Abstract
Many veterans returning to civilian life face medical and mental health issues. As there is a stigma of using mental health services, equine-assisted activities and therapy (EAAT) has been considered a nonconventional intervention to support the mental health and well-being of veterans. In this qualitative study, 14 focus groups with 67 participants and program volunteers and staff of a veteran-led EAAT program were conducted to explore perspectives among current and past participants in the program. Five themes emerged: (a) benefits of EAAT, (b) connections with horses, (c) program engagement, (d) equestrian experience related to military experience, and (e) recommendations for the program. In spite of emotional and physical challenges, they indicated that they felt stronger, confident, and fulfilled. The participants developed meaningful relationships with the horses and developed horsemanship skills. Some participants connected their involvement in the program to their past military experience based on interactions with peers in a group setting. Recommendations made by the participants included efforts to increase community awareness and expand the program by including families and adding therapeutic and aftercare components. Findings from this study suggest relevance for care of veterans reintegrating to civilian life from the point of view of individuals participating in EAAT.
Keywords
Introduction
Reintegration to civilian life from active service can be challenging for military personnel and has been described as “a crisis equal to that of the precipitating injury itself” (Libin et al., 2017). Many veterans returning to civilian life have extensive medical and mental health care needs that may not be met by existing systems of care (Hester, 2017). The insufficient availability of mental health services and the stigma of seeking treatment remain barriers to receiving care (Hester, 2017; Possemato et al., 2018; Williston et al., 2020), and thus the development and application of innovative, alternative interventions to address the psychosocial problems of veteran reintegration are necessary to fill this large void.
Post-Service Reintegration
Veteran reintegration to civilian life is a potentially vulnerable transition and the struggles experienced reverberate through families (Balderrama-Durbin et al., 2015). Reintegration is accomplished at the individual level; however, it is also dependent on multifaceted interactions across interconnected systems, including interpersonal relationships, community systems, and societal structures (Elnitsky et al., 2017; Sayers, 2011). Each system shares influence on reintegration outcomes and can potentially serve either as a protective factor or as barrier to healthy reintegration outcomes (Balderrama-Durbin et al., 2015; Brenner et al., 2015; Sayers, 2011).
For example, family systems can promote social reintegration by serving as a social support and minimizing the impact of common challenges associated with veteran reintegration (Balderrama-Durbin et al., 2015; Brenner et al., 2015). Conversely, several dyadic-level and family-level influences, such as alcohol misuse, unwillingness to disclose combat/deployment experiences with partners (Balderrama-Durbin et al., 2015; Brenner et al., 2015), and infidelity and familial role changes (Sayers, 2011), can place reintegrating veterans at risk for negative reintegration outcomes. Likewise, community and societal systems share impact on the individual which can subsequently influence familial systems (Elnitsky et al., 2017). The overarching theoretical framework for this article, driving the intervention (for veterans and families), methods (focus groups: (Onwuegbuzie et al., 2013)), and discussion of results emerges from ecological systems theory (Bronfenbrenner, 1977).
Among the frequently cited challenges that may hinder veteran reintegration include psychiatric problems (Sayers, 2011), feelings of differentness from civilian society (Kranke et al., 2016), and difficulties coping with separation from the familiar social infrastructure provided by military life (Libin et al., 2017; Morin, 2011). Moreover, veterans unexpectedly and involuntarily separated from the military following disabling combat-related injuries, such as polytrauma (injuries to multiple body parts and organs) and traumatic brain injury inflicted by improvised explosive devices may also be especially at risk for experiencing a sense of identity loss or not belonging, contributing even greater risk for adverse reintegration outcomes (Morin, 2011; U.S. Department of Veterans Affairs, n.d.).
Fortunately, supportive factors can minimize mental health care needs and promote positive psychosocial outcomes after return from deployment (Elnitsky et al., 2017). Supportive factors associated with successful reintegration at the family level include frequent and open communication between significant others, dedication to military life among family members, and family planning for post-deployment reintegration (Balderrama-Durbin et al., 2015). Social networks and feelings of connectedness may also promote successful veteran reintegration (Kranke et al., 2016; Sayers, 2011). Specifically, a capacity for trust of other people and institutions can facilitate psychosocial adjustment. The important role that trust may have on successful veteran reintegration has led to recognition of the need for research into trust-building interventions that may assist veterans rejoining civilian life (Kopacz et al., 2018).
