Conceptualization of Psychotherapy Incorporating Equine Interactions in the United States

While several systematic and mapping reviews have been published in the last decade on the psychological effects of interacting with horses in therapy services, little has been written about how licensed mental health therapists in the United States should best understand, describe, and conceptually position interactions with horses within their clinical practice. To this end, a healthcare-aligned conceptualization of equine interactions in psychotherapy and counseling is presented. Drawing from competencies and statements published by the American Counseling Association and the Human-Animal Interaction section of the American Psychological Association, the proposed conceptualization describes interactions with horses during psychotherapy as a technique and enhancement to existing treatment approaches, not as a standalone intervention or therapy. Additionally, the conceptualization aligns with legal and ethical responsibilities, and the professional identity of the licensed mental health therapist. The proposed conceptualization emphasizes the importance of using science-based information about horses so that their role and function in psychotherapy sessions can be more accurately understood. The conceptualization is proposed to have positive effects on the day-to-day practice of licensed mental health therapists in areas such as professional communication, treatment planning and provision, and engagement with healthcare processes such as service coding, reimbursement and insurance. The conceptualization could also be of use in research efforts as it clarifies how horse interactions should be understood in the context of treatment, which, in turn, affects research design. Use of the proposed conceptualization may help safeguard clients, other stakeholders, horses, and the licensed mental health therapists who incorporate interactions with horses in the provision of psychotherapy.

Issues related to understanding, describing, and conceptually positioning equine interactions within mental health treatment carries consequences for therapists, healthcare systems, clients, researchers, and the public. In this paper, I propose a healthcare-appropriate conceptualization of equine interactions in psychotherapy that aligns with legal and ethical responsibilities of licensed mental health therapists.
In the United States, a licensed mental health therapist may include interactions between a client and a horse in the provision of psychotherapy or counseling. However, no standardized way of how the therapist should conceptually and clinically position these equine interactions within the therapy service exists. How should a licensed mental health therapist think about the nature of interactions with horses in their treatment planning, when they are documenting and coding services, and relative to their professional identity as a healthcare professional? No agreement currently exists about the role and function of the horse during psychotherapy and what the therapist should be doing for the interactions to be therapeutic and intentional. In addition, horses are incorporated into other human service settings, such as into other therapies and into nontherapy areas such as education and learning, with risk of confusion as to the service provided. There has also been much variation in the terminology used to describe horses as part of psychotherapy. Terms such as equine-assisted psychotherapy, equine facilitated psychotherapy, equine-assisted therapy (Eagala, 2015;PATH Intl., n.d.), or the colloquially shortened equine therapy, have likely contributed to conceptualization issues for therapists, clients, and other stakeholders (Wood et al., 2021). For instance, should the term equine-assisted psychotherapy be understood as describing a service separate from psychotherapy? Or, should equine-assisted therapy be compared and contrasted with well-established treatment approaches such as cognitive behavioral therapy (CBT)? These issues, combined with a lack of knowledge about how horses think and communicate, have likely contributed to portrayals of horses as "healers" in healthcare (White-Lewis, 2020). Proposing that the horse provides treatment is neither scientifically accurate or legally appropriate, and is incompatible with practice standards and ethics of licensed therapists (Human-Animal Interactions Ethics Workgroup, n.d.) The conceptualization presented in this paper aligns with the professional identity of licensed mental health therapists and the healthcare settings in which they work. This conceptualization positions interactions with horses during psychotherapy as a technique available to the therapist to tailor the session to the client's treatment goals, and, as such, constitutes a possible enhancer to the therapy process. The conceptualization also separates general horse activities, which can be found in recreation, sport, and during riding and horsemanship instruction for people experiencing barriers to taking lessons in non-adapted settings, known as adaptive riding or therapeutic riding, from the way a licensed mental health therapist skillfully incorporates elements that arise from interaction with horses into the psychological treatment approaches they use.
The first part of the paper elaborates on the proposed conceptualization in the context of professional identity, competencies, and responsibilities of licensed mental health therapists. The necessity of separating horse interactions in healthcare settings from horse interactions in recreation and sport settings is also discussed. The second part of the paper focuses on healthcareappropriate elements that the mental health therapist can intentionally apply when conceptualizing equine interactions as a treatment technique in a psychotherapy session. Dynamics of power and other ethical considerations are also discussed. The final part of the paper proposes benefits of using the conceptualization for both clinical and research settings. In this paper, horse and equine are used interchangeably to mean horses, mules, and donkeys.

