The Effects of an Equine-Assisted Therapeutic Intervention on Well-Being in Persons Diagnosed with Schizophrenia. A Pilot Study

Abstract

The process of personal recovery among persons diagnosed with schizophrenia may be facilitated through innovative health promotion interventions targeting multidimensional aspects of subjective well-being. The current pilot study aims to test the use of self-rated questionnaires as a means of evaluation of the effects of an equine-assisted intervention for persons diagnosed with schizophrenia. Twenty adults diagnosed with schizophrenia were offered a 12-week EAT intervention performed six times once every 14 days by a licensed mental health nurse. Two validated self-rated questionnaires, HSCL-25 and SHIS were used as outcome measurements at baseline and at post-treatment, additionally the self-rated questionnaire PANAS was completed twice a week starting 1 week before the 12 week—EAT intervention. Only six of the 20 participants managed to complete the validated questionnaires. Despite the low response rate of approximately 30%, a significant difference was found between pre and post scores for positive affect and well-being. Effect sizes, ranging from small to large for pre-to-post treatment scores indicated less depression and anxiety, more positive affect, less negative affect, and reinforced well-being. Results suggest that EAT interventions may have beneficial effects among persons diagnosed with schizophrenia and that a varied range of research methods are needed to create a solid evidence base for EAT interventions intended for the target group.

Introduction

Worldwide, more than 23 million people are estimated to have a schizophrenia diagnosis (WHO, 2004) with long lasting and crucial effects on both an individual and societal level. The two to three times increase in likelihood of a premature death among people with schizophrenia may be preventable, since it is often caused by cardiovascular metabolic diseases, treatable infections, and suicide (Casey, 2005). These causes are avoidable as it is related to lifestyle in terms of inactivity, overweight, smoking, and poor diet as well as side effects of antipsychotic medication (Compton et al., 2006). Traditional erroneous assumptions, such as the strong negative correlation between schizophrenia and well-being/psychosocial functioning, have been revised (Van Eck et al., 2018; Vita & Barlati, 2018) and it is generally accepted that there is more to the concept of health and the closely linked construct of recovery, than the mere absence of disease (Anthony, 1993; Jormfeldt, 2011). In fact, well-being has emerged as a vital criterion for treatment success and recovery (Priebe, 2007; Vita & Barlati, 2018).

Personal recovery can be understood as the individual process of finding new purpose and meaning in the face of a mental illness (Anthony, 1993). Importantly, personal recovery is not predicted by psychotic symptoms (Van Eck et al., 2018). It is generally known that well-being is contributing to healthy aging, mental health, and health in general (Lindert et al., 2015). According to the World Health Organization (WHO, 2004), mental health can be understood as "A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" (p. 1). Another useful and remarkable feature of well-being is that it can exist and even improve, despite the destructive ongoing clinical symptoms of a severe and chronic mental illness (Davidson et al., 2008; Slade, 2010). In other words, it is possible for people diagnosed with schizophrenia to experience subjective well-being (SWB) and thus an improvement in psychosocial functioning.

Many of the subjective self-experiences that capture aspects of well-being, such as self-esteem, adjustment to disability, self-determination, sense of self-efficacy, hope/hopelessness, empowerment and confidence, to name a few, are overlapping, linked to each other and constitute various elements of the multi-dimensional construct of personal recovery (Anthony, 1993). Hence self-stigma plays an important role in the personal recovery process since it is closely linked to the patients’ negative self-experiences. The negative and detrimental self-experiences, such as loss of hope and self-efficacy, are partly caused by the social stigma associated with the psychiatric illness of schizophrenia (Anthony, 1993; Corring et al., 2010; Deegan, 1997). Therefore, empowerment could be an important element of personal recovery in patients with schizophrenia, as it might help to reclaim one’s social identity and vocational functioning and hence help patients to learn to live a meaningful and purposeful life, despite or regardless of an ongoing diagnosed illness.

