A Qualitative Study

Anthrozoös A multidisciplinary journal of the interactions of people and animals

ISSN: 0892-7936 (Print) 1753-0377 (Online) Journal homepage: http://www.tandfonline.com/loi/rfan20

Exploring the Meaning and Experience of Chronic Pain with People Who Live with a Dog: A Qualitative Study Eloise C. J. Carr, Jean E. Wallace, Chie Onyewuchi, Peter W. Hellyer & Lori Kogan To cite this article: Eloise C. J. Carr, Jean E. Wallace, Chie Onyewuchi, Peter W. Hellyer & Lori Kogan (2018) Exploring the Meaning and Experience of Chronic Pain with People Who Live with a Dog: A Qualitative Study, Anthrozoös, 31:5, 551-565, DOI: 10.1080/08927936.2018.1505267 To link to this article: https://doi.org/10.1080/08927936.2018.1505267

Published online: 19 Sep 2018.

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aNthROZOöS

VOlUmE 31, ISSUE 5 PP. 551–565

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PhOtOCOPYING PERmIttED BY lICENSE ONlY

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Exploring the Meaning and Experience of Chronic Pain with People Who Live with a Dog: A Qualitative Study Eloise C. J. Carr*, Jean E. wallace†, Chie Onyewuchi*, Peter w. Hellyer‡, and lori kogan‡

ABSTRACT Pain is a significant burden for those with chronic disease and negatively impacts quality of life, causing disability and substantial work and health-care costs. Chronic pain has been identified as one of the most important current and future causes of morbidity and disability across the world. living with a dog has been associated with greater physical activity, less disability, more social ties to the community, and improved mental health. In this study, we sought answers to the research question, “What is the meaning and experience of chronic pain for people who live with a dog?” Using a descriptive qualitative research design, we conducted telephone interviews with 12 patients who lived with a dog, attending a tertiary chronic pain program in western Canada. transcribed interviews were subject to thematic and interpretive analysis. Participants ranged in age from 39 to 70 years of age (average 54 years) and had experienced chronic pain for an average of 15 years. the analysis identified four themes that gave understanding as to how people who live with a dog experience chronic pain: dog gives life meaning; dog as caregiver; dog gives emotional support; and dog provides companionship. For those experiencing chronic pain, living with a dog was reported to positively impact their quality of life, mental wellbeing, physical activity, and social interaction. For some participants, living with a dog provided a reason to live and focus on the future. For people with chronic pain, living with a dog may enhance the quality of their lives and provide support that mitigates their suffering and enables them to live a more meaningful life.

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Address for correspondence: Eloise C. J. Carr, Faculty of Nursing, Professional Faculties Building, University of Calgary, 2500 University Drive NW, Calgary, Alberta, Canada T2N 1N4. E-mail: [email protected]

anthrozoös DOI: 10.1080/08927936.2018.1505267

* Faculty of Nursing, Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada † Department of Sociology, Faculty of Arts, University of Calgary, Calgary, Alberta, Canada ‡ Department of Clinical Sciences, College of Veterinary Medicine & Biomedical Sciences, Colorado State University, Fort Collins, Colorado, USA

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Exploring the meaning and Experience of Chronic Pain with People who live with a Dog: a Qualitative Study

