Promoting mental health in military veterans.
Methodology and evaluation tools in a pilot study involving an Equine-Assisted Intervention

Barbara Collacchi1*, Chiara Ciacchella1*, Marta Borgi1, Alessandra D’Onofrio2, Giorgio Fanelli3, Sonia Merolla4, Marta Riccio4, Paolo Mezzanotte5, Stefania Cerino6*, Francesca Cirulli1*

1Centre for Behavioural Sciences and Mental Health, Istituto Superiore di Sanità, Rome, Italy; 2Sapienza University of Rome, Italy; 3Psychiatry and Psychology Office, Italian Army General Staff, Rome, Italy; 4Italian Defence Veterans Centre, Rome, Italy; 58th “Lancieri di Montebello” Regiment, Rome, Italy; 6Equestrian Rehabilitation Centre “Girolamo de Marco” onlus (CRE), Rome, Italy.

*These authors contributed equally to this work.

Summary. Aims. Military veterans exposed to stressful or traumatic events may experience adjustment difficulties in the post-deployment period, developing a high risk of mental health-related issues. Promising complementary practices such as Equine-Assisted Therapy (EAT) are now widely used, although standardized protocols are missing. The present study aimed to develop an EAT standardized intervention. Material and methods. A total of 16 veterans were enrolled for the study (11 veterans for the EAT group and 5 veterans for the control group). The EAT lasted 9 months and both a quantitative (State-Trait Anxiety Inventory Scale; Hamilton Depression Rating Scale; Symptom Checklist 90 Scale; Warwick Edinburgh Mental Well-Being Scale) and a qualitative evaluation (observations and guided discussions) were carried out. Results. While standardized scales did not show significant results, the qualitative evaluation revealed improvements in participants’ attitudes and behaviors (autonomy, self-confidence, sense of agency), coping strategies, management of anxiety and the gradual overcoming of interpersonal difficulties. Discussion and Conclusion. The EAT intervention was particularly appreciated with a high adherence. The empathetic relationship with the horse allowed the participants to establish positive relationships within the group. A self-awareness process emerged during guided discussions and the EAT intervention allowed veterans to rediscover a new group identity. The intervention methodology proved feasible and sustainable although with important limitations due to the low number of participants, the lack of female veterans and the distance between the equestrian rehabilitation centre and the participant’s residence. The present study highlights the potential of the human-horse relationship in managing adjustment difficulties, consolidating coping strategies and developing veterans’ interpersonal skills.

Key words. Equine-assisted interventions; Adjustment difficulties; Stress management; One-health; Veterans.

Promozione della salute mentale nei veterani dell’esercito. Metodologia e strumenti di valutazione in uno studio pilota che prevede un intervento assistito con il cavallo.

Riassunto. Scopo. I veterani dell’esercito sono spesso esposti a eventi traumatici con conseguenti difficoltà di adattamento e un aumento del rischio di sviluppare problematiche di salute mentale. La terapia assistita con il cavallo viene ampiamente utilizzata allo scopo di attenuare gli effetti dell’esposizione a stress o trauma. Questo studio ha avuto lo scopo di sviluppare un intervento standardizzato e riproducibile da adottare con questa popolazione vulnerabile. Materiali e metodi. Sono stati arruolati 16 veterani (11 nel gruppo di terapia con il cavallo e 5 nel gruppo di controllo). L’intervento è durato 9 mesi, durante i quali è stato effettuato un monitoraggio e la valutazione degli esiti sia quantitativa (State-Trait Anxiety Inventory Scale; Hamilton Depression Rating Scale; Symptom Checklist 90 Scale; Warwick Edinburgh Mental Well-Being Scale) che qualitativa (osservazioni e discussioni guidate). Risultati. Mentre le scale standardizzate non hanno dato risultati significativi, la valutazione qualitativa ha mostrato miglioramenti nelle attitudini e nei comportamenti dei partecipanti (autonomia, fiducia in se stessi, sense of agency), nelle strategie di coping, nella gestione dell’ansia e nel superamento delle difficoltà interpersonali. Discussione e conclusioni. L’intervento è stato particolarmente apprezzato con un’elevata adesione. Il rapporto empatico con il cavallo ha permesso ai veterani di stabilire relazioni positive con il gruppo. Durante le discussioni guidate è emerso un processo di autoconsapevolezza e la riscoperta di una nuova identità di gruppo. La metodologia di intervento si è rivelata fattibile anche se con importanti limitazioni (basso numero di partecipanti, disparità di genere e difficoltà logistiche). Il presente studio evidenzia il potenziale della relazione uomo-cavallo nella gestione delle difficoltà di adattamento, nel consolidamento delle strategie di coping e nello sviluppo delle capacità interpersonali dei veterani.

