Equine-assisted therapy has been used by medical professionals such as occupational therapists, physical therapists, speech and language pathologists, psychologists, social workers, and recreational therapist
Equine-assisted therapy (EAT) encompasses a range of treatments that involve activities with horses and other equines to promote human physical and mental health. The use of EAT has roots in antiquity, and EAT applies to physical health issues in modern form dates to the 1960s. Modern of horses for mental health treatment dates to the 1990s. Systematic review of studies of EAT as applied to physical health date only to about 2007, and a lack of common terminology and standardization has caused problems with meta-analysis. Due to a lack of high-quality studies assessing the efficacy of equine-assisted therapies for mental health treatment, concerns have been raised that these therapies should not replace or divert resources from other evidence-based mental health therapies.
An overall term that encompasses all forms of equine therapy is Equine-Assisted Activities and Therapy (EAAT). Various therapies that involve interactions with horses and other equines are used for individuals with and without special needs, including those with physical, cognitive and emotional issues. Terminology within the field is not standardized, and the lack of clear definitions and common terminology presents problems in reviewing medical literature. Within that framework, the more common therapies and terminology used to describe them are:
A demonstration of hippotherapy in Europe
Most research has focused on physical benefit of therapeutic work with horses, though the most rigorous studies have only been subject to systematic review since about 2007.
EAAT have been used to treat individuals with neurological diseases or disorders such as cerebral palsy, movement disorders, or balance problems. It is believed the rhythmical gait of a horse acts to move the rider’s pelvis in the same rotation and side-to-side movement that occurs when walking; the horse’s adjustable gait promotes riders to constantly adjust to encourage pelvic motion while promoting strength, balance, coordination, flexibility, posture, and mobility.
EAAT have also been used to treat other disabilities, such as autism, behavioral disorders and psychiatric disorders. Due to a lack of rigorous scientific evidence, there is insufficient evidence to demonstrate if equine therapy for mental health treatment provides any benefit.
Therapeutic riding is used by disabled individuals who ride horses to relax, and to develop muscle tone, coordination, confidence, and well-being.
Therapeutic horseback riding is considered recreational therapy where an individual is taught by a non-therapist riding instructor how to actively control a horse while riding. It is used as exercise to improve sensory and motor skills for coordination, balance, and posture.
Most research has focused on physical benefit of therapeutic work with horses, with the most rigorous studies being subject to systematic review since about 2007. Claims made as to the efficacy of equine therapies for mental health purposes have been criticized as lacking proper medical evidence due in large part to poor study design and lack of quantitative data. Ethical questions relating to its expense and its continued promotion have been raised in light of this lack of evidence. While such therapies do not appear to cause harm, it has been recommended they not be used as a mental treatment at this time unless future evidence shows a benefit for treating specific disorders.
Hippotherapy is an intervention used by physical therapist, recreational therapist, occupational therapist, or speech and language pathologist. The movement of the horse affects a rider’s posture, balance, coordination, strength and sensorimotor systems. It is thought that the warmth and shape of the horse and its rhythmic, three-dimensional movement along with the rider’s interactions with the horse and responses to the movement of the horse can improve the flexibility, posture, balance and mobility of the rider. It differs from therapeutic horseback riding, because it is one treatment strategy used by a licensed physical therapist, occupational therapist, or speech and language pathologists. They guide the rider’s posture and actions while the horse is controlled by a horse handler at the direction of the therapist. The therapist guides both the rider and horse to encourage specific motor and sensory inputs. Therapists develop plans to address specific limitations and disabilities such as neuromuscular disorders, walking ability, or general motor function.