keywords: chronic pain, dog ownership, human–animal bond, quality of life, wellbeing. Chronic pain has been identified as one of the most important current and future causes of morbidity and disability across the world (Global Burden of Disease Study Collaborators, 2015; Rice, Smith, & Blyth, 2016). In Canada, 1 in 5 Canadians experiences chronic pain, costing more than cancer, heart disease, and hIV combined (Phillips & Schopflocher, 2008; Reitsma, tranmer, Buchanan, & VanDenKerkhof, 2012). Direct healthcare costs for Canada are more than $6 billion per year, and productivity costs related to job loss and sick days are $37 billion per year (Schopflocher, taenzer, & Jovey, 2011). the prevalence of chronic pain has been called a crisis (Sessle, 2011). Pain has been defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,” and is usually described as chronic after three months (merskey & Bogduk, 1994, p. 211). Chronic pain can result from a specific disease or events, for example, neuropathy with diabetes, postherpetic neuralgia following infection with herpes zoster, or neck pain following a whiplash injury after a road traffic accident. the experience of chronic pain is multidimensional with sensory (physical), affective (emotional), and evaluative (cognitive) components, with central and peripheral changes in neurobiological systems (Dickenson, 2016). Recent understanding of chronic pain has moved from thinking about it in terms of tissue damage, to understanding the neural complexity and dynamic nature of the pain and the structural changes that may take place in the brain (Farmer, Baliki, & apkarian, 2012). to some extent these being to provide an understanding of the profound and debilitating effects of chronic pain on function, sleep, mood and quality of life (van hecke, torrance, & Smith, 2013; toth, lander, & Wiebe, 2009). Chronic pain has been recognized as a chronic disease (Fine, 2011), and as such, some of the approaches to help patients manage their pain have mirrored those employed in the management of other chronic diseases, such as self-management (Sm) skills and becoming an “expert patient” (tattersall, 2002). the original term “self-management” was defined as “learning and practicing the skills necessary to carry on an active and emotionally satisfying life in the face of a chronic condition” and embodies concepts such as self-efficacy (lorig, 1993, p. 64). a recent systematic review identified five core skills required in a self-management program: problem solving; decision-making; formation of a patient-provider relationship; goal setting; and self-tailoring through structured self-management skills (Du et al., 2017). Self-management interventions usually have an informational or educational component and potentially additional supports (e.g., behavioral, educational, psychological, and clinical) to encourage people to take an active role in their own health and better manage their condition (taylor et al., 2014). Unfortunately, these programs are often limited to specialist pain management programs and wait times can be lengthy (lynch et al., 2008; Peng et al., 2007). Regardless, many people with chronic pain have to find ways to self-manage their pain and continue with their lives. Dogs have had a significant role in the lives of humans for thousands of years (Shipman, 2012). In relation to health care, dogs have been used as an intervention or “assisted-therapy” to provide a calming and comforting presence (marcus, 2013). assisted-therapy with dogs has been reported in a range of different healthcare settings including: children’s hospitals (Churhansen, mcarthur, Winefield, hanieh, & hazel, 2014); mental health clinics (maujean, Pepping, & Kendall, 2015); outpatient pain management clinics (marcus et al., 2012); and long-term care facilities (Cipriani et al., 2013). In the home environment, living with a dog has been shown

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to provide several benefits to wellbeing, including improved physical activity (Christian et al., 2016; thorpe et al., 2006), better mental wellbeing (mcNicholas et al., 2005), greater connectedness to the community or “social capital” (Wood, Giles-Corti, & Bulsara, 2005), and reduced medical costs (headey & Grabka, 2007). a companion animal (e.g., cats, dogs) generally includes any animal that shares its life with a human caregiver (Chur-hansen, Stern, & Winefield, 2010). the International Federation on ageing (IFa) recently conducted an extensive review on the benefits of companion animals for older people and endorsed the benefits above, but did not mention any benefits specifically for people with chronic pain, despite it being a prevalent issue for older people (International Federation on ageing, 2014). as described above, the positive effects of living with a dog are well documented, but we found limited enquiry related to the effect of living with a dog for people suffering from chronic pain. One early study considered the effects of living with a dog on migraines and found it provided little benefit (hirsch & Whitman, 1994). a more recent online survey of 173 adults indicated that there may be some benefit of living with a companion animal for people with chronic pain (Bradley & Bennett, 2015). We were unable to locate any studies that had specifically explored how living with a dog may help in the management of chronic pain. We were therefore interested in understanding the meaning and experience of chronic pain for people who live with a dog. more specifically, we explored whether living with a dog is related to the wellbeing and quality of life of people suffering from chronic pain, and if so how? We use the term wellbeing in the broadest sense to encompass physical, mental, and social domains of health to encourage a more holistic approach to disease prevention and health promotion (Slabaugh et al., 2016). Similarly, we view quality of life as a broad concept related to the perception and satisfaction of the individual with their own life (Pinto, Fumincelli, mazzo, Caldeira, & martins, 2017).

