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Being there : relationships between people with cancer and their pets : what helps and what hinders Nitkin, Patricia 2014

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  BEING THERE: RELATIONSHIPS BETWEEN PEOPLE WITH CANCER AND THEIR PETS What Helps and What Hinders  by  Patricia Nitkin B.A. McGill University, 1987 M.A. University of British Columbia, 2000  A THESIS  SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)  March, 2014         ? Patricia Nitkin, 2014      ii Abstract   This qualitative research examined the little studied area of human-pet relationships and their impact on persons with cancer. The goal of this study was to gather information from individuals with cancer who had a pet during their illness and to explore the helpful and unhelpful aspects of that relationship as people dealt with the socio-emotional, physiological and spiritual challenges usually accompanying cancer diagnosis and treatment. The Enhanced Critical Incident Technique method (Butterfield, Borgen, Maglio, & Amundson, 2009) was used to collect information and interpret the interviews of 13 British Columbian women with cancer about their relationships with their companion animals. From these interviews, 13 personal accounts were created to give voice to the women?s experiences. The bulk of the data focused on clear descriptions of the ways in which pets contributed to and/or detracted from the participants? sense of wellbeing during their illness. From this 487 helping critical incidents and 109 hindering critical incidents were formed into 13 categories that represented the areas of impact. In rank order of participation rate the categories are: Companionship & Presence; Emotional & Social Support; Purpose & Role; How Pets are Different from People; Health and Pain Management; Pet Intuition & Adaptability; Being Positive & in the Moment; Pet as Protector & Caregiver; Touch; Unconditional Love & Devotion; Existential & Spiritual Factors; Family Members & Finances, and Caretaking of Sick or Dying Pet.  The findings of the study are congruent with the literature from the fields of veterinary medicine, social work, nursing, and anthrozoology in that they confirm the significant and primarily positive impact of the social support, trust and bond experienced by human beings from their companion animals. The results also indicate the distress caused by the lack of resources for pets when one is ill and the suffering caused by pet illness and bereavement. Other  iii unique findings include participants? experience of their pets as able to intuit subtle changes post-diagnosis and instantly modify their behaviour to attend to their human companions. It is recommended that psychological and psychosocial oncology theory, practice and research engage with further exploration of the relationships between people and their companion animals.    iv Preface  This dissertation is an original intellectual product of the author, P. Nitkin. The fieldwork reported in Chapters 3-4 was covered by UBC Ethics Certificate number H11-01104.     v Table Of Contents Abstract .............................................................................................................................. ii Preface ............................................................................................................................... iv Table of Contents .............................................................................................................. v List of Tables ..................................................................................................................... x List of Figures ................................................................................................................... xi Acknowledgements ......................................................................................................... xii  CHAPTER 1:  Introduction ............................................................................................. 1 Overview ............................................................................................................................ 1 Background of the Study .................................................................................................. 1 Rationale ............................................................................................................................ 2      Human Animal Bond (HAB) ...................................................................................... 2      Connecting the HAB to Cancer Care ......................................................................... 4 Significance of the Study .................................................................................................. 5 Purpose of the Study ......................................................................................................... 7 Study Design Method ........................................................................................................ 8 Summary of Chapter I .................................................................................................... 10  CHAPTER 2: Literature Review .................................................................................. 11 Overview .......................................................................................................................... 11 Historical Perspective of Human-Animal Studies ....................................................... 11 Psychology Research relating to the HAB .................................................................... 13 Animal-Assisted Therapy ............................................................................................... 15 Research on the Health and Psychosocial Effects of Companion Animals ............... 15      Health Effects ............................................................................................................. 15      Psychosocial Effects ................................................................................................... 17      Problems with Pets ..................................................................................................... 20 The Cancer Experience .................................................................................................. 21      Psychosocial Oncology ............................................................................................... 22      Coping and Psychosocial Adjustment ...................................................................... 24      Social Support ............................................................................................................ 26      Wellbeing .................................................................................................................... 28  vi      Non-verbal Communication and Touch .................................................................. 30 Attachment Theory ......................................................................................................... 30      Adult Attachment ....................................................................................................... 32      Attachment and Companion Animals ...................................................................... 33 Counselling Psychology Applications ............................................................................ 36      Companion Animals as a Source of Positive Emotion ............................................ 38 Conclusion ....................................................................................................................... 38  CHAPTER 3:  Method ................................................................................................... 40 Overview .......................................................................................................................... 40 Suitability of the Enhanced Critical Incident Technique  ........................................... 40 Researcher Positionality ................................................................................................. 41      Epistemology and Ontology ...................................................................................... 41      Humanistic Model and Unique Application to HAB Research ............................. 42      Situating the Researcher and Personal Reflexivity ................................................. 43 Origins of the Critical Incident Technique and ECIT ................................................ 45 Study Procedures ............................................................................................................ 47      Participant Selection Criteria ................................................................................... 47      Ethical Considerations .............................................................................................. 47      Recruitment  ............................................................................................................... 48      Interviews .................................................................................................................... 49      Informed Consent ...................................................................................................... 49      Honoraria .................................................................................................................... 50 Participants  ..................................................................................................................... 50 Data Collection and Analysis ......................................................................................... 52 Five Steps in Conducting ECIT ..................................................................................... 52      Step 1: Ascertaining the general aims of the activity being studied ...................... 52      Step 2: Making plans and setting specifications ..................................................... 52      Step 3: Data collection ............................................................................................... 52           Interviews ............................................................................................................... 53           Data Management .................................................................................................. 54      Step 4: Data analysis .................................................................................................. 55   vii      Step 5: Interpreting the data & reporting results ................................................... 56           Participant Personal Accounts .............................................................................. 56           ECIT Credibility Checks ........................................................................................ 57           Independent extraction of critical incidents ......................................................... 57           Cross-checking by participants .............................................................................. 58           Placing incidents into categories by an independent judge.................................. 60           Exhaustiveness ....................................................................................................... 60           Expert opinions ...................................................................................................... 60           Theoretical agreement ........................................................................................... 62           Participation rates .................................................................................................. 62           Descriptive validity ................................................................................................. 63           Interview fidelity ..................................................................................................... 63      Representation of Findings ....................................................................................... 64 Summary of Chapter IV ................................................................................................. 64  CHAPTER 4: Findings ................................................................................................... 65 Overview .......................................................................................................................... 65 Participant Personal Accounts ....................................................................................... 65      Participant #1: Anna and her dog Jack ................................................................... 66      Participant  #2: Stacey and her dog Fluffy .............................................................. 68      Participant #3: Joanne and her dogs Timmy and Meisha ..................................... 69      Participant #4: Lila and her dog Louie .................................................................... 71      Participant #5: Daisy and her dog Haro .................................................................. 73      Participant #6: Alice and her dogs Coral and Mini ................................................ 74      Participant #7: Barbara and her dog Prince ........................................................... 75      Participant #8: Clair and her dogs Zeus and Zena ................................................. 77     Participant #9: Mona and her cat Gris ..................................................................... 79      Participant #10: Ruth and her dog Brownie ........................................................... 80      Participant #11: Maria and her dog Cookie ............................................................ 81      Participant #12: Lucky and her dog Sugar ............................................................. 83      Participant #13: Sarah and her dogs Ganesh and Lakshmi .................................. 84 Defining Wellbeing in the Context of Cancer ............................................................... 86      Wellbeing Categories ................................................................................................. 87  viii       1. Peace of Mind ......................................................................................................... 87      2. Social Support ........................................................................................................ 88      3. Taking Care of my Emotional Needs ................................................................... 88      4. Resolving to Beat Cancer ...................................................................................... 89      5. Putting my Physical Needs First ........................................................................... 89      6. Personal Growth & Purpose ................................................................................. 90 Critical Incidents and Categories .................................................................................. 91      1. Companionship & Presence .................................................................................. 93      2. Emotional & Social Support ................................................................................. 94      3. Purpose and Role ................................................................................................... 96      4. How Pets are Different from People ..................................................................... 97      5. Health and Pain Management .............................................................................. 99      6. Pet Intuition and Adaptability ............................................................................ 100      7. Being Positive and in the Moment ...................................................................... 102      8. Pet as Protector and Caregiver ........................................................................... 103      9. Touch ..................................................................................................................... 104      10. Unconditional Love & Devotion ....................................................................... 105      11. Existential and Spiritual Factors ...................................................................... 106      12. Family Members  and Finances ........................................................................ 107      13. Caretaking of Sick / Dying Pet .......................................................................... 108 Summary of Chapter IV ............................................................................................... 110  CHAPTER 5: Discussion .............................................................................................. 111      Overview ................................................................................................................... 111      Comparisons to Relevant Scholarly Literature .................................................... 111      Participants and their Pets ...................................................................................... 112      Participant Personal Accounts  ............................................................................... 113      Defining Wellbeing in the Context of Cancer ........................................................ 114      Helping Categories ................................................................................................... 115           Social support ...................................................................................................... 116           Attachment theory .............................................................................................. 118  ix      Helping categories in relation to research and theory .......................................... 120      Companionship and presence ................................................................................... 120      Emotional and social support ................................................................................... 121      Purpose and role ....................................................................................................... 123      How pets are different from people .......................................................................... 124      Health and pain management .................................................................................. 125      Pet intuition and adaptability ................................................................................... 125      Being positive and in the moment ............................................................................ 126      Touch ......................................................................................................................... 127      Existential and spiritual factors ............................................................................... 128      Family members and finances .................................................................................. 129 Hindering Categories .................................................................................................... 129 Recommendations for Future Research ..................................................................... 132 Implications of Study .................................................................................................... 134      Counselling Psychology Theory and Clinical Practice ......................................... 134      Psychosocial Oncology ............................................................................................. 136      Public Policy ............................................................................................................. 137 Process of Conducting the Study ................................................................................. 138 Limitations of the Study ............................................................................................... 140 Conclusion ..................................................................................................................... 141  References ...................................................................................................................... 143  Appendix A: Recruitment Poster ................................................................................ 160 Appendix B: Information Letter for Prospective Participants ................................. 162 Appendix C: Recruitment Email to Colleagues and Friends .................................... 164 Appendix D: Informed Consent Form ........................................................................ 166 Appendix E: Interview Guide ...................................................................................... 169 Appendix F: Demographics and Biographical Information ..................................... 173 Appendix G: Participant Check Letter ....................................................................... 174     x List Of Tables Table 1: Participant Demographics and Biographical Information ................................. 51      Table 2: Participation Rates for Categories, Critical Incidents and Wish List Items ...... 92                                            xi List Of Figures  Figure 1: Research Model for Psychosocial and Quality of Life Research in Oncology???23     xii Acknowledgements  I thank my committee members Drs. Buchanan, Borgen and Westwood for their guidance and support. I feel so fortunate to have had Marla on my side?your compassion, wisdom and kind heart kept me going. Bill, what an honour to work with you- your careful attention to content, process and detail made me feel my work was of merit.  Marv, I thank you for always being supportive. I also express my gratitude to Karen Yan for all your help over the years.  Finally I am ever grateful to the team at BCCA for supporting me with this project. I feel honoured to have met and heard the stories of the participants and your pets in this study~ You are courageous and profound women. Thank you for sharing your experiences ? they have inspired me and likely will do the same for others.  Over the years I have had the privilege of working and experiencing life with many individuals and families  ~ Being in the presence of life, death, hope, love, suffering, care, despair and the ?overcoming of it.? (Helen Keller). All of you have taught me much of what I know, and shown me the way. I thank you deeply.  Dear Sammie and George- your beautiful faces, soft nuzzly furry ears & eyes filled with expression, and your mysterious and constant companionship. Thank you for loving to run around joyfully, letting me watch and join in sometimes, and especially for ceaselessly cuddling & wagging your tails and staying by me in times of difficulty- you are gifts of healing and joy.  ?How lucky can a gal be?? I am so grateful to my family and friends for loving me, helping me, making me smile, cajoling me, listening to me kvetch, and especially for believing in me?Anton, Roberta & Eric, Elaine & Gerry, Susan & Jeff, Steve & Bonnie, Rob & Arlene, Ali, Irv and Betty, Mark, Krista, Dodo, Lorne, Heidi, Lucy, Annette and Lisa?I love you all.  I have had the amazing good fortune to have had two extraordinary dads, Ralph and Herb, and one beautiful mother Pearl, all of whom I think smiled down upon me from time to time during this journey in this lovely house you all left for me to feel safe and sound in. I am also thankful for, and shall never take for granted, the many amazing and mysterious animals beyond man?s usual companions that bring to me a sense of love and curiousity, and their natural habitats like the mountains and oceans that bring me a sense of awe and peace. Within these realms, I have found freedom, beauty, laughter, and healing.   And thank you for love. I hope everyone gets as much as I have ?. 1 CHAPTER 1 Introduction "Compassion, in which all ethics must take root, can only attain its full breadth and depth if it embraces all living creatures and does not limit itself to mankind." --Albert Schweitzer, philosopher, physician, musician, Nobel laureate (1875-1965) Overview This introductory chapter will introduce the reader to the fundamental ideas and concepts surrounding the research study. I will outline and explain the rationale, significance and purpose of the study. Finally I will introduce the reader to the research question and the study?s design.  Background of the Study Much evidence, empirical and lived, attests to the fact that human beings need to be closely related to others in order to survive and thrive (Bartels & Ziki, 2004; Reis & Rusbult, 2004). This need for close interpersonal relationship begins at a biological level at conception, continues in the womb and manifests in myriad ways from infancy through to old age. Human beings seem to have innate needs to both be nurtured and to nurture others. Relationship science is now a burgeoning field in psychology and seeks to gain an understanding of interpersonal relationships and their influences on human development, behaviour, emotion, cognition and coping (Reis & Rusbult, 2004). This research focuses on a specific form of relationship, namely that between human beings and their companion animals /pets. The scholars in animal welfare, animal-human research and veterinary medicine currently employ the term companion animal, rather than pet, to reflect the mutual bond between human and animal (Walsh, 2009) and as such, this term will be used interchangeably with pet throughout the dissertation.     2 Rationale  Human-Animal Bond          While human beings and non-human animals (henceforth referred to as animals) are known to have been living and working together since the origin of our species (Coren, 1996; Knight & Herzog, 2009), it is only in the past 30 years that a body of research has emerged which focuses on the human-animal bond (HAB) (Hines, 2003).  A new field of science called anthrozoology is burgeoning. Anthrozoology focuses specifically on the human-animal relationship and bridges the natural and social sciences (Podberscek, Paul & Serpell, 2000). It is generally accepted by most cultures that the companionship of an animal has health-enhancing effects including cardiovascular benefits and decreased levels of stress and loneliness (Risley-Curtiss, Holley, & Wolf, 2006). However, the relationship between humans and the animals with which they co-exist is still poorly understood (Beck & Katcher, 2003; Wells, 2009). Mullin (1999) explains: ?Increasingly, animals serve all at once as commodities, family members, food, and the embodiment of nature; it is therefore no wonder that they present a complicated set of relationships for human beings.?  Current attachment theory research demonstrates that the bonding behaviours once thought to be the sole propriety of infants and mothers are replicated in both adult love relationships (Hazan & Shaver, 1987) and human-companion animal relationships (Kurdek, 2007). Considerable research indicates that companion animals can moderate the effects of stressful life events such as divorce and bereavement, increase levels of social support and reduce levels of depression, anxiety and loneliness (Brodie & Biley, 1999; Walsh, 2009; Wells, 2009). Given the high levels of stress, anxiety and depression in contemporary society combined with the growing isolation due to the diminishment of family in urban centres, companion animals are beginning  3 to be regarded as potential sources of social support (Antonacopolous & Pychyl, 2010). Yet we have not investigated the role of human / companion animal relationships as potentially significant and powerful bonds during illness (Beck & Katcher, 2003; Risley-Curtiss, Holley & Wolf, 2006). To examine the impact of companion animals on people facing adversity, this research focuses on the relationships that people dealing with cancer have with their pets.  It is not difficult to see the links between the great humanist Carl Rogers? core conditions for psychotherapy and the common perceptions of people regarding their pets. Rogers? necessary and sufficient conditions for therapeutic change include genuineness, empathy and unconditional positive regard (Rogers, 1957). These elements are regularly cited as the reasons why many people feel so attached and devoted to their companion animals, and in particular to dogs (Bustad, 1996; Wells, 2009). Intuitively, the positive effects of the HAB are assumed to result from some of these factors, in particular the experience of unconditional love, affection and companionship, increased time spent outdoors and walking (Brodie & Biley, 1999; Walsh, 2009). Yet surprisingly the bulk of this research comes from the veterinary and anthrozoology fields and not from the discipline of psychology. There exists almost no clinically driven research from any branch of psychology regarding the HAB outside of linking animal cruelty to psychopathology (Raupp, 2002). Thus the current socio-historical context of the HAB is one in which there is a growing appreciation of human-animal relationships with limited empirical support from the field of psychology and hesitant appreciation of the importance of human-animal relationships in the society at large (Risley-Curtiss et al., 2006; Walsh, 2009). I hope that this study will be one of many explorations of the HAB by counselling psychology, psychosocial oncology scholars and clinicians in the near future.   4 Connecting the HAB to Cancer Care For most people, the diagnosis, treatment and experience of cancer presents as frightening and distressing (Holland, 2004). Many patients are faced with an overwhelming array of physical, psychological, emotional and social challenges due to the multitude of unnerving possibilities such as disfigurement, pain, functional changes, and death (Preyde & Synnott, 2009). The psychosocial oncology literature strongly supports the link between social / emotional support and better coping responses to cancer and its related challenges (Carlson & Bultz, 2003; Helgeson & Cohen, 1996). Most health and social sciences recognize the importance of relationships for human health and wellbeing and agree that good social support can serve as a buffer against the adverse affects of stress (Helgeson, 2003; Lent, 2004).  The advance of successful medical treatment for many of the over 200 types of cancers has resulted in a dramatic increase in both the life span and quality of life of people with the illness. At the same time, the incidence of cancer continues to grow, in part, due to early detection. Approximately 41% of women and 46% of men in Canada will develop cancer during their lifetime (Canadian Cancer Society, 2013). While it is estimated that 187,600 new cases of cancer will occur in Canada in 2013, there also exists a five-year survival rate of over 63% per cent, the third highest in the world (Canadian Cancer Society, 2013).  In 2009, there were just fewer than 840,000 Canadians who had been diagnosed with cancer 10 years prior. Thus, there is a significant and growing population of Canadians living with cancer who have distinct psychosocial needs (Nitkin, Parkinson, & Schultz, 2010). The notion of cancer survivorship has emerged as a central phenomenon in oncology and is broadly defined as the time frame from diagnosis of cancer through the balance of life (Bell & Ristovski-Slijepcevic, 2012). The new Journal of Cancer Survivorship and numerous reports on survivorship from several countries  5 including the United Kingdom, Australia, Finland, and Canada evidence the growing interest in this field. One can find a bevy of studies looking at survivors and their reintegration into the ?new normal?  (Hill-Schnipper, 2003). Whether one self-identifies as cancer ?patient?, ?cancer ?survivor?, ?cancer victim? or ?person with cancer? (Park, Zlateva, & Blank, 2009) any such label generally comes with considerable psychosocial and existential distress (Halldorsdottir & Hamrin, 1996; Preyde & Synnott, 2009). While cancer is a disease, it is also a life experience that can profoundly affect and challenge the patient and his/her community (Halldorsdottir & Hamrin, 1996). For this reason, I employ the term ?cancer experience? throughout the study. Over the past twenty years, psychosocial oncology programming, services and research have greatly expanded in recognition of these hardships (Owen, Klapow, Hicken, & Tucker, 2001). Psychosocial services include supportive and therapeutic counselling on individual, marital, family and group levels. The types of counselling include: vocational and financial, grief and bereavement, mindfulness and relaxation, cognitive-behavioural, psycho-educational, family communication, and crisis counselling to name a few. Throughout these areas, the notion of relationship and social support consistently stand out as essential components of the coping and adjustment process (Helgeson & Cohen, 1996; Lent, 2007). Often the cancer patient experiences a sense of intense aloneness in their illness experience (Holland, 2004) and companion animals may serve to lessen this suffering. The HAB has been virtually ignored as a potential factor in this process.  Significance of the Study This research has important implications for both the psychology and the psychosocial oncology bodies of literature. The study can open up a greater appreciation for the existing relationships that people facing illness may have with their companion animals. These  6 relationships may be serving unmet needs and/or causing additional distress. In Canada, over half the population has one or more household pets (Leger, 2002; Perrin, 2009) and in the United States, over 63% of households have at least one pet (American Pet Products Association, 2009/2010). Canadians have been substantially spending more on their pets for the past fifteen years (Statistics Canada, 2013). North America is not alone in this respect. Growing numbers of pet-owners in many other countries demonstrate the value that human beings have for their relationships with animals: Australia reports 63% are pet owners (Australian National People and Pets Survey, 2006); England reports 48% are pet owners (Pet Food Manufacturer?s Association, 2008); China has had a consistently growing population of pet owners since 1995 that now stands at 22% (EuroMonitor, 2005). Thus worldwide, the likelihood that a person dealing with cancer has a pet is high. Because the presence of a companion animal has been shown to have significant impacts on human beings (Risley-Curtiss, 2010; Walsh, 2009) it is important that these relationships be incorporated into the clinical realm of psychosocial cancer care. These relationships may offer a potentially untapped resource to augment psychosocial care. In addition, there are many people for whom the primary source of connection is their pet (Risley-Curtiss, 2010). It may be that these individuals are unable to benefit from these relationships when they are sick in part because professional health care providers pay little attention to them. In such cases, ailing individuals may require assistance and resources when challenges in caring for and/or being separated from companion animals arise, just as would be done for any patient?s child or family member. Through a careful exploration of the companion animal factors that help and hinder a sense of well being for people with cancer, I have aimed to shed light on the ways in which people experiencing adversity perceive support and/or distress associated with their pets. Serious  7 illnesses such as cancer tend to initiate changes in help-seeking behavior. People tend to require multiple sources of support and may neither know how nor feel able to get their needs met (Helgeson & Cohen, 1996). My hope is that this study has identified some of the unknown support elements of companion animals specific to individuals facing serious illness. A deepened understanding of these relationships responds to calls from psychosocial oncology and HAB research (Beck & Katcher, 200; Helgeson & Cohen, 1996).  Purpose of the Study While the research on the benefits and impact of companion animals and the HAB are convincing, there remains little empirical and theoretical conception of these benefits, nor on the meanings that individuals and families make of their bonds with companion animals. Positive social supports, interactions and interpersonal relations are known to have moderating effects on stress and coping, while contributing to a person?s health and sense of wellbeing (Lent, 2004). Pets are regularly experienced as non-judgmental, faithful, loving, reliable companions, ceaselessly excited to reunite with their human companions. Such positive relationship characteristics would likely contribute to an individual?s emotional, social and physical wellbeing. However to date, much research approaches the conceptualization of the HAB as either a substitute for, or mode to increase human social interaction rather than a valid relationship in and of itself (Beck & Katcher, 2003). In addition, the bulk of the research comes from a positivist paradigm. This study therefore explores from a qualitative point of view, the in depth experience of individuals who have a pet while also living with cancer. I have focused on an examination of the helpful and unhelpful aspects of having a pet during the cancer experience. In the area of psychosocial oncology there is virtually no research examining the role of pets in  8 the experience of cancer patients and survivors and as such the study fills a gap in that body of literature.  The fields of counselling and clinical psychology have also paid little attention to the human / companion animal relationship. Thus this research also brings some light to this undervalued relationship and challenges an overarching anthropocentrism in psychology. As such this study explores the role of pet relationships in the lives of persons with cancer as well as the related events, feelings and interactions that significantly contribute to, or detract from an experience of wellbeing. This research is an initial fore into the HAB for both the counselling psychology and psychosocial oncology scholarly literature. This research seeks to answer the following question: How does having a pet enhance and/or detract from a person?s sense of wellbeing during their cancer experience? Study Design Method  Because this is a new field of study and involves deeply subjective and personal experiences, I conducted a qualitative study, best suited for exploratory research involving human experience (McLeod, 2001). The Enhanced Critical Incident Technique (ECIT) was selected because it describes phenomena through a careful identification of factors that help promote or detract from the experience of a particular situation. In addition the method has been adapted for counselling psychology research (Butterfield et al., 2009), which is the field of my education and work. I also chose ECIT because it offers a structured yet flexible method for gathering, generating and organizing information from a rich source without imposing fixed definitions of concepts such as support, psychological or physical health, coping, adjustment, attachment, wellbeing and love. The ECIT design allowed me to leave the arena open for participants to explore whatever it is that their pets mean to them and/or did for them that helped  9 or hindered their experience of dealing with their cancer.  ECIT offers a practical approach to qualitative research, lending itself to clinical applications (Butterfield et al., 2005) and one of my goals for this research is to contribute to the clinical forum. Another goal of the study is to contribute to the nascent albeit growing body of knowledge regarding the human-animal bond. Thus, an enhanced ECIT method satisfied the multiple purposes that are suited to a clinically oriented research study of a new area of inquiry.   