Elsevier

EXPLORE

Volume 11, Issue 6, November–December 2015, Pages 461-467
EXPLORE

Original Research
Project Stride: An Equine-Assisted Intervention to Reduce Symptoms of Social Anxiety in Young Women

https://doi.org/10.1016/j.explore.2015.08.003Get rights and content

Introduction

Although there is evidence supporting the use of equine-assisted activities to treat mental disorders, its efficacy in reducing signs and symptoms of social anxiety in young women has not been examined.

Method

We developed and pilot tested Project Stride, a brief, six-session intervention combining equine-assisted activities and cognitive-behavioral strategies to reduce symptoms of social anxiety. A total of 12 women, 18–29 years of age, were randomly assigned to Project Stride or a no-treatment control. Participants completed the Liebowitz Social Anxiety Scale at baseline, immediate-post, and 6 weeks after treatment.

Results

Project Stride was highly acceptable and feasible. Compared to control participants, those in Project Stride had significantly greater reductions in social anxiety scores from baseline to immediate-post [decrease of 24.8 points; t (9) = 3.40, P = .008)] and from baseline to follow-up [decrease of 31.8 points; t (9) = 4.12, P = .003)].

Conclusion

These findings support conducting a full-scale efficacy trial of Project Stride.

Introduction

Social anxiety disorder (SAD) is a very common disorder affecting approximately 15 million American adults in a given year.1 This disorder is characterized by a persistent or excessive fear of social situations. Individuals diagnosed with SAD often fear being negatively judged, scrutinized, or criticized by others. As a result, they often avoid social settings or encounter severe distress in social situations. Anticipatory anxiety (excessive worrying about a situation before it happens) and distorted thinking (false ideas about social situations or negative evaluations by others) are very common in individuals with SAD. In addition, many individuals with SAD fear multiple social settings or situations such as eating or drinking in front of others, going to parties, talking on the phone, and working in front of others. If left untreated, SAD may negatively impact people׳s lives by interfering with relationships, school, work, and other social situations.

Behavioral and pharmacological approaches have been used effectively to treat SAD. The more effective pharmacological treatments include benzodiazepines and antidepressants.2 Cognitive-behavioral therapy (CBT) is another effective approach for treating SAD,3 and it has been shown to have longer lasting effects than drug therapy.4 CBT is a form of time-limited psychotherapy in which therapist provide clients with the necessary tools to increase their cognitive and behavioral skills so that they may function more effectively in everyday life.3 CBT approaches to treat SAD include cognitive restructuring, exposures, and relaxation and social skills training. Although not yet tested, alternative therapies such as equine-assisted activities/therapies (EAAT) could also be used to strengthen the effect of CBT for ameliorating the signs and symptoms of social anxiety.

The term equine-assisted activities/therapies refers to a wide range of activities and therapies that incorporate horses in the treatment of individuals with the goal of improving cognitive, emotional, behavioral, social, and equestrian skills.5 Individuals participating in these types of programs may engage in a variety of different equine-assisted activities such as grooming, handling, riding, lunging, driving, vaulting, and teambuilding. Trained instructors or other professional personnel may combine these equine-assisted activities or administer them singularly to address the specific needs of each client. For instance, clients with cerebral palsy may benefit most by riding a horse rather than participating in ground activities such as grooming. By riding and directing the movement of the horse, these individuals may increase their balance, coordination, trunk control, gross motor functioning, self-confidence, and other physical and neurological functioning.6

A number of clinical reports, case studies, and non-experimental studies have described the usefulness of EAAT in the treatment of patients with post-traumatic stress disorder (PTSD), depression, attention-deficit/hyperactivity disorder, conduct disorders, dissociative disorders, and other chronic mental illnesses.5 EAAT has been used to enhance non-verbal communication, creative thinking and problem solving, assertiveness, leadership and teamwork skills, taking responsibility, relationships, confidence, and attitudes in both clinical and non-clinical samples.7 They have also been utilized to treat a variety of mental health needs such as attention-deficit disorder, abuse and behavioral issues, depression, anxiety, eating disorders, interpersonal relationship problems, and communication deficits.7

The beneficial impact of EAAT has been reported for clinical and non-clinical populations. For instance, in a small, non-experimental study (N = 5) Norbeck8 suggested that combat veterans with disabilities (i.e., traumatic brain injury, PTSD, back injury, borderline personality disorder, and multiple sclerosis) may benefit from therapeutic horseback riding programs. Participants reported higher physical self-efficacy and global self-esteem after the intervention than prior to participating in the program. Another study with a pre-test post-test design (N = 31) targeting patients in a residential treatment program revealed that after engaging in equine group therapy for four and a half days, participants showed decreases in psychological distress, had a stronger focus and greater ability to live in the present, had greater self-reliance and independence, and felt less impacted by negative, self-deprecating feelings such as resentment, regret, guilt, and fear of the future.9 A study by Kaiser et al.10 found that participating in a 5-day therapeutic riding camp significantly reduced anger in a group of 16 able-bodied youth 11–15 years of age with no known physical or psychological disability and no known history of psychotropic medications. The authors suggested that the changes may be related to the child׳s relationship with the horse, the social environment of the camp, the horseback riding, increased contact with nature, or a combination of these factors.

