Article Type : Research Article
Authors : Blackburn D
Keywords : Therapeutic riding; Equine-assisted therapy; Veteran; Post-traumatic stress disorder; Operational stress injuries; Mental health; Complementary approach
Background: This research project focuses on the value and
usefulness of an equine-assisted therapy program for Canadian Armed Forces
(CAF) veterans suffering from an operational stress injuries. The main
objective of this study is to provide a summative evaluation of the program and
to enrich the research as well as the scientific documentation in
equine-assisted therapy.
Methods: A 14 veterans have completed all stages of the
project, including the ten sessions of the program, and they are the sample. These
14 CAF veterans speak French at home, live in the province of Quebec (Canada)
and are diagnosed with a post-traumatic disorder and/or depression disorder. A
qualitative methodology was developed. The participants had to complete a short
sociodemographic questionnaire and to meet the team of researchers in a
semi-directed individual interview. The analysis of the results was carried out
by SPSS 22 and NVivo 11.
Results: Participants identified three differences between
equine-assisted therapy and the clinical care that they received in the past.
The first difference, for half of the participants, between equine-assisted
therapy and psychotherapy is the experiential/practical nature of
equine-assisted therapy. The second difference, for half of the participants,
is that the equine-assisted therapy represents another way of approaching the
problem and the presence of the horse in the intervention play a key role. A
finding is also made by the majority of participants: equine-assisted therapy
is a type of treatment complementary to psychotherapy and pharmacotherapy.
Finally, the majority of participants has the firm intention to continue
equine-assisted therapy sessions and recommend it to their brothers in arms.
Conclusion: In the end, this study highlighted the point of
views and experiences of CAF veterans following their participation in an
equine-assisted therapy program. This project has enriched knowledge in the
field of equine-assisted therapy, operational stress injuries and veterans.
In their quest for
well-being and a better quality of life in the face of post-traumatic stress
disorder (PTSD) or depressive disorder, several Canadian Armed Forces (CAF)
veterans and veterans' organizations have, in recent years, been interested in
alternative or complementary methods of intervention to clinical care (mainly
psychotherapy and pharmacotherapy) [1]. Thus, equine-assisted therapies have
become very popular to help people such as veterans suffering from a variety of
mental health problems [2]. They are considered to be an emerging and
innovative approach [3]. Scientific literature generally provides a positive
assessment of the use of horses in the treatment of physical health problems;
however, to our knowledge, there are very few studies on the benefits of
equine-assisted therapies on mental health problems [4,5]. This deficiency is
even more staggering when it comes to the effects of equine-assisted therapies
on CAF veterans suffering from mental health problems [6]. It is therefore
essential to further study the contribution of horse-assisted therapies for
mental health problems [7]. Recognized best practices for the treatment of
post-traumatic stress disorder are currently based primarily on
cognitive-behavioural therapy combined with medication [8]. Could integrating
equine-assisted therapy into a comprehensive treatment plan that includes
psychotherapy and pharmacotherapy improve the general condition, symptom
management or adherence to treatment for veterans with PTSD or depressive disorder?
This article looks at the experience and perspective of veterans who have
completed an equine-assisted therapy program. It also provides their assessment
of this type of treatment. This article helps mental health professionals
better understand the contributions of equine-assisted therapy comprehensive
perspective in the treatment of veterans with PTSD or depressive disorder.
