Research Supporting Equine Assisted Psychotherapy (EAP) Programs
Background
The incorporation of horses into the therapeutic setting is frequently referred to as equine assisted psychotherapy (EAP) or equine facilitated psychotherapy (EFP). Sessions usually last between 60 to 90 minutes and are facilitated by an accredited mental health professional with equine experience (or an accredited mental health professional working in tandem with an equine professional) (Bachi, Terkel, & Teichman, 2012; Brandt, 2013). Given a horse’s unique characteristics and uncanny ability to reflect human emotion, the use of equines in the treatment of mental illness has grown rapidly in the United States and Europe over the past decade (Bachi et al., 2012; Brandt, 2013). Cantin & Marshall-Lucette (2011, p.52) refer to an increasing body of research suggesting that “people suffering mental health problems, who struggle with more orthodox talking treatments, can be helped by non-verbal interaction with horses.” It seems that horses have an innate ability to ‘read’ people and will respond to an individual’s ‘internal state’ honestly and directly, regardless of that person’s verbal communication (Froug et al., 2010).
Horses are prey animals and, therefore, to ensure their survival they need to be attuned to their environment at all times (Brandt, 2013; Lentini & Knox, 2009). For this reason “horses are excellent at remaining present in the moment and accurately interpreting environmental cues” (Brandt, 2013, p.24). Further, because horses are highly social animals and depend on continuous communication for safety, the process of observing and interacting with horses can provide ample opportunity to foster the development of social and relational skills in people. It seems that a horse can become confused and agitated when there is incongruence between the verbal and non-verbal cues it receives from a person and, in this situation, a horse will instinctively react to the person’s internal emotional state regardless of their outward expression. “While a horse’s feedback is non-judgmental, it is very clear. When a horse feels an emotion, it does not hesitate to express it” (Brandt, 2013, p.24). Humans, on the other hand, tend to control their emotional expressions and will often exhibit incongruence between their verbal and non-verbal communication. This can result in an individual becoming ‘disconnected’ from her/his authentic self which, in turn, can lead to mental illness (Brandt, 2013). Incorporating horses into a therapeutic setting can “create an effective medium through which clients are able to reconnect with their authentic selves” (Brandt, 2013, p.25). A client’s interactions with a horse can also be very informative for the clinician with regards to how the client might behave in other situations.
Given that many ‘at-risk’ individuals will have been exposed to emotional experiences that impact their ability to accept touch, exposure to touch through developing a connection with a horse (through grooming the horse, for example) can also help to heal an individual’s damaged emotional and sensory motor elements (Bachi et al., 2012). Grooming a horse (as well as being in a relaxing rural environment) appears to help promote a willingness on the part of the client to engage in meaningful dialogue with the therapist; something that can be difficult to achieve in an office based setting, particularly with young children (Bachi et al., 2012).
It has also been suggested that developing an ability to control a large and powerful animal can help to provide abuse victims with a sense of authority, validation and accomplishment (Brandt, 2013; Kemp, Signal, Botros, Taylor, & Prentice, 2014; Trotter, Chandler, Goodwin-Bond, & Casey, 2008). It seems that the unique experience of working with such a large animal can assist individuals “to work through fear, develop empathy, cooperate with others, and to develop self-confidence” (Ratliffe & Sanekane, 2009, p.33). It also provides clients (and counsellors) with the opportunity to explore issues related to vulnerability, power and control (Lentini & Knox, 2009).
As summarised in the following section, there have been a number of studies in both Australia and internationally that have demonstrated the efficacy of EAP programmes.
Research Studies
Bachi, Terkel & Teichman (2012)
The study by Bachi et al. (2012) was conducted at a residential treatment facility for ‘at-risk’ adolescents. The study examined the impact of EFP on a treatment group comprising 14 residents matched against a control group of 15 residents who did not receive EFP. The treatment comprised weekly individual EFP sessions over a seven-month period and the results showed a positive change in all four research parameters within the treatment group. Further, the findings one year later showed that 79% of the treatment group had acquired no new police records, while 21% had one new police record. Among the control group 40% of the participants had no new police records, 47% had one new police record and the rest had two or three new records relating to drugs and/or property and/or bodily offenses. In addition, an examination regarding drug use during the following year revealed that among the treatment group 71% of the participants had not used drugs, 21% had used drugs once and 7% had used cannabis twice. In contrast, among the control group only 20% of the participants had not used drugs, 27% had used drugs once, 27% had used them twice and the rest had used cannabis, alcohol and/or other drugs three or four times.
