THE EFFECTS OF EQUINE-ASSISTED PSYCHOTHERAPY ON MINDFULNESS,
SELF-REFLECTION, INSIGHT, AND PSYCHOLOGICAL WELL-BEING
IN VETERANS
by
Carol A. Reive
A Dissertation Submitted to the Faculty of
The Christine E. Lynn College of Nursing
In Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy
Florida Atlantic University
Boca Raton, FL
December 2019
Copyright 2019 by Carol A. Reive
ii
ACKNOWLEDGEMENTS
My PhD journey has given me the opportunity to come to know some wonderfully caring individuals. Their support, expert guidance, and friendship will be with me always.
I wish to thank Dr. Marlaine Smith, my committee chairperson, for her wise suggestions and thoughtful direction and support. Thank you for believing in me; it allowed me to believe in myself. To my committee members: Dr. Nancy Aaron-Jones, thank you for all your insight and the private EEG tutorial; Dr. Beth King, for making me smile and look at things from new viewpoints; and Dr. John Morris, for your patience and willingness in helping me succeed.
I also wish to thank my fellow students and friends Ayse Malatyali and Stacey
Ravid for their unwavering support, late night calls, and coffee sessions. I am grateful to the equine center, its staff, the veterans, and the remarkable horses for allowing me to conduct my study; you are all very special indeed.
I am most appreciative of my parents, George and Joan Reive, for their love. They instilled in me that nothing is impossible, and with hard work your goals can be obtained.
Thank-you to my friend Jody Ellen Schloss who never ceases to amaze and inspire me.
To Jose Carreiro and my son, Stewart, thank you for all your support and love and for staying the course with me. I am fortunate.
iv ABSTRACT
Author: Carol A. Reive
Title: The Effects of Equine-Assisted Psychotherapy on Mindfulness, Self-Reflection, Insight, and Psychological Well-Being
Institution: Florida Atlantic University
Dissertation Advisor: Dr. Marlaine Smith
Degree: Doctor of Philosophy
Year: 2019
The purpose of this quasi-experimental study was to investigate the effects of equine-assisted psychotherapy (EAP) on mindfulness, self-reflection, insight, and psychological well-being in an adult veteran population with mental health concerns.
Specific aims were (1) to determine the effect of EAP on mindfulness, self-reflection, insight, and psychological well-being in veterans with psychiatric diagnoses or mental health concerns; and (2) to describe the relationship of the sociodemographic characteristics (age, ethnicity, gender, education level, income, and deployment history) to mindfulness, self-reflection, insight, and psychological well-being of adult veterans with mental health concerns engaged in EAP. Smith’s (1999) theory of unitary caring provided the guiding theoretical and conceptual framework for the study.
A convenience sampling design was used to recruit 18 participants from a South
Florida therapeutic riding center and an online veterans’ forum. The sample consisted of
v adult veterans ages 18 years and older who had mental health concerns and/or diagnoses.
Assignment to the EAP group (n=9) was determined by the therapy center director based on session days and times and participant availability. The comparison group (n=9) received their treatment as usual.
Paired t-tests for the EAP group showed a statistically significant increase for engaging in self-reflection. Mean scores for all variables except insight demonstrated an increase from pre to post, but did not reach statistical significance; however, the test was underpowered. The main ANCOVA analysis results supported significantly greater increases in mindfulness, the awareness subscale for mindfulness, self-reflection, the engaging in self-reflection subscale, and psychological well-being for the treatment group, compared to the comparison group. There were no significant demographic predictors of mindfulness, self-reflection, insight, and well-being. Additional analysis supported that mindfulness and insight were correlated with well-being in this study, whereas self-reflection was not. Neither deployment history, years since discharge, nor age were found to be moderators of the relationship between self-reflection and well- being. Future studies using larger veteran and other populations, non-English speaking participants, biomarkers, and measures of PTSD and dissociation could offer further insight into the efficacy of EAP as a therapeutic modality. Examination of whether increased mindfulness as a result of EAP mediates well-being is also indicated.
vi DEDICATION
Dedicated to my son, Stewart Grant Reive.
THE EFFECTS OF EQUINE-ASSISTED PSYCHOTHERAPY ON MINDFULNESS,
SELF-REFLECTION, INSIGHT, AND PSYCHOLOGICAL WELL-BEING
LIST OF TABLES ...... xiii
CHAPTER 1. THE PROBLEM ...... 1
Background and Significance ...... 1
Equine-assisted Psychotherapy ...... 4
Problem Statement ...... 5
Purpose of the Study ...... 5
Significance of Study ...... 6
Research Questions and Hypotheses ...... 6
Definitions of Terms ...... 8
Caring Theoretical Framework ...... 9
Theory of Unitary Caring ...... 9
Summary ...... 13
CHAPTER 2. REVIEW OF RELATED LITERATURE ...... 15
Introduction ...... 15
Equine-assisted Psychotherapy Literature ...... 15
Background ...... 15
Equine Communication with Humans ...... 17
viii EAP Outcomes ...... 18
Anxiety, Depression, and PTSD ...... 18
Motivation ...... 23
Concepts of self ...... 24
Qualitative Research Related to EAP ...... 26
Hypothesized Mechanisms of EAP ...... 28
Discussion of Gap in Knowledge Base and Link to Caring Science ...... 30
CHAPTER 3. RESEARCH METHODOLOGY ...... 32
Introduction ...... 32
Research Design ...... 32
Sample, Recruitment, and Setting ...... 33
Sampling ...... 33
Recruitment ...... 34
Inclusion Criteria ...... 35
Setting ...... 35
Research Questions and Hypotheses ...... 35
Instruments ...... 37
Sociodemographic Measures ...... 37
Measurements of Dependent Variables ...... 37
Mindfulness, Awareness, and Acceptance ...... 37
Self-reflection and Insight ...... 38
Psychological Well-being ...... 38
Ethical Considerations ...... 39
ix Data Collection Protocol ...... 41
Sample Assignment ...... 42
Intervention ...... 42
Experimental Group ...... 42
Data Analysis ...... 42
Data Accuracy ...... 42
Demographic Data ...... 44
Primary Analysis ...... 44
Research Question and Hypotheses ...... 45
Research Question 1 ...... 45
Research Question 2 ...... 47
Research Question 3 ...... 49
Strengths and Limitations of the Research Plan ...... 49
Timeline ...... 50
Summary ...... 50
CHAPTER 4. RESULTS ...... 53
Sociodemographic Variables and Descriptive Statistics of Sample ...... 53
Primary Analysis and Hypotheses ...... 56
Research Question One ...... 56
Research Question Two ...... 58
Research Question 3 ...... 70
Additional Analyses ...... 75
Summary ...... 77
x CHAPTER 5. DISCUSSION ...... 79
Overview ...... 79
Discussion ...... 79
Study Findings and Link to Theoretical Framework ...... 84
Manifesting Intentions ...... 85
Appreciating Pattern Self-reflection ...... 85
Attuning to Dynamic Flow ...... 85
Experiencing the Infinite ...... 86
Inviting Creative Emergence ...... 86
Conclusion ...... 87
Study Limitations ...... 87
Implications for Nursing ...... 88
Nursing Practice ...... 88
Nursing Research Implications ...... 90
Summary ...... 92
APPENDICES ...... 97
Appendix A. Self-Reflection and Insight Scale ...... 98
Appendix B. Philadelphia Mindfulness Scale (PHLMS) ...... 99
Appendix C. Warwick-Edinburgh Mental Well-being Scale ...... 101
Appendix D. IRB Approval ...... 102
Appendix E. Letter of Agreement ...... 104
Appendix F. Online Posting for Veteran's Forum ...... 105
Appendix G. Inclusion Screening Questions ...... 106
xi Appendix H. Path International Contraindictions ...... 107
Appendix I. Consent/Authorization Form (For Adults) ...... 108
Appendix J. Demograpic Questionnaire ...... 112
Appendix K. Permission for Philadelphia Mindfulness Scale ...... 114
Appendix L. Permissions for Measurement Use Self Reflection and Insight
Scale ...... 115
Appendix M. Permission for Warwick-Edinburgh Mental Well-Being Scale ...... 116
REFERENCES ...... 118
xii LIST OF TABLES
Table 1. Theory of Unitary Caring Concepts Related to EAP ...... 11
Table 2. Definitions of Variables and Sample Items ...... 39
Table 3. Examples of EAP Activities ...... 43
Table 4. Age and Military Characteristics of Participants ...... 53
Table 5. Demographic Characteristics of Participants ...... 54
Table 6. Paired Samples t-tests of EAP Pretest and Posttest Scores ...... 57
Table 7. Pretest and Posttest Mean Scores, Standard Deviations as a Function of
Group Membership ...... 59
Table 8. Analysis of Covariance of Posttest Mindfulness Scores as a Function of
Group Membership with Pretest Scores of Mindfulness as Covariate ...... 60
Table 9. Adjusted Means After Controlling for the Covariate of Pretest
Mindfulness Scores ...... 61
Table 10. Analysis of Covariance of Posttest Awareness Scores as a Function of
Group Membership with Pretest Scores of Awareness as Covariate ...... 62
Table 11. Adjusted Means After Controlling for the Covariate of Pretest
Awareness Scores ...... 62
Table 12. Analysis of Covariance of Posttest Acceptance Scores as a Function of
Group Membership with Pretest Scores of Acceptance as Covariate ...... 63
xiii Table 13. Adjusted Means After Controlling for the Covariate of Pretest
Acceptance Scores ...... 63
Table 14. Analysis of Covariance of Posttest Self-reflection Scores as a Function
of Group Membership with Pretest Scores of Self-reflection as Covariate ..... 64
Table 15. Adjusted Means After Controlling for the Covariate of Pretest Self-
Reflection Scores ...... 65
Table 16. Analysis of Covariance of Posttest Engaging in Self-Reflection Scores
as a Function of Group Membership with Pretest Scores of Engaging in
Self-Reflection as Covariate ...... 65
Table 17. Adjusted Means After Controlling for the Covariate of Pretest Engaging
in Self-Reflection Scores ...... 66
Table 18. Analysis of Covariance of Posttest Needs Self-Reflection Scores as a
Function of Group Membership with Pretest Scores of Needs Self-
Reflection as Covariate ...... 66
Table 19. Adjusted Means After Controlling for the Covariate of Pretest Needs
Self-Reflection Scores ...... 67
Table 20. Analysis of Covariance of Posttest Insight Scores as a Function of
Group Membership with Pretest Scores of Insight as Covariate ...... 68
Table 21. Adjusted Means After Controlling for the Covariate of Pretest Insight
Scores ...... 68
Table 22. Analysis of Covariance of Posttest Well-being Scores as a Function of
Group Membership with Pretest Scores of Well-being as Covariate ...... 69
xiv Table 23. Adjusted Means After Controlling for the Covariate of Pretest Well-
being Scores ...... 69
Table 24. Generalized Linear Model Parameter Estimates of the Social
Demographic Variables Predicting Mindfulness ...... 70
Table 25. Generalized Linear Model Parameter Estimates of the Social
Demographic Variables Predicting Self-Reflection ...... 72
Table 26. Generalized Linear Model Parameter Estimates of the Social
Demographic Variables Predicting Insight ...... 73
Table 27. Generalized Linear Model Parameter Estimates of the Social
Demographic Variables Predicting Well-being ...... 74
Table 28. Correlations Between Well-being, Mindfulness, Self-reflection, and
Insight Final Scores ...... 75
Table 29. Well-being Predicted from Self-reflection and Deployment History ...... 76
Table 30. Well-being Predicted from Self-reflection and Years Since Discharge ...... 77
Table 31. Well-being Predicted from Self-reflection and Age ...... 77
Table 32. Theory of Unitary Caring Concepts Related to EAP Study Results ...... 84
xv CHAPTER 1. THE PROBLEM
Background and Significance
Much attention has been given to the mental health and treatment of U.S. veterans. Although there have been advances in pharmacologic and treatment therapies for diagnoses such as PTSD, depression, and addiction, the state of veterans’ mental health care is considered one of crisis proportions (Kang et al., 2015). Veteran suicide rates are two times that of the general population despite having an increased number of visits with their primary provider in the year prior to committing suicide (Denneson,
Williams, Kaplan, McFarland, & Dobscha, 2016). Over 2 million veterans (49%) using
Veterans Health Administration services had at least one mental health diagnosis, most commonly, depressive disorder, post-traumatic stress disorder (PTSD), or generalized anxiety disorder (Draper, 2019). Symptoms of intrusive memories, hypervigilance, insomnia, depression, anxiety, and substance abuse were reported, which interfere with relationships, jobs, and physical health (U.S. Department of Veterans Affairs, 2018). The severity of these trauma related symptoms are inversely correlated to an individual’s quality of life (Giacco, Matanov, & Priebe, 2013; Schnurr, Hayes, Lunney, McFall, &
Uddo, 2006).
Post traumatic symptoms can lead to suicidal ideation and attempts, whereas appropriate treatment of PTSD can reduce suicidal ideation (Afifi et al., 2008; Gradus,
Suvak, Wisco, Marx, & Resick, 2013). Psychological well-being is based in meaning,
1 purpose, self-fulfillment, and satisfaction in life (Bowlin & Baer, 2012; Deci & Ryan,
2008). It is purported to have a protective effect on physical health, including reduced cardiac risk, cancer risk, slower disease progression, improved prognoses, and a reduction in mortality (Boehm et al., 2017; Bowlin & Baer, 2012; Deci & Ryan, 2008;
DuBois et al., 2015; Hernandez et al., 2017; Rao, Wallace, Theou, & Rockwood, 2017;
Steptoe, Deaton, & Stone, 2015). Psychological well-being, therefore, is considered by some to be the ultimate objective for health policy (Kottke, Stiefel, & Pronk, 2016).
There has been a recent emphasis on incorporating complementary therapies that demonstrate effectiveness for the mental health treatment of veterans (Lake, 2015).
Adults have increasingly turned to integrative or complementary therapies for mental health concerns. The National Health Statistics Report purported that 34% of adults used some form of complementary or integrative health approaches (Clarke, Black,
Stussman, Barnes, & Nahin, 2015). Veterans are reported to use complimentary medicines for similar reasons as the non-military population, but do so at a higher rate
(44.5%) (Goertz et al., 2013).
Complementary approaches to health use non-conventional treatments along with conventional medicine (National Center for Complementary and Integrative Health,
2018). Adults seek out complementary and integrative modalities for a variety of reasons such as dissatisfaction or lack of results with conventional medicine, lack of access, bias against standard therapies, and adverse reactions to medication (Asher, Gerkin, &
Gaynes, 2017). Adults with neuropsychiatric symptoms were reported to have used one form of complementary or integrative medicine (43.8%) in the past 12 months, with usage increasing as the number of symptoms increased (Purohit et al., 2013). Symptoms
2 for which adults commonly seek complementary therapy include anxiety, depression, attention deficits, insomnia, headaches, stress, PTSD, tobacco cessation, substance abuse, and general wellness (Burke, Lam, Stussman, & Yang, 2017; Purohit et al., 2013).
Midlife and older adults are reported to perceive a reduction in stress, a sense of control over health, improved relationships, sleep, and emotional well-being with complementary and integrative medicine use (Johnson, Jou, Rockwood, & Upchurch, 2018).
Although a variety of integrative therapies are associated with improved psychological well-being, research is advocated for mind-body therapies, in particular mindfulness-based interventions (Boyd, Lanius, & McKinnon, 2018; Insel, 2015).
Mindfulness-based interventions are therapeutic modalities that improve perceptions of emotional processes, reduce fear and anxiety responses, and improve coping strategies and relaxation (Edo, Van Gordon, & Griffiths, 2013). Complementary modalities such as yoga, meditation, movement therapies, progressive muscle relaxation, and guided imagery are examples of mindfulness-based interventions. Mindfulness-based interventions are increasingly used with veterans, resulting in positive effects on anxiety, depression, PTSD, and quality of life (Polusny et al., 2015; Schure, Simpson, Martinez,
Sayre, & Kearney, 2018; Stephenson, Simpson, Martinez, & Kearney, 2017). Preliminary research of equine-assisted psychotherapy (EAP), a form of therapy using horses, has demonstrated outcomes congruent with mindfulness-based interventions, including improved self-awareness, self-perception, and reflective behaviors (Masini, 2010;
Mueller & McCullough, 2017; Buck, Bean, & DeMarco, 2017). Researching the effects of EAP on mindfulness for veterans mental health is warranted.
3 Equine-assisted Psychotherapy
EAP is defined as an intervention using a trained mental health provider and horse for the purpose of addressing psychotherapy goals for an individual (Notgrass &
Pettinelli, 2015). The American Veterinary Medical Foundation (n.d.) has defined animal-assisted therapy as
a goal directed intervention in which an animal meeting specific criteria is an
integral part of the treatment process. Animal-assisted therapy is delivered and/or
directed by health or human service providers working within the scope of their
profession. Animal-assisted therapy is designed to promote improvement in
human physical, social, emotional, or cognitive function. Animal-assisted therapy
is provided in a variety of settings, and may be group or individual in nature. The
process is documented and evaluated. (p. 1)
Although the majority of animal-assisted therapies have involved small companion animals (Arhant-Sudhir, Arhant-Sudhir, & Sudhir, 2011; Brooks et al., 2018;
Cherniack & Cherniack, 2014; Friedmann & Son, 2009; Saunders, Parast, Babey, &
Miles, 2017), the use of horses for mental health therapies has increased. EAP involves the use of horses as a member of the therapeutic team. The therapy is experiential in nature, where interactions between the participant and horse are explored with a mental health provider. As prey animals, horses are attuned to their environment through heightened vigilance and the ability to rapidly interpret stimuli and react in order to survive. It is this characteristic that provides instant feedback, as the horse, by its reaction, reflects the approach and behavior of therapy participants (Buck et al., 2017;
Masini, 2010; Trotter, Chandler, Goodwin-Bond, & Casey, 2008; Vidrine, Owen-Smith,
4 & Faulkner, 2002). Interactions with horses have been shown to strengthen participant self-perception and promote positive changes in anxiety levels, confidence, empowerment, and improved psychiatric symptoms (Berget, Ekeberg, & Braastad, 2008;
Klontz, Bivens, Leinart, & Klontz, 2007; Meinersmann, Bradberry, & Roberts, 2008;
Mueller & McCullough, 2017; Signal, Kemp, Botros, Taylor, & Prentice, 2013; Yorke,
Adams, & Coady, 2008). EAP is a promising therapy with very little research. To date only one study (Earles, Vernon, & Yetz, 2015) has examined the effect of EAP on mindfulness in an adult trauma population; therefore, further research is indicated.
Problem Statement
Mental health care of veterans is a priority. Research of mindfulness-based modalities that demonstrate potential to improve the psychological well-being of veterans is warranted. To date, a single study has supported improved mindfulness for EAP participants, but no studies have specifically examined the effect of EAP on mindfulness, self-reflection, insight, and psychological well-being in a veteran population.
Investigating this therapeutic modality’s potential to positively impact the mental health of veterans is indicated.
Purpose of the Study
The purpose of this study was to determine the effects of equine-assisted psychotherapy on mindfulness, self-reflection, insight, and psychological well-being in an adult veteran population with mental health concerns.
Specific aims were:
5 1. To determine the effect of EAP on mindfulness, self-reflection, insight, and
psychological well-being in adult veterans with psychiatric mental health
concerns.
2. To determine if the sociodemographic characteristics of participants (age,
ethnicity, gender, income, deployment history) are predictive of mindfulness,
self-reflection, insight, and well-being in adult veterans with mental health
concerns engaged in EAP.
Significance of Study
Psychological well-being is inextricably linked to mental and physical health.
