Understanding Empathy in Equine Assisted Psychotherapy by Sheila M. Anderson BSW, University of Northern British Columbia, 2010 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE DEGREE OF MASTERS OF SOCIAL WORK UNIVERSITY OF NORTHERN BRITISH COLUMBIA November, 2021 © Sheila Anderson, 2021 i Abstract Equine assisted therapies are growing in popularity as a modality for treating various mental health and developmental challenges. Many of these challenges require focused work on the development of empathy, perspective taking, and attunement to self and others. This study examines the participants’ experiences and understanding of empathy as it relates to self, humans, and equine partners via structured qualitative interviews with four therapy participants. The interviews conducted for this study demonstrated a distinct common understanding of empathy as the ability to take perspective based on the human’s or animal’s own orientation in the world; an understanding that developing empathy within the context of equine therapy was emotionally laborious and required significant work and emotional engagement on the participant’s behalf. The interviews indicated that the participants’ perceived the horse as emotionally neutral in therapeutic interactions. Furthermore, the study indicated that a central component to the perceived success of this modality of therapy was a parallel process in relationship between the facilitator/client dyad and the client/equine dyad. Keywords: equine facilitated therapy; equine assisted therapy; empathy; attachment; trauma; development; mental health; attunement; thematic analysis; animal assisted therapy; intersubjectivity; Understanding Empathy in Equine Assisted Psychotherapy ii Table of Contents ABSTRACT i TABLE OF CONTENTS ii ACKNOWLEDGEMENTS v CHAPTER 1: Introduction 1 Research Purpose and Question 2 Researcher Context 3 Motivation for Study 3 Framework/Conceptual Lens 5 Definitions 7 Animal Assisted Therapy 7 Empathy 7 Equine 7 Equine Assisted Therapy and Equine Facilitated Psychotherapy 8 Equine Specialist 9 Indigenous 9 Intersubjectivity 10 Mental Health Practitioner 10 Thesis Outline 11 CHAPTER 2: LITERATURE REVIEW 13 Equine Facilitated Therapy 15 Theory of Intersubjectivity 20 Empathy, Emotional Attunement, and Relationship 22 iii Organizations Regulating EAT/EFP 26 Table 1 List of Acronyms 29 CHAPTER 3: RESEARCH METHODOLOGY 30 Researcher Approach 30 Research Design 33 Participants 36 Data Collection 36 Demographic Forms 37 Interviews with Participants 38 Ethical Considerations 40 Confidentiality 40 Safety of the Participants 41 Data Analysis 41 Member Checking 43 CHAPTER 4: FINDINGS 45 Themes 45 Characteristics of Research Participants 45 Interviews 45 Defining Empathy 46 Empathy as Emotional Labor 47 Empathy and Emotional Engagement 50 Parallel Process of Empathy in Facilitator/Client Dyad and Client/Equine Dyad 51 iv Perception of Emotional Neutrality in the Horse 52 CHAPTER 5: DISCUSSION 55 Discussion of Themes 55 Definition of Empathy 55 Empathy and Emotional Labor 56 Empathy as an Emotionally Engaged Process 57 Parallel Process of Empathy in Facilitator/Client Dyad and Client/Equine Dyad 57 Perception of Emotional Neutrality in the Horse 58 Limitations 59 Sampling 59 Comparison of Themes and Literature 60 Suggestions for Future Research 61 CHAPTER 6: CONCLUSION 63 REFERENCES 65 APPENDICES 72 Appendix A Email Template to Practitioners 72 Appendix B Information Letter for Practitioners 73 Appendix C Email Template for Practitioners to Forward to Membership 76 Appendix D Participant Information and Informed Consent 78 Appendix E Confidentiality and Non-disclosure for Transcription 83 Appendix F Demographic Questionnaire for Participants 85 v Appendix G Interview Schedule 86 Appendix H Research Ethics Board Approval 88 Appendix I Research Ethics Board Amendment and Renewal Approval 89 Appendix J Summary of Acronyms 90 vi Acknowledgements First and foremost, I am forever grateful to the research participants who agreed to partake in this study and their generosity with their thoughts, perceptions, and time. I am always humbled by the stories of others, and it is not lost on me that it is an exceptional privilege to bear witness to the journey of others. Without your stories, this research would not have been possible. The sharing of your stories contributed to this study, the body of literature surrounding equine facilitated therapy, and to my professional development. However, beyond the obvious, your stories, experiences, and immense insight served to improve my daily life with my own horses, children, and various other beasts. My horsemanship and my day-to-day experience and work with my equine partners has improved dramatically as a result of your participation in this research, and my own experience of empathy has been deepened. Thank you. Likewise, I am forever indebted to Glen Schmidt. Thank you, Glen. When I completed my under-graduate degree, I often told others that you were the most difficult professor when grading papers, but the feedback and brilliance that you provided were invaluable to your students. Thank you for your patience as I struggled with various life events, piecing this research together bit by bit. Thank you for your mentorship. Much like I said a decade ago, thank you for your feedback and continued brilliance. To Si Chava Transken… you are a diamond embedded in the tiara of womanhood. Beyond academia, beyond grading papers, beyond social work- your complete, beautiful authenticity grants others the permission to extend into themselves. From knowing you, I’ve come to know myself in a much more authentic way, and I cannot imagine this journey without your contribution to my life. Jacqueline Holler, thank you for agreeing to sit on my committee. vii Your feedback and critical contributions at the beginning of this project turned my mind to refining my skills, exploring methodology and challenging myself from an interdisciplinary lens. To my sweet Grandmother, without you, none of this would have been possible. You have been a lighthouse in ocean storms; you have raised me to be the person that I am; and you have ingrained a sense of self development and improvement in me that I would never have been exposed to otherwise. I hope to grow up to be half the woman that you are. Mom and Dad, oh boy, the journey this path has taken me on. Thank you for your strong, steady, and value driven guidance over these nine years of post-secondary work. Thanks for bailing me out over and over, and still finding the patience to support me in all my hair brained adventures. Your parental advice isn’t lost on me, even though it feels like it is sometimes. I will slow down to smell the flowers soon, I promise. Rupi, Rumi, Maya, Bukowski, Van Gogh… you know who you are, and you know that I wouldn’t have done this without you. Thank you to my babies. All four of you have guided me in this journey and have pushed me to keep going when I felt I could not continue with this project. Shaleena, you have seen me through two degrees and over half a lifetime of crazy adventures. Thank you. You have sacrificed the most for my education, and I will hold that close to my heart forever. Your brilliant and complicated mind motivate me in ways I don’t know that you or I fully understand. Ohlund, you are responsible for the idea behind this research. Your challenges and beauty are what motivated me in seeking this degree. Kamijah, thank you for your passion for horses, for reaching out to me during the long hours typing and reading with a hug and “I love you” when I was tired and overwhelmed. Your attunement to others motivates me to improve and to be a better human. Aspen Sophia Grace, thank you for travelling back and forth to Prince George as a new baby, for being wonderful during classes and for your sacrifices to this project. In viii September, you start kindergarten, and you were only a few months old when I enrolled in this program. Your entire childhood thus far has involved this project. Thank you for your patience with it. Finally, thank you to everyone who has lifted me along this path. There are so many people that have contributed to this work and this project. I am humbled by you and grateful to you. Empathy in Equine Facilitated Psychotherapy 1 Chapter 1: Introduction Noske (1997) discussed a recorded history of animals that demonstrated strong empathy in their relationships with humans. This high level of sensitivity to the emotional state of others may serve an evolutionary purpose in animals, specifically prey animals. Animals such as horses are highly attuned to the social and emotional cues of humans and respond to the human’s social and emotional state (Dorsey, Conover, & Dell, 2014). As Dorsey et al. (2014) explain, a horse’s response to a human’s emotion reflects a complex interplay of the lived experience of the animal, evolutionary development, the experience of the human, and the emotional state of each. This interaction between animals and humans is noted by many to have therapeutic benefit with active coaching and competent intervention (Burgon, 2011; Pollack, 2009; Trotter, 2012). Utilizing animals in therapeutic interventions provides immediate, in-the-moment, experiential learning (Trotter, 2012). It has long been believed that horses are particularly effective when used for therapeutic purposes due to their highly attuned emotional response to human beings (Westerman, Westerman, Hargreaves, & Verge, 2008). As empathy is largely recognized as a predictor of success in human relationships (Lapointe, 2016) it is worth exploring and researching therapies that have been noted to improve empathy and emotional attunement. As animal assisted therapies involving horses gain popularity, it is prudent for practitioners, consumers, and researchers to develop an in depth understanding of the benefits of these therapies, the limitations, and the impact on the animal. As the scope of practice and therapeutic use in animal assisted therapy expand to include trauma therapy, somatic therapies, and therapies that are targeted at addressing healing from complex symptoms, such as dissociation and complex identity issues, the clinicians practicing this modality must continue to expand and develop professionally, and to be critically reflexive in 2 their practice. The research contained in this thesis aims to examine the modality of Equine Assisted Psychotherapy (EAP) and its relationship with empathy. Research Purpose and Question The field of Social Work is broad based, and Social Workers exist and are employed in a variety of contexts. In British Columbia, Social Workers can register with the British Columbia College of Social Workers (Social Workers Act, British Columbia, 2008 18(1)). Registration is not always a professional requirement, as some agencies and categories of employment are exempt. Social Workers can be employed to practice in a variety of fields, including individual therapeutic interventions that address trauma, complex family and social dynamics, and oppressive and colonial systems. Social Work has a rich background that is drawn from a variety of social sciences. The purpose of this research is to examine one aspect of therapeutic intervention that a Social Worker providing individual, familial, or group service may utilize. Social work practice demands that we challenge oppressive systems, develop s trength-based approaches, and center practice on the client and social justice. As this document is being completed in partial fulfillment for the degree of Masters of Social Work, the research will reflect Social Work practice, critical analysis, and the Canadian Association of Social Workers current code of ethics. Sudekum-Trotter and Baggerly (2019) discuss the importance of mental health professionals utilizing trauma informed practice principles, and feel that using equines in trauma based therapies can “facilitate safe relationships, restoration, and reconnection” (p.xiii) for trauma survivors. Trauma symptoms often create challenges for individuals and families as the symptomology impacts the survivor’s ability to interact with their environment and with others (Sudukum-Trotter & Baggerly, 2019). Unique developmental profiles, brain injuries, and health and genetic challenges can also impact an 3 individua l’s ability to interact appropriately. However, as the literature is beginning to demonstrate, the brain and body have a remarkable capacity to heal, develop, grow, and expand throughout the course of the lifespan. Carefully planned and executed interventions that are attuned to the needs of the subject can re-wire the brain to form healthy connections with others (Perry, 2006). Attunement and healthy emotional attachment require us to develop empathy for others, and we develop empathy and attunement through modelling and in relationship with others (Lapointe, 2016). Given the importance of empathy in developing healthy relationship, and the emergence of EAT as an intervention for those facing relational challenges, it is prudent to expand our understanding of the relationship between empathy and EAT. This thesis aims to explore the following research question: How do adult EAT/Equine Facilitated Psychotherapy (EFP) participants experience and understand empathy as it relates to EFP/EAP? Researcher Context Motivation for Study I am a cis-gendered, pan sexual woman of Irish-Cree descent living in rural Northern British Columbia. I have lived in the north for the majority of my life and I have worked in the field of social work since my graduation from the University of Northern British Columbia (UNBC) School of Social Work with my Baccalaureate of Social Work degree in 2010. I have worked extensively in the field of child welfare in rural and remote communities, including primarily Indigenous communities in the far north of the province. I have worked as a frontline child protection worker and as a team leader for a child protection team. In 2019 I decided to change focus in my career and moved into the field of mental health and substance use. My role was to serve rural and remote Indigenous communities. I have recently transitioned into a management position for the health authority, providing specialized mental health and 4 substance use services. Throughout my eleven-year career, I have been privileged to hear the stories of many individuals. These stories contain bits of beautiful humanity, but these pieces are often overshadowed by painful narratives of trauma, discord, and disrupted relationships for both the individuals and families. Overwhelmingly, from my lens, both systems that I worked within, including health care and child welfare, fail to adequately address or intervene to both prevent and treat these traumas. Individual services are limited by resources and budgets, and adequate childhood interventions are restricted by the same. This realization has generated curiosity for me. I am motivated to provide effective and engaging interventions that promote healing and growth. I am also an equine enthusiast and I have been around horses and riding horses from, quite literally, before I could walk. My formal and paid experience with horses equates to approximately 42,000 hours of work accrued from the age of ten years old. Informally, I have spent approximately 4-6 hours every day with my own horses from the age of three years old. I cannot remember a time in my life that I was not profoundly impacted by these animals. Anecdotally, as a trauma survivor, and as a person living with the challenges of Complex Post Traumatic Stress Disorder from a young age, I value the role of horses in my own healing journey. I find a deep sense of calm and peace with my four horses (and a myriad of other creatures). Further, I am a single mother of four children ranging in age from four to fifteen years. One of my children lives with extensive extraordinary sensory needs with the unique developmental challenges of living with Autism Spectrum Disorder. Although I have not witnessed enormous therapeutic benefit from his relationship with equines, I have seen an incredible relational dynamic unfold between him and his hedgehog, Sonic. I’ve witnessed the regulatory benefits of having well socialized dogs working with children with developmental 5 challenges and have volunteered for organizations providing equine related interventions to children with exceptional needs. I am motivated to find interventions for my children that promote relational development, emotional health, cultural connection, and kindness. I live a complex and busy life, and I recognize that the various lenses through which I witness the world have impacted not only my choice in study and research, but the entire design, methodology, interpretation and coding of the data. In order to present the findings of my study in an accurate manner, I have had to critically reflect on my own epistemological beliefs and to challenge my ontology as someone that has broad experience with equines, whose beliefs tend to be derived anecdotally. As a Registered Social Worker (RSW) it is critical to me that my contribution to research examines and challenges the status quo as it relates to marginalized populations and populations that face systemic oppression. I have included this analysis throughout the course of this manuscript. Framework and Conceptual Lens It is important to note the framework and conceptual lens from which I approached the research that is contained in this manuscript. As noted above, I am of Cree-Irish descent, and a single mother of four, including a child with significant special needs. I approach this research from the lens of intersectionality. I refer to intersectionality in this document as a description of the multifaceted, complicated and often overlapping social context that I exist within. The social context and complex intersections of the social systems that I exist within shape the experiences that I have. I am at once marginalized and afforded privilege as I navigate life and the various systems that I interact with. Further, I have existed in the space of intersectionality as a parent, experiencing and witnessing oppression, stigma, privilege, and opportunity. It is important to note that my choice of research is grounded in this space. In analyzing the framework and conceptual lens that I am utilizing in this research, I experienced some dissonance related to my framework of choice. Much of the current literature related to psychosomatic and psycho-social healing is grounded in attachment theory. John 6 Bowlby’s framework for understanding attachment has promoted the relationship in the mother child dyad as a fundamental predictor of the physical, mental, and socio-emotional health of the child later in life. Although the literature has evolved over time to recognize that the outcomes of children do not rest entirely on the shoulders of the maternal caregiver, the historical promotion of mothers as the most fundamental attachment for children has contributed to the further marginalization and societal blaming of women. The focus on maternal responsibility within the social context of attachment theory have largely been internalized by all, and has contributed to the subjugation of women as a whole. It has promoted a standard of impossible parental responsibility being placed on women, and a societal shaming and marginalization of women and mothers who do not conform, whether voluntarily or involuntarily, to the largely euro-centric and westernized standard of motherhood. In Dr. Diana Gustafson’s book, Unbecoming Mothers (2005), her and her contributors provide a thoughtful and articulate analysis on the limitations of attachment theory and how it has served to further marginalize women in society. Werner and Smith’s (2001) longitudina l study on the outcomes of ‘at risk’ children, challenges the maternal attachment paradigm as it relates to the long-term resiliency and wellbeing of children deemed to be at high risk due to adverse childhood experiences (ACE). The current literature in resiliency, healing, and lifelong social and health outcomes is still largely grounded in attachment theory, though more recently there has been a shift to a primary caregiver attachment and continued relational attachment rather than the mother-child dyad. However, the dissonance I experienced as a researcher related to a feminist critique of fundamental attachment theory made the literature on psycho-therapeutic interventions a bit challenging. Sudukem-Trotter (2019), Lundgren (2019), and Schlote (2019) offered a different lens through which to view relational attachment as an active contributor to the ebb and flow of relationship, healing, and resiliency throughout the course of the mammalian lifespan. The theory of intersubjectivity that these authors integrate into their therapeutic interventions represents a concept of relational cuing, attachment, dyadic and triadic interaction, and mutual, 7 and individual understanding. A broad-based understanding of both interaction and observation, and similarity and difference in mammalian psycho-social development provided a much more dynamic lens through which I could understand and interpret the literature. Further, I found that this framework allowed for the renegotiation and understanding of neurological, biological, and social change and interaction throughout the course of the lifespan, rather than reducing the social, biological, and neurodevelopmental outcome of the subject or subjects to one primary early attachment. The