i EXPLORING THE LIVED EXPERIENCE OF THE HUMAN-COMPANION ANIMAL RELATIONSHIP FOR PEOPLE WITH CANCER by Nandini Maharaj B.A., The University of British Columbia, 2009 M.A., The University of British Columbia, 2013 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Interdisciplinary Studies) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) October 2019 © Nandini Maharaj, 2019 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: Exploring the lived experience of the human-companion animal relationship for people with cancer submitted by Nandini Maharaj in partial fulfillment of the requirements for the degree of Doctor of Philosophy In Interdisciplinary Studies Examining Committee: Arminee Kazanjian Co-supervisor Bill Borgen Co-supervisor Rosemin Kassam Supervisory Committee Member Ken Bassett University Examiner Marla Buchanan University Examiner iii Abstract More than half of Canadians share their homes with a pet (i.e. companion animal). Outside of the home, researchers and practitioners have increasingly embraced pets for their health-enhancing potential. Still our understanding of the relationship between cancer patients and their pets remains inadequate and incomplete. The purpose of this phenomenological study was to explore the lived experience of the human-companion animal relationship for people with cancer. I sought to examine how people engage in meaning-making through their intimate relationships with their pets. I recruited participants from cancer centres and community-based organizations that provide psychosocial support to cancer patients and their families. Using the method of photo-elicitation, I conducted in-depth interviews with nine women and five men. The participants varied with respect to age, the stage and type of cancer, and the type of pet in their care (e.g. dog, cat, and fish). After transcribing the interviews verbatim, I analyzed the transcripts using an iterative process of reading, reflecting upon, and writing out my interpretations. One such method involved seeking the assistance of researchers and health care professionals to analyze data extracts from the 14 original interviews. From the eight phenomenological themes that I generated, I identified three higher-level themes, known as super-ordinate themes, which correspond to the following meaning-making strategies: disengagement/acceptance, distraction, and support seeking. These super-ordinate themes are presented using anecdotes and quotations from participants, as well as, my own interpretive commentaries. I discuss the findings in light of theoretical constructs and empirical research. Highlighted in the discussion are implications of the study for research and practice in supportive cancer care, along with potential avenues for future investigation. iv Lay Summary The purpose of this study was to explore the meaning of pets for people with cancer. Phenomenology is a research method that can be used to draw out people’s experiences in order to understand what is unique to an individual, and what is common to human experience. I interviewed nine women and five men, and invited them to bring in photos of their pets for discussion. After transcribing the interviews, I read the transcripts repeatedly, wrote out my interpretations, and discussed the findings with researchers and health care professionals. I identified eight themes, which I then organized into three overarching themes. Themes refer to patterns of meaning that repeat themselves in a set of interviews. Some themes confirm findings from previous studies while others offer new insights into the meaning and importance of the human-pet relationship. I conclude with health system implications of the study and directions for future research. v Preface This dissertation, including the research design, data collection, interview transcription, data analysis, and manuscript writing, is my original work. I sought feedback from my supervisory committee in designing and implementing the study protocol, including the participant recruitment strategy and interview guide. After completing a first round of analysis on the 14 interviews, I sought the assistance of two human-animal bond researchers and three cancer care specialists with analyzing data extracts from the interviews. I received approval to conduct this study from the Behavioural Research Ethics Board of the University of British Columbia. The UBC Ethics Certificate number is H16-01471. vi Table of Contents Abstract ................................................................................................................................... iii Lay Summary ........................................................................................................................... iv Preface ....................................................................................................................................... v Table of Contents ..................................................................................................................... vi List of Tables ............................................................................................................................ xi List of Figures..........................................................................................................................xii Acknowledgements ................................................................................................................ xiii Dedication ................................................................................................................................ xv Prologue ..................................................................................................................................... 1 Chapter 1: Introduction ............................................................................................................ 3 1.1 Background of the Study..............................................................................................3 1.2 Relevance of the Study ................................................................................................5 1.3 Defining Key Concepts ................................................................................................7 1.3.1 The Psychosocial Impact of Cancer..........................................................................7 1.3.2 The Human-Animal Bond ...................................................................................... 10 1.3.3 Meaning-Making and Spirituality........................................................................... 14 1.4 Theoretical Framework .............................................................................................. 19 1.4.1 Attunement and Relationship Science .................................................................... 20 1.4.2 Carver’s Model of Resilience and Thriving ............................................................ 22 1.5 Phenomenological Approach to the Study .................................................................. 24 Chapter 2: Literature Review ................................................................................................. 28 2.1 Pets and Human Health .............................................................................................. 29 vii 2.1.1 Salutary Effects of Pets .......................................................................................... 29 2.1.2 Therapeutic Effects of Pets .................................................................................... 31 2.1.3 Companion Animals and Cancer ............................................................................ 36 2.2 Human Health and Spirituality ................................................................................... 39 2.2.1 Cancer and Spiritual Coping .................................................................................. 39 2.2.2 Cancer and Meaning-Focused Coping .................................................................... 44 2.2.3 Cancer and Meaning-Making ................................................................................. 49 2.3 Spirituality and Pets ................................................................................................... 51 2.3.1 Spiritual Significance of the Human-Animal Bond ................................................. 51 2.3.2 Sacred Consumption and the Human-Animal Bond................................................ 53 2.3.3 Meaning-Making and Companion Animals ............................................................ 55 2.4 Conclusion................................................................................................................. 58 Chapter 3: Methodology ......................................................................................................... 60 3.1 Phenomenological Approach to Inquiry ..................................................................... 60 3.1.1 Philosophical Underpinnings of Phenomenology ................................................... 60 3.1.2 Situating Max van Manen’s Phenomenology ......................................................... 63 184.108.40.206 Phenomenology as attitude ............................................................................. 65 220.127.116.11 Phenomenology as method ............................................................................. 67 18.104.22.168 Phenomenology as writing and reflecting ....................................................... 68 3.2 Research Design ........................................................................................................ 69 3.2.1 Methods for Collecting Lived-Experience Descriptions ......................................... 70 22.214.171.124 The experiential data-gathering interview ....................................................... 70 126.96.36.199 Photo elicitation ............................................................................................. 71 viii 3.2.2 Study Procedures ................................................................................................... 71 188.8.131.52 Participant selection ....................................................................................... 71 184.108.40.206 Recruitment and research context ................................................................... 72 220.127.116.11 Interviews ...................................................................................................... 74 3.3 Data Analysis ............................................................................................................ 77 3.3.1 Reflective Methods for Exploratory Noting and Theme Development .................... 79 18.104.22.168 Making initial and exploratory notes .............................................................. 79 22.214.171.124 Developing emergent themes ......................................................................... 80 126.96.36.199 Isolating phenomenological themes ................................................................ 81 3.3.2 Reflective Methods for Writing and Rewriting a Phenomenological Text............... 84 188.8.131.52 The experiential anecdote ............................................................................... 84 184.108.40.206 The vocative method ...................................................................................... 85 220.127.116.11 The data-interpreting interview ...................................................................... 86 3.3.3 Trustworthiness Criteria for Qualitative Research .................................................. 87 18.104.22.168 Conditions for data collection ......................................................................... 87 22.214.171.124 Conditions for data analysis ........................................................................... 88 Chapter 4: Results ................................................................................................................... 92 4.1 Demographic Characteristics ..................................................................................... 92 4.2 Findings ..................................................................................................................... 97 4.2.1 Super-ordinate Theme: (Dis)connecting with the Journey ...................................... 97 126.96.36.199 It’s hard to erase those words ......................................................................... 99 188.8.131.52 It’s amazing how in evolution ...................................................................... 106 184.108.40.206 It flickers by so quickly ................................................................................ 114 ix 4.2.2 Super-ordinate Theme: Pulling you out of yourself .............................................. 121 220.127.116.11 It’s sort of silly, but ...................................................................................... 122 18.104.22.168 It’s a sense of responsibility ......................................................................... 130 4.2.3 Super-ordinate Theme: Speaking Volumes with their Actions .............................. 137 22.214.171.124 It’s a silent kind of love ................................................................................ 139 126.96.36.199 It mattered that they were there .................................................................... 146 188.8.131.52 It’s like each living thing has meaning .......................................................... 152 4.3 Reflections on the Use of Photo-elicitation .............................................................. 160 Chapter 5: Discussion ........................................................................................................... 164 5.1 Overview of the Study ............................................................................................. 164 5.2 Theoretical Framework Revisited ............................................................................ 165 5.3 Key Findings from the Eight Phenomenological Themes ......................................... 171 5.3.1 Kindred Play ........................................................................................................ 171 5.3.2 Mattering Presence .............................................................................................. 176 5.3.3 Impetus to Hope ................................................................................................... 180 5.3.4 Animal-Human Divide ......................................................................................... 186 5.3.5 Transcendent Relationships .................................................................................. 191 5.4 Implications ............................................................................................................. 197 5.4.1 Play and Social Connection .................................................................................. 197 5.4.2 Enrichment and Engagement ................................................................................ 199 5.4.3 Empathy and Imaginal Coping ............................................................................. 202 5.5 Limitations .............................................................................................................. 204 5.6 Future Directions ..................................................................................................... 206 x 5.7 Conclusion............................................................................................................... 209 References.............................................................................................................................. 213 Appendices ............................................................................................................................ 247 Appendix A Literature Review Search Strategy ................................................................... 247 Appendix B Recruitment Poster .......................................................................................... 248 Appendix C Consent Form .................................................................................................. 249 Appendix D Interview Guide ............................................................................................... 254 Appendix E Demographic Questionnaire ............................................................................. 256 Appendix F Example of Exploratory Noting and Isolating Themes ..................................... 258 xi List of Tables Table 1 Participant socio-demographic and cancer information ................................................. 94 Table 2 Pet information ............................................................................................................. 96 xii List of Figures Figure 1 Intersections identified in the literature ........................................................................ 28 Figure 2 The eight phenomenological themes organized into super-ordinate themes .................. 97 Figure 3 Title and abstract screening to identify primary and secondary literature ................... 247 xiii Acknowledgements I gratefully acknowledge the 14 women and men who took part in this study. I was deeply touched by the vulnerability and fearlessness you showed while sharing your stories with me. I wish you and your beloved animals a long and happy life together. I thank my supervisory committee, Arminée Kazanjian, Bill Borgen, and Rosemin Kassam for their continued support and encouragement. Your guidance has been invaluable to the development and success of this project. I acknowledge funding support from the Social Sciences and Humanities Research Council and UBC Affiliated Fellowships. Thank you to Steven Taubeneck and Enid Ho. I offer my gratitude to the following organizations for promoting the study: Callanish Society, BC Cancer Agency, Vancouver ecoVillage, and Simply Natural Raw Pet Food. Thank you to Lyn Rae, Colleen Haney, and Barbara Weber. A very special thank you to Dr. Richard Calland for the care and attention you have shown Dally over the years. It is no surprise that the first poem I ever wrote was about dogs: To Peppy, Lassie, Peppy’s son, and Laddie. And to all the brindle brothers and great southern writers. To Rusty, thank you for breathing life into me. I’ve never needed someone so much. You test my patience everyday but I love you dearly…so until tomorrow… To Frankie, thank you for your warmth, penetrating stare, unabashed jealousy, and total disregard for personal space. With you, under the moonlight, I never feel left behind. To Ma, thank you for bringing light to our home. You are an exceptional mother. Thank you for your care and devotion and all the warm meals and handmade clothes. xiv To Daddy, I hope I’ve made you as proud as when I said “pearl white.” Thank you for keeping me up late to watch Psycho, Jaws, and every Bruce Lee movie (and Cinderella too). I share with you a love of dogs, talent for art, and unmatched loyalty. Please take care of Dally. To mum, with love. You are the first and best teacher I have ever had. I have been listening and learning from you even before we ever laid eyes on each other. You taught me letters and circles and everything in between. I love you more today than yesterday. Thank you for showing me how to be a good mom to Dally—the best mom. And remember all we have learned together: slide on the ice, give ‘em hell army, if you give away one you’ll only have two, it’s nice to be the nice, and doctors can’t change rule number one. You are the Dorothy to my Sophia (alright I’m Rose), and the Harry to my Barbara (alright I’m Carol). ‘Night sweet Prince xv Dedication I dedicate this work to my dearest Dally. You are a truly inspiring creature. You were not the dog I imagined but instead the son I never knew I wanted. Your miraculous capacity to heal yourself never ceased to amaze me. You somehow woke up even handsomer every day. Said the owl to the dove, you’re someone I can’t live without but have to let go. Our sun bathing • bench sitting • deep conversations on our walks • evening walks with Gayatri • chaise lounging • bath time singing • never-ending back scratches and then you pawing at me or biting me to continue scratching • finding a good use for my years of learning TV theme songs • cuddling on your couch at my insistence • the first time you initiated a snug after 8 years • snugs and nuzzles at 12:14 • cleaning your wrinkles every morning • brushing your teeth while you bit my fingers • wrangling you into the bath tub, though you did try to make a get-away each time • tensely clipping your nails • watching you sleep with that grimace on your face • hearing you snore overnight and then worrying when I didn’t hear you snoring • kissing you on your shiny black lip, though you pulled away most times • licking my feet and legs after a shower • bum scratches in the bathroom • sitting at the top of the stairs when it was the first day of school • watching you see a horse for the first time • watching you in the snow on your first birthday • baking you treats • watching you enjoy your treats • our home run on the baseball diamond • taking you to see Santa • chipping my tooth our first Halloween • sneaking your pills into your food • watching you sneakily eat everything and leave the pill behind • pulling me into traffic to get away from someone you didn’t want to pet you • hiding under the coffee table when you didn’t want to go for a walk • our many vet visits and recovery periods • making a bed of anything on the floor 1 Prologue In accordance with van Manen’s (1997, 2014) treatment of the reduction, it was necessary to make my assumptions about the human-companion animal relationship explicit. I discussed my beliefs with others, formally and informally. I engaged in reflective journaling, keeping an audit trail of my questions and insights. I wrote about my profound curiosity and affection towards animals, both the ones I’ve shared my life with and those whom I’ve admired from afar. One such curious animal is the English bulldog or simply the bulldog. Due to unethical breeding practices, this former bastion of athleticism is now ranked among the unhealthiest breeds with significant and enduring health problems. These are the same charges levied against me as the guardian of Dally, a bulldog with characteristic health problems and uncharacteristic strength and resilience, the kind usually reserved for his genetic forerunners. Dally is not my first dog, my fifth in fact, and we share an unspoken bond that always seems otherworldly to me. While waking from sleep, we open our eyes together in synchronous fashion. And even while loving this extraordinary creature whom I consider my son and twin soul, I’m aware that people think that he is just a novelty, a popular dog breed, or worse, a pitiable relic and tragedy of genetics and poor breeding. Dally is not a dog to be underestimated. He walks with great agility and elegance without the distinctive waddle typical of some bulldogs. He eats with fervor, every time looking up as if to say “what’s next?” He sleeps deeply, snoring at times until he wakes himself and turns around to stretch out in another direction. He chews only one side of each new toy. He turns his head away from me as I approach him with a camera. He appears disdainful when I try to kiss him. He always wants me to initiate a cuddle (except for exactly three times). This genetic catastrophe is the love of my life. 2 I often wonder why I relate to him so much and what his story shares with the stories that ground this dissertation. People look at Dally and make up their minds about him. They look at me and my skin colour or see my first and last name. They wonder where I was born and what my first language is or in one memorable instance if I’m Dally’s dog walker. These are the same thoughts I kept returning to while reflecting on the experiences of these 14 individuals. I wondered how they could take of their pets while going through such a difficult time. I wondered if I myself would have the strength to care for Dally if I were in their shoes. I wondered what they thought of me pursuing a PhD about pets, of all things. When they spoke of the inevitability of losing their pet, my eyes welled up too, thinking about Dally. When we shared a laugh, I thought of Dally and his strange quirks. In hearing a participant’s story about euthanasia, I wondered if I would ever have to make such a difficult decision and would it be to end Dally’s suffering or mine. I wondered all these things as I listened deeply to their stories. As I say later in this work, and paraphrase here, I sat with these once healthy human companions now suffering from the effects of the disease and its treatment. And then I thought of Dally and how people discount him and underestimate him at every turn. I know better because of him and from the experiences of these women and men. As in the reduction, I pushed through my beliefs and concepts about what it means to be a cancer patient, attempting to appreciate the person before me. And still, it was not enough to see them as a person but to appreciate them as loving guardians who mattered to their pets. The themes and essences I uncovered are universal as I see them and write about them. But it wouldn’t be entirely true to say that these stories are altogether mine. These are the words and experiences of 14 individuals, filtered through my assumptions and preconceptions. And if I’m truly honest with myself, if you want to know Dally’s story, keep reading…3 Chapter 1: Introduction In this chapter, I introduce the reader to the phenomenon of interest—the human-companion animal relationship for people with cancer. I discuss the relevance of the study in the context of social science and health science research, as well as, contemporary approaches to studying the human-companion animal relationship. After discussing the concepts and theories underlying this research, I invite the reader to look beyond these concepts and theories in order to adopt the kind of “wondering pathos” that exemplifies phenomenological inquiry. Phenomenology begins with wonder and curiosity, meaning we approach our inquiry with an openness and attentiveness to how people describe their lived experience. The chapter concludes with the research question. 1.1 Background of the Study Many people experience a deep sense of affiliation and kinship with companion animals. Companion animals are valued for their affection, companionship, loyalty, and authenticity. Their inimitable qualities strike at the core of who we are as human beings allowing us to find meaning and purpose in the ordinary and mundane aspects of our lives. They remind us of the fragile nature of life and the interconnectedness of all living beings (Skeen, 2011), which has been called the foundation of compassion (Faver, 2009). This sense of interconnectedness along with a need to find meaning may take on particular significance when confronting a life threatening illness such as cancer (Jim, Richardson, Golden-Kreutz, & Andersen, 2006; J. A. Smith, Flowers, & Larkin, 2009). Receiving a cancer diagnosis can profoundly impact people’s beliefs about themselves and their relationships (Girardin, 2000; Vachon, 2008). Some authors refer to this as a “crisis of meaning” or “spiritual crisis,” leading to a search for meaning (Carroll, 2001; van der Spek et al., 2013). 4 People often look to various sources to find meaning, including their interpersonal relationships (e.g. family, friends, community), creative pursuits (e.g. art, music, literature), and spiritual practices (e.g. meditation, prayer, yoga) (Molzahn et al., 2012; Pargament & Mahoney, 2002; Streng, 1976). The outcomes of this search for meaning often have implications for a person’s well-being and adjustment to cancer (Molzahn et al., 2012). While some patients fare poorly in particular domains of psychological functioning such as anxiety and depression (Johnson, Meadows, Haubner, & Sevedge, 2008; Mehnert et al., 2012; Molzahn et al., 2012), a number of them demonstrate personal growth and resilience (Costanzo, Ryff, & Singer, 2009). Understanding the psychosocial factors that promote resilience in some patients and distress in others provides an important topic for investigation (Carver, 1998; van der Spek et al., 2013). During times of stress and illness, some people seek out animals for companionship and spiritual guidance (Anderson & Anderson, 2003; Faver, 2009; Goodall, 1999; Hanrahan, 2011; Holak, 2008; Holt, 2001; Manes, 1997; McElroy, 1998). Borrowed from the words of renowned primatologist Jane Goodall (1999), this affinity toward other living beings can be described as a “sense of wonder, of awe, that can lead to spiritual awareness” (p. 3). Likewise, Temple Grandin’s work as an educator and animal activist demonstrates that animals have much to teach us about our own spiritual development (Grandin & Johnson, 2009). By adopting a stance of openness and curiosity, we can enter into mutually beneficial relationships with animals that transcend notions of human superiority over nonhuman animals (Faver, 2009; Skeen, 2011). Long recognized among indigenous groups, ancient cultures, and non-Western teachings (Coren, 2008; Skeen, 2011), this spiritual kinship or bond between people and animals has garnered increased attention in academic disciplines as diverse as anthropology, philosophy, psychology, literature, and veterinary medicine (B. P. Smith & Litchfield, 2009). However, to my knowledge, 5 this convergence of having a relationship with a companion animal, making meaning, and using spiritual coping has yet to be investigated within the context of cancer. The purpose of this phenomenological study is to develop an essential understanding of the nature and meaning of the human-companion animal relationship for people with cancer (van Manen, 1997). 1.2 Relevance of the Study Research indicates that, aside from physiological benefits associated with having a pet, many people cherish their pets’ companionship and its impact on their quality of life (Podberscek, Paul, & Serpell, 2000; Ryan & Ziebland, 2015; Staats, Sears, & Pierfelice, 2006). Nevertheless, the health-promoting and therapeutic benefits of pets have attracted the most attention in peer-reviewed publications, media releases, and popular works (Becker & Morton, 2002; Sakson, 2009; Thomas, 2015). The emergence of animal-assisted interventions (e.g. visits with therapy animals) is buttressed by research linking interactions with therapy animals to physiological processes that are critical for maintaining one’s overall health (Marcus, 2012b). However, even as hospitals, nursing homes, and cancer care facilities continue to embrace therapy animals in their complementary and alternative programs, our understanding of the close bonds that develop between people with cancer and their companion animals remains inadequate and incomplete (Franklin, Emmison, Haraway, & Travers, 2007; Ryan & Ziebland, 2015). A study from the University of Oxford suggests that the tendency to discount the role of pets in qualitative health research is not uncommon (Ryan & Ziebland, 2015). Ryan and Ziebland conducted a secondary analysis of 61 in-depth interviews with people suffering from long-term conditions and the carers of these patients. The researchers found that the interviewers seldom initiated discussions about pets, even when pets were present, and often chose not to follow-up when participants talked about their pets. Interactions between participants and their 6 pets were described as “interruptions” in verbatim transcripts of the interviews. Such findings are concerning when we consider that companion animals are involved in some of the most intimate areas of a person’s life (Cohen, 2002; E. Power, 2008). These cherished companions can provide researchers with valuable insights into relational dynamics that are important for a person’s health and well-being (Balcombe, 2009; Fraser, 2009; Girardin, 2000; Würbel, 2009b). Historically, research on the human-animal bond has been conducted using positivist methods such as laboratory experiments (Fraser, 2009; Shen-Miller, 2011). Such methods continue to play an integral role in strengthening the scientific credibility of approaches to studying the human-animal bond (Würbel, 2009a). For example, in animal welfare research, the use of behavioural and physiological measures has done much to advance our understanding of animal behaviour and cognition (Fraser, 2009; Grandin, 2005; Shen-Miller, 2011; Würbel, 2009a). National funding agencies have directed their efforts towards studying the health-related effects of pet ownership and pet therapy using robust scientific measures (Cherniack & Cherniack, 2015; Fraser, 2009). Although these findings are instructive, they fall short of providing an empirical understanding of the meaning or essence of the human-companion animal relationship for people with cancer (Ryan & Ziebland, 2015; Shen-Miller, 2011). Many facets of the human-animal bond are not amenable to quantification or experimental manipulation. Qualitative methods can provide the necessary empirical grounding from which to develop clinically meaningful applications and interventions (McPhedran, 2011). A considerable advantage of conducting qualitative interviews is the ability to probe further and elicit details about topics that are pertinent to the very people we wish to know more about in our work (K. T. Ashing-Giwa et al., 2004; Krueger & Casey, 2009; Ryan & Ziebland, 2015). Qualitative methods aim to reveal the complexity of a particular phenomenon within its natural 7 context (Fraser, 2009; Guba & Lincoln, 1994). Accordingly, researchers have the flexibility to move between inductive (i.e. driven by the data) and deductive (i.e. driven by hypotheses) reasoning to understand the meaning that people attribute to their experiences (Morrow, 2007; Shen-Miller, 2011). Consistent with a social constructivist epistemology (Carter & Little, 2007), this study draws upon qualitative methods that allow researchers and participants to co-construct rich narratives that are grounded in the experiences of the participants (Shen-Miller, 2011). In a previous study on the meaning of having a companion dog (Maharaj, Kazanjian, & Haney, 2016), participants described their relationship with their dogs as having a spiritual quality. Some participants reported that their dogs provided a connection to a loved one who had passed away. Others described finding greater peace and enjoyment of being out in nature when accompanied by their dogs. Extending this work, the purpose of this study is to understand the nature and meaning of the human-companion animal relationship during periods of serious illness and recovery. Studying the experiences of people with cancer provides a rich context for exploring the deeply embodied meanings of the human-companion animal relationship. 1.3 Defining Key Concepts 1.3.1 The Psychosocial Impact of Cancer The burden of cancer is considerable, with nearly one in two Canadians expected to be diagnosed with cancer during their lifetime, and one in four projected to die from cancer in 2017 (Canadian Cancer Statistics Advisory Committee, 2018). Many cancer patients describe experiencing pain, functional impairments, chronic fatigue, existential concerns, and family burden (Mehnert et al., 2012; van der Spek et al., 2013). Cultural understandings of cancer as being synonymous with suffering and death remain, in spite of progress in cancer care (Bultz & Carlson, 2006; Waldrop, O’Connor, & Trabold, 2011a). Lung, breast, colorectal, and prostate 8 cancer make up roughly half of new cancer cases and cancer deaths in Canada (Canadian Cancer Statistics Advisory Committee, 2018). Slightly more men than women develop cancer. Canadians over the age of 50 account for the majority (89%) of cancer cases (Canadian Cancer Society’s Advisory Committee on Cancer Statistics, 2015). For most types of cancer, advances in prevention, screening, and treatment have contributed to improved survival rates (Kazanjian, Smillie, Howard, Ward, & Doll, 2012). The term cancer survivorship is used to describe a “distinct phase in the cancer trajectory that occurs between the end of primary treatment and recurrence or end of life” (Doll, Kazanjian, Smillie, Ward, & Chasen, 2012). While 80,800 Canadians are expected to die of cancer in 2017, it is estimated that as of January 2009, over 800,000 Canadians are living with and beyond cancer (Canadian Cancer Statistics Advisory Committee, 2018). This growing population of people living with cancer (i.e. cancer survivors, current and former cancer patients) has unique psychosocial needs (Costanzo et al., 2009; Doll et al., 2012; van der Spek et al., 2013). Psychosocial oncology is a specialty within cancer care that is concerned with understanding and addressing the psychological, social, emotional, spiritual, functional, and quality of life aspects of cancer (Murph, 2010). A whole-person approach is used to provide optimal care for patients through the cancer journey, from prevention to bereavement (Bultz & Carlson, 2006; Murph, 2010). Although research on psychosocial oncology is relatively common in scientific journals and conferences, it is useful to unpack these terms before delving into the literature. The root, “psycho,” refers to aspects relating to the mind, mental states, or mental processes while “social” refers to people’s relationships with others (Murph, 2010). “Oncology” is the branch of medicine that is concerned with the prevention, diagnosis, and treatment of cancer. 9 A related concept is supportive care, a key element of cancer survivorship that encompasses a broad range of services and interventions including the following: self-help and informational resources, support groups, spiritual care, and patient and family counselling (Canadian Cancer Society’s Advisory Committee on Cancer Statistics, 2015; Tighe, Molassiotis, Morris, & Richardson, 2011). Supportive care is not limited to a particular area of practice within cancer care, nor is it dependent upon the phase or type of cancer. Instead, supportive care is an obligation of all cancer care professionals in demonstrating respect for a person’s inherent dignity (Richardson, 2004). At the center of supportive care are the patients, as well as, the carers and family members of those affected by cancer, hence the continued growth of psychosocial interventions. The psychosocial oncology literature attests to the importance of social support as a buffer against the effects of stress, and the essential role of the mind and spirit in healing and recovering from cancer (Bultz & Carlson, 2006; Dunkel-Schetter, Folkman, & Lazarus, 1987). Treatment for cancer is often accompanied by tremendous upheaval and uncertainty. Yet, somewhat paradoxically, maintaining a treatment regimen also provides a level of consistency and certainty (Canadian Cancer Society’s Advisory Committee on Cancer Statistics, 2015). During the survivorship phase, people often resume regular activities as they reflect upon their cancer experience. Although ongoing support is available for some people, others may feel alone in their cancer experience (van der Spek et al., 2013; Yalom & Josselson, 2011). For others, social support may decline as people have less contact with their health care team, and also perhaps, family members and friends. One constant that endures for many people in this journey is the companionship of a beloved pet. Few people can match the level of dedication and 10 unmitigated loyalty of pets toward their human caretakers. Central to this extraordinary relationship is the experience of connection and validation (Blazina, 2011). For people, being able to explore as well as express the meaning of their relationship with companion animals may bring new understandings of their cancer experience and survivorship experience; for health care providers, the agency to better address the needs of patients; and for researchers, improved interpretive power to understand the lived experience of people with cancer (Blazina, 2011). Different theories have been proposed to help account for why some people’s relationships with companion animals are so important for their health and well-being. Before discussing the theoretical framework for the study, I describe key concepts surrounding the human-animal bond, noting definitions that are commonly found in the literature and clarifying my use of these concepts. Next, I draw the reader’s attention to the concept of meaning-making and its pertinence to the cancer experience. 1.3.2 The Human-Animal Bond The relationship between humans and animals has been in existence long before the term, human-animal bond (HAB), came into popular use (Fine, 2011; Hines, 2003). Attributed to the ground-breaking work of Konrad Lorenz and Boris Levinson, the HAB gained formal recognition in the 1970s and 1980s in academic reports and the mainstream media, soon working its way into the public consciousness (Hines, 2003). An entire field of research known as anthrozoology is dedicated to the study of the HAB (Podberscek et al., 2000). Interdisciplinary in its scope, anthrozoology encompasses a broad array of perspectives from business, the humanities, as well as, the natural, social, and applied sciences (Hanrahan, 2011; Vitztum, 2013). Among the manifestations of the HAB is the phenomenon of pet ownership, meaning the keeping of animals for pleasure and companionship (Walsh, 2009a). Pets may be acquired 11 through purchase or adoption, and often reside within or near their caretaker’s home. Although service animals may cohabit with people, these animals are not considered pets from a legal standpoint (Walsh, 2009a). Service animals are working animals and receive extensive training in order to provide assistance to people with disabilities, combat veterans, and law-enforcement personnel (Pachana, Massavelli, & Robleda-Gomez, 2011). Although the terms pet and pet owner are widely used and understood by researchers and the general public, these seemingly benign terms belie the controversy surrounding their use (Grier, 2006; Walsh, 2009a). Some authors are critical of the term pet, arguing that its use signals a failure to recognize the animal’s inherent dignity and self-worth (Sandoe, Corr, & Palmer, 2015). Likewise, the term owner is considered to imply human mastery over non-human animals (Skeen, 2011). Views of animals as “less developed forms of life” once prevailed among behaviourists in the mid to late 20th century (Skeen, 2011). Even today, some purists would argue that objective assessment of animal behaviour is the only suitable subject matter for research (Skeen, 2011). Proponents of an alternate view prefer the terms companion animals and guardians or caretakers to refer to animals and people, respectively (McNicholas et al., 2005; Pachana et al., 2011). These terms are intended to highlight the emotional connection that some people share with animals, as well as, ethical concern for the welfare of animals (Walsh, 2009a). What is clear from the above discussion is that the terms used by researchers to describe animals are not inconsequential. While I agree that pet and companion animal are not equivalent, my use of the term pets is not intended to be demeaning or demoralizing. The very premise of this work is based upon my view of pets and people as being mutual partners in an authentic relationship (E. Power, 2008; Walsh, 2009a). My interest in the potential well-being effect of pets for cancer patients should not be taken to imply that this is the only or most important part 12 of the relationship. Not all pets are considered companion animals, and not all companion animals are considered pets. Firstly, people may care for and live in close proximity with pets and yet, may not experience the kind of emotional connection that exemplifies the human-companion animal relationship (Walsh, 2009a). Secondly, people who are entrusted to care for animals may develop strong emotional bonds with them (e.g. wildlife, zoo animals), yet these animals would hardly be considered pets. Horses are one such example for whom this distinction is not entirely clear, as horses can serve as companion animals, working animals, or both (Keaveney, 2008; Sandoe et al., 2015). In this study, the term pet is used in a broad manner to refer to animals that cohabit with and are cared for by people. The term companion animal is used when I wish to emphasize the emotional connection between pets and people. Consistent with Sandoe et al.’s (2015) conceptual framework, companion animals can be thought of as a “subset” of pets with whom people share a “special interactive bond.” The psychological and reciprocal nature of this bond is considered to be the key and defining feature of the human-companion animal relationship (Sandoe et al., 2015). Accordingly, I have chosen to focus upon cats and dogs, the most common household pets in North America (Sandoe et al., 2015). Moreover, considering that the focus of this study is on pet ownership among cancer patients, it would be a significant omission to overlook the role of pets in a therapeutic context (e.g. animal-assisted therapy, pets as detectors of disease), as much of the research with cancer patients has been conducted in this area (Fleishman et al., 2015; Marcus, 2012b). Some pets, given their temperament and disposition, are trained and certified to provide comfort to people in various settings (Pachana et al., 2011; Walsh, 2009a). What follows is a brief explanation of the terminology used in research on animal-assisted interventions (AAI). 13 In the literature on AAI, substantial variability exists in the terminology used by researchers and clinicians (Fine, 2011; Vitztum, 2013; Walsh, 2009a). Different terms have been identified including animal-facilitated therapy, human-animal interaction, animal-assisted visits, pet mediated therapy, and pet visits (Vitztum, 2013). The two most widely used terms are animal-assisted activity (AAA) and animal-assisted therapy (AAT), both of which are subsumed under the broad heading of animal-assisted interventions (Fine, 2011). AAA refers to interventions such as pet visits in which teams of therapy animals and their handlers visit patients in health care settings (Bibbo, 2013). AAA varies in length and time, can be delivered individually or in a group, and often has no specific goals or objectives (Wells, 2009a). In contrast, AAT is characterized as having explicit therapeutic goals and is designed specifically for a particular client or patient group to address social, emotional, and physical issues (Urbanski & Lazenby, 2012; Walsh, 2009a; Wells, 2009a). Where possible, I have maintained this distinction to be consistent with other reports. As with other psychosocial interventions, current metrics for evaluating the success of AAIs rely upon measurable changes in psychological and behavioural variables before and after the intervention, in line with a positivist orientation (Fleishman et al., 2015; Johnson et al., 2008). The psychosocial oncology literature is replete with examples of this kind of approach, citing the need for larger sample sizes, improved standardization of interventions, and longer follow-up of participants (Henry et al., 2010; Johnson et al., 2008; S. K. Smith et al., 2011). Such aims are appropriate when seeking objective answers, but misplaced when attempting to understand aspects of human experience (e.g. relationships, meaning) that are largely subjective in nature. Moreover, implicit in traditional models of cancer care is an assumption that the person is the agent of change and has the ability to exercise control over his/her environment and 14 behaviour (Giddens, 1991; Pargament & Mahoney, 2002). Undeniably, there are many things that are beyond people’s control that can leave them feeling powerless and ineffective. The question becomes: How do people contend with the inherent tension arising from their attempts to exercise personal agency and the knowledge that there are limits to their control? In the work of Giddens (1991), a person’s capacity to act independently (i.e. agency) is both constrained and facilitated by the rules and resources (i.e. structure) that make up the social system, in this case, the cancer care system. Since structure and agency are thought to influence each other continually (Giddens, 1991), it is conceivable that people going through cancer are not just passively accepting the rules surrounding them, but instead, are actively engaged in making-meaning through their everyday social practices. Accordingly, people with a companion animal can produce new meanings or rules about their relationship with their companion animal (Blazina, 2011), as well as, their cancer experience (e.g. spending time with my companion animal helps me heal). In the next section, I bring together perspectives on spirituality to help frame my discussion of meaning-making. Meaning-making provides a unique lens through which the human-companion animal relationship can be explored in all of its richness and complexity. Although meaning-making and spirituality are conceptually related, spirituality is more commonly used and accepted in psychosocial oncology and anthrozoology. 1.3.3 Meaning-Making and Spirituality In a socio-cultural context where images of death and suffering continue to pervade the minds of those impacted by cancer (Bultz & Carlson, 2006), the poignancy of the bond between a person and his/her companion animal is all the more striking. The experience of cancer may bring about a heightened awareness of a person’s priorities through his/her attempts to find meaning and connectedness with others, referred to by some authors as evidence of spiritual 15 coping (Baldacchino, Borg, Muscat, & Sturgeon, 2012). Though spirituality and its dynamic counterpart, spiritual coping, are burgeoning topics within the health fields (Migdal & MacDonald, 2013), the human-companion animal relationship has all but been ignored as a potential source of meaning and connectedness. Seeking the companionship of an animal may itself be a form of spiritual coping (Faver, 2009; Skeen, 2011). Despite its growing use and assessment in health care (Frey, Daaleman, & Peyton, 2005), spirituality is a term that conjures up mixed reactions. Some researchers regard spirituality as being too personal or private, and believe that the psychosocial aspects of illness are more suitable for empirical research (Baldacchino et al., 2012). Others remain doubtful of attempts to quantify spirituality, considering it misleading to describe spirituality as dichotomous or linear (i.e. one person is more spiritual than another) in nature (Senreich, 2013). Given these somewhat conflicting perspectives, spirituality has been conceptualized as a multidimensional and highly individualized phenomenon (Carroll, 2001; Migdal & MacDonald, 2013; Molzahn et al., 2012; Senreich, 2013). One common approach to defining spirituality is to note its similarities and differences with religion. As with religion, spiritual practices can be undertaken individually or as part of a group. These phenomena are not mutually exclusive. People can see themselves as both religious and spiritual (Pargament & Mahoney, 2002). Highlighting a customary distinction, Pargament and Mahoney (2002) define religion as “a broad individual and institutional domain that serves a variety of purposes secular as well as sacred,” and spirituality as “the key and unique function of religion” (p. 647). Furthermore, while some spiritual belief systems rest on the notion of the “unknowability of existence,” others presume that the nature of existence is in fact known (Senreich, 2013; Yalom, 1980). 