Parole chiave. Difficoltà d’adattamento, gestione dello stress, interventi assistiti con il cavallo, salute globale, veterani.

Introduction

Soldiers deployed in peacekeeping operations – similarly to combat personnel – are exposed to acute and/or catastrophic events and chronic stressors1,2. Although the primary goal of these military operations is to maintain and build peace, soldiers may have to face and manage local conflicts, witness atrocities and are often exposed to dangers such as armed attacks, land mines, endemic diseases or harmful agents that put soldiers’ lives and limbs at serious risk2,3. Sleep disturbances, emotional regulation difficulties, and psychological symptoms (e.g., depression and anxiety) are common consequences of exposure to stressful or traumatic events during deployment1-4.

The effects of experiencing such traumatic events may become manifest only at the end of the operation5. During the post-deployment period, peacekeeping veterans can experience adjustment difficulties that can include the management of disabling injuries, guilt-related problems, as well as interpersonal difficulties and nostalgia for comrades-in-arms2,3. This situation can disrupt veterans’ identity and sense of self and can lead to what can be considered as a “broken soldier”, hampering the ability to continue with their previous life or to be redeployed in the army5. Even in the absence of a fully diagnosed psychopathology, there is considerable evidence that veterans are at high risk of developing mental health-related issues. Rapid reintegration can further exacerbate psychological issues by not giving the veteran adequate time to adjust to the mismatch between fantasies of homecoming and reality3.

In this scenario, it may be difficult for veterans looking for and accessing psychological support, due to the stigma associated with seeking psychiatric help, and the prejudice that this may damage their careers4,6. Even when help is actively sought, traditional therapies or psychological support may not be fully effective for the type of behavioral problems characterizing these individuals7.

Recently, non-pharmacological complementary and alternative medicine practices have been gaining attention for their potential healing role8. Among these, Equine-Assisted Therapy (EAT), which includes mounted riding or ground activities, such as grooming and stable management, has been shown to exert positive effects on psychological, socio-emotional, and physical domains, without the stigma of traditional psychological support9-12. Many studies indicate that horses show high levels of emotional intelligence and can perceive human emotional states without the need for verbal language13,14. EATs have been increasingly used for veterans, especially following traumatic experiences15,16. Trauma consequences often include social isolation and impaired capacity for human physical contact but the human-horse bond that is created during this kind of intervention could provide direct social support through nonjudgmental relationships17. Trials conducted with veterans exposed to traumatic events have shown improvements in patience, trust, relaxation, learned strategies to deal with stressful situations, PTSD symptoms, tolerability to treatment and low dropout rate16,18-20. A recent systematic review on EAT for veterans underlines the poor description of the intervention and the great diversity in outcome measurement, emphasizing the need for standardized procedures and tools that may allow evaluating the effectiveness of this type of intervention15.

In this pilot study, we have developed an EAT standardized intervention to promote the mental health of military veterans, with the main aim of improving coping strategies, psychological symptoms resulting from adjustment difficulties, and interpersonal skills, with the challenge to foster a reworking of values and representations related to one’s military identity. Results indicate the need for implementing studies with larger samples to substantiate the findings and the adoption of a quantitative assessment approach more focused on the psychological constructs characterising the population examined and the relational dimensions elicited by bonding with the horse.

Methods

Ethical Statement

All methods and procedures of this study were approved by the Ethics Committee of the Policlinico Militare di Roma “Celio” (EC protocol number 2022u/04/a-31/12/22). The study was conducted following the Declaration of Helsinki of World Medical Association (1964).

