NADD Bulletin Volume X Number 1 Article 3

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The Effects of Equine Assisted Psychotherapy on Anxiety and Depression in the Chronically Mentally Ill

Robert Froug, M.A., Deanna Baughman, M.A.,
Tricia Bennett, MSW, Rose Renee-Smith, MSW, Sarah Merrill, B.S. and Tom Farrington, MSW

Equine Assisted Psychotherapy (EAP) is a novel therapeutic intervention that shows promise as an adjunct mental health therapy. To date, no empirical research supporting this modality exists. “Incorporating animals into clinical settings represents a dynamic alternative for mental health providers involved in the treatment of [clients], whether in individual or group therapy, in both outpatient and institutional settings” (MacDonald, P.M., 2004).  Fredrickson and DePrekel (2004) suggest that in order to provide effective mental health treatment for individuals with developmental disabilities who also have been diagnosed with mental illness, experiential interventions are needed that address both the developmental difficulties as well as the specific behaviors that disrupt their lives.  Some see the animal, especially the horse, as a therapeutic tool that can facilitate this task (Iannuzzi & Rowan, 1991).  The horse can even be experienced as a colleague who can mirror the client’s experiences; thus, their recent use in a variety of settings such as hospitals, nursing homes, and schools (Rector, 2001). 

Horses are particularly useful for this type of experiential therapy as they are prey animals and are thus extremely sensitive to their environments. Leimer (1997) believes that where horses are honest and respond to situations directly, humans constantly change the rules and verbally communicate in a confusing manner.  Due to the horse’s innate ability to “read” people and respond to a person’s internal state, regardless of the person’s verbal communication, these companions react to a person’s cues honestly and directly (Roberts, et al., 2004).  This honest reaction from the person’s companion provides them with an opportunity to grow and develop appropriate non-verbal cues and responses (Taylor, 2001).  It also provides a canvas for encouragement from the therapist, and a canvas for the individual to work through any social issues that may prevent them from living a more fulfilling life.

Equine Assisted Psychotherapy, or EAP, refers to a “powerful, illustrative therapy modality that cultivates relationship between people and horse(s) and helps individuals gain self-awareness and bring self-acceptance to parts of themselves that have been denied or repressed (Tramutt, 2003). This type of therapy provides an intervention such as Fredrickson and DePrekel suggest is crucial to providing quality care for clients.  EAP combines the skills of the person the horse, the equine specialist and the psychotherapist to provide the individual with a fully comprehensive experiential opportunity for growth. Individuals learn about themselves and others by participating in activities with the horses, and then by processing emotions, behaviors and symptoms that exhibit themselves during the session.

Many of the clients with whom EAP is helpful also have histories of both physical and emotional abuse.  Often histories of this nature result in the development of substance abuse disorders, mood disorders, borderline personality disorder, and anxiety disorders.  The estimated lifetime prevalence of PTSD among adult Americans is 7.8%, with women (10.4%) twice as likely as men (5%) to have PTSD at some point in their lives (The National Comorbidity Survey Report, 2005). One of the central goals of psychotherapy with this population is to provide a supportive relationship for the victim of these types of abuse.  Herman (1997) suggests recovery can only take place within the context of relationships; it cannot occur in isolation. Research suggests that an easy inter-connectedness exists between abused clients and animals that may not develop as easily or fully with a human therapist (Barker, 1997).  Thus, working with horses through EAP can provide not only an experiential way for people to engage in psychotherapy, but a connected and responsive relationship for the individual as well.

Already, studies have shown how “animals have found a place in various therapeutic situations;” however, much more research is needed on the exact effects of this type of therapy on specific symptoms (Mallon, 1992, pp. 53-54).  Thus, this study focused on EAP’s specific effects on depression, anxiety, social behaviors, and goal attainment. Further, the authors attempt to provide quantitative data that empirically supports EAP.

Method

Subjects

 Thirty seven participants were randomly selected from the Aurora Mental Health Center’s Developmentally Disabled with Mental Illness and Community Living Program. During a community meeting the interested parties were asked to volunteer to participate in this study.  Fourteen individuals who volunteered were randomly assigned into a treatment and control group. The participants varied in age from 18 to 55 years old.  All of the participants’ diagnoses varied; however, nine participants were developmentally disabled and had at least one diagnosed mental illness. Eight participants were assigned to a control group and six to an experimental group. 

