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Thanks to the incredible Dr. Patricia Flaherty Fischette, you’ll learn a great deal about animal-assisted therapy, specific to eating disorder recovery, below:

 

My study is a qualitative, exploratory study of Animal-Assisted Therapy (ATT) as an adjunctive component to interventions for adult women with eating disorders. The primary research question for this study is to explore how adult women with eating disorders experience AAT and in particular, whether AAT relates to important aspects of attachment experience and affect regulation ability; two areas also associated with the diagnosis of eating disorders.  The research rested on the conceptual foundation that AAT is a mechanism by which affect may be elicited amongst people with eating disorders and that AAT may serve as a tool for reparative experiences for individuals struggling with eating disorders. Although this study was exploratory in nature, there was a connection between AAT, affect regulation, and attachment reparation among women who struggled with eating disorders.  The findings of this study suggest that talk therapy often fails to take the time to assess the individual’s capacity to symbolically bridge or connect the body and affective states. This is of particular importance for people with eating disorders, because many theories on the etiology of eating disorders point to a particularly inability amongst those with eating disorders to recognize affect states and to connect these with psychophysiological/somatic states.  If one “function” of the eating disorder is that it turns down the volume on the experience of the world, there must be a gradual process of turning the volume on in a reliable, loving, and non-threatening way, which could be accomplished through AAT.  Using the conceptual lenses of attachment and affect regulation theories, AAT, through the animal, may provide the pieces for self-regulatory functions.  Therefore, the animal may provide the affect synchrony (by knowing what the individual needs) that creates states of positive arousal, and the interactive repair (co-regulating in a safe relationship) that modulates states of negative arousal.  In this way, AAT may have some connection with the building blocks of attachment and self-regulatory functions (Schore & Schore, 2008).

Overall, my findings suggest that the symptoms of ED may have a relational functionality for the individual, even if there are other developmental, cognitive, and physical costs associated with these same symptoms.  My conceptual lens of attachment theory and affect regulation frames how impairments in attachment can lead to deficits in identity formation and affect regulatory experiences.  Therefore, AAT may provide, either within individual or group modalities, reparative experiences that help foster a strong link between affect and body experiences.  The results of the study suggest AAT may be a way to achieve connection, which seemed to be highly desired by the women, but in a non-threatening, unconditional, and nonjudgmental relationship.  The lack of verbalization, the unconditional nature of the animals, the simplicity of the interaction, and the lack of expectations within a relationship is the perfect place for them to start the healing.  As described by Jeannette, AAT is, “it’s almost like neosporin on the wound. It’s just like healing it.”

Animal-Assisted Interventions (AAI) is now consistently used in the literature as the umbrella phase to describe any intervention that intentionally includes an animal as part of a therapeutic or ameliorative process (IAHAIO, 2014; Kruger & Serpell, 2006).  Within the umbrella of Animal-Assisted Interventions (AAI), there are three disparate categories: Animal-Assisted Activities (AAA),  Animal-Assisted Education (AAE) and Animal-Assisted Therapy (AAT) (IAHAIO, 2013).  Animal-Assisted Activity (AAA) is an informal and goal-oriented visitation conducted by a human-animal team for motivational, recreational, and/or education purposes (Fine, 2015; IAHAIO, 2014).  An example of an Animal-Assisted Activity is visiting companion animals with residents in nursing homes (IAHAIO, 2014).  Animal-Assisted Education (AAE) is a goal-oriented, structured, and planned intervention delivered by an educational service professional (IAHAIO, 2014).  An example of an AAE would be a dog-assisted reading program delivered by a special education teacher (IAHAIO, 2014).  Lastly, Animal-Assisted Therapy (AAT) is a goal-oriented, planned, and structured therapeutic intervention directed and/or delivered by education, health, and human service professionals (Fine, 2015; IAHAIO, 2014).  AAT is delivered by a formally trained professional (licensure or credentials for field of practice) with the intentional inclusion of an animal in a treatment plan (Fine, 2015; IAHAIO, 2014; Nimer & Lundahl, 2007).  The treatment providers guide interactions between a patient and an animal to achieve specific goals (IAHAIO, 2014).   A wide variety of disciplines may incorporate AAT.  Possible practitioners could include physicians, occupational therapists, physical therapists, certified therapeutic recreation specialists, nurses, social workers, speech therapists, or mental health professionals (Kruger & Serpell, 2006).    Examples of AAT include animal-assisted psychotherapy, animal-assisted social work, animal-assisted physical therapy, and animal-assisted speech therapy (Fine, 2015).  Even with the movement toward standardization of terminology, the application and delivery of AAT services vary greatly depending on the professional identity of the service provider involved, service setting, and goal of services (Fine, 2015).  (by Dr. Patricia Flaherty-Fischette)

