Well, actually I’m not. I’d like to, but I don’t have a horse. Also, I don’t really know how to ride. I’ve only done it a handful of times, and I’m *still* amazed that I didn’t bounce right out of the seat when I hit a canter.
I want to address this article about eating disorders and equine assisted psychotherapy (EAP) that is circulating the internet at an impressively fast rate!
First, let me locate myself so that you know where I’m coming from. I have not participated in EAP. Do I think it would be beneficial for me? Absolutely. Do I think I can recover without it? Of course. Though EAP might be helpful for me personally, I know I can recover without it because I recognize that EAP is one tool among many for treating people with eating disorders, and not a primary treatment. Though I’ve never worked with animals as a client, I am very interested in the use of therapy animals to promote healing. There’s a very good chance that I will incorporate animals into my own clinical practice someday.
What shocks me about this article is not it’s skepticism – many people are skeptical of EAP, and I think that’s largely because it’s true that not a whole lot of research has been done on it. However, not a whole lot of research has been done on the use of DBT with people with eating disorders,* and yet the author of the article is willing to jump on board with that (he even considers it an empirically-supported treatment, even as he recognizes that the empirical evidence has serious holes). No, what shocks me is that people are backing this article even though the author has a very clear, very strong bias. I know that science isn’t bias-free. I absolutely think our cultural and individual values will influence what we find and what we look for.
But, really, in this article, in the *third* sentence, he describes the reaction of him and his wife as “appalled.” Okay, he’s not a fan. I get it. But, seriously, if this article were on DBT and the author made such a strong, negative pre-judgement about the use of that therapy, I’d hope that people would be as skeptical of the author’s biased viewpoint as they are of the therapy. Or at least, I hope they’d take it with a salt lick.
He makes the point that EAP is said to be helpful for a wide-range of mental illnesses. Perhaps this is presumptuous. Perhaps it is not. It’s hard to say without the research. But, CBT has been shown to be effective for a whole host of mental illnesses, and yet that’s not questioned in the same way. And yes, we have research to support CBT. But CBT did not magically become effective when the research said it was. It was ALREADY effective, just like EAP might be. Maybe EAP is effective for some disorders, maybe not for others. Maybe it’s effective for some clients, but not for others. But what is the harm in having more therapeutic tools and experiences at our disposal? And have we considered that perhaps there’s not a whole lot of research on EAP because it’s so often stigmatized, or delegitimized before its researched? (This is not the first article I’ve seen like this recently.)
The thing is, EAP, like DBT actually, is not meant to be a “first-line” therapy in the treatment of eating disorders. It is meant to supplement other modes of treatment. And yes, there is not a lot of evidence for that. And, at the same time, it doesn’t take a whole lot of expertise to look around and see that for some, working with or being in the presence of animals helps them to open up in ways that they might generally feel unsafe doing. Obviously this is not true of everyone, and just like every treatment method used for eating disorders, EAP should not be used for everyone. It’s not a panacea. Nor is DBT. Nor is CBT. Nor is re-feeding. Nor is FBT. Nor is psychotherapy. Nor is nutritional counseling. If there is one thing we know about eating disorder treatment, it is that, more often than not, treatment requires multiple kinds of care and multiple therapeutic modalities to be effective.
So is the jury still out on EAP? Sure. Is it still out on DBT? Yes. Is the neuroscience that many of us are rallying behind still quite new? Yes. But one of these things is not like the other. Why the premature writing off of EAP? Sure, there needs to be more research done. Absolutely. But what if we left the possibility open of having another way to heal people, rather than having such a strong (and premature) bias against it? Frankly, the fact that the research is yet to be done also means that we haven’t proven that it doesn’t work. It could be incredibly effective for treating eating disorders, and we wouldn’t know that yet either.
Every treatment had a time when it lacked evidence. Every one. That’s the nature of research. So, personally, I’m going to support the use of EAP for clients who feel it would be helpful. If you ask me, the more treatment methods there are, the better equipped we’ll be to meet the individual needs of clients who are fighting this devastating illness!
