Several years ago, Thoroughbred owner-breeder Earle Mack began hearing stories about military veterans finding relief from debilitating post-traumatic stress disorder (PTSD) through hands-on therapy sessions with horses.

A U.S. Army veteran who rose to the rank of lieutenant, Mack became keen on further exploring these overlapping passions of his — finding opportunities for ex-racehorses and raising awareness of a full-blown PTSD crisis that afflicts up to 30 percent of veterans nationwide and claims an average of 20 lives per day to suicide.

“For the equine industry, the most important thing to us is the horse and protecting them from being mistreated or slaughtered,” said Mack, a real estate developer and passionate Thoroughbred aftercare advocate. “As a country, one of our top priorities is to help our veterans that suffer from these mental wounds that are as debilitating or more debilitating than a bullet wound.”

Mack could see the potential but also a substantial roadblock. Though dozens of equine therapy programs existed, their results were anecdotal and lacked the verifiable evidence required to access broader financial support and acceptance from organizations such as the U.S. Department of Veterans Affairs.

“You could see these programs getting success with no defined protocol. It was sure to improve with a definitive study and protocol,” Mack said. “There had to be a methodology. You can’t just do it ad hoc.”

Mack needed experts and researchers, so in July 2014 he called longtime friend Dr. David Shaffer, former chairman of Columbia University Medical Center’s Department of Psychiatry, who immediately connected him with Dr. Yuval Neria, an expert in PTSD, and Dr. Prudence Fisher, an expert in psychiatric measurement and PTSD in youth.

Neria and Fisher would become co-leaders in the equine therapy research program initiated by the Man O’ War Project, a nonprofit organization dedicated to the first clinical research study to determine the effectiveness of equine therapy on PTSD. Mack kick-started the effort with a $1.2 million grant from his Earle I. Mack Foundation.

Man O’ War Project Researchers Columbia University researchers Dr. Yuval Neria, left, and Dr. Prudence Fisher at the Bergen Equestrian Center. (Courtesy of Man O' War Project)

“The statistics among veterans are pretty dire with millions of people with PTSD who are maltreated or not treated at all,” said Neria, who is a veteran tank commander for the Israeli Armed Forces. “Even the ones who are treated are not likely to respond more than 50 percent with the best evidence-based treatment, so we are constantly seeking promising treatments. We started looking at equine therapy with veterans across the country, but, unfortunately, no one before us standardized the treatment protocol or never determined if patients had PTSD with any rigor.

“The project with Man O’ War was a great opportunity for Columbia to study this and do things the right way,” Neria said.

The Columbia team had loads of expertise with PTSD diagnosis and in conducting clinical trials but lacked experience with horses. The research team started their horse education at the Wallkill Correctional Facility in New York where inmates care for rescued Thoroughbreds as part of the Thoroughbred Retirement Foundation’s Second Chances program. They then attended the Equine Assisted Growth and Learning Association’s annual conference and visited Rancho Bosque in Arizona to see a program run by Dr. Allen Hamilton and Dr. Jane Hamilton, who would later become consultants.

“We talked to a lot of people who have experience with equine therapy to put something together that looked like what was being done in the field but was more specific and standardized,” Fisher said. “It is still an experiential treatment but within a larger structure." The program uses a team approach that includes a mental health professional, an equine specialist, and an experienced "wrangler" to provide extra safety.

“We piloted our treatment program with two groups to make sure we made the right decisions,” Fisher said. “We changed some exercises that didn’t work very well and replaced them with things that made sense and now we have a manual.”

The pilot program was conducted at the Bergen Equestrian Center near Leonia, N.J., which is only a 15-minute hop over the George Washington Bridge from Columbia. Two groups of four veterans each met weekly for eight weeks. They were evaluated for PTSD using the CAPS scale, which is considered the “gold standard” for assessment by Veterans Affairs.

CAPS evaluates the frequency and severity of 17 symptoms on a scale of 0-4 (none to extreme). A symptom meets the PTSD criteria if it occurs at least one or twice (score of 1) and is at least moderate in intensity, causing some disruption (score of 2). The scores for each symptom are added up to get a final CAPS score. The baseline scores for the pilot program veterans ranged from 46 to 108.

