Your Clients: Stressed or De-Stressed?

Your Brain on Stress

We are constantly taking in and processing information from our environment whether we are aware of it or not. The human brain does an incredible job at recognizing danger, alerting us of trouble, and acting quickly to keep us safe. In an instant, our brain can send signals to our body that activate what most know as the “fight-or-flight” response. A small, almond-shaped structure called the amygdala may be tiny in size, but it has played a huge part in human survival. The amygdala is located in a core part of the brain responsible for basic functioning - think breathing, digestion, or heartbeat - and recognizes threats often before we are even conscious of them.

The neurobiological response to stress involves the brain triggering the release of a variety of hormones which serve specific purposes for the body. When the amygdala detects a threat, it jumps into action by sending an alert to the hypothalamus which acts as the command center for the brain. The hypothalamus then flips the “on” switch to the autonomic nervous system which consists of two main components: the sympathetic and parasympathetic nervous system. The sympathetic nervous system is the “fight or flight” mechanism while the parasympathetic nervous system is for “rest and digest,” or the opposing action to the sympathetic nervous system. A few key hormones are released into the bloodstream during both phases of the stress response. Epinephrine, also known as adrenaline, causes physiological changes such as constriction of blood vessels, more rapid breathing, and increased heart rate. When the threat subsides and the parasympathetic nervous system takes over, acetylcholine allows the blood vessels to dilate and the heart rate to slow, bringing a sense of balance or neutrality once again.

Why Does it Matter?

Stress is simply an inevitable part of life. While we are no longer cave people running from saber tooth tigers, we do still experience stressful situations that activate the same parts of our brain passed down by our primitive ancestors. Stress can be amplified in human healthcare settings, and veterinary clinics are no different. There is evidence that stress can even be contagious, causing similar responses in those who may bear witness to our own stress. This is not species-dependent, meaning your stress can cause your animals to become stressed as well. A study from 2019 examined the levels of a stress hormone called cortisol in dogs and their people. What they discovered was that the concentrations of cortisol were the same in the fur of dogs and the hair of their human counterparts (1.) This demonstrates that there is a significant degree of emotional mirroring between animals living together. Our more sensitive feline friends can even fall ill from stress, causing major health issues and expensive veterinary visits to try and ease their discomfort (2.) 

Just because stress is a normal part of life in veterinary medicine doesn’t mean we shouldn’t try to prevent it whenever possible. There are plenty of ways to try to prevent and minimize the stress response from happening for our clients, and ways to de-escalate if one of our pet parents’ amygdala fires off an SOS signal. 

One of the most fundamental ways we can set our clients up to be de-stressed in our care is to consider their sensory experience in our clinic. Sensory stimulation like sight, sound, and smell can elicit strong reactions in humans and pets alike (3.) The sensory experience begins as soon as clients arrive on the premises. The way your building looks, the size, cleanliness, and accessibility of the parking and outdoor areas, the lobby, and exam rooms are all important aspects of the experiences clients will have. Essentially, any client-facing part of the clinic should be considered opportunities for de-stressing. 

As an example, imagine again that you are the client and your cat is ill and has an appointment to see the vet. Your cat always fights you to get into her carrier, and you weren’t able to give her a dose of sedative in time. You get scratched multiple times as you wrangle your small tiger but finally get her in. You look at the time, realizing you are already 5 minutes late to the appointment. You rush over, dealing with horrible drivers during morning rush hour, and the only parking spot open at the vet is all the way across the lot. Trash and dog droppings are strewn about. Sweaty and out of breath, you finally get in the door. Within the first moments of arriving at the clinic your sympathetic nervous system is already fully engaged. Now imagine the ways your stress can amplify from here. As soon as you check in, you notice the loud buzzing of the extremely bright fluorescent lights. The only available seat is next to a rottweiler on a retractable leash whose owner glued to their cell phone. You realize that your cat is the only feline in a crowded lobby  full of very nervous dogs and they’re all very interested in what you have in that carrier. One of the largest ones just had an accident on the floor and the stench begins permeating throughout the waiting room. You try to focus your thoughts elsewhere but simply cannot stop yourself from feeling nauseated. The clinic phones are ringing persistently, and there is another cat  screaming from the other side of the treatment area door, sending distress signals to every amygdala, both human and animal, in the lobby. How are you feeling now? This is just one scenario out of countless possibilities where stress can compound just within the first few minutes of arriving for an appointment. By the time the veterinarian gets to see the patient and speak with the client, the adrenaline is already flowing. Many people lash out when their stress response is heightened, leaving staff vulnerable to negative interactions. 

How to De-Stress Your Clinic

In order to create a de-stressed environment, veterinary clinics should begin by examining the decor and layout of their clinics beginning with the lobby. This is the first area a client sees and can set the tone for the visit. Anticipating the needs of clients and pets could start with  having separate cat and dog waiting areas. Perhaps the CSR checks in regularly with owners waiting to let them know they haven’t been forgotten amidst another high volume day. Viewing natural stimuli such as wood, plants, or flowers can have a positive physiological impact on the autonomic nervous system when compared with a control (4.) Providing soothing natural stimuli can be as simple as having a couple of low maintenance non-toxic house plants on display in the lobby. 

Another way we can promote de-stressed clients is by using a part of our brain that developed as early human brains started to advance and grow. Communication, or the transfer of an idea from one person (sender) to another (receiver) is a critical part of interacting with one another. Communication can be verbal or non-verbal, with most communication being the latter (5.) In a veterinary setting the goal should be to verbally communicate in clear, easy-to-understand ways so that our clients don’t get lost to medical jargon. That alone could create a divide between the two parties rather than collaboration and teamwork. 

