Running head: A STUDY OF THE EFFICACY OF EAC 1

A Mixed-Methods Study of the Efficacy of Equine Assisted Counseling in the

Treatment of At-risk Adolescents
James M. Ryan
South University

A STUDY OF THE EFFICACY OF EAC 2
Abstract
This research proposal is designed to demonstrate the efficacy of Equine-Assisted Counseling
(EAC) in the treatment of adolescents identified as at-risk by comparing EAC to Adventure
Based Counseling (ABC) for the purpose of establishing a protocol for further research in order
to qualify EAC as an evidence-based practice in SAMHSA s NREPP. High school students
from the Palm Beach County School District are to be selected to participate in the treatment
based upon the aforementioned designation of at-risk by licensed school counselors. The
measures utilized for the collection of the data will include BASC scales previously identified as
applicable to EAC by Trotter, Chandler, Goodwin-Bond, and Casey (2008, p. 274), and a Case-
Conceptualization of each client developed by their therapy-team. Effect-size and relative
efficacy will be measured through the use of descriptive statistical operations based upon the
establishment of parametric or nonparametric parameters following the completion of data
collection.

A STUDY OF THE EFFICACY OF EAC 3
Also known as Equine-Assisted Psychotherapy (EAP) or Equine-Assisted Therapy
(EAT), Equine-Assisted Counseling (EAC) is a specialized treatment approach that incorporates
horses as the primary therapeutic tool in the counseling process (Klontz, Bivens, Leinart &
Klontz, 2007, p. 258; EAGALA, 2010). According to Trotter, Chandler, Goodwin-Bond, and
Casey (2008), EAC has shown to be effective in individual and group counseling modalities, as
well as marriage and family therapies (p. 255; Schultz, Remmick-Barlow & Robbins, 2007, p.
266). Groups that have benefited from EAC include: violent offenders, youth who are at risk or
people seeking personal growth experiences; In-patient psychiatric and substance abuse
programs that have integrated an equine experience have been successful in teaching clients
effective use of both verbal and nonverbal communication (Frewin & Gardiner, 2005, p. 8).
EAC is rooted in a brief strength-based, solution-focused therapeutic orientation (Russell-
Martin, 2006, p. 60). The introduction of horses into the therapeutic process is thought to
circumvent client defense mechanisms, facilitate the development of trust, and provide a safe
environment for clients to take appropriate therapeutic risks (Trotter et al., 2008, p. 255). In
addition, EAC emphasizes responsibility, team-building, and communication skills. EAC experts
believe that the inclusion of horses in the therapeutic process facilitates client-growth more
efficiently than traditional approaches (Trotter et al., 2008, p. 255).
Purpose
The purpose of this study is to provide a template for the collection of evidence for the
inclusion of Equine-Assisted Counseling (EAC) in the Substance Abuse and Mental Health
Services Administration (SAMHSA) National Registry of Evidenced-based Programs and
Practices (NREPP). The study is based on a mixed-methods approach designed to achieve a
comprehensive understanding of Equine-Assisted Counseling as a therapeutic intervention for at-
A STUDY OF THE EFFICACY OF EAC 4
risk adolescents. It utilizes a convergent parallel mixed methods design, which is the merging of
both quantitative and qualitative data to produce a comprehensive analysis of the efficacy of
EAC as a therapeutic intervention for at-risk adolescent population (Creswell, 2014, p. 15).
Theoretical Orientation
The design of the study is rooted in a transformative worldview. This research project is
designed based upon the goal of improving the lives at-risk youth through the use of EAC as a
therapeutic intervention. In addition, the solution-focused, strength-based model of counseling is
consistent with the social constructivist worldview, in that the emphasis is on the clients view of
the world, their strengths, and capacity for success (Creswell, 2014, p. 8). Rather than attempting
to insert something new into the client, EAC draws upon the strengths that already exist within
each individual.
The social and political forces at-work in the lives of adolescent clients are oftentimes
overwhelming to them and their families; it is therefore the job of the mental health professional
to advocate for their clients and their clients families, giving them legitimate treatment options
rooted in strong scientific evidence. Within the world of managed-care programs and insurance-
run healthcare, it has become vitally important for interventions to attain the designation of
evidenced-based practice in order to be considered reimbursable services, oftentimes
determining the attainability of interventions for clients. It is the goal of this study to establish
the protocol for the collection of evidence for the inclusion of EAC in the ranks of NREPP for
just that reason.
