Hippotherapy and therapeutic riding

1. Introduction

Version followed: American Hippotherapy Association (AHA, Inc.) Statements of Best Practice (2023 version, approved August 2023) and AHA safety and media guidance; PATH Intl. terminology as set out in the 2020 US consensus document on optimal terminology and the PATH Intl. Definitions Guide for Researchers (2023); IAHAIO White Paper on Animal-Assisted Interventions (2014, updated April 2018).

Hippotherapy is not a psychotherapy, and the psychotherapist does not deliver it. The AHA defines hippotherapy as the "purposeful manipulation of equine movement as a therapy tool" to engage sensory, neuromotor and cognitive systems toward functional outcomes. It is a treatment tool used within occupational therapy, physical therapy or speech-language pathology, by licensed OTs, PTs and SLPs working within their scope of practice and state law, after continuing education in hippotherapy. It is "not a stand-alone" service; patients work on functional therapy goals, not riding skills. PATH Intl. states that hippotherapy is "not a profession", so "hippotherapist" is avoided in favour of "therapy-first" wording ("a physical therapist who incorporates hippotherapy"). [source: AHA About page; AHA media guidance; PATH Intl. Definitions Guide]

Therapeutic riding is now called adaptive (therapeutic) riding or adaptive/therapeutic horsemanship: a non-therapy service that teaches riding and groundwork adapted for people of diverse abilities, delivered by qualified equine professionals (for example a PATH Intl. Certified Therapeutic Riding Instructor, CTRI, described by PATH as a voluntary, entry-level credential) with a team of volunteers. Its aims are recreational, skill and quality-of-life aims, not rehabilitation. [source: PATH Intl. glossary; PATH Intl. Definitions Guide; AHA media guidance]

A third, separate category is therapy incorporating equines: treatment by licensed medical or behavioural-health professionals (counsellors, psychotherapists, OT, PT, SLP, recreational therapists) within their scope, often with a PATH Intl. Certified Equine Specialist in Mental Health and Learning handling the horse. Equine-assisted psychotherapy belongs here and has its own guide in this family; equine-assisted learning is a non-therapy service. Umbrella terms such as "equine therapy", "horse therapy" or "EAAT" are discouraged because they do not say who delivers what. [source: PATH Intl. Definitions Guide; USU Extension guide]

In IAHAIO terms, hippotherapy sits within animal-assisted therapy (goal-directed, delivered by licensed health professionals, progress documented), while adaptive riding is closer to animal-assisted education or activity depending on its goals [source: IAHAIO White Paper 2018; the mapping of riding onto IAHAIO categories is synthesis].

Core idea of change, as the sources state it: in hippotherapy, the horse's movement provides graded sensory and motor input that the PT, OT or SLP shapes toward functional goals; in adaptive riding, learning a skill with an adapted horse and team builds ability and quality of life. [source: AHA; PATH Intl.] The psychotherapist's contribution is collaborative: helping the client and family choose the right service, preparing the client emotionally (fear, trauma, sensory and touch issues), feeding emotional and behavioural goals to the treating team with consent, debriefing what happens at the barn, and working with its meaning (mastery, disability identity, the bond with the horse, endings). [synthesis]

2. Framework

The sources describe programme processes, not a psychotherapy protocol. No source gives a typical number or length of sessions for the psychotherapist's work; the USU Extension guide notes that equine-assisted programmes range from hours-long retreats to weekly sessions over several months. [source: USU Extension guide]

How the delivering services run (outline):

• Hippotherapy (AHA 2023): the licensed therapist leads a team (equine professional, horse handler, sidewalkers and aides) and decides whether to include hippotherapy through a risk-benefit analysis reached by consensus among patient, guardian, therapists, horse expert and physician; precautions call for further investigation and monitoring, contraindications rule it out; the horse is selected for movement, conformation and temperament; hippotherapy is integrated into the plan of care with other strategies; documentation follows AOTA, APTA or ASHA requirements; reassessment is continuous, and the first goal is to do no harm. [source: AHA Statements of Best Practice 2023]
• Adaptive riding (PATH Intl.): intake paperwork including health history; review of precautions (which need further investigation, for example contacting a physician, therapist or mental health professional) and contraindications (which make the activity inappropriate, permanently or temporarily); re-evaluation at regular intervals; unmounted or driving alternatives may be explored. [source: PATH Intl. standards summary]