People with schizophrenia have been found to have an increased risk in comparison to the general population of developing cardiovascular disease, type 2 diabetes, hypertension, obesity, and metabolic syndrome due to side effects of medication. In fact, the risk of premature death due to cardiovascular disease is almost twice as high among individuals diagnosed with schizophrenia (Casey, 2005; De Hert et al., 2009), and there is a shortened life expectancy of up to 25–30 years compared to the rest of the population (Newcomer, 2007). The use of second generation-antipsychotics significantly increases the chance of weight gain and other harmful medical side effects, which in turn play an important role in the development of the metabolic syndrome (Casey, 2005). Physical activity has been shown to reduce psychiatric symptoms and to enhance health in people with mental illness (Acil et al., 2008; Beebe et al., 2005; Erdner & Magnusson, 2012; Holley et al., 2011). Despite this fact, people with severe and enduring mental illness are often offered a limited range of general health care as well as preventive and health-promoting efforts compared to other groups in the population (De Hert et al., 2009; Jormfeldt & Hallén, 2016). In the treatment and rehabilitation of people diagnosed with schizophrenia, innovative interventions that focus on inactivity, apathy, and lack of motivation are recommended (Nyboe & Lund, 2013).

Although the involvement of animals in the treatment of mental health disorders is still considered untested and without evidence, it is not a new concept. According to Nightingale (1969, p. 102), "a small pet animal is often an excellent companion for the sick, for long chronic cases especially." Animal-assisted therapies are used as alternatives or supplements to traditional one-on-one therapy to overcome the limitations associated with relying solely on verbal communication alone (Schultz et al., 2007; Wilson et al., 2017). There is also evidence that disease symptoms are reduced more quickly when animals are included in the therapeutic process in the treatment of patients with schizophrenia, depression, phobias, and substance abuse problems (Dimitrijevic, 2009). Equine-assisted therapy (EAT) has recently become an increasingly widespread innovative rehabilitation intervention that has shown biopsychosocial benefits and therapeutic results among individuals with various types of mental illness (Lee et al., 2016; Wilson et al., 2017). Several studies have been conducted with young individuals with good results (Bachi et al., 2012; Lee et al., 2016; Schultz et al., 2007; Wilson et al., 2017). Qualitative research on horse-backed therapy conducted since 2015 provides preliminary support for the therapy’s potential to improve young people’s ability to communicate and relate to others, while experimental and quasi-experimental research during the same period indicates that equine-assisted therapy can help increase children’s and adolescent emotional and social functional ability (Lee et al., 2016).

The number of studies looking at the effects of equine assisted therapy and equine assisted rehabilitative interventions for patients diagnosed with schizophrenia, are low in comparison to other populations such as cerebral palsy, autism, and youth at risk (Lee et al., 2016). Several research results have shown that equine-assisted therapy has the potential to promote a positive attachment, reflective ability, and emotional regulation and thus to facilitate personal recovery in people with severe psychiatric conditions (Bizub et al., 2003; Corring et al., 2010; 2013; Gabriels et al., 2012). Furthermore, EAT has also shown potential to improve clinical outcomes in individuals diagnosed with schizophrenia. For instance, Cerino et al. (2011) found a reduced rate of hospitalization, an improvement in negative symptoms and a persistent remission in early and chronic patients with schizophrenia. Bizub et al. (2003) have shown in a minor interview study that participants diagnosed with schizophrenia have been able to acquire basic skills to handle and manage the horse during a 10-week intervention with therapeutic riding and that this has led to increased self-confidence and strengthened self-esteem among the participants.

