Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author. Charlotte Augusta Lawson 11113478 Page 1 of 207 Equine-assisted psychotherapy in New Zealand: A Phenomenological Investigation Presented in fulfilment of the requirements for the degree of Masters of Arts In Psychology At Massey University, Albany Campus, New Zealand Charlotte Augusta Lawson 2016 Charlotte Augusta Lawson 11113478 Page 2 of 207 Abstract This study explores the experiences of two New Zealanders who have undertaken a course of equine-assisted psychotherapy in New Zealand. Using the method of Interpretative Phenomenological Analysis, two participants were interviewed. It was concluded that through the therapy, the participants experienced a process of transformation into a new self, a theme composed of transformation, and a new way of thinking and being. The experienced the therapy as fundamentally different from, but complementary to, traditional therapy. Their experiences were grounded in the real world and real experience, a theme that was made up of the natural environment facilitating different conversations; the experiences with the horses making the therapy real and meaningful; and hands-on, in-the-moment activity. The participants experiences with the horses, and of therapy, was spiritual and beyond explanation, a theme that showed their experiences were spiritual and meaningful, beyond explanation, and that the horses embodied symbolic representations. One participant became a convert and an advocate and this theme was composed of overcoming negative preconceptions, a positive experience, and becoming an advocate for its use. These themes and experiences were supported by the literature and provide insight into how and why equine-assisted psychotherapy is an effective therapeutic intervention. Charlotte Augusta Lawson 11113478 Page 3 of 207 Acknowledgements I would like to thank my supervisor, Clifford van Ommen, for his help and support. I would like to thank my participants for their time, and the privilege of recording their experiences. Finally, I would like to thank my family and friends, and most especially Sam, for supporting me, inspiring me, and giving me the fortitude to complete this project. Charlotte Augusta Lawson 11113478 Page 4 of 207 Table of Contents Abstract .......................................................................................................................... 2 Acknowledgements ........................................................................................................ 3 List of Tables ................................................................................................................. 5 Introduction .................................................................................................................... 6 Literature Review........................................................................................................... 9 Animal-assisted Psychotherapy ..................................................................................... 9 Equine-assisted Psychotherapy .................................................................................... 17 Methodology ................................................................................................................ 39 Introduction .................................................................................................................. 39 Research Aims ............................................................................................................. 39 Qualitative Research .................................................................................................... 40 Interpretative Phenomenological Analysis .................................................................. 42 Procedure ..................................................................................................................... 48 Results and Discussion ................................................................................................ 63 Results .......................................................................................................................... 63 Discussion .................................................................................................................... 66 Conclusion ................................................................................................................. 117 Reference List ............................................................................................................ 119 Appendix A ................................................................................................................ 130 Charlotte Augusta Lawson 11113478 Page 5 of 207 Transcript of Lucinda’s Interview ............................................................................. 130 Transcript of Tom’s Interview ................................................................................... 157 Appendix B ................................................................................................................ 199 Preliminary Thematic Analysis for Each Participant................................................. 199 Appendix C ................................................................................................................ 201 Letter to Psychologists ............................................................................................... 201 Information Sheet....................................................................................................... 203 Participant Consent Form .......................................................................................... 206 Transcript Release Authority ..................................................................................... 207 List of Tables Table One – Table of Themes ...................................................................................... 64 Charlotte Augusta Lawson 11113478 Page 6 of 207 Introduction “Mental disorders, as a group, are the third leading cause of health loss for New Zealanders” (Mental Health Foundation, 2014, p. 1). Psychotherapy is the use of psychological methods by a trained practitioner, in order to assist an individual in alleviating distress, be it as a result of psychological, behavioural, or psychosocial problems (Prochaska & Norcross, 2010). Its foremost function is the promotion of mental health and wellbeing, through treatment and prevention. In New Zealand, issues of mental health (and likewise, research into the mitigation, treatment, and prevention of mental health disorders) are especially pertinent. In 2010, the Ministry of Health began a study analysing the burden of disease, injury, and risk factors in New Zealand in 2006, with projections forward to 2011 and 2016, investigating the level of health loss by New Zealanders due to various causes. Mental health issues were found to be one of the top three causes of health loss for New Zealanders across almost all age groups (Ministry of Health, 2013). It was found that for the overall population, mental health issues were the third most virulent cause of health loss; for youths between the ages of fifteen and twenty four they were second only to alcohol abuse disorders (which in many ways fall within the realm of mental health issues themselves); for young adults between the ages of twenty five and forty four they were the leading cause of health loss; and for middle-aged adults between the ages of forty five and sixty four, they were once again second, after coronary heart disease (Ministry of Health, 2013). These statistics show the pressing need for effective approaches to psychotherapy in New Zealand. Not only is providing for the safety of those at risk of mental health issues of paramount importance, but so is fostering well-being, mindfulness, and increased quality of life. These things will become increasingly important in New Zealand as time passes, as it Charlotte Augusta Lawson 11113478 Page 7 of 207 has been projected that, despite increasing access to a variety of treatments options and decreasing social stigma, mental health issues remain one of the leading causes of health loss in our country and that, the burden will grow (Mental Health Foundation, 2014; Ministry of Health, 2013). New Zealand’s aging population, increasing population size due to immigration, and unique bicultural societal structure, make it imperative that there is a broad range of effective treatment options available for individuals seeking help, as it is the case that what works well for one may not work at all for another. A wide range of treatments, based on an inclusive and comprehensive approach to health (for example, the uniquely Māori philosophy of Hauora, and Te Whare Tapa Whā) provides greater accessibility to a wider variety of people, who may view certain approaches as more or less socially appropriate, effective, and culturally relevant to their own specific background and the issue for which they are seeking help. Alternative therapies are beginning to take the place of more traditional office-bound therapies. The simple act of moving traditional talk therapy into an outdoor setting can have an impact on the client’s outcome, how the client relates to the therapist, and the success of the course of therapy overall (Frame, 2006). Because of the expanding range of therapies available, it is important to have a broad and robust field of data and literature on the effectiveness of the various approaches, both to aid clients in deciding what is the best therapy for them, and to aid practitioners in deciding what course of therapy may be most effective for a particular client’s needs. Research into the effectiveness of the various and emerging therapies is especially important in New Zealand as we have a national health service that entitles individuals to subsidised mental health care in certain circumstances. Research is important in order to establish what works, and who it works for. In New Zealand we have a culture of focusing, and relying most heavily, upon evidence-based practice; therapy models whose effectiveness are backed up by critical research are more likely to Charlotte Augusta Lawson 11113478 Page 8 of 207 obtain government funding and thus be more accessible to those in the community who need them. Animal-assisted psychotherapy is a therapeutic approach that has been gaining popularity and validation in the literature in recent years. Animals are increasingly being seen as a positive influence on human health, both mental and physiological, and as useful and effective adjuncts to psychotherapy for a wide range of psychological issues. Equine-assisted psychotherapy (EAP) is an even more specialised field, utilising horses, donkeys, and mules, both for the positive influence of the human-equine bond, and their apparently unique characteristics as large, highly social prey animals, that behove them to successful participation in the therapeutic process. This thesis will focus upon equine-assisted psychotherapy, looking first to its status in the literature, and second to how two New Zealanders who have participated in a course of equine-assisted psychotherapy on the Kapiti Coast of the North Island experienced this emerging form of therapy. Literature Review Charlotte Augusta Lawson 11113478 Page 9 of 207 Animal-assisted Psychotherapy Animal-assisted psychotherapy is one of the myriad terms used to label an emerging field of therapy, which comes with as many names, purposes, theories, and practices as there are animals used within it. Terms and definitions vary throughout the literature, with the field sometimes being referred to as animal-assisted therapy or psychotherapy, pet or pet- facilitated therapy, animal-assisted activities, zootherapy, and so on (Grandgeorge & Hausberger, 2011). The differences between the terms are oftentimes difficult to discern. Nimer and Lundahl (2007) define animal-assisted psychotherapy as the incorporation of an animal into treatment in order to achieve results that