"The Horses Know What I am Thinking"
For the last year I have had the pleasure of working with a very challenging population- people who have developed psychosis and or a thought disorder. Most clients were young adults (19-29) who were in the prodrome stage of a psychosis. Most of the clients had already had one or more psychotic breaks, and had been hospitalized several times prior to coming to the residential facility. Most clients were delusional or had internal stimuli, were diagnosed Schizophreniform or Paranoid Schizophrenic. Some were diagnosed Bipolar with severe mania and psychotic features, or Depressed with psychotic features. We had only a few Axis II, and about a half of the clients at the residential had dual diagnosis issues.

I think I am one very few, if not the first, to use the EAGALA model with this chronic population. I thought it would be of value to summarize and share what I learned from my experiences this past year with other EAGALA teams who may have this type of a referral, or a desire to work with this population.

This past year I developed an equine therapy program on a 65 acre facility with 20 + animals. We had four therapy horses, seven goats, three baby stallions, two cats and various rescue animals that leased our pastures including a herd of four mini's and two sets of donkey siblings. I facilitated 155 EAGALA sessions (over 300 direct contact hours). We offered equine therapy three times a week for the first part of the year, and then in the summer increased it to five days a week. We tried to keep our routine as consistent as possible. The owner of this residential was not supportive of any type of pre / post testing or symptom assessment, so I was unable to capture quantitative information this year.

What is Schizophrenia?
Schizophrenia is an illness that was identified in 1880. In the last 131 years, there has been significant progress in understanding this disease. In today's field of psychiatry and psychology, we have many more tools such as psychopharmacology and different types of therapeutic interventions that can be used to help those with this life-long disease. Schizophrenia is genetic, it runs in families. For people who develop this disease, they have gotten it through no fault of their own. There is a myth; people think that if you do enough drugs you can make yourself "crazy". Sure, if you do enough drugs, you will be out of your mind literally and not present. You will kill neuropathways and not be able to access information and memory like you used to, and you could at that point of being high, be legally incapable of making decisions and be considered "crazy", however, it is my understanding that there are no specific illegal or prescription drugs that can cause Schizophrenia, just some symptoms that would cause a Substance Induced psychosis.

Those with a genetic predisposition to developing the disease may begin to self medicate in their teenage years. The drugs will induce a psychotic state earlier than expected, but due to the genetics of the person, the break would eventually happen. Once a psychotic break happens, most parents think it is a Substance Induced psychosis and it will wear off in 90 days (like a drug rehab), and their son or daughter can return to their life "like they used to". Sadly, this is not the case. There is a great deal of grief and loss work that needs to be done with these families as well as educational support about the illness.

There are stages to the prodrome of Schizophrenia. Clinicians can interview clients to determine the stages based on self report symptom assessment of functioning.

There are "positive" and "negative" symptoms of Schizophrenia. Positive symptoms occur when there is an excess or distortion of normal functions. For example: delusions (perceptual misinterpretations), hallucinations (seeing or hearing things that don't exist), disorganized behaviors, and thought disorders (difficulty speaking and organizing thoughts). I describe this as "the freeway does not have an off ramp" when you have conversations. Negative symptoms can occur before positive symptoms. Negative symptoms are a diminishment or absence of normal functioning. For example- lack of emotion, loss of interest in everyday activities, reduced ability to plan and carry out activities, social withdrawal, and loss of motivation.

A "New" Kind of Resistance
Most of the clients we worked with went through a stage where they did not see the changes in their behaviors or accept they have an illness. It was pretty common that they had been living with voices (internal stimuli), delusions or thought disordered thinking for over a year prior to their first break. The term when someone cannot recognize their illness is called Anosognosia. Sixty percent of all Schizophrenics have this symptom.

Our clients believed that their symptoms were caused by other things, and they always had lengthy explanations about these sources. I always had to remember that as frustrating as these conversations were (and you had to mindful to not engage in a power struggle) that it was only another symptom of the illness. Anosognosia is different than just regular denial because it lasts for a longer period of time and the beliefs do not change, even when presented with overwhelming evidence to the person that their belief is false. The team countered this by building solid, trusting relationships with each client. It took time - weeks, lots of conversations, engaging and reengaging with clients who did not want to make a connection. Motivating this population has been one of the hardest things I have ever done!

Sessions
The bad news - our clients were disorganized, could not concentrate, were not creative, were rigid, literal thinkers, who had extremely poor problem solving skills, struggled to remember that they had peers in the ring that they could talk to or work with, were mistrustful, and at the beginning of our working together, was often detached and un-empathetic towards the animals. Interestingly, we observed that they could not interpret environmental stimuli and would put themselves in harm's way (i.e. they would move to stand in front of a horse running in a field or move to stand behind a horse that had just exploded and kicked and was unsettled). Over and over, we saw that this population was unaware for their own personal safety. They simply could not read any non verbal body language from the animals or apply environmental information to their person. Common sense, that ability to read, interpret and decisively act accordingly in situations. It was at times a challenge to observe sessions, and it taught me a great deal about my counter transference. My tendency was to jump in and "save" our clients or fix a problem they didn't see a solution for, but that is not the nature of the EAGALA model or experiential therapy. The goal is for clients have to have the repeated experiences and learn in their own time frame, at their own ability levels.

