Running head: INTEGRATIVE REVIEW 1

Are Equine Facilitated Therapies Effective for Symptoms of PTSD: An Integrative Review

Cameron Yeong

Bon Secours Memorial College of Nursing

Arlene Holowaychuk

Nursing Research NUR 4122

April 10, 2018

I Pledge
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Abstract

The purpose of this integrative review was to evaluate the research on effectiveness of equine

related therapies for Post-Traumatic Stress Disorder (PTSD). PTSD is a dramatic and possibly

debilitating set of symptoms that follow a particularly traumatic life event. Negative symptoms

include anxiety, depression, antisocial behaviors, and substance abuse among others. Animal

assisted therapy has been used in a variety of ways to combat the symptoms. Equine facilitated

therapies come in a variety of programs and have been suggested to be effective in treating

difficult symptoms of PTSD. Research methods for this paper included use of databases to find

relevant research to this topic. Once the plethora of studies was selected from based on

specificity and publishing date, the results were compared. In the end, much of the data

supported the effectiveness of equine therapy either alone or with traditional therapy methods for

treatment of a variety of patients. There were limitations to this study based on both source

material and methods used in the review. In the end, both the possibility of implementation of

these therapies and the need for further research emerged from this study.
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Integrative Review

The purpose of this integrative review is to evaluate existing literature on the

effectiveness of equine therapies for treatment of post-traumatic stress disorder (PTSD)

symptomology. Post-traumatic stress as a result of significant psychologically harmful life events

causes many negative symptoms in victims. These symptoms include but are not limited to

anxiety, depression, antisocial behaviors, and substance abuse (Kemp, Signal, Botros, Taylor, &

Prentice, 2013). These sequelae can greatly impact victims over the course of their lifetime and

decrease their ability to successfully interact and trust others, hold meaningful employment, and

generally function in society on a daily basis. PTSD is traditionally treated with a combination of

medication and psychotherapy. Certain groups such as children and adolescents as well as

combat veterans do not see significant improvements with standard therapy due to their

developmental progress or nature of the trauma (Mueller & McCullough, 2017). In order to

describe alternatives, equine assisted therapy methods were examined. Equine assisted therapy is

a specific type of animal therapy that uses directed activities with horses to elicit a specific

therapeutic effect. Equine facilitated psychotherapy is a subset used to treat mental health issues.

The PICOT question for this review is as follows: are equine facilitated therapies effective for

mitigating symptoms of PTSD in participants with history specific traumatic events.

Design and Research Methods

The design of this paper is an integrative review, which collects, summarizes, and

compares research studies on the specific topic. To find material, EBSCO Discovery and

PubMed database searches were utilized. Terms used were “Equine-Assisted”, “Hippotherapy”,

“equine facilitated therapy”, “Post-Traumatic Stress Disorder”, “Trauma”, and “Post-Traumatic

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Stress”. These searches yielded 178 articles, suggesting a significant amount of source material.

These articles were then selected by reputation, type of article, and date of publication. In order

to remain current, articles published before 2013 were eliminated. The articles were further

screened based on type and content. Articles evaluating effectiveness of specific therapies on

specific symptoms were selected. Only articles that were peer reviewed and published in

academic journals were considered. Of the final five articles, four were quasi-experimental and

one was a non-experimental quantative study. These studies were published between years 2014

and 2017. These final articles were each relevant to the PICO question of the effectiveness of the

respective equine related therapy on the symptoms of PTSD.

Findings/Discussion

Overall, the results of the research showed equine assisted therapies were correlated with

significantly reduced PTSD symptoms. Studies used different measurement tools and specific

categories to describe symptoms. For children and youth, the Children’s Revised Inventory of

Events Scale (CRIES-13) was used. The studies involved showed that due to the developmental

differences in maltreated youth, traditional talk therapy was less effective in this demographic.

Use of animal assisted therapies; specifically equine related therapies were effective in youth that

could not engage in traditional therapies due to sequela of their abuse or trauma (Kemp, et al.