Equine-assisted psychotherapy (EAP) or Equine Facilitated Psychotherapy (EFP) is the use of equines to treat human psychological problems in and around an equestrian facility. It is not the same as therapeutic riding or hippotherapy.:221 Though different organizations may prefer one term over the other for various reasons, in practice, the two terms are used interchangeably.:287 Other terms commonly used, especially in Canada, include Equine Facilitated Wellness (EFW), Equine Facilitated Counselling (EFC) and Equine Facilitated Mental Health (EFMH)
While some mental health therapies may incorporate vaulting and riding, most utilize ground work with horses. Some programs only use ground-based work. There are also differences between programs over whether the horse is viewed as a co-facilitator, or simply as a tool.:287
The field of equine-assisted psychotherapy did not publicly become a part of the equine-assisted therapy world until the 1990s, although individuals had been experimenting with the concept prior to that time. The first national group in the United States, the Equine-Facilitated Mental Health Association (EFMHA), now a part of PATH International, formed in 1996. The mental health area of equine-assisted therapy became subject to a major rift when a second group, the Equine Growth and Learning Association (EAGALA) formed in 1999, splitting from EFMHA (now PATH) over differences of opinion about safety protocols.:285–286 Since that time, additional differences have arisen between the two groups over safety orientation, the therapeutic models used, training programs for practitioners, and the role of riding.:51 EAGALA itself had a further split between its founders in 2006 due to legal issues, with yet another new organization formed.:52
As a result, although PATH and EAGALA remain the two main certification organizations in the United States, there has been a significant amount of misunderstanding amongst practitioners, client, and within scientific literature. To resolve these differences, an independent organization, the Certification Board for Equine Interaction Professionals (CBEIP) formed, beginning in 2007, to promote professional credibility in the field.:286 However, the world of equine-assisted psychotherapy remains disorganized and has not standardized its requirements for education or credentialing.:287
Horses have been utilized as a therapeutic aid since the ancient Greeks used them for those people who had incurable illnesses. Its earliest recorded mention is in the writings of Hippocrates who discussed the therapeutic value of riding. The claimed benefits of therapeutic riding have been dated back to 17th century literature where it is documented that it was prescribed for gout, neurological disorder and low morale. In 1946 Equine Therapy was introduced in Scandinavia after an outbreak of poliomyelitis.
Hippotherapy as currently practiced was developed in the 1960s, when it began to be used in Germany, Austria, and Switzerland as an adjunct to traditional physical therapy. The treatment was conducted by a physiotherapist, a specially trained horse, and a horse handler. The physiotherapist gave directives to the horse handler as to the gait, tempo, cadence, and direction for the horse to perform. The movement of the horse was carefully modulated to influence neuromuscular changes in the patient. The first standardized hippotherapy curriculum would be formulated in the late 1980s by a group of Canadian and American therapists who traveled to Germany to learn about hippotherapy and would bring the new discipline back to North America upon their return. The discipline was formalized in the United States in 1992 with the formation of the American Hippotherapy Association (AHA). Since its inception, the AHA has established official standards of practice and formalized therapist educational curriculum processes for occupational, physical and speech therapists in the United States.
Therapeutic riding as a therapy started with Liz Hartel from Denmark. Her legs were paralyzed from polio but with therapy she was able to win the silver medal for dressage in the 1952 Olympic Games. At about that time, in Germany, therapeutic riding was used to address orthopedic dysfunctions such as scoliosis. The first riding centers in North America began in the 1960s and the North American Riding for the Handicapped Association (NARHA) was launched in 1969. Therapeutic riding was introduced to the United States and Canada in 1960 with the formation of the Community Association of Riding of the Disabled (CARD). In the United States riding for the disabled developed as a form of recreation and as a means of motivation for education, as well as its therapeutic benefits. In 1969 the Cheff Therapeutic Riding Center for the Handicapped was established in Michigan, and remains the oldest center specifically for people with disabilities in the United States.
The North American Riding for Handicapped Association (NARHA) was founded in 1969 to serve as an advisory body to the various riding for disabled groups across the United States and its neighboring countries. In 2011, NARHA changed its name to the Professional Association of Therapeutic Horsemanship (PATH) International.
In most cases, horses are trained and selected specifically for therapy before being integrated into a program. Therapy programs choose horses of any breed that they find to be calm, even-tempered, gentle, serviceably sound, and well-trained both under saddle and on the ground. As most equine-assisted therapy is done as slow speeds, an older horse that is not in its athletic prime is sometimes used.
Equine-assisted therapy programs try to identify horses that are calm but not lazy and physically suited with proper balance, structure, muscling and gaits. Muscling is not generally considered to be as important as the balance and structural correctness, but proper conditioning for the work it is to do is required. Suitable horses move freely and have good quality gaits, especially the walk. Unsound horses that show any signs of lameness are generally avoided.
