Response to the 5/20/18 John Oliver Show

This morning my inbox was filled with concerned emails from people who watched last night’s John Oliver show. I don’t watch television and thus have no personal connection to this show. However, I believe John Oliver, in all his crass humor, pointed out a very uncomfortable truth.

The general pubic, and even some providers offering interactions with horses, don’t understand the critical distinction between “petting a horse” and the clinical practice of equine-assisted therapy. Until the vital differences between therapy and non-therapy services are clearly articulated, understood, respected, and adhered to BY THE PROVIDERS THEMSELVES, we cannot possibly expect the public to take this intervention seriously.

Clinical intentionality and the professional competencies required to design safe, ethical, and effective equine-assisted interactions to meet varying treatment goals for different populations are essential components to differentiating between “just petting a horse” and a carefully thought out and well executed treatment intervention (see the ACA’s Animal-Assisted Therapy in Counseling Competencies). Simply exposing patients to horses without these components in place is not sufficient to warrant the use of the term “therapy”.

“Therapy” is a protected term used to describe the treatment of physical or mental illnesses, disorders, or diseases that are regulated or sanctioned by healthcare laws and provided only by credentialed (licensed or registered) healthcare professionals. The licensed professionals who provide therapy go through many years of specialized education and supervised clinical experience and must pass board exams before they are allowed to practice independently. They must also receive additional training and supervision prior to including any new speciality area of practice or novel treatment approach (like equine-assisted therapy). This course of rigorous study, supervision, and regulation helps guarantee a certain level of competence that is intended to keep patients safe.

Unfortunately in the equine-assisted therapy industry (especially when talking about equine-assisted mental health), many licensed healthcare providers offer services that include horses without an adequate depth and breadth of education and training. There are no regulations related to what type, or how much, specialty training and education someone needs to have before providing equine-assisted therapy. Therefore, people who offer these services may have vastly differing levels of knowledge and experience. In some cases, the services may look a lot like “just petting a horse”, because in truth, that’s about all the provider knows how to offer.

In other cases, non-licensed individuals offer services that are not therapy, but are considered (and called) “therapeutic” and look pretty much identical to therapy services from a layperson’s vantage point. Some programs even suggest that non-therapy equine-assisted activities can be used as “treatment” for complex medical or mental health conditions or diagnoses, and list all the psychological and physiological benefits that may be gained from engaging with horses. The problems with this are many and multi-faceted, below are only a few of the possible examples.

  1. Based upon the results of research, when equine interactions are provided by licensed healthcare professionals and adhere to the practice requirements of these various professions, they are MORE EFFECTIVE in the treatment of most medical or mental health conditions than a non-therapy service provided by a non-licensed individual. Although this might seem like common sense, for some reason in this industry therapy and non-therapy services are commonly used interchangeably and many people believe that the benefits should be (or are) the same.
  2. Patients seeking medical or mental health treatment may receive unsafe or ineffective alternatives to therapy rather than being directed to the correct service.
  3. Using therapeutic techniques that resemble those used in therapy without an informed consent and an agreement to “treatment” is unsafe and unethical. Clients seeking life or professional development coaching or participating in educational services may be pushed into areas they are not prepared for or interested in delving into. This is unfair to the clients, and devalues the important and VERY DIFFERENT services a life/professional development coach or educator has to offer.
  4. Both therapy and non-therapy services offer valuable and VERY DIFFERENT (can I just say that again?) benefits, but because they are not clearly separated, in many cases providers compete for the same clients (or patients), resources, and funding rather than clearly articulating the important differences and using a referral system to make sure the client (or patient) receives the right services at the correct phase of his/her healing journey.
  5. Research results are seriously compromised because many researchers study a non-therapy equine-assisted activity as a form of treatment. This, coupled with other methodological issues, impacts the results and the overall validity of the research.

As John Oliver points out, there is little empirical evidence that actually shows working with horses is an effective treatment tool for many of the populations currently served by the various forms of equine-assisted therapy. Although there has been a wealth of research conducted, after reading over 350 peer-review published research articles, I can comfortably say that methodological issues severely limit our ability to understand what is REALLY happening when horses and humans connect, or to state with any level of certainty what is or isn’t effective.

To this end, we as an industry need to come together to get clear on some important points including the value of separating therapy from non-therapy services, using correct terminology, and increasing our expectations regarding provider competencies. I believe these three initiatives will greatly improve the industry and maybe even help people like John Oliver understand the importance and value of the horse-human relationship.

