The doctors prescribing ‘blue therapy’

Ten years after researchers first found that “blue spaces” could be good for us, the concept is proving to be a powerful, practical tool for mental healthAmidst the gentle rock of the sea, the breeze tickling their skin and the distant caw of seagulls, six people in lifejackets close their eyes for a “mindful check-in”. They are aboard the deck of Irene, a 100ft-tall (30m) ship with timber frames and majestic sails which is cruising off the coast of Cornwall in the UK. These kind of mindfulness exercises have become increasingly mainstream in the last decade, but they tend to be practised from the comfort of the home or a therapist’s office – not the deck of a ship. However, UK charity Sea Sanctuary, which operates Irene, believes its combination of marine activities and therapy provides a uniquely beneficial form of mental health support. A practitioner of “blue health” – the concept that being in or near blue spaces such as rivers, lakes and the sea boosts our emotional wellbeing – the charity has been organising trips around the Cornwall coastline since 2006.Many of the charity’s client sailors, largely people who experience anxiety and depression, sign up to a voyage to benefit from sessions with the ship’s therapist while also learning a new skill. They can be referred by charities and social workers or enrol themselves. Steve Ridholls, a former police officer, is sailing with Sea Sanctuary to calm the anxiety and PTSD he battles. “I used to talk people down from cliffs and bridges or respond to suicides and car crashes,” he says. “I saw things my mind can’t unsee. Much of my PTSD came from helplessness – when you witness something you can’t do anything about.” In 2014, Ridholls was signed off from the police force on mental health grounds. Now, he spends most days hugging the shoreline on his 16ft (5m) ­­­red canoe, paddling along Cornwall’s rivers, estuaries and bays. The ocean calms his mind – and, he believes, plays a key part in his recovery.Many experts now believe blue spaces, such as lakes and rivers, could be even more beneficial than green ones (Credit: Islam Dogru/Getty Images)When Homo sapiens first evolved some 300,000 years ago, we lived in grasslands and forests, next to lakes and rivers. It wasn’t until 2007 that we became a majority-urban species. But as urbanisation increases, our access to nature continues to dwindle. The loss of human-nature interaction has been linked to a rising tide of mental health disorders. A growing body of evidence indicates that human health, both mental and physical, is intrinsically linked to nature. Just looking at natural scenery has been found to cause rapid beneficial psychological and physiological changes in salivary cortisol, blood flow, blood pressure and brain activity. Meanwhile, contact with microbes in the environment can “train” our immune systems, reinforcing the good microbial communities on our skin and in our airways and guts.But many experts now believe blue spaces, such as lakes and rivers, could be even more beneficial than green ones. “Blue spaces provide us with distractions that take our mind away from the day-to-day hassles of life,” says Kate Campbell, a health psychology researcher at Te Herenga Waka-Victoria University of Wellington, New Zealand. “The sound of the crashing waves, the smell of salty air, the crunching of sand beneath our toes…The sensations relax our bodies and tell our minds to switch off.” Campbell believes humans have “an innate predisposition” towards natural environments that once benefitted us as an evolving species. Natural spaces that provided pre-modern humans with food, comfort and safety are likely to provide a similar sense of ease even in today’s urban world. Spending time in blue spaces, says Campbell, can feel like “returning home”. The concept of blue health emerged almost 10 years ago when researchers at the University of Sussex asked 20,000 people to record their feelings at random times. They collected over a million responses and found that people were by far the happiest when they were in blue spaces. More recently, experts from Glasgow Caledonian University (GCU) have found that spending time in blue spaces lowers the risk of stress, anxiety, obesity, cardiovascular disease and premature death. Niamh Smith, a researcher at GCU and co-author of the study, says the team found an impact on both mental and general health from spending time in blue spaces. The research also linked time spent in blue space to a reduction in body mass index (BMI) and a lower risk of mortality. “People really value the therapeutic space,” says Smith. “They love the sound of running water, having a reflective space to quietly sit, a place to clear your head away from the busy-ness of daily life. “We know there are four main ways that blue spaces benefit health – through physical activity, stress reduction, providing a space for socialisation [and finally the] environmental factors that have a knock on impact on our health. For example, if a river is tree-lined, you have shade.” In fact, blue spaces are so good for your health they can be now prescribed by your doctor. Blue prescribing “My depression comes