Introduction Equine-assisted psychotherapy
Equine-assisted psychotherapy is an increasingly popular method of treating a
range of physical and mental health conditions by making use of the observed
interactions between a client and a horse (Burgon, 2011; Kendall et al., 2014; Masini,
2010; Siporin, 2012). Since horses are considered to be prey animals (Lentini& Knox,
2015), they are reported to have developed heightened sensitivity to their surroundings,
especially in relation to people and other animals. They react significantly to unexpected
events in their environment; this responsiveness is thought to be especially useful in
working with people who have a range of disabilities (Lentini& Knox, 2015). Put another
way, horses may respond to client behavior in ways that can draw the therapist’s attention
to aspects of the client that might not be seen otherwise (Lentini& Knox, 2015).
Using the internet and library search devices (Google Scholar, Education
Resources Information Center (ERIC), PsychInfo, EBSCOhost Academic Search
Premier), I reviewed a range of terms similar toequine-assisted psychotherapy and
equine-assisted therapy. I discovered that equine therapists work with a wide range of
client conditions, bothphysical and mental, using a variety of methods. Some use
recreational activities that focus more on treating physical disabilities (Rigby
&Grandjean, 2016). Other therapists focus on the mental aspects, for exampletreating
severe mental illness such as psychosis (Nurenberget al., 2011) or less severe mental and
emotional conditions such as mild anxiety, behavioral difficulties, and interpersonal
problems (Saul, 2013).
In the equine-assisted therapy literature, especially in online descriptions of
particular programs, approaches to many of the conditions in the emotional and relational
realm are likely to be called psychotherapy. Several forms of treatment identified as
equine-assisted psychotherapymay result in a range of benefits such as heightened
selfawareness, improved relational skills, and an increase in self-esteem (Bachi, 2014;
Brandt & Cities, 2013; Parish-Plass, 2013; Saul, 2013). A number of the therapists
performing this work are affiliated with formal, accredited organizations like the Equine
Growth and
Learning Association (EAGALA) and the Professional Association of Therapeutic
Horsemanship (PATH) International; both organizationsuse identified theoretical models
(EAGALA, 2012; Kirby, 2010).
Other therapists seem to function independently, using a wide range of
individualized approaches (Gergely 2012; Kemp et al., 2014; Rugari et al., 2013; Trask,
2010). These interventions may be similar to or vary considerably from the approaches
used by the formal organizations. In other words, anumber ofdifferent practitioners call
their individualized work equine-assisted psychotherapy, but how they understand what is
taking placebetween their clients andthe horses may vary greatly(Kendall et al., 2015;
Mota, 2014).
Background of the Study
In my initial exploration ofequine-assisted therapy, I began to collect articles
broadly.As I reviewed a wide variety of articles related to the use of horses in a
therapeutic context,I began to gain a sense of the large field about which I was reading.
Upon attempting to categorize the articles by primary focus, Idiscovered that
manymethods werebeing used to treat quite a number of different conditions
includingphysical and mental issues, both severe and less severe. I scanned a wide range
of resources related to work with horses and people who have some form of disability or
limitation. I was eventually able to divide theminto basic categories according to the type
of population being served.
One group of equine-assisted therapies has the goal of improving physical
functioning, often with people who have medical, physical, and developmental
limitations (Angsupaisal et al., 2015; Haylock&Cantril, 2006; Rigby &Grandjean, 2016;
Thompson et al., 2014).Another group focuses on people who have serious mental illness
(SMI) likeautism, severe depression, or schizophrenia (Cerino et al., 2011; Gabriels et al.,
2012; Nurenberg, et al., 2011; Parker et al., 2014).
The largest group of people I encountered in the literature on Equine-Assisted
Therapy seemed to be a subgroup working with less severe mental illness including
individuals who are experiencing a range of relational issues and problems with
emotional regulation. They are sometimes referred to in the mental health literature as
having less severe mental illness, which is a useful distinction for my purposes in this
study (Gfroerer et al., 2012). At the time of the study, treatment of this less severe mental
illness category seemedto be the least well-defined of the equine-assisted psychotherapy
methods, but one of the most commonly used. It seemed likely that, with further
exploration among the therapists who work with people who have these less severe
conditions, such as difficulties with emotional regulation, it would be prudent to identify
different ways of thinking about this work andto separate out different types of
equineassisted psychotherapy.
A number of studiespertaining to this subgroup have been conducted and help to
illustrate the use of equine-assisted psychotherapy in a wide variety of ways. For
example, Bachi (2013) offered insight into the applicability of attachment theory to
equine-facilitated psychotherapy, and how this theory influences relational skills. She
made recommendations that more research be done in this area in the future.Additionally,
she evaluated the impact of an equine-facilitated prison-based program and examined
how human-horse interaction mighthave an effect on inmate emotions and behaviors
(Bachi, 2014).
In another study, Brandt & Cities(2013) explored how equine-assisted
psychotherapy can be used as a complementary treatment intervention to more traditional
therapy approaches. An additional example of how horses can be used to enhance general
wellbeing when paired with more traditional treatment approaches is illustrated in a study
involvingFirst Nations youth who are in treatment for substance abuse (Adams et al.,
2015).Burgon(2011) also identified the benefits experienced by at-risk youth who
participated in equine-assisted learning/therapy, while Carlsson et al., (2015) provided
insight into the practicality of using mentalizing — understanding the mental state that
underlies basic behavior — to facilitate equine-assisted social work with adolescents who
engage in self-harming behaviors.
Some populations do not respond as favorably to mainstream treatment
approaches as others, but research is beginning to show how using equine-facilitated
body and emotion-oriented psychotherapy in a structured manner can be
beneficial(Johansen et al., 2014).There have also been studies that target specific
populations such as veterans who are seeking to improve the quality of their lives
postcombat (Krenek, 2013).Similarly, Yorke et al., (2008) provided information about the
therapeutic value of equine-human bonding in helping individuals recovering from
trauma.
Move- Lac et al., (2013) evaluateequine-assisted psychotherapy as a creative
relational approach to treating individuals whostruggle with eating disorders while
Maujean et al., (2013) examinedthe use of horses in a therapy context and how the
outcomes have a positive impacton participants.Last, Parish-Plass(2013) exploredthe
more general topic of animal-assisted psychotherapy and how it has evolved. Those
authors offered insight into theory, practice, and implications for the future that add to the
significance of this study.
Problem Statement
To those interested in the development of the field, it seems important to
understand how therapists performing equine-assisted psychotherapy make sense of the
observed interaction between the client and horse, the behaviors of each, and how these
guide the practice of the therapist. I believe this work is significant, because as
equineassisted psychotherapy becomes more recognized, it will be crucial for there to be
clarity about whether equine-assisted therapists are attending to similar or different
behavior and to similar or different ways of understanding that behavior.After reviewing
the professional literature, I concluded that there islimiteddiscussion of how therapists
think about the various forms, purposes, and uses of the different versions of equine-
assisted psychotherapy.
Consequently, there is a need to identify more clearly the range of thought that lies
behind the various approachesdescribed by therapists to guide their practice in equine-
assisted psychotherapy. This constitutes a gap in the professional literature about equine-
assisted practice.The problem is, therapists appear to use different interpretations of what
they observe;in the professional literature the various meaningsthat the therapists use to
guide their work with the clients and the horses has not been researched. I believe there
needs to beclarificationearly on to help guide practice approaches as the field continues to
evolvemove from being experimentalto an evidence-based modality.
Through conducting this study, I attempted to help answer the question of how
therapists who say they are doing equine-assisted psychotherapy understand what is
taking place between the client and the horse. I also attempted to address what similarities
and differences existed in their perception of the work they do. I began the process of
interviewing therapists who do equine-assisted psychotherapy to learn how they
understand what is taking place between the client and the horse. This potentially serves
as an early step in the development of equine-assisted psychotherapy as a more widely
recognized method.
Purpose of the Study
The purpose of this study was to identify how some therapists who
performequine-assisted psychotherapy understand the observed interaction between the
client and the horse. The information collected was examined to help identify and make
sense of similarities and differences in the thinking of the therapists who participated in
the study. This process helped determine whetherparticular theoretical or observational
influences exist in their practice that can be used to further define what takes place in this
therapy approach, and thus allow increased differentiation and definition of the various
methods being used.
With the field of equine-assisted psychotherapy evolving and becoming more
widely recognized as a method of therapy, I soughtto clarify and facilitate the eventual
development of a theoretical basis for use with clinical practice(Parish-Plass, 2013). This
mayalso begin to fill a gap that exists in the identified knowledge base about
equineassisted psychotherapy, clarifying some aspects of the existing knowledge base and
helping to identify further gaps in the understanding of this evolving method. In other
words, I hoped to clarify what is known and what is not yet known about the thinking
behind some of the practice methods of the therapists using equine-assisted
psychotherapy. In this way I attempted to assist with a social change process that seems to
be developing as the field of equine-assisted psychotherapy matures and the increasing
need for theoretical guidance emerges (Parish-Plass, 2013).
Research Question
The research question was developed to identify the individual experiences and
perception of the study participants and is as follows:
How do therapists who say they are doing equine-assisted psychotherapy
understand what is taking place between the client and the horse?
Theoretical Foundation
Although there did not appear to be one definitive theory guiding the entire
practice of equine-assisted psychotherapy currently, I thought there may be particular
theoretical frameworks being used in this work that would help explain how
therapiststhink and use their differences in perception to guide their practice with the
clients and horses. Through this exploratory approach, I anticipated some common
theoretical themes might emerge. Theseincluded, but were not limited to, the theory of
planned behavior, which recognizes that human behavior is controlled by a number of
beliefs including behavioral beliefs, normative beliefs, and control beliefs (Ajzen, 1985;
Fishbein&Ajzen, 1977).
Another theory thatI anticipatedmight influence the practice of the therapists was
attachment theory(Bowlby & Ainsworth, 2013).Bretherton (1992) looked at the seminal
literature and explained some of the dynamics of the relationships taking place that could
be transferred to human-equine interaction. Bachi (2013) also previously explored the
relevance of this theory in direct relation to equine-assisted psychotherapy. Since the
primary goal of this study was to identify how the therapists doing this work think about
what they are seeing and doing, any number of theories could be identified as significant
to the field of equine-assisted psychotherapy and were taken into careful consideration.
This study was very exploratory in nature and as such, a definitive framework was
not established. Essentially, the distinctive idea that drove this study related to the need to
know more about how the therapists who perform equine-assisted psychotherapyand to
understand what guides their clinical process with the client and the horse to seewhether
common themes or significant differences emerged that would provide some insight to
inform practice. I began the study with a guiding research question. Through general
qualitative inquiry, datawerecollected that could be analyzed for repeated ideas and
concepts. The data werethen coded accordingly, so later it couldbe grouped into
categories of concepts that would be useful in establishing connections between key
elements. The same data may be useful in developing a framework for future studies that
may be more explanatory in nature and predictive of specific findings.
Nature of the Study
The research design used for this study was qualitative in nature. After significant
consideration, I determined using a genericqualitative approach seemed to make the most
sense in order to capture a descriptive understanding of the thinking and decision making
of therapists in an individual and personal manner.Although considered by some to be
less established and defined than the more specific methods, selection of this general
approach allows for more methodological flexibility (Kahlke& Hon, 2014, 2018). These
basic qualitative, also known as interpretive, approaches are “not guided by an explicit or
established set of philosophic assumptions.”(Kahlke& Hon, 2014, p. 39).
This refers to one or more of the more commonly known qualitative methodologies, such
as grounded theory, ethnography and/or phenomenology (Caelliet al., 2003, p. 4;
Kahlke& Hon, 2014, p. 39).
To define this sort of generic qualitative research more clearly, it is important to
distinguish the two genres most commonly seen: descriptive qualitative and interpretive
description (Elliott &Timulak, 2021). Descriptive qualitative can be defined as research
that is designed to create a low-inference description of a phenomenon (Kahlke& Hon,
2014, 2018). Interpretive description on the other hand, tends towards use of broad,
interpretive, and what is referred to as “constructivist epistemological assumptions”
(Thorne &O’Flynn-Magee, 2004, p. 49) [that take on a] “naturalistic theoretical
perspective” (Kahlke& Hon, 2014, p. 41). This means the knowledge that is gathered
from the participants is not absolute, but instead is based on the subjective views of the
people who experience it (Kahlke& Hon, 2014, 2018).Since I was looking to gather
information from therapists who perform equine-assisted psychotherapy, and this
information gathering was completely subjective because it involved their perceptions of
what takes place, the latter research genre was more fitting for this study.
I originally consideredusing the case study method for this inquiry, since it is
essentially an exploratory method thatallows detailed information to be collected from
individual respondents in their own words (Yin, 2017).The case study is also described as
a method that examines the “how” and “why” of a phenomenon that occurs in a realworld
context without external manipulation among study participants (Yin, 2017, pg. 6).I
believe that this method may be useful for subsequent studies asI collect the themes
related to how the therapists make sense of their observations and outcomes become more
clearly defined. The use of coding is common in generic qualitative studies as it allows
the researcher to condense broad categories of data into groups of topics (Mihas &Odum
Institute, 2019). As a number of subgroups appear, it willallowfor cross case comparison
through the identification of relevant themesamong participants (Stake, 2006;
Yin, 2017).
A grounded theory approach was also considered (Charmaz & Belgrave, 2019;
Chun Tie et al., 2019; Bryant, 2021).However, as I learned more, it began to be apparent
that the way the therapists think about their work is not consistent enough to be seen as
more than the very beginnings of theory being formed(Levitt, 2021; Walsh et al., 2015).
As such, this study sought to determine how those performing equine-assisted
psychotherapyunderstand what they see happening between the clients and the horses and
also why those therapists might choose particular interventions. I was not questioning the
actual behavior of the therapists; instead,I wasasking them to describe what it is they do
and how they understand it.The information gathered from this study may serve as a
starting point for future studies using a grounded theory approach.
Definitions
The following definitions were referenced throughout this study. They are
outlined below to assist with clarity and distinction:
Equine-Assisted Psychotherapy: A form of therapy that utilizes horses as part of
the therapeutic process, most often facilitated by a mental health professional. The
Equine-Assisted Growth and Learning Association (EAGALA) defines it as a
collaborative effort between a professional who works with horses and a licensed
therapist that focuses on providing treatment to a client in need of psychotherapy
(EAGALA, 2012).
Equine-Facilitated Learning:An experiential learning approach that uses a
planned learning experience that integrates equine-human interaction. The focus of the
learning experience is the development of life skills that will aid participants in the
attainment of professional, personal, and educational goals (Path International, 2016).
Therapists: For the purpose of this study, the term therapist refers to an individual
working in a therapeutic capacity with the participant and the horse. Path International
(2018) defines a therapist as “a licensed mental health professional working with or as an
appropriately credentialed equine professional partner with suitable equine(s) to address
psychotherapy goals set forth by the mental health professional and the client” (Path
International, 2018).
Assumptions
As with any study that is exploratory in nature, the topic of assumptions is
approached with extreme caution. Much of what is being explored through this work is
preliminary; it is not necessarily designed to be a conclusive effort, but rather a starting
point for future reference. My hope is that the findings of this study may set the stage for
additional studies to be done. Whatever themes might be identified through my data
collection can be examined more thoroughly and used to develop assumptions for future
studies- ones which may be more predictive and more likely to confirm emerging
concepts.
Scope and Delimitations
The scope of the study was limited to therapists who identified they are
performing equine-assisted psychotherapy and meet the definition provided above. This
was a very careful consideration given the broadness of the field and the availability of
individuals performing a variety of therapeutic interventions with horses. The therapists
that were interviewed were selected from within the geographical region of the United
States rather than internationally. However, they were not necessarily restricted to one or
only a few states, which allowed for a broad but manageable representation.
Limitations
As with any study, limitations are to be anticipated. As previously noted, the
participants in this study were solely from the United States, but not necessarily from one
particular state or even one general area, like the West Coast.This limitation mayhave
impacted the outcomes especially in relation to the international use of equine-assisted
psychotherapy; while study findings may be useful in some context, they will not account
for any differences in practice that may exist in other countries. With reference to
personal bias, I needed to be cognizant of how my past role as a mental health therapist
and my personal history of owning and working with horses in a number of settings may
have impacted my ability to interpret findings and whether or not these aspects were of
significant concern to my study. I have found horses to be beneficial to my
personal,mental, and physical wellbeing and had to be careful not to project this
assumption when interviewing participants.
Significance of the Study
Significance to Practice
Despite there being a significant amount of literature on equine-assisted
psychotherapy, it appears that both a range of methods and a range of conditions exist
among therapists that do not appear to have been clearly delineated (Switzer, 2016). It
seems important to understand how the therapists who say they are doing equine-assisted
psychotherapy understand what is taking place between the client and the horse, and how
this affects and is affected by what takes place through their interventions. Identifying
similarities and differences that may exist in their approaches will help to support the
ongoing development of the field of equine-assisted psychotherapyand ought to help,
over time, in the evolution of systems of training for therapists and more clearly defined
therapeutic methods (Parish-Plass, 2013).
Significance to Theory
Once the exploratory findings lend insight into what, if any, theories inform the
current practice or therapist’s performing equine-assisted psychotherapy, more can be
done to evaluate whether a new emerging theory or a combination thereofcould be
acknowledged as a foundation for consistent training and practice methods within the
field. This is much needed, as my review of the literature revealed that currently there
appears to be a broad range of methods and thought processes that guide the therapists in
implementing the interventions related to equine-assisted psychotherapy.
Significance to Social Change
In some ways the field of equine-assisted psychotherapy is still in its infancy with
regard to the way it is being utilized and implemented as a research-based intervention.
While the field seems to have generated a great deal of support and interest, there is
significant evolution occurring that has only limited research supporting any consistent
theory or methodology that is being utilized. This makes measuring outcomes a daunting
task for those wishing to research efficacy of the interventions. The use of equine-assisted
therapy as a recognized intervention in its own right, not simply as a subcomponent of
other forms of therapy, would provide access to an additional nontraditional approach for
those who may not respond favorably to conventional interventions. It also would
enhance what we already know about the use of horses in a therapeutic manner.
Summary and Transition
With continual growth occurring in the field of equine-assisted psychotherapy, it
seems more crucial than ever to begin to identify and clarify what we know and do not
know about the field itself. It was important in Chapter 2to grant some historical
significance to the prior developments that have served as precursors to the approaches
we see being used today. I have given additional attention to what theoretical and
conceptual influences have already been identified through scholarly research as well as
which theoretical and conceptual influences have taken on additional significance as a
result of my study findings.
