Experiences of a Therapeutic Equine-Assisted Group Intervention for People with Common Mental Disorders on Sick-Leave

Abstract Common mental disorders such as anxiety, depression and stress-related disorders are increasing worldwide, resulting in long-term sick leave and lower quality of life. Traditional treatment is often insufficient to facilitate the recovery process, and the need for holistic interventions that enable successful recovery is evident. Equine-assisted interventions have shown promising results in health promotion among people with mental disorders, and further research is needed to implement them within the range of available care. The aim of the study is therefore to describe experiences of a therapeutic equine-assisted group intervention for people with common mental disorders on sick leave. The study has a descriptive qualitative design with an inductive approach. Ten participants with common mental disorders on sick leave were interviewed after participating in a 12-week equine-assisted intervention and the data were analysed with conventional content analysis. The analysis generated the overall theme “The equine-assisted group intervention facilitates recovery,” which summons the four categories “The environment of the horses contributes to relaxation and an ability to be in the present,” “The presence of the horses facilitates supportive relationships in the group,” “Interplay with the horses entails physical activity and bodily improvements” and “Emotional interactions with the horses strengthen inner power.” In conclusion, equine-assisted interventions have the potential to facilitate recovery for people with common mental disorders by providing relaxation, promoting the ability to be in the present, cultivating supportive relationships and providing physical activity and bodily improvements as well as emotional interactions that strengthen the participants’ inner power.


Introduction
Worldwide, approximately 13% of the population suffers from a mental disorder.This means that, globally, 970 million people were living with mental disorders in 2019 (World Health Organisation [WHO], 2022).Mental disorders are often divided into severe mental disorders (SMD) including psychotic and bipolar disorders, and common mental disorders (CMD) including anxiety, depression and stress-related disorders (Swedish Social Insurance Agency, 2020).Anxiety disorders and depressive disorders constitute 60% of the prevalence of those with mental disorders, and women have a 50% higher risk than men of being afflicted (WHO, 2022).
CMD are an increasing problem and are now the leading cause of sick leave in Sweden; stress-related disorders, such as exhaustion syndrome, are especially increasing rapidly (Swedish Social Insurance Agency, 2020).A similar development can be seen in most European countries (OECD & EU, 2022).CMD may cause long-term sick leave, lower quality of life and difficulties in coping with daily life.They are moreover associated with high costs for the individual and society, making interventions that support recovery and rehabilitation most important (The Public Health Agency of Sweden, 2018).Equine-assisted interventions (EAI), have repeatedly shown a potential to improve overall health among people with mental illness (Almasloukh, 2022;Bator et al., 2020;Fridén et al., 2022;Højgaard-Bøytler & Argentzell, 2022;Hultsjö & Jormfeldt, 2022).Therefore, it is crucial to investigate experiences of how EAI may affect specific health aspects among participants with CMD.

