Katharina Alexandridis Substance and method of Natural Horsemanship (Pat Parelli) are described and presented in combination with movement-therapeutic approaches of the actual treatment of Anorexia nervosa, Bulimia nervosa and “Binge-Eating”-Disorder. This synthesis results in a horse assisted method of treating patients suffering from eating disorders. Horse-assisted movement-therapy is portrayed by means of concrete examples out of the therapeutic practice. The article ends with a preview of an ongoing evaluation study. Keywords: Horse-assisted movement-therapy, eating disorders, anorexia nervosa, bulimia nervosa, “binge-eating”-disorder, natural horsemanship Horse-assisted Movement-therapy for the Treatment of Eating Disorders mup 1|2009|13 - 26| © Ernst Reinhardt Verlag München Basel | 13 The therapeutic approach of horseassisted treatment of eating disorders evolved from combining Natural Horsemanship (Pat Parelli 1995) with a movementtherapeutic concept developed for inpatients as well as outpatients (Alexandridis 2005; Alexandridis et al. 2007). Body and movement-orientated methods for female patients suffering from eating disorders have been researched upon in some studies, recently (Alexandridis 2005; Wallin et al. 1999; Müller 1998; Laumer et al.1997). Movement-therapeutic treatment of inpatients usually is part of a multi-disciplinary therapeutic approach which is recommended to and provided for most patients. For outpatients, however, the range of provided therapeutic options is usually cut down to psychotherapy in the form of individual therapy. Any form of cross-disciplinary cooperation between psychotherapy, ecothropology, social therapy, art therapy, music therapy and movement therapy as provided by most psychosomatic and psychiatric hospitals, only takes place sporadically. For the field of horse-assisted psychotherapies several works by Scheidhacker (1991, 1992, 2002) apply to “anxiety disorders” and “schizophrenia” indication groups. A quantitative study on orthopedagogical vaulting from the field of horse-assisted therapy for the treatment of Anorexia nervosa has been made by Gathmann / Leimer, 2004. Case studies from the therapists‘ point of view (FAPP 2004) regarding disease patterns such as depression, anxiety and posttraumatic stress disorders and others have been published. However, the concept this article is based on is to be considered a movementscientific one. The term “horse-assisted movement therapy” is not protected. It is supposed to make clear that the concept presented here is provided by a fully trained movement therapist. Movement therapy here is carried through with the “assistance” of horses or rather by integrating horses in the therapeutic process. Dealing with horses is significantly characterised by Natural Horsemanship according to Pat Parelli (NHS). Movement therapy can be considered an umbrella term for a variety of therapeutic methods or schools focussing on the human being as a whole. From the historical point of view there are three sources of origin of body and movement therapeutic methods which are deployed today in the treatment of inpatients as well as, to a certain degree, of outpatients suffering from psychic diseases: Horse-assisted movement therapy for the treatment of eating disorders Horse-assisted movement therapy makes use of body and movement in close contact with the horse as a starting point and therapeutic intervention. Selected body-relevant issues of the disease are worked on via body and movement experience in close contact and communication with the horse. Dealing with the horse follows the principles of Natural Horsemanship according to Pat Parelli. The therapeutic effect is optimised through supplementing it with verbal-therapeutic elements. The goal areas of horse-assisted movement therapy are taken from from general pathology, body perception and movement behaviour associated with eating disorders. The treatment combines psychomotoric therapy, sports therapy and cognitive therapy under consideration of motivational aspects connected with the handling of horses. Definition 14 | mup 1|2009 Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders Methods evolved from psychotherapy Methods evolved from physical exercises Methods taken from sports science The movement-scientific understanding of this article is characterised by sports s c i e n c e a n d d e fi n e s h o r s e a s s i st e d movement therapy in compliance with terminological specifications made by the “Deutscher Verband für Gesundheitssport und Sporttherapie” (German Association of Health Sports and Sports Therapy). Natural Horsemanship (NHS) according to Parelli is based, just like other Horsemanship methods, on the horse‘s natural behaviour. It‘s all about conveying knowledge and attitude. The principles NHS is based on are similar to behavioural-therapeutic principles, its structured and well-designed depiction as well as the way its exercises are carefully based on each other make NHS a perfect basis for horse-assisted therapeutic treatment of eating disorders. Horse training according to