Equine-Assisted Activities and Therapies for Veterans With Posttraumatic Stress Disorder: Current State, Challenges and Future Directions

William R Marchand, Sarah J Andersen, Judy E Smith, Karl H Hoopes, Jennifer K Carlson, William R Marchand, Sarah J Andersen, Judy E Smith, Karl H Hoopes, Jennifer K Carlson

Abstract

Posttraumatic stress disorder is common among military Veterans. While effective treatments exist, many Veterans either do not engage in treatment or fail to achieve full remission. Thus, there is a need to develop adjunctive complementary interventions to enhance treatment engagement and/or response. Equine-assisted activities and therapies (EAAT) are one category of animal assisted interventions that might serve this function. The aim of this article is to review the current state and challenges regarding the use of EAAT for Veterans with PTSD and provide a roadmap to move the field forward. EAAT hold promise as adjunctive complementary interventions for symptom reduction among Veterans with PTSD. Additionally, there is evidence that these approaches may enhance wellbeing in this population. At this time, many gaps in the literature exist and rigorous randomized controlled trials are needed before definitive conclusions can be drawn. The authors of this work provide recommendations as a roadmap to move the field forward. These include standardizing the EAAT nomenclature, focusing mechanism of action studies on the human-horse bond using biological metrics and using a standardized intervention model across studies.

Keywords: Veterans; equine-assisted psychotherapy; equine-assisted therapies and activities; posttraumatic stress disorder; psychiatric disorders.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

© The Author(s) 2021.

Figures

Figure 1.
Figure 1.
Example of a nomenclature for equine assisted activities and therapies based upon the work of Hallberg.

