What We Still Don't Know About Equine Therapy (And Why That Matters)

Here's an uncomfortable truth about equine-assisted therapy: for all the compelling stories, for all the testimonials from people whose lives changed in a barn, for all the research papers with promising findings, we still can't definitively say how it works, why it works, or whether it works consistently enough to call it evidence-based treatment. That's not a criticism, exactly. It's just where we are. The field is young, the questions are complex, and the enthusiasm of practitioners and participants has, in some ways, outpaced the science needed to support their claims.

This matters for several reasons. It matters because insurance companies won't cover treatments without solid evidence. It matters because people seeking help deserve to know what they're getting into and what the realistic expectations should be. It matters because the horses involved in these programs deserve ethical consideration and protection from harm. And it matters because without rigorous research addressing the significant gaps in our knowledge, equine therapy risks remaining on the margins of mental health treatment, dismissed by skeptics and overvalued by believers, when the reality is probably somewhere complicated in between.

A comprehensive review of the equine therapy literature reveals substantial gaps across multiple domains: methodology, standardization, theoretical understanding, equine welfare, and representation of diverse populations and perspectives (Anestis et al., 2014; Bachi, 2012; Contalbrigo et al., 2021; De Santis et al., 2017; Lee et al., 2016; Li & Sánchez-García, 2023; Marchand et al., 2021; Pereira-Figueiredo et al., 2025; Stern & Chur-Hansen, 2019; Stolz et al., 2021). Understanding these gaps isn't just academic housekeeping. It's essential for advancing the field, protecting both human and animal welfare, and establishing best practices that can actually be replicated and verified.

The methodological problems in equine therapy research are substantial and well-documented. Most studies involve small sample sizes, sometimes fewer than twenty participants, which makes it nearly impossible to draw generalizable conclusions or detect effects that might be modest but real (Anestis et al., 2014; Bachi, 2012; Lee et al., 2016; Li & Sánchez-García, 2023; Pereira-Figueiredo et al., 2025; Stern & Chur-Hansen, 2019). Randomized controlled trials, the gold standard for determining whether an intervention actually works, are rare in this field. Most evidence comes from observational studies, case reports, or qualitative research, all of which have value but can't establish causality (Atalaia et al., 2021; Anestis et al., 2014; Bachi, 2012; Lee et al., 2016; Li & Sánchez-García, 2023; Stern & Chur-Hansen, 2019).

The lack of control groups is particularly problematic. When someone feels better after ten weeks of equine therapy, is it because of the horses specifically, or because they spent ten weeks doing something outdoors with supportive people paying attention to them? Is it the human-horse bond, or is it just time and general therapeutic attention? Without proper controls, we can't answer those questions. And without those answers, we can't refine the intervention to make it more effective or determine who's most likely to benefit.

Follow-up periods in most studies are short, often ending when the intervention ends or shortly thereafter (Cantatore et al., 2023; Fuller-Lovins et al., 2023; Müller-Klein et al., 2024; Seery et al., 2025). This means we have very limited data on whether the benefits of equine therapy persist over time. Does the improvement in depression or anxiety last six months later? A year later? Do people maintain the skills and insights they gained, or does the effect fade once they're no longer around horses? These are critical questions for determining whether equine therapy is worth the investment of time, money, and resources, and we simply don't have good answers yet.

The terminology problem in equine therapy is maddening if you're trying to make sense of the literature. Different programs use different names for what might be essentially the same intervention, or use the same name for interventions that are actually quite different (Bachi, 2012; Marchand et al., 2021; Seery & Wells, 2024; Stolz et al., 2021; Wood & Fields, 2019). Equine-assisted psychotherapy, hippotherapy, therapeutic riding, equine-facilitated learning, these terms are sometimes used interchangeably and sometimes refer to distinct practices with different theoretical foundations, training requirements, and intervention protocols.

This lack of standardization makes it nearly impossible to compare findings across studies or replicate interventions in different settings (Fry, 2021; Marchand et al., 2021; Seery & Wells, 2024; Stolz et al., 2021; Wood & Fields, 2019). When one study shows positive effects of "equine-assisted therapy" and another shows null results, we can't know if that's because the intervention doesn't work consistently or because they were actually doing two completely different things that happened to use similar names. The field needs standardized protocols, clear definitions, and consistent outcome measures if we're going to build a coherent body of knowledge.

