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The Effectiveness of Equine Assisted Psychotherapy with Severely Emotionally Disturbed and Autistic Children and Adolescents: A Meta-Analysis

Dissertation
Author: Larisha M. Graves
Abstract:
The poor outcome prognosis of Severely Emotionally Disturbed (SED) and Autistic (ASD) youth has challenged mental health providers. SED/ASD children/adolescents do not respond well to traditional therapy and are in need of innovative treatment modalities. Equine Assisted Psychotherapy (EAP) is an experiential modality of mental health treatment that is a collaborative endeavor between a licensed therapist and equine professional while utilizing horses as an instrument for emotional growth. Specifically, it is asserted that EAP is an effective treatment modality for SED/ASD youth due to EAP's use of non-verbal skills through experiential means. The purpose of this study is to examine the possible empirical validity of EAP as a treatment modality for SED/ASD youth. A meta-analysis was conducted on 17 studies that facilitated EAP sessions with SED/ASD children/adolescents, utilized outcome measures (i.e., behavioral, emotional, functional), and reported data in which a Cohen's d could be computed (i.e., means, standard deviations, t-scores). An overall mean effect size of Cohen's d = 0.67 was generated, indicating EAP has a moderate to large effect on outcome measures with SED/ASD youth. SED children/adolescents appear to benefit more from EAP when sessions are facilitated with a Manualized treatment protocol. Limitations include a dearth of empirical research, no distinction between EAP Models, lack of variance between studies, attrition of participants, a need for control groups, and a lack of diversity among subjects. Clinicians should ensure EAP is conducted with a standardized protocol and be aware EAP may be more effective with SED youth. Keywords : equine assisted psychotherapy, severely emotionally disturbed children/adolescents, autistic children/adolescent

EFFECTIVENES S OF EQUINE AS S I S TED P S YCHOTHERAPY Table of Contents Abstract. .. .. . . .. .iv Introduction... ... ,.. ... 1 Literature Review. ..........2 Theoretical Background of Equine Assisted Psychotherapy ... ... ... ....2 Wilderness Therapy. , . ... ... ... .3 Animal Assisted Therapy. ... ... ... ... .3 Theoretical Framework of Equine Assisted Psychotherapy. .. . ... ... ..6 Historical Background and Definition of Equine Assisted Psychotherapy. . . . . ... .. . .7 Equine Facilitated Mental HEalth Association... ... . ... ... I Equine Assisted Growth and Learning Association... ... ... ... .10 The Session...... . ".....I2 Therapeutic Benefits of Equine Assisted Psychotherapy... .. .........12 Case Studies on Equine Assisted Psychotherapy... ... . ... ... .13 Qualitative Studies Conducted on Equine Assisted Psychotherapy... ... ... ...14 Quantitative Studies Conducted on Equine Assisted Psychotherapy... ... ... .15 Quantitative Studies not Included in Meta-Analysis. .......16 Quantitative Studies Included in Meta-Analysis. ......17 Equine Assisted Psychotherapy and Severely Emotionally Disturbed and/or Autistic Childrer/Adolescents. ......27 ResearchQuestionsandHypotheses..... ........29 Method. .. ..... ...30 StudiesReviewedandEligibilityCriteria ............. 30 Distinguishing Featwes... ... ... ... ... ...31 Research Respondents... ... .. ... ... ,...31 Key Variables.... ...........32 Research Methods. ,.,....32 Cultural and Linguistic Range. ....,.....32 TimeFrame...... ..........32 Publication Type. ... ... .. .. rz SearchProcedure. ..........33 Classification and Coding Systems. ... ... .....33 Computation and Analysis of Effect Size.. .....34 Results. .. ... ..... .35 StudyCharacteristics... ...........35 Overall Effect Size.. .....38

