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Rationale of Hippotherapy Use among Equine Facilitated Therapy Participants
The use of animals to facilitate treatment, especially with children, has become an increasingly common
approach among providers of various types of therapy. In fact, a recent issue of the American Behavioral
Scientist devoted an entire issue to research on the therapeutic use of animals. Equine facilitated therapy (EFT),
or therapy involving the use of horses to treat people, has recently become particularly popular. The three facets
of EFT are (1) physical therapy, which includes hippotherapy and therapeutic riding, (2) mental therapy,
which includes equine assisted/facilitated psychotherapy, and (3) social intervention, which includes equine
assisted growth and learning programs. There are currently over 650 EFT centers nationwide with more than
30,000 clients, and 25 major universities offer EFT programs (Mission 2005). Yet despite its growing popularity,
there is little evidence-based assessment of the effectiveness of using horses in conjunction with physical, mental,
or social therapy. The lack of a best practices model creates great variability in practices of EFT and among
providers who offer this type of therapy.
The concept of using horses in rehabilitative situations has existed for approximately 2,500 years (Park 1996).
The physical, as well as emotional rewards that come from riding horses were discovered as far back as the
5th century, B.C. in Ancient Greece (Anfenson 2000). The therapeutic effectiveness of the horse-rider
relationship was rediscovered only in the last hundred years. In 1875, doctors in Paris began studying
therapeutic horsemanship, and it was practiced formally in Germany after the worldwide polio epidemic in the
1930s (Park 1996). In England, riding was offered as therapy for wounded soldiers at Oxford Hospital during
World War I (Bream 2000). With the assistance of the royal family, the British Riding for the Disabled
Association (RDA) was established in 1969 (Bream 2000). In that same year, the North American Riding for
the Handicapped Association (NARHA) was established (Wollrab 1998).
Proponents of EFT assert that it is useful in treating people with a range of physical and developmental
conditions including amputations, autism, brain injuries, cardiovascular problems, cerebral palsy, Down's
Syndrome, emotional disabilities, hearing impairments, learning disabilities, mental retardation, multiple
sclerosis, muscular dystrophy, spina bifida, spinal cord injuries, and strokes (Mission 2005). The rhythmic gait of
the horse resembles the normal human stride, and physically disabled clients are thought to show improvement
in balance, muscle strength, respiration, circulation, flexibility, and coordination (Mission 2005). Clients with
mental or emotional disabilities can exhibit improvements in communication, concentration, socialization,
patience, and self-esteem, most of which is attributed to the unique relationship with the horse (Efficacy
2003). Despite these arguments for the use of horses in therapy, surprisingly little evidence exists for
its effectiveness. The few studies that have been done involve mostly neuromuscular diseases or spinal cord
injuries. While there are many media and trade articles extolling the value of EFT, there is very little
scientific research, especially within the realm of mental therapy or social intervention.
To explore the rationale behind the use of this alternative therapy, I conducted an exploratory analysis, involving
in-depth interviews with adult hippotherapy clients, or the parents/guardians of children who use hippotherapy.
I interviewed one adult hippotherapy client, and four parents or guardians of children who participate
in hippotherapy. One family had two children who were hippotherapy clients, and so information was collected
for both children.
Participants were asked to address their experiences with EFT, their reasons for choosing an alternative therapy
such as EFT, and their satisfaction with EFT. All participants used the same hippotherapy facility and
provider, although their medical conditions and personal backgrounds were very diverse.
One adult hippotherapy client, Rose, had a surprisingly difficult entrance into the world of hippotherapy. Rose is
an older woman with Multiple Sclerosis. She was diagnosed at the Mayo Clinic in 1980, and before that time she
was, as she says, "in perfect health." Shockingly, after being diagnosed with MS, Rose spent fifteen years under
the care of the same neurologist at a major hospital and was never once offered any form of therapy to help
her condition. As her disease progressed, Rose had increasing problems with walking and with keeping her
balance. She says, "[I was] tripping over my own feet." Of the lack of options presented to her by her
neurologist, Rose says, "I was really having to do this all on my own and I knew that I needed some help." She
heard about hippotherapy through her daughter, who knew someone in the field, and she had also seen a
television program about equine facilitated therapy. Rose initially "thought about just going out and getting a
horse," but realized that she would need the assistance of a professional. Rose's hippotherapy center requires
a prescription from a doctor to participate in hippotherapy, but her neurologist was incredibly reluctant to write
her such a prescription. She says, "I had a hard time talking this doctor into giving me a prescription. But he did,
but he would only give me one to go for that first year. He would not renew it, so I had to go to another
regular family physician to get a prescription to continue to go." When asked if she remembers what the
doctor's objections were, she says, "I don't know. He didn't even want to see how well I had progressed and
what had happened or anything. When I called to see about getting another prescription, he just said 'No.' He
didn't know anything about hippotherapy, evidently. But my family physician said that if it is helping you, I have
no problem giving you a prescription for it. I've continued to get one ever since then to continue going." Rose
now has a new neurologist and has been using hippotherapy for nine years.