The psychotherapist's parallel phases [synthesis]:

3. Guiding principles

• Therapy first, horse second. Name the profession that delivers the service; hippotherapy is a tool within PT, OT or SLP. In practice: refer to "a physical therapist who uses hippotherapy", not to "a hippotherapist". [source: PATH Intl. Definitions Guide; AHA]
• Stay in your scope. The psychotherapist does not deliver hippotherapy and does not teach riding unless separately certified. In practice: collaborate; don't make motor, seating or riding recommendations. [source: AHA; PATH Intl.; extension to psychotherapists is synthesis]
• Do no harm and weigh risk against benefit. The AHA makes risk-benefit analysis and continual reassessment central. In practice: raise psychological risks (panic, dissociation, aggression, self-injury) with the treating team so they become part of that analysis. [source: AHA Statements of Best Practice 2023]
• Precautions are investigated; contraindications exclude. In practice: when the programme asks a mental health professional about a precaution, give a clear, consented, specific answer. [source: PATH Intl. standards summary; AHA]
• Shared decision. AHA describes inclusion as a consensus among patient, guardian, therapists, horse expert and physician. In practice: make sure the client's own voice, or a child's assent, is part of it. [source: AHA 2023; assent point is synthesis]
• The animal is a living being, not a tool. IAHAIO requires that animals be healthy, appear to enjoy the work, are not overworked, and have handlers trained to detect stress. In practice: treat horse stress signals as information that may end or change an activity. [source: IAHAIO White Paper 2018]
• Quiet does not mean comfortable. A Colorado State University presentation hosted by the AHA warns that EAS horses can be "less expressive" and that stress may be present without obvious signs. In practice: never read a still horse as proof that a client's behaviour is acceptable to it. [source: AHA-hosted "Recognizing Shutdown" slides]
• One Welfare. IAHAIO links animal welfare, human wellbeing and the environment; an intervention that compromises the animal's wellbeing would be unethical. [source: IAHAIO White Paper 2018]
• Screen people as well as animals. IAHAIO asks professionals to screen for allergies and apply exclusion criteria for high-risk groups such as immunosuppressed people. In practice: ask about allergies, immune status and animal-related fears at referral. [source: IAHAIO White Paper 2018]
• Competence is credentialed. AHA recommends licensure, clinical experience before adding horses, AHA treatment-principles courses and AHCB credentialing (including HPCS); PATH certifies riding instructors and equine specialists. In practice: check credentials before referring. [source: AHA 2023; PATH Intl. glossary]
• Consent covers information, touch and images. [synthesis] In practice: separate releases for sharing clinical information, for physical support by sidewalkers, and for photographs.
• Confidentiality is harder at a barn. Volunteers, parents and other riders are present. [synthesis] In practice: agree what will be said, by whom, and where.
• Respect the client's culture and beliefs. IAHAIO advises discussing alternatives when beliefs conflict with an animal-assisted approach. [source: IAHAIO White Paper 2018]
• The client authors the meaning. [synthesis] In practice: explore what the horse and the riding mean to the client rather than imposing a story of healing.
• Dual roles are managed, not drifted into. APA Ethics Code Standard 3.05 (Multiple Relationships) applies if the psychotherapist is also a volunteer, instructor or owner at the programme (APA Ethics Code). [synthesis]

4. Intervention inventory

The delivering bodies publish standards for PT/OT/SLP practice, riding instruction and horse care, not procedures for a psychotherapist. The procedures below are therefore therapist-side collaborative procedures; each is marked [synthesis] except where a named source is cited for a specific point. The psychotherapist does not run horse-based activities in any of them.

