Objective: To report on the role of nature in outdoor therapies through review and summary of existing systematic and meta-analytic reviews in an effort to articulate a theoretical framework for practice. Materials and methods: An umbrella review was conducted following systematic protocols PRISMA guidelines. Results: Fourteen studies met the inclusion criteria and represented five self-identified approaches: nature-based therapies, forest therapy, horticultural therapy, wilderness therapy, and adventure therapy. Clear and comprehensive descriptions of theory, program structure, and activity details with causal links to outcomes were mostly absent. Conclusions: A rigorous and determined program of research is required in order to explicit in-depth theories of change in outdoor therapies. Conversely, or maybe concurrently, a holistic theory of integrated relatedness may be developed as a parallel expression of support for nature in therapy while the explanatory science catches up.

Despite considerable progress within wilderness and adventure therapy research over the last decade, researchers are still unable to precisely answer why, how, and for whom this treatment modality works. There is also a need for more knowledge regarding the circumstances under which the treatment does not appear to be effective. In this realist synthesis, we attempt to unpack this “black box” of wilderness therapy more specifically, defined as a specialized approach to mental health treatment for adolescents. Through a focused review of the primary qualitative wilderness therapy studies, empirical findings are used to test and refine a key program theory. The synthesis results in a proposed wilderness therapy clinical model and offers informed implications for future theory development, research, and practice.

Wilderness therapy has the potential to meet the specific needs of the current adolescent population by providing a rather unique outdoor group treatment. Wilderness therapy is not a new approach to mental health treatment, but its theoretical basis is not yet clearly delineated, in part because of the diversity found across programs and contexts. This article presents a critical realist exploration of a wilderness therapy program that was recently implemented as part of adolescent mental health services in Southern Norway. In this study, we combine fieldwork and interviews for an in-depth investigation of the treatment process, where the objective was to acquire a deeper understanding of the opportunities that arise in the wilderness therapy setting. The therapeutic mechanisms and influential contextual premises found across the ecological, physical, and psychosocial factors of this multidimensional approach to treatment are presented, and their underlying conditions are briefly discussed.

This paper investigates the effectiveness of a Norwegian wilderness therapy programme, Friluftsterapi, which is offered to adolescents within a specialized mental health care setting. This mixed methods study incorporated (1) psychometric pre-, post-, and 12 month follow-up data, (2) executive functioning data, and (3) qualitative data from two rounds of individual participant interviews. The results indicate that group averages remained largely the same between the pre- and post-tests, however that health measures generally improved one year later (Cohen’s d effect sizes ± 0.5). Interview data revealed that the processing of the Friluftsterapi experiences takes time and that for many several months are required before the impact is fully internalized and translated into improved daily functioning. In conclusion, the Friluftsterapi experience is perceived as valuable, and it appears to contribute towards improving the mental health of many participants. A refined version of the treatment programme is suggested and briefly presented in the conclusion.

Despite the rich traditions of outdoor life in the Scandinavian countries, structured nature-based therapeutic interventions remain underexplored in adolescent mental health services. We suggest that wilderness therapy is an age-appropriate and effective group treatment that may hold particular appeal for at-risk youth who are less responsive to conventional forms of treatment. Although more widespread in other parts of the world, wilderness therapy may also be a viable treatment modality for the Scandinavian region. Our overall aim of this state-of-knowledge article is to provide an overview of wilderness therapy with regard to conceptualization, practice and research, and to discuss current challenges. Based on the available knowledge, we suggest that the addition of this nature-based group treatment could increase the diversity of treatment options in adolescent mental health services in Scandinavia and recommend rigorous intervention studies exploring what works, for whom, and in what circumstances.

Mentalization-based family therapy and family rehabilitation represent a rich variety of approaches for assisting families with difficult interaction patterns. On the other hand, adventure therapy methods have been successfully used with families to offer them empowering experiences of succeeding together against difficult odds and to improve communication between family members. Further, the health promoting qualities of spending time outdoors are now well established and recognized. The Nordic approach to mentalization-based family rehabilitation combines adventure, outdoor, and systemic therapy. We provide three examples of nature-based family rehabilitation practices that are delivered as brief, multi-family psychological interventions taking place in nearby nature and aiming to support sustainable, systemic change. The current contribution is a description of clinical practice, not a systematic review or a formal evaluation. We propose that recontextualizing mentalization-based family rehabilitation to the outdoors can not only provide added health benefits, but also strengthen intra-familial attuned interaction and emotional connectedness. The outdoor adventure provides the families with embodied, multisensory experiences of verbal and, especially, non-verbal interaction that can be usefully examined through the lens of theory of mentalization. The concreteness of adventure experiences is particularly beneficial for families that have difficulties in verbal communication and/or utilizing executive functions, perhaps due to neuropsychiatric traits, intellectual disabilities, or learning difficulties. Furthermore, outdoor adventure can support the participants’ connectedness to nature.