Social inclusion and recovery – not possible without pets?

I was training a Psychosis Awareness course recently and a video clip that we use in it shows a service user describing how important his dog is to him and his recovery. This led to a discussion, in the group being trained, about the importance of animals to mental health – something that I am very interested in. I muted the idea that it is difficult, if not impossible, for many of our service users to own a companion animal. One of the students said, as a counter argument, that some of the service users, that her assertive outreach team work with, have animals. My reply was to quote the statistic that 50% of UK households have a companion animal and to ask her if 50% of her team’s caseload had animals. They did not.

We talk about recovery in mental illness and the importance of social inclusion for service users but rarely do we really consider these ideas in the context of animal ownership. Those with mental health problems are often discouraged from owning a companion animal by their families, the staff working with them, or other agencies. Usually there are worries about how that person may be able to manage to care for the animal, the cost of keeping it and the accommodation of it should the owner become unwell. Often service users are provided housing that prohibits the keeping of pets.

For many, companion animals provide company, structure to the day and important relationships. Our animals can make us laugh and some may make us feel safer in our homes and communities. Many animals help their owners to have increased social contact, routine and excercise. Why should someone be denied the chance to experience these things, that are options for many of society, just because they have a mental health problem.

Animal assisted therapy is well known and used now in many health care settings. It has a wonderful affect for many of those that the animals come in contact with for short periods, often on a regular basis. Professionals often refer to these experiences for people, thinking that this satisfies the need for contact with animals. Whilst I do not deny that animal assisted therapy is of great value, it is very different to having your own animal in your life on a full time basis. In fact, for me, whose animals are very important, a visiting animal which was not my own, would probably be more distressing than helpful as it would remind me of what I had lost and could no longer have.

We stigmatise people with mental illness if we do not ofer them support to own a companion animal, should they wish to. A large number of our service users can never experience social inclusion unless their wish to have an animal can be accommodated.

So let’s really start thinking about how we might support recovery for our service users who desperately want a companion animal. Instead of dismissing their desires and aspirations in this area, or trying to put them off the idea, let’s support them. Let’s help find them accommodation that suitable for them and their companion animal. Co-write with them care plans that include their pets and ensure adequate crisis and contingency plans are in place should things go wrong, including who they want to take care of their animals. We should be supporting service users to access information and services for their animals, so not only are we thinking of the humans’ welfare, but the animals’ welfare too.

Aniaml ownership is not for everyone, but for those for whom it is important, wherever possible, it should be facilitated.

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Paces – a short story

The following, a short story, is my first piece of written fiction for over 15 years. In it I continue to explore my more academic interest in the impact animals can have on humans, on their mental health and how animals’ lives can be so intertwined with ours. It also examines companion animals end-of-life issues. Human end-of-life is a hot topic currently but it is important to consider this for the animals in our lives, companion or otherwise.

 

Paces

It would have looked peculiar to anyone out early, passing along the village road that ran beside the field.  Had they glanced over the short hawthorn hedge they would have seen a small woman, slumped on the dew dampened grass, next to a prone horse.  The tidy and precise figure in her late forties was speaking gently to the animal.  Any passersby would not have seen the horse appear to register her and his breathing become slightly less laboured.

Libby could do nothing but sit, talk quietly to Dapper and lose herself in the memories. Watching his flanks she matched her breathing to his, aware that it was uneven.  As she spoke to him, memories of half her lifetime and most of his, came in to focus.  She reminded him of the many rides they had been on together.  The summer rides with the smell of wild honeysuckle that grew in the hedgerows along with the short-flowering dog roses.  The winter rides, often short, snatched around work and the available daylight, with Dapper delighting in dancing his way along bridle paths in the sharp, clean cold air.

Since buying Dapper Libby had become a one horse woman, she had hardly ever ridden another.  Now she wondered how many hundreds, if not thousands, of rides they had been on together.  During the years how many miles had they travelled, how many paces, across the open countryside afforded by being close to a network of bridleways, several large swathes of common land and access to a long hill range.

Libby could track most of her adult life thorough the days and seasons spent with Dapper, including her nursing career.  She would see to him around her shifts, worked as a ward nurse, as her career progressed to the role of managing a hectic acute admission mental health ward.  Winter late shifts gave her and Dapper the morning light and sufficient time to get out, even if it was just a walk and a brisk trot across the still, silent common land they would have to themselves.  In the summer, no matter what hours Libby needed to work, there had still been time to ride.  The evening visits after a late shift became something of a pleasure rather than a chore.  She would sit on an upturned bucket next to Dapper as he ate his feed, the solid regular chewing soothing away the stresses of the day, allowing Libby to wind down.  Occasionally raising his head, Dapper would drop small pieces of feed in her hair.

Dapper had a kind and generous ear, listening to all her work problems.  In the early days it had been those tricky issues of finding confidence in her identity as a nurse and developing new therapeutic skills.  There were the difficulties of fitting in to a busy ward team and the emotional toil of the work with her patients.  The main tool Libby possessed to do the job was herself.  She used herself as a person to connect and engage with patients, build therapeutic relationships and empathise with their distress and pain.  She had to learn the fine balance of maintaining professional boundaries yet getting emotionally close to those she nursed, which could take its toll.

Her experience of horses had transferred to and supported her work, most markedly with those who had severe and enduring illnesses.  Patients admitted with bipolar disorder who, when manic would be highly restless, agitated and over active.  They often struggled to keep on track with their thoughts, becoming very distracted and distractible.  The excruciating experience of elevated mood, rather than evoking happiness, made sufferers unable to sleep, or to stay sufficiently focused for long enough to eat, or to even drink.  They could be highly irritable and angry, frustration sometimes moving them to tears.  People with psychosis struggled with their inner torment, their difficulty to connect with the world, and they often experienced a lack of motivation to undertake even the most basic activities of living.  Patients with severe anxiety or depression required from her a gentle confidence and an unrelenting hopefulness that things would improve.  All those admitted to the ward needed compassion, quiet kindness and understanding.

Owning Dapper helped Libby to understand agitated and distressed patients, to see each as an individual with strengths despite their difficulties.  Libby was able to approach them in the same way as she would Dapper when, during those early years, he was difficult, anxious and temperamental.  Just as she learnt with Dapper, Libby the nurse learnt to present as calm and confident, slowing her speech, lowering her tone of voice, being unhurried in her movements and regulating her breathing.