Equine-Assisted Interventions for Veterans
Substantial evidence exists for the positive effects of human–animal relations (Friedman & Krause-Parello, 2018; Resnick, 2020). Research on this relationship falls into three general categories: companion animals, human–animal interactions, and animal-assisted interventions (AAIs: Friedman & Krause-Parello, 2018). AAI is generally characterized as a type of integrative medicine (Hediger et al., 2019; Menna et al., 2019). Different types of AAI have been described and studied for human–animal relations with multiple animals, including horses, dogs, and others (Friedman & Krause-Parello, 2018).
Research on human–animal relationships is considered strongly situated within social, humanistic psychology, particularly in the study of intergroup relationships (Dhont et al., 2019). From a theoretical perspective, AAI emerges from social identity theory (Amiot & Bastian, 2015; Dhont et al., 2019; Tajfel & Turner, 1979, 1986). Individuals define themselves through relationships with others, in this case, with non-human others (Bastian et al., 2012). Personal growth and healing, and central tenants of humanistic psychology interventions emerge from the developing relationship with the companion animal. Consequently, researchers have frequently characterized AAI as a type of integrative medicine (Hediger et al., 2019; Menna et al., 2019).
Equine-Assisted Activities and Therapy (EAAT) is an intervention modality that may be particularly well suited for returning veterans (Boss et al., 2019; Burton et al., 2019; Johnson et al., 2018), a recent systematic review of the EAAT literature (Kinney et al., 2019) characterized the results as promising. EAAT offers a nonconventional approach and an alternative to traditional therapies, thus reducing the common stigma and distrust of mental health care known to be prevalent in veteran populations (Romaniuk et al., 2018). Because EAAT facilitates feelings of trust through working (and bonding) with horses (Lee et al., 2020; Possemato et al., 2018), it may demonstrate the beneficial role of trust in achieving successful veteran reintegration (Kopacz et al., 2018). Another recent systematic review of EAAT has identified a number of different populations that have received EAAT, including children with autism and cerebral palsy; adolescents with diplegia, Down syndrome, and language difficulties; and adult cancer survivors and veterans (Almasloukh, 2022).
Although EAAT has shown promise for improving psychosocial outcomes among veterans (Johnson et al., 2018; Li & Sánchez-García, 2023; Romaniuk et al., 2018), empirical demonstration of its efficacy has not yet been achieved (Boss et al., 2019; Kinney et al., 2019). EAAT has existed for more than 60 years, but this model remains loosely defined with little agreement on what constitutes EAAT beyond the (Johnson et al., 2018; Li & Sánchez-García, 2023; Romaniuk et al., 2018) presence of a horse and rider and some sort of multi-session approach (Li & Sánchez-García, 2023; Marchand, 2023). In a recent article describing an open clinical trial, Fisher and colleagues (Fisher et al., 2021) argued for the need for manualization of EAAT models for veterans to address deficits in outcomes research.
The existing gaps in the literature regarding EAAT interventions for veterans relate to a lack of homogeneity across studies (e.g., diverse program approaches, highly variable program durations, varied or no clinical training of providers of the interventions, individual- versus group-based programs) and inconsistent applications of research methods (e.g., divergent research designs and aims, widely ranging sample sizes including N = 1, different conditions targeted by the programs, samples with mixed or unmentioned demographic characteristics) (Boss et al., 2019; Kinney et al., 2019). A lack of methodological rigor across the EAAT research indicates a great need for further research in this area (Boss et al., 2019; Kinney et al., 2019).
A consistent need identified across research on EAAT is to better understand the mechanisms underlying success in EAAT, including a clearer theoretical focus (Kinney et al., 2019; Marchand, 2023; Rosing et al., 2022). Discussion of the mechanism underlying success echoes humanism in its focus on making meaning, establishing hope, and transformation through the therapeutic relationship (Rosing et al., 2022). To further understand the mechanisms of success, researchers have emphasized the need for qualitative and mixed methods (Almasloukh, 2022; Rosing et al., 2022). Rosing and colleagues (2022) used a phenomenological lens to find the themes of relaxation, relationship, transformation, and hope. This direction for inquiry appears a promising direction for increasing understanding of EAAT, a direction that is followed here.
Study Aims and Objectives
To contribute to the knowledge base on the feasibility of equine-assisted therapeutic interventions for veterans and to explore in greater depths the experience of veterans using a phenomenological lens, the current qualitative study partnered with a veteran-led EAAT program to explore perspectives among current and past veteran program recipients reintegrating into civilian life and program volunteers and staff. The specific aims of this exploratory and descriptive focus group study were to (a) understand the experiences of current participants, alumni, and program volunteers and staff and their perceptions of the services they received, including evidence-based therapy provided in conjunction with equine therapy, riding and experience with horses, meaning and purpose gained through volunteering, and interactions with others to achieve better integration with civilian life and (b) capture the struggles that veterans and family members have transitioning to civilian life within the context of an EAAT program.