theory of intersubjectivity captured and accounted for many of the limitations and challenges that I had in applying fundamental attachment theory to my research. For the purposes of this manuscript, I will provide a more in-depth definition of the theory of intersubjectivity, as reviewed in Lundgren (2019), when I review the various definitions that are outlined to assist the reader in interpreting and understanding this manuscript. Please refer to Appendix J for a complete list of acronyms and their corresponding definitions. Definitions Animal Assisted Therapy Animal assisted therapy (AAT), for the purposes of this manuscript, is defined by Kemp, Signal, Botros, Taylor, and Prentice (2014) as the “deliberate involvement of animals within a treatment to realize specific therapeutic goals” (p.559). Although the therapeutic goals that result in the engagement of animals may vary, the use of animals in therapy has provided an improvement in general therapeutic alliance between practitioner and client, and further, the involvement of animals in therapeutic work has been linked to lower levels of attrition in therapeutic engagement (Kemp et al, 2014). Empathy Empathy and emotional attunement have been identified as primary factors in positive human relationships (Lapointe, 2016). The definition of empathy varies across the literature, but it is generally understood to refer to a person’s ability to accurately interpret another being’s emotional state and to subsequently respond appropriately to this emotional state (Spreng, Mckinnon, Mar, & Levine, 2009). Broad-based empathy allows the individual to view another being’s life within the context of alternative circumstances. This definition is useful in understanding empathy in human and animal relationships. Spreng et al.’s (2009) definition of 8 broad-based empathy incorporates and integrates both cognitive and affective empathy, and will be the definition that will be relied upon for the purposes of the research being analyzed in this manuscript. Emotional Labor For the purposes of this study, emotional labor refers to the intense, yet often unseen emotional ‘work’ that is required to develop or improve emotional regulation and emotional skills within the therapeutic context. Emotional Engagement Emotional engagement for the purpose of this research refers to emotional involvement and emotional participation in the therapeutic process. Pietarinen, Soini and Pyhalto (2014) discuss emotional engagement as critical to the experience of students in school. Ultimately, the level of emotional engagement with teachers and peers appeared to affect the level of cognitive and academic engagement and subsequent learning for the students. This concept of emotional engagement was consistent with the findings of this study, albeit within a different context. Emotional engagement appeared to occur across the facilitator/partic ipant/equine triad, rather than Pietarinen, Soini and Pyhalto’s (2014) discussion of student/teacher/peers. Equine Equine is defined as any animal from the genus Equus, of the family Equidae. Equus includes donkeys, horses, zebras, and offspring of any interbreeding between species, including mules, zorses, and hebras. This genus includes ponies, miniature ponies and miniature horses. EAT/EFP can be facilitated using any member of the genus Equus, though it is most commonly done with horses, donkeys, and ponies. Equine Assisted Therapy and Equine Facilitated Psychotherapy One emerging branch of AAT is Equine Assisted therapies (EAT). Although the equine-human bond has been anecdotally discussed for generations, Trotter (2012) explains: This type of animal assisted therapy is in its infancy in terms or research, theory, and practice, and, as with any newly developing counseling field, the literature on qualitative observations and case studies is greater than empirical-based quantitative research and theory exploration (p.9). 9 EAT and EFP are generally defined as AAT that specifically engage equines in working towards therapeutic goals. Many of the same benefits that are derived from AAT are applicable to equine involved therapies as well. It is necessary to clearly define EAT, EFP , and other equine related therapeutic interventions that involve equines in a human’s therapeutic goals and process as a separate field entirely from the work of equine therapy. Equine therapy refers to the rehabilitative therapy used on horses to ensure their physical well-being. Equine therapy refers to various measures such as massage, osteopathy, physical therapy, etc. that are utilized on performance horses or horses recovering from injury. Finally, EFP/EAP must be differentiated from hippo-therapy and therapeutic riding. Hippo-therapy is defined by the Canadian Therapeutic Riding Association (2018): The utilization of the horse for therapeutic purposes rather than equestrian goals. This field targets acquisition of motor pre-requisites rather than equestrian abilities. Hippotherapy is a rehabilitation strategy using a mobile and live instrument called ‘horse.’ The horse possesses motor and emotional, neuro-sensitive stimulation qualities never equaled by a machine. The horse offers 110 multidimensional movements by impulsion every minute. No therapist, no matter how motivated or talented, can compete with this quality stimulation. Hippotherapy is a specialization reserved to rehabilitation specialists: physiotherapists, occupational therapists and speech language pathologist trained in this field. (Definition of Hippotherapy, para.1). Therapeutic riding is categorized as hippotherapy, and riding is used primarily for the purposes of occupational, physical, and speech therapy. Equine Specialists This term refers to the member of the care team providing EAT/EFP services to the patient that is primarily responsible for the well-being of the equine partner. This person is expected to have a background in equine behavior and to have extensive knowledge about how equines experience and interact with the world, as well as handling equines in a manner that is safe for both the people involved and the equine. Many of the organizations promoting EAT/EFP outlined in the literature review emphasize that the Equine Specialist’s 10 primary responsibility lies in ensuring the wellbeing of the equine participant. Similar to the mental health professional involved, the Equine Specialist’s professional requirements and education vary depending on the organization that they are affiliated with. It is important to note that much like the field of counseling, mental health and therapy in Canada, EAT/EFP is not a professionally and/or legislatively regulated profession. As such, caution should always be used in finding an appropriate EAT/EFP program. Indigenous Indigenous is often understood colloquially to mean original inhabitants of a geographical area. In modern times, it has come to be viewed as synonymous with Aboriginal person, people or community, or even with First Nation person, people, or community. In British Columbia and in a larger context, the legal system has moved towards using Indigenous as a term to replace previous legislative language of Aboriginal, Indian, and/or First Nations. Examples of these changes can be found in the Federal Bill C-32, and in recent legislative changes to the Child, Family and Community Services Act (2019). Ironically, the Indian Act remains a governing piece of federal legislation and has not been completely revised to utilize more accurate terminology. A common critique of the term Indigenous, and one that prompts self-reflection, is that it does not encompass the diverse, complex, and often contradictory identities that are experienced by those whose lives and collective histories were deeply affected by colonialism. It reduces the lengthy and complex ancestral histories of many to a singular term that does not adequately account for these histories. However, for the purposes of this manuscript, the term Indigenous will be used to refer to any individual of varying Indigenous ancestry who has been impacted by the process of colonization. This term includes any individual who self identifies as Indigenous or as being subjugated by the global colonial history as the result of their identity as an Indigenous person or a person with Indigenous ancestry. Intersubjectivity Intersubjectivity is a central concept to EAT/EFP and is defined by Lundgren (2019) as “a sharing of experience [that] points to the interactive aspects of relationship” (p.22). Intersubjectivity in EAP/EFP in grounded in the understanding that the 11 subject(s) must come to develop a shared understanding and interpretation of the experience (Bradfield, 2012). It requires that a relationship between self and other be experienced based on mutual and reciprocal interaction, and is premised on the assumption that this experience is what brings one into ‘being’. Bradfield (2012) suggests that intersubjectivity theory is centered on the core assumption that through shared understanding of meaning, symbolism, beliefs, and language, self and relationship to self and others come to exist. Of particular interest, in relationship with animals, and more specifically, in relationship with equines, a human subject and equine subject would have to negotiate a shared understanding of meaning, symbolism, beliefs, and language in order to come to relationship. Phenomenologica l philosophy would support that the negotiation of shared understanding is an inherent element of intersubjective experience. For the purposes of this manuscript, intersubjectivity is understood as a shared experience between subjects, subject and object, or subjects and objects. It refers to the intersubjective experience between client and facilitator; horse, facilitator and client; horse and client; and other relationships in the lives of the participants, such as child and parent. Mental Health Practitioner This term refers to the mental health professional involved in EAT/EFP. Many of the organizations promoting EAT/EFP require that the team providing services to the patient consist of both a mental health practitioner or mental health professional and an equine specialist. A more comprehensive overview of organizations promoting this therapeutic modality can be located in the literature review. The mental health professional involved in providing therapeutic intervention is expected to have a professional background in mental health services, though the minimum requirement for education and years of experience varies by organization. The professional’s focus is on providing linkages between the patient and the mental health intervention. Thesis Outline This thesis is divided into five chapters. The first chapter contains a general introduction to the topics being researched, including the research question, the researcher’s motivation, contextual lens, and the researcher’s reflections on identity. Chapter 1 also contains several 12 broad-based definitions on concepts and words contained within this manuscript. Chapter 2 contains the literature review including information on the history of EAP/EFP, the current understanding of the benefits and limitations of EAP/EFP, and themes and contradictions within the current body of literature in EFP/EAP as well as examining the current body of literature regarding empathy and its role in relationship. Chapter 3 reviews the research methodology that was used for the purposes of this study, including the general approach to research, the design, sampling, data collection, and analysis of the data. The limitations of this study and ethical considerations are reviewed. Throughout this chapter, I provide my own reflections as the inquirer in this research, and describe how the study was designed. Finally, I conclude the chapter with an overview of how I ensured the validity of the analysis and conclusion. Within Chapter 4 I discuss the findings of the study, including the themes that I derived from analyzing the two primary data sources, interview transcripts and demographic questionnaires, and subsequently reviewing with participants to ensure that the analysis accurately and adequately represents their contribution to the research. This chapter also analyzes the implications of the findings of this study on EAP/EFP interventions. Chapter 5 contains the conclusion and discusses the findings of the study, how the findings compare and contrast to the larger body of literature, and ideas and recommendations for further research and how these findings can be integrated into recommendations regarding EAP/EFP as an effective intervention that promotes empathy. 13 Chapter 2: Literature Review Animal assisted therapy (AAT) as a formalized therapeutic modality was first documented as beneficial in the literature in the 1970s by psychiatrist, Boris Levinson. Levinson stepped out of a therapeutic session with a very difficult child and returned to find the child speaking to his dog, Jingles. Levinson subsequently authored several papers on the subject of AAT and is regarded as a founder of formalized AAT. The idea of non-human animals’ benefiting human mental and physical health is longstanding (Cusack, 1988). Several studies link changes in the human physiological state to contact with animals. For example, Gehrke (2010) explored heart rate changes in humans handling horses and the correlation that this had with heart rate changes in the horses being handled. The study concluded that changes in a horse’s heart rate mirrored changes in the handler’s heart rate. Noske (1997) notes that the mirroring of physiologica l response between humans and animals is well documented. AAT involves utilizing animals specifically trained for the therapeutic process. This purpose contrasts with Animal Assisted Activities (AAA) in that during most AAA sessions, animals are simply present for or involved in the activities but are not necessarily trained for a therapeutic purpose. AAA tends to be more recreational in nature and focuses on engaging the client in new activities with the animals. AAT adheres to specific therapeutic protocol in order to produce a desired psycho-social outcome in the service recipient. Animals in AAT are trained and socialized to work within the specific therapeutic protocol. AAT is applied across various contexts including medical settings, one on one counseling, assisting people living with exceptional physical, emotional, or psychological needs, court work, school and learning environments, and as a method of intervention in lowering the transmission of inter-generational abuse (Parish-Plass, 2008). AAT has been well researched and the benefits of animals in supporting self-regulation, physical health, empathy, socialization, and in reducing challenging symptoms related to mental health, trauma and relational challenges are well documented (Cusack, 1988). 14 Cusack (1988) identified significant benefits related to pet ownership, including physical health benefits such as the reduction of cardiac distress and a reduction in the occurrence of heart attacks. Many of the benefits of pet ownership are noted to be benefits also associated with participation in AAT. Given the complexity of personality traits, behaviors, and preferences for certain animals, AAT may not be beneficial for all potential participants. As the vast majority of AAT programming is voluntary, it is difficult to ascertain if the benefit of AAT is specific to personality traits or characteristics, or if a population with certain personality traits and characteristics is more likely to seek AAT services and subsequently benefit from the service. Cusack (1988) presents a strong case for the use of companion animals in improving quality of life. She explores various physiological benefits, mental health benefits, benefits to family functioning, and benefits to children. Her literature review also included exploring the impact of human dysfunction on animals, and the role of animals in a family experiencing dysfunction. Of note, Cusack (1988) also reviewed the developmental capabilities of children in understanding and empathizing with animals, offering insight into the developmental stages of empathy and compassion in human relationships. Cusack’s (1988) review of the literature suggested that young children are unable to understand that animals can experience pain or exhibit different emotions. The ability to empathize with an animal’s feelings of pain and emotion appeared to develop for children around seven years of age (Cusack, 1988, p. 93). There are many accounts of the benefits of animals in working with children living with exceptional abilities from a young age. One Prince George based psychologist, Dr. Holly Ambrose, suggested that her therapy dog, Elvis, has a significant calming effect on young children being assessed for Autism (Personal communication, September 21, 2015). Dr. Ambrose has Elvis present in the room during the assessment of children of all ages. During one 15 assessment, a three-year-old boy’s behavior was beginning to escalate when he noticed Elvis sitting in the room. He then took his security blanket and lay down beside the dog, sucking his thumb. This appeared to soothe the child and to settle his behavior. The young boy also had a dog at home that he used to self-soothe. Although this does not indicate that the child had an understanding of empathy or animal emotions, it does support the literature in that the presence of the dog contributed positively to the child’s ability to regulate his behavior. It is also worth noting that there was no specific therapeutic intervention outside of having the dog present in the room. The child’s interaction with the dog was organic and not preceded by a prompt to interact with the dog. Given the significant variety in animal preference, personality traits, therapeutic uses and settings, gender affect, and developmental ability to understand and empathize with animals, it is clear that AAT needs to be explored and utilized on a case-by-case basis. Each service recipient group may respond differently to the therapeutic process and may interact differently with the animal based on the above noted variables. In short, it is likely that AAT would not prove to be useful for all service recipients. However, given the well documented benefit of AAT in therapeutic settings, as well as the robust body of literature supporting companion animals as a method to improve quality of life, it is imperative that AAT continue to be explored. Equine Facilitated The rapy Equine Assisted Therapy (EAT) and Equine Facilitated Psychotherapy (EFP) are emerging sub-fields of AAT. Although the research is in its infancy, EAT appears to be very promising in the field of mental health, suggesting that it promotes regulation, therapeutic engagement and alliance between therapist and client, empathy, emotional processing, and selfunderstanding (Burgon, 2011; Chalmers & Dell, 2011; Smith-Osborne & Selby, 2010). Like 16 most emerging therapeutic modalities, the literature investigating EAT is primarily qualitative to this point (Trotter, 2012). The current body of literature emphasizes the level of therapeutic engagement, therapist/client alliance, development of empathy, relationship building, and sense of self mastery and appropriate expression of emotions as positive therapeutic outcomes. Burgon (2011) examined therapeutic adherence and engagement in her case study ethnography with high-risk youth. She concluded that the youth demonstrated significant improvement in interactions, self-confidence, and sense of mastery, self-efficacy, and empathy. Burgon (2011) compared these improvements in intra and inter-personal skills with the resiliency literature and noted that the improvements in these areas were critical to improving resiliency in youth. Trotter (2012) notes that nearly all of the qualitative analysis related to EAT indicates that those participating in EAT demonstrate significant and prolonged improvement in many domains related to sound mental health and quality of life. Pollack (2009) further supports EAP/EAT as an effective method to improve resiliency, empathy, and self-concept in her case study examination of women living with addictions. Pollack’s (2009) study examined women with substance use disorders who were participating in an Equine Assisted Growth and Learning Association (EAGALA) based program. She noted that participants offered significant personal insight after working with the equine facilitators. One participant in Pollack’s study noted that “the horses could feel a little bit of what is going on in your heart and in your stomach and whatever else…they can feel that energy” (2009, p.7). Most of the literature speaks to EAP/EAT providing brief experiential therapy that almost immediately provides participants with feedback on their present emotional state. Many EAP/EAT participants speak to the horses’ providing an emotional mirror, yet the feedback is non-judgmental in nature. As one participant in Pollack’s (2009) study noted: 17 …by having the horses there, it’s basically in your face, you know… it was standing there and reminding me of what I was there to do even though I wanted to block it out… But I think by having him there and attuned to what I was feeling and doing, kept me going… it just gives me the courage to face these issues that I got to face - the ones that I’ve never really talked about and felt- talked about but not felt. And I really think I needed to go there to heal because I was stuck (p.8). The participants in many