Background Exhaustion disorder (ED) is a common mental and behavioural disorder which often leads to severe negative consequences for the individual and the society. Natural environments have positive effects on mental, physiological and attentional recovery in stressed persons, which encouraged us to test if forest visits could improve recovery from ED. The main objective of the thesis was to study if visits to different kinds of forest environments have positive health effects on patients suffering from ED, and if forest visits can be utilized for rehabilitation. Methods Participants in the MiniRest study (n=20) and the Pilot study (n=6) (Papers I and II) were recruited from the Stress Rehabilitation Clinic (SRC) at the University Hospital in Umeå.  Participants in the randomised controlled study, ForRest (n=99) and the Interview study (n=19) (Papers III and IV) were recruited from both the SRC and the Swedish Social Insurance Agency in Umeå. The MiniRest study involved only female ED patients and focused on immediate mental, physiological and attention capacity effects in one urban and three forest environments. The Pilot study investigated the practical arrangements for the forthcoming ForRest study. Participants in the ForRest study were randomised into either a three-month forest rehabilitation group; A (forest visits twice a week/4 hours per day) or to a control condition; B. Both groups received Cognitive Behavioural Rehabilitation (CBR) at 24 occasions/once a week after the three-month study period. Preferences for forest environments, mental state and attention capacity were studied for group A only. Psychological health measurements and sick leave data were compared between the groups after (i) the forest rehabilitation and (ii) the CBR. The Interview study was conducted according to grounded theory methodology and consisted of 19 participants from group A to explore personal experiences from the forest rehabilitation. Data collection was implemented through questionnaires, medical records, physiological measurements, and interviews. Results Exposure to forest environments was associated with higher preference, more favourable mental state and physiological responses, and increased attention capacity compared to an urban environment (Paper I). Open and accessible forest environments were preferred (Papers I, II and III). Recovery from ED was found in both groups in the ForRest study, but there were no differences between the groups over time. In group A, positive effects on mental state and attention capacity were found during the forest visits. An interaction effect was found with more positive effects on mental state during spring compared to autumn (Paper III). Solitude, feelings of freedom and no demands were important for finding peace of mind during the forest visits. Moreover, easier access to peace of mind, reflective thinking and positive feelings were reported as the forest rehabilitation progressed (Papers II and IV). Conclusions Forest visits have restorative effects for ED patients through enhanced mental well-being, easier access to peace of mind, beneficial physiological reactions and increased attention capacity which support the use of forest environments in rehabilitation. However, forest rehabilitation tested in a randomised controlled trial did not improve recovery from ED. Potentially rehabilitation with CBR and forest visits integrated could be more effective and should be further investigated in nature-assisted rehabilitation for ED patients.

Stress-related diseases in Sweden have doubled since 1997. Even longterm sickness related tostress has increased over the last decade. In future there is a need of alternative methods todecrease the amount of people being affected to gain a better population health. Natureassisted therapy (NAT) was shown to be a successful method as part of the therapy of stressand burnout likewise was nature an important factor to prevent people from mentaldisorders. The aim of this study was to analyse the latest research concearning nature and itshealth effects with focus on stress and burnout patients in order to plan health promotingactivities outdoors for these patients. Questions included in the study were what impact natureexperiences have apart from medical and psychotherapeutic methods and how natureexperiences do affect stress and burnout patients. The results show that viewing landscapes,rest activities in boreal environment (especially broad-leaved and pine forest), closeness towater and bright wide surroundings have positive effects on people with stress. There is theevidence that certain nature qualities can serve as resources for recovery from stress. Theycan also reduce the risk for gaining mental health. Nature experience is evoking a relaxingmechanism through the activation of the parasympathetic nerve system. For a longtermeffect affected patients do not only need to be shown meaningful activities outdoors but alsohas nature and outdoor activities to become a part of people’s everyday life.

The connection between human and nature is fading away as society gets more modernised, with increased stress-levels as a result. Interventions based on green care have proven to give stress-reducing effects for a variety of client-groups. Using a qualitative literature study approach, the aim with this paper was to investigate how occupational therapists work within the green care area and what effects such interventions could have. The literature-search was carried out both manually and within databases. Fifteen papers were found that fulfilled the criteria for inclusion and were used for analysis. The data-analysis resulted in four categories; “Activity as goal and means”, “Investigation, evaluation and collaboration”, “Decreasing stress and increasing wellbeing” and “Sense of fellowship and belonging”. Concluding results show that occupational therapists administrates and leads programs within green care. Furthermore, the most pronounced effects were decreased stress and improved well-being. Implementing green care within occupational therapist operations has advantages and can be a valuable therapeutic tool.

Animal-assisted therapy (AAT) and equine-assisted therapy/learning (EAT/L) are innovative techniques in counselling, psychotherapy, mental health, coaching, and other personal growth interventions. Although this field has experienced tremendous growth in the United States, very little is known about its Canadian equivalent. The purpose of this study was therefore to examine the current state of AAT and EAT/L in Canada, by conducting a national, bilingual (English and French) survey of helping professionals who involve animals in their practices. A total of 131 questionnaires were retained for analysis. The results of this study suggest that the field is very diverse, with a multitude of confusing terms and expressions, varying levels of education and training, and disagreement on how different practices are defined, resulting in a fragmented, confusing and inconsistent appearance. Recommendations for the evolution of the field and suggestions for future research are provided.