4.1 Clarifying the service and matching the referral

• Purpose: make sure the client reaches the right service and the right professional. Use at first mention of "horse therapy" by a client, parent, school or physician. [synthesis; categories from PATH Intl. Definitions Guide]
• Steps: (1) Ask what the goal is: motor, sensory, speech or feeding (hippotherapy within PT, OT or SLP); learning to ride or recreation (adaptive riding); emotional or relational work with horses (therapy incorporating equines; see the equine-assisted psychotherapy guide in this family). (2) Translate vague terms: "equine therapy" and "EAAT" do not tell you who delivers what. (3) If the goal is hippotherapy, the route is the client's physician and an OT, PT or SLP who incorporates hippotherapy; the AHA notes that hippotherapy is billed as part of therapy and often covered by health insurance, though some insurers exclude it. (4) Record which service was chosen and why.
• Example language (illustrative): "There are a few different things people call 'horse therapy'. One is physical, occupational or speech therapy that uses the horse's movement; another is riding lessons adapted for you. Which of those fits what you're hoping for?"
• Watch for: families expecting hippotherapy to treat anxiety or behaviour directly; programmes using "hippotherapy" for riding lessons without a licensed therapist (a red flag per AHA terminology). Working: the family can name the service and the professional.

4.2 Evaluating a programme before referral

• Purpose: check quality and safety before you endorse a programme. [synthesis; questions adapted from USU Extension guide, AHA and PATH Intl.]
• Steps: (1) Ask which body certifies or accredits the provider (AHCB credential such as HPCS for therapists; PATH Intl. CTRI for instructors; PATH centre accreditation), or how uncertified staff gained experience. (2) For hippotherapy, confirm the treating person holds a current OT, PT or SLP licence. (3) Ask about written rules, handbooks, emergency procedures, helmet policy, how horses are matched and re-evaluated, fencing and footing. (4) Ask what outcomes they expect and how progress is documented. (5) Ask how they handle a participant's distress or behavioural crisis and whether they accept input from a mental health professional.
• Example language (illustrative): "I'm the client's psychotherapist and, with their permission, I'd like to understand how your sessions run, who will be on the team, and how you'd like me to share anything relevant."
• Watch for: vague answers on credentials or emergencies, promises of cures, no paperwork. Working: you can describe the team and safety plan to the client.

4.3 Consent, release of information and assent

• Purpose: set the legal and relational frame for collaboration. [synthesis]
• Steps: (1) Obtain a specific, time-limited release naming the programme, the treating therapist or instructor, and what may be shared (relevant diagnoses, triggers, coping plan, crisis contacts) and what may not. (2) For a child, obtain parental consent and the child's assent in age-appropriate words; record the child's own view of riding. (3) Discuss the programme's separate forms (health history, physician statement, liability release, photo release) so the client understands them. (4) Agree a stop signal the client may use at any time.
• Example language (illustrative): "You can say 'stop' or raise your hand at any point, and the team will stop. Would you like me to tell them that's your signal?"
• Watch for: a child complying silently; parents signing photo releases the young person objects to. Working: the client can state what has been shared and how to stop.

4.4 Screening for fear, phobia and trauma involving animals

• Purpose: identify histories that change readiness or require preparation. [synthesis; IAHAIO requires screening and exclusion criteria in general terms]
• Steps: (1) Ask about past bites, kicks, falls, being chased, a frightening animal, or loss of an animal. (2) Ask about animal use in abuse or threats, and about sensory triggers (smell, size, noise, being lifted). (3) Rate fear informally and identify avoidance. (4) Decide with the client whether to proceed, prepare first (4.8), or choose another option. (5) With consent, tell the programme what helps and what to avoid.
• Example language (illustrative): "Some people have had scary moments with animals, or animals were part of something hurtful. Has anything like that happened to you?"
• Watch for: disclosures of animal cruelty used as coercion (a safeguarding signal); dissociation when describing animals. Working: a clear, shared plan.