2013; Mueller & McCullough, 2016; McCullough, et al., 2015) In the studies relating to adults,

symptoms of stress were reduced and coping methods such as mindfulness were increased

(Earles, et al, 2015; Ferrulo, 2015). As a whole, the studies suggest that equine therapy may be

an effective method of therapy or adjunct to conventional therapies.

Empowerment
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A reoccurring theme is the ability to empower victims. Participants that had experienced

traumatic life changing events often felt guilt, shame and powerlessness as a result of their

experience. Furthermore, children and adolescents that have experienced severe trauma at a

young developmental age often have lack of trust of adults and stunted communication and

emotional skills necessary for traditional talk therapies (McCullough, et al). For this reason, it

was hypothesized in each of the studies that equine therapy would be beneficial for boosting of

confidence by physical and kinesthetic rather than an emotional approach.

The quasi-experimental study performed by Mueller and McCullough (2017) studies 54

youth that met the criteria of having a score of 12 or higher on the CRIES -13 assessments.

Participants were randomly assigned to a control group, that continued with traditional therapy

and an experimental group that received equine facilitated psychotherapy (EFT). The

experimental group received a 12 weak course consisting of ten sessions of therapy involving

learning to care for and control a horse. Assessments were taken before any therapy, at week

five, and at the end of week ten to reassess post-traumatic stress symptomology. Repeated

measures of analyses variance methods were used to discover that both groups had significantly

lowered CRIES scores at every reassessment.

In a 2015 quasi experimental study by McCullough, Riley-Curtiss, and Rourke, saw a

cohort of eleven youth with significant history of maltreatment who were referred by mental

health providers through weekly sessions of therapy at an accredited facility for eight weeks.

This study also used the CRIES-13 as an evaluation tool and repeated statistical analysis. This

study suggested that the therapy which included caring for the animals needs and learning

respect in an individual setting as well as training and riding reduced signs of hypervigilance and

for some participants decreased overall score or individual facets of PTSD symptomology.
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A 2013 Study by Kemp, et al. followed 30 youth with a history of childhood sexual

abuse. Participants were screened based on initial scores on the Trauma Symptoms Checklist as

well as the Beck Anxiety Inventory and a number of depression screenings. In this study,

participats were assessed for initial status, given traditional counseling, assessed again, given the

experimental equine facilitated therapy, and then assessed a final time. The experimental therapy

took place over the course of six weeks and occurred in sessions once a week. The participants

showed little discernable improvement in overall function between assessments one and two, but

showed significant reduction in symptoms and increase in function at the final assessment. For

abused children, the ability to interact with a living animal, giving it direction and caring for its

needs granted a specific goal as well as a feeling of control of the situation. This was an effective

method for decreasing anxiety and antisocial behavior and in some cases, improving

effectiveness of other therapy methods involving a traditional therapist (Kemp, et al. 2013).

Mindfulness

Depending on the nature of the initial trauma and age of onset, victims experience

hypervigilance and anxiety as a manifestation of their disorder. As a result, they have trouble

functioning in daily life and have trouble forming trusting relationships. Equine therapy was

helpful in this respect as horses are reported to notice the non-verbal indicators of moon and

behavior and act accordingly. By this method, participants can be taught to observe the horse’s

behavior as a reflection of their own state of mind in order to recognize and modify behavior and

cognition (Earles, et al., 2015).

A study by Earles et al. in 2015 assessed the effectiveness of equine-assisted therapy in

16 adults aged 33 to 62 who reported at least one criterion A traumatic event based on the Life

Events Checklist tool. The participants were subjected to group therapy consisting of two hour
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sessions dealing with riding and training. Several surveys were used before and after the

program, including the 18 item trauma emotion questionnaire. At the end, data was analyzed and

the mean level of stress symptoms decreased significantly.

Lastly, the pilot study by Ferrulo in 2015 offered combat veterans a two day program of

equine therapy. While this was a non-experimental design intended to elicit further interest in the

practice, the results of applied surveys asked the participants to quantify any improvement in

their post-traumatic stress symptomology at the end of the course. Over 80% of participants self-

reported improvements in ability to cope and symptoms of stress and depression (Ferullo, 2015).

