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Forest for rest: recovery from exhaustion disorder
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine. (Arcum)
2014 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2014. , 47 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1667
Keyword [en]
Burnout, nature-assisted therapy, rehabilitation, forestry, stress disorders, environmental medicine, restoration, human health, well-being
National Category
Environmental Health and Occupational Health
Research subject
Public health
Identifiers
URN: urn:nbn:se:umu:diva-92589ISBN: 978-91-7601-083-9 (print)OAI: oai:DiVA.org:umu-92589DiVA: diva2:741822
Public defence
2014-09-30, Hörsal Betula, byggnad 6M, Norrlands Universitetssjukhus, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2014-09-09 Created: 2014-08-29 Last updated: 2017-02-14Bibliographically approved
List of papers
1. Restorative effects of visits to urban and forest environments in patients with exhaustion disorder
Open this publication in new window or tab >>Restorative effects of visits to urban and forest environments in patients with exhaustion disorder
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2014 (English)In: Urban Forestry & Urban Greening, ISSN 1618-8667, E-ISSN 1610-8167, Vol. 13, no 2, 344-354 p.Article in journal (Refereed) Published
Abstract [en]

This experimental study investigated differences in perceived restorativeness, mood, attention capacity and physiological reactions when visiting city and forest environments. Twenty female patients diagnosed with exhaustion disorder visited three different forest environments and one city environment in randomized order. They performed a standardized 90-min test procedure in each of these environments. Evaluation of the environments and psychological effects in mood were studied with self-administered questionnaires. Attention capacity was studied with Necker Cube Pattern Control task. Physiological responses were measured with regularly scheduled controls of heart rate and blood pressure, and a single test of heart rate recovery. Visits to the forest environments were perceived as significantly more restorative, enhancing mood and attention capacity compared to the city. This also applies to the results of heart rate and to some extent to the results of the diastolic blood pressure. The results from this experimental study support our hypothesis that short visits to forest environments enhance both psychological and physiological recovery and that visits to forest environments are likely to be beneficial when suffering from exhaustion disorder. 

Keyword
Burnout, City, Human health, Nature, Psychophysiology, Recovery
National Category
Environmental Health and Occupational Health
Identifiers
urn:nbn:se:umu:diva-89305 (URN)10.1016/j.ufug.2013.12.007 (DOI)000337018600017 ()
Available from: 2014-05-27 Created: 2014-05-27 Last updated: 2016-05-25Bibliographically approved
2. Can the boreal forest be used for rehabilitation and recovery from stress-related exhaustion? A pilot study.
Open this publication in new window or tab >>Can the boreal forest be used for rehabilitation and recovery from stress-related exhaustion? A pilot study.
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2011 (English)In: Scandinavian Journal of Forest Research, ISSN 0282-7581, E-ISSN 1651-1891, Vol. 26, no 3, 245-256 p.Article in journal (Refereed) Published
Abstract [en]

It has been suggested that humans suffering from mental exhaustion recover better in environments that do not demand directed attention. Hence, we hypothesized that forests have restorative effects and examined whether the boreal forest in northern Sweden can be used for rehabilitation from stress-related exhaustion in a pilot study. Six participants suffering from stress-related exhaustion were offered visits twice a week, for 11 weeks, in six different forest settings: pine forest, mixed forest, spruce forest, forest by the lake, the forest with a small stream and rock outcrops. The participants chose one forest setting prior to each visit, and the mental state of each participant was evaluated before and after each visit. Interviews focusing on the experience of the forest were conducted after the 22 visits. Solitude and forest settings with light were identified as positive factors for recovery. Despite the limited amount of data, the results showed that the forest visits had significant positive effects on the participants' mental state. The interviews also indicated that the concept is suitable for use in larger randomized studies and that it is important to provide various forest settings to meet individual preferences of the participants and to offer the possibility of solitude.

Place, publisher, year, edition, pages
Taylor & Francis, 2011
Keyword
Attention, burnout, environment, human health, nature, restoration, well-being
National Category
Forest Science Environmental Health and Occupational Health
Research subject
medicinsk beteendevetenskap
Identifiers
urn:nbn:se:umu:diva-41227 (URN)10.1080/02827581.2011.558521 (DOI)000289773800006 ()
Available from: 2011-03-21 Created: 2011-03-21 Last updated: 2016-05-25Bibliographically approved
3. Can rehabilitation in boreal forests help recovery from exhaustion disorder?: the randomised clinical trial ForRest
Open this publication in new window or tab >>Can rehabilitation in boreal forests help recovery from exhaustion disorder?: the randomised clinical trial ForRest
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2015 (English)In: Scandinavian Journal of Forest Research, ISSN 0282-7581, E-ISSN 1651-1891, Vol. 30, no 8, 732-748 p.Article in journal (Refereed) Published
Abstract [en]

Modern society is faced with increasing incidence of mental and behavioural disorders. The objective of this study was to evaluate whether visits to boreal forests can be utilised for rehabilitation from exhaustion disorder (ED). This randomised controlled trial comprised of a forest rehabilitation group (n = 35) and a waiting list group (control group) (n = 43) with subsequent cognitive behavioural rehabilitation (CBR) for all participants in both groups. The recovery from ED was compared between the forest rehabilitation and the control group at baseline, after the forest rehabilitation (3 months), and at the end of the CBR (1 year). Both groups had enhanced recovery from ED after the 3-month intervention period and at the end of the CBR (1 year), and there were no significant differences between the groups in terms of psychological health measures. Mental state, attention capacity and preferences for different forest environments were studied during the forest visits. Mental state was improved, but it showed some seasonal differences. A significant effect on attention capacity was found for single forest visits, but there was no effect found for the rehabilitation period as a whole. The most popular forest environments contained easily accessible, open and bright settings with visible water and/or shelter. Forest rehabilitation did not enhance the recovery from ED compared to the control group, but the participants’ well-being was improved after single forest visits.

Place, publisher, year, edition, pages
Taylor & Francis, 2015
Keyword
burnout, human health, mental disorder, nature assisted-therapy, rehabilitation, restoration, urban forestry
National Category
Environmental Health and Occupational Health
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-92558 (URN)10.1080/02827581.2015.1046482 (DOI)000361601800011 ()
Available from: 2014-08-28 Created: 2014-08-28 Last updated: 2016-05-25Bibliographically approved
4. "Nature's effect on my mind". Patients' experiences of nature based rehabilitation: a qualitative inquiry.
Open this publication in new window or tab >>"Nature's effect on my mind". Patients' experiences of nature based rehabilitation: a qualitative inquiry.
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(English)In: Urban Forestry & Urban Greening, ISSN 1618-8667, E-ISSN 1610-8167Article in journal (Other academic) Submitted
Keyword
burnout, city, human health, nature, psychophysiology, recovery
National Category
Environmental Health and Occupational Health
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-92564 (URN)
Available from: 2014-08-28 Created: 2014-08-28 Last updated: 2017-08-21Bibliographically approved

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