Libby developed the ability to be comfortable with silence, fighting the compulsion to anxiously say anything just to fill the gaps, instead responding to another living being by staying quiet, waiting and watching as she did every day with Dapper.  He taught her how to read body language and to watch for changes in another, a shift in posture, in movement, to observe if muscles were tense or relaxed.   Dapper taught her to tune in to the slightest alteration in him second by second, so much so that it became automatic, intuitive and transferred to her work with people.  She could not identify how and when this happened, it just did.  She wondered now, as she gently smoothed the bleached out, faded grey fur on his neck, whether she would have been a different and probably a less skilled nurse if she had not had this old horse in her life.

Over the years Libby and Dapper developed into a team, with both able to read and respond to the other without conscious thought or deliberate attention.  The steady pattern of routine, of always undertaking tasks in the same way, of seeing Dapper at least twice a day, no matter what, become an important core to her life, a comforting rhythm that was ever present for the past twenty-eight years.  Like most people who owned horses, Libby moaned about being tied to the responsibilities of morning and evening checks, feeds, hay, picking up muck, grooming and, in recent years, of giving medication.  Now Libby watched as his head rested heavily on the short grazed grass, his breathing shallow and too fast.  She should feel guilty for having those past thoughts but rationalised that they were a part of the responsibility of owning a horse.  Most horse owners probably thought similarly at times, but Libby hoped that she would not remember her thoughts sometime in the future and regret them.

Libby wondered if she would look back and agonise about not having spent more time with Dapper, not staying for an extra five minutes while he finished his feed, but instead rushing off to work and leaving him to it.  The days when it had been too hot or too cold, the essential jobs done, and she had quickly left to get back to the air conditioning or the heating of the car.  The routine of owning a horse, the day-in, day-out pattern of their life together, made Libby unthinkingly accept Dapper’s presence in her life, just as a long married couple might take each other for granted.

Like the start of many a relationship, it was exciting, scary and tricky when Libby bought him as a green six year old.  She had been toying with the idea of getting a horse for some months, planning to seriously look at buying one after the coming winter.  Several ponies in the past had filled her childhood and her heart.  Once qualified and settled in to her first staff nurse post, she had wanted to start riding again.  She had in mind a bright, neat chestnut, as shiny as a fresh conker and well schooled, who would help her to regain her confidence as a horsewoman and with whom she could have some fun.

It was autumn when her friend Jane suggested she should see the horse at the small yard where her own horse was kept.

‘Go on, what is there to lose? You are going to have to start looking at horses if you plan to buy one.”’

‘I’ll look after winter,’ Libby said, ‘not now.’ 

‘Just come and have a look at him,’ Jane had insisted.

Eventually Libby had given in and gone to look but she was unimpressed with what she saw.  There he had been, standing in the middle of a rough paddock with his head up, on alert.  He was a stodgy looking cob and evidently very unfit.  He had the dark grey of youth that changed suddenly to smart white socks on his legs, with a clean, sharp definition that made it look as if his legs didn’t really belong to him, as if they had been borrowed.  One walled eye gave him a permanently surprised, slightly shocked, look. 

‘He’s not the right type or the right colour and he is unschooled – I need something I can just get on and ride without any faff,’ Libby said, ‘and what sort of idiotic name is Dapper?’

What did strike her however, were the bits of Dapper’s history that Jane knew.  As usual, a personal history engaged Libby, made her curious and keen to understand the individual, be it human or horse.

‘Dapper’s mum was a Connemara brought over from Ireland by a local dealer,’ Jane said as they started to walk across the paddock towards him.  ‘She was sold to a rough and ready chap who was somewhat surprised to find the mare was in foal.’  The dealer was contacted and he confirmed that an Arab stallion had been at his yard for several months around the same time as the mare.  Consequently, quietly and alone one morning, the mare had produced Dapper.

‘So, he hasn’t had the best start in life.  He was broken, not very well, and then sold to a local girl who was unable to manage him and so he had been passed on and then on.  Not the best for any horse!’ Jane added, ‘I think his legs do give him a rather dapper look, don’t you?’

A succession of young women had found Dapper difficult and had given up on him when he frightened them with his behaviour, some of which had bordered on the dangerous.  Sitting in the field with Dapper, now an old man with none of that sharpness of youth left, Libby wondered what would have become of him if she had not bought him.  His passing from owner to owner, person to person, would have continued, instability causing him to become more anxious and difficult.  It was very likely that he would have ended up in a market somewhere, being sold to the meat man, before even Galvayne’s Grooves appeared on his teeth.

Following Jane’s persuasion, Libby reluctantly agreed to have a ride on him, thinking that it would do no harm and would put an end to Jane’s pestering.   Dapper proved to be green, unbalanced and unschooled with no ability to work on the bit.  He was unruly and difficult and as soon as Libby settled in the saddle he quickly moved off and then skipped unexpectedly sideways.  In that moment Libby immediately knew that he was the one.  There was something about his movement, his paces, even though they were uncoordinated, that was absolutely right and resonated with her.

And that was it.  Libby bought him.  A raw six year old that had not been looked after or treated as kindly as a young horse deserved.  He had little to recommend him, especially as he had built a reputation in the locality of being difficult and at times un-rideable.

Libby had not had him vetted, something she would never dream of doing now she was older and wiser.  However, she had been lucky and he had been sound and fine once he had been thoroughly wormed.  Looking back it seemed as if those decisions had been made by someone else, a young and unwise girl, and that the wound up, spooky horse of then could not be the animal now lying immobile beside her.  They were both older, different, but that time seemed so close, as if it was merely several years, not decades, that had passed.

Within two days of seeing Dapper and the impulsive decision to buy him, Libby negotiated a price with his owner and found a small DIY yard to keep him.  Mill Farm seemed perfect, with grazing, stabling and an outside ménage.  It was when Libby foolishly decided to walk Dapper in-hand to Mill Farm, only a mile or so away across the local common from where he was being kept, that she discovered he did not lead well.  The young horse decided to shy at everything that moved; every leaf, rabbit and squirrel on the way.  Libby was desperately trying to hold on to Dapper as he danced, the Arab in him becoming very evident.  As he flicked his feet out, hooves extravagantly floating above the ground, head and tail held high, she tripped up.  This had really spooked him and he had tried to take off.  In that moment Libby knew she could not let go, aware of the road that ran through the middle of the common, and that should he get loose she very probably would not catch him again.  For some distance Libby slid as Dapper dragged her over the rough and bumpy ground.  Libby hung on to the lead rein until her hands stung, burning with the friction of rope against skin.  Eventually he stopped and Libby scrambled to her feet.  As they both stood, breathing heavily, eyeing each other, they had begun to come to an understanding.  Tightly grasping the rope in her still smarting hands Libby again started to lead him and they began to find a way of walking together, to attune, to synchronise human and equine paces.