  1. Impact of Animal on Relationship: Human Relationships vs. Relationships with Animals

The distinctions between what an animal can provide compared to a human emerged as a salient theme.   Larissa indicated a distinction she made between the comfort provided by humans compared to the comfort provided by the animals, “The dog provided comfort, something that people just can’t do.” In our second interview, she clarifies why she does not think people cannot provide the same type of comfort as a dog, “Like, with people, they have to talk to you and get to know you, but dogs like right away, you just completely like get comfortable around a dog.”  There were four main subthemes related to the comparisons between human relationships and animal relationships which include: the ability to know what the human(s) needs; the unconditional support, the nonjudgmental stance, and the ability to provide protection.  These subthemes will be further explored in the next few paragraphs.

Conceptualizing an eating disorder as changing the relational desires – whether it be acting differently and/or preferring no relationships – led to difficult relationships.  For most of the women, relationships with people while they were entrenched in their eating disorders were either full of conflict, tumultuous, inauthentic, or non-existent.  Notably, the vilification of other people, which Samantha said occurred with her parents, often related to the failure to be understood by others, which is something that links back to comforting relational quality of the animals.   Lily spoke about the way in which the horse could understand her in a way that, sometimes, people could not:

…how can I put this? It felt like the horse just understood you, you know, because it picked up on your energy and it kinda worked with you, it kind…they’re smart, and it just made you feel like the animal understood you because it just sensed your confidence, sometimes your fear. It just made you feel understood.  It was really cool. Whereas in life sometimes I don’t always feel understood by someone and it’s frustrating because you’re going through something and it’s like some people just don’t get you. And when I was there, the horses could feel what you feel.

The process of being understood provided Winona with an ability to think differently about her self and, through the process of knowing what she needed, the animal helped with her feelings of validation and acceptance:

But I also enjoyed the time where it was just us, where I could go and sit by myself and talk with the dog.  I know that sounds really stupid but something that I felt I wanted to off my chest and I needed to just get it out and I could just talk and know that, for some reason, it felt like the animal would connect with me and know what I needed.  But I felt like more that it was being affirmed, that my thoughts and my feelings were more valid towards that.

Samantha further expanded on the process of the animal knowing what she needs:

Interviewer: Uh alright so … you said that um [Name redacted] the dog seemed to know when you were upset and kind of knew what you needed

Samantha: Mmhmm

Interviewer: Why do you think this happened or how do you think this happened?

Samantha: I I don’t know it feels like a connection with um … an animal I don’t know like its like they can sense something that maybe adults can’t other humans can’t um … but I don’t know why that it is I don’t know if they can just, I mean, it is the same with my own dog I feel like she knows when something’s wrong and um when I need when I need her there.

The animals’ understanding of need links to the second emerging subtheme in the relational abilities provided by animals compared to humans: unconditional love and no judgment as a form of protection which may form relational trust.

Nonjudgmental.