The study was conducted with an interpretive approach to data collection and analysis. The Critical Incident Technique (CIT) can be used within a post-positivist or post-modern research paradigm (Butterfield et al., 2005). Interpretivism proposes that there are multiple and equally valid realities of phenomena, and that these realities constantly influence the research process (Haverkamp & Young, 2007). The distinguishing features of ECIT employed from an interpretivist viewpoint allowed me to explore the factors and experiences about having a pet that feel significant and meaningful to participants with cancer, while acknowledging that the beliefs and experiences of both the participants and the researcher are unique and dynamic.   To accurately contextualize participants? experiences with their companion animal, I begin with a brief personal account of each participant?s pet experiences. This is followed by an investigation of the meanings that people with cancer make of their relationships with their pets as well as their perspectives on what wellbeing means during cancer. As a result, the subsequent helping and hindering incidents identified by participants were grounded in their own meaning systems. Since so little is known about people?s relationships with their companion animals during times of distress, I chose the ECIT approach because the categories that arose in regards to having a pet while having a cancer originated from individuals who have experienced the  10 phenomenon. I hope that the clinically relevant themes gleaned from this study will honour the uniqueness and dynamic quality of the participants? experiences.  Summary of Chapter 1  This first chapter has introduced the reader to the purpose and goals of the study by presenting basic information about the Human Animal Bond, the incidence and challenges of persons facing cancer, and the ways in which these two areas meet. These topics along with their actual and potential connections will be further explored in the next chapter that reviews the related bodies of literature.       11 CHAPTER 2 Literature Review Overview  The purpose of this chapter is to present and critique the major research and literature on the HAB and constructs vital to psychology and to cancer care. A brief history of human-animal relations is followed by definitions of the current constructs and areas that are being explored in the field. The chapter will then provide an in depth review of the existing research on the human / companion animal relationship and note psychosocial and counselling psychology applications. Finally, the field of psychosocial oncology is reviewed with particular attention to relational needs.  Historical Perspective of Human-Animal Studies ?The greatness of a nation and its moral progress can be judged  by the way its animals are treated.?   Mahatma Gandhi  Dogs were likely the first domesticated animals as the remains of dogs and humans buried together have been found from over 14,000 years ago (Crockford, 2009). Dogs provided assistance with hunting, protection, herding, and companionship for peoples from every geographic region where they have lived, and the canine has had a significant presence in the spiritualism and mythology of most ancient cultures (Coren, 2002; Crockford, 2009).  For thousands of years, dogs have been genetically modified for human needs and comprise one of the most complex gene pools of any species (Coren, 2002). Evidence from archaeological sites indicate that early human beings benefitted from the companionship of dogs as much as they did from their working skills (Coren, 2002). Humans began to domesticate animals such as cattle, goats, horse and sheep between 13,000 and 2,500 B.C. and human relationships with cats are  12 likely over 8,000 years old (Serpell, 1996). The earliest human art depicts animals more than it does humans and the presence of animals in religion and spiritualism is present and often central across all cultures (Walsh, 2009). Unfortunately, domestic animal abuse has been both common and brutal and animal protection organizations and policies only began to emerge in the nineteenth century (Raupp, 2002; Walsh, 2009). Until the early 1950?s studies in the animal-human connection were primarily veterinary in nature (Coren, 2002). The field of nursing was one of the first to begin to research and promote the importance of the human-animal relationship and social work and public health followed suit (Hines, 2003). The term HAB was coined in the early 1980?s by Leo Bustad, the founder of the Delta Society, who spearheaded many successful programs that continue on today, including shelter animals visiting nursing homes, animal care-taking for female prisoners and the training of dogs for people with special needs (Bustad, 1996; Hines, 2003). Around this time, substantial research was beginning to show that animal companionship helped to reduce blood pressure, stimulate endorphin release and lower stress and anxiety levels in people (Hines, 2003; Walsh, 2009).  The development of the Humane Society in the 1980?s spearheaded research in an area called ?Pet therapy? where animals began to be used purposefully to assist individuals in nursing homes, children with disabilities, and those with hearing and/or visual impairments. In the early 1970?s  Konrad Lorenz developed the field of ethology with his landmark research on the imprinting behaviours of geese.  Since that time, human-animal studies have grown considerably.  The majority of work in the field is still principally conducted in anthrozoology and veterinary medicine with increasing contributions by the disciplines of social work, cardiology, nursing, anthropology, gerontology, and psychiatry.  13 Currently, multiple surveys, reports and studies indicate that people consider their pets to be highly significant elements of their lives (Wells, 2009). Eighty-five percent of pet owners consider their pet to be a family member (Cohen, 2002) and over half of spouses report that they feel closer to their pet than they do to their partner (Beck & Madresh, 2008). More children in the United States live with a pet than they do with both parents and more homes have a pet than have children (Walsh, 2009). Over half of pet owners consider themselves to be a parent to their pets and state that if stranded on a desert island, they would choose their family pet as their primary companion (American Pet Products Association, 2009/2010). Animals provide companionship for millions of elderly widows and widowers as well as young single people and couples. The great majority of cat and dog owners report that pets contribute to their health and provide sources of comfort, relaxation and stress reduction (Allen, 2003; Sable, 1995, 2009). Risley-Curtiss, Holley and Wolf (2006) report that there are few statistical differences found in relationships with companion animals based on the pet owner?s ethnicity. In addition, pet bereavement is becoming a recognized and significant experience for children and families that may have long lasting consequences if not addressed responsibly (Barton-Ross & Baron-Sorensen, 2007; Kaufman & Kaufman, 2006).  Psychology Research Relating to the HAB Unfortunately the field of psychology has been very slow to acknowledge and research the area of human-animal relationships, something that has mystified many scholars in the field (Hines, 2003; Knight & Herzog, 2009; Kurdek, 2008; Walsh, 2009). Until very recently, attention paid to human ? animal relations by the field of psychology has primarily involved cruelty to animals, fetishes and domestic violence (Raupp, 2002). Research has demonstrated that individuals who abuse their pets are more likely to also be abusive to family members (Faver  14 & Strand, 2003). Numerous studies show that many victims of abuse delay leaving because they don?t want to abandon their animals (Flynn, 2000). Abusers often use the threat of harm to pets as a way of coercing and controlling spouses and children (Becker & French, 2004). Repeatedly, the literature indicates that violence toward animals witnessed and perpetrated in childhood is linked to aggressive and violent interpersonal behaviour, and may be a sign of child abuse (Flynn, 2000). These links are jarring and disturbing on a number of levels, and many researchers wonder why so little attention has been paid to the issues (Felthous & Kellert, 1987; Flynn, 2000). Even within this domain, psychology has kept its distance from human-animal studies (Raupp, 2002). Unfortunately, the same neglect exists toward the positive aspects of human-animal relations (Hines, 2003; Melson, 2002).  In my literature search, I utilized PsycInfo and Academic Search Complete to investigate research on people and their pets and companion animals. I began to notice that the great majority of this research was coming from fields outside of my own. I then focused in on the Journal of Counselling Psychology, The Counseling Psychologist, Canadian Psychology, Canadian Journal of Counselling, and the American Journal of Psychology. Within these journals only a total of 18 titles or abstracts with the word ?pet? or ?dog? or ?companion animal? were found. Unfortunately, none of these studies involved the human-animal bond. In very recent years, however, psychological research on the HAB is slowly beginning to sprout, particularly in health promotion and wellness, attachment studies, social psychology, the link between violence against animals and violence against humans, animal-assisted therapy and pet bereavement. The Counseling Psychology section of the American Psychological Association, Division 17, recently added a separate area devoted to research and practice on the topic, entitled Animal-Human Interaction. It is within this context that I seek to research the human-animal bond.  15 Animal-Assisted Therapy          Animal-assisted therapy (AAT) represents a clinical arena that involves the use of animals  to solve and ameliorate human problems. Areas within AAT include: (a) service animals for individuals with sensory impairments, physical disabilities, health and mental health conditions; (b) equine therapy for trauma survivors and children with developmental delays and physical disabilities; (c) trained visiting dogs for individuals in long term care facilities; (d) animals as sentinels for humans at risk for seizures; (e) animals for use with cancer detection; and (f) service animals for people with anxiety disorders (Fine, 2010). Growing research is now being conducted regarding AAT in health and mental health care (Fine, 2010). AAT differs from companion animals in that the animals in AAT are trained for specific application to a particular human need and are essentially working. While deep connections develop between individuals and their service animals, my research has been restricted to the HAB between human beings and their companion animals. Research on the Health and Psychosocial Effects of Companion Animals Health Effects The literature demonstrates numerous health benefits for pet owners. In general, people with pets consistently appear to be healthier than their non pet-owner counterparts (Cutt, Giles Corti, Knuiman, & Burke, 2007). There is strong evidence that links companion animals to significant cardiovascular benefits in both adults and children, including lower blood pressure and cholesterol levels (Allen, 2003; Cutt et al., 2007). This research has been conducted in a variety of situations including children reading aloud, adults completing a mental arithmetic task and individuals experiencing an emotional or physical stressor (Allen, 2003). Results have shown that the presence of a bonded animal can be more effective in moderating physiological  16 stress levels than that of a friend or marital partner (Walsh, 2010).  There is also good evidence that supports significant health-promoting effects on oxytocin levels (a calming neuropeptide), blood pressure and heart rate for both the individual and animal during soothing contact, petting and holding of pets (Miller, Kennedy, DeVoe, Hickey, Nelson & Kogan, 2009; Walsh, 2009). Similar effects have been found to hold true for individuals exposed to a stressor while watching fish in an aquarium (Brodie & Biley, 1999; Cole & Gawlinski, 2000), a finding that has particular significance for elderly people and individuals in acute and long term care settings.  In an oft-referenced study, Friedmann and Thomas (1995) found that pet owners with coronary artery disease had significantly higher survival rates one year after a heart attack than those without companion animals. In their work, pet ownership and high social support were associated with better survival regardless of the severity of the patient?s heart attack or their demographic characteristics (Allen, 2003). Not surprisingly, this finding was associated with increased physical activity on the part of dog owners, a factor that explains some of the health, and social and psychological benefits of pet ownership in general (Cutt et al., 2007). This study has been repeated many times, always with similar results. Perhaps for similar reasons several studies also indicate that senior citizens with pets pay fewer visits to medical professionals and in general, appear to cope better with stressful life events (Allen, 2003).  Not all the research in this area, however, shows the same results. A 2003 Australian study of 1844 adults found no difference in the medical system usage, health or psychological wellness between pet owners and non-pet owners (Cutt et al., 2007). Additionally, few studies have researched the long-term effects of pet ownership on health. Finally, the conclusion that companion animals buffer stress cannot necessarily be inferred. It may in fact be true that healthier people tend to own pets and that socio-economic and cultural factors are at play more  17 than pet ownership. In general, sample sizes are relatively small, and few reports assess the negative aspects of pet ownership (Cutt et al., 2007). Research that examines the influence of these factors with different methodologies and more meaning related and clinical themes are needed (Beck & Katcher, 2003; Walsh, 2009). Psychosocial Effects       A myriad of psychosocial benefits associated with pet ownership can be found in the literature. Research suggests that people experience their relationships with their pets as emotionally supportive and highly significant bonds in their lives (Walsh, 2009; Wells, 2009). This significance is seen to be particularly apparent for single, divorced or widowed people, and for senior citizens and women who live alone; however, the connection is reported across gender; circumstance, and culture (Risley-Curtiss et al., 2006). As addressed in the previous section, we have seen that the presence of a bonded animal elicits the relaxation response and oxytocin levels and therefore is beneficial to individuals under acute or chronic stress or anxiety.         The presence of pets or animals has been shown to increase social interaction between and amongst people. In their research, McNicholas and Collis (2000) found that when a person was out with a dog, there was a marked increase in the number of social approaches to that individual, regardless of the appearance of the dog or the person. This occurred even when the dogs were trained to ignore a passerby. In their study of observed encounters between people in a park setting, 156 of the 250 interactions occurred when the experimenter was accompanied by a dog (McNicholas & Collis, 2000). Far fewer interactions were observed when the experimenter was on their own. While the majority of the interactions were brief, they were primarily from strangers, and on subsequent days, a number of individuals remembered the experimenter and inquired as to the whereabouts of the dog. Similar findings were reported by Wells (2009) who  18 observed 1800 pedestrians and found that people approached a female experimenter with a dog significantly more than when she was alone or with a teddy bear or plant. Wells did find, however, that the effect was not generic and that different types of dogs, such as a Labrador retriever, elicited more social responses than a Rottweiler (Wells, 2009). Other research demonstrates similar increases in social approaches when a person is sitting with an animal other than a dog, such as a turtle or rabbit (Hunt, Hart & Gomulkiewicz, 1992). Finally, Guegen and Ciccotti (2008) conducted four experiments demonstrating that strangers are more likely to assist persons who are accompanied by a dog than they are individuals on their own. The researchers found that confederates who were asked to approach strangers for bus money were assisted significantly more often when accompanied by a dog. No differences were found related to the confederate?s gender. This research suggests that the presence of a dog enhances the social interactions of an individual and thus has meaningful implications for people who struggle with loneliness, shyness and/or social anxiety, or are simply in need of more connection or contact.         In geriatric research, lower levels of loneliness and depression have been found in elderly people living alone who have a companion animal (Brodie & Biley 1999). This effect was not seen however, when senior citizens have a partner living with them. While it is rare that pets are permitted to live with their owners in nursing homes, the presence of a resident animal (pets that live in the facility) and animal assisted therapy have been shown to increase morale, reduce loneliness and agitation, provide reassurance, and evoke a feeling of being needed for residents and caregivers alike (Baun & McCabe, 2003; Filan & Llewellyn-Jones, 2006).  Similarly, studies have found that homeless individuals will often feed their pets before they feed themselves (Kidd & Kidd, 1994; Taylor, Williams & Gray, 2004), and that women who are in violent relationships rely on their pets for emotional support and delay leaving the abusive home for fear the family  19 pet will be harmed or killed (Flynn, 2000). So strong is the bond between human and companion animal, that we see the same sort of altruism normally associated with particularly powerful human/human connections.            The impact of pet companionship for individuals suffering from illness is also an important and growing area of research. The results are mixed. In a small study of caregivers of married couples facing dementia, Connell, Janevic, Solway and McLaughlin (2007) found that the companion animal provided reassurance and a sense of closeness for caregivers as well as reality orientation and calming effects for the individual with dementia. This occurred primarily in the earlier stages of the disease however. Some caregivers reported that as their spouse?s disease progressed, the pet became an additional burden to them (Connell et al; 2007).  Siegel, Angul, Detels, Wesch and Mullen (1999) conducted a large and methodologically strong study of 1,992 persons with AIDS across four major cities in the U.S.A. The results found lower levels of depression in individuals who own a pet and had low social support. This finding was not generalized to all pet owners. Pet owners who had good social support were as likely to be as depressed as those without companion animals, corroborating the aforementioned research on companion animals and senior citizens (Siegel et al., 1999). Tower and Nokota (2006) conducted an Internet survey about pet ownership with 2, 291 respondents and found comparable results. Their analysis revealed that single women benefitted the most from pet companionship, decreasing their levels of depression significantly from single women without companion animals (Tower & Nokota 2006).  One study relating the HAB to cancer was found. Johnson, Meadows, Haubner, and Sevedge?s (2003) exploration of complementary alternative interventions with cancer patients showed that dog visits were viewed as part of therapy and garnered a highly positive response from patients. This study, however, studied animal-assisted  20 therapy and unfortunately, nothing has been found to date on the influence of pet ownership and the cancer experience.    Numerous other areas involving companion animals and people are being explored in the literature. Improved psychological wellbeing of prisoners who have an animal in their care is a consistent finding in research (Bustad, 1996). Companion animals are recently being incorporated as part of Family Systems research, challenging the general anthropocentrism found in researching family and other social relationships (Walsh, 2009). Pet bereavement is also an area that is garnering more attention, with some research demonstrating that the childhood loss of a pet is a significant life event not to be trivialized (Kaufman & Kaufman, 2006). Theoretical and narrative accounts suggest the possibility that pets may provide a close and safe connection for adults who are survivors of childhood emotional and/or physical abuse. Several compelling books, films and publications on the healing power of pets in this realm exist however, they are primarily anecdotal in nature. It is my hope that this research will contribute to the scholarly literature on the HAB from a counselling psychology perspective.  Problems with Pets Like most relationships, the world of human-animal companionship has its share of challenges. While scores of people consider their pet to be a family member, there are also those for whom pets are associated with decreased physical and mental health (Beck & Katcher, 2003). In addition, ten to fifteen percent of the Canadian population is allergic to some sort of animal (National Institute of Allergy and Infectious Diseases, National Institute of Health (http://www.niaid.nih.gov/publications). Even so, a third of people with allergies keep a pet in their home. In 1996, the Canadian Hospital Injury Reporting and Prevention Program found almost 1300 incidents of dog bites reported that year in Canada (Public Health Agency of  21 Canada, 1996). More recent statistics from the U.S. report that dogs bite 4.7 million people annually (Centers for Disease Control and Prevention, 2001) and that over 700,000 of these incidents require medical care. Unfortunately, the highest incidence of dog bites in both countries occurs in children aged 5-7 years. Thus those we call ?man?s best friend? are not always friendly to us. Several studies suggest that pets elicit no effect or decreased morale for certain populations. The association between pet ownership and health seems weakest among the elderly (Wells, 2009). Elderly people who owned dogs or cats have been found to have significantly higher instances of falls. Research involving depression and pet ownership also shows mixed results. There is no conclusive evidence to suggest that having a companion animal is necessarily associated with lower levels of depression. Results are specific to certain groups under particular circumstances (Tower & Nokota, 2006). Human animal studies are still very rare however, and as a result, little is known about the relationships between pet ownership and mental or physical health (Beck & Katcher, 2003; Wells, 2009).  The Cancer Experience   Cancer is by no means a homogenous physiological or psychological experience. There are over 250 different types of cancer that differ in severity, prognosis, treatment and fatality depending on numerous factors including site, stage, grade as well as many others (Stanton, 2006). Despite the proliferation of advances in cancer treatment, the gloomy stereotypes associated with cancer continue to pervade the psyches of most patients diagnosed with a malignancy (Holland, 2004). These fearful stereotypes also pervade the general community, with the result that cancer patients often experience a sense of perceived or actual rejection in their environments (Halldorsdottir & Hamrin, 1996). The term cancer itself is used frequently as a  22 metaphor for anything that grows out of control and ultimately destroys its host. The continued myths around contagion, death, loss, and the anxiety of communicating with seriously ill persons can greatly strain relationships, even with professionals (Stahly, 1989). The consequence for the patient is often a sense of isolation and displacement.         A further stressor in the illness results from the ensuing treatment. Treatment generally involves a combination of surgery, chemotherapy and radiation therapy, each of which produce side effects that may be more unpleasant than the symptoms of the cancer itself. Pain, disfigurement, loss of hair and appetite, fatigue, changes in sexual functioning, employability or ability to work and cognitive impairment are common side effects of typical treatments and pathologies (Holland, 2004). Even well established protocols of treatment will have widely varying degrees of side effects and effectiveness on the same disease in different patients; consequently enormous uncertainty is commonly experienced regarding treatment outcome and prognosis.  When cancer is curable, there is always a chance of recurrence; as a result most survivors feel that their lives have been inexorably altered (Nitkin, 2000). Psychosocial Oncology  The need for mental health counselling in cancer care is fairly self-evident and supported by both patient and professional (Bottomley, 2002; Holland, 2004). People with cancer face enormous challenges in adapting to a disease that usually causes significant psychosocial stressors across the spectrum of physical, emotional, and existential experience. Common problems include anxiety and depression (Massie, 2004), meaning-seeking and explanations for the disease, isolation and helplessness, lack of support (Helgeson & Cohen, 1996), confronting death, and facing physical limitations (Fawzy, Fawzy, Arndt, & Pasnau, 1995). Unfortunately,  23 the continued stigma surrounding both mental health issues and death may further challenge the person with cancer, inhibiting their adjustment or use of psychosocial services (Holland, 2004).  Psychosocial oncology literature is often site specific. The majority of psychosocial oncology research has been done with the breast cancer population. High rates of depression and anxiety are found in women with breast cancer (Ben-Zur, Gilbar, & Lev, 2001; Hack & Degner, 2004).  Distress is regularly associated with body image and identity changes; scarring; reconstruction, sexuality and fertility concerns (Ben-Zur et al., 2001). Other sites have been researched as well. Individuals with lung cancer, head and neck cancers, blood cancers, brain cancer, ovarian cancer also experience distinct psychological challenges. In general, diagnoses of clinical depression and anxiety are significantly higher in the cancer population than the general population (Preyde & Synnott, 2009).   Research in psychosocial oncology is a broad field. I am situating my study in the centre section of J. Holland?s (2004) model for psychosocial and quality of life research in oncology, as seen below. Pet relationships may be part of the ?social supports? and function as a mediating variable for persons with cancer that is as of yet, practically unrecognized in the literature.  Figure 1. Research model for psychosocial and quality of life research in oncology.                                    J. Holland, (2004)  24 Coping and Psychosocial Adjustment   In health and illness literature, coping is a broadly researched construct. Coping theories, strategies, models and linkages have been explored regarding diagnosis, treatment, prognosis, relationships, employment, sexuality, spirituality, personality factors, resiliency, post-traumatic growth and many more. Coping style research is ripe with theories regarding which styles are more vulnerable to which diseases, and how to bolster coping for prevention and treatment. The literature is vast. In cancer care, the term ?adjustment? is commonly used to indicate the ability of a person with cancer to adapt to the multiple physical, social, emotional and functional aspects of the disease (Brennan, 2001). In particular, psychosocial adjustment to the illness is becoming increasingly recognized as a significant factor in quality of life, adherence to treatment, and survival (Carlson & Bultz, 2003; Hack & Degner, 2004).  Lazarus and Folkman (1984) characterize coping strategies as behavioural and cognitive attempts to manage or deal with stressful encounters. They distinguish between problem focused and emotionally focused coping. The latter aims to decrease the negative emotional experience related to a perceived problem. This may include prayer, crying, talking/ telling the story, and other forms of expression. Psychosocial oncology research shows inconsistent conclusions regarding one type of coping being more effective than the other for people with cancer. Cognitive, emotional and behavioural responses all account for the quality of adjustment to the illness (Brennan, 2001). Dunkel-Schetter, Feinstein, Taylor and Falke (1992) identified patterns of coping in their sample of 603 cancer patients using Folkman and Lazarus? Ways of Coping Inventory (1984) adapted for cancer. The following five patterns emerged: a) seeking or using social support, b) focusing on the positive, c) distancing, d) cognitive escape-avoidance, and e) behavioural escape-avoidance. The authors found that these coping patterns were not dependent  25 on gender, age or disease factors (type of cancer, time since diagnosis, pain, fear of future). Rather, individual appraisals of stress due to cancer and social networks were found to be linked to most of the patterns. Most respondents used multiple coping strategies and behaviours. Not surprisingly, emotional distress was associated more with distancing, and escape-avoidance coping. This finding is consistent with much of the research on psychosocial adjustment to cancer suggesting that social withdrawal, emotional suppression, and avoidance-based coping responses tend to result in poor adjustment (Hack & Degner, 2004). Thus coping that includes social support is significantly associated with lower levels of emotional distress (Lent, 2004).  Brennan (2001) has integrated coping responses, social support and cognitive appraisal processes in his development of the Social-Cognitive Transition Model of Adjustment to Cancer. According to his model, psychosocial adjustment to cancer is an ongoing process of learning and adaptation through the myriad changes and challenges over time through diagnosis, treatment, and post-treatment phases (Hack & Degner, 2004). Brennan qualifies the term ?adjustment? as misleading as it suggests a movement from one stage to another, and does not accurately reflect the continual change processes occurring within and around the individual with cancer. Multiple factors such as mourning, posttraumatic stress, and diverse and changing physical illness manifestations are integrated to create Brennan?s model, focusing on both positive and negative adjustments within the social context of the individual (Brennan, 2001). He focuses on the human being?s ability to self-regulate, learn and adjust core assumptions over time and with support and encouragement of personal efficacy. This broader conceptualization of psychosocial adjustment accounts for the ?huge diversity of experiences that people with cancer report? (p. 14) and the challenges in making sense of a condition that can potentially destabilize every element of a person?s existence. Here again, we find that empathic social support is considered to  26 be a significant factor in the adjustment process. We need to know if in fact pets are providing such support for some people with cancer. As such, this research focuses on the relational, emotional and social resources that individuals with cancer may derive from their companion animals to help cope and adjust to their condition.  Social Support  There are multiple taxonomies associated with the broad topic of social support. Most include three basic functions: emotional support, instrumental (practical) support and informational support (Helgeson, 2003). The focus of this research is the emotional domain. Emotional support refers to the provision and reception of companionship, reassurance, listening, care, and sympathy, value and love to and from others. Good social support is considered to be a key factor in wellbeing outcomes in general (Lent, 2004). Helgeson (2003) also emphasizes the difference between perceived support and received support. Perceived support refers to the extent that people believe there is support available to them while received support can only be truly measured by observing a support exchange. Interestingly, perceived support is more strongly related to quality of life than received support (Helgeson, 2003). This bears noting as in general, pet owners tend to express that their companion animals are among their closest friends and provide them with a sense of unconditional love and security (Fine, 2010; Walsh, 2009). I seek to explore the perceptions of people with cancer regarding the role of their pets as potential providers of emotional support. Because cancer is an experience where people clearly benefit from good support, it is of value to know whether or not companion animals play a part in this dynamic. Finally, it is well documented that human beings not only need to be the recipients of support; we also have a need to nurture and provide care to others (Berscheid, 2006; Yalom, 1995). In particular for individuals facing illness, there is often the possibility that one over- 27 identifies with, or becomes exclusively associated with, the role of patient and/or receiver of care. This sense of imbalance, in particular for many women, may be moderated by having a companion animal that continues to seek and require care.   As demonstrated in previous sections of the paper, social/emotional support is repeatedly identified as a salient feature of healthy adjustment to cancer (Helgeson & Cohen, 1996; Lent, 2007). Waxler-Morrison et al. review two of their own studies and show how their qualitative research produced surprising findings that merited further study. In the first phase of a prognostic study of breast cancer patients, a large epidemiological survey was followed by a small qualitative study. Data from the initial survey involving the women?s social support system and network was analyzed after a four year follow up period. From a sample of 133 women, it appeared that women with high survival rates shared certain characteristics. They had more contact with supportive friends; larger social networks; were employed; and were primarily single, divorced, or widowed.  Due to these unexpected discoveries, a set of open-ended ethnographic interviews with some of the breast cancer survivors was developed to further inform the findings.  Informal interviews with the participants focused on the role of work, family, friends, and social support in their cancer experience. A qualitative analysis of the responses produced new hypotheses, which are relevant to counselling. Survivors tended to be women who fostered their ability to continue to give support to others in community, family, or other social settings.  Thus it appears important that people with serious illness maintain the opportunity to display and act upon their concern for others. This inherent need to nurture is a healthy, normal aspect of social interaction (Yalom, 1995) and is often taken away when an individual is seriously ill. Relational-cultural theory strongly supports this mutuality as an essential component of growth-fostering and authentic relationships (Jordan, 2000). A pet may  28 provide a unique opportunity for cancer patients to express and validate this important and often unmet need.  Wellbeing  The concepts of quality of life, personal life satisfaction and various forms of wellbeing are heavily theorized and researched constructs in both psychology and health literature. Multiple measures have been developed to assess the life satisfaction or quality of life of individuals in times of both calm and distress. However, wellbeing remains essentially a subjective experience (Helliwell & Wang, 2011; Lent, 2004). Lent explains that counselling psychology depathologizes these constructs, focusing on the resources and strengths people have, rather than their difficulties and maladaptive tendencies (Lent, 2004). As such, his definition of wellbeing includes the notion of hygiology, the location and development of personal and social resources and adaptive behaviours, even in the midst of distressing life circumstances (Lent, 2007). This term is reminiscent of Antonovsky?s (1979) conception of salutogenesis. Salutogenesis focuses on factors supporting health and wellbeing, challenging pathogenesis (origin and cause of disease) as the dominant paradigm for health and disease (Eriksson & Lindstrom, 2005). The construct was proposed by Antonovsky in 1979 and incorporated into the Ottawa Charter (1986), the central document of the Health Promotion movement (Strandmark, 2007). In an epidemiological study of menopausal women in Israel, Antonovsky observed that many women who survived concentration camps had a great capacity for health and wellbeing despite their traumatic past experiences. This observation highlights the human ability to thrive despite constant exposure to disease and stress. Similarly, the growing movement of Positive Psychology focuses on an individual?s strengths, virtues and resilience as essential components of a life experience that is both fulfilling and meaningful (Seligman &  29 Steen, 2005).  These approaches provide grounding for the notion that a close relationship with a pet may serve to support the health and wellbeing of a person, despite the presence of physiological disease.  Lent identifies two types of wellbeing from the research, namely subjective wellbeing (SWB) and psychological wellbeing (PWB). He explains that subjective (SWB) consists of three interrelated but distinct components: life satisfaction, positive affect, and the absence of negative affect. PWB research rather, concentrates on theoretical qualities that are assumed to reflect healthy functioning, such as life purpose, good relationships and self-acceptance (Lent, 2007).  The literature is not consistent as to whether either of these wellbeing constructs remains stable over time. Finally, trust is also strongly linked to subjective wellbeing.  Helliwell and Wang (2011) explain that trust is ?built on a base of shared positive experience, and is nurtured by continued connections? (p. 57). Intuitively, one can see the parallels here for many people and their companion animals. One of the hallmarks of people?s experiences with their pets is a sense of total trust in them, often beyond their closest family members (Walsh, 2009).   As can be seen, subjective wellbeing is a layered compilation of personally rooted experiences. What tends to be agreed upon is that social and relational resources play an important role in both PWB and SWB. Helgeson (2003), one of the leaders in social support research, stresses that people benefit from different types of social support in very different ways. He contends that research must consider the multifarious, individual aspects of social support including social environment, function, perceived and received support, positive and negative aspects, and reciprocal provision of support. As such, in my study I asked participants to define and expound upon their personal meanings of socio-emotional wellbeing during the cancer experience rather than focus on a particular theoretical model.   30  Non-Verbal Communication and Touch  Studies indicate that both the individual and bonded animal experience relaxation and calm during soothing contact, petting and holding of pets as evidenced by decreased blood pressure and increased oxytocin levels (Miller, Kennedy, DeVoe, Hickey, Nelson & Kogan, 2009; Walsh, 2009). In the cancer experience, touch often becomes linked with invasive medical procedures such as blood tests, surgery, injections, radiotherapy and the associated pain. Disfigurement and hormonal changes due to procedures and treatment, in particular in breast and reproductive cancers often result in major changes to sexual functioning (Katz, 2009). Research on Therapeutic Touch (TT) suggests that it is a beneficial Complementary and Alternative Medicine (CAM) treatment that is particularly effective in facilitating the relaxation response (Nitkin, 2000; Stephen, Mackenzie, Sample, & Mcdonald, 2007). TT consists of a gentle laying of hands or energetic movement near or upon the recipient with intention to heal and comfort. The practice at times appears to be similar to the gentle petting of a companion animal. Since we know that human beings need to both give and receive physical contact, it seems intuitive that the touch between a person and a bonded animal may provide a particularly satisfying and soothing experience for a person with cancer. In humanistic / existential psychotherapy, the healing of a broken or troubled existence occurs through presence: two human beings (client and therapist) meeting and connecting with authenticity, care and honesty (May & Yalom, 1989).  