Pat Parelli covers the high demands made to a well-trained therapy horse. Movement therapy for the treatment of eating disorders Anorexia nervosa, Bulimia nervosa and “Binge eating” disorders are summarised under the term “eating disorders”. The diagnosis criteria listed in table 1 refer to hard criteria as well as to the psychopathology of eating disorders: Negative self-concept and low self-esteem Negative body-concept Identification with beauty ideals Perfectionism Fear of growing up (Anorexia nervosa) Ambivalence between desire for autonomy and security Sports and movement therapy “Sports and movement therapy is exercise indicated and ordered by medical experts along with behavioural components which are planned and dosed by the therapist and monitored in cooperation with the doctor and carried through with the individual patient or in a group. The goal is to get rid of physical, emotional and psychosocial deficiencies (affecting every-day life, spare time and job) or to prevent them, respectively, through suitable means taken from the field of sports, movement and behavioural orientation. Sports and movement therapy is based on medical, training and movement scientific and especially pedagogically orientated as well as social-therapeutic elements. Here, training scientific aspects particularly support the selection and dosage of physical activities for preservation, fostering and recovery purposes. Sports and movement therapy follows the ICF, is based on epidemiological insights and evidence. It intends to achieve decision-making responsibility and interpersonal skills and strives for behavioural stabilisation or change of behaviour aiming at an improved quality of life and economical aspects of the public health care sector.“ (German Association of Health Sports and Sports Therapy o.J.) Definition Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders mup 1|2009 | 15 Dichotomous experiencing of trust and distrust Fear of closeness and loss of emotional control Disfunctional thinking Low social skills displayed in avoiding conflicts, competitiveness and difficulties in socially dissociating oneself from others The goals of movement therapy for the treatment of eating disorders are closely tied Table 1: Diagnostic criteria for eating disorders (according to Fichter 2008) Anorexia nervosa (AN) ICD F 50.0 a 1. Underweight (Body Mass Index (BMI) of 17.5 kg/ m 2 or body weight of at least 15 % below the expected weight, respectively) 2. Self-inflicted weight loss through avoiding higher calory intake or vomiting, exaggerated physical activity, abusing laxatives, appetite suppressants or dehydrating agents 3. Deeply-rooted fear of getting too fat (body image disorder) 4. Hormonal changes (as a result of the nutritional state, state getting normal along with putting on weight, deceleration of a constraint of developmental stages with the disease starting during childhood) Sub-types 50.00 Restrictive (ascetic) Anorexia nervosa F50.01 Anorexia nervosa characterised by “binge eating”- and purging-type with “purging” behaviour in order to lose weight in combination with periods of adephagia gluttony F50.1 Atypical Anorexia nervosa Bulimia nervosa (BN) ICD F 50.1 a 1. Undue dealing with food, figure and weight. Eating large amounts of foods within a brief period of time ( ≥ 2x / week) along with the sensation of losing control of one‘s eating behaviour 2. Self-induced vomiting, abuse of purges, fasting, taking in appetite suppressants, thyroid preparations or diuretica as counter-measures against putting on weight (“purging behaviour”) b 3. Abnormal fear of getting fat Sub-types F50.3 Atypical BN: one (or several) diagnostic characteristics of BN F50.2 are missing F50.4 Binge eating along with other mental disorders F50.5 Vomiting along with other mental disorders “Binge eating” disorder (BES) DSM-IV c Same symptoms as with Bulimia nervosa, but without “purging behaviour” (vomiting, abusing purges etc.) 1. Repeated periods of eating large amounts of food in a relatively short period of time along with the feeling of losing control of one‘s eating behaviour 2. With binge eating taking in food is usually performed faster than usual, eating until an uncomfortable sensation of “feeling full” occurs, eating large amounts of food without being hungry and/ or taking in food alone along with feelings of embarrassment, disgust or guilt 3. The patient suffers severely from this binge eating behaviour 4. Binge eating on 2 days / week min. for over 6 months a ICD-10 = International Classification of Diseases published by the WHO b Vomiting, abuse of purges, appetite suppressants, dehydrating agents or clysters c DSM-IV = Diagnostic criteria of the American Psychiatric Association (APA) 16 | mup 1|2009 Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders to psychopathology and can be aligned along the two poles physioand psychotherapy according to Hölter (1993): The effectiveness of a movement-therapeutic intervention geared towards these goals was able to be verified through an evaluation study (N=80) for Bulimia nervosa (Alexandridis 2005). The