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Research Article
Published: 2024-11-28
https://doi.org/10.20935/MHealthWellB7424
1Department of Medical Science & Public Health, Bournemouth University, Poole, Dorset BH12 5BB, UK.
*email: ahemingway@bournemouth.ac.uk
ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 1 of 11
Equine-assisted learning reduces anxiety and increases
calmness and social skills in young people
Kezia Sullivan1, Ann Hemingway1,*
Academic Editor: Massimo Pasquini
Abstract
Since the COVID-19 pandemic, referrals to equine-assisted services (EAS) have increased, with a majority of referrals focusing on
social, mental, and emotional health, and anxiety frequently included as a referral reason. Early intervention could help prevent
ongoing health concerns from untreated anxiety disorders; this quantitative before and after measures study evaluates an equine-
assisted learning program involved in developing positive social and coping skills in participants with anxiety. Participants with anxiety
aged between 8 and 18 were referred to the program (n = 166), and referrers rated their skills on eight attributes at referral and at a 2-
month follow-up after the program, which consisted of 5 × 2 h sessions of learning natural horsemanship groundwork. Significant
improvements across all eight attributes at post-test, as well as the total score for all attributes combined (p < 0.001), were observed.
The eight attributes were assertiveness, focus, responsibility, empathy, calmness, planning, communication, and engagement in
learning. There was a significant interaction between Time and Age for Planning and Empathy attributes, suggesting that early
adolescence (ages 11–14) is a key period for providing early interventions for skill development, which may help reduce anxiety in other
contexts.
Keywords: equine assisted, anxiety, calmness, social skills, young people, adolescents, equine-assisted learning (EAL), equine
facilitated services, mental health
Citation: Sullivan K, Hemingway A. Equine-assisted learning reduces anxiety and increases calmness and social skills in young people.
Academia Mental Health and Well-Being 2024;1. https://doi.org/10.20935/MHealthWellB7424
1. Introduction
1.1. Context
The prevalence of poor mental health in young people has in-
creased in recent years, in part due to the COVID-19 crisis [1, 2],
with some studies reporting that males aged 11–15 were particu-
larly affected [1]. Although a wide range of mental health issues
in young people have increased because of the COVID-19 pan-
demic, including depression, post-traumatic stress disorder
(PTSD), and eating disorders [1], the most commonly reported
mental health concern was anxiety [3].
Anxiety has a very high prevalence among young people, with re-
search by Zulfiqarova and Dresp-Langley [4] finding that in a
sample of students at a French university, 60% met the criteria
for moderate, severe, or very severe generalized anxiety disorder
(GAD). Several contributory factors have been suggested, includ-
ing the rise of social media [5], reduced time spent in nature set
against humankind’s inherent biophilia [6, 7], social isolation
[8], and overexposure to digital media [9].
Among many features that contribute to the efficacy of equine-as-
sisted services (EAS) for improving the mental health of young peo-
ple, EAS are typically delivered in natural outdoor environments, of-
ten with a focus on developing embodied emotional skills through
experiential learning [10]. This may, therefore, provide a contrast to
hyper-digital urban environments where young people may feel iso-
lated, stressed, and anxious and to typical educational settings that
tend not to favor kinesthetic learning.
1.2. Anxiety in adolescents
The high prevalence of anxiety disorders in young people high-
lights the necessity for developing interventions that support
young people’s mental health. Anxiety can have debilitating ef-
fects, with far-ranging impacts such as increased risk of physical
disease [11] and contributing to comorbid mental health disor-
ders, particularly when anxiety is chronic or has an early age of
onset. Davies et al. [12] found that major depressive disorders
that developed following anxiety disorders were likely to have
younger ages of onset, as well as greater clinical complexity and
significance. Early intervention to reduce the development of
anxiety disorders is, therefore, critical, with Altamura et al. [13]
suggesting that longer periods of untreated illness can lead to re-
duced responsiveness to treatment.
Adolescence is likely a key time for providing early interventions
to prevent the development and maintenance of anxiety, as it falls
within a primary developmental window for several anxiety dis-
orders [14]. Campbell et al. [15] found that earlier-onset anxiety
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 2 of 11
was associated with increased severity, likelihood of comorbidity,
and emotional disorders. Lim et al. [16] found that earlier-onset
anxiety was associated with greater behavioral inhibitions. A
study among young children found that participants with greater
attentional shifting skills were less likely to have anxiety symp-
toms at a later assessment, whereas those with higher inhibitory
control were more likely to have anxiety symptoms. It is sug-
gested that this is due to fear-motivated tendency to try to
overcontrol, leading to an increased experience of anxiety [17].