Trotter et al.11 demonstrated that group EAAT may be effective in treating at-risk children and adolescents by comparing EAAT to classroom-based counseling in a non-random sample convenience study. When comparing within-group pre- and post-treatment scores for internalizing, externalizing, maladaptive, and adaptive behaviors, results demonstrated that the EAAT groups made statistically significant improvements in 17 behavioral areas compared to the classroom-based group that showed statistically significant improvements in only five areas. Participants in the EAAT group also demonstrated a statistically significant increase in positive behaviors and a decrease in negative behaviors on the Behavioral Assessment System for Children (BASC) Self-Rating Scale and on the BASC Parent-Rating Scale.

Despite the numerous reports and rigorous qualitative studies attesting to the beneficial effects of this therapeutic modality, there have been few published clinical trials examining the effects of EAAT. One of the few published interventions12 evaluated the effects of therapeutic horseback riding on social functioning in children (ages 4–10 years) diagnosed with Autism Spectrum Disorder in a small-randomized experimental study (N = 34). Compared to the participants in the waitlist control group, participants in the experimental group improved in central areas, such as sensory integration and directed attention. The experimental group also improved in the areas of social motivation and sensory sensitivity and decreased in the areas of inattention and distractibility.

With support from Horses and Humans Research Foundation,5 a number of clinical trials examining the efficacy of EAAT are being implemented. For instance, Mueler and McCullough (personal communication, February 5, 2014) are conducting a randomized control trial with 60 children/adolescents to investigate the short-term effects of EAAT on levels of PTSD symptomatology. Johnson (personal communication, February 6, 2014) is conducting a randomized control trial to explore the effects of EAAT to reduce symptoms of PTSD in veterans. Results of both studies are not yet available.

Additional evidence supporting the promise of EAAT comes from a recent meta-analysis13 of biopsychosocial equine-assisted interventions. The authors reviewed 14 studies that met their inclusion criteria and found evidence supporting the beneficial impact of this type of therapeutic approach for both clinical and non-clinical samples that included a variety of populations (i.e., at-risk adolescents, youth in general, male and female adults) and ages (4–70 years old). Two studies provided a moderate level of evidence while nine studies yielded statistically significant positive effects for the use of EAAT. None of the studies included in the meta-analysis was a randomized control trial, due to the authors׳ inability to find any experimental study meeting the inclusion criteria during their literature search.

The results of this meta-analysis and the studies reviewed provide some level of evidence supporting further evaluation of EAAT to reduce symptoms of numerous mental health challenges. Despite the high prevalence of social anxiety, particularly among youth and young adults, we did not find a single study that examined the effect of EAAT to reduce symptoms of social anxiety in this population. By designing a group intervention combining EAAT and CBT, clients may practice and apply newly gained skills within a group setting while engaging in innovative recreational activities that provide psychological and physical stimulation.

Coupling EAAT with cognitive-behavioral techniques may have beneficial impacts for both clients diagnosed with SAD and therapists. Unlike traditional talk therapy sessions, EAAT allows the therapist to observe their client׳s behavior firsthand and, if done in a group setting, provides the added benefit of observing interactions among group members. EAAT may also facilitate communication and self-disclosure among clients. For instance, by diverting attention from themselves to the horse and by focusing on completing unfamiliar tasks, clients׳ fears of self-disclosure may be ameliorated.

The goal of this study was to conduct a small-randomized control trial to pilot test a cognitive-behavioral equine-assisted intervention, Project Stride. The aims were to gather preliminary evidence of whether the intervention reduced symptoms of social anxiety among women ages 18–29 and to examine its acceptability and feasibility. We hypothesized that women who participated in Project Stride would score lower than those in the control group on a measure of social anxiety at the immediate-post and the follow-up assessments. We also hypothesized that the intervention would be acceptable to participants and feasible to implement.

Section snippets

Participants

During the month of June 2013, we recruited 12 women to participate in Project Stride using active and passive recruitment approaches. Our passive recruitment included posting flyers at local universities, bookstores, coffee houses, and other community venues. Active recruitment consisted of directly approaching women at universities and other community venues and talking to them about the study. Women were also able to self-refer and/or refer friends. Women interested in participating

Results

To describe the characteristics of the sample, we computed frequency distributions, means, and standard deviations for continuous variables and calculated percentages for categorical variables. For the primary outcome measure, we calculated change scores between the baseline and the two follow-up points as well as between the immediate-post and the follow-up. We performed independent t-tests using these change scores to examine the effect of the intervention between the baseline and the

Discussion

This is one of the few studies to use rigorous experimental procedures to examine the effect of an equine-assisted cognitive-behavioral intervention to reduce social anxiety among young women and to establish its acceptability and feasibility. Despite our small sample size, we found significant differences in social anxiety between the two groups in the hypothesized direction; participants in the experimental group had greater reductions in social anxiety than those in the control group.

Acknowledgments

The authors would like to acknowledge and thank Dr. Margaret M. Bass, executive director at Good Hope Equestrian Training Center, for allowing them to use Good Hope׳s beautiful facility and wonderful program horses and Dr. Holly Bedotto for providing her clinical expertise at each intervention session. Last, the authors would like to thank their study participants for the time and effort they dedicated to this study.

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