Judgment was a very common fear for many of the women when they were in their eating disorders.  In a related way, fear of acceptance of one’s authentic experience was also a very prominent theme.  Unlike humans, the animals offered a way to address these fears since the women felt they were nonjudgmental and provided unconditional support.  Lujan explained the way in which she thought about judgment in relation to the horses versus her therapist:

Lujan: So it was kind of like the…I knew they wouldn’t judge me or tell me what I needed to do instead. That was a big part of it, and wouldn’t be disappointed if I wasn’t doing well, or things like that. It was just kind of like they would take me as I was and it was fine, whereas I felt I always had to…I always felt like I was disappointing my therapist if I wasn’t been doing well or if I purged that week or whatever it was, I was letting them down or they were losing hope in me or whatever.  So I didn’t feel like the horses felt that way though..

Interviewer: Yeah, that makes a lot of sense.

The fear of disappointment and judgment was not something Lujan experienced with the animal.  Maureen, similar to Lujan, expanded on the fear of judgment within her relationships, specific to other individuals in treatment:

Maureen: Because to me a dog is a dog and it just wants your love and affection and attention.  And other than that it doesn’t really care who you are or what you look like, or what you do as long as you take care of it and love it.  Whereas with the other girls there’s kind of this… and it’s also hard to separate because it was group therapy.  So there were other girls present at the time.  But I guess with the girls you always have to kind of be conscious of how you might trigger them.  And sometimes I think… and there’s kind of this comparison even if it’s not said.  Even if it’s just in your head.  And I definitely didn’t compare myself to the dog other than saying, thinking about how the dog was so free to choose what it wanted to choose, yet I place so many value judgements on choices before I even make them.

She went on and said:

I guess I don’t feel like they judge me.  Or like they would judge me… Like when I’m with a friend, I constantly think, “Okay, well if I say this what are you going to think?”  Well, I can say whatever I want to the dog or the cat, and they probably don’t even know what I’m saying, and could care less.  They would rather have me pet them and love on them, and take care of them.  So as long as I feed them, and let them out to the bathroom, and pet them when they want to, they’re fairly happy with me.

Unconditionality.

Not only was the fear of judgment not present but the added unconditionality of their support provided a safer relational experience.  For Josephine, she described the difference between the unconditional relationship with the animal compared to the relationships with mental health professionals:

I feel like they give you more, just love at times than you need and I think that that’s something you don’t really get from the mental health professional.  It’s like this feeling of unconditional love.  Yea, you may have unconditional positive regard, but you don’t have love.  And you don’t feel love in the same way.  Because you know that person is being paid, you know.

Josephine felt the unconditional love from the animal is significantly different than the “unconditional positive regard” from the therapists.  A minute later, she clarified the distinction:

Josephine: And I’m not saying that…I believe there are probably therapists I’ve had that did love me in a certain way. You know? But it’s like at the end of the day they’re not gonna have a relationship with you in the future. You know? Like once you’re done working through your…Whatever you need to work through they do care about you and you have a relationship but then it’s over.

Interviewer: Yeah.

Josephine: And I feel like somewhat with the animals even though [inaudible 00:14:07] and the chance that I moved and all that, you know, you felt while you were there they cared about you and loved you in a different way, I guess.

Felicity also made the distinction between the unconditionality of animals compared to humans:

Felicity: Typically dogs are very, very loyal, um, and they just are always there.  And humans just aren’t, um, we’re all flawed, and we all make mistakes, and they could be the greatest person in the world, but even still, like they’re gonna mess up, and not, they’re gonna fail you at some point.

Interviewer: Yeah.

Felicity: But I don’t feel like a dog will.

Trust and protection. 