in cycles,” says Harune Akthar, speaking from his West London home. Around ten years ago, the 27-year-old was diagnosed with borderline personality disorder, ADHD, depression and anxiety. “When I had a bad day, it would take three to four days for me to come out of it,” he says. “I slept and ignored everyone including my family – and I love my family. I wouldn’t eat. You’d rarely see me.” For years, Akthar tried a range of different therapies but didn’t find any that helped him. Then, in June this year, his doctor referred him to the Blue Prescribing scheme run by the Wildfowl and Wetlands Trust (WWT), a charity. After the first day, he didn’t think it was for him. By the end of the second, he couldn’t wait to go back.Harune Akthar says being by the water has allowed his mind “to pan out, to rest” (Credit: WWT)Single parents, long-Covid sufferers and those with chronic conditions or poor mental health are among those who are eligible for the six-week programme, delivered at the WWT’s London Wetland Centre.      Once a week, participants go for guided walks in the wetlands. They also do sensory engagement activities – birdwatching, clay modelling, herbal tea tasting or creating “scent cocktails”. According to the Mental Health Foundation (MHF), partners of WWT, 65% of people find being near water improves their mental wellbeing. “When people consider what constitutes a psychologically restorative environment, they frequently report a preference for blue space,” says Jonathan Reeves, a WWT health and wellbeing researcher. Watery environments, says Reeves, are less cognitively demanding than the everyday sights and sounds of our busy lives – and allow for “soft fascination”. “Think how easy it is to watch ripples in the water,” he says.Akthar says being by the water has allowed his mind “to pan out, to rest”. “Now, when I feel down, I know to take a step back, breathe. Instead of having four days in my bed, I have one or two. It’s amazing.” This year, the University of Exeter is working with WWT and MHF’s blue prescribing team to lead a feasibility study that – if successful – will lead to a full clinical trial on nature prescribing over the next few years. The trials would evaluate nature as a treatment in the same way as medicines are assessed. Reeves says a medical focus on blue spaces could also help prevent health problems in the first place. “Our health systems are overwhelmingly biased towards treating problems when they arise,” he says. “We should be spending more on preventative solutions and health promotion. In improving our blue spaces, the benefits would be felt in not only health but also the climate crisis, urban liveability, flooding, water quality, biodiversity and community cohesion.” You might also like: Even the sound of water can be enough to reduce stress in people. There are broadly two kinds of human attention: “directed”, the intense concentration we might use when driving a car, and “non-directed”, the involuntary attention we might give to distant noises or passing clouds. The sound of water can gently stimulate this non-directed attention, allowing our minds to rest. The rush of river currents and the sound of waves washing ashore fall into the category of ‘pink noise”. Like white noise, pink noise is made up of all the sound frequencies audible to the human ear – but with less volume at the higher frequencies. It has been found to aid sleep and improve memory. Some experts argue that entering the water provides yet another level of healing. Immersive activities like swimming or surfing induce a sense of environmental attunement – feeling connected to or even part of the environment.   At the Taputeranga Marine Reserve in New Zealand, just a stone’s throw from Wellington’s city centre, a programme by the non-profit environmental trust Mountains to Sea Wellington gives young Māori people the opportunity to engage with their marine environment by immersing them in the Island Bay Snorkel Trail.Wellington Underwater Club members enjoying the marine life in Taputeranga Marine Reserve (Credit: Nicole Miller)Many of the children’s families live in day-to-day survival mode and some have never seen the ocean before. Here, though, they see curious schools of fish zooming around and alien-like creatures hiding between rocks in a wonderland of swirling green and brown seaweed forests. Sunrays hit the red, algae-covered seabed and form dancing rainbows, reflected in the bubbles released by seaweed. Above the water, the mountains of New Zealand’s South Island stand tall in the distance. “You’ll find crayfish, big blue moki, camouflaged critters, colourful anemones and octopuses,” says Nicole Miller, chair of Friends of the Taputeranga Marine Reserve Charitable Trust. “It’s special to see abundant marine life up close. To be able to put on a mask and snorkel, and experience the biodiversity beneath the surface, is a life-changing experience for them.” Getting into the ocean this way gives the tamariki – the Māori children – a deep sense of connection with the environment, as well as feelings of accomplishment, pride and hope for the future. The snorkel experience has a profound impact on those who take the plunge, says