Learning Objective: BRaiNWaSHiNg can Be good!

BRaiNWaSHiNg can Be good! DeSenSitizAtiOn AnD COunterCOnDitiOning DOne right Monique Feyrecilde, BA, LVT, VTS (Behavior) this program was reviewed and approved by the AAvSB race program for 1 hour of continuing education in jurisdictions which recognize AAvSB race approval. Please contact the AAvSB race program if you have any comments/concerns regarding this program s validity or relevancy to the veterinary profession. 20 THE NAVTA JOURNAL NAVTA.NET

Learning Objective: After reading this article, participants will have a clear understanding of classical conditioning, and be able to describe proper desensitization techniques. You have a feline patient with renal insufficiency in the ICU. Part of the orders are to try and get the patient to eat. You offer some fish flavored canned food, and your patient walks over, sniffs it and takes a few bites. She then salivates and walks away looking nauseated. The next time you offer the fish flavored canned food, your patient avoids the dish and refuses to even try the food. This behavior is called conditioned taste aversion, and is widely recognized in feline patients. Conditioned taste aversion is a form of classical conditioning. 1 Classical conditioning is the process by which a previously meaningless or neutral stimulus is linked with a meaningful stimulus. This link is a predictive relationship, where the meaningless stimulus predicts the meaningful stimulus consistently enough that the previously meaningless stimulus begins to elicit the same response as the meaningful stimulus. Scientific texts often use the terminology Conditioned Stimulus (CS), Unconditioned Stimulus (US), Unconditioned Response (UR), and Conditioned Response (CR) when describing classical conditioning. Let s use an example from human learning many people may be able to relate with: the sound of a dentist s drill. Some readers may have cringed while reading that sentence! You are at the dentist, and you need a filling. The dentist starts his drill (CS) and touches the cavity in your tooth. Your nerve block has not fully set up and you experience pain (US) and subsequently fear (UR). You may even flinch (second UR). Your dentist may give you more medicine or allow more time for the regional block to set up, but when he starts his drill again, you experience fear and flinch at the sound alone even before he tries to touch your tooth. You now have a conditioned response (CR) to the sound of the drill alone (CS), which was previously a neutral sound until your unpleasant experience. Sometimes a conditioned response can arise after a single learning experience, other times multiple exposures are required to establish a conditioned response. 1 Some other common examples of classical conditioning include thunder and lightning, the flash of police lights in the rearview mirror, or the sound of the ice cream truck driving through the neighborhood. When we are exposed to a stimulus we are classically conditioned to, we will respond involuntarily. This means the response is beyond our control and just happens to us. These responses include things like emotions, secretions, reflexes, etc. For example, I may flinch at a flash of lightning in anticipation of a loud sound even though lightning is silent. I may experience an adrenaline spike and racing heartbeat if I see police flashers in my rearview mirror, even if I have done nothing wrong. In the past, this stimulus predicted something unpleasant and overstimulating, and now the lights alone provoke that stress response. Conditioned responses can also be pleasant. When I hear the music of the ice cream truck, I may feel happy and salivate. When I smell a perfume normally worn by my best friend, I may smile and feel pleased. If I see a row of 3-of-a-kind on the slot machine, I may get very excited even before I receive any winnings. Tinkling music, perfume, or 3 similar pictures are all neutral on their own. The responses of happy emotions, smiling, and pleasure are all examples of responses which are classically conditioned. VETERINARY NURSING IN ACTION APR/MAY 2016 21

Some people refer to this as a hierarchy of exposure, an exposure ladder, or a desensitization hierarchy. Touch the limb exposure ladder for Nail trimming Shoulder Æ Elbow Æ Carpus Æ Paw Æ Toe Æ Toenail Table 1 exposure ladder for nail trimming. Hold the nail clippers while touching the limb Shoulder Æ Elbow Æ Carpus Æ Paw Æ Toe Æ Toenail Hold the nail clippers near the toe Place nail clippers over a toenail Tap the toenail with clippers Clip one toenail with clippers Clip multiple toenails with clippers veterinary treatment examples Classical conditioning happens every day in veterinary hospitals. The client whose dog takes off running as soon as the ear cleaner bottle appears, or the cat who can not get his insulin because he is hiding under the bed are the beneficiaries of this classical conditioning process. 22 THE NAVTA JOURNAL NAVTA.NET