of the studies speak to the non-judgment of the horse, the horse’s ability to respond without inflicting emotional pain, and learning resiliency in what was previously viewed as failure. Jasmine, a participant in Pollack’s (2009) study on women with addictions in EAP, stated: The fact that the horse didn’t go where I wanted it to go didn’t completely devastate me like it would’ve in the beginning. Like, ‘oh my god, I completely failed’. And, I mean, even a success for me was the fact that I didn’t get down on myself because it didn’t happen. It was like when you’re given a task and you can’t necessarily complete it exactly the way you think it’s supposed to go- it was about finding successes in how I handled the situation or reacted to my disappointment (p.9). Trotter (2012) describes the theoretical underpinnings of EAP as based in the Gestalt therapies. Gestalt therapies emphasize metaphorical insights and experiential learning in the therapeutic process. Gestalt methods are largely based in phenomenology and aim to really examine the meaning that the participant attaches to life events, scenarios, and experiences. EAP is focused on creating scenarios with the horses as co-facilitators and then allowing time for the participant to debrief and communicate their lived understanding of the shared therapeutic experience (Becker & Nussen 2012; Kirby, 2016; Rudolph, 2014). The therapist can offer 18 metaphorical insight, but this is typically only guided, and the participant is asked for their thoughts, feelings, and understanding of the scenario in question. A substantial portion of the literature reviewed for this project was grounded in developing insight and intersubjective understanding of lived experience with the horse and human as the subjects in these interactions. To this point, the majority of this literature review has been centered on qualitative analysis. Although the literature pertaining to EAT/EAP is primarily qualitative in nature, there is a growing body of quantitative, ‘empirical’ data related to this field of therapy. Despite the substantial support of EAP/EAT in the qualitative based literature, there appears to be a significant disconnect between quantitative and qualitative analysis. Many of the quantitative studies regarding EAT/EAP have demonstrated statistically insignificant results, or entirely contradictory results. Some studies indicate improvement in self-esteem, self-efficacy, and behavior while others completely contradict these measures. Ewing, Macdonald, Taylor, and Bowers (2007) produced a mixed methods study examining Equine Facilitated Learning (EFL) in youth with severe emotional disorders. The psychometric measures used at the baseline, and again following programming, indicated no significant improvement in scoring across a variety of domains, including behavior, depression, locus of control, empathy, and loneliness. These results did not bode well for the efficacy of EFL. However, Ewing et al. (2007) then completed the second portion of their study, interviewing care providers, therapeutic facilitators, and participants. The results of the qualitative study completely contradicted the findings of the quantitative portion of the study. The intersubjective understanding of the lived experience of the subjects involved in EFL concluded that the EFL was associated with an improvement in the youth’s behavior, depression, locus of control, empathy and experience of loneliness. 19 It is not clear why there is such a significant disconnect in the conclusions of the research, depending on which approach is used to analyze EFP/EAT. It is critical to analyze the discrepancy, as helping professions, researchers, academics and communities continue to challenge, deconstruct, and decolonize the dominant paradigm of the perceived superiority of empirical data. Researchers are challenging the notion that empirical data is the only valuable evidence and are approaching and critiquing research in a manner that allows for multiple epistemologies. Empirically collected evidence that is intended to measure specific traits, such as empathy, ought to be measuring empathy as it is commonly understood, constructed, and perhaps most importantly, as it is experienced within the populations being studied. It is disconcerting that the psychometric measures designed to measure empathy fail to capture what the overwhelming majority of participants and caregivers view and describe as an unmistakable and substantive change in interactional empathy in the participants. As noted, much of the quantitative literature is contradictory to the qualitative literature and as such, it is necessary to challenge and explore these findings while continuing to gather and assess the data. Performing research in a manner that accounts for experience while challenging status quo epistemological approaches when it makes good sense to do so, is an important aspect of anti-oppressive and decolonizing practice. Tuhiwai-Smith (2012), Linklater (2014), and Chalmers and Dell (2011) argue that much of the empirical research is years behind the experience of Indigenous communities. Tuhiwai-Smith (2012) provides the example of blood memory or bone memory. Blood memory is known among the Maori as the memory of generations past. It is the knowledge that the trauma, history, and triumphs of past generations are passed to new generations through blood. This knowledge has been passed down from time immemorial through the Maori, yet it has only been recently acknowledged in empirical studies. 20 Empirical scientists now know that cell memory captures the historical traumas, triumphs, and history of previous generations in adaptations in gene expression (Lehmer, 2018). Chalmers and Dell (2011) argue that EAP/EAT blends empirical, western epistemology, and Indigenous ways of knowing. They posit that this may be the most effective way to approach Indigenous holistic well-being and that the benefit of EAT for Indigenous participants ought to not be dismissed based on the results of quantitative data analysis. Chalmers and Dell (2011) offer the observation that historically, empirical research has been years behind Indigenous knowledge systems. Ewing et al. (2007) describe this discrepancy between the qualitative and quantitative findings as invalidating of the participant’s experience, demonstrating a bias in the literature towards the validity of quantitative findings. It seems prudent to continue to develop an understanding of the individual experience of therapy, and to examine the way in which participants understand the emotional objective of the therapy they are engaged in. Studies such as Ewing et al. (2007) appear to value the quantitative data above qualitative data. It is critical that each approach to research is viewed as valuable, despite the incongruence in findings. The incongruence in qualitative and quantitative findings may indicate emerging trends, an area of study deserving of future research, or simply an interesting trend. It is an important consideration in reviewing the literature, as discrepancies in research approaches are to be expected, and these discrepancies should not invalidate the results of the approach. Theory of Intersubjectivity As discussed, this theory of relational connection and attachment has been documented throughout the literature in therapeutic interventions involving autism, depression, anxiety, trauma, and mental health challenges (DePrekel & Runge, 2019; Lundgren, 2019; Siporin, 2012; Trotter, 2012). Although this theory is used in a diversity of fields and contexts, for the purposes 21 of this research, the theory will be reviewed as it pertains to human-animal bonds, clienttherapist interactions, and human-human relationship. "Intersubjectivity describes the basic phenomena going on in different kinds of relationships. Basic, but not simple" (Lundgren, 2019, p.20). At its core, the theory summarizes how interactions between subjects, such as horse human interaction, are social and emotional in nature. The theory has risen from phenomenologica l philosophy and is centered on understanding the mutual lived experience of interactions between subjects. The interaction between subjects can promote social and emotional health, or alternatively, these interactions can compromise social and emotional health dependent upon the context in which they are experienced and the similarities and differences in assigned meaning between the subjects. A subject's perceptual meaning is a complex interplay of previous experience, current context, inter-generational legacy, and species-specific needs. The concept of inter-subjectivity captures the idea that each inter-subject interaction, whether it is human to human, human to animal, human to object, mother to child, child to teacher, client to therapist etc., will result in similarities and differences in social and emotional experience and interpretation (Siporin, 2012). This theory recognizes that all participants in EAT/EFP are subjects that bring unique social, emotional, and instinctive context to the interaction and that the unique context of each subject participating in the interaction shapes and creates a new context for all participants in the interaction. This new context will pose differences and similaritie s in each subject’s experience. The theory provides an overall method for understanding the phenomenon that the subjects collectively and individually experience and how this contributes to their social and emotional cognition. It culminates in a complex, multifaceted interaction that is grounded in relational connection. Kirby (2016) discusses the key principles of the Gestalt 22 therapies underpinning EAT/EFP as based in the awareness of the here and now, the immediacy of the present moment, phenomenological practice of observing and describing the subjective experience, the paradoxical theory of change, the creative process of intention, and finally, the developmental lens on which Gestalt therapies are based on (p. 37). Kirby (2016) further integrates some of the work of Peter Levine into her description of somatic experiencing and the neuro-biology of trauma and using horses to deepen these therapeutic techniques. Kirby (2016) describes how the Gestalt based principles of EAT/EFP support the concept of inte rsubjectivity as central to the process of this work. In researching EAT/EFT and in attempting to understand what is occurring in these interactions and how they impact the subjects involved, the theory of inter-subjectivity accounts for the complex nature of relationship with self and relationship with others. Lundgren (2019) suggests that the complexity of interaction in EFP/EAT extends beyond the simplicity of several other theories, such as mirror neuron system theory, predator-prey relationship, or the clients’ individual interpretations and construction of the therapeutic interaction. Inter-subjectivity suggests that all subjects in the interaction leave the exchange socially and emotionally changed. The theory captures the complexity of neuro-development, neuroscience, brain plasticity, mammalian similarity in relational connection, and differences between mammalian species in orientation to the world (Scholte & Parent, 2019). Empathy, Emotional Attunement, and Relationship As noted by Pat Parelli (2012), an internationally acclaimed natural horseman, equines are excellent at perceiving the emotional state of others. This has likely been an evolutionary factor in their long-term survival as a species. Attunement is often used interchangeably with empathy. However, attunement refers to the ability to recognize emotion in others. For example, 23 a mother may recognize that their infant is in distress. They are attuned to the emotion of the child (Lapointe, 2016). It is noted to be of significant importance in nearly all relationship interactions (Lapointe, 2016). Spreng et al. (2009) describe the importance of empathy in relationship, and the importance of understanding broad based empathy. Broad-based empathy refers to both interpreting another individual’s emotional state accurately and effectively responding to that emotional state. Broad-based empathy includes the ability to assess alternative life circumstances and to recognize the individual that exists in relation to the environment. It involves first attuning to the emotion present in another and then seeking to understand and respond to that emotion from the context and perspective of the other individual. The study will focus primarily on broad based empathy in the human participants and on the participants’ understanding of empathy within their EAP/EAT sessions. The purpose of the research is to further examine the relationship between empathy in EAT/EAP while also seeking to develop a more robust understanding of how the participants understand empathy as it pertains to humans and equines. Decety (2010) states that empathy “implies a shared interpersonal experience, [and] is implicated in many aspects of social cognition, notably pro-social behavior, morality and the regulation of aggression” (p. 257). Decety (2010) further argues that: Human empathy involves several components: affective arousal, emotion understanding and emotion regulation, each with different developmental trajectories. These components are implemented by a complex network of distributed, often recursively connected, interacting neural regions including the superior temporal sulcus, insula, medial and orbitofrontal cortices, amygdala and anterior cingulate cortex, as well as 24 autonomic and neuroendocrine processes implicated in social behaviors and emotional states (p.257). Empathy, as it is understood from a neurodevelopment lens, is a complex developmental process that occurs over time and is the result of repeated experiences of affective arousal, emotion understanding, and emotion regulation. Decety (2010) emphasizes that “empathy is not unique to humans as many of the physiological mechanisms are shared with other mammalian species” (p.258). It is adaptive for mammals to understand and evaluate signals of distress in others, but also to take action to soothe and alleviate distress in others as it is recognized. Decety (2010) further notes that although empathy is not unique to humans, it does appear that the higher level cognitive capacity of humans does provide for some behaviors primarily unique to humans and other mammals with high cognitive capacity such as cetaceans. These behaviors include prosocial cooperation between species, such as caring for individuals from other species. Decety’s (2010) discussion on the development and functioning of mammalian empathy assists in understanding the intersubjective nature of human and equine interactions. Carlsson, Ranta, and Traeen (2015) posit that in order for equine assisted activities, Equine Assisted Social Work (EASW), or EAT to really be noted as successful, the facilitators must promote viewing the equine as a subject and participant in the interaction, rather than as an object. Facilitators must discuss animal behavior in terms of a complex interaction or neurology, biology, experience, and relationship in order to emphasize the equine’s active role in the therapeutic process. Carlsson et al (2015) state that “if staff gave instructions and advice similar to traditional equestrian sports in combination with viewing the horse as an object” (p. 329) then the therapeutic goals of the activity were not successful. Carlsson et al. (2015) highlight the necessity of appropriate therapeutic training as well as the need for positive and empathetic 25 facilitators in order for EAT to be successful. Carlsson et al. (2015) make a significant distinction, as a substantial portion of the literature does not emphasize the facilitator training, program background, or theoretical framework being utilized. In much of the current research, it is difficult to discern the framework and activities being utilized for therapeutic purpose. Trotter (2012) identifies this as a limitation of equine facilitated programming at present. As noted above, the therapeutic approach of the facilitator and the ability of the facilitator to promote viewing the equine as a subject in the interaction are critical to the success of EAT programming. Additionally, different horses will introduce diverse and complex personality traits, interaction patterns, reactions, and responses related to their own experiential and intergenerational experience. As mammals, horses establish attachment to their mother in infancy in a similar fashion to other mammals (Lundgren, 2019). The mother’s response to human beings and the world around them will influence the foal’s growing understanding of the world in which they live, as well as their reaction to this world. For example, if the mare is highly anxious or worried around human handlers, she will behave in a protective and reactive way to ensure that her foal remains safe. The foal will then learn to behave in the same protective manner. This learning pattern has evolutionary advantage, but much as in humans, these coping and interaction styles may lose efficacy or advantage over time and in different situations. Much like the brains of human infants, the neuro-development of a horse brain is affected by experience and interaction with the world around them (Payne, DeAraugo, Bennet, & McGreevy, 2016). The fields of epigenetics, neuroscience, and neuro-development are relevant across mammalian species. Although there may be fundamental differences across species, mammals largely share similar brain structure, patterns of rearing offspring, and challenges when healthy development is interrupted. Lundgren (2019) notes: 26 We humans have more in common with horses than what sets us apart, from an emotional and social point of view. The similarities play the more important role, the differences are also important. It is vital with species specific knowledge as well as knowledge of horses’ and humans’ common mammalian background, since we share similar brains, and similar neural networks that work in similar ways. We need to be acute [sic] aware of these similarities and differences to be able to use them in EAT and to ethically let the horse be part of this work… a horse is a subject and not an object (p.20). Payne et al. (2016) assert that horses develop attachment in a similar manner to humans and that healthy neuro-development is facilitated through this attachment process. Possessing a working understanding of the psychological and physiological interactions between horse and human is critical to the potential benefit of horse/human interaction. Although there are several organizations that provide professional development and contribute to the emerging research on EAT, there is no overarching body responsible for regulating the implementation of EFP, EAT, or EAP. Organizations Regulating EFP and EAT EAT as an emerging field is still taking shape. Various organizations are beginning to spring up in response to the need to develop EAT education and promotion, and each of these organizations is contributing to the pool of therapeutic protocols being used in EAT. Several of these organizations differentiate between therapies and offer various certification processes that promote the respective agency’s own therapeutic protocol. Two specific organizations have emerged as leaders in developing equine assisted programming in the helping professions. The Professional Association of Therapeutic Horsemanship (PATH) has grown into an international organization promoting the development of equine assisted programs informed by the literature. 27 PATH International’s (2017) website states that their “mission is to promote the safety and optimal outcomes in equine-assisted activities and therapies for individuals with special needs”. PATH International’s certification process involves different disciplines of horsemanship, including certification for Therapeutic Riding Instructors, Equine Specialists in Mental Health and Learning, Therapeutic Driving Instructors, and Interactive Vaulting Instructors. Driving refers to using therapeutic horses in cart or buggy pulling. Vaulting refers to gymnastic and acrobatics being performed on horseback. PATH international offers training, programming , and an international conference to members of the organization. Each level of training under PATH International’s certification process is further divided into regular, advanced, and master level certificates. These certificates require differing levels of education, professional development, and experience in stable management, equine science, horsemanship, and equine business skills. The certification for therapeutic riding instructors is extremely comprehensive. The Equine Assisted Growth and Learning Association (EAGALA) is another internationally recognized organization promoting the certification and education of equine professionals utilizing equines in activities and therapies. EAGALA is widely recognized and has developed very specific therapeutic protocol, methodology, and activities. EAGALA’s website promotes the organization as “the global leader in equine assisted psychotherapies and personal development” (2017). The website elaborates on EAGALA organizational values and states: Our vision is that every person around the world has access to EAGALA Model services. Achieving this involves: Providing public awareness, research and education about this modality of mental health treatment and personal development; Supporting access to funding; Building a high-quality network of professionals trained to provide ethical, evidence-based, life-transforming services (2017). 