October 2009

Field trip to NCEFT

Yesterday, our class took a field trip to the National Center for Equine Facilitated Therapy (NCEFT). Located in rustic Woodside, Calif., the center has provided equine assisted therapy and activities to individuals with special needs for over 37 years. Today, they treat approximately 100 patients with a variety of health conditions.

What an eye-opening experience for me in many ways, and I had two big revelations.

First, I had never connected the movement of the horses with the movement of humans. Riding a horse creates similar walking patterns in pelvis rotation and twist. Seeing this movement in action helped me understand how powerful equine therapy could be in assisting people develop those same muscles, particularly if they cannot fully walk themselves.

Second, I saw two children, both around ages 6-8, with cerebral palsy undergo personal physical therapy sessions with a horse. While both children required assistance to walk and move, they were simply giddy to see and interact with the large gentle animals. Responding to animals opens up another (nonvocal?) dimension, and watching the kids helped me understand the healing magic that pets might provide. Somehow these two children managed they sit up and play catch on the horses, helping to strengthen their core muscles and improve hand-eye coordination. It was an incredible transformation.

Advise (, Pet,) and (No) Consent

Love makes the world go around but will it help a horse do a very scary thing?

The horse we named Orion or Beau, a large flashy paint, is the horse Sherrie referred to in the previous entry. The youngest of our three "patients," he was completely stopped in his tracks by our laying on the ground a shiny, crinkly space blanket festooned with a hot pink feather boa, several traffic cones, and the always-intimidating white lab coat.

Once Beau expressed his fear, the students made many attempts to get him to walk through the Little Shop of Horrors. Efforts included pulling repeatedly on the lead rope, playing follower-the-leader by walking on the space blanket one's self ("See, nothing to it!"), and the universal (for these exercises) tactic of stroking and petting.

With regard to the latter, almost everyone tries the "I'm your friend, so love me and do what I ask" technique. But what does stroking and petting mean to a horse? As we explained--and observed during round up--when push literally comes to shove, horses don't respond to making nicey-nice. As prey animals, they respond to the strong leader who is going to ensure survival of the herd. Horses push each other around quite aggressively and usually from the rear. The lead horse flicks her ears and says "Move! NOW!" and the submissive horse responds, by moving off, "Yas, MA'AM!"

To a horse being asked to perform a task, petting means "Goo' boy! Do just what you're doing." Petting is a form of positive reinforcement in the technical sense of operative conditioning: positive (adding a stimulus) reinforcement (increasing the behavior).

After half an hour of being petted every time he refused to walk on the space blanket, Beau just figured he was being rewarded for standing in place. In the end, he didn't even seem afraid. He just seemed stubborn and enjoying being petted in exchange for standing still.

What kind of patient does Beau represent? Well, certainly he is typical of patients to whom we physicians give a mixed message: "We think you ought to make changes to improve your health, but it's OK--in fact, we'll reward you--if you don't change." We are unconsciously saying to them, "I'd like you to be healthier, but more than that, I'd like you to like me." We are unintentionally teaching them that there are no consequences to not making healthy choices. These are the patients to whom we keep giving medications to substitute for healthy behaviors--cholesterol lowering drugs for the obese person who refuses to exercise or change his or her diet, pain killers and sleeping pills for those who do not want to face their addictions or get psychological help for their stress. We are, in effect, petting with pills. Do we want to be liked so much that we are unable to provide Tough Love where warranted? (My previous posts on Michael Jackson's doctors also illustrate the professional dilemmas involved.) As we progress from being med students to practicing physicians, we tend to feel more comfortable with our role as leaders. We have enough self confidence and self esteem to not sacrifice our patient's well-being for our need to be liked as a buddy.

At these times we should remember Beau and realize that if crossing the space blanket represents something he needs to do for his own good (and it is to the horse's benefit and our safety to get him over his fears and trusting of human leadership), we are not doing him any favors by being people...er...horse...pleasers.

Varied Responses

Many lessons learned this past week during the “informed consent” portion of our internship with the horses. It is interesting to see emerging both student and horse personalities.

The task at hand was to lead the horse over a shiny, crinkly mylar space blanket. Add to this mild yet stormy weather and a good size human audience and you’ve got some varied responses from our horse “patients”. It was interesting to watch the different approaches. So many lessons were learned in this small space of time! When I attempt to relate this to patient care I am reminded there are many facets to these relationships. What is the clinician’s end goal? What is the patient’s perception of how necessary a test or procedure is? Is the trust established to date enough of a motivator to convince a patient to move forward? Is that trust built on reputation, intimidation or mutual respect? Finally, if a patient declines care, how much of that responsibility should the clinician absorb?

Of the three horses, one examined the blanket by pawing and studying it first before going over. This was impressive! He wanted to figure it out himself. The next horse was fine walking on it but not if we walked on it first and reminded her of the noise it made. The last horse despite much effort just wasn’t having it. These scenarios were such a great representation of how different patients might react to the same situation. You have your investigative patient, your committed but don't remind me what it is going to be like patient and finally your non-compliant (at least for now) one. What a great learning experience!

Informed Consent

Consent to walk over a Mylar blanket? No problem, at least not for me and surely, I thought, not for our teams dream horse the sweet, calm, cooperative, Beau/Orion/ Remy. In my mind it was just a harmless sparkly, blanket. Boy was I wrong!