In a qualitative study, Corring et al. (2010) demonstrated that horseback riding for patients with schizophrenia can increase enjoyment, self-esteem, and confidence, grow a bond between the horse and the patient, as well as a reduction of professional stigma among health care workers. The authors suggested that their findings of enhanced self-esteem and increased confidence might ameliorate the devastating effects of negative self-experiences, such as hopelessness and low self-efficacy, partly caused and reinforced by internalized stigma. A quantitative study by Nurenberg et al. (2015) showed that animal-assisted therapy, in particular horse-backed psychotherapy, appeared to be an effective form of therapy for patients with inadequate impulse control and violence issues in psychiatric care. Further published studies have shown promising results for equine-assisted therapy in reducing social anxiety in young women (Alfonso et al., 2015) and that equine-assisted therapy contributed emotionally during treatment and supported a positive self-image of participants with substance abuse (Kern-Godal et al., 2016). Equine-assisted therapy also involves physical activity, which has been shown to have a positive effect on psychiatric symptoms in people with mental illness (Acil et al., 2008; Beebe et al., 2005; Erdner & Magnusson, 2012). In today’s mental health care with a strong emphasis on medical treatment and considering all the negative side effects of the medications on well-being and quality of life, it is of great importance to consider and pursue holistic treatment methods that can promote personal recovery in people with severe and enduring mental illness. People suffering from severe and long-lasting mental illness, such as schizophrenia, are often offered only a limited range of preventive and health-promoting efforts compared to other groups in the population (De Hert et al., 2009). Equine-assisted therapy and rehabilitation has shown promise in reducing symptoms and in facilitating biopsychosocial benefits in people with severe and chronic mental illness, such as schizophrenia (Jormfeldt & Carlsson, 2018). However, there are a limited number of studies examining the effectiveness of equine assisted therapy and equine assisted rehabilitative activities in patients diagnosed with schizophrenia, and the existing studies often lack generalizability and validity due to methodological issues. Furthermore, the lack of knowledge in healthcare settings about equine-assisted therapy and rehabilitation can constitute a serious obstacle to the therapy form being accepted as an effective therapeutic intervention in various types of mental illness (Wilson et al., 2017). Implementation of more high-quality studies on the effects of equine-assisted interventions (EAI) for adults with different forms of mental ill-health is therefore needed (Anestis et al., 2014; Kendall et al., 2015; O'Haire, 2013).

The aim of the actual pilot study was to test the use of self-rated questionnaires as a means of evaluation of the effects of an equine-assisted therapeutic intervention for persons diagnosed with schizophrenia in terms of whether the severity of anxiety and depression decreases, whether positive and negative affect would change and whether self-rated well-being would improve from pre-to-post treatment through participation in an equine-assisted therapeutic intervention in a sample of individuals diagnosed with schizophrenia. The hypotheses tested were that participants in a sample of individuals diagnosed with schizophrenia would experience a reduction in anxiety and depressive symptoms, increased levels of positive affect and a decrease in negative affect as well as an improvement in subjective well-being from pre-to-post treatment through participation in equine-assisted therapeutic intervention.

Method

Design

The quantitative pilot study is a part of a larger project evaluating an equine-assisted therapeutic (EAT) intervention using both qualitative and quantitative data in the form of interviews and questionnaires. The qualitative results of the project are previously reported and embraced interviews with study participants (Hultsjö & Jormfeldt, 2022) and their relatives (Fridén et al., 2022). The present study used a within-subjects design with data collection at baseline before and during the 12-week intervention as well as a follow up after the intervention was completed to detect possible individual-specific changes related to the intervention (Dallery et al., 2013). The statistical significance was analyzed with the help of the software IBM Statistical Package for Social Sciences (SPSS) 25.

Participants

Participants of the current pilot study were recruited from a local user organization, subsidiary of the World Fellowship for Schizophrenia and Allied Disorders (WFSAD), through oral and written information about the study from the project manager in connection with the local user association’s member meeting in January 2018. The local user organization in southern Sweden has about 60 members consisting of people with their own experiences of having a schizophrenia diagnosis and their relatives, of which about a third of the members have their own experiences of living with a diagnosis of schizophrenia. Participants were included in the study if they met the following inclusion criteria: (1) being diagnosed with schizophrenia, (2) being over 18 years of age and (3) having participated in six occasions in the EAT intervention. In total, 20 people diagnosed with schizophrenia or schizophrenia-like psychosis participated in the EAT intervention during the six intervention sessions. Finally, seven of the participants in the intervention comprising five men and two women, who matched inclusion criteria for study participation, gave their written informed consent to complete the questionnaires. The participants included in the study were not compensated.

