Publikasjoner
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Fernee, Carina R.; Mattsson, Markus Tapani; Lyytinen, Pekka & Harper, Nevin J.
(2026).
The Implicit Ecosystem of Outdoor Therapies: A Grounded Theory Exploratory Study of International Practitioners’ Guiding Frameworks and the Proposition of a Practice Theory.
International Journal of Environmental Research and Public Health (IJERPH).
ISSN 1661-7827.
23(3).
doi:
10.3390/ijerph23030394.
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Human health and well-being are dependent on natural environments, which is the core foundation of the growing discipline of outdoor therapies. However, as with psychotherapy research in general, the field of outdoor therapies lacks descriptive process-oriented theoretical frameworks that precisely reflect this multi-faceted practice. Therapeutic work, whether this takes place indoors or outdoors, comprises numerous implicit relational and environmental dimensions. Implicit aspects are largely sensed, embodied and intuitive, and therefore hard to pin down and describe accurately. In this exploratory study, a survey mapped implicit guiding frameworks amongst outdoor therapy practitioners (n = 68) representing 18 nations. A constructivist grounded theory analysis resulted in the proposition of a practice theory, called the implicit ecosystem of outdoor therapies, made up of eight interrelated components: (1) joint engagement and co-creating agendas; (2) a foundation of safety and trust; (3) being in parallel and not fix; (4) awareness and attunement here-now; (5) the dynamic of outer and inner landscapes; (6) a constantly moving and meaning-making endeavor; (7) creativity, play, and whole-body activation; and (8) working through natural barriers and rewriting narratives. This grounded theory offers a preliminary blueprint of a practice-guiding framework developed from within the outdoor therapy discipline intended to advance theory, training, and research.
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Mattsson, Markus Tapani; Dettweiler, Ulrich; Winje, Øystein; Truelsen, Sigrid Lærke Bring; Løhaugen, Gro & Fernee, Carina Ribe
(2026).
The nature ”pill” for neurodiverse children and youth: a scoping review of plausible mechanisms, explanatory theories and psychosocial outcomes in ADHD and autism.
Journal of Environmental Psychology.
ISSN 0272-4944.
111.
doi:
10.1016/j.jenvp.2026.103013.
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Background
Recent research has demonstrated a multitude of ways in which exposure to nature enhances health and well-being. However, it is unclear whether this is true for neurodiverse children and youth, such as children on the autism spectrum and children with ADHD or Tourette's syndrome.
Objective
This scoping review summarizes plausible mechanisms, explanatory theories, intended outcomes, and the results of studies examining the relationship between exposure to nature and psychosocial outcomes in neurodiverse children and youth.
Design
We searched for peer-reviewed research reports on the relationship between exposure to nature and psychosocial outcomes in 0–18-year-old children and youth with a diagnosis of ADHD, autism or Tourette's syndrome in six online databases with no language restrictions. The search included all years, and the final search was performed in April 2024. Animal-assisted studies and studies on family outcomes were excluded.
Results
This review covers 43 studies (1976–2023), primarily from North America and Europe, with 25 on ADHD and 18 on autism. Our systematic search did not identify any studies focusing on Tourette's syndrome. The most commonly identified causal pathways were restoring and building capacities. The most commonly mentioned theories – Attention Restoration Theory (ART) and Stress Reduction Theory (SRT) – were related to the restoring capacities pathway. Most studies adopted the medical model, viewing neurodevelopmental conditions as disorders. “Nature” was generally defined ostensively or operationally.
Conclusions
Drawing on our analysis of plausible causal pathways, underlying theories, and varying definitions and conceptualizations of nature, we identify five critical research gaps to guide future studies. 1) Exploring diverse geographical and cultural contexts – more diversity is required; 2) Conceptualizing nature – what is it that provides the beneficial effects in nature? 3) A more nuanced view of pathways – it is important to align the plausible pathways with how neurodiversity is conceptualized; 4) Expanding theoretical frameworks – while most studies cited ART and/or SRT, which relate to the restoring capacities pathway, explanatory theories related to the other pathways are needed; 5) Conceptualizing neurodevelopmental phenomena – there is room for building on more varied conceptualizations than the medical model, especially considering that restoring capacities and building capacities were the most commonly identified pathways.
