Horses and Mental Health: An OT Perspective

Introduction

I am happy to be here to talk about horses and mental health. I always feel it is important when I attend a webinar to walk away with something I can apply to whatever practice setting I am in, and I hope to be able to do that for you today.

• Occupational therapy takes a holistic view of all people and mental health is a priority for all clients, families, and systems that we work with.
• Occupational therapy practitioners address psychosocial deficits throughout the lifespan.
• Occupational therapy provides intervention for intensive, targeted, and universal interventions.

When we think about occupational therapy, I always think about the holistic view that occupational therapy takes of people and that mental health is always incorporated into the way that we serve our clients. When we are looking at a client, a family, or a system that we are working with, we always think about mental health as part of that. I think that is so important when we start to look at the way horses fit in as an intervention to address mental health.

We need to think about how occupational therapy practitioners address psychosocial deficits throughout the lifespan. Typically, when we think about horses and occupational therapy, we often picture children, but there is a lot of opportunity for occupational therapy practitioners for other ages including adolescents, adults, and those in late lifespan if they want to incorporate horses. This presentation will hopefully give you a better look at mid-life and late-life lifespan when we are working with horses.

Then, the last part is to think about the types of interventions that we might provide. This might be intensive and look at those already with a diagnosis. Or, they may be targeted for those people who have risk factors for occupational performance deficits. Universal interventions fit really well with the psychosocial model of practice and also fits really well with incorporating horses into occupational therapy practice.

Terminology

• Therapeutic/adaptive riding
• Hippotherapy
• Equine-assisted/facilitated psychotherapy
• Equine-assisted learning/coaching
• Equine therapy

I want to go over the terminology before we start. These are terms that you might hear in reference to occupational therapists working with horses or in reference to the industry in which horses are used with people with physical or mental health disabilities. Each of these terms means something a little bit different. Therapeutic or adaptive riding is a horseback riding lesson for a person with a disability. There is no medical or mental health professional involved in these services. Hippotherapy is a treatment strategy or a tool that focuses on the movement of the horse. It is used by occupational therapy practitioners, physical therapy practitioners, and speech-language pathologists. Equine facilitated or equine-assisted psychotherapy is focused on the mental health aspect. Typically, this is provided by psychologists, social workers, or counselors. Equine-assisted learning or coaching sometimes is confused with psychotherapy, but it is provided by an educator. Many times they might be working on learning outcomes but there is also an area that addresses personal growth and self-learning. The last term equine therapy is actually a term that is used to address therapy provided for a horse with an injury. Sometimes you will see that as a misnomer, but that is actually where a veterinarian or a physical therapist is providing the intervention to the horse that has been injured.

Medical and Mental Health Applications with Horses

• Hippotherapy
  • Refers to how occupational therapy, physical therapy, and speech-language pathology professionals use evidence-based practice and clinical reasoning in the purposeful manipulation of equine movement as a therapy tool to engage sensory, neuromotor, and cognitive systems to promote functional outcomes.
  • Best practice dictates that occupational therapy, physical therapy, and speech-language pathology professionals integrate hippotherapy into the patient’s plan of care, along with other therapy tools and/or strategies. 
• Equine-assisted psychotherapy
  • Defined as an interactive process in which a licensed mental health professional working with or as an appropriately credentialed equine professional partners with suitable equine(s) to address psychotherapy goals set forth by the mental health professional and the client.

Why are these terms important? It is important to understand how occupational therapists might include horses in their practice. The two ways are hippotherapy and equine-assisted psychotherapy. Again, hippotherapy looks at the specific function of the movement of the horse to address a patient's deficits and functional outcomes. We might be working on the sensory, neural motor, or cognitive systems. Then, we are looking at occupational performance at the end. Hippotherapy is always integrated with other tools or strategies that the practitioner is using.

Equine-assisted psychotherapy is an interactive process with a mental health professional working with an appropriately credentialed equine professional and suitable horses or equines. This is used to address the psychotherapy goals set forth by the mental health professional and the client. It is also a team approach. The mental health professional may be the occupational therapy practitioner or psychologist. a social worker, or a counselor. And then, they are going to work with an equine professional. The equine professional can be an equine specialist in mental health and learning or another credentialed equine professional. Their role is to be an advocate for the horse and make sure that the horse is not becoming too stressed with the work that is being done. They are there also to interpret some of the cues that the horse might be providing.

The client and the mental health professional work together to set goals, and the horse is being incorporated to address those goals. When we are looking at the medical and mental health applications of horses, we are specifically looking at either hippotherapy or equine-assisted psychotherapy. So, hopefully, that helps to clarify some of the terminologies that you might see surrounding the use of horses in occupational therapy practice.