Methods Study Design this descriptive qualitative study is the first phase of a sequential exploratory mixed methods design (Creswell, 2003; Creswell, Klassen, Plano Clark, & Clegg-Smith, 2011). mixed methods research is a research design in which the researcher collects, analyzes, and mixes (integrates or connects) both quantitative and qualitative data in a single study or a multiphase program (Cresswell, 2002). there are three basic designs: exploratory sequential; explanatory sequential; and convergent (Fetters, Curry, & Creswell, 2013). the exploratory sequential exploratory design is often used in the development of a survey instrument, where the qualitative phase can identify or inform the development of items for the survey (Onwuegbuzie, Bustamante, & Nelson, 2009). the purpose of this qualitative study was to explore the experiences of people with chronic pain, who lived with a dog, to identify relevant factors to inform the design of a larger quantitative survey to be conducted in the future.

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a purposeful sample was chosen as it identifies participants best able to provide rich qualitative data (moules, 2002). Participants needed to be 18–90 years of age, as it is important to capture a range of experiences from individuals with chronic pain. Participants had to live with a dog at the time of the study and be able to provide informed consent and converse in English, to be able to accurately and comfortably tell their story relating to chronic pain. to facilitate reaching data saturation, where no further new material is identified, it is suggested that

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between 6–20 key informants can be sufficient (Creswell, 2003; Guest, Bunce, & Johnson, 2006). In this study, data saturation was reached after interviewing 12 participants.

Data Collection the data collection method was a semi-structured telephone interview with people who had chronic pain and lived with a dog. Following favorable ethical review by the Conjoint health Ethics Research Board (ChREB#16-2040), recruitment flyers were posted in a large tertiary chronic pain program in a city in western Canada. the flyer asked people who had chronic pain and lived with a dog to make contact with the research team if they were interested in participating in the study. the researchers (EC/JW) were the main points of contact and provided participants with consent forms and study information via email or mail. those who agreed to participate were invited to participate in a telephone interview at a time convenient for them.

Telephone Interviews telephone interviews were chosen as they are particularly helpful when talking about pain. the relative anonymity is thought to encourage more meaningful conversations around pain, and elucidate more detailed information (Carr & Worth, 2001). Participants were at home when the telephone interviews took place. the interviewer (EC) asked participants to reflect on their personal experiences of living with chronic pain and asked: (1) What do you know about chronic pain and what does it mean to you; (2) how do you manage your chronic pain; (3) how has having a dog affected how you experience and manage your chronic pain; and (4) how has living with chronic pain affected your life. In addition, several demographic questions were included. Participants were invited to create a pseudonym, or one was ascribed to them at the point of transcription, to facilitate maintaining confidentiality.

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Data Analysis thematic analysis is a qualitative research method intended to describe and analyze consistent and repetitive themes in human experience (Braun & Clarke, 2006). the analysis was conducted through an interpretive paradigm where the transcribed interviews were coded and these codes clustered to develop sub-themes of similar topics, and finally core themes. Each digitally recorded telephone interview was transcribed verbatim. two team members (EC and JW) separately coded two transcripts and then developed an agreed coding framework for all subsequent transcripts. the text was read thoroughly: words and short statements were identified which captured meaning. For example, one transcript read “But the thing that they do for my sleep is the pattern of sleep to go to bed. So to go to bed when it’s dark, to go to bed at a certain time, wake at a certain time. those things help,” and this was coded as “dog helps sleep routine.” In a different transcript, the sentence “the good thing is that it gets you out of bed every morning and gives you something to do,” was coded as “structure.” Once all the interviews were coded and no new codes were emerging, the codes were then grouped into preliminary sub-groups or topic clusters (EC). For example, the previous two codes became part of the sub-theme “structure and routine.” Following coding of all transcripts the team (EC, JW, CO) met for a half-day workshop. the purpose of the workshop was to further develop and finalize sub-themes and group them into core themes. this was an iterative process, where descriptive and in vivo codes were posted onto boards with similarities (clusters) grouped together to subsequently form themes (miles, huberman, & Saldana, 2014). For example, the sub-theme “structure and routine”

