Deborah Brauser

June 01, 2011

June 1, 2011 (Honolulu, Hawaii) — Equine-assisted therapy provides unique benefits, including calming violent tendencies in hospitalized patients with chronic psychiatric disorders, new research suggests.

A pilot study of more than 100 inpatients presented here at the American Psychiatric Association 2011 Annual Meeting showed that those randomized to undergo weekly group therapy sessions that integrated horse-related tasks had significantly fewer violent incidents during the next 3 months compared with those who underwent canine-assisted therapy or standard-of-care treatment.

"Everyone in the equine therapy group had a positive response," Jeffry Nurenberg, MD, medical director at Greystone Park Psychiatric Hospital in Morris Plains, New Jersey, and clinical associate professor of psychiatry at the University of Medicine and Dentistry of New Jersey (UMDNJ) in Newark, told Medscape Medical News.

Coinvestigator Steven Schleifer, MD, professor of psychiatry at the UMDNJ Medical School, reported that this is the first study to look at how equine-assisted therapy may be useful in an in-hospital setting.

Dr. Steven Schleifer

"The equine group really stood out with a drop in incidents. But what was curious is that the other groups actually did a little worse at the postintervention period compared to the preintervention period. It was all just really interesting," said Dr. Schleifer.

"Animal-assisted therapy is being used increasingly for patients with syndromes not responding adequately to traditional therapies, such as severe stress/anxiety reactions, interpersonal deficits, limited verbal skills, trauma, and violence," write the investigators.

"Some have suggested that larger animals, such as horses, may be more effective therapy enhancers for some patients than the more commonly employed smaller animals," they add.

Dr. Nurenberg reported that his facility has used "canine encounters" for several years. About 5 years ago, a coworker who had often brought horses to senior centers and children's homes brought some to the Greystone hospital.

"The patients were free to interact with them under the control of the horses' owners, and we noticed that those we identified as having a serious problem with violence were very different when they were with the horses. They had a different spontaneity and very different facial responses than we had seen in the past. And we were curious — why would this be?"

He and his colleagues noted 2 key problems they often saw in their patients: unmotivated violence and social isolation due to a long hospital stay.

"We wanted to find out whether it might be worth it in the end for these patients in having the hospital invest in an equine therapy program, which is obviously an elaborate and costly undertaking," explained Dr. Schleifer.

'Dramatic' Functional Improvement

For the study, 104 inpatients (38% female; 37% black or Hispanic; mean age, 44.8 years) from Greystone, a long-term psychiatric hospital (mean days of hospitalization, 1695), were enrolled last spring. They were then randomized to receive 10 sessions of weekly equine-facilitated therapy (EFT, n = 32), canine-facilitated therapy (CFT, n = 27), their standard psychosocial therapy (n = 18), or enhanced psychosocial therapy (ET, n = 27).

All patients were clinically identified as at risk for violence/aggression (n = 65) or were highly regressed or isolated (n = 39). In addition, 61% had affective or schizophrenic disorders.

EFT involved 1 horse per 3- to 4-person group and included horse-related tasks that mostly needed to be accomplished as a team, such as grooming or putting on a saddle. CFT involved 2 dogs meeting with 10 patients at a time in a specialized room and included more 1-on-1 interactions. Both EFT and CFT used Delta-certified therapy animals and handlers in addition to therapists from Greystone.

The ET control group met in a building outside the patients' usual hospital gathering place to ensure that the effects found for EFT or CFT were not due to just a change in environment.

At intake and 3-month follow-up, psychological, behavioral, and functional measures were conducted and compared.

Results showed that only the patients in the EFT group reduced their violence-related incidents during the 3 months after the start of the intervention vs the 3 months preceding study enrollment (P < .05).

"Staff-assessed Overt Aggression Scale assessment of assault against others (P < .05) revealed similar EFT-related changes over 3 months," report the researchers.

There were no between-group differences for nonviolent incidents.

