Information on the possible risks to an animal’s health connected with the wrong kind of diet are often ignored by the pet’s owner. The owner claims that he loves his pet so much that he cannot deny his love in the form of food! The lack of therapeutic team work between veterinarian, client and pet is one of the most significant problems in the prevention and treatment of obesity in dogs and cats. It is worth remembering that some pathological states resulting from behavioural disorders can be at the root of obesity. For example, bulimia is a sign present in conditions of permanent anxiety and chronic depression. Moreover food restriction can worsen the signs of pre-existing behavioural disorders or cause such disorders. When devising a food restriction plan a careful behavioural assessment should be carried out.
THE HUMAN – ANIMAL RELATIONSHIP: THE NATURE OF CARE
In order to assess the importance of the human-animal relationship with regard to the origin of obesity, a recent pilot study (A Comparison of the Feeding Behaviour and the Human-Animal Relationship in Owners of Normal and Obese Dogs; Ellen Kienzle, Reinhold Bergler and Anja Mandernach) recruited 60 owner/obese dog couples and the same number of owner/normal dog couples. Processing the data collected with the help of a questionnaire, it was found that the bond between owner and obese dog is closer than that between owner and normal dog: the owner is less worried about contracting illnesses from his pet, he talks to the animal about lots of different subjects, he often sleeps with the dog, he watches over his pet while it eats, he gives the dog numerous meals and snacks and considers physical exercise and mutual collaboration to be of little importance. These observations indicate that feeding is a pleasing form of communication and interaction with the dog: the owner of an obese dog interprets every one of his animal’s needs as a request for food. Moreover he does not seem to pay attention to his own health and transfers not only his own eating habits, but also his lack of interest in physical fitness to his pet.
E. Kienzle and R. Berglery observed that only a small percentage of obese cats are able to lose weight by dieting. Nevertheless, controlled, clinical studies carried out in the laboratory showed that food restriction did enable cats involved in the study to lose weight. It is, therefore, possible to suppose a lack of compliance (therapeutic collaboration) by owners of obese cats. A recent study (Human-Animal Relationship of Owners of Normal and Overweight Cats; Ellen Kienzle and Reinhold Berglery) involved 120 cat owners, 60 normal animals and 60 obese ones. The study examined the human-animal relationship, some aspects of cat behaviour and some personal characteristics of the owners (for example, health and eating habits). The data, collected by questionnaire, showed that the relationship between owner and obese cat is closer than the one between owner and normal cat: the owner talks to the animal about lots of different subjects (job, family, friends and acquaintances), living with the cat reassures and consoles him and the animal is considered not only a member of the family, but also a baby to look after. The majority of the owners of obese cats watch their pet while they eat. Moreover the owners of normal cats use playtime as a prize, while the owners of obese cats offer their animals their favourite food. The risks of food ad libitum are open to debate. In fact only some of the studies undertaken found that free access to food and obesity are related. The majority of owners of obese cats perceive their animals to be thinner than they really are. One possible explanation for this could be that a pet cat almost never appears in public and consequently people only occasionally comment on the animal’s physical condition. In contrast to the data obtained from the research on dog owners, the majority of owners of obese cats are female.
The observations show that feeding is probably a pleasing way to communicate and interact with the cat: the owner of an obese cat interprets every one of the animal’s needs as a request for food. The authors have interpreted the differences found in the relationship between owner/obese dog or cat as indicators of excessive humanisation of the animal.
ccording to the zooanthropological approach, this relationship is different from simple interaction. In this relationship the animal’s subjectivity is recognized: the dog is a social partner, someone to talk to, a reference point. Humanising the pet allows a mutual exchange not only based on content, but also on social roles which are negotiated. This negotiation of social roles involves the definition of dimensions or levels, each distinguished by a specific function of transaction. One of the basic dimensions of the human-animal relationship is affection: the mutual exchange is based on protection, assurance, offering/asking for help, and on sharing emotions. The expression of affection varies according to the role assumed by the user: epimeletic (offers protection, care, safety, food) et-epimeletic (asks for protection, reassurance, safety, food). The human partner demonstrates protective behaviour towards the animal taking on the role of a parent and behaves like a typical parent. An epimeletic excess can unbalance the relationship and, consequently, cause a projective drift in the relationship. In the case of surrogate tendencies in which the pet assumes the role of animal–baby or animal–child the affective dimension must be integrated with the other dimensions of the relationship (recreational, epistemic, hedonic, social, affiliative) (R. Marchesini).