EFFECTIVENES S OF EQUINE AS S I STED PS YCHOTFMRAP Y Comparison of Effect Size and Study Characteristics... ... ... ...3g Effect Size of Behavioral versus Emotional versus Functional Outcome Measures. ... ... ...39 Effect Size of Manualized versus Non-ManualizedEAPTreatments... ..........39 Effect Size of Severely Emotionally Disturbed versus Autistic Spectrurn Disorder. . .......39 Effect Size of Children versus Adolescents versus MixedAge Groups...... ..........4A Effect Size of published Studies versus Dissertations versus Theses versus Presentations...... ^.... .40 Discussion... . .. . Findings. ............41 Overall Effect Size.. .....41 Behavioral versus Emotional versus Functional Outcome Measures.. .........42 Manual ized versus Non-Manu alized EAPTreatments.. ...........42 Severely Emotionally Disturbed versus Autistic Spectrum Disorder. .....44 Children versus Adolescent versus Mixed Age Groups... ... .. ... ..... .45 Published Studies versus Dissertations versus Theses versus Presentations.,. .. . .......45 Limitations...... ...........45 Implications...... .....46 FutureResearch. ..........47 Summary. .....49 References . ... ..51 Table 1 ... ... ... ...........57 Table 2....,. .............60 Figure 1 ... . . . .. ... ... ..62 Figure 2...... . .. ...........63 Figure 3... ... .,. ... ... ,..64 Figure 4...... ............65 Figure 5...... .....66 Appendix A,.... . . ... .., ..........67 AppendixB.,... ..,......7A Appendix C ... . ... .......71 Appendix D... .. ... ... ....75 AppendixE..... ........77 Appendix F... ... ... .....79 vl

EFFECTIVENES S OF EQUINE AS SIS TED PSYCHOTHERAPY The Effectiveness of Equine Assisted Psychotherapy with Severely Emotionally Disturbed and Autistic Children and Adolescents: A Meta-Analysis Horses have been involved in the treatment of chronically ill and/or disabled individuals since the ancient Greeks and Romans. Greek and Roman texts speak of the "life affirming" relationship between human beings and equines, and the ancient Greeks were known to offer rides for individuals believed to have an incurable illness (Bizub, Joy, & Davidson, 2003). Yet, it was not until 1952 that horses' therapeutic effect gained intemational recognition. Scandinavian athlete LizHarfrlrell stunned the world by winning a silver medal for dressage in the Olympic Games despite being handicapped by polio. As a result, Ms. Hartwell's success made therapeutic riding programs an international phenomenon (Kaiser, Spence, Lavergne, & Bosch, 2004). This prompted the formation of The North American Riding for the Handicapped Association (NARHA) in L969, the Equine Facilitated Mental Health Association (EFMHA) in 1996, and the Equine Assisted Growth and Learning Association (EAGALA) in 1999. EFMHA and EAGALA seek to empirically validate and provide mental health service with the assistance of horses, a treatment modality called Equine Assisted Psychotherapy (EAP). EAP is an emerging field which incorporates horses experientially for emotional growth and learning; it is a collaborative effort between a licensed therapist and a horse professional working with clients and horses to address treatment goals (Equine Assisted Growth and Learning Association, 2006). Moreover, it has been asserted that EAP as a treatment intervention may address limitations to traditional "talk therapy" (e.g., requiring high verbal skills, clients whom utilize intellectualizationhationalization as a defense mechanism) (Shultz, 2005).

EFFECTIVENES S OF EQUINE AS SIS TED PSYCHOTHERAPY Only a limited number of empirical studies utilizing EAP as a treatment modality have been conducted, and the overall therapeutic effectiveness for specific populations has not been established. As a result, a meta-analysis was conducted to explore the possible effectiveness of EAP with Severely Emotionally Disturbed (SED) and Autistic (ASD) youth across behavioral, emotional, and functional domains. These populations were chosen due to their poor prognosis in traditional psychotherapy and need for effective treatment interventions; it is believed that SED/ASD youth will benefit from EAP due to its experiential/non-verbal nature. The Literatwe Review will expound on EAP's theoretical framework, present working definitions /therapeutic benefits of EAP, describe current organizations that grant certification in EAP, summarize qualitative studies that have been conducted, and review quantitative studies that will be utilized for the meta-analysis. Literature Review Theoretical Background of Equine Assisted Psychotherapy Equine Assisted Psychotherapy (EAP) is an experiential modality of mental health treatment that is a collaborative endeavor between a licensed therapist and equine professional while utilizing horses as an instrument for emotional growth. EAP is a unique treatment modality in that it combines elements of Wilderness and Animal Assisted Therapies. P. J. Mandrell (2006) notes that it is estimated we remember 20%o of what we hear, recall 50% of what we see, and retain 80% of what we experience; the experiential nature of EAP appears to be a powerful component of this treatment modality. This section expounds on the theoretical framework of Wilderness and Animal Assisted Therapies in order to better comprehend the underpinning of EAP.