might not otherwise be possible with more traditional therapies. Granger and Kogan (2006) use the Delta Society’s definition of animal-assisted activities, as activities designed to enhance quality of life through “motivational, educational, recreational and/or therapeutic” means (Delta Society, n.d., as cited in Granger & Kogan, 2006, p. 264). Animal-assisted activities are often used for team building, and personal or professional development purposes, whereas animal-assisted psychotherapy is used to “generate change (or learning), allowing people to better overcome their problems” (Grandgeorge & Hausberger, 2011, p. 400). According to Grandgeorge and Hausberger (2011), the catchall term ‘animal-assisted intervention’ has risen to prominence amongst practitioners and researchers as a way of referring to all programs, interventions, and activities involving the use of animals for human aid and well-being. Definitions of animal-assisted psychotherapy vary between publications, but most incorporate trained professionals working within their scope of practice, working in partnership with clients towards therapeutic goals, and involve specifically trained animals as a pivotal cog in the mechanism of therapy (Barker & Dawson, 1998; Berget & Braastad, Charlotte Augusta Lawson 11113478 Page 10 of 207 2011; Dimitrijevic, 2009; Grandgeorge & Hausberger, 2011; Nimer & Lundahl, 2007; Tedeschi, Fitchett & Molidor, 2005). Interventions vary with short term and long term; structured activities, and unstructured interaction; the use of the animal in a companionable way, and the use of the animal as an adjunct, or assistant, in therapy; the animal used; the people it is designed to aid; whether it is a group, or individual therapy setting; and the actual physical setting in which the therapy takes place (Barker & Dawson, 1998; Dimitrijevic, 2009; Grandgeorge & Hausberger, 2011; Netting, Wilson & New, 1987). This broadness of scope and flexibility of definitions does confound the research that is done in this field. Furthermore, there are issues with literature quality, with many being descriptive or reviews, having small participant numbers, poor controls, poor transparency, and a high incidence of researcher bias and conflict of interest (All, Loving & Crane, 1999). A large proportion of the literature does no more than record anecdotal reports of serendipitous interactions with animals and humans, which while occurring in a professional setting, have none of the trappings of the therapeutic process (Beck & Meyers, 1996). All et al. (1999) state that the most basic form of animal-assisted therapy comes in the form of pet visitation, resulting in improved social behaviour, and increased pleasure and morale, among a range of other results. However, when one takes the Delta Society’s definition of animal- assisted psychotherapy into account, which states that the therapy must be goal-directed, it would seem that while this form of ‘therapy’ may result in positive interactions and positive results, simply putting a client and an animal in proximity to one another and celebrating the benefits may not exactly count as therapy as such. Indeed, much of the research focuses less on therapy at all, and more on the benefits of animal ownership and companionship (All et al., 1999). While these benefits seem very likely to exist, and can inform therapeutic practice in a positive manner, focus now needs to turn towards more specific aspects of the therapeutic process, and the wide range of therapy programs in current use internationally, if Charlotte Augusta Lawson 11113478 Page 11 of 207 the field is to grow and improve in the direction of evidence-based practice that is so important for New Zealand psychotherapy. History of the field. It is generally accepted that animal-assisted psychotherapy has its roots in the late 18th, and early 19th, centuries at the York Retreat in Northern England, where William Tuke established an asylum for the moral treatment of individuals suffering from mental illness (All et al., 1999; Grandgeorge & Hausberger, 2011; Heimlich, 2001; Mallon, 1992; Netting et al., 1987; Reichert, 1998). In his treatise on the Retreat and its practices, Tuke’s grandson Samuel Tuke (1813) wrote, The superintendent has also endeavoured to furnish a source of amusement, to those patients whose walks are necessarily more circumscribed, by supplying each of the courts with a number of animals; such as rabbits, sea-gulls, hawks, and poultry. These creatures are generally very familiar with the patients: and it is believed they are not only the means of innocent pleasure; but that the intercourse with them, sometimes tends to awaken the social and benevolent feelings. (p. 96) Later, circa 1867, the Bethel Institute in Germany also began to incorporate animals into its treatment regimen; first for epilepsy, but later extended to patients with a much wider range of both physical and psychological disorders (Grandgeorge & Hausberger, 2011; Netting et al., 1987). Animals were first used in a comprehensive therapy program in the United States of America towards the end of World War II in New York. Recuperating army veterans rode horses and worked at a farm on the grounds of the Army Air Force Convalescent Hospital, as well as a nearby forest, as part of their therapy (All et al., 1999; Grandgeorge & Hausberger, 2011, Mallon, 1992; Netting et al., 1987). Charlotte Augusta Lawson 11113478 Page 12 of 207 The advent of animal-assisted psychotherapy as we know it began with the child psychologist Boris M. Levinson, who coined the term ‘pet therapy’ in 1964 (Cirulli, 2011; Cirulli, Borgi, Berry, Francia & Alleva, 2011; Heimlich, 2001; Mallon, 1992). Levinson noticed that his pet dog, Jingles, who was at the first present only incidentally, seemed to have a positive effect on a severely withdrawn child who had been brought to Levinson by his parents for therapy (Cirulli, 2011; Cirulli et al., 2011; Grandgeorge & Hausberger, 2011). The dog seemed to help to bridge the divide between the therapist and child, naturalising a formal office setting and allowing the child to relax, thus aiding and facilitating a client- therapist relationship where one had previously struggled to form (Friesen, 2010; Grandgeorge & Hausberger, 2011). Following Levinson were Elizabeth and Samuel Corson, psychiatrists who – similar to Levinson – also came upon their revelations of animal-assisted psychotherapy at first by chance and happenstance. The Corsons studied the behaviour of dogs and had kennels installed at the hospital in which they worked (Grandgeorge & Hausberger, 2011). When some patients in the hospital became aware of this, they asked to visit with the dogs and the Corsons, noticing a positive effect from this interaction, embarked upon a study of the use of pets as adjuncts in therapy for those patients who had not been helped by more traditional therapies (Grandgeorge & Hausberger, 2011). They found improvements in feelings of responsibility, self-esteem, and social interactions, and a decrease in psychotropic drug requirements (Grandgeorge & Hausberger, 2011). Both of these serendipitous occurrences and the studies that followed sparked enthusiastic research and practice that has led to the broad and diverse field of animal-assisted psychotherapy that we know today (Mallon, 1992). Beginning in the 1980s, a large proportion of the research surrounding the use of animals in the mental health arena has focused less on psychotherapy programs and more on the specific effects of human-animal interaction. Over the years and across a broad expanse Charlotte Augusta Lawson 11113478 Page 13 of 207 of literature, animals, particularly companion animals, have been found to have a variety of positive effects upon humans who choose to engage with them – so much so that pet ownership has been considered as a valid prescription to treat various ailments, particularly cardiovascular ones, by some practitioners (Beck & Katcher, 2003). In this vein, the human- animal bond has also been a close focus of research, including speculation on the origin and purpose behind the seemingly reciprocal emotional relationships that develop, and the positive effects this bond can have for human and animal wellbeing alike (Bardill & Hutchinson, 1997). It has been shown to mitigate depression, loneliness, and anxiety, and to improve self-esteem by making one feel loved, needed, and accepted by a non-judgemental companion (Bardill & Hutchinson, 1997). Effects of animal-assisted psychotherapy. One of the primary facets of human life that animals seem to have an effect upon is stress and relaxation and, relatedly, autonomic response, blood pressure levels, mood, and anxiety levels (Barker & Dawson, 1998; Beck & Katcher, 2003; Beck & Meyers, 1996; Beck, Seraydarian & Hunter, 1986; Bernstein, Friedmann & Malaspina, 2000; Dimitrijevic, 2009; Fine, 2006; Friedmann & Tsai, 2006; Friesen, 2010; Heimlich, 2001; Lefkowitz, Prout, Bleiberg, Paharia & Debiak, 2005; Yorke, 2010). Research on the physiological aspects of this positive health effect, such as cardiovascular health, has been particularly pronounced. The reason for this is largely due to a pivotal study by Friedmann, Katcher, Lynch, and Thomas (1980) – the first medical publication to show such a link – that found that pet (mainly dog) owners had better rates of survival after a heart attack, compared to non-pet owners (Beck & Katcher, 2003). Lynch (1985, as cited in Allen, Blascovich, Tomake, & Kelsey, 1991) further discovered that when pet-owners spoke to a researcher, their blood pressure rose substantially, whilst their blood pressure stayed the same, or even lowered, when they spoke to their pet. Relatedly, Allen et Charlotte Augusta Lawson 11113478 Page 14 of 207 al. (1991) found that female participants performing a stressful task had far greater levels of autonomic reactivity (indicative of stress levels) when they did so in the presence of a close female friend, than when in the presence of their pet or alone. This is thought to be due to the non-evaluative, or non-judgemental, type of social support provided by a pet, acting as a buffer against the stress of the activity (Allen et al., 1991). These results support the findings of earlier researchers who have shown that the same can be true even if the animal is not the participant’s pet and is unknown to the participant at the commencement of the study, and apparently regardless of the species of animal involved (Barker & Dawson, 1998). The lynchpin of the studies in this vein is that the presence of animals, and interaction with pets, seems to have a calming effect on humans both psychologically and physiologically (Fine, 2006; Kruger & Serpell, 2006). The calming effect of animals upon humans can contribute positively to the therapy process, its nonthreatening presence serving to facilitate the development of a trusting relationship, which can then be expanded to include a therapist (Tedeschi et al., 2005). The presence of, and interaction with, an animal can help a client to relax, easing the development of a therapeutic relationship, and rapport, and facilitating disclosure by both its calming effects, and the distraction it provides. In addition to this, a therapist can use the relationship between the client and animal to gather clues as to wants, needs, and state of mind of an uncommunicative client (Alfonso, Alfonso, Llabre, & Fernandez, 2015; Reichert, 1998; Tedeschi et al., 2005). According to Reichert (1998), clients will often use the animal as a canvas, or mirror, onto which they may project their feelings. The animal can reflect back non-judgemental, unconditional regard, and can both give and accept love and affection in a neutral and nonthreatening manner. Along these lines also falls the idea of animals providing some intangible attribute not otherwise present in therapy involving only a therapist and client – a unique form of support, Charlotte Augusta Lawson 11113478 Page 15 of 207 or benefit to therapy, rapport, or general well-being that would