mup 3|2009|127 - 135|© Ernst Reinhardt Verlag München Basel | 127 Sterntalerhof - Palliative Care with Horses Lisa Graschopf The goal of ‘Sterntalerhof’ is to accompany families in exceptional situations holistically. These situations include but are not limited to serious illnesses, disabilities, and traumatic experiences. Although special attention is paid to our young guests, who are chronically and / or critically ill, the Sterntalerhof considers itself a rest stop (which is the original meaning of hospice) for all family members. Here they can find peace and strength in order to pursue their walk of life with more confidence. Essential for our work are art therapy, music therapy, and therapeutic work with horses including therapeutic horseback riding. Keywords: Palliative care, therapeutic riding, therapeutic vaulting / horseback riding 128 | mup 3|2009 Graschopf - Sterntalerhof - Palliative Care with Horses The ‘Sterntalerhof’ The ‘Sterntalerhof’ (Burgenland province, Austria) has been around since 1999 and was founded by the vaulting instructor and psychotherapist Regina Heimhilcher as well as the clinical pastor Peter Kai. Currently, one to two families as well as 15-20 children as outpatients per week can be accommodated here. In addition, so-called sibling weeks are being organised on a regular basis, whereas the siblings of children or teenagers being chronically ill or suffering from life-threatening illness are being focussed on. During their one or two week stay a fully equipped wooden residence is available to the guests. The operative team of the ‘Sterntalerhof’ consists of a palliative physician, a pastor, a psychotherapist, a pediatric nurse, a special and pedagogical therapist, a music therapist and an art therapist. The ‘Sterntalerhof’ may also be available for several therapeutic stays, if necessary. It is a place of regeneration and recovery for families which are directly threatened or affected by illness, disability or loss. It meets today‘s standards of pediatric palliative care and is thus a link between full medical care at a hospital and living an independent life at home where the family may serve as a vital source of energy. There are currently five trained therapy horses at the ‘Sterntalerhof’, a pony, a Labrador shedog, a cat, a short-ear dwarf buck and two cameroon sheep which are integrated into the therapeutic work. Recharging one‘s batteries, finding peace and confidence are the main goals of affected families. The actual costs for a one-week stay at the ‘Sterntalerhof’ (since it is registered as a non-profit association, no profit is allowed to be made) are approx. € 2,500. Since affected families are rarely able to pay the costs themselves, various possibilities for financing the stay are available. Each family pays as much as it can. The rest is paid by the ‘Sterntalerhof’ itself via donations or it The term “palliative“ (lat. pallium for “cloak“) means ‘protecting‘ and ‘relieving‘. Just like a cloak protects from wind and weather this term today means the protection from the cold within, loneliness, fear; easing mental and physical pain. Palliative care has been specified as a new specialist field by the WHO in 2002 as follows: “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with lifethreatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.“ If it‘s about supporting children and teenagers it‘s called ‘pediatric palliative care‘. For further information, please visit http: / / www.dgpalliativmedizin.de Palliative care, pediatric palliative care Pic. 1: Recharging ones batteries Graschopf - Sterntalerhof - Palliative Care with Horses mup 3|2009 | 129 provides support for families with requests when addressing foundations, institutions, sometimes health insurance companies. Background The number of children requiring treatment has increased during the past years despite or, ironically, due to the medical advancement. Especially with cancer even years after a successful therapy ‘healed’ is not the word to be used here since the possibility of a relapse persists for a longer period of time. Meanwhile 10% of all children are affected by chronic illness. Apart fom the possibility of living in a state of uncertainty for years concerning the outcome of the illness the stress of exhausting therapies is another negative factor. For a small percentage of children suffering from life-threatening illness and their families knowing that surviving the illness is impossible means pain (Petermann / Bode / Schlack 1990, 17 et seq.). Generally speaking, the ways families are affected by stress can be very multifaceted. There is hardly an incident hitting a family harder than the death or a life-threatening situation of one of