Chapter 2: Literature Review
This section contains a comprehensive overview of literature pertaining to the area
of study: it provides information related to current studies in the field of equineassisted
psychotherapyand also to relevant theories that may influence its development. Upon
exploring the topic of equine-assisted therapy, and perhaps even more specifically equine-
assisted psychotherapy, the primary problem I discovered is that in both cases there
appears to be a wide range of ways that the therapy is being implemented, and the role
that individual therapists take in guiding this process or what lines of thinking may
impact their individual practice techniques have not been evaluated. The equine-assisted
psychotherapy field is still in its infancy as to its theoretical development, standards of
practice, and research that evaluates outcomes and supports efficacy (Kirby, 2016). Given
this beginning stage of development, it is especially important to gain insight and
understanding into how therapists who say they are performing equine-assisted
psychotherapy understand the observed interaction between the horse and the client, and
how this understanding influences them in guiding the therapeutic process.
In order to gain a better understanding of the historical significance of the field
and its evolution, I explored equine-assisted therapy as a whole and then narrowed down
the scope of my study to examine equine-assisted psychotherapy more closely. While
equine-assisted therapy is the term used to describe approaches that can include both
physical and mental benefits to clients, equine-assisted psychotherapy is more relevant to
this study as it specifically concerns the mental and emotional benefits resulting from the
client/ horse interaction. It is important to distinguish the two therapies so a brief
overview will be given of each, with the focus then narrowing toequine-assisted
psychotherapy and how it relates to my topic of study.
Literature Search Strategy
When I first began researching the topic of equine-assisted therapy, I really
wanted to gain an understanding of all of the various ways that horses are utilized in a
therapeutic capacity. I reviewed a number of articles and studies I had gathered over the
past year in paper form printed out from journals. I also followed links to relevant articles
colleagues had sent me in emails. In addition, I used various internet and library search
devices independently to locate relevant literature for this dissertation.
These search engines included Google Scholar, Education Resources Information
Center (ERIC), PsychInfo, SAGE, and EBSCOhost Academic Search Premier. I also used
some cross-discipline searches to locate articles in medical journals that documented
benefits of this form of therapy. The following search terms were entered to locate
articles: equine-assisted psychotherapy, equine-facilitated psychotherapy, equine-assisted
therapy, hippotherapy, equine-assisted activities, therapy horses, equine therapy,
therapeutic riding, and animal-assisted therapy.
Searches were conducted regarding the theoretical foundation of equine-assisted
psychotherapyand also qualitative research approaches related to it. These included:
attachment theory, existential psychotherapy, gestalt, psychodynamic theory, theory of
planned behavior, eclectic psychotherapy, grounded theory, case study, generic
qualitative design, and qualitative interviewing techniques.
Theoretical Foundation
Theory Description and Origin
A number of theories have been used in conjunction with the implementation of
animal-assisted therapy, some of which can be more specifically applied to equineassisted
therapy and equine-assisted psychotherapy. These include gestalt therapy, attachment
theory, existential psychotherapy, theory of planned behavior, eclectic psychotherapy,
psychoanalytic theory, and theory of multiple intelligences. While some are only briefly
mentioned, others have entire studies devoted to the use of specific theories to guide
interventions. An overview of theories that have been documented as relevant to
informing practice efforts of equine therapists is provided in the sections below.
Gestalt Therapy
The use of gestalt therapy in conjunction with equine-assisted psychotherapy is
well documented (Kirby, 2010; Kirby, 2016; Lac, 2016). It stems from combined work by
Fritz Perls, Laura Perls, and Paul Goodman in the 1940s and 1950s (Moss, 1999). It is
based on the idea that humans can develop self-regulation skills in response to their sense
of personal responsibility as well as to their social and environmental experiences (Kirby,
2010).Frederick Perls wrote extensively about the characteristics of gestalt psychology as
compared to gestalt therapy in his autobiography In and Out of the Garbage Pail and
noted that gestalt therapy is a form of psychotherapy that is phenomenological in nature
(Perls et al., 1951).It focuses on both the exploration and the causes of behaviors rather
than simply trying to modify them, and this in turn increases self-awareness(Perls et al.,
1951).
Gestalt therapy, when used in relation to equine-assisted psychotherapy, is
essentially an experiential form of psychotherapy that is both client-centered and focuses
on the therapeutic experience that is occurring between the client and the horse in the
present moment (Kirby, 2010; Kirby, 2016). As noted in the literature, gestalt therapy
approaches with equine-assisted psychotherapy have had a number of different
applications. One example has been its noted success as a mental health intervention/
promotion when working therapeutically with children who have experienced intrafamily
violence (Schultz et al., 2007).Other examples include improving conflict resolution
among adolescents (Thomas, 2017), assisting veterans with PTSDto overcome marital
challenges (Skidmore, 2018), and improving life skills (Greve, 2021). While still
considered to be an experiential approach to traditional psychotherapy, equine-assisted
psychotherapy is very similar to gestalt therapy because it centers on the use of body
language:reflective behavior between the horse and the child becomes the foundation of
the intervention (Schultz et al., 2007).
Other authors have cited the usefulness and similarities of equine-assisted
psychotherapy to gestalt therapy as well.In the most recent literature by Lee and Makela
(2018), the authors discuss useful strategies for equine-assisted psychotherapy for
practice within the field of social work, while Hallberg (2017) focuses on the clinical
aspects of using horses within the human healthcare field. Kemp et al., (2014) explore
this briefly in their program evaluation study on the use of equine-facilitated therapy with
children and adolescents who have been victims of sexual abuse. They noted that the
EAGALAmodel uses a person-centered approach that closely resembles both gestalt
therapy and existential therapy (Kemp et al., 2014).
Attachment Theory
Attachment theory was initiated by the work of John Bowlby. He suggested that
children form biological attachments with others as a means of survival; he carried this
theoryover to developmental aspects of adult attachments (Bowlby, 1988, 2008). His
work also provides insight into the importance of bothlong and short-term relationships
and how they influence overall human development (Bretherton, 1992). In 1979, Bowlby
published a selection of lectures from two previous decades under the title The Making
and Breaking of Affectional Bonds. In his book, Bowlby goes into significant depth
regarding similar ideas related to attachment theory and offers an explanation of the
contextual differences. He offers clarification and expands on the distinctive features of
the theory and the relational aspects that apply to human relationships (Bowlby, 2012).
While Bowlby tended toward an “all or nothing” mindset regarding the relevance
of attachments (Bowlby, 1969), additional research by developmental psychologist Mary
Ainsworth throughout the 1960s and 1970s added to the development of attachment
theory and defined differences in the types of attachment people experience (Ainsworth,
1989). Ainsworth defines an attachment as “an affectional bond” that can be seen in a
variety of relationships (Ainsworth, 1989). She also recognized that children develop
different patterns of attachment dependent upon their early childhood experiences; these
experiences then in turn influence their expectations for relationships into
adulthood(Bretherton, 1992). Based on her research, Ainsworth identified three different
classifications for attachment: anxious-avoidant attachment, anxious-ambivalent
attachment, and secure attachment (Ainsworth,1978). A fourth attachment style known as
disorganized- insecure attachment was later identified by researchers Solomon andMain
(1986).
Disorganized attachment as it relates to Ainsworth’s studies involving children can
be described as the lack of a clear attachment pattern with the child often exhibiting a
confusing combination of behaviors (Ainsworth, 1978). Anxious-ambivalent attachment,
while relatively uncommon, is characterized by the child’s inability to depend on his or
her caregiver (Ainsworth, 1978). A secure attachment is defined by Ainsworth (1978) as a
child who is secure in the ability to rely on his or her caregiver.While attachment theory
is primarily applied to studies on childhood development, it became more applicable to
adults in the 1980s when additional research by Cindy Hazan and Phillip Shaver (1987)
explored three styles of attachment pertaining to adult attachment behavior that mirror
prior work by Ainsworth and Bowlby.
Many studies have explored the usefulness of attachment theory toequine-assisted
psychotherapy. One such example focuses on the work of Vincent and Farkas (2017).
They look at the role this theory takes in conjunction with social work practice. Bowlby
affirms that attachment theory focuses on understanding how people internalize their
interpersonal interactions, and how they react and respond to others emotionally and
otherwise. This is something that is transferrable to human/ horse interaction(Vincent &
Farkas, 2017). Other authors have looked at the correlation between theory and practice
with attachment theory being given significant consideration. Burgon et al., (2018) took a
closer look at the use of equine-assisted therapy with young people who were
experiencing psychosocial issues as a result of abuse and/or neglect in early childhood.
They recognized that, although some children may have not been able to form
appropriate, secure bonds with caregivers from an early age, they are still capable of
developing attachment skills later in life through the use of such therapy approaches
(Burgon et al., 2018). This affirms the importance of horses being used therapeutically to
help individuals develop bonding skills.
Existential Psychotherapy
Soren Kierkegaard, who has been referenced as the father of existentialist
thinking, was once quoted as saying “I can be understood only after my death”
(Kierkegaard, 1960, 1967). Existential psychotherapy initially began during the
nineteenth century as a result of work done by Soren Kierkegaard and Friedrich
Nietzsche: bothof them disagreed with the prominent ideologies that were popular at the
time (May & Yalom, 2000). According to Hwa Yol Jung (1969), who contrasts and
compares Confucian philosophy with existentialism, Kierkegaard takes a very subjective
view towards human existence. Kierkegaard experienced a great deal of ridicule and
isolation for his belief that people greatly misunderstood and to some degree even abused
both Christian dogma and what was referred to as ‘objectivity’ of science in an attempt to
avoid experiencing anxiety as part of their human experience (Kierkegaard, 1960, 1967;
May & Yalom, 2000). Nietzsche, who is known for his statement “God is dead”, believed
that the notion of God created limitation for people who might otherwise live life
according to free will, that is, free of moral and societal constraints (Nietzsche, 1968). It
is from this line of thinking that the existential themes of personal responsibility, courage,
freedom, and choice were introduced (May & Yalom, 2000).
Swiss psychiatrist Ludwig Binswanger, a well-known pioneer in the field of
existential psychologyalso made great contributions to the development of psychotherapy
with the help of Needleman (1965), who assisted with translating some of
Binswanger’sbest known work. Binswanger referred to it as “basically no more than an
attempt to bring the patient to a point where he can ‘see’ the manner in which the totality
of the human existence or ‘being in the world’ is structured and to see at which of its
junctures he has overreached himself” (Binswanger, 1963; Needleman, 1965, p. 348,
349). He identified the overall goal of psychotherapy as being able to bring the patient
back from a state of defined extravagance and essentially “back down to earth” and
within touch with reality in the safest manner possible (Binswanger, 1963; Needleman,
1965).
A number of early practitioners are present in the seminal literature demonstrating
the applicability of existential psychology and analysis.The work of Viktor Frankl (1986),
the founder of logotherapy, a form of existential analysis, had a significant impact on the
evolution of existential work and a humanistic approach to psychology thatlater
influenced the importance of spirituality in clinical practice (Puchalski, 2006). Frankl
identified three layers that comprise the dimensions of a human personality:
psychological (psychic), spiritual (noetic), and biological (somatic) (Frankl, 1986;
Podolsky, 1962; Reitinger, 2015).
Much emphasis is placed on the spiritual domain: Frankl, along with other
authors, has recognized that human beings are primarily spiritual beings, more so than the
product of biological and psychological mechanisms, and thus have the ability to act
responsibly and freely through self-transcendence and self-detachment (Frankl, 1986;
Reitinger, 2015). These spiritual qualities which guide behavior show some relevancy to
animal behavior. Frankl also noted in his writings that animals are able to feel anxiety and
respond to it accordingly without necessarily thinking about the response prior. In
contrast, human consciousness is necessary to convert a sense of failure in a physical
sense into feelings of guilt prior to it manifesting (Frankl, 1986; Podolsky, 1962).
Additionally, articles have been published that examine the use of existential
psychotherapy approaches with equine-assisted psychotherapy. An example of this is
Lac’s (2017) study in which the author looks at the use of an existential- integrative
aspect of equine therapy for treatment of anorexia nervosa. This study relates closely to
the development of the human- equine relational development (HERD) approach to
therapy, which was developed by Veronica Lac, PhD, the executive director of The
HERD Institute located in New Albany, Ohio (Lac, 2017). Lac’s institute offers specific
training and guidance for equine facilitated psychotherapy and learning (EFPL)
practitioners wishing to implement such therapeutic approaches and supports the progress
towards equine-assisted psychotherapy becoming recognized as an empirically based
form of treatment and educational modality (Lac, 2017).
Theory of Planned Behavior
This theory, developed by IcekAjzen, essentially focuses on the link between
human beliefs and their behavior (Ajzen, 1985). It explores how an individual’s behaviors
and even the intentions behind such behaviors are a direct result of their perceived
behavioral control, subjective norms and their attitude towards the behaviors(Ajzen,
1985). It stems from preliminary work done by Martin Fishbeinwith collaboration from
Ajzen on the theory of reasoned action (Fishbein &Azjen, 1977). Studies based on this
confirmed that there were high correlations between subjective norms and attitudes to
behavioral intentions as well as between the behavioral intentions and the actual
behaviors (Ajzen, 1985).Interestingly, actual behaviors as well as the noted intentions are
highly predictable when considering norms, attitudes, and perceived notions about
behavioral control (Azjen, 1991).
This makes sense not only in relation to human behavior, but also in relation to
animal behavior (Miller, 2017). The theory is derived from the basic idea that intention to
perform the behavior creates motivation for the behavior to occur (Steinmetz et al.,
2016).In addition to this, the ability for an individual to transition their beliefs and
corresponding motivation into action is largely dependent on their ability to self-regulate
(Quinton & Brunton, 2017). Understanding these salient beliefs, whether they are positive
or negative, help us predict outcomes related to behavior (Lesté-Lasserre, 2018).
Humans as well as animals have the ability to store control beliefs and behavioral
patterns in their memory(Steinmetz et al., 2016).Since horses are herd animals, they rely
largely on intuitive functioning to guide their behavior. It is through their trust and
attachment with other members of the herd that their safety is ensured when a perceived
threat is encountered (Dampsey, 2017). Humans also store normative beliefs, something
that animals are less aware of in relation to their social interaction, as they are not
generally susceptible to social pressures that may influence their behavior (Steinmetz et
al., 2016).
Eclectic Psychotherapy
This form of psychotherapy is based upon the use of multiple therapeutic
approaches to meet the diverse needs of a client. Historically, many forms of
psychotherapy have been implemented as stand-alone interventions; in contrast, this kind
of psychotherapy utilizesa number ofcombinations. Technicaleclectic psychotherapy
methods, for example multimodal therapy, which was developed by Arnold Lazarus
during the 1960s,solely focuses onuse of multiple techniques without regard to their
theoretical backgrounds (Lazarus, 2002).Initially referred to as multimodal behavioral
therapy, then simply as multimodal therapy, it centered on the idea that humans are
biological beings, or more scientifically,also referenced as neurophysiologic/ biochemical
entities (Lazarus, 1989). Humans have the ability toact and react, think independently, use
imagination, interact with others, experience sensory and affective responses, some of
which are transferrable to human/ animal behavior and interaction (Lazarus, 1989).
An example of this can be seen when utilizing equine-assisted therapy approaches
with prisoners, a population that is known for a myriad of self-regulationissues and a lack
of responsiveness to conventional therapy approaches. Rosie Meek, a London professor
who has studied the use of the equine-based curriculum, The Horse Course (THC),
indicated in her study that prisoners who participated were able to increase their
confidence, attention span, ability to persevere, self-efficacy, and skills related to self-
regulation, as well as self-relaxation skills (Meek, 2012). The outcomes of the study also
showed a statistically significant drop in recidivism rates: 36% for those in the curriculum
participation cohort—a 27% drop from the predicted reoffending rate of 63% (Meek,
2012).
More recent examples of studies exploring eclectic theory and the use of horses
for therapeutic interventions have also been published. Carlsson (2016) examined how
these combined approaches paired with equine-assisted social work were an effective
means of treating self-harming adolescents. Additionally, Turner (2018) found in her
study that 12.5% of providers who were performing equine-facilitated therapy utilized
eclectic theory to understand their clients.
In the late 1970s prescriptive eclectic psychotherapy was developed by Richard
Dimond and his colleagues as a way to create individualized treatment plans for each
client(Dimond et al., 1978).Then by the early 1990s another approach known as
systematic eclectic psychotherapy was developed by Larry Beutler and his colleagues. In
this approach, the therapist selects appropriate therapy interventions based on four key
areas: relationship variables, the context of treatment, individual characteristics of each
client, and specific strategies that are individually selected for each client based on his or
her unique needs(Beutler&Consoli, 1992).A combination of these techniques offers
individualized treatment when one single method might otherwise lack effectiveness. A
final comment: behavioral therapy and psychotherapy are seen as basically
indistinguishable (Lazarus, 1976;Smith, 1977).
Psychoanalytic Theory
Sigmund Freud is commonly known as the founding father of psychoanalysis, a
clinical method used in the treatment of mental illness that also developed into a theory
used to explain human behavior.Psychoanalytic theory, perhaps one of Freud’s most
important contributions to the field of psychology in the late nineteenth century, can be
defined as a theory of personality development and organization (Elliott, 2015). It can be
broken down into fivekey areas: dynamic, economic, developmental, structural, and
adaptive (Freud, 1964).Freud believed that using psychoanalysis to release suppressed
and repressed emotions would allow patients to become aware of unconscious thoughts
and this would allow the psychosis to be effectively treated (Elliott,
2015).Psychodynamic theory, which emerged in the early 20th century as a result of
Freud’s ongoing studies, involves a more systematic study of the underlying psychology
related to human feelings, thoughts, and emotions. It continues to be a useful approach to
psychotherapy (Shedler, 2010).
Swiss Psychoanalyst Peter Fonagy, along with Anthony Bateman, has done
additional work related to psychoanalytic theory that focuses more on the concept of
mentalization as a useful treatment process.Mentalization is defined as “a process, by
which we make sense of each other and ourselves, implicitly and explicitly, in terms of
subjective states and mental processes” (Fonagy& Bateman, 2010, p. 12).Their work
focused on three key areas that relate to the concept of mentalization: the therapeutic
stance, the aim of the interventions, and the transference(Fonagy& Bateman, 2010). The
latter concept of transference is most relevant in relation to equine-assisted
psychotherapy, since the interaction between the participant and the horse results largely
from indirect communications and nonverbal cues.
