Urban Forestry & Urban Greening 14 (2015) 438–445 Contents lists available at ScienceDirect Urban Forestry & Urban Greening j ourna l h om epage: www.elsevier.com/locate/ufug Review Whatever happened to the soldiers? Nature-assisted therapies for veterans diagnosed with post-traumatic stress disorder: A literature review Dorthe Varning Poulsen ∗ , Ulrika K. Stigsdotter, Anne Dahl Refshage Department of Geosciences and Natural Resource Management, University of Copenhagen, Rolighedsvej 23, DK-1958 Frederiksberg C, Denmark a r t i c l e i n f o Keywords: Evidence Horticultural therapy Intervention Military veterans Nature-assisted therapy PTSD a b s t r a c t Nature-assisted therapy (NAT) has become more common and recognized in both practice and research. The literature often describes how NAT gradually emerged in the UK and the US offering rehabilitation of soldiers suffering from traumatic experiences after active service in WW I and WW II. The main question of this review is to investigate what happened to this patient group? Consequently the aim is to system- atically review: The literature; the evidence level; the health outcomes; and the transmissibility of the therapy programmes and results for practitioners. The review describes the development and status of practice and research concerning NAT for veterans with post-traumatic stress disorder (PTSD). The systematic review included a seven-step literature search. Relevant data sources were scrutinized in order to retrieve literature meeting the predefined inclusion criteria. Due to the limited amount of peer-reviewed literature, non-peer-reviewed literature was also included in the review. The final selection yielded eleven peer reviewed and nine non-peer-reviewed publications. Three can be characterized as RCT studies, while the remainder is qualitative case studies. Eight themes emerged from the systematic analysis of the qualitative case studies. This review found that a large amount of projects offering NAT to veterans suffering from PTSD exist in many parts of the world and they present no adverse negative results. Recommendations for future practice and research are posed. © 2015 Elsevier GmbH. All rights reserved. Introduction The risk of exposure to trauma has been part of the human con- dition since we evolved as a species, but the history of progressing from the description of a range of symptoms to the development of a specific diagnosis, is relatively new. First in 1980, the American Psychiatric Association (APA) added post-traumatic stress disorder (PTSD) to the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (Binneveld, 1997). Soldiers with battle trauma (shell shock) were treated in mili- tary mental hospitals during and after World War I (WW I). As part of the treatment, corps of volunteers helped set-up gardens, con- structed greenhouses, and planned garden programmes (Selhub and Logan, 2012). The value of these programmes in the mili- tary hospitals was observed. In 1918, the US military initiated ∗ Corresponding author. Tel.: +45 72482690. E-mail addresses: dvp@life.ku.dk (D.V. Poulsen), ukd@ign.ku.dk (U.K. Stigsdotter). horticultural programmes as additional care for veterans with shellshock (later known as PTSD) and horticultural work became a separate therapy-activity developed from occupational therapy (Thyson, 2007; Selhub and Logan, 2012). Establishment of the PTSD diagnosis Approximately 9 million soldiers died with a correspondingly large number of wounded during WW I (Horne, 2012). Descrip- tions of veterans with symptoms of mental illness referred to as ‘shell shock’ emerged in medical literature in the last years of WW I (Crocq and Grocq, 2000). For the doctors, it was challenging to decide whether the post-traumatic symptoms were simulated by the soldiers, with the objective of escaping the frontline, or if they could be explained pathoanatomically, or had a psychological origin (Crocq and Grocq, 2000). Thus, the interpretation of shock shifted from being something requiring a literal wound to being based on traumatic experience. It took most of a century and two world wars before the shame and stigma attached to this type of http://dx.doi.org/10.1016/j.ufug.2015.03.009 1618-8667/© 2015 Elsevier GmbH. All rights reserved.