Advertisement
Browse Subject Areas
?

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Evaluation of an equine-assisted therapy program for veterans who identify as ‘wounded, injured or ill’ and their partners

  • Madeline Romaniuk ,

    Roles Conceptualization, Data curation, Funding acquisition, Methodology, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing

    romaniukm@ramsayhealth.com.au

    Affiliations Gallipoli Medical Research Institute, Veteran Mental Health Initiative, Greenslopes Private Hospital, Brisbane, Queensland, Australia, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, Queensland, Australia, Institute of Health & Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia, Institute of Resilient Regions, University of Southern Queensland, Springfield Central, Queensland, Australia

  • Justine Evans,

    Roles Writing – original draft, Writing – review & editing

    Affiliation Gallipoli Medical Research Institute, Veteran Mental Health Initiative, Greenslopes Private Hospital, Brisbane, Queensland, Australia

  • Chloe Kidd

    Roles Formal analysis, Writing – original draft, Writing – review & editing

    Affiliation Gallipoli Medical Research Institute, Veteran Mental Health Initiative, Greenslopes Private Hospital, Brisbane, Queensland, Australia

Evaluation of an equine-assisted therapy program for veterans who identify as ‘wounded, injured or ill’ and their partners

  • Madeline Romaniuk, 
  • Justine Evans, 
  • Chloe Kidd
PLOS
x

Abstract

The aim of this study was to evaluate outcomes of an equine-assisted therapy program for Defence Force veterans and their partners across the psychological domains of depression, anxiety, stress, posttraumatic stress, happiness, and quality of life, as well as compare the outcomes of an Individual and Couples program. A non-controlled, within-subjects longitudinal design was utilized with assessment at three time points (pre-intervention, post-intervention, and three months follow-up). Between-subjects analysis with two groups was also conducted to compare the outcomes of the Individual and Couples programs. Participants were recruited from ten programs in 2016 with a total of 47 veterans and partners from both an Individual program (n = 25; veterans only) and a Couples program (n = 22). Outcome measures included the Depression Anxiety Stress Scale-21, Posttraumatic Stress Disorder Checklist for DSM-5, Oxford Happiness Questionnaire, and Quality-of-Life Enjoyment and Satisfaction Questionnaire-Short Form. Paired samples t-tests revealed that within both the Individual and Couples programs, there were significantly fewer psychological symptoms and significantly greater levels of happiness and quality of life at post-intervention compared to pre-intervention. Reduced psychological symptoms were maintained at the three months follow-up for participants of the Couples program only. Independent samples t-tests revealed participants in the Couples program reported significantly less symptoms of depression, stress, and posttraumatic stress disorder (PTSD) at follow-up compared to participants in the Individual program. These results indicate there may only be meaningful benefits for equine-assisted therapy in the reduction of depression, stress, and PTSD symptoms for veterans, if partners are integrated into the intervention.

Introduction

Extensive research has highlighted substantial rates of psychiatric disorders as well as symptoms of posttraumatic stress disorder (PTSD), depressive and anxiety disorders among Australian military veterans [15]. Research has also noted that partners of military veterans with psychiatric disorders are vulnerable to increased psychological distress and occurrences of psychiatric disorders themselves [69]. Poor mental health is associated with substance abuse [10], suicidal ideation and behaviours [7, 11], physical health comorbidities [12, 13], and reduced quality of life [1]. Given the elevated rates of disorders in this population, research into effective psychological treatments is vital. PTSD in particular can be a complex condition to treat and there remains evidence of dropout and non-response rates of up to 50% in studies of empirically supported treatments [14]. Within the veteran population there are also additional barriers to seeking traditional psychotherapy for psychological conditions. One of the most dominant barriers noted in past research is the stigma that is associated with mental health disorders and accessing psychotherapeutic treatment [1518]. In an attempt to mitigate the perception of stigma with mental health services, there has been growing interest in the utility of ‘adjunct’ therapy interventions which are not considered the first line treatment for PTSD or commonly co-occurring conditions, but which can be considered a part of the battery of interventions that may be useful in management of mental health symptoms for this population. An adjunct therapeutic intervention that has recently gained a following in the veteran community is equine-assisted therapy.

Equine-assisted interventions

Worldwide, there are now more than 600 equine-assisted therapy programs designed for patients with a broad range of psychological and physical conditions [19]. Equine-assisted therapy is an adjunct intervention that incorporates experiential activities with horses within a traditional therapeutic framework (such as cognitive behavioural therapy or relational Gestalt therapy) to treat a range of psychiatric symptoms and disorders [20, 21]. Research has assessed the effectiveness of equine-assisted therapy programs [2131], equine-assisted activities [32, 33] as well as therapeutic horse riding [34, 35, 36] aimed at reducing psychological symptoms. Participants of these programs have reported reduced anxiety and depression symptoms [22, 29, 32, 33] reduced PTSD symptoms [34, 35], elevated self-esteem and self-awareness [30], improved communication and trust [31, 34], and increased overall well-being [23]. However, the majority of this research has focused on children and adolescents [24, 31, 32] with limited peer-reviewed studies investigating the utility of equine-assisted therapy for military veterans [25, 27, 33].