The different kind of love offered by the animals combined with the lack of judgment provided an interesting relational dynamic which was described by some women as safety, protection, and, for Eleanor, a shield, “It was almost like the dog was like a guard or like a barrier between you and everyone else.  So it’s like you just kind of was more comfortable because it was like [inaudible 00:15:33] dog like a shield type of thing.”  Felicity also talked about the relational protective quality of the animal, “the dog was almost a shield even though, I mean technically it’s like this little puppy, but like still just felt like, you know, it was a barrier between me and bad things.”  Elizabeth felt the word “buffer” was the best word to emphasize the protective quality within animal relationships and how that differs from her experience with human relationships:

Like I don’t feel especially safe forming relationships with humans.  Like, I don’t feel like there is enough of a buffer.  Now that I think about it, that’s a really good word for it.  Like, that’s what I feel like I don’t have with people that I don’t have with a dog.  Like, I need a buffer.  I’m not sure what it is.

The protective barrier, supported by the animal’s lack of judgment and unconditional love, led to feelings of trust that were different than the experience of trust with humans.  Josephine said, “Like, so I think, um I had more difficulty establishing trust and like feeling like someone believed in me versus I kind of felt like the animals you didn’t have….you didn’t have that worry.”  Some women found a relational comfort from the animal that was unlike relationships with people.  The relational comfort afforded through experiencing the animal as unconditional, nonjudgmental, intuitive, and safe may have led to an impression on their emotions.

Emotional (re)connection.

For some of the women, the sensory connection, and subsequent reconnection with their bodies, led to a different way to manage emotions.  For Katarina, she said, “And just the animals, it just kind of brought that out. It brings out that, you know, warm heart.”  She expanded on the warming of the heart and how the animal could access something people could not at the time:

Katarina: when I was in my eating disorder I remember before I went to treatment one of my dogs had passed away. And I basically hated life. I hated everyone. I didn’t want anything to do with humans. I was just kind of like just done. And then, I don’t know, just interacting with these animals again. And then, seeing at my table interact with them too it’s just seeing happiness. For that moment of time at least, for that hour that we were eating, or 45 minutes, there wasn’t…for most days there wasn’t really anything to worry about besides seeing everyone happy for the first time, it was nice to see. And then you, like I said…kind of referring back to the horses and same with the dogs, you create that bond and you learn to kind of…although you weren’t taking care of the dogs, still being able to play with them and stuff, it was nice. And it just kind of taught us that responsibility and it reminded me that I still have a heart — that’s good. You still care for animals. You still care for people, so.

Interviewer: Yeah. Yeah. So it seemed like you were able to access something that maybe you couldn’t get to because you were so entrenched in the eating disorder, which is what it does. Yeah.

Katarina: Right. And I was so bitter towards people. And just the animals, it just kind of brought that out. It brings out that, you know, warm heart.

Katarina was not the only one that spoke about the impact of the animals on the heart.  For Jeannette, when reflecting on the impact of the animals on her emotions, she referred to the process as, “It’s like, ah, and I can just feel it now.  It just flutters, it opens up, it speaks to a deeper self inside you” when she saw the dog in the group therapy.  She provides a more detailed description of how the disconnection from your heart can be reconnected through the experience with the animal:

Jeannette: Yeah, it was very easy to get disconnected from your heart. So you’re in your head. You’re out of your body, where you’re revisiting different centers of your body that’s like hard to really go there. It’s like you are, but it’s the darker side of your heart. It’s like a wound inside. So if you would connect…So, when I think of the heart. So it’s the love, loving side of the heart.

The process of reconnecting to the heart or, conceptualizing this a way to reconnect to emotions, will be explored in the following paragraph.

Animal as emotional buffer. 

Many women described the emotional impact of the eating disorder as having a way of stopping emotions.  Sierra conveyed the emotional impact of an eating disorder, “just like the, the level at which you wanted to experience the world is usually dialed down, I think, for people with eating disorders.”  Katarina further illustrated the absence of emotion as identified by her individual therapist:

she actually had said this to me. She was like, “When you talk about your life and what’s happened,” she’s like, “it’s almost like you’re just saying it. Like, it comes so…” What’s the word I’m looking for? Like, it was just no emotion. I’m just telling my story. And I noticed that was true.

