Of dead dogs and unmet expectations
This is the story of two very different canine patients who met the same end: their people had them euthanized because of their behaviors.
That's what the clients told me; however, I am not wholly sure that this conclusion accurately reflects cause and effect. I don't think the behaviors are unimportant, but I have begun to think that unmet expectations may be more important.
As I pore over record after record of distressed dogs and their frantic people it is impossible not to recognize one glaring correlation. The clients who euthanize their dogs have almost all ticked "yes" for the question: Have you considered euthanasia? These clients are also the only group ticking "yes" for this question.
While dead dogs are exceptional in my patient population, I view these deaths, for the most part, as indications of my failure to create compassionate solutions. Logically, this makes little sense, especially when one considers that no matter how awful the dog is, if my clients are determined to help that dog so that the dog's quality of life improves, the dog improves, and everyone is happier and safer.
There is clearly something about having mentally or emotionally made the transition to considering a life without the dog that renders the outcome more predictably ominous, despite progress or access to help.
The act of consideration of elective euthanasia may, in fact, be the action that breaks the bond. If this is so, it is because the human is changed in his or her thinking by this consideration, and the subsequent behaviors of the dog must then be understood within this context. The two cases that follow illustrate why this may be true.
Hoova was an 18-month old female, spayed Shepherd mix whom the clients had obtained at 9 months of age from a newspaper ad placed by the woman who had found her starving in the streets. She had ended up in a rescue home with other older dogs who had physical problems, so she was confined to a crate much of the day. She was incompletely housetrained when she entered the client's home. The clients had dogs in the past and felt committed to taking in mixed breed strays. In fact, they thought that Hoova would be a good companion for their male 12-year-old Shepherd mix. The wife was a social worker and the husband was a psychiatrist who worked with children with profound behavioral pathology. They had taken Hoova to one group lesson class and felt she was fine in the class.
Case study: Hoova
The concerns that the clients listed at their appointment primarily focused on Hoova's reactions to non-family members. She would bark and lunge at anything rapidly moving close to her, including guests to the home or neighbors passing by the fence or the yard. The clients felt that she was unpredictable. She had inflicted four bites to humans, two of which had broken the skin.
For the two bites that did not break the skin, the husband was between the dog that was barking and lunging, and kids playing with a ball. The dog grazed his leg. Once, Hoova lunged at bikers. When the husband pulled back on her lead, she bit the husband, barely scraping the skin. The last bite involved a visitor who reached for Hoova over her head and was bitten, although not severely. Additionally, Hoova had bitten the client's other dog once, breaking the skin, when he approached her while she was eating.
Meanwhile, during the course of the history we learned that Hoova vocalized if the clients were home but she couldn't see them, snapped or growled if pushed from the bed or couch, barked or growled at the approach of any unfamiliar dog or human, and would snap at any bicyclist, skateboarder or roller blader. The clients also emphasized that they had never tried to do anything forceful like bathing the dog or pushing her on her back after she growled at them on the bed.
The clients had consulted a private trainer in the Philadelphia area who recommended compulsion-based techniques including stepping on the dog's lead until her head was flush against the ground, "popping" her on a choke collar, throwing a tin of pennies when she was troublesome, and holding her down until she gave up. All of these interventions appeared to make the dog more reactive, so the clients sought the advice of a local training school that had an Association of Pet Dog Trainers (APDT) certified pet dog trainer (CPDT) on staff. After one visit, the CPDT recommended an appointment with me.
During the appointment Hoova was wary. She would take treats if she did not have to approach to get them. With time she became a little bolder, and would sit for treats if I didn't look at her. If I looked at her, her pupils dilated and she became a bit more disengaged, but did not get up and leave until I looked away.
Any movement or sound startled her, and for more than two hours she paced, panted and scanned continually. I was never able to approach her, and when she approached me I could see why the clients thought she was unpredictable: this was a scary dog and when people find dogs scary they perceive that they are unpredictable.
In fact, Hoova was wholly predictable. She signaled her concern in every step-but the key was going to be to get the clients to see Hoova as a troubled dog who could not respond to circumstances as normal dogs could.
This is one of the reasons that the new trainer wanted them to see me she was hoping that I could convince them that because Hoova wasn't normal, many of the things recommended to them would not work. In particular, the clients were committed to "correcting" the dog and "being firm" with her, despite the fact that this made her worse at every turn.
While scary, Hoova was not overtly aggressive. It was clear that every time she was faced with an unexpected provocative stimulus she'd react, but if she expected it, she was fine.
For example, the clients could call her from the bed, but if they pulled or pushed on her without warning, she growled. In this case her aggression was not about a need to control. It was about a need to have a rule structure or predictive expectation. Hoova's primary diagnoses were based in uncertainty: fear aggression and generalized anxiety disorder.
