Animal Assisted Therapy
Why the interest?
Animal assisted and animal facilitated therapies have captured the popular imagination. Animals have provided companionship and support to human beings for millenia, and incorporating them into therapeutic approaches is not a new idea.
There are a number of different KINDS of therapeutic approaches, though, and it's important to distinguish between them.
Supportive animals, or therapeutic programs- such as emotional support animals or therapeutic horseback riding programs- are designed to provide adjunctive support to individuals who are engaged in ongoing therapy relationships with professional mental health providers. These are not the same as therapy interventions, although they can add valuable context, support, or skills practice to life for people who engage with them. Emotional support animals are there to help individuals learn to identify triggers and manage symptoms of challenges such as anxiety, fear, trauma, or hypervigilance. While they provide an invaluable support to people who share their lives, they are not covered under laws like the Americans with Disabilities Act, which applies to "service animals." Therapeutic riding programs with horses are another approach to applying practice skills for socialization, focus, attention, management of emotions, and engaging physical therapy principles. These are usually done with a specially trained riding instructor and animals who have received specialized training for this job, but do not usually include a licensed mental health professional.
Service animals are a different category than emotional support animals. Service animals are usually dogs (canines), although there have been cases of monkeys and horses, as well, though these are pretty rare. Service dogs are trained to do specialized tasks, such as recognize onset of seizures or disabling panic attacks, guide people with no or low vision, assist with physical retrieval or movement of objects for people with physical restrictions, etc. These dogs have behaviors that are highly trained- such as a signal to their handler to return to the sidewalk or move to a safe space prior to a seizure, and standing guard over the person during the episode, or activating a help beacon. For veterans with diagnosed PTSD, these dogs often assist with issues related to hypervigilance- providing support for watching the environment, soothing anxiety about stressors that may be encountered, and enabling a struggling individual to engage with the world outside of their home. These animals are protected under the ADA laws and will have visible markers of being a service animal. They are also very well behaved- most people won't even notice they are there.
Canine (dog) programs to support veterans in recovery from trauma
There is a body of evidence supporting the use of dogs as both emotional support animals for traumatized military veterans, and also as service animals. The therapeutic value in either category has been well-established, although research continues to identify the mechanisms of action and best-practices for programs that apply to these models.
Ongoing research, led by Dr. James Whitworth, PhD, LCSW, Lt. Col (AF-Ret), is occurring with a number of community partners. Here are some recent publications/presentations from this work:
- Whitworth, J., Scotland-Coogan, D., & Wharton, T. (2019). Service dog training programs for veterans with PTSD: Results of a pilot controlled study. Social Work in Health Care, 58(4), 412-430
- Whitworth, J., Scotland-Coogan, D., & Wharton, T. (2019; Advance eprint). Outcomes of participation in a service dog training program for veterans with PTSD. Society & Animals. doi: 10.1163/15685306-00001682 Society & Animals.
- Whitworth, J., O’Brian, C., Wharton, T., Scotland-Coogan, D. Understanding spouse and partner perceptions of service dog training programs for veterans with PTSD: Building a bridge to trauma resilience. Submitted to Social Work and Mental Health.
- 2018 Whitworth, J., Scotland-Coogan, D., Wharton, T. Service dog programs for veterans with PTSD: Results of a controlled study. Oral presentation at the Annual Program Meeting of the Council for Social Work Education (CSWE), Orlando.
Equine (horse) programs
Among equine (horse) programs, there are several different distinctions:
- EFP –psychotherapy; licensed clinical mental health provider
- EAL –learning; may or may not have a licensed MH provider.
- Therapeutic Riding –riding, usually in groups, usually w partnered MH provider and riding instructor
- Riding instruction - riding, often adapted for differing physical or cognitive abilities, with a specially trained instructor
- “Certified equine facilitated mental health trainers/equine professionals”- horse people trained for working with therapy, NOT mental health professionals.
www.va.gov/health/NewsFeatures/20110106a.asp (Health Care: Horses for Heroes)
Several organizations have worked to professionalize the field, providing standards and certification. While these are excellent aims, not all programs are members of either PATH or EAGALA. It is important that consumers ask questions about safety protocols, provider and volunteer training, equine training and certifications and how often this happens, licensure and malpractice coverage for licensed mental health providers, and compliance with privacy protections for participants and clients.
