It’s possible that some of you are already rolling your eyes: I know my audience. In the calls for evidence-based treatment, alternative therapies are often sidelined, deemed less important or less effective. While I certainly see that side of the argument, and would advocate for a continued search for treatment efficacy, I’m not ready to abandon the search for alternative approaches. Especially when used in concert with other treatments, I find alternative therapies very intriguing, partially for what they tell us about the complexity of treating eating disorders.
In a recent study, Lac, Marble & Boie (2013) explored the use of equine-assisted psychotherapy (EAP) for eating disorders. Keep in mind that as is the case with many alternative therapies, the article is based on a case study, rather than a large-scale clinical trial. To me, the point of these types of articles is to get us thinking differently about such things as the mind-body connection in eating disorders. Do I think that the article provides us with enough evidence to start using EAP in all cases? Absolutely not. Do I think that there are some fascinating conclusions in the article? Yes indeed, and that’s why I’m writing this post.
Equine Assisted Psychotherapy
Lac and colleagues situate their work within the realm of eating disorder treatments that primarily address the relational aspects of eating disorders. While their focus is on using equine therapy to improve patients’ ability to relate to themselves and others, the authors in no way deny that eating disorders arise from a complex intermingling of genes and environment. Much like those interested in understanding more about the way the body feels in eating disorders (see this post about a study by Zucker et al. for more), they were curious about how people with eating disorders relate to their emotions and to physical sensations, as well as to others in their lives. They use EAP to learn more about the connection between the physical, the relational, and the emotional.
As the authors note, horses are often used in eating disorder treatment, but there is not a lot of literature about how effective EAP is or why it is used. Their work is specifically based in a type of therapy called Gestalt, which works on breaking down the separation between mind and body. In this type of therapy, physical sensations and feelings are intricately tied up and influence each other. The aim of Gestalt therapy is to guide the client into a sense of awareness and being-in-the-present, and to work on relationships between the person and their social world (i.e., other people in the client’s life, their surroundings, etc.). Lac, Marble & Boie note that Gestalt EAP in particular is built on 3 main components: contact, relationships, and experiments.
In EAP, clients work with horses in a “body to body” way. This means engaging in activities like grooming as well as riding. The idea is that by working with horses, who are (as the authors describe) herd animals that work together and form strong bonds, people will become more aware of and in touch with how their bodily sensations are tied to their emotions. The authors describe the benefit of working with horses, specifically:
“Horses are congruent in what they are feeling internally at all times and do not pretend to be something they are not. They are authentic and relate to each other honestly and truthfully and embody their experiences (Rector 2005). They naturally live in the here-and-now. They do not worry about what might happen next or what has happened in the part. This focus on the here-and-now becomes a particularly powerful way of relating to reality because many clients with eating disorders focus on the source of their anxiety in their inner worlds and oftentimes struggle to live their life authentically.” (p. 489)
Building relationships with horses is also designed to encourage clients with eating disorders to connect with other relationships in their lives. The authors do an elegant job of describing how people do not develop eating disorders in some kind of isolated vacuum without moving toward blaming others in their lives for the disorders. They note that while negative relationships can be a contributing factor to the development of an eating disorder, positive relationships and support can be key contributors to the success of treatment and help to facilitate recovery.
So what does Equine Assisted Psychotherapy look like in practice? In their case study, the authors demonstrate the 3 components of EAP in action:
- Contact: one way of establishing contact is through a focus on breath work, where clients stand in contact with the horse and breath in connection; the authors describe this as similar to biofeedback as clients because aware of how they feel being so close to another being (i.e., the horse).
- Relationship: the therapist might encourage the client to compare experiences like contact, mindful breathing with the horse and how their reactions to this kind of situation change as they engage in therapy over time.
- Experiments: breathing exercises and other similar practices are treated as experiments in this type of therapy, which can be used to explore how clients relate to others outside of therapy; the authors suggest that if a client develops a relationship with a horse, which generally accept without judgment, they might see this as evidence that this kind of relationship is possible.
But Does it Work?
So at this point, it is possible that I’ve lost you. You might be wondering if it is all a bunch of “woo-woo” psychobabble. And you might be right: it’s definitely hard to wrap your head around how building a relationship with a horse is like building a relationship with a person, and what this has to do with eating disorder recovery.
The authors do not claim that equine therapy alone can cure an eating disorder. They do note, however, that EAP can be a part of the suite of tools used to facilitate recovery for some. I’m skeptical that, as they claim, EAP might sometimes be used alone- I just don’t think the evidence is convincing enough. However, this kind of therapy, focused as it is on building connections non-verbally, might be an interesting complement to more traditional approaches.
I appreciate the focus on that which can’t be put into words, because eating disorders often defy logic and reason. Given what we’ve learned about bodily experience and sensation in relation to eating disorders, as well, I think that considering approaches that work from bodily sensation outward, rather than outward descriptions in, is worth doing.
What do you think? It is all a bunch of gobbledegook, or a promising way forward? I sometimes hesitate to write about alternative therapies because we’re struggling to provide even therapies with some evidence base. I also recognize that therapies like this may require a certain degree of privilege to access- I imagine it would be exceedingly rare to be able to convince insurance companies that equine therapy is worth funding, in the current economic environment. Still, I’m not ready to abandon the idea that different people respond well to different combinations of therapy. I’m intrigued with what the existence of varied approaches tells us about the complexity and individuality of those with eating disorders.
Lac, V., Marble, E., & Boie, I. (2013). Equine-Assisted Psychotherapy as a Creative Relational Approach to Treating Clients With Eating Disorders Journal of Creativity in Mental Health, 8 (4), 483-498 DOI: 10.1080/15401383.2013.852451