A psychological approach such as substituting a type of behaviour associated with food with a recreational behaviour can improve the compliance of cat owners who participate in weight-reducing programmes (E. Kienzle and R. Berglery)
THE CLIENT: THE STAGE OF CHANGE
The client’s reticence to start a therapeutic process should be interpreted as a problem of motivation towards change and a lack of awareness that a problem exists, rather than as unconsciousness resistance or an attempt to sabotage the therapist’s efforts. This different point of view becomes apparent when considering the client according to his level of motivation, awareness and preparation for change. The attitudes, expectations and interventions of the therapist must, therefore, be adapted. Prochaska and Diclemente (1983) proposed a theory of psychotherapeutic change in five stages. Each stage reflects the client’s perception of the problem situation. According to the authors there is a link between the stage of change and the fundamental psychological processes which must be used to produce a change. In 1992, Young suggested a simplified four-stage model which is well suited to our needs.
In the first stage, called the stage of pre-intention, the client is not aware of the problem situation and is completely reticent towards any attempt to take responsibility for it. According to the client the negative consequences of change are worse than the persistence of the actual situation in which he finds himself. In the next stage, of intention, the client is conscious of the existence of the problem situation, but he diminishes its importance, denies the need for help or believes that nobody can help him. This is followed by the action stage in which the client wants change and starts changing or looking for external help. The therapeutic project can, therefore, be put into practise. Lastly, there is amaintenance stage, whichconsists in preserving the results obtained and leaves scope for further improvement by the client. The authors include a possible relapse in this stage. The therapist must communicate the possibility of a worsening of the symptoms, so that the client’s loyalty is strengthened. In fact, when an event has been foreseen and announced, it is easier to face and overcome by the client–therapist couple.
According to this model, the veterinarian will have to adapt to the level of motivation and the stage of change of the client in order to achieve the therapeutic objective. Only in the action stage will it be possible to implement a therapy aimed at resolving the problem situation.
This concept has also been discussed by Malarewitcz (1996). There is a profound difference between request and therapeutic process. When a client makes an appointment with a veterinarian, he is making a therapeutic request and often the process stops at this point. In fact the client is satisfied by the contact he has made with the doctor and puts his fate into the latter’s hands. During the interview the veterinarian should transform the client’s request into a therapeutic process considering the client’s stage of change and adapting his own therapeutic intervention in consequence. It is, therefore, necessary to give the client the time he needs to assimilate the information received and prepare himself for change.
THE VETERINARIAN AND THE CLIENT: A THERAPEUTIC ALLIANCE
The first stage of the therapeutic relationship consists in establishing a therapeutic alliance with the client. The aim of the interaction is to give a positive impression through empathy, human warmth, sincere concern and the absence of judgement/prejudice. The therapeutic alliance implicates the perception of a job to be done together, of team work for a common aim. In order to promote a favourable interaction, the visit must be conducted within a properly defined setting (for example the examination room). The setting is the grouping together of the whole series of methodological conditions in which it is possible to observe, to describe and to understand the object of study, which allows objectivisation (B. Alessio). The fundamental aptitudes of listening, paying attention, eliciting expression and repetition are essential for the creation of the therapeutic alliance.
The aptitude to paying attention
This consists in displaying interest (in particular by using non-verbal communication) so that the client is aware of the therapist’s interest.
Maintaining visual contact
Visual contact is the most important indicator that a person is listening and is involved. It is, however, important to note that keeping eye contact for too long may not be appropriate. Visual contact should be interrupted occasionally, in a natural way.
Keeping an adequate distance
The physical distance can be varied but, when the therapist and the client are facing each other, it is advisable that there is about 1.50 m between them.
The posture
The therapist must assume a posture “of participation“ (Fig. 1 ): a relaxed but aler
t attitude which communicates willingness to listen. Leaning forward slightly during the emotionally charged, “crucial moments” of the interview communicates the interest of the therapist and his willingness to help the client. Moreover, an open posture, without crossing arms and legs, seems to encourage the client to be more open.
Gestures and facial expressions
The doctor’s facial expression must be appropriate to the emotions shown by the client during the conversation. Moreover, some actions (for example, nail biting, drumming fingers, playing with a pen, changing position frequently) could disturb the interaction, giving the impression of indifference and impatience.
Touching the client
Physical contact can be an important factor in communicating emotional involvement. A careful appraisal should be made of the client’s receptiveness, which kind of contact to use, and at which point in the conversation.
The aptitude to eliciting expression
This aptitude helps the client to talk about himself, in a non-coercive situation, without manipulation.
