Animal-assisted therapy has grown in popularity over the past few decades, with both psychologist and physical therapists using a variety of critters—including dogs and dolphins—to help their patients. Horses are increasingly part of the mix, with hundreds of facilities offering equine-based or equine-facilitated therapy for a wide range of conditions.

While evidence is still largely anecdotal, equine programs are gaining popularity, particularly for treatment of post-traumatic stress disorder (PTSD) symptoms and autism. Like domestic dogs, horses are highly intuitive and have a somewhat unique historical relationship with humans that lends itself to a therapy setting.

“Their prey nature makes them highly attuned to their environment in order to ensure their safety, which is what makes them intuitive and emotionally sensitive to the slightest gesture, body posture or tension, tone of voice, or glance that we humans may unknowingly communicate,” says Liz Dampsey, PhD, clinical psychology post-doctoral fellow at Sierra Tucson, a residential treatment facility in Arizona that was one of the first such providers in the United States to offer equine therapy. “They respond to our non-verbal behaviors and feelings through their body language.”

Many existing equine programs are based on the model established by the Equine Assisted Growth and Learning Association (Eagala), a ground-based  model that now has 2,500 certified members and 640 regional programs in 40 countries. The model does not include riding so horses do not have to perform in a certain way. They can behave more naturally.

Another organization, the Professional Association of Therapeutic Horsemanship International (PATH International), has created a program that does involve riding the horses for both physical therapy as well as behavioral health applications. The organization has roughly 880 member centers, although many of those are focused on physical therapy.

Choices in therapy approaches

Equine therapy programs are found at both large and small providers, and can either be operated on-site or contracted out in the case of providers that don’t want to absorb the expense of boarding their own horses.

Nunnelly, Tenn.-based The Ranch treatment center has a large Eagala-based equine program that includes three barns, 25 horses, two equine psychotherapists and two equine specialists on staff.

There are group and individual sessions. According to psychotherapist Danielle Sukenik, group sessions start with some group work in a separate room in which participants are given a loosely structured exercise, such as building a jump in the arena for the horse. They then have to move the horse to the jump without touching the animal.

“We’re looking at how they problem solve and communicate,” Sukenik says. “Then we go back to the group room and process what happened.”

Sukenik says that equine therapy has been integrated with programming for Ranch clients across the board, including those being treated for addiction, trauma, sex addiction, eating disorders, depression/anxiety and other applications.

At Cumberland Heights, a not-for-profit, 12-Step-based addiction treatment center in Nashville, the equine program was launched thanks to a donor.

“We had several staff members who had a passion for equine therapy. They began to use the new arena, and we built the program from there,” says Tammy Stone, associate clinical officer at Cumberland Heights.

The equine program is one of several expressive therapies (music, art, ropes courses, etc.) aimed at getting clients away from the typical circle of folding chairs.

“If patients are sitting around in a circle looing at each other, we only reach about 50% of them if we’re lucky,” Stone says. “If we get them outside and into an element they might be excited about, they get focused on that element and their defenses start to drop. They get more open to therapy and we can reach them at a different level.”

The facility doesn’t keep its own horses; instead, they contract with an Eagala-trained and certified therapist. The only cost to Cumberland has been making sure they have the correct liability insurance in place and that staff remain certified and trained. However, later this year the facility plans to create a new adolescent program based on the PATH approach, and will begin keeping horses on the property.

Patient response

The majority of equine-based psychotherapy programs were launched by providers who saw equine therapy in action. It’s unclear, though, how much of the benefit comes specifically from the horse versus other factors—being outside, being engaged in additional physical activity, or even the presence of the equine specialist in the therapy session.

There have not been many studies on equine therapy, and much of the existing research suffers from methodological flaws that make it difficult to draw a firm conclusion.

One study, published in Psychiatric Services in Advance in 2015, did compare Eagala-based therapy with canine-assisted therapy, enhanced social skills psychotherapy, and regular hospital care among 90 patients at a state psychiatric hospital with recent in-hospital violent behavior or highly regressed behavior. The animal-assisted approaches resulted in the largest decrease in violent behavior, with the Eagala approach being the more effective of the two.