Horse as Mirror and Metaphor
Horses serve as both mirror and metaphor introducing the client(s) to different ways of
viewing the world and interacting with themselves and others (Schultz et al., 2006, p. 266).
A STUDY OF THE EFFICACY OF EAC 5
Horses provide unique experiences for clients to process transference and projection during the
therapeutic process (Klontz et al., 2007, p. 259). As prey animals, they are equipped with natural
hyper-vigilance and the impulse to escape when feeling threatened or fearful (Klontz et al., 2007,
p. 259). As a result, clients are confronted with the reality of their emotional and physical states,
and the impact those states have on others, facilitating self-awareness and demanding
congruence between feelings and behaviors (Klontz et al., 2007, p. 259). Including horses in the
therapeutic process allows for a wide array of therapeutic issues to surface without the direct
intervention of the therapist (Schultz et al., 2007, p. 266).
According to Schultz et al., (2007) horses have several characteristics that are similar to
humans in their behavioral responses and social structures, thus providing a mirror for the client
to gain insight in a unique and non-threatening environment (p. 266). Pally (2001) emphasizes
the role of nonverbal communication in all human interactions including the therapeutic
relationship (para. 1). In accordance with this prior research, EAC clinicians theorize that the
client-horse relationship serves as an additional therapeutic alliance, enhancing the impact of the
counseling relationship. As the client develops the two therapeutic relationships, with horse and
therapist (and sometimes with the third member of the clinical team, the equine-specialist), they
are receiving additional therapeutic insights otherwise left unseen, oftentimes due to the nature of
transference. Klontz et al. (2007), put it this way:
whereas it may be fairly easy to dismiss a transference reaction to a therapist or
group member as a legitimate reaction to the targets shortcomings or
inappropriate actions, it is much more difficult to attribute a transference reaction
to the shortcomings , inappropriate behaviors, or premeditated offenses of a horse.
As such, transference reactions in equine therapy can often be addressed without
A STUDY OF THE EFFICACY OF EAC 6
the confounding interpersonal factors present in more traditional therapies. (p.
259)
Literature Review
The use of animals in counseling is rooted in a longstanding tradition. Animal-assisted
psychotherapy has been documented as an intervention in the mental health field as far back as
1792 (Klontz et al., 2007, p. 257). Carl Jung suggested that horses embody one of humanitys
deepest mythological archetypes (Frewin & Gardiner, 2005, p. 3). The use of EAC has been
documented in a wide variety of formats, with great success, for a wide-array of mental health
issues (Frewin & Gardiner, 2005, p. 7-8). In recent decades, professional organizations have
developed in order to govern the use of horses in psychotherapy (EAGALA, 2010). However,
research regarding EACs efficacy has been largely qualitative and lacking strong quantitative
evidence for its use in the treatment of various mental health issues.
Trotter et al. (2008) conducted a study with the purpose of providing qualitative evidence
for the efficacy of EAC by comparing it to classroom-based counseling (p. 255). They found a
tremendous lack of qualitative data for the efficacy of EAC in their examination of previous
research, and designed their study in reaction to these findings (Trotter et al., 2008, p. 257).
Utilizing the Behavioral Assessment System for Children (BASC), Self-Rating Scales (SRS) and
Parent-Rating Scales (PRS) at the beginning and end of the treatment, as well as the
Psychosocial Session Form (PSF) on a week-to-week basis, the researchers conducted a
nonrandom sample convenience study (Trotter et al., 2008, p. 258, 259). Their results provided
limited evidence for the efficacy of EAC based upon the following issues with design and
implementation: (a) the researchers utilized the PSF, which was not previously normed, nor had
it been statistically demonstrated to be reliable or valid as an assessment-tool; (b) there was a
A STUDY OF THE EFFICACY OF EAC 7
large discrepancy in the time of therapy- the EAC group receiving two hours per week from two
therapists (2hrs x 2persons = 4hrs of therapy per session), whereas the classroom-based
counseling group received one hour of therapy per week from one therapist; (c) the sample-size
was skewed between the two groups, with the EAC group including 126 participants, while the
classroom-based counseling group only included 38 participants; (d) and the dramatic difference
between the therapeutic environment, with the EAC group participating in counseling in a ranch-
style setting, and the control group receiving treatment in a classroom (Trotter et al., 2008, p.
