Methods The Development of a Cognitive-Behavioral Equine Facilitated Therapy for Children and Adolescents with Anxiety Authors: Mary Acri, PhD; Meghan Morrissey, LCSW; Emily Hamovitch, MPH, MSW; Kimberly Hoagwood, PhD Author Background Process Equestrian School Psychology Social Work Choose population Literature review Regularly scheduled meetings Seek Best Supported Research 118 Protocols 91 Papers 44 Practice Elements PracticeWise “offers innovative tools and services to help clinicians and organizations improve the quality of health care for children and adolescents” Literature Database of Clinical Trials https://www.practicewise.com Search Criteria: ages 2-19 symptoms of anxiety Caregiver Psychoeducation Relaxation Client Psychoeducation In Vivo Exposure 40% 44% 56% 66% 92% Cognitive Skills Of the 44 Practice Elements, 5 elements existed in over 40% of protocols, so authors focused on using those 5 elements to develop into session Department of Child and Adolescent Psychiatry

Intervention - Content Session Goals (mapped from recommended 5 practice elements) Exposure, Cognitive, Client Psychoeducation, Relaxation, & Caregiver Psychoeducation Session 1: CBT Components Build rapport Gather information regarding rider mental status, severity of anxiety, and horsemanship skill Psychoeducation about identification and connection between thoughts, feelings, and behaviors Session 2: CBT Anxiety Focus Normalize anxiety Identifying different types of alarms Gather information about anxiety provoking situations specific to each rider. Session 3: Relaxation Techniques Learn/practice relaxation techniques Learn about horse communication aids Session 4: Review Review all materials/skills in case of missed sessions Session 5: Fear Ladder Finalize Fear Ladder Scenarios that are specific to rider anxiety Scenarios are rated by rider and include 1-10 range of intensity Session 6: Thought Changing Learn/practice thought stopping/changing technique Session 7: Cognitive Distortions Identify fortune-telling thoughts & mind reading thoughts Practice thought changing with rider specific scenarios Session 8: Identify catastrophic thoughts & filtering thoughts Session 9: Problem Solving Learn/practice problem solving steps Session 10: Termination Celebration and Maintenance Review all skills learned Identify/highlight growth areas Identify ways to maintain/generalize skills Flexible to horsemanship skill Provides modification suggestions Provides therapeutic stance for scaffolding, priming, and collaboration Skill building with goals and objectives Exposure and habituation Building a fear ladder specific to personal scenarios that evoke anxiety throughout the entire intervention Fear ladder is useful tool to caregivers as well as traditional therapist In-Vivo Exposure throughout 8 sessions changed to 10 sessions To accommodate possible missed session = added review session To align with study site programming Adjusted from individual to group format

Intervention - Structure Review previous session/homework & Contain any crisis Review 5 Minutes Mount Warm Up Activity 15 Minutes Homework Instruction Caregiver Psychoeducation Cool Down & Dismount Unmounted Time = 15 Minutes Mounted Time = 30 Minutes Start Horse Skill Building Mental Health Skill Building Journal with basic review and homework (progressively more) Depending on how many riders you have, this could take less time Facilitate riders communicating learned material with caregivers Important for generalization to community Models good communication skills Primes caregivers to coach riders though homework Physical warm up (both horse and rider) + Mental warm up (continued review of horsemanship & mental health skills) 45 Minutes Total *can be adjusted Activities include both horsemanship skill building and mental health skill building Scaffold and modify as needed Cool down horse + Rider mindfulness or relaxation exercise Dismount