The population of United States (U.S.) veterans are multifaceted and extremely complex. It is estimated that there are approximately 20 million veterans in the U.S. including 3.9 million post-9/11 veterans [1]. In the group of post 9/11 veterans, 35.9 percent report having a service-connected disability [2]. Many veterans suffer from mental health disorders, substance use disorders, traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), very high rates of suicide, exhibit high risk taking behaviors, chronic pain, homelessness, have long term health effects from hazardous exposures to pollutants and warfare agents, hearing loss from hazardous exposure to excessive noise and vibrations, etc. They have complex deployment and social issues including but not limited to very high divorce rates, unemployment, and basic civilian reintegration issues [3].

Twenty-two veterans commit suicide daily [4]. Veterans have a disproportionate rate of homelessness which may alter their sense of social connectedness and put them at greater risk for depression. They also face the same difficulties and mental and physical health conditions as non-veterans which may compound their servicerelated complications. Many veterans face unemployment challenges after separation from military service. Complex issues related to multiple deployments that may have occurred for veterans complicate unemployment, marital difficulties, and family reintegration [5].

Addressing various significant veteran’s needs requires a multitude of resources and solutions beyond traditional healthcare. With PTSD, for example, trauma focused psychotherapy is one of the techniques utilized in conjunction with antidepressants. Alternative therapies such as acupuncture, meditation, relaxation, yoga are often used in combination with conventional therapies for PTSD and other conditions [6]. Anecdotally, many healthcare providers and veterans support alternative therapies. However, there is limited research to support the use of alternative therapy for many of the issues veterans face, including PTSD. Understanding the importance of including non-conventional therapies in conjunction with or as an alternative to conventional medicine is a key.

This article seeks to inform readers regarding alternative therapies, specifically Equine Assisted Activities and Therapies (EAAT), and its use with veterans. The national VA Healthcare System is calling for utilization of alternative therapies in conjunction with or as an alternative to conventional therapies whenever possible [6].

Complementary and Alternative Medicine (CAM)

“Alternative medicine is a term that describes medical treatments that are used instead of tradition (mainstream) therapies. Some people also refer to it as “integrative,” or “complementary” medicine” [7]. The Veterans Affairs (VA) Healthcare System has a current initiative through the National Center for Complimentary and Integrative Health given the increasing evidence that CAM approaches can be effective and are reportedly available in 89% of VA facilities [8]. Even though CAM approaches are available, there is little research evidence on the efficacy of the approaches. Healthcare providers have a responsibility to seek evidence for improving practice. These approaches are increasingly available to compliment conventional therapy and we need to research the potential for therapeutic benefits to optimize medications and to optimize patient outcomes.

Equine Assisted Activities and Therapies (EAAT), Equine Assisted Learning (EAL), and Equine Assisted Psychotherapy (EAP)

Plach and Sells [9], using the Canadian Occupational Therapy Measure (COPM), examined occupational performance issues facing young U.S. veterans. Occupational therapy examines a person’s engagement and performance in everyday activities such as self-care, productivity, and leisure. The study identified the top five occupational performance challenges as: engagement in relationships, school, physical health, sleeping, and driving. These challenges accounted for difficulties reintegrating into the community and daily life. A small qualitative study examined the use of equine assisted therapy with combat veterans. The participants worked in partnership with the horse to establish a trusting relationship unique to each horse’s personality. The researchers found that the participants applied what they learned in equine assisted therapy to improve familial communication in areas of conflict resolution strategies, emotional regulation and relationship skills [9,10].

Literature on the subjects of equine interventions and veteran populations dealing with trauma show positive correlations between therapeutic horsemanship, equine interventions and the reduction in PTSD symptoms by 87.5% at the end of a 6 week study [11]. Clinical studies suggest that individuals of all ages and levels of cognitive development can benefit from equine assisted learning (EAL) and have found EAL to be effective in treating: depression, anxiety, low self-esteem, attention deficit disorder, behavioral problems, trauma, autism, Tourette’s syndrome, conduct disorder and substance abuse [12-14].

