Discussion
psychological distress, reappraisal and suppression
DISORDER
The present hypothesized that in comparison with control group patients, the patients suffering from substance use disorder exposed to equine-assisted therapy will have significantly better emotion regulation (higher reappraisal and lower suppression scores, higher GSE scores and better perceived self-esteem (lower scores). The results demonstrated that the applied study intervention was a significant positive predictor of the reappraisal score and GSE scores and negative predictor of the suppression of the self-esteem negative score. The findings thus lead to acceptance of the set research hypotheses.The patients were randomized to the intervention and control groups and the randomization process was succesful providing two groups with almost similar demographic and medical charateristics. This is quite important in order to carry out a fair comparison between the two groups. The only difference of statistical significance between the two groups was related to their educational level, where less patients in intervention group were having university education. However, this variable had no confounding effect as shown in the results of the multivariate analyses.According to the current study findings, the age at start of substance use was mostly 15 years or older among the patients in both groups. This is the age of middle adolescence when the youth tend to experiment with new things and have more risky behaviors. In line with this, a meta-analysis reported that the peak age at start of SUD was 19.5 years [As regards the types of substances used, opiates and narcotics as well as sedatives and tranquillizers were most commonly reported among patients in the present study. The findings are in partial agreement with Wakeman et al. [The current study assessed and compared patients’ emotion control (reappraisal and suppression), GSE and perceived self-esteem in the study and control groups before the intervention. The results revealed no significant differences between the two groups, with both having low scores of reappraisals and GSE and high suppression scores. The findings are of great importance given the essential role of emotion regulation in mental health as clarified in a study in Pakistan [Meanwhile, the present study intervention and control patients’ pre-intervention self-esteem median scores were indicative of slight low self-esteem in at least one half of the samples. This is of major importance in the prognosis of these patients since good self-esteem has been shown to protect against psychological distress among patients under treatment of substance use disorder in a study in Norway [The implementation of the current study equine-assisted therapy led to statistically significant improvements in the intervention group patients’ emotion regulation, both reappraisal and suppression dimensions, as well as in GSE and perceived self-esteem. The effect of this intervention was confirmed in the results of the multivariate analyses. The effect of the intervention was additive to the effect of the regular treatment modalities, particularly regarding the improvement of GSE and self-esteem as shown in bivariate analyses of the control group patients. In agreement with the benefits of equine-assisted therapy in substance use disorder, Marchand et al. [Furthermore, the results of the current study are in congruence with those reported by Fridén et al. [Our study has points of strength and limitations. To our knowledge, this is the first study in Egypt utilizing the equine therapy in the management of SUD patients. The main study limitation is the paucity of similar studies published in peer-reviewed journals, which did not help the researchers to introduce the topic and to discuss the study findings. The bias associated with open-label design could not be avoided, but it was dealt with through blinding the processes of data collection and analysis, which were done by individuals other than the researchers.