EAP Participants Diagnosis Control Group Participants Diagnosis

Mood Disorder secondary to general medical condition Bipolar Disorder, Borderline Personality Disorder

PTSD, Substance-Induced Mood Disorder,

Borderline Intellectual Functioning Schizoaffective Disorder

Schizoaffective Disorder Schizoaffective Disorder

Cyclothymia, Panic Disorder, Psychosis NOS Obsessive Compulsive Disorder

Chronic Paranoid Schizophrenia, Pervasive Developmental Disorder Schizoaffective Disorder

Major Depressive Disorder Recurrent Type Generalized Anxiety Disorder

 Schizoaffective Disorder Bipolar Type

 Schizophrenia

 

Both groups continued to receive their regularly attended therapies at Aurora Mental Health Center.  In addition to these therapies, the experimental group received weekly, hour-long, equine assisted psychotherapy (EAP) sessions at Praying Hands Ranches.  Praying Hands Ranches is a non-profit organization that has been providing animal assisted therapy to handicapped children for 19 years.

Instruments

 The Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) were used to determine the participants’ level of depression and anxiety during the course of the study.  For the experimental group, five different horses were used during the weekly EAP sessions.  The arena was divided into two separate fenced off areas allowing two sessions to take place at once.  The participant, their horse, a horse professional, a data recorder, and one of two EAP specialists, Stephanie Brown or Paula Quillen, were all present on the participants’ designated side of the arena at all times.  Materials such as a halter and lead rope, brushes, saddle blanket and saddle, orange construction cones, and a multitude of toys were present for various activities.  The Baughman Behavioral Chart (BBC) was used to rate the occurrence of socially appropriate behavior as well as the occurrence of problem solving and goal attainment abilities.

Procedure

 At the beginning of the sixteen week study, each participant was administered the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) by their mental health therapist at Aurora Mental Health Center (AUMHC).  These two inventories were then administered every four weeks and at the conclusion of the study.   Each EAP session lasted approximately thirty minutes, and two sessions occurred at once in the Praying Hands Ranches arena; thus, the total time spent at the barn for all the subjects in the experimental group was approximately 2 hours, including transition time between sessions.  The order in which the participants attended their sessions rotated each week so that everyone experienced the first, middle and last session time slot.  While participants were not attending their session, they were seated in an upstairs room and had the option of either watching a provided movie, or simply engaging in their own quiet activity. 

 During each EAP session, a data recorder used the BBC to measure socially appropriate responses, attained directives, problem solving accomplishments, as well as anxiety revealing behaviors.  Two data recorders were used, one for each participant during each session, and the data recorders practiced recording internally consistent results before the study began.  The data recorders recorded for the same participant each week, and remained as quiet and non-intrusive as possible during the sessions. The observer counted the number of positive and negative responses for each of the categories on the scale. Each session was broken down into ten minute intervals for recording purposes.

 The BBC was designed specifically for this study and has not been normed or empirically validated. The scale provides a means to organize behavioral data that each observer consistently scores across all participants.

 For the sixteen week study there was a different lesson plan for each week (SEE ATTACHED) developed specifically for this project.  All the participants’ weekly sessions had the same basic lesson plan, and directives to be accomplished.  The main differences between individual sessions were the responses and behaviors from the participants.  Due to different responses and the individual backgrounds and histories of the participants, the support provided and issues addressed by the EAP therapist may have differed between participants, however; the scripts and agenda provided by the equine professional were the same for each session. The participants were unable to observe the other participants during their therapeutic session in the arena.

 An example of a therapeutic session brought the subject into the arena wearing a protective helmet. After entering the stall, haltering the horse, receiving safety instructions and proceeding to the arena, the subject was instructed about the session. The session lasted forty-five minutes and was facilitated by an equine professional who monitored the horse for safety issues. The clinical mental health professional processed emotional issues brought up by the subject. After the session, the subject returned the horse to its stall and proceeded to a secure area of the building where they could not observe other participants during their session.