Methods and Models

Now, we are going to move a little bit deeper now and look at some of the methods and models.

• Hippotherapy
  • Dynamic Systems
  • Biomechanical
  • Motor learning
  • Sensory Integration
  • Principle of NDT
• Psychosocial
  • Task-oriented
  • Psychodynamic
  • Cognitive-Behavioral

The methods and models are based on different frames of reference including the dynamic systems theory, biomechanical theory, motor learning, sensory integration, and principles of NDT (see Figure 1). And when we are looking at the psychosocial practice, we are looking at task-oriented groups, psychodynamic theory, and cognitive-behavioral theory.

Hippotherapy Frames of Reference

Figure 1. Hippotherapy frames of references.

The Dynamic Systems Frame of Reference is where the movement of the horse impacts multiple systems in the client. In the Biomechanical Model, we are looking at impacting the client's capacity for movement and daily occupations. Motor learning is that the horse's movement provides repetitive practice to improve motor outcomes. From a sensory integration perspective, the movement of the horse is multisensory and is graded to improve processing and integration. For principles of NDT, we are looking at weight-bearing, weight shift, and key points of control that are overlaid with the movement of the horse.

Psychosocial Frames of Reference: Task-Oriented

• The group interacts together to complete a project. The leader assists the group in directive or facilitative leadership.
• Some examples of working with horses in a task-oriented group include:
  • leading the horse through an obstacle course created by the group members,
  • cleaning the barn and making a nice “home” for the horses,
  • and completing a bulletin board for the facility about the different horses' personalities.

When we contrast that, we can look at the psychosocial frames of reference for a task-oriented group. When we think about task-oriented groups, we are thinking about occupational therapy mental health practice and looking at the way in which a group of clients or individuals interact together to complete a project. The leader tends to be directive or facilitative. Some examples of working with horses in a task-oriented group include leading the horse through an obstacle course. In this case, we have clients create an obstacle course for the horse, and then they are going to go ahead and lead that horse through the obstacle course. Another option is having the group clean the horse's barn and making a nice home for the horses. Another idea is to complete a bulletin board for the facility about the different personalities of the horses. 

Psychosocial Frames of Reference: Psychodynamic

• The psychodynamic frame of reference uses themes and symbols to focus on the client's ability to view themselves realistically and to be aware of their strengths and weaknesses.
• Examples of OT sessions incorporating horses would be
  • looking at the horse as a metaphor for other people or relationships in the client’s life,
  • working with the horse as a living canvas and painting on the horse, or discussing the horse as a symbol.

When we look at the psychodynamic frame of reference, we are focusing on themes and symbols and the way that the client views themself. We might be looking at the horse as a metaphor for other people in the client's life. If they are always projecting that one horse is angry with them, we might talk about this from a psychosocial perspective. "You are always saying that the brown horse seems really angry. Does the brown horse remind you of anybody that you have a relationship with?" In this way, the horse takes on a metaphorical or symbolic representation for the client. Or, we can work with the horse as a living canvas. We talk about that by painting some sort of art on the horse's coat and then discussing the symbols that the client has created.

Psychosocial Frames of Reference: Cognitive Behavioral (CBT)

• The cognitive-behavioral frame of reference focuses on the thoughts and behaviors of the client as an avenue of change. The client or group will examine thought patterns and beliefs and develop behavioral strategies to direct desired changes.
• Examples of OT sessions including horses and using CBT are:
  • Examining the clients’ or group’s perceptions of the horses’ behavior - “The horse didn’t like me,” or “That brown horse always walks away from me.”
  • Other aspects may include journaling about sessions and work on stress management and coping skills.

In mental health psychosocial practice, many practitioners are familiar with a cognitive-behavioral frame of reference. This approach is focusing on the thoughts and behaviors of the client as an avenue for change. This can be done in one-on-one sessions or as a group. Some examples would be looking at a single client or a group's perception of a horse's behavior, such as "That horse didn't like me" or "The brown horse always walks away from me". What does that say about the client's thoughts? Is this repeated in any of the clients' behaviors in the way that they interact with other people? Other aspects that we might include from CBT would be journaling about sessions. Having clients complete journals at the end of their sessions where they interacted with horses is another great activity. We can also work on stress management and coping tools. Many times when working with horses, they do not always do what we want them to do and that can be stressful for clients. This provides an excellent opportunity to work on stress management or coping skills with clients.

Now, we are going to watch a short video that looks at horses and human health.