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Dahlqvist, Heléne; Ekdahl, Ann; Wiklund, Emma; Jong, Mats; Berntsen, Sveinung & Fernee, Carina Ribe
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(2026).
Managing Late and Long-Term Effects Among Swedish Adolescents and Young Adults Affected by Cancer Following a Wilderness Intervention: Reconnecting with Self and Meaning Through Nature’s Unconditional Presence – A Qualitative Study.
Cancer Control.
ISSN 1073-2748.
33,
s. 1–18.
doi:
10.1177/10732748251414202.
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Introduction Adolescents and Young Adults (AYAs) affected by cancer are at risk of experiencing late and long-term effects following cancer diagnosis and treatment. While structured interventions have demonstrated potential benefits for well-being during the intervention itself, little is known about how AYAs affected by cancer engage with and experience nature in their everyday lives beyond the formal program context. The aim of this study was to explore how a selected group of AYAs affected by cancer—who had participated in a nature-based intervention (the WAYA program)—experience nature and its role in supporting and managing late and long-term effects of cancer and its treatment, beyond the context of the program itself. Method This qualitative study explored the experiences of nature following the WAYA intervention among AYAs affected by cancer. Data were collected by focus group interviews at a three-month follow-up, using participant-selected photographs as visual prompts to elicit reflection on how nature supports management of late and long-term effects of cancer. A photovoice-inspired approach guided discussion questions and facilitated individual and collective meaning-making. Interviews were audio-recorded, transcribed verbatim, and analyzed using qualitative content analysis. Results The analysis of this study showed one theme: Reconnecting with self and meaning through nature’s unconditional presence—beyond human connection. The theme comprises the two categories Nature as a resource for inner balance and Nature as a meaningful companion , and five sub-categories : Managing by being mindful, Managing by experiencing rest and being calm, Experiencing metaphoric recognition, Sparking comfort, hope and positive emotions, and Nature as a space without obligations. Conclusion This study explored how AYAs affected by cancer engage with nature beyond formal programs, revealing its potential in better management of late and long-term effects. These findings can inform low-threshold, personal meaningful, and sustainable approaches to clinical practice, well-being, and rehabilitation for this vulnerable group.
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Hagerup, Anne; Fernee, Carina Ribe; Wijk, Helle; Lindahl, Göran & Olausson, Sepideh
(2025).
Through the lens of patients: a photovoice study exploring inpatients’ sense of safety and well-being in a new Norwegian mental health facility.
BMC Psychology.
13(1).
doi:
10.1186/s40359-025-03375-8.
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Patients’ sense of safety and well-being may be affected in numerous ways while being cared for in hospitals. Often, feelings of alienation arise, as private spaces like the home are inaccessible. One aspect that impacts patients’ safety and well-being is the design of the physical care environment. In this study, we sought to understand the impact of the physical environment and interpret the meanings of the care environment and its contributions to inpatients’ sense of safety and well-being. Fourteen adult patients were being cared for in a new mental health facility where a key feature is the focus on supportive and biophilic design and access to nature. Data were generated using a photovoice methodology (i.e., photos were taken by the participants themselves, followed by individual interviews). We adopted a phenomenological hermeneutic approach to research lived experiences and analyzed the interviews. Three major themes emerged: being sheltered, feeling cared for and dignified, and being held by nature. We found that the patients were able to find calmness, to land, and to rest in the new mental health facility because of the supportive design. Therefore, they were more open to therapeutic interventions that might make the recovery process faster. The insights from this study underscore the importance of prioritizing design features that address the various and holistic needs of patients in mental health care.
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Hagerup, Anne; Fernee, Carina Ribe; Wijk, Helle; Lindahl, Göran & Olausson, Sepideh
(2025).
Psychiatric spaces: a phenomenological case study of staff perspectives after relocation to a new mental health facility.
International Journal of Qualitative Studies on Health and Well-being.