EAAT describes the profession of incorporating equine activities, sentience, therapeutic horsemanship, experiential learning and/ or therapy to human personal growth and development. EAAT encompasses both EAL and EAP and the Professional Association of Therapeutic Horsemanship International (PATH Intl) Center Membership provides standards and safety protocols for both the horses, facilitators and participants in all EAAT programs. Equine Assisted Psychotherapy (EAP) is an experiential psychotherapy treatment modality, which incorporates equines into clinical services facilitated by a Licensed Marriage and Family Therapist and Professional Association of Therapeutic Horsemanship International (PATH Intl) Certified Equine Specialist in Mental Health and Learning. Sessions may be mounted or unmounted, depending on a few factors including medical clearance for mounted work and clinical relevance. Whereas EAL is a learning approach that incorporates experiential activities designed to promote the development of life skills for educational, professional and personal goals through equine assisted activities and interactions. Lessons are led by PATH Certified Instructors and incorporate horsemanship and equestrian skills into the interactive curriculum with the guidance and supervision of a mental health professional. Therapeutic riding centres adhere to the PATH Intl Standards and Code of Ethics, the Code of Ethics of the Florida Board of Clinical Social Work, Marriage and Family Therapy, and Mental Health Counseling, as well as The American Association of Marriage and Family Therapists.

Understanding how our responses shape interpersonal interactions is the foundation for healthy participation in relationships. Personal and professional success depends upon our ability to respond effectively to the needs and desires of our fellow family members, friends, colleagues, and self. Horses provide instant feedback, positive reinforcement, acceptance, and companionship. Working with horses and EAAT staff offers the opportunity to try out new skills and ways of being with a social partner who provides acceptance and non-judgmental feedback. Working outside with a herd of horses allows participants to experience first-hand the ways in which they interact socially and relate to their relationship with their trauma stories. In addition, clinical studies suggest that individuals suffering from chronic medical illnesses may benefit from EAL whereby emotional, cognitive and psychological factors may facilitate or impede compliance with and response to medical treatment.

Horse and human brains develop from the bottom up and inside out [15,16]. EAL is effective in treating depression, anxiety, low selfesteem, attention deficit disorder (ADHD), behavioral problems, PTSD, aggression, and substance abuse [17-21]. Horses speak in body language. They are hyper-vigilant prey animals. Their survival depends upon being “other centered” whereas humans are “self-centered”. Horses see the world as it is. They are 100% honest and communicate only how they are thinking and feeling in each exact moment. They do not misrepresent themselves and they do not manipulate or send mixed signals. It is often said that horses are a mirror of ourselves, whereas our experience has shown in session and herd observation that they attune and authentically respond to our human signals, both physiologically and physically. The attachment style of any particular equine is difficult to know for certain, our clinical team has directly observed horses seek out attuned connection with participants/clients. Jobe asserts that “relational interventions with horses are aimed at reorganizing the horse brain, building cross brain connections into the neocortex so that horses will be able to think for themselves and thus be in partnership with us” (p. 20) [16]. Furthermore, Proops et al. asserts that their study on facial recognition skills of horses “provides clear evidence that some non-human animals (horses) can effectively eavesdrop on the emotional state cues that humans reveal on a moment-to-moment basis using their memory of these to guide future interactions with particular individuals” (p. 1428) [22]. When we are congruent in mind, body and action and when we are not a threat, they will respond accordingly. Horses are prey animals. Incongruent body posture; heart and breath rates indicate stress and potential danger. It is impossible to deceive a horse.

The only way to have a positive relationship with a horse is to build one. First, we must become aware and accountable for ourselves and our own expression. Second, we must understand the principles behind pressure and the dynamics of healthy relationship building. A deep understanding of how we show up in our relationships with ourselves and others will clue us in to where we are most able to affect positive, lasting change within the context of our relationships. We often hide negative emotions from one another but this does not work with horses. If we are feeling anxious or angry, a horse senses this immediately (through our heart rate, breath rate and body language). Who we are speaks loudly to horses. They cannot converse with us but they hear what we say through our body language and through their keen sense of external awareness. Monty Roberts is quoted as saying, “The body language of horses offers profound lessons for communication between humans” (p. 32) [23] in his book Horse Sense for People. EAAT, particularly specializes in helping people translate their new language with horses out of the paddock and into their lives.