One evening after the hot haze of a late summer day, riding along the hill range next to the common, their relationship changed.  They had been taking advantage of the cooler air on the top of Raged Stone Hill when, without warning, a crashing thunderstorm whipped up right above them, the sky suddenly angry and black, lightening throwing the surrounding hillside into sharp and terrible relief.  A short lull and then the rain started, soaking them both within seconds.  Libby had been frightened, feeling so exposed on the hill, but Dapper had been calm and, keeping his head and his footing, had got her down quickly and then safely home.  Steadily and surely he picked his way down the hillside by the shortest route, the Arab and Connemara in him providing sure footedness on the loose gravel moving under the small streams of water.  Libby’s trust of the horse developed and deepened and she found that there was little now to faze her when she was out with him.

They stayed for some years at Mill Farm, a small yard with around ten acres of paddocks.  On the surface it was a nice idyllic set-up, owned by a middle aged couple.  The wife, Mel, had her own horse, as did their daughter, and there were four DIY liveries.  Mel had welcomed her when she arrived with Dapper. 

When Libby explained she had just bought Dapper, Mel said, ‘Ah! He’s new out of the box then!’  It was much later that this struck Libby as more significant than she realised at the time – a telling indicator of an attitude to the horses.

The farm was nestled in a slight dip at the edge of the common land. Once tacked up, Dapper and Libby could be straight out on to open riding with no need for road work, definitely an important factor in those early days when Dapper was so unreliable and often unable to walk in a straight line.  This significant advantage was one of the reasons, Libby now reflected, that she and Dapper had stayed there so long.

They had settled in, quickly becoming part of the yard community with its ups and downs, although Libby was treated as the new girl and as someone who lacked horse knowledge.  Libby had accepted the nit picking and the slightly pointed comments, disguised as kind information giving.  She had instead focussed on the benefits of being on a yard.  Someone was almost always on site and there was the genuine and kind advice from the knowledgeable and sensible Martha.  Libby also learnt the downside of yard life with its minor squabbles.  One annoyance was the obsessively tidy Dee, who would clean and brush the yard, even when it was not required, and then manage to make everyone else feel bad for not doing it.  Dee’s unnerving habit of tidying away other people’s kit and tack without invitation or request was one of the yard jokes, but it was also exceptionally wearing.

Being utterly heartbroken was another reason that Libby had stayed at Mill longer than she should have done. It had coincided with that dreadful time when she could not contemplate more change, more upheaval.  No matter how Libby had been feeling, Dapper’s solid presence had got her through all the heart ache and despair of her divorce.  On the worst days Libby had wanted to pull the duvet over her head, to shut out pain in her heart, but she would have to get up and feed Dapper.  Once up, she would reason that if she could get to Mill Farm and see to Dapper, she would then be able to go in to work.  And so, one step at a time, one pace after another, Libby had got through each day.

The horse lying in front of her had now lost muscle as he aged, his withers and back bone becoming more pronounced.  His rump, once rounded in a happy cobby way, looked like it had sunk in on itself.  Back then Dapper had forced structure into her day, given her a tenuous framework on which to grasp, preventing her from completely drowning in misery.  Dapper had gently taught her that she could face anything that life put in her way.  His solid company gave her companionship when she could not face other people.

It was Dapper that provided Libby with the first small moments when she forgot her troubles and slowly these moments extended to minutes and hours.  Riding him, discovering bridleways and paths that they had not ridden before, finding new views together and holding him back to canter when he was insistent he wanted to gallop, had all helped to stop her intrusive and repetitive thoughts.  When there was a break from the ruminations, the pain in her heart reduced.  Now, as her companion lay with his eyes closed, Libby realised that Dapper was focused on his own pain and it was now he who was shutting out the world.  She felt an overwhelming rush of gratitude for all the times this horse had helped her come through difficulties and anguish.

Libby’s thoughts returned to Mill Farm and that, at the time, she had not realised how much the place had fenced her in, stifled her, until the events of a still, hot summer’s evening.  She had been picking up muck in the paddock, the rhythmic thump of a hay bailer audible from the neighbouring farm.  Dapper and Mel’s large bay gelding cob were stomping about, trying to find a spot with the least flies and Dapper wandered in to the open barn on the far side of the paddock for some shade.  A sudden noise made Libby look up from her muck buckets to see Dapper cornered in the barn with the bay horse repeatedly turning his back to the grey and lashing out with his hind legs.

‘Whoa! Stop! Stop it you!’  Instinctively, Libby started shouting as she ran towards the barn and her raised voice sufficiently startled the bay for him to pause in his assault.  Enough time for Dapper to lunge forward, squeeze past him and out in to the paddock to stand shaking and terrified.  A gash to Dapper’s front leg was bloody, a sticky rivulet livid, first against grey leg and then white sock, as it tricked downwards.  Several lumps were appearing on his chest where other kicks had landed.

This incident in itself had been shocking and upsetting, but it was what had happened after that completely stunned Libby.  Hearing the shouts, Mel had come on the yard as Libby was pulling Dapper out of the paddock, away from the bay and on to hard standing.  As Libby started to clean Dapper’s wound and ran cold water over the swollen areas, she briefly told Mel about what she had witnessed.  Mel was casual and off-hand, insinuating that Libby was making a fuss about nothing.  Libby told her that she did not want Dapper and the bay sharing a paddock together again.

Mel said, ‘Oh, for goodness sake! Stop being so dramatic, you’re over reacting.’

When Libby uncharacteristically persisted, Mel said, ‘We haven’t got the space to rotate the grazing and accommodate everyone’s slightest whim.’

‘I’m sorry but I cannot let Dapper be put in that situation again,’ Libby said, quietly sticking to her guns.

‘I really don’t understand you – it’s not as if he is anything special!’

‘Mel, he may not be anything special, but to me he is very special.’

There and then Libby gave Meg notice that she would be moving Dapper.  She stood firm insisting that, in the mean time, he was not to be put in with the bay.  Within the week Libby had managed to find grazing on a local farm which had no other horses.  That rushed move, so stressful and anxiety provoking, had brought Mike in to her life just when she was adamant that she was not looking for anything else in her life, other than Dapper and work.

Once she moved Dapper,  Libby was without others rely on and solely responsible to get to the farm to see to Dapper twice a day, every day, no matter what she was doing or working.  She had to drag herself out of bed when she was ill, to check, feed and water him, but this responsibility was compensated by the freedom she now had.