An ear cleanser bottle is not, in itself, terrifying. Yet the bottle itself can cause a fear response in the dog. Why? Because the ear cleanser bottle predicted the unpleasant experience of ear cleansing. Through classical conditioning, the fear response to ear cleansing was transferred to the predictive stimulus, the bottle. The sound of a syringe wrapper opening or the sight of an insulin vial begin as neutral stimuli. When they predict a wrestling match followed by a painful prick, a conditioned response of fear can be formed. This classical conditioning process can make treatment difficult, unpleasant, or just plain impossible for pet owners. Common Classically Conditioned unwanted Behaviors Some common unwanted behaviors can be the result of classical conditioning as well. For example, a dog who is reactionary toward other dogs by barking and growling, may begin reacting only to the sound of dog tags, even when another dog is not visible or present. A cat with spinal pain may begin attacking hands even when the hands have not touched the cat or caused any unpleasant sensation.3 Sensitization and Desensitization In some patients, an unwanted existing classically conditioned response may need to be changed. Changing classically conditioned responses usually starts with desensitization. Desensitization is the process by which a certain stimulus is presented repeatedly so that the learner stops responding to the stimulus, having discerned it is not harmful. This process is also sometimes called graduated exposure. 2 With desensitization, the intensity of the trigger stimulus is carefully changed and modulated over time. It is important to progress with caution and careful planning when using desensitization, because the learner will be intentionally exposed to a stimulus which may have produced a fear, anxiety, or stress response in the past. 1 If the stimulus is not presented with care, the result may be the opposite of the desired response. In this case, sensitization can be an accidental byproduct of attempts at desensitization. 2 Sensitization is the process by which the response to a stimulus becomes more intense through repeated exposure. The response often becomes quite exaggerated, or out of context with respect to the intensity of the trigger stimulus 1. When a learner has become sensitized, the trigger can be presented at lower and lower intensities, and still provoke a very intense response. For example, if a child is riding on a long trip with a sibling and the sibling keeps poking the child, the common scenario might look like: Poke. Please don t. Poke. Stop it. Poke. Mom, Sam is poking me! (Mom: Sam, stop it! ) Poke. STOP IT!!! Poke. Sam gets punched in the shoulder. The stimulus of poke remained unchanged in intensity, but presenting it repeatedly caused progressively stronger responses in the learner. The response of saying, Please don t vs. punching someone are quite different, yet the stimulus of poking was unchanged. This is an example of sensitization. It is important to remember that sensitization is an unwanted side effect of repeated exposures to a stimulus when the intensity of the stimulus is not properly controlled. 2 Proper Desensitization Desensitization begins with identification of the trigger stimulus. The trigger stimulus is then deconstructed into a hierarchy of progressive approximations, which can be used for gradual controlled exposures over time. 1 Some people refer to this as a hierarchy of exposure, an exposure ladder, or a desensitization hierarchy. Take the example of someone who is fearful of spiders. A potential desensitization hierarchy for spider exposure might be: Photo of a small spider 6 away Æ Same photo 2 away Æ touching the photo Æ decoy spider 6 away Æ decoy 2 away Æ decoy 6 away Æ touching decoy Æ small spider contained in a safe enclosure 10 away Æ 6 away Æ 2 away Æ 6 away Æ touching the container Æ repeating the process with an open container Æ repeating the process with a real spider behind a partition where the learner approaches, etc. At each stage, the learner is asked to describe any anxiety they may be feeling. If the learner is feeling anxious, the intensity of the trigger was too strong for that stage in the desensitization plan, and moving back to a trigger intensity which did not provoke anxiety would be indicated. The smaller the approximations, the more successful desensitization will generally be. Because it is not possible to ask animal learners how anxious they are, but only infer based on their behavior, I always suggest breaking trigger stimuli into the smallest imaginable increments. The learner s comfort is the most important factor in desensitization therapy. If the learner is noted to have an unwanted response to the trigger stimulus, the intensity of the trigger was increased too quickly. Common ways to decrease the intensity of the trigger include increasing distance, decreasing size, decreasing sensory experience (volume of a sound, tactile intensity, strength of an odor, etc.), moving to a calmer environment. Failure to modulate the trigger stimulus appropriately can result in treatment failure, or worse, sensitization. Some patients may have a hard upper limit on how much of the trigger stimulus they will be able to tolerate, which seems VETERINARY NURSING IN ACTION APR/MAY 2016 23