References

    1. Trivedi RB, Post EP, Sun H, et al. Prevalence, comorbidity, and prognosis of mental health among US veterans. Am J Public Health. 2015; 105(12): 2564–2569.
    1. Wisco BE, Marx BP, Miller MW, et al. Probable posttraumatic stress disorder in the US veteran population according to DSM-5: results from the national health and resilience in veterans study. J Clin Psychiatry. 2016; 77(11): 1503–1510.
    1. Wisco BE, Marx BP, Wolf EJ, Miller MW, Southwick SM and Pietzak RH. Posttraumatic stress disorder in the US veteran population: results from the national health and resilience in veterans study. J Clin Psychiatry. 2014; 75(12): 1338–1346.
    1. Gates MA, Holowka DW, Vasterling JJ.Keane TM, Marx BP and Rosen RC. Posttraumatic stress disorder in veterans and military personnel: epidemiology, screening, and case recognition. Psychol Serv. 2012; 9(4): 361–382.
    1. Bray RM, Pemberton MR, Lane ME.Hourani LL, Matiko MJ and Babeu LA. Substance use and mental health trends among U.S. military active duty personnel: key findings from the 2008 DoD health behavior survey. Mil Med. 2010; 175(6): 390–399.
    1. Lan CW, Fiellin DA, Barry DT, et al. The epidemiology of substance use disorders in US veterans: a systematic review and analysis of assessment methods. Am J Addict. 2016; 25(1): 7–24.
    1. Teeters JB, Lancaster CL, Brown DG. and Back SE. Substance use disorders in military veterans: prevalence and treatment challenges. Subst Abuse Rehabil. 2017; 8: 69–77.
    1. Burnett-Zeigler I, Ilgen M, Valenstein M, et al. Prevalence and correlates of alcohol misuse among returning Afghanistan and Iraq veterans. Addict Behav. 2011; 36(8): 801–806.
    1. Kelsall HL, Wijesinghe MS, Creamer MC, et al. Alcohol use and substance use disorders in Gulf war, Afghanistan, and Iraq war veterans compared with nondeployed military personnel. Epidemiol Rev. 2015; 37: 38–54.
    1. Flanagan JC, Mitchell JM, Baker NL, et al. Enhancing prolonged exposure therapy for PTSD among veterans with oxytocin: design of a multisite randomized controlled trial. Contemp Clin Trials. 2020; 95: 106074.
    1. Fulton JJ, Calhoun PS, Wagner HR, et al. The prevalence of posttraumatic stress disorder in operation enduring freedom/operation Iraqi freedom (OEF/OIF) veterans: a meta-analysis. J Anxiety Disord. 2015; 31: 98–107.
    1. Letica-Crepulja M, Stevanovic A, Protuder M.Grahovac Jiretic T, Rbic J and Franciskovic T. Complex PTSD among treatment-seeking veterans with PTSD. Eur J Psychotraumatol. 2020; 11(1): 1716593.
    1. Bair MJ, Outcalt SD, Ang D.Wu J and Yu Z. Pain and psychological outcomes among Iraq and Afghanistan veterans with chronic pain and PTSD: ESCAPE trial longitudinal results. Pain Med. 2020; 21(7): 1369–1376.
    1. Goodson JT, Lefkowitz CM, Helstrom AW, et al. Outcomes of prolonged exposure therapy for veterans with posttraumatic stress disorder. J Trauma Stress. 2013; 26(4): 419–425.
    1. Eftekhari A, Ruzek JI, Crowley JJ.Rosen CS, Greenbaum MA and Karlin BE. Effectiveness of national implementation of prolonged exposure therapy in veterans affairs care. JAMA Psychiatry. 2013; 70(9): 949–955.
    1. Maguen S, Holder N, Li Y, et al. Factors associated with PTSD symptom improvement among Iraq and Afghanistan veterans receiving evidenced-based psychotherapy. J Affect Disord. 2020; 273: 1–7.
    1. Maguen S, Li Y, Madden E, et al. Factors associated with completing evidence-based psychotherapy for PTSD among veterans in a national healthcare system. Psychiatry Res. 2019; 274: 112–128.
    1. Duek O, Pietrzak RH, Petrakis I.Hoff R and Hrpaz-Rotem I. Early discontinuation of pharmacotherapy in U.S. veterans diagnosed with PTSD and the role of psychotherapy. J Psychiatr Res. 2021; 132: 167–173.
    1. Delic M, Pregelj P. Factors associated with the outcome of drug addiction treatment. Psychiatr Danub. 2013; 25(2):S337–S340.
    1. Hoge CW, Castro CA, Messer SC.McGurk D, Cotting D and Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems and barriers to care. US Army Med Dep J. 2008; July-september: 7–17.
    1. Elbogen EB, Wagner HR, Johnson SC, et al. Are Iraq and Afghanistan veterans using mental health services? New data from a national random-sample survey. Psychiatr Serv. 2013; 64(2): 134–141.
    1. Sinha R. New findings on biological factors predicting addiction relapse vulnerability. Curr Psychiatry Rep. 2011; 13(5): 398–405.
    1. Equine Therapy to Treat Members of the Armed Forces. 2015.