Background
Stressful life events such as financial difficulties, loss of a family member, disease or unemployment increase the risk of mental disorders (Swedish Social Insurance Agency, 2020).Being employed can also be a risk factor when experiencing, for example, high and unclear demands, a heavy workload, low social support and a lack of respect at the workplace (Harvey et al., 2017).Another risk factor is the rising use of both private and professional use of communication and information technologies in modern society that may generate feelings of stress, also called technostress, that can contribute to the emergence of mental disorders (La Torre et al., 2019).Anxiety, depression and stress related disorders share common characteristics as anxiety and depressive symptoms can be present in stress-related disorders and when determining the diagnosis, social, psychological and biological factors must be assessed (Koutsimani et al., 2019).
Being on long-term sick leave due to CMD is a risk factor for premature death, which indicates that the need for strategies in rehabilitation to improve mental health in this group is substantial (Bryngelson et al., 2013).Rehabilitation has different meanings in different contexts, although the concept refers to a holistic healing process contributing to increased health and recovery, not just being cured of illness (Pratt, 2007).Rehabilitation for people with CMD in Sweden mainly consists of anti-depressant medication, physiotherapy and cognitive behavioural therapy (Swedish Social Insurance Agency, 2020).
EAI, is an overarching term for various therapeutic activities in which the horse is the central part, where a qualified equine therapist plans and leads the intervention to improve the participant's health (White-Lewis, 2020).The EAI in this study has a holistic and person-centred approach with a focus on each participant's needs and possibilities as well as focusing on the healthy instead of the disease.This approach is essential in health-promotion interventions to support all aspects of the participants' lives and emphasise and strengthen their abilities (Antonovsky, 1996).EAI has shown positive results when it comes to improving health and wellbeing of people with mental health issues such as psychotic disorders (Fridén et al. 2022;Hultsjö & Jormfeldt, 2022;Jormfeldt & Carlsson, 2018), youth anxiety (Hoagwood et al., 2022;Punzo et al., 2022), posttraumatic stress disorders (Rosing et al., 2022) and substance abuse (Gatti et al., 2020;Kern-Godal et al., 2016).One of the explanations for the positive outcomes is that the presence of the horse acts as a catalyst for the healing process through connectedness and the ability to detect and fine-tune emotions between human and horse, both by body-to-body contact and emotional transfer during interactions (Scopa et al., 2019).Emotional arousal can result in positive outcomes such as calmness, focus and increased self-confidence (Hemingway et al., 2019).Physical activity has been shown to have positive effects on health and recovery for people with CMD, and it reduces the risk of metabolic and cardiovascular diseases and obesity (Schuch & Vancampfort, 2021).In EAI, physical activity is naturally occurring when performing activities with the horses and can be experienced by participants as getting exercise as a bonus without demanding as much effort as exercising in general (Hultsjö & Jormfeldt, 2022).
People on sick leave with CMD face many challenges during their rehabilitation process when trying to find ways to function in their daily lives and improve their health (Nybergh et al., 2021).Holistic health promotion interventions such as EAI for people with CMD are scarce and of the foremost importance.Therefore, the aim of this study is to describe experiences of a therapeutic equine-assisted group intervention for people with CMD on sick leave.

Design
The study employed a descriptive qualitative design with an inductive approach, as this type of design is appropriate when existing literature is limited (Hsieh & Shannon, 2005), as is the case with research on EAI for people with CMD on sick leave.

The intervention
The EAI was included in a primary healthcare project called "Green Rehabilitation" in a county in southwestern Sweden.Primary healthcare physicians referred people with CMD to horse farms to complement their ordinary care, which involved medications, physical therapy, mindfulness or psychological therapy.
The studied intervention took place on two horse farms as part of the Green Rehabilitation project in southern Sweden.The interventions occurred twice a week for 12 weeks in 2018 and 2019.Each session lasted for 4 h.The activities varied in relation to the seasons and could vary from arts and crafts or cultivating plants in the garden to long walks in the forest; nevertheless, horses were present and central in the intervention.Each meeting started with a morning coffee gathering to plan the day.After the activities were performed, the day ended with a shared meal and a discussion about the day and how the participants felt about their achievements.The activities with the horses lasted for an average of two hours per session and comprised the participants caring for them, going horseback riding, riding a horse and carriage, walking with them, or just being near, watching or depicturing them.All the activities were adapted to each participant's personal needs and prerequisites.Ensuring both horses and participants' safety was prioritised by the therapists leading the EAI-sessions.The safety measures included that only healthy horses participated and appropriate equipment such as helmets were used.Also, all participants received instructions on how to safely interact with the horses and always wait for instructions from the therapist responsible for the EAI-sessions before approaching the horses to minimise the risk of injuries of both participants and horses.

Ethical considerations
The study was approved by the Regional Ethical Review Board, Lund University, Sweden, Dnr 2017/709 and performed according to the regulations of the World Medical Association's Declaration of Helsinki (WMA, 2013).The participants received written and oral information about the study's purpose and structure, specifying that participation was voluntary, they could withdraw from the study at any time without having to express any reasons and the interviews would be treated with strict confidentiality.This information was repeated by the interviewer prior to the interviews, and all the participants gave their written informed consent to participate in the study.The therapist responsible for the EAI-sessions informed the participants regarding the importance of confidentiality in the group.Since the study examines a pre-existing intervention and no experiments regarding the animal was conducted, no ethical approval regarding animal welfare was applied for.The well-being of the horses was assessed before and after each EAI-session according to Fine's (2015) definition of animal welfare, defined by the five freedoms: (1) freedom from thirst, hunger and malnutrition; (2) freedom from discomfort; (3) freedom from pain, injury and illness; (4) freedom from fear and worry; and (5) freedom to express normal behaviour.

