The Integration of Choice Theory and Equine-Assisted Therapy within Adolescent Addiction Treatment

The use of illicit substances by adolescents, between the ages of 12 to 17 in the United States of America, has continued to increase gradually each year in the past decade [1]. The 2018 National Survey on Drug Use and Health [1], depicts lifetime use of illicit substances for this age range at 23.9%, with 16.7% reported use within the past year. Among the illicit substances used, marijuana ranks the highest (15.4% lifetime use) followed by inhalants (8.5%) and opioids (7.0%). As adolescence is a crucial developmental period, the use of illicit substances increases the potential development of biological, emotional and behavioral concerns [2]. For instance, the comorbidity of physical or mental health concerns for adolescents who have used illicit substances in the previous year remains high [1], correlated with exacerbated symptomology. The implications of the increase of severity on treatment completion and efficacy proves a primary area of concern for researchers and treatment providers alike.

Previous literature emphasizes the need to refine adolescent addictions treatment towards the enhancement of treatment engagement and completion, as well as efficacy in recovery related outcomes [3,4]. While most adolescent addictions treatment programs will draw upon an eclectic treatment modality approach, there are certain counseling strategies demonstrated as more efficacious. For individual counseling modalities, motivational interviewing, cognitive behavioral therapy and contingency management strategies have been shown to have strong efficacy [3]. For group and milieu treatment modalities, strategies that emphasize personal choice, responsibility and connectedness have emerged among the most impactful for the adolescent addiction population. In particular, choice theory/reality therapy strategies have demonstrated success in improving both substance related outcomes [5], as well as psychosocial and interpersonal outcomes [6]. Despite the variety of treatment modalities demonstrating moderate efficacy, adolescents with addiction continue to disengage from treatment early into a treatment episode and overall outcomes can still improve.

Complementary counseling strategies, when integrated within a standard treatment intervention, have the potential to enhance treatment outcomes. To ensure the best results, strategy integration or combination should seek to bolster the theoretical underpinnings of the counseling interventions, thus enhancing the counseling outcome [7]. The purpose of this paper is to posit the integration of equine-assisted therapy as a complement to choice theory/reality therapy counseling strategies within adolescent additions treatment.

Choice theory and reality therapy were developed by William Glasser in 1965 [8]. The foundations of choice theory are that individuals are responsible for what they choose to do within their own lives [8,9]. Choice theory posits that people are internally motivated to satisfy one or more basic needs (e.g., survival, love and belonging, fun, freedom, power) [9]. Problem development, from the choice theory lens, exists due to a lack of meeting one or more basic need. Further, Glasser [9], attributes problems primarily to relationship satisfaction. Whereas, an individual that has unsatisfactory relationships is more prone to develop problems and those problems lead to the exhibiting of behaviors that perpetuate the dysfunction [10].

The problematic behaviors that lead to dysfunction, according to choice theory, are based around what Glasser [9], described as the seven deadly or controlling habits:

1. Blaming
2. Critizing
3. Complaining
4. Nagging
5. Rewarding to Control
6. Threatening
7. Punishing

Following the concept of personal responsibility, Glasser [9], pointed to the behaviors associated with the seven deadly habits that took attention away from the personal responsibility for the maintenance of problematic relationships. When an individual uses an external control, the focus shifts away from self on to how others are to blame, which pulls one further from making necessary changes to improve relationships. To begin working on making changes, drawing further from the deadly or controlling habit, Glasser [9], recommends replacing each deadly habit with a corresponding connecting habit. The seven connecting habits purported by Glasser are as follows:

1. Listening
2. Supporting
3. Encouraging
4. Negotiating
5. Respecting
6. Accepting
7. Trusting 

The goal of counseling, from a choice theory perspective, is to identify and change the behaviors associated with problems within their personal relationships. Drawing reflection from the deadly habits and connecting habits, individuals can make the conscious choice to engage in more proactive, positive behavioral expressions. These concepts have been successfully integrated into adolescent addiction treatment.               

The use of choice theory/reality therapy counseling strategies have been studied within the treatment of substance use disorders within adolescent populations. Moore [11], explored the use of reality therapy within the treatment of African-American male adolescent substance use disorder treatment. The recommendations from this study were consistent with Glasser’s [9], seven connecting habits. Specifically, Moore [11], found that following behaviors were associated with positive treatment outcomes: Positive regard (e.g., respect), focusing on reality of present behavior (e.g., accepting), avoiding punishment (e.g., supporting, encouraging) and planning alternative behaviors (e.g., negotiating). These results are similar to that of Mocan [12], whereas as review of reality therapy demonstrated strong evidence for its use within the treatment of substance use disorders for adolescent populations. This review further depicted interventions associated with the seven connecting behaviors as associated with the successfulness of treatment interventions. Despite these positive results, the use of choice theory/reality therapy as a stand-alone intervention remains susceptible to higher levels of treatment drop-out/non-completion and lower efficacy rates among adolescent addiction populations [13].