Rose, against her doctor's wishes, pursued hippotherapy partly out of desperation. She was offered no
traditional therapy, so she went on her own in search of an alternative approach. Since her research was
limited, trying hippotherapy was a substantial risk for her.
Ben is an eight year old hippotherapy client. Ben has autistic spectrum disorder and uses hippotherapy to
increase upper body and core muscle strength, to assist with fine motor difficulties, and to aid in his
sensory integration. Ben began using hippotherapy at the recommendation of his occupational therapist. He began
at age five and used hippotherapy for about one year, and then, after a two year break, began hippotherapy again
at the age of eight. He has since been using hippotherapy for one year. His mother Anne says that they
were satisfied with hippotherapy during the first time period in which Ben participated, and only stopped because
of time constraints. Still, when talking about such time issues, she mentions that he was starting school
and undergoing intensive occupational therapy, which indicates that she views hippotherapy as a
supplemental treatment. The main benefit that Anne sees in hippotherapy is that it serves as a form of recreation
for Ben, while also being legitimate therapy. She says that with his kind of disorder, substantial changes are rare,
at best, and so with a quiet resolve she tells me that in regards to hippotherapy, as with most of his therapies,
she must simply believe that it works. Anne's fragile faith seems to have grown out of necessity. She, like
Rose, turned to equine facilitated therapy with a sense of desperation.
Sammy and Matt are an active pair of brothers who also use hippotherapy. They are five and four, respectively,
and their busy professional parents employ a teacher to assist in the boys' various developmental needs after
school. Susan, their teacher, also takes them to hippotherapy, and so she provided most of the information about
the boys. Sammy's pediatrician prescribed hippotherapy for him when he was just 2 1/2 years old. Sammy
has Asperger's Syndrome, Attention Deficient Disorder, and delays in speech and motor developments. Sammy
is very resistant to any type of change or deviation from his normal routine or environment. He also was
previously terrified of animals and remains afraid of dogs. Matt has coordination and delayed motor development,
but his problems are much less acute than Sammy's. Interestingly enough, Sammy's hippotherapist is the one
who first noticed Matt's difficulties when Matt was at the hippotherapy center, simply waiting with their teacher
for Sammy to finish his session. Matt, too, now participates in hippotherapy.
Joseph, another hippotherapy client, is an inquisitive eight year old boy with cerebral palsy. Although he lacks
verbal skills, through his unique brand of sign language, most of which is American Sign Language and some of
which is his own creation, Joseph displays a loquaciousness appropriate to his age. Joseph's grandmother Betty,
who is his primary caregiver, has put a substantial amount of effort into researching his illness and the
various therapies that are available. Joseph participates in other alternative therapies, such as conductive learning.
Katie, a 6 year old hippotherapy patient, has been in some form of therapy since she was 10 days old.
She experienced a brachial plexus injury at birth, which resulted in nerve damage and the inability to use her
left arm. She is an otherwise healthy child. Katie's hippotherapist, Cathy, provides aquatic therapy in the
summers, and when Katie was less than 2 years old she began working with Cathy in aquatics. Cathy thought
that hippotherapy might help Katie's muscle imbalance issues, but she had never offered hippotherapy to someone
so young before. Also, Katie's parents, especially her father, were very skeptical about the validity of
hippotherapy. Her mother, Sarah, says, "Both my husband and I thought it was a tookey kind of thing. We were
like 'yeah, right.'" Sarah knew that Katie had a particular affinity for animals, however, and she says, "As a
mom you're looking for whatever is going to help your kid. You are willing to try anything. I wanted her to have
as normal a life as she could." This sentiment, again, echoes the desperation with which people seem to
approach this alternative form of therapy.