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became part of the core theme “Dog gives life meaning.” there were occasional differing perspectives, but overall there was good agreement on the organization of clusters and generation of themes (Noble & Smith, 2015). to ensure face validity, an important consideration for trustworthiness (Elo et al., 2014), we presented the results (themes) to the wider team, including two patients living with chronic pain and who lived with a dog. this enabled them to evaluate whether the results matched reality, and feedback suggested the themes did match their reality. In qualitative research, the term trustworthiness is used to address concerns around the equivalence of rigor in quantitative research (Guba, 1981), and the transparency of decision making in the analysis and interpretation of data is particularly important (Fereday & muir-Cochrane, 2006).

Results twelve participants (10 women and 2 men) with chronic pain took part in the semi-structured interviews between march and September 2017. the interviews lasted between 13 and 35 minutes (average length 24 minutes). Participants ranged in age from 39 to 70 years of age (average 54 years) and had experienced chronic pain for an average of 15 years (range 1–45 years). ten participants were married or living with a long-term partner, and two were divorced. Only two participants were working (part-time) and the rest were on long-term disability, with the exception of one person who was not working and was not eligible for disability benefits. Participants experienced a range of chronic pain conditions: for example, fibromyalgia, migraine, trigeminal neuralgia, and pelvic pain. the first two interview questions related to participants’ personal stories of their chronic pain, and how they managed it. We draw on these to set the context for the study and describe the lives of these people living with chronic pain. None of the respondents spoke about their dog at this point but often provided very factual details about when their chronic pain started, and their experience with the chronic pain program. We then describe the themes that came from the analysis of the other interview questions. the quotes below offer examples of some of the experiences of living with chronic pain as told by our participants:

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When I went to see her [physician at the chronic pain program] I was really desperate, I suffered from depression, suicidal thoughts and I was in so much pain, I would say at that time it was around 8 all the time, and I was just feeling so physically awful, I was feeling mentally awful and I wasn’t really doing anything I wasn’t leaving the house, I was scared of getting out of bed, I wasn’t always getting dressed. When I went to see her in July I was desperate, I told her we had to do something different, I really just couldn’t live like that and I had been on amitriptyline for 20 years before and Dr. X put me Nortriptyline and that made all the difference. For years and years and years I’ve been taking 650mg of tylenol four times a day and that really helped, and I could tell when my 6 hours was up but I was on that last year when I was in so much pain, but the nortriptyline is really amazing. (Kass)

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I had a car accident in 2008. I have headaches every day and I have migraines 2–3 times a week. and it comes from my neck. It comes from my neck. I used to only have headaches on the right side but after the last couple of years they have progressed to the left side. I have pain that goes down into my arms and into my hands and that. and my low back is my other issue and it goes down into my left leg and affects my walking. (Cora)

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most patients managed their pain in a variety of ways including spinal cord stimulators1, pharmacological, and non-pharmacological strategies: So, medication wise I’ve been on every opioid known to man and that’s not going so good. Ummm … we graduated to one opioid as supposed to several, thank goodness, and I have a spinal cord stimulator and I have a new spinal cord stimulator. It seems to work better, but having said that, it works … even the old one works very well in conjunction with the ketamine that I am on, for some reason ketamine seems to help that machine be more affective for me. (alison) I use a whole lengthy list of strategies. the simplest ones are the pacing and managing stress, and then mild exercise, then we tried all sorts of medications and treatments. Pretty much everything you can imagine. Now I have a neuromodulator stimulator installed, and that been helpful in getting off the pain meds. I even lived in China for 4 months doing acupuncture nine times a week. It was very effective but it didn’t last. (Peter) In pursuing our central research question, four themes were derived from the interview data that gave understanding to the experience of living with chronic pain and living with a dog: dog gives life meaning; dog as caregiver; dog gives emotional support; and dog provides companionship.