28 EAGALA’s certification process involves a minimum of a baccalaureate degree in a helping profession related to mental health, as well as license with the governing body associated with the practitioners training. EAGALA then requires practitioners to participate in a fundamental webinar training and subsequent face to face training, as well as ongoing professional development. In order to become an EAGALA certified equine specialist, the practitioner is required to complete 6000 hours of hands-on equine work and have an understanding of horse psychology, management, ground work, and body language. Additionally, the equine specialist must have 100 hours of advanced professional development. EAGALA’s primary therapeutic approach is Equine Assisted Psychotherapy (EAP). Finally, Canada has developed a therapeutic certification program through the Canadian Therapeutic Riding Association (CanTRA). CanTRA is a nationally recognized body with various certification levels for therapeutic riding and activities, including therapies for those living with exceptional needs and personal wellness. CanTRA has several educational requirements that increase with the level of certification. The program is associated with Canada’s national equestrian development organization, Equine Canada. Equine Canada is part of a larger international organization, the International Equestrian Federation. Equine Canada and CanTRA promote the safe and ethical handling of horses and the development of several disciplines within the equestrian sports world. Equine Canada oversees the various provincial sport organizations in the country that are responsible for the implementation of instructor programs and development programs for young athletes. Although CanTRA is well established as a therapeutic riding body, it has only recently added personal wellness practitioners to the list of certifications that it offers. CanTRA also includes hippotherapy programs. Hippotherapy refers to therapy with horses that has specific physical, occupational, or speech therapy goals. In order to design hippotherapy programs, the practitioner must be a speech therapist, physiotherapist, or occupational therapist. Although people often view CanTRA as synonymous with therapies and psychotherapies related to mental health, the certification program is centered on personal wellness development rather than focusing on overcoming mental health concerns or 29 previous trauma. Ultimately, there are several more methods, protocols and organizations that are developing in this field. It is extremely important to note, however, that there is no professional regulatory board that has any legislative authority in the field of counseling, therapeutic interventions, or branches of equine therapies and activities. There are various organizations that hold credibility in the above noted fields, but equine therapy is not legislatively regulated. The field of Social Work in British Columbia, however, is legislative ly regulated via the Social Work Act (2008) and this writer would suggest that it would be prudent for individua ls seeking therapeutic interventions of any type to find registered professionals, or professionals affiliated with credible certification processes. This literature review has provided an overview of the current body of research as it pertains to EAT/EFT, the theoretical underpinnings of the therapy, the basic definitions that are relevant to this study, and organizations that are engaged in the promotion of EAP/EFP. The following chapter will review the research methodology used for this study, including the overarching theoretical lens of the researcher, the specific methodology used to sample, gather, analyze, and validate the data, and the limitations of the methodology. 30 Chapter 3: Research Methodology The purpose of this chapter is to review all of the components of the research design and process of the research. This chapter will cover the design of the research, including sampling and participant recruitment, data collection, ethical considerations of the study, methods of analyzing the data collected, and the researcher process to ensure that the analysis was valid and representative of what the research participants were conveying to the researcher. The methodology is designed to address and develop a deeper understanding of how adults experience empathy as it relates to equine facilitated psychotherapy. Researcher Approach The initial design of this study and the research proposal originally submitted for approval to the supervisory committee and to the University of Northern British Columbia (UNBC) Research Ethics Board (REB) was a mixed methods study to examine some of the apparent contradictions in the qualitative and quantitative research that had been completed in the area of EAP/EFP and the use of these methods in therapeutic interventions. As noted in the review of the literature, the quantitative research completed to date has employed a variety of psychometric measures to attempt to assess the benefits of EAP/EFP in a standardized manner. However, the quantitative analyses often did not align with the qualitative studies that were being completed. In fact, even within some mixed methods studies, the psychometric measures were not aligning with the participants’ perceptions of their own improvement throughout therapy and intervention (Burgon, 2011; Chalmers & Dell, 2011; Ewing, Macdonald, Taylor, & Bowers, 2007; Trotter, 2012). This contradiction perplexed me as a researcher. Why was the lived experience and perception of individuals, and indeed, groups of individuals, not aligning with the standardized measures that were being used to assess improvement? As I have grown and expanded my understanding and ability to critique research methods, I realize that there are numerous reasons that this occurs, and many of these reasons are grounded in research that reflects a particular paradigm and worldview. Standardized measures often reflect a world view that is imperialistic , Eurocentric, and colonial in nature (Linklater, 2014). However, these 31 measures have allowed for substantial technological advances that promote health, wellbeing, and quality of life. Critically examining the purpose, underlying assumptions, biases, and the motivation to conduct research is an important component to understanding the context of research. Understanding the context of the research assists those reviewing the research in understanding the potential costs and benefits. Although quantitative studies have been used to bolster the privilege of some members of society, and have served to subjugate other members of society, it is also very important to note that studies conducted using quantitative approaches have also benefited marginalized groups. In reviewing the literature, it became appa rent to me as a researcher that research approaches and findings are never neutral, unbiased, or without motivation. There will always be a beneficiary of the results of research, regardless of methodological approach. As I developed my understanding of this point, it became apparent that a social justice approach to research demands that the researcher continuously assesses who the potential beneficiary is in the research, and who may be affected negatively. As my research design evolved due to a variety of challenges, including recruitment challenges, the surge of Covid-19 as a global pandemic, and my continued inquiry into research methodologies and critiques, I began to move away from the quantitative portion of my original submission. Recruitment for this study proved to be very challenging, and this presented further challenges to conducting quantitative research. Denzin and Lincoln (2012), Linklater (2014), and Tuhiwai-Smith (2012) expanded my understanding of research as a potential weapon for oppression and colonization, while simultaneously introducing the idea of research as a tool for social justice. Understanding the implications of research, including the role it has taken in creating and maintaining oppressive social systems, policies, colonization, lateral violence, and power has led me to view research through a much different lens and has enhanced my reflexivity in this process. Many individuals, communities, and indeed, entire populations of people and animals have suffered and have been collectively subjugated directly as a result of conclusions drawn from ‘scientific’ methodologies that serve to label, categorize and, ‘other’. Linklater (2014) and 32 Tuhiwai-Smith (2012) both provide various examples of how research and the research proces s have subjugated populations of people, particularly Indigenous populations. We have seen the horrific outcomes of imperial classification systems developed by identifying superficial characteristics of difference between people. An example is provided by Clark (2009) in which superficial characteristics were used to classify Rwandan tribes known as the Hutu and Tutsi. These classification systems, such as measuring the length of nose, were used to subjugate and other one group from another. The research that was undertaken to classify and differentiate the Hutu from the Tutsi had devastating impacts on relationship, community, socioeconomic wellbeing, health, and ultimately the use of research in this situation promoted the interests of the colonizer while subjugating the colonized. “Research is not an innocent or distant academic exercise but an activity that has something at stake and that occurs in a set of political and social conditions” (Tuhiwai-Smith, 2012, p.5). It critical to acknowledge that formal research can often represent or promote colonial and Eurocentric interests and in endeavoring to promote social justice in research, we ought to reflect on the implications of research in marginalized populations. In reflecting on the purpose of this study, I endeavored to ground myself in the experience of the participants and to represent their understanding, perception, and analysis of their own lived experience. The impact of research is far reaching, and it became very apparent to me throughout my studies and in designing my methodology that research must be conducted in a manner that honors social justice, interaction, reflexivity of the researcher and others, and differences in human experience based on analysis of intersectionality. Creswell (2014) outlines that qualitative analysis ought to produce recommendations and conclude with calls to action with the intent of improving “practice...policy and decision making” (p.119). The intent of this research is to develop a deeper understanding of the lived experience of EAP/EFP participation and the participant’s experience of empathy within this context, with the intent to contribute to the current body of literature and to further improve and understand the practice of EAP/EFP as a therapeutic intervention. 33 Research Design Sundler, Linderg, Nilson, and Palmer (2019) state that “qualitative research in health care is an increasingly complex research field particularly when… dealing with the lived experiences of patients” (p.1). As qualitative inquiry has expanded beyond sociological and anthropologica l fields, several researchers have attempted to solidify methodology related to each broad research approach. Creswell (2014) states that “books have summarized the various types, and complete procedures are now available on specific qualitative inquiry approaches” (p.13). Settling on an approach to qualitative inquiry proved to be one of the most difficult decisions related to the design of this research. During the review of the literature, it was apparent that there is a disconnect in the findings related to the benefits of EAP/EFP, depending on which broad method of inquiry was used for the study. There is a noticeable gap between the qualitative and quantitative analysis. There is a discrepancy in the literature between the lived experience and perception of individual participants and other individuals observing the phenomena, and the data gathered from psychometric measures of empathy. This discrepancy required closer examination, and I felt that a deeper understanding of the lived experiences of those that were participating in EAP/EFP would contribute to a more robust understanding of the particular improvements that participants believed that they experienced as a result of their therapeutic work. Having a more robust understanding of the meaning that participants derive and assign to their interactions with horses and equines in EAP/EFP may inform future research that attempts to address the gap in the literature. As I was attempting to explore some of the gaps in the literature and to develop a robust understanding of the participants’ perspectives, it was determined that the overarching approach to this research project would be exploratory and would include qualitative analysis. The research question being addressed in this study, as outlined in Chapter 1, is: How do 34 adult EAT/EFP participants experience and understand empathy as it relates to EFP/EAP? Creswell (2014) provides a general overview of several methods of qualitative inquiry with emphasis on the researcher’s developing an understanding of what they are attempting to address in conducting the research. The purpose of this research is to develop a more robust understanding of the experience and perspectives of those seeking to use equines in their therapeutic healing. Initially, I had explored phenomenological inquiry as a research methodology. In reviewing the literature related to phenomenology, it was evident that this methodology may work well for the field of EAP/EFT. However, it is a complicated, diverse methodology that presents challenges to novice researchers. Creswell states that: Phenomenological research is a design of inquiry coming from philosophy and psychology in which the researcher describes the lived experiences of individuals about a phenomenon as described by participants. This description culminates in the essence of the experiences for several individuals who have all experienced the phenomenon. This design has strong philosophical underpinnings and typically involves conducting interviews (2014, p.14). Moustaka (1994) outlines the philosophica l underpinnings of phenomenology, as well as a procedural map for utilizing this research design. Trotter (2012) discusses the experiential, metaphorical, and interpretive nature of EAP/EFP, and the theoretical underpinnings of EAP/EFP as being grounded in Gestalt therapies. Gestalt therapy is centered on the individua l’s experience and how their experience is influenced via contextual differences. Gestalt thera py itself is grounded in phenomenological understanding of self (Yontef, 1979). Developing an in depth understanding of the participants’ perspectives and the lived reality of their experience with EAP/EFP, and identifying common themes across the 35 experiences of the participants as they relate to EAP/EFP and empathy is at the core of this inquiry. Further, the theory of intersubjective experience is a central tenant to EFP/EAP. The concept of intersubjective experience of a particular phenomenon is grounded in phenomenologica l understanding and reflection (Bradfield, 2012). Bradfield (2012) discusses that the very “relationship between self and other is mutual and reciprocal and central to the emergence of the self into being” (p.266). The intersubjective world that exists between selves is only possible within a shared contextual understanding of what exists and what does not, and as such any phenomenon exists only by way of experiential awareness. The experience of a phenomena can exist within an individual’s subjective self, the intersubjective space between people, animals or people, and animals (Bradfield, 2012; Scholte, 2019; Sudekum-Trotter, 2014). In formulating the research question, it became apparent that the focus was on developing an understanding of the lived experience of individua ls’ involvement and interpretation of the experience of empathy within a specific context. It was clear that this study was serving to understand the lived experience of a specific phenomenon, a central tenet to phenomenology. However, phenomenology as a research method inherently involves a certain degree of complexity. Errasti-Ibarrondo, Jordan, Diez-Del-Corral, and Arantzamendi (2018) state that “the complexity inherent in phenomenology, at least in part, lies in the fact that it is a philosophy, an approach and a methodology based on qualitative research” (p.1723). Although much has been written about phenomenology and the philosophical underpinnings of the approach, it is exceptionally difficult to find a concrete, step by step procedure to utilize it in research design. This lack of methodologica l script is perhaps best understood through van Manen (2015). Van Manen (2015) asserts that rather than being a set methodology, phenomenology is a philosophica l attitude, and this approach or attitude towards ontological and epistemological 36 views must be carried through the entirety of the research design. Ibarrondo et al. (2018) posit that the approach underlying the method is far more important than the methodological s teps taken. The understanding that “phenomenology is, in some sense, always descriptive, interpretive, linguistic and hermeneutic” (van Manen, 2014, p.26), and that at its core, phenomenology is reflexive, is critical to understanding how to approach the research process. It was important for me to capture the interpretive nature of experience in this research. Understanding the participants’ lived experience and perspective on EAT/EFT could offer valuable insight into therapeutic adherence, therapeutic alliance, and general participation. Although phenomenology as an overall philosophical approach to this study appeared to align well, it was difficult to find a rigorous and structured phenomenologica l method that could guide this research project. As a novice researcher, it was and is a critical component of my learning to develop an in-depth understanding of the process and work that I am completing. After deliberating about my methodological process, I determined that this research would be completed in an exploratory manner, with an overall qualitative approach. I analyzed data utilizing Braun and Clarke’s (2011) description of thematic analysis. Participants The sample for this study was drawn from several equine facilities across British Columbia that advertise for therapeutic equine services. Due to the emerging nature of this therapeutic modality and the limited sample size available, participants were recruited from facilities that utilized a variety of therapeutic protocols, as long as the protocol specifically involved equines in the therapeutic process. Although ensuring that there is consistency in therapeutic protocol is very important in understanding improvements in empathy, it has proven to not be a viable specification to require while recruiting a sample for this study. 