Similar to the interpersonal safety provided by the animals, the animals offered some women a safety with the experience of emotions.   The word “buffer” was used by several women to describe the way the animal helped manage emotions.  Samantha, in her first interview, said “kind of like having some something there to kind of buffer some of the feelings,” and in her second interview further explained the process,

I mean the emotions are still there but it kind of … There’s … it lessens the intensity of the emotions and kind of brings me back to maybe something that I care about like like my dog um… So that I’m not so focused on something like and and so in my head.

Jeannette also used the word “buffer” when she explained her experience with the animal and emotions, “It was like a very pleasant, not distraction…what’s a better word for distraction?  Like a pleasant buffer for anything that might be going on, like what got brought up.” Therefore, the ability to slowly titrate emotion and have an outlet to process overwhelming emotions provided a safer emotional experience for some of the women.

Impact of animal on identity. 

For some of the women, the animal provided a new way to think about their self and their identity.  Sierra expands on her understanding of identity when in the eating disorder and how the animals provided a way to change it:

Sierra: I didn’t know anything about myself besides that I was good at school and that I was good at losing weight.

Interviewer: Mmm.

Sierra: Like I literally could not have identified a single other identity trait.  Um, and so dogs were probably the first thing that I identified, like, oh yea, I like dogs.

Elizabeth found the animals provided a different way to think about her identity and offered more dimensions to her previously one-dimensional identity:

I would say it made me realize that I have, or it was one of the things that kind of made me realize that I’m more than a brain.  That I have more needs than that.  That, you know, it just like, it kind of reminded me that I’m like a body and a human organism, too.  You know, that needs to eat, that needs to like sleep, that needs different things.  I’m not like a word factory or whatever.

The animals provided a way to expand their understanding of their identities.  Samantha said that AAT had an impression on the expansion of her feelings about food, “It helped me understand that my feelings about food were not the most important thing in my life and there were other things going on around me that could be important to me too.”  For Samantha, recognizing that other things could be important to her could be an expansion of her identity.  The impression of AAT on thoughts, in general, had some connections with identity formation or reformation.

Connecting the pieces: functionality of ED, animal as substitute for ED, and links with attachment/affect regulation theory. 

Functionality of ED.

By conceptualizing an eating disorder as having both a relational function and providing a mechanism to modulate affect, we connect back to attachment theory.  Because eating disorders are associated with such a broad array of negative outcomes, it can be difficult to articulate the “relational functionality” that can be provided for the individual by some of the symptoms of the disorder itself.  This is important for practitioners to understand and to keep in mind. Throughout the study, some of the women characterized the eating disorder as providing attachment function(s) and affective function(s).  Sierra sums up the relational and affective protection provided by the eating disorder:

But like, it felt like there was something that I could, like, put on and it would be, like, mine and it would protect me. I could go to, like, whatever, a [redacted] party or whatever, and like I wouldn’t have any hopes or expectations because not eating, if I did that I was succeeding and so nothing else could really hurt me.

Animal as substitute for qualities provided by ED.

The protective quality of the ED was strikingly similar to the affective and relational protection provided by the animals.  Some women described the animals as protection, a shield, a sense of safety, and a buffer for both their emotion regulation and for their attachment needs, which was similar to the descriptions of the protective qualities of the eating disorder.  Within that frame, AAT, through the animal, may offer the protective barrier previously provided by the eating disorder.  The animal may then become a substituting protective barrier that offers comfort, unlike the ED, in a way that is safe, unconditional, nonjudgmental, and healing for women struggling with eating disorders.

Linking to attachment and affect theory.

