradycardic changes in heart rate (affected by norepinephrine [NE]),


• alterations in blood pressure (affected by NE),


• mydriasis (affected by NE),


• vasodilation/constriction (affected by NE),


• alterations in gastrointestinal function (which can result in subsequent diarrhea),


• changes in hypothalamic-pituitary-adrenocortical (HPA) axis function including effects of peripheral blood counts (note that chronic anxiety experienced secondary to chronic stress can blunt HPA axis function, which is why “changes” in function are emphasized),


• salivation,


• muscle tension and concomitant CK/CPK release (this muscle tension is the cause of dander release and damp fur/paws), and


• alterations in sleep and sleep-wake cycles (if the anxiety is long-term).


Fear is usually defined as a feeling of apprehension associated with the presence or proximity of an object, individual, social situation, or class of the above (Overall, 1997, 2005a, 2005b). Fear is part of normal behavior and can be an adaptive response. The determination of whether the fear or fearful response is abnormal or inappropriate must be determined by context. For example, fire is a useful tool, but fear of being consumed by it, if the house is on fire, is an adaptive response. If the house is not on fire, such fear would be irrational and, if it was constant or recurrent, probably maladaptive. Normal and abnormal fears are usually manifested as graded responses, with the intensity of the response proportional to the proximity (or the perception of the proximity) of the stimulus in the case of the “normal” fear and disproportionate or out-of-context with respect to the “abnormal” fear. A sudden, all-or-nothing, profound, abnormal response that results in extremely fearful behaviors (catatonia, panic) is usually called a phobia.


There are two conditions involving fear that affect many animals and that, when defined, will help in this discussion of treatment (also see the discussion in Chapters 7 and 9).



• Fear/fearful behavior



• Criteria: Responses to stimuli (social or physical) that are characterized by withdrawal; passive and active avoidance behaviors associated with the sympathetic branch of the autonomic nervous system and in the absence of any aggressive behavior. Specific behavioral responses include tucking of neck, head, tail and all limbs, hunched backs, trembling, salivating, licking lips, turning away, hiding (even if the only hiding possible is by curling into oneself), averted eyes, et cetera. In extreme cases, urination and defecation are possible. Release of anal sacs may occur. Dander may become apparent, and fur may feel damp.


• Notes: Fear and anxiety have signs that overlap. Some non-specific signs such as avoidance (which is different from withdrawal), shaking, and trembling can be characteristic of both. The physiological signs probably differ at some refined level, and the neurochemistry of each are probably very different. It is hoped that refinements in qualification and quantification of the observable behaviors will parallel these differences.


• Fear aggression



• Criteria: Aggression (threat, challenge, or contest) that consistently occurs concomitant with behavioral and physiological signs of fear as identified by withdrawal, passive, and avoidance behaviors associated with the actions of the sympathetic branch of the autonomic nervous system. When these signs are accompanied by urination or defecation or when the aggression is active/interactive (i.e., defensive aggression)—even if the recipient of the aggression has disengaged from or did not deliberately provoke the interaction—the diagnosis of fear aggression is confirmed.


• Notes: The actual behaviors associated with fear, fear aggression, and any aggression primarily driven by anxiety (see discussion on impulse control and interdog aggression, for example) are poorly qualified and quantified. In extreme cases, the conditions specified will be clear. If the aggression appears mild, it could be due to uncertainty on the patient’s part. Caution is urged in ruling out all other aggressions. The diagnosis that is most consistent and concordant with signs and criteria should be the one prescribed to the patient.


• Fear aggression does not have to occur consistently, although identification of the fearful stimuli will permit assessment of the extent to which the behaviors are consistent and pose a predictable risk.


• All of the behaviors associated with fear can occur with fear aggression, but when fear aggression is the consideration, aggressive behaviors usually occur before behaviors associated with extreme distress (urination/defecation/anal sac release, et cetera) occur or as they are happening.


• Finally, if the patient is affected by fear aggression, aggressive acts are most likely to occur if the patient is trapped or reached toward or as the provocative stimulus moves away while the patient is moving away and/or attempting to conclude the interaction.


Although anxiety and arousal may be the underlying stimuli that give rise to a fearful response, outright anxiety and fear differ because of neocortical processing and signaling that may be, but do not need to be, affected by the behaviors of other individuals involved in the interaction. Fear is characterized by physical withdrawal, decreased social interaction, and clear signaling that interaction will be truncated and that the subject/signaler wishes to disengage and is not an overt threat. Purely anxious behaviors can range from more overt, provocative ones to full withdrawal. If clients understand this, they have a better chance of managing the dog humanely and avoiding injury.