Recommendations/Implications

Each of the selected studies reviewed the efficacy of equine related techniques in

treatment of post-traumatic stress symptoms. Together, these articles suggest a correlation

between equine facilitated therapies and positive outcomes for a variety of participants. These

studies serve to suggest that equine-assisted therapy can be an effective therapeutic technique for

those suffering from PTSD or symptoms of anxiety (Earles et al., 2015). The effects seem

especially pronounced when this sort of therapy is used in conjunction with psychotherapy,

cognitive behavioral therapy, or other traditional mental health practice. The effects of various

types of therapy varied by approach and there were differences in target group, weather

participants were children or adults. Further studies are indicated for evaluating the effectiveness

of treatments on a broader scale. Broader use of the techniques exhibited in the study could be

useful for people who struggle with post-traumatic stress symptoms, even those whose issues

have been resistant to other types of therapy.

Limitations
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This review has a number of functional limitations. The review was naturally not

exhaustive and additional research is out there. Only five articles were used in the end, which is a

limited view of the topic. Research was limited to the last five years, which excluded a lot of

valid data. There have been a number of relevant studies outside of the selected time period.

Finally, this review was completed as a requirement for an undergraduate class and was subject

to scope and time constraints. Lastly, the researcher was a student of nursing with limited

experience with mental health and next to no experience with PTSD or equine related therapy.

The studies themselves had aspects that limited their usefulness to the topic. Several of

the studies used had relatively small sample size and only two had control groups. Selection was

often not random and subject to alteration based on referrals and volunteers. The locations and

methods used in therapy were not well explained but are assumed to be comparable. Therefore,

while overall results suggest effectiveness of therapy, further research is needed.

Conclusion

As a result of this review, it is suggestive that Equine therapy may be used to help ease a

variety of symptoms related to PTSD. The therapies used help to instill a sense of control and

mindfulness in participants that decrease negative effects on daily life. The data differs on

weather equine therapy is effective as a primary method rather than facilitation of traditional

therapy and medication. Overall, this is an area of study with significant potential to benefit

those suffering with symptoms relating to post-traumatic stress. These studies have some use in

that they add to the growing body of evidence supporting positive effects of equine therapy. At

the very least, it could be used effectively in conjunction with more conventional therapies.
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References

Cronin, P., Ryan, F., & Coughlan, M. (2008). Undertaking a literature review: A step-by-step

approach. British Journal of Nursing, 17(1), 38-43. doi:10.12968/bjon/2008.17.1.28059

Earles, J. L., Vernon, L. L., & Yetz, J. P. (2015). Equine-assisted therapy for anxiety and

posttraumatic stress symptoms. Journal Of Traumatic Stress, 28(2), 149-152.

doi:10.1002/jts.21990

Ferruolo, D. M. (2015). Psychosocial Equine Program for Veterans. Social Work, 61(1), 53-60.

doi:10.1093/sw/swv054

Kemp, K., Signal, T., Botros, H., Taylor, N., & Prentice, K. (2013).

Psychoanalytic/psychodynamic psychotherapy for children and adolescents who have

been sexually abused. doi:10.4073/csr.2013.13

Mccullough, L., Risley-Curtiss, C., & Rorke, J. (2015). Equine Facilitated Psychotherapy: A

Pilot Study of Effect on Posttraumatic Stress Symptoms in Maltreated Youth. Journal of

Infant, Child, and Adolescent Psychotherapy, 14(2), 158-173.

doi:10.1080/15289168.2015.1021658

Mueller, M. K., & Mccullough, L. (2017). Effects of Equine-Facilitated Psychotherapy on Post-

Traumatic Stress Symptoms in Youth. Journal of Child and Family Studies, 26(4), 1164-

1172. doi:10.1007/s10826-016-0648-6
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Appendix