Inadequate treatment of mental health disorders of veterans is a major concern. Adverse consequences for the individual include increased morbidity, mortality, loss of function, quality of life, and cost (Domenico et al., 2016; Substance Abuse and Mental Health
Administration, 2014; World Health Organization, 2018). Conventional therapies over the last four decades have not reduced the morbidity or mortality of mental health disorders (Insel, 2015). Participation in EAP by veterans has increased, yet research of this therapy’s effect on mental health lags behind its use (Lake, 2015; Lee, Dakin, &
McLure, 2016). Research of therapies that show potential to improve mental health are needed. This study’s investigator hypothesized that EAP would increase mindfulness, self-reflection, insight, and psychological well-being in a veteran population compared to a treatment as usual comparison group. Results will add to the body of nursing knowledge of mental health.
Research Questions and Hypotheses
The following research questions and hypotheses guided this study:
6 Research Question 1. What is the effect of EAP on mindfulness (awareness, acceptance), self-reflection, insight, and psychological well-being for veterans completing an equine-assisted psychotherapy intervention?
H1. There will be a significant increase in mindfulness for veterans completing an
equine-assisted psychotherapy intervention.
H2. There will be a significant increase in awareness (mindfulness subscale) for
veterans completing an equine-assisted psychotherapy intervention.
H3. There will be a significant increase in acceptance (mindfulness subscale) for
veterans completing an equine-assisted psychotherapy intervention.
H4. There will be a significant increase in self-reflection for veterans completing
an equine-assisted psychotherapy intervention.
H5. There will be a significant increase in insight for veterans completing an
equine-assisted psychotherapy intervention.
H6. There will be a significant increase in psychological well-being for veterans
completing an equine-assisted psychotherapy intervention
Research Question 2. What are the changes in mindfulness (awareness, acceptance), self-reflection, insight, and psychological well-being for veterans completing an EAP program as compared to those receiving treatment as usual?
H1. There will be a significantly greater increase in mindfulness for veterans
completing EAP compared to those receiving treatment as usual.
H2. There will be a significantly greater increase in awareness (mindfulness
subscale) for veterans completing EAP compared to those receiving treatment as
usual.
7 H3. There will be a significantly greater increase in acceptance (mindfulness
subscale) for veterans completing EAP compared to those receiving treatment as
usual.
H4. There will be a significantly greater increase in self-reflection for veterans
completing EAP compared to those receiving treatment as usual.
H5. There will be a significantly greater increase in insight for veterans
completing EAP compared to those receiving treatment as usual.
H6. There will be a significantly greater increase in psychological well-being for
those completing EAP compared to those receiving treatment as usual.
Research Question 3. Are the sociodemographic factors of age, ethnicity, gender, income, and deployment history predictive of final mindfulness, awareness, acceptance, self-reflection, insight, and psychological well-being scores?
Definitions of Terms
Equine-assisted psychotherapy. An intervention using a trained mental health provider and horse for the purpose of addressing psychotherapy goals for an individual
(Notgrass & Pettinelli, 2015) over an eight week period.
Insight. The understanding and evaluation of ones thoughts, feelings, and behaviors, as measured by the Self-reflection and Insight scale (SRIS; Grant et al., 2002)
(Appendix A).
Mindfulness. A dynamic process of attuning one’s attention in a nonjudgmental, accepting way, on an experience, in the present moment (Brown, Ryan, & Creswell,
2007; Kabat-Zinn, 1994; Williams & Kabat-Zinn, 2011), as measured by the Philadelphia
8 Mindfulness scale (PHMS; Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008)
(Appendix B).
Self-reflection. The inspection and evaluation of ones thoughts, feelings and behaviors, as measured by the Self-reflection and Insight scale (SRIS; Grant et al., 2002).
Psychological well-being. A state of having positive affect, satisfying interpersonal relationships, and positive functioning (Tennant et al., 2007), as measured by the Warwick-Edinburgh Mental Well-being scale (SWEMWBS; Tennant et al., 2007).
(Appendix C).
Treatment as usual. Any usual mental health care such as therapy or medication.
Caring Theoretical Framework
The guiding theoretical framework for this study was the middle range theory of unitary caring (Smith, 1999).
Theory of Unitary Caring
The theory of unitary caring is a middle range theory of caring within the perspective of the unitary-transformative paradigm. In this paradigm humans are considered to be open energy fields in ever-evolving patterns of person-environment interactions, moving towards an expanding consciousness (Cowling, 1999; Newman,
1994; Smith, 1999). Five assumptions underpinning the theory of unitary caring are derived from M. Roger’s (1994) science of unitary human beings, Newman’s (1994) theory of health as expanding consciousness, and Watson’s (2005) theory of transpersonal caring: (a) Human beings are unitary or irreducible in mutual process with an environment that is coextensive with the Universe, participating knowingly in patterning, and ever-evolving through expanding consciousness (Barrett, 1989; Newman,
9 1994; M. Rogers, 1992); (b) “Caring is a quality of participating knowingly in human- environment field patterning” (Smith, 1999, p. 20); (c) “Caring is the process through which human wholeness is affirmed and that potentiates the emergence of innovative patterning and possibilities” (Cowling, Smith, & Watson, 2008, p. 44); (d) “Caring is a manifestation and reflection of expanding consciousness potentiating greater meaning, insight, and transformative ways of relating to self and others” (Cowling et al., 2008, p.
42); and (e) Caring consciousness is resonating with the pandimensional universe (M.
Rogers, 1994; Watson, 2005; Watson & Smith, 2002).
Five theoretical concepts describe the phenomenon of unitary caring: (a) manifesting intentions, (b) appreciating pattern, (c) attuning to dynamic flow, (d) experiencing the infinite, and (e) inviting creative emergence. Manifesting intentions encompasses actions that “create healing environments, preserve dignity, humanity and reverence for personhood, focus attention to and concern for the other and facilitate authentic presence” (Smith, 2015, p. 511). Intentions stem from one’s thoughts, beliefs, and perceptions, culminating in plan for action.
Appreciating pattern is “valuing and acknowledging the uniqueness of the person.
It is coming to know the other and acknowledging the person for who they are” (Smith,
2015, p. 512). Central to this concept is acknowledgment and acceptance of the whole person as they are in the moment. Attuning to dynamic flow is defined as “Being truly present in the moment to understand where the other wants to go” (Smith, 2015, p. 512).
This describes and open authentic presence for mutual intuitive communication whether verbal or non-verbal in nature.
Experiencing the infinite is “experiencing the presence of a spiritual connection in
10 the relationship with others. In those moments there is an experience of connectedness to all that is, extending beyond space-time boundaries that define description in ordinary language” (Smith, 2015, p. 513). Inherent in this description is the element of connectedness, awareness, and belief of something more powerful and spiritual than our tangible selves.
Inviting creative emergence is “inspiring the other to birth oneself anew in the moment” (Smith, 2015, p. 513). Possibilities for change emerge that were not previously seen, in moments that cannot be predicted or forced. Table 1 presents the unitary caring concepts as they relate to EAP.
Table 1
Theory of Unitary Caring Concepts Related to EAP
Caring Concepts* EAP Manifesting Intentions Intention for healing with therapist, horse “co-create an environment for healing” and participant (Smith, 2015, p. 511). Appreciating Pattern Horses provide non-judgmental “acknowledge pattern without attempts acceptance and interactions with person to change it” (Smith, 2015, p. 512). Attuning to Dynamic Flow Person relates to horse through flow of “co-creating rhythms of relating in the nonverbal communication and authentic moment” (Smith, 2015, p. 511). presence. The person attends to cues from the horse, informing actions. Experiencing the Infinite Foster spiritual connection between “spiritual connection” (Smith, 2015, p. person, horse and nature 512). Inviting Creative Emergence Interaction with horse and therapist “calling attention to possibilities hidden explore thoughts/emotions and from view” (Smith, 2015, p. 513). possibilities for change Note. *Adapted from “Marlaine Smith’s Theory of Unitary Caring,” by M. Smith, 2015, in M. Smith & M. E. Parker (Eds.), Nursing Theories and Nursing Practice, Vol. 4, pp. 511-513.
11
During EAP, an environment for healing is created by facilitating an authentic presence and therapeutic milieu between the human and equine participants (Walsh &
Blakeney, 2013). Horses are honest in their actions (Vidrine et al., 2002; Walsh &
Blakeney, 2013) and have no agenda, which allows for an environment to elicit what is meaningful to others and the ability to come to know the other. The interaction between horse and human requires an open receptive awareness, where senses and intuition are used for communication. EAP is reported to foster this authentic presence and dialogue, albeit non-verbal. Horses “mirror” participant’s behavior and emotions providing feedback that promotes awareness of one’s own reactions, body language, emotions, and thoughts (C. Brandt, 2013; Proops & McComb, 2010). The therapist assigns task-related goals. Successful completion is contingent on developing awareness and connection through non-verbal communication, while recognizing and accepting what was unsuccessful through self-reflection and modification of approach to the horse (Earles et al., 2015; Lac, 2016; Schaefer, 2002; Siporin, 2012b). Engagement with horses involves inter-species communication in a natural setting fostering awareness and connectedness to more than oneself. By facilitating the human/horse interaction an opportunity for change and growth is created through newfound insight. Thoughts, emotions, actions, and memories are explored during interactions with the horse. These discussions allow for self-reflection and insight into unhealthy or habitual ways of being and offer alternative behavioral choices (Meinersmann et al., 2008; Whittlesey-Jerome, 2014).
In this study it was hypothesized that EAP provides a therapeutic caring environment (manifesting intentions) in which mindful behaviors are elicited during the non-verbal interactions and connection with the horse (appreciating pattern/attuning to
12 dynamic flow, experiencing the infinite). Through examination and reflection of behaviors, thoughts, emotions, and actions elicited during the human/horse interaction, insightful new ways of being can be explored that could result in improved psychological well-being (creative emergence). This EAP research, guided by the theory of unitary caring (Smith, 1999), could provide support for improved mindfulness, self-reflection, insight, and psychological well-being of veterans.
Summary
Interventions that promote mental health and well-being can alleviate the adverse consequences of mental health disorders. Complementary therapies that foster mindfulness demonstrate positive changes in health (Brown & Ryan, 2003; Hernandez et al., 2017; Steptoe et al., 2015). EAP research has demonstrated elements of mindfulness in terms of positive effects on awareness, self-perception, and reflective behaviors; however, no studies have examined the effect of EAP on mindfulness, self-reflection, insight, and psychological well-being, congruent with Kabat-Zinn’s (2015) definition of mindfulness. The purpose of this study was to determine the effects of equine-assisted psychotherapy on mindfulness; specifically: (a) To determine the effect of EAP on mindfulness, self-reflection, insight, and psychological well-being; and (b) To describe the relationship of the sociodemographic characteristics of participants (age, ethnicity, gender, education level, mental health history, current medications) to mindfulness, self- reflection, insight, and psychological well-being in veterans with mental health concerns engaged in EAP. For the first research question “What is the effect of EAP on mindfulness, self-reflection, insight and psychological wellbeing?” the researcher hypothesized there would be a significant increase in mindfulness, self-reflection, insight,
13 and psychological well-being for veterans completing an equine-assisted psychotherapy intervention. For research question two “What are the changes in mindfulness, self- reflection and insight, and psychological well-being for those completing EAP as compared to those receiving treatment as usual?” the researcher hypothesized there would be a significantly greater increase in mindfulness, the subscales of awareness and acceptance, self-reflection, insight, and psychological well-being for those completing
EAP compared to those receiving treatment as usual. The third research question “Are the sociodemographic factors of age, ethnicity, gender, income, and deployment history predictive of final mindfulness, self-reflection, insight, and psychological well-being scores?” explored the predictive relationships of the sociodemographic variables.
The five caring concepts of the theory of unitary caring (Smith, 1999)
(manifesting intentions, appreciating pattern, attuning to dynamic flow, experiencing the infinite, and inviting creative emergence) provided the theoretical framework for this study. During EAP, the intent is to provide a therapeutic milieu in which horse and human interact with the assistance of a trained mental health provider. The facilitated exercises and tasks promote awareness, self-reflection, and acceptance, resulting in newfound insight that allows for positive growth and change to occur. This study adds to the body of caring science and practice for improving well-being in veterans.
14 CHAPTER 2. REVIEW OF RELATED LITERATURE
Introduction
This review first provides a background of EAP, followed by a review of the EAP literature, including outcomes studied and hypothesized mechanisms, and concludes with a synthesis of gaps in the literature related to healing outcomes of EAP.
Equine-assisted Psychotherapy Literature
Background
Civilized human advancement in transportation, exploration, farming, industry, and war, resulted from the use of horses. Historical references describe the relationships with equines as more than beasts of burden. Between 460 and 377 B.C., Hippocrates advocated the use of horses for “natural exercise” and well-being (Hippocrates, Jones,
Jones, & Heraclitus, 1923). Over two centuries ago psychiatric patients learned self- control by working with farm animals in England (Furst, 2006) and horseback riding was recommended by physicians in Germany to reduce hypochondria and hysteria attacks related to mental illness (Reide, 1988). Post World War II saw an increase in the utilization of horses for therapeutic treatment of PTSD and physical injuries. In the
1950s, Scandinavians used horses to assist patients in their recovery form poliomyelitis.
Equine therapy gained attention when Liz Hartel, one of the recipients, credited her horse as the therapist, after winning a silver medal in dressage at the Olympics (Koca &
Ataseven, 2015). More recently, the positive psychological impact of horses has been
15 espoused by Jaycee Dugard and her family after her infamous abduction
(https://thejaycfoundation.org/about-us/), and Paris Jackson, after her father’s demise
(https://www.thesun.co.uk/news/8676548/paris-jackson-secret-visits-horse-therapists- suicide-demons/).
Although many anecdotal success stories credit EAP for therapeutic gains, theoretical and empirical inquiry related to the therapeutic mechanism of action and outcomes of EAP lags behind the therapy’s implementation (Anestis, Anestis, Zawilinski,
Hopkins, & Lilienfeld, 2014; Staudt & Cherry, 2017). Currently, there are over 1,000 equine therapy centers in operation in the United States with more than 7,000 therapists
(Department of Defense, 2016) but only a paucity of research, and those few EAP studies involved children, adolescents, and at-risk youth with few involving adult participants.
Kersten is considered the founder of equine-assisted psychotherapy. In 1972 he implemented the term “equine-assisted psychotherapy” after working with incarcerated youths and noting their subsequent decreased recidivism rates (Kersten, 1972; Siporin,
2012). Ground work (horse-related activities not involving riding) and riding are used in his therapies to process behaviors, feelings, and patterns and to create opportunities to develop responsibility, respect, integrity, and work ethic (Kersten, 1972). Equine-assisted growth and learning (EAGALA) was later developed by Kersten with Thomas as a formal organization to train and certify mental health providers and equine specialists.
(Kersten & Thomas, 1999). EAGALA branched off from Kersten’s (1972) initial work using strictly ground work with the horses (Notgrass & Pettinelli, 2015). Another certifying entity, the Professional Association of Therapeutic Horsemanship International
(PATH), uses the term equine-facilitated mental health for supervised horse-related
16 activities and riding for individuals with cognitive, physical, and emotional disabilities.
(Lee et al., 2016; Notgrass & Pettinelli, 2015).
Equine Communication with Humans
Information during therapy that is conveyed nonverbally is often the most significant (Hayes & Cruz, 2007). As part of the therapeutic team, horses are instrumental in their ability to communicate and provide feedback to the participant. Horses can be taught to respond to verbal commands, but the communication between human and horse is primarily an embodied experience, where non-verbal bodily gestures between the two species co-creates a language (Brandt, 2013).
The nonverbal gestures horses use to communicate involve approach and retreat behaviors, head turning, eye contact, ear and tail movement, facial expressions, and posture. Vocal sounds can include whinnying, nickering, and snorting. A study revealed that horses have the ability to read human cues to attention based on the body and head orientation and gaze of humans (Proops & McComb, 2010). Horses are the second species, apart from dogs, that have demonstrated the ability to communicate referentially with humans by using attention-sharing mechanisms and attention-getting behaviors
(Malavasi & Huber, 2016). Horses in their study were able to communicate to humans what they were looking at and wanted (e.g., a bucket of food) using persistent, alternating gazes from the human to the bucket or by walking to and touching the human.
Facial expressions are a primary means to communicate between humans. The development of the EquiFACS coding system, a facial action coding system applied to horses, has revealed that horses have a large range of facial movements that are similar to humans and other animals, and their number of facial expressions exceeds all animals,
17 with the exception of cats (Wathan, Burrows, Waller, & McComb, 2015). Conversely, another study reported that humans with little or no horse-related experience could correctly identify emotions of the horse from viewing pictures of the horse’s face
(Russell, 2003).
Adult study populations participating in EAP have consisted primarily of those with trauma-related (Asselin, Penning, Ramanujam, Neri, & Ward, 2012; Earles et al.,
2015; Lanning, Wilson, Krenek, & Beaujean, 2017; Mueller & McCullough, 2017) or mental health issues (Alfonso, Alfonso, Llabre, & Isabel Fernandez, 2015; Bachi, 2013;
Kern-Godal, Arnevik, Walderhaug, & Ravndal, 2015; Meinersmann et al., 2008;
Whittlesey-Jerome, 2014). Other healthy adult populations have participated in EAP for learning and leadership purposes (Dyk, 2012; Walsh & Blakeney, 2013). A review of these studies follows.
EAP Outcomes
Anxiety, depression, and PTSD. Rumination as a result of life stressors is considered a risk factor for the development of depression and anxiety symptoms (Michl,
McLaughlin, Shepherd, & Nolen-Hoeksema, 2013). Anxiety and depression symptoms often overlap. Anxiety symptoms consist of excess worry, catastrophic predictions, and irritability and restlessness; whereas depression is characterized by a sense of hopelessness, lack of interest, low energy, and suicidal thoughts, although both may elicit insomnia and concentration difficulties (Beck, Brown, Eidelson, Steer, & Riskind, 1987;
Ghahramanlou-Holloway, Wenzel, Lou, & Beck, 2007). PTSD results from experiencing or witnessing traumatic events and incorporates symptoms of anxiety and depression along with intrusive memories, hypervigilance, insomnia, dissociation, and substance
18 abuse, which interfere with relationships, jobs, and physical health (U.S. Department of
Veterans Affairs, n.d.).
Several researchers have examined anxiety, depression, and PTSD outcomes of
EAP participants. A multidisciplinary, quasi-experimental pilot study (Alfonso et al.,
2015) tested the effect of six sessions of EAP combined with cognitive-based therapy
(CBT) on young women (N=12) with social anxiety disorder. Participants were randomly assigned to the treatment (EAP/CBT) or control groups (CBT). The Liebowitz Social
Anxiety scale (α =0.70) was used as a self-report measure. Measurements were obtained at baseline, post treatment, and six weeks post treatment. Results demonstrated significant reductions in social anxiety scores in the treatment group immediately post treatment (p=.008) and six weeks post treatment (p=.003). The participants had minimal or no previous experiences with horses and according to the researchers this “leveled the playing field” (Alfonso et al., 2015, p. 466). Horses aided in the participants focusing attention away from themselves, and sessions participants could apply and practice new learned behaviors. As a pilot study, the sample size was small and lacked a control group but feasibility was demonstrated for a larger scale study combining EAP with CBT.
Social desirability and testing effect might have influenced results due to self-report measurements taken at three time periods.