The underpinning of this research is that attachment theory is, in essence, a regulatory theory such that the developing ability of the child to communicate and regulate both positive and negative emotional states exists within the attachment relationship (Schore & Schore, 2008).    The developing infant’s variable states of psychophysiological arousal produce important cues for caregivers and the ways in which caregivers respond shapes the developing attachment within the infant-caregiver dyad.  During this psychobiological affective communication, the caregiver appraises nonverbal expressions of the infant’s arousal and then regulates both positive and negative states (Schore & Schore, 2008).  The animal, in a way, may be doing a similar thing.  If the attachment relationship mediates the dyadic regulation of emotion such that the primary caregiver co-regulates the infant’s developing central and autonomous systems (Schore & Schore, 2008), then the affective communications embedded in the mutual gaze and non-verbal episodes between the animal and woman may also be a way to co-regulate.  Therefore, just as a good enough caregiver who misatuned can regulate the infant’s negative state by accurately re-attuning in a timely manner (Schore & Schore, 2008), the animal may be the caregiver addressing previous misatunement and re-attuning in that moment.  This interactive and non-verbal repair between the woman and animal may, like the primary caregiver and infant, set into motion the rebuilding of the self-regulatory functions.  The critical piece is that the animal provides both pieces needed for effective self-regulatory functions – the animal can provide the affect synchrony (by knowing what the individual needs) that creates states of positive arousal, and the interactive repair (co-regulating in a safe relationship) that modulates states of negative arousal.  These two together are the building blocks of attachment and self-regulatory functions (Schore & Schore, 2008).

Interpretations guided by attachment and affect regulation theories.

Even though most of the women described the eating disorder as an effective way to solicit attention, it also provided an interpersonal barrier from the attention.  The eating disorder may create a way to get attention but does so in a way that is still protected and does not feel too vulnerable.  Samantha described how she thought about her relationship with her parents when in the eating disorder, “Yea, um, whether they cared about me or not was based on if they worried about me.”  In this way, the eating disorder is a relational strategy such that an individual can get attention, which may be interpreted as concern, care, and/or worry, but avoid having to tolerate the fear regarding being authentically known.  The effusive demonstration of concern by the attachment figures, emerging from the concern over the eating disorder, may provide temporary relational validation for the individual struggling with the eating disorder.  Connecting back to affect regulation theory, mentalization and reflective functioning is an ability that allows one to maintain the soothing function of an internalized attachment figure in the absence of the attachment figure (Fonagy & Target, 2003).  It seems possible that the eating disorder could be a catalyst for future relational engagement with attachment objects, however, the relating is centered around the eating disorder such that it is removed from the authentic self.  In this way, it addresses the relational anxiety that may be present if the ability for mentalization and reflective functioning is limited, and prevents the individual from being authentically seen.  Now in recovery, Samantha describes the way she prefers her parents to act toward her now, “I actually prefer them to not worry about me um it makes me uncomfortable now….um…I think they show they care by just expressing their their love and support.”  In this way, the eating disorder may have prevented Samantha from accepting love and support as the way to connect with her primary attachment figures.

7.2 Clinical and Treatment Implications 

The treatment implications from the study are important.  If the animal can replace the relational and affective functions previously provided by the ED, then the exploration of using AAT in ED treatment is needed.  Jeannette provides a rich description of what is missing from her experience with eating disorder treatments:

Interviewer: Now what would you say made the [Facility redacted] a place that just wasn’t doing it for you?

Jeannette: The big focus on eating disorder programs, the two that I visited, I’ve been in three times and the two that I visited, is on the eating, which is understandable. And I kind of felt like…I would say my eating disorder went deeper than just the food. It was like the food was definitely…but I used my eating disorder as an emotional release and a way to get out toxicity, to get out negative thoughts, a form of control. It wasn’t necessarily about weight management.

Several women provided ideas for treatment which focused on the bringing an animal into the treatment experience:

But I mean I feel like every treatment center should have a dog (Lucinda).

Yea if they would have a house dog there that would be the coolest thing like if they had a dog like just walks around and just hung out with us I mean that would be the coolest thing (Lily).