its children, be it through an unexpected acute or chronic illness, an accident or a permanent disability. Children suffering from life-threatening illness are categorised as a high-risk group from the psychopathological point of view. They are at a very high risk of developing mental or psychosomatic disorders (Petermann / Bode / Schlack 1990). This can be made clear by taking a look at the salutogenesis model by Antonovsky (see. fig. 1). Antonovsky‘s model is based on the fundamental question why some people stay healthy despite the adverse circumstances they live in while others get sick (mentally or physically) (Knoll 1997, 26). Generally, Antonovsky acts on the assumption that health and illness can‘t be seen as two clearly distinguishable states but as two poles on the same continuum the person‘s ‘health state’ can be located on (Knoll 1997, 26). In order to locate a person on this continuum two areas are of special significance: firstly, there are possible stress factors (of a psychosocial, physical / or biochemical kind), having a stressful impact on the individual, and secondly, Resources (resistance factors) Stress factors (risk factors) Sense of coherence Tension management Psychosocial stress factors Physical and biochemical stress factors Generalised psychosocial resourses State of tension as a result of the individual situation Health illness continuum Generalised genetic and physical resources Fig. 1: Very simplified depiction of the salutogenesis model according to Antonovsky (based on Knoll 1997, Kraus 1987, Antonovsky 1997) 130 | mup 3|2009 Graschopf - Sterntalerhof - Palliative Care with Horses there are possible resources (of a psychosocial or genetic- / physical kind) (Knoll 1997, 27 f). Regarding children suffering from lifethreatening illness it can be stated that, based on this model, they are affected by two stress factors: One the one hand, many stress factors have an impact on them, on the other hand they lack due to the illness they suffer from some resources which are needed for coping with stress. Apart from the sense of coherence (SoC) the Antonovsky model comprises another component on the resource side. “Antonovsky means a global dimension of one‘s personality which can be described as a sustainable feeling of trust in the predictability of an individual‘s internal and external environment“ (Knoll 1997, 29). The sense of coherence is of particular importance for tapping one‘s resources (Knoll 1997, 30). It‘s quite likely that younger children suffering from life-threatening illness have made less experiences in life resulting in a stable sense of coherence than healthy children. Figure 2 makes this clear by giving some examples of stress factors children suffering from life-threatening illnesses are exposed to and which resources may decrease in addition to the illness. The horse‘s relevance in palliative care Even after doing intense research for my final thesis entitled “Palliative care with therapeutic pedagogical vaulting and horseback riding of children suffering from progressive illnesses with the ‘Sterntalerhof’ taken as an example“ (2008) I wasn‘t able to find any literature illustrating the combination of pedagogic and / or therapeutic work with horses and palliative care. However, there are goals described along with basic attitudes within perithanatal issues in the fields of pedagogy, palliatve-medical care and psychotherapy. These goals often have many things in common with researched effects and goals of therapeutic pedagogical vaulting and horseback riding (HPV / R) as well as with field reports from working with horses in a psychotherapeutic way. That‘s why we can act on the assumption, on a theoretical level, that horse-assisted palliative care really does make sense. Unfortunately, going deeper into this matter is beyond the scope of this article. For further information, please refer to Graschopf (2008). Generally speaking, deploying horses in the field of palliative care is aiming at reactivating and strengthening the resources of children suffering from life-threatening illness in order to make it easier for them to cope with the many primary and secondary consequences their specific illness has. Anything that helps support children and teenagers in coping with their illnesses and their consequences should be made use of. Individual likings, the children‘s age, their cultural background as well as their family and social environment must be considered when developing strategies living up to the individual situation. First of all, support and therapy with horses on a physiological and motoric levelis essential, reducing possible physical / biochemical stress and (re-)building physical resources. This