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Critical incidents in grieving the death of companion animals Alexander, David Allan 2011

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    CRITICAL INCIDENTS IN GRIEVING THE DEATH OF COMPANION ANIMALS   by  David Allan Alexander  B.Sc., The University of Victoria, 1992       A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  MASTER OF ARTS   in   THE FACULTY OF GRADUATE STUDIES   (Counselling Psychology)       THE UNIVERSITY OF BRITISH COLUMBIA  (Vancouver)   December 2011   © David Allan Alexander, 2011 ii   ABSTRACT This study examined what bereaved pet owners found particularly helpful and particularly difficult in their grieving process. The Critical Incident Technique (CIT) was used. Eight bereaved pet owners identified 87 helping and 44 hindering categories that formed 12 helping and 7 hindering categories. The following helping categories had the highest participation rate: Social Support, Reminders & Keepsakes, and Calm Final Moments.  The most highly endorsed hindering categories were: Guilt, Regret, and Second-Guessing; Hindering Social Responses and Lack of Support and Understanding; and Difficulty Transitioning to Life Without the Animal. Nine credibility-checks were performed to ensure the integrity of the data and the study findings.  iii   PREFACE This research project was granted Full Board approval by the University of British Columbia Behavioural Research Ethics Board on June 11, 2009. (UBC BREB Number H09-01064)  iv   TABLE OF CONTENTS Abstract ............................................................................................................................... ii Preface................................................................................................................................ iii Table of Contents ............................................................................................................... iv List of Tables .................................................................................................................... vii Acknowledgments............................................................................................................ viii Chapter 1 - Introduction ...................................................................................................... 1 Chapter 2 - Literature Review ............................................................................................. 5 Human Bereavement ....................................................................................................... 5 Definitions................................................................................................................... 5 Symptoms of Grief ...................................................................................................... 6 Theoretical Foundations of Grief and Bereavement ................................................... 7 Bereavement Intervention Efficacy .......................................................................... 12 Companion Animal Bereavement ................................................................................. 13 Disenfranchised Grief ................................................................................................... 17 Euthanasia ..................................................................................................................... 19 Chapter 3 - Method ........................................................................................................... 21 Participant Recruitment ................................................................................................ 22 Participants .................................................................................................................... 23 Data Collection ............................................................................................................. 25 Data Analysis ................................................................................................................ 28 Trustworthiness and Credibility .................................................................................... 29 Interview Fidelity ...................................................................................................... 29 Independent Extraction of the Critical Incidents ...................................................... 30 Exhaustiveness or Redundancy................................................................................. 32 Descriptive Validity .................................................................................................. 32 Participation Rate ...................................................................................................... 33 Independent Judge Places Incidents into Categories ................................................ 33 Participant Cross-Checking ...................................................................................... 34 Have Tentative Categories Reviewed by Experts in the Field ................................. 34 Theoretical Validity .................................................................................................. 35 Chapter 4 - Results ............................................................................................................ 36 Overview of Categories ................................................................................................ 36 v   Helping Categories........................................................................................................ 38 Social Support ........................................................................................................... 39 Reminders and Keepsakes ........................................................................................ 41 Calm Final Moments................................................................................................. 43 Ceremony/Ritual (non-religious) .............................................................................. 44 Spiritual/Religious Beliefs or Practices .................................................................... 45 Having Time to Say Goodbye ................................................................................... 46 Doing Other Things, Distraction............................................................................... 47 Spending Time with Other Animals ......................................................................... 48 Announcing Death, Reaching Out, Telling Story ..................................................... 49 Knowing that they Provided Animal with Good Life ............................................... 50 Sense of Relief .......................................................................................................... 50 Guarded Disclosure ................................................................................................... 50 Hindering Categories .................................................................................................... 51 Guilt, Regret, and Second-Guessing ......................................................................... 52 Hindering Social Responses, Lack of Support and Understanding .......................... 53 Difficulty Transitioning to Life without the Animal ................................................ 54 Reminders (Hindering) ............................................................................................. 55 Feeling that I will not have this Experience Again; Unique, Irreplaceable Loss ..... 56 Anger at Veterinarian/Clinic ..................................................................................... 56 Others Affected by the Loss ..................................................................................... 57 Excluded Incidents ........................................................................................................ 58 Chapter 5 - Discussion ...................................................................................................... 60 Overview ....................................................................................................................... 60 Theoretical Validation of Categories ............................................................................ 60 Categories Supported by the Literature .................................................................... 61 Categories Not Supported by the Literature ............................................................. 70 Summary of Theoretical Validation.............................................................................. 70 Discussion ..................................................................................................................... 71 Limitations .................................................................................................................... 72 Implications for Practice ............................................................................................... 73 Future Research ............................................................................................................ 74 References ......................................................................................................................... 76 Appendices ........................................................................................................................ 87 vi   Appendix A - Consent Form ......................................................................................... 88 Appendix B - Interview Protocol .................................................................................. 91 Appendix C - Demographics ........................................................................................ 93 Appendix D - Counselling Resources Handout ............................................................ 94   vii   LIST OF TABLES Table 1 .............................................................................................................................. 37 Table 2 .............................................................................................................................. 38     viii   ACKNOWLEDGMENTS  This thesis represents one of the most difficult undertakings in the author’s life. The difficulty was in no small part due to the author’s concurrent diagnosis of Adult ADHD, and the considerable challenges it posed in this particular undertaking. On numerous occasions, he was extremely discouraged and doubted his ability to complete the project. And he probably would not have, were it not for the unfailing encouragement and support of three very special people: his best friend since high school, Allan Neilson, his classmate and good friend from the graduate program, Diana Kollar, and his grandmother, Phyllis Goodhand. It is difficult to fully express the extent of his gratitude, thanks, and appreciation to these three individuals.  The author also wishes to thank his supervisor, Dr. William Borgen, for his incredible patience and support throughout the project, and his committee members Dr. Marvin Westwood and Dr. Norman Amundson, who went above and beyond in their accommodating the author on short notice as his defense date approached.  Lastly, the author wishes to thank his study participants who so willingly shared their stories, often through tears. He felt such a wonderful kinship with each and every one of these people who not only shared in his love of animals, but who had been as devoted as he to giving the animals entrusted to their care the most wonderful lives possible.   1   CHAPTER 1 - INTRODUCTION Bereavement resulting from the loss of a significant person to death is considered a major psychological trauma and has been studied extensively (Parkes, 1993). Bereavement resulting from the death of companion animals has received considerably less attention in the literature. Nevertheless, it is now well established that the death of a companion animal can be a serious loss and that, for some owners, it can provoke a grief response comparable to that for a human being (Davis, lrwin, Richardson, & O'Brien- Malone, 2003). Studies have found numerous parallels between the two experiences. Studies have also, however, found significant differences. For example, those bereaved of companion animals tend to receive far less social support (Carmack, 1985; Stewart, 1983) and may have their grief trivialized (Morley & Fook, 2005; Quackenbush & Glickman, 1984) or even ridiculed by family members or peers (Davis et al., 2003; Quackenbush & Glickman, 1984). As a result, they are often reluctant to confide in others (Carmack, 1985; Davis et al., 2003; Dunn, Mehler, & Greenberg, 2005; Weisman, 1990). Even counsellors and psychologists have been criticized for a lack of awareness and sensitivity regarding such losses (Stern & Cropper, 1998; Toray, 2004; Weisman, 1990). As Gerwolls and Labbot (1994) summarize, the grief reaction to the death of a companion animal may be very similar to that for a human, but the mourning process is not. Despite repeated calls for both greater awareness of the issue (e.g., Sharkin & Bahrick, 1990; Sharkin & Knox, 2003; Toray, 2004) and further research (McCutcheon & Fleming, 2001; Quackenbush & Glickman, 1983; Sharkin & Bahrick, 1990; Turner, 2003), there remains a dearth of empirical studies pertaining to the experience of companion animal bereavement and how to best assist those individuals struggling to cope with such a loss. 2    Non-scientific literature has long acknowledged the importance placed on companion animals by humans, but the emotional bond that can exist between animals and humans has only been recently acknowledged in scientific literature (Cowles, 1985). The term “human-animal bond” was first used prominently in 1979, and it was also at this time that research regarding the phenomenon largely began (Hines, 2003). As the emotional bond between human and animal became the focus for researchers across numerous disciplines, the companion animal has, for much of the scientific community, become legitimized as a significant attachment figure (Cowles, 1985).  The human-animal bond has been found to be particularly strong. High rates of companion animal ownership persist despite numerous potential costs, both financial and otherwise (Bonas, McNicholas, & Collis, 2000). Many owners will keep their companion animals despite destructive or dangerous behavior problems (Voith, 1983, 1984). People are often willing to keep their companion animals despite chronic or severe allergies and bluntly refuse medical advice or even lie to their doctors (Baker & McCulloch, 1983; Coren, 1997). Coren even found that, for the subset of his sample for whom allergies had been diagnosed sufficiently long ago that the animal they were living with at the time had since died, despite both their allergies and the advice of their doctors, 70% had replaced their deceased animal with a new one. Elderly people may choose to remain in substandard housing if public housing requires them to relinquish their animals (Levinson, 1972), and they may resist going to the hospital for fear of being unable to care for their animals at home (McNicholas et al., 2005). Women in abusive relationships are known to delay seeking help or remain in abusive situations for fear of harm coming to the family animal (Carlisle-Frank, Frank, & Nielsen, 2004). And in a study where 3   participants were asked to consider hypothetical situations, Cohen (2002) found that more than half of her participants said there was a least one circumstance where they would elect to give a scarce drug to their companion animal in preference to another person.  