Equine-Assisted Therapy (EAT) is part of a larger umbrella of Animal-Assisted Interventions (AAI). As a group, AAI are defined as goal driven intervention(s) that intentionally incorporate an animal for the purpose of therapeutic gain in humans [14]. For psychotherapy purposes, the introduction of AAI are used as an adjunctive therapy, as a means of complementing another counseling intervention or strategy. The choice of an equine as a therapeutic partner, as opposed to other animal species, allows for unique therapeutic qualities and possibilities. Equines have the ability to perceive, respond to and learn from their environments [15]. The perceptual keenness provides rich data within a counseling session, as well as unique experiences between client and equine. Further, as a herd animal with sensitive fight-flight responses, equines interact with the environment (e.g., clients in session) timidly and intentionally [15]. Interaction with a therapy equine has demonstrated positive influences on health and psychosocial outcomes [14]. For example, studies have demonstrated a reduction in cortisol levels (e.g., reduced stress), regulation of heart-rate (e.g., self-regulation) and increase interpersonal alliance or rapport (e.g., bond development) [16].               

Equine-assisted therapy has also been examined within the treatment of adolescent addiction. The integrations of horses as part of the treatment of addictions is particularly powerful as individuals with use disorders often demonstrate feelings of fear or reluctance to engage in treatment due to stigmatizing experiences in their environment [17]. Horses do not judge based on past behaviors, rather they evaluate and respond to the here-and-now behaviors. Once a bond is developed with a horse, the focus on the here-and-now behaviors helps clients to reduce the resistance to treatment engagement, as the fear of judgement and past experiences become less prominent [17].               

The integration of EAT within adolescent addictions treatment has also demonstrated an increase in treatment completion rates. Kern-Godal et al. [18], examined the impact of an EAT program integrated into standard inpatient and day treatment services for youth over an 18-month treatment period. The results of their study found a significant association between participation in the EAT group and successful treatment completion. Participants in the EAT group were significantly more likely to remain in treatment for over 90 days as compared to the treatment as usual group. This is an important finding as research demonstrates that early drop-out of treatment is highly correlated with relapse and other negative outcomes related to substance use disorders [3]. The influence of EAT on emotional status, attachment/bonding and connectedness [19], helps to interpret how integrating EAT within standard treatment can enhance engagement and treatment outcomes.

Successful outcome rates within addictions treatment, while improving, remain lower than other behavioral health disorders [1]. In 2018, an estimated 946,000 or 3.8% of adolescents aged 12 to 17 years needed treatment for a substance use disorder and related symptoms. However, data estimates only approximately 159,000 of adolescents received services, yielding a 16.8% treatment entry rate [1]. To further compound the concern, of those adolescents who do enter treatment, approximately 55-65% would complete [20]. To enhance the potential for treatment engagement, completion, and efficacy of adolescent addiction treatment, innovative approaches are needed.

One such innovative treatment strategy is the integration of EAT within a choice theory/reality therapy-based treatment program for adolescents with substance use disorders. While choice theory/reality therapy has been demonstrated to be effective with an adolescent population [12], the nature of resistance and disengagement that is associated with adolescence has a negative impact of the quality of treatment. Integrating EAT as a complement to choice theory/reality therapy offers an essential buffer for the client – counselor dynamic, often where resistance stems. Further, the bond development between client and equine often transfers to the client – counselor relationship, providing additional reduction of resistance and disengagement.

Table 1 depicts a suggested method of integrating choice theory/reality therapy and EAT. In this model, the connecting habits put forth by Glasser [9], as a desired behavior, as compared to deadly behaviors, are paired with both a therapeutic goal and an equine goal. Of note, the authors chose to combine accepting and trusting habits, as the overlap would be integrated into the interventions. The therapeutic goals for this model reference the desired learning and demonstration of behavior from the adolescent client upon completion of the intervention. Each therapeutic goal ties directly to the associated connecting habit. The equine goals for this model reference the desired interaction between client and equine. The recommended equine goals are based on previous literature demonstrated the connection between client-equine interaction and desired outcome [14-16,18]. 

Table 1: Integration of Glasser’s 7 Connecting Habits and EAT Interventions.

As the prevalence of adolescent substance use disorders continues to rise, there exists a need to augment the current treatment modalities and strategies to improve treatment outcomes. In particular, complementary interventions and strategies that aim to enhance the treatment experience towards increasing treatment engagement and completion, as well as efficacy. As discussed in this review, the integration of EAT within a choice theory/reality therapy-based treatment strategy demonstrates strong promise. Research has demonstrated the integration of EAT within adolescent treatment for mental health and behavioral addiction concern to be successful, particularly related to treatment engagement [13]. Focusing treatment on the underlying behaviors and relational skill develop, as conducted through choice theory/reality therapy, adolescents are building upon skills that transcend just the cessation of substance use. Positive, prosocial relational skills are necessary for long term, sustained recovery. The proposed treatment method aims to build relational skills within a treatment environment that is perceived as less threatening or judgmental and which enhances engagement and rapport development.

None to declare.

Author’s own resources.