In this editorial the author reviews the utilization of Equine Assisted Therapy (EAP) as a model of treatment for patients with various psychiatric and neurological disorders. The editorial addresses the comorbidity between the psychiatric and substance use disorders. It explains the possible relationship between unresolved traumatic experiences which may lead to severe psychopathology, and the development of addictive disorders. EAP may improve the psychiatric symptoms for patients who are resistant to traditional psychotherapy. This may ultimately improve the illicit drugs and alcohol use in this population. The author calls for more research to study the benefit of EAP as a model of treatment for patients with comorbid psychiatric and substance use disorders.
Stress is a normal psychological reaction that occurs in response to environmental factors. Marital disputes and conflicts at work are examples of transient stress that subsides when the cause is resolved. Stress could be considered abnormal if it is of prolonged duration and severe intensity. Being in the front line of a combat zone is an example of being exposed to continuous severe stress. Therefore, individuals who are exposed to a life threatening traumatic experience of severe intensity or prolonged duration are at risk of developing psychological disorders. The age of exposure to these traumatic experiences is another important factor in determining the development of the psychological disorders following the traumatic experience. Posttraumatic Stress Disorder (PTSD) and mood disorders are examples of a psychological disorder that may occur as a result of being exposed to a severe traumatic situation.
Hypotheses have been generated to better understand the relationship between stress and Substance Use Disorders (SUD); however, it is clear that no single explanation fits. A theory suggests that illicit drug or alcohol use increases the odds of an individual developing Posttraumatic Stress Disorder (PTSD) and mood disorders as a result of engaging in high risk behaviors that place them at risk for exposure to traumatic events (e.g. violence, accidents, and sexual assault). Perhaps the more widely accepted theory supports a self-medication hypothesis such that individuals with PTSD or mood disorders use substances to cope with the accompanying psychiatric and functional impairments. Several studies reported that stress could be a trigger for relapse to illicit drugs or alcohol [1-3]. These studies may support the self-medication hypothesis for the comorbidity between stress and drug addiction.
Patients with severe traumatic experiences, especially when it occurs during their childhood, tend to develop severe psychopathology leading to maladaptive coping skills. Children are vulnerable and being exposed to severe traumatic experiences at a young age may negatively affect the child’s ability to trust. The psychopathology of childhood traumas may be manifested by the development of personality disorders during adulthood. Borderline personality disorder is an example of an unresolved childhood traumatic experience that may result in a diffuse sense of self, poor interpersonal relationships and self-destructive behavior during adulthood. Self-injurious behavior and illicit drug use are examples of the poor coping skills in handling stress for patients with borderline personality. Those patients may use illicit drugs or alcohol to self-medicate for their psychiatric symptoms during periods of high stress. Illicit drug or alcohol use itself can lead to more traumatic experiences. The vicious circle of the traumas and illicit drug or alcohol use in this population reinforce the lack of trust in humans and poor interpersonal relationships. Improving poor interpersonal relationships and coping skills are usually the focus of treatment in this difficult to treat population. They have difficulty developing a therapeutic alliance with their therapists due to their unresolved traumatic experiences. The presence of psychiatric disorders e.g. mood disorder or PTSD and SUD in borderline patients are associated with more severe clinical presentations and poorer treatment outcomes.
There has been a new trend in using animals in the treatment of patients with psychiatric disorders e.g. service dogs for patients with PTSD , therapy dogs for inpatient psychiatric patients . The utilization of animals in therapy is based on psychodynamic theories such as object relations. Animal assisted therapy could be beneficial for patients with a history of traumas and personality disorders. Animals are perceived as a safer medium than humans for this population to build trust and improve interpersonal relationships. The evolution of the relationship with the animal is used by the therapist to facilitate the interpretation of the patient’s behavior in a non-judgmental manner. This model of therapy may improve psychiatric symptoms for patients who are resistant to traditional psychotherapy.
