by Michael D. Anestis, M.S.
On one of our first vacations together, Joye and I took a trip to Arizona. While there, we encountered a sign for a program claiming to utilize equine-assisted psychotherapy (EAP) for eating disorders. We were both appalled, knowing full well that there is a range of empirically supported treatments for eating disorders, but we did not do anything about it. After all, we were on vacation and, at that point, we were not yet confident enough in our grasp of the scientific literature to speak out on such issues. Given that I have been on a bit of a mission lately to debunk unsubstantiated claims about unvalidated treatments, I thought I would finally take on this project and discuss the evidence for the utility of EAP in the treatment of mental illness.
What is EAP?
**PBB Edit -- I deleted a sentence characterizing the EAP treatment protocol which numerous readers have described as erroneous. In an effort to help readers not be distracted from the point of this post (a thorough critique of the scentific evidence for EAP), I have removed the controversial sentence** Different resources offer a number of theoretical mechanisms through which EAP is thought to benefit clients, but some of the most consistently endorsed ideas are:
- Improving non-verbal communication skills through interactions with a non-verbal creature
- Improvement of acceptance skills and emotional expression through the realization that a person can not make the horse do things it does not want to do (e.g., lift its hoof)
- Improved mood due to positive interactions with an animal
- Increased awareness of connection to nature through outdoor experiences
What is the controversy?
As is the case with all of the approaches to therapy that have been the subject of substantial criticism on PBB, one of the main causes of my discontent is the excessive claims made about efficacy in treating a wide variety of mental illnesses in the absence of evidence supporting those claims. For instance, a quick Google Scholar search for "equine assisted therapy" brought me to a document written by Edward Cumella and Sharon Simpson of the Remuda Ranch Center for Anorexia and Bulimia (click here for the Google search results. The third item down is the document). In this document, the authors wrote the following:
"Animal-assisted therapy has shown evidence-based efficacy in patients with depression, anxiety, attention-deficit/hyperactivity disorder, conduct disorders, dissociative disorders, Alzheimer's disease, dementia, autism, and other chronic mental illnesses."
To their credit, each of these claims included a citation. Sounds solid, right? Perhaps, but let's take a look at some of those citations. In one of the papers, published in Psychiatric Services in 1998 by Sandra Barker and Kathryn Dawson, the authors examined whether canine assisted therapy for inpatient psychiatric patients reduced anxiety for a number of diagnoses relative to a regularly scheduled therapeutic recreation session. Never mind that this is a completely different setting and species of animal, thereby making generalizations to equine therapy absurd, the results themselves simply were not impressive. First of all, there was no difference between the groups in the degree to which anxiety was reduced post session. The only difference was that individuals in the canine-assisted group who experienced reduced anxiety had a wider variety of diagnoses than did those who benefited from standard recreation sessions. Secondly, the study simply looked at differences in anxiety immediately following the session. This has no bearing on whether or not benefits are maintained or the symptoms of the primary mental illness were addressed. Similar themes emerge in the other references (e.g., although individuals with ADHD have been shown to focus on the horse in session, there is no evidence that increased focus is experienced outside of the session).
The authors of this document were not done making their claims however. Citing a book rather than peer reviewed data, they go on to say:
"By demonstrating the efficacy of Equine Therapy in treating some of the most profoundly disturbed patients - gang members, psychopaths, and sexual predators - the authors recognize that Equine Therapy is not only effective with a variety of DSM-IV Axis I disorders, but is also a powerful adjunct modality in the treatment of patients with the distorted bonding and relational issues predominant in the Axis II disorders."
Where to start with this one. First of all, although psychopathy is akin to antisocial personality disorder (ASPD), it is not actually listed on Axis II. Neither is gang membership or sexual abuse. So, not only did they fail to provide any empirical evidence supporting their claims, they used their unsupported claims to make another erroneous claim. This is essentially like me saying that because eating bacon has been shown to be effective in treating cancer (which it hasn't, sadly), we can recognize that it is also effective in diminishing the deleterious effects of illiteracy. There is simply no logic there.
One thing you might have noted in the quotes above is that, despite this being a center for the treatment of eating disorders, the authors did not mention that animal-assisted therapy has empirical support for treating eating disorders. Well....that's because it doesn't. Try as I might, I can find no peer reviewed published data indicating that any form of animal-assisted therapy is efficacious in the treatment of eating disorders.
A similar issue emerged when I found a review article on EAP published in 2005 in the Journal of Counselling Psychology (not to be confused with the Journal of Counseling Psychology, an APA journal) by Karen Frewin and Brent Gardiner. The review opened with florid text, including the following excerpts:
"With flaring nostrils, long flowing mane and tail, flying hooves drumming across the ground, horses represent strength and nobility, heroes and warriors, intense feelings and unbridled passions. With soft nuzzling muzzle, velvet smooth coat and a tender eye, containment and liberation paradoxically present simultaneously."
"Although many clients have powerful responses to the energies of the horse, for example, 'the magical white pony"; "the fiery chestnut"; "the mystical Arabian", there are certain characteristics of the horse that appear to be important in the success of EAP."
Those quotes, while fairly bizarre, could be seen as compelling. They also lack any empirical evidence supporting their claims, which are disputable at best (e.g., do horses represent heroes and warriors to everyone, or do some folks just like - or hate - animals and think they are nice to look at ?). Later in the article, the authors cited Mann (2001) as demonstrating that recidivism rates of male juvenile offenders improved after horses were introduced into treatment sessions and Mann and Williams (2002) as demonstrating an 82% improvement rate in youth taking part in equine-assisted family therapy. These are great findings!!.....except that the first one was taken off of a website and the second was an unpublished manuscript written at least three years earlier but still unable to find a home in a peer reviewed journal. Just because a citation appears does not mean that the person is citing something legitimate.