4.5 Allergy, infection and medical-flag liaison

• Purpose: ensure health information relevant to animal contact reaches the programme. [source: IAHAIO 2018 on allergy screening and exclusion for immunosuppressed people; 2020 literature review on AAI risks; liaison role is synthesis]
• Steps: (1) Ask about allergies to animals, hay or dust, asthma, and immune suppression (for example chemotherapy). (2) Ask about seizures, balance-affecting medicines and recent injuries, and pass these to the physician and programme with consent; precaution and contraindication decisions belong to them and the physician (AHA lists absolute contraindications such as uncontrolled seizures and spinal instability). (3) Never advise starting, stopping or changing a medicine. (4) Reinforce hand-washing after horse contact. The 2020 review of AAI risks found evidence mainly on dogs (MRSA, C. difficile and other organisms in hospital-visiting dogs) and inconclusive patient outcomes; equine-specific zoonosis guidance should come from the programme's veterinarian [uncertain: equine-specific data not verified].
• Example language (illustrative): "Before you start, the riding centre will ask about your health. Is there anything about allergies, seizures or your immune system I should make sure they know, with your permission?"
• Watch for: clients minimising medical issues to avoid exclusion. Working: the programme confirms it has what it needs.

4.6 Contributing emotional and behavioural goals to the treating team

• Purpose: align the PT/OT/SLP plan of care, or the instructor's lesson goals, with therapy goals. [synthesis; AHA notes the treating therapist leads the team and integrates hippotherapy into the plan of care]
• Steps: (1) Identify one to three observable goals relevant at the barn (for example tolerating transitions, asking for help, coping with waiting). (2) Describe early signs of overwhelm and what helps the client regulate. (3) Offer, do not prescribe; the treating therapist or instructor decides how to incorporate them. (4) Agree how and how often you will exchange updates.
• Example language (illustrative): "One thing we're working on is asking for a break instead of shutting down. If you see her go quiet and stare, a calm 'Do you need a pause?' tends to help."
• Watch for: goals that drift into motor or riding advice outside your scope. Working: the team reports using the cue.

4.7 Preparing the client: what will happen

• Purpose: reduce anticipatory anxiety and surprises. [synthesis; team roles from AHA 2023]
• Steps: (1) Describe the setting: arena, horse, a team that may include the treating therapist or instructor, a horse handler and sidewalkers. (2) Explain helmets (AHA recommends ASTM/SEI-approved helmets where they can be worn safely, with attention to fit and sensory tolerance) and that staff will check equipment. (3) Explain mounting and dismounting in general terms, without procedure. (4) Use pictures or the programme's own materials if available. (5) Rehearse questions the client wants to ask.
• Example language (illustrative): "There will be a few people there: the therapist, someone leading the horse, and people walking beside you. It's okay to ask each of them their name."
• Watch for: helmet intolerance in clients with sensory sensitivities (flag early to the programme). Working: the client predicts the first session accurately.

4.8 Graded preparation for fear of horses

• Purpose: help a fearful client approach participation by choice. [synthesis]
• Steps: (1) Confirm the client wants to participate; fear alone is not a reason to push. (2) In the office, build a hierarchy using images, video and talk about horses. (3) Teach a regulation skill first. (4) Coordinate with the programme about any unmounted or ground-based first steps they offer (PATH notes unmounted alternatives exist); the programme decides what is safe with its horses. (5) Contraindications for exposure work: active psychosis, acute suicidality, unprocessed trauma involving animals where the client has not chosen this work; obtain explicit consent for each step and preserve the right to stop.
• Example language (illustrative): "We'll only go as far as you choose. Today might just be looking at photos and noticing what your body does."
• Watch for: safety behaviours, avoidance disguised as "not interested", and family pressure. Working: fear ratings fall and the client initiates the next step.

4.9 Touch and body-boundary planning

• Purpose: prepare for physical support by sidewalkers and staff, especially for clients with trauma or sensory issues. [synthesis; sidewalkers and gait belts or supportive vests from AHA 2023]
• Steps: (1) Explain that staff may hold or steady the client and use belts or vests decided by the treating team. (2) Ask where touch is acceptable and what announcement helps ("I'm going to hold your ankle"). (3) Ask permission to share this with the team. (4) Plan for a touch-triggered reaction: the stop signal, a grounding phrase, and the team's emergency procedure takes priority. (5) Touch is never sexual; any concern goes to the programme lead and safeguarding.
• Example language (illustrative): "People walking beside you might keep a hand on your leg so you're safe. Would it help if they said out loud before they touched you?"
• Watch for: freezing, holding breath, startle. Working: the client reports feeling in control of touch.