Video: Horses and Human Health

Personally, I don't think adults and human beings are honest enough anymore. I think we've forgotten how to be honest because we're all too scared, to be honest, but I think horse just kinda go you know what? Turn up and I'm going to treat you just as you are and I'm going to respond to what you do. They pick up on all that emotions but also body clues that we put out there and they're doing it in a really honest and they're big. I feel like some of the young people I've worked with, they can't get aggressive with the horse, 'cause it's not going to respond to them.

Horses are prey animals which means every day when they wake up, really what's foremost in their mind is am I going to die today? They have to monitor their environment to make sure that there isn't a predator who is going to harm that animal and because of that, they are highly emotionally intelligent. They are able to read the energy of a person or of a group. They can read intent and they're also highly congruent in their behavior. So, based on what they experience in their environment, they're going to behave in certain ways. So, they offer a great gift to us as therapists as instructors so that we can look at what they're presenting to us in an experience with a person, and then we can help facilitate some conversation with that person whether it's a client or a student about their experience with that animal, about that animal's interaction with them that can allow that person than to use that experience to do some introspection to help heal or to grow in different ways.

So, in the Eagala model, we don't ride horses. It's all ground-based work.

Just the presence of animals, research shows lowers our heart rate. It helps us ground ourselves if we're anxious. So, the horses can provide comfort, support. Sometimes they can provide a challenge because if you're afraid of horses, obviously it might be a challenge to enter an arena and have experience with a horse. But they become the team members. They're part of the treatment team. And they're part of what happens in the arena.

Thank you to Eagala for letting us use that video because I think it incorporates some ways for us to see the way in which clients might be interacting with horses. We are going to go back to our presentation and talk about some of the concepts there in the video that we saw. The video showed a model of using horses for mental health, and we are going to focus on the occupational therapy perspective now.

An OT Perspective

• Occupational therapists working on mental health and illness with clients and incorporating horses have ample opportunity to draw from established OT frames of reference and treatment groups.
• Horses add an experiential learning component to the OT sessions that allow the OT practitioner to address task completion, self-awareness, coping skills, and stress management, and occupational performance through novel situations presented by the horse or horses in the group.

We have a lot of opportunities already drawing from our own OT frames of reference and using treatment groups. We also have the ability to look at experiential learning and the components of how experiential learning focuses on task completion, self-awareness, coping skills, and stress management. Ultimately, our focus is on occupational performance. We are able to set up novel situations either presented by one horse or a group of horses to help clients focus on a lot of these skills. One of the interesting aspects of this is that when we are working with horses and people with mental health challenges, we are often not able to preplan what is going to happen. We do not know what the horses or the clients are going to bring. Thus, we need to be well versed in our mental health practice to be really competent and effective in this area.

Intensive Interventions

• Characterized by AOTA as interventions directed at clients with a mental illness or diagnosis. 
• The OTP is working with a specific client or group to address occupational performance deficits associated with their diagnosis.
• Example:  The OTP runs a group for veterans with PTSD every week to address ADL and IADL skills.  The horses provide opportunities for the group members to practice skills, assess their own physiological reactions to stress, and develop coping skills while performing IADL skills.

When we think about intensive interventions, we are looking specifically at people who have a mental health diagnosis. The occupational therapy practitioner looks at the occupational performance deficits that are associated with the diagnosis. An example would be an occupational therapy practitioner that runs a group for veterans with PTSD every week to address ADL and IADL skills. We can use the horses, in this case, to look at ways that the group members can practice skills to assess their own physiological reactions to stress and develop coping skills while performing IADL skills. When we think about caring for others and pets, horses provide a nice opportunity. The clients can be focused on coping skills as they work through some of the reactions that they might be feeling as they are doing the ADL skills.

Targeted Interventions

• Targeted interventions address groups or populations of people at risk of developing mental illness.
• The OTP is addressing performance skill deficits or occupational performance areas to improve mental health and impact risk-factors.
• Example:  The OTP is working with 4 children in foster care to address issues of trust and attachment.  The horses provide a stable partner for developing trust and bonding.

Targeted interventions look at at-risk groups. We are looking at improving mental health and impacting risk factors. We might work with a smaller group. An example would be four children in foster care working on trust and attachment. In this case, the horse provides a nice stable partner for bonding for these four children. They do not particularly have a diagnosis but we know that they do have some risk factors.

Universal Interventions

• Universal interventions are aimed at promoting mental health.
• The OTP is providing outreach and prevention groups or services.
• Example:  The OTP works with a school to provide a bullying prevention program.  The school children observe a herd of horses and discuss the role of the herd leader and what horse behaviors may look like in groups of people.

