Amy's Story: An Existential-Integrative Equine-Facilitated Psychotherapy Approach To Anorexia Nervosa
Amy's Story: An Existential-Integrative Equine-Facilitated Psychotherapy Approach To Anorexia Nervosa
Amy's Story: An Existential-Integrative Equine-Facilitated Psychotherapy Approach To Anorexia Nervosa
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JHPXXX10.1177/0022167815627900Journal of Humanistic PsychologyLac
Article
Journal of Humanistic Psychology
2017, Vol. 57(3) 301–312
Amy’s Story: An © The Author(s) 2016
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DOI: 10.1177/0022167815627900
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Psychotherapy Approach
to Anorexia Nervosa
Veronica Lac1,2
Abstract
This article offers an existential-integrative framework to working with
anorexia nervosa within an equine-facilitated psychotherapy setting. The
discussion provides an overview of how existential-integrative theories can
be blended into equine-facilitated psychotherapy and offers an existential-
integrative perspective of anorexia nervosa. A case study illustrates the
theories behind this blended approach in praxis.
Keywords
existential-integrative, equine-facilitated psychotherapy, anorexia nervosa
An Existential-Integrative Framework
Freedom is the perceived capacity for choice within the natural and self-
imposed limitations of living. (Schneider, 2008, p. 35)
Authenticity, then, does not consist of rejection of the familiar world. It does
not call for one to deny values, activities, associates, or any aspect of his life.
Authenticity, indeed, must be approached more through alive participation in
all of these. (Bugental, 1965, p. 34)
clients are supported to “reoccupy” (e.g. embody) the parts of themselves that
have been denied. The more that clients are able to reoccupy themselves, the
more they are able to both access and express hitherto estranged dimensions of
themselves, and it is these very dimensions that deepen people’s appreciation
for life. (Bugental, 1965, p. 38)
gaining, through the vehicle of awareness, the capacity to feel the ambient
physical sensations of unfettered energy and aliveness as they pulse through
our bodies. It is here that mind and body, thought and feeling, psyche and spirit,
are held together, welded in an undifferentiated unity of experience. (Levine,
1997, p. 279)
presence (Schneider & Krug, 2009; Yalom, 1980). Related to Buber’s (1958)
I-Thou philosophy, the authentic presence of the therapist invokes and moti-
vates the client to become present in the encounter, leading to a new awak-
ened experience of living for them in that moment (Schneider & Krug, 2009).
An embodied way-of-being allows for authentic living.
This process takes the client out of their left-brain thinking, extracting clients
from their intrapersonal domain into a more mindful and interpersonal realm
with their whole being (Hamilton, 2011).
of problematic corporeal habits at a muscular level, one that was felt before it
was understood or discussable. (Sharpe, 2014, p. 142)
This echoes the attunement necessary to form attachment bonds and is part of
the integrated body–mind healing when working in this way with horses
(Shambo, 2013).
Including horses into the therapeutic space does not mean a negation of
the therapist–client relationship. Instead, EFP “relies not only on the thera-
peutic relationship with the clinician, but is also fueled by the client’s com-
pelling attachment to the therapeutic horse” (Karol, 2007, p. 77). This
opportunity for nurturing a healthier attachment process can also be viewed
through traditional attachment theory concept of “holding” (Winnicott,
1971). Bachi (2013) outlines three aspects of holding within EFP as the phys-
ical sensation of being held while on horseback, the natural setting within a
horse barn providing a nonthreatening environment, and the acceptance and
nonjudgmental nature of the horses. These three elements combine to offer
clients “the provision of a secure base and a haven of safety through a holding
environment” (p. 190) that is essential to secure attachment. In this way,
horses provide a “warm, non-manipulative, nonjudgmental, companionship
as well as essential comfort, and may offer an unconditional support system
to individuals with psychological issues” (Johansen, Arfwedson Wang,
Binder, & Malt, 2014, p. 329).
Furthermore, since horses bring themselves into each encounter authenti-
cally (Hamilton, 2011), they elicit the same authenticity from clients and the
therapist.
It is impossible to hide one’s emotions, as they will appear through the horse’s
behavior. In one way or another, if the individual does not express his or her
true emotions or hides behind appearances, the horse will feel it and will reflect
the inner feeling of the individual and will react with exact congruence to the
perceived human feelings. (Chardonnens, 2009, p. 327)
This process allows clients to experience in the present moment the live
responses from the horse and make meaning from this without the fear of
judgment. It also heightens the therapist’s awareness of his/her own authentic
and embodied responses toward the clients.