16 The intent in this chapter is not to stake claim to a singular and exhaustive definition of spirituality, nor to utilize spirituality as a thinly veiled guise for religion. Spirituality is not always tied to religion. Atheists and agnostics can have spiritual needs of their own (Carroll, 2001). Rather, the intent is to situate the present study in the context of research on psychosocial oncology, making clear my own assumptions and drawing upon concepts (e.g. meaning-making, spiritual coping) that have been formalized in research. In keeping with the spirit of phenomenology (i.e. bracketing my assumptions), my view of spirituality is similar to nontheistic approaches that emphasize humanistic, existential, and secular aspects of human experience (Senreich, 2013). Two themes that predominate in these approaches are meaning and connectedness (Girardin, 2000; Meezenbroek et al., 2010). For example, Girardin (2000) describes spirituality as a “stabilizing force” that helps people stay connected to what is meaningful to them. Connectedness is understood to refer to relationships with oneself, others, nature, and/or the transcendent (i.e. a higher power) (Senreich, 2013). From these perspectives on spirituality, it is not hard to see the connection between the human-companion animal relationship and the humanistic theories (Gestalt psychology, phenomenology, and existentialism), each of which has grappled with the question of what it means to be human (Yalom & Josselson, 2011; Yontef & Jacobs, 2011). These theories place emphasis upon genuineness, authenticity, empathy, unconditional positive regard, and active engagement in the here and now (Yalom & Josselson, 2011; Yontef & Jacobs, 2011), the very qualities that are often attributed to companion animals (Walsh, 2009a). Within humanistic theories, meaning is considered to be a fundamental concern of human life, and people are construed as meaning-making beings (Frankl, 2006; Yalom, 1980). It appears that meaning-making even has a biological basis, such that people are naturally inclined to find a pattern or 17 explanation when confronted with seemingly random stimuli (Yontef & Jacobs, 2011). In his memoir, Frankl (2006) wrote that “the will to meaning” or “this striving to find a meaning in one’s life is the primary motivational force” of human beings (p. 99). While it may appear that meaning is just out there in the world waiting to be discovered, such a view, according to Frankl, masks the reality that life is without intrinsic meaning; people make meaning. Likewise, Yalom counts meaning as one of the inescapable concerns of the human condition, the others being freedom, isolation, and death (Yalom & Josselson, 2011). Although loneliness is ubiquitous to human experience, existential isolation is understood more distinctively as a sense of “despair at living an unobserved life” (Yalom & Josselson, 2011, p. 312). For people, having others witness what they experience in life, helps to alleviate existential isolation (Yalom & Josselson, 2011). It is through these intimate connections with others that people may find solace in the face of stressful life events. However, intimate connections are not limited to those between people. Many people describe experiencing a profound level of intimacy in their relationship with their companion animals (Blazina, 2011; Gavriele-Gold, 2011). Moreover, a paradox exists in that, although people can derive meaning from having intimate relationships with others, they may feel isolated at the same time (Yalom & Josselson, 2011). Commonly observed among people coping with cancer (van der Spek et al., 2013), this seeming paradox speaks to the relational dimension of meaning-making (Blazina, 2011). People attribute meaning to their experiences and may seek out others to validate these meanings (Neimeyer, Burke, Mackay, & van Dyke Stringer, 2010). In the case of companion animals, this kind of validation transcends words and language, and is believed to fulfill a need for attunement (Bowlby, 1982). Introduced here and elaborated upon in the next section (Theoretical Background), “attunement” refers to the experience of being in sync with how 18 someone else is feeling and thinking, and reciprocating through verbal or nonverbal communication (Blazina, 2011; Lasher, 1998). Although not a panacea for loneliness, the human-companion animal relationship embodies the experience of an “attuned relationship” (Blazina, 2011; Faver, 2009). Interacting with a companion animal enables a person, however briefly, to be fully engaged in the here and now. These kinds of here and now experiences have been called mindful moments and kindred relaxation in the literature (Faver, 2009). The notion that being more mindful can promote better health (Nagasawa et al., 2015), perhaps an oversimplification, does not seem so far-fetched. The aim of finding physiological evidence to substantiate this notion falls within the scope of those working from a positivist lens. In contrast, my intent is to examine the meaning that constitutes lived experience, more precisely, the meaning of these here and now experiences as people live through them (van Manen, 1997; Yontef & Jacobs, 2011). Favouring authentic experience over contrived explanations, humanists are cognizant of the impact of using theories that can dehumanize the very people whose experiences and behaviours they are attempting to explain (Yontef & Jacobs, 2011). With this in mind, I extend my discussion of attunement in the next section. Although not considered a theory itself, attunement is a foundational concept in attachment theory (Bowlby, 1982; Winnicott, 1971) and in a sub-discipline of social science known as relationship science (Hazan & Shaver, 1987). Attachment theory is commonly applied to the human-companion animal relationship (Beck & Madresh, 2008; Kurdek, 2008), emphasizing the primacy and universality of the attachment bond between infant and caregiver (Bowlby, 1982). Attunement is believed to operate at an even more fundamental level, providing the basis for developing strong affectional bonds with others throughout a person’s life (Blazina, 2011). 19 It seems that if attunement assists us in understanding the meaning of the human-companion animal relationship, in other words, the piece about meaning-making and connectedness, then a theoretical framework would be useful for exploring how people experience this relationship during periods of serious illness and recovery. Originally proposed by O’Leary and Ickovics (1995), and subsequently expanded by Carver (1998), one model posits that there are four potential consequences that can occur in response to adversity (i.e. physical or psychological stress): succumbing (continued decline), survival with impairment (diminished in some way), resilience (homeostatic return to previous level of functioning), and thriving (exceed previous level of functioning). Carver’s model helps us to situate meaning-making and the human-companion animal relationship within the context of cancer. This is not to say that succumbing and survival with impairment are not possible outcomes. My intent is to move beyond the traditional emphasis upon the negative sequelae of a cancer diagnosis (Carver, 1998; Costanzo et al., 2009; Laranjeira, Ponce Leão, & Leal, 2013). 1.4 Theoretical Framework In this section, I discuss the following theoretical constructs: attunement, resilience, and thriving. I say theoretical constructs with two thoughts in mind. Firstly, these constructs are distinguished from the phenomenon of interest—the meaning of the human-companion animal relationship for people with cancer. Secondly, these constructs are not formal theories in the sense of social theories that can offer “a significant level of predictive power” and can “stand apart from empirical analyses as coherent explanations of social life” (Pascale, 2011, p. 27). The task of the researcher is to develop a framework for identifying relevant phenomena. Not only do researchers bring their theories and assumptions to their research, but these theories and assumptions are also embedded within the research process (Pascale, 2011). To illustrate, 20 Carver’s (1998) model, with its emphasis on resilience and thriving, represents a departure from a traditional focus on impaired functioning and distress in people with cancer (Costanzo et al., 2009). Underlying my use of this model is a belief that some kind of gain or growth can follow from adversity. However, growth does not simply happen. People engage in meaning-making and this occurs within a relational context (Berscheid & Regan, 2016). 1.4.1 Attunement and Relationship Science Acclaimed acting teacher, Stella Adler, whose vision of acting called for authenticity, once said: “It is against the nature of human life to withdraw” (Riley, 2015). Just as we are inclined to find meaning, we are biologically predisposed to develop strong affectional bonds with others (Bowlby, 1982; Hazan & Shaver, 1987). People define themselves in relation to others (Yontef & Jacobs, 2011). Relationship science tells us that close, satisfying relationships are essential to a person’s well-being (Berscheid & Regan, 2016), with some evidence of an association between the human-companion animal relationship and lower morbidity and mortality (Campo & Uchino, 2013; Pachana et al., 2011). A relationship is satisfying to the extent that it meets a person’s needs among which attunement is regarded as a primary psychological need (Bowlby, 1982; Hazan & Shaver, 1987; Winnicott, 1971). Being attuned or “in sync” with how someone else is thinking or feeling requires empathy (Blazina, 2011; Mensch, 2003). Mensch (2003) describes empathy as experiencing “in the other’s body” or sharing the other’s embodiment. One of the predominant goals in the humanistic therapies is to help people develop greater empathy, curiosity, and concern for others (Yontef & Jacobs, 2011). The experience of being in sync with a comforting and responsive relationship partner is as much an element of the human-companion animal relationship as it is of interpersonal relationships (Blazina, 2011; S.-E. Brown, 2011). Companion animals witness 21 and participate in people’s lives, providing a psychological sense of accompaniment (Blazina, 2011; Winnicott, 1971). The dynamic of attunement permits meaningful interactions between people and companion animals (Blazina, 2011). These interactions provide the foundation for the kinds of attachment bonds that are characteristic of the infant-caregiver relationship (Blazina, 2011). Companion animals, particularly dogs, have been described as attachment figures with whom people form strong emotional and psychological bonds (Beck & Madresh, 2008; Kurdek, 2008). On some measures of attachment security, companion animals are rated more highly than romantic partners (Beck & Madresh, 2008). Some researchers regard proximity seeking and maintenance as a form of attachment behaviour (Bowlby, 1982). People often wish to be in close contact with companion animals, petting, grooming, and cuddling with them. Companion animals provide a secure base from which a person can derive comfort when distressed (Kurdek, 2008). A sense of purpose, of being needed, and of having a daily routine are all presumed to be influential in the development of attachment bonds with companion animals (Beck & Madresh, 2008; Siegel, 2011). However, the extent to which the human-companion animal relationship qualifies as an attachment bond continues to be debated, with some authors suggesting that attachment is only one type of affectional bond among others (i.e. friendship), and is less pertinent to adult relationships (Kobak, 2009). Accordingly, some theorists continue to draw upon attunement for its broader scope with respect to lifespan development and to the establishment of different types of affectional bonds, from intimate relationships to formal relationships between people and health care providers (Blazina, 2011; Davis, 2011; Lasher, 1998). Our understanding of attunement is such that we recognize its importance for developing and maintaining satisfying relationships throughout a 22 person’s life, yet we have little empirical understanding of its role in strengthening the human-companion animal relationship (Blazina, 2011). The dynamic of attunement is manifest in people’s tendency to develop shared meanings, in other words, core beliefs about themselves and others that evolve through mutual engagement in daily practices and routines (Neimeyer et al., 2010). These shared meanings may be disturbed or threatened in the experience of cancer (van der Spek et al., 2013). However, losses and negative events do not necessarily invalidate the meanings people attribute to their experiences (Laranjeira et al., 2013). Such a view is consistent with Carver’s (1998) model of resilience and thriving. Although Carver himself does not address how resilience and thriving might generalize to the human-companion animal relationship, his model helps us to understand the importance of having supportive relationships in the face of adversity. Relationships can impact a person’s subjective experience without changing the objective situation; people may feel alone in their experience of cancer but not feel lonely. 1.4.2 Carver’s Model of Resilience and Thriving Central to the construct of thriving is the idea that some kind of benefit or gain can be derived from an experience which may carry forward to future experiences (Carver, 1998; O’Leary & Ickovics, 1995). As with meaning-making, thriving may be elicited by a particular event or prolonged trauma but such an event or trauma is not required for thriving to occur (Carver, 1998). Thriving represents a kind of growth experience, and can be physical or psychological in nature. It is important to note that there are limits to both physical and psychological thriving (Carver, 1998). In the case of physical thriving, for example, people who are in good health prior to an illness may eat better and exercise more, yet still not be as healthy as their pre-illness state. Carver describes three kinds of psychological thriving: skill and knowledge development, confidence, and strengthened personal relationships. Knowing more 23 about a problem or stressor can help a person to manage his/her own emotions or deal with others more effectively. After going through a difficult experience, a person may come away with a renewed sense of confidence in being able to approach similar experiences in the future. Having confidence makes it more likely that an individual will persevere when he/she encounters difficulties (Carver, 1998). With regards to personal relationships, social bonds are strengthened when a person feels that he/she can turn to others for support when faced with an adverse event. These kinds of relationships are characterized by trust, security, and dependability (Carver, 1998). Possible outcomes of thriving include reduced reactivity (i.e. desensitization) to subsequent stressors or faster recovery (i.e. enhanced recovery potential) from stressors (Carver, 1998). A third potential outcome of thriving is that a person is able to function at a level that is consistently higher than that prior to the event (Carver, 1998). While such an outcome may be untenable, many researchers would agree that this is a subjective change, and is dependent upon one’s personal qualities (e.g. personality traits, coping responses) and unique life circumstances (e.g. availability of social support). Thriving may be manifested as a change in one’s orientation to life or a move toward greater acceptance of oneself or others (Carver, 1998). Studies employing comprehensive psychosocial measures provide evidence that supports the construct of resilience, rather than thriving (Costanzo et al., 2009). Following cancer, some people experience a shift in their priorities and greater appreciation of being present and in the moment (Molzahn et al., 2012; van der Spek et al., 2013). For many, this meaning is tied to their intimate relationships (van der Spek et al., 2013). Whether these examples count as resilience or thriving remains to be seen. Carver (1998) suggests that if we encourage people to view a particular situation as an 24 opportunity for growth, growth is more likely to occur. And if we learn more about why people thrive, we can teach it to others and ultimately benefit the overall health care system. This sentiment is admirable and would certainly appeal to anyone who works with people whose lives have been impacted by cancer. Encouraging resilience and supporting people in their efforts to thrive remain in the horizon of possibilities; so too does the possibility of making our experience richer. The latter possibility necessitates a shift in how we approach this kind of inquiry. Rather than finding answers or drawing firm conclusions, phenomenology opens up a way of engaging with questions to provide qualitative insights into the meaning of a particular phenomenon (van Manen, 2014). Phenomenology offers a method of questioning that van Manen (2014) describes as a “wondering pathos.” Experiences that evoke a sense of wonder can lead to phenomenological questions about the nature and meaning of these experiences. For example, we might ask “What is this experience like?” Phenomenology invites us to adopt a particular attitude and an “attentive awareness” to our experiences as we live them as opposed to how we conceptualize them (van Manen, 2014). 1.5 Phenomenological Approach to the Study Perhaps, my aim in pursuing a phenomenological investigation of the human-companion animal relationship for people with cancer could be perceived as rather modest. Everyday experiences are taken for granted, deemed simple, and less worthy of research attention (van Manen, 2014). Phenomenology shows us that these everyday experiences, however ordinary they might appear, are in fact much less simple than we would think. Typically, our thinking stops at our words, concepts, and theories (e.g. relationships are important for our well-being, growth can follow from adversity), and less often do we consider how they shape our experiences as we live them (van Manen, 2014). Phenomenology helps us to go beyond the words, concepts, and 25 theories to get back to the living moments of our experience in all of their richness and complexity. We can widen them, explore their nuances, and make them more precise. When people talk about their companion animal, they “call into being a certain relational quality” of the human-companion animal relationship that is meaningful to them (van Manen, 2014). To take this example further, we seem to know what a companion animal is. Yet, when pressed to define this concept more precisely, we are left with questions such as “Do companion animals have to live in your home to be a companion animal, Do they have to be furry or can they have feathers or scales, Can a robot be a companion animal, So, just what is a companion animal?” In an earlier section, I spent four pages attempting to clarify what I mean by the terms pet and companion animal, and I used the terms attunement, resilience, and thriving to help explain why some relationships are especially meaningful and rewarding in the experience of cancer. Still, these are the words and concepts, which we must continually push through to understand the meaning of lived experience. Again, phenomenology is less about the search for answers to these kinds of questions than it is about our openness and attentiveness (i.e. wondering pathos) in conducting our inquiry (van Manen, 2014). Most of us know someone who has been affected by cancer, directly or indirectly. As such, we may have certain assumptions about what it’s like to have cancer or to have lived through the experience of cancer. But where does this experience really begin and end? What would it be like, instead, to ask about the experience of being a pet owner or companion animal caretaker for someone living with and beyond cancer? In a practical sense, we can call people cancer patients, former cancer patients, cancer survivors, and people with cancer. We can specify the type of cancer a person has and his/her stage of cancer. Regardless of the words we use, certainly we can agree that having cancer carries some kind of lasting significance. The words in 26 a sense prevent us from engaging with the world as we experience it. However, it is through words that we can access these experiences (van Manen, 2014). This study is essentially a “wondering” exploration of relationships in the context of adversity. The human-companion animal relationship tends to be overlooked, in some cases, for the lack of a shared language (i.e. spoken or written) of the kind that occurs between members of the same species (Hirschman, 1994; Sanders, 1993). We don’t really know if our companion animals experience things the way that we do. Yet, we can experience such intimacy in our relationships with them, in the absence of words. Gavriele-Gold (2011) argues that we have this kind of intimacy with companion animals precisely because they do not speak to us the way that people do. They don’t say things to hurt our feelings. They don’t give unwanted advice. Companion animals “keep their silence, yet they bear witness” to our life (Gavriele-Gold, 2011, p. 105). Furthermore, companion animals are rendered meaningful to us through our bodily engagement and social interactions with them. Van Manen (2014) refers to this experience as the kind of embodied knowledge that helps us navigate daily life. We experience this knowledge as if it simply resides in our body and, thus, it is difficult to put into words. For example, we know how much pressure to apply when turning a doorknob, and we know how to shift our body to stay balanced as we are walking. For a phenomenological human science, the body is not simply a transmitter of the physical world but rather constitutes what is meaningful to us (Merleau-Ponty, 2012). Much of positivist science, by contrast, is built upon the idea that we know how things are in reality, and there tends to be a distrust of the body (i.e. our senses can lead us astray) (van Manen, 2014). The separation of the mind (i.e. subject) and the physical reality (i.e. object) is prominent in Cartesian dualism whereas phenomenology treats the body as a vehicle rather than a barrier to 27 acquiring knowledge. Phenomenology invites us to consider how our experience might change if we let go of our belief that we know how things are in reality. It is precisely this kind of knowing and not knowing and the “impossibility” of it all (van Manen, 2014) with which we have to grapple when inquiring into the following research question: What is the lived experience of the human-companion animal relationship for people with cancer? 28 Chapter 2: Literature Review This chapter outlines the results of a narrative review of literature on the meaning of companion animals for people living with and beyond cancer. The main emphasis in this review is on pet ownership that occurs through purchase or adoption, with some attention given to the therapeutic role of companion animals. Along with the primary and secondary literature, the review includes qualitative and quantitative research conducted in both clinical and non-clinical settings (Bratzke et al., 2015; Mays, Pope, & Popay, 2005; Schaepe & Bergjan, 2015). The literature search strategy is described in an appendix to this chapter (Appendix A). As displayed in Figure 1, most empirical research has tended to focus on the areas where each pair of circles intersects. However, the area in the center of the figure, where all three circles intersect, is still relatively new in psychosocial oncology. Figure 1 Intersections identified in the literature In the discussion that follows, I present the findings of this narrative review as I draw upon the works of key authors and additional sources identified through a search of reference lists. This review is divided into three main sections: 1) Pets and Human Health, 2) Human Health and Spirituality, and 3) Pets and Human Spirituality. Pets [Companion animals] Spirituality [Meaning-making] Human health [Cancer] 29 2.1 Pets and Human Health 2.1.1 Salutary Effects of Pets The evidence base on pets and human health is mixed with some reports indicating substantial benefits from owning a pet, others suggesting no difference in health between pet owners and non-owners and, still others finding poorer health outcomes among pet owners (Cherniack & Cherniack, 2015; Siegel, 2011; Virués-Ortega & Buela-Casal, 2006; Wright, Kritz-Silverstein, Morton, Wingard, & Barrett-Connor, 2007). Some investigations are affected by methodological limitations such as small sample sizes, confounding variables, and insufficient follow-up (Siegel, 2011; Wells, 2009b). Nevertheless, research on the human-pet relationship lends empirical support to a widely held belief that pets are good for us (Becker & Morton, 2002; Vitztum, 2013; Wells, 2009b). Benefits observed among pet owners include the prevention of illness and the promotion of mental and physical health (Cherniack & Cherniack, 2015; Friedmann & Tsai, 2006; Knight & Edwards, 2008; Wells, 2009b). Health benefits appear to be more prevalent, although not exclusively, among dog owners, and are often attributed to greater physical activity and social engagement provided by dog-walking (Cherniack & Cherniack, 2015; Knight & Edwards, 2008; Siegel, 2011; Wells, 2009b). Much of the existing research is aimed at older adults and children, with the strongest evidence provided by studies examining the impact of pets on a patient’s likelihood of survival in the aftermath of a cardiac event (Friedmann, Katcher, Lynch, & Thomas, 1980; Friedmann, Thomas, Stein, & Kleiger, 2003; Friedmann & Thomas, 1995). In their 1980 study of patients (N=96) who survived a heart attack, Friedmann et al. found that pet owners experienced greater longevity compared to non-owners. One proposed reason for this difference is the performance of Activities of Daily Living (ADL) associated with pet care responsibilities (e.g. feeding, 30 walking their pet). Follow-up investigations (Friedmann & Thomas, 1995; Friedmann et al., 2003) and subsequent analyses revealed that the greatest benefits were achieved by dog owners. These results, however, could not be attributed solely to an increase in physical activity associated with having a dog. The authors point to greater heart rate variability observed among pet owners as a possible explanation, citing the finding that lower heart rate variability is linked to cardiovascular disease and mortality (Friedmann et al., 2003). Other proposed physiological mechanisms include positive changes in neuroendocrine functioning (i.e. increase in oxytocin, decrease in cortisol) that occur when interacting with pets (Horowitz, 2008; Odendaal, 2000). In one study, researchers found that gazing behaviour from dogs was followed by an increase in the concentration of urinary oxytocin in the owners of the dogs (Nagasawa et al., 2015). The hormone oxytocin is involved in empathy, social bonding, and maternal behaviour (Horowitz, 2008). The release of oxytocin in the dog owners then stimulated affiliative responses (i.e. tactile interaction) from them toward their dogs. This, in turn, resulted in an increase in urinary oxytocin in the dogs who were being talked to and petted by their owners. The results provide evidence of an “interspecies oxytocin-mediated positive loop” which is facilitated by mutual gazing behaviour that developed through the coevolution of dogs and humans (Coren, 2008; Nagasawa et al., 2015). Such modes of communication appear to be deeply engrained in human-dog bonding, and are absent in interactions between humans and wolves, dogs’ closest genetic relatives (Coren, 2008; Nagasawa et al., 2015). Laboratory experiments are instructive, finding reduced physiological reactivity among pet owners compared to non-owners (Allen, Blascovich, & Mendes, 2002; Horowitz, 2008; Wells, 2009b). In a study of dog owners (N=162), participants were randomly assigned to one of three support conditions: companion dog present, close friend present, or alone (Campo & 31 Uchino, 2013). For each condition, participants’ cardiovascular reactivity was measured while completing a mental arithmetic or cold pressor task. The results indicated that the participants’ blood pressure and heart rate was lower in the companion dog condition than in the close friend condition. These findings held across the type of stressor and were observed during and after the task, suggesting that pets not only minimized the effects of stress but also facilitated recovery from stress. The authors speculated that evaluation apprehension (i.e. concern about being evaluated) could help to explain the finding of higher cardiovascular reactivity in the close friend condition, despite receiving positive ratings (Campo & Uchino, 2013). Somewhat surprisingly, the responses of participants performing the task alone did not differ substantially from those who were accompanied by their companion dog. It is conceivable that simply knowing that their dog was nearby, if not in the same room, helped to alleviate distress. There did not seem to be a relationship between participants’ appraisals of their relationship with their dog and their friend, thus, confirming previous findings that pets provide a unique source of support that adds to rather than replaces human companionship (Brooks et al., 2013; Walsh, 2009b). 2.1.2 Therapeutic Effects of Pets The practice of integrating animals into therapeutic interventions for people, is certainly not new (Fine, 2011). Founded in the 18th century, the York Retreat in England was one of the first psychiatric facilities to record the benefits of interacting with an animal for patients with a mental illness (Fine, 2011). The first documented report of cancer patients receiving pet therapy in the form of weekly visits from cats and dogs, was a study in a New York City hospice with 15 participants (Muschel, 1984). Following the 10-week intervention, participants exhibited decreased anxiety and despair. In the 30+ years since this report, a growing number of hospitals and cancer clinics have implemented programs involving visits from therapy animals who are 32 trained and certified to provide comfort, stress relief, and companionship (Horowitz, 2008; Johnson et al., 2008; Wells, 2009b). As noted in Chapter 1, the term, animal-assisted therapy (AAT), is used to refer to structured sessions with a therapy animal that are designed to achieve specific therapeutic goals (e.g. reduce depression) (Urbanski & Lazenby, 2012; Wells, 2009b). However, AAT is used by some authors to describe unstructured visits with therapy animals in hospitals and health care settings (Baun & Mccabe, 2003). The terms animal-assisted activities (AAA) and animal-assisted visits (AAV) are also used to describe therapy animal visits, leading to confusion and a lack of agreement in the literature (Fine, 2011; Vitztum, 2013). To be consistent with the original reports, various abbreviations (e.g. AAT, AAA, AAV, etc.) are used in this section to refer to the therapeutic functions of animals. Researchers in one investigation explored the benefits of animal-assisted activities (AAA) for patients undergoing chemotherapy at a cancer infusion center (Marcus, Blazek-O’Neill, & Kopar, 2014). The dog-handler teams spent a total of 103 hours visiting with 56 participants (33 at the cancer infusion center; 23 in other areas of the hospital). In response to a satisfaction survey (46.3 % response), participants reported improvements in various cancer-related symptoms such as enhanced relaxation, mood, sleep, attitude, and appetite, and decreased anxiety, stress, pain, and isolation. Over 95% of participants reported a positive response to the dog visits with 82.1% expressing an interest in future dog visits, and 91.1% indicating that they would recommend AAA to someone else (Marcus, 2013a; Marcus et al., 2014). Most participants rated the dog visits as having much or great benefit as indicated by the selection of 4 or 5 on a five-point scale. Twenty-eight of the participants reported currently having a dog of their own. There were no significant differences in the results pertaining to gender, location in the hospital where they received AAA, current pet ownership status, and identification with 33 being a dog person. Only a few participants (5.5%) receiving treatment at the cancer infusion center expressed concern about the potential for germs introduced by dogs. In a similar investigation, researchers tested the efficacy of animal-assisted visits (AAV) for patients (N=42) with head and neck cancer who were receiving combined chemotherapy and radiation therapy (Fleishman et al., 2015). The participants’ quality of life (QOL) was assessed at baseline, week 3, and week 7 using a reliable measure (FACT-G). Satisfaction with AAV was also measured. The results indicated that there was a statistically significant and clinically meaningful increase in emotional well-being (EWB) and social well-being (SWB), in spite of moderate to high symptom burden and declines in physical well-being (PWB) and functional well-being (FWB). Satisfaction with the intervention increased during treatment and remained high at the end of the intervention. According to the qualitative data, the dogs were instrumental in providing unconditional love and acceptance (Fleishman et al., 2015). Changes in participants’ outward appearance did not seem to matter to the dogs who were simply happy to see them. Dogs and handlers were perceived as being helpful and supportive (Bibbo, 2013; Fleishman et al., 2015). However, participants felt that visits with volunteers would have been awkward without the dog being present. A few participants reported maintaining contact with the dog-handler team after the study. Despite the use of a valid and reliable QOL measure, there were some methodological challenges. The participants were self-selected and, therefore, may have espoused favourable attitudes toward animals regardless of the effects of the intervention. It was not feasible to use random assignment due to practical considerations such as participants’ schedules and preferences for animal visits. In any case, these study-related limitations are unlikely to pose a challenge when implementing AAV in clinical settings where the uniformity of methods and procedures are less of a concern for clinicians (Fleishman et al., 2015). 34 The results of a post-test study provide additional evidence of the efficacy of AAA for cancer patients (Johnson et al., 2008). Thirty adult patients receiving radiation therapy were randomly assigned to one of three conditions: 12 dog visits, 12 human visits, or 12 quiet reading sessions over a 4 week period. Participants were Caucasian, with the exception of two participants who were African American. There were ten participants in each condition. The following hypotheses were tested: participants in the dog visits group would experience less fatigue and improved mood, self-perceived health, and sense of coherence (1) following the intervention, and (2) in comparison with the other two conditions. Sense of coherence refers to a person’s capacity to manage stressful life events and retain a sense of meaning and understanding when encountering difficulties. Each condition consisted of 15 minute sessions (i.e. received a magazine or a visit from a dog or human alone) delivered three times a week for four weeks. Participants received the session before their radiation treatment. In contrast with the studies described above (Fleishman et al., 2015; Marcus et al., 2014), the handlers were instructed to avoid talking to participants apart from the initial session in which they were asked to introduce the dog and monitor his/her behaviour and how the session went. Participants receiving visits from therapy dogs reported improvements in their health over the four week period (Johnson et al., 2008). Dogs helped to relieve anxiety and distract participants from their illness. Those in the dog therapy group experienced an increase in anger/hostility, confusion, and depression scores, although these changes were non-significant. As well, there were no statistically significant differences between the groups with regards to age, gender, race, education, or cancer site. Given the small sample size, replication is warranted with a larger and more diverse sample, and a longer follow-up period. Another limitation of the study was the absence of information about disease progression or the side effects of radiation 35 therapy during the four-week period. It is possible that the participants’ condition worsened during treatment, thus, affecting the validity of the findings. Contamination was also a potential issue as participants could have discussed the intervention while talking to others in the waiting room. Future research could benefit from controlling the stage and type of cancer, as well as, having additional measures of mood such as neurochemical changes in response to AAA. Findings from systematic investigations provide evidence that AAA can be a valuable addition to supportive care interventions for cancer patients and their families. Some reports suggest that AAA confers similar benefits for health care providers who work with cancer patients (Marcus, 2012a). In one quasi-experimental study, researchers found that the staff (n=34) of an outpatient cancer center generally viewed AAA positively. The dog visits did not add extra stress or work for the staff who agreed that AAA should continue at this facility (Bibbo, 2013). Despite the potential benefits of AAA for health and well-being, research on cancer patients is still limited and some questions remain unanswered. More research is needed to determine the optimal timing and length of AAA sessions, as well as, understand the impact of disease severity on the effectiveness of AAA (Bibbo, 2013). Standardized terminology with clear definitions is needed to advance theoretical and applied research (Vitztum, 2013). All in all, the findings suggest that AAA through volunteer services represent a cost-effective and therapeutically effective intervention that can complement medical care (Marcus et al., 2014). When properly trained, therapy animals are seen as friendly, approachable, calming, and nonjudgmental (Walsh, 2009b; Wells, 2009b). As social catalysts, therapy animals provide support, eliciting physical touch and sociability from people (Fine & Eisen, 2008). AAA can empower patients to retain a sense of control in managing their illness, treatment, and ensuing side effects (Johnson, Meadows, Haubner, & Sevedge, 2003). Although patients may wish to 36 visit with therapy animals and report benefits from interacting with them, obtaining valid and reliable measures of these outcomes remains a challenge (Bibbo, 2013; Franklin et al., 2007; Johnson et al., 2008). However, as Fine and Eisen (2008) warn, if we were to focus exclusively on documenting measurable outcomes, we would miss the “magic” or “brilliance of the process” that is found in the daily interactions between animals and people. 2.1.3 Companion Animals and Cancer At the intersection of pets and human health (Figure 1), there is limited research on how pet ownership impacts health when it comes to cancer. Similarly, despite burgeoning research on the therapeutic effects of animals for people with cancer, there is a dearth of studies on the experiences of cancer patients and their companion animals (Johnson et al., 2008; Nitkin, 2014). A search of the literature revealed a relatively large volume of research reports on comparative oncology, veterinary oncology, and animal-assisted interventions. From the 44 articles retrieved, only 10 focused on the topic of companion animals and cancer. Of these, five were written by the same two research teams, and their primary objective was to evaluate the impact of animal-assisted therapy rather than pet ownership. Only one published study (Larson et al., 2010) and an unpublished dissertation (Nitkin, 2014) were identified that specifically addressed the experiences of cancer patients and their pets. The purpose of the 2010 study was to assess the need for community and financial resources among cancer patients with pets. Participants (N=309, median age=59) were asked whether they had concerns about being able to care for their pets, and if they needed more information on pet-related resources. Of the 309 participants (median age=59, 56% women) surveyed, 170 had at least one pet, with dogs and cats being the most common type of pet. Most of these participants (80%) reported having support from family members to care for their pet following their diagnosis. 37 Participants indicated a high level of attachment to their pets, and believed that having a pet provides health benefits. A small percentage (6%) of participants had concerns about being in contact with their pets while in treatment. Only one participant reported giving up a pet because of a cancer diagnosis, and two participants chose not to acquire another pet due to their illness. Participants reported having concerns about lifting their pets while recovering from treatment, caring for pets with health problems, and having to limit their exposure to farm animals due to the risk for infection. Aside from these concerns, participants tended to emphasize the benefits of having a pet. Pets were described as being able to intuit when participants were stressed or ill. Pets helped participants heal and manage stress. Overall, the findings suggest that cancer patients benefitted from their pet’s companionship and had few concerns regarding the care of their pet during cancer treatment (Larson et al., 2010). Although only a small number of participants were in need of information on pet-related community and financial resources, the results may not represent the experiences of patients who lack similar resources. In the 2010 study, participants were receiving treatment at a tertiary care center. It is possible that these patients already had social support and resources that enabled them to manage their pet’s care without additional intervention. Nevertheless, providing patients with information about pet shelters, legal resources, and veterinary care may go a long way to reducing anxiety from not being able to care for one’s pet while undergoing treatment (Larson et al., 2010). Simply inquiring about pets during routine assessments may help to improve patient-provider communication (Walsh, 2009c; Wisdom, Saedi, & Green, 2009). To illustrate, Dr. Edward Creagan, a professor of medical oncology at the Mayo Clinic, regularly records the names of his patients’ pets in their medical charts, and even “prescribes” pets as part of their treatment plan (Horowitz, 2008). 38 Other investigations that lie at the intersection of pets and human health have examined the potential role of companion animals as a diagnostic tool for cancer detection (Wells, 2012). Dogs, given their olfactory acuity, are able to identify compounds in breath, sweat, and urine that are indicative of illness (Marcus, 2012b; Wells, 2012). This research has been motivated in part by the limitations of traditional screening methods which tend to be invasive, painful, and expensive. In any case, further research is needed to establish the extent to which dogs can identify the presence of cancer as opposed to ill health in general (Wells, 2009b, 2012). The use of small sample sizes and variations in the way that odour compounds are collected make it difficult to draw conclusions about the specificity with which dogs can detect cancer (Wells, 2012). A second area in which pets have been discussed in relation to cancer patients is the risk of interacting with pets among people who are immunocompromised (e.g. young children, pregnant women, older adults) (Larson et al., 2010). The authors of one review indicate that concerns regarding the spread of zoonotic infections (i.e. disease transmitted from animals to humans) are unwarranted (Stull, Brophy, & Weese, 2015). These infections are relatively uncommon among pet owners and are minimized considerably by the use of proper handwashing (Marcus et al., 2014; Stull et al., 2015). In some cases, pets, rather than people, may be at risk for becoming colonized with human pathogens (Marcus, 2013b). In summary, the management of cancer requires a comprehensive approach to address the needs of patients for physical, medical, informational, emotional, social, and spiritual support (Marcus, 2012a; McCorkle et al., 2011). Empirical research on animal-assisted interventions represents an important step in validating anecdotal claims among cancer patients regarding the benefits of interacting with therapy animals. However, research on the experiences of cancer patients and their own pets is currently lacking. Efforts to improve patient engagement require a 39 broader understanding of the daily activities in which people invest their time and energy (Raque-Bogdan et al., 2015). Examining social occupations such as caring for a pet can provide insights into how cancer patients integrate their illness and survivorship status into their identity (Brooks et al., 2013). Being a pet owner is one such identity that speaks to the experience of living meaningfully in the face of a life-threatening illness (Girardin, 2000; Wisdom et al., 2009). 2.2 Human Health and Spirituality 2.2.1 Cancer and Spiritual Coping Coping is defined as the thoughts and behaviours that people use to manage stress (Folkman & Lazarus, 1988). Problem-focused coping refers to a person’s attempts to change or confront a stressful situation (Bigatti, Steiner, & Miller, 2012; Folkman, Lazarus, Gruen, & DeLongis, 1986). Emotion-focused coping refers to a person’s attempts to regulate emotional distress through distraction or avoidance (Folkman et al., 1986; Waldrop et al., 2011a; Wenninger et al., 2013). Spiritual coping, a type of emotion-focused coping, involves attempting to change or redefine the subjective meaning of a situation, for example, by searching for a larger purpose or reason (Molzahn et al., 2012; Vachon, 2008; Waldrop et al., 2011a). Although it is generally accepted that particular coping strategies can contribute to an enhanced sense of inner peace and contentment (Girardin, 2000; Laranjeira et al., 2013; Pargament & Mahoney, 2002), there is little consensus about what to call these strategies. Both spiritual coping and meaning-making are found in the literature, along with other terms such as existential coping (Baldacchino et al., 2012; Migdal & MacDonald, 2013). The link between spirituality and health is such that spiritual coping may lead to improved well-being and quality of life for some people, and greater distress in others (Molzahn et al., 2012; Vachon, 2008; Visser, Garssen, & 40 Vingerhoets, 2010). Moreover, while spiritual coping has particular relevance for some people in dealing with a serious illness, for others, spiritual coping is of little to no consequence. In the study of spiritual coping and cancer, considerable attention has been given to end-of-life issues among palliative care patients, dealing with advanced disease and diminished quality of life (Trevino, Balboni, Zollfrank, Balboni, & Prigerson, 2014; J.-S. Tsai et al., 2012). However, existential distress is not unique to those in palliative care (Girardin, 2000). Accordingly, there has been greater movement towards studying the spiritual resources, meaning-making processes, and coping strategies used by people in other stages of cancer survivorship (Boehmer, Luszczynska, & Schwarzer, 2007; Carroll, 2001; Laranjeira et al., 2013). For example, investigators in one study examined the spiritual practices and spiritual well-being of women (n=85) with gynecologic cancer using quantitative measures (A. J. Lopez, McCaffrey, Quinn Griffin, & Fitzpatrick, 2009). Overall, the participants reported high levels of spiritual well-being, self-efficacy, and life scheme (i.e. meaningfulness). The most common practices endorsed by participants as having a spiritual quality were taking part in family activities, listening to or playing music, exercising, and helping others. Participants less often used meditation, yoga, or communal prayer to express their spirituality. These results lend support to the notion of spirituality as something that gives a person a sense of meaning and purpose in life, while also highlighting the challenges of determining how best to conceptualize spirituality (Frey et al., 2005; A. J. Lopez et al., 2009; Pargament & Mahoney, 2002). The extent to which research terminology used resonates with participants’ experiences is not only a concern of studies that employ quantitative methods. In a qualitative study by Molzahn et al. (2012), participants reported feeling uncomfortable using the word spirituality, believing that it was too closely aligned with religion. Instead, participants preferred using 41 metaphors and talking about their attempts to find meaning in their illness through their relationship with their children, partner, pets, music, and nature. The goal of the study was to examine the spiritual stories of people (n=32, 18 men and 14 women) living with serious illness (e.g. cancer, end stage renal disease, and HIV/AIDS). In-depth narrative interviews were conducted with participants ranging in age from 37 to 83. Three major themes were identified: reflecting on spiritual relationships and personal beliefs, crafting beliefs for one’s own life, and finding meaning and transcending beyond words. Examples of spiritual practices included visualization, gardening, and therapeutic touch. Participants reported experiencing a deepening of spirituality that evolved from a blend of religious and non-religious beliefs. The results indicated that, despite researchers’ efforts to distinguish between religion and spirituality (Frey et al., 2005), few people tended to make this distinction (Molzahn et al., 2012). Such findings alert researchers and practitioners to the importance of engaging with participants in their own terms (Molzahn et al., 2012). Labeling something “spiritual” or “religious” may actually inhibit participants from discussing their beliefs. Accordingly, non-traditional research methods have been proposed, including arts-based approaches, photography, story-telling, and meditation (Harper, 2002; Molzahn et al., 2012; Tighe et al., 2011). Another issue raised by research on spiritual coping is the need for larger and more diverse samples (Jim et al., 2006; A. J. Lopez et al., 2009). Some studies rely upon convenience sampling, yielding self-selected and homogenous samples with characteristics that may not be applicable to other patient groups or the general population (Molzahn et al., 2012). In view of these limitations, the findings of cross-cultural research are instructive for understanding the needs and experiences of underrepresented cultural and ethnic groups (K. Ashing-Giwa & Ganz, 1997; Chang et al., 2014; 42 Molassiotis et al., 2006; J.