exposure ladder for Subcutaneous injections. Patient comes to the handler Patient remains stationary Touching injection area Open a syringe wrapper Æ Handle syringe & medication vial Stroke with fingers Æ Stroke firmly Æ Tent skin gently Æ Tent skin firmly Æ Tent skin firmly and pinch Æ Tent skin firmly and pinch firmly Hold a syringe while touching patient Stroke with fingers Stroke firmly Tent skin gently Æ Tent skin and approach with syringe Æ Tent skin and approach with syringe, pinch skin Æ Tent skin and approach with syringe, tap with capped syringe Tent skin and simulate injection firmly with capped syringe Tent skin and simulate injection firmly with capped syringe Administer subcutaneous injection Table 2 exposure ladder for subcutaneous injections. immovable. These patients may benefit from combination therapies, pharmaceutical assistance, and referral to a specialist. Classical Counter Conditioning and response Substitution Pure desensitization alone is too slow, and too unreliable, for practical application for behavioral modification. 2 For this reason, we generally use desensitization in combination with classical and operant counter conditioning. Classical counterconditioning is the process by which a classically conditioned stimulus is reconditioned to provoke a new, preferred involuntary response. Operant counter conditioning produces a replacement voluntary response and is also called response substitution. To use classical counterconditioning in combination with desensitization, the desensitization stimulus hierarchy is determined in advance. Also, stimuli producing the desired emotional response are identified. To produce a learner who is happy and excited, stimuli which already cause this response are identified. Common examples include high value foods, toys, forms of play, increased distance from triggers, and happy verbal praise. In this process, the trigger stimulus is presented at the low level as planned in the stimulus hierarchy. The learner is then presented with something which provokes a positive emotional response. For example: A cat who fears the pet carrier. The client may walk to the closet where the carrier is kept, then produce the cat s favorite treat. Then the client might touch the doorknob or open the door, then produce the cat s favorite treat. Each step up the desensitization hierarchy now predicts something wonderful which leads to a pleasurable emotional response. The end goal would be for the presence of the carrier to make the cat happy rather than fearful. To incorporate response substitution, once the stimulus can be presented at a reasonable working level, the learner is then asked for a preferred behavior such as sitting, lying down, relaxing, or stepping away. When the learner responds accordingly, the desired item (treat, toy, talk, touch, attention, etc) is provided immediately. When done correctly, the trigger stimulus becomes the cue for the new emotion and the new, desirable behavior. Response 24 THE NAVTA JOURNAL NAVTA.NET

substitution must follow the rules of desensitization, keeping the learner under the anxiety and stress threshold during working sessions. If the learner is fearful or an anxiety response is triggered, the learner will be unable to experience the desired pleasurable emotional response, and will also be unlikely to be able to comply with the cued replacement behavior. When a learner is experiencing stress, fear, or anxiety, it is more difficult for them to comply with higher executive tasks like performing trained behaviors. 2 To use an analogy from the human model, imagine you are afraid of snakes. I ask you to place your feet in a cardboard box, and I then begin adding snakes to the box. Once there are several snakes touching you, I ask you to say your multiplication tables by 8 s aloud. The stress, fear, and anxiety of the snake exposure compromises your ability to recite the multiplication tables. Functional DS/CC for veterinary Care Prevention is everything. You can classically condition patients the right way from the start, to avoid the need for counterconditioning! Common stimuli which can benefit from classical conditioning the right way: Cat carrier, nail clippers, ear cleanser, toothbrush, grooming tools, injections, temperature measurement, physical examination components, physical manipulations/restraint, and more. When performing preventive DS/CC, the steps remain the same. First, a stimulus which could potentially cause a classically conditioned fear response should be deconstructed into its component approximations and a desensitization hierarchy or Done properly, desensitization attempts will not elicit any significant noticeable response from the learner. Animals should be monitored for signs of stress or anxiety and reassessed frequently. I tell clients that it should be about as exciting as watching paint dry. VETERINARY NURSING IN ACTION APR/MAY 2016 25