First Author 
Earles (2015)
(Year)/Qualifications 
Researcher at Wilkes honors college, Psychology
department, Florida Atlantic University.
Background/Problem Researchers sought to evaluate the effectiveness of an
Statement equine-assisted therapy on anxiety/post-traumatic stress,
inspired by the lack of strong existing data.
Conceptual/theoretical  Based on previous research into effectiveness, quasi
Framework experimental design.
Design/  A six week study in which participants had two hour
Method/Philosophical sessions of group equine therapy.
Underpinnings  Patients maintained their respective therapies and
medications and were surveyed before and after the
program.
Sample/  consent forms an initial survey administered by
Setting/Ethical impartial third party
Considerations  safety and ethics not specifically discussed
 16 participants referred by mental health practitioners,
meeting traumatic criterion
Major Variables  post-traumatic stress symptoms, severe emotional
Studied (and their response, generalized anxiety, depressive symptoms,
definition), if mindfulness, alcohol use, proactive coping, life
appropriate satisfaction, social support, physical health, etc.
Measurement  Many established screening tools to measure
Tool/Data Collection variables, specifically 81-item trauma emotion
Method questionnaire, and 7-item anxiety disorder scale.
Data Analysis  Means and standard deviations calculated by
researchers
 power analysis not completed on this study
Findings/Discussion  Patients showed significant decrease in PTSD
symptoms, emotional distress, anxiety and depression
symptoms and alcohol use. Other variables were not
significantly improved.
 No control group weakens validity
 strong evidence for usefulness of EFT
 Structure of experiment may explain areas that did not
improve
Appraisal/Worth to  This is a good study for the review
practice  small group and a variety of variables that are not
usable
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First Author  David Furrulo (2015)

(Year)/Qualifications  National association of social workers
Background/Problem  Military personell psychological disorders are on
Statement the rise since 2001
 this increases chances of poverty, unemployment,
criminality, homelessness
 researchers hope to evaluate use of equine
facilitated mental health therapy on veterans
Conceptual/theoretical  basis in psychotherapy uses psychological framework
Framework to integrate CBT, mindfulness-based stress reduction,
and mindfulness-based therapy
Design/  Non-experimental pilot study of two day retreat for
Method/Philosophical veterans
Underpinnings  based on other previous therapies used for other
disorders

Sample/  7 veteran volunteers in a convince sample

Setting/Ethical  An established therapeutic horse farm under
Considerations supervision of EFMH experts
 Participants received informed consent and IRB
approval was recieved
Major Variables  symptoms of psychological stress, specifically
Studied (and their depression and anxiety
definition), if  improved social skills
appropriate
Measurement  open-ended surveys administered after day one and
Tool/Data Collection day two to evaluate participants feelings about the
Method program

Data Analysis
Findings/Discussion
 little analysis was done as group was very small and
 chi squared analysis to compare results based on
retreat type
 Suggest that EMFH may be effective for combat
veterans with PTSD symptomology
 sample size was small, all male, and voluntary
 not specifically generalizable