EFFECTIVENES S OF EQUINE AS SIS TED P SYCHOTHERAPY Wilderness Therapy. Wilderness therapy is considered a type of experiential learning and is beneficial to one's physical and emotional growth. P. J. Mandrell (2006) gives an excellent overview of Wilderness Therapy, and this section is derived from her work unless otherwise noted. The primitive nature of Wilderness Therapy (e.g., living outdoors for an extended amount of time) provides the opportunity for groups to work and play together while also providing enough rules and structures to insure safety. This experience provides mental health providers with a unique vantage point for assessment, instruction, intervention, and application around therapeutic concerns. Specifically, being involved in organizing, planning, and supervising activities that relate to personal wellbeing typically challenges one to recognize and appreciate cooperative and collaborative interactions; participants tend to develop a sense of responsibility for their own actions while recognizing how their decisions impact others. Moreover, surviving in the wildemess tends to create anatural stress/strain, giving participants the opportunity to utilize problem-solving skills and achieve success. Success in "smaller crises" empowers members and participants feel more competent when "larger crises" emerge in their lives. In essence, change occurs because Wildemess Therapy evokes coping behaviors instead of defense mechanisms. Specifically, it is a difficult, natural, and/or healthy environmental experience with the opportunity to interact with and/or observe animals and plants. Animal Assisted Therapy. Animals and humans havg cohabitated with one another for thousands of years, and their relationship has shifted from necessity to mutual affection. Beneficial components of the human-animal bond have been noted throushout

EFFECTIVENES S OF EQUINE AS SISTED P SYCHOTHERAPY the years. For example, C. M. Johnson (2001) notes that research has indicated physical and psychological benefits when humans connect with animals. Observed effects may be explained by the following theories: Psychodynamic Theory, Self-Psychology, Social- Support, Relational Theory, and Developmental Theory. S. Martin Taylor (2001) and J. Turmutt (2003) encapsulate the historical significance of Animal Assisted Therapy; this section is derived from their Master Theses unless otherwise noted. The initial relationship between humans and animals was parasitic, eventually developing into one of mutuality (i.e., people providing shelter and food for the animals and the animals being used for work, companionship, and to meet psychological needs of their owners). And as animals became domesticated the animal-human bond began to develop. According to Martin Taylor (2001) and Turmutt (2003), H. S. Bossard and Boris Levinson recognized the healing potential of the human-animal bond and are credited with publishing the first papers on animal-assisted psychotherapy in the joumal Mental Hygiene. Bossard's article (The Mental Hygiene of Owning a Dog) indicated the following roles a dog can play in family life: being a source of unconditional love; functioning as an outlet to express love; and a teacher for children on many topics (e.g., sex education, responsibility, life cycle). ln contrast, Levinson (Levinson & Mallon, 1997) illustrated the participation of his dog while in session with children and describes his accidental discovery of "Pet- Orientated Child Psychotherapy." Levinson's portrayal of this therapeutic discovery can be found in Appendix B. Additionally, Levinson noted the following outcomes for a child who owns and trains a pet: enhancement of self-esteem and prestige; an increase in the capacity for empathic interrelationships; and a reduction of social isolation.