Keeping Dapper alone negated the risk of him being beaten up by a field companion but Libby was acutely aware that, as herd animals, horses need companions.  When the farmer asked if his nephew, Mike, could run his elderly ram in the horse’s field she tentatively agreed.  The horse and the appropriately named Willie the ram quickly formed a strong bond and spent their time grazing together or sleeping under the cover of the wide boughed oaks that bordered two sides of their regular field.  On hot, fly-ridden days Willie took to standing under Dapper for shade and to gain the full effect of an accurately flicked tail.

Gradually Libby took responsibility for checking Willie twice a day on her visits to Dapper. She was happy to do this, but when Mike dropped by several times a week Libby assumed he did not trust her minimal knowledge of sheep.  Libby thought little of it, considering it to be mere coincidence, when his visits often coincided with the times when she was at the farm.  When the winter came, with early hard frosts followed by snow, Mike helped her change rugs, put hay put for Dapper and Willie and break the thick ice on the water trough.  She was grateful for his help and for his quiet company on the dark evenings.  Libby told herself that he was being kind and helpful in exchange for her taking care of Willie through the late summer and autumn.  When Mike did not show up for a week she became worried, found herself looking for his dark blue Land Rover, and discovered that she missed his company.

Libby was picking out Dapper’s feet one evening when Mike eventually showed up.  She immediately saw that something was wrong, his tall frame looked gaunt from the weight he had lost, his face taught with worry and his usually clear, sharp blue eyes clouded.  She straightened up, letting the nearside hoof go, and watched over Dapper’s back as Mike walked across the yard towards her.  It was then that Libby realised how little she knew about him.  With a shock she was suddenly aware how selfish she had been.  Having been so taken up her own problems, so closed down to everything and everyone, she had not really, truly seen Mike as a person in his own right.  They had spent time leaning on the old solid wooden field gate many evenings, talking generally about their work, the countryside and wildlife that surrounded them, but Libby had not registered just how much Mike had become a part of her daily routine until he was missing from it.  She had treated him like one of the oak trees, reliable, always there, to give shade and shelter from the elements.

‘Mike?’ she said quietly, as he got close to where she stood.

As they faced each other over Dapper’s broad back, Mike met her concerned gaze and Libby felt that she was looking at him for the first time.  All three, woman, man, and horse, stood seemingly frozen in time.

‘Mike?’ she said, ‘What is it?’

Placing one hand on Dapper’s neck Mike absently ruffled the horse’s mane and the contact with another being seemed to steady, to loosen him.  He told it simply, as if he was reciting someone else’s story. ‘I’ve got two children, girls, Freya is nearly ten and Jen is eleven.  They live….they lived, with my ex in Norfolk.’

Having started, he now seemed unable to stop. ‘I get to see them whenever I can but they are growing up and they want to spend their weekends with friends, not their boring dad.’

Mike took a breath and then said, his voice becoming so quiet that Libby moved forward to hear him, ‘Their mother, Jo, was on her way to a meeting.  There was freezing fog on the motorway, a multiple car pile-up and several people killed. Jo was one of them.’

Both his hands were now resting on Dapper as his voice trailed off, his shoulders sagging.  Libby automatically reached over the horse’s back and took hold of Mike’s hand, knowing that no words, nothing she could say, would make it better.  Without looking up Mike took a grip on Libby’s hand with his own, ‘And now, I need to look after the girls.’ 

Then, taking a deep breath, he told her the rest.  He had been living at Jo’s house in Norfolk to look after and support his children as the arrangements were made to bury their mother.  He was going back to Norfolk that evening and would move to be with them, at least until they had finished the school year.  Clasping Libby’s hand tighter in both of his, he fell silent and they stood, not speaking, hands held over the back of Dapper who now shifted his weight to one back leg, rested the other, and his head drooping, began to doze.

So it had begun, a relationship she had not expected, was not looking for and one that challenged them from the outset as Mike moved hours driving time away to be with his girls.

‘I’ll look after Willie, if you trust me to,’ she had said to him that evening in the yard, half joking, and it was the first time that Mike, albeit briefly, smiled.

The winter turned in to an early but wet spring.  Libby missed Mike more than she could put in to words.  She wanted to share with him the sights and sounds of spring as the weather improved and everything became vivid in so many different shades of green.  The birds began to pair up.  The rooks in the oak trees were busy choosing exactly the right sticks for nest building, then coming each day when she groomed Dapper, waiting until they could hop across the yard and stuff their beaks with his fur and carry it off to line luxury nests.

Mike came back when he could, to check on his house.  At Easter he brought the girls to stay for a week.  He arranged to bring them to the farm to meet Libby, having already told her that Freya and Jen would be moving to live in his home when their school broke up for the summer holidays.  Two pale faced girls, slightly built but tall for their ages, had reluctantly got out of the Land Rover when prompted by Mike.  They stared at their town-shoe shod feet when he introduced them to Libby.

Finding herself at a loss about what to say to these two unhappy children, Libby suggested ‘Come and meet Dapper, my horse?’  They hesitated, then, without meeting her eyes, nodded and so Libby went and slipped Dapper’s head collar on, attached the lead rope and brought him down from the field to tie him up on the yard.  Instinctively Libby fetched his grooming kit and rather than working to engage the girls in conversation she started brushing Dapper.  As she talked to him gently she noticed the girls move a bit closer and, for the first time, begin to take some interest.  Not knowing how to engage with these sad and silent children, Libby thought desperately about how she might get them to come out of their shells.  Having children was not something that she had really contemplated and a relationship with a man who had his own children had definitely not been on her radar.  Until now.  Suddenly, with a strength that completely took her by surprise, she felt an overwhelming need to get this right, to make it all tolerable for these two girls who were so hurt.

Sensing that the harder she worked to get them to talk the less they were likely to do so, Libby decided to use the same approach she would use to try and catch small wily ponies.  Libby busied herself, waiting to see if they would come to her out of curiosity and sensed their attention moving from the floor to Dapper.  Jen took a tentative step, one pace forward, watching what Libby was doing.  Judging her timing, Libby handed Jen a body brush, one that was small enough for her slim hand, and demonstrated how to use it on Dapper’s coat. At first Jen dabbed at the fur but then, watching Libby out of the corner of her eye, she started to copy the smooth strokes.