So if they can incorporate that, [inaudible00:26:30] take the dogs on a walk and get outside yourself and provide happiness for another human being, it’s a give and take relationship (Jeannette).

I would’ve loved if the dog could have been part of the house, or we could have like a house cat or something that would, you know. Because I really missed cuddling at night (Maureen).

I wish that they would you know give an animal to you know everyone that went in, you know like at every treatment center (Katarina).

And if I were to open a treatment center, I would say that it [the animals] be a large part of treatment (Sierra).

The insights from the women about how to improve treatment, women who experienced ED treatments spanning two months to 10 years, are extremely important.  For many of them, increasing the opportunities for interacting with animals was a promising treatment idea.

Based on the experiences shared with me, and the multiple times women had been in eating disorder treatment centers, there is something being lost in translation during the transition from treatment to the real world.  Rather than blaming the women with eating disorders as being resistant, it is imperative to critically analyze the current treatments for women with eating disorders.  The prevailing theoretical lens guiding most ED treatment is cognitive behavioral therapy (CBT) with the recent addition of dialectical behavioral therapy (DBT).  It may be worth expanding the theoretical lenses that guide eating disorder treatment.  Understanding a patient’s attachment representations may be helpful for clinicians on how to personalize therapy and to support patients in treatment.  From an attachment lens, individuals with attachment avoidance may be at risk for experiencing a decrease in the therapeutic alliance and dropping out of treatment (Tasca, Balfour, Ritchie, & Bissada, 2006, 2007) and pressures to self-disclosure, bond with the therapist or group, and express emotions may not be effective or helpful.  Instead, they may need a gradual approach to affective expression and relational connection which could be accomplished with AAT or other treatments.  For individuals with greater attachment anxiety, however, they may require an early and ongoing sense of group cohesion or therapeutic alliance (Tasca, Balfour, Ritchie, & Bissada, 2006, 2007; Tasca et al., 2006; Tasca, Taylor, Bissada, Ritchie, & Balfour, 2004).   For these individuals, it may be helpful to distance from their emotions to strengthen their mentalizing capacities.  Although all patients are unique and it is important to not assume that all ED have the same attachment histories or representations, thinking about the attachment representations may help inform clinicians on effective therapeutic stances that are specific to patient attachment insecurity.

Petrucelli (2014) theorizes that individuals with ED are not adept at communicating in words, and that this awareness must be considered in choosing the most appropriate intervention strategies when working with individuals with eating disorders.  This study supports a refinement of that theory and has particular implications for the treatment of eating disorders.   Rather than viewing women with eating disorders as not able to communicate in words, the findings of this study suggest that perhaps how they are asked to communicate in words is the problematic and ineffective link for treatment.  Traditional talk therapy often fails to take the time to assess the individual’s capacity to symbolically bridge or connect, the body and affective states. This is of particular importance for people with eating disorders, because many theories on the etiology of eating disorders point to a particularly inability amongst those with eating disorders to recognize affect states and to connect these with psychophysiological/somatic states.  If one “function” of the eating disorder is that it turns down the volume on the experience of the world, there must be a gradual process of turning the volume on in a reliable, loving, and non-threatening way.

Since eating disorders can create life-threatening conditions, family relationships and treatment sometimes limit the capacity of the individual with the eating disorder to exert self-determination and agency.  Even so, whether it is through the use of AAT or not, there needs to be a way in which there is space provided for individuals in treatment so they can begin to assert agency.  The infantilizing of individuals in eating disorder treatment is contraindicated.  Instead, there needs to be a strengthening of self with the primer (possibly being a non-verbal and sensory process) of establishing safety and affective reconnection.  Treatment may need to support individuals in building a multi-dimensional identity – promoting agency and confidence such that these individuals feel they can use the skills and strategies when they transition back to the real world.