Lanning and Krenek [33] conducted an exploratory, mixed methods study investigating the outcomes of an equine-assisted activities program for 13 veteran participants. Prior to participation in the program, qualitative analysis revealed common themes of “hopelessness”, “need for healing”, “isolation”, and “depression” as descriptors of the participants’ current state. When the participants were asked to reflect on the changes they experienced as a result of the intervention, themes of “increased sociability”, “reduced feelings of isolation”, “increased sense of trust and hope”, and “increased need to serve others” were noted [33]. Quantitative data indicated that participants who completed the 12 sessions of the program reported less physical and emotional limitations in a number of health domains. Participants also experienced a reduction in depression symptoms over time, as measured by the Beck Depression Inventory (BDI-II). However no statistical analysis was conducted on this data to determine if this drop in symptoms was significant [33].

Results from an evaluation of a series of pilot workshops of an equine-assisted learning program demonstrated positive outcomes for veterans diagnosed with PTSD [25]. The pilot study (n = 31 veterans; n = 25 spouses/partners) utilized a self-report measure developed by the researchers (yet to be validated), which included two sub-scales: Relieving Symptoms of PTSD subscale and Acquisition of Coping Skills subscale [25]. The study found 87.1% of veteran participants reported “very positive perceived benefit” regarding relief from their PTSD symptoms. They also stated 100% of the veterans sample reported “very positive perceived benefit” with respect to acquiring new or enhanced self-mediation coping skills [30]. In terms of the spouses/partner’s experience, 88% of partners rated their veteran spouses/partners as having had a reduction with respect to PTSD symptoms. In addition, 92% of spouses/partners rated the veterans “very positive” for acquiring the coping skills necessary to improve their personal relationships [25].

Recently, Ferruolo [27] described the qualitative outcomes of an equine-assisted psychotherapy pilot program for homeless and unemployed veterans living at a Veterans’ Affairs hospital (n = 8). The program was conducted through an established therapeutic horse farm and facilitators were masters-level trained social work and counselling professionals. The two-day program consisted of four segments including psycho-education, guided experiential equine activities, group processing, and personal reflection. Overall, participants’ qualitative responses about the perceived benefits of the program included “learning about self”, “spiritual connection”, “trust”, and “respect” [27].

Based on the available literature, there are limited conclusions that can be drawn regarding the efficacy of equine-assisted activities and therapy programs as an adjunct treatment for psychological conditions and associated symptoms among veterans. While demonstrating some promising trends, the studies outlined above include a number of limitations such as a large variation in methodological approach, absence of follow-up data, and limited use of quantitative and standardised psychometric assessment tools.

The current study

The current study seeks to expand on prior research and contribute to the growing evidence regarding the utility of equine-assisted therapy programs for veteran populations. The aim is to evaluate the outcomes of an equine-assisted therapy program for veterans who identify as ‘wounded, injured, or ill’ and their partners across the psychological domains of posttraumatic stress, depression, anxiety, stress, happiness, and quality of life, as well as compare the outcomes of an Individual and Couples program using standardised psychometric questionnaires and longitudinal follow-up.

Method

Design

The study utilized a non-controlled within-subjects longitudinal design. Between-subjects analysis with two groups was also conducted to compare the outcomes of the Individual and Couples programs. As the study is an evaluation of an existing program offered within a Veterans Service Organisation there was no random allocation to a control group condition or a naturally occurring control group available for comparison. Psychometric assessment measures were completed prior to starting the equine-assisted therapy program (pre-intervention), on conclusion of the program (post-intervention), and three months following the conclusion of the program (follow-up). Between the post-intervention and follow-up time points, participants continued treatment as usual and did not engage in further equine-assisted therapy or equine activities.

Recruitment of participants

Ethics approval was obtained from the Australian Department of Veterans’ Affairs Human Research Ethics Committee (EO16/005). Participants were members of a Veterans Service Organisation, Mates4Mates, who identify as wounded, injured, or ill and completed the equine-assisted therapy program in the 2016 calendar year. Potential participants were referred to the study by staff at the organisation during the enrolment process. Participants were informed of the purpose and aims of the study verbally by staff and through the provision of the Participant Information Sheet. They were advised that if they declined to participate in the study, it would not affect their enrolment in the program. Written informed consent was obtained prior to any study-specific procedures or assessments. The inclusion criteria for eligibility to participate in the study were: (1) ex-serving Defence Force personnel or partners of ex-serving Defence Force personnel; (2) member of the Veterans Service Organisation, Mates4Mates; and (3) approved to complete the program by a Mates4Mates’ psychologist. There were no additional study exclusion criteria. Membership of Mates4Mates is on the condition that you served/are serving in the Australian Defence Force (ADF) and you identify as ‘wounded, injured or ill’ which includes self-report of a physical and/or psychological condition.