In time the girls moved with Mike to his house and he and Libby began a slow, gentle, unhurried relationship.  It was not easy; the girls were grieving and needed to acclimatise to a new area, a different school, and to make new friends.  Mike was getting used to being a full time parent to two hurt and challenging adolescent girls.  His focus was on them and Libby got what little was left over.  When Mike and Libby made the decision, after months of discussing it, for her to move in to his house, Jen and Freya had alternated between sullenly ignoring her and shouting and banging doors.  The girls, usually sulky and occasionally hostile, made it clear that they did not want to share their father with anyone.  Once, Jen said to Libby, almost spitting the words, ‘You’re not our mum and you will never be.’

Dapper became Libby’s respite from the tensions at home, he provided her with an escape and time to think.  Libby discovered that managing difficult and challenging behaviour at work was different to being the brunt of it at home.  So, when Jen unexpectedly asked to come to the farm with her one afternoon Libby had to swallow her feelings of irritated disappointment before she said, ‘Of course you can, but put on your jeans and some flat shoes.’

Jen learnt to groom Dapper and soon she was going with Libby twice a day, making herself useful, taking on tasks.  Brushing out the horse’s light, fine tail and mane became her responsibility.  Dapper had never looked so well turned out and he stood stock still for the girl when she tentatively started grooming him.  Jen progressed to tacking Dapper up, making sure that the saddle was sitting in the right place, stretching his legs out to ensure that the girth would not pinch him and that the fur was lying flat under it.  Libby started to leave Jen to groom Dapper, using poo-picking as a valid excuse, when she realised that Jen was having long conversations with the horse.  Jen always seemed to be less reserved, less closed off after spending time with Dapper.

Jen’s birthday, the first without her mum, was difficult.  Libby gave Jen her present the day after, careful to not make a tough day more completed.  The gift of jodhpurs, hard hat and boots were opened, tried on and put to use that afternoon when Jen had her first lesson on Dapper.

Now, sitting in the field, Libby realised that it was not just her memories that were wrapped up with this old, tired out horse.  Those two girls, one now at university and the other about to start her training as a veterinary nurse, had memories too.  Dapper had helped them through their grief and the many transitions they made from town kids to country youngsters.

Libby was jolted out of her memories by the sound of the chain being undone and the field gate opening.  Rachel, her vet of many years, quietly let herself in.  When Libby had phoned, Rachel was calm as always, saying she would be there within the hour.

Now Rachel walked towards them, Libby still sitting on the spring grass, the old horse lying prone and motionless beside her.  The dew was gone, dried by the strengthening June sun. The day was moving on.  Libby could not hold back time as it shifted toward something she struggled to contemplate.  Libby knew this was the end, the end of routines, day in, day out.  The end of the most significant friendship she had for over half her life.

Libby understood the decision was inevitable now; he could not go on.  She knew that Rachel would have put the syringe, the needle and vial of medication in the pocket of her fleece.

Libby wondered how far it was from the gate to where she and Dapper were, how many few precious moments she still had with him, how soon it would be before he would be gone. Libby measured the final moments of Dapper’s life in those forty or so paces that took Rachel to get to them from the gate. 

Libby felt abruptly overwhelmed with a raw grief that hung immense and heavy in her chest, and in her stomach.  She found tears were silently dripping onto the almost white fur which still had a few dapples visible in the dusty coat.

She heard Rachel’s quiet voice,

‘Hello old man. You look like you’ve had enough.’

 

Not discharging service users from service – a disservice?

In the twenty years that I have been a clinical supervisor, delivering both individual and group supervision, one of the most consistent issues brought for discussion, or emerging from the reflective discussions, is that of clinicians’ difficulty in discharging individuals from mental health services.  This is generally a community issue when, either a single clinician is the only practitioner working with a service user, or they are the care coordinator and the last clinician still working with an individual after other members of the multi disciplinary team have discharged the person from their own caseloads.  A recent literature search found many papers that discuss the discharge process from hospital for those with mental health problems, but nothing examining discharge from caseloads, or from services in the community. 

Just in case

One of the most cited reasons in supervision for not discharging from service is the ‘just in case’ position.  Here, the service user is often doing well and has little need for input from services, but the clinician still holds them on their caseload ‘just in case’ there is a change.  Whilst this is done with the best of intentions, it is the antithesis of recovery.  By not discharging when appropriate, an implicit message can be given that the service user is frail and needs support.  The progress that a service user has made, and how hard they have worked, can be devalued with a sense that, ‘whatever you do it will never be good enough’.  Not discharging a service user loses the momentum of hope, of which workers should be the bastion.  The chronic retention of individuals on clinical caseloads, signals to service users that they are always going to need services and that they will never be able to manage totally on their own.  Whilst this might be done with the impression of being service user focused, it hints at clinicians’ needs being put first – to manage their concerns about what might happen if they discharge someone.  

Dependence, the new institutionalisation?

Thirty years ago many of the old psychiatric asylums were still standing and in use and institutionalisation was viewed as a secondary diagnosis, one that was caused by the very services that provided care for those with mental health problems.  Whilst institutionalisation is now less of an issue, dependence upon services, and also on others who provide support, is well recognised.  Dependence upon services is often viewed as something that service users, especially those with particular diagnoses, have deliberately created.  Frequently there is a lack of consideration about how workers and teams may have had a significant role in creating the situation.  When discharged from mental health services, many service users need an appropriate, rapid and easy route back to care.  Often these routes do not exist, or are difficult to navigate, and service users and carers are understandably anxious about being able to access help should it be required in the future.

New ways of working

Holding on to service users is often described by workers as wanting to keep the things the same as they always have been because the ‘old’ ways of working with individuals in the community were the best and these provided the optimum support for service users.  Whilst this might have been the case to a certain degree, it is possible that workers use this way of keeping long term consistent caseloads as a method of managing and controlling their own anxiety about the changes in practice that are being asked of services and those who work in them. 

Many clinicians and service users are nervous or sceptical about care clustering in mental health but one positive aspect of care clusters might be that they will outline care pathways for people to move through mental health services, receiving the care they need and with reviews at appropriate points.  Care clusters give criteria that indicate when discharge should be explored and a return to primary mental health services considered (DoH, Mental Health Care Clustering Booklet).  If clear and responsive access routes back to services are made available, if needed, this could really support recovery for individuals.  Care clustering may help all concerned to be clear about the processes during treatment delivery, discharge from services, re-referral and return, should these be needed.  Care clustering could also enable clinicians to feel confident to discharge people from their caseloads.  