4.10 Teaching the client to read the horse

• Purpose: support safety, animal welfare, and the client's mentalising and empathy. [source: AHA-hosted CSU slides on stress signs; IAHAIO on stress detection; therapeutic use is synthesis]
• Steps: (1) Introduce, as psychoeducation, signs that horses may show discomfort, such as ears pinned or stiffly back, tail swishing, head tossing, pawing, tension around eyes and mouth. (2) Stress the caveat that a quiet horse may still be stressed. (3) Explore how the client reads others' signals and how they signal their own discomfort. (4) Remind the client that the handler and instructor make the calls about the horse.
• Example language (illustrative): "Horses tell us they're uncomfortable with their ears, tail and face. What are the signals you give when you've had enough?"
• Watch for: clients interpreting horse behaviour as rejection; harsh handling of the horse. Working: the client respects the horse's limits and connects this to their own.

4.11 Observation visit

• Purpose: see the client in context when this helps therapy. [synthesis]
• Steps: (1) Ask the client and programme first; agree purpose and duration in advance. (2) Agree how you will be introduced, or not introduced, in front of volunteers and other families. (3) Observe from where the programme places you; do not intervene in the activity. (4) Debrief with the client afterwards and document what you observed.
• Example language (illustrative): "If you'd like me to come and watch once, how would you like me to be introduced?"
• Watch for: the client performing for you; confidentiality breaches. Working: observation feeds concrete goals.

4.12 Post-session debrief in therapy

• Purpose: turn barn experiences into therapy material. [synthesis]
• Steps: (1) Ask for a narrative: what happened, best moment, hardest moment. (2) Track body sensations and emotions in each. (3) Link to therapy goals (mastery, trust, asking for help, frustration tolerance). (4) Note anything to pass on to the team (with consent). (5) For non-verbal or young clients, use drawing, play or parent report.
• Example language (illustrative): "When the horse started walking, what did you notice in your body? And what did you do with that?"
• Watch for: only positive accounts (possible pleasing), or only negative (possible fit problem). Working: the client spontaneously links barn and life.

4.13 Mastery and self-efficacy work

• Purpose: consolidate experiences of competence, especially for clients whose disability limits other experiences of control. [synthesis]
• Steps: (1) Identify a concrete achievement the client reports (sitting balanced, giving a cue, grooming). (2) Explore what they did that made it possible. (3) Name the skill in transferable terms (patience, persistence, calm signalling). (4) Plan one use of that skill elsewhere this week.
• Example language (illustrative): "You stayed calm when the horse stopped. Where else could that calm help you?"
• Watch for: comparison with other participants; parents framing progress only in motor terms. Working: the client names their own strengths.

4.14 Working with frustration, plateaus and setbacks

• Purpose: support the client when motor progress stalls or a session goes badly. [synthesis]
• Steps: (1) Validate disappointment. (2) Separate the client's worth from functional progress. (3) Help the family ask the treating therapist about reassessment rather than guessing. (4) Problem-solve emotional obstacles (fatigue, anxiety before sessions). (5) Revisit whether the service still fits.
• Example language (illustrative): "It sounds like you hoped this would be quicker. What would you want to ask your therapist about where things are heading?"
• Watch for: hopelessness, self-blame, or depression. Working: the client stays engaged or chooses an informed change.

4.15 Family consultation

• Purpose: support parents and carers around hopes, cost and logistics. [synthesis; insurance coverage point from AHA media guidance]
• Steps: (1) Explore parental hopes and fears about the service. (2) Discuss cost, travel, insurance coverage and exclusions as practical stressors. (3) Attend to siblings and family schedules. (4) Distinguish the child's wishes from the parents'. (5) Encourage parents to ask the provider about expected outcomes.
• Example language (illustrative): "What would make this feel worth it to you as a family, and what would tell you it's not working?"
• Watch for: parental over-investment, guilt, marital strain. Working: realistic shared expectations.