A lot has been written about the role for “appeasement” in fear and anxiety. We should have two concerns when this term is used in the context of fear or fear aggression:



1. “Appeasement” is seldom defined, given the context. A full understanding of risks, costs, and threats would need to be available to define “appeasement.”


2. There may be more parsimonious explanations for the animal’s behaviors that do not require extrapolation of some “emotional” or “motivational” state that is difficult to measure. Message and meaning analysis (Smith, 1977) provides a more discrete, judgment-free, and value-free way of interpreting complex social interactions by allowing us to know, for example, when one participant is signaling their withdrawal. This approach has an advantage over the motivational approach because it is based on behaviors without any assumptions about how these are interpreted by the dog. No one doubts that dogs and cats experience a complete range of emotions, but our attributions about them may be inaccurate, and what we assume to be a “motivation” may not be as important to the dog or cat as it appears to us. If we are really to move into an era of research that maximizes welfare and QoL issues for our patients, we must be cautious about simplistic approaches that make our lives easier but that may not accurately reflect the dog’s or cat’s behaviors and their interpretation of them.



Environmental Manipulation


The physical and behavioral environments are often factors affecting the dog’s level of arousal. Although these environments may be completely within the normal range of those dogs routinely encounter, for individual dogs certain environments will be sufficient to trigger a problematic response. Given this, understanding the role the environment may play in the response provides help for treatment.


Manipulating the physical environment is often overlooked, yet environmental change can often be the first and easiest step in decreasing the patient’s arousal levels. If our goal is to raise the threshold at which the cat or dog displays the signs associated with the diagnosis or the behaviors associated with the client complaint—and these behaviors could be normal—environmental manipulation may be simple and helpful (Fig. 3-1; this figure also appears in Chapter 2).



image


Fig. 3-1 A, The x axis represents time, and the y axis represents response level. R1 shows a response that is proportional to the stimulus—there is no overall behavioral reaction to this stimulus 1 because R1 does not reach the threshold level for the behavioral reaction (horizontal dashed line). The decay time—the time to return to baseline—is shown by the colored dashed curves. At stimulus 2, the summed proportional responses exceed the threshold, and the dog reacts (R2). At stimulus 3, even a small stimulus now causes a worsening in the response (R3) if the patient is still experiencing the R2 decay/recovery response because the responses are additive and the arousal level is still high. However, if the patient experiences stimulus 3 after R1 has sufficiently delayed or recovered, the additive level is not sufficient to trigger a response. This graph illustrates how important multiple stressors and the time over which they are experienced can be for the behavior of the dog or cat. These graphs assume that the threshold level stays the same across time, but with repeated distressing exposures threshold levels for reactivity lower. B, This graph shows how patients with different types of reactivities may respond to the same stimulus and how reactivities can change with time. For simplicity, this graph assumes that the stimulus is the same for each patient, as is the threshold; however, with repeated distressing exposures threshold levels for reactivity lower.





Patient A reacts to the stimulus but not at a sufficient level to trigger the problematic response. Patient A’s behavior decays to the baseline quickly.




Patient B reacts to the stimulus at a level that just triggers the behavior but recovers, and his behavior decays to the baseline quickly.




Patient C reacts to the stimulus in a way that exceeds the threshold for exhibiting the behavior, and because he had a worse reaction than patient B, he takes longer to return to baseline, but he does recover and return to baseline.




Patient D reacts to the stimulus in a way that exceeds the threshold for exhibiting the behavior, and this changes his future behaviors and lowers his threshold for reactivity. Notice that beginning with patient D the slope of the curve increases—the patient is reacting more quickly. Patient D does not return to baseline. His recovery is incomplete, which increases the ease with which he will become distressed in the future.




Patient E reacts to the stimulus in way that far exceeds the threshold for exhibiting the behavior, he remains reactive for longer than does patient E, he has a longer decay period for his response (during which he is easily stimulated to react inappropriately). Patient E reacts very quickly and does not return to baseline. His recovery is incomplete and he will view all future stimuli from the perspective of always being somewhat aroused and distressed. This is one model for patients with panic disorder.




Patient F shows a very rapid response (see the slope of the curve) with a slow decay that never approaches baseline or the threshold below which he will react. Many small events trigger his response and speed the rate at which he reacts. He is always reactive to some degree, very much like a dog with generalized anxiety disorder (GAD).