Oh, and finally, just so we can all be on the same page about the extent the existing research related to addictions and equine-assisted interactions, here is a list of peer-reviewed papers from 1985-2016. I haven’t updated the list to include the new papers out in 2017 and 2018 – more to come on that front later.

Addictions/Chemical Dependency

Adams, C., Arratoon, C., Boucher, J., Cartier, G., Chalmers, D., Dell, C.A., et. al., (2015). The helping horse: How equine assisted learning contributes to the wellbeing of First Nations youth in treatment for volatile substance misuse. Human-Animal Interaction Bulletin, 1(1), 52–75.

Cody, P., Steiker, L. H., & Szymandera, M. L. (2011). Equine therapy: Substance abusers’ “healing through horses”. Journal of Social Work Practice in the Addictions.

Dell, C. A., Chalmers, D., Dell, D., Sauve, E., & MacKinnon, T. (2008). Horse as healer: An examination of equine assisted learning in the healing of First Nations youth from solvent abuse. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 81–106.

Dell, C. A., Chalmers, D., Bresette, N., Swain, S., Rankin, D., & Hopkins, C. (2011). A healing space: The experiences of First Nations and Inuit youth with equine-assisted learning (EAL).Child and Youth Care Forum, 40(4), 319–336.

*Kern-Godal, A., Arnevik, E.A., Walderhaug, E., & Ravndal, E. (2015). Substance use disorder treatment retention and completion: a prospective study of EAT for young adults. Addiction Science and Clinical Practice, 10(21), 3–12.

*Kern-Godal, A., Brenna, I.H., Kogstad, N., Arnevik, E.A., & Ravndal, E. (2016). Contribution of the patient horse relationship to substance use disorder treatment: Patients’ experiences. International Journal of Qualitative Studies on Health and Well-Being11, 1–12.

*Kern-Godal, A., Brenna, I.H., Arnevik, E.A., & Ravndal, E. (2016). More than just a break from treatment: How substance use disorder patients experience the stable environment in horse-assisted therapy. Substance Abuse: Research and Treatment, 10, 99–108.

Power, Abuse, and Guruism

A breaking news story reported by the Boston Globe speaks of allegations against Dr. Bessel van der Kolk, best-selling author and world renowned expert on trauma.

The mental health community has been rocked by the idea someone like van der Kolk who has made it his life’s work to study trauma and help heal those who have been traumatized would in turn be accused of harming others.

When I heard the allegations, I thought immediately of the dark history of psychology and the many misuses of power so frequently glossed over. I also thought of the traditional role of the therapist, as a removed and somewhat aloof expert whose life (complete with struggles and joys), emotions, and personality remain a mystery to the patient. This dynamic, whether created intentionally or unintentionally, sets in motion a inevitable power imbalance.

The lack of training about the use of authenticity and humanness in therapy can cause therapists to fear being real with their patients. And rightly so, as understanding how to be vulnerable with patients is a highly advanced clinical skill that requires much more than training to achieve. It requires a depth of personal growth, self-introspection, and self-awareness that isn’t demanded in a therapist’s typical training or by the licensure process.

However, when therapists remain veiled behind this wall their personal lives and relationships can be in chaos, they may experience feelings of helplessness and loneliness, or they might use the power derived from appearing they  “know what is best” or “have it all together” to mistreat or abuse others. And all of this can happen isolated from the eyes of the world.

I believe many modern gurus, which include new age healers, doctors, therapists, and yes, even horse trainers, are naturally set up to misuse or abuse their power. Frankly, it takes a special kind of person to know how to handle being in the spot light, and always being asked (and expected) to be the “expert”. The pressures of this role are immense, and the internal desire for greatness sometimes overrules all else.

I have been witness to many abuses of power in the equine world over the years. I myself have fallen victim to the powers of a trainer whose need for perfection placed my horse and I in an impossible and life-threatening situation. The idea that I would have stood up to him, me, a 14-year old girl who desperately wanted to “make it” in the big leagues, was unthinkable. So I pulled myself up off the ground for the second time, blood streaming down my face from a broken nose and no idea where I was or what I was doing (due to a concussion). I stumbled across the arena to walk up behind my shaking, frightened mare. I touched her, and she kicked. It wasn’t her fault. It was his fault. He over faced her. He asked her to do something she wasn’t ready to do. And I couldn’t tell him no. So she kicked. On that day I experienced a great miracle. For that I suppose I can be grateful. I laid dead on that arena ground for over three minutes. Those minutes changed my life.