The use of psychoanalytic theory in conjunction with equine-assisted
psychotherapy approaches has also been discussed in the literature.For example,
psychoanalysis has been used in conjunction with equine-therapy approaches to treat
adults with a history of trauma and personality issues (Kovacs et al., 2020). Another
example of this was a study done by Tuuvas et al., (2017). Theyexplored how former
participants of equine-assisted psychotherapy experienced the relationship they had with
the horse they were in therapy with several years after they completed therapy. The data
analysis and study findings concluded that the horses were still perceived to have been
the most impactful relationship the participants experienced during the time they were
active in treatment. Their family members attributed their improvements during treatment
to be directly related to their relationships with the horses (Tuuvas et al., 2017).While
psychodynamic theory continues to evolve from its psychoanalytic basis, it continues to
remain one f the most adaptive, inclusive and versatile approaches used by therapists
(Fulmer, 2018).
Theory of Multiple Intelligences
In this theory developed by Howard Gardner, the author recognizes that each
individual has his/her own unique learning style and related ways that he/she tends to
learn new information and skills most effectively (Gardner, 1983). Gardner’s work which
began with his studies of developmental psychology and the work of Jean Piaget, carries
into his most recent work and asserts that intelligence can be measured in more ways than
just through IQ ratings (Gardner, 2020). In collaborative research done between Gardner
and Hatch (1989), they looked more closely at how the theory of multiple intelligences
could be applied in educational settings and inform teaching practices. The authors
originally identifiedseven types of intelligence that can be assessed (Gardner &Hatch,
1989).
Ongoing work by Gardner eventually led to the expansion of these types of
intelligence from seven to nine: logical- mathematical, naturalist, existential, musical,
interpersonal, linguistic, bodily/ kinesthetic, intra-personal, and spatial (Gardner, 2016).
Logical- mathematical means being smart with numbers and reasoning, while naturalist
means one is nature smart (Gardner, 2016). Existential refers to an individual being life
smart, interpersonal to being people smart, and intra-personal means one is self-aware or
self-smart (Gardner, 2016).The remaining types include musical, which means sound
smart, bodily/ kinesthetic, which refers to being body smart, spatial, which refers to being
picture smart, and linguistic meaning one is word smart (Gardner, 2016).
Gardner also shared in a recent research publication “Of Human Potential, A
40year Saga” that much of his training has been in social sciences, including sociology
and anthropology, however his ability to look critically at the constructs of human
potential has come from his ability to think and write from the mindset of a psychologist
(Gardner,
2020). This may be an additionalpoint to consider when looking at equine-assisted
psychotherapyas this theory seems relevant when evaluating human behavior and their
response to psychotherapy techniques.
In fact, the use of Gardner’s theory of multiple intelligence in combination with
equine- facilitatedlearning has previously been considered. One program known as
Central Kentucky Riding for Hope (CKRH) specializes in providing both challenging and
motivating equine-assisted activities to children with cognitive, emotional/ behavioral,
and physical disabilities (CKRH, 2018). In order to maximize outcomes (CKRH, 2018),
the Kentucky Program of Studies helped in determining that the programwould use
aspects of Gardner’s multiple intelligences to address multiple learning styles of the
children who attend treatment (CKRH, 2018).
Literature Review
As I first started to explore equine-assisted psychotherapy I began to collect
articles broadly. I soon discovered that a range of methods were being used to treat quite
a number of different conditions including both physical and mental health related issues.
I attempted to scan through the range of resources for which work with horses and people
with some form of disability or limitation was being used. I have divided these conditions
according to their intended use in the following discussion of the background of
equineassisted therapy as a whole. It was through my broad search of the literature
concerned with equine-assisted therapy that I began to gain a sense of the large field I
was reading about. I especially noticed the largest variety of types focused on the mental
and emotional conditions treated through equine-assisted psychotherapy. This helped me
to see how it might be further subdivided for a manageable study.
Historical Overview of Equine-Assisted Therapy
In the next section, I will identify several main subdivisions of equine-assisted
therapy. To begin, I will give a basic historical overview of how equine-assisted therapy,
meaning the use of horses for therapeutic purposes, has evolved so far.I will recognize the
terms associated with the various types of therapy, and the defining factors of each to help
distinguish the different ways horses are being used therapeutically in the field. This
information also will help to establish the timeline and sequence of emergence for equine-
assisted psychotherapy.
Hippotherapy
Hippotherapy is defined as a form of physical therapy that uses the horse as a
therapeutic tool to improve balance, posture, fine and gross motor skills, and overall
coordination for its participants (Thompson, Ketcham, & Hall, 2014).Physical therapists,
occupational therapists, and speechlanguage pathologists joined together in forming the
American Hippotherapy Association based on their utilization of horses and their basic
movement for common therapeutic means (AHA, 2014). They recognized the usefulness
of horses when paired with physical therapy, occupational therapy, and speech-language
therapy for primarily the physical health issues, but laterbenefits related to cognitive and
emotional wellbeing were also recognized (AHA, 2014).
Some existing literature points to the usefulness of this form of equine therapy. In
astudy conducted byPark et al., (2014), outcomes were evaluated for children who
participated in a form of hippotherapy using a horse riding simulator. This allowed
researchers to focus solely on the physical benefits. Twenty-six children with cerebral
palsywere split into two groups that participated in the same exercise routine using the
simulator for 1 hour a day, 3 times per week for the duration of 12 weeks (Park et al.,
2014). In the study outcomes, the authors showed that both groups experienced
statistically significant improvement in their static and dynamic balance, although no
significant difference was noted between the two groups regarding their participation
(Park et al., 2014).
In another study,that also utilized a riding simulator, the authors focused on the
physical benefits, such as gross motor function, experienced by 34 children with cerebral
palsy (Lee et al., 2014). The children in this study participated in hippotherapy sessions
twice a week for a 45-minute session aboard the simulator for the 8-week period during
which the study was conducted. The outcomes of this study were very similar to the
previously mentioned one: children showed marked improvement in overall physical
function and gross motor skills (Lee et al., 2014).
In other studies, researchers evaluated not only the primary physical benefits, but
also the psychosocial and emotional benefits of children with cerebral palsy who
participated in hippotherapy alongside their caregivers. Eight children participated in the
study and were involved in weekly 30-minute sessions for 10 consecutive weeks during
which time the researchers evaluated both their gross motor and psychosocial function
(Jang et al., 2016). In the results of the study, the authors concluded that, while there were
noted improvements in the physical function of the children, the psychosocial and
emotional parameters remained consistent throughout (Jang et al., 2016). While
hippotherapy does focus primarily on physical function, and the effectiveness of it has
been supported through many more studies than the ones outlined above, additional
studies focusing on the mental and emotional benefits gained with the use of real horses
for hippotherapy would likely enhance the overall benefits of this form of therapy.
Therapeutic Riding
This method of utilizing horses in a therapeutic manner for individuals with
physical health impairments focuses on how actually riding the horses has positive
outcomes. Most widely recognized in affiliation with Professional Association of
Therapeutic Horsemanship International, it incorporates a certification process for
instructors from a wide variety of backgrounds, some in psychotherapy (PATH
International, 2013).Therapeutic riding has been adapted for use with a wide variety of
participants: this is illustrated in the published literature.
In one study the impact on autistic children was evaluated to see if regular
participation in therapeutic riding would exhibit positive results. Eight children ages 8-16
years of age attended twenty-four 45-minute sessions(García-Gómez et al.,
2014).Thebehavior assessment system for children (BASC) and a standard quality of life
questionnaire were utilized to measure outcomes. The results showed both a reduction in
aggressive behavior as well as an increase in quality of life indicators such as social
skills, adaptive skills, and leadership skills (García-Gómez et al., 2014).
In another study the question was asked whether or nottherapeutic riding would
improve the balance of older adults in shared living communities(Homnick et al.,
2015).Due to the frequency of falls among this particular elderpopulation, and previous
studies showing significant improvements in balance among individuals with cerebral
palsy, itmade sense to evaluate the usefulness of therapeutic riding for them(Homnick et
al., 2015). Interestingly, while no negative side effects occurred resulting from
participation in the trial and results showed some improvement in balance, the
measurable outcomes never reached statistical significance (Homnick et al., 2015).
Conclusions from the study indicated future studies should be completed with a larger
sample size to support therapeutic riding as a form of exercise and a means of improving
balance in older adults (Homnick et al., 2015).
Equine-Assisted Psychotherapy
Equine-assisted psychotherapy, the use of horses as an experiential form of mental
health treatment, developed as a direct result of the recognition within the field of equine-
assisted therapy that mental health was becoming a notable area of focus. Considered by
the most recent research publications to be an emerging approach, it is still in its early
stages of infancy, since the first empirical research on equine-assisted psychotherapy was
published as recently as 2005 (Lee et al., 2016; Shultz,
2005).Unlikehippotherapy which focuses primarily on the physical needs of participants,
equine-assisted psychotherapyis focused primarily on the mental and emotional needs and
use within the mental health setting. It does not generally involve riding the horse
(Wang, 2017).
Main Divisions of Equine-Assisted Therapy
Treatment for Physical Issues
One group of Equine-Assisted Therapies is aimed at improving physical
functioning, often with people who have medical, physical, and developmental
limitations. For example, in one research study the authors sought to determine if the use
of adaptive riding could improve the overall postural and gross motor control of children
with cerebral palsy (Angsupaisal et al., 2015). The data they collected provided
information about the feasibility of therapist-designed and adapted therapeutic riding. The
protocol which they adapted and implemented had a positive outcome for the six children
who participated: there were marked improvements in their postural mobility
(Angsupaisal et al., 2015).
In another study by Haylock and Cantril (2006), the researchers explored the
usefulness of supporting the recovery process for individuals recovering from cancer
utilizing horses as therapists.While there were physical impacts, mental impact was noted
as well. The authors also speak candidly of the profound impact the horses had on
individuals experiencing terminal forms of cancer and facing the end stage of their lives
(Haylock&Cantril, 2006). It has been suggested that additional studies should be
conducted to examine the ability of horses to serve as comfort companions in terminal
care and to support recovery efforts for treatable physical illnesses (Haylock &Cantril,
2006).
In still other studies,researchers examined the physical benefits of equine-assisted
activities and therapies on improving physical function of the participants.In a study on
the use of hippotherapy in children who have developmental delays, researchers explored
the level of impact on their physical functioning (Thompson et al., 2014). During the
study the researchers also looked at whether there were any resulting psychological
benefits. The outcomes showed that the use of hippotherapy has useful implications for
improvement of physical health function as well as general quality of life (Thompson et
al., 2014).
Rigby and Grandjean(2016) concluded that, while the literature supports the
ideathat equine-assisted activities have significant physical health benefits, more studies
are needed to determine what exact mode and frequency is deemed most effective (Rigby
&Grandjean, 2016). In many of the articles, although researchers were exploring
outcomes on physical health, notable benefits to the participants’ quality of life were
found. Additionally, findings indicate that more focus needs to be placed on the
physiological basis for providing the outcomes and level of effectiveness outlined in the
literature (Rigby &Grandjean, 2016).
Treatment for Serious Mental Illness (SMI)
Another group of articles focused on people who have SMIlikeautism, severe
depression, and schizophrenia.SMI can occur among people of any age group and is
characterized by a disruption in “a person’s thinking, feeling, mood, ability to relate to
others, and daily functioning” (Downes et al., 2013, pg. 1). It can also relate in some
cases, as with schizophrenia, to the presence of psychotic episodes which may require
acute approaches such as hospitalization in order to assist the individual with stabilization
(Downes et al., 2013).
In a study by Cerino et al.,(2011), the researchers evaluated the use of therapeutic
riding as a non-conventional psychiatric rehabilitation approach for individuals with
schizophrenia.A group of 24 subjects participated in a year-long therapeutic riding
program and were evaluated both pre and post treatment. The outcomes showed a marked
reduction in negative symptoms, consistent stability, and reduced hospitalizations among
participants, and what the authors referred to as “constant disease remission” for both
chronic and early onset participants (Cerino et al., 2011, p. 413).
A more generalized pilot study was conducted that addressed how equine-assisted
psychotherapy can be used to enhance treatment for individuals with severe chronic
psychiatric disorders. Nurenberg et al., (2011) looked at how animal-assisted therapy
(AAT) is being used more frequently to treat more severe mental illnesses, including
cases involving aggression and severe trauma, in individuals who may not have
responded favorably to traditional therapy approaches previously. The researchers
developed an animal-assisted therapy protocol that they worked on implementing at a
500-bed state psychiatric hospital located in New Jersey. Based on the research they
reviewed comparing the use of dogs and horses for therapy, the use of larger animals,
such as horsesseemed to reduce some of the physical harm related risks associated
withtreating the chronically violent or highly regressed patients (Nurenberg et al., 2011).
A pilot study was donein which researchers evaluatedthe effects of therapeutic
horseback riding on school-age children and adolescents who were diagnosed with
Autism Spectrum Disorder (Gabriels et al., 2012). Social functioning is one area the
disorder impacts severely, along with communication impairments and a broad range of
emotional and behavioral issues (Gabriels et al., 2012). In the study, 42 children ages 616
years old engaged in 10 weekly sessions. In their results, the authors indicated that the
use of therapeutic riding with the participants reduced negative behaviors and resulted in
significant improvements in their self- regulation skills (Gabriels et al., 2012).
Another pilot study, which focused on the use of animal-assisted therapy for
veterans with serious mental illness, found that exposure to a variety of animals in a
number ofdifferent community settings had beneficial outcomes. The researchers found
that the outings involving the animals resulted in a marked reduction in anxiety and an
increase in communication between the veteran and the clinicians (Pollock et al.,
2017).Overall, although this particular study was small, researchers found results that
were favorable: some of the veterans wanted to continue to visit, or even volunteer to
work or spend time with the animals on an ongoing basis (Pollock et al., 2017).
Lastly, in a study byParker et al., (2014), the authors evaluated the implementation
of cognitive behavior therapy approaches in collaboration with other alternative therapies
for treating depression. The researchers reviewed a collection of original studies along
with the related quantitative analyses to evaluate the use of cognitive behavioral therapy
approaches in conjunction with horses to treat depression(Parker et al., 2014). The
authors concluded that while the effectiveness of cognitive behavioral therapy as a
standalone approach to treating depression is questionable, it may be more effective when
combined with supplemental approaches(Parker et al., 2014).
Treatment for Less Severe Mental Illness
The largest group of people I encountered in the literature on equine-assisted
therapy seems to be a subgroup working with less severe mental illness in individuals
who are experiencing a range of relational issues and problems with emotional regulation.
They are sometimes referred to in the broad mental health literature as having less severe
mental illness, which is a useful distinction for my purposes in this study (Gfroerer et al.,
2012). At present, treatment of this “less severe mental illness” category seems the least
well-defined of the equine-assisted psychotherapy methods but one of the most
commonly used. It seems likely that, with further exploration among the therapists who
work with people who have these less severe conditions, it will be fairly easy to identify
different ways of thinking about this work. Hopefully, with further clarification, theories,
observational methods, and other ways of separating out different types of equine-assisted
psychotherapy will be identified also.
In one studythe discussion centered on how equine-assisted learning (EAL) can be
beneficial to the general wellbeing of First Nations youth who are in treatment for
substance abuse. The researchers focused even more closely on female youth who abuse
volatile substances commonly found and easily accessible such as paint thinner, glue, and
gasoline (Adams et al., 2015). Equine-assisted learning takes a more hands-on approach
to therapy. However, it does not utilize riding the horses. The horse takes the role of the
teacher, while a facilitator helps guide the sessions to maximize feedback to the
participants as a result of their interaction with the horses (Adams et al., 2015). The youth
who participated noted marked improvements to their overall wellbeing, especially with
regard to their physical and spiritual wellbeing (Adams et al., 2015).
Additional studies have been conducted on the use of equine-assisted therapy
approaches with at-risk youth. Burgon (2011) identifies the benefits experienced by atrisk
youth who participated in equine-assisted learning/therapy. These seven young people
were part of his ethnographic study that followed such themes as self-confidence,
empathy, self-esteem, a sense of mastery, self-efficacy. Burgon’s study also followed the
ability of the youth to model behaviors such as being confident, calm, and exhibiting
leadership the horse has reinforced in them through their interaction (Burgon, 2011).In
the results gathered from this small sample size, researchers indicated that the youth
gained some level of psychosocial benefit as evidenced by improvements in self-esteem,
confidence, a greater sense of empathy, and better relational skills. The author suggests
that additional research should be conducted to affirm the benefits of at-risk youth
participating in equine-assisted activities (Burgon, 2011).
While in the previously mentioned study the researchers briefly explored the
impact of equine-assisted activities on relational skills, other researchers have taken a
closer look at this correlation. Bachi, (2013)who offered insight into the applicability of
attachment theory to equine-facilitated psychotherapy, explored how it influences
relational skillsin certain populations and made recommendations for future
applications.Her 2014 study evaluates the impact of an equine-facilitated prison-based
program and examines how human-horse interaction can have an effect on inmate
emotions and behaviors (Bachi, 2014). More recently she worked collaboratively with
another well-known researcher to evaluate the use of relational therapy with children
using animal-assisted psychotherapy (Bachi& Parish-Plass, 2017).
In additional studies that focus on implications for practice, researchers explored
how equine-facilitated psychotherapy (EFP) can be used as a complementary treatment
intervention along with more traditional therapy approaches (Brandt & Cities,
2013).Although the authors talk extensively about animal-assisted therapy (AAT) they
also delve into discussion about equine-facilitated psychotherapy (EFP) and its efficacy
in relation to empirically supported therapy interventions (Brandt & Cities, 2013).
Although they note EFP is more widely used, there is still a need for additional research
supporting it as a therapeutic intervention (Brandt & Cities, 2013).
To counter this idea of EFP as a complementary adjunct to traditional forms of
treatment, Johansen et al., (2014) identify populations that do not respond to mainstream
treatment approaches. They found that using equine-facilitated body and emotionoriented
psychotherapy alone in a structured manner can be beneficial. This form of therapy
centers on the recognition that horses are highly sensitive and emotionally responsive
creatures that can be used to teach self-awareness to participants. The therapist
specifically helps the participant identify how behavior and interaction with the horse
elicits responses. In sessions, they can explore together patterns of behavior and how to
modify the participant’s behavior to achieve desired outcomes with the horse
(Johansen et al., 2014).
In a similar fashion, Carlsson et al., (2015) provided insight into the usefulness of
using mentalizing and emotional labor to facilitate equine-assisted social work with
adolescents in residential treatment who engage in self-harming behaviors.Since horses
are described as having the ability to mirror emotions in such a way that creates genuine
interaction, this creates opportunity to increase the participant’s self-awareness about how
their behavior directly impacts the horse and its response to them(Carlsson et al., 2015).
The outcomes are seen to be beneficial to the participants and can result in a marked
decrease in the negative, self-injurious behaviors.