How we feel about those we work with

Reflecting upon and discussing our feelings about those on our caseloads is difficult. Hawkins and Shohet’s (2006) Process Model of supervision supports supervisors to explore with their supervisees their feelings, thoughts about and interventions with those they work with.  A useful question to ask a supervisee is, “Do you like the individual?”  This is often difficult for workers to answer as they can believe they shouldn’t have human responses to those they work with, although feelings are inevitable when we work at deep levels with other human beings.  When co-teaching a clinical supervisors course, with a social work colleague, we explore this tricky issue of asking supervisees how they feel about their service users.  Our students very often recognise that they can hold on to service users longer than they might because they like the individual.  This positive feeling results in workers wanting to protect the service user, and we come back to the ‘just in case’ position.  More concerning is that clinicians might be holding on to service users as they enjoy working with them as they give clinicians a feeling of job satisfaction.  This idea is not a new one as research, now old, by White and Brooker (1990) highlighted that a client group described as the ‘worried well’ were more likely, at the time, to be attractive to work with for Community Psychiatric Nurses as this group of service users provided more job satisfaction for professionals than did those with severe and enduring mental illness.  When this happens clinicians are meeting their own needs, not those of the service user, and this does not align with a recovery approach. 

My co training colleague has an interesting view on how clinicians feel about those they work with.  He proposes that there is a risk that clinicians will retain on their caseloads service users that they don’t like or about whom they don’t feel positive.  Clinicians can believe such feelings of dislike are inconsistent with their role and this dissonance may cause the clinician to retain the service user for longer than necessary and work harder with them to compensate for their feelings.

How we feel about our service users can be a ‘taboo’ subject.  However these emotions are inevitable and normal when we build significant therapeutic relationships with others and use ourselves as the most important tool in our practice.  We walk alongside service users as they have so many experiences, many of them extraordinary.  We are honoured to be confided in, when service users tell us things that they may have never told anyone before and we are often the keepers of these confidences.  Skilful, reflective clinical practice can support recovery, but when there is a lack of self awareness and openness by clinicians it can build unhealthy relationships, and caseloads, creating dependence and loosing the important principles of recovery.

Therefore, it could be suggested that holding on to our service users for too long is a natural temptation for all practitioners, for a variety of very human reasons.  We should not be ashamed of our feelings about those we work with, rather we need to be open, reflective practitioners and confident to seek space to honestly and professionally explore these.  Clinical supervision is one of the essential support mechanisms in which to do this.  If we do not address these issues within ourselves we cannot be working in a recovery focused way and we, at the very least, do our service users a significant disservice.

Originally published in The Approach (Care Programme Approach Association)

With thanks to my co training colleague Keith Noble for some of the ideas explored within this article.

 References

White E. & Brooker C. (1990) The care programme approach. Nursing Times. 87, 12, 66–67.

 Hawkins,P. and Shohet, R. (2006) Supervision in the Helping Professions. 3^rd edition. Berkshire: Open University Press.

Department of Health. Mental Health Care Clustering Booklet 2013/2014.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216217/dh_132656.pdf   (last accessed 27.8.13)

 

A Good Day Teaching In Mental Health

Today was a great day. I was teaching the Care Programme Approach and Clinical Risk to a varied group of mental health professionals. Driving home I thought about what had made the day so good for me. I knew I had been teaching well, that I had remembered everything I needed to include and that I had trained with a passion for the subjects and with a commitment to being a clinician. But more than this the group had responded to me, and the way that I taught, in a very positive way. This made me wonder if, as teachers, we are only as good as the group we are teaching. Yes, as educators we are responsible for creating a positive learning environment with appropriately designed and delivered course content. We need to facilitate learning and when this works well we join with the group to construct together the required knowledge. But, on some days those that we teach are just not up for it, or their anxieties or scepticism block their ability to be truly open to learning. When we have groups like this, we work hard to teach as best we can, to shift negative attitudes and to lift tired spirits. But, no matter what we do as teachers some of the responsibility for the effectiveness of the training session will always be with the students. This is not to blame them, it is just how it is.

Today’s group were responsive, not scared to ask questions and to have a debate. They were genuinely moved when I showed a DVD of service users talking about risk assessment and management and I could see that it would impact on their clinical practice. Today, as a group, we got back to the fundamental reasons that we are clinicians, the real purpose of the Care Programme Approach and risk assessments and risk management – to make a difference to service users.

Today my colleagues allowed me to steer them through their learning, they were open to working with me, and with each other. We created a synergy as a group and this made for great learning. It also made it one of those day when I know I’m in the right job.

Birthday Reflections on a Nursing Career

Today is the occasion of my 49^th birthday and therefore it is a good day to reflect on many things. One of those is that I am nearer to retirement – six years to go as I am one of a dwindling number of colleagues who have mental health officer status, enabling us to retire at 55.

In two and a half weeks time I will have worked consistently, and full time, for 30 years in the NHS as a mental health nurse. This causes me to reflect on the people I have met along the way and from whom I have learnt so many things. Having a birthday right at the end of August meant that I was one of those children who were up to a year younger than their classmates at school. Therefore, I started my nurse training at just 18, it was tough and I very nearly didn’t make it through to the second year. In my final year I met one of my oldest friends, also a student nurse, and now a very skilled Advanced Practitioner in dementia care. One of the most interesting conversations that I had with her recently was about the the idea of recovery for those with dementia. Nearly thirty years on we continue to have wonderful, exciting conversations about nursing and both of us are still passionate about working with those with mental health problems, probably more so now than we were when we first started as nurses.

Learning from others

For much of my career I have watched other clinicians practise and I have consciously taken on the methods and approaches that I like, and disregarded those I don’t agree with or don’t think will work for me. I wonder if this attempting to emulate others is how others have learnt many of their nursing skills, and also I am reminded of the work of Pat Benner (1984) and how it is still applicable today. I have often admired colleagues who can truly listen, who are calm under pressure, able to smooth situations rather than rustle feathers, are respectful of others but still strong in their own values and ideas. These are the people I have taken inspiration from. One of my current role models, has been my clinical supervisor for 5 years and is now about to move posts and organisations. She is probably one of the best clinicians that I have ever come across, and despite being in a very senior position she remains grounded as a nurse. When I come across a difficult situation, am tempted to cut corners or ignore something, I often think about my supervisor and ask myself what she would do. I always come up quickly with an answer, it is never the easiest method of dealing with the issue, but inevitably it is the right one.

I have worked with some amazing people over the years. Some colleagues have had their own mental health problems that they have worked hard to manage. I have witnessed the excruciating difficulties that they have had when they have become unwell, feeling doubly stigmatised; firstly, as people with a mental health problem and secondly, as a workers in mental health and with illnesses themselves.

