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By: Molly DePrekel MA LP and Kay Neznik LICSW
This article is copyrighted and posted with permission of the authors.
As a licensed clinical psychologist and social worker working with clients who are survivors of trauma, we believe therapeutic interactions with animals have value in their healing process. According to Dr. Bruce Perry[1], “Beginning the recovery process for relational neglect can start with animals.” As a part of this recovery process, our equine-facilitated psychotherapy (EFP) sessions provide clients with a safe environment to begin to deal with the traumatic events, or series of events, that have shaken their ability to function, and/or feel by creating a negative belief systems about their self, others and the world.
Our equine partners help bring our clients, usually young women who have experienced sexual trauma, out of their shells. They motivate them to talk, while at the same time soothing them. Adolescents, in particular, often find it awkward to connect with group facilitators. However, in the process of developing a relationship with an equine partner, an adolescent is often better able to move beyond initial discomfort and build trusting relationships. Clients grow in confidence and gain a more positive sense of power in a world where they have historically felt powerless.
In our work, we are always cognizant of how the human-animal connection acts as a catalyst for communication, insight and change. Through their body language, equines give immediate feedback to clients on how they are functioning and handling their feelings. This feedback helps clients learn how pay better attention to the connection between their body and mind so they can inhabit their body in a new way. Processing this feedback also offers clients insights which assist them in a more productive and healthier expression of their emotions.
In one session, for instance, a group member grew quite frustrated when she could not get her equine to follow her without a lead. She became visibly agitated, so we asked her to take a minute and relax before she tried again. As soon as she let out a breath of air and relaxed her body, the equine came up to her and nuzzled her. This gave her immediate feedback on how she processes tension in her body when she gets stressed. Because the equine responded positively to her physical calming “out breath” response, the client was able to reorganize what she did. This gave her and the group a different approach to talk about how she deals with daily frustration and ways that might work better for her.
Training & Preparation
In working with equine facilitated group therapy, is important that staff have training and experience in therapeutically-relevant skills for working with trauma and that sessions remain safe for all parties. Because therapy may trigger intense stressful or traumatic reactions from the client, the therapist must be able to understand the client’s process and help manage feelings as they surface.
Sessions should also include an equine specialist to monitor the animal’s well-being during sessions. For individual sessions, the clinician and equine specialist may be dually trained and function in both roles; however, it is critical to have two or more staff members present with groups. The staff-to-client ratio in a group is based on the number of clients and equines, as well as the expertise and cross-training of the facilitators.
A main component for successful EFP group sessions is an appropriate facility. It is recommended that the location include a private area conducive to safe expression of potentially strong emotions and check-in spaces. There should be room to meet in a circle and for other experiential activities. It is also imperative that the facility has liability insurance, the facilitators have malpractice/ liability insurance and clients complete appropriate paperwork. This paperwork includes a hold-harmless agreement, an emergency consent form to obtain medical treatment, a release of information form and other relevant HIPPA forms.
It is recommended that facilitators work either with trauma survivors or offenders exclusively until they become highly skilled with both populations. In preparing for EFP group work, it is important for facilitators to:
Marketing & Billing
Our experience has taught us that marketing is most efficiently done through word of mouth and by sending flyers to other clinicians, treatment programs, schools and families. Many times, individual clinical therapists will refer clients, and often the clinician co-facilitating this group has appropriate referrals that are ready for a group process.
Work closely with out-patient treatment programs for sexual abuse; local child protection, county probation and human services groups; social workers; and other referral sources to create a network. Prepare flyers to send and in marketing meetings, and be ready to talk about your group’s goals, content and the potential client benefits.
Decide if your services will be insurance reimbursable, private pay, or both. Will they be funded by the county or a grant? Or will a center raise funds to fully or partially cover clients’ costs? Note that insurance companies and/or other funders may require that one or both of the facilitators be licensed to practice mental health.
Group Rules
In beginning group work, we first go over four, pre-established ground rules adapted from The Four Agreements by Don Miguel Ruiz[2]. These include:
These ground rules are important because they give clients four simple, yet profound, principles to strive for, and they also help define boundaries within the group. We ask group members to continue to put these agreements into practice throughout the group process, which demonstrates how they could practice these ground rules in other areas of their life.
Body Awareness Techniques
Facilitators can engage clients in this type of work in many ways. Our treatment involves not only understanding how trauma plays out in cognitive beliefs, but also how trauma is carried in the body. We believe that being in motion, practicing mindfulness and breathing and understanding how our bodies can carry trauma is critical in resolving trauma.