Participants
The inclusion criteria were to be over 18 years of age and have completed an EAI at one of the two farms included in the study.The participants suffered from CMD and were on whole or partial sick leave during the intervention.All participants had in common that traditional treatment with antidepressants, behavioural therapy and physical therapy had not had the intended or desired effect.Fourteen of the intervention participants were asked to participate in this study, and ten of them agreed.The participants consisted of two men and eight women between the ages of 34 and 49, with a median of 43.5 years.

Data collection
The ten interviews were conducted by a registered nurse with extensive experience in holding dialogues with patients.Since face-to-face meetings were inappropriate during the Covid-19 epidemic, the interviews were conducted by telephone from May 2020 to April 2021, where a semi-structured interview guide with open-ended questions was used.The opening question in each interview was about their EAI experiences and their influence on their health and recovery.Relevant follow-up questions such as "Can you tell me more about that?" were added continuously during the interviews to give the participant the opportunity to develop answers and speak freely about their experiences (Hsieh & Shannon, 2005).The interviews, which were audio recorded and transcribed verbatim, lasted between 20 and 71 min each, with a median length of 44 min.

Data analysis
Qualitative conventional content analysis, according to Hsieh and Shannon (2005), was used when analysing data.First, the interviews were read repeatedly to acquire an understanding and sense of the whole.Then the data were read word by word, and the content related to the aim of this study was identified and coded.The codes with similar content were reflected upon and placed in categories, and one hierarchically superior category emerged as the overall category.To achieve trustworthiness, all four authors repeatedly discussed the findings, and revalued codes and categories until consensus was reached to increase credibility and dependability in accordance with the recommendations of Hsieh and Shannon (2005).The attempt was to find descriptions close to the text, even though some interpretation was required (Hsieh & Shannon, 2005).Examples of the development of categories are shown in Table 1.

Result
The analysis of the data generated one overall category and four categories, as shown in Table 2.

The equine-assisted group intervention facilitates recovery
The overarching category illustrates that the participants experienced the EAI as facilitating their recovery.The horses and their environment played a significant role in the process as they helped the participants to relax, reduce stress and facilitate supportive relationships in the group.The participants experienced that the interplay with the horses entailed physical activity and bodily improvements such as weight loss, better blood pressure and relief of stomach-and headaches and they also experienced that the emotional interactions with the horses strengthened inner power.

The environment of the horses contributes to relaxation and the ability to be in the present
The participants described how they became calm and left the stress behind upon arrival to the horse farm.They experienced that the activities with the horses made them focus on the present since they needed to give the horses all their attention when interacting with the animal.When the participants interacted with the horse, they felt a calmness and serenity they did not feel anywhere else, which helped them control stress.The interaction could be listening to the horse eating, grooming it, "giving it love" and talking to it; all this was experienced by the participants as relaxing as they felt that the horse enjoyed being cared for.Moreover, the horses radiated calmness and warmth, and caring for them contributed to unwinding and harmony, according to the participants.One of the participants described that when riding the horse, she let go of all thoughts, only focused on the present and became one with the horse.
What was good for me when it came to the horses was that I had to master my stress in a different way because I dared to challenge myself and try to get my stress, in other words, become aware of my stress and calm down when I was about the horse so then you kind of got control of your stress and it was good.(213) The participants described the environment around the horse as very calming, and all the impressions from the forest and the horse were relaxing, which made it possible to be in the present.One participant described that they received an opportunity to stop and contemplate and reflect on life, which was not possible in their busy daily life at home.Furthermore, when being outdoors with the horse, the participants focused on the shifts in nature as the seasons changed, something they seldom had noticed before.The participants perceived being in this environment as an extreme contrast to their stressful everyday life and were able to reside in a non-technological environment since the mobile phone coverage was poor at the farm and in the forest.
It was a very good break from mental illness in some way.So, you could focus on other things than just letting the brain steer away and dwell as it did all the time before.It was really nice to go there two days a week and pause, so to speak.Pause the dilemma that you lived in.( 213) Also, the participants felt that the only demand was to show up.After that, all activities were adapted to each individual's possibilities, and they could participate in the activities with the horses at their own pace.