Materials and measures

Equine-assisted therapy program.

Equine Encounters Australia (EEA) was engaged by Mates4Mates as their provider of equine-assisted therapy courses. The equine-assisted therapy program is a live-in residential therapy course held over a period of five days. The programs are led by two EEA facilitators, certified in the Equine Psychotherapy Institute (Australia) Program Model of Equine Assisted Learning/Psychotherapy and accompanied by a registered psychologist who assists in group work throughout the program. Based on the Equine Psychotherapy Institute (Australia) Model of Equine-Assisted Learning/Psychotherapy [28], the program also incorporates Relational Gestalt Therapy, mindfulness, grounding techniques, and elements of natural horsemanship. All sessional work is experiential and based around learning new skills in order to create social engagement. The therapeutic work is integrated throughout the activities by inviting participants to notice and explore their issues, challenges, and behaviours, and build awareness of their responses (e.g., fear, anxiety, and anger). As the work is based on Relational Gestalt Therapy, participants are never asked to recount or revisit their past experiences; instead, all phenomenological enquiry and observations are kept in the present. Additionally, group discussions provide participants with the opportunity to process and reflect on their experiences from the activities and the day and allows enquiry and observation from the facilitation team. The program does not include learning to ride. All programs are run from working horse properties which have outside arenas, small yards and areas for trails. All properties are rurally based and range in size from 40 to 300 acres.

The programs are run in an ‘Individual’ and ‘Couples’ format, with the latter including partners of veterans. The Couples program includes the same therapeutic activities as the Individual program but also incorporates couples dates and couples counselling to improve communication skills, build trust and respect, and develop shared and individual future goals. See Table 1 for a detailed overview of program content. A total of ten programs (six Individual and four Couples) were run in 2016 with group sizes ranging between two to eight participants. For all ten programs, the lead facilitator (and program developer) remained the same. All horses utilised across programs had prior involvement in the EAT program but the horses varied between programs, due to availability.

thumbnail
Table 1. Content for individual and couples equine-assisted therapy program.

https://doi.org/10.1371/journal.pone.0203943.t001

Demographic and service information.

Demographic information included age, gender, and current marital status. Veteran participants also reported service information including length and branch of service, if they were medically discharged, and years since discharge.

Outcome measures.

Participants’ PTSD symptoms were assessed using the Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5) [37]. The PCL-5 is a 20-item self-report measure that assesses DSM-5 symptoms of PTSD. Respondents rate each item along a 5-point Likert scale from 0 (Not at all) to 4 (Extremely) according to how much each symptom affected them over the previous month. A total symptom severity score is obtained by summing responses (total scores range 0 to 80), with higher scores indicating greater severity. A provisional diagnosis of PTSD requires at least one symptom endorsed (rated 2 or above) in symptom Cluster B (items 1–5) and in Cluster C (items 6–7) and two symptoms endorsed in Cluster D (items 8–14) and in Cluster E (items 15–20). The PCL-5 has demonstrated strong psychometric properties in previous studies and is used regularly for monitoring symptom change within interventions [3739].

Participants’ symptoms of depression, anxiety, and stress were measured using the Depression Anxiety Stress Scale– 21 (DASS-21) [40] The DASS-21 is a self-report questionnaire containing three subscales assessing the emotional states of depression, anxiety, and stress. Respondents rate each item along a 4-point Likert scale from 0 (Did not apply to me at all) to 3 (Applied to me very much, or most of the time) according to how much they were affected by the symptom over the previous week. Higher scores on each subscale (subscale total scores range 0 to 21) indicate greater experiences of depression, anxiety, and stress. The scale has demonstrated excellent psychometric properties in previous research [4042].

The Oxford Happiness Questionnaire (OHQ), a 29-item self-report questionnaire, was included to assess participants’ perceived happiness [43]. Respondents rate each item along a 6-point Likert scale from 1 (Strongly disagree) to 6 (Strongly agree). Responses are summed and the total score is then divided by 29. Final scores range between 1 and 6 with higher scores indicating greater levels of happiness. Previous research has demonstrated the measure has good psychometric properties [43, 44].

Participants’ perceived quality of life was assessed using the Quality of Life, Enjoyment and Satisfaction Questionnaire–Short Form (Q-LES-Q-SF) [45]. The Q-LES-Q-SF is a 16-item self-report questionnaire that examines quality of life, enjoyment and satisfaction [45]. Respondents are asked to rate each item on a 5-point Likert scale from 1 (Very poor) to 5 (Very good) according to how satisfied they were in the item domain over the previous week. Total scores are created by summing the first 14 items (total scores range 17 to 70) with higher scores indicating greater quality of life, satisfaction and enjoyment. Previous research has indicated the questionnaire has excellent psychometric properties [46].