otherwise not be present (Friesen, 2010). Through the animal adjunct, communication and understanding may be reached between the therapist and client – or clients, if a group setting – that may not have been possible through the sole efforts of the therapist (Friesen, 2010; Netting et al., 1987). It is because of this unique ability or effect that animals are often described as a social lubricant throughout the literature, easing the path to clients opening up to the therapist and catalysing constructive communication (Mallon, 1992; Netting et al., 1987). Indeed, one of the prime benefits of the incorporation of animals into therapy seems to be that they can improve motivation and participation in the therapy itself (Bardill & Hutchinson, 1997; Barker & Dawson, 1998; Bernstein et al., 2000; Perelle & Granville, 1993). Holcomb and Meacham (1989) found, in their retrospective study on attendance in in-patient treatment groups, that the animal-assisted therapy group had the greatest rates of participation compared to groups in other therapy conditions, and regardless of diagnosis of the participants. Bernstein et al. (2000) reported evidence that animal-assisted psychotherapy programs involving volunteers bringing in animals for residents to interact with, and talk about, can improve positive affect, increase enthusiasm, activity, and social interactions. Cirulli (2011) states that for the treatment of anxiety and mood disorders, dogs are often utilised as they can have an effect on social interaction and communication. Tedeschi et al. (2005) mention a wide range of benefits that the research has shown can be effected by the inclusion of an animal adjunct into a therapy program, including the improvement of cognitive and perceptual deficits; empathetic development and reduced aggression; greater socialisation, motivation, and self- esteem; improved attention and ability to focus; and an overall reduction in stress levels. How it works. Friedmann and Tsai (2006) state that animal-assisted psychotherapy works by facilitating and catalysing “attention to and interaction with the outside world.” (p. Charlotte Augusta Lawson 11113478 Page 16 of 207 96). It is often termed an experiential therapy, and the process is designed to allow and encourage participants to focus on the experience of the present moment, giving them – even if only temporarily – relief from stress and anxieties they might feel as a result of a formal and potentially unsettling therapy setting, and whatever distress has brought them to therapy (Bardill & Hutchinson, 1997; Frame, 2006). This view of animal-assisted psychotherapy draws on the work of Levinson, and fellow pioneer Searles, who believed that the presence of a companion dog could be beneficial for clients suffering from schizophrenia, as the relationship that formed between them helped anchor the client in reality (Barker & Dawson, 1998; Mallon, 1992). With concepts like these in mind, it is not difficult to see why there has been such a surge of interest in the field of animal-assisted psychotherapy. When an individual enters into a therapeutic relationship, they are being asked to divulge potentially distressing details of a highly personal nature to someone who is, or until recently was, a stranger. Anything that can ease the formation of a therapeutic bond, and strengthen rapport between the client and therapist, can only be a positive thing. Likewise, anything that can mitigate the stressful effects of such a situation is worthy of note and further interest. The animals involved can also vary widely. Companion animals, such as cats and dogs, are commonly used as are birds, and fish and, as such, much of the literature focuses upon them; horses, donkeys and mules are also common, as well as other large farm animals but these have been less of a focus for researchers and are only now starting to see a surge in attention directed towards them and their potential benefits for human wellbeing (Adams et al., 2016; Berget & Braastad, 2011). Berget and Braastad (2011) recommend the exclusive incorporation of animals from domesticated species in order to protect the safety and wellbeing of both clients and animals. The notion of protecting and improving the wellbeing of both the human client and the animal adjunct is a common theme throughout the literature Charlotte Augusta Lawson 11113478 Page 17 of 207 (Dimitrijevic, 2009). Also often alluded to – though it is difficult to tell how well implemented it is in practice – is the claim that animal-assisted psychotherapy should only be used where more traditional methods have failed or may prove less effective (Nimer & Lundahl, 2007). The intent behind this is to protect both vulnerable human clients and vulnerable therapy animals. As animal-assisted psychotherapy is feasibly more expensive, and more difficult to arrange, compared to more traditional therapies, and places a risk on the safety and wellbeing of both animal and human, it should perhaps only be used when the risk and cost is justified. Equine-assisted Psychotherapy Equine-assisted psychotherapy, or animal-assisted psychotherapy, using only animals from the genus equus, is, like its parent field, a treatment designed for the help and healing of people suffering emotional challenges and distress, psychological problems, and mental health disorders (Bachi, Terkel, & Teichman, 2012; Klontz, Bivens, Leinart, & Klontz, 2007; Macauley & Gutierrez, 2004; Schlote, 2009). It is client-centered and, like many therapies, it enables a person to explore their experiences, behaviours, feelings and emotions, and allows them to consider these in a safe and supportive environment. An ongoing therapeutic relationship and established rapport between a client and qualified mental health professional, in addition to well-defined treatment goals developed in concert, is necessary for successful therapeutic work (Bachi et al., 2012; Schlote, 2009; Trotter, Chandler, Goodwin-Bond, & Casey, 2008; Symington, 2012). Unlike most therapies, a third and fourth party are also present – a horse, or sometimes horses, which acts as an adjunct to the therapy, facilitating certain activities, techniques, and progress throughout the therapeutic process, and a specialist horse-handler (Chalmers, & Dell, 2011; Frewin, & Gardiner, 2005; Smith-Osborne, & Selby, Charlotte Augusta Lawson 11113478 Page 18 of 207 2010; Symington, 2012). This might be through the client interacting directly with the horse, or observing the horse, or horses, and their interactions with one another (Bachi et al., 2012; Lentini, & Knox, 2009). The client and therapist will explore these interactions to learn more about the client’s lived world, and often they will be used as a metaphor for more day-to-day personal interactions (Symington, 2012). Often the therapy is experiential and solution- focused, using experience in the present moment as an agent for change, while engaging and empowering clients to find and work towards their own solutions (Chalmers, & Dell, 2011; Frame, 2006; Klontz et al., 2007; Schlote, 2009; Smith-Osborne, & Selby, 2010; Symington, 2012). An important benefit mentioned by Alfonso et al. (2015) is the opportunity equine- assisted psychotherapy offers for the therapist to observe the client’s interactions with another creature, and to observe their unmediated behaviour. Importantly, equine-facilitated psychotherapy is distinct from therapeutic riding, in which the learning of equitation is catered to the therapeutic needs of an individual, and from hippotherapy, which is a physical therapy for the treatment of neurological, muscular, and speech disorders to name a few (Vidrine, Owen-Smith, & Faulkner, 2002). Issues in the literature. Equine-facilitated psychotherapy is an important area for further research as, while much of the current literature on the subject has shown that it has strong potential for effectively treating a variety of different mental health issues, the total amount of research that has been done is relatively small, and many of the studies suffer from methodological flaws (Bachi, 2012). In fact, a recent meta-analysis by Anestis, Anestis, Zawilinski, Hopkins, and Lilienfeld (2014) concluded that the literature on what they referred as equine-related treatments for mental disorders was so fraught with methodological flaws and threats to validity that they recommended these forms of therapy not be offered to the public until a body of methodologically sound research could be presented that justified its Charlotte Augusta Lawson 11113478 Page 19 of 207 use. Bachi (2012) conducted a review for similar purposes and found that much of the research focussed on the physical benefits of animal- and equine-assisted intervention to the exclusion and detriment of investigation into psychological outcomes. This is concerning, as the use of these therapies for psychological reasons is increasing internationally. Many of the studies that do focus upon psychological issues rely on individual researchers’ personal doctrines rather than on a standardised theory (Bachi, 2012). This idiosyncratic approach has led to an eclectic range of theories and postulations as to the mechanisms by which equine- assisted psychotherapy may be successful. This eclecticism which characterised the literature weakens the field, particularly when combined with small participant number case studies, and anecdotal reports, described by potentially biased practitioners, and explained in ways that, as yet, have little basis or support. The distinction between different terms and definitions is something of a related problem in the literature as many, if not most, studies available have poorly defined, or undefined terms and definitions, appearing to be chosen somewhat arbitrarily by researchers and practitioners. The term equine-facilitated psychotherapy is equally likely to be used to refer to a mounted, or riding, therapy, as a ground-based therapy and indeed, much of the literature on equine-facilitated psychotherapy refers to mounted therapies (Bachi et al., 2012). While this is not a significant problem, per say, as one can always read further to discover exactly what the authors are focussing on in their study, it does make it difficult for a reader to parse the body of literature into digestible portions, and needlessly confuses a field fraught with other concerns. In addition, the fact that many researchers seem to consider the two interchangeable is somewhat concerning, given the obvious differences. Therapeutic riding grants unique physical benefits, which equine-facilitated psychotherapy does not. It also focuses less upon the relational and social dynamics and use of metaphor, which equine- facilitated psychotherapy hinges upon. Finally, therapeutic riding can easily be considered Charlotte Augusta Lawson 11113478 Page 20 of 207 more physically dangerous, and thus has different issues and concerns for safety and ethical practice. Equine-assisted learning is also a term that complicates matters as, like equine- assisted psychotherapy, it refers to a largely experiential form of intervention (Adams et al., 2016). Differences are difficult to parse from the literature, but it seems to refer to group-only interventions focused on ground-based group activities, which provide “opportunities for participant self-development and to internalize this awareness within the sessions and generalize it to other life situations” (Adams et al., 2016, p. 3). The primary difference seems to be that while equine-assisted psychotherapy will focus upon particular issues or problems which are causing a person distress and then working towards resolving these, equine- assisted learning is focused more upon improving life skills and insight in general. The issues arise when researchers use the definitions and literary evidence of one form of practice towards the aims of another and vice versa, muddying the waters of their distinction. Another issue is that the majority of published studies focus on the effects of equine- facilitated psychotherapy on