The participants varied in their initial exposure to hippotherapy. Some, such as Sammy, received their
information from a doctor. Sammy's doctor so strongly recommended hippotherapy that they proceeded with
the treatment despite his preliminary fear of animals. For others, their doctors impeded their attempts to
pursue hippotherapy. In Rose's case, her doctor blatantly refused to write her a prescription for hippotherapy.
The eagerness or reluctance of certain doctors to encourage their patients to engage in alternative therapies such
as hippotherapy is extremely interesting, and would be an excellent topic for further research.
The question remains, given the range of therapies available, why choose hippotherapy despite the lack
of comprehensive scientific evidence? The participants had a variety of answers. For Rose, the choice was
clear. Hippotherapy unmistakably helped to improve her medical condition. She has received no other form
of therapy and has seen many of her symptoms reverse. She says that in a short-term sense, just after completing
a hippotherapy session, "I'm walking better and my balance is better." Of long-term differences she says, "I'm
not tripping as much over my feet as I used to, and I think that that's what has helped me the most. And I can sit
in a chair and get up without having to use so much force to push myself up."
Anne and her son Ben, however, represent the opposite end of the spectrum. Anne was unable to identify
specific ways in which hippotherapy alone had served to improve Ben's condition. In the absence of both
extensive clinical research and any observable benefits to Ben's medical condition, why would his mother continue
to pursue this type of therapy for her son? Her answer was quite simple. They found a "very understanding"
soccer coach, and Ben joined the team, but it was soon apparent that it would simply not work. They found a
"very understanding" piano teacher, but Ben again was unable to truly participate. They found a
"very understanding" karate teacher, and this venture proved unsuccessful as well, but Anne jokes, "my other
son and my husband are both blue belts now." Anne brings her son to hippotherapy because it gives him
something extra curricular, something recreational, something of his own.
Although many of the participants reiterated this sentiment, Sammy and Matt's teacher Susan most
strongly emphasizes the appeal of hippotherapy to the children. She unapologetically described how she has to
bribe Sammy with skittles to get him to attend and cooperate during his other types of therapy. In regards
to hippotherapy, however, she says the boys are always excited to come, and that Sammy has entirely conquered
his fear of the horses. Sammy and Matt have become very attached to the horse that they ride at the
hippotherapy center, and they spend quite a bit of time talking about "their" horse.
Joseph's grandmother, Betty, views hippotherapy as a supplemental therapy. She says that she would recommend
it to others, but only as an addition to an existing therapy program. Joseph participates in a number of
different therapies, and Betty feels that the more therapy he gets, the better. She feels that he gets
something different from each type of therapy and from each therapist, and says, "I don't think you should ever
limit yourself to just one [type of therapy]." She has seen some minor, but specific changes in Joseph's
condition since starting hippotherapy, although it has only been a few months. She adds the same comment as all
of the other adults responsible for children who use hippotherapy, which is that its value lies in the child's
willingness to participate in the therapy. She says whenever Joseph is not feeling well and she gives him the option
of not going to hippotherapy, he always tells her that he wants to go. Illustrating her inclination towards more
holistic therapies, Betty says, "I think hippotherapy works more with the total child than just physical therapy."
Katie's experience provides one of the best examples of how hippotherapy can be particularly beneficial to
children. By the time that Katie was 2 years old, she had had a traumatic encounter with therapy. Her mother
Sarah says, "She had a horrible occupational therapy experience. She'd scream the whole time. She wouldn't
go. She'd had two surgeries and was heading for a third." Also, Katie was practically mute, and communicated
only by pointing. When they arrived at the hippotherapy center, Sarah says that Katie, who did not speak, "pointed
to the horse and said 'I ride him?' I said, 'You bet baby!' Now she won't shut up." Sarah says, "It's totally
amazing, the transformation [in Katie] and the bond that she's made with that horse."
Sarah has seen definite physical and emotional changes in Katie since starting hippotherapy. Her speech and her
self-esteem have improved immensely. Sarah says that, "seeing her smile and being happy while doing therapy"
is one of the greatest advantages of hippotherapy for Katie. Also, she says, "Katie is now a two-handed person,
and before she was a one-handed person." Hippotherapy has helped Katie recover the use of her left arm. They
call Katie's injured arm "Lefty," and the rule at hippotherapy is "Lefty has to help." If not, says her mother, "She
does not get to ride the horse. It gives her a positive environment where she has to work with Lefty."