Equine Assisted Therapy (EAT) i.e. therapeutic interventions with horses; may be a better model than smaller animals like dogs in achieving this goal. Horses are bigger animals, respond to social cues and offer physical activity for the rider. Gaining control over the horse empowers the rider and improves self-confidence and communications skills. It could also strengthen pelvic muscles, gait and posture for the rider. Several studies reported the effect of EAT on improvement of affective, cognitive, behavioral, and physical parameters for patients with various neurological and psychiatric disorders [6-9]. Therefore, EAT may provide several advantages for SUD patients who are resistant to treatment due to their psychiatric comorbidities. Unfortunately there have not been any studies to date examining the potential benefits of EAT in this population. A couple of articles mentioned its potential benefits for SUD [10-11] and some programs talked about it in scientific conferences .
In this editorial we would like to explain the potential benefits of this model for treatment of patients with comorbid SUD and other psychiatric disorders whom are resistant to usual treatment. The comorbidity of psychiatric disorders in patients with SUD is high. Mood disorders, PTSD and personality disorders are common in patients with SUD. The presence of comorbid psychiatric disorders for patients with SUD has been reported to be associated with poor treatment outcome and high relapse rate. EAT is currently categorized under alternative medicine due to the lack of information about its potential as an evidence based model of treatment. Most of the current studies are limited by the sample size, lack of randomization or the absence of a control group. There is a current gap of research in this population and more research is needed to study EAT for patients with SUD and co-occurring psychiatric disorders.
The author would like to thank Dr. Pamela Eilender, PSyD and Ms. Kelli Crampton, LCSW for their assistance with the editing of this letter.
- Wong WC, Marinelli M. Adolescent-onset of cocaine use is associated with heightened stress-induced reinstatement of cocaine seeking. Addict Biol. 2016; 21: 634-645.
- Odeon MM, Andreu M, Yamauchi L, Grosman M, Acosta GB. Chronic postnatal stress induces voluntary alcohol intake and modifies glutamate transporters in adolescent rats. Stress. 2015; 18: 427-434.
- Mantsch JR, Baker DA, Funk D, Le AD, Shaham Y. Stress- Induced Reinstatement of Drug Seeking: 20 Years of Progress. Neuropsychopharmacology. 2016; 41: 335-356.
- O’Haire ME, Guérin NA, Kirkham AC. Animal-Assisted Intervention for trauma: a systematic literature review. Front Psychol. 2015; 6: 1121.
- Chu CI, Liu CY, Sun CT, Lin J. The effect of animal-assisted activity on inpatients with schizophrenia. J Psychosoc Nurs Ment Health Serv. 2009; 47: 42-48.
- Earles JL, Vernon LL, Yetz JP. Equine-assisted therapy for anxiety and posttraumatic stress symptoms. J Trauma Stress. 2015; 28: 149-152.
- Nurenberg JR, Schleifer SJ, Shaffer TM, Yellin M, Desai PJ, Amin R, et al. Animal-assisted therapy with chronic psychiatric inpatients: equine-assisted psychotherapy and aggressive behavior. Psychiatr Serv. 2015; 66: 80-86.
- Lanning BA, Baier ME, Ivey-Hatz J, Krenek N, Tubbs JD. Effects of equine assisted activities on autism spectrum disorder. J Autism Dev Disord. 2014; 44: 1897-1907.
- Hession CE, Eastwood B, Watterson D, Lehane CM, Oxley N, Murphy BA. Therapeutic horse riding improves cognition, mood arousal, and ambulation in children with dyspraxia. J Altern Complement Med. 2014; 20: 19-23.
- Masini A. Equine-assisted psychotherapy in clinical practice. J Psychosoc Nurs Ment Health Serv. 2010; 48: 30-34.
- Dezutti JE. Eating disorders and equine therapy: a nurse’s perspective on connecting through the recovery process. J Psychosoc Nurs Ment Health Serv. 2013; 51: 24-31.
- Moore L, Wagner P, Jeffrey H. Addiction programming model at its best. Paper presented at the 10th annual conference of the Equine Assisted Growth and Learning Association, Asheville, NC. 2009.