The welfare of the horse is taken into consideration. Each individual animal has natural biological traits but also has a unique personality with its own likes, dislikes and habits. Paying attention to what the animal is trying to communicate is helpful both in sessions of EAAT, but also to prevent burnout for the horse. Some programs refer to the therapy horse as an “equine partner”. Other programs view the horse as a “metaphor” with no defined role other than to “be themselves.” Equine Facilitated Wellness programs, particularly those following the EFW-Canada certification route view the horse as ‘sentient being’: “The equine is a sentient being, partner and co-facilitator in the equine facilitated relationship and process”.
There is some evidence that hippotherapy can help improve the posture control of children with cerebral palsy, although the use of mechanical hippotherapy simulators produced no clear evidence of benefit. A systematic review of studies on the outcomes of horseback riding therapy on gross motor function in children with cerebral palsy was concluded in 2012 with a recommendation for a “large randomized controlled trial using specified protocols” because, although positive evidence was indicated by nine high-quality studies surveyed, the studies were too limited to be considered conclusive.
Overall, reviews of equine-assisted therapy scientific literature indicate “there is no unified, widely accepted, or empirically supported, theoretical framework for how and why these interventions may be therapeutic”  The journal Neurology published a 2014 study finding inadequate data to know whether hippotherapy or therapeutic horseback riding can help the gait, balance, or mood of people with multiple sclerosis. There is not evidence that therapeutic horseback riding is effective in treating children with autism.
There is currently insufficient medical evidence to support the effectiveness of equine-related treatments for mental health. Multiple reviews have noted problems with the quality of research such as the lack of independent observers, rigorous randomized clinical trials, longitudinal studies, and comparisons to currently accepted and effective treatments. A 2014 review found these treatments did no physical harm, but found that all studies examined had methodological flaws, which led to questioning the clinical significance of those studies; the review also raised ethical concerns both about the marketing and promotion of the practice and the opportunity cost if patients in need of mental health services were diverted from evidence-based care. The review recommended that both individuals and organizations avoid this therapy unless future research establishes verifiable treatment benefits.
The Professional Association of Therapeutic Horsemanship (PATH) accredits centers and instructors that provide equine-assisted therapy. The Equine Assisted Growth and Learning Association (EAGALA) focuses only on mental health aspects of human-equine interaction, and provides certification for mental-health and equine professionals.
In Canada, centers and instructors for Therapeutic Riding are regulated by CanTRA, also known as The Canadian Therapeutic Riding Association. The field of Equine Facilitated Wellness is regulated by Equine Facilitated Wellness – Canada (EFW-Can) which provides a national certification program and certifies trainers and mentors to provide independent training at approved programs across Canada.
The American Hippotherapy Association offers certification for working as a hippotherapist. Hippotherapy Clinical Specialty (HPCS) Certification is a designation indicating board certification for therapists who have advanced knowledge and experience in hippotherapy. Physical therapists, occupational therapists, and speech-language pathologists in practice for at least three years (6,000 hours) and have 100 hours of hippotherapy practice within the prior three years are permitted to take the Hippotherapy Clinical Specialty Certification Examination through the American Hippotherapy Certification Board. Those who pass are board-certified in hippotherapy, and entitled to use the HPCS designation after their name. HPCS certification is for five years. After five years the therapist can either retake the exam or show written evidence of 120 hours of continuing education distributed over the five years. Continuing education must include 50% (60 hours) in education related to equine subject matter: psychology, training, riding skills and so on; 25% (30 hours) in education related to direct service in the professional discipline and 25% (30 hours) in any other subject related to hippotherapy. An alternative is to provide written evidence of scholarly activity appropriate to the field of hippotherapy. Acceptable scholarly activity may include graduate education in hippotherapy, publication of articles on hippotherapy in juried publications, scientific research related to hippotherapy, the teaching or development of hippotherapy, or acting as AHA-approved course faculty. AHA, Inc. now recognizes two different AHCB credentials: AHCB Certified Therapist and AHCB Certified Hippotherapy Clinical Specialist.
Therapeutic Benefits of Horseback RidingDogs are common in animal-assisted therapy.
Animal-assisted therapy (AAT) is a type of therapy that involves animals as a form of treatment. The goal of AAT is to improve a patient's social, emotional, or cognitive functioning. Advocates state that animals can be useful for educational and motivational effectiveness for participants. A therapist who brings along a pet may be viewed as being less threatening, increasing the rapport between patient and therapist.[medical citation needed] Animals used in therapy include domesticated pets, farm animals and marine mammals (such as dolphins). The research literature states concerns about the poor quality of medical evidence underpinning AAT.