The quantitative component of a mixed methods pilot study by Whittlesey-Jerome
(2014) examined the impact of EAP on self-efficacy of 13 adult female victims of interpersonal violence. For eight weeks the control (n=7) and experimental group (n=6) received the same therapy (case management and group therapy), with the experimental group receiving an additional weekly 2-hour equine-assisted session. The General Self-
19 Efficacy scale was used to assess optimistic beliefs about the self. The Major Depression
Inventory (Bech, Rassmussen, Raabaek-Olsen, Noerholm, & Abildgaard, 2001), the
Anxiety scale (Burns & Eidelson, 1998), and the Global Assessment of Functioning scale
(American Psychiatric Association, 2013), were used but collected by a human services agency during the same time frame. Validity and reliability were not reported.
Quantitative results with a mixed factorial ANOVA 2x2 design revealed that the equine- assisted group showed a statistically significantly greater improvement in self-efficacy
(p=.003) and depression (p =.027), but not general functioning (p =0.49). A convenience sample was used. Participants were not randomly assigned. Selection bias may have occurred as those assigned to the equine-assisted therapy group had access to a vehicle, whereas the comparison group did not and continued with their usual therapy. Ethnicities were reported as Hispanic and non-Hispanic. It is unclear which ethnicities comprised the non-Hispanic group. The Hawthorne effect may also have been an issue as an observer took notes for the qualitative aspect of the study, and behavior may have changed as a result of being observed. The data collection method from two different entities also may have influenced the self-report measure results (testing and social desirability effects).
In examining equine-assisted therapy for anxiety and posttraumatic stress symptoms, Earles et al. (2015) proposed that working with horses would increase mindfulness, which in turn would decrease anxiety and PTSD symptoms. They recruited
12 female and 4 male volunteer participants, who had experienced a traumatic life event reported by the Life Events Checklist (Blake et al., 1995) and PTSD scores above 31 on the PTSD Checklist – Specific (PCL-S; Weathers, Litz, Herman, Huska, & Keane, 1993).
Three groups of five to six participants attended weekly 2-hour sessions for six weeks.
20 Six weekly tasks were individually performed with the horse: (a) meet horse and develop awareness, concentration, and listening skills; (b) learn about non-verbal interactions and body language; (c) put a halter on the horse and learn about dealing with stress and challenges; (d) leading and backing up a horse to create boundaries; (e) how to avoid distractions and stay focused; and (f) review learned skills and work on stillness and inner stability. Twelve pre and post study measurements were taken to examine (a) physical and psychological health using PCLS (Weathers et al., 1993), (b) LEC (Blake et al.,
1995), (c) Trauma Emotion Questionnaire (Vernon, 2009), (d) Generalized Anxiety
Disorder scale (Spitzer, Kroenke, Williams, & Löwe, 2006), (e) Alcohol Use Disorders
Identification Test (Saunders, Aasland, Babor, De La Fuente, & Grant, 1993), (f) Somatic
Symptom Severity scale of the Patient Health Questionnaire (Kroenke, Spitzer &
Williams, 2002), (g) Five Faceted Mindfulness Questionnaire (Baer, Smith, Hopkins,
Krietemeyer & Toney (2006), (h) Proactive Coping subscale of Proactive Coping
Inventory (Greenglass, 2002); (i) General Perceived Self-Efficacy scale (Schwarzer &
Jerusalem, 1995), (j) Social Support scale (Earles et al., 2015), (k) Satisfaction with Life scale (Diener, Emmons, Larsen, & Griffin, 1985), and (l) Life Orientation Test-Revised
(Scheier, Carver, & Bridges, 1994). Cronbach’s α for all established instruments ranged from .68 to .97. Paired t-tests showed a statistically significant reduction in reported posttraumatic stress (p<.001), trauma emotion (p<.05), generalized anxiety (p<.01), depression (p<.05), alcohol use (p<.05), and improvement in mindfulness (p<.001). No changes in physical health, coping strategies, self-efficacy, life satisfaction, optimism, or social support were evident. The study utilized a small sample size (N=16) and lacked a
21 control group and long-term follow up. Participant fatigue, testing effect, and social desirability may have influenced response on the self-report measures.
In a mixed methods study (Lanning et al., 2017), quantitative data were gathered on changes in depression and quality of life health behaviors in 13 veteran volunteers (3 females, 10 males, ages 29 to 50 years old.). Volunteers participated in activities with horses such as grooming, leading riding the horse, and doing obstacle courses around cones with a focus on physical activity, decreasing stress and communication. After 12 sessions of equine-assisted activities, participants reported an increase in six of the eight health domains tested: physical functioning, physical roles, general health, vitality, emotional roles, and mental health. At 24 weeks this increased to seven out of eight domains, with an increase in social functioning. The participants’ depression scores trended lower over time but did not demonstrate statistical significance, which the researcher attributed to stoicism inherent in a veteran’s training. To offset this limitation qualitative data were gathered (discussed in qualitative themes section). The attrition rate from the 12th to 24th session was 54% and a small sample size was used without a control group.
Klontz et al. (2007) examined psychological distress and psychological well- being in 31 participants (22 women and 9 men), ages 23 to 70, at an equine assisted - therapy program conducted in group therapy format over 4.5 days. Measures were taken prior to treatment, at completion, and at six months post treatment. The therapy involved grooming, leading the horse, riding, equine games, and therapy techniques using role playing, role reversal, mirroring, and gestalt techniques. The Global Severity Index from the Brief Symptom Inventory scale (BSI; Derogatis, 1993) was used to evaluate
22 psychological symptom patterns. The Personal Orientation Inventory (POI; Shostrum,
1974) measured constructs related to self-actualization. The results demonstrated a significant decrease in psychological symptom patterns (p<.05) and improved self- actualization (p<.05). The study lacked a random sample. Ethnicities of participants and the internal consistency and reliability of the measurement tools were not reported.
Mueller and McCullough (2017) studied post-traumatic stress symptomatology and levels of the human animal bond in a quasi-experimental study of adolescents ages
10-18 with post-traumatic stress symptoms. Adolescents (n=36) participated in 2-hour weekly equine-facilitated psychotherapy sessions with a social worker for 10 weeks, and results were compared to a treatment as usual control group (n=32). The Children’s
Revised Impact of Event scale (CRIES-13; Perrin, Meiser-Stedman, & Smith, 2005) measured reported intrusion, avoidance, and arousal symptoms associated with post- traumatic stress at baseline, week 5, and week 10. The Human-Animal Bond scale
(Terpin, 2004) was used only with the equine participants. A repeated measures ANOVA demonstrated no significant difference (p=0.10) between treatment and control group
CRIES scores across the three points in time. There was no statistically significant increase in the Human-Animal Bond scale scores for the treatment group. The study lacked random assignment and took place at two different locations, which may have risked variation in the treatment.
Motivation. The motivational aspects of working with horses was addressed in two studies (Frederick, Ivey Hatz, & Lanning, 2015; Kern-Godal et al., 2015). An experimental, longitudinal repeated measures design was used to test non-riding equine- assisted therapy on levels of hope and depression in at-risk youth ages 11-17. Twenty-six
23 participants (9 males and 17 females) were randomly assigned either to five weeks of equine-assisted learning (EAL) or to the treatment as usual control group. The Major
Depression Inventory (Bech et al., 2001) and Adolescent Domain Specific Hope scale
(Frederick, 2011) were used to test the hypothesis that EAL would increase levels of hope and decrease depression levels. Pre and post intervention hope scores increased significantly (p=.03) compared to the control group, and the ANOVA showed a medium effect size (n2=.13). Depression scores of the treatment group declined from pre to post intervention, but t-scores were not significant; however, there was a small effect
(n2=.082). Limitations of the study included a small sample size, shorter duration of EAP, testing effects, and accuracy of self-report measures.
A prospective study (Kern-Godal et al., 2015) examined the completion and duration rates of treatment for young adults with mental and behavioral disorders due to substance abuse who participated in equine-therapy. Data from 65 participants in the treatment group were compared to 43 participants in a treatment as usual control group over an 18-month period. Treatment completion was significantly associated with the horse assisted therapy (p< 0.001) and the same participants stayed longer in treatment
(p<0.001). The horse-assisted therapy was found to be the only significant univariate predictor for completing treatment after controlling for age, education, sex, and severity of substances used. Although some participants temporarily eloped from treatment, their return was credited to the attachment to the horse and the therapeutic dynamics of working in smaller groups.
Concepts of self. Bachi, Terkel, and Teichman (2011) studied the effect of equine-facilitated psychotherapy in an adolescent at-risk population, specifically
24 examining self-image, self-control, trust, and general life satisfaction. Fourteen resident adolescents were compared with a matched group of 15 residents who did not receive the treatment over a period of seven months. The self-image questionnaire contained three subsets of “self”: psychological, social, and coping The self-control measure assessed adolescents’ self-control methods to solve behavioral problems. Selected items (7) were taken from the Children’s Interpersonal Trust scale (Hochreich, 1973) and modified for adolescents at a treatment center. The Student Life Satisfaction scale (Huebner, 1991) was adjusted for adolescents. Findings were not significant for the interaction between time and group for self-image, self-control, trust, and general life satisfaction.
Researchers reported a trend of increased trust and general life satisfaction, compared to a decrease in the control group. The small sample size may have decreased the possibility of garnering significant results.
Equine guided leadership, a modified version of equine-assisted therapy with a focus on building leadership skills, was used with expert nurses to develop emotional intelligence in a program at the University of Kentucky (Dyk, 2012). The researcher hypothesized that learning transfer would occur to other life realms as a result of the non- verbal interactions that necessitate heightened perception and sensitivity. Dyk (2012) tested perceived emotional intelligence competency between an intervention (n=11) and waitlist control group (n=10) over a 6-month period. The Qualitative Emotional
Intelligence Appraisal (Bradberry & Greaves, 2009) was used for qualitative data and to measure emotional intelligence. Domains examined were personal and social competence involving self-awareness, self-management, social awareness, and relationship management. The treatment group participated in a 1-day equine-guided leadership
25 program. Data were collected again at three (qualitative) and six-months (quantitative).
At six months, the EQ change score for the intervention group was significantly higher than the control group in all domains of personal and social competencies. Study limitations include small sample size and short treatment duration.
Qualitative Research Related to EAP
Qualitative research has demonstrated themes that are congruent with mindfulness. Participants in Dyk’s (2012) study revealed in a follow up survey that they agreed or strongly agreed that working with horses was effective for the development of self-awareness, awareness of others, personal growth, non-verbal communication skills, and ability to accept feedback, and it also fostered changes in how they relate to peers.
Insights participants gained included awareness of their communication habits, the use of positive feedback and encouragement, and how to effectively use body language to communicate.
Asselin et al. (2012) conducted a case study of a spinal cord veteran’s experience over two years with therapeutic horseback riding in the Horses for Heroes program.
Although this study involved therapeutic riding, it is pertinent to mention due to the psychological benefits the veteran revealed including confidence, trust, motivation, physical awareness, and opportunity for social engagement. Similarly, another qualitative study (Meinersmann et al., 2008) explored how equine-facilitated psychotherapy assisted women in recovery from abuse (N=5). Four major patterns emerged: “I can have power”
“doing it hands on,” “horses as co-therapists,” and “turned my life around.” Women realized they could have strength and control, learn to respect boundaries, and communicate clearly. Some participants described trust and comfort while working with
26 horses and the “mirroring” of horses allowed them to see how they appeared to others.
Participants made positive life changes and verbalized hopefulness for the future.
A similar female population (N=14) in the qualitative component of a mixed methods study (Whittlesey-Jerome, 2014) using the Equine-Assisted Growth and
Learning (EAGALA) format, identified themes shared from participant journals. Data were examined that pertained to the quantitative measurements used (self-efficacy, depression, anxiety, and functioning). Examples of themes reported by the participants included “perception, boundaries, assertiveness, letting go, just being, strong, change and power” (Whittlesey-Jerome, 2014, p. 92). The researchers detailed that the therapy provided a safe haven where the women perceived horses listened; they felt less isolated and were motivated to change.
Participants in Lanning and Krenek’s (2013) mixed methods study, 13 veterans, similarly reported increased sociability and less isolation along with increased trust.
When asked to describe the difference of working with the horse as compared to a person, participants described the horses as non-judgmental, good listeners, compassionate, and without expectations. Participants felt they learned to have more confidence, strength, and acceptance of others.
A descriptive phenomenological study (Walsh & Blakeney, 2013) addressed the lived experience of nurses (N=16) participating in equine-assisted learning and being “in the moment” with the horse for one day. Participants were guided through an orientation for safety and seven exercise stations that included haltering and leading the horse, grooming, and walking through obstacle course type set-ups. Five themes were cited:
“the experienced novice; present in the moment; discovery of self; team building; and
27 leadership” (Walsh & Blakeney, 2013, pp. 4-5). Participants recognized the need to adapt their body language and assume the leadership role for the horse to respond and cooperate during the human-horse exercises.
Hypothesized Mechanisms of EAP
Although there is no consensus, the literature suggests a variety of underlying theoretical approaches and perspectives by which EAP is thought to be therapeutic.
Gestalt therapy is an experiential method of psychotherapy that focuses on the meaning and understanding of an individual’s experience in the moment (Lentini & Knox, 2015).
During EAP, through mutual respect and the “I-Thou” relationship (Buber & Kaufmann,
1996), a supportive healing relationship is formed between the triad of horse, therapist, and individual (Lac, 2016). The healing authentic presence of the horse is thought to provide such an environment (Buck et al., 2017; Maurstad, Davis, & Cowles, 2013;
Walsh & Blakeney, 2013)
Attachment theory views secure attachment as the basic human need for an emotional bond. Children who have poor attachment histories distrust and evade as adults
(Bowlby, 1969). The attachment or bond developed with the horse facilitates the therapeutic process (Bachi et al., 2011; Karol, 2007; Siporin, 2012; Yorke et al., 2008).
The bond created between the horse and human also allows for the opportunity for “safe” touch that cannot be provided by therapists without confusing boundaries (Beauchen,
2017; Yorke et al., 2008). Therapeutic touch can augment the therapeutic relationship and provides emotional support and comfort, while increasing sensory awareness and facilitating expression (Beauchen, 2017).
28 The self-psychology perspective requires understanding the individual’s subjective experiences, and through empathy and mirroring the therapist can facilitate change. Mirroring is specifically attributed to horses in several studies (Earles et al.,
2015; Klontz et al., 2007). Horse and humans do not mirror or copy each other, but the horse “reads” the approach and reacts and reflects in his actions, the behavior, emotions, and approach of the participant. With the assistance of the therapist this exchange is explored. When the participant is given tasks and challenged to communicate with the horse, awareness of their own attitudes, emotions, and body language must occur for a modified approach in order to accomplish the task. This “feed-back loop” of non-verbal relating is a co-created language (K. Brandt, 2004) that elicits an awareness and understanding of “self” and “other.”
From a humanistic perspective, concept of self and the need for self-actualization and achievement is recognized. The self-image has a direct effect on self-regard, or how a person perceives and evaluates themselves and interacts with the world (C. Rogers,
Dymond, & Dymond, 1978). A healthy or “fully functioning person” will find congruence between their sense of self (self-concept) and who they feel they ought to be
(ideal-self) (C. Rogers, 1955). Incongruence occurs when there is a discrepancy between a person’s experience and their perception of themselves. Distress and defensive actions occur as a result of not living up to their own expectations (Ismail & Tekke, 2015). A supportive and encouraging environment elicits a positive experience, and therefore a positive view of oneself. EAP is hypothesized to provide such an environment (Asselin et al., 2012; Bachi, 2013; Meinersmann et al., 2008; Whittlesey-Jerome, 2014).
29 A natural environment and interacting with animals has the potential to elicit spiritual, physical, and psychological benefits (Schaefer, 2002). Humans have an intrinsic attraction to nature and its processes, termed biophilia (Wilson, 1984). The inhabitants of nature are sentinels that communicate calm and safety or warnings of danger, which are thought to be processed on a subconscious level (Beetz, 2017; Melson, 2006; Wilson,
1984). Peaceful farm surroundings and animal interaction, such as occurs during EAP, is posited to have a biophilia-effect (Bachi, 2013; Beetz, 2017; Kaufman, 2018; Whittlesey-
Jerome, 2014; Yorke et al., 2008).
Discussion of Gap in Knowledge Base and Link to Caring Science
Mindfulness-based therapies have demonstrated positive changes in mental and physical wellness. By increasing mindfulness, unhealthy patterns are altered/changed to healthier new patterns and ways of being. EAP is an experiential therapy where personal participation allows for multiple ways of knowing. Research of EAP has been approached from a variety of theoretical perspectives such as Gestalt, attachment theory, self-psychology, humanistic, and biophilia. The underlying mechanism of the therapeutic effect of EAP has remained elusive (Anestis et al., 2014; Staudt & Cherry, 2017); however, the transformative effects of EAP on mental health are evident in terms of positive effects on anxiety levels, confidence, empowerment, and improvements in symptoms. The mindfulness aspects of EAP are inherent, as horses enhance concepts of
“self;” in particular, self-esteem, self-control, self-efficacy, self-awareness, and mindfulness (Bachi, 2013, Berget et al., 2008; Earles et al., 2015; Dyk, 2012). The underlying premise of these studies is that horses can promote healing by fostering self- knowledge through their non-judgmental presence and non-verbal reflective interactions
30 with participants. Brandt (2004) identified that horses elicit awareness and several studies noted acceptance as a key component for positive self-regard from a humanistic perspective (Asselin et al., 2012; Bachi, 2013). Only one study (Earles et al., 2015) has reported that using horses for therapy increased mindfulness in a small adult population with PTSD. A research gap is evident, as no studies have investigated the effect of EAP on mindfulness, self-reflection, insight, and psychological well-being in veteran populations.
Caring science recognizes epistemological pluralism and diverse ways of knowing, being-becoming, and evolving (Watson & Smith, 2002). Although EAP is considered a complementary therapy, its primary purpose is one of caring and assisting the other to grow (Mayeroff, 1990). Animal-assisted therapies share a long history within the discipline of nursing. In the late 19th century, nursing’s first scientist Florence
Nightingale (1859/1992) recognized the benefits of animal, stating that “A small pet animal is often an excellent companion for the sick” (p. 103). She defined nursing as “the act of utilizing the environment of the patient to assist him in his recovery” and “What nursing has to do…is to put the patient in the best condition for nature to act upon him”
(Nightingale, 1859/1992, p. 74). Despite the unconventional setting, this study is congruent with nursing’s focus of “caring in the human health experience” (Newman,
Sime, Corcoran-Perry, 1991, p. 3) Guided by the theory of unitary caring (Smith, 1999), the study’s investigator hypothesized that EAP would increase mindfulness (PHMS), self-reflection, insight (SRIS), and psychological well-being (WEMWBS) in a veteran population compared to a treatment as usual comparison group. Results will add to the body of nursing knowledge of veterans’ mental health.
31 CHAPTER 3. RESEARCH METHODOLOGY
Introduction
The purpose of this study was to examine the effects of EAP on levels of mindfulness, self-reflection, insight, and psychological well-being in an adult population with mental health concerns, and to determine if sociodemographic factors (age, ethnicity, gender, education level, deployment history) are predictive of final mindfulness, self-reflection, insight, and well-being levels. This chapter describes the planned research methodology used, including research design, sampling, recruitment, setting, research questions and hypotheses, outcome measures, data collection, ethical considerations, data analysis, strengths and limitations of the study, and a summary.
Research Design
This study used a quasi-experimental research design. Quasi-experimental designs are useful for pre and post test survey research. The primary weakness is that the two groups being tested may not be equal and unknown sources of bias might exist (Tappen,
2015, p. 70). There were two groups, one receiving EAP and the other their treatment as usual (TAU). Measurements of mindfulness, self-reflection, insight, and psychological well-being were gathered before and after treatment and at week one and eight weeks for the comparison group. Random assignment was not possible due to the scheduling of
EAP groups. Threats to internal validity for this study included psychological changes over time (maturation), testing effects, subject attrition, and outside events that may have influenced results (Campbell, Stanley, & Gage, 1963).