Invitations
An invitation indicates the readiness of the doctor to listen. Usually it is made during the first part of the conversation and clearly shows an absence of judgement. The therapist can make observations which invite the client to talk freely, such as “Can you tell me more about it? ”
Encouragement
These are very short verbal responses which communicate interest and involvement leaving the client free to choose which direction he wants the conversation to take. Quite often these are used together with nodding of the head. For example “I see”, “Yes”, “Certainly”, ”I agree”, ”I understand”.
Open questions
It is possible to ask two different types of questions: open or closed. Closed questions are used to ask for a specific piece of information and they require a short answer (often a simple Yes or No). Open questions permit a greater freedom of expression and yield a large amount of information without interrupting the listening process (For example: “Does your dog eat dry food?” is a closed question while “What does your dog eat?” is an open question). Moreover, these are often formulated as affirmative or imperative phrases so as not to give the client the impression of being interrogated.
Attentive silence
Quiet moments allow both the doctor and the client to think. Moreover silence is often the best reaction to painful revelations regarding the client’s life (for example, a bereavement). The therapist should stay quiet so he is present without interfering. Furthermore, silence may stimulate the client to express his own emotions.
Empathy
This is one of the most important instruments available to the doctor. It consists of being able to submerge oneself in another human being’s world: to understand the other’s point of view and emotions and make it clear to the interlocutor that this is so. Empathy must not be confused with sympathy, which is a feeling connected to the participation and communication of emotional states.
Aptitute to repetition
This aptitude conveys a sense of having been understood to the client. The term repetition means reformulating the client’s thoughts and emotions using different terms, so as to be able to communicate a real understanding of the words spoken. Repetition is a way of verbally conveying empathy and it works like a mirror which allows the client to confirm or invalidate the impression communicated to the doctor.
Paraphrasing
This technique is used to reformulate the basic message and transmit it with the words used by the person who is listening. The information returned is based on the content of the message rather than on the emotions transmitted by the person: the accent is on the facts, thoughts and conclusions of the client. Paraphrasing is used both to eliminate any confusion the doctor may feel and to repeat any thoughts or important behaviour contained in the client’s words.
Repetition of feelings
This technique is very similar to the previous one, but the accent is on emotions/feelings rather than on the contents. In doing this the doctor communicates his understanding of the feelings of anger, guilt or sadness justifying their existence without expressing judgement.
Summary
The summary focuses the doctor’s and client’s attention on the most important points of the visit, it synthesizes the content and the emotions/feelings expressed . It can be carried out at the beginning, in the middle or at the end of the visit. It is advisable to use the same words used by the owner during the visit. This technique proves to the client that the doctor has been listening carefully to the conversation and that he has understood everything that has been said.
RESISTANCE: FROM THE PET, CLIENT OR CLINICIAN
The term resistance refers to “the unconscious opposition of the subject under analysis to the doctor, preventing him from being able to understand the subject’s deep subconscious dynamics” (U. Galimberti). The approach to a patient’s resistance was described for the first time by Freud and his successors. Since then various authors have made contribution to this topic. It is important to note that resistance can be raised by all the protagonists of the therapeutic project: the pet, the client and the doctor. Resistance is a normal factor during therapy because the change wanted by the doctor causes an alteration in the homeostasis of the pet/client system.
Resistance from the pet
Dogs and cats can show resistance. In fact, during the establishment of the therapeutic process, food restriction may be at the base of the patient’s opposition to change. The doctor and client should negotiate the desired goal and what the pet likes: for example, a diet in exchange for walks in places where the dog likes to go (dog areas, parks, city centre) or, in the case of a cat, environmental enrichment (a little water fountain, climbing games, a scratch pole, a tunnel).
When planning a food restriction programme, the ethological characteristics of the species under consideration should be remembered. For example, the cat’s alimentary behaviour is very different from the dog’s. Many authors define the cat as a nibbling animal because it has from 8 to 19 little meals in 24 hours. This animal is, in fact, a solitary hunter which captures many small types of prey. Giving the animal food at fixed times could risk causing the onset of behavioural problems such as indoor anxiety (characterized by the appearance of aggressive predatory behaviour and irritation towards the owner), the tiger syndrome (characterized by the appearance of aggressive predatory behaviour towards the owner when it is time to eat), cohabitation anxiety (characterized by aggressive behaviour, caused by the animal’s irritation, towards other cohabitant cats) and for elderly cats some forms of senile dementia. Moreover the unease caused by the diet can make pre-existing behavioural problems worse.