It may be that this type of presence is occurring on nonverbal levels between people and their pets. Attachment Theory Some of the most influential work in the area of relationship science arose during the 1960?s and 70?s with the seminal work on attachment theory developed by John Bowlby (1969)  31 and Mary Ainsworth (1978). Attachment theory focused on the forging and breaking of bonds between infant and primary caregiver with the goal of understanding how children develop emotional attachments to their caregivers and experience distress when separated from them (Feeney, Noller & Roberts, 2000). The theory laid the foundation for the formation of an explanatory framework for human emotion, behaviour and cognition involving close relationships. Attachment theory has become one of the most researched and studied theories of interpersonal relations in the field of psychology (Feeney & Noller, 1996; Fraley & Shaver, 2000).    Bowlby (1969; 1988) identified four features of the attachment process, usually occurring between infant and mother, most of which can be intuitively applied to human ? companion animal relationships. They are:  ? Proximity maintenance: A need to maintain physical closeness and proximity to the attachment figure. ? Separation distress: An experience of distress upon separation from the attachment figure. ? Safe haven: Pleasure and relief upon reunion. ? Secure base: An ability to explore the environment knowing one is protected by the  attachment figure.  Mary Ainsworth brought Bowlby?s work to the United States and developed an assessment process for attachment entitled the ?Strange Situation? (1978) which involved observations of children being temporarily removed from and returned to the presence of the primary caregiver (Ainsworth, Blehar, Walters, & Wall, 1978). Her studies revealed three different attachment styles that an infant may display: (a) secure, (b) avoidant (insecure) and (c) ambivalent (insecure) (Ainsworth, 1978). Further research identified a fourth attachment style  32 called disorganized (insecure), indicating a lack of coping strategies for separation. Ainsworth continued her research on attachment beyond infancy (1989) and identified multiple affectional bonds across species and developmental stages in her later work. She posited that these bonds provide fundamental functions for human beings and other animals including protection, care giving, procreation, affection, child rearing, and solidarity.  Adult Attachment While both Bowlby and Ainsworth viewed the attachment system as an essential component of the human experience across the life span, research and development in attachment theory remained focused on the infant-mother bond for over 12 years (Fraley, 2004). Criticisms of attachment theory noted the paucity of attention paid to peer, family and social relationships as contributors to working models of attachment for both children and adults (Field, 1996). In the late 1970?s, however, researchers began to look at attachment in adult life. They found that similar working models of attachment existed within many adult relationships. In 1987, Hazan and Shaver presented their seminal work introducing the idea that some adult relationships functioned in very similar ways to the infant-caregiver bond. The researchers noted the following similar features in romantic relationships: (a) both feel safe when the other is nearby and responsive, (b) both engage in close and intimate physical contact, (c) both experience feelings of insecurity when the other cannot be accessed, (d) both share new experiences and discoveries with each other, (e) both display a mutual fascination and preoccupation with one another and play with the other?s face, and finally (f) both use baby talk as a form of communication (Fraley, 2004).  These parallels with Bowlby?s original four features served as a foundation for the characterization of romantic love as an attachment system, not unlike the infant-caregiver system. The close relationships literature now shows that adults  33 develop attachments to multiple figures throughout their lives (Kurdek, 2008). Currently, this characterization is being applied to the relationship between person and companionate animal and has fostered a body of research in this area, in particular between people and dogs (Kurdek, 2008; 2009).  Attachment and Companion Animals Until one has loved an animal, a part of one's soul remains unawakened.  ~ Anatole France   There is a developing literature exploring attachment and canine companions that suggests that relationships between dogs and people operate in similar ways to primary caregiver and romantic love relationships (Kurdek, 2008). This research area seeks to better understand the significance of pet companionship as well as give credence to the HAB and associated issues such as pet bereavement. In one of the first studies of its kind, Albert and Bulcroft (1988) conducted telephone interviews with a random sample of 320 pet owners and 116 non-owners regarding their relationships to animals. The authors found that pet owners in general considered their companion animal to be a member of the family and that what appeared to be attachment to pets was highest among dog owners who were either single people (never-married, divorced or widowed); childless couples, newlyweds and empty-nesters (Albert & Bulcroft, 1988). Women who had a dog or cat also reported significantly less loneliness than those without a pet. Since that time, researchers have been looking more closely at pets and attachment within a scholarly context. Because attachment is a term that is often loosely applied, only studies that based their research on conceptual models of attachment to pets were reviewed for this study.  The following research in the area of pet attachment has been selected to provide multiple viewpoints on the topic. In an unique study exploring pet dogs as attachment figures, Kurdek (2008) surveyed four different groups of pet-owners (n=923) to examine the extent to which pet  34 dogs displayed the four features of an attachment figure and whether participants varied in their levels of closeness to people relative to their attachment to their companion animal. Kurdek?s results showed that while mothers, fathers, siblings, friends and significant others exhibited higher levels of the features of safe haven, secure base and separation distress than dogs, the companion animals were consistently above the midpoint of the scale and not far off from their human counterparts (Kurdek, 2008). In fact, dogs were rated equally to fathers and siblings on the proximity maintenance feature. Not surprisingly the most salient feature of attachment to dogs was proximity maintenance, as people seem to greatly benefit from the physical closeness of their pet.  Kurdek found also, however, that secure base was the next strongest feature, one which the author explains, is a feature of attachment only, as opposed to proximity maintenance being a feature of both attachment and care giving (Kurdek, 2008). This is a relevant finding and needs to be followed up with future research. The study also yielded the not-surprising conclusions that individuals with high levels of global attachment to dogs correlated with high levels of global attachment to persons, and that dogs that were more affectionate, intelligent and energetic were linked with higher levels of attachment from their owners than those with aloof or aggressive tendencies. Serpell (1996) reported similar findings in his research but to a lesser extent. He found that pet owners? ratings of their companion animal?s behaviour did not tend to disrupt attachment levels, except for slightly higher attachment levels reported for people with more intelligent dogs and noisier cats (Serpell, 1996). Serpell?s and Kurdek?s findings suggest, as of now, that large attachment variations do not exist dependent upon animal behaviour. However, these studies have primarily been done with volunteer participants who likely respect and care for their companion animals regardless of the pet?s behaviour.  35 Beck and Madresh (2008) also conducted research comparing people?s attachment levels to their pets with attachment levels to other people, in this case, romantic partners. They utilized adapted attachment measures scales for pets in a web-based survey of 192 pet owners. Traditional attachment theory would suggest that attachment styles would remain consistent among relationships. This consistency was only weakly supported, suggesting that human-companion animal relationships are based on different working models than romantic partnerships. They did find, however that adapted attachment scales produced meaningful results in terms of attachment styles with companion animals.  There is now sufficient evidence to include companion animals (particularly dogs and cats) among significant attachment figures (Sable, 1995). Pet owners display attachment behaviours as described by Bowlby and Ainsworth. Pet owners are physiologically and psychologically calmed by the presence of their companion animals, frequently touch and sit close to their pets, and display typical grief reactions to their absence, illness or death (Kurdek, 2008). They are distressed when threatened with disruption of the bond or separation, and they regularly seek proximity to, and security from, their pets (Kurdek, 2008; Sable, 1995). The same may very well be true for the animals in relation to their human companions. In their research utilizing Ainsworth?s Strange Situation procedure with people and dogs, Palmer and Custance (2008) found that the dogs in their study consistently displayed attachment-like behaviour to their human companions, concluding that the dog-human bond also conformed to the attachment system as defined by Ainsworth.  Finally, one of the more controversial questions in attachment research challenges the degree to which attachment styles remain consistent or are subject to change over the lifespan (Feeney & Noller, 1996; Fraley & Shaver, 2000; Fraley, 2004). Within their model, Hazan and  36 Shaver state that working models of attachment developed early in life are very resistant to change.  Some researchers consider this to be a weakness of the theory and claim that people?s working models actually do substantially adjust over time depending on the frequency and intensity of experiences in interpersonal relationships that confirm or disconfirm their expectations (Feeney & Noller, 1996). In her work on interpersonal relationships, Berscheid (2006) reports that research indicates that people?s attachment patterns, or security orientations may reflect the current relationship they are in as much as their inner working attachment model. It would be worthwhile to explore whether individuals with companion animals shift or change their attachment styles over time, particularly if they are insecure or avoidant. It is intuitively reasonable that secure attachment relationships with companion animals may serve to rework unhealthy models of attachment, thereby providing hope and relief for isolated and traumatized individuals at the hands of other people, such as victims of child abuse, violence and rape.  Counselling Psychology Applications  "There is no psychiatrist in the world like a puppy licking your face." ~ Ben Williams  Many important things in people?s lives depend on good adjustment and experiences in relationship. Healthy relational bonds are necessary for human beings and they enhance life; while problems in connecting with others are often accompanied by challenges in learning, social relations, quality of life, mood and self-esteem. Therefore, counselling psychologists must be well equipped with knowledge on the topic in order to assist clients in resolving relational issues. Throughout the human experience, connection, isolation, and trust remain consistent areas of challenge and as such, will likely form the bulk of issues brought to the clinical arena of psychotherapy. Counselling psychology often distinguishes itself from other mental health areas because of its distancing from pathology and focusing on individual?s strengths (Lent, 2004).  37 The human animal bond may indeed be a strength in the life of an individual, family or community, and as such should be considered in our work with clients.  Relational bonding is not a uniform phenomenon and therefore, romantic love, parental love and friendship may represent only part of a client?s relational experiences. While many individuals come to therapy with issues in their romantic and/or family of origin relationships, lessons from relationship science and the distinction between companionate and passionate love suggest that friendship and other types of close relationships are all important material to assess and explore in session (Berscheid, 2006). For many clients, a friend, sibling, other significant person or pet may serve as a significant sense of identity, companionship, connection and fulfillment. Grief reactions to the loss or illness of a pet are often minimized, resulting in disenfranchised grief. There are few socially sanctioned rituals for mourning the loss of a companion animal. Thus an individual for whom their pet is a primary relationship, the death or loss of the animal is likely a very serious event (Chur-Hansen, 2010). For some individuals with histories of abuse, a relationship with a companion animal may be the most significant and/or safest connection in their life. For others, companion animals may provide a reason for living by providing someone or something to care for (Chur-Hansen, 2010).   Since the presence of an animal has been shown to increase positive social interaction (Gueguen & Ciccotti, 2008; Wells, 2004) pets may have the potential to decrease feelings of isolation or loneliness and increase feelings of meaningfulness and quality of life for lonely, depressed, marginalized, chronically ill and/or isolated individuals. This potential may have important implications for counselling such clients. The possibility of including a pet in counselling sessions and the inclusion of companion animal relationships in assessment of client resources or struggles involves the advancement of counselling techniques. In this way,  38 counselling psychologists would be more comprehensively addressing the experiences and psychological needs of the people with whom we work.  Companion Animals as a Source of Positive Emotion Current theories of positive psychology, emotion based therapies and neuropsychology  strongly suggest that the experience of positive emotion is associated with higher levels of creativity, clarity in thinking, wellness and quality of life (Fredrickson, 2001; 2003).  Neuro-imaging research suggests that romantic and maternal love and attachment stimulate both oxytocin levels as well as the brain?s reward system, while suppressing activity in regions associated with negative emotion in humans and other animals (Bartels & Ziki, 2004). Miller, Kennedy, DeVoe, Hickey, Nelson, and Kogan (2009) found similar results, particularly for women, upon examining them interacting with a bonded dog. Studies on the neurological maps of human / animal interaction such as petting one?s dog demonstrate that they are associated with the activation of positive emotion and suppression of negative emotion (Brodie & Biley, 1999). As such a focus on building intimacy through companion animal bonds could provide potentially rich sources of stress and anxiety relief, problem solving abilities, increased fulfillment and possibly decreases in depressive symptomatology.  Conclusion Substantial learning and clinical benefit may be possible through the appropriate inclusion of companion animals to the counselling psychology field. My intent is to apply my knowledge of the human animal bond and the experiences of people with cancer to gather a richer understanding of the helping and hindering components of these relationships for people facing adversity. The human-animal bond or connection for people with cancer provides a rich  39 and untapped resource for innovative counselling psychology and psychosocial oncology research.  Beck and Katcher emphasize these points:  All future studies of human health should consider the presence or absence of a pet in the home, the nature of this relationship with the pet, and how the occupants interact with other aspects of the living environment as a significant variable. No future study of human health should be considered as comprehensive if the animals with which they share their lives are not included.  In sum, there is solid evidence that animal contact has significant health benefits and that it positively influences transient physiological states, morale, and feelings of self-worth; however, there are many inconsistencies in the literature. We do not know the magnitude of the health benefit, the populations that are beneficially or adversely affected, or even how pet ownership compares to other ways of enjoying the living environment. (Beck & Katcher, 2003, p.87)  Given the review of the literature, there exist gaps in both the counselling psychology and psychosocial oncology fields regarding the relationships that people facing illness have with their companion animals.  Therefore the purpose of this research has been to explore the benefits and drawbacks of having a companion animal while facing cancer. It is my hope that the careful listening and presentation of the experiences of a group of individuals who have lived this phenomenon will begin to shed some light on the matter.    40 CHAPTER 3 Method Overview  This chapter describes the research method employed to address my research question, the Enhanced Critical Incident Technique (ECIT). The philosophy and process of ECIT will be presented with details of their application to the study. In order to fully represent the richness of the participants interviewed, short personal accounts were also composed. For this component of the research, the same process used for category development in ECIT was employed.  Suitability of the Enhanced Critical Incident Technique   The research question ?How does having a pet enhance and/or detract from a person?s sense of wellbeing during their cancer experience?? was addressed by the Enhanced Critical Incident Technique (Butterfield, Borgen, Maglio, & Amundson, 2009; Butterfield, Borgen, Amundson, & Maglio, 2005). ECIT is useful as an exploratory tool in the early stages of research (Woolsey, 1986) and is considered to be versatile and robust for innovative research (Butterfield et al, 2009).  It comprises procedures for collecting and exploring experiences and observations of human beings in ways that facilitate their usefulness in solving problems and developing psychological principles (Woolsey, 1986). This research concerns itself with the experiences, interactions and perceptions in a human- companion animal relationship that has potential to contribute to both clinical and theoretical arenas in relationship psychology and psychosocial oncology. The Enhanced Critical Incident Technique (Butterfield, Borgen, Maglio, & Amundson, 2009) was used to explore what aspects of the human/companion animal relationship help and hinder the subjective wellbeing of individuals with cancer. An ECIT study involves three research phases. First, the researcher explores the context of the experience under investigation.  41 The next phase is to inquire about what helped or hindered the phenomenon being studied. Finally, the researcher investigates suggestions regarding what would improve the phenomenon. Part of the reasoning for selecting this method is because one of the challenges put forth by HAB researchers and critics alike, is that human animal studies are most often conducted by pet lovers and therefore are biased toward the positive stereotype of a loving and devoted companion animal (Beck & Katcher, 2003). Embedded in ECIT method is the equal focus given to helping and hindering aspects of a particular phenomenon and as such, participants will be asked to explore both the helpful and unhelpful aspects of having a pet during their cancer experience. A second strength of the method is that it is ideally suited to new areas of inquiry as it involves the reporting of direct observations of self and others. Finally, ECIT is a method that was developed by counselling psychologists and is designed for practical and clinical application (Butterfield et al., 2009). Researcher Positionality Epistemology and Ontology  In keeping with the principles of humanistic psychology, I believe that human experience is a personally and socially constructed phenomenon, and not one that can be captured comprehensively in a static way. The experience of any living creature can only be known to another and possibly to him /herself in a limited way, as it is an ever-changing phenomenon. As such I position myself as a relativist with an interpretivist stance (Ponterotto, 2005). In particular I certainly do not assume that I, or anyone could achieve a full understanding of the experience of a non-human animal that communicates in different ways than we do. I apply this same view of the limits of understanding other human beings? communication and use of language. The experiences of the participants have only been captured in part through language, and ultimately  42 do not remain the same with changing perceptions, personal experience and in particular, interactions and discourse with others. Throughout the research process my role has been to unearth meanings, describe, and interpret the experiences of the human participants to the best of my ability (Haverkamp & Young, 2007). It has also been my responsibility to reflect on and be open about the impact of my own perceptions and experiences. The study aims to reflect high ethical standards, transparency, reflexivity and honesty with the participants and myself.  Along with my interpretivist stance my approach to research is both practical and clinically oriented. There are themes and patterns in the behaviours, feelings, thoughts and experiences of living creatures that can serve to elucidate what may be beneficial or harmful to others in similar circumstances. Because I seek to situate my research in the clinical arena, my purpose for this research is primarily theory and practice-oriented as outlined in Haverkamp and Young?s discussion of the rationale for qualitative investigations (2007). My hope is to contribute to the counselling psychology and psychosocial oncology literature by introducing the human animal bond as an important aspect of client/patient care. Humanistic Model and Unique Application of HAB Research  In accordance with a holistic approach, my view of relationships, including those of a psychotherapeutic quality and those of a human/non-human form, values to the utmost the basic principles of respect, trustworthiness, genuineness, and care. These principles are grounded in the theory of humanistic psychology, in which humanistic theory situates itself, and where I too am located as a person, a clinician and a researcher.   Franklin, Emmison, Haraway, and Travers (2007) propose the development of an entirely new approach that they are calling trans-species methodology. This would require a team of researchers who have expertise in both human and animal communication, behaviour, emotion,  43 and motivation. There is likely an inherent power differential in most human-companion animal relationships that requires an additional ethical component to research on the subject. In addition the ability to explore any pet?s experience is limited due to differences in communication modes. Because my knowledge base is primarily in human phenomena I proceeded with the goal of initiating my research into the HAB from a nearly exclusively human vantage point. In order to approach the research without trepidation, I liken this study to investigating one partner in a friendship, marriage, partnership, or relationship. Throughout the study I have noted my thoughts and observations in this regard, and paid special attention to participants? perceptions about the wellbeing of their companion animal. I was able to meet many of the pets during the interviews that I conducted, and when this was not possible I requested that participants bring a photograph of their pet to the interview. This gave me the opportunity to observe and/or participate in the relationships held by participants and their companion animals, thereby enriching the data. While my expertise does not lie in the field of animal behaviour, I have incorporated both the participants? and my own perceptions of the experience of the companion animals in the study. In many of the categories that will be described in Chapter IV, it becomes evident that a good portion of the participants? experiences of their pet are based on perceptions of what the pet was feeling or thinking as well as the meanings participants gave to pet behaviour.  Situating the Researcher and Personal Reflexivity Because of my personal experience with my own pet during times of personal distress and my eighteen years of clinical experience counselling individuals and families facing cancer and other illnesses, I believe that the relationship between pets and human beings during times of adversity can be significant. It is my belief that people typically need to be cared about; to be touched; to express themselves openly; to be accepted for who they are; to trust those around  44 them; to be useful to others and to nurture; to feel a sense of belonging; to be validated and affirmed by others; to make meaning of their lives and to experience joy as well as suffering. By all accounts, a satisfying companion animal relationship has the potential to fulfill many of these human needs, during times of wellness and times of distress. In many ways, my first dog with whom I and my family cohabitated for thirteen years, provided many of these things for me, and in particular, offered a comforting presence, hope, affection and security throughout some very painful losses. Since his death four years ago, I felt a distinct loss of companionship not unlike the loss of a family member. In my years of counselling individuals and families facing cancer and other illnesses or adversities, I have encountered numerous people who have also experienced their pet as a source of great support and companionship. They described rich stories of impactful relationships and events shared with their companion animals. Conversely I have also worked with individuals who found their pets to be a nuisance or an additional burden. These personal and professional experiences form the backbone of my interest in exploring the phenomenon of companion animals and people facing adversity.  Mertens (1998) explains that the qualitative researcher should monitor his/her process from the beginning of the study right through to the end and share this process with someone who has an open mind and can challenge the researcher?s beliefs. In order to maintain transparency in the research process and increase trustworthiness, I kept a journal of my reactions to all the components of the study. I consulted regularly with my thesis supervisor Dr. Marla Buchanan regarding outstanding interpretations and biases. Elements of my personal reflections throughout the data collection and analysis processes are included throughout this report.  45  A relativist ontology and an interpretivist epistemological approach to the research is consistent with my belief system as they emphasize the uniqueness of the individual and collective experience as well as the awareness that no phenomenon can be captured and described in its entirety. I acknowledge that as a researcher, my beliefs are present in all my interpretations, and that neither I, nor any participant could fully represent human experience through language. I recognize that self-reports and languaged accounts provide a limited representation of experience (Polkinghorne, 2005) and that my beliefs will inform the data collection, interpretation and results to some extent. Nevertheless, it is my belief that some shared human experience exists and that themes can be developed when a topic is handled responsibly, openly and with the involvement of multiple stakeholders. Such themes may serve to develop theory regarding the HAB and may also inform clinical practice. Counselling psychologists have developed ECIT with this in mind (Butterfield et al., 2009) and this is part of the appeal of the method for me.  Origins of the Critical Incident Technique and ECIT The critical incident technique was developed by John C. Flanagan (1954) through studies in the Aviation Psychology Program of the United States Army Air Forces in World War II.  The technique assisted in the development of procedures for selection and classification of pilots and other aircrew members and candidates.  Flanagan sought to establish a basis for pilot selection and performance that relied on the observation of specific behaviours rather than vague comments such as ?lack of inherent flying ability? which had previously been used.  Flanagan?s procedures were found to be very effective in developing a systematic analysis of successful and unsuccessful performance in aircrews. From these origins, Flanagan and other psychologists developed and expanded the application of the critical incident technique into other areas. The  46 paradigm for research in this era was largely positivist. Numerous studies were carried out in order to determine the critical requirements for specific occupational groups or activities such as dentistry, industrial foremen, bookkeeping, sales clerks and instructors of psychology courses (Flanagan, 1954).  The technique has since been used in diverse fields for a variety of purposes and has moved into the relativist paradigm. Its flexibility is due, in part, to its basic, practical, and fundamental approach to research.  Flanagan states: ?People have been making observations on other people for centuries...what is most conspicuously needed to supplement these activities is a set of procedures for analyzing and synthesizing such observations.? (Flanagan, 1954) There are five steps that comprise the original critical incident technique. These are: 1. Determining the aim of the activity to be studied; 2. Setting plans, specification and criteria for the information to be obtained; 3. Collecting data; 4. Analyzing the thematic content of the data; and 5. Interpreting and reporting the findings (Woolsey, 1986).  As the method has been employed quite regularly in the counselling psychology field, it has grown and developed as a qualitative research tool in this domain. As such a group of counselling psychologists revamped the method, which is now known as the Enhanced Critical Incident Technique (Butterfield, Borgen, Amundson & Maglio, 2005; 2009). The developers of the ECIT modified and added to Flanagan?s original method by changing the focus from direct observation to retrospective self-report and the incorporation of several new components to reflect the current state of qualitative research with respect to data collection, data analysis, and achieving credibility (Butterfield et al., 2005; 2009). The five original steps remain, however with modifications. Of primary importance and appeal to me, ECIT now begins with a contextualization section intended to locate the phenomenon in the unique context and experience of the participants. This provides a meaningful backdrop for the  47 helping and hindering incidents that are discovered. In ECIT, the term incident represents any experiences, factors, events or perceptions that either help or hindered individuals in the intended phenomenon, In this study, this refers to anything in regards to having a pet that helped or hindered wellbeing during their cancer experience. Nine credibility checks have been added that reflect the current state of criteria of worth in qualitative research. Finally, participants are now asked to generate a ?Wish List? (Butterfield, 2001) to further elucidate factors that ideally could have contributed to the phenomenon.  Study Procedures   Participant selection criteria.   The criteria for inclusion in the study were: ability to speak English; self-identify as cancer patient or survivor who has or had a relationship with a companion animal for at least three months during their cancer experience; minimum of six months post-diagnosis; and over the age of eighteen. There were no restrictions placed on gender, ethnicity or type of pet / companion animal.   Ethical considerations.  The study was approved by the UBC Behavioural Research Ethics Board (Appendix H). Because I am employed as a clinical counsellor at the British Columbia Cancer Agency (BCCA), I did not interview any patients who I have seen or was scheduled to see in my position of employment. In addition, any work that was done on this research study at the BCCA was conducted outside of my hours of work, and not for remuneration. Finally, because some interested participants were in treatment or experiencing post-treatment and/or disease-related symptomatology, I suggested that they check with their physicians as to whether it was a suitable time for them to participate in this research. When a participant became distressed during any  48 part of the research process, I stopped and reminded them they had the option of terminating their involvement in the research. I also informed them of resources for free counselling. Because I am a trained counsellor who works in cancer care, I was able to provide support as necessary without engaging in therapy. In addition, Dr. Marla Buchanan and Dr. Marv Westwood made themselves available for provision of a debriefing counselling session for any participant. This was not needed following any of the interviews.   Recruitment.  Recruitment posters were placed in multiple health care agencies, pet care locations, businesses and public posting areas relevant to the research population. I was in contact with staff from the British Columbia Cancer Agency, Lion?s Gate Hospital, St. Paul?s Hospital, Inspire Health, Mt. St. Joseph?s Hospital, Canadian Cancer Society, Tisol Pet Shops, Vancouver Parks Board, Starbucks, and Bosley?s Pet Shops. After some communication and provision of the study?s Ethics approval, I was permitted to place posters at all sites. In addition, I sent a ?blind copy? group email (Appendix C) to 50 colleagues and friends working in oncology and/or counselling as well as friends or acquaintances who might be familiar with people who have a pet and have had cancer. Attached to the email was the Letter (Appendix B) to patients and/or clients. The email explained that I would not be informed of the names of those who might be contacted about my research, but that any interested party could contact me by email or phone. When contacted by phone by any potential participants, I spoke with them briefly and provided them with an Introductory Letter and Informed Consent (Appendix D) by email, fax or post, depending on their preference. Interested individuals were given ten days to review the material and those who wished to participate were asked to contact me again. I was contacted by 26 individuals with whom I spoke personally.  Of these 26, 20 fit the inclusion criteria. Of these 20  49 individuals, fifteen were able to schedule initial interviews. Two of these fifteen had to cancel interviews due to advancing illness. The remaining five individuals from the group of 20 did not make contact again with me after I attempted a second call regarding study participation.  Interviews. Interviews were held in various parts of British Columbia including Vancouver, Surrey, Coquitlam, Kelowna and Victoria. Participants were offered a choice regarding their preference of interview location. The only request / stipulation was for neutral space where there could be quiet and confidentiality. Eight interviews were held in the participants? homes, two were held in my home, two were held at the participants? workplaces and one interview was held at UBC in a Counselling Psychology program office.  Pets were invited to all the interviews however the five interviews held outside of participants? homes did not have any pet present. When the pet was present participants were able to demonstrate some of the factors about their interactions with their companion that they felt were significant. This contributed to the richness of the data as proxemics and other forms of non-verbal communication such as touch were observed.  In cases where the interviews were held outside of participants? homes, individuals were invited to bring a photograph of their pet to the interview. This occurred only once out of those five interviews.   Informed consent.  The Informed Consent form (Appendix D) was sent to each participant as part of the introductory package. During the first meeting, the form was read and explained to each individual before the research process began. All participants willingly signed the consent form at the first meeting, ensuring they understood and accepted the parameters of the study. I reminded them again that at any time, they were free to leave the study should they so desire.      50  Honoraria.  A small honorarium consisting of a ten-dollar gift card to a pet store or a coffee shop was provided to each participant.  This choice was offered to each participant as some participants no longer had their pet and I wished to be respectful of this loss. I paid for these honoraria personally.  Participants  Thirteen female participants and no males participated in the research study. Their ages ranged from 34 to 67 years of age. The number of participants required in ECIT to achieve an exhaustive set of categories is dependent upon when new findings stop emerging from the data (Butterfield et al., 2009).  While this seemed to occur after the eleventh interview, I had three more interviews scheduled and did not feel it would be ethical to cancel them. One of these final interviews was with the only male to inquire about the study. Unfortunately however, he was unable to participate in the study due to advancing illness. Personal accounts describing the participant?s relationships with their pets will be presented in Chapter 4. On the following page, Table 1 presents basic demographic, pet and cancer information about the participants.     51 TABLE 1 Participant Demographics & Biographical Information  Part# Age Gender Marital Status Cultural Background  Occupation  # of children  Number & Type of pets during cancer  Type / Site of Cancer Had pets before cancer 1 45 F M Scottish/ Norwegian Architectural Technologist 0 1 dog Sarcoma Y 2 52 F M English Social Worker  2 1 dog Breast Ca Y 3 58 F M Canadian Lawyer 2 2 dogs, 2 horses, several cats Colorectal Ca Y 4 67 F M Irish / Scottish / German Retired  3 1 dog Melanoma Y 5 ? F S Canadian Firewatcher / Student 0 1 dog Breast & Ovarian Ca Y 6 68 F S English Canadian Retired 0 2 dogs Breast Ca Y 7 53 F M  Canadian Manager  1 stepchild 1 dog Breast Ca Y 8 37 F M European / Icelandic / Ukranian Manager  0 2 dogs Breast Ca Y 9 64 F D European Retired Healthcare Executive 0 1 cat Breast Y 10 34 F CL American/ Canadian/ Italian Journeyman welder / Law student 0 1 dog Non-Hodgkins Lymphoma Y 11 38 F M Spanish/ Canadian Bank Advisor 1 1 dog Breast Y 12 43 F D Polish Canadian Ultrasound Technician 0 1 dog Cutaneous T-Cell Lymphoma Y 13 56 F M East Indian Lawyer  1 2 dogs Breast Ca Y   52 Data Collection and Analysis Five Steps in Conducting ECIT  Step 1: Ascertaining the general aims of the activity being studied.    