However, a literature review ordered by the U.S. Department of Defense to investigate the use of equine therapy for veterans with PTSD symptoms found an “insufficient body of evidence to determine the effectiveness and safety of equine therapy.” Specifically, many existing studies either rely on small sample sizes, lack control groups, or included other methodological limitations that could have skewed the results. Researchers at Columbia University have since launched the Man O’War Project to study equine therapy specifically for veterans with PTSD.

Most recently, a January 2018 article in Military Medical Research reports that among a small sample of veterans, the subjects experienced statistically and clinically significant decrease in PTSD scores after six weeks of therapeutic horseback riding. The program aimed to decrease PTSD symptoms and increase coping self-efficacy and emotion regulation.

According to the providers interviewed for this article, patients do respond positively to this type of therapy, and the presence of a 1,000-pound animal in the session certainly leaves an impression. They believe equine encounters can help patients improve communication skills, overcome fears and anxieties, and gain new insights into their own maladaptive behaviors.

Horses will react differently to people depending on whether they are relaxed, anxious, or aggressive. A horse will walk away from a person who is exhibiting negative emotions, for example, which can be revealing in a therapy session.

“You can begin to regulate yourself to get the horse to cooperate,” Stone says. “The horse is mirroring back your nervousness or fear, and you can start to think about how your response to other people in similar situations in the past.”

Setting Up a Program

For practices interested in tapping into this modality, there are a variety of requirements and costs involved. You don’t have to have your own horse and barn, but staffing, liability, and insurance reimbursement issues are still a factor. Among those requirements:

· Staffing and Facilities: In the Eagala model, the equine program must include both a licensed mental health professional and an equine specialist for each session. You also need access to a corral or arena in which to conduct the session.

· Animals: The cost of stabling and caring for horses will vary depending on the facility and number of horses, but some estimates put the cost to care for a single horse between $2,000 to $3,000 per year. Providers that don’t want to keep their own horses can also contract with an outside equine specialist, who absorbs the cost of caring for the horses and can provide access to suitable facilities for the sessions.

· Liability: Programs may also need to have equine liability insurance in addition to their standard liability coverage. This can vary, however. At Sierra Tucson, for instance, the program is covered under general liability insurance.

· Insurance Reimbursement: Billing for treatment can be tricky, and may require some extensive documentation depending on the insurance carrier. “There isn’t a code to bill insurance specifically for equine-assisted psychotherapy similar to other types of therapy modalities and techniques – it is one of the processes used in a psychotherapy session,” says Lynn Thomas, CEO of Eagala.

However, some pay models have flexibility.

“Our client base is insurance dependent, and the equine therapy is wrapped around our services,” says Stone at Cumberland Heights. “We just bill it as a regular therapy session.”

· Marketing: These programs often market themselves—providers that offer equine services to specific clientele like veterans frequently wind up in the media. Some facilities also use their websites, blogs, or other channels to promote equine therapies. Eagala also offers a Horses Help mobile app.

Having a staff member on board that is already passionate about equine therapy is an important component. Dampsey suggests having an equine experience for marketing staff, administrators and other employees to help them better understand and discuss the program. Providers can also seek out certified equine specialists via Eagala or PATH.

For providers that are unsure whether equine therapy would benefit their clients, contracting with an outside equine specialist can provide an opportunity to see if this approach can be integrated with their practice with low costs/risk.

“This gives clients the space to explore and find their own solutions,” Sukenik says of her experience. “Horses reflect things back that we can explore with the client that may not come out in a regular talk therapy session. I can see what is going on with them, rather than just hearing it. I understand them on a different level.”

Brian Albright is a freelance writer based in Ohio.

PHOTOS
Top Left: The Ranch on Piney River
Top Right, Page 1: Danielle Sukenik, Sierra Tuscon
Lower Right, Page 2: Sierra Tuscon