* I have nothing against the use of DBT in e.d. treatment. I’m actually a proponent of it, and I personally have benefited immensely from having DBT be part of my current treatment. That said, there really is very little evidence to prove it’s efficacy for e.d. treatment yet. The small amount of literature that is there is focused mostly on bulimia nervosa and binge eating disorder. But someone has to be the pioneer if a treatment will ever gain empirical support!
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November 5, 2009 at 7:24 pm
Jane
I think the claims that animal assisted therapy has shown evidence-based efficacy is the issue, not the idea of working with animals per se. If people publish these claims they can expect to have them examined.
November 5, 2009 at 7:34 pm
sayhealth
I agree that that was his main issue. I guess my main points about that would be:
a) The fact that the research hasn’t been done neither proves nor disproves the efficacy of the treatment, so his bias against it is, I think, premature and misplaced.
b) Also, I wonder why he is open to DBT treatment of eating disorders, even though there is insufficient evidence for that, yet he finds the use of EAP “appalling.”
November 5, 2009 at 7:51 pm
Mike Anestis
I appreciate your sentiments about my article. As you said, I do have a bias – as does everyone. That being said, my article was not about my being appalled. In fact, you’ll note that in the next sentence I said that we did not do anything about our reaction at that point because we were not yet up to date on the literature and thought we might be missing something. My article was about discussing the nature of the research on EAP and the degree to which claims of its utility are justified by the evidence.
I actually agree with many of the things you said. My point is not that EAP does not work. My point is that there is no empirical evidence as of yet supporting many of the claims being made. There is no “maybe” about saying it is presumptuous to call EAP effective or efficacious in the treatment of mental illness. Without evidence, it is the precise definition of presumptuousness. That being said, should evidence emerge supporting its purported benefits, my response and that of other scientifically-minded psychologists would change. If you read the comment section, you’ll note that an EAP practitioner expressed those sentiments and I agreed with her readily.
I’m not sure where you’re going with your CBT comment. I did not criticize EAP because people say it works for many diagnoses. I criticized EAP because those claims are not supported by any evidence. CBT’s claims are and, as such, I don’t criticize the claim (although for diagnoses like GAD, it lags a bit and for diagnoses like bipolar spectrum disorders and schizophrenia it is only an effective adjunct).
I do not have an anti-EAP bias. I simply support the use of treatments based upon empirical evidence and do not support the use of unvalidated treatments for diagnoses for which empirically supported treatment exist. As new evidence emerges, the empirical status of treatments change – perhaps that will happen for EAP.
With respect to DBT, I’m not sure where you think I have referred to it as a front-line treatment for any ED. I have noted the emerging evidence, which has resulted in it being listed as a “probably efficacious” treatment for BN and BED by APA Division 12. I make no claims of DBT having evidence as being useful in the treatment of any other EDs. This is not information I am making up or a reflection of a bias on my part. It is an honest reporting of the current state of research on the matter.
As you said, evidence does not make a treatment effective and all treatments start off without evidence. That being said, until evidence is accumulated, how can we justify using a treatment simply because a person thinks it would be useful? Would we do that for a surgical procedure? Lilienfeld’s (2007) list of treatments that cause harm (but which are still commonly used) is a clear warning of the dangers of simply taking guesses on matters like these. There is nothing wrong with developing new treatments – but we can not expect them to be considered legitimate without proper investigation.
Anyway, I suspect that you and I agree on much more than you seem to think. Perhaps something about the way I discussed the matter upset you – in which case I apologize – but the purpose of Psychotherapy Brown Bag is to critically examine empirical evidence in a manner that is readable for folks who do not spend all of their time reading psychology journals and, in doing so, sometimes areas with no research support will be spoken about negatively. This is how science works. If EAP proponents want to be seen as performing legitimate work, they need to justify their desire.