Separating Horses in Recreation and Sport from Healthcare
Early accounts of horses and human health from the second century CE into the mid-1900s primarily focused on the effects of horseback riding in leisure settings (Bain, 1965). Not surprisingly, horse activities in recreational settings have been reported to enhance wellness (Davis et al., 2014). Positive physical and mental effects from equestrian pursuits are recognized by countries like Sweden where activities such as taking riding lessons or trail riding in a group can be considered a preventative health benefit and paid for by an employer (Swedish Equestrian Federation, 2018). Adaptive riding and horsemanship instruction for people with physical and cognitive disabilities or conditions is commonly referred to as therapeutic riding in the United States, even though it involves recreational and sport-related goals relative to riding and horsemanship in an adapted environment (Certified Horsemanship Association, 2020, PATH Intl., 2020. While sayings such as "my horse is my therapist" are popular (Davis et al., 2014), there are aspects of recreational horse activities and the horse industry that counteract well-being. Riding and interacting with horses are considered high-risk activities based on accident and injury rates. In fact, activities with horses rank above motorcycling and skiing in risk of injury (Thompson et al., 2015). Socio-economic status and other barriers exist in accessing horses for recreation and sport, and there have been recent pressures in the United States to acknowledge widespread racism in the equine industry (Pells, 2020). Equestrian sports and activities are also not exempt from sexual misconduct and other abuse (Pells, 2018). The mental health impacts of witnessing abusive training practices and violence against horses, often intersecting with the above-mentioned issues, are also increasingly brought to light, both in research and personal accounts (Butler-Coyne et al., 2018;Dennis, 2019). As such, it is not reasonable to assume that horse activities in general would automatically improve mental health in any given person.
A healthcare-aligned conceptualization of the horse in psychotherapy relies on the understanding that horse industry activities such as owning, riding, or simply being around horses are distinctly different from how a qualified mental health therapist incorporates elements of equine interactions into treatment in a skillful and intentional manner. Positioning the horse as a treatment or as a kind of therapist, a conceptualization different than the one presented here, is not scientifically accurate, legally appropriate, or compatible with practice standards and ethics of licensed mental health therapists. Neither is promoting horse interactions, such as those found in recreation or sport, as a separate form of therapy or comparable to existing clinical treatments.

Understanding the Conceptualization in the Context of Professional Identity, Competencies, and Responsibilities of Mental Health Therapists
Each of the six mental health professions who provide psychotherapy in the United States have a clear and legal determination of how practice is conceptualized, what education is needed for the professional title, and the actions required to qualify for and maintain the applicable professional license. Each profession has ethics and practice standards, which include appropriate ways for the therapist to add areas of competence to their practice. Practice standards for these professions typically specify that education, training, and supervision or consultation is needed in any new area of practice that falls within their scope (see e.g., American Association for Marriage and Family Therapy, 2015). As such, the licensed mental health therapist's profession, scope of practice, practice standards, and areas of competence are emphasized in the healthcare-aligned conceptualization of equine interactions in psychotherapy presented in this paper.

Professional Identity
The development of professional identity is a key part of graduate and post-graduate experiences for mental health therapists and involves integrating professional roles, behaviors, attitudes, and values with one's personal identities (Auxier et al., 2003). In the process of becoming guided by theory, concepts, and principles of professional helping, emerging practitioners learn about existing treatment theories and therapy approaches, and develop some kind of alignment with or definite commitment to specific ones (Rønnestad & Skovholt, 2003). A key issue in conceptualizing horse interactions as part of psychotherapy is understanding how to accurately position them within the context of existing treatment theories and approaches.
When referring to treatment that includes animal interactions, the profession held by the provider defines the service provided, not the fact that an animal is included (Stewart et al., 2016). A therapy-first approach is important when conceptualizing the inclusion of equine interactions in psychotherapy and is promoted in a recent terminology-focused publication about horse interactions in various services (Wood et al., 2021). The therapist should work with the populations, the treatment approaches, and frameworks within which they have training, and for which they have received supervision or consultation, also when including interactions with animals into their work. Similarly, the therapist should lead with, and be clear about, the kind of therapy service they provide, and also take care to not imply that the inclusion of horses constitutes a separate treatment or intervention. Using descriptors such as equine therapist or equine-assisted therapist for the mental health therapist who includes equine interactions in their work may create confusion about professional identity for the public and for the clinician themselves. These descriptors do not clarify which of the six mental health professions that the therapist belongs to and may imply that including horses in treatment constitutes a separate profession. Even if the licensed mental health therapist actively recognizes the value of human-animal interactions in several aspects of their professional role (Arkow, 2020), using a descriptor for the therapist that leads with mention of the horse obscures the fact that interactions with horses (not the horse themselves), is one of many treatment techniques or tools that the therapist may use during a session, and as a part of the client's treatment arc. Therapy techniques are used within the therapist's chosen frameworks and treatment approaches (American Psychological Association, 2017). To appropriately incorporate equine interactions in psychotherapy, the licensed mental health therapist leads with and centers their professional identity, as defined by their profession, and positions the interactions with horses as a technique within the treatment approaches they use.