Butterfield et al. (2009) explain that the first step of an ECIT study is achieved by answering the following two questions: (a) What is the objective of the activity? and (b) What is the person expected to accomplish who engages in the activity? ECIT experts recommend the use of simple phrases to denote the objectives. In this study, the literature review and the researcher?s clinical and personal experience are used to functionally describe the activity. The purpose of this study was to learn about the relationships between people with cancer who have a pet. Thus the purpose of the interviews was to explore the benefits and drawbacks of having a companion animal while facing cancer. The participants themselves will speak to those elements about their pets that helped or hindered them while they faced cancer.   Step 2: Making plans and setting specifications.  An interview guide was developed in accordance with the goals of the study and was utilized  (Appendix E) for all interviews. Demographic information was collected after the first interview so that the focus of the interview and content was established as being the participant?s experiences, rather than any of their descriptive characteristics.  Step 3: Data collection. Obtaining the data from multiple sources is consistent with responsible and credible qualitative research.  Data was generated through three sources: First, individual oral interviews were held following telephone and email contact. Secondly, field notes, consultation with my supervisors and a journal of my observations and perceptions were utilized.  Finally, a member  53 check by phone or email was attempted with each participant. Multiple data sources help support the confirmability and transferability of interpretations and conclusions (Morrow, 2005).  Interviews. Thirteen interviews were conducted and held as open-ended qualitative discussions with guidelines but minimal direction (Appendix E).  I met with participants after speaking with them by phone or email to establish a good fit for the study. The depth of interest immediately struck me from all interested parties. On the telephone calls, participants thanked me for choosing to focus on this subject as they reported that few people inquired about their pets throughout their diagnosis and treatment. I approached each interview with warmth, curiousity, openness and non-judgment. Field notes were written immediately after each interview to ensure that paralinguistic elements and researcher impressions could be incorporated into the data analysis.  The interview process began with the execution of the Informed Consent Form (Appendix D). Next, the interview was conducted in three phases. A full description can be viewed in the Interview Guide (Appendix E).  Phase 1: Contextualization of participant experience.   Each interview began with a contextualizing section whereby participants were invited to talk about their pets and their relationships with them while they had cancer. A version of the following statements began the data collection phase of the interview: 1) ?I am interested in your experience of having your pet. Please share with me a little about them, Can you tell me a little about how he/she came into your life?? And 2)? Tell me the story of your relationship with (pet?s name) while you faced cancer.? Following these questions, participants were asked to describe their personal definition of wellbeing during the cancer experience.  Here the following questions  54 were presented to participants: ?What does wellbeing mean to you in the context of your cancer experience / How might you define wellbeing while facing cancer? ?  Phase 2: Exploration of helpful and hindering incidents.   The second section of the interview involved a comprehensive description of the critical incidents (CIs) experienced with their pets that contributed to and/or detracted from the participant?s sense of wellbeing during their cancer experience. Participants were asked to explain the importance of each factor and provide detailed examples. (Zheng, 2010). I employed open-ended prompts including: ?Can you explain a little more how that helped or hindered you? and ?Are there any other experiences that feel important to you about the way your pet impacted you and your family while you had cancer?? This served to enrich participants? descriptions as well as to ensure that as much of what was significant to them was shared during the interview.   Phase 3: Wish-list items   This last phase of the interview consisted of an exploration of behaviours, interactions, or other factors that participants believe they would have benefitted from in relation to their pet during their cancer experience.   Data management. With the aid of a professional transcription company, interviews were transcribed verbatim as soon as possible following the interview in order to stay close to the data. The interviews were listened to multiple times and changes in voice tone as well as field notes indicating paralinguistic elements were noted on the transcriptions by me. Transcriptions were stored with a password known only to the researchers. Participants were assigned case numbers (1-13) and any identifying information about the participants or third parties was removed from the transcripts and/or coded to ensure anonymity.   55  Step 4: Data analysis. Data was analysed in accordance with the ECIT guidelines as outlined by Butterfield,  Borgen, Amundson and Maglio (2005; 2009) and Woolsey (1986). Some of these steps were modified as needed following data collection as per an emergent design and will be discussed in Chapter 4. Traditionally, ECIT data analysis consists of three steps: 1. Determining a frame of reference: This step refers to the intended use of the data and results generated by the study. The clinical arenas of counselling psychology and psychosocial oncology provided the primary context for application of the results.  2. Formulating categories: The formulation of categories is a very subjective process that requires ?experience, judgment, and insight? (Butterfield et al., 2009, p.271). Because I am familiar with both the areas of cancer and companion animals, my experience in these areas helped provide sound judgment. The three sections of each interview were analysed separately. Within each phase of the interview, similar statements and were grouped together and coded. For Phase 2, incidents were considered to be critical (referred to as ?significant? during the interviews) when the participant could recall specific details about the experience or event regarding their companion animal, and / or were able to explain what it was about the experience that enhanced or impaired their sense of wellbeing. CIs were separated into helpful (HE) and hindering HI) groupings. This enterprise involved a repeated series of colour coded highlighting directly on the transcripts, separate coding lists, and extracting critical factors in the data. Codes were initially extracted as quotes from the transcribed interviews and then put into simple phrases maintaining some verbatim content. CIs that were connected or similar were placed into initial categories and checked with Dr. Marla Buchanan and Dr. Bill Borgen.  Following this, repeated themes were collapsed into categories. This process was repeated  56 multiple times until a level of specificity was reached that suited the frame of reference of clinical application in counselling and psychosocial oncology realms. All the developed categories were subject to the nine rigorous credibility checks central to the ECIT method and are described in the next section, ECIT Credibility Checks.  3. Establishing the level of specificity-generality to be used in reporting findings: This  was determined by examining the degree of usefulness for theory development and clinical application. Details of this will be covered in Chapter V.  Step 5: Interpreting the data and reporting the results.   A dated, detailed log of each interview with the participant case number and the extracted  CIs and WL items was created and utilized to organize and work with the data. This log was further used to develop CI and category lists for validation checks with participants and professionals familiar with the content and/or the ECIT method. The rich personal nature of the data leant itself to personal accounts representations of each participant in addition to the wellbeing definition analysis and incident and category formulations.        Participant Personal Accounts.  In order to appropriately and accurately reflect the richness of the data provided in the interviews, a ?Personal Accounts? component to the report was added to the ECIT method. This additional component serves to represent the contextualization section of the interviews where participants were asked to talk about their relationships with their pets. This section of the interviews was very full, idiosyncratic and rich for every participant and as such could not be sufficiently reported by the categories. Participants were very specific and detailed about a number of areas that will be outlined in Chapter IV. As such, I listened multiple times to this section of the interviews and read the transcripts repeatedly in an effort to gain some  57 understanding of each participant?s experience with their pets and with having cancer. From this I identified themes that were present in each of their stories. In combination with the moving experience of being present while these stories were told and immersing myself in the stories and details of the interviews for considerable time thereafter, I created 13 Personal Accounts. All the participants who read their stories endorsed them. The accounts told by participants about their pets and their cancer experiences added important context to the remainder of the interview, which ultimately led to a fuller and richer formation of the helping and hindering incidents and their categories.  ECIT Credibility checks. Butterfield et al. (2007; 2009) developed the following nine credibility checks that were implemented and modified as necessary for the interpretation and reporting of the data.  Independent extraction of critical incidents.   This refers to the convergence of researcher coding of incidents with an outside person  familiar with ECIT. After every third or fourth interview, a portion of the raw transcripts was submitted to Dr. Marla Buchanan who was asked to select out factors that appear complete as per the definition provided earlier. The selected factors were then compared to those that were extracted by the researcher.  Following multiple discussions about the CIs and their thematic content we were able to converge on the final categories. There was a very high level of nuance in several of the CIs and categories. Several incidents could logically be placed in more than one category and it took some time to agree upon the distinctions that would be relevant to both the clinical and theoretical realms. This check served to increase the credibility that the factors extracted were indeed critical elements of emotional wellbeing related to the participant?s pet.    58 Cross-checking by participants.  Mertens (1998) states that the member check is the most important criteria in establishing credibility and confirmability. Confirmability refers to the confidence that the findings of the study are primarily rooted in the source of the participants and that my interpretations are as transparent as possible (Morrow, 2005). Following the initial analysis of the data, I contacted each participant by email or telephone, as per their stated preference in the initial interview. The participants received a Participant Check letter (Appendix G) with a draft report including: their brief biographical personal account describing their experience of having a pet; their definition of wellbeing during cancer; a summary of the categories and incidents and their working definitions; and any of their quotes from the transcribed interviews intended for publication in the final report. Participants were asked to assess whether they felt their experiences were well represented, whether something was missing or unrepresentative of their experience, and whether or not the categories made sense to them.  I was able to reach 11 of the 13 participants but did not hear back from two of them after multiple attempts by telephone and email. After consultation with my supervisory committee it was agreed upon that it would be acceptable to include data from their interviews, in part because they had signed the initial Consent form and because I had communication with them after the interviews in which they stated that the experience was positive. There was sufficient confidence to include data from these 2 interviews as 11 out of 13 participants endorsed the categories so strongly that this provided sufficient strength to include the two I did not hear back from. Particular attention, however, was paid to these two Personal Accounts to ensure sensitivity and anonymity, and no direct quotes of theirs were used in the report.   59 One of the 11 participants who responded to my initial email explained that she was feeling too ill to be able to read and comment on the material. I reminded her that this was completely understandable and that any participation in any part of the study was entirely voluntary. While this participant requested a copy of the member check package as well as the final report, she explained that she would be unable to provide any feedback about them. Naturally, this was completely acceptable.  The remaining 10 participants provided feedback about their Member Check packages by email and/or telephone. In my communication with them, I invited participants to expand upon any information or incidents that came to their mind since the interview. All ten expressed gratitude and appreciation for participating in the study. All ten endorsed the categories and incidents fully and expressed a sense of comfort, reassurance and pleasure in noticing the common themes that came from other participants? experiences. Several participants requested small changes or edits to their personal accounts including: corrections to details regarding person?s and pet?s ages; years when events occurred, and specific cancer details. One participant requested an additional description of some activities she did with her pet to be added to her personal account and a second requested the addition of a portion of her personal story be included. All ten participants endorsed their quotations for publication in the report. One participant offered additional context for some of her quotes and I added some of this to her personal ccount after explaining to her that the purpose of the quotes was to represent the categories but preserve confidentiality. Otherwise, all edits and corrections were implemented into this report.    60 Placing incidents into categories by an independent judge. For this validation check, I worked with an independent judge who is a colleague in the UBC PhD program. As a current researcher and experienced clinician she has shown great interest in my study and its design. She was presented with the category headings, their operational definitions and a random set of 25% of the critical incidents in each category. The judge was asked to place the incidents in the categories where she felt they belonged. These placements were compared with my own. 107 incidents were presented to the judge and her initial placement yielded a 73% match rate with my placements, below the ECIT credibility goal of 80%. As a result, we looked carefully at the incidents that each of us had allocated to different categories. We discussed at length the subtleties of some of the categories and several changes were made to the category location of incidents. This work resulted in a 90% match rate; now well above the 80% ECIT requirement.  Exhaustiveness. By using the log, I was able to watch as new categories emerged with each interview. After 11 interviews, it appeared that new categories stopped emerging from the data. Following every third of fourth interview, I checked the CIs with Dr. Buchanan and we worked together to establish newness or repetition. All remaining interviews were held following the eleventh, despite apparent redundancy as the interviews had been scheduled and the ethical choice was to keep the arrangements. While new incidents emerged in the two final interviews they all could be represented by the existing 13 categories. Expert opinions.   Following the validation checks, the categories were submitted to two experts in the field. I sought out one psychosocial oncology professional and one animal expert to assist with  61 this task. The psychosocial oncology professional is a clinical specialist and supervisor in the BC Cancer Agency Patient and Family Counselling Services department. The animal expert is a pet storeowner and a 20-year animal rights activist in British Columbia. Both professionals were sent a package by email that included: the participant personal accounts; the categories and their descriptions and accompanying quotes; and the first chapter of the thesis. They were asked to assess the usefulness of the categories and comment on any perceptions and unexpected or missing content in the personal accounts or categories based on their knowledge and experience. The psychosocial oncology professional commented that she found the personal accounts and categories as well as the quotations to be consistent with her clinical experience and observations. She also noted that given her own experience as a pet owner and supporter she found the information to strongly coincide with her own experiences and observations of friends and family with companion animals.   In my communication with the second expert, a long time animal rights activist, pet store owner and keeper of multiple pet companions at home, I was pleased to hear that the results of this study were congruent with her professional experiences and observations. Her written response to reading the personal accounts and categories included the following:  These are stories and connections we hear about everyday in our industry, but to a much more heightened degree due to the circumstances. The repetition of experiences such as the pets just knowing their owners were sick and how surprised the owners were by their reactions and their understanding was both heartwarming and yet not very surprising based on the feedback I receive everyday from pet owners. The ability of animals to sense our needs and fulfill them wherever possible has become second nature to them, especially in the case of dogs but also to a large degree cats. Some small portion may be attributed to us seeing what we want, and putting our own emotions onto our pets, giving them qualities or emotions that they are not in fact  62 experiencing.  But that does not explain so much of their behaviour, and so many instances of true love and devotion.  Feelings of guilt are something we hear of all the time as well, but again this was amplified in your study.  For most of our clients it is a lack of time or financial resources, rather than a lack of physical ability.  This study points to the real and genuine need for additional resources for cancer and other patients to help care for their pets, especially due to the very obvious therapeutic benefits they derive.? (L. Gee. Personal communication, July 2013) Based on the responses from these two professionals, I feel confident that the findings of the study are well supported by experts who have direct experience in fields relevant to this study.  Theoretical agreement.  Categories were considered within the realm of both the existing literature and the researcher?s assumptions. Categories were also reviewed to examine both the consistencies and inconsistencies therein. McCormick (1994) suggests that categories that disconfirm previous research might have to be questioned more closely, while categories that are consistent with related research may be used more confidently. The results support much of the existing literature as well as offer new insights into HAB theory. Unique findings and parallels to the literature will be discussed further in Chapter 5.  In terms of assumptions, this study posits that companion animals have distinct influences on the participant?s emotional, social, physical and cognitive experience. The results do support this assumption as outlined in Chapter 1. In addition, some of the data from the interviews unearthed previously unexplored territory. These possibilities will also be discussed in Chapter 5.  Participation rates.  The purpose of this check is to establish the relative strength of each category by reviewing the participation rates therein. Case numbers from the logs indicated the number of  63 participants whose transcripts featured CIs and WI items in each category. From this a percentage of the number of contributing participants was calculated (Table 2). I had decided beforehand that all categories were to be included in the report regardless of the level of participation rates as per my commitment to incorporating each individual?s experience whether or not it is consistent with others? experiences. As such, no Helping categories yielded a participation rate below 69%. Hindering categories and wish lists, however yielded some low participation rates. All categories and participation rates are reported in Chapter 4 and serve to assist in establishing the credibility of the different categories (Butterfield et al., 2009). Descriptive validity.  This check is concerned with verisimilitude. The accuracy of the incidents and categories  must reasonably represent the participants? experiences (Morrow, 2005). For this reason, interviews were taped and transcribed with attention to the paralinguistics recorded in the field notes. Codes and incidents were extracted directly from these transcriptions by the researcher and verbatim quotes from participants are used to highlight and represent the findings. The member checks also contributed to verisimilitude and soundness through participant corroboration and/or divergence. Interview fidelity. The purpose of this check is to ensure consistency in interviewing. The first interview was considered to be a pilot interview in order to assess the feasibility of the Interview Protocol (Appendix E). After consultation with my supervisor regarding the first interview we decided to proceed with the protocol as planned. After every fourth interview, I again consulted with my supervisor to ensure that there was a basic consistency in my manner of interviewing as well as to ensure the style was consistent with the ECIT method, i.e.: that I was not overtly leading  64 interviewees in a particular direction of interest. Dr. Buchanan expressed confidence that the interviews were appropriately open-ended, guided and consistent.  Representation of Findings This paper makes every endeavour to reflect and represent what participants reported and felt about their relationships with their companion animal during their cancer experience. Each participant was offered a copy of the study once complete, and all were invited to attend the University dissertation defense with family or friends. Companion animals were not permitted to be present at the formal dissertation defense.  Summary of Chapter 3 The method and process of data collection, analysis and interpretation was described in this chapter. The next chapter will describe in detail all of these findings, hopefully in the ways that most accurately and respectfully represent them.        65 CHAPTER 4 Findings Overview  This chapter will present the findings from the 13 interviews conducted for the study. It begins with 13 brief personal accounts describing each participant and their relationship with their pet as well as basic details about their cancer experience. Basic demographic data about participants has been presented in Chapter 3 and will not be repeated here.  Following the personal accounts, themes that emerged from the participants? definitions of wellbeing are presented to provide additional context for the categories that were later developed. Finally, the incidents and categories that emerged from the data are presented with substantial description and verbatim quotes to enrich their meaning and description. The themes generated from the wish list are included in the hopes that they may inform theory and/or clinical practice. Participation rates for items in each category are included. Themes, critical incidents and categories are recounted with a description of the emotional, sensory, behavioural and cognitive components that were reported by participants. All participants but two have endorsed the quotes, themes and categories that are included in the report, as discussed in Chapter 3. Because my experience and values have influenced the data collection, generation and interpretation processes, elements of my personal reflexivity are included in the reporting of the findings.  Participant Personal Accounts  In this section, the reader is presented with 13 personal accounts that briefly describe the participants, their relationships with their pets, and their cancer experiences.  Several notable themes emerged from participants? experiences, namely, the seemingly fortuitous acquisition of the pet; the unique relationship with each different pet they have had; the quirky characteristics  66 of each pet; and the devastation of their cancer diagnosis. Even though not directly asked, the participants invariably shared substantial information about their cancer diagnosis and treatment. These personal contextual elements seemed to be as important, if not more so, than participants? definitions of wellbeing. The incidents that emerged later in the interviews were largely relationally based and, as such, these personal accounts served to enrich the depth and meaning of the incidents and categories.  There are two sections within each Personal Account: (1) Background & Brief Cancer Summary, and (2) Pet History & Relationships. Personal accounts were composed with attention to maintaining anonymity while staying true to the experiences relayed to me in the interviews. Each participant was invited to choose pseudonym for themselves, their pets, and their family members. Two participants requested that I choose these names for them. It is of note that when asked to provide pseudonyms, 7 of the 13 participants stated that they wanted their story to be told in full with their identities known to the reader. I explained that this was not possible due to UBC Research Ethics requirements, however this topic will be considered in Chapter V. All participants save the two who I could not reach during the member checks endorsed their own Personal Accounts. They are presented in the order that participants were interviewed.   Participant #1 Anna and her dog Jack Background and Brief Cancer Summary.  Anna is a 45 year-old professional living with her husband ?A? and dog Jack in British Columbia. After a long and arduous process, Anna was diagnosed in the summer of 2011 with a rare type of cancer. The wait for the diagnosis was extremely difficult- she called it ?the dark side? and explains that during this time Jack?s quiet and calming presence was particularly  67 comforting. Even though Anna?s mother is a cancer survivor, Anna struggled with many fears and worries, ?thinking the worst?.  Pet History and Relationships.  Anna explains that she always had pets from the time she was a child, including dogs, cats, hamsters and fish. She and her husband had a dog prior to Jack, who passed away in 2009, a loss that was terribly difficult for both of them. In 2010, they decided they were ready to adopt another canine companion. As soon as they drove up to the gate of the rescue organization, Jack was standing there and Anna remembers, ?he just won my heart over? immediately. Everyone at the organization loved Jack, as he was a particularly sweet and loving dog who had been abandoned by his last owner. Throughout Anna?s experience dealing with cancer and the ensuing treatment, Jack was a constant source of support and companionship. He helped her through physical and emotional pain, was always close by with affection and love, and gave her the motivation to walk and keep active. Jack?s intuitiveness about Anna?s needs and selflessness amazed her. In particular when she struggled with pain, Anna was able to hold on tight to him until the pain subsided. At times it was difficult to get all of Jack?s care needs met as she and her husband did not have a lot of people in the area to rely on. Even still, when a family member offered to take the dog under their care for a few weeks after her surgery, Anna expressed her gratitude but categorically stated, ?I need him.? She subscribes to the saying that ?you don?t always get the dog that you want, you get the dog you need.? Anna was clear that Jack was the dog she needed through this,  ?a dog that would stick to me.? As was clearly apparent throughout the interview, Anna and Jack continue to stick together, with much closeness and affection.    Participant # 2: Stacey and her dog Fluffy    68 Background and Brief Cancer Summary Stacey is a 52 year-old health care professional who lives and works in British Columbia. She is married and lives with her husband and dog and describes their house as always being very full. She and her husband have two adult children and have fostered numerous children over the years. After being diagnosed with breast cancer Stacey was treated with surgery and radiation, both of which brought considerable pain and challenge. She faced the illness and treatment with the attitude ?If I have this stupid disease I better learn something from it.? Pet History and Relationships  Stacey and her family had many dogs over the years. Either her husband or one of the children would bring home a stray dog that needed to be looked after and the stray would soon become the family pet. Finally Stacey decided that the next dog in the house would be her choice. She researched the breed that she felt to be the right fit for her and the family. Stacey went to see a litter of puppies and noted a particular gentleness in a pup that looked like ?a lumbering little fluffy teddy bear? who followed his mother around. She brought Fluffy home and it was an instant love affair for everyone. Fluffy basically rolled over and said ?Love me.? The whole family did.     Stacey explains that when the children were young, Fluffy was simply one of the kids. When the children moved out, the dog took on a different role. The emotional attachment grew in depth and Fluffy became a focal point of nurturance and love. Stacey stated and felt clearly that Fluffy was ?my dog?. This bond was of particular importance throughout Stacey?s experience with cancer. She felt she could rely on Fluffy with no guilt or expectation and was struck by the dog?s intuitiveness about her needs.  Fluffy was warm and affectionate, helped her with managing her pain, and showed a very palpable protectiveness over Stacey. She spoke of  69 the appreciation she felt for Fluffy?s non-judgmental, loving and constant presence. Stacey described the dog?s selflessness, devotion and loyalty to her as helping make the difference between ?surviving and thriving? through the cancer.    Participant # 3: Joanne and her dogs: Timmy and Meisha   Background and Brief Cancer Summary Joanne is a 58 year-old professional woman living in British Columbia. She is married and lives with her two children. Currently the family lives with 2 dogs, several horses and a number of cats living in and around their property. Joanne was diagnosed with colon cancer just before her 50th birthday. Alongside the trauma of a cancer diagnosis, Joanne lived through multiple forest fires causing her and her family to move and/or evacuate different homes or trailers nine times during her treatment. During this time, the dogs often provided her with a sense of safety, but also a sense of worry. She expressed looking back at her burned and ruined home as a metaphor of the ruin in her own body being caused by her illness. Joanne?s cancer journey was arduous, with multiple treatments and harsh side effects, combined with the diagnosis of cancer in several of her friends and co-workers at the same time. Nevertheless, Joanne described facing her treatment with her usual humour and positive attitude, so much so that she and her friends needed their own private room during chemotherapy so that they were able to laugh together in comfort. Joanne continually expressed a genuine love and attachment to her dogs and all the animals in her world, as well as an appreciation of their presence in her life throughout the cancer experience.   Pet History and Relationships  70  Joanne explains that she herself grew up with a cat as a child and always wanted to have a dog. Her attachment to animals developed in part because in her youth, both her parents showed great appreciation and interest in many creatures including birds, squirrels and dogs. When Joanne married, she and her husband got their first dog, a German shepherd, ?B? to whom she was extremely attached. She described him as the ?loveliest, perfect dog? who died of natural causes at the age of 14. Joanne noted that as much as she adored her dog, she had to somewhat ?demote? him when her children were born. However, B took his new role very seriously and showed great protection over the young children, alerting her when they were crying for instance. The children also had rats, bunnies and cats when they were younger and spent much time with the horses as well. The family got two more dogs, Timmy and Meisha, who were both with her during her experience with cancer.  Timmy was a rescue dog who came to them at the age of 4 years. Joanne described him as the nicest dog, but also an unintentional troublemaker. He was easily scared by loud sounds, motorcycles, etc. and hated the horses, chasing them as well as cars regularly. These chases resulted in several hits by cars and numerous kicks in his face by the horses. Joanne consistently described feeling very attached to Timmy, despite and in part because of his quirks. He was affectionate and cuddly with her and always a very loving presence. Their second dog, Meisha came to the family as a puppy who was simply too cute to resist, as they were not planning on getting a second dog. He was the offspring of an extraordinary dog who Joanne?s secretary took in from the street outside their place of work. Meisha had health problems and was more work to take care of for all the family, however Joanne felt very close to her and showed great patience. Joanne described with great delight and humour how neurotic both dogs were, how they both needed anti-anxiety or OCD medication, but that she adored them completely.  She describes one  71 particularly poignant experience when she had to put Timmy down a week after her last chemotherapy treatment. Despite his usual disdain toward the veterinarian, Joanne describes how Timmy quietly welcomed him in the house and lay down and relaxed, next to his ham and steaks by the fire, letting go of life while looking up at her with complete trust. Soon after this, Joanne describes a possible visitation by Timmy, whereby 12 birds surrounded his most hated horse and stood there momentarily in a circle before flying off and leaving a feather at her back door. When I asked Joanne what she felt this might have meant, she explained that she felt a sense of gratitude as she thought Timmy was saying ?thank you? and letting her know that he knew how much she loved him? and also, how much he hated that horse! Joanne?s stories spoke of the broad range of practical and emotional elements involved in having a pet, and of the enduring love that lasts despite and in part, because of their quirks and qualities, sounding much like my image of family.   Participant #4: Lila and her dog Louie  Background and Brief Cancer Summary  Lila and her husband B live in British Columbia with their dog Louie of 10 years.  They have 3 adult children and 4 grandchildren. In 2002, after working in a management position she loved in the insurance business for many successful years, Lila decided to retire at ?the top of her game?. As a dog lover, she became a volunteer dog walker for the SPCA thereafter. In 2010, Lila noticed a lump under her skin and was devastated to find out she had an aggressive melanoma. Within a week, she had undergone a full set of scans and tests and was booked for surgery. Though she was both frightened and overwhelmed at the time, Lila expresses a sense that there was a ?divine hand? involved in her treatment.  Several dates and events converged in  72 meaningful ways and she was brought back to full health after experiencing some ?unbelievable things during her journey.?  Pet History and Relationships  Lila and her husband are both dog lovers. They had their beloved spaniel ?H? for 15 years. Unfortunately in 2001, just around the time that Lila?s mother was dying, they had to put H down, as she was over 15 years old and very ill. Naturally this was an extremely trying time for the family. About eight months later when Lila was volunteering at the SPCA walking dogs, she caught the eye of a golden retriever with a ?rap sheet? sitting in his kennel. It is unusual for this breed to be at the SPCA and Lila became both interested and curious about him despite the fact she was not looking for another dog. Lila wanted to walk him but the staff was considering him for enrollment in an animal assistance program. She signed her name up and was 20th on the waitlist for the adoption application. The SPCA staff recognized her contributions as a volunteer, and Louie came home to live with Lila and her husband B in his forever home.  Lila describes Louie as a deeply intuitive creature who is a significant part of her healing process. She was touched by his ability to be present and give love unconditionally and without judgment. Lila explains that she has observed this same quality in Louie around other suffering people. Lila took Louie through the St. john Ambulance Therapy Dog Program when he was 13.  He passed with flying colours and the two of them volunteered at a seniors/nursing home visiting a number of residents weekly.  He loved them and they loved him. Louie was a real caregiver to Lila when she had cancer. Together they walked, cuddled, and shared all the ups and downs of her experience in the most genuine of ways. Lila feels an incredible sense of good fortune that this dog is a part of her life and considers Louie to be a blessing.   73 Participant #5: Daisy and her dog Haro  Background and Brief Cancer Summary Daisy is a young woman who lives in British Columbia. She worked for many years in Northern Canada in forest work, and it was there that she got her dog Haro. Years later in 2007, Daisy was diagnosed with breast cancer and has been fighting the illness with a variety of traditional and non-traditional approaches since that time.  Cancer has brought enormous difficulty and disappointment to Daisy?s life and she continually faces this arduous journey with a feisty, philosophical and independent approach, much as she describes her dog Haro to be.  Pet History and Relationships  During the time that Daisy worked in Northern Canada, she needed a dog for safety and protection. Her father happened upon the four year old Haro, who needed a home after his former owner who was an elderly man had to move out of their apartment.  Daisy recounts her early memories of Haro who she first met at a farm where he was dirty, covered with mats and constantly barking for attention: ?He was a pudgy little dog who didn?t know he was a dog.?  She and her father cleaned him up and he turned out to be a gorgeous dog who expected all the attention and the petting from everyone around him when he was young. Daisy described him as quirky and in no way your typical dog. Haro?s unique personality seemed to be why she thought of him as ?the greatest dog, just fantastic.?  