258-60, 281-282).
Klontz et al. (2007) published an analysis of 31 participants psychological distress and
well-being based upon the use of the Brief Symptom Inventory (BSI) and Personal Orientation
Inventory (POI) given prior to the administration of Equine-Assisted Therapy (EAT),
immediately following treatment, and six months post-treatment. Their findings were that the
participants reported significantly less psychological distress and significantly higher levels of
psychological well-being as measured by a multiple analysis of variance (Klontz et al., 2007, p.
261). The study demonstrated the following effect size: pre-post effect size for the [Time
Competence] scale was -0.867 s.d., and the pretest to 6-month follow-up effect was -0.768 s.d.
The pre-post effect size for the [Inner Directed] scale was -1.180 s.d., and the pretest to 6-month
follow-up effect size was -0.900 s.d. (Klontz et al., 2007, p. 262). While the statistical evidence
was compelling, it was difficult to interpret because the study failed to provide several
experimental controls, such as lack of a control or comparison group and the use of a non-
random sample (Klontz et al., 2007, p. 263).
A study conducted by Schultz et al. (2007) demonstrated the efficacy of Equine-Assisted
Psychotherapy (EAP) in the treatment of children and adolescent that had been exposed to intra-
A STUDY OF THE EFFICACY OF EAC 8
familial violence, which was defined as any combination of interparental violence and overall
child abuse, including neglect, physical, sexual and emotional abuse, parental substance abuse
(p. 267). The children were given the Global Assessment of Functioning (GAF) prior to the
beginning of treatment, and at three month intervals throughout the treatment process until it was
concluded (Schultz et al., 2007, p. 266). The results demonstrated the short-term efficacy of EAP
in the treatment of children, especially young children, as evidenced by the increase in the mean
GAF score from 54.1 prior to treatment to 61.7 + 5.0 post treatment (Schultz et al., 2007, p. 265).
The study was limited by the fact that the participants were self-selected, the researchers were
unable to determine the reasons that some participants dropped out of the study, the changes in
the GAF score were difficult to contribute to the inclusion of horses in the treatment process, and
the fact that the GAF has been since abandoned by the Diagnostic and Statistical Manual of
Mental Disorders due to issues with inter-rater reliability (Schultz et al., 2007, p. 270).
Currently, research continues to lack strong quantitative, statistically-based evidence for
the efficacy of EAC as a therapeutic intervention. The studies that have attempted to demonstrate
quantitative evidence are severely limited by the lack of controls, lack of comparison groups,
nonrandom sampling, and other confounds. Although evidence does exist in the form of
qualitative research for the overall benefits of EAC, it is still unknown to what extent the horse-
as-therapeutic-tool plays in the improvement of clients. The following study has been designed
in response to the inadequacies of the aforementioned studies. Its purpose is the formation of a
framework from which a convincing body of statistical evidence for the efficacy of EAC can be
gathered for the purpose of meeting the NREPP requirements.
Methods
A STUDY OF THE EFFICACY OF EAC 9
In order to be included in the National Registry for Evidence-Based Programs and
Practices (NREPP) the intervention or program is evaluated in the following six domains:
1. Reliability of Measures- Outcome measures should have acceptable reliability
to be interpretable. Acceptable here means reliability at a level that is
conventionally accepted by experts in the field.
0 = Absence of evidence of reliability or evidence that some relevant types of
reliability (e.g., test-retest, interrater, interitem) did not reach acceptable levels.
2 = All relevant types of reliability have been documented to be at acceptable
levels in studies by the applicant.
4 = All relevant types of reliability have been documented to be at acceptable
levels in studies by independent investigators.
2. Validity of Measures- Outcome measures should have acceptable validity to
be interpretable. Acceptable here means validity at a level that is
conventionally accepted by experts in the field.
0 = Absence of evidence of measure validity, or some evidence that the measure
is not valid.