Universal interventions are aimed at promoting mental health. This is often outreach or prevention. In this case, we could provide an anti-bullying program to schools as an example. All school children would come out to the farm, and they would do a herd observation. This means they are going to observe a herd of horses out in a field or in a natural environment. Then, they are going to look at the role of the herd leader. This is the horse that is in charge and discusses what that looks like in relation to other groups of people or peer groups. We know that you can have a good leader who communicates really well and everybody's happy to follow or you could maybe have a bossy or a bully leader who tells everybody what to do and nobody seems to want to go along. So, we could see that in the horses and then have a discussion about it.

Why Horses?

• Horses are herd animals and respond to social interactions with others.
• Horses are prey animals and respond to factors in their environment.
• Horses live in a social hierarchy and can include humans in their hierarchy.
• Horses have complex neurological and sensory systems and humans can interact with these systems.
• Clients can participate in horse care to improve ADL and IADL skills.

Horses are great because they are herd animals and they respond really well to social interactions. As we heard in the video, they are prey animals so they respond to factors in their environment. Horses also have a social hierarchy. This gives us an opportunity as practitioners to bring that to the client's level of awareness. Horses have complex neurological and sensory systems and humans interact with these sensory systems. We will talk about co-regulation in a moment. It also provides an opportunity for clients to participate in ADL and IADL skills.

Vigilance

• Horses are keen observers of their environment and the herd members in their group. This vigilance is something that many clients in OT sessions can understand.
• Clients with anxiety, OCD, and PTSD also struggle with vigilance or hypervigilance.
• Horses may mirror a client's behavior or emotions. This can allow the OTP to direct the client towards self-reflection.
• The OTP can use the horse's behavior and interactions for feedback and opportunities for the client to check-in and process what is happening in the moment.

One key topic, when we are talking about psychosocial practice and horses, in particular, is vigilance. Horses are very vigilant about their environment. We know that many clients with anxiety, OCD, or PTSD often have trouble with vigilance and hypervigilance. There is a commonality between the horses and the clients. When we take this into the next step, we know that the horses are going to mirror a client's behavior or emotions. We can use this to help the client develop self-reflection. As we look at the horse's behavior, we have a lot of opportunities for feedback and for the client to check-in and process what is going on in the moment. If a horse suddenly becomes alert to something in the environment, we might ask the client to check in with their own body, especially if we are working with a person who already has challenges with vigilance.

Congruence

• Congruence is the fit between the person’s internal state or feelings and their outward behaviors. Incongruence would be acting confident or tough when feeling scared. When you are congruent, your internal state of being matches your external state of being.
• Horses can feel the person’s internal state doesn’t match their facial expressions, words, or their body language.
• The OTP can use the horses’ reactions to confront the client or group on their incongruence.
• Congruent behaviors are key to successful human relationships

Congruence is another area that we really focus on. It is the fit between our internal state or feelings and our outward behaviors. When we meet a horse for the first time, if we are feeling scared or confident, we will project that on to the horse. The horse will pick up on it and display certain behaviors. If the equine professional or the occupational therapy practitioner is well versed in equine behavior and communication, they can point this out and ask the client if what the horse is feeling is the same as what they are feeling on the inside. The horse is also going to pick up on the person's facial expressions, their words, and their body language, and they are going to give a little bit of a read back. In human relationships, congruent behaviors are key to having a successful human relationship. We can have an opportunity when we are partnering with horses to help our clients develop those skills to have more successful human relationships.

Co-regulation

• Horses have a well developed central nervous system that seeks homeostasis and is impacted by the behavior of other horses.
• Humans can impact and be impacted by the state of the horses’ nervous system. The OTP can mobilize the calming effect of the horse to provide a co-regulation effect on a dysregulated client.
• Higher functioning clients can work on self-regulation to produce a calming effect on a dysregulated horse.

As somebody with a strong background in sensory integration, I find the co-regulation that happens between horses and clients or groups of people extremely fascinating. Horses are looking for homeostasis in their daily life and environment and that is impacted by the alertness level of other horses in the herd. We know that when dysregulated clients come into the herd of horses, it can really affect all the horses. It can change their level of homeostasis or their level of regulation. We want to have horses that are well regulated so that they can help co-regulate the clients. And if we work with really high functioning clients, we can actually help them focus on regulating themselves to be more calming to a horse that is dysregulated. So, we can work on the system both ways. We can have horses that are very calm and well regulated to help a dysregulated client, or we can have clients that are really working on some of those higher-level skills work with a horse that is really excited and have that client really focus on calming themselves to see that effect in the horse.

