Long-Term Care / Rehabilitation

A horse is a horse—and sometimes part of a clinical team, too

Perhaps you’ve heard or read lately that horses can serve as members of teams to help people with certain disorders. Equine-assisted activities and therapies (EAATs) are a growing topic, both in the healthcare literature and the general media. EAATs fall into two broad categories:

  • Equine-assisted activities (EAAs) include therapeutic riding and equine-facilitated learning (EFL).
  • Equine-assisted therapies (EATs) include hippotherapy, equine-facilitated psychotherapy (EFP), and equine-assisted psychotherapy (EAP).

The primary difference between EAAs and EATs is in the background and credentials of the person who provides the service. For EAAs, the service provider must have specific education and experience—but not licensing—in an occupation, in addition to equine experience. For EATs, the primary service provider must be licensed and credentialed in his or her respective discipline; examples include physical therapist, occupational therapist, speech language pathologist, psychiatric-mental health clinical nurse specialist, psychiatric-mental health nurse practitioner, licensed professional counselor, licensed marriage and family therapist, and psychologist. Also, this person must have completed additional education to partner with the horse effectively. (See Classifying the types of equine-assisted activities and therapies.)

This article helps nurses inform, refer, and support patients who may be good candidates for EAATs. It also helps nurses choose an option, such as EFL, to promote their own personal development. (See Nurse’s role in equine-assisted activities and therapies.)

Therapeutic horseback riding

Therapeutic riding involves mounted activities, ground activities, or both. A person with a disability benefits from this adapted sport just as an able-bodied person benefits from sports and leisure activities. When people first hear about therapeutic riding, they may form an image of a child with disabilities riding a horse, accompanied by volunteers. In reality, many disabled riders attain high levels of competency and independence.

Riding is beneficial because it requires active participation and physical coordination to learn a new skill—and it’s an enjoyable leisure activity or competitive sport. People with autism, cerebral palsy, Down syndrome, muscular dystrophy, multiple sclerosis, paralysis, or spina bifida, and those who’ve had strokes have been helped by therapeutic riding. What’s more, researchers are finding improved social functioning, self-regulating behaviors, and language and motor skills in children with autism spectrum disorders who’ve participated in therapeutic riding.

Therapeutic riding is based on an educational rather than a medical model, with the goals of developing horsemanship, riding skills, or both. It includes traditional riding disciplines and adaptive riding activities conducted by a therapeutic riding instructor certified by the Professional Association of Therapeutic Horsemanship International (PATH Intl). This instructor leads the therapeutic riding session.


Roots of therapeutic riding

Therapeutic riding gained international recognition in 1952 when Lis Hartel-Holst of Denmark won the silver medal in dressage at the Helsinki Winter Olympics. Her victory was significant partly because it was the first time women competed alongside men in equestrian events. More impressively, Hartel-Holst was a polio survivor who was able to reactivate most of her muscles but remained paralyzed below the knees. She needed help to mount and dismount her horse.

Equine and medical professionals took note of her achievement, and by the 1960s, therapeutic riding centers began to develop. The first North American center was the Community Association for Riding for the Disabled, which started in Toronto, Ontario, Canada. The Cheff Center for the Handicapped was the first U.S. center, opening in Augusta, Michigan.

In 1969, the North America Riding for the Handicapped Association (NARHA) was established to promote safe, effective therapeutic horseback riding throughout the United States and Canada. In 2011, NARHA changed its name to PATH International.

Hippotherapy

Hippotherapy is a physical, occupational, and speech-language therapy strategy that uses equine movement as part of an integrated intervention program to achieve functional outcomes. For example, a person with cerebral palsy may participate in physical therapy that includes the horse’s movement as a treatment strategy. Movement of the horse is used to improve the patient’s posture, balance, and overall function. The patient is placed on a bareback pad on the horse; then a physical therapist directs the horse handler in the type of movement sought from the horse, such as walking or trotting, to provide a rhythmic, swinging motion. Equine movement resembles human walking and has a transient effect on human muscle tone by stimulating the vestibular system. A 2003 study found significant improvement in symmetry of muscle activity after hippotherapy in a group of seven children, compared to a group of six children who sat astride a barrel. All 13 children had spastic cerebral palsy.

A licensed physical therapist, occupational therapist, or speech-language pathologist leads the hippotherapy session. Unlike therapeutic riding, hippotherapy is based on the medical model, with goals related to the patient’s functional outcomes off the horse.

Equine-facilitated psychotherapy

EFP is an interactive process in which a licensed mental health professional (MHP) working with (or as) an appropriately credentialed equine professional partners with a suitable horse to address psychotherapy goals established by the MHP and the patient. Suitable horses include those that look to a person for direction, react moderately to stimuli, show a desire to connect to or curiosity about humans, and are trusted by the MHP.

EFP may include many different natural horsemanship activities, such as grooming, to help achieve these goals; the activities themselves aren’t the goal. The horse is a partner in this interaction by reflecting the patient’s true feelings. Because horses are excellent readers of nonverbal language, the interaction can reveal information of which people aren’t aware. (See Inside an equine-facilitated psychotherapy session.)

