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When patients are not amenable to usual therapy, equine-assisted psychotherapy (EAP) might be a good option. In this podcast, we’ll talk about working with horses as an alternative to, or in conjunction with, traditional therapy.

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Published On: 05/16/2022

Duration: 12 minutes, 38 seconds

Referenced Article: “Using Equine-Assisted Psychotherapy,” The Carlat Child Psychiatry Report, October/November/December 2021

Joshua Feder, MD, and Mara Goverman, LCSW, have disclosed no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Transcript: 

Dr. Feder: Research on equine-assisted psychotherapy has a long history for a number of conditions, including autism spectrum disorders (ASD), PTSD or other trauma, and anxiety disorders. While many of the studies are small and may be limited by inclusion bias, the research is nonetheless promising.

Welcome to The Carlat Psychiatry Podcast.

This is another episode from the child psychiatry team. 

I’m Dr. Josh Feder, The Editor-in-Chief of The Carlat Child Psychiatry Report and co-author of The Child Medication Fact Book for Psychiatric Practice and the brand-new book, Prescribing Psychotropics.

Mara: And I’m Mara Goverman, a Licensed Clinical Social Worker in Southern California with a private practice. 

Dr. Feder: We have some exciting news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.

Mara: When patients are not amenable to usual therapy, equine-assisted psychotherapy might be a good option. In this podcast, we’ll talk about working with horses as an alternative to, or in conjunction with, traditional therapy.

Dr. Feder: As human practitioners, we can have trouble accurately attuning to our clients’ emotional states. Horses are highly attuned to nonverbal cues, emotional tones, and the autonomic state of others. As a prey species, horses have exquisite hearing and smell, with near 360-degree vision—all of which evolved for safety and for connection to the herd—and they’ll naturally pick up on dysregulating states in other animals, including humans. 

Mara: For example, if a child is upset, angry, or tense while attempting to engage with a horse, the animal will most likely react by trotting away. Once the patient is calmer, the horse is able to read the situation, settle down, and reapproach.

Dr. Feder: This is good modeling for children who have trouble regulating their emotions. Clients, especially those who have been hurt by or are reluctant to engage with others, often tell us that they find it easier to trust a horse than another person.

Mara: Horses can perceive the heartbeat and breathing rate of other animals many feet away. This type of attunement supports nonverbal, emotion-mirroring communication. For example, as the connection between horse and person deepens, the horse’s cardiac rhythms synchronize with the person’s. During EAP, the therapist will often have patients feel the horse’s flank to attune their more rapid breath with the horse’s slower breath—which naturally leads into relaxation breathing.

Mara: So, what does equine-assisted psychotherapy look like in practice?

Dr. Feder: Sessions can be individual, family, or group based and sessions are usually conducted with the patient on the ground, although the Professional Association of Therapeutic Horsemanship incorporates therapeutic riding. After initial assessment, the patient has an interactive session with the horse. The therapist might ask the patient, “What would you like to do with the horse?” or “How would you like to connect?” and work with their responses. For instance, if the horse is standing and will not move, the therapist can ask the patient what they think this means, ask “Is the horse angry?” or wonder if the patient has ever been similarly “stuck.” If the patient is grooming the horse, the therapist can use that opportunity to ask about self-care.

Mara: There are also semi-structured therapeutic EAP activities. One activity involves asking the patient to write a different challenge—eg, “managing anger” or “letting go of troubling voices”—on each of four cards, placing one card near each of the horse’s legs. The therapist then talks about each problem while asking the patient to pick up the horse’s corresponding hoof, knowing that the horse initially may not allow the patient to do so. However, as the patient talks, the patient works on emotions and relaxes, and the horse can pick up on this shift and will likely then allow the patient to lift the hoof.

Dr. Feder: In guided imagery, patients imagine that the horse wants to talk or communicate something positive. They paint that message, in words or pictures, on the side of the horse using washable paints. For example, patients may paint the words “I am not broken” or “I am enough,” or create pictures of the sun, a river, or a family.