substance and methods of movement therapy for the treatment of Anorexia nervosa, Bulimia nervosa and “Binge eating” disorders are similar across various treatment centres since these methods evolved from therapeutic practice. They are provided by experts trained in deploying movement-therapeutic methods, sometimes focusses differ from each other, but when compared on an international scale they still have very much in common (Probst et al. 2005). A therapeutic (see Ethic Codex APA, Ethikcodex DGVT) relationship based on trust, a dignitive and unbiased atmosphere, acceptance, equality, co-determination, experiencing autonomy, voluntariness and secure basic conditions all contribute to the therapy‘s scope. Experience driven access to music, games and dance are suitable ways of fighting the rigidity of eating disorders. Any difficulties and options to deal with changes should be made lucid. Debriefings of experiences made are just as important as the therapeutic offer itself. Descriptions of perception and relaxation exercises in practice for the movementtherapeutic treatment of eating disorders can be found with Rytz (2006) and Alexandridis (2005) and shall be explained here by taking a closer look at two exercises taken from the field of movement therapy. Movement-therapeutic exercise example 1: “Exercise for perceiving closeness and distance” (Alexandridis 2005) This exercise is carried out as an instructor-driven partner exercise. Walking towards each other and coming to a halt at various distances (spontaneous “feeling comfortably” distance, neutral distance during conversations) and sensing . Both patients take turns in specifiying the distance by saying “Stop”. They may correct the distance until they feel sure about it. If individual distances differ within a couple a “compromise” needs to be found. Attention is directed: How do I feel with this distance between us? What do I sense (breathing, muscle tone, temperature sensation etc.)? How do these sensations change when getting nearer or further apart? Sports therapy Movement psycho-therapy Physical fitness Control regulation Experiencing and expressing emotions Body acceptance Tension regulation Testing a healthy movement behaviour Realistic body perception Experiencing and shaping of closeness and distance Fig. 1: Goal areas of movement therapy for women suffering from eating disorders between sports therapy and movement therapy Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders mup 1|2009 | 17 Possible topics: The ability to perceive closeness and distance is inhibited or missing entirely. Further exercises regarding the perception of closen e s s a n d d i sta n c e a r e p r ov i d e d a s therapeutic measures. Possible explanations for perception deficiencies are worked out. The ability to perceive closeness and distance can be sensed clearly, yet one‘s own needs are not even tried to get satisfied. Working on giving clear body signals. Checking these body signals for their suitability in daily use. Movement-therapeutic exercise example 2: “Exercise for perceiving strength and cohesion” (Rytz 2006) The patient stands facing a wall with her arms stretched out so that her fingertips touch the wall. She bends her knees slightly and supports herself by placing her palms on the wall. Using her bodyweight she applies pressure to the wall as well as to the ground. Her body serves as a flexible connection between the wall and the ground. In the connection the patient plays with pressure and counter-pressure by bending and stretching her knees and elbows, making little steps fowards and backwards, increasing the pressure as if she wanted to push the wall away. Possible topics: Via sensing one‘s own skeletal muscles strength and cohesion can be experienced. Basics of Natural Horsemanship (NHS) according to Pat Parelli Since the 80s methods regarding dealing with horses (horsemanship) spread across Germany relatively quickly. M. Roberts, L. Tellington- Jones, P. Pfister, H. Welz, S. Halfpenny, A. Ast, K.F. Hempfling, B. Zambeil, M. Bridges and A. Aguilar are names on a list of horse experts that could still be continued, experts with similar “philosophies” regarding the handling of horses and specifying techniques of dealing with horses and riding. They don‘t focus on certain riding techniques but on shaping the relationship to the horse and communicating with it. Pat Parelli is one of the best known “Natural Horsemen”. Compiling systematics of a NHS schools would clearly be beyond the intention of this article. It‘s obvious, however, that even despite a few significant differences there are many parallels. In that vein the NHS principles according to Pat Parelli described below are not supposed to make distinctions but should be seen as examples. Pat Parelli (1995) expresses his principles with the umbrella term “attitude”. A basic attitude of NHS is that handling the horse should neither be aggressive nor soft, but in balance between these two opposites. The human is supposed to be as soft as possible and as determined as necessary. Things are done for and with the