is, for instance, the activating effect trotting has on children feeling tired due to painkillers, or the expectorant effect rhythmic movement has on children suffering from cystic fibrosis. Apart from the physiologic-motorical area, Jenessen (2006) has developed three main areas loosely related to the salutogenesis model for the field of activity of palliative care with horses, all aiming at reducing stress factors and strengthening resources and the sense of coherence: Psycho-emotional support ■ Supporting the process of coping ■ Supporting performance related skills ■ Graschopf - Sterntalerhof - Palliative Care with Horses mup 3|2009 | 131 Psycho-emotional support Psycho -emotionale support is mainly about the attitude of advisors such as pedagogues, psychologists, therapists and pastors towards affected children and teenagers which is indispensable for arranging the relation adequately. E.g. it‘s about availability, closeness, honesty, empathy, acceptance and respect (Graschopf 2008, 60-90). The most important principle of all and the crucial precondition for a successful, empathic relation is establishing a trustful relationship which is to be taken a closer look at in the following: Especially through long-lasting or lifethreatening illness and experiencing pain and fear confidence in oneself, towards others, the environment and to God can be massively affected (Schmeichel 1983, 225). The horse‘s friendly character, its instinctdriven empathy, its willingness to adapt and obey usually allows for quickly establishing a relationship built on trust between the child and the horse (Jaresch-Lehner 1999, 73). It can happen that a fascinating and trustful encounter between man and animnal is the foundation stone of a promising reorientation (Jaresch-Lehner 1999, 60). In Missing / reduced resources with children suffering from lifethreatening illness Stress factors with children suffering from life-threatening illness Physical and biochemical stress factors are e.g.: Physical pain Results of medication & side-effects of pharmaceuticals Side-effects and consequences of an operation Missing or reduced genetic & physical resources are e. g.: Illness as a result of a genetic dispostion Physical consequences of medical treatment Destabilisation / change of physiognomy Psychosocial stress factors are e. g.: Sudden occurrence of illness Unforeseeability of the progress the illness takes, illness progresses in exacerbations Experiencing dependency & need for help Limited scope of action Pitiful reactions from people Experiencing “not being part“ and “being different“ Missing or reduced psychosocial resources are e. g.: Losing or change of familiar social relations in family, school, peergroup Destabilisation of one‘s self-perception, e. g. through physical change, limitation of one‘s scope of activity etc. Cognitive strategies which used to work so far are now realised to be no good anymore Fig. 2: Possible stress on children and teenagers suffering from lifethreatening illness 132 | mup 3|2009 Graschopf - Sterntalerhof - Palliative Care with Horses her theoretical reasonings, Klüwer (2005, 12 et seq.) has formulated ideas concerning therapeutic horseback riding and confidence building. Through the movement dialogue, the similarities between the constellations of moving and holding while riding on horseback and the way a baby or small child is being carried, not only physical developments can be cought up on or supported, it also reaches the layers deep within a person allowing to re-experience the basic sense of trust. Also Gäng (2004, 29) writes that the horse‘s characteristics are particularly suitable to establish or catch up on a basic sense of trust. One can act on the assumption that the horse‘s rhythmic movements, which are experienced through direct physical contact and non-verbal communication, even tie in with prenatal experiences allowing associations of being comforted and feeling safe and secure (Schulz 2009, 88 et seq.). Scheidhacker (2005) adds another aspect of confidence building. The horse is not only a reliable partner in a relationship but also a projection surface for phantasies, desires and an archetype symbol standing for mother, father, child, but also for freedom, boldness and the feeling of being alive, depending on the current development phase. The intense physical contact and the rocking movements while sitting on horseback seem to mobilise early emotions reminding of the archetype of the Great Mother who used to be experienced in a nourishing and carrying manner (Scheidhacker 2005, 162). This also reminds of the conveyance of hope and trust in palliative care as postulated by Spruck (1996, 118) which cannot only be experienced through a