Similarly, Move- Lac et al., (2013) conducted another study that looked at
reducing the impact of self-harm. These researchersevaluatedequine-assisted
psychotherapy as a creative relational approach to treating individuals who struggle with
eating disorders. This approach ties in closely to the use of previously discussed Gestalt
psychotherapy, since it utilized client self-determination and self-awareness to support the
treatment process(Move- Lac et al., 2013).The study reviewed a case example of an
individual with an eating disorder who engaged in equine-assisted psychotherapy and
found her experience to be beneficial. Since the fundamental base of gestalt theory
consists of three elements: experiments, relationships, and contact, it makes sense that the
direct interaction with the horse contributed to the participant feeling a sense of physical
support and increased awareness about his/her own body (Move- Lac et al., 2013).
Although the last few studies seem to place emphasis on physical issues, there are
a number of studies that also evaluate whether equine-assisted interventions are able to
reduce the impact of mental trauma as well. In their study, Yorke et al., (2008) provided
information about the therapeutic value of equine-human bonding in helping individuals
recovering from trauma.
Krenek (2013) examined the effects of equine-assisted activities with veterans to
help improve their quality of life postcombat. Krenek noted that approximately 24% of
combat veterans who served in Afghanistan and Iraq return and experience varying
degrees of posttraumatic stress disorder (PTSD) symptoms (Krenek, 2013). Special
programming can assist the veterans in overcoming their symptoms, especially because
they often will not seek treatment due to fear of the societal stigma related to receiving
mental health care. One such program called PATH International Equine Services for
Heroes Program utilizes horses as part of the actual treatment interventions (Krenek,
2013). The program targets wounded military personnel with the hopes that they will
experience improvements in both their physical and mental wellbeing through interacting
with the horses (Krenek, 2013).
While most of the research is very specific to particular populations and
circumstances, some have taken more of a general approach to identify how the use of
horses in a therapy context relates to outcomes thathave a positive impact. Maujean et al.,
(2013) conducted a systematic review pertaining to the efficacy of equine-assisted
interventions that involve psychological outcomes. The authors explore how the research
has been successful in proving that physical benefits result from such interventions, but
their findings assert that additional research through randomized controlled trials is still
needed to explore whether psychological outcomes are consistently experienced
(Maujean et al., 2013).
Lastly, Parish-Plass(2013) explored in great detailanimal-assisted psychotherapy
and how it has evolved, offering insight into theory, practice, and implications for the
future.The overview relates how, even as far back as the 1970s, roughly 20% of
psychotherapists affiliated with the American Psychological Association incorporated
animals into their work in some way;the trend is growing (Parish-Plass, 2013). The scope
of practice has also broadened immensely to include a wide array of populations with
issues related to trauma, developmental disabilities, emotional regulation problems,
attachment issues, behavioral dysfunction, and a large number of psychological disorders
(Parish-Plass, 2013).
Equine-Assisted Psychotherapy
The term equine-assisted psychotherapyis generally associated with humans
interacting with horses in a therapeutic manner to create opportunity for emotional
healing through the use of psychotherapy techniques. According to the
EAGALA,equineassisted psychotherapy is defined as “a collaborative effort between a
licensed therapist and a horse professional designed to address specific treatment issues
presented by a psychotherapy client” (EAGALA,2012). Participants experience the
opportunity to learn not only about themselves, but also about others through interacting
with the horses by means ofinteractive sessions on the ground with the equine
professional. Participants also process any feelings or behaviors that surface in these
collaborative sessions with the licensed mental health therapist (EAGALA, 2012).
In recent research conducted by Wang (2017), the authortakes a closer look at the
use of equine-assisted psychotherapy using the EAGALA model that is comprised of four
key components. The first of these involves the use of a team to facilitate the
sessions.The team is made up of an equine specialist and a certified mental health
professional (Wang, 2017). Secondly, the therapy sessions do not involve riding the horse
and are conducted solely from the ground level. The third component involves EAGALA
following a professional code of ethics to support credibility and ensure wellbeing of the
organization and its participants (Wang, 2017). Lastly, the fourth component that relates
to the EAGALA modelpertains to operating under a solution-focused approach where
direct observation ofaparticipant’s responses to maximize outcomes of the interventionsis
used (Wang, 2017).Although there are other approaches being used independently to
implement equine-assisted psychotherapy, the EAGALA model seems to have a
significant level of support and is widely implemented, not only in the United States, but
also internationally(Johns et al., 2016).
Equine- Facilitated Psychotherapy
The term equine-facilitated psychotherapy (EFP) refers to a variety of beneficial
activities involving horses that allow healing to take place as a result of human- horse
interaction. Defined by PATH International(2016) as“a form of experiential
psychotherapy that incorporates the use of horses,” it differs from equine-assisted
psychotherapy because it utilizes a broader variety of equine involved activities beyond
groundwork. Examples of this include riding, vaulting, and driving, in addition to
grooming activities (PATH International, 2016).
Like equine-assisted psychotherapy,equine-facilitated psychotherapy (EFP)
requires a collaborative effort between a licensed mental health professional and a
credentialed equine professional. However, this therapy canalsobe implemented by an
individual with dual credentials as both an equine and mental health professional (PATH
International, 2016).The goal of equine-facilitated psychotherapy (EFP) is quite similar to
equine-assisted psychotherapy in that it seeks to assist the individual with the process of
identifying feelings and behaviors and increasing overall self-awareness.In the most
recent research some useful insight into the use of attachment theory to guide
equinefacilitated therapy (EFT) approaches has been shown, although additional research
is needed in this area (Vincent& Farkas, 2017).
Keren Bachi (2013), who has done extensive research in the areas of
equineassisted psychotherapy as well as equine-facilitated psychotherapy
(EFP),conducted a thorough life cycle analysis of the growing field of equine-facilitated
psychotherapy (EFP). She found that there is a general consensus that it developed as a
result of collaborative efforts rather than as the work of a single individual or
organization and this partly explains why many varying forms exist today (Bachi, 2013).
Currently,EAGALA and the PATH International are the two primary accredited
organizations in the field (Bachi, 2013). Due to variations in their philosophies and in the
way they employ their interventions, a dispute arose between the two organizations that
has resulted in a longrunning rift. Some individuals even choose to function
independently without affiliation to either organization (Bachi, 2013). This division in the
field has led to increasing difficulties in the development of standardized methods that
can be evaluated for efficacy—an ongoing concern for those who seek to help the field
gain credibility through empirical research (Bachi, 2013).
Equine-Facilitated Experiential Learning
Equine-facilitated experiential learning (EFEL) can be described as any activity
using horses that is relevant to experiential learning(Stock & Kolb, 2016).Often used in
the literature interchangeably with the term equine-facilitated learning (EFL), it is most
prominently utilized in group settings with participants interacting with the horses from
the ground. Four learning cycle stages are identified for use with group participants: a
concrete experience, reflective observation, abstract conceptualization, and lastly active
experimentation (Stock & Kolb, 2016). Participants work towards achieving four
objectives: getting to know themselves, leveling the playing field, building trust, and
being able to recognize their role as a part of a bigger system (Stock & Kolb, 2016).
One well-known name associated with this form of equine-assisted work is Linda
Kohanov, founder of Epona Equestrian Services Center. She holds a dual role as both a
riding instructor and a counselor with twenty years of combined experience
(Maziere&Gunnlaugson, 2015). Kohanov is a specialist in equi-therapy as well as an
author of four books that are internationally acclaimed: they have raised awareness about
this method of equine-assisted work (Maziere&Gunnlaugson, 2015). Kohanov combines
a number of techniques including spirituality, psychology, natural horsemanship, body
language, and of course experiential learning(Kohanov, 2015).
The implementation of animal-assisted therapy programs in both health and
mental health organizations like those mentioned above is becoming more commonplace.
In their study,Mallon et al., (2006) looked at best practice guidelines for developing and
implementing such therapy programs. The authors explored the topics of safety, liability,
cost effectiveness and animal selection, as well as staffing and client issues. Useful
implications that resulted pointed to the benefits of some standardized approaches that
may maximize potential for positive outcomes (Mallon et al., 2006). These considerations
also demonstrate the importance of clearly delineating and defining the various types of
equine-assisted therapies to allow one to be distinguished from another, while at the same
time keeping some operating mechanisms standard for consistency.
Spirituality and Equine-Facilitated Learning
Some of the current literature has begun to recognize the relevance of spirituality
to equine-assisted work. Spirituality refers to what is occurring within the human spirit,
the changes that take place internally within one’s soul.As mentioned above,Maziere and
Gunnlaugson(2015) explore how horses can be used in a therapeutic manner to teach
individuals in leadership roles about themselvesthrough comparative self-examination
techniques.Sheade (2020) explores the general ability of horses to heal people through the
use of counseling and psychotherapy. Puchalski (2006) examines the importance of
spirituality to clinical practice.The incorporation of horses with spiritual
meditationpractices has also been studied, as has the human-horse interaction and its
impact on not only the physiological state of the human body, but also the impact on the
spiritual subconscious mind of humans(Andelora, 2017).
A recent study published in the Journal of Spirituality in Mental Health that was
conducted among mothers of children with a disability specifically looked at the spiritual
and holistic benefits they believe they received as a result of participation in
equineassisted therapy (Escobar, 2021). Books have also been published that illustrate the
spiritual strengths of horses in a therapeutic capacity. One example, “Zen Mind, Zen
Horse: The Science and Spirituality of Working with Horses” (Hamilton, 2011) focuses
on the usefulness of natural horsemanship techniques to form partnerships with horses
that are based on mutual respect and trust. Hamilton (2011) goes on to explain in his book
that as humans mature, they have the natural tendency to redirect their focus to their
spiritual growth and he asserts that this desire to attain spiritual transformation can be
accelerated by using horses as a sage or guide because they function in the present
moment and can teach us to do the same.These findings have been helpful as part of
meditation, yoga, and the use of mindfulness techniqueswhen implementing integrative
interventions to treat individuals with a variety of physical and mental conditions
(Andelora, 2017).
In another study on the impact of equine-assisted learning (EAL) on First Nations
Inuit youth, the authors explore not only this importance of spirituality to the population
as a whole, but how horses fit into the role of spiritual guide for the at-risk children they
interact with (Dell et al., 2011). In their study, Hunter and Sawyer (2006) also look at
how spirituality plays a key role when working with Native American children to provide
mental health treatment. Additional research related to animal-assisted therapy found that
dogs are capable of forming strong spiritual bonds with their handlers. This notion is
highly transferrable, given what we know about horses and their ability to form similar
attachments (Majaraj et al., 2016).
The implementation of equine-assisted psychotherapy in a culturally responsive
way with other indigenous populations for which spirituality is important has also been
evaluated in a recent study conducted among Aboriginal people in Australia (Bennett et
al., 2019). The study found that the use of experiential therapy involving horses to help
this particular population overcome intergenerational trauma and the effects of
marginalization seems to be promising in its potential to address the trauma and increase
general well-being among participants (Bennett et al., 2019). These findings further
support that there may be a strong connection between spirituality and the use of
equineassisted psychotherapy.
Summary and Conclusions
Although a great deal is known about equine-assisted work, there is still much that
is unknown. The literature shows that there is currently such a broad selection of
implementation methods for horses in a therapeutic context that it has become difficult to
evaluate what guides the practice and lends itself to evolution in the field. Through this
literature review I have been able to define the various ways equine-assisted work is
currently being used and to what degree this work has been compared and contrasted in
the existing literature. I hope that through the sections I have written, the reader will have
a clearer understanding of the differences betweenhippotherapy, equine-assisted therapy,
equine-assisted psychotherapy, equine-facilitated learning and the implementation of
each. I also hope that my overview of the most common theoretical approaches I found
when reviewing the literature will help provide insight into the variances seen in
treatment approaches for the different types of equine-assisted psychotherapy.
It is only through continued research efforts and attempts to synthesize
theexistingbroad collection of literature that we can begin to identify themes and work
closer to defining a unified theoretical foundation.A part of this is recognizing both the
similarities and differences in the way the therapists conducting equine-assisted work
think about what they do in order to further the understanding of what guides their
practice approaches. In the next chapter, an overview of the research design I have
selected will be given as well as an explanation of the methods and rationale forhaving
chosen a generic qualitativeapproach for my study.
Chapter 3: Research Methods
The purpose of my study was to explore how therapists who perform
equineassisted psychotherapy think about and understand what takes place between the
client and the horse and to gain a better understanding of their perceptions and
experiences. Some of the rationale for why I chose a generic approach was explained
under the nature of the study piece in Chapter 1. However, I expand on it in more detail in
this chapter. The research question that guided my study was centered on gathering
knowledge about how therapists performing equine-assisted psychotherapy understand
the work they do and what guides their practice.
Research Design and Rationale
In choosing a research design for this study, it was apparent, based on my research
question and what I wanted to know, that a generic qualitative method would be most
appropriate. It has been noted in the literature about the use of generic qualitative
research approaches that information that is being collected in a psychological sense is
not generally able to be measured statistically and requires a qualitative approach (Elliott
&Timulak, 2021; Kahlke, 2018). However, the more focused approaches such as
phenomenology, case study, ethnography, and grounded theory are not necessarily
appropriate for a variety of reasons(Charmaz et al., 2019; Chun Tie et al., 2019; Levitt,
2021; Percy et al., 2015). I was able to rule out that ethnography wasnot appropriate for
my study since it most generally is used when investigating topics in a cultural context
(Kahlke, 2018; Percy et al., 2015). Although themes related to culture could certainly
have emerged, the primary focus of my study was not related to the context of culture
(Kahlke, 2018; Percy et al., 2015).
Phenomenology, an approach that researchersuse to understand lived experiences,
allows them to capture the essence of what a person or population is going through in
relation to their cognitive process (Kahlke, 2018; Percy et al., 2015). Pietkiewicz and
Smith (2014) note that qualitative researchers are most interested in the overall meaning
of things they are researching, and with phenomenology this translates into how their
subjects experience events and make sense of their lived experiences. While this theory
does look at feelings, attitudes, opinions, and beliefs, it is less concerned with what in
particular may have triggered them (Kahlke, 2018;Percy et al., 2015). I was interested in
knowing not only what guided the thought processes of the therapists, but also if there
were any external factors that provided input into their clinical process.
I did consider conducting my study using grounded theory as the approach.
However, as I began gathering research and writing my literature review, I began to
develop an understanding thatthere is not one definitive theory guiding the practice of
equine-assisted psychotherapy. Grounded theory requires more of an explanatory
dialogue, not necessarily a descriptive one (Charmaz et al., 2017; Chun Tie et al.,
2019;Percy et al., 2015). Grounded theory is commonly defined as the construction of a
theory through collection and analysis of research data (Levitt, 2021;Martin &Turner,
1986).This was examined in depth by a number of prominent researchers including
Charmaz (2014), Corbin and Strauss (2014), and Glaser et al. (2013), who all explored
techniques and procedures for developing grounded theory. Additionally, Corley (2015)
refers to grounded theory as “engaging a phenomenon from the perspective of those
living it” (Corley, 2015, p.601) and asserts that it is not a methodology that is meant to be
allencompassing. While data collected from this study may be useful for future studies
using a grounded theory approach, more needs to be known about how the therapists
perceive what they do in relation to the use of theory to guide their practice.
Lastly, I did evaluate whether a case study method would be beneficial. According
to Percy et al. (2015) a case study is defined as “in-depth investigations of a single case”
(Percy et al., 2015, p.76) and most often involves both multiple methods and sources of
data.Yin (2017) expands on this definition noting that case study is an empirical inquiry
that often asks “how” or “why” and looks at real life phenomena and at the boundaries
between them.Although this is seen as an exploratory approach, not enough is known
about how therapists who do equine-assisted psychotherapy think about their work. I
decided the use of a case study method may be more beneficial once some preliminary
findings could be used to identify themes for a cross-case comparison (Yin, 2017).
To expand on what was written by Caelli et al.(2003) regarding the use of generic
qualitative approaches in a standardized manner, an article was published on the use of a
specific model known as the VSAIEEDC method (Kennedy, 2016). A form of
cognitionbased analysis developed by seminal author Dr. Roland Persson, this method
uses seven steps: variation, specification, abstraction, internal verification, external
verification, demonstration, and conclusion (Kennedy, 2016, pg. 1373). In addition to
this,
Kahlke(2014) highlighted both the benefits and risks of using generic qualitative
approaches and alsowent on to elaborate further on this in a subsequent publication,
providing reflection and commentary on why generic qualitative approaches are a
practical alternative to other forms of methodology (Kahlke, 2018). This particular
approach can be considered to provide some additional structure during the data analysis
phase as this method is not uncomplicated, and difficulties can arise when trying
toimplement generic qualitative inquiry (Caelli et al., 2003; Kennedy, 2016).
Using a generic qualitative approach, Iexploredthrough use of qualitative
interviewing techniques how the therapists think about their patients, what they hope to
accomplish, and how they know whether or notthey are actually achieving their goals in
the sessions. Ilooked at how they knew if these identified outcomes were occurring and
how they understood the changes that do or do not occur in the equine-assisted
psychotherapy sessions. They were asked if there was some particular theory they follow
in thinking about their patients and the work with the horses. In addition, Iasked what
they learn from watchingthe behavior of the horses as well as how they describe the
activities they assign to the clients and the horses.The resulting findings from these
interviews will be used to inform both practitioners and the research community.
Role of the Researcher
While I was working independently on this study,Iparticipated in several different
capacitiesthroughout the completion of it. First, I served as the recruiter and screener for
participants prior to the actual start of the study. Once I was able to schedule interviews,
the role of primary investigator and observer was then assumed. This role allowed me to
collect general information related to the therapist, such as length of time performing
equine-assisted psychotherapy and number of people worked with using equine-assisted
methods, in addition to asking the questions central to my study. Ialso collected general
demographic information about the client population for each therapist (age range,
gender, presenting problems, etc.) and following the actual data collection I served as
data analyst to determine outcomes.Clark and Vealé (2018) support this idea by
referencing how the role of the researcher is multifaceted. They explain how interpretive
thinking and focus take on the utmost importance during the data collection process since
the researcher essentially is the primary instrument to both gather and analyze the
findings (Clark &Vealé, 2018).
I needed to remain aware of some of the challenges I could encounter when
archiving the qualitative data I collected. Fink (2000) identifies seven stages in the
qualitative research process that are carried out in the following order: thematizing,
designing, interviewing, transcribing, analyzing, verifying and reporting. Different factors
throughout the use of this process can impact the outcome:the integrity of the
respondents, the actual collection and proper documentation of the data collected by the
researcher, and how the researcher views his or her method and data materials (Fink,
2000).