Method
Equest, founded in 1983, is a Dallas-based nonprofit agency that provides equine-assisted activities and therapies for children and adults in North Texas (https://www.equest.org/veterans). One of the programs provided by Equest, Hooves for Heroes, serves honorably discharged veterans of the U.S. Armed Forces seeking to integrate into civilian community life, at no cost to the veterans. The program entails five key components in therapeutic approaches, including horsemanship, therapeutic riding, carriage driving, hippotherapy, and equine-facilitated counseling in a mixed EAAT approach. Each session lasts about 1 hr. Therapeutic riding instruction includes exercises to help participants relate to equine behavior and understand their own personal issues in relation to the animals, involving such aspects as trust, confidence, and emotional communication. Separate equine-facilitated therapy sessions are provided by a licensed therapist based on participants’ needs. In addition to one veteran program manager, registered instructors and licensed professional counselors facilitate the program. Its staff are not only proficient in horsemanship but also have extensive clinical experience with physical and mental disabilities and equine management, and are trained in military cultural competency and veterans’ issues. The structure of this program was developed iteratively based on feedback from the participants and their interactions with the clinicians. This process allowed tailoring of the structure to the individuals rather than strict adherence to a manualized intervention. This team’s research has previously found that participant input into structure and content promotes greater participation and adherence (North et al., 2017; Simpson et al., 2017).
Design
This naturalistic in-person focus group study followed an explorative, qualitative design. Qualitative research methods provide a broad starting point for exploring topics by allowing participants to elaborate in their own words on what is most meaningful or important to them (Padgett, 2016). Our choice of focus groups over in-depth individual interviews emerges from humanistic psychology with its focus on human context. We believe that focus groups allow individuals to share their reflected context. Thus, although in-depth individual interviews have the advantage of reflecting more deeply, focus groups are more effective at exposing the shared context of the phenomenon (EAAT). This approach safeguards against the direction of the investigation based on researchers’ preconceived ideas, elicits rich narratives, and provides abundant nuance (Creswell et al., 2007). Focus groups were chosen for their promotion of candor and spontaneity by participants and because they have the potential to yield rich data on the complex experiences, perceptions, and attitudes of participants (Carey & Smith, 1994; Padgett, 2016), and the match to the system’s conceptual framework (Onwuegbuzie et al., 2013). Approval for the research was obtained from the University of Texas Southwestern, and all research participants provided written informed consent at the time of study recruitment.
Sample Characteristics
This EAAT program sought to serve veterans with regard to diversity, equity, and inclusion. The focus group study sample consisted of a total of 67 EAAT participants, including 22 current and 33 past program recipients, with 7 spouses, 31 volunteers, and 2 staff members (with duplicate representation of some former program recipients serving as program volunteers). Approximately half (55%) of the participants were male. Nearly two thirds (64%) identified as non-Hispanic White, 18% as non-Hispanic Black, and 18% as Hispanic. All the non-spouse recipients and volunteers in this study were military veterans.
Recruitment and Study Procedures
After 10 weeks of the Equest Hooves for Heroes program conducted in early 2017, a volunteer sample was recruited into a focus group study through staff announcements, flyers, and word of mouth. Among the study volunteers, there were no refusals or dropouts when the focus groups gathered. The groups were not specifically allocated other than by convenience in gathering members able to participate at the same time. Between August 2017 and January 2018, 14 focus groups were conducted (see Table 1 for details), comprising current program recipients including spouses who participated in program activities along with their recipient partners and were not differentiated from them in the focus group membership counts (five groups), past program recipient alumni (three groups), former program recipient alumni volunteering with the program (four groups), program volunteers (one group), and program staff members as a separate group to avoid influencing the focus group discussions of program recipients and volunteers (Carey & Smith, 1994).
Themes and Content.