relationship with the horse built on trust, not only through advisors, not only through words, but through the concrete experience of being cradled and rocked at any age. Supporting the process of coping In the field of supporting the process of coping most of the attention is paid to strengthening resources within the family, self-confidence and each one experiencing the feeling of selfefficiency. Jenessen (2006) formulates, based on the saluto genesis mode, aspects supporting the process of coping which are defined by three main points: comprehensibility, feasibility and meaningfulness. In terms of comprehensibility it‘s about explaining children and teenagers the situation they are currently in and showing them possibilities how to talk with like-minded people or people they trust about their current needs, worries or requests (Jenessen 2006, 90). HPV in groups can open ways to get in touch with like-minded comrades. Concerning feasibility experiencing mental underor overload during the development processes should be avoided. Through the principles of increasing individual performance as described by Kröger (1998, 117) even the smallest of steps and positive amplification HPV is a way to meet these postulations. Since it is still possible for seriously ill children or teenagers to experience mental overload, aspects of psycho-emotional support are required. The feeling of meaning fulness mainly comes from realising that one‘s own actions have a meaning and are necessary and in experiencing one‘s own self-efficiency and competence. While working with horses one gets aware of these qualities in a very direct way. Not only vaulting exercises and games as described by The horse‘s friendly character, its instinct-driven empathy, its willingness to adapt and obey allows for usually quickly establishing a relationship built on trust between the child and the horse. Graschopf - Sterntalerhof - Palliative Care with Horses mup 3|2009 | 133 Gäng (2004), but especially through handling the horse. All activities connected with this (grooming the animal, the saddle, the stable etc.) are clearly realised as being necessary and done willingly (Gäng 2004, 27). Based on an emotional connection with animals and a probably natural need to deal with them it seems to make sense to take care of them and to show responsibility. The more children and teenagers get to know about the needs their partner “horse“ has the more they want to live up to them (Gäng 2004, 28). Here, it is of great importance that the intensity of contacts with the horse varies. Children and teenagers can decide for themselves which kind of contact is stimulating and feasible to them. Even affected persons which depend on intense care and are thus rarely allowed to decide for themselves can experience situations of selfdetermination. The sensation of having control over a big animal which is actually much more powerful than oneself is another crucial factor. This is a quotation from a girl confirming this: “It feels great when a horse is coming with you because you want it to.“ - “It feels great when you sense such a big animal obeying you.“ Supporting performance-related skills Jenessen (2006, 87) carries on by acting on the assumption that performance related support is crucial for affected children developing a personality. The focus here is on building up stable self-respect and to carry on living a normal life, as far as possible. According to Jenessen the educational challenge here is to stimulate motivation for performance since often difficult illness-related situations result in performance-avoiding behaviour. The big advantage in working with horses in a pedagpogic-therapeutical way is that horses are very appealing especially to children. A horse invites to be watched, touched and stroked, to be fed and cleaned, to be listened to and to be smelled, but especially to be ridden on, of course. Its naturally high requesting nature makes even anxious and shy children try something new and thus broaden their experiences. Ringbeck (1997) writes that children often tell horses about their worries, they seek solace and attention through them and even very introverted children manage to open themselves towards others by using the horse as a ‘relationship bridge’. Firstly, the high degree of motivation children have when dealing with horses and secondly the positive relationship many children have with horses are a good basis for the willingness to set goals and to face challenges. Kröger (1998) works mainly with positive amplification and the principle of the smallest possible steps. So when HPV sticks to the smallest steps principle (i.e. individual increase of performance without mental overload) and