Each step is immediately followed by something wonderful happening, forming a predictive relationship. The end result should be a learner who anticipates the potentially feared stimulus with pleasure rather than anxiety. exposure ladder made. Second, an existing stimulus which provokes a pleasurable emotional response, such as a high value food treat, favorite toy, or favorite game is identified. Stepwise progress is made through desensitization hierarchy, using carefully graduated exposures where the intensity of the potentially fear provoking stimulus is controlled. Each step is immediately followed by something wonderful happening, forming a predictive relationship. The end result should be a learner who anticipates the potentially feared stimulus with pleasure rather than anxiety. If at any time the learner is showing subtle signs of fear or stress, including a lack of expected response from the planned pleasurable stimulus, the desensitization process needs to be slowed down to remain within the learner s comfort and capability. Preventive DS/CC examples When performing preventive DS/CC, each of the exposures on the exposure ladder is immediately followed by something wonderful like a high value food treat. With the example of nail clipping shown in Table 1, the interaction would progress with each step building on the last. Touch the shoulder Æ treat. Repeat as needed until animal responds to touch by anticipating a treat. Æ Touch the shoulder and slide to the elbow, treat. Æ Touch the shoulder Æ elbow Æ slide to carpus Æ treat Æ Touch the shoulder Æ elbow Æ carpus Æ slide to paw Æ treat. Each approximation should be predictable, and the stimulus should be presented in a consistent fashion. By touching the animal the same way each time and immediately providing a treat, we can condition the animal that each touch predicts a treat, creating a conditioned pleasure response to the touching. The animal should appear to anticipate the treat when the touching occurs. This anticipation is a good indicator that a conditioned response is emerging. Another suggested exposure ladder is provided for preventive desensitization to injections, such as vaccinations or insulin administration. Again, each step on the ladder should predict a pleasurable stimulus occurring for the patient. intervention DS/CCC example When an animal has an existing unwanted conditioned response to a treatment, desensitization and classical counter conditioning may be used to replace the unwanted conditioned response with a desired response such as a pleasant emotion rather than a fearful one. One common example is the owner who pulls out a bottle of ear cleanser and the dog immediately runs to hide. This dog has an existing fearful emotional response to the sight of the ear cleanser bottle, and responds with anxiety and avoidance even though no ear cleansing is occurring yet. To replace this unwanted emotional response, a desensitization hierarchy for ear cleansing would be outlined, and then each step in the hierarchy associated with a new stimulus, such as an amazing food treat like steak or chicken, or a toss of the tennis ball for a ball-crazy dog. Desensitization to an existing problem stimulus: Canine ear cleansing Approximations: Touch storage area of bottle, open storage cabinet, bottle visible, cotton balls visible, bottle approaches, cotton ball with odor of ear cleanser approaches, bottle/cotton ball approaches while touching the pet (progress through head, base of ear, cheek, base of pinna, tip of pinna, ear canal opening), apply a tiny amount of ear cleanser while touching the ear, apply gradually increasing quantities, actually cleanse ear briefly, gradual increase of duration up to full ear cleansing. Each approximation is shown to predict something wonderful like chicken bites, canned food, squeeze cheese, or an opportunity to chase the tennis ball. Eventually, when the owner touches the cabinet door where the ear cleanser is kept, the dog will show up to participate because of the anticipation of something wonderful happening! When the dog displays this new happy anticipation, the new conditioned response has been achieved. Conditioned responses like this one can relapse without maintenance. The act of ear cleansing, nail clipping, or giving an injection in the above examples will always be followed by something pleasant in order to maintain the favorable conditioned response. Some patients respond well if some variability is used, such as steak treats one day, and a game of ball the next. Other patients show a strong preference for a single wonderful item, and that item should always be the one provided. Functional DS/CC example for Behavior Patients For patients being treated for common behavioral complaints, here are a few examples of stimulus progressions. Unwanted behavior: Fearful lunging and barking at other dogs Approximations: A neutral helper holds a neutral helper dog 50 away; Helper approaches in increments of 2-5 but no eye contact; Repeat approaches adding occasional eye contact; Repeat approaches adding intermittent direct eye contact and interested social signaling 26 THE NAVTA JOURNAL NAVTA.NET

