struggling with their dog’s aggressive behavior

i n t e r v i e w Overcoming Fear of Vet Visits

In this first of a two-part interview, Susan Nilson and Angelica Steinker speak to Petra Edwards about her recent studies that investigate dogs’ experiences at the veterinary clinic as a means to find out how fear and distress could potentially be reduced

Based in Adelaide, Australia, Petra Edwards is currently working on her Ph.D, which focuses primarily on how dogs experience visits to the veterinary clinic while also looking at possible strategies that could be implemented to reduce or prevent stress.

Last year, she and her coresearchers published the papers, Fearful Fido: Investigating dog experience in the veterinary context in an effort to reduce distress and Investigating Risk Factors That Predict a Dog’s Fear During Veterinary Consultations in an effort to see what measures could be implemented to reduce the levels of fear and/or distress experienced by many dogs when they go to the vet.

There are a number of reasons why stress during veterinary visits is counterproductive, including “the negative impact of stress on longterm health; how frequently a guardian brings their dog to the veterinarian; the veterinarian’s ability to accurately diagnose health concerns; and, stressed dogs can place veterinarians at greater risk of injury.” (Edwards et al., 2019a).

Yet, as the researchers also point out, all dogs will require veterinary care during their lifetime, and each of them will experience their vet visits differently: “From the dog’s perspective a ‘routine’ veterinary visit encompasses walking into a strange place with slippery surfaces, being surrounded by strange sounds, sights, smells, and potentially stressed animals (Hewson, 2014), and then being handled or restrained, while potentially enduring painful or invasive procedures.” (Edwards et al., 2019a).

“At this stage, the research indicates that veterinary visits are stressful for at least some dogs, but we don’t know exactly how common it is,” said Edwards (P. Edwards, personal communication, 2020). “Previous studies vary in their estimates of prevalence of fear and/or stress at the vet. Last year, we published a study from a large worldwide sample that looked at predictive factors for dogs fearful of their veterinary visits and found approximately 40% of guardians reported their dogs showed some form of fear at the vet, and one in seven dogs displayed severeextreme fear (Edwards et al., 2019b).

“There are lots of aspects of a veterinary visit that may exacerbate a dog’s fear or stress response, but unfortunately there isn’t enough research yet to confirm which aspects will make the most difference. The review of the literature Fearful Fido: Investigating dog experience in the veterinary context in an effort to reduce distress (Edwards et al., 2019a) provides some useful tables summarizing the different approaches people and veterinary clinics can use to help ameliorate a dog’s stress or fear during veterinary visits.”

“I don’t want to take my dogs’ good behavior at the vet for granted. My ability to cope with various things that life throws at me is constantly evolving, I see no reason why our dogs would be any different and I want to give them every chance of success as long as it’s safe.” - Petra Edwards

© Petra Edwards Petra Edwards (above, with Gus) has recently published two papers that examine how dogs experience vet visits and identify some of the risk factors that may promote a fearful response

Veterinarian’s Office and Staff

BARKS: In my (SN) experience, vet offices are not necessarily always set up with the animal in mind – e.g. reception areas (which can get noisy) may be located right outside the treatment rooms, or the practice entry doorway might be located right next to one of the treatment room doors, causing a potential bottleneck if both doors open at the same time, or the waiting area is set out more for humans than considering the needs of, say, cats who do not want to be near dogs, or dogs who do not want to be situated near other dogs etc., or floors may be slippery. What can be done in terms of actual setup to avoid adding to already elevated stress levels?