Professional Association of Therapeutic Horsemanship (Link here: PATH) claims 4,544 specialists who have served more than 3,310 veterans and active duty personnel with MH related issues. Equine Assisted Growth & Learning Association (Link here: EAGALA) claims over 600 certified programs to address MH and personal growth.
There is a solid body of evidence that equine-facilitated therapies "work" in clinical practice for many groups of people with particular types of challenges, such as trauma recovery, reintegration from military to civilian life, anxiety, depression, social skills training, and physical therapy needs (a field called hippotherapy, for which there is an extensive body of evidence).
Research, however, is still needed to provide evidence that this type of intervention works as well as, or as reliably as office-based therapies, for which we have a lot of evidence about positive outcomes.
- Research is needed that meets the Institute of Medicine standards for acceptable evidence of efficacy
- The appeal of this type of intervention may be for those veterans who do not want to engage in office-based therapies (stigma), or who drop out.
- Benefit may be most significant to those who have subclinical PTSD or who decline to engage in treatment, and/or to decrease attrition.
- Despite absence of evidence of comparability to office-based therapy outcomes, this is a popular referral. Very few people drop out of equine programs, which is a unique feature of this type of therapy.
Current partnerships are working to document rigorous evidence of valid and reliable outcomes. It's important, however, to acknowledge the criticism in the professional field. There are well-established, very effective treatments for PTSD among veterans that have very high rates of success when clients complete the course of therapy. Drop-out rates remain high, when people even engage (rates are lower than we might wish); Equine therapies have tremendous potential to overcome these controversies by demonstrating not only effectiveness, but also very low rates of attrition (drop-out) and expanded opportunities to engage in therapy that reduces stigma.
- Anestis et al. (2014). Journal of Clinical Psychology
- Selby & Smith-Osborne (2013). Health Psychology
- “Promising,” but no RCTs for efficacy
- Small sample sizes; recent introduction of rigour in research methodology
- Mostly qualitative outcomes and pre-post studies with few validated measures and very few well-documented protocols
Anestis, M., Anestis, J., Zawilinski, L., Hopkins, T., & Lilienfeld, S. (2014). Equine-related treatments for mental disorders lack empirical support: A systematic review of empirical investigations. Journal of Clinical Psychology, 70(12), 1115-1132.
14 experimental studies, but only 6 with a true control group. Only 8 had any kind of manual or treatment guidelines, but all were different. None involved fidelity measures.
The current evidence base does not justify the marketing and utilization of Equine-related treatments (ERT) for mental disorders. Such services should not be offered to the public unless and until well-designed studies provide evidence that justify different conclusions.
We urge all practitioners of ERT to inform their clients of the extremely limited evidence base for their intervention, as well as to educate them regarding alternative and better supported treatment options. (p.1128)
Selby, A. & Smith-Osborne, A. (2013) A systematic review of effectiveness of complementary and adjunct therapies and interventions involving equines. Health psychology, 32(4), 418-32.
13 qualitative studies and 14 quantitative studies with valid measures; (4 pilot studies, 3 single group pre-post, 4 comparison pre-post, 2 program evaluations, 1 experimental efficacy study)
Although research on the effectiveness of interventions involving horses is emerging, practice appears to be thriving. (p.428)
Because of the paucity of studies and the lack of randomized controlled trials to date, the current review is limited by the methodological weaknesses of the studies included… Evidence from the preliminary studies reviewed here is promising, but they underscore the need for more rigorous investigation… It would be helpful to investigate which aspects of these approaches are helpful for which client populations. (p.429)
Why horses for mental health interventions?
- Horses are prey animals uniquely attuned to affective incongruity.
- Provide reflection on behavior and affect.
- Require focus and attention; this assists in occupying the working memory, allowing discussion of challenging topics with less focus on worry/anxiety.
- “Doing”- action, rather than talking is appealing to some.
- Herd dynamics are used to understand relationships and power and control dynamics.
Equine facilitated therapy may take place either in a GROUP, or INDIVIDUAL therapy session. These sessions usually involves combinations of ground work with the horses, discussion, skills-based learning, and riding.
Individuals therapy occurs with a licensed mental health professional, and may also involve an equine professional as a team partner.
Group therapy involves two or more participant/clients, a licensed mental health professional, and usually an equine professional as part of the team.