32 Sample, Recruitment, and Setting
Sampling
The convenience sample included adult veterans aged 18 years and older participating in an established equine therapy center in South Florida. A power analysis using G* Power was conducted. An effect size of η 2=.33 was chosen based on a review of the literature and a similar quasi-experimental study by Signal et al. (2017) that examined the effects of animal-assisted therapy on PTSD symptoms on adult participants using a repeated measures design. Using G* power, the alpha of 0.05 was chosen. The power of the test was the recommended .80 per a consulted statistician. The sample size for two groups and five measurements was computed, resulting in a total sample size of
18 participants. To allow for attrition a sample size of 36 was requested. Following IRB approval from Florida Atlantic University (Appendix D), data were collected on paper surveys and through an online secure survey program. An established equine therapeutic riding center in South Florida signed a letter of agreement (Appendix E) and assisted in recruitment of the sample (N=18). A total of 32 individuals were identified to participate in the study by the equine therapy center staff and an online veterans’ forum hosting a recruitment notice (Appendix F). The veterans-only online forum is a platform for the purpose of socializing with and supporting one another. Of those responding, two potential participants in the EAP group declined without stating a reason. All met the inclusion criteria (Appendix G). Attrition of the total sample (N=32) was 43% (n=14) and reduced the final sample size (N=18), resulting in equal treatment (n=9) and comparison
(n=9) groups. Of the 14 participants leaving the program, four participants in the comparison group failed to complete the final online survey. In the EAP group, four
33 participants withdrew due to work and time constraints. Six participants were absent in more than two equine-assisted therapy sessions and removed by the center staff as their participation agreement allowed for no more than two absences.
Recruitment
The investigator was familiar with the equine therapy center from participation in equine-related local events. The EAP center has an existing partnership with multiple veterans’ centers and offered the therapy at no cost to veterans. The veterans’ centers recruited participants through emailed announcements, flyers, word of mouth, and provider referrals. Individuals who wished to participate met with a therapy provider
(MD, Social Worker, NP/PA) who, in conjunction with the EAP social worker, determined their suitability for the program according to Path International criteria
(Appendix H). Individuals considered for inclusion had mental health concerns, were deemed stable on their medication regime (no new medications or medication/dosage changes in the past month), and in active recovery if there was a substance use history.
Individuals deemed dangerous to self or others, medically unstable, actively substance abusing, actively delirious, demented, dissociative, or confused by the VA provider/ EAP social worker were excluded from participating. Physical limitations did not preclude participation as no horseback riding was involved. After contacting the EAP participants who were already enrolled to participate in the therapy, the director of the EAP facility and social worker provided a list of individuals interested in participating in the study. An explanation of the study was given and any questions were answered. If the individual wished to participate, information was provided and the participant signed a consent
(Appendix I) either online or in person at the first EAP session, at the participant’s
34 convenience. Those from the online veterans’ forum who were interested emailed the researcher to request the online survey.
Inclusion criteria. Eligible veteran participants were required to meet the following additional inclusion criteria: (a) age 18 years or older; (b) speak, read, and write English; (c) have a mental health concern or diagnosis; and (d) expressed interest in working with horses for therapy.
Setting
The study setting for the EAP group was an established, licensed, and insured equine therapy facility in South Florida. The comparison group setting was their usual daily environment.
Research Questions and Hypotheses
Research Question 1. What is the effect of EAP on mindfulness (awareness, acceptance), self-reflection, insight, and psychological well-being for veterans completing an equine-assisted psychotherapy intervention?
H1. There will be a significant increase in mindfulness for veterans completing an
equine-assisted psychotherapy intervention.
H2. There will be a significant increase in awareness (mindfulness subscale) for
veterans completing an equine-assisted psychotherapy intervention.
H3. There will be a significant increase in acceptance (mindfulness subscale) for
veterans completing an equine-assisted psychotherapy intervention.
H4. There will be a significant increase in self-reflection for veterans completing
an equine-assisted psychotherapy intervention.
35 H5. There will be a significant increase in insight for veterans completing an
equine-assisted psychotherapy intervention.
H6. There will be a significant increase in psychological well-being for veterans
completing an equine-assisted psychotherapy intervention
Research Question 2. What are the changes in mindfulness (awareness, acceptance), self-reflection, insight, and psychological well-being for veterans completing an EAP program as compared to those receiving treatment as usual?
H1. There will be a significantly greater increase in mindfulness for veterans
completing EAP compared to those receiving treatment as usual.
H2. There will be a significantly greater increase in awareness (mindfulness
subscale) for veterans completing EAP compared to those receiving treatment as
usual.
H3. There will be a significantly greater increase in acceptance (mindfulness
subscale) for veterans completing EAP compared to those receiving treatment as
usual.
H4. There will be a significantly greater increase in self-reflection for veterans
completing EAP compared to those receiving treatment as usual.
H5. There will be a significantly greater increase in insight for veterans
completing EAP compared to those receiving treatment as usual.
H6. There will be a significantly greater increase in psychological well-being for
those completing EAP compared to those receiving treatment as usual.
36 Research Question 3. Are the sociodemographic factors of age, ethnicity, gender, income, and deployment history predictive of final mindfulness, awareness, acceptance, self-reflection, insight, and psychological well-being scores?
Instruments
Sociodemographic Measures
Once informed consent was obtained, participants were asked to fill out the sociodemographic form (Appendix J). Assistance and clarification in completing the form was provided by the researcher when requested.
Measurements of Dependent Variables
Mindfulness, awareness, and acceptance. Mindfulness was measured using the bi-dimensional Philadelphia Mindfulness scale (PHLMS; Cardaciotto et al., 2008). (See
Appendix K for permission to use the scale.) This scale is intended for use in both clinical and non-clinical populations and measures the constructs of awareness and acceptance separately by intention. All items are measured with a 5 point Likert-type scale (1=never, 2=rarely, 3=sometimes, 4=often, 5=very often) The twenty questions measure two 10-item subscales: awareness (Cronbach’s alpha=.86) and acceptance
(Cronbach’s alpha =.91) (Cardaciotto et al., 2008). Awareness statements such as
“Whenever my emotions change I am conscious of them immediately” are positively worded odd-numbered and acceptance items such as “I try to distract myself when I feel unpleasant emotions” are even numbered and reverse scored. Each subscale is totaled separately, with a higher score reflecting higher levels of acceptance and awareness. The scores of awareness and acceptance subscales are added for the total mindfulness score
(Cardaciotto et al., 2008). Content validity was established during the development of the
37 Philadelphia Mindfulness scale by a panel of six experts demonstrating that the measure includes all of the dimensions of the phenomenon to be measured without extraneous dimensions (Tappen, 2016). Convergent and discriminant validity were tested in students
(N=559) from an undergraduate psychology course alongside an established tool measuring mindfulness, the Mindful Attention and Awareness scale (MAAS; Brown &
Ryan, 2003); the Acceptance and Action Questionnaire (AAQ; Hayes & Cruz, 2004); and the Marlowe-Crowne Social Desirability scale (M-C SD; Crowne & Marlowe, 1960).
The study was replicated in research involving 78 graduate students seeking treatment at a student health center (Cardaciotto et al., 2008).
Self-reflection and insight. Self-reflection and insight were measured using the
Self Reflection and Insight scale (SRIS; Grant et al., 2002). (See Appendix L for permission to use the scale.) A 5-point Likert scale was used (1=strongly agree, 2=agree,
3=neutral, 4=disagree, 5=strongly disagree). Factor analysis involved responses from 260 undergraduate psychology students. The measure consists of 20 total items of which 12 questions address self-reflection (Cronbach’s alpha=.71-.91) with statements such as “I frequently examine my feelings.” Eight questions address insight (Cronbach’s alpha=
.82-.87) with statements such as “I usually know why I feel the way I do.” Eight items are reversed scored. The total scores in each category reflected higher or lower levels of self- reflection and insight. The test-retest reliability was .77 (p<.001) and .78 (p<.001), respectively, over seven weeks in an undergraduate student population (N=28) (Grant et al., 2002).
Psychological well-being. Psychological well-being was measured using the
Warwick-Edinburgh Mental Well-being scale (WEMWBS; Tennant et al., 2007). (See
38 Appendix M for permission to use the scale.) A 14 item, 5-point Likert-type scale
(1=none of the time, 2=rarely, 3=some of the time, 4=often, 5=all of the time) measured both eudaimonic and hedonic aspects of mental well-being. Items were totaled for a score reflective of lower or higher levels of mental well-being. The Cronbach’s alpha was .89 in a student sample (n=348) and .91in a population sample (n=1,749) (Tennant et al.,
2007). Test-retest reliability (0.83) over one week was high (Tennant et al., 2007). Table
2 presents the variable definitions and sample items from the measurement scales.
Table 2
Definitions of Variables and Sample Items
Variable Definition Sample Item*
Mindfulness Awareness of one’s internal I am aware of what thoughts and external experiences are passing through my mind. Non-judgmental stance of I tell myself it’s ok to feel sad. self.
Self-reflection Inspection of one’s I frequently examine my thoughts, feelings and feelings. behavior.
Insight Evaluation of one’s I usually know why I feel the thoughts, feelings and way I do. behavior.
Psychological Well- A state of positive affect I’ve been feeling good about being and psychological myself. functioning Note. * Items (odd numbers) for acceptance are negatively keyed. Items (1, 2, 4, 8, 11, 13, 14, 17) for self-reflection are negatively keyed. Items (all numbers) for well-being are positively keyed.
Ethical Considerations
Prior to the study, the research proposal was submitted to the Florida Atlantic
University IRB for review and approval. A letter of agreement from the equine-assisted 39 therapy facility and therapist was obtained prior to commencing the study. Subjects were voluntary adult veteran participants deemed stable to participate by the EAP social worker and veteran’s therapy provider. They did not represent a vulnerable population.
Participants were fully informed regarding the procedures of the research study and any potential risks and benefits. Participants were required to sign a consent form and were provided a copy if requested. They were made aware of the right to withdraw from the study at any time.
The equine therapy facility is an established program, in existence for more than
20 years and where safety is a priority. The staff members at the center are experienced horse handlers and licensed/certified therapists. The horses are well cared for and trained for the therapy. Activities do not involve horseback riding. All equine therapy participants were required by the facility to sign an informed consent recognizing risks and benefits of interacting with equines. The investigator accessed a group of participants who had already been enrolled in the EAP program at an earlier date. Using survey measures may sometimes elicit uncomfortable memories or thoughts, and participants were informed they could refuse to answer items, not complete the survey, or withdraw at any time. In the event of an emotional crisis a licensed mental health counselor was available on the premises, and referral to the nearest emergency room was also an option.
A breach in confidentiality was a remote possibility. A data management plan with the IT department of the College of Nursing was developed. All data collected were coded and no participants’ names were revealed or published. Data in computer files were password protected and paper files were securely stored in a locked cabinet. Access to the data was solely for the investigator. Data will be destroyed once analysis and
40 reporting and completed, not to exceed three years. Paper will be shredded and disposed, and electronic data will be deleted.
No benefits were promised to the participants; however, they may have gained knowledge about themselves and developed life skills. There were no conflicts of interest. The researcher had no financial ties to the EAP organization providing the research setting and received no remuneration.
Data Collection Protocol
An explanation of the study was given and any questions were answered. If the volunteer wished to participate in the study the researcher determined their preference for formal online or paper consent forms. At that time potential subjects were screened regarding the exclusion criteria. Once the consent was signed the sociodemographic data were collected and participants were asked to complete the pretest measures (PHMS,
SRIS, WEMWBS). Estimated time to complete the surveys was 20-30 minutes. The investigator was available for assistance and clarification of test items. Online data were collected through the secure Redcap® program. Once surveys were finished the investigator checked for completed responses. Immediately after the final session, the measurement questionnaires (PHMS, SRIS, WEMWBS) were re-administered to the participants, collected, and checked for completion by the researcher. At that time a $25 gift card was given as an appreciation gesture for volunteering.
The comparison group continued their usual activities and any care for eight weeks. At the end of the 8-week period the researcher re-administer the questionnaires
(PHMS, SRIS, WEMWBS) and checked the questionnaires for completeness.
41 Comparison group participants received a $25 gift card as a token of appreciation for their time and participation.
Sample Assignment
Assignment to the EAP group and comparison group was predetermined by the equine therapy center director. Participants were assigned to groups based on session days and times and participant availability. Once pretest measures were completed the intervention group participants were thanked and reminded of the posttest measurement on the last day of EAP. The treatment as usual comparison group participants were instructed to continue their usual daily activities and any care. Contact information was verified and the participants were reminded of repeat testing in eight weeks.
Intervention
Experimental group. The EAP group met once weekly for eight weeks. The intervention consisted of 90-minute sessions of equine-assisted therapy with a trained and licensed social worker. During the first session, after meeting the horses, participants were asked to choose a horse with whom they felt a connection. Each week during the
90-minute sessions different exercises or tasks with the horse and therapist were addressed (Table 3). Each topic for the sessions involved a therapeutic activity with the horse with an intended purpose.
Data Analysis
Data Accuracy
Prior to data entry the questionnaires were reviewed for proper identification codes and completed answers. Once data were entered in the database (IBM SPSS version 26.0), random checks for accuracy and a double check of reverse scoring were
42 performed. Frequencies of the variables were generated to evaluate outliers and any missing data.
Table 3
Examples of EAP Activities
Topic Activity Purpose Introduction/Herd Observe and discuss herd Learn awareness of energy/ observation/Meet dynamics, hierarchy body language feeling the horse communication, personality recognition traits, boundaries Grounding Horses at liberty in field- Pay attention to thoughts, introduce self to horse, catch feelings perceptions, and and put on horse halter. horse’s body language Grooming horse Frustration/ Directed challenging activities Discuss elements of frustration/ Tolerance with horses tolerance Motivation Move loose horse in a circle Discussions about What drives without touching them (done as the horse? What drives you? a team) Boundaries Activities to move the horse Learn about establishing focused on physical boundaries healthy boundaries Support Pretend to be shipwrecked on Teamwork, creative thinking, an island – must get supplies flexibility, frustration tolerance, and horses across water without coping skills touching it, using various equipment and supplies Gratitude “mindful grooming” silently Connecting with experiences with music Communication Activities in a round pen with a Work on communication horse at liberty skills/body language Team work Work as a team with horse in Communication skills with the round pen others Recreation “cattle drive” work horses Communication/ body around obstacles without language/“energy” feelings touching them- no speaking between participants
43 Demographic Data
Gender, ethnicity, income, education, mental health treatment, provider type, and medication use were reported in frequency tables. The means and standard deviations were analyzed and reported for the demographic data pertaining to military characteristics, age, deployment length, number of duty tours, and years since discharge.
Primary Analysis
Paired sample t-tests were used to analyze research question one. The paired t-test is a parametric test that compares means of two correlated groups and has four assumptions: (a) the dependent variable is continuous, (b) observations are independent,
(c) there is a normal sampling distribution, and (d) the dependent variable has no outliers
(Field, 2013). Paired t-tests are appropriate for pre and posttest research designs where subjects from the same sample are being compared at two time points (Plichta, Kelvin, &
Munro, 2012, p. 93; Tappen, 2016, p. 357).
Analysis of co-variance (ANCOVA) was used to answer research question two.
ANCOVA combines regression and analysis of variance, using a covariate that has a linear relationship to the dependent variable. It is frequently used in pre and posttest designs to increase power by reducing within group error variance by adjusting the posttest means for any initial group differences (Pituch & Stevens, 2016, pp. 302-303).
ANCOVA assumptions are: (a) groups are mutually exclusive, (b) variances of the groups are equivalent, (c) the dependent variable is normally distributed, (d) the covariate is continuous, (e) the co-variate and the dependent variable show a linear relationship, and (f) the direction and strength of the covariate and dependent variable relationship are similar in both groups (homogeneity of regression slopes) (Plichta et al., 2012).
44 A general linear model analysis was used to answer research question three.
General linear models use regression analysis to predict outcomes and relationships among variables (Plichta et al., 2012, p. 340). Assumptions are: (a) the outcome variable is linearly related to the predictor, (b) for any two observations residual terms are uncorrelated or independent, (c) variance around the regression line is the same for all predictor variable values ( homoscedasticity), and (d) errors are normally distributed
(Field, 2013, pp. 309-311). A moderator analysis was used to further explore correlation results of well-being, mindfulness, self-reflection, and insight. Moderation analysis uses the combined effect of two or more predictor variables in a regression analysis (Field,
2013).
Research Questions and Hypotheses
The following section relates the research questions to the data analyses. The independent variable is the EAP intervention and the dependent variables are the measures of mindfulness including subscales of awareness and acceptance as measured by the Philadelphia Mindfulness scale (PHMS; Cardaciotto et al., 2008); self-reflection and insight, including subscales of engaging in self-reflection and needs self-reflection, as measured by the Self-reflection and Insight scale (SRIS; Grant et al., 2002); and psychological wellbeing as measured by the Warwick-Edinburgh Well-being scale
(WEMWBS; Tennant et al., 2007). A questionnaire collected sociodemographic data which was reported using descriptive statistics.
Research Question 1
What is the effect of EAP on mindfulness, awareness, acceptance, self-reflection,
45 insight, and psychological well-being for veterans completing an equine-assisted psychotherapy intervention?
H1. There will be a significant increase in mindfulness for veterans completing and equine-assisted therapy intervention, as measured by the Philadelphia Mindfulness scale (PHMS; Cardaciotto et al., 2008). A paired sample t-test was used to test the first hypothesis. The primary test compared means of mindfulness scores for the EAP group at pretest and posttest.
H2. There will be a significant increase in awareness for veterans completing an equine-assisted therapy intervention, as measured by the Philadelphia Mindfulness scale
(PHMS) awareness subscale (Cardaciotto et al., 2008). A paired sample t-test was used to test the second hypothesis. The primary test compared means of awareness scores for the
EAP group at pretest and posttest.
H3. There will be a significant increase in acceptance for veterans completing an equine-assisted therapy intervention as measured by the Philadelphia Mindfulness scale
(PHMS) acceptance subscale (Cardaciotto et al., 2008). A paired sample t-test was used to test the third hypothesis. The primary test compared means of acceptance scores for the EAP group at pretest and posttest.
H4. There will be a significant increase in self-reflection for veterans completing an equine-assisted therapy intervention, as measured by the Self-reflection and Insight scale (SRIS; Grant et al., 2002) including subscales of engaging in self-reflection and needs self-reflection. A paired sample t-test was used to test the fourth hypothesis. The primary test compared means of self-reflection (including subscales of needs self- reflection, engaging in self-reflection) for the EAP group at pretest and posttest.
46 H5. There will be a significant increase in insight scores for veterans completing an equine-assisted therapy intervention, as measured by the Self-reflection and Insight scale (SRIS) including subscales of engaging in self-reflection and needs self-reflection
(Grant et al., 2002). A paired sample t-test was used to test the fifth hypothesis. The primary test compared means of insight scores for the EAP group at pretest and posttest.
H6. There will be a significant increase in psychological well-being for veterans completing an equine-assisted therapy intervention as measured by the Warwick-
Edinburgh Mental Well-being scale (WEMWBS; Tennant et al., 2007). A paired sample t-test was used to test the sixth hypothesis. The primary test compared means of well- being scores for the EAP group at pretest and posttest.
Research Question 2
What are the differences in mindfulness (awareness, acceptance), self-reflection and insight, and psychological well-being for veterans completing EAP as compared to veterans receiving treatment as usual?