Dog Gives Life Meaning this theme reflected the central role of their dog in how they experienced living with chronic pain. the impact of chronic pain on their lives had frequently taken away their job, their friends and for many, a purpose in life. their dog created opportunities to build purpose and meaning into their lives. this purpose involved many daily activities of living, from regular routines such as getting up in the morning, to getting out of the house and interacting with other people again. their dog provided the motivation to create these routines in a life that had been severely disrupted by pain: the good thing is that it gets you out of bed every morning and gives you something to do. (Kass) I’ve started walking again. I have a reason to get out and walk. Even though I am in pain I push through. (June) I don’t expect the dogs to do anything except help me get out and do my exercise. I can’t do many of things I used to, such as martial arts, but I can go out for a walk and they help me do that. they are relentless some days when I am not up for it but we go anyway. (Peter)

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I get out to the dog park, so I have [emphasizes the “have”] to socialize with people whether I’m having a good day or bad. (Penelope) I was at that stage where I was dealing with the added depression and anxiety with having had chronic pain for so long and now this whole situation so I was thinking how can I improve both my socialization and my physical health and my emotional health all in one, and I didn’t want to be in a situation where I became more secluded. I was like am going get a dog because that’s gonna get me out of the house, that’s gonna force me to be out walking doing different things. (anne)

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Several participants spoke about how living with a dog gave them someone to care for. living with chronic pain meant that most participants had been taken care of by others and having to look after their dog provided them with a purpose—to care for another being. this could be extremely profound: Well I’ve been suicidal four times since this happened. One of the things that anchored me is the wreckage that would be left behind and one of these aspects is who would care for these animals. You know dogs adjust but the attachment I had particularly with Juno [previous dog]. It’s hard to leave the things/people you loved behind. It was one of the things that anchored me and put me in a position to try and find another way. (Peter) that was a very good time for me as I was so involved with the dog, taking care of her. It took a bit of the anxiety away. I had to drive to the vet to get her but it was super hard for me to do but it was because of the dog. She became my focus. (anne)

Dog as Caregiver all participants spoke about the ways in which they felt their dog provided care to them that helped with their pain. these caring acts ranged from monitoring them, providing physical comfort, and providing a distraction from their pain: a girlfriend of mine was here and she was sleeping in the same room as me, and noticed that Jason [dog] would check on me at about 2 o’clock in the morning, about the same time that the pump alarm went off the first time. So apparently every morning she would check to see if I was breathing by putting her nose by my cheeks. (alison) Because the dog senses when you are having a hard time and will come over and try and provide you with comfort in some way, or whatever way they are able to. Sometimes they will come over and start licking you, to groom you. Whatever she thinks will make you feel good. (Gilbert) he’s been so sweet and even helped me with my daughter when she was little. If a toy dropped, and it hurt for me to bend over, I don’t know how he knows it but he would pick it up and give it to her. he’s been a big help. (Stephanie) For many participants, the experience of chronic pain was relentless. In these situations, their dog offered, through a variety of mechanisms, a distraction from their pain.