-S. Tsai et al., 2012). In this brief sampling of studies, positive and negative aspects of spiritual coping are discussed. In an investigation of the psychosocial needs of African American women with breast cancer, researchers found that participants often drew strength from their spiritual faith (K. Ashing-Giwa & Ganz, 1997). A total of 43 participants were interviewed using key informant interviews, focus groups, and in-depth interviews. Key informants referred to patients as “uninvolved victims,” explaining that patients tended to be passive and had less control over their illness compared to people in “mainstream society.” Patients were inclined to accept medical treatment without questioning their doctors’ recommendations or requesting a second opinion. Patient interviews confirmed key informant views of patients as being less active in managing their illness. Patients reported experiencing psychological distress, employment challenges, and a lack of information and support during their diagnosis and treatment. Additional barriers included a lack of medical insurance and poor relationships with doctors. For these women, their primary source of support and coping was their spiritual beliefs (K. Ashing-Giwa & Ganz, 1997). Having a child also motivated them to get better. A number of women reported that their attendance at church increased following their cancer diagnosis. Some women were reluctant to seek medical help, instead relying upon prayer as an antidote to cancer. Similar findings were reported in a study of Chinese women for whom it was not uncommon to avoid seeking medical care with or without a confirmed cancer diagnosis (Chang et al., 2014). The researchers speculated that having a high level of spiritual support may have contributed to delays in cancer detection (Chang et al., 2014). Such findings highlight a potential risk of spiritual or religious coping among people who rely upon their faith to the detriment of receiving timely medical care (K. Ashing-Giwa & Ganz, 1997). Nevertheless, it should be noted that, in 43 both studies, having a deep spiritual faith motivated patients to heal and recover from their illness (K. Ashing-Giwa & Ganz, 1997; Chang et al., 2014). Another notable finding from the studies discussed above is the view of cancer as being a private matter, and, for some individuals, a “punishment” from God (K. Ashing-Giwa & Ganz, 1997; Chang et al., 2014). Such beliefs, referred to as negative religious coping (NRC), may be accompanied by an experience of being in conflict with God or disconnected from one’s spiritual life and community (Trevino et al., 2014). NRC is associated with poorer quality of life and life satisfaction, as well as, greater depression and suicidal ideation (Trevino et al., 2014; Yeung, Lu, & Lin, 2014). Assessments of NRC may be helpful for identifying people who are vulnerable to spiritual distress and suicidal ideation (Trevino et al., 2014). Moreover, examining spiritual coping can help researchers understand how people make sense of traumatic or critical life events (K. Ashing-Giwa & Ganz, 1997; Yeung et al., 2014). In another investigation, researchers surveyed Latina women (n=330) with breast cancer about their use of spiritual coping (García-Jimenez et al., 2014). The researchers examined the role of spiritual well-being as a potential mediator in the relationship between cancer self-efficacy (i.e. belief in one’s ability to deal with cancer) and self-rated health. Spiritual well-being was assessed using a measure that includes religious (i.e. faith) and non-religious (i.e. inner peace) aspects of spirituality. The results indicated that inner peace was independently associated with better self-rated health (OR= 2.44, 95% CI 1.30, 4.56). Once inner peace was accounted for, there was no longer a significant association between faith and self-rated health. The researchers concluded that inner peace (i.e. meaning or purpose in life) was an important contributor to the health and well-being of participants. However, with less than one-third of the sampling frame included in the study, the results may not be representative of other groups of cancer patients. 44 Still, the findings have implications for women who are at increased risk of psychosocial distress due to ethnic and language disparities (García-Jimenez et al., 2014). Routine distress screening and interventions that promote meaning and purpose, discussed next, may go a long way to improving cancer self-efficacy and overall health (García-Jimenez et al., 2014). By offering culturally competent care, health care providers can address the spiritual and existential needs of patients, as well as, instill hope for patients coping with institutional barriers and inadequate resources (K. Ashing-Giwa & Ganz, 1997; Chang et al., 2014). 2.2.2 Cancer and Meaning-Focused Coping Meaning-focused coping refers to strategies that people use to help make sense of their experiences and promote meaning in life (MIL) (Boehmer et al., 2007; Jim et al., 2006). According to one conceptualization, MIL is comprised of three dimensions: 1) satisfaction with one’s relationships and contributions to the world, 2) beliefs and values pertaining to one’s life and how well these are integrated, and 3) beliefs about life as being part of a pattern beyond one’s individual life (Jim et al., 2006). Meaning-focused coping strategies that involve the use of avoidance, denial, or blame can undermine a person’s long-term adjustment to illness (Jim et al., 2006; Yeung et al., 2014). Despite providing temporary relief, strategies such as ignoring one’s illness or avoiding one’s emotions are less conducive to deriving meaning from an experience such as cancer (Boehmer et al., 2007; Yeung et al., 2014). Conversely, meaning-focused strategies that support a person’s view of the world and him/herself can help to preserve MIL (Jim et al., 2006). Examples of these strategies are acceptance, positive reinterpretation, information and support seeking, and prayer (Boehmer et al., 2007; Costanzo et al., 2009). Accepting or reframing a situation in a more positive light can be beneficial in situations over which people have little control (Boehmer et al., 2007). Rather than attempting to change the 45 situation, people can manage their emotional response to the situation, leading to greater self-efficacy and control (Costanzo et al., 2009). In a longitudinal study, researchers assessed the coping strategies of women diagnosed with breast cancer (N=167, M age=51) at the time of their diagnosis, and assessed MIL two years later (Jim et al., 2006). The Meaning in Life Scale (MiLS) was used to measure the impact of a cancer diagnosis on participants’ reported MIL. Hierarchical multiple regression analyses revealed that participants’ coping ability at diagnosis was a significant predictor of the variance (17%) in MIL at the 2 year follow-up assessment. These relationships remained significant after controlling for depressive symptoms and cancer-related stress at diagnosis. Coping variables accounted for 5 to 43% of the variance in MIL. The results confirmed the original hypothesis that coping strategies have a long-term effect on MIL. Participants who tended to reframe negative events in a more positive light were able to find greater meaning and purpose from these events. It was unclear from the results whether MIL should be thought of as a trait that is stable or variable in response to major life events. Sources of MIL and the types of coping strategies that people use often differ based upon their unique life circumstances and associated challenges (Boehmer et al., 2007; Dunkel-Schetter et al., 1987; Jim et al., 2006). To shed light on the effectiveness of different coping strategies, researchers in one study examined the perceived self-efficacy and coping ability of 175 cancer patients (gastrointestinal, colorectal, and lung cancer) at one and six months after surgery (Boehmer et al., 2007). Also assessed was the influence of social support, both actual (i.e. received) and perceived (i.e. expected), on participants’ adjustment to cancer (Boehmer et al., 2007). Greater perceived self-efficacy was associated with lower stress and depression and greater use of meaning-focused coping strategies. Participants who used meaning-focused strategies tended to have a positive 46 outlook and saw themselves as capable of dealing with difficult situations (Boehmer et al., 2007). In terms of actual support, receiving assistance with managing their disease and recovering from cancer treatments helped to alleviate depression and enhance participants’ emotional well-being. The results also showed a significant association between perceived support and emotional well-being. The findings should be interpreted with caution considering the heterogeneity of the sample (i.e. differences in diagnosis, site and stage of cancer) and the lack of information regarding the refusal rate. Interestingly, some researchers have described perceived support as a personality trait or feeling of attachment (Sarason, Pierce, & Sarason, 1990), meaning it can vary between individuals or within the same individual over time. It remains to be seen whether these constructs (e.g. meaning in life, perceived support, and coping ability) should be thought of as stable or variable in nature. The coping strategies that people ordinarily rely upon may not be as effective when dealing with the tasks of cancer treatment (Boehmer et al., 2007). In response, interventions have been developed and tested with cancer patients to help them learn coping strategies that can improve psychosocial adjustment to cancer (Boehmer et al., 2007; Henry et al., 2010; Reynolds & Perrin, 2004; S. K. Smith et al., 2011). To illustrate, meaning-focused interventions (i.e. the Meaning-Making intervention), designed specifically to address existential issues, have begun to fill an important gap in supportive cancer care research (Harper, 2002; Lee, Robin Cohen, Edgar, Laizner, & Gagnon, 2006). Followed is a brief discussion of these intervention studies. Using a prospective single-arm pilot study, researchers evaluated the Pathfinders program in a sample (n=44, M age=51.5) of women with advanced breast cancer (S. K. Smith et al., 2011). Developed by social workers, the Pathfinders program is a strength-based model designed 47 to enhance participants’ coping skills and resilience. The program helps participants to identify their inner strengths and establish a self-care plan. Over a period of six months, the participants completed assessments to evaluate changes in various resources (e.g. coping, social support, spirituality, self-efficacy, and optimism) and outcomes (e.g. despair, distress, QOL, and fatigue). Multiple linear regression analyses indicated that participation in the Pathfinders program was associated with lower distress and improved quality of life, adjusting for demographic characteristics. Improvements in distress correlated significantly with enhanced coping, social support, spirituality, and self-efficacy. Despite finding positive outcomes in the areas targeted by the program, there were some limitations including the small sample size, lack of a control group, and reliance on correlational data. In one randomized controlled trial, researchers examined the efficacy of the Meaning-Making intervention (MMi) for newly diagnosed breast and colorectal cancer patients (Lee et al., 2006). The MMi is intended to address existential issues by facilitating the development of meaning-focused coping strategies. Consisting of one to four individualized sessions, the MMi involves the discussion of beliefs about faith, religion, and spirituality. Journaling and guided imagery are used to explore the meaning of emotional and cognitive responses to cancer, in the context of previous life events and future goals. In the study, participants were stratified by cancer site and randomly selected to receive usual care (n=39) or four sessions (n=35) of the MMi. Patients with a diagnosis of brain metastases or psychiatric history were excluded from the study. The participants were asked to complete measures of self-esteem, optimism, and self-efficacy at 6 and 12 months. Controlling for baseline scores, the experimental group showed significantly higher levels of self-esteem, optimism, and self-efficacy compared to the control group (Lee et al., 2006). Baseline levels of self-efficacy were not significantly different from the 48 general population. Compared to participants, non-participants were older, less educated, and had lower incomes. Subgroup analyses comparing breast and colorectal cancer patients were not possible as the final sample consisted mostly of women with breast cancer. Researchers in a subsequent investigation sought to evaluate the acceptability and usefulness of the MMi for newly diagnosed (stage III or IV) patients with ovarian cancer (Henry et al., 2010). In this pilot study, participants were randomized to the experimental (n=12) and control group (n=12). The experimental group received usual care plus the MMi, and the control group received usual care and were placed on the wait list for the MMi. The participants’ level of fatigue was an important determinant of the pace and frequency of the intervention which ranged from 30 to 90 minutes. Each session was intended to facilitate participants’ self-exploration regarding existential or spiritual dimensions of living with cancer. The primary outcome of interest was existential well-being. Additional measures included quality of life, distress, anxiety, depression, and self-efficacy. The results indicated short-term benefits of the MMi, including a significant improvement in meaning in life and a trend toward greater quality of life and existential well-being (Henry et al., 2010). No significant effects were found for general self-efficacy or continuous measures of psychological distress. Based upon the findings, it is possible that the observed changes are the result of receiving the therapist’s time and attention as opposed to the intervention itself. The MMi is often used in conjunction with behavioural and educational interventions, making it more difficult to disentangle the effects of the MMi (Lee et al., 2006). One improvement to the study would be the inclusion of a larger sample size and a third comparison group to control for the effects of working with an attentive and supportive therapist (Henry et al., 2010). Improved standardization of the MMi and a longer follow up period would 49 also be useful for observing the impact of the MMi on psychological well-being. Nevertheless, these intervention studies lend empirical support to the notion that positive outcomes can follow from negative events, as some cancer patients even exceeded (i.e. thriving) their pre-diagnosis level of functioning (Carver, 1998; Lee et al., 2006). Meaning-focused coping may be one such mechanism that helps to account for these findings. 2.2.3 Cancer and Meaning-Making At the intersection of human health and spirituality, the study of spiritual coping and meaning-focused coping provides some insight into how people adjust to cancer. Rather than attempting to distinguish between spiritual coping and meaning-focused coping, each of which has some overlapping components, I use the concept of meaning-making (introduced in Chapter 1) to describe the ways in which people tend to derive meaning from their experiences. Meaning-making complements traditional theories of coping that posit a transactional relationship between the person and his/her environment (Bigatti et al., 2012; Folkman & Lazarus, 1988; Waldrop et al., 2011a). Meaning-making takes into account that people have both capacities and limitations which affect their ability to exercise personal agency and control in managing a stressful situation (McCorkle et al., 2011; Pargament & Mahoney, 2002). Although spirituality has received increased attention in the psychosocial oncology literature (Carroll, 2001; Girardin, 2000; Laranjeira et al., 2013; van der Spek et al., 2013), research on meaning-making is still relatively new, and few studies have considered how companion animals may be involved in this process (Nitkin, 2014). In the coping literature, support seeking is routinely reported among the strategies most often used by people to cope with cancer (Bigatti et al., 2012; Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992; Hopman & Rijken, 2015). People make meaning from their experiences 50 and, in many cases, seek out relationships and connections to validate these meanings (Neimeyer et al., 2010). Accordingly, these relationships allow people to experience attunement, meaning the process of “tuning into the subjective experience of another being and responding to that experience” (Lasher, 1998, p. 131). Attunement is regarded as a fundamental need (Bowlby, 1982; Winnicott, 1971) that, when fulfilled, provides a “psychological sense of accompaniment” (Blazina, 2011). Findings from recent studies suggest that some cancer patients do experience enhanced meaning, specifically, as it pertains to their intimate relationships (Molzahn et al., 2012; van der Spek et al., 2013). Relationships can provide a buffer against the effects of stress, and yet, it is also apparent that adjustment to cancer continues well beyond the conclusion of treatment (Bultz & Carlson, 2006; Kazanjian et al., 2012; Waldrop et al., 2011a). For many people, cancer represents a critical life event with enduring psychosocial, existential, and physical consequences (Boehmer et al., 2007; Kazanjian et al., 2012; Vachon, 2008). Research suggests that the stage of cancer can have a greater influence on how people cope with their illness than the specific type of cancer (Hopman & Rijken, 2015). When diagnosed at an advanced stage, a person is faced with the prospect of dying early. Existential issues refer to inexorable challenges of human life including loneliness, death, meaning, and freedom (Yalom, 1980). These issues may come into focus after a cancer diagnosis, prompting a person to reflect upon what is most meaningful in life (Girardin, 2000; A. J. Lopez et al., 2009; Yalom & Josselson, 2011). Research on spiritual and meaning-focused coping has all but overlooked the importance of companion animals. This is a substantial omission considering the potentially health-enhancing effects of human-animal bond practices such as kindred relaxation and mindful moments (Faver, 2009; Fine & Eisen, 2008). On the other side of the coin, for some people, the loss of a pet is both an inevitable and deeply impactful event (R. D. K. Brown, 2006; 51 Morley & Fook, 2005). Pet loss can be compounded by other losses that accompany cancer (e.g. decline in health, loss of a job), and are further complicated by issues surrounding the practice of euthanasia (R. D. K. Brown, 2006; Morley & Fook, 2005). Interventions designed to promote meaning-making and psychosocial adjustment to cancer must take into account both the benefits and risks of sharing one’s life with a companion animal. In summary, spirituality is increasingly recognized as being integral to the provision of holistic, patient-centered care (Carroll, 2001). Some authors question whether spirituality is too nebulous or ephemeral for empirical investigation, while others find the aim of formalizing spirituality into a treatment modality problematic (Girardin, 2000; Pargament & Mahoney, 2002). Some oncology settings include tools to assess spirituality (e.g. FICA, HOPE) as part of their routine assessments (Girardin, 2000). Hospitals and health care facilities offer services to address patients’ spiritual needs including prayer, meditation, blessings, the reading of sacred texts, visits from spiritual leaders, and visits with therapy animals or patients’ own pets (Carroll, 2001; Girardin, 2000). However, this last aspect of spiritual care remains understudied and underutilized in cancer care. Much of the scholarship on pets and human spirituality appears to be theoretical or conceptual in nature rather than empirical. Being in the presence of pets and attempting to relate to them is considered by some researchers as an “act of spiritual growth” (Skeen, 2011). With all that animals have to teach us about our spiritual development, perhaps it is no wonder that people continue to turn to animals in times of joy and suffering. 2.3 Spirituality and Pets 2.3.1 Spiritual Significance of the Human-Animal Bond The significance of animals for human spirituality has been documented throughout history in sacred texts, legends, customs, practices, and religious teachings (Brandes, 2010; R. D. 52 K. Brown, 2006; Coren, 2008; Hanrahan, 2011; Manes, 1997; B. P. Smith & Litchfield, 2009). Admired for their power and beauty, horses were worshipped as gods among ancient civilizations (Keaveney, 2008). In ancient Egypt, cats were associated with the goddess representing the sun, and were honoured accordingly (Walsh, 2009b). Mourning rituals were undertaken to mark the loss of a dog, including mummification and burial in one of Egypt’s animal necropolises (Coren, 2008; Walsh, 2009b). For their loyalty and companionship, dogs were revered as guides for their human caretakers in the afterlife (B. P. Smith & Litchfield, 2009; Walsh, 2009b). In traditional Indigenous Australian spirituality, dogs were thought to be capable of detecting the presence of evil spirits (B. P. Smith & Litchfield, 2009). Moreover, people in other parts of the world have participated in similar burial practices over centuries, attesting to the intensity and endurance of the human-animal bond (Brandes, 2010; Morey, 2006). Even today, some religious organizations offer animal blessings to acknowledge the significance of animals in people’s lives (R. D. K. Brown, 2006; Holak, 2008). Animal blessings can be traced back to St. Francis of Assisi, the patron saint of pets and animals in Catholicism (Skeen, 2011). Notably, these spiritual practices extend to ceremonies commemorating animals who have served in law enforcement and the military (Holak, 2008; Skeen, 2011). A common theme that emerges from research on spirituality is that of animals as “teachers” in relation to people (Grandin & Johnson, 2009; Keaveney, 2008; Maharaj & Haney, 2015). Among the spiritual lessons gleaned from humans’ interactions with animals are an appreciation of diversity, and a recognition of the kinship and interdependence of all living beings (Faver, 2009; Hanrahan, 2011; Keaveney, 2008). These spiritual lessons confer particular obligations including the responsibility of humans to care for the environment and its inhabitants (Hanrahan, 2011; B. P. Smith & Litchfield, 2009). Humans’ very survival and well-being depend 53 on their efforts to preserve the well-being of animals, both domesticated and wild (Faver, 2009; Hanrahan, 2011). When referring to pets, some authors prefer the terms “parent companion” or “human caretaker” instead of pet owner to convey the moral and ethical duty of people to care for animals (Hanrahan, 2011; Walsh, 2009b). Accordingly, domesticated animals are seen as a mediator between nature and culture, allowing people to go beyond traditional understandings of family, friendship, and companionship (Hirschman, 1994; Mosteller, 2008; E. Power, 2008). 2.3.2 Sacred Consumption and the Human-Animal Bond The human-animal bond provides experiences of a spiritual nature (Hill, Gaines, & Wilson, 2007; Holbrook, Stephens, Day, Holbrook, & Strazar, 2001; Keaveney, 2008). Pets are often kept inside the home and their physical proximity with people has particular meanings and implications (Mosteller, 2008). To illustrate, people and pets share a variety of consumption experiences (e.g. walking, eating, travelling, and watching TV) that transcend customary notions of possessors and possessions (Holbrook, 2008). These shared experiences have been referred to as “a sacred and spiritual consumption” (Holbrook et al., 2001). The consumer-pet relationship conveys a kind of intimacy that, according to some reports, is experienced as intrinsically rewarding rather than a means to an end (Holbrook et al., 2001; Podberscek et al., 2000). While pets may serve particular functions such as guarding the house or motivating people to engage in physical activity, these do not appear to be the primary reasons for having a pet (Hill et al., 2007; Holbrook, 2008). Pets may fulfill needs that exceed a person’s original expectations such as assisting in the accomplishment of important life projects or the resolution of existential concerns (Mosteller, 2008). To illustrate, people who see themselves as responsible pet owners may choose to take their dog for a walk everyday regardless of inclement weather. Such practices reinforce their self-concept and self-worth (Brooks et al., 2013; Mosteller, 2008). 54 Researchers have developed postmodern methodologies in an effort to better understand the consumer-pet experience (Hill et al., 2007; Mosteller, 2008). For example, in a phenomenological study, researchers conducted in-depth interviews with six participants regarding their professional work (e.g. breeding animals) in the pet care industry (Mosteller, 2008). The participants reported caring for between 6 and 100 animals at some point during the course of their career. The results suggested that participants were deeply committed to ensuring the well-being of the animals in their care. From their early childhood experiences, participants had been socialized to think of pets as family members, leading them to develop strong emotional attachments to animals (Blazina, 2011; Mosteller, 2008; Walsh, 2009b). Two themes were identified: rescuer and caretaker (Mosteller, 2008). The rescuer theme reflected participants’ views of themselves as having compassion, empathy, and a sense of duty to help animals. The caretaker theme referred to participants’ dedication to animals including the personal and financial sacrifices they made. Participants reported that caring for a large number of animals had a negative impact upon their well-being. At times, participants felt isolated, and, at others, they felt that having animals led to more opportunities to socialize with people. Another example of the use of novel methodologies is provided by a study involving canine life histories which had been developed for the purpose of documenting the lifecycle of companion dogs (Hill et al., 2007). These canine life histories were produced by the principal investigators using in-depth essays and personal self-reflections. An analysis of these ethnographic reports revealed the essential role of pets in family gatherings and important life transitions (e.g. family member going to college). Within the family, pets appeared to have more than one capacity, enabling them to relate to family members in terms of each member’s unique developmental needs. What began as everyday pet care responsibilities soon evolved into 55 cherished routines that helped to solidify the bond between pets and family members (Hill et al., 2007; Maharaj, 2013; E. Power, 2008). Quite simply, pets were seen as the embodiment of what gives meaning to daily life, permitting adults to become engrossed in the kind of delight and rapture that is often witnessed among children (Hill et al., 2007). 2.3.3 Meaning-Making and Companion Animals In view of the foregoing discussion, it is worth noting that the desire and capacity to find meaning in life is not contingent upon experiencing a negative event (Carver, 1998). Meaning-making can be thought of as a normative process that enables people to make sense of their experiences (Jim et al., 2006). For some people, the outcome of this process may be an enhanced sense of self-worth and self-efficacy in dealing with events, both good and bad (Boehmer et al., 2007; Costanzo et al., 2009; Lee et al., 2006). One intriguing aspect of human experience is how people tend to make sense of their relationships with animals, particularly, pets and companion animals. Observed almost universally among pet owners (Serpell, 2003), anthropomorphism refers to the tendency of people to attribute human feelings and qualities onto non-human animals (Hirschman, 1994; Walsh, 2009b). Examples of anthropomorphism range from the mundane (e.g. characters in children’s books) to the extreme (e.g. models of human disease) (Pagani, 2011). With greater access to domestic spaces, pets have become increasingly anthropomorphized, cementing their place as family members (Dotson & Hyatt, 2008; Hoffer, 2011). People talk to their pets, take photos of them, give them presents, celebrate their birthdays, and take them on family vacations (Coren, 2008; Holbrook, 2008; Walsh, 2009b). The idea of animals as being intelligent or having a personality (i.e. to anthropomorphize animals) is considered to be a “cardinal sin” by many human-animal bond researchers (Coren, 2011). Even as I compose this literature review, I am aware of my decision not to comply with 56 the formatting requirements of the American Psychological Association’s Publication Manual, which warn against attributing human qualities to animals or inanimate objects (American Psychological Association, 2010). Without getting into philosophical debates about the existence of mental or affective states among animals (Skeen, 2011), I agree with the common-sense approach advanced by Stanley Coren and Jonathan Balcombe, two leading experts in animal behaviour. These experts explain that the tendency to anthropomorphize animals is not only widespread among pet owners, but is inevitable (Balcombe, 2009) and something that people do “quite automatically” (Coren, 2011). Neither pet guardians nor researchers can ask animals what they think or feel. Instead, they can attempt to understand the animals’ behaviour using qualities (i.e. human characteristics) with which they are most familiar (Balcombe, 2009; Coren, 2008). Some of the concerns raised about anthropomorphism lie in the way that it tends to be conceptualized in research (Balcombe, 2009). To illustrate, it has been suggested that people who view animals merely as an extension of themselves are less capable of empathizing with them (S.-E. Brown, 2011; Hirschman, 1994). This view of animals implies a social relationship wherein the person is erroneously projecting feelings onto an animal and the animal does not reciprocate (S.-E. Brown, 2011). Along with my Master’s research on people and companion dogs (Maharaj, 2013), studies show that people do believe that pets can reciprocate feelings and emotions (Cohen, 2002; Fine, 2011; Sanders, 1993; Walsh, 2009b). Many people regard their pets as sentient (i.e. possess feelings) beings, capable of demonstrating empathy and engaging in goal-directed behaviours (Hirschman, 1994; E. Power, 2008; Sanders, 1993). Even at an early age, children recognize that animals share many important similarities with people and also differ from them in remarkable ways (Pagani, 2011; Pagani, Robustelli, & Ascione, 2008). Acknowledging similarity and acknowledging diversity are two integral 57 components of developing empathy towards others (Coren, 2008; Lasher, 1998; Pagani, 2011). In child development research, diversity is considered a ubiquitous feature of human life, and represents anything that is “not the self” or the “present self” (Pagani, 2011). At any moment, humans are tasked with having to relate to diversity in the natural and built environment which can “mobilize their empathic abilities” (Pagani et al., 2008). For humans, being in the company of animals often evokes curiosity and fascination (Davis, 2011; Faver, 2009; Grandin, 2005). Considering the deep significance of animals for many people, it is not surprising that people spend much of their time trying to understand and communicate with their pets (Cohen, 2002; Coren, 2008; E. Power, 2008). Shedding some light on the role of anthropomorphism in research, Coren (2011) recounts a conversation he had with renowned psychologist Donald O. Hebb. Hebb was describing his work at the Yerkes National Primate Research Center, during which he was attempting to document the temperament and behaviour of chimpanzees using objective language, devoid of human qualities and emotions. While reviewing his notes, Hebb proclaimed that he “couldn’t find any order, pattern or meaning in that kind of data” (Coren, 2011, para. 5). Hebb went on to remark that the animal keepers, who had spent the most time caring for these chimpanzees, often used anthropomorphic statements (e.g. shy or friendly) to describe the chimpanzees. To do their job, the animal keepers needed to be able to understand and explain the chimpanzees’ behaviour. Anthropomorphizing the chimpanzees helped to provide predictability and consistency in the way that the keepers interacted with the animals in their care. Two important points can be gleaned from Hebb’s story that I believe are relevant to understanding the experiences of cancer patients and their pets: the significance of finding meaning in what appears to be chaos, and the importance of understanding people’s everyday 58 experiences with caring for a pet. On a fundamental level, people are driven toward finding meaning and connection (Bowlby, 1982; Frankl, 2006). In studies on cancer and meaning-making, investigators have found that people actively construct a narrative of meaning as they adapt to the psychosocial consequences of living with cancer (Laranjeira et al., 2013; Molzahn et al., 2012; Vachon, 2008). While in previous work, researchers have tended to emphasize the negative sequelae of a cancer diagnosis, there has been greater interest in exploring the potential for growth and positive change among cancer survivors (Carver, 1998; Costanzo et al., 2009; Laranjeira et al., 2013). However, with the exception of research on animal-assisted interventions with cancer patients, the experiences of cancer patients and their pets have been virtually ignored in the field of psychosocial oncology (Larson et al., 2010). Accordingly, the aim of the present study is to develop an essential understanding of the nature and meaning of the human-companion animal relationship for people with cancer. 2.4 Conclusion In summary, I began this literature review with the objective of reviewing research on pet ownership among people living with cancer, prefacing this by commenting on the dearth of studies at the intersection of meaning-making and the cancer patient-companion animal relationship. Perhaps, as Katcher (as cited in Dotson & Hyatt, 2008) noted over 30 years ago, and still relevant today, reluctance toward sentimentality has turned some researchers away from studying the meaning of pets in people’s lives. As researchers continue to study the implications of pet ownership, it is important to remember that obtaining measurable and robust health outcomes is hardly what matters most to their human caretakers (Podberscek et al., 2000; Ryan & Ziebland, 2015). Caring for a pet provides continuity, enabling a person to contribute meaningfully to the welfare of another living being (Brooks et al., 2013). Pets bear witness to, 59 and participate in some of the most intimate areas of a person’s life (Blazina, 2011; Maharaj, 2013; E. Power, 2008). For some people, pets may be the ideal companions to accompany them as they discover what it means to live with and beyond cancer (Horowitz, 2008). This deeply personal and complex relationship should be considered worthy of formal scientific curiosity (Grandin, 2005). 60 Chapter 3: Methodology In this chapter, I outline my approach to addressing the research question: What is the lived experience of the human-companion animal relationship for people with cancer? I begin by describing the philosophical underpinnings of phenomenology. I draw upon Max van Manen’s work to situate the current study within the context of phenomenological inquiry. In describing van Manen’s work, I treat phenomenology as an attitude, method, and process of writing and reflecting. Next, I outline the research design including the study’s eligibility criteria, recruitment process, and research context. I describe the steps undertaken in data collection and analysis. For data analysis, I used a combination of van Manen’s (1997; 2014) and J. A. Smith et al.’s (2009) approaches, the former offering a framework to guide my reflections and interpretations, and the latter providing concrete analytical steps. The chapter concludes with a discussion of the criteria for assessing the trustworthiness of qualitative research. 3.1 Phenomenological Approach to Inquiry 3.1.1 Philosophical Underpinnings of Phenomenology Phenomenology has been described as a philosophy and a discipline. The suffix logy means word or study; phenomenon means “that which appears” without implying a specific domain or subject of study (van Manen, 2014). Phenomenology is comprised of a set of traditions embedded in 19th and 20th century European philosophy (Dowling, 2007; Langdridge, 2007; van Manen & Adams, 2010). A common concern among these varied traditions is investigating the source of meaning in everyday life (van Manen, 1997; Yontef & Jacobs, 2011). In transcendental phenomenology, a tradition that originated in the work of Husserl, phenomenological reflection takes place through the method of the reduction (van Manen, 2014). Whereas, in natural science, reduction entails reducing something to its simpler or more 61 fundamental components, here, reduction means that we embrace the complexity and ambiguity of a phenomenon. The reduction requires that we pull away from the natural attitude (i.e. our everyday beliefs about the world), and remain open to how phenomena present themselves in lived experience (Dowling, 2007; van Manen & Adams, 2010). Importantly, phenomena are not simply retrieved in consciousness but are constituted in terms of what they mean for us (Husserl, 1970). Proponents of Husserlian phenomenology consider description as being a key aspect of this approach, and interpretation as being outside the bounds of phenomenological inquiry (Dowling, 2007; Giorgi, 2000; Langdridge, 2007). Distancing himself from Husserl, Heidegger (2010) argues that phenomena are not just constituted in consciousness but are encountered in the world in which we engage with them. Heidegger proposes an interpretive phenomenology which rests upon the nature of being-in-the-world. From this ontological premise, human existence is already anchored in a “world of meanings” (van Manen & Adams, 2010). All modes of being-in-the-world are already modes of understanding the world. Consequently, people cannot be understood apart from the circumstances that influence their lived experience. While Heidegger prioritizes understanding over description (Husserl does the opposite), he shares with Husserl an emphasis upon exploring the phenomenon itself rather than the theories about the phenomenon. This point is crucial to understanding what phenomenology does and does not do. In phenomenology, we remain oriented to an experience as a possible human experience, and attempt to capture it in such a way that others can experience it (J. A. Smith et al., 2009; van Manen, 1997). Phenomenology does not aim for accurate descriptions of the subjective thoughts and opinions of a particular individual (e.g. case study) or group of individuals (e.g. ethnography) (Dowling, 2007). 62 Like Husserl, Gadamer (1998) sees the methods of natural science as being antithetical to the aims of human science. Natural science is concerned with investigating objects and events using quantitative measurement, detached observation, and controlled experimentation (van Manen, 1997). In the field of human science (e.g. phenomenology, ethnography, symbolic interactionism, critical theory, etc.), researchers are interested in studying people and how they express meaning in the world, for which the preferred methods are description, interpretation, and critical reflection. Human science is based upon an epistemology of language and text (i.e. we know through language) (van Manen, 1997). While nature can be explained using causal or probabilistic explanations, human life is understood by explicating the meaning of a phenomenon (Dilthey, 1987). A phenomenological human science is manifest in a deep fascination with what is unique or singular about a phenomenon (van Manen & Adams, 2010). In striving to grasp the uniqueness or essence of a phenomenon, (Merleau-Ponty, 2012) emphasizes the study of prereflective experience, in other words the experience that we live through in daily life. The essence of a phenomenon is something that without it, the phenomenon would not be what it is (Merleau-Ponty, 2012). To investigate the essence of a phenomenon, the researcher must adopt an attentive awareness (i.e. wondering pathos) and style of thinking that occurs in the attitude of the reduction (Merleau-Ponty, 2012; van Manen, 2014). Through the reduction, we aim to bracket theories and assumptions that prevent us from being in contact with lived experience (Merleau-Ponty, 2012). Not all phenomenologists agree about when or if the reduction is necessary. However, phenomenology demands that we thoughtfully examine our assumptions (Dowling, 2007). Considering that lived experience is mediated by thought and language, it becomes possible to access lived experience through thought and language (van Manen, 2014). 63 Accordingly, a principal concern of phenomenology is “textual reflection” upon lived experience (van Manen, 1997). When we reflect upon a text, we disclose something that is meaningful to us based upon our relationship to the subject matter (Gadamer, 1998). The beliefs and assumptions that are unique to a particular researcher are part of what makes phenomenology a worthwhile form of inquiry (Langdridge, 2007; K. A. Lopez & Willis, 2004). Each phenomenologist has his/her own “personal signature” and style (van Manen, 1997). This is not to say that phenomenology relies upon idiosyncratic research practices, nor is it desirable to imitate the work of others. By grounding our work in the traditions of phenomenology, we begin to “see” and “transcend” our limits (van Manen, 1997). By examining and making explicit our own assumptions (i.e. the reduction), we can be more open and inclusive of others’ experiences (Heidegger, 2010). 3.1.2 Situating Max van Manen’s Phenomenology Phenomenology, as proposed by Husserl and Heidegger, is considered to be a philosophy rather than a research method (Dowling, 2007; Giorgi, 2000; McConnell-Henry, Chapman, & Francis, 2011). Accordingly, I turned to the work of van Manen (1997) whose practical methods and techniques serve as a modern extension of the human science research tradition. Van Manen’s approach entails both the description and interpretation of lived experience (Dowling, 2007). As with Husserl and Merleau-Ponty, van Manen (1997) regards phenomenology as the study of essences or universals but is careful to emphasize that an essence is not some ultimate core of meaning. Where van Manen departs from Husserl is in his treatment of the reduction. Husserl, a mathematician by training, sees the reduction as a process of bracketing our assumptions, almost as if we are meant to separate our assumptions and set them aside (K. A. Lopez & Willis, 2004; van Manen, 1997). Although van Manen considers the reduction 64 necessary, in his view, Husserl’s notion of bracketing is not possible in the sense of complete reduction (Langdridge, 2007). According to van Manen (1997), if we attempt to ignore or discard our assumptions, they are likely to “seep back” into our interpretations and reflections. Similarly, Heidegger (2010) suggests that it is not possible to separate our understanding of the world from our “being-in-the-world.” Van Manen (1997) argues that we should bracket our assumptions and preconceptions not by discarding them but by making them explicit. We should keep our assumptions at a distance without trying to forget them or abandon them altogether. Strategies proposed by van Manen include actively listening to other people’s experiences and engaging in reflective journaling. In line with van Manen’s (1997) point about the reduction being necessary, it is worth noting that we often begin a study by saying that “little is known about this” or “more research is needed on this topic.” Phenomenology invites us to consider that, perhaps, “we know too much” (van Manen, 1997, p. 46). Due to our preconceived notions about the world, we assume we know something of the phenomenon before we fully consider our research question (van Manen, 1997). In Chapter 1, I posed the research question: What is the lived experience of the human-companion animal relationship for people with cancer? To paraphrase van Manen, my objective was to come to an understanding of what makes it possible to say that between a person and his/her companion animal, there exist the human-companion animal relationship. I drew upon six activities proposed by van Manen (1997) for conducting phenomenological research: 1) turning to a phenomenon which seriously interests us and commits us to the world, 2) investigating experience as we live it rather than as we conceptualize it, 3) reflecting on the essential themes which characterize the phenomenon, 4) describing the phenomenon through the art of writing 65 and rewriting, 5) maintaining a strong and oriented pedagogical relation to the phenomenon, and 6) balancing the research context by considering parts and whole (pp. 30-31). Firstly, in carrying out each of these six activities, I strived to be reflective, continually questioning and reflecting upon the importance of the human-companion animal relationship (van Manen, 1997). Secondly, I remained oriented to gathering descriptions of lived experience rather than theories or concepts about this relationship. Thirdly, I treated writing as being inseparable from researching the human-companion animal relationship (van Manen, 1997). Lastly, I considered that the phenomenological text that I produced would be one example among other possible interpretations. Consequently, I would have been remiss in attempting to arrive at a single and exhaustive description of the human-companion relationship (van Manen, 1997). Instead, my aim was to gather concrete examples or instances of the human-companion animal relationship in order to grasp the essences of this relationship for people with cancer. 184.108.40.206 Phenomenology as attitude Phenomenology aims to break through the natural attitude, in other words, the kind of taken-for-granted attitude with which we approach the world. The natural attitude is reflected in our belief that the world exists independently of how we experience it (Husserl, 1970; Mensch, 2003). In phenomenology, the intent is not to deny the natural attitude but rather acknowledge that our concepts and theories shape how we experience the world. In his seminal work, Husserl (1970) described the need for adopting an attitude of openness towards how things give themselves in lived experience. The phenomenological attitude is revealed in our attempt at being reflectively attentive to how people experience something before they conceptualize it. Van Manen (2014) uses the example of pain to illustrate the phenomenological attitude. We can rate 66 or quantify pain using instruments. We can conceive of pain as a sensation but, describing the actual experience is so difficult. It seems beyond words. As in the example of pain, our concepts and theories often originate from our everyday experiences, all of which are part of the natural attitude. Although there tends to be a distrust of theories that constrain our understanding of the world, theories do offer insights that enable us to access lived experience. Phenomenologists draw upon theories to expose what they potentially mask about lived experience (van Manen, 2014). Importantly, when we try to capture lived experience, we are already too late. We can only retrieve lived experience by reflecting upon it retrospectively, as when we recall a situation or event (van Manen, 1997). Accordingly, we are continually striving to capture lived experience and are faced with the impossibility of grasping lived experience. Rather than giving up, van Manen (2014) states that we should embrace this impossibility as part of what makes phenomenology so intriguing and demanding. Phenomenology compels us towards insights, understandings, and meanings that challenge our assumptions (van Manen, 2014). Through description and interpretation, phenomenology helps us to get at the structures of meaning embedded in lived experience. Phenomenology is not prescriptive in terms of its procedures and techniques. However, phenomenology does offer particular research methods that are developed in response to the research question, and are guided by a body of phenomenological scholarship (van Manen, 1997). Phenomenology is ever renewing and reinventing itself as a collection of practices that are creative, poetic, and insightful (van Manen, 2014). In his poem, Malte Laurids Brigge, Rilke states, “Did I say it before? I’m learning to see—yes, I’m making a start. I’m still not good at it. But I want to make the most of my time” (Rilke, 1992). After considering the aim of studying a phenomenon as rich and complex as the human-companion animal relationship, I found it 67 peculiar to think of starting such a project with a pre-determined set of procedures. In the spirit of modesty and optimism, I tried to make a start and make the most of my time. 220.127.116.11 Phenomenology as method Some theorists are wary of attempts to reduce phenomenological inquiry to a sequence of steps and yet, phenomenology is often described as a method (van Manen, 2014). The term method, however, is used to convey the aim of adopting a certain attitude and practising an attentive awareness to experience as we live it before we conceptualize it (Merleau-Ponty, 2012; van Manen, 2014). Husserl (1970) used the term “lifeworld” (Lebenswelt) to describe what people experience prereflectively without interpretation. Phenomenology aims to enrich our understanding of the meaning and importance of everyday experiences (J. A. Smith et al., 2009; van Manen, 1997). Perhaps better described as “meaning-giving methods,” phenomenology entails abstemious reflection, in that we abstain from theoretical or conceptual definitions of a phenomenon (van Manen, 2014). By reflecting upon prereflective experience, we can gain concrete insights into the meaning of a phenomenon. We may ask: What makes this experience distinguishable from others? Or, what is the nature, meaning, importance, or uniqueness of this phenomenon? As such, phenomenology is more a method of questioning rather than providing answers or drawing conclusions (van Manen, 1997). Phenomenology differs in important ways from other methods. Whereas the scientific method involves an objective and impersonal approach to inquiry, the phenomenological method calls for the use of the vocative by means of examples, images, and anecdotes (van Manen, 2014). The vocative refers to the expressive power of language and text which enables us to reveal the essence of a phenomenon. Mensch (2003) refers to this as a shift from exploring what is abstract to exploring what is particular about a phenomenon. In contrast to the social sciences 68 that are concerned with explaining phenomena, phenomenology aims to describe and interpret phenomena. Another notable departure from other methods is that phenomenology does not necessitate repetition, comparison of outcomes, and indexing of data (van Manen, 2014). Phenomenology does not seek to analyze concepts nor does it help us to develop theories to explain why something happens. Instead, phenomenology may bring in theories and concepts to show where these are lacking in terms of experiential meaning. Ultimately, experience is saturated with meaning, and phenomenology helps us to grasp that which makes seemingly ordinary experiences meaningful and lasting (J. A. Smith et al., 2009; van Manen, 2014). 