The presence of the horses facilitates supportive relationships in the group
The participants described that being in a group when interacting with the horses provided an opportunity to spend time with peers who had similar experiences, which aided the recovery process.
The group made the participants feel accepted and allowed them to be themselves.When doing activities with the horses, the participants experienced that they encouraged each other to do things they were afraid of as they saw that the others were able to do them.One of the participants described how she felt strengthened by being the one who knew horses and could support other participants in gaining the courage to interact with them.
I have already ridden in my life, and I don't think it's fun, and I don't feel good riding, these negative thoughts, but the more time you spent with the horse and sort of saw the others: Oh, yes, I could do it!, then you also wanted to do it, of course, I will try, and then it just took off.(213) The participants described that people in the group dared to be vulnerable, and they acquired an understanding of each other, which gave them an affinity and connection that made them feel less alone.Being with peers gave them the opportunity to have fun and laugh together with other people since several of them had been isolated from others as they did not have the energy to socialise.They understood each other's situation in contrast to other people around them, which welded them together as a group.
When you got to know the others and understood that they had similar problems to mine and almost every one of them had "hit the wall".Even if you didn't have the same life situation, you recognised yourself in each other, so it became okay to be in a group, and you might not always hear what the others said because you got lost in yourself, but you were allowed to be who you were and heal there, together.(207) In some situations, the participants felt that being in a group could be negative, like when new participants joined or when their focus was on helping another participant interact with the horses instead of their own recovery.One participant described that they could spend time alone with the horses if they needed a break from social interactions with humans and then return to the group with new strength.
Some people take up more space than others, and then if you don't feel well, it can be hard, but then you always had the opportunity to walk away so you didn't have to; there were always tools for you to feel better.( 113)

Emotional interactions with the horses strengthen inner power
The participants described how the emotional interactions they had with the horses and the environment around them positively influenced factors contributing to their recovery process.
I was picked up in a horse and carriage, and I was tucked in on the wagon and got to lay there and watch the treetops.She also had a hand horse with her, so it was like the whole gang picked me up.It was an amazing experience.I almost cry when thinking about it because it was so beautiful.( 125) Several of the participants described that interacting with the horses generated new energy.When caring for them, they felt needed and that all you gave the horse came back in the form of new energy.When riding, they were able to share the horse's power, and being on the horse made them open to experiencing the beauty of nature around them.
You opened up your eyes to the nature around you while riding.You have been in a haze where you hardly hear or see, but suddenly it opens up!And to feel this power in the horse, you get a little bit of it (207) The participants described how they felt the horse signalling safety, love and tenderness and experienced a magic connection to it.They also felt warmth, harmony, joy and a feeling of being needed when being around the horses.They moreover described traits of the therapist responsible for the EAI that were important for making them feel safe, cared for and welcome, namely being open-minded and present, listening to signals about how they felt and adjusting activities accordingly and also guiding and challenging them.These traits contributed to a mutual trust that enabled progress and empowerment when interacting with the horses and the other participants.I think it is, partly, you don't have to say much, and you can sort of just be.You don't need; the horses don't speak; they just give signals and, in some way, safety, love and tenderness.(113) The participants who had previous experience with horses described how they learned a unique way to interact with them; instead of holding the horse tight, they learned to let go of control, and they learned to take their time and experience the love and connection to the horse.In comparison, the participants with no experience with horses described how they had grown with the task and felt increased self-esteem when they had the courage to interact with them.
When you were out riding with them, and they followed every command, it gave you a huge self-confidence, and then you created a bond between horse and human and that … strengthens the more you worked with the horse.( 120) According to the participants, the therapist responsible for the EAI-sessions also had a significant role in the recovery process.The way she had a balance between pushing and holding back made them feel safe and secure, which enabled growth.
One participant described that after being on sick leave for a while, the recovery process stopped and even went backwards, but when attending the EAI, the process started to go forward again.No other support efforts were perceived to have worked as well as the EAI, and all the participants experienced that the EAI was a significant step in their recovery process; they also felt that what happened afterwards significantly impacted their ability to continue moving forward.All the participants expressed that they would not have come as far as they did without the EAI, yet if the time had been longer or if they had received the opportunity to work-train on the farm or do follow-up visits, the benefits could increase further.
It's a huge difference because … I started a process I hadn't had before, where I got more in touch with myself.What is important to me?What makes me feel good?What shall I think about to be able to get up tomorrow?…I am a new person today compared to what I have ever been before.( 213) The participants disclosed that they learned new skills during the EAI that also helped them afterwards, such as turning to horses and nature to reduce stress, regain energy, and focus on their own needs and abilities, gaining new perspectives on what is important in life.
I have gotten different perspectives on life and what is important … Like not prioritising work in front of family, for example, which I today realise that I might have done on several occasions.(118) However, some of the participants experienced that the transition into work after the EAI and sick leave was traumatic since there were few opportunities to lower the work rate.Furthermore, if you did not "fit into the frame" by recovering in the time presumed by the social insurance agency, it was harder to get the support needed from your healthcare centre, the social insurance agency, the public employment agency and employers, which could lead to loss of income.However, some of the participants described how lucky they were to have had functioning support in the recovery process since they had met a physician, rehab coach or handler at the social insurance agency who listened, was engaged and created a plan for the rehabilitation process, and this was expressed as important in sustaining the positive effects they had gained from the EAI.