Competencies
In 2016, the American Counseling Association (ACA) published a competency document specific to the inclusion of animals in clinical mental health counseling (Stewart et al., 2016). This document provides helpful conceptual guidance for understanding psychotherapy where equine interactions are included. The ACA competency document details knowledge, skills, and attitudes needed for competent inclusion of animal interactions in treatment. The need for formal education, training, and supervision is emphasized, which is aligned with typical practice requirements for new areas of competence. The specialized skillset of including animal interactions integrated within the mental health therapist's theoretical approach to psychotherapy is described, including therapist responsibilities to their own professional development in this area, to their clients' experiences and preferences, and, importantly, to the animals that they incorporate in sessions. A need for in-depth, species-specific knowledge of the animals that the therapist works with is described, and the ability to attend to both client and animal needs simultaneously so that the relational exchanges that occur during sessions are appropriate for a treatment environment. Most importantly, the competency document clarifies that the inclusion of animal interactions in psychotherapy is not a standalone intervention, but a way to enhance the therapeutic process.
Section 13, Division 17 of the American Psychological Association (APA) focuses on Human-Animal Interaction (HAI). A workgroup within the section has provided a summary statement related to APA ethical standards when animals are incorporated into interventions. The document is similar to that of the ACA and specifically states that animal interactions are an enhancement to the treatment process rather than as a stand-alone intervention (Human-Animal Interactions Ethics Workgroup, n.d.) Based on guidance from the ACA competencies and the APA HAI section summary statement, interactions with horses as part of psychotherapy can be conceptually understood as an enhancer to treatment, not as a distinct, separate, or standalone form of treatment. The profession of the therapist providing psychotherapy, along with the theories and treatments that suit them and the clients with whom they work remain at the core of treatment planning, provision, and documentation of services. If having sought formal education, training, and supervision or consultation specific to the inclusion of horses in psychotherapy, the therapist can assess whether specific elements arising from interactions with horses have the potential to enhance the therapeutic process for the specific client. Interactions with horses is one of numerous techniques and tools that therapists use within the treatment approaches they employ, and should be tailored to the different populations with whom they work. This conceptualization is also promoted by the American Hippotherapy Association (AHA Inc.) for other healthcare professions. The AHA represents physical therapists, occupational therapists, and speech-language pathologists who incorporate equine movement within their respective scopes of practice. The association emphasizes a conceptualization of equine movement as a treatment tool in the context of the therapies these healthcare professions provide, and as part of a larger plan of care (American Hippotherapy Association, 2020), In order to align with existing competencies and practice standards, licensed mental health therapists should integrate equine interactions into the therapy approaches they are already providing, and with client populations that they are experienced working with. It is not appropriate for mental health therapists to view the inclusion of equine interactions in psychotherapy as a completely different way of working with clients or assume a therapeutic stance during those sessions that differs from what they typically do.

