mag 06 2011

Biopsychosocial rehabilitative intervention in chronic psychotic

Scritto alle 00:16 in Riabilitazione Equestre

The aim of the following research is to evaluate the efficacy of the horse rehabilitative intervention in chronic psychotic patients assisted by the public services from the ASL 2 and 3 of Turin, ITALY. 

CIRCOLO IPPICO ” LA MANDRIA” TORINO-ITALIA. 

 
Introduction:
 From the late 60s’, when Levinson acknowledged that animals could enhance psychological therapies (Levinson 1969), the bond between animals and humans has been explored as a therapeutic tool to overcome both physical and psychological disabilities in human. However the bond between animals and human in a therapeutic context is yet not fully understood. The theoretical framework of animalassisted interventions (AAI) is therefore somehow controversial and can be based on theories: the attachment subject (involving long lasting bonds), the transitional object (passage from one condition to another) and the social needs (based on the Maslow hierarchy of needs).The AAI using equines are referred to as hippotherapy and equine-facilitated psychotherapy (EFP). The first is mainly focused on physiatrics and speech therapy including improvement of balance and posture and improving articulation and cognitive skills. The EFP is, as the term indicates, focused on psychological therapy. 

The value of animals utilization in mental health management is thought to be related with the reduction of anxiety (Shiloh et al. 2003) and with its role as social mediator (Levinson 1969). Currently, the main objectives of EFP include the stimulation of social interaction, of concentration and attention capacity, of communication, of internal organization, of resistance to frustration, the modulation of inadequate behaviours, and the establishment of rules. The scientific community widely agrees that not all patients and not all horses are idoneous for EFP. Nevertheless, studies on horse therapy in patients with mental disorders are scarce. In addition, animal behaviour and its impact in attaining the goals of AAI were, to the authors knowledge, never explored in scientific studies. Nevertheless, the relationship horse-patient, in all mental disorders, is what makes the difference between a successful or a nonsuccessful therapy.
 
 Material and methods:
 Twenty four psychiatric patients, divided in psychotic (N = 19) and neurotic (N = 5), were declared idoneous for EFP sessions by the psychiatrists. This division has been totally casual as one of the goal of the study was to evaluate if the efficacy of the therapy depended on the kind of pathology. The patients have, in fact, been randomly chosen among mental disorders including schizophrenia and behavioral disorders. They were both male and female and age ranged between 22 and 45 y.o. 

Seven horses were included in this study (six regularly used, one in stand-by), chosen according to their attitudes indoor, outdoor and mounted.
The study was divided in 2 phases. The horses used for therapy worked for five months with the first group (phase 1) and then with the control group (phase 2) with whom they have redone the same activities. During each phase the patients were divided in 2 groups and developed the EFP sessions separately six by six so that each horse was used in therapy sessions of about four patients.
Every session was composed by six horses, six patients and six therapists. Whereas the horse once assigned to the patient remained the same, the therapist changed week by week. This not to have them interfere with the relationship horse-patient and to have them being able to score each therapy session based on a scaled question form (from 1 = nothing to 4 = a lot) that was filled for each pair horse-patient in three different variables: in box – reaction when touched – hand driven. The whole work has been built to facilitate a positive interaction horse-patient and could be summarized in three principal moments: 1) “taking care” which has been mostly developed in the stable (cleaning, brushing, etc), 2) activity in an open space to get confident one of the other and 3) specific exercises the patients have covered an exercise circuit together with the horse.

  The questionnaire included 1 general set of questions including the identification of the horse and patient, developed activities and session setting. Setting was classified as indoor, outdoor and indoor training court. 