    1. Bachi K, Terkel J, Teichman M. Equine-facilitated psychotherapy for at-risk adolescents: the influence on self-image, self-control and trust. Clin Child Psychol Psychiatry. 2012; 17(2): 298–312.
    1. Ferruolo DM. Psychosocial equine program for veterans. Soc Work. 2016; 61(1): 53–60.
    1. Arnon S, Fisher PW, Pickover A, et al. Equine-assisted therapy for veterans with PTSD: manual development and preliminary findings. Mil Med. 2020; 185(5–6):e557–e564.
    1. International PAoTH. PATH Intl Statistics 2016. . documents/2016-fact-sheet-for-web.pdf. Accessed April 27, 2020.
    1. Kinney AR, Eakman AM, Lassell R.and Wood W. Equine-assisted interventions for veterans with service-related health conditions: a systematic mapping review. Mil Med Res. 2019; 6(1): 28.
    1. Cerino S, Cirulli F, Chiarotti F.and Seripa S. Non conventional psychiatric rehabilitation in schizophrenia using therapeutic riding: the FISE multicentre Pindar project. Ann Ist Super Sanita. 2011; 47(4): 409–414.
    1. Corring D, Lundberg E, Rudnick A. Therapeutic horseback riding for ACT patients with schizophrenia. Community Ment Health J. 2013; 49(1): 121–126.
    1. Jormfeldt H, Carlsson IM. Equine-Assisted therapeutic interventions among individuals diagnosed with schizophrenia. A systematic review. Issues Ment Health Nurs. 2018; 39(8): 647–656.
    1. Nurenberg JR, Schleifer SJ, Shaffer TM, et al. Animal-assisted therapy with chronic psychiatric inpatients: equine-assisted psychotherapy and aggressive behavior. PS. 2015; 66(1): 80–86.
    1. Malcolm R, Ecks S, Pickersgill M. ‘ It just opens up their world’: autism, empathy, and the therapeutic effects of equine interactions. Anthropol Med. 2018; 25(2): 220–234.
    1. Hoagwood KE, Acri M, Morrissey M.and Peth-Pierce R. Animal-assisted therapies for youth with or at risk for mental health problems: a systematic review. Appl Dev Sci. 2017; 21(1): 1–13.
    1. Anderson S, Meints K. Brief report: the effects of equine-assisted activities on the social functioning in children and adolescents with autism spectrum disorder. J Autism Dev Disord. 2016; 46(10): 3344–3352.
    1. Borgi M, Loliva D, Cerino S, et al. Effectiveness of a standardized equine-assisted therapy program for children with autism spectrum disorder. J Autism Dev Disord. 2016; 46(1): 1–9.
    1. Gabriels RL, Pan Z, Dechant B.Agnew JA, Brim N and Mesilbov G. Randomized controlled trial of therapeutic horseback riding in children and adolescents with autism spectrum disorder. J Am Acad Child Adolesc Psychiatry. 2015; 54(7): 541–549.
    1. Harris A, Williams JM. The impact of a horse riding intervention on the social functioning of children with autism spectrum disorder. Int J Environ Res Public Health. 2017; 14(7): 776.
    1. Holm MB, Baird JM, Kim YJ, et al. Therapeutic horseback riding outcomes of parent-identified goals for children with autism spectrum disorder: an ABA’ multiple case design examining dosing and generalization to the home and community. J Autism Dev Disord. 2014; 44(4): 937–947.
    1. Kern JK, Fletcher CL, Garver CR, et al. Prospective trial of equine-assisted activities in autism spectrum disorder. Altern Ther Health Med. 2011; 17(3): 14–20.
    1. Srinivasan SM, Cavagnino DT, Bhat AN. Effects of equine therapy on individuals with autism spectrum disorder: a systematic review. Rev J Autism Dev Disord. 2018; 5(2): 156–175.
    1. Trzmiel T, Purandare B, Michalak M.Zasadzka E and Pawlaczyk M. Equine assisted activities and therapies in children with autism spectrum disorder: a systematic review and a meta-analysis. Complement Ther Med. 2019; 42: 104–113.
    1. Cuypers K, De Ridder K, Strandheim A. The effect of therapeutic horseback riding on 5 children with attention deficit hyperactivity disorder: a pilot study. J Altern Complement Med. 2011; 17(10): 901–908.
    1. Hyun GJ, Jung TW, Park JH, et al. Changes in gait balance and brain connectivity in response to equine-assisted activity and training in children with attention deficit hyperactivity disorder. J Altern Complement Med. 2016; 22(4): 286–293.
    1. Jang B, Song J, Kim J, et al. Equine-assisted activities and therapy for treating children with attention-deficit/hyperactivity disorder. J Altern Complement Med. 2015; 21(9): 546–553.
    1. Alfonso SV, Alfonso LA, Llabre MM.and Fernandez MI. Project stride: an equine-assisted intervention to reduce symptoms of social anxiety in young women. Explore (NY). 2015; 11(6): 461–467.
    1. Hession CE, Eastwood B, Watterson D.Lehane CE, Oxley N and Murphy BA. Therapeutic horse riding improves cognition, mood arousal, and ambulation in children with dyspraxia. J Altern Complement Med. 2014; 20(1): 19–23.