4.16 Meaning-making and identity

• Purpose: explore what horses and riding mean to the client: freedom, height, movement, disability identity, belonging. [synthesis]
• Steps: (1) Invite the client's own words about what being on or near a horse means. (2) Explore disability identity and how the client wants to describe themselves. (3) Respect the client's interpretation; do not impose a narrative of cure. (4) Respect cultural and religious views on animals and discuss alternatives where these conflict with the approach (IAHAIO).
• Example language (illustrative): "You said it feels like 'walking tall'. What does that mean to you?"
• Watch for: idealisation of the horse as the only source of relief. Working: richer self-description.

4.17 Responding to a fall, injury or frightening incident

• Purpose: provide trauma-informed aftercare. [synthesis; AHA reports low incident rates in its safety white paper and requires emergency procedures and first-aid cover]
• Steps: (1) Ensure medical care has happened and the programme has documented the incident. (2) Meet soon afterwards; assess acute stress symptoms and safety. (3) Allow a full narrative at the client's pace. (4) Explore whether and how the client wants to return; liaise with the programme about any changes they plan. (5) Watch for longer-term symptoms and treat with evidence-based trauma approaches if they persist.
• Example language (illustrative): "What happened was frightening. You don't need to decide today whether you'll go back."
• Watch for: avoidance generalising to other activities; parent anxiety driving decisions. Working: the client makes a choice they own.

4.18 Endings: discharge, a horse's retirement or a move

• Purpose: process loss of the horse, team or programme. [synthesis; AHA addresses horse retirement]
• Steps: (1) Anticipate endings: discharge, a favourite horse retired or sold, cost or travel changes. (2) Invite the client to mark it (a goodbye, a photo if permitted, a letter). (3) Explore grief and attachment. (4) Plan continuation of gains.
• Example language (illustrative): "You've spent a lot of time with this horse. How would you like to say goodbye?"
• Watch for: unexpressed grief, a sense of abandonment. Working: the ending is named and marked.

4.19 Generalising gains to home, school and work

• Purpose: carry skills beyond the barn. [synthesis]
• Steps: (1) Identify one barn skill per period. (2) Agree a home or school practice with the client and, with consent, parents or school. (3) Review in the next therapy session.
• Example language (illustrative): "You give a clear, calm signal to the horse. Could you try that tone when you ask your teacher for a break?"
• Watch for: skills that only appear at the barn. Working: reports from home or school.

4.20 Deciding on a dual or extended role

• Purpose: handle the case where the psychotherapist volunteers, owns horses, or wants to incorporate horses into psychotherapy. [synthesis; PATH Intl. on therapy incorporating equines and the Equine Specialist role; AHA on competence]
• Steps: (1) Do not describe your work as hippotherapy; that is PT, OT or SLP. (2) If you want to incorporate horses into psychotherapy, seek specific training and work with a certified equine specialist (see the equine-assisted psychotherapy guide in this family). (3) Review APA Ethics Code Standard 3.05 on multiple relationships before volunteering where a client attends. (4) Check professional liability insurance and the programme's insurance for your role. (5) Document the decision.
• Example language (illustrative): "I volunteer at that barn on weekends, so before you start there let's talk about whether that would be comfortable for you."
• Watch for: blurred roles, client discomfort, insurance gaps. Working: roles are explicit and agreed.

5. Handling problems

None of the sources address the psychotherapist's problems directly; all guidance below is [synthesis] unless a source is named.