Petra Edwards: I think veterinary clinics often seem to be built with a focus for practicality, or are existing properties converted into a veterinary space, rather than built with companion animals in mind. Unfortunately, this field of research is only just gaining traction, so we don’t yet know the extent to which clinic layout or surfaces (or smells) play a part in a dog’s fear or stress. Having said that, from a ‘common sense’ per

spective, there are lots of things that can be done that might help a dog (or cat) feel more comfortable when they visit the vet. Some of these things include: • Separate waiting rooms for dogs and cats. • Using a target or ‘Go Find’ behavior to encourage dogs onto the weigh scale of their own accord (without a lure or forcing them). • Weigh scale placement and approach – walking toward or practically into a wall might be confusing for some dogs. • Bringing a nonslip mat for your dog for the wait and consult (especially if they get examined on a slippery table). • Bringing your dog’s favorite reinforcers – food and/or toys to help keep them calm and focused on you in the waiting room and to use consistently during the consult. • Sitting away from other dogs or animals while you wait wherever possible. • Leashes that are 2m (6ft.) or less in length, and that do not extend, can also help your dog not encroach on other animals’ personal space (social interactions are best done in less stressful environments – vet visits aren’t for socialization). • Asking to be taken straight into a consult room, or waiting outside in the car (weather permitting) until a consult room is ready. • Paying after the dog is secure in the car (weather permitting).

To that end, simply requesting any of the above might help highlight the importance of the layout and structure of veterinary visits, and hopefully help veterinary staff make those recommendations for other clients too.

BARKS: Same question for treatment rooms that often feature high ta‐bles, slippery metal tables, small rooms etc. What physical changes could be made to help alleviate stress?

PE: Again, there’s not much research (yet) on what exactly causes, or will help reduce a dog’s stress in the consult room. However, examining animals where they are most comfortable (wherever possible) will help, especially on the floor (but even in the guardian’s lap). Affordable nonslip, washable bath mats can help with slippery flooring or tables, and a mat from home might help with calming smells. If the waiting room is empty, perhaps staying in the slightly larger space might be beneficial. Or guardians or staff might be able to make the space more inviting with some toys on the floor or food treats hidden around the room.

BARKS: What about brightness, color, scent, sounds? How can these be manipulated to make the environment less stressful?

PE: A recent study by Stellato et al. (2019) found that background noise within a clinic was less of an influence on fear responses than the veterinary handling itself. The impact of sounds should still be considered, as some dogs are more noise sensitive than others, but background noise is unlikely the thing causing a dog’s fear at the vet. I can’t think of any other studies that looked specifically at brightness, color or scent – it’s likely these things play a small part in what helps dogs recognize veterinary clinic as ‘The Vet,’ but we just don’t know for sure. I imagine anything that helps make a clinic look or feel more homely will help – less clinical, more plants, sofas, open windows to remove chemical smell, etc. DVM360 has some great recommendations for color palettes and clinic design that might help interested clinics get started (see Resources).

BARKS: What is your opinion on the use of DAP and classical music/spe‐cial “dog” (or “cat”) music as destressors?

PE: At the moment, the research on the efficacy of their use is slightly

“...there’s not much research (yet) on what exactly causes, or will help reduce a dog’s stress in the consult room. However, examining animals where they are most comfortable (wherever possible) will help, especially on the floor (but even in the guardian’s lap).” - Petra Edwards

contentious, but I don’t believe there is any evidence that they will make anything worse. My personal opinion is that these complementary therapies might help the dog feel slightly better, but extreme fears are complex and likely very hard to overcome. I’m sure they will help some dogs with mild stress at the vet cope better, and if they can’t hurt, why not use them?

BARKS: What role does trigger stacking play in terms of the stress levels experienced during a vet visit? How can this be mitigated?

PE: I first came across this from an awesome infographic, The Trigger Stacking Effect by Yaletown Dog Training (see next page, bottom left, and Resources) and through reading more about ‘spoon theory,’ which is definitely worth reading more about both if you haven’t already (see Resources). It makes just as much sense in a veterinary context – little things will add up in quick succession without giving the dog a chance to process or ‘destress.’

These triggers might start at home with putting a harness or leash on, going in the car, arriving at the clinic, walking in, weigh scales, waiting, greeting staff, being around other animals, sights/sounds/smells/ slippery surfaces, walking into the consult room, the examination, etc.