Haro lived to the very old age of 21 and Daisy believed he had nine lives. Unfortunately in the last chapter of his life, Daisy herself was also very ill with cancer and unable to fully care for all his needs as she wished she could have. This caused her great sadness, as she would have liked to be able to give Haro the ending she feels he deserved after being such a good dog. Along with this sadness, Daisy has many wonderful memories of her inimitable companion Haro.   74 Participant #6: Alice and her dogs Coral and Mini  Background and Brief Cancer Summary  Alice is a retired professional living and volunteering in British Columbia with her dog Mini. Alice faced significant employment challenges in the late 1990?s when cutbacks were closing in on hers and many others? positions. At that time, she chose an early retirement that she believed would be temporary. She set out to travel across the U.S. with her dog, and had many incredible experiences. Unfortunately, Alice?s later experiences with the diagnosis and treatment of cancer were fraught with many challenges. After a protracted period of time without a regular physician, but a sense that something was very wrong, Alice was diagnosed with breast cancer. She describes a terribly painful experience, both physically and emotionally as a result of the treatment and the disease.    Pet History and Relationships  Before Alice adopted Coral, she had always had cats, bunnies and birds, from childhood through adulthood. Once she left her place of employment and dealt with an earlier illness, Alice had a vision of travelling across the U.S. with a dog in an R.V. She set out to research and find her canine companion. Unfortunately just around the same time, she experienced a robbery at her home. As a result, protection became another good reason to get a dog. She and Coral put on their seatbelts and proceeded on their big trip. Alice explains that having Coral with her afforded her many wonderful opportunities to socialize that she believes she would not have had if she were travelling alone or with a human companion. Alice clearly states that for her, the dog was an essential part of her life in particular because she lived alone. Having Coral increased her sense of safety, her exercise level, her social interactions and feeling of companionship. Alice also volunteered extensively with Coral visiting elderly and infirm individuals with a group of  75 devoted animal lovers. This activity was something that both Alice and Coral particularly enjoyed as well as it providing a source of purpose meaning to Alice. She has continued on with this volunteering with her new dog Mini.  Not surprisingly, Coral?s death was devastating to Alice. She had gone through a terrible experience with surgery and describes a time of ?bottoming out? in her life where the only way she felt she could cope was to get in her car and drive. Driving was something that tended to relax her throughout her life and Alice followed her gut and drove back down to the U.S.  There she found herself near a kennel run by a woman she knew. Alice chose to adopt another dog very purposefully after some very difficult experiences. She knew that having a dog would bring back a sense of vitality, love and hope back to her life. Alice explains that some people criticized her for getting a dog at this low point in her life. This was particularly hurtful as she stated:  ?If you were going to come back as a dog, you?d want to come back as my dog.?  Not surprisingly, Alice?s internal sense was completely correct. Mini stood by her through the remainder of her health challenges and has remained her tried and true companion. Alice?s relationships with both her dogs Coral and Mini have helped bring her back from the bottom to a place of healing and hope.   Participant #7: Barbara and her dog Prince Background and Brief Cancer Summary Barbara is a 52 year-old professional and avid athlete who lives with her husband ?B? and their recently acquired new dog Hercules. Their first dog together, Prince lived to the age of 14 and she explains that their bond was very strong. He was present with her throughout her experience with cancer and helped her in a myriad of ways.  Barbara was diagnosed with cancer in 2009,  76 what she refers to as the ?wipeout year.? During that time she underwent surgery, chemotherapy and radiation, which she described as the ?scariest, hardest time? in her life. As such Barbara was often housebound and struggling with side effects from the intensive multiple treatments. Being a very fitness-oriented person, this inactive alone time was often hard to bear. Barbara explains that with Prince by her side, however she never felt lonely. When her treatment did finally come to an end, she was chosen by chance to participate in the Torch Run for the Vancouver 2010 Olympics. Barbara describes this event as nothing short of miraculous, allowing her to complete her cancer treatments with a dream that came true.  Pet History and Relationships  Barbara had a dog growing up and has always loved canines. Her relationship with Prince was by far, the strongest human-animal bond she has experienced. She and her husband got him at a garage sale, and he was a very independent and quirky dog, both things they particularly loved about him. Barbara describes Prince as ?larger than life? and has numerous stories about his offbeat, delightful and autonomous character. They did everything together and despite some health challenges, Prince was a full and active member of the family. Once Barbara was diagnosed with cancer, Prince became her constant companion. She explains that Prince was extremely intuitive about her needs and that he would stand, sit, lie or walk close by her depending on what was best for her at the time. Barbara feels he taught her about living in the present, and felt that the non-judgmental, non-verbal and attentive presence of her dog greatly contributed to keeping her calm and able to cope with her illness on both physiological and emotional levels. They nurtured each other and it was a deep and fulfilling connection although naturally she also worried about him. Two years after Barbara?s cancer treatment was complete and her health returned to normal, Prince?s health was failing due to old age. She and B  77 recognized that he was nearing the end of his life, and that they would need to put him down in dignity to avoid any more suffering or pain. Barbara remembers that as difficult as this event was, she was completely committed to being by Prince through it, because he had stood by her during her time of need with utter selflessness and devotion. Barbara recalls in thinking about having to put Prince down: ?He went through that summer with me. I was not going to let him go through that alone. It didn?t matter how much it would bother me ? I knew I had to do it.? Such was the shared devotion of this beautiful pair.   Participant #8: Clair and her dogs Zeus and Zena  Background and Brief Cancer Summary  Clair is a 37 year-old woman, working as a business professional in Vancouver, BC. She and her husband moved to the city in 2003 and soon after got their 2 small dogs, Zeus and Zena, now 9 years old. Clair explains that she and her husband always knew they wanted two dogs and together they form her family. During the interview, Clair lovingly referred to the dogs as her ?fur babies?.  Clair?s cancer diagnosis was extremely stressful and drawn out, in particular because her symptoms were not immediately recognized as cancer. She pursued further diagnostic tests in part due to her own research efforts. Finally after a year and a half, on July 14th, Bastille Day, her own self-referred revolution began when the cancer diagnosis was made. She had to wait again, for over a month for the comprehensive diagnosis and treatment plan. During this time, Clair explains that she and her husband relied heavily on outings with their dogs to keep themselves busy and sufficiently distracted during this ?hellish? time. Once she made the final decisions about treatment, which included major surgery and extensive radiation treatments, Clair and her husband set about to care for the dogs and for herself throughout many challenges. This included both dogs being ill and needing care at the same time as she did. Clair  78 worked until the day before surgery, and took public transit to every treatment, refusing the BCCA volunteer driver services as she  ?felt there were people who needed it more? than her.  She walked the dogs daily for an hour throughout her radiation treatment except for once or twice when the rain was too heavy, something she felt proud of.  Pet History and Relationships  Clair explained that she grew up with a dog, who was very much like a sibling to her as a child. In her teens her family got two small dogs, of the same breed as her current dogs Zeus and Zena. Because she and her husband knew they wanted to include their dogs in all their life activities, they chose this small breed who could, for instance, sit in the airplane cabin with them when they flew to visit family. Clair and her husband got Zeus as a 10 week-old puppy, and a few months later, adopted his cousin Zena. Zena was chosen because she had an adorable under bite that prohibited her from being a show dog, and more importantly, because Zeus took an instant liking to her. While both she and her husband adore both dogs, Clair acknowledges that she and Zeus are more bonded. He is ?her little guy.? She describes him as athletic but skittish, and an extremely ?good cuddler.?  She and her husband?s extended family all have bonded with the dogs and have unique relationships. Clair expresses clearly that having the dogs throughout her cancer experience provided her with family, affection, companionship, emotional support and a reason to get through the hardship. She describes a real protectiveness over the dogs and during the interview, demonstrated how they could be held like a baby and rocked in her arms.  Her love for these non-human family members was apparent throughout the interview. During her treatment however, both dogs got ill and needed their own medical / veterinary care, causing much stress to both Clair and her husband. In particular, the dog?s health problems caused a great deal of additional work and strain for her husband, something Clair felt quite badly about. While  79 these challenges added stress to an already stressful experience, Clair, like every other good mother, continues to talk of her ?fur babies? with love, devotion, awe and delight.   Participant #9: Mona and her cat Gris  Background and Brief Cancer Summary  Mona is a 67 year-old woman, retired from the field of healthcare, and living with her cat in British Columbia. She is an active volunteer and fitness enthusiast. When she was diagnosed with cancer, she had to slow down her activity considerably and this was quite a challenge. Throughout her multiple treatment courses, Mona describes a great deal of support from her community of friends and healthcare team, and in particular, from her deep relationship with her cat Gris.  Pet History and Relationships  Mona explains that she has had cats in her life since her childhood and that she feels a strong connection to the species. Throughout her adult years, she kept 2 cats at once, each living to over 15 years of age. Mona describes the pain she felt when her two previous cats passed away from cancer.  She was heartbroken and thought,  ?I cannot go through this again?. However, in 2001, Mona felt she was ready to bring another cat into her life and began the difficult process of choosing a creature among the many needy cats at the SPCA and other shelters. These visits were hard for her. On a particular day however, she walked into a rescue place recommended to her, and she did so with ?clear intention.?  Mona waited to see which cat would approach her. Instantly, Gris came to her and she noticed that a tear was running down his eye. The next day Mona went back and followed her gut and adopted him. This fortuitous connection had an enormous impact on Mona while she dealt with her cancer. She describes numerous profound moments of connection between herself and the cat: healing moments that  80 helped her move through the illness and treatment with hope and grace. Gris was very specific in his behavioural changes after Mona was diagnosed with cancer. He modified the way he sat or lay with her, vocalized when he had never before, and after all her treatments, he carefully and purposefully went to the area of incision or port and gently licked or warmed the bandage or skin around. Mona relates feeling a sense of authentic communication and trust with Gris throughout this time, so much so that she concentrated on sending and receiving messages of love to and from him while she was in hospital. She states categorically ? He was present to me and what I was experiencing at that moment? I didn?t feel that he was ?doing for?. He was with me on the journey.? Participant #10: Ruth and her dog Brownie Background and Brief Cancer Summary  Ruth is a 34-year-old woman who lives with her boyfriend and her dog, and works in Vancouver. She was completely shocked and devastated when she discovered that she had cancer.  As a young, healthy woman with no overt symptoms, Ruth explains that it took a great deal of time to fully accept the diagnosis. She explained that it was also particularly difficult to deal with the reactions of family and friends who were also as shocked and upset as she was about the illness. One of the themes that Ruth returned to during the interview was how reassuring and comforting it was that Brownie did not see her any differently than prior to her diagnosis. She expressed much appreciation for the stability of the dog?s presence, his complete acceptance and absence of judgment in relation to anything about her. This stood out for her in her world where her family and friends were extremely supportive, however, understandably, also extremely concerned.    81 Pet History and Relationships  Ruth explained that she grew up with a dog from the age of 9 through 18 years of age. Years later, just after she began her university studies, Ruth happened upon the opportunity of getting a puppy. A friend of hers had brought home a dog that she got while living abroad, and the dog unexpectedly had a litter of puppies soon thereafter. Ruth decided it was a good time to get a puppy, as she believed she had more time and that her schedule was relatively flexible. She brought home the 6-week-old pup and has had him for seven years now. Puppy Brownie was a handful however, and she and her roommate at the time worked hard to train and take care of him. Ruth describes the process as labour intensive but also extremely rewarding and well worth the companionship Brownie immediately brought to her life. Brownie was both a buddy and a bit of a nuisance while Ruth faced cancer. He was by her side at home so she rarely felt alone. Ruth pushed through six rounds of chemotherapy and pushed herself to walk Brownie and keep as active as possible throughout. At times, however, it was physically a great strain to get out and walk him. Despite this hardship, Ruth expressed a clear awareness that it would have been much harder to cope with the cancer without her ?buddy? Brownie. She remembered back to when he was a handful as a puppy and she wondered whether or not to keep him.  Now she recognizes how much he helped her and is so very glad that she did.  Participant #11: Maria and her dog Cookie  Background and Brief Cancer Summary  Maria is a 37 year-old woman, who works as a bank advisor and lives with her husband and dog in British Columbia. She describes herself as blessed to be surrounded by immeasurable love and support, but also has faced considerable hardship due to health problems in some of her  82 family members. Once Maria discovered a lump in her own breast, it took an unfortunate protracted period of time until she was finally diagnosed with cancer. While this process was devastatingly hard, Maria decided that, true to her character, she would face the illness not as a victim, but that she would take control and fight it. And she did not fight alone. Maria expressed enormous gratitude for the many sources of support in her world while she fought and conquered the illness. She calls the group of doctors, healthcare professionals, family members, friends, pet-related business people and neighbours her ?Dream Team.?  Naturally Cookie was among one of the main players (if not the MVP).  Pet History and Relationships  Maria explains that both she and her husband grew up with dogs and that they knew they both wanted one once they were living together. Unbeknownst to her, Maria?s husband (L) was quickly falling for a little puppy at a nearby pet store. L was visiting the pup daily but hadn?t mentioned anything to his wife, as initially they had planned to adopt a rescue dog. Just around Valentine?s Day, L brought Maria to the store to see if the puppy was what she wanted for a Valentine?s gift. Maria was smitten. Cookie was smitten, and of course so was L. They took the puppy home and Cookie quickly became their baby and ?Mr. Personality?, ?Happy? and ?Handsome Prince? to the whole community.  Maria smiles widely as she explains that Cookie is a little bit spoilt, slightly pudgy and able to outsmart any pet professionals who have been hired to curb some of her quirky behaviours. In part, these quirky behaviours are what make Cookie so unique and delightful. Throughout Maria?s cancer experience and treatment, her ?baby Cookie? was there to cuddle, comfort, protect and provide endless unconditional love. This did not go unnoticed by Maria?s community. She describes an outpouring of support for helping out with the dog. Friends and  83 family walked and looked after Cookie whenever needed, and the doggy day care and grooming store provided unlimited free services. Maria explains that Cookie?s role in helping her through her cancer was taken very seriously. Now that Maria?s health is strong and stable, she continues to express gratitude and love for the amazing support from Cookie and the Dream Team, and how the ?stars aligned? to help her through a grueling experience.   Participant #12: Lucky and her dog Sugar Background and Brief Cancer Summary  Lucky is a 43 year-old woman living in British Columbia with her dog Sugar.  Lucky has worked as a professional in the healthcare field for many years, and unfortunately began experiencing debilitating dermatological symptoms in 2004. She lived with pain, inflammation and discoloration, all of which found no successful explanation or treatment. Lucky describes the upset caused by regular unsolicited advice from strangers out in public who judged her and stated out loud that she should use sunscreen, assuming she had a sunburn. These kinds of experiences, combined with the constant, untreated pain from her condition made for a very difficult 7 years. In addition, during this time her dog of 14 years, ?J? passed away, leaving her with much loneliness. In 2011 a firm diagnosis of Lucky?s condition was finally made. It was actually a relief for her and her community of friends and family to find out that she had cancer. This made the possibility of treatment and symptom management for her awful symptoms possible as well as giving an explanation for the past 7 years of difficulty. Lucky has had some very successful treatments and continues to undergo treatment to combat her illness. She faces her challenges with a feisty attitude.    84  Pet History and Relationships  The day she received her cancer diagnosis, Lucky went online to look for a dog. She chose Sugar, an adorable small dog with a ?sad, forlorn and scared? look. Something about his face clicked instantly for Lucky, and Sugar was home with her within a week?s time. Sugar had several quirky and challenging qualities, but was simply impossible not to love.  Before Sugar, Lucky had J for 14 years, and part of that time, her mother helped her with the dog?s care as he aged because Lucky?s condition impeded her mobility at times. Losing J had been a very painful loss.  Bringing Sugar into Lucky?s life brought the idea of companionship, exercise and affection back into her world. At first, both she and some family members felt nervous that Lucky would be able to look after the dog given her limitations and pain. Once the family met Sugar, however, they fell head over heels with the dog and all contributed to her care. Sugar got all the care and attention she needed, and turned out to be a significant part of Lucky?s healing experiences. It took a long period of time for her pain to be managed completely, and until that happened, she explained that even though she was in the same amount of pain as before, having to walk and care for Sugar gave her newfound motivation. Lucky considered the cuddling to be therapy as well. Since she adopted Sugar, her ?perfect dog?, Lucky and her have pretty well been together ?24/7? and she states that the timing could not have been better.   Participant #13: Sarah and her dogs Ganesh and Lakshmi Background and Brief Cancer Summary  Sarah is a 56 year-old professional working and living in British Columbia with her husband ?D? and two dogs. They have one adult son. In 2004, Sarah began a long battle with breast cancer and its treatment that brought many challenges to her already busy life. At the time  85 she was living in another province due to employment needs, and the illness and treatment took its toll on every member of the family including the dogs. Sarah explains that everything that possibly could have gone wrong with her treatment, her employment, her living situation and her emotional health did go wrong. The move from B.C. put the family in financial and emotional turmoil. On top of this, the process of having cancer was arduous and debilitating and it overwhelmed Sarah, her husband and their son.   Pet History and Relationships  Sarah explains that she has had dogs since her earliest childhood and that animals have been and continue to be an essential part of both her and D?s lives. Sarah related many stories where dogs and other creatures have had a profound effect on her. They have been her friends, her healers and her companions no matter where has lived or moved to or from. She and her D treat their dogs as they would their children, and as such, experienced a painful loss when their beloved rescue dog, ?N? died in 2001 after suffering for a long time with a congenital deformity. The family did everything they possibly could to care for this dog and it was very difficult to even conceive of getting another one after N passed away. A year later, when a family friend happened upon some newborn puppies, Sarah and her son went each to choose one. It took some softening before Sarah?s husband felt open to having another dog, but when D laid eyes upon Ganesh, he melted and Ganesh was the new love of the family. Six years later, the same family friend asked if Sarah could housesit another newborn puppy until a home was found for her. Not surprisingly, Lakshmi, the new pup found her home instantly with Sarah and D.  Sarah has believed that Lakshmi carries in her some of N?s spirit, the dog they lost years before.  She felt that Lakshmi was her ?saviour? while she was out of B.C., as the dog protected and looked after  86 her, kept her calm, forced her to go out, and enabled her to meet people in a place where she knew no one.  Throughout her experience with cancer, both Ganesh and Lakshmi stand out as pivotal components of her ability to cope and heal. They sat with her when she cried, and stood by her with a loyalty and protectiveness that she truly needed.  Once back in B.C., Sarah continued to face multiple challenges associated with her illness and treatment. She recounts a time where the dogs literally saved her life after a fall. They nudged her, nipped at her feet to encourage her to get up and barked repeatedly until someone on the phone heard them and rushed home to help. Sarah feels strongly that both dogs understand and relate to her with a deep emotional connection. They all live, eat and coexist together as a family. This was quite visible during the interview, where they stayed by her side and nuzzled her continuously. Many unjust things occurred to Sarah during her terrible experience with cancer, however, her dogs remained devoted and true. Defining Wellbeing in the Context of Cancer  The construct of wellbeing is central to the research question and is, by its nature, subjective. In order to capture the context for each of the participants? helping or hindering incidents, participants were asked to describe their personal definitions of wellbeing before they were asked about experiences that contributed to or detracted from it. Each was asked the question ?In the context of your cancer experience, what does wellbeing mean to you??  It is significant that five participants had difficulty responding to this question, one stating categorically ?When I had cancer I didn?t have wellbeing on any level honestly? Everything that I think about wellbeing physically or emotionally or whatever, when I had cancer, it just wasn?t there.? Another participant could not find any ways to conceive of  87 wellbeing during her cancer experience. Several participants did not answer the question directly at the time it was asked and only later, nearer to the end of the interview, added comments that elucidated their definitions of wellbeing in the context of having cancer.  While numerous theoretical approaches have attempted to define wellbeing, as discussed in Chapter 2, it is generally agreed upon that individuals experience the presence or absence of wellbeing in personal ways that have meaning to them.  Despite the challenges in arriving at a universal definition, perhaps the definition that is most applicable to this study is found in Lent (2007). As discussed in Chapter 2, Lent focuses on people?s abilities to both locate and develop personal and social resources and adaptive behaviours in the midst of distressing life circumstances thereby achieving wellbeing.  Wellbeing Categories The process of category development as outlined by ECIT was used to develop the definitions of participants? subjective experience of wellbeing. 67 descriptors of wellbeing from 9 of 13 (69%) participants emerged from the interviews. These items were collated and analyzed repeatedly until 6 salient categories of wellbeing became evident. In rank order of participant endorsement, these categories are now presented and described with supporting verbatim quotes: 1. Peace of Mind 2. Social Support 3. Taking Care of my Emotional Needs 4. Resolving to Beat Cancer 5. Putting my Physical Needs First 6. Personal Growth 1. Peace of Mind This category refers to reported elements that include a sense of calm, peace, acceptance and balance. Descriptions provided by participants included: living in the moment; not stressing about getting things done; feeling that someone is watching over them; and a sense of  88 perspective and wholeness in regards to themselves in the context of who they are, with or without cancer. By nature, this was often experienced as a satisfying connection to self and a sense they were doing everything they possibly could to be true to themselves, i.e. no regrets. Supporting Participant Quotes When the sun is out I feel a sense of wellbeing; when I am with friends I feel a sense of wellbeing; so it isn?t necessarily just a health thing, it?s more a state of mind or a sense of an inner peace or something in yourself.  When I feel centred and grounded within myself, therefore I am more in present time; when I was in present time there was no fear and I was able to experience joy. If cancer is going to take me I?ll feel that I have done everything possible for my own health and wellbeing.  Feeling like someone is watching over me; some higher power. The best thing is just to see sort of a balanced scale and if they tip one way you?re out of balance and your wellness goes down or wellness goes up depending on it. The feeling that everything is as it should be.  2. Social Support The elements in this category related to having supportive people around including family, friends and co-workers. Participants also mentioned the term love regularly, indicating that the giving and receiving of love were salient factors. Supporting Participant Quotes Having a family member who is supportive and caring, the person who says to you -Its gonna be okay, were gonna work through this.  Being surrounded by people who love and care about you. Family and friends that were supportive; family and friends staying positive made it easier. 3. Taking Care of my Emotional Needs This category refers to emotional concerns and needs, affect, maintaining normalcy and the importance of not focusing exclusively on cancer. This included the ability to experience joy,  89 happiness and humour, as well as tending to emotional needs such as keeping a good body image, avoiding stress and feeling capable of coping with sadness and fear. The ability to focus on aspects of their lives other than cancer was endorsed by many as part of emotional wellbeing. Participants valued the sense that at least some of the time, they could maintain normalcy despite the many changes brought on by cancer. In particular, they also reported the importance of getting information about diagnosis and treatment from their health care teams in a timely manner so that they could manage their emotions.  Supporting Participant Quotes. Feeling that lightness even though there is a lot of heaviness going on in the background. Humor, not taking cancer too seriously. Keeping cancer in a frame of mind that was handleable -?ok I?m doing this and going through treatment; I?m doing this thing that?s hopefully going to make me better.  The main thing was to make sure that I didn?t have to deal with work or complicated situations.  Trying not to feel like a cancer patient all the time. 4. Resolving to Beat Cancer This category includes the numerous references made to participant?s resolve to ?beat this disease?,  remain optimistic about overcoming it, and/or do everything possible to face cancer and its treatment with feistiness, strength and conviction.  Supporting Participant Quotes A kind of resolve that this is how you?re going to tackle it.  It?s remaining positive and that you?re going to beat this disease  5. Putting my Physical Needs First This category refers to the physiological aspects of participant?s lives including health, pain management, nutrition, and exercise. This area was often accompanied by the assertion that   90 putting oneself and one?s health first when facing cancer was part of wellbeing at this particular time in their lives.  Supporting Participant Quotes Focusing on my health and wellbeing everyday; focusing on myself every day. Being careful and cautious about my immune system, i.e. don?t go to crowded places, don?t let people kiss or hug me, hand sanitizer, never open doors with my hands. It takes into the whole of my life so that would be physically, so it would be decreased pain.  I had to make cancer my full-time job. 6. Personal Growth & Purpose This category comprises elements of participants? foci beyond merely surviving the illness. This included the possibility of personal development and the hope that something could be learned or gained from having cancer.  Supporting Participant Quotes When you?re looking at cancer if you only look at it from one perspective, it becomes all evil and you forget about the journey, you forget that it can take you towards thriving not just surviving.  If I?m gonna have this stupid thing (cancer), this evil thing then I better learn something from it, I better gain something from it.  I want to better myself and become something that I can share with somebody else.   91 Critical Incidents and Categories   Thirteen categories were developed from the critical incidents and wish lists described by the participants.  A total of 608 items reported by the 13 participants emerged from the data, comprised of 487 Helping Incidents (HE), 109 Hindering Incidents (HI), and 12 Wish List (WL) Items.  The 13 categories were finalized based on the data analysis, member checks and validation checks consistent with ECIT.  Some categories contain HE, HI and WL items while others contain only HE incidents. The WL items are noticeably fewer in number as many of the participants struggled to think of something they ?wished? they would have had during cancer specifically in reference to their pets. They did have many ideas of general things they would have liked help with during their cancer experience, and this finding will be considered in Chapter V.   I have attempted to label each category to most accurately reflect the nature of the critical incidents allocated to it. The categories are presented in order of highest to lowest participation rates, the first 3 categories being endorsed by all 13 participants. The following section provides participation rates for incidents within each category (Table 2) followed by a description of each category with representative verbatim quotes from participants. In rank order, the categories are:1. Companionship & Presence   2. Emotional & Social Support 3. Purpose and Role  4. How Pets are Different from People 5. Health and Pain Management 6. Pet Intuition and Adaptability  7. Being Positive and in the Moment  8. Pet as Protector and Caregiver 9. Touch 10.  Unconditional Love & Devotion 11. Existential and Spiritual Factors 12. Family Members and Finances 13.  Caretaking of Sick / Dying Pet   92 TABLE 2 Participation Rates for Categories, Critical Incidents & Wish List Items    Categories Helping Incidents (HE) (N=487) Hindering Incidents (HI) (N=109) Wish List Items (N=12)  # of PART (N=13) PA  Rate % # of HE Incidents  # of PART (N=13) PA Rate % # of HI Incidents  # of PART (N=13) PA  Rate % # of Items Companionship & Presence  13 100 66 2 15 2 2 15 2 Emotional & Social Support 13 100 60 9 69 35 4 33 4 My Purpose & Role 13 100 42 2 15 12 0 0 0 How Pets are Different from People 12 92 46 0 0 0 1 8 1 Health & Pain Management 12 92 37 9 69 20 3 25 3 Pet Intuition & Adaptability  11 85 60 2 15 6 0 0 0 Being Positive & in the Moment  11 85 25 0 0 0 0 0 0 Pet as Protector & Caregiver  10 77 52 0 0 0 0 0 0 Touch 10 77 33 2 15 2 0 0 0 Unconditional Love & Devotion 10 77 26 0 0 0 0 0 0 Existential & Spiritual Factors 9 69 22 1 8 5 0 0 0  Family Members & Finances 9 69 13 7 54 13 1 8 1 Caretaking of Sick or Dying Pet 6 46 5 3 23 13 1 8 1 PART = Participant,  PA = Participation  93 1. Companionship & Presence   This is one of three categories that were endorsed by all 13 participants (100% participation rate) and included 68 incidents in total. It was notable early on in the interview process that almost all participants repeated a version of the following phrase multiple times throughout the discussion in reference to their pet: ?S/he was just always there?. Helping Aspects: The basic presence of the pet was a central theme that participants returned to throughout the interviews. This involved the sense that the pet?s presence, companionship and constant ?being there? provided comfort and security. The great majority of the time, this presence was experienced in a very positive and reassuring way, decreasing loneliness for participants while they were at home for cancer-related reasons such as treatment, pain, time off work, etc. Participants expressed a sense that their pet would be there physically and emotionally, at all times, no matter what state they were in, what they were doing or what they needed or how they behaved.  Illustrative Participant Quotes  He (dog) was with me with my illness, there was no judgment there was no anything -it was just the ability to just be there and not have to do anything. Being present?Without expectations. It?s so huge because life expects a lot out of us and when you?ve got cancer its just another thing that?s expecting something out of me ? I?ve got to go to appointment after appointment, the emotional impact of it, the physical impact, the psychological, there?s so much expectation there that you need one thing that has no expectations about it. And that?s with being with an animal?it?s just having them be there for you. It?s an anchor. Its somewhere you can go, as crappy as you feel, you can at least go and sit down beside him.  He?s the constant. Everybody else is coming and going but he?s always there, always there. If you need him to go for a walk, if you need to sit with him, he?s there. He?s there. It?s just nice knowing that they were always there. You know, no matter what, if I, you know come home, and all I could was cuddle with him, and that was fine.  94 I didn?t feel that he was doing ?for?. I didn?t have this doing. He was, he was with me, on the journey. That?s all that I can say really. He just never left me alone - like my little shadow - wherever I would go he would follow. Hindering Aspects: In terms of unhelpful aspects to the pet?s presence, two hindering incidents were mentioned in this category, one each by two participants. They reported that very occasionally their pet?s constant presence felt somewhat stifling, thereby causing irritation and stress. Both participants reiterated that this was rare and that the majority of the time, they were comforted by their pet?s close presence.  Wish List: WL items regarding companionship included the desire for pets to be allowed to visit them while they were in the hospital and/or be able to stay over with them in the hospital when participants were admitted overnight.  Similarly, participants would have like to be able to take their pets to public places with them.   2. Emotional and Social Support This category also had 100% participation rate and featured 66 HE incidents, 9 HI incidents and 4 Wish List items. The category encompasses the diverse emotional and social effects that participants described regarding having a pet while they had cancer.  Helping Aspects: This included a sense of emotional support, acceptance, reassurance and calming qualities provided by the pet. It also refers to the increased and/or facilitation of socializing with other people due to having the pet. This occurred in instances such as conversing with both neighbours and strangers who shared an interest in the dogs, cats or horses. These interactions were described as of particular significance because they were often the more rare conversations that did not revolve around the subject of cancer.   95 Illustrative Participant Quotes  You feel accepted, you feel that warmth and affection. He gives you that warmth and affection that you really need because you?re feeling really sorry for yourself. So at that point when I was in vulnerable spots, whether it was when I was diagnosed, when I was post-surgery ?or when you?re going through pain it was a good thing that he was able to then give you that support. It (the dog) is one way of- interacting with people on a non-sick level because they don?t know that I have anything wrong and its kind of refreshing to be a person rather than a cancer victim which I just really abhor that.  When I came back, I had to go to the BC Cancer Agency. I used to sit down on those stairs. I would just cry and G (dog) would sit back, one step higher than me and put his head on my shoulder and then he would lick my tears. I?m telling you nobody could have healed my like that dog did. Especially those nights where you?d wake up scared or a little fearful and you have anxiety- they?d (doctors) given me a prescription for anxiety and I?d keep saying that I didn?t need to. I slept with them (dogs) on the floor because I just couldn?t move. So there?s one side me and one side the dogs. The three of us totally like children in fetal positions. Three of us. Many times when I feel like really crying, they go the places where I go cry. They both will sit there. I am so glad they were sent to me. Hindering Aspects: On the hindering side, participants reported feelings of guilt, stress and worry regarding their pet?s care and the effects of their illness on the pet. They described the sense that the limitations put on them due to their illness were decreasing the quality of life of their pet.  