37 During the completion of this research, sample recruitment was particularly difficult for several reasons. Primarily, potential research participants were very limited in British Columbia as EAP and EFP are still not mainstream methods of therapeutic intervention. Secondly, this research was conducted during a global pandemic related to the novel corona-virus. The rapid changes in public health policy and directives presented challenges with both recruiting a sample and ensuring adherence to the new directives. Under the declaration of a state of emergency in BC in early 2020, public health orders were rapidly changing as the understanding of the virus developed. These changes posed challenges for nearly everyone, and specifically, impacted the interest and availability of study participants. Sample recruitment was done via convenience and snowball sampling. I identified several agencies and practitioners of EFP/EAP across BC that advertised their services online and located their email contact information. A letter was sent via email (see Appendix A) to the practitioners and to the agencies outlining the purpose and methodology of the study. This letter requested that the agencies and practitioners provide the study information to previous and/or current EAP/EFP participants and who could volunteer to participate (see Appendix B). Although, I initially received several responses from agencies and practitioners via email stating they would distribute the study information, I received correspondence following these responses advising that the distribution of Appendix B had been limited due to the emergence of Covid-19 and the subsequent restrictions that were in place as a result of public health orders. However, over the following months, I received requests from four respondents across Northern BC to participate in the study along with their signed consents to participate (Appendix B). Data Collection Once the informed consent package was received from each potential participant, data 38 were collected for this study via two sources. A basic demographic form was sent to participants to complete prior to completing the interview portion of the study. The individuals who agreed to engage in the study participated in EAT/EFP primarily as patients. One participant was facilitator. My original information and consent forms stated that I was seeking a sample of EAT/EFP participants. I had not expected that recruitment strategies would elicit a response from facilitators of programs. However, in reflecting on the literature and process of phenomenologica l intersubjective experience, it made good sense to include these potential participants. Including facilitators provided a robust account of the intersubjective lived experiences of all of the human EAT/EFP participants. Although, ideally, the study would have elicited a more substantial sample for the purposes of phenomenological inquiry, the sample allowed for various perspectives on the shared experience of EAT/EFP. Demographic Forms The demographic form (Appendix C), was developed after the completion of a comprehensive literature review and formulated in consideration of demographics that were identified in various studies. Many of the studies that were cited in the literature focused on work with youth (Burgon, 2012; Ewing et al., 2007; Trotter, 2012), and much of the literature did not specify the age group of participants aside from identifying them as adults (Pollack, 2012). I was unable to locate any studies that discussed diversity in gender identity, although Scholte and Parent (2019) did provide a case analysis regarding a patient who was gender diverse, and had suffered trauma and attachment injuries when they revealed their identify to their parent. Only a few of the studies that I reviewed discussed the Indigenous identity of participants (Chalmers & Dell, 2011; Ewing et al., 2007). As the field of EAT/EFP expands, it will be important to develop a general understanding of which populations benefit from the use of horses in psychosocial therapy, and where there may be limitations. The demographic questionnaire was designed to capture basic data about the participants that may prove useful in expanding understanding about EAT/EFP participants. Interviews with Participants Interviews for the purposes of data collection were designed in advance with very open-ended questions and were supplemented with minimal prompts from 39 the researcher to encourage expansive free narrative from the participants regarding their ow n lived experience in EAT/EFP and the meaning that they attach to that experience. The interview schedule was designed and completed after the thorough literature review and reflected some of the questions that emerged from discrepancies within the literature review. For example, the interview schedule (Appendix D) requests that the participant or what Moustakas (1994) has termed the “co-researcher” provide their own definition of empathy at the outset of the interview. This question was developed specifically to provide a deeper understanding of how human participants define and understand empathy in their lived experience and how this may contrast with academic definitions of empathy or the psychometric measures used to quantify empathy. Moustakas (1994) asserts that “although the primary researcher may in advance develop a series of questions aimed at evoking a comprehensive account of the person’s lived experience of the phenomenon, these are varied, altered, or not used at all when the co-researcher shares the full story of his or her experience of the bracketed question (p.14). I believe that it is very important to clarify that for the purposes of this inquiry, I adhered to the interview schedule and utilized the minimal prompts that were included in the initial research approval of the ethics board. The questions were designed to be very open-ended with the intent of eliciting as much free narrative as possible from the participant, and to promote reflection on the participants’ lived experiences of empathy and EAT/EFP. Once the participants had signed informed consents, completed the demographic form, and agreed to be interviewed, a date and time was determined for the interviews. I had the participants propose the dates and times for interviews, which were scheduled at their convenience. As the sample was being recruited during the emergence of the Covid-19 pandemic, research procedures had to be adapted to eliminate in person contact with study participants. Specifically, face to face contact was eliminated and interviews were conducted via telephone. All interviews were recorded using a digital recording device that was password protected. The interviews were then transcribed verbatim. I transcribed all of the interviews, as I felt that it would assist me in analyzing the data from the interviews and would allow me to 40 review and understand the data thoroughly. During the beginning of the interviews, I focused on rapport building, reviewing the consent package, and confirming verbal consent. I reiterated that there are no incorrect answers in the interview, and that the purpose of the study was to obtain a deeper understanding of the participants’ experiences with empathy and engaging in EAT/EFP. I also reiterated to each participant that there was no time limit to the interview and that if we ran out of time on that particular day and they had more that they wanted to contribute, we could schedule more time on another day. Ethical Considerations I submitted the proposal for this research to the University of Northern British Columbia’s Research Ethics Board and obtained approval (Appendix E). In October 2020, the research was revised and extended to reflect protocols established due to the novel coronavirus. Each person who contemplated participation in the study was provided with an information letter and a consent form that outlined the purpose of the study, potential risks of participation, an overview of the process and methodology of the study, data storage, resources available for emotional support, and the potential requirement of the participant’s time. The letter also outlined that each participant would receive a Time Hortons gift card valued at $10.00 to thank them for their participation in the study. Confidentiality Confidentiality of the participants was of utmost importance during the course of this study. Considering that there was a limited number of individuals able to be drawn from as a sample, it was critical to ensure the anonymity and protection of information. Once the letter of informed consent was obtained, each individual participant was assigned a number and any reference or document containing the data collected from them was coded with this number. All physical documents and information were kept under lock and key at the researcher’s home residence and only the researcher had access to the key. All digital documents were encrypted and stored on a personal password protected device that only the researcher had access to. All recorded data, including the interview recordings will be deleted, and the digital recording device 41 will be completely wiped following completion of the thesis defense or within six months. It was reiterated to participants through the informed consent that all participation in the study is entirely voluntary and that participants can withdraw at any time up until the conclusion of the study and all information will be removed from the analysis and destroyed. In the event that the participant withdrew from the study, they would be notified in writing at the time that their information was removed from the analysis and destroyed. The researcher further reviewed the components of the consent at the beginning of all interviews and confirmed the consent and understanding of the participant verbally, in addition to the signed consent letter that the participants provided the researcher. Participants were informed and offered an opportunity to ask any questions that they may have about the study or their participation at the time that the researcher received the informed consent package, at the time that the researcher contacted them to schedule interviews, and finally, at the beginning of each interview. Safety of the Participants It is recognized that participation in any study involving humans comes with risk. The anticipated risks and benefits of this project were clarified in the information and consent letter and the participants’ understanding of the anticipated risks and benefits was again clarified at the commencement of the interview portion of the study. The risks associated and identified with this particular study included the potential inconvenience of the questionnaires and the interviews, and the potential that the questionnaire and/or the interview could trigger negative feelings and emotions for the study participant. The researcher provided a list of resources available to each participant in the participant’s community in the event that they felt triggered emotionally or experienced negative emotions. The emotional wellbeing of the participant was considered paramount, and if at any time participants were to appear distressed, the research would end the interview and assist the participant in accessing support if required. Data Analysis The data were analyzed utilizing thematic analysis (TA) as outlined by Braun and Clarke (2006). Braun and Clarke (2014) assert that: the version of TA we've developed provides a robust, systematic framework for coding 42 qualitative data, and for then using that coding to identify patterns across the dataset in relation to the research question. The questions of what level patterns are sought at, and what interpretations are made of those patterns, are left to the researcher. This is because the techniques are separate from the theoretical orientation of the research (para. 4). The authors suggest that TA can be utilized for nearly any qualitative inquiry, regardless of theoretical approach. Various qualitative researchers emphasize the need for qualitative inquiry to utilize the organization of the data into clusters of information related to the lived experience of the phenomena, and these clusters or data units can be further sorted into overarching themes (Braun & Clarke, 2012; Creswell, 2014; Moustakas, 1994). Although each research approach emphasizes a different analytical lens when coding data, it is evident that Braun and Clarke’s (2012) approach to thematic analysis is applicable across several approaches to qualitative inquiry. Braun and Clarke (2012) state that “TA is an accessible, flexible and increasingly popular method of qualitative analysis” (p.37). Sundler, Lindberg, Nilson, and Palmer (2018) expand on the methodology of Braun and Clarke and discuss the benefits of utilizing thematic analysis as a method of data analysis in qualitative research that is designed from the epistemological and ontological lens of phenomenology, and specifically, the benefit of this approach in the health care field. Understanding TA as a method of data analysis that can be utilized in a variety of qualitative research methodologies requires one to consider the flexibility of the approach as it pertains to the lived experiences of individuals. The exploratory questions in the interview schedule are meaning based, and TA is the method through which we code and organize the data to develop an understanding of the lived experience of the research participant. The process of thematic analysis that I undertook as a researcher was to first listen to each interview in its entirety twice. I did this in order to fully immerse myself and familiarize myself with the data and to understand the nuanced communication in each interview. Some of the nuances of the interview that are often not captured in the transcription include changes in vocal expression, changes in tone, and the various sounds, false starts, and cutoffs that occur. After listening to the interviews, I felt that transcribing them verbatim and including the orthographic overtures in the interviews was 43 critical to the data analysis. Capturing the nuances of each interview was important given that it lent itself to understanding the lived experience of the participants. Further, Braun and Clarke (2012) promote orthographic recording as useful to the process of TA, and the authors articulate that: We do not advocate ‘cleaning up’ the transcript (such as making it more grammatical removing hesitations, pauses, guggles) when working with data. Depending on your form of TA, such details may be omitted from quoted data (if done, it should be noted) however, because the details can be revealing, we suggest working with a full transcript while doing the analysis (p.60). Once the data were transcribed, I read through each interview prior to beginning to look for the units of meaning related to lived experience that were contained in the interview transcripts. The purpose of this was to again immerse myself in the process of data familiarization. Following the initial stages of data familiarization, I began to review the transcripts and find what data described the lived experiences of the participant. Throughout this process, I took various notes and allowed myself to really absorb the information presented in the data. I reviewed the transcripts three more times to ensure that I felt comfortable with the initial data units or codes. As someone very new to both phenomenological inquiry and thematic analysis, I took a significant amount of time to become familiar with the data. I compiled a list of the verbatim data that identified “the significant, relevant and invariant meanings that provide living descriptions or highlights of the experience” (Moustakas, 1994, p.130). These lists were then organized and clustered to produce my initial codes. Braun and Clarke (2012) suggest that “every time you identify something that is potentially relevant to the research question, code it” (p.62). I revisited each code that I noted as relevant to the research question and assessed it through the lens of the intersubjective lived experience of the participants. Finally, I reviewed the codes and organized them into broader themes related to the shared lived experience of the research participants. Braun and Clarke (2006) state that “a theme captures something important about the data in relation to the research question, and represents some level of patterned response or meaning within the data set” (p.82). To record the codes, the transcripts were 44 reviewed and the data units were color-coded. These color-coded units of data were reviewed several times and were then recorded into codes. Member Checking These collective themes, along with the clusters of codes , were then reviewed with each of the participants in order to ensure that the themes adequately represented what the participant was trying to convey regarding their lived experience. In reviewing the collective codes and themes with each participant, it allowed me to ensure that the analysis reflected the common lived experience of empathy for those that participate in EAT/EFP. Moustakas (1994) describes this inquiry: It involves a return to experience in order to obtain comprehensive descriptions that provide the basis for a reflective structural analysis that portrays the essences of the experience. The approach seeks to disclose and elucidate the phenomena of a behavior as they manifest themselves in their perceived immediacy. The human scientist determines the underlying structures of an experience by interpreting the originally given descriptions of the situation in which the experience occurs (p.13). Given that the “aim is to determine what an experience means for the persons who have had the experience and are able to provide a comprehensive description of it” (Moustakas, 1994, p.13), the review with research participants is critical to understanding the commonalities of lived experience. In order to complete member checking, each participant was contacted by telephone or email to review and validate these codes and themes. Three were in agreement with the analysis and I was unable to contact the fourth interview participant to receive their feedback. This chapter has examined the research design and methodology, including the theoretical lens of the researcher, the step-by-step methodology of the research process, and the method of analysis. The chapter further examines the implications of the current global pandemic on the research process and the limitations of the research methodology. The next chapter will focus on the data analysis, coding and themes that emerged from the data, culminating in the presentation of the research findings. 45 Chapter 4: Findings This chapter will review the findings of my analysis, including an outline of characteristics of the individua ls that I interviewed for this study. I will then discuss the common themes that were identified across the interview data and how they correspond with the original research goal of developing a deeper understanding of empathy as it relates to participation in EFP/EAT. These findings will add to the growing body of literature related to emotional changes in those participating in the above noted therapeutic modalities and will serve to increase our understanding of the intersubjective experience of EFP/EAT. Themes There were five overarching themes identified in the research. These themes included both manifest and latent themes. Manifest Themes: 1) A common definition of empathy; 2) Empathy as emotional labor. Latent Themes: 1) Empathy is experienced as an emotionally engaged process; 2) Parallel process of empathy in the facilitator/client dyad and the client/equine dyad; 3) Perception of emotional neutrality in the equine These findings will be explored in more depth throughout this chapter. Characteristics of Research Participants The sample recruitment for this project resulted in four participant responses. All four of these participants completed both the demographic portion of the study, and the qualitative interviews. Three of the four participants were involved with member checking. Of the four participants, all identified as being from the same broad age category of 39-48 years of age. For the purposes of the research, each participant was assigned the letter P and a corresponding number to ensure their confidentiality in the process of the research, while allowing the manuscript to be organized in a manner that the audience can understand. The 46 participants were identified as P1, P2, P3, and P4. P1, P2 and P3 identified as female and P4 identified as male. P2 identified as a member of the Métis Nation. One of the female participants (P1) had extensive professional experience with horses. P2 and P4 identified as having a novice level of experience with equines and P3 stated that she had an advanced experience level. All four participants highlighted some of their experiences with equines in the course of their interviews. One participant was a participant in EFP/EAT as a facilitator and her equine program serves a diverse base of clients. She provided very valuable insight into the facilitator as participant in therapeutic process. Intervie ws This section will expand on the themes that were identified in analyzing the data. The format of this section will loosely follow the interviewing format, and the sub-headings will discuss the themes that arose in the interview process. Theme One: Defining Empathy Across interviews, empathy was understood and described as trying to feel what the other individua l was feeling, from their perspective. A latent theme that ran across the interviews was the separation of empathy and sympathy. The following are excerpts from each participant’s definition of empathy. P1 explained: You can relate. Sympathy is maybe like, I feel I can understand that that is sc ary. But empathy- empathy is more like you’re trying to feel what that other person is feeling, so having a good understanding of the experience that the other person had, or you know, not just what you imagine it to be or how you see it. P2 shared that “empathy is a matter of heart meaning you feel what the other person is feeling; from where they stand. Not where you stand. There’s a difference.” P3 found empathy to mean something similar to the co-participants and explained to me that: Empathy plays a role in giving me a read. I can see the experience through their point of view. It doesn’t happen easily though; empathy can’t happen if you don’t really understand their world. It can’t happen unless you get them a bit, you know? Like how can you understand from their place if you don’t understand their place? I suppose you 47 could just assume that everyone has a story or a way of seeing and you should probably ask questions to get it a bit more, you know? I can see the emotion, then I need to understand them. Then I have a read and can give ‘em what they need. But I think it’s most important that it’s what they need, from them. Not what I think they need or what I think they are feeling. These quotes provide significant insight into how the participants understood empathy, though at the beginning of the interviews, they were focused on empathy as it relates to human-to-human interaction. P4 succinctly summarized his understanding of empathy as: Without empathy, you’re hollow. How can you truly exist in a relationship without empathy? Our experience is different. I can’t tell you that I know what it feels like to be penalized for my skin color, but I can sure as shit tell you that I can see you in that, I can hear you and I can respond to you and your experience. Step out of my own fishbowl and into your pond. That’s how I can be in relationship; by making an effort to integrate my response and interpretation with your experience. Across the interviews, participants shared a common understanding of empathy as