The strength of the bond is understandable when one considers the many roles that companion animals have come to play in people’s lives. Some people view their animals as companions, some as best friends, and others as surrogate children (Toray, 2004). They are relied upon to meet numerous social needs (Toray, 2004) and are often considered as genuine members of the family (Albert & Bulcroft, 1988; American Veterinary Medical, 2007; Cain, 1985; Carlisle-Frank & Frank, 2006; Carmack, 1985; Cohen, 2002; Voith, 1985). They take on a role and personality of their own within the family structure (Clements, Benasutti, & Carmone, 2003) and their roles may vary among family members (Gage & Holcomb, 1991). When comparing the nature of the human- companion animal relationships to human-human relationships across numerous social scales, Bonas, McNicholas and Collis (2000) remarked that, despite differences, …the similarity between the two structures overall is also striking. This adds empirical weight to the view that human-pet relationships are similar in nature to human-human relationships and, perhaps more specifically, that the supportive aspects of the two kinds of relationships are broadly similar. (p.219) Indeed, on the three scales of reliable alliance, companionship, and nurturance, the researchers actually found higher mean levels among human-dog relationships than among human-human ones. In light of the above, it is understandable that the loss of this bond through death can be significant and can affect people severely (Clements et al., 2003). While the 4   experience of grief can vary greatly from one individual to the next (McCutcheon & Fleming, 2001), it is now well established that the death of a companion animal is a serious loss and in some individuals can provoke a grief response comparable to that for a human being (Davis et al., 2003). It is also a stressor at the family system level and can add significantly to total family system stress (Gage & Holcomb, 1991). Despite the knowledge of both the potential grief resulting from companion animal death and that the experience also differs from human bereavement in significant ways, there is a dearth of counselling psychology literature pertaining to how to assist people in grieving this particular event. In fact, Sharkin and Bahrick (1990) stated, “Given the seriousness of the topic, it is surprising that pet loss has been virtually neglected in counselling literature and research” (p.306). Toray (2004) similarly noted that, despite the potential intensity of bereavement, there has been a lack of attention paid to the ways in which grief related to companion animal loss is dealt with in the therapeutic setting. Furthermore, Turner (2003) stated that traditional grief and loss counselling techniques need to be modified to meet the specific needs of people experiencing companion animal loss. This thesis wishes to increase counsellor awareness and sensitivity to the issues of companion animals and their deaths in the lives of clients. More specifically, it wishes to illuminate the experience and increase the range of information available, with a particular focus on aspects of the experience that bereaved individuals find particularly helpful and particularly hindering in their grieving process. The research question posed by this study is: What have people who have experienced the death of a companion animal found to be particularly helpful or particularly hindering in their grieving process? 5   CHAPTER 2 - LITERATURE REVIEW  This review begins with aspects of the human bereavement literature most relevant to the current study on companion animal bereavement. Key terms are defined, the potential impact of such losses is described, and a summary review of bereavement and coping theories are presented. The current state and limitations of companion animal bereavement literature is then discussed.  Human Bereavement Definitions In the human bereavement literature, Stroebe, Hansson, Stroebe and Schut (2001) define bereavement as the objective situation of having lost someone significant to death, grief as the primarily emotional (i.e., affective) reaction to the loss, and mourning as the expression of grief through social and other acts shaped by the practices of a given society or cultural group. Grieving is often used synonymously with mourning, though Attig  (2004) defines grieving more generally as an active response to one’s loss. For the purpose of this study, the terms grieving and mourning are used synonymously and in accordance with Attig’s more general definition.  Stroebe et al. define coping as the processes, strategies, or styles used by an individual to manage (i.e., reduce, manage, or tolerate) the situation that they are placed in because of their bereavement. Stroebe and Schut (2001) note, though, that the definition does not imply that the strategies and behaviors are necessarily successful. It is when coping is effective that symptomatology should be reduced and the outcome would be more positive for the individual. Weiss (1993) states that the notion of recovery is difficult in bereavement, because individuals 6   who have suffered an extreme loss may never return to the identity or emotional organization that they maintained beforehand; they are permanently changed. Still, the term can be useful when applied to an individual’s level of functioning. Recovery from bereavement, then, can be understood as a return to previous levels of functioning. Symptoms of Grief For most bereaved people the loss of a loved one is a tragedy unequalled by any other (Stroebe, Stroebe, & Hansson, 1993). The resulting grief reaction is a very complex syndrome that tends to manifest diverse symptoms across multiple domains including affect, cognition, behavior, physiology, and social interaction (Hansson & Stroebe, 2007). According to Worden (2002), affective symptoms may include sadness, anger, guilt, anxiety, loneliness, fatigue, helplessness, shock, yearning, emancipation, relief, and numbness. Physiological symptoms may include sensations of tightness in the stomach, tightness in the chest, tightness in the throat, oversensitivity to noise, breathlessness, weakness, and lack of energy. Cognitive symptoms may include disbelief, confusion, preoccupation, sense of presence, and hallucinations. Behavioral symptoms may include sleep disturbances, appetite disturbances, absentmindedness, dreams of the deceased, avoiding reminders of the deceased, searching and calling out, sighing, restless over- activity, crying, visiting places or carrying objects that remind of the deceased, and treasuring objects that belonged to the deceased. Socially, the bereaved person may want to withdraw from other people. Balk (2004) further notes that others may become uncomfortable when the bereaved person is present. The individual experience of grief can also be highly variable from one person to the next, with substantial differences in duration, intensity, expression, impact on functioning, and changes in life circumstances 7   (Hansson & Stroebe, 2007). Hansson and Stroebe summarize grief as a complex emotional syndrome in which many reactions may be present, but none which are necessarily so, or continuous or consistent in the time following the loss. It is now well established that the health of bereaved people is at risk (Stroebe et al., 2001). They suffer elevated risks of both psychiatric disorders and physical illnesses, utilize health system resources at higher rates (e.g., more doctor visits, more medication, more hospitalizations), and experience more days of disability. Furthermore, they are known to experience heightened mortality risk from a variety of causes, including particularly, as Stroebe et al. note, that of suicide. Theoretical Foundations of Grief and Bereavement  Grief was first introduced as a psychological construct by Freud in his seminal 1917 paper “Mourning and Melancholia” (Granek, 2010). Since that time, theories of grief and bereavement have evolved considerably. Following is an overview of the major model categories. Stage Models of Grief  The stage models of grief represent the most influential theoretical approaches to the study of grief and loss (Wortman, Silver, & Kessler, 1993). These models posit that the experience of grief progresses through several predictable, sequential stages or phases, which are each characterized by particular symptom manifestations. For example, Bowlby (1980/1981), a leading stage model theorist whose work is representative of stage models in general (Hansson & Stroebe, 2007; Wortman et al., 1993), maintained that grief typically progresses through the four phases of: 8   1. Numbness or protest, which is characterized by the initial shock of the loss and accompanying psychological and physiological distress. 2. Yearning and searching, which is characterized by preoccupation with the deceased, seeking objects that remind of the deceased, or even adopting qualities of the deceased. 3. Disorganization and despair, which is marked by the full realization of the loss and a sense of hopelessness toward the future and depression. 4. Reorganization, which is marked by the gradual lifting of the depression from stage 3, acceptance of the loss, a return of energy and self-confidence, and establishment of new goals and behaviours.  Other stage-model proponents include Glick, Weiss and Parkes (1974); and Pollock (1987) (as cited in Shuchter & Zisook, 1993). Kubler-Ross’ famous five-stage model (i.e., denial, anger, bargaining, depression, acceptance) (Kübler-Ross, 1969) has also been frequently cited and applied through the years as a stage model for grief despite the model originally being specific to terminally ill patients facing their own death. Only shortly before her death in 2004 did Kubler-Ross formally state that her model could be applied to grief in a more general capacity, or to bereavement specifically (Konigsberg, 2011).   Stage model theories have been criticized for numerous reasons. First, they are largely descriptive of the manifestations of grief and imply passivity on the part of the griever, rather than the more dynamic sense of actively “working through” grief that most grievers report (Attig, 1991; Stroebe & Schut, 2001). Also, despite proponents claiming that individuals may skip stages, experience more than one stage simultaneously, or move 9   back and forth among stages (Wortman et al., 1993), the models are nevertheless criticized as presenting grief as a relatively simple, universal process through a progression of fixed stages, each with typical symptoms, and ignoring the great variability possible in the experience (Stroebe, Hansson, & Stroebe, 1993). Studies have also found that many people are not devastated by loss initially, as claimed by the models, and that positive emotions can sometimes be prevalent in the first weeks and months following major loss despite the presence of such emotions not being acknowledged in the models at all (Wortman et al., 1993). But perhaps the largest criticism is that the stage models pose no specific mechanisms through which grief and loss influence subsequent mental and physical health and cannot explain the diversity in outcomes that occur in response to such losses (Wortman et al., 1993). Task Models of Grief  The task models are similar to the stage models in that they still present relatively distinct and universal phases of grieving. But unlike the stage models, task models present coping as a more dynamic process in which the griever is actively working through grief as opposed to more passively experiencing it. The models describe tasks, or actions, that the bereaved person must perform in order to adjust to bereavement. A leading proponent of the task-type model is Worden (2008), whose model comprises the four tasks of : (1) accepting the reality of the loss, (2) processing the pain of grief, (3) adjusting to a world without the deceased, and (4) finding an enduring connection with the deceased while embarking on a new life. Another leading task-model theorist is Rando (1993, 1995), whose model comprises six tasks. 10    While task models are credited with presenting the grief experience as a more active process (e.g., Servaty-Seib, 2004; Stroebe & Schut, 2001), they still bear many of the same criticisms as the stage models. In particular, there is again concern that the models can be interpreted in too linear a fashion (Servaty-Seib, 2004). Additionally, some researchers believe that other key tasks of grieving are omitted from the models (e.g., Stroebe & Schut, 2001). Contemporary Process Models and the Dual-Process Model  Contemporary models of grief and bereavement have incorporated elements of the stage and task models but have also been heavily influenced by recent research in stress and trauma theory, with its attendant theory on the processes and dynamics of coping with stressors, as well as meaning making processes. Wortman et al. (1993) described two important contributions from stress and trauma research. First, understanding the context in which a stress-inducing event occurs allows a much more detailed understanding of the specific stresses that it evokes for the respondent. In stress and trauma theory itself, context is considered in a very pragmatic sense. For example, the loss of a spouse who provided financial support will elicit financial stressors in addition to grief. But Wortman et al. and other bereavement researchers (e.g., Neimeyer, 1998) came to consider context in a more meaning-oriented sense as well, particularly in regard to respondents’ underlying beliefs about the world. The nature of some losses may cause a respondent’s beliefs about the world to be called into question, or even shattered, and require significant adjustment or meaning reconstruction. The second significant contribution from stress and trauma theory pertains to the insight that personal vulnerability and resistance factors will also influence the coping and outcome for any 11   particular individual. A major advantage of incorporating the preceding elements into a theory of grief and bereavement is that they allow for an accounting for variability of response and outcome.  A leading contemporary model is the Dual-Process Model, first introduced by Stroebe and Schut in 1999 (Stroebe & Schut, 1999) and described as an integration of existing ideas rather than something altogether new (Stroebe & Schut, 2001). The model describes two broad types of stressors that stem from bereavement: loss-oriented stressors refer to a bereaved person’s concentration on and processing of various aspects of the loss experience itself, while restoration-oriented stressors refer to the secondary stressors also experienced by a bereaved person as he or she attempts to adapt to the demanding changes triggered by the loss while continuing to carry out the activities of daily life. Hansson and Stroebe (2007) explain that restoration-oriented stressors can range from straightforward issues, such as having to make alternate arrangements for tasks previously performed by the deceased that contributed to the partnership (e.g., cooking, chores, or financial management, etc.), to the more complex, such as needing to shape a new sense of  personal identity (e.g., from “spouse” to “widow”, or from “parent” to “parent of a deceased child”). Both orientations are associated with distress and anxiety, and both are involved in the coping process.  The Dual-Process Model proposes a dynamic coping process where the bereaved individual alternates between loss- versus restoration-oriented coping, sometimes confronting aspects of each orientation while at other times actively avoiding them, and at yet other times taking a “break” from grieving-related activities altogether (because both confrontation and avoidance, if undertaken relentlessly, can lead to exhaustion 12   (Stroebe & Schut, 2001)). It is this emotional-regulation process of oscillation that most clearly distinguishes the Dual-Process Model from other models of bereavement and coping (Hansson & Stroebe, 2007). Bereavement Intervention Efficacy Numerous intervention programs have been established during the past several decades to assist bereaved individuals with the emotional and practical problems that often follow the loss of a loved one. These programs range from mutual support groups to full therapeutic interventions available in both individual and group settings. However, in regard to their ability to ameliorate grief specifically (as opposed to providing more general forms of social support and practical assistance) research has shown that the vast majority of such programs are largely ineffective (Schut & Stroebe, 2010; Schut, Stroebe, van den Bout, & Terheggen, 2001). Primary preventive interventions, that is, services made available to all bereaved persons upon their bereavement, have not only been found to offer no benefit, but in some cases have even been found to worsen the situation (Schut et al., 2001). The one exception appears to be in cases where the bereaved initiate help through such services themselves as opposed to having it offered to them (Schut & Stroebe, 2010). Secondary preventative interventions, that is, services targeting individuals thought to be at risk to develop complications, have been found to be modestly effective at times, but the effects are often temporary (Schut & Stroebe, 2010; Schut et al., 2001). Lastly, tertiary preventative interventions, that is, services targeted specifically at individuals displaying complicated grief, have been found to offer substantive benefits (Schut & Stroebe, 2010).  13   Companion Animal Bereavement Scholarly articles on the subject of companion animal bereavement generally started appearing in the literature in the 1980s. To date, empirical studies on the subject have largely been limited to examining the impact and emotional intensity of the bereavement experience, or examining factors that might predict which individuals are at risk for more intense reactions. Within the counselling literature, articles are almost entirely limited to anecdotal reports from clinical work, or admonishments to consider such losses as genuine and deserving clinical attention. And while there are numerous books in the popular literature intended to assist those experiencing the loss of a beloved companion animal, there appears to be little or no empirical work within the academic literature upon which their recommendations could be based. Of the empirical studies on the topic to date, some were conducted to specifically examine the impact of such losses while others gathered relevant data during the course of research on other topics. The studies that examined the impact of bereavement are summarized below.  