Participants

The selection of participants belonging to different regions of Italy was carried out by certified psychologists from the Italian Defence Veterans Centre in Rome. Inclusion criteria were the following: being veterans deployed abroad in peacekeeping missions and being involved in traumatic events. Exclusion criteria were allergy and/or fear of horses. A neuromotor assessment was done by a physiotherapist who excluded individuals not suitable for riding. The total sample included 16 veterans (all men from different regions of Italy), divided into two groups: 11 participants were assigned to the group involved in EAT sessions (EAT group), and 5 participants were assigned to the control group (CTRL), who were not involved in horse-related activities. Participants (age 38-60 years) suffered from psychological distress or physical impairment because of experiencing traumatic events during the military operation. During the post-deployment period, 5/16 participants were reintegrated into a civilian role for the Ministry of Defence, while 11/16 participants maintained military roles.

Among the 11 participants of the EAT group, two reported previous experiences with horses (table 1).




Equine-assisted therapy team

The EAT team consisted of qualified professionals in mental health and equine-assisted intervention (EAI), as required by the Italian Guidelines for Animal-Assisted Interventions (AAI)21, and was composed of a project manager, a psychologist, horse handlers, a veterinarian, and the horses. All the professionals were regularly registered on the Digital Pet portal (National Reference Centre for Assisted Interventions with Animals of the Istituto Zooprofilattico Sperimentale delle Venezie - IZSVe). The team was enrolled at the Equestrian Rehabilitation Centre “Girolamo de Marco” onlus (CRE) located at the Military Equestrian Centre of the 8th “Lancieri di Montebello” Regiment in Rome. The project manager was a psychotherapist with psychoanalytic training, in charge of planning the horse-related activities and monitoring the progression of the EAT intervention. The psychologist took care of the participants during the EAT sessions, monitoring their safety and managing their interactions with horses together with the horse handlers, who were responsible for managing the horses during the sessions, in addition to monitoring their well-being. The veterinarian oversaw the selection and eligibility evaluation of the horses, based on health and behavioral characteristics, defined by the Italian National Guidelines on AAI21,22. In addition, the veterinarian regularly monitored the health status of the horses during the study, considering health care, living conditions, work schedules and equipment requirements. A total of 11 horses were selected from the horses of the 8th “Lancieri di Montebello” Regiment for the current study (table 2).




They were all between 11 and 24 years old, 5 horses were geldings and 6 were mares. They were of different breeds; no foals were chosen. The horses were of medium size, in a good state of health, and suitable for EAI as far as morphology, biomechanics and behavior are concerned22.

Procedures

Settings and EAT sessions

The EAT intervention was carried out at the CRE and lasted 9 months (Oct 2022-Jun 2023) for a total of 35 sessions (once a week). Each session lasted 90 minutes and followed a standardized procedure (table 3). Each participant was assigned a specific horse, which remained the same throughout the intervention.




The sessions began with the grooming activity of the horse. This activity is important as a first approach to the horse and is aimed at learning: 1) basic information about the horse’s welfare, morphology and behavior; 2) the main safety rules; 3) proper communication (eye, tactile and vocal contact) and handling of the horse from the ground; and 4) techniques and tools for cleaning and saddling. This initial activity is also essential to foster the establishment of a trusting relationship between the participants and the horse. After the acquisition of these basic notions, the participants were allowed to get on the horse. The riding activities included learning to independently conduct the horse at walk within the riding arena, and how to perform simple riding figures (e.g., circles, volte, half-volte, slalom, serpentine). The riding activity took place in a covered arena, but as equestrian skills progressed, sessions were also held in other larger outdoor arenas by crossing grassy areas characterized by differences in altitude and an artificial pond. This type of environment presented greater challenges than the covered arena and required participants’ increasingly autonomous management of the horse, as well as the ability to deal with complex situations. These activities promote a sense of agency, the management of anxiety, the development of coping strategies, and strengthen the relationship among the participant, the horse, and the intervention team. The psychologist and horse handlers play an important mediating role in fostering interaction between the participant and the horse. Once the riding activities were over, the participants groomed the horses and took them to the stables.

