Amber Miller, LCSW, CEIP-MH

CHA (2 Eng. West Trail Guide)

PATH Certified Riding Instructor

EAGALA ES MH

Kemmerer Village Equine Therapist

www.kemmerervillage.org

217- 226 -2226

217-226-4451

Dialectical Behavior Therapy and Equine Facilitated Therapy, Integrating Balance

Overview:

DBT was originally developed for some of the most challenging clients. It is a therapeutic

approach uniquely suited to integration with EFT due to similarities in both conceptual

framework and skill sets. The DBT/EFT approach is effective because it combines a research

based clinical theory with the unique experiential benefits of equine therapy. Many clients who

are typically resistant to engaging in traditional therapy are eager to participate at the barn. I

have provided one example of how I integrate DBT and EFT. This presentation will include

between 4 and 8 examples including acronyms and other skills, as time allows. The experiential

and strengths based experiences also facilitate the transfer of skills to real life situations. Many

clients who engage in EFT may also see a traditional mental health professional. Integrating

what the client learns in those sessions with EFT is an effective way to increase learning

Speaker Biography:

Amber Miller is a Licensed Clinical Social Worker. She is a certified riding instructor with

PATH and CHA and a Certified Equine Interaction Professional – Mental Health. She is also

certified by EAGALA. She designed and implemented an equine facilitated therapy program at

a residential treatment facility. The program has been successfully running under her leadership

for the past 4 years. This program utilizes both riding horses and miniature horses. Prior to that,

she has 5 years experience in the mental health field, primarily working with children with

severe emotional and behavioral challenges. She was a riding instructor for more than 10 years.

While working in residential treatment, this presenter attended multiple trainings in Dialectical

Behavior Therapy. The DBT approach was broadly integrated in to the residential program and

had favorable results with the youth served. DBT is now regularly integrated at this residential

treatment facility with other EFT activities. The treatment team has observed positive outcomes

for clients participating in these sessions.

Objectives - Give a brief overview of Dialectical Behavior therapy

- Discuss how the conceptual framework of Dialectical Behavior therapy is used at Kemmerer

Village in equine facilitated psychotherapy sessions

- Give specific examples of activities used in such sessions

Dialectical behavior therapy (DBT) is a system of therapy originally developed by Marsha

Linehan, to treat people with borderline personality disorder. DBT combines cognitive

behavioral techniques with mindfulness.

In DBT the clinician works to balance accepting the client and and validating the client’s

feelings with helping the client recognize maladaptive behaviors and teaching them more

adaptive skills.

As in other therapy models, a number of other clinicians have built upon or modified Linehan’s

work. The DBT model that is used as a framework for Equine Facilitated DBT at Kemmerer

Village uses concepts taught by Dr. Kathy Moonshine. A number of the activities and

explanations used here are copied from Dr. Moonshine’s work.

The skill areas that are focused on in DBT are:

Mindfulness

Distress Tolerance

Emotional Regulation

Interpersonal Effectiveness

Dialectics:

- The art of holding 2 or more things in balance that are in conflict or mismatched with each other

- Being dialectical is about balancing completing needs/ideas.

Examples: - Wants and needs

- Feelings and thoughts

- Contemplation and action

- Change and acceptance

- Doing things alone and asking for help

-Having good self esteem and needing to learn skills

BALANCE: Why it is important:

- Being in balance is an effective way to accomplish tasks, manage emotions, tolerate distress,

maintain healthy relationships and sustain self respect

- Balance is not being too much to one side or the other

- Balance is holding many things at once without getting knocked down

- Balance is imperfect

- Staying in balance is an essential ingredient to being dialectical

The concept of balance is woven throughout the fabric of what I do in therapy and horsemanship.

I use this metaphor constantly with my clients. For example, when teaching them to trot I talk to

them about balancing tension and relaxation in their body. I compare this to the DBT skill “Ride

the Wave” which is about experiencing difficult emotions without being overwhelmed by them.

This technique is appropriate to EFP but should not be utilized in EFL or traditional therapeutic

riding.

Example of using the DBT concept of Balance in EFP:

The first time (sometimes the first several times) that a client rides, I lead the horse for them and

we talk about balance. I help them recognize that balance is what keeps them on the horse; and

likewise, balance keeps them afloat in life. I ask clients to identify how they feel balance as they

are riding and how they use and feel balance in their lives. Clients give varying levels of insight

here which is a useful assessment tool. In discussing balance on the horse they may describe - staying on

- being both tense and relaxed

- being afraid but trusting the horse/therapist and themselves

In discussing balance in life they may describe - balancing feeling angry and not losing their temper

- balancing loving their parents and no longer trusting them

- balancing wanting to leave residential treatment and being afraid that they will not succeed

outside of residential treatment

DBT SKILLS: Marsha Linehann and Kathy Moonshine developed a number of DBT “skills” which are useful

tools for clinicians working with clients who struggle with emotional regulation and

relationships. Many of these skills are represented by acronyms.

