Start the Behavior Conversation

By Graham Garrison

June, 2019

Behavioral medicine in veterinary practices isn’t trendy — it’s essential

young black Australian shepherd training in autumn

The reasons a client doesn’t bring up her pet’s behavior during a visit to the veterinary practice vary. For instance, there are times when the client is simply embarrassed by her pet’s behavior, perhaps feeling it’s her fault, and therefore she fails to broach the topic with her veterinarian, says Kenneth Martin, DVM, Diplomate, ACVB, and Debbie Martin, LVT, CPDT-KA, KPA CTP, VTS (Behavior), Veterinary Behavior Consultations. 

Other times, a client may assume that undesirable behaviors of her pet is “normal” or nothing can be done to change the behavior. 

Perhaps, previous attempts to “treat” the undesirable behavior have been ineffective, or the client believes the problem is directly related to her pet’s obedience training, rather than it being an emotional disorder.

Whatever the reason, behavioral problems aren’t something to make light of with clients. For veterinary medicine, it’s serious business. Behavioral issues are the most common reason for the relinquishment and/or euthanasia of healthy pets, say Drs. Kenneth Martin and Debbie Martin. “More pets lose their homes and lives due to behavior concerns than all combined infectious disease. Clients are lost, patients are lost, and human-animal bonds are forever damaged.”

According to experts who Vet-Advantage spoke to, preventive behavioral medicine holds the key to pet retention and providing a full and happy life for the pet and pet owner.

Lack of training

Karen L. Overall, MA, VMD, PhD, DACVB says she’s always known that fear, rough handling and entrapment were problematic. When she was 19, she worked in the oncology group at Children’s Hospital of Philadelphia (CHOP) and “saw how different medical care could be if you engaged sick kids in it actively and cared about their quality of life.”

The behavioral medicine “aha” moment for her in veterinary medicine was early in her residency. A pet owner brought in a dog who couldn’t stop spinning and chasing his paws and tail. And if he was being watched, he would cry nonstop. “For the first time I knew that that behavioral condition was wholly biological and I needed to learn how to fix it.” 

She walked immediately over to the psychiatry department and was hooked, “and really have never looked back. Any chance to make life less difficult for others is a gift.” 

However, Overall says the vast majority of veterinarians lack anything but cursory training in behavioral medicine. “Clinical experience is exceptional. So veterinarians are very aware that they might not know the answer and they don’t want to give misinformation. Also, in part because they lack training, veterinarians are uncomfortable with behavior questions.”

Not knowing the answers — or even what questions to ask next — puts veterinarians in an awkward situation with clients, Overall says. “They want to help, but they know there is a lot of myths and don’t want to have to struggle with a lot of client needs and questions which they are ill prepared to handle.” These two reasons are related, she says. Comfort level depends on knowledge.

There are also unrelated reasons. For example, many veterinarians have little tolerance for aggressive dogs, Overall says. Dealing with aggressive dogs takes too much time, demands too much physical and mental energy, and is a potential risk to the veterinarian, staff, and client. “And, veterinarians worry that these dogs can’t get better (they can!). Many specialists also don’t like seeing aggressive dogs for the same reason.”

But aggression doesn’t happen in a vacuum, says Overall. It’s a call for help. Rather than tell clients that it is “okay” when they apologize for the dog’s behavior, Overall encourages veterinarians to try another route — stop the exam, put the dog in the car, and talk to the client about the pattern and triggers of these behaviors. This process may reveal a way to help a distressed, sad dog and a worried owner, and guarantee a developed client. 

“You don’t actually have to know what you are doing — you can get out the books after you talk to the client,” she says. “But in anything except emergency situations, we’ve been trying to convince veterinarians to see aggression as a call for help, and as the only way the truly distressed dog can tell everyone how much they are suffering mentally. Forcing them to go through with the exam runs the risk of making them worse, and certainly cannot help them. Instead, calming them down and learning about them and why they respond this way can make all the difference.” 