Responsibilities
Respect Client Preferences and Needs. Client preferences and values, one of the three pillars of evidence-based practice (Sackett et al., 2000), should be central to the licensed mental health therapist's decision whether to include equine interactions in treatment. Flexibility in implementation of treatments that have evidence of effectiveness, while maintaining fidelity to the principles of the treatment, is emphasized in evidence-based psychotherapy and can be accomplished through use of different techniques (Cook et al., 2017). If the client is not interested in interacting with horses, or express that they benefit most from only interacting with the mental health therapist, the therapist can continue treatment without equine interactions when using the conceptualization presented here. Similarly, if barriers related to weather or horse availability become apparent prior to or during a psychotherapy session, the client can still receive treatment as the mental health therapist can choose to engage other techniques in the therapeutic process. This mindset is also helpful in cases where contraindications for treatment are present. If the client has severe allergies to horses, or if their capacity to self-regulate is not sufficient for ethical interactions with horses, the mental health therapist can use representations of horses instead of live horses in treatment, or find different ways to engage the client that are also experiential and outside of the traditional indoor treatment setting. Interactions with horses might not be part of every therapy session. The mental health therapist may decide to engage the client experientially with a specific issue in mind through equine interactions only during some sessions, or may conduct all sessions near or directly with horses. Therapists should carefully consider the setup in their physical treatment environment so that interactions with horses becomes an option for the client but is not presented as an expectation for treatment.
Focus on the Therapeutic Alliance and Relationships. The therapeutic alliance between client and mental health therapist is one of the most consistent contributors to treatment outcomes, independent of the type of treatment provided (Norcross & Wampold, 2011). Interactions with horses in treatment should therefore be provided in a way that also facilitates the relationship between the client and the therapist in a positive manner. The mental health therapist needs to consider the inherent power asymmetry that exists between them and the client in the therapeutic relationship (Boyd, 1996), and the substantial power differences that exist between humans and horses (Wadham, 2020). Attention to the vulnerability of both clients and horses may mitigate the potential of harm and exploitation during the session (Stewart et al., 2016). The kind of relational exchanges with horses that the mental health therapist promotes may be important for clinical outcomes. Horses could be positioned in more objectified and utility-focused roles in order to be part of a therapeutic task, or the mental health therapist could promote relational commonalities and mentalizations of the horses' experiences during interactions. Carlsson and colleagues (2015) investigated client outcomes when the horse was positioned more as a task-related object, and when they were positioned as a subject and relational partner. They found that it was necessary for both staff and clients to interact with the horse as a subject in order to access the emotional outcomes promoted in the treatment (see also Carlsson, 2017).
Psychotherapy involves therapeutically helpful and intentionally non-harmful relational exchanges between mental health therapists and clients. As such, interactions between the mental health therapist and the horse, the client and the horse, and, if other non-therapy personnel are present, between them and the horse, should also encompass these qualities. If the mental health therapist is trauma-informed in their practice, it is reasonable that these principles should extend to all parts of the treatment environment, including in interactions with horses. Licensed mental health therapists who maintain alignment with their professional values in all aspects of the therapeutic environment neither plan for nor allow activities or interactions to take place during a treatment session that cause clients or horses undue stress, disregard their individual preferences and capacities, or activate the defense cascade (Kozlowska et al., 2015).
Communicate Accurately about Treatment. Using appropriate descriptors of interactions with horses in psychotherapy is essential in all professional communication by licensed mental health therapists. It is important that clients understand why interactions with horses may benefit their treatment, and how these interactions should be understood in the context of treatment goals. The conceptualization presented here helps provide therapists with language to describe the role of equine interactions in treatment, without misleading the client. Since equine interactions are understood as a technique to enhance existing treatment approaches, the therapist can use plain and science-based language to describe just that. If the focus is inappropriately placed on the horse as a kind of therapist, it can lead to use of terms such as equine therapy or equineassisted psychotherapy (Wood et al., 2021). Such terms can create confusion for the client about what is taking place during treatment.
Clinical records generated by the licensed mental health therapist, such as informed consent documents, treatment plans, and progress notes, must be kept accurate, coherent, and timely (Luepker, 2012). Any mention of interactions with horses in client records should specify that they constitute a treatment technique in service of particular client goals and within a specific treatment approach, not as a separate therapy. Licensed mental health therapists should avoid using terms in clinical documentation that inaccurately position the horse as central to the provision of psychotherapy.
Seek Science-Based Equine Information. In following the process of evidence-based practice (Parrish, 2018), licensed mental health therapists should seek out the best available scientific information about horses and use it to inform interactions during therapy. For equine interactions to be included in treatment in a competent way, mental health therapists need comprehensive and accurate knowledge of horses and their behavior, needs, and communication (Stewart et al, 2016). However, Kieson and Abrahams (2016) found no standards for understanding equine behavior in four large U.S. organizations that provide training to mental health therapists to include horses in psychotherapy. While no studies to date have evaluated the capacity of mental health therapists to correctly asses affective states in horses, misinterpretation of behaviors and lack of awareness for pain and stress is possible, based on outcomes of studies with horse-owning populations, equine professionals, and self-pronounced horse experts (Bell et al., 2019;Hockenhull & Creighton, 2012;Lesimple & Hausberger, 2014). When a therapist's equine knowledge is not based on scientific information, appropriate conceptualization of the horse's role in treatment may fail. In these situations, the best-case scenario is that the possible usefulness of the interaction decreases, the worst case is that the client and the horse become subjected to high levels of physical and emotional risk. Mental health therapists may need to carefully evaluate their personal beliefs and perspectives on horses, such as tendencies to either overestimate or underestimate horses' cognitive capacities, to avoid any unintended consequences for treatment experiences.
Mitigate Risk. The licensed mental health therapist is legally and ethically responsible for the treatment session whether additional, non-therapist personnel are present in the session or not. Mental health therapists who incorporate equine interactions in psychotherapy may consider including support personnel if the setting is logistically complex, such as working with groups or if positioning the client on the horse's back, but must still be knowledgeable about horses and have the ability to attend to both the client and the horse (Stewart et al., 2016). It is not ethically appropriate for a licensed mental health therapist to include equine interactions in psychotherapy without formal education and training on equine behavior, communication, and needs. The need for a non-therapist person in the session, such as a horse handler, should only arise out of logistical challenges or preference, not because the mental health therapist lacks knowledge about horses and needs an assistant in order to conduct the session. The presence of additional persons in the treatment session should be carefully considered in light of the potential impact on the therapeutic alliance, especially if the mental health therapist is working with an individual client.
Mitigation of risk when equine interactions are included in treatment should align with the ethics of healthcare practice. Licensed mental health therapists should strive to increase comfort and decrease risk for all involved in sessions, including the horse. Appropriate and science-based equine knowledge coupled with careful selection, assessment, and work role preparation of horses involved in sessions should reasonably mitigate risk between clients and horses. So should providing the client with relevant and accurate equine information in order for them to engage relationally with the horse. It is the licensed mental health therapist's responsibility to monitor and manage interactions, track affective states, and continuously assess handling and touch between the client and the horse (Ekholm Fry, 2021).

The Conceptualization Applied to Practice
The proposed healthcare-aligned conceptualization of equine interactions in psychotherapy positions the interactions as a technique or tool that the licensed mental health therapist can use during a treatment session with the purpose of enhancing treatment outcomes. As such, it is important to explore the therapeutic elements that may arise from such interactions and how the mental health therapist can intentionally apply them during sessions and in session planning.