• The client refuses or is ambivalent (often a child pushed by family). Treat refusal as communication. Explore what the young person fears or dislikes; separate parental hopes from the child's assent; offer alternatives (another service, ground-based options the programme offers, or a pause). Never use therapy to persuade a child into riding.
• Panic, dissociation or meltdown at the barn. The programme's emergency procedures and the instructor's or therapist's decisions about the horse come first (AHA requires practised emergency dismounts and first-aid cover). Afterwards, review triggers, refine the stop signal and the cue shared with the team, and reconsider readiness. Do not coach the client remotely during a session.
• Aggression or rough handling toward the horse. IAHAIO requires supervising recipients so they do not tease or mishandle animals. Support the programme's limits; explore the behaviour in therapy (anger, imitation of harm experienced, sensory overload) and screen for exposure to violence or animal cruelty as a safeguarding issue.
• The horse shows stress and the activity is changed or stopped. Help the client understand that this is about the horse's needs, not rejection; use it to discuss consent and limits (see 4.10).
• Non-attendance or dropping out. Explore practical barriers (cost, travel, weather cancellations, insurance changes) separately from emotional ones (fear, boredom, embarrassment). Help the client decide, rather than letting it drift.
• Plateau or disappointment. Encourage the family to ask the treating PT, OT, SLP or instructor about reassessment and goals; work with grief about disability and with expectations (see 4.14).
• Weather, terrain and outdoor conditions. Heat, cold, footing, insects and allergens affect people and horses; programmes cancel or adapt sessions under their own safety guidance (AHA includes weather and environmental guidance in its best-practice statements). Prepare the client for cancellations and outdoor discomfort; check tick and allergy advice with the programme and the client's physician. Ensure accessibility (ramps, mounting areas, toilets) is discussed with the programme.
• Confidentiality at the barn. Volunteers, parents and other participants overhear. Agree in advance what you will share and with whom; avoid clinical conversations in public areas; check photo and social-media policies; respect a client who does not want peers to know they see a psychotherapist.
• Conflict between the treating team and the family or you. Clarify roles: the treating OT, PT or SLP leads hippotherapy decisions; the instructor leads riding decisions; you advise on emotional and behavioural issues. Ask for a joint meeting with consent.
• The programme misuses terms or lacks credentials. If a programme sells riding lessons as "hippotherapy" without a licensed OT, PT or SLP, share the AHA and PATH Intl. definitions with the family and help them find a credentialed provider. [source: AHA media guidance; PATH Intl. Definitions Guide]
• An injury or fall. See 4.17. AHA reports low incident rates in its own survey data, but its safety paper is an advocacy document relying partly on self-reported data; keep risk discussion honest and refer medical questions to the physician. [source: AHA safety white paper]
• Infection risk for immunocompromised clients. Refer to the physician and the programme; IAHAIO supports exclusion criteria for high-risk groups. The 2020 literature review found infection-control policies varied widely across facilities and recommended standardised policies and handler education. [source: IAHAIO 2018; 2020 AAI risks review]
• Grief at the end. A horse retires, is sold or dies; a programme closes. Treat it as a real loss (see 4.18). If the client presents with intense, persistent grief, assess for prolonged grief and treat accordingly.
• Safeguarding concerns. Volunteers and staff may be unknown adults with physical access to a child. Ask the programme about its safeguarding policy and volunteer vetting; follow your local reporting duties if you have concerns.
• Rupture with the client over the referral. If the client feels you pushed or blocked participation, acknowledge it, revisit the decision together and make the client's own goals explicit.

Sources

• What is Hippotherapy? (American Hippotherapy Association)
• AHA media guidance letter (Press Kit)
• AHA, Inc. Statements of Best Practice, 2023
• Cook, Erdman, Fields and Peters, Occupational Therapy, Physical Therapy, and Speech-Language Pathology Incorporating Hippotherapy is a Safe Therapeutic Option (AHA white paper) [year uncertain]
• Matlock, Recognizing Shutdown (slides, AHA-hosted) [year uncertain]
• PATH Intl. glossary
• PATH Intl. Definitions Guide for Researchers
• PATH Intl. Standards for Certification and Accreditation: summary
• IAHAIO White Paper on Animal Assisted Interventions, updated 2018 (announcement)
• IAHAIO White Paper 2014, updated 2018 (PDF)
• Risks Associated with Animal-Assisted Intervention Programs: A Literature Review (medRxiv preprint, 2020); also listed on CDC Stacks [authorship attributed to Dalton et al. 2020: uncertain, not verified]
• Pahlke, What Are Equine-Assisted Services? A Practical Guide for Families and Communities (USU Extension, 2025)
• Wood et al. (2020), Optimal Terminology for Services in the United States That Incorporate Horses to Benefit People: A Consensus Document, Journal of Alternative and Complementary Medicine (as reported by PATH Intl. and USU Extension) [uncertain: not verified]
• APA Ethics Code (Standard 3.05)