The dog is a predator which hunts for larger prey in a pack. Furthermore, feeding has a social significance for this species. Food restriction can cause a worsening of pre-existing behavioural problems because of an increase in anxiety caused by the discomfort of being hungry. For example a dog affected by hierarchical imbalance (modification of the role and rank within the human-dog/dog-dog group) could develop a stage 1 sociopathy (a disease characterized by numerous symptoms including aggressive behaviour caused by irritability and dominating behaviour towards owners or other cohabitant dogs). It is, therefore, important to carry out a careful behavioural assessment in order to prevent the onset of behavioural problems or the worsening of those already present.
Optimal management of resistance by the pet includes:
- carrying out a careful behavioural assessment;
- using pheromonal therapy to reduce the discomfort caused by the diet (an environmental diffuser of a synthetic analogue of facial pheromones for cats, an environmental diffuser of maternal appeasing pheromones for dogs);.
- progressively reducing the amount of food or gradually changing the brand.
- for dogs, combining the affective dimension (et-epimeletic) with other relationship dimensions (for example, recreational–cognitive or social–collaborative);
- for cats, integrating the affective dimension (et-epimeletic) with other relationship dimensions (for example recreational-performance or recreational–fun).
Resistance from the client
In the action stage, the client wants to change, but because the process is painful, he unconsciously refuses. Every action involves a reaction: change initially causes avoidance and opposition.
Optimal management of resistance by the client includes:
- asking all the family members to take part in the visit because those absent can impede the change;
- observing the client’s body posture (for example, crossed arms and legs indicate resistance);
- asking the client to make the smallest changes possible;
- suggesting to the client that he implements the change, initially, only for a week, just as an experiment;
- integrating the affective dimension (caring) with the other relationship dimensions (for example, recreational or social).
Resistance from the doctor
The doctor’s resistance also plays a part in the therapeutic process. Generally this opposition derives from the frustration felt when facing the eventuality of therapeutic failure. Resistance can be caused by many factors: motivation (therapist tries to persuade the client to implement the therapy without considering the latter’s stage of change), prejudice (the therapist suspects that the client will not follow the indications given and uses verbal and postural communication that causes a shutdown) and incompetence (the therapist does not believe himself to be qualified in that particular field and uses dismissive communication which confuses the client). Moreover, when a client is particularly nice, the doctor runs the risk of not keeping the necessary therapeutic distance to be able to implement the therapeutic process.
Optimal management of resistance by the doctor includes:
- putting oneself in the client’s place;
- showing empathy;
- explaining the diagnosis and therapy clearly and comprehensively without trying to convince the client;
- maintaining eye contact, an appropriate distance and adopting the correct posture.
CONCLUSION
As in human medicine, the concept of a relational dimension (mother – child) is becoming ever more important. In the past mothers were “educated” to concentrate above all on the dietary dimension (the quality and quantity of food) to the detriment of the relational dimension. Nowadays the trend seems to be quite the opposite, in that it is based on food on request, with the aim of protecting the mother-child relationship, neglected for so long. The veterinarian, when planning a food restriction programme, must consider numerous factors: the presence of behavioural problems, the pet’s ethological needs and the predominant dimension in the human-animal relationship. If this is done the therapeutic process will be successful.
Suggested readings
- B. Alessio, “Setting e dintorni: il significato del primo colloquio nella terapia comportamentale”, Veterinaria, monografia SISCA.
- O. Chambon, M. Marie – Cardine, “Les bases de la psychothérapie”, Dunod, Paris 1999.
- R. Colangeli, S. Giussani, “Medicina del comportamento del cane e del gatto”, Poletto Editore, Gaggiano, 2005.
- U. Galimberti, “Dizionario di psicologia”, UTET, Torino 2000.
- E. Kienzle, R. Berglery, “Human-Animal Relationship of Owners of Normal and Overweight Cats”, American Society for Nutrition. J. Nutr. 136: 1947S–1950S, 2006.
- E. Kienzle, R. Bergler, A. Mandernach, “A Comparison of the Feeding Behavior and the Human–Animal Relationship in Owners of Normal and Obese Dogs”, American Society for Nutritional Sciences. J. Nutr. 128: 2779S–2782S, 1998.
- R. Marchesini, “Canone di zooantropologia applicata”, Apèiron Editoria e Comunicazione S. r. l., Bologna 2004.
- R. Marchesini, “L’identità del cane”, Apèiron Editoria e Comunicazione S. r. l., Bologna 2004.
- R. Marchesini, “Fondamenti di zooantropologia”, Alberto Perdisa Editore, Bologna 2005.