Possible Enhancing Elements for Treatment
A number of studies have explored the elements arising from human-horse interactions as part of psychotherapy in order to establish some kind of theoretical foundation. Studies have focused on practitioner experiences (Dezutti, 2013;Johns et al., 2016;Lee & Makela, 2015;Lee & Makela, 2017;Nieforth & Craig, 2020;Traeen et al., 2012;Wilson et al., 2017), client experiences (Dunlop & Tsantefski, 2017;Meyer & Sartori, 2019;, and theoretical applications (Bachi, 2012;Bachi, 2013;Brandt, 2013;Carlsson et al., 2013;Karol, 2007;Kieson & Abramson, 2016;Lac, 2016;Siporin, 2012;Vincent & Farkas, 2017). Multiple doctoral dissertations have also been dedicated to this topic. In addition, several reviews of psychological outcomes from equine interactions have been published, which include proposed theoretical foundations, but only a few of these of these are specific to psychotherapy (Cantin & Marshall-Lucette, 2011;Carlsson, 2016;Kovács et al., 2020;Lee et al., 2016;Lentini & Knox, 2015). Conceptual challenges are present in these reviews which affect their usefulness. In addition to issues related to conceptualization and service identity previously discussed in this paper, there exists great variety in conclusions reached regarding theoretical underpinnings or the presence of psychologically relevant elements. However, a few general categories can be proposed from the literature to drive further research and clinical application: • Setting/environment o The treatment setting, which is often outdoors and in nature, can help facilitate a more relaxing environment for therapy if the setting and the horses and other animals who are in it are calm and in good health. The setting can also provide additional flexibility in the structure and pacing of the session.

• Touch and movement
o The size and large touch surfaces of horses provide functional opportunities for the client to engage with their bodies and senses. • Relational aspects o A non-human relationship can bring new relational experiences, additional social interactions and sense of support, opportunities for caregiving behaviors, self-awareness, and emotion regulation. There is also potential to strengthen the therapeutic alliance between client and therapist, mediated through interactions with horses, and for the therapist to use comparative psychology and health concepts in psychoeducation.

• Experiential engagement
o The opportunity to practice and reflect on relational exchanges, to try new behaviors and thoughts, have new experiences, and work with tangible representations of issues experientially facilitated during the session can make sessions and the therapeutic content more engaging for clients.
In reviewing commonly referenced theories for the purpose of including animal interactions in therapy (summarized by Fine, 2019) and research on the effectiveness of psychotherapy (American Psychological Association, 2012), I propose four broad reasons why a clinician may decide to include equine interactions in psychotherapy: 1. To provide additional motivation for a person to seek treatment and remain in treatment 2. To increase client engagement in their own treatment 3. To facilitate early rapport building and to strengthen the therapeutic alliance between the client and the therapist 4. To enhance therapy approaches and interventions through introducing additional elements and options for the therapist to apply in treatment It is important to note that these elements and categories are presented in order to assist conceptualization of equine interactions in psychotherapy and to guide further research. Scientific evidence about their effectiveness remains inconclusive due to the lack of well-conceptualized and rigorous studies in this area (Serpell et al., 2017).
Accounts of equine interactions in psychotherapy commonly portray the horse as uniquely positioned to help humans in therapy and describe ways that horses provide treatment (Frewin & Gardiner, 2005). This conceptualization centers the horse, not the healthcare service provided. There is, however, no evidence that horses possess special traits outside of those found in other social mammals for this purpose (Beaver, 2019). Horses are social herbivores and have been an intimate part of human history due to their ability to perform complex behaviors under human control (Bennett & Hoffman, 1999). Their social and emotional features, like those of dogs and cats, enable them to recognize familiar humans (Lampe & Andre, 2012) and respond to human facial expressions (Baba et al., 2019;Proops et al., 2018;Trösch et al., 2019). While equine sensory systems are adapted to facilitate early detection of potential threats and to engage avoidance strategies, such as masking emotions, horses respond to situations based on individual factors such as their temperament, breed, training, history, welfare status, and current experiences (Beaver, 2019; Hall et al., 2018). There is no scientific evidence supporting the notion that horses understand complex human concepts and situations, such as psychotherapy, and that horses would specifically act in response to the client's treatment goals (Brubaker & Udell, 2016;Trösch et al., 2019). Despite this, anecdotes from clinical work tend to focus on unlikely causations, such as a horse defecating when a client verbally expresses that they want to let go of something, or a horse in a group session identifying a client with an unresolved emotional issue by touching them on a specific place on their body or pushing them over. By emphasizing what Nieforth and Craig (2020) categorize as atypical behaviors as the reason for including equine interactions in psychotherapy, incorrect conceptualizations arise about horses themselves and about the process of psychotherapy.
In addition, placing great importance on the categorization of horses as prey animals, especially in their relationship with humans, may lead to notions about horses that do not align with their actual domesticated reality (Goodwin, 2002) nor with the mechanisms of psychotherapy. It may be more helpful to highlight commonalities between humans and horses, instead of differences, especially when clients are meant to practice relational skills or when mental health therapists use comparative psychology in psychoeducation.
Overall, it may be more useful to emphasize the ways humans perceive horses, such as the belief that animals are non-judgmental (Chandler, 2017), and a focus on non-verbal communication as contributing to therapeutic benefit instead of the horse themselves. The size, versatility, and the simultaneous familiarity and otherness of horses as a domesticated animal are possible unique factors (Birke & Thompson, 2018). In psychotherapy, it is the skill of the mental health therapist that facilitates the potentially enhancing benefits of equine interactions, not the horse.