H1. There will be a significantly greater increase in mindfulness for veterans completing EAP compared to those receiving treatment as usual, as measured by the
Philadelphia Mindfulness scale (PHMS; Cardaciotto et al., 2008). ANCOVA was used to test the first hypothesis. The primary test of the hypothesis determined the influence of the independent variable (treatment group) on the dependent variable (final mindfulness scores) while removing the effect of the covariate factor (pretest mindfulness scores).
H2. There will be a significantly greater increase in awareness for veterans completing EAP compared to those receiving treatment as usual, as measured by the
Philadelphia Mindfulness scale (PHMS) awareness subscale (Cardaciotto et al., 2008).
47 ANCOVA was used to test the second hypothesis. The primary test of the hypothesis determined the influence of the independent variable (treatment group) on the dependent variable (final awareness scores) while removing the effect of the covariate factor (pretest awareness scores).
H3. There will be a significantly greater increase in acceptance for veterans completing EAP compared to those receiving treatment, as usual as measured by the
Philadelphia Mindfulness scale (PHMS) acceptance subscale (Cardaciotto et al., 2008).
ANCOVA was used to test the third hypothesis. The primary test of the hypothesis determined the influence of the independent variable (treatment group) on the dependent variable (final acceptance scores) while removing the effect of the covariate factor
(pretest acceptance scores).
H4. There will be a significantly greater increase in self-reflection for veterans completing EAP compared to those receiving treatment as usual as measured by the Self- reflection and Insight scale (SRIS) including subscales of engaging in self-reflection and needs self-reflection (Grant et al., 2002). ANCOVA was used to test the fourth hypothesis. The primary test of the hypothesis determined the influence of the independent variable (treatment group) on the dependent variable (final scores of self- reflection and subscales scores of engaging in self-reflection, needs self-reflection) while removing the effect of the covariate factor (corresponding pretest scores).
H5. There will be a significantly greater increase in insight for veterans completing EAP compared to those receiving treatment as usual as measured by the Self- reflection and Insight scale (SRIS) including subscales of engaging in self-reflection and needs self-reflection (Grant et al., 2002). ANCOVA was used to test the fifth hypothesis.
48 The primary test of the hypothesis determined the influence of the independent variable
(treatment group) on the dependent variable (final scores of insight) while removing the effect of the covariate factor (insight pretest scores).
H6. There will be a significantly greater increase in psychological well-being for those completing EAP compared to those receiving treatment as usual as measured by the
Warwick-Edinburgh Mental Well-being scale (WEMWBS; Tennant et al., 2007).
ANCOVA was used to test the sixth hypothesis. The primary test of the hypothesis determined the influence of the independent variable (treatment group) on the dependent variable (final well-being scores) while removing the effect of the covariate factor
(pretest well-being scores).
Research Question 3
Are the sociodemographic factors of age, ethnicity, gender, income, and deployment history predictive of final mindfulness, awareness, acceptance, self- reflection, insight, and psychological well-being scores?
Strengths and Limitations of the Research Plan
Randomization was lacking in this quasi-experimental design, which can affect internal validity. The volunteer participants were not randomly assigned to treatment and comparison groups, but tests of equivalence were performed on the sociodemographic variables and the pretest data. A small sample size may not have been representative of the population and the study was performed at one location; therefore, results are not generalizable. Participants recruited as EAP participants might have differed from those who would not volunteer for this type of study.
49 Questionnaires have an element of subjectivity. Participants’ answers may have been affected by the testing situation (distractions, interruptions), respondents’ interpretation of the questions, and their level of truthfulness in answering. The questionnaires were 14-20 items and did not require a lengthy time to complete (20-30 minutes). Pretest measures of both groups may have influenced answers on the posttest.
Identified confounding variables were controlled with selection criteria; however, due to unknown differences between groups (due to lack of randomization) not all were identified. The phenomenon of mindfulness, self-reflection, and insight in veterans participating in EAP has not been researched to date. Although findings may not be generalizable, the results provide a basis for further studies and theory development.
Timeline
The study was approved by the FAU IRB on January 25, 2019. Data collection began on March 15, 2019 and was completed on July 19, 2019. Data entry in SPSS® advanced statistical software version 26.0 was completed over a 2-week period. Data analysis was done over a 5-week period. Chapter editing was completed over three months.
Summary
This study used a quasi-experimental pre and posttest design to examine the effects of EAP on mindfulness, awareness, acceptance, self-reflection, insight, and psychological well-being in an adult veteran population age 18 years and older, over eight weeks, as compared to a treatment as usual comparison group, after approval from the FAU IRB and a letter of cooperation from the EAP facility were obtained. A convenience sample of 18 participants (determined by a power analysis using an effect
50 size of n2=.33, alpha of .05, and power of .80) was recruited from an existing cohort of equine-assisted therapy participants at an established facility in South Florida and an online veterans’ forum. Participants of the EAP therapy were screened by the veterans’ providers and the EAP social worker using the PATH International guidelines. The therapy center staff provided a list of interested volunteers for the treatment and comparison groups that could be contacted to participate. Online volunteers requested participation via email. The researcher contacted and explained the study to potential participants (by email or in person). Possible risks and benefits of study participation were given in writing before obtaining informed consent. Those having no mental health concerns; who were unable to speak, read or write English; who were younger than age
18 years; or who did not wish to work with horses were excluded. Ethical considerations were observed, including IRB approval, informed consent, the right to withdraw, safety, animal welfare, risks and benefits, psychological well-being, confidentiality, data management, and conflicts of interest.
Demographic data were collected and three valid and reliable measures, the
Philadelphia Mindfulness scale (Cardaciotto et al., 2008), the Self-reflection and Insight scale (Grant et al., 2002), and the Warwick-Edinburgh Mental Well-Being scale (Tennant et al., 2007) were used to answer the research questions: (a) What is the effect of EAP on mindfulness (awareness, acceptance), self-reflection, insight, and psychological well- being for veterans completing an equine-assisted psychotherapy intervention? and (b)
What are the changes in mindfulness (awareness, acceptance), self-reflection, insight, and psychological well-being for veterans completing an EAP program as compared to those receiving treatment as usual? Pretests measurements of both intervention and comparison
51 groups were taken prior to the first EAP session and repeated after the last session at eight weeks.
The EAP participants received eight weekly 90-minute sessions of EAP with a structured curriculum. Comparison group participants assumed their usual daily activities and care. Both groups received a $25 gift card at completion as a token of appreciation.
During initial data analysis, checks for accuracy, outliers, and missing data were performed. Means and frequencies were used to examine sample characteristics. Paired t- tests, ANCOVA, and GLM were used to answer the main research questions. Study limitations included lack of randomization, lack of objective measurement, sample size, single study location, participant characteristics, subjectivity of questionnaires, participant truthfulness, testing situations, and pre-post testing effects. The study results provide a basis for further research and theory development.
52 CHAPTER 4. RESULTS
This chapter provides a description of the findings, presented in four sections. The first section examines the sociodemographic data, including frequencies means and standard deviations. The second section consists of the primary analysis performed to answer the three research questions and study hypotheses with some additional analyses.
The fourth section consists of a summary presentation of the research findings.
Sociodemographic Variables and Descriptive Statistics of Sample
Study participants completed the sociodemographic questionnaire, which included age, gender, ethnicity, income, education, active duty history, deployment length, time since discharge, current mental health care, mental health care type, and medication use and changes. Data were analyzed using frequencies, means (M). and standard deviations
(SD). Table 4 presents participants age and military characteristics for the control and comparison groups.
Table 4
Age and Military Characteristics of Participants
Treatment/EAP Comparison Characteristic M SD n M SD n Age 57.2 11.64 9 48.55 15.65 9 Deployment Length 18.57 15.05 7 7.3 3.49 5 (mos.) Tours 1.28 .48 7 1.2 .44 5 Years Discharged 28.3 13.20 9 24.43 19.62 8
53 The age of the EAP participants (M=57.2, SD= 11.64) was older than the comparison group (M= 48.55, SD= 15.65); however, no statistically significant difference between the groups for age, t(16) =1.33, p=.201, was found. In the treatment group seven of the nine participants were deployed for active duty while in the military. For the comparison group five of the nine participants were deployed. Deployment length
(M=18.57, SD= 15.05) and number of duty tours for treatment (M=1.28, SD=.48) were greater than the comparison group (M=7.35, SD=3.49 and M= 1.2, SD=.44, respectively).
One participant in the comparison group failed to answer the survey question regarding years since discharge. No statistically significant difference for deployment length, t(10)=1.62, p=.136, and duty tours, t(10) =.310, p=.763, was found. Although a greater number of years had elapsed from discharge (M=38.3, SD=13.2) for the intervention group than the comparison group (M=24.43, SD=19.62), the difference was not statistically significant, t(15)=.485, p=.634. Table 5 illustrates participants’ categorical demographic data.
Table 5
Demographic Characteristics of Participants
Treatment Comparison Characteristic n % n % Gender Male 6 67 7 78 Female 3 33 2 22 Ethnicity African- 2 22 3 33 American Caucasian 4 44 5 56 (continued)
54 Treatment Comparison Characteristic n % n % Hispanic 2 22 1 11 Other 1 11 Income <20K 5 56 4 44 20-50K 4 44 4 44 50-100K 1 11 Education High School 2 22 1 11 Trade 3 33 3 33 Associate’s 2 22 Bachelor’s 3 33 3 33 PhD 1 11 Deployed Yes 7 78 5 56 No 2 22 4 44 Mental Health Care Yes 7 78 6 67 No 2 22 3 33 Provider Type Primary 1 11 MHP 6 66 6 67 Other 1 11 Medications Yes 6 66 5 56 No 3 33 4 44 Medication Changes Yes 2 22 No 6 67 5 56
55 There were more male participants in the treatment (67%) and comparison (78%) groups than females (33% and 22%, respectively). The predominant ethnicity was
Caucasian (44%), followed by African-American (22%) and Hispanic (22%) for the treatment group. Similarly, for the comparison group, there were more Caucasians (56%) than African-Americans (33%) and Hispanics (11%). Only one treatment group participant reported ethnicity as “other.” Education levels were similar for both groups, with one participant in the intervention group reporting a Ph.D. More participants in the treatment group were deployed for active duty (78%) than the comparison group (56%).
A total of 22% of participants in the intervention group and 33% in the comparison group received no mental health care. The remainder equally reported using mental health providers (66%), while one treatment group participant reported use of a primary care provider, and one comparison group participant reported “other” but did not list the type of care provider. Over half the treatment group (66%) and comparison group (56%) used prescription mental health medications. Two of the intervention group participants (22%) reported medication changes within the past two months. Both reported a reduction in medication dosage and no new medications when queried.
Primary Analysis and Hypotheses
Research Question One
There were six hypotheses for research question one “What is the effect of EAP on levels of mindfulness, acceptance, awareness, self-reflection, insight and psychological well-being?” These levels were tested using paired t-tests to determine any differences between the respective pretest and posttest scores of the treatment group. The
56 subscales of self-reflection were included in the analysis. A significance level of .05 was established. Table 6 illustrates the results for the EAP intervention group.
Table 6
Paired Samples t-tests of EAP Pretest and Posttest Scores
Variable Mean Pre Mean Post (SD) t df p
Mindfulness 65.66 71.33 11.66 -1.46 8 0.18
Acceptance 27.88 31.44 8.79 -1.21 8 0.26
Awareness 37.77 39.89 8.68 -0.73 8 0.48
Self-Reflection 41.55 47.22 8.34 -2.04 8 0.07
Engaging in Self 20.33 23.78 3.57 -2.89 8 0.02 Reflection
Needs Self 21.22 23.44 5.19 -1.28 8 0.23 Reflection
Insight 28.11 26.78 3.24 1.17 8 0.28
Well-being 48.55 53.56 11.50 -1.33 8 0.22
A significant increase was not demonstrated by the paired t-test for mindfulness, t(8)=-1.458, p=.18. For the mindfulness subscales of awareness levels, t(8)=-0.730, p=.48 and acceptance t(8)=-1.213, p=0.26, paired t-tests did not demonstrate a statistically significant increase. There was no statistically significant improvement for self- reflection, t(8)=-2.039, p=.07, or for insight, t(8)=1.167, p=.0277. Interestingly, the subscale of engaging in self-reflection demonstrated a significant increase, t(8)=-2.891, p=.02 (two-tailed), representing a large-sized effect, d= 0.81. For well-being, paired t- tests did not reveal a statistical significance, t(8)=-1.33, p=.219). Hypotheses 1-6 were not supported, although self-reflection generally approached significance. Examination of
57 pre and post means for all variable pairs demonstrated a positive increase, with the exception of insight scores. Power may have been insufficient to detect differences in the paired t-tests for this small sample.
Research Question Two
A one-way analysis of covariance (ANCOVA) was conducted to determine any statistically significant difference between the EAP group and comparison group on posttest scores, controlling for pretest scores. Correlations of the corresponding dependent variables and covariates were performed along with scatterplot graphs to test the assumption of homogeneity of regression slopes prior to analysis. GLM custom models also examined the interactions between independent variables and corresponding covariates and none were significant (p<.05). Six hypotheses were tested for research question two, “What are the differences in levels of mindfulness, awareness, acceptance, self-reflection, insight, and psychological well-being for those completing EAP as compared to those receiving treatment as usual when controlling for pretest scores?” The posttest scores for mindfulness (PHMS, including subscales of awareness, acceptance), self-reflection (SRIS, including the subscales of engaging in self-reflection, needs self- reflection), insight (SRIS), and well-being (WARWBS) were the dependent variables; group membership (treatment and comparison) were the independent variables; and pretest scores for the corresponding instruments were the covariates. An alpha value of p=.05 was used. Bonferroni’s adjustment for multiple comparisons was used in each analysis. Effect sizes were reported for partial eta squared values of small (0.01), medium
(0.06), and large (0.14). Results tables are presented with each analysis.
58 H1.There will be a significantly greater increase in mindfulness for veterans completing EAP compared to those receiving treatment as usual.
Hypothesis 1 was supported. Table 7 reports the analysis results for the first hypothesis. There was a significantly greater increase in mean final mindfulness scores,
F(1,15) =7.735, p=.014, while adjusting for pretest mindfulness scores in the treatment group as compared to the comparison group (Table 8). The partial eta squared value=.34, demonstrating a large effect size. A comparison of the estimated marginal means revealed that mindfulness scores were significantly higher for the intervention group
(M=70.638) than the comparison group (M=62.36) (Table 9).
Table 7
Pretest and Posttest Mean Scores, Standard Deviations as a Function of Group Membership
Pretest Posttest
Measurement Source M (SD) M (SD)
Mindfulness EAP 65.67 14.87 71.3 8.34
Comparison 63.00 12.78 61.67 10.44
Awareness EAP 37.78 8.04 39.89 5.82
Comparison 36.11 7.97 33.00 5.27
Acceptance EAP 27.89 9.84 31.44 5.53
Comparison 26.78 9.72 27.89 5.40
Self-Reflection EAP 41.56 9.74 47.22 7.64
Comparison 39.55 8.12 38.11 6.82
(continued)
59 Pretest Posttest
Measurement Source M (SD) M (SD)
Engage in Self- EAP 20.33 4.85 23.78 3.70 Reflection
Comparison 18.89 3.12 17.78 3.63
Needs Self- EAP 21.22 5.45 23.44 4.53 Reflection
Comparison 20.67 5.34 20.33 3.81
Insight EAP 28.11 6.51 26.79 5.76
Comparison 24.00 4.56 24.11 6.10
Well-Being EAP 48.56 14.40 53.56 6.86
Comparison 42.67 10.56 42.11 12.04
Table 8
Analysis of Covariance of Posttest Mindfulness Scores as a Function of Group Membership with Pretest Scores of Mindfulness as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared
Corrected Model 1256.92a 2 628.46 15.94 .000 .68
Intercept 775.05 1 775.05 19.65 .000 .57
Mindfulness 836.42 1 836.42 21.21 .000 .59
Group 305.05 1 305.05 7.74 .014 .34
Error 591.58 15 39.44
Total 81449.00 18
Corrected Total 1848.50 17 Note. a. R Squared = .680 (Adjusted R Squared =.637)
60 Table 9
Adjusted Means After Controlling for the Covariate of Pretest Mindfulness Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 70.69a 2.10 66.16 75.11
Comparison 62.36a 2.10 57.89 66.84 Note. a. Covariates appearing in the model are evaluated at the following values: Total Mindfulness = 64.3333.
H2. There will be a significantly greater increase in awareness (the awareness subscale of the PHMS) for veterans completing EAP compared to those receiving treatment as usual.
Hypothesis 2 was supported. There was a significantly greater increase in mean final awareness scores, F(1,15)=7.121, p=.018, when adjusting for pretest awareness scores for the intervention group as compared to the comparison group (Table10). The partial eta squared value of .322 demonstrates a large effect size. A comparison of the estimated marginal means showed that mindfulness scores were higher for the intervention group (M=39.60) than the comparison group (M=33.28) (Table 11).
61 Table 10
Analysis of Covariance of Posttest Awareness Scores as a Function of Group Membership with Pretest Scores of Awareness as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared
Corrected Model 332.06a 2 166.03 6.65 .009 .47
Intercept 412.03 1 412.03 16.51 .001 .52
Awareness 118.51 1 118.51 4.75 .046 .24
Group 177.72 1 177.72 7.12 .018 .32
Error 374.38 15 24.96
Total 24614.00 18
Corrected Total 706.44 17 Note. a. R squared = .470 (Adjusted R Squared = .399).
Table 11
Adjusted Means After Controlling for the Covariate of Pretest Awareness Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 39.61a 1.67 36.05 43.17
Comparison 33.28a 1.67 29.72 36.84 Note. a. Covariates appearing in the model are evaluated at the following values: Awareness = 36.944.
H3. There will be a significantly greater increase in acceptance subscale scores for veterans completing EAP compared to those receiving treatment as usual.
There was no significantly greater increase in mean final acceptance subscale scores, F(1,15)=2.270, p=.153, while adjusting for pretest acceptance subscale scores for
62 the treatment group as compared to the comparison group (Table 12). The estimated marginal means showed that acceptance scores were slightly higher, but not significantly, for the intervention group (M=31.25) compared to the comparison group (M=28.07)
(Table 13). Therefore, hypothesis 3 was not supported.
Table 12
Analysis of Covariance of Posttest Acceptance Scores as a Function of Group Membership with Pretest Scores of Acceptance as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared
Corrected Model 235.08a 2 117.54 5.90 .013 .44
Intercept 760.89 1 760.89 38.2 .000 .72
Acceptance 178.19 1 178.19 8.94 .009 .37
Group 45.24 1 45.24 2.27 .153 .13
Error 298.92 15 19.93
Total 16376.00 18
Corrected Total 534.00 17 Note. a. R Squared = .440 (Adjusted R Squared = .366).
Table 13
Adjusted Means After Controlling for the Covariate of Pretest Acceptance Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 31.26a 1.49 28.08 34.43
Comparison 28.08a 1.49 24.90 31.25 Note. a. Covariates appearing in the model are evaluated at the following values: Acceptance = 27.3333.
63 H4. There will be a significantly greater increase in self-reflection for veterans completing EAP compared to those receiving treatment as usual.
There was a significantly greater increase in mean self-reflection scores,
F(1,15)=9.705, p=.007, when adjusting for pretest awareness scores for the treatment group as compared to the comparison group (Table 14). The partial eta squared value of
.393 demonstrates a large effect size. The estimated marginal means showed that self- reflection scores were higher for the intervention group (M=46.63) than the comparison group (M=38.67) (Table 15). Therefore, hypothesis 4 was supported.