Burgon (2011)
Burgon’s (2011) qualitative study explored the experiences of seven ‘at-risk’ (foster care) young people who participated in a therapeutic horsemanship (TH) program. The participants included five girls and 2 boys and their ages ranged from 11 to 21. Burgon (2011) notes that a number of the participants appeared withdrawn and lacking in confidence when they first entered the program, however, the relationships and experiences the participants had with the horses contributed to them gaining psychosocial benefits such as confidence and self-esteem, which are identified in the risk and resilience literature as ‘protective factors’. By learning that they could monitor and change their own behaviour through demonstrating confident leadership to the horses in order to gain their trust and co-operation, the young people were able to experience a feeling of mastery and of being able to influence ‘something’.
Kemp, Signal, Botros, Taylor & Prentice (2014)
The study by Kemp et al. (2014) evaluated an Equine Facilitated Therapy Program (EFT) run by Phoenix House, a sexual assault referral centre in Queensland, Australia. Participants included six boys and nine girls (aged 8–11) and 15 adolescent girls (aged 12–17). All participants provided several measures of data designed to establish their levels of psychological distress at three points in time. Time 1—intake into the service; Time 2— following approximately six weeks of in-clinic counselling and pre-EFT; and Time 3 post-EFT (9–10 week duration). Significant improvements in functioning were found between Time 2 and Time 3 assessment across all psychometric measures and for both age groups. No, or non-significant, improvements were found between Time 1 and Time 2 assessments. Overall the results show that EFT proved an effective therapeutic approach for the children and adolescents referred to the service.
Klontza, Bivensb, Leinartc & Klontzd (2007)
In this study Klontza et al. (2007) investigated the treatment outcomes for 31 participants in an equine-assisted, experiential therapy program. Participants completed psychological measures prior to treatment, immediately following treatment, and 6 months after treatment. Reported reductions in psychological distress and enhancements in psychological well-being were significant immediately following treatment and were stable 6-months after treatment.
Nurenberg et al. (2015)
Nurenberg et al.’s (2015) study included 90 patients with recent in-hospital violent behaviour or highly regressed behaviour. Participants were randomly selected to receive ten weekly group therapy sessions of standardized equine-assisted psychotherapy (EAP), canine-assisted psychotherapy (CAP), enhanced social skills psychotherapy, or regular hospital care. Using independently reported clinical incident reports and staff observations showed that (unlike the other interventions) EAP was associated with a significant reduction in violence for at least several months after treatment initiation.
Pendry & Roeter (2013)
Pendry & Roeter (2013) conducted a randomized controlled trial to determine if an 11-week equine facilitated learning program enhanced 5th-8th grade children’s social competence. The researchers randomly assigned 64 physically and mentally able children to either an experimental group or a control group. Children in the experimental group participated in an 11-week equine facilitated learning program designed to increase social competence through a series of once-weekly, 90-minute sessions of individual, team, and group-focused equine facilitated activities. Parents of both groups provided ratings of their child’s social competence at the beginning and end of the 11-week program. The results indicated that the equine facilitated learning program had a significant positive effect on the experimental group in terms of various aspects of social competence, including improvements in children’s self-awareness, self-management, personal responsibility, decision making, goal directed behaviour, and relationship skills.
Pendry, Smith & Roeter (2014)
Pendry, Smith, & Roeter (2014) conducted a randomized trial to determine the effects of an 11-week equine facilitated learning program on the activity of the Hypothalamic Pituitary Adrenal (HPA) axis of fifth through eighth graders through salivary cortisol levels. Children referred by school counsellors were randomly assigned to either an experimental (N = 53) or control group (N = 60). Six samples of salivary cortisol were collected in the participants’ own home over two consecutive days at pre-test, and another set of six samples were collected at post-test in both groups of children. Children in the experimental group who participated in a series of once-weekly, 90-minute sessions of equine facilitated activities were found to have lower afternoon cortisol levels and lower total cortisol concentration per waking hour at post-test, compared to children in the control group. Given the evidence suggesting that lower basal cortisol levels in a relatively normal adolescent sample may constitute a protective influence against the development of psychopathology and health problems in certain populations, the findings from this study indicate that equine facilitated learning programmes may be an effective approach to support a positive development in adolescence.
Schultz, Remick-Barlow & Robbins (2007)
The purpose of the study conducted by Schultz et al. (2007) was to test the efficacy of EAP on a group of children (ranging in age from 4 to 16 years) referred to a psychotherapist for various childhood behavioural and mental health issues. Over an 18-month period sixty-three children received a mean number of 19 EAP sessions. Scores on the Children’s Global Assessment of Functioning (GAF) Scale were determined pre- and post-treatment. The mean pre-treatment score was 54.1 compared to a post treatment score of 61.7; indicating a significant increase in GAF scores. Further, there was a statistically significant correlation between the percentage improvement in the GAF scores and: the number of sessions given; the child’s age (the greatest improvement occurred in the youngest of the subjects); and children who had a history of physical abuse and neglect.