horse without abusing it, a term NHS uses to summarise things like keeping horses in stalls and using horses as pieces of sports equipment. Pic 1: Therapy horses with rope head-collar and 4m-rope 18 | mup 1|2009 Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders According to the principles of NHS the horse is acknowledged as a flight and herd animal. The horse‘s natural need to sense danger, to flee when in fear and to live in herds is being paid respect to. I. e. the human takes on responsibility as a leader regarding the identification of dangerous situations and giving the horse security. In various perception and movement exercises following the desensitisation principle (e.g. anti-spooking training) the horse learns to control its flight instinct by relying on the human. The human adapts the horse to stimuli causing fear by increasing the intensity step by step. Only when the horse has grown accustomed to a stimulus stage by not showing any stress symptoms anymore (motoric unrest, snorting unrest, tense muscles etc.) the training goes on to the next stage. Trust in the human is confirmed in the fact that the horse stays unharmed. Horses bind themselves to those humans they can make fear overcoming experiences with. They show trust in them rather than in strangers, e.g. when walking across swampy grounds or when entering narrow rooms. In order to have a focussed relationship with the horse here and now it is crucial to offer the horse as much variety as possible. This kind of relationship develops via communication. In order to meet the aspect of mutuality of communication the humans needs to open himself to the horse‘s body signals and needs to behave accordingly. Realising the horse‘s needs is crucial as a precondition for handling the horse in a fair way. Within a playful scope based on partnership the human makes unwanted things appear hard to accomplish and wanted things appear easy to accomplish to the horse. Here, partnership-like and playful means that the horse experiences its encounter with the human in the same fashion as contacts within the herd. The NHS exercises described in the following are also called games since they are based on the animals‘ playful movements within the herd. The human relies on that the horse does what he wants it to do but is always prepared to intervene. The horse is sensitised to slight assistance since each request from soft to determined is communicated via a staged advance during which a wanted behaviour is followed by a relief. Behavioural therapy calls this “behavioural shaping through operative conditioning” by using negative amplifiers, e.g. wanted behaviour of the horse results in that a state not considered comfortable is terminated (Fumi 2008). Sensitising results in that the stagewise offering of negative amplifiers at each stage can be interrupted in favour of relief in case wanted behaviour is performed (classic conditioning). The “principle of sensitisation” (Pat Parelli) can be made clear by looking at the example of a horse being “sent backwards”. The initial position is the horse tied to a 4m-rope and facing the humand directly. Staged signals are: 1. Stage: Right-left movements with a raised index finger (no effect on the rope‘s movement) 2. Stage: Right-left movements with the hand (no effect on the rope‘s movement) 3. Stage: Right-left movements with the lower arm (slight effect on the rope ‘ s movement) 4. Stage: Right-left movements with the whole arm, the movement originates from the middle of the body (strong effect on the rope‘s movement) Since the rope is attached to the cord headcollar via a metal hook the swinging of the rope is uncomfortable for the horse. From stage 3 on you could call this a negative Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders mup 1|2009 | 19 amplification. Up to stage 2 these request stimuli can be considered neutral. The expectation of negative stimuli motivates the horse to avoid these negative stimuli by moving backwards. Regarding sensitisation it is important to interrupt the request stimulus as early as possible. Here, a weight shift, a precondition for moving backwards, is immediately “ r ew a r d e d ” w ith th e sti m u l u s b e i n g interrupted. Understanding the horse‘s body signals and getting aware of one‘s own body signals and modelling these is crucial for a successful communication with the horse. Horses learn from humans and vice versa. The combination of experienced riders and inexperienced horses and vice versa is a good precondition for a well-functioning relationship. On the other hand, however, an inexperienced human should not work with an untrained horse. NHS teaches techniques of ground work and riding. The systematic approach starts off with ground work and then switches over to riding. The exercises are designed in such a way that each perception or movement exercise from the ground has its connection with riding aids, the stance of the horse underneath the rider and the quality of movement in the sense of training. In NHS, basic principles such as making it easy to behave in a wanted