Illustrative Participant Quotes Only emotionally.. it was quite a bit of stress after my parents went home of actually getting him walked?. That was a stress because I?m here all day with him (the dog), and I?m concerned about him getting walked, getting outside, and I physically can?t do it, and really we had very few friends and family in the area that could or would do it?I?m not really one to ask for help, so you almost had to rely on people thinking to come help? my sister used to come on certain days and it was a big relief when she would, but there are a lot of days when you don?t hear from anyone, so that was my stress. The first part when you get diagnosed is you don?t want to leave. You think about, ?Oh my god, I?m going to die and what?s going to happen to this dog?... How can I leave him?  96 If I wasn?t feeling that great, like, it was hard to take the dog out?Like definitely guilt would kick in and start to feel like, ugh?I?m sorry! It was terrible for me, because I think I was more worried about him (dog) than myself then. I just didn?t want him to feel that something was so horrible wrong with me, that he was going to be losing me or something. Wish List: Participants reported wishing that there were professional Home care staff that was pet-friendly, as it was distressing to have to put their dog in a separate room when health care professionals came to the home after surgery. One participant would have liked her breast cancer support group to be centred on pets part of the time.  3. Purpose and Role  This third and final category endorsed by all 13 participants involves 42 helping incidents and 2 hindering incidents.  Participants described feeling that their pets provided them with a sense of purpose or clearly defined role that was for the most part beneficial and salutary.  Helping Aspects: The pets seemed to call upon a nurturing aspect of participant?s beings that felt purposeful, healthy and normalizing. Participants expressed enjoying the sense that they could still provide for someone or something else other than themselves. They also talked about the sense of purpose provided by pet caretaking, in particular increased motivation to walk or go outside.  Several participants who had no children or whose children were grown and out of the house referred to their pets as their children, ?fur babies?, family members and babies. This nurturing role was quite significant for many participants.   Illustrative Participant Quotes I did feel very useless while recovering cause I?m not a person to lay around?so that was one thing I could do when A (husband) would walk him in the morning, I would get up and get his food ready. So I got a little small piece of feeling ? of purpose early on. In the start of the day when I could actually help- that was probably the initially thing that made you feel that you?re moving forward.?  97 If I didn?t have L (dog) would I have gone out walking, or would I have sat here feeling sorry for myself watching TV or reading probably. He (dog) made me go out and he made me do things, he made me care for something other than myself. You get sick of yourself actually.   I thought I need something joyful and something fresh and something non-cancer that will absorb me. I did this (adopted the dog) absolutely coldly knowing that I would love the dog?So I used that dog for my purposes and I didn?t feel at all guilty, cause I knew that if I was coming back as a dog I?d want to come back as my dog. I always just, I mean before we knew how bad it was going to be I always just thought that I had to stay around for them.  He made me want to get up even if it was a quick walk around the block, it gave me a reason, 10 minutes, 15 minutes, 20 minutes- whatever I could manage but he gave me a reason to do it.  Three of us (participant and 2 dogs) eat lunch together. Lunch is early like fruit salad or something- So I take bites, they take bites. They take bites, the three of us. We are like a family. They?re my children.   Hindering Aspects: For two participants however, the pet?s presence at times was a reminder of their own incapacitation and illness, thereby contributing to a sense of failure or inability to fulfill purpose.  Illustrative Participant Quotes I did feel very useless while recovering  ?cause I?m not a person to lay around and I said that many times, that I?m useless and this and that- and that?s a specific thing for him (dog), because he?s on the raw diet you can?t leave his food out. Wish List: There were no wish list items in this category.   4. How Pets are Different from People   This category encompasses various ways in which participants described qualities or aspects of their pet in a comparative way to human beings. 92% (12) of participants endorsed this category citing 46 HE incidents, no HI incidents and 1 WL item. At times, pets were directly compared to family members, friends and various other people in their lives, and at other times, comments seemed to refer more to a general comparison of the two species; i.e. ?They (pets) just  98 don?t judge you like people do?.  To clarify, all participants talked about the support that was provided to them by family members, friends, healthcare professionals and even strangers with great appreciation. For many, however, there was also a sense that their pets were able to provide a type of support they couldn?t get from the people in their lives. Helping Aspects: Pets were described with characteristics believed to be unattainable by human beings, i.e.: complete selflessness, lack of judgment, and unending unconditional love and presence. Sometimes these qualities were attributed to the non-verbal quality of pet communication. Mostly, participants described a felt sense of trust toward their pets that existed without frustration to human beings but rather with an acknowledgement that the two species simply functioned differently in the ways in which they relate to others.  Illustrative Participant Quotes If it were a kid they?d be bouncing they would want something from you.. they wouldn?t be close and quiet, that doesn?t happen with a human being right- they?re there for a reason- they want the interaction and its usually about the other person, it?s not about you.. Whereas with the dog, the reason was me. I guess it?s no matter how close you are to your friends or your husband or whatever I think maybe it?s the non-judgmental aspect of a pet. It doesn?t matter who they are. Even if they?re your closest friend, things that you tell them or things that they see, you always know that they?re going to judge you in some way? That?s just the way we all are, right? ?. Whereas dogs just aren?t. They?re just there. They don?t stare at you and go, ?Oh you look funny now.? ?No change, because you?re just you. You?re always just you and that?s all they care about. That?s all they care about. They don?t care about looks or even if you don?t feel good or what?s wrong. They?re so easy?and they?re just so calming that way I guess. The dogs, they don?t judge so it doesn?t matter, they don?t care that I don?t have breasts anymore. If I?m on the floor crying, they don?t care they?ll just, they?ll come over for a kiss and a cuddle and it doesn?t, it really makes no difference to them. And they don?t think that I?m taking too long to get back to work or that I?m, you know not healing fast enough or doing really well or whatever. They just don?t judge that way.  It was a true- an authentic healing experience, because he didn?t say a word, he didn?t ask anything of me, I wasn?t a number, you know chart number, and he wasn?t giving me suggestions on how I could get better, he was just in the moment doing what he felt I needed.  99 I just remember being so thankful that he was there and not like wanting to talk about it, or like ask questions, you know? And not shocked about anything, like you know when my boyfriend ? would take me to chemo treatments and stuff and sometimes when I came home like he wasn?t being mean or anything, but he was just like ?Do you want to go lie down, like you look kind of look like a wax figurine?, like I guess just the way you look after, you don?t look normal. But B (dog) was just like, treat me the same, you know, nothing?s different. I mean sure I had support and love from my friends and family but I don?t know- it?s different, It?s a different kind of companionship?. it?s a different way of communicating. Hindering Aspects: No hindering incidents were reported for this category.  Wish List: One participant stated strongly that she believed that everyone should have a dog when they?re sick, even more so than having people around.   5. Health and Pain Management  This category refers to areas in which having a pet while having cancer either contributed or detracted from health, healthy behaviours, and pain management. 12 participants (92%) reported a combination of 37 HE incidents, 20 HI incidents and 3 WL items.  Helping Aspects: Pets were often associated with increased healthy activities such as walking, exercise and going out of the house. Participants reported that without their pets they likely would have engaged in far fewer healthy behaviours outside of those directly involved with cancer and its treatment and side effects. Pets were also perceived as assisting with pain management through distraction, cuddling, or being held tightly until pain decreased. Participants described at times dramatic instances where their pets behaved in completely selfless ways in order that their actions might help decrease the person?s pain. These participants described being ?amazed? and ?stunned? by these actions.     100 Illustrative Participant Quotes One thing that I really felt when, after surgery, and I was in a fair amount of pain, like, even though I was on pain killers in the night, it would really almost feel like knots in my leg, and what I found was that J, like ?cause the pain killers wouldn?t last through the night, I?d have to wait, take a pill and while I?d wait for them to kick in?.I can grab him like almost how people grab a stress ball, and he will let me like just grab his leg and hold on to it?. He would just let you do it. Well certainly during the radiation?and about a month post-surgery I started walking them, so it always gave me something to do and I usually feel better after a walk so, I think if they hadn?t been around it would have been hard to force myself to go...we went for a walk every day. She (dog) was my saviour in that city because I had to walk her, I had to feed her, I had to play with her and as a result, I was forced to come home on time. I was forced to exercise. Hindering Aspects: Personal health concerns related to pets were also noted by participants, in particular the added strain of daily caretaking duties such as walking and feeding the pet when one felt exhausted, weak, incapacitated or sore.  Illustrative Participant Quotes The fact of the matter is that he needs food. He needs to be walked, so if there?s nobody to do it then I?d have to do it. Even if I did feel weak, it was like any job that you have to do? There was the worry. The worry about fights or M?s (dog?s) health and the worry that if she?s in the house too long she might have an accident. And I couldn?t clean it up? I don?t recall ever cleaning it up when I was sick. I was worried about the house and my health.  Wish List- Several participants felt that there should be pet care help available for people with cancer and their caregivers in order that they could continue to enjoy the health benefits of their pets without having to take care of the more difficult or exhausting care elements.   6. Pet Intuition and Adaptability     This category represents 66 examples (60 HE and 6 HI) provided by 11 (85%) participants where they believed and felt strongly that their pet was able to both pick up on their  101 feelings and needs as well as respond to them. Two participants described 6 hindering incidents in this regard.  Helping Aspects:  Participants described multiple experiences where they felt their pet had an ?ESP? type of connection with them. This connection included both emotional and practical components. These included a strong feeling that the pet was ?in tune? with them and that they understood their situation on a non-verbal level. There was a sense of complete conviction that the dog or cat was watching the participant more carefully than before they were ill, and as such, modifying their behaviours to be more helpful to them. Adaptations to participants? illnesses included increased gentleness and tenderness from normally very active and demanding dogs, dogs requiring fewer and shorter walks, and observable changes in cat and dog behaviour suggesting they knew something was wrong with their human companion. Participants described their pets being particularly careful and gentle around medical equipment as well as around any parts of their bodies that had been treated or had illness. In many cases, the pets altered their activities immediately after diagnosis to better suit the needs of the person. Participants often described these changes as amazing and mystifying, proving conclusively to them that their pets knew, understood and cared for them deeply.  Illustrative Participant Quotes I?m still amazed how much he seems to almost understand what you?re going through. Even with this leg with the drains and stuff before I had surgery he?d often lay right on my legs in bed, he would lay across them. After surgery, he couldn?t and I?m sure the first time I said no but then he never seemed to try again? I used to walk him three times a day- long walks. And he suddenly had to change to being walked later in the morning and later at night and he never bugged me about it.  Post-surgery?so you?ve got this machine, you can?t move really cause you?re hooked up to it, you?re in an excruciating amount of pain. And he (dog) would come and know ? I didn?t want anybody touching me- its like he knew- he would come up and put his backside close enough to you but just far enough away. Seems like had an intuitiveness about him that said ?I know you?re in pain, I?m gonna be here but I?m gonna be far enough away that I don?t hurt you.  102 I could only sleep on my right hand cause it was my left breast...so he couldn?t come up and sleep next to me so what he did was he curled up next to the pillow and got his head around this area on my right arm, he put his head right there on the right? and then he put his left paw in my hand?Then he?d start nodding off and this his paw would move and he?d put it back on. He was very conscientiously putting it there? He?s never done things to that extent you know, before or after. It was really interesting he knew when after surgery- he kinda knew when I had limited mobility so he never came near the bandages- he knew that was off limits. He?s a real lap dog but he wouldn?t- he knew I was hurting there. And even when we walked- I never taught him to walk well on a leash- but he would not pull the least or anything, very calm, which he is not a calm dog. He picked up on things and really just wanted to be a support. When I?m not feeling well he notices it and he?ll either lie with me the whole time or he?ll go and do his own thing and check in on me. ? There were a few times that I wasn?t able to take him for a walk and he pretty much took care of himself in the house. He?d run around and scoot around and get his own exercise ? so if he needs to go for a walk and he sees that I haven?t gotten up, he?ll go take care of himself. Hindering Aspects: One participant also sensed that their pet was negatively impacted by the illness and described this sense as upsetting and troubling. This included a feeling that the pet was distressed, worried and fearful about their human companion?s condition, which in turn distressed the person. There was also a sense of guilt at times that the pets were so selfless and undemanding that they might not be getting their needs met (i.e., dogs being walked less).  Illustrative Participant Quotes He (dog) is like a baby and he goes wherever we go. I think he sensed there was something wrong. He was quite distressed, he started shedding, he got dandruff in his hair ? and I felt really, really sorry for him. It was so bad that you could hear him cry at night. He would sit next to the bed and if he heard me moan a bit, I could hear him cry. We didn?t want to distress him so much. Every time I had to go to chemo or any physio we had to put him in a kennel. He hated that, because they had never been to a kennel before. Wish List: There were no wish list items in this category.  7. Being Positive and in the Moment  This category incorporates 25 examples cited by 85% (11) participants whereby their pet brought a sense of positive energy, joy, grounding and a ?here and now? focus to their lives  103 during their difficult cancer experience.  Cats, dogs and horses provided opportunities for participants to get participant?s mind off their illness and remain in the moment.  This was also particularly felt during the hellish time that participants described while waiting for news of their diagnosis as well as treatment or test results.  There were no hindering incidents or wish list items reported by participants for this category.  Illustrative Participant Quotes How can you not look at your dog and smile? How can you not?! They really do teach you. They teach you about the now. While you?re sitting there going, ?When I get through treatment, am I going to live? What am I going to do? What?s going to happen? Has it come out? You can get pulled back just sitting with your dog. Just getting back to, ?You know what, let?s just sit her today and enjoy the day. ?Let?s go sit in our little backyard and let?s just?That?s the biggest lesson you learn. He (dog) was present to what I was experiencing at that moment, whatever moment that may be, he responded. That?s the biggest lesson I think anybody learns going through this (cancer). I think if you have a dog, they?re able to pull you back because they?re just happy now. Have a look at them. That?s what they do... You know you?re going through the most frightening situation, and it can just come across you. And having a pet, in particular, G, I found it was very grounding. Just like having another? something else alive that you care about, to just sort of interact with, I felt like that helped me stay positive.   8. Pet as Protector and Caregiver  This category was endorsed by 77% of participants and was formed by 52 helping incidents. During the interviews, participants often referred to their pets as nurses (i.e. ?My furry nursemaid), physiotherapists, and healers and as providing the ?best therapy? they could have had.  In particular the presence of their dog was experienced by participants as greatly contributing to a sense of safety described by such commonly used phrases as on duty, keeping watch and feeling protected. Dog behaviours were also described within the realm of practical  104 care giving services such as helping participants when they?ve fallen, waking them up for meals, work, or medication. Participants seemed to be keenly aware that their cancer experience would have been much more difficult without their companion animal. There were no hindering incidents or wish list items cited by participants for this category.  Illustrative Participant Quotes He really seemed to know when you?re not well and not expect a lot so he would lie there for hours until I think it was either someone came in or he needed to go out or something like that but then he?d come back up and it was like he was keeping watch. He was keeping watch to make sure that I was okay. There was quite a protective thing going on? because if the kids would come and wrassle or anything like that he would be right there and very protective that way? he would start to bark if there was too much rough housing. He was very much the protector.  And the sound of that dog- I always felt I didn?t need a burglar alarm. With my first treatment I came home and I sat down and had my arm like this (out on chair arm) and he (cat) came along immediately to smell my hand- there was a bandage there- And then the second time I had it I was on the bed- my arm just resting by me and he came along and he started licking the spot, and they (the nurses) would switch veins you know- from here to there- (indicating alternating spots on her hand) and so then I watched him and then the third time and every other time whenever I came home he would immediately go to my hand, nowhere else, immediately go to my hand and then he would lick from that spot, even if it had a bandage over it- but from that spot up to my wrist . And then the next two weeks after that he would go over here, he wasn?t just generally licking he was very specific. He would almost corral me and ...then almost herd me to the back to the bedroom- very protective. My bed was very high and she was so tiny and she would stand up and her head was looking up and she will do this to me (gentle nudging movement) ?wake up, wake up- you have to get up?. Many times I think they feel if I don?t get up there?s something really wrong with me, they are trying to protect. 9. Touch  This category refers to the effects of physical contact, touch and petting of dogs or cats for participants. 10 participants (77%) described a combination of 33 HE incidents and 2 HI incidents.   105 Helping Aspects: The sense of touch with pets was experienced as comforting and soothing for most participants, in particular the warmth, softness and affection that flowed so easily from companion animals. The act of petting or touching their pets was also experienced as calming, pleasurable, and soothing.  Illustrative Participant Quotes And then there?s that other part, that warm feeling where he comes in, puts his head on my lap, puts his head on the couch, puts his paw up and you just touch that beautiful warm silky fur and that beautiful handsome expressive face? Just to sit with him and just pet him?Dogs are very calming. If you can pet your dog and with your dog you kind of just.. .things just straighten out a little bit. You could sit with him and touch him and lay with him. It just kind of gets you calmed down and back level again.  It?s the physical touch...it?s being close to them. It?s the warmth, it?s the petting. I find that in the mornings I?ll get up and hold him like this (holding like a baby)- And just cuddling him he?ll put his both paws on my arms and on my hands. Being lonely on my own with this and not having somebody significant in my life- I think this makes up for it.   Well, he?s so soft? and I know my mom used to do that to me when I was little, she would always go like this with my hair (slowly runs her fingers through dog?s fur) and so I do that to him.  Hindering Aspects: At times, this physical contact was also experienced by some as ?too much? and therefore unpleasant or stressful. Participants felt they needed some distance from their pets and separated themselves from them for periods of time. This did induce some guilt in themselves however, participants reported that they sensed their pets understood and/or were not perturbed by this.  Wish List: There were no wish list items in this category.  10. Unconditional Love and Devotion  All participants at some point mentioned and described the term ?unconditional love? in reference to their companion animals. 77 % of participants (10) clearly described how this love  106 impacted their cancer experience in helpful ways. They felt that their pets provided unconditional love on a constant basis that offered healing, reassurance and purpose. A sense of intense devotion was described both toward the pet by the person as well as toward the person by the companion animal. These poignant incidents were described in general with tenderness, awe and a sense of good fortune. There were no hindering incidents or wish list items reported by participants for this category.  Illustrative Participant Quotes I just really like having their presence with me cause they?re quiet and you know how dogs just love you intensely, and you can just feel it, they do? and your dog just puts his head on your lap and looks at you and its just so comforting to have that loving presence there with you. You know that this dog will never do anything to hurt you. All he wants is to love you, that?s all he wants.  Give him some food, give him some water, give him a walk?but he just wants you to love him so you automatically feel that outpouring of love without thinking about yourself. I just think the love that surrounds him, this aura around him, this feeling around him is healing to me. I would always be sending him love (during treatment) from my heart and in my thoughts, I would always be sending him love. And I think sending that love? also helped the healing process.  11. Existential and Spiritual Factors  This category represents aspects of the participant ? pet relationship that transcended the practical or corporeal. 69% of participants reported a combination of 22 HE incidents, 5 HI incidents and no wish list items for this area. Participants described feeling deeply and non-verbally connected to their pets in ways that brought spiritual healing, life meaning and a sense that this dog or cat was brought into their lives for a particular reason to stand by them in a time of suffering. Concerns and explorations around mortality were experienced for some as meaningful and important. For others these concerns were a source of worry, in particular fearing  107 what would happen to the pet if the participant died as well as fearing how they themselves would cope if their pet died.  Illustrative Participant Quotes That would be nice if I met B on the other side.. That would be nice? I feel that society has got to realize that for many of us that?s our family, that is the family you have, really it is. I had times when I?m just so low and I think that if I didn?t have this little creature leaning on me next to the couch I don?t think I could go on at times. I?m so down at times and feel so fragile, and there?s no one I can talk to at all, that is people have backed off- I do know that I probably couldn?t go on. I would be considering doing away with myself? but when you have pets- regardless of what happens there?s somebody I have to look after? What I found, that with G (cat) supporting me I was able to be within myself and have my soul, really be in touch with my soul. And heal from inside out in that way.  I was hospitalized for six days, I wasn?t with him (cat) for six days when I was having radiation, and quite frequently during the day, I would just give a silent hello to him and I received hellos back. I could feel his presence. I never believed in reincarnation before but she (current dog) is N - (prior dog that passed away). The way she is. She came back to help me.  12. Family Members and Finances   This category refers to instances where participants felt that the pet was impacting some of their family members, as well as their financial circumstances. These examples were reported by 9% of participants and had an equal number (13) of helping and hindering incidents.  Helping Aspects: Several helping incidents were described whereby participants felt that their children or spouses got emotional support and a sense of usefulness or purpose from their pets. The shared love for the pet was also experienced as a relatively rare source of bonded focus outside the realm of cancer.  Illustrative Participant Quotes It was really good not only for my own kids but for the foster kids that we had because again F (dog) was a safe place and he would feel their angst or whatever and climb up  108 on their laps and lick their face and give lots of nurturing where they would feel really out of sorts and nobody could really get to them- well he could get to them. I think T (dog) was a real help to M, my eldest (dtr) because she told me later she was depressed that year ? I didn?t know she was ? she was fearful and depressed and I think T- I know he really helped her. He would be there with her, T and her- she was really fond of her horse too so she had that going, and they helped her. Hindering Aspects: Participants reported additional financial and practical strains that were put on family members to provide care for pets, thereby adding stress to the individual?s and family member?s lives in a time of already heightened duress due to the participant?s illness.  Illustrative Participant Quotes Her (the dog?s) pancreatitis is acting up so she?s on more medications and ?I think she (dog) has fleas, look at this?. So my husband is like, oh my g-d, And I couldn?t do anything. Like I had 2 drains in, you know hematoma, so he spent the whole day in the bathroom washing the dogs and then the whole rest of the day doing laundry cause like they?re on the bed with us, they?re everywhere, all their beds, so he threw out all the bed, he went and bought new beds, he vacuumed, dusted, did the laundry- thank G-d we don?t have the carpet, but just everything, the entire house, he scrubbed the entire house. I look at the poor guy, he?s just like, ?What next??, What?s next? He?s like ?Dogs, can you please get it together? To walk him an hour is $40.00 ?and that?s when I told my husband how much it was- he said ?well I can hire someone to work the evening for that and I can be home and do it.? So we did do that for a few weeks but it was quite expensive? but you don?t really want stress in your life either at this point but that was the only thing that really was hard. Wish List: Similarly to wishes from other categories, participants would have appreciated government funded dog walking and/or pet care services for sick people.  13. Caretaking of Sick or Dying Pet  Six out of 13 participants endorsed the incidents in this category, the lowest participation rate of all the categories. This category was also unique in that it had more hindering (13) than helpful (5) incidents therein. 6 participants reported these incidents, 3 of which reported only HE incidents, 1 of which reported only HI incidents and 2 who discussed both HE and HI incidents.  109 From the helping point of view, participants expressed that they found satisfaction in providing care to their needy pets. From a hindering point of view, the women felt just the opposite. The added stress of caretaking a sick pet when one is ill themselves proved to be overwhelming both emotionally and physically to several participants whose companion animals were ailing.   Helping Aspects:  Participants felt that caring for their sick pet resulted in a sense of duty, purpose and feeling of being needed. The combination of being ill and caring for a sick companion animal sometimes also proved to be distressing, yet at no time did any participant mention that they wished they didn?t have the pet while they were ill. Three of the participants experienced their dog?s death during their own experience with cancer. This was devastating to all of them but in very different ways. The first two women experienced their pet?s deaths in more positive ways, one even as a peaceful goodbye where she was deeply saddened but also amazed at her dog?s continued selflessness in his last moments of life. Even when he died, when he was on his last breath, when I came home from work- we knew it was coming he was so sick. So I came and we had him on our bathroom floor, we?d made a little bed up for him so he?d be close by to our bed and he was lying there and I came into the bathroom and that silly little dog got up off of his death bed basically and he had to give me a tail was and then flop back down again- he used every little ounce of strength to do this? when I came in he mustered up enough strength to get up off his stomach and shake a tail and fell back down and that was the last he ever did get up. He was just so bonded- he had to do his task.  When we were getting ready to put him down and my husband said, ?You don?t have to do this. You don?t have to be with him? and I said to him ? Oh no, I don?t care how I?m going to feel? I said, ? He went through that summer with me?. I said, ? I was not going to let him go through that alone, I was going to be there for him. That was really important to me.  I really wanted to take care of him the same way he took care of me.   Hindering Aspects: These incidents involved the emotional and physical strain of caring for a sick pet when one is sick themselves. In particular, the second participant who had to care for a dying pet while she faced cancer found the experience draining, guilt-provoking and at  110 times, unbearable. She related feeling desperate, guilt-stricken, and incompetent, so much so that she bitterly punished herself for being an unfit companion to her best friend. These feelings stayed with her for years after her pet died when the interview was held. It was heart wrenching to hear this participant?s self-contempt around this issue, considering her own poor prognosis and long, painful battle with cancer. She stated:  I let him down twice. He didn?t deserve the ending that he got. He deserved to have somebody who was well and who could be there and commiserate with him and send him on his way happily, instead of sick in the other room where we?re both asleep during the day because we are both sick and not getting the attention he deserved.  If you?re getting sick, I don?t know which is worse.  To have a dog that?s also sick and old. When I?m feeling okay I could have handled, but at the end I was carrying him up and downstairs.. No matter how you feel, you?ve got to. And taking him out and then you?re sick and you?re losing weight and you?re cold all the time and the weather is miserable and you?re having to go outside and it was awful. It was awful.   Wish List: One participant stated that she wished there were someone to take care of her sick dog at her home, as the only option she was given was to give him away.   Summary of Chapter 4  In this chapter I have conveyed the findings of my research in 3 sections. Firstly, 13 participant personal accounts that outlined their experiences with their pets and their experience with cancer were presented. Next participants? definitions of wellbeing were reported in thematic representation. Finally, the 13 categories developed from the data were described and illustrated with verbatim quotes. This included 487 helping incidents, 109 hindering incidents and 12 wish list items that emerged from the data. In the next chapter, these findings will be discussed in light of the related literature and implications for theory, research and clinical practice.     111 CHAPTER 5  Discussion  Overview  The stories and experiences of the 13 women who participated in this research were voiced and represented in this study to honour and learn from their experiences of having a pet while having cancer. In this final chapter I will discuss the findings in relation to the existing research and theory presented in Chapter 2. Through a careful exploration of the results and their relationships to the literature, I will demonstrate the ways in which this study supports a great deal of existing theory and research, counters some of it and adds new elements that can serve to broaden our understanding of the role of pets in the human experience. Next I will delve into the resultant implications for research and policy and address the impact of the interviews on the participants and myself. Following this I will discuss the implications for the clinical and theoretical domains of psychosocial oncology and counselling psychology. Finally I will address the limitations of the study.  Comparisons to Relevant Scholarly Literature  The findings from the study substantiate multiple academic, empirical, and theoretical works in the areas of anthrozoology, social work, veterinary medicine, nursing, psychology and psychosocial oncology. The results strongly support theoretical and research based propositions regarding the socio-emotional and health benefits of having a pet. The data confirms topics from the literature regarding social support, attachment theory, existential psychotherapy, coping, psychosocial oncology, non-verbal communication, and the human-animal bond. These are found woven throughout the personal accounts, the categories and the incidents. There are also some results that challenge the literature, as well as results that are unique and new. The  112 associated topics from the literature will be reviewed within the following areas that come directly from the findings and follow their order of representation in Chapter 4: 1) Participants and their Pets; 2) Participant Personal Accounts; 3) Defining Wellbeing in the Context of Cancer, and 4) Categories and Incidents.  Participants and their Pets  Participants in the study were all women whose ages ranged from 34 ? 68, with one participant?s age unknown, resulting in a mean age of 52 years. Out of the 13 women, 8 had breast cancer. While the criteria for study participation had no limitations on age or tumour site, the results do mirror the Canadian statistics whereby 88% of people with cancer are over the age of 50 and by far, the highest occurring tumour site for women is breast cancer (Canadian Cancer Society, 2013). The women, by and large, were well educated and were or had been employed in a range of employment settings. It has also been suggested that women with breast cancer are the most highly researched group in the psychosocial oncology literature (Stanton, 2006) and this study follows suit, with 8 of the 13 participants dealing with breast cancer.     Similarly, the pet demographics of the participants in this study appear to be in line with Canadian statistics. The Canadian Veterinary Medical Association (2009) reports that while 56% of Canadian homes have a pet at home, usually made up of dogs and/or cats, owner behaviours such as regular veterinary visits with dogs suggest that more attention is paid to canine companions than any other types of pet. While several participants had other pets living in or around their homes, 12 out of the 13 participants reported about relationships with dogs and only one about her relationship with her cat. Other studies suggest that the highest levels of social support experienced by pet owners are those that have canine companions, followed by feline  113 companions (Bonas, Mcnicholas, & Collis, 2000). Thus the small sample in the study seems to reflect the Canadian experience regarding type of pet and perceived support.  Walsh (2009) reports that while the great majority of people experience their relationships with their pets as strong emotional companionate bonds, the significance is more strongly seen for women living alone. Because no men participated in the study, this finding cannot be considered. Nevertheless 4 of the 13 women lived alone while the remaining 9 lived with others. Regardless of whether or not the women lived alone, there did not seem to be any significant differences in the level of bond with their pets. In addition 7 of the 13 participants had no children and 6 were parents. Empirical research and multiple surveys in Europe and North America suggest that pet owners consider their companion animals to be members of their family (Cohen, 2002; Wells, 2009). Similarly in this study all the women readily identified their pets as family members. Whether or not they had human children, pets were referred to as their kids, ?fur babies? and other terms of affection for children.  Participant Personal Accounts The priority of the first phase of the interviews was to gain some understanding of the context for the participants? human-companion relationships and how they contributed to or hindered a sense of wellbeing as defined by the participants themselves. What emerged instead was a strong need on the part of the participants to speak at length and in detail about their pets. Without solicitation, every participant spent considerable time describing the story of how they acquired their pet as well as their pet?s unique quirks and characteristics. In addition if the pet had been ill or died, a full description of these events was given. The women who lost their pets described symptoms of grief and loss that were consistent with the loss of a close human being  114 such as spouse, family member or friend. This grief often was exacerbated by their own struggle with cancer.  