Equine-Facilitated Cognitive processing Therapy (EF-CPT)
Protocol adapted from VA-endorsed CPT Therapy Workbook, Veteran/Military Version (Resick, Monson, & Chard, 2010)
Practice manual: Wharton, T., Scogin, F., & Malone, M. (2015) Equine Facilitated Cognitive Processing Therapy: An Addendum to the CPT Patient Workbook, Veteran/Military Version. Available from Amazon in print or Kindle version: Independently published. ISBN: 9781980567646. Available here: https://www.amazon.com/dp/1980567646/ref=cm_sw_r_tw_dp_U_x_LstkCbYV2QS0B
- Solid evidence base for CPT
- Combines an evidence-supported therapy with a novel engagement model using trained mental health provider and a very clear manualized protocol.
- Infuses equine active learning activities into the face to face encounters, but maintains the protocol for CPT otherwise.
- Pilot test has shown very promising outcomes for individual EF-CPT; findings pending publication in peer-reviewed press (see below).
Here are some of the publications/presentations from ongoing work with community partners regarding EF-CPT and therapeutic interventions:
- Wharton, T., Whitworth, J., Macauley, E., & Malone, M. (2019) A quasi-experimental study of a manualized equine-facilitated cognitive processing therapy intervention with veterans diagnosed with PTSD. Psychiatric Rehabilitation. 42(3), 268-276. doi: 10.1037/prj0000359.
- Chakales, P., Locklear, J., & Wharton, T. (2020) Medicine and horsemanship: Evaluation of the effects of equine-assisted activities and therapies on medical students’ levels of stress and depression. Cureus 12(2): e6896. doi:10.7759/cureus.6896
- Monroe, M., Whitworth, J., Wharton, T., Turner, J. (2018). Effects of an equine-assisted therapy program for military veterans self-reporting PTSD. Society & Animals.
- Wharton, T., Sercu, C., Malone, M., & Macauley, B. (2005). An analysis of equine stress levels after participation in therapy sessions. Scientific and Educational Journal of Therapeutic Riding.
- 2019 Wharton, T., Whitworth, J., Macauley, E. & Malone, M. Pilot Testing EF-CPT: A Manualized Intervention For Treatment Of Trauma In Veterans. Poster presentation at Society for Social Work Research (SSWR) Annual Conference, San Francisco
- 2018 Wharton, T., Macauley, E., Whitworth, J., & Malone, M. Equine-facilitated Cognitive Processing Therapy (EF-CPT) for treatment of trauma related social and emotional difficulties in veterans. Poster presentation at the 16th Annual Congress of Equine Facilitated Programmes, Dublin, Ireland.
- 2015 Wharton: Invited presentation to Research Investigators Meeting, VA VISN 8: Developing and testing equine-facilitated interventions: An issue of evidence. September 17, 2015, Gainesville, FL.
- 2006 Malone, M., Macauley, B., & Wharton, T. Panel Discussion: Building an interprofessional team for equine facilitated interventions. Annual conference for the National Association of Riding for the Handicapped (now PATH International), Kansas City.
Group Approaches to Equine Facilitated Psychotherapy
Group approaches are cost-effective for practices, and have demonstrated excellent effectiveness in clinical practice, providing opportunities for group participants to develop bonds and work on social engagement and skills, as well as trauma-related symptoms. This approach has shown reliably that participating veterans experience improved symptom management related to PTSD (hypervigilance, sleep, emotional regulation, flashbacks, focus and attention), depression, anxiety, apathy, and trauma-related guilt.
Programs across the country have instituted group programs for military veterans working to reintegrate to civilian life, and/or learning to manage PTSD or related symptoms. As noted above, research about the effectiveness of these interventions continues.
Dr. Wharton and Dr. Whitworth are engaged with research at the McCormick Research Institute (see photos below), a partnership between UCF, Heavenly Hooves, Inc., and Osceola County, FL. This amazing facility is led by a top-notch professional Executive Director and Board of Directors, and is focused on providing facilities to produce the evidence needed to support advancement of the field.
Dr. Wharton also provides program evaluation support for Horse Spirit for Soldiers in Hayward, WI (see news clip above).
Therapeutic equine programs are most commonly known for serving military veterans, but these programs are well-established for working with children and adolescents, and have a growing demographic in working with older adults who may be struggling with adjustment to life circumstances or mobility issues.
This video created by TROT in Cottondale, AL, includes some of the range of these types of programs. (disclosure: Dr. Wharton is a Board member for TROT)