children. Its use and effectiveness with adult populations has been largely overlooked. Given that this is a branch of therapy that is growing in popularity and practice, there are issues of generalisability - a problem with the overall lack of diverse investigation. One hopes that as the field continues to grow in popularity, and interest peaks, a greater range of research will grow from the base of what exists and rectify these weak points. More concerning is the fact that a large portion of the research that has been done is purely anecdotal, suffers from staggering conflicts of interest, and lacks any clarity or transparency when it comes to methodological processes – effectively rendering replication and verification impossible. Later this will be discussed in greater detail as individual studies are highlighted and their methods, results, and conclusions are evaluated with these issues in mind. Charlotte Augusta Lawson 11113478 Page 21 of 207 The benefit of horses. Prochaska and Norcross (2010) show that there are a number of common factors across different types of therapy that, if they are present, will contribute significantly to its effectiveness. For a therapy such as equine-assisted psychotherapy to be worthwhile, it needs to be effective above and beyond those common traits or it will not be worth the risk and expense. Horses do seem to be uniquely suited to the work of therapy. One common suggestion often repeated within the literature is that their nature as prey, flight, and most specifically herd, animals has caused them to evolve to be highly tuned to a variety of verbal and nonverbal forms of communication, as they depend upon their herd mates for safety and survival (Adams et al., 2016; Frame, 2006). They are also highly tuned to their environment, and potential changes within it, as their safety and the safety of their herd can depend upon picking up on environmental cues instantly (Adams et al., 2016; Smith-Osborne, & Selby, 2010). Once domesticated, humans can take the place of the herd, and horses will look to people with whom they have developed a relationship of trust for safety and security (Frame, 2006; Lentini & Knox, 2009). These features make horses ideal candidates for use as “living biofeedback mechanisms,” as they are able to mirror and respond to extremely subtle verbal and nonverbal cues from the humans with which they work (Smith-Osborne, & Selby, 2010, p. 300). They are able to potentially pick up on changes in mood and behaviour that an individual may not yet have noticed within themselves (Smith-Osborne, & Selby, 2010). A psychologist or psychotherapist well-trained to work with horses will be able to pick up on and interpret the resulting interactions between a client and the equine adjunct, and work with the client to discuss and discover the reasons behind their behavioural, mood, and emotional changes. Yorke, Adams, and Coady (2008) mention the fact that a strong therapeutic bond, or rapport between the client and therapist, can often be more effective in psychological healing than the specific type of therapy, or therapeutic techniques employed. One of the strongest Charlotte Augusta Lawson 11113478 Page 22 of 207 signs for the usefulness of equine-assisted psychotherapy is that the presence a horse, or horses, can facilitate the formation of this bond, and indeed can make it stronger and more effective than it would have been on its own. This facilitates and improves not only the traditional elements of the therapy, but helps the therapist to better understand the interactions between client and horse. Research with children. Much of the research on equine-assisted psychotherapy has focused on children. While the results of this may not be perfectly generalisable to adults, they can definitely be used to inform current practice and future research, if considered within their limitations. Here current research with children has been critically evaluated. Selection of studies to review was limited to interventions with a therapeutic ground-based focus. In 2011, De Rose, Cannas, and Reinger Cantiello’s conducted a pilot study on a rehabilitative donkey therapy program for children aged 6-12 with “emotional-relational disturbances, communication difficulties, psychic distress and depression symptoms, behavioural disturbances, hyperactivity, mental retardation” (p. 393). They found that it was effective for both highly verbal and verbally impaired children, levelling them out to a middle ground of verbal expression, and allowing them to also develop abilities for physical expression. This meant that overly verbal children were able to calm this form of expression when interacting with the donkey and develop their physical expression and communication abilities. At the same time, verbally impaired children were drawn out of their shell, so to speak, and encouraged towards greater verbosity when interacting with the donkey. The researchers used drawings to allow the children to communicate their “emotional-perceptive response” (p. 393) to the therapy and found a greater attention to realistic details and colours Charlotte Augusta Lawson 11113478 Page 23 of 207 in later evaluations, compared to the brief monochrome sketches drawn in the first instance. These results imply that the children were respectively calmed, and roused, depending upon their own specific needs, due to their interactions with the donkey. This development of their interaction styles encouraged them to engage more fully in the world around them, and allowed them to develop alternate methods of communication and expression. This shows that an equine-facilitated therapy can be versatile in its action, effecting improvements for children with diverse needs. While De Rose, et al.’s (2001) study had some interesting results, it was more of an exploratory investigation and, having only four participants and no control group was limited in that regard. Ewing, MacDonald, Taylor, and Bowers (2007) completed a three year study with children aged 10-13 who were recruited from an alternative education school. Many of the participants were identified as having below average IQ in addition to behavioural, emotional, and developmental problems, and “were considered to be at-risk due to a wide range of behavioural problems” (p. 63). The content of the therapy program they used is difficult to parse from their published work, as they combined both equine-facilitated psychotherapy and equine-facilitated learning, and seem to have incorporated therapeutic riding into the treatment regime for some, but not all, participants. However, it consisted of twice-weekly two hour sessions for a total of nine weeks, the incorporation of equine themes into regular school classes, and participants were taught to care for their chosen horse, its tack, and its stall. Unfortunately, none of the hypotheses proposed by the researchers were supported by the study. They found that the therapy program had no effect on the self-esteem, interpersonal empathy, internal locus of control, or feelings of depression and loneliness of the children who participated. However, the researchers also compiled qualitative case studies of the participants, and did go on to detail anecdotal evidence of success with five example participants. With this in mind, it is possible that, if those five examples are indeed Charlotte Augusta Lawson 11113478 Page 24 of 207 indicative of the success of the program as a whole, the researchers simply chose poor methods of either collecting or analysing data - or both. While the researchers did use a number of different measures, the information they provided about each was sparse (only one of five was shown to be internally consistent and reliable, and one other was indicated as having “adequate internal and temporal consistency” and “encouraging” divergent and convergent validity), so it is difficult to evaluate this from simply reading the article (p. 64). The researchers were thorough in their consideration of what may have gone wrong in their study, but it was concerning to read their overly confident explanation of why they were unable to find any significant results. Such explanations can only be speculative until further future research has been conducted, with those limitations dealt with and accounted for. The article read as one written by researchers already convinced about the efficacy of equine- facilitated psychotherapy and, this being the case, the poor results could only be explained as being due to extraneous errors and complications, not due to the therapy program itself. As they say themselves, “equine-facilitated psychotherapy and learning is still in its infancy” and as such, it is entirely possible that it is not, in fact, an effective or worthwhile method of therapy. This is something that one needs to keep in mind both when reviewing the literature thus far accumulated on the subject, and when conducting research oneself (p. 70). Holmes, Goodwin, Redhead, and Goymour’s (2012) study is a prime example of one of the many studies in this field fraught with flaws. The researchers investigated the effects of an equine-assisted activities program on the anxiety levels and self-esteem of a group of eleven 12-14 year old children. The researchers found a significant decrease in state anxiety, but no significant change in self-esteem over the course of the program. The aims of this study are difficult to fully understand as they purport to desire to further research in the field of equine-facilitated psychotherapy and yet the program they use towards these ends is one of activities, not therapy, and they explicitly do not involve a trained therapist in their research. Charlotte Augusta Lawson 11113478 Page 25 of 207 This is an example of a problem that in many ways seems endemic to the field – poor definition of terms and poor distinction between distinct techniques (therapy and activities) towards psychological improvement. Activities are often used to improve self-esteem, in the sense that they promote teamwork and team building, and individual mastery through successful completion of potentially difficult tasks. Activities however are not explicitly a type of psychotherapy in and of themselves, particularly when used in the absence of a psychologist or therapist. The activities program evaluated in this research involved the children learning about and learning to care for horses and their equipment, and used both living horses and a ‘control’ model horse. The purpose of the model horse control is difficult to discern. In its accepted form a control can be one of two things. The first is a confounding variable kept constant in order in minimise its effects on the variables of interest. The second is a control condition, as in a randomised controlled trial, used for comparative purposes in order to see if the condition of interest is different, (often better or more effective) to the control condition (often a placebo, or more standard version of the variable of interest) (Howell, 2008). It is obviously the latter that the researchers were going for in this study, but as there was no randomisation aspect, and as all students interacted with both the live horse and the model horse in every session, outcome measurements taken at the end of each session would not be able to give any indication if either had a different effect. Approach and avoidance behaviours were measured in an attempt to show that, across the course of the study, participants tended to approach the live horse more frequently and avoid the model horse more frequently. The results for these measurements showed no significant change in approach behaviours for either ‘type’ of horse but did show a significant decrease in avoidance behaviours for the live horse only. The researchers attempted to link this behavioural change to the decrease in trait anxiety but found no significant relationship, Charlotte Augusta Lawson 11113478 Page 26 of 207 which even if it had been found would be impossible to confirm as being due to the live horse