The theoretical frameworks explaining how equine therapy produces its effects are underdeveloped, which is a polite way of saying we're not entirely sure what's happening (Burgon et al., 2018; Hemingway et al., 2019; Marchand, 2023; Reis et al., 2024; Ribeiro et al., 2024; Watson, 2019). Is it primarily about the relationship with the horse, with all the neurochemical changes that bonding entails? Is it the physical activity and coordination required? Is it the metaphors and insights that arise from working with a large animal, insights that can then be processed in traditional talk therapy? Is it the outdoor environment, the social component of group sessions, the opportunity for mastery and competence building?

Probably it's all of these things to varying degrees for different people, but we don't have research that systematically isolates these components to determine their relative contributions (Hemingway et al., 2019; Marchand, 2023; Reis et al., 2024; Ribeiro et al., 2024; Watson, 2019). This matters for practical reasons. If the human-horse bond is the critical therapeutic ingredient, then programs should focus resources there. If it's primarily about the physical and outdoor components, then maybe other animal-assisted or nature-based therapies would be equally effective. Without understanding mechanisms, we're essentially running programs based on intuition and anecdote rather than theory and evidence.

There's also a need for validated measurement tools specific to equine therapy contexts (Contalbrigo et al., 2021; Fry, 2021; Marchand et al., 2021; Stolz et al., 2021). Most studies use generic mental health measures, anxiety and depression scales, quality of life questionnaires, which is fine as far as it goes. But we also need instruments that can assess the quality of the human-horse relationship, the specific skills and insights gained through equine interaction, and the unique aspects of this intervention that might not be captured by standard psychological assessments. Some work has been done in this direction, but it's limited and not widely adopted across the field.

Here's where things get ethically complicated and frankly, a bit uncomfortable. The welfare of therapy horses is under-researched and often inadequately considered in program design and implementation (Contalbrigo et al., 2021; De Santis et al., 2017; Fry, 2021; Marchand et al., 2021; Merkies et al., 2018; Müller-Klein et al., 2024; Nicodemus et al., 2021). We use horses as therapeutic agents, we claim that their presence and interaction produces healing for humans, but we've done remarkably little systematic research on how this work affects the horses themselves.

Limited studies have looked at stress responses in therapy horses using physiological markers like cortisol or behavioral indicators of distress (De Santis et al., 2017; Müller-Klein et al., 2024). What exists suggests that some therapy horses do experience stress during sessions, particularly when working with clients who are anxious or dysregulated. Remember that study from earlier showing that a calm horse helps produce a calmer client? The inverse is also true. An stressed horse doesn't help anyone, and might actually be experiencing something we'd consider harmful if we're taking animal welfare seriously.

There's also evidence that many practitioners lack formal training in equine behavior and welfare (De Santis et al., 2017; Fry, 2021; Nicodemus et al., 2021; Seery & Wells, 2024). They may misinterpret signs of stress or discomfort in the horse, believing the animal is calm and engaged when it's actually showing subtle indicators of distress. This isn't malicious. Most people working in this field genuinely care about horses. But caring isn't the same as having the specialized knowledge needed to accurately assess equine welfare, and the consequences of that gap can be significant for both the horses and the humans they're supposed to be helping.

Pain management and assessment in therapy horses is another concern that's barely been addressed in the literature (Nicodemus et al., 2021). These are working animals, often older horses who may have chronic conditions or limitations. Are programs adequately monitoring for pain? Do practitioners know how to recognize subtle signs of discomfort? What protocols exist for retiring horses who are no longer physically or emotionally suited for therapy work? These are basic welfare questions that deserve rigorous attention.

The ethical implications of using sentient animals as therapeutic tools need more serious consideration in both research and practice (Contalbrigo et al., 2021; De Santis et al., 2017; Fry, 2021; Marchand et al., 2021). Horses can't consent to this work. They can't tell us in words when they're tired or stressed or would prefer not to interact with a particular client. We have a responsibility to develop better ways of assessing their wellbeing and ensuring that therapeutic programs don't come at the expense of the animals providing them.

Most equine therapy research focuses on specific populations: children and adolescents, military veterans, sometimes people with autism or ADHD (Cleary et al., 2024; Diaz et al., 2022; Kinney et al., 2019; Letsoalo et al., 2024; Li & Sánchez-García, 2023; Pereira-Figueiredo et al., 2025; Srinivasan et al., 2018; Stern & Chur-Hansen, 2019). This makes sense from a practical standpoint. These are populations where there's interest and sometimes funding for alternative interventions. But it means we have limited evidence for how equine therapy might work with other groups: older adults, people with severe mental illness, individuals from different cultural backgrounds where relationships with animals might be understood differently.