Stewart (1983) interviewed 52 bereaved animal owners, most of whom were dog owners, to get a general level of their distress levels when their animals died. All of her subjects stated that they felt some degree of sadness. Approximately 33 percent reported being very upset but still able to carry on with their normal routine, while 18 percent were temporarily unable to cope with their work-related responsibilities. Unfortunately, Stewart neither specified how her participants were recruited nor how much time had elapsed since the deaths. 14   Quackenbush and Glickman (1984) conducted a retrospective study regarding social work services provided in a university veterinary hospital for distressed animal owners. In a two year period beginning July 1, 1980, veterinary staff referred 218 owners for social work services, 138 of whom were dealing with animal death. Of these 138 subjects, 93 percent experienced some disruption in their daily living routines. Disruptions often manifested themselves as erratic eating and sleeping patterns, changes to levels of food intake, and sleeping difficulties (including nightmares). Social activities diminished for 70 percent, with those affected tending to remain at home, talk less, isolate themselves from others, and spending considerable time thinking about and longing for their deceased animal. Forty-five percent of subjects missed from 1 to 3 days of work. Cain (1985) interviewed 896 family members of military families as part of her study on companion animals in the family system. When she asked family members to describe the degree of loss their family felt when they had a companion animal who had died, was killed, or lost, 94% said that they had experienced an important to extreme loss.  Gage and Holcomb (1991) surveyed 1,650 mid-life couples in a study on stress and coping and found a subsample of 242 couples whose companion animal had died in the 3 years prior to the survey. Forty percent of wives and 28 percent of husbands reported that the death of the family animal was “quite” or “extremely” disturbing. On average, for both husbands and wives, the death of a companion animal was experienced as less stressful than the death of a member of the immediate family or close friend, but more stressful than the death of another relative. For husbands the loss of the family animal was, on average, about as stressful as the loss of a close friendship, and more 15   stressful than children leaving or returning home or getting married. For wives the loss was, on average, about as stressful as losing touch with their married children and more stressful than the loss of a close friendship or children leaving home or getting married. Of the total study sample of 1650 people, death of the family companion animal was the most frequently occurring of all stressors experienced by mid-life families. Twice as many families experienced this event than the next most frequent event, which was children leaving home. Rajaram, Garrity, Stallones and Marx (1993) conducted a study comparing the extent of depression in elderly individuals (i.e, 65 years of age or older) who had experienced the death of a companion animal to those who had experienced the death of a significant person within the previous 12 months. In their national random sample of 1000 subjects in the United States, they found that death of a companion animal was not associated with depressive symptoms to the extent of deaths of significant persons such as a spouse or relative. Death of a companion animal had a much lower association with depressive symptoms and was of approximately the same level as the death of a friend. Archer and Winchester (1994) constructed a questionnaire based on published descriptive accounts of the reactions following human bereavement but re-worded specifically for animal loss. In their survey of 88 people who had experienced the death of a companion dog or cat within one year of the study, they found most of the reactions documented for human bereavement experienced by those who had suffered a companion animal death. For example, items indicating initial numbness or disbelief, preoccupation with the loss, and being drawn to reminders were endorsed by one half to four-fifths of the sample. An even greater proportion felt that “something important in their lives had 16   gone” (p.267). About a quarter reported the urge to search, avoidance or mitigation strategies, and about a quarter reported pronounced negative affect regarding states such as anxiety, depression, anger and self-reproach, endorsing such items as “definitely applied to me”. The one main difference they noted compared to human bereavement was that negative affect appeared less pronounced in their sample. Gerwolls and Labbott (1994) studied 49 adults who had experienced the death of a companion animal within the three weeks prior to the start of their participation in the study. The subjects completed questionnaires at two (on average), eight, and 26 weeks after their animal’s death on grief experience, mood, and physical symptoms, and the questionnaires incorporated measures for which norms existed for human bereavement. At two weeks following the death of an animal, subjects did not score significantly lower on the Grief Experience Inventory (GEI; Sanders, Mauger, & Strong, 1985) than people bereaved of human relationships at six weeks. At eight weeks subjects did not score significantly lower (i.e., more than one T-score standard deviation) than for people bereaved of human relationships at six weeks. And at six months subjects did not score significantly lower than those suffering a human loss at six months. The researchers remarked that their most significant finding was “the experience of the loss of a companion animal is remarkably similar to the loss of a significant human relationship” (p.182). Adams, Bonnett and Meek (2000) surveyed 177 clients from 14 randomly sampled veterinary practices in southwestern Ontario within 1 to 14 days of their animals’ deaths. Their questionnaire was partly adapted from the GEI and consisted of three outcome measures: social/emotional and physical consequences, despair, and 17   thought processes. Thirty percent of their sample experienced severe grief, having high scores on all three measures. These subjects said they felt that life had lost its meaning. A group of approximately equal size scored low on all three outcomes, while the remaining group scored high on one or two of the measures. One study that did explore aspects of coping with bereavement was conducted by Davis et al. (2003). The researchers conducted open-ended interviews with sixty-eight individuals from a variety of religious backgrounds and asked about the extent that religious issues, euthanasia, and other factors impacted their bereavement experience. Though the researchers asked individuals about what they found helpful or difficult in their experiences, these questions were part of a broader interview that placed considerable focus on religious influences. Perhaps as a result, the findings reported in these other areas were somewhat limited, and were presented in summary form without quantification. Additionally, though the study reported using both quantitative and qualitative research methods, these methods were not described and nor was the underlying research methodology. Disenfranchised Grief While the above studies demonstrate that companion animal bereavement can be very similar to human bereavement and can provoke a considerable grief response for some individuals, the experience is also known to differ from human bereavement in several significant ways. Perhaps the largest difference is that bereaved animal owners may find much less social support for their loss. Numerous authors, especially those writing about counselling experiences with clients, include anecdotes of clients who were hurt by the insensitivity of others or reluctant to even disclose their grief for fear of 18   ridicule. Quackenbush and Glickman (1984), in their study of social work services provided to clients in a university veterinary hospital, wrote that many clients complained of being angered and upset by their colleagues’ insensitivity to their feelings. When family and friends did not acknowledge the extent and legitimacy of their reaction, these clients began to question their own mental and emotional stability. Carmack (1985) echoed similar statements from clients she worked with, and Turner (2003) wrote that clients often feel that they are crazy or silly for experiencing such strong grief reactions. Both Carmack  (1985) and Gage and Holcomb (1991) noted that cases of disparate grief within couples, where one partner grieves the loss considerably more strongly than the other, could result in the more intense griever being stigmatized and cause significant disequilibrium and strain within the family. Weisman (1990) noted there was a general reluctance on the part of clients to tell others about their bereavement because they feared criticism, condescension, or curt suggestions such as , “Get another cat”, or “After all, it’s only a dog”. When Adams et al. (2000) conducted their aforementioned study of 177 veterinary clients in Ontario they also assessed participants’ views of societal attitudes toward companion animal death. Approximately 50 percent of participants believed that stigma was associated with grieving the death of a companion animal. This belief, in turn, influenced how they grieved. These individuals felt that there was something wrong with them because they experienced grief. They tried to avoid feeling badly by keeping busy and avoiding conflict with family or friends about whether it was acceptable to grieve a companion animal. Davis et al. (2003), in their aforementioned study of 68 adults, wrote, “one clearly emerging theme was that many of the participants experiencing grief were reluctant to express this to anyone” (P.66). 19   Doka (1989) coined the term disenfranchised grief to refer to circumstances where a person experiences a sense of loss but does not have a socially recognized right, role, or capacity to grieve. In such cases, the loss cannot be openly acknowledged, publicly mourned, or socially supported. The concept recognizes that societies have sets of norms that attempt to specify who, when, where, how, how long, and for whom people should grieve. He states that disenfranchised grief may occur in our society for three reasons: (1) The relationship is not recognized (e.g., two partners in an affair), (2) the loss is not recognized (i.e., the loss is not socially defined as significant, or there is no knowledge of it apart from the griever), or (3) the griever is not recognized (e.g., the griever is very young, very old, or mentally challenged). Clearly, companion animal bereavement can manifest as disenfranchised grief, specifically in regard to reason (2), and Doka’s work has been cited by numerous authors in their writing on the topic (e.g., Archer & Winchester, 1994; Toray, 2004). According to Doka, disenfranchised grief poses a problem in the form of a paradox: its very nature creates additional problems for grief while removing or minimizing sources of support. Euthanasia Another difference between human and companion animal bereavement pertains to issues of euthanasia. Cowles (1985) states that “the need to make choices in response to both impending and actual animal death is an area that, in many instances, is unique to the human-animal bond” (p. 142). She also notes that, in addition to the decision of euthanasia, are decisions such as whether to be present, and disposition of the body. The decision to request euthanasia or accept a veterinarian’s recommendation for the procedure can present a highly charged and upsetting situation for animal owners 20   (Quackenbush & Glickman, 1984) and also open many opportunities for later second- guessing and guilt (Clements et al., 2003). Stern and Croper (1998) report that veterinarians are continually surprised by the number of clients who fear the the bodies of their deceased animals will be used for experimentation. Studies investigating the impact of euthanasia on the experience of bereavement have produced conflicting findings, with some finding it makes the experience more difficult (e.g., Adams et al., 2000; Weirich, 1988) while others report a correlation with less intense grief (e.g., McCutcheon & Fleming, 2001). In their study that found both euthanasia and societal attitudes to companion animal death correlated to grief, Adams et al. noted: These factors are not considered to be predictive of grief associated with human death. This result indicates that attempting to explain client responses to pet death on the basis of theories derived from analysis of human-human relationships and responses to human death is probably not appropriate. (p.1308)  This review of the literature has demonstrated that companion animal bereavement can be a significant life event. It has many similarities to the experience of human bereavement but also several important differences. These differences raise questions about the applicability of human bereavement and coping theories to the issue of companion animal bereavement, and identify a gap in the literature pertaining to coping with the latter.  21   CHAPTER 3 - METHOD This study used a modified version of the Critical Incident Technique (CIT) to address the research question of “What have people who have experienced the death of a companion animal found to be particularly helpful or particularly hindering in their grieving process?”. The CIT was originally developed by Flanagan (1954) for application in industrial and organizational psychology, and was first applied during World War II to identify effective pilot performance. In her comprehensive review of the method, Woolsey (1986) provided an articulate summary of key points and concepts. She described it as an exploratory qualitative method that, in its original form, consists of asking eyewitness observers for factual accounts of behaviours, be it their own or others’, that significantly contributed to a specified outcome. In the method, an incident refers to an event which actually happened and was directly observed by an eyewitness. An incident is critical if it significantly contributes to the specified outcome. Therefore, a critical incident is especially helpful or inadequate in affecting the specified outcome. Flanagan (1954) stated the functional description of an incident specifies precisely what is necessary to do and not to do if participation in the activity is to be judged as successful or effective. Data analysis then consists of categorizing the incidents according to thematic content (Woolsey, 1986). She identified five primary steps in the CIT: (1) determining the aim of the activity to be studied, (2) setting plans, specifications, and criteria for the information to be obtained, (3) collecting data, (4) analyzing the thematic content of the data, and (5) reporting the findings. In their review of the origins, adaptations, and current applications of the CIT in counselling psychology, Butterfield, Borgen, Amundson and Maglio (2005) explained 22   that the method was developed during a period when positivism was the dominant paradigm for social science research. While considered a qualitative method, they noted it was originally seen as a scientific tool to help uncover existing realities or truths and was very behaviourally oriented. They also noted it was very task-focused, with the intent of eliciting and exploring the various key tasks required to accomplish a particular aim. Since its inception in the field of industrial and organizational psychology, the method has been utilized in numerous other disciplines, including counselling, where it has been adapted beyond its behavioural roots (Butterfield et al., 2005) to become an investigative and exploratory tool that can be used within an interpretive or phenomenological paradigm (Chell, 1998). More specifically, it can also be used to explore personal experiences and capture meaning (Butterfield et al., 2005).  