fashion and hard to behave in an unwanted fashon are more important than lessons. Still, flexible behaviour in relation to the current situation is of great importance. In NHS this is called mental, emotional and physical fitness in this respect, required to display just that situation related behaviour. This shows the high demands NHS places on the human ability to learn. Horse-assisted movement therapy Theoretically, movement therapy matches Natural Horsemanship because of many reasons. The horse gives the patients feedback about how they come across in expressing themselves. They experience that presence, the ability to stand one‘s ground are successful in relationships. The negative feedback given by a horse is rather accepted than negative feedback given by a human since the latter is often considered hurtful. The example of Mrs C. shows that the horse has sensed and reflected her unrest. If a therapist had done that through a verbal feedback defiance might have been the result as in other areas of the therapy. Perfectionism is an important issue in treating eating disorders and dealing with horses is suitable in picking it up as an issue Mrs C., 22 years, Bulimia nervosa patient with Borderline personality disorder Mrs C. is even in a clinical environment unable to control her self-harming behaviour. She rejects the “skills” acquired in the skill group (DBT according to Linehan) because she believes them to be useless. Mrs C begins her riding therapy in an emotionally unstable state and wishes to work with a “perfectly trained horse about which she has heard amazing things” (Summy). During ground work Summy does not stand still, prances, moves sideways, piaffes. Mrs C turns to me laughing and claims “not to do anything”. I ask her to concentrate only on standing in the “here and now” and to become calm within by focussing her attention on her feet on the ground and letting her breath flow. Mrs C. concentrates and develops an calmness inside as well as to the outside which is transferred on the horse. She is pround of the impact she has. Later on I ask her to focus on goals and to ride with the rope head-collar with loose reins against the target through her gaze and concentration. Mrs C. gets into a calm and clear connection with the horse and enjoys the harmony. Example 20 | mup 1|2009 Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders and handling it. Also patients who have never worked with horses before start this therapy with high demands placed on themselves such as “I have to do everything right”. But then they experience horse handling as being so multi-faceted that it becomes hard to spot what is wrong or right or even perfectly right. The staged approach fights perfectionism in several ways. On the one hand, the patient is forced, in compliance with the sensitisation principle (see above), to remove a negative stimulus right away and not after the horse has moved the desired distance backwards all the way. On the other hand, she realises that an early relief makes the horse respond even to very light stimuli. Here, it would be a good idea to look, together with the patient, for a possible transfer in dealing with herself. The need for domination when handling horses in NHS is often a problem for patients with eating disorders at first. Dominant behaviour calls for a clear perception of one‘s own space, groundedness, presence, clarity, goal-orientedness. A precondition is that the patient learns to prioritise her own needs over the horse‘s ones. Horse-assisted movement therapy makes it clear that on the one hand subordination to higher ranking animals within the herd is a natural state for a horse, and on the other hand riding and the horse kept as a pet can be considered unnatural. Thus it‘s one‘s personal decision how to behave towards the horse. NHS follows the principle of handling the horse using the language and the rules of the “horse world” and in granting it as much room as possible in the way it is kept. As the provider we keep asking ourselves how much spare time a horse needs in order to be healthy. Physical and mental health are also for horses a good measure to determine whether the basic conditions are right or not. Treating eating disorders is about supporting the patients in getting control over their health. They are supposed to learn to start leading their own lives again and developing the boldness to listen to their own needs instead of the eating disorder‘s ones. Practical experience shows that patients don‘t experience the “pressure” directed towards the horse as being reflected towards themselves. Furthermore, the patients experience the therapy “pressure” not as pressure on themselves but on their disease. Whereas it needs to be taken into consideration that there are stages of this disease in which patients are not able to distinguish between healthy parts and the disease. Generally, patients are very affectionate towards the horse, touching and physical closeness happens very spontaneously. This is used as a bridge to enable neutral ways of touching oneself, e.g. the “enrooted stance”: the patient places both hands on one side of the horse‘s back and senses the horse‘s Pic. 2: Balance on two horses Photo: Manuela Blöchinger Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders mup 1|2009 | 21 breathing with her palms. When she has a positive sensation the patient places her hand on the breating area of her own body, the other one remains on the horse and the patients directs her attention towards the horse and herself. Basic conditions The therapy sessions take place at the Mesnerhof in Thalkirchen (Upper Bavaria). The farmyard offers classic Iberian riding, Natural Horsemanship, horse training and horse production. A total of 17 ponies and horses live here. 6 horses are trained for horse-assisted movement therapy and schooling, 2 others are currently being trained. High demands are made on a therapy horse regarding security and reliability in order to provide a trust-building setting. This is achieved through the systematic training and education of the horses under the supervision of a NHS expert as well as through keeping them in open stables connected with the herd. Apart from that, the horses get a great deal of security and stability through the fact that handling them in training, schooling and therapy is all based on NHS principles and exercises. Therapy horses are also “schooling horses” of the classic Iberian riding school, so that the demands made on them are multi-faceted. The horses walk 3 hours every day, therapy sessions and schooling takes place at the outdoor riding arena or on open terrain. H ors ea s siste d m ove m e nt th era py is geared towards inpatients as well as outpatients suffering from eating disorders. Inpatients have to pay the costs themselves, outpatients may have special deals with their insurance. If the patients wish so cooperation with the pychotherapist in charge is carried out via e-mail and is the usual case. Telephone calls are only made if necessary, in case of a crisis the patients are handed over according to agreements made beforehand, Suicidal tendencies are asked about. Horse-assisted movement therapy is offered as a mono-therapy only for those patients who possess a sufficient degree of stability, the combination with inpatient or outpatient treatment is usually the case. Horse-assisted movement therapy is offered to patients with any kind and level of riding skills and also to those without any riding experience at all. Patients weiging more than 90 kg are not allowed to get on a horse, but they may still participate in the ground work. A helmet, sturdy shoes, clothes suitable for the current weather situation as well as plenty of sun protection are conditions for participation. Having sufficiently warm clothes during winter is often a problem for Anorexia nervosa patients and is being talked about during therapy. Structure of the therapy sessions D uring the first therapy session the farmyard and the therapy horses are being introduced. Here, the patients may select the horses they wish to work with. From the second session on the decision concerning the horse is made together with the therapist, since the horses‘ characters and individual behaviour may support or impede specific therapeutic processes. If a horse doesn‘t get along with a patient, e.g. through showing stress symptoms such as motoric unrest, tense muscles, increased defecating or aggressive behaviour, which is rarely the case, it usually doesn‘t make much sense for the patient to go on working with this constellation. For safety reasons the therapist picks the horse from the herd. As soon as it leaves the stall or the pasture the horse wears the knotted head-collar with the 4.0 m rope. The patients lead the horse independently or assisted by the therapist to the grooming place and from there to the riding arena or out into the open terrain. The 22 | mup 1|2009 Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders session starts with getting used to the horse while it is still standing followed by movement and perception exercises. The session is wrapped up by carrying through attention exercises while the horse is standing, the patient says good-bye in the arena, since there are also private horses not insured for therapy sessions in the same herd standing on the pasture. The patients‘ individual wishes and riding skills determine if and which kind of therapeutic work is to take place on the ground or on horseback. Exercises taken from NHS and movement therapy for the treatment of eating disorders First of all, an exercise taken from NHS and one taken from movement therapy (or dance-therapy, to be precise) adapted to meet the requirements of horseassisted movement therapy are explained, followed by a list of tried and tested exercises in table form. Exercise 1 explained: “Hindleg moving at the rope” (horse wears horseman head-collar) Stand right in front of the horse, rope in hand. Straighten yourself in an upright position with an attentive-relaxed tension. Establish a stable connection with the ground and sense your mid-body while your breath is flowing. Establish eye-contact with the