ISSN 1748-2623.
20(1).
doi:
10.1080/17482631.2025.2485697.
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Introduction: Patients in mental health care rely on staff for their well-being, security, andquality of treatment. However, staff’s perspective of the physical environment where caretakes place remains underexplored. Their insights are crucial to understanding how theenvironment impacts the quality of care. Therefore, the aim of this study is to explore themeanings of the physical environment for inpatient care according to staff shortly afterrelocation to a new mental health facility.Methods: The study employed a phenomenological approach and focus group interviewswith 20 staff working in a newly built mental health facility. Data were analysed using vanManen’s existentials and guided by the theory of affordances.Results: The primary findings were as follows: (a) attempting to provide a therapeutic atmo-sphere, (b) design as symbolism, (c) altering the physical environment means altering time,(d) offering spaces for connection and communication, and (e) embodying the new mentalhealth facility.Conclusion: The findings indicate that regardless of whether affordances are actualized,opportunities and obstacles in the hospital environment impact the staff’s ability to provideinpatient care according to their standards. Conflict arose due to obstacles inherent in theorganization and structure of the new mental health facility that limited opportunities to utilize possible affordances.
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Tofte, Håvard; Fernee, Carina Ribe & Vikene, Odd Lennart
(2024).
Ein relasjonell kurs med eit mål om anerkjenning – utforsking av utandørsterapeutisk praksis frå ein friluftsfagleg ståstad.
Tidsskrift for psykisk helsearbeid.
ISSN 1503-6707.
21(1),
s. 16–29.
doi:
10.18261/tph.21.1.3.
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Fernee, Carina Ribe; Torvik, Siv; Råheim, Målfrid & Blystad, Astrid
(2024).
Et sted å puste: En utforskende studie av et naturbasert dagtilbud for ungdom.
Tidsskrift for psykisk helsearbeid.
ISSN 1503-6707.
21(4),
s. 292–301.
doi:
10.18261/tph.21.4.2.
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Jong, Miek C.; Fernee, Carina Ribe; Stenling, Andreas; Lown, E Anne; Berntsen, Sveinung & Victorson, David E.
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(2024).
Protocol of a randomised controlled multicentre trial investigating the effectiveness and safety of a wilderness programme on the mental and physical well-being of adolescents and young adults affected by cancer: the WAYA-2 study.
BMJ Open.
14(5).
doi:
10.1136/bmjopen-2024-087626.
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Introduction Adolescents and young adults (AYAs) affected by cancer are an understudied group. Effective interventions are needed to support coping with the late effects of cancer, its treatment and to promote quality of life. Nature-based interventions may be promising in support of the self-management and health of AYAs affected by cancer. However, randomised controlled studies (RCTs) on the effectiveness of such interventions are lacking. We performed a first pilot RCT (n=42) that showed that it is feasible and safe to conduct such a study. Here, we propose a full-scale RCT to investigate the effectiveness and safety of a wilderness programme on the mental and physical health of AYAs affected by cancer.<p> <p>Methods and analysis Participants are 150 AYAs affected by cancer, aged 16–39 years, who will be randomised to a wilderness (n=75) or a hotel stay (n=75). The wilderness programme is an 8-day intervention including a 6-day wilderness expedition. This is followed 3months later by a 4-day intervention including a 2-day basecamp. Activities include hiking, backpacking, kayaking, rock climbing, mindfulness and bush-crafting. The comparison group is an 8-day hotel stay followed by a 4-day hotel stay (interventions include two travel days) at the same hotel after 3months. Primary outcomes are psychological well-being and nature connectedness up to 1 year after the study start. Secondary outcomes are quality of life, physical activity and safety parameters. <p>Ethics and dissemination The Swedish Ethical Review Authority approved the study protocol on 27 September 2023 (reference: 2023-05247-01). The recruitment started on 19 February 2024 and the first part is planned to end on 31 December 2027. Study results will be disseminated by means of scientific publications, presentations at conferences, popular articles, interviews, chronicles and books. News items will be spread via social media, websites and newsletters.