Horse CARE Protocol

• The Horse CARE protocol is an example of a 10-week mental health and wellness program designed on the science in the book “Four Ways to Click: Rewire Your Brain for Stronger, More Rewarding Relationship.”
• This group protocol incorporates horses and follows an OT centered view and intervention focus. 
• Topics include ADL’s, roles, rhythms, and social interactions and engagement in meaningful activities. The Horse CARE protocol is a protocol that I developed after reading the book "Four Ways to Click: Rewire Your Brain for Stronger, More Rewarding Relationships." It focuses on occupational therapy interventions. We are going to look at some ADLs, roles, rhythms, and social interactions that incorporate horses and some interventions. It is called the Horse CARE Protocol.

One of the factors of the "Four Ways to Click" is calm. It is based on the smart vagus nerve and looks at developing trustworthy relationships. The herd becomes the safety group. We look for a positive relationship or relational moments with the horse. And in this, we are going to use grooming as an activity of co-regulation. We are introducing to the client a body scan or arousal regulation. 

Occupations

ADLs and IADLs

We are going to discuss with the client grooming the horse but also grooming as a daily routine (see Figure 2).

Figure 2.  Overview of the use of horses and ADLs/IADLs.

Habit, Routines, and Roles

We also want to bring attention to the client their roles. This could be as a son, daughter, student, warrior, patient, worker, et cetera. An overview is in Figure 3.

Figure 3. Overview of the use of horses and habits, routines, and roles.

In particular, we are looking at the dorsal anterior cingulate cortex and the feeling of either being part of a group or not belonging. This is a way of soothing and processing feelings of social anxiety or isolation. Horses are part of a herd. The client could complete a "herd observation" of a group of horses in an arena or a pasture. What does the client see in the herd? Are there any metaphors for their life or any groups that the person is a part of? What roles are a client currently identifying with? Are there any activities that they have to do to fit into these roles? Often in psychosocial practice, the client may identify with a role but have a hard time fitting into that role.

Performance Skills

Figure 4. Overview of the use of horses and performance skills.

For performance skills, we can use the mirror system. Seeing another can be a literal or metaphorical way of reading our emotions. We can look at the rhythm of connection and disconnection. "This week, we are going to talk about the way a horse approaches new objects in their environment. We are going to present the horse with the novel stimulus and see how the horse reacts." We can then see how the client feels about watching the horse experience this. If the horse is fearful, does the client notice it anywhere in their body? We can have them take photos. We can also have the client go back to a body scan or incorporate some journaling about this.

OTPF Review

• The OTPF can be used to provide a framework for OT sessions incorporating horses. This allows us to communicate with other OTPs and professionals in a way that is consistent.
• The OTPF can be used to describe client factors and performance skills as well as the OT process and outcomes such as to promote, create, or restore.

We are now going to look at the Occupational Therapy Practice Framework (OTPF) and how it can be used to describe the way that we incorporate horses into occupational therapy practice from a psychosocial perspective. The OTPF allows us to communicate with other occupational therapy practitioners as well as other professionals in a way that is consistent. I certainly encourage people to look at the OTPF as a way to document and communicate how they are providing interventions.

Application of the OTPF: Occupations/ADLs

• OTP’s focus on addressing meaningful occupations with clients; when incorporating horses many ADLs can be addressed:
  • Clients can groom a horse and reflect on the ADL of hygiene in their own life. How did the horse look before and after grooming? What purpose does grooming a horse serve?
  • Dressing: Horses wear a variety of tack and blankets during certain weather. Clients can assist in tacking up a horse or putting on blankets for turnout. The OTP may be assessing the skills needed for the client to improve independent dressing.

We are going to now look at client factors, performance skills, and then also the OT process for outcomes for promoting, creating, and restoring. When we apply the OTPF looking at occupations or ADLs, we can look at incorporating horses into activities of daily living such as grooming. The client can groom the horse and reflect on their own hygiene. How did the horse look before grooming and after grooming? What purpose does grooming a horse serve? And then ask the client to go ahead and reflect on their own hygiene. Before and after photos of the horse can also be really useful here. Another ADL skill here would be dressing. We know that there is a variety of different types of equipment or tack that horses including blankets during certain weather. Horses can wear a light sheet if it is rainy or a heavier blanket if it is colder. We can have the client assist in putting on the equipment. During this time, we can talk about what skills are needed for independent dressing. Was the client able to match the type of clothing that was needed for the weather and the type of equipment that the horse needed for the activity? Is the client having those same challenges with their own dressing skills?