Is anyone conducting research on EAP?
There are, in fact, individuals out there conducting empirical research on EAP and submitting their results to peer reviewed journals. I will quickly review a couple such studies in a moment, but before doing so, a couple points of clarification are needed. First of all, I am not saying that EAP is harmful, but rather that support for the claims that it can be used to treat a broad range of mental illnesses is lacking. As such, the expensive programs that conduct this form of therapy are overstepping the bounds of professional ethics and misstating the degree to which there is any support for their actions. Second, I am not saying that EAP can not have any positive benefits. As you will see in a moment, studies do show that individuals experience some positive effects. In fact, in the Baker and Dawson (1998) study mentioned above, patients did experience at least momentary reductions in anxiety. The point, however, is that any positive experience (e.g., going to a funny movie) can have such an effect, but that does not mean that such activities constitute efficacious or effective therapies capable of impacting the symptoms of specific mental illnesses.
Okay, on to the studies. Klontz, Bivens, Leinart, and Klontz (2007) published the results of an open trial in which individuals took part in an equine-assisted experiential therapy (EAET) program. Diagnoses, if any existed, were not specified. 66 individuals participated, but only 49 agreed to provide data. 31 of those participants mailed in follow-up data and only those individuals were included in the analyses. No information was given on whether those who participants and provided complete data differed from those who did not. This is problematic, as it means we have no idea whether or not those who did not complete the study experienced no benefits and failed to complete it due to dissatisfaction. The authors found that, on average, general symptoms decreased and well-being increased and that those benefits were maintained at follow-up. This sounds good, but here again, we have some fatal flaws. First of all, there was no randomization, control group, or active treatment comparison. As such, what we see is that people who believed that interacting with a horse might be beneficial and who completed the program reported that interacting with a horse was beneficial over time. We can not rule out that demand characteristics or even the simple passage of time better accounted for the effects. Perhaps even more importantly, there is no evidence that whatever problem the authors were trying to address was addressed more effectively than it would be through the use of treatments with empirical support. To their credit, the authors openly acknowledged that these weaknesses were present and that, as such, readers should be cautious in drawing conclusions, but as we saw in the review article above, readers often are not cautious and will readily cite bad research (or no research at all) to back up wild claims.
In another study, Schultz, Remick-Barlow, and Robbins (2007) examined the utility of EAP in treating children who have experienced intra-family violence. The authors found that, regardless of the form of violence the children witnessed, their global assessment of functioning (GAF) improved through treatment. They also found that, the more sessions the child received, the greater the improvement in GAF, with a range in number of sessions received of 1 to 116 (yes, that's right...116 therapy sessions). The authors listed the number of individuals who met criteria for particular diagnoses; however, they gave absolutely no information regarding how they arrived at those diagnoses, nor did they provide any measure of whether or not the symptoms of those particular diagnoses were addressed by the treatment. This, of course, is akin to asking whether a cancer patient's quality of life improved after treatment without asking whether or not the cancer was still there. Furthermore, there was no comparison group or randomization. A lack of comparison group is always a problem, but this is particularly true when a correlation is found between number of sessions and overall improvement, as such a finding raises serious concerns that treatment benefits had everything to do with the passage of time (e.g., children are resilient and, over time, recover naturally from many upsetting events) and nothing to do with the treatment.
So where does EAP stand?
EAP does not appear to be harmful, but there is no evidence that it is efficacious in the treatment of mental illnesses. There is a paucity of research on the topic and the research that exists is so full of flaws that it is actually rather remarkable that it was published in the first place. Nonetheless, fancy treatment centers charge outrageous fees to provide this service and make grandiose claims regarding efficacy. Just as we covered in our article on touch field therapy (TFT), such behavior is a prime marker of pseudoscience.
I like the idea of using animals to make people feel better. In fact, Joye and I may one day train our sweet playful golden retriever to visit hospital patients in order to provide them with an added moment of happiness. In doing so, however, we will not be under the illusion that such an action would constitute therapy or treat mental illnesses. Our dog would simply provide a positive experience, which can impact mood and perhaps motivate an otherwise ambivalent individual to pursue the type of help capable of addressing the actual problem. When animal-assisted therapy is couched in these terms, it sounds wonderful. When it is presented as a stand alone treatment, however, that is a problem.
Given that this project was originally motivated by my distress regarding claims the EAP is an effective treatment for eating disorders, let me provide you with a few links to articles we have written discussing treatments that actually have empirical support in the treatment of such conditions:
It should also be noted that, while we have not yet written about this topic, interpersonal psychotherapy also has empirical support as a treatment for bulimia nervosa.
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If you would like to learn more about empirically supported treatments for eating disorders, we recommend the following items, all of which are available through our online store for scientifically-based psychological resources:
- Treatment Manual for Anorexia Nervosa: A Family-Based Approach
by James Lock, Daniel le Grange, Stewart Agras, and Christopher Dare
- Overcoming Binge Eating
by Christopher Fairburn
- Cognitive Behavior Therapy and Eating Disorders
by Christopher Fairburn
- Dialectical Behavior Therapy for Binge Eating and Bulimia
by Debra Safer, Christy Telch, and Eunice Chen
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University
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