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Zahl-Olsen, Rune; Severinsen, Linda; Stiegler, Jan Reidar; Fernee, Carina Ribe; Simhan, Indra Laetitia & Rekdal, Sondre Sverd
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(2023).
Effects of emotionally oriented parental interventions: a systematic review and meta-analysis.
Frontiers in Psychology.
14.
doi:
10.3389/fpsyg.2023.1159892.
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Objective: This systematic review and meta-analysis investigates the effects of emotionally oriented parental interventions.
Background: Several emotionally oriented parental interventions have been developed during the last decade. Some of these have gained popularity and spread across several continents. The literature is growing and consists of qualitative studies; intervention only, quasi-experimental, case-control studies; and randomized controlled trials. They indicate effects for parents and children. However, no systematic review or meta-analysis has, to our knowledge, summarized the results.
Method: Using several search engines, we located 8,272 studies. After abstract and full-text screening, 33 studies were assessed for bias and included in the study. Outcomes for parents and children were extracted and combined into three constructs for parents and two for children. Meta-analyses were conducted for each construct to estimate the effect of the interventions using a robust Bayes meta-analysis.
Results: The results indicate the presence of a small to medium effect on parents' mental health, behavior, and use of emotionally oriented parenting, as well as on children's internalizing and externalizing difficulties. Most participants were recruited from the general population, and clinical settings were rare. The results show little evidence of publication bias.
Conclusion: There is evidence of a small to medium effect of emotionally oriented interventions on parents and children.
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Fernee, Carina Ribe; Wahlgren, Sophia Lousie Hjorth & Trangsrud, Lise Katrine Jepsen
(2023).
The potentiality of nature to tug at our heartstrings: an exploratory inquiry into supportive affordances for emotion-focused family therapy in the outdoors.
Journal of Outdoor and Environmental Education (JOEE).
ISSN 2206-3110.
21(1).
doi:
10.1007/s42322-023-00157-x.
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A wealth of studies demonstrate the associations between nature contact and well-being, and gradually, nature-based solutions are becoming more widespread in mental health care and recovery. While emotion-focused therapies generally show promising results, evidence of nature-based family therapy is still scarce. In a forthcoming clinical trial at Sørlandet hospital in Southern Norway, we will compare indoor and outdoor provision of emotion-focused multi-family therapy. The foundation of emotion-focused therapeutic work with families is a deep belief in the healing powers of families, where resources within the “ecosystem” of a given family can be reactivated and nudged towards establishing a greater sense of harmony and connectedness over time. According to a Gibsonian understanding of affordances, humans respond to possibilities and limitations within an environment, where affordances in the context of this article arise from a systemic interplay between nature, participating families and facilitators. In this exploratory inquiry, we are particularly interested in the myriad ways nature may influence four core principles in emotion-focused therapy, including (a) emotion awareness, (b) emotion regulation, (c) reflection on emotion, and (d) emotion transformation. In this perspective article, we propose hypotheses and working metaphors in relation to everything from emotions’ multiple purposes to the delineation of facilitators’ accepting, empathic and curious stance. First and foremost, we attempt to generate a preliminary account of nature’s potentiality to tug at our heartstrings and offer a supportive environment for the novel provision of emotion-focused family therapy in the outdoors.
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Harper, Nevin Jason; Fernee, Carina Ribe; Mattsson, Markus & Lyytinen, Pekka
(2023).
Beyond The Stories We Tell Ourselves:
Implicit Theory and a Proposed
Research Agenda for Outdoor Therapies.
International Journal of Adventure Therapy.
ISSN 2700-7375.
4.
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Kolb, Helen; Dovran, Anders; Fernee, Carina Ribe & Bøe, Tore Dag
(2022).
The magic in the (extra)ordinary: Intensive validation to recalibrate the life-worlds of adolescents exposed to abuse.
Child & Family Social Work.
ISSN 1356-7500.
doi:
10.1111/cfs.12941.