EFFECTIVENES S OF EQUINE AS SISTED PSYCHOTHERAPY Levinson's idea was in stark contrast to what was considered therapeutic and was met with cynicism. Yet, it is now common to find therapy animals at mental health facilities. Initially, the animal-human-based research focused on health related issues. It was not till later that research was conducted to validate Bossard's and Levinson's original work. One of the most significant studies was conducted in1992 by a group of Australian cardiologists. Over a three-year period data was collected on more than 5,000 individuals who signed up for a "healthy heart" project. The following distinctions were found between pet owners and non-owners: women pet owners older than 40 and male pet owners of all ages had lower blood pressures and20Yo lower plasma triglyceride levels than non-owners; and male pet owners between the ages of 30 and 60 had lower cholesterol levels than non-owners. Also, a study conducted in 1990 concluded that Medicare enrollees with pets had fewer doctor contacts over a one-year period than did non-owners. Moreover, research has indicated having a pet increases one's level of psychological well-being. In conjunction, A. H. Fine (2000), the editor of the Handbook on Animal-Assisted Therapy, summarizes recent research, dividing the findings into two groups. The first group asserts that animals are able to induce a physiologically de-arousing state of relaxation by attracting and holding one's attention. The second group exemplifies that animals are capable of providing humans social support charucterized as "stress- reducing." Specifically, social isolation is a primary cause of depression, stress, suppression of the immune system, and other various diseases. Animals are reliable companions that can help fill a lonely void and have a socializing effect (e.g., one is more likely to start a conversation when walking a dog).

EFFE,CTIVENES S OF EQUINE ASSISTED PSYCHOTHERAPY Animal Assisted Therapy (AAT) is usually conducted in a setting that provides a high level of social support. Additionally, the nature of AAT prompts clients to focus on the "present." Ideally, the experience is to be generalized to activities outside therapy and provide an antidote for social isolation. Given the benefits of pet ownership (i.e., the human-animal bond has been noted to spur positive physical, emotional, and social life changes) one can deduce that animal therapies, when guided by the skill of a knowledgeable therapist, would yield therapeutic results. Specifically, the current realm of research extends beyond household pets to other animals, including equines. Theoretical Framework of Equine Assisted Psychotherapy. EAP offers a short-term, goal-focused, and problem-solving approach to mental health issues. EAP draws from several therapeutic models, including Psychodynamic, Gestalt, Transactional Analysis, Behavioral Therapy, Rational, Emotive Behavioral Therapy, Reality Therapy, and Experiential Therapy (Graupner, 2006). For example, the EAGALA Model of EAP (which is described in further detail below) is solidly grounded in the following theories of psychotherapy: Gestalt Psychotherapy; Solution-Focused Psychotherapy; Cognitive- Behavioral Psychotherapy; Psychodynamic Psychotherapy; Reality Psychotherapy; Experiential Psychotherapy; and Adventure Psychotherapy (Equine Assisted Growth and Leaming Association, 2008). According to J. Karol (2007), incorporating an advanced-level clinician in EAP sessions enhances the psychotherapeutic experience. The horse can help enhance a client's self-esteem through a sense of mastery, but can also act as a catalyst for the development of trust between client and therapist; these accomplishments can be the foundation for the psychotherapeutic work rather than the "goal of the method." For

EFFE,CTIVENES S OF EQUINE ASSISTED PSYCHOTHERAPY children, EAP has similar benefits of play therapy and experiential learning. This provides opportunities for children to identifu and understand emotions, develop empathy, gain a sense of responsibility, learn problem-solving skill, and to succeed in new undertakings (Schultz, Remick-Barlow, and Robbins, 2007). Moreover, the barn setting gives clients a unique stage to enact their internal dynamics; the inner world is expressed through the client's interaction with the horse. Specifically, the struggles expressed through behavioral problems a child is having at school/home are often expressed in the way (s)he interacts with the horse. The EAP team then can guide the client in enactments that offers a healthy relational experience (Karol, 2007). Historical Background and Definition of Equine Assisted Psychotherapy As noted above, Equine Assisted Psychotherapy (EAP) is an experiential modality of mental health treatment that is a collaborative endeavor between a licensed therapist and equine professional while utilizing horses as an instrument for emotional growth. Specifically, licensed mental health providers and horse professionals have primarily two treatment models to choose from when they desire to conduct EAP sessions. Both organizations have different philosophies and therapeutic objectives; their organizational background, working definition of EAP, and unique treatment modality is described below. Moreover, it should be noted that both organizations have different terminology for EAP (i.e., Equine Assisted Psychotherapy (EAP) vs. Equine Assisted Therapy (EAT). Thus, the term EAP will be utilized in this paper to designate this modality of experiential therapy.