Appraisal/Worth to  An interesting study that does not specifically imply

practice effectiveness in the greater context
 selection bias due to self-reporting and open-ended
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questions
First Author  Affiliated with Dept. Health and Human Services
(Year)/Qualifications (Australia)
 Researcher at Central Queensland University
Background/Problem  Long term negative mental/ psychosocial outcomes for
Statement victims of childhood abuse
 Depression, anxiety, post-traumatic stress, guilt &
powerlessness, antisocial behaviors, conduct
problems, dissociative disorders, etc.
 Conventional therapy is often ineffective with of CSA in
this age group
 Hyperarousal, distrust of adults, and dissociation
hamper talk therapy
Conceptual/theoretical  Quasi-experimental
Framework  adjuvant to CBT
Design/  Participants were surveyed using established
Method/Philosophical screening tools mentioned below. patients receive
Underpinnings evaluations at three points in the therapy and results
are evaluated by repeat analysis of varices.
Sample/  15 children and 15 adolescents with history of abuse
Setting/Ethical through referral
Considerations  Horse farm with a group setting ant two counselors
with four horses
 Informed consent for both participant and their parent
Major Variables  The effect of EFT on trauma and psychological
Studied symptoms
Measurement  “trauma/psychopathology symptoms” by Children’s
Tool/Data Collection Depression inventory & child Behavior Checklist for
Method children and Trauma Symptom Checklist, Beck
Depression Inventory, & Beck Anxiety Inventory for
adolescents.
 Assessment upon entry to program, with counseling,
and after EFT with counseling
Data Analysis  Repeated analysis of varices (ANOVA) based on the
different test. Mean and SD.
Findings/Discussion  Adolescents showed significantly lowered PTSD as
well as anxiety, depression, etc.
 Limited sample size, no control. Significant for both
children and adolescent
Appraisal/Worth to  This is a strong study, rigorous, low attrition
practice
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First Author  Kieley Meuller (2017) Dept. of clinical sci. Center for
(Year)/Qualifications Animals and Public Policy, Tufts Institute for human-
animal interaction, Cummings school of vet. medicine
Background/Problem  Equine assisted therapy has limited imperial research
Statement on effectiveness. Evaluating post-traumatic stress
symptoms in youth.
Conceptual/theoretical  basis in psychotherapy and cognitive behavioral
Framework therapy
 program design by Professional Association for
Therapeutic Horsemanship
Design/  Quasi- experimental with semi random assignment
Method/Philosophical  test group participates in ten weekly two hour sessions
Underpinnings of equine facilitated psychotherapy (EFP)with control
receiving standard CBT
Sample/  54 youth aged 10-18 (45 males and 9 females) with
Setting/Ethical acceptable scores on a post-traumatic stress
Considerations symptomology metric.
 Control and test group treated at conventional mental
health facility and certified therapeutic riding facilities
respectively.
 experiment approved by tufts IRB, consent from
patients and parents, safety guidelines for animals and
youth
Major Variables  post-traumatic stress symptoms :intrusion, avoidance,
Studied arousal
Measurement  CRIES-13, self-reported measure of stress response
Tool/Data Collection with a 0-5 scale
Method  participants surveyed at the start, week 5, and on
completion (week 10)
Data Analysis  Three rounds of surveys to test effectiveness in both
control and test groups
 repeated analysis of variance (ANOVA) to evaluate
changes across time
Findings/Discussion  CRIES scores decreased for both groups over the
course of the study, but there was no significant
benefit of either one.
 Signiant decrease of PTSD symptoms after EFT,
suggesting it’s use as an alternative to conventional
therapy
 the control group had higher initial scores, while test
group had histories of repeated trauma, potentially
minimizing the effect of therapy
Appraisal/Worth to
practice  this study is useful in that is suggests effectiveness of
EFP, further studies needed
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First Author  McCullough PhD(2015)

(Year)/Qualifications  associate professor Washburn University School of
Social Work, veterinary clinician, 35 year work with at-
risk youth
Background/Problem  Need to evaluate treatments to treat symptoms of
Statement chronic maltreatment of children
 Animal therapy may be effective for non-
verbal/symbolic process of youths
Conceptual/theoretical  Equine Facilitated psychotherapy Model, Diamond
Framework model
Design/  Quasi-experimental, participants receive eight weekly
Method/Philosophical EFP sessions lasting 1-2 hours, CRIES-13 tests
Underpinnings administers at weeks one, four, and eight.
 No control group due to logistical constraints
Sample/  11 participants, 6 males and 5 females aged 10-18
Setting/Ethical referred by their provider due to PTSD symptomology
Considerations  Equine therapy facility in San Antonio
 Informed consent of parents and participants,
Washburn University IRB approved
Major Variables  EFT on PTSD symptomology
Studied (and their  numb affect, hypervigilance, disruptive behavior
definition), if
appropriate
Measurement  Children’s Revised Inventory of Events Scale (CRIES-
Tool/Data Collection 13) administered thrice over the course of the program
Method by impartial research aide
Data Analysis  nonparametric statistics due to small sample size
 alpha significance 0.5
 spearman’s Rho correlation coefficient analysis
Findings/Discussion  nine of eleven participants had overall decreased
scores on post-test
 very small sample size, no control group
 suggestive that therapy may be effective for some
children
Appraisal/Worth to  suggestive when taken with other research, not widely
practice generalizable
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