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This qualitative case study aimed to explore environmental circumstances and inter-actional processes that appeared to be relevant for the dynamics of resilience in ado-lescents exposed to child abuse. Fieldwork at a learning and coping centre forchildren and their families was combined with semi-structured interviews with ado-lescent participants aged 12 to 18 years. A critical realist approach was used tounpack what has been called the‘ordinary magic’of resilience. We found thatinten-sively validating qualitiesof both theenvironmentandrelationshipsseemed to be driv-ing components for resilience. Borrowing ideas from the sociometer theory, wepropose that particularly the consistent intensiveness may offer arecalibrationof theadolescents' immediate life-worlds, in terms of how they perceive the people theymeet and the environments they step into. In keeping with the transactional-ecological model of resilience, we suggest that such a recalibration leads to alteredsocial agency that becomes visible through their immediate social participation.
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Mattsson, Markus; Fernee, Carina Ribe; Pärnänen, Kanerva & Lyytinen, Pekka
(2022).
Restoring Connectedness in and to Nature: Three Nordic Examples of Recontextualizing Family Therapy to the Outdoors.
Frontiers in Psychology.
13,
s. 1–11.
doi:
10.3389/fpsyg.2022.768614.
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Harper, Nevin J. & Fernee, Carina Ribe
(2022).
Unpacking Relational Dignity: In Pursuit of an Ethic of Care for Outdoor Therapies.
Frontiers in Psychology.
13,
s. 1–5.
doi:
10.3389/fpsyg.2022.766283.
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Dignity is a universal principle that requires us to treat every person as having worth beyond who a particular person is or what they do. Dignity is a complex and sometimes contested idea, that at times can be compromised in health care and allegedly also within the practice of outdoor therapy. Outdoor therapies comprise a range of therapeutic approaches including nature-based therapy, adventure therapy, animalassisted therapy, forest therapy, wilderness therapy, surf therapy, and more. Within the literature of outdoor therapies there has been limited research on ethics related to common understandings of care concepts such as relational dignity and human rights. The aim of this paper is therefore to unravel briefly whether dignity in general, and relational qualities of dignified care more particularly, might be a useful concept to apply in order to support an ethical practice in outdoor therapies.
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Stea, Tonje Holte; Jong, Miek C.; Fegran, Liv; Sejersted, Ellen; Jong, M. & Wahlgren, Sophia Louise Hjorth
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(2022).
Mapping the Concept, Content, and Outcome of Family-Based Outdoor Therapy for Children and Adolescents with Mental Health Problems: A Scoping Review.
International Journal of Environmental Research and Public Health (IJERPH).
ISSN 1661-7827.
19(10).
doi:
10.3390/ijerph19105825.
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Outdoor therapy and family-based therapy are suggested to be promising interventions for
the treatment of mental health problems. The aim of the present scoping review was to systematically
map the concept, content, and outcome of combining family- and outdoor-based therapy for children
and adolescents with mental health problems. The Joanna Briggs Institute methodology and PRISMA
guidelines were applied. Eligible qualitative and quantitative studies were screened, included,
and extracted for data. Seven studies were included. Findings from these studies indicated that
family-based outdoor therapy programs have a positive impact on family- and peer relationships,
adolescent behavior, mental health, self-perceptions (self-concept), school success, social engagement,
and delinquency rates. However, participant characteristics, study design, and content and mode of
delivery of the interventions varied substantially, hence preventing detailed comparison of outcomes
across studies. In addition, most of the studies included few participants and lacked population
diversity and comparable control groups. Although important ethical concerns were raised, such as
non-voluntary participation in some of the programs, there was a lack of reporting on safety. This
review indicates that a combination of family- and outdoor-based therapy may benefit mental health
among children and adolescents, but due to the limited number of studies eligible for inclusion and
high levels of heterogeneity, it was difficult to draw firm conclusions. Thus, future theory-based
studies using robust designs are warranted.
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Harper, Nevin; Fernee, Carina R. & Gabrielsen, Leiv E.
(2021).
Nature’s role in outdoor therapies: An umbrella review.
International Journal of Environmental Research and Public Health (IJERPH).
ISSN 1661-7827.