Our therapy incorporates somatic (body) awareness, some sensorimotor psychotherapy techniques based on the work of Pat Ogden and the Sensorimotor Psychotherapy Institute[3] and Tellington Ttouch[4] and TTEAM[4] exercises.
“[Ttouch] is a system of gentle circular Ttouches, lifts and slides that works at the cellular level to activate the body’s potential[4].” We incorporate it as a way to teach clients relaxation and self-soothing skills and connect better with the animals. Not only does it benefit equines in EFP, but it can create deeper rapport between the equine and client. This relational connection develops through an understanding of each other and facilitates more effective communication. We always stress to clients that Ttouch should be done only on the equines or themselves, and not on each other.
TTEAM[3] ground exercises can also be beneficial. “Using a variety of obstacles and ground poles, TTEAM exercises result in self-control, focus, self-confidence, cooperation, balance and coordination.” (Ttouch website)
During and after the sessions, we give clients feedback about how their behavior, individually and as a team, impacts the equine’s behavior and willingness to do what is asked. This can be a powerful technique as it is observable behavior occurring in the moment. We have found this works better than traditional talk therapy group in an office setting. Clients seem to listen better and are able to incorporate more of the feedback with less resistance if they can have a hands-on experience and be in motion in their body during sessions.
Expressive Art Techniques
For some groups, we choose to integrate expressive arts to work on the expression of feelings and issues that surround these feelings. This also provides a rainy day option during inclement weather. Examples include:
Working in the Moment
In our work with clients, topics are introduced in a meaningful manner. We use the idea of incrementally “increased perceived risk” not only with our equine activities but also with the verbal sharing and discussions. As comfort is established, we increase the expectation for clients to share more about themselves and their trauma stories. It is important as the client shares traumatic past issues for the therapist to help them understand the ways they have survived and thrived. Clients can then begin to state competency-based reframes of survival. For example when a client is asked to take a safe and perceived risk with the equine; it may be to ride the equine with their arms extended outward or to close their eyes while on the equine, or lead an equine through a challenge course. The client is asked what they need to do to complete this task to feel safe. The client may ask for side walkers or a staff to be with them. When they have completed the exercise the staff and at times the group members comment on their ability. “Wow, you really took a risk but you were able to keep yourself safe and ask for help, while working with an equine. This is quite a success. If you can do that with this large animal how can you use these skills in your everyday life?” Without directly saying it the client is able to see how they shared power with an animal and that asking for help met his/her needs directly. There are risks that can be taken in your life and still be in control and safe.
At the same time, it is important to understand that group therapy is dynamic and fluid. As the group process progresses, it is important, at times, to be flexible and move away from the planned activities and deal with immediate topics and issues that arise. (i.e., re-victimization, sexual harassment at school/work, sexual acting out). These “in-the-moment” group shifts can create powerful metaphors for the client’s process as a direct result of their work with the equines. Opportunities for growth and therapeutic transformation occur in every moment. Therefore, group facilitators need to be able to shift focus quickly and move into new reframes that will benefit the clients and sometimes the equines.
Closure
Working with this population can be both very stressful and rewarding. The clients develop very close relationships with the equines and with staff. Ending the group can be a very painful process for some of the clients. As the group progresses, some members may continue in the group and others may leave. As part of the therapy, we work on closure rituals to allow members to learn appropriate ways to say goodbye and, if the group is offered again, the ability to make decisions regarding continuing or terminating the treatment process. This can empower clients, giving them a sense of control over their lives and offer them another chance to have a choice, or ‘say’, in their lives.
Again we need to stress the importance of having staff that are clinically skilled in the areas of sexual abuse and perpetration. Clinician can never predict what will be revealed in group. Therefore, they must be able to handle the issues and provide a safe environment for the clients and equines so that this experience is positive and provides growth for the clients, rather than more trauma. For further information please contact us at md@phoenixprocessconsultants.org.
References:
[1] Perry, B. D., MD, PhD., (2006). Applying Principles of Neurodevelopment to Clinical Work with Maltreated and Traumatized Children. In N. Boyd Webb, (Eds.), Working with Traumatized Youth in Child Welfare (pg. 38). New York, NY.
[2] Ruiz, M. A. (1997). The Four Agreements: A Practical Guide to Personal Freedom, Hay House, Inc.
[3] Sensorimotor Psychotherapy, www.sensorimotorpsychotherapy.org.
[4] Ttouch, www.ttouch.com. Pictures used with permission