alone, given the study’s design. Furthermore, the researchers did not administer any measurement scales after the first session in order to avoid the novelty effect, wherein participants in a novel situation respond differently in the first instance to how they would usually respond in a ‘real-world’ setting (Gravetter & Forzano, 2011). This effect is a threat to the external validity of a study, damaging how well the results can be generalised to other populations and situations, as the results until the novelty effect wears off will be specific to that research setting. In this instance, however, the results from the first session, even if they had been unusual due to a novelty effect, would be perfectly relevant as the introduction of children to a new program is a novel experience and how they react to such in the initial exposure is useful information. Schultz, Remick-Barlow, and Robbins (2007) evaluated the progress made by sixty three children aged 4 –16, referred to an equine-facilitated therapy program for a variety of psychological issues including ADHD, PTSD, mood disorders, adjustment disorder, and disruptive disorder. The children received varying numbers of sessions (1 – 116, with an average of approximately twenty), implying that the therapy is flexible to the needs of individual children. The measurement Schultz et al. (2007) used was the Children’s Global Assessment of Functioning (GAF), which measures the psychological, social, and educational functioning of children, and found that all children improved on their GAF scores, and that there was a significant relationship between greater improvement and a greater number of therapy sessions. They also found that female participants showed statistically significant greater improvement compared to males, and younger children compared to older children. Interestingly, they further found that children with a history of physical abuse or neglect, sexual abuse, or parental substance abuse showed greater improvement compared to children without such histories, the difference between children Charlotte Augusta Lawson 11113478 Page 27 of 207 who had been victims of physical abuse and neglect and those who had not being statistically significant. This study recorded and analysed a large amount of data and relationships between different variables, such as age, gender, ethnicity, and number of sessions, finding some interesting correlations. The GAF does not have very specific outcomes and lets one know only the general level of difficulty an individual is experiencing, and not the details of those difficulties. So while it can show general improvement in overall symptoms, it does not show which symptoms the therapy was effective at improving. A similarly conducted study, with more specific hypotheses and which measured more specific problems or diagnoses with tailored measurement scales may give clearer and more precise information about how the therapy was working, and which aspects of psychological dysfunction it was helping to heal. Unfortunately, the researchers only measured GAF scores at baseline and post-therapy. A further administration at a follow-up point in the future would have provided useful information about whether the therapy was successful in engendering long term change without therapy sessions to maintain it. Trotter et al. (2008) compared the efficacy of equine-facilitated counselling with a more traditional classroom-based counselling program, for intermediate school-aged children who had been flagged by their school counsellors as at-risk of academic or social failure. Progress was measured on the Behavioural Assessment System for Children and the Psychosocial Session Form. When rating themselves, children who participated in the equine- facilitated counselling program showed significant improvement on measures of emotional symptoms, clinical maladjustment, atypical behaviours, sense of inadequacy, and relations with parents. Children who participated in the more traditional non-animal therapy showed significant improvement on measures of emotional symptoms, personal adjustment, social stress, and self-esteem. When rated by their parents, equine-facilitated counselling took the Charlotte Augusta Lawson 11113478 Page 28 of 207 lead, with children showing improvements in behavioural symptoms, externalising problems, internalising problems, adaptive skills, hyperactivity, aggression, conduct problems, anxiety, depression, somatization, adaptability, and social skills. This compared favourably to parents’ ratings of their children’s progress in the more traditional therapy, who saw only improvements in depression. While these results appear positive for the validation of equine-facilitated psychotherapy, Trotter et al.’s (2008) study had some limitations. The control had a sample size that was just over a quarter that of the equine-facilitated counselling and session times were halved. With these limitations, it is difficult to say if the equine-facilitated counselling was truly more effective than the control, or if the control was simply handicapped by fewer participants and shorter intervention times. A further limitation is one that often crops up when comparing equine-assisted therapies to more traditional controls. The two therapies being compared were radically different in a fundamental way - in addition to involving horses, the equine-facilitated counselling was also an outdoor therapy, whereas the control therapy was classroom-based. This contextual difference in and of itself is likely to have had an impact on how the children assigned to the different therapies improved in a variety of areas. While one can still make comparisons between therapies, it would require further research to be able to definitively say it was the equine-aspect of the therapy that caused the differences in results – perhaps by comparing equine-facilitated psychotherapy to a non- animal outdoor-based therapy. Chardonnens (2009) described a case study of a single eight-year-old boy. ‘M’ suffered from severe psychological and behavioural problems and was referred to a therapeutic farm for a one year stay, following a year’s hospitalisation in the closed ward of a psychiatric institution. A team of mental health professionals and volunteers worked with ‘M’ using Rogerian person-centred therapy, and specifically person-centred animal therapy. Over Charlotte Augusta Lawson 11113478 Page 29 of 207 the course of a year they were able to help him move beyond uncontrollable crises, violent and aggressive behaviour, abandonment anxiety, multiple phobias, refusal to participate in any form of schooling, and refusal or inability to connect with any of the professionals attempting to help him. At the end of his stay, he had made progress in his learning and was able to read and write (about animals), had formed a therapeutic relationship and rapport with the therapist who worked at the farm, had decreased the frequency of his crises to one a month (or less often), no longer required medication, and had learned and accepted the rules for acceptable social behaviour. The researcher attributes the success of this therapy to its person-centred approach and to the social and relational abilities the child was able to learn from his interactions with the animals on the farm. The animals were a great motivator, as ‘M’ had previously been identified as an animal-lover. Through his interactions with them ‘M’ was able to learn to respect both himself and others, about personal space and intimacy, and that failure to succeed would not lead to rejection (this from the non-judgemental nature of animals, and the unconditional positive regard of Rogerian therapy). Once he was able to establish positive, secure relationships with the animals on the farm, he was able to extrapolate this to the professionals working at the farm. Ultimately ‘M’ was able to accept a therapeutic relationship and schooling, and agreed to undergo psychological testing which successfully disproved a previous diagnosis of intellectual disability. While this seems to have been a highly successful instance of animal therapy, there are limitations. This was a case study of a single participant, and ‘M’’s was a singular and extreme situation. However one of the positive aspects of person-centred therapy is that it is highly malleable to the situation of an individual, as it focuses upon the client and their specific needs. While this study is not necessarily generalisable, what it does do is provide a plethora of examples of the ways in which human-animal interaction can have a positive effect on human behaviour and relational styles. The researcher successfully draws from Charlotte Augusta Lawson 11113478 Page 30 of 207 previous research and theory on the human-animal bond and applies it to the specific situations that were encountered throughout ‘M’’s therapy. The information contained within this research might be used by future researchers to inform the design of their own studies, or to help with the development of therapy programs for at-risk children. Dell et al. (2011) presented an exploratory qualitative study on the usefulness of equine-assisted interventions, specifically equine-assisted learning, for treating First Nations and Inuit children who were struggling with substance (primarily solvent) abuse problems. The purpose of the study was to find out whether this was a viable treatment option for the state to invest in, but the focus was on culturally specific, non-Western aspects of the healing process, as this program was being developed specifically for youths of Canada’s indigenous tribes. They worked with fifteen participants, roughly halved by gender, and aged 12 – 17 years. The male contingent was described by the Nimkee NupiGawagan Healing Centre, where the research took place, as ‘normal’ for their cohort, whereas the female contingent was described as ‘difficult,’ with roughly half of the female participants being briefly incarcerated during the course of the study. The researchers collected data in the form of interviews with participants, as well as the three treatment staff, and journal entries that the youths recorded on a weekly basis during their residency at the treatment centre. Three key themes emerged from the researchers’ engagement with the data: spiritual exchange, complimentary communication, and authentic occurrence. Spiritual exchange referred to an experiential connection with the horse, where participants could exist ‘in the moment’ with the horses, feel welcomed and accepted, trusted and trusting, and in turn could feel similar things in their relationships with the program facilitators. Complementary communication referred to communication skills beyond the verbal, that interacting with the horses allowed the youths to develop. This involved body language, intuition, and a greater awareness of emotions – both the genuine nature of the horse’s emotions and behaviour, and Charlotte Augusta Lawson 11113478 Page 31 of 207 the way that they as humans are able to disguise their emotions and act in a non-congruent way. Complementary communication also extended to the participants’ learnings about mastery over various tasks, and extrapolating their insights to their interactions with facilitators and each other. Authentic occurrence involved the experience of genuine and natural aspects of both everyday life and life specific to the farm-setting. Participants were able to experience healthy physical touch by hugging and petting the horses, something many of them had had negative experiences of with sexual and physical abuse. They were able to learn about caretaking and nurturing, cleaning and hygiene, reproduction and sexual intercourse (as some of the horses were pregnant, or had foals) – all in a safe and healthy environment, where they felt secure and comfortable enough to ask questions and be inquisitive. The facilitators and researchers, coming from an “Aboriginal place of knowing” were able to interpret these themes and how they related to Aboriginal