All sessions were conducted in groups and only in two cases were the horse-related activities adapted according to the specific needs of two participants, a veteran in a wheelchair and another with blindness. Both the participants were supported by two horse handlers during the grooming activities. In addition, an individual activity with the horse led by hand was specifically planned for the participant in a wheelchair: he managed the horse by hand carrying out training exercises, such as slaloming between cones, performing circles and serpentines, first supported by the horse handlers and then independently. Another type of work was also planned for the blind participant who, initially, worked individually and rode the horse with the assistance of a handler, and later rode it independently with the help of the other participants. More in depth, the blind veterans followed the sounds vocalized by the other participants who were positioned at defined points of the covered arena; this allowed him to get oriented autonomously on the horseback without the support of the handler. Mutual support was a key element of the intervention, designed to promote improvement in participants’ interpersonal skills and to work on group identity. In addition, the EAT included monthly discussions (lasting 1 hour) led by the psychotherapist to explore through collective reflections the thoughts and feelings related to the EAT experience and to foster a reworking of representations related to one’s identity.

At the end of the 35 sessions, all EAT group participants joined military personnel serving at the Regiment in an equestrian event. On a symbolic level, participation in this event was planned to foster a reintegration of one’s identity as a member of the army.

Measures

Quantitative evaluation

Standardized psychological scales were administered by psychologists of the Italian Defence Veterans Centre and all measurements were taken at the beginning (before the first session - T0), in the middle (16th session - T1) and at the end of the project (after the 35th session - T2).

The State-Trait Anxiety Inventory scale (STAI) is a widely used scale for assessing anxiety symptoms23 consisting of 40 self-report items on a 4-point Likert scale. The STAI measures two types of anxiety – state anxiety and trait anxiety. Higher scores are positively correlated with higher levels of anxiety.

The Hamilton Depression Rating Scale (HAM-D) for the evaluation of depressive symptoms24 contains 17 items scored either on a 3-point or 5-point Likert-type scale. Higher scores are associated with higher levels of depression.

The Symptom Checklist 90 scale (SCL-90) for the assessment of symptoms related to mental distress25 is a self-report questionnaire consisting of 90 items rated on a five-point Likert scale assessing 10 symptom dimensions (i.e., Somatization, Obsession-Compulsion, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, Psychoticism and Sleep Disorder). A global score index was included, and its higher score is positively associated with higher symptomatology.

The Warwick Edinburgh Mental Well-Being Scale (WEMWBS) is a self-administered scale for assessing psychophysical well-being26. The 14 items are scored on a 5-point Likert-type scale and higher scores are associated with higher levels of mental well-being.

Qualitative evaluation

In addition to the administration of the standardized scales, a qualitative evaluation was conducted at the three assessment time points (T0, T1 and T2) by the psychotherapist in charge of the intervention. This evaluation consisted of: 1) observing participants’ attitudes, behaviors, and emotionality during the EAT sessions, as well as their relationship with the horses and the team; 2) analyzing themes that emerged in guided discussions with participants.

Overall, this qualitative evaluation assessed individual levels of adherence and satisfaction with the intervention and revealed important psychological dimensions related to participants’ needs.

Statistical analysis

All data were collected in a database and subsequently evaluated and interpreted in collaboration with researchers at the Centre for Behavioral Sciences and Mental Health at the Istituto Superiore di Sanità, Rome, Italy.

On data from standardized psychological scales, Mann-Whitney non-parametric statistical test was performed to evaluate group differences (EAT vs. CTRL). Outcome measures were the changes observed between final scores and baseline scores (T2-T0) and between intermediate scores and baseline scores (T1-T0).

Results

Among the 11 participants enrolled in the EAT, 4 never started the intervention for logistic difficulties and one did not finish the EAT sessions as he was involved in paralympic competitions. Therefore, the data collected concerned only 6 participants in the EAT group and 5 in the control group. For the EAT group, adherence to the intervention was optimal and attendance of participants in EAT sessions was consistent.