Adolescence is a time of extensive change to an individual’s phys-
ical and social context [18], which requires great flexibility to nav-
igate successfully; excess behavioral inhibition and rigidity could
lead to exacerbation of anxiety in adolescents.
Research by Troller-Renfree et al. [19, 20] found that behavioral
inhibition alone does not increase the risk of developing anxiety
disorders in children, but that it may be moderated by excess in-
hibitory control. Equine-assisted programs such as the one under
study here may offer participants the chance to break out of ex-
cess inhibitory control as horses respond quickly to environmen-
tal changes and cues, requiring intuitive choices to be made as
participants experience inter-affectivity and close attunement
with the movements of the horses [21]. This could support par-
ticipants to reduce their reliance on an excess of fear-based con-
trol, instead developing positive coping skills toward a more re-
laxed and responsive mode of social engagement. This is sup-
ported by the finding that neurological precursors to excess in-
hibitory control can be observed prior to the diagnosis of anxiety.
A machine learning study by Chavanne et al. [22] found that the
development of clinical anxiety by ages 18–23 can be predicted
from volumes of gray matter in certain brain regions at the age of
14, as shown by a functional magnetic resonance imaging (fMRI).
These regions include higher volumes of the caudate nucleus, a
region associated with executive function and impulse control
[23], and the pallidum, which is associated with intentional
movement and proprioception [24]. The equine-assisted service
under study here offers a chance to practice these skills in a re-
laxed way through interactions with the horses, delivering feed-
back around effective communication via the responses of the
horse in the moment. This could help participants calibrate their
impulse control to a degree that is helpful for social interactions,
rather than exacerbating anxiety [25].
Research by Siddaway et al. [26] identified that both state and
trait anxiety range along continuums from high calmness to high
anxiety, indicating that the development of calmness as a skill is
mutually exclusive with anxiety. Furthermore, Siddaway et al.
[26] found that the degree of calmness or anxiety experienced is
related to other psychiatric conditions such as depression and
substance abuse, with higher anxiety typically associated with in-
creased risks of other psychiatric conditions. This indicates that
interventions that support participants to develop positive cop-
ing skills which lead to increased calmness are likely to be pre-
ventative against a range of psychiatric conditions, some of which
may be related to underlying anxiety.
1.3. Equine-assisted learning and anxiety
Research by Bui et al. [27] highlighted the need for innovative anxi-
ety treatments, following limited developments in pharmacological
interventions across the past 30 years. In recent years, EAS have
grown in popularity, often working with participants who are unable
or unwilling to participate in talk-based therapies. Many equine-as-
sisted learning programs have seen increased referrals since the
COVID-19 pandemic, the largest proportion of which are associated
with social, mental, and emotional health [28].
There are a wide range of EAS available in the United Kingdom,
including hippotherapy, equine-assisted therapy (EAT), and eq-
uine-assisted learning (EAL). These terms are frequently con-
flated as there are currently no set standards within the EAS in-
dustry [29]. Therefore, EAL is defined as activities carried out
around horses, donkeys, or mules (such as basic horse care and a
range of activities with the horse), which contribute to learning
transferrable skills for use outside an equine setting. EAL is usu-
ally delivered by facilitators with good horsemanship skills, but
they are not required to be mental health professionals. This
study will focus on research pertaining to EAL, to start to develop
distinctions between these frequently conflated fields of practice.
This is important to clarify the evidence base around each type of
EAS, developing the understanding of how various types of ser-
vices support participants, and which participant needs each ser-
vice might be effective for.
A variety of outcomes are beginning to be recognized within EAL,
leading to a broad range of referrals to programs. Pendry and
Roeter [30] found that an EAL program increased social compe-
tence, supporting the development of social connections that
could lead to reduced anxiety. Furthermore, Osbourn [31] found
a significant impact of an EAL program for adolescents with anx-
iety, while a study by Davies and Stanton [32] also found that
anxiety was significantly reduced in rural young people following
a 6-week EAL program. Participants learned several topics
around anxiety reduction alongside the activities with the horses
such as mindfulness techniques, journalling, and breathing exer-
cises, with the horses described as the key motivation for attend-
ing the sessions. There were seven participants in the study by
Davies and Stanton [32], yielding qualitative insights around
anxiety and self-efficacy, as well as finding a statistically signifi-
cant improvement on the GAD-7 scale, indicating a large effect
size of the EAL program, although this is a very small sample size.