In light of the above, the adapted CIT was well suited to the research question posed by this study. The research question regarded a specific activity, namely grieving the death of a companion animal, and factors that facilitated or inhibited this activity. In its adapted form, the CIT allowed a particularly rich exploration of not only the behavioural factors pertaining to this activity but also the significant thoughts, subjective interpretations, and personal phenomenologies that underlie the experience of grief. Participant Recruitment Flanagan (1954) explained that, in a CIT study, sample size relates not to the number of study participants but the number of critical incidents that they provide. The sample must be large enough to ensure adequate coverage of the activity being studied and an adequate level of precision in accordance with the data’s intended use. He stated that there is no procedure within the method for determining adequate sample size in 23   advance of data collection, and that the number of incidents needed will generally depend on the complexity of the data. Woolsey (1986) explained that a general rule of thumb is to continue collecting critical incidents until redundancy appears. Put differently, critical incidents are collected until new categories stop emerging from the data as successive batches of incidents are added. In discussing his knowledge and experience of the CIT in counselling psychology research, W. A. Borgen (personal communication, June 10, 2009) stated that redundancy typically starts to appear by the sixth interview and eight to 12 interviews are generally sufficient. In this study, eight interviews were sufficient to generate acceptable levels of redundancy in the data. Participants  Study participants were individuals who had experienced companion animal bereavement first hand and had a strong attachment to their respective animals. Two participants were colleagues/friends of the researcher. They expressed interest in the study upon first hearing about it and volunteered their participation without being solicited. Five participants were recruited through the researcher’s veterinarian, who had his clinic staff recruit participants until an adequate level of data redundancy was obtained. Staff reviewed client records to identify clients who had experienced an animal death at least two months prior. Starting with those most recently bereaved and working backward, clinic staff contacted individuals by phone, explained that the clinic was assisting with a University of British Columbia (UBC) study on pet loss, provided them with a brief overview of the study, and asked if they would be willing to have the study researcher contact them. Those who consented then had their contact information given to the researcher. One additional participant was recruited through a participant who had 24   already been interviewed. She expressed interest in participating after a previously interviewed participant and acquaintance of hers told her about his participation in the study and described his research interview as a positive and helpful experience.  The eight participants ranged in age from 25 to 75. One was male and seven were female. All lived in Metro Vancouver, British Columbia. One participant rated the strength of his attachment to his companion animal as 9.5 out of 10 on a likert-type scale where one represented a weak or absent bond and 10 represented a very strong bond; the other seven participants all rated the strength of their attachment as 10. At the time of bereavement, two of the participants lived alone, five lived with partners or spouses, and one lived with two roommates. There were no children living in any of the households. Four participants had at least one other animal living in their household at the time of their bereavement: Two participants had a surviving cat and two other participants had two surviving cats. Three of the deceased animals were cats and five were dogs. At time of death, the youngest animal was six years of age while the others ranged from 9.5 to 14 years. Six of the eight animals had lived their entire lives with their owners, while two animals had had previous owners and had lived with their current owners for between 6.5 and 7.5 years. One death occurred very suddenly due to the animal being hit by a car, while the other deaths were the result of either acute medical conditions or old age. Apart from the aforementioned sudden death, forewarning in the other cases ranged from several days to more than a year. Six of the eight animals were euthanized. Three of these animals were euthanized at a veterinary clinic or animal hospital while three were euthanized in their homes by an attending veterinarian.  25   Data Collection All participants were first contacted by phone and screened to determine eligibility. They were also provided with additional information about the study and study procedures, and told summarized versions of the two main interview questions so that they could begin reflecting on them. This approach was taken in accordance with Woolsey’s (1986) recommendation to orient each participant to the study in advance of the actual research interview. Data was then collected through individual, semi-structured, open-ended interviews that took place in the participants’ homes. Interviews generally took place within one week of phone contact. They were conducted during the period of May 29, 2009 to October 10, 2009 and ranged in length from approximately 90 to 120 minutes. All interviews were audio recorded and later transcribed in full.  At the beginning of each interview, participants were first given an informed consent form to review and sign (see Appendix A for consent form). The form explained the purpose of the study, participants’ rights, issues of confidentiality, and the fact that participation was entirely voluntary and could be withdrawn at any time. The investigator read a copy of the form aloud and told participants explicit examples of what they could say if they wanted to pause or discontinue the interview. Participants returned the signed form to the investigator and were also given a copy to keep.  Interviews were structured to start with less emotionally sensitive discussion and gradually progress to more sensitive content so that rapport could be built along the way and thereby facilitate the latter (see Appendix B for the full interview protocol). The interview began with basic demographics questions such as the participant’s age, the kind 26   of animal they had cared for (e.g, dog, cat, etc.), the animal’s age when it died, and how long the animal had lived with the participant. Participants were asked whether euthanasia was used when their pet died but were not asked further details about the nature of the death at this time. They were also asked to rate the strength of their bond or attachment with their companion animal on a scale of 1 to 10. See Appendix C for the full list of demographics questions.  The interview then moved to basic inquiry about the deceased animal. Participants were asked questions such as “So tell me a bit about <name>”, “What was he/she like?”, “What was it like living with him/her?”, “What are some highlights that stand out for you?”. The purpose of this step was largely to build rapport, but also to gather a general context of life with the animal.  Participants were then asked about the nature of their animal’s death. They were asked questions such as “Can you tell me a bit about the circumstances of <name’s> death?” and “How did his/her death affect you?” Issues such as the cause of death, whether euthanasia was involved, and the period between the onset of illness and death, were explored.  The CIT component of the interview then took place. Participants were asked about specific experiences in their grieving process that they found particularly difficult or helpful. The question pertaining to hindering incidents was phrased as follows: Please think back to the time of your pet’s death. Think of the time leading up to it, the event itself, and the time that followed and continues to follow. As you reflect on these periods, please identify a specific experience that you felt was 27   particularly difficult or caused you particular pain while you were grieving. This might include something that you did or that someone else did, something else that happened, or particular thoughts or realizations that you had. It could also be something that you refrained from doing, or that others did not do. What was it about the experience that made you feel that way? Take your time to think about a specific experience. When you feel ready, please describe it in as much detail as possible. The question pertaining to helpful incidents was phrased as follows: Please think back to the time of your pet’s death. Think of the time leading up to it, the event itself, and the time that followed and continues to follow. As you reflect on these periods, please identify a specific experience that you felt was particularly helpful, or comforting, or brought you a sense of peace or reassurance while you were grieving. This might include something that you did or that someone else did, something else that happened, or particular thoughts or realizations that you had. It could also be something that you refrained from doing, or that others did not do. What was it about the experience that made you feel that way? Take your time to think about a specific experience. When you feel ready, please describe it in as much detail as possible. Participants were given a copy of each question on a piece of paper and the researcher also read them aloud. Various follow-up questions were used to ensure that participants described incidents in sufficient detail, such as “What was it about that event that made you feel that way?”, “What did that mean to you?”, and “How did that 28   experience impact your grieving process?” If participants referred to a general category of experience, they were asked, “Could you give a specific example of that?” The final phase of the interview then took place. The researcher first summarized and reviewed all incidents with participants for their confirmation. He then asked the participants what their interview experience had been like for them. He reminded them that they may be contacted at a later point in the study if additional clarification was needed. And lastly, he provided them with a handout listing free and low-cost counselling services in the local area (See Appendix D). He explained that such a handout was required due to the emotionally sensitive nature of the interview. Data Analysis Data was analyzed using an adapted version of the CIT for counselling psychology research. Whereas the original method’s behavioural focus restricted incidents to observable behaviors, the adapted method used in this study also considered thoughts, feelings, beliefs, and other subjective aspects of participants’ phenomenological experience that they reported as being particularly helpful or problematic. In preparation for data analysis, all interviews were transcribed in full. Transcriptions were then loaded into NVivo qualitative data analysis software; QSR International Pty Ltd. Version 8, 2008. Each transcript was reviewed within the NVivo program for critical incident content and all relevant passages were identified, tagged, and coded. Verbose client descriptions were condensed while maintaining as much of the participant’s own language as possible. The critical incident summaries were then extracted from the interview to be used in the categorization process. 29   Flanagan (1954) described the purpose of data analysis in the CIT as being to summarize and describe the data in an efficient manner so that it can be used effectively for practical purposes while at the same time sacrificing as little as possible of its comprehensiveness, specificity, and validity. To this end, a categorization scheme is created for all incidents through a process of inductive reasoning: incidents are grouped according to thematic similarity into mutually exclusive categories. The process is necessarily subjective (Woolsey, 1986), and many researchers consider this to be the most important and difficult step of the CIT process (Butterfield et al., 2005). The final categorization scheme yielded 12 helping categories and 7 hindering categories, comprising 135 critical incidents in total. This result included 4 incidents which did not fit within the category system. Trustworthiness and Credibility Butterfield et al. (2005) reviewed the use and evolution of the CIT in the fifty years since its inception, with a particular focus on its use in counselling psychology research. They noted that, as the method expanded beyond its original scope, a series of credibility checks also evolved that were consistent with Flanagan’s (1954) original intent and also enhanced the robustness of the findings. They described nine checks for trustworthiness and credibility that are now used consistently within the Department of Educational and Counselling Psychology and Special Education at UBC for CIT studies. Each of these checks, and its application in the present study, is described below. Interview Fidelity  This check entails having an expert in the CIT research method listen to a sample of interview recordings to ensure that the researcher is properly following the method 30   (Borgen, 2003, as cited in Butterfield et al., 2005). It is designed to ensure that the rigor of the research design is upheld and to ensure consistency. It also checks for leading questions by the interviewer. In Counselling Psychology interviews, this check is typically performed for the first and fourth interviews (W. A. Borgen, personal communication, November 26, 2010).  This check was performed by a colleague of the researcher who was enrolled in a counselling psychology masters program at Simon Fraser University and who had previously co-authored a study that used the CIT and had been published in a peer- reviewed journal. His responsibilities for the published study included, but were not limited to, reviewing CIT interviews. For the present study, he was provided with audio recordings and transcripts from the first and fourth participant interviews. He confirmed that the researcher had properly adhered to the method and had not asked leading questions. Independent Extraction of the Critical Incidents  This check entails having a person familiar with the CIT independently identify and extract critical incidents from a number of interview recordings or transcripts (Butterfield et al., 2005). The purpose of this check is to confirm that the incidents cited are indeed critical to the aim of the activity and not selected or omitted due to researcher bias. Critical incidents identified by the researcher are compared to those identified by the independent reviewer and the level of agreement between the two is calculated. Higher concordance rates indicate greater credibility. For purposes of time, cost, and effectiveness, this check is typically limited to 25 percent of the total critical incidents gathered. 31    In the present study, the same counselling psychology masters student described previously was provided with audio recordings and transcripts from the first and fourth interviews, representing 25% of the total interviews. His extraction yielded an initial agreement rate of 73% for the first interview and 90% for the fourth interview. He and the researcher discussed the reasons for their respective choices and then revised their extractions after considering each other’s comments. This yielded agreement rates of 92% and 100% respectively. The only incident on which the reviewer and researcher were unable to agree concerned an incident that a participant described in passing as being significant but which she did not identify or refer to during the CIT portion of the interview or in response to the specific CIT questions. At the time, the researcher’s understanding of the method was that, for an incident to be considered critical, it had to be identified during the CIT portion of the interview (i.e., the portion of the interview asking about what incidents the participant found especially helpful or hindering), even if the participant had already referred to the incident previously. The reviewer disagreed and believed that an incident described at any point during the interview could be considered if it were described by the participant in a manner indicating it had a significant impact on his or her experience. The researcher consulted his research supervisor, who indicated that the reviewer was correct. As a result, the incident was included in the final extraction, which brough the level of agreement to 100% for both interviews.  The researcher then reviewed the transcripts for the six other interviews based on the new understanding. He identified additional incidents in three of the interviews, yielding a total of six additional critical incidents comprised of three helping incidents 32   and three hindering incidents. For five of the incidents, he contacted participants for their confirmation that the incidents had a significant impact on their grieving process. Exhaustiveness or Redundancy  This check entails having the researcher track the point at which exhaustiveness or redundancy is achieved in the data, and is done by tracking the point at which new categories stop emerging from successive incidents gathered (Butterfield et al., 2005). Redundancy is considered a sign that the domain of the activity being studied has been adequately covered. Because participant recruitment in a CIT study continues until the redundancy threshold is met, the categorization process is typically performed several times. In the present study, redundancy was checked after interviews three, six, seven, and eight.  