Table 14
Analysis of Covariance of Posttest Self-reflection Scores as a Function of Group Membership with Pretest Scores of Self-reflection as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared
Corrected Model 775.78a 2 387.89 13.28 .000 .64
Intercept 299.52 1 299.52 10.25 .006 .41
Self-reflection 402.23 1 402.23 13.77 .002 .48
Group 283.52 1 283.51 9.71 .007 .39
Error 438.22 15 29.22
Total 33982.00 18
Corrected Total 1214.00 17 Note. a. R Squared = .639 (Adjusted R Squared = .591).
64 Table 15
Adjusted Means After Controlling for the Covariate of Pretest Self-Reflection Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 46.66a 1.81 42.81 50.52
Comparison 38.67a 1.81 34.82 42.52 Note. a. Covariates appearing in the model are evaluated at the following values: Self-reflection = 40.5000.
There was a significantly greater difference in mean final scores for the engaging in self-reflection subscale, F(1,15)=13.993, p=.002, when adjusting for pretest engaging in self-reflection scores for the treatment group as compared to the comparison group
(Table 16). The partial eta squared value of .483 demonstrates a large effect size. The estimated marginal means demonstrated that self-reflection posttest scores were higher for the intervention group (M=23.358) compared to the comparison group (M=18.198)
(Table 17).
Table 16
Analysis of Covariance of Posttest Engaging in Self-Reflection Scores as a Function of Group Membership with Pretest Scores of Engaging in Self-Reflection as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared Corrected Model 253.02a 2 126.51 15.29 .000 .67 Intercept 59.06 1 59.06 7.14 .017 .32 Engage in SR 91.02 1 91.022 11.00 .005 .42 Group 115.76 1 115.75 13.99 .002 .48 Error 124.09 15 8.27 Total 8148.00 18 Corrected Total 377.11 17 Note. a. R Squared = .671 (Adjusted R Squared = .627).
65 Table 17
Adjusted Means After Controlling for the Covariate of Pretest Engaging in Self- Reflection Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 23.36a .967 21.30 25.42
Comparison 18.20a .967 16.14 20.26 Note. a. Covariates appearing in the model are evaluated at the following values: Engaging in Self-reflection = 19.6111.
There was no significant difference in mean scores for the Needs Self-Reflection subscale, F(1,15)=3.114, p=.098, while adjusting for pretest scores in the treatment group as compared to the comparison group (Table 18). Comparing the estimated marginal means showed that these subscale scores were slightly higher, but not significantly, for the intervention group (M=23.313) as compared to the comparison group (M=20.465)
(Table 19). There was not a significantly greater increase in needs self-reflection for veterans completing EAP compared to those receiving treatment as usual.
Table 18
Analysis of Covariance of Posttest Needs Self-Reflection Scores as a Function of Group Membership with Pretest Scores of Needs Self-Reflection as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared Corrected Model 148.57a 2 74.29 6.36 .010 .45 Intercept 142.91 1 142.91 12.24 .003 .45 Needs SR 105.02 1 105.02 8.99 .009 .38 Group 36.37 1 36.37 3.11 .098 .17 Error 175.21 15 11.68 Total 8948.00 18 Corrected Total 323.78 17 Note. a. R Squared = .459 (Adjusted R Squared = .387).
66 Table 19
Adjusted Means After Controlling for the Covariate of Pretest Needs Self-Reflection Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 23.31a 1.14 20.88 25.74
Comparison 20.45a 1.14 18.04 22.90 Note. a. Covariates appearing in the model are evaluated at the following values: Needs Self-reflection = 20.9444.
H5. There will be a significantly greater increase in insight for veterans completing EAP compared to those receiving treatment as usual.
Hypothesis 5 was not supported. There was no significantly greater increase in mean insight scores, F(1,15)=.507, p=.487, while adjusting for pretest scores for the treatment group as compared to the comparison group (Table 20). Comparing the estimated marginal means showed that insight scores were slightly lower for the intervention group (M=24.896), compared to the comparison group (M=25.993) (Table
21).
67 Table 20
Analysis of Covariance of Posttest Insight Scores as a Function of Group Membership with Pretest Scores of Insight as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared
Corrected Model 455.16a 2 227.58 24.51 .000 .77
Intercept 1.81 1 1.81 .19 .665 .01
Insight 423.16 1 423.16 45.57 .000 .75
Group 4.71 1 4.71 .51 .487 .03
Error 139.28 15 9.29
Total 12248.00 18
Corrected Total 594.44 17 Note. a. R Squared = .766 (Adjusted R Squared = .734).
Table 21
Adjusted Means After Controlling for the Covariate of Pretest Insight Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 24.90a 1.05 22.65 27.14
Comparison 25.99a 1.05 23.75 28.24 Note. a. Covariates appearing in the model are evaluated at the following values: Insight = 26.0556.
H6. There will be a significantly greater increase in psychological well-being for veterans completing EAP compared to those receiving treatment as usual.
Hypothesis 6 was supported. There was a significantly greater increase in posttest mean scores for well-being, F(1,15)=4.842, p=.044, when adjusting for pretest well-being
68 scores in the treatment group as compared to the comparison group (Table 22). The partial eta squared value of .244 demonstrates a large effect size. The estimated marginal means demonstrated that well-being final scores were higher for the intervention group
(M=52.223) than for the comparison group (M=43.44) (Table 23).
Table 22
Analysis of Covariance of Posttest Well-being Scores as a Function of Group Membership with Pretest Scores of Well-being as Covariate
Source Type III SS df Mean F p Partial Eta Square Squared
Corrected Model 1112.09a 2 556.04 8.24 .004 .52
Intercept 848.10 1 848.10 12.57 .003 .46
Well-being 522.70 1 522.70 7.74 .014 .34
Group 326.77 1 326.77 4.84 .044 .24
Error 1012.41 15 67.49
Total 43309.00 18
Corrected Total 2124.50 17 Note. a. R Squared = .523 (Adjusted R Squared = .460).
Table 23
Adjusted Means After Controlling for the Covariate of Pretest Well-being Scores
95% Confidence Interval
Treatment Mean Std. Error Lower Upper
Intervention 52.22a 2.78 46.30 58.15
Comparison 43.44a 2.78 37.52 49.37 Note. a. Covariates appearing in the model are evaluated at the following values: TOTAL = 45.6111.
69 Research Question 3
“Are the sociodemographic variables of age, ethnicity, gender, income, deployment history, and treatment group predictive of final mindfulness, awareness, acceptance, self-reflection, insight and psychological well-being scores?” A generalized linear regression analysis was used in the analysis. The categorical variables were dummy coded and, in each case, the last category (declared “redundant” herein) was used as the reference category. A significance level of .007 was determined for statistical significance using the Bonferroni’s adjustment for multiple predictors.
Table 24 demonstrates that no sociodemographic predictors of final mindfulness scores (PHMS) were statistically significant. The model using age, gender, ethnicity, income, education, deployment history, and group membership did not explain a significant amount of the variance in the final mindfulness scores: F(12, 5)=1.27, R2=.75,
2 p =.42, R Adjusted = .162. No individual predictors contributed significantly to the model using Bonferroni’s adjustment of .007 significance level.
Table 24
Generalized Linear Model Parameter Estimates of the Social Demographic Variables Predicting Mindfulness
95% CI Variables Parameters B SE t p Lower Upper Partial Eta Squared Intercept 104.97 41.43 2.53 0.05 -1.54 211.47 0.56 Gender Male -7.00 13.33 -0.53 0.62 -41.26 27.25 0.05 Female 0a Ethnicity Caucasian -11.64 16.63 -0.70 0.52 -54.39 31.11 0.09 African -24.89 17.11 -1.45 0.21 -68.89 19.11 0.30 American (continued)
70 95% CI Variables Parameters B SE t p Lower Upper Partial Eta Squared Hispanic -42.01 24.30 -1.73 0.15 -104.49 20.48 0.37 Other 0a Income < 20, 000 12.76 15.81 0.81 0.46 -27.88 53.39 0.12 20-50,000 -6.46 21.15 -0.31 0.77 -60.83 47.91 0.02 50-100,000 0a Education High -10.11 11.69 -0.87 0.43 -40.15 19.94 0.13 School Trade -12.38 10.65 -1.16 0.30 -39.75 14.99 0.21 School Associate’s -1.50 10.15 -0.15 0.89 -27.60 24.59 0.01 Bachelor’s 0a Ph.D. 0a Deployed Yes 6.91 6.75 1.02 0.35 -10.44 24.27 0.17 No 0a Treatment Treatment -8.73 7.32 -1.19 0.29 -27.55 10.10 0.22 Control 0a Age Age -0.16 0.30 -0.54 0.62 -0.93 0.61 0.05 Note. a. This parameter is set to 0 because it is redundant.
Table 25 demonstrates that no sociodemographic predictors of final self-reflection
(SRIS) scores were statistically significant. The model using age, gender, ethnicity, income, education, deployment history, and group membership did not explain a significant amount of the variance in the final self-reflection scores: F(12, 5)=2.745,
2 2 R =.868, p=.14, R Adjusted = .552. No individual predictors contributed significantly to the model using Bonferroni’s adjustment of .007 significance level.
71 Table 25
Generalized Linear Model Parameter Estimates of the Social Demographic Variables Predicting Self-Reflection
95% CI Variables Parameters B SE t p Lower Upper Partial Eta Squared Intercept 131.72 24.56 5.36 0.01 68.59 194.84 0.85 Gender Male -19.25 7.90 -2.44 0.06 -39.55 1.05 0.54 Female 0a Ethnicity Caucasian -24.25 9.86 -2.46 0.06 -49.60 1.08 0.55 African -27.09 10.14 -2.67 0.04 -53.16 -1.01 0.59 Am Hispanic -43.51 14.41 -3.02 0.03 -80.54 -6.48 0.65 Other 0a Income < 20,000 -7.40 9.37 -0.79 0.47 -31.48 16.68 0.11 20-50,000 -20.93 12.54 -1.67 0.16 -53.15 11.30 0.36 50-100,000 0a Education High 2.30 6.93 0.33 0.75 -15.51 20.10 0.02 School Trade 10.31 6.31 1.63 0.16 -5.91 26.54 0.35 School Associate’s 7.23 6.02 1.20 0.28 -8.24 22.70 0.22 Bachelors 0a PhD. 0a Deployed Yes 0.39 4.00 0.10 0.93 -9.90 10.68 0.01 No 0a Treatment Treatment -13.55 4.34 -3.12 0.03 -24.71 -2.40 0.66 Control 0a Age Age -0.62 0.18 -3.48 0.02 -1.08 -0.16 0.71 Note. a. This parameter is set to 0 because it is redundant.
Table 26 demonstrates that no sociodemographic predictors of insight (SRIS) scores were statistically significant. The model using age, gender, ethnicity, income, education, deployment history, and group membership did not explain a significant
2 2 amount of the variance in the final insight scores: F(12,5)=3.01, R =.88, p=.116, R Adjusted
72 =.59. No individual predictors contributed significantly to the model using Bonferroni’s adjustment of .007 significance level.
Table 26
Generalized Linear Model Parameter Estimates of the Social Demographic Variables Predicting Insight
95% CI Variables Parameters B SE t p Lower Upper Partial Eta Squared Intercept 78.97 16.51 4.78 0.001 36.52 121.42 0.82 Gender Male -14.26 5.31 -2.69 0.044 -27.91 -0.61 0.59 Female 0a Ethnicity Caucasian -18.75 6.63 -2.828 0.037 -35.78 -1.71 0.62 African -26.98 6.82 -3.96 0.011 -44.51 -9.45 0.76 AM Hispanic -42.28 9.69 -4.37 0.01 -67.18 -17.38 0.79 Other 0a Income < 20,000 -0.23 6.30 -0.04 0.97 -16.42 15.97 0.01 20-50,000 -16.47 8.43 -1.953 0.11 -38.13 5.20 0.43 50-100,000 0a Education High -0.05 4.66 -0.01 0.99 -12.02 11.92 0.01 School Trade 0.75 4.24 0.18 0.87 -10.16 11.65 0.01 School Associate’s 4.59 4.05 1.13 0.31 -5.81 14.99 0.21 Bachelor’s 0a PhD 0a Deployed Yes 2.06 2.69 0.76 0.48 -4.86 8.97 0.11 No 0a Treatment Treatment -3.038 2.92 -1.04 0.35 -10.54 4.46 0.18 Control 0a Age Age -0.20 0.12 -1.68 0.15 -0.51 0.11 0.36 Note. a. This parameter is set to 0 because it is redundant.
For the generalized linear model of sociodemographic predictors of final well- being (WEMWBS) scores there were no significant predictors (Table 27). The model
73 using age, gender, ethnicity, income, education, deployment history, and group membership did not explain a significant amount of the variance in the final well-being
2 2 scores: F(12, 5)=2.31, R =.85, p=.183, R Adjusted=.48. No individual predictors contributed significantly to the model using Bonferroni’s adjustment of .007 significance level.
Table 27
Generalized Linear Model Parameter Estimates of the Social Demographic Variables Predicting Well-being
95% CI Variables Parameters B SE t p Lower Upper Partial Eta Squared Intercept 48.62 35.24 1.38 0.226 -41.98 139.22 0.28 Gender Male 14.40 11.34 1.27 0.260 -14.74 43.53 0.24 Female 0a Ethnicity Caucasian 11.59 14.15 0.82 0.450 -24.78 47.96 0.12 African 3.73 14.56 0.26 0.808 -33.70 41.153 0.01 Am Hispanic -13.97 20.68 -0.68 0.529 -67.12 39.18 0.08 Other 0a Income <20,000 3.80 13.45 0.28 0.789 -30.77 38.36 0.02 20-50,000 -4.10 17.99 -0.23 0.829 -50.35 42.15 0.010 50-100,000 0a Education High -10.42 9.94 -1.05 0.343 -35.98 15.14 0.18 School Trade -23.15 9.06 -2.56 0.051 -46.43 0.13 0.57 School Associate’s -11.16 8.64 -1.29 0.253 -33.36 11.04 0.25 Bachelor’s 0a PhD. 0a (continued)
74 95% CI Variables Parameters B SE t p Lower Upper Partial Eta Squared Deployed Yes 1.09 5.74 0.19 0.856 -13.67 15.86 0.01 No 0a Treatment Treatment -13.936 6.23 -2.24 0.075 -29.94 2.07 0.50 Control 0a Age Age 0.056 0.26 0.22 0.835 -0.60 0.72 0.01 Note. a. This parameter is set to 0 because it is redundant.
Additional Analyses
Self-reflection and insight have been posited to influence behavior change and well-being (Grant et al., 2002). Of additional interest was whether the final mindfulness, self-reflection, and insight scores correlated with the final well-being scores. Bivariate correlation analyses were performed. Table 28 presents the correlation analysis findings.
Table 28
Correlations Between Well-being, Mindfulness, Self-reflection, and Insight Final Scores
Variable Statistic Well-being Mindfulness Self-reflection Insight Well-being Pearson Correlation 1 .731** .149 .486* Sig. (2-tailed) .001 .555 .041 N 18 18 18 18 Note. ** Correlation is significant at the 0.01 level (2-tailed). * Correlation is significant at the 0.05 level (2-tailed).
There was a significant strong correlation between well-being and mindfulness
(p=.001) and significant correlation between well-being and insight (p=.041) but not for self-reflection (p=.555). Since the study participants were veterans, it was of interest whether deployment history, years since discharge, and age may have influenced the relationship between self-reflection and well-being scores. Specifically, did the deployment history, years since discharge, and age moderate the relationship between
75 self-reflection and well-being scores? A moderation analysis was performed on the treatment and comparison group data separately, after self-reflection, age, and years, since discharge data were centered to offset any multicollinearity.
For the EAP group, neither deployment history, β=-3.01, p= .729 (Table 29); years since discharge, β=.-018, p=.735 (Table 30); or age, β=-.003, p=.965 (Table 31) were found to moderate the relationship between self-reflection and well-being.
Similarly, for the comparison group, deployment history, β=1.48, p=.33]; years since discharge, β=.-03, p=.55; or age β=-.03, p=.55 did not moderate the relationship between self-reflection and well-being.
Table 29
Well-being Predicted from Self-reflection and Deployment History
Treatment Control
95% CI 95% CI
Predictor β p Lower Upper β p Lower Upper
Self-reflection .55 .67 -2.56 3.66 -3.20 .22 -9.10 2.69
Deployment -2.39 .34 -15.57 20.35 3.36 .70 -19.05 26.39
Self-reflection x -3.01 .73 -2.41 1.81 1.48 .33 -2.07 5.03 Deployment
R2 .07 .35
F for R2 Δ .95 .50
76 Table 30
Well-being Predicted from Self-reflection and Years Since Discharge
Treatment Control
95% CI 95% CI
Predictor β p Lower Upper β p Lower Upper
Self-reflection .19 .62 -.72 1.10 -.84 .41 -3.40 1.72
Yrs. Discharged .32 .25 1.30 .93 -.01 .97 -.84 .82
Self-reflection x -.09 .74 -.15 -.11 -.03 .55 -.16 .01 Yrs. Discharged
R2 .28 .201
F for R2 Δ .62 .80
Table 31
Well-being Predicted from Self-reflection and Age
Treatment Control
95% CI 95% CI
Predictor β p Lower Upper β p Lower Upper
Self-reflection .30 .520 -.82 1.42 -.88 .31 -2.86 1.10
Age .33 .255 .33 .97 .04 .91 -.79 .87
Self-reflection .003 .965 -.16 .15 -.03 .55 -.16 .10 x Age
R2 .27 .25
F for R2 Δ .63 .67
Summary
This chapter first examined the sociodemographic variables of the sample.
Overall the treatment group and comparison group were similar. The primary analyses answered the three main research questions and an additional fourth question was
77 examined after results of analyses. Paired t-tests for research question one demonstrated mean scores improved for all variables between pre and posttest except for insight.
Mindfulness (PHMS), acceptance (PHMS subscale), self-reflection (SRIS), engaging in self-reflection (SRIS), needs self-reflection (SRIS subscales), and well-being
(WEMWBS) scores from pre to post intervention improved but were not statistically significant. Although there was a statistically significant difference in pre-post mean scores in the comparison group for the subscale engaging in self-reflection, the self- reflection scores were not statistically significant.
The results for research question two supported the hypotheses that there were statistically significant greater improvements in final mean scores for mindfulness
(PHMS), awareness (PHMS subscale), self-reflection (SRIS), engaging in self-reflection
(SRIS subscale), and well-being (WEMWBS) for veterans in EAP compared to those in the comparison group. There was no statistically significant difference in improvement between the treatment and comparison groups for insight (SRIS) or acceptance (PHMS subscale).
The results for research question three found no significant sociodemographic predictors of mindfulness (PHMS), self-reflection (SRIS), insight (SRIS), or well-being
(WEMWBS). Final mindfulness scores and insight scores correlated with final well- being scores; however, final insight scores did not. Age, years since discharge, and deployment history were not significant moderators of the relationship between self- reflection and well-being. A discussion of the research findings is presented in Chapter 5.
78 CHAPTER 5. DISCUSSION
This chapter is presented in three sections. The overview provides a summary discussion of the research study. Results are presented within the theory of unitary caring framework. In conclusion, the limitations of the study and implications for nursing research and nursing practice are described, followed by a summary.
Overview
The purpose of this quasi-experimental study was to determine the effects of equine-assisted psychotherapy on levels of mindfulness, self-reflection, insight, and well- being in an adult veteran population with mental health concerns compared to a treatment as usual comparison group. The specific aims were (a) to determine the effect of EAP on levels of mindfulness, awareness, acceptance, self-reflection, insight, and well-being in adult veterans participating in EAP, and (b) to determine if the sociodemographic characteristics (age, gender, ethnicity, level of education, income, deployment history, and age) were predictive of mindfulness, self-reflection, insight, and well-being scores.