© Can Stock Photo / gpointstudio There are a number of measures that can be taken to help an animal feel more comfortable when they visit the vet, including separate waiting rooms for dogs and cats, and sitting away from other animals while you wait

And each set of triggers that adds up for each dog will be different based on their perspective and history. What this means is that dogs are likely already slightly stressed before they even enter the clinic – and may be way over threshold by the time the actual examination comes.

Training cats to go into their carriers was found to help reduce stress behaviors in transport and also the length of the veterinary consult (Pratsch et al., 2018), so it makes sense that the same (reinforcing for calm behavior while putting leads and harnesses on, car travel and arrival at the clinic) will benefit dogs too.

Another study found that dogs showed less fear when their guardians interacted with them in a positive, supportive manner in comparison to guardians who were quiet (Csoltova et al., 2017). But other than that, we don’t know enough about a dog’s veterinary experience from a scientific perspective yet to say (with confidence) exactly how we can mitigate this.

However, we do know a lot about learning theory. Training for cooperative care can be incredibly beneficial and empowering for pets and their people. Guardians could also look for a vet and/or vet nurse that has additional low stress handling or fear free certifications (e.g. Fear Free Pets).

Being aware of the triggers for each dog, observing their body language and responding appropriately could help too. The following are only some examples that might help remove a trigger or two from the stack. If a dog:

“From the dog’s perspective a ‘routine’ veterinary visit encompasses walking into a strange place with slippery surfaces, being surrounded by strange sounds, sights, smells, and potentially stressed animals (Hewson, 2014), and then being handled or restrained, while potentially enduring painful or invasive procedures.” (Edwards et al., 2019a).

Is scared and/or reactive around other dogs, waiting outside (weather permitting) or going straight into a consult room. Doesn’t like people, asking vet nurses to avoid approaching may help. Hates slippery floors, bring a nonslip mat, or ask for the examination to occur in the car park, in the car, or other courtyard type area (as long as it’s safe for the veterinarian to do so).

BARKS: Can you talk a little about chemical restraint vs. manual re‐straint? The pros/cons of each?

PE: As I’m not a veterinarian, I wouldn’t feel comfortable providing recommendations about the different types of chemical restraint and the pros or cons involved for each dog. One study found that chemical restraint was beneficial (for healthy dogs cleared for sedatives) over manual restraint in that it showed trends for improving behavior and cooperation in subsequent visits within the study, and was generally quicker and involved less staff (Barletta & Raffe, 2016). Because of that, I think of chemical sedation as part of a ‘preventingfearofvet’ toolbox. Personally, if my veterinarian agrees shortterm sedation is safe for my dog, and it won’t inhibit a diagnosis, I prefer this in situations where the examination might be overtly fear inducing or painful. Likewise for shortterm anxiolytics like Trazodone. I don’t want to take my dogs’ good behavior at the vet for granted. My ability to cope with various things that life throws at me is constantly evolving, I see no reason why our dogs would be any different and I want to give them every chance of success as long as it’s safe. If you do need to use manual restraint, I recommend pretraining as much as possible. If it’s not urgent, reschedule the consult and practice the manual holds the dog needs to be okay with, invest in a good forcefree trainer, and use lots of counterconditioning and/or positive reinforcement for remaining calm. If your dog needs a muzzle –purchasing a basket muzzle and training your dog to love it at home, means they don’t have to have a strange, stressscent © Yaletown Dog Training filled, improperly fit muzzle on them at Reprinted with permission the clinic.

© Can Stock Photo / ckellyphoto A nonslip mat or towel with a familiar scent may help an animal feel more secure if they usually get examined on a slippery table

BARKS: What role can veterinary staff play in the destressing process?

PE: Some things vets might be able to help with are to: assess the structure and layout of the veterinary clinics; scheduling (are consults too close together?); consult length (some dogs may need longer consults); use of DAP or classical music; how they approach and interact with each dog; type and value of treats used; and, being able to accurately identify and respond appropriately to body language.