Karagiozis (2018) also highlights how the interaction between the researcher and
participants can have a significant impact on the outcome of the actual research and the
knowledge derived from it.Understanding potential ethical conflicts, political impact, and
cultural influences is also important and should be given consideration during the
interview process (Karagiozis, 2018).This is further explained byRÅheim et al. (2016),
whooffers a detailed explanation of how qualitative research tends to try to find a
common ground in an epistemological sense between the researcher and participant.
Additionally, the authors noted that the published literature on this methodology seeks to
minimize the gap between the roles of researcher and participant as well as the unequal
distribution of power that exists(RÅheim et al., 2016).
Pozzebon (2018) expanded on the role of the researcher when doing
nonpositivistic qualitative research. She wrote several publications that provided insight
into the principles that affirm such work. Traditionally, researchers who have opted to
conduct qualitative research in ways that vary from mainstream approaches have
struggled to prove its validity(Pozzebon, 2018).She went on to note that the actual role of
the researcher is, not simply to assist in interpreting or analyzing the social reality being
studied, butactually totransform that reality, which is more difficult to justify to the
broader research community (Pozzebon, 2018).
As I completed mystudy I needed to remain aware of any bias I encountered that
potentially could impact the outcomes and the information published related to the
findings.A previous study was conducted that evaluated both dissemination and
nondissemination bias pertaining to qualitative research. In the outcomes, the authors
showed an increased likelihood that researchers will synthesize the findings and
evidence(Toews et al., 2016). I needed to remain mindful that the findings are all of equal
importance: no particular outcome should be given precedence when conveying the
results.
As mentioned previously, although I have worked in the mental health field
before, I have never held the role of equine-assisted psychotherapist. This personal
history is still important however, since I may have a heightened awareness of mental
health conditions as a result. Additionally, I have owned horses for a significant portion of
my life and have found them personally to be therapeutic.In order to avoid bias during the
data collection phase, I needed to be mindful not to project this personal assumption
and/or opinions while interviewing the therapists.My related experiences have given me a
strong bias of believing interaction with horses has therapeutic value. These experiences
also have led me to pursue relationships with other individuals who have the same belief.
In order to avoid any potential conflicts of interest,I also had tobe careful to recruit
participants with whom I did not have any personal connection, nor wereinvolvedwithin
any professional capacity.
Methodology
The research design which was used for this study was qualitative in nature and
utilizeda generic qualitative method. Although I have given an overview of my rationale
for choosing this method in previous sections, I will continue to expand on it here as well.
Generic qualitative approaches were initially brought under strict scrutiny as an approach
to research due to being poorly defined historically(Carter &Laurs, 2014). As more time
and energy has been spent exploring the use of such methods, especially by doctoral
students such as myself, researchers have been able to recognize that there are significant
benefits to using a generic qualitative approach (Auta et al., 2017).
Carter and Laurs (2014) published a book thatgives an in-depth overview of the
risks and benefits of using generic approaches to qualitative research and also gives a
historical overviewof the growth and development of such research methods. In Chapter
3of their book they go on to explain in much greater detail that when looking at the
processes associated with generic qualitative approaches, they are able to teach students
the importance of still being able to accurately define what they are doing in order to
demonstrate that critical evaluation has taken place despite not using a more traditional
approach to qualitative research (Carter &Laurs, 2014).
Kahlke (2014, 2018) referenced this generic qualitative approach in several
publications, which is also referred to as an interpretive or basic qualitative approachas
being less clearly defined than the established methodologies that fall under qualitative
research. As such, those approaches do not support anyparticular theoretical assumptions
and are less theory driven, though not entirely atheoretical (Kahlke, 2014, 2018). More
recently, Jahja et al., (2021) also evaluated the use of these generic approaches and
indicated that qualitative research must have an understanding of theory, philosophy, and
terminology which can result in conflicting perspectives. To add to this, Elliot et al.
(2021) evaluated the use of a generic approach and included some analysis into the use of
descriptive- interpretive qualitative research. This general approach allows for much more
flexibility in terms of what the researcher wants to know, as well as tothe obtaining of
answers to the questions the researcher has that may not align with any particular formal
methodology (Kahlke, 2014, 2018).When using the descriptive qualitative approachcodes
are generated using the language from the actual data itself (Renate et al., 2014).
When considering what I wanted to know and what information was required to
accurately answer my research question, there were numerous approaches that couldhave
beenutilized. According to Lichtman (2013) the purpose of qualitative research is to
understand and interpret the meaning of both social phenomena and the basis of human
interaction. Despite trying to apply the various qualitative frameworks to my study it
became apparent that outcomes would be difficult to capture using the more traditional
and compartmentalized approaches. It is for this reason primarily that a generic
qualitative approach provided a greater degree of flexibility and made the most sense for
my study from a research standpoint.
Participant Selection Logic
The participants I was targeting for my study were therapists who said they
perform equine-assisted psychotherapy with people who have conditions that fall within
the less severe range of mental health. To clarify, this range refers to those individuals
who are stable and do not require acute hospitalization for psychosis, yet who still
encounter challenges related to their daily functioning, emotional regulation, and ability
to relate to others (Downes et al., 2013, pg. 1). Ideveloped a flyer for recruiting purposes
that had a list of the requirements participants must meet to be in my study. Criteria for
participation that were outlined on the flyer included therapists who are licensed or
certified in accordance with their state’s laws(e.g.,licensed practical counselor (LPC),
licensed social worker (LSW), doctor of philosophy (PhD), medical doctor (MD), and
licensed psychologist) who call their work with clients“psychotherapy”, and have 3-5
years of experience performing equine-assisted psychotherapy. I indicated that I was
interested in learning more about how they think about their work and also about what
guides their practice.
The flyers were distributed via the social media site Facebook to recruit
participants. I provided my contact information for any questions related to participation
and to acknowledge interest in being part of the study.I decided on social media as a way
to recruit in order to avail myself of the possible diversity of participants not just from a
local area, but from across the United States. This method of recruiting seemed to offer
the broadest reachwithin the most reasonable time constraints. I was hoping to have
between 5-10 respondents willing to participate in the study.I set up interviews with each,
and the interviews were to be conducted in person if possible, based on location/
proximity. Other options for interviews, when face-to-face interaction was not possible,
included phone contact, or the use of Skype.In order to obtain informed consent, I had
participants sign a consent form I provided in advance of the interviews either in
person,via email, or by mail, whatever was most convenient for the participant. By
utilizing an interview consent form with participants, permission was obtained to audio
record the interviewsand capture verbatim responses. This allowed for the most accuracy
when transcribing the data collected.
Instrumentation
For this studyI developed an interview protocol combining the approaches
ofSeidman (2019) and Rubin and Rubin (2011)that usesa number of questions related to
my research question (see appendix). Through the use ofthese questions,I interviewed the
therapists who say they perform equine-assisted psychotherapy. In addition to this
protocol, open-ended reflective questioning was used, based on the methods suggested by
Rubin and Rubin (2011) who recommend a series of layered questions aimed at gaining
increased depth of response.
The importance of using advanced listening skills during the interviews cannot be
emphasized enough, since it has been found that participants tend to talk most about the
areas of discussion that the interviewer seems most interested in and appears to listen
to(Evans et al., 2017). Since my study was exploratory rather than explanatory, the
information I collected could potentiallyserve as a baseline for further studies and may
not offer conclusive outcomes. As such the question of the sufficiency of the data
collected should remain relatively open.
Procedures for Recruitment, Participation, and Data Collection
After the initial recruitment efforts noted above in the participant selection logic
section were completed, Icompleted consent forms to make the participants in my study
aware of any potential risks and/or benefits related to their involvement.Once consent
was obtained, I interviewedparticipants in depth using open-ended questioning
throughresponsive interviewing; a form of qualitative inquiry described by Rubin and
Rubin (2011). I tried to learn how they think about their work and what they think is
taking place with their clients and with the horses, as well as how they measure the
efficacy of their interventions.Responsive interviewing provides in-depth insight because
the researchers respond to and ask additional questions based on what they hear from the
participants being interviewed as opposed to relying only on predetermined questions
(Rubin &Rubin, 2011).
Data Analysis Plan
The semi-structured responsive interviewing style mentioned above was
beneficial to this study becauseit allows the researcher to have some room for digression:
unexpected topics may arise that may not directly relate to the primary area of study, but
may still be considered relevant to some degree (Morris, 2015). Then while he/she has
specific topics he/she wants to cover related to the research questions, the study
participant can feel free to elaborate, and the researcher is able to clarify what the
participant says and why it is said (Morris, 2015). The participant’s responses are
thenrecorded and closely examined in a qualitative context using open coding by hand to
break down the interviews into subtopics to help identify emerging themes and
significances (Salmons, 2014).Additional insight into designing a coding system and
using this method to analyze data was given by Vanover et al. (2021) as well as
considerations for use of a qualitative data analysis software (QDAS) versus the use of
hand coding. The authors highlighted the importance of considering these options in the
early stages of the study to aid the data analysis process(Vanover et al., 2021).
Belotto (2018) identified in his article that qualitative approaches are well suited
for the earlier stages of research when particular variables have not yet been identified.
Since this was an exploratory study, minimal pre-codes wereused and were limited to
basic terms in therapy that can serve as a starting point to help sort and possibly code the
data. Additionally, data collected from participants wascross-compared for repetition of
terms that could point to themes.While Vaughn and Turner (2016) identified that a variety
of software can be used to sort and organize data, for this inquiry a method described by
Damien Gorden (1992) that involves transcribing all of the interviews from the
recordings and then reviewing them individually was used.
I was able to underline any repetitious words or phrasesand give each word or
phrase an identification numberthatcoincided with its location in the transcript. The
number used represented the line of the actual transcript and a letter such as A,B, C, D,
etc. was also be assigned in cases where there was more than one word or phrase per line
(Gorden, 1992). Overall, when opting to hand code instead of using software, it is
beneficial to the coding process to be able to sort through the large amount of collected
data one question at a time in order to organize it (Vaughn & Turner, 2016).
Once all the words or phrases were identified they could be classified into
categories of relevant information and defined accordingly. This process is referred to by
Saldaña (2015) as a splitter technique of coding that, as it asserts, allows the researcher to
split large chunks of data into smaller categories of codes. This allowed me to compare
the content of the interviews for the same topics and to summarize the results by
evaluating the frequency of each type of information given in the interviews (Gorden,
1992). As previously mentioned, the data collected from these interviews will be used to
provide implications and recommendations for future studies. The outcomes from the
study will be made available to any of the participants who provided data and have an
interest in knowing the results of the study.
Issues of Trustworthiness
Since this study was qualitative in nature it faced some limitations in terms of its
level of trustworthiness. Unlike quantitative research that has various statistical measures
that can be applied, qualitative research looks at four specific domains related to
trustworthiness: credibility, transferability, dependability, and conformability (Noble&
Smith, 2015).Korstjens& Moser (2018) also reiterate these four domains and assert that
an integral part of ensuring quality and transparency of qualitative research is
reflexivity.In addition to this, specific protocols related to characteristics of rigor are often
used to increase trustworthiness in qualitative research (Amankwaa et al., 2016).
Johnson et al. (2020) also expanded on the relevance of rigor and reflexivity to the
level of trustworthiness. They noted that the insight a researcher has into their own biases
will impact their decision-making rationale throughout the study and contribute to the
level of trustworthiness (Johnson et al., 2020). Giving special attention to the criteria
associated with each when involved in not only the planning, but also in the conducting
and documentation stages of the research is essential in proving to both the readers and
evaluation that the research meets high quality research standards (Ponelis, 2015).
Trustworthiness in qualitative research can be defined as “the degree of
confidence in data, interpretation, and methods used to ensure the quality of a study”
(Connelly, 2016; Polit & Beck, 2014, p.435). Chang (2014) goes into great detail about
the use of member checking, or sharing the data and interpretations with those from
whom the data was collected from, in order to ensure accuracy. Diane (2014) also
identified how effective the use of triangulation or using multiple sources of data or data
collection methods such as interviews, note taking, and observations to draw conclusions
can be.It is all important to take into consideration that ultimately researchers are
considered human instruments; how well-prepared they are to fulfill their role as data
collectors has a tremendous impact on the outcomes of the study (Goodell et al., 2016).
Credibility
Credibility, much like internal validity, refers to the internal consistency of the
study and measures how well the researcher’s portrayal of his or her participants matches
the actual participants’ perceptions (Ponelis, 2015).The use of deep observations when
interacting with the participants assisted in preserving the credibility of the data collected.
Also referred to as having “confidence in the truth of the findings”, credibility strengthens
trustworthiness (Amankwaa, 2016, p. 10; Guba& Lincoln, 1981). As referenced by
Shufutinsky (2020) establishing how inductive researchers will be able to apply “use of
self” methods to increase rigor, transparency, trustworthiness, and credibility takes on
significant importance.
The use of member checking to verify that both the experience of the researcher,
as well as the data collected is accurate according to the participant aids in ensuring
credibility (Diane, 2014). This has been considered a “gold standard” and a “crucial
tactic” for establishing trustworthiness in qualitative studies (Kornbluh, 2015, p. 397;
Guba & Lincoln, 1985). Respondent validation allowing the participants to review and
comment on the transcripts from the interviews was utilized to investigate whether the
final concepts and themes that are recorded were reported accurately (Noble & Smith,
2015). Additionally, audit trails, engagement, and methods of observation can also be
used to support credibility of the study (Diane, 2014).
Transferability
Transferability refers to the degree to which the study has been successful in
making it viable for those reading it to apply the findings from the investigated situations
to other similar situations (Ponelis, 2015). Amankwaa (2016) asserts that this also
involves a researcher’s ability to show that the findings are applicable in multiple
contexts. It is important that all evidence from the study is reported so the reader has
some way to determine that the findings are a direct result of the experiences and data as
opposed to subjectivity and bias on the part of the researcher who conducted the study
(Ponelis, 2015). A qualitative study is said to have met the criteria of transferability if
individuals not connected to the study are able to relate the results of the study to their
own experiences in some way (Diane, 2014).
Dependability
Dependability refers to the quality of the actual data collection and analysis
(Ponelis, 2015). It must show that the research systematically studied what it intended
to.Since qualitative research is not like quantitative research in its ability to generalize
findings, the dependability of the study relies on the specific focus of the study and the
related consistency of the data under conditions that are similar (Diane, 2014). An effort
must be made to compare and contrast across all participants to identify similarities and
differences, as well as to offer equal representation for all different perspectives of the
participants to be included in the outcomes (Noble & Smith, 2015).
Confirmability
Also known as neutrality, confirmability refers to the acknowledgement that there
is a certain level of objectivity within any given study (Noble & Smith, 2015). While it is
not possible to achieve 100% objectivity, the use of confirmability to provide integrity
and allow replication of the study is feasible. This is discussed when looking at the
quality assessment factors of qualitative research, which, in the case of my study,
involved a generic approach. The importance of confirmability can vary slightly
depending on what sort of approach a study uses.
For example, while the topic of credibility seems to take on greater importance for
grounded theory studies, the issue of confirmability is held in higher regard for studies of
an ethnographic focus (Hannes, 2017; Toye et al., 2013). This is because transparency is
essential to preserve an externallocus of control. Several tactics include developing
specific research protocols and being aware of any researcher bias (Ponelis, 2015).This
allows for replication to occur at a later date, if need be, and reduces likelihood of
researcher bias based solely on interpretations (Hannes, 2017; Toye et al., 2013).
Ethical Procedures
The American Psychological Association identified five principles for research
ethics to assist researchers with their responsibility for implementing ethical strategies
(APA, 2018). The topic of intellectual property is identified as one of these strategies.
Although issues of authorship will not be of concern because I was the sole researcher for
this dissertation, it was of utmost importance that I properly cited all work that has
contributed to the development of my study.
The second principle relates to having multiple conflicting roles as a researcher
(APA, 2018). As previously mentioned, I have identified the areas of potential bias I have
related to my experiences as a horse owner and a former mental health therapist.However,
the level of conflict would have drastically increased if I were currently working as an
equine-assisted psychotherapist. The third principle identified by the American
Psychological Association is the importance of following the rules surrounding informed
consent (APA, 2018). The informed consent must make the participant aware of any
potential benefits or risks of participation, the purpose of the research, procedures used
for the research and anticipated duration, limitations that may impact their confidentiality,
incentives offered in exchange for participation (if any), who the participant can contact if
they have any questions, and lastly their right to withdraw from the study (APA, 2018).
The privacy and confidentiality of the study participants was of utmost
importance. This is recognized as the fourth principle identified by the American
Psychological Association (APA, 2018). This study was required to undergo stringent
reviews by the Institutional Review Board (IRB) to ensure full compliance with their
standards. The Institutional Review Board (IRB) is responsible for ensuring all research
involving human subjects is conducted in accordance with all institutional, federal, and
ethical guidelines (Walden University, 2017).
Since the use of in-person, face-to-face consent was impeded by distance related
logistics, the concept of teleconsent, completing/sending a consent form electronically,
was explored. While this is a relatively new concept in relation to research participation,
this approach has been used with great success in relation to clinical telehealth
services(Lopezet al., 2018). It eliminates many barriers related to study participation and
both increases access and protects the anonymity of the participants (Lopezet al., 2018).
The data collected was de-identified as much as possible to ensure privacy of the
participants: identification numbers wereassigned for data tracking purposes.
Additionally, encryption of the electronic data and proper destruction of the data through
deletion of files following completion of the study werealso used to protect the
participant’s privacy and confidentiality throughout the entire study process.
Lastly, the fifth principle the American Psychological Association (APA, 2018)
identified pertains to the use of the ethics related resources available to researchers.This
includes reviewing the code of ethics APA developed and considering other resources
such as The Belmont Report when developing the ethical framework to implement the
study (APA, 2018). Overall, maintaining a high level of awareness about potential ethical
dilemmas that could arise throughout the course of the study was of utmost importance.
Summary
This chapter gave an overview of the chosen research design and rationale for
using a generic qualitative approach as opposed to a more traditional method of
qualitative inquiry. The decision to utilize an exploratory methodwas based on the lack of
research on how therapists who perform equine-assisted psychotherapy think about what
they do and what guides their practice. Any issues related to trustworthiness and ethical
procedures were given careful consideration and techniques for addressing each were
considered. Chapter 4 will consist of a presentation of the data as well as discussion
surrounding research findings and future implications.
Chapter 4: Results
Introduction
The purpose and research question for this exploratory, generic qualitative study
was to gatherinsight into how therapists who say they are performing equine-assisted
psychotherapyunderstand what is taking place between the client and the horse. The
research questionwas developed to identify the individual experiences and perception of
the study participants. An interview protocol specifically designed with the research
question in mind was used with the participants.