horse. You are present and focussed. When you feel a stable connection with the horse, intensify your eye-contact and start moving towards its hindlegs, almost in a sneaking manner. Your index finger is pointed at the hindhooves. Your body signals the horse to move its hindlegs away from you. If the horse does not respond, toss the rope as an increased stimulus towards the horse‘s backside. If this is not enough as a movement stimulus, toss the rope as an even stronger stimulus right at the horse‘s backside. If you want the horse to stand still again, stop moving and keep standing in a relaxed position with your arms hanging down. Possible topics and effects: The patient is getting aware of her body signals just by observing the effect they have. Experiencing competence via body expression, focussing on what‘s currently going on , attentive self and contact experiencing in various concentrations and mixtures of “presence of mind” and “being in contact” may occur. Self-esteem and shaping a relationship are experienced in a positive way. Exercise 2 explained : “Ritual” for strengthening self perception (adapted from movement therapy/ dance therapy, unknown source): The patient is sitting on horseback and is lead by the therapist walking or lunging. Skilled patients can also walk the horse themselves. The movement ritual consists of 10 courses of movements expressing different aspects of self-perception. The therapist guides in firstperson manner, explains and demonstrates the movement while walking on the ground. Pic. 3: Being one with oneself and in contact: “Moving the hindlegs” Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders mup 1|2009 | 23 These exercises may be varied regarding their order and ways of movement. Experience has shown that elevated sitting and the feeling of “getting carried” result in that patients can get into strengthening their own selves more easily than during dance therapy. Possible topics and effects: Different aspects of self-experience are experienced in a holistic and individual way. Effects: self-esteem, self-confidence, emotional balance can occur. “ Issues ” and strengths can become clear. Joy, but also sadness about aspects which can‘t be accessed are experienced. In case of sad feelings it is appropriate to name and understand them. If, for instance, a patient starts crying during the “I protect myself” movement the therapist may ask in a soothing way whether she knows what these feelings are connected with, which feeling is the strongest one etc. Often the patient is sad about the fact that she wants to protect herself in an accepting fashion but keeps rejecting this and hurting herself. It has proven its worth to re-phrase “I protect myself” into “I want to learn to protect myself”. The ritual may cause very individual emotions and sensations depending on the “I let myself fall” Bend your upper body over, relax your neck, jaws, the base of your tongue, rounded spine (skilled riders are able to lie on horseback on their stomachs or on their backs) “I straighten up” Straightening vertebra after vertebra, let your breath flow “I support myself” Place one palm on your lower back and the other one on your lower stomach. The space between your hands serves as the goal space of your breathing. “I protect myself” Cross your arms in front of your chest and place your palms on your shoulders. Your arms touch your upper body without applying any pressure. “I dissociate myself” Stretch your arms in all directions possible while sitting; the heels of your hands guide your movements. “I defend myself” Turn your hands into fists, protective block of hands and lower arms in front of your face and upper body. One hand is always used for protective purposes, the other one is used for making boxing movements “I give when I feel like it (and as much as I like)“ Giving gestures “I take and take in” Broad taking gesture. Roll your lower arms around each other from your body downwards to the middle of your body. Hold your hands pretending to hold a big bowl in front of the middle of your body “I check out what I want to keep and what I want to let go of” Let your arms hang down in a relaxed manner. Relaxed wide opening of your hands “I secure what‘s important and precious to me” Place your gently folded hands on the middle of your body (symbol: “bowl of treasures”) “I grow” Sprawl and stretch in all direction “I am I” Speak this sentence aloud in a rhythmic fashion, perceive your own voice; loosening one saddle hump (“I”), loosening other saddle hump (“am”), getting heavy on both saddle humps (“I”). 24 | mup 1|2009 Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders respective situation. The physical experience is talked about with the patient afterwards. That way the patient‘s current needs can be addressed directly in further exercises. As a side-effect this exercise is very good for teaching beginners how to keep their balance on horseback. Preview on the evaluation study regarding horse-assisted movement therapy for the treatment of eating disorders A first ongoing study examines the effect of horsea s s i s t e d m ove m e n t t h e ra py o n t h e acceptance of one‘s own body, deliberate self-perception, experiencing emotions, social competence and self-respect in the form of a pilot study analysing individual cases. 