E,FFECTIVENES S OF EQUINE AS SISTED PSYCHOTHERAPY Equine Facilitated Mental l{ealth Association. It was not until the mid 1960's that therapeutic riding centers became established in the United States and Canada; this was prompted by the formation of The North American Riding for the Handicapped Association (NARHA) in 1969. NARHA is dedicated to ensuring that therapeutic riding is safe and accessible. Currently, NARHA represents a variety of equine-assisted therapies and activities, some of which include recreational riding for disabled individuals, hippotherapy (i.e., a form of occupationaUphysical therapy), driving, vaulting, competition, and EAP (I.{orth American Riding for the Handicapped Association, n.d.). NARHA founded the Equine Facilitated Mental Health Association (EFMHA) in 1996; this was the first organization created exclusively for providing mental health services with the assistance of horses. EFMHA strives to advance the field of EAP for individuals who partner with equines to promote human growth and development by maintaining the following objectives: establish and disseminate functional terminology for EAP; continue to develop and disseminate standards and safety guidelines for EAP; prepare and continue to develop a curriculum to train NARHA instructors/equine professionals to assist mental health professionals who practice EAP; catalog the body of research related to the practice of EAP; continue the strategic planning process for the evolution of the EFMHA; develop and implement a certification process for mental health professionals who practice EAP; develop a certification process for Education Professionals who teach Equine Facilitated Learning; promote education through workshops, networking, newsletters, and other publications (Equine Facilitated Mental Health Associatio n,2007;Equine Facilitated Mental Health Association, 2008a).

E,FFECTIVENES S OF EQUINE AS SISTED PSYCHOTHERAPY Moreover, EFMHA defines EAP as an experiential psychotherapy that includes equine(s). It may include a number of mutually respectful equine activities (e.g., handling, grooming, longeing, riding, driving, vaulting) but is not limited to such. EAP is to be facilitated by a licensed, credentialed mental health professional working in conjunction with a qualified equine professional. EAP may be facilitated by a mental health professional that is dually credentialed as an equine professional (Equine Facilitated Mental Health Association,2}}7; Equine Facilitated Mental Health Association, 2008e). Members of EFMF{A who desire to conduct EAP utilizing their model must follow EFMHA's Code of Ethics; a copy of this document can be found in Appendix C. EFMHA asserts that EAP may promote healing and psychosocial growth in the following areas: enhancing self-esteem and self-awareness; developing trust in a safe environment; honing social skills; encouraging sensory stimulation and integration; combining body awareness exercises with motor planning and verbal communication; developing choice-making and goal-setting skills; developing sequencing and problem- solving skills; encouraging responsibility; and promoting pro-social attitudes through care-giving experiences (Equine Facilitated Mental Health Association, 2008c). Yet, EFMHA does not recommend EAP for individuals that are dangerous to self/others (e.g., suicidal, homicidal, aggressive), delirious, demented, dissociative, psychotic, severely confused (including severe delusions involving horses), medically unstable, and/or actively abusing substances (Equine Facilitated Mental Health Association, 2008b). Furthermore, EFMHA recornmends appropriate precautions be taken in an EAP session if a client has history of animal abuse, fire setting, abuse (i.e., physical, sexual verbal and/or

