By Kathryn Yao
Nancy Heller remembers teaching a 6-year-old boy with noncommunicative autism to ride. On that particular day, she decided to have him ride with a bareback pad, which helps with movement, on Forrest, a brown bay pony in his 20s.
The exercise was called “Around the World,” where the rider puts one foot over the front of the horse and rides side saddle. The feet are on the side and one foot is on the back so the rider is basically riding backwards. After the boy went around the arena, he took his finger and made a circle with it and pointed toward the horse’s ears.
Heller, now a therapeutic horseback riding instructor at Potomac Horse Center in Gaithersburg, Md., took this to mean the boy wanted to turn frontwards. She moved his leg over the rump in the same direction he moved his finger in a circle, in order to let him know she was understanding what he was trying to communicate.
“Big smile, like he had overcome his fears and that he communicated to me and I understood what he was saying,” Heller said.
He took his feet out of the stirrups and then he signed “Finished.”
Heller was so happy because the boy usually babbles and mimics signing, but this time he communicated. Heller was really proud. The boy’s caregiver, who was watching the whole time, was thrilled. He didn’t need assistance tapping his feet against the horse.
“I’ve never had a breakthrough like this before,” Heller said.
For Heller and other experts on equine therapy in the Washington, D.C., Metro area, this and many other similar stories reinforce something they say humans have known for centuries: Horses have a unique ability to help people with therapy and rehabilitation from physical and psychological ailments.
Therapeutic riding began around 5th century B.C. in ancient Greece, when wounded warriors used horses for therapy and rehabilitation, said Marty Leff, a NARHA advanced certified therapeutic horseback riding instructor and one of the founders of the therapeutic riding program at Potomac Horse Center In Germany, horses were used for physical therapy, especially after World War I and II.
“Building a relationship with an animal is very rewarding in many aspects,” said Heller, a registered certified therapeutic horseback riding instructor who has been at Potomac Horse Center for nearly six years.
When those with an emotional, social or psychological disability are given trust and loyalty from a horse, they feel very important and their self-esteem rises, she said. The reassurance allows riders to extend their relationship with horses to personal relationships with other people, she added. “Horses also help people feel in control of their situation because there is a direct correlation between action and reaction.”
Horses mirror and read the rider’s emotions and body language. Horses cannot lie. These characteristics aid the human therapist or instructor, as well as human assistants, by letting them know exactly what’s going on with the rider in attitude, personality and emotions almost immediately. Horses change a rider’s awareness of his or her surroundings so the rider can be more attentive and engage with others where they wouldn’t interact with anyone at all, said Colleen Murphy, a physical therapist who used to work in the D.C. area but who now owns a private practice in Kentucky that focuses on sensory processing.
Horses help the human therapist or instructor find hidden emotions and issues in a more proficient and accelerated manner, which aids the rider and the therapist in developing problem-solving skills. Most times, riding a horse and contact with the horse are motivators forcing riders with noncommunicative autism to sign or verbally communicate, said Davorka Suvak, the program director at SPIRIT Open Equestrian Program in Herndon, Va.
For those with autism who are also noncommunicative, they physically connect and thus communicate with the horse and eventually learn to communicate with people. The noncommunicative autistic learn to focus on something outside themselves, interact with other people and respond to verbal cues from the instructor to complete specific tasks, Suvak said. Thus, horses give those in the noncommunicative spectrum of autism a voice.
According to Susan Avjian, a hippotherapist for more than 20 years who worked with students with autism at the Katherine Thomas School in Rockville, Md., horses not only heal physical ailments, but also fill gaps of emotional need.
A woman with mutiple sclerosis made a goal to be able to walk down the aisle on her wedding day. After a period of therapy, walking down the aisle didn’t look like it was going to be possible for her, but she had a plan. The wedding party knew about it, but the guests didn’t. The horse center where she went for therapy sessions worked with her and she was able to ride a therapy horse down the aisle.