an emotional process that happens within the context of relationship that seeks to understand the other subject’s position in the experience. It involves stepping outside of one’s own understanding and experience in the world and really seeking to understand the other subject’s experience of what is happening to them, and their emotional response. Interestingly, all of the participants further emphasized that empathy does not exist unless there is a response to the other subject’s experience and emotional cue. Bradfield (2019), Moustakas (1994), Scholte (2019), and van Manan (2015) all highlight that lived experience can only happen within the context of an intersubjective exchange. The participants’ concepts of empathy appear to align with this view, as they all emphasize the necessity of the intersubjective exchange in their definition of empathy. In the participants’ view, the response and interaction of the subjects is the process of true empathy. Theme Two: Empathy as Emotional Labor “This shit isn’t easy. Its heart work. It’s 48 HARD work. You don’t step into this because it is easy and you sure as hell don’t stay in it because it’s easy.” This quote summarizes the difficult, emotional work that the participants engaged in during their therapeutic exchanges with horses. Empathy was viewed as emotionally challenging work. It was seen as an engaged process, without space for passivity. However, the data demonstrated that participants’ experiences with equines was less emotionally laborious than their experience empathizing with humans. “Safety is really important (in empathy) but sometimes humans aren’t safe, you know. They can lie, they can manipulate… horses can’t. They can’t manipulate. They just are.” Other participants described the empathizing with equines as “soft”, “easy”, “safe”, and “emotionally easier”. Across participants, there was a recognition that the human ability to be intentionally deceptive had the potential to cause suspicion, which served to degrade empathy for both subjects. If one has to assess the intention behind another person’s interaction, behavior, or emotion, they become focused on how that behavior, interaction, or emotion is going to affect them. Empathy, in this sense, becomes a process of mindfulness and presence. Once a person is unable to remain mindful in the interaction because their perception is that their emotional or psychological safety may or has been compromised, they are no longer empathizing with the other’s emotional presentation. The fact that horses do not have the cognitive ability or theory of mind to manipulate the empathy of a human handler seemed to create a sense of safety for the participants. This view is supported by Jenkins (2019) in describing the hypo and hyper arousal of EFT patients. Both hypo and hyper-arousal affect the client’s ability to emotionally attune, engage, and be present. Remaining mindful and present become central to the process of intersubjective empathy. The authentic presence of the horse seemed to remove the barrier of suspicion for the participant, allowing them to be more mindful in their interactions, and to understand the behavior of the horse as a true reflection of the horse’s experience. Of course, there is significant academic debate about the authenticity of an equine’s response in interaction (Jones, 2020). As Jones (2020) outlines, horses are often instinctively deceptive in their presentation due to their evolution as a prey animal. For example, horses will instinctively 49 conceal distress or pain as a mechanism of managing the perception of predators. If a predator perceives weakness, distress, health issues, or injury in the equine, the equine becomes more susceptible to being hunted. As Jones (2020) describes, horses are remarkably adept at minimizing the expression of pain responses. Pain cues are incredibly subtle in the equine. The focus of this study is on the lived experience of the study participants, and their experience of empathy with equines. However, it is important to note that the overwhelming perception of horses and animals used in therapy as completely authentic in their presentations in a therapeutic setting is colored by adaptive differences between species, and that “authentic presence” as humans understand it does not necessarily align with the current literature regarding the neurobiology of horses and other animals used in therapeutic settings (Jones, 2020; McGreevy et al., 2018). However, the participants recognized that humans can behave in a manner that is not congruent with their current state, and this realization appeared to leave them often feeling as though they had to invest more emotional work into understanding and empathizing with humans than horses. One participant summarized this experience as: Human to animal (empathy) almost seems easier in a way. I don’t know, I have a, it seems when I am around an animal you almost get softer in a way, you slow down, I slow down. You don’t have the verbal communication and b.s. to sort through. It’s, it’s, you know, a lot of sight, maybe there is more touch, softer… but there is definitely things moving a lot slower. You approach an animal slower than a human. You have to work out what they are saying without words. You look for signals and you become almost attuned with an animal because you are both reading each other and nobody is saying anything and you’re just there waiting for little cues. Empathy plays a huge role in working with animals, but man is it easier than humans. P2 stated that “the horse isn’t playing games with you. That’s the beauty of the horse. You can trust the horse; you can’t trust the human”. It is important to note that all of the participants did share in their interviews that they had 50 experienced trauma within relationship with other human beings. The participants’ historical experiences warrant further consideration when discussing their experiences of empathy and trust with humans and equines. Theme Three: Empathy and Emotional Engagement Empathy was experienced as an emotionally engaged process that required significant cognitive and emotional resources from the participants. Participants described the continued requirement of self-awareness in interactions as requiring a particularly intense focus. Body language, both horse and human, becomes a consistent area of focus throughout the interaction. The human facilitator and participant must analyze their own body language and that of the horse. The participant has to focus intently on how their own presentation is affecting the response of the equine and make appropriate adjustments. The facilitator must articulate these adjustments and promote reflection. P1 states “we talk about body language right from the beginning, right… what does it mean when the horse is trying to push into your space? What does it mean if he is trying to eat?” The participants must constantly be assessing, interpreting, observing and attempting to understand the equine partners. All of the participants discussed the critical component of emotional engagement and presence, and how being conscious and emotionally engaged was part of the difficult emotional labor of the therapy. Some participants discussed emotional engagement in terms of manipulating their emotions; when prompted to discuss this further, two of the participants stated that it was not entirely manipulating emotions, as much as they were recognizing and becoming conscious of their emotional state and engaging in self-regulation exercises to shift their internal state. A participant provided insight into the mindfulness involved in the interaction and the shift in emotional state that occurred: The horses just stayed away. They wanted nothing to do with us. We stood there, and they wouldn’t even approach us. We started talking, we were bickering and started talking through it. He was feeling… like he was feeling I don’t like this. I don’t like horses. What is the point in this? And so the horses stayed away until we got our shit 51 together and started talking it out. Then they started to approach. But we had to see the reaction, understand it, and get it under control by talking through it. We couldn’t just fake it, you know? We had to actually get in a different head space. In this sense, the horses provided an external prompt to become mindful of the participant’s internal state, at which point the participant could engage in an activity that shifted their internal state. The behavior of the equines was interpreted by the participants as a reflection of their current emotional state and this interpretation subsequently prompted the participants to name or label their emotional state and to engage in a regulation exercise. Perry (2017) would suggest that these subtle interactions and the intentional processing of the emotional state, engagement in positive self-regulation and the resulting change in state will lay the foundation for longer term behavioral change and emotional engagement as the brain makes new neural connections and ‘practices’ using these new skills. This experiential work may promote quicker changes in neurobiology than traditional skills based or talk therapy (Sudukem-Trotter, 2012). Theme Four: Parallel Process of Empathy in Facilitator/Client Dyad and Client/Equine Dyad The research participants further discussed the necessity of the facilitator prompting emotional reflection. Each participant discussed the importance of having another individual present to support them in engaging in a reflective process in order to remain emotionally engaged with the horse and to stay mindful of their own internal experience. The intersubjective exchange that occurred at this point in the interactions was consistently described as the participants’ viewing the behavior of the horse, the facilitator’s prompting reflection for the participant in how or why the horse is behaving in the manner that they are and completing an emotional and somatic check in with the participant, and the participant working through what they notice from this check in. The facilitators then prompted the participant to examine and reflect on the horse’s new behavior. The success of the therapy was dependent upon the facilitator’s own process and their level of emotional attunement to the internal state of the participant. Furthermore, the facilitator had to demonstrate a high level of skill in interpreting the 52 horse’s behavior and emotional state. The skill of the facilitator in reflecting the participant’s emotional experience is critical to the participant’s being able to reflect upon the emotional experience of the horse. P1 stated: Without the facilitator, I don’t know that I would have figured it. I would just get to this place of being wild. Like I couldn’t settle my brain down long enough to figure out what the hell the horse was reacting to. But then she would just quietly ask me to take a deep breath and scan my body. I’d hear my heart racing, or blood rushing through my ears. She’d tell me to say “Ohm” really, really loud, which was kind of weird, but it worked. My heart would slow down, my brain would come back to me. And then I could look at the horse and see that they were feeling my crazy. But seriously, without someone there to show me, er, talk to me, I wouldn’t have figured it. Her ability to see my shitty response was 100 per cent critical to the success of the thing. Other participants reiterated this perspective stating that the facilitator was “indispensable”; “offered reflection”; “helped me reflect”; “gave me the tools to do the work”; “modelled the way”; “modelled emotion”; “ I learned empathy from her”; “she showed me how to empathize with the horse”; and “she helped me reflect”. The ability of the facilitator to empathize and attune was seen as critical to the participant’s development of these skills. Interestingly, although the interviews reflected an understanding from the participants that the program facilitator’s skill in empathy and emotional attunement directly impacted the participant’s ability to engage in emotionally attuning to and empathizing with the horse, the participants also reported that they experienced the horse as an emotionally neutral being. Theme Five: Perception of Emotional Neutrality in the Horse It was thematic throughout the study that the participants perceived the horse’s behavior and the horse’s interaction with their environment to be the result of the human’s emotional state. The participants’ perception was that the horse was living in a response state, and that the primary stimulus influencing the horse was the human’s emotional state. This assumption is challenged by Jones (2020) and McGreevy (2018) as it does not reflect the literature regarding the response 53 states of horses. The perception that the horse’s behavior was the sole result of the human’s internal state was thematic across interviews. In analyzing the themes, it became apparent that within the therapeutic setting, participants experienced the horses as emotionally neutral and the participant’s perception was that the horses existed moment to moment and that the emotional state of the equine was not impacted beyond the moment of interaction. P2 stated “they can’t manipulate, yeah. They don’t have the capacity to manipulate. They just are and they exist moment to moment”. P1 stated “horses just have this incredible ability to live in the moment. They aren’t worried about the future or consumed by the past like we are”. P4 shared that “the horse is just doing its regular old thing and living life. It just goes through life moment by moment and doesn’t get all caught up in the emotion”. Finally, P3 shared the following points about the emotional neutrality of the horse: The horse comes to the therapy without baggage. They just are. They just stay in the moment and react to the moment. The work isn’t as hard for them, because they just go through it. They have an incredible knack for staying here and now. When I prompted each participant to elaborate on the horses’ experience of empathy in the sessions, it was reiterated that the horse lived moment to moment, they remained emotionally present and in a neutral state unless the human stimulus promoted an emotional reaction. One participant shared: I don’t think it affects their lives unless someone really broken or very aggressive were to remain in their lives. And then, yeah, maybe they could be traumatized. But otherwise, I think they are just moment to moment, they carry on with their lives and go out in the field and forget about it. Participants described the horse’s behavior as “just responding”; “just existing”; “responding to my energy”; “mirroring my emotions”; “acting as a mirror”; and as “an emotional mirror that is accurate every time”. The perception of the participants reflected the belief that the equine partners are largely emotionally neutral in their existence, and that they primarily respond to the emotional intention of the human participants. 54 In conclusion, the themes that were evident in the data compiled from the interviews with study participants suggest that there was a common understanding of the meaning of empathy. Each participant described empathy with similar language use and defined empathy as an emotional connection to the experience of other people and animals. The interviews suggested that empathy is an emotionally engaged process that requires significant emotional labor, thought, and energy in order to empathize and to reflect on one’s impact on others. Study participants also emphasized the importance of the parallel process of empathy and attunement between the facilitator/client dyad in improving empathy and attunement in the client/equine dyad. Finally, the interviews suggest that there was a perception amongst the participants of the horse as an emotionally neutral participant. Chapter five will provide a discussion of the research findings, including a brief comparison of the findings of this study with the current body of literature, implications of this study in current practice and policy, and suggestions for future research. 55 Chapter 5: Discussion Equine facilitated therapies are growing in popularity, though they are still far from mainstream. As I disclosed earlier in this manuscript, my position in the research is multifaceted: I am a therapeutic, helping professional, an invested mother of a child living with autism, an equine enthusiast and a person who has lived through traumatic experiences. I write and research from the perspective of an individual living with complex post-traumatic stress disorder (CPTSD), and I understand that all of the above influence my approach to researching equine facilitated psychotherapy (EFP) and equine assisted therapies (EAT). Throughout the process of thematic analysis, I came to learn a significant amount about myself and how my background with horses impacted my interpretation and understanding of the data. Submerging myself in the data, reviewing it carefully several times, and including the entire orthography of the interviews, as Braun and Clarke (2011) suggest, allowed me to challenge my inherent assumptions and biases. More to the point, analyzing the data in this way forced me to confront my own assumptions and approach. Recording, analyzing, and organizing the lived experience of others is not simple work. It challenges our core beliefs, our judgements and importantly, it highlights our subtly preconceived notions of what the ‘right’ answer is to our inquiry. As reported in the findings section, the themes that were established throughout the analysis of the qualitative data for this project include a common definition of empathy; empathy as emotional labor; empathy as an emotionally engaging process; parallel process of empathy between the facilitator/client dyad and the client/equine dyad; and the perception of emotional neutrality in the horse. This chapter will further explore these themes through a reflexive lens in addition to providing a description of the limitations, a brief comparison of the findings of this study with the current body of literature, implications of this study in current practice and policy, and suggestions for future research. Discussion of Themes Definition of Empathy Participants shared a general understanding in their definitions of empathy. Each participant discussed empathy as a feeling state, rather than a cognition about 56 another’s experience. For example, participants stated that “you have to really feel it. It’s not about how you think they should feel. It’s not about assigning feelings that are actually yours”, “it’s a deeper jump into what they are actually experiencing and feeling, it’s feeling their feelings”, and “it’s a heart feeling. It’s not about your head or what you think. It’s about what they feel and trying to really understand what that feeling is from their shoes”. The fact that all of the participants elaborated the point that empathy is a feeling state was not something that I anticipated in this research. In my experience as a social worker, I have often viewed empathy as a cognitive process for many individuals. In my anecdotal experience, I have seen people attempt to empathize with others by understanding the other person’s experience primarily through their own lens. Empathy is then an exercise in cognition or thinking about what another individual must be experiencing, rather than understanding what another individual is actually feeling. This point is an important consideration in understanding empathy, and in ensuring that we are careful to not assign emotions and experiences to others without first validating and verifying their experience. It was a surprising and pleasant theme in the interviews that the participants had committed to understanding empathy as an exercise in inquiry into another’s emotional state and response. This definition of empathy aligns well with the literature regarding emotional attunement and its role in forming healthy relationships and promoting personal development. The participants also emphasized the importance of empathy’s role in understanding others, but also in understanding self. One participant stated “without empathy, you’re hollow”. The high level of investment in the emotional state of others has important implications for the efficacy of EAT/EFP in improving relationship, communications and relationship with self and warrants further investigation. Empathy as Emotional Labor The intense emotional labor associated with the process of therapy and empathy was highlighted throughout the interviews. Participants discussed the careful and difficult work of completing therapy sessions and applying the skills and learning that they received from therapy and practicing it in their daily life. They all discussed the intensity of this process, and the subsequent exhaustion that occurred when working to shift 57 engrained patterns of behavior. Empathy was viewed as an emotionally laborious process that required intense and extensive effort and drained cognitive and emotional resources. Empathy as an Emotionally Engaged Process The participants discussed the necessity of emotional engagement in the session. Initially, when coding the data, this theme appeared to emerge as a subset of the previous theme: Empathy as emotional labor. However, it became apparent in coding the data that emotional labor is very separate from emotional engagement. Emotional labor represented the “hard work” that was being completed by participants. The emotional labor could refer