Wilson's (1984) biophilia hypothesis is based on the premise that our attachment to and interest in animals stems from the strong possibility that human survival was partly dependent on signals from animals in the environment indicating safety or threat. The biophilia hypothesis suggests that now, if we see animals at rest or in a peaceful state, this may signal to us safety, security and feelings of well-being which in turn may trigger a state where personal change and healing are possible. A contrast is sometimes made with Animal assisted activity (AAA). AAA is more casual and unstructured than AAT, involving perhaps more than one patient and with the primary focus on the presence of the animal itself. By contrast, AAT includes a handler which together with the animal has been trained for the role. AAT is more structured with specific objectives for each session. However, in common usage terms like these for animal assisted interventions are often used rather loosely.
Animals can be used in a variety of settings such as prisons, nursing homes, mental institutions, hospitals and in the home.[medical citation needed] Assistance dogs can assist people with many different disabilities; they are capable of assisting certain life activities and help the individuals navigate outside of the home.
As with all other interventions, assessing whether a program is effective as far as its outcomes are concerned is easier when the goals are clear and are able to be specified. The literature review identified a range of goals for animal assisted therapy programs relevant to children and young people. They include enhanced capacity to form positive relationships with others i-relief in pet ownership.Pets may promote kindness in children.
Therapists rely on techniques such as monitoring a child's behavior with the animal, their tone of voice, and indirect interviewing. These techniques are used, along with the child's pet or other animal, in order to gain information. Before pet therapy can be useful, the child and the animal must first develop a sense of comfort with each other, which is easier to achieve if the child's own pet is used. The applied technique that generates the most helpful information about the victim's experience is telling the child that the animal wants to know how they are feeling or what happened. AAT can be used in children with mental health problems, it can be used as a stand a lone treatment or it can be used along with conventional methods. Animals can be used as a distraction method when it comes to various situations, pain, and can also help bring in happiness, pleasure, and entertainments to the pediatric population. Animals can also help improve children's moods and reinforce positive behaviors while helping to decrease negative ones.
Pets may provide an opportunity for fun and relaxation for people in institutions.
Prison based animal-assistance programs involve an inmate working with a qualified handler to train an animal through a structured and goal-oriented program. The overall aim of using animal-assisted therapy in prisons is to relieve stress of the inmates and workers, enhance cognitive and behavioral capabilities, improve social skills, and to teach love, patience, and empathy in a realistic setting. Animal-assisted therapy is directly linked to increased physical and mental health benefits, induced relaxation, self-confidence, improved intrapersonal and interpersonal skills, and better environmental conditions. As of 2016 there are not many studies that examine animal-assistance programs at the prison level, especially in terms of long-terms effects, so the success rate cannot be accurately measured. However, effects from similar case studies such as rehabilitation programs or nursing homes can be evaluated and applied to the current state of the prison system in order to examine other alternatives to reform programs. If applied in prison settings results may show an increase in better environmental conditions and social support among staff and inmates by teaching them how to cope with hostile environments. It is likely the inmates will transfer the knowledge and skills learned in the correctional program to their transition outside of the institution, contributing to the larger society by generating productive members of society. Time in prison should be geared toward helping inmates build the life skills needed to push them down the right track, especially in the face of mental illness, loss, or addiction. The effect that animals have on a person's ability to understand love, empathy, and compassion are reasons to further explore animal-assisted therapy in correctional settings.
Animal assisted therapy draws on the bond between animals and humans in order to help improve and maintain an individual's function and is being used to assist in the process of enhancing the individual's quality of life in nursing homes.[non-primary source needed] Psychologists and therapists notice increasing unfavorable behaviors of elderly people that are transferred to nursing homes. Once the patients become settled into their new environment, they lose their sense of self-efficacy and independence. Simple, everyday tasks are taken away from them and the patients become lethargic, depressed, and anti-social if they do not have regular visitors.