by the helper dog; Repeat approaches with sniffing, wagging or barking by the helper dog; Approach closely enough for the neutral dog to greet for 1-3 seconds; Approach closely and greet for a prolonged period. Counter Conditioning plan: Each approximation predicts and results in administration of cream cheese from a squeeze tube for the dog. Response Substitution plan: Once the patient can tolerate a dog being within 5 to 10 and is eagerly anticipating the food pieces, introduce the cue for Sit, Watch. Dog appears, handler asks for Sit, Watch, then immediately produces food pieces. If the dog is calm enough to perform Sit, Watch at distances less than 1, greetings can be permitted as outlined. Progressing through a plan like this one could take a day, weeks, months, or more depending upon the individual patient. It is important to have realistic and flexible expectations, and to realize that like the veterinary examples, some patients benefit from multimodal intervention and referral rather than DS/CC/CCC alone. Closing tips Remember, prevention is key. Classical conditioning done right from the start can be used to develop a strong, desirable emotional response. Demonstrating these techniques to clients during routine preventive care visits, especially when patients are young, can create a strong sense of teamwork between the client and the veterinary care staff. Clients who are taught how to employ basic desensitization and classical conditioning and counterconditioning are likely to experiment with these techniques at home, helping their pets tolerate medical care and husbandry more easily. When prescribing serial treatments such as injections, ear treatments, husbandry care, wound cleansing, etc., taking a few moments to teach the client how to prevent an unwanted classically conditioned response will enhance compliance. Many clients fail to comply with recommended treatments because they perceive the treatments are unpleasant for the pet. The pet may respond with fear or anxiety, may have become classically conditioned and hides or successfully avoids treatment. In these cases, the treatment can even become damaging to the human-animal bond. By recognizing the possibility for this process exists and protecting against it by including a behavioral component into treatment recommendations, practitioners can increase the likelihood patients will receive necessary treatment and clients will be satisfied with treatment outcomes. Clients should be advised that if an unwanted response, such as fear, stress or anxiety develops as a result of treatment, the veterinary team should be notified so desensitization should be used. Desensitization must progress only at the rate the learner can calmly tolerate. Progressing too rapidly can lead to side effects, such as treatment failure or sensitization. Sensitization to treatments can severely limit the client s ability to appropriately care for the pet, and can damage the trust between the patient, the client, and the veterinary team. Counter conditioning is best used in combination with desensitization to not only eliminate the unwanted response, but install a new, desired response. Operant counter conditioning, or response substitution, can be used to teach an alternate replacement behavior for long-term success. By understanding the science of classical conditioning, and how it occurs, practitioners can help patients avoid being classically conditioned to fear veterinary and husbandry care. Further, the veterinary team can help to reverse existing fearful responses to care by properly employing desensitization and counterconditioning with patience and careful planning. ReFeReNceS 1. Shaw, J. K., & Martin, D. (2015). Canine and feline behavior for veterinary technicians and nurses. Ames, iowa: Wiley. 2. Martin, G., & Pear, J. (2016). Behavior modification what it is and how to do it. London ;new york: routledge. 3. Mcsweeney, F. K., hinson, J. M., & Cannon, C. B. (1996). Sensitization-habituation may occur during operant conditioning. Psychological Bulletin, 120(2), 256-271. * these example situations are used to illustrate concepts and do not represent a treatment recommendation for a specific patient. Every patient is unique should have an individual plan created based on individual history, preferences, and response to the program. CONTINUING EDUCATION Quiz online visit VetMedteam.com and log in with your Vet Med Team Profile. Monique Feyrecilde, BA, LVT, VTS (Behavior) Monique is a veterinary technician specialist working full time in general private practice. She enjoys opportunities to educate veterinary professionals at conferences, in-clinic CE events, and through publications. Away from the clinic, Monique enjoys training her own pets and competing in agility, obedience, and sheepdog events. Currently, she is the president of the Academy of Veterinary Behavior Technicians. VETERINARY NURSING IN ACTION APR/MAY 2016 27