 At the completion of all six sessions on a given day, all of the experimental participants were invited to return to the stalls of their horses and present their horse with a treat, by placing it in the horse’s food bucket.  After all participants had presented a treat to their horse, they returned to the bus to travel back to AUMHC.

Results

Beck Depression Inventory and Beck Anxiety Inventory

 The results of the BDI and BAI were consistent with the observations made by recorders and therapists during the study.  Table 2, summarizes the results of the BDI, and Table 3 summarizes the results of the BAI.  Four out of six participants’ scores decreased by the end of the sixteen sessions.  It was the same two participants who did not show a decrease on either their BDI or BAI scores.  These participants’ scores did not decrease at week sixteen, but they did show a decrease during weeks eight through twelve.  By week sixteen their scores had increased to their original level. 

Two clients in particular stood out for their impressive decrease of scores on both the BDI and BAI.  One of these client’s scores decreased by 13 points on the BDI, and the other’s score decreased by 13 points on the BAI.  By the end of the sixteen week treatment, both of these clients were presenting with minimal depression and anxiety.  One participant in the experimental group was unfortunately absent for the fourth BDI, BAI administration; however, before his absence, his BAI scores had shown increasing improvement.

Baughman Behavior Chart

 Each index on the BBC increased or decreased in a manner that would indicate a positive effect on the participant’s well-being.  The two most dramatic results were found in the occurrence of unaccomplished directives and self-defeating verbalizations.  Both of these indices decreased for the first seven weeks, spiked briefly at week eight which will be discussed later, and returned to the same low score until the last week of the treatment.  During weeks three through seven, and nine through thirteen, these scores for both of these indices were down to almost zero.  Table 4 illustrates the decrease in unaccomplished directives, and Table 5 shows the decrease in self-defeating verbalizations.  The same two participants, who decreased to extremely low scores on the BDI and BAI, were the same participants who seemed to improve on the BBC indices.

Qualitative Observations

 All observers, including mental health therapists, recorders, and EAP specialists noted significant improvement in several of the participants, and their BDI, BAI, and BBC scores correlate with these observations.  Paula Quillen noted that “the self esteem that emerged [in the participants] from the project was all that we could hope for&ldots;” and they now have “a foundation that they can grow with.”  This noted increase in self esteem, problem solving ability and a reduction in negative social interactions were the most profound changes observed.  Stefanie Brown noted that “although every client worked on the same task each week, every new task brought up individual issues for each individual client.”  These issues would not be as easily identified or worked on in more traditional therapy settings.

 One of the most significant changes noted was in a client, K.  Initially, K arrived at the barn with her head low, staring at the floor and a scuffle and dragging of her feet as she walked.  K was also extremely hesitant to speak, stand up for herself, and her hands consistently shook from anxiety.  As the weeks progressed, K became more verbal, began to laugh and tease with her instructors and therapists, and began walking upright with confidence.  By the end of the sixteen weeks, K was readily interacting in conversations with others, and had completely lost her scuffle when she walked.  One of the therapists would continually refer to K’s horse by the wrong name throughout treatment.  During the last five sessions, K was standing up for her horse by continually correcting her therapist.  K’s BDI, BAI, and BBC results corresponded to the observations made by therapists and recorders as her anxiety and depression had decreased remarkably and her accomplished problem solving increased.

Discussion

        Analysis of observations and qualitative data suggest that EAP may be a promising form of therapy for selected clients.  This pilot study enabled researchers to identify which aspects of this intervention appear promising and what needs to be explored in the future. Observational data indicated significant improvement in several participants. Scores on the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the Baughman Behavioral Chart (BBC) provided researchers with ideas regarding changes to be made to the intervention, as well as hypotheses that may explain why certain scores changed at certain points during treatment.

 There were several issues that became apparent as data and observations were collected: the spike in scores at week eight suggested the need for a category for appropriate boundary setting; more participants; another experimental group, and a formal method of obtaining qualitative records from therapists and observers.

           The first problem was the spike in all scores for week eight.  Data analysis suggested that the lesson plan for week eight had raised anxiety, depression levels, and negative social interaction.  This was a challenging lesson, and one that brought up many important issues for clients.  Analysis and discussion suggested a more gradual approach to this work should be utilized in the future.  The other spike in scores that should be acknowledged is during week sixteen when participants were terminating with their horses.  Information obtained from the BBC, suggested ways to arrange lessons plans for future administration, as well as indicating that during the last week of treatment observation scores may increase to nearly initial levels. 