The good news- our clients learned to form relationships with the horses and the other animals in their own ways. Clients enjoyed grooming and really opened up verbally after about working with the horses and other animals after 35 - 40 days. They began to talk to the animals - greet them, tell them about their day, ask staff how they were on days they didn't come to the barn. They began to care if they got a scratch while out in the pasture.

I focused on non verbal learning challenges weekly through games and session challenges. We were always looking for teachable moments. We also used Linda Tellington's Touch series for further non verbal communication with the animals. They really enjoyed sessions that used their tactile sensory capabilities.

Horses
Our horses were great. They were normal horses, some days they were grumpy and some days flighty, but each one had their unique ways of trying to get through to our clients. They were patient and seemed to understand when the clients were confused and had no idea of what to ask or do with the horse. We had a few sessions where the horse literally walked in the box, through something created and literally showed them what the accomplished task was!

There is a paint gelding named Cherokee who would nip at clients when they had a great deal of internal stimuli going on. I would always watch our horses reactions and interactions with our clients each session, but more so when I was not sure of where the clients were at in their heads, even if they were present in body, because the horses always knew.

Observations
We kept the routine at the barn as simple as possible, we always met before a session in our session group, checked in with everyone to see how they were doing, made sure all electronics were off, shared the challenge and discussed any questions they might have (expectations, organization). We reviewed safety rules and helped plan who would do what and bring what horse to the ring (safety and supervision). After the session, the group usually divided up to do chores or groom animals. I am happy to report that we only had a few toes stepped on through the year and not one major injury to client or animals. Time management was a huge issue for our clients and we would prompt clients to be mindful of what they wanted or needed to get done and how much time was left to be at the barn (30 minutes to departure, 15 minutes to departure).

Often our clients with the most internal stimuli would present themselves in the following manner - they didn't "play", they were not goofy, spontaneous. They did not self initiate. They would laugh but it would depend on the situation. I coined the phrase "screensaver mode" when clients seemed to be physically present, but not interacting with the things going on in the ring. We noticed early in our work with them that when they completed a task, they did not recognize task completion and they would not verbally say anything to the team to acknowledge it being "done". They would just stop wherever they were in the ring, and go into "screensaver mode", kind of hang out. As a team we left them alone to find their way and they would come over to us in about 5-10-15 minutes. They were very unsure if they had completed a task or what to do next. We also found it interesting when a client was attempting to manipulate and use their psychosis (the voices are too loud) to avoid trying a challenge/session.

Teamwork was a huge challenge for this population. Our clients did not want to work with their peers. We determined that running a group with no more than four clients was the best. We observed our clients avoiding problem solving or discussing alternatives. Someone from a group would always seek a therapist or a staff close to the ring and try to solicit answers or directives as to what to do. While we facilitated the sessions, we did a great deal of walking away, smiling and shoulder shrugging.

Cognitive distortions were exaggerated when displayed with the psychotic clients tenfold. We never saw overt anger or aggressiveness. Only once did a loud verbal challenge happen when a client wanted to smoke and we would not allow it. Never did any of the clients do anything aggressive to the team or the animals. They avoided conflict.

Our clients responded when we gave them some structure to the session. The sessions that did not go well were the open ended sessions where you would ask clients to move a horse around the pasture or into the four corners. We used colorful props when we could. We used blindfolds once they were comfortable with the horses, tied up legs, even used bailing twine to tie them together to get them to work together! That was a powerful theme, giving them another disability.

Our clients struggled with focus and memory. They couldn't remember the challenges so often I wrote it on a white board that was against the fence so they could refer to it.

Implicit vs. Explicit Memory
I wanted to say a little about Schizophrenia and memory. One session that went terrible for our team was the game of H-O-R-S-E. The clients could not keep the different activities in order that their peers were doing and they could not mimic/duplicate the tasks. I felt so bad that session, I felt like I had set them up to fail. The team observed over the year clients with psychosis could not watch a peer do one or two tasks such as picking up the tail and then rubbing their hand down the horse's leg, see the task and then apply it to themselves with the horse when it was their turn. The clients however did try different things such as blinking their eye lashes, clapping or jumping around a horse when they could not remember what the peer before them had done. So, they tried in their own way, but ordering was not a skill they could do well with their illness.
Implicit learning means that learning occurs unconsciously, without awareness (non-rule based). Often it is procedural (for example- learning to swim or ride a bike), whereas explicit learning is conscious (rule-based) and is information based. The brain is more active when using explicit memory and it is here that schizophrenic's struggle applying rules and ordering. The team saw examples of these struggles time and time again in our sessions so our experiences support many published research findings.

Reflections
My experience this year taught me that the EAGALA model is once again a solid model for treatment. Although I do not have the quantitative outcome measures to prove my conclusions, I did see the learning, the improved social, emotional and behavioral functioning of the clients that attended our equine therapy challenges.

As I mentioned earlier, about 45 days into running regular sessions, we began to see clients internalize the process. Prior to this timeline, it felt like each session was a first. At the 60 day point they began to make declarative statements to the success or failure of the challenge. Clients began to check in as a group and really discuss the session. At the 90 - 100 day period I began to see the clients who participated the most began to slightly offer suggestions to their peers for solving challenges and once or twice they asked other peers why they did or did not do something. The more they participated the more they related to the horse as a part of the team.

I am very thankful to have had this experience developing this program. I enjoyed working as an EAGALA mental health clinician and as an EAGALA equine specialist when the primary therapist was present for sessions. I highly encourage any EAGALA team out there to consider working with this population in their community.