Being aware of each dog’s triggers, and writing short notes on the clinical record for each dog and how they coped might help other staff interact with that dog differently next time (e.g. ‘Fido hates being petted on the head,’ ‘Rover’s favorite treat is chicken,’ ‘Bella can’t wait near other dogs – straight into consult room’ etc.). Veterinary staff can also upskill through certification programs like low stress handling or fear free pets, which will help provide a much more detailed approach to each aspect of veterinary care in an effort to reduce distress.

I think we’re lucky in that there are a huge range of recommendations to reduce fear that work very well anecdotally (see tables 1‐5 in Fearful Fido), and so I would encourage veterinary staff to look through each of the options and pull out any that they can do feasibly and with the support of their clinic. Perhaps clinics could employ a new strategy every month (or quarter?) and keep adding them on as they go through the year. That way change might feel less overwhelming as new habits form, but there’s a consistent evolution toward focusing practice on reducing stress overall.

BARKS: “Veterinarians treating dogs trained with aversive methods should be aware the dogs may be more susceptible to experiencing dis‐tress during their care.” (Edwards et al., 2019a). Can you expand on this?

PE: To be clear, we don’t know if there is a link between positive punishment (the application of an aversive as a consequence for an unwanted behavior) and fear at the vet (or risk to veterinarians) – this hasn’t been studied yet. However, positive punishment is associated with increased problem behaviors, stress and aggression. The same correlations are simply not observed with the use of positive reinforcement (the provision of something pleasant as a result of desired behavior).

© Can Stock Photo / thesupe87 Examining animals where they are most comfortable (wherever possible) may help reduce fear and stress, e.g. on the floor

As such, positive punishment can be another trigger in the stack, meaning they may be more stressed or prone to aggression at the onset of the visit. There may also be less warning a dog is becoming increasingly distressed, which could put veterinary staff at risk of injury. Suppressing unwanted behavior (through punishment) isn’t the same as having dogs actively engaged and cooperating eagerly in their own health care through positive reinforcement training techniques.

BARKS: Do you have a preference for low stress handling vs. fear free? If so, why?

PE: I prefer any approach that actively and thoughtfully caters to the dog’s emotional state and wellbeing as a priority, over and above nonurgent veterinary care (critical care is a different story of course). I think the priority is that you need to have a basic understanding of how counterconditioning (and positive reinforcement to a certain extent) work, and then be imaginative about how you can employ them in a veterinary context. I have completed the initial Fear Free certification and really enjoyed it – I thought it was insightful, with a great selection of practical and common sense examples and ideas for modifying interactions with dogs to reduce fear/ stress in every aspect of the veterinary visit. The low stress handling university is on my list of things to learn.

BARKS: “Strategies to reduce stress will be most successful where they can be adapted for each dog’s unique perception and experience.” (Ed‐wards et al., 2019a). How can this be done?

PE: This is more a suggestion that there is likely no onesizefitsall approach to reducing distress in the veterinary context. Stress is mainly based on the perception of the stressor. Therefore each dog will have a different perception of each aspect of their experience – which triggers do and don’t add up will be unique for every dog. For example – booking a consult when the clinic is quiet for a dog fearful of other animals might work best for one dog, but for another a nonslip mat might make the most difference. I would recommend it best to have as many ‘easy’ strategies to reduce stress in place as possible for every dog, and then adapt for each individual dog as needed.

Summary

BARKS: You conclude Fearful Fido by saying that “stress experienced by dogs visiting veterinary clinics is a complex issue.” Can you sum up the complexities in a nutshell, i.e. what can be done to alleviate what is ob‐viously a very common problem?

PE: The journey that leads to dogs becoming fearful of their veterinary visits is complex because, to our best understanding of the research so far, there are so many different moving parts to a veterinary experience. These can include, but aren’t limited to, their: • Previous experience. • Interactions with people or other animals. • Associations and history with handling and grooming. • Idiosyncrasies of audible or olfactory sensitivities or walking on slippery surfaces. • Pain or other symptoms they’re feeling. • How they cope with car rides or being on leash. • Whether they’re hungry, thirsty, tired or stressed from the weather, etc.