The Equine-Assisted Therapy Veterans
Assistance Program (EAT-VAP)
This program, developed
in 2015 by the team of the Therapeutic equestrian centre, Équi-Sens in
Terrebonne (Quebec), would be the first Francophone therapeutic equine-assisted
therapy program in Canada for veterans living with PTSD [9]. Built on the
American model of Equine-Assisted Psychotherapy (EAP) and Equine-Assisted
Learning (EAL), it is based on the expertise of the Equine-Assisted Growth and
Learning Association (EAGALA) in equine-assisted therapy for military
personnel, veterans and their families [10,11]. Equine-assisted therapy
sessions last 60 minutes, on average, and take place on the ground so that
participants do not have to ride the horses. Sessions are supervised by a
trained and certified equine specialist, as well as by a mental health
professional who is a member of a professional association. The approach
promoted by EAT-VAP is one where the team, which includes the horse(s) in
certain activities, the mental health professional and the equine specialist,
works together with clients during sessions [12]. The horse plays a crucial
role in the therapeutic activities [13]. For the Equi-Sens centre: "The
horse, through its authenticity, sensitivity and availability, is the support
that allows the frail person to find a place of relaxation, an open environment
that allows self-expression. It is because of the horse's ability to relate,
and with the support of the facilitators, that the person will become aware of
the following" [9]. Role-playing situations or games involving the horse
are organized depending on the needs identified. Hoops, wooden boards and cones
are used to represent difficulties, significant people or traumatic events on
which the veteran will work with the horse [14]. The participant is invited to
identify a metaphor through the horse's behaviours and to interpret it while
establishing links between his personal life and his interactions with the
horse [15]. During the sessions, the management of emotions stressors and
anxiety-provoking stimuli, self-esteem and self-confidence are discussed.
A total of 25 veterans
was recruited to participate in the research project. Of these, 14 veterans
formed the sample. These CAF veterans speak French at home, live in the
province of Quebec (Canada) and are diagnosed with PTSD or depressive disorder.
Eleven participants were unable to start or complete the EAT-VAP for personal,
medical or administrative reasons. A qualitative methodology was used.
Participants completed a short sociodemographic questionnaire and participated
in a semi-directed individual interview after attending ten equine-assisted
therapy sessions as part of the EAT-VAP. The semi-structured interview covered
the pre-equine-assisted therapy period, the experience during the 10 sessions
and the post-equine-assisted therapy period. All interviews were conducted by the
main investigator. The results were analysed using SPSS 22 (description of
sociodemographic data) and NVivo 11 (qualitative analysis of change). An ethics
certificate from the University du Québec en Outaouais was obtained on November
20, 2015.
Participant information
In terms of personal and
family data, the sample consisted of 13 men and one woman. The mean age of the
participants was 50.14 years [32 to 69 years old; standard deviation (SD)
11.12]. Of these participants, 85.7% were married and 78.6% had between one and
three children. In terms of military career, only one officer-ranked
participant participated in the project. The other 13 were non-commissioned
officers (NCO). The average years of service in the CAF were 20.79 years [12-37
years; SD: 6.96]. Over the course of their military career, the participants
had an average of 4.36 postings [1-10 postings; SD: 2.59] and 2.64 operational
deployments of more than three months [0-7 deployments; SD: 1.78]; however,
78.6% of participants left the CAF for health reasons, 14.3% were released
voluntarily, and 7.1% for misconduct. Of the participants, 57.1% left the CAF
between 2011 and 2016. All participants have a formal diagnosis of a mental
health problem by a mental health professional. The participants’ diagnoses
are: PTSD (10); PTSD and Anxiety Disorders (1); PTSD and Substance Use Disorder
(1); and Depressive and Anxiety Disorder (2). At the time of the study, all
participants were still in treatment with a psychologist (12) and/or
psychiatrist.