Signal, Taylor, Botros, Prentice, & Lazarus (2013)
Signal, et al. (2013) examined the efficacy of an Equine Facilitated Therapy (EFT) program run by Phoenix House (a sexual assault referral centre in Queensland, Australia) in reducing depressive symptoms across three age cohorts of victims of child sexual abuse. Participants included 15 children (aged 8-11 years), 15 adolescents (aged 12-17 years) and 14 adults (aged 19-50 years). A quasi-experimental, repeated measures design was used to evaluate changes in the participants’ depressive symptoms using the Child Depression Index or the Beck Depression Inventory (as appropriate) at three points in time. A comparison of scores between Time 1 (intake to service) and Time 2 (post in-clinic counselling) and Time 2 and Time 3 (post-EFT program) indicated that regardless of age (or ethnicity) EAT proved to result in a greater decrement in depressive scores than in-clinic counselling.
Trotter, Chandler, Goodwin-Bond & Casey (2008)
In this study, Trotter et al. (2008) demonstrate the efficacy of an Equine Assisted Counselling (EAC) programme in comparison to an award winning school-based counselling program called Kids Connection (KC). A total of 164 grade 3 to grade 8 students that were identified by their school counsellors as ‘at-risk’ were invited to participate in either the EAC or KC programme over a 12-week period. The findings indicated that the EAC participants achieved significant improvement in 17 behaviour areas, while the KC participants showed improvement in only 5 areas.
Conclusions
As noted by Shirley (2015), children who experience conduct, developmental or learning difficulties are ‘at risk’ of developing serious emotional disorders during adolescence which, if not regulated and controlled can, in turn, result in serious mental health issues during adulthood. Based on the evidence provided in a variety of studies it seems reasonable to conclude that combining the natural affinity that exists between humans and horses with traditional psychotherapy techniques can help to enhance the healing process in individuals challenged by emotional and mental health conditions in a way that is truly unique to EAP (Bachi et al., 2012; Brandt, 2013). EAP has been found to be more effective than traditional interventions in enhancing self-esteem, trust, relationships, interpersonal effectiveness and overall feelings of well-being in clients. Further, “EFP has been found to significantly decrease psychological symptoms in individuals with trauma or abuse, eating disorders, depression, anxiety, attention deficit disorder, or autism spectrum disorder” (Brandt, 2013, p.24). It seems that when a trained clinician works in an EAP setting “the therapeutic work can move from a narrow use of cognitive-behavioral techniques, here-and-now therapies, and limited stages of personality development to a more complete psychotherapeutic experience” (Karol, 2007, p.78). The horse can help enhance a client’s self-esteem through a sense of mastery and can also act as a catalyst for the development of trust between client and therapist. Indeed, the “joy the child or adolescent experiences in being with the horse can help him or her attend and participate fully in the therapy even when facing the most painful of therapeutic issues” (Karol, 2007, p.88).
EAP sessions can provide a range of enjoyable activities that allow clients to develop social skills, coping resources and distress tolerance which, in turn, can help to foster long-term change and relapse prevention (Brandt, 2013). Due to their willingness to express emotion, incorporating horses into a therapeutic setting creates an effective medium through which clients are able to reconnect with their authentic selves. This can be seen from the moment an individual comes into contact with a horse. People frequently are drawn to a horse that reflects their personality, often feeling an immediate connection with horses that resonate with their core issues (Rothe et al., 2005). “Being in the presence of horses, and in relationship with horses, provides opportunities for humans to reflect on their relational impact, stretch into different styles of contact, build self and relational awareness, and, feel into their body, energy and feelings as information for strengthening self regulation, choice and responsibility” (Kirby, 2010, p.62).
Bachi et al. (2012) also suggest that when clients travel to a rural setting they can hide the fact that they are attending therapy and this is particularly important when dealing with adolescents who are facing identity formation and object to being labelled as ‘patients’. It seems that EAP “provides a safe and secure environment that nurtures inner healing and encourages optimal growth and development” (Trotter et al., 2008, p.255). In summary, it appears that the “equine-human bond, in tandem with the client-therapist relationship, allows for the processing of painful emotions and experiences while simultaneously developing intimacy, identity, and partnership” (Brandt, 2013, p.24) and, further, the greater the number of sessions the greater the benefit (Schultz, Remick-Barlow, & Robbins, 2007).
References
Bachi, K., Terkel, J., & Teichman, M. 2012. Equine-facilitated Psychotherapy for At-risk Adolescents: The Influence on Self-image, Self-control and Trust. Clinical Child Psychology and Psychiatry, 17(2): 298-312.