The focus groups were conducted by two facilitators each. The facilitators were clinician members of the research team who had no involvement with the EAAT program or participants (although the study’s leader [CSN] volunteered at Equest in barn-cleaning and therapeutic riding activities after the study was completed). The facilitators were rigorously trained in qualitative focus group methods and had considerable experience in conducting focus groups with this team in multiple published qualitative research studies. The facilitators collected limited demographic information on sex and race/ethnicity to preserve the privacy of the participants. The facilitators also provided a brief introduction asking participants to discuss their experience in the program as a recipient, volunteer, or staff member, specifically how they initially learned about the program, the program activities in which they participated, the role Equest played in their lives, perceptions of the program and its participants, and recommended improvements or changes. Focus group participants were instructed to speak freely into an audio recorder without further prompting. The audio-recorded focus groups lasted approximately 90 min each and were transcribed by an Institutional Review Board (IRB)-approved professional service within the university for analysis. No financial or other incentives were provided to participants for their involvement in the study.
Data Analysis
The thematic analysis for this project followed the successful methods developed and implemented by this research team in several prior studies (Dang et al., 2022; North et al., 2013, 2015). Initially, transcripts were reviewed by one investigator who identified preliminary themes characterizing the content of the focus groups and developed definitions for these themes. Two raters then independently coded transcribed passages into these themes until excellent (kappa ≥ .8) (Fleiss, 1981) interrater reliability was achieved, with kappa values ranging from .90 to 1.00. Interrater differences in coding were resolved through discussion and consensus, which generated definitions of the themes, inclusion and exclusion criteria, and rules for differentiating content among themes. ATLAS.ti software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used for qualitative data analysis. The themes and coding were examined for systematic errors across themes and combined. This process resulted in themes that represented individual coder validation and team consensus. After that, one rater coded the transcribed content into the identified themes. The researchers who identified the themes that arose in the focus groups and coded the responses into the themes were not involved in the facilitators’ instructions to the focus groups and thus were fresh to the materials they reviewed for this study. The material in these themes was analyzed and summarized by the authors as number of passages and description of overall thematic content. The findings were informally triangulated across several members of the research team who have extensive experience working with veterans reintegrating into society, ensuring face validity of the stated discussion. Several participants reviewed the written findings to provide suggestions and ensure the validity of the material, and the authors reviewed the findings to achieve complete consensus within the research group.
Results
Themes
Five themes emerged to characterize the focus group discussion content. Table 1 lists these themes and summarizes their content. The numbers and percentages of coded items in the themes are listed in Table 2. As seen in Table 1, each theme was discussed in most, if not all, of the focus groups, favoring combined presentation of focus group findings rather than by each focus group type. The following sections summarize the focus group discussion content, organized by themes in order of greatest to least numbers of coded comments (Table 3).
Numbers and Proportions of Coded Passages Overall and by Focus Group.
Focus Groups and Participants.
Benefits of EAAT
Participants identified the benefits of the program to their emotional and physical well-being. They credited these personal gains specifically to the Equest environment, program staff, and other participants. Benefits of EAAT had the greatest number of coded comments (two thirds of the total). Despite the frequency of the number of responses, the quotes included scant elaboration and more repetition than those in Connections with Horses (second largest theme, with one-fifth of the total).
Participants described their emotional and physical benefits as emerging in tandem with newfound horsemanship skills. Benefits included developing confidence and mastery, gaining insight into feelings, and alleviation of difficult emotional states. Confidence and mastery were tied to their interactions with the horses. One participant summarized personal change over the course to the program as, “I was afraid to get on the horse, and here I am walking it over fire.” Another disclosed the incremental improvements: “I felt literally stronger every time I got off that horse.” In addition to improving feelings of confidence and mastery, participants credited the program with helping them gain insight into their own feelings. One participant stated, “[Equest] was like a mirror. . .of what you’re going through. . .and how emotionally you. . .are responding to it.” Perhaps the most significant benefit was the alleviation of difficult emotional states. Some discussed the positive impact the program made on their posttraumatic stress and depression symptoms. One remarked, “I’ve been going through a grieving period. . .[Equest] has definitely helped.” Another said, “We come down here and fill up because people drain us.”
Participants singled out Equest’s pastoral environment as an important therapeutic benefit: “I can be stressed out. . .but the second I get out of my car and I smell that barn, boom, it’s gone.” Participants described Equest as “an escape. . .to be with the horses. . .out in the woods” and remarked that “being out in nature and seeing what’s here [is] therapeutic” and allowed them to “[focus] on enjoying the present moment” in which “your problems seem to disappear because you’re with wonderful animals and people.”