Prior to the eighth interview, two incidents remained uncategorized. The eighth interview yielded 16 critical incidents, consisting of four hindering incidents and 12 helpful incidents and representing 15.4% of total incidents. All four hindering incidents were sorted into existing categories. Ten of the twelve helpful incidents were sorted into existing categories, while two remained unsorted. After this interview, four of the 135 incidents remained uncategorized. This represented an acceptable threshold for redundancy as suggested by Flanagan (1954), and so data collection was concluded. Descriptive Validity Descriptive validity pertains to the accuracy of the researcher’s account of participants’ statements and the critical incidents within. Numerous steps were taken to ensure sufficient validity. During interviews the researcher took extensive notes, summarized all incidents for participant confirmation, and audio recorded the entire 33   process. The audio recordings were then later transcribed in full. Incidents were identified and extracted from these transcripts while consulting the notes taken during the interviews. Finally, once incidents were condensed and summarized, participants were again contacted to review the summarized versions and confirm that they still accurately reflected their original comments. Participation Rate The participation rate is calculated for each category and reflects the percentage of study participants who cited incidents in the category (Butterfield et al., 2005). A higher participation rate indicates a greater proportion of participants reporting incidents within that category, and that the category represents a more common kind of experience and is more likely to be important to the aim of the activity. While Andersson and Nilsson (1964) cautioned that one must be careful not to regard a low participation rate alone as indication that a category is unimportant, Butterfield et al. (2005) cited Borgen and Amundson’s (1984) recommendation that a category should have a participation rate of at least 25% to be considered valid.  Borgen and Amundson’s (1984) recommendation of a minimum participation rate of 25% was applied to this study. This corresponded to requiring that each category be endorsed by at least two participants. This resulted in one category, containing two incidents from the same participant, being dropped from the final results. Independent Judge Places Incidents into Categories  This check requires having an independent judge place 25% of the critical incidents (randomly chosen) into the tentative categories formed by the researcher. 34   The independent judge is provided with the incidents, in random order, along with the titles and descriptions of the categories that the incidents are to be sorted into. The higher the rate of agreement between the researcher’s placement of incidents into the categories and the independent judge’s, the more sound the categories are thought to be (Butterfield et al., 2005). In the present study, the same counselling psychology masters student described previously was enlisted to perform this check. The initial agreement rate was 88.9%. Incidents that were categorized differently were discussed in an effort to reach consensus. After discussion and re-sorting, the agreement rate rose to 100%. Participant Cross-Checking  Participant cross-checking entails having a second interview with each study participant to have them (A) review the critical incidents they provided in their initial interview and make any additions, deletions, or alterations as that they deem appropriate; and (B) confirm that the categories make sense and adequately represent their experience. While the researcher was able to have study participants complete portion (A) of this check, he was unable to have them complete portion (B) due to an extended medical issue on his part during the period that this check was required. This inability represents a limitation in the study. Have Tentative Categories Reviewed by Experts in the Field This check entails submitting the tentative categories to two or more experts in the field for their review. The experts are asked whether the categories appear useful, if they are surprised by any of the categories, or if something appears missing based on 35   their own experience. It is believed that if the experts agree with the categories then the credibility of the categories is enhanced. The present study enlisted the aid of three masters-level counsellors, each with substantial work experience, including two with substantial experience in working with issues of companion-animal bereavement, and the third having considerable experience with human bereavement counselling. Both of the first two counsellors reported the findings being very consistent with their own experiences in working with clients. The third counsellor reported many of the findings being consistent with her own clinical experience as well, while other findings less applicable to cases of human bereavement struck her as nevertheless plausible for cases of companion animal bereavement. Theoretical Validity Theoretical validity pertains to the extent that support for the categories can be found within the existing academic literature, which suggests soundness in the findings. In cases where support is not found in the literature, it must then be considered whether the discrepancy suggests a lack of soundness in the findings or  that the study has uncovered something new and not yet documented in the literature. The categories identified in the present study are reviewed against the literature in the Discussion chapter.  36   CHAPTER 4 - RESULTS Overview of Categories The eight study participants identified 87 incidents that had been helpful in their grieving process, and 44 that had been hindering, for a total of 137 incidents. The incidents were sorted into 12 helping categories and 7 hindering categories, with 2 helping and 2 hindering incidents remaining unsorted, and a helping category containing two incidents also excluded from the results due to an insufficient participation rate. Tables 1 and 2 present the distribution of incidents by category. Categories are listed in order of descending participation rate and number of incidents.     37   Table 1 Helping Categories (abbreviated) by Participation Rate and Number of Incidents   Helping category No. incidents No. participants Participation rate  Social Support 35 8 100% Reminders & Keepsakes 11 7 87.5% Calm Final Moments 5 4 50% Ceremony/Ritual (non-religious) 4 4 50% Spiritual/Religious Beliefs or Practices 6 3 37.5% Having Time to Say Goodbye 6 3 37.5% Doing Other Things, Distraction 5 3 37.5% Spending Time with Other Animals 4 3 37.5% Announcing Death, Reaching Out, Story 3 3 37.5% Know Provided Animal with Good Life 3 3 37.5% Sense of Relief 3 2 25% Guarded Disclosure 2 2 25%  Total number of helping incidents 87*  * Four additional helping incidents were excluded from the categorization scheme: two single incidents that could not be categorized, and two incidents within a category that had an insufficient participation rate. 38   Table 2 Hindering Categories (abbreviated) by Participation Rate and Number of Incidents   Hindering category No. incidents No. participants Participation rate  Guilt, Regret & Second-Guessing 10 6 75% Hindering Social Responses 11 4 50% Difficulty Transitioning to Life without Animal 9 4 50% Reminders (Hindering) 5 3 37.5% Unique, Irreplaceable Loss 4 3 37.5% Anger at Veterinarian/Clinic 3 2 25% Others Affected by the Loss 2 2 25%  Total number of hindering incidents 44*  *An additional 2 hindering incidents could not be categorized and are excluded from the above categorization scheme. Helping Categories  Slightly over two-thirds of the critical incidents provided by study participants were helping incidents. These incidents were divided into 12 categories. Listed in order of participation rate, from highest to lowest, they are: Social Support; Reminders and Keepsakes; Calm Final Moments; Ceremony/Ritual (non-religious); Spiritual/Religious Beliefs or Practices; Having Time to Say Goodbye; Doing Other Things, Distraction; 39   Spending Time with Other Animals; Announcing Death, Reaching Out, Telling Story; Knowing that they Provided Animal with Good Life; Sense of Relief; and Guarded Disclosure. Each category is described below, and a number of sample incidents in proportion to the participation rate for the category are also provided.  Social Support Participation rate: 100% (8 participants) Incidents: 35  Social support is the largest helping category in several respects. First, it is the only category having a participation rate of 100%, meaning that every study participant contributed at least one incident in this category. Second, with 35 incidents, it contains the largest number of incidents of any category by a considerable margin. This category is comprised of a wide range actions and behaviours of other individuals that participants interpreted as being supportive and helpful in their grieving process. Two key benefits of these incidents were that participants felt their grief was both valid and acknowledged. Participants also described other benefits such as feeling understood, realizing that their reaction was normal and reasonable (i.e., the support had a normalizing effect), a sense of being given permission to grieve, being offered accommodations with regard to practical matters, and feeling connected to others and not alone in their experience, among others.  After emailing friends to tell them the news, several replied and said they had been through the experience too, and were devastated. And so I knew they 40   understood. And I felt genuinely acknowledged in my grief, and that it was acceptable, and to be expected, and okay. It was okay to these people to be having a huge grief reaction. And I think it sort of gave me more permission to be okay with it too.  My boss and coworker had been through the same experience. They knew I was going through a hard time and gave me the space I needed. If I was really sad I could just maybe close my office doors and they'd be okay with that, and [I would] not have to explain too much about it or talk to them about it. And if I needed time off work they were okay with that. They were very understanding.  A girlfriend I talked to [about my cat dying] told me she went through hell when her cat died. She grieved and cried and cried and cried her eyes out. And I realized there are people that really care for their pets the same way I care for mine. It made it seem natural and okay to be concerned about your animal.  My husband was very patient with my grieving process. He tried hard to understand it and even admitted he found it hard to understand sometimes. He would say like “it was hard for me too, I see that it seems harder for you. I’m trying to understand that. And whatever you need to do is okay with me.” He was never cruel, pushy, frustrated or impatient with me. He was patient, kind, and supportive. And I think that allowed me to do what I feel I needed to do. Gave me 41   permission to grieve openly around him and not have to put it on hold when he came through the door.  Something else that I found extremely helpful is I had a very supportive neighborhood.  It's a really good neighborhood, a lot of dog people here.  And I got cards from people, and people expressing their well-wishes. And that was great. I mean it was really great to have that support. And it was nice to get it from pet owners because you felt more of a bond.  Reminders and Keepsakes Participation rate: 87.5% (7 participants) Incidents: 11 Many study participants identified keepsakes and other physical reminders of the deceased as being helpful and comforting in their grieving process. In the context of this category, reminders and keepsakes refer to tangible items that belonged to, or were otherwise associated with, the deceased and that were kept by participants because of their sentimental value. The nature of the items varied. Numerous participants were comforted by the presence of an item that had been in physical contact with their animal, such as an item from the animal’s personal effects (e.g, collar) or that the animal had otherwise interacted with (e.g., small rug it used to sleep on), or physical elements of the animal itself (e.g., fur-clipping, cremation ashes). Several participants reported that looking at photos of 42   their animal was helpful. And one participant obtained a tattoo in memory of her deceased dog. Most participants found personal effects and physical elements helpful because they provided a sense of physical closeness and connection with the deceased. Some also valued them as reminders of their animal’s physical characteristics, or as evidence that the animals had actually existed. Photos were helpful because they provided visual records of the animals’ physical appearances and also reminded participants of significant moments in their animals’ lives. They appeared especially valued in situations where an animal had later been encumbered by illness because the photos reminded participants of periods when the animal had been healthy and happy. In a lone contrary case, one participant reported that rearranging one personal effect and storing the rest out of view had been helpful. The rearranged item signified to the participant that his circumstances were now different, while moving the other items out of sight reduced the presence of painful reminders of his loss.  I've kept his collar. And I think I'll keep that forever. Most of the time the memories are just of things that we did, or his personality. But his collar makes me think of his size and his physical presence. His big chest and his fur.  I took some fur from her and put it in a little envelope and put it in a box. It’s like a piece of the physical reality of her. That she actually did exist. And I can look at the colour. She had beautiful markings.  43   [Shortly after she was euthanized at home,] I put away her food and water dishes and her toys and things like that. So that when I came home after toasting her, I wouldn't have the reminders being here. I'd have the memories, but not the painful reminders. That really did help.  Pictures helped a lot. It helped because I could look at her. I can see how cute she was when she was a puppy. And all the good times I had with her. Like the shots I have of them swimming in the pool, like those are the greatest memories I have. I think it’s really important to have that visual aid. It really helps. That’s when she was healthy and fun and happy (i.e., before she got sick).  I got a tattoo [before he died]. I didn't want his name, I didn't want a physical picture or anything. (ie. The tattoo is a symbol that represents him. Others would not recognize the meaning of the tattoo without the participant telling them). And it's always gonna be there. It makes me really happy. It feels comforting. And makes me feel grounded, in a weird way.  Calm Final Moments Participation rate: 50% (4 participants) Incidents: 5 Half of the study participants found certain aspects of the death experience itself, or issues related to it, to be helpful in their grieving process. These aspects included the participant’s perceptions of their animal’s experience of dying as well as their own 44   experience of their animal’s death. The dominant theme expressed in this category is that participants found it helpful when the death experience was calm, or at least not as difficult as some feared it might be.  Dr. [name] came to our home to do the [euthanasia] procedure. So it felt like it was more intimate. And he didn't have to die somewhere like a clinic. This way he wasn't frightened. He was in his familiar surroundings, on his little pillow in his usual spot.  She died without euthanasia and without struggling at the vet's. Even though I’d made an appointment to have her euthanized, I dreaded taking her in. She always hated going to the vet, and I felt like it would have been a horrendous experience. And I would have felt like I was murdering her.  Ceremony/Ritual (non-religious) Participation rate: 50% (4 participants) Incidents: 4  Several participants held funeral or wake-type ceremonies to mark the passings of their animals. These ceremonies appeared similar in many respects to those typically held after a human death, except perhaps in regard to the number of attendees. Three of the four participants in this category performed funeral/burial-type ceremonies, which they conducted together with their spouses or partners who had shared in the guardianship of the animals. In all three of these cases, attendance at the event consisted of only the 45   participant and their spouse/partner. The fourth case appeared similar to a wake-type ceremony, which was attended by the participant together with the animal’s previous owner.  When we buried him we wrapped him in a really nice table cloth and lit small candles all around him. I did this out of love. It was important to me to treat him reverently. It made the goodbye special.  After she was euthanized, her previous owner (who also attended the euthanasia procedure) and I went out to a pub and we had a toast to her.  Spiritual/Religious Beliefs or Practices Participation rate: 37.5% (3 participants) Incidents: 6 Three participants identified spiritual or religious beliefs as having been helpful to them in their grieving process. A key aspect of these beliefs was that they entailed an element of the supernatural. First, all three participants expressed belief in some manner of “life after death” for their animals. They believed that death was not a final, permanent state but rather a phase after which some manner of conscious essence of their animal still remained, and continued to live on in some way. Two of the participants also expressed a belief that they and/or the deceased could influence the other from across the spiritual divide between life and afterlife. 