The intervention

The design of the Equine-assisted intervention (EAI) was initially developed based on two doctoral dissertations regarding experiences of a holistic individualized lifestyle intervention for people with psychotic conditions (Blomqvist, 2020; Lundström, 2020) and a systematic review of equine-assisted therapeutic interventions among individuals diagnosed with schizophrenia (Jormfeldt & Carlsson, 2018). The study involved a 12-week EAI for individuals with a diagnosis of schizophrenia performed six times, once every 14 days between April and October 2018. Eligible participants were offered communicative activities with the horses from the ground within the framework of the local user organization’s activities. The equine-assisted therapeutic intervention was carried out in small groups of three to five participants once every 14 days. The sessions were led by a licensed mental health nurse with a doctoral degree in nursing certified by The Swedish National Organization for Horse-assisted Interventions (OHI) to offer equine-assisted interventions in the frame of the licensed profession. Equine-assisted therapeutic activities were performed, once every 14 days over the course of spring and autumn 2018. The purpose of the intervention was to support holistic health by offering the participants physical activity and togetherness characterized by equality conveyed by verbal and non-verbal communication with the horse as well as with the other group members in an environment close to the nature. When the participants arrived at the horse farm the session stared with a short introductory gathering where the participants planned the 1 hour walk of the day with the horses in the rural landscape. The activities together with the horses were adapted to the needs of each individual participant and to ensure the safety of both participants and horses there was one handler for each horse available during the walks. The activities were conducted followed by a meal and a concluding gathering encompassing a reflective dialogue about feelings and needs related to the participants’ everyday lives evoked during the activities with the horses. The reflective dialogue was performed with the aid of nonviolent communication cards focusing on needs and emotions (Rosenberg, 2015). Each session lasted 4 hours including the joint 30 kilometers journey back and forth to the horse farm and the urban area previously described by Hultsjö and Jormfeldt (2022) and Fridén et al. (2022).

Data collection

Participants completed The Positive and Negative Affect Scale (PANAS), The Salutogenic Health Indicator Scale (SHIS) and The Hopkins Symptom Check List 25 (HSCL 25) at baseline and post-treatment. Additionally, the PANAS was completed twice a week starting 1 week before the 12 week-intervention. Study participants who needed help filling in the questionnaires received support from their relatives or residential supporters.

The Positive and Negative Affect Scale (PANAS)

The Swedish short version of the PANAS, is a self-rated questionnaire measuring positive and negative affect, and it is composed of 12 adjectives describing the dimensions of positive and negative affect (Watson et al., 1988). One half is measuring positive emotions and the other half negative emotions. The 12 items are rated on a Likert scale, with total scores ranging from 0 to 600. The internal reliability for positive affect is estimated to range between .88 and .90 and for negative affect between .84 and .87 (Watson et al., 1988). The estimated value of the test-retest reliability after 1 week for positive affect is .79 and for negative affect .81 (Watson et al., 1988).

The Salutogenic Health Indicator Scale (SHIS)

The Salutogenic Health Indicator Scale (SHIS), a self-questionnaire, which measures 12 salutogenic health indicators from social health, psychological and physical dimensions, with a six-degree response scale based on the last 4 weeks (Bringsen et al., 2009). Each of the 12 items can be scored between one and six (semantic differential). Total scores range from 12 to 72, with better salutogenic health indicated by higher total scores. The majority of instruments measuring health are based on the traditional science of pathology. Bringsen et al. (2009) developed the SHIS on a theoretical framework based on well-being and health, as defined by the WHO (Garmy et al., 2017; WHO, 2004). The psychometric components of the SHIS such as concurrent, discriminant and criterion validity, in addition to internal reliability were rated of positive quality in a comparative analyses of subjective well-being measurement scales in a recent review (Lindert et al., 2015).

The Hopkins Symptom Checklist 25 (HSCL 25)

The Hopkins Symptom Checklist-25. HSCL-25 (Parloff et al., 1954) is measuring symptoms of depression and anxiety experienced in the past week. The self-questionnaire contains 25 items, the first 10 items are used to estimate anxiety and the remaining items to estimate depression. The total score can range from one to four, with higher scores indicating higher levels of experienced symptoms during the past week. The HSCL-25 is frequently used as a screening tool for anxiety and/or depression related diagnosis, with a cut off value of ≥1.75, with an estimation of the criterion value of Cronbach’s alpha of .9 (Tinghög & Carstensen, 2010).