An EI approach to EFP necessitates a creative synthesis of the two modali-
ties and is conducted with individual clients, couples, families, or groups with
the therapist being dually credentialed as mental health and equine profes-
sional (Smith, 2010). From an existential framework, this approach focuses on
a phenomenological and experiential process as it unfolds in the here and now,
and holds that the primary source of healing occurs in the relationships
Lac 305
between the client, horse, and therapist (Kirby, 2010). At its core is the concept
of I-Thou relating (Buber, 1958) that emphasizes interconnectedness and dia-
logue, and is characterized by authentic meeting and the co-creation of a sup-
portive and healing relationship, that enhances a sense of self (Hycner, 1990).
While sessions are not riding lessons, mounted work can become part of the
session (Lac, 2015). People familiar with horses know that they respond to the
most subtle cues from the rider, and when a rider is disconnected from his/her
own body, “the horse will express it behaviorally or actually even become
locked up in his body” (Rector, as cited in Kohanov, 2001, p. 202). Based on
the foundations of present-centered awareness, relational connectedness, and
an embodied way of being, this approach has redefined and refined the impor-
tance of the bodymind (Lac & Walton, 2012). When in contact with horses,
not only does one need to be highly attuned to their own bodymind process but
also that of their equine partners.
Amy’s1 Story
The day before Amy’s first session with me was traumatic. I had only just
started working at the therapeutic equine facility the week before, and was
partnering with an outpatient eating disorders clinic that had started referring
clients to me there. The night before our first session, three horses in the herd
were randomly attacked. A teenage boy had slashed the horses with a machete
leaving deep gashes across their hindquarters. Thankfully, the injuries were
not fatal and the veterinarian was able to attend to the wounds and administer
some painkillers. Less than 24 hours after the attack, the horses were back in
their paddock grazing, while the human staff members were still reeling in
shock.
Amy had been referred to me by the clinic, newly released from her latest
stint in residential care for the treatment of anorexia nervosa. At 16 years old,
Amy had already been battling this disorder for 4 years, had been in and out
of residential care, and was severely depressed and actively self-harming.
Her primary therapist at the clinic had been working with her for 2 years and
thought that an equine-facilitated approach might ease her jaded attitude
toward traditional office-based therapies. Amy had been exposed to cogni-
tive-behavioral, dialectical-behavioral, psychodrama, art, and nutritional
therapies, in individual, group, and family settings. Nothing seemed to break
through enough for her to be able to sustain her recovery. From an EI
approach, my focus in working with Amy was to introduce her to a more
experiential process in an attempt to connect with her on an embodied level.
Amy arrived at the facility on a hot Virginia summer’s day wearing a
thick long sleeved top. As we walked into the paddock where the horses
306 Journal of Humanistic Psychology 57(3)
were grazing, I noticed her pulling at the ends of her sleeves. Her eyes were
downcast and her breathing was shallow, but she fixed a smile on her face in
answer to every question I asked. The horses were at the opposite end of the
paddock, about a hundred feet away from where we stood, when she noticed
their injuries. I told her what had happened the day before as she stood
rooted to the spot, transfixed by their scars, but still continuing to pull her
sleeves down over her hands.
VL: I notice how you’re pulling your sleeves over your hands.
Amy: Yeah, it’s a bad habit I have. I feel self-conscious of my scars.
Amy pauses and squints at the horses still grazing in the distance; I wait to
see what meaning she is making from seeing their scars.
Amy ponders for a moment before taking a couple of steps toward the horses
and stops.
Amy : I don’t want to force them to be friends with me, but I do want
them to notice that I’m here.
VL: How would you like to get them to notice you?
Amy begins to roll her sleeves up and slowly extends her arms, palms fac-
ing upward, toward the horses. As she does this, the three injured horses
raised their heads, stop grazing, and begin to move toward us. The rest of the
herd remained at a distance and continued to graze. Amy stood still with her
arms outreached, with her scars on display on her forearms, as one by one the
horses come toward her. They take it in turn to sniff her arms before moving
over to make space for the next horse to do the same. When all three horses
had greeted her, they remained standing around her, waiting attentively. Amy
began to cry softly. As she cried, one of the horses stepped forward and rested
her head on Amy’s shoulder. Throwing her arms around the horse, Amy
began to sob. As she cried, the horse leaned into her, and I encouraged Amy
to lean in and feel the embodied sensation of the horse supporting her full
weight. I paid attention to her breathing, and raised her awareness to it by
encouraging her to breathe in synch with the horse. Throughout this encoun-
ter, the other two injured horses remained by her side.