The questions regarding the patient were organized in 2 sets of inquiry as follows: 1) affective-relational set including one question regarding the relationship with the horse and 2) psychomotor behavior set including questions on general movement coordination and perception of danger. The last set of questions was related with horse reactivity during therapeutic sessions and included behavior previous to EFP session (box), reaction to contact with humans involved in sessions, cooperation while conducted at hand. All these data were then related to the activity of that specific day and setting. Each operator was randomly assigned to a patient duringeach working session in order to avoid subjective evaluations. Before starting (T 0), at the end of the first phase (T1 ) and at the end of the second phase (T 2) all the patients undertook the following battery of tests:
  
SCL – 90
  Toronto Alexithymia Scale T.A.S -20
 Gambrill & Richey Asserion Inventory
 SF – 36
 Survey
 GFE

 

Data were analyzed using the Chi-square test. Statistical analysis was done using SPSS 17.0 (SPSS Inc. Chicago, IL).The experimental unit was the single therapy session. The variables measured were scores on patient-horse relationship, patient general motor capacity, horse behavior in the box before therapy sessions, horse reactivity to human contact and horse collaboration while driven by hand. The influencing factors considered were experimental phase, group, number of sessions, days in therapy, patient pathology, patient age, horse, setting, and therapist. Moreover the interaction of pathology and setting was considered as influencing factor.
The relationship between horse and patient behavior were analyzed using linear regression between horse-patient relationship and patient general motor capacity, patient danger perception, horse behavior before therapy sessions, horse reactivity to human touch and horse collaboration while driven by hand, between patient general motor capacity and horse collaboration while driven by hand, between patient danger perception and horse behavior before therapy sessions, reactivity of the horse to human touch and horse collaboration while driven by hand. Regression analysis were done separately to the two pathology groups.
 Results and discussion: 

Effect of phase: In the second group the relationship with the patients was worst then with group 2 (p= 0.016) but with a similar tendency during time. The repetition of easy activities does not improve significantly horse reactions, whereas the patient he is in relation with has more influence.
 Effect of number of sessions:
 The quality of the relationship between the patient and the horse increased through the whole therapy session. The main differences were found between the first and the second part of the therapy, whereas the execution of the exercises did not improve the values concerning the relationship.
The reaction of the horse to contact has significantly decreased during therapy session. The number of sessions positive influenced horses, decreasing their reactivity to human touch.
 
 

Effect of pathology: 

 The psychotic patients are more seriously invaded by the pathology but their behaviour is apparently more controlled, whereas the neurotics tend to emphasise every action, also showing symptoms. Horses used by psychotics were more easily conducted by hand than those applied in therapy by neurotics (p=0.009). Different behaviour has affected the horses while conducted by hand, when in fact the patient can better manifest emotions.
 
 Effect of patient age:
 Patients aging between 20 and 30 years old had worse relationship with horses than did older patients (more than 40 years old) because the first had higher observations of sufficient relationship (grade 2)(A) and lower observations of good relationship (grade 4)(B) and the older patients were less frequently scored as sufficient relationship (grade 2)(C) and more frequently as good relationship (grade 4)(D) than expected.
Reaction to contact was higher in horses involved in therapy sessions with younger patients (between 20 and 30 years old) than with older patients (above 40 years old).
The observations of few reaction to contact (grade 2) were less frequent (A) and those of high reaction (grade 4) were more frequent (B) than expected in younger patients while older patients induced more frequently few reaction (grade 2)(C) and less frequently high reaction (grade 4)(D) to touch than expected.
 

  

Effects of horse:
 Each horse showed specific attitude for a specific part of the therapy. Horse 2 contributed better to patients motor capacity while horse 3 had inverse results. Knowing that the horse is used by the patients has a mirror in which he reflects reality, every single horse, according to its specific characteristics guides the patient in perceiving reality. That brought for example to a higher perception of danger for the patients assigned to horse 2 and 7, whereas horses 3 and 5 induced lower danger perception. 

Better results were obtained by horses 4 and 6 when driven by hand than the horses 1 and 5. While horses 2 and 3 were more collaborative before the therapy session. Therefore is demonstrated that each horse can show good attitudes in a particular field and be less collaborative in other activities, strictly depending on its background, passed experiences and education.
 