The participants also benefited interactions with the program staff. They described the staff as “diplomatic in their mission” and having an innate sense of “when to. . .plug in and when to step back.” Participants appreciated that the staff helped them generalize their learning from the horses to real-life human situations. In one instance, a counselor was able to relate interactions between two horses to a problem a participant was having with two colleagues. The participants expressed feelings of security and connection generated by the staff combining their therapeutic abilities with their Equestrian knowledge. Participants particularly commented on the effectiveness of the personalized tailoring of the sessions to individual needs and goals by the staff, for example: “I just came off of a divorce, and. . . [the Equest counselors] allowed me the space. . .to process how I was, even though they had a curriculum.” This allowed variation in the inclusion of the horse: “If I don’t feel like working with the horses I could just go to the trails and we can just talk. . . .”
Connections With Horses
Participants offered detailed, personal, and unique anecdotes about their Connections with Horses. Although this theme represented only one fifth of the coded comments, participants provided rich descriptions that showcased their meaningful relationships with the Equest horses. Participants spoke of the importance of grooming when connecting with the horses, the symbiotic relationship between participants and horses, and the intangible attributes of their connection.
Participants noted that grooming was an important way and a critical first step for them to connect with the horses, for example: “I walked my horse and just groomed him for probably four weeks. . .until I felt comfortable to get on the horse.” Another emphasized the emotional bond that developed through grooming: “You actually groom them and they see you and they feel you and they sense you and all, that’s where the real connection came from for me. And that was magnetic right there. That was incredible.” Similarly, a different participant expressed feelings of reciprocity: “[The horse] wanted to be groomed and it wanted to be bonded with. And I think that was really therapeutic for me.”
The symbiosis between participants and horses extended beyond grooming. Participants described feedback loops in which the horses responded to their emotional states. For some participants, horses extended trust and engendered it: “You see their head dropping down as they are getting more comfortable with you and they’re vulnerable and. . .so trusting of you.” Others spoke of horses accepting them: “When you are with horses, they see that part of you, they see the most innocent part of you and accept it.” Equine acceptance was deeply moving for one participant: Having those horses just come up to me and just love on me. And they don’t even know me from nothing, and they just accept me and love on me, and it’s just such an experience that I leave with that is so fulfilling.
Another described the horse’s benevolence: “The animal doesn’t care who or what you are but they want to help you. They don’t ask anything from you [sniffling] and sometimes that’s all we need.” Participants also found their animals as responsive to agitation as to trust. One said, “[If] you’re all tense and. . .peeved at the world. . .the animal is just not going to work for you.” Another concurred: “If you’re angry toward the horse you get kicked in the face.”
Participants also talked about the intangible aspects of their connections with the horses. Some compared the experience to worship: “I come in for a session, it’s like going to church on Sunday”; some described the experience as being “close to the Spirit.” One participant stated, “There is something that’s metaphysical; I choose to think of it as God, but something intangible and something difficult to quantify.” Another described the power of this connection: The connection that I experienced with the horse was instant and something that was unexpected for me. I really hadn’t connected like on a deep level with very many people after I left the military, so that unexpected and even unspoken connection with the horse was incredibly powerful for me.
The connection of one participant to his horse revealed a metaphor for life: “The path is not meant to be easy, but it is meant to travel on, and I can see that with the horses.”
Program Engagement
Participants framed their discussion of Program Engagement around their personal characteristics and backgrounds. In addition, they discussed obstacles to and facilitators of their participation. This theme comprised almost one fifth of all of the coded content.
Characteristics and backgrounds of participants provided in the focus group discussions included both their psychosocial features and their experience with horses. Before joining Equest, participants had experienced a variety of emotional and physical challenges. These included posttraumatic stress disorder (PTSD) and depression, and musculoskeletal ailments, such as arthritis, scoliosis, low back pain, amyotrophic lateral sclerosis (ALS), Parkinson’s disease, and wheelchair dependence. In addition, some participants described struggles with social withdrawal, for example: “I closed everyone out and. . .didn’t trust anybody” and “I was very shut, just closed off.”
Participants varied in the level of experience they had with horses before joining Equest. A few had been around horses since childhood and had a professional level of experience working with horses, either on ranches or for show circuits. Others had only minimal exposure or none at all, for example: “I had never been around horses until. . .four years ago” or “I’d never touched a horse in my entire life.”
Obstacles to participants’ involvement in Equest included primarily schedule and transportation difficulties. Participants’ work hours and family obligations conflicted with the scheduled sessions and limited their capacity to commit to additional time for program involvement. A number of participants reported geographic difficulties, including the distance of the program from public transportation routes and inconvenient class times necessitating traversal through rush hour traffic.