“For her to be able to not be bound her wheelchair was just a phenomenal experience,” Avjian said. “It was just such a wonderful way for her to do something different, to feel more like everybody else and to have something special in her life on her wedding day.”
To Avjian, the bride was an example of why equine therapy is important.
Defining equine therapy
Some believe the theories behind horse therapy developed from Gestalt Therapy, a psychotherapy in the 1950s focusing on the individual’s experience in the moment, the therapist-client relationship and the environmental and social contexts in which these things take place. In 1969, the North American Riding for the Handicapped Association (NARHA) was founded for those with physical disabilities. The Equine Facilitated Mental Health Associated became a branch of NARHA in 1996 to cater to those with nonphysical disabilities.
The expanse of what horse therapy actually covered became so vast, from grooming a horse to vaulting (a running jump over an obstacle on horseback), that NARHA only goes by the acronym now. NARHA also changed the official term for equine therapy to equine-assisted activity and therapy (EAAT). EAAT has only become more widely recognized in the last four years, and horse therapy terms are constantly changing.
In therapy involving horses, the horse can be seen as the teacher, the assistant or the tool. “Working with horses provides the therapist with an object in the space on which to promote projection and identification,” said Dr. Elisabeth Reichert, a social work professor at Southern Illinois University in Carbondale, Ill.
The goals that are to be achieved are basically the same in an equine environment as it is in the clinic. Avjian said the only difference is the tool or equipment.
In the clinic, a therapist is limited to inanimate objects, such as a swing or ball. In an equine environment, the horse and the arena are the tools. Horses offer a recreational component for motivation that dead objects can’t. The motivation assists the rider to carry their skills into the functional realm of their everyday lives, she added.
“We’re treating our clients in a very holistic way. We don’t just slice it and say I’m a PT, and OT, I’m this or that,” said Avjian. “The whole body works together and we incorporate it all. Any good instructor or therapist is going to look at things in that way as well.”
According to Murphy, America’s health care system of payment requires therapists to segment into small areas. A good therapist works on improving every part of the rider, she said. “We’re all doing the same things, we’re just writing the goals up in different ways to kind of slant toward our profession.”
A proper horse therapy session for students who can’t ride on their own involves five humans: the lead next to the horse’s head, two spotters on each side of the horse, the student on the horse’s back, and the therapist at the center of the arena or moving alongside the horse.
At Potomac Horse Center each student gets half an hour of riding. Adjusting the stirrups and feeding the horse is part of the allotted time. Heller employs 19 horses for therapy in the small arena. She has 30 students. One-third of them have autism, one-third have a learning disability of some sort and one-third have something that doesn’t fall into those categories. Students as young as 5 years old can ride under Heller’s supervision, but she makes exceptions. Currently, her youngest student is 3 years old and her oldest student is 59.
“To some people, it gets through to them where none of the other therapies do get through to them,” Heller said. “To some people, they’re just tired of the same old therapy in a room, especially physical therapy.”
Not only is equine therapy a more exciting form of therapy, but Murphy believes students gain tremendous self-esteem when they can maneuver a 1,000-pound beast. A 3-year-old former student of hers has only been speaking in one or two-word sentences and after his first day of leaving hippotherapy, he got back into the car with his mom and said, “Want Costco, slice of pizza.” It was the longest sentence he had every communicated with his mom. And she was just incredibly teary-eyed and so excited for him to move over into the new domain of language.
All about horses
Horses are flight and instinct animals, but also majestic, large and powerful. For the noncommunicative autistic, a horse’s innate instincts are a huge benefit.
“Horses are so big that when someone who doesn’t have a lot of success in life is able to succeed on horseback, that’s really a big thing,” Leff said. “When you tell the horse to go left and it actually goes left—that’s a big deal.”
Horses can be intimidating, thus when riders accomplish any task involving a horse they overcome their fears and problems, establish and grow self-confidence and sometimes even begin healing and curing the issue at hand.