Thanks or reading.
November 6, 2009 at 6:04 pm
Sayhealth
Thank you for taking the time to read this entry and respond to it. I appreciate your willingness to engage.
My concern about your bias is not rooted in your actions. Bias does not have to be acted upon to exist. Regardless of whether or not you acted on the bias (and I think it shows admirable professional restraint that you did not react at that time), it was still present. Additionally, the fact that you had the reaction of being appalled without being caught up on the literature may actually support the fact that your bias was strong, given that it was already present even without empirical support (or lack thereof).
As far as my CBT comment, I am not questioning whether or not it helps many. Like you said, there is more empirical support and more research for CBT than there is or EAP. My point is that that was not always the case. There was a time when CBT did not have empirical support. Does that mean it was not effective then? No. It just means there wasn’t “proof” of its effectiveness. What a shame it would have been if practitioners let their bias get in the way of using CBT to practice previous to empirical support!
I didn’t say that you stated that DBT should be a front-line therapy. I was just saying that DBT is similar to EAP in that they are both therapeutic tools, not front-line therapies. My point about DBT is that there is very little evidence or its success in treating eating disorders, a fact that you point out in your piece about DBT and e.d.’s. And yet, you do refer to it as an “empirically-supported treatment,” and you don’t seem to be biased against it in the same way as your are with EAP, both of which lack substantial empirical support at this time.
You ask, how can we justify using a treatment until it is proven to be empirically effective? I ask, how can we *not*? Yes, experimental treatments are risky. Yes, we don’t know if they’ll work. But EVERY treatment starts off as experimental. Every treatment lacks evidence in the beginning. Frankly, if clinicians weren’t willing to take a leap of faith (or a leap of theory), we would have no treatments. I they weren’t willing to take that leap, I wouldn’t have had such a beneficial experience with DBT, or example. If we’re not willing to engage with treatments that lack empirical support, if we let such strong biases get in the way, how will they ever gain empirical support? How can we research something that’s not being used? And frankly, how can we disprove its effectiveness, if that’s what needs to happen?
Please know that I am not judging you or what I see as a bias. We all have our biases. We’re human. I know that I have mine. And, I personally would refrain from writing an article about a treatment method that I know I might not be able to present without bias. Or, at the very least, I would be forth-coming with my own opinion and how it might affect the ways that I look at and read the available literature (or how I consider the fact that literature might be missing).
November 6, 2009 at 7:34 pm
Mike Anestis
Thanks for your thoughtful reply as well. It seems to me that, even when disagreements are present on topics like these, civil conversations are possible, so I’m more than happy to engage.
For the sake of clarifying a few points that I think might have not been presented clearly enough in my comment, I want to add just a few replies to yours.
- No doubt my bias was strong, but we have to be careful in defining what we mean by bias. At the time of my encounter in Arizona, I was approximately one year into my training in Thomas Joiner’s research lab, which does a heavy amount of research into the origins and treatment of eating disorders. At that time, I had already begun work on a growing list of studies on eating disorders. That being said, I was fully educated on the nature of empirically supported treatments for eating disorders and was surprised to see EAP presented in the way that it was: as a cure for for all eating disorders. Perhaps “appalled” was not the right word choice and I should have used “taken aback” instead, but the point remains, my bias was founded in a discomfort with a treatment lacking research support being presented the way it was presented. I did not have a background in the nature of the treatment, but I was aware that it was not an empirically supported treatment.
- All that being said, it is unclear how my apparent bias influenced my discussion of empirical research. Did I misinterpret the numbers? Did I fail to refer to something as a controlled trial that was? Without question, as you said, my feelings influence any editorial comments I make about the concept of EAP; however, as a scientist, I am more than capable of discussing empirical data and my own feelings separately, and I make no secret of my own beliefs on the site. As often as I can, I remind readers to consult studies on their own and consider the numbers more than my opinions. My presentation of the numbers, however, is not a reflection of my bias (unless somebody can point out a time what that has occurred, which is certainly possible).