One of the lessons I learned that day was how to stand up for myself and those I love. Even to gurus. I learned to listen carefully and be mindful that even well meaning people might not always know what is best for me. I learned to gratefully accept what I can from the wise ones, but never become swept away by their fame or their name or their power. They are, after all, just people.

But, that being said, with great power comes great responsibility and it is up to these “gurus” (including us therapists) to do better. Although we all must learn to “speak our truth” even in the face of greatness, it is clear to me that whoever holds the power must be even more aware, and create safe opportunities for others to confront and provide feedback that is taken with respectful gratitude.

Help Advance the Equine-Assisted Mental Health & Learning Industry: Day 30 Survey Updates

Hello Colleagues,

This marks the end of the first month our Idaho State University survey has been live. TWO MORE MONTHS TO GO!

For those unfamiliar, this research study is aimed at gathering data that will help identify and differentiate between the various models or approaches to equine-assisted mental health and equine-assisted learning. The data, once collected, analyzed, and published, will help both practitioners and researchers better understand the models and approaches available. At present, there is little if any empirical evidence related to the manner in which the various models or approaches to equine-assisted mental health or equine-assisted learning are actually implemented. Most knowledge of this topic is based upon anecdotal experiences and the trainings provided by various organizations or individuals. Due to this, it is impossible to make generalizations as so much of what is “known” is based upon personal opinions, experiences, and unique ways of practicing. This research project marks the beginning of a very important area of study for the industry of equine-assisted activities and therapies.

Our survey asks professionals to choose the model or approach they use when providing either equine-assisted mental health or equine-assisted learning. The participant then answers all the research questions based upon the philosophy, beliefs, and practices of this model or approach. After 30 days of being live, our survey participant number has increased to over 100, which is still nowhere near enough, but certainly provides us with new information. Here is the latest data update about the prevalence of the use of various models or approach we’ve collected.

  • 30.69% identify “other” as their approach to equine-assisted mental health or learning (models not included in the original survey list) Of the “other”, the majority (26%) identify the FEEL approach, followed by the Equine Facilitated Wellness – Canada Approach (22%), then the IFEAL approach (6.45%) and the E3A model (6.45%) – A few other models were individually identified, but by only one respondent.
  • 22.77% of respondents use an “integrative” approach to either equine-assisted mental health or equine-assisted learning and do not claim any specific model.
  • 13.86% of respondents use the EAGALA model of equine-assisted psychotherapy or equine-assisted learning
  • 8.91% of respondents use the Natural Lifemanship model of trauma-informed equine-assisted psychotherapy.
  • 8.91% of respondents use the Equine Psychotherapy Institute model of equine-assisted psychotherapy
  • 4.95% of respondents use the PATH Intl. Diamond model of equine-facilitated psychotherapy or equine-facilitated learning
  • 3.96% of respondents use the HERD Institute model of equine-facilitated psychotherapy and learning
  • 2.97% respondents use the Eponaquest model of equine-facilitated psychotherapy or equine-facilitated learning
  • 1.98% of respondents use the Gestalt Institute of the Rockies model of Gestalt equine psychotherapy
  • .99% of respondents use the HEAL model of equine-facilitated psychotherapy or equine-facilitated learning
  • 0% of respondents report using the Adventures in Awareness model of equine-facilitated psychotherapy or equine-facilitated learning

Although MUCH more representative of the many different models and approaches available, I know we are still missing some models, and WE MUST INCREASE OUR SAMPLE SIZE to get valid data. Which means we NEED YOU!

Please take this survey yourself if you offer any type of equine-assisted mental health or equine-assisted learning, and forward it to anyone else you know. Lets get some serious data collection going!

FOLLOW THIS LINK TO THE SURVEY

https://survey.az1.qualtrics.com/jfe/form/SV_6lh1eprlszECJLf

Thank you so much for your help advancing our knowledge about equine-assisted mental health and equine-assisted learning.

Feeling Grateful

Hello Friends and Colleagues,

It was recently brought to my attention that a letter I wrote in 2008 is still being circulated today.

https://efwmfc-cannewsletter.weebly.com/november-2017.html#english

I had forgotten all about it until I was contacted recently by the Equine-Facilitated Wellness-Canada organization. I feel immensely honored to know that this letter was helpful in supporting the process of “deep learning” about equine-assisted mental health and equine-assisted learning.

Developing competency in this emerging area of practice is essential, both for the safety and wellbeing of the participants, and for that of our equine partners. Hats off to Equine-Facilitated Wellness-Canada for their dedication to the advancement of the equine-assisted mental health and equine-assisted learning industry!