It’s important to also be aware of the non-verbal forms of communication that take place between clients and veterinary staff. A client could potentially perceive a veterinarian as impersonal or uninterested if there is a stream of simple yes/no questions, lack of eye contact during discussion, or if the vet is facing their computer the whole time while asking questions about the pet’s history. However, a veterinarian who asks open-ended questions, who makes appropriate eye contact and rephrases the client’s words to demonstrate understanding can help a client feel cared for and important. 

De-escalation and Repairing Ruptures

So what do you do if you’ve achieved serenity in your clinic, you do your best to be an excellent communicator, and a client still gets upset? Sometimes the nervous system is so activated that clients may not act in ways that they would have if they were in a more regulated state. This can cause them to raise their voices, become tearful, or even argumentative. Reactivity often stems from fear, and the response of veterinary staff members when handling a reactive human can be the difference between a client remaining stressed or becoming de-stressed. Earlier in the article we mentioned that stress is contagious. When dealing with an irate human, we may notice our own sympathetic nervous system becoming engaged. Being aware of your own response to the stress of another gives us an opportunity to utilize a coping skill like connecting with our breath so that we can enter an interaction in the most neutral, calm way possible. 

There is a commonly practiced breathing exercise in yoga called the 4-7-8 pranayama breathing technique. This involves taking a breath in for four seconds, holding your breath for seven seconds, and then releasing your breath for eight seconds. The idea is to repeat the breathing pattern at least five to ten times and check in with your body to notice any relaxing or soothing sensations. This technique has been proven to reduce anxiety and calm the nervous system in times of acute stress. 

Many people simply wish to be heard when they’re feeling upset. Practicing active listening with clients can demonstrate that what they are saying is truly being understood and retained by the recipient. Active listening can be demonstrated with both verbal and non-verbal cues. Verbally, we can say things like “uh huh,” “then what happened?” and “go on” which can serve as brief check-ins to indicate we are ready for more information. We can reflect and rephrase what a client is saying, ensuring we are understanding correctly before receiving more information. For example, one could say “what I’m hearing is Buster has not been acting like his normal self lately, and you’re worried something might be going on with his stomach.” Non-verbally, we can validate clients when they’re speaking by nodding, making appropriate eye contact, and ensuring our posture stays neutral. Someone with crossed arms will often appear less approachable than someone who is standing with their arms to their side or in a more open, relaxed position. Taking a collaborative approach with clients is necessary, as veterinary professionals rely on pet owners to be their pet’s voice and greatest advocate. 

When de-escalating a client, it can be helpful to bring the focus back to the pet, reminding the client and staff that there is a common goal shared among all, and it’s to get the pet feeling better. It would be appropriate to say to the client, “I understand it’s been a really scary few days for you and Buster. We are here to help. I want to hear more about what’s on your mind and how we can work together to get Buster feeling better.” Providing a safe, non-judgmental space for a pet owner to speak, and enlisting their help can be the difference between a ruptured relationship and a repaired one.  

There are those rare times when no matter what you do, a client continues to be aggressive or even abusive toward staff. While heightened emotions are common in the veterinary world, it does not mean staff should be expected to accept poor treatment. This only contributes to moral injury and burnout which is a huge problem in the veterinary field. Each clinic should have an agreed upon policy addressing client behaviors and when “firing” a client may be indicated. In the unfortunate event that a client needs to be dismissed from the practice, a transfer of care should be initiated to a nearby hospital to ensure the pet continues to receive medical care. As in the human healthcare field, it may be appropriate to send a 30-day termination notice in writing including a list of nearby clinics and offering to send records to a clinic of their choice. Different states may have different requirements when ending a veterinary client relationship so be sure to check that before proceeding. While firing a client is often uncomfortable, it’s important for veterinary professionals to maintain healthy boundaries in order for this work to be sustainable. 

If a clinic is in a position to hire a veterinary social worker (VSW,) this could be an invaluable addition to any team looking to have built-in support for humans so that veterinary professionals can focus more on their patients. A VSW is a specialized mental health professional who can provide counseling, assist with end-of-life discussions, grief support, crisis intervention, and general emotional support for clients going through a tough time. Social workers are experts at knowing what interventions and resources might be helpful to clients and can take a huge burden off of veterinary staff who frequently find themselves taking on the role of mental health support for clients. A veterinary social worker can also be an excellent resource for veterinary professionals, who have extremely difficult jobs in the midst of a global mental health crisis in veterinary medicine. 

Conclusion

Minimizing the chances of sensory stress in a veterinary setting can foster a more peaceful and welcoming environment amid situations that can often be an enormous source of tension. Paying attention to the stimulus in your clinic and being mindful of the ways in which you communicate with clients can serve as stress prevention for not only clients, but veterinary staff members as well. De-stressed clients lead to a healthier work environment for veterinary staff, resulting not only in occupational gratification and fulfillment, but better health outcomes for our animal patients. 

Sources:

1.  Sundman, A.S., et. al.  (2019, June 6). Long-term stress levels are synchronized in dogs and their owners. Nature News. https://www.nature.com/articles/s41598-019-43851-x

2. Finka, L. R., et. al. (2019, February 5). Owner personality and the wellbeing of their cats share parallels with the parent-child relationship. PLOS ONE. https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0211862

3. Spence, C. (2020, September 18). Senses of Place: Architectural Design for the multisensory mind - cognitive research: Principles and implications. Springer Open. https://cognitiveresearchjournal.springeropen.com/articles/10.1186/s41235-020-00243-4#citeas 

4. Jo, H., et. al (2019). Physiological Benefits of Viewing Nature: A Systematic Review of Indoor Experiments. International journal of environmental research and public health, 16(23), 4739. https://doi.org/10.3390/ijerph16234739 

5. Mehrabian, A. (1972). Nonverbal Communication. New Brunswick: Aldine Transaction.