The core discipline for veterinary practices

Being attentive to behavioral problems saves lives. It also keeps patients in the practice, says Valarie V. Tynes, DVM, DACVB, DACAW, Veterinary Services Specialist with Ceva Animal Health.

“A pet’s behavior is vitally important to the pet owner,” she says. “Behavior problems are a significant reason for pet relinquishments to shelters! Regardless of how much we love our pet, our relationship will quickly become strained if the pet is exhibiting what the owner deems to be bad behavior. It doesn’t have to be that serious a problem either; behavioral complaints by those relinquishing dogs to shelters can be as simple as ‘the dog jumps on people’ or he ‘counter surfs.’” 

Behavioral concerns aren’t just a peripheral issue or symptom. They are the entry level condition, says Overall. “If you help clients with distressed pets, they’re yours for life. On the other hand, if you scare those pets, those clients may leave. Clients who care enough to help a dog or cat with a behavioral concern are vested in the entire animal and will expect state-of-the-art care for all life stages. Only if veterinarians keep this large number of patients in the population, will the field develop the expectation of such care at all stages in the private practice world. Treating the whole patient grows the field financially and intellectually.”

That’s the practical answer, at least. The more complex answer is that behavior is the final integrating pathway of all organ system responses, Overall says. “The core discipline in any practice should be behavioral medicine. GI problems? There is likely a behavioral component. Breakthrough pruritus? Behavior. Ingestion of foreign objects? Behavior. Broken teeth? How did they do it? Check their behavior. Endocrinopathies that are tough to diagnose or control? Get a behavioral history. Fostering kittens or puppies and having difficulty with respiratory illness? It’s behavioral … calmer, petted, less anxious animals are more resistant to infectious disease. Seizure activity incompletely controlled? Anxiety may play a role and concomitant treatment may help. The list goes on, but everything we do is done because of what we see behaviorally, at some level.”

Having a veterinary practice that has a defining capability in behavioral medicine can provide a differentiating advantage over other practices, says Eric Shreves, DVM. “Helping the clients address and manage their pet’s behavioral issues will not only improve the behavioral health of the patient, but doing so will also strengthen the human-animal bond between the patient and client, helping to keep that pet in a happy and healthy environment.” 

In the U.S., greater than 40 percent of abandoned dogs are relinquished due to behavioral problems, Shreves says. In pet cats, behavior problems are still the most common cause of euthanasia. Addressing behavioral medicine not only helps to strengthen the human-animal bond, but also the practice’s bottom line. “It is estimated that veterinarians will lose approximately 15 percent of their patient base each year due to relinquishment to animal shelters and/or euthanasia,” he says. “This may be due to veterinarians being excluded from discussions regarding behavioral medicine. Less than half of pet owners seek veterinary advice when faced with an anxious pet. Clients are more likely to seek advice from the internet, breeders, and friends. Clients may often feel guilty about not properly training or handling their pet and may not even realize behaviors could result from a medical problem. Having behavioral medicine as a core competency in a practice can help break this trend and keep clients in-house while improving the patient’s quality of life.”

Better outcomes

At Veterinary Behavior Consultations, clients and their pets are seen on a veterinary referral basis from surrounding veterinary practices. After reviewing a thorough behavioral and medical history and discussing client concerns, the client is given a behavioral diagnosis, prognosis, and appropriate treatment plan for their pet. 

Behavioral modification, environmental modification, and training protocols are discussed and/or demonstrated by one of their skilled behavioral technicians. Treatment recommended by Veterinary Behavior Consultations often includes the use of nutraceuticals, pheromones, and/or behavioral medications to reduce fear, anxiety, and stress and help facilitate learning.

A majority of cases seen on referral at Veterinary Behavior Consultations will incorporate behavioral supplements and/or conventional medicines as a component of their treatment, the doctors say. “Medications and supplements when combined with behavioral and environmental medication can expedite learning and vastly improve behavioral outcomes,” say Drs. Kenneth Martin and Debbie Martin. “They are unlikely to be effective as a sole option therapy and are recommended to be combined with behavioral and environmental modification.”