Examples: GIVE - Gentle in relationships, Interest in others, Validate, Easy manner FAST – Fair to self, Apologize less, Stick to values, Truthful with self

TRUST –Trust yourself, Redirect impulses and urges, Use your skills to be effective, act consistently how you want others to See you, Tame your emotions and reactions I use these skills as a starting point for therapeutic discussion and teaching. I have used these

activities in group, individual and family discussions.

Using “GIVE” in an Individual Ground Session:

I hang a laminated sheet outlining the specific DBT skill at the front of the arena and laminated

letters around the arena (corresponding to the DBT acronym). I turn miniature horses loose in

the arena. The number of horses, specific horses chosen, and the availability of equipment such

as halters and lead ropes is determined by a number of factors.

These factors generally include the following: - the client’s equine skill level

- the client’s judgment

- the number of adults present for the session

- the client’s presenting clinical issues

- the energy level of the horses

GIVE -

This skill aids one with improving and maintaining his or her relationships, whether they

are with friends, coworkers, family, romantic partners, etc.

Gentle: Use appropriate language, no verbal or physical attacks, no put downs,

avoid sarcasm unless you are sure the person is alright with it, and be courteous

and non-judgmental.

Interest in others: When the person you are speaking to is talking about

something, act interested in what they are saying. Maintain eye contact, ask

questions, etc. Do not use your cell phone while having a conversation with

another person!

Validate: Show that you understand a person’s situation and sympathize with

them. Validation can be shown through words, body language and/or facial

expressions.

Easy Manner: Be calm and comfortable during conversation, use humor, smile.

In an individual session, I have the client review the “GIVE” skill sheet and then ask the client to

get one of the miniature horses to the letter “G”. I engage the individual in a discussion of how

or if they used the skills in “Gentle in Relationships” to accomplish getting the horse to the “G”.

- Client may use Gentle by petting and talking to the horse and walking to the letter together.

- Client may have used a Gentle voice tone

- Client may have used encouraging body language

I then engage the client in a discussion of how they use or can use “Gentle in relationships” with

people.

- Client may offer a friend help

- Client may use kind words

- Client may use soft body language

I follow this basic format with each of the letters for the DBT skill “GIVE”.

Additional role of the horse:

- Did client pick a “gentle horse”?

- Did a “gentle” horse pick the client?

- How did they know?

- Is horse behaving in a gentle or validating manner at any point during the processing – bring this

up!

- Is the client’s “Easy Manner or lack thereof during processing affecting the horse?

I then link these issues back to the client’s day to day life again.

Balance:

Balance continues to be an integral part of this therapy on the part of the therapist. The therapist

is balancing discussion of:

- The horse

- The client

- Transfer of skills

- The lesson plan

- Issues the client brings to the session

- What comes up (and be aware of the ‘S)!

Using “FAST” in a Group Ground session:

I hang a laminated sheet outlining the specific DBT skill at the front of the arena and laminated

letters around the arena (corresponding to the DBT acronym). I turn miniature horses loose in

the arena. The number of horses, specific horses chosen, and the availability of equipment such

as halters and lead ropes is determined by a number of factors.

These factors generally include the following:

- the clients’ equine skill level

- the clients’ judgment

- the number of adults present for the session

- the clients’ presenting clinical issues

- the energy level of the horses

- the group dynamics

FAST -

This is a skill to aid one in maintaining his or her self-respect. It is to be used in

combination with the other interpersonal effectiveness skills. This skill helps you balance

investing in yourself and others.

Fair to self

Apologize less

Stick to Your Values

Truthful with self

In a group session, I the clients to review the “FAST” skill sheet and then get one of the

miniature horses the letter “F”. I engage them in a group discussion of how or if they used “Fair

to Self” to accomplish getting the horse to the “F”.

- Clients may use “Fair to self” by using teamwork.

- Client may use “Fair to self” by asking for or getting a tool such as a lead rope.

- Client may use “Fair to self” by working alone.

- Client may use “Fair to self” by choosing an “easy” horse

I engage the clients in a discussion of how they use or can use “Fair to self” with people.