The interview questions I developedwere open ended and consisted of seven
guiding questions to encourage open dialogue and maximize the collection of qualitative
data. An eighth and final closing question was also included in this interview protocol.
This was done in an attempt to capture the broadest range of responses from the study
participants. In some cases during the interviews, additional informal questioning in
addition to the protocol questions took place for clarification purposes. More details on
the research methodology, the generic qualitative design which was chosen to conduct the
study, participant selection, and the ethical procedures used in the collection of the data
were included in Chapter 3.In this chapter I revisit the research question, the setting,
demographics of participants, data collection and analysis, evidence of trustworthiness,
and present the detailed results and findings of the study.
Setting
The setting of the study was my private office at my personal residence and
interviews were conducted via telephone due in part to the distance of the participants and
concerns related to the COVID-19 pandemic.No letters of cooperation were needed since
no external organizations were involved in conducting my study, and there were no
conflicts of interest that impacted the study or participants. Approval to conduct the study
was granted by Walden University’s Institutional Review Board (IRB) and the associated
reference number assigned was 10-15-19-0323973.
Participation in my study was entirely voluntary and no recruitment efforts were
made prior to formal approval from the IRB.In regards to personal and organizational
conditions, the only significant potential impact on the study was the COVID-19
pandemic that occurred during the data collection phase of my study. Most, if not all of
the participants were impacted on some level, either personally or professionally or
both,by the pandemic. Some expressed that their organizations operations had been
temporarily suspended or were operating with a limited number of staff resulting in
hardship and changes to their normal procedures and schedules.
Demographics
The five study participants consisted of four females and one male. Each of the
participants was assigned an identification number in the order I conducted their
interviews ranging from #001 to #005 in order to preserve anonymity and to allow for
data tracking purposes. While all of the participants were from the United States of
America, as required by the study criteria, all were from different states. These states
included Utah, Massachusetts, Tennessee, Pennsylvania, and Hawaii.
All five study participants were actively working with programs that offered
equine-assisted psychotherapy with mental health populations and while the study
requirements specified a minimum of 3years of experience, all five participants who
consented to participation exceeded this criterion. Additionally, all five participants were
licensed or certified in accordance with their individual state laws to practice
psychotherapy. The actual credentials for the five participants involved in the study
consisted of an LCSW/DCSW, a state licensed SUDC (Substance Use Disorder
Counselor), an MSW/LSW, an LICSW, and an LPC-MHSP. I also collected basic
demographic information about the client population for each therapist (gender, location,
credentials, etc.). The chart below provides a compilation of this demographic
information.
Table 1
Demographics of Study Participants
Participant ID
Gender
Location
Credentials
#001
Female
Pennsylvania
MSW/LSW
#002
Female
Hawaii
LCSW/DCSW
#003
Female
Massachusetts
LICSW
#004
Female
Tennessee
LPC-MHSP
#005 Male Utah State Licensed SUDC
Data Collection
Data for the study was collected using a generic qualitative approach and
qualitative interviewing techniques to determine how the therapists think about their
patients, what they hope to accomplish, and how they know whether or notthey are
actually achieving their goals in the sessions.I used a semistructured interview protocol
(refer to Appendix A) that consisted of seven guiding questions and an eighth closing
question.Some questions were asked out of order in the interviews in response to attempts
made by the participants to lead the discussion.Open-endedreflective questioning and a
responsive interviewing style wereutilized to encourage maximum dialogue and
collection of data from the participants.Interviews were anticipated to last approximately
1hour and only one slightly exceeded that time frame by 9 minutes and 49 seconds.
Five participants gave informed consent to participate in the interview process and
all five interviews took place via phone during the time frame from January to July in
2020. Originally, it was considered a potential option to be able to conduct studies in
person whenever possible; however due to the locations and distance of each participant
this was not feasible as all participants were over 2hours away from me. I currently reside
in Pennsylvania, and four of the five participants resided in Utah, Massachusetts,
Tennessee, and Hawaii. The remaining participant, although residing within the state of
Pennsylvania, was located at the opposite end of the state near Philadelphia, Pennsylvania
which is almost 6 hours away from where I reside. In this case, a phone interview was the
most logical option and provided the most consistency in my data collection process.
Interviews were conducted from my private home office in Cranesville, Pennsylvania to
preserve confidentiality of the participants.
I began each interview by asking if there were any questions about the informed
consent or the study itself and by collecting the general demographic information about
the client population for each therapist (age range, gender, presenting problems, etc). The
interviews were then recorded using a digital recorder to allow transcription following
completion. Transcripts of the interviews were created using Microsoft Word and
responses and dialogue recorded verbatim. Additionally, notes were taken during the
interview process to allow me to cross reference the information collected in case
clarification with participants was necessary.
While participants had the right to discontinue the interview at any time, all five
participated in entirety.No unusual circumstances occurred that disrupted the data
collection processduring the actual interviews. It did take a longer than anticipated time
frame to obtain the required number of participants and conduct the interviewsdue in part
to challenges related to the onset of the COVID-19 pandemic in March 2020. It was
because of this that both the recruitment and data collection phases were run concurrently.
Two participants who had initially reviewed the informed consent and agreed to
participate earlier on in my data collection phase ended up postponing the actual
interviews due to dealing with the crisis at hand. A sixth potential participant ultimately
withdrew citing challenges related to the impact of the pandemic and being overwhelmed.
Data Analysis
The data that was collected during the interviews using a responsive interviewing
style allowed me to respond to the participants and ask additional questions based on
what they shared with me in addition to what they shared in response to my
predetermined questions on the interview protocol. While this provided the opportunity
for more information to be collected, it did make the data analysis slightly more
challenging as I could not simply code according to the specific questions and the
corresponding responses. The data that was collected wasexamined in a qualitative
context by using open coding by handto break down the interviews into subtopics and this
helped identify any emerging themes. It is important to note that minimal precodes were
used during this process other than specific keywordsrelated to basic terms in therapy that
could serve as a starting point. These included the following terms associated with the
guiding questions: “equine-assisted psychotherapy”, “theory”, and “treatment modality”.
I was able to go through each individual interview transcript and underline key
words and phrases and assign them an identification number (or if there were multiple
key words in the same line of the transcript, both a number and a letter were assigned) for
later comparison. Once the frequency of keywords was documented for each of the
individual interviews categories and themes were able to be identified using the splitter
technique identified in Chapter 3, I was able to look at the information collectively for all
five of the interviews.This technique allowed me to split the larger sections of data into
smaller categories of codes that could be compared across interviews and ultimately
summarized.
In order to move inductively from these smaller coded units to a broader, much
larger representation that would allow for a thematic analysis, I then reviewed the
transcripts again and used active listening by focusing completely on the participant and
their feedback to review the recorded interviews while applying the initial codes I
hadidentified. I then used descriptive labeling to capture larger themes and identify
categories represented by the data.It is important to note that when new codes were added
during this second review, the descriptions of the initial codes were sometimes changed to
create new codesto avoid having different codes for the same responses found in the
different parts of the interviews.
A number of specific codes, categories, and related termsemerged from the data
that contributed to identifying themes. As expected the term “Equine-Assisted” was
frequently used as well as “therapy”, “psychotherapy”, “treatment”, “practice”, “model”,
“modality” and “theory” and these served as codes during data analysis. Additional
categories and related terms that reoccurred in the interviews according to my coding
efforts included“behavior”, “approach”, “attachment”, “framework”, “outcomes”,
“mindful”, “safety”, “language”, “field”, “regulation”, “awareness”, “experiential”,
“organic”, “environment”, “intervention”, “self-awareness”, “self-esteem”, “boundaries”,
“spiritual”, “emotional”, “intuitive”, “therapeutic”, “communication”, and “trauma”.
The majority of these codes, categories, and related terms were present in multiple
interviews, and in many cases mentioned multiple times in individual interviews giving
them significance to the coding process. In relation to how the level of importance was
determinedand the qualities of discrepant cases were accounted for, a flat coding frame
was used. As noted by Turner (2021), some researchers have a preference for flat coding,
essentially avoiding pre codes and sub codes that may give more importance to certain
terms. Additionally, flat coding allows the researcher to see all the codes and avoids them
grouping codes into themes before the coding process has been completed (Turner,
2021). Although a hierarchical one was considered, because of the broad range of data
across the five interviews, I did not want to place more importance on certain terms than
others and I also wanted to remain flexible in my ability to analyze the data moving
forward.
Evidence of Trustworthiness
Credibility
As previously mentioned in chapter 3, interviews were audio recorded with
permission from the participants to allow for accurate transcription and review.I was able
to listen to these recordings and capture the responses verbatim.Barrett et al. (2018)
identified three core approaches to the data collection process: interviews, focus groups,
and observations that allow the researcher to gain significant insight and preserve the
quality of the data being collected. Not only did I utilize interviews, but also made use of
deep observations during the interviewing process to help accurately capture responses
from the participants and helped preserve the internal consistency. Additionally, member
checking when clarification was needed aided me in verifying the perception of the
participants and ensured validation of the respondents. In some cases additional
information was also provided by participants voluntarily via email to expand on the
information they provided during the interview process (i.e.: website information,
program information, etc.) that also provided an additional point of reference to ensure I
understood the information they shared with me accurately.
Transferability
While I as the researcher cannot necessarily prove the findings of this study will
be applicable in all cases, I am able to assert with considerable confidence that the results
can be easily generalized by those not directly connected to the study. The findings are
based on a small sample, however the five participants in my study offered a diverse
range of insight and feedback through their interview responses that supports external
validity and all of these findings can be applicable in some context to larger populations
of equine-assisted psychotherapists. This will allow the findings of the study to be applied
with larger populations, such as in replicated studies with the inference that the results
and findings would be either the same or quite similar.
Dependability
The dependability of my study aimed to ensure that my study findings were
consistent with the raw data that was obtained throughout the interview process. While I
did not conduct an external audit to achieve this, I did pay careful attention to the data as
I collected it, reviewed it, and analyzed it to form my interpretations and conclusions to
ensure accuracy in my final reporting. Carcary (2020) identified that qualitative research
by design is more complex and that the research design has the ability to change and
emerges throughout the data collection and analysis process. Based on this she notes that
strategies such as an audit trail need to be incorporated into the research process early on,
maintained, and followed through to benefit the reader and allow them to justify the
actions taken by the researcher and to provide transparency (Carcary, 2020).
I was extremely careful in my data analysis stage to review each interview and
related transcript individually to avoid confusing the content of each interview and to
make sure that the coding and themes that resulted were easily traced back to the
interview from which they were sourced. This was accomplished using a detailed
organization and recording process to provide an audit trail.I used color coded folders and
matching labels to help with this process and kept notes and observations separate and
labeled according to the assigned participant ID number.
Confirmability
As previously mentionedin Chapter 3, some level of personal awareness had to be
maintained throughout my interviews and during the data collection and analysis process
given my personal history of owning horses and working in the mental health field
previously. Although I have never worked in the capacity of an equine-assisted therapist,
some of my close associations to key areas related to my study could contribute to a level
of bias had I not remained cognizant of these connections and recognizing the impact
they had on my interpretation of the data. I was able to remain subjective and
communicate the findings based on the content of the interviews and this supported the
confirmability and overall trustworthiness of the study.
Results
This results section is organized by three potential themes that emerged
whichrelate to the research question and could potentially be used to inform future
research studies. I have incorporated supporting data for how I identified each of these
themes by including participant statements from the interview transcripts in each section.
My interview protocol consisted of eight questions, seven of which were guiding
questions and the eighth which was the closing question. As previously mentioned, the
five participants were assigned an identification number in the order I conducted their
interviews ranging from #001 to #005 in order to preserve anonymity and to allow for
data tracking purposes. It is important to note that although I made every effort to ask the
questions in sequence during the interviews, there were times the participants responses
also guided us into responding to the other questions included in the protocol (see
appendix A). The three identified themes from the data include: sense of belonging,
empowerment, and client function and have been presented below in that order with any
subthemes that were identified associated with each.
Themes
Theme 1: Sense of Belonging
The first major theme that emerged from the data was clients developing a sense
of belonging or connectedness with the program, horses, and staff. This seemed to be
important in regards to the outcomes of the therapy sessions, and the overall perception of
the efficacy of the equine-assisted psychotherapy work. A number of categories and
related terms led to the identification of this particular theme. The terms “therapy” and
“psychotherapy” were noted in the dialogue provided by all five participants and related
to having a therapeutic, clinical alliance of one or more parties, generally with a specific
outcome in mind. The term “equine-assisted” was also used and referred to the
involvement of a horse in the therapeutic dynamic. Several subthemes also
emergedincluding attachment, safety, and inclusivitywhich were supported by the
interview responses provided by the study participants.
Attachment
The terms “attachment”, “connection”, “bond”, werereferenced by three of the
participants during the interview process and seemed to support having a sense of
belonging as being a central theme in the work they do.The response of participant #003
to the question that referenced the use of theorists and theories specifically related
toattachment theory and the work of John Bowlby and stated “I would definitely say
attachment theory”. She went on to name additional theory/ theorists that influence her
work stating “Internal family systems because that is kind of the trauma work, and the
research that has come out of the trauma center with Bessel vander Kolk- that is sort of
the body keeps the score, and Peter Levine’s work also has been a huge part- I would
definitely say that has influenced me- that theoretical kind of cake that I have digested
and it is a big part of the sort of body awareness when working with horses”.
This same participant latermade reference to the concept of biophilia and work by
E.O. Wilson, an American biologist and entomologist. She noted the original concept of
biophilia was later explored more by psychologist Erich Fromm and centers around the
idea that “humans possess an innate tendency to seek connection with nature and other
forms of life”. Lastly, she noted the work of psychoanalyst Donald Winnicott in
developmental psychology has had an impact on the work she does as it allows her to
focus on the connections that occur between humans and horses.
Some of the additional findings from the data related to this particular theme and
the subtheme of attachment also involved the term and related category of “theory”. For
example, when I began exploring the responses to the fifth question in my interview
protocol which focused more on the theoretical influence of the work performed by the
therapists, participant #001 provided a theoretical reference in line with this identified
major theme of having a sense of belonging. The work of Dr. Daniel Hughes and the
dyadic developmental therapy (DDT) was noted in her responses. More meaning behind
how this relates to the theme of having a sense of belonging will be presented when we
discuss the implication of the findings in Chapter 5, however, participant #001 shared
through her responses how this particular theory influences the work she does with their
population of focus that experiences a variety of challenges related to trauma, emotional
regulation, and attachment related disorders.
This same major theme resurfaced again when participant #003 was asked the
eighth and final question in the protocol. She did not have anything additional to say
initially, but after a brief moment of thought responded in detail going back to the topic of
biophilia and the human tendency to seek connection with nature and other forms of life.
She shared candidly noting that there is science and data related to the efficacy of the
work that is done within the concept of biophilia, and that there are other people to whom
they have been talking who do this work and who believe in the related hypothesis and
use it to inform their work. She went on to say “there has been some really interesting
discussions” and that the Institute for Human-Animal Connection has a connection to the
larger organization the International Association of Human-Animal Interaction
Organizations (IHAIO).
Participant #003 also referenced Nina Ekholm Fry who is the Director of Equine
Programs and is affiliated with the Institute of Human-Animal Connection at the
University of Denver as being a noteworthy person to contact for additional information.
She also spoke on the topic of connection between people and horses on a physical level
and noted “there is a lot of work within the veterinary world and they are really looking
at equine physiology and wellness and making sure that people who are doing this work
have a solid foundation in that as well”. She shared that the head of the University of
Pennsylvania veterinary school spoke at a conference they attended and that the research
is showing when humans and canines cohabitate they are actually starting to share the
same microbiomes- gut microbiomes. She ended with “we are both better off for having
these shared microbiomes, so my question would then be do we have the same thing with
horses”? Overall, attachment and development of a bond in the therapeutic relationship
seems to be an area of interest in relation to the primary research question and how the
therapists understand what is taking place in the therapy sessions they facilitate.
Safety
“Safety” was also a term that was brought up by several of the study participants
as being important to the work they do. Instilling a sense of safety and maintaining a safe
environment helped individuals with being able to form those necessary therapeutic
connections with both the therapists and the horses and achieve desired
outcomes.Working with large animals like horses tends to create sense of vulnerability
among humans due to the difference in size and strength and this creates a dynamic which
fosters trust between the therapist who has experience working with the horses and the
client who relies on them to maintain a level of safety in the therapeutic sessions.
To illustrate this point further, the first question in the interview protocol closely
aligned with the research question I developed for the study that inquires how the
therapists understand what is taking place between the client and the horse. When
answered by the second participantit resulted in a dialogue about safety as the priority,
and that the individuals receiving the therapy, as well as everyone involved in working
with the horses, remain safe during the process which requires a certain degree of trust
and connectedness. In addition to this, that same participantalso highlighted the major
theme of having a sense of belonging when sheexplained that “the underlying purpose is
to increase children and adult’s sense of confidence, their sense of being special” citing
that self-esteem and a sense of belonging to a collective is important when measuring
outcomes of what they do. This subtheme of safety seems to overlap with the other
subthemes including developing a sense of attachment and feeling a sense of belonging
based on the trust that is fostered in the therapeutic sessions using safety as a foundation
for the work they do.
Inclusivity
Additional findings related to this major theme of having a sense of belonging
included the term “inclusivity”. Participant #002 did not elaborate on a particular theorist
in response to question five, rather spoke in alignment with this first theme about the
importance of inclusivity by“letting them feel welcome and that they can just be
themselves, imperfect beings that we all are”. She cited the relevance of this stating “I
believe- and what I wanted was less focused on skill and more focused on emotional
belonging”.She noted how they take a “client-centered” approach at their program and
strive to see their clients “invest their energy so that they are a part of the whole deal- a
cog in the wheel- and they feel that way- like they are important and they matter”.
Later, the eighth and final question of the interview protocol addressed if there
was anything else the participants wanted to share with me about equine-assisted
psychotherapy. This was presented as an open-ended question to allow the participants
some freedom to include any additional pertinent information that otherwise might have
been excluded by my more targeted questions in the protocol. Keeping with this theme of
a sense of belonging, the participant #002 gave the following response to this particular
question in the protocol noting “I would say that it works, whether we have 100 articles
scientific research projects to prove that or not- my experience from the get go is that it
works and because it’s motivational, it is not a chore for the rider- it’s fun”. She added to
this original statement noting:
The side effect of all that fun is they have more serotonin in their brain they feel
better, they have a better outlook on life, less depressed, and the same way that
they learn how to partner up with horses, they then transfer that to their human
relationships and they learn to partner up with human beings. They learn that
what’s best for all is best for them- that everybody rides together so all the horses
are taken good care of then everyone wins- the horses win, the kids win, the riders
win, I win.