These emerging effects may be due to the emotional safety experi-
enced by participants in EAL settings as they are able to feel safe, re-
spected, and connected [33]. Participants were interviewed follow-
ing an EAL program, describing feeling calm and trusting the horses,
contributing to the perception of emotional safety. Veale et al. [34]
described emotional safety as essential for meeting the needs of
those with mental health issues; the program under study was in-
strumental in developing skills essential for emotional safety to sup-
port participants in behaving in emotionally safe ways, both inter-
nally and in their relationships with other people. These skills in-
clude assertiveness and boundary setting [35], as well as communi-
cation and empathy [36]. These skills can improve social relation-
ships [37], which can in turn prevent isolation which contributes to
an increased risk of anxiety [38].
EAL programs are usually undertaken over a medium term of
around 6–12 weeks as they are often integrated with school
terms. However, the program under study here offers partici-
pants an intensive course of 5 × 2-hour sessions over the course
of a week. Green [39] suggests that within an equine context,
changes can be achieved in a single session due to the embodied
nature of the experience, where participants learn to communi-
cate with the horses through body language, resulting in rapid
embodied learning [25].
Research into the effects of EAL suggests that social competence
and anxiety may be improved via EAL; this is reinforced by the
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 3 of 11
findings that many referrals relate to these topics, suggesting
wider acceptance of EAL as effective in these areas with the refer-
rer’s local teams or organizations. These include social workers
(local authorities), teachers (local schools), and CAMHS (Child
and Adolescent Mental Health Services, NHS) teams. This study
will examine whether a short course of EAL will support partici-
pants with anxiety to develop improved skills such as calmness, em-
pathy, and planning, which are aimed at contributing to reducing
anxiety outside of the program through improved social connections
and improved calibration of inhibitory control.
1.4. The intervention
The intervention works with principles of natural horsemanship,
focusing on developing partnerships and harmonious communi-
cation through body language, as well as recognizing and re-
sponding to the experiences of the horses during tasks. The tasks
are linked to the behaviors to be developed from the Skills Star
(see Figure S1, Supplementary materials)—for example, fetch-
ing hay for a horse as part of perspective-taking and empathy,
and leading the horse at liberty (without a lead-rope, using only
body language) to demonstrate and develop focus.
The tasks are designed to increase harmony between the partici-
pant and the horse by developing the necessary skills for each
participant. For example, excessively shy participants might
learn assertiveness by practicing leading on the outside of a turn,
which requires them to hold their own personal space in order to
maintain harmony. Each session focuses on a series of tasks that
are chosen according to the development needs of the partici-
pant, as well as taking into account the experience of the horse on
the day. Activities are built up over the course of the 5 days, so
that the participants are supported in being successful at each
stage.
1.5. Current study setting
The setting and EAL program for this study are the same as the
setting described in Hemingway and Sullivan [29]. Therefore, it
is not fully reproduced here. However, welfare and ethics are crit-
ical to the safe and ethical practice of EAL, and hence, they are
described in the following.
1.6. Equine welfare, handling, and selection
Each horse involved in the course is provided with access to a
natural environment including trees, hedges, and other horses.
The horses primarily live outdoors, with free movement between
barns and fields according to their choice. Each horse has a light
workload, which is logged in line with the charities welfare policy
and averages approximately 5 hours per week. The horses are
consistently handled and trained using natural horsemanship by
facilitators trained in natural horsemanship, as informed by the
charities’ welfare policies. The center also holds a local authority
welfare license. All horses are vet-checked and receive routine
farriery and dental care. Rescue horses are also retrained before
taking part in the program and then are rehomed as appropriate
through the charities registered rescue charity.
1.7. Ethics
The researchers employing universities ethics panel (REF, 8750)
granted ethical approval for this study. The data were accessed via
the charity through a data-sharing agreement, and all data were
anonymized prior to being shared with the researchers. All anony-
mized data were stored on a password-protected university com-
puter in compliance with UK data management and storage Data
Protection Law. The registered charity under study here carries out
risk assessments for all participants, and participants are always ac-
companied when around the horses. The ethical review included
welfare implications for the horses during the program, ensuring
their well-being and humane treatment throughout. The “ethogram”
of horse behavior [40] was used to observe the horses throughout
the course for possible stress/distress. All activities would cease im-
mediately if any distress was observed. Horses are highly sensitive
and are easily stressed, and therefore, their welfare must be priori-
tized in EAL interventions.