EFP may be indicated for people with anxiety, mood, or psychotic disorders; personality disorders; behavioral difficulties; attention-deficit hyperactivity disorder; autism; depression; major life changes (such as divorce, grief, and loss); posttraumatic stress disorder; receptive or expressive language disorders; and schizophrenia. One study found EFP an effective and less time-intensive intervention for adult female survivors of abuse.

How EFP got its start

Barbara Rector introduced EFP to the United States in the early 1990s. In 1973, she recovered from a serious riding accident with the help of a friend and physical therapist, Nancy McGibbon. Together, the women cofounded Therapeutic Riding of Tucson (TROT). Rector left TROT in 1989 to pursue graduate work and was later hired by Sierra Tucson, the premiere treatment center for addictions, to develop and implement the first-of-its-kind EFP program. Rector’s active involvement in NARHA led to the development of the Equine Facilitated Mental Health Association (EFMHA) in 1996. (EFMHA was a section of NARHA with its own board of directors and committee structure until 2009, when leaders in both organizations decided to merge into one association representing all members and disciplines.)

EFP pioneers include Adele von Rüst McCormick and Marlena Deborah McCormick (a mother-and-daughter team), Maureen Vidrine (an advanced practice nurse), and Marilyn Sokolof (a psychologist). Vidrine is a psychiatric-mental health clinical nurse specialist and one of the first advanced practice nurses in the United States to offer EFP.

Equine-assisted psychotherapy

EAP incorporates horses experientially for emotional growth and learning. It’s a collaborative effort between a licensed therapist and a horse professional working with patients and horses to address the patients’ treatment goals.

In the 2000 movie 28 Days, Sandra Bullock plays Gwen Cummings, an alcoholic who enters a rehab center that uses EAP. There, she is asked to clean a horse’s hoof but is unable to lift it. Her “insides” need to match her “outsides” for her to clearly communicate her intentions to the horse; at that point, she lacks such congruency.

Another example of EAP is a group activity called Appendages. Three people stand side by side, with the person in the center playing the part of the brain. The “brain” stands with arms intertwined; the other two people stand on either side of the “brain.” The person on the left is the left appendage (arm), while the person on the right is the right appendage. Together, the three must put a halter attached to a lead rope on a horse. Only the “brain” is allowed to speak and give directions. The right and left appendages may not speak, but they may move their right and left arms, respectively. The goal is to build teamwork as the participants experience being a leader or a follower. This activity promotes the personal growth of each participant and development of work or life skills through equine interactions.

In these examples, the activities include a horse without focusing on the relationship between the horse and the patient. In other EAP sessions, the horse-patient relationship may first surface through an activity that helps the patient frame a metaphor, which is then applied to the patient’s life. For example, the MHP may ask patient whom the horse represents in the patient’s life.

The origins of EAP

EAP is a term used by the Equine Assisted Growth and Learning Association (EAGALA) to identify its specific model. In the 1990s, horseman Greg Kersten started using his work with horses to help humans. Together with Lynn Thomas, a licensed mental health professional, he founded EAGALA in 1999.

Nursing implications

Partnering with a horse is one option for addressing a patient’s physical or emotional needs. Collectively, the various types of EAATs offer many options for how a horse is included. EAAT is a growing and evolving field. (See Resources for equine-assisted activities and therapies below.) As a nurse, your knowledge of EAAT options and strategies and your ability to share them may provide a tremendous benefit to patients.

Resources for equine-assisted activities and therapies

For more information, visit the websites below.

American Hippotherapy Association

American Quarter Horse Association; Equestrians with Disabilities

American Riding Instructors Association

Certified Horsemanship Association

Equine Assisted Growth and Learning Association

Professional Association of Therapeutic Horsemanship International

Special Olympics; Equestrian

Selected references

Bass MM, Duchowny CA, Llabre MM. The effect of therapeutic horseback riding on social functioning in children with autism. J Autism Dev Disord. 2009;39(9):1261-7.

Benda W, McGibbon NH, Grant KL. Improvements in muscle symmetry in children with cerebral palsy after equine-assisted therapy (hippotherapy). J Altern Complement Med. 2003;9(6):817-25.

Gabriels RL, Agnew JA, Holt KD, et al. Pilot study measuring the effects of therapeutic horseback riding on school-age children and adolescents with autism spectrum disorders. Res Autism Spectrum Disord. 2012;6(2):578-88.

Hallberg, L. Walking the Way of the Horse: Exploring the Power of the Horse-Human Relationship. Bloomington, Indiana: iUniverse; 2008.

Meinersmann KM, Bradberry J, Roberts FB. Equine-facilitated psychotherapy with adult female survivors of abuse. J Psychosoc Nurs Ment Health Serv. 2008;46(12):36-42.

Vidrine M, Owen-Smith P, Faulkner P. Equine-facilitated group psychotherapy: applications for therapeutic vaulting. Issues Ment Health Nurs. 2002;23(6):587-603.

Susan M. Rugari is an associate professor and director of the Graduate Nursing Program at Tarleton State University in Stephenville, Texas. Sayda M. Major is a hospitalist/internal medicine acute-care nurse practitioner at Parkland Health and Hospital System in Dallas, Texas. Alexis Kennedy is a pediatric nurse practitioner at Children’s Medical Center in Dallas, Texas.

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