Evaluation of
equine-assisted therapy experience following the 10 sessions
The main differences
with clinical treatments received in the past
The first difference, for
half of the participants, between equine-assisted therapy and psychotherapy is
the experiential/practical nature of the first one. The participant has to
interact with the horse, with the facilitators, and has to think and react. He
must also be attentive to his emotions and behaviours in order to understand
the nuances in the horse's reactions. Some participants stated that the horse's
feelings and the "mirror effect" of the horse's behaviours are added
values of equine-assisted therapy. Equine-assisted therapy involves being constantly
in action, as opposed to the static nature of a psychotherapy session. Interacting
with an animal, working with an animal as if it were the psychologist. It's
special, an animal, a horse, it doesn't have a "poker face", and it
will react a lot to our emotions, even if we try to hide them. You may want to
control your frustration, but it's going to know. I find that you can't hide or
diminish what you're feeling. Even if you say, "Ah, I'm in a good
mood," but it's going to know if you're not, more than someone (another
person) who just listens to you. The interaction is very different.” The second
difference, for half of the participants (7), is that equine-assisted therapy
represents another way of approaching the problem or part of the problem, due to
the presence of the horse in the intervention. One participant explained that
psychotherapy "digs" into wounds with the help of speech, and that
this is very demanding and tiring, all in an unwelcoming environment. In
equine-assisted therapy sessions, the place seems more neutral, and the horse,
by its presence, plays a mediating role in the intervention on emotions and
behaviours. This participant believes that the presence of the horse is
soothing, as is being outdoors in nature, that it is a privileged moment
between man and animal, and that these interactions help to make the link with
the present moment. According to him, equine-assisted therapy would be less
exhausting than psychotherapy. "The first notable difference is the
environment. In psychotherapy, you're in an office. White walls, then almost
nothing on the walls, with two chairs, and you're sitting with a box of
Kleenex, there. Then, a clock that you don't see, but he sees it, and then he
says it's time to end the session. Whereas over there, it's not like that. You
arrive, there are boxes and horses. There's a lot going on. There's activity.
There are horses being cleaned, being walked. It's as if you arrive in one
environment, while the other is not a living environment. It's a place that I
personally more or less like to go to (psychologist's office). Before, during
my military service, I didn't want to go there at all, so the physical
difference is noticeable.”
"Not the same
context at all. Then, when I left, yes, I was a little tired, but not as tired
as I can be with Ste Anne's Hospital So, it's a good therapy that tires me less
than an office therapy, and then I work just as hard.” The majority of
participants (10) also noted that equine-assisted therapy is a complementary
type of treatment to psychotherapy. Therefore, they do not consider
equine-assisted therapy as an alternative treatment to psychotherapy. A few
participants believe that the optimal treatment, depending on the nature of the
mental health problems, is a combination of psychotherapy offered by a
psychologist, pharmacotherapy offered by a psychiatrist and equine-assisted
therapy taught by an equine specialist and a mental health professional. In
addition, according to some participants, repeating some of the experiences of equine-assisted
therapy during psychotherapy sessions helps to progress and link theory to
experiences, while putting what has been learned into perspective in an overall
treatment plan. According to one participant, the psychologist supervising the
psychotherapy should obtain the member's permission to communicate with the
mental health professional and with the equine specialist introducing
equine-assisted therapy. He believes that collaboration between these different
types of care (psychotherapy, pharmacotherapy and equine-assisted therapy)
would contribute to significant positive outcomes for PTSD treatment. "One
could very well complement the other by working, by preparing. Psychotherapy
could prepare for equine-assisted therapy. Equine-assisted therapy could be a
complement, like a kind of clinical team that talks to each other. They can
complement each other, and it would be up to me to make the connection, and
perhaps with my psychologist. I talk about all my frustrations of the day,
whereas in equine-assisted therapy, I will work more on the symptoms, the
injury, and play with the images. But I think a good link between the two could
be something quite interesting!”
"It's a plus in my case, it's very complementary to the work I do with my psychologist in the office. I bring things that come from equine-assisted therapy, and then she puts them in her own words, so that I can understand them and then there's that, I have a report, and I put it into practice, because I don't understand everything they want to do in equine-assisted therapy, so it's good to put it into context. The context in equine-assisted therapy is completely different.” That said, one participant felt that a treatment sequence prior to integration into equine-assisted therapy should be proposed. He considers that psychotherapy should be preparatory to equine-assisted therapy because it allows the participant to grasp the theoretical and clinical elements related to his condition. Over the course of the sessions, the person is better able to understand his condition and symptoms. According to this participant, it is only once the person has recognized his condition and managed to stabilize his condition and medication that equine-assisted therapy should be added to his treatment plan for equine-assisted therapy, you have to have gone through a fairly long therapeutic process before you can do that. Because I find it hard to conceive that I, when I had just been diagnosed, would embark on therapy as well. I think I would have been far too fearful or too stressed. I feel like it takes a little bit of therapy, at least to know your symptoms and then how you feel. I don't think it would work if you're not all there. Because I don't think you can get there with the full symptom to do equine therapy. Because I couldn't imagine myself doing that in the first place. You also have to have good control. Then after that, in my opinion, it can become super beneficial.”