    1. Kang KD, Jung TW, Park IH.and Han DH. Effects of equine-assisted activities and therapies on the affective network of adolescents with internet gaming disorder. J Altern Complement Med. 2018; 24(8): 841–849.
    1. Frederick KE, Ivey Hatz J, Lanning B. Not just horsing around: the impact of equine-assisted learning on levels of hope and depression in at-risk adolescents. Community Ment Health J. 2015; 51(7): 809–817.
    1. Bunketorp-Kall L, Lundgren-Nilsson A, Samuelsson H, et al. Long-Term improvements after multimodal rehabilitation in late phase after stroke: a randomized controlled trial. Stroke. 2017; 48(7): 1916–1924.
    1. Cerulli C, Minganti C, De Santis C.Tranchita E, Wuarante F and Parisi A. Therapeutic horseback riding in breast cancer survivors: a pilot study. J Altern Complement Med. 2014; 20(8): 623–629.
    1. Fields B, Bruemmer J, Gloeckner G.and Wood W. Influence of an equine-assisted activities program on dementia-specific quality of life. Am J Alzheimers Dis Other Demen. 2018; 33(5): 309–317.
    1. Earles JL, Vernon LL, Yetz JP. Equine-assisted therapy for anxiety and posttraumatic stress symptoms. J Trauma Stress. 2015; 28(2): 149–152.
    1. Shelef A, Brafman D, Rosing T.Weizman A, Stryler R and Barak Y. Equine assisted therapy for patients with post traumatic stress disorder: a case series study. Mil Med. 2019;
    1. Burton LE, Qeadan F, Burge MR. Efficacy of equine-assisted psychotherapy in veterans with posttraumatic stress disorder. J Integr Med. 2019; 17(1): 14–19.
    1. Malinowski K, Yee C, Tevlin JM, et al. The effects of equine assisted therapy on plasma cortisol and oxytocin concentrations and heart rate variability in horses and measures of symptoms of post-traumatic stress disorder in veterans. J Equine Vet Sci. 2018; 64: 17–26.
    1. Johnson RA, Albright DL, Marzolf JR, et al. Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans. Mil Med Res. 2018; 5(1): 3.
    1. Steele E, Wood DS, J Usadi E.and Applegarth DM. TRR's warrior camp: an intensive treatment program for combat trauma in active military and veterans of all eras. Mil Med. 2018; 183(suppl_1): 403–407.
    1. Duncan CR, S, C, JM. Can praxis: a model of equine assisted learning (EAL) for PTSD. Can Mil J. 2014; 14(2): 64–69.
    1. Lanning BA, Wilson AL, Krenek N.and Beaujean AA. Using therapeutic riding as an intervention for combat veterans: an international classification of functioning, disability, and health (ICF) approach. Occup Ther Ment Health. 2017; 33(3): 259–278.
    1. Sylvia L, West E, Blackburn AM, et al. Acceptability of an adjunct equine-assisted activities and therapies program for veterans with posttraumatic stress disorder and/or traumatic brain injury. J Integr Med. 2020; 18(2): 169–173.
    1. Wharton T, Whitworth J, Macauley E.and Malone E. Pilot testing a manualized equine-facilitated cognitive processing therapy (EF-CPT) intervention for PTSD in veterans. Psychiatr Rehabil J. 2019; 42(3): 268–276.
    1. Nevins R, Finch S, Hickling EJ.and Barnett SD. The saratoga WarHorse project: a case study of the treatment of psychological distress in a veteran of operation Iraqi freedom. Adv Mind Body Med. 2013; 27(4): 22–25.
    1. Romaniuk M, Evans J, Kidd C. Evaluation of an equine-assisted therapy program for veterans who identify as ‘wounded, injured or ill’ and their partners. PLoS One. 2018; 13(9):e0203943.
    1. Lanning BA, Krenek N. Guest editorial: examining effects of equine-assisted activities to help combat veterans improve quality of life. J Rehabil Res Dev. 2013; 50(8):vii–xiii.
    1. Hallberg L. The Clinical Practice of Equine-Assisted Therapy: Including Horses in Human Healthcare. London: Routledge, 2018.
    1. Wood W, Alm K, Benjamin J, et al. Optimal terminology for services in the United States that incorporate horses to benefit people: a consensus document. J Altern Complement Med. 2020; 27(1): 88–95.
    1. (2014–2018) I. The IAHAIO definitions for animal assisted intervention and guidelines for wellness of animals involved in AAI [White Paper]. . Accessed April 27, 2020.
    1. American Hippotherapy Association. . Accessed January 16, 2021.
    1. Ajzenman HF, Standeven JW, Shurtleff TL. Effect of hippotherapy on motor control, adaptive behaviors, and participation in children with autism spectrum disorder: a pilot study. Am J Occup Ther. 2013; 67(6): 653–663.