18.104.22.168 Phenomenology as writing and reflecting Phenomenological writing is a process that entails both researching and reflecting upon the meaning of lived experience. Reflection takes place in the practice of writing, and writing is essential to the phenomenological method (van Manen, 2014). A related term is hermeneutics which is a methodology or philosophy that is concerned with interpreting text. Hermeneutic means that when we engage in reflection, we are aiming for discursive language as we interpret and ascribe meaning to the phenomenon under study (K. A. Lopez & Willis, 2004; van Manen, 2014). Much of phenomenology has hermeneutic or interpretive aspects but not all hermeneutics are phenomenology (van Manen, 2014). In using the term phenomenology, I am referring to hermeneutic or interpretive-descriptive phenomenology. Interpretive-descriptive phenomenology uses a systematic approach of questioning and reflecting in order to articulate the meanings that are rooted in lived experience (van Manen, 2014). The result is a phenomenological text that is designed to “awaken” an experience and to create a “sense of resonance” in the reader (van Manen, 2014; van Manen & Adams, 2010). 69 It is common in phenomenological writing to use the pronouns “I” or “we” where possible. This linguistic device is intended to communicate to the reader that a particular experience could be his/hers, and also that the reader’s experience could resonate with others, including me (van Manen, 1997). Phenomenological writing requires interpretive skills and creative talents on the part of the researcher to express the meaning of lived experience. Between reflecting and questioning is what van Manen (2014) calls “reflective insight” and “narrative ability.” Phenomenologists make use of expressive, poetic, and vocative language to evoke particular meanings that cannot be done with formal prose. Often used are anecdotes, stories, and concrete examples. Such experiential descriptions speak to our cognitive and noncognitive sensibilities. As van Manen (1997) suggests, a phenomenological text is not meant to express something that we know, but instead the text lets us experience something that we do not know in an intellectual sense. Similar to poetry, meanings are strongly embedded in a phenomenological text such that the text cannot be easily summarized or paraphrased (van Manen, 2014). While phenomenology often borrows insights from poetry, phenomenology is not the same as poetry. Phenomenological themes make explicit, essences, whereas, in poetry, themes remain “implicit and particular” (van Manen, 2014). Phenomenology uses vivid examples to make the participants’ experiences more accessible, thus, allowing the reader to grasp what is singular about the phenomenon. 3.2 Research Design Through systematic and empirical methods, I drew upon van Manen’s (2014) phenomenology to explore the relational meaning and importance of having a companion animal for people with cancer. In keeping with the attitude of the reduction, I did not treat the human-70 companion animal relationship as a concept, nor did I rely upon theories to make predictions or generalizations about this relationship. My objectives were to inquire about what makes this relationship unique and meaningful, and how this relationship arises in lived experience. To gather lived-experience descriptions, I used two methods described below: 1) the experiential data-gathering interview, and 2) photo elicitation. 3.2.1 Methods for Collecting Lived-Experience Descriptions 22.214.171.124 The experiential data-gathering interview My purpose in undertaking the interviews was to explore how people experience their relationship with their companion animal(s) as they were living with and recovering from cancer. I remained oriented to the meaning of the human-companion animal relationship as an “essentially human experience” (van Manen, 1997). I collected lived-experience descriptions by inviting participants to share anecdotes, stories, examples, and recollections (van Manen, 1997). As Merleau-Ponty (2012) stressed, I sought to elicit straightforward descriptions from the participants rather than their opinions or generalizations. My concern was less about the factual accuracy of the participants’ accounts, but rather the experiential quality (i.e. details, examples) of their descriptions (van Manen, 1997). Throughout the process of collecting data, it was valuable to keep in mind that lived-experience descriptions are not the same as lived experience. Lived experience, by its very nature, is elusive; we are always too late to capture it. Lived-experience descriptions are already transformed in some way by the fact that they are being recalled retrospectively (van Manen, 1997). Nevertheless, the experiential data-gathering interview allowed me to “borrow” other people’s experiences and carefully attend to their reflections on lived experience (van Manen, 1997). My concern was with the nature of the human-companion animal relationship in terms of 71 the following kinds of questions: How is this experience an example of the human-companion animal relationship? Is this what it means to connect with a companion animal? 126.96.36.199 Photo elicitation Prior to the interview, I invited the participants to bring in photos that depicted daily events or experiences involving their companion animal for discussion during the interview (Latham, 2003; Rose, 2003). I encouraged participants to share photos that were meaningful to them (Latham, 2003). My objective in using photo-elicitation was to bring the participants’ everyday experiences into the research process by encouraging them to reflect upon their experiences over a broader period of time than would have been possible without the use of photos (Latham, 2003; E. R. Power, 2013). I drew upon the following questions to elicit information about photos: Can you tell me what this photo means to you? What was it about this experience that you wanted to capture? Is taking photos of your pet something you would normally do? How are you experiencing the photo right now as we are looking at it? 3.2.2 Study Procedures 188.8.131.52 Participant selection I used a purposive sampling strategy (Flick, 2014; Miles, Huberman, & Saldana, 2014) to identify participants with the following attributes: at least 19 years old, fluent in written and spoken English, currently have a cat or dog, have received a diagnosis of cancer at least six months ago, and have had time to think about the importance of their pet since their diagnosis. There were no eligibility restrictions in terms of age, gender, or type of cancer. I focused on recruiting people with cats and dogs primarily, as these tend to be the most common pets in North America (Sandoe et al., 2015). Given variations in the life expectancy of cats and dogs, participants were not required to have had a pet prior to their cancer diagnosis. It was, however, 72 required that participants were currently living with their pet, and were one of their animal’s primary caretakers. With regards to sample composition, it was reasonable to expect that participants would be similar to one another in terms of being a pet owner, but could be heterogeneous in other respects such as age and occupational status. Heterogeneity was also anticipated among participants with the same type of cancer, considering the uniqueness of the cancer experience. The decision to recruit participants who were at least six months post-diagnosis was informed by research suggesting that this time period is useful for capturing changes which are important to a person’s adjustment trajectory (Linden, MacKenzie, Rnic, Marshall, & Vodermaier, 2015). In the first six months after diagnosis, it is likely that participants have completed a first wave of treatment. Within the next six months, participants are thought to have entered a “period of survivorship that is no longer overshadowed by acute treatment and its side effects” (Linden et al., 2015, p. 1392). Moreover, previous investigations have found that the stage of cancer can have a greater impact on a person than the specific type of cancer (Hopman & Rijken, 2015). It was preferable to recruit as many participants as possible at the stage of treatment completion (i.e. roughly 6 months post-diagnosis) and follow-up care given that these patient groups have not been studied as extensively as people who are more recently diagnosed (Hopman & Rijken, 2015; Linden et al., 2015; Waldrop, O’Connor, & Trabold, 2011b; Wenninger et al., 2013). 184.108.40.206 Recruitment and research context Following ethical approval, I contacted organizations that provide psychosocial support to people with cancer, and sought their permission to put up posters in their clinics or centres (Appendix B). The program coordinators of two cancer care organizations allowed me to 73 advertise the study in their respective newsletters. These newsletters were emailed to cancer patients and professionals working in oncology settings who had opted-in to a mailing list. I was also permitted to put up posters in pet stores, veterinary clinics, community centers, and coffee shops. The posters were intended to attract the interest of people who saw their relationship with their companion animal as being important to their cancer journey. Lastly, I reached out to individuals involved in human-animal bond initiatives including animal behaviour research, dog clubs and shows, and pet therapy programs. Three of the people I contacted agreed to post the study advertisement on their Facebook page. Recruitment took place over a four month period. Upon being contacted by phone or email, I arranged a brief phone call to confirm the participant’s eligibility and provide more information about the study. I emailed interested participants a copy of the consent form and requested that they contact me if they agreed to take part in the study or had any further questions. Most participants responded within a day or two after reviewing the consent form. In a few instances, I waited a week before following up with participants. During our second phone call, I sought the participants’ verbal consent to take part in the study, and arranged a time and place to conduct the interview. I reminded participants about the use of photos in the study and the option of bringing cell phone images or printed copies for discussion during the interview (Latham, 2003; Rose, 2003). All in all, 20 individuals contacted me 14 of whom took part in an interview. Three of these participants were referred to the study by a friend whom I had interviewed previously. Among the three people who declined to participate in the study, two did not reply when I emailed them and one agreed to participate and did not show up for the interview. The three remaining individuals contacted me a few weeks after the fourteenth interview at which point I had decided not to conduct any additional interviews. This decision was informed by the 74 recommendations of researchers that it is appropriate to suspend data collection once enough concrete examples have been collected from participants in order to produce detailed descriptions and anecdotes (Langdridge, 2007; J. A. Smith et al., 2009; van Manen, 1997). After reviewing the tapes and my notes, I determined that it was appropriate to conclude data collection. In phenomenology, the issue of sampling is important for collecting a rich dataset of concrete and experiential descriptions from people with relevant experience, as opposed to obtaining a specific number of participants (van Manen, 2014). Smith et al. (2009) have suggested interviewing six to eight participants as a reasonable sample size. However, I found it useful to collect data from a larger sample size given the relative diversity of the participants whom I interviewed. Considering that phenomenology aims for uniqueness and singularity rather than frequency and repetition (van Manen, 1997), my primary concern was not with achieving saturation, meaning the point at which no new information arises from subsequent interviews (Braun & Clarke, 2006). Instead, I sought to obtain comprehensive accounts from both cat and dog owners, men and women, and people at different stages in their cancer journey. 220.127.116.11 Interviews Eight interviews were held at the participants’ home, three at a university campus, two at a coffee shop, and one by phone due to geographical distance. Pets were present for interviews that took place at the participants’ home. At the start of our meeting, I reminded participants of the purpose of the study, and explained that the results would form the basis of my doctoral dissertation. Next, I gave the participants an opportunity to review and complete the informed consent form (Appendix C). I sought permission from participants to audiotape the interview and informed them that their names and pets’ names would not be included in any reports of the final 75 study. I explained that pseudonyms would be used for pets. I offered the participants a small honorarium of $25 to thank them for their time. One participant declined the honorarium; a second participant donated the money to a university program. After obtaining their consent, I informed the participants that the tape would begin recording. In an effort to build trust and rapport with participants, I began with the following statement: “I’m interested in what your relationship with your pet(s) is like, how it is important to you, and what it has been like over time and during your cancer journey.” I reminded participants about the photos and invited them to share these with me at any point during the interview. Some participants showed me collections of photos such as a photo calendar or memory book. Others shared video clips such as their pets’ birthdays, trips to the beach, and household chores. Still others opted to share only a few pictures that were particularly meaningful to them such as reuniting with their pet after being in the hospital or enjoying their nighttime routine with their pet. Some photos were taken recently while others were several years old. Early on in the interview, I asked participants to tell me about their diagnosis and cancer experience. Next, I asked participants to describe their pet and what makes this relationship important to them. My intent was to capture the stories of participants’ relationships with their pets during their cancer journey. The following question was used as an anchor point for the interview: When we go back to when you got your pet(s), what was it like then? Next, I followed-up by asking what their relationship had been like since then to get a sense of participants’ experiences with their pets over time. Some participants had their pet before receiving their cancer diagnosis whereas others had acquired their pet following their diagnosis. Considering that the chronological order of these two events (i.e. acquiring a pet, receiving a 76 cancer diagnosis) differed among the participants, it seemed wise to avoid using the time of diagnosis as an anchor point for the interviews. For participants who had their pet pre-diagnosis, I did not want to presuppose any changes to their relationship with their pets following their cancer experience. In addition, although a cancer diagnosis represents a significant life event, I wanted to be alert to other experiences that were pertinent to their relationship with their pet. For example, some participants emphasized the importance of their pets during other stressful periods such as ending a relationship with a romantic partner, dealing with addiction or substance use, and coping with mental health concerns. Moreover, I saw this approach as being consistent with the attitude of the reduction, which calls for the interviewer to listen to participants’ stories with openness and attentiveness to their lived experience (van Manen, 2014). Throughout the interviews, I remained oriented to the phenomenological aim of gathering detailed stories and anecdotes as opposed to general opinions and beliefs (van Manen, 2014). I drew upon a list of open-ended questions and neutral prompts to guide the interview (Appendix D). Examples of prompts were: What were you doing, What was your pet doing, Can you describe the place, How did you feel? The questions evolved over time with the aim of building rapport with participants and allowing them to discuss their interests and concerns (Flick, 2014; J. A. Smith et al., 2009). I refrained from asking participants to explain why something happened or what they thought about a particular issue (van Manen, 2014). More often, I opted to use silence or restate the participant’s last comment to elicit more information. When describing their pets, participants often mentioned recurring events such as meal times and daily walks. In these instances, I encouraged participants to recall a specific example or a recent experience and describe what was happening in as much detail as possible. 77 In determining when to conclude the interview, I tried to be mindful of participants’ body language and facial expressions. In some cases, participants appeared fatigued or requested a break. Some participants made comments such as “I think that’s about all I have to tell you” or “I can’t think of too much else to say.” Others asked me if I had any further questions for them. At this time, I inquired about whether there was anything else that participants wanted to share or if there was something we hadn’t covered up to this point. I sought their agreement to close the interview and stopped the recorder. Lastly, I asked the participants to provide demographic information by completing a short questionnaire (Appendix E). After the first three interviews, I met with my supervisors to discuss the interviews. During these conversations, we explored additional strategies such as emphasizing to participants the importance of providing as much detail as possible and describing what made a particular photo or story memorable to them. I also incorporated van Manen’s (1997) suggestions for eliciting information: active listening, being patient, paraphrasing the participant’s words sparingly, using silence, attending to the participants’ body language and facial expressions, and giving them space (van Manen, 1997). As a credibility check, my supervisor reviewed two of the audiotapes to ensure that I was refraining from asking leading or close-ended questions. In preparation for data analysis, I transcribed all 14 interviews myself. I kept the interview transcripts, audiotapes, and questionnaires separately from the participants’ contact information. All written and audiotaped material were encrypted and stored in password-protected electronic files, or secured in a locked filing cabinet to ensure the participants’ privacy and confidentiality. 3.3 Data Analysis In developing a systematic approach to analysis, I focused on the following research activities: reflecting on essential themes, which characterize the phenomenon, and describing the 78 phenomenon through the act of writing and rewriting (van Manen, 1997, p. 30). One objective was to develop themes which render the human-companion animal relationship a unique and distinguishable phenomenon. A second objective was to describe the importance of this relationship for people with cancer, through reflective writing and rewriting. Guided by van Manen’s analytic approach, I treated reflection and writing as parallel activities. The use of reflective methods enabled me to engage with the transcripts repeatedly by: a) making initial and exploratory notes, and b) isolating phenomenological themes through concrete methods and questions (van Manen, 1997). I sought to identify similarities, differences, and nuances within the data (J. A. Smith et al., 2009; van Manen, 1997). Along with van Manen’s reflective methods, I incorporated strategies from Smith et al. (2009) for actively reading the transcripts, preparing initial and exploratory notes, and working with a relatively large body of data. Considering that phenomenology is fundamentally a writing activity, it was important to continually reflect upon my position as a researcher. I kept in mind Smith et al.’s (2009) notion of the researcher as being “engaged in a double hermeneutic,” meaning that I was attempting to make sense of the participants’ experience as the participants were trying to make sense of their lived experience. I also considered the place of theme development within the context of producing a phenomenological text. For van Manen (1997), themes represent “creative shorthands” and “structures of experience” that enable us to get at the meaning of an experience, and bring order and coherence to our writing (p. 79). Themes help us to capture the meaningful aspects of a phenomenon without being exhaustive of a phenomenon. I drew upon van Manen’s methods for transforming lived experience descriptions into phenomenological descriptions: d) the experiential anecdote, e) the vocative method, and f) the data-interpreting interview (van 79 Manen, 2014). During data analysis, I employed these reflective methods in an iterative rather than linear sequence of steps. However, I describe them separately for the purpose of clarity. 3.3.1 Reflective Methods for Exploratory Noting and Theme Development Throughout the analysis, I kept a research journal to record descriptions of the data, as well as, my understandings, questions, and insights. I developed themes through an inductive process by grounding my interpretations in the participants’ accounts as opposed to outside preconceptions or assumptions (J. A. Smith et al., 2009; van Manen, 1997). In undertaking phenomenological reflection, I regarded phenomenological themes as being similar to anchor points around which I could develop phenomenological descriptions and interpretations of the human-companion animal relationship (van Manen, 1997). Themes enabled me to express and give shape to this phenomenon using concrete examples and stories from participants. 18.104.22.168 Making initial and exploratory notes During the process of transcribing the audiotapes, I began writing out my initial impressions and observations (J. A. Smith et al., 2009). Examples include: healing takes time and in the right conditions; people have a desire to let pets be in their natural spaces. The purpose of documenting my initial impressions was to become more aware of them so that I could then turn my attention to the participants’ words and meanings. Following data transcription, I selected an interview that I found to be particularly compelling with detailed stories and descriptions (J. A. Smith et al., 2009). I listened to the tape for a second time to remind myself of the participant’s tone of voice, pace, communication style, pauses in speech, and emotional responses such as laughter and tearfulness. Using van Manen’s (1997) wholistic approach, I read the transcript and highlighted phrases or words that were important to the research question. I pulled out data extracts that could be developed into an exemplary story or anecdote (van Manen, 80 2014). I took notes on the semantic content and the participant’s use of language (J. A. Smith et al., 2009). Employing a selective approach, I recorded phrases that were “particularly essential or revealing” about the human-companion animal relationship (van Manen, 1997, p. 93). Similar to van Manen (1997), Smith et al. (2009) have likened this process to “free textual analysis,” meaning that the researcher closely attends to the participant’s use of language to help make sense of the participant’s lifeworld or context (p. 83). Rather than dividing the transcript into segments and assigning codes to the data, my aim was to create detailed and comprehensive notes for each transcript. In my subsequent readings of the transcripts, I used three types of exploratory notes (J. A. Smith et al., 2009): descriptive comments, linguistic comments, and conceptual annotations (Appendix F). For descriptive comments, I took note of key objects, experiences, and events; for linguistic comments, I recorded the participant’s tone of voice, emotional responses, pauses, repetition, and pronoun use; for conceptual annotations, I engaged in an interrogative dialogue by asking questions and checking my interpretations against the participant’s account. This mode of questioning provided a critical foundation for building up to a more abstract level of interpretation, which is necessary for developing themes. 22.214.171.124 Developing emergent themes I drew upon van Manen’s (2014) and Smith et al.’s (2009) recommendations for transforming my exploratory notes into emergent themes. In reading over my notes, I asked: What do these notes say about the participants’ relationships with their pets, what do they say about the participants’ cancer experience, what meanings do the notes convey, what kinds of words and phrases can I use to capture these meanings? I sought to develop concise and expressive statements to condense the volume of exploratory notes while also preserving the participants’ original words, as much as possible (Appendix F). Once I had produced a set of 81 emergent themes for the first transcript, I moved to the next transcript and repeated this sequence of making exploratory notes and developing emergent themes. Given the inevitability of being influenced by the previous transcript, I tried to set aside my findings and approach each transcript in its own terms (J. A. Smith et al., 2009). 126.96.36.199 Isolating phenomenological themes In keeping with the attitude of the reduction (van Manen, 2014), it was important for me to be clear about what phenomenological themes are and are not. In terms of the former, I considered that themes are useful for bringing together my understandings and the participants’ understandings of their experiences. Regarding the latter, I considered that the process of isolating themes is not a purely cognitive or intellectual exercise (van Manen, 1997); themes are not derived by developing codes, taxonomies, or generalizations (J. A. Smith & Osborn, 2008; van Manen, 2014); themes are not merely constructed around a few vivid examples from the interview data (Braun & Clarke, 2006). Themes must retain their idiographic focus (J. A. Smith et al., 2009). In other words, they must be oriented towards the uniqueness of the participants’ lived experience while also remaining abstract enough to speak to the “essence of a certain type of experience” (van Manen, 1997, p. 97). Next, I returned to my research objectives, namely: to identify that which renders the human-companion animal relationship a unique and distinguishable phenomenon, and to describe the importance of this relationship for people with cancer. I typed and printed out the themes, cut them into strips of paper, and started arranging them. I used different colours of paper to keep track of the source (i.e. the transcript) of the themes. I identified patterns and connections by making note of emergent themes that were similar, parallel, or contradictory to one another (J. A. Smith et al., 2009). I treated emergent themes as examples or instances of the 82 human-companion animal relationship. I used the following questions as a guide for organizing emergent themes into phenomenological themes: What is the meaning of these emergent themes? What do these emergent themes reveal about the human-companion animal relationship? How does this emergent theme relate to others? Are there temporal relationships between the emergent themes? Are there areas of convergence/divergence? What is the overall narrative or context for these emergent themes? How can I capture these emergent themes using a phenomenological theme? Reflecting upon these questions led me to revise some of the emergent themes while discarding others or setting them aside for further consideration. In addition, I used concrete methods to identify relationships between the emergent themes (J. A. Smith et al., 2009). In the method of abstraction, I grouped together similar themes. I asked the following questions: Does an emergent theme in this transcript illuminate or extend a theme in another transcript? Which emergent themes are common across the cases (i.e. transcripts)? Next, I returned to the transcripts and began grouping together interview extracts that were similar in terms of content. I kept track of the extracts using the transcript IDs and line numbers. I used Microsoft Word to compile interview extracts that supported a particular theme. Aside from looking for areas of convergence, I used polarization to look for differences or oppositional relationships between the emergent themes. A third method known as contextualization was instructive for determining whether emergent themes were related to significant life events such as undergoing cancer treatment, moving residences, changing careers, or ending a relationship. 83 Through the methods of abstraction, polarization, and contextualization, I developed eight phenomenological themes that were relevant to the sample of participants as a whole (J. A. Smith et al., 2009). I retained an idiographic focus by selecting extracts from the individual cases to show the richness and diversity of participants’ experiences (J. A. Smith et al., 2009). Another strategy used to further refine the eight phenomenological themes was “free imaginative variation” (J. A. Smith et al., 2009; van Manen, 1997). According to van Manen (1997), this method involves imagining changes to phenomenological themes and asking whether these themes are an essential part of the phenomenon. I asked the following questions: Can I imagine the human-companion animal relationship without this theme? Is the relationship still meaningful if I were to “imaginatively change or delete this theme from the phenomenon” (van Manen, 1997, p. 107)? Proposing changes to each of the themes allowed me to consider what was invariant about the themes. In working with a relatively large dataset, such as a sample of 14 participants, it was helpful to have a measure of recurrence, meaning how often a phenomenological theme appears across the set of interviews (J. A. Smith et al., 2009). Van Manen (1997) addresses recurrence when he describes a theme as an “element (motif, formula or device) which occurs frequently in the text” (p. 78). I used the following criterion to define what I considered to be an indication of recurrence: a phenomenological theme was considered recurrent if it was present in at least one third (n=5) of the interviews. However, as Smith et al. (2009) caution, I did not place too much emphasis upon frequency counts, instead using recurrence as a means of exploring patterns and commonalities across the interviews. Finally, I looked for connections between the phenomenological themes, using the method of subsumption to develop three super-ordinate themes. Phenomenological themes that shared higher order concepts were then arranged to form 84 a super-ordinate theme that was applicable to several cases. For example, the phenomenological themes, “It’s sort of silly, but” and “It’s a sense of responsibility,” were organized into the super-ordinate theme, “Pulling you out of yourself” in an effort to reflect the higher order concept of pets as providing a meaningful distraction from their illness. 3.3.2 Reflective Methods for Writing and Rewriting a Phenomenological Text In the process of writing, I aimed to create a text that would have resonance for the reader, meaning that he or she could recognize the participants’ experiences as plausible human experiences even if he/she had not experienced them personally (van Manen, 2014). I used the following reflective methods to transform lived experience descriptions into a phenomenological text: the experiential anecdote, the vocative, and the data-interpreting interview (van Manen, 2014). In doing so, my intent was not to arrive at a fixed or normative understanding of the human-companion animal relationship but rather to show the uniqueness of the person’s understanding—both the participants’ understanding and mine as the writer (Gadamer, 1998). In line with van Manen (2014), I aimed for precision by using words and phrases that would highlight the tone, texture, and richness of the participants’ accounts. 188.8.131.52 The experiential anecdote The process of developing experiential anecdotes required a close reading and re-reading of the transcripts to identify illustrative data extracts for each of the phenomenological themes. In accordance with the criteria of explicitness and vividness, I sought to edit or condense data extracts such that the participants’ lived experience could come through more explicitly and vividly (van Manen, 2014; Whittemore, Chase, & Mandle, 2001). A second purpose of editing the anecdotes was to enhance readability. I formatted the anecdotes using indentation, single-spacing, and plain font. Where possible, I retained the words that participants had repeated for 85 the purpose of emphasis, and used dashes to show hesitation or pauses in speech. I used an ellipsis to remove identifying information (e.g. names of people and locations), as well as, to omit extraneous material such as minimal encouragers (e.g. hmm, um). I preserved pets’ anonymity by using pseudonyms from an online list of popular dog and cat names. I used rounded brackets to indicate the type of pet that participants were referencing in a particular anecdote. Square brackets were used to identify words that I had added to the text to maintain the participants’ anonymity, or to enhance the readability of an anecdote. Aside from using plain font, I developed anecdotes, shown in italics, based upon van Manen’s (2014) suggestions for creating an experiential anecdote. These italicized anecdotes share the following features: illustrate a particular incident or experience, contain concrete details, and feature a compelling story. I produced these anecdotes by putting them into the present tense, deleting pauses or repetitions, adding personal pronouns or pseudonyms for pets, and highlighting the emotions displayed by participants. In constructing anecdotes, my intent was not to make generalizations based upon the participants’ experiences. Instead, I considered whether their experiences were plausible, or, in other words, if they seemed true to what the reader would expect if he/she had encountered these experiences personally (van Manen, 2014). 184.108.40.206 The vocative method While the reduction can be thought of as a style of thinking, the vocative refers to an expressive style of writing for developing phenomenological themes and experiential anecdotes (van Manen, 2014). In applying the vocative method, I drew upon narrative devices such as alliteration, repetition, imagery, and metaphor. For example, in the phenomenological theme “It’s amazing how in evolution,” I used the metaphor of pulling on a thread to illustrate the impact of cancer upon participants’ relationships with pets and people. In the phenomenological 86 theme, “It flickers by so quickly,” I referred to photos as moments flickering by, in an effort to describe the experience of loss. The process of transforming lived experience descriptions into a phenomenological text involved pulling out rich and detailed examples from the interviews and offering my interpretations of these examples. I used poetic devices to intensify the meaning of the text, and to draw the reader’s attention to the importance of the human-companion animal relationship. To illustrate, in the phenomenological theme, “It’s sort of silly, but,” I used descriptors for different bodily senses to capture what I referred to as “transcendent play.” In the phenomenological theme, “It’s a sense of responsibility,” I drew the reader’s attention to the home as a tableau and rich backdrop for the intimate moments shared between participants and their pets. 220.127.116.11 The data-interpreting interview Through data-interpreting interviews, I sought the assistance of cancer care professionals and health researchers with analyzing extracts from the 14 original interviews. Specifically, I invited them to read a few anecdotes and share their impressions and insights with me. This analytic method differs from member-checking which involves returning to the original interviewees and asking them to confirm the accuracy of the interview transcripts or the researcher’s interpretations of the data (McConnell-Henry et al., 2011). By engaging in thoughtful and collaborative dialogue, the purpose of these data-interpreting interviews was to add interpretive insights rather than attempting to verify my findings (van Manen, 2014). These insights helped me to revise my interpretations and refine the set of phenomenological themes (van Manen, 1997). Interview prompts included: How does this anecdote resonate with your experience? What aspects are surprising or not surprising? 87 3.3.3 Trustworthiness Criteria for Qualitative Research In this section, I outline research conditions that helped to enhance the rigour of data collection and analysis. I discuss four criteria that were used to assess the trustworthiness of the findings. Trustworthiness refers to the “quality” of the research design, or, in other words, the use of systematic and verifiable methods that yield plausible and convincing results (Lincoln & Guba, 2016; van Manen, 1997). 18.104.22.168 Conditions for data collection Prior to beginning the study, I familiarized myself with the historical and philosophical traditions within which the study is grounded (K. A. Lopez & Willis, 2004; van Manen, 2014). I consulted primary sources (e.g. Husserl, 1970; Gadamer, 1998), as well as, secondary and tertiary texts. With regards to the research design, I used a purposive sampling strategy to select participants who were diagnosed with cancer at least 6 months ago, and currently had a cat or dog. Importantly, this sampling strategy did not only apply to the eligibility criteria. I made use of purposive sampling to collect examples of “experientially rich descriptions,” meaning interview responses that contained vivid, concrete, and detailed descriptions of the participants’ experiences (van Manen, 2014). Toward this end, I made clear in the recruitment poster that I was intending to speak with people regarding 1) how they experience their relationship with their pet during and after their cancer experience; 2) what makes the human-pet relationship, unique and meaningful to them; and 3) how this relationship is important to their cancer journey. During the participant interviews, I kept in mind that my objective was to elicit detailed stories and examples rather than opinions or beliefs about pets in general. A second objective was to gain a shared (i.e. between myself and the participants) understanding of the participants’ lived experience. I listened to their stories with openness and curiosity (van Manen, 2014). I 88 sought clarification when needed. I avoided rushing participants. I used paraphrasing judiciously. I opted to use silence, open-ended questions, and neutral probes to encourage participants to elaborate upon their responses (e.g. tell me more about that, what happened next?). The use of audiotapes and verbatim transcripts helped to preserve the participants’ words and verbal cues (e.g. pauses, disfluency, laughter, etc.) that accompany speech. The recruitment of 14 participants is consistent with the goal of triangulating data from multiple sources to promote trustworthiness (Lincoln & Guba, 2016). However, rather than attempting to achieve a particular sample size or sample composition, I sought to collect a sufficient volume of concrete experiential descriptions that would enable me to explore the nuances and complexities of the human-companion animal relationship (J. A. Smith & Osborn, 2008; van Manen, 2014). These experiential descriptions provided ample material with which to develop phenomenologically rich accounts that contained detailed examples and anecdotes. The term saturation typically refers to the point at which the data no longer reveal anything new or different from earlier interviews (Braun & Clarke, 2006). In an effort to reach saturation, I elicited a wide array of experiential descriptions from participants that captured unique and significant aspects of their relationship with their companion animals (J. A. Smith et al., 2009; van Manen, 1997). 22.214.171.124 Conditions for data analysis Consistent with van Manen’s (1997) approach, I demonstrated objectivity by remaining focused on the overall aim of the study (the lived experience of the human-companion animal relationship for people with cancer). At the same time, I displayed subjectivity by considering each participant’s unique experiences and understandings. I used comprehensive exploratory notes and reflective questions to guide my analysis as opposed to analytic codes and frequency 89 counts. Some anecdotes were largely unedited while others were revised using van Manen’s (2014) approach to constructing an anecdote. By editing these pieces of raw data, I questioned whether I was falsifying the data or lessening their credibility. Once again, I returned to the principles that distinguish phenomenology from other approaches. According to these principles, phenomenology aims to show human experience in its possibility and variety (van Manen, 2014). Its understandings are meaning-based. Phenomenology uses empirical material without making empirical generalizations (McConnell-Henry et al., 2011; van Manen, 2014). To assess trustworthiness, I considered four criteria that are relevant to establishing confidence in the findings and interpretations of a qualitative study: credibility, transferability, dependability, and confirmability (Lincoln & Guba, 2016). Firstly, I used systematic methods of data analysis, involving sustained engagement with and reflection upon the audiotapes and verbatim transcripts. Along with attending to negative cases, I employed triangulation of sources (i.e. 14 participants), investigators (i.e. data-interpreting interviews with professionals), and theories (i.e. comparison of study findings with relevant theories and investigations) (Lincoln & Guba, 2016; J. A. Smith et al., 2009; J. A. Smith & Osborn, 2008; van Manen, 2014). Secondly, in the methods and results chapters, I provided as much detail as possible regarding the research context and participant accounts, keeping in mind the aim of illuminating other people’s experiences (Lincoln & Guba, 2016). I considered how these detailed narratives could shed light on the experiences of people in other settings and contexts. As such, my intent was to promote the transferability of the findings without claiming that the results would necessarily hold true for other population groups; the ability to generalize study findings or interpretations is not an objective of qualitative research (Lincoln & Guba, 1985; J. A. Smith & Osborn, 2008; van Manen, 2014). Furthermore, I understood transferability as a quality that is 90 determined neither by me, the researcher, nor by means of particular analytic methods. To be clear, transferability is based upon the reader’s consideration of the text and the extent to which the study findings are applicable to him/her (Lincoln & Guba, 2016). Do the findings resonate with him/her? In accordance with transferability, the findings were intended to be rich in experiential detail so as to compel the reader to reflect upon his/her own experience. In line with the third and fourth criteria, I sought to achieve dependability and confirmability by keeping an audit trail (i.e. research journal) throughout the entire research process. This audit trail helped to ensure that the findings would be grounded in systematic and verifiable procedures that could be reproduced by other investigators. I began by recording my assumptions about the experience of cancer and the human-companion animal relationship (Creswell & Miller, 2000; Lincoln & Guba, 1985, 2016). An audit trail is also consistent with the method of the reduction as it allows the researcher to examine critically his/her role as an interviewer and analyst (van Manen, 2014). I continued recording my reflections on the research process, documenting the methods I used to arrive at my findings and interpretations. I solicited feedback from my supervisory committee regarding my data collection and analytic methods. I also sought the assistance of two human-animal bond researchers and three cancer care specialists to improve the rigour and coherence of my analysis (van Manen, 2014). The use of peer debriefing through data-interpreting interviews was important not just from the standpoint of intersubjectivity (i.e. shared understandings) but also triangulation (van Manen, 1997). The knowledge and expertise of these five individuals provided a credibility check, encouraging me to reexamine my analytic methods and develop more abstract interpretations of the interview data (Creswell & Miller, 2000). Several aspects of the data-interpreting interview were especially illuminating with respect to understanding my role as 91 researcher. This method helped me to appreciate that phenomenological understandings are not fixed but, instead, are co-constructed by both the participants and me (Gadamer, 1998; van Manen, 2014). The data-interpreting interview was also useful for addressing the social desirability bias, which refers to the tendency among interviewees to try to say the “right thing” when responding to the interviewer (van Manen, 2014). Had I elected to undertake participant validation, for example by using the technique of member-checking, I could have run the risk of leading participants in a specific direction or encouraging them to express agreement with my interpretations (McConnell-Henry et al., 2011). Leading participants, even unintentionally, would have gone against the spirit of openness that exemplifies phenomenology. Furthermore, it would have been incorrect for me to assume that confirming the accuracy of the results would effectively determine the quality of the study as a whole (McConnell-Henry et al., 2011). As noted above, the criterion of dependability refers to the reproducibility of the research process (i.e. methods and procedures) not the results. 92 Chapter 4: Results This chapter begins with an overview of the socio-demographic characteristics of the participants. The eight phenomenological themes are presented in Figure 2. Using the method of abstraction, I have arranged these eight themes into three higher level themes, known as super-ordinate themes (Smith et al., 2009). Each super-ordinate theme is introduced with an illustrative anecdote, followed by a brief definition and description of the phenomenological themes captured under the super-ordinate classification. Within each of the eight phenomenological themes are detailed anecdotes and quotations, drawn from the interviews with participants. In addition, I provide interpretive insights and commentaries that I developed using reflective methods such as the vocative and the data-interpreting interview. The chapter concludes with my reflections regarding the use of photo-elicitation during the interviews. 4.1 Demographic Characteristics Table 1 presents socio-demographic data and cancer information collected from the nine women and five men who took part in the study. Demographic characteristics Participant n=14 Age 30-39 1 40-49 5 50-59 1 60-69 6 70-79 1 Gender Female 9 93 Male 5 Ethno-cultural background Caucasian 12 Caribbean 1 Metis 1 Highest level of education High school 1 Vocational 1 University/college 10 Graduate/post graduate 2 Employment status Employed 2 On-leave/on disability 5 Retired 7 Relationship status Single 4 Married/domestic partnership 8 Separated/divorced 1 Widowed 1 Living arrangement Alone 4 Partner/children 9 Roommate/friend 1 Cancer type/primary tumor site Breast 5 Cervical 1 Ovarian 1 Prostate 1 Lymph nodes 2 94 Liver 1 Colon 1 Intestinal/peritoneal 1 Bone marrow 1 Type of treatment(s) Surgery 1 Radiation therapy 1 Chemotherapy 3 Combination of treatments above 9 Time since diagnosis < 1 year 2 1-3 years 7 10+ years 5 Time since last treatment < 1 year 9 1-3 years 1 8+ years 4 Table 1 Participant socio-demographic and cancer information As noted in Table 1, the majority of participants were Caucasian, over the age of 40, university- or college-educated, and living in a household with other people. Roughly half of participants described themselves as married or in a relationship. Of the participants who were unemployed at the time of the study, some had taken early retirement while others were on leave from work due to their illness. There was considerable variability in the type and site of cancer, with breast cancer being the most commonly reported cancer. Five participants reported having a tumor in 95 more than one part of their body. These tumors were either the result of a metastatic cancer or an unrelated secondary cancer. Nine participants described undergoing a combination of treatments that included surgery, chemotherapy, and/or radiation therapy. For more than half of the participants, between one and three years had elapsed since their initial diagnosis, and most participants had received some form of cancer treatment within the past year. Information pertaining to pets is presented in Table 2. The results are presented by participant demographic characteristics and pet characteristics. Demographic characteristics Participant n=14 Type of pet in their care Cat 5 Dog 6 Both cat and dog 2 Fish 1 Had a pet previously Yes 14 No -- Acquired current pet(s) Before cancer diagnosis 11 After cancer diagnosis 3 Number of pets Single-pet household 10 Multi-pet household 4 96 Pet characteristics Cat Dog Fish n=13 n=10 n=1 Sex Female 9 8 -- Male 4 2 1 Age <1 year -- -- 1 2-5 years 5 4 -- 6-10 years 4 4 -- 11-16 years 4 2 -- Table 2 Pet information A total of 24 pets (13 cats; 10 dogs; 1 fish) were currently in the care of participants. Of those living in multi-pet households, participants had two, four, or six pets. The age range was 2 to 16 years (Mage=8) for cats; 3 to 12 years (Mage=7) for dogs; and one month for fish. Participants had a variety of cat breeds including Tabby, Maine Coon, Siamese, Tortoiseshell, and mixed breeds. Most participants had small- (less than 20lbs) to medium-sized (30 to 45lbs) dogs including the Cairn terrier, Miniature Pinscher, Shih Tzu crosses, Poodle mix, Pug, and Border Collie x Shepherd cross. Large-sized (55 to 80lbs) breeds were the Chocolate Labrador Retriever and Golden Retriever. The breed of fish was Betta, also known as Siamese fighting fish. All participants reported having a pet prior to their current pet, and two participants indicated that it was another family member’s wish to have their current pet. The most common reasons cited for having a pet were companionship, love of animals, desire to give pets a good quality of life, and 97 a perception that pets provide fun, humor, and joy. Other notable reasons were getting exercise, learning life lessons, and receiving acceptance and compassion. 