when pedagogues realise these steps in an individual order with children experiences which are able to achieve something will occur. Here, HPV as movement orientated intervention has the special advantage that one‘s own achievements can be experienced very directly and don‘t need to be judged by Pic 2: Performancerelated support while playing on horseback 134 | mup 3|2009 Graschopf - Sterntalerhof - Palliative Care with Horses others. “In the field of pedagogy I don‘t know of any other medium that allows the learner to experience that many successful events as vaulting does. (…) I‘ve never experienced children to respond any other than that. All of a sudden they won‘t allow others to push them aside, They discover their creative side and also present a series of exercises on horseback. They finally are somebody again! “ (Kröger 1998, 117). Statements like these make it easy to understand to which degree the experience of success is able to contribute to building up self-respect and allows to present oneself with a personal and social identity. Summary Horses are suitable for being worked with in the field of palliative care in many ways. They can be watched, touched, groomed, fed, ridden on. They are demanding partners and usually very reliable in terms of behaviour. They display unbiased tolerance in judging the respective degree of closeness and distance. Horses have a sensitive nose for the mental state of individual humans and are absolutely authentic in their behaviour. They don‘t judge, feel sorry or punish. Through the possibility of riding on horseback a sensation of being carried and cradled occurs. This makes horses perfect for ‘healing’ damaged trust and to satisfy the need of getting positive attention. Still, after all the enthusiasm for HPV and the therapeutic work with horses, certain limits need to be adhered to. HPV is no panacea and can‘t turn ill children and teenagers into healthy ones. It is able to accompany the process of handling the illness and the process of dying and might relief it due to the reasons mentioned above, it can create what one would refer to as “magic moments“ moments of bliss, of feeling safe and secure in hard times. The effects of HPV offer ill children and teenagers possibilities to cope with special situations in various ways one should not abstain from light-mindedly. At the Sterntalerhof experiences were made during the last years which confirm the theoretical statements made above. The horse convinces through its character with empathy, authenticity and absolute acceptance. This attitude, indispensable in the field of palliative care in order to focus on human dignity again, is something horses often seem to be able to get closer to than humans. Bibliographical references Antonovsky, A. (1997): Salutogenese. Zur Ent- ■ mystifizierung der Gesundheit. dgvt, Tübingen Gäng, M. (2004): Heilpädagogisches Reiten. ■ In: Gäng, M. (Hrsg.): Heilpädagogisches Reiten und Voltigieren. 5. Aufl. Ernst Reinhardt, München / Basel, 27-104 Graschopf, L. (2008): Die palliative Begleitung ■ progredient erkrankter Kinder durch Heilpädagogisches Voltigieren und Reiten am Beispiel des Sterntalerhofes. Diplomarbeit, Universität Wien Jaresch-Lehner, K. (1999): Haltung: Ein Beispiel ■ aus der Heilpädagogik. Das Heilpädagogische Voltigieren. In: Sedlak, F. (Hrsg.): Auf die Haltung kommt es an. Ein Nachdenk- und Impulsbuch für Eltern, Lehrer / innen und Schüler / innen. Wien: Lisa Graschopf Special and therapeutic pedagogue (M.A.), three years of social-medical service work in the field of mobile care, working at the Sterntalerhof since May 2006, vaulting coach, HPV in general Contact: Lisa Graschopf · Sterntalerhof-Verein für ganzheitliche Lebensbegleitung · Grazer Str. 58 · 7551 Stegersbach Austria E-mail: lisa.graschopf@sterntalerhof.at Die Autorin Graschopf - Sterntalerhof - Palliative Care with Horses mup 3|2009 | 135 Bundesministerium für Unterricht und Kulturelle Angelegenheiten, Abt. Schulpsychologie / Bildungsberatung, 59-90 Jenessen, S. (2006): Systemisches Verstehen ■ von Entwicklung und Sozialisation bei progredienter Erkrankung als Grundlage schulpädagogischen Handelns. Heilpädagogik online 02 / 06, 61-98. In: www.heilpaedagogik-online.com / 2006 / heilpaedagogik_online_0206pdf , 08.03.2009 Knoll, M. (1997): Sporttreiben und Gesundheit. ■ Eine kritische Analyse vorliegender Befunde. Karl Hofmann, Schorndorf Klüwer, B. 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(1996): Die Pflege des krebskranken ■ Kindes. Ein Konzept zur psychosozialen Betreuung für Pflegekräfte, Eltern und Angehörige. BVS, Baunatal WHO (2009): WHO Definition of Palliative ■ Care. In: www.who.int/ cancer/ palliative/ definition / en/ , 13.03.2009