2. Materials and methods
This before and after measures study uses quantitative data col-
lected by an EAL intervention to explore whether the 5-day EAL
course improves the social skills of participants referred to the
course with anxiety. The course teaches the participants to com-
municate with horses using their body language to play games
and lead and move with the horses on a long rope and the partic-
ipant on the ground. The anxiety category for all participants was
recorded on the written referral forms for the intervention. The
Skills Star measures were completed by the referrer to the pro-
gram—normally a social worker, teacher, or CAMHS team mem-
ber at referral and at a 2-month follow-up to generate a score for
each skill, ranging between 0 (“Stuck”) and 4 (“Independent,
needs little—no support”).
The measures were a modified mental health recovery star with
eight attributes ([41, 42], see Figure S1, Supplementary materi-
als), in line with the standard practice of the intervention and the
observational design of this study. The degree of participant anx-
iety was inversely assessed via “Calmness” scores on the modified
mental health recovery star.
2.1. Participants
The study was a before and after measures study, including anon-
ymized data from a total of 166 participants aged between 8 and
18 years with an average age of 12.8 years, who were referred with
anxiety. Of these, 113 participants were female and 53 partici-
pants were male. For the analyses, participants were grouped
into four age categories, which corresponded to education Key
Stage levels in the United Kingdom. The categories were as fol-
lows: 8–10 years old, 11–12 years old, 13–14 years old, and 15–18
years old; see Table 1 for full participant details.
Table 1 • Participant Genders and Age Groups
8–10 Years old
11–12 Years old
13–14 Years old
15–18 Years old
Total
Female
19
24
32
38
113
Male
15
12
15
11
53
Total
34
36
47
49
166
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 4 of 11
The inclusion criteria for the study were as follows: participants
aged 8–18 years at the time of referral, participants referred with
anxiety, and participants with complete data available at both re-
ferral and 2-month follow-up.
The exclusion criteria for the study were as follows: participants
without a complete dataset, participants with inconsistent data
across the time period, and participants who did not complete the
program.
Participants were, therefore, an opportunity sample of young
people referred to the intervention over a 5-year period.
2.2. Materials
Outcomes were determined by comparing pre- and post-inter-
vention scores, with increases in scores indicating a positive ef-
fect of the intervention across skills including calmness, asser-
tiveness, empathy, communication, perseverance, taking respon-
sibility, planning, and engagement as a learner.
The analysis includes 166 participants aged between 8 and 18
years with an average age of 12.8 years, who were referred with
anxiety. Of these, 113 participants were female and 53 partici-
pants were male. For the analysis, participants were grouped into
four age categories, which corresponded to education Key Stage
levels in the United Kingdom. The categories are as follows:
8–10 years old, 11–12 years old, 13–14 years old, and 15–18 years
old.
2.3. Procedure
Mixed-measures analyses of variance (ANOVAs) were used to
show the effects of Time, Gender, and Age Group on the Total
Skills Star scores, as well as each of the Skills Star Attribute
scores. The Total Skills Star scores and scores for each of the eight
Skills Star attributes were, therefore, dependent variables. Gen-
der and Age Groups were between-participant independent vari-
ables, and Time was a within-participant independent variable.
3. Results
3.1. Total Skills Star scores
A mixed-measures ANOVA was carried out, with Time as a within-
participant independent variable, while Age and Gender were be-
tween-participant independent variables. The dependent variables
were the scores on the Skills Star before and after the intervention.
Neither Levene’s test for homogeneity of variances nor Box’s test of
equality of covariance was significant. See Table 2 for full ANOVA
results for Total Skills Star scores.
3.1.1. Within-participants effects
There was a significant main effect of Time (F(1, 158) = 178.066, p <
0.001, ηp2 = 0.53), with participants scoring higher at post-test (M =
18.4, SD = 6.7) compared with pretest (M = 11.4, SD = 5.7), as well as
a significant interaction between Time and Age Group ((F(3, 158) =
4.158, p = 0.007, ηp2 = 0.07), shown in Figure 1. However, there
were no significant interactions between Time and Gender or among
Time, Gender, and Age (p > 0.05).
3.1.2. Between-participants effects
There was no significant main effect of Gender nor Age Group,
though there was a significant interaction between Gender and
Age Group (F(3, 158) = 3.924 , p = 0.010, ηp2 = 0.069).