- Client may voice their feelings

- Client may set physical limits

- Client take a self time out

I follow this basic format with each of the letters for the DBT skills “FAST”.

Remember the horse and balance.

Using “IMPROVE” in an Individual Mounted Session:

I hang a laminated sheet outlining the specific DBT skill at the front of the arena and laminated

letters around the arena (corresponding to the DBT acronym).

IMPROVE the moment

This skill is used in moments of distress to help one relax.

Imagery - Imagine relaxing scenes, things going well, or other things that please

you.

Meaning - Find some purpose or meaning in what you are feeling.

Prayer - Either pray to whomever you worship, or, if not religious, chant a

personal mantra.

Relaxation - Relax your muscles, breathe deeply; use with self-soothing.

One thing in the moment - Focus your entire attention on what you are doing right

now. Keep yourself in the present.

Vacation (brief) - Take a break from it all for a short period of time.

Encouragement - Cheerlead yourself. Tell yourself you can make it through this.

In an individual session, I review the “IMPROVE” skill sheet with the client and then assist the

client to ride a horse to the letter “I”. I engage the individual in a discussion of how or if they

used “Imagery” to accomplish getting the horse to the “I”. - Client may have visualized success

- Client may have no idea what I am talking about!

-this provides an opportunity to teach

-therapist could opt to focus more on life applications

-therapist can discuss that not every question has to be answered

I engage the client in discussion about how they might use or have used imagery to regulate their

emotions when feeling overwhelmed. The client can use the immediate experience of feeling

overwhelmed getting the horse to the letter “I” or an experience from their day to day life.

- This is a good opportunity to do a mindfulness exercise or create a “safe place exercise” with

clients

-Have them notice all of the scents, sounds, feelings, motions of the horse

-Have the client try to breathe with the horse

-Have the client practice visualizing having a difficult moment and recalling this

image/safe place

Remember the horse and balance

Using “DEARMAN” in a Family Session (Ground): I hang a laminated sheet outlining the specific DBT skill at the front of the arena and laminated

letters around the arena (corresponding to the DBT acronym). I turn miniature horses loose in

the arena. The number of horses, specific horses chosen, and the availability of equipment such

as halters and lead ropes is determined by a number of factors.

These factors generally include the following: - the clients’ equine skill level

- the clients’ judgment

- the number of adults present for the session

- the clients’ presenting clinical issues

- the energy level of the horses

- the family dynamics

DEARMAN -

This acronym is used to accomplish a task or meet an objective

Describe your situation.

Express why this is an issue and how you feel about it.

Assert yourself by asking clearly for what you want.

Reinforce your position by offering a positive consequence if you were to get

what you want.

Mindful of the situation by focusing on what you want and ignore distractions.

Appear Confident even if you don’t feel confident.

Negotiate with a hesitant person and come to a comfortable compromise on your

request.

In a family session, I ask family members to review the skill sheet and then work together to get

one of the miniature horses the letter “D”. I engage the family in how or if they used “Describe

your situation” to accomplish getting the horse to the “D”. - Family may note that they relied on a family member that was familiar with horses to describe

what they should do

- Family may note that the usual leader of the family described a plan

- Family may note that they saw a horse close to the “D” and joined the horse there

- Family may note that it was difficult to describe because the situation was so unfamiliar

Next, I engage the family in a discussion about how they use “Describe your situation” in family

interactions. - This is a good time to discuss how family rules are arranged

- Discuss other situations that are unfamiliar to the family and thus difficult

- Identify other opportunities that the family has been able to use to help them such as

community resources

- Discuss when family roles are helpful or not helpful

Integrating Skill Discussion across sessions:

After teaching some of the specific DBT skills via EFP, I build discussion of the skills into future

sessions.

For example, when teaching a client to lead a horse on a lead line using correct equestrian skills,

I engage them in discussion about how they are using both GIVE and FAST. This may include:

– Using Gentle in relationships by walking with the horse not dragging them (GIVE)

-Using Fair to self by not allowing the horse to jerk the rope out of their hand to graze (FAST)

- Using Interest in others to pay attention to the horse’s body language as you lead them and

attending to the environment as the horse might see it as you lead them. (GIVE)

-Using Apologize less by sticking to the direction that you intend to go with the horse rather than

allowing the horse to drag you off to their area of interest (such as a grassy patch or another

horse). (FAST)

Of course, the next question always goes to the transfer of skills to situations outside of the

session. I ask the client how they can or have used these DBT skills with people. Whenever

possible, I use a Solution Focused lens here by asking clients to give examples of times that they

have been successful in using these skills and then asking them how they can do this more. If the

client is not able to identify times that they have used the skill successfully, their success using

the skill with the horse becomes the example of success to build on.