Program features facilitating their participation included endorsement of the program by other veterans and the experience itself. Both participants and volunteers described having initially become aware of Equest through word of mouth from fellow veterans in the community. The volunteers discussed the altruistic mission of Equest and connection to the Dallas community through this organization as having attracted them to join Equest. This engagement was further solidified with experience in the program that granted emotional benefits, enjoyment of a pleasant atmosphere, communion with horses, immersion in a community of people with similar interests and backgrounds, and “a better outlook on life in general.”
Equestrian Experience Related to Military Experience
Some participants related their experience with the horses to experiences during their military service. Specifically, they mentioned how their experience with Equest paralleled their military experience and assisted with reintegration, and the importance of having veterans as staff members and volunteers. Equestrian Experience Related to Military Experience represented nearly one fifth of the overall comments.
Participants commented on how their involvement in the EAAT program paralleled their past military experience. One respondent equated the “heritage of armor and tanks [and] horse cavalry” to the horses in the program. The thrill of risk and danger inherent in working with horses was described as mirroring their past military experience.
Reintegration into civilian life involved losing the tight connection of their comrades. Having to leave their battle buddies to return home left “a real empty feeling” and the sense of loss and connection with a team: “I realized how much I missed [it].” Participants described the equestrian community as filling the void. One stated that when “riding with the other veterans you build a cohesive team unit.” Another said, “[My] peers helped me keep my head above water.” This sense of community provided a support system for the participants that held personal meaning: “Synergy comes from having someone that can understand your struggle.”
The participants cited the importance of program staff who are veterans themselves. They specifically identified that counselors with a military background “can cut through so much. . .because of that understanding.” In addition, participants noted that staff with a military background provide advantages to the program’s programming, marketing, and structuring.
Recommendations for the Program
Few participants provided recommendations to improve the program, with the majority of comments clustered around expanding access to and increasing the types of services. Participants felt that Equest was underused among veterans and recommended expanding access via increasing community awareness. A participant said, “It’s sad how hidden they [Equest] are,” and another wished for “some kind of. . .way to magically encourage other veterans to check out what this place can do.” Another suggested a viable option for alerting veterans to Equest’s benefits: “If they had some way to make VA personnel more aware of the facilities and what types of service that they provide, perhaps it might create an influx of people.” Another recommended expansion of access to more veterans by adding Equest locations. One participant focused on the Dallas/Fort Worth metropolitan area and suggested, “An Equest on every corner. There needs to be, like, ten of them in the Metroplex.” Another set a wider vision: “The only thing they’re missing is the funding to have a place in every county.” One recommended a national approach: “It’s a program that should be funded heavily by the federal government.”
Participants recommended that Equest should expand its services by including families, increasing therapeutic opportunities, and adding an aftercare component. One participant suggested the inclusion of spouses: “We need to do more for the married couples.” Several spoke of considering children in programming, either through inclusion in EAAT programming or via child care. One participant considered, “I think that’s a growth opportunity for Equest to bring in the families and have it become a family bonding and healing time. I think it would be very, very powerful.” Some recommended expanding therapeutic services with more counselors available on site, providing after-hours counseling services, developing weekend programming, and hosting overnight retreats. Others suggested alumni opportunities to support maintenance of gains and continued growth. Potential aftercare program ideas included follow-up, alternate programming, and alumni events to strengthen camaraderie. One suggested periodic reunion: If they just had, like, a once-a-quarter or once-every-other-six months. . .party or reunion of past participants, that would be great—even like a Christmas party reunion or something. . .celebratory that’s low stress and kind of keeps us more connected.
Another participant was in favor of using social media to sustain connectivity with other participants: “They might consider. . .making a private Facebook page for past participants and their families.” Several participants echoed a suggestion: “to build a community of those that participate in the class and [create] more of a connection with everybody.”
Discussion
This qualitative focus group study examined the experiences of veterans involved in an EAAT program from the perspectives of receiving and providing this service and to describe their struggles within the context of this program. Discussions across focus groups generated fresh insights into the benefits observed by both program recipients and providers, and aspects of the program regarded as instrumental to the gains made through the EAAT program. Two prominent findings reflected general agreement that the EAAT program was beneficial and that horses were uniquely integral to its benefits.
The theme with the largest number of comments emerging from the 14 focus groups addressed the benefits of the Equest program, revealing general agreement and extensive focus on how beneficial the program was to its participants. The majority of participant comments reflected appreciation for the physical and psychosocial gains from participation in the program. These findings fit with the overwhelmingly positive tone of the general literature on EAAT (Johnson et al., 2018; Lee et al., 2020; Schneider & Harley, 2016; Seredova et al., 2016; Vermöhlen et al., 2018).