Smith’s (1999) theory of unitary caring was used as a guiding theoretical and conceptual framework.
Discussion
An examination of the paired t-test results showed an overall trend of increase in mean posttest scores for all dependent variables, with the exception of insight; however, only the subscale for engaging in self-reflection was statistically significant. This analysis was likely underpowered, as the power analysis for this study was performed for the
79 ANCOVA analysis. A paired t-test has less power and needs a larger sample size than a regression analysis with a covariate (Hedberg & Ayers, 2014). A retrospective power analysis using G*power with an effect size of .33 for paired t-tests would have required a sample size of 75.
While the EAP group scores improved for all but insight, the comparison group scores appeared to remain the same or worsen slightly over an 8-week period. This is concerning as veterans in the comparison group seemed to show little improvement with their usual care. An additional independent t-test was performed to determine if the difference between group pretest scores was statistically significant. The Levene’s test showed equality of variances were assumed on all pretest variables and mean scores between groups were not significantly different; in all likelihood, the test was underpowered. Lack of changes in scores could have been a sign of stability in treatment, but, of note, baseline mean scores were generally lower and 33% of the comparison group received no mental health care compared to 22% in the EAP group.
The veterans in this study reported selective serotonin re-uptake inhibitor (SSRI) use and conventional therapy sessions as their primary form of mental health treatment.
Data were not collected on the length or duration of current therapy or medication use.
The lack of score increase for the comparison group is not atypical as treatments can plateau and conventional therapies can take longer to reach therapeutic effectiveness.
Typically it can take months of adjusting medication dosages every few weeks to obtain the desired therapeutic effect (Blier, 2009). Therapeutic response rates to SSRIs vary and are reported to be less than 60%, with barely 20-30% of the patients achieving full remission of PTSD symptoms (Berger et al., 2009). Similarly, there is also a wide range
80 in duration of conventional psychotherapy treatment and the rate of any therapeutic change is not consistent (Cloitre et al., 2011; Stulz, Lutz, Kopta, Minami, & Saunders,
2013). Less than 67% of patients improve with 12 therapy sessions in clinical trials and improvement rates are less outside of the research setting (Hansen, Lambert, & Forman,
2002). For complex PTSD it can take as long as 9 to 12 months to achieve stabilization and process trauma and even longer to facilitate treatment ending (Cloitre et al., 2011). It is important to investigate additional treatment options for more expeditious mental health improvement.
Support was demonstrated for the positive effect of EAP on levels of mindfulness, self-reflection, and well-being, including the subscales of awareness (PHMS) and engaging in self-reflection (SRIS) as compared to the comparison group of usual care.
Results supported increased mindfulness and awareness for the veterans in the EAP group, similar to Earles et al. (2015) study, which reported increased levels of mindfulness in adults with PTSD. The current study is the first study known to the researcher that supports increases in mindfulness levels for veterans participating in EAP.
Working with horses may have promoted participants mindfulness and awareness of the effects of their body language, tone, and approach as a result of the horses’ feedback.
Non-verbal interactions necessitate heightened sensitivity as well as perception (Dyk,
2012). Although no EAP studies have specifically measured awareness, Walsh and
Blakeney (2013) and Asselin et al. (2012) found themes of awareness in their qualitative studies. This is the first EAP study of veterans to measure the mindfulness component of awareness.
81 Acceptance, the ability to let go of judgment and interpretation, is a key component of mindfulness (Cardaciotto et al., 2008). Acceptance may have been difficult for a veteran population, with self-reported PTSD, anxiety and depression symptoms, and perhaps elements of dissociative behavior. Acceptance has been reported to be difficult for novice meditators to achieve, as initially they tend to self-analyze, but can improve with practice (Kabat-Zinn, 2015). This issue may have occurred in the EAP setting. The therapist and participant interactions may not have offered the opportunity to address acceptance during the EAP sessions. In addition, many of the participants had no prior exposure to horses. Non-judgmental acceptance of thoughts and experiences is difficult in a new setting with an intimidating large animal. The horse may have been a distracting factor in this case. Future EAP sessions might emphasize the aspects of “letting go” and
“non-judgment” for improved acceptance /mindfulness.
The “mirroring” of horses during the EAP activities may have improved participants’ self-reflection, the ability to recognize and examine their physical and emotional states (Grant et al., 2002). Conversing with horses non-verbally involves continuous adjustments of approach and retreat behaviors based on the horse’s reactions.
This necessitates an examination of one’s mood/emotional state and how it influences outward demeanor. This is the first study known to the researcher to demonstrate the effect of EAP on self-reflection.
Insight is a higher order function or top-down process requiring an understanding and evaluation of ones thoughts, feelings, and behaviors (Grant et al., 2002; Guendelman,
Medeiros, & Rampes, 2017). Insight may not have improved as truly being in the moment with the horse may not have been conducive to analytical processes (Vidrine et
82 al., 2002; Walsh & Blakeney, 2013). Opportunities may have been missed to enhance insight with individual participants, as the EAP was in a group setting. Although several
EAP studies have referred to insightful interactions during EAP (Dyk, 2012; Walsh &
Blakeney, 2013), insight may have been difficult to achieve for this veteran sample. The majority of veterans in this study reported PTSD or related symptoms. PTSD symptoms include emotional numbing, increased rumination, and avoidance behaviors (American
Psychiatric Association, 2013). Attention should be given to these veteran characteristics for development of modalities to improve insight in future EAP treatments and studies.
Some EAP literature has eluded to improved aspects of well-being (Alfonso et al.,
2015; Earles et al., 2015; Klontz et al., 2007; Koca & Ataseven, 2015). This study demonstrated improved psychological well-being for veterans in EAP. Well-being is different for each individual and reasons for this improvement may vary (Diener, 1984).
Interpersonal relationships, affect, and positive function may have improved due to increased mindfulness as a result of working with horses. Increased mindfulness has been reported to be a positive predictor of psychological well-being (Baer, Lykins, & Peters,
2012; Baer et al., 2008; Harrington, Loffredo, & Perz, 2014). Increased mindfulness was highly correlated with psychological well-being in this study of veterans participating in
EAP.
Age, deployment history and years since discharge did not significantly moderate the relationship of self-reflection and well-being. Similarly, age, ethnicity, gender, income, deployment history, and treatment group membership were not predictive of mindfulness, self-reflection, insight, or psychological well-being final scores. Both the moderator analysis and the regression analysis were underpowered with large degrees of
83 freedom, which can increase the likelihood of type I errors (false positives) (Kim, 2015).
These tests should be performed in future larger samples.
Study Findings and Link to Theoretical Framework
The theory of unitary caring (Smith, 1999) guided this study of EAP and its effect on mindfulness, self-reflection, insight, and well-being in a veteran population. The therapeutic process of EAP and the study results are presented within this framework and are summarized in Table 32.
Table 32
Theory of Unitary Caring Concepts Related to EAP Study Results
Caring Concepts* EAP Dependent Variable Results Manifesting Intentions Intention for healing with “co-create an environment for therapist, horse and healing” (Smith, 2015, p. 511). participant Appreciating Pattern Horses provide non- Mindfulness improved “acknowledge pattern without judgmental acceptance and Acceptance - no attempts interactions improvement to change it” (Smith, 2015, p. 512). Attuning to Dynamic Flow Nonverbal communication Self-Reflection “co-creating rhythms of relating in and authentic presence improved the moment” (Smith, 2015, p. 511). Experiencing the Infinite Foster connection to horse Awareness improved “spiritual connection” (Smith, and nature (mindfulness subscale) 2015, p. 512). Inviting Creative Emergence Interaction with horse and Insight - no “calling attention to possibilities therapist explore Improvement hidden from view” (Smith, 2015, thoughts/emotions and Well-being improved p. 513). possibilities for change Note. * Adapted from “Marlaine Smith’s Theory of Unitary Caring,” by M. Smith, 2015, in M. Smith & M. E. Parker (Eds.), Nursing Theories and Nursing Practice (Vol. 4, pp. 511-513).
84 Manifesting Intentions
The triad of horse, therapist, and EAP participant co-created a caring environment for healing to occur. Intentions were evident in the horse’s authentic presence, in the therapist by their caring intentions to facilitate the therapy, and in the EAP participants by their intention for self-care and healing. The environment and interactions within the triad provided a safe place for healing to occur (Whittelsey-Jerome, 2014, p. 93).
Appreciating pattern self-reflection. Mindfulness and awareness involves continuous monitoring of internal and external stimuli of the current experience without pre-occupation (Cardaciotto et al., 2008). During EAP the horse and human come to know each other through non-verbal relating and the horse’s authentic non-judgmental presence. As a human becomes mindful of the horse’s body language and releases his or her fears, an appreciation of the horse’s uniqueness occurs. Through this appreciating pattern during EAP, mindfulness and awareness improved.
Attuning to dynamic flow. In this study self-reflection improved for veterans.
“The human cannot depend solely on verbal language, which necessitates an authentic awareness and sharing of body awareness and intention” (Vidrine et al., 2002, p. 591).
Once fears of the horse have subsided and the human starts to trust, the mutual communication improves through self-reflective patterning and learning the horse’s language (mirroring) (K. Brandt, 2004; Vidrine et al., 2002). Horses are considered good listeners without ulterior motives or expectations (Lanning & Krenek, 2013) and allow for the opportunity of safe touch, which enhances communication and connection.
Energy shifted to relaxation and being in the moment with the horse.
85 Experiencing the infinite. Interacting with animals in a natural environment has the potential to elicit physical, psychological, and spiritual benefits (Schaefer, 2002).
Experiences with the horse may have promoted awareness of a spiritual connection to nature. Significant associations have been found between mindfulness, well-being, and nature (Howell, Dopko, Passmore, & Buro, 2011). Participants in EAP studies have articulated horses give them “change and power” and hope (Lanning et al., 2017,
Frederick et al., 2015; Whittlesey-Jerome, 2014).
Inviting creative emergence. Insight is the understanding and evaluation of emotions, thoughts, and behavior. Activities during EAP facilitate communication and may elicit any underlying psychological issues such as frustration, anger, fear, and anxiety. Any issues that surface are explored with the therapist. Veterans may not have experienced improved insight as “intellectualization can actually break the resonant field that is created through true presence” (Smith, 2015, p. 512). In this sense, the experience of being with the horse is what benefits the person, not the understanding/ intellectualization of the experience. This suggests that the horse’s presence is the transforming entity (Newman, 2008,) or stimulus for increased mindfulness and psychological well-being during EAP.
It was hypothesized that EAP provides a therapeutic caring environment
(manifesting intentions) in which mindful behaviors are elicited during the non-verbal interactions and connection with the horse (appreciating pattern/attuning to dynamic flow/experiencing the infinite). Through examination and reflection of behaviors, thoughts, and emotions elicited during the human/horse interaction, insightful new ways of being can be explored, which could result in improved psychological well-being
86 (creative emergence). This EAP research, guided by the theory of unitary caring (Smith,
1999), provided support for improved mindfulness, self-reflection, and psychological well-being of veterans.
Conclusion
Study Limitations
In this quasi experimental study randomization was lacking as the facility director scheduled the EAP participant groups; this can affect internal validity. Examination of the sociodemographic data, however, showed both had similar characteristics. Asian ethnicity was not represented in this study. Participants were limited to those who spoke, read, and wrote English. The study sample was small and may not have been representative of the general population. Some analyses may have been underpowered; however, for statistically significant results the effect sizes were mostly large. The study was performed at one location; therefore, results are not generalizable, which affects external validity. Participants recruited for the EAP group may have differed from those who would not volunteer for this type of study.
Questionnaires have an element of subjectivity; truthfulness level, social desirability, and testing effect may have affected participant responses (Tappen, 2015).
Participant answers could have been influenced by the testing situation (distractions and interruptions). Pretest measures may have influenced posttest answers; however, eight weeks elapsed between measurements. The questionnaires for this study were valid and reliable measures. The response burden for the surveys was approximately 15 to 20 minutes, but may have been fatiguing for some participants. Participants were given the option of completing the surveys on paper or online. Participants were not queried about
87 any history of traumatic brain injury (TBI). Emotional and cognitive changes can result from TBI, which may affect processing abilities and influence responses (Gallagher,
McLeod, & McMillan, 2019).
An attrition rate of 43% was high, but according to the literature on veteran studies, recruiting and retaining study participants in the veteran population is a challenge and not unexpected (Bush, Sheppard, Fantelli, Bell, & Reger, 2013; Cook & Doorenbos,
2017). Most EAP research to date has been primarily with small samples, which impacts external validity (Anestis et al., 2014). Those who left the EAP program did so for personal and work-related issues. Several re-scheduled for the following session. The
EAP sessions were done in a group setting of 4-5 participants per group. Variation in treatment might have occurred although the EAP program followed a structured format.
Opportunities for personal interaction with the therapist could have been missed; however, group environments also offer the opportunity to observe and learn from the experiences of others. Debriefing sessions following EAP with an emphasis on insight might improve insight levels.
Implications for Nursing
Nursing Practice
This study illustrates that the caring relationships between horse and human can enhance well-being. Synthesizing this caring treatment modality into practice offers nurses and patients a complement to conventional therapies for improving mindfulness, self-reflection, and psychological well-being. Understanding and implementing available treatment options for patients is an integral component of nursing practice. Nurses are in a prime position to identify individuals who may benefit from EAP. Those individuals
88 who show interest in working with animals and those who may have had less than optimal results with traditional therapies might benefit from EAP. Nurses can suggest this modality and refer their patients as indicated.
Nurses could benefit from EAP sessions to improve mindfulness. The ability to attend to consciousness, to be present, and to be mindful in the moment is vital for self- care and caring for others (Watson, 2009). A study by Dyk (2012) demonstrated nurses developed self-awareness and awareness of others as a result of working with horses.
Similarly, in the Walsh and Blakeney (2013) study, nurses revealed themes of being present in the moment and discovery of self. Nurses in administrative and leadership roles might also benefit from EAP for improved mindfulness of communication habits, body language awareness, and use of positive feedback/encouragement for a caring approach in their dealings with others (Dyk, 2012; Walsh & Blakeney, 2013).
Educational opportunities such as in-services and continuing education units could be created that would increase nurse knowledge of EAP as a complimentary healing modality. The American Holistic Nurses Association (n.d.) provides a platform for content that is congruent with their holistic standards of practice and scope of nursing, to care for the entire person while recognizing the interconnectedness of body, mind, spirit and environment, which is consistent with the elements of EAP. The American
Holistic Nurses Credentialing Corporation (n.d.) offers holistic nurse certification across the spectrum of nursing degrees, from undergraduate to graduate level, which can be accessed on their website.
EAP could also be introduced in the formal nursing curricula as a component of caring options for healing. A focus on healing-presence and therapeutic communication
89 using horses would be beneficial. Nursing students could be encouraged to participate in
EAP sessions to learn about and practice authentic presence and improve body-language and communications skills for caring nurse-patient interactions.
A focus on the veteran population is also needed. There is room for improvement in the mental health care of veterans. Veterans sometimes experience symptoms that are refractory to conventional treatments and face issues other than that of the general population (Boyd et al., 2018). Caring is the quality of participating knowingly in human- environment field patterning (Smith, 1999); therefore, an understanding of these differences should be integrated into the formal curriculum for greater transpersonal caring.
Certification through the Equine-Assisted Growth and Learning Association (n.d.) and PATH International (n.d.) are also options for nurses interested in participating in
EAP. The O.K. Corral Series (n.d.) is offered by Greg Kersten, the EAGALA founder with sessions specific to the veteran population. Opportunities to become a certified equine specialist are available through these entities. Career advancement opportunities include degrees in mental health counseling or as a psychiatric advanced practice nurse
(APRN) through formal programs and state licensure.
Nursing Research Implications
The study results suggest future research is needed to replicate this study’s findings of the effect of EAP on mindfulness, self-reflection, and well-being. Although no statistically significant findings were observed for insight and acceptance as a result of
EAP, this study should still be replicated in veteran populations as well as in others.
Concurrent measures of PTSD and dissociation levels would be of value. Asian, other
90 minorities, and non-English speaking participants should be included. Demographic predictors and potential moderating variables should also be explored. Given the strong correlation between mindfulness and well-being, future studies should consider examining whether the therapy increases mindfulness, which then mediates the effect of well-being.
Research is advocated for interventions that recognize the interconnectedness of mind and body for veterans and those with PTSD symptoms (Boyd et al., 2018). Nurses’ caring relationships with patients put them in a prime position to recognize and research these patterns of connection. Biomarkers that have been found to support the mind-body effects of mindfulness should be included in studies of EAP and mindfulness to investigate any similarities or differences. Biomarkers such as EEG power and coherence, brain derived neurotrophic factor (BDNF), Adrenocorticotrophic factor
(ACTH), urine catecholamine tests, blood pressure, heart-rate variability, and cortisol are examples. Nurses can already take credit for some of the preliminary EAP research
(Asselin et al., 2012; Dyk, 2012; Walsh & Blakeney, 2013), but the inclusion of biomarkers is needed to demonstrate EAP’s efficacy within veteran and other populations.
Establishing caring connections to facilitate interdisciplinary research would benefit future research of veterans and EAP. Networking with interested researchers; equine-therapy center professionals; and local, state, and national veteran organizations could build a sustainable partnership of individuals interested in furthering EAP and veteran research. This would help in the organization and implementation of multicenter studies for larger samples, in the evaluation of EAP methods, and in theory testing.
91 Multicenter studies risk variation of EAP treatment methods; however, larger studies would also assist in determining which types of EAP may be better suited for improving mindfulness, self-reflection, insight, and psychological well-being. EAP is a caring- healing modality. Future EAP studies should be theoretically based in caring science for testing and advancement of caring theories. Advocating for funding is necessary for EAP studies within the veteran population as well as reimbursement to centers providing the therapy. Current funding is sparse, with occasional private research grants such as those from the EQUUS Foundation (www.equusfoundation.org) and Horses and Humans
Research Foundation (www.horsesandhumans.org). Only recently has federal funding been provided through a bill passed in the House of Representatives. An adaptive sports grant to the Department of Veterans Affairs has $1M allocated to equine-therapy for disabled military veterans. This is a promising area as there may be designated funds for
EAP research.
Summary
Caring for veterans with mental health concerns can provide unique challenges.
Nurses and other healthcare professions can advocate for the use of non-conventional mindfulness-based treatment modalities that show potential to improve mental health.
Horses and humans during EAP co-create an environment that has the potential to improve mindfulness and psychological healing.
The purpose of this quasi-experimental study was to investigate the effect of EAP on mindfulness, self-reflection, insight, and well-being in an adult veteran population with mental health concerns. Specific aims were: (a) to determine the effect of EAP on mindfulness, self-reflection, insight, and psychological well-being and (b) to determine if
92 sociodemographic characteristics of the participants (age, gender, ethnicity, income, education, and deployment history) were predictive of final mindfulness, self-reflection, insight ,and well-being levels.
The study research questions were:
Research Question 1. What is the effect of EAP on mindfulness, self-reflection, insight, and psychological well-being for veterans completing an equine-assisted psychotherapy intervention?
Research Question 2. What are the differences in mindfulness, awareness, acceptance, self-reflection, insight, and psychological well-being for veterans completing
EAP as compared to those receiving treatment as usual?
Research Question 3. Are the sociodemographic factors of age, ethnicity, gender, income, and deployment history predictive of final mindfulness, awareness, acceptance, self-reflection, insight, and psychological well-being scores?