-Using Gentle in relationships by listening to a friend who is upset. (GIVE)

-Using Fair to self to not let the friend’s challenges or sadness ruin your day (FAST)

-Using Interest in others to pay attention to a person’s body language and words to learn more

about them and make friends. (GIVE)

-Using Apologize less by sticking to the decision not to use drugs/alcohol despite peer pressure.

(FAST)

The focus in these discussions also ties back to the original concept of balance. The client is

experientially practicing balancing “GIVE” and “FAST” as we discuss these concepts. I help

them identify how it feels in their body when they are able to balance.

Using Modified “Pony Express” activity in a ground session:

Set up: 1. Label miniature horses with emotions:

Angry

Sad

Frustrated

Embarrassed

Afraid

Happy

2. Hang DBT skills on stalls:

FAST

Fair to self

Apologize less

Stick to Your Values

Truthful with self

Half Smile

Even in the middle of a difficult situation or stress, you can probably find something to be a

little bit happy about or something that is enjoyable.

This skill is about finding at least one thing to have a small and genuine smile about. You

could hold this “Half Smile” with the stress and difficulty you are currently experiencing.

Mindfulness

Be aware of the present moment without judgment.

Let go of ruminating

Just notice your experience without getting caught in it.

Notice sights, sounds, smells, sensations

Ride the Wave

The skill is about learning that our emotions and impulses are always with us, just like the

tides. They come and go. They are strong at times and weak at other times. The tides create

waves just like your emotions. Use this skill to harness the energy of your emotions to “Ride

the Wave”. By being mindfully aware of your emotions, but not acting on them, you can

take the energy of the emotion and redirect it in a more effective manner.

Radical Acceptance

This skill is about identifying what you have control over, what you don’t have control over,

and knowing the difference between these two. (The Serenity Prayer). There are many things

in life that are out of you control, including people and the environment. What you do have

control over is yourself. You can control your thinking, feeling, impulses and behavior. It

doesn’t mean that you have to like what’s happening. It is accepting the reality of what is.

Opposite Emotion

3. Place papers with behaviors in a bucket

Hollering/Cursing

Clenching fists

Crying

Smiling

Sleeping

Laughing

Hitting

Eye rolling

Covering face

Shaking

Running

Gasping

Process: 1. Clients pick a behavior from a bucket

2. Clients get a horse labeled with an emotion that might trigger the behavior which they picked

from the bucket.

3. Clients lead the horse from the enclosure (arena/paddock). Prior to leaving the enclosure,

they discuss with the therapist how the emotion and behavior might be linked using

personal examples as clinically relevant.

4. The therapist allows the client to take the horse on to the stalls where they look over

skills and select a skill that may be more effective in dealing with the identified emotion.

5. The client goes in the stall with the miniature horse and thinks about ways they can use

the skill in their life. (Pending dynamics – you may limit 1 horse/client pair per stall)

6. The therapist visits each stall to help the client process their thoughts about the skill and

how it can be used in situations in their life.

Using Mindfulness in EFP:

Mindfulness

Have client spend some time practicing mindfulness with a horse.

Grazing sounds

Do a guided body scan or mediation with clients alongside or on a horse.

Using Half Smile with EFP:

Half Smile walk

I take the client for a walk around the stable area and ask them to identify as many half smiles as

they can. Often times just coming to the stable is a half smile for clients. If it is not many other

things are such as:

- A horse nuzzling them

- A horse making a funny face

- Horses engaging in mutual grooming

- Horses running across a pasture

Some Favorite Moments

During a family session, while working with the minis on “GIVE”, the mother was working

particularly hard to keep 3 minis who were trying to be close to her away. The family was

engaged in a discussion about “Gentle in relationships”. I observed the interaction aloud. The

mother stated that she does not like much touching. This allowed discussion about her

daughter’s perception that her mother did not feel affection for her.

During a mounted session, a tiny girl who struggled with asserting her needs in an appropriate

manner was riding a huge Warmblood. As the horse meandered across the arena ignoring her

feeble rein cues, she squealed loudly “Danger! Danger!”. The horse continued to meander

aimlessly across the arena. I asked the client how her communication strategy was working for

her and encouraged her to use a more effective strategy (such as “Dear Man”). Over the course

of a few more sessions, she was able to do this and displayed significant improvement in her

riding and assertive communication.