EFFECTIVENESS OF EQUINE ASSISTED PSYCHOTHERAPY emotional), seizure disorder, gross obesity, medication side effects, stress-induced reactive airway disease (e.g., asthma), or migraines (Equine Facilitated Mental Health Association, 2008d). Equine Assisted Growth and Learning Association. The Equine Assisted Growth and Learning Association (EAGALA) was founded in 1999 in order to address the need for resources, education, and professionalism within the field of EAP. EAGALA strives to educate professionals in the clinical and human development fields in order that they may accept EAP as a valid and effective treatment for clients; to promote, educate, and provide standards of practice, ethics, and safety within the field of EAP is the mission of EAGALA (Equine Assisted Growth and Learning Association, 2003). The following is derived from the Fundamentals of EAGAIAI Model Practice Training Manual (Equine Assisted Growth and Learning Association, 2006) unless otherwise noted. EAGALA defines EAP as an experiential modality of treatment which incorporates horses for emotional growth and learning. Specifically, it is a collaborative effiort between a licensed therapist and a horse professional working with clients and horses to address treatment goals. It involves setting up and participating in activities with horses which will require clients to utilize and hone life-skills (e.g., non-verbal communication, assertiveness, creative thinking, problem-solving, leadership, work ethic, personal responsibility). It should be noted that the EAGALA Model is theoretically grounded in Wilderness/Animal-Assisted Therapy as well as Gestalt, Solution-Focused, Cognitive-Behavioral, Psychodynamic, and Reality Psychotherapies (Equine Assisted Growth and Learning Association, 2008). 10

EFFECTIVENES S OF EQUINE AS SISTED PSYCHOTHERAPY Moreover, EAGALA has attempted to develop a therapeutic standard in order to provide a structure for conducting EAP sessions. Specifically, the EAGALA Model entails the following components: The Team Approach; Focus on the Ground; Solution- Oriented; and Code of Ethics. First, it is imperative to note the therapeutic work of EAP is a collaborative process of a qualified team consisting of a mental health professional and equine specialist; the treatment team must include two facilitators. Both are to incorporate their unique skills and knowledge in order to benefit clients. Next, EAP work is to be accomplished on the ground with horses. Thus, mounted work is notto be incorporated into EAP practice. Specifically, EAGALA's rational for this stance is ground work is safer for clients and tends to produce a more therapeutically rich experience. In essence, utilizing only ground work causes the treatment team to put more trust in the therapeutic/experiential process, fostering a more effective treatment for clients. Additionally, EAGALA's Model is Solution-Oriented, affirming the belief that clients have their own solutions, either in their relationship with people, things, concepts, or the EAP horse. Clients can find these solutions if given the opportunity to discover them. Such occasions include re-creating situation and "working through it" with the horse, utilizing an open style of communication (e.g., observation statements, reflective listening, and question-asking), focusing on the "process of the session" versus "the task at hand," and striving for "long-term solutions" instead of "quick fixes." Moreover, member of EAGALA are expected to maintain a high level of professionalism work towards the overall health/wellness of clients, and adhere to the 1l

EFFECTIVENESS OF EQUINE ASSISTED PSYCHOTHERAPY organization's Code of Ethics. A detailed description of the EAGALA and their Code of Ethics can be found in Appendix D. The Session. As described above, EAP sessions are facilitated by a licensed mental health provider and certified horse professional; EFMHA sometimes supports session facilitation by a mental health clinician that is dually credentialed as a horse specialist. EAP sessions are experiential in that the client partakes in activities with the horse(s) that reflect hislher life circumstance. This empowers clients to learn about themselves/others by active participation and discussing emotions/behaviors elicited through the process (Frewin & Gardiner,2005). P. J. Mandrell (2006) provides examples of individual, family, and group sessions; an example of an EAP session can be found in Appendix E. Therapeutic Benefits of Equine Assisted Psychotherapy Experientially, EAP typically involves setting up activities with horses which will require the client (i.e., individual, family, or group) to apply, hone, and develop some of the following skills: non-verbal communication; assertiveness; creative thinking; building a healthy level of self-confidence; problem-solving; leadership skills; work ethic; personal responsibility; teamwork; and enhancing interpersonal relationships. Additionally, EAP is considered a short-tenn approach due to its intensity and effectiveness; it is considered a powerful intervention for individuals, youth, families and groups. Moreover, EAP is able to address the following mental health and developmental concerns: conduct/oppositional defiant disorder, affention- deficitftryperactivity disorder, substance abuse, eating disorders, abuse issues, depression, anxiety, mood disorders, personality disorders, post-traumatic stress syndrome, t2