While Hoova was concerned with the world as a whole, she only reacted aggressively when she became truly afraid. Forceful behavior made her more afraid than anything else. While she cringed when the husband yelled at her, she also braced herself for a response and the husband had come to know that she would grab him if he reached for her at such times.
Treatment was going to involve changing the way in which the clients reacted to her so that she could learn to take the cues about her behavior from them and treating her anxiety with medication.
If the dog is to take cues from the clients, the clients cannot appear threatening. They need to guide the dog to calmer behaviors and reward all incremental steps. Hoova had learned that her people, particularly the husband, were "unreliable" from her perspective and that she had to be vigilant.
The husband was not abusive at all, but he yelled at her and believed that she must "obey". My job was to convince the client of two important conclusions.
- Many, if not all, of the normal dogs that respond to yelling respond despite what you do, not directly because of it. After all, normal dogs can tell when the threat is real.
- Abnormal, distressed, anxious dogs don't have the mental space to step back and ask if the threat is real; they can only react. One of the facets that characterizes generalized anxiety is that reaction precedes data collection about the broader context in which the stimulus occurred. When dogs so afflicted have no aggressive propensities, they withdraw and/or freeze. When they have some aggressive tendencies, they provoke and then must try to control the behavioral environment, as occurred in Hoova's case.
The medications discussed for Hoova were sertraline (Zoloft), a selective serotonin reuptake inhibitor (SSRI) that has been extremely efficacious in treating generalized anxiety disorder in humans, and amitriptyline, the cheap, entry-level, relatively non-specific tricyclic antidepressant (TCA) that benefits 75 percent of my patients about 75 percent of the time. I only suggested amitriptyline because it was likely to provide a faster, albeit lesser and non-specific, effect and we could piggy-back sertraline to it later, if needed. Both TCAs and SSRIs act to increase serotonin by inhibiting its recycling at the presynaptic receptor, but SSRIs tend to be more specific for the receptor subtype involved in anxiety. Both of these classes of medications appear to augment learning at the cellular level by facilitating the production of new receptor proteins, a process that takes three to five weeks to gear up to any significant level and six to eight weeks to become routine. Accordingly, the more specific that action, the better the effect for the patient. There is also a transient effect solely attributable to increases in circulating neurochemicals, and much of amitriptyline's early response may be associated with this.
Although the husband was a psychiatrist, the clients were not keen to use medication until they understood that it could facilitate the rate at which behavior modification was acquired - a finding from a large placebo-controlled, double blind study on the efficacy of clomipramine (Clomicalm) for the treatment of separation anxiety. The clients then decided to start amitriptyline, hoping for a rapid effect.
Discharge instructions included an outline of the predictable circumstances in which Hoova could be guaranteed to react and an emphasis on avoiding those circumstances. The clients were asked to give Hoova the option of quiet time in which they did not interfere if she seemed to want it and if it calmed her. They were asked not to put her in situations with any unfamiliar human who would provoke her-including those who were afraid of her or any large dog. The clients had a head collar but didn't like the concept of it because they thought it made her look aggressive. I pointed out to them that this was not false advertising and that their attitude about using a more humane device that could help prevent the dog from getting into sticky situations would say more about how she appeared than anything else. The clients were to practice the Protocols for Deference and Relaxation in circumstances in which she did not react before they even exposed her to provocative stimuli. I noted that teaching Hoova to relax and to alter her rule structure so that instead of just reacting she looked to others for cues was key to eventually working with more provocative circumstances. Finally, I noted that a "suspicious" nature may have served her well in her past life on the streets, but that she could learn to change her behavior if the clients always, always signaled their intentions clearly and not subject her to circumstances in which her default reaction was aggression.
These clients were work; they wanted to hold onto the concept that the dog 'should' be different. Comparisons to the children with whom the husband worked helped a bit, but I was still struggling with the image the clients held that the dog was 'rescued' now and she "should" be different. I told them that I had reason to believe with time and work she would be, but that now she was as distressed as humans who cannot cope. Finally, I admonished the clients with my standard warnings: the dog might get worse before she gets better because she now has a rule structure but will still have to provoke it to learn about it.
The trainer had come to the appointment and both the clients and trainer were excited about starting to practice teaching Hoova to relax and learn new rules. I received a few questions by e-mail over the next few days from the clients checking to make sure that their responses when Hoova didn't seem to be able to get it were correct. The trainer was working with the clients two to three times a week to help them progress, and they thought that they had already seen some calming effects of the medication and work.
Yet, less than three weeks after their appointment, Hoova was dead. The client and trainer both sent emails. The husband had seen Hoova sleeping and she looked so angelic he bent down to kiss her. She bit his lips. He took her to the vet and had her euthanized immediately. The e-mail from the client came after this, and was mostly about guilt and remorse, and how they wished they'd tried harder.
Next month: The second part of the series will explore what went wrong with this case. Was there a chance to save this dog?