Mindfulness was measured using the Philadelphia Mindfulness scale (PHLMS;
Cardaciotto et al., 2008). Self-reflection and insight was measured using the Self-
Reflection and Insight scale (SRIS; Grant et al., 2002). Psychological well-being was measured with the Warwick-Edinburgh Mental Well-being scale (Tennant et al., 2007).
All were deemed valid and reliable measures.
Paired t-tests were used to analyze the EAP pre and post treatment scores of mindfulness (PHMS), self-reflection and insight (SRIS), and well-being (WEMWBS).
Analysis of covariance (ANCOVA) was used to examine any significant differences between the EAP and comparison group after eight weeks for mindfulness, acceptance, awareness (PHMS), self-reflection, insight, needs self-reflection, engaging in self-
93 reflection (SRIS), and well-being (WEMWBS), adjusting for respective pretest scores.
Sociodemographic data as predictors of mindfulness (PHMS), self-reflection and insight
(SRIS), and well-being (WEMWBS) final scores were determined by generalized linear model analysis. An additional moderator analysis examined whether deployment history, years since discharge, and age moderated the relationship between self-reflection and well-being for both intervention and comparison groups.
Paired t-tests for research question one demonstrated mean scores improved for all variables between pre and posttest except for insight. Mindfulness (PHMS), acceptance (PHMS subscale), self-reflection (SRIS), engaging in self-reflection (SRIS subscale), needs self-reflection (SRIS subscale), and well-being (WEMWBS) scores from pre to post intervention improved but were not statistically significant. Although the engaging in self-reflection subscale scores were statistically significant, the self-reflection scores were not. The test was underpowered.
The results for research question two supported statistically significant greater improvements in scores for mindfulness (PHMS), awareness (subscale PHMS), self- reflection (SRIS), engaging in self-reflection (subscale SRIS), and well-being
(WEMWBS) for veterans in EAP compared to those in the comparison group. Insight
(SRIS) scores were not statistically significantly for greater improvement.
The results for research question three found no significant sociodemographic predictors of mindfulness (PHMS), self-reflection (SRIS), insight (SRIS), or well-being
(WEMWBS). Final mindfulness scores and insight scores correlated with final well- being scores; however, final insight scores did not. Age, years since discharge, and deployment history were not significant moderators of the relationship between self-
94 reflection and well-being. The theory of unitary caring (Smith, 1999) provided support for improved mindfulness, self-reflection, and psychological well-being of veterans.
Study limitations were discussed: lack of randomization, response truthfulness of questionnaires, social desirability, lack of generalizability, small sample size, sample attrition rate, and potential treatment variation. Implications for nursing practice include
(a) identification of patients who may benefit from EAP, (b) nurses participation in EAP to improve presence and mindfulness, (c) educational opportunities, (d) specialty credentialing and training, and (e) incorporation of veteran mental health issues and complimentary treatment modalities into formal nursing curricula. Study findings need replication in diverse and larger samples. Researching biomarkers of participants in EAP could demonstrate any mind-body effects. Establishing caring connections with researchers, EAP providers, and veteran groups could further advance research, theory testing, and advocacy for funding and re-imbursement.
Mental health of veterans is a priority. Research of modalities that show potential for improvement in psychological well-being is critically important. Equine-assisted psychotherapy is increasingly being used by veterans for mental health. Initial studies and anecdotal evidence have supported its positive effect on mental health: however, more research is needed. This study, guided by the theory of unitary caring (Smith, 1999), supported that veterans working with horses in EAP sessions had greater improvement in levels of mindfulness, self-reflection, and psychological well-being over eight weeks than a comparison group. Insight and acceptance levels did not improve statistically as characteristics of the treatment and the population may have influenced results. In this study, EAP appeared to improve mindfulness, self-reflection, and psychological well-
95 being over an 8-week period, which represents a shorter time span than conventional treatment. Any benefits of EAP for veterans over the long term needs to be studied.
Although the term equine-assisted psychotherapy situates the modality within psychology, in reality it is a caring, healing intervention of mind-body and spirit. Nurses can and should play a key role in EAP research, treatment referral, and EAP sessions.
96 APPENDICES
97 Appendix A. Self-Reflection and Insight Scale
Respond to the statements as follows: “Strongly agree, agree, neutral, disagree, strongly agree” Strongly Agree Neutral Disagree Strongly agree disagree 1 I don’t often think about my thoughts 1 2 I am not really interested in analyzing my behavior 2 3 I am usually aware of my thoughts 3 4 I am often confused about the way that I really feel about things 3 5 It is important for me to evaluate the things that I do 2 6 I usually have a very clear idea about why I have behaved in a certain way 3 7 I am very interested in examining what I think about 2 8 I rarely spend time in self-reflection 1 9 I am often aware that I am having a feeling, but I often don’t quite know what it is 3 10 I frequently examine my feelings 1 11 My behavior often puzzles me 3 12 It is important to me to try to understand what my feelings mean 2 13 I don’t really think about why I behave in the way that I do 1 14 Thinking about my thoughts makes me more confused 3 15 I have a definite need to understand the way my mind works 2 16 I frequently take time to reflect on my thoughts 1 17 Often I find it difficult to make sense of the way I feel about things 3 18 It is important to me to be able to understand how my thoughts arise 2 19 I often think about the way I feel about things 1 20 I usually know why I feel the way I do 3
Items 1,2,4,8,11,13,14, and 17 are reversed 1. Component a) engaging in self reflection 2. Component b) need for self-reflection 3. Component c) Insight
98 Appendix B. Philadelphia Mindfulness Scale (PHLMS)
Mindfulness- Philadelphia Mindfulness Scale (PHLMS) Please select how often you experienced each of the Some- Very Never Rarely Often following statements within the times Often past week. PHLMS1 I am aware of what
thoughts are passing 1 2 3 4 5 through my mind. (Aw) PHLMS2 I try to distract myself
when I feel unpleasant 1 2 3 4 5 emotions. (Ac) PHLMS3 When talking with other people, I am aware of their facial and body 1 2 3 4 5 expressions. (Aw) PHLMS4 There are aspects of
myself I don’t want to 1 2 3 4 5 think about. (Ac) PHLMS5 When I shower, I am aware of how the water is running over my body. 1 2 3 4 5 (Aw) PHLMS6 I try to stay busy to keep
thoughts or feelings from 1 2 3 4 5 coming to mind. (Ac) PHLMS7 When I am startled, I
notice what is going on 1 2 3 4 5 inside my body. (Aw) PHLMS8 I wish I could control my
emotions more easily. 1 2 3 4 5 (Ac) PHLMS9 When I walk outside, I am aware of smells or how the air feels against 1 2 3 4 5 my face. (Aw) PHLMS10 I tell myself that I
shouldn’t have certain 1 2 3 4 5 thoughts. (Ac) PHLMS11 When someone asks how I am feeling, I can identify my emotions 1 2 3 4 5 easily. (Aw)
99 PHLMS12 There are things I try not to think about. (Ac) 1 2 3 4 5 PHLMS13 I am aware of thoughts
I’m having when my 1 2 3 4 5 mood changes. (Aw) PHLMS14 I tell myself that I shouldn’t feel sad. (Ac) 1 2 3 4 5 PHLMS15 I notice changes inside my body, like my heart
beating faster or my 1 2 3 4 5 muscles getting tense. (Aw) PHLMS16 If there is something I don’t want to think
about, I’ll try many things 1 2 3 4 5 to get it out of my mind. (Ac) PHLMS17 Whenever my emotions change, I am conscious of them immediately. 1 2 3 4 5 (Aw) PHLMS18 I try to put my problems out of mind. (Ac) 1 2 3 4 5 PHLMS19 When talking with other people, I am aware of the emotions I am 1 2 3 4 5 experiencing. (Aw) PHLMS20 When I have a bad memory, I try to distract myself to make it go 1 2 3 4 5 away. (Ac)
Scoring the PHMS: Awareness Subscale: items 1, 3, 5,7,9,11,13,15,17,19 Acceptance Subscale: items 2,4,6,8,10,12,14,16,18,20
My total My item average PHMS -TOTAL Awareness Acceptance
100 Appendix C. Warwick-Edinburgh Mental Well-being Scale
101 Appendix D. IRB Approval
102
103 Appendix E. Letter of Agreement
104 Appendix F. Online Posting for Veterans’ Forum
Carol Reive is a Nurse Practitioner and Doctoral student doing research evaluating how horses may help with mental health of veterans. You can participate in 2 sets of surveys that are 8 weeks apart and receive a 25-dollar gift certificate after completing the second surveys. All survey responses are anonymous. The survey link will be sent to you by email, and does not require personal meetings. If you are interested, you can email Carol Reive at Creive@ health.fau.edu or XXXXXXXX. Thank you.
105 Appendix G. Inclusion Screening Questions
Before we proceed to the study information, could you answer some initial questions to see if you are eligible to participate?
1. Are you over the age of 18? Yes No
2. Do you have any mental health concerns? Yes No
3. Are you comfortable speaking, reading and writing in English? Yes No
4. Would you consider participating in a therapy group involving the use of horses? Yes No
Thank you for your interest.
106 Appendix H. Path International Contraindications
Client is currently:
• Actively dangerous to self or others (suicidal, homicidal, aggressive) • Actively delirious, demented, dissociative, psychotic, severely confused (including severe delusion involving horses) • Medically unstable • Actively substance abusing
Narrative for Contraindications:
“Dangerous to self or others” is the clinically accepted term to describe those clients experiencing a psychiatric emergency. Equine experiences cannot be safely facilitated for clients exhibiting these behaviors.
“Actively delirious, demented, dissociative, psychotic, or severely confused” as well as “actively substance abusing” reflects the committee’s agreement that equine experiences cannot be safely facilitated when clients are exhibiting serious alterations in mental status.
“Medical instability” can be associated with a variety of psychosocial challenges. The committee seeks to enhance awareness that physical/medical issues must always be considered as part of a thorough clinical assessment.
107 Appendix I. Consent/Authorization Form (For Adults)
CONSENT/ AUTHORIZATION FORM (for ADULTS)
.
Consent Form Version & Date Version 6.0 May 8. 2019
1) Title of Research Study: The Effect of Equine-assisted Psychotherapy on Mindfulness and Wellbeing
2) Investigator(s): Principal Investigator Marlaine Smith PhD, RN, AHN-BC FAAN Co-Investigator Carol Reive MSN, RN, FNP-BC, ERNP-BC
3) Purpose: To understand how working with horses may affect awareness, acceptance, self-reflection, insight and wellbeing
4) Procedures: There are two groups. The first group will be in an equine-assisted therapy program. The second group will continue their usual daily routine and healthcare as usual. If you are in the first group you will complete three questionnaires before your first session and three questionnaires at the last session. If you are in the second group, you will complete three questionnaires and repeat the questionnaires in 8 weeks. Your time commitment will be approximately 1-2 hours to complete 2 sets of 3 questionnaires. This includes 10 minutes to read and sign the consent form and complete the demographic information. It will take 20-30 minutes to complete the 3 questionnaires. For the first group, the first set of 3 questionnaires will be completed online, after you sign the consent, and before the equine-therapy sessions start. The second set of 3 questionnaires can be completed online or on paper at the equine therapy center. If you are in the second group you will do both surveys online. You will receive a 25-dollar gift card after completion of both sets of questionnaires. If you complete the first questionnaire only, or do not complete the equine therapy sessions you will not receive the gift card. If you do not wish to participate in the study your participation in the equine-assisted therapy sessions will not be affected.
1366090-3 Consent HIPAA Authorization Template FAU/RI: Version 4.0 - 6/28/2018 1 Approved On: May 21, 2019
Institutional Expires On: Not Applicable Review Board
108
5) Risks: Occasionally thinking about questionnaire statements may make you uncomfortable. You may choose to stop the questionnaire at any time. If you require emotional assistance a trained mental health worker is available to assist you. Your identity is confidential, you will complete these forms anonymously and codes will be used for identification. There is a remote chance that your questionnaire results may not be kept private, which could pose a risk to your reputation, employability, insurability, and/or criminal and civil liabilities. To reduce that risk, your name will not be associated with the questionnaire results.
6) Benefits:
No benefits are promised to you, but your questionnaire responses may help improve equine- assisted therapy practices, and help researchers in future studies of equine-assisted therapy.
7) Confidentiality/ Data Collection & Storage: The principal investigator and co-investigator will have access to your data. Your identity will be protected by removal of your name and use of a code number. Paper responses will be kept in a locked filing cabinet. Online consents and questionnaires are collected using an encrypted secure program and responses will be kept in a password protected encrypted file. Any information collected about you will be kept confidential and secure and only the people working with the study will see your data, unless required by law. The data will be kept for 3 years in encrypted password protected electronic format. Data on paper will be stored in a locked cabinet. After 3 years, electronic data will be deleted and paper data will be shredded and destroyed. Sometimes researchers need to share information that may identify you and your research records with people that work for the University, the Institutional Review Board (IRB), Research Integrity staff, regulators or the study sponsor. These people are responsible for making sure the research is done safely and properly. If this does happen, we will take precautions to protect the information you have provided. We may publish what we learn from this study. If we do, we will not let anyone know your name/identity unless you give us permission.
8) Authorization to Use Protected Health Information Protected Health Information (PHI) is protected by a federal law called the HIPAA Privacy Rule. As part of this research, Dr. Marlaine Smith and Carol Reive APRN would like your permission to collect, use, and share the following protected health information: Mental health history, type of care received, mental health diagnoses and medication names.
You can list any particular information that you do not want us to use or share here: ______If you list nothing here, then no information will be excluded.
The health information will only be used for the study described in this document.
1366090-3 Consent HIPAA Authorization Template FAU/RI: Version 4.0 - 6/28/2018 2 Approved On: May 21, 2019
Institutional Expires On: Not Applicable Review Board
109
If we share your information with persons or institutions who are not required to follow the Privacy Rule, there is no guarantee that your information will be protected.
You can refuse to sign this form. If you do not sign this form, we will not collect, obtain or share your health information and we will not enroll you in this research study. However, your care outside of this study will not change and no one will treat you differently.
You can cancel your permission at any time by sending a letter saying you wish to withdraw your authorization to use this health information in the research.
To cancel your permission, please write to: Principal Investigator: Dr. Marlaine Smith For IRB Study # Address College of Nursing Rm 301 777 Glades Road Boca Raton, Florida 33431
If you cancel your permission after you have started the research study: We will stop collecting new information; We will use the information collected BEFORE you cancelled your authorization. This information may already have been used or shared with others, or we may need it to complete and protect the validity of the research; and Staff may need to follow-up with you if there is a medical reason to do so.
We expect our study to take 1 year. After the study is done, we will no longer use or share your health information. Your health information may be stored for 3 years and then destroyed.
9) *Contact Information: If you have questions about the study, you should call or email the investigator(s) Dr. Marlaine Smith at (561)-297-3206 or [email protected] or Carol Reive APRN or [email protected] If you have questions or concerns about your rights as a research participant, contact the Florida Atlantic University Division of Research at (561) 297-1383 or send an email to [email protected].
10) *Consent Statement: I have read or had read to me the information describing this study.
1366090-3 Consent HIPAA Authorization Template FAU/RI: Version 4.0 - 6/28/2018 3 Approved On: May 21, 2019
Institutional Expires On: Not Applicable Review Board
110
All my questions have been answered to my satisfaction. I am 18 years of age or older and freely consent to participate. I understand that I am free to withdraw from the study at any time, for any reason, without penalty. I have received a copy of this consent form.
I agree ____ I do not agree ___ be audiotaped/videotaped.
Printed Name of Participant:
______
Signature of Participant:______
Date: ______
Printed Name of Investigator: ______
Signature of Investigator: ______
Date: ______
1366090-3 Consent HIPAA Authorization Template FAU/RI: Version 4.0 - 6/28/2018 4 Approved On: May 21, 2019
Institutional Expires On: Not Applicable Review Board
111 Appendix J. Demographic Questionnaire
Participant ID______Date ______
1. Age______
2. Gender (check)Male (1) ______Female (2) ______
3. Ethnicity (check) _____ (1) African American
_____ (2) Asian American
_____ (3) Caucasian
_____ (4) Hispanic
_____ (5) Other
4. Income (check) _____ (1) Less than 20, 000
_____ (2) 20-50,000
_____ (3) 50-100,000
_____ (4) Over 100,000
5. Education (circle highest level completed)
1) High School 2) Trade School
3) Associate’s Degree 4) Bachelor’s Degree
5) Master’s Degree 6) PhD
6. Were you ever deployed for active duty? (circle) 1) Yes 2) No
For how long? (months)______# of tours______
How long since you have been discharged?______
112 7. Do you currently receive care for any mental health concerns such as anxiety,
depression, difficulty sleeping, problems concentrating, feelings of disconnection or
any other concerns?
(circle) 1) Yes 2) No
If Yes, what type of care? (Circle)
1) Primary Doctor
2) Mental health provider
3) Alternative therapy (yoga, mindfulness, meditation etc.)
4) Other (state)______
8. Are you currently on medication to help with your mental health concerns? (circle)
1) Yes 2) No
(If yes list medication(s)______)
If yes, has any new medication been started or dosages of current medications changed in the past two months? (circle) 1) Yes 2) No
9. What is the reason(s) you decided to try equine-assisted therapy? (state)
113 Appendix K. Permission for Philadelphia Mindfulness Scale
Philadelphia Mindfulness Scale Version Attached: Full Test PsycTESTS Citation: Cardaciotto, L., Herbert, J. D., Forman, E. M., Moitra, E., & Farrow, V. (2008). Philadelphia Mindfulness Scale [Database record]. Retrieved from PsycTESTS. doi: http://dx.doi.org/10.1037/t20686-000 Instrument Type: Rating Scale Test Format: Items are rated on a 5-point Likert-type scale (1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = very often) according to the frequency each item was experienced over the past week. To obtain the Awareness subscale score, all odd items are totaled; higher scores reflect higher levels of awareness. To obtain the Acceptance subscale score, all even items are reverse scored and totaled; higher scores reflect higher levels of acceptance. Source: Cardaciotto, LeeAnn, Herbert, James D., Forman, Evan M., Moitra, Ethan, & Farrow, Victoria. (2008). The assessment of present-moment awareness and acceptance: The Philadelphia Mindfulness Scale. Assessment, Vol 15(2), 204-223. doi: 10.1177/1073191107311467, © 2008 by SAGE Publications. Reproduced by Permission of SAGE Publications. Permissions: Test content may be reproduced and used for non-commercial research and educational purposes without seeking written permission. Distribution must be controlled, meaning only to the participants engaged in the research or enrolled in the educational activity. Any other type of reproduction or distribution of test content is not authorized without written permission from the author and publisher. Always include a credit line that contains the source citation and copyright owner when writing about or using any test
114 Appendix L. Permissions for Measurement Use Self Reflection and Insight Scale
C REIVE
On Monday, October 22, 2018 10:55 PM, Anthony Grant
Dear Carol Good to hear from you. Please feel free to use the SRIS. I’m attaching some papers that might be of interest. Regards Tony
PROFESSOR ANTHONY M GRANT PhD C.Psychol. MAPS Director: Coaching Psychology Unit | School of Psychology THE UNIVERSITY OF SYDNEY
Room 424, First Floor Brennan Building (A18) The University of Sydney | NSW | 2006 | Australia T +61 2 9351 6792 | M 0413 747 493 E [email protected] | W www.psych.usyd.edu.au/coach CRICOS 000268 This email plus any attachments to it are confidential. Any unauthorised use is strictly prohibited. If you receive this email in error, please delete it and any attachments. Please think of our environment and only print this e-mail if necessary
115 Appendix M. Permission for Warwick-Edinburgh Mental Well-Being Scale
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