Monty is one of the most renowned international natural horsemen in the world. He grew up in an abusive household where he was exposed to “breaking” horses and to violence himself. This inspired him to seek new ways to communicate. Breaking horses never sat right with him and so he set out to discover better ways to communicate and ultimately discovered the language of equus. He employs methods to “join up” with horses instead of “breaking” their spirit and pride. He has found that his techniques have also worked amazingly well with people, particularly people who have had their own spirits broken, such as foster children in his own experience but this may easily translate to veterans. “Join up” in natural horsemanship is based on the principle of healthy attachment in relationships and is one of the many activities veterans can practice through EAAT.

Dr. Bruce D. Perry, founder of the Child Trauma Academy [24,25] asserts that “trauma informed care” is based on core elements of positive developmental, educational and therapeutic experiences. These core elements are: knowledge (the neurobiology of trauma informs professional practice), rhythm [which normalizes stimuli], relationship (is the vehicle for change), relational (safe), relevant (developmentally matched), repetitive (patterned), rewarding (pleasurable), rhythmic (resonant with neural patterns and respectful (child, family, culture [and equine]). According to Tim D. Jobe and Bettina N. Schulz-Jobe [16] founders of the principles of the Natural Lifemanship and Trauma Focused Equine Assisted Psychotherapy model, in all trauma informed care, relationship is the vehicle for change. Each partner, whether horse or human has the right to answer both yes or no to the request for connection in the relationship. Healthy relationship building with self, spouse or horse starts with attuned connection.

The hypervigilance in horses is a very natural quality than enables horses to dramatically help the hypervigilant and vulnerable human (the veteran) and facilitate the healing process of wounded individuals [26]. Horses teach humans that they can become alert and revert to homeostasis quickly and with ease. Veterans living with trauma respond well to learning the grounding techniques horses use to transition. Experiencing fluidity of arousal states and attempting new skills with a trusted equine partner develops neural plasticity and encourages further practice of the newly acquired skill set. Dynamics in horse and human relationships initiate deep human awareness. Personal breakthroughs and epiphanies are illustrated in the video links at the end of this article. The videos are very compelling. We believe EAAT is cutting edge as it seeks to re-enforce complementary and alternative methods to improve care for veterans. It is an optimal time to correlate with the National VA Healthcare System’s current initiative regarding incorporating holistic care for veterans since traditional therapies and prescription drugs have largely failed in preventing the incredible numbers of suicides and suicide attempts. Mental health and social disorders have continued to rise in the U.S. veteran population. That which is broken in relationship, must be healed in relationship. EAAT, the trained trauma focused equine assisted psychotherapists and interprofessional healthcare teams are uniquely suited to address the biopsychosocial needs of the veteran and foster the skills needed to achieve lasting social connection and the reduction of traumatic symptomology.

While much of the available EAL, EAP and EAAT literature [19] attempts to adequately examine the therapeutic nature and benefit of horse-human interaction [21], there remains a dearth of study on social connectedness, emotional regulation, self-efficacy, and the ability to form connected and attuned relationships. Further study with a focus on the interplay between human attachment, relationship building, and emotional regulation in EAAT was cited as deserving further exploration [27].