- On the DBT front. It’s not me who is calling it an EST. That is Division 12 of APA, the committee responsible for summarizing available treatment research and detailing the degree to which particular treatments have support as efficacious and/or effective for particular diagnoses. This is a link to their site describing ED’s (http://www.psychology.sunysb.edu/eklonsky-/division12/disorders/eating_main.php). Here are a few citations of studies that have directly examined the utility of DBT in the treatment of BN and/or BED:
Chen, E.Y., Matthew, L., Allen, C., Kuo, J.R., & Linehan, M.M. Dialectical behavior therapy for clients with binge eating disorder or bulimia nervosa and borderline personality disorder. International Journal of Eating Disorders, 41, 505-512.
Palmer, R.L., Birchall, H., Damani, S., Gatward, N., McGrain, L., & Parker, L. (2003). A dialectical behavior therapy program for people with an eating disorder and borderline personality disorder: Description and outcome. International Journal of Eating Disorders, 33, 281-286.
Safer, D.L., Lock, J., & Couturier, J.L. (2007). Dialectical behavior therapy modified for adolescent binge eating disorder: A case report. Cognitive and Behavioral Practice, 14, 157-167.
Safer, D.L., Telch, C.F., & Agras, W.S. (2001). Dialectical behavior therapy adapted for bulimia: A case report. International Journal of Eating Disorders, 30, 101-106.
Telch, C.F., Agras, W.S., & Linehan, M.M. (2000). Group dialectical behavior therapy for binge eating disorder: A preliminary, uncontrolled trial. Behavior Therapy, 31, 569-582.
Telch, C.F., Agras, W.S., & Linehan, M.M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061-1065.
Some of these studies are better than others, but in total, they represent a growing mountain of evidence indicating that this treatment is, in fact, useful in the treatment of these disorders. As such, it is classified as empirically supported. That being said, fewer trials exist testing DBT than for CBT and, as such, it is not yet considered a front-line treatment. This is not to say that CBT outperforms DBT – no direct comparisons exist as of yet – but rather that the research foundation is stronger for CBT than for DBT. Where does EAP fit into this? Currently, no comparable trials exist. As such, it has no empirical support. For this reason, I comfortably refer to DBT not as a tool, but as a treatment that has, in fact, been shown through empirical data to be successful in the treatment of BN and BED.
- One last point. I completely agree with you that the evidence does not make a treatment more or less effective or efficacious. It is what it is and the evidence simply reveals that truth in layers. I also agree that, if we did not have experimental treatments, no treatments would exist, as at some point nothing have ever been researched. Where you and I diverge is on the issue of how we go about establishing support. From what I read – and I could totally be misreading you – you seem to support the idea of clinicians freely utilizing experimental treatments without support for conditions where empirically supported treatments already exist. In my opinion, innovation is absolutely pivotal, but efficacy needs to be established through controlled trials before clinicians should be allowed to practice a particular approach. Without such safeguards, ineffective or – worse yet – iatrogenic treatments can proliferate and that absolutely happens. Perhaps EAP will eventually be shown to be wildly successful, but until it is – and it has not yet, regardless of one’s bias – I can not see a justification in allowing it to be practiced.
Thanks for the fun back and forth! Hope to hear more from you on these and other issues.
November 5, 2009 at 8:41 pm
Serial Insomniac
I love PBB myself, but wish psychotherapy / psychological magazines would publish a balance of articles vis a vis criticism of different types of therapy. Unfortunately CBT and DBT (and apparently specifically ‘mindfulness’) are the current vogue symbols of psychology.
What a lot of psychologists apparently fail to notice is that not everyone agrees that CBT and DBT are the panaceas the health services believes them to be. As a committed hater of CBT in particular (having been patronised through it for several months with absolutely no gain, and indeed much loss), I’ve come across a wealth of studies that dispute its supposed efficiency across many disorders.