OTPF: Performance Patterns: Habits, Routines, and Roles

• Performance patterns assist clients in achieving personal goals such as employment, education, independent living, or sobriety.
• OTPs can work with clients or groups and horses to address habits, routines, and roles (or role acquisition).
• Habits - horses like familiarity and prefer to be approached and haltered the same way every time
• Routines - horses expect to be fed and cared for at the same time of day; clients can assist in everyday barn routines

We look at performance patterns, habits, routines, and roles. We need to communicate with others about the unique role of occupational therapy in mental health practice. One area includes personal goals such as employment, education, independent living, or sobriety. Performance patterns are what helps the client to achieve these goals. If they are having trouble with their habits, routines, or role acquisition, they are often going to have difficulty with employment, educational prospects, living independently, or sobriety, Horses like things to be the same. They like to be fed at the same time of day and handled in the same way. And, they like people to approach them in the same way. We can also start to get our clients familiar with habits. Which habits are helpful and which are not? Clients can start to assist in everyday barn routines to develop more functional performance patterns. This routine is going to serve them in a job situation or if taking online education classes. What routines are they going to need to set up for themselves? If they can start to understand how routines work for horses, they can be more successful when they start to set up those routines for themselves.

OTPF: Performance Skills

• Common areas to address include sensory and praxis skills, social skills, emotional regulation, and interpersonal communication.
• Through the understanding of the horses’ physiology, the OTP can work with clients and groups on stress management, anger management, or executive functioning.
• Group activities and team building sessions are common interventions to include horses into OT sessions.

Performance skills include sensory and praxis skills, social skills, emotional regulation, and interpersonal communication. Often, these are the areas that people with psychosocial challenges have difficulty. The way that we interact with horses includes vigilance, congruence, and co-regulation. These same characteristics really fit very well into the performance skill category. If we understand the physiology of the horse, we can really focus on client's or groups' issues with stress management, anger management, and executive functioning. We can do group activities or lead team-building experiences that include horses. We can use a group of horses, or as a team-building exercise, we can use one horse and really focus on interpersonal communication. For example, we might work with corporate groups or non-profit volunteers as part of team-building. 

Performance Skills Examples

Here are some performance skills examples. One group of clients might have to figure out how to move a horse safely into a box or area of the arena without touching the horse. This activity would be then used to assess the social skills of the group. How did they problem-solve? Did they scare or entice the horse? There are lots of different ways that they might approach this task, but we are looking at interaction and problem-solving.

We can also focus on emotional regulation. If we have a client with anger issues, we might choose a horse that is very sensitive to incongruent behaviors and then set up a situation that is challenging. We can then see if the client can remain congruent. We can also reflect on the behaviors that the horse is showing to the client.

Task-oriented groups can work on improving or promoting the stable. This is a nice community outreach. A group of people with anxiety might be able to reach out to other people with anxiety in the community. They could create a brochure or complete a short video of themselves talking about the benefits of interacting with horses. This would serve two purposes. It is helping the current group that you are running, but it also helps with outreach.

Occupational Therapy Outcomes

• Create/promote: Clients develop healthy living routines by caring for horses (physical activity).
• Establish/restore: Clients address social skills and communication in a group with several horses.
• Maintain: Clients attend as volunteers at the facility in a peer support group to maintain sobriety.
• Modify: not directly applicable, but OTP may address with information gained in interventions with horses
• Prevent: develop a list of stress management cues to prevent illness symptoms from interfering with work roles

We can look at occupational therapy outcomes in different ways. The first outcome is to create or promote. Clients can develop healthy living routines by caring for horses. There is a lot of physical activity that comes with cleaning up a barn, mucking out a stall, dumping water buckets, et cetera. Some of our clients with depression have trouble with physical activity and healthy living routines. This might be a way to start to have clients engage and get involved. They feel like they are caring for the horses, but at the same time, they are developing healthy living routines.

We can look at establishing or restoring social skills. Clients can address social skills and communication when in a group interacting with horses.

For maintaining as an example, clients can come to the stable as a volunteer or as part of a peer support group to maintain sobriety.

Modifying is not something that we are doing when we are focused on interventions that include horses, but the intervention may give us information to be an advocate for the client outside of the work with horses. We may learn something about the client that would be really helpful to their employer or to a professor that they have. We may try to modify another situation with the information that we gain through their interaction with horses.

Lastly, we can look at prevention. We could have the client develop a list of stress management cues to prevent illness symptoms from interfering with their work roles. Through interactions with horses, the client may become aware of things that really work well for them when addressing stress. They can then use these stress management cues to maintain their role as a worker.

Case Study

8-week Group to Address Social Skills

• 6 Adolescents with identified learning and emotional disabilities
• 3 veterans that have self-identified as isolating from social interactions
• 1 client with bipolar disorder is having difficulty with her marriage and relationships with her children

Here are some examples of 3 different types of groups addressing social skills. The first group is six adolescents with identified learning and emotional disabilities. The next is three veterans that have self-identified as isolating from social interactions. Lastly, we have one client with bipolar disorder who is having difficulty with her marriage and relationships with her children. We are going to frame each of these as an eight-week intervention. For the adolescent group, coping skills and co-regulation might be a challenge for them. For the veterans, they have already identified that they have difficulty with social interactions and use isolation as a coping skill. So, we might be looking at different coping skills with this group of veterans. We might also want to look at different ways that they might pursue interactions. And then for our one client with bipolar disorder, we might look at the congruence of her behaviors in relation to the horse. 