The Veterinary Behavior Consultation doctors say it should be noted that any products or devices meant to inhibit or punish behavior should be avoided. “Corrections and punishment, although they can inhibit behavior, do not treat the underlying condition or motivation and will increase fear, anxiety, and stress in pets. When recommending products or referring clients to behavioral services, it is imperative that the approach is a positive one designed to enhance the physical and emotional welfare of the pet and pet owners.”

When it comes to behavioral medicine, a multi-modal approach is thought to be the gold standard when addressing these issues, says Shreves. “Pharmaceuticals, behavioral modification/training, and supplements are all tools for veterinarians to utilize when addressing behavioral concerns.” 

Overall says she’s a big fan of “better living through chemistry.” She uses medications in three contexts involving basic veterinary exams:

  • • To give before the visit so that the patient is calmer and happier. “We often start these 2-3 days before the exam.”
  • • To give during the visit if the patient becomes distressed, “so that we can achieve an anamnestic effect and not contribute to creating fear of the vet’s.”
  • • To give to the patient after the exam if they are still a bit worried or don’t like travel.
Cute puppy sitting near wet spot

Collaboration needed

Distributor reps can play an important role in adopting behavioral medicine practices, especially when it comes to properly evaluating products that can be used in the practice. Veterinary medicine is a field that is all about accurate information and teaching veterinarians and clients about science-based principles, says Overall. “We under-use and under-inform these staff with respect to most fields, but here is one where with some investment in accurate and practical information, they could do a lot of good. And, they get to see lots of practices — sharing tips that can work should be a forte.”

Collaborating with veterinary behaviorists and supporting education in behavior, such as through a lunch and learn within the veterinary practices, can help to get all team members involved, say Drs. Kenneth Martin and Debbie Martin. “When the team believes in a product, because of education on use, effectiveness, and what conditions they are most indicated, behavioral products will be supported and recommended often.”

There are numerous profit centers that can be generated by adding behavior services, says Tynes. These could include trained technicians who could charge for time spent desensitizing pets to veterinary procedures, longer appointments to give preventive behavioral advice to new pet owners and even consultations on choosing a new pet. “When pet owners know these services are available to them, many will take advantage of them.”

Tynes says the bottom line is when an owner doesn’t feel anxious or hesitant about taking the pet to the veterinary hospital, it results in better care. “If we invest the time to make visits fun for the pet or the pet owner, they will come more often. When pets receive better care because exams are more thorough and more frequent, they will live longer and happier lives.”

Naughty dog - dog in the middle of mess in the kitchen

Changing the Environment

Whether used in-clinic or at home, pheromones have become a popular approach to relieving stress in pets

Often pet owners won’t spontaneously ask about behavior because they don’t realize there are things the veterinarian can do to help reduce or eliminate the problem, says Valarie V. Tynes, DVM, DACVB, DACAW, Veterinary Services Specialist with Ceva Animal Health. Some pet owners are also embarrassed to talk about things like house soiling or things they think are bad manners. “It’s important for a veterinarian to ask about issues that could be a sign of stress or an underlying medical issue.” 

It’s also important for veterinarians to be up to date on the products, services, and training they can use to help their clients in-clinic, or at home. 

Pheromones can be a very effective part of the Fear Free™ practice, says Valarie V. Tynes, DVM, DACVB, DACAW, Veterinary Services Specialist with Ceva Animal Health. “A growing number of veterinary practices are discovering pheromone use in the clinic can make a big difference in how animals perceive the clinic environment. Many pets greeted with pheromones from the moment they enter the clinic remain less anxious and fearful and become less stressed. They are then easier to handle and do not learn to fear the visit.”

Among the benefits of using pheromones Tynes cited: 

Reducing stress behaviors. “Stress behaviors such as vocalizing, hiding, inappropriate elimination or damaging household items can be reduced by helping the pet feel secure and safe at home.”