 

Help Advance Our Knowledge of Equine-Assisted Mental Health and Equine-Assisted Learning

Recently, I posted a link to participate in an Idaho State University research survey aimed at gathering data that will help differentiate between the various models or approaches to equine-assisted mental health and equine-assisted learning.

This data, once collected, analyzed, and published, will help both practitioners and researchers design studies using more clearly defined and operationalized terminology, and have the empirical evidence to develop specific and standardized protocols for each type of intervention.

At present, there is little if any empirical evidence related to the manner in which the various models or approaches to equine-assisted mental health or equine-assisted learning are actually implemented. Most knowledge of this topic is based upon anecdotal experiences and the trainings provided by various organizations or individuals. Due to this, it is impossible to make generalizations as so much of what is “known” is based upon personal opinions, experiences, and unique ways of practicing. This research project marks the beginning of a very important area of study for the industry of equine-assisted activities and therapies.

Our survey asks professionals to choose the model or approach they use when providing either equine-assisted mental health or equine-assisted learning. The participant then answers all the research questions based upon the philosophy, beliefs, and practices of this model or approach. After 15 days of the survey being live, here is some initial data about the prevalence of the use of various models or approach we’ve collected.

  • 35.48% of respondents use an “integrative” approach to either equine-assisted mental health or equine-assisted learning and do not claim any specific model.
  • 25.81% of respondents use the Equine Psychotherapy Institute model of equine-assisted psychotherapy (WAY TO GO MEG KIRBY AND CREW!)
  • 9.68% of respondents use the EAGALA model of equine-assisted psychotherapy or equine-assisted learning
  •  9.68% of respondents identify “other” as their approach to equine-assisted mental health or learning (this includes models not included in this list)
  • 6.45% of respondents use the PATH Intl. Diamond model of equine-facilitated psychotherapy or equine-facilitated learning
  • 6.45% of respondents use the Eponaquest model of equine-facilitated psychotherapy or equine-facilitated learning
  • 3.23% of respondents use the Gestalt Institute of the Rockies model of Gestalt equine psychotherapy
  • 3.23% of respondents use the HEAL model of equine-facilitated psychotherapy or equine-facilitated learning
  • 0% of respondents report using the Adventures in Awareness model of equine-facilitated psychotherapy or equine-facilitated learning, the HERD model of equine-facilitated psychotherapy, or equine-facilitated learning or the Natural Lifemanship model of trauma-informed equine-assisted psychotherapy.

This data tells me our survey isn’t reaching all possible user groups. I am sure there are far more people using some of these (and other) models than this data suggests, and I need YOUR HELP getting the word out there to these various groups and practitioners. Please take this survey yourself if you offer any type of equine-assisted mental health or equine-assisted learning, and forward it to anyone else you know. Lets get some serious data collection going!

https://survey.az1.qualtrics.com/jfe/form/SV_6lh1eprlszECJLf

THANK YOU FOR YOUR ASSISTANCE!

New Research Survey

As many of you may know, I published Walking the Way of the Horse: Exploring the Power of the Horse-Human Relationship in 2008 after many years of study and research related to equine-assisted mental health and equine-assisted learning. At that time, the options for understanding the industry were mostly limited to opinion-based materials using anecdotal stories, and the collection of professional experiences through interviews and surveys.

In a recent literature review I conducted for my latest book, I discovered one hundred empirical research studies related to equine-assisted mental health or equine-assisted learning were conducted between 1985 and 2016 that met my specific criteria. Of those studies only twelve were published PRIOR TO 2008. This gives a sense of how limited the data was prior to 2008, and how much more information we have today.

Even with all of these new studies, our understanding of equine-assisted mental health and equine-assisted learning is still in its infancy. The vast majority of current studies seek to “prove” that equine-assisted mental health or equine-assisted learning is effective for a variety of populations. But, most lack essential details about the design of the intervention or service including the demographic information of the providers (licensure type, experience, education), the approach or model used, the activities conducted, and the role of the horse as an agent of change. Furthermore, most current studies do not include research on the mechanisms of change as related to therapeutic outcomes. All of this makes it very difficult to compare results or conclusively suggest efficacy.

A few days ago I signed a new contract with Routledge (the world’s leading academic publisher in the humanities and social sciences) to publish a book that will replace Walking the Way of the Horse with an updated and current text to educate professionals and students about equine-assisted mental health and equine-assisted learning.