I try not to think of my pain. I use my head and use other things—I put more attention on her [dog]. (Penelope) Just watching them interact they are very snuggly. It gives me like peace. (June)

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It’s like when I worked the thing that helped me was “how could you do that if you were in so much pain.” Distraction really helps me. I was a runner and I didn’t realize how much mindfulness and meditation went along with that. You get that payback with your dogs. You could be just talking to them on the couch or looking at them. there’s a payback there for that in your brain. (Cora)

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I think distraction is probably one of the biggest benefits. they help you focus on others areas. I think they are plugged into that and give you distraction. (Peter)

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Dog Gives Emotional Support Whilst the previous themes captured the ways in which dogs were seen to provide care or a therapeutic input for their owners, this theme captures an overarching emotional connection between the person with pain and their dog. this was often referred to as an intuitiveness the dog demonstrated about their pain or suffering, and the positive attributes of their dog being a good listener. their dog seemed to know and respond to their needs: they are certainly sensitive to when the pain is making you grumpy and I growl at them “go and lie down” and they go “OK it’s one of those days.” (Peter) I don’t know how he does it but he knows when I am not going to be moving that day. he just cuddles up a little more and licks me more and snuggles in or brings his toys to me instead of me going to the toys. I think he just has a sixth sense. OK we’re going to have a lazy day and he just cuddles in and watches tV with me. (Stephanie) the role of their dog as a listener was mentioned by several participants: and the dog comes, she does, and she’ll sit beside me and she looks at me with her big brown eyes and she’s just … she … she’s just like a really solid friend. She’s just there. She can’t take the pain away, I know that. I know that and I’m sure she knows it somewhere deep too (Sue) I think the payback is there – even before I had chronic pain, my old dog Zoe, she knew all my troubles. Right? You have that and there was payback before I even needed anything from her. For all my trials and tribulations in my life she was there. (Cora) I do talk to him he doesn’t understand all of it but I do chat with him, so there always is somebody to listen. (anne) the emotional attachment and safety their dog offered enabled many to feel and express the emotional burden of their chronic pain to their dog. as well as being a listener, their dog seemed to facilitate the process of connecting with others, and enabling an expression of their emotions:

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Just petting her. Coming in from a situation, I can just pet her, feel her fur and feel my anxiety coming down. I can connect with feelings I have been devoid of for a while. I can retain some of myself. (leah) I know that sounds awfully ridiculous but I grew up in a household where feelings were not allowed. Not at all, zero. No emotions, no nothing, very cut and dried … and the dog has given me permission to cry. When I am in that much pain and medication isn’t working and I’m expecting it to, she allows me to cry. She really does. there’s no “you shouldn’t be crying, you don’t have time for that.” there is none of those messages. She just comes in and embraces the time and you know what? I’m crying my eyes out and she doesn’t tell me it’s wrong, she doesn’t tell me to stop, or it’s inappropriate, or anything like that. and does it help? Yes, it does. (Sue)

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Dog Provides Companionship Participants talked about living with chronic pain and the loneliness that often surfaced due to not working, and the loss of friends and other social connections. they spoke of how their dog

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often provided much-needed companionship. they reported feeling comforted by the physical proximity of their dog at night, when loneliness was often heightened, as well as recognizing the positive impact of their dog’s loyalty: You know I always got somebody to cuddle and make me feel loved when I am lonely and in pain and when am trying to sleep. (anne) You know Juno is my second [dog]. an amazing companion, attentive, obedient. how much that dog wants to please. the loyalty is a little frightening when you compare to what you expect from people. (Peter) Companionship embraced just being there and staying alongside the owner regardless: I recall distinctly the dog at that time really stuck by me. It would follow me everywhere. It followed me to the basement and if I stayed down there it stayed down there all day with me. (Gilbert) If I’m not feeling great and I’m going to go for a bath he won’t leave me and stays right by the bathtub. my husband works from home so he could be with my husband but he doesn’t, he almost watches over me. (Stephanie) For some participants, reflecting back to a time when they didn’t have a dog, and the loneliness they experienced, highlighted the positive impact that having a dog had made in their lives and often motivated them to live with a dog again: You know we’ve got a nice home and a good life, but I would always feel lonely, especially you know, when I was in pain all the time it was horrible. But I am not there now. (Kass) It’s better than being alone, I can tell you that, because the 6 months I was without a dog … For 6 months I had no dog and it was horrible. It was horrible because of the loss too. It was quite profound to me a dog that was old that didn’t do much and all that, left such a big hole. (Cora) I’ve had dogs my entire life. When I could no longer work with this injury one of the things we did was go and get a dog as a companion for me. (Peter)