Interplay with the horses entails physical activity and bodily improvements
The participants described that the physical activity came as an integrated part of being with the horse, and it was performed without any feelings of pressure, which made them more physically active than they thought was possible.The participants described how they had difficulties doing things, which led to low activity levels.During the interplay with the horses, the participants described how they exercised and increased their physical activity level.
One thing that can happen when you don't feel well is that you automatically don't move around and you don't do things, and when being there, we moved a lot, and that is positive too, you know that it is scientifically proven how beneficial it is to humans.(113) The participants experienced that the interplay with the horses entailed physical activity that they previously had been unable to do.One participant shared that when caring for the horses, she noticed that her physiological capacity had increased, and she was able to do things like scratch the hooves of the horse, which she could not do in the beginning due to pain or lack of energy.One of the participants felt that the horse's need and appreciation were a motivator to ride or walk with it, making it worth the physical discomfort in the form of pain or exhaustion that it might cause.
You had pain in your body for various reasons …. yet you have the physical strength to do it.It becomes so tangible, I couldn't do this when I started, but now I can.(205) The participants described that they experienced improved physical health during the EAI such as weight loss, better blood pressure, better sleep, lower stress levels, and the relief of stomach-and headaches.Also, the participants revealed that being in nature with the horses made breathing easier; they received lots of fresh air and felt that their physical health improved.One of the participants expressed that he did not need to take any anti-depressant drugs during the intervention, and he felt that EAI works far better than medications.
I got much more out of it than I thought I would… I didn't think I would lose weight; I did that, and I didn't think my blood count would improve, and I didn't think that the stress levels would disappear as they did and that my general wellbeing would become as good as they did.(120)