Equest participants described staff characteristics and abilities as helpful for achievement of their personal improvements. Specifically, staff expertise in equestrian skills was recognized as imparting horsemanship proficiency, promoting therapeutic interpersonal skills, and encouraging completion of the program’s activities for program participants. The community of veterans was also identified as an important element of the program’s therapeutic process. These findings are consistent with the literature which has identified peer navigators (veterans who have successfully reintegrated into civilian life and offer support for others) as a key resource to veterans in transition (Ahern et al., 2015; Kranke et al., 2016).
After the theme conveying the benefits of the EAAT program, the next largest part of the discussion focused on the connection to the horse. The horse was portrayed as the essential and irreplaceable element of the therapy. The participants’ emotional connections to the horses were powerful, simple, and direct. Many participants described connecting with the horse in emotional terms without constraints of higher cognitive processes characterizing interpersonal relationships with humans. The power of the relationship with the horse was described as an integral part of the immense physical presence of the horse. Many participants described an initial intimidation that evolved into mutual trust through bonding with the horse. Mirroring this finding, a systematic review across qualitative studies on the benefits of EAAT for veteran populations (Kinney et al., 2019) found a common theme of trust observed. The important role of trust on veteran mental health outcomes has been reported, and a positive correlation between trust levels and social interactions (Kopacz et al., 2018).
The findings of this study point to activities with the horse, such as grooming and riding, as a fundamental basis for forming emotional bonds with the horse and instrumental in developing horsemanship skills and self-confidence with the horse. The unique connection between participants and their horses has also been observed as a trust-building factor in previous studies of EAAT interventions (Frewin & Gardiner, 2005; Lee et al., 2020). Once these gains were secured, the participants in the current study explained that they were then able to move to the next therapeutic step involving generalization of emotional growth and relationship skills from the horse to self-understanding and application to interpersonal relationships with humans. The discussants also described the pastoral equestrian setting as a particularly salutary influence.
The participants’ descriptions of their journeys to psychological growth through interacting with the horses invoke some parallels with established concepts of therapeutic processes. In therapy, therapists engage their clients emotionally, following the principles of attachment theory and humanistic psychology (Bachi, 2013; Bowlby, 1988; Kern-Godal et al., 2016), by enveloping them in a warm, secure, and accepting ambience facilitating internal exploration, discovery, and growth through the relationship with the therapist. In this sense, the horse may be conceptualized as a therapeutic tool that extends the functions of the therapist in equine-assisted therapy interventions (Bachi, 2013; Corring et al., 2013; Kern-Godal et al., 2016). The descriptions also led to an intriguing possibility emerging from the system’s theory perspective and prior discussions of animal–human relations—namely that the horse itself might be included as part of both the therapeutic system—and indeed, although this represents a bit of a stretch, as part of the family system.
The instinctual nature of the horse as an animal and its innate responses to the emotions of other animals and humans on a preverbal level of communication (Bachi, 2013; Corring et al., 2013) has the potential to establish emotional attachment and bonding in ways not always attainable by psychotherapists (Kern-Godal et al., 2016). It is thus possible that the horse may have a role in providing therapeutic avenues not accessible to human therapists unaided by horses. This possibility is consistent with the focus group members’ descriptions of their experiences with the horses in EAAT.
Strengths and Limitations
A strength of this study was its relatively large sample (N = 67) participating in 14 focus groups. Another strength was the inclusion of various roles of individuals involved in the program (current and former program participants and their spouses, staff, and volunteers), revealing a breadth of experience with the program. Importantly, providing unstructured questions during focus groups contributed to spontaneous, rich, and insightful discussion, although the theme “recommendations for the program” may have been influenced by its suggestion by the facilitator among many examples of material in the initial instructions for the focus groups. In addition, participants may have painted a positive-oriented portrait of their experience in the program in their enthusiasm with it and desire to please program personnel who might view these results. The qualitative data analysis was rigorous and systematic, with achievement of excellent interrater reliability in coding of the content into themes.