4.2 Findings Figure 1 The eight phenomenological themes organized into super-ordinate themes 4.2.1 Super-ordinate Theme: (Dis)connecting with the Journey I feel pieces of stories coming up, it’s interesting. I’m having a difficult time. I’m thinking about my journey with her after being diagnosed like when I had just gotten her. It’s interesting being on the other side of it and seeing how disconnected in many ways I am to the journey, to the cancer experience where it was so raw for so long but I’ve done so much work on it, all the retreats, support groups, day healing sessions, yoga, and breath work and everything else I’ve done have definitely gotten me to where I am now. But then adding these two (pets) into it is a whole different facet of things (Female, cats and dogs). In cancer, the cells grow and multiply uncontrollably, defying normal biological processes of renewal and decline. This proliferation of cells takes root in the body, staying put or extending its reach into the surrounding tissues and organs. Some cancers are classified by the The Human-Companion Animal Relationship (Dis)connecting with the Journey • It’s hard to erase those words • It’s amazing how in evolution • It flickers by so quickly Speaking Volumes with their Actions • It’s a silent kind of love • It mattered that they were there • It’s like each living thing has meaning Pulling you out of yourself • It’s sort of silly, but • It’s a sense of responsibility 98 cells and tissues from which they originate rather than the parts of the body that are affected if the cancer spreads. The disease we call cancer is as varied as the experiences of people directly affected by cancer. Much like the disease itself the experience of cancer often runs counter to people’s expectations about the normal course of events in their life. This insidious cluster of cells quietly dwells in the body until the silence is shattered by the words “you have cancer.” If participants were asked to draw a straight line from the onset of their symptoms to the beginning of treatment, the line would barely touch the twists and turns that they had encountered while going through the diagnosis phase. To paraphrase a participant, getting the trauma out of their body, called for swift action to remove or slow the growth of cancer. At the conclusion of treatment, participants felt as if they had been cut off abruptly and sent off into the unsteady terrain of living without the consistency and regularity of being a full-time patient. The once galvanizing force of a cancer diagnosis now seemed to lose its hold on the participants’ team of supporters, which included their family members, friends, co-workers, and health care providers. The loss of these relationships was compounded by the sense of chaos and uncertainty surrounding cancer treatment and the potential for a cancer recurrence or secondary cancer. It was apparent from the participants’ accounts that trauma did not begin and end with cancer. Like cancer, having a pet underscored the impermanence of life. For some participants, watching their pets languish from illness or old age became a painful reminder of the trauma that they had endured during treatment. This super-ordinate theme captures the meanings participants attributed to their cancer experience and the importance of their relationships with their pets. The term journey is suggestive of an experience that takes place over time, with an indeterminate beginning and end. The use of a parenthesis in the title highlights the tensions that arise in the experience of cancer 99 such as in the masking and unmasking of the disease, the doing and undoing of relationships, and the failing and unfailing grasp on moments shared with pets. Relationships with pets, although not impervious to the stress of cancer, provided a meaningful connection, and one that evolved from their shared journey. Participants seemed grateful for the time they had spent with their pets during treatment, both moments of quiet and stillness and those of joy and relief. This super-ordinate theme is comprised of three themes: 1) It’s hard to erase those words; 2) It’s amazing how in evolution; and 3) It flickers by so quickly. 126.96.36.199 It’s hard to erase those words This theme captures how cancer is unmasked and revealed to the person (i.e. diagnosis), and how cancer is revealing in the sense of leaving the person unmasked and revealed (i.e. effects of cancer and treatment). Firstly, the manner in which cancer was revealed had different meanings for participants. Some described experiencing unsettling and inexplicable symptoms prior to their diagnosis. As in the comments below, participants’ concerns grew exponentially amid curious bouts of pain, fatigue, and nausea, followed by doctor’s appointments and emergency room visits: I had a problem with neuroendocrine tumors or carcinomas. It’s not easily diagnosed because it’s masked by so many other things like panic attacks…It wasn’t until a large bulge started to grow right here that they thought it was twisted bowel syndrome and so they gave me medication to relax the bowels and of course it wasn’t going away and then it started to go ischemic. I went to the hospital because I couldn’t stop throwing up…I was in a lot of pain and then they found the tumor with the CT scan (Female, cats). I was starting to get some strange symptoms. I was going in and out of the doctors and nothing really came up. For the first half of the year my energy was just really starting to decline. My focus and concentration were starting to go and I was starting to look like I was six months pregnant. The doctor did a sonogram on me and I was absolutely terrified because I knew I was not pregnant. There were a lot of symptoms and that began the journey of going into see a specialist, then went for emergency surgery and four weeks later was diagnosed and started chemotherapy three days later (Female, cats and dogs). 100 These comments highlight the participants’ distress in response to the sudden onset of symptoms. These signs and symptoms alerted them to the possibility of something sinister in their body while also continuing to mask and conceal the cancer until it was disclosed to them. In the process of going through testing, participants described how their test results would come back negative or inconclusive until that which seemed inexplicable was now revealed with the words YOU--HAVE--CANCER. The once nebulous array of signs and symptoms, powerful and perplexing, took shape and was given the name cancer. In the words of a participant: Until you have that dreaded name cancer in your body—we’re just lucky we got it in time. Until you have it or somebody close to you, you don’t understand what that word means, not at all. Somehow she’s (dog) picked up that something was wrong and just her friendliness and wanting to be petted. It’s all part of saying I’m here to help (Male, dogs). That “dreaded name” seemed to cling to the body just like the cancer itself. As this participant stated, to truly know the meaning of this word is to have the word touch you or someone close to you. This word rang hollow when it came to pets who instead picked up on the sense that something was wrong. A second participant described the comfort she received from her dog: She gave me a lot of strength, bolstered me up into pushing through any of the fear and the kind of stories that I would create in my head, or if I would read or hear about other people’s stage IV situations…and this one oncologist actually said to me “well you might already be stage IV, the cancer might have already spread and we just don’t know.” She was very negative and after that it’s hard to erase those words. I would attach to those words and create a story based on those words. I would just get so much comfort from holding Stella and stroking her and just feeling her “My little love” (Female, dogs). Some participants attributed their cancer diagnosis to lifestyle choices with one explaining “in many ways my experiences and my decisions created my cancer.” Others believed that genetic and environmental factors had made them more susceptible to illness. In some cases, these beliefs were confirmed through genetic testing. Still other participants were confronted 101 with questions such as “why me?” and “why should I even bother?” Even in the absence of satisfactory answers, participants found solace in their relationship with their pets: I was at home and I was really depressed and trying to make a decision about how far I want to go and this and that. And I looked at Rocky and Penny who were sleeping by my bed and I was thinking, you selfish human being, I mean you adopted them. You promised them that you’d be there for the rest of their life. Just by taking them and adopting them, you made that promise to them (Female, cats). For many participants, being told that they had cancer came as a shock. One participant called it “a big trajectory change in terms of life, career and pretty much everything else.” In some cases, the diagnosis happened to coincide with other significant life events such as ending a long-term relationship. In others, it was the diagnosis itself that had prompted these events. With regards to career, some participants had to go on stress leave with a few commenting that they still have not been able to return to full-time work. Others reported taking early retirement such as a participant who exclaimed “it was the cancer that forced the retirement” going on to say “if I’m dying why am I working?” Another retiree expressed concern for fellow cancer patients: I’ve talked to people and they say that they have financial issues. They can’t work and they don’t have any source of income and I don’t know how they can do it because there are just so many other things demanding of your body and your mind and to have this other stuff weighing on you, it must just be totally overwhelming (Male, dogs). The shock of a cancer diagnosis seemed to heighten the emotions surrounding other life events. One participant recounted the precise moment she found out she had cancer, saying “I’d just gotten my dream job and it was the first day that I was there, the first hour at my new job and I got the phone call. I had surgery and took about five weeks off.” Similarly, a second commented: We found out when I had a colonoscopy. And right then the doctor came back and said “You have cancer” and I was sitting there, “whoa,” and he said you have it in two places at both top ends of your colon. Then he said I’ve already talked to the surgeon, and I’m still waking up from the drugs, and he said she’ll see you in two weeks so I walked out of there. I sort of woke up and I said oh I’ve got colon cancer (Male, dogs). 102 Akin to the experience of being roused from sleep, life changed in an instant with the words “you have cancer.” Unlike the transitory nature of sleep and dreams, once cancer was revealed, the words could not be called back; the words could not be excised from the body or radiated away. Secondly, participants’ experiences during and after cancer treatment were revealing in a number of ways. At the hospital or cancer clinic, participants recalled waiting for the elevator and the long walk through dimly lit hallways. They remembered the feeling of polished linoleum floors beneath their feet, the sounds of machines nearby, and the image of a blank wall staring back at them. The loneliness they felt while waiting in these rooms laid bare the gravity of their pets’ companionship. A participant with fish said “there’s nothing more soothing than looking at a water feature when I’m trying to sleep after chemo.” Another said of his dog “she’s a companion and it’s taken me a long time to realize the trauma I went through and what it caused to other people and how to try to get the trauma out of your system.” Two others said: I was involved in a clinical trial during my breast cancer treatment where we had to go to the gym two or three times every week during chemo…I would come home, and her and I would cuddle up on the couch and watch a show and have lunch. I would put the blanket and she would climb up on the couch and we would just sit there for a couple hours…That really became such a routine and it was very comforting (Female, cats). Duke’s been very good about it and when I first had chemo there was a lot of “oh my god where’s the bathroom” and after one of those sessions he always came and cuddled me. He would get in bed with me and cuddle (jingling noise), I can hear him. He knows I go once a month to the cancer clinic and when I come home he’s always here (Female, cats). Notably, pets were not always seen as a source of comfort during treatment. A participant with fish said “there were times when I did feel they held me back because I knew if I went anywhere, they probably wouldn’t make it.” Another said of her cat, “I didn’t take the best care of her because I couldn’t even do it for myself.” To avoid costly vet visits, a few participants recalled having to administer at-home treatments to their cats, one of whom shared the following story: 103 I did not do well with having an IV in my arm. My treatments were five days on and two weeks off. I did four rounds of that…so when I had to give her (cat) a daily IV, that was terrifying. I did because I knew it would help flush out her kidneys but I had a really hard time with it…and it was this particular needle I would put into the back of her neck and ugh that still makes me feel sick…there were experiences I had with her that reminded me of my cancer experience and brought it back up again (Female, cats and dogs). In deciding among treatment options, some participants felt moved by the resounding call to “get it out” of the body or “stop it from growing.” Others discussed having reservations about their doctors’ recommendations, fearing the outcome of treatment more than the disease itself. Such fears were confirmed in certain instances. For example, one participant described going into septic shock followed by a ten-day period during which he was in a coma and on life-support. Another came close to dying more than once, after being overdosed with chemo and enduring a significant loss of mobility. A third described her experience by saying: When I started chemo I had a heck of a time with it. I just did not respond well whatsoever. I thought it was absolutely normal everything I was going through so I didn’t really speak up too much. I totally became that superwoman type persona and just kept pushing through until I had to be hospitalized. I started getting some energy work done through chemo and my cat Loki basically never left my side…I was bedridden for most of my treatments…and she was my bestie at the time (Female, cats and dogs). Responses to treatment varied considerably across participants. Some participants felt better after the first surgery or round of treatment, noticing less pain and discomfort. One participant, after having part of his colon removed, recalled waking up and phoning his friends soon after surgery. Another who had a growth that was obstructing his ability to swallow said: As soon as I started the treatment the tumor shrunk. The oncologist was quite amazed that it actually shrunk right away…When I started the treatment I didn’t feel that much nausea or anything, I was able to eat and I ate a lot, like five meals a day, just because I had lost so much weight...and then I was starting to get healthy again but as I say I didn’t feel—like everyone said “aren’t you awfully tired?” I didn’t feel tired (Male, dogs). In contrast, others fared worse, such as a participant who experienced increased sensitivity to medication, making it difficult to treat an unrelated, chronic condition. Some participants 104 reported becoming anemic following chemo. The need to consume red meat came into conflict with their values. One participant called himself a “reluctant vegetarian” while another said: I really believe that animals have souls. I go through this moral dilemma about eating meat every once in a while. I have a really hard time with it. I know it’s necessary sometimes and I need the protein because of the illness but I tend to stick to fish if anything rather than meat. Eating mammals really bothers me. It’s not that I don’t think fish have souls but not as much as mammals (Female, cats and dogs). The effects of treatment also manifested themselves in participants’ outward appearance. To illustrate, one participant remarked “my white blood cells dropped and my skin took the worst of it.” Another said “there were kinds of disfigurations, I was doing prednisone; I had the moon face, skinny arms, and bloated belly, and [was] very self-conscious.” Another talked about changes in the texture of her hair after chemo, saying “losing my hair was such a trauma, as a woman I think, it’s our hair, you look in the mirror and you’re bald.” She went on to say: I have no problem being vulnerable around these two, people, it’s difficult to not feel judged and to not take things personally and be totally fine with your confidence and body image. She’s (dog) taught me it’s okay to go out first thing in the morning in your pyjamas with no bra on and your hair is a mess to take her out to go to the bathroom. Like years ago I wouldn’t be caught dead without makeup (Female, cats and dogs). Other notable effects reported by women were those related to the treatment of cancers affecting the breasts and reproductive organs. Some women described going into menopause several years before the expected age of onset, affecting their ability to conceive children. Others experienced hot flashes, changes in mood, night sweats, and/or weight gain. Two participants commented: With the breast cancer, I got fortunate, there was no chemo. It was radiation therapy. The last four treatments [caused] a horrific burn. It took all of the skin off of my breasts. They were treating me as a burn victim. For eight weeks I couldn’t even wear a bra. I was doing these saline compresses three or four times a day. With the breast cancer there were two lumpectomies because the surgeon cut too close to the margin (Female, cats). My tumor was quite large too about the size of a large mango so that was pretty decent. It was like I was carrying a child. I’ve always wanted to have a family and I haven’t even now. It’s been 10 years and I’m not sure my body can handle it anymore…the emotional 105 aspect of it has been absolutely horrible and the way my body has responded to it has not been great either. So it’s shown me a lot and it’s taken a lot (Female, cats and dogs). For the women and men at the center of treatment, cancer had the effect of showing and taking from them in ways that they had not anticipated. For one participant, cancer was a “culmination of [her] pushing too hard” with treatment prompting a “continual cycle of ups and downs.” Cancer revealed the cracks in what participants had envisioned for their future. Some participants expressed doubt about whether there was even such a future ahead: I was diagnosed with Cholangiocarcinoma, stage IV which is inoperable. I can’t get a transplant either. It’s not available for this type of cancer so they’re treating me with chemo to try in the off-chance to reduce the size of the tumor or stop it from growing so they may be able to operate. They said it’s a very long shot, it’s not successful in a lot of cases but the cancer has stopped growing so that’s a good thing (Male, dogs). Of the different types of breast cancer, most have drugs that are targeted therapies to keep the cancer from coming back. The one I have doesn’t have that yet. So the first three years after diagnosis are usually very stressful. There’s a lot of anxiety for triple negative patients because they don’t yet have a targeted therapy to keep it away. And it doesn’t seem to matter necessarily with staging…it’s a very aggressive cancer (Female, cats). Others found themselves having to deal with more than one type of cancer. One participant, treated previously for colon cancer, shared what happened while undergoing follow-up tests. He said “my GP suggested they do a bone scan while I’m in the hospital; so I go down and found out I have prostate cancer, so things seemed to progress.” Similarly, a fourth participant stated: I did the chemo, radiation and then surgery and then the next four years on pills and we all thought it had gone away. Then I had noticed some lumps on my head and my doctor thought they were cysts so he arranged to cut them out but when he made the first cut he realized that they were not cysts, they were cancer. So we started again and the breast cancer had metastasized to my ribs, lungs and spine (Female, cats). The examples above make clear that treatment is seldom confined to a single event. Even after the news of a clear PET scan or blood test, participants continually stopped short of referring to themselves as “recovered.” As one participant stated “it’s been this ongoing 106 challenge of doctors and specialists and nobody can figure out what it is; it’s all imagined and it’s not the case.” Two other comments highlight participants’ fears about cancer recurring: I have a deep-seated fear of what is going to happen. Is it going to rear its ugly head again? It’s always in the back of a person that’s gone through cancer. Is it going to come back? Is it going to kill me the next time? That was three cancer journeys and hopefully that’s it. If you want to hear about the kitty that really made my journey so much easier, that is Holly. Holly went through five surgeries with me, three for cancer (Female, cats). When we sign in [at the support group], we say what cancer we have but your cancer is not the discussion. The discussion is how you’re dealing with your life, having it so affected by cancer. Anybody that tells you, “oh I had cancer, I’m cured,” sorry, no, no, you’re never cured. It was in your body. It’s going to be there still, somewhere. It’s like an escape when I just get away from life and go for a walk with her (dog) (Male, dogs). These examples also speak to the role of pets in easing the journey and providing an escape. The story of a third participant suggests how pets act as a “bridge” when encountering people: It’s been very cathartic having her around especially as a puppy and getting myself out of the house and learning how to be a person again, how to approach life and people and do the whole face-to-face contact again. She was my bridge between that. She would greet people. I didn’t have to and the times where I really didn’t want to be seen and just hid, she would be that connection with the other person. It didn’t have to be me. I didn’t feel ashamed, not feeling okay in my body and walking down the street with her. She created a space where she was just being herself. I couldn’t do that. I’m still having a hard time with that. I’d watch her and see how she is in the world (Female, cats and dogs). In feeling unmasked and exposed, pets then provided a kind of shield, enabling participants to connect and disconnect when they didn’t want to be seen. 188.8.131.52 It’s amazing how in evolution This theme begins with an analogy. Picture a loose thread hanging off a knitted garment. A common impulse is to pull at the thread with our thumb and forefinger after which one of three things can happen. The thread snaps and breaks off in our hands. The thread pulls away as the garment begins to unravel. Or still yet, the thread remains taut as the surrounding fibers become more tightly intertwined. Such is the experience of cancer and its impact on participants’ 107 relationships with pets and other people. The title of this theme highlights the notion that, despite our evolution as a species, human intellect and empathy can fall short when it comes to dealing with emotions. Through this analogy, this theme captures participants’ relationships as they were breaking apart, unraveling, and becoming more intertwined. Firstly, the news of participants’ cancer diagnosis had an almost magnetic pull. As one participant put it, “people came out of the woodwork” to offer support. Another said that her friend built “mini stairs” to help her get into the house. Over time, like the thread snapping under pressure, some relationships seemed to break apart rather abruptly. The comments below speak to changes in participants’ relationships with their health care team during and after treatment: The time I was in treatment the days seemed to be pretty full. And when you’re a cancer patient, you basically become a full-time patient trying to recover. My doctor’s receptionist said that my full-time job is to gain weight basically all the time that I could. And between eating, walking the dog and eating some more, walking the dog, eating some more, basically the day was gone…so I had no trouble filling the day (Male, dogs). During the time of the treatments, in some ways it was easier because you’re very focused on the physical and you have something to do every day. You feel like you’re participating in your fighting of the disease. Everybody’s attention is on you. You have the support of your oncologists and your whole team. There’s that level of support. Then that ends and the oncologist is like “Oh yeah, we’ll see you in six weeks” and you’re just kind of sent off…so I found it was harder once I stopped treatment (Female, dogs). As suggested by these comments, during treatment, the days were full and discernable from one another. Following treatment, as one participant explained, “you go into this strange place where the days just merge [and] everything becomes this sort of blur.” With regards to their significant others, having the support of a partner was important for both participants and their pets. One participant commented “during treatment my wife was with me all the time taking me down and everything. I see people coming in by themselves especially 108 elderly people. I don’t know how they can do it.” Partners also served as a welcome distraction for pets, giving them much needed attention, as one participant explained: There would be partners and boyfriends and stuff that would come in and distract them (pets) from whatever I was going through so they would get a little bit more attention from them. I had a guy who lived with me for a while and he was a really good guardian to the two of them for the period of time we lived together which was very short but he was very kind and generous to the two of them and [my partner] was really fantastic with Loki. He ended up getting her a beautiful cat tree and she’d get more Christmas presents than I would (laughing) half the time from him (Female, cats and dogs). While some relationships endured in the wake of cancer, others came to an end. Participants pointed to the diagnosis or recurrence of cancer as the catalyst for their break-up: Honestly, it was hell. It ended a long-term relationship I was in. He was just about to propose and he already asked for my hand from my parents and so it seemed to be one thing after the next and the losses were incredibly great (Female, cats and dogs). My ex-partner and I had a lot of friction between us, so there was a lot fighting. My refuge was going to the dog. And whenever we would fight I would just go and cuddle with the dog. That was my second relapse…I was kind of paralyzed from the rib cage down. I was told while being prepared for the MRI to be prepared for the palliative type thing. I was obviously devastated. My partner was still at work. I still had to work, so my dog was my companion. It was the only companionship I received (Male, dogs). In addition, friendships did not go unscathed by cancer. In a typical exchange between two people, one person says How are you? to which the other responds I’m fine, how are you? The unchanging rhythm and repetition of these phrases, provides an element of predictability. As one participant said “when you’re not sick, people ask you how you are, of course it’s just a figure of speech but if you are sick, a lot of people just avoid you, even close friends, because it’s awkward.” A second participant spoke about being in the hospital, saying “it’s funny that of my friends that came to see me are those that have had cancer or have had somebody in their family with cancer.” A third participant spoke about the loneliness people feel during treatment: You’d think people that you’ve loved and been in a relationship for a long time would be right there with you but it falls apart. People don’t know how to emotionally handle 109 watching their significant other or best friend go through this. It’s amazing how in evolution we’ve still not evolved that capacity naturally. It seems like as soon as a person is sick, we pull ourselves away from them. You see that in the animal kingdom all the time…but you’d think with our evolved brain that we would get past that emotional-ness and into the intellectual thought that it takes to be compassionate for the person you’re with…it’s a really harsh reality to come to terms with when you get sick (Female, cats). Normally, a simple exchange of pleasantries allows people to interact with each other at a safe distance. When someone is sick, this distance narrows, leading some people to pull away. Secondly, some relationships remained intact following the participants’ cancer diagnosis, only to unravel over time. Participants’ relationships with health care providers varied in duration and intensity, with some lasting a few weeks and others continuing for several years. One participant described his nurse by saying “she would come and see me and she got me up and walking way more than any physio.” Another said of the nurses at the hospital “it’s a special breed that can work in those kinds of environments, making you feel as calm as you could possibly be.” For other participants, the deterioration of the patient-provider relationship was not surprising given its tenuous foundation. One participant referred to his physician, saying “you hear about bedside manners, he was very blunt; that’s all he told me, cancer, and then sent me to this oncologist.” A second participant said “there was a lot of prejudice from the health care workers for me drinking alcohol…and judging how I’d been dealing with the pain.” A third participant said “after many times going to see different oncologists and emergency a couple of times, they didn’t think that I still had cancer and so they couldn’t accept it.” A fourth participant recounted her experience: Everything had gone so terribly wrong. My specialists kept saying “this shouldn’t have happened, something’s wrong.” Then when I went to see my hematologist, he went “she’s (oncologist) overdosed you with chemo.” He knew right away but she wouldn’t admit to it and that was before I actually ended up in the hospital but at that point, I was so low that if I didn’t have my pets I wouldn’t be here (Female, cats and dogs). 110 Friendships and intimate relationships were more likely to unravel among participants for whom several years had passed since their initial diagnosis. Some participants attributed the loss of contact and communication to a perception among people that cancer ends at the conclusion of treatment. One participant explained “other people perceive you as ‘Oh well she’s fine now, she’s well now, she doesn’t have cancer anymore’ whereas you live with that fear that it might still be there.” Other participants believed that some people are simply ill-equipped to deal with the emotional aspects of cancer. Prior to cancer, it was not unusual for people to drift in and out of their lives. Cancer put a spotlight on these relationships, and what some participants described as the inadequacy of human intellect and empathy. To illustrate, two participants said: My best friend shaved her head with me when I lost all my hair through chemo and she’s now in [another country] so we’re not very close anymore…it’s interesting when something like that happens versus now, zero people have been around. It’s this emotional aspect of things. I think people are really terrified of that. I’ve had one person stand by me through the last two years and these guys (pets) (Female, cats and dogs). When you first get diagnosed you have a lot of people around but when you have cancer for a long period of time, people kind of drop by the wayside. People can’t handle the impact of cancer. They’re just not capable emotionally of being able to do that. It’s an unfortunate thing but it happens to every cancer patient. People drop away because they’re not able to handle what’s happening and your pets don’t do that (Female, cats). Many pets seemed undeterred by the emotional aspects of cancer. According to participants, pets stand by you because they are kept as pets. One participant said “they don’t have a choice, they can’t earn money, they can’t be on their own.” And yet, participants repeatedly expressed that pets provide “unconditional love.” One participant echoed “it was that unconditional aspect that I knew I could depend on—people aren’t so much.” Even still, a few participants referred to “periods [when pets] would become a bit less bonded” to them: There were times I smelled really funny and she (cat) wouldn’t approach me after chemo. I smelled really weird and she wouldn’t give me hand licks and I felt really gross about myself …That was kind of a difficult time in our relationship and learning how to 111 navigate that. And there were a lot of times when I didn’t actually want her around like I really did just want alone time …I remember feeling kind of wrong and dirty because of chemo. It didn’t last too long but I remember that (Female, cats and dogs). My ex and I separated which was kind of devastating, not so much the separation, that had to be done. It was just a matter of how we transitioned and moved on. My biggest issue was the dog. How do we kind of share the dog? Unfortunately, while I was going through the chemotherapy I was not able to walk the dog. I was kind of bed-ridden and …because I was not physically able to participate in the dog’s activities, my ex-partner became alpha male. The dog became more loyal to him than with me (Male, dogs). In both examples, pets seemed to know that something—the smell of their skin, their energy level—was different, and this led them to pull away. Accordingly, such examples demonstrate that even unconditional love can unravel beneath the strain of illness and separation. Thirdly, some relationships neither snapped nor unravelled in response to cancer, but rather intensified as in the analogy of the thread becoming more intertwined. One participant said “when I had cancer my mum would stay with me and Loki (cat) got looked after mostly by my mum and my ex would come in a lot and help out.” Another said “I recouped at my parents’ initially. My parents are very close with Stella (dog). They don’t see her a lot but my dad has a really close, special relationship with her.” A third said “my mom is a great part of my healing too but she lives far away so she can’t be here the way she’d like to be so I have my surrogate parents (her pets).” As captured in the following comment, support did not only involve being physically present but also being there to validate participants’ feelings and experiences: I’m learning that with my family and my partner to be okay with letting go and receiving love. I’ve been in such a fearful place for so long not just because of cancer. It would have been many other things that have gone on and being able to come back to a place where it’s like I know that I’m accepted for whatever I’m going through. They’re not going to say anything and they’re going to treat me exactly the same way is really rewarding and it just feels good (Female, cats and dogs). Although participants were grateful to have support, they expressed some ambivalence about relying upon their loved ones for help with cooking meals and getting to medical 112 appointments. One participant explained “when you’re sick you don’t want to burden people all the time.” Interestingly, some participants reported dealing with these concerns by helping other cancer patients and developing a wider social network, such as in the examples below: I phoned him (support group leader) and we had a good hour and a half yak and he said come and try the Wednesday group. So I went and I got pretty emotional. I had a lot of tears and the three regular ladies have all gone through six operations and it’s just a whole different feeling. You just feel that you’re amongst long lost old friends that are able to talk about things and so I’m helping them now. [My wife] was pretty burnt out through this whole thing and at times I felt like I’m being a burden and all that sort of stuff and then we learned at the peer group that you’re not a burden (Male, dogs). Community, that’s another thing that’s become quite obvious to me. Before I was working so much and I had my friends but there was an idea of always being able to do things on my own and don’t ask for help and be self-sufficient. I don’t think that’s really now the way I think. We really do need community, connection with people and to have people that have your back. You want to help them and they help you (Female, cats). Similarly, a third participant described how his dog has helped him to build new connections: When I can’t walk her, neighbours come in and look in on us and take her for a walk. I guess it’s my support as much as anything else. Because of her I have people checking in. I guess they use it as an excuse to check in on Ginger so it really is beneficial having that one-on-one relationship with her and people checking in on both of us. And the same thing goes with my neighbour who has a dog. When his dog barks excessively I check in on him if his wife isn’t home…so dogs being the alert system is unique (Male, dogs). The sense of mutuality observed in their interpersonal relationships was also apparent in their relationships with pets. For participants and their pets, it was easy to give and receive love without reservation. One participant said of her cat, “we get along fine, he’s not too demanding, I’m not too demanding; there’s certain things in your life that are there so you have some stability as well.” Following cancer treatment, the sheer amount of time spent with pets, as well as, pets’ attentiveness to participants served to deepen their bond. Two participants commented: He’s given me a lot of comfort since I’ve been diagnosed. He’s like a constant companion for me so he’s making my journey with cancer a lot easier. I mean my wife helps too but when you’ve got a little dog that makes you laugh all the time just from things he does…Since I’ve had the diagnosis of cancer, he’s just been a little closer to me 113 than my wife. He used to be mummy’s boy, now he’s daddy’s boy…maybe I’m giving him more affection so he’s reciprocating (Male, dogs). Physically and emotionally you’re going through such a difficult experience so she (dog) gives you some sense of normalcy and routine. She’d give me laughter and joy because she’s got a quirky sense of humor. I guess I would have gotten through it without her but she made it bearable and she just gave me so much in that time and I think in some ways, definitely, I felt even closer to her after. We just really bonded (Female, dogs). Lastly, back to the thread analogy, a fourth scenario is possible in that we pull on the thread and nothing happens. This scenario reflects the experiences of participants whose loved ones did not come out of the woodwork, so to speak. One participant spoke about the importance of her pets, saying “I’m on my own, I don’t have contact with family and I don’t have a spouse or children or siblings, so there’s just so much unconditional love.” Two others said: I’m important to my family but not in the same way, not in the day-to-day. He (cat) accepts me as I am in my housecoat and slippers or grumpy or happy. He’s just accepting and another living being that apparently likes you. I think that’s important for everybody to feel that they’re important or necessary to somebody or something (Female, cats). The most important thing in the journey right now is they’re keeping me alive because as much as I love my daughter, there are times when I don’t always like her which is true of any human relationship when you live with someone. You love them but there’s times when their behaviour is such that you can really ring their necks. I never feel that way about the dogs and…there is no one else, no other siblings (Female, cats and dogs). Accordingly, pets did not seem encumbered by the same fears and expectations that people tend to have when a person in their life falls ill. Emphasizing this point, one participant said: [Pets] never leave you, they never leave your side and when you’re not feeling well, they’re the closest to you that anybody or any creature could possibly be and so you’re never suffering alone, you’re never doing this by yourself. And that’s another comfort that people really underestimate. Just their presence in your life will give you that feeling of connectedness even when there’s not a single human being around (Female, cats). Pets provided this feeling of connectedness even when emotions prompted others to pull away. 114 184.108.40.206 It flickers by so quickly The photos shared by participants were revealing of their relationship with their pets. Some photos documented meaningful occasions such as birthdays and Christmases. Others depicted ordinary events that had been repeated a multitude of times such as pets sleeping. Still others were blurry and out-of-focus just barely capturing the vigorous movements of pets. With a flash of the camera, it was as if these moments had been frozen in time. Drawing upon photos as living moments of experience, this theme delves into participants’ accounts as they were experiencing loss, anticipating loss, and fighting back against loss. Firstly, loss was a recurring theme in participants’ relationships with their pets. More than half of participants had experienced losing a family pet in their childhood. Such losses took on new meanings as an adult facing the uncertainty of a cancer diagnosis. Cancer brought home the impermanence of life and the need to preserve meaningful experiences that could otherwise “flicker by.” Participants documented pets through photos, videos, collages, paintings, and journaling. One participant described a memory book featuring her cat who had passed away: I got to design the whole thing which was really neat. It was really fun to do this and to go through the space of reliving what it was like to have her in my life. She had these gorgeous, gorgeous blue eyes… all the memories and experiences. I love that I have a book for her. Things change over time and I forget more of those things but I know it’s important to me to take the video and the images to have of her because she’s such a big part of my life and was my best friend for those years (Female, cats and dogs). A second participant described what it was like to look back at old photos, commenting: They just bring me so much joy that you want to capture that on picture to remember but then later you’ll look at the picture and it’s hard because it’s not the same as when they’re there. There’s lots of pictures of past fish that are moved on and you can remember what that feeling was like…but it’s still not the same as when they’re there (Female, fish). Photos of pets had a dynamic quality, retaining rich and vibrant memories. And yet, after the passing of a beloved pet, these same photos came to embody the sense of loss that 115 participants had felt. Of the participants who had lost a pet following their cancer diagnosis, most were at least one year post-treatment or were facing a recurrence of cancer or secondary cancer. One participant spoke about undergoing multiple surgeries for cancer and for knee injuries: Holly was the most comforting of all our cats. The others were to a certain extent but not as much as she was. I was so worried that she wasn’t going to be there from the first knee replacement. She only lasted for three days because she was having trouble breathing but she hung in there long enough to greet me when I came home (Female, cats). A second recounted how one of her fish outlived his expected lifespan despite having a tumor: The fish hung on and I knew he was with me. That one seemed really special, so intuitive. He had the tumor and everything the same time as me and survived my being gone back and forth…I had been thinking the treatment at the cancer agency is coming to an end and my fish has done this journey for me. It’s probably time for him to pass on. As much as I’d like him to stay, he passed just about the same time I got my discharge papers. And it was sort of like we were done with that chapter of our life (Female, fish). A third participant described her experience with having to put her cat to sleep: When I had to put her down, that was like losing my best friend who was there for me through this journey. She was there for me two years pre-diagnosis and then Hazel (dog) came into the picture…I brought Hazel into the vet when I decided to put Loki down. I’ve heard that animals, if they leave the home and never come back, they just continue to look for them…I had the two of them side-by-side. As the drip went in and her life drained out Hazel paid zero attention to her anymore. It was interesting to observe how they see life force. After it was like there was nothing there (Female, cats and dogs). The examples above suggest that the loss of a pet did not happen all at once. Signs of aging became apparent with growing patches of white fur and changes in their pets’ gait and mobility. Although many pets’ personalities remained largely unchanged, there was a noticeable decline in their energy level. Pets couldn’t jump as high as they used to and daily walks became shorter and shorter. For participants, coming to terms with having an aging pet was entangled with the knowledge that their pet’s life could be in their hands. The same participant above said in reference to Loki, “it became a bit of wanting to extend her life and I did extend it a little longer than was probably okay with IV treatments and syringe feeding; I just didn’t want to let 116 her go.” What’s more, in the experience of cancer, losing a pet was overlaid by a sense of remorse from witnessing their pets hanging on and clinging to life for the participants’ sake. Although not the same as the death of a pet, having to separate from a pet was experienced as a loss, nevertheless. Some participants recalled having to leave a pet behind after moving away from their family or needing to return a pet to a friend after assuming temporary guardianship. In other cases, this kind of separation was the result of an ill-fated adoption. Aside from cancer or other health challenges, the need to consider the welfare of other people or pets influenced participants’ decision to relinquish a pet. One participant commented “I attempted to adopt another cat to grow the family and the older cat said no way.” A second participant said: I found this cat that I absolutely just loved and I brought her home and I was sick right away. I missed four weeks of work…An old lady who had her, had passed away and she ended up at the SPCA. The vet said she was too nice of a cat to put down…so I brought her home and went out and actually spent a couple hundred dollars getting her a scratch post and toys…I just got her feeling comfortable that this was her home and she was such a great cat. It broke my heart…but I had to because I was too sick (Female, fish). A third participant described how he had surrendered his dog, Leo, to a friend with an agreement that Leo would have a permanent home. Without the participant’s knowledge, Leo was then sold to a buyer on Craigslist. This participant shared what happened after this experience: Everybody agreed that Leo was in good care so up until knowing that, I was very depressed thinking I did something really bad. He was on Craigslist. There’s a lot of dog fighters who will pick up these rescue dogs and basically feed them to vicious dogs. The thought of it just terrified me. Because of what happened with Leo I decided I couldn’t keep a dog anymore. A couple months later, I was completely socially isolated. A friend of mine had a dog that had been abused and abandoned…so I said I’ll foster her for a couple of days and I just fell in love with her…she’s just an amazingly sweet, loving, and caring dog. I honestly could not ask for a better companion (Male, dogs). As with the untimely death or relinquishment of a pet, some losses were clear and indelible while others were less tangible in their effects upon participants. For example, participants described forgetting particular memories in the years following cancer treatment, 117 with one participant lamenting “it’s funny you lose a lot of memory when you go through chemo and I don’t really remember a lot of her as a puppy.” A second said while describing her dog “it’s hard to remember back because it’s 12 years ago now and my memory is not so great since going through chemo and radiation.” Fortunately, such memories were not altogether lost but could be recalled by looking at a photo or sharing a story about their pets. During an interview, for example, one participant whose cat had passed away suddenly exclaimed “oh I have no pictures of that—she would hug me, so she would put both of her arms around my neck and I totally forgot that actually, because I really miss that with her.” Another participant spoke about losing a memory card which contained hundreds of pictures of her two cats, saying “for him he was sort of grown up but for her, it’s like losing baby pictures, it’s heartbreaking because you’ll never get that time period back.” Two others described how photos helped them to hold onto precious memories: I cherish the moments. I cherish having these pictures, these experiences with the two of them. There’s little things that happen and I’m like [Partner’s name] “get the phone, get the camera, we need to take a picture of this.” I can remember that because they flicker by so quickly and unless we write them down or capture them in a way, often we forget about them and how important they were to us in those moments. The important things just seem to get piled up with stress—yeah I cherish these guys (Female, cats and dogs). I like to document her…I think sometimes we really think of ourselves as a family, so it was kind of a way to welcome her into the family, document that, have it to look back on. I took pictures of her when she was in her little cage at the SPCA. Sometimes we’ll look back and remind ourselves where she came from, when she came into our lives. In a way I do feel like she has helped save my life and we also helped save her life hopefully. As I would take pictures of friends or family members, it kind of feels similar (Female, cats). While it was important to safeguard memories of their pets, some experiences during cancer were better left undocumented, free to flicker by and be forgotten, as one participant explained: I don’t think I have any pictures of myself when I was lying in bed or anything like that. Like those were a lot of images that I chose not to have taken I guess. I do have a few of 118 myself when I was going bald but for the most part I did not take pictures of my experience. I just I hated the whole thing (Female, cats and dogs). Secondly, in looking through photos of their pets, participants remarked that it was hard to remember one moment from another. One participant said pets are “somewhat repetitive.” The experience of cancer brought these moments into suspension, prompting participants to contemplate the thought of dying. One participant said “I’m just praying that God gives me enough time that these guys are gone,” expressing concern for her pets in the event of her demise. Two others expressed fear for their cats’ well-being if their cancer were to come back: I felt very protective of her because of her age and I also was really worried that if my cancer came back there’s not really too much they can do. They say it’s about a nine-month window between a recurrence and the average time of dying. So I was also really nervous that she would be left alone again and I could kind of understand how her first home dropped her off. She’s just such a sweet cat that I can’t imagine anybody giving her up so but it made me nervous that she would be left on her own again (Female, cats). I really hope we go at the same time because I don’t know how I would feel if Duke went before me and then you worry about what would happen if I go before Duke. I know some people would not have a pet because of that but we had Duke before I was diagnosed. I don’t like to think about it. He’s an important part of my life and some people might think that’s pathetic but they don’t have Duke, the cat (Female, cats). From the participants’ accounts, it appeared that cancer was not alone in reminding participants of the brevity and fragility of life. Being a guardian to a pet also meant having to face the inevitability of loss. One participant who had lost her cat previously said in reference to her dog, “I’m terrified, this brings me to tears; I’m terrified of having to go through that with her; I really hope that she lives many, many years longer.” A second participant said: I do worry about her dying (tearful). Since she is already old I know that when she does—I mean hopefully there’s lots of years left but it will definitely be a part of my life that I will always remember because it will be so tied to my cancer experience. I mean people always say if they get another pet it will never be the same as that pet or something. But her relationship with me is so surrounded and encapsulated in that experience that it will always be quite an intense memory I think for me (Female, cats). 