Ethical considerations

The study was performed in accordance with the ethical standards of the World Medical Association Declaration for Helsinki (2013) and has been approved by the Regional Ethical Review Board, Lund University, Sweden, Dnr: 2017/709. The participants were informed by the research leader that participation in the study was completely voluntary and could be interrupted at any time without this affecting the conditions for continued care, rehabilitation, or membership of the user organization. The participant also received information on safety regulations in connection with EAI sessions. The participant gave his/her written informed consent to participate after having received oral and written information about the study. Collected data are being kept in accordance with the Personal Data Act (GDPR). From an ethical approach to the horse’s involvement in the current pilot study, the well-being of the horses were checked and assessed continuously before and after each intervention occasion based on Fine’s (2015) definition of animal welfare, defined by the five freedoms: (1) freedom from thirst, hunger and malnutrition; (2) freedom from discomfort; (3) freedom from pain, injury and illness; (4) freedom from fear and worry; and (5) freedom to express normal behavior.

Data analysis

Descriptive analyses were conducted using SPSS 25.0. To investigate how participation in the intervention affects well-being a paired samples t-test was utilized. To see whether assumptions were met, the four main assumptions were checked (continuous dependent variable, approximately normally distributed, outliers, independent observations). All data was analyzed using IBM Statistical Package for Social Sciences (SPSS) 25. A significance level of p < .05 was chosen for every statistical test. To interpret the magnitude of effects, Cohen’s d was chosen as an appropriate standardized measure. According to Cohen’s guidelines, d = 0.2 suggests a “small” effect size, d = 0.5 a “medium” and d = 0.8 a “large” effect size (Cohen, 1988).

Results

Of the 20 individuals who participated in the EAT intervention six participants (two women, four men) ranging from 29 to 53 years of age completed the questionnaires which corresponds to a response rate of about 30%. One man did not complete the follow-up questionnaires due to his psychotic condition. All the participants met the criteria for a diagnosis of schizophrenia. The length of the psychiatric condition had a range between 5 and 29 years. All the participants were single, had at least finished high school, were unemployed, and lived from social support. Four of the participants lived in community supported housing, while two participants lived in an own apartment with support from the municipality. Main characteristics of participants are presented in Table 1.

Table 1. Participant characteristics.

Characteristic
Gender, n (% female/males)	7 (30/70)
Age in years (average)	45.8
Education level (years)	>12

Change in positive and negative affect

The model showed good fit to the data (PPp = 0.33, 95% Confidence Interval [−8.90. 19.85]). During the data collection period the average level of negative affect was 25.01 (SD = 8.30) and positive affect was 54.82 (SD = 21.43), respectively. There was, on within-person level, a negative correlation between positive and negative affect (r = −0.48, 95% CI = [−0.60, −0.33]). There was a credible decrease in negative affect during the period (B = −0.36, 95% CI = [−0.63, −0.10]. For positive affect there was no credible change (B = 0.10, 95% CI = [−0.13, 0.34]).

Differences in clinical symptoms

The data for the clinical total scores of anxiety and depression were obtained from the HSCL questionnaire. When comparing the baseline condition (M = 1.97, SD = .72) to the posttreatment condition (M = 1.71, SD = .42), no significant difference was found between pre and post symptoms of depression and anxiety combined, z(5) = 1.47, p = .14. However, a medium effect was observed in the expected direction (d = .68).

Differences in subjective well-being

The data for the scores of subjective well-being was obtained from the SHIS questionnaire. When comparing the baseline condition (M = 47.5, SD = 12.69) to the posttreatment condition (M = 54, SD = 10.28), a significant increase in pre-to-post subjective well-being scores was found, z = −2.03, p =.042. Furthermore, a large effect was observed in the expected direction (d = −1.8).