Use of the Conceptualization in Session Planning
Interactions with horses in psychotherapy takes place within the therapeutic approaches the licensed mental health therapist uses to support their client's treatment goals and needs. Therefore, it is important for mental health therapists to not think of interactions with horses as activities around which to center the session, but instead consider whether the elements arising from equine interactions and the equine environment, which are mostly experiential, relational, and somatic in nature, could enhance therapeutic intentions and the content of treatment. Instead of thinking of things to do with horses during therapy sessions, licensed mental health therapists using the conceptualization presented in this paper intentionally apply elements arising from interactions with horses during treatment, such as the opportunity for experiential engagement with an issue in the client's life, or the purposeful facilitation of a relational element such as caregiving between the client and the horse. Session planning using the conceptualization does not center the horse but does include careful consideration of the horse's experiences throughout the session. In accordance with the therapist responsibility of focusing on the therapeutic alliance and relationships discussed earlier in this paper, session content should provide therapeutically helpful and non-harmful relational exchanges between clients and horses.

Additional Ethical Considerations for Practice
Licensed mental health therapists should carefully evaluate whether practices common in the horse industry are suitable for the context of their treatment environment and they should resist suggestions from horse professionals that involve violence and punishment of horses (McLean & Christensen, 2017). It is worth noting that best available, scientific information about horses may not always align with common equestrian practices. For instance, mental health therapists should be careful not to promote dominance and leadership concepts commonly referenced in equestrian settings but which are not supported by research (Hartmann et al., 2017). Doing so may create modeling for clients that has no therapeutic benefit for human-to-human interactions. An example of this is asking the client to make a horse run inside a round enclosure without much instruction to the client of how to do so as a way to create a sense of accomplishment or problem-solving for the client. The therapist should carefully deconstruct their reasoning for including activities in treatment sessions from both power and privilege perspectives, and from a client relational learning perspective. If the horse is positioned as a relational partner, are there unintended consequences of presenting activities that emphasize dominance over the horse when there is already a power difference in the relationship, and do such activities clearly enhance therapy without compromising the ethics of the treatment environment?
Mental health therapists can make use of their understanding of human behavioral change, stress, and trauma in their interactions with horses to ensure an appropriate treatment environment for all present. For instance, typical human-horse interactions, such as grooming, may not take into consideration the length, frequency and kind of body care activities that the horse prefers (McGreevy, 2012). In order to align with relational goals and processes for clients in psychotherapy, areas such as boundaries, preferences, and body integrity, may need to be considered more carefully for horses in the psychotherapy setting. Relatedly, the practice value of social justice for mental health professions (e.g., American Counseling Association, 2014; National Association of Social Workers, 2017), may also need to be understood in the broader context of human-animal interactions. This can be accomplished by applying a trans-species social justice framework to psychotherapy services where animal interactions are included (Matsuoka & Sorenson, 2014).
A consideration for licensed mental health therapists who include equine interactions in psychotherapy is that sessions typically take place in or near where the horse spends most of their time, thus exposing the client to the horse's living conditions. While the outdoor setting is often considered a positive reason for including horses in treatment, it is worth noting that many horses are deprived of basic needs such as access to fiber, movement, and the opportunity to form close social bonds with other horses due to the design of their living environments (Hartmann et al., 2012;Hausberger et al., 2009;Lesimple et al., 2016;Murray & Eichhorn, 1996;Ruet et al., 2019). Questionable living standards that may be normalized for a person working in the horse industry, such as small enclosures or long periods separated from other horses, may not be comfortable to witness for the client, and may lead to statements such as, "this is my paradise, but I don't think it's theirs" (Ekholm Fry, 2017, p. 125). Since licensed mental therapists are responsible for their treatment environment, they should consider whether conditions for horses and other animals at the location where psychotherapy is provided align with their overall practice values.
Licensed mental health therapists need knowledge and experience with horses in order to competently include equine interactions in their treatment. As such, it is important to consider that systemic barriers to accessing horses and horse settings exist. Racism and the lack of diversity in the equine industry has been increasingly brought to light in the past years (Pells, 2020). Influential organizations such as the United States Equestrian Federation (2020) now have diversity and equity action plans to promote more inclusive equestrian environments. Inequities in access to equine environments affect Black and other underrepresented mental health therapists in particular, and may, in turn, determine which therapists include equine interactions in psychotherapy and which clients receive psychotherapy services in this setting.