2 = Measure has face validity; absence of evidence that measure is not valid.
4 = Measure has one or more acceptable forms of criterion-related validity
(correlation with appropriate, validated measures or objective criteria); OR, for
objective measures of response, there are procedural checks to confirm data
validity; absence of evidence that measure is not valid.
3. Intervention Fidelity- The experimental intervention implemented in a study
should have fidelity to the intervention proposed by the applicant. Instruments
A STUDY OF THE EFFICACY OF EAC 10
that have tested acceptable psychometric properties (e.g., inter-rater reliability,
validity as shown by positive association with outcomes) provide the highest
level of evidence.
0 = Absence of evidence or only narrative evidence that the applicant or provider
believes the intervention was implemented with acceptable fidelity.
2 = There is evidence of acceptable fidelity in the form of judgment(s) by experts,
systematic collection of data (e.g., dosage, time spent in training, adherence to
guidelines or a manual), or a fidelity measure with unspecified or unknown
psychometric properties.
4 = There is evidence of acceptable fidelity from a tested fidelity instrument
shown to have reliability and validity.
4. Missing Data and Attrition- Study results can be biased by participant attrition
and other forms of missing data. Statistical methods as supported by theory
and research can be employed to control for missing data and attrition that
would bias results, but studies with no attrition or missing data needing
adjustment provide the strongest evidence that results are not biased.
0 = Missing data and attrition were taken into account inadequately, OR there was
too much to control for bias.
2 = Missing data and attrition were taken into account by simple estimates of data
and observations, or by demonstrations of similarity between remaining
participants and those lost to attrition.
A STUDY OF THE EFFICACY OF EAC 11
4 = Missing data and attrition were taken into account by more sophisticated
methods that model missing data, observations, or participants, OR there were no
attrition or missing data needing adjustment.
5. Potential Confounding Variables- Often variables other than the intervention
may account for the reported outcomes. The degree to which confounds are
accounted for affects the strength of causal inference.
0 = Confounding variables or factors were as likely to account for the outcome(s)
reported as were the hypothesized causes.
2 = One or more potential confounding variables or factors were not completely
addressed, but the intervention appears more likely than these confounding factors
to account for the outcome(s) reported.
4 = All known potential confounding variables appear to have been completely
addressed in order to allow causal inference between the intervention and
outcome(s) reported.
6. Appropriateness of Analysis- Appropriate analysis is necessary to make an
inference that an intervention caused reported outcomes.
0 = Analyses were not appropriate for inferring relationships between intervention
and outcome, OR sample size was inadequate.
2 = Some analyses may not have been appropriate for inferring relationships
between intervention and outcome, OR sample size may have been inadequate.
4 = Analyses were appropriate for inferring relationships between intervention
and outcome. Sample size and power were adequate. (National Registry for
Evidenced-based Programs and Practices, 2014, para. 6-11)
A STUDY OF THE EFFICACY OF EAC 12
In order to meet these criteria the study has been developed based upon the previous
design of Trotter et al. (2008) with added controls for the purposes of isolating the
independent variable, which is identified as horse-as-therapeutic-tool (p. 260-270).
In addition, the research design includes the use of the aforementioned criteria
from the NREPP to maintain the applicability of the following study for its identified
purpose. A third-party observer, trained by the NREPP in the evaluation of the above 6
program domains, will evaluate the study design prior to the beginning of the project, and
at 3 and 6-month intervals to ensure its acceptability. Adjustments will be made
according to the recommendations of the outside rater at each of the identified intervals,
in order to ensure the solidity of this study as a foundation for further research.
Participants
Participants will be offered the opportunity to participate in the study based upon
the designation of at-risk made by their school counselor. At-risk is defined as having
significant social, behavioral, emotional or academic problems. Participation in the study
will be completely voluntary, with participants being informed that they can terminate
their involvement at any time without any negative repercussions. Parental consent will
be obtained in addition to the adolescents agreement prior to participation in the study.
Adolescents from Palm Beach County School District high-schools, designated as at-risk,
falling into the age range of 13-17 years of age will qualify for participation in the study.