Patient G may or may not be at baseline, but he reacts almost instantly and to a quite high level. Once he reacts, he is very slow to calm. Patient G panics.


Figure 3-1, A, shows the effect of repeated stimuli, baseline levels of reactivity, and thresholds on the exhibition of behaviors. If the patient is already aroused, a stimulus that would be below the level at which he or she would react may cause reaction. If multiple stimuli are presented to the patient before he or she has returned to baseline levels, they may act additively, causing the patient to react more profoundly or in more situations than that patient would have otherwise reacted. This graph shows how important controlling the stimulus environment can be. If you allow the patient to return to baseline between provocative events, you do not trigger the response. If you continue to force the patient to be exposed to provocative events, the patient reacts to ever higher levels. Because the reaction is profound and the duration of the decay of the response is lengthy (Pitman et al., 1988), you cannot teach appropriate behaviors because the cortisol and epinephrine levels interfere with genetic transcription of information. You can only reinforce fear and avoidance. This application should resonate with veterinarians who have experienced treatment of patients using high levels of restraint.


Note that Figure 3-1, A, was developed using only patient A’s response, and patient A is the most normal of the patients. The basal response level or response surface of the patient interacts across time with the intensity and frequency of the stimulus to produce the overall behavioral response.


Because of these patterns of reactivity and arousal, the most unexploited of the possible manipulations involve the physical and social environments. Protecting dogs and cats from situations that they may find distressing or stressful promotes two changes essential for improvement:




Physical Environments


The physical environment includes:



Other animals are part of the physical environment—they take up physical space and use the same resources. They are usually, but not always, also part of the behavioral environment: a dog that can be seen through a window may be sufficient to trigger a reaction from a dog or cat indoors, although the outside dog was not part of any direct social interaction.


Because “perception” is so critical in the evaluation of the physical environment, clients’ schedules and use of space must also be considered. Some problems, such as separation anxiety in dogs, may become apparent when the only environment that changes is the temporal one: day length shortens or the clients’ schedules change. Part of the treatment must address this environmental change.


The physical environment may need to be modified because it is a direct part of the problem (e.g., insufficient space for exercise) or because changing the physical environment can help solve the problem.



• Example 1: In a shared, roofed kennel, comfortable, personal/individual doghouses with good visibility can divide the physical space in a way that allows the dogs in the kennel to choose not to interact. The doghouses all provide individual shelter so the dogs are not all crowded in the kennel in one place. As long as no bullies are present, this design can relieve social stresses imposed by group housing.


• Example 2: The dog becomes aroused and destroys the mail every day when it is put through the slot in the door. If a mailbox is installed at the fence, the mail carrier does not have to come to the door, and the dog does not become aroused. Also, the dog can no longer destroy the mail.


• Example 3: The dog meets the criteria for a diagnosis of territorial aggression and constantly monitors approaches to the house. When a person passes on the sidewalk, the dog begins to snarl and lunge at the window as soon as the person comes into view and continues to react until the person passes from view. A gate could be installed to keep the dog in the back of the house. Opaque film, curtains, or blinds could be installed on the window so the dog could not see the people passing.


• Example 4: The client’s cat sits in the window. Whenever she sees the neighbor’s cat come out the cat door and sit in the sun in her own yard, the client’s cat becomes distressed and sprays the window. Closing the door to the room where the window is will not “fix” the cat’s behavioral response, but it will stop it from being triggered. This may be enough of a change for the client. If the cat is otherwise distressed, this is not enough of a change for the cat, regardless of whether the client is content. However, closing the door may help lessen the frequency with which the behavior is triggered, which, when combined with medication, may be sufficient to raise that cat’s reaction threshold. Closing the door also allows the client to avoid having to clean up sprayed urine, which helps the client to understand the cat’s needs separate from her own anger and disgust.


• Example 5: The dog meets the diagnostic criteria for and has been diagnosed with inter-dog aggression secondary to GAD and noise phobia. Any loud, echoing noises make the dog more reactive and worsen the GAD. When this happens, the dog threatens his housemates. By having the dog wear Mutt Muffs (www.muttmuffs.com), the overall arousal level is kept low, the GAD triggers are minimized, and the probability of a dog fight is lessened.

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Aug 15, 2016 | Posted by in SMALL ANIMAL | Comments Off on Changing Behavior: Roles for Learning, Negotiated Settlements, and Individualized Treatment Plans
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