As a critical component of the research I will do for this book, I have partnered with Dr. Leslie Stewart of Idaho State University, the primary author of the American Counseling Association’s Animal-Assisted Therapy in Counseling Competencies to conduct an international cross-sectional research survey. Like myself, Dr. Stewart is dedicated to advancing our knowledge related to the practices of equine-assisted mental health and equine-assisted learning through empirical study.

Our survey is designed to gain a detailed understanding of the theoretical foundations of the various models or approaches commonly used when providing equine-assisted mental health or equine-assisted learning. This important survey includes questions related to provider demographics, theoretical foundations, mechanisms of change, the role of the provider and various staff/volunteers, and the role and demographics of the horses who are included in the various models of equine-assisted mental health or equine-assisted learning.

We will distribute the outcomes of this research back to our community both through my next book, and also by publishing the data in a peer-reviewed journal (assuming we are able to collect enough data and our article is accepted). We may also be able to present our findings at industry conferences or other events.

Without your participation in this survey, and others like it, our understanding of this emerging speciality area of practice will continue to be limited to personal opinions and anecdotal stories. Please consider taking the time to help advance our industry by taking this survey! THANK YOU FOR YOUR HELP AND SUPPORT.

https://survey.az1.qualtrics.com/jfe/form/SV_6lh1eprlszECJLf

Scope of Practice

When including horses and nature in human healthcare, questions frequently arise about scope of practice.

Scope of practice laws define the procedures, processes, and actions a licensed healthcare provider may perform. Scope of practice also explains the limits or extent to which a licensed healthcare provider is allowed to practice. 

In the United States, each state has specific stipulations related to scope of practice, and licensed healthcare professionals are responsible for remaining firmly within their legal boundaries, regardless of whether or not they include horses. If they act outside of their scope, they face legal action and could lose their license.

Bringing a patient to the farm and adding horse, animal, or nature activities to a counseling practice or a physical, occupational, or speech therapy therapy session is considered outside of the traditional scope of practice of most licensed healthcare professionals. This type of unique treatment is typically classified as a speciality area of practice or an emerging treatment technique, tool, or method. To provide any emerging treatment without prior education, training, and supervision is considered acting outside of one’s scope of practice and therefore unethical according the the following professional membership associations:

American Psychological Association Ethical Principles of Psychologists and Code of Conduct 2.01 Boundaries of Competence:

(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.

American Counseling Association Code of Ethics C.2.b. New Specialty Areas of Practice:

Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and protect others from possible harm.

American Occupational Therapy Association Code of Ethics, Beneficence: 

Principle 1: Occupational therapy personnel shall demonstrate a concern for the well-being and safety of all recipients of their services.

  1.  Provide occupational therapy services, including education and training, that are within each scope of practitioner’s level of competence and scope of practice.
  2.  Take steps (e.g., continuing education, research, supervision, training) to ensure proficiency, use careful judgement, and weigh potential harm when generally recognized standards do not exist in emerging technology or areas of practice.

American Speech-Language-Hearing Association Code of Ethics

Principles of Ethics II: Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.

  1. Individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.

TO CLARIFY,  scope of practice is typically determined by the educational content provided during a professional’s graduate level course of study, and any different approach, treatment specialization, or treatment tool that falls outside of that course of study requires additional training, education, and supervision. Animal-assisted therapy, equine-assisted therapy, and nature-based therapies generally fall outside of the traditional scope of practice for most mental health professionals, occupational therapists, speech therapists, and physical therapists because content related to including animals and nature in clinical practice is not commonly provided by the educational institutes granting advanced degrees.

Therefore, if licensed professionals wish to offer any of these therapies, they are responsible for obtaining ADDITIONAL training, education, supervision, and experience to a level that would constitute competency.

For Non-Licensed Folks

Non-licensed providers of animal-assisted, equine-assisted, or nature-based activities do not have a scope of practice as their services are not regulated by law. Instead, these providers offer important services that are uniquely different than those offered by licensed healthcare professionals.

In the United States, it is actually illegal for non-licensed individuals to use protected terms and titles proprietary to licensed healthcare professionals, to offer services provided by a licensed healthcare professional, or to duplicate services using a different non-protected title (Glosoff, et. al., 1995; AOTA, 2007; APTA, 2016; Human Services Guide, 2016). These are serious offenses that can lead to legal action.

Understanding scope of practice, and taking the steps necessary to remain within one’s scope of practice, or to stay outside of the scope of practice of licensed healthcare professionals is an important step in legitimizing the inclusion of animals and nature in healthcare.