The 13 personal accounts were strongly aligned with social support literature from psychosocial oncology and attachment theory literature, both of which will be discussed in a following section. In all the participant?s descriptions there were themes of special connections and fortuitous acquisitions of their pets. The women spoke with much gratitude, delight, and depth of emotion, often shedding tears and laughing while recounting their stories. These were the moments in the interviews where I found myself particularly drawn in emotionally. I likened this to moments in my counselling work where I felt that clients were sharing crucial elements of their lives through story and making meaning in my presence. Through the process of data analysis I realized that these personal stories were being constructed to help make sense of the participants? life changing experiences with cancer. As Riessman (2008) explains, personal narratives include information that is ?selected, organized, connected, and evaluated as meaningful for a particular audience.? During these sections of the interviews, the women seemed to embody their experiences, making new meanings about their relationships with their pets.  All of the participants reported that this was a subject that few people had ever inquired about in any detail.  Defining Wellbeing in the Context of Cancer  As discussed in previous chapters, the closest definition of wellbeing found in the literature pertinent to this study comes from Lent (2004). Here the author focuses on the human capacity for finding and building resources and adapting to hardship, resulting in a subjective sense of wellbeing. While some of the participants in this study struggled to define wellbeing in the context of having cancer, 9 of them illuminated six categories that are reflective of Lent?s  115 theory. In their efforts to describe the elusive concept of wellbeing, participants explained that they recognized and actively sought out sources of wellbeing within themselves and in their environments. These included: the benefits of nature; humour; peace of mind; spiritual support; remaining positive; a resolve to heal from their illness; focusing on healthy eating and physical exercise, and seeking purpose and growth from their cancer experience. Finally, strong social support, which has always been a mainstay of wellbeing in the literature (Helgeson, 2003; Lent, 2004), was among the strongest elements that participants described about their companion animals. Participants overwhelmingly reported the awareness that their cancer experience would have been ?significantly harder? or ?more difficult? if they hadn?t had their pet by their side.  Helping Categories    As discussed in the literature review, much research suggests that companion animals can moderate the effects of stressful life events such as divorce and bereavement (Brodie & Biley, 1999; Walsh, 2010). The helping incidents and categories that emerged from the data concur with these findings as applied to the stress of living with cancer. In this study a total of 596 incidents emerged from the interviews, comprised of 487 helping incidents and 109 hindering incidents. This profusion of positivity may be in part due to the fact that the study participants were all volunteers who love their pets, but it likely also reflects the strength and support of the relationships that people tend to have with their companion animals. This finding is congruent with conclusions made from research in the fields of anthrozoology, veterinary medicine, nursing and social work (Walsh, 2009; Wells, 2009).   Support in the literature can be found for all 13 categories. What is perhaps most striking about the categories and their content are the similarities between what participants value about their pets and what people tend to appreciate about their human relationships. Of the 13  116 categories, 12 refer to relational elements that could be experienced interchangeably in both types of relationships. The data in these categories are consistent with the massive body of psychological literature on relationship, a domain that focuses almost exclusively on the human-human relationship (Knight & Herzog, 2009). In fact, the single category that deviates from this is entitled ?How Pets are Different from People?, and in this category, participants refer primarily to relational abilities in their pets they did not find present in their human support system.   Because the categories are so relationally based, there is overlap within them. There was a great deal of nuance within the incidents, in particular those that focused on companionship, social and emotional support, touch, love and pet as caregiver. Woven throughout these and other categories were themes of intimacy, support, bonding, physical closeness, and trust. I will explore the two major areas in which all the categories and incidents are linked to existing research and theory. These areas are Social Support and Attachment theories. Following this, I will focus on 9 of the 13 categories where other relevant links, differences and additions to the literature were found.  Social support.  The term social refers to the interaction of living organisms with other organisms and the experiences and behaviours of individuals in groups. Social refers to living species in general, and even includes the tendency of types of flora to group together and ?form cooperative and interdependent relationships with others.? (Merriam Webster, 2013). Somehow when the term ?support? follows the term ?social? however, organisms other than homo sapiens seem to be dropped from the equation. It is concerning that the psychological domain focuses only on social support that comes from other human beings. Bonas, McNicholas and Collis? (2000) study  117 indicates that in the realm of support, human-companion animal relationships are highly comparable to human-human relationships. My study, along with many others in the HAB literature, confirms that people with pets regularly experience their companion animals as sources of significant comfort, assistance, reassurance, and emotional sustenance, namely social support.   The categories in this study show many linkages to the psychosocial oncology literature regarding the benefits of relational fulfillment and emotional support for good coping and adjustment during illness. Individuals facing cancer commonly experience anxiety and depression, loneliness and isolation, and the need for increased support (Helgeson & Cohen, 1996; Massie, 2004). Participants in the study often commented that they did not feel lonely with their pets around them. Several even acknowledged the awareness that ?they could have been lonely? during this time. Pets were cited as one of the primary reasons participants did not feel isolated while at home dealing with side effects from surgery, radiation or chemotherapy.  In Folkman and Lazarus? frequently cited Ways of Coping Inventory (1984), the seeking out and receipt of social support is one of the five coping patterns discussed in the authors? oncology adaptation of their theory. Cicero, Lo Coco, Gullo and Lo Verso, (2009) found that cancer patients who perceived sufficient receipt of social support experienced significantly lower levels of distress and coped better psychologically. In my study this was apparent. The participants repeatedly reported positive experiences of support from their pets: the provision of care, concern, affection, assistance and companionship throughout their cancer experience. As discussed in Chapter 2, Helgeson (2003) explains that higher levels of quality of life are more strongly related to a person?s perceived support than they are to observable support exchanges, what the author refers to as received support. Thus in Helgeson?s paradigm, pets clearly  118 constitute part of the participants? reservoirs of perceived social support. In many cases this appeared to be even more so than the human beings in their lives. In the category ?How Pets are Different from People?, participants explained that the support they received from their pets was unique and unlike anything available from the human beings in their lives.  The last area of social support to be explored is the topic of pets functioning as social lubricants for their owners/companions. In the work of McNicholas and Collis (2000), it was found that the presence of pets or animals increased social interaction between and amongst people. They observed a rise in social approaches to people in public parks when accompanied by an animal. This finding was most noticeable when the animal in question was a canine. This finding has been replicated and further considered in relation to the breed of dog accompanying people. Invariably participants in my study described this same type of social lubrication provided by their pets as illustrated by the following quote: ?When you?re out on a walk, people like to talk to them or, you know, so they?ll talk to you a little bit, so I get a bit more interaction. Which is good because I?ve noticed like I think I?ve been out of sort of a social world for quite a long time now and ..this way it gives me the opportunity to talk to other people ?cause they want to talk about the dogs or tell me about their dogs or whatever?? This is significant because loneliness is a well-known problem in the cancer world (Preyde & Synnott, 2009).  Attachment theory. Attachment theory (Bowlby, 1969; 1988; Ainsworth, 1978) is the cornerstone of psychology?s understanding of the development and maintenance of intimate bonds and close human relationships. The original theory identifies four features of the attachment process that have been broadly studied within the context of infant-parent relationships, intimate love relationships and more recently within human-companion animal relationships. Three out of  119 these four features are clearly present in the personal accounts and categories of this study and will be explored. The fourth feature, ?Secure Base? was not observed as readily in the data. Of particular note is that many of these elements were evident in the behaviours of both the participants and their pets.  Proximity Maintenance:  ?Companionship and Presence? was the most highly endorsed category in this study, essentially describing proximity maintenance as defined by attachment theory. All 13 participants focused on the fact that their pet was always there. They repeatedly commented on how helpful and comforting it was to have their pet physically close by to them throughout the highs and lows of their cancer journeys. As shown in the ninth category ?Touch?, endorsed by 10 of 13 participants, pets were cuddled, held and touched providing warmth and security similar to that of a parent or a romantic partner. ? Wherever I was going, that?s where he wanted to go?You were never lonely, you were never lonely and you could have been. When you?re so sick and you?re in a house by yourself you could get lonely pretty quick, I would think. But you never were because you never were alone.?  Separation Distress: Similarly, participants did not want their pets to be far away. Despite the fact that many of them found the caretaking of their pet to be stressful at times, the thought of being without their pet was not desirable, indicating separation distress. The women also grieved the illness and/or death of their pets, often causing mournful longing and sadness.   Safe Haven: The 8th category, ?Pet as Protector and Caregiver? was endorsed by 10 out of 13 participants and provided clear linkages to elements of ?Safe Haven? as described by attachment theory. Participants described feeling secure with the knowledge that their pet was close by. They perceived their pet to be alert and on guard for them in ways that  120 increased emotional and physical safety, as evidenced in this quote: ?My pets made me feel safer. If I was home alone and also when I went for walks they would always be with me. And I live in a rural area so I feel safer being with my dogs. Walking was the only exercise I could do? and they made me feel safe.?  Research on attachment and companion animals also provides strong linkages with the results of this study. The primary researcher in the field, Kurdek (2008) demonstrated that pet owners seek closeness to their companion animals and find this proximity to be of comfort. The 13 participants in this study described the same type of comfort received from closeness with their pets. They trumpeted the related benefits of healthy attachment to their companion animals. This seemed to occur whether or not participants were living alone or with someone, had children or were childless. This also supports Hazan and Shaver?s (1987) findings that attachment occurs beyond infant and parent, playing out in romantic relationships, friendships and more recently in companion animals (Kurdek, 2008; Serpell, 1996). Attachment to pets may serve to mitigate additional stressors that could result from living alone with an illness and feeling unsafe or more vulnerable than prior to one?s illness.  Helping categories in relation to research and theory.  Companionship and presence.  This first and most strongly endorsed category indicates that participants found that the presence and companionship from their pets helped them face the myriad psychological, emotional, interpersonal and intrapersonal challenges accompanying cancer. In her longitudinal study of elderly people with companion animals, Enders-Slegers (2000) reported that participants believed their pets helped them to fend off feelings of loneliness. The participants in this study regularly voiced that the presence of their pets helped them minimize feelings of isolation. Many  121 of them described their pets as being ?on their cancer journey with them? and/or ?sticking by their side through thick and thin.? In this way it appeared that the women felt they were not going through the difficult experiences of diagnosis, treatment and side effects alone.  For those participants whose only live-in companion was their pet, that relationship seemed critical. As such, wish list items in this category included the hope that pets could have visited them while in hospital and accompanied them in public places. It is possible to liken the denial of their pets visiting in hospital to the denial of family member visitations, something that is only done in the most dangerous health situations. Even when there is significant concern for contagion, close family members are permitted to see their hospitalized kin with protective coverings or in separate rooms. One participant talked about visualizing her cat and sending love to him during or while waiting for radiation therapy. Three others found the time when they were separated from their pets to be painful and demoralizing. Finally one participant who could not care for her pet due to her own illness was offered by Social Services to have her pet relocated to another family. This option was both insulting and devastating to her. If in fact, as the existing literature and this study suggest, people are experiencing their pets as next of kin (Beck & Madresh, 2008), then it becomes unimaginable to consider sending a family member away or denying a cancer patient access to their closest loved ones. Unfortunately this may be a regular occurrence for people with illness who have close relationships with their companion animals.   Emotional and social support. Within the multifarious areas of relationship science, it is widely accepted that good emotional and social support are key elements in mental health, wellbeing and quality of life (Reis & Rusbult, 2004). This second category, also endorsed by all participants, demonstrates that they clearly experienced their pets as supportive in both emotional and social dimensions. The social  122 support component was covered in a prior section so I will address emotional support here.  It is well established that the diagnosis, treatment, and survivorship of cancer brings with it considerable emotional distress (Bultz & Carlsson, 2006). The incidents in this category are littered with examples where participants felt emotionally supported and cared for by their pets. They explained that their pets were able to soothe them during times of emotional suffering and were capable of helping and accompanying them through moments of anguish and sorrow. Four participants talked about crying with and talking to their pets for comfort during times of distress and emotional upheaval. One explained: ?I would sob and sob?.and he would lick my tears?? Almost all the women expressed the experience of being calmed down by their pet during times of agitation. This calming quality seemed to occur on both psychological and physiological planes, supporting the HAB literature regarding the health and psychosocial benefits of pet ownership (Wells, 2009). Participants loved and felt loved by their pets. They reported experiencing this love and devotion as comforting, reassuring and healing. Finally, this category contained multiple incidents where participants described feeling reassured by their pets that they were ?still the same person? as before their cancer. The need for this type of reassurance is well established in the psychosocial oncology literature (Preyde & Synott, 2009). In their meta analysis of psychosocial interventions for cancer patients they found that patients? primary psychosocial challenges included altered self- perceptions and problems interacting with family members and significant others. As a result of the disease and its treatment, cancer patients regularly face substantial changes in their appearance and abilities including disfigurement, hair loss, constant fatigue and difficulties with concentration and clarity of thought. Understandably any of these changes might be as difficult for family members and significant others as they are for the patients themselves. Somehow however, these types of  123 changes do not negatively seem to impact the behaviour or perceived feelings of pets toward their human companions. The participants found this fact to be settling and comforting given the regular, multiple physical and cognitive changes they faced. As stated by a participant: ?When my hair fell out, with B (dog) it?s just ?oh hey you know you?re the same person? so? I felt that was really reassuring you know. Just to help me feel like the same person, so emotionally definitely I felt like he was a big support.?  Purpose and role. Having cancer often involves challenging one?s basic assumptions about self and the world. Cancer patients tend to feel inadequate, vulnerable, less in control of their lives and more confused about their identity and role, as Preyde and Synnott (2009) reveal in their meta analysis. In this third category with 100% participant endorsement, the women described feelings of purpose and competence because of their companion animals. In particular, they spoke of their ability to continue to provide nurturing to their pets. For both the mothers and those without children, all expressed a satisfaction felt from being able to care for their companion animals in whatever form they were able. This finding is consistent with current theoretical research on the need to nurture. Walker (2011) explains in her book about childfree living, that the human need to nurture and care for others is fundamental, but that it can be expressed through relationships other than parenthood in fulfilling ways. In this category, participants provided multiple examples of feeling purposeful through nurturing their pets. They experienced a positive sense of personal purpose and goal achievement by feeding, walking and tending to pet?s daily needs.   Social work and health care researchers have also acknowledged the importance of altruism and a sense of competence in helping others when people are ill (Ironson & Powell,  124 2005). Participants conveyed that looking after someone/something else other than themselves when they were ill helped to maintain normalcy and a sense of competence and purpose: ?It gave me some focus other than myself, making sure that he was fed.? This suggests yet another potentially unrecognized benefit of pet ownership during times of adversity or illness.  How pets are different from people. When asked to specifically explore which aspects of their pets helped and/or hindered their socio-emotional wellbeing, 12 of 13 participants readily identified differences between their companion animals and the people in their lives. All these differences were aspects of pet behaviour or characteristics that were superior to those of human beings. This finding is linked to the research reporting that people feel often feel closer to their pets than they do to family members, in particular during times of personal challenge (Albert & Bulcroft, 1995; Beck & Madresh, 2008). The results of this study perhaps flesh out the reasons for this to be so common.   Multiple studies indicate that people often experience the presence of a companion animal as more effective in providing comfort and decreasing stress levels than the presence of a friend or partner (Bonas, McNicholas, & Collis, 2000; Walsh, 2009). In this study pets were described as ?more grateful?, ?not manipulative or phony?, ?more easy going than people?, and as behaving without judgment or guilt. They felt their pets didn?t tell them what to do or cause any drama and experienced them as completely forgiving, something that was lacking in the people in their world. One can easily see why people, particularly those who are ill and vulnerable, might find the company of their pets more palatable. Participants also described their pets as offering a type of healing or presence simply not possible from other human beings: ?I had a surgeon, surgery, the chemo, and my oncologist and nurses, you know and pharmacists and then I also went to an acupuncturist and  125 did hypnotherapy and went to a naturopath and all these people, and I had a friend doing Reiki for me and people praying for me? with my cat, I was just able to cuddle him. And it was just a healing that, I can?t express it, it was a healing in my own home. And it was different, totally different.?  Health and pain management.  Participants recognized that their pets offered increased opportunities and motivation for physical exercise and movement. Participants noted that they would not have walked as much if they didn?t have to take their dog out.  Likely, at the very least, their cardiological health would have benefitted from this increased activity as has been shown in the findings of Friedmann and Thomas (1995).  Participants also marveled at the ability of their pets to assist with pain management. It is well known that pain is primarily perceptual and is best assessed by self-report (National Cancer Institute, 2013). Pain management is a highly individualized phenomenon often requiring a combination of techniques and approaches. The women in the study explained that their pets were able to assist them with pain management through distraction, holding, and presence. Their dogs allowed them to squeeze them until pain subsided and did not leave their side until there was some relief:  ?He?ll just let me squeeze his leg until that painkiller would end. It amazed me, of course and it helped me to touch him, and mostly I would get his leg and just grab and not, not a sound would come out of him.? It is possible then that pets may be underutilized sources of pain management for patients with bonded animals.  Pet intuition and adaptability.          This category, endorsed by 11 of the 13 participants represents previously unreported findings in the HAB literature to my knowledge. Much has been written, across many  126 disciplines, anecdotal reports and informational books about the area of animal emotion. It is well documented that animals other than humans display joy, sadness, grief, and empathy, as well as have complex social networks and methods of communication (Moussaieff -Masson & McCarthy, 1995). The women in this study spoke of an intuitive sense they perceived from their pets regarding their needs. I have lovingly called this PSP (Pet Sensory Perception), a term that participants responded quite positively to during the member checks.  Participants reported feeling surprised and amazed by their pets? intuition and immediate behavioural adaptations once they were diagnosed with cancer. ?He would just have such intuition, knew when you were sick, would come up, wouldn?t bounce on you, he would come up and just lie right there and stay very quiet and look up at you. I can just picture him- looking up at you to make sure that you?re there.?  The notion that pets have an ability to read their human companions has been explored by Sheldrake (1995, 2002) and other researchers. It has been found that dogs, for instance, seem to know at least 30 minutes in advance of when their ?owners? are coming home from work or outings, regardless of changes in their time of departure.  The capacity of pets to adapt to their human companion?s needs is a fascinating area that warrants further research and exploration.   Being positive and in the moment. Positive psychology has demonstrated that optimism and life meaning help us to cope with the management of life?s challenges, including serious illness (Ironson & Powell, 2005). In their study, Cicero, Lo Coco, Gullo and Lo Verso, (2009) found social support to be positively associated with fighting spirit and an optimistic outlook, and negatively associated with a fatalistic attitude toward illness. In this category, endorsed by 11 of 13 participants, the women described their pets as ?keeping them going?, keeping them ?focused? and providing inspiration  127 and ?positive mental attitude?. These were often linked to a sense of being balanced, grounded and ?in the moment.? Current research on the benefits of mindfulness training support these findings. The work of Jon Kabat-Zinn (1990) involving Mindfulness Based Stress Reduction (MBSR) is being broadly researched and found to be of great success for people suffering from anxiety and depression and a host of other conditions. In their study involving 59 patients with breast and prostate cancer, Ledesma and Kumano (2008) found that MBSR participation was found to increase quality of life and decrease stress for the great majority of subjects. It is possible that companion animals naturally provide some of the same benefits offered by mindfulness practice, or perhaps that some non-human animals have more innate capacities for mindfulness.  Touch.  Caring physical touch is an essential factor in both healthy attachment and social support. It is also often cited as a primary positive aspect of having a dog or cat. There is ample evidence indicating that both the human and pet experience health benefits such as increased oxytocin levels and lowered blood pressure and heart rate from touching, cuddling, petting and holding each other (Miller, Kennedy, DeVoe, Hickey, Nelson & Kogan, 2009). Participants explained that touching, snuggling and stroking their pets helped to bring warmth, calm and comfort into their experience of cancer. They perceived that the pets experienced similar positive responses as both readily sought out this physical contact. ?It sounds weird but just to cuddle with him- and I find giving him a massage relaxes me. It?s just that slow repetitive motion of doing it, and being quiet and him being quiet and calm - it?s very therapeutic on it?s own.?  Research in therapeutic touch (TT) in cancer care has shown that, despite the need for more empirical support, the gentle laying of hands in TT as a supportive care intervention is  128 highly beneficial for many patients (Stephen, Mackenzie, Sample, & Mcdonald, 2007). Even more relevant is the reminder from health care specialists in oncology such as Dr. Shapiro (2013) that touch and affection among couples and family members during cancer is paramount. In their interactions with each other, human beings and their companion animals seem to know and act upon this instinctively and without fail.  Existential and spiritual factors.  The loss of or difficulty in experiencing relational fulfillment may be a significant source of distress for persons with cancer. These struggles may stem from the inevitable desperation that is encountered when individuals develop a heightened awareness of their vulnerability to isolation, death and the responsibility in finding or creating life meaning and connection in times of adversity (Nitkin, 2000; van Deurzen, 2002). This can be exacerbated by the multiple myths and stigmas surrounding both cancer and mental health (Holland, 2004). We have seen in the findings of this category, endorsed by 9 of 13 participants, that many of them felt their pets provided them with a meaning, reason to live, to fight or go on: ?The love for this pet gave me a purpose beyond my illness.?   Existential and humanistic psychotherapeutic theories highlight universal (human) concerns such as the need for relationship and to overcome separateness (May, 1963), the need to be affirmed (Buber, 1923), and the need for meaning in life (Frankl, 1984; Van Deurzen, 2002). For many of the women in this study, their pets clearly provided them with a source of meaning during their cancer experience, one that is often associated with considerable existential suffering (Henoch & Daniellson, 2009). Participants also experienced a decreased sense of isolation due to their pet?s presence, and for some, this presence continued on after the death of the pet.   129 In addition, from a spiritual point of view, many participants talked about a feeling of transcendent connection to their pets. Weaver and Flanelly (2004) suggest that people with cancer who rely on spiritual and/or religious beliefs tend to use more active coping mechanisms and focus on their condition with a more positive and purposeful approach. This was evidenced in several participants who expressed strong spiritual links with their pets. Often they were motivated to face treatment when in hospital or alone by spiritually connecting with their pet, be they alive or deceased. These connections served as sources of companionship and hope that lay outside the physical realm.   Family members and finances. This category, endorsed by 9 of 13 participants had an equal number (13) of helping and hindering incidents, although the HE?s were more strongly supported. From the helping perspective, some participants found that the shared love and devotion to their pet strengthened their partnerships with significant others as a unit against the cancer. Others with children felt that the pets provided a unique source of support to their kids. As Cohen (2002) discusses in her work seeking to discover what people mean when they say: ?My pet is a member of the family?, pets function as family members for the great majority of homes with companion animals. They provide affection and intimacy, are considered in decisions that impact the home and family and are treated like kin in most ways. She goes on to say that this is so ?even if the support they provide cannot be neatly plugged into standard social network categories? (Cohen, 2002). This quote provides an excellent illustration of what was heard by the participants in this study.  Hindering Categories Beck and Katcher (2003), one veterinary professor and one psychiatry professor well known in the anthrozoology field, note that up until recently much of the existing HAB research  130 is derived from studies where human participants volunteered their time and as such, the domain may be biased toward situations where people feel primarily positively about their pets. The professors recommend that future HAB research pay attention to both the positive and detrimental elements of the human-animal bond, as we know little about either. This was an important part of my rationale for using the ECIT method as it specifically inquires about unhelpful elements of a phenomenon, in this case, having a pet while dealing with cancer.  The study unearthed several more troubling aspects of having a pet during illness, thereby challenging the western media?s stereotype of pets always being wonderful and loving companions. Out of a total of 596 incidents, 109 of these were of a hindering nature. Thus just less than one-sixth of participant?s experiences with their pets were experienced as detracting from, rather than contributing to, their wellbeing. 9 of the 13 categories included hindering incidents, and one category had more HI?s than HE?s (Caretaking of Sick or Dying Pet).  The bulk of hindering incidents fell within the emotional realm. Participants expressed that they often worried and felt guilty about their pet?s health and quality of life, and whether or not their caretaking needs were being sufficiently met. The women made comments such as: ?I?m not taking good enough care of him?; ?What if he isn?t walked enough, or gets sick?? and ?I don?t want him to suffer or worry about me.? These concerns were very real for the women. While all participants stated that the positives outweighed the negatives, it is notable that considerable stress was added to their circumstances from worry about their companion animals. As touched upon previously, this was most strongly felt when pets were sick or dying.   When pets were sick, significant additional strain was put on the patient and their family members. They expressed a sense of failure in being able to provide for their pet?s health care needs in the way they normally would have. There were feelings of regret and guilt at times  131 mixed with frustration and being overburdened: ?How can I take care of him when I can?t even take care of myself?!? One participant and her husband whose dogs were both sick while she had cancer felt uncomfortably pulled between meeting the needs of their sick pets and herself. They coped impressively but were certainly faced with increased physical and emotional demands as a result. Naturally this category included wish list items for financially supported programs that help with sick pets when owners are incapacitated.  For the participant whose dog suffered from serious illness and later died, she described the experience as ?hell.? In her search for help in Vancouver, the only assistance she could find was through a social worker and Animal Control Services, both of which stated all they could do was to take the dog off her hands and find him another place to live and die. One can only imagine the devastation of such an offer. Following this interview I searched for any services of this ilk and found there was none readily available. Clearly there is a gap in service that should be addressed by the S.P.C.A., veterinary services, government agency, or private sector.   Other participants described the fear that their pet would die, or that they would die and leave their pet alone and abandoned. While several spoke to family members or friends about caring for their pet if need be, the majority of the time, participants felt uneasy addressing this potentiality with the people in their lives. Zhang and Siminoff (2003) report that many cancer patients and their families fear death, but neither can express those fears to the other for various reasons. The authors cite mutual protection and fear of emotional overwhelm as two of the potential explanations for this lack of communication about death and dying. It seems plausible that the same phenomena may be occuring with people with cancer and their pets.   132 Additional HAB research shows that pets are not always helpful. In Connell, Janevic, Solway, & McLaughlin?s study (2007) of caregivers and spouses of people with Alzheimer?s disease, the authors found that while the majority of partners felt the illness deepened their bonds with their pets, many caregivers also acknowledged that the animals became increasingly more of a strain as the ailing person?s condition deteriorated. The women in this study expressed a similar increasing strain caused from worry, guilt regarding the caretaking of pets as their own condition worsened due to treatment side effects or advancing illness. This phenomenon was most intensely experienced when participant?s pets were ill or dying. Wish list items confirmed this distress, showing that what participants really wanted was someone to take care of their pets so that they could still be with them.  Finally, participants at times were disadvantaged financially and physically due to caring for their pets. They found that feeding, walking, and caring for their pets ate into their already limited energy and economic resources. At times they felt this worsened their sense of weakness or incapacitation: ?I just don?t have the strength, I don?t feel well enough to feed him, it makes me feel useless.? Some of them worried the pet would negatively affect their own health due to infection from their compromised immune systems. Several women and their partners experienced the financial strain of hiring dog walkers to assist when the participant was unable to go out. None of these participants wanted to part with their pets. Their wish list items called for financial assistance in looking after the needs of their companion animals. Recommendations for Future Research Throughout this chapter I have made reference to important areas for future research that emerged from the study?s findings. I will address these and others further here. Because the field of anthrozoology is so young, unexplored, and significant, I found that the process of this  133 research left me inundated with ideas of important theoretical and empirical studies that should be explored by psychology and anthrozoology scholars.  First and foremost, the question of how we see and treat animals and pets as compared to our own species requires much consideration. As Mullin (1999) explains, human beings and animals represent a complex set of relationships. We eat some animals; we live with, love and care for others; we are frightened and disgusted by some; are mystified and fascinated by yet others; and dissect and research others for the betterment of our own species. What of this animal hierarchy? The question of defining personhood is the subject of philosophers and ethical theorists, but also comes into question for pet owners. What rights do companion animals have? What rights do people with pets have? Pets are denied access to most public institutions and places of retail. Only service animals are permitted in such places. In this study as well as others, it is clear that many people greatly rely on their pets both emotionally and physically, even though they are not formally ?service animals?. While AAT is a highly valuable field, there now exists a hierarchy whereby those animals working for humans and their ?employers? are given higher status. Based on the findings of this research, it would be important to further explore the experiences of people who rely on their pets for support yet are denied open access to public places and daily life activities with their companion animals.  Secondly, the field of psychology should explore the impact of companion animals on people with mood disorders, both from theoretical and clinical viewpoints. The findings of this study as well as many others in the HAB strongly support the emotional benefits of pet ownership. This was a small study that focused on individuals with cancer, generally a group that faces multiple psychological, physical and emotional challenges. Many of the helping incidents leaned toward implications that pets helped participants to mitigate anxiety and depression. Only  134 one or two studies considering this point have been done. The impact of companion animals for people with mental health challenges and other illnesses needs to be expanded. A further important area to be considered for psychological research is the role of pets as surrogate/adoptive children in people?s lives. An unexpected finding from this study was the importance of the ?child role? that pets took on for over half of the participants. They benefitted from the nurturing, caretaking, attachment bonds and affection they experienced with their pets. Clearly companion animals are fulfilling the role of child for many individuals whether or not they have human children of their own. Given the growing incidence of childlessness and infertility, pets and the human animal bond may be an area of important consideration for childlessness research. A brief Internet search suggests there is no scholarly work on the topic.  