Benefits of the Conceptualization and Next Steps
The healthcare-aligned conceptualization of equine interactions in psychotherapy presented in this paper will likely be beneficial in two broad areas: in healthcare and in research. By using the conceptualization presented here, licensed mental health therapists in the United States can better work within the legal and ethical frameworks of their professions. In addition to benefitting the mental health therapists who are using the technique, the conceptualization can assist other healthcare providers, researchers, educators and learning professionals, and professionals in the equine industry, such as riding instructors or equine facility managers, in better understanding interactions with horses in psychotherapy.

Coding, Billing, and Treatment Documentation
When interactions with horses and the possible enhancing elements that arise from these interactions are conceptualized as a therapy technique or tool in treatment planning, licensed mental health therapists can appropriately engage within healthcare-related systems, such as with coding, billing, and reimbursement. The mental health therapist should plan, actualize, and document the service they are coding and billing for, which is psychotherapy. Psychotherapy in the United States is a service where length of session as well as individual, family, or group designation are the main coding determinates (American Medical Association, 2019). Treatment documentation should focus on the client's therapy goals and the treatments the therapist is applying (Luepker, 2012). If the mental health therapist choses to use the technique of equine interactions as a way to enhance their treatment, it does not fundamentally change the service they are providing or the therapeutic approaches they are taking. The level of detail provided in clinical records varies by setting, and this may impact whether the licensed mental health therapist documents the specific techniques or tools used during sessions.
At the time of writing, there are no known exclusions for including interactions with horses as a technique within established psychotherapy treatment approaches for clients in either federal or state health insurance programs, or for those with private health insurance. Mental health therapists may, however, carry additional costs related to leasing treatment space and horses, even if the psychotherapy service itself is reimbursable by health insurance companies.

Professional Liability Insurance
Using the healthcare-aligned conceptualization presented here, mental health therapists can also gain clarity regarding professional liability insurance. A recent communication from the Health Care Providers Service Organization (HPSO), a professional liability (malpractice) insurance provider for three of the mental health professions mentioned in this paper contained the following statement regarding the inclusion of animals in therapy: Professional liability coverage is intended for counselors providing professional services for which they are licensed, certified, accredited, trained or qualified to perform. Counselors are responsible for and expected at all times to be familiar and current with all laws and professional practice regulations in their state of practice. While we cannot provide a guarantee of coverage for any specific situation in which a claim might arise, the use of animals as a therapeutic tool while providing professional services within your scope of practice, would not be excluded. (Health Care Providers Service Organization, 2020) While it is not appropriate to describe an animal as a tool, the conceptualization proposed here positions the interaction with the horse as a technique or tool in line with the above statement. In addition to mandatory professional liability insurance, mental health therapists may consider general liability coverage for their therapy business, and should appropriately interact with an equine activity liability act, if enacted as a statute in the state where they are located (Kopf, 2018).

Terminology
The conceptualization presented in this paper could assist in further clarifying appropriate terminology for equine interactions in healthcare. A recent terminology-related publication proposed therapy-first language when horses are incorporated into various therapies, which is consistent with the language used in this paper (Wood et al., 2021). Therapy-first language is also recommended for occupational therapists, physical therapists, and speech-language pathologists who make use of equine movement as a treatment tool (American Hippotherapy Association, 2020). Any misinterpretation of the horse being centered as the main source and provider of therapy, including via use of terms, is damaging for licensed mental health therapists. These misunderstandings could threaten their current autonomy to make use of the techniques, tools, and elements in their treatment sessions that are appropriate for their professional scope and areas of competence. Using broad and general terms such as equine-assisted therapy, equine-assisted therapies, equine-assisted interventions, or equine-assisted services does not provide a description of what kind of service is provided, and creates the impression that "equine-assisted" is a service or therapy delivered in a standalone manner, which it is not in the United States healthcare system. A lack of precision and transparency can mislead service recipients and other stakeholders.
The conceptualization presented in this paper helps creates separation between interactions with horses in different settings. The legitimacy of receiving psychotherapy where equine interactions are included in a skillful and clinically enhancing manner could be called into question if there is an implication that horseback riding, or otherwise interacting with horses in a recreational or sport-like manner, is what constitutes psychological treatment. Because of this, the conceptualization could further assist mental health therapists in avoiding the use of broad and general terms, such as those noted above, some of which group treatment together with activities that are part of non-therapy professions or even leisure settings. These terms may imply that the nature of service could change from recreational to therapeutic just because a horse is present, which conflicts with the healthcare-aligned conceptualization presented here. The conceptualization also helps mental health therapists to center the industry their professions are situated it, which is healthcare. Referring to a separate equine-assisted industry may create confusion around service description and professional identity (American Hippotherapy Association, 2020).
More work is needed in the area of terminology to promote the consistent use of healthcareappropriate terms and descriptors for licensed mental health therapists who include horses in their treatment.