18(10).
doi:
10.3390/ijerph18105117.
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Fernee, Carina; Gabrielsen, Leiv Einar; Andersen, Anders Johan W. & Mesel, Terje
(2020).
Emerging stories of self: long-term outcomes of wilderness therapy in Norway.
Journal of Adventure Education and Outdoor Learning.
ISSN 1472-9679.
doi:
10.1080/14729679.2020.1730205.
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Gabrielsen, Leiv Einar; Harper, Nevin & Fernee, Carina Ribe
(2019).
What are constructive anxiety levels in wilderness therapy? An exploratory pilot study.
Complementary Therapies in Clinical Practice.
ISSN 1744-3881.
37,
s. 51–57.
doi:
10.1016/j.ctcp.2019.08.007.
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Fernee, Carina Ribe; Mesel, Terje; Andersen, Anders Johan W. & Gabrielsen, Leiv Einar
(2018).
Therapy the natural way: A realist exploration of the wilderness therapy treatment process in adolescent mental health care in Norway.
Qualitative Health Research.
ISSN 1049-7323.
doi:
10.1177/1049732318816301.
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Fernee, Carina Ribe; Gabrielsen, Leiv Einar; Andersen, Anders Johan W. & Mesel, Terje
(2017).
Unpacking the Black Box of Wilderness Therapy: A Realist Synthesis.
Qualitative Health Research.
ISSN 1049-7323.
27(1),
s. 114–129.
doi:
10.1177/1049732316655776.
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Fernee, Carina Ribe; Gabrielsen, Leiv Einar; Andersen, Anders Johan W. & Mesel, Terje
(2015).
Therapy in the open air: Introducing wilderness therapy to adolescent mental health services in Scandinavia.
Scandinavian Psychologist.
2.
doi:
10.15714/scandpsychol.2.e14.
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Gabrielsen, Leiv Einar; Fernee, Carina Ribe; Aasen, Gunnar & Eskedal, Leif Torvald
(2015).
Why randomized trials are challenging within adventure therapy research: Lessons learned in Norway.
Journal of Experimental Education.
ISSN 0022-0973.
39(1),
s. 5–14.
doi:
10.1177/1053825915607535.
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Fernee, Carina Ribe
(2025).
Where Wild Things Grow: An action research project that develops and implements nature- and activity-based approaches for children with neurodivergence in school, health care, family and leisure settings in Southern Norway.
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Fernee, Carina Ribe; Åsen, Gunnar Oland; Palucha, Vibeke & Major, Camilla Larsen
(2025).
Where Wild Things Grow: An action research project that develops and implements nature- and activity-based approaches for children with neurodivergence in school, health care, family and leisure settings in Southern Norway.
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Skoglys, Emilie; Winje, Øystein & Fernee, Carina Ribe
(2024).
Friluftslæring, en vei til mestring i skolehverdagen?
Fædrelandsvennen.
ISSN 0805-3790.
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Skoglys, Emilie; Winje, Øystein & Fernee, Carina Ribe
(2024).
Friluftslæring, en vei til mestring i skolehverdagen?
Fædrelandsvennen.
ISSN 0805-3790.
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Fernee, Carina Ribe
(2023).
Helsegevinster i naturen: En skog av muligheter.
lokalavisen fedrelandsvennen.
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Gabrielsen, Leiv Einar & Fernee, Carina Ribe
(2015).
Wilderness therapy within the mental health care in Norway - creating opportunities and navigating challenges.
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Gabrielsen, Leiv Einar & Fernee, Carina Ribe
(2014).
Psykisk helsearbeid i naturen - friluftsliv inspirert av historie og identitet.
Tidsskrift for psykisk helsearbeid.
ISSN 1503-6707.
11,
s. 358–367.
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Mesel, Terje; Andersen, Anders Johan W.; Gabrielsen, Leiv Einar & Fernee, Carina Ribe
(2019).
Into nature. A realist exploration of wilderness therapy in adolescent mental health care in Norway.
Universitetet i Agder - Fakturamottak.
ISSN 9788271179342.
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16. apr. 2024 11:11