When elderly people are transferred to nursing homes or LTC facilities, they often become passive, agitated, withdrawn, depressed, and inactive because of the lack of regular visitors or the loss of loved ones. Supporters of AAT say that animals can be helpful in motivating the patients to be active mentally and physically, keeping their minds sharp and bodies healthy. Therapists or visitors who bring animals into their sessions at the nursing home are often viewed as less threatening, which increases the relationship between the therapist/visitor and patient.
There are numerous techniques used in AAT, depending on the needs and condition of the patient. For elderly dementia patients, hands on interactions with the animal are the most important aspect. Animal assisted therapy provides these patients with opportunities to have close physical contact with the animals warm bodies, feeling heartbeats, caress soft skins and coats, notice breathing, and giving hugs. Animal assisted therapy counselors also plan activities for patients that need physical movement. These planned tasks include petting the animal, walking the animal, and grooming the animal. These experiences seem so common and simple, but elderly dementia patients do not typically have these interactions with people because their loved ones have passed or no one comes to visit them. Their mind needs to be stimulated in the ways it once was. Animals provide a sense of meaning and belonging to these patients and offer something to look forward to during their long days.
There are many types of AAT ranging from the use of dogs, to cats, even to small animals such as fish and hamsters. The most popular forms of AAT include canine therapy, dolphin therapy, and equine therapy.
Dolphin assisted therapy refers to the practice of swimming with dolphins. Proponents claim for such encounters "extraordinary results of the therapy and breakthroughs in outcomes",[non-primary source needed] however this form of therapy has been strongly criticised as having no long term benefit, and being based on flawed observations. Psychologists have cautioned that dolphin assisted therapy is not effective for any known condition and presents considerable risks to both human patients and the captive dolphins. Dolphin assisted therapy's agenda is to help people with autism, Down syndrome, and Cerebral Palsy with rehabilitation in motor function, speech, and language as well as to maintain and increase the client's attention span. The child has a one-on-one session with a therapist in a marine park of some kind. An ethical issue with data on dolphin-assisted therapy and the effectiveness of it is that most of the research is done by people who operate the dolphin-assisted therapy programs. Dolphin assisted therapy is an alternative medicine/therapy option for people who do not respond or are not keen on traditional medicines/therapies and it is a controversial therapy. John Lilly, who studied dolphin-human interaction, first considered this idea that interactions with dolphins can have rewarding benefits on humans in the 1960s. David Nathanson, who was a clinical psychologist, came up with much of the existing research on this therapy today. Nathanson's theory was that children with disabilities would increase their attention to related stimuli in the environment in hopes they would get to interact with the dolphins, helping motivate the child to do the task at hand and to give the appropriate responses according to that child's therapy program lessons.Hippotherapy is promoted as a treatment for people with physical or mental challenges.
A distinction exists between hippotherapy and therapeutic horseback riding. The American Hippotherapy Association defines hippotherapy as a physical, occupational, and speech-language therapy treatment strategy that utilizes equine movement as part of an integrated intervention program to achieve functional outcomes, while the Professional Association of Therapeutic Horsemanship International (PATHI) defines therapeutic riding as a riding lesson specially adapted for people with special needs. According to Marty Becker, hippotherapy programs are active "in twenty-four countries and the horse's functions have expanded to therapeutic riding for people with physical, psychological, cognitive, social, and behavioral problems". Hippotherapy has also been approved by the American Speech and Hearing Association as a treatment method for individuals with speech disorders. In addition, equine assisted psychotherapy (EAP) uses horses for work with persons who have mental health issues. EAP often does not involve riding. Additional information pertaining to equine assisted therapy can be seen with Laira Gold's open clinical study of EAT.