culture, and the ways this had been disrupted and damaged by the historical and ongoing effects of colonisation (p. 330). One of the important findings of this research was that the therapy and farm-setting provided an alternate experiential space, where participants could reclaim aspects of their culture, and cultural way of being. This reclamation came through connecting with nature and each other in a physical immediate way and a more spiritual and holistic way. As the authors addressed, the study was limited by its highly specific topic of enquiry, but despite this it may be useful in informing similar situations in New Zealand, as the history and present circumstances of the First Nations and Inuit peoples mirrors (to an extent) that of the Māori in New Zealand. Research with adults. While much of the research on equine-assisted psychotherapy has focused on children, there have been a number of useful studies with adult participants. Klontz et al.’s (2007) study on experiential equine-assisted psychotherapy has shown some Charlotte Augusta Lawson 11113478 Page 32 of 207 positive results. Participants were 23-70 year olds who attended group equine-facilitated experiential therapy. While the researchers do not detail the reasons for which participants sought therapy, they do show that there were significant short and long term decreases in psychological distress, and increases in psychological well-being. Participants reported feeling more oriented to and better able to live in the present moment, as well as less concerned with fears about the future. They also reported decreases in feelings of regret, guilt, and resentment, and greater independence and self-supportiveness. The researchers used the Brief Symptom Inventory, and specifically its Global Severity Index. They found that at baseline, 60% of their participants scored in the clinical range. After the conclusion of therapy, this had improved to 20% (a significant improvement), and after a six month period, this dropped by only 7% (a non-significant decline). They also used the Personal Orientation Inventory, a measure of self-actualisation, or the motivation to meet one’s full potential. They found significant improvements from baseline to post-therapy, and slight, non-significant, declines at a six month follow-up point. As noted by the researchers themselves, the study was not a randomised controlled trial, and so there is some difficulty when interpreting these results as to whether they are due specifically to the therapy itself, or perhaps to some extraneous conditions, or confounding variables in the self-selected sample. They also note that equine-assisted therapy as a whole could benefit from a dismantling study, in order to assess to what degree the horses themselves affect treatment and outcomes, and in what areas. This is a very good point because, as mentioned earlier, when one is supporting the establishment of a new, but potentially more dangerous or risky, treatment there should be an onus to show that it is better, or different, than current established treatments, and in what way. In an unpublished doctoral dissertation, Russell-Martin (2006) compared equine- facilitated to solution-focused couple’s therapy. Participants were heterosexual couples aged Charlotte Augusta Lawson 11113478 Page 33 of 207 21 – 45. She found that after six weeks of therapy there was a significant difference between the efficacy of the two therapies, with the couples participating in equine-facilitated couple’s therapy scoring more highly on measures of consensus, satisfaction, cohesion, and affectional expression. It is also worth noting that she found no significant gender differences among participants, implying that the therapy program was equally effective for men and women. As the researcher notes herself, there are a number of limitations with this study, the first and possibly more important one being that the therapist involved in the study was also the one doing the research. This presents a significant conflict of interest, as there is no way of knowing whether her (conscious or unconscious) desire to see one therapy outperform the other may have affected the results of the study. In addition, as the researcher also notes, there was no control group. Two control groups present themselves upon first consideration – a waitlist group, comparison to which it would be possible to determine how the couples’ relationships may have improved or degraded over time without therapeutic intervention, and also an outdoor therapy control group to see if the change in setting from office-bound traditional therapy to an outdoor, novel environment may have had an effect on its own, thus mitigating the effect of the equine-aspect (Frame, 2006). Christian (2005) presented a case study of how equine-assisted psychotherapy was used in the context of a residential Christian treatment centre to help a young woman in her twenties in overcoming anorexia nervosa. A variety of mounted and unmounted activities were described, in which the horses were used as props or tools in exercises that functioned as larger-than-life metaphors. These were designed to help ‘Lori’ gain understanding and insight into situations and relationships in her life, and how they may be helping or hindering her progress in overcoming her difficulties. Lori participated in a variety of other therapies each week, but the equine-assisted psychotherapy was credited with giving her motivation to engage in the therapy process, helping her form and maintain healthy boundaries and Charlotte Augusta Lawson 11113478 Page 34 of 207 relationships, and helping her develop a greater sense of self-esteem and mastery. These results were attributed, beyond interaction with the horses, to successfully completing tasks that involved lateral thinking, and complex problem solving. There is a possible conflict in that the author is herself an equine-assisted therapist, and worked at the treatment centre during the time that Lori was being treated. While this is not necessarily a problem, one should keep this in mind when reading the article, and most especially when reading the conclusions drawn regarding the success of the equine-assisted therapy program. Because Lori was also participating in a variety of other types of therapy multiple times a week, it is possible that her progress was due to any of these other therapies, or even simply to the therapeutic milieu of the centre (though the latter is unlikely, given the author’s report of Lori’s criticism and negativity regarding just that). Alfonso et al. (2015) conducted a randomized controlled trial with twelve participants – young women between the ages of eighteen and twenty nine – in order to investigate the effectiveness of a cognitive behavioural equine-assisted psychotherapy in ameliorating social anxiety. Their participants were initially self-selected. Further participants were selected via snowball sampling, and all were then screened for eligibility via a measure on which they needed to identify a minimum of four symptoms of social anxiety with which they suffered. Participants were randomly allocated to the experimental group, which received the therapy, or the control group, which received no therapy. All participants completed the Liebowitz Social Anxiety Scale at three different points over the course of the study – first to establish a baseline, prior to treatment group randomisation, then approximately six weeks into the study (called immediate-post), and finally six weeks after the second administration (called follow- up). One problem with this design immediately becomes clear: it is difficult to interpret results where the control group is a non-treatment group, due to the common effect that Charlotte Augusta Lawson 11113478 Page 35 of 207 merely receiving attention can cause an improvement in psychological symptoms. A better design would have been to have the experimental group undergoing the new equine-assisted cognitive behavioural therapy, and the control group undergoing regular cognitive behavioural therapy – a therapy which has been shown by a large body of literature to be effective at treating anxiety disorders (Prochaska & Norcross, 2010). What the study, as designed, shows is that the equine-assisted cognitive behavioural therapy the researchers have developed may be better than no therapy at all, but it is impossible to say whether improvements would be due to the common factors between this therapy and traditional cognitive behavioural therapy, or the additional presence of horses and the unique activities possible because of them. What they would show with a traditional cognitive behavioural therapy control group is how it performs compared to an established, effective therapy, and that any improvements were likely due to the added benefit of the horses. The results of the study show, as might be expected, that participants in the experimental group showed a significantly greater decrease in social anxiety symptoms between baseline and immediate-post, and immediate-post and follow-up compared to those in the control, and that these differences were not due to any apparent differences between the two participant groups. The authors postulate that the success of the therapy program was due in large part to the way in which it encouraged participants to divert their attention from themselves onto their equine partner, allowing them to successfully complete tasks, positively reinforcing this and the coping skills they had been asked to employ. Something that Alfonso et al. (2015) emphasised in this study, which has important implications for the current research, was the acceptability and feasibility of the therapy for the participant. Feasibility was judged by the fact that 80% of participants attended every session, and the remaining 20% attended five out of six sessions, though transportation was described as the greatest barrier to attendance. Acceptability was judged by measures of usability, comprehension, and Charlotte Augusta Lawson 11113478 Page 36 of 207 competence of facilitators, which all participants scored highly. An important facet of therapy, which many studies leave unmentioned, is whether or not the participants themselves find the therapy useful, worthwhile, and effective. Despite its flaws in design, this study does well to mention this aspect of the effectiveness of a therapy. Earles, Vernon, and Yetz (2015) conducted a study on the effects of the Equine Partnering Naturally program, an equine-assisted psychotherapy program developed and practiced by co-author Jeanne Yetz, on adults suffering from anxiety and post-traumatic stress disorder. They recruited sixteen participants, twelve female and four male between the ages of thirty three and sixty two. Participants attended therapy in groups of five or six, for a weekly two hour session, for six weeks. Group therapy sessions involved a mixture of learning about horses and horse-involved exercises, and more typical therapeutic topics such as setting boundaries, listening skills, and dealing with stressful situations. Baseline measures were completed a few weeks prior to the start of therapy, and a second set immediately after the final therapy session. The test battery consisted of thirteen different measures, for psychological and physical health, mindfulness, coping strategies, and social support. Each measure, bar one, was recorded alongside its Cronbach’s α value, denoting its internal validity (or how well the items on a test relate to each other item) and these ranged from .68 to .97. While this is a valuable piece of information for determining the acceptability of a measure, further information is generally required to evaluate its suitability for what it is attempting to measure. Earles et al. (2015) found a significant decrease in symptoms of PTSD, anxiety, and depression, in addition to decreased emotional distress, alcohol use, and mindfulness. No change was found for physical health, proactive coping strategies, feelings of self-efficacy, life