In the spring of 2019, four women with trauma histories visited a small farm in Lexington, Massachusetts, to try a new type of therapy. These sessions turned out to be quite a change of pace from typical group therapy—but not just because they involved horses.
Equine-facilitated psychotherapy (EFP), also known as equine-assisted psychotherapy, is, as the name suggests, therapy that features interactions with horses. Unlike therapeutic horseback riding, a licensed mental health professional facilitates EFP group sessions, and, in many cases, no horseback riding is involved. EFP instead focuses on caring for and working with horses to achieve goals similar to those of traditional psychotherapy.
How does EFP work? How well does it work?
That’s what Sherry R. Winternitz, MD, clinical director of the Dissociative Disorders and Trauma Programs at McLean Hospital, and her co-investigator, researcher Stephanie A. Maddox, PhD, aim to show through the results of a McLean-led study at Lexington’s BINA Farm Center. BINA is a nonprofit focused on helping people of all ages and abilities thrive, primarily through equine-assisted activities and therapies.
Winternitz and Maddox are collaborating with BINA group facilitator Kate Ford, LICSW, PATH Intl. ESMHL, to assess whether EFP indeed makes a difference and, assuming it does, to figure out how it elicits therapeutic breakthroughs. The groups are co-led by Emily Rivers, PATH Intl. CTRI.
“We want to find out how these simple things that people learn in a barn transition to the outside world,” said Maddox. “A lot of it is about gaining confidence.”
One group of four women and another group of six have completed the eight-week EFP program at BINA. All the participants thus far have come from McLean’s trauma-focused programs for adult women, the Hill Center for Women and the Dissociative Disorders and Trauma Inpatient Program.
The focus on recruiting of trauma survivors has been deliberate, as preliminary research done elsewhere has shown that EFP can have a positive effect on patients with trauma-related conditions. Historically, such research has focused on reducing PTSD symptoms in military veterans.
While the McLean study aims to further evaluate EFP’s impact on reducing trauma-related symptoms, such as intrusive memories, nightmares, and flashbacks, it is also exploring the therapy’s potential to build trust and enhance connection.
Building confidence and establishing trust are done through developing horse skills and focusing on the present. No one is asked to dig deep into the past and disclose details about their traumatic experiences.
“We’re not asking these women to talk about their trauma. We’re not even necessarily asking them to talk about what they struggled with during the week,” said Maddox. “What we’re doing is setting up a framework where we put people in situations with horses that fosters inward reflection, confidence building, and emotional grounding.”
Based on participant feedback and clinician observation, several core elements of EFP appear to contribute toward making this therapy impactful. These include the presence of civilian volunteers and being in a group.
The centerpiece of EFP, however, is the horse, of course.
The BINA equine “staff” specializing in EFP includes Annie, Beanie, Chico, Claire, Destiny, Gracy, Halo, Jaxon, Oreo, Sammy, Shamus, and Winston.
Ford and Maddox describe these horses as ideal beings for giving feedback, as their responses to a human’s caretaking are instant, predictable, and non-judgmental.
“If you’re not grounded and clear about what you’re asking for, they’re not going to respond. When you do give them what they need, they respond automatically,” said Ford, who is both a licensed mental health professional and a credentialed equine professional. “It is like an automatic biofeedback process with a sentient being. It’s incredibly powerful.”
Ford explained that if a group participant is calm and grounded while grooming their equine partner, the horse’s head tends to drop, their ears will relax, and they will gently lick and chew. If the handler is tense and nervous, however, the horse may exhibit “horse cues” of tension, such as popping up the head, not standing still, or pinning the ears back.
Each human participant is paired with one equine partner. Ideally, they stay together throughout the eight-week program. This enables the individual to develop a relationship with the horse, progress together, and develop trust.
Developing such a bond can be easier with an animal, said Maddox.
“A lot of people that have trauma backgrounds—especially if we think about interpersonal trauma, sexual trauma, early-life trauma—lack trust in other people,” said Maddox. “Having these activities involve an animal, a horse, can help the participants take a step toward being more willing to engage in social interactions with other people.”
As the women develop their horse care skills, they also develop everyday life skills. They start with learning basic caretaking tasks, such as grooming and feeding, and move on to horse handling skills, such as leading a horse around the arena.
“It sounds really easy,” said Ford. “But it’s really, really hard. If you aren’t focused and centered, and in connection with your horse, it’s going to be almost impossible.”
The horse handling experiences become progressively more challenging until the horses are “at liberty” during the last two sessions. Ford says that when she watches the group confidently and successfully working with horses that are completely untethered—no lead, no halter—she sees the women “experience moments of pure joy.”
All these experiences, the joyful and the not so joyful, are shared. The women support each other. The volunteers support the women. Everyone supports the horses.
That camaraderie was solidified early in the first group.
Ford asked the group during one session to write down something that is a major obstacle in their daily life. After each woman privately denoted their obstacle on an index card, they were asked to simultaneously reveal what they wrote. Every card had the word “fear” on it.
“Amidst the sadness of this they all started laughing,” said Winternitz.
The group then turned away to see one of the horses, Oreo—not wanting to be left out—chewing on one of the index cards. The metaphor wasn’t lost on them as everyone continued to laugh.
They realized, of course, that their treatment wouldn’t be so simple. But they soon recognized that their equine partners—along with the help of clinicians and volunteers—would help them slowly eat away at fears that had weighed on them for many years, often decades.
That progress has been noticed not only by Ford, her co-facilitator, and the researchers, but also by the volunteers. Having the participant’s progress witnessed by people who are there voluntarily, who aren’t professionals, bears great significance for the women.
“Some of the women have said that it wasn’t just the fact that they got to do these exercises, get to know the horses, and have these experiences, but also that their experience was witnessed by a layperson,” said Ford. “These people have been through personal wars, profound trauma and abuse. To have their experience witnessed by laypeople made them feel safe, that maybe they could go out into the world and trust other people.”
“These incidental conversations that volunteers have with participants really help generate trust, normalcy, focus on a task, to get them thinking about what is possible,” added Dale McCarthy, BINA’s executive director, who has a background in working with domestic violence survivors.
Is EFP Effective?
Aside from data, there are numerous anecdotes attesting that EFP has had an immediate and substantive impact on these women. They have gone from talking about anxiety, fear, and anger to talking about joy, peace, and possibility.
Winternitz says that there was a woman in the first group who one day noticed that she felt completely in charge and powerful as she led her horse around, but surprisingly didn’t feel angry.
“Sometimes the only way individuals who have been traumatized feel empowered is if they’re enraged,” said Winternitz. “Power, for her, had always been associated with her abuser. Now she realizes that she doesn’t have to be abusive or angry to be in power. That was an incredible moment.”
“I’ve been working with survivors of childhood abuse for the last 30 years, and I have never seen anything with such immediate benefit to folks who struggle with trauma-related issues.”– Dr. Sherry Winternitz on the effects of equine-facilitated psychotherapy
That woman and her co-participants are no longer participating in EFP, but that doesn’t mean they’re no longer invested in it. Winternitz says the participants thus far have universally expressed their feeling of validation in being asked to participate and their hope that “somebody else will benefit from what I’m doing.”
The researchers, however, understand that much more data has to be gathered before EFP can be considered an evidence-based therapy.
“I can tell you day in and day out how horses have touched my life, and other people can do that too,” said Maddox. “But we still need the hard data.”
On a personal level, however, they are already convinced.
“I’ve been working with survivors of childhood abuse for the last 30 years,” said Winternitz, “and I have never seen anything with such immediate benefit to folks who struggle with trauma-related issues.”