So I suppose what I am saying, in an incredibly convoluted fashion admittedly, is that while I am interested in critiques of therapies such as EAP, I also think it responsible for issues with more ‘fashionable’ therapies to be critiqued too.
In fairness to PBB, it’s one of the more balanced such magazines that I’ve come across, and is probably my favourite source of information for this type of thing. But, like everyone, of course there are times when I may disagree with the arguments espoused therein.
Anyway, enough. All the best to you.
November 6, 2009 at 3:16 pm
Jane
CBT doesn’t always come out on top in research studies, as this RCT for AN shows. http://ajp.psychiatryonline.org/cgi/content/full/162/4/741
November 6, 2009 at 6:10 pm
Sayhealth
Your absolutely right. The *vast* majority of the literature that touts CBT as an effective treatment for eating disorders claims that it is effective primarily for BN. My guess is that the author above was referring to the fact that CBT is claimed to be effective for a whole host of mental illness, outside of eating disorders alone. And that’s not to say it isn’t effective! It’s just a warning not to over-emphasize the effectiveness, I believe.
November 6, 2009 at 6:07 pm
Sayhealth
I agree with you that treatment methods that are “in vogue” need to be examined as thoroughly as those that are not seen as favorably. I would argue that the new neuroscience/biologically-based illness model is another “fashionable” research topic right now.
And this is not to say that they are not important. It’s just to say that all treatment methods should be fairly examined.
It’s true that CBT doesn’t work for everyone, and there are a couple of articles that just came out that show that it may not be as effective as many would claim. We need to pay attention to that research too, if clinicians want to be best equipped to support and treat their clients.
November 6, 2009 at 7:00 pm
Serial Insomniac
Absolutely agreed on this: CBT is certainly effective for some, and I completely accept that. I just wish that the literature on the ‘newer’ types of therapy would consider that not everything is as black and white as some psychotherapists seem to think (kind of ironic coming from someone diagnosed with BPD
)
At the end of the day, I think psychotherapy – in whatever form it takes – is much more ‘grey’ than what the proponents of any one specific type of it woul like to think. Psychoanalysis works for some, psychodynamic for others, CBT or DBT for yet, more, EMDR, EAP etc etc etc for others. I’m still of the view, rightly or wrongly, that one of the main issues in therapy is the relationship between therapist and patient.
But that’s a whole other post
Thanks for your reply and engagement – very best wishes to you
November 6, 2009 at 12:18 pm
Marcella
I accept that the original blog post was criticising the claims that EAP was evidence based rather than the therapy itself. It is true that there isn’t a lot of empirical evidence for it. There isn’t a lot for most treatments of eating disorders – eating disorders not being fashionable topics for research budgets. CBT etc ARE studied but then they’re a lot cheaper than EAP TO study, AND to administer which makes them attractive to healthcare providers.
November 6, 2009 at 3:08 pm
Jane
It’s become common to suggest that CBT is “favored” in research funding, but anyone is free to compete for that funding. Treatment research, including CBT research, is expensive. The current Chicago/Stanford adolescent BN study, which will compare CBT, FBT and supportive individual therapy, is a 2 million dollar study.
November 6, 2009 at 6:13 pm
Sayhealth
Honestly, I agree with both of you! Yes, all treatment research is expensive – whether that’s treatment about CBT, EAP, FBT, what-have-you. That said, I do think that I do think that there is a MAJOR deficit of research funds for eating disorders, and it seems that the most attention-catching disorders and treatments are often studied.
I think that this is the symptom of a great many factors (capitalism, our health care industry, etc.), not necessarily the intent of the researchers.
November 16, 2009 at 12:10 am
healthywoman80
Just wanted to chime in and say your blog is so evocative! I really appreciate it. I am also recovered and have started a similar blog -
http://anotherpieceofcake.wordpress.com/.
Keep it up!
Thanks,
Amanda