Miller. “We swam in the marine reserve. I saw so many fishes, pauas and crayfish – it’s such a healing place for the soul,” one student told Miller, after taking her first dip in the Taputeranga Marine Reserve. Urban water In a bid to bring blue health to more people, some experts are turning their attention to creating – or rediscovering – watery spaces within urban environments. Nearly 2.4 billion people around the world – that’s about 40% of the total global population – live within 100km (62 miles) of the sea. Yet more people live alongside rivers or on the shores of lakes. But obstacles – such as accessibility or pollution – can prevent people from soaking up the benefits of blue spaces. In 2016, a European research initiative, Blue Health, was founded to collect evidence on the health benefits of blue infrastructure in urban spaces. Its network of epidemiologists, public health experts and urban planners have carried out experiments to tweak the design of blue spaces in cities, measuring the impacts of these changes on human health. In one project in Plymouth, UK, Blue Health worked in communities to rejuvenate run-down public blue spaces. Small-scale changes, like creating a path to the river or adding a small pontoon or seating area, were found to lead to significant improvements in community mood – local residents and visitors reported more positive emotional states and higher life satisfaction after these changes were made.Participants of the blue prescribing scheme go for guided walks at the London Wetland Centre – a large urban wetland (Credit: WWT)James Grellier, an epidemiologist at the University of Exeter and researcher at Blue Health, believes these results send a “key message” to policymakers. But the benefits of blue spaces, he says, largely depend on their quality. “These spaces have the potential for health, not just the health of the ecosystem but for the people who might visit.” Unsurpisingly, though, a brown-coloured canal full of old shopping trolleys did not prove to be a good quality blue space. “Nor is a marina that has been privatised or developed into luxury flats, which shuts people out,” says Grellier. Larger spaces are also being designed to maximise the benefits of blue health for city-dwellers. On the outskirts of Bristol, south-west England’s most populous city, a 75-acre (30-hectare) “wave garden” known as The Wave gives people a rare inland surfing experience. At the human-made lake, “perfect waves” roll in one after another. Not just a playground for thrill-seekers, it is a centre for “surf therapy”, welcoming inner-city children, religious groups, veterans and disabled people – all groups which might feel socially excluded from water-based activities.This year, The Wave collaborated with Open Minds Active, a social impact organisation, to offer a six-week introduction to surfing to Muslim women in the UK – with modest wetsuits, all-female coaches and lessons on a separate side of the surfing lake for men and women. Sarah Ahmed, one of the participants, was surprised that surfing came naturally, despite cultural barriers. “I didn’t know if it would be for me, as I wear a headscarf and long dresses, but it’s one of the best things I’ve ever done.”While Ahmed lives in a built-up suburb of Bristol, getting out into nature is now more important than ever for her family. “Lakes were always a no-go growing up, we never thought that you could actually just get in one and start swimming. Now I’m planning more trips so my kids can be exposed to the water.” As more people immerse themselves in blue spaces, there are of course public safety aspects to consider. Even for the experienced swimmer, water can be dangerous, and judging tides, temperatures and currents tricky. Meanwhile, in the UK, polluted waterways are also a growing problem. A parliamentary committee recently described England’s rivers as a “chemical cocktail” of slurry, agricultural run-off and sewage, with only 14% of these rivers meeting good ecological status in 2019. But whether it is diving in or relaxing nearby water, the growing body of research on blue health suggests these blue spaces have a beneficial effect on our minds and bodies. Back in Cornwall, Andy Thornton, the qualified therapist on today’s Sea Sanctuary sail, is checking in with the sailors about what tools they could take away from the sail for use in later stressful situations. Thornton, who has worked for Britain’s National Health Service (NHS) for over 30 years, is convinced the charity’s “broader approach” to wellbeing with an emphasis on nature-based solutions could be a more affordable and well-rounded alternative to conventional therapy. “There’s something about the colour, the movement, the awe-inspiring size of the sea,’ he says. “You see a marked change while people are on board and it’s brilliant to know that people can take that home with them.”  —  Join one million Future fans by liking us on Facebook, or follow us on Twitter or Instagram. If you liked this story, sign up for the weekly bbc.com features newsletter, called “The Essential List” – a handpicked selection of stories from BBC Future, Culture, Worklife, Travel and Reel delivered to your inbox every Friday.