3.2. Skills Star attributes
A mixed-measures ANOVA was carried out for each of the Skills Star
Attribute Scores. For each, Time was a within-participants inde-
pendent variable, while Age and Gender were between-participants
independent variables. The dependent variables were the scores on
the Skills Star attributes before and after the intervention. Findings
relevant to reducing anxiety in adolescents via calmness, empathy,
and planning are summarized in Table 3. For the full results of
mixed-measures ANOVAs carried out on the additional attributes,
see Table S1 in Supplementary materials.
Table 2 • Results of a mixed-measures ANOVA for Total Skills Star scores
ANOVA results
Source
Type III SS
df
Mean square
F
p
ηp2
Noncent.
parameter
Observed powera
Within-participants effects on Total Skills Star scores
Time
3,467.189
1
3,467.189
178.066
0.000
0.530
178.066
1.000
Time * Gender
27.620
1
27.620
1.418
0.235
0.009
1.418
0.220
Time * Age Group
242.896
3
80.965
4.158
0.007
0.073
12.475
0.846
Time * Gender * Age Group
30.762
3
10.254
0.527
0.665
0.010
1.580
0.156
Error (Time)
3,076.479
158
19.471
Between-participants effects on Total Skills Star scores
Intercept
59,583.167
1
59,583.167
1,126.184
0.000
0.877
1,126.184
1.000
Gender
187.244
1
187.244
3.539
0.062
0.022
3.539
0.464
Age Group
34.070
3
11.357
0.215
0.886
0.004
0.644
0.090
Gender * Age Group
622.848
3
207.616
3.924
0.010
0.069
11.772
0.822
Error
8,359.331
158
52.907
a Computed using alpha = 0.05. *Interaction between independent variables.
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 5 of 11
Figure 1 • Interaction between Time and Age Group on Total Skills Star scores.
Table 3 • Results of mixed-measures analysis of variance for Skills Star attributes related to anxiety
ANOVA results for attributes related to anxiety
Source
Type III SS
df
Mean square
F
p
ηp2
Noncent.
parameter
Observed powera
Within-participants effects on calmness scores
Time
78.869
1
78.869
106.741
0.000
0.403
106.741
1.000
Time * Gender
0.148
1
0.148
0.200
0.655
0.001
0.200
0.073
Time * Age Group
4.636
3
1.545
2.091
0.104
0.038
6.274
0.527
Time * Gender * Age Group
0.665
3
0.222
0.300
0.825
0.006
0.900
0.107
Error (Time)
116.744
158
0.739
Between-participants effects on calmness scores
Intercept
835.606
1
835.606
552.529
0.000
0.778
552.529
1.000
Gender
1.722
1
1.722
1.139
0.288
0.007
1.139
0.186
Age Group
3.800
3
1.267
0.838
0.475
0.016
2.513
0.229
Gender * Age Group
8.742
3
2.914
1.927
0.127
0.035
5.780
0.491
Error
238.948
158
1.512
Within-participants effects on empathy scores
Time
37.850
1
37.850
57.905
0.000
0.268
57.905
1.000
Time * Gender
2.109
1
2.109
3.226
0.074
0.020
3.226
0.431
Time * Age Group
7.038
3
2.346
3.589
0.015
0.064
10.766
0.783
Time * Gender * Age Group
1.891
3
0.630
0.964
0.411
0.018
2.892
0.260
Error (Time)
103.278
158
0.654
Between-participants effects on empathy scores
Intercept
1,090.338
1
1,090.338
703.838
0.000
0.817
703.838
1.000
Gender
11.162
1
11.162
7.206
0.008
0.044
7.206
0.761
Age Group
0.130
3
0.043
0.028
0.994
0.001
0.084
0.055
Gender * Age Group
10.296
3
3.432
2.216
0.088
0.040
6.647
0.554
Error
244.763
158
1.549
Within-participants effects on planning
Time
49.119
1
49.119
80.887
0.000
0.339
80.887
1.000
Time * Gender
0.225
1
0.225
0.370
0.544
0.002
0.370
0.093
Time * Age Group
4.876
3
1.625
2.676
0.049
0.048
8.029
0.644
Time * Gender * Age Group
1.406
3
0.469
0.772
0.511
0.014
2.315
0.213
Error (Time)
95.946
158
0.607
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 6 of 11
Between-participants effects on planning
Intercept
870.828
1
870.828
925.478
0.000
0.854
925.478
1.000
Gender
1.367
1
1.367
1.453
0.230
0.009
1.453
0.224
Age Group
1.196
3
0.399
0.424
0.736
0.008
1.271
0.133
Gender * Age Group
9.419
3
3.140
3.337
0.021
0.060
10.010
0.750
Error
148.670
158
0.941
a Computed using alpha = 0.05. *Interaction between independent variables.