At the end of the program, the veterans’ baseline scores dropped between 32 percent and 74 percent.

“We were happy to see people improved to a greater extent than we usually see with PTSD treatments, so we swiftly moved to the study,” Neria said.

The Man O’ War Project started its clinical trial last September with the goal of completing the study by July 2018. Neria said the team needs 50-60 veterans to produce statistically meaningful results. So far, 35 veterans have participated with a majority having completed the eight-week program. The research team continues to put a lot of effort into recruiting through open houses and agencies that provide services to veterans.

“Recruitment is always a challenge but there seems to be a demand for this treatment among both men and women. They are responding well to a treatment outside the office,” Neria said.

Neria and Fisher said the clinical trials have produced some remarkable results to date.

“People have less anger and are engaged emotionally with their surroundings ... their kids, their spouses. They go back to work and are not afraid to be seen in public,” said Neria. “In addition, we see good evidence of symptom improvement across the board including better sleep, less nightmares, less flashbacks, less hyper-vigilance, better concentration, and better memory.

“The beauty of this effect has yet to be fully explained by us or other people,” Neria continued. “What is it in this interaction with the horse and the experience in the pen that can bring about this amount of change in the veteran’s life? Many of them suffer for years and years and years, and never recover. We are optimistic about bringing them back to a fuller life.”

Fisher said a key component of the treatment seems to be the sensitivity horses have to emotion and body language. Because horses are prey animals and hyper-vigilant to any perceived threat, a veteran has to become more self-aware in order to earn a horse’s trust.

“They’re reactive, and because of their size, when a horse does something you notice,” Fisher said. “If you approach it and you’re aggressive, it will react to that. The veterans can then reflect on the energy they are sending out. Even with how you hold the shank. When you want to stop, do you look like you want to stop or are you unsure? The horse picks up on when you are unsure, the non-verbal part of how you are communicating.

“I had a guy say to me, ‘I’d go to these group therapies and I never knew what I was reaching for. Now I do,’ ” Fisher continued. “People who are participating really rejected getting therapy in the past. They may get to the end and still need treatment, but now they are open to it.”

The program also provides veterans with valuable experience in how to cope with stressful situations at home and at work.

“A circumstance will come up where they catch themselves about to react in an angry way that was normal for them,” said Anne Poulson, who is president of the Man O’ War Project board of directors and a former chair of the Virginia Racing Commission. “They remember the reaction and reframe themselves and react in a more appropriate way.”

Fisher noted the progressive format of the treatment protocol steadily builds up self-confidence and a sense of accomplishment that results in other positive changes.

“We have had people say, ‘If I can get here every week, then I can go do this, too,’ Or say stuff like, ‘I am doing stuff I never thought I would do again,’ ” she said. “They also learn how to ask people for help and not be afraid to ask for help. They are learning how to function socially and be comfortable.”

Once the clinical study is done and the results published, the long-term goal of the Man O’ War Project is to share the training manual with other groups in order to enhance their programs and make this treatment available throughout the country. With a standardized, statistically valid approach, these treatment outlets may one day be eligible for support through grants. In late July, for example, a congressional appropriations bill was approved with an amendment from U.S. Rep. Andy Barr (R-Ky.) that provided an additional $5 million for equine therapy for veterans during fiscal year 2018.

“We feel we are well-positioned to take advantage of that funding by having the research and the protocols in place,” Poulson said.

As more programs open for veterans, more second-career opportunities will be created for ex-racehorses.

“We have wonderful programs, like those supported by TAA [Thoroughbred Aftercare Alliance], and many horses will go on to a show career or pleasure career, but there are a lot of horses that can’t have riding careers,” Poulson said. “They can still have useful careers. This provides an outlet for horses that don’t have another outlet but they are kind.”

“A lot of the horses themselves unfortunately were abandoned,” noted Neria. “This is an opportunity to create something good to address the needs of both the horses and the humans. It is really a very rare opportunity.”

More information about the Man O’ War Project or about seeking treatment through its programs are available at mowproject.org.