There are horses who take advantage of the helpless and then there are generous and kind ones that are born to do therapy, she said.
“My therapeutic horses were my other set of hands,” Leff said.
Her first requirements for a horse is soundness and attitude. She tests to see if the horse is therapy material by jumping up from behind something and screaming at the horse. “You never know and if you have some kids from the extreme end of the autism spectrum, they can do all kinds of interesting things so the horse has to be close to bombproof.”
Leff started the therapeutic riding program at Potomac Horse Center in 1994. She wrote the groundwork manual, including therapeutic riding rules and guidelines, for the center’s program. She worked with the center on teaching people about horses and riding as well as how to care for a horse. Leff is involved with “remedial-psychoeducational and recreational riding and groundwork” and incorporated her extensive training in hippotherapy and sensory integration into the center’s curriculum.
Leff has had students who were afraid and had to be coaxed to get on a horse. But when they find themselves riding a horse, “they feel like they’re 1,000 feet tall,” she said. “What it does for self-esteem is just remarkable.”
One of her former students was a very bright girl — gifted but with severe learning disabilities, she said. During a school bus ride, a bunch of boys were bullying another student. The girl got up, told them to sit down, behave and leave the other student alone.
“I figured if I can ride a 1,000 pound horse, I can tell a couple of 100-pound boys to behave,” the girl said.
While riding a horse improves the rider’s circulation, muscle control and coordination, Suvak said, the more important aspects include “a very profound bond riders develop with their horses.” Horses are companion animals, attuned to the smallest movement, attitude and emotion, she said. They look to their riders for direction and love.
Horses are simple creatures. They aren’t demanding. They want to understand their riders and want the riders to understand them.
“Because of the love and trust they give, their fine-tuned responses, and desire to please, they are extremely effective in creating a bond with autistic riders that encourages communication and interaction,” she added.
Equine versus clinic therapy
Children with some form of autism in the pre-school years can greatly benefit from a combination of therapies and experiences, said Virginia Kane, director of occupational therapy at Skill Builders, a speech-language and occupational therapy organization in Arlington, Va.
According to Dr. Stanley Greenspan, a well-known psychologist in the D.C. metro area, parents should spend the money they would have for their children’s college on establishing skills during the pre-school years for children with autism so that they may have the opportunity to even think of college.
“So much can happen before they get to kindergarten,” Kane said. “Children with autism are very oftentimes involved in occupational therapy for work on their sensory motor skills, body awareness—so they can have a better sense of how to interact with other bodies.”
They’re also getting speech therapy coupled with play therapy or psychology counseling in order to figure out all the effects autism has on the individual, she added.
At the elementary school age, a child should be able to handle the school day, sit upright at a desk, lift their head up and look at the board and write. Occupational therapists help children work on trunk control, shoulder and wrist stability, finger skills and insolated control of the muscles. Riding a horse helps those slower in learning develop trunk control by encouraging good posture with a straight back, Kane said.
Skill Builders sees many children with sensory processing issues, sensory integration dysfunction and learning disabilities, either coupled with sensory integration dysfunction or as the main problem.
Sensory processing is essential to normal functioning. The three primary sensory systems are vestibular, proprioception and tactile. According to Murphy, when a person has sensory processing disorders, the person usually has problems in all three areas. “The proprioception has a bigger job than just knowing where our body is,” she said. “It is also the input that regulates our sense of being. It’s a very regulatory input. Those are direct links into the brain.”
Therapy in a clinic also involves visual perception and visual motor activities. “We do a lot with bilateral coordination because in OT we look at providing a child with a good sensory motor foundation,” Kane said. “If they don’t have the good core muscle strength, the right-left coordination in their bodies, theoretically it’s more difficult to get refined left-to-right across the paper.”