satisfaction, optimism, or social support. They explained these results as positive, showing that equine-assisted psychotherapy can be effective at treating PTSD in spite of Charlotte Augusta Lawson 11113478 Page 37 of 207 other important factors that may impact mental health remaining unchanged. There was a significant conflict of interest in this study, in that one of the three researchers is also the developer and sole practitioner of the therapy program under inspection. There is opportunity for, and no way to rule out, either deliberate or unconscious bias on the part of this researcher, given what is at stake for them should the results prove negative. But even taking that into consideration, the results do show a strongly significant improvement in symptoms of PTSD. This study could have been improved with the addition of a waitlist control group, especially given that the participants continued whatever treatment and/or medication they were already receiving, making it impossible to say whether improvements were due specifically to the equine-assisted psychotherapy administered in the study. The Current Study As can be seen from the current literature as it has been reviewed here, the field of equine- assisted psychotherapy has a number of areas in which there is room for improvement, and greater research focus. This study has been undertaken by a researcher who is not a practitioner, who has not previously been involved with this kind of therapy, and who therefore has no stake in the results. This is important, as it removes an opportunity for potential bias. Much of the research in the field of equine-assisted psychotherapy has been performed by, or involving, the same professionals who practice it, a situation which is less than ideal, as when it comes time to evaluate the results of these studies, one can never be entirely secure in their legitimacy. This study has also endeavoured to be thorough and transparent when it comes to methodology and procedure. That much of the research published in this field lacks these characteristics has contributed significantly to how difficult it is to critically evaluate these studies and determine to what extent one can accept their Charlotte Augusta Lawson 11113478 Page 38 of 207 results as reflective of reality. When reviewing the literature, it has often been difficult to discern the exact methods and procedures different researchers used. While there is not necessarily anything biased or nefarious in this, this lack of clarity adds uncertainty to a field already fraught with it. This study involves participants describing their experiences of equine-assisted psychotherapy, and the conclusions they have drawn about it. It is hoped that this will add important and meaningful information to the current literature, as most of the eclectic theory behind how and why it works, and which aspects of it have the biggest effects in which areas have been developed by practitioners through anecdotal evidence and intuitive opinion. While these participants did discuss some of the established theory with their therapist, in large part their experiences were spontaneous and the conclusions they drew were based on their in-the-moment experience of the therapy. A client’s experience and opinion of whether this therapy works, how and why it works, and whether the horses themselves added anything unique or significant is a valuable piece of information that will help to develop a more standardised and evidence-based body of theory, from which future researchers will be able to draw. This study has also been undertaken from a qualitative approach, and specifically from an interpretative phenomenological standpoint. Qualitative research is under- represented in the literature, and for a therapy that involves a holistic and multi-modal experience, it is important that a research method that is able to capture this nuance is used to investigate such an area. Charlotte Augusta Lawson 11113478 Page 39 of 207 Methodology Introduction “. . . [M]an is in the world, and only in the world does he know himself.” (Merleau-Ponty, 1962, p. xi). The quote by Merleau-Ponty (1962) above refers to one of the key tenets of qualitative methodologies, and especially Interpretative Phenomenological Analysis (IPA), the lived- world context. IPA is a qualitative research methodology that was developed in the mid- 1990s as a distinctly psychological research paradigm (Eatough & Smith, 2008). As psychology is the study of mind and behaviour, and qualitative research is used to study the nature of human experience, IPA is used for a close examination and interpretation of the lived-world experiences of human individuals and how they make sense of those experiences (Eatough & Smith, 2008). It is, in many ways, an attempt to bring psychological research back to the natural human, in the context of their physical and social environment, as opposed to the usually reductionist and isolationist principles of quantitative research methodologies. Research Aims This research project aims to explore the experiences of individuals who have completed a course of equine-assisted psychotherapy in New Zealand, and how they were affected by these experiences. A qualitative research methodology, specifically IPA, was selected as the methodology of choice due to the emphasis on individual human experience and how participants make sense of their experiences. In much of the research on the greater topic of equine-assisted psychotherapy, to date, there has been little consensus on the efficacy of Charlotte Augusta Lawson 11113478 Page 40 of 207 various programs, and while there seems to be greater consensus for the mechanisms of success, there is little evidence to back these theories up. By undertaking a qualitative investigation, with a bottom-up, inductive analysis method, it is hoped to gain insight into how participants have actually experienced this form of therapy, setting aside the anecdotal claims and conjecture which is so heavily peppered throughout the current literature. By identifying what parts of the therapy were most important and what the various aspects of therapy actually meant to participants, we can further our understanding of this form of therapy which shows great potential, and find ways to strengthen its usefulness for those in need. According to Ashworth (2003), the founder of phenomenology, Husserl, advocated his philosophy of a ‘return to the things themselves’ as a way to combat this problem exactly – imperfectly and partially developed concepts – by seeking greater information about the phenomena in question, as it exists in its contextualised, natural state. Qualitative Research When formal psychological research began, the research method most highly regarded was the scientific method, experimental and quantitative, the gold standard of which being the randomised, controlled trial (Ashworth, 2003; Biggerstaff & Thompson, 2008; Draper, 2004; Golafshani, 2003). In many ways, and in many other fields, this is still the case, but a penchant for qualitative methodologies is growing more prominent with each passing year, as researchers begin to recognise the limitations of the quantitative approach, and the depth and richness of data that can be gained by using qualitative methods (Ashworth, 2003; Willig, 2008). Quantitative research predominantly takes a positivistic approach, holding to the assumption that the world is constructed of observable, measurable, and objectively Charlotte Augusta Lawson 11113478 Page 41 of 207 comprehensible facts and phenomena (Aguinaldo, 2004; Ashworth, 2003; Draper, 2004; Golafshani, 2003). Its object is the quantification, measurement, and analysis of causal or directional relationships between variables (Draper, 2004; Golafshani, 2003). These variables are arrived at through the reduction of phenomena into measureable and controllable fragments, representations of a greater whole, just as participant samples are seen to represent greater populations (Ashworth, 2003; Golafshani, 2003). It seeks to answer specific questions of how much, how many, or to what degree, by the testing of pre-postulated hypotheses and expressing results in the form of statistical statements, and likelihoods of generalisability (Ashworth, 2003; Draper, 2004). Generally speaking, qualitative research is simply research that does not involve results arrived at through statistical methods (Golafshani, 2003). In the field of psychology, qualitative research methodologies (for they are many and varied) are often used to attempt to access the inner world of individuals’ experiences (Ashworth, 2003; Draper, 2004; Willig, 2008). Qualitative researchers attempt to capture a glimpse of the phenomenon of interest as it occurs within its natural context, usually with as little input as possible from the researcher (Draper, 2004; Golafshani, 2003). While quantitative research is certainly accepted as a valid method of research for certain phenomena, qualitative researchers consider it inappropriate for the study of the human life-world, consciousness, or the nature and content of human experiences (Ashworth, 2003; Biggerstaff & Thompson, 2008). Qualitative research strives towards the explication of a first-person perspective – always accepting and acknowledging that the inevitable processes of translation and interpretation will render this imperfect at best. It is a perceptual approach, assuming that knowledge is gained through consciousness and thus is necessarily subjective (Ashworth, 2003). It is idiographic and concerned with an in-depth investigation of individual accounts of the phenomena of interest (Ashworth, 2003; Biggerstaff & Thompson, 2008). In many of Charlotte Augusta Lawson 11113478 Page 42 of 207 the qualitative methodologies, to greater or lesser degree, it is considered that consciousness, behaviours, and ways of assigning meaning to experiences are socially constructed – a result of the social and historical culture of a person’s upbringing – and that language is a primary tool with which reality and meaning is conceived (Ashworth, 2003). Participant selection in qualitative studies is purposive, drawing from a specific group which has had a specific experience, and thus will have something to divulge about the phenomena of interest that will deepen our understanding of that particular aspect of human experience (Draper, 2004). The data gathered is rich and dense, in the form of semi- structured interviews, diaries, focus groups, observation, and in-depth case studies, and data collection is flexible and participant-driven, relying on the insider-knowledge of the participant to show what is most important about the topic under consideration, and minimising the influence of the researcher in the direction data collection may take (Draper, 2004; Thorne, 2000). Interpretative Phenomenological Analysis Interpretative Phenomenological Analysis (IPA) is an experiential research methodology that seeks to explore, in detail, the lived-world experiences of individuals, and how individuals make sense of their world. Its focus is experiences and the meanings individuals ascribe to them (Biggerstaff & Thompson, 2008; Chapman & Smith, 2002; Finlay, 2008; Smith & Osborn, 2003). IPA has roots in phenomenology, or the philosophy of experience, due to its interest in individuals’ perceptions of phenomena, and in hermeneutics, or the philosophy of interpretation, due to its focus on translating the meanings individuals assign to personal experiences from a personal account to a concise set of themes (Biggerstaff & Thompson, 2008; Larkin, Watts, & Clifton, 2006; Smith, 2004). Charlotte Augusta Lawson 11113478 Page 43 of 207 Phenomenology. Phenomenology is a philosophical movement that arose in the early 20th Century and was interested in experiential ways of knowing (Eatough & Smith, 2008). It is concerned with human experience, and its proponents postulated that our perception of the world is as a result of practical experiences with others, objects, and phenomena, and that these experiences