Lac 307
As Amy began to pet the horse closest to her, she explained that she spends
most of her time trying to hide her scars, her pain, and her eating disorder, not
just to everyone else around her but also to herself; that this process, in her
words, “is eating [her] up inside”; and every time she feels that she might
have made a connection with someone, that person ends up leaving because
her anorexia is too much for him/her to bear witness to. Amy longed to “just
be herself” with people. The horses had accepted her without question and
stayed with her in her pain. This embodied experience of support and accep-
tance, over time, allowed her to recognize for herself how she abandons her
own existence through self-harming and anorexic behaviors, and was some-
thing that we returned to as we continued to work together.
Anorexia nervosa can be conceptualized as the ultimate in existential
inauthenticity, where the constraints on being are so rigid that it results in the
starving of oneself of existence itself, perhaps in an effort to mask the terror
of being more visible in the world. In this process, the EI therapist is faced
with witnessing a slow and deliberate extinction of life and the welcome of
bodily death. Questions that may arise in this process include the following:
What aspect of his/her life does the client want to end; what makes living an
impossible choice; and what does it feel like on an embodied level to be con-
flicted about living or dying? These questions may invoke the actuality of
experiences for clients (Schneider, 2008) who have become numb to their
destructive process, or they may act as metaphors for clients to rest their
experiences on (Duker & Slade, 2003). There is a paradox within this
dilemma in the client’s own feelings of worthlessness that drives the client
toward thinness, believing that once thinness is achieved, he or she would be
worthy to live, love, and survive. Yet it is in the client’s striving for that same
thinness that will potentially cause death.
Amy’s journey continued with a focus on her felt sense of being “too
much” for those around her. She was literally making herself smaller to con-
front this existential fear. This smallness can be conceptualized through
Schneider’s (2008) constrictive/expansive continuum, where Amy con-
stricted not just her fear but also all sensations of living. Over several months,
we worked with the horses by being on the ground and on horseback as she
began to “reoccupy” (Schneider, 2008) her sense of herself. This approach
included experimenting with mindfully grooming the horse while paying
attention to her breathing; leading the horse around the arena while focusing
on her physical sense of boundaries; energetically connecting to a horse “at
liberty” (i.e., without being attached to a lead rope), resulting in the horse
following her every move around the arena; and lying bareback, spine to
spine with the horse, and feeling herself being fully supported. This last
experiment was exceptionally challenging for Amy, as it required her to trust
308 Journal of Humanistic Psychology 57(3)
that she was not too heavy a burden for her horse to carry, both literally and
figuratively. She had chosen to work with one of the smaller horses, who also
happened to be the one who had initially supported her crying in the first ses-
sion, and she was worried that she would be too heavy for her. Processing this
dilemma in the moment with Amy allowed her to feel the experiential libera-
tion of trusting herself and her horse enough, while staying connected in their
relationship, and opened her up to the possibility of living more fully.
I had been working with Amy for a year when my husband’s job necessi-
tated our relocation to Ohio. Amy had been making steady progress and the
multidisciplinary team at the eating disorders clinic had been preparing to dis-
charge her. Our final session was marked by a celebratory trail ride through the
woods as we reviewed her progress. Amy spoke of her growing confidence in
taking up more space in the world, and becoming more visible in her relation-
ships with others. Her ability to take charge and lead her horse and steer through
obstacles on the trail ride was a testament to her progress. The trail ride was
something that she had always yearned for but had not felt confident enough to
do. So I felt great pride in witnessing her confidence and empowered spirit.
Living with anorexia nervosa is a lonely existence. Social engagements,
which often involve communal eating, are fraught with anxiety and purpose-
fully avoided (Duker & Slade, 2003). Amy had become isolated from her peers
and family, further confirming her view of herself as unworthy of attention
(Granek, 2007). In the world of social media, this existential isolation is increas-
ingly overcome by seeking out pro-anorexia support groups to find “thinspira-
tion” (Williamson, 2014) that results in peer pressure like no other. This is the
process through which Amy rapidly attached to and created her anorexic iden-
tity, where the awareness for the need to belong and relate to like-minded oth-
ers catapulted her back into her relapse, time and again. From an EI perspective,
it was here that I most needed to rely on my own ability to stay present and
available for connection within the relationship with Amy. In true existential
tradition through Buber’s (1958) I-Thou approach to relating, I viewed her ill-
ness as an illness of her “relations with the world” (Friedman, 2014, p. 454).