The discussion then led to the notion that humans crave connection and they begin
to understand the importance of the relationships between everything and that they are
part of a larger whole. Making the process fun, from the perspective of the therapist lends
to the assumption that the individuals will be more receptive to therapeutic interventions
and more likely to be open to developing a therapeutic alliance and becoming part of the
process.
As the data showed, having a sense of belonging seems to be a central theme that
relates closely to the initial research question of how the therapist understands what is
taking place between the client and the horse. The importance of maintaining a sense of
safety and inclusivity as well as the use of theory to help assess how to build those
therapeutic connections between the therapist, horses, and the people participating in the
therapy to maximize therapeutic outcomes will be more closely examined in Chapter 5
when exploring the implications of these findings.
Theme 2: Empowerment
A second major theme that emerged from the data was client empowerment. This
encompassed several subthemes as well including having a sense of accomplishment,
more confidence/ improved self-esteem, and a general increase in satisfaction and
personal wellbeing. Revisiting the research question posed by this study which tries to
identify how therapists who say they are doing equine-assisted psychotherapy understand
what is taking place between the client and the horse, it makes it possible to see how a
client’s response to the therapy is an important area for the therapist to remain aware of
during the therapeutic process. Three subthemes emerged related to this major theme of
empowerment: having a sense of accomplishment, seeing an improvement in confidence
and self-esteem, and having an increase in personal satisfaction and general wellbeing.
Sense of Accomplishment
Through the participant responses there seemed to be a common perception that
success was largely dependent on the client experiencing a sense of accomplishment and
achievement from the interaction that took place with the horses and staff in the
equinepsychotherapy sessions. Seeing an increase in a client’s personal satisfaction,
confidence level, and general wellbeing were identified as important for the therapists to
know the clients were meeting identified goals.Participant #005 responded to the initial
question of the protocol by elaborating on how he strives to help their clients “to
recognize their own ability to fix their own issues” and to “learn how to ask for help
when in need”. He spoke about how the shame and guilt encountered by many of those
they serve with mental health issues is what “keeps them from asking for help”. He went
on to note “that is what keeps them sick as well”.
When responding to the question in the protocol which read “How do you tend to
understand the nature of your client’s difficulties?”participant #001 went into great detail
about the impact of trauma and compounded stress on the population she serves and how
she tries to help them overcome it through the use of education and empowerment. She
elaborated on trying to understand the source of the trauma, whether it is developmental,
environmental, or systemic in nature in order to be more effective in treating the
compounded issues that can affect the clients and in some cases their families as well.
This participant referred to viewing the population she works with through a “trauma
lens” to be able to understand the nature of their difficulties.
Lastly, participant #005 responded to the same question that he has a connection
with the population of focus based on his personal experience. He shared that he has
personal experience with both substance abuse and being in recovery, as well as with
mental health- particularly dealing with depression and anxiety. He noted that this allows
him to understand what the clients he serves are experiencing first hand and can aid them
with a sense of empowerment. Overall, it seems that helping clients overcome their
barriers and instilling a sense of accomplishment seems to be central idea that relates to
the research question which asks how the therapists understand what is taking place in the
work they do with the clients and the horses.
Confidence/ Self-esteem
The second subtheme that was identified was seeing an improvement in the
client’s confidence and self-esteem. How this was tracked and measured seemed to vary
between the study participants, some through observation while others used more formal
methods such as treatment planning and goal setting. For example, participant #002
focused more on the treatment planning aspect as a method of goal setting and
empowerment in her response to the questions. She shared how while treatment plans are
utilized, there is plenty of room for flexibility and individualizing based on the needs of
the clients they serve, and how the clients are responding to the therapy. She went on to
explain the importance of this in a group setting since each client may be experiencing
different levels of progress in relation to their individual goals. Lastly, she noted that
while the prescribed goals are good, the main goal is “that they learned something today
that made them walk away feeling good about themselves” which aligns with the theme
of empowerment and subtheme of improving confidence and self-esteem.
In keeping with themajor theme of empowerment and the related subtheme of
improving confidence and self-esteem, the response offered to the seventh questionin the
protocol by participant #002 focused on a few key questions that she shared with me:
“Did they have a good time? Did they feel good about what they did and do they keep
coming back? Week after week, after week? Camp after camp? Like that- that is
important”. She went on to add “I look for, you know, if I am interested or they are
physically able to move forward in their riding skills and of course I am always looking
for a little bit more in time” when referring to the individual progress she looks for with
the clients she serves.Lastly, she also referenced the ability for the skills clients learn in
their equine-assisted psychotherapy sessions to be transferable to other areas of their life
that continue to foster a sense of empowerment noting:
Sure, I am happy to take kids and produce independent riding- it does wonders
for their self esteem, but it is not my goal- their goal is they should have a good
time and they should feel accomplished and as a side effect of increasing their
body tone and their balance and their stability when they are walking- at least that
they can do other things- It opens their world in a whole other way.
In relation to thismajor theme of client empowerment from the data, participant
#005 shared in the response to question seven in the protocol how it tends to be reflected
in how much the clients take personally in the sessions with the horses and also how
willing they are to ask for help. He explained how at the first session the clients are
expected to pick their horse and when this process unfolds often times the horses may not
want to be caught and some clients take this personally and jump to the conclusion that
the horse doesn’t like them when the truth of the matter is they are simply avoiding work.
Increasing confidence and self-esteem also relates closely to an individual’s
ability to set boundaries in personal relationships. An exampleprovided by participant
#005 that keeps with the major identified themeof empowerment and related
subthemesinvolves the use of boundaries and how well clients negotiate them. The ability
to set boundaries, enforce them, and remain assertive increases self- confidence and
provides a sense of accomplishment for the clients. He went on to share:
I do a little physical exercise where the client has to back the horse up 10 feet
without moving their feet-so they have to stand in a hula hoop and get their horse
to back up- my lead ropes are all 12-15 feet long so they have to get that horse to
back up 15 feet basically, and none of the clients know how to back up my horses
unless they have been in a group before with me, and until somebody asks me
how to back them up I won’t tell them- and then even after I have given
instructions how there will be close to 50% that won’t be able to do it because
they are not assertive enough.
He went on to identify that this highlights the challenges related to self esteem and
lack of boundaries which then become a clinical focus of the future sessions.Participant
#005 ended hisresponse to this question noting that “I have kind of a mantra that you
never end on failure and I never let a person go out of this arena without them feeling
some kind of accomplishment”. In general, this shows the importance of making sure the
client’s have a positive and empowering experience as being one area the therapists pay
close attention to in the work they do.
Increase in Personal Satisfaction/ General Wellbeing
The third subtheme which emerged from the data was the therapist being able to
see the client experiencing an increase in personal satisfaction and general wellbeing as a
result of their participation in therapy. This closely overlaps with both the major theme of
empowerment and the other identified subthemes. The final question, which was also
referred to as the closing question in my interview protocol reads “Is there anything else
you would like to share with me about equine-assisted psychotherapy?”One participant
response to this question related to the major theme of client empowerment. Participant
#001 responded noting “I think that there is a lot to be said for how impactful this
approach to treatment is” and gave a detailed explanation of how it is raising awareness
to the importance of alternative treatment approaches.She went on to add “I think that-
again, being experiential, and solution oriented it very much empowers clients that so
much is done-the deep therapeutic and intensive therapeutic work… to become more
evidence based-this is a young kind of model they’re working actively to be you know-
rooted in research”.
This second major theme which focuses on clients developing a sense of
empowerment also relates closely to the primary research question asking how the
therapists understand what it taking place between the client and the horse. Areas such as
setting boundaries, overcoming barriers, and developing a sense of accomplishment
seemed to be encompassed in this theme and subtheme of seeing an increase in personal
satisfaction and wellbeing according to the participant responses and data that was
collected. More explanation of what defines empowerment in this context and
implications of how it can be applied to the clinical work done by the therapists using the
horses will be provided in Chapter 5 when exploring implications of these findings.
Theme 3: Client Function
A third major theme that emerged from the results of the interviews focused on an
improvement in the clients’ overall ability to function.This was an extremely broad
category with many variables between clients according to what was shared in the
participant responses, thus no subthemes were identified. This major theme of improving
client function, however, helps to answer the research question posed by the studythat
asks how therapists who say they are doing equine-assisted psychotherapy understand
what is taking place between the client and the horse.Although all of the five participants
highlighted different ways they assess this when observing the client and the horse, each
participant also seemed to align with the idea that the clients who participate in the
equine-psychotherapy tend to show improvement in a number of areas related to their
general functioning including emotional regulation, interpersonal skills, self-esteem, and
even physical functioning resulting in a better quality of life for the clients and their
families.
Participant#001expressed during the response she gave to the initial question in
the protocol that the overarching goals of the work she does is to reduce the stress level of
the participants and to help them to have a better quality of life overall.
Participant#003 responded to the very same question by noting the “common thread” for
the clients served is being able to develop “internal regulation” and outcomes are
measured to some degree by their ability to both identify and develop the skills to be able
manage their internal state. The response given by participant #004to this same question
identified that he the equine work is not used as a standalone therapy when doing the
individual work, but becomes useful when a client is encountering triggers and reaches a
“fight, flight, or freeze” moment and “shuts down” meaning they are not responding to
traditional therapy approaches.
Continuing with this theme of improving client function, participant #002
responded to the second question in the protocol by crediting her skills gained from being
a social worker and being “alert” and “hyper-vigilant” in order to remain aware of what is
going on at all times as allowing her to understand the clients she serves better. She went
on to say “for me it is about being super mindful and conscious about a rider’s - not just
physical limitations, but their emotional connection to their physical limitations”.
Additionally, she went on to note that in the program she works in they make every effort
to turn weakness into strengths stating “It might be a teachable moment when they are
having a hard time”.
Participant #003 responded to the second question of the protocol in a two part
explanation, the first of which referenced the information gathering that takes place at
intake that combines the necessity of paperwork, while also affording the opportunity “to
get a read on the client” and familiarize themselves with the needs involved as well as
strengths the client possesses. The second part of her response focused on identifying
points of resistance with the clients she serves and being able to use the insight she gains
from the work with the horses to reduce or eliminate the client’s resistance so therapy can
take place. In closing for this question, this participant noted when referring to the work
she does using the horses “it is less threatening and I get much less resistance working at
the barn than in any other clinical setting”.
The response to the second question in the protocol by participant #004was more
clinical in nature and referenced the use of a Cognitive Behavioral lens and understanding
basic brain function and how it affects the client’s ability to perform basic tasks with the
horses to establish trust in order to increase the client’s functioning. She also mentioned
their use of the EAGALA model to work on the fundamentals of selfregulation citing the
majority of the identified population they work with are in “a constant state of fight,
flight, or freeze” and lack self-regulatory skills. Posing questions on a treatment plan such
as “what is my body telling me?” and “how do I use my words to get my needs met?” and
“how do I accept it- how do I make choices and compromises?” also support this process
according to participant #004.
In response to the third question in the protocol which states: “What do you
consider when deciding on a particular form of therapy for a client?”, participant #001
delved into how in her particular program she uses a combined approach to integrate the
equine-assisted psychotherapy with dyadic developmental therapy (DDT) to support
client function.She also mentioned that they incorporate specialized training to have an
even greater impact. The training mentioned, known as neurofeedback, is designed to
assist with stabilization of the clients they serve within the program.
In keeping with this major theme of improving client function, participant #003
responded to this same question noting that the way she decides on therapy approaches
for a client hinges on a format she has personally created over the years based on all of
the collective knowledge she has gained from trainings and experiences. She gave a much
more detailed explanation of this noting: “I have basically based it on all of the various
trainings I’ve done and you know- the work I have read from people who do the work-
who I respect and think are doing the work in an ethical and appropriate way, so it’s
quite- I will say quite organic, its fluid and really depends on the needs of the client”. She
also elaborated on the usefulness of work done by Yalom Irving, a therapist who has
significantly influenced their group work. In addition to this, she mentioned her interest
in getting certified in IFS- internal family systems (Schwartz, 1995) and eventually
incorporating those techniques into the work she does with the horses.
Also related to the theme of improving client function, participant #004
referenced her connection to the EAGALA model as well as the use of trust-based
relational interventions in her current work as far as a consistent format of working with
clients. She explained that this approach primarily centers on ground work, meaning the
clients interact with the horses at ground level through handling them, but do not get on
or ride the horse. Although EAGALA is what is currently being used in her program, this
same participant expressed an interest in learning more about PATH as an approach
involving riding if she were to “step out of direct care”. Additionally she noted “I think
that if you are going to do equine therapy across the board you are not going to find a
consistent treatment model”.
Pertaining more to the evaluation of whether a client’s functioning is improving,
participant #005spoke about the importance of doing assessments with hispopulation of
focus to allow him to assess the individual needs of each of the clients he serves. He
noted that this is often accomplished in a “process group” format where he will spend
approximately 10 minutes talking with each client to find out “what is going on in their
life and what their needs are”. He shared that this typically takes place in a group of 8
clients but there have been as many as 15 at a time which can make it more challenging to
accomplish. These groups range approximately 2 ½ to 3 hours in duration and the
sessions generally take place weekly, although the length of involvement can vary greatly.
The following collection of responses from the fourth question of the protocol
which asked “Are there certain kinds of behavior (concerns, problems) that you think you
tend to pay more attention to?” seemed to align with the emerging theme of improving
the clients overall ability to function.Participant #001 sharedabout how many of the
individuals she serves in her program’s population of focus present with attachment
disorganization issues and how trauma is also a primary concern. She went on to share
other key areas of focus being “attachments, relational aspects, emotional regulation, and
expression” versus cognitive behavioral approaches due to looking at the “behavior as a
symptom of a much deeper rooted issue”. In addition to this she shared that the
equineassisted psychotherapy program she works with “stems a lot from experiential and
solution oriented approaches to treatment”. She noted that it is “really believing that your
client has solutions within them, and what works for one person or what works for you or
works for I is going to be different from each and every person”.
Participant #002 evaluated client function from a different perspective and
answered the fourth question by detailing some of the client challenges she faces and how
they overcome them, particularly with high need children such as those diagnosed with
attention deficit hyperactivity disorder (ADHD) that attend their program and require
constant monitoring by the staff to keep them safe during the therapeutic process.
According to what she shared, some clients can be more “impulsive” and “labor
intensive”, and require creative approaches such as having them do range gym and ride
backwards in the saddle. She went on to share that:
I don’t really personally understand why it works, and I tell folks all the time I
don’t know how electricity works either, I just know how to turn on the switch
and that is how I feel it is with the program- we need more science behind it so
that the insurance companies will validate our experience that children and adults
get from being involved with horses.
Participant #003 also provided a different perspective on how they assess a
client’s ability to function, and responded to the fourth question in a different fashion,
highlighting that she approaches the process by “very carefully focusing on how
regulated or dis-regulated is this client in that moment” and in addition to the regulation
piece she also pays attention to the attachment taking place stating “what is the beginning
of our relationship looking like- our therapeutic- the therapeutic relationship”. She went
on to describe in more detail how trauma has also become an area of focus but that
shestill looks at the regulation and attachment issues noting “I have gotten into more of
the trauma based work, but that the regulation- the issue around internal regulation- it’s
just- it was there like this common thread- that is very much what I focus on” and “it all
does have that common theme of- you know- self-awareness”. Additionally, she noted
that therapists working in their program are PATH certified and working in a PATH
member center although it is not currently PATH accredited so this influences their
approach to the clients they serve.
The response to the same question by the participant #004traces back to a clinical
approach. She identified the use of a cognitive behavioral lens as the basis for viewing the
ability to function and behavior of those she works with. She referenced how her prior
experiences working with juvenile offenders as well as subsequent work with victims in
the capacity of forensic interviewing have influenced her current work. She noted “as
soon as I can make that connection I have lowered their stress level and so now they are
not thinking fight, flight, or freeze anymore- so anything I teach them in that moment is
going to be able to stay because it is registered up in the prefrontal cortex”.
Participant #004 also referenced the EAGALA model as it relates to the clients
ability to function and how it is important to help clients understand the relationship
between their physiological and emotional/mental state and the regulation that goes along
with it. Observing the behavior of the client, both their physical and emotional state also
influences the way treatment plans are developed also plays a key role. She went on to
note “If I had a template for a treatment plan it is going to be what is my body telling me,
how do I use my words to get my needs met, and how do I accept it- you know- how do I
make choices and compromises”.
Some significant problem areas related to a client’s ability to function were also
identified in the interviews. Participant #005 responded to the fourth question in the
interview protocol noting three problem areas stand out in his current work- trauma,
learned helplessness, and self-esteem. He went on to explain that these particular clients
“are glaringly apparent when working with horses”. He noted that he finds it useful to
incorporate mindfulness techniques, use of positive affirmations, and attentiveness into
his work to support these individuals and that having small group sizes with an average of
8-15 clients also helps when working with those with trauma.
The relevance to the theme of overall improvement in client function was also
seen when the next question in the protocol was asked, even though it explored the idea
of guiding theory. To reiterate, the fifth question in my interview protocol focused more
on theoretical influence on the work they do and read: “Are there particular theorists
whose work you find especially helpful in working with your client population?”
Participant #001 identified the work of Dr. Daniel Hughes and DDT as notable. She
shared how it has influenced the work she does with their population of focus that
experiences a variety of challenges related to trauma, emotional regulation, and
attachment related disorders. She gave more applicable experience of how this is used in
the next question in the interview protocol.
The response of participant #004to this same question while looking more closely
at theoretical connectionsidentified how the use of an attachment-based approach known
as trust-based relational intervention (TBRI) with the population she serves has been
relevant. She places focus on the meeting of basic needs and establishing a sense of safety
in the clients internal environment as an initial treatment focus which includes getting
enough sleep, addressing basic needs like hunger and thirst, all of which improves their
ability to cope and function better in terms of emotional regulation.She also affirmed the
usefulness of groundwork according to the EAGALA model, however expressed interest
in the methods used by colleagues that utilize the PATH model involving riding the horse.
Participant #005also referenced an improvement in client function and noted most
of his training has been focused on the Fundamentals of Natural Lifemanship because the
focus is on trauma and recovering from its effects. He also cited training and certification
he received from Greg Kirsten who is the founder of the OK Corral series as being
influential in the work he does as well as the horsemanship experience he gained from
internationally known clinician and horseman Mike Bridges who has spent over 16 years
teaching clinics in the United States and Europe. He went on to note “I spent most of my
life until I was 40 in the agricultural business. I have a lot of practical life experience that
I use as well that supports the equine side of things which I have found is extremely
helpful”.