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In this study we were interested in understanding the meaning and experience of chronic pain for people who lived with a dog and had chronic pain. twelve participants gave rich descriptions of their lives and provided further understanding and insights of how living with a dog related to their wellbeing and quality of life. many of the positive benefits of living with a dog reported in our study have already been described in other populations. however, this study provides new insights related to people with chronic pain, and the ways in which dogs support them in their efforts to manage their pain and live more meaningful lives. For people with chronic illness, meaning-making has emerged as an important concept. It is thought to be significant in the positive adjustment to chronic illness through reorganizing or re-evaluating the situation (Sherman & Simonton, 2012). meaning-making occurs through relationships, particularly family relationships, and the connection to friends (Sloan, BrintzenhofeSzoc, mistretta, Cheng, & Berger, 2017). Dogs are often considered part of the family (Irvine & Cilia, 2017; Walsh, 2009) and in our study many participants felt their relationship with the dog gave their lives meaning.

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the centrality and prominence of the relationship with their dog was often quite profound. the importance of the human–animal bond has been well documented in the literature (Friedmann & Son, 2009; Irvin, 2014; Winefield, Black, & Chur-hansen, 2008) and it was evident that many participants in our study regarded their dogs as family members (Irvine & Cilia, 2017; maharaj & haney, 2015), reflecting the humanistic category of “beloved persons” (Blouin, 2013). People with chronic pain frequently experience a significant sense of loss related to occupational abilities, social networks, relationships, future plans, as well as physical function and reduced quality of life (Carr, mcCaffrey, & Ortiz, 2017; Gullacksen & lidbeck, 2004). Whilst the dogs in our study were not trained as assistance dogs, participants reported that they fulfilled many of the same roles by increasing functioning and supporting their psychological and emotional health (Irvin, 2014). Bradley and Bennett’s (2015) online survey study, in which they also conducted interviews with seven people with chronic pain, suggested that living with a dog provided people with a purpose in life—yet they were unable to provide insights of how this was achieved. Our study supports and advances their research by providing insights into how dogs provide meaning for people with chronic pain. It also supports the recommendations that health professionals who ask patients about their pets can improve communication and the therapeutic alliance (hodgson, Darling, Freeman, & monavvari, 2017). People who endure chronic pain often face an adversarial struggle as they reconstruct their lives, negotiate the health care system, and prove legitimacy (toye et al., 2013). the erosion of identity and meaning associated with the loss of one’s job, social ties, and relationships can be devastating on top of coping with chronic pain. Future research that further explores the role that dogs may play as meaningmakers for people with chronic pain, as well as exploring other potential meaning-making activities, is critical. Chronic pain is a multidimensional experience with sensory, affective (emotional), and social components (turk, 1996). Due to the multidimensional nature of chronic pain, and the fact that adverse events and complications often mitigate the effectiveness of pharmaceutical interventions, multimodal interventions should be prioritized (Chen & michalsen, 2017). Studies have shown that living with a companion animal can have a positive effect on an individual’s mental health and physiological status, with most studies reporting decreases in anxiety, depression, loneliness, and increases in exercise (Friedmann & Son, 2009): all factors that can significantly contribute to the improvement in wellbeing and quality of life as reported by those experiencing chronic pain. Participants in our study reported that their dogs contributed to their wellbeing through a variety of ways, such as distraction, comfort, bringing joy and happiness, and encouraging them to exercise and interact with others in their community. these aspects of their lives appeared to be integrated into the ways they self-managed their pain. Self-management programs have become a cornerstone for the management of chronic disease (World health Organization, 2012). however, these programs have been criticized as taking a biomedical approach with an emphasis on disease rather than a broader biopsychosocial perspective (Sadler, Wolfe, & mcKevitt, 2014). this limitation was emphasized by patients, in a systematic review and narrative syntheses of lay and health professionals understandings of self-management, where lay people understood self-management more broadly to reflect biomedical, psychological, and social aspects (Griffiths, Foster, Ramsay, Eldridge, & taylor, 2007; Nolte & Osborne, 2013). Of further concern is the lack understanding about what outcomes are important from the perspective of the patients (Boger et al.,