 The second issue that was noticed was the lack of a measurement for boundary setting.  Many of the tasks during treatment involved setting boundaries or limits with the horse and others in the participant’s life. Data analysis suggested that it is important to teach participants how to set boundaries with care-givers, family members and friends.   There is currently no section to record this behavior on the BBC which is illustrated in Table 1.  Thus, it became apparent that this section would need to be added for future research. 

 Another consideration for future research is the number of study participants.  Due to the low number of participants during this sixteen week session, the results of quantitative analysis were not statistically significant.  It is suggested that another experimental group be added to the study to increase statistical power.  This would also help to determine whether simply taking a field trip away from Aurora Mental Health Center influenced the participant’s measurements on the different indices.  It could be possible that the act of taking a special trip, and not the EAP, could be responsible for some of the improvements observed.

 Lastly, a method of obtaining observational data from therapists, Equine specialists and from the participants should be developed.  A simple comment from each person could be collected at the end of each session, or a progress note for each participant could be filled out by each therapist and Equine Specialist. 

Overall, the participants in the EAP treatment improved on all measures by week eight, but because of the spike in scores due to a difficult lesson plan for that week, the improvement was not consistent throughout the sixteen week treatment.  Although scores improved almost immediately after week eight’s session, they spiked again during the last session.  This increase in depression and anxiety was understood by the researchers to be the result of  separation from the participants’ animal companion. With the suggested changes to the procedures of the pilot study, a follow-up study should proceed more smoothly and yield more significant results.

References:

Barker, S. (1999). Therapeutic aspects of the human-companion animal interaction. Psychiatric Times, February, 45-46.

 

Fredrickson, M., & DePrekel, M.  (2004)  Animal-assisted therapy for at-risk youth and families.  Paper presented at the Can Animals Help Humans Heal?  Animal-Assisted Interventions in Adolescent Mental Health conference, Philadephia, March.  [On-Line].  Available:  http://www.vet.upenn.edu/research/centers/cias/pdf/Proceedings.pdf

 

Herman, Judith (1997). Trauma and Recovery (p.133). New York, NY: Basic Books.

 

Iannuzzi, D., & Rowan, A. (1991). Ethical issues in animal-assisted therapy programs.  Anthrozoos, IV (3), 154-163.

 

Kessler, Robert C., et al., Posttraumatic Stress Disorder in the National Comorbidity Survey Archives of General Psychiatry, 52(12), 1048-1060 (December 1995)

 

Leimer, G. (1997). Indication of remedial vaulting for anorexia nervosa.  In B.T. Engel (Ed.), Rehabilitation with the aid of a horse: A collection of studies (pp. 35-54). Durango, CO: Barbara Engel Therapy Services.

 

MacDonald, P.M., Williams, J.J., Johnson, A.L., & Bowers, M.J.  (2002).  The effectiveness of an equine experiential learning program with at-risk youth: Quantitative and qualitative evidence.  Poster session presented at the annual meeting of the North American Riding for the Handicapped Association, Bloomington, MN.

 

Mallon, G.P. (1992). Utilization of animals as therapeutic adjuncts with children and young youth: A review of the literature. Child & Youth Care Forum, 21 (1), 53-67.

 

Rector, B.K. (2001). The handbook of equine experiential learning: Through the lens of adventures in awareness.

 

Roberts, F., Bradberry, J., & Williams, C.  (2004).  Equine-facilitated psychotherapy benefits students and children.  Holistic Nursing Practice.  18 (1): 32-35.

 

Taylor, S. (2001).  Equine Facilitated Psychotherapy: An emerging Field.  A major paper submitted to the faculty of the program in Clinical Psychology of Saint Michael’s College in partial fulfillment of the requirements for the degree of Master of Arts.  Winooski Park, Cochester, VT.

 

Tramutt, J. (2003). Opening the gate: Cultivating self awareness and self acceptance through equine-facilitated psychotherapy.  A master’s paper submitted in partial fulfillment of the requirements for the degree of Master of Arts Transpersonal Counseling Psychology department Naropa University.