Table 1: Information on participants.
|
Name of participant * |
Biographical information |
Academic level |
Family income (in $) |
Reason of release |
Rank in CAF |
Years in CAF |
# of postings |
# of deployments |
|
Denis |
Between
50 and 60 years old, male, married with between 0 and 2 children |
Professional |
Less
than 59 999 |
Medical |
NCO |
22 |
4 |
2 |
|
Steven |
Between
40 and 50 years old, male, separated with between 0 and 2 children |
High
School |
60
000 to 99
999 |
Medical |
NCO |
17 |
4 |
4 |
|
Omer |
Between
40 and 50 years old, male, divorced with between 0 and 2 children |
Professional |
Less
than 59 999 |
Medical |
NCO |
26 |
4 |
3 |
|
Julien |
Between
50 and 60 years old, male, married with more than 3 children |
High
School |
60 000
to 99
999 |
Medical |
NCO |
37 |
4 |
3 |
|
Ghislain |
Between
50 and 60 years old, male, married with between 0 and 2 children |
University |
Less
than 59
999 |
Medical |
NCO |
21 |
8 |
2 |
|
Gilbert |
Between
40 and 50 years old, male, married with between 0 and 2 children |
High
School |
Less
than 59
999 |
Medical |
NCO |
21 |
3 |
4 |
|
Jean |
Between
60 and 70 years old, male, married with between 0 and 2 children |
High
School |
Less
than 59
999 |
Medical |
NCO |
31 |
10 |
3 |
|
Camil |
Between
60 and 70 years old, male, married with more than 3 children |
Professional |
Less
than 59
999 |
Voluntary |
NCO |
20 |
7 |
3 |
|
Jocelyn |
Between
40 and 50 years old, male, married with between 0 and 2 children |
University |
60 000
to 99 999 |
Medical |
Officer |
22 |
4 |
2 |
|
Ludovic |
Between
30 and 40 years old, male, married with between 0 and 2 children |
Professional
|
More
than 100,000 |
Medical |
NCO |
20 |
6 |
7 |
|
Jerome |
Between
50 and 60 years old male, married with between 0 and 2 children |
High
School |
60 000
to 99
999 |
Voluntary |
NCO |
15 |
1 |
0 |
|
Jasmin |
Between
30 and 40 years old, male, married with between 0 and 2 children |
High
School |
Less
than 59
999 |
Medical |
NCO |
14 |
2 |
3 |
|
Mylene |
Between
60 and 70 years old, female marroed
with between 0 and 2 children |
High
School |
Moins
de 59
999 |
Misconduct |
NCO |
12 |
3 |
0 |
|
Tony |
Between
40 and 50 years old, male, married with between 0 and 2 children |
High School |
60 000
to 99
999 |
Medical |
NCO |
13 |
1 |
1 |
The continuation of equine-assisted
therapy
Most participants (12)
are committed to continuing equine-assisted therapy sessions. There appears to
be as many reasons to continue with EAT-VAP as there are participants in the
study. Some participants spoke of the need for more sessions in order to
continue their progress and consolidate their gains. Other participants simply
appreciate the environment and the relationship with the horses. "Ah,
that's for sure I'm going to continue, because that's what has done me the most
good so far! So, it's like my time of the week when I take care of myself and
then my head! It puts things back in place, and then you also do a little bit
of thinking when you finish the session.”