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2015). In our study, there were several aspects of living with a dog that appeared to be connected to self-management: for example, participating in physical activity by walking their dog and recognizing that anxiety could be reduced by cuddling or stroking their dog. Patients living with chronic pain have reported that they prefer to manage pain their own way, often without medication, and health care providers need to identify strategies patients might already be using and integrate these into self-management approaches (Crowe, Gillon, Jordan, & mcCall, 2017). Further research is required to explore, for people who already live with a dog, how this might be a tool in the armory of self-management knowledge and skills. Outcome measures should reflect the broader benefits of living with a dog including psychological and social benefits.

Future Directions the purpose of this qualitative study was to explore the experiences of people with chronic pain who lived with a dog to identify relevant factors to inform the design of a future survey. this survey will include people who do not live with a dog, and explore if there are differences in outcomes between these two groups. For example, does living with a dog in itself confer more meaning to life or are there other factors involved? For people with pain, these factors may be different from the general population. a quality of life questionnaire for dog owners has been recently developed incorporating three factors: emotional wellbeing, social and physical activities, and burden/stress (Oyama et al., 2017). Whilst it includes items related to emotional aspects (e.g., companionship and emotional support), it does not include questions about meaning-making or providing a purpose to life, both of which may be of particular importance to people with chronic pain. We believe our research has uncovered a new avenue for research that explores the potential health and social benefits of living with a dog for people with chronic pain by further developing specific outcomes measures identified from the literature (e.g., general health and wellbeing and dog walking), as well as new concepts that have not been examined in the context of pain management.

Conclusion the benefits of living with a dog have been explored in many different populations but few studies have considered people experiencing chronic pain, and particularly those attending a tertiary pain program. this study has shed new understanding on the myriad ways that living with a dog appears to enhance the wellbeing and quality of life for these participants

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Due to the recruitment process, participants were self-selected and perhaps more likely to hold positive views of living with a dog related to their experiences of chronic pain. Potential negative aspects of living with a dog, such as added responsibility and financial costs, were not mentioned in any of the interviews. Our sample, however, should not be viewed as positively biased in telling their stories as many were living with severe, debilitating chronic pain for decades. Patients attending tertiary pain programs (chronic pain programs) are frequently more complex than pain sufferers in the community, showing higher levels of functional impairments and psychosocial difficulties (mailis-Gagnon et al., 2007). For a qualitative study, the generalizability of the findings is less important than the rigor and trustworthiness of the data and its interpretation (Guba, 1981). to demonstrate rigor, it is important to ensure transparency of decision making in the analysis and interpretation of data, and we have described these in the methods section (Fereday & muir-Cochrane, 2006; Koch, 1994).

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experiencing chronic pain; perhaps in a more profound way than some other populations. these benefits touched upon the physical, emotional, and social aspects of their lives that were affected by chronic pain. the study has helped identify relevant factors that will inform further research pertaining to living with a dog for people with chronic pain, and what role a dog may have in the self-management of their pain.

Acknowledgements this study was funded through a Catalyst grant from the O’Brien Institute, University of Calgary. We thank the participants who generously gave their time and shared their insights of living with a dog and experiencing chronic pain.

Conflicts of Interest In accordance with taylor & Francis policy and our ethical obligation as researchers, we report that we have no financial and/or business interests in a company that may be affected by the research reported in this paper.

note

1. a spinal cord stimulator is a small device implanted near the spine that generates mild electrical pulses to interfere with pain pathways and reduce pain.

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