46   Beliefs in an afterlife were beneficial for two reasons. First, participants expressed a sense of continued connection with their animals. Second, they envisioned the animals now having a higher quality of life than when they were alive. Additionally, one Buddhist participant was able to express her grief through a spiritually sanctioned activity and further believed that she could send her deceased animal love and compassion in the afterlife, giving her a continued sense of personal agency in regard to its well-being.  My other dog (which deceased used to live with) has gone up [to Heaven] too. So they're together again. She got to have her man back. They were inseparable on Earth and they're inseparable in Heaven. I don't want her to be scared or alone. And the fact they're together up there keeps them closer with me down here.  According to my Buddhist beliefs at the time, in the 40 days that his soul or essence lingered after death I could send him love and compassion to help him ascend to a more contented form. It made me feel good to be able to help him in this way. Even after he'd died, I was still able to do something nice for him.  Having Time to Say Goodbye Participation rate: 37.5% (3 participants) Incidents: 6  Three participants felt that having forewarning of their animal’s impending death had been helpful in their grieving process. They felt that this allowed them to not only begin to reflect and to prepare themselves mentally for the loss, but also to make good 47   use of the time remaining by spending extra time with their animals and engaging with them in particularly meaningful ways. In addition to providing the animals with extra attention and affection, participants also fed them their favourite foods and, as was the case with dogs, took them on final visits to some of their favourite areas (e.g., parks, beach). Two participants described this process as “saying goodbye”.  In the two weeks before her death, we went to McDonald Beach where she loved to swim. And it was very difficult… I knew that this was probably the last time that I'd share the experience of going to the beach with her [seeing how weak she was]… but I was really glad I did it.  On his last day (i.e., before he was euthanized) we took him out. We took him to the beach. And we fed him his favourite foods. Really just spending that day with him. That was very helpful. Like, because I didn't really have a chance to say goodbye to my parents [before they died], we sort of wanted to do it properly with [name].  Doing Other Things, Distraction Participation rate: 37.5% (3 participants) Incidents: 5 Three participants deliberately engaged in activities for the purpose of distracting themselves and gaining respite from their grief. For two of the three participants the specifics of the other activities did not appear significant so long as the activities were 48   engaging enough to keep their thoughts occupied. The third participant, meanwhile, endeavoured to develop new interests and activities to fill the time in her day that she previously spent with her dog.  Just trying to be occupied with other things. Like, my fiance's friends are in town and they have two kids, so we've pretty much gone out with them every weekend. And we're planning a wedding.  Spending Time with Other Animals Participation rate: 37.5% (3 participants) Incidents: 4  Three participants felt that spending time with other animals had been helpful in their grieving process. For two of these participants, the other animals they referred to had been other companion animals in their care (including animals not obtained until the deceased had already passed), or in the care of friends. These participants appeared to value the companionship the animals provided, as well as the mutual sharing of affection between the animals and themselves. The third participant had been comforted by spending time with non-companion animals, namely wild/non-domesticated birds that she encountered in her yard, neighbourhood, and parks. In fact, bird watching had become a new hobby for her. In addition to taking pleasure in simply observing the birds going about their activities, she set up bird feeders and other accessories in her yard to draw them to her home and also, perhaps, to contribute to their lives in some positive way.  49   Having my cats. They were a big consoler for me. (participant listed numerous reasons, the most significant being “I can still continue to put my love onto something. Like, I have so much love to give.”)  Accepting another dog. Having a new dog in my life.  Announcing Death, Reaching Out, Telling Story Participation rate: 37.5% (3 participants) Incidents: 3  This category contains incidents where participants initiated contact with others to inform them of the death of their animal. Participants found this action to be helpful in several ways. First, they appeared to value sharing the news of their bereavement with others whom they believed would be receptive. This sharing appeared helpful even before the other parties responded. Second, the participants anticipated receiving positive, supportive responses from those they contacted and they appeared to take comfort in this. And third, participants found the process of preparing their messages and describing their stories to be helpful also.  I sent an email to a best friend who now lives in a different city. She knew [name] and she loved him. I knew she would have some good things to say. And it was also the first time trying to write about it. I spent a lot of time choosing the right wording and stuff, so I could have some sort of framework for myself in thinking about him. 50    Knowing that they Provided Animal with Good Life Participation rate: 37.5% (3 participants) Incidents: 3 Participants in this category were comforted by the belief that they had provided their animals with a good life.  I realized that she really loved living here. I think that was part of what helped me with the guilt was realizing that we had provided her with a really wonderful life here. And she just, she really did love it here.  Sense of Relief Participation rate: 25% (2 participants) Incidents: 3  Two participants expressed a sense of relief that their animal’s suffering had ended, and one of these participants expressed an additional sense of relief at being relieved of caretaking duties.  A sense of relief that he's not suffering anymore. And that he doesn't have to take his four pills a day. And be home by himself while we go to work.  Guarded Disclosure Participation rate: 25% (2 participants) 51   Incidents: 2  In the final helping category, two participants described being cautious and selective in sharing news of their experience with others in order to protect themselves from potentially hurtful responses. One participant did this from the outset whereas the other became cautious after several negative experiences.  I'm very careful about who I share information with about my dog. Or (past) dogs. There's a lot of people that just aren't dog people. Or pet people. And they just don't understand that connection. If someone's not gonna understand, they may consciously or unconsciously be flippant or curt or just move on, when I need someone to acknowledge it, basically. I didn't tell people that I felt wouldn't understand.  Hindering Categories  Slightly under one-third of the critical incidents provided by study participants were hindering incidents. These incidents were divided into seven categories. Listed in order of participation rate, from highest to lowest, they are: Guilt, Regret, and Second- Guessing; Hindering Social Responses, Lack of Support and Understanding; Difficulty Transitioning to Life without the Animal; Reminders (Hindering); Feeling that I will not have this Experience Again / Unique, Irreplaceable Loss; Anger at Veterinarian/Clinic; and Others Affected by the Loss. Each category is described below, and a number of sample incidents in proportion to the participation rate for the category are also provided.  52   Guilt, Regret, and Second-Guessing Participation rate: 75% (6 participants) Incidents: 10 The largest hindering category, with a participation rate of 75%, pertains to feelings of regret and guilt experienced by participants and their associated second- guessing of issues and events in hindsight. Incidents fell into one of three sub-categories: In the first, participants did not feel guilty or personally responsible for events but simply regretted that they had transpired. In the second, participants experienced feelings of guilt and a sense of personal culpability. And in the third, participants were unsure whether they should feel guilty and were distressed by the possibility and the uncertainty.  In his final days, he couldn't chew his food because the vet took five of his teeth out. I had a feeling he was going to go but I didn't want him to go that way (ie. unable to chew his food and enjoy his treats). I had to soak all his food for him. He used to love the dry.  I missed an appointment with the vet when my cat was sick because I was honouring a friend's birthday party. So I didn't find out that my cat was very sick and I went out that night. After he died several days later I felt very guilty. And I really kind of beat myself up for some time afterwards of I wasn't there for him and he was in distress and pain.  53   I let my cat go outside because that's where he was most happy. But I knew it was dangerous. And when he was killed by a car I felt responsible. I felt like I killed him.  I often look at past events and I say "Did we do the absolute best that we could have done? Could he have had a better shot? And what if there had been a different vet at the emergency hospital [instead of the one who misdiagnosed him]? What if I had insisted he stay another night in the hospital?" That's the regret.  Hindering Social Responses, Lack of Support and Understanding Participation rate: 50% (4 participants) Incidents: 11  Half of the participants reported being very upset by comments and behaviors of others either during their bereavement or, in some cases, while their animals were still alive. In more than half the cases, participants believed the other parties had actually intended their comments to be helpful. Nevertheless, participants experienced incidents in this category as very hurtful and perceived the other parties as lacking understanding, empathy, and an appreciation for the significance of their loss.  In some cases, participants felt that their grief reaction, or the care and concern they devoted to their ill animals, was disapproved of.  54   My friend said "It's just a cat". It was horrifying. I mean, it was a cat. But to me it was almost like a family member. I'd spent 14 years of my life with [name] and we'd been through a lot together in terms of bonding and life experience. It was almost like she was saying he was kind of like an inanimate object, sort of devaluing our connection, our bond. Maybe was worthless? It was so hurtful.  Other people thought I was a little strange, not going on trips because of [name] being sick. One friend sort of looked at me like "What, you wouldn’t go away because your cat is not well?" I found that a little hurtful. People don't really understand how close you can get to your animals. They really are child substitutes. It's like a person in your family is dying and you're concerned about them. And I don't think everybody understands that.  A friend said "oh, well, you can get another cat."  I think she was trying to make me feel better but it wasn't empathic and seemed to minimize his significance. [Name] will never be replaced. He's irreplaceable.  I never cry about it in front of my husband because he might think I'm crazy. He doesn't really understand why I cry. So I try to suppress it. He's a nice guy but he's not as sensitive.  Difficulty Transitioning to Life without the Animal Participation rate: 50% (4 participants) 55   Incidents: 9  Half of study participants reported difficulty in transitioning to life without their companion animal. Some would catch themselves performing certain behaviors out of habit before remembering that the behaviors were no longer appropriate, and the sudden realization heightened their sense of loss. Others missed their animal’s participation in activities that they had previously engaged in together, or had needs previously met by the animal that were now going unfulfilled.  You’re constantly looking in a certain direction, or a certain place that they used to sit all the time or sleep.  We used to always have the dog with us camping. He used to lie there and be there. The dog participated a lot with our camping. And now it’s just the two of us, you know? And we are so lonely.  I need to feel that I'm needed. Or I get depressed.  Reminders (Hindering) Participation rate: 37.5% (3 participants) Incidents: 5  Though some participants found various reminders of their animals to be helpful in their grieving process (and said reminders, as indicated previously, constitute the second-largest helping category), other reminders were identified by participants as 56   hindering their process. Interestingly, all three participants represented in this category are represented in the helping reminder category as well, indicating that they found some reminders particularly helpful while others were particularly difficult for them. Also of interest is that one participant identified looking at photos as hindering when, as described in the helping reminder category, three other participants found looking at photos to be particularly helpful in their grieving.  It's hard to see other people with their dogs. It just makes you miss your own even more. And they're just everywhere you go.  Feeling that I will not have this Experience Again; Unique, Irreplaceable Loss Participation rate: 37.5% (3 participants) Incidents: 4  Some participants were discouraged by thoughts that they would never again have such experiences as those they had with their animals.  I was worried that I wouldn't be able to get that level of bond with another animal that I had with [name].  I'm too old to get another dog.  Anger at Veterinarian/Clinic Participation rate: 25% (2 participants) 57   Incidents: 3  Two participants expressed anger toward clinic staff, believing that the staff had taken financial advantage of them when they were in a state of duress, or that staff had made poor decisions that were both unprofessional and that negatively impacted their animals.  The vet [at the emergency clinic] said my cat was stable and discharged him when he wasn't and should have been kept in the clinic. The vet I took him to later said he was critical and never should have been discharged. She also looked at the x- rays that the emergency clinic took and said you could see the kidney stones blocking his urethra. She said the only reason he was seizuring were because of his kidneys, since he wasn't absorbing any creatine. The Emergency clinic just said his bladder looked inflamed. When they discharged him, they recommended getting a liver ultrasound, which was a thousand dollars, and maybe a neurological consult which was fifteen hundred.  Others Affected by the Loss Participation rate: 25% (2 participants) Incidents: 2 In the final hindering category, two participants said that the impact of their animal’s death on others, including other animals, also contributed to the difficulty of their experience.  58   Talking to my father [about my dog] was very hard (after dog died). (Background: Mother was living with participant's sister in another city at the time, assisting with childcare. Father was home alone with the dogs. Participant's dog did not live with participant at time of death but with her father.)  Before, it was always reassuring, the dogs are there, okay well at least he's got the dogs. Now he's really alone. (Participant explained it being difficult for 3 reasons: (1) now I feel like he's alone, (2) he's not as close to me now; when he had my dog he had little things to remind him of me, and (3) he loved her so much.)  Excluded Incidents The two unsorted helping incidents were:  I had dreams of him at night and those helped a lot actually. It made me feel that even though he's not here, he's still a part of me.  The vet and her staff really seemed to care about me and my cat [when they were trying to save him].  The two unsorted hindering incidents were:  Carrying the body out to the vet's vehicle after she'd been euthanized [at home], and putting her on plastic sheets.  59   I had a recurring dream that was weird and troubling (occurred both before and after passing of dog).  The helping category that was excluded from the results due to an insufficient participation rate was titled “Sense of Gratitude”, and contained the following two helping incidents:  She brought a sense of family into my life. I got to participate in her having, and raising, her family. I couldn’t have children myself and I was really thankful to her for letting me participate in her family.  She became more affectionate during her illness. Like she would lie on top of me in bed. And she’d never been like that. So there was a sense that we had some closeness.   