We began our walk as usual with Beau calm, gentle, and willing, until we got within a few feet of the blanket. The entire expression and motion of this Paint horse changed. He signaled loud and clear how very frightened he was. His eyes widened, ears pointed forward, his nostrils flared, and his feet and body refused to move forward toward the blanket. I thought if I showed him I was calm and walked him forward he would follow. He did not. I tried to be playful and encouraging, he was still terrified by an object I saw as harmless. Nothing I did seemed to help this sweet horse relax or feel any safer. On reflection of our interactions, I believe, I should have gone even slower, no rush in trying to convince Beau to go over the dreaded blanket, to sign his informed consent, so to speak, today. I think for Beau going slower is perhaps the best and fastest way for him to learn and to accomplish this goal.

I know in my work as a healthcare provider, I often ask children or their parents to accept a procedure, a medication, or sign a consent, right now. My interactions with
Beau have allowed me to better understand that something I perceive to be harmless, routine, or needed might, in fact, be incredibly stressful or frightening; even though I do not perceive it as such. I will be more mindful of this as I work with children and their families.

Choose or be Chosen

Choose or be chosen?

Wednesday our second day of class at Webb Ranch was so interesting, insightful, and so much fun. Even though I have been around horses for the past few years I have little understanding of their body language or meaning.

I feel so honored to be a part of this class. What I have learned so far has allowed me see the horses actions and interactions much more clearly. I actually think I understood much of what they were saying with their body movements and facial expressions. I am so excited by the fact that I can learn to have interspecies communication!

I chose the horse whose name we did not know; he was the beautiful white and chestnut Paint Quarterhorse. I believe now from just reading the Blog that is his name is Dream. How very strange I am now thinking, as I remember the first day of class I wore a tee shirt with large print that read "Dream". Is this destiny, a case of synchronicity, or just a strange coincidence? Who knows and I am not sure that "Dream"
is really his name. I will ask next class. Even if it is not it certianly seems most fitting for him. He was truely a Dream (patient) during his physical exam and during the entire class as he stood and walked with us in the corral.

I look forward to our journey with each other and with the horses. Eileen

First Day with the Horses

Without a doubt humans have much to learn from all species of animals. I feel this is especially so of horses for me in that I have such minimal exposure to them.

The power of non-verbal communication is not to be underestimated, nor is the importance of learning another “language”. To learn their language is very necessary in order to foster these new relationships. I couldn’t help comparing interaction with them to the one I have with cats. With cats I instinctively know what they want and look forward to having this connection with the horses.

The biggest challenge for me with the horses is that I’ve never been fond of being in control of animals. Safety dictates this element of the relationship and it was something I was acutely aware of on my first day with "Spice". You must be aware of every position of the horse in relation to other people, other horses and yourself in addition to making sure the horse is comfortable. I now understanding “being present” in a whole new light.

The positive environment is very conducive to accepting these differences in ourselves and much appreciated. Can't wait for the next class!

Out of the Starting Gate - First Class

Last Wednesday, the 30th, was the first week of class. I have tremendously good feelings about this quarter.

For one thing we're full--almost had 1 too many, too. For another thing, it's an unbelievably diverse group. We have:

3 med students
1 pediatric endocrinology nurse practitioner*
1 clinical coordinator for one of our oncology clinics
1 mechanical engineering PhD candidate (w/ biz comm background)
1 transpersonal psychology PhD candidate
1 biotech consultant w/ a psychospiritual & relationship training practice

*This gal has done research on natural substitutes for estrogen products made from PMU (pregnant mare urine)-cruelty farms.

Thirdly, in the good feelings dept, since this is about the 6th time I am teaching M&H at Stanford, I find that the course has finally fallen into a familiar rhythm. After years of experimenting with different time slots and exercises, the main structure of the course is more or less established. I can now attend to making it better from a place of being confident that the core pieces are in place. That is, from a place of confidence, I can get more creative.

"Established," however, does not mean autopilot, as witness Unintended Consequence #1: Background: The weekend before class, I e-mail our horse requests to the ranch owner. I describe what activities we'll be doing and she selects suitable equine assistants. I used to know everyone in the lesson herd, now I know maybe half.

So, we get the schedule back and come to see that I didn't know any of the 3 horses we're assigned. So Liz and I go out to introduce ourselves to the horses the day before. (We also mentally tell them about the class and what we are going to ask of them.)

We get to the lesson herd and find out that we are assigned 3 black geldings. Ay! Ach! Oy! [big forehead slap] We had to explain to management that we need horses that are visually distinctive, especially for folks who aren't used to seeing horses. Heck, Liz and I could hardly tell them apart. Having different looking horses is also important for inducing projection dynamics.

Day #1 once again opened with the drama of round-up: 40 horses funneled into a smallish corral, re-establishing boundaries, staking out real estate, chasing eachother, making ears, swishing tails, kick-gesturing, swinging haunches--much fodder for our intro to body language,leadership, hierarchies, etc. Body language is the start of doctor patient communication. Patients notice this about us as soon as we walk into the exam room.

We then went over to where we had put the 3 horses (now, thankfully, a black, a chestnut, and a strawberry roan) into an arena. Unintended Consequence #2: the mare was in season, the dominant gelding chased his rival at a full gallop all around the arena. We decided it wasn't a safe situation for Choose or Be Chosen. So we ended up doing our meet-and-greet over the fence line, and not being able to get the students in w/ the horses. Oh well. As Sugarland says, "Shhh, It Happens."

Today is class #2. Take 2 with Choose or Be Chosen. This time we have Mr T, Dream's ("as seen on TV!") old boyfriend, a cuuuuuute little chestnut Arabian. Hopefully they all behave so we can get all 8 students, 3 facilitators, and 2 press people in the (very large) arena.

More gorgeous weather predicted--75 and sunny.