Both the patients with affective (vs schizophrenic) disorders and males showed greater incident reductions (P < .04).

In addition, "clinical observations identified dramatic functional improvement with EFT in some highly regressed and violent patients," write the study authors.

Program Expansion Planned

Dr. Nurenberg especially noted 1 patient who had been hospitalized for 2 years and was nonresponsive, depressed, and regressed/isolated before undergoing EFT.

"The patient was very enthusiastic about the project and showed more verbal interaction with others and more humor. He also stated that grooming the horses and other kinaesthetic activities reduced his anxiety. And he was discharged just 1 month post project."

Dr. Jeffry Nurenberg

Another EFT patient, who was frequently violent during 15 years of hospitalization, went from 17 violent incidents in the 3 months before the program to just 9 in the 3 months afterward. In addition, there were 4 incidents of seclusion/restraint in the month preceding the project, 2 during the first month of the project, and none during the succeeding 6 months.

"A third patient was hospitalized for neurologic impairment. After being involved with the horses, he showed a lot of reduced reactivity to perceived negative interactions and significantly fewer violent incidents," said Dr. Nurenberg.

He reported that several of the investigators have opinions as to why the EFT group did so well compared with the other groups.

"My speculation is that a large animal helps someone who is struggling with self-control, especially if it's a benign and well-regulated animal that isn't dangerous, to regain control as if externalizing what is absent from themselves."

Dr. Schleifer said that it also could be that many of these patients have felt like they have been treated poorly by other powerful people and having this "corrective type of experience" with a powerful creature that gives instant feedback is helpful.

"Frequently, the response was not the cuddly kind of thing you see with dogs but that in itself may be resetting some kind of processing to past traumas."

The researchers added that they are now in the process of figuring out possible ways they can offer EFT regularly, at least in the warmer months.

"We're also hoping to eventually offer a workshop on what we learned in this and in the next study to help others to perhaps take this program to their institution as well," said Dr. Nurenberg.

Thinking Outside the Box

"Although this is the first time I've seen something done specifically with horses, the use of animals is actually not very new," David Baron, DO, executive vice-chair and the psychiatrist-in-chief at the Keck School of Medicine at the University of Southern California, Los Angeles, told Medscape Medical News.

Dr. David Baron

Dr. Baron, who was not involved with this research, said that animal-assisted therapy, especially with dogs, has been used "for a long time" in selected populations, including geriatrics and children.

"So the core concept is in no way a new one, and it has been demonstrated that it's something that patients oftentimes really enjoy. They can relate to an animal in a calming way."

He noted that some of his colleagues have used EFT before, although not in a clinical trial setting.

"I think the general idea makes sense and the data are very interesting. The question, though, is going to be: how many places have the availability of horses? Dogs are just easier to bring in. So I think it probably will be restricted to places that have horse facilities," said Dr. Baron.

"Still, I think this was an interesting study and really underscores the importance of allowing patients to interact with another living thing. But I was surprised with the finding that the equine therapy seemed to be better than the canine therapy, especially because horses are larger and could have been viewed as threatening."

He pointed out that that may be in part due to the EFT members being required to work together as a group.

"To learn to work as a team, sharing specific tasks, the reward of then seeing the animal's enjoyment — it just all adds up to a very reasonable explanation."

Dr. Baron said that this type of study is important because it reminds clinicians that they need to think about innovative and creative ways to get people to feel some level of joy, whether that is dealing with animals, playing video games, or listening to music.

"What studies like this tell us is that there are many things that we should be considering beyond just pharmacotherapy or traditional psychotherapies. We certainly know that exercise, if it's enjoyable, can be therapeutic. And as clinicians, I think we need to remember to give people permission to do the things that they enjoy."

The study and program was funded in part by the Greystone Park Association. The study authors and Dr. Baron have disclosed no relevant financial relationships.

American Psychiatric Association (APA) 2011 Annual Meeting: Poster NR07-06. Presented May 16, 2011.

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