PATH Intl. reports 880 member centers and more than 8000 individual members in countries all over the world. The U.S. hosts the most centers. International members are from Europe, Latin America, Asia, and beyond. PATH International reports the involvement of 7,800 equines and over 5,000 certified professionals. Of these centers, they report that 335 offer programing for veterans [28]. There are additional equine centers, as membership in PATH Intl. is not required to provide some of these programs. A website, “Operation We are Here” [29], focusing on resources for U.S. veterans, lists 74 equine programs for veterans. A sampling of these programs includes “War Horses for Veterans” located in Kansas, “Heroes and Horses” located in Montana, “Battle Flag Ranch” located in Tennessee, “A Helping Hoof for Veterans” located in Utah, and “Horses for Heroes” located in Georgia. Offerings at these locations differ according to services available and differing design of programs. There are also special events at some locations that are not designated as veteran centric including “Freedom Reins” an event held in 2017 at Vinceremos, Wellington, Florida.

There are a number of riding and lesson centers who do not offer EAAT but do offer free riding/lessons to veterans as a leisure or recreational activity. Many riding centers indicate on their websites that riding is free to veterans with military/veteran identification (ID). Some indicate that is it also free to military/veteran families which are extremely generous and kind. Veterans are encouraged to inquire about free or discounted riding even if it is not advertised since so many people in the United States are interested in improving the lives of veterans in return for all they have sacrificed.

There are several compelling news and anecdotal stories on veterans and interactions with horses. Below are a few links to a few popular television shows where veterans and horses have been highlighted.

https://www.youtube.com/watch?v=qx-UTXE1MbM

Oprah Winfrey Show: “How Horses Help an Army Veteran Heal from PTSD.”

https://www.youtube.com/watch?v=Z7EedCwJ4ww

National Geographic: “Horses Help Heal Veterans’ Invisible Wounds.”

https://www.youtube.com/watch?v=inpnfqN0a88

Inside Edition: “How Vets with PTSD are Using Horses to Help Them Heal.”

As mental health and social disorders continue to rise in the veteran population, now is the time to align with the U.S. VA Healthcare System’s current initiative regarding incorporating holistic care for veterans and increasing research into complementary and alternative approaches. Healthcare professionals need to better understand the benefits of these interventions and be prepared to offer this underutilized approach. Evidence suggests that benefits of nature and natural environments can promote health and well-being by reducing stress and enhancing mood [30]. EAAT combines the therapeutic benefit of horses and professional support within a naturalist environment. EAAT provides instant feedback, positive reinforcement, acceptance, and companionship in a naturalistic environment, giving veterans the opportunity to try out new skills and ways of being with a social partner who provides acceptance and non-judgmental feedback [31]. EAAT can optimize patient outcomes by having veterans interact with multiple factors that could facilitate and/or augment response to medical treatment.

The authors report no conflicts of interest in this work.