EFFECTIVENESS OF EQUINE AS SISTED PSYCHOTHERAPY family/marital problems, and communication needs. (Equine Assisted Growth and Learning Association,2006; Equine Assisted Growth and Learning Association, 2008; Mandrell,2006) Moreover, EAP offers several therapeutic benefits. It is not uncommon for participants of riding programs to gain a stronger sense of confidence, worth, and awareness. Ultimately, the aim of such programs is to improve the quality of life experienced by their clients (Bizub, Joy, & Davidson, 20A3). Additionally, E. J. Cumella (2003) eluded that one may benefit in the following areas from participating in EAP: self- confidence, self-efficacy, self-concept, communication, trust, perspective, decreased isolation, self-acceptance, impulse modulation, assertiveness, boundaries, creative freedom, and spiritual growth. Yet, when attempting to answer the question if EAP is an effective treatment modality, the author responded: ...it would appear that Equine Therapy is effective.... But some degree of interpretation is needed to make this leap. The truth is, according to the scientific standards of evidence-based practice, we cannot yet say for sure. (p. 1a6) Thus, there is a need for empirical research in order to validate the effectiveness of EAP. The following is a sunmary of Case Studies, Qualitative Research, and Quantitative Studies conducted utilizing EAP as a treatment modality. The latter will be utilized to conduct a meta-analysis in order to support EAP as a viable treatment modality with S everely Disturbed and Autistic children/adolescents. Case Studies on Equine Assisted Psychotherapy Many initial studies veriffing the effectiveness of EAP are Case Studies. For example, Krueger, Hey, and Reynes, (2005) give a report of how EAP assisted in the l3

EFFECTIVENESS OF EQUINE ASSISTED PSYCHOTHERAPY treatment of two adolescents girls (one struggling with anorexia nervosa and the other with bipolar disorder) and an adult female (that was facing cancer for the second time). These ladies reported receiving a sense of empowerment and control over their circumstances. Moreover, J. E. Christian (2005) gives an in-depth perspective of a client called "Lori" whom was residins. at aresidential center for anorexia nervosa. At the onset of treatment Lori was r"riJr*t, not wanting to improve her health and relationships. Yeq it was through EAP that she was able to tangibly work on issues of boundaries. This was a tuming point in Lori's recovery, equipping her with the skills needed for emotional and relational healing. Qualitative Studies Conducted on Equine Assisted Psychotherapy Moreover, there have been several Qualitative Studies conducted in order to deduce trnderlying themes of EAP. G. P. Mallon(1994) interviewed and observed 80 children living at a residential center and volunteers at a local farm where the former would visit; a qualitative analysis was utilized. The finding suggested that the majority of the children (24%) indicated that the horse was the favorite animal, and 49o/o of the subjects identified "riding" as their favorite activity. Eighty+hree percent of participants reported feeling "excited" when visiting the farm, and 67Yo reported visiting the farmlanrmals when they felt mgry, sad, frustrated, or overwhelmed. Horses were favored by the older children in comparison to the younger. Additionally, J. Hayden (2005) noted the following themes that emerged while conducting EAP with 10 at-risk youths: treatment was enjoyable, challenging, better than previous interventions; "talking" was a vital component of therapy; utilizing the horse as a metaphor and mirror was necessary; self-esteem; mastery; positive relationships with t4