Statistical analysis

All analyses were conducted using IBM SPSS 24. Independent samples t-tests were used to examine differences on outcome measures at pre-intervention between programs as well as completers and non-completers, and a Pearson’s chi-square test to compare drop-out rates at follow-up between programs. Due to the missing data at follow-up, repeated measures ANOVAs could not be reliably used. As such, paired samples t-tests were used to examine differences between pre-intervention, post-intervention, and follow-up for each program. Independent-samples t-tests were used to examine if significant differences were present at each time point between the programs. The assumption of homogeneity of variances was upheld for all analyses. Bonferroni correction was applied to account for multiple testing (p < .017) [47] and Cohen’s d effect sizes [48, 49] were calculated to assess the degree of change. Finally, Pearson’s chi-square were utilized to examine if rates of provisional PTSD diagnoses significantly differed at each time point between programs. Assumptions for chi-square tests were met.

Results

Study sample

Forty-seven participants (Individual, n = 25; Couples, n = 22) completed the equine-assisted therapy program. Demographic and service data for veteran participants are provided in Table 2. In the Couples program, partners of veterans included 1 males and 10 females aged between 31 to 57 years (Mean = 40.82, SD = 9.42).

thumbnail
Table 2. Demographic and service information for participants of the equine-assisted therapy programs.

https://doi.org/10.1371/journal.pone.0203943.t002

Independent samples t-tests revealed no significant differences between programs on any outcome measures at pre-intervention. Due to a data collection error, five participants from the Individual program did not complete the PCL-5 at pre- and post-intervention. All participants returned the other questionnaires post-intervention (100%) and 28 participants returned the PCL-5 (66.67%) and other measures (59.57%) at follow-up. Independent samples t-tests revealed no significant differences at pre-intervention between those who were ‘lost to follow-up’ and those who completed the follow-up questionnaires. Results of a chi-square test revealed no significant difference in ‘lost to follow-up’ rates between programs. Two participants at post-intervention and five participants at follow-up did not complete 13 or more items on the OHQ and as such, these incomplete questionnaires were removed from subsequent analyses. Table 3 displays frequency, means, and standard deviations for each measure across data collection time points.

thumbnail
Table 3. Frequency, means, and standard deviations of measures across data collection time points.

https://doi.org/10.1371/journal.pone.0203943.t003

Within-subjects analyses

For each program, paired samples t-tests were used to examine if significant changes on the measures occurred between pre-intervention and post-intervention, post-intervention and follow-up, and between pre-intervention and follow-up. Table 4 displays the results of these analyses.

Individual program.

For participants of the Individual program, analyses revealed significantly lower scores on the DASS-21 and PCL-5 at post-intervention compared to pre-intervention scores. Participants also reported significantly higher scores on the OHQ and Q-LES-Q-SF at post-intervention compared to pre-intervention. However, compared to post-intervention, participants reported significantly higher scores on the DASS-21 depression and stress subscales and the PCL-5 and significantly lower scores on the OHQ and Q-LES-Q-SF at follow-up. There were no significant differences between pre-intervention and follow-up on any of the measures. Effect sizes were examined and interpreted utilising Cohen’s d guidelines; r = 0.2 (small effect), r = 0.5 (medium effect), r = 0.8 (large effect) [48, 49]. Effect sizes for all significant differences were large.

According to interpretive guidelines of the DASS-21 [36], participants’ depression subscale scores started in the ‘Severe’ range at pre-intervention, dropped to ‘Mild’ at post-intervention, and returned to ‘Severe’ by follow-up. Anxiety scores fell within the ‘Extremely Severe’, ‘Moderate’, and ‘Severe’ ranges at pre-intervention, post-intervention and follow-up respectively. While scores on the stress subscale fell within the ‘Severe’, ‘Mild’, and ‘Moderate’ ranges at pre, post, and follow-up respectively. In terms of PTSD symptoms, the mean score on the PCL-5 reduced by greater than 10 points from pre-intervention to post-intervention, indicating a “clinically significant” change, although this change was not maintained at follow-up [50].

Couples program.

For participants of the Couples program, analyses revealed significantly lower scores on the depression and stress DASS-21 subscales as well as the PCL-5 at post-intervention and follow-up compared to pre-intervention and significantly lower scores on the anxiety subscale at follow-up compared to pre-intervention. There was no significant difference in anxiety scores between pre-intervention and post-intervention and no significant difference in DASS-21 and PCL-5 scores between post-intervention and follow-up. Participants also reported significantly higher scores on the OHQ and Q-LES-Q-SF at post-intervention compared to pre-intervention; however, there was no significant difference between pre-intervention scores and follow-up on these measures. Additionally, participants reported significantly lower Q-LES-Q-SF scores at follow-up compared to post-intervention. Effect sizes for all significant differences were large.