60   CHAPTER 5 - DISCUSSION  Overview This chapter begins with an examination of the study categories for theoretical validity by comparing them with the existing literature base. New findings are identified and discussed. Limitations of the study are then presented, followed by implications for practice and future research.  Theoretical Validation of Categories  The theoretical validation of CIT study findings is generally accomplished by determining the extent to which identified categories are supported by, or can corroborate, aspects of the existing academic literature base. However, as discussed in the literature review in Chapter 2, apart from the single study by Davis et al. (2003), in which general issues of coping with companion animal bereavement were subsumed in a larger study focusing on the impact of religious beliefs on such losses, no empirical studies pertaining to coping with this particular type of loss have been conducted. Therefore, this analysis of theoretical validity will also draw upon clinical literature on the topic, as well as the general body of literature (i.e., empirical, theoretical, and clinical) for human bereavement, and the clinical experience of the three grief and loss experts who were enlisted for trustworthiness and credibility check number eight, as described in Chapter 3.     61   Categories Supported by the Literature Helping categories. Social Support  Social support is well represented in the literature pertaining to both companion animal bereavement and human bereavement as a factor significantly influencing the grief experience. In the companion animal bereavement literature, numerous clinical articles describe individuals struggling because of a lack of social support (e.g., Carmack, 1985; Katcher & Rosenberg, 1979; Turner, 2003). This finding suggests that the provision of social support would be helpful. Furthermore, in his study examining the grief reactions of 138 bereaved veterinary clients who obtained social work services, Quackenbush (1984) reported that 70% of the owners specifically stated that to having someone accept and understand their feelings was helpful in their efforts to resolve the emotional stress accompanying pet loss. And in their study examining the impact of religion and other factors on the coping of 68 bereaved owners, Davis et al. (2003) stated that “Many owners also reported that it was helpful to be able to talk about their experience of their pet’s death with others.” (P.70). Meanwhile, Stylianos and Vachon (1993) reviewed social support within the human bereavement literature and reported that it can serve a variety of potentially helpful functions.  Reminders and Keepsakes  Numerous authors in the human bereavement literature (e.g., Klass et al., 2001; Wortman et al., 2001) have noticed a gradual shift from the assumptions underlying original psychoanalytic theories of grief to a more contemporary focus. Original 62   psychoanalytic theory believed that grieving required the breaking of bonds with the deceased and that such detachment allowed the recovery of the psychic energy invested in the now unavailable relationship. This energy needed to be recovered so that other relationships could be embarked upon. While this theory was enormously influential initially, a growing number of researchers now believe that some sense of continuing bond or sense of connection with the deceased is not only possible but actually quite common. Further, it is also believed to be healthier for the bereaved as it can provide a sense of solace, comfort, and support (Wortman et al., 1993). Stroebe et al. (2001) state that personal effects or photos can be consoling and trigger a sense that the deceased is still accessible. Very similar sentiments were expressed by participants in the present study when speaking of reminders and keepsakes being helpful. In the animal bereavement literature, numerous bereaved owners in Cowles’ (1985) study also kept keepsakes of their animals, though the number and percentage of owners doing so was not specified. And in Archer and Winchester’s (1994) survey of grief reactions following companion animal loss, 34.1% of the 88 bereaved owners endorsed the survey item “At times I have found myself wanting to be near places and objects that were closely associated with my lost pet” (P.262).  Calm Final Moments No literature directly supporting calm final moments in general was identified through the research for this chapter of the thesis. However, one of the clinical counsellors enlisted as a field expert to review the tentative categories as described in Chapter 3 identified this category as being particularly consistent with her own 63   experience in working with clients. She stated that calm final moments are “definitely always helpful for clients, especially when they feel in control of what is happening, and not rushed.”  These related notions of having a sense of control and not being rushed have been identified in the literature as being helpful in regard to euthanasia issues both in the study by Davis et al. (2003) and in Lagoni’s (2011) discussion of contemporary veterinary practices.  Ceremony/Ritual (non-religious) Numerous clinical and empirical articles in the human bereavement literature support ceremonial or ritual-type activities as assisting with the experience of bereavement. Rando (1985, as cited by Lagoni, 2011) stated that memorializing helps bring meaning to loss and helps draw closure to relationships. Castle and Phillips (2003) conducted a study exploring facilitative aspects of post funeral rituals with 50 participants and concluded that appropriate rituals can facilitate adjustment to bereavement. Vale- Taylor (2009) also conducted a study with 43 participants to explore which post funeral remembrance activities were most significant to participants and why they were chosen. The most common reason reported for choosing a ritual was to maintain a bond with the deceased. And as was already mentioned in the preceding Reminders and Keepsakes category, it is now believed by numerous researchers that maintaining a bond with the deceased is, in many cases, desirable from a coping perspective. In the companion animal bereavement study by Davis et al. (2003), the authors reported that 32 of the 68 participants (i.e., 47%) held some manner of ceremony for their 64   deceased animals. Unfortunately, they did not explicitly state whether these ceremonies were considered helpful from a coping perspective.  Spiritual/Religious Beliefs or Practices  Davis et al. (2003) reported that, in their study,  religious beliefs were found to assist with coping provided that the beliefs included an afterlife for the deceased animal. The finding is consistent with the present category as all participants in the category expressed belief in some manner of afterlife for their animals.  Having Time to Say Goodbye  Stern and Cropper (1998) observed that “Grief does not start upon death but rather upon the realization that the current condition will in all probability lead to death” (P.151). Rando (1986) defined anticipatory grief as “the phenomenon encompassing the process of mourning, coping, interaction, planning and psychological reorganization that are stimulated and begun in part in response to the impending loss of a loved one” (P.24). The experience of participants in this category appears consistent with the belief that anticipatory grief can act as a mitigating influence on post-death grief (Ball, 1977, and Parkes, 1975; as cited by Lagoni, 2011; and as confirmed by Carey, 1977).  Doing Other Things, Distraction This category appears similar to the survey item on Archer and Winchester’s (1994) study labelled “At times I have avoided thinking about my lost pet because it upsets me”, which was endorsed by 29.5% of bereaved owners. In a clinical counselling 65   article regarding animal loss, Toray (2004) similarly reports of bereaved owners attempting to distract themselves from their grief by keeping busy at work or devoting extra time to social activities. The fact that three participants reported engaging in unrelated tasks for the purpose of taking their minds off of their grief, and that two of these participants were generally unconcerned with what these other tasks entailed so long as their minds were kept occupied, also appears highly consistent with the emotion regulation system of oscillation described in Stroebe and Schut’s (1999) Dual Process Model of bereavement and coping. The model, as was described in Chapter 2, proposes that there will be times when bereaved individuals take deliberate breaks from a loss-oriented coping orientation, or from coping activities of any kind.  Spending Time with Other Animals  In Archer and Winchester’s (1994) survey of 88 bereaved animal owners, 60.2% of owners endorsed the item “I found I was drawn towards animals that reminded me of my lost pet” (P.262). However, the survey did not explicitly assess whether the owners found this behavior helpful.  Announcing Death, Reaching Out, Telling Story In the human bereavement literature, the empirical work of Pennebaker, Zech and Rime (2001) indicated that self-disclosure and social sharing can help some bereaved individuals. The animal bereavement literature provides many documented cases of owners who struggled with their grief but were reluctant to reach out to others due to 66   feeling embarrassed or anticipating negative responses. Empirical studies by Davis et al. (2003) and Quackenbush and Glickman (1984), as well as many clinical articles, suggest that reaching out can be beneficial in these cases. Furthermore, each participant in this category described taking considerable time and care in preparing their announcements and reported that this process was helpful in its own right. Support for this finding exists in the empirical work of Pennebaker et al. (2001).  Guarded Disclosure  There is extensive support in the companion animal literature for the existence of this category and its relevance in coping companion animal bereavement. There are many examples of bereaved owners being reluctant to disclose (see preceding category Announcing Death, Reaching Out, Telling Story) or being hurt and offended by the responses of others to their disclosure (see category Hindering Social Responses; Lack of Support and Understanding). However, it is difficult to interpret the utility of this category in a universal sense. The animal bereavement literature indicates that many bereaved owners had their grief exacerbated by the reactions of others, and in such cases guarded disclosure would appear beneficial. But, as was described in the previous category of Announcing Death, Reaching Out, Telling Story, many bereaved individuals find the act of disclosing to be helpful. In those cases, not engaging in self-disclosure could be limiting. Therefore, the utility of this category likely depends on the accuracy of the assessment of safety when deciding whether to disclose.  67   Hindering categories. Guilt, Regret, and Second-Guessing There is extensive support in the animal bereavement literature documenting the struggles of many bereaved owners with issues of guilt and second-guessing (e.g., Clements et al., 2003; Kotch & Quackenbush, 1988; Moneymaker, 1988; Stewart, 1983; Weirich, 1988). However, care must be taken when interpreting this category. Guilt is a common symptom of bereavement. Rather than describing an external agent or event that influenced their coping with the loss, it appears that participants in this category had described particular aspects of their loss itself that they found especially difficult to cope with.  Hindering Social Responses, Lack of Support and Understanding There is extensive support in the animal bereavement literature for this category (e.g., Davis et al., 2003; Harris, 1984; Katcher & Rosenberg, 1979; Morley & Fook, 2005; Quackenbush & Glickman, 1984).  Difficulty Transitioning to Life without the Animal There is considerable literature in the domain of companion animal bereavement which indicates that transitioning to life without the deceased is difficult for many bereaved individuals. Numerous articles detail examples similar to those identified in the present study. For example, separate studies by Cowles (1985) and Archer and Winchester (1994) both reported instances of participants continuing to engage in habituated patterns that they had engaged in with their animals, as well as having the urge 68   to search for the animal in their home, or temporarily sensing that the animal was present and in its usual space. In the study by Davis et al. (2003), numerous bereaved owners were distressed by the absence of previously routine events. But as was the case with the aforementioned category of Guilt, Regret and Second-Guessing, the present category is generally considered to be part of the bereavement experience itself. It does not appear to represent an external influence that impacted participants’ ability to cope, but rather is part of the experience that participants struggled to cope with.  Reminders (Hindering) Support for this category exists in two empirical studies within the animal bereavement literature. In the study by Archer and Winchester (1994), 29.5% of bereaved owners endorsed the survey item stating that “At times I have deliberately avoided people or situations that act as reminders” (P.262). And Davis et al. (2003) found that  “Cues that reminded [bereaved owners] of the animal, such as leashes, toys and food bowls were commonly perceived as distressing…” (P.68).  Anger at Veterinarian/Clinic  Just as with human bereavement, the occurrence of anger directed toward others by bereaved pet owners has been reported extensively in the literature (Cowles, 1985). Cowles (1985) and Harris (1984) state that this anger is often directed toward the veterinarian because the veterinarian is simply the most available person at the time, while Sharkin and Knox (2003) and Toray (2004) add that the veterinarian may also be perceived as not having done enough to prevent the death. 69     Still, it is unclear whether this category represents an influence on coping with the loss, or a part of the loss that participants found particularly difficult to cope with. Anger is a common symptom of bereavement. Though the anger of the participants may be entirely justified, it is still possible that, as with the hindering categories of Guilt, Regret, and Second-Guessing; and Difficulty Transitioning to Life without the Animal, this category represents part of the actual loss being grieved as opposed to a later influence on coping.  Others Affected by the Loss In the literature on human bereavement, Stylianos and Vanchon (1993) describe bereavement as a “social network crisis”. The loss creates a vacuum in the network that can draw in multiple members and render some members unable to support another member for whom the loss is even more profound. A similar though not identical point was raised by one of the clinical counsellors enlisted as a field expert (see Chapter 3). In her clinical experience with bereavement, one issue that hindered her bereaved clients was when friends or relatives “needed the griever”, whether to assist them in coping with the same loss or with some other issue. It is easy to see how each of the aforementioned scenarios could hinder grieving. In both cases the griever is deprived of potential supports, and in the second case must also contend with additional stressors.    70   Categories Not Supported by the Literature  No supporting literature was identified for three categories. These categories are the two helping categories of Knowing that they Provided Animal with Good Life and Sense of relief, and the hindering category Feeling that I will not have this Experience Again; Unique, Irreplaceable Loss.  