This study is not without limitations. Importantly, the participants represented a volunteer sample that may have presented biases related to unknown characteristics, and the groups were not randomized with members allocated to them. However, important demographic characteristics related to representation in the sample were collected: all non-spouse program recipients and volunteers were military veterans, sexes were equally represented, and more than one third of the participants were of racial/ethnic minorities, indicating that the participants represented diversity, equity, and inclusion in the demographic variables collected. Volunteer samples are well known to hold favorable attitudes toward an intervention and may not accurately represent the population (Ganguli et al., 1998). It is possible that group participants may have had reticence to express their complete opinions in the presence of one another in a focus group setting. Furthermore, focus group participants may have influenced one another in generation of the material provided in these discussions that would not be a factor in individual interviews; however, the division of participation into many focus groups in this study may have mitigated this potential influence. Due to the recognized reticence of service members to participate in research (Cook & Doorenbos, 2017), the limited data provided on participants’ demographic information did not permit stratification of military rank and combat cohort on participants’ experience of the intervention. The transcriptions did not link passages to specific speakers, preventing cross-referencing within individuals. This study examined only one program in one location and may not generalize to other equine-assisted therapy programs for Veterans. Because this program was relatively unstructured and informal, it may not provide the basis for comparison with formal evidence-based studies. Finally, although the data for this study were collected several years ago, the findings remain relevant to current military reintegration experience, which can be potentially addressed by equestrian therapy.
Future studies can benefit from the collection of additional demographic data on age, gender identity, sexual orientation, disability status, socioeconomic status, mental health service user status, and other relevant attributes, to further examine the representation of groups with the above characteristics and to study different evidence-based EAAT programs in different locations to compare their experience. In addition, future research is needed to compare the experiences and observations of different individuals involved in EAAT programs (i.e., participants, alumni, family members, volunteers, and staff). Finally, an important feature to include in future research on EAAT for veterans might be the effect of different cultural aspects within this population.
Implications
Practice
The overwhelmingly positive views of the EAAT program and its benefits expressed by participants, family members, staff, and volunteers involved with the Equest program indicate that it was highly regarded, suggesting an enduring potential and relevance for care of veterans reintegrating to civilian life. Of interest, the focus group participants spontaneously mentioned the role of mental and physical health among their personal challenges prior to joining the EAAT program. These findings indicate the potential for EAAT to help fill existing gaps in interventions for veteran mental and physical recovery, potentially encouraging further efforts to develop, implement, and test the efficacy of programs specifically addressing these issues. The findings also indicate potential for humanistic clinical practice, including the development of self-actualization through participation in EAAT.
A suggestion from these focus groups was that family members should be included in the EAAT program, reflecting well-established family aspects of veteran reintegration difficulties and previous demonstration of enhanced therapeutic benefits of EAAT with inclusion of partners (Romaniuk et al., 2018). Another suggestion from these focus groups was to conduct communal activities in parallel with EAAT (e.g., alumni events including former participants), a finding substantiated by the number of volunteers in the current program who were former program participants. Inclusion of family and social systems in EAAT for veterans is consistent with systems approaches involving multiple levels of reintegration (Elnitsky et al., 2017). Dissemination of EAAT awareness through outreach to other veterans was another consistent recommendation by participants.
Research
Although the findings of this and many other studies indicated strong approval of EAAT programs to support veteran mental health needs, research with rigorous methods including randomized controlled studies is needed to determine the effectiveness of this intervention for veteran populations reintegrating into civilian life. Further research on EAAT is needed to clearly define what constitutes EAAT, potentially through manualization, as argued in the work by Fisher et al. (2021). The literature on EAAT to date lacks methodological rigor (Boss et al., 2019; Kinney et al., 2019). To address this gap, future studies need to replicate programs with consistent methodology and measure intervention outcomes with valid and reliable instruments to be able to compare findings across studies. Longitudinal studies will also be needed to determine the persistence of the benefits realized from these programs for long-term adjustment. In addition, operationalizing the themes identified in this study into mediating variables may further the understanding of mechanisms for success with EAAT models.
Another logical direction for future research on EAAT is further qualitative inquiry into the experiences of veteran participants and their families with the model. The current study suggests the importance of the human experience of the veterans in their relationships with horses. In one sense, this reinforces the importance of further inquiry into EAAT with a humanistic psychology lens, with its focus on developing trust and fulfilling relationships through generalizing experience with horses. Examining relationships with other members of the veterans’ social systems and how that changes in relation to EAAT may also provide a fruitful exploration of the context in which EAAT occurs.
Footnotes
Correction (August 2024):
The funding information is added for this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Texas Health and Human Services Commission, Texas Veterans + Family Alliance Grant Program, 5/1/17-6/30/19 (to Dr. North, Principal Investigator, and Metrocare Services): Equest Hooves for Heroes Program for Veterans with PTSD.