According to interpretive guidelines of the DASS-21 [40], participants’ depression scores started in the ‘Moderate’ range at pre-intervention, dropped to ‘Normal’ at post-intervention and ended in the ‘Mild’ range by follow-up. Anxiety scores started within the ‘Severe’ range at pre-intervention, dropped to ‘Moderate’, at post-intervention and dropped further to ‘Mild’ by follow-up. Scores on the stress subscale fell within the ‘Moderate’, ‘Normal’, and ‘Mild’ ranges at pre, post and follow-up respectively. Additionally, from pre-intervention to post-intervention, the mean score on the PCL-5 reduced by greater than 10 points, indicating a “clinically significant” change that remained three months following the intervention [50].

Between-groups analyses

Independent samples t-tests were used to compare scores on each measure, at pre-intervention, post-intervention, and follow-up, between the Individual and Couples programs (Table 5). The results of these analyses revealed no difference in baseline scores between programs, but significant differences in the depression and stress DASS-21 subscales and PCL-5 at follow-up, with participants in the Couples program reporting significantly fewer symptoms compared to participants in the Individual program. There were no additional significant differences between the programs reported. Effect sizes for significant differences were large.

thumbnail
Table 5. Independent samples t-Tests comparing individual and couples program scores on each measure across time points.

https://doi.org/10.1371/journal.pone.0203943.t005

Chi-square tests were utilized to determine if there were significant differences in frequency of provisional PTSD diagnoses between programs at pre- intervention, post-intervention, and follow-up (Table 6). Results revealed no significant differences between programs at pre-intervention and post-intervention. There was a significant difference at follow-up with fewer participants in the Couples program meeting criteria for provisional PTSD diagnosis compared to participants in the Individual program. Fig 1 represents mean scores on outcome measures at pre-intervention, post-intervention, and follow-up for each program.

thumbnail
Fig 1. Mean scores on outcome measures at pre-intervention, post-intervention, and follow-up for each program.

Grey line represents Couples Program. Black line represents Individual program. Error bars represent standard errors.

https://doi.org/10.1371/journal.pone.0203943.g001

thumbnail
Table 6. Chi-square tests comparing provisional PTSD diagnoses between programs at each time point.

https://doi.org/10.1371/journal.pone.0203943.t006

Discussion

This study aimed to evaluate the psychological outcomes of an equine-assisted therapy program for veterans and their partners, specifically across the domains of depression, anxiety, stress, posttraumatic stress, happiness, and quality of life as well as compare the outcomes of an Individual and Couples program. Given the limited research and methodological limitations in the existing literature examining the utility of equine-assisted therapy within military and veteran populations, this research contributes to the international literature through the inclusion of a couples condition as well as follow-up assessment.

The analyses of the Individual program indicated that symptoms of depression, anxiety, stress, and PTSD significantly reduced and participants’ self-reported happiness and quality of life significantly increased from the beginning of the program to the conclusion of the program. However, results also demonstrated these gains were short-term, with scores on all measures, except anxiety, returning to pre-intervention levels three months following the conclusion of the program. Analyses of the Couples program indicated that symptoms of depression, stress, and PTSD significantly reduced by the conclusion of the program and this reduction remained three months later. The analysis also demonstrated a gradual reduction in anxiety symptoms from pre-intervention resulting in a significant reduction at the three month follow-up point. Participants’ self-reported happiness and quality of life significantly increased from the beginning to the conclusion of the program, although, this increase did not remain three months later. The results of the Couples program are in line with previous findings suggesting some benefits exist for the use of equine-assisted therapy with veterans with mental health difficulties [25, 33].

When comparing participants’ outcomes in the Individual and Couples programs, both veterans and partners who completed the Couples program reported significantly less symptoms of depression, stress, and PTSD three months following the conclusion of the program, despite no difference prior to commencing the program or at post-intervention. In addition, significantly fewer participants in the Couples program met provisional diagnosis of PTSD at follow-up compared to participants of the Individual program. Further, the clinically significantly reduction in PTSD symptoms noted at post-intervention only remained three months later for participants of the Couples program. It could be possible that the Couples program may facilitate greater psychological outcomes long-term than the Individual program. As the Couples program includes involvement of the veteran’s partner, this perhaps indicates that adaptive coping strategies developed during the program can be rehearsed and reinforced with the partner once the program concludes, leading to ongoing stability of psychological symptoms. This is in line with previous literature, which suggests involvement of a family member in therapy may be beneficial for veterans [51, 52]. The Couples program also included additional couples therapy strategies within the intervention. As such, the difference may also be influenced by the improved quality of the intimate relationship, which has been associated with better mental health generally in previous research [53, 54]. It may also be possible that veterans with partners willing to engage in therapy are likely more supportive which may lead to better long-term outcomes for the veteran, independent of type of intervention.

Limitations

Despite the strengths of the research, there are limitations that must be acknowledged. First, as this was an evaluation of an existing service, the study design did not include a control group. As such, conclusions regarding efficacy of the intervention cannot be made as outcomes could be attributed to other non-controlled factors including participation in other therapeutic activities. Additionally, the sample size for quantitative data analysis remained small and as such, the type of analysis that could be conducted was restricted. In particular, the impact of the dyadic data on the outcomes was not able to be assessed using multi-level modelling, and analysis of variance between the 10 programs was not completed. Finally, a substantial proportion of participants were lost to follow-up at three months. This further restricts the interpretation of the findings.

Future research and practical implications

To determine the utility of equine-assisted therapy within a veteran population with more certainty, future research should proceed in a number of ways. Conducting a wait-list controlled trial of the equine-assisted therapy program, increasing the sample size, and improving data collection procedures at follow-up to improve response rates would be of use. Using a mixed methods approach and collecting both qualitative and quantitative data may also be useful in determining effectiveness of a program, as well as providing greater insight regarding the mechanisms of change of the intervention. Finally, including an assessment of relationship quality would also be useful in the future, and may help determine if there is a mediating role of relationship quality between the Couples program and improved mental health. In terms of practical implications for the field, this study generates some questions regarding the durability of treatment gains of a five day EAT program. This means that EAT program developers and clinicians may need to carefully consider the length of the intervention being delivered and to ensure a method of follow-up is included, to mitigate potential mental health deterioration among participants. This may include the implementation of EAT ‘booster sessions’ which occur at regular intervals following core program conclusion, or referral to a mental health provider at the end of the program to facilitate ongoing self-reflection and consolidation of skills learnt. However, robust recommendations cannot be made until findings of this study are replicated with the above limitations addressed.

Conclusions

Given the limited research examining the utility of equine-assisted therapy within veteran populations, this research contributes to the international literature by assessing the psychological outcomes of an EAT program using quantitative psychometric measures, comparing the outcomes of both a Couples and an Individual EAT program, and by including follow up assessment, 3 months after the program. The results indicate that equine-assisted therapy might be useful in the reduction of depression, anxiety, stress, PTSD symptoms and the improvement of happiness and quality of life, but that these gains may only be short-term unless partners are integrated into the intervention. While these findings demonstrate a promising trend, no conclusions regarding efficacy can be made and a controlled trial, with a larger sample size would help determine if equine-assisted therapy is an effective adjunct intervention for veterans.

Acknowledgments

The Gallipoli Medical Research Institute would like to thank those who assisted with the evaluation process including: Suzanne Desailly, Brenda Tanner, the psychology team at Mates4Mates, Georgia Richards, Rebecca Theal, John Gilmour and Gina Fisher.

References

  1. 1. Ikin JF, Creamer MC, Sim MR, McKenzie DP. Comorbidity of PTSD and depression in Korean War veterans: Prevalence, predictors, and impairment. J. Affect. Disord. 2010; 125: 279–86. pmid:20071032
  2. 2. Ikin JF, McKenzie DP, Gwini SM, Kelsall HL, Creamer M, McFarlane AC, et al. Major depression and depressive symptoms in Australian Gulf War veterans 20 years after the Gulf War. J. Affect. Disord. 2016; 189: 77–84. pmid:26409313
  3. 3. Kang HK, Natelson BH, Mahan CM, Lee KY, Murphy FM. Post-traumatic stress disorder and chronic fatigue syndrome-like illness among Gulf War veterans: A population-based survey of 30,000 veterans. Am J Epidemiol. 2003; 157(2): 141–8. pmid:12522021
  4. 4. McKenzie DP, Ikin J, McFarlane A, Creamer M, Forbes A, Kelsall H, et al. Psychological health of Australian veterans of the 1991 Gulf War: An assessment using the SF-12, GHQ-12 and PCL-S. Psychol. Med. 2004; 34(8): 1419–30. pmid:15724873
  5. 5. O'Toole BI, Catts SV, Outram S, Pierse KR, Cockburn J. The physical and mental health of Australian Vietnam veterans 3 decades after the war and its relation to military service, combat, and post-traumatic stress disorder. Am. J. Epidemiol. 2009; 170(3): 318–30. pmid:19564170
  6. 6. Manguno-Mire G, Sautter F, Lyons J, Myers L, Perry D, Sherman M, et al. Psychological distress and burden among female partners of combat veterans with PTSD. J. Nerv. Ment. Dis. 2007; 195(2): 144–51. pmid:17299302
  7. 7. O'Toole BI, Orreal-Scarborough T, Johnston D, Catts SV, Outram S. Suicidality in Australian Vietnam veterans and their partners. J Psychiatr Res. 2015; 65: 30–6. pmid:25914085
  8. 8. Outram SUE, Hansen V, Macdonell G, Cockburn JD, Adams JON. Still living in a war zone: Perceived health and wellbeing of partners of Vietnam veterans attending partners' support groups in New South Wales, Australia. Aust. Psych. 2009; 44(2): 128–35.
  9. 9. Westerink J, Giarratano L. The impact of posttraumatic stress disorder on partners and children of Australian Vietnam veterans. Aust. N. Z. J. Psychiatry. 1999; 33(6): 841–7. Epub 2000/01/05. pmid:10619210.
  10. 10. Mills KL, Teesson M, Ross J, Peters L. Trauma, PTSD, and substance use disorders: Findings from the Australian National Survey of Mental Health and Well-Being. Am J Psychiatry 2006; 163(4): 652–8. pmid:16585440
  11. 11. Kuehn BM. Soldier suicide rates continue to rise: military, scientists work to stem the tide. JAMA. 2009; 301(11): 1111–3. pmid:19293405
  12. 12. Kelsall HL, McKenzie DP, Forbes AB, Roberts MH, Urquhart DM, Sim MR. Pain-related musculoskeletal disorders, psychological comorbidity, and the relationship with physical and mental well-being in Gulf War veterans. PAIN. 2014; 155(4): 685–92. pmid:24361580
  13. 13. McLeay SC, Harvey WM, Romaniuk MN, Crawford DH, Colquhoun DM, Young RM, et al. Physical comorbidities of post-traumatic stress disorder in Australian Vietnam War veterans. Med J Aust. 2017; 206(6): 251–7. pmid:28359007
  14. 14. Schottenbauer MA, Glass CR, Arnkoff DB, Tendick V, Gray SH. Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations. Psychiatry. 2008; 71(2): 134–68. pmid:18573035
  15. 15. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med. 2004; 2004(351): 13–22.
  16. 16. Hoge CW, Terhakopian A, Castro CA, Messer SC, Engel CC. Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans. Am. J. Psychiatry. 2007; 164(1): 150–3. pmid:17202557
  17. 17. Kulesza M, Pedersen ER, Corrigan PW, Marshall GN. Help-seeking stigma and mental health treatment seeking among young adult veterans. Mil Behav Health. 2015; 3(4): 230–9. pmid:26664795
  18. 18. Pietrzak RH, Johnson DC, Goldstein MB, Malley JC, Southwick SM. Perceived stigma and barriers to mental health care utilization among OEF-OIF veterans. Psychiatr. Serv. 2009; 60(8): 1118–22. pmid:19648201
  19. 19. Russell E. Horses as healers for veterans. Can Med Assoc. 2013; 185: 1205. pmid:24003092
  20. 20. Lee PT, Dakin E, McLure M. Narrative synthesis of equine‐assisted psychotherapy literature: Current knowledge and future research directions. Health Soc. Care Community. 2016; 24(3): 225–46. pmid:25727575
  21. 21. Masini AP. Equine-assisted psychotherapy in clinical practice. J Psychosoc Nurs Ment Health Serv. 2010; 48(10): 30–4. pmid:20873699; 20873699.
  22. 22. Earles JL, Vernon LL, Yetz JP. Equine‐assisted therapy for anxiety and posttraumatic stress symptoms. J. Trauma. Stress. 2015; 28(2): 149–52. pmid:25782709
  23. 23. Klontz BT, Bivens A, Leinart D, Klontz T. The effectiveness of equine-assisted experiential therapy: Results of an open clinical trial. Soc Anim. 2007; 15(3): 257–67.
  24. 24. Tsantefski M, Briggs L, Griffiths J, Tidyman A. An open trial of equine‐assisted therapy for children exposed to problematic parental substance use. Health Soc. Care Community. 2017; 25(3): 1247–56. pmid:28147452
  25. 25. Duncan R, Critchley S, Marland J. Can Praxis: A model of equine assisted Learning (EAL) for PTSD. CMJ. 2014; 14(2): 64–9.
  26. 26. Duncan C, Critchley S, Marland J. Equine Assisted Therapy to Help Couples with PTSD: The Evidence for Improved Personal Relationships. Canadian Military Journal. 2017;17(2):45.
  27. 27. Ferruolo DM. Psychosocial equine program for veterans. Soc Work. 2015; 61(1): 53–60.
  28. 28. Kirby M. A psychotherapy model of ‘equine assisted psychotherapy & learning’ 2016 [cited 2018 5 February ]. Available from: http://www.equinepsychotherapy.net.au/epi-model/
  29. 29. Lefkowitz C, Prout M, Bleiberg J, Paharia I, Debiak D. Animal-assisted prolonged exposure: A treatment for survivors of sexual assault suffering posttraumatic stress disorder. Soc Anim. 2005; 13(4): 275–96.
  30. 30. Palley LS, O’Rourke PP, Niemi SM. Mainstreaming animal-assisted therapy. ILAR J. 2010; 51(3): 199–207. pmid:21131720
  31. 31. Matuszek S. Animal‐facilitated therapy in various patient populations: Systematic literature review. Holist Nurs Pract 2010; 24(4): 187–203. pmid:20588128
  32. 32. Holmes CM, Goodwin D, Redhead ES, Goymour KL. The benefits of equine-assisted activities: An exploratory study. Child Adolesc Social Work J. 2012; 29(2): 111–22.
  33. 33. Lanning BA, Krenek N. Examining effects of equine-assisted activities to help combat veterans improve quality of life. J Rehabil Res Dev. 2013; 50(8): XV–XXI. pmid:24458903
  34. 34. Lanning BA, Wilson AL, Krenek N, Beaujean A. Using Therapeutic Riding as an Intervention for Combat Veterans: An International Classification of Functioning, Disability, and Health (ICF) Approach. Occupational Therapy in Mental Health. 2017;33(3):259–78.
  35. 35. Johnson RA, Albright DL, Marzolf JR, Bibbo JL, Yaglom HD, Crowder SM, et al. Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans. Military Medical Research. 2018;5:3. pmid:29502529
  36. 36. Lanning BA, Wilson AL, Woelk R, Beaujean A. Therapeutic horseback riding as a complementary intervention for military service members with PTSD. Human-Animal Interaction. 2018; Forthcoming.
  37. 37. Blevins CA, Weathers FW, Davis MT, Witte TK, Domino JL. The Posttraumatic Stress Disorder Checklist for DSM‐5 (PCL‐5): Development and Initial Psychometric Evaluation. J Trauma Stress. 2015; 28(6): 489–98. pmid:26606250
  38. 38. Bovin MJ, Marx BP, Weathers FW, Gallagher MW, Rodriguez P, Schnurr PP, et al. Psychometric properties of the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (PCL-5) in veterans. Psychol Assess. 2016; 28(11): 1379. pmid:26653052
  39. 39. Wortmann JH, Jordan AH, Weathers FW, Resick PA, Dondanville KA, Hall-Clark B, et al. Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychol Assess. 2016; 28(11): 1392–403. pmid:26751087
  40. 40. Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995; 33(3): 335–43. pmid:7726811
  41. 41. Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychol Assess. 1998; 10(2): 176–81.
  42. 42. Weiss RB, Aderka IM, Lee J, Beard C, Björgvinsson T. A comparison of three brief depression measures in an acute psychiatric population: CES-D-10, QIDS-SR, and DASS-21-DEP. J Psychopathol Behav. 2015; 37(2): 217–30.
  43. 43. Hills P, Argyle M. The Oxford Happiness Questionnaire: A compact scale for the measurement of psychological well-being. Pers Individ Dif. 2002; 33(7): 1073–82.
  44. 44. Robbins M, Francis LJ, Edwards B. Happiness as stable extraversion: Internal consistency reliability and construct validity of the Oxford Happiness Questionnaire among undergraduate students. Curr Psychol. 2010; 29(2): 89–94.
  45. 45. Endicott J, Nee J, Harrison W, Blumenthal R. Quality of Life Enjoyment and Satisfaction Questionnaire: A new measure. Psychopharmacol Bull. 1993; 29(2): 321–6. pmid:8290681
  46. 46. Stevanovic D. Quality of Life Enjoyment and Satisfaction Questionnaire–short form for quality of life assessments in clinical practice: A psychometric study. J Psychiatr Ment Health Nurs. 2011; 18(8): 744–50. pmid:21896118
  47. 47. Shaffer JP. Multiple hypothesis testing. Annu Rev Psychol. 1995; 46(1): 561–84.
  48. 48. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, N.J: L. Erlbaum Associates; 1988.
  49. 49. Cohen J. A power primer. Psychol Bull. 1992; 112(1): 155–9. pmid:19565683
  50. 50. Weathers FW, Litz BT, Keane TM, Palmieri PA, Marx BP, Schnurr PP. The PTSD Checklist for DSM-5 (PCL-5) 2013. Available from: www.ptsd.va.gov.
  51. 51. Glynn SM, Eth S, Randolph ET, Foy DW, Urbaitis M, Boxer L, et al. A test of behavioral family therapy to augment exposure for combat-related posttraumatic stress disorder. J Consult Clin Psychol. 1999; 67(2): 243–51. pmid:10224735
  52. 52. Sherman MD, Fischer EP, Owen RR Jr, Lu L, Han X. Multifamily group treatment for veterans with mood disorders: A pilot study. CFP. 2015; 4(3): 136. pmid:26336613
  53. 53. Amato PR. Marriage, cohabitation and mental health. Family Matters. 2014; (96): 5.
  54. 54. Holt-Lunstad J, Birmingham W, Jones BQ. Is there something unique about marriage? The relative impact of marital status, relationship quality, and network social support on ambulatory blood pressure and mental health. Ann. Behav. Med. 2008; 35(2): 239–44. pmid:18347896