Discussion

The overarching goal of the present pilot study was to test the use of self-rated questionnaires as a means of evaluation of the effects of an EAT intervention for persons diagnosed with schizophrenia. The response rate of 30% indicate that it may be difficult for people with a diagnosis of schizophrenia to answer questionnaires even though they can very well assimilate and benefit greatly from an EAI, which is supported by the qualitative interviews with the study participants in the intervention (Hultsjö & Jormfeldt, 2022) and with their relatives (Fridén et al., 2022). The difficulty for people with severe mental illness to be able to complete questionnaires with sensitive questions may be an explanation to the lack of evidence-based knowledge about equine-assisted therapy and rehabilitation in healthcare settings (Anestis et al., 2014) which has been highlighted as a serious obstacle for EAT interventions, obstructing such interventions from being accepted as an effective therapeutic intervention in various types of mental illness (Wilson et al., 2017). Further high-quality studies on the effects of EAI for adults with different forms of mental ill-health is therefore required Kendall et al., 2015; O'Haire, 2013).

A second aim of the pilot study was to evaluate the effects of the EAT intervention on psychiatric symptoms such as depression and anxiety, as well as affect and self-rated well-being among individuals diagnosed with schizophrenia. The results of the study were in line with the expectations of an improvement post intervention participation. The key findings included an enhancement of well-being and a decrease in psychiatric symptoms such as anxiety and depression following the EAT intervention. Furthermore, an enhancement in positive affect and a decrease in negative affect were found at post treatment.

The results in the present pilot study partially support the hypotheses that anxiety and depression were expected to decrease due to the participation in the EAT intervention. No significant results were found but the general direction of the results for (both anxiety and depression together) demonstrated a decreasing trend, indicated by a medium effect size. It can be argued that levels of depression did not really change in the present study, but it is noteworthy that depressive symptoms did not deteriorate, keeping in mind the high prevalence of the comorbid diagnosis of depression among individuals diagnosed with schizophrenia. Even though the difference between baseline and post treatment was not significant for either anxiety or depression, a medium effect size was approached for anxiety and a small-to-medium effect size for depression found in the expected decreasing direction. Previous studies support the presented data of this small pilot study regarding decreased anxiety due to EAI participation in people with schizophrenia (Alfonso et al., 2015; Scheidhacker et al., 1991) and studies regarding animal assisted therapy interventions (AAT) demonstrating a decrease in symptoms of depression in psychiatric inpatients (Beck et al., 1986; Hundley, 1991). Symptoms of anxiety and depression have been associated with poorer psychosocial functioning such as optimism, personal mastery and perceived stress, hence resulting in a higher risk of suicide and relapse, in addition to compromised vocational functioning (Lysaker & Salyers, 2007). Accordingly, the actual pilot study support further research regarding equine-assisted interventions to facilitate personal recovery among individuals diagnosed with schizophrenia in terms of positive psychosocial functioning and well-being.

The results support the second hypothesis that participation in the EAT intervention could improve positive affect and decrease negative affect. In the present pilot study positive affect was expected to increase and negative affect to decrease. A significant effect on positive affect was found. Even though no significant result was found on negative affect, the general direction for negative affect, indicated the hypothesized trend. Specifically, participants reported a decrease in negative affect, with a medium observed effect size for the baseline and post treatment scores and a large observed effect size for the participants’ positive affect scores. The results support the previous finding by Corring et al. (2010), which demonstrate that horseback riding can increase the experience of positive emotions and enjoyment in people with schizophrenia. Furthermore, the results are in line with the finding by Gabriels et al. (2012) that EAT interventions can enhance emotional regulation in clinical populations. It has been found that people with schizophrenia experience less positive and more negative emotions in their daily lives (Cho et al., 2017). Previous findings in the literature have reported lower positive and higher negative affect when using the self-questionnaire PANAS to measure the emotional experience in people with schizophrenia (Cho et al., 2017). The experience of positive emotions is an important aspect of well-being. Thus, targeting the impaired emotional experience and emotional regulation by aiming for an increase in the positive emotional experience and decrease of negative emotional experience should be an important objective/feature of an intervention designed for people with schizophrenia, since affective domains have been found to be a significant predictor of personal recovery (Van Eck et al., 2018). Furthermore, it has been found that apathy and lack of motivation are frequent features of schizophrenia (Fulford et al., 2018). Thus, designing new innovative innovations which could possibly counteract the negative impact of these frequently encountered negative features of schizophrenia on well-being and recovery by increasing enjoyment and positive emotions, such as equine assisted therapy interventions, could have important implications for the focus of healthcare services. Therefore, our finding that the EAT intervention shows potential to increase positive affect and decrease negative affect in persons diagnosed with schizophrenia is promising.