Outcomes: What Can We Expect?

• Group 1: Adolescents will use appropriate social greetings with one another.
• Group 2: Veterans will identify the benefits of social interactions.
• Client 3: The client will improve her ability to be congruent in her verbal and non-verbal communications.

What kind of outcomes might we expect from each group and the individual client? For our first group, we may want the group of adolescents to use appropriate social greetings with one another. For our veterans, we may want them to identify the benefits of social interactions. And for our individual client, we may want her to improve her ability to be congruent in her verbal and non-verbal communications. 

Interventions: What Will We Do?

• Group 1: Adolescents will develop a greeting habit with horses. The group members will practice approaching the horses showing the back of their hand and touching the horses’ shoulder before haltering.
• Group 2: Veterans will do herd observation and discuss the benefits of living in a herd. The discussion will be facilitated to explore the ways the horses interact and how they can seek these interactions in their daily life.
• Group 3: The client will work with one horse and attempt to accomplish the task of catching, haltering, and leading the horse to the barn. The client will need to demonstrate adequate self-regulation, congruence, and communication skills to be successful. The OTP will lead the processing to help the client apply the experience to her interactions with her family.

To address our goal, adolescents could develop a greeting habit with horses. The group members would practice approaching the horses, showing the back of their hand, and touching the horse's shoulder before haltering. This is a common greeting or acceptable way of approaching a horse, and it makes the horse feel calm and safe. We could then transition this over into a discussion about the way that the adolescents approach and greet one another. For our veterans, we could have them do a herd observation and discuss the benefits of living in a herd. The occupational therapy practitioner could then facilitate the discussion. We would want to look at the ways in which the horses interacted and discuss how the veterans could incorporate some of those interactions into their own daily life. For our third client, this client could work with one horse and attempt to accomplish the task of catching, haltering, and leading the horse to the barn. This may sound like an easy task, but depending on the horse that the occupational therapy practitioner and the equine specialist have selected, this is going to challenge the client's self-regulation, congruence, and communication skills. The occupational therapy practitioner is going to then help the client process that experience and apply it to her interactions with her family. What does she do when she gets frustrated? Does she do the same thing that she did with the horse with her husband in her marriage? We are going to be helping her to connect those two scenarios together.

Summary

I hope you have learned a little bit about how occupational therapy can incorporate horses into mental health. I can now take some questions.

Questions and Answers

What are some of the qualifications needed for practicing in this area?

That is a great question. You really want to have a good knowledge base of mental health practice as an occupational therapy practitioner and also some equine experience. The focus when working in mental health with horses is a team model. Typically, there is an equine specialist involved. If the occupational therapy practitioner is not very experienced with horses, then they need to have this specialist. We touched upon that a little at the very beginning. There are two main organizations in the United States that provide education for mental health practitioners who are looking to incorporate horses into their practice. There are Eagala and PATH. These two organizations provide information about mental health practice with horses and have some resources available. In our education as occupational therapy practitioners, we have a strong background in mental health and running treatment groups. That is a strength for us. We need to articulate our value and focus to be able to communicate with the equine professionals what we need out of our sessions. We also need to communicate what types of horses we need, what goals we are working on, and what we feel comfortable with in terms of whether we want to work with one horse and one client or work with a number of horses. As a side note, it is important for any professional, whether you are working on the hippotherapy side of things or on the mental health side of things, to understand basic horse safety and language. So, if you are not a really strong horse person and you are going to be working with an equine professional or equine specialist, it is still our practice license that is on the line if something goes wrong. It is important to get some mentoring in this field so that you can keep your clients safe when they are around horses.

What different groups do you work with?

As I said at the beginning, we can look at this through the lifespan model. We talked about some examples of children in foster care or adolescents with behavioral disorders. We can look at mid lifespan and adults and the different roles that they might play. These roles can be a worker or parent. We can work with people that have mental health challenges like anxiety, OCD, bipolar disorder, or depression. People who have depression tend to respond very well to the setting. It helps for them to be in a different environment. They tend to open up and interact with the horses. In fact, many times the horses will approach and interact with them in a way that they might not be ready yet to initiate on their own. There are also many groups for seniors. It could be groups for active aging or those with dementia. Dementia is a new practice area. And, a lot of times when we are looking at the late lifespan, these individuals may have had experience with horses in the past. Thus, it can bring out a lot of nostalgia for them and be a very positive focused experience. 