 

  Effect of setting: 

No significant differences were found between different settings in which therapeutic sessions where performed during phase 2, whereas phase 1 showed differences in the activity indoor. 

 
 
 

 Effect of therapist: 

  Every evaluation was highly dependent on the therapists (p=0.000), either regarding the patient responses or the horse reactions. Considering that operators were randomly assigned to patient in each session, the measured effect of other factors should not have been influenced by this strong link between therapist and the evaluated parameters. Therapists attending less than 10 sessions were excluded from the statistical analysis in order to respect the chi square pre-requisites. 

 
 
 

  Relationship between horse and patient behaviour: 

 In psychotic patients no correlation was found between patient and horse behavior. In neurotic patients, danger perception and reaction of the horse to human contact were highly correlated (R = 0.81) and in particular during the last 20 sessions in therapy (R 2 = 0.81 in session group 2 and R= 0.79 in session group 3). The perception of danger was also closely related with hand driving when considering the second set of therapy sessions (R = 0.90). during the same period, the relationship between the patient and the horse was related with general motor capacity (R = 0.62). 

 
 

 Conclusion:

 Criteria used to select horses for physiatrics interventions cannot be the same applied for horses used with psychiatric patients. Ones need to have specific morphological characteristics, the others have to be empathic with the patient and well react in different settings and situation so that the patient can trust. That is the basis on which sets the whole therapy. That is why is so important to find the right parameters to evaluate if a co-therapist is suitable for this kind of relationship. 

The chosen variables have showed that the scale used (from 1 to 4) is sufficiently precise to accept horses with an average ≥3.
The way horses react with psychotics and neurotics is significantly different.
Therefore what influences the horse is presumably their different way to show emotions. The horse seems not to perceive the inner anguish of the psychotic patients, but is more sensitive to the neurotic anxiety.

  

While planning a therapy with horses it is necessary to consider the time they use to get confident with a new person and a new situation. Even though the quality of the relationship with the patient increased through all the therapy session, this study shows that the middle period was more significant than the other two in terms of good cooperation. This result might also depend on the better attitude of the patients who, by that time, have learned how to treat and move around the horse. 

The values concerning horses collaboration in the first and the second phase demonstrate that their reactions are significantly linked to the behaviour of the patient and less to the activity and the setting. This had been previously found in the analysis of the first phase alone (Bisacco et al. 2009). 

In conclusion this investigation pointed a wide choice of parameters that can be used to choose the right horse. Therefore, as this study is concerned with mental and not physical disorders, every horse will also have to be selected according to its natural attitudes in order to match with the ones of the patient. In this way the person involved will have the chance to get identified with the horse and let him being an efficient therapy aid. 

References:
 
 
 

 Levinson B.M. 1969. Pet-oriented child psychotherapy. Charles C. Thomas (Publisher), Springfield (IL).Shiloha S., Sorek G., Terkelb J. 2003. Reduction of state-anxiety by petting animals in a controlled laboratory experiment. Anxiety, Stress & Coping 16(4):387-95. 

 Bisacco F., Valle E., Bergero D., Bisacco G. 2009. Nutrition and management practices with horses used for therapy – Reactivity evaluation in a study with psychological disabilities. Proc. 11  th   This scientific research is not an aid based on psycho-social support such as token economy, social skills training and social re-education, but an intervention that pursues stress reduction by working on the relation with the outside. 

congress “New findings in equine practice” , pp., Druento (TO) Italy. 

  

The relationship with the horse is in fact strictly connected with different levels of social function. 

First the project is conducted in a very beautiful and special place that interrupts the the repeated scheme of the everyday life. 

Second, as Winnicot explains, the horse can be used as the transactional object and help the change from subjective omnipotence to the commonly recognized reality. 

Through the relationship with the horse, our try is to contribute to create in the patient a positive and more mature identity. 

 

 

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