The service users that I have worked with over the years have probably taught me the most about myself and about being a nurse. I have learnt to listen to them, to really listen. I have learnt to not be afraid of feelings, to be intuitive in asking questions and not to worry if they get upset. I learnt about substance misuse as a new ward manager, not just from the very experienced staff on my ward, but more so from the service users who could not sleep during the long nights of detoxes and spent the time telling me their life stories. As a CPN, I have been honoured to see people in their own homes, for them to open their doors and their hearts to me at such difficult times of their lives. Much of my community work has been in rural areas, and coming from country background myself, I felt most comfortable in this setting. I could understand the difficulties of rural life, the hidden poverty, others in small communities knowing your business and the importance of landscape and animals to health and to illness, but how to nurse in this setting was something I had to learn.

I have been fortunate to have been given so many training and development opportunities by the organisations for which I have worked. I have completed supervision courses, a CPN certificate requiring a year in University with community placements, a THORN course (psychosocial interventions for psychosis), a BSc, PGCHE and most recently an MSc in Advanced Practice. All of this learning has transferred in some way to practice and has allowed me to develop as a practitioner and as a person. Many that have taught me, especially fellow clinicians on the THORN course, have inspired me to undertake teaching myself. These THORN trainers gave knowledge and information freely, with such an altruistic delight in developing others that has become a value that I work to replicate.

In my current teaching role I often work with younger, newer staff, many of whom amaze me with their skilfulness, their kindness and their enthusiasm for the work they do. I see so many young mental health nurses and practitioners from other disciplines who do not realise just how good they are as clinicians. Nursing is having a difficult time at the moment and a bad press, but these young practitioners give me hope for the future of nursing and for mental health care. They will hopefully still going long after I am retired and probably after I have shuffled off this mortal coil.

So, today, as I reflect on my career, as I look back at a 30 year journey and forward for the next six years of my career I want to focus on how I can keep going with the same passion and drive that I have right now – I want to retire with a bang, not a whimper. In the meantime, the one thing that I am clear about is that, I wouldn’t have any other job than being a mental health nurse.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. California: Addison-Wesley.

Photo by Sherria Hind

The Place of Animals in Mental Health Recovery

The following is an article published in the Care Programme Approach Association journal, The Approach. It is reproduced here, with kind permission from the CPAA, in a slightly shorter form.

The Place of Animals in Recovery

Half of UK households own a pet (Reynolds, 2006), therefore many people experiencing mental health problems will have companion animals and their relationships with these are often significant and important.  Owners will each have a different level of attachment to their animals and where several are owned it is likely that the individual will have a different connection with each one (Peacock, Chur-Hanson and Winefield, 2012).  However, mental health services very rarely consider the significance of animals in people’s lives, their role in recovery or how they impact on risks.  Understanding an individual’s relationship and attachment to animals could be a significant element in recovery that is being missed.  Whilst animal assisted therapy for mental health, as well as other health problems, has been fairly well researched, examination of the significance of actual animal ownership and effect on mental health has had little consideration (Walsh, 2009; Peacock, Chur-Hanson and Winefield, 2012).

Owning a companion animal can allow us to have an important relationship, one that is safe, trusting and uncomplicated.  It brings responsibility and a role, as well as an opportunity to focus on another living being.   Animals provide unconditional love and affection which, for those who are isolated and stigmatised due to mental health problems, can be highly important and affirming and can also provide physical contact and reassurance.  For many, companion animals are considered to be a member of the family, may be included in celebrations and given presents (Walsh, 2009).

Mental health workers are required to collate a great deal of information about service users, starting at the first assessment, but individuals’ relationships with their animals are rarely asked about, or considered to be important, therefore they are unlikely to feature in care plans or reviews.  If workers do not understand, or even acknowledge a service user’s animals in assessments, in conversations and in care plans there can be a significant gap in holistic care.  Peacock, Chur-Hanson and Winefield (2012) identified that any psychological assessment should include information about attachment and relationships with animals.  At the very least talking about a person’s animals is a good method of building rapport and engagement, often helping someone to start to talk about them self.

Recovery based care is an important and recognised approach but when services do not consider a person’s animals and their significance, care cannot be truly individualised and recovery focused.  Animals can be helpful in building resilience to mental illness and can provide a routine that supports important coping strategies.  If we are to use a truly holistic approach which considers every aspect of peoples’ lives, their animals should feature.  For many, both those who are experiencing mental health problems, and for those who are not, animals can give meaning to their lives.  Therefore care plans need to take in to account the part played by any animals in service users’ lives.

For many, animals can reduce risks, as they can be protective factors for those who self harm or are suicidal.  The thought of leaving their animal behind has been shown to prevent individuals from harming themselves, can give them a focus (Walsh, 2009) and animals can be a comfort which provide solace and affection.  In these situations a companion animal can offer hope and help a service user develop a belief that they can cope with life and Walsh (2009) identified that animals can support individuals through difficult events and transitions.

For many, animals provide a purpose and a structure to the day by giving them a sense of worth and control over part of their life (Slatter, Lloyd and Kind, 2012).  Those with poor motivation may find that they will get up and out for their animals when they would not do so for themselves.  Routines based around animals can support the development of coping strategies for difficult times.

Where animals provide livelihoods there will be different attachments to them by their owners but these are no less important than those with companion animals.  Farmed animals are often given names (Brown, 2006) and the impact on mental wellbeing for farmers and others when they lose their stock can be profound as demonstrated in the last foot and mouth epidemic, the ongoing tuberculosis infections of cattle and the recent losses of stock in the severe weather of spring 2013.

For some individuals the owning of animals can increase risk.  As circumstances change, due to factors such as illness and reduced finances, owners can become overwhelmed with the care that their animals require.  Physical risks in the form of trips and falls can be a problem with those who are physically infirm; however owners with dogs and who walk them have been shown to be physically fitter (Smith, 2012).  Owning an animal can expose previously unidentified issues.  When they first own an animal the nurturing that it requires can be overwhelming for some individuals due to their own experiences of poor nurturing or neglect by their families.

For some, the thought of being separated from their animals will lead them to delay treatment (Peacock, Chur-Hanson and Winefield, 2012) or prevent them from moving to appropriate accommodation (Morley and Fook, 2005).  This has been the case for older people needing a care setting and also for homeless individuals who will not take up accommodation if their animal is unable to go with them (Slatter, Lloyd and King, 2012).  Concern about one’s home, including pets, has been identified as a factor in absconding from hospital (City University, 2003).