to self-reflection, epiphanies, following through with appointments, overcoming anxiety, and working through the process. Emotional engagement was interpreted to reflect that idea of remaining engaged in the process, staying present, and engaging in the intersubjective exchange with the equine and facilitator. Emotional labor can exist without emotional engagement; however, it appeared that emotional engagement could not exist without emotional labor. One could exhibit significant effort, emotional distress, effort or frustration (emotional labor) without necessarily emotionally engaging in the intersubjective exchange. Engaged mindfulness relating to their emotions was of critical importance to feeling as though they were improving their ability to empathize and be present in relationship. Actively recognizing their emotions, receiving feedback from the facilitator, and completing exercises that shifted their level of emotional regulation were described as essential to the therapeutic process of EFP/EAT. Furthermore, the conscious effort of the participants to emotionally engage in the process was viewed by all study participants as a critical component to improving their ability to empathize with others. Parallel Process between the Facilitator/Client Dyad and the Client/Equine Dyad The parallel relational process between therapist/patient and patient/equines was felt to be of critical importance to the therapeutic process by the participant. Participants emphasized the necessity of having a facilitator who was attuned to their emotional state and could assist them in identifying their own internal process and experience. Once the participant was assisted by the facilitator in recognizing and regulating their internal state, they were then able to attune to the horse’s 58 behavior and interpret the horse’s emotional state and ability to regulate. The idea that the participant’s attunement to the equine paralleled the facilitator’s ability to emotionally attune to the participant’s internal state suggests that the ability of the facilitator to empathize and engage in the emotional labor of attuning to the participant’s needs is important to unpack and explore further. Understanding the underlying therapeutic process and the key characteristics of effective facilitation will be of utmost importance as EAT/EFP continues to develop as a therapeutic modality. Perception of Emotional Neutrality in the Horse The theme of participants’ viewing the horse as emotionally neutral challenged my own thought process as my initial perception was that it actually contradicted the participant’s perception and reported definitions of empathy in the intersubjective exchange. My own perception and experience of equines felt as though it was in direct contradiction to the information being presented in the interviews with participants. I train liberty horses and teach lessons primarily to children with developmental disabilities, and my experience of horses has been that they are deeply emotional animals. Although they have a high level of emotional attunement, and they do possess a mirror neuron system (Jones, 2020), horses are also observational and experiential learners and they have very strong working memories. A horse is able to witness distress in another animal or subject and apply the observations situationally (Jones, 2020). Jones (2020) explains that horses can witness another horse load into a horse trailer and experience emotional and physical distress. When the horse witnesses the experience of another being, they can integrate the emotional response and will likewise experience distress while loading in the trailer. This transference of emotional experience suggests that horses are not emotionally neutral creatures that exist in a response state, but rather that they are experiencing their own process of internal attunement, regulation, challenges, and process. This process suggests that horses are active emotional participants in the intersubjective exchange of EFT/EAP. This theme somewhat challenged the initial themes that were found in the data. Participants viewed the equine participants as emotionally neutral in the intersubjective exchange. The interviews revealed that equine partners were viewed as primarily 59 emotionally neutral, though it was noted that they had an emotional effect on the participants. This theme was initially unexpected, as the participants discussed at length that horses were highly emotional and empathic, and that they felt that the horses had a positive emotional effect of their internal emotional state. However, when describing interaction between themselves and the horses, the participants were clear that the horses were just existing in the moment and that the horse’s reactions were as a direct result of the participant’s own emotional state. This finding was difficult to integrate with the other themes, however, it was certainly thematic across the data sets. It would be worth exploring this finding further in future research. Limitations Sampling Recruiting a sample for the purposes of this study proved to be quite challenging. I had originally received a number of responses to the information that I distributed to EAT/EFP practitioners across the province. However, the final sample was limited to four participants, and the geographical location of the participants was limited to British Columbia. The pool of participants to draw from was initially limited due to the small number of facilitators and participants engaged in this therapeutic modality. The pool was further limited by the novel corona virus outbreak. Organizations and facilitators were temporarily closing down during the time I was attempting to recruit. It was important for me at the outset of this research project to gather data that contributed to an intersectional analysis of research participants. I had initially hoped to recruit a diverse sample of participants and I anticipated that I would receive responses from individuals of all backgrounds. Sample recruitment elicited responses from four individuals and all four individuals completed and submitted the demographic form. The form provided basic information about these individuals including their preferred sexual identity, a broad age category, their level of experience with equines, and whether or not they identified as Indigenous. In reviewing these forms and with the benefit of hindsight, I would have preferred to create a more comprehensive demographic form that allowed for a more robust understanding of 60 the individuals I was interviewing. I found that after the completion of the interviews, I had several questions left unanswered that could have been captured in the demographic form. For example, the original questionnaire requested that the participant disclose their level of experience with equines. I would have liked to have the participants elaborate on this point, possibly specifying their years of experience, their preferred discipline, or their approach to work with equines. All of the participants in this study had previous experience with equines and it would have promoted a deeper understanding of their experience if I had gathered more information on the questionnaire. The final sample did provide for some diversity in identity and gender; however the sample was not large enough to include an in-depth analysis of these topics. The novel corona-virus also shifted the research process to telephone interviews rather than in person interviews, and I believe that some of the richness of data was lost when interviews were conducted in this fashion. Facial expression, congruence of affect, and emotional expression may be lost when conversation is conducted via telephone rather than in person. Further, it is important to note that the increased stress of a global pandemic and the very real fear, anxiety, health challenges, and economic shifts that individuals were facing at this time may have impacted data collection given the shift in day-to-day context for the participants. Comparison of Themes and Literature The interviews revealed that the participant’s experience of empathy and EFT/EAP was emotionally laborious, and required intentional and strategic emotional engagement. The necessity of engaged parallel process from facilitator to participant, and participant to equine was viewed as critical by the participants. The process of parallel attunement and engagement was necessary to promote the participants’ reflection on their own internal emotional states, and to support their participation in exercises that assisted them to emotionally regulate. Finally, an interesting finding of this study was that participants experienced the equine partners as emotionally neutral in the interaction, and that the horses primarily responded to the emotional state of the human. Participants experienced the horses influencing participants’ own emotional states, suggesting that horses promoted “softness”, “empathy”, “quiet reflection”, and “lightness” 61 in the human. However, participants were not clear on how horses promoted these experiences. For example, participants could easily articulate that horses encouraged them to be “softer”, however, they could not clarify what it was about the horse that promoted the shift in feeling state. The findings of my research were consistent with what exists within the current body of qualitative literature regarding empathy and EAT/EFP. Participant experience of EAT/EFP reflected an improvement in empathy; they felt that they were better able to attune to other’s emotional states and subsequently better able to empathize with others. The participants identified some of the challenges of EAT/EFP in developing and improving empathy. The challenges of improving one’s empathy in EAT/EFP were explored, though I was unable to locate any previously existing studies that spoke specifically to the challenges and barriers in utilizing this therapeutic modality for this type of work. Suggestions for Future Re search The findings from this study are limited by both sample size and the subject matter that was explored. The interviews for this study focused on a ‘high level’ approach to the subject matter, and certainly each theme that was identified could be further explored in future research. Although the findings suggest that EAT/EFP is beneficial to participants, and specifically, beneficial to their understanding of empathy, the sample was limited in size and provided a very broad overview of the topic of research. Future research that takes a “deeper dive” into the themes identified in this study may help develop a more comprehensive understanding of what specific practices or tools in EAP/EFP contribute to the perception of improved empathy. The concept of parallel process in client/facilitator and equine/client dyads ought to be more robustly explored as this study suggests that this process is critical to the therapeutic goals of improving empathy. Developing a more comprehensive understanding of this process and specifically what steps the facilitator takes in this process may contribute to the development of a more comprehensive, step by step approach to EAT/EFP as a therapeutic intervention. Future research that examines specific client populations may also be beneficial. This 62 study focused on broad sample criteria. Given the potential benefits of EAT/EFP that have been identified in the literature and in this study, it would be appropriate to begin to explore which client groups appear to benefit the most from this style of intervention, and to identify in which ways each client group appears to benefit. Understanding the improvements and therapeutic process more comprehensively will allow organizations promoting EAP/EFP to develop best practices and policies that ensure the safety and well-being of clients, as well as maximal therapeutic benefit. 63 Chapter 6: Conclusion The overarching goal of this research was to develop a more in depth understanding of the lived experiences of those who chose to participate in Equine Facilitated Psychotherapy (EFP) and Equine Assisted Therapy (EAT) and their understanding of empathy as it pertains to EAT/EFP. My research suggested that the individuals who participated in the study had a strong understanding of empathy as it pertained to human relationships. They experienced their participation in EAT/EFP to be beneficial to their personal and relational development and specifically, their lived experience was that the EAT/EFP directly improved their ability to emotionally attune and empathize with other humans. Participants described empathy as a process of “feeling what others feel”, and the thematic description of empathy was that it was not a cognitive understanding for another’s situation, but rather a deepfelt sense of another’s emotional experience. The interviews conducted for this research revealed robust information regarding EAT/EFP and the participants’ lived experience of the intersubjective exchange that occurred between the facilitator, the equine, and the participant. As noted in Chapter 4: Findings, the sample for this study was relatively small, with four participants. Of these four, three identified as female, one as male. All of the participants were from the same age category. Of note, throughout the interviews, all four participants identified that they had experienced relational trauma in critical relationships with their families of origin. Although the participants had varying levels of experience with horses in their lifetimes, and various levels of engagement in EAT/EFP, each did confirm that they had previous experience with horses. The nature of these experiences was not further explored for the purposes of this research. 64 In conclusion, EAP/EFT appears to promote the perception of improved empathy amongst participants in EAP/EFT, as well as their understanding of empathy as critical to improving relationships in their life. Although the literature suggests that psychometric measures of empathy do not appear to increase in correlation to participation in EFP/EAT (Ewing et al., 2014; Trotter, 2012), the lived experience of participants suggests that there is an increase in the experience of empathy and there is an intersubjective exchange between all involved participants including the facilitator, patient, and equine that reflects empathy. In counselling and therapy, very little exists in black and white, and it is acknowledged that therapeutic relationship and continued engagement in therapy is more relationally based than grounded in specific protocol (Gergely, 2012). Given that relationship and lived experience influence therapeutic adherence and retention, it is very important to develop an understanding of the participants’ lived experiences, their perception of success and perception of improvement. Future research into EAT/EFP ought to examine these matters closely and seek to deep dive into the participants’ experiences. Doing so will inform future best practices in EAT/EFP as the field continues to expand and grow. It is also worth continuing to explore how different cohorts experience EAT/EFP, including but not limited to youth, adults, persons living with disabilities, and other marginalized populations. Continuing to explore the lived experiences of participants respects their autonomy in the work and allows for them to develop and direct treatment planning in a manner that makes sense in their journey. Working from the client’s perspective allows us to develop treatment plans that are grounded in their life experience and centered on their goals. 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The thesis project requires that I conduct my own research under the careful supervision of a UNBC faculty member. I am working Glen Schmidt, PhD to complete my research. I am writing this email because you were identified through your website as an Equine Facilitated Therapy (EFT), Equine Facilitated Psychotherapy (EFP), Equine Facilitated Wellness (EFW) and/or Equine Assisted Activities (EAA) facilitator. I am requesting your assistance in recruiting a sample group for the purposes of my study. The title of the study is Understanding Empathy in Equine Assisted Psychotherapy (EFP). I have attached to this email an information letter outlining the nature of the research, and what is being requested of you as a practitioner. Additionally, I have attached a copy of the participant information letter and consent in order to provide you with an understanding of what will be requested of the research participants. This study is a qualitative project focusing on participants perception of empathy and how it relates to participation in EFP/EFT/EFW/EAA. Research participants may be contacted for qualitative data collection via interviewing following a random selection process. Please review the attached documents and advise if you would be willing to assist with recruiting a sample for the project. As part of the ethical requirement to safe guard research participants against the potential harms of research, I am also requesting your assistance in compiling a document containing local resources and supports for the participants in this study. Thank you very much for your kind consideration. Sincerely, Sheila Marie Anderson (RSW) University of Northern British Columbia andersonsm@unbc.ca (778) 349-2112 Faculty Supervisor Glen Schmidt University of Northern British Columbia Glen.Schmidt@unbc.ca 250-960-6519 73 Appendix B Information Letter for Practitioners Date: March 20, 2020 Project Title: Understanding Empathy in Equine Assisted Psychotherapy Project Lead: Sheila Anderson (Student Researcher) University of Northern British Columbia Prince George, BC V2N 4Z9 andersonsm@unbc.ca or 778-349-2112 The below research project is being conducted as partial requirement for the completion of a graduat e degree. The student researcher is conducting this research to fulfill the academic requirements for a Master of Social Work (MSW) at the University of Northern British Columbia (UNBC) The UNBC faculty member from the School of Social Work that is supervising the project is Glen Schmidt and his contact information is as follows: Glen Schmidt, PhD. School of Social Work University of Northern British Columbia Prince George, BC V2N 4Z9 glen.schmidt@unbc.ca Purpose of Project This project is a qualitative study that aims to examine the relationship between Equine Facilitated Psychotherapy (EFP) , Equine Facilitated Wellness (EFW), Equine Assisted Activities (EAA) and Equine Assisted Therapy (EAT) and empathy in humans. This study requires that a group of participants be recruited that have participated in an EFP/EFT/EAA and/or EFW program prior to participation in the study The researcher is requesting that you review the below information and determine if you would be interested in assisting with recruitment of potential participants for this research project. What will happen during the project? The researcher is requesting your assistance in recruiting a sample of participants for this research project. During the project, participants will be asked to complete the following: If the participant determines that they would like to voluntarily participate in this study, they will be provided with a basic demographic questionnaire. This questionnaire will include age, sex, commencement date of EFP/EAT, and how many sessions that the participant has completed. As part of completing this questionnaire, the participant will be asked if they wish to participate in an interview with the researcher regarding the participants’ views on empathy. The participant will be asked to complete the demographic questionnaire and to return this item to the researcher. If more than five participants are agreeable to being interviewed, the researcher will select interview participants via random draw. Finally, following the analysis of the interviews, the researcher will 74 verify the analysis with the participants to ensure that the analysis adequately represents the participants perspective. What is being requested of the Equine facility? Facilities are being asked to assist in the recruitment of a participant sample for the purposes of this study. Specifically, the researchers are requesting that facilities forward the recruitment information attached to this email to their membership list. The researchers contact information is included in the email template, allowing the potential participant to contact the researcher directly. The researcher is also requesting your assistance in identifying local support resources to provide to the study participants in the event that they feel they will require support during or following the study. Please note that the facility and facilitator are not being asked to participate directly in the study, but rather to assist with the recruitment of a sample and to assist with compiling a list of resources for researcher participants. Risks or benefits to individuals participating in the project There are potential benefits and risks to participating in the project. Some participants may find the questionnaires to be inconvenient, or the questionnaires could potent ial trigger negative feelings and emotions for the study participant. Further, the outcome or conclusion of the study may generate unpleasant emotions for the study participants. The researcher will provide the participants with a detailed list of resources available to them in their communities in the event that they experience negative emotions. The potential benefits of the study are to broaden knowledge related to empathy and EAT/EFP and to develop a deeper understanding of this therapeutic modality. I have attached a copy of the participant information letter and informed consent for your perusal to ensure that you understand the process of the study and what will be requested of potential participants. Confidentiality, Anonymity and Data Storage All identifying information will be coded by the researcher to maintain participant confidentiality and anonymity. All physical documents and information will be kept under lock and key at the researcher’s home residence. Only the researcher will have acces s to the data. All digital documents, data and information will be kept under password protection, all files will be appropriately encrypted and only the researcher will have access to digital data. A transcriptionist may be used to transcribe the intervi ews completed in the study. This person will be subject to a confidentiality and non-disclosure agreement. All data collected will be destroyed and deleted following the completion of the thesis defense. The anticipated completion date is February 28, 2021. The study will take approximately one year for completion. The researcher will need to be able to contact and follow up with participants several times over the course of the year. Please note that participation in the study is entirely voluntary and that participants may withdraw from the study at any time and any data collected from them be removed from the analysis and destroyed. For the disposal of electronic records, all information will be permanently deleted and removed from the researcher’s personal device. The participant will be notified in writing that all information collected from them was destroyed. Participants have the right to refuse to answer any question that they do not wish to answer. All of the data will be retained by the researcher until the research has been completed, unless the participant withdraws from the study. Physical data will subsequently be shredded, and all digital data will be deleted following the thesis defense. 