119 Another wished to be reunited with her pets in their final resting place and in the afterlife: My final wish is that all of our ashes will be put together. One of my cats passed away and his ashes will be put with mine and hopefully all these guys will be put with mine. We’re going to try and find a meadow and have the ashes sprinkled. It’s probably silly, but in my head the idea of heaven is being in a meadow with my pets, being with nature, having them all around me. There’s a wonderful poem called the Rainbow Bridge. That to me is heaven, to be reunited with all my ones that have gone (Female, cats and dogs). While some participants retreated from the topic of death, others felt that cancer was an inescapable reminder of their mortality. One participant remarked “after I’d gotten this cat my nana had passed away from breast cancer so when I was diagnosed, that was synonymous to death for me.” A second participant said that cancer “galvanized” her, prompting her to plan her own funeral, and spare her family any added stress. A third participant contemplated the meaning of dying: Thinking about dying, in a way, is necessary because our culture doesn’t really allow you to process those concepts. No one wants to talk about it. They don’t really even want to talk about you being ill. I’m glad I did have that time to think about it. It’s painful but it happens to everybody. There’s ways that you can live your life so that when you get to that time of dying, you’re not going to be regretting how you lived your life. So to be conscious of the fact that you are going to die perhaps you’ll live your life differently…When you’re facing your mortality, you start to question “What am I doing with my time, what have I done so far, what kind of life have I lived” (Female, cats)? This same participant described a “switch” from thinking about dying to thinking about living, saying “I feel like I have more permission to enjoy…this is my time to be living and enjoying.” Thirdly, not captured in participants’ photos were the moments that had yet to occur, moments that were often overshadowed by cancer and a sense of impending loss. Cancer pulled death from the periphery, leaving it hanging over them like an ominous shadow. Participants were left to confront past losses while also considering the consequence of future losses for themselves and their pets. One participant described his experience in the following way: 120 Animals are just, when you have cancer, it’s such a unique feeling. If you don’t have cancer it’s really hard to understand what the journey is like because you’re looking at mortality. Every day is your mortality and when you have an animal, it takes you away from all of the stuff in here and the energy is now focused on this animal (Male, dogs). Although losses were inevitable in the experience of cancer, pets allowed participants a momentary reprieve from dwelling upon loss. As suggested in the following comments, pets became a “beacon of light” in some of the darkest moments of their cancer experience: I had been in the hospital about four weeks and I was really missing them. I would talk about the dogs and the therapist said “why don’t you bring them in, there’s a lot of people here that would love to see your dogs.” They came in and everybody was crying and the dogs were so excited. All three dogs were trying to kiss me and love me. They jumped onto the bed, curled up with me, and we had a nice visit. When I had left for the hospital, it was so sudden and my dogs didn’t really understand. I think it brought them some closure because they settled down after that. After they left I was really depressed. It made me more determined to find a way to get home (Female, cats and dogs). I was in the hospital for 10 days and these guys were my impetus to get out of bed and move and get home as soon as possible…it’s amazing how much they play a role in all of that...that initial impetus. When you’re really low even the faintest hope you hold onto and these guys were the hope I needed to continue to push and survive. Later it became for me and everybody I loved but these guys were the beginning (Female, cats). Perhaps, it is not sufficient to say that pets simply gave participants hope. Rather, pets were someone participants could grasp hold of when such hope seemed beyond their reach. Finding hope was akin to the experience of dragging an anchor beneath a boat waiting for it to catch hold of the seabed. Participants’ resolve to remain hopeful while facing the possibility of dying was a decision in and of itself, the alternative being that they would give in to the disease. Two participants said: She’s been an integral part of my healing and she’s given me a lot of hope. I kept thinking, oh my god, I might actually die…there was this sense in me that, I couldn’t. I’d never considered the possibility that I would leave her. She is my little baby. I’ve been lucky that she’s come into my life…she’d probably be fine without me. She’d live with my parents but I wasn’t prepared to let that happen so she gave me that will to fight and to think “I’m going to be one of the 50 percent that survive and thrive” (Female, dogs). 121 These guys are at the mercy of who is left to care for them and I couldn’t bear for me to go and know they’re not going to be properly cared for…They’re my reason for fighting as long as I can and to keep going. I could have given up twice now, I nearly died in February and I knew I had to fight back because of them (Female, cats and dogs). A third participant talked about what it means to fight back against cancer: I’m a fighter, I like to fight and if you give me something to fight for that’s even better. At first it was for Rocky and Penny and now it’s for the three of us. It’s a brutal way of happening but it was a journey that has been well worth it for me…they’ve really been the reason why I fought so hard and in the healthiest way…I’ve integrated them so much into my life that they’ve become a huge part of the healing process. Without them I wouldn’t be where I am right now. In fact, I don’t know if I’d even be alive to be honest or had the strength or power to make the hard decisions…it would’ve been really easy to go off into the other direction and give myself up to the disease (Female, cats). Together, these comments bear out participants’ fears of dying, and of continuing to live in spite of these fears. Pets not only gave participants the impetus to fight but also the impetus to hope. 4.2.2 Super-ordinate Theme: Pulling you out of yourself All of her toys are everywhere. We play constantly. It’s a great impetus to get out of bed even when you’re not feeling well. They give you that willpower to get outside of yourself. It’s very easy to get stuck in being ill and when you have two beautiful little animals that pull you out of yourself and get you out of bed to make sure their litter is clean and they’ve got nice fresh food in their dishes and the floor is clean. You know that you have somebody that needs you and depends on you to be as healthy as you can (Female, cats). This super-ordinate theme reflects participants’ experience of their pets as providing a meaningful “distraction” from their illness. Pets took their minds off of cancer and what some of them referred to as “the inevitable,” meaning the inevitability of dying and leaving their loved ones behind. With fears of cancer progressing or recurring, participants sought to distract themselves from their illness. Such a reprieve came in the form of playful exchanges with pets and participants’ caretaking responsibilities towards their pets. Whether participants were actively engaged in play or simply observing their pets play, play allowed participants a semblance of routine and normalcy. Play provided a way for participants to distance themselves 122 from cancer, making laughter and silliness permissible and even necessary for healing. At times, play had a calming quality. In other occasions, play meant being patient and making allowances for chewed up furniture or broken keepsakes. For participants with aging pets, play meant coming to terms with pets slowing down and losing interest in cherished games and rituals. As with play, caretaking responsibilities prompted participants to turn their attention from being a cancer patient to being a guardian and caretaker to their pets. Being a guardian required patience and understanding. It meant caring for their pets with the same degree of love and attention as if they had been a human family member. In upholding this responsibility, participants felt compelled to attend to their own well-being, knowing how much their pets relied upon them to be in good health and spirits. Others saw themselves as parents, treating their pets as their own children with the accompanying joys and trials of parenting. The process of learning to anticipate and respond to their pets’ needs served to strengthen and nurture their bond. Similar to play, caretaking not only helped to shape participants’ daily routines but also changed in response to the needs of both pets and people. These two aspects, play and caretaking, are described in the following themes: 1) It’s sort of silly, but; and 2) It’s a sense of responsibility. 220.127.116.11 It’s sort of silly, but The view of pets as being playful was shared by all participants. Play had different meanings and expressions for participants and other people with whom pets interacted. Seven facets of play are described: humorous play, predictable play, unpredictable play, mutual game play, rough-and-tumble play, instinctual play, and transcendent play. With regards to humorous play, pets seemed to have an unlimited capacity to make participants laugh. One participant remarked “I don’t whether he (dog) has had anything to do with my cancer sort of being in remission or not but they say laughter is the best medicine, so 123 maybe he does.” Pets were effective at keeping things light. Pets’ silly and goofy behaviours provided a common source of laughter for people. In these moments, everyone was focused, however briefly, on what their pet was doing. When pets were present for the interview, participants often laughed as they saw their pets snoring loudly, hiding in a corner, eating a treat, or jumping on my lap. Even when pets were not in attendance, participants appeared more animated, smiling and laughing as they recounted stories about their pets such as those below: Stella used to go to doggy daycare…and apparently she would be the ball police. Her favourite thing to do would be to go around…the daycare and collect all the balls and she would actually put them in a line and then she wouldn’t let anybody else touch them (laughing), they were like her balls. And she actually, she can flick them. She puts them in her paws and she puts it together and they fly out. So she can actually entertain herself quite well with them. That’s kind of her party trick I guess (Female, dogs). Rocky is a [certain breed] and they’ve got a very distinct character like they’re very playful, very needy, and one of the descriptions is, the males tend to be clownish (laughing) which is Rocky to a tee. I mean you just couldn’t get more clown-like when he’s in that kind of playful mode. You’ll play mousy-mousy with him and he’ll get all excited and everything and then he’ll scare himself and he’ll run away. It’s like he runs away from stuff but it’s not the toy, he scares himself, it’s just hilarious (Female, cats). A second facet of play that elicited laughter was the unrelenting predictability of pets. Take the analogy of a comedic joke. Humor is often heightened by the unexpectedness of an effective punchline. However, it was as if pets had mastered the art of comedy, eliciting boundless laughter at the same old jokes and often with no punchline. Participants delighted in being able to anticipate certain behaviours from their pets after years of studied observat ion. Examples of recurring behaviours from cats were: sleeping with a grimaced expression, drinking from the sink faucet, making funny poses for the camera, purring excitedly, and favouring particular toys to the exclusion of others. Examples from dogs were: moaning when it was time for a walk, hiding under the bed at the sight of the nail clippers, nudging the participant’s hand for a treat, refusing to give a ball back after fetching, and biting the garden hose. As evidenced 124 by their wagging tails, boisterous barks, and resounding purrs, pets displayed an infectious zeal for seemingly mundane routines. With pets, everyday occurrences could take on the whimsy of a time-honoured tradition or battle of wills. Two participants shared the following stories: If you’re cleaning the deck, Sadie always has to help and same if you’re vacuuming the house, she just started doing it. She chases the vacuum and she just barks her head off, ruff, ruff, ruff and she’s running around. She makes the job longer but it’s a lot more fun. You see down here, if you sweep the deck, one of her favourite things is, she just grabs the broom. I don’t know why, even if you’re raking the leaves she’s got to come out and grab the broom…like usually you’re in a hurry, you only have so much time…but you don’t mind because the dog needs exercise and she needs activity (Male, dogs). The other thing she does, it always makes me laugh, whenever we’re out on walks she tries to eat food all the time and so I tell her “don’t eat that” and I tell her not to do it. And then what she’ll do is she’ll put it in her mouth and she’ll just pretend that it’s not in her mouth and then as we start to walk along I’ll see her turn her head and (laughing) she’s eating it without showing me, she’s quite sneaky that way and she never forgets where there’s food outside. She’ll always want to go to that area and she’s also exceptionally stubborn so…she just won’t walk certain directions and she only usually likes walking downhill (laughing). She has some strange little desires (Female, dogs). Thirdly, in some instances, it was the apparent unpredictability of their pets’ that participants found amusing. Participants repeatedly described being surprised by their pets’ behaviour. Common descriptors for pets included “trickster” and “mischievous” such as the case of a cat who would camouflage herself under pillows and suddenly pounce at her human caretaker while bearing full teeth and claws. Another recalled how her dog seemingly ignored a box of chocolates for weeks only to surprise her one day by climbing on the couch, devouring the last piece of chocolate, and leaving the box empty and crumpled on the floor. A third participant shared the story of an eventful exchange between her dog and a neighbour’s dog: One time recently we’re walking along and Rosie is minding her own business and this sweet lady comes up with some little toy dog. The dog comes up and starts to sniff and poke its nose into Rosie and bark. After several seconds, Rosie turns on this dog and goes “Rah” and puts her paws on top. She’s not biting the dog but she lets out some rather intimidating noise and pins it to the ground. The little dog stops and the lady freaks out and I burst out laughing and start apologizing and take Rosie away. I remember saying 125 something like “I don’t think she wants to play” and I just could not stop laughing. That lady was not reading signals at all. Rosie didn’t do anything harmful to her dog except teach her a lesson. So we have the occasional moment like that where it’s us against the world. We totally get each other and that’s very fun too (Female, dogs). Along with being a witness to their pets’ humorous antics, participants described instances of mutual game play between themselves and their pets. Games had two notable features, namely, mutual engagement and movement. Some games were brief and unstructured while others had rules and expectations. Examples of unstructured games are provided below: He likes to play, we play tug all the time. He’s got lots of chewy toys, plush toys and he likes to play tug with me so we play tug until he tires out and goes and lays down for a while or I throw his toy. He likes playing fetch and he brings it back and then we tug some more and then I throw it, so yeah. He’ll play with other dogs but one-on-one usually not in the dog park so that’s about Jackson in a nutshell (Male, dogs). Duke has his little rituals like my friend there, she is Aunty Scrubbler because when she comes in, she scrubbles him. He lies down there and she has longer finger nails than I do and he loves that. And then sometimes I’ll pick him up and say ‘I’m going to scrubble your tummy’ (low and booming voice) and just little things like that (Female, cats). Examples of games involving rules include the following: We have this game where this carpet gets laid out and vacuumed. Then at night time she pulls it all up. She sharpens her claws on the under carpet so there’s little blue pieces of foam everywhere and I come in and go “Penny did you make this mess” (animated voice) and she looks so proud. So I clean it all up and she gets all mad at me and at night she rips it all back apart again. It’s become our game, it’s a perpetual game for her but she has all her toys out. Everything is all over the place. We’ll put them back in a pile and they’ll be back out overnight again. I’ve never seen a cat play like her (Female, cats). When I couldn’t really walk a heck of a lot my cat was an awesome goal tender. I would take a little foam ball throw it down the hallway and she’d bring it back to me, she was like having a dog it was really bizarre…she was an awesome goal tender and we would often play ball down the hall bouncing the foam ball. She was super quick, she’d jump three feet in the air and would catch this. It was unbelievable (Female, cats and dogs). Peek-a-boo is one of their games. So when I look at him, he gets excited and will look and then kind of go away. He’ll do a loop around his bowl and come back just stopping right before me to check to see if I’m looking and then if I look he’ll go the other way sort of in a circle, come back again and stop…and then when I look again, he goes back around, so we play this game (laughing). It’s sort of silly but they do this (Female, fish). 126 In general, pets tended to rely upon subtle cues to initiate play such as making eye-contact, crouching down, or growling. Descriptions of these games are as follows: If I’ve been out in the car, I come back through the basement and he’s usually down there at the basement door, he must hear me coming and there’s steps down to the basement and he’ll sit at the bottom of the stairs and…he’ll wait to be petted and have his head scratched and make like he can’t possibly climb these stairs (exaggerating) by himself so you go to pick him up and he races up (laughing) yeah so he has his habits (Female, cats). One cute little quirky thing about Holly was when we would have staring contests. It was usually me that gave in and looked away. She would sit on the cat perch beside my recliner and stare and stare and stare at me not moving a whisker. I would say “Holly stop staring at me, you’re creeping me out.” It did not work and this would go on for the longest time. It was like she was playing a game with me. She just wouldn’t waver from her stare, and I said “you’re nothing but a demon kitty” (laughing) (Female, cats). These examples highlight the importance of being mutually engaged. Both parties had an end goal and needed to act in certain ways to fetch the ball or win the staring contest as it were. Mutual game play was especially important for participants who were on-leave from work or largely house-bound due to their illness. Participants believed that being physically active, even for short periods, was beneficial for them and their pets. Despite experiencing pain and fatigue, participants felt compelled to take their dogs for walks or visits to the park. Indoor cats were seen as needing more play time and interaction compared to outdoor cats. Play provided the participants with a sense of purpose and routine, helping them contain their worries. One participant said “it’s made my life richer, calmer, less anxious; I feel an unconditional love, laughter, humor, sense of peacefulness, connection and enjoyment; it feels safe.” A fifth facet of play was “rough-and-tumble” play, wrestling, or play fighting. To illustrate, one participant said that his son would often wrestle and tease their dog whereas his daughter tended to hold and cuddle their dog. His dog seemed to be tolerant of both types of play. Likewise, a second participant said that while her partner would tease their cat until she ran 127 away, she tried to be mindful of her cat’s “subtler looks” to avoid pushing her “to a place of not being happy.” A third participant described how her cat would quickly escalate from playing gently to clawing and biting her in what she called his “play-play” or “killer” mode. She often tried to deter her cat from getting too worked up whereas her roommate would encourage this behaviour. Rough-and-tumble play was seen as more acceptable when pets were playing with other animals or when pets were known to enjoy this kind of play. Illustrating the former case, one participant proudly exclaimed “my dog can hold her own” when playing with other dogs. Regarding the latter, another described her cat’s curious enjoyment of a particular activity: Holly was the one kitty that had perfect balance and never slipped. She would jump over two railings to get to the neighbour’s side. Holly loved to be swung all around the room in her nylon tunnel, long it what would be a five, six foot nylon tunnel. All the time I was swinging her I would say “zoom, zoom Holly” and as I swung her higher and faster she loved it, she was the only one of our cats that wanted to play like this (Female, cats). Somewhat related to rough-and-tumble play is instinctual play, meaning pets’ tendency to engage in dominant (e.g. pouncing or mounting another animal) or submissive (e.g. bowing or rolling onto their back) behaviours. For example, one participant reported that her fish would expose their bellies to her during play as a “sign of submission” and trust. A participant with an outdoor cat, recalled “running around in [her] nightgown with a towel trying to catch a mouse in the middle of the night.” Another reported that her cat was “quite feral” when she adopted her, explaining “she would attack me in bed and run after my ankles and I have plenty of scars to show for this one.” Yet another described his cat in the following way: I think it’s instinct, I think it’s bred into the breed. He’s a hunter. There’s other cats who might be docile but this guy is a hunter. And you see evidence of it. He will sit there for hours and I feel there’s no way he can catch a bird but he will sit there for hours and you go somewhere and there is a bird carcass …and it’s uncanny…he will sit there and watch the raccoons and the raccoons will be in the yard and he will be sitting there and sitting there. So long as they don’t make a move, he won’t make a move (Male, cats). 128 Such hunting behaviours, though regarded as acceptable for cats, were generally discouraged in dogs. For example, one participant talked about avoiding tug-of-war games with his dog to maintain his position as “alpha” and prevent behavioural issues such as aggression. Another lamented about her dog’s uncharacteristic display of aggression on a particular occasion: I’m not proud of this whatsoever. She attacked a gosling and harmed it to some degree and I felt very responsible like there were kids around. It was just a nature thing that happens but I didn’t have full control of her and it really brought me to, as much as we train and domesticate them they are still wild animals at heart (Female, cats and dogs). A seventh facet, transcendent play, refers to occasions when participants ventured outside of their homes with their pets. In some instances, transcendent play meant being an onlooker to their pets’ lively pursuits and athletic feats while in others, participants were actively engaged in play with their pets. Transcendent play was the kind of play that happened when participants were absorbed in nature with the sights and sounds of leaves rustling, blades of grass crunching, wind blowing through the trees, wet sand sinking below their feet, or puddles rippling with each drop of rain. The following comments provide some insight into this facet of play: Walking out in the forest with a dog just makes the walk even so much more profound. You take them with you and…it’s like having a small child with you. It’s seeing it through a whole different set of eyes. Yeah, such a good boy, such a good boy (whispering to her cat), what do you think Rocky (cat grunts) (Female, cats). I’m very grateful to have her and to have those experiences with her…and she pulls me along (laughing), like hiking up that mountain the other day I was like I don’t know…if we can do this and she’s like “Come on mom lets go”…It’s like I get to be a kid again. I get to re-experience maybe things I didn’t do a lot of or feel comfortable doing when I was little so to have this creature that’s like a kid all the time and never really changes from that. It’s like being able to re-experience that and I know with that my partner as well it’s really increased an element of fun and play into my life (Female, cats and dogs). Given the importance of nature, transcendent play was more common among pets who were given access to outdoor spaces. Even among indoor pets, participants found ways to bring nature to them. One participant said that she prefers to put live plants in her fish bowls, explaining: 129 It’s very beautiful because they glide and so I try to sort of strategically arrange their plants because he needs leaves as sort of shelves to sit on and also to hide in for privacy but also then I want to allow him enough room in there to be able to swim and have him glide and it is really beautiful to see them go across (Female, fish). In the case of cats, time spent outdoors meant playing on the balcony or backyard. Some participants felt conflicted about letting their cats go outside due to the threat of wildlife. One participant reported that her cat had been injured twice, likely following a confrontation with a raccoon. Another expressed guilt, saying “we’ve taken her on a couple of leash trips outside to the park and I need to do that more often because I feel bad that they just get stuck in these concrete places.” Despite their reservations, all but two of the participants did in fact let their cats out regularly. One participant described his cat by saying “he does have his wild side…it’s been a real problem keeping him in, especially in the nice weather, he will scream.” Another said: He’s nocturnal and I’m nocturnal…he goes out and has his, whatever cats do outside at night, and then comes back in. That’s our routine. I thought that Duke was going to be an indoor cat because some people have the opinion that if you let your cat out you’re a bad cat person because they could get run over but Duke did not want to stay inside. My husband who was a great gardener and loved being outside would be out there. Duke would be at the front door with his paws out there going (groaning sound) so my husband thought it was cruel to keep him in so he became an outdoor cat (Female, cats). In the case of dogs, play tended to spill out into a wider range of recreational spaces including parks and beaches. All sense of time was lost as participants watched their dogs shake off their outercoat of domestication. One participant said of his dog “she’s like I’m outside now, I’m a wild animal, I’m not a pet.” A second said that “being out on the earth and being around the nature” had a revitalizing effect upon her dog. Another recalled how his dog immediately took to the water, remarking “we were afraid that she would just swim away and never come back.” Two participants commented about the significance of going to the beach: She actually hates going in the water...but what she loves is barking at the waves and running in and out on the sand…it’s so funny to watch her, she just looks hilarious 130 (laughing). It’s like she’s sort of managing the waves and she seems completely in her element like she’s full of this energy and full of life…I’d be able to take off her leash and just see her just go full power, like she’d go a hundred miles an hour, it was pretty fast and the sand would be flying up in the air and she’d just be going. It’s like everything unleashed and it would give me this real, I don’t know, incredible joy (Female, dogs). The waters tend to be very peaceful and the dogs race up and down the beach. You know Max, he’s a very calm dog at home but he gets here and he just lets loose and runs up and down the beach. He’s scared of the water which is hilarious but he gets in there and digs lots of holes. Daisy and Molly, their favourite thing to do down there when it’s a hot day is to go in the water up to their necks. That water is pretty cold but they just love it and they get in there and hunker down. Then a boat comes down and and they run off again. The beach is the one place I can get Ellie to run (Female, cats and dogs). Participants described feeling better after being outside with their pets. As one participant said “you get a better outlook on life when you’re outside more than sitting inside all the time.” 18.104.22.168 It’s a sense of responsibility Many participants found it deeply humbling to know that they were responsible for another living being. Others expressed that they would not have made the effort to heal without their pets. This theme captures the responsibilities of caring for pets as a parenting experience, bonding experience, and restorative experience for participants. Firstly, being responsible for a pet meant keeping them safe, happy, healthy, fed, and groomed. As one participant stated “they are bred as pets, so we are responsible.” Another said of his cat “he didn’t ask to come into our family; we went and sought him out so we have to look after him.” While it was not uncommon for participants to use the word “pet owner,” many felt that the terms “parent” or “guardian” more aptly reflected their relationship with their pets. A participant with children said “they’re like my kids, they’re who I talk to, they’re who I administer to.” A participant without children commented “[when] you have a dog, you basically have a kid and they don’t grow up right.” Two others made contrasts between pets and children: 131 When I have to care for her there’s less focusing on myself. I want to keep her safe and it takes some of the focus on your own health away from you. At the same time because I don’t have children it’s not a stressful thing. There’s not some of the stress that comes with having kids that you have to be continually there. I just have to open up a can of food, it’s much more simple. I can’t say she’s similar to having a child but there’s probably some similarities for having another being to care for (Female, cats). Dogs are stressful like anything else. You can love your children but they’re still stressful. And she’s just been a huge support in my life. I honestly couldn’t imagine my life without her. Some days I wish I didn’t have a dog. I would just go and kind of do my own thing, but coming home and having her there is absolutely amazing. It’s absolutely crucial, that companionship…just having that one-on-one with somebody (Male, dogs). For participants, being responsible for their pets’ well-being stirred within them a mix of emotions from fear and doubt to pride and contentment, as demonstrated in the comments below: And I do remember feeling this intense kind of fear and panic that I suddenly was now responsible for this little creature here. And it’s learning the process of being able to communicate. So I found that…it took time and just learning the best way I could take care of her (Female, dogs). It creates quite a bond for one thing and trust between the two of us and there’s meaning for me as well to be responsible for her and to be the guardian of her life right now and make sure that she’s kept safe and healthy (Female, cats and dogs). Participants’ beliefs about parenting seemed to have their roots in early memories and experiences. One participant said “we grew up with dogs and had lots of animals when we were children and we always felt very passionate about dogs in particular.” Two others recalled being drawn to animals since their childhood: I’ve always had a relationship with animals, always (emphasis), my whole life. I was the kid that went out and rescued kittens and brought them home, but maybe that’s different because I’m more in tune with them and understand [them] than somebody who has never had a pet and never understood (Female, cats and dogs). Every cat we’ve ever loved has taught us something. They all have their special quirks, their own individual personality. It’s like having children. They’re our four-legged children and that’s how we think of them. I’ve had cats all my life, we did have dogs…but from the time I was living on my own I always had a cat (Female, cats). 132 Other participants reported growing up without pets or not being allowed to have a pet. Interestingly, the parents of participants who had been adamant about not having pets went on to acquire a cat or dog in the years after their adult children had moved out of the family home: When we were younger, my dad didn’t want us to have pets, particularly cats. Now he loves cats, it’s so weird but when we were kids we weren’t allowed to have cats or dogs. The first thing I did when I moved out was I got a cat and it’s been a huge part of my life ever since. It’s my affection for cats. I’ve always had an affinity for them and so when I adopted these two it was for the mutuality…that’s why I went to the [animal shelter] because I wanted to adopt cats that really needed somebody (Female, cats). In contrast with the previous example, a third participant described enjoying the company of cats and dogs as a child, only to have to avoid them in her adult years. A combination of allergies and the effects of cancer treatment left her with a compromised immune system. As she explained, “I would play with other people’s pets but then I’d get sick and be covered in hives.” As we delve into this parenting experience, imagine the home as a tableau of people and pets engaged in various caretaking practices. Picture the kitchen as the site of meal preparations and gatherings; the living room, with cozy couches and blankets, as a space for rest and refuge; and the bathroom, with its bright lights and floor tiles, as a place where pets often accompanied participants in some of their most intimate and vulnerable moments. Within these vivid tableaux, these static images would come to life as participants paused to look at their pets, holding them in their gaze, as they scanned their pets’ face and body. One participant shared her experience: They’re stuck in this bowl and they’re whole world is me. So that’s why I feel it’s so important to connect with them several times a day so that they’re not just sitting there because…I’ve tried to give these fish the best life I could and it’s been my therapy and in return they’ve blessed me tenfold (Female, fish). Another emphasized the value of these intimate moments through the practice of grooming: Touch is really important, she’s so soft. It’s so nice to touch her and there’s kind of a symbiotic. I know she feels good if I touch her and pet her and brush her with her comb and then that makes me feel good. She’s so soft it makes me feel good that I can keep her 133 healthy by relaxing her and combing her hair out so she doesn’t get hairballs and throw those up. For me the tactile nature of it, it’s so soft, it makes me feel better (Female, cats). Secondly, participants spoke about caretaking responsibilities in the context of their overall affinity toward animals, and their unique bond with their pets. This affinity for animals led participants to welcome a pet into their home, and yet bonding meant something quite different. In describing this distinction, one participant made reference to therapy dogs, saying “meeting somebody else’s dog is not at all the same as having your own dog.” A second said: I think the hardest part was when I was in the hospital and after my surgery because I couldn’t see her and I couldn’t be with her and also when I would go and get my chemo treatments because they’d bring other dogs to the hospital and it would irritate me because I would want Stella to be there with me, but she wasn’t allowed (Female, dogs). To explain the importance of bonding, some participants described feeling an immediate or instantaneous connection with their pet. As one participant said “as soon as we saw Rocky that was it, we fell in love with him…when we picked him up he was nuzzling under the chin right away, he was super affectionate.” Another summarized her experience accordingly: There’s a special bond between pets and their guardians and we have been blessed to experience this with ours. Our kitties currently and all the ones no longer with us have given of themselves wholeheartedly to us. Their love for us has known no boundaries. We have been so fortunate to share our lives with such wonderful pets. We cannot imagine life without our most treasured kitties (Female, cats). In addition to displays of love and affection, the element of fate seemed to heighten the experience of bonding with a pet. Participants spoke about events in their personal life such as beginning a new relationship or overcoming challenges with substance use, and how these circumstances came together to make it possible for them to welcome a pet into their life. One participant stated “dogs come into your life when they’re supposed to.” Offering her perspective, a second participant shared her experience of bonding with her cats: 134 It’s unconditional love. It’s not even like any human interaction because, the love is just, for me at least, an automatic bond. And I really have always loved animals but with them, I hate using the word pets but they’re more like my children…the relationship I have is much more like children. I coddle them and love them and cuddle them and it’s just [an] absolute and total love, that’s pretty well what I can describe it as. I look forward to when I get home…when I’m not feeling well, they’re right there with me (Female, cats). Other participants remarked that bonding took time, often months and years. One participant said of her dog “it wasn’t like I just got her straight home and I immediately felt this overwhelming love, I didn’t necessarily, it’s like that love had to develop as my relationship and bond grew with her.” Bonding tended to occur through daily caretaking responsibilities such as: feeding pets, taking them to relieve themselves, and providing them with a space to sleep and rest. Furthermore, caretaking often went beyond a pet’s basic needs. For example, some dogs held sway over when and how often they would go for walks. Cats who were resolved to avoid using the litter box were let out at their discretion. In regards to feeding, dogs were seen as less discerning about their food preferences, with a few having some unique predilections. For example, one dog would happily crunch away on her hormone pills without any complaints. Another dog would eat discarded marijuana joints off the street, getting stoned in the process. Some cats had specific feeding challenges. For example, one participant recalled trying to feed her cat after being injured by another animal, saying “I got some kitten food and watered it down. We were syringing it into his mouth, force-feeding him and it took a week before he started drinking water on his own.” A second described the feeding regimen for one of her cats: They call her a special needs kitty…and the first year of her life she’d be eating her food and she’d bring it up right onto her plate and it hadn’t even hit her stomach. Our vet finally found out she was born with a narrow esophagus. She’d be eating hurriedly and the food would just “whoop” out it goes. So he says feed her on an eight inch raised bench many meals throughout the day. It’s lucky I was working from home…so I could every four hours, a heaping table spoon or else she’d starve to death (Female, cats). 135 Providing a contrasting example, another participant talked about how her fish altered their eating habits when she was travelling frequently for radiation therapy: I had somebody come in and feed them every day and they were fine throughout this. I’m amazed because that’s never happened before. They usually don’t eat for anybody else but they did. It’s like they seemed to know that I needed them here for when I was done [with radiation] and for when I was home on the weekends (Female, fish). Thirdly, participants viewed their responsibilities towards pets as a restorative experience, helping them strive toward healing and recovery. Participants recalled needing to remain calm while struggling against the uncertainty of not always knowing what their pets needed. Participants felt helpless while watching their pets throwing up or having a seizure without any foreseeable cause. As one participant said, “you worry about them when they’re not feeling well, and part of you is wounded as well.” Another said “when they get sick and because they can’t talk to you…it’s just kind of devastating because they bring you so much happiness.” Participants were at a disadvantage having to look for signs as to how their pets were feeling. Pets too were at a disadvantage seeing their once healthy human companion beset with fatigue, nausea, and pain during cancer or other types of illness. As one participant commented: With Loki honestly I was just a robot for years. I didn’t know what I was doing and I didn’t do a great job of it when she was around. I was not home enough with her. I felt quite guilty as her health started to decline. Before I was sick I was a healthy twenty something year old. I was out and about a lot and her health was not good when I first got her. She was thin and not well. So for me to rebuild her health and then thinking about what I went through just a year or so after, wanting to rebuild mine…There was a lot of times I didn’t want to play with her anymore. I didn’t have the energy for it so it’s been very different between the two (cat and dog) of them (Female, cats and dogs). Just as pets could not communicate in words that they were sick or in need of help, participants could not simply tell their pets that they were trying to heal and recover from cancer. They had to show them. Even the seemingly small act of getting out of bed each day was revealing of their commitment to caring for their pets. As one participant said, “this morning I 136 was like, I don’t want to get out of bed, she just jumps straight on to my chest. It’s like okay, it’s time to go out. I’m hungry so get me some food.” Similarly another said: And Duke is very good at making sure I get up in the morning because if I don’t he comes and pats my face because he wants to be fed and I know I have to feed him because he’s my responsibility (Female, cats). Moreover, participants discussed making lifestyle changes that they saw as beneficial to their health. Examples were eating a healthy diet, taking nutritional supplements, reducing their alcohol intake, increasing physical exercise, and using organic cleaning products in the home. One participant stated “we try our best to give her a healthy life because I think it’s an extension of your life…she stays healthy, you stay healthy.” A second said “I feel very responsible for her health which in a sense is a reflection of my own,” going on to say: Especially with having Hazel in my life, I’m not sure what it would be like without her regarding my health. I’m not sure I would have made the effort that I have and been consistent with reaching for a better space in my health. I want to be out and having fun with her. I want to be out and going on these hikes with her. I want to be feeling better so that she gets to do these things (Female, cats and dogs). With regards to diet and nutrition, some participants discussed choosing organic foods for themselves and their pets, and treating ailments with natural remedies such as essential oils. Others stressed the importance of cutting down on sugar, fat, and toxins in order to reduce inflammation in their body and slow the growth of tumors. To illustrate, two participants spoke about the importance of their pets while they were dealing with alcohol addiction: When I gave up drinking I went through a lot of depression and some other mental health stuff around some pretty serious trauma that I’d experienced so she (dog) was there through a lot of tears and a lot of my own healing. So in some ways I feel like when I had this cancer experience she’d already sort of been there with me through so many emotional experiences that we already had that deep bond and connection (Female, dogs). I now regret that I drank at all when I first got them. You kind of look back at it and go “I could’ve been so much better of a parent.” But they were the first thing I thought of when I got home from work and I played with them all the time and cared about them so I don’t 137 think I ever neglected them when I was drinking because they were more important to me than even I was. When I got sick, they were definitely the reason why I fought so hard to start off with, and they still are the major reason I continue to fight so hard (Female, cats). From these examples, it seemed that pets were not only there to witness trauma but also provided a window into what motivated participants to heal from trauma. In the case of exercise, many participants believed that walking their dogs was mutually beneficial with one participant calling it “part of the treatment and recovery.” Others said that they would feel guilty if they didn’t take their dogs for a walk. One participant stressed “you can’t sit at home and feel sorry for yourself when you’ve got a dog looking at you saying it’s time to go.” Another said “as you get older, sometimes you feel you’ve become a bit sedentary and she pushes us out of that.” Two other examples highlight the benefits of dog walking: I’m sure for myself that my health is much better because of walking the dog…In some ways it gives me a feeling of pride in my own accomplishment that we are getting out with the dog and making sure she gets exercise and it shows some fortitude on our part. Like, it’s pouring rain and “so what, you got to go out.” It’s interesting when we walk up to [the park] this morning, there was a lot of people there but if it starts pouring, it just clears out. No matter what we’re still going to be there…it’s like a badge of honour to say that we have a [dog] and we walk her (Male, dogs). She’s certainly been good company and fun for walking. It kind of gives you an excuse because you have to get all this exercise and having the dog makes it imperative that you get out and do all of that walking because it’s for the dog too and the neighbours don’t that think you’re going in and out of your house like a yoyo for no reason (Female, dogs). Taken together, the decision to get up in the morning and feed and exercise their pets was the embodiment of participants’ attempts at healing and recovering from cancer. Caring for a pet was not only a source of bonding but also renewal and restoration. 