And how each of these things all interact and accumulate on any given day. I imagine there will be no onesizefitsall approach for all dogs, and all veterinary staff, in all clinics. The Fearful Fido review (Edwards et al., 2019a) provides a list of the strategies that might help for anyone interested. More research is needed to learn more about what aspects of the visit contribute most to fear, and which interventions are most beneficial in reducing it. I am so excited to see research like this gaining traction and hope more guardians and vets can feel empowered to focus on our pets’ emotional wellbeing as part of the veterinary industry standards of care. n

Study Article References

Edwards, P.T., Smith, B.P., McArthur, M.L., & Hazel, S.J. (2019a). Fearful Fido: Investigating dog experience in the veterinary context in an effort to reduce distress. Applied Animal Behaviour Science (213) 142 Edwards, P.T., Hazel S.J., Browne, M, Serpell, J.A., McArthur, M.L., & Smith, B.P. (2019b). Investigating risk factors that predict a dog’s fear during veterinary consultations. PLoS ONE 14(7)

About Petra Edwards Petra Edwards holds the Professional Canine Trainer accreditation through the Pet Professional Accreditation Board and has a Bachelor of Science (Hons), with a specialization in animal behavior. She is also a Fear Free certified professional and has her CAP 1 and 2 qualifications in clicker training.

She has been involved in the dog training industry since she was 12, when her mother, Mim Edwards, started Adelaide Pet Dog Training. She is passionate about animal behavior and welfare and the amazing achievements and relationships that force‐free training facilitates. She is currently undertaking a Ph.D, analyzing how dogs experience veterinary clinics and looking at strategies to reduce or prevent stress.

She and her partner share their home with their Rottweilers, Gus (pictured on p.30) and Gwen.

References

Barletta, M., & Raffe, M. (2016). Behavioral response and cost comparison of manual versus pharmacologic restraint protocols in healthy dogs. Canadian Veterinary Journal 57 258–264 Csoltova, E., Martineau, M., Boissy, A., & Gilbert, C. (2017). Behavioral and physiological reactions in dogs to a veterinary examination: owner-dog interactions improve canine well-being. Physiology and Behavior 177 270–281 Stellato, C., Hoffman, H., Gowland, S., Dewey, C.E., Widowski, T.M., & Niel, L. (2019). Effect of high levels of background noise on dog responses to a routine physical examination in a veterinary setting. Applied Animal Behaviour Science 214 64-71 Pratsch, L,. Mohr, N., Palme, R., Rost, J., Troxler, J., & Arhant, C. (2018). Carrier training cats reduces stress on transport to a veterinary practice. Applied Animal Behaviour Science 206 64-74

Resources

Fear Free Pets Gifford, B.E. (2019). What is the Spoon Theory? Lewis, H.E. (2014). Building your veterinary practice color palette. DVM360 Lewis, H.E. (2015). Fear-Free: What you see is not what the cat or dog gets. DVM360 Yaletown Dog Training. (2017). Dogs do not bite “out of the blue”

Susan Nilson BA (Hons) DipCABT PCBC-A is editor of BARKS from the Guild and a Reuters-trained journalist with over 10 years’ experience in print journalism in Europe, Asia and the Middle East. She also studied feline behavior under the tutelage of Prof. Peter Neville at the Centre of Applied Pet Ethology (COAPE) in the United Kingdom and completed her diploma in companion animal behavior and training with COAPE in 2005. She is also an accredited professional canine behavior consultant through the Pet Professional Accreditation Board. In 2018, she co-authored Pet Training and Behavior Consulting: A Model for Raising the Bar to Protect Professionals, Pets and Their People.

Angelica Steinker PCBC-A owns and operates Courteous Canine, Inc. DogSmith of Tampa, a full service pet business and dog school specializing in aggression and dog sports. She is the national director of training for DogSmith Services, and co-founder of DogNostics Career College.