Mara: Patients might write letters to the horse, with prompts such as “What do I want to remember about you?” or “What have I learned from you?” Patients read the letters, substituting their own name for the horse’s name. This projection usually prompts supportive insights for the patient. For children who have difficulty working with metaphor, or ideas outside of the present moment, the therapist can choose more developmentally appropriate exercises.

Dr. Feder: And, after each session, the therapist debriefs with the patient and may assign homework like journaling, art activities, or practicing a skill they learned during the session, such as checking their assumptions or asking for help.

Mara: Which psychiatric conditions have been shown to benefit from equine-assisted psychotherapy?

Dr. Feder: Equine-assisted psychotherapy can help in many disorders, including autism spectrum disorder, trauma/PTSD/abuse, ADHD, and it can help with anxiety and at-risk behaviors. 

A literature review of equine-assisted psychotherapy for children and adolescents with autism spectrum disorder reported that 17 of 18 studies published between 2008 and 2018 reported positive psychosocial outcomes. These ranged from improved social interaction and communication to improved processing speed. The authors theorized that an enjoyable relationship with horses enhances patients’ understanding of others’ emotions and improves executive functioning.

Mara: For example, a 16-year-old boy with ASD became aware of others’ personal space by observing a horse’s body language, specifically its ears moving backward, as he encroached on the horse’s personal space. He translated this awareness first to his cat’s responses and then to his encounters with family and peers. 

Dr. Feder: And, in PTSD, patients frequently have trouble relating traumatic events verbally to therapists. Equine-assisted psychotherapy for PTSD may interrupt symptoms, reducing isolation, eliciting positive emotions, and releasing oxytocin. A 2014 study compared in-office therapy with equine-assisted psychotherapy for survivors of sexual abuse and found effect sizes in the range of 0.583–0.880 among children and effect sizes between 0.702–0.905 for adolescents.

Mara: Children and teens with ADHD and externalizing disorders may be unaware of their own arousal. It can benefit them to see a horse running away in response to hyperactive or impulsive behavior. Researchers have conducted several controlled trials and a systematic review of equine-assisted psychotherapy for ADHD with good results, including significant improvements in global executive function, working memory, and initiation.

Dr. Feder: Lastly, equine-assisted psychotherapy might help shy, depressed, or anxious children and youth. A 2016 literature review found modest evidence that equine-assisted psychotherapy enhances children’s and adolescents’ emotional, social, and behavioral functioning.

Mara: So, what are the logistics of equine-assisted psychotherapy? 

Dr. Feder: The fees for this psychotherapy modality can be anywhere from $80–$400 for 60–90 minutes, with an individual hour-long allied health equine-assisted psychotherapy session costing around $175. Therapy is usually weekly for several weeks, but may be several years for long-term goals. Some programs require two certified professionals in a session, which increases cost; however, rapid progress can improve cost-effectiveness. Some nonprofits offer sponsorship, while some are covered by insurance. There is some Medicaid coverage for EAP. 

Mara: And, which organizations should our listeners reach out to if they’re interested in using this therapy?

Dr. Feder: There are several schools of equine-assisted psychotherapy, including Eagala, which is the Equine-Assisted Growth and Learning Association, Eponaquest, OK Corral Series, and the Human-Equine Alliance for Learning, also known as HEAL. 

Mara: As a bottom-line message, equine-assisted psychotherapy is supported by a growing body of evidence for autism spectrum disorder, PTSD, ADHD, and anxiety, and it’s perhaps the ultimate in experiential therapies. The combination of an outdoor setting, an empathic horse, and the use of metaphor can be helpful, especially for patients who struggle with talking therapies.

Dr. Feder: The newsletter clinical update is available for subscribers to read in The Carlat Child Psychiatry Report. Hopefully people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits. 

Mara: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry. 

Dr. Feder: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust. 

Mara: Go to www.thecarlatreport.com to sign up. You can get a full subscription to any of our four newsletters for $30 off using the coupon code LISTENER.

As always, thanks for listening and have a great day!