    1. Alemdaroglu E, Yanikoglu I, Oken O, et al. Horseback riding therapy in addition to conventional rehabilitation program decreases spasticity in children with cerebral palsy: a small sample study. Complement Ther Clin Pract. 2016; 23: 26–29.
    1. Ambrozy T, Mazur-Rylska A, Chwala W, et al. The role of hippotherapeutic exercises with larger support surface in development of balance in boys aged 15 to 17 years with mild intellectual disability. Acta Bioeng Biomech. 2017; 19(4): 143–151.
    1. Beinotti F, Correia N, Christofoletti G.and Borges G. Use of hippotherapy in gait training for hemiparetic post-stroke. Arq Neuropsiquiatr. 2010; 68(6): 908–913.
    1. Bronson C, Brewerton K, Ong J.Palanca C and Sullivan SJ. Does hippotherapy improve balance in persons with multiple sclerosis: a systematic review. Eur J Phys Rehabil Med. 2010; 46(3): 347–353.
    1. Champagne D, Corriveau H, Dugas C. Effect of hippotherapy on motor proficiency and function in children with cerebral palsy who walk. Phys Occup Ther Pediatr. 2017; 37(1): 51–63.
    1. Deutz U, Heussen N, Weigt-Usinger K, et al. Impact of hippotherapy on gross motor function and quality of life in children with bilateral cerebral palsy: a randomized Open-Label crossover study. Neuropediatrics. 2018; 49(3): 185–192.
    1. Stergiou A, Tzoufi M, Ntzani E.Varvarousis D, Beris A and Ploumis A. Therapeutic effects of horseback riding interventions: a systematic review and meta-analysis. Am J Phys Med Rehabil. 2017; 96(10): 717–725.
    1. Beetz A. Theories and possible processes of action in animal assisted interventions. Appl Dev Sci. 2017; 21(2): 139–149.
    1. Beetz A, Uvnas-Moberg K, Kotrschal JH. K. Psychosocial and psychophysiological effects of human-animal interactions: the possible role of oxytocin. Front Psychol. 2012; 3: 234.
    1. Marchand WR, Klinger W, Block K, et al. Mindfulness training plus nature exposure for veterans with psychiatric and substance use disorders: a model intervention. Int J Environ Res Public Health. 2019; 16(23): 4726.
    1. Marchand WR, Klinger W, Block K, et al. Safety and psychological impact of sailing adventure therapy among veterans with substance use disorders. Complement Ther Med. 2018; 40: 42–47.
    1. Anderson DC. Assessing the Human-Animal Bond: A Compendium of Actual Measures West Lafayette: Purdue University Press; 2007.
    1. Cho SH. Effects of horseback riding exercise on the relative alpha power spectrum in the elderly. Arch Gerontol Geriatr. 2017; 70: 141–147.
    1. Cabiddu R, Borghi-Silva A, Trimer R, et al. Hippotherapy acute impact on heart rate variability non-linear dynamics in neurological disorders. Physiol Behav. 2016; 159: 88–94.
    1. Matsuura A, Maruta H, Iwatake T.Nakanowatari T and Hodate K. The beneficial effects of horse trekking on autonomic nervous activity in experienced rider with no disability. Anim Sci J. 2017; 88(1): 173–179.
    1. Yoo JH, Oh Y, Jang B, et al. The effects of equine-assisted activities and therapy on resting-state brain function in attention-deficit/hyperactivity disorder: a pilot study. Clin Psychopharmacol Neurosci. 2016; 14(4): 357–364.
    1. Marchand WR, Yabko B, Herrmann T.Curtis H and Lackner R. Treatment engagement and outcomes of Mindfulness-Based cognitive therapy for veterans with psychiatric disorders. J Altern Complement Med. 2019; 25(9): 902–909.
    1. Chang LY, Chang SM, Andrews L.and Saeedi O. Equine-related eye injury: a case report of globe rupture and vision loss in a post-stroke hippotherapy patient. Am Med Stud Res J. 2018; 5(1): 110–113.
    1. Fershtman JI. What is an “inherent risk” with horses? . Published 2020. Accessed January 16, 2021.
    1. Genik LM, McMurtry CM. Prevalence and impact of bumps, bruises, and other painful incidents among children while handling and riding horses. J Outdoor Recreat Tour. 2019; 27: 100229.
    1. McKinney C, Mueller MK, Frank N. Effects of therapeutic riding on measures of stress in horses. J Equine Veterinary Sci. 2015; 35(11–12): 922–928.
    1. Merkies K, McKechnie MJ, Zakrajsek E. Behavioural and physiological responses of therapy horses to mentally traumatized humans. Appl Anim Behav Sci. 2018; 205: 61–67.
    1. Mendonça T, Bienboire-Frosini C, Menuge F, et al. The impact of equine-assisted therapy on equine behavioral and physiological responses. Animals (Basel). 2019; 9(7): 409.
    1. Hockenhull J, Young TJ, Redgate SE, et al. Exploring synchronicity in the heart rates of familiar and unfamiliar pairs of horses and humans undertaking an in-hand task. Anthrozoös. 2015; 28(3): 501–511.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe