Experiences of Equine Assisted Therapy and Its Influence on Occupational Engagement among People with Mental Health Problems

Abstract

Equine Assisted Therapy (EAT) has positive influence on health. However, research is scarce regarding how people with mental health problems experience EAT and if it influences occupational engagement. Eleven people with mental health problems were interviewed regarding this issue. Data was analyzed using a hermeneutic phenomenological approach. Results showed that EAT had a positive influence on personal development and occupational engagement in forms of a catalytic experience, taking control in daily life, and being active and building relationships in life. Although the study is small in size, the results indicate that EAT could be used to facilitate meaningful occupations.

Keywords:

• Animal-assisted Interventions
• daily occupations
• equine assisted therapy
• mental illness
• occupational engagement

Introduction

Research on the daily life of people with mental health problems show that they have great difficulties in managing daily life and often lack routines as well as different forms of occupational engagement, such as being social and engage in paid work (Bejerholm & Eklund, 2004). Engagement in occupation is in this study defined as including the subjective experience from performing a daily task, as described by Pierce (2001). Research further shows that people with mental health problems most often engage in calm occupations, such as resting and sleeping, alone in their home (Bejerholm & Eklund, 2004) and report trouble in finding meaningful occupations (Argentzell et al., 2012). Research hence highlight that the target group needs help with the creation of engagement in daily occupations (Argentzell et al., 2012; Bejerholm & Eklund, 2004). National guidelines for treatment further suggest that the target group is in favor of different forms of interventions and support to manage daily life and be able to engage in occupations (Danish Health Authority, 2009). However, few rehabilitation methods exist focusing on increasing occupational engagement (The National Board of Health & Welfare, 2018) and further options for rehabilitation are hence needed.

Internationally, there is an increased focus on mental health interventions that are non-medical and focus on personal recovery of the individual, i.e., enhancing meaningful occupations (Leamy et al., 2011). In the scope of this new thinking, different forms of alternative interventions such as nature- and animal-based interventions are given more attention and are viewed as fit for purpose (Iancu et al., 2014; Palsdottir et al., 2014). Animal-assisted rehabilitation involves the interaction between animal and person for a therapeutic purpose on an individual as well as group level (Velde et al., 2005) such as the well-used Equine Assisted Therapy (EAT). EAT is an animal-assisted intervention defined by Sharon (2020): “a human participant with an equine physically present to assist the human participant, a treatment or intervention as a result of the interactions between an equine and a human participant, a purposeful and regulated interaction and a positive health outcome goal from the interaction” (p. 61). Further, EAT is an incorporation of grooming, feeding, and caring for the horse including stable work (Sharon, 2020; The National Board of Health & Welfare, 2018).

EAT is a rehabilitation form that has been used within both somatic health and mental health care for many years. The treatment is provided by different professionals such as physiotherapists, psychologists, pedagogs, nurses, social workers, and occupational therapists (The National Board of Health & Welfare, 2018). Regarding research effects there is some evidence of effects of treatment (Anestis et al., 2014; Hallberg, 2017; Kendall et al., 2015). For example, research has shown that EAT has both physical (Sharon, 2020; Stergiou et al., 2017) and psychological (Hultsjö & Jormfeldt, 2022; Kendall et al., 2015; Young & Bracher, 2005) benefits. EAT is further a promoting factor for a good body posture, good health, prosperity, and well-being in the treatment of people with physical disabilities (Bracher, 2000; Favali & Milton, 2010; Heine, 1997) and mental health problems (Cantin & Marshall-Lucette, 2011; Hultsjö & Jormfeldt, 2022; Kendall et al., 2015; Schneider & Harley, 2016). Earlier research (Heine, 1997) has also shown that EAT provides a possibility for vestibular stimulation and continual motion of the sensory integrative system, since riding promotes constant vestibular stimuli through the movement of the horse, which generates improved physical functioning and increases both physical and mental wellbeing.

Regarding specific effects of EAT for people with mental health problems, a recent review by Damian et al. (2020) shows that EAT may be effective for people with PTSD and schizophrenia, highlighting work from Jormfeldt and Carlsson (2018) showing that EAT helps to stimulate people suffering from schizophrenia to take an active role in their rehabilitation and hereby facilitate recovery. The review also highlights research from Earles et al. (2015) showing that participants who received EAT treatment had a significant reduction of symptoms of PTSD, experienced less serious emotional reactions and had fewer symptoms of depression. The study further showed that the informants receiving EAT reduced their alcohol consumption and improved strategies of self-awareness.

Research has also shown that EAT reduces symptoms of anxiety for people with mental health problems (Alfonso et al., 2015; Holmes et al., 2012). Besides, in articles in the review by Damian et al. (2020), other authors have argued that EAT improves empathy, confidence, self-esteem, and self-efficacy (Bizub et al., 2003; Burgon, 2011). EAT has shown to help to reduce violent and aggressive behavior among people with long-term psychiatric problems (Nurenberg et al., 2015). A recent study by Hultsjö and Jormfeldt (2022) showed that horses can help to facilitate personal identity, maturity, and interactions with others among participants with psychotic conditions. Further, participants’ identities and growth develop through a mutual friendship with the horses which can help to evoke a healing power.

Despite these positive results, Hultsjö and Jormfeldt (2022) acknowledge a call for more studies that could increase the potential benefits of the involvement of horses in interventions toward people with mental health problems. Although studies have shown that EAT has a positive impact on health for the target group it is only used to a limited extent by occupational therapists in treatment of people with mental health problems. This is partly due to a lack of knowledge of the intervention (Funk & Smith, 2000; Govender et al., 2016) as well as the lack of training opportunities in the concept (Bracher, 2000; Funk & Smith, 2000; Govender et al., 2016). Further, research from an occupational therapy perspective focusing on the influence of EAT on occupational engagement is also lacking which demonstrates the relevance of this study. Overall, although there is research of the effects of EAT, the empirical support within equine related treatments for people with mental health problems is still scarce (Anestis et al., 2014; Hultsjö & Jormfeldt, 2022; Kendall et al., 2015), and studies focusing on engagement in daily occupations is lacking. Therefore, the aim of the current study was to explore lived experiences with EAT and its influence on occupational engagement among people with mental health problems receiving this treatment.

Material and methods

Study design

This study has a qualitative design with a hermeneutic phenomenological approach inspired by Van Manen (1997). Phenomenology is a method of reflection on the basic structures of the lived experience of human existence (Van Manen, 1997). This approach was chosen since the purpose was to illuminate and interpret the meaning of the experiences with EAT as they were lived by the informants. The study was explorative to determine experiences with EAT and to understand how this therapy may influence occupational engagement, here defined as including the subjective experience from performing a daily task (Pierce, 2001).

Informants

The informants in the present explorative study consisted of ten women and one man between 18 and 68 years of age with a mean age of 32 years. They all had mental health problems, including neuropsychiatric conditions such as anxiety, depression, PTSD, borderline personality disorder, eating disorder, schizophrenia, and ADHD. Also stress related symptoms were seen among the target group. The informants all followed or had completed an EAT program in Denmark, which lasted from 4 months up to nearly 2 years. One had gone through an EAT program for 4 years and was still following the program (Table 1). The time interval for the program was primarily once a week, for 1–2 h.

Table 1. Overview of the length of EAT for the informants.

Laura	Tilde	Maja	Malene	Simon	Johanne	Nanna	Sofie	Alberte	Marie	Emma
5 months	5 months	11–12 months	21–22 months	7–8 months	4 months	11–12 months	12–18 months	2 × 6 months	4 years	21–22 months

Fictive names are used.

The EAT programs

Some of the EAT programs included care of the horse and riding, while others included both care of the horse, riding, and stable work or more focus on the interaction and presence with the horses. There was a client centered focus in all programs, and in some there was also a focus on setting goals for the therapy in collaboration with the participant. The EAT therapists at the facilities had different professional backgrounds such as nurse, occupational therapist, family therapist, social worker/pedagogue, caseworker, lecturer in pedagogy, cognitive therapist, psychotherapist, and riding instructor. In addition, most of them had a riding handicap instructor training, and some had further training in cognitive therapies, mindfulness, courses in riding therapy, body therapy, trauma therapy or systemic therapy.

Study setting

The study was carried out from June 2015 to September 2016. Before the study was conducted a pilot interview was performed to test the questions from the interview guide. The study then took place in settings where it was possible to find informants with mental health problems who were given EAT as a form of therapy. The informants were interviewed in different rural areas in Denmark. Eight interviews took place in riding therapy facilities, one interview in a community-based psychiatry facility, one at the informant’s private residence and one was conducted as a telephone interview.

The EAT facilities involved in the study were run by private companies although some of them had municipalities and community-based psychiatry as business partners. The facilities that had collaboration with municipalities and community-based psychiatry offered EAT to people with different kinds of mental health problems. Some of the informants who started in an EAT program would later get an internship on site as part of their progress toward work or education. Most of the informants got information about the EAT facilities through their contact persons in the municipality or community-based psychiatry but a few had searched for information about attending an EAT therapy without being helped by professionals.

Data collection

In qualitative methods the researcher searches for a variation of the homogeneous/heterogeneous population (Van Manen, 1997). Since there are few riding facilities where EAT is used for the target group it was necessary to contact most of the present riding facilities to find enough informants. The first author contacted riding facilities who offered EAT. Facilities which did not offer EAT for people older than 18 years with mental health problems were excluded in the study. The reason was that some facilities only offer EAT for children, primarily with physical impairments or disabilities, which was not the target group of the current study. When contact was established with the facilities, the aim of the study was described to the EAT therapists who were encouraged to give oral and written information about the study to their clients and ask them if they would be interested in participating. Individuals who wanted to participate gave written consents and were informed about their rights to withdraw from the study without any given reason, and that participating was treated anonymously. The informants were not given any incentives to participate.

The study was empirical, and the data collection was conducted using semi-structured interviews. An interview guide was developed by the first author and then triangulated with the second author to validate questions. Changes that occurred after triangulation were primarily that questions were comprised in order to have fewer and more open-ended questions in the final interview guide. A test interview was performed to pilot the interview guide. The final questions were established based on seeking knowledge about the informants’ experiences with receiving the treatment EAT and about the possible influence of EAT on their occupational engagement. The interview guide had opening questions related to age, gender and diagnoses or mental health problems. The following questions focused on how the informants were introduced to EAT and the length of the EAT therapy. An example of the questions was: “How were you introduced to equine assisted therapy?” The following questions were more in depth about the informants’ participation in EAT and if their occupational engagement had changed through the intervention. An example of this set of questions was: “What experiences do you have with equine assisted therapy?” and “Can you describe in detail what the therapy has meant to you?” (e.g., increased activity, improved daily life, more social relationships, getting back to work/start working, better self-confidence/self-esteem, strategies in daily life etc.) and “Has the therapy in any way affected your chances of doing activities and participating in daily life? If yes, in what way?” (e.g., leisure activities/social activities/domestic activities/self-care). The first author attempted to use similar follow-up questions with all informants, whenever possible. This gave the informants the opportunity to deepen their answers and talk more freely about the subject. The interviews were recorded and transcribed verbatim.

Procedure

The interviews were organized with interviews of one to three informants per day. The length of the interviews was between 40 min and 1 h and 23 min. All interviews were conducted individually and face to face, except one that was done by phone. All interviews were carried out by the first author in a separate room at the EAT facility.

Data analysis

The analysis process of the collected material was categorized to find understanding or explanation of the phenomena of EAT and how it may influence occupational engagement following the analysis method of Van Manen (1997). According to Van Manen (1997) the research process should be seen as a dynamic interplay between six different research activities. These include that the researcher turns to a phenomena of serious interest, investigating experiences as they are lived rather than how they are conceptualized, reflecting on the essential themes of the phenomena, describing the phenomena, maintaining a strong and oriented pedagogical relation to the phenomena, and finally balancing the research context between parts and the whole.

The first step in the analysis process consisted of reading and re-reading the collected material from the interviews and reflection on meaning units and essential themes of the aim of the study; the phenomena of EAT and how it may influence occupational engagement. The material was then condensed and finally split up into themes and sub-themes. This process was repeated several times until an overarching theme was generated in the material and themes and sub-themes were formulated (see Table 2). The phenomena were then defined through a description of the overarching theme, themes, and sub-themes, and finally the results were discussed. During the process, the analysis was triangulated between the first author and second author to develop a rich and nuanced reading of the material in a reflexive manner and to validate the progress and the findings.

Table 2. Example of analysis steps.

Meaning unit	Condensed meaning unit (close to the text)	Condensed meaning unit interpreting the underlying meaning	Sub-theme	Theme
“I have become more social. That is because I have learned to be with other people without being afraid and dare to be myself.”	EAT helps to become more social and have the courage to be oneself when socializing	Socializing and experiencing togetherness	Creating relationships and togetherness in daily life	Being active and building relationships in life

Ethical considerations

Informed consent was obtained from all informants prior to data collection. In line with Declaration of Helsinki (World Medical Association [WMA], 2013) and ethical principles, the informants were provided written and verbal information about the study and voluntary participation, anonymity, their right to withdraw participation from the study without giving any reason, confidentiality of data collected, and furthermore, that no findings can be associated with them.

In relation to pre-understanding and earlier experiences, the first author collecting the data is an occupational therapist who has experience of working within psychiatry, however not with any of the informants in this study. The author also has knowledge about EAT and different interventions with horses due to personal interest in horses and training as handicap riding instructor.

The National Committee on Health Research Ethics in Denmark was contacted for the study but did not need to give any consent since the study does not include personal identifiable information. For the same reason, the study did not need to be approved by the Danish Data Protection Agency.

Results

The results showed that EAT generally was experienced as meaningful and affected the informants’ occupational engagement in a positive way. Through the interpreting and analysis of the data, an overarching theme was developed together with three main themes with related subthemes. The overarching theme was: The relationship and togetherness with the horse enables personal development and occupational engagement. This theme was generated in different ways in each of the informants’ experiences with EAT. The three main themes with related sub-themes are presented below (Table 3). Fictive names were used when presenting the results.

Table 3. Overarching theme, themes, and related sub-themes.

The relationship and togetherness with the horse enables personal development and occupational engagement
The catalytic experience	Taking control in daily life	Being active and building relationships in life
Being comforted and building friendship	Being in control and setting boundaries	Creating relationships and togetherness in daily life
Becoming confident and experiencing trust	Becoming aware of one’s body and mind	Building the day and creating structure in life
Feelings of not being alone	Being calm and present in the moment	Positive development and feelings of hope

The catalytic experience

One theme that was developed among the informants’ experiences was that of being in the present and having a form of togetherness with the horses, which was viewed as a very important part of the EAT therapy. The informants talked about the horses in terms of being like catalysts for feelings such as love and emotions like inner peace and feelings of being comforted. The horses also seemed to give the informants the opportunity to immerse themselves and show care. This type of experience was also generated when realizing that one was not alone and that one could get support from peers in the EAT group.

Being comforted and building friendship

One of the present sub-themes, generated among several of the informants, was how the horses comforted the informants and how a friendship and an emotional bond was built with the horses.

Malene, who suffered from anxiety and had a depression earlier in life, talked about the emotions that she felt when she lay on the horse and felt the warmth from it. She also expressed that thanks to EAT she learned to master emotions such as anxiety. Her anxiety disappeared when she was with the horse as the horse gave her peace and love which was experienced as close friendship. She explained:

It was almost like getting a hug from the horse. At first it was a bit uncomfortable (to lie on the horse), but then I got used to it and then it was a nice feeling […] I felt love from the animals and to the animals […] The animals are another kind of friend.

The results also showed that togetherness with the horse and special types of exercise on the horse in different ways gave feelings of comfort. Johanne, who had a psychological crisis and somatic symptoms after a head trauma, said:

Every time I came up on Hector (horse) and when Ellie (EAT therapist) made a body scan with me either by sitting on him or holding my arms around him, it made something complete, something really noticeable to me, well it is like being comforted when you are a little child.

Included in the catalytic experience was that EAT not only gave feelings of becoming friends with the horse but also helped informants to “become friends with themselves” by building better self-esteem and self-confidence. This was done through having the responsibility for the horses and taking part in tasks related to the horses and stable work. Managing these tasks greatly impacted how the informants viewed themselves, and their growth into maturity. Sofie, a young woman who had been through several psychological problems in her life, difficulties in social relationships and earlier problems with drug addiction, said:

I have become friends with myself. To explain; before I started here with Ellie (EAT therapist), I could stand and knock my head into a mirror a thousand times a day. Well, I stood and said to myself that I was strange, I was stupid, I was ugly. Today I can look at myself in the mirror and think “I am the most beautiful girl in the world” and that is such a great feeling.

Becoming confident and experiencing trust

Another sub-theme generated was that the horses helped the informants to experience confidence and trust in a relationship. The informants expressed that they could then later transfer this experience into their daily life and social relationships with humans. Laura, who was in recovery from an emotionally unstable personality disorder (borderline), said that EAT had helped her, and seemed to also have helped her peers in the EAT therapy, through slowly being challenged in the work with the horses, building trust with the horse and confidence in herself. She said:

Everyone I see who has been through it (EAT), they started as little grey mice, and they simply flourish […] You are seen as the person you are. You slowly become stronger. You start trusting the horses and then slowly, you start trusting yourself and then you are challenged, little by little. And it is always at the person’s own pace.

Maja, a young woman who suffered from PTSD, depressive thoughts, and anxiety, had gained trust in the relationship with the horse by learning to read the signals of the horse and simply to be around the horse. Maja highlighted that having focus on the horse, helped her feel safe and diminish negative thoughts about herself as well as giving her a respite in her daily life. She explained:

It is just such a big animal that can be so calm around you, and you can stand and hold your arms around it and feel it breathe when it is breathing […] I feel confidence and I can get rid of all negative thoughts because I simply focus so much on this horse and then I become so happy and also relieved, you might say I get a respite.

Similar to Maja, Malene also expressed that EAT and being with the horse diminished psychiatric symptoms:

I did not feel anxious when I was together with the animals, I felt confident.

Feelings of not being alone

The informants talked about how they through EAT could help themselves through cooperating with others in the therapy, a form of informal peer support which also was a catalytic experience. They experienced this as being part of a unified group where everyone had similar experiences and supported each other in feeling better. Several of them had experienced being part of an EAT group where everybody supported and helped each other and had a special form of understanding for one another because all had different kinds of mental health problems. For Nanna, who was diagnosed with anxiety, the social aspects of being in a group in the EAT program gave her the opportunity to be herself and experience feelings of not being alone. She said:

There is no one who judges anyone out here, and we all have something we struggle with, and we are all together, we help each other […] That helps a lot to those who have problems and just want to be somewhere and just be themselves.

Taking control in daily life

Through participating in EAT, informants learned to take more control in their lives, become aware of their boundaries with other people, and set limits in daily life. They became aware of their bodies and learned to use and control their body language in their communication with other people and found strategies to better handle anxiety and crises in their daily life. Several of them became more aware of their own thoughts and feelings, since they found peace and learned to be present in the moment as well as recognize feelings during the interaction with the horses.

Being in control and setting boundaries

The informants worked with their own boundaries and learned to set limits since this was necessary when leading the horse. This influenced how they gained control in other parts of their lives by for example, knowing how to send signals and set boundaries through body language to people around them. Tilde, a young woman who was diagnosed with social anxiety and had earlier diagnoses of OCD and Tourette syndrome, described how respect and fear for the horse turned into knowledge about how to take control and how this could be used in interactions with people. She said:

It is a big animal that most people pay respect and fear at first, but you learn to be comfortable with it and learn that it is you who have control. That is something you can transfer to interactions with people afterwards. That, ok, if I can manage such a big animal, then I can also control who is going to be in my life and what they are allowed to do with me.

Maja shared this feeling and said:

If you can control your body, you can also manage a body language that says; you are not welcome to talk to me, or you are welcome to talk to me.

In EAT, informants learned to use different tools to manage the horses, which was useful in other situations in daily life. This had an influence on Malene who used these tools to take control in her life and to distract invalidating thoughts. She explained:

When my catastrophic thoughts come, I stop them with the tools I have learned in riding therapy. When we had to stop the horse, we would say “halt”, that means stop and I say that word to myself every time my catastrophic thoughts appear in my head and then they disappear.

The informants expressed that EAT generally had a positive influence on the way they learned to handle anxiety and different forms of crisis in their lives. Emma, a young woman who suffers from an eating disorder, used the horses to take control and distract her anxiety about food. She said:

I could be very anxious after eating food, but when I had eaten my lunch and then gone out to the horse, then the anxiety was gone. Or it was at least-the horse took all the attention, and I was distracted from all those thoughts.

Becoming aware of one’s body and mind

Several of the informants had trauma history from different types of abuse in childhood or as adults. Through work with horses, they became more aware of different emotions in the body connected to the trauma and how they could handle these emotions better, which influenced them physically and mentally. Maja found that she got an awareness of her body that was new for her:

When you are on medication, then you become unaware of your body and especially if you have been exposed to any abuse on the body then you will forget so I only feel from the head and upwards and I have learned that when you’re sitting on a horse, you will have to use the whole body if you are going to ride properly. Then you must squeeze with your legs, sit right up and all these things, and it has helped me to be aware of it (the body).

Simon, who suffers from stress and ADHD, also learned to get in touch with his feelings and become aware of his body. This was very difficult because he never had allowed himself to feel his emotions or experience sensations in his body. He said:

I am allowed to “feel myself” - I am sitting down in the saddle - I have always been in the brain, now I am sort of “in the body”.

Learning about different feelings and emotions in the body and becoming aware of one’s own needs through the interaction with the horses in EAT, was also a topic the informants talked about. Alberte, who was diagnosed with borderline personality disorder and earlier had social anxiety, explained:

I really got to know my body, the different emotions in the body. This has been a big gray zone for me for many years. I have now become aware of when I have earlier been mad or when I have cried, that I have actually been sad.

Johanne acknowledged a sadness due to a trauma she experienced and was not aware of this before her progress in EAT. After becoming aware of her feelings, she began to work with these sad feelings to feel better. She explained:

I had such sadness within me, and it was only when I discovered that I had sadness within me, after about I think 5-6 sessions out here, then I simply could feel that something had happened. That the heavy sadness it was - well it was first when it was gone, I really realized it had been there […] Well, it was - in short, like balm on my soul.

Being calm and present in the moment

The informants expressed that the horses helped them to be calm and stay present in the moment. For some this was very hard and challenging. However, when they managed to stay calm and present, this had a positive influence. Sofie learned to be present in the togetherness with the horse and said:

It was quiet when I was finally in the moment; it was that strange feeling of “I am here” and that feeling of “you are here” (the horse). “You are here, I am here”, “we are fine”. Well, I really did not like it in the beginning […] The more I got into the moment, the more we found Sofie.

To be calm and present in the moment was something that required a lot of energy from the informants, and they developed these skills through different exercises with the horses. This included learning about deep breathing and mindfulness. This exercise helped Simon to become present and be in the moment with the horse. He explained:

First, it was being with the horse. Just to put your fingers in his hair, Baldur’s (horse) hair- just to stand and hug his head […] Try to find calm and deep breathing and concentration to feel and to be in the moment.

An important aspect of EAT is that it requires the informants to be present in the togetherness with the horses in a way that was very different from other kinds of therapies. Emma explained:

It has definitely been the best therapy I have had, and I have gradually tried different things […] It demands more of you than when you sit and are creative with something. It just does not require the same kind of presence. You can sit down and disappear into your own thoughts at the same time. You cannot do that with the horse. There you must just focus on the horse and drop everything else and leave it.

Being active and building relationships in life

The EAT therapy, the support given by the therapist and just being with the horses seemed to influence the informant’s possibility of building relationships and to socialize with other people during therapy as well as outside therapy. Furthermore, through EAT the informants learned to work with their goals for the future and began to engage in different occupations in their daily life and become more active. Finally, it seemed that EAT helped informants to improve their functional levels physically and mentally, such as gaining more courage and self-confidence, relaxation and feeling better both physically and mentally, form a balance in daily life, getting more energy and physically feeling more movement in the body.

Creating relationships and togetherness in daily life

In this sub-theme informants told how EAT had influenced their abilities to become more social and able to build relationships with other people. Laura believed that the relationship with the horse was about both “taking and giving”. Through general care such as feeding and brushing the horse and giving the horse a massage, she could give something back to the horse. She learned to transfer this to daily life and have the same equal relationship to a new boyfriend. She explained:

You also learn to take care of others when taking care of the horse […] It is the “take and give relationship” […] I like the fact that you are equal in a relationship. In a relation. And I have also brought that with me now, where I have got a boyfriend just recently. And it is also a very equal (relationship) - where we give and take.

Several of the informants reported that they had become more social and gained courage in building social relationships while doing the EAT therapy together with others. Malene told that EAT helped her to dare being with other young people and interact and socialize with them, which had been very hard for her earlier. She said:

I went to a club for young people and at the beginning, I was very insecure, and I did not say much. Now I have started to say no […] Before I was only able to talk to one person at a time, but now I can join in in a conversation with 2-3 people.

When a trusting relationship was created the EAT therapist seemed to have a great influence on the informants to complete the EAT process and the relationship also had an influence on how the informants felt about themselves. It was an important support that the therapist was proud of the informant’s progress. Maja explained:

At the beginning I found it hard to recognize and acknowledge that it was me who did all the work, but Ellie (EAT therapist) has made me very aware of that it is me that has done it all, and it has been so cool - well to be made aware of this by another person who was proud of me.

Malene explained that the support from the EAT therapist helped her when she had days where it was difficult to get up and leave the house in the morning. She said:

I sometimes wrote that I did not feel well that I was ill, and I could not come. Then she (EAT therapist) still just picked me up and got me out of bed.

Building the day and creating structure in life

The daily routines with the horses, such as taking care of the horse, feeding the horse, doing stable work, and doing different exercises with the horse helped the informants to gain structure in life. It also taught the informants to be responsible and careful around the horses which they reported was important for their future life, for example a work situation. Sofie said:

I wanted to be here in the morning because it helped me to get up in the morning and to help feed the horses and to hear that munching. It really helped a lot on structuring (my daily life), and it also helped on both getting up and to arrive to something […] Well, all the things that you will also need in a workplace.

EAT also influenced the informants’ ability to set goals for the future and be more active and engage in different things, such as education, work, or social activities. Furthermore, the informants reported that they had improved their functional skills, and it became easier to perform daily activities such as taking a bus or a train. EAT had helped several of the informants to participate in different social activities they loved to do earlier but had not done for a while because of mental health problems. For Johanne it was a big victory being able to participate in activities again. She explained:

I have always liked to go to concerts, open air concerts, festivals, and such in the summer. This summer I have been to the summer festival but not all the time, but I - it was a victory that I could endure and hear a whole concert […] I dared to go to the cinema just recently, and it turned out well.

Other informants found the initiative to carry out different home chores such as cleaning the house or washing clothes. This was because they got energy from participating in EAT and transferred this energy to their daily life, even though EAT was very energy demanding. Emma explained:

At home I could walk around and think, I should have done this and that, and I would like to do this, but I did not get it done and could not really take the initiative to do it. But after riding therapy, then I could come home and then I had to do everything; vacuum, clean the house and wash clothes, and then I just suddenly had enormously much energy, even though I was really tired.

Positive development and feelings of hope

EAT had an important influence on the informants’ lives because through the process of being in the therapy, they experienced development, felt progress and their lives changing in a positive direction. Further, this helped the informants to create hope for a positive future. For some, EAT had influenced their mental health in a positive way because they had fewer relapses and readmissions to the psychiatric hospital. Laura said:

The positive is that you really can feel your personality “move”. You can feel how you can handle all sorts of things around you much better.

The fact that EAT helped the informants to gain hope for the future had a major influence on their daily life. They began to gain more positive thoughts about themselves and their possibilities, and their ambitions changed in terms of getting an education or paid work. EAT also helped the informants to believe in their own abilities. Sofie learned to view herself as a person with several positive attributes that created a feeling of hope for the future. She explained:

I have got much more hope of that I can do it. I can get out and I can get an education. I can have a nice boyfriend. I can have friends and I can have a family […] I know I will have a good future. I know I can take care of myself after being out here and that matters to me.

Informants also said that in making progress within EAT, they found they could get help and be supported from peers and EAT therapists, but to develop, they had to do the work by themselves. Maja said:

What has been important to me is that it is possible to see progress, and it had to come soon for me after I started. I just wanted to go on and then when I went here, I could quickly notice a difference, but at the same time, I realized that okay, this is actually a quite long journey, and I must do all the work myself.

All the informants reported that EAT had influenced their physical and mental well-being, and the therapy helped them to improve functional levels and become stabilized in their bodies, so that different forms of negative symptoms lessened or disappeared. Further, they had more energy, slept better at night, ate healthier, stopped taking medicine and became more aware of themselves and their own needs. Laura said EAT helped to stabilize her mental well-being, which had influence on several things:

It has stabilized it (mental well-being) very, very much. Because when it is that I am using the body, my thoughts do not wander. They almost stopped running in my head because I get physically tired, I sleep better at night, and yes, I eat better now.

The informants also became more aware of their physical and mental health needs such as taking care of themselves. For Maja it had been very difficult to do something nice for herself due to a trauma earlier in life. Taking care of the horse in EAT helped her to transfer this attention to her self-care, and she became much better at taking care of herself and giving herself a treat. She said:

It has really changed to the point of now I am taking care of myself. I have had a hard time to like myself and it made me feel dirty and maybe I have been scrubbing myself and well, really a lot. And now I have started to be like that, ok, now you have had a hard day, so treat yourself by doing a little extra, a hair treatment, you know, lubricate myself with some nice body lotion.

Experiences with EAT also worked as an alternative form of therapy that helped informants cope with their thoughts, learn about new and useful strategies such as stress management and coping skills and to become more focused and positive. This seemed to be due to the practical tasks within the EAT protocol, combined with interaction with the horse. Both the program being physical and practical and that it was outdoors in nature seemed to play a big role in how EAT influenced the informants. One of the participants, Marie, said:

The interaction with the horse where it also becomes very physical and the thing about that it is physical and practical, is really good for me, because I tend to be “in my head” as she says (EAT therapist) and in the thoughts, myriads of thoughts and that we are out in nature that is also very rewarding for me.

Discussion

The aim of the study was to explore experiences with EAT and its possible influence on occupational engagement. The result of the study implies that EAT had a positive influence on several areas in the informants’ lives. The relationship and togetherness with the horses seemed to enhance a form of personal development and influenced occupational engagement in a positive direction.

The results indicated that through a catalytic experience, general well-being and “befriending oneself” through being comforted and becoming friends with the horse was enhanced during participation in EAT. Aspects of becoming friends with oneself has also been shown in other occupational based group interventions for people with mental health problems (Lund et al., 2019). Some informants also described how they began to feel empathy for the horses and then learned to transfer this feeling toward people in their lives. These results imply that EAT seems to improve people’s well-being and to help toward enhancing aspects of self-awareness and self-confidence, also in line with earlier research on EAT (Bizub et al., 2003; Burgon, 2011).

Further, the present study indicates that the daily progress in EAT had a positive influence on the informants’ ability to also engage in various occupations outside the EAT program such as work and social interaction. According to Champagne (2011) and Bejerholm and Eklund (2004), people who suffer from mental illness or trauma often have difficulties with engagement in daily activities. In the present study the informants described how different social activities and practical tasks, such as having the responsibility of performing different practical maintenance tasks for the horses, such as feeding and grooming, helped them to improve their occupational abilities. The informants reported that they learned new skills and could transfer these into their daily life which created an increased feeling of occupational engagement. That people with mental health problems who are engaged in occupational based group interventions may transfer new skills learned in the group into their daily life has been reported in other studies for the target group, showing this as a positive result (Lund et al., 2019).

The present study further showed that the informants, through active horsemanship, learned to take control of the horse. This was generally experienced as a new ability that also helped toward taking control and own leadership roles in daily life outside EAT. This result is in line with Bracher (2000), who describes that through horsemanship the rider learns to control the horse with hands, seat, leg, and voice. It requires a partnership between the horse and the rider to gain mutual success which then gives the rider motivation and potential achievement (Bracher, 2000; Hultsjö & Jormfeldt, 2022), which seems to be in accordance with the results from the current study. This implies that forms of control and empowerment are achieved when engaging in EAT which are also important factors for personal recovery (Leamy et al., 2011).

The informants in the present study also reported that being in EAT taught them to generally be able to control daily life by becoming calmer and more present in their lives, which in turn helped them to better manage mental health difficulties. The informants learned how to be relaxed and present together with the horses since this was necessary, both to control the horse and make the horse stay calm. The informants described how the EAT therapist used mindfulness exercises while the informants lay on the horse, which seemed to help the informants improve body awareness and diminish anxiety and negative thoughts. Generally, informants reported that togetherness with the horse had a diminishing influence on anxiety and other negative mental health symptoms. These results are in line with earlier research showing reduction of symptoms among participants in EAT (Alfonso et al., 2015; Damian et al., 2020; Holmes et al., 2012; Hultsjö & Jormfeldt, 2022). Also, research has shown that the use of specific mindfulness exercises in non-medical treatments may help to reduce anxiety, depression, and other negative mental health symptoms (Chiesa & Serretti, 2011; Sundquist et al., 2017) and improve well-being and occupational functioning (Hoge et al., 2017). Furthermore, it has been shown that mindfulness interventions may increase people’s ability to participate in different forms of activity, such as work (Hoge et al., 2017), which was also a result of the current study.

The informants described that they increased their body awareness through different sensory stimuli such as feeling the hair of the horse, hearing the horse chew, and feeling the warmth of the horse or its breathing. In addition, the results showed that EAT provided an opportunity for tactile stimulation which can be related to models of so-called sensory modulation (Brown et al., 2019). In this way EAT seems to include sensory elements embedded in the treatment, and in the present study this was reported to diminish feelings of anxiety, which hence could be related to results of earlier research on more formal sensory based interventions (Wallis et al., 2018). Further, in the current study the informants seemed to become more relaxed when riding and being with the horse. According to Champagne (2011) and Champagne and Stromberg (2004) people with mental health problems or trauma often experience difficulties with sensory modulation due to distortion in sensory processing. Research shows that many people with mental health problems also are sensitive to sensory inputs and use different sensory strategies to calm and alert themselves (Andersson et al., 2021; Champagne & Stromberg, 2004; Sutton et al., 2013). This can be seen in the current study with informant stories of being present, feeling relaxed and calm in togetherness with horses due to the occurrence of modulated sensory inputs. According to Wallis et al. (2018), sensory modulation interventions are shown to improve participation in occupations, which seems to be what occurred in the present study.

The present study further showed that taking part in EAT helped the informants to build relationships and generally be able to interact more in social relationships outside of the EAT program. Not feeling alone and being together with other peers in EAT was important and seen as part of a catalytic experience. Bejerholm and Eklund (2004) describe that social interaction often is difficult for people with mental health problems. However, research shows that being social and having friends is viewed as meaningful for the target group (Argentzell et al., 2012; Forrester-Jones et al., 2012) and is also important to increase well-being and achieve mental health and recovery (Le Boutillier et al., 2011). Having a group format seemed to be valuable in the program and therapeutic factors could be seen that were in accordance with Yalom and Leszcz (2021) and Lund et al. (2019) such as the importance of relationships, and group members having a mutual feeling of being valued and accepted (Lund et al., 2019). The informants also reported a sense of not being alone which is a factor of universality (Yalom & Leszcz, 2021). So called informal peer support was also expressed in these stories. Research frequently highlights peer support as a key factor for recovery (Rosenberg & Argentzell, 2018), which underscores the importance of this aspect of the experience in the EAT intervention.

The informants also reported that they through EAT increased their psychological and physical well-being and gained more hope for their future. According to Spandler and Stickley (2011) and Leamy et al. (2011) hope is a key factor in recovery since it has the function of being both a stimulus in the recovery process and also a maintenance factor. The authors describe that compassion is necessary and must be nurtured in relationships, healing environments, contexts, and cultures for people to gain hope and recovery. This is in line with the informants’ experience of perceived social support from the EAT therapists that helped them to acknowledge their own abilities, create more structure and to generally dare to engage more in their lives. The importance of support from the therapist has been reported in earlier occupational based interventions (Lund et al., 2019). The results of the current study also generally indicate that EAT as a client centered treatment would fit well as a rehabilitation form for recovery from mental health problems, putting the client and his/her needs of hope and connectedness first (Hultsjö & Jormfeldt, 2022; Slade et al., 2012).

Limitations

Since only a limited number of occupational therapists in Denmark use EAT as a rehabilitation method, and few use it with people with mental health problems, it was difficult to find participants within the target group for this study. EAT therapists at other EAT facilities than those in this study were asked if they had clients who were appropriate to participate. Potential informants were not able to attend due to hospitalization or being too fragile to participate, according to their EAT therapists. The number of participants in the study were hence limited and the study should be viewed as exploratory.

Another consideration is that according to Van Manen (1997) it is not possible for a person to reflect on lived experience while living through it. According to this reasoning it would be difficult for informants who are participating in an EAT program to reflect on their experience with EAT. However, since almost all the informants were in the last part of the EAT program, it was possible for them to reflect on their lived experiences. For a few informants who had been in EAT some years earlier, it was hard to recall and remember their experiences. The first author tried to evoke their experiences with follow-up questions and by giving examples that helped the informants to recall their memories.

Conclusion and clinical implications

The results of the present study show that EAT and the horses enhance personal development and influence occupational engagement in a positive way among people with mental health problems. The informants described having a catalytic experience by e.g., being comforted by the horse and they reflected on the daily process as a way to build the day’s routine and create structure in life. The informants further learned how to take control of themselves and their lives by being aware of body and mind as well as staying calm. They became more active in life by building relationships, setting goals, and improving their mental functioning. The result from the current study is in line with earlier research showing that EAT enhances self-confidence and mood (Govender et al., 2016) important to living a full life in the community.

Regarding clinical implications the results indicate that the horse may be used as a therapeutic tool and EAT as an intervention could be used by occupational therapists to facilitate occupational engagement for people with mental health problems. This is of importance since, as mentioned earlier, EAT is only used to a limited extent by occupational therapists (Bracher, 2000; Funk & Smith, 2000; Govender et al., 2016). Hence an increased opportunity for occupational therapists to use EAT as intervention would be desirable.

Although there is much evidence in the physical benefits of EAT there is still a lack of scientific evidence regarding the experiences of EAT among people with mental health problems and its influence on occupational engagement. Since the current study is small, further research is needed to increase evidence for EAT as an occupational intervention for people with mental health problems.

Acknowledgement

Thanks to all the informants who participated in this study and to all the EAT therapists who helped finding informants for the interviews.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.