AAT may be useful because it provides ways to access a broader range of feelings, including the potentially lost feelings of “fun” and “lightness.”  The affective experiences of AAT could be an avenue for rich discussions within individual or group therapies.  Most the women in the study described not speaking about AAT with their individual therapist.  Yet, the women had such rich descriptions of the AAT process in our conversations.  I think it could be an avenue for rich discussions within the therapeutic relationship, too.  I think strengthening the connection between individual therapy and AAT could help address any feelings that may be more complicated that get prompted within the individual by AAT.

Lastly, there needs to be more of a connection to life outside of treatment.  This could be accomplished in a variety of ways—home visits, volunteer opportunities at local animal shelters, book clubs, day trips, career counseling, etc.  These individuals need to be supported not only to develop an awareness of their eating disorder but also of their ability to live, feel, and tolerate the distress of the unregulated world.  The goal of treatment should be supporting women to thrive in an unregulated, volume on, “feeling all the feels” kind of life.

Cumella, Lutter, Osborne and Kally (2014) explored the efficacy of an Equestrian Therapy (EQT) program with eating disorder patients in an inpatient facility.  This study targeted previous observations that EQT may influence the eating disorder symptomatology and common co-occurring symptoms of impaired self-efficacy, drive for thinness, interpersonal distrust, impulse dysregulation, depressed mood, and anxiety in ED patients (Cumella, Lutter, Osborne, & Kally, 2014; Cumella, 2003).  Their randomly selected sample included seventy-two female inpatients treated at an inpatient ED facility between December 2005 and April 2008, and they employed a pre-test/post-test design.  To measure EQT outcomes, they used the Eating Disorder Inventory-2, the Beck Depression Inventory-II, and a ND Beck Anxiety Inventory.  In addition to these scales, they used four EDI-2 subscales: drive for thinness, ineffectiveness as a measure of impaired self-efficacy; interpersonal distrust; and impulse regulation.  They measured participation in the EQT by the total number of minutes spent in any EQT activity during treatment (TEM), and the patient’s length of stay (LOS) was used as the logical analogue.  To analyze the data, they ran six linear regression models to compare the efficacy of standardized treatment to that of standardized treatment plus EQT in ED patients.  In each model, the dependent variable was the discharge score, and the independent variable was TEM, with the control variables (admission score and LOS) added into the equation.  Notably, they found all six models as highly statistically significant.  As a result, they interpreted this as a significant relationship between number of minutes of EQT and patients discharge scores on drive for thinness, ineffectiveness, interpersonal distrust, impulse regulation, depression and anxiety.  As they hypothesized, all models showed an inverse relationship between TEM and discharge scores.  Based on their interpretations of the results, they suggested that an increase of EQT leads to a decrease in patients’ discharge scores.  For each symptom, Beta coefficients from the regression equations suggested the amount of symptom improvement gained from four one-hour EQT sessions may represent clinically meaningful additions to standard treatment for ED.  Instead of using a basic outcome design (comparing non-EQT group to an EQT treatment group), they used an outcome design capable of capturing the effects of different doses of EQT.   This was a limitation of their study.  Even so, this may suggest a need for further research into EQT as an adjunctive treatment modality for eating disorders.

Although less recent, Kunz (2008) used both quantitative and qualitative methods through a psychodynamic lens to study women diagnosed with anorexia nervosa (AN) who participated in equine-assisted psychotherapy/equine facilitated psychotherapy (EAP/EFP).  The sample included 30 women with AN and the women were interviewed after 20 therapeutic riding sessions.  The activities focused on relaxing exercises, stimulating awareness, and physical balance while on the horse.  After the sessions, discussions included the emotional and physical experience of riding and interacting with the horses.  The discussions were analyzed and the investigator created a thematic key.  In addition to the discussions, the subjects were given a 31 question written survey. Riding instructors were surveyed to collect demographic data and assess the scope of EFP usage in the three European countries.  The results from both groups suggested that EFP helped clients to improve self-esteem, decrease fears, and adopt an outlet for constructive aggression (Kunz, 2008).

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