Discussion
The results show that the participants experienced that the EAI contributed to a significant step forward in their recovery process, and that being with the horses led to enhanced mental, social, physical and emotional abilities and well-being.All the participants emphasised the calming and relaxing effect of being in the horses' environment, which efficiently reduced their stress levels.Several other studies confirm that this seems to be a common phenomenon experienced by participants in EAI, independently of what conditions the participants suffered from (Fridén et al. 2022;Højgaard-Bøytler & Argentzell, 2022;Hultsjö & Jormfeldt, 2022;Punzo et al., 2022).Today's demanding modern technological society is filled with constant information input and demands that the brain seldom receives the opportunity to tune out.People are always reachable (La Torre et al., 2019), and the participants in this study described how difficult it was to find the possibility to pause and relax in their busy everyday life.Being with the horses was described by the participants as facilitating being in the present, in a way they could not achieve in other situations, which indicates that EAI has the potential to make people find inner calm and reduce stress.Social interactions often diminish due to a fear of being questioned since their sickness does not show on the outside, which can lead to isolation when on sick leave (Karlsson et al., 2023).The horses in the intervention contribute to a context in which the participants could interact with others on their own terms in a calm and non-judgemental setting.
In the results, it became apparent that the participants appreciated the opportunity to meet others in similar situations.This is consistent with other studies on EAI for people with mental illnesses (Collingwood et al., 2021;Højgaard-Bøytler & Argentzell, 2022;Hultsjö & Jormfeldt, 2022), which showed that participants felt supported, less alone and could build new friendships when meeting other people in the environment around the horses.This suggests that being in a group with peers in EAI may contribute to positive outcomes.
Furthermore, the results show that the interactions with the horse contribute to creating different positive emotions such as joy, happiness, calmness, love and self-confidence, and the participants described several situations with the horse that felt magical and amazing.Moments where you experience emotions of amazement and magic can be described as awe-inducing experiences (Luo et al., 2021), and these have the potential to promote other positive emotions such as love, connectedness, self-esteem and pride (Nelson-Coffey et al., 2019) supporting the recovery process by facilitating well-being (Rudd et al., 2012).The results demonstrate that EAI includes rich possibilities for awe-inducing experiences.
The results also show that the participants experienced an improvement in their physical health due to the exercise inherent to the activities with the horses.Since finding motivation for physical activity is often a barrier for people with mental disorders (Schuch & Vancampfort, 2021), engaging in activities together with horses seems to function as a motivating and efficient way to increase bodily movement and promote physical health in this group.Previous research has also shown that intrinsic motivators connected with rewards such as positive feelings of joy, love and self-confidence, are more likely to make people with mental disorders maintain and continue performing physical activity (Schuch & Vancampfort, 2021).Therefore, EAI has the potential to promote physical activity while interacting with the horses since these interactions contribute to positive emotions and a motivation to take part in physical activity, as the participants experienced.Several other studies have also described participants' positive experiences concerning how EAI increase the motivation to be physically and socially active (Collingwood et al., 2021;Højgaard-Bøytler & Argentzell, 2022;Tuuvas et al., 2017).
People on sick leave due to CMD have, in previous research, described the importance of a well-coordinated rehab team for recovery (Holmlund et al., 2022).This concurs with the result, as the participants described how they experienced moving forward in the recovery process after the EAI required support from primary health care and the involved agencies.Therefore, when developing interventions for people with mental disorders, a holistic perspective that includes planning for what happens afterwards is essential to facilitate the recovery process and sustain the positive outcomes derived from health-promoting interventions such as EAI.

Strengths and limitations
A limitation of the study is the small sample of ten participants, yet the data were rich and the last two interviews resembled data from the earlier interviews, which could indicate that saturation had been reached and that the number of participants was sufficient (Malterud et al., 2016).Performing interviews by phone may have limitations as one cannot perceive body language.However, there can also be advantages such as interviewees can be more open without feeling inhibited or judged; therefore, interviews by phone can be an appropriate alternative (Ward et al., 2015).The time between the intervention and the interviews may be beneficial since it enabled the participants to reflect on their experiences after being in the midst of them (Van Manen, 1997).A possible limitation is that eight women and only two men were included in the study, mirroring the fact that the majority of the participants in the EAI were women.The participants, the context with the horses and the data analysis were described as accurately as possible, and interview citations were used to increase transferability (Graneheim & Lundman, 2004).

Conclusion
Equine-assisted interventions have the potential to facilitate recovery in people with CMD by promoting relaxation and facilitating the ability to be in the present and take part in supportive relationships and emotional interactions that strengthen the participants' inner power and motivation for physical activity, leading to bodily improvements.

Relevance for clinical practice
This study places emphasis on the horses' contributions to the positive effects of nature-based rehabilitation interventions and contributes with valuable knowledge about how people with CMD can experience participation in a horse-assisted intervention and how this can be helpful to facilitate recovery.This knowledge can assist mental health nurses, primary healthcare nurses, physiotherapists and occupational therapists in finding helpful ways to support the improvement of holistic health in people with CMD.

Table 1 .
example of meaning units, condensed meaning units, codes, subcategories and the overall category.
riding.You have been in a haze where you barely hear or see, but suddenly it opens up! and to feel this power in the horse, you get some of it.(207) Your eyes open up while riding.You have been in a haze, but it suddenly opens up.You feel the power in the horse and get some of it.I got much more out of it than I thought I would, much, much more.I didn't think I would lose weight, I did that, and I didn't think my blood count would improve, and I didn't think that the stress levels would disappear as they did and that my general wellbeing would become as good as it got.(120) I got more out of it than I thought I would, I lost weight, my blood count improved, my stress levels disappeared, and my general well-being improved

Table 2 .
Overall category and categories of the experiences of the equine-assisted therapeutic intervention.