Katie participates in unmounted activities, such as brushing the horse, bathing the horse, tying ribbons in the
horse's mane, or actually finger painting on the horse's body. In all of these activities, she must use her left arm.
As a reward for using "Lefty," she then gets to ride the horse, but therapy continues when mounted, as they work
on muscle imbalance issues.
Katie's mother is passionate about the benefits of hippotherapy. She says, "Society probably thinks that
this [hippotherapy] is a real fun time for a kid, but people won't donate time or money because they think that it
is just play and fun. Unless you've experienced it firsthand, you think it's a hokey thing, but it is not. It really,
really intrigues the kids and changes the environment. If you can manipulate the environment and make it
more positive, then the therapy is more productive. Hippotherapy alters the environment and allows kids to
have therapy in a setting that they love." Sarah says, "Henry [the horse] was the first influence in her life
that encouraged her to use the left side of her body." Sarah recounts a story in which she asked Katie, "Do you
think that the horse will be excited to see you?" Katie responded, "Yes, I can hear him calling my name. He's
saying 'Katie, Katie.'" Sarah says, "That's the power that these animals have over these kids. They become
entranced and are willing to do anything." When asked what Katie thinks of hippotherapy, Sarah says, "To her,
she's not going to therapy. She's going to ride Henry. She thinks he's her horse."
While the participants' rationales for using EFT are varied, there are a few patterns that can be discerned from
their responses. Some participants, such as Rose and Katie, have experienced undeniable, visible improvements
in their medical conditions. This is certainly the most clear and simple reasoning. For them, EFT works, so they use
it. Other participants, such as Ben, who is autistic, use EFT as a kind of dual therapy-recreation activity. Ben's
mother says that with her son's condition, distinct improvements are infrequent with any form of therapy, and
so with EFT, she says that at least he is outside and enjoying himself.
One theme which can be seen in all of the interviews involving children who use EFT is that this form of
therapy offers something to children that traditional therapies may not. EFT engages children and provides them
with an incentive that is hard to rival with traditional therapy. Certainly, most forms of therapy designed for
children use some type of positive reinforcement, but the enthusiasm and willingness that EFT seems to create
in children is a critical part of providing productive, effective therapy. Moreover, the parents of child EFT
clients repeatedly emphasized their feelings that while legitimate treatment and rehabilitation is taking place,
their children do not view their time at the hippotherapy center as therapy. This concept seems to be the key to
the motivation that EFT fosters in children.
All of the participants, or the participants' children, have some form of chronic disorder. None of them are
attending hippotherapy sessions to rehabilitate a broken arm or leg. All are dealing with life-long, life-
altering conditions. When facing such a challenge, people may be more willing to pursue alternative therapies such
as hippotherapy. Whether they use it as their primary form of therapy or not, and whether they think that it
greatly improves their condition or not, all of the participants feel that hippotherapy offers them something
that traditional therapies cannot provide.
I asked Rose what she considered the greatest benefit of hippotherapy. She paused for a long time, in
thoughtful silence. Finally, 72-year-old Rose, with her perfect silver hair, freshly pressed clothes, and vibrant
red lipstick, looked at me and said, very deliberately, in her sweet Southern drawl, "Well the main thing is that
I continue to be independent. I can continue to walk on my own. I can continue to drive and all that. I continue to
1. Anfenson, Christina Rae. "Special Effects of Horseback Riding." 2000. http://www.Microserve.net/~eclogue/thr2.html.
2. Bream, Jennifer A., and Spangler, Jr., William Q. "Therapeutic Horseback Riding: An Overview." 2000.
3. "Efficacy." Equine Facilitated Mental Health Association. 17 December 2003. http://www.narha.org/
4. "Mission Statement." North American Riding for the Handicapped Association. 12 January 2005. http://www.
5. Park, Heather. Country Barn Newsletter. 1996. www.countrybarn.com
6. Wollrab, Trisha I. "Therapeutic Riding: Horses Helping Humans." Journal of the American Veterinary
Medical Association. 15 Feb. 1998. www.avma.org/onlnews/javma/feb98/5021598c.htm
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