For Amy, as an individual suffering from anorexia, her relationship with the
world, and herself, was through her way of being with (out) food, such that her
ability to restrict food has become not just the difference between being good
or being bad, being a success or a failure. It has become the difference between
being and not being. It has become [her] solution to being at all. (Duker &
Slade, 2003, p. 134)
would be in town and asked if I would have a session with Amy, who was
back in treatment with her.
I watched Amy get out of the car, shoulders slumped forward, head low-
ered and eyes downcast, and wondered what had happened to her to trigger
another relapse into the destructive cycle of anorexia. Amy stood before me
feeling defeated and angry with herself and the world, believing that no one
cared enough to notice her struggles. She was angry with me for leaving her
a year ago. Now her friends had all left for college and she did not want to
admit to them that she was feeling left behind, so had withdrawn from any
contact with them. Even her primary therapist had left the clinic, leaving her
to start anew with someone else whom she did not feel a connection with. She
felt utterly abandoned and alone. Everything had changed and everyone else
had moved on; even this herd of horses that she had felt so connected to pre-
viously had now doubled in size with new members since we had last worked
together, and thus felt unfamiliar to her.
As we stood in the paddock, Amy began to describe her sense of futility,
collapsing in on herself as she spoke. What began as a litany of reasons why
she was unworthy of attention soon turned into her acknowledging the despair
she was feeling in her isolation. She was convinced that once “out of sight,
out of mind.”
As she began to describe her fears, one by one, all six of the original herd
members that she had worked with previously began to make their way over
to us from the other side of the paddock where they had been grazing. One by
one, they stood before her, sniffed, bowed their heads, and then stepped to
one side to make room for the next. One by one, they greeted her and pre-
sented themselves to be available to work with her, connect with her, and be
a shoulder to lean on for her. They stood in a circle facing her, waiting
patiently. I asked her if she had noticed that all her old friends had come to
greet her. She was uncertain and told me that the horses had come to see me
and their presence had nothing to do with her. Quietly, I stepped away from
them all until I was about 30 feet away, trusting that the horses would stay
with her. As Amy reached out to each horse and greeted them in turn, her eyes
shone with tears as she breathed in a new reality where she could begin to
believe that she mattered, that she had an impact on those around her, and that
she was not alone.
In their attempt to find meaning in their way of being in the world, clients
with anorexia position their ability to restrict food intake as their moral com-
pass and the sole measure of personal meaning (Duker & Slade, 2003). This
is dialectical to their feelings of insignificance and the lack of value that they
place on their life, so much so that they are willing to starve to death. Against
this backdrop of existential nothingness of being, clients often present to the
310 Journal of Humanistic Psychology 57(3)
Conclusion
Amy’s story demonstrates the power of equine-facilitated therapy when
approached from an EI psychotherapy framework. Holding the space for the
potential for Amy’s re-occupation of herself, my presence provided a sense of
safety, both emotionally and physically around the horses, as she explored
ways in which to increase her own presence in the world. The authenticity of
the horses, their presence, and their ability to bear witness to her pain,
anguish, and despair, allowed Amy to find her place in the herd in an embod-
ied way. This sense of belonging alleviated some of her constricted ways of
being in the world and enabled her to feel that she is of significance in the
world.
Funding
The author received no financial support for the research, authorship, and/or publica-
tion of this article.
Note
1. Client name has been changed to protect confidentiality.
Lac 311
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Author Biography
Veronica Lac, MA, LPC, GEP, attained her MA in Gestalt
psychotherapy in the United Kingdom and has been in private
practice for 10 years. Since moving to the United States in
2011, she is now a licensed professional counselor and a certi-
fied Gestalt equine psychotherapist through the Gestalt Equine
Institute of the Rockies. She is currently a PhD candidate in
psychology at Saybrook University, with a research interest in
equine assisted therapy. She specializes in working with eat-
ing disorders, trauma, and attachment and has developed
equine- and canine-assisted programs for at-risk adolescents
in collaboration with residential treatment centers and eating
disorder clinics. She is also a PATH-registered therapeutic riding instructor for clients
with cognitive, physical, and emotional disabilities.