Sylvia is 7 years old, referred for long-standing school refusal after CBT proved ineffective. You confer with her therapist about trying a different approach.

When patients are not amenable to usual therapy, equine-assisted psychotherapy (EAP) might be a good option. In this article we’ll talk about working with horses as an alternative to, or in conjunction with, traditional therapy.

The theory behind EAP
As human practitioners, we can have trouble accurately attuning to our clients’ emotional states. Horses are highly attuned to nonverbal cues, emotional tones, and the autonomic state of others. As a prey species, horses have exquisite hearing and smell, with near 360-degree vision—all of which evolved for safety and for connection to the herd—and will naturally pick up on dysregulating behavior. For example, if a child is upset, angry, or tense while attempting to engage with a horse, the animal will most likely react by trotting away. Once the patient is calmer, the horse is able to read the situation, settle down, and reapproach. This is good modeling for children who have trouble appropriately expressing emotions. Clients, especially those who have been hurt by or are reluctant to engage with others, often tell us that they find it easier to trust a horse than another person.

Horses can perceive the heartbeat and breathing rate of other animals many feet away (Bee V. 3-Minute Horsemanship. North Pomfret, VT: Trafalgar Square Books; 2013). This type of attunement supports nonverbal, emotion-mirroring communication. For example, as the connection between horse and person deepens, the horse’s cardiac rhythms synchronize with the person’s (www.tinyurl.com/adyt6hnj). During EAP, the therapist will often have patients feel the horse’s flank to attune their more rapid breath with the horse’s slower breath—which leads naturally into relaxation breathing.

EAP in practice
After initial assessment, the patient has an interactive session with the horse. The therapist might ask the patient, “What would you like to do with the horse?” or “How would you like to connect?” and work with their responses. For instance, if the horse is standing and will not move, the therapist can ask the patient what they think this means, ask “Is the horse angry?” or wonder if the patient has ever been similarly “stuck.” If the patient is grooming the horse, the therapist can use that opportunity to ask about self-care.

There are also semi-structured therapeutic EAP activities. One activity involves asking the patient to write a different challenge—eg, “managing anger” or “controlling the voices”—on each of four cards, placing one card near each of the horse’s legs. The therapist then talks about each problem while asking the patient to pick up the horse’s corresponding hoof, knowing that the horse initially may not allow the patient to do so. However, as the patient talks, works on emotions, and relaxes, the horse can pick up on this shift and will likely then allow the patient to lift the hoof.

In guided imagery, patients imagine that the horse wants to talk or communicate something positive. They paint that message, in words or pictures, on the side of the horse using washable paints. For example, patients may paint the words “I am not broken” or “I am enough,” or create pictures of the sun, a river, or a family.

Patients might write letters to the horse, with prompts such as “What do I want to remember about you?” or “What have I learned from you?” Patients read the letters, substituting their own name for the horse’s name. This projection usually prompts supportive insights for the patient. For children who have difficulty working with metaphor (ideas outside of the present moment), the therapist can choose more developmentally appropriate exercises.

During her EAP sessions, Sylvia designates parts of the arena as “home” and “school,” leading the pony representing herself to “school.”

After each session, the therapist debriefs with the patient and may assign homework like journaling, art activities, or practicing a skill they learned during the session (such as checking their assumptions or asking for help).

Does EAP help?
Research on EAP has a long history for a number of conditions, including autism spectrum disorders (ASD), PTSD or other trauma, and anxiety disorders. While many of the studies are small and may be limited by inclusion bias, the research is nonetheless promising.

ASD
A literature review of EAP for children and adolescents with ASD reported that 17 of 18 studies (nine controlled, four RCTs) published between 2008 and 2018 reported positive psychosocial outcomes (Tan VXL and Simmonds JG, Rev J Autism Dev Disord 2019;6(3):325–337). These ranged from improved social interaction and communication to improved planning speed. The authors theorized that an enjoyable relationship with horses enhances patients’ understanding of others’ emotions and improves executive functioning. For example, a 16-year-old boy with ASD became aware of others’ personal space by observing a horse’s body language, specifically its ears moving backward, as he encroached on the horse’s personal space. He translated this awareness first to his cat’s responses and then to his encounters with family and peers.

Trauma/PTSD/abuse
Patients frequently have trouble relating traumatic events verbally to therapists. EAP for PTSD may interrupt symptoms, reducing isolation, eliciting positive emotions, and releasing oxytocin (Naste TM et al, J Child Adolesc Trauma 2018;11(3):289–303). A 2014 study compared in-office therapy with EAP for survivors of sexual abuse and found effect sizes in the range of 0.583–0.880 among children and 0.702–0.905 among adolescents (Kemp K et al, J Child Fam Stud 2014;23:558–566).

ADHD
Children and teens with ADHD and externalizing disorders may be unaware of their own arousal. It can benefit them to see a horse running away in response to hyperactive or impulsive behavior. Researchers have conducted several controlled trials and a systematic review of EAP for ADHD with good results, including significant improvements in global executive function, working memory, and initiation (White E et al, Complement Ther Clin Pract 2020:39:101101).

Anxiety and at-risk behaviors
EAP may help shy, depressed, or anxious children and youth. A 2016 literature review found modest evidence that EAP enhances children’s and adolescents’ emotional, social, and behavioral functioning (White et al, 2020; Lee PT et al, Health Soc Care Community 2016;24(3):225–246).

EAP logistics
EAP sessions can be individual, family, or group based. Fees are $80–$400 for 60–90 minutes, with an individual hour-long allied health EAP session costing around $175. Therapy is usually weekly for several weeks, but may be several years for long-term goals. Some programs require two certified professionals in a session, which increases cost; however, rapid progress can improve cost-effectiveness. Some nonprofits offer sponsorship, while some are covered by insurance. There is some Medicaid coverage for EAP (see https://mayonahorse.com/qa/does-medicaid-pay-for-equine-therapy.html for more information).

There are several schools of EAP, including Eagala (Equine-Assisted Growth and Learning Association; www.eagala.org/org), Eponaquest (www.eponaquest.com/about), OK Corral Series (www.okcorralseries.com), and HEAL (Human-Equine Alliance for Learning; www.humanequinealliance.com). EAP sessions are usually conducted with the patient on the ground, although the Professional Association of Therapeutic Horsemanship (PATH; www.pathintl.org/what-is) incorporates therapeutic riding.

After eight EAP sessions, Sylvia returns to school, wearing a horsehair bracelet as a transitional object that allows her to remember her supportive, secure bond with her pony alter-ego.

CCPR Verdict: Supported by a growing body of clinical research, EAP is perhaps the ultimate in experiential therapies. The combination of an outdoor setting, an empathic horse, and the use of metaphor can be helpful, especially for patients who struggle with talking therapies.