Equine-assisted therapy
recommendations to their brothers and sisters in arms
The 14 participants in
this research project would recommend EAT-VAP to their brothers and sisters in
arms who have a mental health condition. "Well, I would recommend it to
anyone. It takes you completely out of your zone. So, especially the military,
it takes you completely out of your comfort zone, because you can't control the
situation. So, yes, I would recommend it, because it teaches you, especially
people who are very Cartesian, who are very white/black, well, it teaches you,
okay, we're going to work in the grey zone.”
"I would say that you should try it, because it's done me a lot of good, and you can be surprised at what the horses bring you. I would say, 'At least try a session to see, and it doesn't commit you too much. I would reorder it at 100 miles per hour.”
Based on the results, it
appears that the veterans positively assessed their participation in the
EAT-VAP and also noted significant differences from clinical care. Some
participants also recognized the complementarity of equine-assisted therapy to
their treatment plan. None of the veterans questioned the need for clinical
care to understand their psychopathology, stabilize related symptoms and
develop strategies to enable them to function on a daily basis. On the other
hand, the comments made about more traditional therapies, when used in
conjunction with equine therapy, suggest that equine therapy can facilitate
compliance with treatment by allowing participants to gradually open up to the
idea of receiving help. Studies have shown that veterans have a high drop-out
rate when they participate in so-called "traditional" psychotherapy
[16]. This finding was highlighted in this study because for the veterans who
participated, psychotherapy, which relies on verbal exchanges and takes place
in an office, seems to have limits and generate a saturation effect after a few
years of treatment. In this regard, it is recognized that existing clinical
treatments have certain limitations and need to be improved [17]. In addition,
many questions have been raised regarding the clinical treatment of veterans
suffering from PTSD in terms of the solutions to provide and the methods of
intervention adapted to meet the real needs of this specific population [18,19].
The experiential and practical nature of equine-assisted therapy, i.e., being
outside and interacting with the horse, the equine specialist and the mental
health professional from the very first session, seems to allow veterans to
continue on the path begun in psychotherapy, and to re-experience important
life situations and interpersonal relationships [20]. In this way, veterans can
address what Corey identifies as "unfinished business" that is,
exploring unexpressed emotions in relation to past situations that impact
current functioning [19]. As equine-assisted therapy is integrated after
psychotherapy and medication, it is necessary to consider its contribution to
the overall treatment plan and the way in which it influences veterans'
functioning [21]. Although equine-assisted therapy seems to be a promising
complementary treatment [22], some issues need to be raised. First, a recent
literature review does not support the conclusion that equine-assisted therapy
is effective [23]. Secondly, the field of equine-assisted therapy in Quebec
needs to be better supervised [24]. In fact, Freyd states that: "Here, in
Quebec, it is a bit like the Wild West. Sometimes, there is not even training,
neither in equine-assisted therapy nor in mental health. This can be dangerous”
[24]. Clearly, the variable quality of equine-assisted therapy programs
tarnishes this type of treatment [25]. Similarly, well-designed research is
needed to assess, standardize and document the effects of equine-assisted
therapy programs [25].
This study has some
limitations. With a sample size of 14 participants, the results presented
cannot be generalized to all veterans with PTSD and/or depressive disorder. The
participation of only one woman in the project also limits the scope of the
results for female veterans. Finally, the fact that participants all spoke
french at home, lived in the province of Quebec and that the time period since
their release from the CAF was highly variable diminishes the external validity
of the study.
The results presented in
this article help mental health professional better understand the appreciation
that veterans with mental health problems have for equine-assisted therapy from
a global treatment perspective. Given the worrisome drop-out rates in certain more
"traditional" forms of therapy, the criticisms raised by participants
with regard to these forms of therapy, but also the comments regarding the
contribution of equine-assisted therapy in their therapeutic process, it would
be interesting to further investigate the effects of equine-assisted therapy in
terms of concomitant treatment and to evaluate whether equine-assisted therapy
impacts veterans' commitment toward and retention in the therapeutic process.