The sample size will be limited to the availability of students that fit these criteria. The
sample population will be representative of the ethnic and gender diversity present in the
Palm Beach County School District over the course of the three-year duration of the
study.
A STUDY OF THE EFFICACY OF EAC 13
The participants will be required to sign an informed consent agreement prior to
their participation, for the purposes of explaining the environment of the therapies, the
randomized assignment of therapeutic-groups, the research-based purpose of the data
collection and its proposed use, the anonymity of the clients in future publications of the
research, and the dangers associated with Adventure-Based Counseling (ABC) and EAC.
In addition, clients and their parents will be asked to sign an agreement to complete the
weekly assessments, and a termination interview if they decide to discontinue their
participation in the study. The consent documentation will include a contact-waver for
the purpose of the above interview. The termination-interview will be administered in
order to ensure the most comprehensive understanding of client reactions to treatment,
including possible aversions to EAC or ABC modalities. Clients who terminate their
participation will still qualify for the Case-Conceptualization portion of the study, but
will be excluded from the statistical analysis of the BASC scales and Session Rating
Scale.
Therapeutic-Groups and Therapy-Teams
Over the course of the three-year study, 18 treatment groups (six per year)
comprised of 8-10 clients will participate in both the EAC and ABC groups; the target
sample will be 300 individuals total, with 150 individuals per treatment type divided
evenly between males and female groups. The assignment to therapeutic group will be
randomized, with individuals being assigned a participant-number, and then assigned to
either the EAC or ABC group based upon a randomizing computer-program. Once
assigned to the EAC or ABC therapy group, each participant will be placed in a
therapeutic-group of a gender-homogenous type. The purpose of this is to reduce the
A STUDY OF THE EFFICACY OF EAC 14
number of confounds during the therapeutic process by reducing the complexity of the
relational variables at-play amongst participants. Each group will then be assigned to a
therapy-team.

The foundation of EAC is based on a partnership between a licensed mental
health professional experienced in EAC and a horse professional also experienced in
EAC interventions (Trotter et al., 2008, p. 256). Therapeutic teams will be comprised of
a Licensed Mental Health Counselor (LMHC) with EAC training and certification
through EAGALA, and an equine-specialist with experience with the EAC modality, as
well as certification through EAGALA. Each team member will be required to have a
minimum of two-years of experience in the treatment of adolescents, and the use of
horses in psychotherapy. For ABC teams, their qualifications will be scrutinized
equivalently based upon their experience with the ABC modality, and the treatment of
adolescents. Therapeutic-team member qualifications must also include a body of
statistical evidence of their treatment efficacy, revealed through a statistical analysis of an
Desired Division of Therapeutic Groups
EAC M
EAC F
ABC M
ABC F
A STUDY OF THE EFFICACY OF EAC 15
accepted outcome measure, for example: either Session Rating Scale (SRS V.3.0) or
Outcome Rating Scale (ORS) data. This practice is designed to reduce the likely
confounding variable of differences in individual effectiveness of therapists. Addressing
this concern in the design of the research reduces the identified confounds relevance in
later analysis of data.
Instruments
A modified Behavioral Assessment System for Children (BASC) will be utilized
for the collection of data. The following sections of the BASC will be employed due to
their previous demonstration of reliability and validity: Emotional Symptom Index
(p=0.027), Clinical Maladjustment Composite (p=0.030), Atypical Scale (p=0.002),
Sense of Adequacy Scale (p=0.004), and the Relationship with Parents Scale (p=0.018);
PRS sections include Behavioral Symptoms Index (p=0.000), Externalizing Problems
Composite (p=0.000), and the Internalizing Problems Composite (p=0.000) (Trotter et al.,
2008, p. 274). These scales will comprise one-half of the instruments used on a weekly
basis to develop the quantitative data for the efficacy of EAC.
In addition, the Session Rating Scale (SRS V.3.0) designed by Dr. Scott Miller
will be utilized at the end of each session to quantify the change in client perception over
the course of treatment (Shaw & Murray, 2014, p. 56). The implementation of this
instrument weekly gives the researchers the opportunity to advance their understanding
of the phenomenological experience of the study participants, while simultaneously
expanding the data set. Furthermore, the recognized validity and reliability of this
instrument adds to the overall strength of the study.