75 Compensation Each participant will receive a gift card for the value of $10.00 to Tim Hortons for their participation in the study. Study Results The results of the study will be published as a thesis project. The completed work will be available at the UNBC library. Facilities involved in recruitment for the study will be provided copies of the thesis project. The research findings may be presented at conferences and as educational material to a wider audience. The research findings could be published and disseminated to a wider audience. Questions or Concerns about the project In the event that you have any questions regarding this study, please contact: Sheila Anderson (MSW student and student researcher) University of Northern British Columbia 778-349-2112 or andersonsm@unbc.ca Glen Schmidt, PhD. (Faculty supervisor) University of Northern British Columbia glen.schmidt@unbc.ca In the event that you have had concerns or complaints regarding the study, please contact: Office of Research University of Northern British Columbia reb@unbc.ca Phone: 250-960-6735 Fax: 250-960-5156 76 Appendix C Email Template for Practitione rs to Forward to the Membe rship List Date: Hello, I hope this email finds you well. You are receiving this email because you have expressed an interest in participating in Equine Facilitated Psychotherapy (EFP) with our facility. Our facility has been approached by a student researcher, Sheila Anderson. This student is currently completing her Masters of Social Work and is completing a study on EFP and empathy. The study is entitled Understanding Empathy in Equine Facilitated Psychotherapy. The researcher is attending the University of Northern British Columbia (UNBC) and her research is being supervised by Glen Schmidt, PhD. The study is a qualitative study focusing on empathy and how it relates to EFP/EFT/EAA/EFW, as well as focusing on selected participants lived experience of empathy and EFP. Our goal is to recruit a study sample that meets the following criteria: • Eighteen years of age or older • Has previously participated in EP/EFT/EFW/EAA The researcher is seeking a sample to complete a basic demographic questionnaire. This questionnaire will also clarify if the study participant would be willing to complete face to face interviews with the researcher regarding the participants experience of empathy and EFT/EFP/EFW/EAA. Of the study participants that indicate they would like to participate in the interview process, five will be selected via random draw to be interviewed. It is anticipated that this study will take approximately one year to complete. The study will be fully completed by February 28, 2021. The study consists of a demographic questionnaire, and face to face interviews between the researcher and the study participant. It is anticipated that the demographic questionnaire will take approximately ten minutes to complete. The researcher intends to have gathered all of the completed demographic questionnaires by June 1st 2020. It is anticipated that the interview portion of the study will take approximately two hours of participants time and will be completed by October 20, 2020. Study participants that are willing to engage in the interview portion of the study and have been randomly selected to do so will be contacted to arrange face to face interviews prior to August 20, 2020. The researcher will contact interview participants following the data analysis in order to review the results of the analysis. The review of analysis will take approximately thirty minutes. The purpose of this review is to ensure that the results accurately represent the participants views. The review of the analysis will either occur in person, or over the telephone, depending on the geographic location of the participant. If you are interested in participating in the study, please contact the principal investigator, Sheila Anderson via the email address listed below. You will be provided with an informed consent letter for your review. If you are agreeable to participating, you will be asked to complete the 77 consent and to return it to the researcher via email. You will then be provided with the demographic questionnaire via mail. The questionnaire will have a postage paid, self-addressed envelope included to allow participants to securely return the questionnaire to the researcher. ***Please note that this study has been reviewed by the UNBC Research Ethics Board.*** If you are interested in participating in this research project, please contact: Sheila Marie Anderson, RSW Phone: 778-349-2112 Email: andersonsm@unbc.ca University of Northern British Columbia If you have any concerns regarding this project, please contact: Office of Research University of Northern British Columbia reb@unbc.ca Phone: 250-960-6735 78 Appendix D Participant Information and Informed Consent Date: April 7, 2020 Project Title: Understanding Empathy in Equine Assisted Psychotherapy Project Lead: Sheila Anderson (Student Researcher) University of Northern British Columbia Prince George, BC V2N 4Z9 andersonsm@unbc.ca or 778-349-2112 The below research project is being conducted as partial requirement for the completion of a graduat e degree. The student researcher is conducting this research to fulfill the academic requirements for a Master of Social Work (MSW) at the University of Northern British Columbia (UNBC) The UNBC faculty member from the School of Social Work that is supervising the project is Glen Schmidt and his contact information is as follows: Glen Schmidt, PhD. School of Social Work University of Northern British Columbia Prince George, BC V2N 4Z9 glen.scmidt@unbc.ca Purpose of Project This project is a qualitative study that aims to examine the relationship between Equine Facilitated Psychotherapy (EFP), Equine Assisted Therapy (EAT), Equine Assisted Activities (EAA) and/or Equine Facilitated Wellness (EFW) and empathy in humans. This study requires that a group of participants be recruited that have participated in EAT/ EFP/ EFW/EAA. The researcher is requesting that you review the below information and determine if you would be interested in participating in this project. What will happen during the project? If the participant determines that they would like to voluntarily participate in this study, they will be asked to complete the consent portion of this document and return it to the researcher via the email to andersonsm@unbc.ca. Upon receiving the signed informed consent document, the researcher will mail the participant a basic demographic questionnaire. The questionnaire will arrive with a selfaddressed, postage paid envelope to return to the researcher. This questionnaire wi ll include age, sex, commencement date of EFP/EAT/EFW/EAA, and how many sessions that the participant has completed. It is estimated that the demographic questionnaire will take ten minutes to complete. The participant will also be asked if they wish to participate in a face to face recorded interview with the researcher regarding the participants’ views on empathy and EFP/EAT/EAA/EFT. The interview portion of the study will require approximately two hours of participants time. The participant will be asked to return the questionnaire to the researcher by June 1, 2020. If more than five participants express an interest in completing the interviews on the demographic questionnaire, participants will 79 be selected via random draw to complete the interviews. The researcher will contact the participants that are selected for the interview by August 20, 2020 to arrange interview date, location and time. Interviews will be recorded using a digital voice recording device, and subsequently transcribed into written format. A transcriptionist may be hired to assist with this process. Please note that if a transcriptionist is hired, they will be required to complete a written contract in which they agree to keep all information accessed during the research confidential. Data gathered from the interviews will be reviewed and analyzed using thematic analysis. Following the data analysis, the researcher will contact study participants to review the analysis and ensure that the analysis accurately represents participant views. The review of the data analysis will require approximately thirty minutes of the research participants time. Risks or benefits to participating in the project There are potential benefits and risks to participating in the project. Some participant s may find the questionnaires and interviews to be inconvenient, or the questionnaires could potential trigger negative feelings and emotions for the study participant. Further, the outcome or conclusion of the study may generate unpleasant emotions for the study participants. The researcher will provide the participants with a detailed list of resources available to them in their communities in the event that they experience negative emotions. The potential benefits of the study are to broaden knowledge related to empathy and EAT/EFP/EFW/EAA and to develop a deeper understanding of this therapeutic modality. There are potential benefits to the therapeutic community as well in the event that the study indicates a positive result. Confidentiality, Anonymity and Data Storage All identifying information will be coded by the researcher to maintain participant confidentiality and anonymity. All physical documents and information will be kept under lock and key at the researcher’s home residence. All digital documents and information will be kept under password protection. All data collected will be destroyed and deleted following the completion of the thesis defense. The anticipated completion date is February 28, 2021. All recorded data, including the interview recordings, will be deleted, and the digital recording device will be completely wiped following completion of the thesis defense. Please note that participation in the study is entirely voluntary and that partic ipants may withdraw from the study at any time and any data collected from them be removed from the analysis and destroyed. For the disposal of electronic records, all information will be permanently deleted and removed from the researcher’s personal devic e. If the data was collected in hardcopy format, the researcher will shred all information at the participants request. The participant will be notified in writing that all information collected from them was destroyed. Participants have the right to refuse to answer any question that they do not wish to answer. All of the data will be retained by the researcher until the research has been concluded, unless the participant requests that data pertaining to them be removed from the study. Physical data will be shredded, and all digital data will be deleted and wiped following the research defense. Compensation Each participant will receive a Tim Hortons gift card for the value of $10.00 for their participation in the study. 80 Study Results The results of the study will be published as a thesis project. The completed work will be available at the UNBC library. The researcher will provide the study participant with a summary of the findings. The completed thesis will also be provided to facilities that ass isted in recruitment. Additionally, the results of the study may be utilized for presentation at conferences related to EFP and may be provided to the larger therapeutic and academic community. A summary of the research will be provided to study participants. Please include your email and contact information below in order for the researcher to forward this information to you. The researcher will also use the mailing address on this form to send the demographic questionnaire to the participant. Name: Email: Mailing Address: Questions or Concerns about the project In the event that you have any questions regarding this study, please contact: Sheila Anderson (MSW student and student researcher) University of Northern British Columbia 778-349-2112 or andersonsm@unbc.ca Glen Schmidt, PhD. (Faculty Supervisor) University of Northern British Columbia Glen.schmidt@unbc.ca In the event that you have any complaints or concerns with the study, please contact: Office of Research University of Northern British Columbia Reb@unbc.ca Phone: 250-960-6735 Fax: 250-960-5156 Participant Consent and Withdrawal CONSENT I have read or been described the information presented in the information letter about the project: YES NO I have had the opportunity to ask questions about my involvement in this project and to receive additional details I requested. YES NO I understand that if I agree to participate in this project, I may withdraw from the project at any time up until the report completion, with no consequences of any kind. I have been given a copy of this form. YES NO I understand that I may refuse to answer any question that I do not wish to answer and that my response is entirely voluntary YES NO 81 I understand that upon withdrawing my consent to participate, that all data collected from me will be destroyed. YES NO Follow-up information (e.g. a summary of the research, a list of local resources that can be accessed) can be sent to me at the above noted e-mail or mailing address: YES NO I understand that the research findings may be presented and disseminated to a larger audience, including but not limited to conferences, publications and educational workshops . YES NO I understand that if I am willing to be interviewed and selected to do so, the interview(s) will be recorded using a digital recording device. If I am willing to be interviewed and selected to do so, I consent to the interview(s) being recorded. YES NO I understand that the interview(s) will be transcribed and that a transcriptionist may be hired to assist with transcription. YES NO In the event that you are experiencing any psychological or emotional discomfort or distress, please review the following free resources that are available for emotional support and services to you in your local community. You are able to access these resources in your community: Quesnel Women’s Resource Center 690 Mclean Street, Quesnel 250-992-8472 Northern Health Authority Community Health Services GR Baker Memorial Hospital 543 Front Street 250-985-6828 Westside Community Mental Health 395 Elliot Street, Quesnel 250-992=5189 Canadian Mental Health Association 102-345 Anderson Drive, Quesnel 236-424-1946 Quesnel Shelter and Support Society 146 Carson Drive, Quesnel 250-991-0002 Quesnel Child and Youth Support Society 655 Front Street, Quesnel 250-992-1555 North Cariboo Aboriginal Family Programs Society 324 Hoy Street North, Quesnel 250-992-9160 82 Signature: Name of Participant (Printed): Date: If you would like to participate in this research project, please sign this informed consent package and return it to the researcher via email at andersonsm@unbc.ca. You are able to scan the documents into email or you can take a picture of the signed documents and attach them to the email. 83 Appendix E Confidentiality and Non-Disclosure Agreement for Transcription This study, Understanding Empathy in Equine Assisted Psychotherapy, is being undertaken by Sheila Anderson (the “Principal Investigator”) at the University of Northern British Columbia (“UNBC”). The study has the following objective: 1. To examine how adult EFP participants experience and understand empathy as it relates to EFP/EfT/EAA/EFW; Data from this study will be used to develop an understanding of the therapy participants perspective on empathy and EFP. I, (the “Recipient”), agree as follows: 1. To keep all the research information shared with me confidential by not discussing or sharing the research information in any form or format (e.g. disks, tapes, transcripts) with anyone other than the Principal Investigator(s); 2. To keep all research information in any form or format secure while it is in my possession; 3. I will not use the research information for any purpose other than to transcribe the content of the interviews; 4. To return all research information in any form or format to the Principal Investigator when I have completed the research tasks; 5. After consulting with the Principal Investigator, erase or destroy all research information in any form or format regarding this research project that is not returnable to the Principal Investigator (e.g. information stored on computer hard drive). Recipient (Print name) Principal Investigator: (Signature) (Date) 84 (Print name) (Signature) (Date) If you have any questions or concerns about this study, please contact: Professor Glen Schmidt, PhD. Glen.Schmidt@unbc.ca 85 Appendix F Demographic Questionnaire for Participants 86 Appendix G Intervie w Schedule The researcher will review confidentiality and informed consent The researcher will confirm that the participant is still voluntarily consenting to participate and will obtain verbal consent. 1) How do you define empathy? Researcher may utilize minimal prompts: Could you tell me more about that? Can you explain that? Can you help me to understand that? Could you elaborate on that? 2) What role does empathy play in human to human interaction? Researcher may utilize minimal prompts, as noted above. 3) What role does empathy play in human to animal interaction? Researcher may utilize minimal prompts, as noted above. 4) What is your understanding of the horses’ experience of empathy? Researcher may utilize minimal prompts, as noted above. 5) What is your understanding or your beliefs about empathy’s role in EFP? Researcher may utilize minimal prompts, as noted above. 6) Throughout your participation in EFP, did you experience any changes in your beliefs regarding animals? If so, please tell me about the changes. Researcher may utilize minimal prompts, as noted above. 7) Throughout your participation in EFP, did you experience any changes in your beliefs regarding empathy? If so, please tell me about the changes. Researcher may utilize minimal prompts, as noted above. 8) Throughout your participation in EFP, did you experience any changes in your own level 87 of empathy? If so, please tell me about the changes. Researcher may utilize minimal prompts, as noted above. 9) If you experienced any changes in your own level of empathy, can you please tell me if these changes have had an impact of your day to day life? If so, please tell me about the changes. Researcher may utilize minimal prompts, as noted above. 10) How do you view the horses experience as a participant in EFP/EAP? Researcher may utilize minimal prompts as noted above. 11) What considerations do you believe should be made concerning the animals being utilized in EAP/EFP sessions? Researcher may utilize minimal prompts, as noted above. Researcher will thank the participant for the interview and will advise that after the interviews have been analyzed, the researcher will contact the interviewee to ensure that the analysis is consistent with what the interviewee was trying to communicate during the interview. 88 Appendix H Research Ethics Board Approval 89 Appendix I Research Ethics Board Amendment and Renewal Approval 90 Appendix J Summary of Acronyms Acronym AAA AAT CANTRA EAA EAGALA EASW EAT EFT PATH Definition Animal Assisted Activities Animal Assisted Therapy Canadian Therapeutic Riding Association Equine Assisted Activities Equine Assisted Growth and Learning Association Equine Assisted Social Work Equine Assisted Therapy Equine Facilitated Psychotherapy Professional Association of Therapeutic Horsemanship