Therapist Training
There are growing numbers of educational opportunities and trainings focused on equine interactions in the United States, with many of them simultaneously catering to both therapists and non-therapists. The healthcare-aligned conceptualization could assist therapists in carefully evaluating training options and consider whether they align with the practice standards and values of their profession. As equine interactions in psychotherapy functions as a technique as to enhance existing treatments, and not as a treatment in itself, the therapist should assess whether the proposed ways of providing equine interactions in any given training are based on scientific understanding of horses and whether they can be modified to suit the therapist's existing practice, professional identity, and client populations served.
The conceptualization presented here could be used along with the ACA competencies and the APA HAI section summary statement referenced earlier to develop national, educational standards for mental health therapists who wish to incorporate interactions with horses into their treatment. The existence of education standards could provide more clarity and guidance for the content of training offerings and may serve as an important next step for further professionalization in this area.

Benefits for Research
Using the conceptualization presented here may have benefits for research. It is worth asking how conceptual and theoretical issues may be contributing to the gap between clinician reports and empirical investigation of equine interactions in psychotherapy. For instance, Bachi (2012) highlighted inconsistency between the definition of the intervention and the evaluated intervention as one of the key problems found in their review, with misunderstanding and misuse of concepts as a proposed reason for this. Serpell et al. (2017) emphasized the lack of strong explanatory theories generally for inclusion of animal interactions in services, and how appropriate research questions and study designs are typically selected based on the existence of such theories in well-conceptualized research. Carlsson (2016) discussed specific issues with definitions and conceptual understanding of horses as part of treatment, which makes studies and practice difficult to evaluate. Researchers conducting systematic reviews and meta-analyses may be misled by inconsistent and incorrect definitions of equine interactions in services provided by practitioners and interest groups, which could be a reason for why therapy and non-therapy studies are, at times, grouped together in reviews. By using the healthcare-aligned conceptualization proposed in this paper, researchers may better understand which studies are possible to compare with each other, leading to more accurate systematic reviews and meta-analyses.
Research reviews published in the last ten years examined psychological outcomes of equine interactions in both therapy and in non-therapy settings (Anestis et al., 2014;Bachi, 2012;Bator et al., 2020;Kendall et al., 2015;Kinney et al., 2019;Selby & Smith-Osborne, 2012;Stern & Chur-Hansen, 2019), and some focused specifically on psychotherapy (Cantin & Marshall-Lucette, 2011;Carlsson, 2016;Kovács et al., 2020;Lee et al., 2016;Lentini & Knox, 2015). Problems specific to research design and methodology referenced in these reviews included small sample sizes, issues with sampling procedures, lack of reasonable homogeneity in participants, lack of control groups or inappropriate control conditions, insufficient details of intervention or treatment protocol for replicability, confusion about nature of service provided, lack of standardized measures and/or inappropriate application of measures, issues with researcher expectancy effects or biased raters, issues with interpretation and overgeneralization of results, and issues related to both duration of intervention and follow-up.
As the conceptualization presented in this paper has the potential to strengthen research efforts through clarifying how equine interactions in psychotherapy should be understood, it may assist in resolving some of the issues highlighted above. For instance, use of the conceptualization has implications for study design, especially in the comparison of treatment conditions. Since the inclusion of equine interactions in psychotherapy is not a standalone intervention, studies should not position it as such. A study on equine interactions in psychotherapy should not compare simply horses, horse interactions, or horsemanship activities with a psychological treatment. This would imply that the horse themselves or general horse activities done in the same manner as in recreation constitute treatment of mental disorders by licensed healthcare providers, which is not accurate. For example, if a study involves a clinical protocol that is based on cognitive-behavioral therapy (CBT) principles, two versions of the same protocol could be compared, one that includes specifically selected elements from equine interactions with the purpose of enhancing the proposed mechanisms of the protocol, and one without these elements.
Finally, the elements arising from equine interactions and the equine setting presented in this conceptualization could be investigated for their potential to strengthen identified mechanisms of change in treatments for various disorders (see e.g., Gallagher et al., 2013), in addition to effects on motivation, engagement, and the therapeutic alliance from interactions with horses. As Carlsson and colleagues (2015) suggested, the quality of the relational interaction with horses, how the horse is experience during the session, may be related to clinical outcomes. Research in this area could also assist in differentiating between the nature of equine interactions taking place in healthcare settings and those taking place in equestrian sport and recreation (Limegård & Montén, 2016).

Next Steps
The conceptualization of equine interactions presented in this paper may function as a superstructure in the development of specific criteria for ethical and effective inclusion of equine interactions in psychotherapy. Current models and teachings directed at licensed mental health therapists could be evaluated for their alignment with the healthcare-appropriate practices proposed in the conceptualization.

Conclusion
The conceptualization presented in this paper accomplishes several things. This conceptualization separates interactions with horses in psychotherapy from horse industry activities such as riding or simply being around horses; it clarifies the function of equine interactions in treatment in a way that aligns with the professional identity, responsibilities, and the overall healthcare context of licensed mental health therapists; it builds on existing competencies for including animals in psychotherapy and counseling; and it promotes sciencebased understanding of horses, all to promote ethical and effective practice. In addition, the