Finally, the notion of pet intuition and adaptability and the term I have coined ?PSP? (Pet sensory perception) form another unique finding that would be a fascinating area of study for psychology and other domains interested in communication, social support and healing. Participants experienced their pets as somehow able to both intuit and immediately respond to their changing needs after diagnosis. These abilities were of great benefit to participants in that they felt they did not need to articulate difficult feelings or needs that were being met by some of their closest companions. What are dogs and cats able to do to help alleviate suffering in such an effortless way, and what can we learn from them about this astounding capacity?  Implications of the Study  Counselling Psychology Theory and Clinical Practice  This study was done in the hopes that some of the findings would serve to develop theory and inform clinical practice regarding the HAB and its place in people?s lives, and thus in the field of psychology.  Well over half of Canadians have pets (Perrin, 2009). There are striking  135 similarities that exist between human-human and human-companion animal relationships and this study found several areas in which participants experienced their pets as providing them with superior support to their human systems. Currently no literature in counselling psychology that directly explores these relationships has been found. Given the apparent import of human-pet relationships, the results of this study concur with multiple researchers and clinicians who are puzzled by the paucity of theoretical, research and clinical attention paid to the HAB by the field of psychology (Hines, 2003; Kurdek, 2008).   The findings of this study strongly suggest that pets constitute extremely significant aspects of people?s lives and relationships, in particular, when they are facing adversity. The interviews were longer than expected; participants were bursting to tell the stories of their pet special pet relationships. Counselling psychology came into being by identifying itself as a profession that took into account the broader socio-emotional factors impacting upon people and their relationships such as socioeconomics, culture and diversity, and privilege and power. It is clear from this study and HAB research that pets are considered to be family members (Cohen, 2002) and sometimes the only sources of support in people?s lives. It is possible that pet owners may have a distinctive culture and set of needs that are not being addressed when seeking therapy. If counsellors do not ask about companion animals, they may be missing salient information about their client?s inner world, constellation, system, support resources, and emotional and practical needs.    Pet bereavement is also a growing reality in the western world. When people lose their companion animals, they often experience the same grief reaction as they would to the death of any loved one (Barton-Ross & Baron-Sorensen, 2007). Individuals may be ashamed that the grief associated with the loss of a non-human is so disruptive to their lives. Academic or  136 employment institutions do not acknowledge this loss. Students or employees who lose a pet may often not be given the same consideration as those who have lost a family member or close friend. Given what we know about the similarities people feel for their pets and the people in their lives, queries and interest in client?s pets would be met with appreciation. It is my belief that counseling psychology is once again the ideal forum to bring forth this important example of diversity by formally welcoming the HAB into the clinical world of counselling.   Psychosocial Oncology   One of the main purposes of this study was to examine the role of companion animals as potential sources of social-emotional support in the lives of cancer patients and survivors. The results overwhelmingly suggest that this is regularly occurring. It is then incumbent upon psychosocial clinicians in cancer care to incorporate pets into their assessments and therapeutic work. Counsellors, social workers, and nursing care providers should educate themselves about the human animal bond and the impact that pets may be having in patient?s lives. Both inpatient and outpatient clients may need additional practical help to look after pets while they are in treatment or hospitalized, or while they are at home but incapacitated by their illness, treatment or side effects. This kind of assistance may include financial resources for help with pet care, feeding, and dog walking.  It is important that human-companion animal relationships at least be considered in the clinical realm of psychosocial cancer care. These relationships may offer an untapped resource to augment the service. Clinicians may find that companion animals offer new opportunities for support and exploration for clients and their family members. For some people dealing with prolonged disease, their pet may provide a unique opportunity to maintain their caregiver role; remain needed and strong, and avoid getting lost in the role or identity of patient.   137 There are also many people for whom the primary source of connection is their pet (Risley-Curtiss, 2010). It may be that these individuals are unable to benefit from these relationships when they are sick in part because professional health care providers pay little attention to them. In such cases, ailing individuals may benefit from assistance and resources when challenges in caring for and/or being separated from a companion animal arise, just as would be done for a patient?s child or needy family member. It would also be helpful to know more about the experiences of patients with a different type of cancer than breast cancer.  Psychosocial research on therapy for cancer patients can benefit from research that explores the complex and unique ways in which people navigate all their relationships including those with their pets.  Public Policy  It is significant and of concern that Statistics Canada does not collect relational or demographic information about pet ownership (Statistics Canada, 2013) and yet the average annual spending on pets exceeds spending on childcare (Statistics Canada, 2013). Pet food and pet health industries do the bulk of survey work regarding pet ownership worldwide. From the findings of this study as well as the bulk of HAB research, it would seem important that the government show interest in such a large portion of the Canadian population and the benefits and challenges of having pets. In addition, B.C. law continues to allow landlords the right to deny pet owners rental of their lodgings. This fact may deny many isolated, sick or needy individuals the ability to fulfill their needs for support and companionship through a companion animal. Many professionals in the animal welfare and business domains are attempting to have this legislation changed. I concur with them.   138  From the health care perspective of the study it seems clear that people who are ill may benefit from and even need to have contact with their companion animals while being treated for their conditions. As such, Canadian hospitals and health care centres should allow greater access to people and their pets. Given the problem of contagion and allergies, I propose that health care facilities have rooms or areas designated for patients who require their pet for support. There is also a substantial need for government and/or private funding for pet care when someone is hospitalized or unable to carry out their caregiver duties to their pets. This way patients could continue to benefit from the social support they receive from their pet without having to experience the additional stress of feeding or walking them when the person responsible for them is incapacitated.  These suggestions are presented from an idealist viewpoint. Given my years of clinical experience in health-care I understand the enormous financial limitations that medical and health-care organizations face. While it may be unrealistic to expect that patient?s pets become a focal point in health care policy and funding, it also seems clear that the complete neglect of companion animals is unfair to patients for whom their pets play an essential role.   Finally, some health care personnel should be trained to deal with animals so that pets do not have to be sectioned off in their own homes when home care support comes to assist a sick person who is highly reliant on their companion animal. In general, there is a growing need for health care and public policy to pay attention to people and their pets, given the number and impact of companion animals in our country (Globe and Mail, August 2013). Process of Conducting the Study  The interviews were emotional experiences for all 13 participants. They noted that they had not talked before about the role their pets played in their cancer experience and the memories and feelings were often very tender. The experiences of cancer described by participants were  139 very wrapped up with their relationships with their pets. It seemed to me that the interview offered an opportunity to potentially construct new identities and meaningful ways of conveying the bond with their pets (Reissman, 2008).   Although the intent of the interviews was not psychotherapeutic, participants expressed that they felt both a sense of relief and emotional catharsis following our discussions. This may in part be due to my natural inclination and experience as a clinical counsellor whereby I tend to employ empathy and collaboration in my interpersonal communications. I did feel a sense of Rogerian (1957) genuine care, interest and compassion for all the participants I met with and communicated this care openly to them. Their relief may also be indicative of the unique form of interviewing often found in qualitative research, one in which Polkinghorne (2005) states ?there is considerable overlap between the skills involved in research interviewing and those needed by counselling psychologists in their counselling and psychotherapeutic work.? He goes on to say, however that the goals of both activities differ significantly. With this in mind, I was mindful to gently bring participants back to the subject matter at hand when we seemed at risk of straying too far off into the therapeutic domain. What seems most pertinent to me is that many of them stated that they had never talked about their pets for such a protracted period of time, and that the subject allowed for the emergence of new and unique considerations from their cancer experience.   I have worked for close to twenty years in the health care field, primarily in palliative care, oncology and long-term care. As a music therapist, I have explored the role of music as an agent of therapy and healing on the physical, emotional and psychological planes. I have also delved into the field of relaxation and mindfulness meditation as supportive interventions in my palliative care and oncology work. Thus I am no stranger to alternative therapeutic forms. The  140 human animal bond and the impact of pets in people?s lives have been the most personally and professionally impactful area I have explored. This is likely because it is the most relational topic of all those I have been drawn to. I have been moved and amazed by the relationships that participants described with their pets, as well as by the power of animals to transform lives and offer hope. As a pet owner myself who is besotted with dogs, cats, horses, cows, deer and pigs, I have developed an even deeper gratitude for the dogs in my life and to the animals in my surroundings.  Limitations of the Study  All research has its limitations. In particular, in the field of relationship science and psychology, the nature of studying phenomena, constructs and creatures that have constantly changing variables acting upon them is often poorly represented by quantitative research. For this reason, I chose a qualitative method that I believed to best suited to the subject matter at hand. ECIT provided an excellent format for exploring the benefits and drawbacks of having a pet while dealing with cancer. The method however, generates a large body of data, some of which is not fully represented in categorizing themes from the incidents and context questions.   Secondly, the results of this study cannot be generalized to any group. The number of participants in the study was small and included only women. Thus, we have not learned anything about the experience of men with cancer who have pets. The type of pets was limited as well. Twelve of 13 participants spoke about their dogs and only one about their cat. A few of the participants briefly discussed the impact of horses and other farm animals, however, while the findings are reported with the term ?pet? and ?companion animal?, the data is in actuality reflective of numerous dogs and one cat. I also did not ask about the type of dog or cat that  141 participants had, and since the interviews, I have seen that the literature does explore differences in the human-canine bond based on breed.   Finally, because the participants were all volunteers for study, I likely was not exposed to people with cancer who found their pets to be disastrously troubling throughout their illness, or even those who had pets and didn?t really care for them but had them for other reasons than companionship or because of another family member. Future research in the area will hopefully expand on some of these limitations.  Conclusion The young but fast growing field of anthrozoology illustrates the enormous impact that non-human animals and human beings have on each other. This study demonstrates that the lives of the13 participants in this research were greatly affected by their pets while they went through cancer. In support of the findings in psychosocial oncology, pets are seen as providing four out of five of the psychological needs as found in Helgeson and Cohen?s (1996) meta-analysis: 1) enhancement of self esteem; 2) restoration of perceived control; 3) making meaning of the experience; and 4) emotional processing.  The research offers new insights for theory and clinical practice. Pets may be able to intuit and respond to their human companion?s needs in ways that have not been explored. People are connecting with their pets on spiritual levels that are of benefit to them when they are ill. They are sources of intimacy, meaning, and pain management. In addition, it is clear that many people with cancer are relying on their pets for the much-needed social and emotional support required to cope with serious illness. It is also significant that cancer patients may require financial and/or practical assistance for pet care needs in order to continue to benefit from that support.  142 The primary goal of this research study has been to explore the meanings, benefits and challenges of having a pet during times of distress and/or illness. In my attempt to bridge some of the gaps that were identified in the HAB and psychological bodies of literature, this study demonstrates the great significance of pet relationships in the lives of the 13 participants facing cancer. This small study has illuminated some of the cogent elements related to the poorly understood and under researched phenomenon of pet ownership during illness.  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Therapeutic value of equine-human bonding in   recovery from trauma. Anthrozoos, 21(1), 17-30.  Zhang, A.Y. & Siminoff, L.A. (2003). Silence and cancer: Why do patients and families fail to    communicate. Health and Communication, 15 (4), 415-429.  Zheng, L. (2010). The experiences of mainland Chinese immigrant professionals who believe   they have made a successful transition: Strategies that help or hinder. (Doctoral  Dissertation). Retrieved from https://circle.ubc.ca.    160 Appendix A Recruitment Poster   A	 ?Study	 ?Exploring	 ?Relationships	 ?	 ?Between	 ?People	 ?with	 ?Cancer	 ?and	 ?their	 ?Pets	 ?  We would be very interested in hearing your experience IF v? You had or have a pet for at least three months while dealing with cancer v? Your diagnosis was over four months ago v? You are over 18 years of age AND v? You are willing to talk about your experiences in a confidential 90 minute interview.  The purpose of this research project is to explore the relationships and experiences of individuals who have had a pet while dealing with cancer. Little is known about how pet companionship affects people during times of illness and adversity. You will have the opportunity to discuss how your pet has helped you and/or made things more difficult for you during your cancer experience. All information will be kept strictly confidential.   161 If you would like to participate or find out more about the study, please contact Patricia Nitkin, PhD Candidate. Patricia Nitkin, MA, CCC, is conducting this study as her Ph.D. dissertation research in Counselling Psychology at the University of British Columbia (UBC). The principal investigator and supervisor of this research project is Dr. Marla Buchanan, Professor in the Department of Counselling Psychology at UBC.  Please contact Patricia Nitkin for information about the study.  162 Appendix B Information Letter for Prospective Participants  Introductory Letter Relationships Between People with Cancer and their Pets  Dear Prospective Participant:  My name is Patricia Nitkin and I am investigating the experiences of people who have or had a pet while personally dealing with cancer. This research is part of my PhD work in Counselling Psychology at the University of British Columbia. Upon completion it will result in a doctoral dissertation that will be housed in the UBC library and available to the public upon request.   I am interested in learning about both the helpful and challenging aspects of having a pet during an illness experience. So little is known about how pet companionship affects people during times of difficulty. This study is personally meaningful to me as my companion animal was of great importance to me during times of difficulty. It is my belief that the relationships that people have with their pets are poorly understood, and often both the negative and positive aspects are underestimated. I hope that the results of this study will contribute to a better understanding of what it is like to have a pet during times of personal adversity.  I also work as a part-time clinical counsellor at the British Columbia Cancer Agency (BCCA) and have spoken with many individuals who experienced both benefits and challenges from having a pet during their diagnosis and treatment. For ethical reasons, I cannot interview you if we have already worked together in a professional capacity. In addition, I would not be able to work with you in a professional capacity in the future should you wish to participate in the study. This research is being conducted as part of my student role at UBC and is not formally related to my work at BCCA.  You are receiving this letter because I have asked some of my professional colleagues to forward the letter to individuals they believe may be interested in the study. I will not be informed of the names of people who are being sent this letter. Only those individuals who contact me directly to indicate their interest in participating in the study will become known to me. In addition, the person who sent this letter to you will not be informed of  the names of people who show interest or participate in the study.   I am seeking adult volunteers (over the age of 18) who are willing to talk about their experiences of coping with cancer and having a pet. This study will involve one face-to-face interview and a follow up consult by email or phone. The interview will be approximately two hours long, and within 3-6 months, you would be contacted to check the results by email or phone. Participants will be invited to describe their relationship with their pets and the ways in which they have been a source of support and/or a nuisance. There will be a series of questions including ?What does /did wellbeing mean to you in the context of having cancer?; What about your pet made you feel better emotionally, physically or mentally?; and What about your pet made feel worse in those ways?. Some demographic information will be asked and all information will be kept   163 strictly confidential. Any and all questions, including biographical information, will be optional to answer.  Within a few months following the interview, a summary of the themes and findings of the researcher will be sent to you for review. You will be asked whether or not the themes represent your experience well and what you would like added or edited from the report. Before the study is completed, it will be of utmost importance that each participant is comfortable with the findings and the way they are presented. You will receive a copy of the study when it is completed.   The interview will be audiotaped and transcribed and given a code number to ensure that your identity remains anonymous. The total time will be approximately 3-4 hours within a three to six month period. Any and all information that is gathered during the research process will be kept strictly confidential. All research documents will be kept in locked filing cabinet and only my supervisor, Dr. Marla Buchanan and I will have access to the interviews. Participants will not be identified by the use of names or initials, only by the code number.  Your participation in the study is entirely voluntary. You may refuse to participate in any section of the study and/or withdraw from the research at any time without prejudice of any kind. As a token of appreciation to you and your pet, each participant will receive a ten-dollar gift card for use at a reputable pet store.  If you wish to participate in this study, or would like more information please contact me. You are welcome to leave me a confidential voice-mail message if I am not available, and I will return your call as soon as possible. The principal investigator for this project is my dissertation supervisor, Dr. Marla Buchanan. She can be reached at the University of British Columbia.  Thank you so much for your interest in the study. I look forward to working together with you.  Yours sincerely,   Patricia Nitkin, M.A., CCC PhD Student University of British Columbia Counselling Psychology Program Department of Educational and Counselling Psychology, and Special Education   164 Appendix C Recruitment Email to Colleagues and Friends  Dear Colleagues and Friends,  As some of you may know, I have begun recruitment for my dissertation research. I am investigating the experiences of people who have or had a pet while personally dealing with cancer. The study will explore the role a pet or companion animal may play for people who are coping with their own cancer diagnosis, treatment, and/or survivorship experiences. This research is part of my PhD work in Counselling Psychology at the University of British Columbia (UBC) and has been approved by the UBC Research Ethics Board. As such, I am attaching the UBC Ethics Board Certificate of Approval. I am writing to you as some of you may know of people (clients, friends, family members)  who may be interested in participating or finding out more about the study. In order to maintain confidentiality I am not to be informed of the names of any prospective participants who you provide this information to, and I, in turn, will not inform you of the names of people who make contact with me. I am attaching a "Letter to Prospective Participants" as well as a flyer and poster with my contact information and a brief description of the research, and I respectfully ask that you forward this information to anyone you feel may be interested in participating. I am happy to provide any of you with hard copies of posters, Letters to prospective participants and UBC Ethics Approval as needed.  Interviews can be held in participants' homes or at UBC, and all information will be kept strictly confidential.  Below is a little more about the study: I am interested in learning about the helpful and supportive aspects of having a pet during an illness experience, as well as what is challenging and difficult. So little is known about how pet companionship affects people during times of difficulty. It is my belief that the relationships that people have with their pets are poorly understood, and often both the negative and positive aspects are underestimated. I hope that the results of this study will contribute to a better understanding of what it is like to have a pet during times of personal adversity. The study will be conducted as qualitative research utilizing the Enhanced Critical Incident Technique (Butterfield, Borgen, Maglio, & Amundson, 2009). I also work as a part-time clinical counsellor at the British Columbia Cancer Agency (BCCA) and have spoken with many individuals who experienced both benefits and challenges from having a pet during their diagnosis and treatment. For ethical reasons, I cannot interview anyone I have worked with as a BCCA patient and would not be able to provide counseling in the future to anyone who wishes to participate in the study. This research is being conducted as part of my student role at UBCand is not formally related to my work at BCCA. I am seeking adult volunteers (over the age of 18) who are willing to talk about their experiences of coping with cancer and having a pet. This study will involve one face to face interviews as well as a follow up consult. The interview will be approximately two hours long, and within 3-6 months, participants will be contacted to check the results by email or phone.  Participants will be invited to describe their relationship with their pets and the ways in which they have been a source of support and/or a nuisance. Some demographic information will be asked and all information will be kept strictly confidential. Any and all questions, including biographical information, will be optional to answer.  Within a few months following the interview, a summary of the themes and findings will be sent to participants for review. They will be asked whether or not the themes represent their experience well and what they would like added or edited from the report. Before the study is completed, it will be of utmost importance that each participant is comfortable with the findings and the way they are presented. Each participant will receive a copy of the study when it is complete.  The interviews will be audio-taped and transcribed and given a code number to ensure that participants? identities remain anonymous. The total time will be approximately 3-4 hours within a three to six month period. Any and all information that is gathered during the research process will be kept strictly confidential. All research documents will be kept in locked filing cabinet and only my  165 supervisor, Dr. Marla Buchanan and I will have access to the interviews. Participants will not be identified by the use of names or initials, only by the assigned code number.  Participation in the study is entirely voluntary. Participants may refuse to participate in any section of the study and/or withdraw from the research at any time without prejudice of any kind. As a token of appreciation, each participant will receive a ten dollar gift card for use at a reputable pet store. If you would like more information please contact me. You are welcome to leave me a confidential voice-mail message if I am not available, and I will return your call as soon as possible. The principal investigator for this project is my dissertation supervisor, Dr. Marla Buchanan. She can be reached at the University of British Columbia.  Thank you very much for considering this study for those you know who may be interested. Yours sincerely, Patricia   Patricia Nitkin, MA, CCC PhD Candidate University of British Columbia Counselling Psychology Program Department of Educational and Counselling Psychology, and Special Education   166  Appendix D Informed Consent Form   a place of mind        THE UNIVERSITY  OF  BRITISH COLUMBIA     Informed Consent Form    ?Relationships between People with Cancer and Their Pets? Principal Investigator: Dr. Marla Buchanan,   Professor     University of British Columbia  Department of Educational & Counselling Psychology, and     Special Education       Co-Investigator Patricia Nitkin, Ph.D. Student     University of British Columbia    Department of Educational & Counselling Psychology, and     Special Education       This research is being conducted as part of the requirements for Patricia Nitkin for the Doctor of Philosophy (Ph.D.) degree in Counselling Psychology at the University of British Columbia. The  results of this research will be included in a dissertation that will become a public document in the University Library once completed. The results may also be published in appropriate academic and/or  professional journals.     167 Purpose The purpose of this research project is to explore the experiences of people who have or had a pet while dealing with cancer. We would like to understand what about having a pet was helpful and supportive during the cancer experience, as well as what was challenging and difficult for you.   Procedures This study will involve one face to face interview and a follow-up discussion by email or phone. The interview will be approximately two hours long. Participants will be asked to talk about what it is like to have a pet during an illness as well as describe what wellbeing means when one has cancer. Following this, participants will be asked to describe what about having a pet contributed to a sense of wellbeing during the illness, and what about having a pet detracted from a sense of wellbeing. Some demographic  information will be asked including your age, gender, type of cancer, type of pet and cultural/ethnic  background. This information will be presented in a separate table in the report. All questions are optional to answer.  Within three months following the interview a summary of the themes and findings of the researcher  will be sent to you for review. Participants will be asked whether or not the themes represent your  experience well and if you would like anything added or edited.  The interview will be audio-taped and transcribed and given a code number to ensure that your identity  remains anonymous. The total time will be approximately 3-4 hours within a three to six month period.  Confidentiality Any and all information that is gathered during the research process will be kept strictly confidential. All research documents will be kept in locked filing cabinet and only Dr. Marla Buchanan and I will have access to the interviews. Participants will not be identified by the use of names or initials, only by a code number assigned to each interview.  The final report will use pseudonyms and avoid any details or information that could potentially identify  an individual All questions in the interview are optional to answer, as we understand that any detailed  information about a cancer diagnosis combined with type of pet owned may possibly identify a person.   168 Participants will have an opportunity to view the report in progress and comment on it before it is  submitted.  All information will be kept strictly confidential.  Compensation Each participant will receive a ten-dollar gift card for use at a reputable pet store. Contact for Information about the Study For any questions about the study?s purpose or procedures, please feel free to contact Patricia Nitkin  or Dr. Marla Buchanan.   Contact for Concerns about the Rights of Research Participants If you have any concerns about your treatment or rights as a research participant, you may contact the Research Subject Information Line in the UBC Office of Research Services.  Consent Your participation in the study is entirely voluntary. You may refuse to participate in any section of the  study and/or withdraw from the research at any time without prejudice of any kind.  Your signature below indicates that you consent to participate in the study.  Your signature indicates that you have received a copy of this consent form for your own records.  __________________________      ____________________ Participant Signature     Date  Printed Name of the Participant signing above  The signature of a Witness is not required for behavioural research.  Thank you for your willingness to participate in this study.  169 Appendix E Interview Guide   Date of Interview:           Start & End Times of Interview:  Place of Interview Interviewee Name: Interviewer Name: Pet Type and Name: (Please bring a photograph of your pet to the interview)  Overarching Research Question: ? How does having a pet enhance and/or detract from a person?s sense of wellbeing during their cancer experience? Interview Phases ? Phase 1: Contextualization   A. Tell me a little about your relationship with your pet and what he or she means to you?  B. What is the meaning of wellbeing to you in relation to your cancer experience? ? Phase 2: Helping and Hindering Factors ? Phase 3: Wish List Interview Introduction: Thank you for meeting with me. The reason we are meeting today is to talk about your experience of having a pet while you had/have cancer. I believe you can help me develop a better understanding of what it is like to have a pet during times of adversity, such as being diagnosed, treated, and/or living with cancer. I will be asking you some questions and respectfully request that you answer them in a way that you feel comfortable and open. Please remember that there  170 are no right or wrong answers. I am interested in your experience, which belongs to you, and only you and therefore can neither be right or wrong?.Some of the thing we discuss today may stir up some emotions for you. If, at any time, you feel you wish to take a break or stop the interview, please let me know.   There are three sections of the interview. 1.- The first will be concerned with what it means to you to have a pet, and also what the idea of wellbeing during cancer means to you. 2. -The second set of questions will centre around two different components: things about having a pet that helped you achieve wellbeing during your cancer experience, and things about having a pet that hindered you during your cancer experience, and 3.- the third will be about what you might have wished your pet could have done for you during your cancer experience. During the interview I may stop to ask some questions or clarify something you have said, to ensure that I am understanding you to the best of my ability. At any time, if you have any questions, please feel free to ask me. Any time you need a break, please let me know? As you know, I will be audiotaping the interview, and I welcome you to reach over and stop it at any time should you wish to take a break. (Demonstrate use of recorder) Does this sound all right with you? Any questions before we begin?  Phase 1 A. (Introduction to photograph of pet) ..I am interested in your experience of having your pet. Please share with me a little about them; Can you tell me a little about how he/she came into your life?. ?. ?OR Tell me the story of your relationship with (pet?s name?) while you faced having cancer.  171 B. As you know, a large reason for this study is to look at how your pet has impacted your emotional wellbeing during your cancer experience.  I am interested in what that idea / concept means to you: ?wellbeing? during cancer.. When you feel ready, we will move on to the next phase of the interview. Please focus on your experience with your pet during your cancer diagnosis / treatment/ post-treatment. Phase 2 A. Helping Focus ~Think of a time when (pet?s name) really helped you during your cancer experience (diagnosis, treatment, post- treatment ? these will depend upon the interviewee).  ~Tell me exactly what about your relationship with your pet helped you and/or what (pet?s name) did to help you?  In what ways did the relationship help you? ~What about (pet?s name) made you feel better, emotionally, physically, mentally or spiritually?  ~Any other times? B. Hindering Focus ~ Think of a time when (pet?s name) really hindered you emotionally during cancer (diagnosis, treatment, post- treatment ? these will depend upon the interviewee). ~ Tell me exactly how your relationship with (pet?s name) made it difficult for you and /or what did (pet?s name) do to hinder you? In what ways did the relationship hinder you? ~ What about (pet?s name) made you feel worse emotionally, physically, mentally or spiritually?  Phase 3: Wish List As you know, I am interested in what kinds of things or experiences may help people emotionally during their cancer experience.  Could you share with me perhaps, a wish list~ of what other things would have helped you emotionally during your cancer experience?  172 Final Question Is there anything else you would like to share about having (pet?s name) while you were dealing with your illness? Closing Thank you so much for your time and your interest in this study. Within a few months, I will forward you the initial results of the study that came from this interview and ask for your feedback. It will be important that you agree on how what you have said today is reported and described. It is of utmost importance that you feel it reflects your experience as much as possible, so nothing will be published without your consent? I look very much forward to being in touch with you again.  Please feel free to contact me before then if you have any questions. 173  Appendix F Demographics and Biographical Information   ALL QUESTIONS ARE OPTIONAL Age: Gender: Marital Status: Children: Occupation: Cultural Background: Country of Birth: Education Background: History of Pet Ownership:  Type / Site of  Cancer: Treatment(s): Date of Diagnosis: Date of last Treatment:   Length of Interview:           174 Appendix G Participant Check Letter Thank you so much for participating in the study and for your patience in receiving this report summary. As you may remember, the purpose of the study is to explore what about having your pets helped and hindered you in relation to your experience with cancer.  This section of the research involves me presenting you a summary of the findings so that you can check them and see if: a) the categories and incidents make sense to you, (even if some of them may not have been reported by you)  b) you are comfortable with any quotes of yours I am using for the report c) you feel that I accurately described you and your situation and pet relationship I am very interested in your feedback- it is in many ways the most critical part of the study. It is essential that I represent as closely as possible what you shared with me. If there is anything that feels wrong, doesn?t make sense, needs to be corrected or is missing, please let me know and I will change things for the final report. We can discuss any concerns or questions that you have over the phone or by email, as per your preference.  Please also remember that the purpose of the research was to explore what about having a pet made it easier and/or harder for you while you were facing cancer. The short Personal Accounts I have written about you in no way represent the depth and richness of the stories you shared with me. I apologize if I have left any significant information out. I hope the short story honours your experience and I will add or remove anything you wish.  You and your pets have been assigned a participant # to protect your anonymity. Please check the quotes with your participant # beside it.  Please also, at this point, do not share this information with anyone other than your significant other, as it must be checked by all participants before being shared.  The package includes: 1. Your information from the biographical table of participant information 2. Your brief Personal accounts- about your pets and your experience with cancer 3. The categories with a short description and the incidents (incidents refer to examples or factors that make up the category- they come right from the interviews) 4. Any quotes of yours I am proposing to use. 5. HE- refers to things that helped you about having a pet, and HI refers to things that hindered you about having a pet You are all welcome to attend my final University defense at UBC which will be held sometime this September or October- I will keep you posted and would be honoured to have you and any of your family members there. Thank you so very much, Patricia Nitkin-  

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