1. U.S. Department of Veteran Affairs (2018) Department of Veterans Affairs Statistics at a Glance.
2. National Center for Veterans Analysis and Statistics (2018) Profile of Post-9/11 Veterans: 2016.
3. Olenick M, Flowers M, Diaz VJ (2015) US veterans and their unique issues: Enhancing health care professional awareness.  Adv Med Educ Pract 6: 635- 639.
4. U.S. Department of Veteran Affairs (2017)  Suicide data sheet, Florida, USA.
5. Keita MD, Diaz VJ, Miller AP, Olenick M,  Simon S (2015) Transitioning from military medics to registered nurses.  J Multidiscip Healthc 8: 495-502.
6. Strauss JL, Lang AJ, Schnurr PP (2017) Complementary and alternative medicine (CAM) for PTSD.
7. WebMD.com. (2018). What exactly is alternative medicine? Retrieved from https://www.webmd.com/balance/guide/what-is-alternative-medicine#1
8. Ezeji-Okoye SC, Kotar TM, Smeeding SJ, Durfee JM (2011) State of care: Complementary and alternative medicine in Veterans Health Administration: survey results. Fed Pract 30:14- 19.
9. Plach HL, Sells CH (2012) Occupational performance needs of young veterans. Am J Occup Ther 67: 73–81
10. Hilary V, Delano M, Herlache-Pretzer E, Meyer K, Stawowy K (2017) The impact of equine-assisted therapy on communication within familial relationships of veterans with posttraumatic stress disorder. Am J Occup Ther  71: 7111520272p1
11. Johnson RA, Albright DL, Marzolf JR, Bibbo JL, Yaglom HD, et al. (2018) Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans. Mil Med Res 5: 25.
12. Wilkie KD, Germain S, Theule J (2016) Evaluating the efficacy of equine therapy among at-risk youth: A meta-analysis. Anthrozoös 29: 377- 393.
13. Wiese C, Simpson R, Kumar S (2016) The effectiveness of equine-based therapy in the treatment of social and behavioral aspects of children with autism spectrum disorder: A systematic review. The Internet Journal of Allied Health Sciences and Practice. 14: 12.
14. Stergiou A, Tzoufi M, Ntzani E, Varvarousis D, Beris A, et al. (2017) Therapeutic effects of horseback riding interventions: A systematic review and meta-analysis. Am J Phys Med Rehabil 96: 717- 725
15. Equine Behavioral Health Resource Center (2018) The Horse’s brain.  Retrieved from:  http://www.ebhrc.com/article2.html
16. Jobe T, Schultz-Jobe B, McFarland L (2016) Fundamentals of Natural Lifemanship: Trauma-Focused Equine Assisted Psychotherapy (TF-EAPTM). Liberty Hill: Natural Lifemanship, Texas, USA.
17. Klontz BT, Bivens A, Leinart D, Klontz T (2007) The effectiveness of equine-assisted experiential therapy: Results of an open clinical trial. Soc Anim 15: 257-267.
18. Yoo JH, Oh Y, Jang B, Song J, Kim J, et al. (2016) The effects of equine-assisted activities and therapy on resting-state brain function in attention-deficit/hyperactivity disorder: A pilot study. Clin Psychopharmacol Neurosci1 4: 357–364
19. Staudt M, Cherry D (2017) Equine facilitated therapy and trauma: Current knowledge, future needs. Advances in Social Work 18: 403.
20. Scheidhacker M, Bender W, Vaitl P (1991) Die wirksamkeit des therapeutischen reitens bei der behandlung chronisch schizophrener patienten: Experimentelle ergebnisse und klinische erfahrungen. Der Nervenarzt 62: 283 - 287
21. Kendall E, Maujean A, Pepping CA, Downes M, Lakhani A, et al. (2015) A systematic review of the efficacy of equine-assisted interventions on psychological outcomes. Eur J Psychother Couns 17: 57-79
22. Proops L, Grounds K, Smith AV, McComb K (2018) Animals remember previous facial expressions that specific humans have exhibited. Curr Biol 28: 1428-1432.
23. Roberts M (2000) Horse sense for people.  Penguin Books, Middlesex, England, UK. 
24. Perry BD (2018) Child Trauma Academy.  Retrieved from http://childtrauma.org/.
25. Perry B (2013) Integrating principles of neurodevelopment into clinical practice [PowerPoint slides]. Retrieved from https://www.thenationalcouncil.org/?api&do=attachment&name=bruce-perry-on-helping-children-recover-from-trauma&index=0&type=webinars
26. Hayes T (2015) The power of horses to heal:  Riding home.  St. Martin’s Press, New York, USA.
27. Dampsey E (2017) The effects of equine-assisted psychotherapy on emotion regulation: Self-efficacy and self-awareness as potential mediators. Doctoral dissertation, Fielding Graduate University, California, USA.
28. Professional Association of Therapeutic Horsemanship International (PATH) (2018) Retrieved from https://www.pathintl.org/.
29. Operation ‘We Are Here’ (2018) http://www.operationwearehere.com/EquineTherapy.html.
30. Capaldi CA, Passmore HA, Nisbet EK, Zelenski JM, Dopko RL (2015) Flourishing in nature: A review of the benefits of connecting with nature and its application as a wellbeing intervention. Int J Wellbeing 5: 1-16.
31. Bachi K, Terkel J, Teichman M (2011) Equine-facilitated psychotherapy for at-risk adolescents: The influence on self-image, self-control and trust. Clin Child Psychol Psychiatry 12: 298-312.