There's also a geographic bias in the research, with most studies conducted in Western, developed countries (Letsoalo et al., 2024; Li & Sánchez-García, 2023; Pereira-Figueiredo et al., 2025; Stern & Chur-Hansen, 2019). Cultural factors likely influence how people experience and benefit from animal-assisted interventions, but we have very little cross-cultural research to inform programs in diverse contexts. The assumption that equine therapy will work similarly across all populations and settings is probably naive, but we don't have the data to know for sure.

Stakeholder perspectives are also underrepresented in the literature (Diaz et al., 2022; Fry, 2021; Marchand et al., 2021; Seery et al., 2025; Seery & Wells, 2024). Most research focuses on client outcomes, which is obviously important, but we also need systematic investigation of practitioners' experiences, challenges, and observations. What do the people actually doing this work think is most important? What barriers do they face? What training do they wish they had? Some qualitative work has begun exploring these questions, but it's limited.

And then there's the elephant in the room, or rather, the horse in the arena. The horses' perspectives are almost entirely absent from the research. Obviously we can't interview horses, but we could be doing much more sophisticated ethological observation, more comprehensive physiological monitoring, better behavioral assessment to understand how horses experience this work. If we're claiming that the horse is a therapeutic partner, not just a tool, then we need to take seriously what partnership means and whether horses are genuinely willing participants or simply compliant in the face of human control.

Some studies in the equine therapy literature show no effects beyond placebo or the passage of time (Anestis et al., 2014; Fuller-Lovins et al., 2023; Tseng et al., 2013). This isn't necessarily evidence that equine therapy doesn't work, but it's evidence that it doesn't work for everyone or in every context or as implemented in some programs. The field needs to take these null findings seriously rather than dismissing them, because they probably contain important information about moderators and boundary conditions, about which components are essential and which are incidental, about who benefits and who doesn't.

The gaps in equine therapy research aren't just academic concerns. They have real-world implications for people seeking help, for programs trying to deliver effective services, for horses whose welfare may be compromised, and for the field's credibility and sustainability. Without rigorous evidence, programs struggle to get insurance coverage or institutional support. Without standardized protocols, quality control is nearly impossible. Without understanding mechanisms, we can't optimize interventions or train practitioners effectively. Without attention to equine welfare, we risk harming the very animals we claim are helping people heal.

Addressing these gaps will require sustained investment in research infrastructure, collaboration across disciplines (psychology, animal science, neuroscience, social work), and willingness from the field to submit its practices to rigorous scrutiny even when that scrutiny might reveal uncomfortable truths. It will require larger sample sizes, longer follow-up periods, proper control groups, and standardized measures. It will require theoretical development and mechanism research, not just outcome studies. It will require serious ethical consideration of what we're asking of the horses involved in these programs.

The enthusiasm and commitment of people working in equine therapy is admirable. The stories of transformation and healing are compelling. But enthusiasm and stories aren't enough to establish an intervention as evidence-based or to ensure that programs are implemented safely and effectively. The field is at a crossroads. It can continue operating primarily on belief and anecdote, remaining on the fringes of mainstream mental health treatment. Or it can do the hard work of building a robust evidence base that addresses current gaps, establishes best practices, and earns the credibility that comes with rigorous science.

That work won't be easy or quick. Research is expensive and time-consuming. Standardizing a field that has grown organically with diverse approaches and philosophies will require negotiation and compromise. Taking equine welfare seriously might mean acknowledging that some current practices need to change. Subjecting programs to rigorous evaluation might reveal that some of what we thought was working isn't, or isn't working in the ways we assumed.

But for a field that claims to be about healing, about authentic connection, about honesty and presence, there's something fitting about confronting these gaps head-on. The horses we work with don't lie. They respond to what's actually there, not what we wish were there or claim is there. Maybe the field of equine therapy could learn from that. Maybe the next phase of development requires the same kind of honest assessment and authentic engagement that we're asking clients to bring to their work with horses. That would be uncomfortable, probably. It would require vulnerability and the willingness to sit with uncertainty. But if we're asking that of the people and horses in our programs, we should be willing to ask it of ourselves and our field as well.

References

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