Summary of Theoretical Validation Sixteen of the nineteen categories have at least some support in the literature. This is believed to increase the credibility of these categories. There are several caveats, however. First, the amount of support varies considerably among the categories. Second, several hindering categories appear to reflect symptoms of grief or aspects of the loss that participants found particularly distressing, rather than external factors that influenced their ability to cope. Third, due to limitations in the animal bereavement literature, significant portions of supporting literature were drawn from clinical articles on animal bereavement and the general literature for human bereavement. Empirical studies are preferred to clinical articles for studies of this kind. Similarly, articles from the human bereavement literature were extrapolated to the present topic of animal bereavement and the accuracy of this extrapolation is unknown. It should be noted that less support in the literature is not necessarily an indication that study findings are unsound (Butterfield et al., 2005). If a study uncovers findings that were previously unknown to researchers, such findings will understandably be absent in the existing literature. Therefore, lower levels of theoretical validation must be interpreted carefully, especially given the exploratory nature of the CIT. 71   Discussion  Despite the paucity of empirical research on coping with companion animal bereavement, once the literature review was expanded to include a wider range of articles there was remarkable support for the majority of categories found in the study. The study identified considerably more helping categories than hindering categories and considerably more helping incidents than hindering incidents. There are several possible explanations for this finding. One possibility is that the distribution reflects relatively universal aspects of the coping experience that follows the death of a companion animal. If this universality is the case, the categories and incident distribution would be expected to remain largely the same no matter the personal circumstances of the bereaved owners. Another possibility is that both the categories and the distribution of incidents among them are dependent on factors pertaining to personal circumstances of the bereaved owners. For example, the majority of participants in the present study appeared relatively well adjusted and were not displaying symptoms of complicated grief. It is unclear whether the same categories would emerge if a different group of participants were interviewed, such as individuals who were not coping as well with their experience. It is similarly unclear to what extent other personal characteristics of bereaved individuals may influence category formation and incident distribution. All but one participant reported that the interview process had been a positive and helpful experience. Some participants expressed considerable gratitude to the researcher for their involvement in the study. This finding is consistent with results in the human bereavement literature that research participants tend to view the research experience as a 72   positive one (e.g., Cook & Bosley, 1995). The remaining participant considered the interview experience to be neither particularly positive nor negative. Limitations  There are numerous limitations in the present study. First, while not technically a limitation, it should be acknowledged that the findings are not generalizable to other populations. This lack of generalizability is due to a qualitative research method being used. Lack of generalizability is an accepted consequence of qualitative methods, which are instead able to gather and analyze richer, more detailed and nuanced datasets than are possible using quantitative methods. A definite limitation in the study was that one of the nine credibility checks described in Chapter 3 was only partially completed. The check, known as participant cross-checking, entails contacting the study participants sometime after their original interviews to have them review the incidents that they originally provided (and making changes as necessary) and the tentative categories to confirm that they are understandable and adequately represent their experience. While participants were successfully contacted to review verbally condensed versions of their incidents, a protracted medical issue experienced by the researcher prevented the tentative categories from being reviewed with participants during the required time period. The study was also limited by several other factors. Though acceptable levels of data-redundancy were achieved, six critical incidents were not included in the final categorization scheme. Additional interviews could have determined more definitively if these incidents were outliers or if they had a broader significance. However, additional interviews were not conducted due to time and resource constraints. A considerable 73   gender imbalance also existed among participants, with seven of the eight participants being female, and deceased animals were limited to dogs and cats. Another potential limitation in the study was the use of self-reporting by participants. Flanagan (1954) stated that the CIT was frequently used to report observations from memory and was generally satisfactory for this purpose so long as the incidents reported were fairly recent and the participants were motivated to make detailed observations when the incidents occurred. In the present study, participants had no knowledge of the study during the initial months of their bereavement. Therefore, their level of motivation to take notice of incidents would have been very low. Fortunately, participants were able to describe incidents in considerable detail, perhaps as a result of the incidents occurring in emotionally charged environments.  But it is less clear as to whether they were able to successfully recall all relevant incidents. Implications for Practice This study has confirmed that companion animal bereavement has the potential to be both a highly significant event for some individuals and also a very distressing one. Numerous factors were identified that substantially influenced the experience of bereavement for individuals in the study. While these initial findings are not generalizable and further research is needed to determine the extent that they and other factors may influence the experience of bereaved individuals at large, they do suggest considerable similarity between factors known to influence the experience of human bereavement and those of companion animal loss. The most notable difference appears to be that certain factors identified as being particularly helpful to individuals experiencing 74   the former are often much less available, or even exist in the converse, for individuals experiencing the latter. Nowhere is this truer than in matters pertaining to social support. Future Research  This study has added valuable findings to the counselling and bereavement literature. While numerous empirical studies have examined bereavement reactions resulting from the death of a companion animals, this study appears to be only the second to examine potential coping moderators that can influence the course of grieving. There are several suggestions for further research.  First, several categories were identified that found support in the human bereavement literature but not in the companion animal bereavement literature. The fact that many similarities are known to exist between the experiences of human and companion animal bereavement suggests that the lack of support in the latter body of literature is less likely due to the categories not being valid and more likely due to the limited research in this domain. Further research is warranted to confirm their validity in the domain of companion animal bereavement. Second, no support could be found in the existing animal or human bereavement literature for the three study categories Knowing that they Provided Animal with Good Life (helping), Sense of Relief (helping), and Feeling that I will not have this Experience Again; Unique, Irreplaceable Loss (hindering). While the companion animal bereavement literature is quite limited, human bereavement literature, in contrast, is quite extensive. Therefore, it is possible that support for these categories exists in the human bereavement literature but was not located during the review. Alternatively, these categories may hold particular significance in the domain of companion animal 75   bereavement that is not matched in the domain of human bereavement. Additional research is warranted to determine the saliency of these four categories.  More generally, the expanded literature review conducted for the theoretical validation of the study categories found significant support for numerous categories within the human bereavement literature and adds to the growing body of research that has identified numerous similarities in at least some aspects of coping with losses in the domains of human and companion animal bereavement. However, while it is known that grief reactions for these two losses can be quite similar, it is also known that similarities do not fully extend to the respective mourning processes (Gerwolls & Labott, 1994). 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Washington, DC US: American Psychological Association.   87   APPENDICES 88              Critical Incidents in Grieving the Deaths of Companion Animals from the Owner’s Perspective  Consent Form  Principal Investigator:  Dr. Bill Borgen, Department of Educational and Counselling Psychology and Special Education, University of British Columbia. Tel. xxx-xxx-xxxx  Co-Investigator:  Dave Alexander, Department of Educational and Counselling Psychology and Special Education, University of British Columbia. Tel. xxx-xxx-xxxx  Purpose:  The purpose of this study is to develop a better understanding of bereaved pet owners’ grief experience by exploring experiences that helped or interfered with the owners’ grieving process.  Study Procedure:  You will be asked to participate in an approximately 60-90 minute interview conducted by the co-investigator. During this interview you will first be asked some basic questions about yourself and your living situation (eg. your age, gender, number of people in your home, etc.) and you will also be asked about your deceased pet. You will then be asked to discuss events and experiences that made it easier or harder for you to grieve the death of your pet. The interview will be audio recorded and later transcribed to assist in analyzing your comments. You may be contacted later by the co-investigator to confirm his understanding of your comments or to clarify them. You may also be contacted later, once all participants have been interviewed, to share your feedback on common themes that emerged during the interviews.  Potential Risks: There is a possibility that, in the process of sharing your experiences, strong feelings may arise. If at any time during the interview you become distressed, you may choose to either take a break or withdraw your Department of Educational and Counselling Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel  xxx-xxx-xxxx  Fax  xxx-xxx-xxxx Appendix A - Consent Form 89   participation from the study. If you choose to withdraw from the study then none of the information that you have already provided will be included in the study.  At the end of the interview you will also be given a list of reduced-cost counselling services. This is standard practice when interviewing people about potentially sensitive topics. You may wish to consider these services if the interview triggers strong feelings or issues that you wish to explore further.  Confidentiality: Your identity and any information you provide will be kept strictly confidential. Only the principal- and co-investigator will have access to your name and your interview materials. All documents will be kept in a locked filing cabinet when not in use, and all computer files will be encrypted with a password. In any publication resulting from this research, participant names and any other identifying information will be altered. As per university policy, all information and data obtained in this research study cannot be destroyed until at least five years after the publishing of the research in a refereed academic journal.  Remuneration/Compensation: You will not receive monetary compensation for your participation in this study.  Contact for information about the study: If you have any questions or desire further information about the study, you may contact Dave Alexander at xxx- xxx-xxxx or  Contact for concerns about the rights of research subjects: If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the UBC Office of Research Services at xxx-xxx-xxxx.  Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without any negative consequences. If you have any questions about the research study or your participation in it, please address these with the interviewer before signing this consent form.  Your signature on the following page indicates that you have received a copy of this consent form for your own records.  Your signature indicates that you consent to participate in this study.  Your signature indicates that you consent to be audio recorded during the interview. 90       _____________________________ Name (please print)   _____________________________          ___________________ Signature                                              Date    91   Critical Incidents in Grieving the Deaths of Companion Animals From the Owner’s Perspective  Interview Protocol    Informed Consent ____ Read aloud to participant while they read along on their own copy ____ Emphasize participation being voluntary. Can take a break at any time. Can choose to withdraw at any time. ____ Give participant examples of what to say for breaks or withdrawal:  “You know, I think I could use a break” or  “I’m having second thoughts about participating in this study” or  “I’ve decided I want to withdraw from this study” ____ Any questions? (ie from participant?) ____ Obtain signature, provide participant with copy.   Begin audio recording, inform participant   Demographics  Ask participant the basic demographics questions rather than have them fill out a form him or herself. This way participant will not be distracted by non-applicable questions   Basic inquiry about pet  “Can you tell me a bit about <pet>?  What was he/she like? What was it like living with him/her?”   Nature of death  “Can you share with me the circumstances of <pet>’s death?” Explore and note:  Cause,   eg. old age, disease, accident?  Euthanasia involved?  Special circumstances   Time frame,  eg. sudden vs anticipated etc. “Can you tell me a bit about how <pet>’s death affected you?”   Main Interview Questions  Hindering / Helpful incidents. Use the printed guidelines. Follow-up questions:  (specific example of a time if not provided)  What was it about that event that made you feel that way?  What did that mean to you?  How did that experience impact your grieving process?   Last Q before review  “Is there anything else that you wished would have happened that would have been Appendix B - Interview Protocol 92   helpful in your grieving process?”   Incident Review  Read back all incidents for confirmation / clarification  Ask if anything we missed, or anything they’d like to add   Interview Conclusion ____ ____ ____ ____  What has this experience been like for you?  Give participant copy of Counselling Resource List  Remind re: future contact for clarification and/or review  Thank participant   END (recorder off)   93   Critical Incidents in Grieving the Deaths of Companion Animals From the Owner’s Perspective  Demographic Information  Age (of participant): __________      Gender (of participant): _____  Kind of pet? (eg. dog, cat, etc): ______________      ( Name: ____________    Gender: _____ )  How old was your pet? (if known) (years): __________  How long had your pet lived with you? (years):  __________  When did your pet die? (approx date okay): __________  Ownership of pet? (eg. Participant only? Shared?  Other owner(s) etc?) ______________________________________________________________________________  How many people, including yourself, were living in your household at the time your pet passed on? __________  How were the other people in the household related to you? (eg. partner/spouse, child, roommate, brother, sister etc)  Provide age of children, if known. _________________________ ______________________________________________________________________________ ______________________________________________________________________________  Where there any other pets living in the household at the time your pet passed on? (Y/N): __________  Kinds of animals and quantity of each  ______________________________________________ ______________________________________________________________________________   Ownership of these other pets? (eg. Participant only? Shared?  Other owner(s) etc?) ______________________________________________________________________________   Euthanasia involved? (Yes/No): __________    On a scale of 1 to 10 how strong a bond did you feel with your pet? (circle)                          1        2        3        4        5        6        7        8        9        10                No bond, or                                                                              Very                very weak                                                                           strong bond Appendix C - Demographics 94          Critical Incidents in Grieving the Deaths of Companion Animals from the Owner’s Perspective  Counselling Resources   Crisis Line  If you are feeling particularly distressed as a result of the interview then please call the Vancouver Crisis Line at xxx-xxx-xxxx.   Community Counselling Services  The following agencies offer services on a sliding scale based on income level.   Family Services of Greater Vancouver xxx-xxx-xxxx   Oak Counselling Services xxx-xxx-xxxx   Catholic Family Services xxx-xxx-xxxx You do not need to be Catholic, or religious, to obtain services at this agency.   New Westminster / UBC Counselling Centre xxx-xxx-xxxx 821 8 th  Street, New Westminster Priority is given to New Westminster residents, but all Lower Mainland residents are welcome. This is a training centre and it charges no fee. All counsellors are graduate students in the UBC Counselling Psychology program at either the Masters or Doctoral level.  Department of Educational and Counselling Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel  xxx-xxx-xxxx  Fax  xxx-xxx-xxxx Appendix D - Counselling Resources Handout


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