Mann-Whitney tests revealed no significant differences between EAT and CTRL groups on T2-T0 changes observed, maybe due to the low number of participants. In particular, statistical significance was not reached for the global score index of the SCL-90 (U=16.000; p=0.876), STAI state anxiety subscale (U=12.000; p=0.432), HAM-D score (U=15.500; p=0.755) and WEMWBS score (U=9.500; p=0.202). No significant differences between EAT and CTRL groups on T1-T0 changes were observed. In particular, statistical significance was not reached for the global score index of the SCL-90 (U=11.500; p=0.343), STAI state anxiety subscale (U=16.000; p=0.876), HAM-D score (U=15.500; p=0.755) and WEMWBS score (U=11.500; p=0.343).

Observations performed by the psychotherapist revealed improvements in participants’ attitudes and behaviors during the sessions (autonomy, self-confidence, sense of agency), increased involvement in the activities, and the gradual overcoming of interpersonal difficulties, allowing them to establish positive relationships with companions and the intervention team. Improvements in the management of anxiety and complex situations also emerged during the sessions, resulting in an increase in coping strategies. In addition, they established a significant bond with their horses, characterized by trust, unconditional interest, and empathy. The “mirror” effect of this bonding fostered the acquisition of awareness on emotional and interpersonal difficulties. The guided discussions highlighted significant psychological themes elicited by the EAT intervention: the presence of a narcissistic wound related to the construction of a new professional identity emerged, with an evident gap between the Ego Ideal related to a heroic representation of the Self and the real conditions of post-deployment. Participants reported feelings of anger related to the new “limited” operational duties, no longer useful to the army and, therefore, not corresponding to their heroic image. Feelings of anger are also consequent to the strong need for social recognition and the knowledge that being honored for their military actions in high-risk war zones did not preserve them from physical injury and traumatic experiences. The EAT intervention organized in a group allowed them to gradually rediscover a new group identity and develop a new sense of belonging, based on mutual solidarity, loyalty and work for a common purpose.

Discussion

With the present pilot study, we report the standardized EAT intervention’ methodology used to promote the mental health of military veterans involved in peacekeeping operations and the evaluation tools used to detect psychological outcomes. Results indicate that the intervention showed good feasibility with a consistent adherence to the EAT sessions. While no effects were detected through standardized scales, the qualitative assessment carried out by the psychotherapist revealed improvements in participants’ coping strategies, attitudes and involvement in the sessions, as well as the gradual overcoming of interpersonal difficulties. Noteworthy, the collective reflections brought out relevant psychological themes elicited by the EAT intervention, fostering the reworking of representations related to military identity and discovering a new sense of belonging.

Overall, the intervention was well accepted and a high degree of adherence was found. The dropouts were due to the concomitance of the veteran’s other commitments (i.e., participation in Paralympic competitions) and logistic difficulties (i.e., coming from different regions of Italy). The equine-assisted intervention was particularly appreciated because it gave participants a chance to contact a natural environment and get involved with challenges they had never previously approached, allowing them to improve coping strategies and acquire new skills. EATs include both horse handling and riding, activities that require leadership and could benefit veterans by challenging themselves, regaining their autonomy and sense of agency in a safe and less stressful natural environment27. These results are in line with what has been reported in previous studies where participants felt satisfied with the EAT and wished it had lasted longer18,27,28. This seems particularly relevant considering the resistance toward traditional therapies and the high dropout rate among veterans18,27,28.

This innovative intervention also facilitated the therapeutic experience through the establishment of empathetic relationships with both the animals and the intervention team, as already reported in previous studies20,27,29. In the present study, it was observed that at the beginning of the intervention, veterans considered the horses a “working tool”, almost inanimate, and all the attention was focused on their performance. Only after the first three months of EAT sessions, as the veterans became more familiar with the riding activities, their attention gradually shifted to the horses, showing interest in their feeding habits, behaviors, and needs. Therefore, a non-verbal communicative channel was opened, and the initial curiosity evolved into an empathetic relationship with the animal. With the establishment of an empathetic relationship with the horse, the relationship with the intervention team and the other participants was also observed to improve. This effect was found in previous studies, indicating that the relationship with the therapeutic animal may promote improvements in interpersonal skills and support the establishment of the therapeutic alliance29. In fact, for traumatized people who have interpersonal difficulties, it may be easier to rely first on the therapeutic animal and then on the human being14,27,30.