For many owners the loss or death of a companion animal will cause a grief reaction that is often experienced similarly to the death of a loved person (Brown, 2006; Walsh, 2009).  The level of grief experienced will be related to the level of attachment to the animal (Donohue, 2005).  This is normal especially as companion animals are generally considered to be family by owners.  What often causes problems are the responses from others, including health workers, who give trite reassurances such as pointing out that it was only an animal or that another can be obtained.  Responses such as these further compound the individual’s grief and sense of loneliness (Brown, 2006).  Sometimes the death of an animal has a wider significance when it is a last link to a human that they have lost.

Women in abusive relationships have delayed or not left the situation due to either, not being able to take their animals or their children’s animals with them, or due to threats of harm to the animals from the abuser (Krienert ,et al 2012; Allen, Gallagher and Jones, 2006).  The abuse of animals has been identified as a possible indicator for domestic and child abuse (Blewett, 2008) with agencies in some USA states routinely sharing information where animal abuse has been identified (Patronek and HARC, 2001).

The responsibility, time and cost of caring for a companion animal will increase risks for some individuals but will reduce them for others.  Caring for an animal can become overwhelming and can be costly which may result in a service user ‘going without’ to provide for their animal.  For some individuals caring for animals runs out of control, in worst cases producing animal hoarding situations (Williams, B. 2014).  Here numbers of animals are kept in conditions that not only do not meet their needs, but significant cruelty, suffering and death are caused.  The impact on humans in animals hoarding situations is also enormous as children and vulnerable adults can be living in the household.  Animal hoarding situations are often driven by changes in circumstances including physical illness, but it is very likely that there will be comorbid mental health problems (Patronek, Loar and Nathanson, 2006).  Animal hoarding is more common than many think but is often ignored by agencies as it is seen as a ‘lifestyle choice’ (Reinisch, 2008).

It is important to consider if there is an impact on carers when those they support have animals.  Carers can experience an increased burden by having to take responsibility for animals when a service user is unable to do so.  For some this may be something that they are willing and able to do, but services should not just assume that a carer is able to meet the welfare needs of someone else’s animals, including the financial implications.  The role of the care coordinator and good care planning is essential to identify what is the best for a service user, carers and the animals should there be a crisis or if circumstances change.

In the current times of economic austerity some may feel that taking the time to understand and support service users’ relationships with their animals is inappropriate, but if we are to work in a truly recovery based way we need to understand what is important to service users.  Those with mental health problems are stigmatised enough without services ignoring or dismissing an element of their lives, which may be immensely important and helpful to them.

Workers, services and others may believe that those they work with do not have the ability or resources to care for a pet.  As long as the animals’ welfare needs are sufficiently met as required by law (Animal Welfare Act, 2006, see box 1), there is a positive impact for the service user and the responsibility is manageable for them, why would there be a problem?  We can work with service users to ensure they chose appropriate animals for them and their circumstances.  We can care plan with crisis and contingency plans including details of how their animals can help or increase symptoms and risk when they are becoming unwell.  We can also support the drawing up of clear plans for where animals should go should the service user become unwell.

Box     1 An animal’s needs shall be taken to  include; (a)     its need for a suitable environment, (b)     its need for a suitable diet, (c)     its need to be able to exhibit normal behaviour patterns, (d)     any need it has to be housed with, or apart from, other animals, and (e)     its need to be protected from pain, suffering, injury and disease. (The Animal Welfare Act, 2006, section 9)

Mental health workers are already pressured for time and may consider discussing a service user’s animals as a waste of time or unnecessary, however this then misses an opportunity for aiding engagement, for understanding what is really important for the individual and their life. It also can mean that certain risks and protective factors are missed.  Many mental health workers own animals that are hugely important to them, so why should our service users be treated any differently?  For many their relationships to animals are important, life affirming and profound. Recovery approaches cannot be authentic if workers and services chose to ignore this significant aspect of service users’ lives.

In summary, there is a significant part of people’s lives that is often missed by services and if we are to really deliver supportive, meaningful and individualised care we need to consider the role of animals in peoples’ lives.

 References

Allen, M., Gallagher, B. & Jones, B. (2006) Domestic Violence and the Abuse of Pets: Researching the Link and Its Implications in Ireland. Practice. 18,3, 167-181.

Animal Welfare Act (2006) HMSO

http://www.legislation.gov.uk/ukpga/2006/45/contents (Last accessed: April 22 2013).

Blewett, J. (2008) The link between animal cruelty and child protection. Community Care. 1745, 26-27.

Brown, K. (2006) Pastoral concern in relation to psychological stress caused by the death of a companion animal. Mental Health, Religion and Culture. 9, 5, 411-422.

City University Department of Mental Health and Learning Disability (2003) Anti-Absconding self-training package for ward staff. http://www.citypsych.com/index.html

(Last accessed: April 15 2013).

Donohue, D. (2005) Pet Loss: Implications for Social Work Practice. Social Work. 50,2, 187-190.

Krienert, J., Walsh, J. & Mathews, K. et al (2012)  Examining the Nexus Between Domestic Violence and Animal Abuse in a National Sample of Service Providers. Violence and Victims. 27, 2, 280-295.

Morley, C. & Fook, J. (2005) The importance of pet loss and some implications for services. Mortality. 10, 2, 127 -143.

Patronek, G. & HARC (2001) The Problem of Animal Hoarding. Municipal Lawyer. 19, 6-9.

Patronek, G., Loar, L. & Nathanson, J. (Eds) (2006) Animal Hoarding: structuring interdisciplinary responses to help people, animals and communities at risk. http://vet.tufts.edu/hoarding/pubs/AngellReport.pdf (Last accessed February 15 2013).

Peacock, J., Chur-Hansen, A. & Winefield, H. (2012)  Mental Health Implications of Human Attachment to Companion Animals. Journal of Clinical Psychology. 68, 3, 292-303.

Reinisch, A. (2008) Understanding the Human Aspects of Animal Hoarding. The Canadian Veterinary Journal. 49, 12, 1211–1214.

Reynolds, A. (2006) The therapeutic potential of companion animals. Nursing and Residential Care. 8, 11, 504 – 507.

Slatter, J., Lloyd, C. & King, R. (2012) Homelessness and companion animals: more than just a pet. British Journal of Occupational Therapy. 75, 8, 377-383.

Smith, B. (2012) The ‘pet effect’. Health related aspects of companion animal ownership. Australian Family Physician. 41,6, 439-442.

Walsh, F.  (2009) Human-Animal Bonds 1: The Relational Significance of Companion Animals. Family Process. 48,4, 462-480.

Williams, B. (2014) Animal Hoarding: devastating, complex and everyone’s concern. Mental Health Practice. 17, 6, 35-39