4.2.3 Super-ordinate Theme: Speaking Volumes with their Actions Their presence in my life made me heal faster and in a much more profound way. It would have been a really lonely journey without them and I’m not sure if I would have had the strength to do it on my own. With them being part of the whole process—I mean I still have cancer but I’ve achieved a level of healing that I don’t think I would have done 138 on my own without their help, their presence, their love. It’s an unconditional love. It’s a very profound, very silent kind of love. They never come out and say “I love you” like a human being does but their actions speak volumes (Female, cats). This super-ordinate theme delves into the complexities of human-pet communication. For participants, the knowledge that their words and actions could undermine their pets’ well-being made them more mindful about their tone of voice, choice of words, mannerisms, and body language. Participants tended to see their pets not as inanimate vessels, passively absorbing their emotions, but rather, as intuitive confidants who were no less vulnerable to the sting of harsh words and sounds. Accordingly, participants often spoke to their pets using an exaggerated and animated form of speech known as motherese or baby talk. The purpose of motherese was to acknowledge pets, and encourage their involvement in everyday routines such as sitting down for coffee in the morning or cuddling on the couch to watch TV. Being in their pets’ presence was a tangible reminder that they were not alone. The ease with which participants could talk to their pets, along with the comfort of knowing that they didn’t have to talk, allowed participants to experience both companionship and solitude. The term language typically brings to mind spoken and written forms of communication. Participants and pets often communicated with each other through nonverbal and intuitive means. The language of the human-pet relationship could be understood as a means of exchanging care and affection. Human-pet communication was subtle, yet explicit in the sense that it was comprehensible to both pets and people. Such communication relied upon much more than the exchange of words to facilitate mutual understandings. In fact, words served as a way of communicating intimacy inasmuch as they were an impediment to such intimacy. One important mode of nonverbal communication between people and pets was their physical nearness or proximity with one another. Proximity seeking appeared to be fluid and dynamic, with pets most 139 often establishing the parameters for these interactions. Even when separated by walls and floors, participants were very conscious of where their pets were in the house. Likewise, pets seemed to have an uncanny awareness of when to seek physical contact and when to keep their distance. As highlighted in the following themes, pets had much to say through their physical proximity, mattering presence, and capacity to tune-in to others, respectively: 1) It’s a silent kind of love; 2) It mattered that their pets were there; 3) It’s like each living thing has meaning. 22.214.171.124 It’s a silent kind of love For participants, the invariable question of what their pets were thinking and feeling, stirred within them a profound sense of curiosity and attentiveness to their pets’ subtle looks, sounds, and gestures. In the words of a participant, “I’m always wondering, it’s like that constant mystery of how they think.” Another described the relationship as a “one-on-one love and affection without having to say anything—it’s so intuitive.” The language of the human-pet relationship could be most aptly described as an “unspoken connection.” This theme is comprised of two facets that illuminate the dynamic nature of human-pet communication: developing intimacy through proximity and distance, and being explicit without having to speak. Firstly, human-pet communication was manifest in the degree to which participants and pets maintained physical proximity. Proximity could mean simply being in the same room, or experiencing the kind of closeness described by a participant: “She would lie down on me and then we would have some sort of intimate time and just exchange care and love.” Participants derived comfort from the softness of their dogs’ fur and the warmth of their bodies. Similarly, dogs yearned for closeness with people. One participant said “[with] Max, I cannot lay down for a nap without him being right beside me; he curls up in the small of my back and stays there.” 140 Another described his dog by saying “he’s a lapdog…he always wants to be part of what’s going on.” A third said “we joke and call her shadow because she just follows me around the house.” Examples of proximity were not unique to dogs. Fish readily followed the participants’ gaze and movements. One participant said “the fish can be sitting there and as soon as they know you’re looking at them they start swimming like crazy.” In the case of cats, some were quite discerning, only willing to approach a select group of people. Others cats were eager to socialize, expressing affection by curling up with participants under their chin or sleeping on their chest. One participant said referring to her cat “she liked to come under the covers and she would push her little warm paws under me and it was just such a comfort.” A second said “if I’m cleaning, they’re with me the whole time, [my friend] calls them my entourage.” A third commented “she was a total lap cat and loved to snuggle, so it was having that affection when I really didn’t want to be touched by anyone else.” A fourth shared the following example: He will voluntarily climb onto my lap without the treat temptation and he will come and snooze by me. He’ll sit beside the bed and look up at me and meow until I say ‘upy, upy.’ I know that’s childish talk but he understands it. So he chooses to spend his time with me. He doesn’t have to but he chooses to (Female, cats). For participants and pets, proximity seeking conveyed their mutual interest, love, and affection. However, there were some instances when pets and participants sought distance and separation from one another. Over time, the kitten or puppy that would follow participants underfoot, developed into an adult pet in need of quiet space as in this example: She follows me into the bathroom a lot. She’ll just come in, sit somewhere and wait for me. If I don’t let her in then, when I open the door she’s lying on the floor right outside waiting for me…sometimes we’ll be like “where is the dog” and realize that she’s come in here and is having a nap in her crate. If she does something bad...she looks terribly sheepish and…she actually will go to her crate and give herself a timeout (Female, dogs). 141 As with this example, many pets were given wide-ranging access to indoor spaces with a few even having their own room in the home. As such, it was not uncommon for pets to venture off, seeking a sunny spot by the window or a warm place to hide. One participant said referring to her cat “If I noticed she wasn’t in the room I would be like oh, why is she under the bed…then I would coax her out and let her know it was okay to come out.” Another said: She’s under the bed, that’s her go-to place. It’s weird with my mom, she’s not like this at all, she comes right out when my mom is here…but anybody else she’s gone, you never see her. A lot of people joke, “she’s just a figment of your imagination” (laughing) but I have pictures to prove it so she does exist…she and I are really interconnected. She knows exactly how I’m feeling and…hers is a quiet kind of love (Female, cats). Some pets were well-disposed to being picked up and held by people. Others resisted such attempts at being embraced, especially among pets who had a history of abuse. One participant said “she doesn’t like being picked up but she does like to cuddle but it’s sort of on her own terms.” Echoing this point, a second participant remarked: You have to be really patient; you can’t push yourself on a stray. You have to gain their trust and allow them to make the rules about how intimate you’re going to be. At first all you could do is scratch under her chin and then go to her cheek and then a little more. Now, she still doesn’t like me picking her up. I can stroke her or rub her belly and she sleeps with me now but it took a long time for her to build that trust up (Female, cats). Similarly, dogs were not uniformly accepting of being touched and cuddled with one participant remarking “she’s not a lap dog; she doesn’t come over and lick and wag but she does want to be near us most of the time unless she’s busy sleeping somewhere.” Another said: She’s not like an over-the-top cuddly dog like some dogs are. I think it’s part of [her breed] so I often have to force her to cuddle. I mean she is very affectionate, she’s just not overly clingy. Some dogs like to be on you all the time and she’s not really like that. She likes to have a little cuddle and then she likes a bit of space (Female, dogs). 142 Furthermore, there were times when participants found it difficult to reciprocate when their pets were initiating play or expressing affection towards them. A lack of energy or a need for space left participants wanting to be alone, even avoiding their pets: I’m having a hard time connecting with Loki (cat) who I know that I pushed away a lot of the time. I just didn’t want to be touched but she would either sit on the edge of the bed or she’d come up and lie next to me. I specifically remember when I was going through chemo and lying in bed and having the energy worker there and she would come in …I was frustrated and took it out on them. I wouldn’t allow even Hazel (dog)…it’s like “don’t go near mummy right now, she’s not in a good space” (Female, cats and dogs). Through their unspoken connection, pets and participants learned to navigate when it was best to disengage, and when closeness and intimacy were needed. Secondly, human-pet communication was often unspoken, yet explicit in that pets tended to display consistent and recognizable behaviours. Even the most stoic of pets could not conceal their joy at being reunited with their human companions after a brief separation. Cats would rub up against participants’ legs, curling their tails and rolling onto their backs. Fish would swim around vigorously, producing voluminous bubbles. Dogs, in particular, were known for their effusive greetings. One participant commented “those cold wet black noses, licks, kisses, and wagging tails…you come in the door and you’d think I’d been gone for days.” Another said: Just coming home and having that unconditional love. I have so many names for her, Happy Feet, because she does her little dance with her bum wiggling all over the place. Just acknowledging coming home and having this creature love you and happy that you’ve made it home. And I’m equally happy that I did make it home (Male, dogs). When communicating their displeasure, pets made no bones about expressing their feelings. One participant said that his dog knocks over the garbage can when he comes home late, saying “she’s basically telling me this is not acceptable.” Another said that her cat once scattered the contents of his litter box because “it was offensive to his dignity.” A third said “he’s a majorly 143 affectionate cat but he definitely has a problem with me being gone for any length of time, so going to a hospital was agonizing because I knew what it was going to be like for him.” Participants often described their pets as being attentive to their words and gestures. One participant said “just the word intuitive, she (dog) can pick up on moods.” Another commented “she (dog) can figure out what’s going on, or interpret your facial expressions to see if she’s doing the right thing.” A third participant described her fish by saying “they do what you’re doing. If you’re sitting there looking ahead they’ll face the same way but when I talk to him, he turns around and looks at me.” With orchestra-like precision, pets reacted to the slightest change in participants’ inflection and intonation by tilting their heads or raising their ears. Rarely did participants need to utter a word before pets knew that something was wrong: When I would come home from the treatments, I had a lot of nausea and vomiting. I was having radiation every day and chemo every week and surgeries during that time. It was a very intense period because of the treatments and I always feel like she was sort of virtually and metaphorically holding my hand. She became much more cuddly and wanting to be attached to me, to help me, and to just be there. I don’t know how I would have gotten through that without her. She’s this little stoic presence (Female, dogs). It seems like since I’ve been diagnosed, he’s closer to me. He’s always sitting on my knee or leaning against me or sleeping next to me…yeah, maybe he’s got a sixth sense, he knows something is going on, I don’t know, but he’ll just sit there and stare at me. He can do that for an hour, just look at me…if they could only talk (Male, dogs). Similarly, one participant saw a remarkable shift in her cat’s behaviour after experiencing a death in the family. This cat went from biting her ankles and peeing on her clothes to faithfully sleeping by her side by the time she was diagnosed with cancer. Two others commented: There were times when I don’t know if there was food poisoning but I would get so sick. I was literally laying on the floor vomiting and thinking I should go to the hospital. And she’s laying beside me the whole time. She just would not leave my side and my neighbours were aware of my health challenges. If they hear Ginger barking excessively, they’ll always come over…And the one time when I was sick on the floor, she barked excessively and it alerted a neighbour who found me and kind of helped me…and it was all because of Ginger. She basically saved my life (Male, dogs). 144 There was one time the summer before and I had just started recovering. I had taken the dogs down to the beach for their run…but as I transitioned onto soft sand, I lost balance…I went down. I hit my head on a log and all three dogs came and laid beside me. Somebody yelled for help and…those dogs never left my side until I was vertical again and everybody was just like “wow you have such great trained dogs.” It’s just they know when you’re sick. They know when you’re not well (Female, cats and dogs). In homes with multiple pets, one pet would often assume the role of the participant’s protector. One participant said “when I finally got out of the hospital, Zoe (dog) became little miss bossy pants, nobody could go near me and with every noise, she was barking.” Participants’ belief that pets had an intuitive or sixth sense was further reinforced when they observed their pets carefully avoiding certain areas of their body when they were recovering from surgery: Holly seemed to know when I was hurting and in pain after the surgeries and her comforting presence was so welcome and had me soon feeling better. If I was lying in bed, she would carefully lay herself beside me never once stepping on my chest. After the mastectomy I was in a lot of pain. Her quiet and calm presence were a blessing to me. It was especially nice when she would lie next to me under the covers. Her little body pressing against mine was pure heaven. Holly was such a sweet kitty (Female, cats). Rocky was so good he never left me pretty well, like he slept with me the whole time. He was right underneath my chin and he learned really quickly not to walk on my stomach and little Penny slept with me for the first time too during that surgery and for a stray, that’s a big, big thing. It takes a long time for them to bond with a human (Female, cats). In addition, participants described how their pets would zero in on any changes in their body’s appearance or odour. One participant said that her dog would chase her around, determined to lick one of her toes that had gotten infected. As the infection cleared up, her dog’s licking declined, providing a “good barometer” of its healing. A participant with a history of prostate cancer said that his cat would always make a “beeline” to him, jumping on his lap. He went on to say “he knows that something is up, so that’s his way of helping me through the process.” Lastly, human-pet communication seemed to rely upon a subtle interplay between decoding and responding to each other’s facial expressions and body language. Without saying a 145 word, a tentative gaze from participants signalled to their pet that it was time to pull out the favourite blanket or grooming brush. The prickly feeling of their dog’s tongue licking away at their hands or feet beckoned vigorous head scratches and belly rubs. The rich sounds of their cats purring reverberated through their body producing a “calming sensation” and a “sense of serenity.” The following examples highlight the reciprocal and ineffable qualities of interacting with a pet: There’s sort of this unspoken connection. Sometimes I try and talk to her when she’s meowing and see how she’ll react. And if I tap the couch or the bed, or if I make a sound like tick, tick, tick, there’s sort of like a little communication. There’s a few things that she’ll do regularly so she’s not necessarily trained like a dog but there are a couple of things that feel like our language that’s developed (Female, cats). It’s neat to share that with an animal other than a human being. It’s like having this connection with something different, like she can’t talk to me. It’s all very little nuances of how you are doing. It’s eye contact or how she’s holding her body or how her ears are…I can tell if there’s something going on in a person’s eyes or with their body language and you pick up on those things having a dog (Female, cats and dogs). As in the second example, it was difficult for participants to put into words the precise meaning of their pets’ gestures, for example, how participants knew that an upturned ear meant doubt in one situation and curiosity in another. And yet, participants came to develop an intimate knowledge of their pets’ needs and preferences by attending to the nuances of their behaviours: I’m really attentive to his cries. I have a pretty good idea as to when he wants to go out and when he wants to be fed. I can’t tell you a detailed picture of what it is, but it’s something I sense. Somehow I just feel like he’s in a hurry to go out and that view is reinforced when I bring him out because usually he goes and hides but he comes straight to the door so I know that it’s a different need other than feeding (Male, cats). I find it so interesting that she’s so complicated and all of the times she’s trying to communicate in very subtle ways…the communication becomes much more ingrained and I see the ways that she’s asking for things. Sometimes I’ll go and pick her up from my parents and they don’t seem to have that ability to know what she needs. I’ll get there and I’ll be able to tell right away she needed to go and do a poop…they don’t have the level of relationship, that intuitive sense that you develop over time (Female, dogs). 146 Another remarked “it’s a very profound, very silent kind of love; they never come out and say ‘I love you like a human being does but their actions speak volumes.” 126.96.36.199 It mattered that they were there When participants needed a companion who would just listen without giving advice; when they wished to go for a walk in silence; when they couldn’t sleep; when their work-life ceased to provide structure for the day; when they were anxious and alone, it mattered that their pets were there. This theme addresses how participants experienced their pets’ presence in the context of their illness, by considering three facets of human-pet communication: upholding the silence, filling the silence, and enriching the silence. Firstly, pets were effective at upholding the silence, lifting the burden of having to talk. By contrast, some interpersonal relationships were saddled with conditions and expectations for how people should act. At times, people’s well-intentioned efforts were overlaid by an almost palpable sense of discomfort, heightened by the feeling of not knowing the right thing to say. With pets, participants felt relieved of any obligation to talk: I found that when I was feeling very ill, it’s hard to talk to people. My wife is always saying “Come on think positive.” You can only take so much of that. I’m the one that’s sick. I’m recovering but I still have some issues to deal with and sometimes it’s easier to be with a dog than to be with family members or friends that are very concerned about your health and “What’s going on? How are you doing?” Sometimes you get tired of it, so I find that the dog is a great companion because she just wants to go out (Male, dogs). My family is very supportive but they’re not here. Duke’s (cat) here and quite frankly Duke is the kind of comfort you want when you’re really sick because he’s not persistent. He’s not always asking how you’re feeling. He’s just there. He’s warm and he’s purry and it makes a big difference. He gives you a reason to go on. He seems to know when you’re not feeling well…He has a big advantage over a person in some ways. I can put his food out and go back to bed if I’m not well and that’s okay with him (Female, cats). With pets, silence was a permissible and acceptable way of responding to illness. One participant said of her cat “he doesn’t give judgement; he doesn’t give advice (laughing) unless you count 147 the wagging of his tail.” By allowing silence, pets left an impression that words were unnecessary and, perhaps even, a hindrance to intimacy and connection. The energy required to engage with another person led some participants to retreat from these kinds of interactions: A year and a half ago I could barely leave the house, I had so much anxiety. I would spend a lot of time on my own but she was a comfort and was there for me during that time when I didn’t want to see people and wasn’t relating to a lot of people or didn’t have the energy. She was company so I actually didn’t feel really alone (Female, cats). Another notable instance of pets upholding the silence was in the experience of walking with a dog. Participants derived comfort from the rhythm and repetition of their shoes hitting the sidewalk as they moved in unison with their dogs. One participant referred to walks as his “meditation” and “quiet time,” explaining “she (dog) just walks alongside and every so often looks up.” A second participant said “[it’s] the most relaxing thing when you’re away from cancer and you can just sort of be one with nature and the dogs.” Another said: I’ve changed a lot as a human being. I’m a lot more compassionate, wanting to help people. Even though she’s four legged and can’t talk to me, I know she’s part of it. I just have to mention that word (W-A-L-K) and she’ll be right over here saying “when are we going”…she’s the one who gets me out for walks because she enjoys it and I enjoy her company. When I walk down there in the woods it’s like a gentle massage in the back of my mind being with her and talking to her. We’d sure be lost without her (Male, dogs). The effects of cancer treatment affected participants’ regular walking routines with their dogs. For instance, one participant said “when I got home with the walker I could go about three houses, and within about two months I could walk a mile.” For others, daily walks increased in frequency, especially, for those who were retired or on leave from work. One participant said: At the beginning of each cycle, like every three weeks I had to go in for treatment, I had to take prednisone, and it just makes you manic. It was like I couldn’t sleep for probably two or three days so I would find it was really good to have a dog because I would take her, we would go for walks at least three times a day for like an hour each time so it was really good for me to have a companion and she’s a very good listener (Male, dogs). 148 Not all dogs were equally enthusiastic about walking. Some required an incentive such as a treat or car ride while others rushed to the door with the mere mention of the word W-A-L-K. One participant said “I just have to look at her and say let’s go and it’s brought peace to me.” Secondly, pets were adept at filling the silence, acting as a “conduit” for communication. One participant said that his dog “helps to ease communication because she’s just there and everybody wants to scratch her and talk to her.” There was an ease in being with a pet such that participants were often unaware of themselves talking to their pets. A participant with a cat said “I do probably talk to her a lot more than I think but when you’re alone you don’t always know that you’re doing it.” Another with fish said “I call him names like Love and Precious, sort of silly I guess, if you were listening you might think I was a little crazy.” Two others said: If we’re out walking I’ll say “which way shall we go, let’s go over here,” just like talking to a person really. Or if it’s getting close to her meal time, the tickedy, tickedy following everybody around will increase and she’ll become sort of more in your face and finally somebody will say “oh Rosie have you been fed?” And when the kids come home, she’s always the first person they talk to, “oh Rosie the Dosie how are you” (Female, dogs). Having this lingering death at your door, the dog helped a lot…you can always talk about the dog, you can always talk to the dog and our family, we would all laugh at the things that she would do and especially when you have young adult aged children, there’s not a lot of communication going on even when someone is seriously ill and the dog is just something there and “aw Sadie did this and Sadie did that” and everybody is always interested, not “oh gee I felt really sick today.” No one wants to hear that (Male, dogs). To understand human-pet communication, take the metaphor of walking along the beach. Everyday routines with pets created a secure foundation akin to standing on packed sand. The waves lapping against the shore mirrored the ebb and flow of their conversations with pets. What cancer did was make the participants more cognizant of where they placed their feet on the sand. To illustrate, participants recalled talking to their pets during cancer treatment: One of the hardest times [was] in the morning when I was having treatment. She (dog) would come in and jump up on the bed. And just being there as a presence, I’d scratch 149 her around her neck and she’d like that. And she’d just lay there sometimes for an hour. She was very calming and not being demanding, just being there because sometimes I’d be up in the middle of the night just unable to sleep and restless and everyone else would be asleep and she didn’t mind if you came over and talked to her…but sometimes her presence is, even if it’s a quiet presence, is better than loneliness (Male, dogs). With Rudy, most of the things I said when nobody was around were directed to her. She was the one that was around every day that I cried. I was in such rough shape physically that I couldn’t leave the house. I could barely walk around my apartment for months and months after treatment…Rudy was that consistent piece (Female, cats and dogs). Not only did pets fill the silence by prompting conversation, they also elicited particular vocal cues from people. To illustrate, the following statements were made by a participant at different points during an interview: “Stella, are you having a nap sweetie?” “Hey, sweetheart, been my little belly.” “Stell- what is it sweetheart, you okay, would you like to contribute something sweetheart? “Stella, you’re such a sneak, yes you are, yes.” During another interview, in response to her cat making an aggressive motion, another participant said “oh Rock-, whoa, whoa, whoa, hey cut it out.” A second warning came minutes later: “hey no claws, you can cuddle but no claws, good boy.” A third warning ended with “Rocky, you’re so beautiful, you’re so pretty, you’re so gorgeous, look at this belly, no bitey, bitey, that’s not very nice.” Such examples revealed participants’ affection toward their pets through their use of repetition, nicknames (e.g. Stell-), and elongated words (e.g. bitey). Two participants reflected upon this tendency to modify their speech when addressing their pets: I’m really conscious about sounds…maybe Luna can’t understand the words I’m saying but I feel like she can probably understand the kind of intonation you’re using to talk to her. So I feel like I don’t want to, even if it’s joking around, use words and sounds that she can take negatively and I guess maybe that comes from some of the cancer stuff too because they say to stay positive and stay with good vibes (Female, cats). Ginger is very much a lap dog. She just wants to be loved. But she always knows when I’m angry. I tend to vent and slam things. When I see her cower and run away, it means I’m out of control and my dog is afraid of me. I have to tone it down which helps me to center myself, so I can comfort her and let her know that I’m sorry and it’s going to be 150 okay. So I really do watch my tone, mannerisms and behaviours. If I’m in an emotional state that I can’t seem to control, I’ll just go for a walk and calm down (Male, dogs). Thirdly, pets were effective at enriching the silence and fostering a sense of solitude. However, this silence was not devoid of sound, and this solitude was not tantamount to loneliness. Pets stirred participants’ sensory capacities through their sights, sounds, and smells. The discernible beauty of pets was not lost on participants many of whom found themselves captivated by their dogs’ expressive eyes and flowing fur, their cats’ agility in navigating a tall scratching post, or their fish’s ability to blend into their surroundings. A participant with a dog said “she’s so pretty and her ears are so soft, we just really like admiring her and playing with her.” Participants felt soothed watching their pets sleeping or sitting still. With the rise and fall of their pets’ ribcage, participants felt their own breathing slowing down. Two participants commented: It’s a little bit like when you see your kids sleeping, you just get this peaceful feeling that everything is okay in one compartment of your life…you tuck your kids into bed and they actually go to sleep and it’s like “oh perfect (sighs), they’re healthy and peaceful and comfortable” and [it’s] just very reassuring. And so with the dog it’s a little bit like that. She’s clearly not suffering if she can go have a nice peaceful little nap (Female, dogs). If she’s (cat) cuddled up with me…I’ll focus more on our connection rather than letting my head go off into “Why is my back sore? Or what’s that little headache? Is that rash skin cancer?” So there’s just kind of a peaceful feeling that she brings over me so I don’t have as many of those thoughts. I guess I don’t feel alone when she’s with me. There’s less of a feeling of anything bad coming to me even though that maybe isn’t rational. I just have more of a sense that things will be okay when she’s with me (Female, cats). Along with their visual appeal, pets made their presence known through their expressive vocalizations. The pulsating hum of their cats’ purr and the pitter-patter of their dogs’ feet provided a soothing backdrop to their daily life. A participant with a cat said “her purring, if she’s on my lap or on my chest, there’s such a nice sound and vibration that goes through me and helps calm me down.” Two others spoke about the meaning of their dog’s company: 151 It’s been nice having the company in the house. I think any dog owner finds that if your dog’s not there in the house all of a sudden, the house feels really empty, you’re listening for the tick, tick, tick of the feet on the ground and so it magnifies it a little bit just that I’m not working, so I’m around more. She’s been a very good dog. Once in a while if I’ve been kind of blue she’s come up to put her nose on my knee (Female, dogs). There is someone when you come home. If you come home to an empty apartment, it’s cold and it’s quiet and it’s boring. Sometimes I think boredom is the worst thing that you can have and it really makes you seem like your life is not worthwhile at all. So just the company is a big thing anytime (Male, dogs). As for smells, some pets were affectionately described as being “stinky” while others were prized for their remarkable cleanliness. One participant referred to his dog, saying “her paws are completely wiped, it’s like the dirt just sheds off her.” Aside from the odour of kitty litter and the occasional discovery of pee and poop in the house, the smell of their pets appeared to be a familiar and comforting scent. Pets groomed themselves, licking their paws and rubbing their bodies on items of clothing and furniture. One participant remarked “you can probably see cat hair everywhere in this house but that’s part of living with a cat.” A second said of her dog, “she’ll flop in one direction and then she’ll get up and flop in the other direction on the sofa and it’s like she’s trying to smell up the whole thing evenly.” Another said referring to her dog “she had her own couch for a while but it’s been given away because it had too many hairs on it.” For participants, the confluence of these sights, sounds, and smells gave rise to a feeling that their home was abuzz with life and activity, and that all of this could recede into silence when they needed quiet and stillness. For participants, it mattered that their pets were there: She went through my entire diagnosis. She was there and that was all that really mattered like it didn’t matter if nobody else could take me to an appointment. Well, it did matter but having her and knowing that she was around and that I could come home to her and it was consistent—that made it okay (Female, cats and dogs). Their presence in my life made me heal faster and in a much more profound way…it would have been a really lonely journey without them. I’m not sure if I would have had the strength to do it on my own. I still have cancer, but I’ve achieved a level of healing 152 that I don’t think I would have done without their help, their presence, their love...I wake up and they’re both sleeping on me and I’m nice and warm under my blanket and I just revel in that. It’s a small thing, but it’s quiet and serene and relaxing (Female, cats). 188.8.131.52 It’s like each living thing has meaning Participants tended to use terms such as creature, being, living thing, and living being to describe their pets. The impact of these so-called living things and beings did not go unnoticed by participants. Through their actions, pets embodied particular qualities or ways of being in the world that participants aspired to emulate. Pets exemplified the importance of demonstrating care and compassion to others, and to oneself. This theme addresses these ways of being in the world by examining the role of pets in helping participants become more in-tune with the experiences of others, as well as, their own. Firstly, it was clear that no two pets are alike. Some pets elicited awe and admiration while others inspired envy. For example, one participant said “they have such a fantastic frickin’ life, they get fed well, have a warm place; they have cuddles and if only people could have lives like that.” Similarly, cats and dogs were described by some participants as having notable differences. One participant said her cat “was very different, the personalities and with regards to independence; the cat can stay at home for three or four days at a time with a bowl of food and water; you can’t do that with a dog.” Another remarked “cats are quite happy to be by themselves, dogs are not.” Two others alluded to these differences, saying: People say “are you a cat person or a dog person?” To me, cats are just like things that will be there when they want to be there. They have such a different personality. Some cats are different. I think dogs are just more companions. My wife is allergic to cats but I couldn’t really see us owning cats. I find a dog just seems to be more enthusiastic about doing things…You’ve got to walk them and everything but for me it’s part of the enjoyment of the dog. It’s work that I don’t mind (Male, dogs). I love cats but all cats are autistic and they don’t have the ability to show emotion the way a dog does. These guys (dogs) when I was diagnosed, and especially when I was in 153 the hospital, it was like they knew right away something was wrong, they picked up on it right away… the cat really couldn’t care less (laughing) (Female, cats and dogs). The suggestion that cats are less in-tune with people compared to dogs did not hold true for all participants. One participant spoke about her relationship with her cats, explaining “it’s a mutual thing; these two needed a home and somebody to love and care for them, and I definitely needed the love and care that I always seem to get from cats.” Another participant commented: Loki (cat) is very comforting. Hazel is (dog) more about the action and fun. Hazel is not as open to it. If I’m balling my eyes out and I grab hold she’s kind of like “Yeah I’m okay with that” whereas with Loki she’d be all over it. She’d be like “Okay, what can I do to help you?” She’d lick my tears you know it was a different relationship. The idea of being vulnerable is difficult in this society. What meant a lot to me was being able to do that with these guys and not feel like I was being judged (Female, cats and dogs). Furthermore, some participants described their dogs as being quite discerning about the people and animals with whom they interacted. One participant said “Stella (dog) doesn’t bond with everybody; there’s just certain people that she’s more drawn to than others.” Interestingly, another striking example of pets being in-tune concerned neither cats nor dogs but rather fish: I knew something was wrong but I didn’t know what and that was about the time my fish started acting funny… and here this tumor kept growing in me and it was weird. It was like he was so in tune with me and the same thing kind of happened to him. He had a great big growth around his eye and before I even knew what was going on with me, it was like “oh my fish has this tumor” and then I was diagnosed. So we were right in sync with each other…when I had my surgery, his tumor went away too (Female, fish). Although participants were careful to avoid calling pets, people or human beings, it was seldom that they talked about pets without making reference to human attributes or interpersonal dynamics. One participant said “I don’t want to humanize him (cat) but I see him very playful, like a child.” A second participant said “I recognize that he’s (cat) an animal and has his own dignity and space.” A third remarked “to have this other—I won’t say human being—but this 154 other living person (dog) helping us and she really has been good to everybody.” In describing the differences between pets and people, participants discussed the importance of emotions: I’m pretty sure he likes me and that makes life worth living when something maybe loves you. It’s hard because cats are cats. They’re not people and yet we use people words to describe their feelings. That’s why I say like rather than love but I think in his own cat-way he does love me but it’s not the same as a people-love (Female, cats). Another participant went further to suggest that not only do pets have distinctive qualities but, in fact, they tend to elicit these very same qualities from people: Most people like to think of animals as being a lesser creature. I don’t think that at all. I think actually human beings based on our behaviour are far less on the scale of goodness and I think having a relationship with them makes human beings—it brings out, in some people abuse, but with most people it actually elevates them as a human being. It makes them more compassionate, understanding, and caring (Female, cats). In the case of interpersonal dynamics, pets were considered to be family members, children, siblings, and friends. Along with having distinct personality traits, pets seemed to develop unique relationships with each member of the household, being standoffish with some and affectionate with others. The experiences of a participant with fish suggest that pets tended to display human-like attributes, as well as, those characteristic of other kinds of pets: I’d always liked the Betta fish because they’re very beautiful with long tails and fins and colourful. I’d got one after a break-up and it was nice to have something living in the house. They’re very responsive and take to one person. If you’ve left the room for even five minutes and come back and look at him, he just gets so excited. He will start swimming and it’s like a dog if you think of a puppy and how they get so excited and knock everything over with their tail…They can’t live together because they fight and have problems and I can kind of relate to that. I’m by myself and kinda like it that way but it is quite lonely and the fish has been a good companion for me (Female, fish). Apart from this example, conflicts between pets living in the same household, tended to be spontaneous and short-lived, akin to the kind of jealousy and rivalry observed among human siblings. Without warning pets would erupt into play and then just as suddenly begin fighting. Some pets would tease their sibling by growling or pawing at them while others were often 155 found cuddling and sleeping together. One participant shared a photo of her cats, explaining “oh that’s them curled up together…this is what they used to do all the time and she’d just basically curl up on top of him and almost disappear.” A second participant recalled her family’s experience with getting their dog, Ellie, after which they decided to adopt Zoe (dog) as a companion for Ellie: I said to my daughter “okay we’re just going to look” and of course came home with a puppy. We had her for a year and I was still working full-time and my daughter was at school and I thought in all fairness, she’s left alone, it would be really nice if she had a companion so the following summer, we went online again and saw Zoe. Zoe had been beaten to a pulp and forcibly removed from a home…We went out there and I took Ellie and they seemed to get along, so I ended up taking Zoe home (Female, cats and dogs). This participant went on to describe how Zoe then responded to the addition of their cat, Oscar: My daughter was working at [the mall] and hears this “mew” and finds Oscar in a dumpster…so we took him home and…I spent time introducing them and Zoe just realized it was a baby and started walking it all over and tucked it between her legs…and from that point on, Oscar became Zoe’s pup and she raised it (Female, cats and dogs). The examples above demonstrate the meaning participants derived from watching their pets receiving and embracing another animal. In a similar vein, participants expressed the importance of socializing their pets such as a participant who said “before she (dog) was a year old, I introduced her to ducks and all the animals around and I was like these are your friends.” Socialization was seen as a necessary measure to ensure the safety of both pets and others around them, and to enact specific values that participants held dear. For example, one participant recalled the time when she and her partner had kept a stray dog overnight, telling her own dog “I’m really proud of you for allowing another animal in our home.” Aside from these interactions between pets and other animals, participants spoke about occasions when their pets showed compassion towards people. Such instances evoked similar feelings of pride and gratitude from participants towards their pets. One participant described the 156 impact of having pets, saying “it’s teaching me a bit more about compassion and to read the nuances of people.” A second participant recounted how his dog reacted to a close friend who was gravely ill with cancer, pointing to a blurry photo of his dog running into his friend’s house: The door was open. I couldn’t hold her (dog). She ran away from me and ran right into him. He was just sitting there and she went right to him. Unfortunately, that’s the only picture I got because it all moved but she just ran right to him. You wonder how dogs treat people. She knew he was sick and stuff. She ran right to him and put her head there (on his friend’s lap) and wouldn’t move. And that says a thousand words (Male, dogs). A third participant described how his dog would readily offer comfort to people, even strangers: One day we were walking by and there was a woman in a blue hospital gown and a fellow with his arm was around her, obviously in a lot of distress. I have an extendable leash and all of a sudden Jackson wasn’t following me. He was sitting up on the bench next to them about 15 feet back. I came back and said “come on, Jackson, get down” and I saw the woman. She had her hand on him and was patting him and she said “no, it’s okay”…He changed their whole demeanour from being sad, unhappy…and totally dissolved the problem…yeah he’s done his fair share of healings (Male, dogs). Such encounters tended to be more common among dogs who were taken out for daily walks. Nevertheless, even when pets were not physically present, participants found opportunities to connect with other people through their shared affinity for pets such as the example below: He’s a good conversation starter. “Oh yes I have a cat, do you have a cat, what kind of cat?” When I go to the cancer clinic, there’s a wait between dropping off my prescription and picking it up, so sometimes there’s people waiting for rides. Last month there was this older lady and we got to talking about our cats and she told me a lot about her life and it was nice…She obviously wanted to talk to somebody and it made my time go quicker so we talked about Duke-the-cat and then talked about her cat (Female, cats). Secondly, having a pet reinforced the value of treating oneself with care and compassion. One participant said “it’s like each living thing has meaning and whether it’s to teach us a lesson that’s not so nice or to be there as comfort and guidance.” Another remarked “I find I get quite emotional sometimes and it’s not typically like me whether it’s reminding me of the treatment, and the dog can almost absorb excess feelings.” The effects of cancer were like powerful winds 157 that unearth the roots of a tree, leaving the tree standing but the roots exposed. With their roots laid bare, participants found themselves learning and re-learning to care for themselves. One participant said “I’ve been doing other kinds of supportive care since my chemo and radiation…to help heal myself and my body.” Another commented: I continually work on skills like lowering my anxiety. I do a lot of meditation and yoga. I did a yoga teacher training course and that was like exercise, spirituality, creativity, community building...there’s so much that is being studied now with the mind and meditation and how that changes your cells and everything and tumors…I’ve changed my diet completely…so a big part of it is cooking and getting my groceries and, so putting it in practice. I started Tai Chi and Qi Gong, so those are both spiritual and exercise. I did an art therapy class I really enjoyed…so that’s creativity and spirituality (Female, cats). The comment above highlights the importance of physical activity, creativity, and spirituality. Other participants referred to these three aspects while also emphasizing how their pets help them stay active, creative, and spiritual. To illustrate, one participant said “they make me much more in-tune with myself.” With regards to physical activity, pets encouraged play and exercise. Calling herself “the girl with the little white dog,” one participant spoke about the meaning of daily walks with her dog: I look and see how she’s being responded to and how she responds to things and it’s like I really don’t have to take all of this stuff so seriously. It’s really not the big deal I’m making it out to be. It allows me to switch gears in that moment (Female, cats and dogs). Another participant shared how walking helped her to understand her own and her dog’s needs: When she (dog) was younger I would spend hours walking her around because I’d be convinced that she needed to do a poop but then she wouldn’t do one. Because she’s a girl, it takes her forever to go to the toilet. She needs to find the perfect spot...so I would find that frustrating sometimes because there was that conflict between her needing her slow time and me being in a rush so that was a point of frustration, learning how to navigate those two conflicting places. Now, it’s like the more I’m in tune with myself, the more I’m in tune with her. I’m able to be in that intuitive part of myself (Female, dogs). In the case of cats, one participant described her experience of doing yoga and meditation: 158 If I try to do yoga, forget it. They’re climbing all over me. It ends up being more funny than anything because Rocky crawls right on top of me…Penny just stares at me like “what are you doing?”