Keeping the peace. Pheromones can provide comfort for a dog with separation anxiety by signaling everything is OK even though they are distressed about being alone, says Tynes. Pheromones also help for multiple animals living in one household. “Our FELIWAY MULTICAT pheromone helps maintain harmony among multiple cats sharing the same space. It can help prevent conflict among cats or keep existing conflict from escalating into aggressive behavior.”

Relieving stress from new situations. Any break in the routine can also make a pet feel fearful or stressed, says Tynes. “Travel, loud music, fireworks, visitors to the home, holiday traditions which are fun for us, are terrifying for many pets. Pheromones can be useful to relieve some of the signs associated with those feelings of stress.”

Ease of use. “Especially if the alternative treatment is giving an oral medication, most pet owners would much rather put a collar on their dog, plug in a diffuser or spray a bed or carrier a few times day than struggle to give their pet a pill.”

Repeat business. In addition, the fact that retail sales of pheromones by pet owners continue to grow, and repeat purchases are common, further demonstrate that clients like the products, believe they help their pets and they are using them at home, says Tynes.

Find Their Why

How could behavioral medicine as a core competence transform a veterinary practice? Dr. Karen Overall suggests your veterinary practice customers consider three ways:

1. Their patients will be happier, mentally healthier and valued. 

2. Veterinarians and their staff will be happier and genuinely be able to see how much of a positive difference they make. 

3. Veterinary practices will make more money. “These are the patients people give up on, but once they realize someone cares … the clients are committed. Charge for your time. You might be shocked.”

Getting Started with Skills

Karen L. Overall, MA, VMD, PhD, DACVB, has written extensively about how veterinarians and their staff can develop the skills and knowledge to start working with patient behaviors that they might have previously avoided. She provided a few “easy-peasy ways” to get started.  

Things that involve active responses from veterinarians and staff:

No. 1: Find out what is coming in the door before it gets there. A one-page questionnaire (available online, see AAHA guidelines) can be sent to clients and returned before the visit. Veterinary practices can use that to strategize the visit. Failing this, the receptionist can hand the questionnaire out. 

No. 2: Use stress scales. Veterinary practices can use them in the waiting room (receptionists get good at this). Use them on the scale, use them as the dogs enter the exam room and a few times throughout the exam. These are 5-point scales that take seconds to complete but can direct whether and how you go forward.

No. 3: Unless the dog or cat is used to being held on a table, leave him on the floor or a low bench or platform and sit down. Have the client sit down. Standing indicates higher levels of readiness to go and arousal for dogs than sitting. Leave cats and small dogs in their carriers if they are happier there. Veterinarians and staff can tell clients that carriers with top access are preferred/mandatory for the mental health of their pet.

No. 4: Offer the dog a delicious treat. String cheese or liver are good bets. 

No. 5: Look at the client, ask clear questions, wait for the answers and proceed. 

No. 6: Encourage the dog to come to you. Offer a stuffed Kong (whipped cream cheese, peanut butter, frozen EN or ID) or jar of beef, lamb or chicken baby food during the exam.

No. 7: Talk to the dog, go slowly, if you can keep a hand on the dog, and pet under the neck on the chest, not on the head. Leave the temperature until last. 

Things that don’t require active responses:

No. 1: Schedule appointments sanely. 

No. 2: Keep the waiting
room empty. 

No. 3: Separate dog and cat waiting areas, rooms, surgery and recovery areas.

No. 4: Let distressed dogs calm in empty quiet rooms.

No. 5: Use noise buffers, indirect and on demand lighting, play classical music. Use an app to play audiobooks for hospitalized patients (the cadence is calming). Get a dB meter and pay attention. If it goes much over 70 dB, dogs and cats will be on alert. If the hospital is too noisy, veterinarians and staff will also be reactive — 50-60 dB is great.

No. 6: Find and work with a positive, insured, certified dog trainer who can teach dogs and cats to ‘go to the vet’ and to offer their body parts for examinatio