EFFECTIVENESS OF EQUINE ASSISTED PSYCHOTHERAPY individuals and the horse; increased communication skills; alternative coping skills; and an increased awareness of internal experience. Bizub, Joy, and Davidson (2003) attempted to create and implement a therapeutic riding program for individuals suffering from severe and persistent psychiatric disabilities. Five adults (ages26-46) with primary diagnoses within the schizophrenia spectrum participated in a l0-week therapeutic riding program. Additionally, participants were involved in a post-riding process group that used artistic and creative exercises to foster individual expression. Through a semi-structured interview participants reported that in leaming basic horsemanship skills they experienced an increase of self-efficacy and self-esteem. It is not uncofilmon for participants of riding programs to gain a stronger sense of confidence, sense of worth, and self-awareness. Ultimately, the aim of such programs is to improve the quality of life experienced by their clients. Thus, the authors suggest that combining therapeutic riding with traditional mental health techniques can facilitate the recovery process. Quantitative Studies Utilizing Equine Assisted Psychotherapy There is a dearth of quantitative studies validating the effectiveness of EAP, and many of these contain methodological concems. EAGALA (2008), in their Research Summary for the American Psychological Association, notes the following: These studies have consistently found statistically significant positive changes on clinical outcome measures as a result of equine assisted psychotherapy. While these studies have provided strong support for the effectiveness ofequine assisted psychotherapy, the results are limited by weaknesses in research design including 15

EFFECTIVENES S OF EQUINE ASSISTED PSYCHOTHERAPY difficulties such as small numbers of subjects, a lack of pretreatment assessment, variations in treatment protocols, and a lack of treatment comparison groups. Moreover, not all studies met inclusion criteria and were not included in the final analysis. Yet, their findings are noteworthy and will be summarized below. Quantitative Studies not Included in Meta-Analysis. Kaiser, Spence, Lavergne, and Bosch (2004) wanted to determine the effectiveness of a five-day therapeutic riding day camp on children's anger, quality of life, and perceived self- competence. The sample included 16 individuals (ages ll L 4.4 years) with no known history of physical or psychological disability or use of psychotropic medication. The following scales were administered before riding on the first day and afterward on the fifth day: The Children's Anger Inventory; Peds Quality of Life; and the Self Perception Profile for Children. After five days of therapeutic riding the total score for anger and subscales (except frustration) significantly decreased. These changes may be related to the child's relationship with the horse, social environment of the camp, riding, increased contact with nature, or a combination of these factors. This study was not included in the meta-analysis due to its use of a non-clinical population. Additionally, M. M. Aduddell (2003) e-mailed questioners to 150 treatment facilities that provide EAP services; this was to determine aspects clinicians found beneficial from EAP. Fifty-nine facilities responded, yet data from 30 sites were not utilized due to the following conditions: centers were too new within the field of EAP; accurate data was not available; practices were no longer utilizing an EAP treatment modality. Details for the latter were not available. Thus, 26 responses were returned and utilized by the examiner. The questionnaire provided general background data on t6

Full document contains 87 pages
Abstract: The poor outcome prognosis of Severely Emotionally Disturbed (SED) and Autistic (ASD) youth has challenged mental health providers. SED/ASD children/adolescents do not respond well to traditional therapy and are in need of innovative treatment modalities. Equine Assisted Psychotherapy (EAP) is an experiential modality of mental health treatment that is a collaborative endeavor between a licensed therapist and equine professional while utilizing horses as an instrument for emotional growth. Specifically, it is asserted that EAP is an effective treatment modality for SED/ASD youth due to EAP's use of non-verbal skills through experiential means. The purpose of this study is to examine the possible empirical validity of EAP as a treatment modality for SED/ASD youth. A meta-analysis was conducted on 17 studies that facilitated EAP sessions with SED/ASD children/adolescents, utilized outcome measures (i.e., behavioral, emotional, functional), and reported data in which a Cohen's d could be computed (i.e., means, standard deviations, t-scores). An overall mean effect size of Cohen's d = 0.67 was generated, indicating EAP has a moderate to large effect on outcome measures with SED/ASD youth. SED children/adolescents appear to benefit more from EAP when sessions are facilitated with a Manualized treatment protocol. Limitations include a dearth of empirical research, no distinction between EAP Models, lack of variance between studies, attrition of participants, a need for control groups, and a lack of diversity among subjects. Clinicians should ensure EAP is conducted with a standardized protocol and be aware EAP may be more effective with SED youth. Keywords : equine assisted psychotherapy, severely emotionally disturbed children/adolescents, autistic children/adolescent