Therapy focusing on visual development assists a noncommunicative rider with autism, who never looks in the eye of individuals or who is very ego-centric, to think of somebody else, Murphy said. “Part of the riding is brushing the horse and taking care of the horse and it starts to move them out of ‘me me me’ to a ‘we.’ ”
In a clinic, a therapist would use a pencil to gauge the student’s awareness of their muscle and joint position, and knowledge of how tightly and efficiently the student is using the pencil. In an equine setting, the horse therapist or instructor uses a horse to find and develop the rider’s self-awareness of their bodies. Sensory processing is the base on which the rider builds a good knowledge of his or her body to even go off into other areas, Murphy said. “There has to be a strong sensory core to have good self-esteem.”
Equine therapy: the positives, negatives
The Centers for Disease Control and Prevention’s 2009 ADDM autism prevalence report concluded the prevalence of autism had risen to one in every 110 births in the United States and almost one in 70 boys. The news was not a surprise to the Autism Society or to the 1.5 million Americans living with the effects of autism spectrum disorder. Nonetheless, the spotlight shown on autism as a result of the prevalence increase opened opportunities for the nation to consider how to serve these families facing a lifetime of supports for their children.
The Autism Society estimates the lifetime cost of caring for a child with autism ranges from $3.5 million to $5 million, and the U.S. is facing almost $90 billion annually in autism costs (including research, insurance costs and non-covered expenses, Medicaid waivers for autism, educational spending, housing, transportation, employment, and related therapeutic services and caregiver costs).
Leff doesn’t think horse therapy is the most cost-effective form of therapy, but the cost of non-horse therapy is comparable to horse therapy, especially when you’re paying for a horse, instructor, horse care and overhead, she said. “But I think that it’s an expensive sport and that is the problem with it and I don’t know any way we’re going to get that included in the health bill.”
On the other hand, Murphy and Avjian believe the field of horse therapy is becoming more widely accepted by scientific communities. According to Murphy, the DSM is recognizing sensory processing, which leaves insurance companies no choice to to pay for services. In turn, a wide variety of therapy, including equine, that has not been presently accepted will become available.
According to Murphy, the pricetag for an hour of equine therapy in D.C. is somewhere in the $120 to $130 range. Potomac Horse Center charges $61.50 for a 30-minute private lesson. Riders can buy a package of 10 or 12 lessons, which is cheaper at $58 per lesson coming to a total of $580 for 10 weeks.
“One thing that you find as a parent is if your child needs something, you will do anything to try to help your child,” Avjian said. “If they’re hurting, in pain—if you think there’s something that could improve their quality of life and functioning, you are going to do it.”
Getting second mortgages on homes and borrowing money from wherever and whomever are some examples she mentioned. Avjian has seen many parents making sacrifices, no matter the cost, to pay for therapeutic horseback riding. Research is lagging in showing the benefits and effectiveness of horse therapy, but that will change with time, she added.
The future of equine therapy
Today, according to Leff, the majority of those with disabilities seeking horse therapy are in the autistic spectrum. Horse therapy is just as important as playing a sport or doing physical activities—something everyone needs, she said. “For a person with a disability who can’t walk normally, to be able to ride a horse is like, for us, to be able to fly.”
She added that sport and therapy are inseparable.
According to Heller, a person’s background is irrelvant when it comes to equine therapy. “Horses speak to everybody and there is psychotherapy and physical therapy, and socialization and directionality, especially for people with disabilities,” she said. “Horses can really teach you a lot if you’re willing to listen.”
One downside to equine therapy is it’s very much of a man-powered therapy. “Unfortunately, we see less and less volunteerism happening. I’m hoping that will not prevail and people will still be willing to give to others,” Avjian said. “I know here in the D.C. area or in Montgomery County, the students have to put in a number of volunteer hours to graduate—I think that’s great.”
According to Avjian, research is an integral component where more work needs to be done and restrictions, such as time and money, have prevented equine therapy from being widely-accepted. “When we look at things now, especially because things are so expensive, you want to get ‘the most bang for your buck’ and I think this is just a wonderful way to have so many people have a positive impact in their life from social, emotional and therapeutic standpoints of physical and sensory therapy.”