To add to this,the sixth question in my interview protocol served to further explain
in greater detail how theory or certain theorists might have influenced the actual work
they do and read as follows: “Do you use any of this work with your clients and if so,
how?” Participant#001 noted that the previously mentioned DDT is what she usesstating
“it’s what sets up the framework and it absolutely guides every single session and how we
approach clients”. She went on to say “that experiential model or modality absolutely
guides practice because you have to set sessions up in a way to play out- you know with
incorporating the horses- then they really become sort of the metaphor and the symbol as
does everything in the space, everything around the space”.
In addition to this she noted “anything can become representative of the client’s
story, so there is a lot of symbolism and metaphor that comes into play too.”Lastly, she
mentioned how this can help clients that are transitioning through the stages of change
noting that when clients are “not even aware that there perhaps is a problem somewhere-
or in tune to what perhaps is going on- you know helping clients in the pre-contemplative
stage of change all the way through preparing to make change and then actually taking
action to make that change.”
Going back to our earlier discussion on client-centered approaches and how each
client has individualized care based on their unique needs, participant #002spoke in more
detail about how each client has “their own little team” of staff and noted “as they
become more independent we want to move them forward with the skill set so that they
feel good about themselves and they don’t get bored and the horses don’t get bored”. She
elaborated further on this by stating “The client centered piece for me is more emotional
than it is physically- to improve someone’s physicality” and added “It’s all about being
tuned in to that rider’s behavior that day, their emotions that day,what we did that week
and what we taught about that week- it is the client drives the interaction as opposed to
the facilitator driving the interaction because she has got a plan.”
The response obtained fromparticipant #003 regarding this related to our prior
discussion on the concept of Biophilia. When I asked what this would look like when
used in sessions with clients she stated “I would say that it really is about attending to
what is happening at the moment in the barn. And it also sort of works in conjunction
very nicely with some of the aspects of EAGALA which is a certification I have- It’s like
one of the approaches of doing equine-assisted psychotherapy, but it is very much based
in experiential learning”. To further this she added “so by using the EAGALA method
formed by this concept of Biophilia I focus a lot on slowing things down and what is
happening around us in the barn” and noted “I spend a lot of time talking about horse
cues and people cues like how do we come to understand horses so that- so that we can
know how to interact with them safely”.
A different participant responded to this same question by noting the most
consistent thing that she does from an equine standpoint is their weekly groups.
Participant #004 shared that the groups, which are not closed in nature, run on a 6-week
rotation and utilize the EAGALA approach that utilizes both a mental health professional
and an equine-specialist to work with their clients. She went on to state “there really isn’t
one particular counseling theory that we adhere to”, but did go on to say they do use the
“eclectic” treatment model trust-based relational intervention (TBRI) which takes into
account the past trauma, abuse, and or neglect experienced by the population they serve
in her program, whether that be due to organic brain disorder, behavioral issues,
environmental issues and how to support not just the client, but the family also to have an
improved outcome as a result of their treatment involvement.
The final respondent to this question, participant #005 shared that everything he
does traces back to helping the clients overcome their fear, learned helplessness, and self
esteem issues noting “I work off of intuition and the way I feel” noting that each of the
clients they work with is already working with a primary therapist who has developed a
treatment plan and takes care of the documentation aspect so he can focus on the work
with the horses and the interaction that is taking place between the client and the horse
noting “I watch for everything” noting that he has two rules that start every group “have
fun” and “ask for help” and how the clients handle those two rules tell him a lot about
their needs. He noted that most of their sessions focus on two aspects- “looking at a
situation and solving a problem- and most all problems can be solved by asking
somebody for help”.
Relating closely to this theme on improving client function, the seventh question
in the interview protocol read as follows: “What are some indicators you use to determine
if your clients are meeting treatment outcomes?” Participant #001 spoke about the use of
a pre and post test outcome questionnaire to help her measure the success rate of the
clients she works with. She cited how the use of these assessments as part of the
treatment process shows if there is “an improvement in overall client distress”. Lastly
she noted that “in core sessions we sit down and attempt an assessment and we set forth
goals for the treatment planning and we also go back to the treatment plan so that gives us
a way to track progression and change”.
This same participant went on to explain more of how this process relates to the
DDT approaches she uses and how she starts by helping the clients identify the stress and
express the distress noting “You know if you have a young client- or a client who has so
much compounded trauma and issues then they might not know exactly where the issues
stem from we spend a lot of time increasing awareness and mindfulness around what is
happening”. She went on to add “The ability to even first identify the stress and express
the distress- that can take months in itself so then hopefully we get to a place that they
are ready to create change or to learn to cope with that and work through that”.
Participant #001finished expanding on this by noting that the DDT program is focused on
attachment and sometimes involves them transitioning through different developmental
stages. Lastly, she noted “those issues run so deep that it is a longer time in treatment- we
have folks that are 6 months to a year, but we have also had folks that have been here for
several years and we continue to be a very stabilizing place in their functioning” citing a
psychoanalytic piece to the treatment she does and mentioning the
Gestaltsystemic approach.
Another participant placed the treatment planning process as the primary way she
tracks progression and outcomes in treatment. In response to my question participant
#003 noted “I would say by the second or third session we have a treatment plan in place
with specific goals and objectives that I would say 95% of the time I would create with
the clients and we agree on goals and outcomes that they want to work on and then we
assess that in every session”. She further elaborated this process stating “I assess that at
every session keeping notes and depending on the length of treatment periodically assess
that with clients so it is a pretty fluid process of assessing in conversation with the client
how they feel things are going- it just depends on the client what their goals are but they
are quite specific and for clients I work with longer I get into deeper layers of work”.
Participant #004 responded to this question by expressing that an indicator of
progress towards improving client function is how well the clients she servesare able to
recognize what their body is telling them, as well as seeing them improve in their ability
to use communication to get their needs me in an appropriate way. Their ability to
convey basic needs and manage self care such as drinking enough water and getting
enough sleep also relates to the outcomes and how well the client may be responding to
the directives given by the therapist. She noted “we have a treatment model when you
come into the behavior regulation program- there is a parent component and they meet
with another therapist and they do about 4 weeks of the treatment model the trust-based
relational intervention (TBRI)- like how do I connect with my kid in order to correct my
kid? Connection before correction, we talk a lot about self safety”.
She also provided additional clarification on what self-safety consists of by stating
“So in order to have self safety I have to teach my kids about how they have to make sure
their inside environment and their outside environment is safe and the one they have the
most control over is their inside environment”. She went on to explain that the “inside
environment” involves making sure they are not hungry, thirsty, or tired. In addition to
this she noted when those basic needs are met, they tend to do better in the therapy
sessions overall. This keeps with this theme of improvement in overall ability to function.
This same participantalso providedan additional response to this question that
looked more closely at proving efficacy, stating “It is interesting to me- I believe that
there are going to be so many ways to look at the efficacy of it- doing specific research on
how successful- you are going to be pretty general about what is success and what’s not,
right? Because, there are so many ways…”. She elaborated on this response further
stating “but if you generalize it- from the horse standpoint- like PATH is specific, but
even within PATH there are so many ways to document success”. The remainder of their
response then shifted towards equine-assisted psychotherapy as a billable service with her
noting “Everyone is trying to get insurance to cover it as experiential”. She elaborated on
this stating “Technically play therapy, sand therapy, art therapy- all of that- there is an
extra code that you can add outside of individual or family but so many insurance
companies don’t cover that- there are very few that cover equine specifically but anytime
you ask what the code is and it is the same interactive therapy code”. In closing she noted
the challenge to this stating “they can’t determine the difference between our therapy and
equine therapy. Horses have to have an empirical database associated with it”.
Lastly, participant #005 brought up the importance of spirituality to human
functioning and noted for them there is a spiritual component and that horses are always
living in the present and have the ability to teach humans how to be mindful and live in
the present too which helps with improving their ability to function in the current
moment. He noted in closing
I feel I have really been blessed by God- my interaction with horses over the
years- I was kid and I actually broke my first horse when I was probably 7 or 8
and I’ve been blessed to have really good people and challenging horses in my
life and I really feel that in this business you have the blessing of intuitiveness and
I feel like God has really blessed me with the ability to see into people and if I can
see into people I can help them- I believe in a God that is definitely concerned
about each one of us as his children and I feel that blessing when I start working
with people and get little inspirations that happen in different things that support
positive things in their lives.
Given this information, an improvement in spiritual functioning is also another potential
area to examine when evaluating whether a client experiencing benefits of such
interventions.
Summary
This chapter provided an overview of the three identified themes and related
subthemes that emerged from the participant responses to my interview protocol: Sense
of Belonging, Empowerment, and Client Function. Identifying these themesand
subthemes supported the process of answering the original research question identified by
my study:How do therapists who say they are doing equine-assisted psychotherapy
understand what is taking place between the client and the horse?As previously noted the
research question was developed to identify the individual experiences and perception of
the study participants and according to the broad range of responses received in response
to the interview protocol, it seems to have functioned in this capacity.
Although I was hoping to identify additional themes related to the theories and
evidence based practices that are used to guide equine-assisted psychotherapy, it appears
that no singular theory takes precedent rather each therapist utilized a combination of
their personal experiences and professional background and training to create their
approaches to working with the clients and horses. There seems to be more of aneclectic
oran existential approach being used to guide the therapeutic interventions and these may
be worth considering as a possible framework for equine-assisted psychotherapy,
especially existential psychotherapy (Binwanger& Angel, 1958). In addition to this, the
need to individualize services for the unique needs of each of the populations served by
the participants became apparent during the interview process and by the responses
provided to each of the questions in my interview protocol.
Overall, it is important to reiterate that this study was exploratory and as noted in
the prior section on assumptions these findings should be interpreted with caution. The
findings from this study should serve as a point of reference for future studies. It is my
hope the identified themes can be evaluated more thoroughly and guide future research in
the area of equine-assisted psychotherapy.
In Chapter 5 I willrevisit why I decided to conduct my study. I will also
summarize and interpret my dialogue with the literature and the key findings of my
studyin relation to the theoretical foundation I expanded on in Chapter 2. Lastly, I will
identify the limitations of my study as well as future recommendations for research.
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
To begin, the purpose of my study was to identify how therapists who
performequine-assisted psychotherapy understand the interaction between the client and
the horse. I was attempting to develop a better understanding of the similarities and
differences in the thinking of the therapists who participated in the study. I also hoped to
establish whether any theoretical or observational influences existed in their practice that
can be used to further define what takes place in this form of therapy.The field of
equineassisted psychotherapy is still evolving and although currently considered
experimental it is becoming more widely recognized and interest in its clinical
applications is increasing. I hope my research findings will help with the eventual
development of a theoretical basis for use in clinical practice.
Key findings of my study based upon the responses of thefive participants
reinforced the idea that equine-assisted psychotherapy is being used with a wide variety
of populations and in a number of very individualized ways lacking a standardized
approach in the way it is implemented program to program. Although some of the
participants utilized specific training and application methods set forth by EAGALA and
PATH International, for example, others used combined personal and professional
experiences paired with other trainings and methodologies that they felt were relevant to
the work they were doing.
In addition to this, when looking more closely at the problem statement identified
by my study and how the therapist understands what is taking place between the client
and the horse, three notable themes emerged based on the interview responses. These
themes mentioned previously are as follows:clients developing a sense of belonging or
connectedness, client empowerment, and an improvement in clients’ overall ability to
function. All three of these underlying themes may be used to inform future studies and
serve as the basis for clinical practice in the field of equine-assisted psychotherapy.
Interpretation of the Findings
The existing research on the field of equine-assisted psychotherapy, as was
illustrated in Chapter 2, has served as a helpful foundation and supports why additional
research is needed. Although my sample size was small, consisting of fiveparticipants,
this was enough to confirm and support what the other existing research has indicated on
a larger scale, which is that equine-assisted psychotherapy is being used in a variety of
ways with a variety of populations of focus and lacks uniformity. Each participant
described very different applications of therapy approaches and although some
similarities existed such as the use of treatment plans to identify goals for the therapy
sessions, in most cases there were more differences than similarities which seemed
dependent on the population they served and what training and experience each
individual therapist had received that guided their practice.
As for the theoretical foundation, all of the participants offered feedback
indicative of some theory or model that influenced the work they do with their respective
populations of focus. All five participants relayed in the interviews that a combination of
their lived experiences and professional training were used together with this to develop
and implement the practice methods they were using in the programs in which they
worked doing equine-assisted psychotherapy. Additionally, all but one of the participants
mentioned multiple influential theories and/or models that they find relevant to the work
they do.
Interestingly, three of the participants made some reference to attachment theory
and the related seminal literature (Ainsworth, 1985, 1989, 2015; Bowlby, 1988, 2008,
2012; Bowlby & Ainsworth, 2013).This theory was also referenced by previous studies
on equine-assisted psychotherapy (Bachi, 2013;Bachi& Parish-Plass, 2017;Maujean et
al., 2013; Masini, 2010;Parish-Plass, 2013). The relevance of this theory to equineassisted
psychotherapy was especially apparent when exploring the theme of having a sense of
belonging and the connectedness between people and horses, in this case specifically the
participants involved in equine-assisted psychotherapy and the horses used in those
programs.
This has several useful implications, the first of which is it could potentially be
used to measure outcomes and efficacy of the therapeutic value of such interaction. In
addition, it can also be used to look more deeply at variables of connectedness in this
form of therapy including spiritual, emotional, and physical realms.Attachment theory
has already been integrated into some clinical practice involving equine-assisted
psychotherapy and research supports additional development of interventions using it
(Bachi& Parish-Plass, 2017).
Attachment theory was not the only theory that was identified during the data
collection process as being relevant to equine-assisted psychotherapy. One participant
referenced Gestalt therapy, which I had discovered during my review of the existing data
and provided a detailed explanation in Chapter 2. The use of Gestalt therapy approaches
in conjunction with equine-assisted psychotherapy has also been documented in the
current existing literature (Kirby, 2010; Lac, 2016).Additionally, the term existential was
used by one of the participants when referencing equine-assisted psychotherapy, which
relates closely to the work of Soren Kierkegaard, whose contribution was also explored in
the literature review (Kierkegaard, 1960, 1967).
The therapists also spoke in great detail about their training experiences; for
example, one spoke of trauma-informed care and the work of Bessel Van Der Kolk
(2014) as being instrumental in their work with the horses and their clients with trauma.
Based on the findings of my study, the use of equine-assisted psychotherapy to treat
individuals who have experienced some form of trauma seems to be a common factor
across all five of my participants, all of whomnotedthat they hadworkedwith individuals
that hadexperienced trauma in some way. A number of studies also support the
assumption that equine-assisted psychotherapy can be a targeted approach to be used with
populations that have experienced trauma (Bachi, 2014; Burgon, 2011; Dell et al., 2011;
Kemp et al., 2014;Krenek, 2013; Mota, 2014).
Limitations of the Study
As with any study limitations did exist. As noted previously, all participants in
my study from the United States, and were not limited to one region or demographic area.
The field of equine-assisted psychotherapy is not strictly limited to the United States and
is being used on an international scale as well, so my study findings while still applicable
in some regards, will not account for any differences in practice that may exist in other
countries outside of the United States. Additionally, my past role as a mental health
therapist and my personal history of owning and working with horses may have in some
ways impacted my ability to interpret my study findings, although I made every attempt
to remain aware of my bias. In addition to this, I was especially careful not to project my
assumptionsthat horses are beneficial to one’s personal, mental, and physical
wellbeingwhen I was interviewing participants.
Recommendations
As I mentioned in previous sections, this study was exploratory in nature and
meant to be a starting point for future studies in the area of equine-assisted
psychotherapy, even more specifically to the thought process that guides the clinical
practice of the therapist’s performing such work. I have some recommendations in terms
of future studies that may be conducted using my findings as a basis, the first of which
would be to expand the sample size to include participants from as many of the 50 states
as possible, or conduct studies in specific demographic regions to compare and contrast
(i.e.: New England, Midwest, etc.). This recommendation comes from my discovery that
each individual state appears to have their own licensing standards, credentialing
requirements, and in some cases their own certification processes related to the practice
of equine-assisted psychotherapy. This recommendation could also be expanded to
include international areas since the use of equine-assisted psychotherapy is not exclusive
to the United States and is being used in many countries around the world.
Additionally, more attention could be given to the actual personal demographics
of the participants chosen for future studies. Gender was one area in which there was a
variable since four of my participants were female and only one of the therapist’s was
male. Although this may not have had an impact on outcomes, there is simply no way to
know unless a study is conducted that looks at variables such as gender and age in
relation to the participants, their perceptions, and their responses.
Lastly, a larger sample size would confirm findings and perhaps even offer
additional data not captured in my study. I had originally intended to interview up to 10
participants, however unforeseen challenges with my recruitment phase related to the
COVID-19 pandemic resulted in a smaller sample size of 5. Although this was still
helpful and provided much insight into my topic of study, more participants may have
resulted in additional themes being recognized.
Implications for Social Change
It was my greatest intention when conducting this study to influence some level of
positive social change. My study only serves as a starting point and offers helpful
considerations for future research that may also influence growth in terms of the clinical
application of equine-assisted psychotherapy. Once we can begin to understand how the
therapists performing this work perceive the interaction between the clients and the
horses and the work they do therapeutically, more contributions are made to the research
that supports it as evidence –based practice. This will potentially lead to more
developments in the field that will provide the recognition it needs to be considered more
than a form of experiential therapy.
This may also begin to fill a gap that exists in the identified knowledge base about
equine-assisted psychotherapy, clarifying some aspects of the existing knowledge base
and helping to identify further gaps in the understanding of this therapy method. Through
my work, I had hoped to clarify what is known and what is not yet known about the
thinking behind some of the clinical practice methods of the therapists using
equineassisted psychotherapy. With these findings I attempted to support the social
change process that seems to be developing as the field of equine-assisted psychotherapy
matures and the need for theoretical guidance becomes more apparent.
Conclusion
Equine-assisted psychotherapy continues to evolve and grow as it gains
popularity as a treatment option for a wide variety of populations. There is an ongoing
need to continue to research and gain a greater understanding of all of the various ways it
is being implemented both to evaluate efficacy, and also to support the validity of it as a
form of evidence-based practice that can be used as more than anexperimental form of
therapy. Results from my study suggest that equine-assisted psychotherapy can be used
effectively in a variety of ways with a variety of populations, but this process is guided
primarily by the individual therapists based off of a combination of their personal
experiences and professional training. This study serves as a starting point for future
studies, perhaps focused on grounded theory as the clinical practices of therapist’s
performing equineassisted psychotherapy continues to evolve and gain competency that
aligns with those practicing other evidence-based therapy approaches.