are innately meaningful (Eatough & Smith, 2008). Its originator, Edmund Husserl (1859-1938), established the original concepts of phenomenology as a way to develop a standardised theoretical basis for the fundamental concepts underlying not only psychology, but all disciplines – sciences and humanities alike. He believed that for most concepts and constructs in various fields of knowledge, definitions were based on assumption and ‘common sense,’ rather than systematic investigation. Husserl wanted to provide a firm foundation of technical terms to facilitate clear, concise, and accurate discussion and further research (Eatough & Smith, 2008). In order to facilitate this, he advocated a ‘return to the things themselves’ as they are experienced by people without confusing or conflicting preconceptions and assumptions. As this refers to IPA, we seek ‘the things themselves’ by focussing upon the experiences of the individual as they are perceived by that individual, initially setting aside (or bracketing) what we think we already know about the phenomena and instead engaging with the individual’s personal account of their experience of it (Eatough & Smith, 2008; Finlay, 2008). Participants are considered to be experts of their own experiences, and as we are interested in the insider-view, we should attempt to record and present this in as pure a state as possible, without tainting it with what we think we know about the phenomenon (Larkin et al., 2006; Reid, Flowers, & Larkin, 2005). In equine-assisted psychotherapy in particular, where the current state of the literature is rather chaotic and lacking in systematic enquiry, rife with anecdotal and arbitrary understandings of mechanisms of action and which components are required for successful therapy, this is of particular import. It is important Charlotte Augusta Lawson 11113478 Page 44 of 207 that the field of equine-assisted psychotherapy be given an opportunity to bracket the ingrained persistence of the largely unsubstantiated claims that govern its practise and allow for the development of new, evidence-based ideas from the fresh well of those who have sought its aid (Eatough & Smith, 2008). Important to Husserl’s philosophy of phenomenology is intentionality, or the idea that consciousness must always conscious of something (Finlay, 2008). In order to perceive, there must be an object of perception, something must be loved, hated, wanted, scorned, etcetera, and this ascription of meaning to the perception of objects translates them to a phenomena of experience (Finlay, 2006). One cannot observe without inadvertently performing some act of judgement, thus the internal self and the external world are linked by intentionality (Willig, 2008). It does not happen that one experiences this, and it means that; the meaning of an experience, and the experience itself are inextricably linked, as one interprets meanings as objects are perceived; “perception is always intentional” (p. 51, Willig, 2008; Finlay, 2008; Larkin et al., 2006). It is because of the intentional nature of consciousness that the study of experience becomes also the study of meaning. Meaning is essential in the study of psychological topics, as it is the way by which external phenomena are translated into internal, psychological ones. It is of signal import in the study of therapeutic processes, as these typically involve another – the therapist – external to the individual seeking support, guiding and helping an individual with distressing internal thoughts, feelings, or emotions. In the case of equine-assisted psychotherapy in particular, the therapy itself focuses heavily on metaphor, using examples contained within the therapeutic setting to illustrate issues that extend beyond it. The horse as adjunct may be used to ‘mean’ one thing or another, and so a research method that recognises the significance of meaning-making, and sense-making will help to ascertain whether and how these approaches might work, and how various aspects of the therapy program are mentally processed by participants. Charlotte Augusta Lawson 11113478 Page 45 of 207 Martin Heidegger (1889-1976) was a student of Husserl and added to the philosophy the concept of Dasein (being-in-the-world) or the idea that humans are inextricably situated in a greater context, and it is only through this context that we can know of the world (Eatough & Smith, 2008; Finlay, 2008). Dasein rejects the division of self and world, mind and body, instead embracing the idea that the body is an important, and inescapable, aspect of mental experience, and the self is embedded within the world (Finlay, 2006; Larkin et al., 2006). One perceives and experiences through one’s body, and as one’s body is unique, one’s experiences and how one makes sense of them are also unique (Eatough & Smith, 2008). The body is important to both Husserl’s and Heidegger’s conceptualisations of phenomenology as it is only through one’s body and one’s embodied consciousness that one can experience the world, or understand reality (Finlay, 2006; Larkin et al., 2006). The lived-world is what we call the interwoven web of context in which an individual exists, combining social, historical, and physical influences and experiences (Eatough & Smith, 2008; Finlay, 2008). Because one’s lived-world is unique, we can only learn about another’s experiences through them, specifically through the first-person accounts they may offer us (Larkin et al., 2006). It should be obvious how this aspect of IPA is important to the study of psychotherapies. While any two individuals may seek therapy for the same basic concern, the intricacies of each individual’s situation will be entirely unique due to the life they have lived, how they have lived it, who they have lived it with, and also the body they have lived it in. A research methodology that takes the idiographic nature of mental distress, the causes thereof, and how it might be mitigated, into account can only be appropriate in the study of psychotherapy. While it is absolutely true that mental health issues are a concern for people from all walks of life, and are in that sense somewhat nomothetic, is it also true that each person experiences these issues differently according to their lived-world (Eatough & Smith, 2008). Charlotte Augusta Lawson 11113478 Page 46 of 207 With equine-assisted psychotherapy, the lived body has special significance, as many of the therapeutic techniques used involve physical interaction between the client and the horse, and the ways a participant may react to this, or gain benefit from it will depend upon the enmeshed context of their life and experiences leading up to that point. A savvy individual with previous equestrian experience will likely not experience the therapy in the same way as one naïve to such experiences; similarly a physically more robust or confident client will have a different experience compared to one who is smaller, more vulnerable, or less confident. These differences in people’s lived bodies, the subsequent differences in experiences and – most importantly – the meanings ascribed to those experiences, mean that each participant will tell a unique account of their therapy, and the researcher with their own lived-world context will interpret those diverse accounts in different ways (Engelsrud, 2005). It is here that phenomenology intersects with hermeneutics. Hermeneutics. Hermeneutics is the philosophy of interpretation and was originally developed as a method for interpreting and deriving intended meanings from biblical texts. It is now extended to the interpretation of texts in general (Eatough & Smith, 2008). In IPA, data is collected as, or transcribed post-collection into, a written account, and thus hermeneutics is an important philosophical approach for researchers attempting to analyse these pieces of data. According to Moustakas (1994), hermeneutics involves reading a text so that the intended meaning behind it becomes clear and understood. IPA, however, involves a double hermeneutic. In divulging their account, the participant is trying to make sense of their lived-world, and in analysing their account, the researcher is trying to make sense of the participant making sense of their lived-world (Larkin et al., 2006; Smith, 2004; Smith & Osborn, 2003). Paul Ricoeur (1970, as cited in Ashworth, 2003) considered hermeneutics to break down into two distinct forms – meaning-recollection and suspicion. In IPA we are much Charlotte Augusta Lawson 11113478 Page 47 of 207 more concerned with the hermeneutics of meaning-recollection, as this focuses upon accurate disclosure and attempts to describe a participant’s account as faithfully to their intended meaning as possible (Larkin et al., 2006; Smith, 2004). The hermeneutics of suspicion do have a place within IPA. This refers to a method of analysis in which one attempts to look within the account offered by a participant and challenge its accuracy, and the intent behind what has been divulged (Smith, 2004). All involved in research can be thought of having some often undisclosed motive – a good researcher is seeking to discover new, or previously unknown information, but a participant may be trying to articulate a particular meaning or portray their experiences in a particular light, or indeed may be unwilling to entertain a certain view of themselves or what they have experienced. These motives will become apparent to the researcher when interpreted critically (Smith, 2004). It is important to be completely faithful to the hermeneutics of meaning-recollection in the first instance, and only once this level of analysis is complete should one aspire to reconsider this interpretation through the hermeneutics of suspicion (Smith, 2004). If one does go down that path, transparency, full-disclosure and intensive reflexivity are necessary to make plain any biases, conscious or otherwise, which will influence the results of that enquiry (Reid et al., 2005). Because the researcher is attempting to develop the formal knowledge on a particular subject, a further level of interpretation where the sense-making activities of the participant are evaluated in light of existing knowledge and theoretical constructs is required (Larkin et al., 2006; Smith, 2004). This interpretative activity deconstructs the action of bracketing, linking what has been faithfully evaluated from the participant’s account with current evidence in the field. Language is obviously an important aspect of IPA, and indeed all forms of research, as data is collected through spoken language, transcribed to written language, and analysed and the subsequent results disclosed via the same. Unlike methodologies like discourse Charlotte Augusta Lawson 11113478 Page 48 of 207 analysis, the composite parts of language are less important to IPA, compared to the way in which it may be translated or interpreted; the way an experience is spoken of, or described, is at least as important as the experience itself (Vis, 2008; Willig, 2007). Symbolic interactionism has a place here, with its belief that consciousness and language are continually constructed through social interaction (Eatough & Smith, 2008). This is an important consideration for research into psychotherapies, as one is enquiring into a somewhat unusual type of interaction, between a therapist and client (and, in the case of equine-assisted psychotherapy, rendered even more unique by the addition of an equine ‘personality’ into the therapeutic relationship), and as the method of enquiry involves a further unusual social interaction between researcher and research participant. These aspects of this type of research will certainly have an effect both on how the participant divulges their experiences, and how the researcher both responds during data collection, transcribes the account, and interprets it during analysis (Eatough & Smith, 2008; Engelsrud, 2005). Procedure Sampling. This study used purposive sampling. As a research method, interpretative phenomenology is used to explore the experiences of individuals