The lack of studies done on Animal-assisted therapy has led to large controversy in whether it is effective or not. With such diversity in AAT there are many scholarly articles that are positive and negative. The effectiveness can not be determinant with out talking to a physiologist. There has been criticism as to the effectiveness of AAT. According to Lilienfeld and Arkowitz animal-assisted therapy is better considered a temporary fix. They point to the lack of longitudinal data or research to see if there is evidence for long term improvement in patients undergoing the therapy. They then suggest that this further supports the idea that AAT is more of an affective method of therapy rather than a behavioral treatment. They also state the dangers of these therapy programs in particular the Dolphin assisted therapy. Dolphin assisted therapy has not been shown to have significant results when dealing with a child's behavior. Instead Lilienfeld suggest that again animal assisted therapy might be a short term reinforce, not a long term one. They also suggest that studies dealing with children should look into more balanced measures, such as having one group of children in the Dolphin group and the other in a setting where they still receive positive reinforcement. It is also suggested that DAT is harmful to the dolphins themselves; by taking dolphins out of their natural environment and putting them in captivity for therapy can be hazardous to their well being. There are not many quantitative studies about the effect of swimming with dolphins have on social behavior. Of the few studies, data has seemed limited or mixed in results. The first research on the effects of Dolphin-Assisted Therapy as a treatment was a case study by Betsy Smith in 1987. The dolphins were used to motivate a child with autism to communicate. Smith concluded that the use of Dolphin-Assisted Therapy has shown promising results on increasing attention spans and improved interaction and play behavior in the children. Other studies after concerning Dolphin Assisted Therapy yielded about the same results but failed to take into account other situational factors, what is also known as a confound, one or more effective ingredient in a study that may affect results in the study.
Another limitation of pet therapy also centers on the application during scenarios that involve adults who have been sexually assaulted. While pets do tend to cause more comfort to victims, pet therapy may not be the catalyst that provides positive success in therapy sessions. As mentioned above, adults tend not to focus as much on having an animal companion, and therefore, pet therapy cannot be attributed as the reason for success in those types of therapy sessions. Pet therapy does not raise any ethical concerns as far as advancing nonscientific agendas. On the other hand, there are some ethical concerns that arise when applying pet therapy to younger victims of sexual assault. For example, if a child is introduced to an animal that is not their pet, the application of pet therapy can cause some concerns. First of all, some children may not be comfortable with animals or may be frightened, so there would be ethical concerns with using pet therapy, which could be avoided by asking permission to use animals in therapy. Second, a special bond is created between animal and child during pet therapy. Therefore, if the animal in question does not belong to the child, there may be some negative side effects when the child discontinues therapy. The child will have become attached to the animal, which does raise some ethical issues as far as subjecting a child to the disappointment and possible relapse that can occur after therapy discontinues.
The AAT program encourages expressions of emotions and cognitive stimulation through discussions and reminiscing of memories while the patient bonds with the animal. Many of the troubling symptoms in elderly dementia patients include decreased physical functioning, apathy, depression, loneliness, and disturbing behaviors.
In 2014 a study was unable to find evidence to make any recommendations for the use of AAT to alleviate agitation in older people with dementia; only three studies had been done to that date, with mixed results.
A study in 2017 evaluated results from ten research articles and found that animal assisted therapies (particularly using dogs) resulted in measurable quality of life improvements.
Animal-assisted therapy sprouted from the idea and initial belief in the supernatural powers of animals and animal spirits. It first appeared in the groupings of early hunter gatherer societies. In modern times animals are seen as "agents of socialization" and as providers of "social support and relaxation". Though animal assisted therapy is believed to have begun in these early human periods it is undocumented and based on speculation. The earliest reported use of AAT for the mentally ill took place in the late 18th century at the York Retreat in England, led by William Tuke. Patients at this facility were allowed to wander the grounds which contained a population of small domestic animals. These were believed to be effective tools for socialization. In 1860, the Bethlem Hospital in England followed the same trend and added animals to the ward, greatly influencing the morale of the patients living there.
Sigmund Freud kept many dogs and often had his chow Jofi present during his pioneering sessions of psychoanalysis. He noticed that the presence of the dog was helpful because the patient would find that their speech would not shock or disturb the dog and this reassured them and so encouraged them to relax and confide. This was most effective when the patient was a child or adolescent. The theory behind AAT is what is known as Attachment theory.
Therapy involving animals was used in therapy by Dr. Boris Levinson who accidentally discovered the use of pet therapy with children when he left his dog alone with a difficult child, and upon returning, found the child talking to the dog. However, in other pieces of literature it states that it was founded as early as 1792 at the Quaker Society of Friends York Retreat in England. Velde, Cipriani & Fisher also state "Florence Nightingale appreciated the benefits of pets in the treatment of individuals with illness. The US military promoted the use of dogs as a therapeutic intervention with psychiatric patients in 1919 at St Elizabeth's Hospital in Washington, DC. Increased recognition of the value of human–pet bonding was noted by Dr. Boris Levinson in 1961".