12 patients suffering from Anorexia nervosa or Bulimia nervosa diagnosed according to DSM IV are examined by the author in cooperation with Heidelberg university carrying through a 7 week study. The results may be presented in spring 2009. Further scientific projects are supposed to follow. Pic. 4: Being protected and one with oneself on horseback Table 2: Collection of exercises Exercises adapted from NHS Exercises adapted from movement therapy Leading technique - Cleaning hooves - Game of friendliness with and without a rope - Moving forelegs playing the hedgehog game - * and over the rope Moviong the hindlegs playing the hedgehog game and over the rope Sending backwards playing the hedgehog game and over the rope Calling it over the rope and free - Lateral lunging - Handle riding walking freely or led (stopping, back- wards, moving forelegs, moving hindlegs, steering, lateral curves) a. o. - * The hedgehog game are those exercises in which the horse is prompted to move through touching it with one‘s hands. Attention exercises such as: “Standing enrooted”, - Accompanying the breathing of the horse by placing the palms next to the spine on the horse‘s stomach. Leaning with one‘s stomach against the horse - Leaning against the horse with one‘s back - Guiding attention of being 100 % with oneself down to 50 % with oneself and 50 % in contact “Body journeys” on horseback - Breathing techniques to one‘s lower breathing area on horseback Accepting assistance with getting on the horse - Jumping onto the horse independently - Sliding off the horse via its backside a. o. - Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders mup 1|2009 | 25 Bibliographical references Alexandridis, K. (2005): Bewegungstherapie und Bulimia nervosa - Evaluation einer stationären Körpertherapie. Diss. Deutsche Sporthochschule Köln. -, Schüle, K., Ehrig, C., Fichter, M. (2007): Bewegungstherapie bei Bulimia nervosa. Bewegungstherapie und Gesundheitssport 2, 46-51 Deutscher Verband für Gesundheitssport und Sporttherapie (o. J.): Was ist Sport- und Bewegungstherapie? Definition. In: www.dvgs.de/ index.php? article_id=38&clang=0, 14.12.2008 Fachgruppe Arbeit mit dem Pferd in der Psychotherapie (FAPP) (2004): Psychotherapie mit dem Pferd. Beiträge aus der Praxis. FN Verlag, Warendorf Fichter, M. (2008): Magersucht und Bulimie. Mut für Betroffene, Angehörige und Freunde. Karger, Basel Fumi, M. (2008): Unveröff. Skript zur psychotherapeutischen Fortbildung, Medizinisch- Psychosomatische Klinik Roseneck, Prien am Chiemsee Gathmann, P., Leimer, G. (2004): Heilpädagogisches Voltigieren bei Anorexia nervosa. Peter Lang, Frankfurt a. M. Hölter, G. (1993): Mototherapie mit Erwachsenen, Sport, Spiel und Bewegung in der Psychiatrie, Psychosomatik und Suchtbehandlung. Hofmann, Schorndorf Laumer, U., Bauer, M., Fichter, M., Milz, H. (1997): Therapeutische Effekte der Feldenkrais-Methode „Bewusstheit durch Bewegung” bei Patienten mit Essstörungen. Psychotherapie. Psychosomatik, Medizinische Psychologie 47, 170-180 Müller, R. (1998): Bewegungstherapie mit Anorexia nervosa Patientinnen. Unveröff. Diss., Medizinische Fakultät der Univ. zu Köln, Köln Parelli, P. (1995): Natural-Horse-Man-Ship. Kierdorf, Wipperfürth Probst, M., Alexandridis, J. u. K., Wege, D., Rytz, T. (2005): Essstörung ist keine Antwort. Kongressbeitrag. Innsbruck September 5-9 -, van Coppenolle, H., Vandereycken, W. (1995): Body experience in anorexia nervosa patients: an overview of therapeutic approaches. Eating Disorders: The Journal of Treatment and Prevention 3, 145-157. Rytz, T. (2006): Bei sich und in Kontakt. Körpertherapeutische Übungen zur Achtsamkeit im Alltag. Huber, Bern Scheidhacker, M. (1991): Die Wirksamkeit des therapeutischen Reitens bei der Behandlung chronisch schizophrener Patienten. Der Nervenarzt 62, 283-287 - (1992): Kurzzeit- und Langzeitwirkungen des Therapeutischen Reitens bei der Behandlung chronisch schizophrener Patienten. Krankenhauspsychiatrie 3, 117-121 - (2002): Über die Behandlung von Angststörungen mit dem Psychotherapeutischen Reiten. Krankenhauspsychiatrie 13, 145-152 Wallin, U., Kronovall, P., Majewski, M. L. (1999): Body Awareness Therapy in Teenage Anorexia Nervosa: Outcome after 2 Years. European Eating Disorders Review 8, 200-205 Dr Katharina Alexandridis M.A. sports science, Master in Adapted Physical Activity (EMD- APA), sports and movement therapist since 1996 working at the Medizinisch-Psychosomatische Klinik Roseneck (department of sports and movement therapy, Am Roseneck 6, 83209 Prien am Chiemsee, Germany), now also working as a freelancer in “horse-assisted developmental psychology and movement therapy” since 2005“ Contact: Dr Katharina Alexandridis · Lindenstr. 22 · 83253 Rimsting · Germany e-mail: jk.alexandridis@web.de The author 26 | mup 1|2009 Alexandridis - Horse-assisted Movement Therapy for the Treatment of Eating Disorders