Brandt, C. 2013. Equine-Facilitated Psychotherapy as a Complementary Treatment Intervention. The Practitioner Scholar: Journal of Counseling and Professional Psychology, 2(1): 23-42.
Burgon, H. L. 2011. 'Queen of the World': Experiences of 'At-Risk' Young People Participating in Equine-Assisted Learning/Therapy. Journal of Social Work Practice, 25(2): 165-183.
Cantin, A., & Marshall-Lucette, S. 2011. Examining the Literature on the Efficacy of Equine Assisted Therapy for People with Mental Health and Behavioural Disorders. Mental Health and Learning Disabilities Research and Practice, 8(1): 51-61.
Froug, R., Baughman, D., Bennett, T., Renee-Smith, R., Merrill, S., & Farrington, T. 2010. The Effects of Equine Assisted Psychotherapy on Anxiety and Depression in the Chronically Mentally Ill. NADD Bulletin, 10(1).
Karol, J. 2007. Applying a Traditional Individual Psychotherapy Model to Equine-facilitated Psychotherapy (EFP): Theory and Method. Clinical Child Psychology and Psychiatry, 12(1): 77-90.
Kemp, K., Signal, T., Botros, H., Taylor, N., & Prentice, K. 2014. Equine Facilitated Therapy with Children and Adolescents Who Have Been Sexually Abused: A Program Evaluation Study. Journal of Child and Family Studies, 23(3): 558-566.
Kirby, M. 2010. Gestalt Equine Psychotherapy. Gestalt Journal of Australia and New Zealand, 6(2): 60-68.
Klontza, B. T., Bivensb, A., Leinartc, D., & Klontzd, T. 2007. Th e Effectiveness of Equine-Assisted Experiential Therapy: Results of an Open Clinical Trial. Society and Animals, 15(3): 257-267.
Lentini, J. A., & Knox, M. 2009. A Qualitative and Quantitative Review of Equine Facilitated Psychotherapy (EFP) with Children and Adolescents. The Open Complementary Medicine Journal, 1(1): 51-57.
Nurenberg, J. R., Schleifer, S. J., Shaffer, T. M., Yellin, M., Desai, P. J., Amin, R., Bouchard, A., & Montalvo, C. 2015. Animal-Assisted Therapy With Chronic Psychiatric Inpatients: Equine-Assisted Psychotherapy and Aggressive Behavior. Psychiatric Services, 66(1): 80-86.
Pendry, P., & Roeter, S. 2013. Experimental Trial Demonstrates Positive Effects of Equine Facilitated Learning on Child Social Competence. Human-Animal Interaction Bulletin, 1(1): 1-19.
Pendry, P., Smith, A. N., & Roeter, S. M. 2014. Randomized Trial Examines Effects of Equine Facilitated Learning on Adolescents' Basal Cortisol Levels. Human-Animal Interaction Bulletin, 2(1): 80-95.
Ratliffe, K. T., & Sanekane, C. 2009. Equine-assisted Therapies: Complementary Medicine or Not? Australian Journal of Outdoor Education, 13(2): 33-43.
Schultz, P. N., Remick-Barlow, G. A., & Robbins, L. 2007. Equine-assisted Psychotherapy: A Mental Health Promotion/Intervention Modality for Children Who Have Experienced Intra-family Violence. Health and Social Care in the Community, 15(3): 265-271.
Shirley, L. 2015. Horses for Hope: Evidence Base. Prepared for UnitingCare Cutting Edge by Lyn Shirley UnitingCare West.
Signal, T., Taylor, N., Botros, H., Prentice, K., & Lazarus, K. 2013. Whispering to Horses: Childhood Sexual Abuse, Depression and the Efficacy of Equine Facilitated Therapy. Sexual Abuse in Australia and New Zealand, 5(1): 24-32.
Trotter, K. S., Chandler, C. K., Goodwin-Bond, D., & Casey, J. 2008. A Comparative Study of the Efficacy of Group Equine Assisted Counseling With At- Risk Children and Adolescents. Journal of Creativity in Mental Health and Social Care in the Community, 3(3): 254-284.
Additional Readings
Frewin, K., & Gardiner, B. 2005. New Age or Old Sage? A Review of Equine Assisted Psychotherapy. The Australian Journal of Counselling Psychology, 6(1): 13-17.
Masini, A. 2010. Equine-Assisted Psychotherapy in Clinical Practice. Journal of Psychosocial Nursing and Mental Health Services, 48(10): 30-34.
Selby, A. 2009. A Systematic Review of the Effects of Psychotherapy Involving Equines. Dissertation, Master of Science in Social Work, University of Texas at Arlington, Arlington.
Trotter, K. D. 2006. The Efficacy of Equine Assisted Group Counseling With At-Risk Children and Adolescents. Doctor of Philosophy, University of North Texas, Texas.