…but meditation is much easier...Rocky will curl up underneath my throat or sit on my chest or legs and Penny will usually curl up on my legs. I’ll sit there with or without music and just relax and breathe and control my thoughts and he’ll be right there on top of me. He’s not a distraction the way he is with yoga. His breathing becomes calmer with me and almost hits a relaxed state as well. It’s a luxury that most people don’t have time for or don’t give themselves the time (Female, cats). The link between pets and physical activity was not surprising. Somewhat unexpectedly was the way in which pets provided an outlet for creativity. One participant described creating a video, explaining that her dog, Stella, is the narrator of the film and “it starts with Stella on the beach and she’s having this philosophical dilemma [about] her relationship to the beach and the waves and nature; it’s like her narrating the story of our family.” She went on to say “it was a creative practice of me being able to actualize my profound love for her, and also have some play around that.” Other participants described making portraits or photo collages of their pets: I started drawing Rocky when I couldn’t get out of bed, just as drawing exercises and something creative to start doing again, getting the creative mind going. I had wanted to start writing children’s stories about Rocky, the adventures of Rocky, so I started taking pictures of him in different sleeping positions because that’s the basis of the book. All of his adventures are actually in his head while he’s sleeping (Female, cats). Along with creativity, pets helped participants become more in-tune with different aspects of themselves, from the emotional to the spiritual. Participants described losing a sense of structure and routine following cancer, such as a participant who spoke of getting through the “bumps and bits and pieces” with her pets. Another participant said that when her dog first came into her life, she was “going through some personal struggles and having some issues around drinking.” She remarked that, after going through cancer with her dog at her side, it feels like the “narrative has come full circle.” Similarly, a third participant said: When I allowed myself to get swelled by everything, work and an abusive relationship and alcohol, I just sort of let go of all of that. The only positive glimpse I ever had of real 159 love and connection was with animals…they were the beings that really I connected to completely and wholly and felt any kind of real spiritual love and oneness with. And when I got sick, they helped me to really start healing and I re-found that poor, neglected part of me that just needed to be cared for with diet and exercise, reconnecting with the more spiritual side of myself and just caring about myself again (Female, cats). Another notable example pertaining to spirituality came from a participant who described taking part in a spiritual practice known as the Blessing of the Animals. She explained: It coincides with the Feast of St. Francis of Assisi. It’s usually held late September or the first week of October. There’s a special service in the afternoon and people can bring their animals to church…and they are blessed by the priest…It’s amazing, there’s quite a few people who come out who wouldn’t normally go to church but they’ll bring their animals in to be blessed…There was the time when I had Ellie and Zoe (dogs) and two cats and a guinea pig. That was pretty memorable and keeping them all organized in the pew. And it’s amazing, they do seem to know, they all behaved (Female, cats and dogs). Only a handful of participants expressly used the word spirituality. More often, participants discussed the importance of their pets for their “healing process” or “healing journey.” For some participants, healing was not just a matter of recovering from illness but straddling the line between life and death. One participant suggested that his dog “could be the salvation” for him. Another said of her cat, “I feel like she’s helped save my life; I said that already but I don’t know how the last year and a half would be without having her relationship.” A third participant shared how her cats have influenced what it means to heal from cancer: It’s hard to even put in words how much they’ve been part of that whole process. And not just healing from the cancer but kind of re-finding myself, giving myself back to myself. I didn’t like myself much before and I wasn’t taking very good care of myself. I was just simply going to work, coming home, drinking, going to sleep, and repeating the pattern over and over again and when I started going through the whole process of healing from the cancer, it became healing the whole, the complete self (Female, cats). For this participant and others, one aspect of healing was addressing patterns in their life that prevented them from caring for themselves. A second aspect of healing involved attending to the 160 whole, complete self, something that did not always come easily to participants. One participant stated “it’s easier to give to an animal your love and affection and dedication.” Another said: I’m just really grateful to be a guardian to these guys and they’re able to be who they are with me. Something I’m learning to do is to just be who I am and not be so concerned about what everybody else thinks. We have a lot to learn from animals and especially domesticated ones and the wild ones…and I honestly don’t know where I would be if it weren’t for them in my life. I would be going through so much grief and sadness and anger and frustration, and taking it out on them…They’ve honestly just taught me so many little things, a lot of patience, a lot of calm, a lot of time for play…it’s been learning a lot about letting go, receiving love, letting things in (Female, cats and dogs). In the process of becoming more in-tune with their pets, participants were able to reclaim aspects of themselves which had been neglected or consumed by illness and the stresses of daily life. 4.3 Reflections on the Use of Photo-elicitation The discussion of photos took place at different points during the interviews, with some participants sharing photos early on, and others continuing to reference photos throughout the interview. Participants shared photos by swiping their finger on a screen, flipping through a stack of pictures, or turning a page in photo album or calendar. Along with photos, the sharing of videos added movement and sound, helping to animate the telling and re-telling of vivid memories and anecdotes. These still images and video clips allowed me to see how participants’ relationship with their pets had evolved over time. Moreover, they provided insights into important relational dynamics between pets and people, and between pet siblings. To illustrate, one participant pointed at a picture of her two cats, saying “that’s a cute shot of those two, they’re face to face.” The photos had a visual and tangible appeal, inviting participants to talk about pets who had passed on, and pets who were currently in their care. As suggested by the comments below, looking at photos helped to transport participants back to a time when their pets were young and new routines were beginning to take shape: 161 I know I’ve got pictures of her when we first got her. We were just looking at them the other day, they disappeared. Oh here we go, did I say 2011, it’s 2012, so that’s her when we first got her, that’s my wife and you see, she was about nine weeks. My wife saw her—we had a dog that passed away in 2009. We had her for 14 years. It was a border collie cross. So in 2009, for a couple of years, we didn’t have a dog. So you sort of feel like your home is empty in a way because even though we still have two kids, it’s a lot less responsibility (Male, dogs). So did you want to see any pictures? I don’t know whether these are in any particular order. I’ll try starting them off. Yeah that’s when he was pretty young. He was just a puppy there. You see the size of the couch and the size of him. That’s my wife and him. He loves sitting on my wife’s knee and in the morning she has coffee and reads the paper and he’s always laying on her lap or sitting on her knee. And that’s where he is first thing in the morning and then he gravitates over to me (Male, dogs). We have lots of pictures of him in these baskets. Let me see if I can show you one. I sent one to [my daughter] especially now that she’s away to show what her cat is up to…a lot of these women are always showing pictures of their grandchildren, well with me I share pictures with her of Dusty (Male, cats). Other comments seemed to suggest that pets are not only important to participants but are also a ubiquitous presence in their life: I went on a couple of cancer retreats and we were asked to bring pictures of significants, you know most people brought pictures of their kids or something or their spouses and family pictures, and I took pictures of my fish (Female, fish). It’s interesting to see her change. Now I know when she wants her hugs and I know when she wants her snuggles. She does this certain position and she really loves my partner, that’s him (pointing to a picture), actually you can see, he’s the guy in the middle. That’s our vision board up here and that’s me. I put a little picture of Hazel next to me on here because honestly, she goes pretty much everywhere with me (Female, cats and dogs). Participants seemed to revel in the opportunity to talk about their pets and showcase their unique quirks and attributes. The following comments highlight the humor and playfulness exhibited by participants while telling me about their photos: That was another Christmas, Jackson dressed up as a reindeer. And that’s a picture of Jackson and I. Yeah he’ll sit there with his head right on my shoulder here and behind me. It’s like a parrot…I remember taking all those pictures of him and that’s not all of them either, I have a lot more but didn’t want to bore you with them (laughing). I think it 162 was 70 pictures but it just makes me feel how lucky I am that we have a dog like that and I guess everybody’s dog is their best friend and Jackson is definitely mine (Male, dogs). I should show you a picture if I may. [I] talked about it and you reminded me of it. “Taz (talking to neighbour’s cat) it’s not of you.” How could you resist that (pointing to a photo of her cat)? He has a cat door but that doesn’t mean he wants to use the cat door, no, no, no. That means that he wants you to get up and let him in. I’ve got a beautiful one of him hiding in the garden. There he is. You see how he blends in. It’s not me, I’m not really here. No, I’m not doing rude things to your garden (Female, cats). In the first comment, the participant likens his dog to a parrot, calling to mind a comical image of his dog perched on his shoulder. He jokes that he doesn’t want to bore me, knowing that I’m the one who asked to see photos of his dog. In the second comment, the participant addresses both me and a neighbour’s cat who has stopped by for a visit. She begins by remarking on her cat’s chameleon-like beauty, and then seamlessly adopts her cat’s persona by speaking in first person. Such examples of playful banter were common across the interviews, attesting to the joyful and endearing nature of the human-pet relationship: I’ll show you a picture of her. She’s just so funny and she just barks her head off. She’ll put her mouth right up to the [hose] nozzle and gets sprayed right in the head, she just goes crazy. It’s quite funny. She just chases it all over like a lunatic (Male, dogs). But yeah he’s a ridiculous cat (laughing), he’s sort of like, the first ones, if you just keep going (pointing to pictures) you’ll see. Okay, so that’s just him sleeping. He’s so funny like even when he’s sleeping, he’s comical…There’s a good picture, he loves getting pictures taken of him (laughing), he’s funny, oh my god (Female, cats). She (dog) loved running up and down next to the waves, barking at the waves, sort of like her little passion every day. So I made a video of her on the beach and sort of narrated this little film (laughing). My parents are very sweet. They still watch it apparently and text me and say, we were just watching the movie of Stella (Female, dogs). In the examples above, photos evoked smiles and laughter while, in other instances, they prompted silence and tears. Participants seemed to appreciate each and every one of their pets for the meaning that he or she had brought to their lives. Discussions about photos provided a window into their intimate experiences and their individual journeys toward healing and 163 recovery. For example, only a few participants showed pictures of themselves during cancer treatment, remarking that some moments were just too painful and raw to remember. Among participants who shared photos of their cancer experience, some of their comments were: I remember I had this picture of myself holding her as a puppy and my hair is very, very short and I still look kind of not myself and I was just so, so happy. Like I was just so thrilled but terrified to make the decision to bring her (dog) into my home, going back with Loki, the cancer experience was horrid. Like none of it was fun, none of it was good, none that I can remember anyway (Female, cats and dogs). I mean I look at the pictures and we can remember them and stuff. There’s lots of pictures all over of her. I do remember when I got out of the hospital I was sitting right there and I do remember she wouldn’t leave, like “where have you been all this time, what’s wrong?” I would say you know besides the person with cancer, it’s what the dog does for the family too (Male, dogs). That’s when I lost my hair, “hey Sadie” (dog). But she’s just a very gentle dog and in some ways when she was younger she used to be quite intimidated by other dogs at the park, not so much now she’s quite into rough and tumble playing with other dogs. It’s always fun taking her out because she’s excited to go out for walks (Male, dog). Interestingly, the third comment is from an interview that took place at a coffee shop where the participant’s dog was not present. Simply looking at the photo prompted this participant to speak to Sadie as if she had been there. The words of another participant powerfully summarize what these photos mean to participants, and how it feels to relive them time and time again: A friend of mine shared with me years ago, take as many photos and videos as you can because it goes by so fast and the next thing you know they’re gone and what do you have to show for it right. I came across a video that I’d taken of Loki…and the two of them were in it and I was playing with her and yeah, it was nice to revisit those moments and just have them (Female, cats and dogs). 164 Chapter 5: Discussion In this chapter, I discuss the meaning of the findings in light of theoretical constructs and empirical research. I begin by reviewing the theoretical framework outlined in Chapter 1. With reference to the eight phenomenological themes, I discuss key findings that confirm or expand our understanding of the lived experience of the human-companion animal relationship. Some themes replicate previous research while others offer new insights into the importance of this relationship for people with cancer. Next, I describe the implications of the study for research and practice in supportive cancer care. The chapter concludes with a discussion of the limitations of the study and directions for future research. 5.1 Overview of the Study The purpose of the study was to explore the lived experience of the human-companion animal relationship for people with cancer. The study is unique in psychosocial oncology as one of only a handful of investigations whose primary objective is to explore the phenomenon of pet ownership among people with cancer (Larson et al., 2010; Nitkin, 2014). As noted previously, more research has been aimed at evaluating the therapeutic benefits of companion animals. The present study contributes to the literature by highlighting the importance of meaning-making in the context of people’s relationships with their companion animals. In framing this discussion, I drew upon the concepts of attunement, resilience, and thriving to help explain why people’s relationships with their companion animals can be especially meaningful and rewarding in the experience of cancer. Consistent with the method of the reduction, I strived to set aside these concepts as I gathered lived experience descriptions and reflected upon the essential themes which characterize the human-companion animal relationship (van Manen, 1997). 165 5.2 Theoretical Framework Revisited The model proposed by Carver (1998) posits that an individual can experience some kind of growth or gain following a stressful life event such that he/she may function more effectively when confronted with similar events. This kind of growth is considered to be an example of thriving. In this study, my aim was not to assess whether people demonstrate evidence of resilience or thriving following their cancer experience. Instead, my concern was with exploring meaning-making strategies that help to account for instances of resilience and thriving among people with cancer (Carver, 1998). While some people experience distress or a loss of meaning, others are able to draw upon particular strategies to help make sense of their experiences. It is here that I focused my efforts on understanding the ways in which people engage in meaning-making in the context of their relationships with pets (Berscheid & Regan, 2016). I argued that intimate connections, although not a precondition for meaning-making, can help people find greater meaning from their experiences (Yalom & Josselson, 2011). Through phenomenological reflection, I identified three super-ordinate themes that align with the following meaning-making strategies: disengagement/acceptance, distraction, and support seeking. These meaning-making strategies find support in the coping literature as examples of problem-focused, emotion-focused, and meaning-focused coping (Folkman, 2010; Folkman et al., 1986; Waldrop et al., 2011a; Wenninger et al., 2013). Problem-focused coping refers to a person’s attempts to change or confront a stressful situation while emotion-focused and meaning-focused coping refers to strategies used by an individual to manage negative and positive emotions, respectively (Bigatti et al., 2012; Folkman et al., 1986). These three types of coping, although different in their functions, tend to operate in conjunction with one another (Folkman, 2010; Folkman et al., 1986; Waldrop et al., 2011a; Wenninger et al., 2013). Meaning-166 focused coping may prompt an individual to reconsider his/her beliefs, values, or priorities in life. This type of coping is substantiated by empirical research suggesting that cancer patients experience both positive and negative emotions during periods of stress (Folkman, 2010). Meaning-focused coping encourages people to see a stressful situation as a challenge rather than a threat, and helps them persist in coping. The super-ordinate theme, (Dis)connecting with the Journey, reflects participants’ attempts to disengage from, as well as, accept difficult or challenging aspects of their cancer experience. Research suggests that strategies involving disengagement from the cancer environment or the experience of being a patient, tend to be associated with greater distress while those characterized by acceptance are linked to lower distress and depression (Alcalar, Ozkan, Kucucuk, Aslay, & Ozkan, 2012; Kvillemo & Bränström, 2014). In this study, disengagement/acceptance strategies were not mutually exclusive. For example, thoughts of dying were unavoidable, from the looming threat of a cancer recurrence to the trauma of surviving a near death experience. In such occasions participants felt the need to reflect upon the meaning of dying, even preparing themselves or others for this outcome while, in other occasions, thoughts of dying shifted to thoughts of living, and living more consciously. Participants believed that it was important to their pets that they were alive and trying to heal and recover from cancer. In many cases, pets provided a reprieve from thoughts of dying and, for some participants, the “will to fight” and be “one of the 50 percent that survive and thrive.” Accordingly, participants were not necessarily avoiding the subject of death but instead were trying to reframe the meaning of dying (i.e. emotion-focused coping) and redirect their thoughts to caring for their pets and living more consciously (i.e. problem-focused coping). Participants’ 167 efforts to confront their mortality can be viewed as instances of problem-focused coping. This type of coping is associated with better adjustment to cancer in the short-term and lower distress overall (Drageset, Lindstrøm, & Underlid, 2016). The present study makes clear that existential concerns are not limited to thoughts of one’s own death as participants were left to confront the inevitability of losing a pet. Such findings echo those of similar investigations which suggest that a person’s attempts to confront existential concerns can lead to a deepening of relationships, a redefining of one’s priorities in life, and a greater sense of compassion towards others (Drageset et al., 2016; Molzahn et al., 2012; van der Spek et al., 2013). The super-ordinate theme, Pulling you out of yourself, reflects the ways in which participants tried to make meaning by seeking a source of distraction. Also considered to be a form of emotion-focused coping (Folkman et al., 1986; Waldrop et al., 2011a), distraction is a defining feature of play with pets, as well as, caretaking responsibilities towards pets. Play and caretaking helped to shape participants’ daily routines, offering a sense of structure and direction for their everyday life. As in other investigations, participants tended to have fewer thoughts of cancer when they were able to focus their attention on a particular activity (Drageset et al., 2016). Some authors have described how people use distraction by seeking positive or neutral experiences (Webb, Miles, & Sheeran, 2012). These examples of distraction differ from avoidance or emotional distancing which has been found to exacerbate stress (Boehmer et al., 2007; Yeung et al., 2014). While play and caretaking shared some positive elements, it would be more appropriate to characterize these strategies as a meaningful distraction rather than positive or neutral. To illustrate, some participants described themselves as being their pet’s guardian or parent which has both positive and negative aspects. Moreover, while play was often 168 accompanied by humor and laughter, there were times when play evoked anger or distress such as when pets destroyed participants’ possessions or displayed signs of aggression towards them. Along with seeking distraction, participants engaged in meaning-making by seeking connection. The following quote seems appropriate here: “rarely can a response [i.e. verbal] make something better; what makes something better is connection” (The RSA, 2013). Participants turned to their pets for support and companionship. The super-ordinate theme, Speaking Volumes with their Actions, is concerned with the relational dimension of meaning-making. When participants were in need of support, pets would climb onto the couch or bed, cuddling or sleeping with participants. When participants wished to be left alone, pets would physically distance themselves from their human caretakers, giving them space or going into another room. Through their ability to respond and adapt to participants’ needs, pets were able to convey powerful meanings through simple and subtle gestures such as pressing their chin on the participants’ knee or leaning in and making eye contact. Some researchers regard these gestures as a form of emotional support that can promote strength and resilience (Brooks et al., 2013; Walsh, 2009b). The supportive functions of pets confirm findings from previous studies regarding the relationship between social support and improved well-being (Boehmer et al., 2007; Bultz & Carlson, 2006; Cavanaugh, Leonard, & Scammon, 2008; Costanzo et al., 2009; Maller, Townsend, Pryor, Brown, & St Leger, 2006; Marcus, 2012b; Wills & Ainette, 2012). Social support is broadly understood as the degree to which a person feels integrated in his/her community, and believes that he/she can rely upon others for help (Wills & Ainette, 2012). While there is little dispute that social support can be protective for health and well-being, not all support is created equal. Social support can be measured by the number of social connections a 169 person has (i.e. structural measure) or by the quality of support that a person actually receives. Support can be categorized into different types (i.e. functional measure) including emotional, informational, instrumental (e.g. transportation, childcare), and companionship support (Brooks et al., 2013; Wills & Ainette, 2012). As trusted confidants and leisure companions, pets provide emotional and companionship support, respectively (Wills & Ainette, 2012). Based upon the participants’ accounts in this study, connection seeking rather than support seeking seems more applicable in describing meaning-making. Firstly, the term connection highlights the intimate, reciprocal, and enduring nature of the human-companion animal relationship. Previous studies suggest that structural measures of social support are not strongly correlated with functional measures (Wills & Ainette, 2012). Consequently, a person can have a wide social network that includes primary relationships (e.g. spouse or partner, children, etc.), and be lacking in intimate connections. Secondly, the use of functional measures to assess support from pets, paints a limited picture of the ways in which pets impact a person’s well-being. I would add that pets offer what can be described as validation support by affirming or validating the meanings participants derived from their experiences. Validation support is especially relevant in the experience of cancer. In this study, participants remarked that cancer patients are often advised to “think positive” and “stay with good vibes,” as negative thoughts are believed to accelerate the progression of disease (Slakov & Leslie, 2003; Youll & Meekosha, 2013). However, a reliance upon positive thinking is no more helpful than using avoidance strategies if people are ignoring or denying their suffering (Vianna et al., 2013). By validating participants’ feelings, both positive and negative, pets reinforced participants’ efforts to make meaning through acceptance and connection seeking. 170 When viewed in the context of literature on coping and social support, these meaning-making strategies (disengagement/acceptance, distraction, and connection seeking) may not seem especially surprising or illuminating. What is of note is the lack of attention given to companion animals in research on psychosocial adjustment to cancer. Pets are seldom discussed (Costanzo et al., 2009; McCorkle et al., 2011) except for a brief mention in descriptions of pleasurable activities (Lockwood & O’Connor, 2017) or sources of social support (Molzahn et al., 2012). Moreover, the evidence base all but overlooks a significant form of psychological thriving that was demonstrated by most, if not all, of the participants in this study, namely, strengthened personal relationships (Carver, 1998). Participants’ relationships with pets and the deepening of these relationships through meaning-making is itself a form of thriving. Many participants felt closer to their pets following cancer while others experienced a temporary loss of intimacy only to be renewed again with the same or newly acquired pet. Over the span of their relationship with their pets, participants had dealt with various challenges from death and divorce to mental illness and substance use. Accordingly, cancer was not the only catalyst for instances of thriving. Another indicator of psychological thriving concerned participants’ knowledge of cancer. By researching information and interacting with health care professionals, participants displayed a wealth of knowledge about the types and outcomes of various cancer treatment options, in some cases, applying this same information to the care of their pets. For example, participants spoke about the importance of being physically active, avoiding certain medications or cleaning products, and choosing organic foods and supplements. A third example of thriving was participants’ orientation to life, and life beyond cancer. For participants, cancer was an ever-present threat; it could still be there; it could always come back. The residue of cancer remained, 171 but with the touch of a cold wet nose, prickly tongues, and warm paws, participants were reminded that there were food bowls to be filled, litter boxes and fish bowls to be cleaned, and bellies to be scratched. As such, thriving did not manifest itself as a sustained or higher level of functioning (Carver, 1998). Thriving happened in the moments when participants were able to disconnect from cancer and re-connect with their pets (Halm, 2008). In the words of participants, pets helped them switch gears, navigate conflicting places, and control their thoughts. In this way, play and caretaking carried meaning well beyond distraction and stress-relief. 5.3 Key Findings from the Eight Phenomenological Themes As noted in Chapter 3, themes are “creative shorthands” that enable us to look at cross-cutting trends and patterns (van Manen, 1997). The eight phenomenological themes are intended to show the diversity and uniqueness of the participants’ experiences. In this section, I describe several key findings that bridge more than one of the eight themes. I give particular attention to findings that confirm, contradict, or extend results from the available literature. 5.3.1 Kindred Play Through the medium of play, pets provided a wellspring of amusement. Some participants regarded their pets as being childlike in their fervor to explore their surroundings. Other participants viewed play as a counterbalance to the darkness and despair of their cancer experience. Importantly, pets were not simply the object of their amusement as participants were often engaged in play with their pets, hence the term kindred play. Pets were especially adept at eliciting playfulness in people and other animals. At times, it was the unabashed predictability of pets that turned a mild annoyance into a source of amusement, such as pets’ insistence on chasing the vacuum or fleeing at the sight of nail clippers. In other instances, the element of spontaneity appeared to heighten participants’ enjoyment of humorous play and unpredictable 172 play. Spontaneity helped to stem the tide of negative thoughts and fears running through their minds, allowing participants a momentary release in the form of laughter. Notably, research suggests that laughter promotes cardiovascular and immune health by increasing positive affect, reducing stress, and strengthening social bonds (Aron, Norman, Aron, McKenna, & Heyman, 2000; Savage, Lujan, Thipparthi, & DiCarlo, 2017; Valeri, 2006). It is useful to clarify that play and playfulness are not one and the same. As noted in the work of Csikszentmihalyi, play is thought to involve “intense focus using skills to meet goals and losing a sense of time and self” whereas playfulness is seen as a personality trait or predilection for spontaneity and fun-seeking (Lockwood & O’Connor, 2017, p. 56). For example, professional sports and gambling involve play but not playfulness, as the primary focus is on competition rather than amusement (Lockwood & O’Connor, 2017; Sommerville, O’Connor, & Asher, 2017). Playfulness has a developmental component, reaching its peak among children and young animals and declining with age (Lockwood & O’Connor, 2017). Among people, playfulness is associated with greater use of adaptive coping strategies and less reliance upon avoidance strategies (Magnuson & Barnett, 2013). People who exhibit playfulness are more likely to view a stressful situation as a minor or temporary stressor (Drageset et al., 2016; Lockwood & O’Connor, 2017; Magnuson & Barnett, 2013; Waldrop et al., 2011a; Wenninger et al., 2013). Although play seems so obvious to our sensibilities—we know it when we see it—there is a lack of consensus in the animal behaviour literature on how to define play (Byosiere, Espinosa, & Smuts, 2016). Some authors describe play as being intrinsically rewarding and involving behaviours that can be repeated in a flexible manner (Palagi et al., 2016; Sommerville et al., 2017). The seven types of play identified in this study can be classified as object play (i.e. 173 involving toys or objects) or social play (i.e. involving humans or animals) (Bradshaw, Pullen, & Rooney, 2015). Play also varied in frequency and intensity depending on the pet’s age, individual preferences, and breed-specific personality traits. For example, one participant remarked that her cat is a perfect match to the clownish traits that are characteristic of his breed while another said that his cat has the qualities (e.g. sharp reflexes) of a hunter. In the case of dogs, retrievers and collies were known to enjoy chasing toys or other dogs while terriers and pugs showed a preference for mutual game play, especially when their human caretakers were involved (Coren, 2008; Howse, Anderson, & Walsh, 2018). Interestingly, a preference for social play over object play, and play with people over conspecifics (i.e. animals of the same species) was also observed among some cats and fish. The results of observational studies suggest that cats are more inclined to play when they encounter prey-like (e.g. small, furry, moving rapidly, etc.) objects, and tend to engage in behaviours that are reminiscent of their predatory instincts to find, capture, and consume prey (Bradshaw et al., 2015; Hall, Bradshaw, & Robinson, 2002). In a similar vein, play seems to have been hardwired into the biology of dogs, with some authors suggesting that play was selected for during domestication to facilitate human-dog bonding (Bradshaw et al., 2015; Coren, 2008; Sommerville et al., 2017). Findings from the present study challenge traditional views of play as being largely predatory-driven in cats, and socially-oriented in dogs (Bradshaw et al., 2015; Howse et al., 2018). For example, cats not only engaged in instinctual play but also initiated rituals and games with their human caretakers. Moreover, dogs were not alone in being motivated by the social rewards of interacting with people (Bradshaw et al., 2015). Fish were also described as being playful and responsive towards people, thus, providing more than just ambient stimulation. 174 Whereas participants were generally more accepting of instinctual play in cats compared to dogs, the opposite seemed to be true in the case of rough-and-tumble play (abbreviated as RTP in this section). In human-animal or animal-animal RTP, one partner tries to gain an advantage over the other through roughhousing or play-fighting (Palagi et al., 2016). RTP relies upon improvisation, requiring partners to shift gears quickly and respond in a flexible manner (Eig, 2017; Palagi et al., 2016). Given the competitive nature of RTP, verbal and nonverbal communication is important for negotiating play and curtailing aggression. In this study, participants used motherese when speaking to their pets, as well as, various play signals that were intended to mimic their pet’s gait, posture, facial expressions, or vocalizations (Eig, 2017; Palagi et al., 2016; Rooney, Bradshaw, & Robinson, 2001). Dogs, as evidenced by their tail wagging and barking, seemed to enjoy RTP with participants and other dogs (Howse et al., 2018) while few cats tolerated being teased or wrestled in this manner. Consistent with other investigations (Bradshaw et al., 2015; Eig, 2017), men were more likely than women to engage in RTP with both dogs and cats. One proposed reason for this gender difference is that RTP allows individuals to communicate their emotions indirectly, for example, teasing someone to express affection (StGeorge, Goodwin, & Fletcher, 2018). Play, and RTP in particular, requires skills in problem-solving and emotional regulation as individuals must be able to respond to novel and unexpected situations (Eig, 2017; Palagi et al., 2016; Sommerville et al., 2017). Implicated in stress and reward pathways, play activates hormones that help people and animals cope with stress (Sommerville et al., 2017). Research suggests that children who engage in RTP with their parents experience fewer social and emotional challenges later on in life (StGeorge et al., 2018). Therefore, RTP may be an indication of a strong and affectionate parent-child relationship, as well as, a means to develop 175 such a relationship. Human-animal RTP is also associated with enhanced bonding and affection (Eig, 2017). For instance, dogs show a reduction in stress hormones when playing with people (Bradshaw et al., 2015). In one experiment, dogs who were administered oxytocin tended to initiate play more frequently with other dogs, play for longer periods, and use more play signals compared to dogs in a control condition (Romero, Nagasawa, Mogi, Hasegawa, & Kikusui, 2015). Aside from regulating stress, play fosters resilience by encouraging creativity and resourcefulness in both people and pets (Bradshaw et al., 2015). In the present study, play signals were not unique to pets as participants often adopted their pets’ vocalizations and body language to initiate or prolong play (Bradshaw et al., 2015; Sommerville et al., 2017). Accordingly, people and pets do in fact speak the same language when it comes to play. The use of play signals helped participants and pets negotiate when to engage in proximity and distance seeking. While it was easier for participants to interact with pets rather than people, play seemed to be one exception. Participants had recalled instances during cancer treatment when they were too exhausted to play. In another study, participants expressed concern about their cats having few opportunities for social interaction and physical activity (Strickler & Shull, 2014). Of the 277 people surveyed, 25 percent reported playing with their cat once a day for at least 5 min. Participants, who played with their cats regularly, reported fewer behavioural problems. Without assuming cause and effect (i.e. play reduces behavioural problems), play appears to be one such mechanism for building rewarding relationships between people and their pets. Although the frequency and duration of play was not measured in the present study, the general takeaway was that participants valued play in their relationship with their pets, as evidenced by their efforts to play even while being bed-ridden or suffering from pain and 176 exhaustion. For most participants, avoiding play was the exception rather than the norm. While other studies have emphasized the role of people in determining the length and frequency of play with pets (Palagi et al., 2016), this study is unique in highlighting the role of pets in establishing the rules and parameters for play (e.g. type, intensity, degree of physical contact). In reflecting upon the title of the theme, “It’s sort of silly, but,” it is critical that we attend to the word “but.” Play, in all its apparent silliness, is not a futile endeavour but rather a vibrant medium for exchanging positive affect and reinforcing social bonds between pets and people (Donoff & Bridgman, 2017). 5.3.2 Mattering Presence Being in the presence of a pet was unlike any other interaction participants had experienced. There was a felt sense that something was different. Take an example involving sensory stimulation. If we blow on our fingertips, we feel a steady stream of air that can be warm or cool depending on our body temperature. The same stream of air now feels cold and tingly on our wrist, encircling the tiny hairs covering our skin. Physiological explanations would tell us that these sensations are due to the type of nerve endings and sensory receptors found on different parts of our body. For us, in our lived experience, something just feels different. For participants, having a pet was a daily reminder that their very being in the world mattered to someone. This mattering presence was apparent in their pets’ touch, proximity to participants, and their facial and bodily expressions. With pets, there was no obligation to speak, and yet words came rather easily, prompting participants to talk to their pets frequently and effusively. This running commentary helped to foster a sense of accompaniment, or as one participant put it, a feeling that pets were “metaphorically holding [their] hand” (Blazina, 2011; Winnicott, 1971). 177 Some of the more striking examples of this mattering presence tended to involve elements of movement and repetition. To illustrate, participants described feeling a sense of peacefulness while watching the rise and fall of their pets’ ribcage with each breath. The sight of water bubbling and rippling as fish swam around their bowls helped participants to feel relaxed, lulling them into a state of restful sleep. The purring of cats had a calming effect on participants with its rich vibrations pulsating through their chest and body. Daily walks allowed participants to focus on the sensation of walking and moving with their dogs. The experience of being absorbed in the repetitive sights and sounds of pets, shares an intriguing parallel with the therapeutic effects of arts-based practices. For instance, free-form colouring (i.e. colouring a blank page) requires people to structure their experience by making choices about what to draw. This type of colouring is less effective at reducing anxiety compared to colouring therapy which involves filling in ready-made geometric designs (Curry & Kasser, 2005). The use of symmetrical figures with repeating patterns is thought to disrupt negative thoughts and emotions, drawing people into an almost meditative state (Curry & Kasser, 2005; Vennet & Serice, 2012). For participants in this study, observing the repetitive movements of their pets induced a state of calm, perhaps, similar to that of colouring therapy. Repetition was also an inherent part of being a caretaker to a pet. The responsibilities of feeding, grooming, and exercising their pets provided participants with a sense of structure and direction (Brooks et al., 2013). Other instances of caretaking were motivated less by a sense of responsibility but by the mutual enjoyment of participants and pets. For example, participants relished the opportunity to cuddle with their pets, deriving comfort from its intimate and tactile nature. Some pets also enjoyed cuddling as evidenced by their efforts to initiate or prolong these encounters through proximity seeking, pawing, and making eye contact. In many instances, touch represented an important 178 means of exchanging positive affect between participants and pets. Considering that the human-fish relationship is less amenable to touch, alternate strategies were necessary to facilitate communication. Participants and fish engaged in social mimicry by mirroring each other’s behaviour (Salazar Kämpf et al., 2018). Fish would look in the same direction, following the participant’s gaze and hand movements. Observed in both people and animals, social mimicry occurs spontaneously and unconsciously, and is thought to satisfy a basic need to affiliate and belong (Howse et al., 2018; Salazar Kämpf et al., 2018). In this study, cats and dogs not only imitated participants but also adjusted their activity level (e.g. slowing down or moving faster) or body language to match their human caretakers. Pets seemed to recognize when participants were feeling ill and would lean in, gently resting their body against the participants or curling up beside them. Moreover, when participants were smiling or talking in an animated tone of voice (i.e. motherese), pets would reciprocate or even amplify these affective cues through specific vocalizations such as barking, purring, or growling. Participants and dogs also communicated using referential gestures (e.g. pointing) which are used by an individual to draw another’s attention to a particular object or event (Worsley & O’Hara, 2018). Researchers have identified 19 referential gestures that dogs tend to use when interacting with their human caretakers (Worsley & O’Hara, 2018). Taken together, the use of social mimicry, gestures, and vocalizations highlights the essence of being in an attuned relationship such as that described by participants in the theme, It’s like each living thing has meaning. An attuned relationship is one in which relationship partners are able to recognize and respond to each other’s feelings (Blazina, 2011; Lasher, 1998). The sense of accompaniment that participants felt in the presence of their pets was a testament to the capacity of pets to be able to tune-in and understand the experiences of people. Through 179 repeated observation, pets and participants came to learn the meaning of subtle gestures and nuanced vocalizations (Worsley & O’Hara, 2018). Participants repeatedly emphasized instances during which pets seemed to know that something was wrong and adjusted their behaviour to reflect this knowing (Brooks et al., 2013). For example, pets avoided stepping on certain areas of their body or greeted participants by gently nuzzling against them rather than jumping or pouncing on them. Likewise, participants seemed to know when something was wrong with their pets, and to paraphrase one individual, part of them felt wounded as well. Compared to communication in the animal kingdom, interpersonal communication permits numerous combinations of words and symbols. Yet, people manage to converse with non-human animals whose communication patterns do not seem to share these generative and recursive features. For example, referential gestures are relatively rare among non-human animals, especially during inter-species communication (Worsley & O’Hara, 2018). The ability of dogs to use these gestures in their interactions with people, attests to the level of engagement that is required to accurately interpret and respond to another species’ nonverbal gestures (Worsley & O’Hara, 2018). If we were to prize interpersonal communication for its verbal intricacies, we would miss the truly boundless form of communication that characterizes the human-pet relationship. In the present study, pets often relied upon sensory (e.g. sounds, smells) cues to know when to approach participants, how close they could be, and when to disengage from them. Importantly, some pets were not receptive to being touched or picked up by people. Similar to examples concerning play, pets demonstrated agency in helping to shape the rules about human-pet intimacy. Also relevant in the discussion of agency is the role of silence in cultivating a mattering presence. Pets allowed for silence without the boredom and loneliness that looms over an empty 180 home or hospital room. This silence did not mean the absence of communication but rather the suspension of social pressures (e.g. judgment) that can accompany interpersonal relationships (Brooks et al., 2013). Moreover, this silence was intentional and communicative as opposed to an expression of awkwardness or hostility (Bartels et al., 2016; Knutson & Kristiansen, 2015). In interpersonal communication, silence can be met with confusion or disaffection on the part of the recipient (Knutson & Kristiansen, 2015). Alternatively, silence can engender closeness between communication partners such that a shared connection is felt but remains unspoken (Bartels et al., 2016; Knutson & Kristiansen, 2015). This “shared silence” has been described as a “gateway for healing” as communication partners can exercise agency in determining whether to speak or not (Knutson & Kristiansen, 2015, p. 1). In the cancer context, by choosing to remain silent, a person can retain a sense of autonomy in situations over which he/she feels little control (Bartels et al., 2016). Silence has also been found to be an effective tool for facilitating communication between patients and physicians. For example, oncologists use silence to demonstrate attentiveness and develop rapport with their patients (Bartels et al., 2016). The present study is unique in highlighting the communicative importance of silence for the human-pet relationship. With pets, participants felt relieved of any obligation to speak, prompting them to reflect upon these experiences and redefine their meaning (Knutson & Kristiansen, 2015). Such encounters provided an opportunity for participants to exercise agency and control, as well as, honor their pets’ agency in creating a mattering presence. 5.3.3 Impetus to Hope The familiar excerpt, “Hope springs eternal,” from a poem by Alexander Pope, hardly seems to capture the lived experience of participants in this study (Pope, n.d.). As with meaning-181 making, hope did not materialize out of thin air. Hope was not some inexhaustible resource, limitless in its abundance (Folkman, 2010). Instead, hope represented the participants’ continual striving towards healing and recovery. To illustrate, one participant referred to her dog as the motivation for “reaching for a better space in [her] health.” Another described her cats as being the reason she has fought so hard, and continues to fight back against cancer. While hope appeared to have an element of choice, loss was deemed inevitable in the case of both people and pets. The pragmatic approach (e.g. funeral planning) taken by some participants, in anticipation of their own demise, seemed untenable when they spoke about their pets dying. The loss of a pet was inevitable, and yet inconceivable, even among participants who had lost a pet previously. Some pets experienced a forced separation as they were relinquished to the care of another person while other pets departed from their human caretakers in death. In the latter case, losing a pet did not happen all at once. The effects of illness and aging slowly eroded the vitality of pets, bringing new caretaking responsibilities and ways of relating to pets. Some pets seemingly “hung on” for participants, seeing them through cancer treatment or awaiting their return from the hospital. Similarly, participants described not wanting to let go of their pets. To illustrate, the example concerning euthanasia offers a poignant description of the complex nature of loss when an animal’s life is in our hands. Euthanasia is defined as “a humane method of terminating the life of an animal who is dearly loved, but has little or no hope for recovery” (Lagoni, 2011, p. 181). It is no coincidence that the noun hope comes up in this definition of euthanasia. Hope is also a verb that refers to something we do quite naturally when confronted with loss or some other threat to our well-being (Butt, 2011; Folkman, 2010; Herth, 2000). In turn, the experience of loss can erode our sense of hope, resulting in hopelessness and despair (O’Shaughnessy, Laws, & Esterman, 2015). 182 Formal theories of hope point to an individual’s capacity to find a path towards particular goals, as well as, his/her agency in achieving those goals (Snyder, 2002). For example, Snyder, Irving, and Anderson (as cited in Snyder, 2002) define hope as “a positive motivational state that is based on an interactively derived sense of successful (a) agency (goal-directed energy), and (b) pathways (planning to meet goals)” (p. 250). Consistent with phenomenology (van Manen, 2014), scholarly definitions and theories can be brought into a discussion to show where they might be lacking in experiential meaning. Rather than attempting to substantiate a particular theory, I regard the participants’ accounts as providing valuable insights into the experiential meaning of hope and how it shows up in lived experience. Snyder’s (2002) description of hope as a “rainbow of the mind” may in fact come closer to the meanings I gleaned from the participants’ experiences (p. 269). For Snyder, the rainbow symbolizes hope. It shows the “spectrum of human strength” and “makes us think of what is possible.” Likewise, hope manifested in the participants’ ongoing efforts to heal and recover from cancer. As a psychological construct, hope can be thought of as a stable trait, as well as, a characteristic that becomes relevant in the context of specific goals (Folkman, 2010; Scioli, Scioli-Salter, Sykes, Anderson, & Fedele, 2016; Snyder, 1994). The recognition that hope has positive and negative aspects is central to theories of health promotion (Scioli et al., 2016). Hope has been linked to a lower risk of morbidity and greater use of adaptive coping strategies (Butt, 2011; Folkman, 2010; Herth, 2000; Snyder, 1994). According to one theory, hope is constituted by four underlying motive systems: attachment, mastery, survival, and spiritualty (Scioli et al., 2016). People then draw upon various resources to fulfill their need for attachment (e.g. trust in family and friends), mastery (e.g. understanding of one’s priorities), survival (
UBC Theses and Dissertations
Exploring the lived experience of the human-companion animal relationship for people with cancer Maharaj, Nandini 2019
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