What groups are appropriate and not appropriate?

There are precautions and contraindications when we are working with a mental health diagnosis. If a client has a history of animal abuse, we obviously would not want to include horses in their treatment sessions. Another one to think about is somebody who has an active psychosis. Generally, the main goal with somebody who has an active psychosis is to get them stable. Intervention with horses can come a little bit later on when they have been stabilized. Someone who has a history of fire setting is often contraindicated because of the risks around the farm environment.

There are many appropriate treatment groups. There is a lot of information about working with veterans and horses. Working with support groups tends to be a nice way of interacting with the community. They may be interested in working with you and doing either a certain number of sessions with you. Examples might include Alcoholics Anonymous or Narcotics Anonymous. Support groups for postnatal and perinatal depression or mood disorders are others that can respond really well. People who have been incarcerated need transitional types of experiences. Occupational therapy and horse interactive groups can be very beneficial for this population.

How long might a group run?

When we are looking at evaluation to discharge, some of that is going to depend on if you are seeing a client individually or a group of people. If we are seeing a group of people, we generally have a number of weeks that the group is going to meet. Similar to other mental health settings, if you are running a group protocol, it might be an 8-week, 10-week, or 12-week group protocol. Occasionally shorter group protocols such as four weeks can be effective and successful. Your goals are going to be modified to represent that shorter timeframe, but eight to 12 weeks tend to be a really nice time period to see good change and to have the group be fairly cohesive. If I am working one-on-one with a client, it is similar to how I would see them in any other way. During the initial evaluation, we would decide on their goals and decide how long we think it would take to meet those goals. This program might last four to eight months, seeing them weekly. Then, when doing a reevaluation, it is decided if treatment sessions should continue or if they are ready to discharge to a different setting or ready to start putting those skills into practice in their daily life.

For the individual session time, an hour is a good amount of time. For larger groups with more than six individuals, I might want my group to be an hour and a half, just to give a little bit more time for introductions and closure. For smaller groups and individuals, an hour is plenty of time from both the horse's perspective and from our occupational therapy group perspective. We want enough time for processing and for closure of our group. If you are doing something like corporate training, those can sometimes be a half-day, but that is a little bit of a different scenario.

How do you match the horse and clients? What are some considerations for matching horses and clients?

This is a great question because it is really about knowing your horses, the client(s), and having a good professional working relationship with your equine specialist. For individual clients, we want to know their goals and overall personality. Are they overreactive? Do they tend to have some trouble focusing? Do they need a horse that is going to draw them out? Or, do they need a horse that they are going to go towards? Those are all things that I think about when I am looking at a client. When I am thinking about a group, I view the group as a collective individual. What does the energy of the group bring? Are they a quiet group? Are they a really noisy boisterous group? Are they an interactive group? This going to give me a lot of information about how I am going to match the group with the horses. There are also horse characteristics that I look at during the matching process. Do I want one horse or do I want a group of horses? If I am doing a herd observation, I might want to use horses that go out together all the time or I can "facilitate" a herd. I might pick out three horses that are compatible but do not normally go out together. This newer group is going to display a lot more behaviors than a herd that is used to being together. I might want a horse that is reactive and is going to give the client a lot of feedback. Or, I might want a horse that the client really has to work to elicit a reaction. There are a lot of factors to consider, and I rely on my equine specialist to help give me input about the horses and what might work in my treatment session.

References

Banks, A. (2017). Four ways to click: Rewire your brain for stronger, more rewarding relationships. London: Allen & Unwin.

Equine Assisted Growth and Learning Association. (2012). Fundamentals of EAGALA model practice: Equine assisted psychotherapy certification program (7th ed.). Santaquin, UT: Author.

Frame, D. L. (2006). Practices of therapists using equine facilitated/assisted psychotherapy in the treatment of adolescents diagnosed with depression: A qualitative study (Doctoral dissertation). New York University, New York.

Irwin, C. (2001). Horses don’t lie: What horses teach us about our natural capacity for awareness, confidence, courage, and trust. New York, NY: Marlowe.

Kersten, G., Thomas, L. (2000). Equine assisted psychotherapy: Training manual. Santaquin, UT: Equine Assisted Growth and Learning Association.

Here are the references that were pulled together for this presentation. The "Four Ways to Click" book that was used in the Horse CARE Protocol. There is a lot of information out on the practice of incorporating horses into mental health. Eagala is the Equine Assisted Growth and Learning Association. The video in this presentation came from them, but they also provide education to practitioners, mental health practitioners, and equine professionals. They are currently working on developing a team model.