3.2.1. Calmness
Box’s test of covariance was not significant, and nor was Levene’s
test for the homogeneity of variances.
Within-participants effects
There was a significant main effect of Time on Calmness scores
(F(1, 158) = 106.741, p < 0.001, ηp2 = 0.403), with post-test scores
(M = 2.3, SD = 1.0) higher than pretest scores (M = 1.2, SD = 1.1),
though there were no significant interactions between Time and
Age Group, Time and Gender or Time, and Gender and Age
(p > 0.05).
Between-participants effects
There was no significant main effect of Gender or Age Group on
Calmness scores, nor was there a significant interaction between
Gender and Age Group (p > 0.05).
3.2.2. Empathy
Box’s test of covariance was not significant, and nor was Levene’s
test for homogeneity of variances.
Within-participants effects
There was a significant main effect of Time on Empathy scores
(F(1, 158) = 57.905, p < 0.001, ηp2 = 0.268), with scores at post-
test (M = 2.4, SD = 1.0) higher than those at pretest (M = 1.7, SD
= 1.1), as well as a significant interaction between Time and Age
Group (F(3, 158) = 3.589, p = 0.015, ηp2 = 0.064), shown in
Figure 2. However, there were no significant interactions be-
tween Time and Gender or Time, Gender, and Age (p > 0.05).
Between-participants effects
There was a significant main effect of Gender on Empathy scores
(F(1, 158) = 7.206, p < 0.008, ηp2 = 0.044), with female partici-
pants scoring significantly higher (M = 2.2, SE = 0.9) than male
participants (M = 1.8, SE = 0.1). However, there was no signifi-
cant main effect of Age Group on Empathy scores (p > 0.05).
There was also no significant interaction between Gender and
Age Group (p > 0.05).
3.2.3. Planning
Box’s test for equality of covariances was significant (F(21,
27435) = 2.011, p = 0.004). Therefore, Pillai’s trace values were
used. Levene’s test for homogeneity of variances was significant
for pre-scores (F(7, 158) = 2.297, p = 0.030), but not for post-
scores (F(7, 158) = 0.228, p = 0.978).
Within-participants effects
There was a significant main effect of Time on Planning scores
(F(1, 158) = 80.887, p < 0.001, ηp2 = 0.339), with participants
scoring higher at post-test (M = 2.2, SD =0.89) compared with
pretest (M = 1.4, SD = 0.90). There was also a significant interac-
tion between Time and Age Group, shown in Figure 3 (F(3, 158)
= 2.676, p = 0.049, ηp2 = 0.048). However, there were no signif-
icant interactions between Time and Gender or Time, Gender,
and Age (p > 0.05).
Figure 2 • Interaction between Time and Age Group on Empathy scores.
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 7 of 11
Figure 3 • Interaction between Time and Age Group on Planning scores.
Between-participants effects
There was no significant main effect of Gender or Age Group on
Planning scores (>0.05), although there was a significant inter-
action between Gender and Age Group (F(3, 158) = 3.337, p =
0.021, ηp2 = 0.060).
4. Discussion
The results of this study indicate a positive impact of the EAL
program across each of the eight attributes measured, the devel-
opment of which mitigates the impact of anxiety disorders via the
development of specific skills such as calmness, empathy, and
planning. There was also a significant improvement in the Total
Skills Star scores, indicating a generalized sociocognitive im-
provement for participants referred with anxiety. This could un-
derpin reductions in behavioral patterns, which may contribute
to anxiety in participant’s lives, such as struggling to maintain
healthy boundaries or to act calmly.
There was a significant interaction between Time and Age across
the Total Skills Star scores, revealing that participants in their
early teens (aged 11–12 and 13–14) tended to enter the program
with lower scores across the Total Star, and then leave with
higher scores than those aged 8–10 or 15–18 years. The transition
from primary school to secondary school and the onset of puberty
could be critical periods for early interventions to support young
people who are identified as at-risk for developing anxiety disor-
ders, with short-term experiential programs offering a chance to
reflect and develop skills during this vital period.