A STUDY OF THE EFFICACY OF EAC 16
Finally, each participant will be the subject of a Case-Conceptualization (CC)
aimed at mapping their progress through treatment. Each therapy-team will act
cooperatively to develop the CCs for the clients in their respective therapy-groups. The
CCs will be developed at the end of the 8 week treatment period from the session notes-
to be written by both members of the therapeutic team following each session for each
client. The purpose of these studies is to generate a phenomenological framework from
which to view the quantitative data, offer a more comprehensive understanding of the
variation among participants, and identify possible aversions clients may have to EAC or
ABC interventions.
Treatments
The counseling process will be based upon the model described by Trotter et al.
(2008) and EAGALA (2010). The EAC groups will participate in the equine-based
activity during the first half of each session (approximately 1 hour) followed by an hour
of group psychotherapy facilitated by the therapy-team. Likewise, the ABC groups will
complete the adventure-based activity during the first half of the session followed by a
psychotherapeutic process group. Refer to the pages 260-270 of the article written by
Trotter et al. (2008) for the activities to be utilized during the counseling sessions for both
groups, examples include: Building A Relationship with Your Horse, Horse Body Parts,
Catch and Release, Lifes Little Obstacles, Give and Take, and Equine Billiards for the
EAC groups; Marshmallow River, The Bull Ring, One True Path, and Horse and Rider
for the ABC group. The activities for both EAC and ABC groups will be completed
within the riding-ring of the equine facility in order to control for the impact of
environment.
A STUDY OF THE EFFICACY OF EAC 17
Therapy-teams will keep detailed accounts of the interventions they implement
throughout the treatment process, in order to establish a protocol for the use of EAC.
Utilizing the previously established treatment protocol designed by Trotter et al. (2008)
will serve to address the issue of treatment fidelity (p. 260-270).
Materials
The materials necessary for the completion of this study include a ranch-style
therapeutic riding center, 8-10 horses trained according to the American Horse Council
(AHC) standards, a male and female LMHC with training in EAC interventions, and a
male and female equine-specialist certified through the three-tier EAGALA certification
process (American Horse Council, 2012, para. 2; EAGALA, 2010). In addition, four male
and four female LMHCs with certifications in the use of ABC treatment with
adolescents will comprise the ABC therapeutic-teams.
Additional Controls
As previously stated, this study will expound on the work of Trotter et al. (2008).
In order to improve this previous research, the current design includes a randomized
sample, controls for time and environment, with both EAC and ABC groups performing
the activities in the same arena at the same facility, as well as equality of therapy styles
including the number of therapists present for each session (two). In addition, this study
will endeavor to obtain information about clients that chose to terminate their
participation in the study with interviews, and questionnaires designed to elicit feedback
regarding the reasons for termination. Table 1.1 illustrates a hypothetical, graphical
representation of client reasons for discontinuing therapy.
A STUDY OF THE EFFICACY OF EAC 18

Table 1.1
Summary
This study has been designed to establish a protocol for further research substantiating
EAC as an evidenced-based practice. The influence of managed-care and insurance companies
demands that EAC be included in the NREPP if it is to be available for the treatment adolescent
clients. Having been designed in response to the lack of quantitative evidence for the efficacy of
EAC, and being based upon previous work allows for the expansion of relevant procedures and
the development of further controls improving the overall quality of the evidence gathered from
the study. The third-party ratings (prior to commencement, and at 3 and 6-month intervals) will
allow for continued adjustments further strengthening this foundational investigation of the
efficacy of EAC. The additional controls and procedures are designed to reduce the likelihood of
confounding variables, while simultaneously affirming the efficacy of EAC gathered from this
study.

0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Group 1 Group 2 Group 3 Group 4 Group 5 Group 6
Other
Therapy ineffective
Logistical Issues
Aversion to Therapy
A STUDY OF THE EFFICACY OF EAC 19
References
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Retrieved from http://www.horsecouncil.org/welfarecode
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approaches (4th ed.). Thousand Oaks, CA: SAGE Publications, Inc.
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http://www.eagala.org/
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psychotherapy. The Australian Journal of Counseling Psychology, 6, 13-17.
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A STUDY OF THE EFFICACY OF EAC 20
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