The third hypothesis, that levels of self-rated well-being should increase after participation in the EAT intervention was supported as the results indicate both a large observed effect size and a significant difference between baseline and post treatment levels of subjective well-being in the participants. The data suggests that participation in an EAT intervention has an enhancing effect on subjective well-being and general health, which supports previous findings in the literature regarding beneficial effects of EAT on aspects of well-being (Bizub et al., 2003; Holley et al., 2011; Karol, 2007; Lechner et al., 2007; Schultz et al., 2007; Seredova et al., 2016; Vidrine et al., 2002). The subjective experience of well-being is often low in people with schizophrenia. It has been linked to lower optimism and resilience, higher perceived stress, and lower self-efficacy, resulting in an increase in depression and anxiety symptoms, related to negative consequences such as increased isolation, loss of social identity and vocational functioning (Palmer et al., 2014). Therefore, this study’s significant finding on increased subjective well-being is important since it suggests that participation in EAT interventions for people with schizophrenia may strengthen empowerment and facilitate personal recovery and the achievement of a meaningful and purposeful life.

Methodological considerations

The methodological issue of a small sample size decreases the study’s statistical power and increases the likelihood of a type II error. Another possible source of error is the lack of a control group, consequently no definite conclusion can be drawn from the results regarding if the horse is the real causal agent of the intervention. Given the small sample size and lack of control group, caution must be applied. However, individual interviews with the study participants (Hultsjö & Jormfeldt, 2022) and their relatives (Fridén et al., 2022) support the findings of this small pilot study and illumine the role and importance of the horse in the intervention.

Limitations notwithstanding, the results of the current pilot study suggest that participation in an EAT intervention may be beneficial for both personal and clinical recovery of people diagnosed with schizophrenia. The intervention shows promise in facilitating well-being and quality of life, even in the light of the complications related to the diagnosis of schizophrenia, which is often considered as one of the psychiatric diagnoses most difficult to treat. In this study 20 individuals diagnosed with schizophrenia participated in and benefited from the intervention but only six of them were able to complete the pre- and post-test questionnaires due to their mental health condition. As the null hypothesis cannot be rejected based on the results of this small pilot study, due to weak statistical power, it is recommended that EAT interventions for individuals diagnosed with schizophrenia are further investigated by means of both qualitative and quantitative research methods. Future research should preferably address methodological issues, such as finding strategies to increase the sample size and adding a control group to further investigate the horse as a causal agent of the EAT intervention.

Conclusion

In conclusion, the low response rate in the present pilot study indicate that it may be difficult for people with a diagnosis of schizophrenia to complete self-rated questionnaires even though they can very well assimilate and benefit greatly from EAT interventions. The results support the assumption that self-rated questionnaires should be combined with other types of data collection methods, such as qualitative interviews with study participants and their relatives beside clinical outcome measures, in evaluation of holistic health promoting interventions. However, based on the findings of this small pilot study, further pursuit, and establishment of a solid evidence base for EAT interventions for persons diagnosed with schizophrenia are warranted. Establishment of EAT interventions as a possible future mainstream mental health nursing intervention as a complement to the traditional clinical approach may promote a higher proportion of successful recovery among persons diagnosed with schizophrenia.

Additional information

Funding

The study was approved by the Regional Ethics Committee at Lund University, Sweden (Dnr 2017/709) and has been performed in accordance with the ethical standards of the World Medical Association Declaration for Helsinki (2013).