Blum et al. [18] argued that early adolescence (ages 10–14) is one of
the most critical developmental periods for understanding long-
term health outcomes due to the extent of the rapid biological and
contextual changes. Health outcomes are driven by several factors
relating to anxiety, which are developed throughout adolescence,
such as impulse control, response to stress, and emotional well-be-
ing [43–46]. Programs that support healthy patterns of adolescent
development across these areas could improve long-term health out-
comes, as well as reduce anxiety. This is likely to function as a virtu-
ous cycle. Raknes et al. [47] found that adolescent anxiety is related
to poor health-related quality of life, while poor health can also be a
significant driver of anxiety [48].
This period of increased sensitivity to the effects of the interven-
tion for participants in early adolescence was also shown for
scores on Empathy, whereby participants in early adolescence
(aged 11–12 and 13–14) showed lower scores than younger (aged
8–10) or older (aged 15–18) participants at pretest and higher
scores following the intervention. In line with our results, Van der
Graaf et al. [49] found that girls tended to score higher on empa-
thy than boys, with a differential development trajectory of per-
spective-taking during adolescence across genders; perspective-
taking in girls tended to be higher and increased faster compared
with that of boys. However, no significant interaction between
gender and time was found in our study, suggesting the presence
of key stages during adolescence during which interventions can
be particularly effective for supporting the development of empa-
thy across genders.
There was also a period of higher sensitivity to the intervention
effects for participants aged 11–12 and 13–14 years found for
Planning. This may, therefore, be an area that requires specific
support in early adolescence for young people suffering with anx-
iety. A longitudinal study by Troller-Renfree et al. [19, 20] found
that for children with high behavioral inhibition as toddlers, in-
creased proactive cognitive control (i.e., tendency to plan, rather
than react) is associated with lower anxiety at age 13. This implies
that interventions such as EAL, which improve proactive plan-
ning and alleviate excess inhibitory control, could help reduce
anxiety in early adolescence.
There may be a more complex relationship between the develop-
ment of empathy and reduction of anxiety. Gambin and Sharp
[50] found a positive correlation between empathy and anxiety
for adolescent participants at an inpatient unit, suggesting that
high empathy could result in overwhelming feelings or maladap-
tive states (e.g., guilt), thereby contributing to the development
of anxiety. However, Klimecki et al. [51] found that training in
compassion improved positive impact and reversed the potential
negative impact of developing increased empathy, which was also
conducted via training. This highlights an important nuance that
should be considered in the development of interventions for so-
ciocognitive skills; the benefits of compassion; sharing the emo-
tional experience of another with the desire to alleviate distress,
compared with empathy; the sharing of emotional experiences
with another [52]. In the EAL program under study, the attribute
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 8 of 11
of “Empathy” is defined as “sees the needs of others, offers care
and support, feels closely connected.” It is, therefore, likely that
the program may be developing compassion within participants,
as referenced by actively offering care and support to others—ra-
ther than simply experiencing shared emotions. The develop-
ment of compassion as a skill could represent a critical turning
point for participants with anxiety driven by maladaptive or lim-
ited empathy as they learn to take action to help where possible
or/and limit the extent to which the emotions of others are able
to affect them.
The results of the current study indicate that an EAL program fo-
cusing on embodied communication may significantly improve
the calmness of young people within a relatively short 10-hour
intervention, although more research is needed to substantiate.
Traditional anxiety treatments such as cognitive behavioral ther-
apy often have over 20 hours of contact time spread across sev-
eral weeks [53] as well as high dropout rates of around 26.2%
during treatment [54]. The program under study here has a com-
pletion rate of 94% [55], indicating that participants not only im-
prove their sociocognitive skills via the program but also enjoy
attending.
The efficiency of the program may be partially attributable to the
embodied approach of the EAL program, supporting embodied
learning in a short time, as described by Green [39]. The program
offers young people the opportunity to experiment with ways of
managing their internal state; the success of which is indicated
through the behavior of the horse in the manner of biofeedback.
As herd animals, horses have evolved to psychophysiologically
synchronize with others in the herd to flee from predators with
greater efficiency. This synchronization could be termed biofeed-
back for participants and has been demonstrated between horses
and their handlers; Lie [56] found that horses show emotional
contagion with their handlers, and a study by Merkies et al. [57]
found that therapy horses had increased heart rates around peo-
ple with PTSD compared with people without trauma. A system-
atic review by Alneyadi et al. [58] found that biofeedback is a useful
inclusion for programs that aim to treat anxiety in young people; the
psychophysiological synchronization of the horse to the human
could be helping participants better understand and reflect on their
emotional states, although more research is needed in this area.