The horse can also act as a “mirror” for its rider, reflecting his emotions and helping his self-consciousness and emotional awareness31. The self-awareness process emerged during collective reflections led by the psychotherapist in guided discussions, in which a gap between the veterans’ Ego Ideal and reality became evident. The Ego Ideal is considered as an ideal self-representation, which contains an identity project in embryo32,33 and in our group of veterans was related to the life choice of attending peacekeeping operations in high-risk war zones. According to what emerged in the guided reflections, those who chose this type of military duty project their Ego into an epic and heroic dimension that involves self-assertion, the pursuit of social recognition, courage, loyalty and helping others. The new veterans’ identity placed them in a “limited” operational space that does not reflect the Ego Ideal at the basis of their primary life choice, leading to a narcissistic wound; this is also strengthened by the growing awareness of limited heroic dimension: saving the lives of others and being recognized by honors did not preserve them from physical wounds and traumatic experiences. This ambivalence emerged strongly during the discussions, where feelings of anger and a decrease in self-esteem appeared. The ambivalent oscillation between the Ego Ideal and recognition of current reality generates adjustment difficulties, a trait that emerged in the whole group. Adjustment difficulties were also related to the loss of group identity, which identifies and qualifies members based on reciprocal solidarity and working for a common purpose34. In the military context, the need to build a “group” is well recognized and constitutes a stable identity basis35, where a sense of belonging and sharing is developed, which, in the case of veterans returning from war scenarios, is linked to experiences that are both traumatic and heroic. Living a group experience through the EAT intervention allowed veterans to rediscover a new group identity, no longer tied to traumatic experiences alone. Moreover, the involvement of both veterans and military personnel serving in the Regiment during the equestrian event, which occurred at the end of the study, promoted the symbolic reintegration of veterans into the army, exerting the competencies acquired during the EAT sessions.

The intervention methodology proposed in the present study proved feasible and sustainable due to the training of the staff involved in the team, the suitability of the horses employed, the adequate equestrian facilities and the activities proposed to veterans with increasing complexity. However, the study has some important limitations. The major critical issue was that the participants lived in Italian regions far from the equestrian rehabilitation Centre, which was in Rome, overall reducing the feasibility of participation in the intervention. Quantitative evaluation of the intervention did not provide meaningful results, owing to the small number of participants. Moreover, the present study did not include female participants, thus, the results are not representative of the whole veteran population. Future studies should include larger samples, gender balance, standardized instruments calibrated to the clinical characteristics of the selected sample and to the characteristics of EATs (e.g., instruments evaluating human-animal interactions/relationships), as well as considering long-term evaluations (follow-up) to verify if the benefits obtained through the intervention are still present after the sessions have ended. In addition, observations of the participants should be regularly carried out by psychotherapists, allowing for continuous monitoring of the study.

In conclusion, the present study highlights the potential of the human-horse relationship in managing adjustment difficulties, consolidating coping strategies and developing veterans’ interpersonal skills. The EAT intervention allowed the exploration of relevant psychological themes related to self-image and group identity, which underlines the psychological experience of veterans involved in traumatic experiences.

Conflict of interests: the authors have no conflict of interests to declare.

Funding: the study has been funded by the Italian Army General Staff.

Acknowledgements: the authors of this study would like to acknowledge all individuals and organizations that contributed to its realization, including: Italian Defence General Staff, Italian Army General Staff, Logistic Command of the Army - Veterinary Department, Italian Defence Veterans Centre, 8th “Lancieri di Montebello” Regiment for believing in the project and supporting it with great participation; Equestrian Rehabilitation Centre “Girolamo de Marco” onlus (CRE) together with all the operators for hosting the activities.

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