The availability of biofeedback via interactions with the horses is spe-
cific to EAS which make active use of this connection between horses
and humans. Other popular animal-assisted therapies such as ca-
nine-assisted therapies provide support to participants with therapy
dogs working in the role as “Man’s best friend” [59]. In contrast,
horses choose how to engage based on the behavior of the partici-
pants—highlighting areas where personal growth would support
more positive interactions for participants, both with horses and in
other contexts. Furthermore, communication with horses is nonver-
bal, reinforcing embodied learning for participants [25], which can
lead to significant changes in a short period of time [39] as people
learn to identify and manage different feelings. This type of detailed
embodied communication is not necessary in animal-assisted thera-
pies with smaller animals, such as cats or guinea pigs—representing
a key therapeutic advantage of EAS.
4.1. Limitations
The current study investigated outcomes related to anxiety, such
as calmness [26], but did not examine the impact of the program
using a validated anxiety measure. This was largely due to the
pragmatic design of the study, as the data were collected by the
charity as part of their usual operations. Therefore, participants
were not contacted or asked to fill out additional anxiety-specific
measures. Instead, data from participants referred with anxiety
were analyzed across the eight sociocognitive attributes and at
the total level. Future research could include measures of anxiety
to more directly understand the impact of EAL programs on the
degree of anxiety experienced or whether diagnoses of anxiety
were removed further to the intervention.
The generalizability of the study findings may also be limited as
there was no randomization or control group. The study explored
the scores of young people across a range of ages at two time
points: pre- and post-intervention. To further investigate the po-
tential for early intervention and to identify and validate critical
time periods during adolescent development where additional
support is most beneficial, larger-scale randomized studies may
be beneficial. However, it is important to note that of the young
people referred to this EAL, almost a third are not engaging with
CAMHS or other services; therefore, finding an appropriate com-
parison or control group is currently problematic.
5. Conclusions
This study has found a significant impact of a 5-day EAL program
on eight sociocognitive skills. The development of these skills is
likely to reduce anxiety in children and adolescents by supporting
them to adopt adaptive strategies such as developing calmness
and improving communication and assertiveness. Although anx-
iety can often be related to external circumstances, rather than
stemming directly from impairment across these skills, develop-
ment of sociocognitive skills could contribute to improved rela-
tionships and functioning in daily life, which could indirectly re-
duce the frequency or severity of anxiety. Further research could
investigate the direct impact of the EAL program on anxiety using
a targeted anxiety measure to validate these findings.
Acknowledgments
The authors thank the Equine-Assisted Charity involved with this
study. A special thanks to Harriet Laurie MBE who is the CEO,
and to all the horses who contributed to this intervention.
Funding
The authors declare no financial support for the research, author-
ship, or publication of this article.
Author contributions
Conceptualization, A.H.; methodology, K.S. and A.H.; formal
analysis, K.S.; investigation, A.H. and K.S.; data curation, K.S.;
writing—original draft preparation, K.S.; writing—review and ed-
iting, A.H.; visualization, K.S.; supervision, A.H.; project admin-
istration, A.H.; project funding, A.H. Both authors have read and
agreed to the published version of the manuscript.
Conflict of interest
The authors declare no conflict of interest.
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ACADEMIA MENTAL HEALTH AND WELL-BEING 2024, 1 9 of 11
Data availability statement
Data supporting these findings are available within the article, at
https://doi.org/10.20935/MHealthWellB7424, or upon request.
Institutional review board statement
The study was conducted in accordance with the Declaration of
Helsinki and approved by the Institutional Review Board (or Eth-
ics Committee) of Bournemouth University UK (REF, 51113, ap-
proved on February 10, 2023).
Informed consent statement
Informed consent was obtained from all subjects involved in the
study, and this study utilized secondary data analysis of anony-
mized data only.
Supplementary materials
The supplementary materials are available at https://doi.org/
10.20935/MHealthWellB7424.
Additional information
Received: 2024-08-14
Accepted: 2024-11-08
Published: 2024-11-28
Academia Mental Health and Well-Being papers should be cited as
Academia Mental Health and Well-Being 2024, ISSN 2997-9196,
https://doi.org/10.20935/MHealthWellB7424. The journal’s offi-
cial abbreviation is Acad. Ment. Health WellB.
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